Mulberries

I wonder how many people know about the mulberry tree inside the NJH campus. 

I had snapped the berries while they were raw last year. 

I remembered them only this year when they had become quite ripe and juicy. 

Making childbirth a horror

(The snaps in this post could be repulsive to many. Viewer discretion advised)

Last week, we had one of the worst rupture uteri we've ever seen. Worst in the sense that it was quite repulsive when we got the history. 

SS, a 30 year old lady with no living issue had become pregnant the third time. As with her previous two pregnancies, she had thought that she would deliver without any problem at home. Her previous two babies were born at home but died before they attained the ages of five.

However, the progress of labour in the third pregnancy was eventful. The baby just refused to come down as the previous two had come. The family sensing that something was wrong took her to the nearby government health centre. There was no doctor or nurse at the place. 

Someone suggested a 'reliable quack'. 

The quack gave her two injection and started to applied pressure with his bare hands on her bulging tummy. He was trying to somehow push the baby out of the uterus. He had not even done a per vaginal examination. After about half an hour of applying pressure on the abdomen, she felt something give way. 

But, there was no baby. The tummy still looked swollen. The labour pain had disappeared. But she started to feel quite nauseated and sick. By this time, one of her relatives who was a Sahiya had turned up. She realised that something had gone wrong. 

It was around evening when the family reached NJH with SS. As always, the diagnosis was quite easy . . . a rupture uterus . . . 

Snaps of the surgery and how it looked . . . A grim reminder of how archaic obstetric care remains for quite a lot of our fellow citizens . . .

Tried to get a snap of the abdominal contour in a rupture uterus.
There is fullness of the suprapubic and the epigastric regions. 

The surgical team led by Dr. Shishir . . . 

The baby appears like he's sleeping . . . 

The aftermath of the violent abdominal massage . . . 

The uterine rent well sutured . . .

Comparing costs

Recently, Isaw a website which showed cost of foodstuff in different parts of the world.

Sometime last week, I happened to buy some vegetables in a nearby village market. After I came come, I realized that it may be a good thing to put up the below snap of whatever I brought and request my blog readers to put up here the cost of the same amount of vegetables in their town.

The amount of different vegetables and their costs are put up in the table below - - -

Item	Cost per kilogram	Nos. of kilograms	Total cost
Tomato	10.00	2	20
Cauliflower	8.00	1.250	9
Greens	5	2	10
Carrot	10.00	2	20
Capsicum	20.00	0.50	10
Beans	10.00	2	20
Grand total		9.75	89

1 kilogram (kg) equals about 2.2 pounds (lbs). 

Unbelievable . . . but true. When I called one of my friends and made a comment about this, he volunteered to check the costs in his place and get back. The costs totaled approximately 250 INR.

Would like readers to get back regarding this post and tell the cost of vegetables kept in the snap, in their town or city . . . 

Oh . . . the suffering

One of the major changes that we've seen in our patient profile over the last one year after the roads have been repaired is the huge increase in road traffic accidents. I suppose, we get almost 20 patients a week who get into some sort of an accident in our region. 

And all this, when it is quite common knowledge that we do not have the necessary infrastructure both in terms of facilities and personnel to manage such cases. 

Of course, poverty is the major reason that many patients come to us for treatment after accidents. It is quite heart-wrenching to see them explore alternate ways of treatment especially when there are broken bones or head injuries. I've lost track of the number of head injuries who just could not afford to go ahead. The same with fractures. 

However, today, I had one of the most pathetic story of a family involved in an accident. 

One extended family was taking one of their young men who had become mentally unstable and got a wild predisposition over the last 2 days to show a doctor in the nearby town. The young man was so uncontrollable that he was bound up and held by couple of his cousins in the tempo. 

As fate would have it, the cousins had dozed off or they had thought that the patient had settled when all of a sudden, the young man become violent, loosened his restraints and pounced on to the driver. The driver lost control of the vehicle and went off the road and overturned. 

Both the cousins who were holding the patient had serious fractures. One of them had a complex open fracture in the elbow region with distal neurovascular injury. The other had a bad comminuted supracondylar fracture of the left humerus. There was one more cousin who had a fracture of the clavicle All the others including the driver and the psychiatric patient escaped unhurt. 

We had to refer both the cousins. I am quite doubtful if the doctors at Ranchi would be able to save the forearm of the young man with the complex fracture. 

