Neglect and . . . Issues to contempate

Yesterday late night, we had a patient which is a prototype of the sort of patients we get here. 

We shall call her RN, a 30 year old lady who came at around 8:30 pm. 

From an antenatal point of view, a high high risk patient. A Cesarian section done about 18 months back. She was never taken for any antenatal check up. No hemoglobin values, no blood group, no body willing to donate blood . . . leave alone an ultrasound.

We usually follow the dictum of getting one pint of blood ready in spite of a normal hemoglobin value when the patient is a previous Cesarian section. We agreed to take her if the relatives could arrange one unit of blood. 

We waited for almost 3 hours for the blood. Which never came. 

Around 11:30 pm, the relatives started to make a big fuss on why the surgery was not being done. Our doctor on duty explained the reasons. They could not agree on what was being explained. 

I got called. I explained to them. They were ready to get the surgery done without any blood. With the consent that 'there can be unexpected complications which could be fatal to the patient'. The husband was ready to sign that even if his wife and child dies, he would have the surgery done at NJH. 

Meanwhile, the patient was in severe pain. There was severe scar tenderness. It was very obvious that the husband just wanted to get the surgery done somehow. He was hardly interested in the welfare of his wife or baby. 

He started to talk very rudely and was joined by 3 other male bystanders who also started berating the quality of care and our attitude. It seemed now that we were responsible for the sad state that this poor lady.

We all very well know that we were only facility where repeat Cesarian after a previous Cesarian was done for a radius of more than 80 miles. If I send her off, she will go to the nearest district hospital from where she would be refused any management. She could end up with a rupture. . . and could even die. 

And if she dies, there would not be much tears shed for her. Her husband will find another wife.  

We took a decision to take her in for surgery without blood. I could only pray that she would not have any complications. The lower segment of the uterus was very much thinned out. She could have ruptured in another hour if we had not intervened. 

Then, the nurse told me that she has got a Smart Card (RSBY). Well, this was her second pregnancy and therefore the Smart Card was swiped. 

Inside the theatre, I asked the lady why she never bothered to get a check up in spite of the fact that she lived within 10 miles of the hospital. She replied that her husband never bothers. She is his second wife and this child would be his 6th child. His first wife had died few years back after being managed in the village for fever. 

The surgery was thankfully uneventful. 

Now, questions that lingered in me - - - 

1. A patient who has regular ante-natal check ups in easier managed with regard to costs as well as predictability compared to a patient who never had any antenatal care. Should RSBY rules include a clause which makes it mandatory for patients to have at least 2 or 3 antenatal check ups in the facility where she plans to deliver? 

2. For RN's husband, this will be his 6th child. For RN, it is only her 2nd pregnancy. So, do we put her under RSBY or do we exclude her and make the family pay? 

3. What can be done to address the neglect that women and children face from their menfolk. I'm sure that it goes without a doubt that until our women and children especially girl child is cared for, our society is not going to progress much. Stories about of such neglect . . . but there seems no light at the end of the tunnel. 

A Clarion Call . . . for Life

Most of my posts have been mainly on maternal healthcare with very few focus on the children. We all know that in places where maternal health care is poor, child survival is much worse. And it has not been quite different at NJH and the surrounding communities. There are quite a few incidents of still births which happen in the villages and even among deliveries that arrive late to hospital. 

However, recently I had a shocker of how prevalent is infant and child deaths in the community. 

The above is snap taken on a recent visit to the ancestral village of one of our senior staff. This is the graveyard of the village which is predominantly Christian (almost 100%). Hope you noticed the small mounds of earth (which are many more) compared to the bigger mounds (graves of adults). These small mounds of earth are those of children - - - most of them children. Of course, there are few (very few) mounds which represent revered ancestors. 

I've read that the start of collection of vital statistics started from church registers in medieval Europe. The information thus gathered proved to be key in the estimation of birth and death rates. 

Considering into fact that churches in these remote villages such as the one I went should be keeping information on Baptisms and Requiem Mass (Mass for the dead), there should be a mine of information out there. 

Some more information about the background of the region. 

The village is about 5 kms away from the State Highway connecting Mahuadanr and Netarhat. Mahuadanr is 25 kms away and Netarhat 15 kms away. Located on a plateau, the soil is of poor quality. And the water table is quite low (means you have to dig a lot for water - - almost upto 1000 feet)

I saw lot of millets being grown. The villagers informed me that they grow quite a lot of sorghum, samai rice  (little millet) and ragi (finger millet). A nice place to start off a project on encouraging millet farming. 

Health facilities was a premium. There was poor transport facilities. The nearest proper hospital is in Mahuadanr. Which sort of explains the high number of child and infant graves. 

And similar to many such areas, the area is rich in minerals . . . bauxite. One of the major mining companies have set up mines. And it is such thing to see the place especially as you travel to this village. 

Almost everything is red. And so dusty. The villagers informed me that there is constant pressure to cede their lands on long lease to the mining companies. Life is tough. There is no electricity in the village. For that, there is no electricity even in Mahuadanr. 

