Over the last couple of days, the Indian media has been awash with the 'sensational news' of ward boys in a district hospital giving injections and stitches to patients. There has been already quite a lot of debate going on about the ethics and propriety of their doing it. The government has also got into action with an enquiry being ordered.
The paradox of the incident is that Bulandshahr is just 50 miles from the national capital, New Delhi.
I'm not going to comment on whether this is right or wrong - but do go through the situations we had to face yesterday night (rather early morning today) with one patient . . . and then another one later today.
PD had come at around 1:00 am early today morning.
PD is a 20 year old lady who is yet to celebrate her first wedding anniversary. She was at full term and had started to contract since 6 pm of 10th July. The traditional birth attender at the village advised that she delivers in a hospital.
The family took PD to the nearest district hospital by around 10:00 pm. The nurse at the place told them that she should deliver by early morning. Nothing much happened overnight.
At around 8:00 am the next day, 11th July, PD threw couple of episodes of seizures. Couple of injections (which we later found out to be Diazepam) were given and the person on duty asked them to give water continuously to the patient. They were reassured that the delivery should take place any time.
The family waited till around 5:00 pm, when a new nurse advised them to go the neighbouring district hospital. They reached the place by around 8:00 pm. However, the nurse who was on duty told them that this sort of problem can only be managed at NJH.
The family were faced with another problem. No driver was willing to bring them from Daltonganj to NJH on account of the highway robberies which have become more often since last couple of weeks.
They found a vehicle to bring PD here by around midnight. . .
On arrival at NJH, PD had a blood pressure of 180/130, urine albumin of 2+ and was not maintaining oxygen saturation beyond 75%. There were evidences of severe hypoxia.
We tried our best to refer the patient. The relatives were quite tired and were not at all in a position to go further. The driver also was not ready to take them to Ranchi.
I needed to get the patient intubated and ventilated. We took her to the theatre. We put in a NG tube. There was clear fluid oozing out, rather gushing out through the NG tube. As soon as we intubated, it was funny . . .She was pouring out water from her lungs. We could not explain. It was not the typical sort of frothing which we find with pulmonary edema. This was something different.
I could think of only one thing . . . The water she had been drinking. Most probable, she got drowned in that . . .
She arrested in no time. We could not secure the airway.
The only correlation I could make was the diazepam and the water she drank. Most probably after being sedated, the water she was drinking was going directly into her lungs . . . And later, the relatives told me that they have fed her almost 5 bottles of water . . . No intravenous fluid was given . . .
It was terrible . . .
Coming back to incident at the district hospital in Bulandshahr and similar incidents which have been brought to light - I do not think it is different in umpteen of our district hospitals in many parts of the country especially the Empowered Action Group states. . .
In India, a large proportion of the country especially those in the rural areas have no qualms about accessing quacks for their primary health needs and most of the time, the primary health care provider including primary health centres and hospitals such as ours are in an embarrassing competition with quacks.
To make matters worse, most of the EAG states are facing a severe crunch of health manpower. And there is no indication from any of such states to increase the manpower in the public healthcare institutions.
When there is a shortage of manpower, I'm not sure what else can be done other than catering with the resources and infrastructure one has.
As I write this, I've one more patient, SfD who has come in with Eclampsia. She has already arrested twice and is not fit to be taken for surgery. I do not know about the details. . .
Maybe, this would be one of the last posts I would be doing about the maternal deaths we have at NJH. . . There appears to be nothing much happening . . . When I came here first in 2004 - the situation was the same. I thought that writing about these deaths and filling up institutional maternal death reviews may have started to make some difference among policy makers. . .
We need to think of a new paradigm to counter the poor state of public health care in many of our rural areas. In order to achieve the health related MDGs, we need to look beyond doctors. . .
I suspect that training nurses and paramedical staff in clinical care through the use of protocols may be one answer to prevent situations similar to which PD and later SfD are facing. . .