Who shall treat? . . . Maternal deaths continue . . .

Over the last couple of days, the Indian media has been awash with the 'sensational news' of ward boys in a district hospital giving injections and stitches to patients. There has been already quite a lot of debate going on about the ethics and propriety of their doing it. The government has also got into action with an enquiry being ordered. 

The paradox of the incident is that Bulandshahr is just 50 miles from the national capital, New Delhi.

I'm not going to comment on whether this is right or wrong - but do go through the situations we had to face yesterday night (rather early morning today) with one patient . . . and then another one later today. 

PD had come at around 1:00 am early today morning.

PD is a 20 year old lady who is yet to celebrate her first wedding anniversary. She was at full term and had started to contract since 6 pm of 10th July. The traditional birth attender at the village advised that she delivers in a hospital. 

The family took PD to the nearest district hospital by around 10:00 pm. The nurse at the place told them that she should deliver by early morning. Nothing much happened overnight. 

At around 8:00 am the next day, 11th July, PD threw couple of episodes of seizures. Couple of injections (which we later found out to be Diazepam) were given and the person on duty asked them to give water continuously to the patient. They were reassured that the delivery should take place any time. 

The family waited till around 5:00 pm, when a new nurse advised them to go the neighbouring district hospital. They reached the place by around 8:00 pm. However, the nurse who was on duty told them that this sort of problem can only be managed at NJH.

The family were faced with another problem. No driver was willing to bring them from Daltonganj to NJH on account of the highway robberies which have become more often since last couple of weeks. 

They found a vehicle to bring PD here by around midnight. . . 

On arrival at NJH, PD had a blood pressure of 180/130, urine albumin of 2+ and was not maintaining oxygen saturation beyond 75%. There were evidences of severe hypoxia. 

We tried our best to refer the patient. The relatives were quite tired and were not at all in a position to go further. The driver also was not ready to take them to Ranchi. 

I needed to get the patient intubated and ventilated. We took her to the theatre. We put in a NG tube. There was clear fluid oozing out, rather gushing out through the NG tube. As soon as we intubated, it was funny . . .She was pouring out water from her lungs. We could not explain. It was not the typical sort of frothing which we find with pulmonary edema. This was something different. 

I could think of only one thing . . . The water she had been drinking. Most probable, she got drowned in that . . . 

She arrested in no time. We could not secure the airway. 

The only correlation I could make was the diazepam and the water she drank. Most probably after being sedated, the water she was drinking was going directly into her lungs . . . And later, the relatives told me that they have fed her almost 5 bottles of water . . . No intravenous fluid was given . . . 

It was terrible . . . 

Coming back to incident at the district hospital in Bulandshahr and similar incidents which have been brought to light - I do not think it is different in umpteen of our district hospitals in many parts of the country especially the Empowered Action Group states. . . 

In India, a large proportion of the country especially those in the rural areas have no qualms about accessing quacks for their primary health needs and most of the time, the primary health care provider including primary health centres and hospitals such as ours are in an embarrassing competition with quacks. 

To make matters worse, most of the EAG states are facing a severe crunch of health manpower. And there is no indication from any of such states to increase the manpower in the public healthcare institutions. 

When there is a shortage of manpower, I'm not sure what else can be done other than catering with the resources and infrastructure one has. 

As I write this, I've one more patient, SfD who has come in with Eclampsia. She has already arrested twice and is not fit to be taken for surgery. I do not know about the details. . . 

Maybe, this would be one of the last posts I would be doing about the maternal deaths we have at NJH. . . There appears to be nothing much happening . . . When I came here first in 2004 - the situation was the same. I thought that writing about these deaths and filling up institutional maternal death reviews may have started to make some difference among policy makers. . . 

We need to think of a new paradigm to counter the poor state of public health care in many of our rural areas. In order to achieve the health related MDGs, we need to look beyond doctors. . . 

I suspect that training nurses and paramedical staff in clinical care through the use of protocols may be one answer to prevent situations similar to which PD and later SfD are facing. . . 

Nursing . . . An Invitation . . .

