Marathon Cesarian Sections . . . Cont'd

Over the last week, I've tried to pull your attention to the poverty of this region. In addition, there was the day when we had to do 7 Cesarian sections on the trot . . . all of them, Maternal Near Misses.

They all got discharged without any sort of complications except for the babies of KD and AF. 

Below is the chart once more. This time, I've added 2 columns . . . which shows the final bill and the charity we ended up giving.

Name	Time and date of surgery	History	Final management and comments	TOTAL BILL (INR)	CHARITY (INR)
RtD	20th july, 11:00 am	Previous LSCS, had come for ANC on 20 june, Hb: 8 gm%, never bothered to arrange blood	Boy baby, apgar 9 and 10. Had waited almost a day for the blood	13162	3979
SMD	20th july, 12:36 pm	Obstructed labour since previous day 8 pm	Boy baby, apgar 6 and 10. Almost a rupture	16101	6851
MD	20th july, 2 pm	Primi at 40+6 with labour pain since previous night. Later obtained history of leaking 4 days. Irregular fetal heart.	Girl baby apgar 8 and 10. Well off patient – did not go to Ranchi.	15658	490
AF	20th July, 3:14 pm	Labour Pains since yest afternoon and leaking, short 136 cm, obstructed labour	Sick girl baby, apgar 1 and 4. Died later, Almost a rupture	16541	3109
KD	20th July, 5:24 pm	Prev LSCS  with iud and Hb 8 gm%	Dead girl, Hysterectomy for placenta percreta	17320	6524
RnD	21st July, 2:17 am	G4P3L2D1, pedal edema 2 weeks, headache followed by seizures 2 pm, 20th july	Baby boy, apgar 6 and 10. IUGR	16498	1053
SrD	21st July, 3:30 am	Short primi, pedal edema > 2 weeks, was having laboru pain since 12 pm on 20th July, BP 140/100. Urine alb 3+	Cervix edematous and head high, inadequate pelvis – lscs, boy baby apgar 3 and 7. Gr 3 Meconium Stained Amniotic Fluid	19235	2438
	TOTAL			114,515	24,444

Well, why do I have to show this . . . When some hospital asks for a small amount and people don't pay, they make into the newspaper. I know of quite a number of healthcare institutions who do quite a lot of charitable work and do not even find a mention anywhere. Just imagine, almost 20% of our costs going into charity . . . This is a fraction of a day's work. 

As I write this, I've 2 patients who are in the ward for whom I would have to give full charity. . . 

The first one, NK, who delivered her first baby and was brought to us about 5 days back with a history of seizures after she delivered a baby about 5 days back. We've not been able to bring down the blood pressure. We tried to refer them the first day. But, to no avail. Today, the father came to me. He requested me to discharge the patient as they did not have any more money with them. He told, 'I will take her home and then we would wait for her to die'. I've told them that we shall continue treatment for 2 more days and they need not pay any more money . . .

The second one, RD was operated 5 days back. Stuck by polio at the age of 3 years, she had got married to a blind young man from her village. She had a pregnancy 3 years back - she had a normal delivery, but the baby was dead. I wonder how she delivered with both legs stuck with polio. When she came to NJH, it was not a classical Rupture Uterus. On operating, it was like someone had done a Cesarian section without opening the abdomen. 

The family does not have even one rupee with them. We'll have to write off the entire bill . . . 

The consequences of such charity work can be terrible on an institution such as ours . . . But, then, there is no other option for most of our patients . . . I wish we had some sort of support .. .. .. 

Case discussion . . . Need suggestions

We had a 35 year old lady who came with multiple swellings of the tongue and the oral cavity. Grossly, the swelling looked vascular. Would appreciate suggestions on where she can get this managed. The family is lower middle class . . .

Praise and Prayer Bulletin . . .30th July, 2012

1. We are thankful that the Nursing School selections went smoothly. There was no interference from anywhere. Kindly pray that we would be able to influence each of the students as they are with us for the next 2 years that they will develop the qualities of a good nurse. 

2. We thank the Lord for the major increase in all of our statistics. There has been quite a number of poor patients who've started to access us. Unfortunately, this has brought about quite a big burden of charity given for hospital bills. Kindly pray that we will be able to balance our hospital finances well. 

April-June	Outpatients	Inpatients	Deliveries
2008	6338	876	211
2009	5536	699	208
2010	5611	804	304
2011	5775	731	267
2012	7861	1253	360

3. The region around the hospital has received a fairly good amount of rains. However, we understand that the rainfall pattern in the whole of the region has been very inconsistent because of which there are fears of an impending drought in some of the places. Please pray that we would have some more rains.

