Nowhere to go . . .

It was the festival of colors early this week. The whole country was in celebration. With our Prime Minister getting a major boost to his 'make India great again', the celebratory mood was well felt in every nook and corner of our communities. There were major things coming for the poor . . . the rich will be taken to task . . . there will be no more corruption . . . no-one will ever go hungry . . . there will be no more deprivation . . . there will be no more need for charity . . . 

I'm encouraged . . . I see a glimmer of hope for the marginalized and the poor in our communities. 

On the day of the Holi festivalI had just the sort of patient, who I feel should not exist in 2022, when the country celebrates it's 75th Independence Day. 

Mrs. A was not an unknown face. In fact, quite a many members of her family comes to us when there is a serious medical issue. In fact, it was just few weeks back that her nephew was brought to us with clinical meningitis and he made a miraculous recovery. I've known Mrs. A since the day we reached here. She was a known hypertensive and had been on irregular treatment. But, the last time we saw her was in October, when we diagnosed her to also have quite severe Ischaemic Heart Disease with some amount of cardiac failure and a bad pneumonia. 

As with the majority of our patients, she did not want to be taken to a higher centre. The maximum we could do to evaluate her was a Peripheral Smear and an ECG. Yes, not even an X-Ray. She made a miraculous recovery. 

But, she never returned for treatment. Alas, we also did not notice that she had not turned up for her regular medications. 

Her husband brought her in a miserable state sometime late morning last Monday (Holi). She was coughing with quite a lot of phlegm. Clinically, she got a bad pneumonia again which was causing quite a lot of stress on her badly damaged heart. I told the family that she needs evaluation. They told me that the maximum they could spare today was 500 INR. As usual they were not willing to take her ahead.

Over two days with some medicines to treat her lower respiratory infection and support her flailing heart, she made a miraculous recovery.

Reasons for her not coming for regular treatment for her high blood pressure and cardiac failure - they are very poor. There is one son who goes to work in the nearby town. He cannot go far as he has to look after his aged parents. There are couple of other sons who are earning a living in faraway places. They hardly come.

Now, it would be a great thing if such patients are taken care of. There are two ways to do it. The first is to ensure that the public health care system is robust.

And the other is to imagine that they don't exist. If the latter is the solution, people like me remain busy. 

Geriatric Care . . . cont'd

The elderly lady sitting in front of me in the medical camp couple of days back in a village near Panki was the epitome of all what stood for geriatric care in rural India.

The rugged creases on her face and forehead would have been the delight of any professional photographer. She had such an artistic expression of the ruggedness of the countryside.

Then I looked carefully into her face. Both her eyes were glazed, caused by hypermature cataracts. I wondered how long she has been blind. I looked more carefully. In addition to the cataracts, she had pterygium in both her eyes.

Then I noticed that she was feeling her surroundings with her hands. I was having the glass of 

Sprite which was on table while she was helped to the patient’s chair by one of the volunteers.

As I helped her hands on to the table, I was horrified to see that both her hands were stiff from the shoulder down. The elbows were bent and fixed at an obtuse angle. The muscles had obviously wasted away. I asked her about her hands. Small pox . . . that was the answer.

The best thing I could do was to help her out with her cataract. However, the volunteers told me that she had come alone. They could not trace anybody who knew her. Tracing her home could take some time as people from more than 50 villages had come for this medical camp.

I wrote on her case sheet. - Bilateral cataract. However, no relatives to help with decision.

I gave her some multivitamins. And, a dosage of deworming medicine.

She got up to take leave. She wanted to know if she got some medicine. I told her I have written some. She was happy. She gave me a toothless smile . . . very similar to the one that a baby gives you when you give her a cuddle.

And as she stood up, I was horrified to find out that she was bent over. She had  a very bad spinal gibbus. It needed quite an effort from her to change her position. 

I once again asked the volunteer to ask her about her relatives. She had overheard me. She waved her hand and told me that nobody bothers about her. So, there was no point in asking that.

A very simple condition like a cataract was a major challenge for her. We were ready to treat her, provided she had someone to take care of her during the peri-operative period.

The sad state of our society where the elderly find themselves at the margins with nobody to turn to for help says quite a lot. 

(The snap used in the post is not that of the lady mentioned in this post. This has been googled.)

Geriatric Care . . . cont'd

I had posted couple of times about the challenges we face in caring for the elderly in a place like NJH. The below snap is of a very lovely couple who are our regular patients.

We don’t know where they live. Couple of times I had thought of finding out where they made their home.

However, every time one of them gets sick, they come to NJH.

As we don’t know about their antecedents, we also don’t know if they have any children. Couple of my staff told that the couple claimed that they don’t have anybody to look after them.

Our first serious interaction with this couple occurred when the lady was admitted with a very serious infected abscess of the buttocks which took quite some time to heal. They were in the hospital for almost 2 months.

The costs were approximately 25,000 INR. We had to write it off as they hardly had any money to even buy food. Lot of staff pitched in with food and money.

