THE GIRL CHILD . . .

With each succeeding year, having a girl child in the family becomes a very unpopular event in many parts of the country . This has been reflected in the fall of the sex ratio in quite a lot of regions within India. The government has been trying to do its bit – but there have been quite a number of loopholes and there are glaring instances of how the law has turned a blind eye to the practice of female infanticide. The birth of a baby is a quite happy event in any family – but of late I’ve had quite a many instances when the happiness becomes quite subdued when the family learns that the baby is a girl.

The last instance of the same happening occurred just about couple of hours ago. As mentioned in my previous blog (http://jeevankuruvilla.blogspot.com/2011/09/duty-diary-thursday.html), Dr Nandamani is on duty – but I had to cover him for a possible complicated delivery which was taking place in labour room as he was busy operating. The patient RD was post-dated for about 1 week and she had been leaking for the last 5 days. She was admitted elsewhere and most probably they were trying to induce her – which they had failed and had asked permission for a Cesarian section. The family was not happy for the same and brought her to us today morning.

To have leaking in a term patient for 5 days and her not having gone into labour was a bit tricky – and I told them that I would also want to do a Cesarian section. But they would not have anything of it. After getting a risk form signed for the baby, I went ahead and induced her with oral misoprostol. I was a bit concerned that they had not much care for the baby. I guessed that they would have known earlier about the sex of the baby. And I was right. By God’s grace, RD responded to induction and she delivered a healthy girl baby. The mother was very glum after the delivery. I asked her the reason. She told me that everybody knew that it was going to be girl baby – but she was just hoping that the ultrasound would be wrong.

I met the father and the grandfather of the baby. They were quite ecstatic about the normal delivery. Later, as I hovered around in the wards – I overheard the grand-father talking to someone. He was making a long distance call and he was shouting – it was easy to overhear. In Hindi, he was telling – ‘The doctors here are too good. We were asked for a Cesarian in Daltonganj. We knew it was not a boy. How can we spend so much for delivering a girl baby? If it a boy, it is worth spending some money. Anyway, the mother and the baby are fine…’  

1 week back, while I was on duty, I had a mother who was G3P2L2 – the first two were home-deliveries. The family was quite well off. The present baby looked a bit on the bigger side. As she came in, I asked about the history – I realized that both her previous babies were small, the first one 2 kilograms and the second one 2.2 kilograms.

I thought she must have had diabetes. Then, I realized that she had quite a good ante-natal care including multiple visits to good obstetricians in the nearby town of Daltonganj and Ranchi. The blood sugar levels were quite normal. Even tests like Thyroid Stimulating Hormone was done. She had quite an uneventful time of labour. However, the accompanying relatives were quite finicky. They were quite hovering over the lady and were quite obtrusive and frequent enquiries about the progress.

Sometime during the period of labour I happened to go for a per-vaginal examination and found out that the liquor had become a bit meconium stained. I met the bystanders and told them the same. The response was immediate. 'Please do a Cesarian and get the baby out as soon as possible.'

I explained that she was progressing well and should deliver without any problems within couple of hours. They would have nothing of it. They wanted a Cesarian section immediately. As I called my theatre team, I told them about this – they suggested that during the surgery we ask the lady whether she knew that the baby was a boy. The answer was the same. She had got a ultrasound scan in Mumbai for Rs. 3000 where they told her that the baby was a boy. And that explained the relatives’ eagerness to get the baby out as soon as possible.

There is a law called the Pre-Natal Diagnostic Techniques Act (www.pndt.gov.in ) which bans telling of the sex of the unborn fetus – however, it is very evident that there are scan centres all over the country who flout the laws. Recently, I met one of the activists who campaign for saving the girl child. The stories she told me were very sad. She told me that many doctors in our region told the expecting mother about the sex of the baby. One doctor told her that he just tells his patients to keep a particular sweet ready when the baby is delivered. It seems that in communities here, it is customary to give jelebis if it is a girl and laddoos if it is a boy. So, the doctor tells the patient to keep jelebis ready for him when the delivery happens if it is a girl and vice versa if it is a boy.

Not all the scans turn out to be correct. About a year back, we had a patient with septic abortion attempted at 7 months gestational age. They had obviously attempted the abortion as they had found out that the fetus was a girl child. But, the sonologist got it all wrong. It was a boy. One should have seen the grief of the relatives when we got the dead fetus out.

