Narrative writing – Shantas Pharmacology

Disclaimer: These reflections are based on my clinical experiences as an Intensivist during my tenure in the Intensive Care Department. Sharing stories might help colleagues learn and unlearn: challenges in diagnosis, importance of clinical scrutiny and professional values. The names of all the characters have been changed to protect their identity and confidentiality.

1: Cobra bite nightmare: vigilance to success

It was a relatively calm and still morning that day in the hospital, and there would have been absolute silence if it had not been for the constant ticking of my Rolex and the flutter of pages as I flipped through my favourite textbook titled “The ICU Book” by Paul L Marino. It was around 2.30 am, and all thoughts of sleep had evacuated my mind as the contents of the book permeated it instead, slowly driving out all other thoughts. I would have stayed that way for quite some time if it hadn’t been for the sharp ring of the phone in the central monitoring room that sliced through the thick silence that had settled around me. A cloud of oblivion lifted from my mind.

I quickly slammed the book shut and scrambled up to reach the phone.

“Good morning. Dr. Sunil speaking from the ICU,” I spoke through the speaker.

The familiar voice of a doctor greeted me from the other end of the line. “Good morning, doctor!

We have a patient, Ananya, here in casualty with some sort of bite mark on her ankle.”

“What about her vitals?”

“Her vitals are stable. But I can’t seem to get an answer from her,” she said.

I rubbed my temples with a sigh. “Is she mute?”

“No. But she seems unable to speak now,” came back the reply.

A sharp tingle ran through my spine. It was an all-too-familiar sensation that coursed through me every time I attended a new emergency case – one that took over me effectively until the case was taken care of.

“Shift the patient to the ICU immediately, doctor. I’ll see you with her,” I said before placing the phone back down.

The shift from casualty to ICU usually took around five to seven minutes after the CMO sanctioned admission to the ICU, and it was very clear to me that the patient would require ventilatory assistance any minute then. I barked out sharp instructions to the resident intern and the staff nurse to get the ventilator ready just as the door opened to let two young women in.

A junior doctor, Ritu, had her arms poised around a pretty girl who hardly seemed older than twenty, whispering a string of reassurances into her ear and rubbing her back softly.

“Do not panic, Ananya. We’re going to take care of you,” I said warmly, trying to calm down the frightened girl.

Ananya had her hands clutched around her throat; eyes wide with anxiety – a sure sign of dysphagia due to neurotoxicity of the toxin with which she had been bitten. Within just a mere five minutes, she ceased breathing, and we had her promptly intubated and started on artificial ventilation. I was surprised that she had needed the ventilator that soon.

It took a while for us to get her stable, but when we did, I knew I had to get the whole story.

We had her examined thoroughly and had come to the conclusion that she had been bitten by a snake with neurotoxic venom. She was immediately started on an anti-snake venom regimen. Ritu had Ananya’s father brought in so we could ask him everything we wanted to know. Mr. Singh looked terrified; the rim of his eyes was red from crying, and runny red nose to match. He pushed his shaking hands into the pockets of his pants in an attempt to keep them still as he recounted the story with a wobbly voice. Apparently, Ananya had woken up around 2 am wanting a drink. Finding the bedside pitcher empty, she had gone into the kitchen to fetch some water. When she had come back, she had been hysterical as she had complained about something biting her and about having a terrible throat pain. She had been brought to the hospital then.

They had found a King Cobra coiled, only later, by the refrigerator. Mr. Singh was shaken and sobbed harder, asking us to help his daughter. He believed in myths that claimed that cobra bites were fatal and seemed to wallow in the fear of having been too late in bringing Ananya in.

“Your daughter reached in time and is in good hands here, Mr. Singh,” I said sympathetically with a small pat on his arm.

“We’ve started the treatment just on time, and Ananya is going to be perfectly normal soon. Just hold on. Cobra venom may act fast but gets neutralised just as soon.”

True to my word, Ananya seemed to get better quickly with vigilant care. She was a bright and charming girl who had easily managed to strike an easy friendship with everyone she came to meet. It was only a matter of ten days before Ananya was completely cured and was feeling herself. In two weeks, she had been discharged free of any complications, healthy and with a glow.

