Charity - giving, giving and giving . . .

Couple of days back, one of my colleagues questioned me about our policy to going overboard to help patients get their lives back. The specific instance arose when I requested one of my staff to donate blood for SD about whom you can read here. Dinesh, the engineer here, readily donated blood – but I was taken aback when one of my closest confidantes chided me about the decision.

To recap things, SD was brought to our emergency in a quite bad state on 5^th September morning. She had delivered a dead baby at around midnight and her placenta was stuck. She had been bleeding all through the night and into the day. Her hemoglobin was 1 gm% and she was sinking. With a AB positive blood group, the chances of her surviving were remote.

 

 

The fact is that SD is still alive. She has stopped bleeding. Her vitals are all normal. During my attempts of removing the placenta and from the history it was very obvious that the baby had been dead for days and the whole of the uterus was terribly infected. She has received two pints of blood so far of which the first pint was given by my engineer, Mr. Dinesh.

 

 

I clearly understand that volunteering to give blood in such situations is a very personal decision. I’ve known colleagues who weigh in the possibilities of a patient surviving before they donate the blood.

 

 

However, when I look it from the perspective of how Jesus looked at problems and their solutions – I am very much encouraged by the incident of the ‘Feeding of Five Thousand’ – which we read in all the 4 gospels in the Holy Bible (Matthew 14:13-21, Mark 6:31-44, Luke 9:10-17 and John 6:5-15). The most absorbing spectacle in the incident is the readiness of the disciples to tell Jesus on how little they had. And Jesus was looking at their readiness to share the little they had.

 

 

I’m glad that the Lord led us as a team to decide on giving this patient the one pint of blood which was the only thing other than our prayers which we could offer her to sustain her life. She has pulled through so far. We still do not know how things will progress – but we are encouraged by the unseen but the very much felt hand of the Holy Spirit that leads us each day.

Medicine as a business

I write this post in the light of case being heard in the Supreme Court of the country between the pharmaceutical company Novartis and the Indian government regarding the patenting of new forms of old medicines. The drug in question is Gleevec about which quite a lot has been written. You can read more about this here.

When I read this – I’m reminded of a story told my one of my senior mentors in college who happened to be a retired professor in medical school. He was speaking to a group of freshers (new admissions in MBBS) in one of the medical colleges in Kerala sometime in the early 1980s. He asked the new entrants on what their desires in life were. Along with the usual answers which you get during that time like the desire to serve, the doctor father wanting his progeny to follow suit, the desire to do research to help mankind etc., and one kid told him that he wanted to buy a Mercedes Benz. The professor replied that leave alone a Mercedes Benz, he would not be able to buy even the tire of a Mercedes if he becomes a doctor.

Unfortunately, times have changed. My mentor was wrong. Medical profession is one of the most lucrative professions in India. The flash and the glamour associated with the profession are quite on the rise. We have heard about stories of one of our professors coming for work in their cycles. But, not anymore. The flashy cars doctors drive to work is one of the major driving forces for many a parent to dream about sending their children to study medicine.

I’m sure that one of the major contributors to the transformation the of medical profession as a lucrative business is the pharmaceutical industry (My blog on pharmaceuticals). And the Novartis vs Indian government is just the tip of an iceberg of the extreme profiteering that pharmaceutical companies want to continue doing. The way new drugs are being pushed into the market is just an indication of how much profits they look towards making.

I remember a drug called Rofecoxib which was brought about in the Indian market sometime when I was finishing my house-surgeoncy. It was marketed as the wonder drug for pain relief especially in osteo-arthritis. I had gone for it’s ‘release’ in Trivandrum. It was a very glamorous event. Later, I was told that our professors were taken to a more glamorous event in Chennai for its’ inauguration in South India. Most of the doctors know what happened to Rofecoxib in the next 5 years.

A lot of unaccounted deaths due to cardiac failure started to happen and investigations revealed that Rofecoxib has cardiac side effects. The shock came when it was found out that that Rofecoxib was in fact found to have fatal cardiac side-effects even during clinical trials information of which was suppressed. However, over the 5 years the company had made its’ profit.

Once I happened to go to a meeting where the main speaker was someone who had made quite a lot of money in the stock market. I remember him telling the audience very clearly – ‘Always be on the lookout for oil companies and pharmaceutical companies. Do not miss investing in them whatever be the cost. Humans need oil for their machines and medicines for their bodies. The demand will never go’. He was true.

