Poverty . . .

Over the last 2 weeks, we had two instances where we were exposed to the stark reality of how poverty affects families, especially when it comes to healthcare. 

I shall start with the patient who I mentioned in my previous post on obstetric care. 

We shall call her Kkd. Yes, the lady who came in with a hemoglobin of 4.6 gm% and then had a hemoglobin of 2.6 gm% more than 12 hours after the delivery. I just got news from Acute Care that the relatives were able to arrange a pint of blood; almost 24 hours after she had delivered. 

Now, the whole question was about the reason why the family never brought her for delivery to the hospital. It seems that she was taken to the place where she had her antenatal check ups as well as to the nearest district hospital. She was turned away from everywhere. 

If we had got couple of pints of blood, we would have done off the Cesarian in no time. 

I believe that it was the good Lord's providence for her that she delivered normally. And then the family could arrange one pint of blood. Most probably, that is the maximum that they can arrange. 

The whole exercise of a Cesarian section with couple of pints of blood transfused would have resulted in quite a financial strain for the family. I realized it today morning when the nurses told me that they did not have money to pay for the medicines. In fact, we had admitted her without any advance. 

The relatives had been running helter-skelter to get some decent treatment for this poor lady. The fact was that almost all of their money had been spent paying for transport. 

However, while the process of getting blood was on, one of our nurses had caught bits of their conversation and found out that they were in the process of paying a huge amount to buy blood. 

In our nearest blood bank, the usual practice is to allot a pint of blood for 350 INR if the relatives are able to donate blood. However, when one cannot arrange a donor, there are processes quite unknown to most of us by which you can buy the blood from elsewhere at rates ranging from 2400 to 4000 INR. 

We somehow convinced the relatives to arrange a donor and get the pint of blood for just 350 INR. I'm happy that they heeded the advice. 

However, it was obvious that the family had run out of financial resources. 

All of us have failed them. From the very beginning. 

They had gone to a doctor in his private clinic thinking that they would get the best treatment. He/She had written quite expensive iron, multivitamin and calcium tablets. Which they brought. Instead of 30 tablets for a month, they had brought one strip (10-12 tablets) which was used for 2 months. 

They never got clear advice on what needs to be done when she goes into labour. No plan . . .

And even after she got admitted . . . unless our staff overheard the conversation about the blood, they would have spend much beyond their capacity and got the blood, which many a time is of very poor quality.

To be frank, for the poor, there is nothing much left in our country. They are the mercy of anybody and everybody. The question is whether 'the haves' of our country are listening. 

Leaving alone the subject of poverty . . . if there is 2 things which could improve maternal morbidity and mortality in this part of the country which is more of a problem for the poor and marginalised, I firmly believe that it is free availability of Iron tablets along with an awareness about the intake of these tablets and the second one - undoubtedly, UDBT.

Shadow of death . . .

Since yesterday night, we are sitting on tenterhooks regarding the second patient whom I mentioned in my last post.

It’s more than 24 hours since this lady came in. Her haemoglobin had been around 5 gm% for almost the whole of her antenatal period. She had a Cesarian section after she had eclampsia. Unfortunately, the baby died soon after birth.

It’s been two years. After she got pregnant, the family had been taking her for regular antenatal care in the nearby town. There is mention of her low haemoglobin during each of her visit and Iron appears to have been prescribed.

She’s come in labour yesterday. We had wanted to do a Cesarian section as I felt that there was not much space for the baby to come and there was grade 2 meconium. Her haemoglobin was 4.6 gm%. We told the family that we would touch her only after the family arranges at least 2 pints of blood.

The relatives are yet to arrange blood. But, the lady’s found favour with the Almighty. We were quite worried and could only pray.

She delivered normally late yesterday night . . . of course, the baby was severely IUGR. The labour room team worked hard to ensure that there was not much bleeding.

The problem is the haemoglobin. Today morning, I did it just to find out how it was. She looks a bit uncomfortable. It was just 2.6 gm%.

I can only pray that at least one pint of blood comes before she goes into a hemodynamic complication . . . Once again, another case which would have benefited from UDBT.

Bizarre Obstetric Care . . .

As I write up about the different patients to come to us for care, I always pray that things get better as each day passes. Unfortunately, it does not seem so. The number of patients with rupture uterus and eclampsia continue unabated. Of course, on and off, we get patients who were saved from certain death because of timely intervention . . . 

But, one lady who came yesterday broke all limits of imagination on how careless and ignorant can people be when it comes to obstetric care. . . 

I was in Out Patient yesterday (13th April, 2012) when at around 2 pm, a lady with a distended abdomen was wheeled in. The history was that she had a normal delivery on 10th April elsewhere following when the abdomen got progressively distended. They also told me that somebody had diagnosed her to have a rupture uterus following the delivery . . . 

The lady has been married for 12 years. . .  and the family did not have children for about 8 years. The first delivery was a tragedy. For reasons unknown, she ended up with a Cesarian section, but lost the baby. . . The next two deliveries were normal . . . and one done at home and the other in hospital ! ! ! In between, she had 2 abortions. 

Then came the fourth one, they tried a home delivery . . . but started to have difficulties, for which they came to the district hospital. She ultimately delivered normally. The baby was dead but she started to become sick. She was brought to us in a terrible shape on 11th April, 2012. So, she was P4L2D2A2. 

It was obvious . . . the uterus had ruptured. Her Hemoglobin was 4 gm%. We asked the relatives to get blood. She had about half a dozen male relatives but nobody was ready to give blood. 

It was fine, if there were no relatives to donate blood or if all the relatives got their blood group checked and then none of them matched. In such a situation, many of us from among staff have donated blood to patients. 

We told the relatives that they better take the patient to Ranchi. They did not hesitate to take her away. 

We had forgotten about her. 

And then they came back yesterday. We shall call her AD. Now, it took some time for me to discover that AD was the same patient who came to us on 11th April, 2012 and was supposedly taken to Ranchi. 

So, I was quite inquisitive to find out what happened after the relatives took her from here on the 11th. It seems they took her to the district hospital in the adjacent district. They told her everything will be fine once blood is transfused. And they managed to get hold of 3 units of blood. . . Nothing else was done. 

It was obvious that the patient was deteriorating. Later, someone told them that this sort of patient can only be managed at NJH or Apollo. And, therefore, she was brought here a second time. 

The patient was obviously sick. The hemoglobin was 10 gm%. She was dehydrated. We were sure that we will operate only if we had at least one pint of blood. Unfortunately, the relatives were not relenting. It required quite a lot of counselling from our side. I'm glad that they arranged one pint of blood today morning (14th April). As I write this, Dr Nandamani would have started operating. 

We pray that she will do well . . . 

Now, major lesson learnt here - lack of adequate medical facilities within the country. I had written quite a mouthful on a new act which is going to be implemented soon. What will patients like AD do when such a act is implemented?