Wednesday, September 26, 2012

Mixed bag of happenings . . .

The whole of this week has been quite peaceful at NJH compared to preceding weeks. The reasons are manifold . . . First of all there were couple of bandhs, which put us on tenterhooks. Then there was a spate of festivals starting off with the Viswakarma Puja, going on to Teej, then Ganesh Chaturthi and today Karma Puja . . . Still, it was amazing that we crossed 100 patients almost every day. 

The biggest miracle last week was VO, the young man who was in the ventilator for almost 6 days. The amazing thing was that he survived a brief period of time when our oxygen cylinders ran out on account of the bandh. It is quite heartening to see him sitting up today morning as I went for rounds.

VO along with his father . . . 
Later towards the end of last week, our Ophthalmologist's grandson who was born after a high risk pregnancy became sick with unexplained episodes of hypothermia and later hypoglycemia. He was referred to a higher centre where he's on his way to recovery. We praise God. 

Today morning, we had a 10 year old boy coming in with a history of 5 days fever. Below is a snap of his investigation report. 

The family had an RSBY card . . . unfortunately, the boy's name was not on the card. However, considering that he was from a neighbouring village, we offered him free admission. Unfortunately, before I could talk to the relatives, the parents too the child home. I hope he makes it.

The family of the young boy is the reason why there has to be a robust public healthcare system. In spite of the fact that we are able to give subsidized treatment to a certain extent, the poverty of our country is such that quite a large portion of our population would be left out if we don't have a system where healthcare would be easily accessible both in terms of distance and affordability.  

We have the daughter in law of our retired staff admitted with Preterm Premature Rupture of Membranes at 31 weeks and a baby in transverse lie and intrauterine growth retardation. It is much more than what we can handle . . . but the family is absolutely sure that they don't want to take her anywhere else.  Please pray for the family and the young lady . . . 

The best part was that we could finish finalising our calendar for the year 2013 . . . And the day I went to finalise the printing of the calendar, we had a total of about 200 patients in outpatient. 

It has been busy, sometimes disappointing, but ultimately a very fulfilling week of serving . . . Sorry, it's only half the week over . . . There's 3 more days left. 

Sunday, September 23, 2012

Bandhs . . .Bringing Life or Death

Well, many of you may not know what does a 'bandh' mean. Well, it's basically the term given for a general strike in India. There is one more name for a general strike . . . hartal. For me, a native of Kerala and a present resident of Jharkhand . . . both the words are quite familiar. During my school days, we all used to look forward for a bandh as that would mean a welcome break from school. Now that I head an institution, a bandh is not a very welcome word as that would mean a decreased patient flow to the hospital and a hurdle in procuring supplies. 

Yesterday was the 30th bandh of the present financial year in this region. There are umpteen bandhs organised at the national level, state level, district level and now even at the panchayat level. We've had many occasions when a visit to the nearest town, Daltonganj or the state capital, Ranchi had to be cancelled midway as the locality through which we were travelling had organised a bandh. 

We had 2 days of bandh occurring quite close . . . 20th was a Bharat Bandh against multiple issues especially the hike in diesal prices and 22nd (yesterday) was a state wide bandh organised by teachers to protest against the government not giving in to their demands. Usually, it is announced that most of the bandhs exclude essential services like healthcare . . . However, ultimately no-one is totally immune to these bandhs. 

For us, the lack of regular medical and surgical supplies ensue that even a bandh day could become crucial in the smooth running of the hospital. 2 days of bandh in a space of 3 days with 23rd being Sunday has brought in havoc. On the 19th, we had taken enough plans to store enough cyclinders. Unfortunately, our plans were done all awry by a heavy demand on oxygen supply because of two eclampsia patients and one krait bite on ventilator. Another unconscious patient brought in by one of our close friends only made matters worse. 

It is quite a paradox. Many a time, one feels that the reason for calling a hartal or bandh is quite justified. But the amount of damage it does to people is something totally unacceptable. On one hand we hear about so much million rupees lost because of the strike . . . But, we do not hear much stories about individuals and families who lose out because of a bandh.

The young guy on the ventilator has been on it since the last 5 days. The oxygen supply to the ventilator is going to run out any moment . . . And then, it will just be atmospheric air being pushed into his system. He has started to respond after almost 4 days in the limbo . . . GCS of 3/15. 

There had been occasions when patients who were ready to go to a higher centre could not proceed on account of a bandh. 

