The Lord Cares . . .

For Angel and me, the call to be in a remote mission setting has been a definitive call. It is not uncommon that we get questions about our saneness. The questions have increased proportionately with the increase in our number of kids. Some of the recent ones have been like – ‘4 kids and living in a place where the nearest pediatrician is 120 kilometers away’, ‘how do you manage without an outing to a mall’, ‘3 days to go home and meet your parents, are you nuts?’  

Of course, it’s not uncommon that we look at adverse possibilities.

Exactly a month back, we faced such a situation. Our younger daughter, Hesed, aged 2 years old and the most active of our four children took a jump from the upper deck of our double-deck cot and landed on her right forearm. The hand took quite an impact. She was not allowing us to touch her right elbow.

And we were at Barwadih. The nearest help was about 30 kilometers away and we knew very well that the orthopedician did not deal with such injuries. We had a plan to visit Ranchi the next day. Thankfully, there was no swelling of the elbow although there appeared to be some pain.

Overnight, Hesed did fine. However, the next day as we travelled to Ranchi, we realized that there was a bit of a swelling of the right elbow. It was difficult to find out if there was much of a problem as Hesed was a left hander.

As we travelled, the first thought that came to me was to call up our friend orthopedician, Dr. Kenny David at CMC, Vellore. To our amazement, he was at a place near to Ranchi and was on his way to Ranchi airport to catch a flight.

It was amazing - - - looking from a point of chance. The number of times, we visit Ranchi as a family is only once in 3-4 months. The number of times that Dr. Kenny David will come down to Ranchi is maybe once a year. The chance of one of our children getting an elbow injury is maybe once in a generation. And to have all of them together in such a way that Hesed gets consultation from the pediatric orthopedician of a premier healthcare institute of the country when we are stationed at a remote corner of the country.

Don’t you think this is amazing? We are definite that the Lord was in control and took care of Hesed’s elbow.

Dr. Kenny saw Hesed at Ranchi. We got her X-Ray and then put her on a slab. The X-rays got reviewed by the pediatric orthopedician at Vellore. 

Today, it is one month since the incident.

Hesed is doing well. We thank God . . .

We learnt that how much precious we are for the Lord.

Vaccination of backyard chicken

We, at NJH, got onto a new frontier of community development last Saturday. We got into veterinary care in our surrounding villages. This was done on a pilot basis. 

As we met quite a few of our Self Help Groups and discussed on the best possible intervention which could improve their lives . . . what came up was quite surprising. 

As was mentioned in a previous post, the intervention was to look into vaccination of backyard chicken. 

We went ahead with the mass vaccination . . . Snaps from the exercise. 

We had a very enthusiastic group of medical students from the Christian Medical College, Vellore who had come to visit us as part of their Secondary Hospital Posting. They made our work so easy.

For old timers, we did this in Charwadih village. The process was not easy. 

The villagers told us that the best time for us to do the vaccination would be early morning. We reached at around 5 am. However, all the birds had gone out by then. In the villages, they don't have any separate coops for the fowl. They spend the night along with the families in their homes. 

Therefore, as soon as the family woke up and opened the doors in the morning, the chicken were also out and it was difficult to catch them. 

So, we went back in the evening. It was quite late. The reasoning was that we could do the vaccination when the chicken come back to the houses as soon as the sun sets. 

It worked. 

We vaccinated a total of 250 chicken . . . We pray and hope that they are all now protected from Ranikhet disease (Newcastle disease) which is quite rampant during the harsh summer. 

Healthcare Sciences – Opportunity with EHA

Emmanuel Hospital Association gives the opportunity to students to serve in its hospitals through the system of sponsorship to graduate/diploma courses including MBBS, Nursing courses in Christian Medical Colleges, Vellore and Ludhiana. There are quite a lot of a number of people who took this opportunity and went on to leave lasting impressions in the areas they served.

For getting sponsorship, the prospective student would need to visit one of our hospitals for a period of 5 days. I write this post as there seems to very less information about this to most of such students who look for such an opportunity.

Over the last 3 years, I get flooded with calls/inquiries about the exposure visits during Feb/March. There are of course deadlines for such visits. Every year, it is the 30^th of March of that year by which the exposure visit needs to be completed.