All had ended well, but I couldn’t help feeling a little shaken about the whole thing. Thinking back, the doctor who had informed me about Ananya over the phone when she had said that the patient was unable to talk. I hadn’t been able to comprehend if she had been muted from birth or the effects of the venom.

I could probably blame the predominant GABAergic activity that had slowed down my decision-making capability. We had managed to get the ventilator ready long before the patient had arrived, but I had not realised that the situation would be so dire that she’d require it as early as she had. It scared me to think of the alternative- the patient succumbing to respiratory arrest on the way to the Hospital or her shift to the ICU being delayed by even minutes.

That night, I realised something I’d already known, on a spiritual level – alertness and anticipation must be extremely sharp in the ICU. Everything wasn’t what it actually seemed, and what might look like a simple case could turn out to be lethal if not for timely action and presence of mind.

2: Buried certainty: a case of OP poisoning

“This is taking longer than usual,” Dr. Aryan complained as he trailed behind me, looking a little glum as he checked his watch again.

I gave my intern a small smile as we moved on to the next patient. “Checking your watch every few seconds isn’t going to help,” I said softly.

I couldn’t blame him, though. It had been a busy day at the hospital, but quite frankly, a dull one. The afternoon seemed to crawl by with no real excitement, and everyone was about completing their routine work like drones.

The nurse who accompanied us seemed to echo Aryan’s thoughts, sighing every time he peered into his wristwatch.

“We’ve hardly completed checking on three patients,” I said, briskly walking to the next bed for the day’s rounds with two pairs of tired feet shuffling behind me.

We never really made it to the next bed because right then, a new patient was brought into the ICU, where I was immediately summoned.

The ward boys shifted a thirty-something unconscious woman onto the bed before making way for my company and me. I was satisfied to see that Aryan and the nurse were completely alert, all signs of boredom having deserted them immediately. I could feel the adrenaline rush through me already as I leaned over to check on the patient, Mrs. Malini.

In the quiet urgency of the ICU, we interrogated relatives for a brief history. As per their opinion, she was well till noon until teatime gloom ransacked her alertness.

She was brought up in an unconscious state, and we assessed her airway, breathing and circulation as we should.

She seemed to have bradycardia, her pulse rate just bordering on 40 beats per minute and a blood pressure of just 80/60 mmHg. Her breathing was laboured with oxygen saturation below 60%.

I cursed softly and knew immediately that I had to secure her airway for mechanical ventilation. I barked out orders to the intern and the nurse, and they were prompt, getting the intubation kit ready for me within seconds.

I had managed to insert the laryngoscope into her mouth and found that it was filled with watery secretion and that her airway wasn’t visible. I had originally thought that the patient had pulmonary oedema, but the watery fluid in her mouth immediately ruled out that possibility. This wasn’t typical of a pulmonary oedema case at all.

The wheels in my mind were turning quite frantically as I sought out the cause, even as I suctioned out the liquid from her airway and hastened to put her on a ventilator. I sucked in a breath of quick relief when I finished.

“Dr. Sunil? I think you should take a look at this,” Aryan said as I washed my hands in the sink. I dried my hands and stepped over to see what he had found.

I whistled slowly when I looked down at what he was pointing – pinpoint pupils.

I knew at once what had happened. But just to be sure, we had her evaluated, and lab results for serum cholinesterase were obtained. I smiled grimly when I saw that my diagnosis had been confirmed.

Of course, it wasn’t pulmonary oedema. No, it was organophosphorus compound poisoning.

I called in her family for a quick word. “Were you ever going to let us know that Mrs. Malini had attempted suicide?” My voice was hard with bitterness.

Her relatives gaped in shock, surprised that I had deduced the cause even from the lack of their information. “We’re sorry, Doctor…”

I cut them off with a sharp look. “Don’t apologise. I hope you know how difficult it would’ve been to treat her without knowing the actual cause. I’m appalled at your behaviour.”

Her relatives looked ashamed of themselves, and I was glad that my words had cut through to them. We had been lucky that we had diagnosed her immediately, but I knew that it wouldn’t always be the case without a reliable history.

