Something good . . . from a tragedy

I'm sure quite a few of my readers would have become envious of my alarm clocks. 

Tragedy stuck us last week when all the 4 of our roosters succumbed to disease. I was busy in hospital and a trip to our sister hospital in Fatehpur. The onset of disease was quite fast and they were dead within 48 hours. 

Phone calls to our newly acquired friends in the field of veterinary science confirmed the diagnosis as Newcastle disease, called Ranikhet disease in India. 

Yes, we knew about it . . . but was not very serious about getting them vaccinated. The major reason - you don't get single dose vaccination vials. The minimum you get is 500 dosage vials . . .

Later on casual talk with staff, I found out that almost all of my staff who had kept poultry lost their flocks to disease over the last month. And the clinical features fit in well with Ranikhet disease. 

Now, there was something else happening over the last couple of weeks. Before I leave on a 3 week break to Kerala, our Community Health team had arranged meetings with all the 46 Self Help Groups that our CH team had facilitated to discuss and throw up ideas on Income Generation Programs. 

Almost all the groups were doing well with the set standards of running Self Help Groups and it was good time to engage them in discussions about IGPs. 

So far, I've met 10 groups . . . We've had major discussions on various possible means of income generation that our groups could focus on . . . handloom weaving, food packaging, pickle making, small scale grocery stores, goat rearing, pig rearing, poultry . . . there was quite healthy discussion. 

The challenges we had was mainly of 500 odd women most of whom who had not seen the outside world and has been dependent much on their menfolk for their day to day existence. We were giving them ideas about making a bit of extra income. There were odd ones who stood out. One lady who had some idea about large scale poultry farming, another one who had worked in a carpet factory before she got married to someone in our neighbouring village. 

It was obvious that it was better for us to start small . . . 

Our staff did quite a lot of research . . . It was in the fourth or the fifth group I met that the issue of backyard poultry was brought up. No one was quite serious about it. But, later as we researched on the net, we found out that there were quite a number of aspects about backyard birds that made it quite a good thing for women to try out for additional income. 

Most of us knew, heard about and had eaten more broiler chicken. There was quite a little knowledge on country chicken and backyard poultry. 

We went back to the earlier groups and had further discussions . . . And oh man . . . they were all so sad with the 'tunki bimari' the local term for Ranikhet disease. They loved to keep birds, but the disease was doing so much harm.

Chicken at home was really an advantage . .. ... the local chicken fetched quite a good rate. 200 to 300 INR per kilogram. A sudden guest could be well taken care off; a sudden need for money was not a problem with few chicken around; with vast tracts of agriculture land, there was food for the chicken all the time; there was no additional work involved, and there was a bird on the table at a regular interval . . . all came to an end with huge losses as soon as the birds got the disease.

Now, the question was about what we could do for the disease. We knew that there was a vaccine. 

After quite a lot of discussions . . . we took a decision to look at facilitating vaccination of the remaining healthy birds of the groups we met so far. A rough calculation told us that the 10 groups (about 120 members) we met so far had lost a total of about 2000 birds over the last month to Ranikhet disease. The loss was much much more if one took the entire village. 

Now, we have taken a decision to vaccinate birds in 2 villages where the groups have put up a specific request for vaccinating birds. Considering into fact the birds have never been vaccinated before, after discussions with expert veterinarians, we have zeroed in on the LaSota strain vaccine which was be put into the eyes of the bird. 

I brought the vaccines today. 2 vials of 500 dosages each. 

Do pray for us as we get into this business . . . quite an unexpected thing for me to do . . . I have a hunch that this could get us into bigger things . . . after we started discussions on this, I've got inquiries on if I had some idea on diseases in goat . . . It seems that word has traveled around fast . . . 

My reading over the last two weeks was more on chicken and goats rather than on maternal health, child health or tuberculosis which I usually prefer to read. 

Maybe soon, I would be forced to put out an advertisement for a committed missionary veterinarian . . . 

An unusual presentation

JO was a 15 year old jovial boy who suddenly took up sick with fever about a month back. He was sick for almost 2 weeks and was treated successfully elsewhere. After discharge, JO’s father noticed that his son was not his former self. He suspected something was wrong.

His suspicion turned out to be true within a couple of days, when JO became unconscious gradually. Even his family did not take the way he became unconscious seriously as it looked more of JO becoming more and more sleepy over the day.

When JO was wheeled into our Acute Care, he was hardly breathing. JO had something very bad in his brain. He was running a high fever and had anisocoria. We had to do a CT Scan. But, JO was hardly breathing on his own.

After almost 2 days of mechanical ventilation, we could wean out JO from the ventilator. Considering the sort of diagnoses that a young boy with anisocoria can have, we were anxious for the CT Scan Brain. With a backup for ventilation, we rushed him to the nearest town for the CT Scan.

