Dangerous

Almost everyday, we at Kachhwa are reminded of how dangerous a disease, tuberculosis is turning out to be. Last week, we had a perfect example of how the disease has got itself entrenched in our communities and how helpless we have been in controlling the spread.

Mr. KK, a young man, about 25 years was brought to our outpatient with complaints of cough and fever since the last one year. He had already completed 8 months therapy of DOTS under the Revised National TB Program of the government. He had not improved. He had skipped medicines in between and therefore the 6 month long treatment took 8 months.

He did not remember whether he checked his sputum or not. He had only one X-Ray with him which he had taken 2 weeks back. The picture was bleak. 

2 weeks back someone told him that the persisting cough and fever was dangerous and therefore, he had been running from one hospital to the other – a whopping 4 places in 15 days.

The prescriptions are self explanatory. There is mention of MDRTB in at least 2 prescriptions. One place demanded a payment of 20000 INR which he could not cough up and therefore the concerned doctor crossed off the prescription.

Please note the crossed off medications.
Crossed off, as the patient could not afford 20,000 INR which the doctor demanded for admissiona and treatment.
The patient claims that this doctor guaranteed cure . . . 

The biggest problem is he is still not aware about the seriousness of the condition.

The challenges in Tuberculosis treatment remain quite basic –

1. Non-adherence to regular treatment

2. Late diagnosis and improper follow up

3. No mechanism in the ground level to detect resistance

4. Availability of anti-tuberculous medication as over the counter drugs

5. Mistrust of drugs provided through public healthcare

We’ve referred him to a tertiary care centre. I hope he gets the right management.

However, as each day progresses, we realise how dangerous MDRTB is slowly turning out to be. I wonder if the calculated prevalence rates are low . . .

I hope that we would be able to do at least the following in our Community Health Centres over the next year . . .

a. Drug sensitivity testing for all cases of tuberculosis

b. Curtail sale of anti-tuberculous medication over the counter. 

Till this is done, the situation can continue to become worse . . . 

Photo credit: StopTB

From the battlefield

This is Sergeant Kuruvilla, reporting from the battlefield in the war against Tuberculosis.

Thank you for your greetings on World Tuberculosis Day. It’s been more than a century since we’ve sighted the enemy, but alas there seems to be no end to the hoards of their armed regiments. 

At the front, Lieutenants Rifampicin and Isoniazid continue to do a commendable job inspite of the fact that the enemy has designed specific weapons against them called Drug Resistance. Lieutenants Pyrazinamide and Ethambutol continue to serve well, although there are reports of our own troops being injured by them unknowingly during combat.

I understand that new troops with extra fighting capabilities have been identified. It is very essential that they be deployed in our sector at the earliest. Lts. Isoniazid, Rifampicin, Pyrazinamide and Ethambutol have been in the field for quite long and the enemy knows their capabilities quite well. Sometimes, I wonder if the war is going beyond our grip. The new mercenaries of the enemy, MDRTB, XDRTB and TDRTB are ample evidence that we’ve not been diligent. We need the state-of-the-art technology radars available with usto detect these rouges and more potent weapons to fight them.

However, I need to point out issues which our own troops have been guilty of. Quite a few of our troops do not heed to the leadership of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol after some period of time. Instead, they put themselves susceptible to the machinations of the enemy tubercle bacilli. It is quite sad to see this happen.

Meanwhile, there are issues which need to be dealt by the social development wing of the nation. Social determinant issues such as malnutrition, overcrowding and poor livingconditions need to be addressed on a war footing.

Is it true that the enemy is advancing in at least some of our fronts? It is sad to know that even today, in the age of internet and smart phones, people have poor knowledge and attitude about the disease. It pains me to see people spit wherever they want, in spite of the fact that there is evidence of higher spread of the disease because of such practices. Of the last 10 patients, whom I diagnosed to have tuberculosis, more than half of them could not acknowledge and accept the fact that they had the disease. I believe that this is one of the major reasons that there is a delay indiagnosis.

There are quite a lot of the enemy who has infiltrated into our territory without our knowledge. Considering that the private and voluntary sector is the favoured point of contact for a large number of our population, we need to take them into confidence.

