The hidden pregnancy . . .

(All the pictures in this post are per-operative pictures which could look gory - kindly view with caution)

Well, here is the first of the interesting cases that we had last Saturday. 

GD, had come to us with a history of abdominal pain after having been pregnant for about 4 months. She was pale, tachycardic and had been diagnosed elsewhere to have an intrauterine death. 

She had been sick for the last 4 days. We did an ultrasound. Surprisingly, the dead fetus was outside the uterus. Well, the possibilities - 

1. The family was not giving us the full picture. She could have gone for a septic abortion using a stick. The stick could have caused an injury pushing the fetus into the abdominal cavity. 

2. It could be an abdominal pregnancy . . . 

We once again confirmed the history. They were very definite about not being in the former scheme of things. 

Well, what was she doing for the last 4 days. For the first 2 days, she was in our adjacent district headquarters trying to get a diagnosis. They had treated her anemia. Investigations elsewhere showed a hemoglobin of 5 gm%. She had already recieved 2 pints of blood. She was referred to the nearest district headquarters as nothing was happening. The family informed us that they were waiting for the dead fetus to be expelled. 

At the adjacent district hospital, they went ahead and induced her for delivering the dead fetus. The lady was there for more than a day. 

Since, 'nothing' much was happening, they decided to come down here. 

We told the family that she needs to be operated on. The family was well off. And as Nandamani and the rest of the team discussed the case, possibilities of intestinal involvement etc. weighed on us. We gave them the option of going to a higher centre. The family was tired after having visited quite a number of hospitals. 

The next problem was the availability of blood. The family had already arranged 2 pints of blood. They tried their best and arranged one more. One of our staff volunteered to donate so that we could start the surgery soon. We were already looking at the possibility of septicemia as she had been sick since the last 4 days. 

Below are the snaps from the surgery - 

As we opened the abdomen

The pregnancy in the broad ligament. The uterus and the right ovary can be clearly seen

Placental adhesions to the intestines . . . 

The diagnosis - Left broad ligament pregnancy ruptured with adhesions of the placenta to the sigmoid colon and the small intestine. . . 

Twelve pregnancies . . . Experiences varied . . .

Yesterday (28th April, 2012), our youngest doctor, Dr Titus was on duty. And what a duty did he ultimately end up having. . .

I'm very sure that a post-graduate in Obstetrics in a pretty big Medical School would turn green on hearing the cases Titus ended up managing yesterday. Of course, it was with active support from the others including Nandamani.

Altogether, he ended up managing 12 pregnancies . . .

I shall try to narrate the significant ones in a later post . . . Here is the list with a brief account of the history . . 

1. AB – a primi who delivered without much problem.

2. BD – another primi, but had been trying to deliver at home. Was about 9 cm dilated at arrival with Grade 2-3 Meconium Stained Amniotic Fluid.

3. NDD – a primi, a bit towards the elderly side. Had been coming to us for antenatal check-ups. We had diagnosed Intra-uterine Growth Retardation quite early and referred her to Ranchi. The family could not afford the trip and tertiary consultation. We had to ultimately do a Cesarian for her. Mother and child are doing well. 

4. SB – another routine delivery without any complication.

5. BD – the first pre-eclampsia to come in. We induced her – but deleloped fetal distress in no time. Post Cesarian it turned out to be good decision as per operatively, the baby was sick.

6. AD – a G2P1L1 routine delivery,but with very anxious relatives who gave us a harrowing time.

7. SD – A G6P5L4D1 – Had been trying at home since early morning. Did not have any clue why she was not delivering. Ultimately decided to come to hospital. Reached NJH at around 10 in the night. We did not need an ultrasound to diagnose hydrocephalus. Of course, we confirmed with an ultrasound. Delivered after craniocentesis. Baby was dead. However, she was lucky to have got away with it as she could have ruptured her uterus. 

8. MD – A primi who came in with an IUD. She had been kept for normal delivery elsewhere. I wondered how someone could have missed the very obvious Inadequate Pelvis. Problems with not having followed protocols too as the patient has been in active labour for more than 16 hours. 

9. ND – the second pre-eclampsia of the day. However, ended up with an normal delivery after periods of uncertainty and anxiety.

10. SD1 – Someone we had induced. But ultimately ended up with an obstructed labour and a Cesarian section. Baby and mother turned out to be fine. Thank God for Partograms and Protocols. . 

