How doctors at Aster go beyond diagnosis to ensure optimal outcomes

Around 6pm on September 11, a 40-year-old named Anto was admitted to Aster MIMS Hospital in Kozhikode. He was transferred from another hospital in Vadakara, after he showed severe pneumonia symptoms and breathing difficulty. Soon after his arrival in Aster, Anto died of cardiac arrest.

A day earlier, two other patients―a nine-year-old boy named Rizwan and his 25-year-old uncle Raheem―had been admitted to the hospital with similar symptoms. Dr Anoop Kumar, director of Aster North Kerala Cluster (Critical Care), was already looking into the cases. “Since we came to know that Rizwan’s father, Jalal, had died showing similar symptoms just two weeks earlier at a local hospital, we were on high alert,” said Dr Kumar. “We came to know that Jalal had a multi-organ failure, and he died without a proper pathological diagnosis.”

Raheem, Jalal’s brother-in-law, said pneumonia was diagnosed as the cause of death. “He was in ICU first and later on ventilator,” Raheem recalled. “Back then, we (Raheem and Rizwan) had no symptoms. But within 10 days, I got fever and Rizwan developed breathing difficulty along with fever. And, by September 10, we both were admitted to Aster.”

The Aster team found out that Jalal had developed diplopia (double vision) and slurring of speech―unusual in pneumonia cases, hinting at a potential brain problem. Rizwan also showed pneumonia-like symptoms and generalised convulsions, and was on non-invasive ventilatory support.

“A patient with pneumonia-like conditions, but developing convulsion, suggested that there is brain involvement. Also, we could observe the formation of a cluster from the primary case (Jalal),” says Dr Kumar. These clues led investigators back to the events of 2018, marked by a Nipah outbreak originating at Soopikada near Perambra, Kozhikode, which had a profound impact on the state. In 2018, Dr Kumar played a pivotal role in detecting the outbreak early and taking measures to contain it.

The current cluster of patients emerged from Maruthonkara, a place close to the epicentre of the 2018 outbreak. But their predominant symptoms differed from those observed in the 2018 patients. So, alongside the ongoing Nipah investigation, Dr Kumar and his team decided to concurrently explore the possibility of new emerging viruses.

Anto was brought to Aster at a time when Dr Kumar’s team was sending the samples of the Maruthonkara patients and two of their relatives. The Aster team initially faced difficulty in determining the epidemiological link between Anto and Jalal. Anto’s relatives then revealed that, in the last week of August, he had attended to his father-in-law at a private hospital in Kozhikode―the one where Jalal had also sought treatment.

That it was another Nipah outbreak was soon confirmed. The state health department swung into action, initiating containment measures and comprehensive contact tracing. “This left us with two patients: the adult was under my care, and the child was under the treatment of Dr K. Sathish Kumar, senior consultant in the paediatric ICU,” says Dr Kumar.

This treatment was a milestone in the annals of medical science. “For the adult patient, we started an antiviral drug called Remdesivir, which was initially used in Covid management and later on in Ebola management; there are some animal studies in Nipah patients also. For the boy, we used a drug called Ribavirin. But as his condition was worsening, we had to put him on ventilator support. The brain MRI scan showed that even his brainstem was affected, which resulted in his poor prognosis. But then he started responding to our treatment and, after seven days in ventilator, came back to life.” The boy’s recovery marked the first global instance in which a Nipah patient who was on a ventilator regained health.

At times, even after diagnosis, the doctor may need to understand the intricacies of the case and go beyond typical solutions. The case of Hariharan, a 34-year-old from Kochi who had a urinary problem, illustrates this need. For almost six years, Hariharan suffered from frequent urges to urinate. Even a minimal amount of urine in the bladder would trigger so irresistible an urge that activities like travelling or watching a movie became impossible for him. His life became miserable, and he had trouble staying hydrated.

An overactive bladder typically responds to medication, but Hariharan’s troubles continued even after taking medicines. No one could identify what was wrong. Hariharan finally sought treatment at Aster Medcity, Kochi, where he consulted Dr Kishore T.A., senior consultant in urology. Recognising the intricacies of Hariharan’s case, the urology team at Aster Medcity explored alternative treatment avenues.

Dr Sandeep Prabhakaran, senior consultant and program director in LASER Endourology, investigated the case. “The action of the urinary bladder is controlled by sacral neurons. Recognising that the hypersensitivity of the bladder is caused by the neuronal output, we decided to modulate these outputs,” said Dr Prabhakaran.

The Aster team identified that an implantation surgery, utilising an electronic device called InterStim, could effectively neuro-modulate the sacral nerve and solve Hariharan’s issue. “What we did was to place an implantable device near to sacral neurons. This device sends mild electrical pulses to the sacral nerves and modulates the sacral neuron overactivity,” said Dr Prabhakaran. “Within two days, since we implanted this device through a minimally invasive surgery, the patient could revive his normal life.” This was the first instance in Kerala of a patient suffering from an overactive bladder receiving sacral nerve neuromodulation surgery.

Every day, the advances in medical technology introduces new solutions. It is crucial for health care professionals to stay abreast of latest technologies and ensure optimal outcomes for patients. Dr Umesh Srikantha, senior consultant of neurosurgery and head of spine services at Aster CMI Hospital in Bengaluru, illustrates this with a recent case. The patient, a 72-year-old Bengaluru resident named Lakshmi Gopal, sought treatment at Aster CMI with a diagnosis of vertebral body fracture. “I had suffered a fall, and I was experiencing severe lower back pain,” Gopal told THE WEEK.

Said Dr Srikantha: “Her issue was diagnosed before she came to us: One of the [back] bones had fractured, and that was causing her so much pain.”

Addressing such issues used to require open surgeries involving the placement of screws and rods to stabilise the fracture. But advancements have led to a percutaneous method―inserting a special balloon into the bone, inflating it, deflating it, and filling the resulting cavity with cement.

But the balloon method had some drawbacks, including the risk of bone collapse upon deflation. Considering the age-related risk factors for Gopal, doctors decided to do vertebral stentoplasty, a novel yet intricate vertebral augmentation procedure.

A team of skilled neurologists and neurosurgeons collaborated on the procedure. “In this innovative technique, a stent―a metallic cage―is inserted into the cavity to prevent the bone from collapsing. During the procedure, the stent was inserted along with the balloon in the vertebra, and the balloon was inflated with the objective to raise the collapsed vertebra,” said Dr Srikantha. “Upon inflation, the stent was also expanded and it remained so within the newly created vertebral cavity even after the balloon was deflated. The cavity was filled with bone cement to support the bone surrounding. This swift procedure, lasting less than an hour, resulted in significant post-surgery improvement, enabling the patient to walk comfortably without assistance.”

Gopal became the first patient in south India to undergo this surgical intervention tailored for the elderly. “The surgery provided instant relief, and she regained the ability to walk within just 24 hours,” said Dr Srikantha. “Moreover, this procedure has demonstrated long-term benefits, enhanced the patient’s posture, and diminished the occurrence of back pain.”

Some names have been changed.