I’m encouraged that there is evidence that if standard epidemic control measures are put inplace, we would achieve control on the spread of the disease. We need to follow the basics of public health care. The eight essential components of ‘Primary Health Care’, outlined at the Alma Ata declaration give us enough guidelines to stifle the enemy.

With poor primary healthcare and emphasis on setting up tertiary care institutes all around the battle fronts, this objective is not going to be met. Priorities on tackling malnutrition, rural to urban migrations and overcrowding have to be given priority.

It is sad to note many of our fellow human-beings reap a profit off the victims of the enemy. The government needs to act.

Considering this year’s slogan, I’m sure that there need to be some major changes in our approach to treat tuberculosis. Reaching each of our patients would be a reality only if we allow active detection of cases. The World Health Organisation charter for treatment for tuberculosis has already accepted the superiority of daily drug therapy to intermittent therapy. In India, we need to slowly shift to daily treatment. There is presently no mechanism to ensure that patients remain cured after the completion of treatment. Relapse and re-infection remain hugely unaccounted for.

Unless, we areserious of my above mentioned issues, the slogan for this year – Reach the 3 million: Find, treat, cure TB’ will just be another catchy phrase and an issue to write articles on.  

I assure you of my team’s commitment to the control of the tubercle bacillus. 

Priorities . . .

Since the beginning of 2015, we're in the midst of a flu epidemic. Newspapers have gone head over heels to report from every nook and corner of the country. There is quite a lot of panic about the situation in the country. 

I found it quite amusing to have a young man come to our outpatient wearing a surgical mask. He had been told at his college that the surgical mask will prevent swine flu infection. He also claimed that authorities in his college had distributed about 2000 masks to students and teachers.

As of today, there have been 743 deaths caused by Swine Flu since January 1, 2015. 

I thought of calculating the number of deaths by other major causes (mainly preventable) in our country during the same period. The calculations are based on figures provided from previous year data. There should not be a more than 5% decrease from those numbers.

Cause of Death
Tuberculosis	76849
Road Traffic Accidents	18360
Malaria	27945 *
Childhood Diarrhoea  (11m and less)	13973
Childhood Pneumonia  (5 years and less	44433
Maternal deaths	6986

* This number would be certainly much less than this as it is not malaria season.

Yes, you read it right. If the news sources are to be believed, almost 10 times the number of swine flu deaths have been accounted by maternal deaths during the last 50 days. And nobody of us even noticed. 

I can only hope that the sources of my information about deaths every year in the country is wrong.

I hope we can get our priorities right . . . 

Ominous signs

Today, in outpatient, I had a 30 year old lady walking in. Her history was quite shocking. 

Diagnosed to have tuberculosis without a sputum AFB more than a year back, she was on treatment for almost 10 months with a multitude of medicines including 90 injections of streptomycin. 

The problem was that she had not felt better throughout the course of her treatment. 

Below are 3 X-Rays she had with her. 

Feb 2014

Sept 2014

Feb 2015

I await for her sputum AFB. 

I'm not sure if I would do justice to her if I just refer her to a higher center nearby. 

Earlier in the day, I had another patient who was invariably depressed. The interesting thing was that this guy had absolutely no symptom suggestive of tuberculosis. However, he was on anti-tuberculous medications since the last 2 months. The reason - - - some doctor had done a Quantiferon TB Gold Test on him and it was positive. 

Just a glimpse of the scenario of tuberculosis control in the country. 

Of course, I would be glad to get feedback on the management of the patient . . .   

Menace

As most of us, tuberculosis is a major problem all over the country. 

One of the major issues in tuberculosis management is over the counter medications. Almost all anti-tuberculosis medicines are available very easily. 

Yesterday, in OPD, there was a boy who came with a peculiar skin lesion. We did a biopsy of the lesion. However, the boy also had a prescription written by someone on a piece of paper. He was told that this medicine is quite strong and should clear out the disease. 

He was smart to have not taken the prescribed treatment and opted to have it checked with a doctor. 

