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 . . . 

Close shave

Last week, we had an incident at home which brought us so close to the reality about how easy it is to get oneself burnt. Of course, we see quite a lot of burns patients in our clinical practice at NJH. And many a time, we wish so badly that the incident had never happened. All the more, when most burns are preventable.

If you look carefully, one can see
the faint scald on her chin

I was a bit careless as I kept a cup full of hot tea on the edge of the kitchen counter. I did not see that Chesed was also around and was trying to get something to drink. And she loves tea and recognises tea quite well.

It was not even 5 seconds after I had kept the cup on the edge, when I heard a shrill cry. The cup was on the floor and the tea had obviously fallen on Chesed after she had managed to get hold of the handle of the tea cup. However, we could not find any burn mark till about couple of hours later . . . when faint reddish marks showed up on her chin and chest.

We knew that it was only the Lord’s grace that she did not get burnt badly. I had just poured myself the tea directly from the stove.

I was also quite careless in the way I had put the cup on the edge.

A very common cause of burns in children occurs when they latch onto something jutting out of a vessel. In the case here, the handle of the cup was towards the edge.

I have seen a very bad case of scalding of almost the entire body after the victim managed to pull the handle of a sauce pan full of boiling sambhar.

And then there is the case of a boy who latched onto a ladle which was jutting out of a vessel with hot oil.

The methods to prevent burns in children are quite simple.

But, then parents of small children know quite well on how much they depend on a guardian angel to keep them safe. We say that as the order of the child increases, the number of guardian angels needed increases.

We thank God that a very much bad case of burns was averted only by His grace. 

Abandoned . . .

This is the story of a lady with a very bad burns who was brought to us about 2 months back. 

Initially, we did not know why she tried to commit suicide. Now, we know. 

Her husband had another woman and it was difficult for her to accept it. We came to know about it only towards the fag end. 

TD had doused herself with kerosene and set herself aflame. She sustained about 40% deep burns mainly of her face and trunk. It was very difficult

However, she fought valiantly . . . before she gave up. She gave up as she realised that there was no adult to whom she could look up for support. 

For about couple of weeks, her husband came on and off. Then, her constant companion was her daughter. She had a teenage son whom we never say.  

It was a sombre atmosphere during rounds each day when we could not tell much to this little girl. 

The staff eating in the mess shared their food. But, that was not enough. She needed blood . . . more food . . .  someone to hold her when the dressings took place. And there was none. 

The bystanders of her fellow patients said that she better be gone as her life is going to be miserable. 

Another story of the abandoned and uncared woman in the household. 

In another room near to where TD died lies CD, the new mother with 2 girl babies . . . both of them weighing not more than 1.5 kilograms. Every day I visit CD, the gloom pervades the room. It's very obvious that the family looks forward to CD getting pregnant again soon and try to deliver a boy baby. The fact that she went through a difficult pregnancy (twin pregnancy with eclampsia) does not hold any value for the family. 

Yes . . . another example of women being left to fend for themselves in a male dominated world. 

The total cost of treating TD was about 75,000 INR for almost 2 months. Her family had raised about 25,000 INR. We're glad that we've been able to write off the rest. However, this would mean that we need help to subsidise the care of such patients. 

Plastic Surgery . . .

The term 'plastic surgery' conjures up images of perfect smiles, chin lifts, ironed out crease lines of the forehead, smoothened wrinkles for most of us . . .

We've been privileged to have Dr. Ron Hiles from England coming almost every year to teach and facilitate our surgeons to do 'plastic surgery'. Most of the time, it involves straightening out contracted limbs following accidents . . . especially burns . . . most of them neglected when they should have been well taken care of. 

Accompanying Dr. Hiles is Ms. RuthAnn Fanstone, an accomplished Physiotherapist, also from England who specialises in burns management. 

Since Dr. Nandamani is away on a long leave, we've requested him also to be around when these special surgeries take place. This year, it's going to be another milestone for us as a new physiotherapy graduate, Ms. Sheron Mathew from the Christian Medical College, Vellore would join us.

And for the first time, we tried some advertising on the radio. For most of us, it's a forgotten means of communication media. But, it still holds fort in remote areas such as ours. 

We've already got about 15 patients lined up only for the 'plastic surgery'. Cases as severe as the burn contracture in this one year old child . . .

. . . to the love-stuck young man who realised the folly of permanently tattooing his first love's name on his forearm. 

There would be quite a lot of patients who would not be able to pay for their surgeries. If you would like to make a contribution to help us subsidize the cost, please get in touch. 

