The rush continues... Rupture uteruses and maternal deaths

Although we are quite busy with the Golden Jubilee celebrations, we continue to see patients who are quite sick. I'm glad that I've got Drs. Nandamani, Shishir and Johnson working fulltime and Dr. Angeline, my better half. This has been an unusual period of increased patient load which we have been having over the last couple of weeks.

Over the last 5 days, we had 2 rupture uteruses, one of whom died and another maternal death who had come with eclampsia. So, I did fill up the facility based maternal death forms and submit to the district nodal officer. Hope they were not shocked to see 2 reports come in after the meeting we had last week.

Last 2 days, we had more sad cases. There are 2 mothers with eclampsia for whom we did cesarian section and were blessed with live healthy babies. Unfortunately, we had a mother with pre-eclampsia on whom we did cesarian section and delivered a sick baby. The baby died soon after.

Today, there was one more near miss. The lady had been in labour since 2 days, before the family decided to take her to the district hospital. They kept her in the district hospital for about half a day before they decided to refer her.

On arrival in NJH, we found out that it was indeed a hand prolapse and a dead baby. We were not very sure how long she was in labour. We decided against doing an internal version as there was a bit of a doubt on the integrity of the uterus.

Ultimately, we did the Cesarian section to deliver a dead baby.

Almost all the patients  mentioned above who survived could have died if we had not done anything on them when they came to us.

The last sick patient in the ward is a little boy with a very bad fever. His counts have been rising after admission and I suspect him to be in a very bad septicemia. The father badly wants to take the boy to a higher centre, but has no money.

If he stays on - I shall do an LP on him tomorrow.

However, over the next 5 days, I pray that we would not have many sick patients as I'm afraid we would not be able to do full justice to them in the middle of a very busy week of celebrations of 50 years of the existance of NJH closely followed by the Eastern Regional Administrative Committee meeting.


And to top it all, there is a young man with tetanus who has uncharacteristically turned up quite early and has been doing well.

Pray for us . . .

Golden Jubilee celebrations - The Beginning

We kicked off our Golden Jubilee celebrations by welcoming Dr Mark Kniss and his son, Mr James Kniss to NJH. Dr Mark and James had arrived one day back in Ranchi and were staying with an old friend.

I was blessed to pick up Dr Kniss and Mr James from Ranchi. After a long drive taking almost 4 hours, thanks to inhospitable roads - we reached NJH by around 6:30 pm to be greeted by almost the whole campus including the families.

There was traditional dance organised quite well by the nursing school students which escorted the guests to the chapel in the middle of the campus.

There was the traditional hand-washing ceremony followed by garlanding of the guests.

As soon as we had finished welcoming Dr Kniss and Mr James, Dr Nandamani's vehicle with Dr Ron Hiles arrived.

Once everybody was settled, Dr Nandamani was also pushed in to sit along with the guests.

Little did he know that we still remembered that it was his birthday and we ended the programme garlanding him and singing 'Happy Birthday'.

Disappointment . . .

As we look forward for our Golden Jubilee celebrations, we have been quite encouraged by the response from the local community towards the care we give at NJH.

The local health authorities have also been showing quite encouraging signs one of which has been the meeting for training on maternal mortality review.

Close to the heels of the session, I was informed by one of the officials that due to technical reasons, the government would not be able to renew its' contract with us for the implementation of the Janani Suraksha Yojana. (JSY)

Without doubt, the JSY has played quite a significant role in improving maternal health care in the region. The technical reasons were quite dubious from the scenario of Indian healthcare especially in relation to the rural areas of the country.

The technical reason for the refusal to renew the contract was that there we did not have any consultant in obstetrics, pediatrics or anesthesiology. For the same technical reason, none of the other private institutions in the region has been authorised to implement the JSY.

The same day there was a news item about the number of quacks operating in Delhi. The same system who cannot ensure that non qualified people do not practice medicine is trying to ensure that only specialised doctors deal with obstetric care through which almost all families go through at least once in their lifetime.

Leave alone Delhi - look at the number of quacks in Kerala - which boasts of world standard health indices.

One needs to visit many of the district hospitals in many of our states in the night with a complicated pregnancy and find out how many of them have a obstetrician, an anesthetist and a pediatrician on regular call readily available to rush in any emergency.