11. GD – Very confusing history. But an ultrasound gave it away. It was an abdominal pregnancy – the sac had given way. The baby was about 20 weeks gestation. Shall do a detailed post on that later.

12. SoD – Maternal death. Did not deliver. Came with history of seizures. Had anuria, thrombocytopenia and was unconscious. Died within 4 hours of admission. We tried to ventilate but her heart would not yield to any medication. Again will give a detailed post later. 

This is the obstetric work alone. In addition, we had the sick babies getting admitted to NICU to be looked after, surgical and medicine patients needing extra attention. . . . The list goes on and on. Well, there was one more patient, UD who had come in with a history almost similar to SoD who's in the process of pulling through in the Acute Care Unit. That would also deserve a detailed post later. 

Well, ultimately friends, we need help. Looking forward for medicine and paediatric consultants along with nurses committed towards work in under-served areas. 

Malaria . . . Challenges . . .

Yesterday was World Malaria Day. It was not uncommon to see quite a many programs and rallies all over the world including India. . . Quite a lot of us are being made to convince that malaria is slowly on its way out. I find it difficult to comprehend numbers. In India, we've had much of a controversy last year over mortality statistics which were arrived at by researchers and the government. As usual, the government claims a much lesser mortality than the research group.

Well, over the last week, we've had malaria cases coming back. I thought of jotting down few observations on malaria over my stint at NJH.

1. Malaria continues to be a major clinical issue in rural areas of Jharkhand.

2. The major challenge is the possibility of evolution of drug resistance due to the rampant misuse of anti-malarial drugs. There are multiple issues here. Let me illustrate. 

Over the last week, we had about 10 patients who presented with symptoms suggestive of malaria. Only 2 of them tested smear positive for malaria. All the rest were negative by smear. 3 of them (all smear negative) had low platelet counts. Two of them died. 8 of the patients who had tested negative for malaria smear had a history of at least one contact with another health provider who had invariably given them anti-malarial medicine - all of them had received oral Artesunate and few even intravenous Artemesin derivative. And only couple of days treatment. 

As I had mentioned in previous posts, the question of a proper diagnosis looms over the conclusion that malaria is the only major killer. I'm sure that we are dealing with other infections like dengue, rickettsia, Japanese encephalitis etc. 

The partial treatment of all fevers with anti-malarials makes the issue only worse. 

Both our patients who tested positive for malaria smear had come straight-away to NJH. And they've gone home fine without any complications. 

Well, we've reports coming in that malaria continues to be a scourge in Jharkhand and Orissa. It was interesting to note the comment in the last part of the above article - 'The only solace, maintained state health department officials in Jharkhand, was that there has been no malaria deaths so far in the year.' 

How will there be malarial deaths, when we have so much of partially treated malaria who will have no laboratory evidence of malaria when they come terminally ill?

It is sad. Almost all of our public health system appears to live in a 'Fool's Paradise'. Someday, the situation is going to get the better of us. What concerns me is the emergence of non-communicable diseases in a big way in places like ours. Within 10 years, if we do not take control of our problems with malaria and tuberculosis in addition to the maternal and child health issues, we could be neck deep in trouble where the development of the country could be in doldrums because of the abysmal healthcare situation of the country. 

It would be unfair if I do not suggest at least couple of simple steps which could be taken  - 

1. A robust Disease Surveillance Programme where each case of fever death is accounted for.

2. Full fledged research into causes of fevers in remote areas of the Empowered Action Group states (the old BIMARU states) 

Syphilis . . . Forgotten foe . . .

Syphilis . . .The very mention of the term used to send shudders in patients and was the darling of medicine professors for quite a long time. It was described as 'the great imitator' by Sir William Osler. One of my professors used to tell that in the olden times, a post-graduate student of Internal Medicine was assessed by how much he knows about syphilis and it seems that the same status is presently enjoyed by HIV-AIDS. 

Well, why I started a post of Syphilis? Over the last week, I had two families diagnosed as having the TPHA test positive. None of the members of the family had any symptom. 

Here are their stories . . . I know there may be quite a lot you may want to comment on them, which I would like to hear . . . 

The first patient was MS, on whom we had to do a Cesarian Section after a complicated trial of labour elsewhere. Before the Cesarian section, MS was diagnosed to have a low hemoglobin and we asked her relatives to arrange blood. The husband had her same blood group and he was ready to arrange blood. Well, on screening of the donor we found out that he is TPHA positive. As a rule, we do not do TPHA on patients who come at term. We do them only for those who come in the first trimester.

