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 . . .

Safe in His Arms

This is the post I promised about SD, the second patient mentioned in the previous post. 

SD had come with bleeding per vagina as she finished 7 months of her second pregnancy. Her first child was just 1 year old. On arrival, she was in shock. She looked white. Hemoglobin came as 4 gm%. We were sure that it should be lower than that as she was quite dehydrated after being to multiple places over a period of more than 12 hours since her symptoms developed. 

She was too sick to even go for an ultrasound. She responded well to intravenous fluids. With a hemoglobin of 4 gm%, we were sure that she needed blood. We sent her relatives off to get blood. She could die any moment. The lady had come at around 10:00 am. 

We were worried as no blood came even after 12 hours. It was good to find one relative return with one pint of blood in the midnight. We had asked for three pints. We had to transfuse that pint of blood. 

She somehow pulled through. And the night was uneventful. We saw a new relative the next day. It was her father. He told us that her husband's family was too poor to bother. That was when we realized that nothing much was done towards bringing the three pints of blood. 

Meanwhile, we had an ultrasound which showed a complete placenta praevia. The baby was dead. 

A repeat blood test showed her hemoglobin as 2.5 gm% and she was in sepsis. A lowered hemoglobin after a blood transfusion . . . either she was so dehydrated on admission or the blood bag contained diluted blood. 

The father returned late evening. We were glad to see 3 pints of blood in his hand. One pint was on immediately and she was posted for Cesarian Section. However, the joy was short-lived. One staff noticed that the pints looked quite watery. The next two pints were sent for their hemoglobins . . . You can see the results . . . 

It was horrible . . .  Time was running out. One bag's hemoglobin was 5.2 gm% and the other 5.6 gm%. 

Then, we realised that SD had not bled after her admission here. We thought about thinking a way out without doing a surgery. As usual we contacted Dr. Hilda Yenuberi, consultant obstetrician at Christian Hospital Chattarpur, one of our sister units. She suggested that we try a normal delivery if she has dilated to some extent. This was only because we did not have quality blood and time was running out. 

A gentle per vaginal examination showed that she was not bleeding even on touch and her cervix had dilated to 6 cms. With prayerful hands, we induced her. 

The induction was uneventful. She delivered just after midnight. There was not much bleeding. However, we gave all the pints of blood that the family brought for whatever good it could do to her. 

They had gone again to get 2 more pints of blood. But, she had turned worse by morning. She was running high grade fever with chills and rigor. Repeat blood investigations showed that her hemoglobin continued to remain below 3 and there was evidence of sepsis. 

We changed to higher antibiotics. It was a miracle that she responded. Meanwhile, her father came with 2 more pints of blood. The quality was the same . .. ... water (most probably Normal Saline) mixed with blood. 

By today, she looked alright. We did not do any more blood tests. 

We thank the Lord that SD is alive. In spite of all the risks . . . Undiagnosed placenta praevia . . . no antenatal care . . . hemoglobin of 2.5 gm% . . . husband not bothered . . . difficult procedure to get blood . . . adulterated blood . . . and a vaginal delivery with placenta praevia . . . a centre (NJH) with no obstetrician/anesthetist . . .

I should say that her 1 year old child is so blessed to have her alive . . . I hope her next pregnancy is less eventful. 

Now, looking at interventions which could have eased the processes we and her family went through, if there is one intervention which could have made life easy, it would have been a UDBT (unbanked direct blood transfusion) at NJH.  

I would encourage your comments on this . . .

Poverty . . .

Over the last 2 weeks, we had two instances where we were exposed to the stark reality of how poverty affects families, especially when it comes to healthcare. 

I shall start with the patient who I mentioned in my previous post on obstetric care. 

We shall call her Kkd. Yes, the lady who came in with a hemoglobin of 4.6 gm% and then had a hemoglobin of 2.6 gm% more than 12 hours after the delivery. I just got news from Acute Care that the relatives were able to arrange a pint of blood; almost 24 hours after she had delivered. 

Now, the whole question was about the reason why the family never brought her for delivery to the hospital. It seems that she was taken to the place where she had her antenatal check ups as well as to the nearest district hospital. She was turned away from everywhere. 

If we had got couple of pints of blood, we would have done off the Cesarian in no time. 

I believe that it was the good Lord's providence for her that she delivered normally. And then the family could arrange one pint of blood. Most probably, that is the maximum that they can arrange. 