I have enough cases which tell me that there isn't enough specialists available in our public health facilities. Even if there are specialists available from a statistics point of view - how many of them would be ready to work in places like Latehar, Palamu or Garhwa - the nearest 3 district headquarters to NJH.

And more than the availability of specialists, I would like to press my case with regard to the availability of all 3 of them together at a given point of time. I've seen many times when complicated pregnancies were turned away because one of the three specialists (obstetrician, pediatrician, anesthetist) supposedly needed during the intrapartum care of a patient is on leave.

On one side, there were efforts from the side of the government to start a course called Bachelor of Rural Medicine and Surgery targeted to improve healthcare in the rural areas - whereas on the other side they stiffle efforts taken by qualified doctors to improve healthcare in these needy areas by bringing in draconian rules.

Now, when I've mentioned about this problem which has occured with us - I need to bring your attention to another law which is called the Clinical Establishment Act which is already in force to its full extent in states like Assam and Orissa. One of the most draconian rules under the CEA ensure that unless specialists are available in a healthcare centre - the concerned procedure cannot be done in the said hospital.

Which ultimately means that if you do not have an obstetrician, no deliveries can be conducted in your clinic. You would not be able to do any surgery unless you have an anesthetist. And you can ultimately end up interpreting the rule to such an extent that a surgeon may not be able to even treat his own child for a respiratory tract infection.

Meanwhile, we end up in a situation where quacks and RMPs flourish whereas a qualified MBBS graduate would be worrying whether he will end up in the hands of the law if he does certain procedures which are part of somebody elses' speciality.

This again brings me to plead for the inclusion of the speciality of Family Medicine as a recognised speciality under the Medical Council of India. There is already a Diplomate of the National Board for which exams are conducted. However, we need to move beyond that and ensure that there is Masters and Diploma degrees in the speciality.

I understand that there is staunch resistance from the professional bodies of specialist doctors. Their fears are unfounded. Many of them are afraid that they would lose their earnings to the new found specialist group of Family Physicians. However, it is very evident that the nation would gain very much from a cadre of Family Physicians in the healthcare system.

That is exactly what we have at NJH. We have only one surgeon. The rest of us are all family/community  physicians. All of us can give spinal anesthesia, resuscitate a baby, do a cesarian section - take decisions on ventilating a patient etc etc. If we had waited for many of our patients to go to a specialist they would have been long dead.

If taken in the right spirit, the speciality of Family Medicine would be the toughest and the most exiting speciality in the realm of healthcare academics. The major challenge will be ensure that the MCI takes a positive decision on this as well as develop a syllabus which is robust enough to transform graduates of medicine to family care specialists dedicated to the cause of holistic care to patients.

The culprit identified . . . SK.

Yesterday, SK who had come with an unknown bite and went into quite a lot of complications ultimately went home.

She was looking quite cheerful.

The diagnosis on her discharge summary read -

UNKNOWN BITE RESULTING IN

- DRY GANGRENE OF THE RIGHT LEG FOLLOWING COMPARTMENT SYNDROME,

- ACUTE RENAL FAILURE,

- MYOCARDITIS RESULTING IN PULMONARY EDEMA AND

- SEPTICEMIA.

Her highest level of S.creatinine was 7.8 mg% and we had wished that we could try out peritoneal dialysis.

We are thankful that she pulled through. She was in the ventilator as well as manually bagged by her parents for almost 72 hours.

Now, we made an attempt to identify the culprit. When Seema came to my office before discharge, I decided to give it another try. She clearly told me that she was bit by a 'Khapar Bitcha'. I summoned some of the local staff and tried to figure out the creature. 'It looks like a large lizard and a coarse chameleon' - that was how someone put it.

I figured it is something like a monitor. So, I searched the web and came up with some pictures. Ultimately, when I showed her the wikipedia page about the Bengal monitor, she was absolutely sure. However, I had a problem. I could not find out anywhere that the Bengal monitor was that poisonous.

Sometimes I wonder if we had made her more sick by giving her Anti Snake Venom - we did it as her Clotting Time was more than 20 minutes. Or was it a result of septicemia which resulted following the gangrene which set in because of the compartment syndrome.

