Blood . . . rarest commodity . . .

Some time back I had put in a terrible snap of a blood bag which relatives of one of our patients had brought from our nearest district headquarters. 

Yesterday, we had 2 patients who had come in with hemoglobin values of around 5 gm%. 

The first patient, RK was the mother of 4 children and she was pregnant at 7 months gestation. She was from quite far away. She had suddenly started to bleed early morning. By the time she reached here sometime late afternoon, she was quite pale with no fetal heartbeat audible. Her hemoglobin was around 5.8 gm%. I informed the relatives that we could not do much without at least a couple of pints of blood. 

That was when the husband informed us that the unavailability of blood in the district headquarters was the reason for her being referred to NJH. In fact, the relatives wanted to know if they could take the patient to Ranchi. I was relieved - but later realized that she was continuing to bleed and the vitals were going down. But, without blood I did not have any choice. 

In the available circumstances, doing the 135 kilometer journey through bad roads was the best choice that RK and her family had. RK's relatives were well off and it was not quite difficult for them to take a decision to move ahead. I ensured that RK had two lines going in with intravenous fluids. 

As soon as RK left, came the next one. SD, another multiparous lady with bleeding since early morning. Contrary to RK, SD's family was very poor. It had taken them quite a long time to arrange transport and other arrangements to make it to NJH. SD had another episode of bleeding earlier last month. However, it had subsided within few minutes. I told the family of my predicament of not having blood readily available. 

The family expressed their inability to go any further. The husband told me, 'Sir, please do what you can. Even if the baby dies, please save the mother.' The blood results came. Hemoglobin of 5.3 gm% and the blood group was not matching with that of any of the relatives. It was quite late into the night and the relatives informed me that they would go to arrange blood as soon as it is daylight. I told them that it is a very risky plan. If she bleeds, we've had it. 

Meanwhile, we did an ultrasound. It was a low lying posterior placenta with abruption. The baby was alive. I could only pray that she would not bleed. Soon, she was into her labour pains. I was surprised that she did not have any bleeding. Within couple of hours, the baby was on the way. She delivered a dead baby. Thankfully, she did not bleed much. 

Blood transfusion facilities are a premium in almost all parts of rural areas of third world countries. In emergency cases, we keep few blood bags where we directly bleed for donation. It is illegal - but we do it so that lives can be saved. 

The present policies of blood donation are quite archaic and it becomes quite difficult in difficult areas such as ours. And since the last few days, we had run out of blood bags . . .  We are yet to get them . . . We could have managed RK if we had at least couple of blood bags, if not given her a better chance of surviving the journey to Ranchi . . . 

Comrades in arms . . .

It's been 7 months since I started to post regularly in this blog and the results have been amazing. More people knowing about the work that has been going on, more prayers raised for our patients and our needs and of course a small increase in gifts for upgrading our services and facilities. 

Of course, there are quite a lot of similar endeavors being attempted all over the country. Quite a lot of them get no publicity and go along with their work remaining unsung. NJH, the hospital through which I serve belongs to a bigger movement and there are quite a lot of us who serve different parts of North India trying our best to be truthful to our mission and vision. 

One of the major challenges which we have is the dearth of qualified healthcare personnel which makes it quite difficult to provide the best for our patients. One can imagine our predicament when we, a group comprising of 3 family physicians, 1 surgeon, 1 ophthalmologist and 1 medical officer end up managing complicated cases of high risk obstetric cases including rupture uteruses, severe anemia complicating pregnancy, severe cases of hypertension complicating pregnancies including eclampsias, cases of complicated malaria, cases of snake bites and some unusual bites with terrible consequences, All this in the midst of problems with poor communication facilities, a society in civil unrest and poor infrastructure.  Quite a lot of our patients have survived - SD who came to us with 1 gm of hemoglobin was a miracle survival, yet another was SD and her baby.. However, we had our terrible disappointments - our worst one was SK, who was bitten by a Bengal monitor and was on the ventilator for few days - I came to know last week that she suddenly collapsed sometime during the last week of 2011 at her home and was brought dead to NJH. 

