Critical Care . . .

Something for which I was never prepared when I joined NJH in June 2010 was the amount of critical care work which I would end up doing.

Having a background in Community Medicine (Public Health), it was a challenge to get into using ventilators, managing pulmonary edema, rupture uteruses, cerebral malaria. More of a challenge since my last year in the Christian Medical College, Vellore was spent among the Jawadhi tribal community trying to convince them to come for antenatal check-ups, getting them to run small scale income generation programmes, conducting mobile health clinics etc.

From an healthcare institution point of view, NJH was quite peculiar.

Situated in the middle of a heavily forested area along a National Highway linking Ranchi with Gwalior, one would have expected hardly much of a crowd. Yeah, we do not get much of a crowd. The routine cases of malaria, enteric fever and normal deliveries are dealt by the motley crowd of quacks and dais in the villages.

So, if you come to our outpatient, you may think that there is not much work. But our repertoire of cases will put a Medical College to shame. You want to know, what we have in our 6 bedded Intensive Care Unit now. Here’s the list –

1.    A young man who’s survived a krait bite. He was in the ventilator for about a fortnight. Then he went into pulmonary edema. He’s slowly on his way to recovery.

2.    A young lady who went into pulmonary edema following eclampsia. She lost her baby. We had very little hope of salvaging her.

3.    A middle aged woman with organophosphorus poisoning. Again, we were not very sure of getting her alive. She had drunk too much of poison. She’s also slowly recovering.

4.    A little girl with partially treated meningitis. Still not very sure of what the outcome will be.

5.    A young man who’s just come in with a clinical diagnosis of cerebral malaria. For him to be admitted, we had to shift out a young lady who had a molar pregnancy. She had a hemoglobin of 2 gms%. By God’s grace, we could do an evacuation and she’s doing ok.

6.    An elderly lady with a very bad pneumonia. She has already been managed at Ranchi.

Then there are 3 more patients with severe malaria who are waiting in the General Ward. I would have wanted them also to be under close observation. In addition, there is a young lady with bad obstetric history (G6P5L1D4) having severe pre-eclampsia at 28 weeks who’s refused to go elsewhere.

I can only pray that there is no patient with rupture uterus or eclampsia coming in during the next 24 hours.

Well, what do I want to convey?

Critical care is something that we in mission hospitals need to look at very seriously. Traditionally known to be bastions of surgical care, there has been a major shift.

The major reason being that very few hospitals are interested in critical care and when there are facilities for critical care, it is too expensive for the common man.

So, along with palliative care, geriatric care, care of HIV AIDS etc . . . something very unusual is being expected from us in the form of critical care.

However, the ultimate question is about getting committed young men and women to serve alongside us.

Experience with RSBY (5)

There has been one major issue being faced by hospitals like ours in management of patients who come with the smart card.

The reimbursements alloted under the RSBY Program for hospitals is the minimum costs that any clinical establishment spends.

Kindly see the following clinical scenarios. They are quite common in settings such as ours.

1.    KP, a 15 year old boy is brought to the Emergency Department with a history of loss of consciousness since one day. On taking detailed history, we found out that the boy had been receiving partial treatment from a Registered Medical Practitioner (quack) in his village for fever since the last 10 days. On further examination, we find that he is going into respiratory depression and would need to be put onto the ventilator. He has Plasmodium Falciparum in his blood. He is in sepsis as he appeared to have developed aspiration pneumonia. He is also anemic which needs blood transfusions. The costs of treatment are much higher than what the RSBY Scheme will pay the hospital. Most probably, KP was having malaria. He was not given anti-malarials by the quack. If he had come straight to us at least 2-3 days since developing fever, we would have treated him in outpatient and would not have ended up with all these complications.

