Maternal Health Care in Palamu - Red letter day

Today was a red letter day in the history of maternal health care of our region.


The UNICEF along with the district health authorities of Palamu district had arranged for a training session on Facility Based Maternal Death Review. I understand that soon there would also be efforts taken for training grassroot workers on Community Based Maternal Death Review.


Mr Prabodh Kujur and myself represented NJH as we have quite a large burden of adverse maternal events including maternal mortality. Over the last 1 year, we calculated about 20 maternal deaths within the facility. This excludes at least 5 patients who were brought dead.


One of the key messages which was conveyed to all the doctors who came was about the absence of a blame factor in the whole exercise. Many a time, adverse health events are not reported because of a fear of punishment. I was very glad that the message was conveyed well.

As I sat there, images of mothers who died or almost died, those who ended up with lifelong complications and dead babies flashed before me.

I remembered AB's baby who just made it whereas she should have been referred faster. BD, whose life has turned for the worse was a poignant face whom I would remember for the rest of my life. One of the major finding I would expect from the reviews is the strong association between malnutrition and anemia. 

The mental stress that KD's family endured was still fresh in my mind. Our experiences with patients like RD, who lost her baby or SD, for whom we had to intervene heroically have already taught us that the delay in taking the decision to go to the healthcare provider and the delay in implementing the decision is quite costly in the lives of mothers and newborn. I'm certain that this is going to be one of the major learning in this exercise.

I'm excited about the whole excercise. We look forward to a time of learning and understanding determinants influencing maternal health care in this region during the maternal death review meetings at the institutional and district level.

More than that we look forward to a period in our surrounding communities where pregnancy is more safe whereby families will cherish and enjoy motherhood which would be the ultimate aim of such an exercise.

Unknown bite - and more venomous

SK about whom we were quite concerned about for quite a long time finally improved well enough for us to start thinking about discharging her.

SK came about 10 days back with a history of an unknown bite. The relatives were quite confused about the identity of the creature which bit SK. We send for the clotting time which came elevated. There were local signs of envenomation. So, we came to a presumptive diagnosis of viper bite and started anti-snake venom.

SK improved very soon and her clotting time came to normal limits. There were 2 other patients with viper bites and the 3 families formed a sort of bond. The other 2 patients recovered without much problem. SK also had compartment syndrome and underwent fasciotomy. The 3 patients send us into a situation where Anti- Snake Venom was running short.

However, we noticed that SK’s renal status was deteriorating and was going into anuria. Meanwhile, the other 2 were improving. I called up SK’s father and told him about a possible need for referral. SK’s father told me that he has already sold 2 of his bullocks and 1 goat to fund SK’s treatment. And as he was not going for work – so he had to provide for the family’s day to day existence.

A funny side of the treatment process was the constant stream of visitors that SK had – mostly local leaders and pretender leaders. Couple of them came and met me and told that they would take care of all the costs and to do the best for the patient. After some important looking leaders came and met me – I called up SK’s father and asked him about it.

He would start sobbing – telling that none of them including his villagers has given even a single rupee for the treatment even to the extent of taking responsibility to care his other children. He told me that if we cannot manage her, he would rather take her home to die.

We convinced him to allow us to do whatever we could to try to save SK.

Meanwhile SK was worsening. We realized that she was going into pulmonary edema. We were juggling on what could be the cause of the pulmonary edema. Renal failure was thought of as the cause and we became quite stingy with the fluid management. However, there was no relief. In addition, we had to put her on mechanical ventilation.

She had also gone into sepsis. We changed antibiotics – but without much improvement. Later, Dr. Nandamani explored the chance of cardiogenic pulmonary edema. Ultimately, we decided to start SK on a GTN drip.

And we praised God when she responded to the GTN drip. After 3 days in the ventilator, SK was weaned out of the ventilator. She is quite tired. 3 days on the ventilator was quite a bit stressful on both our ventilators – the older one and the newer one – and for quite a lot of time, she was manually bagged by both the parents.

I’ve send for further investigations about her renal status. Clinically, she appears to be on the road to recovery.

Today morning, I got to talk to her. We were already a bit suspicious about the creature which bit SK. SK was quite sure that it was not a snake. She told that it looked like a large lizard. SK’s father told me that if it was the creature – usually people die after this creature bites. After the case of a spider bite which caused quite a lot of stress to a family, it is quite interesting that we do have other creatures which can be as dangerous as venomous snakes like cobras or vipers.

Aluminium Phosphide poisoning

Aluminium Phosphide, commonly called Alphos in our region is one of the most dangerous poisons used to commit suicide. The ultimate result is almost certain death. And I hardly remember a patient who made it, until we found out about a new approach to treat such patients. But, before I describe about the new treatment which we happened to stumble upon – something about the poison.

You can read more about the poison by clicking here. I remember talking to one of my friends who used to work in the Food Corporation of India quite a long time ago during my high-school days. He was the first one who told me about this poison as well as showed me couple of tablets of aluminium phosphide. To demonstrate the potency of the poison, he showed me how one tablet was used as a insecticide for quite a large amount of foodgrains stocked up in gunny bags. Only one tablet was needed to be kept in the middle of a pile of about 100 gunny bags of food grains to keep the whole lot free of pests.

So, one can imagine how poisonous the substance was.

So, what is it that we are doing new? We’ve already had 4 patients who have gone home alive. The usual treatment comprises of maintaining blood pressure by giving dopamine drip. We also give magnesium sulphate injections. However, there are conflicting reports on how it helps.

I was having a casual talk about this with one my friends who were doing his post-graduation in one of the medical colleges nearby. It happened that his thesis happened to be about ‘Alphos’ poisoning. He told me about the part of giving coconut oil along with activated charcoal after the stomach wash. So, we started to do it on a experimental basis.

