Untold misery

This is Kunti Kumari. Elder of three girls who lost their father to Naxalite violence. We don’t know the details.

Kunti was brought to us few days back in a confused state by her uncle. Considering that she was having fever since two days and she was from our ‘malaria endemic’ zone, there were no guesses to arrive at a provisional diagnosis. Laboratory report confirmed the diagnosis. Mixed malaria infection with features of impeding complications.

She responded well to treatment. Considering the rush of patients that we had been having, we missed the tragedy that befell the family. We did not know that Kunti had lost her younger sister to high grade fever just the previous day.

It was one of our nurse aides who told us about the sad story. Kunti's younger sister was having fever since few days and was being managed by a quack in the village. She had suddenly become unconscious and died the same morning when Kunti was brought to us. 

The last ten days we saw more than 25 patients with malaria. Except 2, all of them had mixed infections. We were ill equiped to manage four patients whom we had to refer to Ranchi. Two of them have renal failure and are still on dialysis. One little child has unexplained hemolysis needing repeated transfusions. One little boy of twelve years died within one day of admission to our nearest teaching hospital.

From the nearby villages, we’ve heard about 5 deaths so far. No one has been proved to have had malaria. They had high grade fever for couple of days which was managed by the local quack. And they just died.

The interesting thing this year is the total absence of the coverage of malaria deaths and high incidence in the local media, leave alone at the state and national level.

How long shall we cover up the truth? The truth of an India which is still grappling with preventable diseases like malaria and the unnecessary deaths . . . 

PS: Consent was taken from Kunti and her guardians to put her story and snap in public

The Preventable

A major scourge of healthcare in India is the presence of preventable diseases. The incidence of malaria has definitely been on the decrease. However, I’ve few friends who believe that there is not much of a decrease in incidence, rather, it is a failure of reporting that has sort of given across the message that the incidence has decreased.

At Kachhwa, we see quite a few cases of malaria every week. Most of them are Plasmodium Vivax cases. 

Yesterday, we had a very interesting patient. A young man working in a town in North Bihar, he had come with fever of quite a long duration – almost couple of months. We had seen him about a month back and had treated him as Enteric Fever. And he had responded well to treatment.

However, he came back within couple of weeks of stopping treatment. We did a malaria smear and this is what we got.

The smear was full of gametocytes. In fact, almost every field had at least one gametocyte and surprisingly we could not find any ring forms. It is not very common that we got a field with 3 gametocytes.

The scenario of having Falciparum Malaria cases in the community is frightening. It exposes the population to a chance of morbidity and mortality from severe forms of malaria. And it is a harsh reminder of the infantile public health scenario of the country. 

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. 

The Village Visit

Few days back, I had the opportunity of doing visits to few villages as part of our community health projects. It is not that I do not visit villages regularly. These village visits were quite different as I had the opportunity to walk through an entire village after quite a long time.

As is the custom, my colleague and I went straightaway to the village headman’s (mukhiya) house as soon as we reached the village. After exchanging pleasantries, we got into the serious discussion about the issue of people with disabilities for whom we had made the visit. 

I shall write about this in another of my posts.

The mukhiya was from a caste which is designated as backward. He got the opportunity of being elected as the mukhiya because the panchayat had the status of being a reserved panchayat where only a person from the backward caste could be elected.

What I would like to portray here is my walk from the mukhiya’s house to the government run village play school (anganwadi).

The mukhiya’s house was very close to the main road. However, his immediate neighbours were all people who were deemed as that of a higher caste. It was obvious that most of these people did not want to do anything with the mukhiya.

Cursory glances went up as we walked through this ‘high caste street’. There was no word uttered. Contrary, there were murmurings going on mainly between the womenfolk who were sitting in the courtyards of their homes.

The next street belonged to people of another caste whose major occupation was dairy farming. However, here the mukhiya had people asking him very sarcastically about the work he was doing. There were women asking him if there was some new government scheme in the pipeline. The tone and mannerisms did give away the mistrust they had on him.

The anganwadi was in the area where another caste was dominant.

I enquired about the Harijans - the supposedly lowest caste. Gandhiji gave them the name Harijan which means God’s people.

One of the men pointed to clump of thatched houses a bit distance away from the anganwadi.