4. The obstetric work has increased quite a lot. As I write this, there are 4 patients with severe eclampsia who are fighting for their lives in Acute Care. Please pray that each of them will recover well. 

5. There has been a spurt in cases of acute diarrhoeal disease in the region over the last 2 weeks. Kindly pray that we would be able to control the outbreak soon. 

6. There were over 15 patients who came with accidental or suicidal pesticide poisoning over the last 2 weeks. All the patients have made it. We thank the Lord. 

7. We find quite a lot of discrimination against the girl child which gets to very terrible proportions many a time. Please pray that the girl child will be valued in our communities and families. And that we would be means of helping out families realise the importance of the girl child and improved status of women in the society.

8. The hospital is being patronised by the RSBY card-holders in a major way. We thank the Lord that we've able to cater to the poor through the RSBY. We also thank the Lord that we are part of a project on the community monitoring of the RSBY. Kindly pray that we would able to facilitate the RSBY to reach the poorest of the poor. 

9. There is a major need for more consultant staff to join NJH as well as other units of the EHA. Kindly pray that the Lord will move the hearts of qualified people. 

10. Kindly pray for a patient, Nandu Ram. Nandu Ram was in all the local papers over the last week. One of the local quacks had done an appendicectomy on him which has gown awry. He was taken to Ranchi where the doctors had given a very poor chance of survival. The local MLA requested us to take care of him and do the maximum possible. He's got admitted today morning. We pray that the name of the Lord be glorified as we care for Nandu Ram. 

Too Poor . . . Cont'd

As the story of the 4 day old baby dying in a hospital has made quite a headline in many of the country's newspapers and other media, I got more ammunition to strengthen my case for building up the public healthcare system of the country. Of course, I've been getting quite a lot of e-mails after my first post on healthcare for the poor. 

Yesterday, I came across a very good article in 'The Hindu'. I was flabbergasted to know that deliberations within the Planning Commission was leaning towards state funded insurance rather than efforts to rebuild public healthcare systems. 

It seems as if 'Corporate Healthcare' is well poised to hijack public healthcare. It is not without everybody's knowledge that private healthcare is always associated with profits. Therefore, the motives would remain profit making rather than public good. 

I remember going to a investment advisory meeting quite some time back. I was seriously thinking about going into share market, along side my medical studies. It was the first meeting of such a nature which I was attending. The guy on the podium was all dressed up. He communicated quite well . . . 

One part of the monologue went something like this . . . 'You know where you should invest if you don't have much money to play around with.' Hand went up . . . Someone told 'cement'. Others 'cars'. Someone else 'infrastructure'. Our friend gleefully negated all of them. 'There are two areas in which you can always be assured of profits - - petroleum and healthcare especially pharmaceuticals. The 2 Ps'. 'Of the 2 if you have to chose one, it is always pharmaceuticals', he blabbered on. I was stunned. 

I was just into medical school. And had very less knowledge about industries and business. This guy educated me that healthcare would always be profitable. There would always be customers come rain or shine.  

Today morning, I had 2 groups of medical representatives come in. They told me they only dealt with branded medicines. No dealings in generic cheap medicines. All this when there is a Central Government order on promoting generic cheap medicines. The bottom line was about the profits I could make.

So, the corporate world's involvement in healthcare is for profits. You know, how they can advertise one event of philanthropy and ensure that they have everybody's goodwill. I beg our guys in Planning Commission not to fall for the gimmicks being shown by private healthcare providers. They talk well . . . smoothly . . . and before long you'll be the main source of their profits. 

With a poor global economy, healthcare is something the corporates are eyeing. They wait in the riverbanks like vultures eyeing a feast at the expense of the common man who has been let down by public healthcare of the country. 

At the end, what do we have to do . . . It goes without doubt that the government cannot shy away from the responsibility of ensuring public healthcare in a country like India. It is the worst crime against it's own citizens to outsource healthcare to private healthcare providers. 

Would the government ever think about outsourcing the security of country's borders to private security firms . . . Or call private armies to ensure law and order. Diseases occur due to as well as result in a breach in the health of a citizen. Outsourcing the business of proper healthcare to a motley group of 'cash rich but still hungry' healthcare businessmen is not we should be even discussing about. 

As mentioned in the article, we have enough research as well as global models to support a public funded healthcare system. Let's not allow healthcare to become an industry. Or if it has become an industry to at least some extent, let's prevent it from continuing as an industry. 

