MISMANAGED BURNS

LD had just finished bringing in light to every corner of the house as is the customary Hindu tradition sometime in the first week of June. The light source she used was a old tin filled with kerosene with a hole in its lid for a wick. Different places know it by different names – in quite large parts of the country it is known as ‘kuppi batti’ and is notorious for causing burn injuries. In fact during one of the conferences I attended on burns, I learnt that there is quite a large movement to abolish use of these ‘kuppi battis’ and it is not only prevalent in the Indian subcontinent but also in other South Asian countries as well as Africa and South America and is a leading cause of burn injuries in all these places.

LD must have been a bit careless. She kept the lamp on the floor and was just about to turn around when she realised that the free end of her sari had accidentally tipped over the lamp and the kerosene had drenched the tip of her sari. Within no time, her sari was on fire. LD does not remember quite well about what happened next. By the time, she came to her senses the only thing she knew was that the area below her waist has been fully burnt. Her husband later narrated that it was only because of the presence of mind of her nephew who cried out 'fire, fire' that she did not get fully burnt - quite a number of people nearby ran to her rescue and put off the fire.

But the damage was done. The family took LD to the district hospital where she was admitted for about 3 weeks. LD's husband noticed that nothing much was being done and she was not at all healing. Instead, the wounds had become a dirty yellowish in colour and was stinking. He knew he had to act fast. On his own will, he brought LD to a private practitioner in Daltonganj. He had a very interesting experience here. A junior person, an old acquintance of the family, presently working along with private practitioner warned him that the private practitioner is in fact not a qualified person and that he is more interested in extracting money from his patients. He advised the family to bring LD to NJH.

NJH has now been with us for almost 2 months. When she came, she was in quite a very sad state - with infected crusts all along the area of her burns - which extended from her waist downwards to include the perineum and the upper two thirds of both legs. As is always the case with mismanaged or neglected burns, the percentage of burns (about 25%) had increased because of the superadded infection. She has had quite a number of surgeries after admission. There have been ups and downs. Her skin grafts have taken up well. She's glad that she has ultimately come to us.

Unfortunately, to many of us at NJH, LD and her family looked well off. The family was initially paying off the bills. Then, we noticed that they were finding it difficult. We also did not insist that they pay. Suddenly, the husband came with quite a hefty amount and paid off quite a large part of her bill. Dr. Nandamani found out how this was done. LD's husband had sold off quite a good part of his agricultural land to rake up some money to at least pay some part of her bills. It was something unfortunate.

We have insisted that they do not pay anything more. However, the outstanding bills amount to something around Rs. 40,000. Similiar to MI (http://jeevankuruvilla.blogspot.com/2011/08/prodigal-son-attempt-to-come-back.html), we are looking at the option of well-wishers and good Samaritans pitching in to cover part of her treatment costs.

 

 

LD looks forward to getting back home to her village in far away Garhwa soon.

PHARMACEUTICALS IN INDIA

This blog is written in the light of the article (

http://www.downtoearth.org.in/content/harmful-combo-drugs-flood-market) published in the magazine 'Down to earth'.

Combination drugs have always been a major issue in the Indian subcontinent. The major reasons for the popularity of combination drugs are quite a lot. I tried jotting down many of my thoughts on this issue which has been a bane to practicing medicine in India.

The foremost reason for the high popularity of combination drugs has been the fact that most of the doctors recieve their practical pharmaceutical education from medical representatives. I very much remember our days during internship when we had no clue on why we wrote a certain brand of iron or calcium tablets or even an antibiotic. Basically, there was a major gap between pharmacology classes in the second year and the medicines which were available in the market.

As I read through the article in 'Down to earth', I remember how one medical representative tried to convince me of the great advantages of a combination drug of diclofenac and ranitidine. Another drug - 'Dexorange' is an absolute favourite with many doctors and patients. I know couple of families who are regular customers of this tonic. Even well meaning doctors write this syrup very regularly for their patients. Very few of them realise that it's the alcohol within the syrup which makes them feel good.

