Back from the dead

At first glance, there could be little in common between Michael Schumacher and teenager Shyamal Adhikari. But the teenager, who lives in a nondescript lane in north Kolkata's Baranagar, has virtually come back from the dead, much like the Formula 1 legend.
For about two weeks, Shyamal, had been suffering from meningoencephalitis, was in an induced coma ? a near-vegetative state during which all of his physiological functions were performed by machines.The long procedure ? extremely rare, because of the risks involved ? was performed in a government hospital in Kolkata, and left his family emotionally and financially drained. But Shyamal had a miraculous cure. It was slow, but he is now almost ready to resume normal activities. The 18-year-old football lover has not missed a single match played in the recent FIFA World Cup. And though he is not quite able to start playing yet, that's only a matter of time, feel his doctors.
Two years back, Shyamal was sleeping when he experienced severe bouts of convulsions. His elder brother Samar, who was sleeping by his side, noticed ? to his horror ? blood oozing out of Shyamal's mouth. His family members rushed Shyamal to RG Kar hospital.
"When we got the boy, he was unconscious. And the severe bouts of convulsions made the situation worse," recalls Dr Udas Ghosh, under who Shyamal was admitted. "As he had no history of any serious ailment, all we could do was control the convulsions while we ran several diagnostic tests."
What followed was an intense struggle by the doctors to save the boy. The meningoencephalitis was causing an inflammation of the brain as well as of the meninges, the membrane covering the central nervous system. And medicines did not seem to help. Shyamal kept sinking and the convulsive bouts were starting to become uncontrollable. After three days, the boy was shifted to the critical care unit (CCU) and put on ventilation.
"The infection was spreading fast and the boy's condition was deteriorating rapidly," says Dr Sugata Dasgupta, a specialist in critical care. "We decided to put him on induced coma as a last-ditch effort to save him."
Medically induced coma is a procedure wherein the patient is put into coma through medicines ? mostly barbiturates ? in order to put the brain to rest to protect it from further damage. The process, said doctors, has been in use for about three decades but it is not widely used because of the risks involved, controversies regarding the procedure itself and very little documentation on the subject. Schumacher's case has brought it to focus in recent times.
A medical team was created from the department of anaesthesia and critical care medicine, that included, apart from Dr Ghosh, neurologist Dr Arup Dutta. "Through this procedure, we aimed to achieve two targets. First, to reduce intracranial pressure; two, to control the continuous convulsions in between episodes of fits without regaining consciousness," Dr Dasgputa says. He explains that the increasing intra-cranial pressure paused the threat of "brain herniation", which creates extreme pressure on the brain, thereby cutting off blood supply to various parts of the brain. It is a fatal condition.
But inducing coma is easier said than done. The insufficient infrastructure at a government hospital, inadequate equipment ? especially that of an intra-cranial pressure monitor ? and administering the right dose of barbiturates were just a few of the challenges that the medical team had to overcome. "An inadequate dose would mean the boy would not go into coma. An excess dose, however, could prove fatal. We had to walk a very tight rope to conduct the procedure correctly," said Dr Dipasri Bhattacharya, the anaesthesiologist.
In the absence of an intra-cranial pressure monitor, the doctors had to "play blind", so to speak. They had to depend on clinical signs to check whether the artificial coma was serving its purpose. Meanwhile, the CCU staff kept round-the-clock vigil on the boy to ensure that his blood pressure and heart rate were normal. And the nurses ensured that the boy did not get bed sores.
"To be very frank, I was a little shaky when the subject of induced coma was brought up," said neurologist Arup Dutta. "After all, it was something we had just heard about. It happened thanks to the courage of doctors like Dr Sugata Dasgupta, who was ready to take it head-on."
The team of doctors did not want to keep Shyamal on coma for too long, as that could have hampered his chances of bouncing back to a normal life. Therefore, the next two weeks were critical. After noticing clinical signs that the coma was working, the medical team decided to slowly reduce the dosage of barbiturates. And they noticed, to their relief, that the boy was showing signs of improvement. Gradually, the dosage was further reduced in stages as part of the waking-up process.
But reversing the coma was just half the battle won. Shyamal was kept on further ventilation in ICU for almost three months ? not only for treatment, but also to enable him to fully recover from the coma. After that, he was shifted to a general ward. Shyamal remained in hospital for another two months before being sent home. Even now, he needs to go back regularly for follow-on check-ups. But he can now stand up, walk and do daily chores without support.
His father, Swapan, recalls the horrifying ordeal of the hospital stay. "Even as I knew how close my son had been to death, I was not ready to give up. He was too young to die. I requested the doctors to do whatever they could to save him."
Even then, the family was taken aback when the doctors said they had to put him in a coma. "The word ?coma' is terrifying," said brother Samar. "No one wants their near ones to go into a coma. So, when we were told that my brother would be put in a coma, we were distraught. Then, Dr Dasgupta explained what an induced coma was, and how it was the last resort. We agreed readily, as that would ensure my brother a second life."
Samar ran from one laboratory to the other for the numerous tests the doctors prescribed, as some could not be performed in the hospital. The family even had to borrow money so that Shyamal was not devoid of certain expensive drugs that were unavailable at the hospital. The family ended up spending about Rs 5 lakh on medication and diagnostics.
"Even after he was pulled out of coma, my son lay in bed, still as a corpse," said Swapan. "I was afraid that the coma had not worked. But my joy knew no bounds when he responded to my calls for the first time after weeks of waiting and prayers. I could not help myself from bursting into tears. All my pain was gone. Yes, Rs 5 lakh is a big amount for us. But it's nothing in return for a life. All that mattered to me was that my son came back to life."
"People complain of neglect in government hospitals. But all I saw was the dedication by the medical team," Samar says. "Even junior doctors, like Dr Hazra, treated my brother's case as something special. Dr Dasgupta would even call up his staff at 3am to check whether they were monitoring him properly. They were a godsend."
Dr Amitabha Chanda, consultant neurosurgeon with Fortis Hospital, Kolkata, explained why induced coma is not a very common procedure. "First, it is not an easy process. It has got its own limitations, and there are various risks involved," he said. Dr B K Singhania, a neurosurgeon at Apollo Gleneagles Hospital, Kolkata, feels that inducing coma in a patient, especially in the absence of intra-cranial pressure monitoring, is like taking a "blind chance". In India, most hospitals ? even private ones ? do not have this system in place. "After all, inducing coma in a patient is to reduce intra-cranial pressure. And, in the absence of a monitoring system, how do we know whether there is an improvement? That is one reason why such a procedure is rarely used here," Dr Singhania said.
Shyamal is well on the way to recovery, but the football-crazy teen rues that he isn't fit enough to play. "I am still unable to lift my leg high enough to kick the football. But I am confident of playing football with my friends soon," he says.
Director of medical education, Dr S K Bandyopadhyay, lauded the medical team's efforts for skilfully taking up the challenge. "I have heard the boy is doing very well. Despite constraints, the doctors dared to tread a path that not many would be willing to walk."
For Shyamal and his family, it has been a long walk to recovery. But, thanks to the dedicated team of doctors, the teenager lives to walk ? and play football ? some day.