BETLA DIARY DAY 2 AND THE QUACK. . .

Combined continuation of Betla Diary 1 (

http://jeevankuruvilla.blogspot.com/2011/08/betla-diary-day-1.html

) and QUACKS / RMPs (Registered Medical Practitioners) (

http://jeevankuruvilla.blogspot.com/2011/08/quacks-rmps-registered-medical.html

)

After a quite night at the 'Tree House' we were up early for the elephant ride. Unfortunately, the gentle beast, named 'Anarkali' was not at all in a good mood. To make matters worse, my son Shalom decided not to mount the elephant. Therefore, it was me, Angel and Charis who made the trip. The ride was quite a bumpy one and we did not see much of wildlife - only the tracks of elephants and bison. We had a fleeting glimpse of a pheasant and a large eagle.

Having finished our time at Betla, we had decided to drop in at the quack's joints on the way back. I had promised to give a detailed description of the visit.

To start with, the quack whom we shall call RNP, is in his late 20s. He had come to me about 3 weeks back requesting me to help him out if there are any complications in his clinic. I told him that what he was doing was quite dangerous. It was a bit difficult to believe him - but he claimed that he was doing hydrocelectomies, herniorrhaphies and appendicectomies under ketamine. It seems he had worked along with one of his relatives who was a surgeon in Ranchi and had picked up quite a lot of skills. He had got hold of a degree called BIMS - supposed to be Bachelor of Indian Medical Science.

I reached his clinic at around 12:00 pm today. There were two more people in his clinic whom he introduced as his compounders. On his table was a stethoscope, a quite old edition of Hutchinson and a microscope. He had prescription pads with his name printed on them with the degree BIMS in the end. I had wanted to get photographs of the place, but later decided against it as I felt that he could get suspicious about my intentions.

More important than the clinic was it's location. Situated between the towns of Daltonganj and Barwadih - the place was very strategically located. There were hardly regular vehicle services to the region. Even if someone got sick, the nearest place where there is a good hospital is Daltonganj which is Rs. 700 away by jeep. NJH is also Rs. 700 away from this place. Maybe that is the amount RNP would charge for a day's treatment of malaria with intravenous medicines.

After about half a minute in the clinic, he wanted me to visit his ward and operation theatre. And I got the shock of my life - the ward comprised of a room which must be about 20X15 feet with dirty floors and the operation theatre comprised of a plyboard walled off space of about 6X8 feet. Funnily, he did not show me what was inside of the walled off space.

There were three patients in the 'ward'. The first patient he introduced as a patient with fever whom he was giving intravenous quinine. The second was a lady on whom he had done an appendicectomy 3 days back and the third was a young man on whom he had done a surgery for hydrocele 4 days back. There must have been a total of about 10 people in the 'ward' - bystanders of the 3 patients.

On my way out from the ward, I asked him how much he charges. He charges according to the capacity. For the appendicectomy he had charged Rs. 3000 and for the hydrocelectomy Rs 2000. For the poor people in this remote area of Latehar, he was a life saver. He may have been a life taker too. However, isn't that true with us too - qualified medical professionals?

One of my acquintances who has known RNP for the last one year told me that there have been complications - but he is such a remote area the locals think that he does quite a big service to them that they do not make much of an issue with cases that go awry. I've seen the same happen with many other quacks too - where the patient readily accept any complication that happens, with the excuse that he is a quack rather than a qualified doctor.

I'm happy to made acquintances with a 'reputed quack'. He will be definitely keeping in touch with me for tiding over his complicated cases. I'm sure that I would be able to convince him to learn about the public health aspect of conditions which we find in such rural areas. Whatever said and done, people like RNP would find more favour in the eyes of the common poor man in remote areas of the country than fully qualified clinicians like me who is too busy, too far away and too much complex sounding for the rural poor.

QUACKS / RMPs (Registered Medical Practitioners)

The first point of contact for healthcare for almost 60% of the Indian population is not a qualified doctor, but someone who has some sort of experience in treatment of diseases. For qualified medical practitioners, it is quite unthinkable to even contemplate about unqualified people practicing medicines. I used to think that quacks are a problem in only in the rural areas of the country, till I had a conversation with my dad – that was when he told me that when he was posted in Tinsukia, a town in North East Assam, there were hardly any qualified doctors. When any of us fell sick, it was to a quack we went for treatment. Of course, the quacks were more polished than the ones I see now in the villages around NJH.

I remember quite well the chamber to which we used to go when I or my brother used to fall sick. My father later told me that the ‘doctor’ whom we used to consult was in fact an apprentice to a former army doctor. Of course, we used to get better after the treatment from the quack. With the present state of medical care in the country, they have become a sort of ‘necessary evil’.

There have been enough efforts taken at various levels to involve quacks in the evidence based management of cases. The Revised National Tuberculosis Control Programme, the Acute Flaccid Paralysis Programme etc. are few national level programmes who have tried to involve them. We had tried to involve them in helping them find out danger signs whereby they would be able to refer patients to hospitals at the earliest. Unfortunately, the response from them have been quite disappointing.

However, the saddest story in the medical care sector of the country has been the overwhelming commercialization of the pharmaceutical industry, which is unblatantly interested only obtaining profit by hook or crook. A related post (

http://jeevankuruvilla.blogspot.com/2011/08/pharmaceuticals-in-india.html ) to this is the proliferation of unethical combinations of medications which are very freely used by quacks and doctors alike. Unfortunately, the pharmaceutical industry has been well supported by quacks in increasing the market of medicinal preparations and more so for the unethical combination preparations. Among the quacks they have also found brother-in-arms to combat the cost effective generic preparations.

What makes quacks so popular? There are quite a lot of things which we need to learn from the quacks. One of the major aspects which make them quite endearing to communities, especially in the rural areas is their ready availability for service. It is quite common to see them moving around in our nearby villages in cycles or mopeds with a bag filled with all the necessary implements, medicines including injections. The bag which they carry around with them has given them the name ‘jhola chap’ to such doctors in our part of the country.

Now imagine a patient coming to my emergency. The present system is that the nurse would first take the vital signs, and then inform a doctor – it takes some time for the doctor to come, most of the time it would need an admission. And with that come the costs - which bring us to the next advantage with the quack. They take their payment any time and in any kind, which is very difficult to obtain in the present system of treatment in any hospital of the country.

