Tiger spotted . . .

We've great news in the wildlife front from the Palamu Tiger Reserve, which is about 10 miles from our place. Newspapers reported today about a tiger being snapped up by the automatic camera within the reserve. 

English translation: The camera trap at Palamu Tiger Reserve, Betla took the snap of a tiger on last Sunday at 9:41 pm. The forest staff has identified the tiger to be 'Maharaja'. Previous to this, the camera trap had photographed a tiger on 21st February. Over the last 2 months, tigers have been spotted thrice in the Betla National Park. It is difficult to comment on how many tigers are there. But there are tigers here.

By the way, we would going there along with the students from the Christian Medical College, Vellore sometime this week. The students are visiting us for a week under the secondary hospital program. Dr. Shubhankar Mitra from Medicine 4 is the consultant in charge.   

Neglected Hand . . . Need Help

I need help to manage a patient.

This 45 year old lady came to us with a very bad ulcer of her left wrist. And it is stinking very bad. It seems that there are maggots inside. 

The X-Ray shows dislocation of the metatarsophalangeal and distal interphalangeal joints of the thumb. There appears to be gas gangrene too. 

We tried our best to send them off to a higher centre. They are only willing to go home if nothing can be done here. 

The additional challenge is that she has a hemoglobin of 5 gm%. And an ESR of 150 mm/hr. And no evidence of diabetes. 

My plan is to do an amputation as soon as we get couple of pints of blood. 

Any other choice . . . I would appreciate responses . . . 

Information Technology

I got quite a few enquiries on what an Information Technology Manager would be doing in a place like ours. So, here is a brief write up of things he plan to do. 

1.    Allocation of workstations across the departments in wards, consultation rooms, labs, x-ray and nursing stations.

This will distribute the work on the HMS evenly across the departments thus reducing the load and chances of error at the billing. It will also offer past diagnostic details of patients for consultants and for Labs, x-ray and ultrasound departments.

2.  IT Training for staffs and nursing students.

This intends to sensitize the employees and the students about the role of IT and give them hands on training on HMS modules.

3.  Modeling of a new RSD( requirement specification document) for a new HMS and its implementation.

Bringing a new system requires planning and the RSD aims to give a clear view of our requirements thus making clear the developers our needs.

4.  Setting up of a new server that can take the load of 40 workstations.

If workstations are allocated across the departments, a server upgrade is a definite necessity. This server will be a dedicated server for the HMS.

5.  Setting up of a communications server for intra-unit communications.

We also plan to setup proper communications network for file transfer, internet sharing and intra communication services. At present there is no internet gateway server and so security is at risk. With the implementation of the communication server, internet access will be filtered and secure in the network.

6.  Setting up a proper server management. This includes a cooling system such as an air conditioner, server racks and server security software.

Server management is one of the most important aspects of maintaining information systems. With introduction of a cooling system, the server temperature can be maintained below the critical temperature. Also server racks will help in keeping dirt away from the server components and out of touch from unauthorized access.

We already had a glimpse of what the future could be. The major thing I'm looking at is helping the patient go home as soon as possible after meeting the doctor. 

We've already started to bring in changes. The major hurdle is the funds involved. The total estimate to revamp the entire system and bring in all the above changes is about 2 million Indian Rupees. (25,000 GBPs or 40,000 USD/AUD/Euros)

We would welcome suggestions as well as prayers. Please do remember that we're trying to implement this in a resource poor region, which means that we would be looking at the option of external funding. 

Poison . . . wrongly identified

Yesterday afternoon, we had an unconscious middle aged lady wheeled into emergency. She was gasping and had allegedly taken some poison.

The relatives identified the poison as Furadan, a carbamate poison. However, our attending doctor was quite knowledgeable to question the involved poison as Furadan. There was no characteristic violet color discolaration of the tongue or stomach contents. And there was no smell. And most important, there was tachycardia, no constricted pupils or increased secretions.

She had couple of seizures before reaching hospital. We had already started midazolam and phenytoin. As we tried to intubate her, she had more seizures. All her teeth were in the worst side of decay and couple of them got removed during intubation. And she had a short neck. Ultimately, we had to give her scoline to get complete relaxation.

With her on the ventilator, we had to find out the real poison. We placed our bets on Endosulphan. We had already seen couple of endosulphan poisonings over the last year. And the presentation was quite similar.

Titus had already asked the relatives to get a bottle of the offending poison.

The relatives brought the poison. We asked one of them what it was. The answer was ‘furadan’.

It was quite disconcerting. What was being passed on as ‘furadan’ was ‘endosulphan’, one of the most toxic of all poisons in the world.