The Pomegranate . . .

Late yesterday night, I was called for a second opinion about an elderly lady with burns on both her legs. The burns was already more than 3 weeks old. She was being managed at one of the plastic surgery institutes in Ranchi. I suppose they ran out of funds and therefore took a discharge against medical advice. 

According to her discharge report, she was doing well and could be discharged. The plastic surgeon was probably waiting for a skin graft. 

As per my colleagues description, the patient was quite sick and no intervention seemed to work. 

The patient was gasping. She did not have fever. But, oxygen saturation was quite low. And she was anemic. 

On examining the chest, it was obvious that she had a bad pneumonia in both her lungs. And it appeared that she had aspirated. I rechecked with the relatives. 

I got a very interesting history. 

Couple of days back, the patient had become a bit stuporous. Most probably because of the opioid analgesic she was on. Someone in the village suggested that she would do good with a some pomegranate juice. And that's what exactly they did.

The relatives pushed down half a glass of pomegranate juice down her throat. Most probably, quite a bit of the juice went into her lungs. 

Pomegranate juice . . . is known to be the elixir of life in this part of the country. Maybe, in quite a large part of the country  and maybe quite a part of the world. It is not uncommon to see juice shops selling pomegranate juice at quite a hectic pace. I understand that it is commonly thought to be an aphrodisiac . . . 

It is not uncommon among quite a lot of our patients to ask if they can eat pomegranate. 

I don't advice it it too expensive and many a time, I fear that the ones we get in the market is quite laced with pesticides and some sort of wax is put on them so that they look shining and attractive. I'd rather advice them to buy bananas or dates. 

I wonder if the pomegranate juice had caused her death. 

I can never confirm as the lady was dead within one hour of arriving into emergency. Maybe a bronchoscopy would have confirmed. 

Photo Post . . . 28 Dec 2013

Miscellaneous snaps taken by our staff . . .

Recently few of our staff spotted Bison at the Betla National Park (courtesy: Mr. Abinash Biswal)

Another couple seen by the same group (courtesy: Mr. Abinash Biswal)

Dentition of one of our patients . . . Believe me, this is his normal look (courtesy: Dr Nandamani)

Another snap with the fog in the background (courtesy: Dr Nandamani)

Oral cancer with extensive spread (courtesy: Dr Nandamani)

Snap taken when the roof of the burns unit was being laid . . . (courtesy: Dr Nandamani)

Skin graft which has well taken up . . . (courtesy: Dr Nandamani)

Christmas celebrations in Community Health Department

Burns . . . Heart wrenching . . .

Well, couple of days back, the last Thursday to be exact, I was called in to help Dr Johnson in his duty. Dr Johnson was operating. And there were five patients coming together into Emergency - quite a crowd for any ER. 

The first two who came were couple of drunk city kids on their way to a marriage function in Daltonganj. They had not seen some road work happening and had skidded over a barrier which was put up. They did not have much problems other than some contusions and minor lacerations. 

Soon came in this family - mother and two children burnt. The culprit - a burst kerosene lantern. Nobody was quite sure on how it happened. The mother, in her late twenties was badly burnt in her left arm. Another girl was burnt a little over the back and buttocks. 

The saddest part was the boy in the house, 8 years old. He was burnt all over - Nandamani calculated 89%. The family was devastated. We thought that he would die soon. It's Monday evening today. He's pulled through so far. We are just managing him symptomatically. There is hardly anything we can do. Nowhere is there any skin to do a graft. 

The worst part is that the rest of the family is that the mother is so depressed that she is not willing for her own treatment. Even Nandamani was in depression . . . 

When I gone for the Burns Retreat in Sylhet, Bangladesh, there was so much discussion about the kerosene lantern - called 'kuppi batti' in that area.  It causes quite a lot of the burns that we see in this part of the country too . . . 

There are crude ones like the one below. Many a time, they are just old bottles with a wick screwed on the top. 

And then there are the better 'safer' ones like the one below. Many people think that they are safer than the above ones. Of course, safer if used properly. I've had many instances of these bursting. Even a personal experience of one bursting in front of me and I getting away without much injuries. 

Well, the problem as far as I realise occur in 3 ways - 

The first one, is a problem with cleaning of the wick and the lamp regularly. Many a time soot accumulates and sometimes some foreign body especially insects get entangled within the soot. If you don't do the regular cleaning, the soot along with the foreign body mixes up with the oil and catches fire - resulting in the lamp getting burst. Almost functions like a Molotov cocktail. 

