The Girl Child . . . Positive Deviance . . .

Today, I had a very unusual patient. ZA had come about a week back with his wife, KZ who had an abortion and we had to do a curettage of the uterus. That was when ZA asked me whether I was from Vellore. He told me about his 8 year old daughter, BZ who was specially abled after she suffered from a delay in normally reaching developmental milestones.

This was amazing. In a society who gave quite a lot of prominence to male children and treated its female children with lesser care, ZA and his wife, KZ stood out. It was quite encouraging.

They had invested quite a lot in the well being of his 8 year old daughter so much so that KZ underwent a manual termination of pregnancy (MTP) couple of years back, so that they could give extra care for her.

It was quite a long time since I was seeing a specially abled child in outpatient. The child was quite smart. As seen with many of the special children, BZ was also quite interested in music and stories . . . It was quite unlike quite a majority of parents who have girl babies with a probability of not being 'normal'.

It was wonderful that I could get through to one of my old friends at CMC, Vellore who readily agreed to review BZ. I know that there may not be much happening, but it is encouraging to know that attitudes are slowly changing for the better. I wish this change would be infectious and a time will come when the girl child is cherished and valued more in Indian homes . . .

I had already planned many things in administration today, and therefore did not find much time to talk with the family. However, the major finding I had about the family was that the mother was a graduate. . . and the father a teacher. . . There must be other factors too . . . I’m going to probe into them some time, but if it is female education which will make a difference, then we have miles to go . . .

Experiences with RSBY (3)

I did not have the time to blog last week after I had returned from Delhi when I had to deal with quite a bad near maternal miss.

RP, a 20 year old primi at near term was brought unconscious with a history of seizures since early morning last Saturday (Feb 25) morning. The lady was in a terrible state and it was obvious that she was going to pulmonary edema following eclampsia. The oxygen saturation was hovering around 70% even after stabilising her. We had to intubate her.

It was quite obvious that the family was quite well off. We did not have much of a choice as it was very sure that she would not make it to Ranchi.

We gave them the option of operating her immediately. I’m not sure – after many of our experiences we have come to the conclusion that the faster we take out the baby, the better the prognosis. I was a bit afraid. But, we’ve done umpteen number of them and our mortality with eclampsias was quite low.

Our a detailed risk consent including a death on the table consent, we went about with the surgery. By God’s grace, everything went on well. She remained on ventilator for 6 hours after the surgery. And she made a very quick recovery. For the pulmonary edema we had to give her a GTN drip. It was so wonderful to see her fully conscious by late evening.

She continued her recovery and the sad turn of events started yesterday morning. Her father turned up with an RSBY Card into the newly furnished RSBY counter. Dinesh did not know much about the patient and readily checked the card which he found out to be outdated. He started to haggle Dinesh and Malaya for renewing his card and putting RP under the scheme. Dinesh and Malaya told him that there was no chance of doing anything as the patient was admitted almost a week back.

I never knew about this and I had this man coming to me sometime late afternoon demanding that I somehow give him the facilities available under the Smart Card. I told him that was not possible as the patient was admitted much before the RSBY program started. He started to threaten me and rang up the local Member of Parliament and demanded that I talk to him.

I left him ranting at me. Later in the evening, when I went to attend a call, one of my nurses told that this man has threatened us saying that he would file a criminal case against us. I told the nurse to ignore him. But, that did not end with that. He was waiting on the way to have a word with me and started to beg me to somehow give him full charity under the Smart Card.

I told him what I really felt about such behaviour. Now, here was a patient, who would have definitely died if we had not intervened heroically. On the other side, this family did not deserve to have the Smart Card with them. The father, the fellow who came to claim the said benefits was a teacher earning almost 30000-35000 INR per month – a far cry above the poverty line. RP’s husband was a poultry farm business man. So, one can assess well.

At the same time, I had a very poor patient with a very bad Herpes Zoster eruption in the Male Ward. The family was too poor to even afford food. They did not have an RSBY Card.

It was quite obvious on who has got their names into the BPL list and thereby got hold of a card. I’ve few of my own staff who earn more than 2 USDs a day who have got their names into the BPL List. It is a bit embarrassing.

It is not quite uncommon to expect people to demand services. Couple of instances . . . I’ve a old lady in the private ward, whose family came to see me saying that they have the RSBY card with her name on it and therefore demanded reimbursement. I refused it outright. They have threatened action against me. Couple of patients who came for cataract surgeries demanded that they have imported lenses put in during the surgery. 

That demand has also been rejected. The only relief was that the latter patients understood what was being told. . .

When I hear about BPL, I envisage visions such as that of the row of children at the beginning of the post. Not people who are on a payroll of the government or some institution like ours. I wonder if we could report patients whom we do not think deserve the BPL card, when they come for treatment . . . If that is allowed, I know where to start from . . . From my own staff . . . Although that is going to be a tough ask . . . 

Experiences with RSBY (2)

MD, aged about 30 years came yesterday morning with one of the most terrible bed sores I’ve ever seen. MD had been bed-ridden for the last 8 months after a bout of fever. To me, it looks like a case of transverse myelitis. Unfortunately, she developed bed sores over the last one month and there was nothing much the family did for her.

