post traumatic diabetes insipidus

Dear All,
My colleague, Dr. Mistry and I had just about finished an inguinal hernioraphy. A couple of skin stitches were required to finish the operation. I had a dynamic theatre sister, a sister Octavia who had her eyes all over the hospital. Straight from the casualty on a stretcher she brought in a patient in dirty clothes and mud all over him and started moving the hernia patient even before we had finished closing the skin. “Doctor”, she said “I will finish this, you must do something for this patient, I can barely feel his pulse. He has been gored by an elephant and then picked up and thrown”. The story that unfolded later was that on most evenings the mahout would go to the toddy shop and drink his glass or two and he would bring his elephant a bottle of the same. On this particular evening he was short of money and did not bring his elephant his usual drink. The elephant must have smelt the toddy on him and started trumpeting for his drink. It is well known that elephants love alcohol. When he was not given his drink in anger he gored the mahout and then picked him up and threw him.
            On the stretcher we stripped him off his dirty clothes and cleaned him as best as we could. The anaesthetist had already got a line in and fluids were running into him. It was obvious that the patient was in shock, he was cold and clammy. A quick examination revealed a huge wound of entry in the right para-vertebral region, strange to say there was good air entry on the right side but no air entry on the left side of the chest. Based on this one clinical finding I decided to open the left side of his chest. As I left the theatre for a quick scrub I shouted to Dr. Mistry to position him for a left thoracotomy. “Sir”, he shouted back “I am positioning him for a right thoracotomy, the wound is on the right side”. “For God’s sake I shouted back do as I say”. We made a quick entry into the chest only to find the chest full of blood. We shovelled the blood out with a kidney tray and lo and behold what did we find? The lung completely transected at the hilum, just hanging there by a shred of bronchial tissue. We grabbed the hilum with our fingers and put a curved intestinal clamp across the hilum and waited for the anaesthetist to push a couple of units of blood. In about 15 minutes we had a recordable blood pressure. The vessels were ligated and the bronchus was closed with interrupted sutures of black silk. A toilet was performed of the chest cavity, a large dependant drain was placed and the chest was closed. The large wound of entry in the right para-vertebral region was lightly packed with glycerine acriflavine roller gauze. We had no ICUs in those days and so the patient was sent to the ward. By now he had been given eight units of blood. His blood pressure was normal. The owner of the elephant who had promised to pay all costs had disappeared. Putting two and two together we concluded that the tusk that entered the right para-vertebral area had reflected the right pleura missed the heart and the great vessels and transected the hilum of the left lung. He also had a large tempro-parietal haematoma, obviously sustained when he was thrown. The pleural drain was removed on the fourth day and the pack in the right para-vertebral wound was out by the sixth day.
            The patient had become quite a celebrity, and was walking about the hospital and relating his story to curious visitors who came to see him. The father Director, a compassionate priest waved aside all the charges including cost of medicines etc. His skin sutures were removed on the tenth day, we did not discharge him because we thought his para- vertebral wound of entry needed some care which he would not get in his village. Besides we hung on to him because we wanted to enjoy his miraculous recovery for a few more days. But it was not to be the story has a tragic ending.
            On the 14th post-operative morning I had a frantic call from Dr. Mistry. “Sir come soon, I don’t know what is happening”. When I reached the ward there was Dr. Mistry sitting at the patient’s bedside with his head in his hands. He had passed a catheter and there were 15 bottles of clear urine lined up under the bed. “What is happening”, I asked again his reply was, “I don’t know sir. He had a distended bladder, he was uncomfortable, so I catheterised him and urine is just pouring out like a tap”. I phoned up my dear friend Dr. Farokh Udwadia of respiratory and intensive care fame. A brilliant physician and told him my story. There was silence for a long minute and then slowly in a hardly audible whisper he asked:- “Hirji, has your patient also sustained a head injury too”? “No”! I said, “But on second thought I said that now that you ask, he did have a fairly large left tempro-parietal haemtoma for after being gored he was thrown”. “My God” he said “the answer is simple his posterior pituitary must be damaged and he has classical manifestation of diabetes insipidus. Have you got posterior pituitary extract? Have you done his electrolytes?” “Farokh” I said, “where in Trichur can I get post, pituitary extract and my laboratory does not do serum electrolytes”.
            “Hirji”, he said “I shall send you the injections by air but I doubt if it will reach you in time. I am afraid you have a dead man on your hands”. The poor mahout died the next day of severe dehydration. God knows what his electrolytes reading were. You can imagine the gloom that descended upon us all.
This was indeed a freak injury of a very grievous nature. There was nothing spectacular or brilliant about the surgery that was done. There was elementary clinical judgment on ausculatory findings to open the left side of the chest and not the right. In spite of the fact that the wound was on the right side. But luck was against this poor man. To recover from such an injury and then to die was tragic.
 
H.S. Adenwalla

Head of the Charles Pinto Centre for Cleft Lip, Palate

and Craniofacial Anomalies.

Jubilee Mission Medical College and Research Institute

Trichur-680005

Posted by: Charles Pinto <charlespinto102@gmail.com>

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