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Saturday, February 27, 2010

NIGHTMARE OF 26/11

This is a small write up of what an anesthetist went through on 26/11. I thought it was an amazing read and asked if it could be reproduced here. It is unmodified and exactly as she wrote it out. 



"It all started around 10 p.m. There was a lot of confusion in the casualty. We heard some terrorists were gunning down innocent people.

Patients were being brought to the casualty and directly being admitted to the ICU where the initial steps of resuscitation i.e. Airway, Breathing & Circulation were being taken care of. Patient’s that were brought unconscious were immediately intubated with Nasogastric Tube insertion, considering all were full stomach.

The anaesthesiologists were called in the casualty & ICU to help initially, but later, we realized this was turning out to be a mass casualty. As the patients were pouring into the hospital in battalions, we knew more was to be done. We got the Major O.T., the orthopedic O.T. and the neurology O.T. opened. All this took place in such a fast pace only due to the great co-operation of the O.T. Matron and sisters & ward boys. There was blood shed everywhere. Victims were being rolled in. We mobilized extra trolleys for anesthesia drugs. All 7 operation theatres were opened.

All the anaesthetist consultants were stuck at home because of the curfew situation so the anesthesia residents were left to manage this critical situation. I, Dr. P.R. was a 3rd post anaesthesia resident with 5 more juniors with me. Our team was led by Dr. J.C. who was the chief resident. We were ordered to use Ketamine & scoline for crash induction & muscle relaxant Pavlon (Pancuronium) for maintenance. We assumed all patients to be full stomach & accordingly carried out crash induction.

Ketamine: Drug of choice for induction because unlike propofol / pentothal, it causes tachycardia & hypertension thus maintaining vitals in a haemodynamically compromised patient.

Scoline: Induction relaxant of choice as scoline brings up the pressure, also causes
excellent relaxation & is the agent of choice in crash intubation.

Pavlon: (Pancuronium) long acting muscle relaxant. Relaxant of choice as it causes sympathetic stimulation, tachycardia, hypertension. Also due to long duration of action requires less top ups for maintenance. As we were short staffed & had to manage multitude of tasks including fluid electrolyte balance & blood management, pavlon really helped us.

Most patients brought in were critical with multiple bullets, in a state of shock, so patients were maintained on100% oxygen and muscle relaxant top ups. These patients were not reversed at the end of operation & were sent to I.C.U with the tube for staged weaning after confirming their general condition.

Some patients with minor injuries were extubated on table provides they had good vitals to begin with & were conscious.

Aspiration prophylaxis Ondensetron & Rantac were given.


Patients with multiple bullet injuries were brought in, most of them with shock, feeble pulse, unrecordable blood pressure. A direct arterial line was managed in those cases where central lines were not possible. Peripheral lines with wide bore cannulae were used to push blood. ‘O’ Rh –ve blood was used when cross matches were not available. Fluid management with initial crystalloids & colloids was carried out and as blood became available after cross matching, we pushed it along with Fresh Frozen Plasma and Platelets.

Ionotropes namely dopamine, adrenaline and nor adrenaline were started to maintain falling blood pressures.
Resuscitation was done in full swing and monitoring of Pulse, Blood Pressure and SPO2. Keeping the blood pressure in mind, sedatives like midazolam were avoided.

One of the cases was a Japanese National who was very critical with multiple bullet wounds in the liver & intestines. We tried our best to resuscitate him along with CPR and shock but alas, couldn’t save him.

Of particular interest was the case of J. N. This female was brought in with multiple bullet wounds with a multitude of fractures including arms, pelvis, spine and left brachial artery tear. Her pulse was feeble, blood pressure unrecordable and only after crash induction were we able to obtain a Right Femoral arterial line (left femur was bruised and fractured). We started ionotropes alongside fluid resuscitation and blood, FFP and platelet transfusions.After 12 hours of surgery, on the next day she was taken to the ICU where further management of her DIC (disseminated intravascular coagulation) and general care took place. We thought she wouldn’t survive but miraculously she pulled through.

Totally 23 operations took place that night, out of which two expired on the table. The cases kept rolling in, some commando’s included in them. For 4-5 days the hospital was a war zone. In this way, the mass casualty was managed in a hospital in Bombay!"



