The saga of the pregnant Indian woman . . .

It’s been quite a long time since there has been a post. There were multiple factors for the lull. The major issue being that the hospital has been terribly busy over the last couple of weeks. I’m not sure on how we were pulling through. Today, we had already crossed 1750 outpatients and 250 inpatients for the month of September.

I continue with my banter about the unfortunate souls who come through us for treatment and their stories.

It was about 5 days back as I did my rounds that I noticed a very youngish looking lady rather girl, RDB in the first bed of Maternity Ward. Usually the first bed in Maternity Ward is kept aside for very sick patients so that the nurse on duty can have a close watch.

The ward was full and I asked the duty nurse the reason for this young lady to be in that bed. To my shock, the nurse told me that RDB had a rupture uterus and she had been very sick. It was only today that she was able to sit up.

A rupture uterus. RDB hardly looked 16 years. I asked her how old she was? Her chart told 22 years. Even for 22 years, a rupture uterus was a very harsh affair to deal with.

RDB’s story was not very unfamiliar. Married off around 4 years back, her first pregnancy ended up in a Cesarian section after a prolonged labour at home. The baby was dead . . .  Nobody had even told her that she needs to have a hospital delivery the next time.

She tried to deliver at home. She was taken to a hospital from where she was referred here. Her hemoglobin was low. She waited for almost a day for blood. The rupture was a very bad one. Our surgeon did not do a tubectomy as a tubectomy would ensure that she would be destitute in no time.

I could only whisper a prayer for her future as I walked on.

Yesterday, as we were in theatre, Dr Titus informed us of a pregnant lady brought dead after having seizures. We were too busy to even go and have a look. Later that evening, as I reminiscenced about our attitude towards the women in our community . . . I wondered if we were all busy to take any note of the women who were dying in our communities . . . almost all of them preventable deaths.

As we develop newer and complex treatment modalities for many a rare disease, the saddest thing remains that a majority of preventable deaths in the world occurs due to conditions for which very simple steps for prevention and treatment have been discovered long back.

I’ve one more patient in the Acute Care. A young mother with her first pregnancy at around 8 months of gestation. She had been having seizures for about 12 hours before the relatives decided to bring her here. She was hardly breathing.

With no facilities of even a First Referral Unit, we’re forced to manage her. The adequate facilities for her treatment are available only 135 kilometers away. And there also, she would need admission to a private facility who would be about 2 to 3 times more expensive than us . . . leave alone the transport and indirect costs.

The husband has given us a death in the hospital consent.

As soon as she arrived, she was intubated. In severe pulmonary edema, we did not have much of a choice. After about 24 hours, she is out of the ventilator and semi-conscious. We’ve trying to deliver her baby out fast. I was not very confident about taking her up for surgery. To make matters easy, the relatives absolutely refused surgery.

We wait for her to deliver. For her to survive without any sequela would be a miracle.

However, as I thought about all the umpteen patients whom we had been managing over the years . . . many of them who would have done better elsewhere under specialist care . . . I wondered how long this sort of care can continue on . . . 

(Just as I finished writing it, we had a referral of a lady with post-partum eclampsia . . . and she was referred to us from a private medical college . . .  and the family came driving about 100 miles)

Kits ? ? ?

As I finished a very busy outpatient department today evening, there were couple of Medical Representatives waiting for me. As the offices were already closed, I asked them what they were trying to sell as I walked towards the wards. 

I was shocked by the answer. 'Dengue testing kits' . . .  one retorted. The look in my face must have brought quite an astonishment. I don't know how it looked. 'How much it is going to cost?' was my next question. 'Only 300 INR . . . shall give it to you for a good price'. 'And it's a antibody plus antigen strip test . . .  the new technology and our research ensures that the diagnosis is made on day zero.' 

I was furious. I asked them if they knew anything about what they were talking. One fellow told me that he could show me literature. 

I could not bear to hear more. I told them that I was a doctor who was interested in the welfare of people as much as coming to a correct diagnosis. And there was enough research on the 'usefulness' of the tests based on the antibodies and antigens . . . And the fallacy of diagnosis being made on day zero. 

They realised that it would be dangerous to talk more. . . and beat a fast retreat. 