I look forward for comments regarding the same. Especially from the experts on such bites. Maybe we've found something new that could be reported.

The story about SK would not be complete unless I put in something which we did for her family. If you have read my previous blog about SK, you will understand that her father wanted to take her home to die. We pleaded with him not to and give us a chance to try to heal her. Ultimately, I had to tell the father that we would treat her for free.

Unfortunately, once the father saw that SK was getting better, he had gone and sold a part of his land and got some money. He was ready to pay about 10,000 rupees when the discharge was all made. The total bill had come to about 30,000 rupees. I kept my promise and did not take a rupee.

However, such things are quite burdensome for the institution. We look forward for contributors from well wishers towards SK's treatment.

Food at NJH

Well, you may find this piece of posting a bit of an odd thing among the themes I usually write about.

This is in response to one of my friends who phoned me the other day and queried about the culinary options in our place. The place is quite famous for not getting the usual gastronomical delights which we cherish.

Many a time we wait for a trip to Daltonganj to feast on dosas, chaat etc. There are umpteen number of stories on how families used to survive on only potatoes or okra for days together. Even recently, one of my colleagues was commenting on how he and his wife was surviving only on rice and eggs as he could not find the time to go to Daltonganj and shop.

Comparing to olden days, things have improved quite a lot. Many of the things are available just outside the campus and there is a choice of vegetables to choose from. However, once in a while it becomes a bit difficult especially during the summer months.

But, when my friend called, I told him that things continue to be difficult when it came to access to food varieties.

When I came home yesterday after I had talked to my friend, there was a bit of a paradoxical statement on my dinner plate - which is put below.

For the untrained eye on Malayalee food, the items are as follows -

1. Pomfret fry: Considered a delicacy. Can cost upto 500 Indian rupees per piece in a five star hotel. Called 'avoli' in Kerala. Brought it from Ranchi couple of days back while on an official visit.

2. Beef tikka: Minced meat mixed with spice and deep fried in oil. Brought from Daltonganj and baked for 3 minutes at 300 degree celcius.

3. Beetroot patcchadi: Beetroot sliced into thin pieces and cooked in curd.

4. Yam fritters: Yam (called Chena in Malayalam) made in thick pieces and cooked dry.  

So, I've discovered that if one could plan and has a caring wife, we could have quite an array of foods accessible.

Therefore, for all of those who like to become part of our team, but hesitant because of culinary limitations, I hope that this post will encourage them to positively consider joining us.

SCARY . . . ULTIMATELY HILARIOUS

Since the last 2 days, we were having or supposedly having a really destructive rodent in our administrative office. Rats have always been an issue in almost all of our homes and hospital.

One of the main job descriptions of Mr. Jorang, our helper in the office is to keep a rat trap at the end of the day. According to Mr. Majerus, our finance person, the menace was quite more in the earlier years and there were days when simultaneously two traps were successfully operated each day.

Today morning, the damage was quite significant. There were files which had been badly damaged. The internet connection was gnawed through. There were quite large scratch marks over the plywood temporary partitions.

Yesterday evening, Mr. Joram had remembered to keep the trap. The bait was untouched. There was an emergency meeting to decide on the future course of action. There was unanimous agreement that we are dealing with quite a large rat – maybe a bandicoot – ‘the type you find in railway stations’ – that was how someone put it.

The trap was definitely out of question – since it was too small for so large a rat. There was unanimous agreement that we would not try to poison the creature. The reason was that the last time we did it – the unfortunate thing had died in an inaccessible part of our building, because of which the area was sticking like a fish market for almost 4 weeks.

I had some experience in trapping bandicoots when I was a kid. So, I told them that I would take care of the job the following evening once office was over.

New spread around fast about the ‘bandicoot’ which had taken residence in the office and how the Medical Superintendent has taken responsibility of trapping it.

The days are quite busy here with the Golden Jubilee celebrations fast approaching and the busy inpatient. So, it did not take me long to forget about the matter. And the previous night, I had already dealt with a rat who had taken up residence in the hardly used air-conditioning unit of our bedroom.

