Monday, February 27, 2012

Prayer and Praise Bulletin – Feb 28

 worship 1. We’ve had quite a few bad obstetric patients over the last couple of weeks. We are thankful that all of the made it including the 2 rupture uterus patients.

2. We had 3 babies who weighed less than a 1200 gms over the last week of which one baby is just 750 gms. The littlest one has clung on to his life for the last couple of days. Please pray that all the babies will be safe.

3. Today, we had the RSBY Scheme installed in our hospital. We plan to run it on beta for the first week and officially inaugurate the service from next Monday. We thank the Lord that in spite of umpteen challenges we’ve been able to get it going. Kindly pray that our experience with RSBY would be rich.

4. We thank the Lord for Wendy and Jerry from Grace Babies who have been with us since the last 2 weeks. We’ve also been able to start the full fledged functioning of the NICU. Please do pray that we would have a full time paediatrician to care for our sick babies.

5. We thank the Lord for the progress of the Burns Unit. We also thank the Lord for a significant contribution that has been raised through the efforts of one of our friends in Australia. Over the next two weeks, couple of major purchases for the Burns Unit in the form of a Skin Graft Mesher and a Brick Making Machine would be made. Kindly pray for all the logistics involved.

6. One of the major possibilities after the introduction of RSBY in the hospital is a sudden surge in our outpatient and inpatient numbers. I’m not very sure about the quality of care that we would be able to provide if such a surge is there. Something which we need quite badly are staff of all cadres who are committed with a soft corner for the poor and the marginalised.

7. Construction of newer residences is a crying need for the unit. We pray for funds as well as opportunities for construction of new staff quarters.

8. Couple of our doctors (Drs Ango and Titus) would be travelling for the Medicine CME arranged at Herbertpur Christian Hospital. We thank the Lord for such opportunities as well as pray that it would be a great time of learning and sharing experiences.

9. Kindly pray for Namiyani, one of our staff nurses whose mother suffered a stroke. We thank the Lord that she has made a good recovery. Please pray that she will be completely healed.

10.  We are thankful for the time of prayer and study from the Word which the staff and their families had on Feb 24th.

11. Kindly pray for Sr. Dulari who has a inevitable abortion on the way as well as for Sr. Chandrakala who has a severe growth retardation in her pregnancy. 

12. We are thankful that Dr Shishir has recovered quite well and his evaluation has also not revealed anything serious. One of our staff, Sr. Elmira had met with an accident couple of weeks back and had an avulsion of the heel pad. We send her to Robertsganj for treatment. She is on her way to recovery. Please pray for her complete healing.

Neonatal Care . . .

Neonatal care has always been a challenge. However, we’ve been able to save quite a bit of little lives over the years. You can find quite a lot of stories on my blog. The post I can remember fast is that of KD's baby.

Jerry and Wendy
Now, a major influence in neonatal care in NJH along with many other EHA Units has been Mrs Wendy and Mr Jerry, a lovely couple from Maine, US. They have facilitated the setting up of the neonatal unit at NJH.  The construction of the unit had happened couple of years back and we also had the supportive equipment including warmers, incubators etc. Unfortunately, we found it quite difficult to operationalize the set-up because of the shortage of committed staff and the necessary administrative will-power. However, I was quite encouraged when Mrs Wendy decided to push through with the starting of the unit during her present visit to NJH.

And, she also was kind enough to give us an extended period of stay at NJH to facilitate opening of the unit. We are blessed and are thankful.

We’ve already have few very sick as well as small babies coming in. The tiniest one is about 26 weeks by gestational age born to a lady with abruptio placenta and placenta praevia. He’s just 700 gms and has made it so far.

I understand that Grace Babies, the movement through which Jerry and Wendy has been helping hospitals like us is a registered American charity with facilities for Tax Deductible Donations.

Of course, as we had been praying for quite a long time for a pediatrician, we have also been planning to upgrade the neonatal care unit with more equipment. For a start, we have realised that we need couple more each of baby warmers as well as phototherapy units.  DSC08295 In faith, we look towards a time when we will have a paediatrician coming in to be part of our team. . .  Meanwhile, we thank the Lord for the commitment Wendy and Jerry has shown towards the care of poor Indian babies many of whom would have died if not for their support.

And please remember the 750 gm hero in your prayers . . .

RSBY . . .

I had been mentioning about the Rashtriya Swasthya Bima Yojana (RSBY) in few of my earlier posts. Emmanuel Hospital Association, which is the parent body of our hospital, along with the UNDP has been running a programme aimed at strengthening the RSBY since the last year (from October 2010) and couple of days back, we had a meeting aimed at putting in the experiences in the field.

