And Primitive Behavior . . .

The second story is that of CC, a 2 month old boy. Similar to BB, CC also was brought in a very serious condition. The baby was small for his age and he was in full blown sepsis. CC was born with a birth weight of 2.3 kilograms and now, after 2 months, he weighed 2.4 kilograms.

We all tried our best to refer CC to a higher centre. CC’s parents were dirt poor. They told that they had some problems at home and therefore it was totally out of question to take him elsewhere.

With the customary high risk consent, we started off treatment. There was no respite for the first 2 days. The baby was listless and was not at all feeding. Both these days we tried our best to ensure that he is taken to a specialist centre.

On the evening of the 2^nd day of admission, his condition looked so bad that the local parish priest went to the parent’s village to convince the village elders to take the baby to a higher centre. He was surprised to find a panchayat in progress with the baby’s father sitting in the centre.

Later, we found out that the panchayat had met following a complaint against the baby’s parents from the grandmother of the baby that she was thrown out of the house and that they were not taking care of her. We also found out that CC’s mother was the second wife and the first wife was also living in the same house. And it was not uncommon for either of the wives to mistreat the other as well as the other’s children.

And to make matters more complicated, there was hardly any hour of the day when the father did not have alcohol running in his veins. In fact, after the panchayat was over, he came to the clinic reeking of alcohol. 

We confronted the father about the problems in his home. There was hardly anything to eat at home. The customary breakfast was boiled corn meal and the dinner was rice gruel. There was no lunch. No lentils (dhal) . . . no vegetables . . . leave alone egg, milk or fish . . .

It was by now very obvious that the family had hardly any resources to take the baby even to a local private clinic. He brought him to us expecting us to give concessionary treatement.

By God’s grace, the child showed some amount of improvement on the third day and by the fourth day, he started to feed.

We’ve written off the entire bill.

Well, this is quite a common story for me since I’ve come to know this region. And from colleagues and friends working in similar situations in many of the EAG states, the situation is no different.

I wonder what does the Mangalyan mission mean to parents of CC and BB and similar families in the rest of the country? 

Maybe, we should have send her home . . .

Couple of days back, we had a very sick pregnant lady being wheeled in.

As DD was wheeled in, we were quite sure that we were dealing with a very sick patient. She had been in labour for more than 4 days. It was very obvious that she had been through a tough time. She was in a terrible shape; all bloated up; the birth canal was so edematous. The baby was obviously dead. The head was so high up and appeared to be stuck. The abdomen had a very abnormal contour which is quite commonly seen with those who sustained a rupture uterus.

There was a high chance that the bowel and the bladder were all ischaemic because of the abdominal massage she had over the last 4 days. There was only a 4-5 centimeter diameter of the birth canal. Even if we tried a craniotomy, there was high chance of severe birth canal injuries. There was also a chance of a rupture uterus.

She was also in severe sepsis.

There was only one thing that we could think about . . . to operate and remove the dead baby. The family were very very poor. They had not even a single rupee to take. They had been to couple of other places. The travel from their home to the various centres and lastly to NJH had taken up all the money they had.

Considering the chance of a rupture uterus and bowel injury, we decided to operate. On hindsight, the decision was a ill thought one. The uterus was not ruptured. But, the lower segment was like mincemeat. Putrefaction had set on the baby. On opening the uterus, there was a gush of pus and foul smelling gases.

The bladder was distended and edematous. So was the bowel. There was no necrosis or ischemia . . . but it was obviously unhealthy to look at.

I somehow closed the uterus and came out of surgery.

She did well for the first 24 hours. Then, her condition just deteriorated. She was running high grade fever round the clock. We had to hook her to the ventilator. There was foul smelling material coming out of the uterus. Her urine output was fine, but it was getting bloody and brownish. Her creatinine is about 6.

Today evening, she is all puffed up.

The costs of the treatment has been on the house. However, we will not be able to give her high end antibiotics like Piperacillin-Tazobactum. We helped the family arrange one pint of blood. We’re quite sure that we would not get any payment for this patient. The family had a RSBY card. We’ve blocked her under the scheme.

Please remember DD in your prayers . . .  

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. 

The fatal massage

The word 'massage' brings into most of our minds scenes of serenity and comfort. Quite a lot of us are quite familiar with traditional massage systems starting from quite complicated massage processes in the Ayurveda for which Kerala is quite famous to the massage you get at the barber's saloon. 

