Requirement . . .Urgent

Today morning, we had something unfortunate happening in our Acute Care Unit.

Our first ventilator went off dead in the middle of ventilating a patient who had come unconscious in the morning. It just refused to function the way it used to. However, it had served its' purpose for quite long.

Our engineer was quick to come down and do few rapid diagnostic tests - and the conclusions were obvious. The motor had given way and we would need to do some major repairing on it. And it will take time and may not give long lasting results.

However, it did not need much of thinking to come to a conclusion that we would do better with couple of more of this type of a ventilators.

Our new ventilator has not been quite cost effective and guzzles quite a lot of oxygen which makes the whole process of ventilating quite expensive for our poor patients and it has not been that user friendly.

A couple of phone calls and manufacturers of the first ventilator tinformed us that they still produce such machines. The cost is Rs. 65,000 and it is only made on order.

We have realised that the new ventilator is more suited for use along with the Boyle's machine and she has performed quite well in the cosy environments of the theatre.

So, all those who has been reading about our work - please do help us. Over the last 3 months, the patients we had been ventilating has gone up quite a lot. And we would do well with couple of such ventilators.

We would need about 150,000 Indian Rupees (approximately 3000 USDs/2250 Euros/2000 GBPs) to cover the costs of buying 2 such ventilators including the transportation. Looking forward to hear from quite a few of you...

CLOSE CALL FOR ANOTHER BABY AND A NEAR MATERNAL MISS (maybe)

SD has had a very uneventful life so far. Life has been quite a mixed bag of joys and sorrows – more of sorrows like quite a lot of her friends in the rural hinterlands of the country.

Married about 6 years back, this was her 3^rd pregnancy. Unfortunately, none of her previous 2 children were alive. The first one had died at the age of 4 years after a bout of fever. And the second one which was born in a hospital died 3 days after he was born.

The present pregnancy was precious to her. However, neither she nor any of her family members deemed it fit to have a regular antenatal check up. Her labour pains had started very early today morning. SD’s first child, a girl was born at home – there had been no problems.  The second child was born in the hospital – thanks to the Janani Suraksha Yojana – she ensured a hospital delivery so that she would get the financial incentive. For a poor family 1400 rupees was quite a large amount.

However, she lost her second child, a son – much treasured in Indian homes, within duration of 3 days. He was sick on the night of the 3^rd day after birth. The family stayed close to the nearby town and decided that they would go to a doctor as soon as it was daylight. But the child was dead by dawn. It was a tragedy.

The financial incentive that the family received looked quite insignificant in the light of the dead baby. Meanwhile within the next 2 months, the elder one, the daughter had fallen sick. The doctors in the district hospital diagnosed cerebral malaria. They treated her for about 1 week, at the end of which she was also dead.

The family was overjoyed when SD became pregnant for a 3^rd time. However, they had quite decided that the delivery would be a family affair at home rather than a physician/nurse assisted one.

The labour pains came quite strongly. SD had taken the help of one of her relatives who knew something about childbirth. Nothing much had happened by afternoon. The relative who came to help out was smart enough to realize that something was wrong.

She took the lead along with the rest of the family to mobilize SD to NJH. Going to the district hospital was not an easy choice considering the ‘bad result’ that the family had with both their other children. In spite of very bad roads from Daltonganj to NJH – the family somehow got hold of a vehicle to bring them here.

I happened to see SD as she came into labour room. She did look to be in distress. On examination, it was obvious that it was not a vertex presentation. And the uterus was in a constant state of spasm. Ultrasound confirmed that the baby was lying transverse. She was straightaway rolled into theatre after the necessary formalities. I had not asked much of the history.

On opening the abdomen, I realized that I was in for trouble. The uterus was shaped like a inverted pot with a long neck. It was obvious that the lower segment was hardly stretched and the baby was fully in the uterine body. I was not sure whether the lower segment will expand enough to deliver the baby. I opened a bit high closed to the uterine body.