Previous experience has taught us that it may not be wise to rush to this group. The problems would be the maximum here. But, almost the whole of any rural Indian village do not consider them humans. We would visit these houses at a later time.

Other than the caste system, one more aspect which concerned me . . .

The filth and dirt in the streets was appalling. One of the villagers commented that if it rains it becomes worse. Of course, the situation was worst in the area where the dairy farming caste was living. Conditions were perfect for the outbreak of an epidemic of any water borne disease. It would be a miracle if nobody got malaria in the entire village every week. And of course, the worst part . . . there were no toilets. It was open air defecation all around.

Any good things . .. …

There were televisions and music systems in quite a few houses. There were jazzy bikes parked in front of few houses. There was a sort of serenity and peace in the whole place although the divisions within the community was obvious. 

It is not uncommon to see romantic depictions of rural Indian vistas portrayed in many avenues.

However, I’m sure that what is depicted above is not an uncommon scene in many of our villages.

(Apologies for no snaps from the visit in this post. This is because of feedback about villagers not being comfortable about outsiders taking snaps. There is regular talk about the press and NGOs taking snaps from villages and using it for nefarious purposes. The snap given above is that from another village) 

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.

Funding . . . The Paradoxes in Indian Healthcare - Part 2

The other day during a meeting, someone commented on how easy and freely available is HIV testing in almost all government facilities compared to other investigations such as hemoglobin, urine albumin etc. Someone suggested that even there are places where HIV testing is available, but a sphygmomanometer to measure blood pressure is not available. 

I'm afraid that this situation is actually true. 

There is quite a lot of funding available for HIV. But, no money for Reproductive and Child Health Care. So, no sphygmomanometers or instruments to measure hemoglobin or urine albumin. Well, I would not need to do explanations on the importance of doing a hemoglobin for a pregnant lady as part of her antenatal care. Or a routine check up of blood pressure. 

I'm not touting for HIV testing to be stopped . . . it is a lifeline for babies who are born to mothers who could be diagnosed to be HIV positive. But, we need to rule out anemia for all our women who become pregnant . . . for anemia is supposed to be the commonest indirect cause of maternal mortality in the world. 

Talking about maternal mortality . . . it irritates me when the Polio Surveillance officer calls me every Monday to check out if there has been any case of Acute Flaccid Paralysis in the hospital over the week. I'm not irritated because I don't like this guy . . . he's in fact a good friend. I'm irritated because there are young mothers dying while giving birth. We fill up the Institutional Death Reviews and send them . . . On October 18th, it will be one year since we've started the reviews. Till today, I've not been called for any meeting related to any of the deaths. 

Leave alone maternal deaths, I've had men, women and children coming with symptoms suggestive of viral hemorrhagic disease most probably dengue . . . nobody turned up until someone accidently put it in the papers. Still the response has been quite muted. There were 3 proved cases of cholera in the hospital. I informed the authorities responsible. No response. 

It does not need any brains to explain that nobody is interested in maternal deaths, tuberculosis, malaria or cholera as there is hardly any money in it. There is money in HIV, Polio . . . even cancer. And now, Non-communicable diseases. Because that's what the West is quite concerned of. HIV, polio . . . because they are quite concerned that we will transmit the diseases to them. 

Non-communicable diseases - - - so that they can get back all the expenditure spent on research of drugs which have been proved to be either useless or has side-effects. Recently, I had a mail from one of my elderly friends (not a doctor) who told me how he was 'detoxified' from all the medicines he and his wife had been prescribed by his cardiologist et al in India, after he went to the US to be with his son. He was put on a regular regime of exercises and dieting. He is doing good with no problems . .. ... 

My previous post had been on the pharmaceutical industry. Even for the pharmaceutical industry, there is nothing much in store from maternal or child health and infectious diseases such as malaria or cholera. 

There is only one solution for this issue. Our friends in the Health Ministry needs to realise the pressing healthcare issues of the country and ensure that funds and personnel are available for research on those issues. We have enough research to show that the metabolic functioning varies in cultures and races. Following research, we need to have systems put in place such that the research can be converted into action. Only then, can the real needs of healthcare in India be addressed . . . 