The lady has improved well over the last 24 hours. We could extubate her by today morning.

She should do well.

However, the fact that highly toxic pesticides like ‘endosulphan’ is commonly available and is being unknowingly used by farmers is very concerning. 

Praise and Prayer Bulletin, 16-30 April, 2013

Our latest Praise and Prayer Bulletin . . .

 1. We thank the Lord for the new faces that joined us. The team is quite energetic and young. Please pray that we would not be discouraged by the challenges, but be enthusiastic about the possibilities and attentive to the hearing the Will of God for this place as well as the staff.

 2. We specifically thank for Ms. Meghala, who joined as administrator. As mentioned in a previous post, she comes with a vast experience. Please pray that she would remain encouraged and accepted by all.

 3. We thank the Lord for the changes we are planning in the IT Department under the leadership of Mr. Jonathan. There is a need to computerize our services to a higher level so that we can serve our patients faster. We need about 1,000,000 INR to make this a reality. Please pray for Jonathan who is leading the effort.

 4. Over the last weeks, quite a lot of us were doing quite a lot of travelling. We thank the Lord for keeping all of us safe.

 5. We thank the Lord for the progress we’ve made in the burns unit. We’ve had a steady rise in the number of patients. Please pray for funds to complete the unit (2,000,000 INR) as well as funds to subsidize care (approximately 2,500,000 INR per year).

 6.We thank the Lord that we continue to remain empanelled with RSBY. We started the cycle for the year 2013-14 from today. Please pray that through RSBY, we would be a great blessing for the region especially the poor.

 7. We’ve 7 students who would be with us for about a week from Monday next accompanied by Dr. Shubhankar Mitra, consultant, Medicine4, Christian Medical College, Vellore. We pray that they would be a blessing to the region.

 8. The audit of the hospital finances starts in couple of days. Please pray for the processes involved.

 9. The first visit from the donors of the project on Community Based Rehabilitation and the Community Based Adaptation towards Climate Change is scheduled from May 1 to 3. Kindly pray for the travel of the team as well as the planning of the visit.

  10. We thank the Lord for the very good climate that we’ve been enjoying over the last week. The summer has been less harsh so far.

  11. Please pray for more consultants to join us. We are looking at the option of new consultants in Pediatrics, Orthopaedics and Surgery.

  12.   We’ve started to get cases of Malaria. Please pray for protection for staff from the disease. 

  13. Over the time, we've been involved in Palliative Care in some form or the other. Kindly pray as we take a decision about formalising the program. 

  14. The Obstetric care continues to be very challenging. We also thank for the miracles we've been having. 

  15. Human trafficking is a major issue in our region. Please remember Injot, our sister project in Khunti district who are directly involved in this issue. 

The Great Escape

I was going through old snaps from my previous stint as NJH and found this great story. 

It was a Sunday afternoon, when we had a young lady come in with a very peculiar complaint. I appreciated that she was quite forthright. The family had decided that she would abort her baby. It was her second pregnancy and her first baby was a girl.

She was already into her third trimester. 

Her in-laws had taken her to a quack. The poor guy did what he knew best. And he did not know his anatomy. 

He pushed in a laminaria tent into the urethra instead of into the uterus. And the laminaria tent had gone through the urethra into the bladder. The peculiar design of the laminaria tent ensured that it got stuck. 

We were in a peculiar position. 

The baby was about 28 weeks old. And there was a laminaria tent inside her bladder with the thread sticking out. 

Our surgeon thought it best to do a cystotomy (opening the bladder through a small operation in the abdomen) and remove the laminaria tent. 

And that's what we did. 

The lady came back and delivered about about couple of months. I was away on leave. But everybody remembered her. 

And of course, the baby was a beautiful girl . . . a very very lucky girl. 

Broken bones

One of the major changes in the profile of patients that we have been receiving of late is the major increase in road traffic accidents and of course the increase number of patients who come with fracture.

The major reason is obvious. The roads have become much better over the last 6 months. And vehicles move more faster than they used to earlier.

Day before yesterday, we had a passenger autorikshaw which went off the road. And there were 3 patients who had fractures of some sort.

And this is the time, we wish that we have an orthopaedician in our team.

Today morning, I had to go to Daltonganj for some work. In the 25 kilometer stretch, we had 2 accidents which happened over the last 24 hours. 

Considering into fact the recent new arrivals in the team at NJH, we are confident that we're in a better position to have more specialists coming in. And during 2013, an orthopedic consultant in the team would be a major item for prayer. 

