Photo Post . . . 30th August

Few snaps from our day to day work . . .

Ring enhanced lesion in a young boy who had come with seizures. Something we see very regularly. After the CT Scan, he was seen elsewhere and started on anti-tuberculosis medication . . . 

We had thought pre-operative that this lady had a rupture uterus. However, on opening, we found that it had not yet ruptured. . . but the lower segment was battered into a mass of 'minced flesh' enclosed by the peritoneum outside and the amniotic membranes inside. I wonder if there is a name for that yet . . . If there isn't, we shall coin one . . . 

Massive pericardial effusion. We found malignant cells in the fluid which we got following a pericardial tap.
The lady passed away after she was referred to Ranchi. 

Steven Johnson's syndrome following Tab Septran. There was candidiasis too. . . 

Pine tree on the way to Netarhat . . . Something I did not expect in Jharkhand

An Allwyn refrigerator. Fond memories. . . I wonder if anybody remembers this refrigerator company . . .

Artemesia plant . . . From which we get Artemesin derivatives . . .  

Our new generator . . .  

The Bengal Monitor . . . Questions remains

The last time, I had done a post about the possibility of the bite of a Bengal Monitor being fatal, I had quite a few mails from people who told me that it is not known to be venomous. But the victim, SK ultimately succumbed. 

Well, yesterday, I had a young boy who came with a confirmed bite of a Bengal Monitor. Similar to the case with SK, I confirmed the offending creature by showing the victim snaps of the reptile from wikipedia. The snap he identified is the one below - 

Below is the snap of the bite site.

The bleeding from the gums.

The creature had bit him at around 4 in the evening. And he started to vomit blood at around 4:30 pm. He was at NJH by 5:00 pm. He was bleeding from his gums. Clotting time was more than 20 minutes.

Well, there are things about which we still do not have any idea. We gave an option to go to a higher centre, which the parents accepted. We have got the family's phone number. Shall post if we come to know anything . . . 

The Occult . . . The Paradoxes of Indian Healthcare - Part 3

India has always been associated with the occult. And you may be surprised that the myriad religions, the thousands of gods and goddesses Indian culture is associated with has nothing to do with this. Irrespective of religion, caste, economic status . . . people depend on the occult for healthcare . . . 

Today, I came across 3 patients who tried it out . . . and it's usually the case for the conditions involved. 

The first was a young boy who had an acute episode of seizures in the morning. The relatives brought him straightaway to hospital. After the seizures was controlled, the brought in one of the local exponents of black magic to throw out the evil spirit from the boy. Our staff had quite a tough time dealing with the relatives as they were quite well off. 

The second patient was not that lucky. Bitten by a cobra early morning today, the family had been subjecting him to all mumble jumble till about afternoon when they realised that he may do better in a hospital. He arrived at around 5 pm at NJH. There was no respiratory effort. There was a faint heartbeat. From our previous experiences with cobra bites, Titus commenced CPCR . . . then he realised that it may not of any use. The pupils were already dilated. 

The third patient was also a snake bite victim, a young girl with viper bite, who came in more than a day after the bite with a very bad compartment syndrome. Dr Nandamani did a fasciotomy only to find out that one part of the leg was already badly gangrenous. 

We were sure that the chances of her going into a below knee amputation was quite high. We referred the girl. 

Unfortunately, the parents were too poor to take the girl elsewhere. However, I did not want to manage a potential high risk surgical condition without the surgeon around. They promised to take the patient elsewhere next day. Sometime later that evening, I found out there was a commotion in the Acute Care where the girl was admitted. 

It seemed that the family had arranged for a 'witch-doctor' to come and do sorcery on her. I chased them out. Later, I found out that couple of my staff were also involved in arranging the witch-doctor. I called them and asked for an explanation. However, they denied any involvement. I did not have any evidence. However, later, I found out that they had initiated a discussion with few other staff on the reasons why I should have allowed them to do the sorcery. 'The doctors are anyway referring, so what is the big thing about the relatives trying out jaad-phook (black magic) for their daughter'. . . that was the justification. 

It was shocking . . . unfortunate, but true. 

The worst aspect of the use of occult is that  most of the diseases where the populace invokes the witch-doctors are clinical conditions which merit immediate medical attention . . . SNAKE BITES, SEIZURES, ECLAMPSIA . . .the major ones we're concerned about. One more disease for which the witch-doctor is consulted is HEPATITIS. However, since it is not an acute condition, we do not hear much about it. 

The amount of money that these witch-doctors make is enormous. 

Considering that modern medical facilities are very much far away in terms of accessibility, availability and affordability, it would take quite a lot of effort to turn away the common man from these money mongers. Talking about money mongers, the sadder aspect is that modern clinical practice is also very much in danger of reducing it's practitioners to money mongers . . . which is not much different from our 'witch-doctors'. More about that in my next post on the Paradoxes of Indian Healthcare . . . 

Funding . . . The Paradoxes in Indian Healthcare - Part 2

The other day during a meeting, someone commented on how easy and freely available is HIV testing in almost all government facilities compared to other investigations such as hemoglobin, urine albumin etc. Someone suggested that even there are places where HIV testing is available, but a sphygmomanometer to measure blood pressure is not available. 

I'm afraid that this situation is actually true. 

