Weekend diary - NJH

The weekend at NJH starts on Friday evening. There are hardly any weekends when it is not busy. And we usually end the week with quite a number of surgery cases which has been inadvertently postponed over the week days to the end of the week.

However, this weekend was different. Friday evening was madness. I find out at 4:00 pm that there are no filled up oxygen cylinders in the store. The reason - the fellows in the store were fighting on who would go to fetch cylinders on Thursday morning. And they kept quiet about it for the next 2 days - inspite of realising that the hospital was hopelessly busy. Both the culprits got a piece of my mind for their slackness. Later, we arranged for oxygen cylinders to be procured from the nearest town, Daltonganj. We usually procure our cylinders from Ranchi. The costs in Daltonganj are more than twice that of Ranchi.

There were a total of 5 surgeries posted. However, the morning started with a sudden discovery of neck stiffness in one of staff kids - who was down with fever for the last 7 days. We had presumed that it was viral in the beginning and later malaria and later enteric. Considering his VIP status, we had to refer him to a pediatrician in Ranchi. The parents were quite upset and all of us took a decision that I should accompany the patient. The OPD looked busy - but there was no other option. Dinesh and me were on our way quite oblivious of what would be happening in hospital. I knew that I had to be back soon as I was on duty.

Nandu started the theatre list with an elective cesarian section which was soon over without much confusion or complications. This was followed by the dilatation and curretage of one of our staff who had a missed abortion. Kindly pray for this lady who had the abortion for a second time over the last year.

However, poor Nandu did not know that it was just the calm before the storm. The next in line was a middle aged lady who had come with bleeding per vaginum. Nandu had looked quite carefully for some clinical or sonological evidence of malignancy. However, to his horror, when he operated, there was malignancy of the uterus extending to the the pelvis.

There is another side story of this lady - when she came to us, we told her of our willingness to do a hysterectomy if everything is fine. Later, she asks us how much it will cost. We tell her that it would be about Rs. 10,000. Later, she tells us that she will have to sell part of her land to pay that much. So, we ask her how much she can pay without selling off her land. She says Rs 3000. So, we agree for Rs. 3000 and we congratulated ourselves that we have prevented her from selling off her land which could be sustaining her family. There has been enough research which shows that medical costs in India push quite a lot of people into poverty.

Unfortunately, it seems now that she has a long way to go. The family is so poor that I wonder whether they would be able to afford any sort of further treatment. Radiotherapy facilities are only available in Varanasi which is about 200 kms from here.

Earlier in the day, Nandu had admitted a little girl of 7 years with intestinal obstruction. She was stabilised by then and was ready for surgery. There were quite a lot of things inside the little ones abdomen. A Meckel diverticulum, a constricted portion of the small intestinal and multiple adhesions of the intestines. All of the problems were taken care of and by the time Nandu was getting out of theatre at 7:30 pm, word came from the labour room that a Cesarian section needs to be done. The LSCS passed uneventfully and he was ready to go home by 9:00 pm.

The hysterectomy and the intestinal obstruction was interspersed by yet another incomplete abortion which needs a cleaning of the uterus. The surgeries had taken up so much time that one of the burns patients on whom we were planning to do skin graft had to rescheduled for the next week.

Meanwhile, I was in Ranchi with the staff's kid. The consultant pediatrician was not very convinced about my suspicion. But his attitude changed when he saw the peripheral smear report - toxic granules with a shift to the left. The little fellow who was feverish and stiff in the morning was sitting quite comfortably in the examination room munching a chocolate bar. The pediatrician decided to do a lumbar puncture along with the routine investigations. The staff called me as I was on my way back - to tell me that the lumbar puncture was confirmatory of bacterial meningitis. The boy has been admitted to the Children's Hospital at Ranchi.

While I was doing the consultation with the child, our engineer was doing shopping for the hospital and ensuring that all the empty oxygen cylinders are filled up. We started back from Ranchi by around 7:00 pm - and reached NJH by 10:30 pm.

I was welcomed back at NJH with a overflowing labour room and a cent per cent full hospital wards. Labour patients were still pouring in. To supplement, a middle aged lady was brought in - bitten by a yellow and brown snake at around noon. Her family had completed all formalities of taking her to the traditional healer and the village quack before they noticed that she was bleeding from her mouth. She came in almost 12 hours after the bite. Her clotting time was much beyond 15 minutes and she is going into oliguria. I've already pumped her with 12 vials of anti-venom. The problem of acute renal failure and the need of hemodialysis was explained to the bystanders. They look quite poor to even pay the costs of the anti-venom.

Meanwhile, I thought that the crowd in the labour room was coming down. I somehow got time to go home. Shalom, my son was sick throughout the day. He had got up at 1:00 am for a snack. He was happy to see me back. Just as I thought of getting couple of winks, there was another call. 2 ladies had simultaneosly arrived in labour. The first one was in early labour and did not need much intervention. The second one was quite complicated. She had 4 episodes of convulsions since morning. But her blood pressure was normal and urine albumin was nil. So, eclampsia seemed unlikely. Later one of the bystanders told me that she had fever and vomiting 3 days back - was treated by some quack. I examined her - there were features of meningitis. We don't have facilities to do CSF examination - that's the first priority after Angel joins from Monday. Therefore, started off on antibiotics. She has settled so far.