The most flagrant misuse of all such combinations is most in the management of diarrhoea. I recently found out that there are companies who have started coming out with lactobacillus in ORS (oral rehydration solution) preparations. When we know that the most common cause of diarrhoea is viral - it is very unfortunate to find pharmaceutical companies trying push down all sorts of combination down the patient's throat - Ciprofloxacin+Tinidazole, Metrogyl+Norfloxacin, Ofloxacin+Ornidazole... The list is inexhaustive.

Another reason for this situation is the aggressive marketting of drugs in the Indian subcontinent and the huge profits which are at stake. The image of the generic drugs which were supposed to bring down pharmaceutical costs to quite a large extent has been badly tarnished. Generic drugs were potrayed as something sub-standard. I was shocked when my previous store keeper told me about 'unethical drugs' being kept in my store. I could not believe my ears when I realised that medical representatives had taught him that generic drugs are actually unethical drugs.

Since I started my second stinct in NJH, on many occasions I've realised that sometimes it is actually difficult to get a cheaper basic variety of a drug than a costlier 2nd or 3rd choice drug for a particular condition. A typical example was the availability of Hydrochlorothiazide (HCT). I had so much difficulty convincing my suppliers that this drug was the first choice for the management of hypertension. Couple of suppliers went to the extent of making fun at me. They told me that Losartan and Amlodipine AT are the latest medicines. A strip of 10 tablets of HCT 25 mg cost 4 rupees whereas Losartan cost 50-60 rupees. One can imagine the margin you can get from the latter. And we talk about cost effective management of non-communicable diseases.

To find out more about this is to request any doctor friend of yours to rummage through the drugs they recieve as samples. You may be surprised to find that there would be very few sample medicines which are commonly used and which are cheap. Most of them would be quite expensive medicines and there would not be enough to cover a complete course - especially when it comes to antibiotics. The game is simple - you give some of them free. Then you have buy the rest. I recently heard that this was the same ploy that the English used to popularise drinking of tea in the Indian subcontinent.

The story goes that when the English established tea estates, they found out that there was quite a lot of wastage as they only used the high quality tea dust. They somehow realised that that the low quality tea dust which was thrown out was also tasty. So, they organised free tea stalls for the local population. And as soon as drinking of tea became quite a popular past-time among the locals, the low quality tea dust was available at the cost - thereby ensuring that there was a revenue. (No idea on how true the story is. I heard it on a recent visit to Bangladesh)

Drug resistance especially with antibiotics is a major issue. Nowadays, it is very uncommon to see anyone prescribing antibiotics like septran or amoxycillin. Augmentin, Levofloxacin etc rules the roost and that too for a one day fever. A very simple medicine for urinary tract infection is Furulic Acid or Nitrofurantoin. Very few medical practitioners knows that this is the best antibiotic for community acquired urinary tract infection. In addition, there are only few companies who produce the tablet form which comes very cheap. And it is not very easy to get.

Whatever said and written, the bottomline is that the pharmaceutical industry has made a mockery of medical science in the country. I hope that the latest initiative from the planning commission will bring in some amount of control in the manufacture and sale of drugs whereby ethical preparations are available at a cost which the poorest of the poor can afford.

PRODIGAL SON . . . AN ATTEMPT TO COME BACK . . .

MI belonged to a lower middle class family in our nearby village of Satbarwa which was our local market. MI used to work in Mumbai. He was unmarried. And he had returned home about a month back.

MI was brought to NJH is this state on the 10^th of July, 2011. The story was that he was making tea when the stove burst and he suffered burns on his upper part of the body. It was very obvious from the burns that the story was not really true – but MI and his relatives held on to their story. MI was in danger of having suffered inhalational injury. We gave a very guarded prognosis and offered to help him get shifted to Ranchi for expert treatment – which the relatives were not very keen.

In addition, there was a possibility of severe edema resulting in closure of the oral cavity and the airways at a later stage. There was very high risk of infection. However, MI and his family members consisting of his parents and 3 doting sisters – were very determined to help MI recover.

The recovery has been very painful and long. It was very helpful that the family, especially his 3 sisters have helped him to cling on to his life so far. With a burns percentage of 50%, it is amazing that he has made quite lot of ground.