2.    JP, a 25 year old housewife, pregnant for the second time had been trying for home delivery since early morning. She has reached NJH at around late evening, saying that she cannot feel any fetal movements. We diagnose rupture uterus. And to our horror, a midline vertical incision on the abdomen. Her previous delivery was by Cesarian section. Her second delivery should have been in a hospital with all full fledged facilities. She has ended up in this situation because of trying to deliver at home. The cost of an elective Cesarian section or a V-BAC (Vaginal birth after C-section) in NJH would have been much cheaper. Her husband says that the family has a smart card.

3.    MS, a 20 year old young male with a snake bite was brought to emergency 8 hours after suffering a snake bite. He is from the nearby village. It is obvious that it is a krait bite. The patient is already in respiratory failure and is intubated fast. The Anti Snake Venom is rushed in. On asking why it took so much time to reach, the relatives tell us that they were trying black magic (jhad phuk). MS would not have been this sick had he come early. Now, the costs and the duration of care has increased exponiantially and his chance of survival is less.

I could go on and on. Basically, these are patients with the following characteristics –

a.    The reached the hospital late on account of their slack attitude.

b.    They were being treated elsewhere by unqualified healthcare personnel.

c.    They have received treatment which has endangered their life and brought in complications, which would not have been there if they had come straightaway.

The million dollar question is whether we should take them under the RSBY scheme. I would like to hear suggestions and opinions . . . 

Precious lives . . .

The next week, I've received an invitation to be part of a meeting where we are going to discuss about malnutrition in Jharkhand. I shall put in more about it after I attend it and receive permission from the organisers to write about it. I'm quite interested in this as from the agenda it seems that there is some survey findings that this group wants to share with us. 

As per the State Hunger Index in India, Jharkhand has the dubious distinction on being second last in the list of 17 states which were studied. In addition, it was terrifying to know that 57% of the children in the state are underweight. I don't know the details. 

Well, these are numbers. However, for people like me who dab in clinical care as well as public health, it is not uncommon to keep a very watchful eye on children who come to us for clinical care. And it does not need much experience to put forth the fact that almost 60% of under five children whom we see are underweight. More so if they belong to the tribal population or lower socio-economic status. . 

Last week, we had this boy whom we shall call MK. MK was all bloated up. I was on my way to the Palamu Fort fair when the outpatient nurse called me to take a look at this boy. NK was past 5 years,  but was all bloated up. My instant diagnosis was Nephrotic Syndrome. I wrote off the necessary investigations. 

Later, as I was at the fair, Titus called me up saying that the investigations have all turned up normal for renal function. No nephrotic or nephritis. I told him to admit the patient. 

The next day, I had a re-look at little MK. I could only shudder at what could be a possible diagnosis. Severe Protein Energy Malnutrition. Off went investigations to look at Serum Albumin and Protein. Serum Albumin was 1 gm% and Serum Protein was 3 gm%. His liver parameters and renal parameters were all fine. 

We started him on 'food'. Eggs, high energy biscuits, soya bean chunks . . .  The results were amazing. I found it difficult to identify him during rounds. The swelling of his limbs came down. His abdomen which was distended tense became more flabby. His breathing became more relaxed. He had started to walk when we thought of sending him home and to review him weekly. 

Well, before I wind up this story of MK, I would also like to mention that MK had already been seen by 2 paediatricians and both of them had made a diagnosis of glomerulonephritis . . . put him on antibiotics. The family has been on the run for the last 6 months to treat their child who was all swollen up. 

Malnutrition is the bane of rural India. Unhealthy food habits, non-availability of nutritious food, ignorance about nutritional qualities of different food materials, disappearance of traditional food stuff like millets . . . all of these has been factors. Poverty has made matters worse. 

And most of the serious disease conditions are many a time because of malnutrition or is made worse and fatal by malnutrition . . . leave alone, the resultant morbidity. 

It is sad when the medical profession fails to recognise malnutrition as a disease. In fact, many a time I feel that in our rush for statistics, we fail to recognise individual cases. Lives does not matter to us. Numbers do. 

I hope children in Jharkhand will benefit from the meeting . . . 

