Photo post . . . 28 March. . .

18 day old girl baby presenting to OPD with early breast development. There were no other features of precocious puberty.

This 35 year old man came to Emergency with history of cough and fever for 10 years. He was so breathless that I sent him straightaway to the ward and planned to evaluate him later. It turned out that he has visited almost all the best institutes in North India. On doing CT Scan, the diagnosis was staring at us – Interstitial Lung Disease. A not so common diagnosis in our place. I’m sure that there are a lot more undiagnosed cases. The saddest part was that nobody had told him about this diagnosis and the prognosis . . . 

A 60 year old man with a poorly managed supracondylar fracture. Resulting in a gunstock deformity.

CT scan of a 20 year old girl with focal seizures. Shows unilateral parietotemporal atrophy of the brain. I wonder what could be the cause. The history is of about 10 years duration.

This is a drain built by our local panchayat to facilitate smooth flow of household waste water. Unfortunately, it had got blocked. And see who’s breeding inside. Enough ammunition for a malaria epidemic.

The internet and cell phone connections at NJH has been dead over the last one week. Being the end of the financial year, it has been quite tough on us. Well, I found out a corner of my house where I could get good Airtel mobile connection. And this is the result. The funny thing is I get calls – and by the time I take the cell phone out from the hook on the wall, it gets cut. I must find where my earphones are . . .

Since, we just celebrated World TB Day, I thought about putting in couple of snaps of Chest X-Rays of TB patients. The first one - A very bad case of pulmonary tuberculosis with extensive destruction of the right lung and miliary mottling of the left lung. The patient has been on irregular anti-tuberculosis medication from a quack for quite a long time before he planned to visit us.

Chest X-Ray of another mismanaged pulmonary tuberculosis. This time it’s a lady.

A very bad case of atopic dermatitis with secondary infection. She had similar lesions in the nape of the neck too.

Another accident . . . provoking thoughts. . .

There has always been a debate on the cost at which societies have achieved development and progress. However, it is not an unknown truth that most of the progress we see around us happens at the expense of the poor and the marginalised. The issue becomes more sad when lives are lost in the process.

It has not been many days before we had another accident in front of our hospital which claimed yet another life. The difference being that the unfortunate victim this time was a boy on his way to school.

The accident occurred at around 9 in the morning. I got to know it as it involved one of our senior staff. Mr. Tapeswar oversaw the functioning of a hostel for kids from remote villages who went to schools nearby. There were not many kids – but it was enough to keep him busy.

The unfortunate victim was about 6 years old. And was on his way to school when an overspeeding Bolero jeep smashed into him. From the people who had seen it happening, it was obvious that the boy died on the spot.

The site soon after the accident. The body lies on the road and the locals prepare to block the road 

Well, the stretch of road in front of our hospital is quite good and there is a tendency for vehicles to speed up. I wonder if the number of accidents would increase once the whole of the terrible stretch of road between Ranchi and Daltonganj is repaired.

And we are having our road repaired on a war footing since couple of days. We’ve heard that the Deputy Commissioner of the district has given an ultimatum to the Public Works Department to complete the work by the 15th of April. This is good news for us especially our school children who travel about 60 kms to and fro daily.

That night, I wondered about how inequality reigns in our society is. Most of the infrastructure development happens which do not directly benefit the real poor. Rather, the development occurs at the expense of the poor and the marginalised.

We’ve high speed express highways between cities that speed up traffic but which hardly brings any development in the poor villages that line the highway. It is not an uncommon scene where electricity high tension wires pass through villages which has not seen electricity. High speed express trains whiz past malnourished children waving at the passengers.

The little boy may not have died if the road was not too smooth for the Bolero to whiz past at such a high speed. I tried to contact some officials from the Public Works Department about the possibility of putting couple of humps on the road where there is a possibility of drivers trying to speed. I was told that humps are not permitted in the National Highways. I’m not going to give up.

The accident brought into light the aspect of development about which I had been referring to at the beginning of this post. The collateral damage that communities pay to ensure smoother lives for better off fellow citizens is sometimes quite large. I remember an incident that an agrarian family narrated to me while I was doing part of my post-graduate posting in RUHSA. It was about herds of cattle and goats being mowed down by high speeding trains.

The railways have of course brought the land for laying the rail tracks. But, they created a barrier to many a family from accessing prime pasture land or water bodies. It is of course impossible to provide throughfares at short intervals. But, I understand there are countries like Japan where elevated rail lines were specifically created so that there would not be disturbance to normal lives of people living along the route.