Of course, I'm sure that with a 1.2 billion and booming population, no private healthcare institute worth its salt would need to close down. I recently heard about small private hospitals in Kerala becoming non-viable. Of course, that's how it should be. Public healthcare should have prominence and should be the first choice for point of healthcare for any citizen of the country. 

I know that there is much more to be put in . . .which I would do in due course of time. I've enough cases which we got over the last 2 days . . .which all resulted because of a poor public healthcare system. 

Please share this post to build awareness about the need for strengthening public healthcare.

Too Poor . . .

Today morning there was a news-item about a 5 day old baby who died because her parents could not afford to pay a 200 INR advance to keep her in an incubator. I'm surprised that this has become front page news. . . because, this is quite a common story in many of our towns and villages and even cities. 

I remember the first Cesarian I did independently at NJH. She was expecting her first baby. . . The family had been trying to deliver her at home. And after almost a day, they decided that they needed expert help. One examination it was quite obvious - her baby was too big to pass through the birth canal. And the baby was becoming sick. . . 

Quite enthusiastic, I told the husband about the need for a big operation to save the baby and the mother. He looked quite worried, which I naturally expected. I requested that he give permission fast so that we can operate soon. He told me he needs to think about it. I was shocked. . .what does he have to think. He was off in a huff. 

After about 10 minutes he was back. He wanted to take her elsewhere for a second opinion. I tried tor reason to him about the futility of such a step. The next place where they did a decent Cesarian was 80 miles away. 

While I tried to reason, I found out that he was not planning to take her elsewhere. She was planning to take her home to die. 

His reasoning. . . The cost of doing a Cesarian Section is about 7000 INR. To obtain 7000 INR at such a short notice, he would need to sell his 2 oxen. With the rains coming soon, the rest of his family would suffer if he sells off the only 2 cattle heads he had. So he concluded that it would be better for him to let his wife die and then plan to marry anew next year. Thereby, he would ensure that the rest of the family do not suffer. 

Fast forward today. . . Today, Thursday is a half working day at NJH. As I was coming out of hospital at around 2:00 pm, I saw a mother and her baby looking quite forlorn . . . Along with them was a familiar face of one of our DOTS Provider who helped us with tuberculosis work. 

She told me that the baby was sick and was not feeding since morning. I examined the baby. The baby was toxic and really sick. I took the baby inside and requested Titus to get the baby admitted and started off on antibiotics. 

About 10 minutes later, I got a call from Acute Care that someone tried to slap one of the nurses. I reached the ACU to find that the culprit was none other than the baby's father. Totally drunk, he was shouting at me that I should have asked if they had any money before admitting the baby. I told him him that we never asked anybody for money before admitting a patient. 

He went on blabbering on how we squeezed patients out of whatever they had. I was the one who was responsible. 

It was unfortunate. He had already taken the mother and the baby out. A small crowd had gathered. There were a couple of relatives of other patients who wanted me to give permission to give the guy a sound thrashing. 

But, there was no point . . .The fellow was stinking drunk. 

I just pray that the baby would heal on her own. 

The fact that many of our citizens cannot afford basic healthcare in the absence of a properly run healthcare system should be a major concern for each one of us. . . Otherwise, stories such such that of a baby dying for want of an incubator will continue to remain common happenings, most of which nobody will ever hear . . .

However, with the massive increase in costs of healthcare, there is another angle to all this. . . Advances in healthcare has come to such a point where it is possible to prolong life in many cases if you have the necessary finances . . . 

2 examples with which I could make myself clear . . . 

A friend of mine whose wife has a very bad cancer. They are a middle class family. The doctor told them about this medicine, herceptin which is really expensive . . . He asked me about it. I checked it out and found out that it will just prolong life. But the costs involved was huge. This guy went all out and got quite a lot of the money. He needed about 4 million INR. He managed to get about 2 million INR and therefore she could only be partially treated. 

He is tired of knocking at doors for help. He's given up. His wife is in a vegetative state. She could die any day. He wonders if it was worth all the effort to raise 2 million INR just to give her a partial treatment. 

As I discussed the case of the baby dying because of a lack of incubator, I'm sure the costs are not going to be limited to 200 INR. Even if it is public healthcare, the indirect costs of neonatal care are huge. I wonder if there is going to be a change in the outcome even after all the attention it has garnered. 