To my horror, the bag of membranes was black in colour. It was meconium and the baby was caked in it. I already told someone to call Dr Nandamani to help with the resuscitation of the baby. The presentation of the baby in a tonic uterus made the extraction of the baby quite difficult. Somehow, I delivered the baby.

Dr Nandamani was quite fast to come to theatre and he did quite a good job with the resuscitation. As I started stitching the uterus, the nurse anesthetist was already talking with the patient on any other relevant history. It seemed that the kind relative had given her intravenous fluids and couple of injections to increase her pain.

The baby was lucky to have made it.

Quite a number of lessons I learnt from this patient. The importance of ensuring that a patient has a pleasant experience during an interaction with a healthcare provider is quite key to her trusting hospitals and doctors at a later stage. Communication regarding identifying danger signs in babies is quite important at the time of discharge of mothers after delivery. Cash transfers such as JSY motivates patients for institutional deliveries, but as I wrote earlier, we need to ensure that their experience is quite pleasant. Of course, there are more lessons I would need to learn from such patients.

A tale of two malaria patients

It is already cold in Palamu. Nights are quite cold enough to warrant the use of quilts. But, the climate is quite unusual for malaria. Maybe, after all the posts against malaria, the malarial parasite and the mosquitoes are getting back at me. There have enough reasons for me to suspect things other than malaria.. There was a well documented case where I was sure that it was imported leptospirosis from Kerala. There has already been an epidemic of viral encephalitis in the neighbouring districts. Of course fevers in NJH has always been baffling me and I still strongly believe that we have more causative agents other than just malaria or typhoid.

 
Coming back to malaria we’ve already had about 5 cases of Plasmodium Falciparum and another 4 cases of Flasmodium Vivax over the last week. However, yesterday, I had 2 little children who came in with confirmed blood smears of Plasmodium Falciparum. Read their stories.

 

The first to come in was PS who came in late in the morning. The history was very peculiar. PS was doing quite well in the morning and was playing with his friends, when he suddenly collapsed and became unconscious. The history initially looked like he had a head injury. On examination, DK was quite stuporous, crying incessantly and quite significantly appeared to be hemiplegic on the right side of the body. The right side of the body was in a state of spasm with flexion of both the upper limb and lower limb.

 

All the possible causes of a young stroke raced through my mind. But the blood tests brought about a surprise. He had falciparum teeming in his blood and he started to run a very high grade fever. Since there was a hemiplegia involved, I started to condition the parents to take the patient to Ranchi for a CT scan. But, the family was very poor.

 

I started him on the classical treatment for Cerebral Malaria. I was surprised when I saw him in the night. His hemiplegia was resolved and he was crying for food.



However, the next patient was not very lucky. SB, a 5 year old boy from one of the nearby villages was visiting relatives elsewhere where he had fallen sick since the last 5 days. One of the village quacks were providing treatment. Today early morning he had become unconscious. The parents realized the gravity of the situation and rushed him to his home village nearby.


Unfortunately, the first place they went to was again one of the local quacks. By nightfall, they realized that SB was quite sick. SB came to NJH at around midnight. On examination, it was obvious that SB was quite sick and only a miracle could save him. The blood investigations only confirmed the inevitable. Hemoglobin was a pathetic 5 gm% and 75% of his Red Blood Cells contained the falciparum parasite. His platelet count was 17,000/cu mm.


The parents wanted to know if taking to Ranchi would be of any benefit. I told them of the pros and cons. Ultimately, they took the decision to take to Ranchi. I wrote off the referral letter. However, I started to harangue them for some blood to transfuse. But, the response from the parents was very cold.


The labour room was also quite busy. I was busy attending to other patients too. Somewhere in my mind I lost track of the child considering into fact that the parents have already taken the option of referral. Unfortunately, what I did not realize was that the parents were waiting till daybreak before they took SB to Ranchi.


The next thing I know is Dr Nandamani informing me at 7:30 next day morning that SB died. There was nothing we could do. Later I realized that I had written the chart for SB and the treatment was started.

Maybe if had some blood, SB would have survived. But again with a platelet count of 17,000, I’m not very sure.