About couple of hours, there was a commotion from the finance section. Majerus happened to observe a furry thing moving in the corner of his table. It had disappeared by then. However, Majerus was certain that the bandicoot was there. So, we had the ‘office team’ moving in fast. Meanwhile, someone spied the movement under the table and found out that it was more a cat like animal than a rat.

Well, there was quite a lot of talk on the probability of it being a wild cat, considering the proximity of a wildlife park wildlife park near the hospital. As the talks were going on, the ‘bandicoot’ ran across the room. It was a cat. Poor thing – probably the fellow was trapped within the office complex and was quite hungry that he started gnawing on whatever he could eat. And the bait was untouched because I don’t know of cats that eat potatoes unless you lace it with fish.

I was reminded of the story we heard in school of an entire village mobilized by a group of boys who spied a head which was looking out of a hole – which they concluded was that of a cobra. The villagers spent almost a day dugging up the soil around the hole and ultimately found out the ‘cobra’ were in fact a fat chameleon.

I ultimately took a decision to leave the cat to find its’ way out rather than we trying to poke it out of wherever it was hiding. I’m not sure whether he has left his new found home, which I’m sure he’ll do in a couple of days.

Lesson learnt - Most of our problems are more imagined than actual.

Maternal Health Care in Palamu - Red letter day

Today was a red letter day in the history of maternal health care of our region.


The UNICEF along with the district health authorities of Palamu district had arranged for a training session on Facility Based Maternal Death Review. I understand that soon there would also be efforts taken for training grassroot workers on Community Based Maternal Death Review.


Mr Prabodh Kujur and myself represented NJH as we have quite a large burden of adverse maternal events including maternal mortality. Over the last 1 year, we calculated about 20 maternal deaths within the facility. This excludes at least 5 patients who were brought dead.


One of the key messages which was conveyed to all the doctors who came was about the absence of a blame factor in the whole exercise. Many a time, adverse health events are not reported because of a fear of punishment. I was very glad that the message was conveyed well.

As I sat there, images of mothers who died or almost died, those who ended up with lifelong complications and dead babies flashed before me.

I remembered AB's baby who just made it whereas she should have been referred faster. BD, whose life has turned for the worse was a poignant face whom I would remember for the rest of my life. One of the major finding I would expect from the reviews is the strong association between malnutrition and anemia. 

The mental stress that KD's family endured was still fresh in my mind. Our experiences with patients like RD, who lost her baby or SD, for whom we had to intervene heroically have already taught us that the delay in taking the decision to go to the healthcare provider and the delay in implementing the decision is quite costly in the lives of mothers and newborn. I'm certain that this is going to be one of the major learning in this exercise.

I'm excited about the whole excercise. We look forward to a time of learning and understanding determinants influencing maternal health care in this region during the maternal death review meetings at the institutional and district level.

More than that we look forward to a period in our surrounding communities where pregnancy is more safe whereby families will cherish and enjoy motherhood which would be the ultimate aim of such an exercise.

Unknown bite - and more venomous

SK about whom we were quite concerned about for quite a long time finally improved well enough for us to start thinking about discharging her.

SK came about 10 days back with a history of an unknown bite. The relatives were quite confused about the identity of the creature which bit SK. We send for the clotting time which came elevated. There were local signs of envenomation. So, we came to a presumptive diagnosis of viper bite and started anti-snake venom.

SK improved very soon and her clotting time came to normal limits. There were 2 other patients with viper bites and the 3 families formed a sort of bond. The other 2 patients recovered without much problem. SK also had compartment syndrome and underwent fasciotomy. The 3 patients send us into a situation where Anti- Snake Venom was running short.

However, we noticed that SK’s renal status was deteriorating and was going into anuria. Meanwhile, the other 2 were improving. I called up SK’s father and told him about a possible need for referral. SK’s father told me that he has already sold 2 of his bullocks and 1 goat to fund SK’s treatment. And as he was not going for work – so he had to provide for the family’s day to day existence.

A funny side of the treatment process was the constant stream of visitors that SK had – mostly local leaders and pretender leaders. Couple of them came and met me and told that they would take care of all the costs and to do the best for the patient. After some important looking leaders came and met me – I called up SK’s father and asked him about it.

