Thursday, October 31, 2013

Bengal Monitor . . . Revisited

Yesterday, we had a middle aged man who came in with a Bengal Monitor bite

Snaps of the bite site. The bleeding was not stopping

The relatives took the patient to a higher centre. 

We had taken some blood to look at clotting time. 

And it never clotted . . . 

The bleeding site of the bite . . .

Sr. Puneet showing the blood sample which had not clotted even after 3 hours
We've got the phone numbers of the relatives of this patient. 

Shall keep informed about the progress . . .

Wednesday, October 30, 2013

2 Rupture Uteri . . . and one live baby

About 10 days back, we had 2 rupture uteri. I had  written about it in an earlier post

SktD and NmnD . . . the patients. SktD's baby was not lucky as NmnD's baby. 

Couple of days back, I got the consent to publish the snaps of NmnD and her baby. 

By the grace of God, NmnD and her baby are doing fine. SktD was discharged couple of days back. 

Both of them benefited from the Maternity Charity Fund supported by one well-wisher. 

The snaps . . .

That is how NmnD's baby looked soon after delivery. The baby was in a face presentation.
I hope you remember UD whose baby also had a similar presentation

NmnD and her baby just before discharge . . . 

Tuesday, October 29, 2013

Medical Education in India . . . A clarion call for Family Medicine as Specialty

The scenario of public healthcare in quite a large part of the country is in shambles. This is no secret. There are powerful lobbies within the country that are bent upon seeing off the remnants of public healthcare in whatever state they are in now. Healthcare as of now has become a commodity which is much beyond the reach of an average Indian in most of the states of the country.

There are questions being asked about the propriety of healthcare being put in as a basic right of each of the citizens of the country. The result has been quite gruesome.

Basic health indices like Maternal Mortality Rate, Infant Mortality Rate etc. are so dismal in quite a many parts of the country that both the care-givers and the cared are well versed in sweeping adverse health events under the carpet. Latest reports say that we're in for real trouble with tuberculosis.

States like Kerala, Tamilnadu etc. have made major strides in healthcare whereas states earlier known as the BIMARU states, and presently designated as the Empowered Action Group states are a major blot for the healthcare prestige of the nation.

The question remains on how serious we are about this?

One aspect to look at is the healthcare manpower of states in general. I would like to start off with the availability of doctors in various regions of the nation. I do not have numbers from the respective State Medical Councils. However, there is readily available information about the number of seats for MBBS in the different states of the country.

Of course, I would have critics tell me that the presence of doctors alone is not enough to ensure that the nation is healthy. There are countries like Sri Lanka who depend more on nurses for primary care than doctors, thereby ensuring that healthcare indices are much better than even places like Kerala or Tamil Nadu.

Going back to availability of medical graduate seats in various states, I would like to draw your attention to the table below . .. …

Take a look at the below facts . . .

a. Kerala and Tamil Nadu which has got a combined population which approximately totals the population of Bihar has 70 medical colleges with a total of about 9000 MBBS seats whereas Bihar has a measly 13 medical colleges with a total of 1200 seats.

b. I thought of looking at Gujarat as we have NaMo, the present Chief Minister claiming all qualities to don the mantle of Prime Minister after the next parliamentary elections. With a population which is almost double that of Kerala, Gujarat does neither have the number of Medical Colleges nor the MBBS seats that Kerala has. Poor marks for that, Mr. Modi!

c. You may be wondering on how I arrived on the calculation of doctor per 100,000 population. I made the supposition that each medical graduate would serve the nation for at least 40 years after graduation. However, there is a problem here too. For India, the calculation says that there would be about 160 doctors per 100,000 population. However, on the ground, we have only 62 doctors per 100,000 population. For comparison, Cuba has 672 doctors per 100,000 population. I have not taken into account the major brain drain in the field of healthcare which continues in the country.

d. I’ve not taken also into account doctors who are graduating from other countries and coming back to India. Experience says that the numbers of such doctors are also more from the better off states rather than the EAG states. And of course, doctors who would have spent quite a lot for their studies abroad will never be much inclined to serve the rural areas. However, I’m sure that there is no point blaming them as our graduates too do not prefer serving Bharat and instead preferring the shining India. 

Now, I’m going to give another twist to this whole issue. Recently, there was a major statement from a leading healthcare professional about the need for more specialists in the country especially for the specialities of cardiology, diabetes etc.

