THE COSTLY DELAY – 2

This is a continuation of the post THE COSTLY DELAY – 1 (http://jeevankuruvilla.blogspot.com/2011/09/costly-delay-1.html) Unfortunately, the protagonist of the this post was not as lucky as LR.

RD was in labor pains since the last evening.  It was her first baby. She was just about 8 kms away from our hospital – she had never been to an antenatal check up.

Dr Nandamani saw RD as soon as she came into our labour room the following day morning. RD was in terrible pain. On cursory examination, it was evident that there were enough complications in store. Obviously pale, RD was in obstructed labour.

Per vaginally, the baby was stuck at the outlet – the baby wedged so tight that Nandamani knew that a Cesarian Section also could be traumatic. The Fetal Heart Rate was about 100 per minute and was going down. There was thick gravy like meconium coming out from the vaginal opening during each contraction. The baby’s head which had formed quite a big caput had become a pulpy mass by now.

There was no other way. We had to take out the baby by forceps. Once we decided, Dr Nandamani was in action. The baby came out with only the heartbeat. Leaving the mother with the attending nurse – the baby was promptly intubated. He had aspirated too much of the meconium. I came in at this point. On laryngoscopy, there was too much of meconium coming out from the airways. I knew that we did not have much of chance. After sucking out quite a lot of the muck, we intubated him and started mechanical bagging.

The initial response was good – but it was only a matter of time before pneumonitis and respiratory distress syndrome could set in. He was not at all responding. There was hardly any respiratory effort although the heartbeat was going strong. We decided to continue bagging. That was when I thought about trying out our new ventilator (http://jeevankuruvilla.blogspot.com/2011/08/new-ventilator.html) on the baby – however, it could not perform well.

The hospital was quite busy and we had manually ventilated the child for quite long. And we had to attend to other patients. We had to find out a way out – I wish we had a neonatal ventilator. We decided to teach the relatives to bag the baby. There have been quite a number of occasions before when we asked relatives to mechanically ventilate a patient. The most vivid one I could recollect was a young man with cobra bite whom we ventilated manually for about 6 days – before he made a recovery – we had run out of Anti-snake Venom.

But, RD’s child was more challenging. There was much meconium clogging the lung tissue and considering that there was evidence of fetal distress for quite long – I knew that we had very little chance. There was nothing more we could offer. After a 15 minute session of educating 3 members of the family to mechanically ventilate the baby – we set off for the rest of the day’s work. The nurses were keeping a tab on the baby.

At around one in the afternoon, the nurse called me and informed the baby had started to desaturate. I took some time to reach the nursery. When I reached the nursery I had the shock of my life. The relative who was supposed to bag was sitting on the floor. I rushed in started bagging the baby. The saturation was 55%. On questioning the bystander, he told me that he thought of taking a break as he was quite tired. He also gave a excuse that since the oxygen chamber was bubbling, anyway oxygen was going to the baby – and so he concluded that nothing will go wrong. I did not know what to tell him.

Any more of intervention was of no use. The pupils were already dilated. It was only a matter of time. The baby was declared dead at around 3:00 in the afternoon.

The delay to come to hospital has cost KD her baby. One can only wish that patients like KD and LR teach their neighbours on how valuable time is when it comes to taking the right treatment at the right time and the right place. There is more in store for KD - her Hb was only 7 before the delivery. We have already asked for blood. But, the relatives are hardly bothered. Today, I saw KD - she looks quite puffed up. Considering that she had quite a long time of labour, and should have lost some amount of blood during the delivery and a very big episiotomy wound, having couple of pints of blood is essential for her to return to routine work.

However, she is luckier than SD who died following delivery today morning. But more of that in the next post.

THE COSTLY DELAY - 1

You may have read this statement somewhere –

‘If you want to know the value of one year, just ask a student who failed a course.

If you want to know the value of one month, ask a mother who gave birth to a premature baby.

If you want to know the value of one hour, ask the lovers waiting to meet.

If you want to know the value of one minute, ask the person who just missed the bus.

If you want to know the value of one second, ask the person who just escaped death in a car accident.

And if you want to know the value of one-hundredth of a second, ask the athlete who won a silver medal in the Olympics.'

Couple of days back, I had two patients who would have done better if they had not delayed coming to us on time. I shall narrate the story of the first patient in this post and in a later post, the story of the second one.