There is quite a lot of funding available for HIV. But, no money for Reproductive and Child Health Care. So, no sphygmomanometers or instruments to measure hemoglobin or urine albumin. Well, I would not need to do explanations on the importance of doing a hemoglobin for a pregnant lady as part of her antenatal care. Or a routine check up of blood pressure. 

I'm not touting for HIV testing to be stopped . . . it is a lifeline for babies who are born to mothers who could be diagnosed to be HIV positive. But, we need to rule out anemia for all our women who become pregnant . . . for anemia is supposed to be the commonest indirect cause of maternal mortality in the world. 

Talking about maternal mortality . . . it irritates me when the Polio Surveillance officer calls me every Monday to check out if there has been any case of Acute Flaccid Paralysis in the hospital over the week. I'm not irritated because I don't like this guy . . . he's in fact a good friend. I'm irritated because there are young mothers dying while giving birth. We fill up the Institutional Death Reviews and send them . . . On October 18th, it will be one year since we've started the reviews. Till today, I've not been called for any meeting related to any of the deaths. 

Leave alone maternal deaths, I've had men, women and children coming with symptoms suggestive of viral hemorrhagic disease most probably dengue . . . nobody turned up until someone accidently put it in the papers. Still the response has been quite muted. There were 3 proved cases of cholera in the hospital. I informed the authorities responsible. No response. 

It does not need any brains to explain that nobody is interested in maternal deaths, tuberculosis, malaria or cholera as there is hardly any money in it. There is money in HIV, Polio . . . even cancer. And now, Non-communicable diseases. Because that's what the West is quite concerned of. HIV, polio . . . because they are quite concerned that we will transmit the diseases to them. 

Non-communicable diseases - - - so that they can get back all the expenditure spent on research of drugs which have been proved to be either useless or has side-effects. Recently, I had a mail from one of my elderly friends (not a doctor) who told me how he was 'detoxified' from all the medicines he and his wife had been prescribed by his cardiologist et al in India, after he went to the US to be with his son. He was put on a regular regime of exercises and dieting. He is doing good with no problems . .. ... 

My previous post had been on the pharmaceutical industry. Even for the pharmaceutical industry, there is nothing much in store from maternal or child health and infectious diseases such as malaria or cholera. 

There is only one solution for this issue. Our friends in the Health Ministry needs to realise the pressing healthcare issues of the country and ensure that funds and personnel are available for research on those issues. We have enough research to show that the metabolic functioning varies in cultures and races. Following research, we need to have systems put in place such that the research can be converted into action. Only then, can the real needs of healthcare in India be addressed . . . 

Depending on funds from any organisation abroad would only ensure that public healthcare issues of those regions would only be addressed and we would remain with healthcare issues such as Maternal and Child Health, Tuberculosis, Malaria etc which we have been continuing to grapple with since ages. 

Coming to funding . . . there are more issues. Like the issue of adequate infrastructure not available for Primary Health Centres and other public healthcare institutions to start. And worse than that is the all out dependence on Private Medical Colleges to help us with staffing our Health Centres with doctors . . . Well, that is fodder for another post . . .

Snake Bites . . . A Query

We manage quite a lot of snake bites and the cases that we've been handling have been quite a lot compared to the previous years. Unfortunately, most of our snake bite cases reach us quite late. 

I look forward to answers from experts about our observations with regard to snake bites who come late for treatment.  

When patients come late, more than 6 hours after the bite, we've seen that the chance of having a anaphylaxis reaction to the Anti Snake Venom (ASV) is quite high. In fact, we've got this experience of patients bitten by krait (which is more common here) go into respiratory arrest as soon as the ASV is given.  However, I do agree that when we give it within the first 4-6 hours after the bite, we do not have to face this problem.

Is there any evidence regarding the time interval after the snake bite upto which ASV can be given - when all features of envenomation has set in? By the way, I've heard of hospitals using upto 200 vials of ASV to treat viper bite when the clotting time was abnormal after more than 24 hours of the bite.

As of now, I've 3 patients with krait bite who came about more than 6 hours after the bite. The first person came after about 9 hours of the bite. He was given ASV elsewhere (5 vials). I did not give him any more ASV and he is doing well now. There was another lady who had come in almost 12 hours after the bite. We did not give her any ASV in the beginning. However, one of our doctors thought the next day (almost 24 hours after the bite) that it did not look good. He started off ASV. The next thing I know was that she went into a respiratory arrest. She was in the ventilator for 2 days following which she has recovered. 

The third patient came just about 4 hours back (4 pm) following a bite sometime early morning. He was maintaining the saturation quite well. I was not sure about starting ASV. However, I thought of starting it later. Within an hour of starting ASV, he had gone into respiratory arrest (almost more than 12 hours after the bite). He is on the ventilator now.

We also get late presentations of viper bites.

Below is the gangrenous leg of a boy who was bitten by a viper. He presented to us more than a day after the bite. He did not get ASV as his Clotting Time was normal. However, we had to do extensive surgery on the leg including skin graft.

So, the ultimate questions being  - 

'Is there a higher chance of anaphylaxis on giving ASV to patients who present late after a snake bite?'

'Is there a time limit beyond which ASV would not be of any use for a patient with systemic signs (hematotoxic/neurotoxic) of envenomation?'