Well, by that time the Cesarian was over. We tested the mother and the baby. Both were positive. They very well understood when we counselled them about the disease. 

When I rejoined NJH in June 2010, I had done a re-look at the blood tests we do. Since, almost all of our patients are poor, we were trying to cut down on the tests. We did not find any TPHA positives in any patient for almost 2 years. There were few HBsAg positives and no HIV positives among the antenatal patients. I decided to drop doing TPHA, the main reason being that quacks were quite prompt in prescribing antibiotics and therefore I came to conclusion that this must be the reason that there was no TPHA positive for so long a time. 

However, the protocol was do TPHA in the first and second trimester for all ante-natal patients and drop it for those who come in late third trimester or directly to labour room. 

I was contemplating on whether I should bring back the policy of doing TPHA for all pregnant patients when the next patient arrived. 

One of our antenatal patients who landed up in labour room was found to have a reactive TPHA which was missed in the antenatal period. There was nothing much we could do now other than to re-check TPHA. Unfortunately, the TPHA turned out positive and after the delivery the baby also was reactive. 

I called the father, a man in the armed police force. The fellow looked quite disturbed and a bit drunk. I told him about the TPHA reactive status of his wife and child. He seemed to be hardly bothered. The only thing he wanted was to go home ASAP. I told him that he also needed to get tested. He would have nothing of it. He told me that he had issues to attend to at home and therefore needed to get discharged immediately. 

We tried our best. Ultimately, armed with consent forms on what all will happen and accepting full responsibility if something untoward happens in the future, he was off with his wife and child. 

Questions I have in my mind . . . 

1. TPHA is expensive. Should I do it for all pregnant patients irrespective of when they come - especially when they reach Labour Room straightaway after Antenatal Care elsewhere. Most of the places, VDRL or TPHA is not commonly done. 

2. When I have patients like the latter, what do you do? They are high risk to the community. 

3. Could we have donated blood from the TPHA positive husband to the TPHA positive wife? We had a bit of difficulty getting blood after the husband was refused as a donor. Crossed my brain only now . . . it could have been done. 

2 Happy Families . . . Could have been tragedies . . .

Over the last week, in addition to the tragedy of 3 members of a single family getting burnt, we did have our moments of joy. . .

The first reason for the same was SD1. SD1 came about 10 days back in a terrible state. It was SD1's first pregnancy. There was no antenatal check up. She had turned up at the neighbouring district hospital after being in labour at home for some time. It was sometime before the people there realised that SD1 looked a high risk case.

SD1 had a hemoglobin of 5 gm%. On per vaginal examination, the cervix was edematous with dilatation of 5 cms and there was meconium pouring out. I was in a fix. The referral letter mentioned that SD1 is being referred to Ranchi. We needed blood. There was only one bystander.

I was thankful when the blood matched. But, one pint was never enough. I was sure that the hemoglobin would be lesser than 5 gm%. However, we had to do the surgery. Otherwise, we risked having a rupture uterus and a dead baby.

We went ahead with the surgery. The baby was sick. But, he somehow pulled through. The bystanders were  quite fast is arranging two more pints of blood. It was quite a relief when SD1 recovered soon to be discharged.

The challenge for us was the bill. Because it involved 5 blood transfusions and neonatal care, the total bill was around 20,000 INR. The family was too poor. It did not need much convincing that they would not be able to afford even half of this bill. They paid about 10,000 INR. The rest went as charity. It is a burden for the hospital. But, considering our vision and mission, we have to make such concessions. . . 

The next patient was SD2. Married for 14 years, the family did not have issues. The interesting aspect was that she had a whopping 8 abortions. And the saddest part was that she did not take much interest to do any antenatal check up during the present pregnancy. The delivery was uneventful. It was a pleasure to watch the joy of the family as they adored the new arrival. 

The last one was 2 days back. SS had come with usual labour pains after an uneventful antenatal period. On arrival in labour room, Dr Johnson diagnosed a breech presentation. Since she was a multi, we did not anticipate much problems. But, as soon as the breech was out, Dr Johnson was sure that there was one more baby inside. And yes, she had a surprise twin delivery to add to her already large family of 3 children. 

All the 3 deliveries, especially the first two could have ended up as tragedies. We are thankful that all the babies and mothers are doing well.

