Critical Care at NJH - An appeal to gift

20 year old PrD had been with us for the last days. When PrD came to us 10 days back, she was having seizures for more than 12 hours. Her baby was dead. We tried to deliver her normally. But, she did not deliver. She had been in the ventilator throughout from the time of admission. We had to take her up for a Cesarean section, the last resort. After the Cesarian, she has held on for the last 7 days. She continues to be on the ventilator and we think that she would have done better with a full fledged ventilator rather than the anesthesia ventilators that we have.

This takes me to a request that I’ve trying to put across to garner funds for the Acute Care Unit. 

Below is a note from Dr. Roshine requesting for funds to upgrade the Acute Care Unit –

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Dear friends,

Over the past years, we have been having a large number of critically ill patients being managed in our hospital. This is due to the lack of health services capable of providing intensive care in our locality as well as the fact that the nearest highest referral centre is 165 kms away in Ranchi. As for the poor, a referral to Ranchi is a nightmare as they have to often bear  unnecessary expenses, get lost in the crowd as there is no proper guidance and often do not receive the  care expected of a tertiary level hospital.

For these reasons, we are very keen on developing a department of critical care in our hospital. The majority of  patients who require intensive management have been snake bite victims, patients with meningitis, acute febrile illness with multi organ dysfunction and high risk obstetric patients, all of whom can be potentially treated and cured. However, in our management of critically ill patients, we have been forced to compromise on several areas due to the lack of infrastructure.

We currently have a 6 bedded ACU ‘acute care unit’ where we manage emergencies, critically ill patients and most post operative patients. The last rainy season was particularly difficult as we had to shift out patients who were not completely stabilised to the general wards for lack of beds in ACU. Another requirement would be an area for casualty where patients are triaged and emergency procedures can be carried out before timely referral. This would greatly help in ensuring that the patients in ACU are not transferred out. 

Creating a 12 bedded Intensive care unit would be ideal as it would also benefit post operative patients who can be monitored closely in their post operative period. This would need additional space.

1. Medical equipment:

a. Multipara monitors: A multi para monitor for every 2 beds

b. Ventillators: Currently we have two ventilators that are meant for use in the operation theatre. The drawbacks of these machines have been that they cannot be used in children and do not provide adequate pressures in patients with pulmonary edema. We have been manually ventillating these subset of patients. We have been greatly encouraged by the donation of a CPAPmachine which ensures that a few patients who come in pulmonary edema are being managed effectively now.

d. Nebulisation port for use in ventilators

e. Infusion pumps 

2. Furniture:
a. Fowler beds

b. Emergency trolleys

3. Centralised Oxygen supply

These are our current requirements and we pray that God will provide for us and we would use our resources wisely.

In future, once our basic infrastructure and quality of care has improved, we hope to address other issues that are pertinent to the health needs of our population. 



Dr. Roshine Mary Koshy

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I'm sure that you've seen a fund request that I had put about a month back for upgrading and re-equipping out critical care unit. Please pray and pass the message along.

Here is the budget we are looking at. Please forward to friend and well-wishers who may be looking at opportunities to give a Christmas gift .  .. ...

	Requirement	Cost
1	900 square feet of space	9,00,000
2	Ventilators (2)	15,00,000
3	Multiparamonitors (4)	3,00,000
4	Syringe pumps (6)	3,00,000
5	Furniture	3,00,000
6	Electricity back-up	1,00,000
7	Other instruments	1,00,000
	TOTAL COSTS	35,00,000

Well, the costs put here are only an estimate. In foreign currency, this would be about 55,000 USD/ 42,000 Euros/60,000 AUD/16,000 KD/36,000 GBP.The centralised oxygen supply should amount to an additional 500,000 INR

If anybody is interested please send me a e-mail to either jeevan@eha-health.org or jeevan53@gmail.com

Pandora's Box ?

After reading through my better half’s guest post on the importance of laboratory services at NJH, I’ve been stuck by the sudden increase in the number of cases where we ended up diagnosing as meningitis. 

Of course, Dr. Roshine taking over as consultant physician has done quite a lot towards this. The number of patients who’ve been subject to a lumbar puncture has gone up. I’m sure that many of the patients who had been stamped as cerebral malaria in the earlier years are being diagnosed as meningitis now, thanks to the assurance of a lumbar puncture.

I was quite inquisitive about the trends of the meningitis patients over the last 6 months. I requested information from the the Acute Care Unit about the distribution of patients. This was the slip I received.

Now, this has fuelled an exercise where Dr. Roshine would be looking at the patient load with probable diagnosis of meningitis. Watch out for the initial findings which should be out soon. 

I'm sure that we have quite a surprise waiting for us . . . 

The Acute Care Unit

Over the last couple of months, especially after Dr. Roshinetook over the functioning of the Acute Care Unit, something which has bothering us is the major shortcoming in infrastructure for our very sick patients.

