Thursday, September 29, 2011

Kolkota Ramblings . . Hunger

For some reason, one of the major facets of life in Kolkota is the amount of poverty you see in the street. By this, I do not mean that there is any less poverty in the other cities of the country.

Once you arrive in Kolkota station, the filth and the dirt that stretches all the way from the station to the Howrah bridge makes a sorry first impression to any new visitor to the ‘City of Joy’.

I expected things to change after the Red Brigade gave way to the Trinamul Congress in the Writer’s Building. I’ve made pep talk to quite a lot of people ranging from Taxi Drivers to Industrialists and most of them are quite crestfallen when asked to comment on the change.

One of the very common scenes which you find quite often in Kolkota is the vehicles laden with food who dish them out to the people living in the street. I happened to see it again this time and managed to click a scene. I have heard of organizations that does this in many of the cities in the country and abroad. Especially those who collect wasted food from restaurants and distribute it to the have-nots.

Hunger continues to be a major problem in our country. Certainly, collecting food which could potentially end up in waste bins and redistributing them is a great idea and well appreciated. But, much more needs to be thought about it – especially the strengthening of the public distribution system. Food needs to be made accessible to the poorest of the poor.

One of the major fallouts of a poor food security in a community is the impact it has on the lives of women and children. Women suffer and their pregnancies suffer bringing about chronic malnutrition and anemia which ultimately affect the newborns. The children suffer as they are deficient in energy and essential elements for growth – ultimately affecting their overall growth and they are forced into early labour to feed their impoverished families.

Arachnid Horror - Revisited

I hope you had read about my previous blog about NV who was bitten by an unknown spider and later had a reaction which ultimately resulted in the dry gangrene of his entire subcutaneous tissue of the leg.

We had done quite an extensive work of grafting skin on the affected area and NV had ultimately gone back home. Unfortunately, we could not get another photograph of the healed leg.

Unfortunately, NV returned yesterday with severe itching of the leg with small crusts forming over the affected area. Dr Nandamani was initially perplexed as he could not find any other evidence of bacterial contamination of the skin grafts – and to his horror found out that the entire area has been infested with scabies.
Scabies is quite a major problem in our part of the country. We have found quite a lot of our patients infested by the same. And unfortunately, many of our quack friends do not realize this condition and we find patients coming to OPD after having put steroid ointments and other condiments which flare up the infestation. Even among general practitioners we’ve found that scabies is fairly unrecognized and we’ve had even senior staff with the condition. One of my staff did not even acknowledge that she had the problem and I sent her to a dermatologist who confirmed the diagnosis.

We praise God that we could diagnose it quite fast and start the necessary treatment. Kindly remember NV in your prayers that the scabies infestation is easily controlled and the healing of his leg will be complete.

The Avulsed Ear

Last week, on my duty day, I had a peculiar and difficult situation.
One of our staff, Mr JK, a ward boy – a habitual alcoholic was brought to emergency in a rather sorry state after an allegedly fall off his bike. We initially thought that he had a head injury, but later to our trepidation found out that his right ear was almost avulsed off. There was only a bit of skin and cartilage which was keeping it still attached to his temple.


I waited patiently for about a week before I could post this story as we were not very sure if the ear will stick on after any sort of surgery. Against all odds, Dr Nandamani did quite a superb work on the ear after explaining to JK that there is a very high chance of the whole ear getting necrosis. Our worst fear was of possible gangrene as JK had taken some time before he decided to make it to hospital.  
I had put in a request for prayer. We are glad that things have gone well with JK's ear. After one week of the accident, the suturing appears to have gone well. There is no evidence of any gangrene of the area - rather the avulsed part looks healthy. We praise God.  

JK's wife AK is also a staff nurse of the hospital. She is presently undergoing specialized training in obstetric care at Herbertpur Christian Hospital. They have two children. JK’s alcoholism has taken a toll on the family. Please continue to remember them in prayers as also the rest of the group of alcohol abusers in our campus.

