WEEKEND DIARY 3

Well, it turned out that I was on duty for a third weekend running. The reason I could not pen the happenings on the blog was non-co-operation from our telephone department. It had been raining quite hard over the last week and our communications have gone for a six. As we are quite corruption unfriendly, the telephone department takes least interest in repairing our lines. The lines are still dead. You can read my accounts of the other two weekends at http://jeevankuruvilla.blogspot.com/2011/07/weekend-diary-njh.html and http://jeevankuruvilla.blogspot.com/2011/08/weekend-diary-2b.html


I could put this on to the web as I'm travelling - going to Delhi to get a better half for our ventilator http://jeevankuruvilla.blogspot.com/2011/07/pneumatic-war-horse-tribute-to-silent.html. The company was planning to send it to us by truck parcel - but later had double thoughts because of heavy rains and bad rains which had been lashing most of North India over the last week. They asked us to take personal delivery of the same.


I penned part of this in Daltonganj station. As I sit and write this, there is quite a swarm of mosquitoes trying to suck my blood and if possible inject malaria or dengue into me. But, I have this local application material called the 'Mosbar' - basically diethyltoluamide put in a soapy base. Initially when someone told me about it, I was quite sceptic about how this works. However, once I started using it, I was determined to promote it's usage and therefore I thought that I shall put a word about this here. It is made by Maheshmunda Holy Cross Sisters of Belatani, Giridih district, Jharkhand. It costs Rs.8


When I talk about mosquitoes, I need to tell you about 2 very sick malaria patients whom we had over the weekend. Both of them are over 60 years old. One of them whom I shall call PD has improved after Artesunate injections. He was not as sick as SD when he arrived. SD continues to remain unconscious - though not on the ventilator. Both of them had Falciparum malaria teeming in their blood.


Obstetric wise, we had a rupture uterus and couple of Cesarian sections on Saturday. Two eclampsias and one more cesarian section on Sunday. CF, who had the rupture uterus was quite a sad case. CF had a cesarian section 3 years back. She reached the local district hospital on a wrong day - it being Rakshabandan (Indian festival where brothers take the vow to protect their sisters - symbolised by the tying of a sacred thread around the hand of the brother by the sister), there must not have been many qualified hands to deal with her. Her pains had started on Saturday early morning. She reached the district hospital some time late morning. God only knows what they were trying to do with her over the whole day. Sometime around midnight, the family was told that it seemed that CF would need more expert medical care. They rushed CF to the private hospital nearby where they were told that things were quite bad and they would need to go to Thumbagara.


I recieved CF at around 6 am on Sunday. The diagnosis was obvious. Far worse, CF was in shock. She was very pale. She needed to be operated on fast and she needed quite a lot of blood. 3 male relatives readily volunteered to donate blood. But they had different blood groups. I decided to call on one of our staff to donate blood as we were quite concerned of her hemodynamics. Consequent to few extra number of surgeries on Saturday and the incessant rain we were running short of theatre gowns. So, I decided to call on Dr Nandamani since I could end up calling him for help if the rupture was a complicated one. And thus, we could save one theatre gown. Per operative it was not a very clean rupture. I was glad that Nandamani was doing the surgery.


I saw CF just before I started today's journey. The journey towards parenthood had been quite traumatic for the family. We had given the option to the relatives to try to have a second child. But, they would have had nothing of it. The first child, a girl was born by cesarian section and it had been very expensive for the family. Now, the second pregnancy has given more trauma. It was so unfortunate that the delightful physiological experience of pregnancy and delivery of a child has been transformed to a nightmare partly due to lack of health education and quite a lot due to apathy from health delivery professionals like me.


The other two cesarian sections on Saturday were uneventful. The first one was for BD, whose mother was being regularly seen by us for her depression http://jeevankuruvilla.blogspot.com/2011/08/depressed.html. BD was post dates. We had tried to induce her but she had not responded even after about almost a day. We did not have much choice. The second one was CD, who had been seen by couple of senior obstetricians in Daltonganj and was advised Cesarian section. The problem with CD was that she could not percieve fetal movements since 2 days. We could hear her fetal heart. I screened her by ultrasound and suspected that the umblical cord was wound over the fetus. In addition, the baby looked quite large. With no qualified obstetrician around, I could not offer the family anything less than a Cesarian section.


I was glad that we did surgery. The baby was 4 kgs and the cord was wound quite tight twice around the baby's body.


The highlights of the week were that both ZB http://jeevankuruvilla.blogspot.com/2011/08/maternal-near-miss-another-one.htmland and UD http://jeevankuruvilla.blogspot.com/2011/08/maternal-near-miss.html have made amazing recoveries. We praise God.


As I came out of the hospital, I could see little Naveen http://jeevankuruvilla.blogspot.com/2011/07/arachnid-horror.html waiting for admission for his second round of skin grafting. Other than obstetrics, Dr Nandamani has been having quite a lot of success with his surgeries and especially with management of burns. I wish I will be able to put it soon in the blog.

