Monday, December 10, 2012

Neglect and . . . Issues to contempate

Yesterday late night, we had a patient which is a prototype of the sort of patients we get here. 

We shall call her RN, a 30 year old lady who came at around 8:30 pm. 

From an antenatal point of view, a high high risk patient. A Cesarian section done about 18 months back. She was never taken for any antenatal check up. No hemoglobin values, no blood group, no body willing to donate blood . . . leave alone an ultrasound.

We usually follow the dictum of getting one pint of blood ready in spite of a normal hemoglobin value when the patient is a previous Cesarian section. We agreed to take her if the relatives could arrange one unit of blood. 

We waited for almost 3 hours for the blood. Which never came. 

Around 11:30 pm, the relatives started to make a big fuss on why the surgery was not being done. Our doctor on duty explained the reasons. They could not agree on what was being explained. 

I got called. I explained to them. They were ready to get the surgery done without any blood. With the consent that 'there can be unexpected complications which could be fatal to the patient'. The husband was ready to sign that even if his wife and child dies, he would have the surgery done at NJH. 

Meanwhile, the patient was in severe pain. There was severe scar tenderness. It was very obvious that the husband just wanted to get the surgery done somehow. He was hardly interested in the welfare of his wife or baby. 

He started to talk very rudely and was joined by 3 other male bystanders who also started berating the quality of care and our attitude. It seemed now that we were responsible for the sad state that this poor lady.

We all very well know that we were only facility where repeat Cesarian after a previous Cesarian was done for a radius of more than 80 miles. If I send her off, she will go to the nearest district hospital from where she would be refused any management. She could end up with a rupture. . . and could even die. 

And if she dies, there would not be much tears shed for her. Her husband will find another wife.  

We took a decision to take her in for surgery without blood. I could only pray that she would not have any complications. The lower segment of the uterus was very much thinned out. She could have ruptured in another hour if we had not intervened. 

Then, the nurse told me that she has got a Smart Card (RSBY). Well, this was her second pregnancy and therefore the Smart Card was swiped. 

Inside the theatre, I asked the lady why she never bothered to get a check up in spite of the fact that she lived within 10 miles of the hospital. She replied that her husband never bothers. She is his second wife and this child would be his 6th child. His first wife had died few years back after being managed in the village for fever. 

The surgery was thankfully uneventful. 

Now, questions that lingered in me - - - 

1. A patient who has regular ante-natal check ups in easier managed with regard to costs as well as predictability compared to a patient who never had any antenatal care. Should RSBY rules include a clause which makes it mandatory for patients to have at least 2 or 3 antenatal check ups in the facility where she plans to deliver? 

2. For RN's husband, this will be his 6th child. For RN, it is only her 2nd pregnancy. So, do we put her under RSBY or do we exclude her and make the family pay? 

3. What can be done to address the neglect that women and children face from their menfolk. I'm sure that it goes without a doubt that until our women and children especially girl child is cared for, our society is not going to progress much. Stories about of such neglect . . . but there seems no light at the end of the tunnel. 

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