We’ve a rush of students coming to be with us over the next 2 weeks. However, it would be much easier for us if the visits are planned much in advance. Only one student had come to us in December over the last 3 years.

Therefore, this post is mainly for all those who’ve just finished their 10^th standard exams or going to start 12^th standard (+2). We appreciate if you could come for your exposure visits in a much more planned manner.

Please do share this information with your friends and relatives who could find this beneficial. For more information, you can visit the EHA website and also write to sponsorship@eha-health.org  

100 days at NJH

This is a guest blog from our Physician at NJH. She responded to my request for a post after she completed 100 days of selfless service at NJH. We had been praying for her for quite a long time and it was a dream come true for me when she joined NJH. 

Dr. Roshine Mary Koshy completed her graduation and post-graduation in Internal Medical from the Christian Medical College, Vellore. She hails from Kerala and was a topper in the State MBBS Entrance Examinations. Her father, Rev. George Koshy pastors the Marthoma Church, Krishnarajapuram, Bangalore. I hope her former school mates from the Marthoma Residential School, Tiruvalla and Mathews Mar Athanasius School, Chengannur will appreciate her work. 

After her graduation she had also served at Marthoma Hospital, Chungathara and the Fellowship Hospital, Kumbanad. 

Over 3 months into working as a consultant physician in NJH has been an eye opener for me. This write up is an attempt on my part, as someone new in this field, to share my experiences and observations/musings over the past 3 months in the hope that anyone who might be interested in getting involved in improving health care in North India might have something to ponder about and those who intend to be spectators might want to take a closer look.

I feel that a great challenge as a health care provider is being able to identify the population with greatest need and to constantly focus on allocating all available resources within our constraints for their benefit. Just a few months experience and I know this is easier said than done.

Who are the poor that this hospital takes care of?  It is a heterogeneous group and the two distinctions I make are purely based on my observations as I care my patients and talk to their families in a hospital setting.

There are the real poor. They are hardly seen in the hospital because the hospital is their last resort to which they often don’t reach on time. But I remember a few of them who did come to us. They come really sick, treated by traditional healers, wanting their loved one’s life saved. If I were to tell them the critical condition of the patient and paint the obvious bleak outcome, they would rather take the patient home than get treated. But if they do decide to get treated and the patient gets relatively well in a day or two, they want to be discharged immediately because they can’t bear the expenses of the remaining days. They get better, go home very happy and never beg for charity.

I learnt this the hard way. 8 year old Reena came to us with GTCS for almost half an hour. There were no beds in the ICU. We controlled her seizures and I explained that they would need to take her to a higher centre. It seemed reasonable enough to me. It never dawned on me that the nearest higher center is Ranchi, a 5 hr journey with an expense of 6000 Rs if the family makes it both ways with additional expenses in Ranchi. I was happy to see them arranging a vehicle with the referral letter in hand. I am grateful for one of my colleagues who happened to notice the scene and told me that they were taking the child home. It took only a little extra effort to arrange a bed and manage her medical problems. She turned out to have TB meningitis, developed partial lateral rectus palsy while in the ward which resolved with treatment and she went home a happy little girl.

The thought that if this health service had not been available for her, that she would not have lived was a hard truth for me to swallow. After seeing the health status of the poor here, having been able to save a life does not appear heroic to me. It just speaks volumes of the complacency of my profession in fulfilling its solemn duty to society.

The not so poor patients, I have grouped together because though their socio economic status varies, they have something in common. Their health issues have not been properly evaluated; they have been extensively and unnecessarily investigated and treated. I find this to be one of the greatest challenges while working in this part of the country, the fact that the practice of medicine is not a science but a trade. I sensed it during my first month when my patients were very offended because i seemed to be ‘probing’ into the history of their clinical complaints. Listening to their history and examining them before ordering an investigation was unusual. It was more frustrating to me when healthy patients came asking purely for investigations because they wanted to confirm if they had ‘typhoid’. 