Photo Post . . . 30th Nov, 2012

Snaps from the hospital . . . 

Mother-daughter duo. Both senior citizens who needed clinical care. Geriatric care . . . A pressing need in India which has a huge number of elderly . . . 

Worm infestation is quite common in India. However, we do not see this sort of pictures much often. A round worm brought to outpatient by one of our patients. He had vomited it out. Lucky that it did not crawl into his trachea.

Recently, we had brought quite an array of hospital furniture. They arrived yesterday from Delhi. The place’s gonna look a lot different once these things are put in place. 

This symmetric looking organ is actually the uterus of GD for which I did a B-Lynch suturing. The uterus was more like that of a flaccid leather bag and I had to do it twice. The patient was on the ventilator for 2 days and is making a good recovery. Today, we extubated her. 

'Snow storm appearance' of a Hydatidiform Mole  - - - also called a Molar Pregnancy. We were forced to manage this case as the family was quite poor and did not have any resources to go to a higher centre. SD had been bleeding since yesterday. Her hemoglobin was 2 gm%. However, it was encouraging that her relatives tried all their resources and arranged 3 pints of blood. For us, it was a moment of faith as we knew that she could die any time. By God's grace, everything went fine. She doing well. The question remains on how we are going to follow her up. She is from a remote area in the middle of the forest in the Manatu region of Palamu. 

Injustice . .. ... (RSBY)

The RSBY Programme, has been there with us from the last 8 months. The cycle for the Palamu district finishes by 30th November, 2012. Which means that we'll have to wait for re-enrollment to treat patients from December 2012. However, patients from Garhwa and Latehar would continue to benefit. 

Yesterday, we had a very well off patient come to us and waste quite a lot of our time demanding that we admit under RSBY. I had an issue as they were insisting on having a private room. They started off by bugging the nurses. Then, they demand that they see me. I happened to see the family while doing my night rounds. They started to boss about saying who they were and what all connections they had. It was nauseating. 

I could only think of some of my patients whom I had seen earlier in the day who were very poor, but did not have a RSBY Card. But, here was one patient with bystanders sporting branded jeans, leather jackets, gold chains on the neck . . . they were claiming that the patient was Below Poverty Line . . . 

The next day, the group was back. This time, they targeted the Nursing Superintendent. But, to no avail. They came again back to me. They wanted us to adjust. I stood my line. Ultimately, they got the RSBY facility cancelled for their patient and got her admitted in the private ward. 

I thought of doing a small exercise. There was about 40 patients in the hospital at that point of time. To my horror, I found out that 5 out of 9 patients who were in the private ward possessed the RSBY Card (and of course the BPL card) whereas only one out of the rest of the patients who were admitted in General Ward had the Smart Card. (we did not give any benefit to the patients in private ward)

So much for social equity. 

We've raised this issue in many forums. But to no avail. I'm not sure whom to blame. Everyone says that things will become fine from the next time onwards. However, I'm doubtful. 

We see this phenomenon of well off families possessing social benefit schemes for the poor very often. It is not very difficult to explain. Most of the time, when the people for enrolment arrive, it is usually the empowered people in the village who benefit. The people with no voice are left behind. 

Well, the story does not finish here. One of the relatives of this patient commented to one of the nurses that they shall teach us a lesson. They did not show any outward emotions . . . later, they were quite good to me. 

I got few call couple of hours later from couple of people who told me that they were from the press. They asked me about details of the RSBY programme. And how we were running it. 

However, there was no news report today morning. Maybe, they realised that it was futile to put any sort of report on this. 

Unfortunate, but true. How the high and well off retain their 'high status' in the society at the expense of the poor and the marginalised. 

Today, I happened to read the story about poor working conditions of factory workers who died in a fire in Bangladesh. Factories which manufacture apparels for the big brands. These big brands would do all possible to keep their names a secret. Another type of exploitation of the poor so that others can remain rich. 