From a healthcare point of view, things are bleak. If there is need for secondary care, NJH is the nearest place . . . 135 kilometers. Ranchi is 175 kilometers away. Not an easy thing when someone needs specialised care in this village. And there are quite a few villages, all heavily populated in this area. 

After I visited the place, there were villagers requesting this NJH staff to ask me if we could make up a plan for a healthcare and community development facility somewhere near this place. Quite a huge ask . . .  But, very relevant request. 

One does not need rocket science to prove that that the dead children lying in that grave yard have died of preventable and easily treatable causes. The villagers informed me that a lot of young men and women are also buried there. 2 middly aged men took me to couple of graves and told me that it is of their sons who died of tuberculosis few months back. 

Our countrymen dying young in the age of computer science and jet engines should be a matter of concern for each one of us. I can only hope and pray that this post penetrates the hearts of people who read it. 

A great opportunity for anyone in public health or community development who want to start from scratch. 

Life on the edge . . . Not by choice, but by neglect

Things have become a bit relaxed in NJH. And it should remain same for the rest of the month. If it becomes busy, it could become quite taxing on us. From this week, we only have 3 full time doctors for the entire hospital. With a average busy labour room and full Acute Care Unit, it can be taxing on us. 

Couple of days back (2nd Dec, 2012), we had another example of how neglected a lady can be in this part of the country. BD, a 30 year old mother of four, at term pregnancy came to us late into the night with a hand prolapse. The history was unbelievable. 

BD was having labour pains since late evening of 30th November, 2012. Since all of her deliveries were conducted at home, she thought that this would also happen without much hassles. Well, it did not turn out that way. 

The pains continued throughout the night and it seemed to have subsided by 1st December. But, then the relatives thought that she was having a distension of the abdomen. Still, they thought to wait and watch . . . masterly inactivity. 

However, early morning of 2nd December, she again started to have pains. The relatives decided it was time that a doctor takes a look at her. She was brought to the nearest District Hospital at around noon on the 2nd December. The staff (I'm not sure if a doctor was involved in the management) assured that she should deliver without much problem, although they could not localise the Fetal Heart. 

Sometime around 3 pm, things started to go awry. The baby's hand popped out. 

The staff immediately bundled her up and sent her to the nearest private hospital. On reaching this private hospital, they were told that this cannot be managed there and would need to be taken to NJH. 

They spent almost 4 hours searching for a vehicle to take her to NJH. 

On reaching NJH, there was more problems. The baby looked quite macerated. The hemoglobin was 6 gm%. And the relatives were totally exhausted to take her any further. 

We agreed to operate if they could arrange at least 3 pints of blood. They arranged that . . . after more than 12 hours. We took a decision not to take her for surgery until we have blood. 

In between, BD delivered . . . without any intervention. But, it was obvious . . . she had already ruptured her uterus.

Dr Shishir took her up late in the evening of 3rd December. It was a mess inside the peritoneal cavity. There was foul smelling ascitic fluid . . . peritonitis. The uterus was ruptured in the left side and the rupture extended to the cervix. There was necrosis of the vault of the pelvis. 

The surgery took almost 2 hours. We had to do a sub-total hysterectomy. 

She's making a slow recovery. 

If we have similar patients over the next month, it would really stretch our limits. 

There was no need for BD to have ended up in this situation. It is a crime. But, who's listening . . . 

Before I sign off, there was this article in the New England Journal of Medicine which sort of supports the post on Critical Care. Hope experts in medical education of our country will take note. With the experience we had in the Neuro Intensive Care Unit of our nearest Medical College, we have a long way to go. 

Experience in a Medical College . . .

Today, there was quite a well written article in The Hindu about the plight of district hospitals of the country. 

Couple of days back, one our staff had first hand experience about the state of affairs in our nearest Medical College Hospital. You can make a guess of the institution if you are a regular reader of my blogs. 

The story goes like this. 

At around late morning, we had a young boy brought to the emergency at NJH with a very obvious head injury. The vehicle he was travelling in - an overcrowded jeep had overturned. And he was on the side to which the vehicle overturned. The people who brought him in told me that he was pulled out from under the vehicle. 

He had a saturation of 50% and his pulse was 50 per minute. We got the boy intubated immediately and started to mechanically bag him. There was no respiratory effort. His pupils were starting to get dilated. But, his heart was going on strong. 

After quite a lot of deliberations, it was finally decided that he will be somehow taken to a higher centre. By this time, there was quite a crowd who had gathered, including all the local leaders from various levels. As always, everybody wanted to show how much they cared. They told us to do the best. One of the leaders requested me to send somebody along with the boy. 

I was not initially very much forthcoming. However, I asked for volunteers. And one of our staff volunteered.

I was glad I sent him. Because now, I know what to tell relatives of such patients on what to expect in a government medical college in this region. Of course, there are corporate institutions like the Apollo group of hospitals in the same city. But, the costs would be too much for the poor patient. 

Please do remember . . . the patient was being mechanically bagged. And he was bagged throughout the 4 hour journey. I had told the relatives that the boy could die on the way. 