Working in a rural area and ensuring that the practice of medicine is both science and art is challenging but extremely rewarding. I am grateful for my training in the Christian Medical College, Vellore, for the privilege of being mentored by excellent clinicians. For those young doctors who think that working in a secondary set up in a rural area is dull, I thought I would just give you a list of a few of the medical problems that we encountered in the past 3 months.

Snake bites both poisonous and non-poisonous, Organophosphorus poisonings, meninigitis, strokes, tetanus, neurocysticercosis, pneumothorax, staphylococcus empyema, rheumatic heart diseases, tuberculosis, connective tissue disorders, apart from malaria, rickettsial infections and the like. Being able to clinically diagnose them with basic supporting investigations and manage them is very satisfying. As for scope for improvement, the area of critical care has great potential in our area and we are focusing on it.

Working in rural areas which have been neglected and among communities that have often been exploited can be very frustrating because good intentions can be looked upon with suspicion and appreciation for the work that one does is often hard to come by. The advice that my colleague gave me is something worth contemplating and I end my ramblings with the wise words of Oswald Chambers.

“If we are devoted to the cause of humanity, we shall soon be crushed and broken hearted, for we shall often meet with more ingratitude from men than we would from a dog; but if our motive is to love God; no ingratitude can hinder us from serving our fellow men”.

Tiger spotted . . .

We've great news in the wildlife front from the Palamu Tiger Reserve, which is about 10 miles from our place. Newspapers reported today about a tiger being snapped up by the automatic camera within the reserve. 

English translation: The camera trap at Palamu Tiger Reserve, Betla took the snap of a tiger on last Sunday at 9:41 pm. The forest staff has identified the tiger to be 'Maharaja'. Previous to this, the camera trap had photographed a tiger on 21st February. Over the last 2 months, tigers have been spotted thrice in the Betla National Park. It is difficult to comment on how many tigers are there. But there are tigers here.

By the way, we would going there along with the students from the Christian Medical College, Vellore sometime this week. The students are visiting us for a week under the secondary hospital program. Dr. Shubhankar Mitra from Medicine 4 is the consultant in charge.   

Exposure . . .

I've been at the Christian Medical College, Vellore since the last 2 days. Was part of a process which is unique to CMC, Vellore where medical students visit secondary hospitals such as ours. Similar to last year, a batch of 2nd year medical students will spend one week with us. 

A major learning experience for these budding doctors. And we're excited about it. 

The ultimate outcomes of the program being to encourage these students to be part of institutions such as ours for at least some part of their lives if not the whole part. Only time will tell if this program achieved this outcome. 

Today evening, few of the consultants from the participating hospitals sat discussing about the big need for more people to come over to hospitals such as NJH. The refrain from each one of them was the same . . . of doctors getting exhausted . . . and nobody to share the workload.

We shared stories of our colleagues who had gone off for a break . . . gone off abroad . . . got frustrated . . . left with quite a lot of bitterness . . .  and the work load only increasing. No sign of any respite.

I had just got a phone call from back home at NJH that there were 2 maternal deaths in the last 24 hours.

The need for more people to help us was very much evident. 

I thought of the place where we sat. I wondered if CMC, Vellore has lived up to the expectation of sending more doctors to rural areas of the country.

Nowadays, when we talk to our colleagues on going to poorly served areas of the country, the conversation changes to the problems associated with such a posting. The lack of schooling, poorer salaries, needs of parents, crude living conditions . . . the list goes on and on.

Yeah . . . all of them genuine reasons. And that is when we appreciate the contribution that medical missionaries from abroad has made to the country . . . where they left their homes far far away to serve a land quite alien to them. 

There is a paradigm shift in the approach of healthcare professionals towards sickness and the sick. It has not done good for the poor and the marginalised. 

I hope and pray that as the students from Vellore come to have their one week of posting with us, we would be able to make some amount of impact in their lives and the choices that they make in the future. 

Plastic Surgery . . .

The term 'plastic surgery' conjures up images of perfect smiles, chin lifts, ironed out crease lines of the forehead, smoothened wrinkles for most of us . . .

We've been privileged to have Dr. Ron Hiles from England coming almost every year to teach and facilitate our surgeons to do 'plastic surgery'. Most of the time, it involves straightening out contracted limbs following accidents . . . especially burns . . . most of them neglected when they should have been well taken care of. 