Unless, we can rein in such prescriptions, we are inviting avenues for emergence of Drug Resistant Tuberculosis. Of course, another cause of DRT is sub-optimal prescription doses of anti-tuberculosis medicines. 

The question is about any of us being serious about this issue. 

A Challenge

Over the last few weeks, we have had quite a lot on how India’s ancient were quite progressive in science and technology and it was only an irresponsible government coupled with left wing ideologues who suppressed such information.

I’m sure that there were quite a few things we knew about India’s contribution to science and technology. I’m very familiar with the names of Sushruta and Aryabhatta from childhood. And of course later names such as JC Bose, CV Raman, S. Chandrashekhar, Hargobind Khorana etc. are quite familiar.

However, as of now, we all know that our country is struggling with a myriad number of issues which can be solved. The Mangalyan exploration proves that we have quite innovative and brilliant scientists who will excel if given the right environment.

Last year saw a lot of challenges. In this post, I challenge my countrymen to come up with 5 issues which need to be addressed by Indian scientists as a priority. Here is my list of 5 challenges to each one of us, especially those of us who are students of science - - -

1. Tuberculosis continues to be a major killer in our country and other developing countries. We still rely on sputum microscopy which is quite an ancient test by medical standards for routine diagnosis. To make matters worse there has not been much change in the drugs which are used to treat the disease. We need faster and cheap diagnostic techniques and newer drugs which can be taken for shorter duration and has low drug resistance.

2. We depend quite a lot on fossil fuels. We’re yet to increase our reliance on non-conventional and environmental friendly sources of energy. In fact, we seem to have joined the race of development at the expense of the livelihood and existence our many traditional people groups who live in areas of fossil fuel deposits. We need research on solar energy and other possibilities of energy sources.

3. The human race generates lots of waste. And waste pollutes. Could we have research on minimizing and recycling waste?

4. Non-communicable diseases are a major scourge. Traditional systems of medicine promise quite a lot forprevention and treatment. However, there is very poor research done on their efficacy.

5. Our eco-diversity is under threat. Even some of the foodstuff which was common is not seen of recent. Traditional foods are slowly on the way out. Whatever research was done on them have shown them in good light. More research needs to be done. Can we look at our ancient texts about spices, vegetables and cereals used in ancient times? We not only need to conserve them but also popularise them. It can only be done through proper research.

Few reasons I can think about as reasons for non-acknowledgement of our contribution to science and technology.

a. We don’t document anything. Whatever is documented is done in a language which is not understood by much of the population. Therefore, the first step can be to translate all Sanskrit documents into a commonly used language.

b. We bicker among ourselves. We are famous for pulling each other down. I hope you heard about the story of the Indian crabs.

c. Whatever we discover, we do not share with the wider population. The discovery remains with a few elite and the technology is not shared for common benefit. Documentation in an elite language ensures the knowledge being limited to a certain group of the population.

If we are so sure of our scientific capabilities, I challenge the government and our scientists to take these issues seriously. If we do, I’m sure that the next century is going to be that of India. 

Tuberculosis . . . The Affair Continues

It’s been couple of months since we started to serve at Kachhwa.

One of the things that that has followed us here from NJH is the high prevalence of Tuberculosis. I only wonder if the prevalence is a bit more higher than Palamu region as the density of health care institutions including tertiary centres are more here. 

I personally saw 4 pulmonary tuberculosis patients, 2 abdominal tuberculosis, 1 tuberculous lymphadenitis and 2 tuberculous meningitis. The experience in NJH has been such that we have the diagnosis of tuberculosis in the back of our mind once the patient complains of cough or comes with vague complaints. I’m sure many would echo my view.

Couple of interesting cases . . .

DES, a 45 year old lady came to us about couple of weeks back with pain on passing urine and vague abdominal pain. We sent her for routine urine examination which showed a bad urinary tract infection. She was started on oral antibiotics, but did not respond to treatment. She came back. Ultrasound showed features of early pyelonephritis. She was admitted and started on intravenous antibiotics.

She did not improve. Rather, after admission, she started to complain of breathlessness at night. Later, on probing, she told us she has been breathless since the abdominal pain started. We took a Chest X-Ray.

