Hektoen International

A Journal of Medical Humanities

The patient on the brink

Ravi Shankar

A look over the Western Ghats of India.

The St. Xavier’s hospital in the village of Ellakkal is in a magnificent location nestled in the Western Ghats of the Idukki district in the Southern Indian state of Kerala. The Ghats are a series of hills that reach about 2,000 meters high and run parallel to India’s west coast around 75 kilometers inland. The hospital is about twenty meters above the winding, blacktopped road on one of its small green hillsides. Here the mornings are clear and the river can be seen meandering its way through the valley floor far below. In the evenings the clouds come down slowly and drape the mountains as the light fades and the hills darken—brooding shapes waiting for the dawn to awaken them from the slumber of the night.
St. Xavier’s, once a major medical center in the region, slowly declined in importance as other hospitals sprang up and a multispecialty hospital opened in Adimali around twenty-five kilometers away. The hospital was run by a group of Roman Catholic nuns, the Medical Sisters of St. Joseph, who were competent, efficient, and caring.

It was to this hospital that Ramu1, a short, swarthy, muscular man in his thirties with a thick moustache, came complaining of fever and severe muscle pains. We decided to admit Ramu and keep him under observation. He was decidedly worse by evening rounds. The muscle pain had increased; the conjunctiva had acquired a muddy tinge. We were beginning to suspect leptospirosis or rat bite fever, and decided to keep the patient under close observation. He was started on a course of parenteral crystalline penicillin.

At around nine his condition had worsened. We did a platelet count, which was the best we could do in our limited set up. We had already carried out routine blood and urine investigations. The anxiety within the hospital was accompanied by an equally wild night outside! The wind was fierce, the rain was pouring down, and lightning flashes were frequent. The power failed.

The patient was rapidly deteriorating. His level of consciousness decreased. His blood pressure was dropping. Working by candle light, we started an intravenous line. We had only crystalloid fluids, but we started a dopamine drip in the other arm.

The blood pressure was 90/60 mm Hg, but holding steady. Around midnight the patient took a further turn for the worse. He became unconscious; there were hemorrhages on his conjunctiva and some on his skin. We were keeping vigil by his bedside. His family had gathered outside the room. The patient was too sick to be referred to other centers, and we had to try to stabilize him.
Around one o’clock in the morning the blood pressure plummeted. The sister decided that the patient was beyond us doctors and she called a priest. The priest was soon at the bedside, and the patient’s father also came. The ritual took about ten minutes, and then the priest left convinced he had prepared the patient for the after life.

The blood pressure was around 50 mm Hg systolic. We decided to continue our ministrations while there was still life. A blood urea and serum creatinine test was carried out and showed a high value. The patient’s kidneys had shut down from muscle breakdown and low blood pressure. The best we could do was to keep him alive till sunrise and then see what could be done. The night was tense and busy.

The morning dawned clear after the stormy night. The patient was still hanging on. The blood pressure had risen to 90/60 mm Hg, the patient was stuporous, and we decided to send him down. As the family members had managed to rent a jeep, we sent him to the hospital at Adimali with the intravenous fluids running. A sister went along to keep the intravenous fluid line patent and monitor the patient.

We later heard that the patient was eventually sent to the Medical College over 150 kilometers away where the diagnosis of leptospirosis was confirmed. He received dialysis, and survived. We were relieved and pleased that so much had been achieved with so few resources.

About two months later, we ran into Ramu in the market place. He was thinner and looked fatigued. My colleague told him that this was his second life and he was lucky to have survived. His new life was a gift from the Almighty, and he was to handle it with respect and care. Ramu agreed and said he would give up alcohol, stop gambling, try hard to get a regular job and take better care of his wife and children. He would be a different man in his second life!


  1. His name was changed to protect his privacy.

DR. P. RAVI SHANKAR is a Clinical Pharmacologist and Medical Educator at KIST Medical College, Lalitpur, Nepal. He is interested in trekking and photography and is fascinated by the magnificent Himalayas. He writes short stories, poems and travelogues and is keenly interested in the Medical Humanities.

Highlighted in Frontispiece Volume 2, Issue 1 – Winter 2010

Winter 2010



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