Krait Attack - 2

Prameela went home after quite an uneventful period of admission in the hospital. However, Prameela was an eye-opener about why many snake bite victims are already dead when they reach the hospital.

Prameela reached last Sunday late evening. She was just alive. Gasping for breath with secretions flowing out of her mouth and nostrils, she would have been a goner if the family was late by another fifteen minutes in bringing her.

Prameela was bitten about 15 hours back, sometime before dawn. Her family members had woken up hearing her scream and caught the intruder which had bit her – a 2 feet long krait. Beliefs demanded that the krait be taken to a safe place and let free. The family was more concerned about setting off the snake free than about Prameela who was bitten.

They took the snake quite far away, deep into the jungle to release it which took them about 4 hours. By the time they came back, Prameela was not feeling well with feeling of something in her throat and abdominal pain. It was about 6 hours after the bite that Prameela was taken to a hospital.

At the hospital in the district headquarters, Prameela was administered intravenous fluids and some injections, the total cost of which was only 600 INR, which means she was not given Anti-Snake Venom. As Prameela’s condition appeared to worsen, someone suggested that she be brought to us.

We had to intubate her immediately. And she was in the ventilator for a good 48 hours. Thankfully, her recovery was quite fast.

Now, the worst part of any snake bite is what hit us next - The cost of treatment.

Prameela ended up with the requisite 20 vials of ASV. It was obvious that the total costs were much beyond the reach of the family. With tight budgets this year, we also were finding it difficult to write off bills. The family came to us begging for charity. We could not afford to give more than a 5% charity on the bill which was raised, which already gave her a charity of around 20%.

This is one of saddest parts of any snake bite. It is the rural poor who are the most affected. Since the last 3 years, the cost of Anti Snake Venom has risen by about 200%.

I feel that there are 2 solutions to the problem.

The first solution would be make ASVs freely available in all government facilities as well as designated facilities like ours which have a reputation for snake bite management. Closely linked to this would be efforts to decrease cost of making the ASVs.

Till that happens, patients such as Prameela would be dragged down the poverty hole by snake bites . . . 

Lessons learnt - 

1. TRADITIONAL BELIEFS CONTINUE TO BE A HINDRANCE TO TREATMENT OF SNAKE BITE VICTIMS. 
2. THE ONSET OF RESPIRATORY PARALYSIS CAN BE DELAYED BY AS LONG AS 15 HOURS IN KRAIT BITES. 
3. COST OF CARE IS A MAJOR ISSUE WITH SNAKE BITE CARE. 
4. KNOWLEDGE OF CARE PROTOCOLS FOR SNAKE BITE VICTIMS ARE VERY POOR AMONG DOCTORS

The patient I mentioned in the previous post, Alokita gave consent to be photographed and her story to be shared in my blog . . .

Alokita with her parents

Too Poor . . .

This is another of my experience with poverty in the region we live.

This incident happened last Saturday. Although it was not busy, there were enough patients in the outpatient to keep us happily engaged.

It was just around lunch time, when Sr. Sanjeetha came running to my cubicle. She could hardly contain her excitement as she told about a lady who just came in. The cause of her excitement - The lady had been carrying her baby for the 11^th month. Her last menstrual cycle was on the 5^th of November, 2012. It was past her 11 months.

I asked Sr. Sanjeetha to bring the family in. There was poverty written all over the couple. 

The lady was bloated up. The pregnant tummy was the only flesh which protruded out. There was quite a bit of edema to make her appear plump. The husband looked a little waif. It was all bone and thin muscles. Not an inch of fat.

The husband and his uncle who came along narrated how they had been thinking over the last 2 months on why the baby was not getting delivered. Yes, it took them 2 months to make a decision to access care. I got an ultrasound done on her. There was very less amniotic fluid. There were some thick calcified areas on her placenta.

As I tried to help them, the only query they had was on what I was planning to do. The answer was obvious . . . to try to deliver her as soon as possible. The risks were well explained.

