Thursday, August 30, 2012

Photo Post . . . 30th August

Few snaps from our day to day work . . .

Ring enhanced lesion in a young boy who had come with seizures. Something we see very regularly. After the CT Scan, he was seen elsewhere and started on anti-tuberculosis medication . . . 
We had thought pre-operative that this lady had a rupture uterus. However, on opening, we found that it had not yet ruptured. . . but the lower segment was battered into a mass of 'minced flesh' enclosed by the peritoneum outside and the amniotic membranes inside. I wonder if there is a name for that yet . . . If there isn't, we shall coin one . . . 

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

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

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

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

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

Our new generator . . .  

Friday, August 24, 2012

The Bengal Monitor . . . Questions remains

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

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

Below is the snap of the bite site.

The bleeding from the gums.

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

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

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

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

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

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

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

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

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

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

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

It was shocking . . . unfortunate, but true. 

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

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

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

Wednesday, August 22, 2012

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

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

I'm afraid that this situation is actually true. 

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

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

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

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

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

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

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

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

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

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

Tuesday, August 21, 2012

Snake Bites . . . A Query

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

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

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

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

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

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

We also get late presentations of viper bites.

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

So, the ultimate questions being  - 

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

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

The preference for the boy continues . . . 4 stories

There were 3 cases last week, where I was almost sure that the relatives quite well knew the gender of the fetus that the respective patient was carrying. That was when the 4th one came. 

The snap above is that of RD's baby - born sometime early morning today by emergency cesarian section. Yes, you have diagnosed correct. It was a case of Hand Prolapse. She was lucky to have made it alive although sick. However, there was no reason that this baby should have born sick by Emergency Cesarian. 

Because . . . RD had come yesterday sometime in the morning with leaking per vagina. And Dr Ango had correctly diagnosed a transverse lie and had asked the relatives for a Cesarian section immediately. The relatives told her that it was RD's fourth pregnancy and she should deliver normal as her birth canal should be quite large enough. 

They left for elsewhere. The next thing we know is that RD came with a hand prolapse early morning. I'm yet to find out what all happened in between. 

Later, in the afternoon, I had a pep talk with one of the relatives and it was well evident that the family knew the baby was a girl and a Cesarian section was considered too expensive to deliver a baby girl. 

However, I'm happy that they came just in time to deliver a live child. 

The other 3 cases where it was also quite evident that the family knew about the gender of the child are narrated below - - - 

1. 5 days back, some time early morning, there was SD who came with a foot presentation with severe intrauterine growth retardation. SD had been leaking since late night. She had been around for antenatal check ups to quite a number of places - - but the family claimed that no one told them that the baby had growth retardation and had an abnormal presentation. To make matters difficult, they did not have any papers of her antenatal care. The baby was alive . . . I gave them the option of doing a Cesarian section. With much reluctance they gave me permission. The baby came out with great difficulty . . . and was a girl. The family showed no interest in keeping her . . .  Yesterday, they got a discharge against medical advice and left . . . Here again, it was quite obvious from the way the family was behaving that it was well known to them that the fetus was a girl . . .

2. 3 days back, I got a call from Titus who was on duty. There was a very rich family who had come with their daughter who was 8 months pregnant. RS was leaking and was having severe pre-eclampsia. Her husband was working in one of the metros. Titus was trying his best to refer her. In fact, the patient wanted to be referred. Her relatives would have none of it and wanted the treatment to be done here. Her blood pressure was rising and Urine Albumin was already 4+. We gave them the option of a Cesarian immediately. The surgery went well. The baby was in fact term but had severe growth retardation. We offered a referral for the baby, which was not taken was the relatives. However, the husband arrived yesterday evening. Our doctor at NICU, Dr Johnson explained about the baby and he readily arranged for the baby to be shifted to a higher centre. I was glad to see him quite furious with his in-laws for the way they dealt with his wife. 