However, over the 6 weeks that he had been with us in hospital, Dr Nandamani and the nursing staff has made quite an impact on the young man that the real story of his burns has come out. MI had a quite violent past. He had been an alleged drug addict for some time. Few weeks back MI’s mother had presented him with a cell phone which was worth about 5000 rupees. For the family, in the rural Indian male centric world, MI was the epitome of all their aspirations and dreams.

Unfortunately, MI was quite spoilt – indulging in all sorts of vices and in addition, allegedly falling prey to alcohol and drugs. MI sold the 5000 rupee mobile which his mother had gifted him for a paltry sum of Rs 500 to fuel his drug habit. His mother came to know about it in no time. There was a huge argument in the house following which MI poured kerosene over his head and set himself on fire. That explained for the deep burns on the back of his body.

MI has since repented and he wants to get back to his normal life. He has been going through a very painful experience which has broken him down. In addition to the pain, the treatment has been quite expensive. The family must have spent about 50,000 rupees so far in his treatment. They still have outstanding bills of about Rs 40,000. He already had two sittings of skin graftings.

MI is quite miserable about the life which he has wasted so far. I’ve assured him of putting out his story to people who could remember him in prayers as well as help him pay at least a part of his outstanding bills.

[This story was put in the blog after taking consent from MI and his family including putting photographs. There are quite a number of patients who come to us with burns for whom we have to write off quite large amounts, which puts quite a lot of financial strain on the unit. Other stories are that of VM (http://jeevankuruvilla.blogspot.com/2011/07/pediatric-burns.html) as well as that of PD (http://jeevankuruvilla.blogspot.com/2011/07/neglected-burns.html ). We plan to start a fund to help our burns patients with regular treatment and if needed additional support to restart and rebuild their lives.]

MALARIA – Or is it something else?

35 year old IS works somewhere in the Jharkhand-Uttar Pradesh border as a daily wage labourer. 4 days back, he had high grade fever with chills and rigor. He was treated for malaria by the local quack. As the fever was persisting, he thought of going back home along with one of his fellow villagers who worked along with him.

IS was brought in an almost unconscious state to our casualty sometime today afternoon. The look on his face was enough to tell us that he was gravely ill. The whole of his face was flushed, the sclera of his eyes very chrome yellow and the conjunctiva was all congested. The breathing was labored and chest examination revealed that there was quite a lot of fluid in the lungs. His liver was tender. It looked more like Weils’ disease than malaria to me.

The investigations were terrifying – the serum bilirubin came an astounding 51 mg%, the total count was in the range of 50,000, the platelets 15,000 and a serum creatinine of 4 mg%. Medically speaking, he cannot survive with the sort of facilities we have. The saving grace was that his hemoglobin is 8.9 gm%. And of course, his blood cells was teeming with falciparum malaria.

After reaching his village in Leslieganj yesterday, IS continued to have fever and he became unconscious sometime around midnight. IS’s family is very poor. The reason for IS working so far away from home was to earn a living for his family - 3 little children and a young wife. IS was brought to NJH by fellow villagers and his elder brother.

The elder brother and his villagers were aghast after we pronounced our prognosis and gave them an option of taking the patient elsewhere. As I write this, IS has pulled through so far. I’ve asked the people who brought him to arrange for blood.

In addition, I’ve started him on anti-malarials and treatment for leptospirosis. Many a time, we’ve seen that presence of malarial parasite in the blood tends to be a red herring.

After the persistant rains over the last 2 weeks, it has now become very humid – quite a good environment for the mosquitoes to breed.

We are having quite a lot of malaria than last year. After the last year, when we had lesser cases – most probably due to the drought, I have a feeling that people had started to take possibility of contracting malaria quite lightly. To compound this problem is the practice of single dose treatment by many quacks – it is not uncommon to see people who come with persistent fever after having taken a single injection of artesunate or quinine.

From my experience of 2003-04, one more condition which becomes quite common during high incidence of malaria is the occurrence of injection abscesses. Giving quinine as deep intramuscular injections is something practiced by quacks and many of them ultimately end up as big abscesses. This year, I’ve seen one where the abscess had already organized, solidified and probably fibrosed– sparing the poor sufferer of an incision and drainage surgery.

