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 . . . 

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 . . .