Baking Cakes

Baking was a new thing for my wife. She got the bug of baking cakes while as part of her post-graduate studies she spend 6 months in the Pathology Department where couple of consultants gave her quite vivid and juicy descriptions about the joy of baking cakes. My taste buds prayed quite a bit that she would take up this as a serious routine in our home.

So, one of the first new possessions that we brought after we shifted from Vellore to NJH was the Murphy Richard’s OTG (oven, toaster, griller). With internet around, it was not so difficult to find good recipes. Being quite away from town was a bit difficult especially when it came to procuring the baking ingredients especially butter. Occasionally, we used to get Amul butter – but it was not recommended because of the additives and the salt.

There is a good shop in Ranchi where we could get fresh butter. So, when someone made the long trip to Ranchi, at least a kilogram of butter was a constant order.

It did not take long for our kids to develop a liking for cakes. Considering the fact that we could not make cakes often because of butter not being available regularly – cakes were always in good demand when they were made. Both of them particularly took a liking for the eggless variety of chocolate cake which Angel modified quite well even with the addition of eggs.

Our first challenge was Shalom’s birthday party last September. The problem was about trying to decorate the cake. We wanted to make the cake as well as decorate it. That was when we found out that we could use colour coated chocolate bits marketed under the trade name ‘Gems’ could very well be used. It has become a favourite with both the kids. When Charis had her birthday celebrations in April, Shalom was quite clear about what type of cake we should have.

However, the kids have discovered that the joy of baking cakes is actually in waiting to lick the batter before the cake is baked.

Shalom discovered it on his own. Charis needed a bit of introduction from Angel. However, now Charis is the dominant player as you can see from this picture.

Initially, baking cakes used to be a family event. Unfortunately, of late, I’ve not been able to take part because of the workload in the hospital. I look forward to a day when I can be part again of the fun of baking cakes.

Fever, fever and fever. . . .

Over the last couple of weeks, we have been having patients galore with fever of all types. Of course, most of them have already had treatment elsewhere, especially with the quacks about whom you can read here.

The majority of them do not test positive for anything except for a few who will have features suggestive of septicemia in their blood picture. Very few of them show the malaria parasite in their smear - and most of them who have a falciparum positive picture would have come straight to us.

Over the last many years I know of this place – there have been only two diagnosis – malaria or enteric fever. One of my colleagues here has the following different diagnosis for all sorts of fever. Malaria, probable malaria, chronic malaria, resistant malaria, recurrent malaria etc. He does not believe that there can be any other diagnosis.

We are looking at the options of being part of looking at the various causes of fever in this part of the country. Couple of weeks ago we had an epidemic of fever of which couple of them had tested to be CSF positive for bacterial meningitis. Almost all of them were only responding to either erythromycin or azithromycin and we had assumed that H.influeza must have been the cause.

I’m sure that if we do a study, we’ll find quite a number of new viruses and there is high possibilities of finding leptospirosis. Dengue has already been documented last year. Chikungunya has already been documented in our nearby districts. We had one typical case in the OPD last week. However, unless we do a systematic study we would not able to find the cause.

Maternal near miss and a miracle

DD, was pregnant for the 9^th time in her life. To compound the problem, her blood group was O Negative. Her first 3 children were alive and the next 5 had died soon after childbirth. DD came to our Outpatient department for the first time yesterday. It was very obvious from the history that her children had all died because of Rh incompatibility. And she had hemoglobin of 7 gm%.

After having had a couple of bad experiences with patients who had a negative blood group, I made it very firm to the relatives that it would be better for them to go to Ranchi and have the delivery. The family was of the lower middle class, and not very poor. Our Outpatient department and the in-patient wing were bursting to the seams. We did not want another potential crisis in our labour room. In addition, we had an appraisal visit from the Central Tuberculosis Division exploring our preparedness for the start of the DOTS Plus programme. And Tuesday was Dr Nandamani’s operating day.

