Photo blog, 26th August, 2014

Miscellaneous snaps . . .

Few weeks back, while we visited a village, we found one of the villagers had trapped a wild cat (locally called bhado). The snap does not do justice to the size of the cat.
It was about 5 feet long and should have weighed at least 7-8 kilograms. 

A common treatment for impetigo of the scalp. Mud applied to the scalp . . . 

A cobra bite. There was no systemic envenomation. But, he had put a tourniquet around his finger so tight that the tip became gangrenous. Initially, we thought we could manage it conservatively. Unfortunately, after couple of days, we had to amputate the tip off. 

The damaged hip joint of a 18 year old young man who was being managed as Tuberculosis Hip elsewhere. After we consulted with Dr. Kenny David, orthopediacian at CMC, Vellore, we found out that it was Perthe's disease. 

In a remote village church, women put up a play of David and Goliath. Goliath is the one with a helmet. David is holding the mike. And King Saul is standing on the extreme right (with the red blouse and plastic bag on her head). 

Faith . . .

Every year at NJH, everybody looks forward to the time of fishing. Our last season catch totaled almost 600 kilograms of fish. Last year the pond did not dry out for us to clean the place out. 

However, this year's drought ensured that the pond got dried out. Unfortunately, the drought also ensured that there was less rains. However, we've been hopeful. 

Once the water level was about a meter, we took a decision to put some fingerlings . . . We decided to adhere to the traditional choice of rohu, catla, mrigal, silver carp, common carp and grass carp. We learnt that pangasius (tengra) cannot be put along with these . . . 

We put a total of 11 kilograms of fingerlings . . . Snaps of the efforts . . .

The low water level . . . You can see the bags with the fingerlings inside them . . .

Few fish did not survive the journey from Daltonganj to NJH . . . 

Kindly pray for more rains so that these fish will not die off .. .. ..

Our little singers . . .

After the last video of our children singing, it was only couple of days back that I was able to respond to Shalom's repeated requests to film one of their singing sessions. 

For this point in time, the song was a very telling reminder of what God is to each one of us. The song was their selection . . .

Ritika, who is a new friend joined them for the performance . . .

Of poor healthcare . . .

I'm away from the hospital for some unforeseen reasons. We've been staying at another place for the last week. As we stayed at this particular place, word went around that I was a doctor. I had quite a number of people coming to see me and take advice on their medical conditions. 

I thought I should mention two cases - both these cases summarize the present state of Indian healthcare. 

The first one - A couple in their late thirties. They had been married 14 years - and were not able to conceive. Since the last 3 years, they had been going to multiple places for treatment. The impressive part - there was already a diagnosis made of azoospermia. That was 3 years back. The horrifying part - the poor lady has been subject to all sorts of tests to check out problems from her side . . . including a laparoscopy.

To investigate the wife extensively for infertility when the husband has a problem of azoospermia . . . I wonder how will you justify this. The couple had spent about 30,000 INR so far . . . 

The second one - The place I stay in had a large party for the local villagers. As my friends and me walked through the grounds where all the villagers were having their food, I noticed one young mother feeding a very malnourished child. As I moved closer, it was obvious that the child had cerebral palsy. I asked the mother about the child. The child was more than two years old. She looked all skin and bones and the whole body was limp including her neck. She must have weighed about 5-6 kilograms. 

The mother told the sad story. She had given birth to the child at home. The newborn did not cry after birth. One of her relatives rushed the baby to a nearby health centre run by Catholic nuns. The journey took a whopping 2 hours. I was surprised to hear that the baby cried as soon as the sisters at the dispensary gave the treatment. 

A hospital delivery should have most probably given the poor mother a healthy baby. It was so difficult to visualize how this child was going to grow up in a remote village where the nearest road was a one hour walk away. Electricity, potable water, regular availability of food . . . all of it was a premium. 

First of all . . . a very corrupt healthcare system. Second . . . a healthcare system which is more concerned about building super-specialty hospitals and researching about rare medical conditions when quite a lot of countrymen do not have basic access to healthcare . . . 

Over the last week, it is becoming obvious that we may not be able to continue to NJH . . . However, my heart breaks to know that I would be leaving a community whom we were trying to help out from the effects of both the above issues . . . 

Searching for help . . .

The country celebrated it's 68th Independence Day today. Over the day, we had stark reminders of how languished many of our fellow countrymen are. 

The first reminder we had today. 

Around 4:30 pm today, we had a young boy being wheeled in. He was dead. 

Although brought in a Maruti Dezire by a well off guy, it was very evident that the boy hailed from a impoverished background. The history - - he was bitten by a krait at around 4 am today morning. For quite some time, they were doing witchcraft (jaad-phuk). Then someone suggested that they take the boy to a hospital. 

