Of doubtful intentions . . .

Couple of days back, I thought of checking the status of the application for getting Janani Suraksha Yojana for the hospital. We had been getting positive vibes from one of the senior consultants in the district. The application for the same had been submitted as long as 3 months back. There was no reason why we should not be empanelled under the JSY.

However, I was in for a shock. One of the district officials who was to put the main signature on the papers was ready to do it. However, he needed the signature of one of his juniors.

The senior person called up this junior official and told him that the document for empaneling NJH was long overdue. Over the phone, the latter started to tell about how illegal it was for NJH to do all the stuff we do now. However, he agreed to come for more discussions.

As we waited for this person, one more senior doctor in the district turned up. I was introduced to him and we were exchanging pleasantries when he also started to berate us on working without specialists.

By that time, the junior officer had also arrived. And I was at the receiving end from both these doctors, who were quite senior in the district. Both of them had no post-graduate qualification . . . but made statements which made themselves look so pathetic.

Few of the statements . .  .

Why are you running NJH when you cannot provide specialists? I wanted to ask him the same. Why there was a district hospital without specialists? And more than that many  time without doctors . . . I remembered about the incident quite a long time back, when another senior doctor in the district had asked me on how we were running a tuberculosis unit without a Chest Diseases consultant. How many District TB Officials are Chest Disease consultants? How many RNTCP consultants in the state are Chest Disease Physicians?

Well, I told him that this sort of an arrangement is quite accepted for hospitals in rural and remote areas .. .. ..  Well, that brought out the next question.

Who told you that NJH is in a remote location? According to him, NJH was on a National Highway and therefore for no reason it could be called remote. By this time I knew that I was talking to a guy who was quite ignorant of local topography and social issues. He went on to tell me on what defines the remoteness of a place.

I was searching for the next question to ask him, when I remembered about the eclampsia patient who had come to us after being referred from the nearest District Hospital. I asked the group on what I should do when such a patient comes to NJH, which is quite common. I hid the fact that most of the time they are referred from the District Hospital.

‘You get the numbers of the Mamta Vehicles which are designated for your place and send the patient to the district hospital’, the 'well informed' of the lot advised me.

I realized that it was close to lunchtime and there was the water-tank dedication scheduled for 4 pm. I could not waste any more time.

I told the group that considering the number of requirements which was being put forward for getting empanelled under JSY and our inability to meet even 20% of those requirements, I would rather withdraw my application.

That’s when one of the group suggested that I do want most other hospitals do. Get the names of the respective consultants who work in Ranchi, pay them a small amount and get to put up their names on our list of doctors. I was glad when one officer in the group told them that NJH would never do such a thing.

I was glad that there were guys who accepted our sincerity and transparency.

However, what I realised at the end of my 2 hour wait was the fact that the real poor had nobody to care for them. All the doctors and officers in the group knew very well knew that NJH offered the most affordable and quality care for obstetric and newborn care. However, they were not willing to speak up for us. Rather, most of them were interested to see us closed down.

One had commented, ‘It’s only because of the absence of a strong administration and long history of service that hospitals like NJH remain untouched.’ I could only wonder about the half a dozen hospitals which had opened shop over the last year with one junior doctor in place and all the other consultants who sit elsewhere but have their names put up under this hospital.   

However, two doctors spoke up for me as I stood up to leave. They suggested that a quality evaluation be made about our services and then a decision be taken about our getting empaneled under JSY. It’s going to be a week tomorrow and I’m yet to hear from any of them.

Shadow of death . . .

Since yesterday night, we are sitting on tenterhooks regarding the second patient whom I mentioned in my last post.

It’s more than 24 hours since this lady came in. Her haemoglobin had been around 5 gm% for almost the whole of her antenatal period. She had a Cesarian section after she had eclampsia. Unfortunately, the baby died soon after birth.

It’s been two years. After she got pregnant, the family had been taking her for regular antenatal care in the nearby town. There is mention of her low haemoglobin during each of her visit and Iron appears to have been prescribed.

She’s come in labour yesterday. We had wanted to do a Cesarian section as I felt that there was not much space for the baby to come and there was grade 2 meconium. Her haemoglobin was 4.6 gm%. We told the family that we would touch her only after the family arranges at least 2 pints of blood.

The relatives are yet to arrange blood. But, the lady’s found favour with the Almighty. We were quite worried and could only pray.

She delivered normally late yesterday night . . . of course, the baby was severely IUGR. The labour room team worked hard to ensure that there was not much bleeding.

The problem is the haemoglobin. Today morning, I did it just to find out how it was. She looks a bit uncomfortable. It was just 2.6 gm%.

