Monday, January 27, 2014

Sarai . . . Progress

Snaps of the Sarai construction. 

You can still contribute to this venture. 

Friends in the United States - please note that you can contribute directly through this website url - 

Please do let us know if you are making a donation. And Foreign Exchange regulations in India demand that each donation is designated for a specific purpose and the same is communicated to the recipient. 

As you can very well see, we did it quite simply with sparse resources. It cost us much less than the budget of 1.5 million INR

Point of no return

 This is the Chest X-Ray of PD.

PD is a 35 year old lady who died 4 weeks back. Mother of 4 children and the only lady in the house. 

PD had been diagnosed to have tuberculosis 3 years back. Unfortunately, we do not have any details of what treatment she took.

We saw her in outpatient about 3 months back. Her lungs were quite a lot damaged. To complicate matters she had severe anemia and we wondered whether she also had Valvular Heart Disease. We wanted an Echo to be done, but the family was too poor to make the trip to Ranchi.

The problem was that she was not too regular with her treatment. In fact, we were surprised she did well with her bronchodilators and anti-failure medicines.

Not when she skipped couple of days of medicines. Her husband had slipped out of the village for about a week to earn some extra money. The review for PD was due and they missed the date. The severe cold weather ensured that the delay was fatal.

She was puffing and putting out bloody froth when she came in. She responded to treatment for the first two days. And then her heart and lungs just could not take the stress.

Quite a lot of diseases bring patients to a point of no return. A patient after a stroke finds it quite difficult to return to normal life. Someone who had a heart attack finds it difficult to do things the way it used to be done. A baby who had birth asphyxia gets so bad brain injury that he/she is never a normal child.

I think, after Hansen's Disease, tuberculosis is the worst infectious disease which can end up with such a point of no return . The damage done on the lungs is so profound that in the absence of an early diagnosis, patients become so much affected that a normal life is hardly possible at all. They are just lucky to cheat death whenever there is an infection, period of malnutrition or extreme climate.

All all this gets very easy in poverty . . . the chances of survival are very slim.

Which of course, brings us back to the reality of socio-economicdeterminants of health . . . 

Thursday, January 23, 2014

The Determinants

Public health believes very much in the socio-economic determinants of health.

Many a time, we find it quite common to very good clinicians treating their patients with hardly any regard to these determinants of health. One of my teachers told me that if a clinician, however good he is, if he/she does not heed to the socio-economic factors related to his patient, he is never a good doctor.

The unfortunate part of this is that in an impoverished place like ours, although we know about socio-economic issues related to a patient, there is hardly much we can do in many cases. I’m not sure how many will remember Sabita Devi (SD). SD graced the inside cover page of our Annual Report 2012-13 (after page 16). SD’s story was one of our Human Interest Stories.

SD along with her husband turned up yesterday. It seems that SD’s condition had suddenly turned for the worse. She had skin growing over almost the whole of her burnt area. She was doing good. 

The family had some amount of land where they cultivated grain. The produce was quite good this year. But, that was not enough to sustain the family as there was added burden of SD’s treatment. The husband decided that he could make some extra money and therefore went as a migrant labour. But, that was a terrible decision.

The absence of her husband ensured that SD was not well taken care of. There was nobody to ensure that she got her dressings on time. And more than that, there was no one to buy food and coax her to eat well.

SD’s husband came home after about a fortnight to check out on her. SD had lost weight. The skin which covered her burnt parts of the body had started to fall off. He called Dr. Nandamani who advised them to bring her to NJH.

It was obvious. She was terribly malnourished. Investigations confirmed it. Hemoglobin of 7 gm% and Serum Albumin of 2 mg%.

We requested her to get admitted. But the family would not have any of that. I told them that they’ll need to pay only for the dressings. But, the family had worked it out. The indirect costs were too much. There was a crop to be harvested . . .

I don’t know whether SD will return back . . . If she returns, that would be another miracle . . . 

Wednesday, January 22, 2014

Safe in His Arms

This is the post I promised about SD, the second patient mentioned in the previous post

SD had come with bleeding per vagina as she finished 7 months of her second pregnancy. Her first child was just 1 year old. On arrival, she was in shock. She looked white. Hemoglobin came as 4 gm%. We were sure that it should be lower than that as she was quite dehydrated after being to multiple places over a period of more than 12 hours since her symptoms developed. 