Over the last 2 weeks, the 'marriage season' has started in this region. It is very hilarious. Everything revolves around the weddings. Almost everybody in the ward requests for a discharge citing excuse to attend a wedding or to get married . . . We expect quite complicated cases to come in during this period. In addition, we have students from the Christian Medical College, Vellore visiting us for the next 2 weeks. Do continue to follow the blog . . . there should be interesting posts continuing . . . 

Burns . . . Heart wrenching . . .

Well, couple of days back, the last Thursday to be exact, I was called in to help Dr Johnson in his duty. Dr Johnson was operating. And there were five patients coming together into Emergency - quite a crowd for any ER. 

The first two who came were couple of drunk city kids on their way to a marriage function in Daltonganj. They had not seen some road work happening and had skidded over a barrier which was put up. They did not have much problems other than some contusions and minor lacerations. 

Soon came in this family - mother and two children burnt. The culprit - a burst kerosene lantern. Nobody was quite sure on how it happened. The mother, in her late twenties was badly burnt in her left arm. Another girl was burnt a little over the back and buttocks. 

The saddest part was the boy in the house, 8 years old. He was burnt all over - Nandamani calculated 89%. The family was devastated. We thought that he would die soon. It's Monday evening today. He's pulled through so far. We are just managing him symptomatically. There is hardly anything we can do. Nowhere is there any skin to do a graft. 

The worst part is that the rest of the family is that the mother is so depressed that she is not willing for her own treatment. Even Nandamani was in depression . . . 

When I gone for the Burns Retreat in Sylhet, Bangladesh, there was so much discussion about the kerosene lantern - called 'kuppi batti' in that area.  It causes quite a lot of the burns that we see in this part of the country too . . . 

There are crude ones like the one below. Many a time, they are just old bottles with a wick screwed on the top. 

And then there are the better 'safer' ones like the one below. Many people think that they are safer than the above ones. Of course, safer if used properly. I've had many instances of these bursting. Even a personal experience of one bursting in front of me and I getting away without much injuries. 

Well, the problem as far as I realise occur in 3 ways - 

The first one, is a problem with cleaning of the wick and the lamp regularly. Many a time soot accumulates and sometimes some foreign body especially insects get entangled within the soot. If you don't do the regular cleaning, the soot along with the foreign body mixes up with the oil and catches fire - resulting in the lamp getting burst. Almost functions like a Molotov cocktail. 

The second one, is the issue with getting good quality oil. Unscrupulous traders mix diesel or petrol or even old cleaning oil along with the kerosene oil resulting in bursting of the lamp during use due to differential inflammable temperatures of the different oils. 

The last problem and the third one, which is more common occurs due to someone tipping over the lamp, especially when it is kept on the floor. As you can see, most of these lamps come with a small base which tips over fast. . . 

Many a time I wonder why we can't mass produce cold sources of light and distribute them as part of the Public Distribution System of the country. . . We can save many a family from getting burnt . . . 

It is so depressing whenever I see one of the relatives of the family . . . The family is so poor. They cannot afford anything unless the father goes for some manual labour . . . Oh my, oh my . . . Why do I see things like these ? ? ? 

Licensing . . . Easier to Kill than Heal . . .

Well, over the last few weeks, I've been struggling at various fronts about the laws slowly being implemented which would make it quite difficulty for healthcare institutions and providers to be in the service of improving health in the country especially for the common man. 

It is of course true that we boast world class facilities in healthcare such that 'Medical Tourism' has become a very common term for many a corporate hospitals. But, the fact remains that the doctor : population ratio remains abysmally low in almost a majority part of the country. More so, as I mentioned in a previous post, the consultant : population is all the more in a precarious state. 

Over the last couple of years, I've been trying to push the  need for Family Medicine consultants as well as Maternal & Child Health consultants in the country on a larger scale to cater to primary and secondary health care needs of the population. Although the National Board of Examinations have accredited DipNB in Family Medicine and Maternal & Child Health, there has not been much of an encouraging response from the Medical Council of India. 

In fact, it is not very difficult to come to a conclusion that healthcare in India would benefit much from the presence of more Family Medicine and Maternal & Child Health consultants rather than other speciality consultants. 

Just one incident and a thought which went through me when it comes to issue of consultants managing all cases pertaining to a specific speciality. Now, as I had mentioned about this in a previous post, I put my arguments in the light of the high densely populated regions of rural India where even the presence of a doctor with an MBBS degree is a luxury. 