Kolkota Ramblings. . . Taxis from Howrah Railway Station

Last couple of days I was in Kolkota, this time along with Dinesh and Malay. The objective was to find out more about buying electrical accessories as well as some surgical items.

We left by bus from NJH two days back (Monday, 26th Sept) and reached Ranchi around 6 in the evening. After sending off Malay to the railway station along with the luggage we had, Dinesh and myself scoured Ranchi for shops selling electrical accessories. We found one after quite a long time. By the time, we got a quotation it was time for us to rush to the railway station.

As usual we had booked tickets by the Hatia-Howrah Express. All of us had uninterrupted sleep till the train pulled into Howrah at around 7:30 am. We were glad that it was not much late as it had been during the recent times.

But, we had a hard time in the pre-paid taxi stand. I’ve had previous experience of long queues in the pre-paid counter of terminal 2. And I had avoided getting out through terminal 2 of the Howrah station for quite a long time. Today, I was a bit hungrier than usual and thought of picking up something to eat before we left the station in the ‘Comesum’ joint.

It was a tragedy. By the time we came out, there was quite a long queue. We had to wait a good 90 minutes before we got a taxi. I have not been to many Indian cities, but the system in Howrah is certainly not one of the most encouraging one for travellers.

First of all, there are 2 systems working in tandem for hiring taxis. The first one is the pre-paid system and the second one is a system of directly getting taxis on hire. First of all, there a shortage in the number of taxis which are available – as most taxi drivers do not agree readily to come down to Howrah station from town – unless you agree to hire them well high above standard charges. When we had to return today from Burra Bazar to Howrah station, no taxi driver was ready to come without a minimum charge of at least Rs. 200 which was exhorbitant considering that the distance is not even a mile.

There was a tragic comedy of sorts in the taxi stand when one of the taxi drivers who came into the pre-paid counter found himself to have a flat tyre after having been allotted a passenger. It was terrible to find the pre-paid counter refusing to change the allotment of the hapless passenger to another taxi. Meanwhile the taxi driver made himself look like a clown trying to change the tire. First of all, he had a malfunctioning jack to lift the car while he changed the tire.

He tried to hoist the jack couple of times – and by the time he had the car hoisted up and started to remove the bolts, the jack gave way and he was back to square one. The third time, he got all the bolts out and then the jack gave way. It was getting a bit dangerous and he decided to give up.

He was also explaining to his passengers that he does not seem to succeed in doing much.

He went off trying to find another of his fellow taxi-drivers to arrange another jack. By that time, we had got our allotment of our taxi and was on our way to ‘Sceptre’ where we usually stay during our visits to Kolkota.
So, anybody visits Kolkota – advice from me. Even if you arrive at Terminal 2, try to get a taxi from Terminal 1 in the Howrah Railway Station.

Tuesday, September 27, 2011

Rikshaw Wallahs . . .

A common feature in many Indian towns, rikshaw pullers is quite a impoverished lot. I fondly remember my school days in Kollam, where we used to go to school at St. Joseph’s in a rikshaw. I forgot the name of our rikshaw puller – but he was associated with bidis (rolled up leaves of tobacco), alcohol and a characteristic smell of sweat.

As I started my career in healthcare, I learnt further about the plight of rikshaw pullers in many places of the country. In the EHA meetings, I came to know about the special clinics which were run for rikshaw pullers in few of the units. Tuberculosis and other diseases related to tobacco and alcohol abuse were the most common.

The other day, I happened to pick up a good conversation with a rikshaw puller in Ranchi. PL was from Gumla district and had been peddling his rikshaw in Ranchi since the last 20 years.

Like quite a number of rikshaw pullers whom I have known in my travels, I found out that PL was educated for his profession. He claimed to have started doing his graduation when he was forced to enter some profession to bring food to the family table.

Having younger siblings, the onus of providing education for them was upon him. He came down to Ranchi and started working in odd jobs before being initiated into rikshaw pulling.