The second one, is the issue with getting good quality oil. Unscrupulous traders mix diesel or petrol or even old cleaning oil along with the kerosene oil resulting in bursting of the lamp during use due to differential inflammable temperatures of the different oils. 

The last problem and the third one, which is more common occurs due to someone tipping over the lamp, especially when it is kept on the floor. As you can see, most of these lamps come with a small base which tips over fast. . . 

Many a time I wonder why we can't mass produce cold sources of light and distribute them as part of the Public Distribution System of the country. . . We can save many a family from getting burnt . . . 

It is so depressing whenever I see one of the relatives of the family . . . The family is so poor. They cannot afford anything unless the father goes for some manual labour . . . Oh my, oh my . . . Why do I see things like these ? ? ? 

Images from NJH . . .

An assorted group of images from NJH over the last couple of weeks . . .

RKS's hand after skin graft

The palmar aspect of RKS's hand. We would be able to do a better job next time as we have acquired a skin mesher.

Diabetes was not a problem till about 3-4 years back. Now, we get bad diabetic foots like this.

A raspberry tumor

A truck which smashed into a tree near the hospital.
But, below is the snap of what he did before he crashed into the tree.

The pillion rider, a lady lost her life. The bike rider was lucky to escape with not much injury. 

The new RSBY counter in the outpatient department of the hospital

Thermospots, an innovation from TALC being used at NJH thanks to Wendy and Jerry

Snap of an Intra Uterine Death where the umblical cord made a true knot around the leg

A limbs of a langur monkey and her kid through the window of the Neonatal ICU

An ovarian tumour found during a routine Cesarian Section

X-Ray of a man with tuberculosis. Quite a common sight in NJH

Agrarian injury. It is quite common for such incidents in our community.
This child walked into a threshing fan and was lucky to have escaped with only this. 

Branchial sinus. Nandamani did a successful surgery for this. . . 

Experiences with RSBY (2)

MD, aged about 30 years came yesterday morning with one of the most terrible bed sores I’ve ever seen. MD had been bed-ridden for the last 8 months after a bout of fever. To me, it looks like a case of transverse myelitis. Unfortunately, she developed bed sores over the last one month and there was nothing much the family did for her.

Then somebody told her about NJH and the ‘good treatment’ we offer. So, MD came to us. She had actually 3 sores. One on her back and two on the the flanks where the pelvis bone was in direct contact with the skin.

It was stinking. And the family was very poor. I’ve written a mail to the insurance company saying that this treatment would not fit into any of those mentioned. According to Dr Nandamani, she would need a thorough debridement (INR 5000), following by daily dressing for about a month (INR 500 X 30 = 15,000) and last of all, a skin graft (INR 8000 – FP00500243).

We’re yet to hear from the insurance company, but we’ve started the treatment and Dr Nandamani felt that it could be fatal if we waited and the patient goes into sepsis.

Another patient was yound RKS, who sustained scalding of his right hand 5 days back and needs a tangential excision and skin graft. However, the amount put in was too low for any sort of surgery. I ultimately put him in FP00500243 which would give us 8000 INR. In this patient too, we feel that the compensation is too low especially when you take into consideration the expertise involved.

Both the patients had their surgeries today. We pray that both of them would recover fast.

Meanwhile, UD who had a dead baby and was our first  RSBY in-patient has got discharged.

We are yet to officially inaugurate RSBY services at NJH and we’ve not yet given much publicity to the fact that we have been empanelled. However, we had 15 patients in OPD and IPD together of which only 4 were valid cards. We had an unfortunate incident today which is a forewarning to all of us on how unpleasant can things turn out to be with programs such as the RSBY without the responsible involvement of the community . . . That would be my next blog . . .

Tragedies . . . and Painful . . .

I was on duty yesterday…Sunday….

And the morning rounds was a sad one….

We had 3 children with burns over the last 48 hours.

RR, a 3 year old boy was the first to come. It is quite common in rural India for households to cook on the floor. There is no elevated portion within the kitchen to keep the fire. Usually, there is no kitchen… A portion or corner of the house or many a times the outdoors is used for cooking.

RR’s mother was cooking rice for breakfast on a improvised stove outside the house when RR happened to tip over the boiling pot of rice and fell on it. RR ended up with about 20% burns. I could have been worse if the boiling water had fallen over him while the pot tipped over.

The second patient was RK, another 3 year old who had a history very similar t RR. This time the offending item was boiling milk rather than rice. RK’s father owned a tea shop in front of his shop.