Then somebody told her about NJH and the ‘good treatment’ we offer. So, MD came to us. She had actually 3 sores. One on her back and two on the the flanks where the pelvis bone was in direct contact with the skin.

It was stinking. And the family was very poor. I’ve written a mail to the insurance company saying that this treatment would not fit into any of those mentioned. According to Dr Nandamani, she would need a thorough debridement (INR 5000), following by daily dressing for about a month (INR 500 X 30 = 15,000) and last of all, a skin graft (INR 8000 – FP00500243).

We’re yet to hear from the insurance company, but we’ve started the treatment and Dr Nandamani felt that it could be fatal if we waited and the patient goes into sepsis.

Another patient was yound RKS, who sustained scalding of his right hand 5 days back and needs a tangential excision and skin graft. However, the amount put in was too low for any sort of surgery. I ultimately put him in FP00500243 which would give us 8000 INR. In this patient too, we feel that the compensation is too low especially when you take into consideration the expertise involved.

Both the patients had their surgeries today. We pray that both of them would recover fast.

Meanwhile, UD who had a dead baby and was our first  RSBY in-patient has got discharged.

We are yet to officially inaugurate RSBY services at NJH and we’ve not yet given much publicity to the fact that we have been empanelled. However, we had 15 patients in OPD and IPD together of which only 4 were valid cards. We had an unfortunate incident today which is a forewarning to all of us on how unpleasant can things turn out to be with programs such as the RSBY without the responsible involvement of the community . . . That would be my next blog . . .

Firefighting at NJH . . .

After the fire tragedy at a hospital in Kolkota couple of months back, we took a decision to install fire-fighting equipment in our hospital. It is of course a costly affair, but it was something mandatory and therefore, our management committee took a decision to go ahead with the same. The total cost of putting the necessary equipment which includes extinguishers containing chemical powder, carbondioxide gas and water cost us a whopping 120,000 INR.

Unloading the tanks

Elias trying out the fireman's helmet

Today was the installation and demonstration of all the equipment. And we had a great and hilarious time.

After the company arrived with the equipment, they requested us to get a good fire going so that they could demonstrate the equipment.

Our maintenance department was up to the task and there was no doubt on who performed better at the end of the show. The snaps say it all.

Starting the teaching session

Starting the fire

Resham trying to douse the fire

Realised that the fire is quite a bad one . . .

Resham's extinguisher runs out . . . 

The third one being tried . . . 

The fire still burns . . . 

The biggest one is brought in . . .

Which malfunctions . . . 

 I wonder if we could have done without the equipment. But, our maintenance fellows had fuelled the fire with waste cloth used to clean the generators/vehicle, old gasoline scrapped from the fuel tanks of the generators when they are cleaned, dry wood and cardboard boxes from the stores. . .  

So, lesson learnt at the end. It's better to prevent a fire from starting rather than try to douse a fire . . . How true . . .

Experiences with RSBY - 1

I thought of starting off a subsection of posts just for RSBY matters.

1. We had our first patient yesterday, a young lady into her first pregnancy who has ended up with an intrauterine death. She was admitted and delivered the dead baby sometime yesterday evening.

2. We also had 8 other patients who came with the card – but they all had problems. Almost all of them had not renewed their card. Rather it was an old card. They never saw the need to renew as there were only very few healthcare institutions where they had to do.

3. The next patient was one of our village volunteers who had to get his tooth removed. Nobody of us were quite sure if this procedure was included. But, it was. I was glad that he came to me in the office to check and I had the list where it was there. Since the first lady is not discharged yet, technically this elderly man was our first completed patient.

But, we had problems with the tooth extraction procedure. The item coded as FP00100009 was priced at 100 INR. Now, this was the amount we had to give for transport which meant that nothing would come to hospital. However, we decided to go ahead with registering him and the computer refused to take him in saying that the amount has to be 200 INR or above. And the program was refusing us to change the amount.

We called the phone numbers given to us and it was surprising that this was the first time somebody has actually done this procedure under RSBY – maybe in the whole of the country. And that’s the reason nobody thought of it. I’m not very sure if it is correct.

The person on the phone advised us to put the procedure as something else which would cost more than 200 INR and promptly do it off. So, we put the procedure as Flap Operation Per Tooth which cost 250 INR – 100 INR to the patient and 150 INR to the hospital and did it off.

Regarding this procedure – removing a tooth – the charges are quite less. In Ranchi, it costs about 350 INR and for us the actual costs would be about 200 INR. Therefore, the best price for this would be INR 250 which would mean that the RSBY Price should be 350 INR of which 100 INR should go to the patient.

4. Meanwhile, today I got hold of the full list about enrolment of BPL card holders into RSBY in Satbarwa region. Of the 10,000 odd eligible families, only 3500 odd has been registered. The strategy of not involving the care provider which was adopted by the Insurance Company, about which I had mentioned in my previous blog about RSBY, has obviously backfired. Now, from tomorrow, we are going to help out the Insurance Company and the Software Provider to do the enrolment. Let us see how it will turn out . . .