I'm afraid that few of our patients are going to lose out. They have come here because they are too poor to go elsewhere. 

I've failed them by not ensuring that we have enough oxygen cylinders. There was a time when 8 oxygen cylinders used to last a week. Now we need at least 5 cylinders a day . . . With no bandhs I would not have had any difficulty at all . . . We have about 12 cylinders of our own and the daily school trips ensure that we have an uninterrupted supply. 

All because of couple of bandhs . . . lives unnecessary lost or maimed for life . . . 

Thursday, September 20, 2012

Praise and Prayer Bulletin . . . 20th Sept

It has been almost a month since we've had the praise and prayer bulletin. There are umpteen number of reasons, the first and foremost being the huge increase in the patients accessing our services. To have some sort of an idea, here is couple of graphs, the first one is that of our outpatient load and the second one, our inpatients . . . 

Outpatients over the last 5 years

Inpatients over the last 5 years. 

Of course, our first praise point would be the above 2 graphs. However, along with the praise point comes the prayer point for more qualified people to serve along with us. The rest of the points are the following - - - 

1. Last week, we've hosted a Community Health Training Programme at NJH. We thank the Lord that everything went fine and the participants had a wonderful time. 

2. Over the last couple of weeks, we've had quite a number of very sick mothers who came with either eclampsia or rupture uterus. We thank the Lord that we are continually being used to avert almost certain maternal deaths. We also thank the Lord for the safe delivery of Somalika, our consultant ophthalmologist's daughter who went into uncontrolled severe pre-eclampsia. The baby and mother are doing fine so far. 

3. We thank the Lord for Sr. Meena Neema, one of the very senior nurses of EHA who has come to help us with organising our nursing services in the light of the increased demand of services. We also thank the Lord for Ms Alina who has come to help us in the office and stores. We also thank Premsewa Christian Hospital, Utraula who deputed her. 

4. The Lord has enabled us to make some major purchases for the hospital . . . a new Olympus microscope, some new Dental equipment, quite a lot of linen material etc. We thank the Lord for the resources. Kindly pray as we plan to purchase a new Operation Theatre table, Fowler beds for the Intensive Care Unit etc. Suggestions and donations for the same are welcome. 

5. We were having some problems with the Burns Unit construction. However, the issues have been resolved and the construction has been restarted. Kindly pray that we would be able to operationalise the unit as soon as possible. 

6. We thank the Lord for new staff . . .  Ms Ruth in Nursing Services, Mr. Ebez George and Ms Rachel in Community Health. Kindly pray that their tenure at NJH would be a time of blessing to each of them as well as that they would be a blessing to those around them. 

7. We have quite a lot of snake bite patients who come to us for treatment. There has been a shortage of Anti-Snake Venom of late. Please pray that we would be able to procure ASV before stocks run out. 

8. We have got a new generator which has helped us tide over the present power crisis. However, we would also need to sell couple of old generators and buy new ones. We thank the Lord as well as request prayers. 

9. Kindly pray that we would be able to purchase the school bus which continues to be a dire need for the children going to school.

10. We request prayers for a surgeon. Dr Nandamani tendered his resignation couple of days back. He would be leaving NJH by the middle of December. In addition, we also need a Medicine and Pediatric consultant. We request prayers for Nandamani's wife, Ango who would be attending her practical exams for the Diploma from the National Board in the speciality of Family Medicine. 

11. There is an effort being taken to bring the issue of poor maternal health of the region into focus especially from an academic and scientific perspective. Before I reveal details, could I request you to pray for efforts being taken. We plan a meeting on the 10th October for the same. 

12. Quite a lot of us have been travelling over the last month. Dinesh was away for almost a week attending training programmes in Delhi on Water Harvesting and Waste Water Management. I have been shuttling between Ranchi, Chandwa and Daltonganj attending meetings . . . Nandamani was away in Bangalore. He would again be travelling to Delhi the next week. The new projects in Community Health necessitates quite a lot of travelling. We thank the Lord for keeping us safe as we travel as well as request prayers for journey mercies.

13. We thank the Lord for Mr. Ravee (Duncan Hospital, Raxaul) and Mr. Nithi (Premseva Hospital, Utraula) who did our Internal Audit couple of weeks back. 
Mr. Resham, Mr. Neethi, Mr. Ravee and Mr. Majerus
14. There has been good rains over the last couple of weeks. We thank the Lord. 