I thought that I had enough to write a blog - and started to write this. Within ten minutes, I had my next call. One of the pregnant patients at term in the ward admitted with a low lying placenta for observation suddenly started to bleed torrentially. I had no option but to take her up for Cesarian section. As soon as this was over, another patient who had been in labour room with decreased fetal movements started complaining of absent fetal movements. She was also posted for Cesarian section. By the time everything has sort of settled down, it is 4:00 am.

As I was finishing suturing up the second Cesarian section, there is urgent call from the Emergency Nurse - there is a young man brought in with a krait bite. I ask her to start off the ASV. He is lucky to have come fast. The best part was that the relatives have brought in the culprit snake - the biggest banded krait that I had ever seen - which will be the only snap for this blog - but quite worth it. We are only half way into the weekend and what a day it has been... I wonder what is in store for us today...

LOST CHILDHOOD

Last 3 days, I've been travelling. Had to go to Kolkota to make few major purchases for the hospital. Everytime I travel, there is some theme into which I get fixated on and try to explore its' various facets in the places I visit. As I left the hospital, I was wondering about the topic I would focus on my present trip. Well, it did not need much of thinking. I was drawn into one of the worst shames that developing nations have been forced into inspite of rapid strides of development happening in many of such countries especially India.


Child labour - I know there are people who try to justify the situations into which children get into by which their getting into work become imperative in the sustanence of the family. However, I just could not help not putting my view on the whole situation.


The first child whom I observed on the journey was someone who I'll called PP. We found PP sitting and washing dishes in the hotel in Kuru where we stopped for breakfast on the way from NJH to Ranchi. I tried to talk to him. But I was very much aware of couple of pairs of starring eyes from inside the hotel which gave me quite a fright. PP was quitely sitting and washing all our plates. However, I got a time to chit chat with him as I went out to wash hands. I asked him if he did not enjoy school. He told he had no other option as money was required in the family. And food being a scarce commodity at home, working in a hotel did wonders as there was plenty of leftovers in the evenings to take home. And, PP did not look malnourished. He was quite plump. But of course illiterate - maybe 10-12 years.


We were in a hurry - so could not ask more questions. Anyway, this route is quite a regular one for me and I plan to ask PP more about himself over the days.


As we stood waiting for our train in the station, we could see hordes of teenage boys who were waiting to jump into the unreserved compartments of the Howrah Express. All of them trying to make a living for themselves in the bustling alleys of Kolkota - the city of joy.


Once you reach Kolkota, I was quite taken aback by the fact that it was

mainly in restaurants, road side eateries and tea shops that child labour had a marked presence. Boys cleaning the tables and washing dishes were a common sight in almost all places of food or drink. I somehow managed to capture in picture a boy of maybe about 8 years cutting pototoes early in the morning before the Ezra street in Kolkota buzzles with activity.

It is not quite difficult to somehow make a connection between child labour and food/eating joints. Many of the families send their children to these places as there is assured food at the end of the day. I can understand this connection for all places except tea shops - however, the number of tea shops where I found child labour always had some amount of things to eat too.

I've heard about child labour in sweat shops, glass and carpet factories, but most of them happen without much notice - very discretely and behind heavy curtains. I get the feeling that the open existence of child labour in the unorganised fast food sector is an indication of lack of food security in quite a lot of families of our community. It is sad when families have to make their children work for the sake of food.

One more aspect of the children whom I found working in such food joints was that most of them looked quite healthy. Obviously, they were well fed at the end of the day. The question was about what they were eating. From the hotel where PP was working - it was not a place where you would want to eat for two consecutive days. Puris and vegetable dripping in oil and hydroxygenated fat laden and heavily sugared sweets ruled the roost. So, that could have accounted for PP's overweight if not obesity. I noticed it in many of the other eateries too. The only malnourished ones where in the Chai shops.

I know that I cannot make any inferences here. But, there is a wealth of insights to be extracted here about the lives of the a part of the futuof our country. Lives which are totally dependent on how to get food at the end of the day - I sometimes wonder about the values being instilled into them as they wait for the end of the day to get their portion of leftovers.

Story of our dam...

I thought that I had already written about this somewhere. I know I had lectured about this in couple of meetings.

Somebody recently asked me if I had written about it in my blog. I thought I had - but later found out that I hadn't.

We have a pretty dam near our hospital. It is quite a welcome relief to most of us as we go there to chill out after a week of hard work. Many of our staff have developed good skills in fishing on that dam. It is however recently that I discovered the sinister side of the dam.

This discovery came during the process of a needs assessment of our local community in health and development. One of the major problems that our region faces are frequent intervals of long standing drought. The last one was from 2009 to 2011. We would have been in really big trouble if we did not have rains during monsoons this year. There have been similiar situations before. There was one famous famine here in 1967 which quite a lot of people remember quite vividly as there was a lot of external assistance from abroad when people got to eat many alien foods. There have been anecdotal references of how people viewed biscuits from abroad with quite a lot of suspicion and would feed them to cattle before they themselves tried it.

Around the time a decision was made at the higher levels to construct a dam. As everywhere else, it was met with quite a lot of opposition. There was one person who was allegedly killed for leading the opposition to the construction. Nobody knows much about why the construction was opposed. However, the pro-dam lobby ultimately had its way. About 25 villages were submerged and they were relocated. All these villages were supposedly givent the right to earn their living from the dam.