I did not believe my ears when I heard their reply. They had asked me on how much a delivery would cost. I told them that a complicated one could end up costing up 5000 INR. However, I told them that I’m willing to give them ample concession to ensure that she delivered at a hospital. I promised to do everything for 2000 INR if it was a normal delivery.

The uncle told me that they would arrange at least 2000 INR and then get the lady admitted for delivery. All my arguments fell into deaf ears. They were gone before I could make up any new reasons. As they left, one of them told the nurses that they will back in 2 days time.

Yes, the cost of even 2000 INR for a normal delivery was too much for them. They did not have any RSBY card. And I wondered if they found it too hurting that I was ready to treat them for a lesser charge.

Learning from the poor . . . they are honest, they are people with self-respect and they are more in touch with reality than the rich. And we have quite a lot of people like this family out there. You'll not even hear about them . . . they cannot afford to see us. 

The rich . . . most of them are dishonest, they would stoop to any extent to get some concession and they expect everybody to stoop in front of their riches. And it’s obvious that quite a lot of the rich get their wealth at the expense of the poor.

No wonder . . . our Lord had a soft corner for the poor . . .

And of course, if our Lord had the partiality towards the poor, we better have the same . . . 

Geriatric Care . . . cont'd

I had posted couple of times about the challenges we face in caring for the elderly in a place like NJH. The below snap is of a very lovely couple who are our regular patients.

We don’t know where they live. Couple of times I had thought of finding out where they made their home.

However, every time one of them gets sick, they come to NJH.

As we don’t know about their antecedents, we also don’t know if they have any children. Couple of my staff told that the couple claimed that they don’t have anybody to look after them.

Our first serious interaction with this couple occurred when the lady was admitted with a very serious infected abscess of the buttocks which took quite some time to heal. They were in the hospital for almost 2 months.

The costs were approximately 25,000 INR. We had to write it off as they hardly had any money to even buy food. Lot of staff pitched in with food and money.

The man had come last week with some ailment. Again we had to write off everything free.

Recently, we had a well wiser help us with some designated funds for high risk obstetric care. 

I’m sure that a designated fund for geriatric care will go a long way in helping our elderly patients to access care at NJH. 

Patients who taught me - 1

Patients teach us a lot about life. And I’m sure that they are not one-off incidents. I’m thankful for these patients who instilled qualities in me which I value very much.

The first incident occurred during my previous stinct at NJH. Ms. RK was a 9 year old girl who came to us with a perforated intestine, most probably following enteric fever. The family did not look poor to not afford surgery at our place.

The treatment which included surgery went on without any hitches. Their total bill had come to around 12000 INR. Since there was not any complications and the admission period was uneventful, we did not remember much about RK and her family.

Not until about 6 months later.

I had been part of setting up a TB Clinic at another hospital about 100 miles away from our place. I usually travelled to this place by jeep early morning.

In one of the trips, I stopped at a wayside shack for tea early in the morning, when this middle aged man who was making the tea came out of his shop and touched my feet. He told me that we had saved his daughter’s life some time back.

I could not place the identity of the family till RK came running out from behind the shack.

The shack comprised mainly of 4 heavy pieces of wood in the corners and plastic sheets and sack cloth dividing the space into 3 rooms. Bricks were arranged in a very haphazardous manner to make the outer walls.

It took me some time to recognise RK.

I was surprised at the severe poverty in which the family lived. The father was ready with the tea.

As I sipped the tea on that cold winter morning, I asked the father how he was able to pay our bill 6 months back, considering the poverty he was in. I was in for a shock.

The father replied, ‘We had seen better times till RK fell sick. By the time, we reached your hospital, we had already spent about 20,000 for RK’s treatment. It was just after planting our crops that RK fell sick. So, I did not have any money with me. Therefore, we had to take a loan from the local money lender. Unfortunately, the crops failed because of a poor monsoon. We had to sell our home and the little land that we had to repay the money lender. After that, our life has been this shack.’

He took me about 50 metres down the road and pointed to a hut, much better than their present residence and told me that they used to live there before RK fell sick. 

The winter appeared to sort of envelope me in a terrible chill when I heard this.