The whole exercise of a Cesarian section with couple of pints of blood transfused would have resulted in quite a financial strain for the family. I realized it today morning when the nurses told me that they did not have money to pay for the medicines. In fact, we had admitted her without any advance. 

The relatives had been running helter-skelter to get some decent treatment for this poor lady. The fact was that almost all of their money had been spent paying for transport. 

However, while the process of getting blood was on, one of our nurses had caught bits of their conversation and found out that they were in the process of paying a huge amount to buy blood. 

In our nearest blood bank, the usual practice is to allot a pint of blood for 350 INR if the relatives are able to donate blood. However, when one cannot arrange a donor, there are processes quite unknown to most of us by which you can buy the blood from elsewhere at rates ranging from 2400 to 4000 INR. 

We somehow convinced the relatives to arrange a donor and get the pint of blood for just 350 INR. I'm happy that they heeded the advice. 

However, it was obvious that the family had run out of financial resources. 

All of us have failed them. From the very beginning. 

They had gone to a doctor in his private clinic thinking that they would get the best treatment. He/She had written quite expensive iron, multivitamin and calcium tablets. Which they brought. Instead of 30 tablets for a month, they had brought one strip (10-12 tablets) which was used for 2 months. 

They never got clear advice on what needs to be done when she goes into labour. No plan . . .

And even after she got admitted . . . unless our staff overheard the conversation about the blood, they would have spend much beyond their capacity and got the blood, which many a time is of very poor quality.

To be frank, for the poor, there is nothing much left in our country. They are the mercy of anybody and everybody. The question is whether 'the haves' of our country are listening. 

Leaving alone the subject of poverty . . . if there is 2 things which could improve maternal morbidity and mortality in this part of the country which is more of a problem for the poor and marginalised, I firmly believe that it is free availability of Iron tablets along with an awareness about the intake of these tablets and the second one - undoubtedly, UDBT.

Shadow of death . . .

Since yesterday night, we are sitting on tenterhooks regarding the second patient whom I mentioned in my last post.

It’s more than 24 hours since this lady came in. Her haemoglobin had been around 5 gm% for almost the whole of her antenatal period. She had a Cesarian section after she had eclampsia. Unfortunately, the baby died soon after birth.

It’s been two years. After she got pregnant, the family had been taking her for regular antenatal care in the nearby town. There is mention of her low haemoglobin during each of her visit and Iron appears to have been prescribed.

She’s come in labour yesterday. We had wanted to do a Cesarian section as I felt that there was not much space for the baby to come and there was grade 2 meconium. Her haemoglobin was 4.6 gm%. We told the family that we would touch her only after the family arranges at least 2 pints of blood.

The relatives are yet to arrange blood. But, the lady’s found favour with the Almighty. We were quite worried and could only pray.

She delivered normally late yesterday night . . . of course, the baby was severely IUGR. The labour room team worked hard to ensure that there was not much bleeding.

The problem is the haemoglobin. Today morning, I did it just to find out how it was. She looks a bit uncomfortable. It was just 2.6 gm%.

I can only pray that at least one pint of blood comes before she goes into a hemodynamic complication . . . Once again, another case which would have benefited from UDBT.

Urrgghh . . . UDBT

From today, we start a unique experiment with regard to first calls in NJH. It's just Dr. Shishir and me for taking first calls for the next one week. The arrangement is that we are going to do alternatively 12 hours of first call . . . The reason being that both of us in the wrong side of 35 seems to do better with periods of 12 hour rest. 

May sound a bit hilarious, but I thought that the harsh early winter and our poor respiratory systems would benefit from such a system of taking calls. 

Leave that alone . . . I wanted to talk about UDBT again. Oh . . . how I wish that this was legal? 

The story was that we had a lady with a rupture uterus today afternoon, KD, who had a hemoglobin of 7 gm%. She was hemodynamically stable. We got assurance from the relatives that they would arrange for blood from Daltonganj as soon as possible. 

The relatives were quite a few and therefore we thought that we would get the blood soon and we decided to take her up for surgery. Dr. Shishir did the surgery and the post-operative period was uneventful. However, the promised pints of blood never came. 

As soon as KD's surgery was over, we had another lady with a rupture uterus, SD, who also a very similar history. 