Human Trafficking . . . Untold stories

Today, I am in Ranchi for a project committee meeting of the Injot Project, which serves the Koel Karo region of Khunti District.

A major news item in today’s newspapers is of the death of 2 young girls who were off to Delhi (rather taken to Delhi by a broker) in search of jobs. The broker had promised them well paying jobs. Thepapers report that these girls have died after falling sick during their time in Delhi. One of them died soon after she arrived in Ranchi and the other died in Delhi. An effort is being made to do a post-mortem on the first girl and the latter one’s body is kept in the Safdarjung hospital.

Human traffikking is a major issue in our part of the country. I don’t know the statistics. And I’m told that nobody knows about the real picture.

And it’s quite organised. I’m also sure that this would not happen without the knowledge of the so called leaders of the land.

Both these girls are 12 years old. For many, this is a necessary social evil. The poverty at home and the culture of giving secondary status to the girl child contribute to such incidents.

I understand that there are many instances where the parents hardly bother about their own children especially girls after they migrate elsewhere in search of work. The attitude is that there is so much poverty at home that even if they return, it would be difficult to feed them.

I am told that one of the girls’ parents in this incident was not even bothered to file an FIR.

I wonder if these two young girls did not fall for the violence to which women are much subject to in our country. I hope that a post-mortem is done on both these girls.

Nobody is sure about the number of girls/women who are subject to human trafficking who end up in the flesh trade.

There are quite a lot of organisation and individuals who are fighting this dreaded trade. The question is about issues such as education, job security, family ties, respect to the female gender etc. which need to be in place if such incidents are to be stop from happening.

Below are clippings from other newspapers . . . 

PS: There was a newspaper report in the Indian Express today about this incident. And later another good article in The Hindu. 

Palliative Care . . .

Whenever we talk about Pallitative Care, the 2 groups of patients who come to our picture are those who suffer from stage 4 malignancies or hiv-aids. At NJH, we’ve another group who  comes to us for end-of-life care.

Last week, we had one such patient.

Mr. GD suffered from severe breathlessness and he could not maintain his saturation to even 80% on room air. He looked quite familiar to me. Later, I remembered. He had come to us more than an year back. We had diagnosed him to have severe bronchiectasis secondary to tuberculosis.

He had already taken Anti-Tuberculosis medicines twice.

The family had already spent quite a lot of money for his treatment when I saw them last year. They were planning to sell their land and do further treatment.

And now, when I saw him last month, the family had already sold their land and spend about 400,000 INR over the last year. They had hardly any money with them.

On examination, in addition to the bad lungs, he also had a very bad right heart failure,  severe ascites, secondary bacterial infection in his lung. He responded to antibiotics to a certain extent.

His dependency on oxygen decreased from 5-6 litres per minute to half a litre per minute over the first 3 days of admission. But, he remained sick. He started to have evening rise of temperature.

To our surprise, his ascitic fluid examination showed that he had tuberculous peritonitis.

There was no way that his family was going to take him elsewhere for further treatment. After selling all their land, the only thing left was their house.

GD pulled on for about 3 weeks. He always needed at least half litre of oxygen. Ultimately, his heart gave up and he died.

The issue was his bill. We had already told the family that he would not live for long. And whatever we did was to ensure that he lived without pain. And it was expensive. The total bill came to 61,000 INR. I was sure that the family did not even have money for food.

There were phone calls from quite a number of people. And one of the mukhiyas came. Everyone wanted to take responsibility for our writing off the bill.

Of course, it is tough. We are yet to have a formal palliative program. I wonder if it is time that we request people to support us in helping out with such patients. 

The smiling buffalo

Some funny snaps of a pair of buffaloes I encountered during one of my forays into the villages. 

The first snap . . .  A very smart pair. 

As I walked on, one of them seemed to ask me if I would like to take more snaps

And below are 3 snaps of various poses . . .

At last, he got really tired and went off to nap . . . 

3 maternal deaths . . .

 Over the last 3 days, we had 3 maternal deaths . . . 

Not much of a description . . . but I hope these are documented here.

The first one . . . Happened on Monday. We shall call her A. Brought with a breech presentation, her baby was hanging out with the head stuck inside since one whole day. She was very toxic. As we tried to take the head out, the uterus prolapsed (not inverted). The next thing we knew was that she had collapsed. None of our efforts could revive her. 

The second one . . . occurred on Tuesday early afternoon. B had delivered at a nearby PHC couple of hours back. Her referral letter showed that she had severe pre-eclampsia. But, she was gasping now. And she was in shock. We did not have any clue about what had happened. We had her intubated. But, she did not make it. Most probably, a amniotic fluid embolism. 