The CT Scan showed a hypodense area in the periventricular white matter of the right temporal region.

After he returned, the anisocoria stayed. However, a fundoscopy did not show any features of a raised Intracranial Tension. With a guarded prognosis, we took a decision for a lumbar puncture. The family readily agreed . . . in fact, we had not given them even a day for their JO to survive.

Lumbar puncture was suggestive of a partially treated bacterial meningitis with a higher protein levels than usual. Considering the long history of the illness, we took a decision to come to a diagnosis of Tuberculous Meningitis.

JO has responded well to anti-tuberculosis treatment. However, he’s yet to be completed fit for discharge.

We’re blessed to be a blessing in the life of JO and his family. Kindly pray that this young boy will be completely healed. 

Long haul ahead . . .

It’s been more than a month. BY, a 28 year old young man with a young family was brought to us for care after he had been in a tertiary hospital for a condition which did not have a diagnosis. He’s had couple of brain surgeries including the placement of a ventriculoperintoneal shunt was made.

BY is quite dependent. He has a tracheostomy, a very badly infected pressure sore on his back and badly wasted muscles of his limbs. He was being fed through a nasogastric tube . . . The family had spent about 800,000 for his treatment. They had sold quite a lot of their land for his treatment.

Before BY’s admission, his father came and talked to us. He told us of his predicament. 

BY had gone for giving an final exams for his graduation. In the exam hall, he had become unconscious. He was brought to NJH from where he was sent for a CT Scan. The CT Scan was normal. But, they did not come back to NJH as his condition was deteriorating. 

Someone suggested that he be taken to Ranchi. They went to the best hospital possible. 

After spending so much for the treatment, there was a danger of the family losing all their possessions if they continued treatment in the tertiary hospital.

However, we've also been at a loss to come to a conclusion about his diagnosis. 

By God’s grace, BY made quite amazing progress for the state he was in when he was brought in. He’s since been shifted to the general ward from Acute Care. Even the pressure sore looks much better than how it was when he got admitted at NJH.

There is quite a lot more for him to progress before the family can think about taking him home. The family’s expectations are quite high. We’re a loss when the family enquires about how things will turn up. Couple of weeks back, while BY was in Acute Care, his wife delivered their second child few metres away in our Labour Room.

Everytime I see BY, I’m reminded of how helpless we are in spite of all the amazing amount of medical research that’s happened so far. However, I’m assured of a Saviour who always heeds the call of the helpless and voiceless. We at NJH can only show the family the nail pierced hands of our Saviour who is the Master Healer. In fact, that’s the best that we can do for BY and his family.

We’re absolutely sure that BY and his family needs a divine intervention . . . and for that, we request prayers. 

Bringing in the sheaves

Today, on Easter morning, we harvested the wheat crop . . .

Snaps of the harvest . . 

We wait to thresh it and find the quantum of harvest . . . 

Maybe, we should have send her home . . .

Couple of days back, we had a very sick pregnant lady being wheeled in.

As DD was wheeled in, we were quite sure that we were dealing with a very sick patient. She had been in labour for more than 4 days. It was very obvious that she had been through a tough time. She was in a terrible shape; all bloated up; the birth canal was so edematous. The baby was obviously dead. The head was so high up and appeared to be stuck. The abdomen had a very abnormal contour which is quite commonly seen with those who sustained a rupture uterus.

There was a high chance that the bowel and the bladder were all ischaemic because of the abdominal massage she had over the last 4 days. There was only a 4-5 centimeter diameter of the birth canal. Even if we tried a craniotomy, there was high chance of severe birth canal injuries. There was also a chance of a rupture uterus.

She was also in severe sepsis.

There was only one thing that we could think about . . . to operate and remove the dead baby. The family were very very poor. They had not even a single rupee to take. They had been to couple of other places. The travel from their home to the various centres and lastly to NJH had taken up all the money they had.

Considering the chance of a rupture uterus and bowel injury, we decided to operate. On hindsight, the decision was a ill thought one. The uterus was not ruptured. But, the lower segment was like mincemeat. Putrefaction had set on the baby. On opening the uterus, there was a gush of pus and foul smelling gases.

The bladder was distended and edematous. So was the bowel. There was no necrosis or ischemia . . . but it was obviously unhealthy to look at.

I somehow closed the uterus and came out of surgery.

She did well for the first 24 hours. Then, her condition just deteriorated. She was running high grade fever round the clock. We had to hook her to the ventilator. There was foul smelling material coming out of the uterus. Her urine output was fine, but it was getting bloody and brownish. Her creatinine is about 6.

Today evening, she is all puffed up.