Someone told of the good hospital that was at Tumbagara village, in Palamu who offers good treatment for snake bite. Off they set from Tilouthu town searching for our hospital. 

Do search in google maps. Tilauthu is how it is spelt in google maps. Tilauthu to Satbarwa is whooping 165 kilometers. For those of my friends from Kerala, that is more than the distance from Kottayam to Trivandrum. 

I wonder how they missed the fact that Tilauthu to Varanasi was the same distance and the road was much better. Varanasi has big hospitals and the famous Banaras Hindu University which has a Medical College. Nearer is Gaya which also boasts of a Medical College. 

When the group drove from Tilauthu to Satbarwa, they traveled through 3 districts. They had started off at around 8 am today morning. On the way, someone advised them of a more powerful wizard in a place called Japla. So they went to Japla. They left Japla at around 2 pm to reach NJH at 4:30 pm. 

Now, if you look at the map, you see that Tilauthu and Japla are on either side of the Sone river. Initially I thought that that the family somehow crossed the Sone river to Japla. But, that was not the case. The family had reached Chattarpur at around 10 am on the way to NJH, when someone gave the advice about the wizard in Japla. 

So, they actually took a detour to go to Japla. The family claimed that when they left Japla at 2 pm the boy was breathing. 

If the family had straightaway come to NJH, maybe we could have saved the boy. 

But, the incident brings to the fore the sad state of healthcare available to many of the communities around us. And of course, the ignorance about snake bite and its treatment. 

Hope at least by next year's independence day, lesser lives will be lost to snake bites . . . 

Hospital Information System

Today is one of those days where our energies are being tested to its limits. 

Everything revolved around a computer crash-down after our Hospital Information Software went bust. And to our horror, we realized that we lost data from 11th July to 7th August. Everything, totally wiped off. 

We've been trying to find funds to obtain new software and hardware since about a year. The present arrangement of HMS has been on since 2006. However, things have not been going smooth since quite some time. Things had been kept on hold for long for want of funds. 

One of the major issues in remote and impoverished locations such as ours is the inability to raise capital. With an impending drought in the region, the future for increasing prices etc., thereby raising capital look quite bleak. The non-payment of dues from the government programs have only made matters worse. 

So . . . how much we need to somehow get our systems going once again smoothly? 

My IT manager says that he needs a minimum of 200,000 INR for the hardware and another 400,000 - 500,000 INR for the software. A welcome addition would be an additional 400,000 INR to equip all our officers with laptops. So that makes a total budget of around 1,000,000 INR (

Yes, we've had major plans for the IT department where the budget has been put at around 2,000,000 INR. However, that has not materialized so far. 

Meanwhile, please pray for the whole administrative team along with the nursing team and maintenance team who are working round the clock to ensure that things get back to normal by tomorrow morning with the old software.

Pediatric ICU

It is not even one week since I received a call from a prospective pediatrician for NJH about the pediatric workload at NJH. Well, this post is sort of an answer . . . 

Today's patients in the Acute Care Unit . . .

Bed Nos. 1: 3 year old boy, AA. Admitted with complaints of one day history of fever, multiple episodes of seizures and altered sensorium since today early morning. We had to intubate him and mechanically bag him within minutes of his admission. The diagnosis - Meningoencephalitis with aspiration pneumonia. The boy is quite sick.

Bed Nos. 2: LK, a 9 year old girl, who was sick with fever since 4 days. Since today morning, he had multiple episodes of seizures. The diagnosis - Meningoencephalitis with aspiration pneumonia. Her condition is better than AA, but needs oxygen to maintain saturation although she is not intubated. 

Bed Nos. 3: 9 year old girl, NK, who came on the 3rd August after a krait bite. She has been intubated since. By God's grace, her condition has improved quite a lot. Weaning off the ventilator would take some more time.  

Bed Nos. 4: 20 year old young lady, KK, who had a cobra bite at around 3 pm yesterday and was brought around 8 pm after going through the customary rituals of 'jhad-phuk' and couple of visits to other hospitals. We had to intubate her within minutes of her arrival . . . She continues to be on the ventilator. To make matters worse, she has a bad ischaemia of the site of the bite - Right middle finger - which most probably needs amputation. The only adult patient now in the ACU. 

Bed Nos. 5: 16 year old boy, who was bitten by a krait on 2nd of August. He has also been on the ventilator since admission. Dr. Roshine plans to take him off the ventilator sometime later today. 

Bed Nos. 6: 10 year girl, BK, admitted today morning with the history of fever since 8 days, headache and vomitting since 3 days and couple of episodes of seizures since yesterday. Lumbar puncture is suggestive of a tuberculous meningitis.

So, 4 out of 6 patients in ACU are children, another one is a teenager. That provides the answer to the prospective pediatrician . . . 