Depending on funds from any organisation abroad would only ensure that public healthcare issues of those regions would only be addressed and we would remain with healthcare issues such as Maternal and Child Health, Tuberculosis, Malaria etc which we have been continuing to grapple with since ages. 

Coming to funding . . . there are more issues. Like the issue of adequate infrastructure not available for Primary Health Centres and other public healthcare institutions to start. And worse than that is the all out dependence on Private Medical Colleges to help us with staffing our Health Centres with doctors . . . Well, that is fodder for another post . . .

Maternal Death . . . The second one

I came from Ranchi after a meeting on Maternal Mortality . . . I made a promise of writing up about all the maternal deaths I come across. Something that I'm seriously thinking about doing is to find out maternal deaths which occur in the community through our volunteers who are involved in other projects through NJH. Who knows . . . we may come up with quite a lot of revelations. 

It was not even an hour after I had arrived, when a patient was brought dead to casualty. She was pregnant. It was busy otherwise. So, not much of a thought was given and relatives took the body home. 

Later, today morning, Johnson called me up to say that the dead pregnant lady had come from Piprakala, one of our neighbouring villages. It's a shame.  

Sometime around mid-day, there was one more very sick pregnant lady who was brought in. There was nothing much to do. She was gasping. Titus told them to go ahead to Ranchi . . . which they really agreed for.

But, the relatives made a beeline to my office and was soon pleading to do the best that we could. I was caught up with work, but somehow made to Acute Care. 

MD looked hardly 20. She was puffing and huffing. Papery white, with a tint of yellow. There could be only one diagnosis. . . Malaria.

I explained everything to the relatives. We had to get her ventilated. She could collapse any minute. We got a sample of blood for the baselines. And had her hooked to the ventilator in no time. Then, she suffered a cardiac arrest. . . we got her heart working. From the look of her eyes, it was obvious that it was going to be tough. Tough it was as she got into another cardiac arrest. . . And her pupils had started to become unequal.  

Meanwhile the results from the lab came in. Platelets of 14,000/cu mm. And 90% of her Red Blood Cells infested with Plasmodium Falciparum. 

She hardly had a chance. . . 

We declared her clinically dead at 2:30 pm, about 2 hours after she had come in. 

She was being treated elsewhere for the last 3 days. . . Nobody had diagnosed malaria. I wonder how even a quack would have missed out on the diagnosis. 

Thoughts on this maternal death . . . 

- A failure to diagnose malaria. She had been to hospital, but the malaria smear is put as negative. 

- Who knows she may have been treated with anti-malarials. It is very difficult to imagine quacks not giving anti-malarials in fever cases. Maybe, we are having resistant cases. 

Talking about malaria, we are having quite a number of fever patients coming in. As we had suspected last year, we still have a hunch that it's not only malaria that we are dealing with.

Well, today afternoon I plan to visit the house of the lady who was brought in dead. Shall put up a post as soon as we come back. . . 

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) 

Photo post . . . 28 March. . .

18 day old girl baby presenting to OPD with early breast development. There were no other features of precocious puberty.

This 35 year old man came to Emergency with history of cough and fever for 10 years. He was so breathless that I sent him straightaway to the ward and planned to evaluate him later. It turned out that he has visited almost all the best institutes in North India. On doing CT Scan, the diagnosis was staring at us – Interstitial Lung Disease. A not so common diagnosis in our place. I’m sure that there are a lot more undiagnosed cases. The saddest part was that nobody had told him about this diagnosis and the prognosis . . . 

A 60 year old man with a poorly managed supracondylar fracture. Resulting in a gunstock deformity.

CT scan of a 20 year old girl with focal seizures. Shows unilateral parietotemporal atrophy of the brain. I wonder what could be the cause. The history is of about 10 years duration.

This is a drain built by our local panchayat to facilitate smooth flow of household waste water. Unfortunately, it had got blocked. And see who’s breeding inside. Enough ammunition for a malaria epidemic.

The internet and cell phone connections at NJH has been dead over the last one week. Being the end of the financial year, it has been quite tough on us. Well, I found out a corner of my house where I could get good Airtel mobile connection. And this is the result. The funny thing is I get calls – and by the time I take the cell phone out from the hook on the wall, it gets cut. I must find where my earphones are . . .