Of course, with only measly group of medical graduates passing out each year in terms of requirement of the country, it becomes all the more tough to make them specialists in various fields of medicine. And the biggest question is whether we require specialists for each branch of medicine.

In one of my previous posts, I had explained quite in detail about the realities about availability of specialists in remote areas of the country, such as ours.

Here, I would like to look at how we would end faring if the situation remains status quo.

One major concern is poor obstetric care. Why don’t we look at the speciality of obstetrics?

Below is a very similar table to the one above. The only difference being that, we’re looking at the number of obstetricians that colleges in the same states churn out every year.

The number of obstetricians who pass out each year in Tamil Nadu is more than twice that of Kerala. There is no point in looking at numbers from the other states. Uttar Pradesh, which has almost 3 times the population of Gujarat has almost the same number of obstetricians passing out each year. The maximum overall conversion rate from graduates to obstetricians is a measly 4%. For comparison, almost all developed countries has more than 10 obstetricians per 100,000 population.

In a hospital setting where we have a sick baby, a mother for antenatal care, an elderly man for diabetic control, a mother in labour room who needs an emergency Cesarian section, we expect to have a Pediatrician, Obstetrician, Internal Medicine Specialist, and an Anesthetist.

I was trying to do some calculations.

Suppose one obstetrician can supervise approximately 200 deliveries in a month, which amounts to about 2400 deliveries in a year. In Jharkhand we have an approximate birth rate of 24 per 1000 population. Therefore, we would do well with one obstetrician for 100,000 population. Unfortunately, although this looks good when we calculate availability according to the number of post-graduate seats in obstetrics, it does not work well. For example, the region of Palamu, Garhwa and Latehar districts which has a total population of approximately 4 million has only about 10 obstetricians on paper. It should have had 40 obstetricians. I understand that practically, there are only 3-4 obstetricians in the region.

Now, according to rules, we need to have an anesthetist wherever there is an obstetrician. Below is a table showing status of anesthetists in the same states.

But, do remember that anaesthetists are not only required by obstetricians, they are needed to work alongside any of the different surgical specialities. So, the anaesthetists need to be much more than the number of obstetricians.

Now, if we apply the same rule to other conditions, we shall soon find out the enormous challenge that we have in our hands.

I’m sure that this is the case scenario for almost all specialities. All of us know quite well that the number of post-graduate training opportunities available to MBBS graduates is on the lower side. The National Board has tried to offset this shortcoming by arranging DipNB courses in private hospitals. There are challenges here which are beyond the scope of this article. 

To complicate issues, on the healthcare side, the burden of non-communicable diseases is on the increase. There are calls for more specialists in the areas of diabetes, cardiology, oncologists etc. However, do remember that we still grapple with basic healthcare issues such as maternal and child health care, infectious diseases such as malaria and tuberculosis. For completion sake below is a table which shows the number of Internal Medicine consultants and cardiologists who pass out from the same set of states.

Availability of clinical care in rural areas of the country is a major issue. Of course, there needs to be major inputs into infrastructure development of public health facilities in all tiers of clinical care. States such as Tamil Nadu and Kerala has already shown us the way in this realm.

If one closely looks into the Kerala model of healthcare, one can very easily find out that the availability of graduate doctors in grass-root public health facilities, namely the Primary Health Centre and Community Health Centres has been one of the key reasons for healthcare equity. The challenge is to replicate this model in this era of specialisation.

And in Kerala, I find the justification about equipping PHCs and CHCs adequately. Because till about 5-10 years back, the total medical graduate seats in Kerala was not more than 800 seats. And still with that number, Kerala was successful in bringing to quite a certain extent in bringing about healthcare equity.

In the present era, considering into fact the reality that post-graduation is the norm in the field of healthcare, we are in a quandary. In addition, there is a fall in standards of medical education all over the country. It is not uncommon to find MBBS graduates who do not understand anything about clinical medicine and finds it difficult to practice. In such a scenario, a post-graduate speciality for training in general practice is very much necessary.

And this is exactly where a Masters course in Family Medicine would be of benefit.

