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) 

Waiting . .. ...

(This post was written on Monday, the 29th July, 2013)

As we wait for rains . . . I’ve been waiting for something else since today early morning.

When I arrived for work today early morning, Titus had news for me about a rupture uterus which has been refusing to go to a higher centre after she arrived her at around 5 am today morning.

This is the second rupture uterus over the last 24 hours.

Dr. Shishir did the first one on Sunday evening.

MD had come sometime early morning on Sunday (28th July). MD had been in labour since 4 am on Saturday (27th July). This was her 3^rd pregnancy. By around 10 am on Saturday, the family realised that there was some problem. She was shifted to the nearby PHC.

The doctor at the PHC was smart enough to realise that there was some complication and she was shifted to the nearby district hospital. At the district hospital, it took some time before the family was told that she appears to have a rupture uterus.

It was late evening. The family was told that the best place for them would be a private hospital in the adjacent district. However, no vehicle was ready to take them to the adjacent district.

They were told that it would be dangerous to be in the district hospital. Therefore, they took refuge in a private hospital for the night.

Very early in the morning, they set out to the Daltonganj. The private hospital they were referred to refused to have anything to do with the patient. It was much beyond their skills. They promptly referred the lady to NJH.

They reached NJH by around 8 am on Sunday. The problem was that she had very high counts and her haemoglobin was just above 7 gm%. It was unthinkable to do anything without blood. We sent the relatives to the nearest blood bank in Daltonganj for 3 pints of blood.

The relatives returned by around 3 pm. Dr. Shishir operated. It was quite tough. She was in severe sepsis and appeared to be going to severe Acute Respiratory Distress Syndrome. She has pulled through the night. 

As I write this (Monday night), MD continues to be on oxygen.

The next maternal near miss, the one I mentioned at the beginning of this post, arrived today morning. RD, had a Cesarian section for her previous delivery. Similar to many of our previous rupture uterus following a Cesarian section, the family was ignorant of the fact that she needed an institutional delivery.

She was better off than MD. Her haemoglobin was 9 gm%. Still considering the time she was in labour and the long period of dehydration, we were definite that there was hemoconcentration.

RD had arrived at 5 am today. It was 5 pm by the time the relatives could arrange blood from Daltonganj. The surgery was uneventful. However, her uterus was quite damaged to conceive another baby.

To top the 2 rupture uterus, we had a severe eclampsia sometime around mid-morning. We kept her for normal delivery as she appears to progress well. However, we realised towards the beginning of her second stage of labour that there was a malrotation and she may not deliver normal.

We ended up doing a Cesarian section for her. As it was a second stage Cesarian section, there was lot of problems. The uterus was in atony for quite some time after delivery of the baby. And she lost quite a lot of blood.

Again, we needed blood. We tried to send the relatives to Daltonganj for blood. But, it was too much of an ask. We have to ensure that she does not bleed more during the night.

The availability of blood is quite a crucial aspect in the smooth running of a centre like ours.

Last year, we’ve had about 1500 deliveries. And with quite a large proportion of them accounting for high risk obstetrics, if we need to develop further, we urgently need to think about setting up of a blood bank.

And not to mention the very high chance that all three of them could have ended up as maternal deaths if NJH was not around. 

However, the big question remains about committed personnel who would be willing to come all the way to a remote location such as ours . . . and continue the good work and look at possibilities of new avenues of quality care. 

A miracle . . .

We've had couple of setbacks last week in obstetric care. And I was quite wary of one more bad case. 

Yesterday, we had a 40 year old, mother of four who came in at term. 

MD was in the last week of her pregnancy and had been bleeding for almost a day. She was taken to one of the primary health centres from where she was referred to Ranchi. 

They reached here at around 3 in the afternoon. 

It was a nightmare. A grand multipara at 40 years with Hemoglobin of 4 gm%. The baby was dead. There was blood dripping from her uterus. 

I could only think of all the possible complication . . . all of them which would only ensure her death in a set-up such as ours. 

And we did not know the full history as she was being managed elsewhere. 

The uterus appeared quite flaccid without any hint of getting contractions. 

We talked to the relatives. We needed at least 4 pints of blood. And we were not sure of what all complications she could end up with. 

The husband had about 2000 INR with him. Not enough to even get a vehicle to go to Ranchi. 

We could only pray and request prayers. 

We called up one of the people in government health services and told about my predicament. He informed the concerned people and got about 3 pints of blood arranged. We sent the husband to Daltonganj to get the blood. 

My plan was to do a Cesarian as soon as the blood arrived. 