He would start sobbing – telling that none of them including his villagers has given even a single rupee for the treatment even to the extent of taking responsibility to care his other children. He told me that if we cannot manage her, he would rather take her home to die.

We convinced him to allow us to do whatever we could to try to save SK.

Meanwhile SK was worsening. We realized that she was going into pulmonary edema. We were juggling on what could be the cause of the pulmonary edema. Renal failure was thought of as the cause and we became quite stingy with the fluid management. However, there was no relief. In addition, we had to put her on mechanical ventilation.

She had also gone into sepsis. We changed antibiotics – but without much improvement. Later, Dr. Nandamani explored the chance of cardiogenic pulmonary edema. Ultimately, we decided to start SK on a GTN drip.

And we praised God when she responded to the GTN drip. After 3 days in the ventilator, SK was weaned out of the ventilator. She is quite tired. 3 days on the ventilator was quite a bit stressful on both our ventilators – the older one and the newer one – and for quite a lot of time, she was manually bagged by both the parents.

I’ve send for further investigations about her renal status. Clinically, she appears to be on the road to recovery.

Today morning, I got to talk to her. We were already a bit suspicious about the creature which bit SK. SK was quite sure that it was not a snake. She told that it looked like a large lizard. SK’s father told me that if it was the creature – usually people die after this creature bites. After the case of a spider bite which caused quite a lot of stress to a family, it is quite interesting that we do have other creatures which can be as dangerous as venomous snakes like cobras or vipers.

Aluminium Phosphide poisoning

Aluminium Phosphide, commonly called Alphos in our region is one of the most dangerous poisons used to commit suicide. The ultimate result is almost certain death. And I hardly remember a patient who made it, until we found out about a new approach to treat such patients. But, before I describe about the new treatment which we happened to stumble upon – something about the poison.

You can read more about the poison by clicking here. I remember talking to one of my friends who used to work in the Food Corporation of India quite a long time ago during my high-school days. He was the first one who told me about this poison as well as showed me couple of tablets of aluminium phosphide. To demonstrate the potency of the poison, he showed me how one tablet was used as a insecticide for quite a large amount of foodgrains stocked up in gunny bags. Only one tablet was needed to be kept in the middle of a pile of about 100 gunny bags of food grains to keep the whole lot free of pests.

So, one can imagine how poisonous the substance was.

So, what is it that we are doing new? We’ve already had 4 patients who have gone home alive. The usual treatment comprises of maintaining blood pressure by giving dopamine drip. We also give magnesium sulphate injections. However, there are conflicting reports on how it helps.

I was having a casual talk about this with one my friends who were doing his post-graduation in one of the medical colleges nearby. It happened that his thesis happened to be about ‘Alphos’ poisoning. He told me about the part of giving coconut oil along with activated charcoal after the stomach wash. So, we started to do it on a experimental basis.

There were few papers on this in the research available in the internet. You can read about it either here, or here. It has worked wonders so far. There were 2 patients who had gone into hemodynamic failure. The other two had come quite early that they did not go into shock after we had given them stomach wash followed by coconut oil put into the stomach.

Later I found out about anecdotal reports of local healers in Africa especially Morocco who treat patients with clarified butter (ghee). I was a bit surprised that not many clinicians had heard about this although I found research papers published as early as 2005.

However, there are quite a number of factors which are known to determine survival in ‘Alphos’ poisoning which include aspects such as vomiting after poison ingestion, the number of tablets which is taken and how fresh the ingested tablets were. It seems that if the tablets are kept in the open for quite some time, they lose their potency.

I’m not sure if any other oil will work. However, it is quite funny that coconut oil which is more of a part of South Indian cuisine is found to be useful in ‘Alphos’ poisonings which is more prevalent in the north of the country. One of my patients had complained about the odd taste of the coconut oil which he could not tolerate. But, I told him that maybe it was the ‘unpalatable thing’ that saved him.  

The Occult

SK's parents had a very peculiar request about 4 days back. Initially, they told that they wanted to take her to Ranchi. I knew that this was not going to happen as couple of her neighbours had informed me quite early that the family was too poor to even pay the medical bills at NJH.

I called the father separately. I asked him about the request to take to Ranchi. He told me that the family was planning to take SK home to die. But, he was also going to try out some black magic – called ‘jhad phuk’ in local terms by the witchdoctor called ‘ojha’.