3. Yesterday, we had a lady who came early morning with labour pains. The doctor on duty decided that the contraction were not good enough and gave medicines to accelerate labour. I reached the labour room at around 8:30 am and was a bit concerned with the extra attention that the patient was receiving from her relatives. I also found the uterus a bit funny shaped. As I was examining her, her male bystanders were making a fuss about knowing her latest status. I decided to do a Per Vaginal examination after which I was almost sure that she had an Occipitoposterior Presentation and there was minimal meconium staining of the liquer. And she had not progressed at all from early morning when she came. I told the relatives of the predicament. I could have waited for couple of more hours as this was her 3rd pregnancy and both her previous deliveries had occurred normally. As soon as I dropped the 'Cesarian' word, the family wanted to immediately have the surgery and get the baby out ASAP. I went ahead with the surgery. The baby was a boy. It was quite unusual for the relatives to agree for a Cesarian section that fast

We are all quite aware about the fall of the child sex ratio in the country. The stories I tell here are only the tip of the iceberg. We've had worse experiences. And there are some hilarious experiences too . . .

I'm not sure on where we are heading with regard to the care of the girl child . . . But, someone has to do something . .. ... The issue of the neglect of the girl child is much more serious than what we perceive . . .

Monday, August 20, 2012

Satbarwa's Niagara

We had gone for a trip to a hostel run by the Catholic Church in a place called Garu. It was quite a hectic day for the team as we had to see through approximately 300 children. There was an epidemic of fever going on in the place since one week and that was the reason we were called for.

After everything was over, the authorities in charge of the hostel asked us if we would like to visit a waterfall nearby. It was just about a kilometer and therefore we decided to visit. And wow . . . it was worth the trip.

Well, the trip was also quite picturesque too. A few snaps from the trip. Unfortunately, I was quite tired after a very hectic week. And was more tired after the camp. Thanks to our dentist, Dr Basil and our engineer, Mr. Dinesh who ensured that we have enough photographs of the trip.

The last picture was the best thing that our kids enjoyed during the journey. We had to cross 10 such sections of the river running over the road during the journey. And Dinesh, who drove us ensured that all those with the windows open got sprayed with the water. The snap would surely make it to the Annual Report next year.

Shall post details of the Medical Camp after I get the blood tests too.  

Pharmaceuticals - The Paradoxes in Indian Healthcare . . . Part 1

We are all well aware of how sick our system of healthcare is. While for the rich and the famous, it is nothing much of a major concern . . . for the middle class and the poor, healthcare is a major issue of concern.

However, what concerns me are reasons for the government being only hardly bothered about what sort of healthcare the common man has access to. One on side, we are proud of how good we are with tertiary care and we are looked upon as one of the major spots for health-tourism. We have states such as Tamil Nadu who are looking at up scaling of cadaver organ donation whereas on the other side, we've states where something as basic as availability of blood is a major issue.

I'm a bit concerned about the sort of media attention that issues such as cadaver organ donation, celebrity health issues garner compared to the status of basic public health care in the country. One issue which has been sort of been ignored is the state of tuberculosis in the country. I've taken up the issue many a time in my blog.

Well, you may say that we have the Revised National Tuberculosis Control Programme, a world award winning public health program which has won accolades at many a venue.

I take the issue of Tuberculosis today on account of one patient whom Titus saw in Outpatient today.

SDS was a unmarried 26 year old man who hailed from a village within 10 kms of our hospital. Hailing from a rich family, SD had been diagnosed to have Type 1 Diabetes Mellitus 7 years back. Then he had been diagnosed to have tuberculosis about 4 years back.

The sad aspect was that he did not access the free government tuberculosis drugs. He had quite a large file of his medicine prescriptions. It was quite a sad array of paper work he carried around.

Initially, he was started off only with Rifampicin and Isoniazid. Nobody was there to monitor his treatment. He took medicines for about 2 months and he left treatment when he started to feel better. Then, he became sick again. He went elsewhere and was started on medications again . . .

Unfortunately, by early 2010, someone had sent his sputum for culture testing. Below is the report.

But, I was in for a shock when I saw the prescription from the 'tuberculosis specialist'. All protocols of Multidrug Resistant Tuberculosis was thrown to the wind. It's more than 30 months. He's still on treatment.