Yesterday, I had a call from our Insurance Provider of RSBY. He wanted reason why we did a Osteotomy Femur of a young man who had been struggling with the condition for almost 5 years. This guy had a accessory piece of bone jutting out from the lower aspect of his thigh. He had multiple episodes of injury. The treatment was to remove it. The problem was that he had gone to couple of orthopedicians and all of them wanted a hefty amount which his family was unable to afford. 

Then, he came to find out about NJH being empanelled under RSBY. He wanted to know if this surgery could be done. Our surgeon, Dr Nandamani was confident that he could do it. The young man underwent the procedure and is doing fine. Now, our Insurance Provider wants to know why we did the surgery without an orthopedician. 

I asked the local fellow on whether he had an orthopedician empanelled under the scheme in the nearby region. The answer was no. The complete truth was that there was an orthopedician who was empanelled under the scheme last year, but he had come to the conclusion that RSBY was not paying him enough and decided not to continue it when the option for re-empanelling arose. 

The other option would be to go to Ranchi and find out an RSBY empanelled orthopedician and get the surgery done. But, that involves quite a lot of overhead expenses which the insurer would not pay. Therefore, he got the surgery done at NJH. 

Now, I thought of doing the same exercise I did for the obstetricians in the last post. The question was about the ideal orthopedician : population ratio. Well, as per my information, there are 3 orthopedicians in the whole of Palamu, Latehar and Daltonganj. 

Now, coming to the thought that crossed my mind last week

I hope all of you know about the Medical Termination of Pregnancy Act of the Government of India. I remembered the clauses which stipulate on who can do an abortion. I could not believe when I contemplated on the same. In addition to an obstetrician, any doctor who has done 6 months of internship in Obstetrics and Gynecology in a teaching institute OR one year of work in Obstetrics and Gynecology department of a hospital OR assisted 25 cases of MTP in an institution recognised for the purpose. 

I had studied this many a time for my graduate and post-graduate examinations. But, did you notice the last part. Just assisting 25 cases of MTP would actually give you the 'licence to kill'. And mind you, you could end up killing both, as a MTP is not without any associated danger to the mother. 

In the light of this, could we look at procedures which heal. Medical graduates without post-graduate training has been doing yeoman service in many areas of the country in rural areas doing procedures which would cause frantic scenes in the Emergency Rooms of many a super-speciality hospital. In fact, there was one generation of doctors who believed in training up willing medical graduates in all aspects of medical specialities as people in rural hinterlands of the country could never think about going to a superspecility centre. 

Unfortunately, very few of our policy-makers are aware about ground realities. They bring in acts like the CEA where you need consultants of different specialities to attend to a simple physiological condition like a normal delivery. 

If the legislature can give the license of kill once a medical graduate observes 25 MTPs, I'm certain that it would be unethical not to give the license to practice any speciality of medicine to a doctor who passes out with a MBBS degree. But, of course - the patient should be well aware of who he is going to. In places like ours which are umpteen in 3rd world countries, a couple of well qualified and experienced medical graduates would be more worth than the hoard of quacks who populate the area. 

The fact that there are quacks who freely practice modern medicine including surgeries without any sort of qualification should deter the government from being upfront in demanding that only specialists manage the corresponding disease condition concerning their specialities and nobody else do anything with them. 

A common refrain that we here at many of the mission hospitals including NJH. . . 

Doctor saab, humlog yeham thak bahut ummid ke sath aye hain . . .Hamare liye ye bahut bada baat hai. Hum aage nahim leke ja sakte. . . Jo karna hai, aapko hi karna hai . . . (Dear doctor, we have come till here with great faith in you. Coming till here is a big achievement for us. We can't go further. Whatever needs to be done, has to be done by you.)

The last one to give me this dialogue was the parent of a little boy for whom we could not come to a diagnosis. Most probably, he had a brain stem tumour. I asked the parents to take him home. He was referred by someone we knew - he died at home 2 days later. . . 

So food for thought for the weekend . . . If we can obtain the license to kill our unborn without much difficult, why all the fuss being made about need for specialists especially when you have so few of them . . . more so, when it comes to under-served and remote areas of the country. . . 

Doctor Shopping . . .

3 days back, I had a young man in Emergency with fever for a duration of 7 days. Quite an expected event with the advent of summer. Last year I had written quite a lot on the umpteen number of fever cases that we ended up managing. 

The interesting aspect was that NJH was the 5th healthcare provider his family has taken him to. The unfortunate part was that NJH was more close to his home than the rest of the other providers if you exclude the village quack to whom he had gone initially. 

He had already received almost all the common high end antibiotics that is available in the market as well as all anti-malarials except Quinine. And he was from a well to do family with some amount of education . . .

