Friday, June 23, 2017

To do list

Few weeks back, I had a unique experience.

Early morning at around 7 am, a man was rushed into our clinic with complaints of chest pain since the last 2 days. He was taking some local treatment elsewhere when the pain became unbearable since midnight. He had a feeling that his life was coming to an end.

We made him comfortable, gave some analgesics and went ahead with an ECG. It was obviously a heart attack in progress.

He asked me if he was having a heart attack which he knew could be fatal. I told him that he appears to be having a heart attack. Although in severe pain, he asked one of the bystanders, who seemed to be his son to bring him a paper and a pen. We provided him with one.

He was in too much distress to write. He told his son to write as he dictated. It was basically names of people along with amounts of money which they owed him. It took some time for him to remember, but he thought he had all names. The total was quite a bit of an amount .. .. ..

As I witnessed this exercise, I remembered about how people like Moses, Joseph, Abraham etc. of the Old Testament in the Bible called all his children and blessed them as they lay dying.

I wondered what I will have to tell my children and grandchildren as I reach my last days on earth . . .

My prayer is that it would only be to tell my family about how good the Lord has been and how good is it to trust and follow the Lordship of Jesus Christ . . .

Thursday, May 25, 2017

Misleading . . .

One of the major group of patients whom we serve at Barwadih are those who present with diarrhoea. Since last few months, quite a many of the patients tell us not to prescribe Oral Rehydration Solution powder as there is a ready to drink ORS preparation available in the market. 

I did not care much as this drink called ORSL was quite commonly available in the market and patients especially children preferred it over the ORS powder which we prescribed. On and off, we used to get patients who said that they did not feel better and requested for the ORS powder. 

However, I was in for a shock today, when a patient with diarrhoea walked in with this packaged drink. The snaps of the tetrapack are self-explanatory. 

The manufacturer has very clearly stated that IT IS NOT TO BE USED FOR DIARRHOEA and there is no mention of the WHO accepted formulation for ORS. 

For those who don't know the formula for the current WHO oral rehydration solution (also known as low-osmolar ORS or reduced-osmolarity ORS) is 2.6 grams (0.092 oz) salt (NaCl), 2.9 grams (0.10 oz) trisodium citrate dihydrate , 1.5 grams (0.053 oz) potassium chloride (KCl), 13.5 grams (0.48 oz) anhydrous glucose per litre of fluid. This fruit drink has a whopping 12 gms of sugar per 200 ml. 

So, why the name - ORSL - which appears to stand for ORS Liquid. 

I've seen patients buy this drink in cartons from local pharmacy shops. 

Now, for the shocker . . . The below snap shows the price for this 200 ml drink which misleads people to think that it is a medicine. 

32 INR . . . when the ORS sachets are available free in public healthcare facilities and the maximum cost of a ORS sachet which makes 1 litre of the fluid is about 16 INR. So, a misled patient could end up spending 160 INR per one litre of ORSL instead of 16 INR. 

Quite misleading marketing strategy to make a quick buck . . . Can't someone take this company to task for misleading people into buying this sugary drink, which is in fact harmful to health. At least they should print 'Do not use during diarrhoea' in larger print and the local vernacular language. Instead they have printed ORSL in Hindi to mislead the unsuspecting poor and the half literate Indian. 

A typical example of how crony capitalism makes it's profits . . . 

Saturday, April 15, 2017

My goats are on the hill

It's diarrhoea season at our place now. Patients of all ages are coming in various stages of the disease. So far, the good Lord has healed everyone.

Yesterday, we got the sickest of the lot. Around late morning, an elderly lady was carried in with a history of high volume rice water diarrhoea along with severe vomitting. We could not palpate any pulse.

We were blessed enough to get a vein on her. After about 2 litres of fluid, we could measure her blood pressure.

By teatime, she was up and talking. However, she appeared so tired. During evening rounds, she wanted to go home. I told her that considering the state in which she was brought in and it being evening, it would be better for her to go the next day. I said to her that she looked tired and would benefit from a day's rest. 

She told me, 'I'm not able to close my eyes to get some sleep. The moment I close my eyes, I only see my goats which I had to leave as I was brought here. They are still on the hill. I need to ensure that they are back safe'. One of her sons told her that she needn't worry about the goats as someone had already brought them back home.

Amazing . . . even when she was so sick, the only thing she could think about was her goats. In rural areas, animals are the major asset for everyone. That was their bank balance. But, you had to regularly take care of them, unlike a bank account where you are assured of the money which was deposited there. Anytime they need some money one of the animals was sold. 

In the changing scenario of the country, when there is a push towards vegetarianism, I can only wonder at the fate of the poor who will have to look for other avenues of income. Or maybe, there will be no more poor . . . 

Sunday, April 2, 2017

Gas . . . Gas . . . and Gas

Three days back, we had a elderly lady being brought. Carried in her son's arms, she was worn out and thin with a protruding abdomen. Clearly a case of ascites or a large abdominal tumour. 

Since it was close to afternoon, I did a quick examination and sent her off for a 30 kilometer journey for an ultrasound abdomen. 

She was back just before sunset with the ultrasound report. It was just ascites. No tumour. There was mention of a possibility of a chronic liver disease.

That was when I took a detailed history. She had been having this much abdominal distension since the last 1 month. She had already been treated at multiple places and had spent almost 15000 INR. It was not that they could afford that much. That was what the quacks demanded for the treatment. 