I can only pray that at least one pint of blood comes before she goes into a hemodynamic complication . . . Once again, another case which would have benefited from UDBT.

Waiting . .. ...

(This post was written on Monday, the 29th July, 2013)

As we wait for rains . . . I’ve been waiting for something else since today early morning.

When I arrived for work today early morning, Titus had news for me about a rupture uterus which has been refusing to go to a higher centre after she arrived her at around 5 am today morning.

This is the second rupture uterus over the last 24 hours.

Dr. Shishir did the first one on Sunday evening.

MD had come sometime early morning on Sunday (28th July). MD had been in labour since 4 am on Saturday (27th July). This was her 3^rd pregnancy. By around 10 am on Saturday, the family realised that there was some problem. She was shifted to the nearby PHC.

The doctor at the PHC was smart enough to realise that there was some complication and she was shifted to the nearby district hospital. At the district hospital, it took some time before the family was told that she appears to have a rupture uterus.

It was late evening. The family was told that the best place for them would be a private hospital in the adjacent district. However, no vehicle was ready to take them to the adjacent district.

They were told that it would be dangerous to be in the district hospital. Therefore, they took refuge in a private hospital for the night.

Very early in the morning, they set out to the Daltonganj. The private hospital they were referred to refused to have anything to do with the patient. It was much beyond their skills. They promptly referred the lady to NJH.

They reached NJH by around 8 am on Sunday. The problem was that she had very high counts and her haemoglobin was just above 7 gm%. It was unthinkable to do anything without blood. We sent the relatives to the nearest blood bank in Daltonganj for 3 pints of blood.

The relatives returned by around 3 pm. Dr. Shishir operated. It was quite tough. She was in severe sepsis and appeared to be going to severe Acute Respiratory Distress Syndrome. She has pulled through the night. 

As I write this (Monday night), MD continues to be on oxygen.

The next maternal near miss, the one I mentioned at the beginning of this post, arrived today morning. RD, had a Cesarian section for her previous delivery. Similar to many of our previous rupture uterus following a Cesarian section, the family was ignorant of the fact that she needed an institutional delivery.

She was better off than MD. Her haemoglobin was 9 gm%. Still considering the time she was in labour and the long period of dehydration, we were definite that there was hemoconcentration.

RD had arrived at 5 am today. It was 5 pm by the time the relatives could arrange blood from Daltonganj. The surgery was uneventful. However, her uterus was quite damaged to conceive another baby.

To top the 2 rupture uterus, we had a severe eclampsia sometime around mid-morning. We kept her for normal delivery as she appears to progress well. However, we realised towards the beginning of her second stage of labour that there was a malrotation and she may not deliver normal.

We ended up doing a Cesarian section for her. As it was a second stage Cesarian section, there was lot of problems. The uterus was in atony for quite some time after delivery of the baby. And she lost quite a lot of blood.

Again, we needed blood. We tried to send the relatives to Daltonganj for blood. But, it was too much of an ask. We have to ensure that she does not bleed more during the night.

The availability of blood is quite a crucial aspect in the smooth running of a centre like ours.

Last year, we’ve had about 1500 deliveries. And with quite a large proportion of them accounting for high risk obstetrics, if we need to develop further, we urgently need to think about setting up of a blood bank.

And not to mention the very high chance that all three of them could have ended up as maternal deaths if NJH was not around. 

However, the big question remains about committed personnel who would be willing to come all the way to a remote location such as ours . . . and continue the good work and look at possibilities of new avenues of quality care. 

Eclampsia Galore

Dr. Shishir is on duty today. It should have been mine. I had exchanged it with him for tomorrow. 

I'm glad I'm not on call today. It has been a long day. About 130 patients in outpatient. Dr. Johnson also had not slept the previous day as it was busy. So, technically there were only 2 doctors in outpatient most of the time. And then the theatre had gotten busy. 

And today it had been eclampsias all the way. Couple of days back, we had quite a bad one. We were blessed to have saved the mother and the baby, although the baby was very sick. Of course, they took the baby to Ranchi as it was a boy. 

We had 3 more eclampsia patients today. All sick. I wonder why people don't take them to Ranchi when they are breathing well and keeping their saturations well. 

I got to put my hand in the last patient who came before we crossed midnight. Pathetic, pathetic history. We shall call her BDD. 

The family had been on the run since early morning. They resided in Garhwa district. They have knocked doors in almost all hospitals along the way till they reached NJH and decided that they could not go any further. The paradox about this patient . . . she works as a maid for a senior doctor in town. 

I'm not sure about her antenatal check-ups. 

Then, she is already going into HELLP syndrome. However there was a glimmer of hope as we found out that she was fully dilated. However, we could not get any heartbeat of the fetus. We had got everything ready for intubation. She was desaturating on and off. 