Photo-0001It was an amazing time of learning and sharing.

It was a bit unfortunate that I had to leave sometime in the afternoon. And well, that was an embarrassing story, which I could narrate sometime later. 

Health care costs, as is everywhere else in the world is a major concern for policy makers. 

There are enough research papers which tell us about how families are either dragged or kept in poverty due to health care costs.

Now, I understand that quite a lot of organisations including few of our sister units have been trying for quite a long time to put in systems in place whereby poor patients would be benefitted by some sort of an insurance scheme, so as to prevent huge healthcare expenses hampering the financial stability of a family.

The RSBY has been a brilliant idea and it is already working wonders in many a poor families all around the country. We were quite blessed to have Mr. Anil Swarup, the prime architect of the program in our learning seminar at Delhi and it was a double blessing for me to be part of the meeting he had at Ranchi the very next day for discussions with the Jharkhand team. 

Now, what we have been doing is to do a project aimed at strengthening RSBY. And that too at a time when we were not empanelled for treatment under the scheme. However, we tried quite a lot of things to convey the message to the people.

Below are the list of challenges we faced -

1. The root of quite a major crisis is the BPL (Below Poverty Line) list. I’m told the list which was followed by Insurance Company during the enrolment periods was outdated. Now, for people who do not have a BPL card, they have a APL (Above Poverty Line) Card. Now, what we found out was that many of the APL card holders had the smart card and those who are supposed to have BPL card have been left out of the scheme. The best solution for this would be to enrol everybody in the scheme with those who have a regular income or land having to pay the total premium in comparison to the poor families for whom the government would pay the premium. Well, I agree it’s not going to be all that easy. But, there are states who are doing it.

2. Insurance company did not make Smart Card in a systematic way in the Community. Insurance company did not inform to government nor supportive/facilitative organisations about their activities. Many a time, even the villagers did not know when the insurance company was coming for enrolment. Well, to be frank there was an apparent lack of co-ordination between the insurance company and the agency doing the IEC campaign. But, today I found out the real reason -  it seems that few of the insurance companies had issued a diktat to its staff not to tie up with any of the health care service providers to facilitate the issuing of cards. Well, the ultimate result was that the poor man lost out. . .

3. There was a delay in providing the smart card. Many a time, this was because of poor infrastructure especially availability of electricity.

4. There was an allegation of insurance company avoiding the empanelment of certain hospitals and even when empanelment was done, there was a delay in providing the necessary equipment to operationalize the program.

5. There are lot of mistakes in card in the name, age, and sex which is found in the card. Now, I cannot blame anyone. In our registration department, I’ve seen the following versions for a same name within a single inpatient chart before the arrival of computerised records – shobana, sobana, shovana, shobna, sobna. Coupled along with this is multiple aliases that an individual keeps.

6. There are quite a lot of people who have been enrolled who have no clue on what the card is used for. Some people had the perception that this smart card is some sort of an ATM Card or Identity Card.

7. There have been reports that few hospitals included under RSBY scheme did not provide RSBY facility in proper way.

Well, as soon as I reached back to NJH, the insurance and software provider was behind me to get the software installed into our system.

And ultimately, we ended up doing it today – Sunday afternoon.

Many a time, I’ve been trying to convince many of my colleagues and acquaintances about the poor state of communications in our area. Unfortunately, I found it quite difficult to convince couple of government officials during one of the meetings at Ranchi about the difficulties we faced with communications and electricity.

And, today afternoon I had the district program manager for RSBY and staff from the software company arriving at the hospital to set up the software in our machines. To start with, we did not have internet communications. But, we were quite a determined lot. And the following snaps would tell you the story.
The team below the place we get the best internet connection with the tata photon dongle


Yes, we actually carried the desktop to the best place we can so as to get a internet connection using a dongle. Why not a laptop? It is not supposed to be used for RSBY as the chances of cheating is much higher. And we could install the program in only one computer.

Well, after all the effort we could not fully register the program. It would take one more day. And the Lord willing, we would be part of the famed program within couple of days.
For us, it has been a journey of faith. We are quite unsure of how the whole exercise would turn out. We pray that the objective for which the RSBY has been set up will be met and we would be able to be more effective in catering to the poor and the underprivileged in the society. . .

Wednesday, February 22, 2012

One more rupture uterus and more . . .