We’ve come a long way over the last 3 years. Acquiring 3 ventilators, 4 multipara-monitors, 6 fowler beds etc has not been an easy affair considering the sort of poor patients who come to us. But, we need to look for more and better facilities for our patients.

Part of our Acute Care. Here two children, both below 3 years of age being manually ventilated. 

As I write this, sitting in Acute Care, I’ve three patients who would have done with better machines for ventilation and monitoring. In addition, we also have a shortage of space. We’ve sort of developed a habit of shifting the least sick patient out as soon as a more sick patient comes in.

Many a time, the former patient would have benefitted for a few more hours of close observation.

Below are our requirements.

	Requirement	Cost
1	900 square feet of space	9,00,000
2	Ventilators (2)	15,00,000
3	Multiparamonitors (4)	3,00,000
4	Syringe pumps (6)	3,00,000
5	Furniture	3,00,000
6	Electricity back-up	1,00,000
7	Other instruments	1,00,000
	TOTAL COSTS	35,00,000

Well, the costs put here are only an estimate. In foreign currency, this would be about 55,000 USD/ 42,000 Euros/60,000 AUD/16,000 KD/36,000 GBP.

Please pass this message around to friends and acquaintances that could help us in this matter. 

If anybody is interested please send me a e-mail to either jeevan@eha-health.org or jeevan53@gmail.com. 

Two Maternal Deaths

Yesterday, we lost SHD. She was sick, but stable, while I saw her in the morning. I was in outpatient department, when I got a call that she had a cardiac arrest. The problem was that it was some time after that she had the arrest and the nurses could not find a doctor in the immediate vicinity to come and help.

I knew that there was no point in attempting a resuscitation. However, we tried the routine procedures. . . . but without any success.

And then we lost LD 4 days back. Couple of days after the surgery, she went into florid septicemia. She was being ventilated. And she started to pour out pus from the lungs, abdominal drain and also from her vagina. The relatives requested that we do not do anything heroic. Obviously, they were poor and was slowly noticing how the expenses went up.

After quite a long time, I withdrew life support for a young life.

Then, there was PD. A primi in her last weeks of pregnancy. She had not been doing well since about 2 weeks. Yes, 2 weeks. And she was taken from hospital to hospital. She was gasping as she was wheeled into NJH three days back. In fact, the relatives told us that she has been gasping for breath since 2 days. Dr. Johnson, our doctor on duty realised that there was nothing much he could do.

2 gm% was her hemoglobin. By the time, he found out a donor, she was dead.

So, we had 2 maternal deaths due to anemia last week. I wonder how long it will take for our guys in the thrones of power to realise that such preventable deaths are a major deterrent to development.

There is now one more near maternal miss patient in acute care. BDD, whom I wrote about in the last post has been weaned off the ventilator today morning. Kindly pray that BDD would recover completely.  

OP Poisoning

A common term in most of the emergencies of hospitals in South East Asian countries, OP poisoning stands for organophosphate poisoning. 

We had the worst OP poisoning case ever in the annals of NJH couple of days back. 

SHD, a 26 year old, mother of 3, had gulped down an entire 120 ml bottle of Malathion after a tiff with her hubby. When she arrived, we had to literally pour Atropine down her veins to ensure that she remained asymptomatic. It was only after we had given about 3500 mgs of Atropine over 24 hours that she stabilised. 

Over the next day, we had weaned her out of the ventilator. However, we were very sure that 'Intermediate Syndrome' was just around the corner. I prayed that it would happen when we are around during daytime. 

But, that was not to be. I was just getting ready to hit the bed when she went into respiratory arrest. Dr. Shishir was operating on a severe pre-eclampsia patient with fetal distress when it happened. 

By God's grace, we've been successful in getting her well supported. Again, the staff in ACU did a magnificent job. The presence of mind and diligence was all the more evident as there were 3 eclampsia patients in the ACU. 

The next 24 hours are going to be crucial. 

We request prayers that she will be completely healed . . . and of course, specialist advice is definitely welcome. 

Geriatric Care . . . 'To let go' or 'To treat'

Over the last 2 week, I was put into a very complex situation where we ended up managing few patients who had crossed 80 years of age. We started our Christmas celebrations, but the work in the hospital continues. It's been busier than usual. Many think that geriatric care would be for the urban areas, but of late, we have been exposed to the stark truths of caring for the elderly. With the quality of care we give, we expect geriatric care to become a major speciality of care at NJH in addition to the maternal and child care. 

I wanted to narrate about 3 patients. Let me put them one by one . . . 

1. It was early morning. I reached the Acute Care Unit for rounds. A 86 year old gentleman, whom we shall call AB was wheeled in almost unconscious. He had fallen from his bed early in the morning with his head hitting the floor. There was a bump on his forehead. The blood pressure was very high initially but started to fluctuate after that. The pulse rate was low. The obvious diagnosis was a head injury. They gave a history which seemed to be like a seizure, but the description was not a classical one. However, we had started him on Phenytoin. 

