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 . . .

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. 

Complicated . . .

Yesterday night, we had a very obviously sick obstetric patient wheeled into the labour room.

SSD looked quite old for an 18 year old lady. She was all puffed up. The blood pressure was quite high. And she was quite breathless.

The history was very vague. The only aspect I could latch onto was that she had a blood transfusion at Daltonganj. The outside investigations showed haemoglobin of 8 gm%. Urine albumin showed 2+.

On clinical examination, it was obvious that she was into early cardiac failure. I was left wondering about her cause of cardiac failure. It was good that we have a Medicine consultant now. As usual Dr. Roshine was quick to arrive and assess the patient.

It seems that SSD was always breathless since her childhood. Dr. Roshine suspected valvular heart disease.

The investigations in the morning confirmed our diagnosis.

The management was easy now. Refer . . . refer . . . refer. Of course, she needed more evaluation.

Pregnancy in its last leg . . . with pre-eclampsia . . . valvular heart disease, most probably a mitral stenosis with regurgitation . . . there were features of pulmonary hypertension too . . . would have been the most critical patient in a high risk obstetric care set-up.

But, the relatives were quite certain that NJH was the best they could provide for SSD. Travel beyond NJH was something that they could not fathom. The problem was the necessary finances.. .. .. there was a fear of the big hospitals and the funds needed.

I tried all the tricks in my bag to somehow refer them . . .

Nothing worked . . .

We request prayers as we manage SSD.

As I mention about SSD, I also would like to put a word for help we would appreciate in the month of October and December. Quite a few of our doctor colleagues will be on leave. It would be a good opportunity for new graduates in medicine to have a feel of work at NJH.

Especially for those who dream to do a post-graduation in Internal Medicine . . . All the more when Dr. Roshine is around. But, more about that, in another of my posts. 

Fear and Frustration

As I heard the story of SD, it was the sad face of PD which came before me. And her moans of pain and distress. 

PD had a history very similar to SD. 

After having tried to deliver normally at her home, PD came to us couple of days back. The diagnosis was almost the same as SD. 

Rupture Uterus with septicemia and severe anemia. She was on the verge of going in a circulatory collapse. Few years back, we would have taken her in. Maybe one of our staff themselves would have donated her blood. And we would have taken her in for a laparotomy. And she would have made it. 

Now, things have changed. A sort of fear has come after recent happenings in one of our sister institutions. 

The next best thing we could ask was for them to arrange for blood. 

It was nearing dawn when PD was wheeled in. Everything was explained. As always, the first choice was for them to take her to a higher centre in Ranchi. They preferred that we manage her. 

PD pulled through till the blood came. But, we were in for a surprise. We had asked for 3 pints of blood. 

The relatives came with one pint. The doctor on duty did not need to look much into the pint of blood to decide that it was diluted blood. We sent it for hemoglobin. It was a measly 3.6 gms. 

On further inquiry, we found out that they had paid 3500 for the blood, ten times of what it took to get blood from the government blood bank. It was obvious . . . the blood bank in the district hospital did not have the required blood group. And they could not give them a donor. 

So, someone had fixed them up with an agent who arranged the pint of blood. 

It was nearing evening when I went to talk with PD's relatives. I told of the predicament. Meanwhile, some more relatives of PD had arrived. 

Thankfully, they were ready to take PD to a higher centre. 

There is not much reason to believe that she would not have survived the journey to Ranchi. But, she could have ended up as a maternal death too. I don't know.  

However, we could have served her well had we had the freedom to draw blood here, transfuse her and do the surgery. I'm sure that the family would end up selling quite a lot of their possessions to fund her expenses. 

Yes, we would have broken the law and ran the risk of ending up in prison. 

I wish we had an additional clause in the laws of blood banking in India, where hospitals which are beyond a certain distance from a blood bank which could guarantee the supply of blood 24X7 be allowed to draw fresh blood and use it in emergencies. 

Could someone advocate for this? And we could do well with quite of few supporters of this amendment in the law. 

Breaking Rules . . .

SD got discharged today. 

She is alive today because someone went the extra mile to take care of her. 

SD had been trying to deliver her baby at home for 2 days before she arrived at the rural hospital quite far from her home. This particular hospital was not her first choice of care. She had gone to the government hospital. They refused to take her. 

She was quite pale and looking bloated up. It was an obvious rupture uterus. And she was in shock.

The nurses rushed to the doctor on duty, 'No b.p, pulse . . . what shall we do?'