The next point is something which is quite an important aspect which needs to be noted by every qualified medical professional. That is the ability to communicate – clearly, logically and in a language which the patient can comprehend. We have very little time for our patients. Each of our patients are cases and beds. The humanity and identity of the patient vanishes the time they enter our ivory towers.

The last point is the treatment of demand which most of the quacks readily obliges. This makes them quite popular. I never took this aspect quite seriously until I met a quite senior medicine consultant in a mission hospital in the South of India. I was shocked to find quite well looking people in the emergency lying in the beds in the emergency ward taking intravenous fluids. I enquired about this – when she told me that many people came to her for i.v fluids for strength. It was a bit difficulty and when I enquired about the ethical part of it – she told she knew that there was not much of a evidence in giving i.v fluids for no reason, but that was what the villagers wanted. She took over the hospital when it was really going down – she struggled for the first two years. Later, just to make ends meet, she started to slowly oblige the villagers' demands for specific treatments. And within no time, she was quite popular. At the end of the visit, I felt she looked more of a quack than a qualified medicine consultant.

Except the last point, I strongly feel that the rest of them are major learning points for modern medical practitioners. By the way, I recieved an invitation to visit one quack and his practice in a nearby village. I've heard that he managed to even do surgeries - herniaplasties and hydrocelectomies... I happened to meet him during my break at Betla (

http://jeevankuruvilla.blogspot.com/2011/08/betla-diary-day-1.html). Please watch out for a blog on the interactions with him.

BETLA DIARY, Day 1

It was only couple of days back that we took a decision to take a break from hospital work for couple of days and be at the Betla National Park which is only about 15 kms as the crow flies, but about 40 kms away by road. It was the first park in the Indian subcontinent where a tiger census was done sometime in the 1910s. However, over the years the number of tigers have come down from to technically 8, but practically one which was sighted sometime in January 2011.


We arrived after a hurried day for me at the office. We had finished our selection process for the nursing school over the last couple of days. I had barely any time to pack, but my sweet better half had ensured that all my essentials were taken. I had hired one of the outside vehicles for the trip rather than take a hospital vehicle.

The drive was uneventful. The scenery was superb after the regular rains we had over the last couple of months. It was so pleasant to see the Auranga river full of water.


We had not done our homework well on where we would stay. We had booked a room in the Jharkhand Tourism Development Corporation guest house called 'Van Vihar'. The decision was a tragedy. However, we were blessed to have the 'Tree House' of the Forest Department unoccupied and we shifted over to the same, today afternoon.

We had a quiet overnight stay at the former place. Today morning, we came down to the park entrance for an elephant ride. Unfortunately, the gentle beast was booked for the day. The mahout offered us a booking for the next day which we gratefully accepted. However, we decided to try our fortune to sight some animal by taking a jeep-ride. The only thing we spotted was few monkeys and a peacock. The guide assured us that we would definitely spot elephants if we came back in the evening. We had come down to get some time of peace and quietness. Therefore, we politely declined the offer.


Later, in the morning, we had a time of worship at the Gems mission centre. It was humbling to see very poor people come down to this place. Pastor Santosh is doing a very good work among the people in this region.


After a simple lunch at the Forest Guest House of which the 'Tree House' is a part, we had a good afternoon siesta after quite a long time. We planned to go to the museum before it closed for the day. Unfortunately, the staff had decided to close it early and we will have to postpone our visit to the museum for our next trip to the park.


By evening, quite a big horde of deer had come down from the forest to the 'Tree House'. We had a good time just watching them graze.

We wait patiently for the elephant ride tomorrow. Who know? We may see the tiger tomorrow (http://jeevankuruvilla.blogspot.com/2011/08/tyger-tyger-burning-bright.html).

MISMANAGED BURNS

LD had just finished bringing in light to every corner of the house as is the customary Hindu tradition sometime in the first week of June. The light source she used was a old tin filled with kerosene with a hole in its lid for a wick. Different places know it by different names – in quite large parts of the country it is known as ‘kuppi batti’ and is notorious for causing burn injuries. In fact during one of the conferences I attended on burns, I learnt that there is quite a large movement to abolish use of these ‘kuppi battis’ and it is not only prevalent in the Indian subcontinent but also in other South Asian countries as well as Africa and South America and is a leading cause of burn injuries in all these places.

LD must have been a bit careless. She kept the lamp on the floor and was just about to turn around when she realised that the free end of her sari had accidentally tipped over the lamp and the kerosene had drenched the tip of her sari. Within no time, her sari was on fire. LD does not remember quite well about what happened next. By the time, she came to her senses the only thing she knew was that the area below her waist has been fully burnt. Her husband later narrated that it was only because of the presence of mind of her nephew who cried out 'fire, fire' that she did not get fully burnt - quite a number of people nearby ran to her rescue and put off the fire.

But the damage was done. The family took LD to the district hospital where she was admitted for about 3 weeks. LD's husband noticed that nothing much was being done and she was not at all healing. Instead, the wounds had become a dirty yellowish in colour and was stinking. He knew he had to act fast. On his own will, he brought LD to a private practitioner in Daltonganj. He had a very interesting experience here. A junior person, an old acquintance of the family, presently working along with private practitioner warned him that the private practitioner is in fact not a qualified person and that he is more interested in extracting money from his patients. He advised the family to bring LD to NJH.

NJH has now been with us for almost 2 months. When she came, she was in quite a very sad state - with infected crusts all along the area of her burns - which extended from her waist downwards to include the perineum and the upper two thirds of both legs. As is always the case with mismanaged or neglected burns, the percentage of burns (about 25%) had increased because of the superadded infection. She has had quite a number of surgeries after admission. There have been ups and downs. Her skin grafts have taken up well. She's glad that she has ultimately come to us.

Unfortunately, to many of us at NJH, LD and her family looked well off. The family was initially paying off the bills. Then, we noticed that they were finding it difficult. We also did not insist that they pay. Suddenly, the husband came with quite a hefty amount and paid off quite a large part of her bill. Dr. Nandamani found out how this was done. LD's husband had sold off quite a good part of his agricultural land to rake up some money to at least pay some part of her bills. It was something unfortunate.