The second example - - - another of my friend's father - - - again from a lower middle class family. He had a myocardial infarction about an year back. The doctors advised angiogram. . . The elderly gentleman would not have any of it. A month back, he suffered from another myocardial infarction. The doctors were hardly bothered . . . They retorted - 'we had asked him to get an angio last year, but he hardly bothered'. They treated him. . .but it was a losing battle. He passed away couple of days later. 

When I talked with my friend, he told that his father was quite concerned about the family finances and therefore did not go for a angiogram. Even after an angiogram, he would not have been happy to shell out the amount needed for further treatment, be it stenting or bypass surgery. 

You can judge for yourselves. . . 

But, I'm of the opinion that unless there is a robust public healthcare system in place, there is no place for such sensational news. . . 

Marathon Cesarian sections . . . almost all MNMs

The start of the last weekend was quite hectic one. . . By standards of many big hospital, it may not be that hectic. . . But for us, it was quite a busy time. . . Not only for us, for each of the patients involved it was a close brush with death . . .  all of them mothers delivering babies. I thought I'll share each one of them. To make things easy, I've put it in a table. 

Name	Time and date of surgery	History	Final management and comments
RtD	20th july, 11:00 am	Previous LSCS, had come for ANC on 20 june, Hb: 8 gm%, never bothered to arrange blood	Boy baby, apgar 9 and 10. Had waited almost a day for the blood
SMD	20th july, 12:36 pm	Obstructed labour since previous day 8 pm	Boy baby, apgar 6 and 10. Almost a rupture
MD	20th july, 2 pm	Primi at 40+6 with labour pain since previous night. Later obtained history of leaking 4 days. Irregular fetal heart.	Girl baby apgar 8 and 10. Well off patient – did not go to Ranchi.
AF	20th July, 3:14 pm	Labour Pains since yesterday afternoon and leaking, short 136 cm, obstructed labour	Sick girl baby, apgar 1 and 4. Died later, Almost a rupture
KD	20th July, 5:24 pm	Prev LSCS  with  and Hb 8 gm%	Dead girl, Hysterectomy for placenta percreta
RnD	21st July, 2:17 am	G4P3L2D1, pedal edema 2 weeks, headache followed by seizures 2 pm, 20th july	Baby boy, apgar 6 and 10. IUGR
SrD	21st July, 3:30 am	Short primi, pedal edema > 2 weeks, was having labour pain since 12 pm on 20th July, BP 140/100. Urine alb 4+	Cervix edematous and head high, inadequate pelvis – lscs, boy baby apgar 3 and 7. Gr 3 Meconium Stained Amniotic Fluid

We lost 2 of the 7 babies. But we could have lost all the 7 as well as few of the mothers. The major challenges we faced - 

1. Availability of blood. 

2. Patients not following advice given during Antenatal Care. 

3. Ignorance of leaking per vagina as an indication for coming to hospital

4. Previous Cesarian section patients appears to be so ignorant about the fact that they need to have an institutional delivery

5. As we conversed with MD and AF's relatives, we realised that relatives have come to the conclusion that they have conceived girls. Especially, MD could have taken her easily to a higher centre. 

The weekend was thankfully not as busy as it threatened to become. . . 

However, do remember little GS, a little 6 year old girl who had come with a viper bite on her hand. Compartment syndrome has set in her hand very badly. 

I tried my best to refer the little girl, but without much response from the parents. We did a fasciotomy in the morning. Only tomorrow we shall know how much better it is going to be. . .

Then we had 4 kids who came in with accidental pesticide poisoning. 

After all the weekend rush, today was very quiet. Most probably on the occasion of a local festival . . .

And one more word of prayer for BD, who has delivered a baby at her home yesterday evening who came in with a retained placenta. On arrival, her hemoglobin was a paltry 2.4 gm%. The relatives have arranged blood just few minutes back. Shishir and Titus would be trying to do a manual removal of placenta within the next couple of hours. . . .Please pray that she will make it . . . It is almost similar to the case of SD who survived almost a identical history with a hemoglobin of 1 gm% ! ! !

Managing diarrhoea . . . Complicating things

Yesterday, I was taking rounds when I came to a little boy, 11 months. He looked irritable and took my presence with much protest. I wondered why he should be admitted. 

The case sheet showed - 'Loose stools: 3 days. Being managed elsewhere. Baby has no relief'. 

There is no history of fever or any difficulty in feeding. There was couple of episodes of vomiting which has since settled . . .