For uncomplicated cases of pregnancy, do we need an obstetrician around to supervise delivery? For a routine care of diabetes, can we afford to have diabetologists all around the country? Even, for an acute cardiac event, are we entertaining the possibility of only a cardiologist managing the case? Of course, for the rich and the powerful, affording a specialist would not be an issue. The question remains of the common Indian citizen.

And this is where exactly a Family Physician would fit in.

In a situation where we can equip our Primary Health Centres with couple of Family Physicians, the workload on our referral centres would come down quite a lot. And the cost of healthcare would come down to quite a large extent.

Would like to have feedbacks for this post . . . 

On diseases of the heart

Recently I chanced upon an article about an interventional cardiologist in the US, who has been sent to jail for performing unnecessary coronary angioplasties.

I was sort of transported 18 years back when a senior cardiologist in town had asked my dad to undergo cardiac surgery for a problem with a cardiac valve. I had just started my graduate studies in medicine. Therefore I had the privilege of getting in touch with friends who knew cardiologists. We decided to take him to a public care facility which had a cardiology department. The doctors there just put him on anti-failure medicines and told us that dad need not undergo the surgeon’s blade as of now.

We continued to take him for his routine check-ups every year. He had his last check up couple of months back and he is still on the good old medicines. Not many medicines . . . furosemide tablets and digoxin. And, it’s eighteen years.

The first cardiologist we saw had brought my mother to tears saying that unless we did surgery there was not much hope.

Couple of months back when I was at home, one of my cousins were telling about how interventional cardiology centres were sprouting all around the state. It was quite a good investment and returns were quite assured. There were stories about targets of the number of angiographies and angioplasties being given to the interventional cardiologists being employed in such centres.

Coming back to NJH, about 3 months back, I had 2 patients who had undergone angioplasties. It is quite common for patients who have got angioplasties to have compact discs of the images of the angiogram and the procedure. However, I was surprised to find that they only had hand-drawn images of the artery blocks. I could not resist thinking on how true were the supposed artery blocks that both my patients had.

Regarding Dr. Mehmood Patel, he was convicted only because this happened in the US. The major news item today in India is about the record compensation that has been doled out for a case of medical negligence in Kolkotta.

Unnecessary medical procedures are something very rampant in the country. It starts with basic blood investigations. I’ve heard of laboratories within hospitals that have specific codes from doctors for tests which need not be done but are charged. The tests are charged, but not done and normal values of the same are recorded. Then there are investigations such as IgM/IgG for tuberculosis, serological tests done before the stipulated time (e.g. Widal test done on 1-2 day fevers), Erythrocyte Sedimentation Rate (ESR) etc. which are of no use to the patient.

There have quite a good number of uteri that are removed in the country for no reason. We’ve had news about such hysterectomies which were done under the Rashtriya Swasthya Bima Yojana. Then there are asymptomatic gall stones, tonsils, appendices etc which are operated on for no obvious reasons. And one should not forget the umpteen number of unnecessary Cesarian sections done.

News about Dr. Mehmood and Mr. Kunal Saha’s successful litigation should be a clear message for each of us in the healthcare profession to be truthful to our patients. This has far reaching implications.

On the lighter view, I remembered a anecdote . . .

‘It is common for elderly men from well to do families in my community in Kerala to unbutton the upper part of their shirt. It is usually done to show off the gold chain on the neck. That used to be during the olden days. Nowadays when they do the same . . . and it is done . . . to show off their bypass scars’ . . . However, with interventional cardiology, those days will also be gone soon.

I leave with a link to an article I read in The Hindu about Paul Dudley White, who is known as the founder of Preventive Cardiology as well the father of American Cardiology.

I’m sure that there is much more for the heart in terms of prevention of heart diseases than the sole choice of interventional cardiology.

Friday, October 25, 2013

Donating sparsely used/unused stuff

Recently, I had a friend who after reading about the post on the donated CPAP machine, suggested that I put a list of things we need in the hospital for patients and staff. 

There are quite a few stuff which many a time ends up getting wasted in a developed country setting and quite a lot in many of our homes. There is also stuff which may be left out when a hospital or clinic is being refurbished or upgraded.

Below is a short list which few of us made up. Yes, there are stuff like canulas which needs to be new. Others like bed sheets and blankets could be sparsely used ones . . .