The antigen and antibody kits have made a mess of clinical diagnosis. It is not much time since WHO came out with a paper about the useless of Tuberculosis IgM and IgG tests. I remember seeing a patient who had a huge filarial leg . . . the relatives told me that they had confirmation that he had filariasis . . . and showed me a Antibody test for filariasis positive done elsewhere. 

One of the shocking things I had during my first stint at NJH was the rampant use of Widal test and Typhidot for all sorts of fever. Even patients with one day history of fever was requesting of Widal or Typhidot. Even among my colleagues I had to spent quite a bit of energy to convince them that doing it before 5 days was as good as not doing it. 

One can only imagine the mayhem the can be caused by introducing 'dengue testing kits' which have a very high false positivity rate. 

Talking about kits, I'm very much against even the 'malaria testing kits'. As far as I understand 'malaria testing kits using antibodies/antigens' was introduced as there was difficulty training technicians to do malaria smears. As I sit in outpatient, it is not uncommon to see patients who have tested positive for the parasite with one of the kits and having been treated for malaria . . . and as you take a good history and clinical examination, it is very evident that you are dealing more likely with Enteric Fever. 

All fever patients whom we see are tested positive elsewhere with the kit . . .  But, nothing comes up when we do the smear. . . even when they have not had the treatment. 

I'm glad that there are quite a number of learned people within the community who have realised this and come to us directly to do a smear . . . And of course, we are blessed to have very good technicians who can really fish out the parasite from a thick smear . . . 

And the bottom line for my friends who are in some part of their training or practice . . . even for infectious diseases, nothing can substitute a good history taking and clinical examination . . . 

One aspect which I leave for you to decide is . . . on whether we should come out openly against companies who make a quick buck from selling such kits. I remember the 'chikungunya kits' which were produced by some companies while the Chikungunya epidemic was going on sometime in 2007. 

I would propose that the government come up with a regulatory body for such investigation kits . . . But, having failed miserably in being able to regulate the pharmaceutical market, regulating the laboratory industry would be a far cry. 

A Justification . .. ...

I need to keep reminding myself on how I started off this blog . . . I've had many a person writing back to me  telling me how inappropriate it is to put many of my posts in the blogsphere. 

Very recently, after my post on the very unusual post about the rupture uterus, after I cross-posted it in a public healthcare site, I had someone ask me if it was appropriate to have posted it there. I thought it was appropriate . . . I don't mind if someone thought that it was inappropriate . . . 

About a week back, one of my staff told me that I belittle the region I'm in by portraying deficiencies of healthcare in the region by stuff I post. I asked him about what I should be posting. He told me he would think about it and let me know . . .  I've not heard from him ever since. 

Everybody loves to have beautiful romantic stuff posted . . . And it's not that I don't do that. 

Why do I write about cases of maternal deaths, near misses, tuberculosis cases etc. etc. 

It's because they are all so successfully treatable if not preventable to quite a large extent. 

The lady with the rupture uterus . . .  You should hear her story. 

We shall call her AAD. She had her first baby by Cesarian section for a reason about which she has no clue about. According to her after she was discharged after her Cesarian, nobody told her about not trying to deliver at home for her next deliver. Result . . . she did not bother to even do a routine antenatal care for her next pregnancy.

AAD started to have contractions early morning. The local village dai (traditional birth attendant) was called. She told the family that everything was fine and she should deliver by afternoon. Sometime mid morning, the dai felt that he was not progressing well and gave her four intramuscular injections . . . by our usual experience, it's pitocin. By afternoon, AAD had started to contract violently. It was excruciating pain. 

By around 3 pm, the family felt that she should take her to the district hospital. Whoever saw her at the district hospital was sure that the baby was doing well and she would deliver soon. She was there till around 7:00 pm, when they decided to move on. 

She reached us at around 9:00 pm. We did not need rocket science to find out that it was a rupture uterus. Per operatively, it was very evident that the rupture uterus had happened quite recently. The baby was a fresh still birth. 

I did not have any choice other than to do a tubal ligation (Family Planning) as the rupture was quite a bad one . . .  Like many of our previous stories, the husband would most probably abandon her for another woman who will be able to offer him more babies . . . 

The first time, when I told a similar story to one of my classmates, he told me that it was so unthinkable a story. But the fact remains that we have so many similar stories in our country and the world which are unfathomable to have occurred in an era when cutting edge medical science is looked upon with awe . . .