Now, the whole picture is how the people were adjusting to the droughts prior to the construction of the dam. The area used to be quite fertile though dry and the local population was very much used to cultivation and use of millets for food. Rice was one of the the many crops which were practiced. Along with rice, finger millet (ragi/madua), pearl millet (bajra/jowar), little millet (samai/sawai) and kodo millet were common cereals produced in the region. In addition, during good rains, vegetables very cultivated. The dry, arid, occasional rain fed area was very much favourable to a mixed pattern of farming.

The dam changed all of this. Rice was being purported as the miracle grain for the future. India was in the threshold of the Green Revolution. The major victim was the millets - many of us never thought that later we would be regreting about this. We have enough research at present which shows the superiority of millets in almost all facets of nutrition over rice and wheat. The damage which has been done is so much that a common weaning substance for infants, finger millets is hardly available in the region.

Now, we had been having discussions in the communities about reintroducing millets into their diet as well as cultivation. It was then that we realised how much the dam has damaged the ecosystem. The dam was supposed to have increased the rice production. Unfortunately, over time the local farmers realised the dam would not be able to supply them the altogether required amount of water. For the rice, they needed quite a lot of water. The droughts had been so fierce that releasing water from the dam has been a great challenge.

The paradox was that because the dam had come up, the soil had become too wet for any millet cultivation. Thus the idea of going back to millets did not find much takers. In addition, some form of prejudice towards millets as a poor man's food arose which further alienated the community from millet cultivation. Someone came up with the idea of vegetable cultivation - it was a good idea. But, the only problem was marketing. With the poor law and order situation and the frequent bandhs in the area - there were hardly any buyers. Still, quite a lot of villagers cultivate vegetables. The only problem being - last year, I remember occasions when okra (bhindi) was being sold at 75 paise per kg, tomatoes at 10 rupees for 5 kgs, garlic at Rs 30 per kg, radish at Rs 1 per kg and squash for 2 Rs for 5 pieces.

I'm very sure that this story is not unique to Tumbagara area. There have been many instances of environmental, ecological and behavioural revolutions due to similiar man made projects. Here, we see that the problems initially look very subtle, but over the years it assumes monstrous proportions that affect entire communities suffer without their own knowledge.

Meanwhile, all of us including my son, Shalom enjoy the quiet environs of the dam quite oblivious to the damages and changes that it has done to the communities which were displaced and even those live downstream.

2 Eclampsias and 1 Rupture Uterus

Just wanted to put in notes about 3 out of 5 patients who came with complicated childbirth over a period of 48 hours. All the 5 cases are impossible to imagine in a modern obstetrics. While I was doing my graduation in Trivandrum, we were taught that to have an ecalmpsia in the community is criminal. Regular ANCs should ensure that early identification of pre-eclampsia is done and progress to eclampsia is prevented. Unfortunately, in quite a large portion of the country, ante-natal check up is a distant dream to many. Even when there is ante-natal check ups, there are doubts on the validity of the exercise in many places. I have come across instances where the ante-natal check up is put as done, but not even blood pressure is taken.

For all the 5 ladies, the experience has been a journey through the valley of death. They could have died any moment. A journey which could have been prevented at the departure point.

LD, 25 year old married since the last 1 year hails from a very poor family. Although, she lives with her husband in a remote area of Latehar district, about 30 kms from the hospital, when she became pregnant her family was well aware of the need for regular check ups. Her husband, SS, who has studied till 6th helped her make the 15 km ride to the nearest health centre every month for the antenatal check up. However, since the last week, her husband noticed that his wife was getting a bit blown up especially her legs. Later after 2 days, she developed on and off headache. The family thought that it will settle off. However, things went out of control on the 22nd July midnight. LD started to have convulsions. There were multiple convulsions and she had become unconscious. There was no vehicle available in the village. So, they had to wait till the morning to get a vehicle from the nearest junction.

They went straight to the district headquarters - where they went straight to a private hospital, who told them that nothing can be done. It was about 12 in the afternoon of 23rd July when LD reached NJH. By the time she reached, her husband had lost count of the number of times that his wife had convulsions. She was unconscious with a GCS of 3/15. Her blood pressure was 180/110 with Urine Albumin of 4+. Thankfully, the baby was still alive. Her platelets was 96,000/mm. However, her liver enzymes were normal. She was progressing into what is known as the HELLP syndrome.

We took her up for delivering the baby by surgery. The surgery went off uneventful. The baby was sick with an Apgar of 5 and 8 at 1 and 5 minutes respectively. Considering the number of seizures she had, she has made a great recovery.

SD's story is also very similiar. The difference is that she hails from the other adjacent district, Garhwa. Married for about a year, she started to have convulsions on the evening of 23rd. She was taken to a private hospital in Garhwa where the family members were told that she has too low a hemoglobin and so needed blood transfusion. However, the seizures continued. So, they continued to Daltonganj, the district headquarters of Palamu where she was asked to take to NJH. She arrived in NJH sometime in the midnight. The baby was already dead. SD was hardly breathing. We took a decision that the baby needs to be out. To put her for normal delivery would take quite a long time and put her organs in stress. The decision was taken to operate and deliver the baby.

Under general anesthesia, the surgery was done. However, SD went through a very uncertain phase. She was not breathing well. Then we had to put her on the ventilator. Today evening, she has become conscious, but still groggy. She has been maintaining good saturation. The next 48 hours is going to be crucial for her survival. We pray that she would not have any further complications. In addition, she needs blood - her hemoglobin remains at 5 gm%.