I was on duty on Sunday and although we did not very heavy like quite a few weekend duties I was quite tired at the end of the day.

I received a call at around 4 am on Monday that there was a 2nd gravida in labour with per vaginal findings which were a bit funny for the attending nurse. She told me that she was sure that the baby would not come by normal delivery. Well, it was a brow presentation.

She had been in labour for quite a long time and I was sure that we would need to take her up for Cesarian section quite fast.

By the time, I finished doing the Cesarian, it was around 6:00 am. Something made me finish off the rounds within the hospital. Dr Johnson was on leave and with Dr. Shishir on his way to Delhi for further evaluations, we were short of hands.

But, Dr Nandamani was joining back and there was an anticipation of a heavy rush of surgical patients in Outpatient. It was good that I finished the rounds.

I rushed back home just in time for a steaming cup of coffee, when I suddenly realised that I needed to make few announcements in chapel. After chapel, someone came and told me of a new patient in the labour room.

And my, what a patient we had. KD was delivering breech and the after coming head was stuck in the pelvis. And it was stuck like that since 12 midnight. She started having labour pains since late evening and the torso of the baby delivered by midnight. This had happened in the nearest district hospital.

I could think of only one possibility. A large aftercoming head – most probably hydrocephalus. On per abdomen examination, it looked so – but there was one more funny finding. I could palpate the uterus separately. There was only one possibility – a rupture uterus. Something very rare to happen in a breech delivery. . . It was a bit difficult for us to imagine having 2 rupture uteruses to deal with within a space of 48 hours.
The hydrocephalic after coming head . . .
 I took her to the ultrasound room. Yes, it was a hydrocephalus. Meanwhile, Nandamani was in hospital. I requested him to go ahead with the craniotomy and delivery of the baby. After the delivery, he also was sure about the rupture uterus.

The unfortunate lady went straight to surgery. Meanwhile, my better half announced that there was a crowd building up in the outpatient. And there was couple of patients in labour who needed urgent attention. The first one, a primi with a height of 135 cm and a large baby. The second one, a supposedly post dated primi at 42 weeks gestation.

And, quite a lot of surgical patients for follow up as well as new patients had come to OPD. Dr Nandmani requested me to start off with the surgery for the rupture uterus, so that he could minimise the volume in the outpatient.
On opening the abdomen

The placenta lying free in the peritoneal cavity . . .

The rupture on the lateral wall of the uterus

The anterior wall . . . 
I started it off and soon I realised that it would be better for Dr. Nandamani to handle it. . . 
Dr Nandamani suturing up the rupture . . .  
 Soon, SD was also readied for surgery. It was a routine Cesarian, but did not turn out to be. SD also had polio. So, we decided to give General Anesthesia. As we pushed in the pre-anesthetic, SD arrested . . . Nandamani rushed in and resuscitated her . . . which she thankfully responded to.

Considering that she had a reaction, we took a decision not to do the case at NJH and rather refer her to Ranchi. But, the relatives were not willing. . . We got a high risk consent for the surgery. Then, Dr Titus got an idea to do a skin test for lignocaine and try to do the surgery under spinal.

To make matters worse, she reacted to the lignocaine skin test. So, we were again talking to the relatives trying to send them to Ranchi. They came with few of the local leaders and soon it was a high profile case. The relatives were adamant that they could not take her any further. . .

So, armed with another set of high risk forms and a decision taken that one of us will give the spinal – we went ahead. We thank God that the surgery was uneventful and she delivered a healthy live girl baby.

Well, in between the rupture uterus and the Cesarian section on the lady with drug reaction, we had one more Cesarian section. And this was for a lady who came to us 3 weeks back with leaking per vaginum. She was in her 28th week of gestation when she had come to us. She was admitted couple of days back with a minimal amount of labour pains.

As always we had given them the option of referral. Now she had just started her 31st week of pregnancy. While we were managing the patient with rupture uterus, word had come in that she gone into full blown labour pains.

Now, about 6 hours later, we realised that she was not progressing and the uterus was contracting against a tightly closed uterine opening. We explained to the relatives about the predicament we were in and opted to go in for a Cesarian section. The baby was just 1200 gms . . .
Sr. Wendy discussing care of the little premie with Dr. Johnson and Sr. Bharati
 Thanks to Wendy and Jerry from the Grace Babies, we’ve been encouraged to manage the baby here. The relatives, who are not that well off to afford a referral to Ranchi are happy. So far, the baby has done well. Kindly pray that both the mother and baby will be fine. As we opened a premature uterus, we realised that there was some amount of chorioamnionitis . . . and Nandamani had to come in to help me some extra bleeding . . . It was good to have him back. . . 