From the last few years in the heartland of mines and factories, I can tell you that almost all of the success stories of shining India are at the expense of the poor and marginalised of this country. 

The exploitation of government welfare programmes by the rich at the expense of the real needy are just the tip of the iceberg . . .  And I'm sure that I would have enough people who would share similar stories. But, the question remains on whether anybody is interested in changing this. 

Eclampsia with Pulmonary Edema

The ink had hardly dried in my pen that wrote the Death Review forms of the last maternal death. Today morning, I had another shocker of a patient. 

GD, another young mother-to-be at term pregnancy came to us with hardly any breathing, and putting forth pink frothy phlegm with each gasp and having seizures. GD had gone into labour at her home in the adjacent district yesterday evening. The family thought that everything was going on normal. 

Around midnight, GD started to have seizures and became unconscious. They could not arrange a vehicle till dawn. In between, she had 3 more episodes of seizures. 

They reached the first healthcare provider sometime around 5 am, who referred her to the adjacent district hospital. They went to 2 more hospitals, both of whom referred them to NJH. 

Something which was quite disturbing was that in none of the hospitals did a doctor examine the patient. Considering into fact that she had seizures and she was unconscious, it was quite pathetic that nobody took her blood pressure, leave alone give her a dose of Magsulf. 

Well, as soon as she reached NJH, which was around 10 am, we had to intubate her and hook her on to the ventilator. I clearly remember all the eclampsia patients who had come to us with pulmonary edema. We could only save one of them. SDe was her code name. And this is the fourth patient. The other two died. 

Accidentally, a technician from Medisys, our provider of ventilators had come down to service of ventilators. He was quite taken aback by the load which we were putting on our ventilators. He started explaining to us that we needed more high end Intensive Care Unit ventilators to deal with such patients. Well, that would cost us about 600,000 INR. 

Our basic ventilator was not enough to deal with GD's problem. We bagged her manually. And she was maintaining saturation. However, the pulmonary edema was worsening. With a huge dose of Lasix and a GTN drip, things appeared to have settled. 

However, we had more problems. The baby appeared dead and there was sepsis. Most probably a dead baby in the uterus for long. The per vagina finding was hardly encouraging. 

We discussed with the relatives and took a decision to do a Cesarian and take the baby out. I know I would have enough consultants contesting this decision. 

Per-operatively, there was pus inside the uterus. The baby was macerated. The uterus was so unhealthy that couple of times, the thought of doing a hysterectomy crossed my mind. Then after we sutured up the uterus, the uterus was not contracting. B-Lynch suturing was done. The uterus was so flabby that we had to do it twice over. 

GD continues to be on GTN drip and on ventilator. Please pray that she would make a smooth recovery . . . 

Another maternal death . . .

Today early morning, Dr Shishir had a very interesting patient brought into casualty. RD, who was married for just about a year was brought in with severe breathlessness. She was pregnant and was nearing term.

The pulse could not be felt. The heart beat was quite muffled. The baby was dead. Obviously dead for quite a long time. There was edema of the fetus which had obviously increased the abdominal volume thereby compromising her lungs.

RD has been sick for quite a long time . . . since 3 months. The family did not bother to take her to any hospital. It was only when she became quite sick that they took her. The doctor had told her that it looks like tuberculosis.

From her history it looked like miliary tuberculosis. And she was all emaciated . . . only skin and bones . . .

I reviewed her ultrasound. There was fluid all around the heart . . .  a pericardial effusion.

She had already gone into labour. I did not know what to do. 

Then she had a cardiac arrest. No CPCR worked. 

I had hoped that we would be able to deliver her somehow.

But, we had lost the battle long back. It was sad to see another maternal death.

It’s been quite a long time since we've seen a maternal death caused due to most probably tuberculosis. There was no direct obstetric cause, save for the dead baby.

Another stark reminder on how dangerous tuberculosis continues to be in places such as ours . . . 

