Golden Jubilee celebrations - The Beginning

We kicked off our Golden Jubilee celebrations by welcoming Dr Mark Kniss and his son, Mr James Kniss to NJH. Dr Mark and James had arrived one day back in Ranchi and were staying with an old friend.

I was blessed to pick up Dr Kniss and Mr James from Ranchi. After a long drive taking almost 4 hours, thanks to inhospitable roads - we reached NJH by around 6:30 pm to be greeted by almost the whole campus including the families.

There was traditional dance organised quite well by the nursing school students which escorted the guests to the chapel in the middle of the campus.

There was the traditional hand-washing ceremony followed by garlanding of the guests.

As soon as we had finished welcoming Dr Kniss and Mr James, Dr Nandamani's vehicle with Dr Ron Hiles arrived.

Once everybody was settled, Dr Nandamani was also pushed in to sit along with the guests.

Little did he know that we still remembered that it was his birthday and we ended the programme garlanding him and singing 'Happy Birthday'.

Disappointment . . .

As we look forward for our Golden Jubilee celebrations, we have been quite encouraged by the response from the local community towards the care we give at NJH.

The local health authorities have also been showing quite encouraging signs one of which has been the meeting for training on maternal mortality review.

Close to the heels of the session, I was informed by one of the officials that due to technical reasons, the government would not be able to renew its' contract with us for the implementation of the Janani Suraksha Yojana. (JSY)

Without doubt, the JSY has played quite a significant role in improving maternal health care in the region. The technical reasons were quite dubious from the scenario of Indian healthcare especially in relation to the rural areas of the country.

The technical reason for the refusal to renew the contract was that there we did not have any consultant in obstetrics, pediatrics or anesthesiology. For the same technical reason, none of the other private institutions in the region has been authorised to implement the JSY.

The same day there was a news item about the number of quacks operating in Delhi. The same system who cannot ensure that non qualified people do not practice medicine is trying to ensure that only specialised doctors deal with obstetric care through which almost all families go through at least once in their lifetime.

Leave alone Delhi - look at the number of quacks in Kerala - which boasts of world standard health indices.

One needs to visit many of the district hospitals in many of our states in the night with a complicated pregnancy and find out how many of them have a obstetrician, an anesthetist and a pediatrician on regular call readily available to rush in any emergency.

I have enough cases which tell me that there isn't enough specialists available in our public health facilities. Even if there are specialists available from a statistics point of view - how many of them would be ready to work in places like Latehar, Palamu or Garhwa - the nearest 3 district headquarters to NJH.

And more than the availability of specialists, I would like to press my case with regard to the availability of all 3 of them together at a given point of time. I've seen many times when complicated pregnancies were turned away because one of the three specialists (obstetrician, pediatrician, anesthetist) supposedly needed during the intrapartum care of a patient is on leave.

On one side, there were efforts from the side of the government to start a course called Bachelor of Rural Medicine and Surgery targeted to improve healthcare in the rural areas - whereas on the other side they stiffle efforts taken by qualified doctors to improve healthcare in these needy areas by bringing in draconian rules.

Now, when I've mentioned about this problem which has occured with us - I need to bring your attention to another law which is called the Clinical Establishment Act which is already in force to its full extent in states like Assam and Orissa. One of the most draconian rules under the CEA ensure that unless specialists are available in a healthcare centre - the concerned procedure cannot be done in the said hospital.

Which ultimately means that if you do not have an obstetrician, no deliveries can be conducted in your clinic. You would not be able to do any surgery unless you have an anesthetist. And you can ultimately end up interpreting the rule to such an extent that a surgeon may not be able to even treat his own child for a respiratory tract infection.

Meanwhile, we end up in a situation where quacks and RMPs flourish whereas a qualified MBBS graduate would be worrying whether he will end up in the hands of the law if he does certain procedures which are part of somebody elses' speciality.