The last story is that of MD, 25 year old mother of a 3 year old boy. She had an eneventful pregnancy although her first child was born through Cesarian Section. Unfortunately, the place where she had been going for her regular check ups thought that she can be delivered normally. The decision turned out to be tragic if not lethal. Her pains had started yesterday early morning. Somehow, her vaginal dilatation progressed without much problem. The problem started just around afternoon when she started to push after the nurse had decided that the vaginal outlet was fully dilated. We do not know for how much more time they tried. However, the husband took a decision to bring her to us at around 2 pm.

She reached NJH by around 5:00 pm yesterday evening. The snap you find here is not something we regularly find - the abdomen looking like a Bactrian camel's hump. My medical officer thought it was a Bandl's ring. I opened it. It was butchery inside the abdomen. The uterus was ripped open with the lower segment looking more like mashed meat. I had to get my surgeon, Nandamani to put back the uterus into place, as I could make heads or tails about the distorted anatomy. In addition to the rupture uterus, MD had collections of pus within the pelvic cavity. I've no idea how this has occured.

The encouraging thing is that MD is doing good 24 hours after the surgery.

All the above 3 patients along with the 2 other patients about whom I did not mention here could have contributed to the maternal mortality of the state. The lessons to be learnt are very obvious. The million dollar question is of us taking these issues seriously -

1. Availability of trained doctors in the taluk hospitals or at least the district hospitals. There has been so much talk about the FRUs. The problem here is that you need to have the specialists of obstetrics, anesthesia and pediatrics if you need to manage any of these 3 patients. In addition to this, you need to have the necessary medicines and other infrastructure. The challenge is that the probability of having all of these together at a point of time is very rare. This is where we need to encourage the speciality of family medicine in our country. There used to one more speciality aimed towards both Maternal and Child Health from the National Board. Unfortunately, both the specialities have been given a step-motherly treatment by the medical fraternity of the country.

2. Availibility of transport for sick and antenatal patients in labour. You need not live in a rural area of India to realise how difficult it is to obtain transport especially when it comes to transporting the sick. Many of the states have made quite a lot of impact by making free ambulance services (called 108) in most areas.

3. Uncertainity about treatment. The training of medical personnel in the country has taken a turn for the worse. It is not uncommon to find doctors not knowing how to manage a common conditions. I've seen many clinicians behaving like magicians - trying one medicine after the other - citing personnel experiences. There is enough material available on need for practicing evidence based medicine. Unfortunately, these things have not reached the grassroot level. This is where establishment of protocols and stress on following protocols in patient management needs to given priority. The implementation of a system of re-licensing through continuing medical education programmes needs to be on the hot-list of government priorities in streamlining healthcare.

I know there are many more lessons for us to learn from these stories. The final question is ultimately whether we as healthcare providers care for the people of this country. I know that this blog would be read by people from various parts of India who are well settled in places abroad and has made a name and fame for themselves in various clinical specialities. The unfortunate aspect is that when research is being done on how to do intrapartum surgery on the unborn fetus and we have state of the art ultrasound facilities to visualise fetus' faces intrautero, we have mothers who die because there was no one to take a decision to give Magnesium Sulphate for a eclamptic patient, no one to teach proper ante-natal care to the batch of nursing students, no one to teach evidence based medicine to students in a regional medical college. . . ultimately, no one to care for. . . Do I hear whispers of sarcasm, or prayers for the young healthcare fraternity of this country to rise to the challenge?

Romance with the railways... the saga continues

Railways has always been a fascination for me and my brother since childhood. I think it all started with us living near the railway tracks in Kollam, Kerala (then Quilon) early in our childhood. I remember going to the terrace of our home in AG Nagar and watching the trains come and go in the Kollam railway station. It was quite easy during that time to recognise trains - especially the New Delhi-Trivandrum Kerala Express with its distinct yellow-green livery, Himasagar Express (Kanniyakumari to Jammu Tawi) with Blue and White livery, the Venad Express (at at time running between Trivandrum and Ernakulam) with its 2 double decker coaches. Unfortunately, the colourful trains soon changed to the drab brownish marroon coaches over the time and then to the present colour of blue.


My heart used to race when I read about the fast trains of France and Japan. I used to look for an opportunity to go near the tracks and watch the goods trains being shunted around. Our biggest break came when Dad decided to take us to Delhi and Pathankot to visit our cousins. Both of us kids were quite excited at the prospect of sitting in the training for about 3 days. And man, we enjoyed the trip. The highlight of each day used to be the pantry guys who used to bring all sort of lip smacking stuff. I got introduced to the North Indian delicacies like the Potato Bonda which I still look forward to have during any trip.


In those days we did not have double lines in our part of the country. There were only diesel engines. Electric engines were a far cry and it was quite difficult to imagine 2 parallel lines So, it was quite exciting to see faster moving electric engines and trains zipping in the opposite direction along the parralel lines as we travelled towards Chennai or Delhi. Our nearest station with electrification used to be Jolarpetai. During the many trips to Delhi, both of us used to keep awake on the first night of the journey to see the electric engines at Jolarpetai.

As we grew up, the excitement never faded. Waking up early or keeping up late to watch the train pass over big bridges in Vijayawada, Rajamundry and Dehri-on-Sone, looking forward for the bolis, vegetable cutlets and masala dosas in the Bangalore-Chennai and Coimbatore-Chennai day trains, waiting to buy Mango Jelly in Vijayawada, Kozhidode halwas in Trichur, lemon tea along in and around Asansol, Aloo Bondas in the Alleppey-Dhanbad express, surfing the youtube for snippets of trains in different parts of the world - all of them was quite normal stuff.