The Palamu Fort Mela . . .

Every year since the year 1965 (if I understood it correct), there is a fair held on the banks of the Auranga river below the Palamu fort of the erstwhile Chero kings. People from all over the Palamu division and beyond come to attend the festivities. 

According to folklore, it is celebrated in honour of Medhni Raja, one of the Chero kings who was well accepted and considered a just and ideal ruler. 

We had been part of the fair couple of times earlier. After quite a long break, we decided to attend this year's fair. 

Few snaps from what we did at the fair. 

A health education play in progress . . . This one is on Tuberculosis.
We did plays on the topics of Maternal and Child Health, Tuberculosis, Preventable Blindness,
Inclusion of the disabled into society, snake bites . . . 

Now I know where people gets swords from. There were quite a lot of swords available for sale.

A play on climate change in progress. 

The Auranga river which separates the fort and the fair grounds . . . 

Tattoo artists are work . . . 

Quite a enticing sight of sweets . . . 

Staff having fun during lunch break . . . 

Another view of the crowds . . . 

The local MLA, Mr. Harikishan Singh inaugurates the fair . . .

The view of the Palamu Fort from a distance.

The team setting up the stall and the banners . . . 

Our staff distributing pamphlets on RSBY and snake bite. 

 

A section of the crowd watching the plays . . .

A play showcasing exclusion of the disabled in society and campaigning for integration of the disabled into society. 

I had been part of this 8 years before. However, today's fair was quite a different one in the sense that it opened my eyes to how history books ignore quite a lot of history . . . More about that in my next post . . . 

A solution for the mice . . .

It is quite some time back I had narrated the difficulties we were finding with mice in the hospital. As well as in our homes. There were quite a few who send in suggestions . . . most of them were based on putting poison baits and traps. There was one friend who suggested a cat. But, being a hospital, we never took that seriously.

However, since the last 2 months, we’ve had a very helpful occupant in the hospital. A kitten had adopted the hospital building as her home. Many a time, I found her sleeping comfortably on my chair. Once, my colleague mistook the little one for a large rat. And since I returned from holiday, I saw him at least once a day, sneaking along.

Considering the busy schedule, we did not have much time to chase the little fellow away. Over two months, he has become sort of part of the hospital.

Late evening today, as I went for rounds, I found the fellow taking a nap in the store room of the Intensive Care Unit. That was when I found the time to ask the staff about him.

The cleaning staff were all quite indebted to the kitten. It seems that the mice nuisance has come down to quite a large extent. Nurses confided that incidences of mice jumping out of cupboards, finding pinkish mouse babies under hospital linen etc. has almost become old stories. And maintenance records show me that the incidences of snapped wires inside medical equipment and air conditioners have  touched a record low.

Usually during winter, the mice menace would be at it’s peak.

Well, I was surprised. Here was most probably one of our most efficient staff serving us without any salary or appointment letter. The only thing he got was leftovers of food brought by patient.

I’m quite aware of the infections and problems that a cat can bring into the hospital. But, I’ve seen quite a lot of hospitals with cats all over the place.

I would have to soon decide on keeping him for good. But, cats select their masters rather than the other way around. Maybe, I should at least have a name of him, if not an appointment order.

There are already quite a number of names . . .  Osler, Napolean, Bismark, Bilroth, Kaiser . . . are few of the names under consideration. Would appreciate suggestions . . . even on the idea of throwing him out. 

A Rupture Uterus and a nagging Snake Bite . . .

Two patients bothered me as I woke up today morning. 

The first was SD, a lady with a rupture uterus. SD had a Cesarian section couple of years back. But, as has been the case with many of our other patients, nobody told her that her next one should also be an institutional delivery. We had lost our previous patient, AD with a rupture uterus following a previous Cesarian section. 

SD’s pain started early morning yesterday. She was being managed at home. They decided to take her to the nearest district hospital, where she reached at around 6 pm yesterday. From the district hospital, they asked her to be referred here.