And I was quite interested to know about what happened to the mentally unstable patient. It seems that the family had got so terrified of the whole episode that they have put him under lock and key in a nearby house. 

I'm sure it's not quite often that we find such an interesting association between psychiatry and orthopaedics . . . although the story was a grim reminder of how bad things can turn out in the absence of knowledge and in the absence of easily accessible facilities. 

Mistaken Identity - a fishy affair

Last Saturday, we started to fish from the pond. Along with the usual fish, we also had a fish locally called 'Tengra' 

Now, none of us had expected the 'tengra' to be there in our catch, as we had not put 'Tengra' fingerlings. Now, there was a chance that someone had contaminated our pond with 'tengra'. Unless . . . what we knew scientifically as Pangasius was locally called 'tengra'. 

Yes . . . we had put about a hundred fish fry of Pangasius in July 2013.

'Tengra' was a cheap fish which was commonly seen in the local fish markets, but quite unpopular. Cheap it was, and quite a blessing for families like ours where the children loved fish. The reason - - 'It had only a single bone and no small bones'. 

According to my staff, it was not as tasty as the 'rohu' or the umpteen number of carps, which according to me were all full of little bones. 

So off we are on a research on the 'tengra'. On googling 'tengra', it was obvious that what is commonly called the 'tengra/tingra' was a totally different variety. The common agreement was that what is commonly called 'tengra/tangra/tingra' is of a genus called Mystus - common varieties being 'Mystus bleekeri' and 'Mystus vittatus'. 

So, I've sort of come to the conclusion that what is locally caleed the 'tengra' is actually Pangasius . . . to zero in further - - Pangasius bocourti. 

I would like to hear from the experts. 

If I'm sure that this is 'Pangasius bocourti', it means quite a lot for us as we had put the fingerlings sometime in the first half of July, 2013. It's not even 9 months and we got 2 of them weighing above 1500 gms. We did not give them any special feed as is recommended.

They say that this fish is quite strong and therefore is quite difficult to catch. Maybe we would be getting more of this fish in the next catch . . . which should happen in two week's time.

The pale flesh of the fish. The only disadvantage is that the meat is quite soft . . .

It's possible . . .

See what is sitting on the table in accounts office today. 

Majherus, our point person in finance had successfully grown broccoli in his farm. About 4 months back, I had got hold of some broccoli seeds and had distributed to few staff who had small farms around their homes outside the campus. 

I had also planted few seeds in my backyard . . . but because of work had ignored it. 

It was a joy to see broccoli grow in parched Palamu. More snaps . . . 

Next year, I would like to try out chard, Brussels sprouts, lettuce, kale etc . . . And of course, we are going to encourage vegetable farmers in our surrounding villages who regularly grow cauliflower to try out broccoli . . . Would welcome donations of the said winter vegetables, especially from those who visit us from abroad. 

For beginners, please click here if you want to compare broccoli with cauliflower. 

Ignored symptoms

I'm not sure about the category into which this blog post will fit. This is more of an educative post. 

It's going to be 4 years since I've been at NJH for my second stint. There are 2 conditions in pregnant women which I've found here that people do not take seriously. 

The first one is preterm rupture of membranes and second one, urinary tract infections. 

First - Preterm Rupture of Membranes. Over the last 2 days, I've had 4 of them. All mismanaged elsewhere. 2 of them sent home with no proper advice, leave alone antibiotics. One turned out to be so bad that the endometrium and the baby was stinking. 

Even I've found that it's very difficult to convince people that once the waters have ruptured, it is almost a irreversible thing. Two days back, we had a lady who had been leaking since 8 days. Her liquer volume had come down to dangerous levels, but she and her family just could not understand that it was dangerous for her and the baby. They only wanted us to give them some medicine to seal the leak. 

We were horrified when she opted to go back home. 

I would like advice on how to put it across to our patients. I've used many analogies . . . equating the amniotic cavity to a balloon filled with water . . . how difficult it is to close . . . ascending infection etc. etc. 

However, I've failed quite a lot of times. 

The second one - Urinary Tract Infections. Interestingly, many of our diagnoses of Urinary Tract Infections are made per-operative and retrospectively. I'm sure quite a few obstetricians will find it quite interesting. I wish I could do a study on this. 