But, there are instances within our own country where the needs of the ‘people along the way’ have been taken care of. The first one I can remember is the service roads which are provided alongside high speed expressways. The Chennai-Bangalore have quite a lot of them especially in small towns. Another example is of railways building footpaths beside rail-bridges allowing local villagers to use them rather than the rail-bridge to cross.

However, there are larger stories of exploitation prevalent in areas of our country whereby entire people groups are displaced for the purpose of bringing about development. Well, that is an entirely different story and a larger issue which has brought people groups into conflict.

Like the road blockade that was put on after the incident in front of the hospital, there are similar protests which only serves to bring the attention of the administration and community for a short duration. However, there are no long lasting solutions achieved nor attempted. Once the road blockade is over, everybody forgets about the root cause of similar accidents and nothing more is done. 

I’m sure there are interventions possible in development of public infrastructure whereby loss to life and resources can be brought down to a significant extent. If that happens, we can prevent more of such ghastly incidents from happening. However, this would require quite a lot of political will as well as community mobilisation . . . 

Obstetric care . . . The stories continue . . .

It has been quite some time since I posted a post on obstetric care at NJH. After the empanelment of NJH into RSBY, it has been quite busy. Today morning, as I visited NICU, I was surprised to find a baby wailing and quite hungry. The reason I was surprised. Couple of days back, we had delivered this little fellow and we had hardly any hope that he would make it. The story of LD’s mother will mirror the stories that I’ve been sharing through this blog over the last 8 months.

LD’s mother as well as SD, about whom I shall share in the latter part of this post comes from Garhwa, the western most district of Jharkhand. It is one of the most impoverished regions in the entire country with stories of hunger and exploitation quite common but hidden from the rest of the world. As part of the overall backwardness of the district, the health services are also very poor. Due to some reason, almost 80% of our complicated patients especially in obstetrics come from this district.

LD was pregnant for the first time. She had couple of antenatal check ups from Daltonganj which is the district headquarters of Palamu, Garhwa’s neighbouring district. She even had an ultrasound scan sometime in the 32nd week saying that the baby has an abnormal lie. However, her family claims that she had a check-up at some place couple of weeks before where she was told that the baby has come into the normal position.

LD came to us late night on 26th March. She had started contracting sometime around the evening of 25th and her membranes had broken sometime early morning of the 26th. When she did not deliver by late morning, she was taken to the nearest health centre from where she was referred to Daltoganj. However, they came to NJH straightaway. She was told that the baby is coming legs first.

I saw the patient as soon as I had finished a Cesarian section on SD. The first thing I noticed was how small her abdomen looked. On per vaginal examination, it was obvious that the baby’s shoulder had presented and the hand was on its’ way to slip out. I had to do a Cesarian immediately.

The best part was that on Cesarian section, it was obvious that she had received umpteen number of oxytocin injections. It was already tonically contracted over the baby and there was hardly a drop of liquor. I feared the worst with a compound presentation. The head and the torso was folded over each other with the back presenting at the site of the uterine incision. I had to ultimately end up putting an inverted T incision on the uterus.

On delivery, the baby was flaccid like a rag doll. There was no pulsation of the cord. Only the heartbeat was there. I was sad . . . we were going to end up with a dead baby after a LSCS. Dr. Titus was there for the resuscitation. He went through the motions of resuscitation, thanks to the classes from Wendy of Grace Babies. After about 5 minutes, there was a whimper and then a small cry . . . By the time, I closed the skin, the baby was wailing. However, there was grunting and I had asked the relatives to take him to a higher centre.

It was good to see the baby live and healthy after such an uncertain and dangerous period. Which, could have been avoided. That’s my point. Home deliveries are such a bane to the developing world. More so in countries such as India where there is no skilled birth attendants. However, even when there is a skilled birth attendant, I’m sure that a home delivery is such a dangerous thing. Many of you may be quite aware of a growing following of people who promote home deliveries, even in the west!!! Recently, I came across people writing about this.

Well, one should realise that the most common causes of maternal mortality and death are complications like excessive bleeding, obstructed labour, infections for which nothing can be done in a home delivery. Few months back, one of my friends lost his wife in a delivery done at in a small hospital in a big city. She developed a complication for which there was nothing available in that hospital. . . not even a laryngoscope for intubation or ambu-bag to mechanically ventilate. You can imagine the predicament if it was a home delivery.