 

Angel with Shalom
in the Chennai Mail

Shalom drawing his selection of trains.
His favorites are the
Garib Rath and Rajdhani Expresses

After getting married, the relationship with the trains continued. Angel was posted in Palakkad and with me in Vellore, the relationship with trains got cemented. We used to alternate going to each others places by train. During our first pregnancy, the journeys continued and we used to wonder what effect it will have on the baby. The effect showed within a week after the delivery. We decided that Angel will be along with her parents with newborn Shalom for couple of months before she came back to Vellore. Shalom slept all the way from Katpadi to Tiruvalla in the train. He was just about 2 weeks old.

Charis enjoying time in the
Delhi-Ranchi Garib Rath

As Shalom grows, when I see the excitement on his face when the mention of trains is made - I know where it comes from. The best part occured couple of weeks back - we could not get train tickets to go to Chennai. So, Angel and kids decided to fly. After getting into the flight, Shalom insisted that he deplane and take the train. He could not find any reason to be in a flight.

Our second one, Charis is also not far behind. Although she is not as excited as Shalom about trains - train journeys does not bore her. She behaves quite well and knows exactly what to do. She insists that she eats pantry food. Nowadays, after couple of unsuccessful attempts of carrying packed homemade food, we find it easier and lighter with pantry food - both kids prefer that to whatever we pack. Quite a blessing for families like us who have to make at least couple of long train journeys each year.

SNAKES

It was quite recent that one of my colleagues in a sister hospital informed that he had 11 cobras inside his house and had to kill them. So, I thought that I should put a blog on my experiences with snakes in NJH. I've not seen any cobra, but quite a number of kraits and vipers.

My last encounter with one was couple of weeks back when I went to visit one of my colleague sometime late in the evening. The sight that greeted me as I entered the courtyard was unbelievable. There was a 1 feet long krait sitting directly under the light above the gate and having a feast of insects who were attracted to the light. As I stood watching the spectacle, the fellow noticed my presence. To my surprise, he did not mind me watching him and continued with the feast. However, my paternal instincts convinced that the fellow could be a potential killer and decided to finish him off. So, off came my sandals from my foot and he was dead after 2 sharp blows to his head.

Now, there are few photographs which I took over different times. Hope that I would remember the story behind each one of them.

The first one (on the right) is this 6 feet long viper which one of our nurse-aides killed while returning from the evening ladies fellowship. It was one of the largest vipers that many of us had ever seen, because of which there were quite a number of photo-opportunities for quite a long time. Unfortunately, I was busy with something and managed only couple of snaps.

The second snap is of a pair of kraits (on the left) which we found lodged in one of the crevices behind the doorframe of the ultrasound room. One of the nurses almost got bitten by one of them. It took quite a great deal of patience to coax both of them out of the crevice and kill them. Sorry for the gory picture. We are taught to go for the head. And sometimes I wonder why - especially our chowkidars beat these creatures to such a pulpy mass that identification becomes difficult.

It is not uncommon to hear of snake stories almost every alternate day in the hospital especially immediately after the rains - someone killing a snake somewhere, snake found under the bed, snakes in the toilet, snake coiled around the stove. Then we have the occasional bizzare ones which we hear from patients.

The best one I heard was 2 months back. One of the patients came with cobra bite - not one, but multiple - on the palm of his hand. The story was that the unfortunate victim who was on his way back from work was quite heavily drunk with alcohol and thought that the cobra which was on the road was a good piece of leather which he could use to keep his dhoti in place. Well, you can imagine what would have happened next. He was lucky to have a close friend of his coming just behind him. He was brought quite fast to emergency here. By the time he came, his hand was swollen up like a baseball and we had to go for a fasciotomy to relieve the compartmental syndrome which was setting in. By God's grace, he made a quick recovery.

However, in spite of the umpteen number of snakes we find here - I do not remember of anyone narrating any incident of any staff getting bitten by a snake. Even, yours truly had 3 very close encounters with snakes - kraits being the culprits all the time - the last one where I had stepped on a coiled fellow with my bare feet. How true is the promise we have in Christ where Jesus promises us, his disciples, about the protection we will have from snakes and scorpions (Luke 11: 19).

PEDIATRIC BURNS

VM, aged 4 years was sitting along with his mother on a late April morning. Although winter was long over, the chill in the air was enough for VM's parents to get a fire going to boil water for bathing. VM still complained that it was cold that his mother wrapped a shawl around her son. His mother was busy with all the morning's cooking and other activities. VM's shrill cries caught her attention - her son had accidently gone too close to the fire where water was kept for boiling. The shawl had caught fire. By the time they could put out the fire, the damage was done.

VM along with his parents and little sister lived quite far away from the main town. There was only a single bus service to the village - and it was quite jampacked that very few of the villagers planned to make a trip to town. VM's father worked in the local Catholic school. In fact, it was the association that NJH has with the Catholic dispensaries through the Global Fund Tuberculosis Programme that helped VM to come to us after being burnt.

After VM got burnt, both the parents did not understand the gravity of the situation. They requested the local nurse in charge at the Catholic dispensary to provide them with some burn balm. The nurse got suspicious and asked that she see the burns. She understood that things were quite bad and VM required urgent treatment. Somehow, she convinced the parents to take VM to a good doctor. The parents took VM to various doctors in the nearby town of Daltonganj. They were refused treatment at all places - everybody advised that he needs to go to a higher centre.