Needless to say, my mind was troubled by this for the rest of the day. I hated that people continued to hide information from us despite knowing that one should never lie to their doctors. But a part of me knew that I had to accept it.

The incident taught me a crucial lesson: sometimes, relatives may not disclose complete information either due to anxiety or ignorance. The path of healing ultimately depends on the clinician’s skill in uncovering these omissions, not confessed by loved ones guiding us through the labyrinth of hidden narratives.

3: The ice-cream promises and resilience of an adorable schoolgirl

There are very few people who leave an impact on our lives, even when the time we do get to know them is less. I often look back on my professional experience and wonder about the patients who left behind a mark.

There was one such patient who always remains in my heart for her simple innocence and courage.

It had been a busy afternoon, but I had laboured through my daily rounds and had been content to sit in my chair and stretch my weary legs. I hardly got twenty minutes to myself when the nurse in charge hurried in with an air of urgency.

“We have a new patient. A thirteen-year-old girl, Miss. Ruchu with breathlessness,” she announced.

I sprang to my feet at once and followed her out, where the patient was rushed in.

Ruchu was a lean and pretty girl who currently looked terrified. Her mother seemed to be in a state of panic as she recited the history to me.

Ruchu had developed abdominal pain and vomiting that morning, and since then, her condition had only deteriorated, with a pulse rate of 120 beats per minute and a respiratory rate of more than 40 breaths per minute. Her blood pressure was normal.

After a complete systemic examination, the primary diagnosis of acute cholecystitis was made. Her blood was sent for routine and special investigations along with Arterial Blood Gas (ABG) analysis.

Despite the diagnosis, her bedside ultrasound did not show anything abnormal and seemed completely normal. Confusion set in along with a slight twinge of frustration.

But when the nurse walked in with Ruchu’s ABG report, confusion gave way to shock because the results showed high anion gap metabolic acidosis. I moved quickly and asked to get her blood glucose levels immediately.

The results were out in no time, and I gaped in silent horror at the digits printed across the report.

515 mg/dl.

Of course, diabetic ketoacidosis (DKA).

I momentarily hated myself for having missed something so important. I couldn’t shake the guilt off, even when my Critical Care Director assured me that it was quite common for such complications in a previously unreported case of Diabetes Mellitus. There had been no previous history, but I was unhappy.

I left it there and started Ruchu on the DKA regimen and insulin therapy.

It pained me deeply to witness Ruchu’s mother break down with the diagnosis.

“Diabetes, at this age? Are you sure, doctor? Could you recheck the reports?

“The reports are correct. Unfortunately, she has to take insulin throughout her life,” I nodded softly.

“This is the butterfly age, meant for happiness, freedom, surely not for the pricking of her tender skin every day.” Her voice was barely above a whisper.

“I can understand your pain and concern, but we have to face what has appeared in front of us.” I tried to calm her.

“But why? Why my daughter?” She wailed, looking thoroughly miserable. “She loves ice cream too much. My Ruchu will never be able to taste it again.”

I desperately wanted to console her, but Ruchu beat me to it. She said, “If I do not get ice cream throughout my life, so what? In their entire life, some people leave without eyes and are not able to see this beautiful world created by god. Compared to their pain, mine is nothing.”

She gently assured her mother that she’d be alright and that everything would turn out alright.

My heart squeezed for the little girl’s tiny smile and realised that courage and resilience often come in the smallest voices.

I knew that Ruchu would forever be someone who’d never leave my memories. She had printed an emblem of courage in my heart.

I learnt that resilience and courage are two sides of the same coin; it is essential to remain contained, successful and happy in difficult situations.

4: When words speak louder: A close call in Addison’s crisis

It was just another day at the hospital. It was abuzz with the presence of patients who had come in search of healing and hope. And then came a patient, who, after a series of events, imparted a profoundly valuable lesson that shaped my clinical acumen in every direction. Mr Babu was brought in by his father. He had suffered from convulsions and visited the hospital for a cure. Primary screening was undertaken. He was then advised to undergo a routine blood investigation and a CT scan of the brain. Soon, the test results were in – all the reports were normal, but there was a catch: the serum sodium level was notably low. Nothing was alarming, but it needed attention. He was treated with antiepileptics for the complaint he had come for.