Since, we just celebrated World TB Day, I thought about putting in couple of snaps of Chest X-Rays of TB patients. The first one - A very bad case of pulmonary tuberculosis with extensive destruction of the right lung and miliary mottling of the left lung. The patient has been on irregular anti-tuberculosis medication from a quack for quite a long time before he planned to visit us.

Chest X-Ray of another mismanaged pulmonary tuberculosis. This time it’s a lady.

A very bad case of atopic dermatitis with secondary infection. She had similar lesions in the nape of the neck too.

First working day of the New Year . . .

Today was my first day after the brief vacation and oh...my....it's turning out into a major one.

To start off, as I left chapel and entered the hospital, Dr Johnson requested me to convince MD to undergo a Cesarian section. Johnson was convinced that MD was obstructed - and I was also convinced. I was thankful when Johnson went out for one more round of negotiations and returned victorious.

MD had been in labour at her home since late afternoon of the previous day. She had also recieved 6 intramuscular injections, half of which were oxytocin. She had arrived sometime after midnight, and had not progressed.

And, I was glad we operated. The outer uterine muscle fibres were starting to snap, there was petechia in the lower uterine wall, the bladder was edematous and there was a part of the lower uterine wall through which I could see the flakes in the amniotic fluid. She would have ruptured within the next one hour. The baby girl had a surprising Apgar Score of 9 and 10.

As I was starting off MD's Cesarian Section, word came that there was a Previous Cesarian without any antenatal check up who had come in with labour pains. She was also posted for surgery as soon as MD's was over.

Patients such as KD actually prevent us from readily jumping in for Cesarian Sections even when there is a faint indication for one. It was unbelievable. KD, who had a previous Cesarian 2 years back, did not even have a tetanus toxoid injection leave alone a proper antenatal check up. KD's Cesarian section was also uneventful although we had to arrange blood as her hemoglobin was only 8 gm%.

Well, I forgot about LD - who was wheeled in as we were taking a decision on MD. LD was about 32 weeks and had come in all the way from Ranka - about 60 miles away. LD was hardly conscious , had convulsions the previous day and was being managed elsewhere before they referred her to us. There was no fetal heart and the abdomen looked too big for 32 weeks.

Shishir promptly did an ultrasound and confirmed dead twins in the uterus. Then we found out that her birthcanal was almost fully dilated. But, for some unknown reason, we ended up doing a craniotomy to deliver the first twin and then the other one was pulled out breech. LD is still not fully conscious.

Then, we had two more normal deliveries, one of which was a small for gestational age baby. And another one which was an Intrauterine Death.

I'm glad we do not yet have a case of Rupture Uterus. But, we do have a elderly primi with post dates whom we've induced. I hope she delivers normally - but sometime back, the labour room nurse has informed me of couple of high diastolic blood pressure readings . . .

Well, for all those who want to know about other patients - we had two proven malaria patients today. SK aged about 19 years had been sick since Wednesday. It was quite obvious - he was shivering as he came to OPD. Then we had VS, who just came in very sick. He has been sick since January 2. He was all yellow - I tried my best to refer him - but to no avail.

Rajeev, our lab technician telephoned me VS's blood tests - Falciparum malaria positive, Total Count 21,000/ cu mm, S. Bilirubin 9 mg%, Platelets 30000 / cu mm . . . I am yet to see the full reports.

I've the ventilator ready . . . And another 12 more hours before I hand over to Dr Johnson . . .

And to top it all, two more young ladies with attempted poisioning. One had taken organophosphorus and the other permethrin shampoo . . . Both are doing well . . .

Before I sign off, an X-Ray from OPD today. There was one more good one . . . but I forgot to take a snap . . .

Blackwater fever . . .

(This post was drafted on 15th Dec, 2011)

We have been having quite a lot of patients with malaria over the last 2 months and it seems that they would continue to come all through the winter. We have some sort of a cold wave going on here with temperatures around 5-10 degree celsius in the night and it is a bit unnerving that we continue to get very sick malaria patients.

The latest two patients whom we have are quite sick. ND, a young housewife who is 7 months pregnant came today afternoon with long standing fever. She was being treated in Daltonganj for the last 1 week. 50% of her red blood cells were infested by the malarial parasite. And her liver enzymes were mildly elevated. We offered her a referral as we thought that the family looked well off, she was pregnant and her platelet counts were 41,000/cu mm.