15. We have a very high incidence of fever cases in our region since the last one month. Few of our staff were also sick. However, we thank the Lord that nobody became too sick to necessitate a referral. Please continue to pray for protection of staff and their families from sickness. 

(The other reason for the lull in putting up the bulletin has been very bad internet services over the last few weeks)

Wednesday, September 12, 2012

The saga of the pregnant Indian woman . . .

It’s been quite a long time since there has been a post. There were multiple factors for the lull. The major issue being that the hospital has been terribly busy over the last couple of weeks. I’m not sure on how we were pulling through. Today, we had already crossed 1750 outpatients and 250 inpatients for the month of September.

I continue with my banter about the unfortunate souls who come through us for treatment and their stories.

It was about 5 days back as I did my rounds that I noticed a very youngish looking lady rather girl, RDB in the first bed of Maternity Ward. Usually the first bed in Maternity Ward is kept aside for very sick patients so that the nurse on duty can have a close watch.

The ward was full and I asked the duty nurse the reason for this young lady to be in that bed. To my shock, the nurse told me that RDB had a rupture uterus and she had been very sick. It was only today that she was able to sit up.

A rupture uterus. RDB hardly looked 16 years. I asked her how old she was? Her chart told 22 years. Even for 22 years, a rupture uterus was a very harsh affair to deal with.

RDB’s story was not very unfamiliar. Married off around 4 years back, her first pregnancy ended up in a Cesarian section after a prolonged labour at home. The baby was dead . . .  Nobody had even told her that she needs to have a hospital delivery the next time.

She tried to deliver at home. She was taken to a hospital from where she was referred here. Her hemoglobin was low. She waited for almost a day for blood. The rupture was a very bad one. Our surgeon did not do a tubectomy as a tubectomy would ensure that she would be destitute in no time.

I could only whisper a prayer for her future as I walked on.

Yesterday, as we were in theatre, Dr Titus informed us of a pregnant lady brought dead after having seizures. We were too busy to even go and have a look. Later that evening, as I reminiscenced about our attitude towards the women in our community . . . I wondered if we were all busy to take any note of the women who were dying in our communities . . . almost all of them preventable deaths.

As we develop newer and complex treatment modalities for many a rare disease, the saddest thing remains that a majority of preventable deaths in the world occurs due to conditions for which very simple steps for prevention and treatment have been discovered long back.

I’ve one more patient in the Acute Care. A young mother with her first pregnancy at around 8 months of gestation. She had been having seizures for about 12 hours before the relatives decided to bring her here. She was hardly breathing.

With no facilities of even a First Referral Unit, we’re forced to manage her. The adequate facilities for her treatment are available only 135 kilometers away. And there also, she would need admission to a private facility who would be about 2 to 3 times more expensive than us . . . leave alone the transport and indirect costs.

The husband has given us a death in the hospital consent.

As soon as she arrived, she was intubated. In severe pulmonary edema, we did not have much of a choice. After about 24 hours, she is out of the ventilator and semi-conscious. We’ve trying to deliver her baby out fast. I was not very confident about taking her up for surgery. To make matters easy, the relatives absolutely refused surgery.

We wait for her to deliver. For her to survive without any sequela would be a miracle.

However, as I thought about all the umpteen patients whom we had been managing over the years . . . many of them who would have done better elsewhere under specialist care . . . I wondered how long this sort of care can continue on . . . 

(Just as I finished writing it, we had a referral of a lady with post-partum eclampsia . . . and she was referred to us from a private medical college . . .  and the family came driving about 100 miles)

Thursday, September 6, 2012

Kits ? ? ?

As I finished a very busy outpatient department today evening, there were couple of Medical Representatives waiting for me. As the offices were already closed, I asked them what they were trying to sell as I walked towards the wards. 

I was shocked by the answer. 'Dengue testing kits' . . .  one retorted. The look in my face must have brought quite an astonishment. I don't know how it looked. 'How much it is going to cost?' was my next question. 'Only 300 INR . . . shall give it to you for a good price'. 'And it's a antibody plus antigen strip test . . .  the new technology and our research ensures that the diagnosis is made on day zero.' 

I was furious. I asked them if they knew anything about what they were talking. One fellow told me that he could show me literature. 

I could not bear to hear more. I told them that I was a doctor who was interested in the welfare of people as much as coming to a correct diagnosis. And there was enough research on the 'usefulness' of the tests based on the antibodies and antigens . . . And the fallacy of diagnosis being made on day zero. 