Meanwhile, from Tuesday till Friday, I’ll be away in Delhi . . . Pray as Nandu, Johnson, Titus and Angel manages the work. Shishir is undergoing medical evaluation in Delhi . . . We pray that everything will be alright. . .

Monday, February 20, 2012

Photo post . . .

The previous one was a blog full of prose. And some terrible snaps. . . More of the terrible snaps that we get to find here . . .

1. The first one, a 16 year old girl who presented in OPD with history of cough for about 10 years. She was being managed by quacks in her village and also with roots and herbs as part of traditional treatment. Till, she started to have fever since the last 6 months. And one day before reaching her, she started to spit out blood – which prompted her to come here. And the worse part was that she was severely hypoxic (SpO2 70%) that she was so confused.
2. Chest –Ray of a 45 year old lady who came in with chest pain and breathlessness.
3. A swarm of wasps who started to make their next on the roof of one of the campus buildings. Over the last 4 months, we had 2 patients who came in with anaphylaxis after wasp stings. Fortunately, both of them had survived.
4. The badly infected scalp wound of AM, who came to us last week. In my previous post, I had mistakenly mentioned that AM had gone to some health centre immediately after the injury. It was not true. The family thought of going to a health care provider only few days back from where he was referred here.
5. Chest X-Ray of one of our local villagers who fell through a partially constructed bridge while coming back home from work. Cannot blame the bridge alone as he was quite drunk to realise that he had fallen through. Only the next day, he realised that he was having difficulty in breathing as well as severe chest pain. And then he started to spit out blood . . .
6. Something which we had been searching for quite a long time. A skin mesher for use in our skin grafts. It’s quite expensive . . . 75,000 INR (approximately 1500 USD/AUDs, 1000 GBPs) Wondering if we could find a donor . . .
2012-02-06 10.48.28
7. And the final one. . . X-Ray after bullet injury on the thigh of a 20 year young man . . .
2012-02-17 22.49.36

Well, before I sign off this post, need to tell you that we had an amazing day of obstetric care at NJH today. Do watch out for the next post . . . 

Sunday, February 19, 2012

Rupture Uterus . . .

Kindly note that this post contains surgical images which are very revolting. Please use discretion in viewing them.

KwD came to Emergency sometime just before we start work for the day.

Dr Johnson was on call. He was almost sure that it was a rupture uterus.

The story was very familiar. The yearning for a male baby had landed yet another lady into yet another tale of misery and pain.

KwD was in her 5th pregnancy. All her previous pregnancies were home deliveries and all were girl children. As is the custom, everybody wanted a boy baby.

KwD’s fifth pregnancy was also uneventful. Couple of days back, she had done her antenatal check up with one of the private doctors in the town near her village and she was given a clean chit.

KwD went into labour sometime early afternoon yesterday. After having kept at home for some time, someone told the family that it would be good if they delivered in the hospital as it was her fifth pregnancy and as a bonus they could get some cash.

KwD’s elder brother took her to the government PHC nearby. They reached sometime around 6:00 pm. The nurses assured them that everything should be alright. However, nothing much happened till about 9:00 pm. Couple of intramuscular injections were also given.

The nurses sensed that something was not ok and therefore referred KwD to the nearest district hospital. The government ambulance in fact took them to the biggest private hospital in the district where they reached sometime around 11:00 pm. The nurses took a look at her and informed her that she looks quite bad and therefore she would need to take her elsewhere.

Off they left for the government hospital – however, nobody attended to them. Sometime early morning today, after KwD’s husband reached the hospital, a decision was taken to bring her to NJH.

And so she reached NJH at around 7 am. Nandamani, our surgeon was away for a day and therefore I told about our limitations. They also told me about their limitations to take her elsewhere. So, I decided to go ahead after all sorts of consents in hand including the terrible ‘death on the table’ consent.

Well, one of my obstetric professors had told me quite long back that she has never seen a rupture uterus in her life. And I had also realised that I never had pictures to show anybody. So, below are the pictures of what we found inside . . .