Meanwhile, as we counselled the patients to take him to Ranchi, he had a very bad episode of seizures. And then he became totally unconscious. I had sent for electrolytes - which came as normal. The relatives were all out to somehow save him. I told them that there may not be much chance for him. 

They took him to Ranchi. I knew few relatives of the patient. I found out that in Ranchi, they did a CT Scan and found out that he had no problems. In fact, his sodium was on the lower side.  

Today, it's crossed a week after he was admitted in Ranchi. His sodium is still fluctuating and he is in Intensive Care. Yesterday, his son told me that the expenses are now beyond their means. 

2. About 20 minutes after AB was admitted came FG, a 82 year gentleman on whom we had diagnosed cancer of the anal canal about 6 months back. FG was severely breathless and confused. 

FG was being treated in Varanasi with chemotherapy. His last cycle of treatment was about 5 days back. I suspected septicemia. We started him on oxygen and antibiotics. I told the relatives that we do not have much experience of managing side effects of chemotherapy. But, they told me that they were quite exhausted with the care they had been giving FG. The son told me, 'Please do whatever you can. We cannot take him any further'. 

The blood results came after couple of hours. He was in a very bad pancytopenia. The lab staff could spot only 3 white blood cells in the entire peripheral smear. And there were no platelets. They called me and let know the result. 

I called the son and explained the predicament. The chances of survival was almost nil. He graciously accepted it. A decision was taken not to resuscitate should FG arrest. 

He arrested within 10 minutes. 

3. Around the time that FG arrested, came in a very rich family with a 82 year old. At a glance, it was obvious that she was not breathing. There was a very faint heart sound. The pupils were reacting. 

CD has been sick for the last 2 months with difficulty in breathing. They had been seeing quite a number of doctors. She has been on quite a number of medicines. 

The history was that one of the doctors had referred her to NJH. She was talking till about 1 minute back when she collapsed. The relatives were ready to spend any amount possible to get her alive. 

We put her on the ventilator and initiated CPCR. The heart got going. However, there was a very harsh murmer. The ECG leads showed cardiomegaly. There was massive hepatomegaly. The cause of her sickness was her bad heart. But, we did not have the facilities to pin point a diagnosis. 

I told the relatives that a clinical examination showed that there was not much that we could do. It was quite difficult to convince them. One of the sons suggested that we do heart surgery. However, couple of other relatives arrived who conversed sensibly. 

She arrested after about 20 minutes. I told them point blank that the heart had stopped again and I am not going to resuscitate her. She was taken off the ventilator. I requested the eldest son if we could do an ultrasound post-mortem to confirm the clinical diagnosis. He agreed. 

There was massive cardiomegaly and it appeared like the heart had herniated through the diaphram into the abdomen and pushing the liver down. The liver was enlarged. 

Geriatric care is one of the modern sub-specialities of medicine which would be needed to a great extent in the coming years as the elder members of our communities would grow in number and non-communicable diseases become common. 

To make matters worse, nuclear families, poverty and post-modernist views complicate geriatric care. When people have the necessary finances to look after the elderly in the family, there is a lack of family members who have the time to look after them. When there are relatives to care for the elderly, there is a lack of finances. There is an emphasis on the growth of the individual rather than an effort to care for others. 

As I write this, one of our staff who had admitted her 100 year old mother came and requested for discharge. In the beginning, they were quite pro-active in getting the elderly lady the best possible treatment. None of the children was free enough to be around with the lady to look after her. They had the money to take her to the best facilities. 

I'm sure that each of us are going to face this issue when it comes to our parents and would one day face it ourselves when we ourselves our old. Something that sends shivers down the spine. 

I can only think about the famous Serenity Prayer . . . 

God, give me grace to accept with serenity

the things that cannot be changed,

Courage to change the things

which should be changed,

and the Wisdom to distinguish

the one from the other.

Living one day at a time,

Enjoying one moment at a time,

Accepting hardship as a pathway to peace,

Taking, as Jesus did,

This sinful world as it is,

Not as I would have it,

Trusting that You will make all things right,

If I surrender to Your will,

So that I may be reasonably happy in this life,

And supremely happy with You forever in the next.

Amen.

Paraphrasing this, I would put it like . . . 

Lord, when I have elderly patients, 

please give me grace to convey them hope to face the unknown,  

courage to tell them the truth 

knowledge and wisdom to minister to them.

May we learn to live one day at a time,

Enjoy one day at a time

Accepting hardship as a pathway to peace

Taking, as Jesus did,

This sinful world as it it, 

Not as we would have it, 

Trusting You to make all things right

If we surrender to Your will

So that we would remain reasonably happy in this life

And supremely happy with You in the next. 

Amen