SD reached NJH at around midnight. It was an obvious rupture uterus with a dead baby. And the family was so poor. They did not know what to do. Till morning they did not go anywhere. They did not know what it took to arrange blood. To make matters she was also in sepsis.

Sometime around morning, couple of our staff agreed to donate blood. And we proceeded with the surgery.

The mother is doing well. We hope she will recovery without problems.

The best part about SD was that she had a referral letter . . . 

The second patient I was quite concerned about was Loric Singh, who has been in the ventilator for more than couple of weeks. He was on the road to recovery till today morning, when he started to deteriorate because of which he had to be put once again into the ventilator. 

I was thinking aloud of whether it could be something else which bit him.

That was when the bystander told me that the type of krait which bit him was of a very poisonous nature. I told him that I thought all kraits were of the same type. Then he told me that the snake had been kept safe with the family back in his village. A very common custom in the region, where the snake is caught and kept alive till the victim is cured or dead.

I enquired if it is possible to bring the snake.

The snaps of the snake are below.

The villagers know this a ‘ghadait’ . . . a coarser version of ‘krait’. It is the elder of the krait . . .  a very old krait. Some claimed that it was a different species.

However, on closer examination, it is evident that it is a krait.

However, according to many of our staff from the villagers, it is commonly believed that a ‘ghadait’ bite is always fatal. One of the elderly villagers told me that he does not know anybody who has survived a ‘ghadait’ bite.

Something new . . .  An elderly krait has a more potent and lethal venom than an young krait . . .

Would appreciate your comments . .  .

Magnesium Sulphate . . .

In this part of the world, we continue in the holiday season. Today and tomorrow is Chatt, a local festival where the Sun is worshipped. And therefore, the outpatient crowd was quite low. The inpatient is a bit busy as there are quite a number of sick patients. Mr. Loric Singh is out of ventilator, but continues to remain sick. Please pray that he'll be completely healed. 

After the quite busy obstetric crowd couple of days back, we've had a relatively free day yesterday. Although there were 2 patients with Eclampsia, one went to a higher centre and the other had a uneventful instrumental delivery

Just as I was coming out of the hospital, there was this primi lady, UD looking quite sick who was just wheeled into the labour room. With a Glasgow Coma Scale of 3 or 4 and laboured breathing with gurgling sounds, she does not look to stand a chance. She had been having seizures since daybreak. It's already crossed 12 hours. 

The only best part was that someone has managed to give her Injection Magnesium Sulphate. Injection MagSulf as it is known has become a life saver for patients with eclampsia and pre-eclampsia. There are quite a few of my friends who campaign for making Magsulf available with the ASHA workers (called Sahiyas/Mitanins etc).

Drugs given elsewhere. It is very rare that we get to know what was given elsewhere. 

I'm sure if it was not for Magsulf, UD might have had more than a dozen seizures. She's had only 3 episodes. 

However, after the Magsulf, she was not managed actively. Ideally, she should have got for a Cesarian section immediately. That did not come to pass. I think they were expecting her to deliver normally. 

She's already in severe sepsis with aspiration pneumonia.

With the customary death on the table consent, we took her for Cesarian section. 

The baby was sick . . . however, he should survive. Apgar was 5 and 8 at 1 and 5 minutes. And, UD was breathing without the ventilator after the surgery. . . quite an encouraging sign.  

The night is going to be crucial. Please pray that UD would do well. 

However, patients like UD remind us that Magsulf may only one part of the solution. Unless we have full fledged centres who are catered to deal with sick patients, we may not make much progress with controlling maternal morbidity and mortality. 

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

1. We thank the Lord for the Regional Administrative Council in Madhepura Christian Hospital. We travelled by road which was a new experience for all of us. Kindly pray that the Lord will supply all the necessary resources in terms of manpower and finances for the plans we submitted. And more important that we are within the Lord’s will and plans.