There has to be change of heart among us if we have to resolve the issue of this terrible genocide which is going on. I’m sure that RD’s relatives would not have minded if the baby was lost during delivery.  Isn’t it a big paradox that in a country which have looked to women to give leadership (Late Mrs. Indira Gandhi, Present President Mrs. Pratibha Patil, Mrs Sonia Gandhi – the Congress Chairperson, Ms. Mamta Banerjee – the Bengal Chief Minister, Ms Jayalalitha – the Tamil Nadu Chief Minister), there is no value for the girl child?

DUTY DIARY – THURSDAY

I was on duty on Thursday. As I had mentioned in my earlier post about Thursday (http://jeevankuruvilla.blogspot.com/2011/08/tiring-thursday.html), I hope you know the peculiar position the doctor on duty gets into.

The day started off with two quite well off portly ladies (AS and PK) in labour made their presence in the Labour Room. I hate when private patients come for delivery in our unit. Of course they bring in extra revenue – but I’ve always felt that they extract far more attention from all staff which actually robs you of sleep and concentration that ultimately divert the attention you give to the rest of the patients. From the time they came in, I had an inkling that both will go for Cesarian Section.

And of course, both of them ended up with Cesarian Sections, AS in the midnight and  PK on Friday early morning. In addition, there was a mother with polyhydramnios and a malformed baby (AD) who was not responding to any induction. She was induced thrice - first time with oral misoprostol followed by vaginal misoprostol, the second time with oxytocin drip and the third time with a higher dose of oxytocin drip. She had been leaking since the last two days and we tried a fourth time with a higher dose of vaginal misoprostol, which she ultimately responded to. The baby was quite malformed with the eyelids sealed shut, bilateral cleft lip and palate, cardiac lesions and a enlarged liver and weighed just about a kilogram. We decided not to resuscitate him - he came out with only a heart beat. It was AD's seventh pregnancy - but, she had only 3 live children.

Below here, is the list of other patients we had. I’m not going into greater detail about each patient – but shall try to provide them in a later post.

1. SD, who had come in labour with a Hemoglobin of 1.8 gms and expired at around 10:30 pm (http://jeevankuruvilla.blogspot.com/2011/09/maternal-death.html).
2. SB, a 14 year old girl was brought to at around 5:00 pm with a history of Krait bite which happened in the morning. She was hardly breathing and had aspirated quite a bit. Her saturation on arrival was 55% and she got hooked straight into the ventilator. We had to pump in about 20 vials of Anti-Snake Venom before she made a remarkable recovery.
3. FA, an 8 year old boy who came in a history of Krait bite at around 8:00 pm. He came in quite fast considering into the fact that the bite took place at around 5:00 and he lived couple of hours away by jeep. The signs of envenomation had just started and he was quite lucky to have escaped from the ventilator.
4. RK, a 9 year old boy had come in with a very short history of fever and seizures. CSF examination did not yield anything. He was going on having fits and we had to give him quite a lot of anti-seizure medications. We started him on empirical antibiotics and antimalarials – but there was no improvement. He arrested yesterday (Friday) morning and was hooked onto the ventilator. However, today (Saturday) morning the parents decided that we had tried enough and wanted the boy taken off from the ventilator – following which he died.

There was couple of sick patients in ICU (admitted earlier) which kept me occupied.

1. GS, a 70 year old man who was admitted about 4 days back with a long history of fever which was being treated as malaria had become sick suddenly. The previous day, we had found couple of apical lesions in the lungs and had concluded that he had tuberculosis. I’m not sure, whether the anti-tuberculous treatment actually made him sicker. However, he responded well to steroids.
2. PB, a 12 year old boy was a very atypical case. He had come on the 30^th August with history of high grade fever and seizures. Initially, he looked like a case of tetanus – his jaws were clenched tight and he had opisthotonus. But, there was no wound. The other diagnosis was meningitis – but the CSF examination did not yield anything. This was when I thought about tetanus. And he responded to treatment for tetanus. There is already medical literature about tetanus occurring without a visible wound.

My duty spilled on to Friday with a whole lot of serious patients coming that I could leave for home only by Friday evening. We had about 90 patients in OPD and by the end of the day; the beds in the wards were all full. I will narrate the quite eventful happenings on Friday in another blog. However, Dr Johnson who was on call later in the day had an uneventful time.