PL worked quite hard. He married 10 years back. He brought 3 cents of land in Ranchi and set up house. He has two children – a 8 year old girl and a 3 year old boy. He has dreams for his children. I was glad to hear that he was bent upon sending both of them to school.

I ultimately asked him about the alcohol problem which is much prevalent among rikshaw pullers. ‘Sir, it comes along with the profession. Without some alcohol in the blood it is very difficult to get sleep in the night. My whole body pains if I do not have the stuff.’ – the typical answer I hear from almost all the rikshaw pullers I’ve encountered.

PL works quite hard. He earns about Rs 200 per day. His wife works as a part time maid in couple of houses. She earns a total of Rs. 1000.

PL was quite satisfied with his life. He has been responsible towards his family. Of course, he could not rise up to the levels which most of his younger siblings have come up to. Couple of them is in the armed forces, one of them in the police and one of them is even a teacher.

I asked him if his younger siblings help him out if they are times of need. He replied, ‘I do not expect them too. Times have changed. Everybody is quite busy raising his own family. There is so much of time invested in raising up children. So, all of them are busy. I get to see them couple of times a year, during Christmas and Easter.’

My journey was quite a short one for any more conversation. PL wanted to know whether I was a journalist. He told me that I look like one. Before I had replied he went on to request that I write a story about him. He was already ready posing before his rikshaw for a photograph. I did not have my camera. However, managed one snap with my mobile phone camera.

I asked him what I should write about him. He told me that he wanted the world to know that there are people like him who work hard without getting involved in any corrupt practices to make a clean living. He has only given to whoever has come along his life.

I’m amazed at people like PL. We read quite a lot about politicians, government officials, policemen etc. who are corrupt. But, it is heartening to know that people like PL exists, who believe in the ethics of working hard and giving their all for the sake of the community.

Sunday, September 25, 2011

Moms and Babes

I've started a new blog for the obstetric work which happens in our hospital.

Please read my first post - Story of an eclampsia.

For our prayer requests and reflections on my spiritual journey, I've started another blog where you can read the latest post on a note of gratitude for SD about whom you can read either here, here or here.

Thursday, September 22, 2011

ALL THE WAY FROM HOME (God's Own Country) . . .

BK, a 20 year old young man was brought by his brothers to the emergency at NJH sometime late afternoon. I happened to see him as soon as he came in. He looked quite sick and had yellowish eyes and was putting out dark colored and blood tinged urine.

BK’s brother told me that BK has just reached his home in a village nearby in Manika block. He works in somewhere in South India and has developed fever in the train. It was very high grade fever associated with chills and rigor. BK had blood shot eyes and it was obvious that he either had hepatitis or something else.

But, the diagnosis was quite easy once I found out where he worked. BK was a bit stuporous but he was conscious enough to answer my questions. To my astonishment, BK worked in Kerala. And where in Kerala? He worked in a pineapple estate.

As he told pineapple – I knew the diagnosis and my heart could not wait to ask the next couple of questions and it was obvious that most probably he had leptospirosis.

BK had been working in Kerala for the last 2 years somewhere near Perumbavur, Kerala in a pineapple plantation. It is very commonly known that workers in pineapple plantations are very much susceptible to leptospirosis. It basically occurs because of the pricks they receive from the pineapple thorns. And when they touch contaminated water, they get the disease.

Then I found out that BK knew Malayalam. You should have seen his face, when I asked the next few questions in Malayalam. Poor guy, he got the shock of his life to find a Keralite doctor working near his village. So much so that he was soon out of his stuporous state – though looking sick.

But more surprise waited for him in the Acute Care Unit. He must have got really psyched out when he found out that the nurse who attended to him as he reached the Acute Care Unit was also from Kerala.

His blood investigations were also very much suggestive of leptospirosis. He was lucky that his renal parameters were just turning bad when he came in. He has made an amazing recovery with high dose Penicilline.

Today evening, as I took rounds, BK told me that the previous day he thought he was dreaming when he found the doctor and the nurse asking him questions in Malayalam. He believes that a miracle has brought him here where we could make the correct diagnosis.

