Girgit

Muskan, this little 8 year old girl in the snap appears all set to break into a dance if some music is put on. As one of my colleagues put it, smiles like this one can really take the stress off a very very busy day.

There is more reason for Muskan to put so much of a smile. Muskan came to us more than a fortnight back after having been bitten by a chameleon in her aunt's house where she had gone for a visit. The problem was that after the chameleon bite, she started to feel very weird.

She had a funny feeling in her throat and she found it difficult to open her eyes.

Her father was a sensible man and brought her to the 'bite hospital' which is us. My colleague received her in emergency and she told him that she was bitten by a girgit – that's the word for a chameleon.

Dr. Ao did not feel that things were okay. He called for a second opinion and while I was repeatedly asking her if she was quite positive that the culprit creature was a girgit, it was very obvious that the ptosis was worsening.

I told my suspicion of a cobra bite to the relatives. They wanted to know about the costs involved and was reluctant to give Anti-Snake Venom. To buy time, I told them that I'll start off with a small dose and see how things progress. However, as our staff got the ASV ready, she went into a respiratory arrest and we had to put her on mechanical ventilation.

Muskan immediately after the intubation. I got the snap to use later if there were medicolegal issues. Notice the bite mark with black surrounding skin. Incidentally, when I photographed here on one of the review days, she was wearing the same dress which she wore the day she got bitten. 

Things became easy for us. Very soon, she was receiving treatment for cobra bite. 

With the ASV, atropine and neostigmine, she was conscious, breathing on her own and talking after 3-4 hours. I again asked her about the animal that bit her – girgit was the answer.

By now, her bite site had swollen up quite a bit and it was obvious that it was a cobra bite.

The next day, Muskan narrated on how she had turned to take some rotis which was kept on a window sill and as she turned after taking the food, she saw a chameleon sitting beside the plate of rotis, which lunged at her and bit her on the upper part of her right arm. That narration was difficult to believe as chameleons are quite timid creatures and they run for their lives when they see someone.

However, Muskan was the first of our two patients who misidentified the animal that bit them.

About our second patient, in the next post. And I can assure you that it is hilarious. 

Back to square one

Over the last 2 weeks, we were on the move once again and are now based at a small mofussil town in Eastern Uttar Pradesh, about 300 kilometers from Palamu region. We’re not quite sure about the future, but for now, we would be based at Kachhwa Christian Hospital, Kacchwa, Mirzapur District.

We are about 50 kilometers from Varanasi or Banaras. In fact, the river Ganges is just 2 kilometers from where we are now.

Coming to the hospital, it serves the small town of Kachhwa. I shall write about the place in a later post. The best part of my first week was a 30 year of mother of two who was brought in gasping after she got bitten by an unknown snake. She was almost dead.

Our team got her intubated and resuscitated in no time. Considering that she did not have swelling over her bite site, we were quite sure that it was a krait bite. We had ASV pumping into her veins in no time. And what did we have for the mechanical ventilation?

I could not believe my eyes when I saw the machine. It was the same one; the war horse we had at NJH when we reached there in 2010.

The Newmon ventilator did a wonderful job for about 24 hours before she ran out of steam.  The relatives did manual ventilation for about 8 hours before the machine started to work again.

Thankfully, the lady could be weaned from the ventilator by 48 hours. Unfortunately, we discovered that she had some amount of brain damage, which may have occurred during the period of cardiac arrest (We do not know on how long she had not been breathing. The relatives told that she stopped to breathe about 5 minutes before we intervened.).

Our patients would definitely benefit if we had one more Newmon ventilator. It costs about 80,000 INR now (1350 USD, 820 GBPs, 1050 Euros) and the people here know where the machine can be purchased.

More on the clinical exploits at Kachhwa and about the place in a later post . . . 

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. 

Critical Care at NJH - An appeal to gift

20 year old PrD had been with us for the last days. When PrD came to us 10 days back, she was having seizures for more than 12 hours. Her baby was dead. We tried to deliver her normally. But, she did not deliver. She had been in the ventilator throughout from the time of admission. We had to take her up for a Cesarean section, the last resort. After the Cesarian, she has held on for the last 7 days. She continues to be on the ventilator and we think that she would have done better with a full fledged ventilator rather than the anesthesia ventilators that we have.

This takes me to a request that I’ve trying to put across to garner funds for the Acute Care Unit. 