We took a decision to pull the baby out by vacuum. And then hook her onto the ventilator. 

The ploy worked out well. The best part was that the baby was alive and responded well to resuscitation. 

Kindly pray that BDD gets well soon. 

I was very proud of my ACU staff. They have put up a very good show considering the amount of work going on in the unit. 3 patients with eclampsia of whom one is now in ventilator, 1 patient with organophosphorus poisoning (on ventilator) and one elderly gentleman with a very bad cor-pulmonale . . . it's going to be really tough at night. 

Would value your prayers . . . and of course, we were expecting help from Monday for a week. I hope things get a little light tomorrow . . . for I'm going to be on call.

3 maternal deaths . . .

 Over the last 3 days, we had 3 maternal deaths . . . 

Not much of a description . . . but I hope these are documented here.

The first one . . . Happened on Monday. We shall call her A. Brought with a breech presentation, her baby was hanging out with the head stuck inside since one whole day. She was very toxic. As we tried to take the head out, the uterus prolapsed (not inverted). The next thing we knew was that she had collapsed. None of our efforts could revive her. 

The second one . . . occurred on Tuesday early afternoon. B had delivered at a nearby PHC couple of hours back. Her referral letter showed that she had severe pre-eclampsia. But, she was gasping now. And she was in shock. We did not have any clue about what had happened. We had her intubated. But, she did not make it. Most probably, a amniotic fluid embolism. 

And the third one . . . which happened yesterday. C was admitted on Wednesday night with severe anemia (hemoglobin: 7 gm%). She had already got couple of blood transfusions elsewhere. We had induced her. The relatives arranged one pint of blood. Then she went into pre-eclampsia which we had got control of. However, the patient did not progress. The baby was going into fetal distress. We did not have a choice but to operate. 

The surgery went on well. However, she became sick soon. And then in the Acute Care, she went into a refractory Post Partum Hemorrhage. With no blood, we could only watch her die. The baby, although sick is still in NICU. 

It's terribly discouraging. But, I wonder if we could have done any better. 

The third case would have benefited if there was a blood bank at NJH. 

But, the first 2 cases. They should have come earlier. 

Another cry for better facilities and personnel in a region like ours . . .

Anybody listening ? ? ?

Miracle of the night

After quite a long period of a lull in high risk obstetrics, we've had something to cheer about tonight. 

And it was extra-special after we had a dubious record of 3 maternal deaths happening over a period of 72 hours. I shall definitely post about that later. But, before that, the cheerful item. 

If you look carefully the baby above, you'll notice that the right hand and left leg are swollen. In fact the right posterior aspect of the head is also swollen up, which was not captured in the snap. 

This baby's mother had been in active labour since late evening yesterday. Deep within the jungles of the Palamu Tiger Reserve somewhere near Garu, it took the family almost a whole day to realise that she would not deliver normally like her previous 4 pregnancies. 

The family took her to the Catholic dispensary nearby from where the sisters brought her here. 

It was a compound presentation. The right hand and left leg were already hanging out of the vagina and the head was pressing hard on it. 

We did the surgery within an hour. 

The mother is anemic. We're yet to get blood. The baby has aspirated quite a lot of meconium. 

Kindly pray that there would not be any further complications. 

Much beyond rape . . .

There has been much written in the web and print media about the violence against women in our country after the very sad incident of a young lady being gang raped inside a moving bus in Delhi. 

My take on this issue . . . 

As many of us know very well, this is not an isolated incident. This article in 'The Hindu' has highlighted other such incidents. Even, the other day, it was not a difficult thing to spot out 3 incidents of violence against women including rape which was reported by our local newspaper. None of these hogs any limelight. The fact remains that women and the girl child occupy quite a lower rank in the social order. Time and again, I see this being emphasised by families during my clinical practice. It's many a time disgusting. 

In addition, I know families where the son has been given all facilities to do his studies, whereas the girl remains uneducated and uncared. 

When such an attitude prevails in the family, one need not search much to find out the sort of ideals which is instilled in the young men of the family. As they get out of the home environment, they look at women as objects to be used for satisfying their pleasures. 

Not many a day is not passed where the woman is not undressed in their thoughts and minds. And the pleasure so attained graduates to lewd comments and eve-teasing. The media of our day complements such thoughts and actions. Molesting and rape is just the extreme methods of this mindset. 

It seems that one requires to become an eunuch to be immune to such an attitude towards women. And any such protective attitude could end you in trouble as the two young men discovered last year. 

Well, where do we start? 

I believe that our learning starts at our homes where a daughter is as prized as the son. Our homes should be places where the husband will treat his wife with respect and kindness that the son would behave likewise with the women he meets in his life. Our daughters should not know what dowry means. 