Accompanying Dr. Hiles is Ms. RuthAnn Fanstone, an accomplished Physiotherapist, also from England who specialises in burns management. 

Since Dr. Nandamani is away on a long leave, we've requested him also to be around when these special surgeries take place. This year, it's going to be another milestone for us as a new physiotherapy graduate, Ms. Sheron Mathew from the Christian Medical College, Vellore would join us.

And for the first time, we tried some advertising on the radio. For most of us, it's a forgotten means of communication media. But, it still holds fort in remote areas such as ours. 

We've already got about 15 patients lined up only for the 'plastic surgery'. Cases as severe as the burn contracture in this one year old child . . .

. . . to the love-stuck young man who realised the folly of permanently tattooing his first love's name on his forearm. 

There would be quite a lot of patients who would not be able to pay for their surgeries. If you would like to make a contribution to help us subsidize the cost, please get in touch. 

Focus . . . Snakes and snake bites . . .

Last week, NJH was part of a group of hospitals who were invited by the Christian Medical College, Vellore to look into snake bites and their management . . .

I leart quite a lot of things. It was a privilege to rub shoulders with who’s who in herpetology. Romulus Whitaker, Gerry Martin, Dr. Oommen V Oommen, Dr Bawaskar, Dr Punde . . .quite a lot of big names in the field.

Yesterday, I was talking to my staff in Community Health and Development about how fast we draw conclusions without looking into evidence.

Over the last month, I had put up the post on the clientele we serve at NJH. And later something about neurocysticercosis and their cause. Regarding the former topic, quite a good number of our staff thought that we serve a higher number of poor. I got quite a number of feedback about the ‘new information’ they received in the post on neurocysticercosis.

The common aspect about snakes and snake bites are the myths that surround them.

Couple of the myths that I harbored for long were given the boot after the meeting.

The first one . . . I was under the impression that a venomous snake bite late in the night or early daybreak would be less venomous compared to a bite in the evening. The reason . . . the snake would have already spent it’s venom on a prey and therefore a lesser amount only would be available to inject into the next victim. The same logic applying to snake bites on two consecutive victims by the same snake. The second victim would have lesser venom injected thereby causing lesser envenomation in the second victim.

The venom is the saliva of the snakes. Even after a biriyani, you’ll continue to secrete saliva if there is ice-cream after that. Similarly, the snake would continue to secrete the venom irrespective of the fact whether it had a prey before biting a victim.

The second one . . . a non-poisonous snake in your backyard means no poisonous snake in the same area. Absolutely wrong. Any snake seen means more snakes in the area. It was reported that it is not uncommon for a venomous and non-venomous snake to share the same hole!!! I remember someone tell me that it is not good to kill a non-venomous snake as it’s place in the habitat may be taken by a venomous one.

There is nothing like a territory for a snake. . . the way they have for tigers etc.

The third one . . . which is quite frightening. I used to believe that use of chemicals such as phenol would help keep out snakes. And after we had couple of snakes inside the house during our first year at NJH, we’ve not seen them inside after we started to regularly use phenol to wipe the floor. In fact, there is no evidence to support the fact that snakes dislike phenol. However, snakes don’t like clean places. They love dirt and areas with things like papers, leaves etc. piled up. The fact that snakes are not entering the house is because of cleanliness that accompanies a daily wipe with phenol and not the smell of the chemical.

However, the best ones . . .

Kindly see the snap below. The blue bordered regions are places where a proper taxonomy of existing snake species has not been done. Quite an exciting thing for mission hospitals in North India such as ours as we can be base for quite a lot of work on getting to know more about these creatures.

The final straw . . . The snap below. Kindly note the thing written in red. This is the number of vials of antivenom that will neutralise the maximum possible venom that is injected during a bite of the concerned snake.

The question is now going to be about how WHO has come up with a protocol of 20 vials to be used for any sort of snake bite. . .For units such as NJH, this has major implications . . . as a low dose protocol should theoretically be enough to salvage viper and krait bites . . .

We’re quite excited of the future . . . we could be part of path-breaking research on snake bite syndromes and their management.

Pray for us . . .