The relatives did not buy any of our arguments for referring the patient. They forced us to admit her to our labour room. She was in very early labour. Dr Nandmani was on duty on Monday. By around 4 am early today morning, she was about 4 cm dilated. I came in at around 8:00 am – she had progressed to only about 6 cm dilatation. The head seemed to be in an occipitoposterior position. I feared the worst. However, since she was a grand multipara, there was a chance that the head may somehow come out – but there was also a chance of rupture of the uterus.

We decided to take our chances. The relatives somehow wanted to deliver normally. We waited till 12:00 pm – not because we had to wait, but because the theatre was too busy. By around 12:30, we took her in – with no blood and very high consent of even death on the table. We also had explained to the relatives earlier about this baby also not making it because of the problem of Rh incompatibility.

Dr Nandamani did the surgery. The baby was well – he was in fact an occipitoposterior position and had failed to descend well. There was a bit extra bleeding from the uterus and we took up quite a lot of carboprostin for arresting the bleeding.

The miracle was that the baby’s blood group turned out to be O negative – the same as that of the mother. So, he will not have the problem with incompatibility.

After couple of hours of the operation, we were quite encouraged that the husband got hold of one pint of blood. Kindly pray that DD will recover fast and that we would get at least more pint of blood.

Income generation as part of Public Health

IGP or Income Generation Programme is a common terminology used in the development sector. Development of new IGP have always been seen a focus point for Development Organisations in bringing about financial and social upliftment of communities. Some of the famous examples are Amul (the milk products giant in India), NOGA (Nagpur Orange Growers Association, apple cultivation in Himachal Pradesh, Lijjat Pappad etc.

The area where we are has a dearth of innovative options of income generation for the communities around. The drought over the last 3 years has brought about a dire need to look into options of alternate income generation. Migration of unskilled labour to the irrigated parts of the country was the major source of livelihood. There have been a lot of groundwork which has gone in over the last year within our Community Health Department along with various stakeholders in our community. Need for skill training and options of alternate sources or income were identified as possible solutions for the poverty in the communities.

After much deliberations, we identified mushroom cultivation and poultry as 2 options which we could explore. Poultry was a bit more resource intensive and with the recent findings in health with relation to climate change, it does not seem a wise choice for introduction into our communities. Mushroom cultivation was the automatic choice. Couple of our staff had earlier experience of the same and we sent one person for training to Allahabad Agricultural University.

About 2 months back, we have started to develop a demonstration plot for mushroom cultivation in one of the old garages within the campus. The first lot did not turn up at all. The high temperatures were given the blame. However, the team did not give up. They came up with a more traditional technique which has yielded results. We have taken a small step forward in faith. I pray that our efforts will bear more fruit and we will be able to convince various groups of people in our communities to adopt mushroom cultivation for income and nutrition.

 

In addition to mushroom cultivation, our Community Health team has also taken up the challenge to promote other IGPs like local manufacturing of papad, masala powder, soap, detergents etc. Couple of training programmes have already been conducted. However, we've decided to give a priority for a food product as nutrition of communities is matter of grave concern. And mushrooms score quite high for the amount of proteins and nutrients it has. Of course, there is a problem with transport for marketting - however, that would encourage more local consumption - that is the assumption.

Our vision is for the transformation of communities. It does not need much logic to disprove that managing a 100 bedded hospital would bring transformation within communities. Education, Income Generation Programmes, and Vocational Training have been identified as the major development needs in this place.

After the experiment with mushrooms and the other IGPs, I would explore the option of developing community college concept for vocational training in our campus. Our engineer is quite confident of developing courses in welding and electrical repair. We look at ideas and options on how we can participate in the transformation of our surrounding communities. However, we need your prayers as we plan.

Story of a maternal death

KD, aged 19 years, married for about a year came into labour room at around 5:30 pm yesterday. It was a bit sorry to see her in such a state. She was fully bloated up, looking quite dehydrated and exhausted. KD was at term and she had been in labour since the day before. Admitted in one of the hospitals at Daltonganj she was referred couple of hours back with a diagnosis of obstructed labour. Her relatives were told that we would be able to pull the baby out with special instruments which we had in NJH. They must have been referring to the forceps or the vacuum extractor which we had.