There were few papers on this in the research available in the internet. You can read about it either here, or here. It has worked wonders so far. There were 2 patients who had gone into hemodynamic failure. The other two had come quite early that they did not go into shock after we had given them stomach wash followed by coconut oil put into the stomach.

Later I found out about anecdotal reports of local healers in Africa especially Morocco who treat patients with clarified butter (ghee). I was a bit surprised that not many clinicians had heard about this although I found research papers published as early as 2005.

However, there are quite a number of factors which are known to determine survival in ‘Alphos’ poisoning which include aspects such as vomiting after poison ingestion, the number of tablets which is taken and how fresh the ingested tablets were. It seems that if the tablets are kept in the open for quite some time, they lose their potency.

I’m not sure if any other oil will work. However, it is quite funny that coconut oil which is more of a part of South Indian cuisine is found to be useful in ‘Alphos’ poisonings which is more prevalent in the north of the country. One of my patients had complained about the odd taste of the coconut oil which he could not tolerate. But, I told him that maybe it was the ‘unpalatable thing’ that saved him.  

The Occult

SK's parents had a very peculiar request about 4 days back. Initially, they told that they wanted to take her to Ranchi. I knew that this was not going to happen as couple of her neighbours had informed me quite early that the family was too poor to even pay the medical bills at NJH.

I called the father separately. I asked him about the request to take to Ranchi. He told me that the family was planning to take SK home to die. But, he was also going to try out some black magic – called ‘jhad phuk’ in local terms by the witchdoctor called ‘ojha’.

It was unbelievable. But, true in rural areas in third world countries. After much persuasion, he agreed to allow us to try to save his daughter.

It is not uncommon to see new amulets being tied around patient’s wrists or put along with a necklace while they are still admitted in hospital.

Couple of photographs of patients with things tied around their bodies.

IK, who was clinically diagnosed to have encephalitis - he was too sick to be even taken elsewhere. He made a remarkable recovery. If you look carefully you can see one blue colored and a white colored thing tied over his left shoulder. IK's father had quite a lot of faith on the treatment we were giving him. Then, I asked him about the reason for the extra things which used to change almost every alternate day. IK's father would only giggle in reply.

I found this tied on AS's arm couple of hours after I had admitted him. I am sure that it was not there when he had come in. Unlike what I had expected, AS was taken to the nearest medical college hospital the next day morning. But, he passed away the very next day.

It is quite rare that we see patients especially with medical complaints who does not have one of these amulets tied around their neck or wrist. Many a time, especially with snake bites, they perform quite elaborate rituals before they bring the patients for treatment.

I'm not sure of having seen such practices in any other place to such an extent as I've been seeing here. I don't know about practices in other parts of the world.

UNUSUAL RUSH

It has been quite unusually busy at NJH over the last week. Usually, work is quite light after the Dusserha celebrations start and continues on like that for almost the whole of winter – except for the cataract surgeries.

Unfortunately, I have to away from hospital attending work related to the Golden Jubilee celebrations scheduled towards the last week of this month. Yesterday (Friday), the business was quite evident as I was away in Ranchi attending to work. And the situation would remain such for almost the whole of next month.

It all started with the theatre where Dr Nandamani had posted couple of surgeries, one of them a cholecystectomy. He was only halfway into the surgery when he was informed about a pregnant lady with the babies’ hand prolapsed per vagina and baby was alive. Somehow, he rushed through the rest of the surgery and got the lady posted for an emergency cesarian section to deliver a healthy baby.

Immediately afterwards came a rupture uterus. It was again a very peculiar rupture uterus as the uterus had ruptured in the posterior wall and the rupture extended upto the vagina. It is quite a difficult surgery and he was the Lord’s graciousness that he realized halfway into the suturing up of the uterus that he had unwittingly ligatured the ureter.

Dr Nandamani told me that it was one of the most difficult of rupture uteruses that he had operated on for quite a long time.

While the rupture uterus was going on – in came a previous cesarian in full fledged labour. Everybody was quite relieved to find out the lady was in second stage and she had an uneventful normal delivery.

However, one of the major reasons for the hectic time in the hospital is because of one young girl, SK with history of bite by an unknown creature. – we had presumed that it was a viper as her clotting time was prolonged. She had gone into compartment syndrome and in addition had developed renal failure. Since the last couple of days, she started to have episodes of breathlessness which we ultimately diagnosed to be pulmonary edema.

Many a time, the girl’s parents wanted to get her discharged and take her home. The reason was that they did not have any money. Considering that she is from the nearby village, we agreed to treat her free. She is on the ventilator and maintaining a good urinary output.

I have a feeling that she has developed some amount of myocarditis secondary to the venom and we may be dealing with some other venomous creature bite. Kindly pray that SK will recover fast.

In addition, there have been umpteen numbers of malaria and other cases of acute febrile illness which has come in.

To top up things, there was one maternal death. The lady was in the early part of the 3^rd trimester. And she had developed fever. She was on treatment elsewhere. Later, she developed jaundice. That was when they decided to bring her to NJH. On arrival, she was quite sick. Her blood smear showed hoards of malaria parasite and the platelet count was only 16,000. We asked the relatives to take her to Ranchi. They were too poor. No blood could be arranged. She died sometime around midnight.

I’m not complaining. We are here to serve. But, sometimes we feel that we would be better off with some more fresh expert hands joining ours. With the Golden Jubilee celebrations approaching and the expected arrival of a new baby in Dr Johnson’s family, if we continue to have such a patient flow in the hospital, we know that we are going in for a tough time.