The costs of the treatment has been on the house. However, we will not be able to give her high end antibiotics like Piperacillin-Tazobactum. We helped the family arrange one pint of blood. We’re quite sure that we would not get any payment for this patient. The family had a RSBY card. We’ve blocked her under the scheme.

Please remember DD in your prayers . . .  

Alarm Clocks

Over the last couple of weeks, we've been woken up quite a few days by . . .

Well . . . where did  they come from . . . Another snap of the quartet getting ready to sleep . . .

The kids have a great time feeding and watching them .. .. ..

I hope you remember the 'turkey poults' that a fly-by-night salesman' sold me in January. I had been suspicious all the time. However, the guy had done a good job shaving off their necks and coloring their heads. He would have got them by paying some broiler hatchery worker for the roosters. The male chicks are usually killed in broiler hatcheries. 

I'm not complaining though . . . In a couple of weeks, we'll have some good meat on the table . . . .  

No second choice

(This is a purely medical post. There are images which can be quite revolting to most of you. User discretion advised)

Couple of days back, we had a very interesting patient in labour room. RD, a 30 year old mother of three came to us with the complaint that she had a spontaneous abortion early morning. She was in her fifth month. The problem was that she was diagnosed couple of weeks back that she had a twin pregnancy. Only one baby had come out. According to her, the second baby has not yet been expelled. 

I wish I had taken her snap when she was wheeled in. Her abdomen looked as if it contained one term pregnancy. On palpation, it was quite funny. There was a good fluid thrill and the abdomen contour was quite uneven. 

On ultrasound, she had huge ascites and there was a solid mass inside the abdomen. We got the ascitic fluid drained out. It was obviously a malignancy. She gave a history of 5 months . . . and she had attributed the gradual onset of her abdominal swelling to the pregnancy. And the ultrasound done couple of weeks back gave her a report 

Then the problems started . . . We discussed about referral and further treatment. She was quite young. She had little children. The family was very very poor. 

The husband and her mother made it very clear that they are taking her home to die. Both of them came and met me today morning and told that if we could do anything to relieve her pain. 

We discussed on what could be done. We took help from Dr. Hilda, our gynecologist colleague in Chattarpur. Considering the huge swelling, I was sure that some amount of debulking of the tumour would do her a lot of good. Of course, there could be secondaries. An ultrasound and X-Ray showed that the lungs and liver were clear. 

After a long interview with the family we decided to go ahead with the surgery. 

It was a huge swelling . . . certainly the largest we had recently. The mass weighed 3.6 kilograms. Thankfully, the mass which originated from the ovary did not have much adhesions. The sad thing was that she had seedling in the peritoneal cavity. 

Kindly pray as she recovers. We've send the mass for histopathology . . .  We would also like to people contributing for her treatment. The total costs would be about 20,000 INR. 

Angel practising her skills of 'grossing'

The cross section of the swelling

Finger Millet-Corn Meal Chocolate Cake (Gluten Free)

As we have been working with propagation (rather re-introduction) of millets in our region, we’ve had some excellent support from agriculturists, academicians and researchers. When we came up with the recipe booklet of traditional madwa (fingermillet/ragi) food-items, quite a few of them encouraged us to come up with original recipes of food-stuffs which are more acceptable to an urban population. 

Of course, there are quite a lot of recipes for making cakes etc. However, we thought of developing our own recipes. Over the last 6 months, few of us have been working quite hard on this and we’ve come up with 3 recipes for cakes.

This recipe has been voted the best by our kids.

Ingredients:

Unsalted butter: 1 cup

Sugar: 1 cup

Corn meal: ¾ cup

Ragi/Fingermillet flour: ¾ cup

Unsweetened cocoa: ¼ cup

Eggs: 3 large ones

Salt: ¼ teaspoon

Vanilla extract: 1.5 teaspoon

Baking powder: 1 teaspoon

Boiling hot water: ¼ cup

Method

1. Separate the whites and yolk of the eggs.

2. Whisk the whites.

3. Sift the corn meal, ragi flour and cocoa powder along with baking powder and salt.

4. Add ¼ cup of boiling hot water to the above flour mixture and mix it well. Keep aside to cool.

5. Cream the butter and sugar.

6. To this, add the yolk of the eggs and vanilla extract and mix well.

7. Add flour mixture (item nos. 4) to the butter-sugar-egg yolk mixture to get a medium consistency batter.

8. Fold the whisked egg whites (item nos. 2) to the batter.

9. Bake at 170 degree Celsius for 50-60 minutes. 

System of Wheat Intensification

As part of the CBA Project, we had started off doing demonstration plots in various crops since last October. In one small plot of approximately 70 square metres, we did wheat cultivation as per techniques used in System of Wheat Intensification. Abinash Biswal, one of our project staff took the leadership in doing it and he's put it in his blog. 

