However, I decided to listen to them to see if I can help at all even from far or guide them on to something helpful. I have a profound exposure and experience in management of all types of stones, having worked in some of the top institutes of UK and Australia. My knowledge, experience and skills are methodically backed by my research and evidence-based practice as well as expertise in advanced stone management techniques. Not all the stones need surgery as some can be treated by helping spontaneous passage. I wanted to assess from listening to them as to how best I could help with managing the stone, particularly in this unprecedented situation of Covid-19.

The lady was 58 years old with few medical problems except diabetes. I wasn’t going to be able to travel to Mumbai, nor she was going to travel to Surat during the lockdown. My usual approach is to initially reassure and obtain as much as medical history. My immediate aim was to help relieve her pain and help the family out of that stressful situation. From the conversation I could gather that they knew that there was a stone in the lower part of her kidney (Lower pole calyx). However contrary to her age, co-morbidities (medical problems) and the location of asymptomatic stone she was advised surgery which she had refused. Her reason for refusal was out of their socioeconomic status, as the family had no affordability. However, in my opinion on the medical grounds their decision was sensible considering the location, size, her age, medical conditions and stone not causing major problems. These types of stones can be treated just by observing and a yearly follow up with X-ray or ultrasound scan.

4 days prior to calling me she had developed sudden pain in her right flank which was on and off. With some leading questions I came to know that there was no blood in the urine, and stone had not passed. Her local doctor referred them to urologist. The urologist had organised the CT scan, and she was managing pain with pain killers. Their son immediately sent me photos of films and report, which confirmed a 6.5 mm stone in the lower part of her ureter (kidney tube) causing mild swelling (mild hydronephrosis) of that kidney. She had no signs or symptoms of sepsis and from the scan it was evident that there were no other stones and her left kidney was normal. I have always emphasised to junior doctors or doctors in training the importance of making sure that there is no leaking aneurysm, an Abdominal Aortic Aneurysm (AAA), which is like a timebomb in body, especially above the age of 50 years. This swelling of the big blood vessel in tummy, is extremely fatal when leaking. This can mimic exactly like a kidney stone in the age above 50 and sadly people have lost their lives due to missing the diagnosis of leaking AAA. I made sure there was no evidence of swelling of big blood vessel on the scan. Difficulties were lying further ahead for all of us.

The lady was given a quote of ₹ 2 Lacs (₹200,000) for the operation of her stone by her urologist who advised urgent surgery at any cost. I failed to understand as to how ₹ 2 Lacs was justified for such type of stone sugary and at the same time, I was amazed that during such pandemic such medical professionals attempt to exploit the patients. Family was poor and had no possibility of gathering that much of money at such short notice. They requested the doctor to treat it without operation, but her urologist was firm on his opinion of surgery and stated there is no other option, and if she is not operated soon the lady would be in big trouble. Scared to death, having no money for operation, family returned back home deeply worried as to how to tackle this grave situation. I was humbled when Mr Patil explained that he saw a ray of hope when his son came across my profile on social media and managed to read about me through my website. I was humbled further when he said that he had complete confidence and trust in my capabilities to get her out of her sombre situation and that is the reason they had called despite being aware I was far.

After thorough discussion with Mr and Mrs Patil, and after careful consideration of stone size, location, her symptoms and the kidneys on CT scan I explained to them that I would be able to treat her stone with a treatment option called Medical expulsive therapy (MET). In MET the stone passage can be observed and facilitated by the combination of medications with an option to intervene if necessary. They agreed to follow all my advice correctly, which was most important. For me, it was my little contribution in fight against Covid-19, by helping this poor woman in return of their blessings and nothing else. I started her on combination of medications for MET as well as to tackle infections if any. Her son assured me that he would find the medication same evening. I sent them the name of the medications as a phone message and the son was to call me upon reaching the pharmacy so that I can authorise the medications to the pharmacist. This is what the son did, and helpful pharmacist took my medical registration details and released the medication on checking my authenticity as doctor. Objectives of my treatment were to help spontaneous stone passage, prevent infections and also to control pain. I explained them about 61% chance of spontaneous passage of her stone without surgery. Both husband and wife were happy with the treatment plan and assured me their full cooperation. My advice was open and clear to the family that in Mrs Patil’s case there were three circumstances in which she would need surgical intervention, a continuous pain nonresponding to medications, sepsis or infection and if her kidney functions deteriorates.