Baby blankets
Intravenous canula
Portable wheelchair
Bed sheets
Intravenous sets
Pulse oximeter
Steam Inhaler
Central Lines
Multipara monitor
Sterile Wipes
Cpap masks
Nasogastric tubes
Suction Cather
Electric blankets
Suture material
Foley's Catheter
Syringe pump
Infant clothing
Pillow covers
Syringes of various sizes
Infant warmers
Insulin Syringe
Portable toilet seats
Water beds

Please do contact me at or if you wish to make a donation/contribution in kind or cash. 

Wednesday, October 23, 2013

Medicines for all - DPCO

Couple of years back I had written a post where I commented about thenon-availability of cheap but effective medicines in the general market. The drug is question at that time was Hydrochlorothiazide, which is the first choice drug for uncomplicated systemic hypertension.

Recently, quite a few medicines were brought under the Drug Price Control. This means that the government has fixed prices for quite a lot of drugs. This resulted in drugs becoming more affordable

Many of us had expected problems for some time. We did not face any problems in the beginning.

However, now we are faced with a major issue. Over the last 2 weeks, we’ve a shortage of commonly used medicines. The list my store clerk sent reads – Injection and Tablet Hyoscine (Buscopan), Tablets and Injection Frusemide, Asprin tablets, Normal saline nasal drops, Salbutamol Tablets, salbutamol Inhaler, Injection Benzyl Peniciline (Crystalline Penicilline)and Injection Haloperidol.

All the above are quite commonly used medications. And also quite cheap.

And the latter is the exact reason they are not easily available.

‘No margin, sir’, the supplier says.

However, the pharmaceutical companies have come out in droves against the order.

A side effect of this issue . . . comparatively expensive medicines are easily available in the market. We were surprised recently to see even quacks prescribe medicines such as Cefpodoxime.

Unfortunate . . . but true. How long will it take for the government and now the judiciary to realize that the pharmaceutical industry can make a mockery of science . . . and that too medical science.

I’m sure about what is the latest on this. One of my friends told me that the industry has gone to the court and the DPC list is stayed. However, my suppliers tell me that after DPC, their margins have come down a lot. There were also news reports about this few days back.

My take on the matter is that the healthcare community needs to take a very strong stand against this move of the pharmaceutical companies. 

Calendar 2014 - Final

Friends, the calendar is finally on print . . . 

For those who would like us to send you copies, please order them quite early. Last year, we had run out of copies by the last week of December. 

Unfortunately, we had to take a decision not to send copies to countries abroad this year. This was because, quite a few packets were blocked by Indian customs last year and were returned to us. 

The cost of a packet of 5 calendars would be 1000 INR which include postage. 

Within India: 5 copies for a suggested minimum donation of 1000 INR. 

Please send your donations in Indian Rupees to NAV JIVAN HOSPITAL in either of the following accounts (only for payments from within India) -

1. Punjab National Bank A/C 0107000100251342 Daltonganj, IFSC Code: PUNB0010700

2. State Bank of India A/C 0011648040650 ADB Satbarwa Branch, IFSC Code SBIN0006063

As mentioned before, we would not be shipping the calendars to outside India.

Tuesday, October 22, 2013

Moving on

A reality in life is the need to move on. And even in a place like NJH, where there are lots of needs, in terms of committed staff and finances, times come when people have to move on. The Lord has brought lots of committed doctors and other staffs to NJH over periods of time and all of them have played a part in the building up of the hospital. We’re proud that many of our former staff are in positions of tremendous responsibility in India and abroad. Over the last three and half years since we’ve been here, we’ve also been blessed by some really committed staff. Few of them are in the process of moving on especially for post-graduation and better exposure.

Committed and qualified staffs have always been a premium for NJH. There are many reasons which most of you probably are well aware of.

I thought that it is time that I put this down so that we could have people praying about it and that the Lord will move the hearts of healthcare professionals that they explore setting apart a part of their lives to serve in areas such as NJH.

Drs. Titus and Grace with SwrD
Junior Medical Officers are the forte of any hospital. We have been blessed to have Dr. Titus Raju serve us for almost two years. Midway through his posting here, he got married to Dr. Grace Mary George that ensured that NJH had extra hands. Dr. Titus plans to do post-graduation in ENT and his better half in the speciality of Dermatology or Anesthesia. Dr. Titus finishes two years of service in February 2014 following which the family plans to take a break to pursue post-graduation.