SB could have been saved had we got a blood smear done and started him on Chloroquine quite early. PS’s presentation still perplexes me. I saw him today morning. He has improved quite a lot. 

Ultimately, whatever said about newer emerging and newer emerging diseases, malaria continues remain as a scourge in the public health scenario of places such as ours.

FOR WANT OF CHLOROQUINE TABLETS (Most probably)

I am sure we are all familiar with the rhyme which goes . . .

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.

I had a frantic call from our duty nurse sometime around 7 pm today (4^th November, 2011). There was somebody who was brought dead and she just wanted me to come and confirm the death. Something which is quite routine in many of the hospitals.

I took my sweet time to go in. On reaching the emergency, I was surprised to see that the unfortunate soul was a very young lady. However, there was one more person – a living one, lying in the bed adjacent to the stretcher carrying the dead body. I thought it was quite unusual.

I identified one of the local fellows whom I was familiar. The story he had to tell was a very tragic one. It seems that the young lady lying dead in the stretcher was the wife of the man lying on the examination cot. Both of them had been sick since the last week and presumably had been on some treatment from the local quack.

The lady had been unconscious since yesterday after having been very sick with high grade fever for the last one week. Her husband was also sick. The neighbours had noticed it and had been advising them to go to a doctor. But, they never took it seriously.

It was only today morning that the couples relatives and neighbours realized that things have taken for the worse. They had been pestering the husband to take his wife and himself to NJH. The husband needed a whole day of persuasion to bring his wife to hospital. But by the end of the day, she was dead.

I examined the husband. He looked severely sick. He was running a very high temperature. His eyes were bloody red and his sclera showed that he was severely jaundiced. Most probably, hepatitis secondary to falciparum malaria which probably killed his wife too.

I wrote out the inpatient chart for him and ordered for some basic investigation before starting treatment.  I went back home after writing some intravenous fluids to get him hydrated. As soon I reached home, I received a call from the emergency nurse who told me that the young man has refused admission. The reason – ‘we are quite expensive, and he did not have any money.’

He had walked out of the hospital and was nowhere to be found. The rest of the people had gone with the dead body of his wife and he had also gone behind them.  There was nothing we could do.

I felt sad for the family. While I was examining the young man, one of relatives was holding the only child of the couple – a two year old girl – quite oblivious of the tragedy that has befallen her. From the way the man had responded to us – I could only shudder at the future of the little girl, with no parents to raise her.  

Stories such as these are very common in the rural parts of the developing world. Lives which are quite cheap; lives which are expendable. Nobody cares if such people died. I felt sad that poor people around our institution finds us quite expensive. I wish we could be such a place where the poorest of the poor can walk in and get life-saving treatment.

Treatment for this young couple who are in the prime of their life would not have been expensive if they had come in the very beginning. It may have involved giving a course of chloroquine or a course of antibiotics. The paradox remains on how difficult it is to convince the ignorant and the poor about how easy it is to save lives.

So, ultimately, families are being destroyed all for want of a basic knowledge that timely health care can save lives. But, the problem remains on access to basic healthcare for quite a lot of our population. Is anyone listening?

Golden Jubilee - The Big Dinner

The main programme of the Golden Jubilee was the grand dinner we had together with the guests which included Dr Mark Kniss and his children as well as previous staff, retired staff and staff from other EHA hospitals.

The programme started off with our staff dancing a tribal welcome to bring the guests from the front of the church to the badminton court where the Jubilee celebrations and dinner was arranged.

After prayer and the welcome address, we moved onto a birthday cake cutting ceremony led by Dr Mark Kniss and Sr. Suniti Masih, the first Nursing Superintendent.

All the guests were welcomed with the specially designed Jharkhand tribal shawl and a souvenir coffee mug. The retired staff were honoured on the occasion. The present staff were introduced to the guests.

This was followed by a sumptous dinner enjoyed by one and all.

After the dinner there was the customary time of tribal dancing well participated by everyone including the guests.