Her family ultimately decided to treat her here after much deliberations.

Sometime late in the evening came MS, a middle aged man with history almost very similiar to ND. However, he looked more sick. 20% of his red blood cells were infested by the malarial parasite, but he had a platelet count of only 15,000/cu mm. The worst was his urine. Although his creatinine levels were on the higher side of normal, the colour of the urine was very frightening.

In the earlier days, I understand that this used to be called blackwater fever. And I've read somewhere that Dr Paul Brand's father died of this condition.

I hope that both MS and ND will pull through. As we discussed about these patients, Nandu was quite apprehensive about having to manage such patients alone from Saturday. Shishir has already left for his vacation and I would also be going off south to home from Saturday.

NS – story of ignorance and apathy

NS, a 4 year old boy came the next day after the 2 sisters were admitted. NS was quite sick. The history was more suggestive of acute intestinal obstruction with severe anemia. And interestingly his mother was also quite sick. The only difference being that NS looked very sick and was almost unconscious.

NS’s blood tests were terrible. Hemoglobin of 4 gm%, 40% of the RBCs filled with the falciparum parasite and a platelet count of 20,000/cu mm. We needed blood fast. A peripheral smear showed all signs of hemolysis. NS reminded of Shalom, my son. He was almost of the same age.

NS was from Phulwaria – a village along with banks of the river nearby. Phulwaria is a common name for villages in this part of the country. The basic characteristic of all Phulwarias I know of is that they are usually the name given to the outer neglected part of the country side. And it is the same with the Phulwaria that NS’s family came from.

Families living in utter poverty and neglect. The only attraction for them to live there is the river that flows nearby. Most of the families live on some odd labourer jobs and most of them are at the mercy of the local landlords. The women live collect wood from the forest part of  which is sold and the rest used to cook whatever they can afford to buy. The perennial river ensures that there are collections of pools of water at many places away from the area of water which flows constantly. And this supposedly is the place for breeding of mosquitoes spreading all diseases which the mosquito spreads.

I told the relatives that if we need to save him, we needed blood. Off the 3 male relatives went off to get blood. It was then I realized that I was fit for my next donation and our blood groups matched. And I did not have to give much for a 10 kg child. Off went the donation and the blood was being transfused in no time.

I was with the child for about half an hour as the blood was being transfused. I was looking at the possibility of intubating NS and ventilating him. The other option was to put him on CPAP. But his saturation was maintaining well.

I thought of rushing home and getting freshened up. I had just reached home when I got a call from Acute Care that NS had arrested. Nandamani was in the next room doing a cut down on FD. He had NS intubated but he was not responding to any resuscitation.

By the time I reached ACU, there was nothing we could do. It was not surprising that NS collapsed so fast considering his hematological parameters.

The next day, Angel reviewed the peripheral smear of NS where she found out evidence of severe hemolysis. Most probably, NS had gone in a state of auto-immune hemolysis which is commonly seen in severe malaria.

The saddest part of the story was that the male relatives came almost 3 hours after NS had died. I told them that we had tried our best. As I was conversing with them, I realized that all 3 of them very stinking alcohol and I was talking to 3 fully intoxicated men. I realized the futility of my talking and left them to take the dead boy home.

It was sad. NS was the only child of his parents. As with almost every family in Phulwaria, NS’s family also had a hand to mouth existence. Everybody drowned their sorrows in alcohol which was available plentiful. If the local women did not make the country brew, it could be brought in the nearby Satbarwa village or they could always buy a bottle of ‘English liquor’ which was a bit more expensive. The story about alcohol use would distract you from the objective of my post.

Malaria continues to ravage in parts of Jharkhand in an almost vengeful manner. There are multiple factors which would continue to ensure that the parasite would remain in the communities we serve. Unqualified medical practitioners also compound the problem.

I could only watch helplessly as the nurses removed the almost full pint of blood. They asked me what to do with the rest of the pint. I told them to keep it in the fridge. Maybe, if I got someone else with a A positive group, I could transfuse the rest of the blood. I wish I waited to donate blood for another patient who had a better chance of surviving.

Malaria Galore. . .