They realised that it would be dangerous to talk more. . . and beat a fast retreat. 

The antigen and antibody kits have made a mess of clinical diagnosis. It is not much time since WHO came out with a paper about the useless of Tuberculosis IgM and IgG tests. I remember seeing a patient who had a huge filarial leg . . . the relatives told me that they had confirmation that he had filariasis . . . and showed me a Antibody test for filariasis positive done elsewhere. 

One of the shocking things I had during my first stint at NJH was the rampant use of Widal test and Typhidot for all sorts of fever. Even patients with one day history of fever was requesting of Widal or Typhidot. Even among my colleagues I had to spent quite a bit of energy to convince them that doing it before 5 days was as good as not doing it. 

One can only imagine the mayhem the can be caused by introducing 'dengue testing kits' which have a very high false positivity rate. 

Talking about kits, I'm very much against even the 'malaria testing kits'. As far as I understand 'malaria testing kits using antibodies/antigens' was introduced as there was difficulty training technicians to do malaria smears. As I sit in outpatient, it is not uncommon to see patients who have tested positive for the parasite with one of the kits and having been treated for malaria . . . and as you take a good history and clinical examination, it is very evident that you are dealing more likely with Enteric Fever. 

All fever patients whom we see are tested positive elsewhere with the kit . . .  But, nothing comes up when we do the smear. . . even when they have not had the treatment. 

I'm glad that there are quite a number of learned people within the community who have realised this and come to us directly to do a smear . . . And of course, we are blessed to have very good technicians who can really fish out the parasite from a thick smear . . . 

And the bottom line for my friends who are in some part of their training or practice . . . even for infectious diseases, nothing can substitute a good history taking and clinical examination . . . 

One aspect which I leave for you to decide is . . . on whether we should come out openly against companies who make a quick buck from selling such kits. I remember the 'chikungunya kits' which were produced by some companies while the Chikungunya epidemic was going on sometime in 2007. 

I would propose that the government come up with a regulatory body for such investigation kits . . . But, having failed miserably in being able to regulate the pharmaceutical market, regulating the laboratory industry would be a far cry. 

Tuesday, September 4, 2012

A Justification . .. ...

I need to keep reminding myself on how I started off this blog . . . I've had many a person writing back to me  telling me how inappropriate it is to put many of my posts in the blogsphere. 

Very recently, after my post on the very unusual post about the rupture uterus, after I cross-posted it in a public healthcare site, I had someone ask me if it was appropriate to have posted it there. I thought it was appropriate . . . I don't mind if someone thought that it was inappropriate . . . 

About a week back, one of my staff told me that I belittle the region I'm in by portraying deficiencies of healthcare in the region by stuff I post. I asked him about what I should be posting. He told me he would think about it and let me know . . .  I've not heard from him ever since. 

Everybody loves to have beautiful romantic stuff posted . . . And it's not that I don't do that. 

Why do I write about cases of maternal deaths, near misses, tuberculosis cases etc. etc. 

It's because they are all so successfully treatable if not preventable to quite a large extent. 

The lady with the rupture uterus . . .  You should hear her story. 

We shall call her AAD. She had her first baby by Cesarian section for a reason about which she has no clue about. According to her after she was discharged after her Cesarian, nobody told her about not trying to deliver at home for her next deliver. Result . . . she did not bother to even do a routine antenatal care for her next pregnancy.

AAD started to have contractions early morning. The local village dai (traditional birth attendant) was called. She told the family that everything was fine and she should deliver by afternoon. Sometime mid morning, the dai felt that he was not progressing well and gave her four intramuscular injections . . . by our usual experience, it's pitocin. By afternoon, AAD had started to contract violently. It was excruciating pain. 

By around 3 pm, the family felt that she should take her to the district hospital. Whoever saw her at the district hospital was sure that the baby was doing well and she would deliver soon. She was there till around 7:00 pm, when they decided to move on. 

She reached us at around 9:00 pm. We did not need rocket science to find out that it was a rupture uterus. Per operatively, it was very evident that the rupture uterus had happened quite recently. The baby was a fresh still birth. 

I did not have any choice other than to do a tubal ligation (Family Planning) as the rupture was quite a bad one . . .  Like many of our previous stories, the husband would most probably abandon her for another woman who will be able to offer him more babies . . . 

