Praise and Prayer Bulletin, 15 February

1. Last week, we had the graduation and capping ceremony of our Nursing School. The function was conducted quite smoothly. We thank the Lord for His mercies during the program and the dinner hereafter. Kindly pray for all those who graduated as well as those who were capped. 

2. Dr. Ango lost her mother last week. She had been not doing well for sometime. We thank the Lord for her life. Dr. Ango along with her husband, Dr Nandamani was in Manipur when she passed away. They were able to rush back fast and participate in the funeral. We request your prayers for the bereaved family.

3. Sr. Sandhya's father went to be with the Lord last week. Kindly remember the bereaved family in your prayers. 

4. Dr. Shishir has not been keeping well of late. We have decided to send him to Delhi for further tests. We request your prayers for his health as well as for the travel to Delhi. 

5. Today morning, one of our staff, Sr. Elmirah was involved in an accident. We're thankful that she did not have any major injury. Please pray that the injury on her foot will be healed soon. 

6. Last week, we've been signed in for accreditation under the Rashtriya Swasthya Bima Yojana, the public health insurance scheme. We praise God for this long standing prayer request. We are also thankful to one of our well wishers who donated a good amount of money for setting up the initial infrastructure for the program. Kindly pray for the smooth functioning of the scheme in the unit. 

7. We are thankful that RR and RK, who had burn injuries are on the road towards healing. RK may need some amount of skin grafting. Please continue to pray for both these kids. 

8. We are thankful for Sr Wendy and Mr Jerry who would be visiting us for a month. Sr. Wendy has been helping hospitals in EHA towards providing quality care for newborn babies. Do pray for Dr Johnson and the team of nurses who would be facilitating leadership in newborn care at NJH. However, a pediatric and medicine consultant is a crying need for the place. Please continue to pray. 

9. The burn unit construction is constructing smoothly. We've been informed that more funds are on the way. We pray that the Lord will bless all those who have contributed so far. We have also decided to buy a hollow brick making machine, which is something new in this region. Please do pray that we would be able to get this machine fast. 

10. We are in dire need of the following items - a new transformer from the Electricity Board, purchasing a new generator (approximately 400,000 INR)and putting up fire fighting equipment for the hospital (approximately 120,000 INR). Kindly pray for the needs.

Ethical prescriptions . . . taught by pharmaceutical companies . . .

I was prompted to write this blog after few minutes I gave to one of the pharmaceutical representatives to 'educate' me. I was amazed at the audacity of the efforts being taken by these representatives of the pharmaceutical industries, small and big, to go to any extent to promote their medicines. Well, what did this fellow had to offer me rather insisting that I store it in our pharmacy? 

The antibiotic called 'Linezolid'. I have only read about it. Has never seen it, forget about using it. I remember to have read about it being used as a last resort. Later, Dr Titus enlightened me about it being used in MRSA. It was appalling. This fellow wanted me to try it out for patients who do not respond to routine antibiotics. And, if I'm not mistaken, one is not supposed to use it without a culture and sensitivity test. 

There is no point crying over antibiotic misuse if we can allow unscrupulous pharmaceutical companies to market their products in this manner. Many of the people in the leadership level may be great men of integrity, but things are quite different in the grassroot level. 

2 incidents which I should narrate. Both told to me by acquaintances few years back who had worked earlier in the pharmaceutical industry. The first one was about this guy who used to tell me about training sessions that he used to undergo as he prepared for a career in pharmaceutical promotion. The first 90% of the time was spent on learning all the merits of the company and the technical details of the popular drugs which the company produced. The next 10% involved discussions with some of the most successful representatives of the company and the ways and means to 'trap' leading clinicians into prescribing 'our brands'. He left the profession as he did not fit in. 

The second one was about this guy whose wife was suffering was terminal cancer. He was invited to a gala dinner by his colleagues and it turned out to be celebration party for achieving year end target of the same anti-cancer drug which his wife was on. You can imagine his predicament. 

Fast forward to a meeting I had with an organisation who provides drugs to not for profit hospitals in Ranchi last week. The staff of this group was explaining to me about the difficulty in getting medicines which are under the Essential Drug List of the government. The reason - there is a drug price control on such medicines, and therefore nobody was interested in neither manufacturing, marketing or purchasing this medicine. 

And that is true. When, I took over NJH, it was surprising to find that there was no thiazide diuretics readily available. The store keeper informed me that it was too difficult to obtain from the market. Can you imagine that? The first line of management in uncomplicated and few types of complicated hypertension was difficult to obtain in the market. But, it was quite easy to get the costlier forms of antihypertensive medication. Losartan, telmisartan, ramipril etc. are quite easy to obtain. And you won't believe - it remains the same. I raised this issue with one of our major supplier. He asked me, 'Sir, why are you so interested in thiazide? It hardly brings you any margin'.

