DA 3. The Tower of Babel

Utter chaos at the ER with doctors grappling with the quizzical task of making a seemingly sensible diagnosis for poor Mr Om....and did they succeed?

3. The Tower of Babel

The waiting stretcher trolley came as big relief. The orderlies deftly extricated the weak frame of the old man from the back seat and lay him gingerly on the trolley. Then with lightening speed the gasping casualty was rushed to the ER.

Terry pulled out his vibrating mobile phone as he sprinted to keep pace with the speeding trolley. “Hi Darling, yeah, we reached here and all’s being taken care off. Yes, I’m with him. Of course he seems ok…. and is now in safe hands... Yeah, shall keep you posted of the happenings. No no, I won’t leave him until he recovers fully”. He smiled with relief. Sandra shared his concerns for Mr Om. She’d specially instructed him to be by his side, come what may, and until any of the ‘kins’ showed up.

The ER buzzed with activity… Mr Om looked around bewildered as they tucked him into a neatly made bed and adjusted the pillows .....Terry thanked God for keeping the old man well till they reached here.

Events rolled in quick sequence thereafter. Terry’s grip was disengaged from Mr Om’s hand as doctors and nurses went about the preliminaries..... attaching the oxygen mask to the struggling client; connecting him to the various monitors overhead, that instantly came alive blinking and beeping rhythmically.

Connected by an unknown sense of bonding, Terry hung close by trying to calm and reassure Mr Om, as he also helped the nurses to secure the leads….. The old man’s eyes darted about with childlike curiosity, peering through the maze of wires, at the motley crowd of doctors and nurses bustling about.

“Welcome Mr uh…. Om…eesh… ella”. A nurse smiled to him, squinting hard at the clip board. “How do you do?” The patient gave a wan smile. “I must draw some blood samples…..” She continued with a professional tone, “… will let us know what’s it that’s gone wrong with you. Now, lemme have your hand…. please?”

Before he could make up his mind, she held his left hand and deftly wound a tourniquet up his arm. Perhaps bewildered by the sudden assault, he pulled hard, but the grip was firm. Another nurse joined in the ‘tug-of-war’. Such happenings were commonplace in the ER. The patient’s struggles only increased further. He gave a loud wheeze and pulled again with renewed vigour, fighting their every effort to hold him down.

“Oh please, calm down Mr Om. We are here to help you”, the exasperated head nurse tried her best to soothe the struggling patient.

“The name just doesn’t match the old man”, is all what Terry kept pondering.

He was shaken out of his reverie, as the client struggled to be free of the oxygen mask, what with both his hands attached to ECG leads and other tubes…. Terry once again made a vain attempt to explain the need for it. But Mr Om would have none of it, and at last it was taken off.

“Oh Jeez!.... Dr John, what do you make of the ECG?” It was Dr Kevin, an intern gaping at the waves that showed up on the cardiac monitor. He tugged at the cords and pushed in the plugs… The screens went blank….. and just as immediately the waves showed up….totally unmatching with the variations of ‘pqrst’ waves. The spiral patterns that showed up astounded him. Hitting the button, he promptly obtained a rhythm strip, which he ran through his fingers, trying to make sense of the most bizarre pattern, which he even hesitated to call an ECG pattern. He then handed it to Dr John.

“Hmmm….. this is weird… indeed…….unmatching anything I’ve read so far….. and where’s the pqrst configuration?” Dr John, the bewildered medical specialist scanned the strip over and over again, as if searching for the proverbial ‘needle in the haystack’ among the spiralling pattern of waves.

He scanned the monitor. The blood pressure, heart rate and respiration also showed wide fluctuations not in keeping with someone as stable as the old man appeared to be.

“Check the heart rate and pulse again”. He commanded, trying to get over the embarrassment of the undecipherable readings.

The nurse promptly put a steth to the old man’s chest. “Dr John, it’s way too loud and irregular. I’m sorry but I’m unable to count”. She had pulled out rather too soon.

Dr John decided to not refute her findings, knowing very well that she was the best. Mrs Priya, the Nurse had 10 years to her credit, working in the ICU and the Casualty, and was well known for her clinical skills. Now if she had to report so, things were truly anomalous……

“It’s all right. He appears stable enough to me, though a bit agitated with the activities around him. Just leave him alone”. Dr John gave further instructions to Dr Kevin, and was relieved to hear that the Cardiologist has arrived.

The nurses who struggled in vain to find an access to the superficial veins, with the violently resisting patient, finally gave up…. as the patient’s wheeze got louder and scarier. It appeared much more sensible to let him be and prevent too much of vacillation of the parameters. As they awaited the arrival of the Cardiologist, they wiped away their perspiration, standing in the air conditioned Casualty unit.