We have insisted that they do not pay anything more. However, the outstanding bills amount to something around Rs. 40,000. Similiar to MI (http://jeevankuruvilla.blogspot.com/2011/08/prodigal-son-attempt-to-come-back.html), we are looking at the option of well-wishers and good Samaritans pitching in to cover part of her treatment costs.

 

 

LD looks forward to getting back home to her village in far away Garhwa soon.

PHARMACEUTICALS IN INDIA

This blog is written in the light of the article (

http://www.downtoearth.org.in/content/harmful-combo-drugs-flood-market) published in the magazine 'Down to earth'.

Combination drugs have always been a major issue in the Indian subcontinent. The major reasons for the popularity of combination drugs are quite a lot. I tried jotting down many of my thoughts on this issue which has been a bane to practicing medicine in India.

The foremost reason for the high popularity of combination drugs has been the fact that most of the doctors recieve their practical pharmaceutical education from medical representatives. I very much remember our days during internship when we had no clue on why we wrote a certain brand of iron or calcium tablets or even an antibiotic. Basically, there was a major gap between pharmacology classes in the second year and the medicines which were available in the market.

As I read through the article in 'Down to earth', I remember how one medical representative tried to convince me of the great advantages of a combination drug of diclofenac and ranitidine. Another drug - 'Dexorange' is an absolute favourite with many doctors and patients. I know couple of families who are regular customers of this tonic. Even well meaning doctors write this syrup very regularly for their patients. Very few of them realise that it's the alcohol within the syrup which makes them feel good.

The most flagrant misuse of all such combinations is most in the management of diarrhoea. I recently found out that there are companies who have started coming out with lactobacillus in ORS (oral rehydration solution) preparations. When we know that the most common cause of diarrhoea is viral - it is very unfortunate to find pharmaceutical companies trying push down all sorts of combination down the patient's throat - Ciprofloxacin+Tinidazole, Metrogyl+Norfloxacin, Ofloxacin+Ornidazole... The list is inexhaustive.

Another reason for this situation is the aggressive marketting of drugs in the Indian subcontinent and the huge profits which are at stake. The image of the generic drugs which were supposed to bring down pharmaceutical costs to quite a large extent has been badly tarnished. Generic drugs were potrayed as something sub-standard. I was shocked when my previous store keeper told me about 'unethical drugs' being kept in my store. I could not believe my ears when I realised that medical representatives had taught him that generic drugs are actually unethical drugs.

Since I started my second stinct in NJH, on many occasions I've realised that sometimes it is actually difficult to get a cheaper basic variety of a drug than a costlier 2nd or 3rd choice drug for a particular condition. A typical example was the availability of Hydrochlorothiazide (HCT). I had so much difficulty convincing my suppliers that this drug was the first choice for the management of hypertension. Couple of suppliers went to the extent of making fun at me. They told me that Losartan and Amlodipine AT are the latest medicines. A strip of 10 tablets of HCT 25 mg cost 4 rupees whereas Losartan cost 50-60 rupees. One can imagine the margin you can get from the latter. And we talk about cost effective management of non-communicable diseases.

To find out more about this is to request any doctor friend of yours to rummage through the drugs they recieve as samples. You may be surprised to find that there would be very few sample medicines which are commonly used and which are cheap. Most of them would be quite expensive medicines and there would not be enough to cover a complete course - especially when it comes to antibiotics. The game is simple - you give some of them free. Then you have buy the rest. I recently heard that this was the same ploy that the English used to popularise drinking of tea in the Indian subcontinent.

The story goes that when the English established tea estates, they found out that there was quite a lot of wastage as they only used the high quality tea dust. They somehow realised that that the low quality tea dust which was thrown out was also tasty. So, they organised free tea stalls for the local population. And as soon as drinking of tea became quite a popular past-time among the locals, the low quality tea dust was available at the cost - thereby ensuring that there was a revenue. (No idea on how true the story is. I heard it on a recent visit to Bangladesh)

Drug resistance especially with antibiotics is a major issue. Nowadays, it is very uncommon to see anyone prescribing antibiotics like septran or amoxycillin. Augmentin, Levofloxacin etc rules the roost and that too for a one day fever. A very simple medicine for urinary tract infection is Furulic Acid or Nitrofurantoin. Very few medical practitioners knows that this is the best antibiotic for community acquired urinary tract infection. In addition, there are only few companies who produce the tablet form which comes very cheap. And it is not very easy to get.

Whatever said and written, the bottomline is that the pharmaceutical industry has made a mockery of medical science in the country. I hope that the latest initiative from the planning commission will bring in some amount of control in the manufacture and sale of drugs whereby ethical preparations are available at a cost which the poorest of the poor can afford.

PRODIGAL SON . . . AN ATTEMPT TO COME BACK . . .

MI belonged to a lower middle class family in our nearby village of Satbarwa which was our local market. MI used to work in Mumbai. He was unmarried. And he had returned home about a month back.

MI was brought to NJH is this state on the 10^th of July, 2011. The story was that he was making tea when the stove burst and he suffered burns on his upper part of the body. It was very obvious from the burns that the story was not really true – but MI and his relatives held on to their story. MI was in danger of having suffered inhalational injury. We gave a very guarded prognosis and offered to help him get shifted to Ranchi for expert treatment – which the relatives were not very keen.

In addition, there was a possibility of severe edema resulting in closure of the oral cavity and the airways at a later stage. There was very high risk of infection. However, MI and his family members consisting of his parents and 3 doting sisters – were very determined to help MI recover.

The recovery has been very painful and long. It was very helpful that the family, especially his 3 sisters have helped him to cling on to his life so far. With a burns percentage of 50%, it is amazing that he has made quite lot of ground.

However, over the 6 weeks that he had been with us in hospital, Dr Nandamani and the nursing staff has made quite an impact on the young man that the real story of his burns has come out. MI had a quite violent past. He had been an alleged drug addict for some time. Few weeks back MI’s mother had presented him with a cell phone which was worth about 5000 rupees. For the family, in the rural Indian male centric world, MI was the epitome of all their aspirations and dreams.

