Who comes to us?

It has been some time since someone requested me to look at who accesses services in our hospital and we wanted to look at whether it was the deserving people who had the RSBY (Rashtriya Swasthya Bima Yojana) Smart Card with them. 

One of the major problems with all welfare schemes is that many a time it is middle class who corner away most of the benefits which are supposed to go down to the masses who have are worse off than them. 

Below are the preliminary results. 

The socio-economic score we used was the Uday Pareekh scale for rural areas. The duration of the study was 5 days somewhere in the first half of December. And we looked at all patients who came to general outpatient department on those 5 days. The number of patients who accessed outpatient during those 5 days were very less because of the severe cold. 

So, the first question .. .. .. We at NJH, consider ourselves to exist for the welfare of the most marginalised and backward community groups of our region. So, who are the people who access our services?

Socio-economic category	Nos of patients	Percentage of total
Lower class	46	24%
Lower middle class	115	61%
Middle class	27	14%
Upper middle class	2	1%
TOTAL	190	100%

The second question was about the number of people in each socio-economic category who possessed a RSBY Smart Card . . . a major welfare initiative by the Government of India for the poor. And below is the result. 

Socio-economic category	Number of patients	Number of patients with RSBY Card	Percentage of patients with RSBY Smart Card
Lower class	46	16	35%
Lower middle class	115	22	19%
Middle class	27	7	26%
Upper middle class	2	0	0%

So, there you are . . . It is the middle class who garner quite a lot of the benefits and more needs to be done to ensure that the benefits seep down to the more poor among our countrymen . . . However, I feel that 35% of the lower class possessing the RSBY Card is quite an achievement for the government. 

One can say that the sample size is small and it was done during a very lean season. I wish I could do the study during a very busy outpatient like what we have nowadays. I've a hunch that the results are not going to be much different. 

Comments are invited .. .. ..

(Acknowledgement: Special thanks to George Savio Chalam who helped us with the survey and part of data entry and Ms Pheba Zachariah who did the other half of the data entry and rechecked data)

Sad stories . . .

It has been a very unusual Wednesday so far .. .. .. 3 cases within 6 hours which tells you a whole lot about the condition of healthcare in most parts of our great country . . . 

I had just walked into office when one of the local villagers brought a very sick looking girl into casualty. The 9 year old girl had been sick for the last 15 days with fever. The local village quack was managing her . . . with herbs and roots. 

Yesterday, she became unconscious. And the family did not know what to do till one of the neighbours told them to rush the girl to us. 

She was all yellowed up. And only a sigh of her breathing told us that she was alive. GCS of 3/15. Her serum bilirubin was a whopping 28 mg%. We are still not sure of what we are dealing with. 

So sick and they did not even think it worthwhile to show her to a proper doctor. 

Well, you'll realise what use is it many a time even if you show to a regular doctor. 

Just couple of hours after the above patient came in, a young lady was wheeled into emergency. She was dead. It did not need much of a history for Dr Johnson to make a diagnosis. 

Mother of a little girl who just turned two yesterday, she experienced severe abdominal pain at 3 AM today early morning. She had missed her periods by 2 months. 

She had visited 4 very good doctors over the 6 hour period she had spend in our nearby town. All big, big names in clinical practice. Anafortan . . . fortwin-phenergan . . . these were the drugs she recieved. 

Nobody could think about a ruptured ectopic. We took permission for a undocumented ultrasound and the results were there. It was a ruptured ectopic. 

It was unthinkable .. .. .. A young mother who celebrated her daughter's birthday less than 24 hours back lay dead in front of us. 

The last case was another young lady my colleague saw in outpatient almost the same time. A very obvious case of enteric fever . . . She has received about 20 different types of medicines from 2 quacks and 1 qualified doctor. All of them has nothing to do with enteric fever. 

One cannot blame a patient who goes to a quack if he fails to get a clear communication and evidence based treatment from a doctor who has a recognised medical qualification . . . 

Time we look seriously into medical training in India . . . 

Brick making machine . . .

The last post on the brick making machine has been a great success and I was really overwhelmed with the response. Many readers wanted more snaps and videos . . . So here are few more snaps and a video. 

The stone dust . . . It comes free at our place.
We only pay for transport. It lies waste in the quarries.
However, once the machine is popular, people are going to sell it. 

The machine . . .

The stone chips . . .

The final product . . 