To tell you the truth – this was one of the worst rupture uteruses I’ve ever seen in my life. The snaps would tell you the rest of the story . . .
The external appearance. . . For an experienced obstetrician at one glance, it is obvious that something is amiss . . 
The view on opening the rectus sheath . . .
The badly injured uterus . . .
Posterior aspect of the uterus . . . 
Another view of the uterus. On the right is the cervix along with the bladder
Hematoma within the mesosalpinx . . . 
The operating team . . .
The retroperitoneal laceration. This view is after the uterus was removed. Note the meconium which has stained the retroperitoneum. The rent extended about 10 inches superiorly . . 

Well, what I need you to pay attention is the last photograph. Difficult it was, mainly because I did not have a firm lower vault to suture up the lower segment. It was all like mince meat.

But, what stumped me was the fact that the rupture after it had involved almost two third of the lower segment of the uterus had torn off into the posterior aspect exposing almost a third of the retroperitoneal contents.

The triangular area which you see in the last snap is the ripped open retroperitoneal region. On one side, I could visualise the ureter. One of the ureter could not be visualised. I hope that that is safe. If you also look careful, it is not easy to miss the meconium staining within the area.

It’s now about 24 hours since the surgery. RwD has done well so far. She recieved 3 pints of blood. She is putting out enough urine. However, I would reserve my prognosis until few days are over.

Please do remember RwD in your prayers . . . .

Lessons learnt . . . 

1. You cannot blame RwD for the predicament she is in. She went to the right places . . . But, she never got the right diagnosis and right treatment. Another justification for my plea for getting our health centres and hospitals equipped with qualified staff and adequate equipment, before we tom tom about need for adequate awareness amongst our countrymen regarding healthcare issues. 

2. The secondary status of women in Indian society. I was stunned to find out that RwD has already married off her first daughter . . . at a tender age of 15 years . . . It's already been one year . . . It is so difficult to dream of seeing light at the end of the tunnel for gender discrimination in our society. 

Friday, February 17, 2012

Poverty and disease . . . The vicious cycle . . .

I was debating to post the story of a little boy who came to our outpatient department yesterday. I worry that I look like a crybaby who keeps lamenting at the sad state of health affairs in places such as ours. . . 

AM, a 7 year old came sometime yesterday morning to OPD. His head was caked with pus. My Angel was wondering on what the diagnosis could be. To her horror, the cause of the severe infected wound of the head was a lacerated wound over the scalp. Almost half of the scalp was involved. 

It all started with a small wound caused by a freak accident at home. From their explanation, initially the wound was quite small. They had taken him to a local health centre where Tetanus Toxoid and cleaning of the wound. After they reached home, the wound appeared to start healing. But, then it appeared not to heal. 

They just could not afford another visit to a doctor. They heeded to the advice given by the local villagers. They started to put sindoor, turmeric powder and even cow dung over the wound. Somehow, the mother realized that she had to make a visit to a doctor. But, she just did not have the money. 

Well, couple of days back, she got hold of some money and has reached here. I've not yet gone into the details. I shall over the next few days. Today morning, after Nandamani came and reviewed the boy, the mother was in my office requesting that he be discharged as soon as possible. On asking the reason - she had only very little money and it would be difficult to be here. Nandu feels that the wound is quite bad and the scalp may give way and we may end up with a pedicle graft. 

Well, what prompted me to write this. I read this article in 'The Hindu' where 2 youngsters from the US tried to live in India at a 'an average Indian' with an 'average income'. Please do read this. 

To imagine an additional burden of health care costs is something unthinkable for almost 70% of the population. I face this stark reality almost everyday. As I sat writing this, one of my neighbors was at the door. His mother had a very bad episodes of burns about 5 days back. He wanted me to prescribe some medicines so that he could take it to her when he visits her tomorrow. She lives far away - about 40 kms away. But, it is too expensive for him to bring her to me, leave alone afford the costs of dressings or skin grafts or intravenous antibiotics . . .

Which is one of the major reasons why alternative and quackery systems of healthcare survive in rural parts of the third world . . . And one of the major reasons for my advocating fully subsidized care for burns injuries in our proposed burns unit . . . . 

And when people spend on healthcare, the most vulnerable within the family suffers . . . The women and the children . . . Well, I can go on and on - but the truth remains that empty stomachs haunt quite a lot of our countrymen when the better off among us look forward to McDonald's and Kentucky Fried Chicken opening near to our homes . . .  

Speaking of food, I should tell you about SD, who continue to be admitted. She was very sick after the surgery and we realized that she was quite anemic and had severe hypoproteinemia. I asked the family to bring eggs and milk for her diet. It took couple of days before they could buy it for her. I'm sure that they had to go to a moneylender for the extra resources. 