The man had come last week with some ailment. Again we had to write off everything free.

Recently, we had a well wiser help us with some designated funds for high risk obstetric care. 

I’m sure that a designated fund for geriatric care will go a long way in helping our elderly patients to access care at NJH. 

Dilemma

Over the last fortnight, we had 3 elderly gentleman in various stages of some form of cardiac failure. The major issue was that they were quite painfully breathless. Couple of them had not slept for days.

The amazing thing about them was that all three of them did quite well following admission at NJH in the Acute Care Unit. Fowler beds, oxygen on continuous flow through a mask or nasal prong and a comfortable climate away from the heat . . . all of them played a good part in facilitating their recovery.

The issue was that I could not shift them out to the general wards leave alone think about sending them home. The oxygen, the comfortable bed and the temperature was the major issues giving them the short lived relief.

But, then I had a very pressing issue. Who was going to pay the costs involved in such a care? Oxygen on continuous flow, regular monitoring, mechanical ventilation for one of them. The relatives were already squabbling about the inheritance they would end up having once these elderly gentlemen passed away.

We had a serious problem with one of these them. The family was quite rich. But, none of the sons wanted to pay for the treatment of their father. Ultimately, we had to go into one long session of counselling and some amount of acting from my side.

They paid up, but took the gentleman home soon after. The same happened with the other 2 patients. The latter two realised that the acute care admission of the elders in the family would result in quite huge holes in their pockets.

I don’t blame them. In a setting where the resources are limited and there were other pressing needs in the family, a decision had to be taken.

Yesterday, I had a similar patient, this time, a lady. Her oxygen saturation was just 60% without oxygen. Very much in line with our experience with the 3 gentlemen, she also did quite well in acute care with all the support systems.

The options for the family of this lady was not much. They had agreed for admission as she had a RSBY Card. We could not keep her in acute care for more than 3 days.

For her Chronic Obstructive Lung Disease, the family could not even afford a spacer for their inhaler. Our staff fashioned out one with an empty intravenous drip bottle.

With advances in technology and availability of better medicines, even the poor have started to live longer. However, costs involved in chronic non-communicable disease care is quite a lot. The fact that there are better but costly treatment modalities for prolonging life as well as ensuring a better quality of life put many families into terrible guilt as they do not want to be seen as ignoring their loved ones.

Without a strong public health care system, the costs are going to be very high. Considering into fact that our public health care systems have not been able to respond to basic healthcare issues, I wonder how fast we would be able to deal with such situations of chronic disease care in the near future.

Till that happens, families would have to think twice before they take their elderly for treatment that does not do much more than just make them feel better and comfortable.

And for institutions such as ours, it involves taking ethical decisions for our patients. And it's not the first time that we've had to ponder over our decisions regarding managing such patients. 

Geriatric Care . . . 'To let go' or 'To treat'

Over the last 2 week, I was put into a very complex situation where we ended up managing few patients who had crossed 80 years of age. We started our Christmas celebrations, but the work in the hospital continues. It's been busier than usual. Many think that geriatric care would be for the urban areas, but of late, we have been exposed to the stark truths of caring for the elderly. With the quality of care we give, we expect geriatric care to become a major speciality of care at NJH in addition to the maternal and child care. 

I wanted to narrate about 3 patients. Let me put them one by one . . . 

1. It was early morning. I reached the Acute Care Unit for rounds. A 86 year old gentleman, whom we shall call AB was wheeled in almost unconscious. He had fallen from his bed early in the morning with his head hitting the floor. There was a bump on his forehead. The blood pressure was very high initially but started to fluctuate after that. The pulse rate was low. The obvious diagnosis was a head injury. They gave a history which seemed to be like a seizure, but the description was not a classical one. However, we had started him on Phenytoin. 

Meanwhile, as we counselled the patients to take him to Ranchi, he had a very bad episode of seizures. And then he became totally unconscious. I had sent for electrolytes - which came as normal. The relatives were all out to somehow save him. I told them that there may not be much chance for him. 

They took him to Ranchi. I knew few relatives of the patient. I found out that in Ranchi, they did a CT Scan and found out that he had no problems. In fact, his sodium was on the lower side.  

Today, it's crossed a week after he was admitted in Ranchi. His sodium is still fluctuating and he is in Intensive Care. Yesterday, his son told me that the expenses are now beyond their means. 

2. About 20 minutes after AB was admitted came FG, a 82 year gentleman on whom we had diagnosed cancer of the anal canal about 6 months back. FG was severely breathless and confused. 

FG was being treated in Varanasi with chemotherapy. His last cycle of treatment was about 5 days back. I suspected septicemia. We started him on oxygen and antibiotics. I told the relatives that we do not have much experience of managing side effects of chemotherapy. But, they told me that they were quite exhausted with the care they had been giving FG. The son told me, 'Please do whatever you can. We cannot take him any further'. 