The team on duty was busy managing SD. It was only late evening that we realized that KD's blood never reached. Then, our nurses started asking them about what was happening about the pints of blood. Then to our chagrin, we found out that KD's relatives have not even gone to Daltonganj for getting blood. We had given them a request at 2:30 pm and while this was going on, it was past 8 pm. 

I came to know that there was a problem at around 10 pm, when the Acute Care nurse called me saying that there was fellow shouting and threatening everybody. 

I reached the Acute Care to find out a burly middle aged man in a agitated state. He wanted to know who ran the hospital and who the doctor was. He said to me that he will ensure that we drew blood. He then threatened to file a case against me for obstructing blood donation in the hospital. 

He went on ranting. I thought it was a matter of time before he hit me. I thought I'll give him a chance to slap me. Maybe, this was the moment I would get to bring up UDBT into the headlines of the country's media. 

That was when the whiff of country liquor clouded my senses. The fellow was drunk. The sniffles of winter had kept the smell of alcohol in his breath away from me. 

I remarked to a onlooker on how a drunk can be allowed into the hospital. The mention of the word 'drunk' had him make a hasty retreat. 

However, I'm still in a quandary. I've a rupture uterus lady with 7 gm% hemoglobin operated upon without a chance of getting even a pint of blood in the next 12 hours. I can only pray that she'll make it through the night. 

After the drunk relative was gone, I called another relative who was thankfully sober and explained about the problem. He apologized for allowing the drunk fellow come in. But, it was too late into the night. The dipping temperatures and the possibility of being looted ensured that no vehicle owner was ready to ply till early morning. 

Before I end, the common history of SD and KD. 

Both of them had delivered by Cesarian sections before. Their families were attempting home deliveries since yesterday night. In fact, KD's relatives told me that her abdomen was been regularly massaged since the last 2 days and it was so surprising that the baby did not deliver normally. 

I told KD's relatives that I find it surprising that KD is alive. 

Please pray that the relatives will get blood by early morning. 

And also a wish that UDBT would soon be legal for hospitals such as ours . . .

Avoidable Maternal Death

We had a maternal death today at NJH. 

The major aspect was that the death could have been avoided if somebody had identified risk factors, taken extra precautions and had been a bit more careful.

FmB, 22 year old mother of two came to us about 3 hours after delivering a healthy baby in a health facility about 5 miles from our place. She was gasping with a feeble heart as she was wheeled it. In addition, she was papery pale. There was nothing left for us to do. There was no blood in her veins. All of it had bled out. 

Although we had her intubated and pumped her with ionotropes, she did not respond.

FmB had been bleeding after the delivery. The care-givers had been giving her some injections to stop the bleeding. 

Unfortunately, by the time they realized that it could be fatal, it was too late. 

FmB had come to us couple of times for ante-natal care. Her hemoglobin was 8 gm% about a month back. I can't find much reason that it would have increased much although she was on regular Iron tablets. 

I'm sure that her care provider during the delivery had much idea about her anemia. There was no documentation of hemoglobin having been done elsewhere. 

Of course, if she had come to NJH, she would have ended up getting a repeat hemoglobin and a request to arrange one pint blood if the hemoglobin was below 9 gm%. 

Of course, I've had one of my dear colleagues in a sister hospital debating upon how one could manage conservatively without blood transfusion. In a situation where there is readily available blood, I may not arrange the one pint blood. 

And if UDBT was legal, this would be one classic case which would have made it if she had come in about half an hour earlier. 

To sum it up . . . FmB's death was a wake-up call for quite a few of us attending to her. A very normal process of delivering a baby ending up in a tragedy . . .

No eclampsia or rupture uterus . . . maybe, the uterus refused to contract . . . or a bad birth canal injury . . .

But, at the end of the day, a preventable maternal death . . . 

I feel sad for the husband and two very young daughters, the first one, just completing 2 years of age and the second one, born today . . .

The Short Lady

Today early morning, we had a lady who came with a neglected previous Cesarian. She was brought in quite late. SwrD had started to contract sometime late evening yesterday. They lived quite away from a place where a Cesarian section could be done. It was midnight by the time she reached a place in our nearest town. Being Dussehra, there was no doctor there. They reached NJH today dawn (15th October, 2013).

SwrD, about 25 years old was 125 cm tall. It was quite obvious that the labour was obstructed. Her haemoglobin was only 8 gm%. Titus send off the relatives to get blood. He also got consent to operate without blood. It may look very foolish but that was the only option considering that she was fully dilated, the baby was stuck and very much alive.