Over the last couple of months, there has been quite a hue and cry in my homestate, Kerala about working conditions of nurses as well as the compensation packages being given in private hospitals. There has been violence in one of the well known superspeciality hosptials. Conditions in many of the private hospitals around the country are also not much different. I recently found out that it has affected one of the hospitals under my church. 

I do have relatives who serve in the nursing services in private as well as government hospitals. One of my cousins who is a BSc Nurse, quite a smart chap and popular with patients gets a take home salary of about 6000 INR and works a 10-12 hour shift. Mr. Selvin who joined us about 6 months back also tells us about similar conditions in hospital he worked in before he joined us. He was getting about 5000 INR and living in a single room along with 4 of his colleagues.

I’ve been telling quite a number of my friends and relatives about the much superior working conditions and staying facilities that EHA units such as ours offers to nursing staff. I had been keeping myself away from putting this up for quite a long time till I discovered that the problems continue to remain in spite of umpteen number of agitations etc.

There is a dire need for qualified nurses and nurse leaders within the organisation. The major deterrent to people coming to organisations such as EHA is the remoteness of the places where most of our hospitals are. However, there are quite a lot of nursing staff from India who go all the way to t he Gulf, US or UK. And with the arrival of technology such as skype and faster travel, it is not that difficult to be in regular touch with relatives and friends.

One more major deterrent is the much needed experience that many of them need in super-speciality hospitals so as to make a career in countries abroad. However, I feel that this can be offered in few of our hospitals too.

Well, ultimately you may need to know how much we offer. I do not want to outrightly put it here, but what I need to tell you is that a newly joining ANM in EHA gets almost the same salary as that of a BSc Nurse in Kerala/Tamil Nadu.

And before I sign out, I need to put the fact that we are a bit choosy with selections as we need to ensure that prospective staff would be in line with the mission and vision of the organisation . . .

But for the bottomline, more than the superior working conditions or the better stay facilities, it is the opportunity to serve some of the most poor communities in the world and to become part of a movement that looks at transforming and strengthening such communities that drew me to join EHA. And of course, we pray that the Lord will give you a burden for such an effort and for joining institutions/organisations such as ours . . .

Opportunity to be a part of us

Today morning, as I reached ACU, I was suddenly overwhelmed by the fact that unless we have more qualified, dedicated and sincere staff, we could be getting burnt out any day. The forthcoming Golden Jubilee celebrations make things all the more tough.

So, whom do we need?

1. Lady medical officers: Preferably freshly passed out MBBS graduates who are willing to learn to rough it out. Preference would be for people from the North Indian or North East India who are looking forward to do a post-graduation in Pediatrics or Obstetrics.
2. Consultant in Medicine: Preferably a MD/DipNB/FRCP/MRCP/Certificate from the American Board in Internal Medicine with exposure to the Indian environment in clinical management.
3. Consultant in Pediatrics: Preferably a DCH/MD/DipNB/FRCP/MRCP/Certificate from the American Board in Pediatrics with exposure to the Indian environment in clinical management.
4. Consultant in      Surgery: Preferably a DCH/MD/DipNB/FRCS/Certificate from the American Board in Surgery with exposure to the Indian environment in clinical management.
5. General Nursing and Midwifery: Preferably a fresher in the GNM course from an accredited Nursing School. There are positions vacant for both men and women. Preference would be given to those who show specific interest in burns management, obstetrics and neonatal care.
6. Store Assistant: A graduate in any discipline with exposure to basic mathematics. However, preference would be given to people with experience or a degree in material management.

For graduates from countries abroad, please note that you will need to take the necessary clearance from the corresponding Indian councils before you plan to join us.

What can I assure you? I can assure you a time of hard work with opportunities to influence the lives of thousands of the most poor and marginalized in our part of the country. Of course, we pay enough to make a good living. There is an organizational pay structure which we follow.

For further information, please contact me either at jeevan@eha-health.org or jeevan53@gmail.com. Since we belong to the organization - Emmanuel Hospital Association (EHA), appointments would happen only through the Central Office. You may wonder why I did not put the number of required posts. EHA has a total of 20 units spread out all over the country and quite a number of them are in situations which are very similar to ours.