I've been encouraging quite a lot of my friends to come down and be part of us since quite a long time. In addition, I've been requesting quite a lot of my colleagues within the organisation to write about their experiences . . . At one point of time, Christian Mission Hospitals provided the backbone of healthcare in the country . . . they still continue to be beacons of hope and succor to many a region in the world even today. However, the major challenge remains of getting qualified and motivated personnel . . . 

As I write this, I was encouraged to see my dear friend, Dr Augustine, who serves at the Madhepura Christian Hospital reviving a blog that was started quite long back. Please do take time to follow this blog . . . Although, he is in the district headquarters, the challenges he faces are almost similar. The needs of the places like these are enormous.

Before I sign off, few blessings which I'm thankful for, which happened over the last week. 

1. The local government authorities had invited us for the Block Development Festival in Satbarwa Block Office. I understand that this is the first time that we received such an invitation. We had put up quite a good show. 

2. We have been signed up to provide services under the National Health Insurance Scheme (RSBY) of the government. This is a major development for us which would help us to be more relevant to the healthcare needs of the poor and marginalised. 

3. One new medical officer has joined our team. Dr Titus Raju, a graduate from Medical College, Trissur plans to be with us for the next two years. Kindly remember him in your prayers. . . 

Babies . . . All God's creations . . .

Today (Friday, 3rd February) morning has been very taxing. I had decided quite beforehand that we needed to take a firm decision on continuing PD on the ventilator. The previous day, she went into status epilepsy and we had to really drug her and she was slowly slipping into multiorgan failure. The relatives tried their best to get an ambulance with a ventilator to transfer her to Ranchi but to no avail. 

As I arrived in acute care, PD's brother had made up his mind to take her by manually ventilating her all the way to Ranchi. I could not convince him that nothing more may happen considering the long time she has been in ventilator and the signs of multiorgan failure which was becoming very obvious. As I started writing the referral letter, I noticed that PD's heart rate had suddenly started to dip. I rushed in just to realise that she was going into a cardiac arrest. We started cardiac resuscitation. 

After about 10 minutes of resuscitation, her heartbeat was back - but she had a very high blood pressure. And she started to have seizures. I looked at the pupils to notice anisocoria. It was not there in the morning when I had reassessed her. We realised that we were losing PD. Within the next 15 minutes, she suffered one more cardiac arrest and she did not respond to any more resuscitation. PD was declared dead. It was heart-wrenching to realise that 4 girls aging 10 years and below would not have a mother in their lives anymore. 

The total bill had come to about Rs. 70,000. The family paid about 30,000. And that was our first maternal death of the year . . . 

Later, as I sat in my office, I enquired about one of the babies that was born last week by emergency cesarian section who had multiple deformities. I was given the impression that the baby would be taken by the parents to a higher centre in Ranchi for further evaluation. From our side, we had realised that the baby had an imperforate anus - rather a rectourethral fistula, talipes valgus, a tracheo-oesophagal fistula with a blind esophagus among few more minor problems. 

The father came to me  in no time and explained that the family was trying to get finances to take the baby to Ranchi. I explained that we cannot keep the baby longer. As I discussed, my thoughts turned to the fact that maybe they were not interested in the baby. So, I suggested adoption. Encouraged by the response of one of my colleagues and dear friend, I started to dream that maybe, we could find someone similar who could care for this little boy. . . 




However, the family has all along maintained that they would take the baby sometime. . . 




Well, before I sign off . . . I need to tell about the delivery I had today morning. . . PD, a 3rd gravida with no live issues - both of the previous babies dying during childbirth. To complicate matters, PD had been quite regular on her antenatal check ups - and there were enough problems - TORCH test positive for Cytomegalovirus and Herpes Simplex, Intrauterine growth retardation and a breech presentation. . . . 