I've one child in acute care who has come in with diarrhea with severe malnutrition. It's obvious that the family has nothing to provide nutritious diet for the child. The best they can give is biscuits. . . And before I sign off . . . DR came for review couple of days back. He looked quite good. He told me that he is getting one egg and on and off vegetables in his diet . . . I wonder how he's managed it . . .  But, I'm happy that he's managed it and he's definitely improved . . . 

Wednesday, February 15, 2012

Praise and Prayer Bulletin, 15 February

1. Last week, we had the graduation and capping ceremony of our Nursing School. The function was conducted quite smoothly. We thank the Lord for His mercies during the program and the dinner hereafter. Kindly pray for all those who graduated as well as those who were capped. 

2. Dr. Ango lost her mother last week. She had been not doing well for sometime. We thank the Lord for her life. Dr. Ango along with her husband, Dr Nandamani was in Manipur when she passed away. They were able to rush back fast and participate in the funeral. We request your prayers for the bereaved family.

3. Sr. Sandhya's father went to be with the Lord last week. Kindly remember the bereaved family in your prayers. 

4. Dr. Shishir has not been keeping well of late. We have decided to send him to Delhi for further tests. We request your prayers for his health as well as for the travel to Delhi. 

5. Today morning, one of our staff, Sr. Elmirah was involved in an accident. We're thankful that she did not have any major injury. Please pray that the injury on her foot will be healed soon. 

6. Last week, we've been signed in for accreditation under the Rashtriya Swasthya Bima Yojana, the public health insurance scheme. We praise God for this long standing prayer request. We are also thankful to one of our well wishers who donated a good amount of money for setting up the initial infrastructure for the program. Kindly pray for the smooth functioning of the scheme in the unit. 

7. We are thankful that RR and RK, who had burn injuries are on the road towards healing. RK may need some amount of skin grafting. Please continue to pray for both these kids. 

8. We are thankful for Sr Wendy and Mr Jerry who would be visiting us for a month. Sr. Wendy has been helping hospitals in EHA towards providing quality care for newborn babies. Do pray for Dr Johnson and the team of nurses who would be facilitating leadership in newborn care at NJH. However, a pediatric and medicine consultant is a crying need for the place. Please continue to pray. 

9. The burn unit construction is constructing smoothly. We've been informed that more funds are on the way. We pray that the Lord will bless all those who have contributed so far. We have also decided to buy a hollow brick making machine, which is something new in this region. Please do pray that we would be able to get this machine fast. 

10. We are in dire need of the following items - a new transformer from the Electricity Board, purchasing a new generator (approximately 400,000 INR)and putting up fire fighting equipment for the hospital (approximately 120,000 INR). Kindly pray for the needs.

Tuesday, February 14, 2012

Ethical prescriptions . . . taught by pharmaceutical companies . . .

I was prompted to write this blog after few minutes I gave to one of the pharmaceutical representatives to 'educate' me. I was amazed at the audacity of the efforts being taken by these representatives of the pharmaceutical industries, small and big, to go to any extent to promote their medicines. Well, what did this fellow had to offer me rather insisting that I store it in our pharmacy? 

The antibiotic called 'Linezolid'. I have only read about it. Has never seen it, forget about using it. I remember to have read about it being used as a last resort. Later, Dr Titus enlightened me about it being used in MRSA. It was appalling. This fellow wanted me to try it out for patients who do not respond to routine antibiotics. And, if I'm not mistaken, one is not supposed to use it without a culture and sensitivity test. 

There is no point crying over antibiotic misuse if we can allow unscrupulous pharmaceutical companies to market their products in this manner. Many of the people in the leadership level may be great men of integrity, but things are quite different in the grassroot level. 

2 incidents which I should narrate. Both told to me by acquaintances few years back who had worked earlier in the pharmaceutical industry. The first one was about this guy who used to tell me about training sessions that he used to undergo as he prepared for a career in pharmaceutical promotion. The first 90% of the time was spent on learning all the merits of the company and the technical details of the popular drugs which the company produced. The next 10% involved discussions with some of the most successful representatives of the company and the ways and means to 'trap' leading clinicians into prescribing 'our brands'. He left the profession as he did not fit in. 

The second one was about this guy whose wife was suffering was terminal cancer. He was invited to a gala dinner by his colleagues and it turned out to be celebration party for achieving year end target of the same anti-cancer drug which his wife was on. You can imagine his predicament. 