Below is a note from Dr. Roshine requesting for funds to upgrade the Acute Care Unit –

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Dear friends,

Over the past years, we have been having a large number of critically ill patients being managed in our hospital. This is due to the lack of health services capable of providing intensive care in our locality as well as the fact that the nearest highest referral centre is 165 kms away in Ranchi. As for the poor, a referral to Ranchi is a nightmare as they have to often bear  unnecessary expenses, get lost in the crowd as there is no proper guidance and often do not receive the  care expected of a tertiary level hospital.

For these reasons, we are very keen on developing a department of critical care in our hospital. The majority of  patients who require intensive management have been snake bite victims, patients with meningitis, acute febrile illness with multi organ dysfunction and high risk obstetric patients, all of whom can be potentially treated and cured. However, in our management of critically ill patients, we have been forced to compromise on several areas due to the lack of infrastructure.

We currently have a 6 bedded ACU ‘acute care unit’ where we manage emergencies, critically ill patients and most post operative patients. The last rainy season was particularly difficult as we had to shift out patients who were not completely stabilised to the general wards for lack of beds in ACU. Another requirement would be an area for casualty where patients are triaged and emergency procedures can be carried out before timely referral. This would greatly help in ensuring that the patients in ACU are not transferred out. 

Creating a 12 bedded Intensive care unit would be ideal as it would also benefit post operative patients who can be monitored closely in their post operative period. This would need additional space.

1. Medical equipment:

a. Multipara monitors: A multi para monitor for every 2 beds

b. Ventillators: Currently we have two ventilators that are meant for use in the operation theatre. The drawbacks of these machines have been that they cannot be used in children and do not provide adequate pressures in patients with pulmonary edema. We have been manually ventillating these subset of patients. We have been greatly encouraged by the donation of a CPAPmachine which ensures that a few patients who come in pulmonary edema are being managed effectively now.

d. Nebulisation port for use in ventilators

e. Infusion pumps 

2. Furniture:
a. Fowler beds

b. Emergency trolleys

3. Centralised Oxygen supply

These are our current requirements and we pray that God will provide for us and we would use our resources wisely.

In future, once our basic infrastructure and quality of care has improved, we hope to address other issues that are pertinent to the health needs of our population. 



Dr. Roshine Mary Koshy

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I'm sure that you've seen a fund request that I had put about a month back for upgrading and re-equipping out critical care unit. Please pray and pass the message along.

Here is the budget we are looking at. Please forward to friend and well-wishers who may be looking at opportunities to give a Christmas gift .  .. ...

	Requirement	Cost
1	900 square feet of space	9,00,000
2	Ventilators (2)	15,00,000
3	Multiparamonitors (4)	3,00,000
4	Syringe pumps (6)	3,00,000
5	Furniture	3,00,000
6	Electricity back-up	1,00,000
7	Other instruments	1,00,000
	TOTAL COSTS	35,00,000

Well, the costs put here are only an estimate. In foreign currency, this would be about 55,000 USD/ 42,000 Euros/60,000 AUD/16,000 KD/36,000 GBP.The centralised oxygen supply should amount to an additional 500,000 INR

If anybody is interested please send me a e-mail to either jeevan@eha-health.org or jeevan53@gmail.com

The Acute Care Unit

Over the last couple of months, especially after Dr. Roshinetook over the functioning of the Acute Care Unit, something which has bothering us is the major shortcoming in infrastructure for our very sick patients.

We’ve come a long way over the last 3 years. Acquiring 3 ventilators, 4 multipara-monitors, 6 fowler beds etc has not been an easy affair considering the sort of poor patients who come to us. But, we need to look for more and better facilities for our patients.

Part of our Acute Care. Here two children, both below 3 years of age being manually ventilated. 

As I write this, sitting in Acute Care, I’ve three patients who would have done with better machines for ventilation and monitoring. In addition, we also have a shortage of space. We’ve sort of developed a habit of shifting the least sick patient out as soon as a more sick patient comes in.

Many a time, the former patient would have benefitted for a few more hours of close observation.

Below are our requirements.

	Requirement	Cost
1	900 square feet of space	9,00,000
2	Ventilators (2)	15,00,000
3	Multiparamonitors (4)	3,00,000
4	Syringe pumps (6)	3,00,000
5	Furniture	3,00,000
6	Electricity back-up	1,00,000
7	Other instruments	1,00,000
	TOTAL COSTS	35,00,000

Well, the costs put here are only an estimate. In foreign currency, this would be about 55,000 USD/ 42,000 Euros/60,000 AUD/16,000 KD/36,000 GBP.