And the third one . . . which happened yesterday. C was admitted on Wednesday night with severe anemia (hemoglobin: 7 gm%). She had already got couple of blood transfusions elsewhere. We had induced her. The relatives arranged one pint of blood. Then she went into pre-eclampsia which we had got control of. However, the patient did not progress. The baby was going into fetal distress. We did not have a choice but to operate. 

The surgery went on well. However, she became sick soon. And then in the Acute Care, she went into a refractory Post Partum Hemorrhage. With no blood, we could only watch her die. The baby, although sick is still in NICU. 

It's terribly discouraging. But, I wonder if we could have done any better. 

The third case would have benefited if there was a blood bank at NJH. 

But, the first 2 cases. They should have come earlier. 

Another cry for better facilities and personnel in a region like ours . . .

Anybody listening ? ? ?

Miracle of the night

After quite a long period of a lull in high risk obstetrics, we've had something to cheer about tonight. 

And it was extra-special after we had a dubious record of 3 maternal deaths happening over a period of 72 hours. I shall definitely post about that later. But, before that, the cheerful item. 

If you look carefully the baby above, you'll notice that the right hand and left leg are swollen. In fact the right posterior aspect of the head is also swollen up, which was not captured in the snap. 

This baby's mother had been in active labour since late evening yesterday. Deep within the jungles of the Palamu Tiger Reserve somewhere near Garu, it took the family almost a whole day to realise that she would not deliver normally like her previous 4 pregnancies. 

The family took her to the Catholic dispensary nearby from where the sisters brought her here. 

It was a compound presentation. The right hand and left leg were already hanging out of the vagina and the head was pressing hard on it. 

We did the surgery within an hour. 

The mother is anemic. We're yet to get blood. The baby has aspirated quite a lot of meconium. 

Kindly pray that there would not be any further complications. 

My Introduction to Female Feticide

The snaps contained in this post are quite hideous, repulsive, very sickening . . . very unpleasant . . . all synonyms one can think about something very nasty and distasteful. Please view with discretion and ensure children are not around when you view this post. 

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The following incident was my first exposure to the ghastly practice of female feticide in the country.

This happened in 2003 while I was in NJH as a junior doctor. I had lost all these snaps till I found them in a old CD which was kept in our office. 

I took some time deciding whether I should post this here. 

It was towards winter of 2003 when a lady was brought in by her family in vague complaints of bleeding from the vagina. She was in shock and sepsis. We did an ultrasound which showed a contracted uterus with some retained products inside. The relatives agreed that she had an abortion. They said she was 3 months pregnant. 

One of our senior consultants took her in for a curratage of the uterus. In the theatre, he discovered that the uterus was perforated after the sound he put into the uterus went all the way in.

He took a decision to operate her. 

And this was what we found inside the peritoneal cavity. 

 

A macerated dead GIRL baby of approximately 28 weeks gestation

And this is the posterior wall of her uterus. 

The photographs say it all. An attempted septic abortion where the abortionist had perforated the posterior wall of the uterus and baby slipped into the peritoneal cavity. 

Such incidents continue to happen. Couple of weeks back, one of my local acquaintance confided that there was a maternal death in our nearby village about 6 months back after the lady tried to abort more than half way through her pregnancy. 

Please excuse if this post has hurt you. But, this is reality. 

The Call . . .

Every time I write a posting about the need for more committed people to hospitals such as NJH (there are about 100 odd hospitals who are in situations similar to us with a similar mission and vision), I receive mails and long phone calls from people who feel that I'm questioning those who serve in more affluent parts of the globe and the country.

One of my friends told me outright not to take people on a guilt trip.  

At the onset, let me apologise if I've hurt anybody by such sort of posts. 

However, I feel that healthcare professionals should know that there are places within our large country where people are dying because of the lack of basic medical facilities. Like facilities (personnel and infrastructure) to do Cesarian sections, blood transfusions, early diagnosis of tuberculosis, regular antenatal care, neonatal care etc. etc. 

I'm fascinated by institutions like the Christian Medical College, Vellore which was started because of a young girl witnessed 3 maternal deaths. Similarly, there are umpteen other healthcare facilities which were started by people, mainly missionaries from abroad, as a result of witnessing or hearing about one incident of poor/absent healthcare facilities in some part of the country. 

I can only wonder why such a sort of enthusiasm is not seen during the present age. At that point of time, people seemed to have a calling for such sort of work. And I firmly believe that one needs to have a specific calling for this. 