A month later, Babu was back – and he was back with the same illness. We had to readmit him. Now, Babu has become a familiar face to all ICU staff, including doctors. They used to greet him as a friend, brother or son. It was also noted that he would default on therapy and never adhere to prescribed medications after discharge for some reason. The hospital admission was not a financial burden for Babu’s family, as his father was a central government employee. During admission, Babu’s father used to pester us with the same anxious advice – to have a blood transfusion done for his son. We used to make sure to convince him that a transfusion wasn’t necessary.

Soon after, he was indeed readmitted – this time for 2 episodes of convulsions and hypotension. His blood pressure plummeted to 90/60 mmHg. Ritu, my resident, approached me and informed me about his admission. She said, “Sir, Babu has come into the ICU. I have started IV Fluids and infusion with Fosphenytoin as per your opinion.”

“OK,” was my immediate response.

I examined him more vigilantly to confirm whether something lingered below the surface. I was quite puzzled about the cause of hypotension. I could find no answer. Next, as per protocol, I had a word with Babu’s father. I explained his clinical condition and prognosis. His father then told me that Babu had not eaten adequately for the past three days. He then narrated a long story and then asked me, “Doctor, would you please transfuse blood to my son?”.

“It is needless! It will increase the risk of blood-borne infections!” I responded and tried to convince him.

“Doctor, please transfuse at least 2 bottles, my son will surely be alright.” He retorted.

“I’ve told you and I will say again, this is not necessary at all”. I was firm and visibly annoyed.

“Doctor! Can’t you see his skin getting darker? Just transfuse blood, he’ll be alright!”.

With considerable persuasion, I managed to convince Babu’s father for a temporary moment that a transfusion could be avoided. Most doctors neither consider nor pay heed to such advice from patients or their relatives. I was no different.

Half an hour later, Ruchu approached me. “Sir, Babu has presented with convulsions and hypotension. I cannot understand the cause of hypotension.”

“Ruchu.. That’s what we have to find out. He hasn’t eaten well for three days,” I responded to her. “How are her serum electrolytes?”

“Sir, there is hyponatremia with a marginal increase in serum potassium level. Should we repeat the tests?”

“No, that shouldn’t be required.”

We heard light footsteps approaching us. “Doctor, Babu’s father is requesting to meet you. Shall I send him in?” Our conversation was interrupted by the staff nurse.

I was very sure that Babu’s father was going to ask me the same question. I was exhausted by how persistent this man was! But I had no other choice; I had to face him.

“Please send him in,” I asked the staff nurse.

Babu’s father entered and sat down in front of me. His face was expressionless. I knew what was coming.

“Doctor, when are you planning for a blood transfusion?”

“I haven’t planned anything of that sort as it isn’t necessary.”

“But why, doctor?!” He was surprised.

“Please listen to me. His Haemoglobin level is normal; he does not have any blood loss. Why should we transfuse blood? Please understand!”

“Doctor, for the past week, he hasn’t been eating well, and his skin is getting darker. If you transfuse blood, he will be fine.”

“What?” I shot back, the pitch of my voice rising.

“His skin is getting darker by the day, and you’re telling me there is no blood loss!”

I again pressed upon the fact that Babu didn’t require a transfusion. With dismay, he left the ICU. I managed to convince him, but I had a hunch that Babu’s father was trying to tell me something–something that I unfortunately couldn’t catch. His father’s repeated words about darkened skin were making me ponder what it could be. “Why is he telling me that his son’s skin has become dark? What is he trying to say?” I thought to myself. I racked my brains trying to figure out what it could be.

Hyperpigmentation was beginning to give me a clue…And finally, it struck me! The diagnosis of Addisonian crisis popped up in my brain! I was excited and relieved at the same time! I proceeded to inform Ruchu and asked her to administer intravenous (IV) Corticosteroids. After a week, he recovered and was discharged.