This was when, the nurse calls me and asks whether we could take a look at VM. VM arrived at NJH at around 12 pm, about 7 hours after the incident had occured. It was a terrible sight. The boy had burnt both his arms, front of his chest and neck. In addition to dehydration, compartment syndrome was setting in both the upper limbs. I somehow convinced the parents to allow us to do a fasciotomy of both the limbs.

I knew this was going to be a tough case. The boy was in the ward for about 2 weeks - unfortunately, the parents were not willing for a tangential excision and skin grafting. The wounds started to heal on its own. Then, they wanted to go home - and even intensive counselling did not yield any results.

The family left for home. Somehow, we got in touch with them - again thanks to our network through GF TB work - and counselled the family again on the need for regular treatment. Unfortunately, the scars were causing contractures, which thankfully alerted the family to seek medical care. VM has come back to us last week. Nandamani did some amount of contracture release of his limbs yesterday. Kindly pray that the family will be able to understand and heed our advice on further management.

Once more, we have a family where things could have been prevented at various levels. First of all the burns could have been prevented had the parents been a bit careful. The healing could have been faster and more appealing if they agreed for a tangential excision and skin grafting.

NEGLECTED BURNS

Mrs PD never imagined that her habit of alcoholism can put her into so much trouble. As usual, PD had her usual evening binge and was having a good time. She thought that she would do better with one more go of the local drink (Hadiya) when she lost balance and fell backwards on the open fireplace where she was simultaneously cooking food.

The incident was sometime in the first week of June. She was brought to us where one of our medical officers saw her. She was not willing for admission and wanted only some local balm and injections. She went off home with the medicines - not heeding for admission.

She turned up after 3 weeks - saying that the wounds have worsened. And this is what we saw. I don't think I need to describe this grotesque picture of her legs. A part of the major burns is on her buttocks which I did not include in the picture for obvious reasons. I'm not sure if she had put any other local application.

We knew that we had to act fast - escharotomy and skin grafting was decided. We went ahead and wait to see how the grafts have taken. The wounds needed about 3 sittings for total debridement before she could be taken for grafting. The wound over the buttocks were a bit too deep as we could see the schiatic nerve (the main nerve to the leg).

Kindly pray for this lady. We need to work on this lady's life - Alchoholism among village women is a serious issue in this part of the country. Availability of home brewed liquor called 'Hadiya' makes the issue more worse. Pray that we would be able to look at options of having qualified people who would be able to counsel such patients.

PNEUMATIC WAR HORSE - A TRIBUTE TO A SILENT CHAMPION

This piece of blog I write to salute a silent champion and life-saver to many, who completes 5 years of service in our hospital. Her speciality has been to save patients whose respiratory efforts fails following some disease - the most common cases happening following cobra or krait snake bite, organophosphorus poisoning, and eclampsia.

The reason we did not have her till 5 years back was that most of her clan members came at a very high cost. They used to cost something between 700,000-1,200,000 Indian Rupees. They still cost the same. Till her prototype was locally manufactured by an anesthetist. Of course, she would not claim to be able to do the many intricate functions her fellow clan members boast about. But, she could do the most important function which we needed - and that was to ensure that we pump in oxygenated air into the lungs of a sick patient unable to breath.

The cost was about 60,000 Indian Rupees. The design was very simple. I understood it out only recently. It comprises of a wiper engine (the ones we use in vehicles), collapsible corrugated rubber bag and some basic electronic circuits designed to control the extent of collapsability of the rubber bag by which determine the volume of air needed to pump into a patient's lungs. She was called the Newmon Ventilator.

She has stood the ravages of time. Seen couple of surgeons, umpteen number of nursing staff and students, 3 Medical Superintendents and must have saved at least 300 patients. It was only recently that her recent boyfriend - our Engineer - told me that her collapsible bag usually does not last more than 3-4 years. We made the discovery about the bag only recently when she refused to respond to our manevoures and we had to open her up. We've tried contacting her original makers about replacing the collapsible bag, but had no response. In addition, she had her internal wiring bitten away at least couple of times by rats, which again was rectified only by our engineer.

Now, the hospital has become busier - we've realised that we need at least 2 more of her siblings. Since there was no response from her original makers, we scouted elsewhere. And we've found a company in Delhi who makes similiar machines and encouragingly with more functions. However, they cost extra - excluding freight and road tax, it is about 150,000 Indian Rupees. We were planning to buy two new machines - but with the increased cost, we can afford only one as of now, and that too because of kind financial help from churches in England through Dr Colin Binks. FRCS who served NJH from 1981 to 2009.

Neverthless, I salute our Newmon ventilator - who served us well for the last 5 years. With her new friend, the engineer, we have grand hopes of her serving us one more stinct of 5 years.

Arachnid Horror

First of all a warning to those who may not be used to seeing lot of blood and bad wounds.

Little NV (5 yrs) was playing outside his house on evening of the 25th of June, 2011 when he was bit by a spider on his right leg. The spider was a bit larger than the usual ones. His parents did not take take it much seriously - but the leg had turned into a funny colour by the next day morning and it was started to swell up and few blebs developed around the site of the bite. He was taken to the local quacks who gave him some injection and medicines. However, the leg continued to pain and swell.