Please pass this message around to friends and acquaintances that could help us in this matter. 

If anybody is interested please send me a e-mail to either jeevan@eha-health.org or jeevan53@gmail.com. 

Almost missed . . .

Couple of days back, we got a patient who came in late into the night with vague complaints of abdominal pain and weakness of the limbs. 

He was already seen at multiple places where diagnoses of all sorts were made. 

The history was that JPJ, a 40 year old man woke up at around 3 am in the morning with severe abdominal pain. He was immediately taken to the hospital where the doctors could not come to a conclusive diagnosis.

The relatives took him to a total of 3 places . . . over a period of about 18 hours. 

The snaps of the prescriptions are given below . . . 

Please note the diagnosis - Pulmonary edema with acidosis with cerebral malaria. 

The patient had investigations like widal and chest x-ray

By God's grace, somehow Titus who was on duty suspected that JPJ had a krait bite. There was ptosis. 

In addition to the complaints of abdominal pain and weakness, the team noticed that his respiration was becoming labored. 

After discussions with the rest of the team, we sort of convinced the family that it looked like a snake bite. 

Within no time, he was gasping. We had him hooked onto the ventilator. 

With ASV on flow, he made a slow recovery. After 2 days, we thought that he was ready for extubation. On extubating, we discovered that his larynx was all swollen up. It was only a miracle that we could get him re-intubated. 

The relatives were quite agitated. They just could not accept the fact that he was doing good and suddenly had deteriorated. It was then that we realized that the family was quite well off and had the required good connections in Ranchi. 

After quite a lot of discussions, we told them of the futility of trying to shift him to Ranchi without a mobile ventilator. After quite a bit of conference with the relatives with the help of couple of doctors in Ranchi, the family decided that they stay back. 

He was on the ventilator for 2 more days. 

Today, Dr. Roshine told me that he is doing good and would be going home soon. 

A strong reminder to all of us on how a krait bite can turn out to be. With no bite marks, it is quite a tough task for the clinician to come to a diagnosis. And more difficult to explain to the relatives. If JPJ had come to us early in the morning, we could have also made all sorts of diagnoses. 

It was a lesson for all of us . . . regarding krait bite presentation . . . and how misleading can the history be. 

In addition, a strong affirmation for our service and a glowing example of how NJH continues to be the only lifeline for people like JPJ in this part of the country. 

Cerebral Malaria .. .. ..

Mr. R coaxing his son Mr. P to smile as I took his snap

Talking about ventilators, one of our latest success stories is that of Mr. P who was in the ventilator after he was diagnosed to have Cerebral Malaria. When Mr. P came about a week back, very few of us had much hope his surviving.

To make matters worse, when we intubated Mr. P, we found out that he had a wedge of turmeric wedged in his throat. Apparently, his relatives had put the turmeric piece in between his teeth when he had a seizure.

It was almost fatal.

Mr. P was in the ventilator for about 2 days. However, he made a remarkable recovery. Another of the umpteen patients who are alive just because of the cheap anesthesia ventilators we have at NJH.

In addition, Mr. P's father, Mr. R was also diagnosed to have Falciparum malaria one day after his son was admitted. It was a joy to see both of them doing well. 

Nevertheless, as I mentioned in my previous post, of late, we have been having patients who would have done better if we have a full fledged adult ventilator.

Once more, requesting prayers and funds for the same.

Fatal viper bites

Over the last 2 days, we’ve had 2 patients with viper bite with whom we had major issues of clinical care.

The first was 50 year old SD, who was bitten by a viper sometime in the evening. By the time she came, she was pouring out quite a lot of blood. And then, she was in shock. We started her off on Anti-Snake Venom.

After which, she went into a refractory shock, which was totally unresponsive to Dopamine or Adrenaline. She was ventilated for almost 24 hours. At last she passed away today morning, after her heart became totally unresponsive to any medications.

Within a couple of hours came the next patient with a viper bite - a 15 yr old girl from the nearby government school. She was promptly started off on ASV. However, as time passed, she started to deteriorate. Her clotting time was prolonged. She was already bleeding from her gums and nose when she arrived.

She appeared to be going into myocarditis. She went into a respiratory arrest. We hooked her on the ventilator. But, soon, she was bleeding profusely from her gut. Her nasogastric tube brought out copious amounts of blood. Then, we realised that she was going into pulmonary edema.

