Weekend Diary 2

Sorry, for all those who may think that this is the second day of the last weekend diary that I wrote (http://jeevankuruvilla.blogspot.com/2011/07/weekend-diary-njh.html). I was too tired that I slept through the next day. Dr Ango was on duty. She mentioned about an eclampsia patient whom she had to operate. By God's grace, both mother and baby are doing fine. Then, there were the umpteen number of fever and couple of snake bites. Almost all of them went home healed.


For a change, this weekend, I am handicapped by the absence of Dr Nandamani and Dr Ango. They are off to a time of rest and retreat for 3 days. The should be back by Monday evening. And I find myself taking the call for another weekend. And as expected, I've got some time to come to my office as I wait for the results of MD who just came in. She claims she is at term. However, she has a discharge summary from us dated about 6 weeks back saying that she has a complete placenta praevia. It also says that her Hemoglobin is 7 gms%. She has been having pains since morning. It was good that someone remembered that we told her that it was dangerous to try a normal delivery. MD has other problems too. She had been pregnant 4 times before and everytime the baby had died sometime around 1 or 2 years of age. She has also disclosed that she is taking some treatment for convulsions. Her husband has shown me some tablets wrapped in a piece of paper.


By God's grace, she has brought along with her a hoard of male relatives. So, all of them have gone to the laboratory trying to find out if any of them is fit to donate blood. As soon as the blood comes, I'll operate.


Morning has also been busy. We had couple of Cesarian sections, one hysterotomy and one curretage of the uterus for incomplete abortion. Basically, after rounds, I was closeted inside the cool environs of the theatre.


LD, for whom I had do a Cesarian Section had her first baby by Cesarian section. It is not very wise to try to do a normal delivery in places like ours for quite a lot of reason. I was almost deciding on trying out for a normal delivery, but it was quite risky considering the technical and manpower backup that I had - and that too on a weekend when things really hot up. The second Cesarian was for a lady who was supposedly having a precious baby. Belonging to quite a rich family, she had gone in for infertility treatment as she did not conceive within the first year of her marriage. She conceived within 6 months into the infertility treatment and had come to us for delivery. Now, the problem was that she was a bit on the plump side and was not able to percieve fetal movements regularly since the last couple of days.


In addition, she had an ultrasound which showed lesser liquor volume. On clinical examination, the baby looked fine although the liquor volume was on the lower side. I asked for a repeat ultrasound, which showed even lesser liquor volume that the previous scan. The relatives were really petrified. I calmly told them that we would try to induce and try for a normal delivery. But, I knew this was going to be tough. Within couple of hours the nurse from labour room called me saying that the lady was creating a scene saying that she could not percieve fetal movements and the relatives were intrusively anxious.


Well, I needed to have an indication - nowadays, there is a good one - Non-reassuring Fetal Status. Off she went to the theatre and she delivered a girl baby. On the table I found out the reason for the absent fetal movements - the liquer was actually very low and in addition, the umblical cord was tightly wound around the fetus. Maybe she would have ended up with the Cesarian ultimately.

Well, they are calling me to the labour room. There is one more new patient... Shall write more if I get time... There was one more new thing we tried today.... And a patient with really bad falciparum malaria.... That would be after I see what's cooking new in the LR...

Breastfeeding Week

The World Health Organisation celebrated the last week starting from Aug 1st to the 6th as the World Breastfeeding Week. There are quite a large number of programmes which are being done all over the world including institutions like us. The Nursing School is facilitating the celebration in NJH. I used to wonder why there is a week just to promote breastfeeding when it seemed to be the most natural thing for a mother to do after childbirth.

But I was wrong. All along my 16 years in the field of healthcare sciences, it has been very painful to note how subtly breastfeeding has been discouraged in our communities. Just wanted to share 3 experiences.

Scene 1: I vividly remember the day. I was an intern in Obstetrics in Trivandrum. There is this medical representative who turns up and requests me to write prescriptions for some milk substitute for all the patients I was discharging. He was even offering me few free sachets to give to poor patients who I think could not afford to buy the milk substitute. I had to make quite a lot of effort to politely refuse to entertain his request.

Scene 2: One of the mission hospitals I worked in - there was this funny thing I found during rounds in the obstetrics ward. Everyone had a feeding bottle. I tried to investigate and the finding was alarming. It seemed that the hospital had a nursing school attached to it. One of the procedures for the nursing students used to be training mothers with decreased milk secretion on how to bottle feed - basically teaching them to use clean bottles. Now, what was happening was that there were about 5 deliveries per day and a total of 50 students. The poor students had to do their procedure on some patient. And ultimately, every patient ended up buying a bottle and learning how to use it properly. It was hilarious but the truth was that each patient who came to this place went back with the message quite ingrained in them that bottle feeding was the in thing. It took me some time to convince the authorities about the horrible thing which was taking place.