Unfortunately, MI was quite spoilt – indulging in all sorts of vices and in addition, allegedly falling prey to alcohol and drugs. MI sold the 5000 rupee mobile which his mother had gifted him for a paltry sum of Rs 500 to fuel his drug habit. His mother came to know about it in no time. There was a huge argument in the house following which MI poured kerosene over his head and set himself on fire. That explained for the deep burns on the back of his body.

MI has since repented and he wants to get back to his normal life. He has been going through a very painful experience which has broken him down. In addition to the pain, the treatment has been quite expensive. The family must have spent about 50,000 rupees so far in his treatment. They still have outstanding bills of about Rs 40,000. He already had two sittings of skin graftings.

MI is quite miserable about the life which he has wasted so far. I’ve assured him of putting out his story to people who could remember him in prayers as well as help him pay at least a part of his outstanding bills.

[This story was put in the blog after taking consent from MI and his family including putting photographs. There are quite a number of patients who come to us with burns for whom we have to write off quite large amounts, which puts quite a lot of financial strain on the unit. Other stories are that of VM (http://jeevankuruvilla.blogspot.com/2011/07/pediatric-burns.html) as well as that of PD (http://jeevankuruvilla.blogspot.com/2011/07/neglected-burns.html ). We plan to start a fund to help our burns patients with regular treatment and if needed additional support to restart and rebuild their lives.]

MALARIA – Or is it something else?

35 year old IS works somewhere in the Jharkhand-Uttar Pradesh border as a daily wage labourer. 4 days back, he had high grade fever with chills and rigor. He was treated for malaria by the local quack. As the fever was persisting, he thought of going back home along with one of his fellow villagers who worked along with him.

IS was brought in an almost unconscious state to our casualty sometime today afternoon. The look on his face was enough to tell us that he was gravely ill. The whole of his face was flushed, the sclera of his eyes very chrome yellow and the conjunctiva was all congested. The breathing was labored and chest examination revealed that there was quite a lot of fluid in the lungs. His liver was tender. It looked more like Weils’ disease than malaria to me.

The investigations were terrifying – the serum bilirubin came an astounding 51 mg%, the total count was in the range of 50,000, the platelets 15,000 and a serum creatinine of 4 mg%. Medically speaking, he cannot survive with the sort of facilities we have. The saving grace was that his hemoglobin is 8.9 gm%. And of course, his blood cells was teeming with falciparum malaria.

After reaching his village in Leslieganj yesterday, IS continued to have fever and he became unconscious sometime around midnight. IS’s family is very poor. The reason for IS working so far away from home was to earn a living for his family - 3 little children and a young wife. IS was brought to NJH by fellow villagers and his elder brother.

The elder brother and his villagers were aghast after we pronounced our prognosis and gave them an option of taking the patient elsewhere. As I write this, IS has pulled through so far. I’ve asked the people who brought him to arrange for blood.

In addition, I’ve started him on anti-malarials and treatment for leptospirosis. Many a time, we’ve seen that presence of malarial parasite in the blood tends to be a red herring.

After the persistant rains over the last 2 weeks, it has now become very humid – quite a good environment for the mosquitoes to breed.

We are having quite a lot of malaria than last year. After the last year, when we had lesser cases – most probably due to the drought, I have a feeling that people had started to take possibility of contracting malaria quite lightly. To compound this problem is the practice of single dose treatment by many quacks – it is not uncommon to see people who come with persistent fever after having taken a single injection of artesunate or quinine.

From my experience of 2003-04, one more condition which becomes quite common during high incidence of malaria is the occurrence of injection abscesses. Giving quinine as deep intramuscular injections is something practiced by quacks and many of them ultimately end up as big abscesses. This year, I’ve seen one where the abscess had already organized, solidified and probably fibrosed– sparing the poor sufferer of an incision and drainage surgery.

Today evening, I’ve seen one more patient, a pregnant lady who has come in with fever. Blood examination shows falciparum.

Deaths which could be directly attributed to malaria are quite less nowadays. This is mainly because many of the fever cases come after some form of partial malaria treatment. As far as I remember, almost all the patients who tested positive by smear for malaria have recovered completely.

There has been one death over the last 2 weeks – a 16 year old girl with fever. She had been treated as malaria elsewhere. She had hemoglobin of 3 gm% and was unconscious since the day she came in. She never tested positive for malaria. Most of my colleagues strongly felt thatit was malaria.

Now, this is where we need to do some sort of research on. Are we only dealing with malaria alone or are there other infectious diseases which are very similar to malaria – dengue, leptospirosis, rickettsia etc. I wish we could have help whereby we could explore more on this . . .

DIABETES – making communities poor . . .

I remember the cold Wednesday morning in the OPD at NJH sometime in Winter 2004. There was a old man in his middle 60s sitting in front of me. He had come to NJH for his foot which was decaying. His problem was very obvious and not at all uncommon to me who came from the south of India. He had diabetes and had an ulcer in his right foot which was refusing to heal. But for NJH it was something rare. Diabetes was believed to be uncommon in this part of the country. That was the first and the only patient with diabetes whom I saw at NJH during my stinct in 2003-04.  

Fast forward to today (21^st August, 2011), the last patient I saw in emergency - someone I shall call SDP. SDP has been hypertensive for quite a long time. He claimed that he is not a diabetic. His relatives even showed me a blood test which showed GRBS as 141 mg%!!! SDP has come in very sick. He has been having a angry looking swelling of the right foot and obviously he had infection - he was febrile and breathing heavily and fast. His GRBS was above 200 mg%. Obviously he must have had high sugars and somehow it was not picked up. 

In the wards, we have 3 patients who have diabetes. On an average, in the out-patient department we have about 3 new diabetic patients every week and more than a dozen of them coming for them coming for their repeat medications every week.

However, what I need to tell you about a very peculiar history that many of them give. Quite a lot of them have been diabetics for 10 years or more. So, where were they when I was at NJH in 2003-04? I've not done a detailed study on this - but have been asking quite a lot of the present patients about the same. The answers have been shocking. It seems that quite a lot of them had been frequenting hospitals at Ranchi (135 kms away) and Kolkota (12 hours by train) just for the treatment of diabetes. When I ask them about the reason they did not come to NJH - the answer was that they thought that mission hospitals are mainly for surgical management and there was no 'diabetes specialist'.