I counselled his parents and told him about the futility of getting treatment like this. I was not at all interested in taking the young man in for treatment. The family was well off, they could afford to take him to Ranchi and a continuous fever of 7 days duration was not something trivial. 

Armed with a high risk consent, we started to manage him. On examination, we got a suspicion of meningitis. But, the lumbar puncture was negative. The blood tests were negative for malaria. There was lymphocytosis with increased polymorphs with toxic changes and a shift to the left. Renal and Liver functions were within normal limits. 

I covered him with high dose antibiotics and anti-virals. For 24 hours, there was no respite of the fever. Then, I started him on intravenous quinine. His high grade fever has come down. But, he again had one spike, although a smaller one in the evening. I hope that he'll become better and I was most probably dealing with a partially treated malaria. 

Now, Doctor-Shopping is a major problem with the sort of healthcare we have in India now. 

With almost 70% of actual healthcare happening in the private sector, patients are on the run searching for the magician who will get rid of their sickness. The competition between doctors and healthcare institutions makes things more worse. . . In the modern era of evidence based medicine, there is not much of a choice in varying treatments. The impetus is on making a good diagnosis. 

Rather, by doing Doctor-Shopping, patients put themselves at a high risk of getting multiple types of antibiotics and medications. Of course, things become difficult when there is a challenge in getting investigations of your choice with assurance of good quality. 

The quality of medical education only makes things worse. 

Recently, I came across a colleague working in obstetrics in a big hospital in the city. I came to know that his department routinely prescribes intravenous Ceftriaxone for all Cesarian patients irrespective of the indication for a total of 7 days. It was pathetic. He told me that nobody wants to take any chances. It was so unfortunate. It was done so that patients would not go doctor-shopping. But, at what expense. 

Drug resistance in almost all the spheres of microbiology is a major challenge to healthcare. Doctor shopping is something which would built up drug resistance. 

Protocols for diagnosis and treatment prepared by different agencies on various disease conditions and symptoms are available for almost all major diseases. A strict adherence to the algorithm almost always helps in the correct diagnosis. It is cheaper and easier process to go through. 

Now, the question is who will adhere to protocols. This is the situation where a family practice consultant would be of benefit to the patient, especially when he/she is poor. Another point in favour of introducing family practice consultants in a big way in the Indian healthcare scenario . . . I hope the concerned people lend a ear . . .

Bizarre Obstetric Care . . . The Sad End . . .

Sometime around 12 in the afternoon, we declared AD clinically dead. She had been struggling after the surgery. She could hardly breathe on her own and she was hooked onto the ventilator. 

We had trouble maintaining her blood pressure and was on ionotropes. 

Per-operatively, the abdomen was a mess. According to Nandamani and Titus who did the surgery, the uterus was like 'putrefactive minced meat' and the peritoneal was all stinking with dilated bowel loops. There was no way the uterus could be removed as the uterine vault was all necrosed and flimsy. They closed the uterine rent and came out after putting in couple of drains. 

The nasogastric tube was draining all stinking coffee ground material. 

As I sat with the AD's husband to fill up the Facility Based Maternity Death Review, it was very obvious that he had hardly been caring for his wife. Married for 10 years, the only thing he had to say was how burdensome his wife was for all these years. The tone was bordering on how good it was that she died . . . 

It did not need much questioning to realise that he hardly bothered how his wife fared. The first baby born by a Cesarian section had died at birth as the labour pains were happening at home and he took her late to hospital. The next delivery he tried at home and when nothing much happened, he took her to hospital, where she had a normal delivery. The third delivery was again tried at home. 

That was his excuse for trying the fourth one at home . . . there was some problem. So, he took her to hospital. Delivered in hospital where nobody picked up the rupture uterus. They brought her here as she was not feeling good after delivery. Then, we asked for blood. I found out that the husband's blood group was same as that of AD . . . but, he was hardly bothered about donating blood. 

He took her back to the place where she delivered rather than to Ranchi . . . They transfused 3 pints of blood without doing any surgery. . . It was already 4 days after the rupture uterus when she came here a second time. The family told us that they were not willing to take her anywhere else. . . If she dies, she dies . . . 

She died. . . The husband was worried about the children . . . 2 girls aged 3 years and 2 years. . . They would be orphans . . . . more so if the husband remarries . . . 

