Sunday, August 31, 2008

Organophosphorus Poisoning : Don't try this at home !

Q:What happens when a 35-year old male shows up at the emergency room having consumed two whole bottles of insecticide ? 

Ans: He gets 130+  ampoules of atropine i.v. stat  ( 720 mg !! ) before he gets atropinized and stabilized .  His pulmonary oedema resolved and he didn't need to get intubated . 

This was followed by a continuous infusion of atropine in normal saline and PAM every 8 hours . 

This guy's lucky to be alive . Not only that , he was also lucky not to have suffered form Intermediate syndrome ( Polyneuropathy and autonomic disturbances , possibly life-threatening which occurs 48-72 hours after consumption of OP poison ) 

He was discharged in a stable condition after a 5-day stay at the hospital . 

Wednesday, August 13, 2008

Literally Surviving your internship

As most persons in the lower levels of the Medical Food Chain know , you have to face a lot of hardships, major and minor , in the early stages of you career . These include ( but are not limited to ) egoistic and arrogant senior doctors , mean nurses , being overworked , filling up forms , getting test results , uncooperative patients and in some cases even a non-functioning kitchen sink .

But I'm pretty sure that not many people have to face violent mobs , tear gas and curfews .

For a brief background , I recommend this Amarnath Land Row Chronology

Monday , 11th August

8.00 AM
I wake up . I groan . I have my night-shift today as well as OPD and Medical casualty . That means a 32 hours at the hospital . The city's been tense since last week , when the highway was blocked by protesters in Jammu . Shops have started to run out of stocks , several petrol pumps have had to shut down . There's been a general strike since 3 days . People have been talking about marching towards Muzzafarabad and the Line of Control in order to establish an alternate supply route . No violence yet , doesn't seem that todays going to be much different .

I get ready to go out . Not much traffic on the streets . I wait for the ambulance ( the usual means of transport on days that a strike is called ) . Make it to the hospital . Everything seem OK on the way .

10.00 AM
I reach the hospital . Today is Medical Unit V's OPD and casualty . Both are located right next to the Surgical Unit and casualty . I head towards the female OPD . Patient attendance is thin , not unexpected for a day like today . Along with two other interns and the P.G student , we start examining patients . On a usual day the OPD lasts from 10 AM- 4 PM and we see around 150 patients . Today we wind up our OPD at 12. We examined a grand total of around 15 patients .

12.00 PM
As we get ready to head to the OPD we start getting news that several protesters have been injured and are being transported to the hospital .

The injured start rolling in . A trickle at first , they rapidly increase as injured are brought in form protests in different parts of the city and surrounding areas . All the surgical units head towards the Surgical emergency room and casualty . The Surgical OPD is shut down . We watch from the Medical casualty as crowd starts to gather near the Surgical Casualty and Hospital gate .

We head back to the OPD , hiding our stethoscopes. People accompanying patients , especially trauma and other emergencies have been know to get violent and physically harm doctors.

12.30 PM
The OPDs are nearly deserted now . But there are still a few patients in the Male OPD . We decide to treat them before heading back to the casualty . Groups of people head towards the Trauma Theater or for emergency x-rays . The patient in every stretcher is a young man. Each stretcher also has a grim entourage of friends , brothers , uncles , fathers. Some are subdued . Most are angry .

We can hear the crowd getting louder . Suddenly we hear a series of distinct thuds followed by the sound of gunfire and people running . I wonder whether the noise was a grenade or tear gas? We see people running past us , heading towards the Main Hospital building. Everyone is running . The young , the old , men , women children .

We wait in the OPD. After a while a P.G Student return from the Medical Casualty . He says tear gas was used against a mob just outside the hospital gates . One shell managed to land within the hospital premises. Landed right next to the surgery casualty . A nurse was knocked out , but thankfully regained consciousness. The smoke drifted into the Medical Casualty . He says that it's is difficult to breath over there and we should shift the casualty to the OPD section and examine patients there . Our Registrar and Consultants agree .

2.00 PM
We wait in the OPD for patients who don't show up . The injured continue to roll in . One patient expires in the Trauma theater . A bullet right above the heart . The crowd gets violent and they damage the entrance to the trauma theater . The police charge at them and again they head past us towards the main building . By now we are extremely worried . No reports of violence towards doctors yet . But with an extremely high strung police and paramilitary , and an agitated mob , no one can predict what can happen .

3.00 PM
Half of the team has gone for lunch. The Registrar suggests that the female interns should stay in the ward while the males should man the OPD/Casualty . In case something happens , he feels we have a better chance of running away .
Reports continue to come in of violent protests and skirmishes throughout the city . Ambulance after Ambulance arrive .

I go to the canteen for lunch . The rest of the hospital is quiet . The News channels continue to bring in reports of an increasingly disturbed law-and-order situation throughout the state. Massive protests , lots of injuries . Some heading towards our hospital .

