TIRING THURSDAY . . .

We had a comfortable journey back from Delhi. The Garib Rath reached Daltonganj on time. After the rush in Delhi, it was a bit unthinkable for me to take first call on Thursday. For most of you who may not know about the weekly schedule in NJH, Thursday happens to be a half day. The major reason for this is to allow staff to do their weekly shopping and banking. Being far away from the town, this was very much needed in the olden days. However, most of the patients do not remember about this and still keeps on coming even in the afternoon. So, anybody on duty on Thursdays ends up seeing quite a lot of OPD patients in the emergency.


My day started quite interestingly. First of all there was DD, a G3P2L2 with a big baby in breech position. She had normal deliveries both times earlier at home and the second delivery was a breech delivery. However, the local dai who had taken her delivery both the initial times was not very confident about this one delivering normally. Even, we thought the same. But, by the time she reached NJH, she was already about 8 cms dilated and with good contractions. We posted her for a cesarian section but in theatre we realized that baby was quite on its way before we started. I was quite surprised that we could do a breech extraction without much difficulty. The poor family was quite overjoyed that a Cesarian was avoided.


After that we had SD. SD was having an uneventful pregnancy till yesterday midnight. At around 11 pm she threw a fit followed by a number of them. The family lived quite remote and by the time they got some sort of conveyance it was dawn. The reached a hospital in Garhwa by around 6 am from where they were referred to Daltonganj. The private hospital in Daltonganj again referred her to us after giving few injections which included Diazepam and she reached us around 10 am. She was unconscious, but the baby was alive. We had to deliver the baby fast. Unfortunately, the baby came out quite sick – was not breathing and had to be ventilated for almost two hours. Probably the diazepam and the Magnesium Sulphate had done the damage. The baby was improving but over the night, he became quite sick and is again on mechanical ventilation. SD has improved but she is still groggy and it would take some time before we can confidently say of her complete recovery.


Immediately afterwards, we had CD who was a previous cesarian and also had a cholecystectomy before. I’ve known surgeons who would be very hesitant to open the abdomen a third time. But, we did not have much of a choice. CD had scar tenderness. We had her opened up in no time and she was lucky. The scar was giving way and we were just on time. CD and family were quite happy to get a boy baby – her first one was a girl. The issue of not having a male heir in the family supposedly creates a major crisis in Indian families. I should have mentioned that for the earlier patient, SD has 3 girl children.


After the 2 surgeries, I was lucky to get some sleep after lunch. My next call was a bomb. RD, 22 years with a twin pregnancy and 36 weeks gestation, with at least one ante-natal check up every 2 weeks had landed up with history of multiple episodes of seizures since 2 in the afternoon. She was also straightaway referred to NJH. This family was very rich and could afford the best treatment in the country. But they were at least 4 hours away from the next tertiary centre. And, she was unconscious with phlegm clogging all over her lungs. The Blood Pressure was an astounding 230/150 mm Hg and Urine Albumin was 4+. She had also received some injections which included Inj. Diazepam. I was worried about the babies.


Meanwhile the family was juggling the option of taking her onto Ranchi. I told them about the pros and cons. Ultimately, the agreed for a emergency cesarian section with all full risks explained.


The Cesarian section was uneventful. As expected, both the babies were heavily sedated. We had to ventilate them quite a bit before they started breathing on their own. Unlike SD’s babies, KD’s babies have improved quite a lot and are doing well. Even, KD is doing far much better. KD’s story is a clear demonstration of how much the family needs to be educated on the danger signs of pregnancy. Later, I found out that KD had her last ante-natal check up 2 weeks back and there were no problems. However, after about a week, she had started to swell up which the family did not take seriously.

As I finished suturing up KD, I got a call that there was a polytrauma. More about that in the next post. . .

DILLI DIARY

I had a quite busy time in Delhi. We got our ventilator - quite a compact instrument. Cost us 150,000 Indian Rupees. This has been helped through funds which had been facilitated through Dr Colin Binks, our former surgeon through a block contribution from churches in England - The St Francis’ Church, Westborough, Guildford, UK; The St Clare’s Church, Park Barn, Guildford, UK; Castle Square United Reformed Church, Treforest, UK and the St Mary’s Church, Ash Vale, UK. We are grateful for the kindness from the parishioners of all the four churches as well as to Dr. Binks who helped in raising awareness about our needs.