Mr Om lay back panting and wheezing, with the relief of having done away with the irritants.

“A case of cardiomyopathy of old age, ….brought in by Dr Terence.” Dr Mehta, the i/c of ER, breezed in, giving a brief of the patient as he escorted the Cardiologist, Dr Kutappa as others gave way for them to pass by. “No relevant history available. Says he is kind of homeless and with no kith and kin. Dr Kevin is already there getting the preliminaries done…….”

“If that’s the case, why is he here?”, Dr Kutappa guffawed condescendingly, “Doesn’t Terence know about the exorbitant costs of diagnostics and treatment regimen here, add to it the other charges….?”

“Not to worry Sir. He was brought in, in a precarious condition. We’ll do a check up and transfer him out to the govt hospital, after the emergency management. But I hear there are some complications……” Mehta motioned to Dr Kevin to give a report on the patient.

“Good morning Sir”, Dr Kevin stammered, “the patient, Mr Om apparently in his late 80s was brought in at around 8.30 am, in a near critical state. No relevant history could be gathered as Dr Terence here is not family and the patient is apparently homeless and a destitute…….”

“Come to the point”. Dr Lalwani studied the client as he shifted about impatiently scratching his greying stubble, “Give me his clinical picture”.

Dr Kevin’s heart hammered in his throat. Never in his career of five years had he been faced with such a gruelling ordeal. A gold medallist for MBBS and MD Medicine, he had always prided in his diagnostic skills and strived hard to be clinically efficient. His reputation was one of the best in the hospital. Anyways, he cleared his throat and launched on whatever he’d strived hard to gather in the past 30 minutes.

“On arrival, the patient appeared to be in a state of shock and was gasping. He was administered oxygen for exactly 10 minutes after which it was discontinued at the patient’s insistence……actually he was too restless. The ER protocol had to be suspended as the patient is highly anxious and uncooperative.” Attempts at gaining access to his peripheral veins failed for similar reasons. At the moment he seems to be slipping in and out of ………”

“His vitals….?”

“Oh God!” Dr kevin broke into cold sweat. What was he to say? … that he couldn’t count the patient’s heart rate?..... his respirations?..... “Sir actually, myself and Dr John here tried our best to ……. Parameters appear weird, showing up with patterns never seen before.” He began to fumble for words……;

“That will do. Let me take a look.” D Kutappa moved forward, rolling up his sleeves.

Dr Kevin was never so glad to step back, as he heaved the longest sigh of relief….!

The Nursing Assistant quickly slid in front of the computer, to type, as was the protocol, when a senior doctor conducted an examination of a patient. This helped save a great deal of time.

The LAN within the hospital further helped to directly communicate with all essential departments, without having the patients or their relatives or friends running about with investigation forms and treatment sheets. The Earth Hospital was indeed excellently equipped to not just treat the patients, but also to reduce all kinds of discomfort to their near and dear ones, besides even having efficient facilities for follow-up care and door-step health care delivery system for their clientele. What more, every health worker in the hospital, right from the senior most doctor to the cleaner were handpicked for their excellent knowledge and skills in their respective fields of work…

“…The client looks pale,.........has cyanosis, .......... peripheral cyanosis.... On palpation…..”, Dr Kutappa stepped forward and held the pulse of the casualty, he continued dictating the preliminaries in a clipped language, while the nursing assistant’s fingers flew adeptly over the keys….. “and the pulse”, …..He held the wrist, “… bounding, irregular,… now feeble,….. huh?” and with a violent jerk, pulled away, as if hit by a high volt current..... His finger tips hurt with the powerful thrust of the pulse…… “Strange..”, he muttered under his breath.

The nursing assistant’s fingers hovered over the keys, squinting at the Cardiologist for his seemingly bizarre behaviour. Being aware of the quirky nature of the senior doctors, he maintained silence and waited patiently… Dr Kutappa, now mildly uncertain, placed the stethoscope over the patient’s chest and tried to look nonchalantly into space ,.. eyes closed…. The nursing assistant turned to the computer, his ears ready to catch his words… “Aaaah!...” was all she heard … and wondered how was he to type it out in the medical report… The Cardiologist had pulled off the steth and was rubbing his ears as if to relieve the ache of some deafening sound.

