The AIIMS Reports: How Jayalalithaa got unwell and died, according to doctors from Delhi

In a surprise move, the Tamil Nadu government on Monday released the entire set of medical reports on Jayalalithaa’s health as maintained by the Apollo Hospital in Chennai, and also the 5 reports filed by the various doctors from AIIMS, Delhi. The doctors from AIIMS made multiple visits to Apollo Hospitals in Chennai to treat the late Chief Minister and consult with the team treating her.

The first visit of the doctors from AIIMS was on October 5, and they stayed on till October 7. The team of doctors included Dr GC Khilnani, Dr. Anjan Trikha and Dr. Nitish Naik.

VISIT ONE

The doctors note in their first report that Jayalalithaa had diabetes mellitus for 20 years and was under medication for that, and that she also had a history of asthma and bronchitis. She also had hypothyroidism and features of irritable bowel syndrome, according to the doctors.

The treating team at Apollo informed the AIIMS doctors that she was admitted on September 22 with ‘history of feeling uneasy, altered level of consciousness and low blood pressure.’ She had fever and leukocytosis (high white blood cells count) at the time of admission.

She had fever for 7 days before the visit of the AIIMS team, which was due to a urinary tract infection, for which she was given oral antibiotics. She also had ‘atopic dermatitis’ (Atopic dermatitis is a chronic eczematous skin disease that usually begins in childhood.  Acute atopic dermatitis produces weeping, oozing plaques of very itchy skin.), for which she was given corticosteroids. Her urine culture had E. coli, and she received anti-fungal treatment for the same. Her diabetes was uncontrolled.

She was on oxygen support, given injectable antibiotics and several other oral antibiotics. Tests showed that she had mitral annular calcification (a degenerative process in the heart linked to ageing) and mitral valve regurgitation (a valve in her heart was leaking blood).

She was also suffering from repeated breathlessness. She received diuretics and antibiotics, which brought her fever down and white blood cell count improved.

According to the AIIMS doctors, on September 28, she had severe breathlessness and was not responding to treatment. She was sedated, intubated and put on mechanical ventilation. The mitral annular calcification and mitral valve regurgitation continued. Her blood pressure was stabilized through medicines.

On the day AIIMS doctors visited, October 5, they say that she was on full ventilator support and x-rays pointed to a pulmonary oedema, which is excess liquid in the lungs. The AIIMS doctors suggested tracheostomy, which is an incision made into the windpipe to help the patient breathe properly. Dr Naik suggested immediate surgery, but due to the high risk, the suggestion was not taken. On October 6, her condition remained same, and it was conveyed to government officials. The traceostomy was finally done on October 7 at 4:30am, and it was completed without any untoward incident.

At this stage, the late CM was characterized as ‘critically ill’ by the team. The doctors wanted aggressive physiotherapy, and control of infection. With this, the first visit of the AIIMS doctors ended.

VISIT TWO

On October 9, Dr. GC Khilani returned to Chennai for another visit. When he reached Apollo at 10pm, there was a change in Jayalalithaa’s condition in the form of “increasing lung shadows in the X-ray of the chest”. Due to this, there was change in her “respiratory parameters”.

“I opined that the change in the health condition was because of collection of pleural effusion (collection of fluid in the cavity covering the lungs) on both sides,” he writes in the report. It was decided by the doctors to intensify therapy to drain the fluid.

She also had urinary tract infection and the same bacteria cultured from there was found in the secretion from the lungs (“tracheal aspirate”). Antibiotic “Meropenem” was decided on based on the “sensitivity report”. She continued to be on full support through mechanical ventilation. Diabetes was controlled with intravenous insulin therapy.

Dr Khilnani visited her again on October 10 at 8 30am, and Jayalalithaa was stable and on life support. It was decided to continue Meropenem for total period of 7 days. To hasten recovery, the team decided to reduce sedation and liberate from mechanical ventilation. Dr Khilnani returned to Delhi after this.

