Poverty . . .

Over the last 2 weeks, we had two instances where we were exposed to the stark reality of how poverty affects families, especially when it comes to healthcare. 

I shall start with the patient who I mentioned in my previous post on obstetric care. 

We shall call her Kkd. Yes, the lady who came in with a hemoglobin of 4.6 gm% and then had a hemoglobin of 2.6 gm% more than 12 hours after the delivery. I just got news from Acute Care that the relatives were able to arrange a pint of blood; almost 24 hours after she had delivered. 

Now, the whole question was about the reason why the family never brought her for delivery to the hospital. It seems that she was taken to the place where she had her antenatal check ups as well as to the nearest district hospital. She was turned away from everywhere. 

If we had got couple of pints of blood, we would have done off the Cesarian in no time. 

I believe that it was the good Lord's providence for her that she delivered normally. And then the family could arrange one pint of blood. Most probably, that is the maximum that they can arrange. 

The whole exercise of a Cesarian section with couple of pints of blood transfused would have resulted in quite a financial strain for the family. I realized it today morning when the nurses told me that they did not have money to pay for the medicines. In fact, we had admitted her without any advance. 

The relatives had been running helter-skelter to get some decent treatment for this poor lady. The fact was that almost all of their money had been spent paying for transport. 

However, while the process of getting blood was on, one of our nurses had caught bits of their conversation and found out that they were in the process of paying a huge amount to buy blood. 

In our nearest blood bank, the usual practice is to allot a pint of blood for 350 INR if the relatives are able to donate blood. However, when one cannot arrange a donor, there are processes quite unknown to most of us by which you can buy the blood from elsewhere at rates ranging from 2400 to 4000 INR. 

We somehow convinced the relatives to arrange a donor and get the pint of blood for just 350 INR. I'm happy that they heeded the advice. 

However, it was obvious that the family had run out of financial resources. 

All of us have failed them. From the very beginning. 

They had gone to a doctor in his private clinic thinking that they would get the best treatment. He/She had written quite expensive iron, multivitamin and calcium tablets. Which they brought. Instead of 30 tablets for a month, they had brought one strip (10-12 tablets) which was used for 2 months. 

They never got clear advice on what needs to be done when she goes into labour. No plan . . .

And even after she got admitted . . . unless our staff overheard the conversation about the blood, they would have spend much beyond their capacity and got the blood, which many a time is of very poor quality.

To be frank, for the poor, there is nothing much left in our country. They are the mercy of anybody and everybody. The question is whether 'the haves' of our country are listening. 

Leaving alone the subject of poverty . . . if there is 2 things which could improve maternal morbidity and mortality in this part of the country which is more of a problem for the poor and marginalised, I firmly believe that it is free availability of Iron tablets along with an awareness about the intake of these tablets and the second one - undoubtedly, UDBT.

Shadow of death . . .

Since yesterday night, we are sitting on tenterhooks regarding the second patient whom I mentioned in my last post.

It’s more than 24 hours since this lady came in. Her haemoglobin had been around 5 gm% for almost the whole of her antenatal period. She had a Cesarian section after she had eclampsia. Unfortunately, the baby died soon after birth.

It’s been two years. After she got pregnant, the family had been taking her for regular antenatal care in the nearby town. There is mention of her low haemoglobin during each of her visit and Iron appears to have been prescribed.

She’s come in labour yesterday. We had wanted to do a Cesarian section as I felt that there was not much space for the baby to come and there was grade 2 meconium. Her haemoglobin was 4.6 gm%. We told the family that we would touch her only after the family arranges at least 2 pints of blood.

The relatives are yet to arrange blood. But, the lady’s found favour with the Almighty. We were quite worried and could only pray.

She delivered normally late yesterday night . . . of course, the baby was severely IUGR. The labour room team worked hard to ensure that there was not much bleeding.

The problem is the haemoglobin. Today morning, I did it just to find out how it was. She looks a bit uncomfortable. It was just 2.6 gm%.

I can only pray that at least one pint of blood comes before she goes into a hemodynamic complication . . . Once again, another case which would have benefited from UDBT.

Fields of Joy

These are snaps of the agricultural work that we had been doing as part of the project on Community Based Adaptation towards Climate Change.

Fields of finger millet and System of Rice Intensification (SRI) methods for Rice cultivation . . . 

Finger millet

Finger millet . . . lots of stalks

Good yield with SRI

SRI, another view

Ripe stalks of Finger Millet

Lac cultivation . . . Reintroducing lac in our communities. Our next venture.

Maddening Obstetrics

I thought that the 2 rupture uterus patients had given us enough trouble for the next 24 hours. 

I was terribly wrong. 

At 2 am early morning today, came a lady nearing term in very early labour. Thankfully, she had come 2 months back at around 32 weeks to us. And she had our documents. 

Documents . . . which made me shudder. 