We had not even bothered to ask the family about their resources when they came to pay their bill.

The family was very thankful that their little girl did well after our treatment. There was no hint of any remorse in the father’s or the family’s conversation with us about the poverty they were dragged into because of their daughter’s illness.

But, I learnt a very important lesson. I’ve heard only about statistics of how 40% of poverty was caused by ill-health in the family. I was seeing a real life story of one of our patients.

From then on, I make it a point to enquire if our patients our selling their only possessions to pay their healthcare bills. Yeah, the situation has occurred because of a poor public healthcare system.

I’m sure that I may be taken for a ride by many of my patients when they know about my attitude towards patients who have to sell their land or homes to pay for their treatment.

However, I believe that there will be genuine patients who’ll be benefited for life if we enquire about where their resources come from.

The ultimate answer would be to push for a well oiled and competent public healthcare system.

But till that happens, mission hospitals like ours can make a difference in the lives of at least few of such families.

The big killer . . .

Come spring, and we have quite a spurt in the number of patients with respiratory diseases. And quite a good number of them would be tuberculosis patients . . . A selection of cases .. .. ..

The first one, a young lady who has been on and off treatment. The first 3 X-Rays here are her's taken over one year. It's very obvious that the second film is a bit better than the first one . . . but that was when she had stopped treatment after she was feeling better after about a month of treatment. Then, she was quite sick after the winter. And the third X-Ray was taken after that.

The next one is that of a middle aged lady who also has been on irregular treatment. 

The one below is that of a young man, who had been sick for about 5 months now. He had stopped tuberculosis treatment after 2 months as he was feeling better. Now, he has about one third of his total lung left. 

And the final one- A 10 year old who has been sick for almost 1 year. He has been sick on and off. The main finding . . . he weighs a measly 15 kilograms. 

The common links between all the 4 patients . . .

All of them are poor and there is a major issue with food security in all the four families. 

I've written quite a lot of poor nutrition last year. As the number of poor patients who access our facility increase, the strong association between poor nutrition and disease is very much evident. 

We've focussed quite a lot on Human Immunodeficiency Syndrome which is a cause of an immuno-compromised state (all 4 patients are HIV Negative). I wonder how long will it take for healthcare providers and policy makers to understand that the most common cause of an immuno-compromised state is M A L N U T R I T I O N . 

Moneylenders . . .

The rural Indian hinterland is not complete without the active presence of moneylenders. They usually belong to the business class. They are know by different names in different regions of the country.

Today I was reminded of the chaos that a moneylender can bring about in the life of a commoner. I was sitting in the cool air-conditioned environs of my office, when a shabby looking young lad of about 19 years walked in. It was obvious. He wanted a concession for the treatment of his wife. 

GD, his wife had come about a week back after having been in labour for more than a day. And she was terribly anemic. We operated after the relatives arranged one unit of blood. Per-operatively we found out that the uterus was already ruptured. The baby was lucky to have made it alive, although a bit sick. 

The total bill for both mother and baby came out to about 17,000 INR. He had brought 10,000 INR. The baby's bill was about 2000 INR for which we gave full charity from Grace Babies. That left 5000 INR. I haggled with him to at least pay 2000 INR more. He fell to my feet and told me that he has brought all that he could afford. 

I asked him how he managed 10,000 INR. It seems he had taken it from the local moneylender.

To all of you who know the moneylenders in the rural areas of India, this may not be new. 

I asked him about the interest he would have to pay back. The calculations are astronomical and unethical. Let me put it in simple terms. 

The interest he is being charged in 10% per month. And he is paid 10% less of what is taken. 

Which means, if I borrow 100 INR, I would get 90 INR. If I pay within one month, I would have to pay 110 INR. If I pay the next month, that would be 121 INR. So you can calculate how much I would have to pay if I take one year to pay the money off. 

If my mathematics is correct, if I pay a 100 INR loan after 1 year, I would end up paying 314 INR. Imagine, getting a loan for 90 INR and paying back 314 INR. Recently, someone told me that there are some fairer moneylenders who take 10 INR per month for 100 INR. So, if you calculate that way, that would still be 220 INR after one year.