It was very unfortunate. The minimum amount of drugs which many of the 'diabetic consultants' wrote for these patients were about five and the expenses involved has been quite huge.  Many of the patients had also been misled by traditional and alternative healers for radical cures of the disease - and they had also spent quite huge amounts on them.

Quite a large number of our present diabetic patients who had been on treatment for long durations – and the treatment have literally made them paupers. And that was the reason that they started coming to us.

So, how are we going to respond? We have already planned to start a chronic diseases clinic of which diabetic management would be one of the major components. I wish we can send one of our doctors and few of our nurses for training for diabetes management. To decrease the load in our laboratory and to streamline management we are going to get a Nycocard machine for HbA1C and urine microalbumin.

As I finish writing this, Angel informs me that one of the new admissions in the ward who is a diabetic has ketoacidosis. It is ages since I’ve managed one. I fondly remember my MBBS days at Trivandrum as an intern in Medicine 2 where we honed the art of managing diabetic ketoacidosis.

Unfortunately, the major question remains on how much is rural India ready to take on the demon of diabetes and hypertension. With the requirement of regular treatment – which is a concept quite alien to the Indian psyche – there has to be major shift in the attitude of communities towards chronic diseases. We are still grappling with infectious diseases and inadequate reproductive health care. The additional burden of non-communicable diseases could quite increase the morbidity within communities, the consequences of which we may be facing sooner or later.

The concern is that, many of us, especially in the rural agrarian societies of the country do not know very clearly on what the consequences could be.  

FLOOR PATIENTS. . . SOS

You may be wondering what this is. For graduates from private medical colleges and both the Christian Medical Colleges, I know what I’m going to talk about is unthinkable.


As I was writing articles for my blog, I got a call from Dr. Nandamani saying that there are quite a lot of patients pouring into the hospital. Since the last 3 days, all the beds in the hospital are full. Yesterday night and today morning, we have had problems with allotments of private ward rooms with patients’ bystanders almost coming to blows.

The situation in the general ward is worse. We are discharging patients quite soon now. So, as we departed for the evening, we’ve decided to make a consent sheet for patients who want to get admitted in spite of the space crunch. We thought that the wordings in the consent would turn away patients. But, I am mistaken.

So, I think for the first time after many years we have patients on the floor in NJH. I’ve heard about patients in the floor before the construction of Acute Care Unit and the new Maternity Block.

As I write this I’m reminded of my MBBS days in Trivandrum when we used to have patients on the floor. We had only about 20 odd beds each in the male and female wards and there used to about 60 admissions in each ward. So, we used to have a system of allotting floor spaces for patients. The sickest used to get the beds and as soon as they were better and if there was a sicker patient coming in the poor fellow would be demoted to the floor.


Sometimes it used to become hilarious. There have been many occasions when a ‘floor patient’ cannot be traced and then we find him/her happily sleeping under someone else’s bed. Then, there was another occasion when a patient's bystander who was taking a nap taken for clinical case session for the medical students. It was only after quite some time in the class that we knew that we had a normal fellow in front of us. Of course, he had a good snack and tea which we customarily used to arrange for patients coming for clinical case classes.


Well, anybody out there who would like to come and help us out – doctors and nurses. We have couple of more EHA units who need extra hands . . . My contact details are on the margins of this blog . . . S.O.S . . .

THE NEW VENTILATOR

As I reached NJH with the new machine, I was like a little boy waiting to open and try out his new toy - so I was waiting for the opportunity to unpack the machine and and use it. There were quite a lot of things to be settled before I could get my hands on the same. However, I was glad that I could spend about ten minutes as soon as I was a bit free. Dinesh had already unpacked the machine and had positioned it on the lower shelf of the Boyle’s machine.


I was glad to have spend some time tinkering with it because I had a patient very soon. SD (http://jeevankuruvilla.blogspot.com/2011/08/tiring-thursday.html) who had eclampsia and a live baby was the first customer for the ventilator. I was quite impressed with the performance expect for the fact that the warning lights did not come on when the patient started to breathe on her own at the end of the surgery. The theatre nurses, Suman and co. were also quite pleased as they were free from the business of manually pumping air into the patient’s lungs. They were quite free to do other things and it was helpful when the baby arrived as we had extra hands for the resuscitation.

The ventilator was brought into action in the surgery on KD too as she was also eclamptic.

Sr. Suman with KD after the surgery

So, from the initial impression, it has been quite a worthwhile purchase for us – saving quite a lot of muscle power and giving us additional hands.


Now, I wait for a time when I can use it in the ward – where the circuit which needs to be used to quite a different one. I shall update you on the same as soon as we use it in the ward.

TIRING THURSDAY . . .

We had a comfortable journey back from Delhi. The Garib Rath reached Daltonganj on time. After the rush in Delhi, it was a bit unthinkable for me to take first call on Thursday. For most of you who may not know about the weekly schedule in NJH, Thursday happens to be a half day. The major reason for this is to allow staff to do their weekly shopping and banking. Being far away from the town, this was very much needed in the olden days. However, most of the patients do not remember about this and still keeps on coming even in the afternoon. So, anybody on duty on Thursdays ends up seeing quite a lot of OPD patients in the emergency.


My day started quite interestingly. First of all there was DD, a G3P2L2 with a big baby in breech position. She had normal deliveries both times earlier at home and the second delivery was a breech delivery. However, the local dai who had taken her delivery both the initial times was not very confident about this one delivering normally. Even, we thought the same. But, by the time she reached NJH, she was already about 8 cms dilated and with good contractions. We posted her for a cesarian section but in theatre we realized that baby was quite on its way before we started. I was quite surprised that we could do a breech extraction without much difficulty. The poor family was quite overjoyed that a Cesarian was avoided.


After that we had SD. SD was having an uneventful pregnancy till yesterday midnight. At around 11 pm she threw a fit followed by a number of them. The family lived quite remote and by the time they got some sort of conveyance it was dawn. The reached a hospital in Garhwa by around 6 am from where they were referred to Daltonganj. The private hospital in Daltonganj again referred her to us after giving few injections which included Diazepam and she reached us around 10 am. She was unconscious, but the baby was alive. We had to deliver the baby fast. Unfortunately, the baby came out quite sick – was not breathing and had to be ventilated for almost two hours. Probably the diazepam and the Magnesium Sulphate had done the damage. The baby was improving but over the night, he became quite sick and is again on mechanical ventilation. SD has improved but she is still groggy and it would take some time before we can confidently say of her complete recovery.