One of the major issue which we’ve faced with the anesthesia ventilator is the inability to give high pressure ventilation which is needed in condition like pulmonary edema.

Over the last couple of weeks after Roshine joined us, we have been planning to invest in a full fledged adult ventilator. It’s quite expensive for us. And considering the situations of power supply and oxygen procurement, we need to think twice before such an investment twice.

But, we’ve been quite unanimous in our acceptance of the need for a full fledged adult ventilator. The approximate cost for a low end adult ventilator will be about 650,000 INR which will include transport from the place of purchase.

We request help from people who would interested to support this endeavor. Below is what we dream to have. 

You have the unique chance of being history as this would be the first full fledged ventilator in this whole region . . . the next ventilator to the east is in Varanasi which is about 300 kilometers away, the north, Gaya which is about 200 kilometers away, Ambikapur (200 kms) to the south and Ranchi (130 kms) to the west. The total population we would cater would be about 5 million.

(PS: The 15 year old girl passed away today morning)

Glimpses of possibilities

Yesterday, Titus called me to say that they ran out of ventilators for patients. 

There were 4 patients who needed a ventilator at the same time. And with the the nearest ventilator 80 miles away, there was no other choice than to manually ventilate using a bag.  

Patient A, a 25 year old lady who came with unknown poisoning. She came with seizures and later had a respiratory arrest. She was on the ventilator for almost a day before she was weaned out.

Patient B, a 17 year old young man with organophosphorus poisoning. He was gasping when he came in. He  obviously took the second ventilator. 

Patient C, a 48 year old man who came in with a krait bite. In spite of being started on a high dose ASV, he went into respiratory arrest. When Mr. C came in, B and C were already in the ventilator. Mr. C was manually bagged for around 12 hours, when we felt that Patient A could be weaned out. 

Patient D, a 9 year old girl who came in gasping after a krait bite. She was intubated immediately and was bagged till Mr. B was out of the ventilator. 

Then, there was a patient E, a 12 year old girl who was rushed in from the local village after a krait bite. We gave her an option to go to a higher centre. They have rushed her to Ranchi. 

We did not have a bag to ventilate her if she had a respiratory arrest. Even, we were not sure of starting ASV as we did not have a bag to ventilate (2 patients were being manually ventilated) if she had an anaphylaxis. 

Such a situation puts us in a position where we need to seriously ask questions about expanding our resources - - both in terms of infrastructure and qualified personnel. 

To start off things, we eagerly wait for Dr. Roshine, the medicine consultant who'll join us on the 22nd, the coming Saturday. 

Thru' the valley of death

RD was a very non-suspecting high risk antenatal patient. The issue was with her hemoglobin. It never crossed 8 gm%.

However, considering her family’s financial situation, wehad decided to take her at NJH for delivering her baby by Cesarian section. This was her second baby and her first baby also was delivered by Cesarian section.

None of us had any inkling of the crisis we were going to face.

She had a blood transfusion before the surgery. Unfortunately, the doctor who operated did not do a repeat hemoglobin value before taking her in for surgery. Per-operatively, she developed a reaction to the blood transfusion. There was nothing much of a problem.

After the surgery, she was comfortable. However, there was a nagging issue. She was not maintaining her saturation. However, the saturations became normal when oxygen was given. A hemoglobin done on her turned up a value of 6.6 gm%.

Alarm bells started to ring on my head. We decided to wait overnight.

The decision turned out to be almost fatal. She started to have breathlessness in the night. Her saturations took a dip for the worse. She was going into pulmonary edema.

By morning, she was in the ventilator. But, she was also putting out pink frothy sputum. We had to give about 1 gm of Furosemide over the first 24 hours to control the pulmonary edema.

By God’s grace, she responded well to treatment.

And she got discharged last Sunday, exactly 7 days after her surgery.

However, RD’s incident has prompted me to put in strict control on hemoglobin values of our prospective patients. Anemia is quite prevalent in our part of the country. It is not very common for a pregnant lady to have a hemoglobin of above 10 gm%.

Meanwhile, the debate on anemia always cause me to wonder if we have some form of a blood dyscrasia in our part of the country, which is not yet diagnosed. 

Two Maternal Deaths

Yesterday, we lost SHD. She was sick, but stable, while I saw her in the morning. I was in outpatient department, when I got a call that she had a cardiac arrest. The problem was that it was some time after that she had the arrest and the nurses could not find a doctor in the immediate vicinity to come and help.

