Referral well made

It is quite common to see public healthcare facilities being given regular bashing in the media and our regular conversations. 

However, yesterday, I had a very encouraging experience when one patient was referred to us at the opportune time before she went into a complication. 

Although the indication for referral was a bit different, I was impressed that the person who wrote this referral letter timely identified that the patient needs to be referred. 

The staff at this PHC had diagnosed obstructed labour. However, on examination, we found out that there was third degree cephalopelvic disproportion although it had not into the stage of an obstructed labour. The delivery would have become badly obstructed if the delivery was allowed to progress. 

Please join me in acknowledging and applauding this unknown staff in a remote Primary Health Centre of Palamu district. 

Glimpses of possibilities

Yesterday, Titus called me to say that they ran out of ventilators for patients. 

There were 4 patients who needed a ventilator at the same time. And with the the nearest ventilator 80 miles away, there was no other choice than to manually ventilate using a bag.  

Patient A, a 25 year old lady who came with unknown poisoning. She came with seizures and later had a respiratory arrest. She was on the ventilator for almost a day before she was weaned out.

Patient B, a 17 year old young man with organophosphorus poisoning. He was gasping when he came in. He  obviously took the second ventilator. 

Patient C, a 48 year old man who came in with a krait bite. In spite of being started on a high dose ASV, he went into respiratory arrest. When Mr. C came in, B and C were already in the ventilator. Mr. C was manually bagged for around 12 hours, when we felt that Patient A could be weaned out. 

Patient D, a 9 year old girl who came in gasping after a krait bite. She was intubated immediately and was bagged till Mr. B was out of the ventilator. 

Then, there was a patient E, a 12 year old girl who was rushed in from the local village after a krait bite. We gave her an option to go to a higher centre. They have rushed her to Ranchi. 

We did not have a bag to ventilate her if she had a respiratory arrest. Even, we were not sure of starting ASV as we did not have a bag to ventilate (2 patients were being manually ventilated) if she had an anaphylaxis. 

Such a situation puts us in a position where we need to seriously ask questions about expanding our resources - - both in terms of infrastructure and qualified personnel. 

To start off things, we eagerly wait for Dr. Roshine, the medicine consultant who'll join us on the 22nd, the coming Saturday. 

The second story . . .

This is the second story mentioned in my previous post.

It was a busy day . . . Dr Nandamani came to my office and requested me to see a young girl from the nearby village who has been diagnosed elsewhere to have leukaemia. 

About an hour later, I reached the outpatient department. I knew the family. We had treated the girl's father about a year back and since it was a difficult case, I remembered him. The girl was along with her mother. 

The first diagnosis was arrived at a hospital in Ranchi. The diagnosis was a wrong one . . . not the correct type of leukaemia. The diagnosis changed after the family was sent to a premier institution elsewhere. An institute which should have all the latest technologies available. 

The strange fact was that in spite of this girl been seen in this 'premier institute' all her blood tests were sent to private laboratories who had charged exorbitantly. One visit to this city has drained the family of whatever resources they had. 

The doctors told them that the total costs of chemotherapy would be approximately 350,000 INR. They have got letters from the hospital as well as the local Member of Parliament for the Prime Minister's relief fund. They can start the treatment only after a letter releasing the money comes. 

When I saw her at the hospital, she had a hemoglobin of 2 gm%. We transfused blood . . . That was the best  we could do for her. 

Again, I realised that we knew better places where she would have been better taken care of. A wrong supposition that a premier government institute could treat the patient completely has ruined the family. 

Of course, you can say that it is a failure of the system that the 'premier institute' do not have all the necessary facilities to manage a condition like leukaemia. But, we know quite well now about where good treatment facilities are available or not available. 

The family would have done better if they had received the correct information . . . or the 'premier institution' had the necessary laboratory facilities. 

Again a lack of care and commitment from the healthcare community . . . 

Referrals . . .And a need . . .

One of the best parts I learnt from one of my professors, Dr Joy Philip at Trivandrum Medical College was to write proper referral letters. During the college days, it used to be letters back to doctors who used to send patients for tertiary care to the Medical College OPDs and casualty.

I took this practice to heart and insisted that my colleagues write proper referral letters whenever a patient was being sent for a second opinion and even when a patient asked for a referral to a higher centre. It has served me good - when many a consultant has called us back and told us how they appreciated the well written referral letter.

Well, today we had a patient from one of the nearby hospitals. SDe, a first time pregnant lady at term was brought by her family with a history of convulsions since yesterday night. The patient was very very sick. We could not get a fetal heart sound and the patient was in obvious pulmonary edema, bringing out frothy pink colored sputum. The blood pressure was 170/130 and non-responsive to any medication.

And she was desaturating fast with shallow breathing. We got her hooked into the older ventilator. It was then I noticed that the patient was not maintaining saturation - but was maintaining good saturation with manual bagging. However, it was encouraging to notice that the family members readily volunteered to do it as well as did not complain.

I got our engineer and what he found out was heartbreaking. The collapsible corrugated rubber bag was irreparably damaged. I could only watch helplessly as Dinesh displayed it. Someone had promised help to purchase couple of new ventilators, but the finances have not come through and the prospective donors have also not been much forthcoming when we contacted them recently.

We had to get the dead baby out fast. Cesarian section was the only option to give some chance for SDe to survive. With the customary high risk consent including a risk for the chance of a 'death on the table', I went ahead with the surgery. We were blessed that the family understood that they had to allow us to be pro-active with the management.

The surgery went off smooth - it was terrible to find out that the baby was a fresh still born. Maybe if the family had straightaway brought SDe to NJH without going elsewhere, we may have got a live baby. But, then SDe also started having problems. Her blood pressure was varying from nil to 180/140. And she was putting off pink colored froth. The breathing effort was terrible. It was obvious that she would need ventilation.

We got the new ventilator which is only used along with the Boyle's machine along with the patient to the ward. We had to put her on a GTN drip to manage her pulmonary edema - but then she went into shock - for which we had to start her later on a Dopamine drip. We spent almost close to 6 hours managing SDe.

Please pray that SDe will make it. She is on ventilator and on ionotropes.

And we need a new ventilator. We could do with a copy of our older model or even better the newer model which is twice more expensive than the older model. We would actually prefer to have two more ventilators.

Coming back to referrals, I just wanted to put the piece of paper which I recieved as referral from the previous hospital that SDe was in. It is pathetic.

But, when I told about it to one of my colleagues, he told me that I was lucky that I have a piece of paper with the names of the medicines given so far. Yes, he is true - most of the time, we have no clue on what has been given in the previous hospital.

And please do remember the need for couple of new ventilators and for prayers for SDe to pull through . . .