LR is a 55 year old man from a nearby village, Rankikala. Since the last 1 month LR has been sick with vague symptoms. It started off with fever on and off in the evening. He went to the local practitioner (RMP) in our market village, Satbarwa who prescribed him some tablets. He improved for couple of days, after which the fever had come back. In addition, he developed something new – he had episodes of seizures of his right leg alone.

Satbarwa is famous for a Vaid (traditional healer) who is specialized in neurological ailments. I’m told that he uses the extract of garlic to make a concoction which is given as an intramuscular injection. I’ve had quite a lot of patients who vouch for this remedy in the treatment of neurological ailments. However, I’ve noticed that the recovery mainly occurs in patients who had ischemic strokes – which would have healed otherwise too. Since LR felt that having seizures is something related to the nerves, he straightaway went to the vaid at Satbarwa.

Unfortunately, nothing much happened. He still had a fever and cough was worsening. However, he felt that those symptoms are secondary and he needed to get treatment for his seizures. The seizures continued to occur. The Vaid decided that this needed further evaluation and send him to one of the physicians in Daltonganj. The doctor of Daltonganj also treated him for about 2 weeks – before LR decided that there was not much improvement.

LR came to NJH OPD couple of days back – He was frail and it was obvious that he had lost quite a lot weight recently. His pulse was feeble and Blood Pressure was just 80/50. His chart came to my table – as he entered my room, the diagnosis was obvious - Lung abscess. The stink from his breath was unbearable. It was difficult to fathom how one could miss the stink. And from his blood pressure and history of seizures  - possibilities narrowed down to either a disseminated malignancy or disseminated tuberculosis. Sputum AFB turned out positive for tuberculosis. I did an X-Ray which is put up here.

LR's Chest X-Ray

LR had spent almost 10,000 rupees by the time he came to us. He would have done better with a CT Scan Brain. But, he just did not have the money to make a trip to Ranchi leave alone the CT Scan. In addition to the Anti-Tuberculosis treatment, we have also started him on Steroids and Anti-seizure medications.

LR waits with his son for his anti-tuberculosis medicines

I’m confident that he will do well. However, things would have been easier had he turned to us early – which brings us to question on why people avoid coming to people like me in the first place. Money is obviously the major issue is institutions such as ours. However, he would not have had to spent this much if he had come to us straightaway. But, I did not understand why this does not happen, until I heard about ‘agents’ about whom I shall post soon.

My only prayer is that the delay would not turn out to too costly for LR whereby he may lose his life – unlike RD about whom I shall write in my next post (http://jeevankuruvilla.blogspot.com/2011/09/costly-delay-2.html).

BETLA DIARY DAY 2 AND THE QUACK. . .

Combined continuation of Betla Diary 1 (

http://jeevankuruvilla.blogspot.com/2011/08/betla-diary-day-1.html

) and QUACKS / RMPs (Registered Medical Practitioners) (

http://jeevankuruvilla.blogspot.com/2011/08/quacks-rmps-registered-medical.html

)

After a quite night at the 'Tree House' we were up early for the elephant ride. Unfortunately, the gentle beast, named 'Anarkali' was not at all in a good mood. To make matters worse, my son Shalom decided not to mount the elephant. Therefore, it was me, Angel and Charis who made the trip. The ride was quite a bumpy one and we did not see much of wildlife - only the tracks of elephants and bison. We had a fleeting glimpse of a pheasant and a large eagle.

Having finished our time at Betla, we had decided to drop in at the quack's joints on the way back. I had promised to give a detailed description of the visit.

To start with, the quack whom we shall call RNP, is in his late 20s. He had come to me about 3 weeks back requesting me to help him out if there are any complications in his clinic. I told him that what he was doing was quite dangerous. It was a bit difficult to believe him - but he claimed that he was doing hydrocelectomies, herniorrhaphies and appendicectomies under ketamine. It seems he had worked along with one of his relatives who was a surgeon in Ranchi and had picked up quite a lot of skills. He had got hold of a degree called BIMS - supposed to be Bachelor of Indian Medical Science.