Not to give up, he placed the diaphragm of the steth over the chest in an attempt to auscultate. Instantly he pulled away, his ear drum aching from the thunderous sounds of the heart beats and the deafening whoosh of the respiration. Maintaining his composure, what with the others watching intently for his verdict on the patient’s condition, he placed his palm over the patient’s chest and he actually felt something rock-hard hitting his open palm. Now what was this? The insides of his palm hurt with the ‘thing’ hitting out! He held his hand there…. perplexed at what should be his next step….. Rivulets of perspiration snaked down his temples and down the back of his neck, …….

Thankfully for him, the client suddenly groaned with pain, prompting him to take away his hand.

“Turn up the AC”. He instructed, as the Nurse Assistant awaited further dictation…..his fingers hovering over the keyboard. Dr Kutappa‘s eyebrows furrowed with growing discomfiture at the confusing clinical picture. Gosh what a shame would it be, to admit to the outrageous clinical (?) findings! He could now figure out the uneasiness of Dr Kevin while he reported on the client….

He gestured to Dr Mehta, to go ahead with the physical examination, while he went ahead to read the monitors. Dr Mehta joined him very soon…… with a familiar puzzled look, which actually calmed the edgy nerves of D Kutappa.

Instructing Dr Kevin to take over, the two made their way to the Doctor’s office. They huddled together and held a quick discussion. Shame!... had they lost their diagnostic skills??.... but whoever thought that they’d be confronted with a weird emergency case as this! This was indeed a strange case..... no apparent threat to life (or, was there?),.... yet the client seemed to be on the verge of collapse....... But the big question was how could they report their colossal failure to the GPs of the ER, and perhaps to the relatives….. or Dr Terence, who seems to be his Next-of-kin?

Then to circumvent the knotty hurdles of a manual examination of the patient, the two began to cite novel diagnostic tests, extolling their unique sensitivity and successes. But no consensus could be worked out between the two. Finally the Dr Kutappa put his foot down literally (though unintentionally) stepping on the delicate foot of Dr Mehta, who squealed with pain and hopped out of the way.

Fervently apologizing for the mishap, Dr Kutappa, sent word for the Nursing Assistant, and hurriedly continued with his dictation.

What followed was a bevy of technicians from the biochemistry lab, closely followed by those from the dept of radio-diagnosis. The client was pulled and turned as he gasped and heaved, posing and giving in to the lethal radiations that hit point blank. They even managed to draw out needed blood samples and rushed to the lab for quick analysis. The red bulb glowed outside the ER indicating that action was in progress within.

The specialists paced up and down more out of anxiety of arriving at a seemingly sane diagnosis than out of concern for the patient.

A little beep made the two of them to jump and rush to the monitor. They peered and pored over the results of the diagnostic tests that flashed " The GPs waited with bated breaths for the outcome....... Inside, the medical specialists peered and pored over the results of the diagnostic tests

" CBC normal, blood profile " normal, urine and stool " normal.

CXR showed a large heart…. Cardiomegaly?

ECG " the waves failed to confirm to the ‘pqrst’ pattern and no conclusion could be drawn

Echo cardiogram " the bizarre picture failed to name a diagnosis

EEG, CAT scan, MRI " The weird pictures put the doctors in a quandary

The now sweating and disgruntled medical specialists had the scan reports sent to the radiologist, for his expert opinion at the earliest.

The patient seemed to be rested and sleeping, after having been given an injection of Nitrazepam as ordered by the med specialist, and appeared to be in no distress!...............

Then what was the problem???

They got back on time after a cup of tea from the canteen outside the ER. The report from the Radiologist was waiting. The report simply stated that the CAT scan and MRI showed cardiomegaly, and the brain showed some abnormally dense areas.

The patient was sleeping still. He showed no signs of any ailment as he lay there. They at last jointly conceded that there was no apparent organic disorder

Dr Kutappa then talked with Dr Terence, “Well, as you see, we have failed to find an organic cause for Mr Om’s problems. We’d like you to put him through a Psychiatric check up, just to rule out… you see. To summarise it all, this appears to be a simple case of severe exertional disorder, and we’ve failed to find any organic cause for it. Hence, I suggest that he be seen by a good psychiatrist. We have Dr Mathai, a renowned Psychiatrist. I’ll put in a word with him about the case. How about tomorrow?”

Terry looked at Mr Om, who was apparently tired out and sleeping after the fight. “Ok then, tomorrow. What time?”

Nurse Nancy handed him the medical case sheets along with the results of laboratory diagnoses. “I’ll make the arrangements and let you know.”

Terry turned the last page of the case sheet and saw the Provisional diagnosis:

Provisional diagnosis : SEDUO (Severe exertional disorder of unknown origin)

* * * * * * * * * * * ***

…………..Continued..

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