Dying young . . . .

Over the last week, I came face to face with 3 young adult deaths. In the present world, in spite of all the modern developments in the field of healthcare sciences, the fact remains that people continue to die young. The reason I narrate these 3 instances is because the different causes of death in each of these cases are the leading causes of death in the young adult. And the most important aspect of all the 3 causes is that - all of them could have been prevented.

The first one is that of someone I'll call AM. I came to know of AM's death through the newspaper. AM was the son of one of the well known sweet shop owners in our capital town. The reason I know them is because I used to be a regular customer in this shop for their Dahi Vadas and AM's dad had somehow made a note of my regular visits. It was not difficult for him to guess that I was not a local guy and my Hindi must have given my South Indian identity away. One of the last visits, he made it a point to pick up a conversation with me. The reason was to advise AM about his future. The dad was bent upon making him an engineer. So, the next time I visit, I agreed to talk to AM. AM was summoned the next time I was in the shop. He was also equally interested and we had a good discussion time of chit chat.

Now, the story is how AM died. AM had a liking for bikes. And it was reported in the papers that he was trying to ride his friend's bike in one wheel - the way you see in the stunt ride shows. Well, somewhere he had slipped - and went straight under a heavy truck's back wheel. He died after reaching the hospital. His friend, the owner of the bike, who was pillion riding escaped with not-so-serious head injuries. Both of them were not wearing helmets. AM was just 18.

The second is that of NN - relatives of one of our staff. 22 year old - just on the verge of being called for a job. He had finished his ITI. He had finished his dinner and was just getting out of his parents' newly built house. It was a bit wet because of the occasional rains. He had slipped somewhere and had fallen on to the ground where his head hit against a stone. There was a big wound in the head. He died on the way to hospital.

The third happened last week. SS, 18 year old girl who used to live along with a couple friend of mine in their home. SS was a distant orphaned relative of my friend. This couple friend had helped SS complete her 10th standard examinations and was exploring options on how they could help her find a foothold in life. Somewhere along SS had come to the conclusion that she was a burden to everybody around her. And she decided to end her life by hanging on her own dupata. It has been heartwrenching for my friends - they have ended up in a quandry after trying to help SS out. Had SS even mentioned about her thoughts about this to them, this could have been avoided.

So, the next time you find a young man trying to ride his bike without a helmet - advise him about the advantages of wearing a helmet as well as driving with care. There are dangers lurking in the form of slippery floors, unsafe electrical connections, illegal gas connections and faulty gas stoves, unsafe furniture etc in many of our homes. They could be the death knell for our own loved and dear ones. We need to pro-actively get involved in the emotional lives of our youth. Many of them live in fairy tale palaces made in air - with no amount of reality in them. The modern media has been fuelling such thoughts which do not have any amount of reasoning in them.

Young adult deaths are preventable. The question is about how much we have the time, patience and will power to address the issues which cause such preventable deaths. I know the stories similiar to the above 3 are so familiar to many of us. But 3 deaths happening within one week prompted me to put a note about this.

Maternal Near Miss...

UD a mother of three girls was quite an experienced expecting mother. In addition to the 3 daughters she had, she had delivered 2 boys who had died soon after birth. In addition, her second daughter was born by a cesarian section. And, the rest of the deliveries had been conducted at home. Her eldest daughter, the first born was 15 years old. She had lost both her babies in the last 2 deliveries. So, she was a G6P5L3D2.

UD came on the at around 1:30 am yesterday. She had been having pains since early morning the previous day. As all her previous deliveries, UD had thought that it would go about without much problems. However, since afternoon, she got a feeling that this is not going to be a uneventful delivery.

UD's husband is away in Delhi working in a factory. He is yet to arrive. He has supposedly got into a train from Delhi. UD's brother told me that he should be here by late night or tomorrow morning.

By the time, UD's relatives arranged for a vehicle and took her to the nearest health centre it was 4 in the evening. There was a doctor at the PHC who told them that she looked really anemic that it would not be safe for them to deliver there. They rushed to the nearest town, about 70 kms away. By the time they reached it was around 8 pm. They initially took her to a private hospital. She had some relatives who worked there. They talked with the doctor - who told them that they'd better take her to the District Hospital. However, no doctor examined her.

They arrived at the District Hospital at around 9:00 pm. She was taken in to the emergency. Couple of paramedics (compounder) examined her. They supposedly had a discussion with a doctor who told them to bring her to NJH. Once again, it seemed that the doctor never saw the patient.