The things to be thanked for . . . all the 6 patients are sick and it was such a relief to see all of them hooked onto multipara monitors. Thanks to all those who helped us to get to this state of affairs. 6 multipara monitors, 1 full fledged ventilator, 2 anesthesia ventilators, 2 syringe pumps . . .

The sad thing was to see little AA being manually ventilated . . . However, you know, there are no ventilators of any type other than those we have for a radius of almost 150-200 kilometers. 

Of course, many more things to be done before it would become a full fledged ICU . . . more on that in the next post . . . 

Looting in broad daylight . . .

Today, a poorly built young man come to one of our doctors. He had a contrast enhanced 18F-FDG whole body PET-CT Scan in his hand which he held out to me and told me that the concerned doctor has told him that he has tuberculosis in his blood.

He had come to NJH as we had a reputation for treating tuberculosis patients. 

One look on his face and his history was enough to make a very strong suspicion of Sickle Cell Anemia. He had a huge file with him. Our doctor was hopeful that there would be something in there about the diagnosis. The names of the hospitals he had gone through were huge enough to have their own websites and online fixing of appointment etc.

Other than the PET-CT Scan, he had a complete hemogram (4 times), liver function tests (4 times), serum iron studies, detailed stool examination (3 times), ASO titres, echocardiogram, HIV, ultrasound abdomen, widal tests, couple of chest X-Rays. He has been admitted and on multiple intravenous antibiotics for quite some time. 

The total costs of the latest treatment for him has come to something around 70,000 INR.

The poor guy had gone to one of the metropolitan cities in the country for job. And then he fell very sick with severe body pain and fever.

He was always sick since childhood. He had been to many places. Nobody has told him anything till he took the PET-CT Scan when the concerned doctor told him that he appeared to have tuberculosis in the blood. 

However, the reason for me to put up this post was because of the absence of a peripheral smear report in his treatment file. Nobody had told him about the possibility of sickle cell anemia. 

I wait for the reports of the sickling test and peripheral smear . . .

Obstetrics . . . still on . . .

Couple of hours back, someone messaged me asking the reason for stories of high risk obstetric care vanishing from my blog. It's not that they have vanished . . . the fact is that the numbers almost remain the same although there has been a fall in the number of deliveries. 

I just returned from the labour room after being called for a lady who had come to deliver her first baby after she started to have pains since afternoon today. 

RD was from one of the nearby villages. In fact, married to someone in the nearby village. She was away at her mother's house which was more far away. The family had been waiting for her to deliver. 

They knew that she had completed her term almost a month back. We calculated her gestation age as 45 weeks and one day. The poor family also wondered aloud to me that it has been quite some time since she crossed term. 

I hope she has wrong dates. 

But, there was more to come. Blood pressure showed 160/110 mm Hg with a Urine albumin of 3+. She was blessed not to have thrown a seizure. On examining the abdomen, the uterine size just about corresponded to 28 weeks size. She was contracting. 

On per vaginal examination, she was in full blown labour. There was grade 2 meconium. 

Teenager with her first pregnancy, post-dated, severe intrauterine growth retardation, with meconium stained amniotic fluid . . . not an uncommon story that we've seen. 

RD was away at her mother's house till today morning. Her husband sighed that it would have been better for her to remain with him. But then, he had go far for work as a migrant laborer. 

She delivered within couple of hours. The baby weighed a measly 1400 gms, had meconium bubbling from the oral cavity and the nasal cavity. The heart rate was too slow . . . And while getting ready for resuscitation, we noticed that the pupils were already dilated . . . 

As RD was shifted to the ward, we had our next bad obstetric patient . . . a 24 year old mother of one who had delivered couple of days back at home, coming with severe lower abdominal pain and no urine output. She was in shock . . . no pulse or measurable blood pressure. She is in acute renal failure and she's pouring out pus from her uterine cavity . . . 

More on SD, if I find time . . . 

Land of milk, and . . .

When we joined NJH in 2010, one of the major issues we faced was the scarce availability of milk. There was not even an ounce of cow’s milk to be brought. Buffalo milk was available,  but in very small quantities. Providing milk to the children was always a challenge and most of the time, we were dependent on packaged milk.

Well, things have changed a lot.

As most of you have read in the news media, we are in the middle of a bad drought.

However, there is no scarcity of milk nowadays. We get cows’ milk for giving the kids. And there is quite an abundance of buffalo milk.

Such good milk that we get approximately 100 gms of butter every day. Recently, we had so much butter stored up in the refrigerator that we made ghee (clarified butter) out of it.

It’s so amazing. Poor availability of milk was something we put before the Lord when we reached here in 2010.

With the sort of agriculture work that is happening (in spite of a drought), I’m sure that the Lord will bless us with honey also in no time.

All praises to God, Jehovah Jireh, the provider of all things good for his children.