I was told that one of the best pre-operative antibiotics in clean cases is Injection Cefazolin. I have not yet found a supplier who could get it for me. I was surprised when one supplier told me that he was finding it difficult to provide 'Hyoscine butylbromide' - popularly called Buscopan. He could give me a combination medication which contains an unethical combination of dicyclomine and diazepam. 'Works the same as buscopan' according to my 'tutor'. 

I'm not sure how long we should be mere spectators to this sort of machinations of the pharmaceutical industry. I'm sure that somewhere the government needs to step in and ensure that medicines which are there  in the essential drug list are easily available in the market. However, that does not absolve the clinical care community from taking strong ethical stands regarding prescription of medicines in defiance of the arm twisting and lucrative deals from the pharmaceutical industry. . . 

Tale of 2 pregnancies . . .

I had 2 ladies in the labour room yesterday (Sunday, the 12th February, 2012).

The first one was SD. . .  In fact, it was a bit funny. Dr Titus was on co-call with me. And I was just commenting about how long it had been since we had a patient with eclampsia. SD came in sometime around 2 pm. She has been in labor for quite a long time. . . In fact, almost 36 hours. She had initially tried to deliver at home. After which she was in the district hospital for almost a day before she decided to go to a nearby private hospital today early morning. By afternoon, as the relatives saw that nothing much was happening, they decided to bring her to NJH.

We saw SD walking in through emergency. In fact, we realized that she had a urinary catheter. And was it blood tinged? Yes, it was. . . We really scratched our grey cells on why this patient was kept in labor for quite a long time. We found out  - - more than an hour later.

After a detailed examination, we decided to keep her for normal delivery for another 2 hours. The baby seemed fine although the liquer was a bit meconium stained. She was about 8 cms dilated which prompted us to keep her for normal delivery. As the nurses were ordering the medicines, one of the relatives asked her if she could use some of the medicines which was purchased in the previous hospital. The nurse asked them to bring the lot . . . and along with the normal medicines used in the course of labor, there were half a dozen ampules of magnesium sulphate.

The nurse immediately informed Titus. We asked the history once again. Well, the lady had 2 episodes of seizures sometime during the time she was trying to deliver at home. They did not realise that the history was important. Somehow, it was almost couple of hours after she was admitted. And, we did a repeat per vaginal examination. Nothing much had changed. 

SD was posted for a Cesarian section. The baby was a bit sick, but after a good resuscitation, he's done well. SD was also sick during the post-operative period. However, overnight she has made a good recovery. 

The second one who we'll call RD . . .  It was RD's first baby. RD had been in labor since the last 3 days and she had been leaking since almost 36 hours. RD was trying for a home delivery with the help of a retired nurse. The interesting aspect was that RD had another 3 more weeks to go before her due date. On a detailed history, the pain with she started did not look like normal labor pains. I thought that it looked more like a urinary tract infection. But, she was put on intramuscular oxytocin injections - to speeden up the process. And there was no looking back. 

To complicate matters, she had started to leak. But, she did not take it seriously and did not report it to any of her relatives. The delivery having been planned at home - most probably, there was not much of a seriousness in the whole affair. However, sometime around Sunday afternoon, the relatives started to become concerned - which is when they brought her to NJH. 

With RD having been leaking since 36 hours, I had to explain to the bystanders about the possible complications of chorioamnionitis and a prolonged labour. They looked quite well off for our usual clientele and therefore, I gave them the option of taking to a higher center. They initially refused and allowed us to manage her. I was not much in favor of going in straightaway for a Cesarian section. 

She was about 3 cms dilated with full effacement. I explained to they relatives about us taking the risk of trying for a normal delivery. I decided to give it a try as long as there was no sign of a fetal distress. I was surprised that RD progressed textbook fashion. But then, she suddenly stopped contracting at full dilatation. I had to do a vacuum extraction of the baby. 

The mother and the baby are doing well. 

Both SD and RD could have ended up with severe complications endangering the lives of both mothers and babies. They are blessed to have had happy endings. We praise the Lord for the same. . . 

As I had mentioned in many of my posts, the solutions are not very difficult. SD need not have run from one hospital to the next, trying for a good management. RD should have been investigated for urinary tract infection, before a decision was taken to induce her. . .  And how was the induction done . . .Intramuscular Pitocin . . . It continues to be a scourge in maternal healthcare all over the country. And RD was quite unaware of the dangers involved when she started to leak . . . And the worst of all - especially when a patient comes from another healthcare provider - the lack of a proper referral letter . . . SD and RD could have been provided referral letters by their previous respective care providers . . . 

All these are not rocket science . . . We've been shooting off rockets with satellites into space, manufacturing supercomputers and contributing heavily into the information technology field and more interestingly developing into a medical tourist destination . . . But, what a paradox - when it comes to providing safe delivery facilities for our sisters and mothers, we come up a cropper . . . 

Obstructed Labour . . .