About 20 years back, coming to NJH was a big challenge. In fact, telephones arrived at NJH only in 1995. Now, facilities have grown so much that I can skype anybody in the world sitting at NJH. I can fly directly to my home in Trivandrum within 24 hours if there is an emergency. One cannot imagine the challenges faced by Dr. Kniss and his family 51 years back when there was not even electricity. 

Today morning, I happened to have 2 sisters from a hospital in Bihar. A 300 bedded hospital, they've had to close down as there were no doctors. Quite a huge healthcare set-up during it's heydays, one could not believe that this could happen to them. 

And there are quite a number of similar hospitals which are already closed down or is on the verge of shutting down . . . A major issue. 

Then I wonder . . . Has the Lord stopped calling people? Maybe, Christian mission healthcare institutions have lost their relevance. 

Or more important . . . Have we stopped hearing the call? If this is the case, our prayer would be that more of us would hear the call . . . and be true to the call . . .

New faces . . .

Over the last 2 weeks, we've had 2 major appointments at NJH. And we are quite thankful and proud of them. 

Yesterday, Ms. Meghala Ramaswamy joined as our new Administrator. Someone for whom we had been praying for quite a long time. Ms. Meghala comes with experience in some of the major mission hospitals of the country including the prestigious Christian Medical College, Vellore from where she had done her MPhil in Hospital Administration, the Christian Fellowship Hospital, Oddanchatram, the Graham Steines Hospital, Hospital and H4B. 

Mr. Jayakumar, Regional Director, EHA of our region introducing Ms. Meghala

Mr. Jonathan Hongsha has taken over Information Technology since the last 2 weeks. A graduate in Information Technology from Delhi, Jonathan would be taking the lead in co-ordinating the further computerisation of the hospital and streamlining of information storage. 

Jonathan Hongsha at his work-station

Please remember both of them in your prayers . . . 

Exposure . . .

I've been at the Christian Medical College, Vellore since the last 2 days. Was part of a process which is unique to CMC, Vellore where medical students visit secondary hospitals such as ours. Similar to last year, a batch of 2nd year medical students will spend one week with us. 

A major learning experience for these budding doctors. And we're excited about it. 

The ultimate outcomes of the program being to encourage these students to be part of institutions such as ours for at least some part of their lives if not the whole part. Only time will tell if this program achieved this outcome. 

Today evening, few of the consultants from the participating hospitals sat discussing about the big need for more people to come over to hospitals such as NJH. The refrain from each one of them was the same . . . of doctors getting exhausted . . . and nobody to share the workload.

We shared stories of our colleagues who had gone off for a break . . . gone off abroad . . . got frustrated . . . left with quite a lot of bitterness . . .  and the work load only increasing. No sign of any respite.

I had just got a phone call from back home at NJH that there were 2 maternal deaths in the last 24 hours.

The need for more people to help us was very much evident. 

I thought of the place where we sat. I wondered if CMC, Vellore has lived up to the expectation of sending more doctors to rural areas of the country.

Nowadays, when we talk to our colleagues on going to poorly served areas of the country, the conversation changes to the problems associated with such a posting. The lack of schooling, poorer salaries, needs of parents, crude living conditions . . . the list goes on and on.

Yeah . . . all of them genuine reasons. And that is when we appreciate the contribution that medical missionaries from abroad has made to the country . . . where they left their homes far far away to serve a land quite alien to them. 

There is a paradigm shift in the approach of healthcare professionals towards sickness and the sick. It has not done good for the poor and the marginalised. 

I hope and pray that as the students from Vellore come to have their one week of posting with us, we would be able to make some amount of impact in their lives and the choices that they make in the future. 

Plenty . . .

In one of my posts towards the beginning of my blogging life, I had mentioned about how cheap vegetables could become in our region especially if the climate is really good. 

After that post, the prices of vegetables did not come down as much as during that time . . .   till last week. 

And it happened within the campus. 

We have one drum stick tree (moringa oleifera) in the nursing school. One of our senior staff informed me that the tree is full of the drumstick fruits. And that it needed to be harvested. 

I requested the guys from the maintenance department to pluck the fruits. I expected about 100 odd fruits to be brought to my office. Instead, I had about a quintal of them brought it. 

And then I found out that it did not have much takers. There were if I was going to distribute them free. 

And only the office staff know the difficulty with which we disposed off the fruits ensuring that none was wasted. There were quite a lot of them who commented on how often they had been having this vegetable for some time in the recent weeks. 

About the drumstick . . . it is touted as an answer to malnutrition in the third world countries. 

I wish we could do some more planning and ensure that everybody understands it's nutritional and commercial value.