The first time, when I told a similar story to one of my classmates, he told me that it was so unthinkable a story. But the fact remains that we have so many similar stories in our country and the world which are unfathomable to have occurred in an era when cutting edge medical science is looked upon with awe . . .

I've taken it up as a duty to bring to light such stories so that nobody who reads them will ever tell that they never knew there were such regions where such basic issues of healthcare were never taken care of and they could have played some role in alleviating the pain . . . .

That would bring me once again to the point of inviting more of my fellow healthcare professionals (rather nagging) to move out into needy areas of the country where your presence would end up saving lives and showing people that there is a God who cares . . . 

Sunday, September 2, 2012

RSBY Success Story . . . But . . .

On the 24th of last month, MDO, a 20 year old young man was searching for some thing in his house late in the night, when he was bitten by a krait on his hand. As is the prevalent practice, his relatives summoned a local faith-healer who assured them that everything was alright.

However, as time passed, the father realised that something was amiss. MDO was not able to breathe properly and was looking very sleepy.

NJH, being very near to his home and one of his cousins being a chowkidar in the hospital – the family rushed MDO to NJH.

On arrival at NJH, Dr Johnson attended the call. MDO was hardly breathening and was bluish all over. There was no response to stimuli and his pupils were mid-dilated and hardly reacting. MDO was intubated and was put on the mechanical ventilator. The relatives were explained about the very small chance of survival. It was about 1:00 am of 25th August. 

Meanwhile, our chowkidar, Mr. Jamuna who was MDO’s cousin told us about the RSBY Smartcard (Rashtriya Swasthya Bima Yojana) the family had. It was brought immediately and was promptly blocked for treatment of snake bite.

It was only recently we were having a discussion of snake bites being covered under RSBY as there was a major increase in costs of Anti-Snake Venom (ASV).

Since, we were yet to come to a conclusion on the increase in ASV costs, we decided to treat him fully under RSBY.

By the 25th morning, when I came for rounds, MDO’s pupils were fully dilated and fixed. There was no reaction till about 26th afternoon.

He was in the ventilator for 80 hours. And intubated for 104 hours. 120 hours of Acute Care admission. . . 30 B-type oxygen cylinders . . . 20 ASVs - the cost of which alone is 13000 INR

MDO is getting discharged today. The problem was that his total bill had come to a whopping 45000 INR and RSBY was going to pay us 10500 INR.

MDO with his father
We’re not sure on how to approach this. The family is ready to pay us 7500 INR more. But, as per RSBY policy we are supposed to be giving cashless service. I’ve sent a mail to our Insurance Providers explaining about our predicament. I hope that they would respond positively.

The interesting part is that we have 3 more patients in the ward with krait bite. And all of us are in some part of their ventilatory support . . . I’m glad that we have 2 ventilators . . . But still, we’ve to refuse all patients who could end up needing a ventilator since yesterday . . .  eclampsias, snake bites, severe pneumonias etc . . .

The recent increase in cost of ASV make it quite difficult to treat snake bite victims under any protocol of snake bite management under RSBY. I hope that the concerned authorities would take note and do the needful . . . 

(Consent to publish the photograph and the story has been obtained)

Images of an unusual Rupture Uterus . . .

(This post is purely of medical academic interest and contains snaps which could be offensive. 
User discretion strongly advised)

I hope you remember this image from my earlier post. This is RD's baby who came in with a hand prolapse after she was diagnosed earlier with a transverse lie. It was only after Dr. Titus read the post that he told me that I had forgotten to mention that RD had a previous Cesarian. 

I did not know that since I was not directly involved with RD's management. 

Talking of previous Cesarian Section, about a week back we had another patient with a previous Cesarian who came in with a Rupture Uterus. Below are the snaps taken per-operatively. Kindly excuse for the messy background as we were in quite a hurry to finish the surgery as the patient was quite sick. 

Area of rupture which was along the left lateral wall of the uterus, into the broad ligament.

Another view of the ruptured area after we started to suture it up. 

Hematoma from the ruptured region which extended along the mesosalpinx

The avulsed round ligament . . .

The surprise . . . The intact uterine scar of the previous Cesarian section which was marked very clearly by the bleeding which tracked along the suture line. We double checked it to ensure that there was no breach of the incision.  

It was quite amazing that the uterine incision of the previous Cesarian section was intact and the rupture was through the lateral wall into the broad ligament. One can only imagine the pain that the lady went through. 

However, by God's grace, she had an uneventful post-operative period and was discharged yesterday.