Rupture Uterus and Broken Dreams

BD was 22 years old and was married 3 years. Her last 2 pregnancies had ended up as first trimester abortions. So, when she got pregnant for the 3rd time, she was quite careful. Her family was poor. Therefore, she could not afford to go to any of the major doctors in town. Her local Anganwadi and the nearby Primary Health Centre provided the basic antenatal care including iron tablets and the tetanus injection.

BD went into labour on the 18th evening at around 7:00 pm. There was no way she could reach the nearby PHC as it was quite dark. Her family arranged for a vehicle to take her to the PHC in the morning. There was no doctor in the PHC the whole day. A nurse who was in the centre was on and off examining her contractions. By evening, the family was quite frustrated that nothing much had happened. Therefore, they decided to take her back home and have a home delivery. Unfortunately, nothing happened overnight.

BD was back at the PHC on 20th morning where the nurse informed the family that they should think about taking the family to the district hospital at Daltonganj. They reached the district hospital at Daltonganj by around 10:00 am where they were told that she was quite serious and that she can only be managed at NJH.

When BD reached NJH, we were having a quite hectic day in OPD and the theatre. There were quite a number of elective surgeries posted, Dr Nandamani was sick, Dr Johnson was away and I was looking after OPD as well as doubling as the anesthetist in the theatre as couple of patients for elective surgery was elderly.

Drs Angel and Shishir saw BD and a diagnosis of rupture uterus was not difficult. After explaining the risks to the family, we decided to operate as soon as one pint of blood was available. All the relatives who accompanied BD had their blood tested – unfortunately, either each of them did not have a match and when they had a match, the donor hemoglobin was not enough to donate. So, off the relatives went to arrange blood.

By the time, a pint of blood was available it was quite late in the night. Dr Shishir who was on duty operated. It was a mess inside the abdomen. It was quite a long time since the uterus had ruptured and the uterus was quite gangrenous. Shishir realized that the uterus has to be sacrificed if the patient needs to survive.

It was a tough decision for the family to take. Neverthless, they gave the consent and Shishir went ahead with the partial hysterectomy.

It has been 36 hours since the surgery. BD continues to remain sick. She would need more blood as well as stronger antibiotics. I sincerely pray that BD somehow survives.

Her family is quite ignorant about what is happening. I have mixed feelings about BD’s future. In a society which is so obsessed with having a male progeny, her status within the family is going to nose-dive. Most probably, her husband – although very concerned as of now – would most probably marry a second time.

But, issues such as PHCs being manned by staff who have no basic idea about the physiological process of pregnancy and normal delivery and especially in identifying danger signs in a mother in labour needs to be seriously looked into.

After MD, it was quite a long time since we had a rupture uterus and I was feeling happy that the incidence of rupture uterus was on the low - but the experience with BD has made me realise that there is always a possibility of us seeing more of similiar cases in the future. But, BD's story was the saddest story I had encountered of rupture uteruses I've come across.

Tuesday, September 20, 2011

Near death experience of a young man with diarrhoea

DD, a 20 year old young man hailed from the nearby village. DD earns a living by selling off wood which he brings from the forest.

DD was suddenly taken sick yesterday afternoon, when he developed severe vomiting and loose stools. DD’s parents got hold of the local 'jhola chap' (travelling quack) who gave him a prescription of intravenous fluids, Injection Amikacin, Injection Dexamethasone along with some more medicines. I had managed to get hold of his prescription which is put here.

DD was brought to NJH at around midnight yesterday. He was very very sick. He had a thread pulse and we could not record his blood pressure. The symptoms were very much typical of cholera. Since it was midnight, we had to wait till day time for a ‘hanging drop test of stool’ for cholera bacteria.

Later I found out that DD had not put out any urine since yesterday morning. We put him on a catheter and there was hardly any urine.
DD responded quite well to intravenous fluids and Tablet Doxycycline. By morning, he had started to put out urine in small amounts. Although the frequency of passing stool had decreased, we managed to get a sample for the ‘Hanging Drop’ and it tested positive for cholera.