I could actually feel what she must have gone through. This post is dedicated to her bravery and spirit of working right through the calamity. We will never forget!

Wednesday, February 24, 2010

Are you Branded?

I came across a man who was recently married and was unable to concieve. His preliminary reports pointed towards azoospermia (an absolute zero sperm count) and bilateral varicocele. He was from the middle east and had a diagnosis of infertility. He knew about the varicocele and had heard that in some cases its responsible for azoospermia. He also mentioned that he sometimes saw semen in his urine (retrograde ejaculation). He had no issues with potency and secondary sexual characters were well developed.

He insisted on a full workup and even consented to a testicular biopsy. He also mentioned a procedure he had undergone back home, but due to language issues, we weren't very clear what it was. Until we took him on the table for the biopsy. He was branded. With a red hot iron rod. Thinking that it would cure the varicocele and all his problems!

These are the actual pictures on his skin. The first one is something he underwent when he was small. It was a pattern of five such prints on his upper back, supposedly to cleanse his blood.
The second one was at his left lower abdomen, and was done specifically to cure his varicocele and increase his sperm count!!

The process of branding the skin is known as scarification (scaryfication is more like it). Generally voluntary, though often under severe social pressure, branding may be used as a painful form of initiation, serving both as endurance and motivation test (rite of passage) and a permanent membership mark.  Endorphins can be released in the scarification process that can induce a euphoric state. 

The longer for a wound to heal, the more pronounced the scar will be. Thus, in order to have pronounced scars, the wound is kept open for a protracted time. This is by abrading scabs and irritating the wound with chemical or natural irritants such as toothpaste or citrus juice. All this can be understood when it comes to the tribes and ancient cultural practices.


What amazes me, is that this very same practice is being carried out in the modern world with the tag of it being a cure for certain diseases, which now have a scientific basis and known cure!
The line between modern medicine and traditional values is running very thin and sometimes these practices may be lethal. (Read here for the post on alternative therapies taking lives)


Another strange fact is this, if the person getting branded develops an infection, the tribes apparently have a code - LITHA - literally translating to leave it the hell alone!!

Tuesday, February 16, 2010

Would you be able to walk with these?


Over the past few weeks, it seems, I've been getting relatively common things in relatively uncommon places. Coming off from the fishbone story (read here, if you haven't already), I now have something as common as a lipoma in someplace as uncommon as the anteromedial aspect of both knees!


These were so huge that they actually prevented the patient from walking normally, sitting on a regular chair and even going to the washroom! Taking a closer look at the picture will show you that you can barely even see the knee joint. It's almost as if the lipoma's had pushed the knee joint away!


Anyway, an ultrasound and doppler were done to ascertain the feasibility of surgery and whether it would really help. Luckily, both sided did not have major vessels in the lipomatous mass and they were confirmed as lipomas.

The surgery was difficult, took two hours, and required a lot of patience. A large amount of skin was to be sacrificed in order to achieve closure and keep the dead space as minimal as possible. Suction drains were kept for draining the collection which was bound to happen. The surgery went off well and the patient was able to go home on the same evening. The best part is that she walked out of the hospital on her own and by her own admission feeling like the life had come back into her legs, thats how light she was feeling!!

The third day post op dressing revealed no real seroma formation or any degree of contamination or ooze. She came walking to the clinic, walked out, even thought about shopping for a bit before returning to her place of residence. Hopefully, the sutures should be out in a week and she will be absolutely normal.

Would you have been able to walk with these??

Till the next thing that comes in a totally unexpected place!!

Thursday, February 11, 2010

Fish bone In His Elbow!

Out of all the places for a fish bone to go and get stuck, this poor man could not have asked for a worse location. It's quite common to have a fish bone stuck in your throat while eating, but the question almost everyone asked me the moment I mentioned this is, How in the world did he manage to get it stuck there?!?!?



Well, the explanation is quite simple. All it needs is a little bit of lateral thinking. It's like the question of a plane crashing and burying the survivors, or the rooster that laid the egg that both neighbour's wanted to claim.....

The man was not eating the fish but was a fisherman who was chopping it into pieces to sell in the local fish market, when the fish decided to do one last heroic act before dying and made the bone fly into his elbow!!
He was in obvious pain, with some amount of swelling and infection forming around the wound (his cleanliness was no where next to Godliness).

