Gas . . . Gas . . . and Gas

Three days back, we had a elderly lady being brought. Carried in her son's arms, she was worn out and thin with a protruding abdomen. Clearly a case of ascites or a large abdominal tumour. 

Since it was close to afternoon, I did a quick examination and sent her off for a 30 kilometer journey for an ultrasound abdomen. 

She was back just before sunset with the ultrasound report. It was just ascites. No tumour. There was mention of a possibility of a chronic liver disease.

That was when I took a detailed history. She had been having this much abdominal distension since the last 1 month. She had already been treated at multiple places and had spent almost 15000 INR. It was not that they could afford that much. That was what the quacks demanded for the treatment. 

The quacks had been telling the family since the first day that it was just gas that is pent up in the intestines. They even had a X-Ray abdomen to prove the point. 

She had not yet been seen by a proper doctor. 

I got into a mini-conference with two of her male relatives and told of the possibilities. They wanted me to give her some medicines to dry out the fluid collection. They did not want an ascitic tap to take out the fluid and do some tests. The only test we could do was a microscopic examination. Under no circumstances, they were ready to take her ahead for treatment. 

She did not respond to the diuretics that I tried. Ultimately, they agreed for a tap with the fiat that whatever tests I had to do with it has to be done here. They just did not want to take her nor the fluid ahead for any tests. 

I did the tap today. It was a hemorrhagic tap. Microscopy showed almost 99% lymphocytes along with the red blood cells. It was more in favour of a cancer. Well, it could be tuberculosis too. Liver function tests were all normal. 

The best I could do for her was to start her off on anti-tuberculous medication and send her home. 

But, it would have been better if she came straight to us before they blew up 15000 INR for the quacks to remove the gas . . . 

The big question is how I can enable families like these to see us as their first choice for access to healthcare . . . rather than these quacks . . . 

Immuno-compromised by Malnutrition

One of my favorite quotes is that by William Osler about the usage of medicine.

Unfortunately, almost all of us believe that medicines are the elixir of life. And when we take medicines, we want quick relief. Almost all over the country, quacks and non-qualified practioners have thrived on this and one of the major challenges in the healthcare scenario of the country is the unbridled use of medicines especially antibiotics and steroids. Of course, the pharmaceutical industry all the more promotes such usage. 

And as doctors we fail to understand the inherent nature of the body to heal itself, which is very evident by the way many of us prescribe medicines.

This becomes a major issue in poor and marginalized communities of the world as it is quite a fashionable thing to resort to medicines and injections and get well. A very dangerous trend when we look at the fact that issues of sanitation and nutrition are hardly given any serious thought.

I personally believe that in India, malnutrition is the most serious form of immune-compromised state. As medical students, we were trained to think of only HIV patients and patients on immune-suppressive medicines to be immunosuppressed. I hope to see a change in the attitude that many of our medical colleges have towards malnutrition. We don’t see many HIV patients or patients on immunosuppressive medicine, but we see so many malnourished.

In Barwadih, the population of which comprises mainly on permanent residents of the Kherwar tribe and a migrant population of people from Bihar and Munda tribals from the Ranchi plateau, we are stunned by the amount of malnutrition we see. We did a rough survey of children who come to us and it was quite alarming to find that almost 70-80% of under-fives who come to us are at least moderately malnourished. I’m sure the situation would be worse if we do a community based survey.

And I dream to do a community based survey to highlight the gravity of the problem in hard-to-reach areas. I’m sure that there are going to many determinants of this health issue which could be different from other regions.

The challenge is to find long term solutions especially in a situation where more than half of the nation’s under fives are malnourished. 

Judge for yourselves . . .

I just returned after a workshop on 'Snake Bite' held at the Christian Medical College, Vellore. 

I wish I got some rest. Alas . . . that was not the case . . . 

About couple of hours after I got into the NJH campus, there was a lady who was into her fourth pregnancy and at term. She had started to contract from sometime late afternoon.

The family had called a doctor to help out with the delivery. 