I reached his clinic at around 12:00 pm today. There were two more people in his clinic whom he introduced as his compounders. On his table was a stethoscope, a quite old edition of Hutchinson and a microscope. He had prescription pads with his name printed on them with the degree BIMS in the end. I had wanted to get photographs of the place, but later decided against it as I felt that he could get suspicious about my intentions.

More important than the clinic was it's location. Situated between the towns of Daltonganj and Barwadih - the place was very strategically located. There were hardly regular vehicle services to the region. Even if someone got sick, the nearest place where there is a good hospital is Daltonganj which is Rs. 700 away by jeep. NJH is also Rs. 700 away from this place. Maybe that is the amount RNP would charge for a day's treatment of malaria with intravenous medicines.

After about half a minute in the clinic, he wanted me to visit his ward and operation theatre. And I got the shock of my life - the ward comprised of a room which must be about 20X15 feet with dirty floors and the operation theatre comprised of a plyboard walled off space of about 6X8 feet. Funnily, he did not show me what was inside of the walled off space.

There were three patients in the 'ward'. The first patient he introduced as a patient with fever whom he was giving intravenous quinine. The second was a lady on whom he had done an appendicectomy 3 days back and the third was a young man on whom he had done a surgery for hydrocele 4 days back. There must have been a total of about 10 people in the 'ward' - bystanders of the 3 patients.

On my way out from the ward, I asked him how much he charges. He charges according to the capacity. For the appendicectomy he had charged Rs. 3000 and for the hydrocelectomy Rs 2000. For the poor people in this remote area of Latehar, he was a life saver. He may have been a life taker too. However, isn't that true with us too - qualified medical professionals?

One of my acquintances who has known RNP for the last one year told me that there have been complications - but he is such a remote area the locals think that he does quite a big service to them that they do not make much of an issue with cases that go awry. I've seen the same happen with many other quacks too - where the patient readily accept any complication that happens, with the excuse that he is a quack rather than a qualified doctor.

I'm happy to made acquintances with a 'reputed quack'. He will be definitely keeping in touch with me for tiding over his complicated cases. I'm sure that I would be able to convince him to learn about the public health aspect of conditions which we find in such rural areas. Whatever said and done, people like RNP would find more favour in the eyes of the common poor man in remote areas of the country than fully qualified clinicians like me who is too busy, too far away and too much complex sounding for the rural poor.

QUACKS / RMPs (Registered Medical Practitioners)

The first point of contact for healthcare for almost 60% of the Indian population is not a qualified doctor, but someone who has some sort of experience in treatment of diseases. For qualified medical practitioners, it is quite unthinkable to even contemplate about unqualified people practicing medicines. I used to think that quacks are a problem in only in the rural areas of the country, till I had a conversation with my dad – that was when he told me that when he was posted in Tinsukia, a town in North East Assam, there were hardly any qualified doctors. When any of us fell sick, it was to a quack we went for treatment. Of course, the quacks were more polished than the ones I see now in the villages around NJH.

I remember quite well the chamber to which we used to go when I or my brother used to fall sick. My father later told me that the ‘doctor’ whom we used to consult was in fact an apprentice to a former army doctor. Of course, we used to get better after the treatment from the quack. With the present state of medical care in the country, they have become a sort of ‘necessary evil’.

There have been enough efforts taken at various levels to involve quacks in the evidence based management of cases. The Revised National Tuberculosis Control Programme, the Acute Flaccid Paralysis Programme etc. are few national level programmes who have tried to involve them. We had tried to involve them in helping them find out danger signs whereby they would be able to refer patients to hospitals at the earliest. Unfortunately, the response from them have been quite disappointing.

However, the saddest story in the medical care sector of the country has been the overwhelming commercialization of the pharmaceutical industry, which is unblatantly interested only obtaining profit by hook or crook. A related post (

http://jeevankuruvilla.blogspot.com/2011/08/pharmaceuticals-in-india.html ) to this is the proliferation of unethical combinations of medications which are very freely used by quacks and doctors alike. Unfortunately, the pharmaceutical industry has been well supported by quacks in increasing the market of medicinal preparations and more so for the unethical combination preparations. Among the quacks they have also found brother-in-arms to combat the cost effective generic preparations.