She was too sick to even go for an ultrasound. She responded well to intravenous fluids. With a hemoglobin of 4 gm%, we were sure that she needed blood. We sent her relatives off to get blood. She could die any moment. The lady had come at around 10:00 am. 

We were worried as no blood came even after 12 hours. It was good to find one relative return with one pint of blood in the midnight. We had asked for three pints. We had to transfuse that pint of blood. 

She somehow pulled through. And the night was uneventful. We saw a new relative the next day. It was her father. He told us that her husband's family was too poor to bother. That was when we realized that nothing much was done towards bringing the three pints of blood. 

Meanwhile, we had an ultrasound which showed a complete placenta praevia. The baby was dead. 

A repeat blood test showed her hemoglobin as 2.5 gm% and she was in sepsis. A lowered hemoglobin after a blood transfusion . . . either she was so dehydrated on admission or the blood bag contained diluted blood. 

The father returned late evening. We were glad to see 3 pints of blood in his hand. One pint was on immediately and she was posted for Cesarian Section. However, the joy was short-lived. One staff noticed that the pints looked quite watery. The next two pints were sent for their hemoglobins . . . You can see the results . . . 

It was horrible . . .  Time was running out. One bag's hemoglobin was 5.2 gm% and the other 5.6 gm%. 

Then, we realised that SD had not bled after her admission here. We thought about thinking a way out without doing a surgery. As usual we contacted Dr. Hilda Yenuberi, consultant obstetrician at Christian Hospital Chattarpur, one of our sister units. She suggested that we try a normal delivery if she has dilated to some extent. This was only because we did not have quality blood and time was running out. 

A gentle per vaginal examination showed that she was not bleeding even on touch and her cervix had dilated to 6 cms. With prayerful hands, we induced her. 

The induction was uneventful. She delivered just after midnight. There was not much bleeding. However, we gave all the pints of blood that the family brought for whatever good it could do to her. 

They had gone again to get 2 more pints of blood. But, she had turned worse by morning. She was running high grade fever with chills and rigor. Repeat blood investigations showed that her hemoglobin continued to remain below 3 and there was evidence of sepsis. 

We changed to higher antibiotics. It was a miracle that she responded. Meanwhile, her father came with 2 more pints of blood. The quality was the same . .. ... water (most probably Normal Saline) mixed with blood. 

By today, she looked alright. We did not do any more blood tests. 

We thank the Lord that SD is alive. In spite of all the risks . . . Undiagnosed placenta praevia . . . no antenatal care . . . hemoglobin of 2.5 gm% . . . husband not bothered . . . difficult procedure to get blood . . . adulterated blood . . . and a vaginal delivery with placenta praevia . . . a centre (NJH) with no obstetrician/anesthetist . . .

I should say that her 1 year old child is so blessed to have her alive . . . I hope her next pregnancy is less eventful. 

Now, looking at interventions which could have eased the processes we and her family went through, if there is one intervention which could have made life easy, it would have been a UDBT (unbanked direct blood transfusion) at NJH.  

I would encourage your comments on this . . .

Birthday Cards

We had given Shalom a handcrafted birthday card last year. This time, both the older kids were determined to make me birthday cards on my birthday couple of days back.

Below are the scanned copies of the cards . . .

The first side of Charis' card

The inside part of the card Charis made
Cover portion of Shalom's card

Inside of Shalom's card

CH Picnic

We usually have once a fortnight meetings of the Community Health and Development department. 

Since about a month, the staff had been suggesting that we meet in one of the villages. With a river flowing along the fringes of our block, it was not difficult to get a scenic place to meet. 

It rained quite a bit . . . still, we had a good time of fellowship and discussions . . . 

Few snaps of the place . . . 

The first group . . . trying to start the fire in the middle of the rain . . . 

The second team . . . again caught in the rain . . .

Buffaloes gave us company

Trying to make rotis . . . 

The scenic Auranga river . . . 

This is just below the Palamu fort. Unfortunately, the snaps show very clearly littering done by picnickers. 