I know it is quite a difficult thing to attract MBBS graduates to hospitals such as ours in this era. However, I’m sure that whoever had done a short stint in a rural hospital had major changes in perceptions about healthcare and the post-graduation they needed to pursue. And I hardly know of anybody who regretted the decision to do a short period of service in a difficult place soon after their MBBS graduation.

So, what are we looking at? Rather, who should look to apply? I firmly believe that it is the Lordship of Christ in our lives which should help us to decide on what to do and what not to do. We fervently pray for couple of MBBS graduates.

Below are a few things on what sort of work to expect and the opportunities if you plan to work here.

NJH is the place where someone who would go on to do Obstetrics or Pediatrics should work. As of now, there is no obstetrician here who will be able to mentor a junior person. However, there is quite a lot of work. Most of our specialist work in OG and Pediatrics are done with the help of seniors specialists over the phone/internet. Things have worked well so far.

If you plan to do post-graduation in General Medicine, I’m sure that this is the place where you should be. Dr. Roshine has made a great impression here and the amount of learning that you can have from this young lady is tremendous. There are quite a lot of cases which will give you enough exposure to both infectious and non-infectious.

We’ve quite a good laboratory with my better half, Dr. Angeline at the helm which will also give you some amount of experience with clinical pathology. 

The speciality of Community Health/Public Health is not a very favoured subject for graduates. However, I am of the opinion that we need quite a good group in this subject. Considering into fact that we have quite a wide network of like-minded organisations working alongside us and the influence that we have in the theme of healthcare in the region, NJH can provide you a whole lot of experience. In addition, there is a separate Community Health Department who works in the thematic areas of Community Based Rehabilitation for People with disability and Community Based Adaptation towards Climate Change. We are also a Tuberculosis Unit catering to a population of almost 700,000.

So, friends – please spread the message around that we are looking at the prospect of having couple of junior doctors joining us sometime during the next few months. 

Praise and Prayer Bulletin . . . October 2013

It’s quite a long time since we’ve put in a praise and prayer bulletin. Apologies . . .  Below is the latest list . . .

1. We had an amazing time with YWAM team who ministered to us about a week back. The thank the Lord for each of the members. Kindly pray that the Lord will use them mightily in the coming days.

2. Over the last few weeks, we’ve had some amazing patients who made it in spite of challenges. We thank the Lord for healing each one of them.

3. The water tank construction is in smooth progress. We thank the Lord. Please pray that we would also be able to raise some funds for laying new pipelines.

4. We thank the Lord for Dr. Roshine and the amazing work she’s been doing. She has completed about 4 months of service at NJH. We look forward for a junior medical officer to help her work. And also, the acute care unit is in dire need of more facilities and space. Please pray and spread the message.

5. We thank the Lord for the kind donation of the bilevel CPAPmachine. Kindly pray for the family who made this donation.

6. Maternal and child health continues to be of a major challenge. Kindly pray for the Lord’s guidance.

7. The surgery load in this region is quite high. Dr. Nandamani has been kind enough to come and help us once in 2-3 months. However, we pray for a permanent surgeon at NJH. Please pray and pass the message along.

8. Kindly pray that we would able to get electricity connection to the campus as soon as possible. 

9. We start work on the Sarai today. This is the place where patients who need long term care but not hospital admission, can stay on without getting admitted. It will also provide space for the umpteen number of relatives that accompany patients.

10. Considering the huge increase volume of work over the last few years, we’ve come under Income Tax scrutiny this year. Please pray for wisdom to our administrative and finance team that necessary precautions be taken in their work.

11. Kindly pray for the Lord’s leading as we plan for outreach work during Christmas season. We look back with gratitude when we remember the last year's program we had for our surrounding villages. 

12. Kindly pray for our staff and their immediate relatives who are sick.

13. Our calendar 2014 has gone into print. Kindly pray for all logistics involved. Also thank the Lord for everybody who put their lot behind the effort. 

14. Few organisations including EHA has been advocating to the government to legalize Unbanked Direct Blood Transfusion. Kindly pray for the efforts going on. Hospitals like NJH would be able to serve the poor more effectively if UDBT is allowed. 

15. We're pained to hear stories of families who do not value their girl child. Please pray for the communities around us that they would value boys and girls in the same measure. (By the way, our hunch regarding the patient mentioned towards the end of this post was correct. It was a girl)