'Rush fluids . . . and ask one of the relatives to donate blood', the reply was fast. 

There was no blood bank in the hospital. There was no chance that a blood bank could be there. Electricity was a premium. Then, there was the need for qualified staff and space. 

A technician drew the blood . . . Quite oblivious of rules, rather laws, which could end with him in jail. Possession of empty blood bags in a hospital without the license for a blood bank was in itself a criminal offense.  

The hospital was in a remote location. Nobody in the administration bothered much about what was happening. It was an area which was infamous for social unrest. And there were stories about frequent incidents of highway robbery on the way. There was the fear of being taken hostage or looted if one went to inspect the place. 

And it had the aura of being famous for people getting better after being given no hope elsewhere. And there was not much money involved. After a long journey to this place, there was not much hope of being paid under the table for favors given. 

So, nobody bothered.

It was good for SD that nobody bothered. She is alive today because of the emergency blood transfusion. The nearest blood bank which guarantees blood of all groups round the clock is about 5 hours away. She would have been most probably dead if the family took her further. 

However, things have changed. News was conveyed about how a similar hospital has been taken to the dock for flouting rules. 2 staff were jailed. Another 3 have been called and is in danger of being jailed for nothing less than 3 years.

Another patient who would come now with a history similar to SD will be referred. Unless, the staff in the same hospital decide to volunteer to go to jail.

The fact that SD would have been a Maternal Death makes this issue all the more serious.  

Intriguing, ain't it. Technology has grown so much that we have been able to save lives which would have been long dead in it's absence. But, to counter it have come in laws which has affected the way technology is used.

(This is a true incident which happened in a remote hospital in India last week. The identity of the hospital and the people involved are not disclosed as this can invite criminal proceedings) 

Thru' the valley of death

RD was a very non-suspecting high risk antenatal patient. The issue was with her hemoglobin. It never crossed 8 gm%.

However, considering her family’s financial situation, wehad decided to take her at NJH for delivering her baby by Cesarian section. This was her second baby and her first baby also was delivered by Cesarian section.

None of us had any inkling of the crisis we were going to face.

She had a blood transfusion before the surgery. Unfortunately, the doctor who operated did not do a repeat hemoglobin value before taking her in for surgery. Per-operatively, she developed a reaction to the blood transfusion. There was nothing much of a problem.

After the surgery, she was comfortable. However, there was a nagging issue. She was not maintaining her saturation. However, the saturations became normal when oxygen was given. A hemoglobin done on her turned up a value of 6.6 gm%.

Alarm bells started to ring on my head. We decided to wait overnight.

The decision turned out to be almost fatal. She started to have breathlessness in the night. Her saturations took a dip for the worse. She was going into pulmonary edema.

By morning, she was in the ventilator. But, she was also putting out pink frothy sputum. We had to give about 1 gm of Furosemide over the first 24 hours to control the pulmonary edema.

By God’s grace, she responded well to treatment.

And she got discharged last Sunday, exactly 7 days after her surgery.

However, RD’s incident has prompted me to put in strict control on hemoglobin values of our prospective patients. Anemia is quite prevalent in our part of the country. It is not very common for a pregnant lady to have a hemoglobin of above 10 gm%.

Meanwhile, the debate on anemia always cause me to wonder if we have some form of a blood dyscrasia in our part of the country, which is not yet diagnosed. 

Syphilis . . . Forgotten foe . . .

Syphilis . . .The very mention of the term used to send shudders in patients and was the darling of medicine professors for quite a long time. It was described as 'the great imitator' by Sir William Osler. One of my professors used to tell that in the olden times, a post-graduate student of Internal Medicine was assessed by how much he knows about syphilis and it seems that the same status is presently enjoyed by HIV-AIDS. 

Well, why I started a post of Syphilis? Over the last week, I had two families diagnosed as having the TPHA test positive. None of the members of the family had any symptom. 

Here are their stories . . . I know there may be quite a lot you may want to comment on them, which I would like to hear . . . 

The first patient was MS, on whom we had to do a Cesarian Section after a complicated trial of labour elsewhere. Before the Cesarian section, MS was diagnosed to have a low hemoglobin and we asked her relatives to arrange blood. The husband had her same blood group and he was ready to arrange blood. Well, on screening of the donor we found out that he is TPHA positive. As a rule, we do not do TPHA on patients who come at term. We do them only for those who come in the first trimester.