I've taken it up as a duty to bring to light such stories so that nobody who reads them will ever tell that they never knew there were such regions where such basic issues of healthcare were never taken care of and they could have played some role in alleviating the pain . . . .

That would bring me once again to the point of inviting more of my fellow healthcare professionals (rather nagging) to move out into needy areas of the country where your presence would end up saving lives and showing people that there is a God who cares . . . 

RSBY Success Story . . . But . . .

On the 24^th of last month, MDO, a 20 year old young man was searching for some thing in his house late in the night, when he was bitten by a krait on his hand. As is the prevalent practice, his relatives summoned a local faith-healer who assured them that everything was alright.

However, as time passed, the father realised that something was amiss. MDO was not able to breathe properly and was looking very sleepy.

NJH, being very near to his home and one of his cousins being a chowkidar in the hospital – the family rushed MDO to NJH.

On arrival at NJH, Dr Johnson attended the call. MDO was hardly breathening and was bluish all over. There was no response to stimuli and his pupils were mid-dilated and hardly reacting. MDO was intubated and was put on the mechanical ventilator. The relatives were explained about the very small chance of survival. It was about 1:00 am of 25th August. 

Meanwhile, our chowkidar, Mr. Jamuna who was MDO’s cousin told us about the RSBY Smartcard (Rashtriya Swasthya Bima Yojana) the family had. It was brought immediately and was promptly blocked for treatment of snake bite.

It was only recently we were having a discussion of snake bites being covered under RSBY as there was a major increase in costs of Anti-Snake Venom (ASV).

Since, we were yet to come to a conclusion on the increase in ASV costs, we decided to treat him fully under RSBY.

By the 25^th morning, when I came for rounds, MDO’s pupils were fully dilated and fixed. There was no reaction till about 26^th afternoon.

He was in the ventilator for 80 hours. And intubated for 104 hours. 120 hours of Acute Care admission. . . 30 B-type oxygen cylinders . . . 20 ASVs - the cost of which alone is 13000 INR

MDO is getting discharged today. The problem was that his total bill had come to a whopping 45000 INR and RSBY was going to pay us 10500 INR.

MDO with his father

We’re not sure on how to approach this. The family is ready to pay us 7500 INR more. But, as per RSBY policy we are supposed to be giving cashless service. I’ve sent a mail to our Insurance Providers explaining about our predicament. I hope that they would respond positively.

The interesting part is that we have 3 more patients in the ward with krait bite. And all of us are in some part of their ventilatory support . . . I’m glad that we have 2 ventilators . . . But still, we’ve to refuse all patients who could end up needing a ventilator since yesterday . . .  eclampsias, snake bites, severe pneumonias etc . . .

The recent increase in cost of ASV make it quite difficult to treat snake bite victims under any protocol of snake bite management under RSBY. I hope that the concerned authorities would take note and do the needful . . . 

(Consent to publish the photograph and the story has been obtained)

Images of an unusual Rupture Uterus . . .

(This post is purely of medical academic interest and contains snaps which could be offensive. 

User discretion strongly advised)

I hope you remember this image from my earlier post. This is RD's baby who came in with a hand prolapse after she was diagnosed earlier with a transverse lie. It was only after Dr. Titus read the post that he told me that I had forgotten to mention that RD had a previous Cesarian. 

I did not know that since I was not directly involved with RD's management. 

Talking of previous Cesarian Section, about a week back we had another patient with a previous Cesarian who came in with a Rupture Uterus. Below are the snaps taken per-operatively. Kindly excuse for the messy background as we were in quite a hurry to finish the surgery as the patient was quite sick. 

Area of rupture which was along the left lateral wall of the uterus, into the broad ligament.

Another view of the ruptured area after we started to suture it up. 

Hematoma from the ruptured region which extended along the mesosalpinx

The avulsed round ligament . . .

The surprise . . . The intact uterine scar of the previous Cesarian section which was marked very clearly by the bleeding which tracked along the suture line. We double checked it to ensure that there was no breach of the incision.  

It was quite amazing that the uterine incision of the previous Cesarian section was intact and the rupture was through the lateral wall into the broad ligament. One can only imagine the pain that the lady went through. 

However, by God's grace, she had an uneventful post-operative period and was discharged yesterday.