It was unbelievable. But, true in rural areas in third world countries. After much persuasion, he agreed to allow us to try to save his daughter.

It is not uncommon to see new amulets being tied around patient’s wrists or put along with a necklace while they are still admitted in hospital.

Couple of photographs of patients with things tied around their bodies.

IK, who was clinically diagnosed to have encephalitis - he was too sick to be even taken elsewhere. He made a remarkable recovery. If you look carefully you can see one blue colored and a white colored thing tied over his left shoulder. IK's father had quite a lot of faith on the treatment we were giving him. Then, I asked him about the reason for the extra things which used to change almost every alternate day. IK's father would only giggle in reply.

I found this tied on AS's arm couple of hours after I had admitted him. I am sure that it was not there when he had come in. Unlike what I had expected, AS was taken to the nearest medical college hospital the next day morning. But, he passed away the very next day.

It is quite rare that we see patients especially with medical complaints who does not have one of these amulets tied around their neck or wrist. Many a time, especially with snake bites, they perform quite elaborate rituals before they bring the patients for treatment.

I'm not sure of having seen such practices in any other place to such an extent as I've been seeing here. I don't know about practices in other parts of the world.

UNUSUAL RUSH

It has been quite unusually busy at NJH over the last week. Usually, work is quite light after the Dusserha celebrations start and continues on like that for almost the whole of winter – except for the cataract surgeries.

Unfortunately, I have to away from hospital attending work related to the Golden Jubilee celebrations scheduled towards the last week of this month. Yesterday (Friday), the business was quite evident as I was away in Ranchi attending to work. And the situation would remain such for almost the whole of next month.

It all started with the theatre where Dr Nandamani had posted couple of surgeries, one of them a cholecystectomy. He was only halfway into the surgery when he was informed about a pregnant lady with the babies’ hand prolapsed per vagina and baby was alive. Somehow, he rushed through the rest of the surgery and got the lady posted for an emergency cesarian section to deliver a healthy baby.

Immediately afterwards came a rupture uterus. It was again a very peculiar rupture uterus as the uterus had ruptured in the posterior wall and the rupture extended upto the vagina. It is quite a difficult surgery and he was the Lord’s graciousness that he realized halfway into the suturing up of the uterus that he had unwittingly ligatured the ureter.

Dr Nandamani told me that it was one of the most difficult of rupture uteruses that he had operated on for quite a long time.

While the rupture uterus was going on – in came a previous cesarian in full fledged labour. Everybody was quite relieved to find out the lady was in second stage and she had an uneventful normal delivery.

However, one of the major reasons for the hectic time in the hospital is because of one young girl, SK with history of bite by an unknown creature. – we had presumed that it was a viper as her clotting time was prolonged. She had gone into compartment syndrome and in addition had developed renal failure. Since the last couple of days, she started to have episodes of breathlessness which we ultimately diagnosed to be pulmonary edema.

Many a time, the girl’s parents wanted to get her discharged and take her home. The reason was that they did not have any money. Considering that she is from the nearby village, we agreed to treat her free. She is on the ventilator and maintaining a good urinary output.

I have a feeling that she has developed some amount of myocarditis secondary to the venom and we may be dealing with some other venomous creature bite. Kindly pray that SK will recover fast.

In addition, there have been umpteen numbers of malaria and other cases of acute febrile illness which has come in.

To top up things, there was one maternal death. The lady was in the early part of the 3^rd trimester. And she had developed fever. She was on treatment elsewhere. Later, she developed jaundice. That was when they decided to bring her to NJH. On arrival, she was quite sick. Her blood smear showed hoards of malaria parasite and the platelet count was only 16,000. We asked the relatives to take her to Ranchi. They were too poor. No blood could be arranged. She died sometime around midnight.

I’m not complaining. We are here to serve. But, sometimes we feel that we would be better off with some more fresh expert hands joining ours. With the Golden Jubilee celebrations approaching and the expected arrival of a new baby in Dr Johnson’s family, if we continue to have such a patient flow in the hospital, we know that we are going in for a tough time.

Domestic Violence . . . Bizzare and Cruel

(Warning: The photograph is this blog is very disturbing.)