Today (Saturday) has been quite busy. And having the hospital management committee meeting did quite a lot of damage to patient care. But we did not have many options as it had been due for quite a long time. By the time we finished OPD it was 5:00 pm – something which has not happened at NJH for quite a long time. Dr Nandamani is on duty today. He is having a tough time. I’ve been on and off been out there helping him out. I would be on duty tomorrow. If time and the internet connections permits, I shall keep you updated about happenings here over the weekend. And mind you, of late, Sundays are never dull at NJH.

MATERNAL DEATH

We had a mother die today morning. Her time in the hospital was just 6 hours. The doctor on call who saw SD come in at around 4:00 am today morning – found her terribly breathless and in labour. She was pale as a pearl. Hemoglobin was a pathetic 1.8 gm%. Literally, water flowing through her veins. There was a pansystolic murmer on examining the heart.

Whether she had a heart disease or not – it was difficult to comment considering the severity of the anemia. She delivered a dead female baby at around 7:30 am. Her relatives were very poor. They were not ready to deliver blood. We did not even know where the husband was. She was too sick that we did not bother to ask too many questions.

There was some amount of blood lost during the delivery which definitely pulled her to the edge of death which ultimately devoured her at around 10:30 pm. We could only watch helplessly.

Another addition to the maternal death statistics of the world – and that too because of anemia. What a shame? I thought of talking to the family before they took the body. Unfortunately, I could not as I got caught with some other matter. I wish I could have given more details.

THE COSTLY DELAY – 2

This is a continuation of the post THE COSTLY DELAY – 1 (http://jeevankuruvilla.blogspot.com/2011/09/costly-delay-1.html) Unfortunately, the protagonist of the this post was not as lucky as LR.

RD was in labor pains since the last evening.  It was her first baby. She was just about 8 kms away from our hospital – she had never been to an antenatal check up.

Dr Nandamani saw RD as soon as she came into our labour room the following day morning. RD was in terrible pain. On cursory examination, it was evident that there were enough complications in store. Obviously pale, RD was in obstructed labour.

Per vaginally, the baby was stuck at the outlet – the baby wedged so tight that Nandamani knew that a Cesarian Section also could be traumatic. The Fetal Heart Rate was about 100 per minute and was going down. There was thick gravy like meconium coming out from the vaginal opening during each contraction. The baby’s head which had formed quite a big caput had become a pulpy mass by now.

There was no other way. We had to take out the baby by forceps. Once we decided, Dr Nandamani was in action. The baby came out with only the heartbeat. Leaving the mother with the attending nurse – the baby was promptly intubated. He had aspirated too much of the meconium. I came in at this point. On laryngoscopy, there was too much of meconium coming out from the airways. I knew that we did not have much of chance. After sucking out quite a lot of the muck, we intubated him and started mechanical bagging.

The initial response was good – but it was only a matter of time before pneumonitis and respiratory distress syndrome could set in. He was not at all responding. There was hardly any respiratory effort although the heartbeat was going strong. We decided to continue bagging. That was when I thought about trying out our new ventilator (http://jeevankuruvilla.blogspot.com/2011/08/new-ventilator.html) on the baby – however, it could not perform well.

The hospital was quite busy and we had manually ventilated the child for quite long. And we had to attend to other patients. We had to find out a way out – I wish we had a neonatal ventilator. We decided to teach the relatives to bag the baby. There have been quite a number of occasions before when we asked relatives to mechanically ventilate a patient. The most vivid one I could recollect was a young man with cobra bite whom we ventilated manually for about 6 days – before he made a recovery – we had run out of Anti-snake Venom.

But, RD’s child was more challenging. There was much meconium clogging the lung tissue and considering that there was evidence of fetal distress for quite long – I knew that we had very little chance. There was nothing more we could offer. After a 15 minute session of educating 3 members of the family to mechanically ventilate the baby – we set off for the rest of the day’s work. The nurses were keeping a tab on the baby.

