Ending 2013

We had amazing last few hours in the labour room on December 31, 2013.

3 patients . . . and they made our day.

All of them very very high risk patients who should have gone on to a tertiary centre. All of them poor and . . . coming here just because they could not afford a trip to Ranchi. They trusted us . . . wrote the high risk papers . . . we could only pray . . . and the Lord gave them deliverance and healthy live babies.

The first one, JB, who had come around noon-time. She was one of our regular ante-natal care patients. We had told the family that it would be good to have her delivery in Ranchi. The reason – she had lost her first baby. But, the family could just not afford to go ahead. To make matters difficult during admission she had couple of high blood pressure readings. Thankfully, the BP stayed normal after admission. She responded well to induction and delivered a girl baby just before the clock chimed 12 midnight.

The second one, SD had all of us in tenterhooks for quite some time. SD had lost both her babies the previous time and the family did not seem it worth to get her a regular antenatal care when she was pregnant a third time. And both the previous pregnancies had delivered by Cesarian section elsewhere. A G3P2D2L0 with both previous Cesarians. The only saving grace was that her haemoglobin was 11 gms%. After the customary high risk papers were signed, we sent off the relatives for one pint of blood. I took a decision to operate only if I’ve a pint of blood. We’ve had previous experiences of patients bleeding heavily when they’ve had a Cesarian elsewhere.

To our horror, SD went into full fledged labour pains. She had terrible lower segment tenderness. We decided to take her for Cesarian without the blood having arrived. We were afraid that she would rupture. To our surprise, we found that she had dilated fully by the time we took her to theatre and to cut the story short, she delivered normally. The baby and the mother are doing fine.

The third one, TB came from another centre after she was referred for pre-term labour. We found out that she was in fact term. But, there were issues. Her haemoglobin was only 7 gm% and she was in sepsis. She had been leaking for almost 48 hours which the family had ignored. She also progressed so fast that the baby was delivered normally and the mother has done well so far.

It was so satisfying to finish the year having been part of the management of these three ladies all of whom had come to us expecting a miracle.

We thank the Lord for using us to be a blessing to these families. 

Tale of 2 ladies . . . and a third one

(This post was done on Monday, 7^th October, 2013. Our internet connections are back to a very poor state of affairs. With Supercyclone Phailin on the way and the Dussehra festivities on, it looks a remote possibility that we would have fast internet connections for the next week too)

My yesterday’s Sunday duty (6^th October, 2013) was quite a light one. There were only 2 women in the labour room throughout the day. One of them was rich and the other poor.

However, both of them shared the characteristic that they were not taken very seriously by their families. The reason? Both of them were high risk pregnancies. And neither of the families was bothered about it.

The first one RD, was quite well off. This was her second pregnancy. The first one was quite an eventful one. She had severe pre-eclampsia and she had delivered a pre-term small for gestational age baby. She had come four times for antenatal care of her second pregnancy. 

Each time, she was told to come more often so that we could ensure that we make an early diagnosis of any high blood pressure. The first 3 visits were in the first and second trimester. 

Her last visit was 3 days back. She was almost nearing term and she had a blood pressure of 150/100 mm Hg. We had advised admission.

She went off home and came today after she started to contract. The blood pressure remained high. I just received news that she delivered.

I would say that her family should have been more careful with her treatment. They’ve got away with very lazy approach to her present pregnancy.

The next patient, SD was not that well off. Her blood group was O negative and her last haemoglobin was 8.5 gm%. We had seen her in outpatient more than a month back. The doctor who had seen her had well explained need for blood as well as absence of a blood bank in NJH. Of course, the difficulty of getting a O negative donor was also put across well.

The patient came in labour. There was no sign of arranging for any blood. Rather couple of male relatives vent their anger at us for not telling them things early.

SD was lucky. Being her second delivery, she progressed so fast that she delivered soon. Gladly, there was not much blood loss. The mother and baby are doing well.

Again, one more case which could have gone awry.

Well, there was a third lady too. She was not that lucky. I hope things will turn out well for her in the couple of days.

This was her 5^th pregnancy. We’ll call her CD. She has only 2 live children . . . both girls. 2 of her babies had died. The urge to have a boy child resulted in this pregnancy.

I’m not sure about her regular antenatal care. But, the relatives told me that she was not doing well since the last 3 days. And she is just into her 8^th month of pregnancy.

Her complaints . . . headache and blurred vision. They had gone to 4 hospitals over the last 3 days. In fact, they returned home after a circuit of hospital visits only on Friday evening. She was given a clean chit everywhere.

Today morning around 9 am, CD had multiple episode of seizures. The family rushed her to a hospital in the nearest town. The doctor told the family that she is very sick and only NJH can do anything. The reached around 2 pm.

Blood pressure was 210/140 mm Hg and Urine Albumin was 4+. The family had lost count of the number of seizures she had. In fact, when I reached to see CD in labour room, she was continuously seizuring.

She has not yet gone into a HELLP Syndrome. But, she is very sick. We’ve induced her. Please pray that she will deliver soon.

The first two cases were outright instances of ignorant and careless family members.

But, what about the third case? The medical fraternity had failed her. A typical complaint of pregnancy induced hypertension, headache and blurred vision, was totally ignored. The shocker. . . 

The family was very sure that nobody in the four hospitals had checked her blood pressure!!!

I have only one prescription in my hand. There is no measured reading of any blood pressure.

How long will we tolerate this sort of management?

PS: CD delivered the next day (8^th Oct, 2013). She got discharged couple of days back. 

Complicated . . .

Yesterday night, we had a very obviously sick obstetric patient wheeled into the labour room.

SSD looked quite old for an 18 year old lady. She was all puffed up. The blood pressure was quite high. And she was quite breathless.

The history was very vague. The only aspect I could latch onto was that she had a blood transfusion at Daltonganj. The outside investigations showed haemoglobin of 8 gm%. Urine albumin showed 2+.

On clinical examination, it was obvious that she was into early cardiac failure. I was left wondering about her cause of cardiac failure. It was good that we have a Medicine consultant now. As usual Dr. Roshine was quick to arrive and assess the patient.

It seems that SSD was always breathless since her childhood. Dr. Roshine suspected valvular heart disease.

The investigations in the morning confirmed our diagnosis.

The management was easy now. Refer . . . refer . . . refer. Of course, she needed more evaluation.

Pregnancy in its last leg . . . with pre-eclampsia . . . valvular heart disease, most probably a mitral stenosis with regurgitation . . . there were features of pulmonary hypertension too . . . would have been the most critical patient in a high risk obstetric care set-up.

But, the relatives were quite certain that NJH was the best they could provide for SSD. Travel beyond NJH was something that they could not fathom. The problem was the necessary finances.. .. .. there was a fear of the big hospitals and the funds needed.

I tried all the tricks in my bag to somehow refer them . . .

Nothing worked . . .

We request prayers as we manage SSD.

As I mention about SSD, I also would like to put a word for help we would appreciate in the month of October and December. Quite a few of our doctor colleagues will be on leave. It would be a good opportunity for new graduates in medicine to have a feel of work at NJH.

Especially for those who dream to do a post-graduation in Internal Medicine . . . All the more when Dr. Roshine is around. But, more about that, in another of my posts.