Late in the night, Titus found the husband sitting in front of the hospital. The vehicle he went in to Daltonganj broke down and he returned. And he looked quite resigned about the condition of his wife. 

However, the lady went into spontaneous labour early morning today and delivered the dead baby. Our guys did a great job ensuring that she did not bled much. The placenta had separated early (abruptio placenta) which was responsible for the ante-partum hemorrhage. 

She's alive . . . and the husband has returned with 2 pints of blood. 

We thank all those who prayed. 

We don't see much cases where a patient has severe antepartum hemorrhage, a hemoglobin of around 4 gm% and later delivers normal.  

Anemia . . . ? Lack of Evidence

3 days before I started on my holiday, we had a pregnant lady at term who was bleeding from the morning come to us sometime in the evening . . .  and die couple of hours later. Dr Shishir who was on duty called me to report the maternal death. The history was appalling. The lady should never have died.

She had her routine antenatal care. Her hemoglobin done few weeks back showed 8 gm%. No ultrasounds were done. She was on oral iron. She had started to bleed in the morning. The relatives had taken her to the district hospital. She was there for quite a long time. The relatives were not sure what was done. Later they took her to a private hospital from where she was referred here. 

We could not measure any blood pressure on her and there was no pulse. She was white like paper. Hemoglobin came as 5 gm%. I'm sure it must have been lesser. There were no relatives to give her blood. We tried our staff. Although, the blood group was a common one . . .there was nobody who was fit to give blood . . . couple of them were sick, others had given recently. 

Her blood pressure or pulse never came . . . without blood, there was no option. She died . . .

Talking about her hemoglobin of 8 gm%, it is not an uncommon thing at NJH. We routinely see hemoglobin values of 8 and even lesser. The reason I write is the recent discussions I had with few of my friends and an article I read today about the use of parenteral iron in situations such as ours. 

If we keep the cut off of 11 gm% to diagnose anaemia in NJH, I'm sure we'll diagnose almost 100% of our pregnant women anaemic. Values of 9-10 is the highest you will find here. Almost all studies done at many places in India gives the prevalence of anaemia in pregnancy as something between 30% and 100%. 

So, I was quite surprised when I read in the article mentioned above that the patient Ahmedbi whose hemoglobin was 9.8 gm% got a drip of Iron-Sucrose. Well, I can imagine the justification of the doctors who have started doing this in spite of not much evidence for such a practice. 

Anybody who has taken the Iron tablets given by the government would vouch for how unpalatable it is. And to have it during pregnancy is something which many a pregnant lady would not really like. Over my clinical practice, it has been quite common to have patients confess that they have not taken their prescribed medicines and pregnant women not taking their Iron and Calcium form a major chunk. 

And even when they take it, there are other issues involved. I've somehow come to believe in the theory of the chronic malnourished state. I remember someone talking about it . . . but can't remember who it was. The theory is that in many of the impoverished regions of the world, the chronic state of malnourishment results in the body being adapted to function with a below optimum level of nutritional states. Which ultimately results in a poor absorption even in a situation when there is adequate nutrition available.

Otherwise, I cannot explain how in NJH we see so many people from rural areas who would have been labelled terribly sick in a tertiary hospital elsewhere survive tough surgeries and major illnesses like malaria, enteric fever etc. 

The chronic malnourished state continues even the lady becomes pregnant and no amount of iron and vitamin B12 pushed down the gut brings any change in the hemoglobin levels. 

Well, I'm sure that this would need to be researched well before we can draw conclusions. 

One more reason why I suspect a faulty absorption of nutrients in states of chronic malnutrition. We see quite a lot of patients with clinical features suggestive of Cyanocobalamine deficiency who do not respond to oral Vit B12 . . . but respond well to Vit B 12 Injection. I do not expect a high prevalence of Intrinsic Factor deficiency in the population . . .  Well, another explanation is the low IF values in people with chronic malnutrition states. 

Whatever it is . . . one thing have I realised. The knowledge we have about something as simple as anaemia is quite limited . . . leave alone complex diseases like cancer . . . 

So, anybody interested in research in this area . . . 

The parting shot . .. ... Sometimes I wonder, in a country like India . . . even evidence and scientific explanations are sometimes of no use. It might surprise you . . . We do not have provision of free Iron and Folic Acid tablets for our Antenatal patients . . . This is when we have enough of evidence about how Iron and Folic Acid tablets could be the lifeline to Antenatal patients . . . 

Preventing maternal deaths as the one mentioned in this post . . We do not have blood banks where there is round the clock availability of blood. And this holds true for the 4 million population in catchment population . . . Well, that is a post for another day . . .