After the injections, she had very severe pain. However, things did not proceed as they wanted to. And she started to bleed heavily . . .The doctor also referred them to NJH.

And the injections . . . the doctor concerned had given a well written prescription . . .

Below are the portions of the prescription blown up . . . 

We did an ultrasound . . . The baby was already dead. And the placenta was separated . . . the cause of her bleeding. She has suprapubic tenderness. I wonder if she had ruptured with the amount of overdose of oxytocin she received. 

We wait for blood investigations . . . Do pray that we would intervene without much complications . . .

And of course . . . would appreciate comments on the prescription.

Sad stories . . .

It has been a very unusual Wednesday so far .. .. .. 3 cases within 6 hours which tells you a whole lot about the condition of healthcare in most parts of our great country . . . 

I had just walked into office when one of the local villagers brought a very sick looking girl into casualty. The 9 year old girl had been sick for the last 15 days with fever. The local village quack was managing her . . . with herbs and roots. 

Yesterday, she became unconscious. And the family did not know what to do till one of the neighbours told them to rush the girl to us. 

She was all yellowed up. And only a sigh of her breathing told us that she was alive. GCS of 3/15. Her serum bilirubin was a whopping 28 mg%. We are still not sure of what we are dealing with. 

So sick and they did not even think it worthwhile to show her to a proper doctor. 

Well, you'll realise what use is it many a time even if you show to a regular doctor. 

Just couple of hours after the above patient came in, a young lady was wheeled into emergency. She was dead. It did not need much of a history for Dr Johnson to make a diagnosis. 

Mother of a little girl who just turned two yesterday, she experienced severe abdominal pain at 3 AM today early morning. She had missed her periods by 2 months. 

She had visited 4 very good doctors over the 6 hour period she had spend in our nearby town. All big, big names in clinical practice. Anafortan . . . fortwin-phenergan . . . these were the drugs she recieved. 

Nobody could think about a ruptured ectopic. We took permission for a undocumented ultrasound and the results were there. It was a ruptured ectopic. 

It was unthinkable .. .. .. A young mother who celebrated her daughter's birthday less than 24 hours back lay dead in front of us. 

The last case was another young lady my colleague saw in outpatient almost the same time. A very obvious case of enteric fever . . . She has received about 20 different types of medicines from 2 quacks and 1 qualified doctor. All of them has nothing to do with enteric fever. 

One cannot blame a patient who goes to a quack if he fails to get a clear communication and evidence based treatment from a doctor who has a recognised medical qualification . . . 

Time we look seriously into medical training in India . . . 

Degrees, degrees everywhere . . . but . . .

Not an uncommon sight in many parts of India. 

Doctors with multiple degrees . . . however, none of them after MBBS could be googled.

And they flourish . . . at the expense of evidence based medicine and common sense.

To make matters worse, the government wants to have specialists all over the place . . . in fact, wants only obstetricians and paediatricians to be around when a mother delivers a baby . . .

But, they won't mind all such doctors who freely flaunt all these non nonsensical degrees. . .  

Another opportunity for a plea to take the speciality of Family Medicine seriously . . .

Mismanaged Diarrhoea . . . How quacks do it . . .

Yesterday, I had a post on how medical school educated graduates manage diarrhoea. 

Today, in outpatient, I had a 18 month old child who was being managed by a quack . . .  And below is the snap of the medicines, he has been on. 

And this is his prescription . . . 

For those who could not understand the writing - 

1. Ondansetron Syrup

2. Dexamethasone Injection

3. Ofloxacin plus Ornidazole Suspension

4. Ceftriaxone Injection

5. Aristozyme digestive enzymes. 

The parents claimed that the baby was also prescribed Oral Rehydration Solution . . . But, there was no sachet to be seen . . . They claim that the baby was initially better, but later started to have diarrhoea and vomiting since last night. 

And the most interesting aspect . . . Similar to yesterday's patient, this young boy weighed 6 kilograms . . . instead of at least 10 kilograms which a healthy child of this age should have. 