Talking about girls, over the last week, we've had enough stories of violence related to the female gender. The one which happened in Bangalore was very very sad . . . The second incident which happened near Kolkotta crossed all limits of cruelty one can witness . . . 

And after I had penned this post, yesterday night, I had this unfortunate lady being wheeled into emergency. She was beaten up by her alcoholic husband . . .Bones in both her hands have been crushed into multiple pieces with some foreign body lodged in one of the hands . . .

The unnerving aspect of all such incidents is that one gets the feeling that such incidents are on the rise . . . which is not a good sign for the society. . . When I look at Maternal Health care, I'm quite convinced that things would not improve until we give more respect and value to the women and girl children around us . . . 

Praise and Prayer Bulletin. . .15th April, 2012

1. We thank the Lord for the safe delivery of Dr Angeline. Our third one, Chesed Tabitha Kuruvilla arrived after a very short period of labour pains at 8:35 pm on the 11th April. Please continue to pray for Mrs. Chandrakala and Mrs Kanchan who are also expecting within the next 2 weeks.

2. We praise God for the healing given to BS, who was unconscious for almost a week (We had done a lumbar puncture on him and there is a snap of cobweb appearance). He had to be put in ventilator for a day. It is such a blessing to see him smile as we go for rounds each day.

3. Our RSBY work is going in full swing. We had our first patient with a snake bite who was treated successfully using RSBY Smart Card facilities. Please also pray for the 8 year old girl who has been admitted with the snake bite.

4. All of our obstetric patients who came over the last week have recovered well, including MD have recovered without much complications. We thank the Lord. However, we have yet one more patient AD who is quite a bad shape after surgery today. Please pray that she would make a miraculous recovery. Dr Nandamani did surgery on her. The uterus was very friable with a bad peritonitis. She is on ventilator and ionotropes. 

5. The Clinical Establishment Act is in the process of being implemented in Jharkhand. There are quite a lot of implications for institutions such as ours. We need more staff with qualifications. Kindly also pray that there would be separate regulations for rural institutions such as ours. 

6. Dr Ango is on her way today night to attend to her DipNB Practical Examinations at Nagpur on the 17th April. Kindly remember her and Dr Nandamani as they travel.

7. The electricity problem in the region continues to be in a bad shape. We need almost 150 litres of diesel every week to ensure round the clock electricity supply to the hospital and about 10 hours of supply to the residences. Please pray that there would be improvement in electricity supply. 

8. We thank the Lord that the repairs are happening on the road to Daltonganj. Please pray that the repairs would be completed soon. 

9. Tuberculosis continues to be one of our major concerns. The load of patients whom we see baffles me and I'm quite concerned about what is happening with regard to development of resistance due to partial treatment. I pray that someone will be burdened to develop a Respiratory Diseases Centre at NJH. Considering that we are already a Tuberculosis Unit, there is a huge potential.

10. The Burns Unit construction is going on in a full swing. We praise God for the funds received so far. We are also getting quite a few patients whom we've managed well... We thank the Lord for all of those who have supported us so far. We need more committed staff to manage a full fledged burns unit. Please pray. . . 

Start of the new season . . . Snake Bites . . .

Summer has started and patients with snake bites are back. Over the last one week, we had 3 patients - first one with viper bite, and the other 2, cobra bites - both of them coming over the last 2 days. 

The second patient, and the first cobra bite victim, a middle aged lady who was bitten yesterday night had come sometime early morning yesterday. She was hardly breathing and was in a total neuromuscular paralysis. It seems they had been trying black magic (locally called 'jhad phuk) to remove the poison all through the night. 

Early yesterday morning, someone suggested that she be taken to NJH for treatment. 

She had to be intubated immediately and started on mechanical ventilation. She responded quite well and was out of the ventilator within 2 hours after having received 10 vials of the anti-snake venom. By evening, she was sitting up and we kept her for observation overnight. She has some local swelling which would take some time to subside. 

Well, she is a milestone patient for us as she has been treated completely free under the RSBY.

The third patient, a young girl with an unknown bite came sometime late afternoon today. The diagnosis was very obvious - either a krait bite or a cobra bite. The clotting time came out normal. Therefore, cobra bite. In went 10 vials of the anti-snake venom and she was soon on her way to complete recovery. 

However, I should tell you a bit more about the little girl. She had been bitten sometime early morning. She came straightaway to the district hospital. She was kept there for about couple of hours although a diagnosis of snake bite was made. And at around 1 pm, she was referred to Ranchi. Someone suggested that they try out NJH. And that's how they reached here. 