The problems started after he opened up the uterus. Till the delivery of the baby, there were no obvious problems. However, as soon as Titus started to suture the uterine opening, he realised that there was a problem. There was torrential bleeding from below the uterine incision. That was when he realised that the previous Cesarian scar was quite low and it had given way.

With a hemoglobin of 8 gm%, it was only a matter of minutes before she got drained of her blood. We acted quite fast. I realised that the prolonged labour had made the proximal part of the uterine opening quite friable. We somehow got her sutured up and achieved hemostasis. However, there were very much evident signs of shock.

We were blessed to have the relatives come quite fast from Daltonganj with one pint of blood. We had asked for two. 

By God's grace, she responded well to whatever we offered her. It's midnight now as I write this. She has been shifted to the general ward from acute care. 

This is a typical case where a UDBT would have helped the patient and given a peace of mind for the doctors involved in her treatment. If the relatives were not that forthcoming, only a UDBT would have saved her. I later found out that the relatives had someone known within the blood bank . . . and that was the reason they got a blood bag fast. They had also taken someone to donate.

I understand that the government is considering to legalise UDBT. Hospitals like us would definitely benefit . . .

Risky . . .

(This post was written on yesterday, 13th October, 2013)

We had a very high risk delivery in our Labour Room yesterday (12^th October, 2013).

SD had come in almost in second stage sometime late afternoon. It was her first delivery. She had been in labour since midnight elsewhere. The family felt that the labour was not progressing. After doing the per-vaginal examination, I also felt that she may not deliver normally. However, there was a minimal amount of malrotation of the head. We took a decision to wait for an hour for a normal delivery.

As I went to talk with the male relatives, I got another history which the female relatives accompanying SD did not give. (In our labour room, female relatives accompany the patient inside.) SD had been having very high fever since the last week. She was on treatment on and off. When I came back, the nurse on duty told me that SD was febrile. We send off the basic blood investigations. Anyway, we planned to wait an hour before we took her up for a Cesarian section.

The lab guys were in a frenzy to get back with the report. The major issue was that SD had Vivax malaria and her platelet count was only 20,000. Meanwhile, there was the call from labour room saying that SD is delivering. I could only think about SD bleeding to death soon after the delivery. The whole team knew we could be in for a maternal death.

Over a space of 10 seconds, we had a plan put in. Roshine, our medicine consultant was going to overlook the general well-being of the patient, Titus was going to take care  of the baby, the lab guys were trying to arrange for a fresh pint of blood, I was going to take the delivery. The plan was to put a vacuum without an episiotomy. The justification that a episiotomy could result in freshly cut vessels which could bleed. And then, there was a prayer on everybody’s heart that we would not lose the mother or the baby.

Everything went according to clockwork. The baby was as predicted sick. Titus and his team of nurses did a superb job. Roshine was happy that she did not have to do anything heroic. There were few small lacerations which were bleeding. We initially thought that we were not getting the bleeding controlled. Off went a call to Dr. Shalini, our obstetric consultant at EHA Central Office, who advised us to just keep pressure on the lacerated areas. And to try to get at least a pint of fresh blood.

We had our nursing students who enthusiastically kept guaze pads pressed on the lacerated areas for almost an hour. She was still oozing. Someone suggested that we pack the vaginal vault with guaze. It worked.

Now, the question was about getting some fresh blood. Her blood group was A positive. Before one of us could volunteer, we thought of asking the relatives to donate. The effect was that all the male relatives expect one old man disappeared in no time. Nobody wanted to donate.

However, SD was doing good. It did not look like she had a platelet count of 20,000. However, it was true. Couple of people had double-checked it.

We thought of not giving her a fresh pint of blood. It was risky for her. However, it was illegal too to give UDBT (Unbanked Direct Blood Transfusion). The fact that her relatives did not want to donate blood made us take the tougher stance of no staff donating the blood.

It’s more than a day since she delivered.

A UDBT would have given us a bit of comfort. I could have easily requested one of the staff to donate blood.

I hope our decision will stand vindicated. However, the plight of this lady is quite same as those whom I mentioned in my previous post. Blood donation is something about which more awareness needs to be made. And UDBT is something that would do quite a lot of good for hospitals like ours. But, with poor awareness about blood transfusions, even UDBT would be of not much use.

At the end of the day, I’m thankful to God. I’m certain that its patients such as SD that make mission hospitals quite a great place to be.