Immediately afterwards, we had CD who was a previous cesarian and also had a cholecystectomy before. I’ve known surgeons who would be very hesitant to open the abdomen a third time. But, we did not have much of a choice. CD had scar tenderness. We had her opened up in no time and she was lucky. The scar was giving way and we were just on time. CD and family were quite happy to get a boy baby – her first one was a girl. The issue of not having a male heir in the family supposedly creates a major crisis in Indian families. I should have mentioned that for the earlier patient, SD has 3 girl children.


After the 2 surgeries, I was lucky to get some sleep after lunch. My next call was a bomb. RD, 22 years with a twin pregnancy and 36 weeks gestation, with at least one ante-natal check up every 2 weeks had landed up with history of multiple episodes of seizures since 2 in the afternoon. She was also straightaway referred to NJH. This family was very rich and could afford the best treatment in the country. But they were at least 4 hours away from the next tertiary centre. And, she was unconscious with phlegm clogging all over her lungs. The Blood Pressure was an astounding 230/150 mm Hg and Urine Albumin was 4+. She had also received some injections which included Inj. Diazepam. I was worried about the babies.


Meanwhile the family was juggling the option of taking her onto Ranchi. I told them about the pros and cons. Ultimately, the agreed for a emergency cesarian section with all full risks explained.


The Cesarian section was uneventful. As expected, both the babies were heavily sedated. We had to ventilate them quite a bit before they started breathing on their own. Unlike SD’s babies, KD’s babies have improved quite a lot and are doing well. Even, KD is doing far much better. KD’s story is a clear demonstration of how much the family needs to be educated on the danger signs of pregnancy. Later, I found out that KD had her last ante-natal check up 2 weeks back and there were no problems. However, after about a week, she had started to swell up which the family did not take seriously.

As I finished suturing up KD, I got a call that there was a polytrauma. More about that in the next post. . .

DILLI DIARY

I had a quite busy time in Delhi. We got our ventilator - quite a compact instrument. Cost us 150,000 Indian Rupees. This has been helped through funds which had been facilitated through Dr Colin Binks, our former surgeon through a block contribution from churches in England - The St Francis’ Church, Westborough, Guildford, UK; The St Clare’s Church, Park Barn, Guildford, UK; Castle Square United Reformed Church, Treforest, UK and the St Mary’s Church, Ash Vale, UK. We are grateful for the kindness from the parishioners of all the four churches as well as to Dr. Binks who helped in raising awareness about our needs.

As we contemplated on what else to do in Delhi - there were quite a lot of hospital needs which came up. Having Dinesh along was a blessing. We scouted around for bedsheets first. With the increasing number of patients in the wards, we were running short of bedsheets. We were glad to find shops inside Delhi Cloth Market near the old Delhi station. Dinesh was surprised to find that the sheets we ultimately decided to buy came from his homestate of Tamil Nadu. We got about 160 metres of good cloth for about 8500 rupees. This would give us about 65 bed-sheets. From our previous experience in Ranchi and Kolkota, it was quite a profitable venture.

Then, we went to search for some surgical instruments that Dr. Nandamani wanted. Dr. Nandamani like all surgeons has developed special interest in some makes of the instruments. We use quite a lot of skin grafting blades. And Dr Nandu has taken particular liking for a Chinese make which we find quite difficult to get. We were glad to have got hold of 13 blades which

should last about 2 months. Then there was something called a 'mesher' which we could not get hold of. Nobody had any idea where to find this instrument - it's basically used to make a mesh of skin so that more surface area can be covered during skin grafting.

The grant from the churches in UK had also allowed us to purchase a Nycocard Reader II which would help us to estimate HbA1C, Urine microalbumin, CRP and D-Dimer. You may be wondering why a rural hospital like ours would need these tests. It was taken after quite a lot of discussions. Our diabetic crowd is on the rise and doing FBS/PPBS has become quite cumbersome and very difficult especially when patients find it difficult to reach the hosptial early in the morning. With the increasing number of deliveries and lots of babies born with high risk of sepsis, CRP would be of much use. HbA1C costs Rs. 1300 to be done in Daltonganj and CRP Rs. 600. So, we are going to give a tough competition to the rest of the crowd.

So, we had been scouting for this machine for quite a long time. The price which was quoted by our local supplier was quite high. It was by accident that we got into one of the shops to look at some Neubaur counting chamber cover slips which Angel wanted. They had quite a lot of laboratory materials. And it turned out that they were the major dealers for the Nycocard reader. The propreitor promised us a live demonstration the next day.

It was in the laboratory supply shop we heard on television about the drama which was unfolding in Central Delhi over Anna Hazare's arrest. The shop owner advised us to make a run to wherever we were put up. Our appointment with the ventilator supplier was at around 5 in the evening. As we rushed by Metro to Lajpat Nagar and then by auto to Ashram, my thoughts were on the struggle which Mr. Hazare was leading against corruption. I have written about my experiences with corruption -

http://jeevankuruvilla.blogspot.com/2011/08/experiences-with-corruption.html - which makes me quite dissillusioned about the possibility of eradicating corruption in India.

We reached their office by around 5 pm. Mr.

Rajput and his colleagues were kind enough to give a full demonstration of the machine. They also warned us to head back home as soon as possible. The machine was quite well packed and we lugged it to my uncle's place at Sai-udullah Jaib. As always, it was quite a time of unwinding for me and Dinesh at Josh uncle's place.

Early morning, we were at EHA central office. We were blessed to be part of the morning devotions. Dr Santosh shared about the feeding of the five thousand with five loaves and two fish. More on that in another blog. It was quite reassuring that we are remembered by so many people in their daily prayers. After some time of discussions in EHA office - Dinesh and me were off to the railway station. We were still not very sure about the aftermaths of Anna Hazare's detention. We did not want to take any chances.

