Skin Graft Mesher . . .

We were quite thankful when the Burns Unit support team at UK comprising Dr Ron Hiles, Dr Colin Binks and Ms RuthAnn Fanstone allowed us to buy a Skin Graft Mesher from funds which were allocated for the burns unit. 

It has been with us for sometime. But nobody requiring a graft was coming to us. Even when there was someone who would have benefitted from the graft - we did not get consent. 

Ultimately, we got a patient - but he was not a burns patient. The young boy had a snake bite and was managed at home. Unfortunately, his skin got necrosed and started to slough off when he thought about coming to healthcare. First seen at a Catholic dispensary in Latehar - he was referred to us. 

After almost quite a month taken to make the wound clean - it was ready for the graft. And of my, we were all so excited to use the machine. Below are few snaps of Nandamani and team getting the graft on to the exposed leg . .  .

The leg to be grafted . . .

Nandamani at work . . .

Starting the work . . .

The graft almost complete . . .

We are very much thankful to all those who donated towards the burns unit, the funds of which were used to buy this machine. And of course to our support team in UK who facilitated the same . . .

Monsoons . . .

Monsoon . . . A word that is unique to the country. When I recollect the word being mentioned during my childhood, I used to think that it was slang for rain. It was after quite a long time, I realized what it meant.

Childhood memories remind me of the first day to school. In Kerala, usually school starts sometime during the first week of June. And I remember that most of the days, the first day of school was characterized by heavy rains . . . 

I distinctly remember one of the years during our stint at Kollam, Kerala. We used to travel by a cycle rikshaw to school. I was in the 1st or 2nd standard. There were about 6 of us, crammed together. It had started drizzling by the time we had made some progress towards school. We could see the dark clouds laden with all the water coming at us when our rikshaw puller decided to put plastic sheets improvised to shield us from getting wet . . . 

Our rikshaw driver also had a custom made conical shaped plastic sheet which he draped over his head. It was quite a sight. 

As expected, the rains lashed us as we crawled through the town towards our school. It was as if someone was pouring huge buckets of water on us. We had expected the rains to stop as soon as we reached school. On nearing school, it was a nightmare. The roads were all water-logged. 

And it being the first day of school - there was quite a large crowd. In addition to parents, there were proud grandparents, uncles, aunties etc who had come to see off their grandchildren, nephews, nieces etc to school. Our rikshaw driver realised that we would have to wade through the water. 

I looked down on my shoes with brand new white socks. Then at the brackish water from the overflowing drains . . . It was revolting. Then our rikshaw-driver made the most amazing offer. He offered to carry each one of us to school. I don't remember who he carried first. 

I felt very awkward. Although only being in the 2nd standard, I was not exactly of that built that anybody will want to lift me up. Being on the heavier side and being a bit self conscious, I did not my friends to see me being carried to school through the flooded road. 

I made up my mind. I was going to remove my shoes and socks and walk through the water myself. As I prepared, our friend was back for his next trip - but confidently told us that he has found a short cut to take us nearer to the school gate. I was relieved. . . 

Over the years, I've realized what monsoons mean for the country. If reports are true, 60% of cultivable land in the country depend on the monsoons exclusively and 60% of the country's population depend on the farm sector for a livelihood, although it only accounts for only 15% of the Gross Domestic Product of the country. 

Years later, as I sit in the hot environs of Jharkhand, I wish I could be witness to the magic of the monsoon as it hits Kerala. The idle evenings after school spent watching the rains fall and fall, the nights when the pitter patter of the rains seem like a symphony gone awry, the days when we had to run in the rain after we had forgotten to take our umbrellas, walking through the slush with the unexpected puddle hidden somewhere, vehicles dashing through the road splashing mud and water on us, the Sunday morning walk to church . . . I miss all of those . . . 

Last year was a blessing for us. We had enough rains. Our pond had got filled up. We had put fish in it. . . and harvested about 250 kilograms of common carp, grass carp, silver carp, rohu etc . . .

Today, I heard that the rains have hit the coast of Kerala. . . We pray that we would receive a sliver of it as it progresses towards the North. . . Palamu district is known to be a rain shadow region. But, we pray that 2012 monsoon would remember our region. We dream to see a filled up pond. . . and to grow fish for the next year . . . we dream to see greenery around us, people working hard on their fields, people not needing to go away from home for work . . . and of course temperatures to come down . . . 

It was only recent that I read about theories of how successive years of monsoon failures may have wiped out the Harappan civilisation . . . Amazing that we are the mercy of the winds bringing moisture from the southeast seas to fuel our supposedly trillion dollar economy . . . We can only pray and wish that we would have a bountiful monsoon 2012 . . .

Bandhs . . . Contributing to disease mortality . . .

It's a bandh here today - the Indian name for a General Strike. The best part is that nobody had any clue about it till today morning. Our vehicle was on it's way to Ranchi to pick up one of our good friends when we found about the strike. It seems that the call for the strike came yesterday night. And to add insult to the injury, it's a 2 day strike. 