However, in quite a few parts of the country, including ours, there is a process of massaging the uterus just as the pains of childbirth starts. And they also do that when they feel that the gestational age of the baby has gone beyond term. 

The massage ranges from very tender rubs on the gravid tummy with oil to vigorous working up of the abdomen with ones fist extending to even using planks of wood. Even today, the last patient whom I've just seen in the Labour Room has had a massage. 

But, last week, we had a patient who had got the most horrible massage one can imagine. Yes . . . a massage with a plank of wood on her tummy. I had seen quite a few during my earlier stint at NJH. 

We shall call our patient PhD. A 30 year old mother of one, who had crossed her expected date of delivery of her fourth pregnancy came to us 4 days back. Yes, of her earlier three deliveries only one had survived . . . A 7 year old girl. 

All her previous deliveries were at home. And she had taken her fourth delivery as just another chore. But, this did not go as she had thought it will. When she reached NJH, she was already in labour for 48 hours. In addition, she had got quite a lot of massages, culminating in the massage with the plank of wood. 

The process was well evident on her tummy. The angry looking skin was quite obvious. And the uterus was tense. It was like a balloon. Couple of us thought that she had ruptured. The blood tests turned out to be very bad. She was in full blown sepsis (total leucocyte count of more than 30,000) and was anemic. I was sure that she was dehydrated and therefore the hemoglobin was more low than we expected. 

And she had a hand presentation . . .

The only choice she had was to undergo an emergency Cesarian to remove the dead baby and to repair if she had ruptured. My only fear was gangrene of the intestine. We had lost a similar patient couple of years back after she had intestinal ischaemia following massaging of the abdomen. 

We somehow got hold one pint of fresh blood and she went to theatre . . .

We were relieved to find out that she was yet to rupture. But, the lower segment of the uterus was totally battered into a pulp between the endometrium and peritoneum. There was a good chance that the lower segment will not hold well when I deliver the baby. After thinking it out, we decided to put a inverted T incision on the uterus. 

We were glad that we took that decision. As soon as I put a nick on the uterus, there was a gush of putrid gas which gave us quite a tough time. The baby was badly macerated. The surgery was over in an hour. Thankfully, the patient did quite well after surgery. She should be discharged over the next couple of days.  

I've been trying to convince our local community about this totally unscientific practice. Unfortunately, nobody seems to listen. I came to know that the procedure of massaging the abdomen is so much ingrained into the local traditional healthcare of the pregnant woman. 

For PhD, the massage brought in quite a lot of troubles. Her socio-economic situation made things even worse. She was from quite a remote area. When she was brought by the government nurse in her village, none of her relatives were accompanying her. Her husband was a tuberculosis patient. I'm sure that we'll have to write off quite a lot of her bill. 

Another story of one more live saved because of the Lord working through the team at NJH. 

Please scroll down if you're interested in seeing few snaps taken of the lady and her baby. May I warn you that the snaps are very very repulsive. Be warned . . . the snaps are horrible . . .

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Sr. Sushma, our Nurse Anesthetist praying hard before we start the surgery. 

The badly macerated baby

The uterine incision. You can see the vertical portion of the inverted T incision is sutured.
The lower segment was very very unhealthy and we just got the edges opposed.

She need not have died

5 days back, there was a lady who came to us with a history of hand prolapse. We shall called her PDD. The history was quite short. Which of course, was difficult to believe.

The problem was that of severe anemia. Of course, she was in bad sepsis too. Hemoglobin was 5 gm%.

As usual, we referred. And as most of the time, the family did not have much means of going beyond NJH. And the recent fear of draconian laws on blood transfusion ensured that we asked the family to bring blood.

The blood arrived after about 6 hours. This time, the blood was better than what SSD received. And there were 2 pints of this blood. 

The surgery was quite eventful. The baby was quite macerated. The uterus was stinking. We had to put an abdominal drain after the surgery. Quite unusual unless there is a rupture uterus involved. Post-operatively, PDD went into shock . . . most probably secondary to sepsis.

She was in the ventilator for almost 2 days. We prayed that she’ll recover well.

But by yesterday evening, she had become so sick that we had to put her on the ventilator. 

She needed more blood. Her Hemoglobin was still hovering around 5 gm%.

Overnight, she went into refractory shock. She arrested today morning. The mother of two was dead.

I am certain that UDBT (Unbanked Direct Blood Transfusion) would have given her a better quality of life post surgery and a better chance to live.

Anothercase for all those who advocate UDBT . . . at least for places like NJH.