It all started yesterday with 2 sisters, both below 5 years coming to Emergency with quite high grade fever associated with chills and rigors. Both of them were grandchildren of one of our watchmen, Mr. Jithen. They were being managed in the village.

However, the parents or rather the grandparent realised that both of them need serious medications.

When they came in on Sunday morning, both of them were partly conscious, one of them had falciparum plenty within her red blood cells whereas the other one did not have obvious parasitemia. Both were terribly anemic with haemoglobins of half the normal values.

As I had written in my previous blogs, there has been quite a lot of malaria in this part of the country since the last month. Even, the local newspapers have been reporting increase in the number of deaths as well as large number of villages being terribly affected by the malady.

Both of them have been started on quinine and the relatives were able to arrange blood transfusion for both the children. They have improved quite well and should be fit enough for discharge in a couple of days.

However, it is very evident that both these little girls are quite lucky compared to NS, a little boy who came with very severe anemia yesterday, about whom I shall write in my next post.

A tale of two malaria patients

It is already cold in Palamu. Nights are quite cold enough to warrant the use of quilts. But, the climate is quite unusual for malaria. Maybe, after all the posts against malaria, the malarial parasite and the mosquitoes are getting back at me. There have enough reasons for me to suspect things other than malaria.. There was a well documented case where I was sure that it was imported leptospirosis from Kerala. There has already been an epidemic of viral encephalitis in the neighbouring districts. Of course fevers in NJH has always been baffling me and I still strongly believe that we have more causative agents other than just malaria or typhoid.

 
Coming back to malaria we’ve already had about 5 cases of Plasmodium Falciparum and another 4 cases of Flasmodium Vivax over the last week. However, yesterday, I had 2 little children who came in with confirmed blood smears of Plasmodium Falciparum. Read their stories.

 

The first to come in was PS who came in late in the morning. The history was very peculiar. PS was doing quite well in the morning and was playing with his friends, when he suddenly collapsed and became unconscious. The history initially looked like he had a head injury. On examination, DK was quite stuporous, crying incessantly and quite significantly appeared to be hemiplegic on the right side of the body. The right side of the body was in a state of spasm with flexion of both the upper limb and lower limb.

 

All the possible causes of a young stroke raced through my mind. But the blood tests brought about a surprise. He had falciparum teeming in his blood and he started to run a very high grade fever. Since there was a hemiplegia involved, I started to condition the parents to take the patient to Ranchi for a CT scan. But, the family was very poor.

 

I started him on the classical treatment for Cerebral Malaria. I was surprised when I saw him in the night. His hemiplegia was resolved and he was crying for food.



However, the next patient was not very lucky. SB, a 5 year old boy from one of the nearby villages was visiting relatives elsewhere where he had fallen sick since the last 5 days. One of the village quacks were providing treatment. Today early morning he had become unconscious. The parents realized the gravity of the situation and rushed him to his home village nearby.


Unfortunately, the first place they went to was again one of the local quacks. By nightfall, they realized that SB was quite sick. SB came to NJH at around midnight. On examination, it was obvious that SB was quite sick and only a miracle could save him. The blood investigations only confirmed the inevitable. Hemoglobin was a pathetic 5 gm% and 75% of his Red Blood Cells contained the falciparum parasite. His platelet count was 17,000/cu mm.


The parents wanted to know if taking to Ranchi would be of any benefit. I told them of the pros and cons. Ultimately, they took the decision to take to Ranchi. I wrote off the referral letter. However, I started to harangue them for some blood to transfuse. But, the response from the parents was very cold.


The labour room was also quite busy. I was busy attending to other patients too. Somewhere in my mind I lost track of the child considering into fact that the parents have already taken the option of referral. Unfortunately, what I did not realize was that the parents were waiting till daybreak before they took SB to Ranchi.


The next thing I know is Dr Nandamani informing me at 7:30 next day morning that SB died. There was nothing we could do. Later I realized that I had written the chart for SB and the treatment was started.

Maybe if had some blood, SB would have survived. But again with a platelet count of 17,000, I’m not very sure.


SB could have been saved had we got a blood smear done and started him on Chloroquine quite early. PS’s presentation still perplexes me. I saw him today morning. He has improved quite a lot. 

Ultimately, whatever said about newer emerging and newer emerging diseases, malaria continues remain as a scourge in the public health scenario of places such as ours.