And the worst shocker of all . . . He never had a sputum AFB done. . . of course, there was a sputum culture done about 2 years after the first diagnosis.

Well, you could blame SDS for not taking interest in the government run RNTCP programme.

But, I wonder why anti-TB drugs of all combinations and dosages are available in the open market when there is a government run programme to combat tuberculosis.

To make matters worse, there are quite a large majority of doctors who openly tell their patients that government medicines are of no good. SDS was told the same thing by every doctor whom he accessed for treatment.

Recently, the government has come out with an order on generic drugs. The pharmaceutical industry has already launched an all out cold war against this. They have even invented a term for generic drugs - 'unethical drugs'. And the branded drugs are called 'Ethical drugs'. So much to educate the common man on the terminologies of drugs.

Well, it was quite incidental that I came to find out that there is no Iron tablets in the Primary Health Centres around our place. But, Iron capsules are available in the Pharmacy shops and they were doing great business. Even, we are doing great business with Iron capsules. I remember that during my stint elsewhere in the South, the Medical Representatives were all out 'educating' us on how unpalatable the Iron tablets are compared to their 'double coated chocolate flavoured' and of course expensive Iron capsules.

SDS is most probably going to pay for his ignorance of the existence of a government scheme which would have monitored his drug compliance and disease progression. Now, he is getting a MDRTB treatment protocol which is totally out of line from what he should be getting.

I'm sure that this is part of the influence of private players who are very well aware of the inexhaustible gold mine of profits made in the name of healthcare. It is sad that the government is not realising the folly it is in by allowing such a back-door entry for private players in healthcare. The influence looks subtle, but the consequences are going to be disastrous for the common man.

The government order on making generic drugs freely available is a decision in the right direction. I was quite encouraged to see the 'Generic drug store' in the Latehar district hospital during a recent visit. I'm sure that the private drug companies and retailers would go on an all out war against it, at least indirectly if not directly. More initiatives such as these are necessary if the common man has to regain his confidence on public healthcare.

However, it is going to be quite a long journey for all of us who are mooting for a full fledged robust public healthcare. The question is how many of us are going to continue fighting to see a day when that happens.

Thursday, August 16, 2012

Praise and Prayer Bulletin . . . 15th Aug, 2012

1. We thank the Lord for 65 years of Independence. Sometimes, I wonder how responsible and proud we have been as citizens of this great Nation. We have miles to go before each Indian can feel proud of being a citizen of this great Nation. Pray for our Nation.

2. We thank the Lord that the statistics of the hospital continues to rise. We need more qualified and dedicated staff especially in the areas of critical care, neonatal care and internal medicine. I know that I mention this in almost all of my prayer bulletins.

3. We are thankful that projects have been approved to be implemented through our Community Health Project Team. However, here also, we need more committed staff. We are thankful that Mr. Thomas John, Co-ordinator, Climate Change, EHA is with us to facilitate implementation of the Climate Change Project. Kindly pray for all the planning being done. 

4. Maternal healthcare in the region continues to be an area of concern. Please pray . . . Meanwhile, the number of deliveries happening at NJH are on the rise. In July 2012, we've had 170 deliveries. 

5. We thank the Lord for the life of Mr. K D Lakra who retired from NJH. He spent his whole life praying and being a part of the initial building up of NJH.

6. Over the last week, we had quite a lot of very sick patients. Prominent among them was Mrs. MD, who came and had a cardiac arrest after coming with a Krait bite. Then there was SD who fell sick during a long road-journey. We are thankful that all of them went home well. 

7. We thank the Lord for Dr Basil who has taken charge of our Dental Department after Dr Aji Mathew left after completion of her service agreement. Kindly pray that Dr Basil will be a blessing to many and that NJH will leave an impact in his professional life. 

8. Dr. Nandamani's mother has not been keeping well for some time now. Kindly pray for her. Quite a lot of our staff are quite far away from their homes and loved ones. Please pray for extra protection and health for all our parents and loved ones far away. 

