X-Ray Spine Finding . . .

The X-Ray given below is of a 65 year old man who came with severe back pain and evening rise of temperature since the last 2 weeks. In addition to the extensive amount of osteophytes, we just could not come to a conclusion on a faint homogenous opacity jutting out to the left at L3-L4. His ESR is 124 mm.

Kindly throw light if anybody has a clue about what it could be.

Blackwater fever . . .

(This post was drafted on 15th Dec, 2011)

We have been having quite a lot of patients with malaria over the last 2 months and it seems that they would continue to come all through the winter. We have some sort of a cold wave going on here with temperatures around 5-10 degree celsius in the night and it is a bit unnerving that we continue to get very sick malaria patients.

The latest two patients whom we have are quite sick. ND, a young housewife who is 7 months pregnant came today afternoon with long standing fever. She was being treated in Daltonganj for the last 1 week. 50% of her red blood cells were infested by the malarial parasite. And her liver enzymes were mildly elevated. We offered her a referral as we thought that the family looked well off, she was pregnant and her platelet counts were 41,000/cu mm.

Her family ultimately decided to treat her here after much deliberations.

Sometime late in the evening came MS, a middle aged man with history almost very similiar to ND. However, he looked more sick. 20% of his red blood cells were infested by the malarial parasite, but he had a platelet count of only 15,000/cu mm. The worst was his urine. Although his creatinine levels were on the higher side of normal, the colour of the urine was very frightening.

In the earlier days, I understand that this used to be called blackwater fever. And I've read somewhere that Dr Paul Brand's father died of this condition.

I hope that both MS and ND will pull through. As we discussed about these patients, Nandu was quite apprehensive about having to manage such patients alone from Saturday. Shishir has already left for his vacation and I would also be going off south to home from Saturday.

Wish list for 2012 . . .

Last week we were having a discussion on Christmas and how it has influenced the local culture including businesses even in places where Christians are a minority group. One of my friends suggested that for a believer of Christ, Christmas is everyday. Yeah, it's true.

However, traditions have come to stay. One favorite thing of almost everybody in this world is getting gifts. Since it's Christmas time, I thought of putting a wish list of possible gifts that we would be praying for as we start the New Year. We pray that if the Lord will's, he will open the hearts of well-wishers and friends all over the world to give for the work that we do here at NJH and similiar units of our parent organisation, Emmanuel Hospital Association.

When you look at our unit, there are certain capital needs that we had decided as an unit. So, I shall put them first which are usually very high end needs and later the smaller ones which are of lesser value. Considering the amount of charity work that we end up doing it is quite impossible to plan for keeping finances aside for capital and development needs. I shall write up about our major capital needs which are quite hugh in another detailed write up.

However, we've also realised the need for the following more pressing needs which needs to be realised faster. The expenses for these are a bit more on the lower side compared to the major capital needs.

1. Centralised oxygen and vacuum for the acute care unit, theatre and labour room: 450,000 Indian Rupees (9,000 USDs/Euros/AUDs, 5625 GBPs)

2. Change of water supply and construction of a new water tank: The present water supply system is almost 30 years old and comprises of old galvanised pipes which have become quite rusted and damaged at many places. 1,500,000 Indian Rupees (30,000 USDs/Euros/AUDs, 19000 GBPs)

3. Change of electricity wiring for residences and the hospital: Similiar to the water supply, the electricity wiring is also quite old and are very much susceptible to short circuits. 1,500,000 Indian Rupees. (30,000 USDs/Euros/AUDs, 19,000 GBPs)

4. Construction of 'sarai'. ('Sarai' is a living space for relatives of patients who come from long distances who have to stay overnight. We have one which is quite dilapated.)1,500,000 Indian Rupees. (30,000 USDs/Euros/AUDs, 19,000 GBPs)

5. Upgradation of the ACU excluding centralised oxygen and suction: 750,000 Indian Rupees. (15,000 USDs/Euros/AUDs, 9500 GBPs)

6. Extension of Nursing School Hostel: 3,000,000 Indian Rupees (60,000 USDs/Euros/AUDs, 37,500 GBPs)

7. Construction of the Burns Unit: 2,400,000 Indian Rupees (48,000 USDs/Euros/AUDs, 30,000 GBPs)

8. Purchase of a hollow brick/block maker: 200,000 Indian Rupees (4000 USDs/Euros/AUDs, 2500 GBPs)

9. School Bus: 1,300,000 Indian Rupees (26,000 USDs/Euros/AUDs, 16,250 GBPs)

10. Four wheeler for hospital: 750,000 Indian Rupees (15,000 USDs/Euros/AUDs, 9500 GBPs)

3 maternal near miss . . .

Over the last 2 weeks, we have accumulated 3 antenatal mothers who were quite sick. Unfortunately, they continue to be sick. I've already narrated the story of SDe. SDe has made a good progress over the day - however, she continues to be on mechanical ventilation. I feel that we should be able to wean out SDe out of the ventilator soon.

One young lady about whom I had not mentioned about my blog is SeeD, who had been admitted about 2 weeks back with a very bad rupture uterus. It is a very sad story. SeeD, a mother of 5 had been trying to deliver at home almost 2 days before she reached us. The story is almost the same as we've had for many of the other maternal patients.