He had come to NJH on time. If he had waited some more time, we could have lost him. The management of the quack continues to be the same as that of what used to happen 20 years back. I wonder if we could train some of these quacks to provide life saving treatment.

Monday, September 19, 2011

Anemia and Malnutrition

Over the last 1 month, we have been facing the brunt of morbidity that anemia can cause in our patients. Today (19th September, 2011), I had to face the havoc it could play in our patient’s lives. We ultimately end up taking uncalled risks in the management of our patients.

Anemia in obstetric patients in this part of the country has always been a constant problem. Over the last 2 weeks, we had 6 bad wound infections after Cesarian section. Overall, our practices of sterile techniques and patient management protocols are quite robust to ward off any possibility of infection.

The constant feature we saw in each of the 6 wound infections was a pattern of low hemoglobin associated with a history of having been handled elsewhere. It is quite easy to find excuses and shift the blame to something else. Of course, I’ve already started a process of reviewing our processes and ensured that fumigations are done at the necessary places as well as tested the autoclaving processes.

In addition to the low hemoglobin, we’ve discovered something else too. And that is the low serum protein levels in such patients. Of course, before I come to a conclusion, we need to compare it with the other patients who do not develop wound infections.

Nevertheless, I just wanted to put in this post something which I’ve been thinking for quite a long time. I suspect that most of our patients are chronically malnourished. When I look at my anemic patients, many of them have told me of having taken their iron tablets. But, when I ask their dietary practices, I get very terrible replies. For most of them, their basic diet is rice with a little dal which becomes more watery as you become poorer.

Basically, none of these people have much of any protein in their diets. Well, if you know medical biochemistry, iron transport occurs in our body through protein substances called ferritin and transferrin. When people have such a protein deficient diet, how can you expect their bodies to make transferring and ferritin which are very much essential in the absorption, transfer and storage of iron?

One more facet of anemia which has been quite known to quite a number of clinicians but quite ignored in clinical teaching is the role played by Vitamin B12 and Folic Acid in the synthesis of red blood cells. After Angel joined work, I’ve been encouraging my colleagues to send peripheral blood smears of patients who have anemia as well as tingling/burning sensation or numbness of the limbs. Angel has been reporting macrocytosis, and hypersegmented neutrophils which is very much suggestive of Vitamin B12 deficiency.

I wish we could do an epidemiological study into this aspect of anemia. I understand that I could be wrong – but there is enough evidence to warrant a proper look into this by the scientific community. There are quite a lot of things which I suspect – there could be a Intrinsic Factor deficiency in the community, the diet could be poor in Vitamin B12 deficiency, there may be inhibitors of the absorption of Vitamin B12… However, there is a common denominator to all this – and that is the lack of a balanced diet in the community.

The lack of a balanced diet is very much linked to the issue of food security. The nutrition is quite skewed towards the carbohydrates and the fats. Proteins are a definite no-no in most of the diets which I’ve experienced in the communities here. And one more matter of concern is the lack use of vegetables in the diets here in spite of the local cultivation and availability of vegetables.

I’ve always felt that the lack of Public Distribution System has played havoc in the dietary patterns of our communities and patients like the one I described in my earlier post reinforce this. When I look back at my childhood in Kerala, the Public Distribution System played a very significant role in ensuring that no family went to bed without food. If it is true that the chronic malnutrition which is being purported as a cause of the various deficiencies which we commonly see in the rural communities, there is a strong case from the healthcare research community to strongly establish (in some places re-establish) the Public Distribution System in every nook and corner of the country.

Monday diary

We start Mondays in NJH with much anticipation and preparedness. Usually, they are very busy and it would be very difficult to find any of us sitting doing nothing. I knew that today was going to be tougher than usual as Dr Nandamani who was on duty on Sunday was running a very high fever with body pain and Dr Johnson was on leave.