Miliary tuberculosis was the diagnosis. She was started on treatment. And the recovery was dramatic. DES is at home now.

The second story is that of a little boy and his grandmother. MS, a 2 year old boy was brought with history of long standing cough. MS weighed just about 5 kilograms and on probing gave a history of exposure to probable tuberculosis. His grandmother was a chronic cough patient and had taken 2 months of tuberculosis treatment.

Meanwhile, in another cubicle of our hospital, another doctor was examining his grandmother and had made the diagnosis of tuberculosis. The parents did not think it wise to tell to the doctor who examined MS, that his grandmother had also come and was being examined at another cubicle.

Below is MS’s X-ray. We were quite taken aback at the extent of the disease.

Meanwhile, MS’s grandmother also got her X-Ray. Later, her sputum was also positive.  

It took some time before we realised that both MS and his grandmother was diagnosed to have tuberculosis the same time in our hospital without the knowledge of either doctors.

When, we told the family that MS should have got the disease from his grandmother, the family was not willing to believe stating that MS visits his grandmother only once a month.

This is nothing uncommon that we see when we try to educate people about the spread of the disease. 

There is one more patient whose story I wanted to narrate. That would be in another post . . . 

Looting in broad daylight . . .

Today, a poorly built young man come to one of our doctors. He had a contrast enhanced 18F-FDG whole body PET-CT Scan in his hand which he held out to me and told me that the concerned doctor has told him that he has tuberculosis in his blood.

He had come to NJH as we had a reputation for treating tuberculosis patients. 

One look on his face and his history was enough to make a very strong suspicion of Sickle Cell Anemia. He had a huge file with him. Our doctor was hopeful that there would be something in there about the diagnosis. The names of the hospitals he had gone through were huge enough to have their own websites and online fixing of appointment etc.

Other than the PET-CT Scan, he had a complete hemogram (4 times), liver function tests (4 times), serum iron studies, detailed stool examination (3 times), ASO titres, echocardiogram, HIV, ultrasound abdomen, widal tests, couple of chest X-Rays. He has been admitted and on multiple intravenous antibiotics for quite some time. 

The total costs of the latest treatment for him has come to something around 70,000 INR.

The poor guy had gone to one of the metropolitan cities in the country for job. And then he fell very sick with severe body pain and fever.

He was always sick since childhood. He had been to many places. Nobody has told him anything till he took the PET-CT Scan when the concerned doctor told him that he appeared to have tuberculosis in the blood. 

However, the reason for me to put up this post was because of the absence of a peripheral smear report in his treatment file. Nobody had told him about the possibility of sickle cell anemia. 

I wait for the reports of the sickling test and peripheral smear . . .

An unusual presentation

JO was a 15 year old jovial boy who suddenly took up sick with fever about a month back. He was sick for almost 2 weeks and was treated successfully elsewhere. After discharge, JO’s father noticed that his son was not his former self. He suspected something was wrong.

His suspicion turned out to be true within a couple of days, when JO became unconscious gradually. Even his family did not take the way he became unconscious seriously as it looked more of JO becoming more and more sleepy over the day.

When JO was wheeled into our Acute Care, he was hardly breathing. JO had something very bad in his brain. He was running a high fever and had anisocoria. We had to do a CT Scan. But, JO was hardly breathing on his own.

After almost 2 days of mechanical ventilation, we could wean out JO from the ventilator. Considering the sort of diagnoses that a young boy with anisocoria can have, we were anxious for the CT Scan Brain. With a backup for ventilation, we rushed him to the nearest town for the CT Scan.

The CT Scan showed a hypodense area in the periventricular white matter of the right temporal region.

After he returned, the anisocoria stayed. However, a fundoscopy did not show any features of a raised Intracranial Tension. With a guarded prognosis, we took a decision for a lumbar puncture. The family readily agreed . . . in fact, we had not given them even a day for their JO to survive.

Lumbar puncture was suggestive of a partially treated bacterial meningitis with a higher protein levels than usual. Considering the long history of the illness, we took a decision to come to a diagnosis of Tuberculous Meningitis.

JO has responded well to anti-tuberculosis treatment. However, he’s yet to be completed fit for discharge.