The patient, SD on whom I had done the Cesarian section before LD had arrived was more terrible. She was 140 cms tall and had a Cesarian for her first delivery. She had been having contractions since early morning of the 25th, leaking since 25th evening…she had been trying to deliver at home and ultimately came to us sometime on 26th evening when nothing much was happening. To make matters worse, she had seen one of the best obstetricians in town and in her prescription, it was clearly written that the next pregnancy would be an Elective Cesarian and one pint of blood would need to be arranged.

I was thankful that SD’s Cesarian section went off uneventful. It was quite surprising that even after so many risk factors present in this patient, the relatives were quite careless as there was no blood arranged and we took quite a long time to convince the relatives of the need of a Cesarian section.

She could have died of a rupture uterus any time.

Talking of maternal deaths, I just remembered about someone making a statement sometime that one of the most common causes of female deaths of the reproductive age group in developing countries is tuberculosis. I remembered it because we’ve a 30 year old mother of five in acute care, who has come to us with one of the most terrible Chest X-Rays I have seen recently. She can hardly lie down as she is quite breathless and has a saturation of only 70% even with oxygen in full flow… The snap below is that of her X-Ray . . . 24th March was World TB Day, which we celebrated in the district. A post on that later . . .

The joy of making pickles . . .

As was mentioned in one of my very earlier posts, a common aspect here is the cost of vegetables which go down to unbelievable extents. After a good monsoon the previous year and a not very cold winter, the vegetable production in this region has been quite good.

And to my horror, couple of weeks back, I found out that garlic was just 25 INR a kilogram. And the same time, I called up my friends in the south and found out that it cost 160 INR a kilo there. I just could not let the opportunity go waste.

So, out went a search for a good garlic pickle. And the results were great that already 3 kilograms of garlic has turned into pickle.

Well, for those interested, the recipe - - -

THE INGREDIENTS

1 kilogram of garlic cleaned . . . This is a painful job. Thanks to our maid, Malu, who baby sits Charis, we did not feel the pain.

10 gms each of Coriander seeds, Fenugreek seeds (methi/uluva), cumin seeds (jeera) and Asafoetida (hing/kayam). Fry them without any oil and grind it together into fine powder.

100 gms of brown sugar/jaggery

10 gms of mustard seeds

Juice of 20 lime. You can use the lemon rind to make lime pickle.

Salt to taste – Depends on how salty you want the pickle to be. I used about 8 teaspoons

Chilly powder – Again depends on how hot you want it to be. I used about 3 teaspoons

Tamarind paste – 4 teaspoons. I’ve always used dried tamarind dipped in water for about an hour to make the paste rather than the ready made tamarind paste.

200 ml of oil. Connoisseurs demand gingelly oil but I used refined soyabean oil for convenience sake.

PREPARATION

1. Heat the oil. Once well heated, put mustard seeds till they all burst and become darkish.

2. Add the garlic to the oil. Keep in low fire for about 10 minutes till the garlic is cooked. Ensure that you stir it every 2 minutes.

3. Mix the salt in the lime juice and add this mixture to the garlic.

4. Add the prepared masala powder mix to the garlic and cook for about 5 minutes.

5. Add the chilly powder followed by tamarind paste and last of all the jaggery. It is better to powder the jaggery before adding to the pickle.

6. Cook for another 10 minutes.

As I told earlier, the results were smashing. Three bottles disappeared in no time. We had to make more.

Well, couple of days back, we had one of our retired staff who brings vegetables for sale bringing cherry tomatoes.

I tried the same recipe substituting the garlic with the cherry tomatoes. Again, the resulting pickle was a grand success. Below are few snaps. 

Shalom admiring the cherry tomatoes

The tomatoes half cooked

We're almost there . . . 

The final product . . . 

Prayer Bulletin . . . 24th March, 2012

1. Today is a bandh (general strike) in this region. It is the 57th bandh of this financial year. A bandh does quite a lot of damage to the state. Kindly pray that there will be a change in the social milieu of this region where people will be able to live peacefully and without hitches. I hear that before the end of this month, there will be 2 more bandhs.

2. We have a young boy of about 4 years admitted today evening. We strongly suspect if it is an index case of viral encephalitis which was quite common last year. He is totally unconscious. We have started him on antibiotics and anti-viral drugs. He's made some improvement. Please pray that he makes a complete recovery.