NV was brought to NJH on the afternoon of 27th June. The snap of his leg is shown here. It looked toxic and the muscle compartments were very tight. We explained to the parents that the leg looks quite bad and we would need to do a fasciotomy to release the tension of the inflammed muscles. To make matters worse, there was evidence that one of the nerves of the leg was damaged. There was foot drop. His parents did not find the prospect of putting incisions over the already discolored and damaged leg, logical as part of the treatment.

We started him on antibiotics, put a splint for the foot drop and started regular Magsulf dressings on his leg. Unfortunately, the leg was becoming worser. The skin started turning into black. Now, the parents somehow gave consent to go ahead with a fasciotomy - however, we feared the worst. More worrying was the black colour of the skin.

We went ahead with the fasciotomy. The skin had by now become completely black. We decided to take off the black skin and plan skin grafting. We've done that in part of the leg - and is waiting with bated breath on the outcome. The only encouragement has been the healthy tissue beneath the ischaemic skin.

I'm sure that not many of such cases would have been seen. It looks more like a snake bite. Had it not been for the piece of leg of the traitor spider carefully kept safely by the parents, we would have definitely put the blame for the same on a snake bite. But, then, there was no systemic signs of any envenomation. However, it is quite difficult to comment on whether the spider bite alone could have resulted in so much damage. The parents had taken him to some local practitioner immediately after the bite. However, he had no systemic problems.

Kindly pray that NV would make a quick recovery - especially that his nerve damage is reversed. We also need the parents to remain patient about the recovery of their son. If they suddenly decide to take him away all our efforts will go to waste.

Being Thankful

Since the day I joined here, the major crisis that I faced was the absence of rains in this region since the last 2 years. The prospect of a severe drought loomed large. Unfortunately, the drought continued. So, it was very much necessary that we have rains during the present monsoon season. Somehow, this region called the Palamu commisserate was famous for droughts since time unknown. In fact, the origin of EFICOR, the indigenous Christian relief agency happened here during one of similiar droughts in the 1960s.

Some of the photographs of the drought are put here. It was very depressing. Within the hospital, we spent about 400,000 rupees more during the last financial year (April 2010-March 2010) just to ensure that we had water. We dug 4 new borewells. 2 of the borewells, one of which went 600 feet deep did not yield even a single drop of water. By the last week of March 2010, we had to come down to supplying water for just about one hour every day. I feared that there will be tensions from patients and staff. Thankfully, nothing happened. The water situation was worser outside the hospital campus. The geology department reported that the water table has gone down by almost 40-100 feet in the whole region.

We knew that we needed the Lord's mercies. Many of our friends and well-wishers joined us in prayers for rains. The monsoons arrived in the Malabar coast ahead of time, giving us hope. I happened to be in Trivandrum during the arrival of monsoon - I was there for 8 days and it rained continuously 7 days. I prayed that this would happen when we reach back to NJH.

We arrived back at NJH on the 13th. It started to rain the same night. And it did not stop for the next 3 days. After couple of days it started to rain again continuously for about a day. We were overwhelmed by the Lord's mercies. The rains were too much that it was difficult to comprehend. Our pond filled up. However, the extent of drought which haunted us for the last 3 years was evident when the water level in the pond went down by about 8-10 feet whenever the rains stopped. However, the most unfortunate aspect which I noticed during the rains was the total unpreparedness of the local government in any form of watershed management. It was depressing to see rain water running off into the streams and the rivers.


I wish that our Community Health Department over this year, would be able to do some amount of work in motivating local villagers through the Panchayati Raj institutions to do some amount of work themselves to harvest rainwater and increase the water table in the region.

After we had the rains, we decided to thank the Lord in a unique way. We did it by holding a worship session in the middle of heavy rains beside the pond which was getting filled up. It was an unique experience for all of us. None of us gave any care to the rains wetting us or the slush dirtying our clothes. It was so refreshing and the Lord has been blessing us with regular rains on and off so far. The water table is still lower than normal - but we are certain that the Lord is at work and will give us adequate water from now on.

We've started plans to plant trees all around the campus during this time. We need to plan for water harvesting during this year so that we do not face problems in the future. Kindly pray as we plan and mobilise financial resources for the same. The campus is really green now - shall post few pictures in the next blog....

Eventful Day

Yesterday was eventful in many ways. The 75 odd general hospital beds were 100% occupied for the first time since many people could remember. There was not an inch to move. About 20 deliveries, 18 surgeries, a tubectomy camp which started from Monday and a host of fever patients resulted in that.

However, more significant was Dr Nandamani's first cholecystectomy in NJH. It was not the sort of case any surgeon wants as his first case in a new place. But, that is how it turned out. The clinical and sonological diagnosis was gall stones with infection of the gall bladder. After a course of antibiotics, the patient AM was posted for surgery.

Per-operatively, it turned out the gall bladder was very badly infected and was filled with pus and two large stones. The full excision of the gall bladder was not possible. Only a partial excision and removal of two stones was possible.

Kindly pray that the patient makes a smooth recovery.

THE COSTLY MISS...

The scenario which I'm going write now would be very unfamiliar to most of the people reading this blog. It is unfortunate that this has happened to MS in the 'Shining India' which boasts of nuclear armaments, satellite rockets, the cricket world cup, state of the art health facilities encouraging 'health tourism' etc.

59 year old MS was on his way back after procuring ornaments in bulk for his business when he fell down from the vehicle he was traveling in and had a lacerated injury of his right foot. He was taken to a local doctor by the driver of the tempo vehicle where the wound sutured up. The wound stretches all along the dorsum of his right foot and needed about 20 sutures.