He actually presented at the clinic and not the hospital. With limited resources, all we were armed with was an X-ray of the offending bone (lying close to the ulna) and our tactile sensations. We had a sonologist in the next consulting room, so we tried to get it out under sono guidance. We could locate the bone but the sono being an echo study, the moment we tried to insert the forceps to hold it and pull it out we interrupted the image.

Finally it was decided that the only simple way to do it would be under Image Intensifier and fluoroscopy as he was not ready for a local exploration at that point of time. Well, he was taken to the hospital and it was successfully removed. He decided to take the offending bone home and said he would make a locket out of it!

Just hope he doesn't smell of fish....

Sunday, February 07, 2010

SurgeXperiences - Edition 316

Welcome to the 316 Edition of SurgeXperiences - The Surgical blog carnival. I was overwhelmed with the number of submissions I got and it was nothing short of a party for me to read all the posts.


Without further ado, lets jump straight in.

A very interesting learning blog with some strange facts that most of us must have learnt but never paid much attention to is at Gastrointestinal Gutwrencher. The Life in the fast lane author has made it even more interesting by putting in short question answer paragraphs!

Dr. Wes seems to have come across a gem. Bangalore in India has done the unthinkable (at least to me) Peforming Wide Awake Open Heart Surgery. The picture says it all. Expect a lot of comments on this one.

Sticking with strange and unheard of surgeries, China seems to be at the forefront of all things new with fingerprint surgery. Still not sure whether it would be considered legal in any country other than China, this definetely needs a look at.

Rlbates of Suture for a Living gives us an education in plastic surgery with Neoumbilicoplasty. A well researched post about "the only scar that perhaps all of us want." She details fantastically the various options plastic surgeons face while creating that perfect umbilicus for a variety of indications.


Women Neurosurgeons may be a rare breed but they may just be the most caring doctors. We find here a case of a doctor having to make that very very difficult decision of operating upon a close associate and friend....Sometimes, it is better to refer away! It no longer remains a matter of trust but of judgement.

Inspirational stories are the need of the hour at Haiti, after the nation reels under the enormity of the devestation caused by the Earthquake. Dr. Sanjay Gupta, of CNN, provides just that with this report on performing Neurosurgery on board a U.S. Military Ship.

To lighten the mood, Aggravated DocSurg gives us a song listing all the places he has been in the human body (didn't know some of those names, by the way) in his song - I've been....Everywhere!

A brilliant concept - Domino Surgery - which I think could be the way ahead in the future for transplant patients gives people the option of getting organs when their relatives don't match or are unable to provide for them. Brilliant read, I think!

Coming to something I know a bit about, Bariatric surgery. A nice bit of news coming out says that Bariatric weight-loss surgery is considered safer than living with obesity. Read the whole article here. Personally, I have seen many patients literally starting a new life after bariatric surgery and consider it a boon for such cases.

Some more surgical news while we're at it. Asian news International reports on A novel technique that can help young patients to delay, or even possibly avoid altogether, the need for a total hip replacement. 

The Hopkins PodBlog gives us startling news for women of the world. Women are almost 70 times more likely to require hospitalization for VTE following inpatient surgery. Blood clots and surgery details the information for us.

Stephanie Aurora Clark Nielson returned from an almost fatal plane crash, and is going to have some of plastic / reconstructive surgery. This small post gives us an insight into the mind of a patient fighting it out for normalcy.

One thing for all surgeon's to remember, I think, is to be respectful to all the support staff and ancillary staff in the O.R. You never know when someone you have rubbed the wrong way would be the very person you need. This is exactly what happened with this Norwegian Medical Photographer. The post describes how the surgeon could not even get a word in before the blogger got in, got the photo and walked out. Read about it here at Be quick or be dead.

A different kind of blog was brought to my attention by Jeffrey Leow, concerning Gender Reassignment Surgery. The writer of this particular post comes off as being so passionate about the post that you can't but help support her cause.

That is all for this edition of SurgeXperiences. However, if you do want to browse through older editions, you can do so here. Thanks for the patient read and your support in helping this first time host to manage this cyber party. Cheers!

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