My treatment and monitoring were based on monitoring pain level, helping with pain relief, monitoring signs of sepsis and to monitor kidney functions. I discuss with them how they can go about getting her Kidney function tests carried out next day. Since I was not able to give them the instruction in writing, we agreed a solution that they reach the pathologist and I would explain the pathologist what is required. They called me next day upon reaching the pathology lab. I spoke to the pathologist and provided her my medical registration details as well as my contact details in order for her to carry out the Kidney functions along with inflammatory markers. I was glad that all the lab tests came back as normal. One can imagine my stress level of managing a case from far distance in lockdown period, where neither of us are able to travel to each other, making sure that there is no deterioration and making sure the progress is in desired direction. I had given them complete freedom to contact me any time if any problems with her stone disease and I spoke to them daily sometimes few times a day. My backup plan was also ready in case she needed operation and spoke to my friend in Mumbai where free or extremely subsidised surgery could have been possible. I had specifically made them aware that in life threatening situation of blocked infected kidney, she would definitely need a surgery.

In my opinion, it is important to consider surrounding aspects before offering or forcing surgical options and that surgery should be the last resort where possible. Doctors must keep themselves up to date with research, clinical trials and the up to date evidence-based practice as well as the practice guidelines. My knowledge about the evidence-based practice, knowledge of research and trials (in this case knowledge of DUST and SUSPEND trials) and the up to date knowledge of the European as well as American guidelines gives me confidence in treating condition in correct, honest and ethical way. The EAU (European Association of Urology) guidelines and AUA (American Urology Association) guidelines strongly suggests that with uncomplicated ureteral stones (kidney tube) ≤10 mm should be offered observation, and those with distal stones of similar size should be offered MET with α-blockers.

In above background Mrs Patil was managing well with painkillers and α-blocker medicines. Her pain was negligible with fewer episodes. I was particularly making sure that her kidneys are safe and there is no infection. It was the sixth day of my monitoring when that evening Mr Patil called me in excitement telling me that his wife managed to pass the stone. I was rather relieved and happy for Mrs Patil. I also made sure that the stone was intact. The family was ecstatic as she managed to pass the stone and saved ₹ 2 Lacs (₹200,000), which any way was beyond their affording capacity.

Currently I am treating my relative same way and even his case is interesting in different aspect. I’ll let you know the outcome of the case in my next post. Coming back to Patil family, I spoke to them couple of days ago when Mrs Patil informed me that she is now pain free, has no other issues and doing really well. They are planning to make a special trip to Surat once lockdown finishes to thank me personally. It is rewarding and satisfying whenever I am able to help somebody. Pandemics don’t recognise emergencies, but I still hope that during this difficult situation no one should go through these types of problems, which not only put economical and other challenges in front of them but also make compulsion to seek medical opinion and get themselves exposed to coronavirus infection.

MY ADVICE:

• Every kidney stone does not need surgery, some of them can be treated with regular observation.

• In kidney stone patients, fever or rigors (chills) could be an indication of severe infection, which can lead to life-threatening sepsis, don’t delay, see a urologist urgently.

• If you have only one kidney and stone disease its better to get it treated urgently.

• Plain CT scan is the best investigation for stones, blood tests looking for infection signs and kidney functions are necessary.

• Over 50 with kidney stone pain like symptoms should make sure that they get investigated as soon as possible as there could be a leaking blood vessel, which could be fatal.

• Ask your doctor the advantages and disadvantages of the treatment offered including surgery, and the rationally behind their advice.

• Always ask for dietary advice from your doctor for prevention of stone formation.