3. Last week, we’ve had quite a number of visitors. We thank the Lord that everything went smoothly. There were no bandhs during their period of visit, the trains were all on time, nobody fell sick, the weather was good . . . lots of things to be thankful about.

4. As expected, after the implementation of RSBY in the hospital, there has been a steady increase in the patients. Any day we would be breaking through the magic 200 outpatient barrier. We thank the Lord that we are becoming more accessible to the poor. Till date, there have been about 80 outpatients and 25 inpatients treated under RSBY. I've not been able to post about many very sick patients including maternal near misses we've had over the last month. We thank the Lord for all the patients. 

5. We thank the Lord for journey mercies for all of our staff who were travelling. Especially Dr Titus, who was at Herbertpur for the Medicine CME.

6. The burns unit construction is on steady progress. Kindly continue to pray for the needs as well as speedy progress of the work.

7. We are delighted to have facilitated a workshop on Advocacy last week at Ranchi. We thank the Lord for the work happening through Mr. Mark Delaney. We’ve formed a forum for furthering this endeavour. Kindly pray that the Lord will use us to minister to the poor and the marginalised through this.

8. We are coming to the end of this financial year. We thank the Lord for the all the progress and learning we had. Kindly pray that the Lord will give us discernment to evaluate well on how we fared and on how we should go ahead.

9. Summer has already arrived. It is quite hot and we depend on the Lord for seeing us through the harsh weather especially with regard to availability of water until rains come. Kindly pray for the health of all staff during the very hot summer.

10. We’ve 3 staff expecting babies within the next month. Kindly pray for each of them – Sr. Chandrakala, Sr. Kanchan and Dr Angeline. We thank the Lord that one of our staff kids was saved miraculously from a possible serious burn injury. Boiling milk fell on Anush, 2 years old, daughter of Sr. Deepti and she escaped with about 3% of scalding of the chest. It could have been worse.

11. The NH 75 which connects us to Ranchi and Daltonganj is in quite a bad shape. In addition, we had been having accidents on a regular basis. Over the last week, 2 people lost their lives. Kindly pray that the road repair work would progress fast and we would have good roads at the earliest.

12. We thank the Lord for the installation of fire fighting equipment in the hospital early this month. Kindly pray that we would never be able to use it.

13. We thank the Lord for the smooth functioning of the neonatal unit. We already feel the pressure of a high rate of admission. We need a full time paediatrician in addition at least couple of warmers and phototherapy units.

14. We continue to be on the look out for a physician and an additional surgeon. There are vacancies for at least 2 more BSc nurses and 4 GNM nurses for the smooth functioning of the unit. EHA plans to present North Indian mission is a Church Camp at Kothamangalam, Kerala during the Passion Week. Kindly pray for Dr Sam David who will be giving the challenge to the believers attending the camp towards outreach missions in North India. Kindly pray that the Lord will move the hearts of committed young men and women to respond to the needs of the places like ours.

15. Dr. Nandamani is on his way to Vellore for attending a worshop on Secondary Hospital Posting for MBBS Students from CMC, Vellore. Kindly pray for his travel as well for each of the students who would be visiting us in the last week of April.

16. Today is World TB Day. TB patients make a major chunk of our clinical work. Incidentally over the last 2 weeks we had 7 patients for whom we had to put a chest tube. Please pray for the work we do is a source of hope for each tuberculosis patient who comes to us. Dr Johnson leads the TB work at NJH along with Mr. Manohar, Mr. Sunil and Mrs Namitha.

Visitors at NJH . . .

Over the last week, we had quite a crowd at NJH.

It was amazing as we got a church group to come over to NJH and see for themselves what we were doing. I'm not very sure if there has been quite this large a group from a church come over before.

The Parish Mission of the Marthoma Church, Kolkota under the leadership of Rev. Issac  arrived at NJH via Ranchi and left on Sunday, the 18th March.

It was amazing that the train arrived on time. We had been planning for a late arrival. Since the train was on time, we got time to visit the St. Thomas School, Ranchi. It was quite an encouraging time that we had at the school which is being taken to new heights under the leadership of Rev. Joseph Ayrookuzhy.