SeeD wandered to many places for around 48 hours before she reached us. After we had opened her up, we realised that she had ruptured quite a long time back and her bladder also was quite badly damaged. There was already pus collection in the peritoneal cavity and the bladder wall and the uterus was quite ischaemic. Shishir had to do a hysterectomy and repaired the bladder with the hope that it is heal well.

 

Then, we had some problem which we still cannot explain. SeeD could not be weaned out of the ventilator. In addition, she developed features of a raised Intracranial Pressure. We requested the family to take her ahead to Ranchi. They told us that they had no money to go ahead for any sort of treament.

To complicate matters, the bladder repair has given way. And she started to put out urine through her peritoneal drain. She remained in the ventilator for about 5 days. And then suddenly, she became conscious and started breathing spontaneously. However, we would need to open her up again to repair the bladder.

After SDe and SeeD, we had another lady come in with a rupture uterus. We shall call her SakD. Once again we ended up doing a hysterectomy after her relatives arranged blood from Daltonganj. I'm yet to collect a complete history from Sakd. But similiar to few of earlier posts where the patient in labour recieved intramuscular oxytocin Sakd had also recieved the same and progressed into a rupture uterus. The fact that she was fourth gravida only made the uterus quite vulnerable to a rupture.

All 3 of them could have died if our colleagues had not intervened soon. A major concern is the bills that they would be getting. SeeD already has a bill of around Rs. 35,000 which is to be paid for the procedures which we've done for her. SakD would have a bill of around Rs 15,000. SakD's family appears to be well off - but SeeD hails from a very poor family. I'm not sure on how they are going to foot the bill. SDe, also has quite a number of interventions including mechanical ventilation going on.

As I see patients like SDe, SakD and SeeD, I wonder whether we should be looking seriously at developing our acute care unit and other capabilities, especially at the level of qualified personnel. However, the bottomline remains on whether people will be interested in coming - especially with the limitations we have and the need to improvise.

Before I sign off, I need to tell you of the couple of multipara monitors we recieved recently through a kind donation from churches in the United Kindom. In the snap below is SDe, connected on to the ventilator and the new MPMs.

Referrals . . .And a need . . .

One of the best parts I learnt from one of my professors, Dr Joy Philip at Trivandrum Medical College was to write proper referral letters. During the college days, it used to be letters back to doctors who used to send patients for tertiary care to the Medical College OPDs and casualty.

I took this practice to heart and insisted that my colleagues write proper referral letters whenever a patient was being sent for a second opinion and even when a patient asked for a referral to a higher centre. It has served me good - when many a consultant has called us back and told us how they appreciated the well written referral letter.

Well, today we had a patient from one of the nearby hospitals. SDe, a first time pregnant lady at term was brought by her family with a history of convulsions since yesterday night. The patient was very very sick. We could not get a fetal heart sound and the patient was in obvious pulmonary edema, bringing out frothy pink colored sputum. The blood pressure was 170/130 and non-responsive to any medication.

And she was desaturating fast with shallow breathing. We got her hooked into the older ventilator. It was then I noticed that the patient was not maintaining saturation - but was maintaining good saturation with manual bagging. However, it was encouraging to notice that the family members readily volunteered to do it as well as did not complain.

I got our engineer and what he found out was heartbreaking. The collapsible corrugated rubber bag was irreparably damaged. I could only watch helplessly as Dinesh displayed it. Someone had promised help to purchase couple of new ventilators, but the finances have not come through and the prospective donors have also not been much forthcoming when we contacted them recently.

We had to get the dead baby out fast. Cesarian section was the only option to give some chance for SDe to survive. With the customary high risk consent including a risk for the chance of a 'death on the table', I went ahead with the surgery. We were blessed that the family understood that they had to allow us to be pro-active with the management.

The surgery went off smooth - it was terrible to find out that the baby was a fresh still born. Maybe if the family had straightaway brought SDe to NJH without going elsewhere, we may have got a live baby. But, then SDe also started having problems. Her blood pressure was varying from nil to 180/140. And she was putting off pink colored froth. The breathing effort was terrible. It was obvious that she would need ventilation.

We got the new ventilator which is only used along with the Boyle's machine along with the patient to the ward. We had to put her on a GTN drip to manage her pulmonary edema - but then she went into shock - for which we had to start her later on a Dopamine drip. We spent almost close to 6 hours managing SDe.

Please pray that SDe will make it. She is on ventilator and on ionotropes.

And we need a new ventilator. We could do with a copy of our older model or even better the newer model which is twice more expensive than the older model. We would actually prefer to have two more ventilators.

Coming back to referrals, I just wanted to put the piece of paper which I recieved as referral from the previous hospital that SDe was in. It is pathetic.

But, when I told about it to one of my colleagues, he told me that I was lucky that I have a piece of paper with the names of the medicines given so far. Yes, he is true - most of the time, we have no clue on what has been given in the previous hospital.

And please do remember the need for couple of new ventilators and for prayers for SDe to pull through . . .