The history is classic . . .  failure to induction. Then we do the Cesarian . . . only to find a thick bladder quite adherent to the uterine wall . . . many a time with quite a bleed when bladder is pushed down along with peritoneum. Then the history of pain of passing urine is asked for and there is it . . . they give a great history of a urinary tract infection. 

I ask them if they felt it was unusual. The usual answer I receive is . . . they were told that it is quite normal to have a bit of pain/discomfort while passing urine when one is pregnant. 

Now, as most of us know, urinary tract infection in pregnancy can be quite asymptomatic. Public health specialists have always advised screening for Urinary Tract Infections using simple tests. Although it has been advised in most primary healthcare manuals, the sad fact remains that it is hardly done in most public health facilities. 

I would be quite interested to find out the burden of neonatal loss due to these two conditions in pregnant women - Delayed diagnosis and treatment of Preterm Rupture of Membranes and Urinary Tract Infections. 

Would appreciate feedback from the experts . . . 

UDBT . . . Disappointed

Emmanuel Hospital Association was one of the major partners of the Christian Coalition for Health in India who had advocated for the legalization of Unbanked Direct Blood Transfusion. Although we had put up quite a united front, the Drugs Technical Advisory Board has decided to continue with the existing ban on UDBT which came up in 1999. 

It was only a week back when we had to refer one mother who had delivered elsewhere and had post-partum hemorrhage. Her vagina was tightly packed with guaze. We just did not have the courage to remove the packs for fear of allowing her to bleed to death. She may have had a hemoglobin of 2 or 3 gm%. 

UDBT would have made the situation quite easy for us to try to manage. 

For a remote hospital like ours which is quite far away from a licensed blood bank, the decision is a major setback. The biggest losers are going to be the poor. The poor, who cannot afford to take the patient all the way to the nearest tertiary centre which is 135 kilometers away. 

Our nearest blood bank also struggles to provide us regular supply of blood. 

There is also another aspect where unnecessary blood transfusions take place when UDBT is not allowed. If UDBT is allowed, we can always keep a donor waiting even in an emergency surgery. In a situation, where UDBT is illegal, and in a location like ours, I would rather have a pint of blood ready rather than send the relatives running helter-skelter if there is an emergency need for blood. 

With UDBT continuing to be illegal, I would propose that the DTAB allows UDBT in special situations where the hospital is more than 25 kilometers away from a licensed blood bank and there is a clinical situation where emergency transfusion is needed. I'm sure that DTAB can retort that such patients be referred to a higher center with blood bank facilities. 

Well, that is when the reality of field situation should be thought of in a practical manner rather than decisions taken based on pure theory. Unsafe roads, poor law and order, absence of transportation etc. are factors which play major role in smooth availability of blood when UDBT is illegal. 

I still believe that we can take more practical decisions rather than push about draconian rules that benefit nobody . . . such laws rather does harm than good . . .

Fish in the NJH Pond

Snaps of the various varieties of fish in our pond . . .

Catla, also called Indian Carp. Cyprinus catla

Common Carp, Cyprinus carpio

Grass carp, Ctenopharyngodon idella

Rohu, Labeo rohita

Silver carp, Hypophthalmichthys molitrix. This one weighed about 2500 gms

Locally called 'Tingra'. More on this in my next post . . . 

It's a girl . . . so why bother?

I had been waiting for some time to put up this post. For beginners, it is just another post where I expose our double standards when it comes to respecting the Indian women. Many think that it is a problem only among the poor. But, it is an open secret that girl babies are not welcome into most of the middle class homes of the country.

It was another Sunday afternoon. We had one unbooked patient in our labour room, who had been progressing fine. However, we had given the family an option to take to a higher centre, the main reason being her Negative Rh blood group. They were no forthcoming.

The lady progressed well till her birth canal was fully dilated. Then problems started to happen. The baby just refused to come down. It was around 4 pm that we had kept a deadline for the baby to delivery. The head of the baby was too high for a forceps or a vacuum and it looked like an occipitoposterior presentation. We had to go for a Cesarian section.

That was when the tamasha started. The family did not want to have a Cesarian, They wanted a normal delivery. I bluntly told them that she could end up with a rupture uterus if they insisted for a normal delivery. The lady was having quite unbearable pain. On one hand I had the relatives refusing for a Cesarian section whereas the lady was shouting at the relatives to allow us to do a Cesarian section on her.