Similar to this site, there are many other sites which have quite a lot of potential to develop into tourist spots. 

Unfortunately, very little is done towards this . . . nor does anybody think much about it . . . 

Living on the edge

It's sometime that I've written about the high risk obstetric patients that we continue to have at NJH. Of course, winter is considered to be off-season for obstetric care. 

The first one was TB. TB was into her fourth pregnancy. Her first 2 deliveries were at home. The third one was a Cesarian section done 5 years back. She had no clue on why the surgery was done. 

She came in with labour pains since about 12 hours. They were trying to deliver her at home when someone thought that something was amiss. On arrival, we were quite convinced that she had ruptured the uterus. 

On opening, there was something funny. The rupture was not along the previous suture line. The rupture had happened along the lateral aspect of the body of the uterus.

There can be only one diagnosis. The gravid uterus was massaged and thus the rupture happened. On finishing the surgery we asked the relatives whether some sort of massage was done. They were quite surprised that we found that out without their telling it to us. 

TB's 3 children are lucky to have their mother alive. 

The next patient, whose story I am going to narrate is not yet out of danger. SD, a young mother of a one year child came around the 8th month of her pregnancy. The problem was she was bleeding. 

We could tell that clinically, her hemoglobin did not look beyond 3 gm%. She had a complete placenta praevia. It was horrifying to note that she had spotting on and off and her relatives never thought that the condition could be life-threatening. 

More on SD in my next post . . . 

Tuesday, January 21, 2014

View from the top

The water tank in our campus is almost complete. 

Today, I got to climb to the top. 

Snaps of our campus from a height of about 75 feet . . . 

Charis and Chesed in front of the CH Office 
The east . . . 

Looking north . . .

Looking to the south . . .

The view to the west . . . 

The view of the hospital and the church

Angel and kids watch with bated breaths as I come down . . . 

Monday, January 20, 2014

Photo Post, 20 Jan, 2014

Miscellaneous snaps from NJH . . .

We had a 1 year old child come down in shock after becoming dehydrated from severe diarrhoea. We had to put in an intraosseous line. We found out that the line would flow if there was a bit extra pressure. The best way to attain that was to put the intravenous bottle as high as possible. The intervention worked well and the boy survived. Dr. Koshy from Baptist Hospital, Tezpur helped us over phone to put in the line. 
The harvest from the Ragi fields and SRI Rice fields are finally over. One of the farmers gifted us about 8 kilograms of the finger millet. The farmers who worked with us produced a total of 5 tonnes of paddy from about 4 acres and about one tonne of finger millet from about 5 acres. Of course, the yield can be more, but it was unbelievable when the farmers told us that they got about 1.5 tonnes of paddy more than what they usually got. Nobody remembers about previous finger millet productions as it's quite some time since anybody had done finger millet farming in this region. 

Pilatus enjoying the warmth of the library (doctor's duty room)

We've a traditional healer in Satbarwa village who's quite well known for his treatment of strokes. I know this guy and has heard that he treats his patients with an extract of garlic. Only recently, I saw the medicines that he prescribes for his patients. There was one branded preparation of Ashwagandha extracts, then one packet of unidentified medicines and a orangish fluid which was supposed to be injected once a week for 6 weeks. The total cost 1300 INR. This was brought to us by one patient with Bells's palsy. She came to us for a second opinion after seeing this traditional healer. She was a bit concerned about the orange colored potion which was to be given as an intramuscular injection.

Our almost completed water tank. It's about 75 feet tall. Last Sunday, I took a trip to the top. 

I took some snaps which I shall put up in a later post . . . The view from the top is awesome . . .

Finger Millet Recipes Book

As part of the Climate Change project activity of promoting use of millets, we've come out with a finger millet recipe book. 

Below are the pages from the first draft. Would love suggestions . . . The size of the paper is A5 (half that of A4)

The English version of the recipe book is in various parts of my blog. Please click the links below for the respective recipes . . .

Sunday, January 19, 2014

Dosa Plaza, Ranchi

Last weekend, we had lunch from Dosa Plaza, Ranchi. 

That was first time, the kids saw a 'rocket dosa'. 

Shalom and Charis put that into paper as soon as they came home . . .

Shalom's version

Charis' rendition . . .