10 days later, MS started feeling very funny - he had difficulty swallowing, which was slowly associated with an inability to open the mouth and a vague back pain. He was taken to the district hospital, where some antibiotics were prescribed. Unfortunately, he was getting worser.

MS landed in our OPD along with his relatives on the 4th of July - The diagnosis was easy, but difficult to imagine an adult having it in this era of high tech medicine - Tetanus.

MS was put on a cocktail of diazepam and phenergan. In addition, as we found out that the wound had become badly infected - the sutures had to be removed, and we had to do a thorough debridement. We are thankful to God that he's made a good recovery from his tetanus. His wound is clean but has a long way to go to completely heal.

Meanwhile, I had a chat with one of his sons, who happens to know quite a lot about medicines - most probably a local practitioner in his village. He was aghast when he came to know that his father is suffering for want to one TT injection. I got hold of the prescription of the place where MS was taken first after the injury.

You can see very clearly that Inj TT was cut off. Most probably, it was out of stock in the place or they were asked to purchase it from outside and give it. A small lapse and the price that MJ and his family had to pay has been costly.

Inj. Tetanus Toxoid has been around for quite a long time - but it is sad that people still suffer for the lack of awareness about this. Years before, neonatal tetanus was quite common in this place - thankfully, the incidence has come down appreciably.

However, patients like MS teach that India has a long way to go when it comes to basic health care to the common man.

NJH diary

Wanted to put in a list of cases which we have ended up managing here. Would appreciate your prayers too.

1. KD - 30 year old came in with pain abdomen and vomitting since 4th of July. We had made a diagnosis of Sigmoid Volvulus and she had improved symptomatically on conservative management, so much so that she took a discharge against medical advise. However, she came back in 2 days time with worser symptoms. We posted for an exploratory laporotomy - and she had a necrosed distal jejenum which needed resection anastomosis. Later we found out that she had gone for abdominal massage - which could have caused the condition. It is 3 days now, since the surgery and she is doing well.

2. SD - 22 year old primi who came with Eclampsia and Twin Pregnancy yesterday night. We delivered her by emergency LSCS. The babies are very small - however doing fine. However, her blood pressure remains quite high. Kindly pray for a quick recovery.

3. JP - 18 year old came with organophosphorus poisoning yesterday evening. He brought in quite sick after almost 4 hours after the poison intake. He had to be intubated - we've already pumped him with about 200 vials of atropine. He was weaned away from the ventilator today evening. However, he would have benefited from mechanically assisted ventilation.

4. MK - 14 year old who was bitten by a krait today early morning. Brought in after 4 hours of the bite with no pulse or blood pressure, she continues to be very sick. She continues to be in ventilator.

5. Today we had one lady with eclampsia who died suddenly after LSCS. We do not know the cause. She was quite sick on arrival. The relatives had made quite a lot of fuss although they were explained about the high risks associated with the condition. Kindly pray that there would not be any more problems.

6. Today, we had 3 patients who needed ventilator simultaneously. We have been planning for a ventilator - now I'm sure we need to accelerate the efforts. Kindly pray as we take a decision tomorrow to purchase a new ventilator.

There are 4 burn patients in the ward now. I would definitely like to share our experiences with their management especially the success that Dr Nandamani is experiencing after doing tangential excision and skin grafting on them. That would be in my next post....

A tragedy revisted

It is after quite a lot of proding from one of my friends that I've restarted the blog. It has been almost a week since I had been trying to think about what I should start on. And then, today afternoon, something happened which I felt should be put in...

I remember the sultry afternoon almost one year back. I was in the office, sorting some matters related to taking responsibility of the hospital I give leadership to now. One of my medical officers called me and told of a lady in labour with a hand prolapse. Usually, when a hand prolapse occurs the baby is dead. But, she thought she heard a heart sound. I went to see the patient. It was one of the many gruesome scenes I had ever seen. The baby's hand was protruding out of the vagina - and it was bluish black and edematous. Since, she was in the OPD, I pushed in for a scan and lo the baby was alive.

We somehow got her posted for an emergency LSCS - the hemoglobin was 6 gm%. The baby was sick - the inside of the uterus was stinking. She was in labour since about 3 days and the hand had been sticking out for almost a day. Unfortunately, the baby succumbed after 12 hours of struggle. Now, the effort was to ensure that the mother did not go into sepsis. We were glad that she made a good recovery. Since, there was no more complications I did not get to hear much about her again.

Fast forward one year - Today, I was in the office, when Dr. Ango rushes in saying that there is a rupture uterus on a previous LSCS. So, what was the great thing? Rupture uteruses are the order of the day in NJH. We get about 20-30 of them every year. Well, the thing was that the subcuticular skin suture was still on the patient.

Dr. Nandamani operated on the patient. The baby was dead and the uterus was sown back. In the meantime, I made discreet enquiries on how it is possible for the skin suture to have remained. It seems that the patient had absconded before she could be discharged. And the skin suture remained on her.

I felt really bad. Here was a patient who ran off most probably because she could not afford the bill - and then later comes back with a rupture uterus within 1 year. Something needs to be done here. Now, the lady has already been twice pregnant and both the time she ended up with complications and dead babies. She would need to become pregnant again if she would want not to be abandoned by her husband.

I'm going to meet this family and talk to them tomorrow. They look really poor and illiterate. Will have to convince them to come for regular antenatal check ups and then if she gets pregnant - to plan for a early elective Cesarian Section.