Today sometime around afternoon, we had a patient with burns all over the face.

It was a bit unnerving as the burns was only limited to the face and just extending to the scalp. Not even a centimetre of burns anywhere else in the body.

Initially, I thought that it looked like an acid attack - I had seen photographs and few victims during my visit to Bangladesh. But, there were no marks of acid having flown down the body. Dr Nandamani noticed that she was smelling kerosene over the burnt area - but this was not a typical case of burns where the kerosene is poured on the head and the victim trying to set it on fire.

Then it dawned to me. There was only a chance for this sort of burn. She or somebody had forcefully dipped her head in a fire. The relatives who had brought her was not forthcoming. After consoling her - we found out the truth.

Her own words - 'My husband tried to burn me after pouring kerosene on me. I tried to run away. Then he caught me on my hair and dipped my face onto a vessel of boiling oil which was being heated up for cooking. Then he ran off'. The reason - She was upset with him for the way he was spending it and she had asked him for some money.

It is going to be long haul for her. However, the manner in which she got burnt is something unfathomable. The paradox was that later she described her husband as a good man without any vices. Maybe it was done in a rush of anger.

Domestic violence as a major aspect of public health needs to be further re-examined especially in the light of violent incidents such as these. Prevention of such incidents is possible if there is good family and community support.

THE LORD IN CONTROL . . . Trusting HIM

We were in a very peculiar situation since the last week.

Our hospital is in a very high snake-bite prone area. Therefore, we keep about 40 vials of the Anti-Snake Venom separately for our staff use. Unfortunately, since the last 2 weeks, we faced difficulty procuring the ASV. And to make matters worse there was no dearth in the the number of our admissions of patients with venomous snake bites.

About 5 days back, I was relieved to know that one of our suppliers agreed to give us about 120 vials of ASV. He promised to come on Friday last. Unfortunately, he did not come. And on Thursday night, there was a snake bite victim on whom I ended up using 16 of the 40 vials kept of our staff. I was in a fix and I prayed that there should not be any snake bite victims over the weekend.

Meanwhile, the supplier phoned up and confirmed that he would arrive surely on Monday. I somehow got hold of 5 more vials of ASV from the local retail pharmacies – most of them had none or at the most 1 or 2. And we had one more snake bite victim on Sunday night – and I used up 8 of the vials.

I was in for trouble – the supplier’s train got cancelled on Monday. So, I was looking like a fool with 11 vials of ASV and I knew that I could only pray hard. And that’s what I did. The supplier called me and confirmed that he had got a ticket for Wednesday, the 12th October.

But, I had almost 48 hours to get through with only 11 ASV vials with me. Then, out of the blue – the good Lord gave me a thought. Dinesh, our engineer had gone along with Sr. Rita, the Nursing School Principal to Ranchi. I asked Dinesh if he could just try to scout for some vials of ASV. I was glad when he could get a total of 15 vials from different places.

And today, I knew that the thought of getting some more vials happened only for a little girl who came at around 11 am today with absolutely no respiratory effort. She was apparently bitten by a cobra. Later we found that the hematological parameters were also awry – so conclusion that it must have been a large krait.

We intubated and mechanically ventilated her. 8 vials of ASV were flowing into her veins in no time and 8 more went in over the next 4 hours. It was good to see her conscious and sitting up comfortably when I left hospital in the evening.

The incident had a very simple message to me – on whom I should be trusting. There is a verse in Psalms 20 – v7. Some trust in chariots and some in horses, but we trust in the name of the Lord our God.

The supplier confirmed just now that he is finally in the train on his way to NJH. I’ve asked Dr Nandamani to go ahead and use the remaining 15 ASVs if there is a need in the night. I sleep peacefully in full faith that the Lord is trustworthy.

Tetanus - help from a Good Samaritan

CD who was with us for almost a month got discharged couple of days back. He was quite in a bad shape when he had come in.

It was a matter of concern for us on how he will make his way back home. He came from almost 100 kms away and it was not on the main highway. With great difficulty he arranged for food. We were quite sure that the family did not have any money.

