A RACE AGAINST TIME TO SAVE A LITTLE HEART

At 11 AM during a busy Friday clinic, I saw Baby N with her mother. The baby was 2 months old and was referred to me by her pediatrician because of feeding difficulty and a murmur. Her breathing was faster than normal and her liver was enlarged. I could hear an ejection click and an ejection murmur at the base. I had a fair idea what to expect when I commenced the echocardiogram and I suspected the baby had severe aortic stenosis due to a congenital bicuspid aortic valve. Of greater concern though was that her left ventricular function was starting to deteriorate because of the constant need to pump against an obstructed valve. She had moderate ventricular dysfunction. The obstruction would need to be relieved ASAP before the heart function further worsens

The procedure of choice in this scenario is a balloon dilatation of the valve to relieve the obstruction. The balloon is passed backwards from the femoral artery which is the main blood vessel to the legs. When such a procedure is done in small babies, there is a risk of injury to the delicate blood vessels of the body and hence specialised hardwares (catheters, guide wires and balloons) are needed. Most large pediatric cardiac units routinely stock such balloons on their shelves. But when you are starting out and based in a tier III city, it is a luxury to be able to have expensive hardware readily available. Even before I spoke to the parents, I quickly called Mr Jayaraman, the Cath lab store manager and asked him to enquire about the availability of the Tyshak Mini balloon of the size I needed. I spoke to the parents and appraised them of the need for a procedure urgently and they agreed to undergo the procedure the very next day.

Within the next 1 hour, a representative of the stockists for the ballon contacted me to check my requirement. He confirmed that the balloon was only available in Delhi and appraised me that he had already set in motion the process for moving it to my hospital. He anticipated that the balloon would reach the hospital in the early hours of the morning. Because of the tight time frame available, he suggested that the procedure be planned after 10 AM in case of unexpected delays in transport.

Our cardiac catheterisation lab had a few complex procedures planned between 2-5 PM on the Saturday and I was loath to do a procedure on a sick baby late in the day when everyone is mentally and physically exhausted. With the next day being a Sunday, further delays would mean waiting till Monday morning. We reasoned that noon would be the best time to start the procedure.

The balloon was to be airlifted from Delhi to reach Chennai by 10 PM. A representative of the stockist would wait at the airport and then ship it to a courier office which agreed to take the shipment on one of its late ferries to the South. The cut-off time for the courier service to receive the parcel was midnight failing which they could only ship it the next day.

As fate would have it, the flight from Delhi was delayed. With each nail-biting minute, the chance of sending it by courier continued to recede. Finally as the clock stuck midnight, we realised this needed an alternate transport modality. The stockists then contacted drivers of public and private buses plying passengers between the 2 cities to see if they could carry it with them on their journey. A kind hearted government bus driver, who was booked to drive a passenger bus from Chennai to Madurai at 2AM, agreed for the proposal. The flight landed at 1 AM and the stockist received the parcel at 1.30 AM. He rushed to the bus stand at the other end of the city to deliver his precious load before the bus started its journey and reached just as the driver was warming his vehicle

We anticipated that the bus would reach at 10 AM based on normal travel timings and prepared for a noon procedure. But the stars were not inclined to listen to our plans and the bus was delayed by traffic hiccups along the way. As the clock ticked passed 10 AM, I was reminded by the cath lab managers that the procedure will need to be completed before 2 PM. They did not believe we will start by noon and were gently cautioning me to have realistic expectations. Mr Jayaraman who had been in constant touch with the stockists as well as the bus driver, realised the predicament and drove on his motorbike to wait at the entrance of the bus stand even before the bus reached. He called me at 11.45 AM to update me that the bus had entered the city and asked us to go ahead with starting the case at noon. As we prepared to wheel the baby in, I received another call confirming that he had received the balloon and just as I obtained the vascular access, the cath lab technician walked in triumphantly carrying the balloon. I anticipated that the procedure would take more than an hour. To my pleasant surprise, we had exhausted our share of procedure related uncertainities and complications even before the baby reached the catheterization lab and we completed the procedure without a hitch. By 1 PM, the baby had reached our recovery room and was in the mother’s lap

I acknowledge my cath lab team of doctors, nurses and technicians when I post on an interesting intervention but always forget the back room team involved in planning and executing the procedure. Mr Jayaraman’s job profile did not involve using his personal vehicle to ship hardware from the bus-stand to the hospital and standing in expectation under the hot noon sun would hardly be advisable to a man with chronic health problems. Yet he took it upon himself to do his best to ensure the procedure happened on time. This was not the first time he had bailed me out of a tight corner by raising above the confines of his job description. This was not a balloon I use regularly (I would buy one balloon a year) and the stockist was likely to earn only a few hundred rupees from the transaction. If I were asked to wait in the airport for hours on end and dash across the city in the middle of the night for a paltry sum, I would not have cared to be polite in declining the offer. But when I told him that a small baby needed it and delaying the procedure by a day may not be in the baby’s best interests, Mr Shiva never bated an eyelid and was actually thankful to me for providing me an opportunity to help the baby.

When I reviewed the baby in clinic yesterday and noted that the function was already back to normal and the residual obstruction was only minimal, my mind immediately went back to the numerous back room players who ensured that I was in a position to help the baby at a critical juncture. I was trained to perform such procedures and helping Baby N was my professional calling. I could not take any special credit for helping the family. My cath lab team thrived on the adrenaline rush of performing and assisting critical procedures in sick patients. Mr Jayaraman, Mr Shiva and his team as well as the unknown bus driver who refused to constrict themselves to imaginary shackles of job parameters were the true heroes for the baby girl. Their race may not have been Usain Boltesque (on the contrary it was built on undue delays and a creaking 50 cc motorbike), it brought as much joy as 9,58 seconds on a mid-summer evening at the greatest stage of all.

P.S. Although I have taken some literary liberties while writing this post, the timelines described in the story are entirely accurate