This is where I hear the very different message from the Holy Bible. Jesus Christ, whom I believe as my Lord and personal Savior was the best doctor. There have been many instances of him healing the sick. And if we read the instances where he healed the sick – there are few things which come to our immediate notice which are major learning points for us in the business of health care. In the light of my meditations on Matthew 8 and 9 over the last 2 days, I just thought of jotting few aspects which could help us to be better doctors to our patients.

The first is ‘Touch’ – instances of Jesus touching his patients – Matthew 8:3, 13; Matthew 9: 21, 25, 29. And the second aspect is ‘Compassion’ – which is quite a easy word to understand but quite difficult to practice. Matthew 9: 36. The third aspect is the speed with which he was doing things. Being God, he could completely heal people so fast. But, when I look at myself, many a time I find myself scheming on what to do to the patient. How much I’ll make out of him? How much investigations I need to write? How much medicines I’ll give to him? If I do such a thing, will this fellow come back to me?

The very fact that we do not have much time to talk to our patients is in itself a major problem whereby our patients do not find immediate relief upon coming to us. This is something where ayurvedic practitioners and quacks (read more about quacks here) score quite high over us.

I think most of the problems that we in the medical profession faces today where we stand accused to be next only to politicians in the making of money can be got away with if we could rediscover the art of touching patients, being compassionate to our patients as they come to us and looking at immediate and fast ways and means to make their lives easier in the given circumstances. And this ultimately it would do a lot of good in keeping us in favor with both God and man.

Theatre Musings

I write this as I give moral and anesthesia support to Dr Nandamani as he is operating on JH, a 70 year old retired teacher from Satbarwa, our nearest market. JH had come about a week back with an acute retention of urine. We had put in a catheter and found out that he has enlargement of the prostate gland, a common condition in elderly males.

Doing the open prostatectomy

JH is fairly well off considering that he was a retired government teacher. And he is rich enough to go off to Ranchi and get a TURP done. TURP stands for Transurethral Resection of the Prostate where we widen the route of the urine  through the urethra by slicing off parts of the prostate using a endoscope which is put through the urethra. There are quite a lot of people who swear by TURP whereas the older surgeons would vouch on how better is an open prostatectomy.

We gave the options of either getting a TURP done at Ranchi or an open prostatectomy at NJH. We are not sure why – JH opted for the open prostatectomy which Dr Nandamani is doing today.

We request your prayers as Nandamani finishes his surgery and continues on with his list of surgeries today. Before this surgery, we already had a hysterectomy and a hydrocelectomy. Once the prostatectomy gets over, we would proceed to a burn contracture release for a patient who acquired the injury quite a long time back which has handicapped her.

And then there is a young man with an intestinal obstruction who has a hemoglobin of only 4 gm%. We told his relatives that we can operate only if we have at least 3 pints of blood. They have brought the blood today. So, we could be operating him soon after the burn contracture release surgery is over.

Dr Nandamani examining the burn contracture before surgery

Talking of low hemoglobins, we had a 37 year old lady, SD with a 1 gm% hemoglobin. Seems outrageous. She delivered her 3^rd pregnancy sometime in the midnight. And her placenta was not coming out. The baby was dead – for the relatives’ description – it must have been dead for quite a long time. We knew that we had a uphill task. However, we took it up as a challenge. Dinesh, our engineer donated one pint blood and we proceeded to attempt to remove the placenta. It was a disaster. It seems like placenta accreta and the products being removed was stinking. I removed whatever I could.

The relatives have gone to get more blood. Her blood group being AB positive – that is not going to be easy. SD has pulled on so far. From a medical science perspective, she does not stand much chance. But here at NJH, we see quite a lot of miracles. And we pray for one more.

In the OPD, as I had written about in a previous post (http://jeevankuruvilla.blogspot.com/2011/09/tuberculosis-are-we-winning-war.html), we had more tuberculosis patients of whose 2 X-Rays are shown below.  

Friends from Germany

Just wanted to acknowledge the visit of medical students from Charite, University of Berlin, Germany - Ms Doerthe Stolbrink from Dortmund and Ms Manuela Loux from Overath (Near Cologne). Both of them were with us for the last month as part of their compulsory period of electives.