On arrival at NJH, Johnson saw the patient first and he suspected a rupture uterus. He called me first. Since Dr Nandamani (surgeon) was around, I suggested that he be called as we are never sure about what all would be involved in a rupture uterus. In addition, I needed to leave for Ranchi at 5 in the morning. Dr Nandamani also came to conclusion that UD had a rupture uterus.

She was posted for surgery. Her hemoglobin was 11 gm% - which could have only been because of a dehydrated patient. Dr Nandamani had the shock of his life when he opened the abdomen. The uterus was open with the baby in the peritoneal cavity. In addition, the bulb of the Foley's catheter (urinary catheter) was also in the peritoneal cavity. He thought that someone had inadvertently put the catheter into the vagina rather than the urethra. However, it was only after some time he realised that the bladder had ruptured and the catheter was sticking out of the rent in the bladder.

The repair took almost 3 hours. By the time, it was all over, it was around 6:30 pm. She needed 2 pints of blood.

One aspect which was very much noted during the narration of the whole line of events by the patient's brother was that there were 2 places where a decision was taken without a clinician examining the patient. I pray that this is not true or that the bystander somehow missed seeing the doctor come and examine the patient. In addition, in spite of the patient having visited 3 healthcare providers, nobody had thought about putting an i.v canula or at least measuring her blood pressure.

It is unthinkable that such a high risk pregnant patient had to travel 100 kilometers visiting 4 healthcare facilities before she got to be properly examined by a doctor and any sort of treatment started.

UD's male family members does agricultural work in their own fields of about 4 hectares. Since the last 2 years because there were no rains, many of the menfolk including UD's husband had migrated to cities like Delhi to earn a living. This year, the rains have just started and they should be involved in agricultural work - but, now, they are all busy caring for UD. UD brother sounded very apprehensive about the coming year as they have not been able to start the agricultural work.

Considering the extent of surgery which was done, they would end up with quite a heafty bill. I was told that UD earns about 5000 IR per month. I'm sure that UD's treatment costs would not be less than Rs. 15,000. Elsewhere, it would have been twice this cost. We don't need much evidence to prove that healthcare costs pulls quite a lot of families into penury.

UD has done well so far. Kindly pray that she will make a fast recovery.

WEEKEND DIARY - 2B

Continuation of action from http://jeevankuruvilla.blogspot.com/2011/08/weekend-diary-2.html

Well, there were quite a lot of things happening in LR. The best part was that MD (with placenta praevia) slipped out of the LR without anybody noticing. She wanted to discuss something with her family. And suddenly she realised that she was bleeding. That was why they called me. There was a puddle of about 500 ml of fresh blood on the floor. We had to act fast. Blood or no blood available for transfusion - I had to do a Cesar to save both MD and her baby. As I was trying to hasten things, two more patients landed up in LR.

The first was MT. In her middle 30s, she was into her 6th pregnancy. Since 4 pm, she was having painless vaginal bleeding and she was almost term. I pushed her to the ultrasound room and there was a area of seperation of the placenta - Abruptio placenta. I was wondering how could this have happened. She also needed to be taken for surgery.

The second was VS. Also in her middle 30s, she was into her 7th preganancy. One look at her was enough to tell anybody that she either had twins or had too much of fluid in her uterus. She went in to the ultrasound room after MT and lo, she had twins. She was also trying to deliver elsewhere and had come when nothing was happening. Poor lady - her family did not even think that there was any worth in doing at least one ante-natal check up. Her family claimed that she has been seen by the local Sahiya. All this after she had multiple risk factors - elderly multigravida, previous history of twins pregnancy and severe swelling of her body. It seems VS was having contractions all through the day - but suddenly it stopped. On per vaginal examination, I found out that she was fully dilated and I prayerfully did a guarded rupture of her membranes. Then I went to the theatre to operate on MD and later MT.

I reached the theatre to find out that we did not have any blood to operate on MD. It was a miracle that the baby was alive. The placenta praevia had started to seperate. When I opened the uterus it was the placenta which came out first. The baby came out later. He was lucky to have made it. The rest of the surgery was uneventful. MT was the next one. On opening the abdomen, she had multiple petechial spots on the uterus - couvelaire uterus. They had not given a correct history. Neverthless, I opened the uterus. The baby was ok. The placenta was hardly attached to the uterus and there were blood clots behind. After we finished, the theatre nurses confronted the relatives about any additional history - they confessed that she had a really good massage of her abdomen in the morning. Massaging the gravid abdomen is a very common practice in our area. It is thought to improve blood circulation of the uterus and help in uneventful labour.