I was called in to see KD. There was no question of getting a live baby per vaginally. The head was stuck firmly in the vaginal opening. Along with the caput which had formed, there was edema of the scalp which had worsened the situation. I was in a dilemma. The baby was alive. I went to talk to the bystanders. They wanted something to be done. But, the story they told me made me all the more confused.

 

KD had been diagnosed to have severe anemia for quite some time. Her hemoglobin was 4 gm% four days back following which she was brought to a doctor in Daltonganj. KD was from the border region of Jharkhand and Bihar. The family was quite poor and one of her uncles in Daltonganj volunteered to help her with her delivery in Daltonganj.

 

Nobody was willing to take her with a hemoglobin of 4 gm%. One of the places however took her with the condition that the family provided 6 units of blood. The uncle arranged the 6 units of blood which was transfused over 2 days. Meanwhile she had gone into labour.

 

When she reached us she was already completed more than 24 hours of active labour. After discussion with the relatives which included her uncle, we decided to take her for Cesarian Section. They had one pint of blood with them.

Her hemoglobin before surgery was 9.6 gm% and with one pint blood, it was worth the risk. However, considering her previous hemoglobin of 4 gm%, I took a very high risk from the patient including chances of uterine atony as well as vesicovaginal fistula. I gave them a very guarded prognosis for both mother and baby.

The pre-operative phase was uneventful. Once I opened the abdomen, I realized that I was in for trouble. The intestines were all edematous and there was quite a lot of fluid in the abdominal cavity. The bladder was edematous and there was edema on the anterior uterine wall and the space between the peritoneum and the lower segment of the uterus was also filled with fluid. As is routine, I incised the peritoneum over the lower segment and pushed it down along with the bladder. When I opened the uterus I knew that this was going to be a struggle. The baby had passed meconium and was totally caked in it. The inside of the uterus was stinking.

After somehow extracting the baby who had poor Apgar scores (3 at 1’ and 6 at 5’), I cleaned the uterus. However, it was refusing to contract. After about 3 ampules of carboprostin it contracted. I had also started to suture the uterus back. However, I noticed that she was bleeding from the edges of her wound. I could tell that the patient was going into Disseminated Intravascular Coagulation. The bleeding somehow stopped in between. So, I started to close the incision. Meanwhile, I realized that the uterus has again started to relax and her blood pressure was not recordable. She had gone into uterine atony. More injections of carboprostin went in after which the uterus contracted again.

We shifted her to the acute care unit and put her on the ventilator and started dopamine. She was bleeding again from the uterus when we noticed that the uterus had relaxed yet again. When we gave the carboprostin injection again, the blood she lost was enormous. We needed more blood. The relatives had donated quite a lot and they just could not find more donors.

Meanwhile, Dr Johnson had done quite a good work with the baby. He was crying and was doing fairly good.

However, by now we knew that we were losing KD. She was not responding to dopamine nor adrenaline. Most probably, she had gone into a septicemic shock and compounded with the obstructed labour and the state of anemia which she was in and the DIC, she had gone into a state of non-response to whatever intervention we were trying out.

I declared her dead at 10:30 in the night. I was quite confused on whether I had taken the best decision for KD. During the discussions with the relatives earlier in the evening, one of them had suggested that I kill the baby and somehow pull him out.

Later, as I reminisced about how things went about – maybe I should have waited for the baby to die, then do a craniotomy and pull the dead fetus out. But, she still could have gone into uterine atony.

But, all of this could have been prevented – had she got a regular antenatal check up and got a good hemoglobin whereby at least one of the high risk factors could have been got away with. However, the obstructed labour had made things worse.

The baby has been left behind by the family for us to care for till he is well enough to be taken home. I hope they will come back for the baby.

I just wished that things had turned out well for both the mother and the baby. But, that remained a dream for the family and us.