Dinesh went straight to the New Delhi station along with the luggage and I went to see the Nycocard machine. Unfortunately, the technicians had brought a machine which was damaged. They had not noticed it. They apologised profusely and requested me about an hours time to come back with a new machine. I had about an hour to kill. I rushed back to Nehru Place and brought a 500 GB hard-disk and few books for Shalom and Charis. I was back at the lab shop by around 3 pm. They took about 30 minutes for the demonstration. I was glad to find that my HbA1C was around 5.

They finished by about 3:40 pm and I had 30 minutes to rush from Bhagirath Palace to New Delhi railway station to catch the Garib Rath. There were queues at the Chandni Chowk metro as well as in the New Delhi Railway station. As I entered the train, the train started moving.

Just wanted to acknowledge the Lord's grace in guiding us to the right places at the right time and getting quite a lot more things done than what was planned.

EXPERIENCES WITH CORRUPTION

Indians all over the world have been gripped with the happenings in Delhi over the last couple of weeks - where Anna Hazare has been leading a crusade against corruption through pressing for a LokPal Bill which he and his team has drafted.

There has been quite a debate on how the war against corruption has to be waged in the country. Many of us has been quite overwhelmed by the sort of crowds that Mr. Hazare and his team has been able to muster.

However, we need to realise that corruption is very much entrenched in our present culture. Since I came to know about Mr. Hazare's campaign and the fiascos which have been unearthened regarding the 2G spectrum allotment, the commonwealth games etc. I was reminiscing about my trysts with corruption.

Since I've been travelling quite a lot over the last few months, the first thought that comes to me is the Indian Railways. Even as I sit in the New Delhi-Ranchi Garib Rath, I've seen the Ticket Examiner discretely calling passengers with Reserved Against Cancellation (RAC) tickets to the vestibular area between the coaches and offering them confirmed berths at an unaccounted extra cost. It is quite common to see this happening whenever the train is fully booked. And it becomes quite rampant during festival season when almost the whole country is travelling.

If you go to the metro cities it is very common to find people coming and ask you if you need confirmed train tickets. It does not need much imagination to conclude about a possible unholy nexus between the reservation agents and the railway authorities.

The most unfortunate part is that many people do not see this as corruption. I've had people giving me all sorts of explanation for this sort of thing. Few people told me that it is part of human behaviour and few told me that many poor earn their livings such. However, I'm very definite that this is corruption and steps need to be taken to discourage such practices in the railways.

The second instance which comes to my mind is an account of my friend who was trying to get his land registered in his name after his father had passed away. There was a clear will which was written whereby the land was bequethed to him. To formalise the procedure, he had taken the help of a lawyer. My friend told me that the first thing the lawyer told him was that he should be ready to pay a certain amount to the tehsildar and the land records office so that everything will be done smoothly. My friend was shocked - here was a man who is supposed to a custodian of the law telling him outrightly to encourage corruption.

The third instance is that of my friend about whom I had narrated in my blog http://jeevankuruvilla.blogspot.com/2011/08/dying-young.html. Someone in his family had committed suicide. The police told him very clearly that things could be unpredictable unless he is ready to cough up some money. The 'some money' was 20,000 Indian Rupees. If the money was not given, they could not assure him that the case will be closed without any problem. My friend who was already in quite a lot of stress ultimately ended paying up. Later, we tried finding out what problems could have occured. It seems that anyone can be framed for instigating suicide and if the police wanted it, they could really prolong the case and harass the family members. One of the policemen also stated that the usual charges was 50,000 Indian Rupees and because they knew my friend, the 'costs' were discounted. It was quite frightening.

I know that quite a lot of us would be able to narrate such incidences. In many instances similiar to the third story I just wrote, it becomes quite difficult. However, we need to realise that the crowds we see on television is just a miniscule of our population. The fact remains that majority of our population approve of corruption and using money-power to acquire our needs and wants have become the order of the day. I know of companies and organisations who have budgeted for corruption. The other day I came to know of an organisation who was budgeting 'speed money' as 'extortion money'.

Before I close this post, I should tell you about one of our former nurses who had applied to rejoin. We were quite surprised that she wanted to rejoin, as all of us knew that she had paid quite a large amount of money (about 200,000 Indian Rupees) to get a government job which pays her about three times of what she earns with us. I happened to talk to some of her acquaintances and I enquired about the reason why she is coming back. The explanation baffled me - it seems that nurses in government recieved their salaries once in 4-6 months and the amount being quite large - they had to pay part of it at various levels in the treasury office (place from where the salaries are made and given). So, this lady had calculated that working in a mission hospital like ours is better - although she will get a lesser salary, she will get it regularly without any hassles.

I sincerely pray that the efforts being taken by Anna will make each Indian think and take a decision to stand against corruption at all levels. The war against corruption needs to reach the grassroot levels.

WEEKEND DIARY 3

Well, it turned out that I was on duty for a third weekend running. The reason I could not pen the happenings on the blog was non-co-operation from our telephone department. It had been raining quite hard over the last week and our communications have gone for a six. As we are quite corruption unfriendly, the telephone department takes least interest in repairing our lines. The lines are still dead. You can read my accounts of the other two weekends at http://jeevankuruvilla.blogspot.com/2011/07/weekend-diary-njh.html and http://jeevankuruvilla.blogspot.com/2011/08/weekend-diary-2b.html


I could put this on to the web as I'm travelling - going to Delhi to get a better half for our ventilator http://jeevankuruvilla.blogspot.com/2011/07/pneumatic-war-horse-tribute-to-silent.html. The company was planning to send it to us by truck parcel - but later had double thoughts because of heavy rains and bad rains which had been lashing most of North India over the last week. They asked us to take personal delivery of the same.


I penned part of this in Daltonganj station. As I sit and write this, there is quite a swarm of mosquitoes trying to suck my blood and if possible inject malaria or dengue into me. But, I have this local application material called the 'Mosbar' - basically diethyltoluamide put in a soapy base. Initially when someone told me about it, I was quite sceptic about how this works. However, once I started using it, I was determined to promote it's usage and therefore I thought that I shall put a word about this here. It is made by Maheshmunda Holy Cross Sisters of Belatani, Giridih district, Jharkhand. It costs Rs.8


When I talk about mosquitoes, I need to tell you about 2 very sick malaria patients whom we had over the weekend. Both of them are over 60 years old. One of them whom I shall call PD has improved after Artesunate injections. He was not as sick as SD when he arrived. SD continues to remain unconscious - though not on the ventilator. Both of them had Falciparum malaria teeming in their blood.