The third patient was KK, a 7 year old girl whose case was a very bad one. KK’s mother was in the kitchen cooking when someone called her outside to the shop which adjoined their home. KK’s mother went to attend the customer and returned back to the kitchen. She lighted the match for the stove and the next thing she knows is that there was a big blast and the bed on which her daughter was sleeping nearby was on fire.

The blast brought her other family members rushing to the scene. Somehow, they pulled out KK from within the debris. Luckily, KK’s mother was not hurt.

The whole house along with the shop was completely gutted… We calculated that 90% of her body was burnt with areas of deep burns including her face, neck and genital regions.

KK’s family was into a major tragedy. They are quite well off. But, within the flash of an eye, they are in a major quandary. It was so sad to see KK’s father sitting beside KK within this head buried deep in his hands and bursting into tears on and off.

We offered them a referral which the family readily accepted. Meanwhile, I took RD to the theatre and did a thorough cleaning up and dressing. He had a circumferential burn of his right hand which needed fasciotomy.

Kindly remember all three children in your prayers.

Meanwhile, do note that all three episodes of burns could have been prevented. In fact, we've had similar episodes before too.

1. I remember during one of the conferences which I had attended on burns, there was a solution provided by one of the participants on putting up barriers made of mud or bricks in households where the cooking was done on the floor. Something which would go a long way in preventing small children from wandering into the fire.
2. It is quite common to see teashops and small hotels function from within houses. The womenfolk also help out in the chores in these eateries. And many a time, children end up wandering into the areas where the food is cooked and end up with accidents including burns. Parents of both RK and KK ran such shops.

I happened to glance through the folder of 20^th National Conference of National Academy of Burns (NABICON 2012) in New Delhi. There is a message in the last cover page which goes – Best Treatment of Burns in Prevention. Of course, we are in the process of putting up a burns unit. I pray that we would be ultimately able to play a key role in interventions which would prevent the occurrence of burns within our communities. 

We need a miracle . . .

On the 21st evening, I had a peculiar patient in emergency.

It was a bit difficult to believe about the history, but that was how the husband put it.

FD was making tea about 10 days back, when her clothes caught fire and she ended up with quite a very bad burn injury of her body. Treated initially in Daltonganj, she was referred to Ranchi where she was in the Government Medical College for about a week.

Today afternoon, the doctors at Ranchi decided that they were fighting a losing battle and decided to take the patient back home to die. The patient was also quite listless and the relatives had also given up home.

The patient was from Rehla, Garhwa district and NJH was on the way from Ranchi to her home. It seemed that they had some relatives who lived in our nearby village.

FD is quite sick. I presume that she must have started with a burns of about 40% but after infection setting in, the burns has increased to about 65%. The relatives just cannot accept that she will die. They want to give it a try.

After explaining about all the pros and cons of trying to manage such an extensive burns at NJH, we took a decision to take her in. We’ve promised that we shall try to intervene once we have at least 5 pints of blood.

I know that humanely speaking we are fighting against all odds. But, we’ve been seeing miracles here. We request you to stand with us and pray for this lady and her family. We want His Name to be glorified.

Domestic Violence . . . Bizzare and Cruel

(Warning: The photograph is this blog is very disturbing.)

Today sometime around afternoon, we had a patient with burns all over the face.

It was a bit unnerving as the burns was only limited to the face and just extending to the scalp. Not even a centimetre of burns anywhere else in the body.

Initially, I thought that it looked like an acid attack - I had seen photographs and few victims during my visit to Bangladesh. But, there were no marks of acid having flown down the body. Dr Nandamani noticed that she was smelling kerosene over the burnt area - but this was not a typical case of burns where the kerosene is poured on the head and the victim trying to set it on fire.

Then it dawned to me. There was only a chance for this sort of burn. She or somebody had forcefully dipped her head in a fire. The relatives who had brought her was not forthcoming. After consoling her - we found out the truth.

Her own words - 'My husband tried to burn me after pouring kerosene on me. I tried to run away. Then he caught me on my hair and dipped my face onto a vessel of boiling oil which was being heated up for cooking. Then he ran off'. The reason - She was upset with him for the way he was spending it and she had asked him for some money.

It is going to be long haul for her. However, the manner in which she got burnt is something unfathomable. The paradox was that later she described her husband as a good man without any vices. Maybe it was done in a rush of anger.

Domestic violence as a major aspect of public health needs to be further re-examined especially in the light of violent incidents such as these. Prevention of such incidents is possible if there is good family and community support.