This again brings me to plead for the inclusion of the speciality of Family Medicine as a recognised speciality under the Medical Council of India. There is already a Diplomate of the National Board for which exams are conducted. However, we need to move beyond that and ensure that there is Masters and Diploma degrees in the speciality.

I understand that there is staunch resistance from the professional bodies of specialist doctors. Their fears are unfounded. Many of them are afraid that they would lose their earnings to the new found specialist group of Family Physicians. However, it is very evident that the nation would gain very much from a cadre of Family Physicians in the healthcare system.

That is exactly what we have at NJH. We have only one surgeon. The rest of us are all family/community  physicians. All of us can give spinal anesthesia, resuscitate a baby, do a cesarian section - take decisions on ventilating a patient etc etc. If we had waited for many of our patients to go to a specialist they would have been long dead.

If taken in the right spirit, the speciality of Family Medicine would be the toughest and the most exiting speciality in the realm of healthcare academics. The major challenge will be ensure that the MCI takes a positive decision on this as well as develop a syllabus which is robust enough to transform graduates of medicine to family care specialists dedicated to the cause of holistic care to patients.

The culprit identified . . . SK.

Yesterday, SK who had come with an unknown bite and went into quite a lot of complications ultimately went home.

She was looking quite cheerful.

The diagnosis on her discharge summary read -

UNKNOWN BITE RESULTING IN

- DRY GANGRENE OF THE RIGHT LEG FOLLOWING COMPARTMENT SYNDROME,

- ACUTE RENAL FAILURE,

- MYOCARDITIS RESULTING IN PULMONARY EDEMA AND

- SEPTICEMIA.

Her highest level of S.creatinine was 7.8 mg% and we had wished that we could try out peritoneal dialysis.

We are thankful that she pulled through. She was in the ventilator as well as manually bagged by her parents for almost 72 hours.

Now, we made an attempt to identify the culprit. When Seema came to my office before discharge, I decided to give it another try. She clearly told me that she was bit by a 'Khapar Bitcha'. I summoned some of the local staff and tried to figure out the creature. 'It looks like a large lizard and a coarse chameleon' - that was how someone put it.

I figured it is something like a monitor. So, I searched the web and came up with some pictures. Ultimately, when I showed her the wikipedia page about the Bengal monitor, she was absolutely sure. However, I had a problem. I could not find out anywhere that the Bengal monitor was that poisonous.

Sometimes I wonder if we had made her more sick by giving her Anti Snake Venom - we did it as her Clotting Time was more than 20 minutes. Or was it a result of septicemia which resulted following the gangrene which set in because of the compartment syndrome.

I look forward for comments regarding the same. Especially from the experts on such bites. Maybe we've found something new that could be reported.

The story about SK would not be complete unless I put in something which we did for her family. If you have read my previous blog about SK, you will understand that her father wanted to take her home to die. We pleaded with him not to and give us a chance to try to heal her. Ultimately, I had to tell the father that we would treat her for free.

Unfortunately, once the father saw that SK was getting better, he had gone and sold a part of his land and got some money. He was ready to pay about 10,000 rupees when the discharge was all made. The total bill had come to about 30,000 rupees. I kept my promise and did not take a rupee.

However, such things are quite burdensome for the institution. We look forward for contributors from well wishers towards SK's treatment.

Food at NJH

Well, you may find this piece of posting a bit of an odd thing among the themes I usually write about.

This is in response to one of my friends who phoned me the other day and queried about the culinary options in our place. The place is quite famous for not getting the usual gastronomical delights which we cherish.

Many a time we wait for a trip to Daltonganj to feast on dosas, chaat etc. There are umpteen number of stories on how families used to survive on only potatoes or okra for days together. Even recently, one of my colleagues was commenting on how he and his wife was surviving only on rice and eggs as he could not find the time to go to Daltonganj and shop.

Comparing to olden days, things have improved quite a lot. Many of the things are available just outside the campus and there is a choice of vegetables to choose from. However, once in a while it becomes a bit difficult especially during the summer months.