Shazia, Angel, Aji, Doerthe, Manuela, Ango, Nandamani

The clinical staff and our families enjoyed their time with us. Both of them were on their first visit to India and after their time in NJH, they have left to Darjeeling as part of a 1 month tour of other parts of India.

In the beginning of the year, we had 2 medical students from the University of Zurich, Switzerland. I’m not putting their names here as I’ve not taken their permission.

Ms Doerthe and Manuela were luckier than their Swiss counterparts as the hospital was quite busy during their stay here and they saw quite a number of diverse cases. Both of them were kind enough to donate 4 finger pulse oximeters for the hospital, which are being quite amply used. I hope that they have learnt quite a lot about a different approach to healthcare which will be definitely quite a lot different from what they are learning in Germany.

We look forward to see more people visiting us in the future. More than people from other countries, we look forward to Indian medical and nursing students visiting us and exploring options of working in needy situations like ours at least for part of their lives.

Meanwhile, we wish Doerthe and Manuela a relaxing time of holidaying over the next one month and a safe journey back to Germany.

Tuberculosis - Are we winning the war?

The two X-Rays shown below are of two ladies – the one on the left is that a very young lady, MD with a 2 year old child and the one on the right is that of an elderly lady, LD with adult children.

Both these ladies came in during the later hours of Saturday evening. They must have come in as the OPD was closing. It was very evident from both the histories that they have tuberculosis. The reason we took the X-rays was because I was unsure of how much healthy lung tissue they had left. I’ve already started them on anti-tubercular treatment without waiting for a sputum test as the sputum test will happen only on Monday morning.

The RNTCP higher-ups have been going gaga about the success that RNTCP (Revised National Tuberculosis Control Programme – www.tbcindia.org ) has achieved in bringing tuberculosis under control. RNTCP is a highly acclaimed programme run by the Government of India aimed at the control of tuberculosis in the country. Quite a lot of clinicians have many misgivings about the programme – but that is another story.

NJH has been partnering in implementing RNTCP since its inception – as a Microscopic Centre catering to a population of 100,000 since 2001 and as a Tuberculosis Unit since 2006.

I need to say this – we have been having an increase in the number of patients whom we are diagnosing tuberculosis over the last 2 weeks. Even as I write this (10:40 pm), I’ve a patient who’s just come in and it looks like tuberculosis. I’ve 4 patients in the inpatient wing waiting for sputum AFB tomorrow morning. We’ve had quite a number of patients over the last week who had been diagnosed as malaria or enteric fever outside and we came to a diagnosis of tuberculosis – and they’ve improved after Anti-tuberculosis treatment. Unfortunately, they include quite a number of children.

I’m not sure of the reason for the sudden increase in the number of tuberculosis suspects. One reason which I can think of is the drought situation which has been prevalent in the region for the last 3 years by which the poverty among the communities have worsened. This has been followed by very heavy rains over the last 3 months – which has increased the incidence of water and vector borne diseases.

Most probably what is happening is that the other diseases  like malaria, dengue, diarrhoeal diseases etc are occurring which is decreasing the already poor immunity of the impoverished population making them susceptible to flaring up of tuberculosis infections to which quite a lot of the population is exposed to.

The reason I suspect is because of a very peculiar history which we notice in many of the patients whom we ultimately diagnose to have tuberculosis. They come with a history of fever 2-3 weeks back following which they are treated at a quack’s place (http://jeevankuruvilla.blogspot.com/2011/08/quacks-rmps-registered-medical.html) usually with artemether or levofloxacin or a combination of both – following which they are asymptomatic for about a week after which they again get fever. Initially, it does not give the peculiar symptoms of tuberculosis – but over a week, they have the pattern of evening rise of temperature, loss of appetite etc. Unfortunately, many a time, we do not get a positive report on sputum – most probably because of unscrupulous use of Ciprofloxacin and Levofloxacin, both of which have anti-tuberculosis bacilli activity. We conclude based on typical X-Ray finding of apical consolidation and cavity formation. And of course – the best support - history of exposure to another case of tuberculosis.

I would definitely like to hear expert comments. Of course, I’m quite interested in the stories of KD and LD and will try to put them up in a later post. I’m sure this would be quite interesting especially from the perspective of the socio-cultural and economic set up of the region.