The blood results came after couple of hours. He was in a very bad pancytopenia. The lab staff could spot only 3 white blood cells in the entire peripheral smear. And there were no platelets. They called me and let know the result. 

I called the son and explained the predicament. The chances of survival was almost nil. He graciously accepted it. A decision was taken not to resuscitate should FG arrest. 

He arrested within 10 minutes. 

3. Around the time that FG arrested, came in a very rich family with a 82 year old. At a glance, it was obvious that she was not breathing. There was a very faint heart sound. The pupils were reacting. 

CD has been sick for the last 2 months with difficulty in breathing. They had been seeing quite a number of doctors. She has been on quite a number of medicines. 

The history was that one of the doctors had referred her to NJH. She was talking till about 1 minute back when she collapsed. The relatives were ready to spend any amount possible to get her alive. 

We put her on the ventilator and initiated CPCR. The heart got going. However, there was a very harsh murmer. The ECG leads showed cardiomegaly. There was massive hepatomegaly. The cause of her sickness was her bad heart. But, we did not have the facilities to pin point a diagnosis. 

I told the relatives that a clinical examination showed that there was not much that we could do. It was quite difficult to convince them. One of the sons suggested that we do heart surgery. However, couple of other relatives arrived who conversed sensibly. 

She arrested after about 20 minutes. I told them point blank that the heart had stopped again and I am not going to resuscitate her. She was taken off the ventilator. I requested the eldest son if we could do an ultrasound post-mortem to confirm the clinical diagnosis. He agreed. 

There was massive cardiomegaly and it appeared like the heart had herniated through the diaphram into the abdomen and pushing the liver down. The liver was enlarged. 

Geriatric care is one of the modern sub-specialities of medicine which would be needed to a great extent in the coming years as the elder members of our communities would grow in number and non-communicable diseases become common. 

To make matters worse, nuclear families, poverty and post-modernist views complicate geriatric care. When people have the necessary finances to look after the elderly in the family, there is a lack of family members who have the time to look after them. When there are relatives to care for the elderly, there is a lack of finances. There is an emphasis on the growth of the individual rather than an effort to care for others. 

As I write this, one of our staff who had admitted her 100 year old mother came and requested for discharge. In the beginning, they were quite pro-active in getting the elderly lady the best possible treatment. None of the children was free enough to be around with the lady to look after her. They had the money to take her to the best facilities. 

I'm sure that each of us are going to face this issue when it comes to our parents and would one day face it ourselves when we ourselves our old. Something that sends shivers down the spine. 

I can only think about the famous Serenity Prayer . . . 

God, give me grace to accept with serenity

the things that cannot be changed,

Courage to change the things

which should be changed,

and the Wisdom to distinguish

the one from the other.

Living one day at a time,

Enjoying one moment at a time,

Accepting hardship as a pathway to peace,

Taking, as Jesus did,

This sinful world as it is,

Not as I would have it,

Trusting that You will make all things right,

If I surrender to Your will,

So that I may be reasonably happy in this life,

And supremely happy with You forever in the next.

Amen.

Paraphrasing this, I would put it like . . . 

Lord, when I have elderly patients, 

please give me grace to convey them hope to face the unknown,  

courage to tell them the truth 

knowledge and wisdom to minister to them.

May we learn to live one day at a time,

Enjoy one day at a time

Accepting hardship as a pathway to peace

Taking, as Jesus did,

This sinful world as it it, 

Not as we would have it, 

Trusting You to make all things right

If we surrender to Your will

So that we would remain reasonably happy in this life

And supremely happy with You in the next. 

Amen 

Photo Post . . . 30th Nov, 2012

Snaps from the hospital . . . 

Mother-daughter duo. Both senior citizens who needed clinical care. Geriatric care . . . A pressing need in India which has a huge number of elderly . . . 

Worm infestation is quite common in India. However, we do not see this sort of pictures much often. A round worm brought to outpatient by one of our patients. He had vomited it out. Lucky that it did not crawl into his trachea.

Recently, we had brought quite an array of hospital furniture. They arrived yesterday from Delhi. The place’s gonna look a lot different once these things are put in place. 

This symmetric looking organ is actually the uterus of GD for which I did a B-Lynch suturing. The uterus was more like that of a flaccid leather bag and I had to do it twice. The patient was on the ventilator for 2 days and is making a good recovery. Today, we extubated her. 

'Snow storm appearance' of a Hydatidiform Mole  - - - also called a Molar Pregnancy. We were forced to manage this case as the family was quite poor and did not have any resources to go to a higher centre. SD had been bleeding since yesterday. Her hemoglobin was 2 gm%. However, it was encouraging that her relatives tried all their resources and arranged 3 pints of blood. For us, it was a moment of faith as we knew that she could die any time. By God's grace, everything went fine. She doing well. The question remains on how we are going to follow her up. She is from a remote area in the middle of the forest in the Manatu region of Palamu.