Scene 3: I happened to buy some milk substitute for my son - it was basically to tide over events like travel where feeding sometimes becomes cumbersome. It remained unused. Since it was well packed, I thought I shall give it to one of my paramedical colleagues who recently had a baby. It was almost 6 months later when I bumped into him in some social event that I asked him about his baby. He told me that the baby is doing good. He later asked me how I used to afford the milk substitute which I gave him. It seems that this family had taken my gift of the milk substitute to heart and had been regularly buying it for their kid - and sure it was costing them a fortune maintaining this diet. They thought that since I, the head of the unit had given it to them, it must be something really good that their child should not forfeit the benefit of having it.

Of course, there are quite a lot of rules and regulations about the advertisement and sales of breastfeeding substitutes. However, the companies which market them have already made quite a lot of impact on parents and healthcare providers. It is very common for parents of new-borns to come and ask for substitution feeds. And when I refuse, they give me quite a funny look as if their baby is being refused something very basic.

It sure needs more than a week to convince parents all around the globe that promoting breastfeeding is very crucial for the future of mankind.

Tyger, Tyger Burning Bright....

The starting lines of this immortal poem by the English poet, William Blake used to always thrill me whenever I came across them. When I joined EHA way back in 2003, one of the facts which thrilled me was that quite a number of our hospitals including NJH was sort of near to Tiger Reserves or some sort of wildlife parks. The others being Lakhnadon, Chattarpur, Makunda, Tezpur, Herbertpur, Mussoorie and Utraula.

NJH was special as the Palamu Tiger Reserve which borders the hospital, had the privilege of having had the first census of any kind for tigers in the Indian subcontinent way back in the 1920s. It seems about 120 tigers were counted during that time. Various factors contributed to the fall in tiger numbers over the years. Over the last 20 years, the numbers had come down to single digit numbers.

On reaching NJH, I was disappointed to know that the last tiger was spotted quite a long time back and there were unconfirmed reports that no more tigers really roamed the Palamu Tiger Reserve. But, I had gone for a elephant ride in the reserve sometime in 2004 and the mahout had pointed out a supposedly tiger pug mark along a muddy stream bed. I flaunted the photograph for quite a long time until one of the wildlife wardens I befriended in Vellore told me that the pug mark need not always be that of a tiger, but could be of any of the large cats like jaguar, wildcat which could be seen in any forest. And after seeing my snap of the pug-mark he expressed his doubts about this being that of a tiger.

I never got the time or the opportunity to go again to the Palamu tiger reserve. However, couple of days back we've had news that there was evidence from the park that there were at least 8 tigers inside the reserve. This is joyful news indeed for quite a lot of us. Of course, there have been some sceptics who have not taken the news well. They have expressed reservations over how the conclusions have been arrived.

Neverthless, it has reignited the desire in few people like me to explore options of visiting the reserve with the desire and prayer that we would be the first to see this magestic animal face to face after a gap of almost 10 years.

My new Bible

I thought I will advertise about the new Bible which I got hold of after a prolonged search for about 8 months. It's been about 2 weeks since I acquired a copy. I had heard about a year ago that the Bible Society of India had started production of a bilingual English-Hindi Bible, called Diglot.

Since, I was planning to come to North India, I was definite about getting hold of one. There were 2 sizes - a big one and smaller one. The big one was quite big and was difficult to carry around. I wanted the smaller one for mobility's sake.


Last week I was quite surprised to find out that there was one copy of the smaller one available at 'The Bible Centre' in Ranchi. It was 800 rupees - quite affordable for the bilingual type. For all those people who have to preach in Hindi with an English Bible, this is a very good alternative. Highly rated stuff for all those who usually read their Bibles in English but live in North India.


Later, I contacted the BSI Office in Ranchi and they have quite a number presently with them. After I told about this in our chapel, I've already got 10 people placing an order for the same. Quite a good number considering the cost - Rs 800.


I have already started enjoying reading the English and Hindi versions together. It is now quite easy especially to take studies for a Hindi audience. Otherwise, it used to be a painful long wait requesting someone to read out. And many a time, I would be searching for the Hindi word of a particularly difficult word in the middle of the preaching. So, anybody having any second thoughts - go for it before the stocks get exhausted.

THE DEPRESSED

It was only quite recently that I read about a study about depression being highly prevalent in most countries of the world in alarming proportions. It seemed that it is the fourth largest cause of morbidity in the world and Indians are also quite depressed.