Fast forward to a meeting I had with an organisation who provides drugs to not for profit hospitals in Ranchi last week. The staff of this group was explaining to me about the difficulty in getting medicines which are under the Essential Drug List of the government. The reason - there is a drug price control on such medicines, and therefore nobody was interested in neither manufacturing, marketing or purchasing this medicine. 

And that is true. When, I took over NJH, it was surprising to find that there was no thiazide diuretics readily available. The store keeper informed me that it was too difficult to obtain from the market. Can you imagine that? The first line of management in uncomplicated and few types of complicated hypertension was difficult to obtain in the market. But, it was quite easy to get the costlier forms of antihypertensive medication. Losartan, telmisartan, ramipril etc. are quite easy to obtain. And you won't believe - it remains the same. I raised this issue with one of our major supplier. He asked me, 'Sir, why are you so interested in thiazide? It hardly brings you any margin'.

I was told that one of the best pre-operative antibiotics in clean cases is Injection Cefazolin. I have not yet found a supplier who could get it for me. I was surprised when one supplier told me that he was finding it difficult to provide 'Hyoscine butylbromide' - popularly called Buscopan. He could give me a combination medication which contains an unethical combination of dicyclomine and diazepam. 'Works the same as buscopan' according to my 'tutor'. 

I'm not sure how long we should be mere spectators to this sort of machinations of the pharmaceutical industry. I'm sure that somewhere the government needs to step in and ensure that medicines which are there  in the essential drug list are easily available in the market. However, that does not absolve the clinical care community from taking strong ethical stands regarding prescription of medicines in defiance of the arm twisting and lucrative deals from the pharmaceutical industry. . . 

Monday, February 13, 2012

Tale of 2 pregnancies . . .

I had 2 ladies in the labour room yesterday (Sunday, the 12th February, 2012).

The first one was SD. . .  In fact, it was a bit funny. Dr Titus was on co-call with me. And I was just commenting about how long it had been since we had a patient with eclampsia. SD came in sometime around 2 pm. She has been in labor for quite a long time. . . In fact, almost 36 hours. She had initially tried to deliver at home. After which she was in the district hospital for almost a day before she decided to go to a nearby private hospital today early morning. By afternoon, as the relatives saw that nothing much was happening, they decided to bring her to NJH.

We saw SD walking in through emergency. In fact, we realized that she had a urinary catheter. And was it blood tinged? Yes, it was. . . We really scratched our grey cells on why this patient was kept in labor for quite a long time. We found out  - - more than an hour later.

After a detailed examination, we decided to keep her for normal delivery for another 2 hours. The baby seemed fine although the liquer was a bit meconium stained. She was about 8 cms dilated which prompted us to keep her for normal delivery. As the nurses were ordering the medicines, one of the relatives asked her if she could use some of the medicines which was purchased in the previous hospital. The nurse asked them to bring the lot . . . and along with the normal medicines used in the course of labor, there were half a dozen ampules of magnesium sulphate.

The nurse immediately informed Titus. We asked the history once again. Well, the lady had 2 episodes of seizures sometime during the time she was trying to deliver at home. They did not realise that the history was important. Somehow, it was almost couple of hours after she was admitted. And, we did a repeat per vaginal examination. Nothing much had changed. 

SD was posted for a Cesarian section. The baby was a bit sick, but after a good resuscitation, he's done well. SD was also sick during the post-operative period. However, overnight she has made a good recovery. 

The second one who we'll call RD . . .  It was RD's first baby. RD had been in labor since the last 3 days and she had been leaking since almost 36 hours. RD was trying for a home delivery with the help of a retired nurse. The interesting aspect was that RD had another 3 more weeks to go before her due date. On a detailed history, the pain with she started did not look like normal labor pains. I thought that it looked more like a urinary tract infection. But, she was put on intramuscular oxytocin injections - to speeden up the process. And there was no looking back. 

To complicate matters, she had started to leak. But, she did not take it seriously and did not report it to any of her relatives. The delivery having been planned at home - most probably, there was not much of a seriousness in the whole affair. However, sometime around Sunday afternoon, the relatives started to become concerned - which is when they brought her to NJH. 

With RD having been leaking since 36 hours, I had to explain to the bystanders about the possible complications of chorioamnionitis and a prolonged labour. They looked quite well off for our usual clientele and therefore, I gave them the option of taking to a higher center. They initially refused and allowed us to manage her. I was not much in favor of going in straightaway for a Cesarian section. 