We’re blessed to be a blessing in the life of JO and his family. Kindly pray that this young boy will be completely healed. 

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 . . . 

Looking forward

It’s going to be 4 years since we have been serving at NJH. When I first saw this place in 2003, I was fascinated by the possibilities in this place. And I’m thankful that the Lord has used us as a family to bring hope and smiles to the lives of quite a lot of people.

Over the last year, we were in the middle of a decision making process about Angel going ahead for a Master’s qualification. We had requested quite a lot of our friends to pray over it. 

We did not want that to happen just for the heck of it. We were quite sure that we are going ahead with it only if it was within the Lord’s will.

Couple of weeks back, we were led to believe that the Lord wanted us to continue here over the next year.

From the world's view, this was the best time for Angel to do her masters. However, we are convinced now that it does not fall into God’s plan for us for the time-being.

Now that we’re sure that we’re staying on, I thought I should jot down my dreams for this place. When there are dreams, there needs to be things put in place if they need to become reality. People . . . infrastructure . . . the major things.

It was couple of hours back that Dr. Roshine, our Medicine Consultant, Mr. Dinesh, our engineer and myself were in the ward looking at temperatures in the different areas. It’s been too cold over the last couple of days. And we had to do some checking to see if patients were comfortable. As we went into the Neonatal Intensive Care Unit, we could not stop wondering aloud on how much we need to have a paediatrician at NJH.

Of course, if you ask any mission hospital doctor, the first need anybody will blurt out is the need for more doctors, especially specialists.

As we continue our stint in NJH, we look at the prospect of more co-labourers . . .

It is now 52 years since the founding of the hospital. Most of the buildings are more than 30-40 years old. This means that we need quite a lot of new buildings. Hospital area including new outpatient areas, theatre complexes, intensive care units etc and residential spaces for staff are a crying need.

We have a nursing school which needs to be upgraded to a GNM/BSc nursing training facility. Qualified and committed staff along with more buildings is needed.

Could I request you to pray specifically for us as we continue at NJH? The dreams are quite huge. But, I think they are quite possible. But, more important is that we stay within the Will of the Lord for our lives . . .

To start off, we look forward to few specific things we would like to see in 2014. Permit me to put them down here.

1. Tuberculosis is a major challenge in the region. We want to do more in this area. Having a Tuberculosis Unit in NJH gives us quite a lot of leverage. Kindly pray that we will be able to do more for controlling tuberculosis in the region and the country. There are couple of things we are looking at. The first is research and the second thing is starting off Drug Sensitivity and Culture.

2. Starting a specific facility for non-communicable diseases in a rural set-up like ours is something I look forward in 2014. Kindly pray as Dr. Roshine sets it up at NJH.

3. Dr. Nandamani returns to NJH in January 2015. I would like to complete the Burns Unit by then. Please pray for resources including committed staff.

4. We have seen quite a few patients dying of Carcinoma Cervix in the region. Angel has been quite pressing to start off PAP Smear or VIA for Ca Cervix screening. Please pray as we plan.

5. New residential complexes are a pressing need.

6. Kindly pray as we consolidate the impacts we have made through the Community Health projects.

7. Consultant leaders in the specialities of Surgery, Obstetrics, Orthopaedics and Pediatrics with a belief in the saving grace and healing of Jesus Christ are something we should benefit from.

8. We’ve got a team of young and enthusiastic staff. Kindly pray that they’ll continue to grow in the Lordship of Jesus Christ. 

9. Complete ground work to start a blood bank.

10. Develop the specialty of Neonatology with emphasis on training. 

We value support and prayers . . . again, more prayers to remain in His Will. 

Wish all of you a blessed 2014 . . .

The fatal massage

The word 'massage' brings into most of our minds scenes of serenity and comfort. Quite a lot of us are quite familiar with traditional massage systems starting from quite complicated massage processes in the Ayurveda for which Kerala is quite famous to the massage you get at the barber's saloon. 

However, in quite a few parts of the country, including ours, there is a process of massaging the uterus just as the pains of childbirth starts. And they also do that when they feel that the gestational age of the baby has gone beyond term. 