Today evening, I’ve seen one more patient, a pregnant lady who has come in with fever. Blood examination shows falciparum.

Deaths which could be directly attributed to malaria are quite less nowadays. This is mainly because many of the fever cases come after some form of partial malaria treatment. As far as I remember, almost all the patients who tested positive by smear for malaria have recovered completely.

There has been one death over the last 2 weeks – a 16 year old girl with fever. She had been treated as malaria elsewhere. She had hemoglobin of 3 gm% and was unconscious since the day she came in. She never tested positive for malaria. Most of my colleagues strongly felt thatit was malaria.

Now, this is where we need to do some sort of research on. Are we only dealing with malaria alone or are there other infectious diseases which are very similar to malaria – dengue, leptospirosis, rickettsia etc. I wish we could have help whereby we could explore more on this . . .

DIABETES – making communities poor . . .

I remember the cold Wednesday morning in the OPD at NJH sometime in Winter 2004. There was a old man in his middle 60s sitting in front of me. He had come to NJH for his foot which was decaying. His problem was very obvious and not at all uncommon to me who came from the south of India. He had diabetes and had an ulcer in his right foot which was refusing to heal. But for NJH it was something rare. Diabetes was believed to be uncommon in this part of the country. That was the first and the only patient with diabetes whom I saw at NJH during my stinct in 2003-04.  

Fast forward to today (21^st August, 2011), the last patient I saw in emergency - someone I shall call SDP. SDP has been hypertensive for quite a long time. He claimed that he is not a diabetic. His relatives even showed me a blood test which showed GRBS as 141 mg%!!! SDP has come in very sick. He has been having a angry looking swelling of the right foot and obviously he had infection - he was febrile and breathing heavily and fast. His GRBS was above 200 mg%. Obviously he must have had high sugars and somehow it was not picked up. 

In the wards, we have 3 patients who have diabetes. On an average, in the out-patient department we have about 3 new diabetic patients every week and more than a dozen of them coming for them coming for their repeat medications every week.

However, what I need to tell you about a very peculiar history that many of them give. Quite a lot of them have been diabetics for 10 years or more. So, where were they when I was at NJH in 2003-04? I've not done a detailed study on this - but have been asking quite a lot of the present patients about the same. The answers have been shocking. It seems that quite a lot of them had been frequenting hospitals at Ranchi (135 kms away) and Kolkota (12 hours by train) just for the treatment of diabetes. When I ask them about the reason they did not come to NJH - the answer was that they thought that mission hospitals are mainly for surgical management and there was no 'diabetes specialist'.

It was very unfortunate. The minimum amount of drugs which many of the 'diabetic consultants' wrote for these patients were about five and the expenses involved has been quite huge.  Many of the patients had also been misled by traditional and alternative healers for radical cures of the disease - and they had also spent quite huge amounts on them.

Quite a large number of our present diabetic patients who had been on treatment for long durations – and the treatment have literally made them paupers. And that was the reason that they started coming to us.

So, how are we going to respond? We have already planned to start a chronic diseases clinic of which diabetic management would be one of the major components. I wish we can send one of our doctors and few of our nurses for training for diabetes management. To decrease the load in our laboratory and to streamline management we are going to get a Nycocard machine for HbA1C and urine microalbumin.

As I finish writing this, Angel informs me that one of the new admissions in the ward who is a diabetic has ketoacidosis. It is ages since I’ve managed one. I fondly remember my MBBS days at Trivandrum as an intern in Medicine 2 where we honed the art of managing diabetic ketoacidosis.

Unfortunately, the major question remains on how much is rural India ready to take on the demon of diabetes and hypertension. With the requirement of regular treatment – which is a concept quite alien to the Indian psyche – there has to be major shift in the attitude of communities towards chronic diseases. We are still grappling with infectious diseases and inadequate reproductive health care. The additional burden of non-communicable diseases could quite increase the morbidity within communities, the consequences of which we may be facing sooner or later.

The concern is that, many of us, especially in the rural agrarian societies of the country do not know very clearly on what the consequences could be.