She was about 3 cms dilated with full effacement. I explained to they relatives about us taking the risk of trying for a normal delivery. I decided to give it a try as long as there was no sign of a fetal distress. I was surprised that RD progressed textbook fashion. But then, she suddenly stopped contracting at full dilatation. I had to do a vacuum extraction of the baby. 

The mother and the baby are doing well. 

Both SD and RD could have ended up with severe complications endangering the lives of both mothers and babies. They are blessed to have had happy endings. We praise the Lord for the same. . . 

As I had mentioned in many of my posts, the solutions are not very difficult. SD need not have run from one hospital to the next, trying for a good management. RD should have been investigated for urinary tract infection, before a decision was taken to induce her. . .  And how was the induction done . . .Intramuscular Pitocin . . . It continues to be a scourge in maternal healthcare all over the country. And RD was quite unaware of the dangers involved when she started to leak . . . And the worst of all - especially when a patient comes from another healthcare provider - the lack of a proper referral letter . . . SD and RD could have been provided referral letters by their previous respective care providers . . . 

All these are not rocket science . . . We've been shooting off rockets with satellites into space, manufacturing supercomputers and contributing heavily into the information technology field and more interestingly developing into a medical tourist destination . . . But, what a paradox - when it comes to providing safe delivery facilities for our sisters and mothers, we come up a cropper . . . 

Thursday, February 9, 2012

Obstructed Labour . . .

Just wanted to post couple of photographs and couple of thoughts related to a Near Maternal Miss we had today morning. . . 

As you are all aware, obstructed labor is one of the major causes of maternal mortality. If I'm not mistaken, obstructed labor is either the fourth or the fifth most common cause of maternal mortality. Of course, the most dangerous presentation of obstruction is a rupture uterus.

I would be sinning if I do not admit the fact, it was couple of eclampsia patients and one rupture uterus which actually started this blog moving. . . 

Many of the babies in an badly obstructed labor do not make it. And we had a very bad one today morning. The only thing we had in our favor was that the uterus was still intact and the baby was alive. 

SD was in labor since yesterday evening. She started her pains at sometime around 6 pm in the evening. And from 8 pm, she was in the district hospital. She was started on a drip with some medicine - the family was not sure on what it was. . .  All through the night, she was contracting . . . Unfortunately, nobody did a pervaginal examination on her till today morning, sometime around 6:30 am, and she was asked to come to NJH. . . 

I'm impressed. We've had terrible cases where patients were kept in the lurch in healthcare institutions, both public and private. Here, SD was referred within 10 hours of her admission although she could have been monitored a bit more better as well as had antenatal check up. 

Well, that is the reason, she did not end up with a rupture uterus. 

I was in the middle of a Cesarian section at around mid-morning when the news about SD's reaching NJH reached my ears. Dr Johnson saw her first and immediately posted her for Cesarian. . . The baby was wedged tight in her pelvic outlet. . .  He was worried if I'll have difficulty getting the baby pulled out from the abdomen . . . 

And, oh my! It was the worst obstructed labor that I had ever seen. . . The uterus looked quite funny from the outside - was suggestive of bladder edema and dilated bowel loops. I decided to open the abdomen through a midline vertical and oh boy! Was I not overjoyed? The snap below tells the story . . . 

The finger is on the upper part of the incision and shows the bladder. The second snap shows the place I put the stay suture before I opened the uterus. . .In my career of 10 years, that was the highest stay suture I've ever put . . . .

Of course, the baby was sick . . . However, my colleagues including the new kid on the block, Dr Titus ensured that the baby was breathing well . . . It was then that we noticed that the baby had a head little larger than usual. . . A head circumference of 40 cms for a 3.5 kilogram baby is definitely on the higher side. . . We've given an option to the relatives to take the baby to Ranchi for evaluation . . . Surprisingly, there is no caput or cephalhematoma . . . 

One more aspect about the whole incident was the time taken by the patient to reach NJH from the place where she was being managed earlier. . . A decision was taken to refer her to a higher center was taken at around 6:30 am . . . however, she reached us only by 9:30. The place she came from is only 30 kms away . . . Inadequate transport facilities, bad roads etc contribute. . . 

We got the baby out at 11:12 am . . . We could have done it faster had the theater been free. . . When the patient arrived, another Cesarian was on and I was sure that the Cesarian on SD be done on General Anesthesia. And I was thankful to the Lord that we did it on GA as the surgery took more time than normal as well we needed more muscle relaxation . . . 

We still need to go a long way . . . And the most easiest aspect of this journey is that the interventions, such as protocols, identification of danger signs etc that we need to implement are simple and inexpensive . . .