Just wanted to post couple of photographs and couple of thoughts related to a Near Maternal Miss we had today morning. . . 

As you are all aware, obstructed labor is one of the major causes of maternal mortality. If I'm not mistaken, obstructed labor is either the fourth or the fifth most common cause of maternal mortality. Of course, the most dangerous presentation of obstruction is a rupture uterus.

I would be sinning if I do not admit the fact, it was couple of eclampsia patients and one rupture uterus which actually started this blog moving. . . 

Many of the babies in an badly obstructed labor do not make it. And we had a very bad one today morning. The only thing we had in our favor was that the uterus was still intact and the baby was alive. 

SD was in labor since yesterday evening. She started her pains at sometime around 6 pm in the evening. And from 8 pm, she was in the district hospital. She was started on a drip with some medicine - the family was not sure on what it was. . .  All through the night, she was contracting . . . Unfortunately, nobody did a pervaginal examination on her till today morning, sometime around 6:30 am, and she was asked to come to NJH. . . 

I'm impressed. We've had terrible cases where patients were kept in the lurch in healthcare institutions, both public and private. Here, SD was referred within 10 hours of her admission although she could have been monitored a bit more better as well as had antenatal check up. 

Well, that is the reason, she did not end up with a rupture uterus. 

I was in the middle of a Cesarian section at around mid-morning when the news about SD's reaching NJH reached my ears. Dr Johnson saw her first and immediately posted her for Cesarian. . . The baby was wedged tight in her pelvic outlet. . .  He was worried if I'll have difficulty getting the baby pulled out from the abdomen . . . 

And, oh my! It was the worst obstructed labor that I had ever seen. . . The uterus looked quite funny from the outside - was suggestive of bladder edema and dilated bowel loops. I decided to open the abdomen through a midline vertical and oh boy! Was I not overjoyed? The snap below tells the story . . . 

The finger is on the upper part of the incision and shows the bladder. The second snap shows the place I put the stay suture before I opened the uterus. . .In my career of 10 years, that was the highest stay suture I've ever put . . . .

Of course, the baby was sick . . . However, my colleagues including the new kid on the block, Dr Titus ensured that the baby was breathing well . . . It was then that we noticed that the baby had a head little larger than usual. . . A head circumference of 40 cms for a 3.5 kilogram baby is definitely on the higher side. . . We've given an option to the relatives to take the baby to Ranchi for evaluation . . . Surprisingly, there is no caput or cephalhematoma . . . 

One more aspect about the whole incident was the time taken by the patient to reach NJH from the place where she was being managed earlier. . . A decision was taken to refer her to a higher center was taken at around 6:30 am . . . however, she reached us only by 9:30. The place she came from is only 30 kms away . . . Inadequate transport facilities, bad roads etc contribute. . . 

We got the baby out at 11:12 am . . . We could have done it faster had the theater been free. . . When the patient arrived, another Cesarian was on and I was sure that the Cesarian on SD be done on General Anesthesia. And I was thankful to the Lord that we did it on GA as the surgery took more time than normal as well we needed more muscle relaxation . . . 

We still need to go a long way . . . And the most easiest aspect of this journey is that the interventions, such as protocols, identification of danger signs etc that we need to implement are simple and inexpensive . . . 

Health Education . . .

Last week, when we were invited for participating in the block development festival at Satbarwa Block Office, I realized that as a healthcare institution we did not have much of any display material on health and diseases. 

The only model which we had was a cross section of a female abdomen showing an almost term baby in the uterus. And oh my . . . what a crowd we had just to see that model. I counted at least 20 people taking photographs of the same using their mobile cameras. 

And I felt sad that we did not have anything more to show other than few display charts on malaria, tuberculosis and nutrition. There were few charts in the nursing school, but they were in quite a poor shape to warrant a public display . . . 

I remembered my days in Kerala when it was common for us to have regular road shows and the nearby medical school putting up a show of quite a lot of their specimen, models and charts. And later, when I joined medical school, it was quite a common thing for us to go and volunteer in these exhibitions. 

And when I interacted with my colleagues who came from medical schools around here, nobody could remember about a similar thing happening here. 

As I sat contemplating on planning to develop a museum of some sort, it was quite surprising when I received a catalogue of healthcare related models and charts.

The catalogue was quite a good one. . . There were quite large charts and models on almost all the topics which we deal with quite regularly. Tuberculosis, complicated obstetrics, eye problems, malnutrition . . . almost all of them . . . 

Now, as in most of the cases in institutions such as ours, the discouraging aspect is the cost involved. However, considering the support I've been receiving from friends and well wishers, I have decided to put this as a post and request for help. . . 

I'm sure this would go a long way in helping us to promote health and prevent diseases within our target populations and put up better shows in events such as the block development festival in the future. More than that, with a nursing school as well as the regular continuing medical and nursing education sessions that we have been having, it would be a major asset to the institution . . . .