MATERNAL NEAR MISS . . . ANOTHER ONE

I never thought that I would be writing so soon about one more 'maternal near miss' so soon. ZB could still end up as a maternal death.

ZB, married off to KA, who works as a dumper truck and forklift operator in a major company in Chennai had returned 2 months back to her husband's house in Palamu district - about 70 kms north to the district headquarters of Daltonganj. She had been doing well till today early morning. Since the pregnancy was uneventful, her in-laws did not think much about doing regular antenatal check-ups. Moreover, they believed that she had a clean chit given during her ante-natal check up at Chennai.

The spate of unfortunate events started at around 4 in the morning today. She threw a fit while she got up to drink some water. Her in-laws did not think that as something serious until she looked to become stupourous. They rushed her to a local non-qualified medical practitioner (called RMP - Registered Medical Practitioner) in the nearby railway town which was about 1 km away. The RMP gave her some intravenous fluids. In between, she had another 4 episodes of seizures. By now, they realised that they needed to take her further. Someone told them that the best treatment for such conditions is got in NJH.

Instead of hiring a vehicle, they bundled the semiconscious ZB into the Dehri-on-Sone to Barwadih passenger train which passes through Daltonganj. This is the first time I have heard of someone do that to an unconscious patient. The journey was about 2 hours long and by then she had convulsed another 2 more times. They reached Daltonganj by around 6 in the evening. They hired a tempo and reached NJH by around 7 pm. On the way from Daltonganj to NJH (35 kms), ZB had one more episode of convulsion.

I had just come back home from hospital after couple of Cesarian sections. Drs Johnson and Kumudh were taking their customary evening walk around the campus when ZB arrived and they were quite near to the labour room. The duty nurse noticed that ZB was convulsing and noticing my colleagues called out to them. By the time I arrived, they already had a line going on and anti-convulsant injections were on its way in.

ZB was in a pathetic state. Her blood pressure was a whopping 180/130 and her urine albumin was 4+. We knew that she would develop complications if the baby was not taken out fast. Meanwhile ZB's mother-in-law informed that she was not yet term. However, on examination, the cervix was very unfavourable. We discussed the situation with the ZB's family and a decision was taken to take out the baby by Cesarian section. Her saturation was just 85% and she had aspirated quite a lot. We could not wait for a normal delivery although we found that her baby was dead. We were encouraged by her platelets, liver and kidney function to go ahead with surgery.

The surgery was uneventful. ZB is presently on the ventilator. She is sedated and has been maintaining saturation quite well. I hope to have a positive update on both ZB as well as UD

http://jeevankuruvilla.blogspot.com/2011/08/maternal-near-miss.html). Sorry to keep you bored with these maternal health events. I have couple of other patients coming up soon... Just that I need some more background information before I put them on...

Dying young . . . .

Over the last week, I came face to face with 3 young adult deaths. In the present world, in spite of all the modern developments in the field of healthcare sciences, the fact remains that people continue to die young. The reason I narrate these 3 instances is because the different causes of death in each of these cases are the leading causes of death in the young adult. And the most important aspect of all the 3 causes is that - all of them could have been prevented.

The first one is that of someone I'll call AM. I came to know of AM's death through the newspaper. AM was the son of one of the well known sweet shop owners in our capital town. The reason I know them is because I used to be a regular customer in this shop for their Dahi Vadas and AM's dad had somehow made a note of my regular visits. It was not difficult for him to guess that I was not a local guy and my Hindi must have given my South Indian identity away. One of the last visits, he made it a point to pick up a conversation with me. The reason was to advise AM about his future. The dad was bent upon making him an engineer. So, the next time I visit, I agreed to talk to AM. AM was summoned the next time I was in the shop. He was also equally interested and we had a good discussion time of chit chat.

Now, the story is how AM died. AM had a liking for bikes. And it was reported in the papers that he was trying to ride his friend's bike in one wheel - the way you see in the stunt ride shows. Well, somewhere he had slipped - and went straight under a heavy truck's back wheel. He died after reaching the hospital. His friend, the owner of the bike, who was pillion riding escaped with not-so-serious head injuries. Both of them were not wearing helmets. AM was just 18.

The second is that of NN - relatives of one of our staff. 22 year old - just on the verge of being called for a job. He had finished his ITI. He had finished his dinner and was just getting out of his parents' newly built house. It was a bit wet because of the occasional rains. He had slipped somewhere and had fallen on to the ground where his head hit against a stone. There was a big wound in the head. He died on the way to hospital.