Well, by that time the Cesarian was over. We tested the mother and the baby. Both were positive. They very well understood when we counselled them about the disease. 

When I rejoined NJH in June 2010, I had done a re-look at the blood tests we do. Since, almost all of our patients are poor, we were trying to cut down on the tests. We did not find any TPHA positives in any patient for almost 2 years. There were few HBsAg positives and no HIV positives among the antenatal patients. I decided to drop doing TPHA, the main reason being that quacks were quite prompt in prescribing antibiotics and therefore I came to conclusion that this must be the reason that there was no TPHA positive for so long a time. 

However, the protocol was do TPHA in the first and second trimester for all ante-natal patients and drop it for those who come in late third trimester or directly to labour room. 

I was contemplating on whether I should bring back the policy of doing TPHA for all pregnant patients when the next patient arrived. 

One of our antenatal patients who landed up in labour room was found to have a reactive TPHA which was missed in the antenatal period. There was nothing much we could do now other than to re-check TPHA. Unfortunately, the TPHA turned out positive and after the delivery the baby also was reactive. 

I called the father, a man in the armed police force. The fellow looked quite disturbed and a bit drunk. I told him about the TPHA reactive status of his wife and child. He seemed to be hardly bothered. The only thing he wanted was to go home ASAP. I told him that he also needed to get tested. He would have nothing of it. He told me that he had issues to attend to at home and therefore needed to get discharged immediately. 

We tried our best. Ultimately, armed with consent forms on what all will happen and accepting full responsibility if something untoward happens in the future, he was off with his wife and child. 

Questions I have in my mind . . . 

1. TPHA is expensive. Should I do it for all pregnant patients irrespective of when they come - especially when they reach Labour Room straightaway after Antenatal Care elsewhere. Most of the places, VDRL or TPHA is not commonly done. 

2. When I have patients like the latter, what do you do? They are high risk to the community. 

3. Could we have donated blood from the TPHA positive husband to the TPHA positive wife? We had a bit of difficulty getting blood after the husband was refused as a donor. Crossed my brain only now . . . it could have been done. 

CHILD DEATH . . .

We had a horrible beginning of a day today. After devotions, I found out that there was a little girl, AK aged just above 2 years who had come in with a history of fever for the last 10 days. I wondered what the family doing for that long time. Unfortunately, I did not have much time to take a detailed past history or socioeconomic history.

AK was very sick with labored breathing. She was so pale – that I knew that her hemoglobin would not be more than 2 gm%. Her saturation was about 70%. If she had to survive, she needed blood and mechanical ventilation.

Luckily for AK, the ventilator was free and we could hook her onto that soon. The problem was with the blood. I went along with the father of the child and ensured that he checked his blood group. It matched. He requested 10 minutes to go and have food as he had not had anything to eat since the last 12 hours.

The laboratory results left me stunned. The father told me that she was on Injection Artesunate. You can see the laboratory results in the snap beside you. Later, Mr. Anil told me that 60% of the RBCs were filled with the malarial parasite.

She did not have much chance unless she had the blood. I went back to her bedside. She had suffered a cardiac arrest and the nurses were already starting a CPCR. The father who was supposed to be back could not be found. With a hemoglobin of 1.4 gm%, I knew that we did not have much of a chance.

The father came after about half an hour. Her heart had started to beat again. I had rushed fluid. As a last ditch effort, I started her on a dopamine drip – which was foolish considering her pathetic hemoglobin. She suffered another cardiac arrest after which we could not revive her.

She died at 10:00 AM exactly 2 hours after she had come in.

I’m concerned about 2 things.

The first one is about the injectable artesunate which was used. There can be only two things which can be concluded. Either it was a duplicate medicine or there is resistance emerging to artesunate compounds in our region. There are reasons to believe either of them, both of which are reasons of major concern to us.

Duplicate drugs are a major issue in most parts of the country.

However, there is much reason for us to believe about emergence of artesunate resistance as during the last 2 months; we have quite a lot of patients who had been started on artesunate derivatives from outside, especially the quacks as well as legitimate doctors. They had no relief and we have seen them respond to quinine.

My second concern was about the attitude of the father to the condition of the little girl. He could have at least tried. I’m not saying that the girl would have survived if we got the blood. He was least bothered when he came in first.

Neverthless, I saw him weeping silently after I told him that his daughter has died. But, if he had brought her in earlier she would have definitely survived.  

After this little girl left, we had 2 more admissions in the Acute Care Unit of similar patients with a similar history. More about them in the next blog.