Our guy reached this place which had a Neuro ICU. The Neuro ICU had 7 beds. One bed was vacant. But, there were patients on the floor. There was not even one ventilator in sight. No nurses on duty. The duty doctor, who looked like a Post Graduate student asked the patient to be laid on the empty bed. Meanwhile the mechanical ventilation continued.

One doctor after examining the patient told the relatives that the child is dead. However, later another doctor re-examined and told that the patient is alive. 

Our staff was looking at the opportunity to leave the boy and come back. However, the duty doctor requested him to continue the mechanical ventilation. Meanwhile, one nurse walked inside. Our staff requested her for an ambu-bag. She did not have a clue about what the contraption is. To his horror, the doctor replied that there was none. 

The person whom we sent was well versed with what has to be done in such a set-up. He wondered when the prescription for a CT Scan would come. It never came. Instead, the doctor gave prescriptions for antibiotics, mannitol and glyerine. And he was gone. 

He came after sometime. It looked like the boy was having some respiratory effort. He asked that the bagging be stopped. It was a relief to see that the boy was breathing well now, although unconscious. It was amuzing that one of the doctors did not know what a T-tube was. Meanwhile, one of the nurses had put a nasogastric tube from the oxygen cylinder directly into the Endotracheal tube. 

Our staff had to return. He mumbled an apology and left with the Ambu-bag. I'm sure that this was the maximum that we could have done. It is only recently that we started to send staff along with patients referred to higher centres. 

Well, I'm sure that this would be state of the Intensive Care Units of many of our Medical Schools. I know of umpteen number of healthcare professionals who serve in such centres who are frustrated because of the lack of basic equipment for patient care. 

There are major implications - 

1. These are institutions where our future doctors train. Unless you have facilities for Mechanical Ventilation, where do the young doctors learn about clinical management of patients who come in a critical state after a head injury. 

2. Head Injury is a common condition in our towns and cities. If this is the condition of Neuro ICUs in a Medical College, one can imagine the fate of poor people who suffer head injury.

The best option in such a situation would be to try our best to avoid head injuries to the maximum possible.

In the light of such an experience, I'm sure that I shall think twice before I refer such a patient to the Government Medical College. Of course, there are couple of corporate hospitals which can handle such sort of patients. 

As for me, I'm quite concerned about this picture conveyed by my staff. If this is the state of the Government Medical College, there is quite a long way to go before we can even think about saving lives in District Hospitals. 

Praise and Prayer Bulletin . . . 1 Dec, 2012

We've reached the fag end of an year which has been a year of happenings at NJH. Please join us in thanking the Lord for the blessings as well as joining hands to pray for us and the needs of the place. 

1. Last week, we had a big lot of hospital furniture including new operation table and lights, fowler beds for the acute care unit etc. come by truck all the way from Delhi. We thank the Lord that everything came safely without damage. 

2. The load on the acute care unit is increasing as each day progresses. There has been quite a lot of patients who made it in spite of being at the edge for days together. We especially thank the Lord for the healing. At the same time, we need more qualified and skilled staff to man the acute care unit. We also explore ways to expand the facilities for intensive care. 

3. There has been a spate of patients with deliberate self harm through poisoning over the last week. We explore ways to minister to them. 

4. Malnutrition is a major issue in Jharkhand. There's a meeting arranged for the same in Ranchi on the 7th Dec. Please pray for the same. 

5. Over the next two days, we would be putting the concrete roof of the burns unit building. We request your prayers for smooth proceedings. 

6. We thank the Lord for the life of Mrs. Lucia Leela, mother of Mrs. Julita, one of our staff. Mrs. Lucia went to be with the Lord yesterday. Please remember the family in your prayers. The funeral went off smoothly today afternoon.

7. Over the next two weeks, quite a few of our staff would be travelling to attend couple of meetings at Herbertpur and Delhi. Kindly pray for journey mercies as well as for the meetings. 

8. Please remember our nursing school students in your prayers. Quite a few of them face difficulties in their studies. The problems stem from poor quality of school education which these students undergo before coming to us. 

9. Next week, we are going to be short of doctors. Please pray that the rush will be manageable. We've requested for help but is yet to receive a positive response. 

10. Many of our staff would be travelling over the next few weeks as part of their Christmas vacation. Kindly pray for their journey mercies. Do also remember the team who would be holding fort at the hospital. 

11. Please continue to remember in your prayers the need for consultants in surgery, medicine and paediatrics. 

12. Alcohol is an issue among few of the staff families. We pray that there will be a transformation among these families. We've tried to approach them to help them out. But, the staff appears to be quite uninterested. Please pray. These families especially the children are facing the consequences.

13. Tertiary obstetric care continues to challenge us and stretch our limits. However, the presence of the grace of our Lord has been amazing. We especially thank the Lord for the miraculous healing given to Mrs. GD and Mrs. SD.

14. Please pray for Mr. Nainshuk Minz, one of our local pastors who has End Stage Renal Disease. He is at present in Vellore and exploring various treatment options. 

15. The first cycle of the RSBY program in the Palamu district is coming to a close. We thank the Lord that we could serve quite a number of poor patients by being empanelled under the RSBY.