VISIT THREE

On October 13, Dr. Khilnani and Dr. Trikha were in Chennai again. Dr. Naik joined them on October 14.

When Dr. Khilani and Dr. Trikha visited Apollo on 1.30pm on October 13, Jayalalithaa was still on life support and there was collection of fluid in her pleural cavity (lung cavity), which was drained externally with a pig tail catheter. She was responding to verbal commands and communicating with lip movements. She also retained unassisted movement of her legs and feet.

She was receiving injectable antibiotics. CT scan of the chest and abdomen was done, for which she was sedated. On October 14, Khilani and Naik reviewed CT scan reports. All specialists had a meeting in the office of Dr Prathap Reddy to decide next course of action. It was decided to not do any active intervention for pleural effusion and continue with ongoing treatment: negative fluid balance and life support.

An hour-long video conference was arranged with Dr. Russel, a cardiologist of John Hopkins Institute, with all treating physicians. Dr. Russel agreed with the line of treatment decided.

On October 15, Jayalalithaa was better and her blood oxygen parameters showed improvement. After this, senior minister and govt officers (including chief secretary Rama Mohan Rao) were briefed about Jayalalithaa’s medical conditions. The team told the officials that she would take a few weeks to recover completely. The ministers and Prathap Reddy appreciated AIIMS sending the team thrice on short notice.

The team returned to Delhi on October 15.

VISIT FOUR

On December 3, the AIIMS doctors returned to Chennai again, but this time Dr. Nikhil Tandon, an endocrinologist from AIIMS, also accompanied the three doctors. This was just a follow up visit, and the doctors were told that Jayalalithaa was improving well and undergoing physiotherapy. She was fully conscious and required minimal respiratory support. She could sit on the chair for 20 minutes, but could not stand. The team suggested that she undergo physiotherapy to improve further. At this stage, Jayalalithaa seemed to have been recovering well, according to the report. So, the team returned to Delhi the same evening.

VISIT FIVE

On December 5, Dr. Khilani, Dr. Trikha, Dr. Narang and Dr. Devagorou reached Chennai at 5pm on and went to the hospital, where Jayalalithaa was in the ICU. The team had visited four times before, and this was a follow-up visit.

In a briefing that took place with Dr. Prathap Reddy, the team was informed that Jayalalithaa had suffered a cardiac arrest at about 4.30pm on December 4, 2016. She received cardiopulmonary resuscitation for 45 minutes. After this, an open cardiac massage was done and she was put on ECMO (extracorporeal membrane oxygenation) and external cardiac pacemaker.

ECMO is a process in which functions of the heart and lungs are carried out outside the body using a special machine.

She was also put on hypothermia (her body temperature was reduced) and was on continuous dialysis.

While Jayalalithaa was not responding to external stimuli, the neurologist opined in the meeting that her true neurologic status could not be ascertained due to hypothermia.

It was then decided to bring her body temperature back to normal. Her status would be assessed a few hours after normal body temperature was attained.

At 10pm, her status was assessed after normal body temperature was restored.  However, it was found that Jayalalithaa was not responding.

“On clamping the ECMO tube, there was a rapid drop in blood pressure, indicating that the heart had no function. Also, on momentarily switching off the pacemaker there was a straight line on the ECG monitor. There was no neurologic improvement as opined by the neurologist. All parameters denoted ‘futility’ of life support,” says the report.

Following these observations, another meeting was held under Dr. Prathap Reddy. After a detailed discussion, the team of doctors and specialists agreed on the “futility of life support in view of clinical parameters”.

It was decided in the meeting that the team would discuss Jayalithaa’s current clinical parameters with her family members and relatives and take the next step.

The report of the doctors ends by stating that the team returned on the morning of December 6, 2016, implying that she was removed from life support on the night of December 5.

GEETIKA MANTRI & RAMANATHAN S

Courtesy: thenewsminute.com

 

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