It is not quite difficult to believe that. Recently, Dr. Nandamani, our surgeon was sharing about a patient who had an abdominal surgery and was slipping into depression that he was afraid that the patient would not make a normal recovery. It was too good of Nandamani to diagnosis depression in a post operative patient. However, when we sit in OPD, it is quite obvious that depression presents in different ways and it is very few generalists or non-psychiatrists who would be able to pick out a symptom of depression in the patient. Even, in a mission hospital like ours working in quite a remote area, depression is a diagnosis which we could find if we seriously look for it.

Couple of patients whom I wanted to share with you. The first one was a student who was brought by her father, a policeman - with the complaint that she was accumulating air in her body and it was preventing her from sleeping and eating enough. This happened during my first stinct at NJH. The 16 year old girl looked normal to me except for her forlorn face and sense of anticipation for some relief. I was quite fresh from college - and remembered someone teach us that if a patient does not eat well and sleep well - you need to rule out depression. The best part about this girl was that her father, the policeman was quite a talkative character. He was very sure of the diagnosis. He had been taking this girl to many places and someone had diagnosed bilateral pneumothorax. He was told by some quack that she was leaking air from both her lungs and there were permanent holes in her lungs. I was in charge of the TB department and that was the reason he brought her to me - he somehow concluded that since tuberculosis affects the lungs, I would be the best person to handle it.

Chest examination was normal - good air entry on both sides. Good heart sounds with no murmer. I asked the girl umpteen questions. One of her cousins was there along with her and he blurted out all her symptoms had started after her 10th standard results came. That revelation was quite a leading and I was definite that I was looking at a depressed person. I sat and talked with the family for quite long. Unfortunately, the father could not be drawn to the possibility that her daughter was having depression following her poor 10th standard results. He was just bent upon getting treatment for the 'holes in both her lungs'. I somehow tried to get her a prescription for anti-depressants and to follow her for psychotherapy - both of which were refused politely. I used to wonder what happened to her till recently when someone from the police station nearby made a passing reference of her having committed suicide about 4 years back. It was very unfortunate.

My second patient was luckier. She had 3 children - the elder 2 placed in the paramilitary forces. The youngest one was doing his graduation and had also made up his mind to enter the paramilitary/military force. The 55 year old lady lived along with her husband - a very calm person who was running a road side eatery. He told me that he did not run the eatery for a living. He used to have a government job as a peon. After he retired he took to cooking as a hobby and thought that he would pass his time cooking pakoras and samosas in a small tea shop and chatting with his customers. To his surprise, he was doing a roaring business and was having a good time. Unfortunately, his wife, my patient had a lot of free time. Her time was spent worrying about the children. The 2 paramilitary sons were always on the move pursuing Naxalites or militants. With her youngest son also opting for a career in military - it was a nightmare for her.

She hardly ate nor slept. She wanted to die, not wanting to see the death of her children. She was imagining bad things happening for her children. She went to a quack who told her that removing her uterus would solve all her problems. And that was the reason she came to us. After much talking with her husband, we were definite about what needed to be done. I talked to her children over the phone - first, the elder one and later the second one. I convinced them that their mother had depression. I told him that the best option would be take psychiatric consultation - since I was not a trained one. The answer I got surprised me. The elder one told me that if she is taken to a psychiatrist, the village and family would brand her as mad.

I gave him the option of us treating her with the help of one of our psychiatric colleagues in a sister hospital of EHA. The arrangement was very much acceptable to him. However, I got a written consent from him for the same. The lady has been taking treatment from us for quite a long time now. I see her occasionally. In fact, she brought couple of her acquintances who had some form of psychiatric complaints. We could manage them quite well. Meanwhile, her son changed his mind to go into the military and recently wrote exams to enter banking services. A lot of her symptoms have been relieved. I recently got a 'thank you' call from the eldest son. He being in paramilitary forces had consulted some psychiatrist and was told to continue the same treatment.

From the many cases of depression that have come to our OPD, I've realised the need for few things -

1. Need for integrating practical psychiatric training into the graduate medical education.

2. Sensitisation about mental illnesses in communities and the need for mainstreaming them.

3. Psychiatrists have always been seen as doctors treating mad people. Much needs to be done to bring them closer to the common man.

Studies all over the world have been constantly warning us of the impending epidemic of 'depression' within our communities. The jet set lifestyle, high expectations of parents from their children, materialism, breakdown of families etc which have the hallmarks of recent times would only accelerate this epidemic. The question remains about whether we would be ready to help the world out of depression. Or rather, would we be looking at options to prevent depression in the fellow beings?