Snaps of the same . . . most of them taken by Mr. Thomas John, Co-ordinator, Climate Change, EHA. 

From left to right - Prabodh, Mahendar, Rajeev, Sr. Rita, Mathias, Dinesh, Amit William, Jeevan, Dr. Roshine, Ms. Meghala, Ebez, Rachel, Sheron, Abinash

A closer look

Beetroot

The champion plant - had 46 heads from a single plant

Slipping away

Last week, we had a 50 year old man who was wheeled to emergency by his relatives. This man whom we shall call MS had a very peculiar history. He was feeling increasingly sleepy over the last month. The drowsiness progressed so much that now he was totally unconscious. The previous day, he had woken up for few minutes. 

It was obvious that he had some space occupying lesion. 

We sent him for CT Scan . . . Below are the snaps . . . 

The report read - Large acute on chronic SDH along the left cerebral convexity causing mass effect and 21mm rightward midline shift with subfalcine herniation of the left cerebral parenchyma.

I understand that this is a treatable condition. 

Unfortunately, the relatives decided not to take him ahead for treatment because of the costs. The family was not that poor, but they had people in Ranchi who inquired about costs. And they did not think it worth to take him. 

Couple of days later, MS slept on to never wake again .. .. .. forever . .. ...

First day of school

Today, our daughter, Charis had her first day of school. Snaps of her getting out of home . . . 

Too shy to pose for a snap

Shalom comes out to say bye . . . Chesed leads the way . . .

Chesed continues to lead the way

Finally, Charis poses for a snap . . .

Please pray for Charis and Eva who started school today. They go to the Sacred Heart School, Chianki, Daltonganj which is affiliated to the ICSE board. The quality of education is quite good. The only hitch is the 25 kilometer drive. 

Hiding the horror

I’m sure that the sad story of SS is quite fresh in your minds. However, you’ll be stunned when you hear the story of RD who came to us few days back.

RD arrived sometime in the midnight. As is the protocol, the nurse on duty took the history which looked quite innocuous. RD, a primi was quite regular with her antenatal care check ups at NJH. The last time she came to NJH, she was already 5 days past her Expected Date of Delivery. 

The doctor in outpatient had asked for admission so that we could induce her. The family left with a promise to come back the next day. They did not turn up the next day, but arrived at midnight of this particular day which was about five days after her last visit to outpatient department.

According to the family, RD had started to have contractions from 6 pm – about 6 hours before she arrived at midnight. On per-vaginal examination, she was already 8-9 cms dilated. A perfect progress if not a fast progress of labour. The plan was put up for a re-assessment at around 3 am in the morning. There was only one thing which worried the team. The head was a bit higher than usual and a small caput had formed.

At around 2 am, the doctor on duty received a call to attend to another emergency. After that was settled, he decided to take a look at RD before it turned 3. Per abdomen, the head was still palpable. A repeat pervaginal examination showed that the head was still quite high and the caput had increased in size. During this pervaginal examination, there was a foul smell coming out from her vagina. The staff asked the patient once again about any leaking which started earlier.

The patient had been quite positive that there was no leaking. However, a new relative who had just come blurted out that she had been leaking for 3 days.

The family was conveyed the decision to take her up for Cesarian. And of course, the high chance of having a sick baby and septicemia in the mother.

Per-operative, the uterus appeared quite edematous and the liquer was stained with meconium. The baby was quite sick. Something was amiss.

The doctor closed the uterus and as is the usual protocol checked the posterior wall of the uterus. And what he got was the shock of his life. There was a hole in the posterior wall. Below is the snap of the posterior wall.

The patient was wide awake to talk. The team told her what has happened. The doctor told them that he suspected that she had been subject to abdominal massage and longer period in labour.

The story she told us unbelievable. After she returned from outpatient 5 days back, RD had gone gone to a quack who gave her some injections to increase pain. Nothing happened for the first two days. On the third day, she was again given injections and a massage of the uterus was done. She started to have contractions on the fourth day. When the contractions were quite good for about 6 hours, the quack did more vigorous massage with the intention to push the baby out. But, nothing happened.

One of the relatives realized that it may be better to go to hospital.

They had concealed the original history.

RD is lucky. The baby had very bad birth asphyxia and meconium aspiration. It was a baby boy. They have rushed the baby to a tertiary centre in Ranchi.

We pray that RD would recover without any problems. She was in florid sepsis when blood tests were done. And also remember the baby in your prayers. 

Fishing 2014 - Part 2

Snaps from the 2nd round of fishing from the NJH Pond. 

We got a total of about 125 kilograms.