But, when my friend called, I told him that things continue to be difficult when it came to access to food varieties.

When I came home yesterday after I had talked to my friend, there was a bit of a paradoxical statement on my dinner plate - which is put below.

For the untrained eye on Malayalee food, the items are as follows -

1. Pomfret fry: Considered a delicacy. Can cost upto 500 Indian rupees per piece in a five star hotel. Called 'avoli' in Kerala. Brought it from Ranchi couple of days back while on an official visit.

2. Beef tikka: Minced meat mixed with spice and deep fried in oil. Brought from Daltonganj and baked for 3 minutes at 300 degree celcius.

3. Beetroot patcchadi: Beetroot sliced into thin pieces and cooked in curd.

4. Yam fritters: Yam (called Chena in Malayalam) made in thick pieces and cooked dry.  

So, I've discovered that if one could plan and has a caring wife, we could have quite an array of foods accessible.

Therefore, for all of those who like to become part of our team, but hesitant because of culinary limitations, I hope that this post will encourage them to positively consider joining us.

SCARY . . . ULTIMATELY HILARIOUS

Since the last 2 days, we were having or supposedly having a really destructive rodent in our administrative office. Rats have always been an issue in almost all of our homes and hospital.

One of the main job descriptions of Mr. Jorang, our helper in the office is to keep a rat trap at the end of the day. According to Mr. Majerus, our finance person, the menace was quite more in the earlier years and there were days when simultaneously two traps were successfully operated each day.

Today morning, the damage was quite significant. There were files which had been badly damaged. The internet connection was gnawed through. There were quite large scratch marks over the plywood temporary partitions.

Yesterday evening, Mr. Joram had remembered to keep the trap. The bait was untouched. There was an emergency meeting to decide on the future course of action. There was unanimous agreement that we are dealing with quite a large rat – maybe a bandicoot – ‘the type you find in railway stations’ – that was how someone put it.

The trap was definitely out of question – since it was too small for so large a rat. There was unanimous agreement that we would not try to poison the creature. The reason was that the last time we did it – the unfortunate thing had died in an inaccessible part of our building, because of which the area was sticking like a fish market for almost 4 weeks.

I had some experience in trapping bandicoots when I was a kid. So, I told them that I would take care of the job the following evening once office was over.

New spread around fast about the ‘bandicoot’ which had taken residence in the office and how the Medical Superintendent has taken responsibility of trapping it.

The days are quite busy here with the Golden Jubilee celebrations fast approaching and the busy inpatient. So, it did not take me long to forget about the matter. And the previous night, I had already dealt with a rat who had taken up residence in the hardly used air-conditioning unit of our bedroom.

About couple of hours, there was a commotion from the finance section. Majerus happened to observe a furry thing moving in the corner of his table. It had disappeared by then. However, Majerus was certain that the bandicoot was there. So, we had the ‘office team’ moving in fast. Meanwhile, someone spied the movement under the table and found out that it was more a cat like animal than a rat.

Well, there was quite a lot of talk on the probability of it being a wild cat, considering the proximity of a wildlife park wildlife park near the hospital. As the talks were going on, the ‘bandicoot’ ran across the room. It was a cat. Poor thing – probably the fellow was trapped within the office complex and was quite hungry that he started gnawing on whatever he could eat. And the bait was untouched because I don’t know of cats that eat potatoes unless you lace it with fish.

I was reminded of the story we heard in school of an entire village mobilized by a group of boys who spied a head which was looking out of a hole – which they concluded was that of a cobra. The villagers spent almost a day dugging up the soil around the hole and ultimately found out the ‘cobra’ were in fact a fat chameleon.

I ultimately took a decision to leave the cat to find its’ way out rather than we trying to poke it out of wherever it was hiding. I’m not sure whether he has left his new found home, which I’m sure he’ll do in a couple of days.

Lesson learnt - Most of our problems are more imagined than actual.