9. The need for a bus and a generator continues to remain. Please pray for the resources. The school bus would cost us around 1,300,000 INR (26,000 USD/AUDs, 15,300 GBPs). The generator is about 750,000 INR (13,000 USD/AUDs, 7,750 GBPs)

10. The weather has been very unpredictable since the last 2 weeks. We've had days with pleasant weather and heavy rain interspersed with hot and humid periods. The result has been that quite a lot of people have been keeping sick. Malaria and dengue are on the increase. Kindly pray for protection from both these menaces. 

11. There is some property which one of our former staff donated to the hospital long time back. Some of the local villagers were claiming ownership. We've decided to go ahead with putting up a boundary wall around the property. Kindly pray that there would not be any untoward incident.

12. Since quite a long time, we've been thinking of starting a Community College. We've taken a decision to start off with an Electrician course from January 2012. Mr. Dinesh would giving leadership for this. Please pray that we will be able to do this well. 

Wednesday, August 15, 2012

Remembering K D Lakra . . .

I had never noticed the short elderly gentleman during my previous stint at NJH. It was only after I rejoined work in June 2010 I took note of him. Mainly because of his very rugged renditions of very traditional Christian songs in Sadri . . . It was very attractive to hear. Although I did not understand much about what he sang, it was not much difficult to guess the meaning as he peppered his songs with Biblical character names. 

I remembered many of the traditional Malayalam Christian songs which we don't happen to hear much these days as I looked forward to regular hear his renditions of Sadri songs every Sunday.

Mr KD Lakra unveiled the redesigned logo of NJH during the start of the Golden Jubilee celebrations
 About 2 months back, he came in quite sick late in the night. I was a bit upset with his relatives as they were trying to do symptomatic management at home. The blood tests were very bad . . . Hemoglobin of 3 gm%, Total count of 700/cu mm. It was malignancy or a bad infection which was overwhelming his system. 

I told the family of the prognosis . . . I also gave them the option of going to Ranchi, which they ultimately did. I was leaving for some meetings the same night. I went to meet Mr. Lakra . . . knowing very well that I may seeing him again only when the Lord comes back. 

I told him how much I enjoyed his songs and looked forward to hear them every Sunday. He was smiling. I requested him if he could sing me a song one more time. He told me, 'Doctorji, I have sung enough. I'll sing when I'm back at my Father's house'. He very well knew that he was on his way.

The family took him to Ranchi. They had diagnosed him to have Myelodysplastic Syndrome. He was in and out of consciousness. I did not have the opportunity to see him again. 

He passed away in his sleep last week. 

It was only some days later that I came to know what K D stood for. . . Krus Dhari Lakra. That was his full name. Means 'Cross carrying Lakra'.

He was the last of a generation of hospital staff who gave all their lives for the Lord through the NJH. Mr. Lakra served in the Registration Department till his retirement in the early 1980s.

KD Lakra being felicitated during the Golden Jubilee celebrations
I don't think anybody of the present generation would even remember the Sadri songs he sang. In fact, I used to feel sad when the rest of the congregation giggled when he went up to the pulpit to sing. It is unfortunate . . . Somewhere there has been a break . . .  You may call it a generation gap. But, I wonder if it's something beyond a generation gap. 

I wish we had staff like K D Lakra . . . I look forward to the day I'll meet him at heaven and listen to him worship the Lord through his rustic Sadri songs . . . 

The sick wayfarer . . .

About a week back, we had a peculiar problem not commonly faced by most hospitals . . . 

There was one middle aged man with an intestinal problem which needed urgent surgical intervention . . . Read his story . . . 

SD was a helper of a truck with a National Permit. The whole of India was his backyard. He knew each city and town like his own village . . . He was from one of the major cities of the country. 

SD and his friend who was the driver was taking a consignment to Ranchi. SD started having pain as the were passing through the middle of Madhya Pradesh which continued as they entered Uttar Pradesh. In fact, they stopped to see a doctor (most probably as quack) in Robertsganj. It would have been better if they had visited our sister hospital at Robertsganj rather than the quack. The quack prescribed some medicines - antibiotics and antispasmodics. 

