The baby was “almost dead”, but doctors did not give up
On the mend: Little Clevan in good hands at the Negombo Hospital
Lifeless, the baby was brought on November 2 from Munnakkara. Just six months old on November 1, Clevan Aashel had three big ‘Fs’ intent on snuffing out his young life – liver failure, renal failure and respiratory failure.
Touch-and-go it was – but he was brought to the right place even though it may not have been the right time.
He should have been rushed in earlier, but he arrived at the Emergency Treatment Unit (ETU) of the Negombo District General Hospital on the evening of November 2.
His mother Ayesha Iroshini says that on October 30 (Saturday), Clevan her precious firstborn, had fever and they showed him to a doctor close to their home. The doctor and the parents assumed that the fever was due to teething and so they went back home and gave him paracetamol syrup. By November 1 (Monday), the fever had dropped but the next day Ayesha felt his forehead to be rasnei (warm) again.
When she made ready to dress him up for another visit to the doctor, “baba amuthu vidihata biththiya paththata harila hitiya” (the baby who had turned towards the wall looked strange) and his eyes had gone up. With a sinking heart, the parents rushed Clevan to the Negombo Hospital.
The baby was “almost dead”. There was no pulse, no blood pressure and no respiration (he was not breathing) and he had a fit (seizure) at the ETU. All that the doctors could hear through the stethoscope was a very faint heart rate indicating that the heart had not stopped………yet.
The ETU, as was usual, called the paediatric team and when the doctors ran to the baby’s side, they could not get intravenous access to pump in vital medicines, fluids or blood products, as his veins had collapsed. Promptly, they resorted to ‘intraosseous cannulation’ to give him saline. [Intraosseous cannulation means placing a sturdy needle through the cortical bone (dense outer surface of the bone), in the case of Clevan it was the tibia or shin and into the medullary cavity (the hollow part of the bone which contains bone marrow.]
What ailed the baby, wondered the doctors, not ready to give up the fight for the little one’s life even though the odds seemed stacked against him.
Dr. Lakkumar Fernando
They contacted the Clinical Head of the Centre for Clinical Management of Dengue & Dengue Haemorrhagic Fever (CCDDHF), Negombo & Consultant Paediatrician, Dr. LakKumar Fernando, while Consultant Paediatrician Dr. Krishan Thalgahage arrived on the scene.
It was Day 3 of fever and most fever fits occurred on the first day, sometimes the second day but rarely on the third day. Immediate blood tests included the Dengue NS1 antigen test.
The important bed-side antigen test, the results of which came in 15-20 minutes, pointed them in the direction of dengue, saving precious time for right management, before the full blood count indicated that the baby’s platelet count was just 6,000 when it should be between 150,000 and 450,000.
With an ultrasound scan showing “heavy” leakage of fluid to both the baby’s lungs as well as abdomen, the team determined that it was not plain and simple dengue but Dengue Haemorrhagic Fever (DHF) which had descended into Dengue Shock Syndrome, DHF’s final and often fatal stage.
“The picture became grimmer as the other test results came – liver enzyme level was over 5,900 indicating prolonged shock,” says Dr. Fernando, stressing that most medical teams would have given up in despair, but they did not!
Dr. Fernando was on leave, looking after the Dengue Unit online and on the phone from home. Looking back to that Tuesday evening, he says the prognosis for such dengue and, more so, for an infant was “extremely poor”.
According to data shared by dengue expert Prof. Siripen Kalayanarooj of the Queen Sirikit National Institute of Child Health, Bangkok, Thailand, (who has been a great supporter in Sri Lanka’s war with this viral disease spread by a mosquito), if prolonged shock is untreated for over 10 hours, the tragic consequence is death.
If prolonged shock with liver failure is untreated for over four hours, there is only a 50% survival rate; if there is both liver and renal failure there is only a 10% survival rate and if there is failure of three organs (liver, renal and respiratory failure), the survival rate is nil.
Leave or no leave, Dr. Fernando and his team at ground level were not about to give up. The battle began armed with evidence-based medicine, unrelenting hard work and monitoring and skill.
With his in-depth knowledge of dengue management, he made a ‘clinical assumption’ that the baby was at the end of the critical stage of fluid leakage, as there had already been very heavy leakage.
It was Day 3 of fever, he deduced, with fever starting on October 31 (Sunday), the fever continuing on November 1 (Monday), reduced feeding and lethargy and on November 2 (Tuesday) development of seizures. “I concluded that the baby would complete massive leaking in a short duration,” he says.
The challenges came fast and furious – no Intensive Care Unit (ICU) bed that could be used to ventilate (provide life-saving breathing support) for the eight-kg baby. With every minute, nay second being critical, they rushed him to the Premature Baby Unit (PBU) and put him on a ventilator meant for neonates (newborns).
The management included switching between dextran slow infusions, albumin, blood, fresh frozen plasma, cryo and saline, along with tiny doses of frusemide based on physiological principles to keep the vascular, tissue and renal perfusion, while addressing liver failure and adequate urine output.
That very night around midnight Consultant Surgeon Dr. Ashoka Wijemanna had rushed to Negombo from Colombo and secured intravenous access by doing a femoral ‘cut-down’ through the right groin of the baby.
The efficient management and care of the baby began showing signs of success. But just as Dr. Fernando, Dr. Thalgahage, Dr. Wijemanna and the team breathed a slight sigh of relief, came an “unexpected” but “major” event. The baby began bleeding from the femoral cut-down with a possible blood loss of around 50-60ml.
Even though busy on an important Zoom call, Dr. Fernando alerted Dr. Wijemanna, who once again went to the baby’s bedside and stemmed the significant blood loss, while the team gave a blood transfusion.
Thirteen long days after, the little one is on the road to recovery. He is off the ventilator with oxygen saturation being 100%, while breathing on his own from last Sunday (November 7).
The slow feeding had started on Day 4 (96 hours after admission to hospital), bringing a relieved smile to the faces of his hapless parents.
Now mother Ayesha is “godak sathutui” (very happy) because Clevan flashes her a cherubic smile and gurgles “aww, aww” when he sees her.
As the unsung heroes of this major life-saving effort – Dr. Fernando, Dr. Thalgahage, Dr. Wijemanna and the doctors and nurses of the PBU, the Paediatric Unit and the Dengue Unit – go about their routine work, many who have been around the baby whisper that it is a miracle.