2. I would use this opportunity to also request your prayers for the MadhepuraChristian Hospital. Dr Augustine, an Internal Medicine consultant is the Medical Superintendent and Mr. Daniel Dey is the Senior Administrative Officer.

3. We thank the Lord for Sr. Mary Nima, Nursing Director at Herbertpur Christian Hospital, Herbertpur who is helping us to reorganise our Nursing Services. We’ve ordered some new furniture for the hospital. Today, it’s being loaded for transport from Delhi. We thank the Lord for the resources and request prayers for safe transport to NJH.

4. Last week, 9 students from MGM Medical College, Jamshedpur and 2 students fromMedical College, Gaya were with us for 3 days. We thank the Lord for each of them as well as Dr Vikram Tirkey who facilitated the visit. Please pray that the Lord has touched their hearts.

5. Kindly pray for Mr. Loric Singh, a young man with a family comprising of 3 little children who has been battling for life since the last 10 days. He was brought to us very sick with history of krait bite. He has already had a cardiac arrest.

6. Kindly pray for Mrs. Lucia, mother of Mrs. Julita Thithio, who co-ordinates the Global Fund Tuberculosis work in Palamu district. Mrs. Lucia has been sick for quite sometime.

7. Over the last week, we have had a steady load of eclampsia and rupture uteruspatients. Except one patient, all of them survived. We thank the Lord. Please pray for the initiatives we take for further understanding maternal healthcare in the region.

8. The cataract surgeries are on in full swing. Kindly pray for Dr Pradhan and team.

9. We require a Surgeon at the earliest. Dr Nandamani would be proceeding on long leave from the middle of January. Please convey the message. In addition, we also require a Pediatrician and Medicine consultant at the earliest.

10. On 20^th November, NJH will complete 51 years of service in this region. We celebrated the occasion last week. We thank the Lord for all of those who were part of this mission at some point of time. Please pray that the Lord will continue to use us for His glory and the extension of His Kingdom.

11. We thank the Lord for travel mercies for quite a lot of our staff who were onholiday during the last month.

12. The winter has arrived couple of weeks earlier than usual. Please pray for protection of staff and families from the biting cold. 

Photo post . . . Nov 15, 2012

Some interesting snaps. Thanks to Dr Nandamani who took most of them . . .

A flowering tree in our campus. The violet flowers are really beautiful.
I wish that we'll have this tree all over the campus.
Anybody who knows the name of this flowering tree . . . 

This doc thinks that passing Diplomate of the National Board, Part 1 examination is a qualification

Pale tongue of the boy on comparing with grandfather . . . 

A well taken skin graft . . . 

Stones mined from the gall bladder of a patient . . . 

A fresh skin graft. 

E.g of Luke 10:19. This cobra was not killed with a stick.
A watchman in Madhepura Christian Hospital stepped on it's head. 

A very apt poem. Snapped from a wall hanging in Madhepura Christian Hospital

Dentition of a 10 year old girl with Down's syndrome. She had this multiple dentition before our dentist, Dr. Basil offered to remove it. The girl is doing well now. The procedure was covered under RSBY by which we could offer free treatment.

Medical students visiting . . .

As I mentioned in my previous post, one of the highlights of this week has been the visit by about a dozen medical college students, most of them from MGM Medical College, Jamshedpur and couple of them from Medical College, Gaya.

I’m not sure on how much the visit has excited them. However, few of us in the Emmanuel Hospital Association has been motivating medical students from nearby Medical Schools to visit us and see the work we do. 

Few snaps from the visit. 

Students watching yours truly preparing NB for Cesarian.
NB had come after about 15 episodes of seizures. 

Students watch proceedings in the neonatal unit. 

Ready for an outing to the dam

The dam . . . 

Again, at the dam . .  .

Nandamani's teaching rounds . . . 

Of course, there were times to relax . . . 

We hope the visit would expose the students to the realities of healthcare in rural India. Only time will tell if it has made any impact in their lives.