They continued their journey. The pain did not seem to subside. Now, he had episodes of severe vomiting and his abdomen started to bloat up. They asked people on the wayside on what to do. The next nearest city was Ranchi, their final destination. 

After they crossed Daltonganj, the pains worsened. Somebody told them about a hospital in Satbarwa. They got down in Satbarwa. Someone told them about a good doctor . . . again another quack. The quack recognised that SD was quite sick and told his friend to bring SD to us at NJH. 

Nandu saw the patient and it was obvious that he had an intestinal obstruction caused by a Sigmoid Volvulus. The problem was that he needed immediate surgery. And SD's only bystander was his driver . . . We had the unenviable task of doing an emergency surgery without any immediate relatives of the patient. 

We contacted the local police station and informed the District Medical Officer. After conveying the matter to his relatives, we got the go ahead for the surgery. It was good to have got through to our ED for advice. We had one more problem. He needed blood. That was when we realised about one patient who died in the afternoon while being prepared for surgery. Someone had donated one pint of blood for this guy. 

It was still in the fridge. It was a life-line for SD. Thankfully the blood matched.

We went ahead with the surgery. It was good that we operated on him. One part of the inflated bowel was on already looking unhealthy, but not enough to warrant a colostomy. 

SD made a remarkable recovery. 

He got discharged today morning . . . 

It was good to see him walk out happily. We thank the Lord for helping us be good Samaritans for this man. If he had become sick in a city or town, he would not had much of a problem - - - but to have become so severely sick in the middle of a journey and having had to undergo emergency surgery - - -  he was blessed . . . .

Tuesday, August 14, 2012

Image Challenge . . .

This young man came to us couple of days back. The history was baffling . . .

Any guesses on what had happened . . .

Scroll down to find out the history . . .

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The young man was shot point blank. His assailants thought that the bullet had gone through his head and left him for dead. Most probably, the bullet had exploded inside the pistol. The sound and the shock could have made him unconscious. The exploding bullet would have produced splinters which has left his face including his eyes burnt. . . Another explanation is that he may have turned his head away at the last moment, the bullet missed its target and the explosion within the gun sent splinters which burnt his face. . . Comments from ballistic experts are invited . . . 

As for the really lucky fellow, we referred him to a higher centre as we were not sure about how badly his eyes were affected. His hearing appears to be normal . . . But he was in sort of a daze . . . 

Saturday, August 11, 2012

Photos Post . . .Snake Bites

The cobra which had bitten a lady. I insisted on seeing the snake after the relatives told me that a viper had bitten her. And I was sure it was either a krait or a cobra. I was not surprised when they brought the snake in. The 10 cc syringe was put in to show the actual size. Amazing . . . .isn't it? That people find it quite difficult to identify snakes . . . 

Well, here the relatives had identified the snake correctly. A common krait . . .

A viper bite of the hand. We had to do extensive fasciotomy of the hand.
The young girl has recovered well . . . 

Friday, August 10, 2012

Fascination for the 'phoren'

Last month, we had taken a decision to do cataract surgeries at a reduced cost for our poor patients as well as do some amount of publicity work to do cataract surgeries under RSBY. We used all our contacts to disseminate the information. 

Its been 10 days today . . . Today morning, we were reviewing how the whole thing was going as today was the last day for registration for this special scheme. The patient response has been very good. 

However, what my ophthalmologist told me was baffling. Very few people wanted to do the surgery under the reduced rate or under the Rashtriya Swasthya Bima Yojana. The reason . . . Almost all the patients wanted to put an imported lens. We had taken a decision that we would only use a intraocular lens made in India unless someone asked specifically for an imported lens, for which normal rates would be applicable . . . 

But, after all the developments that we have had in our country, folk prefer to have an imported intraocular lens . . . As far as I understand, India produces intraocular lens which are as good as imported lens . . . I hope to hear from ophthalmologists who differ . . . 

For all the swadeshi movement stalwarts . . . isn't it intriguing that our countrymen still prefer foreign goods even when we produce quite a lot of stuff which are commonly used. 