The ply boards on which the bricks are laid out . . . 

And here is the video . . . 

Photo post . . . 25th Feb, 2013

Few miscellaneous snaps from my camera . .. ...

That's a meal served at a meeting we had in a village in Khunti district, Jharkhand

A get-well-soon amulet on a patient on whom we diagnosed tuberculous peritonitis. 

Titus helping out in maintenance.
Trying out cutting boards for the brick making machine.

The suction bottle with the pus we removed from SRD's peritoneal cavity.
SRD was our first maternal death of 2013. 

No clue on this fruit which is in our campus . . . 

Clearing our forests . . .

Below are 3 snaps I took today early morning, 3:30 am when I went to the Daltonganj Railway Station. 

Bundles of wood being brought by the early morning, Gomoh-Dehri-on-Sone passenger train. Some of the bundles were covered by plastic sacks so much that it did not look to contain pieces of wood. 

If you took into account all the wood which was unloaded from the passenger train, it should total at least 3 large trees. 

I had a chat with the people bringing them. They were from Chipadohar and Barwadih railway stations. Most of them impoverished poor tribals from the interior villages. 

That must be the only source of income from these families. 

However, one cannot ignore the damage they could be causing the forest cover of the region. Couple of people told me that the consignments were lesser as it was a Sunday. 

But, one cannot ignore the right of these tribals to the forests. One can easily argue that it is dead wood. However, if you calculate the total  amount of wood which was laid on the platform today morning, it was equivalent to at least 3 large trees. 

And it is not uncommon to find similar bundles of wood being transported over road everyday . . . 

Something which should be of concern to us . . .

The Pomegranate . . .

Late yesterday night, I was called for a second opinion about an elderly lady with burns on both her legs. The burns was already more than 3 weeks old. She was being managed at one of the plastic surgery institutes in Ranchi. I suppose they ran out of funds and therefore took a discharge against medical advice. 

According to her discharge report, she was doing well and could be discharged. The plastic surgeon was probably waiting for a skin graft. 

As per my colleagues description, the patient was quite sick and no intervention seemed to work. 

The patient was gasping. She did not have fever. But, oxygen saturation was quite low. And she was anemic. 

On examining the chest, it was obvious that she had a bad pneumonia in both her lungs. And it appeared that she had aspirated. I rechecked with the relatives. 

I got a very interesting history. 

Couple of days back, the patient had become a bit stuporous. Most probably because of the opioid analgesic she was on. Someone in the village suggested that she would do good with a some pomegranate juice. And that's what exactly they did.

The relatives pushed down half a glass of pomegranate juice down her throat. Most probably, quite a bit of the juice went into her lungs. 

Pomegranate juice . . . is known to be the elixir of life in this part of the country. Maybe, in quite a large part of the country  and maybe quite a part of the world. It is not uncommon to see juice shops selling pomegranate juice at quite a hectic pace. I understand that it is commonly thought to be an aphrodisiac . . . 

It is not uncommon among quite a lot of our patients to ask if they can eat pomegranate. 

I don't advice it it too expensive and many a time, I fear that the ones we get in the market is quite laced with pesticides and some sort of wax is put on them so that they look shining and attractive. I'd rather advice them to buy bananas or dates. 

I wonder if the pomegranate juice had caused her death. 

I can never confirm as the lady was dead within one hour of arriving into emergency. Maybe a bronchoscopy would have confirmed. 

Maternal Death . . . 3 Orphaned . . .

Yesterday, we had a maternal death. 

Not much to write about. Considering the previous death, this one was fast. 

We did not get much time to do anything. 

Because, she died within 15 minutes of arriving at the hospital. 

She was pale as paper and it was an obvious rupture uterus. Usually, we don't get many cases of rupture uterus who dies. Most probably, she was severely anaemic even before the rupture happened. 

The interesting thing about her. She did not have an intravenous line put on even though she had been to 3 hospitals. When we asked about the same to the relative . . . it was difficult to believe the reply. 'The patient's body is too swollen to put an intravenous line'. 

She had got couple of intramuscular injections throughout the day. Her contractions had started at 3 AM same day morning. Since, it was her fifth delivery, (3 children alive and one still birth), the family had decided to attempt a home delivery. 

Since nothing was happening, they took her to a hospital at around 9 AM. 

She reached at NJH a full 12 hours after that. 

The case sheet reads . . . Time of arrival: 9:30 pm, Time of death: 9:45 pm. 