We had begged the relatives to take her to a tertiary centre at Ranchi. They did not relent. PD turned up with quite good contractions and bleeding per vagina. I took her in for Cesarian section and I had a tough time. She was blessed with a 2 kg boy baby . . . The relatives were delighted. . . And within no time, the relatives had decided to take the baby for a second opinion in Ranchi . . . I wondered if they would have done the same if the baby was a girl. . .  

Block development festival - Satbarwa

Today, we had a civic programme in our block headquarters at Satbarwa Block Development Office. I was surprised to receive an invitation for the hospital to be part of the programme. So, after some quick planning with the nursing school and the community health department, we chalked out a plan for putting up the stall. It turned out to be a great success. Below are few snaps taken from the venue . . . 

Block development festival - the entrance

The local school presenting their craft creations

The stalls . . . NJH stall on the left . . . 

Our new medical officer, Dr Titus Raju and engineer, Dinesh admiring some of the local produce

The champion vegetable grower with a 3 kg radish

The inauguration function . . .

The dignitaries visiting the NJH stall . . . 

The Jila Parishad, Mrs Roshan Ara visiting NJH stall . . . 

Patient being examined in the NJH stall . . . 

NJH stall was quite busy . . . We had visitors coming in even after the end of the programme . . . 

Unwanted girl babies . . . and the sought after male heir (2)

I was wrong about SA in the blog I wrote yesterday. SA delivered a boy and that too uneventfully at around 7 am today. Since the pregnancy was complicated the nurses had called me for the delivery. As I walked back home, I berated myself on the tendency I’ve to jump into conclusions. I was very sorry that I ended up writing about SA on my blog. I mumbled an apology to the good Lord about my evil heart.

I reached back to the office at around 8:30 am. There were a host of male relatives of SA waiting to see me and they were so profuse in thanking me for ensuring that the delivery went well without any complications. There was quite a lot of things to do and since I did not have anything much to do with SA, I became immersed in the office work and a quick review of the sick patients. It was sad to see that PD continued to be sick.

At around11:00 a m, I had a surprise with the RSBY officers from Ranchi coming in to sign the papers related to implementation of RSBY in the hospital. It was a surprise. In between the signing of the papers, I could see SA’s father peeping on and off into the office. Considering the complications SA had, I called him in and asked him what the matter was.

SA’s father wanted me to review the baby. I asked him if there was any problem which he immediately denied. I told him that I would come in a couple of minutes. SA had got admitted in the general ward the previous day. Therefore, I went there in search of SA. The nurse told me that SA’s family took a private ward in the morning.

I went to the private ward. SA and her relatives were there. The husband was beaming as he handed me a box of sweets. He told – ‘we thought that the baby was a girl’. I asked if they knew for which he gave some vague answer. Well, I put things together. I could see no other reason why they shifted out from the general ward to the private ward.

During my last stint in NJH, we had received a very sick mother about whom we could not get a diagnosis. Her only complaint was that she had attempted to abort and then her bleeding was not stopping. Dr Colin Binks, our consultant surgeon during that period started to do a curettage of the uterus. And then, he found out that there was a perforation of the uterus.

And so, the patient went in for a laparotomy. And what we found out was gruesome. Inside the peritoneal cavity was a macerated female fetus of about 30 weeks. And there was a large rent on the posterior wall of the uterus. Somewhere, they had made a diagnosis of a girl baby and had attempted to abort resulting in the gruesome end result. The mother made it after a closure of the uterine rent and a long recovery period.

Then few months, before I had taken over, there was a attempted abortion at 32 weeks – the relatives were given a diagnosis of a female fetus from some ultrasound clinic. And when the delivery happened, it turned out to be a boy – which had died during the process. Many of the staff still recollect the unforgettable expression of grief by the family – one of the senior sisters had told me that the cries of the family members still echoes in her ears.

I’ve my fair doubts if SA and her family had got into a similar predicament. But, they were lucky.

Or is it again my intuitions. I’ve been reading Sherlock Holmes and his exploits of late. . . But, here I’ve enough evidence to support my intuitions . . . Haven’t I? Before I sign off, a penny for your thoughts for PD who continues to be on the ventilator . . . Request your prayers . . .