At around one in the afternoon, the nurse called me and informed the baby had started to desaturate. I took some time to reach the nursery. When I reached the nursery I had the shock of my life. The relative who was supposed to bag was sitting on the floor. I rushed in started bagging the baby. The saturation was 55%. On questioning the bystander, he told me that he thought of taking a break as he was quite tired. He also gave a excuse that since the oxygen chamber was bubbling, anyway oxygen was going to the baby – and so he concluded that nothing will go wrong. I did not know what to tell him.

Any more of intervention was of no use. The pupils were already dilated. It was only a matter of time. The baby was declared dead at around 3:00 in the afternoon.

The delay to come to hospital has cost KD her baby. One can only wish that patients like KD and LR teach their neighbours on how valuable time is when it comes to taking the right treatment at the right time and the right place. There is more in store for KD - her Hb was only 7 before the delivery. We have already asked for blood. But, the relatives are hardly bothered. Today, I saw KD - she looks quite puffed up. Considering that she had quite a long time of labour, and should have lost some amount of blood during the delivery and a very big episiotomy wound, having couple of pints of blood is essential for her to return to routine work.

However, she is luckier than SD who died following delivery today morning. But more of that in the next post.

THE COSTLY DELAY - 1

You may have read this statement somewhere –

‘If you want to know the value of one year, just ask a student who failed a course.

If you want to know the value of one month, ask a mother who gave birth to a premature baby.

If you want to know the value of one hour, ask the lovers waiting to meet.

If you want to know the value of one minute, ask the person who just missed the bus.

If you want to know the value of one second, ask the person who just escaped death in a car accident.

And if you want to know the value of one-hundredth of a second, ask the athlete who won a silver medal in the Olympics.'

Couple of days back, I had two patients who would have done better if they had not delayed coming to us on time. I shall narrate the story of the first patient in this post and in a later post, the story of the second one.

LR is a 55 year old man from a nearby village, Rankikala. Since the last 1 month LR has been sick with vague symptoms. It started off with fever on and off in the evening. He went to the local practitioner (RMP) in our market village, Satbarwa who prescribed him some tablets. He improved for couple of days, after which the fever had come back. In addition, he developed something new – he had episodes of seizures of his right leg alone.

Satbarwa is famous for a Vaid (traditional healer) who is specialized in neurological ailments. I’m told that he uses the extract of garlic to make a concoction which is given as an intramuscular injection. I’ve had quite a lot of patients who vouch for this remedy in the treatment of neurological ailments. However, I’ve noticed that the recovery mainly occurs in patients who had ischemic strokes – which would have healed otherwise too. Since LR felt that having seizures is something related to the nerves, he straightaway went to the vaid at Satbarwa.

Unfortunately, nothing much happened. He still had a fever and cough was worsening. However, he felt that those symptoms are secondary and he needed to get treatment for his seizures. The seizures continued to occur. The Vaid decided that this needed further evaluation and send him to one of the physicians in Daltonganj. The doctor of Daltonganj also treated him for about 2 weeks – before LR decided that there was not much improvement.

LR came to NJH OPD couple of days back – He was frail and it was obvious that he had lost quite a lot weight recently. His pulse was feeble and Blood Pressure was just 80/50. His chart came to my table – as he entered my room, the diagnosis was obvious - Lung abscess. The stink from his breath was unbearable. It was difficult to fathom how one could miss the stink. And from his blood pressure and history of seizures  - possibilities narrowed down to either a disseminated malignancy or disseminated tuberculosis. Sputum AFB turned out positive for tuberculosis. I did an X-Ray which is put up here.

LR's Chest X-Ray

LR had spent almost 10,000 rupees by the time he came to us. He would have done better with a CT Scan Brain. But, he just did not have the money to make a trip to Ranchi leave alone the CT Scan. In addition to the Anti-Tuberculosis treatment, we have also started him on Steroids and Anti-seizure medications.

LR waits with his son for his anti-tuberculosis medicines

I’m confident that he will do well. However, things would have been easier had he turned to us early – which brings us to question on why people avoid coming to people like me in the first place. Money is obviously the major issue is institutions such as ours. However, he would not have had to spent this much if he had come to us straightaway. But, I did not understand why this does not happen, until I heard about ‘agents’ about whom I shall post soon.

My only prayer is that the delay would not turn out to too costly for LR whereby he may lose his life – unlike RD about whom I shall write in my next post (http://jeevankuruvilla.blogspot.com/2011/09/costly-delay-2.html).