New residents

Last Sunday, we got some new members into our household . . .

It has been sometime since our Community Health department had been exploring new options in rural livelihoods. We had also made some visits to the Veterinary Department of the Agriculture University in Ranchi. 

We got some amount of success on our inquiries regarding pigs, sheep and chicken.

However, I was more interested in getting few turkeys for the campus. Although the concerned department had few turkeys, they did not have any poults (baby turkey) to sell. 

But, I had a surprise last week. As we drove back from Ranchi after a weekend break, I had to stop to buy some vegetables from one of the local markets. 

As I explored the village shanty, I was attracted by a crowd of villagers around one man with about 30 chicken who was quite vociferous. 

'40 kilogram chicken for sale . . . 40 kilogram chicken for sale . . . ' 

I was quite interested. I asked him what the name of this 40 kilogram chicken was. He showed me a picture. And it was the snap of a turkey . . . 

I was not sure . . . I asked the guy about the cost . . .  3 poults for 100 INR. 

A one day old chick of chicken cost nothing less than 30 INR. I thought of trying my bargaining skills. I asked him for 5 poults for 100 INR. He agreed for 4 for 100 INR. 

Thus, I came back to the jeep with the 4 poults. There was some amount of opposition from my sweet better half. However, after some pleading we were on our way back home. 

Snaps of the quartet. 

One of the previous doctors at NJH, Dr. Colin Binks, had kept rabbits in cages. And these cages were in the maintenance dump. 

We had them readied up in no time and the poults have a very comfortable home. 

Now, the advantages of having these birds . . .

1. All the crumbs from the dining table goes into the bird feed. They are voracious eaters. 

2. There is new entertainment for the kids.

The downside . . . I'm not sure if they are really turkey poults . . . They could be chicks of normal fowl. The fly by night salesman could have been selling normal chicks with their heads shaven off . . . 

But, then, I do not lose anything . . . they had cost me only 100 INR . . .

Internal Medicine at NJH

There is always a wrong notion going around that NJH do not have much of interesting cases, especially such ones which warrant the presence of a physician doing Critical Care work. Dr. Roshine  tries to dispel this notion through this post. 

We also look forward for fresh graduates who would like to learn from her and the medicine work here. 

A glimpse of the medical work at NJH over the past 6 months, challenges and opportunities ahead.

1. Snake bites continue to plague the community. Here’s some statistics on the increasing number of snake bite victims needing our services. Thanks to the group of students led by Dr Shubhanker from CMC, Vellore, who compiled the data and whose work was acknowledged as the best paper in the young researchers category this year in CMC,Vellore. (Title: Clinico-epidemiological profile of snake bite over 6  years period from a rural secondary care centre of Northern India – A retrospective observational study)

Below is a table showing the number of cases over the last 5 years. 

The numbers are increasing with 118 snake bite patients admitted over the first half of 2013.

Our management of snake bite victims is challenging for various reasons. Awareness of the symptoms of systemic envenomation is sorely lacking in the community and the  strong influence of traditional healers in the community delays  initiation of therapy. To put across a horrific thought, over the past 6 months , we have had roughly 17 patients brought dead after a history of  snake bite with the delay being largely preventable.

Another challenge has been management of viper bites and there has been reason to suspect other species of snakes prevalent in our area that are not covered by the standard ASV being used.

In this respect, we are grateful for the opportunity to be part of a multi centric study by the toxicology group, CMC Vellore, in collaboration with other partners which will focus on envenomation syndromes and more importantly snake species identification .Also hoping that the study will shed light on ASV schedules being used in our country considering the huge costs involved in treatment of such patients.

2. We have been particularly alarmed at the number of patients diagnosed with probable TB meningitis, many of whom have had atypical presentations. I had put some details up in my previous blog.

3. Acute febrile illnesses are rampant during the rainy season. Being able to diagnose rickettsial illnesses,malaria and viral hemorrhagic fevers have helped a great deal in reducing unnecessary higher antibiotic usage.

Eschar in a patient with fever . . . 

A great challenge in the management of acute febrile illnesses has been the indiscriminate use of antibiotics and antimalarials by diagnosing these diseases using  malarial antibody kits and typhoid kits in the community. There are very few health centres doing malarial smears and tube agglutination tests. It is a matter of great concern and we are hoping that good evidence based medicine would be recognised and encouraged  by the medical fraternity in this region. More on the malarial kits in a later blog.

4. Finally, chronic diseases are on the rise. Patients over the age of 40 with no routine medical check up presenting with hemorrhagic strokes.

Considering the large number of diabetic and  hypertensive patients  we see on a regular basis in OPD , knowing they represent the tip of the iceberg, we are soon planning to start a chronic diseases clinic focusing on primary and secondary prevention.

The above are just a few of the areas of interest in Internal Medicine in NJH. Of course, we are keen on doing more in these areas as well as venture into new thematic areas.






I'm grateful that the Lord has been using us. We pray for more people to join the team here and be part of greater things.  

Meningitis . . .

This is part of a write up on medicine management at NJH put up by Dr. Roshine. First of a series, this post gives a glance of meningitis case management at NJH over the last 6 months. 

We have been particularly alarmed at the number of patients diagnosed with probable TB meningitis, many of whom have had atypical presentations. In our setting where patients come to us as at the last resort, to be able to diagnose TB meningitis confidently and initiate therapy early is vital. We have compiled the statistics over the past 5 months and are awaiting further inputs from the medical fraternity. We had an opportunity to present it in a recent CME on TB at the district level. We would value inputs on this. Kindly go through the following set of information.

Dr. Roshine presenting this data at a CME on tuberculosis in Daltonganj

Warning Bells

About a week back, we got a rude shock when one of our patients with a laboratory diagnosis of bacterial meningitis did not respond to our routine choice of Ceftriaxone. And to our horror, responded so well to Piperacillin-Tazobactum. 

Yes, I would have purists who would say that Crystalline Penicilline and Chloramphenicol should have been tried. Unfortunately, both these antibiotics are quite labour intensive and with the shortage of competent staff we have, it’s quite a challenge.

Now, there has been quite mind-boggling research going on in the area of antibiotics.

However, I’m sure that unless we are prudent in the usage of antibiotics, how much ever research we do, nothing much is going to change.

But, today I was quite surprised to find a news item about the dangers of unscrupulous use of antibiotics. 

I hope our communities and quacks would take note . . . However, I wonder who is going to rein in the pharmaceutical companies and their representatives . . .

The Best Christmas Gift

This year, we at NJH had a special gift on Christmas day. Many a time, quite a lot of us ponder over whether we are at the right place or doing the right thing for ourselves and our families.

On Christmas morning, we had a Cesarian section. The indication was that the lady had a previous Cesarian section and there was a scar tenderness. We decided to operate as soon as the family arranged blood.

All of us took it as a routine case of Previous Cesarian section. It was only when I started to open the abdomen, I felt that something was amiss. The whole of the subcutaneous tissue was badly fibrosed and was full of adhesions. I asked the patient about what had happened during the previous surgery.

I could not believe my ears when I heard that this was a patient we operated sometime in September 2010 who came in unconscious with severe eclampsia and was on the old ventilator for few days. She was severely anemic and we had done the surgery only for the sake of getting the live baby. Her GCS was 3 and we had no hope. She had received a total of 7 pints of blood.

Later she had wound infection, but at the end she made it.

She went on to have her second baby for which she never thought about having any ante-natal care, but ended up having an uneventful delivery. 

One of the best Christmas gifts we could get . . . an affirmation about how NJH has been a beacon of hope for such families.