The third happened last week. SS, 18 year old girl who used to live along with a couple friend of mine in their home. SS was a distant orphaned relative of my friend. This couple friend had helped SS complete her 10th standard examinations and was exploring options on how they could help her find a foothold in life. Somewhere along SS had come to the conclusion that she was a burden to everybody around her. And she decided to end her life by hanging on her own dupata. It has been heartwrenching for my friends - they have ended up in a quandry after trying to help SS out. Had SS even mentioned about her thoughts about this to them, this could have been avoided.

So, the next time you find a young man trying to ride his bike without a helmet - advise him about the advantages of wearing a helmet as well as driving with care. There are dangers lurking in the form of slippery floors, unsafe electrical connections, illegal gas connections and faulty gas stoves, unsafe furniture etc in many of our homes. They could be the death knell for our own loved and dear ones. We need to pro-actively get involved in the emotional lives of our youth. Many of them live in fairy tale palaces made in air - with no amount of reality in them. The modern media has been fuelling such thoughts which do not have any amount of reasoning in them.

Young adult deaths are preventable. The question is about how much we have the time, patience and will power to address the issues which cause such preventable deaths. I know the stories similiar to the above 3 are so familiar to many of us. But 3 deaths happening within one week prompted me to put a note about this.

Maternal Near Miss...

UD a mother of three girls was quite an experienced expecting mother. In addition to the 3 daughters she had, she had delivered 2 boys who had died soon after birth. In addition, her second daughter was born by a cesarian section. And, the rest of the deliveries had been conducted at home. Her eldest daughter, the first born was 15 years old. She had lost both her babies in the last 2 deliveries. So, she was a G6P5L3D2.

UD came on the at around 1:30 am yesterday. She had been having pains since early morning the previous day. As all her previous deliveries, UD had thought that it would go about without much problems. However, since afternoon, she got a feeling that this is not going to be a uneventful delivery.

UD's husband is away in Delhi working in a factory. He is yet to arrive. He has supposedly got into a train from Delhi. UD's brother told me that he should be here by late night or tomorrow morning.

By the time, UD's relatives arranged for a vehicle and took her to the nearest health centre it was 4 in the evening. There was a doctor at the PHC who told them that she looked really anemic that it would not be safe for them to deliver there. They rushed to the nearest town, about 70 kms away. By the time they reached it was around 8 pm. They initially took her to a private hospital. She had some relatives who worked there. They talked with the doctor - who told them that they'd better take her to the District Hospital. However, no doctor examined her.

They arrived at the District Hospital at around 9:00 pm. She was taken in to the emergency. Couple of paramedics (compounder) examined her. They supposedly had a discussion with a doctor who told them to bring her to NJH. Once again, it seemed that the doctor never saw the patient.

On arrival at NJH, Johnson saw the patient first and he suspected a rupture uterus. He called me first. Since Dr Nandamani (surgeon) was around, I suggested that he be called as we are never sure about what all would be involved in a rupture uterus. In addition, I needed to leave for Ranchi at 5 in the morning. Dr Nandamani also came to conclusion that UD had a rupture uterus.

She was posted for surgery. Her hemoglobin was 11 gm% - which could have only been because of a dehydrated patient. Dr Nandamani had the shock of his life when he opened the abdomen. The uterus was open with the baby in the peritoneal cavity. In addition, the bulb of the Foley's catheter (urinary catheter) was also in the peritoneal cavity. He thought that someone had inadvertently put the catheter into the vagina rather than the urethra. However, it was only after some time he realised that the bladder had ruptured and the catheter was sticking out of the rent in the bladder.

The repair took almost 3 hours. By the time, it was all over, it was around 6:30 pm. She needed 2 pints of blood.

One aspect which was very much noted during the narration of the whole line of events by the patient's brother was that there were 2 places where a decision was taken without a clinician examining the patient. I pray that this is not true or that the bystander somehow missed seeing the doctor come and examine the patient. In addition, in spite of the patient having visited 3 healthcare providers, nobody had thought about putting an i.v canula or at least measuring her blood pressure.

It is unthinkable that such a high risk pregnant patient had to travel 100 kilometers visiting 4 healthcare facilities before she got to be properly examined by a doctor and any sort of treatment started.

UD's male family members does agricultural work in their own fields of about 4 hectares. Since the last 2 years because there were no rains, many of the menfolk including UD's husband had migrated to cities like Delhi to earn a living. This year, the rains have just started and they should be involved in agricultural work - but, now, they are all busy caring for UD. UD brother sounded very apprehensive about the coming year as they have not been able to start the agricultural work.

Considering the extent of surgery which was done, they would end up with quite a heafty bill. I was told that UD earns about 5000 IR per month. I'm sure that UD's treatment costs would not be less than Rs. 15,000. Elsewhere, it would have been twice this cost. We don't need much evidence to prove that healthcare costs pulls quite a lot of families into penury.

UD has done well so far. Kindly pray that she will make a fast recovery.