G3P2D2, the first one a still birth and the second one a late neonatal death, with a hemoglobin of 4 gm% at 32 weeks whom we had referred to Ranchi as the pregnancy was so so precious. The second delivery was a Cesarian section. 

Clinically, the hemoglobin did not look any better. Her conjunctiva was papery white. 

The family did not take her to Ranchi when we had referred them to a higher centre 2 months back. They had gone home. 

The family wanted me to do whatever I could. With hemoglobin of 4 gm% and the rules on blood transfusion making UDBT totally illegal, I had to refer them. 

I wonder where they have gone. They are from a nearby village. Therefore, I will be able to find out if they really went. Or if they went home and she had a miracle delivery or ended up as another maternal death. 

The tamasha continued later in the day too. 

I just came back from Labour Room after admitting a 21 year old G2P1L1 at term who had a previous LSCS for eclampsia. She was in the ventilator for quite some time and she lost her baby too later. 

This lady had her antenatal care elsewhere. She had consistent values of hemoglobin values less than 6 throughout her antenatal period. The family appeared to have no clue. Or did they want to convince me that they had no clue. 

When I did per-vaginal examination, the situation turned for the worse. She had ruptured her membranes and the liquor was heavily meconium stained. And she had a badly contracted pelvis. 

Shivnath, our lab tech, called me and told that the hemoglobin was only 4.6 gm%. 

The relatives were so poor to take her elsewhere. 

I've send them to Daltonganj for at least 2 pints of blood. 

I wonder if I would get a healthy baby. I can only pray. 

By the way, thanks for remembering KD in your prayers. She held on with a pre-operative hemoglobin of 7 gm%, in spite of periods of shock, till her relatives turned up with one pint of blood late in the afternoon. 

Urrgghh . . . UDBT

From today, we start a unique experiment with regard to first calls in NJH. It's just Dr. Shishir and me for taking first calls for the next one week. The arrangement is that we are going to do alternatively 12 hours of first call . . . The reason being that both of us in the wrong side of 35 seems to do better with periods of 12 hour rest. 

May sound a bit hilarious, but I thought that the harsh early winter and our poor respiratory systems would benefit from such a system of taking calls. 

Leave that alone . . . I wanted to talk about UDBT again. Oh . . . how I wish that this was legal? 

The story was that we had a lady with a rupture uterus today afternoon, KD, who had a hemoglobin of 7 gm%. She was hemodynamically stable. We got assurance from the relatives that they would arrange for blood from Daltonganj as soon as possible. 

The relatives were quite a few and therefore we thought that we would get the blood soon and we decided to take her up for surgery. Dr. Shishir did the surgery and the post-operative period was uneventful. However, the promised pints of blood never came. 

As soon as KD's surgery was over, we had another lady with a rupture uterus, SD, who also a very similar history. 

The team on duty was busy managing SD. It was only late evening that we realized that KD's blood never reached. Then, our nurses started asking them about what was happening about the pints of blood. Then to our chagrin, we found out that KD's relatives have not even gone to Daltonganj for getting blood. We had given them a request at 2:30 pm and while this was going on, it was past 8 pm. 

I came to know that there was a problem at around 10 pm, when the Acute Care nurse called me saying that there was fellow shouting and threatening everybody. 

I reached the Acute Care to find out a burly middle aged man in a agitated state. He wanted to know who ran the hospital and who the doctor was. He said to me that he will ensure that we drew blood. He then threatened to file a case against me for obstructing blood donation in the hospital. 

He went on ranting. I thought it was a matter of time before he hit me. I thought I'll give him a chance to slap me. Maybe, this was the moment I would get to bring up UDBT into the headlines of the country's media. 

That was when the whiff of country liquor clouded my senses. The fellow was drunk. The sniffles of winter had kept the smell of alcohol in his breath away from me. 

I remarked to a onlooker on how a drunk can be allowed into the hospital. The mention of the word 'drunk' had him make a hasty retreat. 

However, I'm still in a quandary. I've a rupture uterus lady with 7 gm% hemoglobin operated upon without a chance of getting even a pint of blood in the next 12 hours. I can only pray that she'll make it through the night. 

After the drunk relative was gone, I called another relative who was thankfully sober and explained about the problem. He apologized for allowing the drunk fellow come in. But, it was too late into the night. The dipping temperatures and the possibility of being looted ensured that no vehicle owner was ready to ply till early morning. 

Before I end, the common history of SD and KD. 

Both of them had delivered by Cesarian sections before. Their families were attempting home deliveries since yesterday night. In fact, KD's relatives told me that her abdomen was been regularly massaged since the last 2 days and it was so surprising that the baby did not deliver normally. 

I told KD's relatives that I find it surprising that KD is alive. 

Please pray that the relatives will get blood by early morning. 

And also a wish that UDBT would soon be legal for hospitals such as ours . . .