As I was midway between the surgery on MD, one of the ward nurses informed me that one of the patients who had come in with severe malaria had respiratory depression. We'll call him DS. DS was from the nearby village of Bari. DS was sick with fever since the last 5 days. He came in sometime in the afternoon. Almost in a comatose state. On investigation, almost 50% of his RBCs were infested with Plasmodium Falciparum. He looked quite healthy but his hemoglobin was just 7 and his platelets was just 24,000. I knew that he did not have much of a chance in our setting. Ranchi was too far away and he also looked to have developed a intracerebral bleed. I had explained everything to the bystanders. The decision was taken on doing whatever we could.

After admission, he continued to deteriorate. This could have been prevented. The relatives showed me the rapid test kit for malaria which was negative. However, they told me that he was diagnosed to have falciparum malaria by the local quack. I asked what medicine was given by the quack. They showed the medicine. I could not believe my eyes. The quack had given Ciprofloxacin tablets instead of Chloroquine. Poor guy - got the spelling on the blister packet all wrong and now MD did not stand a chance of survival.

Suman, our anesthetist nurse rushed to the ward to take a look at MD. She promptly intubated him and started him on CPCR. But with very poor blood parameters there was nothing much we could expect. We declared MD dead at midnight.

As I got out of theatre, I was called again to the LR. The first baby of VS was delivered without much difficulty. The second one appeared to have got stuck and the nurse was struggling. So, I went in and had to help do a breech extraction of the second fellow. Both the babies were doing fine by God's grace.

As I thought that this is end of the adventures for the day - we had one little girl in the emergency. She was having convulsions. The history was almost similiar to that of DS. The only difference being that her malaria smear was negative. It looked more like a viral hemorrhagic fever. I somehow convinced the relatives to take her to Ranchi - which they ultimately did in the morning.

I was lucky to get a little amount of sleep from 3 am to 5 am - interspersed with calls about medication orders. Early morning, we had a man with a krait bite almost 24 hours back, but with very definite signs of envenomation - he had ptosis and difficulty in swallowing. His respiratory efforts were fine. It was only very recently I had read this article about how silent and inconspicuous these krait bites can be. You can read about it in http://www.facebook.com/media/set/?set=a.208033779216299.52888.100000290346946#!/photo.php?fbid=208033929216284&set=a.208033779216299.52888.100000290346946&type=1&theater. This man had hardly any visible sign of the krait bite.

There were 2 more uneventful normal deliveries... Quite a handful for the start of a weekend. Do remember Dr Shishir as he is on call today...

Weekend Diary 2

Sorry, for all those who may think that this is the second day of the last weekend diary that I wrote (http://jeevankuruvilla.blogspot.com/2011/07/weekend-diary-njh.html). I was too tired that I slept through the next day. Dr Ango was on duty. She mentioned about an eclampsia patient whom she had to operate. By God's grace, both mother and baby are doing fine. Then, there were the umpteen number of fever and couple of snake bites. Almost all of them went home healed.


For a change, this weekend, I am handicapped by the absence of Dr Nandamani and Dr Ango. They are off to a time of rest and retreat for 3 days. The should be back by Monday evening. And I find myself taking the call for another weekend. And as expected, I've got some time to come to my office as I wait for the results of MD who just came in. She claims she is at term. However, she has a discharge summary from us dated about 6 weeks back saying that she has a complete placenta praevia. It also says that her Hemoglobin is 7 gms%. She has been having pains since morning. It was good that someone remembered that we told her that it was dangerous to try a normal delivery. MD has other problems too. She had been pregnant 4 times before and everytime the baby had died sometime around 1 or 2 years of age. She has also disclosed that she is taking some treatment for convulsions. Her husband has shown me some tablets wrapped in a piece of paper.


By God's grace, she has brought along with her a hoard of male relatives. So, all of them have gone to the laboratory trying to find out if any of them is fit to donate blood. As soon as the blood comes, I'll operate.


Morning has also been busy. We had couple of Cesarian sections, one hysterotomy and one curretage of the uterus for incomplete abortion. Basically, after rounds, I was closeted inside the cool environs of the theatre.