The front of the school with the Mar Thoma Church, Ranchi

Meeting Rev. Joseph

The visitors

After spending about one hour at the school, we were on our way to NJH. I had planned to take them to a rural church in the region. I selected a church under the Bihar Mennonite Mandali. The members of the team were amazed at the faith of the fledgling church in Boddha, a remote area of Latehar district near Chandwa.

Proposed railway route between Lohardaga and Chandwa.
Once this becomes operational, Ranchi would be easily accessible by rail from NJH

Walking to the village

Mennonite Church, Bodha

With the believers of Bodha church

After lunch at Chandwa, we reached NJH by around 5 in the evening.


The team had a quite hectic time at NJH.


In between, we also had a very quick visit from Pastor Clive and his wife, Joy from New Zealand. They were kind enough to visit us along with Mrs. Margaret, our Regional Director, who happened to visit us on Saturday last. We are thankful to the wonderful family for the visit . . .

Mrs Margaret, Regional Director along with Pastor Clive and Mrs Joy

The team at NJH. Almost all the snaps were taken by Adv. Chacko Mathai

We at NJH have been encouraged by the visit from all of you.

Images from NJH . . .

An assorted group of images from NJH over the last couple of weeks . . .

RKS's hand after skin graft

The palmar aspect of RKS's hand. We would be able to do a better job next time as we have acquired a skin mesher.

Diabetes was not a problem till about 3-4 years back. Now, we get bad diabetic foots like this.

A raspberry tumor

A truck which smashed into a tree near the hospital.
But, below is the snap of what he did before he crashed into the tree.

The pillion rider, a lady lost her life. The bike rider was lucky to escape with not much injury. 

The new RSBY counter in the outpatient department of the hospital

Thermospots, an innovation from TALC being used at NJH thanks to Wendy and Jerry

Snap of an Intra Uterine Death where the umblical cord made a true knot around the leg

A limbs of a langur monkey and her kid through the window of the Neonatal ICU

An ovarian tumour found during a routine Cesarian Section

X-Ray of a man with tuberculosis. Quite a common sight in NJH

Agrarian injury. It is quite common for such incidents in our community.
This child walked into a threshing fan and was lucky to have escaped with only this. 

Branchial sinus. Nandamani did a successful surgery for this. . . 

RSBY . . . Update

Well, the reason for not having any posts regarding RSBY has been because we’ve been caught up with work and I was away for an important meeting.

Since 5th March, 2012, when we officially rolled out RSBY at NJH, we’ve had quite a good crowd. The whole of last week we had about 800 OPD and about 40 deliveries. Of which, 75 OPD and 21 in-patients were treated under RSBY.

And our experiences have been varied.

1. The best part has been about patients who may have never thought about coming down for treatment readily coming for treatment. 2 girls with inguinal hernia – a rare occurrence in females came for surgeries. I’m sure that they would not have been brought for treatment if not for the RSBY Card. So, an example of emancipation of the girl child through the RSBY Card.

2. The food was well received by almost all patients. However, we had one episode where one of the patients had stolen the tiffin box in which food is given. However, we were able to trace out the culprit and ensure that it was returned.

3. There were couple of episodes where the Smart Card Holder wanted to take a Private Ward by paying the rest of the bill. I had quite a tough time denying the option. We have taken a decision to be quite strict in this matter as we are sure that this is going to be quite a very common demand.

4. One patient had gone off without thumb printing after discharge. She was from a nearby village and therefore we did not have much problem.

5. One potential problem we’ve recognised is that of patients coming with pre-term labour. The first one, we admitted as normal delivery, but later her pre-term pains subsided and then we discharged her after unblocking her from the normal delivery package. We put her on medical treatment but later realised that we get only the amount from the day we register her as medical treatment. Thereby we lose money. It also happens when we take couple of days to come to a diagnosis. And also, if there is a change in diagnosis.

6. The most unfortunate story was that one of our potential success stories decided to take a discharge against medical advice. It was a shame – but we had tried our best, but to no avail. For those of you who had been following this case, we found out that the lady did not actually have any lower limb weakness. Rather she was malingering – and there was something more to it.

7. And we’ve put notices all over the hospital regarding RSBY, so that no body will miss it. Unfortunately, after all the publicity we find patients who are totally unaware about the usefulness of the Smart Card.

The counter

Information banner

Another view . . .

8. There were also some hitches with the software. I’m not putting details here as it is quite intricate. However, we’ve had quite a good help from Mr. Maneesh, Eagle Software co-ordinator at Palamu District.