Breathless . . .

Few days back, one of my friends reminded me that I'm yet to post much about patient management at KCH. There have been quite a many . . . but I've been busy . . . 

Today was a significant day for the hospital as we had more than a 200 outpatients (227 to be exact) for the first time in 2015. 

Very similar to one of my first posts when I was at NJH . . . a small account of some critical patients. Though the volume is not yet up to NJH levels, I'm sure all five cases would interest you . . .

5 patients . . . all of them breathless . . . a glimpse into patient care today . . . I'm sure an medicals student would have been overwhelmed . . .

1. AAH, a 70 year old gentleman who had been with us since the last few days. Surprisingly, he had been going from hospital to hospital with a pneumothorax since the last 2 months. And after he came here, he was not allowing us to put a chest tube. The relatives initially told us that if we can give them a guarantee, we could insert a chest tube. I was not very confident considering that his pneumothorax was 2 months old. However, within 48 hours of his admission, he became quite sick that the relatives realised that it may be better to give us a chance. The procedure was uneventful and he is doing well. 

2. BH, a 60 year old gentleman came in with history of fever and cough since the rains 10 days back. He attributed his illness to the wet weather. He was not very much willing to take our diagnosis of a miliary tuberculosis. In fact, he continues to be so sick that he needs regular oxygen. 

3. CH, a 50 year old gentleman came to OPD today. He was in severe pain and was breathless. He had a X-Ray Chest taken 3 days back. There was a effusion. An aspiration showed empyema. The interesting aspect - he wanted to take a second opinion with some doctor he knew before starting treatment here. He promised to return tomorrow.

4. DDH - a 35 year old young man was brought in a confused state, gasping and frothing from the mouth. He had tried to commit suicide by hanging. The relatives had cut down the rope and brought him. He appears to have some amount of brain hypoxia. We've tried our best to refer him for elective ventilation. They are too poor to even afford the vehicle to Varanasi. I wish we had a better ventilator. He's till in the ward. He's a bit better, but, I'm sure that a ventilator would have done him a lot of good. 

5. SH - a 80 year old elderly lady was brought with breathlessness since 2 months. Since 2 days, she developed severe left sided chest pain. An ultrasound showed cholelithiasis as well as a massive pericardial effusion. I wonder how she's still alive. The relatives were given the option of taking her to a higher centre for pericardiocentesis. They've left after quite a long discussion on further course of action. I've a feeling that most probably, she would be brought back to us in a couple of days. 

I'm sure many will ask on how to help out . . . 

Well, 227 with 3 doctors (one Junior doctor, one Clinical Pathologist and one Community Health Physician) and one nurse practitioner is no small work. I wish we had more experienced hands to help out. 

And of course, some more equipment in the ward . . . the immediate need - couple of more multipara monitors and couple of ventilators . . .

More of that sometime later . . . 

100 days at NJH

This is a guest blog from our Physician at NJH. She responded to my request for a post after she completed 100 days of selfless service at NJH. We had been praying for her for quite a long time and it was a dream come true for me when she joined NJH. 

Dr. Roshine Mary Koshy completed her graduation and post-graduation in Internal Medical from the Christian Medical College, Vellore. She hails from Kerala and was a topper in the State MBBS Entrance Examinations. Her father, Rev. George Koshy pastors the Marthoma Church, Krishnarajapuram, Bangalore. I hope her former school mates from the Marthoma Residential School, Tiruvalla and Mathews Mar Athanasius School, Chengannur will appreciate her work. 

After her graduation she had also served at Marthoma Hospital, Chungathara and the Fellowship Hospital, Kumbanad. 

Over 3 months into working as a consultant physician in NJH has been an eye opener for me. This write up is an attempt on my part, as someone new in this field, to share my experiences and observations/musings over the past 3 months in the hope that anyone who might be interested in getting involved in improving health care in North India might have something to ponder about and those who intend to be spectators might want to take a closer look.

I feel that a great challenge as a health care provider is being able to identify the population with greatest need and to constantly focus on allocating all available resources within our constraints for their benefit. Just a few months experience and I know this is easier said than done.

Who are the poor that this hospital takes care of?  It is a heterogeneous group and the two distinctions I make are purely based on my observations as I care my patients and talk to their families in a hospital setting.

There are the real poor. They are hardly seen in the hospital because the hospital is their last resort to which they often don’t reach on time. But I remember a few of them who did come to us. They come really sick, treated by traditional healers, wanting their loved one’s life saved. If I were to tell them the critical condition of the patient and paint the obvious bleak outcome, they would rather take the patient home than get treated. But if they do decide to get treated and the patient gets relatively well in a day or two, they want to be discharged immediately because they can’t bear the expenses of the remaining days. They get better, go home very happy and never beg for charity.

I learnt this the hard way. 8 year old Reena came to us with GTCS for almost half an hour. There were no beds in the ICU. We controlled her seizures and I explained that they would need to take her to a higher centre. It seemed reasonable enough to me. It never dawned on me that the nearest higher center is Ranchi, a 5 hr journey with an expense of 6000 Rs if the family makes it both ways with additional expenses in Ranchi. I was happy to see them arranging a vehicle with the referral letter in hand. I am grateful for one of my colleagues who happened to notice the scene and told me that they were taking the child home. It took only a little extra effort to arrange a bed and manage her medical problems. She turned out to have TB meningitis, developed partial lateral rectus palsy while in the ward which resolved with treatment and she went home a happy little girl.

The thought that if this health service had not been available for her, that she would not have lived was a hard truth for me to swallow. After seeing the health status of the poor here, having been able to save a life does not appear heroic to me. It just speaks volumes of the complacency of my profession in fulfilling its solemn duty to society.

The not so poor patients, I have grouped together because though their socio economic status varies, they have something in common. Their health issues have not been properly evaluated; they have been extensively and unnecessarily investigated and treated. I find this to be one of the greatest challenges while working in this part of the country, the fact that the practice of medicine is not a science but a trade. I sensed it during my first month when my patients were very offended because i seemed to be ‘probing’ into the history of their clinical complaints. Listening to their history and examining them before ordering an investigation was unusual. It was more frustrating to me when healthy patients came asking purely for investigations because they wanted to confirm if they had ‘typhoid’. 

Working in a rural area and ensuring that the practice of medicine is both science and art is challenging but extremely rewarding. I am grateful for my training in the Christian Medical College, Vellore, for the privilege of being mentored by excellent clinicians. For those young doctors who think that working in a secondary set up in a rural area is dull, I thought I would just give you a list of a few of the medical problems that we encountered in the past 3 months.

Snake bites both poisonous and non-poisonous, Organophosphorus poisonings, meninigitis, strokes, tetanus, neurocysticercosis, pneumothorax, staphylococcus empyema, rheumatic heart diseases, tuberculosis, connective tissue disorders, apart from malaria, rickettsial infections and the like. Being able to clinically diagnose them with basic supporting investigations and manage them is very satisfying. As for scope for improvement, the area of critical care has great potential in our area and we are focusing on it.

Working in rural areas which have been neglected and among communities that have often been exploited can be very frustrating because good intentions can be looked upon with suspicion and appreciation for the work that one does is often hard to come by. The advice that my colleague gave me is something worth contemplating and I end my ramblings with the wise words of Oswald Chambers.

“If we are devoted to the cause of humanity, we shall soon be crushed and broken hearted, for we shall often meet with more ingratitude from men than we would from a dog; but if our motive is to love God; no ingratitude can hinder us from serving our fellow men”.