The quacks had been telling the family since the first day that it was just gas that is pent up in the intestines. They even had a X-Ray abdomen to prove the point. 

She had not yet been seen by a proper doctor. 

I got into a mini-conference with two of her male relatives and told of the possibilities. They wanted me to give her some medicines to dry out the fluid collection. They did not want an ascitic tap to take out the fluid and do some tests. The only test we could do was a microscopic examination. Under no circumstances, they were ready to take her ahead for treatment. 

She did not respond to the diuretics that I tried. Ultimately, they agreed for a tap with the fiat that whatever tests I had to do with it has to be done here. They just did not want to take her nor the fluid ahead for any tests. 

I did the tap today. It was a hemorrhagic tap. Microscopy showed almost 99% lymphocytes along with the red blood cells. It was more in favour of a cancer. Well, it could be tuberculosis too. Liver function tests were all normal. 

The best I could do for her was to start her off on anti-tuberculous medication and send her home. 

But, it would have been better if she came straight to us before they blew up 15000 INR for the quacks to remove the gas . . . 

The big question is how I can enable families like these to see us as their first choice for access to healthcare . . . rather than these quacks . . . 

Sunday, March 26, 2017

Oh . . . Ragi . . .

After quite a long time since we had been trying to reintroduce Ragi into the local diet (since 2011), we still don't have any data to prove that we've made any impact.

However, I keep hearing stories on how many more farmers grow millets in the Palamu region now.

And, on and off we get to eat ragi dishes when I visit mission stations, like the 'Ragi puttu' we were served last week at Chandwa.

I was told that this dish is relished by quite a many of the residents there.

May the tribe of ragi lovers increase . . . 

Thursday, March 16, 2017

Nowhere to go . . .

It was the festival of colors early this week. The whole country was in celebration. With our Prime Minister getting a major boost to his 'make India great again', the celebratory mood was well felt in every nook and corner of our communities. There were major things coming for the poor . . . the rich will be taken to task . . . there will be no more corruption . . . no-one will ever go hungry . . . there will be no more deprivation . . . there will be no more need for charity . . . 

I'm encouraged . . . I see a glimmer of hope for the marginalized and the poor in our communities. 

On the day of the Holi festivalI had just the sort of patient, who I feel should not exist in 2022, when the country celebrates it's 75th Independence Day. 

Mrs. A was not an unknown face. In fact, quite a many members of her family comes to us when there is a serious medical issue. In fact, it was just few weeks back that her nephew was brought to us with clinical meningitis and he made a miraculous recovery. I've known Mrs. A since the day we reached here. She was a known hypertensive and had been on irregular treatment. But, the last time we saw her was in October, when we diagnosed her to also have quite severe Ischaemic Heart Disease with some amount of cardiac failure and a bad pneumonia. 

As with the majority of our patients, she did not want to be taken to a higher centre. The maximum we could do to evaluate her was a Peripheral Smear and an ECG. Yes, not even an X-Ray. She made a miraculous recovery. 

But, she never returned for treatment. Alas, we also did not notice that she had not turned up for her regular medications. 

Her husband brought her in a miserable state sometime late morning last Monday (Holi). She was coughing with quite a lot of phlegm. Clinically, she got a bad pneumonia again which was causing quite a lot of stress on her badly damaged heart. I told the family that she needs evaluation. They told me that the maximum they could spare today was 500 INR. As usual they were not willing to take her ahead.

Over two days with some medicines to treat her lower respiratory infection and support her flailing heart, she made a miraculous recovery.

Reasons for her not coming for regular treatment for her high blood pressure and cardiac failure - they are very poor. There is one son who goes to work in the nearby town. He cannot go far as he has to look after his aged parents. There are couple of other sons who are earning a living in faraway places. They hardly come.

Now, it would be a great thing if such patients are taken care of. There are two ways to do it. The first is to ensure that the public health care system is robust.

And the other is to imagine that they don't exist. If the latter is the solution, people like me remain busy. 

Thursday, March 9, 2017


It's been a long time since I blogged in this one. It's almost an year since we got back to Palamu region, in a smaller place than before, where I'm much more accessible to those who could benefit from my skills.

I thought an incident which happened few days back in one of the peripheral dispensaries that I serve deserves a documentation.

At around noon, a group of villagers reached this place with an middle aged lady who apparently had a snakebite early in the morning. It was already 6 hours past. She showed no symptoms nor signs of any envenomation.

To make things easier, they had brought the snake along.

It was an easy identification. A Common Kukhri.

After the bite the patient had tingling sensation at the bite site, by which the villagers concluded that it was a venomous snake bite. A 'snake expert' in the village confirmed the same explaining that snakes with bands are poisonous and all the more colorful the snake, all the more venomous.

A 'jhad phuk' was called. He agreed to flush out the poison for a princely sum of 5000 INR, which the family readily agreed on.

So, here was a family who had already spent 5K INR and wanted me to treat her for envenomation.

I told the family that there was no symptoms and signs of envenomation, which I don't expect from a non-venomous snake. The family was absolutely sure that the snake they brought was the culprit.

I told them to throw off the dead snake into the heavily forested area nearby and go back home.

Couple of them appeared not much convinced. There was talk on taking her to another 'jhad phuk'. They carefully packed the snake into a bottle and was off for a second opinion.