The big killer . . .

Come spring, and we have quite a spurt in the number of patients with respiratory diseases. And quite a good number of them would be tuberculosis patients . . . A selection of cases .. .. ..

The first one, a young lady who has been on and off treatment. The first 3 X-Rays here are her's taken over one year. It's very obvious that the second film is a bit better than the first one . . . but that was when she had stopped treatment after she was feeling better after about a month of treatment. Then, she was quite sick after the winter. And the third X-Ray was taken after that.

The next one is that of a middle aged lady who also has been on irregular treatment. 

The one below is that of a young man, who had been sick for about 5 months now. He had stopped tuberculosis treatment after 2 months as he was feeling better. Now, he has about one third of his total lung left. 

And the final one- A 10 year old who has been sick for almost 1 year. He has been sick on and off. The main finding . . . he weighs a measly 15 kilograms. 

The common links between all the 4 patients . . .

All of them are poor and there is a major issue with food security in all the four families. 

I've written quite a lot of poor nutrition last year. As the number of poor patients who access our facility increase, the strong association between poor nutrition and disease is very much evident. 

We've focussed quite a lot on Human Immunodeficiency Syndrome which is a cause of an immuno-compromised state (all 4 patients are HIV Negative). I wonder how long will it take for healthcare providers and policy makers to understand that the most common cause of an immuno-compromised state is M A L N U T R I T I O N . 

Obstetric care . . . The stories continue . . .

It has been quite some time since I posted a post on obstetric care at NJH. After the empanelment of NJH into RSBY, it has been quite busy. Today morning, as I visited NICU, I was surprised to find a baby wailing and quite hungry. The reason I was surprised. Couple of days back, we had delivered this little fellow and we had hardly any hope that he would make it. The story of LD’s mother will mirror the stories that I’ve been sharing through this blog over the last 8 months.

LD’s mother as well as SD, about whom I shall share in the latter part of this post comes from Garhwa, the western most district of Jharkhand. It is one of the most impoverished regions in the entire country with stories of hunger and exploitation quite common but hidden from the rest of the world. As part of the overall backwardness of the district, the health services are also very poor. Due to some reason, almost 80% of our complicated patients especially in obstetrics come from this district.

LD was pregnant for the first time. She had couple of antenatal check ups from Daltonganj which is the district headquarters of Palamu, Garhwa’s neighbouring district. She even had an ultrasound scan sometime in the 32nd week saying that the baby has an abnormal lie. However, her family claims that she had a check-up at some place couple of weeks before where she was told that the baby has come into the normal position.

LD came to us late night on 26th March. She had started contracting sometime around the evening of 25th and her membranes had broken sometime early morning of the 26th. When she did not deliver by late morning, she was taken to the nearest health centre from where she was referred to Daltoganj. However, they came to NJH straightaway. She was told that the baby is coming legs first.

I saw the patient as soon as I had finished a Cesarian section on SD. The first thing I noticed was how small her abdomen looked. On per vaginal examination, it was obvious that the baby’s shoulder had presented and the hand was on its’ way to slip out. I had to do a Cesarian immediately.

The best part was that on Cesarian section, it was obvious that she had received umpteen number of oxytocin injections. It was already tonically contracted over the baby and there was hardly a drop of liquor. I feared the worst with a compound presentation. The head and the torso was folded over each other with the back presenting at the site of the uterine incision. I had to ultimately end up putting an inverted T incision on the uterus.

On delivery, the baby was flaccid like a rag doll. There was no pulsation of the cord. Only the heartbeat was there. I was sad . . . we were going to end up with a dead baby after a LSCS. Dr. Titus was there for the resuscitation. He went through the motions of resuscitation, thanks to the classes from Wendy of Grace Babies. After about 5 minutes, there was a whimper and then a small cry . . . By the time, I closed the skin, the baby was wailing. However, there was grunting and I had asked the relatives to take him to a higher centre.

It was good to see the baby live and healthy after such an uncertain and dangerous period. Which, could have been avoided. That’s my point. Home deliveries are such a bane to the developing world. More so in countries such as India where there is no skilled birth attendants. However, even when there is a skilled birth attendant, I’m sure that a home delivery is such a dangerous thing. Many of you may be quite aware of a growing following of people who promote home deliveries, even in the west!!! Recently, I came across people writing about this.

Well, one should realise that the most common causes of maternal mortality and death are complications like excessive bleeding, obstructed labour, infections for which nothing can be done in a home delivery. Few months back, one of my friends lost his wife in a delivery done at in a small hospital in a big city. She developed a complication for which there was nothing available in that hospital. . . not even a laryngoscope for intubation or ambu-bag to mechanically ventilate. You can imagine the predicament if it was a home delivery.