As soon I finished the rounds in the Maternity Ward and before I started rounds in the Male ward, I managed to peep into the OPD and was surprised to find it quite empty for a Monday morning. I took things a bit lightly and did a very relaxed round in the Acute Care Unit and the Male Ward.

Well, silly me. It was just the calm before the storm. As soon as I finished Male ward rounds, I got a call from Dr. Nandamani requesting me to review a patient in OPD. KD who had a LSCS about a month back had come with pus pouring out of her vagina and pieces of catgut too. The patient was otherwise doing fine. She had come quite sick for her delivery. She was unconscious and having continuous seizures following which we had do an emergency cesarian section. She was in the ventilator for 4 days. The relatives had given up hope. Somehow, she had lived. I asked for an ultrasound. She was quite pale. I’m yet to follow up on the investigations.

As I came out, there was a call from Labour Room. There was CD, a 27 year old G3P2L2 with leaking since early morning. The duty nurse requested me to come fast as the abdomen looked abnormal. One look was enough to suggest that it was either a transverse lie or a Bandl’s ring had formed, the former more likelier than the latter. There was more in store. I did a per vaginal examination and to my horror, a good 2 inches of the umblical cord was hanging out of the cervix and it was pulsating well. The patient had started to contract and there were no membranes. I was not sure if the baby was alive. The nurse was sure she heard the fetal heart.

I took CD for an ultrasound abdomen. Thankfully, the baby was alive. The question was how much longer she would hold on. The only saving grace was that the baby being in a transverse lie, there was nothing putting pressure on the cord.

I rolled her straight from the ultrasound room to the theatre where a call from the laboratory put me in trouble. Her hemoglobin was only 6 gm%. I had no other choice but to operate immediately if I wanted a live baby. With a prayer that the Lord will protect the mother and the baby and very high risk consent from the bystanders, we went on with the surgery. The mother and the baby are doing fine. By evening, the bystanders had arranged couple of pints of blood.

There was more happenings going on elsewhere. Shazia, our community health staff was helping us take the delivery of a Nycocard reader in EHA Central Office in Delhi. The person from the company had called me just before the surgery on CD and had told me that they did get any intimation of the NEFT transfer of the required funds for the purchase of the machine. I explained that the transfer has been made and requested that the machine be handed over. I’m glad that the machine was given although the confirmation of the transaction of funds is yet to happen.

As soon as CD’s surgery was over, I went over and scanned a copy of the NEFT transfer slip and send it over. Later, there was a problem in the pharmacy as it turned out a batch of Ranitidine tablets were becoming semisolid like - almost  liquid-like. So, I had to officially intimate the suppliers as our requirements are quite voluminous.

I made my way to the OPD, where Angel was having trouble with a patient with hallucinations and delusions. The patient was quite poor. From the history, it was obvious that the patient was going into Schizophrenia. I told them of the option of going to Ranchi, but it was quite obvious that it was going to be difficult. So, I had to call up my friend, Dr Raja at Burrows Memorial Christian Hospital, Alipur and soon I had put in a plan of action for the patient and they were quite relieved. That’s telemedicine for us.

Soon, we had our next obstetric emergency. EE, a 34 year old G3P2L2 who had been in labour elsewhere had turned up in the OPD. She had an abdomen like a pear. We had a similiar patient couple of months back. It was obvious obstruction. The only question that remained was whether she had started to rupture. Once again, I was not sure about the baby’s status. The ultrasound showed a fine baby. I had to operate her.

She looked sure anemic. My only prayer was that she would be at least 8 or 9 gm%. She was 7 gm%. But the severity of obstruction she had made me to take a decision to go ahead with the surgery as soon as possible. After sending the relatives to somehow get hold of 2 pints of blood I took the baby in. Once I opened the uterus, I wished I had put in a midline vertical incision rather than a Joel Cohen Incision. The bladder had been pulled quite high up. I had to reflect the upper flap of the abdominal wall quite high to reflect the peritoneum down.

My prayers were answered when we delivered a live girl baby. She had a poor Apgar initially, but was well resuscitated by the theatre team. When I went in the evening to review her, she was bawling out. And oh my, the only time you feel so happy to see a child cry out.