LD, for whom I had do a Cesarian Section had her first baby by Cesarian section. It is not very wise to try to do a normal delivery in places like ours for quite a lot of reason. I was almost deciding on trying out for a normal delivery, but it was quite risky considering the technical and manpower backup that I had - and that too on a weekend when things really hot up. The second Cesarian was for a lady who was supposedly having a precious baby. Belonging to quite a rich family, she had gone in for infertility treatment as she did not conceive within the first year of her marriage. She conceived within 6 months into the infertility treatment and had come to us for delivery. Now, the problem was that she was a bit on the plump side and was not able to percieve fetal movements regularly since the last couple of days.


In addition, she had an ultrasound which showed lesser liquor volume. On clinical examination, the baby looked fine although the liquor volume was on the lower side. I asked for a repeat ultrasound, which showed even lesser liquor volume that the previous scan. The relatives were really petrified. I calmly told them that we would try to induce and try for a normal delivery. But, I knew this was going to be tough. Within couple of hours the nurse from labour room called me saying that the lady was creating a scene saying that she could not percieve fetal movements and the relatives were intrusively anxious.


Well, I needed to have an indication - nowadays, there is a good one - Non-reassuring Fetal Status. Off she went to the theatre and she delivered a girl baby. On the table I found out the reason for the absent fetal movements - the liquer was actually very low and in addition, the umblical cord was tightly wound around the fetus. Maybe she would have ended up with the Cesarian ultimately.

Well, they are calling me to the labour room. There is one more new patient... Shall write more if I get time... There was one more new thing we tried today.... And a patient with really bad falciparum malaria.... That would be after I see what's cooking new in the LR...

Breastfeeding Week

The World Health Organisation celebrated the last week starting from Aug 1st to the 6th as the World Breastfeeding Week. There are quite a large number of programmes which are being done all over the world including institutions like us. The Nursing School is facilitating the celebration in NJH. I used to wonder why there is a week just to promote breastfeeding when it seemed to be the most natural thing for a mother to do after childbirth.

But I was wrong. All along my 16 years in the field of healthcare sciences, it has been very painful to note how subtly breastfeeding has been discouraged in our communities. Just wanted to share 3 experiences.

Scene 1: I vividly remember the day. I was an intern in Obstetrics in Trivandrum. There is this medical representative who turns up and requests me to write prescriptions for some milk substitute for all the patients I was discharging. He was even offering me few free sachets to give to poor patients who I think could not afford to buy the milk substitute. I had to make quite a lot of effort to politely refuse to entertain his request.

Scene 2: One of the mission hospitals I worked in - there was this funny thing I found during rounds in the obstetrics ward. Everyone had a feeding bottle. I tried to investigate and the finding was alarming. It seemed that the hospital had a nursing school attached to it. One of the procedures for the nursing students used to be training mothers with decreased milk secretion on how to bottle feed - basically teaching them to use clean bottles. Now, what was happening was that there were about 5 deliveries per day and a total of 50 students. The poor students had to do their procedure on some patient. And ultimately, every patient ended up buying a bottle and learning how to use it properly. It was hilarious but the truth was that each patient who came to this place went back with the message quite ingrained in them that bottle feeding was the in thing. It took me some time to convince the authorities about the horrible thing which was taking place.

Scene 3: I happened to buy some milk substitute for my son - it was basically to tide over events like travel where feeding sometimes becomes cumbersome. It remained unused. Since it was well packed, I thought I shall give it to one of my paramedical colleagues who recently had a baby. It was almost 6 months later when I bumped into him in some social event that I asked him about his baby. He told me that the baby is doing good. He later asked me how I used to afford the milk substitute which I gave him. It seems that this family had taken my gift of the milk substitute to heart and had been regularly buying it for their kid - and sure it was costing them a fortune maintaining this diet. They thought that since I, the head of the unit had given it to them, it must be something really good that their child should not forfeit the benefit of having it.

Of course, there are quite a lot of rules and regulations about the advertisement and sales of breastfeeding substitutes. However, the companies which market them have already made quite a lot of impact on parents and healthcare providers. It is very common for parents of new-borns to come and ask for substitution feeds. And when I refuse, they give me quite a funny look as if their baby is being refused something very basic.

It sure needs more than a week to convince parents all around the globe that promoting breastfeeding is very crucial for the future of mankind.