As we contemplated on what else to do in Delhi - there were quite a lot of hospital needs which came up. Having Dinesh along was a blessing. We scouted around for bedsheets first. With the increasing number of patients in the wards, we were running short of bedsheets. We were glad to find shops inside Delhi Cloth Market near the old Delhi station. Dinesh was surprised to find that the sheets we ultimately decided to buy came from his homestate of Tamil Nadu. We got about 160 metres of good cloth for about 8500 rupees. This would give us about 65 bed-sheets. From our previous experience in Ranchi and Kolkota, it was quite a profitable venture.

Then, we went to search for some surgical instruments that Dr. Nandamani wanted. Dr. Nandamani like all surgeons has developed special interest in some makes of the instruments. We use quite a lot of skin grafting blades. And Dr Nandu has taken particular liking for a Chinese make which we find quite difficult to get. We were glad to have got hold of 13 blades which

should last about 2 months. Then there was something called a 'mesher' which we could not get hold of. Nobody had any idea where to find this instrument - it's basically used to make a mesh of skin so that more surface area can be covered during skin grafting.

The grant from the churches in UK had also allowed us to purchase a Nycocard Reader II which would help us to estimate HbA1C, Urine microalbumin, CRP and D-Dimer. You may be wondering why a rural hospital like ours would need these tests. It was taken after quite a lot of discussions. Our diabetic crowd is on the rise and doing FBS/PPBS has become quite cumbersome and very difficult especially when patients find it difficult to reach the hosptial early in the morning. With the increasing number of deliveries and lots of babies born with high risk of sepsis, CRP would be of much use. HbA1C costs Rs. 1300 to be done in Daltonganj and CRP Rs. 600. So, we are going to give a tough competition to the rest of the crowd.

So, we had been scouting for this machine for quite a long time. The price which was quoted by our local supplier was quite high. It was by accident that we got into one of the shops to look at some Neubaur counting chamber cover slips which Angel wanted. They had quite a lot of laboratory materials. And it turned out that they were the major dealers for the Nycocard reader. The propreitor promised us a live demonstration the next day.

It was in the laboratory supply shop we heard on television about the drama which was unfolding in Central Delhi over Anna Hazare's arrest. The shop owner advised us to make a run to wherever we were put up. Our appointment with the ventilator supplier was at around 5 in the evening. As we rushed by Metro to Lajpat Nagar and then by auto to Ashram, my thoughts were on the struggle which Mr. Hazare was leading against corruption. I have written about my experiences with corruption -

http://jeevankuruvilla.blogspot.com/2011/08/experiences-with-corruption.html - which makes me quite dissillusioned about the possibility of eradicating corruption in India.

We reached their office by around 5 pm. Mr.

Rajput and his colleagues were kind enough to give a full demonstration of the machine. They also warned us to head back home as soon as possible. The machine was quite well packed and we lugged it to my uncle's place at Sai-udullah Jaib. As always, it was quite a time of unwinding for me and Dinesh at Josh uncle's place.

Early morning, we were at EHA central office. We were blessed to be part of the morning devotions. Dr Santosh shared about the feeding of the five thousand with five loaves and two fish. More on that in another blog. It was quite reassuring that we are remembered by so many people in their daily prayers. After some time of discussions in EHA office - Dinesh and me were off to the railway station. We were still not very sure about the aftermaths of Anna Hazare's detention. We did not want to take any chances.

Dinesh went straight to the New Delhi station along with the luggage and I went to see the Nycocard machine. Unfortunately, the technicians had brought a machine which was damaged. They had not noticed it. They apologised profusely and requested me about an hours time to come back with a new machine. I had about an hour to kill. I rushed back to Nehru Place and brought a 500 GB hard-disk and few books for Shalom and Charis. I was back at the lab shop by around 3 pm. They took about 30 minutes for the demonstration. I was glad to find that my HbA1C was around 5.

They finished by about 3:40 pm and I had 30 minutes to rush from Bhagirath Palace to New Delhi railway station to catch the Garib Rath. There were queues at the Chandni Chowk metro as well as in the New Delhi Railway station. As I entered the train, the train started moving.