It's not even a week since we had a 2 day strike - on the 30th and 31st May. The second day was a strike all over India in protest against the price rise of petrol.

For NJH, bandhs have rather been a regular feature. During the 2010-11 financial year, we had a total of 75 bandhs. 2011-12 has been better with only 54 days of shutdown. The current financial year has already seen 14 days of bandhs (including todays).

The curse of the bandh culture did not even spare us during our summer vacation. The day we were supposed to travel from Trivandrum to Othera turned out to be a bandh . . . with us losing our train tickets. 

When we were kids, bandhs used to be a welcome break. It is still not an uncommon sight to see kids playing cricket on the street during bandh days. 

However, it is not so for the country as it is calculated that we loose quite a lot on the economic side when the politicians decide to call a strike for a day, leave alone two days.

From a healthcare point of view, it is a terrible tragedy. We've had umpteen number of very sick patients who arrive too late or find it difficult to travel to a higher centre in Ranchi. 

We already have a patient, UD, a 30 year old mother of 3 who was bitten by a krait sometime early morning today. Although the family knew that she had to be brought as soon as possible, it took them almost 6 hours to find a driver who was willing to drive them to us. By she reached a good 8 hours had passed after the snake bit. 

She was in respiratory depression. Interestingly, there was no derangement of blood parameters. Usually, krait venom is both neurotoxic and hematotoxic. Now, it's almost 12 hours since the patient came. Unfortunately, the paralytic symptoms continue to persist. She is not yet on the ventilator. But, we are keeping a very close watch. . . 

I'm sure if she could have come earlier, her symptoms would not have been this bad. 

There are more stories I could tell you about patients who lost their lives because of bandhs. It could be different in cities but in areas like ours where is not much of a choice when it comes to selecting a care-provider, bandhs can turn out to contribute to disease mortality and morbidity . . . .

Please do pray that UD will make it . . .

Summer Vacation . . . Part 2

Following are snaps taken in the later part of our vacation in Kerala . . .

Shalom and Charis on a bus ride in Trivandrum. Charis looked quite nervous throughout. . .

Initiating Chesed into reading . . .

I went to visit one of the companies offering biowaste energy. This is a prototype of a machine to produce biogas from household vegetable waste. We are actively exploring prospects of using biowaste for energy generation at NJH . . .

Streetvendor selling butter-milk in Trivandrum . . . Something of the olden days . . . Makes it a point to have it every time I visit Trivandrum zoo where this guy has his shop . . .

Mango festival at Kanakakkunnu Palace . . .

They had quite a lot of variety in display . . .

Vegetable gardens are a major craze in Kerala . . . Model vegetable garden made in jute bags filled with soil . . . aimed at those with no planting space . . .

Bonsai plants for sale . . .

And they had mangoes for sale too . . .

Having fun with Ammachi at Trivandrum . . .

Christian Medical Fellowship, Trivandrum

Charis playing with Achappam

At the dinning table with Appachan in Trivandrum . . .

By the Pamba river near Othera . . .

Shalom and Charis in a contemplative mood . . .

Eclampsia . . . Solutions . . .

The patient about whom I had mentioned in my previous blog, PD who was in HELLP and on the ventilator passed away sometime around noon time couple of days back. . .  

As I sat with the relatives for filling up the institutional Maternal Death Review forms, I was stunned to find out that PD had been having symptoms of sudden onset of swelling of the leg and episodes of severe headache along with nausea, vomiting and abdominal pain since about a week before she had more than a dozen episodes of seizures. She had consulted one of the local quacks and she was told that this was common in the first pregnancy . . .

PD had her last antenatal check ups couple of weeks before she had the acute onset of seizures . . .  And she had quite regular antenatal check ups . . . Unfortunately, they did not help her to realize that she was having complications setting in . . .

We have quite a large number of patients who come with various forms of hypertension in pregnancy . . . Most of them are managed without much problems . . . However, last month, we've had 5 deaths due to eclampsia . . . Mind you, we had given the option to all of them to be taken to a higher centre . . . However, I suspect, if anyone would have tolerated the four hour journey to Ranchi. 

I'm sure it is very much evident that prevention of eclampsia requires much more than a routine ante-natal check up. Explaining to the patient and relatives about the warning signs, such as swelling of the legs, headache, nausea etc has to be done very thoroughly.

Nobody is quite sure about the aetiology of the condition . . . Theories abound . . . I wonder if it has some relation to some vitamin or mineral deficiency . . Something else which I've noticed is the aspect of the husband being away from the patient for quite a long time in almost all the cases of eclampsias. . .I would love to do a case control study . . . Provided I've the time and required help. . . 

However, till we have definite evidence about the aetiopathogenesis of the condition, the best we can do is to education communities and families about the warning sings of pre-eclampsia which should ultimately have them rushing to their health-providers  for help . . .