I’m yet to see the total bill. It should be something around at least 20,000 Indian rupees excluding the medicines which also we helped him to buy. Tetanus is not a great disease to have. He took almost a month to recover, of which he was heavily sedated for about 20 days.

I come to the story on how the good Lord arranged for people to arrange for his travel back home.

I was in my office when a middle aged gentleman walked in. He did not look that rich though he could have been even poor. He told me that he was the father of a lady who had come for delivering.

I was very dismissive of him thinking that he has come to ask for some charity. Meanwhile I asked him to sit. He asked me how CD was doing. I told him he is fine but would need some more physiotherapy before he could be fully back to his normal routine.

The gentleman told me that CD was his neighbor. And also that during normal days, CD’s family had struggled for food. CD getting tetanus had made things worse. He requested me if he could allow CD to come back with him when his daughter was discharged. Thus, CD could have a comfortable ride back home.

CD (seated) with the good Samaritan (on the extreme right)

I was thrilled. It was so good to see a caring neighbor. I wish we have more people in our villages, who would care for each other especially when it came to issues of healthcare and food security. I wondered how long it has been since I’ve seen somebody offer help without being enticed for the same.

Hard working and over worked . . .

We have been always hearing about the less number of healthcare personnel especially doctors available to work in the rural and remote areas of our country. It is no secret that even public health facilities at the district level run with skeleton staff and inadequate infrastructure.

Yesterday morning, our local newspaper carried out a front page article on the lesser number of doctors available to serve the nation.

'No doctors, how will there be treatment'

There were statistics given about the statistics of shortage at the state (Jharkhand)level and the national level.

However, more interesting was a small article within the main article narrating the story of one of the senior doctors in Latehar district hospital who apparently fainting during his duty following severe exhaustion caused by continuous work.

I've heard about the goodness and sincerety shown by Dr Harold Hansda in his work. The question remains on how much people like him get appreciated. I will certainly run into him some day. And I shall tell him that I appreciate the work ethics shown by him. Hope that there will be more doctors who can work at least selflessly to some extent, if not to the extent shown by Dr Hansda.

Encephalitis around - SOS

Yesterday, sometime around 3 in the afternoon, I had a patient in the outpatient department with a history of fever since the last 5 days and illegible conversations since yesterday morning. He was being managed elsewhere for malaria. The family was well off and our wards were quite full. I gave them the option of going ahead. They were not very forthcoming. Later, one of the relative turned up and asked me what I think about the diagnosis. I told him it is some fever which is affecting his brain. Then he told me that he was already on treatment for malaria and typhoid.

We had been having quite non-specific fevers over the last month and we've been suspecting viral encephalitis. Some of them seemed to have done good and improved. There are couple of them who did not make it and I had few children who has neurological sequelae.

I told the doctor about my suspicion of encephalitis. Later, there was one of the local leader who came in for discussions. I was thankful that they ultimately took the decision to move ahead to Ranchi. However, I had sent for blood tests before the results had come. After they left, I was more relieved when the blood tests came. His platelet count was just 50,000.

I bumped into the village leader today afternoon. He updated me about the patient. It seemed that he was diagnosed to have viral encephalitis in Ranchi. Overnight, his condition deteriorated. He is in the ventilator. The doctors have told him that he has brain edema and the chances of survival is quite bleak.

So, we are in the midst of an epidemic of encephalitis. It is very surprising that I'm yet to recieve any intimation from the government machinery. I had called the Civil Surgeon couple of weeks back and told him about my suspicion.

I still have about 5 patients in the ward whom I suspect encephalitis. I've asked my store manager to get intravenous acyclovir. Without a medicine consultant it is very exhausting to manage these patients. And to make things complicated, we had been suspecting other causes of fever for quite long.

One of the 5 patients, 7 year old IK was doing good and improving with oral acyclovir. I wanted to refer him - but the family was too poor. He developed seizures yesterday and has become unconscious again. Today evening, he shows signs of improvement. I praise God. I pray that he does not have any neurological sequelae.

I'm concerned about the surrounding poor villages and our staff families. I pray that this epidemic will move on without causing much more damage. I wonder where the government machinery is. I wonder when shall we grow out of the 'malaria and typhoid 'malaria and typhoid only' attitude. It is high time we plan to explore more on what causes fevers in many areas of the country.