Just wanted to acknowledge the Lord's grace in guiding us to the right places at the right time and getting quite a lot more things done than what was planned.

EXPERIENCES WITH CORRUPTION

Indians all over the world have been gripped with the happenings in Delhi over the last couple of weeks - where Anna Hazare has been leading a crusade against corruption through pressing for a LokPal Bill which he and his team has drafted.

There has been quite a debate on how the war against corruption has to be waged in the country. Many of us has been quite overwhelmed by the sort of crowds that Mr. Hazare and his team has been able to muster.

However, we need to realise that corruption is very much entrenched in our present culture. Since I came to know about Mr. Hazare's campaign and the fiascos which have been unearthened regarding the 2G spectrum allotment, the commonwealth games etc. I was reminiscing about my trysts with corruption.

Since I've been travelling quite a lot over the last few months, the first thought that comes to me is the Indian Railways. Even as I sit in the New Delhi-Ranchi Garib Rath, I've seen the Ticket Examiner discretely calling passengers with Reserved Against Cancellation (RAC) tickets to the vestibular area between the coaches and offering them confirmed berths at an unaccounted extra cost. It is quite common to see this happening whenever the train is fully booked. And it becomes quite rampant during festival season when almost the whole country is travelling.

If you go to the metro cities it is very common to find people coming and ask you if you need confirmed train tickets. It does not need much imagination to conclude about a possible unholy nexus between the reservation agents and the railway authorities.

The most unfortunate part is that many people do not see this as corruption. I've had people giving me all sorts of explanation for this sort of thing. Few people told me that it is part of human behaviour and few told me that many poor earn their livings such. However, I'm very definite that this is corruption and steps need to be taken to discourage such practices in the railways.

The second instance which comes to my mind is an account of my friend who was trying to get his land registered in his name after his father had passed away. There was a clear will which was written whereby the land was bequethed to him. To formalise the procedure, he had taken the help of a lawyer. My friend told me that the first thing the lawyer told him was that he should be ready to pay a certain amount to the tehsildar and the land records office so that everything will be done smoothly. My friend was shocked - here was a man who is supposed to a custodian of the law telling him outrightly to encourage corruption.

The third instance is that of my friend about whom I had narrated in my blog http://jeevankuruvilla.blogspot.com/2011/08/dying-young.html. Someone in his family had committed suicide. The police told him very clearly that things could be unpredictable unless he is ready to cough up some money. The 'some money' was 20,000 Indian Rupees. If the money was not given, they could not assure him that the case will be closed without any problem. My friend who was already in quite a lot of stress ultimately ended paying up. Later, we tried finding out what problems could have occured. It seems that anyone can be framed for instigating suicide and if the police wanted it, they could really prolong the case and harass the family members. One of the policemen also stated that the usual charges was 50,000 Indian Rupees and because they knew my friend, the 'costs' were discounted. It was quite frightening.

I know that quite a lot of us would be able to narrate such incidences. In many instances similiar to the third story I just wrote, it becomes quite difficult. However, we need to realise that the crowds we see on television is just a miniscule of our population. The fact remains that majority of our population approve of corruption and using money-power to acquire our needs and wants have become the order of the day. I know of companies and organisations who have budgeted for corruption. The other day I came to know of an organisation who was budgeting 'speed money' as 'extortion money'.

Before I close this post, I should tell you about one of our former nurses who had applied to rejoin. We were quite surprised that she wanted to rejoin, as all of us knew that she had paid quite a large amount of money (about 200,000 Indian Rupees) to get a government job which pays her about three times of what she earns with us. I happened to talk to some of her acquaintances and I enquired about the reason why she is coming back. The explanation baffled me - it seems that nurses in government recieved their salaries once in 4-6 months and the amount being quite large - they had to pay part of it at various levels in the treasury office (place from where the salaries are made and given). So, this lady had calculated that working in a mission hospital like ours is better - although she will get a lesser salary, she will get it regularly without any hassles.

I sincerely pray that the efforts being taken by Anna will make each Indian think and take a decision to stand against corruption at all levels. The war against corruption needs to reach the grassroot levels.

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...