After about half an hour of pleading, they started to call up multiple people over the phone. Then they wanted me to talk to some doctor. They claimed that the doctor was the elder brother of the patient. He started in a quite rude way on why Cesarian was being done. I told him about the partogram and the way we do things. He told me in a huff that if that was the only way, I could go ahead.

It took the family another 10 minutes to give us consent.

Ultimately, we did the Cesarian. The blog post title gives away what came next.

Yes . .. .. it was a girl baby. The mother was not at all interested to see the baby. ‘I know it’s a girl, is'n't it’? she sighed. ‘My brother had helped me do to find out the gender.’ ‘The doctor brother’? I queried. ‘Yes . . .’ she replied as she drifted to sleep.

As I sutured her skin, she had woken up for a short time. She told me, 'I got married to a family who is not educated. They treat me like filth.' After the discovery that she was carrying a girl, nobody bothered to take much care of her. Her husband had gone off on a business trip although he was well aware that she could go into labor any minute. 

I told her, 'But, it was your own brother who helped you find out the gender of the baby.' 

It is no secret that healthcare workers especially doctors in developing countries have more boys than girls. I'm told that there are at least couple of surveys which prove that. 

I wonder what use are laws like the PNDT Act when we (health professionals) ourselves murder/neglect the girl child. 

Fishing 2014 - snaps

As is the custom every year, we had fishing this year too. Last year, we had not put much of spawn. However, the initial catch was very encouraging. 

Look carefully - the fist's trying to escape

Good catch . . . 

One of the biggest catch - - request species identification. Locally called 'Tengra' . . .

We caught more than 110 kilograms . . .  I suspect that there should be at least 2 quintals more of fish . . . 

One satisfied customer . . . 

NJH Donations exempt from tax under 80G

It was only recently that one of my friends told me to advertise the fact that donations to NJH are exempt from Income Tax under Section 80G. Considering into fact that there have been major needs emerging over the last years, we need serious funding . . . 

If you’re making donations to us, please specify the cause you want the donation to be used for.

The urgent needs for the hospital are as follows –

1. Construction of new residential buildings: This is something which we have received some funds to start off the construction (about 10% of total cost). 

2. Up gradation of Critical Care Unit. We still require about 2,500,000 INR to make the full fledged changes. 

3. Construction of burns unit: Here also the requirement is for about 2,500,000 INR more. 

Please, please do spread this message to friends and relatives . . .

From within India, you could send your donations in Indian Rupees to NAV JIVAN HOSPITAL in either of the following accounts -

1. Punjab National Bank A/C 0107000100251342 Daltonganj, IFSC Code: PUNB0010700
'or'
2. State Bank of India A/C 0011648040650 ADB Satbarwa Branch, IFSC Code SBIN0006063

If you are sending us donations from outside India, please transfer by foreign currency to

NAV JIVAN HOSPITAL SOCIETY,
Punjab National Bank A/C 0107000100090484 Daltonganj IFSC Code: PUNB0010700
SWIFT BIC: PUNBINBBRAN, Clearing Code: 822024002

As mentioned in my previous post, those in the US can directly transfer funds through the website - http://www.ehausa.org/donateportal.htm 

Healthcare Sciences – Opportunity with EHA

Emmanuel Hospital Association gives the opportunity to students to serve in its hospitals through the system of sponsorship to graduate/diploma courses including MBBS, Nursing courses in Christian Medical Colleges, Vellore and Ludhiana. There are quite a lot of a number of people who took this opportunity and went on to leave lasting impressions in the areas they served.

For getting sponsorship, the prospective student would need to visit one of our hospitals for a period of 5 days. I write this post as there seems to very less information about this to most of such students who look for such an opportunity.

Over the last 3 years, I get flooded with calls/inquiries about the exposure visits during Feb/March. There are of course deadlines for such visits. Every year, it is the 30^th of March of that year by which the exposure visit needs to be completed.

We’ve a rush of students coming to be with us over the next 2 weeks. However, it would be much easier for us if the visits are planned much in advance. Only one student had come to us in December over the last 3 years.

Therefore, this post is mainly for all those who’ve just finished their 10^th standard exams or going to start 12^th standard (+2). We appreciate if you could come for your exposure visits in a much more planned manner.

Please do share this information with your friends and relatives who could find this beneficial. For more information, you can visit the EHA website and also write to sponsorship@eha-health.org