I was interested in the 'management elsewhere' - 

And these were the list of medicines the little child was on - - -

1. A combination syrup of Salbutamol and Guiphenasin: 5 ml three times a day. 

2. Inj Ceftriaxone and Tazobactum - twice a day

3. Resicadrotil drops - 20 drops twice a day

4. Syr. Colistin Sulphate - 3 ml thrice a day

5. Inj Amikacin - one injection a day since the last 3 days

6. Neopeptine drops - 20 drops at night

7. Promethazine + Paracetamol syrup: 5 ml thrice a day

8. Ofloxacin + Metrogyl syrup: 5 ml thrice a day

9. Probiotic powder (Lactobacillus)

10. Dicyclomine drops: 5 drops thrice a day

11. Syrup Loperamide: 2 ml when needed

Well, I wonder if the little boy needs food at all . . . There would be no space in his little tummy after he's taken all those syrups . . .

This is the knowledge many of our doctors have about managing diarrhoea. 

You don't want to miss anything - so hit all the bacteria you've heard about or use all the antibiotics whose name you've heard of . . . I'm sure that if they had heard about any anti-virals, that would have also been started. . .

Below is a snap of all the medicines . . .

The worst part of the prescription. There was no Oral Rehydration Solution at all. . . If the doctor had added ORS to the prescription, that would have made it 12 medicines to treat a case of diarrhoea. . . 

We've stopped all medications. The baby's doing well . . . 

Quo vadis . . . Education

The other day, Angel and me were having a discussion on education and the sea of change that has happened in schools and colleges over the years. The main point of discussion was about all the various standards which have come into place in the field of education especially in our home state, Kerala. There were few of our friends and relatives who were busy preparing for qualifying tests to teach. With all sorts of names like NET, SET etc. these standards were in fact keeping potential new teachers on their toes. 

Fast forward to today. . . I was part of a panel interviewing candidates for our school of nursing. The minimum qualification was a pass in Plus 2 or Intermediate. 

Interestingly more than half of the candidates whom we interviewed had a graduate degree. They were finding it difficult to get a job and therefore felt that a Auxiliary Nursing and Midwifery degree would help them get a good paying job fast. . . 

Well, what was disconcerting was the fact that almost all potential candidates knew much less than basic standards expected of their qualifications. 

There was one girl with a Bachelor of Arts in the Hindi language. I asked her about some of the literary giants of the Hindi language and she did not have a clue. There was another candidate who had a Bachelor of Arts in English language and she did not know who Shakespeare was. I was at my wit's end when I asked her to spell 'heart' (told her the hindi word) and she spelt it 'hurt'. 

As I glanced through the test papers, it was horrible. Hardly anybody knew how to do calculations with fractions. Half of the batch of examinees agreed that it was Mother Theresa who laid the foundation for nursing as a profession. There were quite a few who agreed that 'gravity' was discovered by Abraham Lincoln. Many in the crowd did not know how many inches make a feet or how many centimetres make a metre. 

Then we had a shocker - one girl who requested that her name not be put on the rank list as she did not like nursing. She had applied because her mother has forced her to apply. 

We had wives of 2 quacks . . .obviously, they had applied to learn the tricks of the trade and help their husbands. We were relieved that both of them did not do the test papers well. 

The common refrain we got everybody singing was how much they loved the great profession of nursing . . . There were quite a lot of them born dreaming about how much they wanted to become a nurse. There were about half a dozen of them who swore that they would do nursing even if they did not get a salary. 

We did quite a lot of career guidance too in the midst of the interviews. What else do you tell people who are in the middle of their post-graduations while our qualification requirement is only a 12th standard pass?

After I came out of the interview room, I was left to wonder at the wide chasm that is developing between education being offered at different parts of the country. On one side, we have high class education systems put in place where children vie with one another to be placed in some of the most elite institutions in the world. Whereas on the other, we have students passing exams without any check on the standards. It is not uncommon to see 10th standard students not knowing how to read or write well, graduate students of a particular discipline not knowing the basics of the subject they've learnt . . . 

I can only imagine the plight of the healthcare sector where half learnt graduates and post-graduates are churned out and given responsibility of caring for the lives of fellow-citizens. It is not uncommon to see such instances all around us . . . nurses not knowing how to check blood pressure and temperatures, doctors not knowing to arrive at a clinical diagnosis, lab technicians not knowing how to identify an eosinophil, graduates of accountancy/finance looking blank when you talk in financial language at them. . . 

It is very evident that unless someone takes the responsibility of bringing in some amount of standards in the field of every form of education, it would not be soon before we could have to face major issues in our day to day life. . . Or are we facing it already. . .