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

Life on the edge . . . Not by choice, but by neglect

Things have become a bit relaxed in NJH. And it should remain same for the rest of the month. If it becomes busy, it could become quite taxing on us. From this week, we only have 3 full time doctors for the entire hospital. With a average busy labour room and full Acute Care Unit, it can be taxing on us. 

Couple of days back (2nd Dec, 2012), we had another example of how neglected a lady can be in this part of the country. BD, a 30 year old mother of four, at term pregnancy came to us late into the night with a hand prolapse. The history was unbelievable. 

BD was having labour pains since late evening of 30th November, 2012. Since all of her deliveries were conducted at home, she thought that this would also happen without much hassles. Well, it did not turn out that way. 

The pains continued throughout the night and it seemed to have subsided by 1st December. But, then the relatives thought that she was having a distension of the abdomen. Still, they thought to wait and watch . . . masterly inactivity. 

However, early morning of 2nd December, she again started to have pains. The relatives decided it was time that a doctor takes a look at her. She was brought to the nearest District Hospital at around noon on the 2nd December. The staff (I'm not sure if a doctor was involved in the management) assured that she should deliver without much problem, although they could not localise the Fetal Heart. 

Sometime around 3 pm, things started to go awry. The baby's hand popped out. 

The staff immediately bundled her up and sent her to the nearest private hospital. On reaching this private hospital, they were told that this cannot be managed there and would need to be taken to NJH. 

They spent almost 4 hours searching for a vehicle to take her to NJH. 

On reaching NJH, there was more problems. The baby looked quite macerated. The hemoglobin was 6 gm%. And the relatives were totally exhausted to take her any further. 

We agreed to operate if they could arrange at least 3 pints of blood. They arranged that . . . after more than 12 hours. We took a decision not to take her for surgery until we have blood. 

In between, BD delivered . . . without any intervention. But, it was obvious . . . she had already ruptured her uterus.

Dr Shishir took her up late in the evening of 3rd December. It was a mess inside the peritoneal cavity. There was foul smelling ascitic fluid . . . peritonitis. The uterus was ruptured in the left side and the rupture extended to the cervix. There was necrosis of the vault of the pelvis. 

The surgery took almost 2 hours. We had to do a sub-total hysterectomy. 

She's making a slow recovery. 

If we have similar patients over the next month, it would really stretch our limits. 

There was no need for BD to have ended up in this situation. It is a crime. But, who's listening . . . 

Before I sign off, there was this article in the New England Journal of Medicine which sort of supports the post on Critical Care. Hope experts in medical education of our country will take note. With the experience we had in the Neuro Intensive Care Unit of our nearest Medical College, we have a long way to go. 

Critical Care . . .

Something for which I was never prepared when I joined NJH in June 2010 was the amount of critical care work which I would end up doing.

Having a background in Community Medicine (Public Health), it was a challenge to get into using ventilators, managing pulmonary edema, rupture uteruses, cerebral malaria. More of a challenge since my last year in the Christian Medical College, Vellore was spent among the Jawadhi tribal community trying to convince them to come for antenatal check-ups, getting them to run small scale income generation programmes, conducting mobile health clinics etc.

From an healthcare institution point of view, NJH was quite peculiar.

Situated in the middle of a heavily forested area along a National Highway linking Ranchi with Gwalior, one would have expected hardly much of a crowd. Yeah, we do not get much of a crowd. The routine cases of malaria, enteric fever and normal deliveries are dealt by the motley crowd of quacks and dais in the villages.

So, if you come to our outpatient, you may think that there is not much work. But our repertoire of cases will put a Medical College to shame. You want to know, what we have in our 6 bedded Intensive Care Unit now. Here’s the list –

1.    A young man who’s survived a krait bite. He was in the ventilator for about a fortnight. Then he went into pulmonary edema. He’s slowly on his way to recovery.

2.    A young lady who went into pulmonary edema following eclampsia. She lost her baby. We had very little hope of salvaging her.

3.    A middle aged woman with organophosphorus poisoning. Again, we were not very sure of getting her alive. She had drunk too much of poison. She’s also slowly recovering.

4.    A little girl with partially treated meningitis. Still not very sure of what the outcome will be.

5.    A young man who’s just come in with a clinical diagnosis of cerebral malaria. For him to be admitted, we had to shift out a young lady who had a molar pregnancy. She had a hemoglobin of 2 gms%. By God’s grace, we could do an evacuation and she’s doing ok.

6.    An elderly lady with a very bad pneumonia. She has already been managed at Ranchi.

Then there are 3 more patients with severe malaria who are waiting in the General Ward. I would have wanted them also to be under close observation. In addition, there is a young lady with bad obstetric history (G6P5L1D4) having severe pre-eclampsia at 28 weeks who’s refused to go elsewhere.

I can only pray that there is no patient with rupture uterus or eclampsia coming in during the next 24 hours.

Well, what do I want to convey?

Critical care is something that we in mission hospitals need to look at very seriously. Traditionally known to be bastions of surgical care, there has been a major shift.

The major reason being that very few hospitals are interested in critical care and when there are facilities for critical care, it is too expensive for the common man.

So, along with palliative care, geriatric care, care of HIV AIDS etc . . . something very unusual is being expected from us in the form of critical care.

However, the ultimate question is about getting committed young men and women to serve alongside us.

Oxygen . . . Oops . . .

The end of last week, we were caught napping. And the cost was a terrible one. We had to refer 3 patients with eclampsia as we ran out of oxygen. We have 12 B-Type oxygen cylinders which we usually fill up once a week. Over the last 2 months, we had been filling them almost twice to thrice a week. 

Ultimately, our support systems collapsed. The truck which usually delivers the oxygen had a break-down on the way from Patna and the factory that supplies us from Ranchi (which is our alternative) was closed down for about a week on account of a local festival. Perfect recipe for making us look like fools. 

One of the 3 eclampsia patients was really poor. We had 3 oxygen cylinders. I was wondering about taking the risk and operating on her. Then we had 4 patients in the ward who were highly oxygen dependent. PD, the snake-bite patient, although off the ventilator needed oxygen to maintain saturation. There were couple of post-partum eclampsia patients who also needed oxygen. Then, a middle aged man with long standing duodenal perforation whom we operated couple of days back - who had been just weaned off ventilator. 

It was risky to take one more patient who had a possibility of being dependent on oxygen for some time. 

The poor family of the lady with eclampsia pleaded with us to somehow manage her at NJH. I consulted our Director. Managing such a sick patient without oxygen was unethical - - - they may not take her to Ranchi. After much pleadings, they relented. The family took her. I'm not sure where. 

Well, we need facilities for more oxygen supply. To give you an idea of how much we had been using up oxygen at NJH of late . . . the following statistics would help . . . All B-Type Oxygen cylinders.

2009-10: 256

2010-11: 170

2011-12: 305

2012-13 (April-June): 170

If this flow of patients continues, we would need to think of centralised oxygen supply. 

We look forward for ideas from experts about this. I'm not too sure. There have been proposals coming in from couple of service providers for centralised oxygen supply and suction. The total cost is about 800,000 INR (15,000 USD/AUD/Euros or 1000 GBPs). 

Another option would be to have oxygen concentrators. But, with the sort of electricity connections we have, it would be difficult to run and maintain. 

Talking about oxygen, I think it would be out of place if I do not mention about the opportunity which we could offer to doctors and nurses who are interested in critical care. With eclampsias, rupture uteruses, cerebral malarias and complicated surgeries becoming more common, we would do better with a Internist or Anesthetist managing critical care rather than a Public Health guy . . .