I knew that there was no point in attempting a resuscitation. However, we tried the routine procedures. . . . but without any success.

And then we lost LD 4 days back. Couple of days after the surgery, she went into florid septicemia. She was being ventilated. And she started to pour out pus from the lungs, abdominal drain and also from her vagina. The relatives requested that we do not do anything heroic. Obviously, they were poor and was slowly noticing how the expenses went up.

After quite a long time, I withdrew life support for a young life.

Then, there was PD. A primi in her last weeks of pregnancy. She had not been doing well since about 2 weeks. Yes, 2 weeks. And she was taken from hospital to hospital. She was gasping as she was wheeled into NJH three days back. In fact, the relatives told us that she has been gasping for breath since 2 days. Dr. Johnson, our doctor on duty realised that there was nothing much he could do.

2 gm% was her hemoglobin. By the time, he found out a donor, she was dead.

So, we had 2 maternal deaths due to anemia last week. I wonder how long it will take for our guys in the thrones of power to realise that such preventable deaths are a major deterrent to development.

There is now one more near maternal miss patient in acute care. BDD, whom I wrote about in the last post has been weaned off the ventilator today morning. Kindly pray that BDD would recover completely.  

OP Poisoning

A common term in most of the emergencies of hospitals in South East Asian countries, OP poisoning stands for organophosphate poisoning. 

We had the worst OP poisoning case ever in the annals of NJH couple of days back. 

SHD, a 26 year old, mother of 3, had gulped down an entire 120 ml bottle of Malathion after a tiff with her hubby. When she arrived, we had to literally pour Atropine down her veins to ensure that she remained asymptomatic. It was only after we had given about 3500 mgs of Atropine over 24 hours that she stabilised. 

Over the next day, we had weaned her out of the ventilator. However, we were very sure that 'Intermediate Syndrome' was just around the corner. I prayed that it would happen when we are around during daytime. 

But, that was not to be. I was just getting ready to hit the bed when she went into respiratory arrest. Dr. Shishir was operating on a severe pre-eclampsia patient with fetal distress when it happened. 

By God's grace, we've been successful in getting her well supported. Again, the staff in ACU did a magnificent job. The presence of mind and diligence was all the more evident as there were 3 eclampsia patients in the ACU. 

The next 24 hours are going to be crucial. 

We request prayers that she will be completely healed . . . and of course, specialist advice is definitely welcome. 

Eclampsia Galore

Dr. Shishir is on duty today. It should have been mine. I had exchanged it with him for tomorrow. 

I'm glad I'm not on call today. It has been a long day. About 130 patients in outpatient. Dr. Johnson also had not slept the previous day as it was busy. So, technically there were only 2 doctors in outpatient most of the time. And then the theatre had gotten busy. 

And today it had been eclampsias all the way. Couple of days back, we had quite a bad one. We were blessed to have saved the mother and the baby, although the baby was very sick. Of course, they took the baby to Ranchi as it was a boy. 

We had 3 more eclampsia patients today. All sick. I wonder why people don't take them to Ranchi when they are breathing well and keeping their saturations well. 

I got to put my hand in the last patient who came before we crossed midnight. Pathetic, pathetic history. We shall call her BDD. 

The family had been on the run since early morning. They resided in Garhwa district. They have knocked doors in almost all hospitals along the way till they reached NJH and decided that they could not go any further. The paradox about this patient . . . she works as a maid for a senior doctor in town. 

I'm not sure about her antenatal check-ups. 

Then, she is already going into HELLP syndrome. However there was a glimmer of hope as we found out that she was fully dilated. However, we could not get any heartbeat of the fetus. We had got everything ready for intubation. She was desaturating on and off. 

We took a decision to pull the baby out by vacuum. And then hook her onto the ventilator. 

The ploy worked out well. The best part was that the baby was alive and responded well to resuscitation. 

Kindly pray that BDD gets well soon. 

I was very proud of my ACU staff. They have put up a very good show considering the amount of work going on in the unit. 3 patients with eclampsia of whom one is now in ventilator, 1 patient with organophosphorus poisoning (on ventilator) and one elderly gentleman with a very bad cor-pulmonale . . . it's going to be really tough at night. 

Would value your prayers . . . and of course, we were expecting help from Monday for a week. I hope things get a little light tomorrow . . . for I'm going to be on call.