WEEKEND DIARY - 2B

Continuation of action from http://jeevankuruvilla.blogspot.com/2011/08/weekend-diary-2.html

Well, there were quite a lot of things happening in LR. The best part was that MD (with placenta praevia) slipped out of the LR without anybody noticing. She wanted to discuss something with her family. And suddenly she realised that she was bleeding. That was why they called me. There was a puddle of about 500 ml of fresh blood on the floor. We had to act fast. Blood or no blood available for transfusion - I had to do a Cesar to save both MD and her baby. As I was trying to hasten things, two more patients landed up in LR.

The first was MT. In her middle 30s, she was into her 6th pregnancy. Since 4 pm, she was having painless vaginal bleeding and she was almost term. I pushed her to the ultrasound room and there was a area of seperation of the placenta - Abruptio placenta. I was wondering how could this have happened. She also needed to be taken for surgery.

The second was VS. Also in her middle 30s, she was into her 7th preganancy. One look at her was enough to tell anybody that she either had twins or had too much of fluid in her uterus. She went in to the ultrasound room after MT and lo, she had twins. She was also trying to deliver elsewhere and had come when nothing was happening. Poor lady - her family did not even think that there was any worth in doing at least one ante-natal check up. Her family claimed that she has been seen by the local Sahiya. All this after she had multiple risk factors - elderly multigravida, previous history of twins pregnancy and severe swelling of her body. It seems VS was having contractions all through the day - but suddenly it stopped. On per vaginal examination, I found out that she was fully dilated and I prayerfully did a guarded rupture of her membranes. Then I went to the theatre to operate on MD and later MT.

I reached the theatre to find out that we did not have any blood to operate on MD. It was a miracle that the baby was alive. The placenta praevia had started to seperate. When I opened the uterus it was the placenta which came out first. The baby came out later. He was lucky to have made it. The rest of the surgery was uneventful. MT was the next one. On opening the abdomen, she had multiple petechial spots on the uterus - couvelaire uterus. They had not given a correct history. Neverthless, I opened the uterus. The baby was ok. The placenta was hardly attached to the uterus and there were blood clots behind. After we finished, the theatre nurses confronted the relatives about any additional history - they confessed that she had a really good massage of her abdomen in the morning. Massaging the gravid abdomen is a very common practice in our area. It is thought to improve blood circulation of the uterus and help in uneventful labour.

As I was midway between the surgery on MD, one of the ward nurses informed me that one of the patients who had come in with severe malaria had respiratory depression. We'll call him DS. DS was from the nearby village of Bari. DS was sick with fever since the last 5 days. He came in sometime in the afternoon. Almost in a comatose state. On investigation, almost 50% of his RBCs were infested with Plasmodium Falciparum. He looked quite healthy but his hemoglobin was just 7 and his platelets was just 24,000. I knew that he did not have much of a chance in our setting. Ranchi was too far away and he also looked to have developed a intracerebral bleed. I had explained everything to the bystanders. The decision was taken on doing whatever we could.

After admission, he continued to deteriorate. This could have been prevented. The relatives showed me the rapid test kit for malaria which was negative. However, they told me that he was diagnosed to have falciparum malaria by the local quack. I asked what medicine was given by the quack. They showed the medicine. I could not believe my eyes. The quack had given Ciprofloxacin tablets instead of Chloroquine. Poor guy - got the spelling on the blister packet all wrong and now MD did not stand a chance of survival.

Suman, our anesthetist nurse rushed to the ward to take a look at MD. She promptly intubated him and started him on CPCR. But with very poor blood parameters there was nothing much we could expect. We declared MD dead at midnight.

As I got out of theatre, I was called again to the LR. The first baby of VS was delivered without much difficulty. The second one appeared to have got stuck and the nurse was struggling. So, I went in and had to help do a breech extraction of the second fellow. Both the babies were doing fine by God's grace.

As I thought that this is end of the adventures for the day - we had one little girl in the emergency. She was having convulsions. The history was almost similiar to that of DS. The only difference being that her malaria smear was negative. It looked more like a viral hemorrhagic fever. I somehow convinced the relatives to take her to Ranchi - which they ultimately did in the morning.

I was lucky to get a little amount of sleep from 3 am to 5 am - interspersed with calls about medication orders. Early morning, we had a man with a krait bite almost 24 hours back, but with very definite signs of envenomation - he had ptosis and difficulty in swallowing. His respiratory efforts were fine. It was only very recently I had read this article about how silent and inconspicuous these krait bites can be. You can read about it in http://www.facebook.com/media/set/?set=a.208033779216299.52888.100000290346946#!/photo.php?fbid=208033929216284&set=a.208033779216299.52888.100000290346946&type=1&theater. This man had hardly any visible sign of the krait bite.

There were 2 more uneventful normal deliveries... Quite a handful for the start of a weekend. Do remember Dr Shishir as he is on call today...