The massage ranges from very tender rubs on the gravid tummy with oil to vigorous working up of the abdomen with ones fist extending to even using planks of wood. Even today, the last patient whom I've just seen in the Labour Room has had a massage. 

But, last week, we had a patient who had got the most horrible massage one can imagine. Yes . . . a massage with a plank of wood on her tummy. I had seen quite a few during my earlier stint at NJH. 

We shall call our patient PhD. A 30 year old mother of one, who had crossed her expected date of delivery of her fourth pregnancy came to us 4 days back. Yes, of her earlier three deliveries only one had survived . . . A 7 year old girl. 

All her previous deliveries were at home. And she had taken her fourth delivery as just another chore. But, this did not go as she had thought it will. When she reached NJH, she was already in labour for 48 hours. In addition, she had got quite a lot of massages, culminating in the massage with the plank of wood. 

The process was well evident on her tummy. The angry looking skin was quite obvious. And the uterus was tense. It was like a balloon. Couple of us thought that she had ruptured. The blood tests turned out to be very bad. She was in full blown sepsis (total leucocyte count of more than 30,000) and was anemic. I was sure that she was dehydrated and therefore the hemoglobin was more low than we expected. 

And she had a hand presentation . . .

The only choice she had was to undergo an emergency Cesarian to remove the dead baby and to repair if she had ruptured. My only fear was gangrene of the intestine. We had lost a similar patient couple of years back after she had intestinal ischaemia following massaging of the abdomen. 

We somehow got hold one pint of fresh blood and she went to theatre . . .

We were relieved to find out that she was yet to rupture. But, the lower segment of the uterus was totally battered into a pulp between the endometrium and peritoneum. There was a good chance that the lower segment will not hold well when I deliver the baby. After thinking it out, we decided to put a inverted T incision on the uterus. 

We were glad that we took that decision. As soon as I put a nick on the uterus, there was a gush of putrid gas which gave us quite a tough time. The baby was badly macerated. The surgery was over in an hour. Thankfully, the patient did quite well after surgery. She should be discharged over the next couple of days.  

I've been trying to convince our local community about this totally unscientific practice. Unfortunately, nobody seems to listen. I came to know that the procedure of massaging the abdomen is so much ingrained into the local traditional healthcare of the pregnant woman. 

For PhD, the massage brought in quite a lot of troubles. Her socio-economic situation made things even worse. She was from quite a remote area. When she was brought by the government nurse in her village, none of her relatives were accompanying her. Her husband was a tuberculosis patient. I'm sure that we'll have to write off quite a lot of her bill. 

Another story of one more live saved because of the Lord working through the team at NJH. 

Please scroll down if you're interested in seeing few snaps taken of the lady and her baby. May I warn you that the snaps are very very repulsive. Be warned . . . the snaps are horrible . . .

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Sr. Sushma, our Nurse Anesthetist praying hard before we start the surgery. 

The badly macerated baby

The uterine incision. You can see the vertical portion of the inverted T incision is sutured.
The lower segment was very very unhealthy and we just got the edges opposed.

Surgery at NJH

During my short vacation, it was quite a blessing to have Dr. Nandamani and Dr. Ango to be with us. 

And I believe that it was a big relief for quite a few of our patients, especially to 2 young men who came with acute abdomen. 

The first one was VK, a 16 year old who came in with acute abdominal pain and distension. Of course, it was intestinal obstruction. 

On opening the abdomen, this is what we found . . .  

In addition, there was an area of constriction caused by tuberculosis which caused the obstruction. 

Then, there was one more young man who is still recuperating from the surgery for a duodenal perforation. 

After quite a long time, we had quite a large renal stone (staghorn calculus) removed. 

It does not need much research to conclude that a surgeon is a very much essential component in the scheme of things in a mission hospital. I wish we had a surgeon who was always around. Our surgical load is immense. Dr. Nandamani did about 70 surgeries in a space of around 2 weeks. 

Dr. Nandamani coming on a bimonthly basis is a major relief for us. We praise and thank the Lord for his bigheartedness. 

Could I request prayers for a regular surgeon to be at NJH? 

VK just before discharge . . .