I had staff from the hospital where EE was admitted for the last 3 days. It seemed that she was asked to go to a higher centre on Saturday night as the doctor had felt that the baby had not rotated properly and she could need a Cesarian Section – but the family had not taken it seriously. And having waited for quite long – they had taken a very high risk.

As soon as I finished surgery, Sr. Bharati, the Nursing Superintendent had news for me. Dr. Nandamani could hardly sit, leave alone work. He had told me that he was feeling quite sick in the morning and I had told him to take sick leave if he finds things difficult. Dr Nandamani had left OPD and there was quite a large crowd.

As usual, there was a bunch of tuberculosis patients, couple of patients with bronchial asthma, two patients with long duration of fever with typical features of dengue and a low platelet count whom I ultimately admitted.

However, I need to tell you about a patient who I felt so bad about. She was SD, a 65 year old lady with a swelling over her right cheek. It was obvious oral malignancy which was spread locally. There was nothing much I could do. As soon as I told the husband that he needed to take his wife to the Medical College under Banaras Hindu University, both of them started to cry. I asked them about their children. More tears rolled down their cheeks – there was so much of hopelessness in their eyes.

I told them that I’ll help them to obtain help in going. They sat down and talked for a long time. It seemed that their children were doing well. But, they had no time for the parents. I gave letters for them to give to the local government authorities so that they could request help.

Like the many malignancies which we have been seeing of late, most of these poor people have nowhere to go.

In between, we had a elderly lady with electrical burns. There was only about 10% of burns and most of it was quite deep. Since electrical burns could be quite deep such that it could involve even the bones, the patient was quite elderly and the family looked quite well off, I gave them the option of taking her to Ranchi which they promptly did.

By the time, we finished OPD it was 5:30 pm. As with each day, we had learnt quite a lot. There are concerns which I would share in my later posts especially about the prevalence of anemia which is responsible for quite a lot of morbidity and mortality in this part of the country.

I also realized that Dr Shishir, Dr Nandamani, Dr Angel and I had dealt with quite a number of sick patients whose management could have resulted in quite a number of complications and I acknowledge the grace of God in whatever we did during the day. My prayer is that our patients also realize the same in their lives.

Sunday, September 18, 2011

Visitors at NJH

It was a privilege to have Ms RuthAnn from Interburns and her friend, Mrs Juliet over the last week. Ms RuthAnn visited us as part of the work she is doing with Interburns to popularize and promote burn care in NJH. I shall put in a post about Interburns later as time permits.

Burn care in NJH is not anything new and we had been talking about a separate unit for managing burns in this part of the country. As far as we know, we are the only unit in West Jharkhand who manages burns. As evident from my previous posts (Pediatric Burns, Neglected burns, Prodigal son, Mismanaged burns), we have been quite busy managing burns.

Ms RuthAnn is a trained physiotherapist who has developed a specific interest in burn care during her time at Duncan Hospital, Raxaul – another unit of Emmanuel Hospital Association.

As far as I understood, Interburns has been standing for a more active management of burns with tangential excision of burn wounds and skin grafting along with active physiotherapy. To the layman – it sounds complex. Well, let me explain.
RuthAnn along with the EHA team in Burn Care Retreat at Bangladesh

The older management of burns involved daily dressings which used to be messy and took quite a long time. In addition, there was also contracture formation which made life quite difficult for the patient. In tangential excision, the burn wound is excised as soon as possible and a skin graft is done immediately. It speedens up healing, decreases the amount of time the patient spends in hospital and prevents contractions.

One of the major accomplishments RuthAnn has made is to popularize the use of commonly available materials to make splints designed to prevent contractures after skin grafting. To help us with the making of splints, she graciously donated a heat gun to us.
RuthAnn teaching Dinesh to make splints

MI recieving a locally made splint to prevent contracture of his left axilla

MI being helped with physiotherapy

RuthAnn’s friend, Juliet accompanied her and helped us in umpteen numbers of ways including helping her with the classes for nurses, accompanying the Community Health team and encouraging us and providing a good time for many of us. We are quite thankful to Juliet for the time she spent in prayer for us.