It is unfortunate that the district hospital has no facilities to keep ASV, when the prevalence of snake bites are quite high in the region. 

Bizarre Obstetric Care . . .

As I write up about the different patients to come to us for care, I always pray that things get better as each day passes. Unfortunately, it does not seem so. The number of patients with rupture uterus and eclampsia continue unabated. Of course, on and off, we get patients who were saved from certain death because of timely intervention . . . 

But, one lady who came yesterday broke all limits of imagination on how careless and ignorant can people be when it comes to obstetric care. . . 

I was in Out Patient yesterday (13th April, 2012) when at around 2 pm, a lady with a distended abdomen was wheeled in. The history was that she had a normal delivery on 10th April elsewhere following when the abdomen got progressively distended. They also told me that somebody had diagnosed her to have a rupture uterus following the delivery . . . 

The lady has been married for 12 years. . .  and the family did not have children for about 8 years. The first delivery was a tragedy. For reasons unknown, she ended up with a Cesarian section, but lost the baby. . . The next two deliveries were normal . . . and one done at home and the other in hospital ! ! ! In between, she had 2 abortions. 

Then came the fourth one, they tried a home delivery . . . but started to have difficulties, for which they came to the district hospital. She ultimately delivered normally. The baby was dead but she started to become sick. She was brought to us in a terrible shape on 11th April, 2012. So, she was P4L2D2A2. 

It was obvious . . . the uterus had ruptured. Her Hemoglobin was 4 gm%. We asked the relatives to get blood. She had about half a dozen male relatives but nobody was ready to give blood. 

It was fine, if there were no relatives to donate blood or if all the relatives got their blood group checked and then none of them matched. In such a situation, many of us from among staff have donated blood to patients. 

We told the relatives that they better take the patient to Ranchi. They did not hesitate to take her away. 

We had forgotten about her. 

And then they came back yesterday. We shall call her AD. Now, it took some time for me to discover that AD was the same patient who came to us on 11th April, 2012 and was supposedly taken to Ranchi. 

So, I was quite inquisitive to find out what happened after the relatives took her from here on the 11th. It seems they took her to the district hospital in the adjacent district. They told her everything will be fine once blood is transfused. And they managed to get hold of 3 units of blood. . . Nothing else was done. 

It was obvious that the patient was deteriorating. Later, someone told them that this sort of patient can only be managed at NJH or Apollo. And, therefore, she was brought here a second time. 

The patient was obviously sick. The hemoglobin was 10 gm%. She was dehydrated. We were sure that we will operate only if we had at least one pint of blood. Unfortunately, the relatives were not relenting. It required quite a lot of counselling from our side. I'm glad that they arranged one pint of blood today morning (14th April). As I write this, Dr Nandamani would have started operating. 

We pray that she will do well . . . 

Now, major lesson learnt here - lack of adequate medical facilities within the country. I had written quite a mouthful on a new act which is going to be implemented soon. What will patients like AD do when such a act is implemented?

Photo Post . . . 14 April 2012 . . .

A glimpse of happenings at our place over the last week . . . .

X-Ray abdomen showing Sigmoid Volvulus

The same patient per operatively . . . 

Gall bladder with stones . . . 

This man with multiple swellings on his nose has been wanting to get it removed. . .
Recently, he had acquired a RSBY Card. I've promised to review when Dr Hiles comes visiting next time . . . 

Another view of the same patient . . . 

This patient already had tuberculosis treatment three times. As of now, his sputum is not positive for Acid Fast Bacilli. The major problem is that his lungs have been badly damaged. Damaged lungs and its management is one aspect of tuberculosis treatment which is hardly given much importance . . . 

Another patient with tuberculosis

Another patient who came with breathlessness who had anti-TB treatment for about a month about 10 years back . . . 

Miliary Tuberculosis 1

Miliary tuberculosis - 2

The spread of the disease and drug resistance is on the rise because of prescriptions like these . . . 

Pelvis of a young man on whom a murder attempt was made by running a tractor over him . . . Alleged caste violence. . . 

This is how a patient rather 'a dead body' was brought couple of days back. The patient was brought all the way from Gaya in Bihar. From the old treatment prescriptions, it looked like he was suffering from cardiac disease. . . Unfortunately, he died on the way . . . Tells volumes of healthcare in our part of the country . . . Gaya is about 250 kms from our place and has tertiary care facilities . . . . For those who could not recognise the snap, there is a body lying at the front of a mini truck . . .