Six months have passed by, and Babu has not visited our hospital. It is good news. Every word uttered by the patient or his relative is crucial in making a diagnosis. In Babu’s Case, his father was giving a hint in the form of hyperpigmentation, albeit initially, we failed to pick up the clue. Even though his father insisted on a blood transfusion, no one considered his words. Fortunately, we could pick up the diagnosis a second time. Sometimes, relatives give us clues to diagnosis, but we must catch the clue at the right moment and correlate it clinically.

Babu’s father taught us an important lesson: always listen to patients and their relatives and never overlook minute details of the patient’s history because sometimes words speak louder than we give them credit for. Never underrate what they say; it may provide you with vital information to reach a final diagnosis.

5: An Unforeseen path in a case of abdominal pain

A 27-year-old male patient, Kumar, was admitted to the hospital with complaints of pain in the abdomen and vomiting. He was under the supervision of Dr Prashant, an eminent surgeon of our hospital. The pain was reported to be in the left hypochondrium. The relatives mentioned that the patient had consumed heavy amounts of alcohol two days before hospitalisation. He was thoroughly examined, and taking into account the positive history, he was provisionally diagnosed to have Alcoholic Gastritis.

Routine investigations turned out to be normal except for mild leucocytosis. The chest X-ray, abdominal sonography and liver function tests showed no abnormality. He was then started on antibiotics, anti-spasmodics and drugs to reduce acid secretion.

Dr. Prashant had a busy morning in the theatre, so he could buy time to see the patient by evening. To his relief, Kumar had a significant improvement and seemed to be comfortable after admission. Dr. Prashant gave the necessary advice to the staff nurse and left.

Day 2 was uneventful.

Surprisingly, on the 3^rd day, his pain worsened, and he was reported to be febrile and looked toxic. His abdominal examination did not show tenderness, guarding or organomegaly. Sonography of the abdomen (USG-Abdomen) was repeated and reported as normal, which prompted Dr Prashant to demand a CT scan of the Abdomen.

However, day 3 happened to be a national holiday, so only emergency facilities were functional. After some thought, Dr Prashant called his good friend Dr Santosh, a dynamic radiologist and requested him to get the patient’s CT scan done.

CT plates were ready by the time Dr Santosh arrived. He carefully evaluated and analysed the CT scan findings. He then called in Dr Prashant to discuss about the patient’s CT report.

“Dr. Prashant, the abdomen is normal, but there are surprising findings in the left lung; haziness in some CT sections is visible. Can we go for an HRCT-Thorax?” asked Dr Santosh.

“Patient is not affording, and he may not agree to spend another 5k.”

“Patient’s abdominal pain might be worsening, but my instincts tell me that the pathology lies in the chest. We need to go for an HRCT-Thorax.”

“Ok, let me explain it to the relatives before you take the patient to the CT room.” Dr Prashant responded.

The HRCT was done.

“Dr Prashant, the abdomen is normal, but there is left lower lobe pneumonitis!” proclaimed Dr Santosh triumphantly, with a mild degree of alarm in his voice.

“Oh! That’s why the patient is toxic and febrile!” Dr Prashant exclaimed.

“But how did he not show any symptoms of Pneumonitis?” Dr. Prashant further questioned, perplexed by his initial symptoms.

“My radiological diagnosis is left lower lobe pneumonitis. But I am not sure why he didn’t show classical symptoms of pneumonia.” Responded Dr. Santosh.

Moments later, the patient was referred to the Pulmonary Medicine department. Consequently, he was treated with intravenous (IV) antibiotics and symptomatic therapy. His condition improved after a week, and he was finally discharged.

This was a tricky case. The patient didn’t present with the classical symptoms of pneumonia, i.e. chest pain and cough. The abdominal pain distracted us from a respiratory cause. The relatives of the patient also reported alcohol ingestion, further muddying a clinical diagnosis. In pneumonia, the patient classically presents with pleuritic chest pain with mucoid sputum. Sputum is usually purulent and may also contain traces of blood. It was quite puzzling that none of these features were present in the patient.

This is indeed a lesson for us to learn. Comprehensive history taking always remains the cornerstone of accurate diagnosis. But some exceptional cases may lead to a diagnostic dilemma in the absence of classical clinical features. Always keep the common diseases in mind, as they follow a typical pattern, but their uncommon presentation can challenge clinical intuition.