by Prof Dr M S Khuroo
Over the years I take a second opinion in about 5-10 percent of patients from colleagues/hospitals in town or those from tertiary care centres from other metropolitan cities.
On June 6, 2022 (8.20 am), I received a call to see a patient add-on in the clinic. It was said to be an emergency case.
The receptionist contacted the relative and found the patient admitted to a hospital in Srinagar. On my inquiry, the patient was unwell for four days and on the second day was referred from one nursing home to the tertiary care hospital.
The patient had started with hepatitic illness and had reported abnormal behaviour needing restraint and possible referral to a psychiatrist. I was told that a consultant was to evaluate the patient during morning rounds at 10.30 AM.
By that time, however, I went through the medical record of the patient that the family had sent to me. I counselled the family to get ready to shift the patient to a transplant centre. The Head of the hospital, in the meanwhile, was requested to generate an urgent consultant opinion, ventilate the patient and stabilize the patient’s metabolic parameters.
I contacted the transplant centre. A referral was made and the patient was shifted to the centre in an air ambulance by late afternoon, that day.
I had a detailed discussion with the team of doctors about patient status and received regular updates (verbal and written). The patient had a high INR, severe cerebral oedema, renal failure, pneumonia, and systemic infection. Protocol for acute liver failure was instituted including plasma exchanges and many parameters were stabilized.
A live donor liver transplant (LDLT) for survival was felt mandatory. Multiple relatives were evaluated and rejected as donors based on the volumetric evaluation. I along with the patient’s family contacted several transplant centres in town and other cities including Hyderabad and Chennai but it proved difficult to get a liver.
I advised the family to be patient and hope for the best. On June 12, a cadaveric liver was available in town and the patient had a successful deceased donor liver transplantation (DDLT). Alhamdulillah, the patient is on a road to recovery as of now. I continue to be in touch with the treating team about the patient clinical status and with family for counselling.
This patient, unfortunately, had an explosive life-threatening illness, which has a high mortality (over 80%) and a successful liver transplant gives hope to save around 2/3 of patients. Emergency/urgent liver transplant for acute liver failure is rather complex and many patients die waiting for a liver or unavailability of a liver or being in the healthcare without a liver transplant centre. This patient’s story tells all that.
I am indebted to the medical caregivers of town including nurses, young doctors, consultants, and administrators who successfully transferred such a sick patient to the liver transplant centre. This tells us the story that our medical system is vibrant. Of course, the tertiary centre did a phenomenal job. The family members need a special tribute and appreciation as they went all the way to serve their loved one. I did my little bit to understand the seriousness of the situation, contact the transplant team, advise the urgent transfer and continue discussing management policies with the team. I believe all this is an excellent disposition for good healthcare for patient survival.
To conclude, the second opinion is sought by a primary physician who he feels will benefit from another doctor/Institution for diagnosis, management, therapeutic intervention, or life-saving surgical procedure. Over the years I take a second opinion in about 5-10 percent of patients from colleagues/hospitals in town or those from tertiary care centres from other metropolitan cities. Principles of seeking a second opinion by a primary physician are well depicted in this referral and the accompanying slide.
(Leading gastroenterologist, Dr Khuroo is a scientist, who headed SKIMS earlier.)