We look forward to RuthAnn and Juliet coming back to see a flourishing burns unit and a improved hospital set up.

Saturday, September 17, 2011


CD, aged about 50 years is a farmer in the nearby district of Chattra which was quite far away. CD suffered a small injury of his left foot about 10 days back which he managed by putting some local medications.

Over the last 7 days, CD noted that he could not swallow, which slowly progressed to a stiffening of his back. As usual, he was taken to many a place before he ended up couple of days back at NJH. It impressed me that someone had actually diagnosed tetanus elsewhere and had referred him to us.

After MS, this was the third patient whom we had. We use the WHO protocol for management which we put him in. We had problems putting in a nasogastric tube as his oesophagus had gone into a terrible spasm. Till date, I’ve not been able to do anything about it even after he was put in all the available muscle relaxants.

Well, the reason I wrote about this patient was because of something I missed about this patient. Dr Nandamani noticed that the bystanders had got almost all of their medicines as hospital supply and it crossed his mind that if the family did not have money – did they have something to eat? Well, his hunch was true. The family had not eaten for almost a day after they reached NJH.

He got them something to eat from Raju’s shop. It was sad to see the family sitting in the waiting shed and whopping down the food.

It is unfortunate that even in the midst of the plenty that we claim to have in this country, people remain hungry and would not even open their mouth to tell others that they have not eaten anything for quite a long time.


We had a horrible beginning of a day today. After devotions, I found out that there was a little girl, AK aged just above 2 years who had come in with a history of fever for the last 10 days. I wondered what the family doing for that long time. Unfortunately, I did not have much time to take a detailed past history or socioeconomic history.

AK was very sick with labored breathing. She was so pale – that I knew that her hemoglobin would not be more than 2 gm%. Her saturation was about 70%. If she had to survive, she needed blood and mechanical ventilation.

Luckily for AK, the ventilator was free and we could hook her onto that soon. The problem was with the blood. I went along with the father of the child and ensured that he checked his blood group. It matched. He requested 10 minutes to go and have food as he had not had anything to eat since the last 12 hours.

The laboratory results left me stunned. The father told me that she was on Injection Artesunate. You can see the laboratory results in the snap beside you. Later, Mr. Anil told me that 60% of the RBCs were filled with the malarial parasite.

She did not have much chance unless she had the blood. I went back to her bedside. She had suffered a cardiac arrest and the nurses were already starting a CPCR. The father who was supposed to be back could not be found. With a hemoglobin of 1.4 gm%, I knew that we did not have much of a chance.

The father came after about half an hour. Her heart had started to beat again. I had rushed fluid. As a last ditch effort, I started her on a dopamine drip – which was foolish considering her pathetic hemoglobin. She suffered another cardiac arrest after which we could not revive her.

She died at 10:00 AM exactly 2 hours after she had come in.

I’m concerned about 2 things.

The first one is about the injectable artesunate which was used. There can be only two things which can be concluded. Either it was a duplicate medicine or there is resistance emerging to artesunate compounds in our region. There are reasons to believe either of them, both of which are reasons of major concern to us.

Duplicate drugs are a major issue in most parts of the country.

However, there is much reason for us to believe about emergence of artesunate resistance as during the last 2 months; we have quite a lot of patients who had been started on artesunate derivatives from outside, especially the quacks as well as legitimate doctors. They had no relief and we have seen them respond to quinine.

My second concern was about the attitude of the father to the condition of the little girl. He could have at least tried. I’m not saying that the girl would have survived if we got the blood. He was least bothered when he came in first.

Neverthless, I saw him weeping silently after I told him that his daughter has died. But, if he had brought her in earlier she would have definitely survived.  

After this little girl left, we had 2 more admissions in the Acute Care Unit of similar patients with a similar history. More about them in the next blog.