4.00 PM
We decide to head back to the casualty . The air is breathable . The crowd is still outside the Surgical casualty , but seems subdued . We start examining patients . Some children who cant make it to the children's hospital . We try our best . An ischemic heart patient is being examined by my senior . Things seem to be calm . Suddenly another ambulance arrives . We look as another stretcher is brought out , along with about 10 burkha-clad women . They start chanting pro-freedom slogans . The crowd goes into a frenzy . They climb onto C.R.P.F (Paramilitary) Bunker. The occupants quickly abandon it . The crowd starts dismantling it . We start turning back , knowing the situation can get nasty at any moment.

Another thud. More shots being fired . People running. As people move past the casualty , so do we . We tell the patients to stay in the room and keep the door locked .We tell them to make it to the ward. As we run , I see the son of the patient with IHD . I'm running to save myself . Bu the only thing on his mind is his father . Suddenly I feel very small .

5.30 P.M
we are now in the wards. In the Doctors room now . It's been nearly 40 min . A curfew has been declared throughout the city as well as the sate . The IHD patient was safe after all . He gets shifted to the CCU .
The registrar shows up. He decides to move the casualty to the ward . He tells me to come along with him to check in the casualty . Outside , the crowd's gathered again . A child shows up with pneumonia . The registrar starts to treat him . A woman with hysteria arrives . As I try to calm her down , another thud. Firing. It almost seems routine now . I literally push her out the casualty and make her run , taking history in the process .

6.30 PM
We finally officially shift the casualty to the ward until further notice . Everyone's been informed . So the patients now come directly to the ward .

Because of the curfew the situation is more calm now . No more crowds . People are lining up to donate blood . All OTs are full , so people are being shifted to to the hospitals .

9.00 PM
The canteen is closed down because they've run out of supplies . We head to the P.G Hostel on the other side of the road. We see the remains of the Bunker . So much tear gas has been used that even now , our eyes start to water slightly . The windows of the surgical casualty are broken. The streets are deserted . Police and Paramilitary everywhere . In the canteen , exhausted surgeons are watching the news. These guys have been working under the Most dangerous and stressful conditions the whole day .

11.30 PM
We head towards the Casualty . Things are calm now . We stay up until 1 , waiting for patients . Only a few show up . We sleep in the side room . A few patients show up during the night . 2 of them get shifted to the other hospital , since our CT was non-functioning and all the local labs were closed . We admit another 2 for observation .

12th August

9.00 AM
Our shift in the casualty comes to an end . The other unit takes over. Today seems calm enough because of the curfew . Back to the wards .

11.30 AM
The ward round are over . We are now completely exhausted . The previous day's events have taken their toll on us . All told , 75+ injured . 3 deaths in our hospital .
Thing seem calm .
Not for long .

Casualties start rolling in again . The curfew was lifted for a while , but then reimposed as people started protesting again. People are on a rampage throughout the city . The curfew is reimposed.
Tear gas . Firing .
People climb atop an ambulance in the casualty .

2.00 PM
Discharged people want to leave . But theres no transport. We tell them that they'll just have to stay in the hospital . Even ambulances plying from their villages can no longer take them back . Too many casualties . Limited fuel stocks . Dead bodies are not being transported . Only those who have a chance of survival .

4.00 PM
Our shift finally ends .
But the curfews still on , so all transport has shut down .
But the ambulances are still tied up .
Protests continue . 50, 000 people have gathered for a funeral about 1.5 Km from our hosptial . Smaller protests continue to take place .
People are still gathered at the casualty .

But then , in something that can only be described as divine intervention , it starts to rain . The protesters begin to disperse . Apparently they're more put off by the thought of catching a cold than taking a bullet .

We wait near the OPD entrance , way from the casualty. Another stretcher rushes by . A 18-year old schoolboy who got hit by ah object in the face . He has a nasal fracture , orbital fracture , and has probably lost his right eye . Covered in bandages . Gets put in the ambulance , and is transfered to the tertiary care hospital .

Finally our ambulance arrives . As we move through the city , all the roads are deserted . Except for stray dogs , an occasional car or person the only other people visible are the police and C.R.P.F. On the way we see a small demonstration , so our driver quickly changes the route. We get stopped on the way and are asked to show some proof of identification .

An ophthalmic surgeon tells us about another boy. Multiple facial injuries and fractures . He was lucky that his eye got saved . But his parents only found out later . Took them 6 hours to reach the hospital .

We start lamenting about how all the casualties seem to be school-children and young men . About how for them a protest is just something cool . But they don't realize the dangers are all-to-real dangers and so are the consequences . But in the end , they're just cannon fodder . Someone else decides to fast until death in the comfort of his home and it makes front page news . These guys are lucky if they even get taken to the hospital .The experienced protesters know when things are about to turn and when to run for it .You rarely see them getting injured .

As I reach home , I see that one of the routes is blocked by a burring cart . My area is usually peaceful , so I know something serious has happened . We take another road .

5.00 PM
I finally make it home . People on the street tell me the a 20something male was shot dead.
The locals ask me for about what the situation at the hospital was . I give them a 1 minute summary and go in .