Well, I don't think the village folk here are exceptions . . . I remember how my folk back home used to flash imported saris. It was quite later that I realised that how come there are saris made abroad when the sari was an Indian dress. 

Many of us would really like to get imported chocolates, pens etc as gifts. So, I don't find anything wrong about preferring imported things . . . 

But, do remember, we in India produce stuff which are quite good to compete with those made abroad . . . And when it came to healthcare, I do not think that things like intraocular lens made abroad are any better than Indian made ones . . . Hope that we could feel proud of things that are produced in India . . . 

Tuesday, August 7, 2012

The First Maternal Death . . .

This is an account of the first of the three maternal deaths which came through NJH over 24 hours of last Sunday-Monday. This lady, SD was brought dead. We did not know till yesterday that she was from one of our nearby villages, Piperakala. 

Later, we had 2 more maternal deaths which have been mentioned in my previous posts. 

We found some time today afternoon to visit the family. 

It was a very depressing time. The house was in the middle of the village. Quite in the middle of filth and rubbish, the house was quite a symbol of severe poverty and despair. 

An old woman and a below 2 year old boy was sitting in a charpoy inside the house. The air smelt of rotting cow dung. Houseflies hovered all around the place. The old woman started to cry as we entered the house.

After introductions, we asked about SD. The old woman who turned out to be SD's mother told us that this was SD's fifth pregnancy. She had lost her second and third babies. The first child, a girl was about 7 years old. She came into the house weeping in the middle of our visit. The second child, another girl died at 10 months age. No one knew how she died. She had fever and then died. The third child was still born. The fourth child, a boy had just turned two. 

SD had come to us sometime back for her antenatal check up. For some reason, we had given her a referral to Ranchi. I would need to get hold of the out patient chart some time.

Her contractions had started sometime on Sunday morning. It was quite uneventful. Sometime in the evening, since nothing much was happening, the family had summoned the Auxiliary Nurse and Midwife of the area. She had given her couple of intramuscular injections, following which she had collapsed and the family rushed her to NJH. 

The interesting aspect was many people in the village did not know about SD becoming serious and ultimately dying. Many people came to know of the news when our team went visiting. 

Dr Johnson who had seen SD's lifeless body told us it looked very much like a Rupture Uterus. 

Later, we had some discussions with some of the villagers. There was much anger against the Auxiliary Nurse who came to help with the delivery. It seems that she gave quite a few intramuscular injections and demanded money. 

Well, ultimately, what mattered was that there was a maternal death in the block after almost a year. 

There are unanswered questions - - - 

1. How come many of the villagers did not know about SD's complicated labour. Was the family ostracised?
2. Was it intramuscular pitocin that SD recieved? It is quite common even for someone as qualified as an Auxiliary Nurse to give intramuscular pitocin for delivery in most of rural India. 
3. Why do patients not prefer to come to hospital for delivery but have no problems in paying up quacks as well as other persons who come and try to do the delivery at home. There is an allegation that the concerned Auxiliary Nurse demands speed money from those she helps to deliver at home. And the rates being quoted are not small . . .

There are major issues which need to be sorted out if deaths such as that of SD has to be avoided. The question remains about our political will to bring about healthcare reforms . . . 

I shall reserve more comments on this till I hear from those who read about these unnecessary deaths. . . However, what is going to haunt me is the helpless frightened look on the faces of SD's first two children. I'm not sure how secure their future, especially that of the daughter, is going to be . . . 

Maternal Death . . . The Third One

This is the account of the 3rd maternal death we had over the last 24 hours.

RKD was brought just in as we were doing the final and last attempts of resuscitation onMD. RKD looked dead except for the faint gasps. We intubated her and had her hooked to the ventilator. Her blood pressure was a whooping 280/175 mm Hg. Urine albumin was 4+.

RKD’s history was mindboggling and spoke volumes of the care available for women as well as about how expensive we were to the common man.

RKD who was about 7 months pregnant with her third child suffered her first bout of seizures sometime on the 29th of July. As is common, they summoned the local wizard to do the needful. The seizures were controlled and she did well.