There should be as much joy in a home when a daughter is born as when a son is born. The women in the house eats along with the rest of the family . . . 

I could go on and on. 

The situation is so worse in many of the regions of the country that the attitude towards the girl child has resulted in a situation the young men have to go in search of brides to other places. I saw the terminology of gendercide in this article. I'm not sure of how correct the terminology is . . . but the fact is that we have a situation of genocide which is targeting the female gender. 

What we see in the protests in Delhi is to quite a lot of extent, a mob response to this whole affair. I'm sure that there are quite a few aspiring leaders who would want to use this opportunity to make themselves heard. 

Things need to go to a micro-level . . . homes, communities, social groups etc. . .  if we want to see any change in this issue. 

On maternal care . . .

This quickly written post is in response to a couple of phone calls about why there has been a sudden fall in posts related to clinical care especially complicated obstetrics which started off this blog. 

The straightforward answer is that we have quite a lot of patients. Maybe I've become a bit lazy to put them in. That's all. 

As I write this, our 6 bed acute care unit has 3 patients with some form of eclampsia, 1 patient with viral hemorrhagic fever, 1 patient with a krait bite (on ventilator) and 1 elderly lady with severe pneumonia. 

Stories about one of the 3 eclampsia patient. We shall call her NB. Pregnant for the first time, NB never had any antenatal care. She started to have convulsions sometime at dawn yesterday. As usual, she was taken by her relatives to the nearest hospital headquarters where a consultant obstetrician told them that she be taken to Ranchi. The family was poor and therefore came to NJH. 

She reached NJH by around 3 pm. She already had 15 episodes of seizures. With a GCS of 7-8 and oxygen saturation of 80%, I was quite doubtful of her surviving. To make matters worse, nobody knew her dates. Clinically, she looked about 30 weeks. Ultrasound showed 32 weeks gestational age. The cervix was unfavourable. 

The encouraging aspect was a family who was poor although willing to go the extra mile. One of the male members was off to Daltonganj after the relatives could not find a match among themselves.

Meanwhile, with the patient showing features of deterioration, we had no choice but to go ahead with the surgery. The surgery was uneventful. The baby was of course sick. Dr Johnson did quite a commendable job resuscitating the baby. The patient was on the endotracheal tube till today morning. Now both the mother and baby is doing well. 

But, last week we had a maternal death. AD, a G3P2L2 residing within city limits of our district headquarters, Daltonganj. Both the previous deliveries had occured by Cesarian section. The only problem was that the last delivery was 9 years back. Somewhere she was told that since the surgery was done quite a long time back, she should not have much problem with the present pregnancy. 

The family attempted for a home delivery. She was also given injections to increase the pain. She was taken to the nearest district hospital from where they referred her. She went to a nearby private hospital. All this travel took place in the dead of the night. 

They arrived at NJH early morning 3 AM. She was in shock and with severe anemia. The clinical decision of a rupture uterus was made quite early. One of the relatives donated one pint of blood. As she was in shock, we transfused the blood. However, to operate we needed more blood. 

The relatives were in no position to take the patient further. They sent frantic word to their relatives in town. By the time couple of potential donors arrived, it was too late. Dr Johnson was trying to resuscitate her after she collapsed once again mid-morning. Her frail body did not respond. 

The family was well off. As I talked to the husband while filling the Maternal Death Review forms, he was aghast that nobody had bothered to tell him that she should have undergone a Cesarian section. 

Sometimes I feel that I've forgotten to mention about the umpteen number of babies we lose at NJH due to delay in decision making. 

Last week, we had 3 babies who died for no reason. All of their mothers were attempting deliveries at home for more than 12 hours. Drowned in their own meconium, the babies have hardly any chance of survival.

Well, the icing of the week was 30 year old DD. A G3P2L2, who again had 2 previous Cesarian sections came to us last week with seizures. The best part was that the patient started to have seizures since 7 am and she was at NJH by 12:30 pm. Something we don't commonly see. Her blood pressure was 210/120 and she had a Glasgow Coma Scale of 8-9. We took her up for Cesarian section. And lo, we had twins. Both term . . .  Having had no antenatal check ups, it was a surprise for the family. And a relief to us that the Cesarian section went off uneventfully with the presence of so much risk factors. 

Well, the current week is going to be exciting. We already have 9 students from the MGM Medical College, Jamshedpur and 2 students from Medical College, Gaya on an exposure visit. And today evening (13th November), we have the Founder's Day dinner. Our Founder's Day is on 20th November . . . but considering that we have a local holiday on 13th, we've decided to celebrate it early. 

More on the above 2 things in my next post.