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. 

Malaria . . . Challenges . . .

Yesterday was World Malaria Day. It was not uncommon to see quite a many programs and rallies all over the world including India. . . Quite a lot of us are being made to convince that malaria is slowly on its way out. I find it difficult to comprehend numbers. In India, we've had much of a controversy last year over mortality statistics which were arrived at by researchers and the government. As usual, the government claims a much lesser mortality than the research group.

Well, over the last week, we've had malaria cases coming back. I thought of jotting down few observations on malaria over my stint at NJH.

1. Malaria continues to be a major clinical issue in rural areas of Jharkhand.

2. The major challenge is the possibility of evolution of drug resistance due to the rampant misuse of anti-malarial drugs. There are multiple issues here. Let me illustrate. 

Over the last week, we had about 10 patients who presented with symptoms suggestive of malaria. Only 2 of them tested smear positive for malaria. All the rest were negative by smear. 3 of them (all smear negative) had low platelet counts. Two of them died. 8 of the patients who had tested negative for malaria smear had a history of at least one contact with another health provider who had invariably given them anti-malarial medicine - all of them had received oral Artesunate and few even intravenous Artemesin derivative. And only couple of days treatment. 

As I had mentioned in previous posts, the question of a proper diagnosis looms over the conclusion that malaria is the only major killer. I'm sure that we are dealing with other infections like dengue, rickettsia, Japanese encephalitis etc. 

The partial treatment of all fevers with anti-malarials makes the issue only worse. 

Both our patients who tested positive for malaria smear had come straight-away to NJH. And they've gone home fine without any complications. 

Well, we've reports coming in that malaria continues to be a scourge in Jharkhand and Orissa. It was interesting to note the comment in the last part of the above article - 'The only solace, maintained state health department officials in Jharkhand, was that there has been no malaria deaths so far in the year.' 

How will there be malarial deaths, when we have so much of partially treated malaria who will have no laboratory evidence of malaria when they come terminally ill?

It is sad. Almost all of our public health system appears to live in a 'Fool's Paradise'. Someday, the situation is going to get the better of us. What concerns me is the emergence of non-communicable diseases in a big way in places like ours. Within 10 years, if we do not take control of our problems with malaria and tuberculosis in addition to the maternal and child health issues, we could be neck deep in trouble where the development of the country could be in doldrums because of the abysmal healthcare situation of the country. 

It would be unfair if I do not suggest at least couple of simple steps which could be taken  - 

1. A robust Disease Surveillance Programme where each case of fever death is accounted for.

2. Full fledged research into causes of fevers in remote areas of the Empowered Action Group states (the old BIMARU states) 

Fever, fever and fever. . . .

Over the last couple of weeks, we have been having patients galore with fever of all types. Of course, most of them have already had treatment elsewhere, especially with the quacks about whom you can read here.

The majority of them do not test positive for anything except for a few who will have features suggestive of septicemia in their blood picture. Very few of them show the malaria parasite in their smear - and most of them who have a falciparum positive picture would have come straight to us.

Over the last many years I know of this place – there have been only two diagnosis – malaria or enteric fever. One of my colleagues here has the following different diagnosis for all sorts of fever. Malaria, probable malaria, chronic malaria, resistant malaria, recurrent malaria etc. He does not believe that there can be any other diagnosis.

We are looking at the options of being part of looking at the various causes of fever in this part of the country. Couple of weeks ago we had an epidemic of fever of which couple of them had tested to be CSF positive for bacterial meningitis. Almost all of them were only responding to either erythromycin or azithromycin and we had assumed that H.influeza must have been the cause.

I’m sure that if we do a study, we’ll find quite a number of new viruses and there is high possibilities of finding leptospirosis. Dengue has already been documented last year. Chikungunya has already been documented in our nearby districts. We had one typical case in the OPD last week. However, unless we do a systematic study we would not able to find the cause.