There was no point in resuscitating as she was pale like paper. And there was no way we could get blood so fast. 

2nd maternal death of the month (February 2013) after a maternal death free month in January 2013. 

Last week, we were forced to tabulate the number of maternal deaths in 2012. Below are the numbers and the causes . . . 

Nos. of maternal deaths in 2012 (Jan-Dec)		CAUSE OF DEATH	Nos. of maternal deaths in 2011  (Jan-Dec)
•27 deaths •Total deliveries: 1544 •LSCS: 482	18	Eclampsia /Pre-eclampsia	11	•  24 deaths •  Total deliveries: 1280 •  LSCS: 439
	0	Septic abortions	3
	1	IUD	3
	1	Unknown	2
	0	Valvular heart disease	1
	0	Obstructed Labour	1
	1	Rupture Uterus	1
	5	Sepsis	1
	1	Malaria	1
	0	Severe anemia	0

Cutting costs . . . Part 2

This is for guys who may be involved in lots of construction within their institutions and if you're doing the constructions yourselves (without the involvement of a contractor). 

Here, at NJH, we need quite a lot of new constructions as almost all of our buildings are quite old and much beyond repair. In addition, we need newer buildings for new facilities. 

When the burns unit construction started, few of my friends who were in the business of constructing buildings advised me to invest in a brick making machine. 

Now, it's quite a time since we had been using it. 

We did a little costing exercise to help us find out if the machine is worth buying. 

Now, a concrete hollow brick is equivalent to 8 smaller oven baked bricks. 

The costs . . . 

Bricks made per day (min 500, max 550)
Labour cost (12 labourers X 130 INR)				1300
Cement (12 sacks X 350 INR)				4200
Gravel/Stone chips (2 tractors X 1800 INR)				3600
Stone dust (2 tractors X 300 INR)				600
Electricity (max 50 units)				300
TOTAL COST				10000

Therefore, the cost per brick is about 20 INR if you discounted the machine cost. 

To substitute the 500 hollow bricks, we would need about 4000 (500X8) oven baked bricks the cost of which would be approximately 20,000-24,000 INR in our part of the country. (In South India, the cost per oven baked brick is about 8-9 INR)

That's a 50% saving. And if you consider the cost of the brick making machine, we break even as soon as we have made 12500 bricks (25 days of working). We've already made about 3000 bricks. 

There are quite a lot of advantages of the hollow brick. However, the best thing I like about them . . . they are much environment friendly compared to the oven baked red bricks. Of course, we have a control on the quality of the brick. 

The reasons . . . we use waste material (stone chips and stone dust); there is no baking of the bricks, we save cement during the finishing of the building as the surface of the hollow bricks are quite smooth, the hollow space saves quite a lot of materials used . . .

If you liked this post, you will also like Cutting costs.

Cutting costs . . .

Institutions such as ours have to be always on the lookout on how to cut costs. And our engineer, Mr. Dinesh has always been looking out on how to cut costs . . . 

Couple of things we've started doing to bring down costs. 

One of the major costs of any hospital is cleaning costs. We require about 20 litres of phenyl and about 3 litres of toilet cleaning liquid (solutions like Harpic, Cleanmate etc) every week to keep our wards and toilets clean. 

About a year ago, we found out that we could make our own phenyl. 

One can buy Phenyl concentrate along with a chemical for fragrance in any Chemical shop. 

The costs are as follow . . . 

Cost of one litre of Phenyl Concentrate				200 INR
Amount of phenyl made from one litre of phenyl concentrate				10-15 litres
Cost of one litre of Phenyl				14-20 INR

We use approximately 20 litres of Phenyl a week. The local supplier used to supply us at 60 INR per litre. And that was a very diluted. Which means we save about 1000 INR every week. 

The next is toilet cleaning liquid. 

Below are the costs. 

Hydrochloric acid				2500 gms	65 INR
Toilet cleaner concentrate (Tropic)				800 gms	360 INR
Water				7-12 litres	Free
Total costs					425 INR
Cost per litre					28-43 INR

The costs does not seem to be much. However, we're assured of the quality and the contents of the toilet cleaner. 

Dinesh mixing the chemicals. 

Please note that the chemicals which are used are very corrosive and would need expert handling. If you do not have staff who are careful and do not regularly follow safety procedures, I strongly advice that you don't attempt this in your unit.