Greetings of the day !
Mrs Radha (name changed) a 28 year old female was admitted with a history of recurrent vomiting and Jaundice of one day duration to our hospital. She had no history of viral prodrome , fever or any offending drug intake .She was conscious oriented, and had mild icterus .
Her systemic examination was normal. An Ultrasound of the abdomen did not reveal any obstruction in the biliary system .All routine investigations required were sent and the patient was started on supportive treatment.
Although she had mild elevation of Bilirubin and Liver enzymes, her INR (coagulation profile ) was 4 times the upper limit of normal.
While peeping into her liver cell function tests , it was obvious that her liver was failing .She was managed as a fulminant liver cell failure in the Intensive Care Unit of the hospital.
What led to her Jaundice and high INR left all of us clueless.
In the evening at around 8pm the resident doctor on duty got an alert call from the central laboratory.
“Doc! INR of Mrs Radha has prolonged further and it is now 18 times normal”, the technician on duty informed the doctor .Repeat blood test confirmed the deranged coagulation pattern .
She was conscious but this high INR was making her prone to develop an unprovoked internal bleed and death, so the resident doctor called the head of the dept.
“Dr Ibrahim are you at home? Let us see Mrs Radha together,” Prof Prasad (name changed) the head of the department, called at around 9pm.
I immediately changed my dress and headed towards the hospital which is at a walking distance from our residence.
Prof Prasad had examined the patient during the day time but her alarming INR made the astute clinician restless at home .He drove from his home which is nearly 10 kms away from the hospital.
We went together near her bed in ICU and started discussing various causes leading to such a clinical scenario but there was no clue to the diagnosis.
With an infectious smile , Prof Prasad approached Mrs Radha .
He affectionately kept his hand on her forehead.
My dear daughter ,has your vomiting settled”? .
Yes doctor, I feel better now.
Did you consume any medication before admission, we are not getting any clue of your illness till now ?
“No doctor” , Mrs Radha replied .
“Doc ! Do you perform a kidney transplant here in this hospital”? Mrs Radha inquired.
Yes, we do . Prof Prasad replied .But why , Prof Prasad asked her . "You do not need a renal transplant".
Doc! I had an ice cream yesterday .
Yes, yes , tell me more , we are here to help you ,Prof Prasad affectionately said.
What happened then” , everyone takes an ice cream , no need to worry.
Doc! Do you perform Kidney transplantation in this hospital? She again asked the same question.
Yes! my daughter, we are routinely doing a kidney transplant here.
Your kidneys are alright and you do not need renal transplant .
Tell me more , what happened then ,yes go on, we are here to help you”
Prof Prasad affectionately went on in this vein.
I want to donate my kidney to clear the hospital dues because we are poor.
Her voice started breaking .I do not want anyone to be in trouble and a stream of tears started rolling from her eyes on her anxious face. Doc! Please don't tell my home people.
Doc ! I am fed up with family stresses . I do not want to live any more.
Doc ! yesterday when I purchased an ice cream from the market I mixed a bottle of blackish colored rat poison with it .I consumed the whole of it .She went on weeping bitterly .
I know I am dying, let me go peacefully from this world. I request you not to tell my home people.
Our jaws fell in shock, both of us felt speechless .
The answer of high INR was thus solved in a jiffy by her.
But unfortunately we had nothing to offer her .
Intake of Rat poison is fatal and invariably the victim dies.
With every tick of the clock she was certainly treading towards death .
She was too anxious and a dying look was obvious on her innocent face as if she was threatened by the look of an obese person in a jet black dress with moustaches upwards , waiting to pull down the gallows , closing her story for ever.
Only a liver transplant could help her out, but who would donate her liver?
With such a high INR who would be the daring surgeon to operate upon and conduct this hours long surgery. Added to this, they had bitter poverty.
You guessed correctly , it was to ask for the moon.It was shocking to listen to her painful story
We immediately went to the counselling room and called her parents and husband .It was hard to break this sad news . Despite our all efforts days later she breathed her last and that ice-cream proved to be her last ice cream. May her soul rest in peace
To conclude I must emphasize an empathetic approach in any clinical encounter. Alcoholism is disastrous despite its lusty tax returns to the Govt. Further , we must focus to reduce domestic violence .We must identify people with suicidal tendencies .They go aloof for a few days before, appear withdrawn and their sleep pattern changes .Such people must be admitted in a psychiatric hospital before their suicidal attempt.