What makes quacks so popular? There are quite a lot of things which we need to learn from the quacks. One of the major aspects which make them quite endearing to communities, especially in the rural areas is their ready availability for service. It is quite common to see them moving around in our nearby villages in cycles or mopeds with a bag filled with all the necessary implements, medicines including injections. The bag which they carry around with them has given them the name ‘jhola chap’ to such doctors in our part of the country.

Now imagine a patient coming to my emergency. The present system is that the nurse would first take the vital signs, and then inform a doctor – it takes some time for the doctor to come, most of the time it would need an admission. And with that come the costs - which bring us to the next advantage with the quack. They take their payment any time and in any kind, which is very difficult to obtain in the present system of treatment in any hospital of the country.

The next point is something which is quite an important aspect which needs to be noted by every qualified medical professional. That is the ability to communicate – clearly, logically and in a language which the patient can comprehend. We have very little time for our patients. Each of our patients are cases and beds. The humanity and identity of the patient vanishes the time they enter our ivory towers.

The last point is the treatment of demand which most of the quacks readily obliges. This makes them quite popular. I never took this aspect quite seriously until I met a quite senior medicine consultant in a mission hospital in the South of India. I was shocked to find quite well looking people in the emergency lying in the beds in the emergency ward taking intravenous fluids. I enquired about this – when she told me that many people came to her for i.v fluids for strength. It was a bit difficulty and when I enquired about the ethical part of it – she told she knew that there was not much of a evidence in giving i.v fluids for no reason, but that was what the villagers wanted. She took over the hospital when it was really going down – she struggled for the first two years. Later, just to make ends meet, she started to slowly oblige the villagers' demands for specific treatments. And within no time, she was quite popular. At the end of the visit, I felt she looked more of a quack than a qualified medicine consultant.

Except the last point, I strongly feel that the rest of them are major learning points for modern medical practitioners. By the way, I recieved an invitation to visit one quack and his practice in a nearby village. I've heard that he managed to even do surgeries - herniaplasties and hydrocelectomies... I happened to meet him during my break at Betla (

http://jeevankuruvilla.blogspot.com/2011/08/betla-diary-day-1.html). Please watch out for a blog on the interactions with him.

BETLA DIARY, Day 1

It was only couple of days back that we took a decision to take a break from hospital work for couple of days and be at the Betla National Park which is only about 15 kms as the crow flies, but about 40 kms away by road. It was the first park in the Indian subcontinent where a tiger census was done sometime in the 1910s. However, over the years the number of tigers have come down from to technically 8, but practically one which was sighted sometime in January 2011.


We arrived after a hurried day for me at the office. We had finished our selection process for the nursing school over the last couple of days. I had barely any time to pack, but my sweet better half had ensured that all my essentials were taken. I had hired one of the outside vehicles for the trip rather than take a hospital vehicle.

The drive was uneventful. The scenery was superb after the regular rains we had over the last couple of months. It was so pleasant to see the Auranga river full of water.


We had not done our homework well on where we would stay. We had booked a room in the Jharkhand Tourism Development Corporation guest house called 'Van Vihar'. The decision was a tragedy. However, we were blessed to have the 'Tree House' of the Forest Department unoccupied and we shifted over to the same, today afternoon.

We had a quiet overnight stay at the former place. Today morning, we came down to the park entrance for an elephant ride. Unfortunately, the gentle beast was booked for the day. The mahout offered us a booking for the next day which we gratefully accepted. However, we decided to try our fortune to sight some animal by taking a jeep-ride. The only thing we spotted was few monkeys and a peacock. The guide assured us that we would definitely spot elephants if we came back in the evening. We had come down to get some time of peace and quietness. Therefore, we politely declined the offer.


Later, in the morning, we had a time of worship at the Gems mission centre. It was humbling to see very poor people come down to this place. Pastor Santosh is doing a very good work among the people in this region.


After a simple lunch at the Forest Guest House of which the 'Tree House' is a part, we had a good afternoon siesta after quite a long time. We planned to go to the museum before it closed for the day. Unfortunately, the staff had decided to close it early and we will have to postpone our visit to the museum for our next trip to the park.


By evening, quite a big horde of deer had come down from the forest to the 'Tree House'. We had a good time just watching them graze.

We wait patiently for the elephant ride tomorrow. Who know? We may see the tiger tomorrow (http://jeevankuruvilla.blogspot.com/2011/08/tyger-tyger-burning-bright.html).