Imagine, GD's husband getting 9000 INR. He would be having to pay anything between 22,000 to 31,000 INR if he manages to pay back within one year. And there is the spectre of bonded labour which continues without much notice in most of our villages . . .

Poor families in rural India take such loans for three major reasons - agriculture (for purchasing seeds and fertilizer), unexpected ill-health and marriage ceremonies. Unless the monsoon rains fail, he is able to repay for agriculture costs. The problem is with the next two. 

My prayer would be that public health facilities would improve so much so that patients like GD would get the best possible treatment such that they would not need to approach facilities such as ours. Until that happens, I pray that we would be able to write off bills for patients like GD. . .


However, the Rashtriya Swasthya Bima Yojana is the best option available before us to bypass the moneylenders at least when the issue of unexpected healthcare costs arises. Unfortunately GD's family did not have an RSBY card.


We are proud to say that till today morning, we've had 868 RSBY beneficiaries accessing outpatient facilities (free registration and consultation) and 141 accessing in-patient care. The total costs should be around 700,000 INR of which we have got about 380,000. I'm glad that we could be of service to these many RSBY card holders in a short duration of not more than 4 months.  

FOR WANT OF CHLOROQUINE TABLETS (Most probably)

I am sure we are all familiar with the rhyme which goes . . .

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.

I had a frantic call from our duty nurse sometime around 7 pm today (4^th November, 2011). There was somebody who was brought dead and she just wanted me to come and confirm the death. Something which is quite routine in many of the hospitals.

I took my sweet time to go in. On reaching the emergency, I was surprised to see that the unfortunate soul was a very young lady. However, there was one more person – a living one, lying in the bed adjacent to the stretcher carrying the dead body. I thought it was quite unusual.

I identified one of the local fellows whom I was familiar. The story he had to tell was a very tragic one. It seems that the young lady lying dead in the stretcher was the wife of the man lying on the examination cot. Both of them had been sick since the last week and presumably had been on some treatment from the local quack.

The lady had been unconscious since yesterday after having been very sick with high grade fever for the last one week. Her husband was also sick. The neighbours had noticed it and had been advising them to go to a doctor. But, they never took it seriously.

It was only today morning that the couples relatives and neighbours realized that things have taken for the worse. They had been pestering the husband to take his wife and himself to NJH. The husband needed a whole day of persuasion to bring his wife to hospital. But by the end of the day, she was dead.

I examined the husband. He looked severely sick. He was running a very high temperature. His eyes were bloody red and his sclera showed that he was severely jaundiced. Most probably, hepatitis secondary to falciparum malaria which probably killed his wife too.

I wrote out the inpatient chart for him and ordered for some basic investigation before starting treatment.  I went back home after writing some intravenous fluids to get him hydrated. As soon I reached home, I received a call from the emergency nurse who told me that the young man has refused admission. The reason – ‘we are quite expensive, and he did not have any money.’

He had walked out of the hospital and was nowhere to be found. The rest of the people had gone with the dead body of his wife and he had also gone behind them.  There was nothing we could do.

I felt sad for the family. While I was examining the young man, one of relatives was holding the only child of the couple – a two year old girl – quite oblivious of the tragedy that has befallen her. From the way the man had responded to us – I could only shudder at the future of the little girl, with no parents to raise her.  

Stories such as these are very common in the rural parts of the developing world. Lives which are quite cheap; lives which are expendable. Nobody cares if such people died. I felt sad that poor people around our institution finds us quite expensive. I wish we could be such a place where the poorest of the poor can walk in and get life-saving treatment.

Treatment for this young couple who are in the prime of their life would not have been expensive if they had come in the very beginning. It may have involved giving a course of chloroquine or a course of antibiotics. The paradox remains on how difficult it is to convince the ignorant and the poor about how easy it is to save lives.

So, ultimately, families are being destroyed all for want of a basic knowledge that timely health care can save lives. But, the problem remains on access to basic healthcare for quite a lot of our population. Is anyone listening?