FLOOR PATIENTS. . . SOS

You may be wondering what this is. For graduates from private medical colleges and both the Christian Medical Colleges, I know what I’m going to talk about is unthinkable.


As I was writing articles for my blog, I got a call from Dr. Nandamani saying that there are quite a lot of patients pouring into the hospital. Since the last 3 days, all the beds in the hospital are full. Yesterday night and today morning, we have had problems with allotments of private ward rooms with patients’ bystanders almost coming to blows.

The situation in the general ward is worse. We are discharging patients quite soon now. So, as we departed for the evening, we’ve decided to make a consent sheet for patients who want to get admitted in spite of the space crunch. We thought that the wordings in the consent would turn away patients. But, I am mistaken.

So, I think for the first time after many years we have patients on the floor in NJH. I’ve heard about patients in the floor before the construction of Acute Care Unit and the new Maternity Block.

As I write this I’m reminded of my MBBS days in Trivandrum when we used to have patients on the floor. We had only about 20 odd beds each in the male and female wards and there used to about 60 admissions in each ward. So, we used to have a system of allotting floor spaces for patients. The sickest used to get the beds and as soon as they were better and if there was a sicker patient coming in the poor fellow would be demoted to the floor.


Sometimes it used to become hilarious. There have been many occasions when a ‘floor patient’ cannot be traced and then we find him/her happily sleeping under someone else’s bed. Then, there was another occasion when a patient's bystander who was taking a nap taken for clinical case session for the medical students. It was only after quite some time in the class that we knew that we had a normal fellow in front of us. Of course, he had a good snack and tea which we customarily used to arrange for patients coming for clinical case classes.


Well, anybody out there who would like to come and help us out – doctors and nurses. We have couple of more EHA units who need extra hands . . . My contact details are on the margins of this blog . . . S.O.S . . .

THE NEW VENTILATOR

As I reached NJH with the new machine, I was like a little boy waiting to open and try out his new toy - so I was waiting for the opportunity to unpack the machine and and use it. There were quite a lot of things to be settled before I could get my hands on the same. However, I was glad that I could spend about ten minutes as soon as I was a bit free. Dinesh had already unpacked the machine and had positioned it on the lower shelf of the Boyle’s machine.


I was glad to have spend some time tinkering with it because I had a patient very soon. SD (http://jeevankuruvilla.blogspot.com/2011/08/tiring-thursday.html) who had eclampsia and a live baby was the first customer for the ventilator. I was quite impressed with the performance expect for the fact that the warning lights did not come on when the patient started to breathe on her own at the end of the surgery. The theatre nurses, Suman and co. were also quite pleased as they were free from the business of manually pumping air into the patient’s lungs. They were quite free to do other things and it was helpful when the baby arrived as we had extra hands for the resuscitation.

The ventilator was brought into action in the surgery on KD too as she was also eclamptic.

Sr. Suman with KD after the surgery

So, from the initial impression, it has been quite a worthwhile purchase for us – saving quite a lot of muscle power and giving us additional hands.


Now, I wait for a time when I can use it in the ward – where the circuit which needs to be used to quite a different one. I shall update you on the same as soon as we use it in the ward.

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.