Pharmaceuticals - The Paradoxes in Indian Healthcare . . . Part 1

We are all well aware of how sick our system of healthcare is. While for the rich and the famous, it is nothing much of a major concern . . . for the middle class and the poor, healthcare is a major issue of concern.

However, what concerns me are reasons for the government being only hardly bothered about what sort of healthcare the common man has access to. One on side, we are proud of how good we are with tertiary care and we are looked upon as one of the major spots for health-tourism. We have states such as Tamil Nadu who are looking at up scaling of cadaver organ donation whereas on the other side, we've states where something as basic as availability of blood is a major issue.


I'm a bit concerned about the sort of media attention that issues such as cadaver organ donation, celebrity health issues garner compared to the status of basic public health care in the country. One issue which has been sort of been ignored is the state of tuberculosis in the country. I've taken up the issue many a time in my blog.

Well, you may say that we have the Revised National Tuberculosis Control Programme, a world award winning public health program which has won accolades at many a venue.

I take the issue of Tuberculosis today on account of one patient whom Titus saw in Outpatient today.

SDS was a unmarried 26 year old man who hailed from a village within 10 kms of our hospital. Hailing from a rich family, SD had been diagnosed to have Type 1 Diabetes Mellitus 7 years back. Then he had been diagnosed to have tuberculosis about 4 years back.

The sad aspect was that he did not access the free government tuberculosis drugs. He had quite a large file of his medicine prescriptions. It was quite a sad array of paper work he carried around.

Initially, he was started off only with Rifampicin and Isoniazid. Nobody was there to monitor his treatment. He took medicines for about 2 months and he left treatment when he started to feel better. Then, he became sick again. He went elsewhere and was started on medications again . . .

Unfortunately, by early 2010, someone had sent his sputum for culture testing. Below is the report.

But, I was in for a shock when I saw the prescription from the 'tuberculosis specialist'. All protocols of Multidrug Resistant Tuberculosis was thrown to the wind. It's more than 30 months. He's still on treatment.

And the worst shocker of all . . . He never had a sputum AFB done. . . of course, there was a sputum culture done about 2 years after the first diagnosis.

Well, you could blame SDS for not taking interest in the government run RNTCP programme.

But, I wonder why anti-TB drugs of all combinations and dosages are available in the open market when there is a government run programme to combat tuberculosis.

To make matters worse, there are quite a large majority of doctors who openly tell their patients that government medicines are of no good. SDS was told the same thing by every doctor whom he accessed for treatment.

Recently, the government has come out with an order on generic drugs. The pharmaceutical industry has already launched an all out cold war against this. They have even invented a term for generic drugs - 'unethical drugs'. And the branded drugs are called 'Ethical drugs'. So much to educate the common man on the terminologies of drugs.

Well, it was quite incidental that I came to find out that there is no Iron tablets in the Primary Health Centres around our place. But, Iron capsules are available in the Pharmacy shops and they were doing great business. Even, we are doing great business with Iron capsules. I remember that during my stint elsewhere in the South, the Medical Representatives were all out 'educating' us on how unpalatable the Iron tablets are compared to their 'double coated chocolate flavoured' and of course expensive Iron capsules.

SDS is most probably going to pay for his ignorance of the existence of a government scheme which would have monitored his drug compliance and disease progression. Now, he is getting a MDRTB treatment protocol which is totally out of line from what he should be getting.

I'm sure that this is part of the influence of private players who are very well aware of the inexhaustible gold mine of profits made in the name of healthcare. It is sad that the government is not realising the folly it is in by allowing such a back-door entry for private players in healthcare. The influence looks subtle, but the consequences are going to be disastrous for the common man.

The government order on making generic drugs freely available is a decision in the right direction. I was quite encouraged to see the 'Generic drug store' in the Latehar district hospital during a recent visit. I'm sure that the private drug companies and retailers would go on an all out war against it, at least indirectly if not directly. More initiatives such as these are necessary if the common man has to regain his confidence on public healthcare.

However, it is going to be quite a long journey for all of us who are mooting for a full fledged robust public healthcare. The question is how many of us are going to continue fighting to see a day when that happens.