Obstetric wise, we had a rupture uterus and couple of Cesarian sections on Saturday. Two eclampsias and one more cesarian section on Sunday. CF, who had the rupture uterus was quite a sad case. CF had a cesarian section 3 years back. She reached the local district hospital on a wrong day - it being Rakshabandan (Indian festival where brothers take the vow to protect their sisters - symbolised by the tying of a sacred thread around the hand of the brother by the sister), there must not have been many qualified hands to deal with her. Her pains had started on Saturday early morning. She reached the district hospital some time late morning. God only knows what they were trying to do with her over the whole day. Sometime around midnight, the family was told that it seemed that CF would need more expert medical care. They rushed CF to the private hospital nearby where they were told that things were quite bad and they would need to go to Thumbagara.


I recieved CF at around 6 am on Sunday. The diagnosis was obvious. Far worse, CF was in shock. She was very pale. She needed to be operated on fast and she needed quite a lot of blood. 3 male relatives readily volunteered to donate blood. But they had different blood groups. I decided to call on one of our staff to donate blood as we were quite concerned of her hemodynamics. Consequent to few extra number of surgeries on Saturday and the incessant rain we were running short of theatre gowns. So, I decided to call on Dr Nandamani since I could end up calling him for help if the rupture was a complicated one. And thus, we could save one theatre gown. Per operative it was not a very clean rupture. I was glad that Nandamani was doing the surgery.


I saw CF just before I started today's journey. The journey towards parenthood had been quite traumatic for the family. We had given the option to the relatives to try to have a second child. But, they would have had nothing of it. The first child, a girl was born by cesarian section and it had been very expensive for the family. Now, the second pregnancy has given more trauma. It was so unfortunate that the delightful physiological experience of pregnancy and delivery of a child has been transformed to a nightmare partly due to lack of health education and quite a lot due to apathy from health delivery professionals like me.


The other two cesarian sections on Saturday were uneventful. The first one was for BD, whose mother was being regularly seen by us for her depression http://jeevankuruvilla.blogspot.com/2011/08/depressed.html. BD was post dates. We had tried to induce her but she had not responded even after about almost a day. We did not have much choice. The second one was CD, who had been seen by couple of senior obstetricians in Daltonganj and was advised Cesarian section. The problem with CD was that she could not percieve fetal movements since 2 days. We could hear her fetal heart. I screened her by ultrasound and suspected that the umblical cord was wound over the fetus. In addition, the baby looked quite large. With no qualified obstetrician around, I could not offer the family anything less than a Cesarian section.


I was glad that we did surgery. The baby was 4 kgs and the cord was wound quite tight twice around the baby's body.


The highlights of the week were that both ZB http://jeevankuruvilla.blogspot.com/2011/08/maternal-near-miss-another-one.htmland and UD http://jeevankuruvilla.blogspot.com/2011/08/maternal-near-miss.html have made amazing recoveries. We praise God.


As I came out of the hospital, I could see little Naveen http://jeevankuruvilla.blogspot.com/2011/07/arachnid-horror.html waiting for admission for his second round of skin grafting. Other than obstetrics, Dr Nandamani has been having quite a lot of success with his surgeries and especially with management of burns. I wish I will be able to put it soon in the blog.

MATERNAL NEAR MISS . . . ANOTHER ONE

I never thought that I would be writing so soon about one more 'maternal near miss' so soon. ZB could still end up as a maternal death.

ZB, married off to KA, who works as a dumper truck and forklift operator in a major company in Chennai had returned 2 months back to her husband's house in Palamu district - about 70 kms north to the district headquarters of Daltonganj. She had been doing well till today early morning. Since the pregnancy was uneventful, her in-laws did not think much about doing regular antenatal check-ups. Moreover, they believed that she had a clean chit given during her ante-natal check up at Chennai.

The spate of unfortunate events started at around 4 in the morning today. She threw a fit while she got up to drink some water. Her in-laws did not think that as something serious until she looked to become stupourous. They rushed her to a local non-qualified medical practitioner (called RMP - Registered Medical Practitioner) in the nearby railway town which was about 1 km away. The RMP gave her some intravenous fluids. In between, she had another 4 episodes of seizures. By now, they realised that they needed to take her further. Someone told them that the best treatment for such conditions is got in NJH.

Instead of hiring a vehicle, they bundled the semiconscious ZB into the Dehri-on-Sone to Barwadih passenger train which passes through Daltonganj. This is the first time I have heard of someone do that to an unconscious patient. The journey was about 2 hours long and by then she had convulsed another 2 more times. They reached Daltonganj by around 6 in the evening. They hired a tempo and reached NJH by around 7 pm. On the way from Daltonganj to NJH (35 kms), ZB had one more episode of convulsion.

I had just come back home from hospital after couple of Cesarian sections. Drs Johnson and Kumudh were taking their customary evening walk around the campus when ZB arrived and they were quite near to the labour room. The duty nurse noticed that ZB was convulsing and noticing my colleagues called out to them. By the time I arrived, they already had a line going on and anti-convulsant injections were on its way in.

ZB was in a pathetic state. Her blood pressure was a whopping 180/130 and her urine albumin was 4+. We knew that she would develop complications if the baby was not taken out fast. Meanwhile ZB's mother-in-law informed that she was not yet term. However, on examination, the cervix was very unfavourable. We discussed the situation with the ZB's family and a decision was taken to take out the baby by Cesarian section. Her saturation was just 85% and she had aspirated quite a lot. We could not wait for a normal delivery although we found that her baby was dead. We were encouraged by her platelets, liver and kidney function to go ahead with surgery.

The surgery was uneventful. ZB is presently on the ventilator. She is sedated and has been maintaining saturation quite well. I hope to have a positive update on both ZB as well as UD

http://jeevankuruvilla.blogspot.com/2011/08/maternal-near-miss.html). Sorry to keep you bored with these maternal health events. I have couple of other patients coming up soon... Just that I need some more background information before I put them on...