She had another episode of seizures sometime on Wednesday, the 1st of August. Someone advised them to come to NJH, but someone else dissuaded them saying that it is expensive. Instead they went to one of the private hospitals in Daltonganj, where they were asked to come to NJH.

Instead, they went to the local district hospital. The doctors at the local district hospital asked them to go to NJH. They could not make up their mind. On 2nd August morning, someone told them about a ‘famous practitioner’ in the neighboring district.

The relatives promptly took her to the ‘famous practitioner’ who did his treatment. She did not have any more seizures and she looked better. After that, they took her to the wizard in her village again - just to ensure that she would not become sick again. She looked better.

On Saturday, the 4th August, sometime in the evening, she suffered another episode of multiple seizures which continued over the night. The witch doctor was again summoned who told them that it was beyond his powers. She was unconscious by morning. They took her again to the ‘famous practioner’ in the neighboring district on Monday morning.

The ‘famous practioner’ also told them that the disease was something he did not have much control on. He recommended NJH.

Thus after all the efforts of running all around the district and the neighbouring district, they decided to come to NJH . . . just 10 kms away from their house.

It was around 2 PM on Monday, the 6th of August, when they finally reached us.

There was hardly any urine coming out. Her lungs were all clogged out. The conjunctiva was congested and edematous. It was only a matter of time. . . before the rest of her organs collapsed. 

She arrested sometime during the midnight . . .

I don’t know what to say . . . please draw your own conclusions. .. … ….

By the way, I’m going to the nearby village of Piperakala where there was a maternal death couple of days back. .. … They had brought the dead body to us. Shall post a report as soon as I return. . . 

Maternal Death . . . The second one

I came from Ranchi after a meeting on Maternal Mortality . . . I made a promise of writing up about all the maternal deaths I come across. Something that I'm seriously thinking about doing is to find out maternal deaths which occur in the community through our volunteers who are involved in other projects through NJH. Who knows . . . we may come up with quite a lot of revelations. 

It was not even an hour after I had arrived, when a patient was brought dead to casualty. She was pregnant. It was busy otherwise. So, not much of a thought was given and relatives took the body home. 

Later, today morning, Johnson called me up to say that the dead pregnant lady had come from Piprakala, one of our neighbouring villages. It's a shame.  

Sometime around mid-day, there was one more very sick pregnant lady who was brought in. There was nothing much to do. She was gasping. Titus told them to go ahead to Ranchi . . . which they really agreed for.

But, the relatives made a beeline to my office and was soon pleading to do the best that we could. I was caught up with work, but somehow made to Acute Care. 

MD looked hardly 20. She was puffing and huffing. Papery white, with a tint of yellow. There could be only one diagnosis. . . Malaria.

I explained everything to the relatives. We had to get her ventilated. She could collapse any minute. We got a sample of blood for the baselines. And had her hooked to the ventilator in no time. Then, she suffered a cardiac arrest. . . we got her heart working. From the look of her eyes, it was obvious that it was going to be tough. Tough it was as she got into another cardiac arrest. . . And her pupils had started to become unequal.  

Meanwhile the results from the lab came in. Platelets of 14,000/cu mm. And 90% of her Red Blood Cells infested with Plasmodium Falciparum. 

She hardly had a chance. . . 

We declared her clinically dead at 2:30 pm, about 2 hours after she had come in. 

She was being treated elsewhere for the last 3 days. . . Nobody had diagnosed malaria. I wonder how even a quack would have missed out on the diagnosis. 

Thoughts on this maternal death . . . 

- A failure to diagnose malaria. She had been to hospital, but the malaria smear is put as negative. 
- Who knows she may have been treated with anti-malarials. It is very difficult to imagine quacks not giving anti-malarials in fever cases. Maybe, we are having resistant cases. 

Talking about malaria, we are having quite a number of fever patients coming in. As we had suspected last year, we still have a hunch that it's not only malaria that we are dealing with.

Well, today afternoon I plan to visit the house of the lady who was brought in dead. Shall put up a post as soon as we come back. . .