The patient, SD on whom I had done the Cesarian section before LD had arrived was more terrible. She was 140 cms tall and had a Cesarian for her first delivery. She had been having contractions since early morning of the 25th, leaking since 25th evening…she had been trying to deliver at home and ultimately came to us sometime on 26th evening when nothing much was happening. To make matters worse, she had seen one of the best obstetricians in town and in her prescription, it was clearly written that the next pregnancy would be an Elective Cesarian and one pint of blood would need to be arranged.

I was thankful that SD’s Cesarian section went off uneventful. It was quite surprising that even after so many risk factors present in this patient, the relatives were quite careless as there was no blood arranged and we took quite a long time to convince the relatives of the need of a Cesarian section.

She could have died of a rupture uterus any time.

Talking of maternal deaths, I just remembered about someone making a statement sometime that one of the most common causes of female deaths of the reproductive age group in developing countries is tuberculosis. I remembered it because we’ve a 30 year old mother of five in acute care, who has come to us with one of the most terrible Chest X-Rays I have seen recently. She can hardly lie down as she is quite breathless and has a saturation of only 70% even with oxygen in full flow… The snap below is that of her X-Ray . . . 24th March was World TB Day, which we celebrated in the district. A post on that later . . .

Tuberculosis - Are we winning the war?

The two X-Rays shown below are of two ladies – the one on the left is that a very young lady, MD with a 2 year old child and the one on the right is that of an elderly lady, LD with adult children.

Both these ladies came in during the later hours of Saturday evening. They must have come in as the OPD was closing. It was very evident from both the histories that they have tuberculosis. The reason we took the X-rays was because I was unsure of how much healthy lung tissue they had left. I’ve already started them on anti-tubercular treatment without waiting for a sputum test as the sputum test will happen only on Monday morning.

The RNTCP higher-ups have been going gaga about the success that RNTCP (Revised National Tuberculosis Control Programme – www.tbcindia.org ) has achieved in bringing tuberculosis under control. RNTCP is a highly acclaimed programme run by the Government of India aimed at the control of tuberculosis in the country. Quite a lot of clinicians have many misgivings about the programme – but that is another story.

NJH has been partnering in implementing RNTCP since its inception – as a Microscopic Centre catering to a population of 100,000 since 2001 and as a Tuberculosis Unit since 2006.

I need to say this – we have been having an increase in the number of patients whom we are diagnosing tuberculosis over the last 2 weeks. Even as I write this (10:40 pm), I’ve a patient who’s just come in and it looks like tuberculosis. I’ve 4 patients in the inpatient wing waiting for sputum AFB tomorrow morning. We’ve had quite a number of patients over the last week who had been diagnosed as malaria or enteric fever outside and we came to a diagnosis of tuberculosis – and they’ve improved after Anti-tuberculosis treatment. Unfortunately, they include quite a number of children.

I’m not sure of the reason for the sudden increase in the number of tuberculosis suspects. One reason which I can think of is the drought situation which has been prevalent in the region for the last 3 years by which the poverty among the communities have worsened. This has been followed by very heavy rains over the last 3 months – which has increased the incidence of water and vector borne diseases.

Most probably what is happening is that the other diseases  like malaria, dengue, diarrhoeal diseases etc are occurring which is decreasing the already poor immunity of the impoverished population making them susceptible to flaring up of tuberculosis infections to which quite a lot of the population is exposed to.

The reason I suspect is because of a very peculiar history which we notice in many of the patients whom we ultimately diagnose to have tuberculosis. They come with a history of fever 2-3 weeks back following which they are treated at a quack’s place (http://jeevankuruvilla.blogspot.com/2011/08/quacks-rmps-registered-medical.html) usually with artemether or levofloxacin or a combination of both – following which they are asymptomatic for about a week after which they again get fever. Initially, it does not give the peculiar symptoms of tuberculosis – but over a week, they have the pattern of evening rise of temperature, loss of appetite etc. Unfortunately, many a time, we do not get a positive report on sputum – most probably because of unscrupulous use of Ciprofloxacin and Levofloxacin, both of which have anti-tuberculosis bacilli activity. We conclude based on typical X-Ray finding of apical consolidation and cavity formation. And of course – the best support - history of exposure to another case of tuberculosis.

I would definitely like to hear expert comments. Of course, I’m quite interested in the stories of KD and LD and will try to put them up in a later post. I’m sure this would be quite interesting especially from the perspective of the socio-cultural and economic set up of the region.