Malignancies Cont'd. . .

After the story I wrote about KD who had a extensively invasive oral cancer we had been having quite a number of patients with malignancies who came to OPD. Although most of them look quite bizzare, just wanted to draw your attention to an unmet need for care for cancer patients in rural India.

12 year old boy with a biopsy proven soft tissue malignancy of the chest wall musculature who has been running from hospital to hospital for some sort of treatment. We were not equipped to treat it and we ultimately referred him to the Department of Oncology, Banaras Hindu University Medical College. It has almost been a year since the swelling started the size of a pea. I wonder if it is too late to do anything. The boy had quite a number of files of consultations at various centres – but none of them venturing into a definite treatment.     

40 year old man with history of oral ulcers who came from almost 200 kms away in Bihar. I just could not understand why he did not go to a higher centre at either Gaya or Banaras which is nearer to his home. The lesion was quite invasive with the cheeks perforated at 2 places.

50 year old lady from one of our nearby villages who had an ulcer of the tongue. Surprisingly, a well known superspeciality teaching centre in a nearby city refused to entertain the possibility of malignancy. However, the family decided to take a second opinion where a biopsy was done which confirmed squamous cell carcinoma. The family wants to take the patient for treatment at either Mumbai or CMC, Vellore.

50 year old man with the history of a swelling of the right tonsil for the last 15 years which has started to bleed since the last 2 months. I’m definite that there is malignancy. He has requested for a referral to CMC, Vellore.

Burns Unit - NJH

We have been talking about a separate facility for the management of burns patients at NJH for quite a long time.

The initial process of deciding on the final details had been going on for the last one year. Sometime during last February, we had Dr Ron Hiles do a symbolic removal of a brick from a portion of the building which we plan to renovate as part of the burns unit.

There are 3 key people who have been very instrumental in pursuing the dream of a separate facility for burn patient management at NJH. Dr Colin Binks, who was the surgeon at NJH for quite a long time – almost 30 years, Dr Ron Hiles, consultant plastic surgeon from the UK who has been regularly visiting NJH since the last 25 years and Ms RuthAnn Fanstone, consultant at Interburns.

Later, I had the opportunity to be part of a Burns care workshop organized by Interburns in Srimongol, Sylhet, Bangladesh. It was a great time where I could grasp more concepts about the setting up of the burns unit at NJH.

RuthAnn was with us in September, where further discussions took place on the organization of the burns unit and we were well set to start the process of constructions.

The construction was kicked off with few of us starting off the digging for the foundation of the building sometime in early October.

Later, during the celebration of the Golden Jubilee, Dr Ron Hiles and Dr Santosh Mathew laid the foundation stone for the building in the presence of quite an august audience. Work has been progressing since then.

We have started the construction of the building in faith. The total budget for the building is about 32, 00,000. As of now we only have about 25% of the money. We depend on the Lord for the rest of the funds necessary to complete the construction. And we need to get it quite fast as delay in the completion would only raise the costs involved.

In addition, we also need a good committed and dedicated team to build around Dr Nandamani who leads the initiative. As the work among burns patients are on the increase, we also look at the possibility of having one more surgeon who would be able to shoulder the increasing number of general surgery patients.

Please keep us in prayers and do respond in whichever way possible.

Miracle baby 2

We had been quite concerned about one of our patients who had come to us with a very high blood pressure. As told in the previous post about KD, she was quite a high risk candidate and with no live baby - there was quite a lot of pressure on her from her husband's family. 

I tried to send her off to a tertiary care centre in Ranchi. But, the family was too poor to go beyond NJH. 

After admission, she went into labour. With a platelet count of 20,000/cu mm there was nothing much we could do other than arrange blood transfusion - which the husband readily did. 

The blood pressure responded to medications and she delivered a preterm baby girl of 1300 gms. It is about a week now since the delivery. The baby has done quite well so far and has been started on oral feeds. She has already started to gain weight and has a voracious appetite which is a good sign. 

I'm certain that we and KD experienced something which goes much beyond a chance happening of having delivered a live preterm baby after all the previous experiences of losing babies in the last trimester. And we praise God for that. 

Tragedy . . . And a Paradox

Before you can start of imagine what could be the tragedy – yes, another maternal death.

SD, aged 22 years and married for the last 3 years was brought to our labour room in the wee hours yesterday with history of leaking and seizures since midnight. She was unconscious and threw another episode of fits in the labour room. She had already been to one of the private hospitals in Daltonganj. We were not sure of what all medications she got there – but she was told that something can be done only in NJH.

According to dates, she had one month more to go before being full term. I noticed that she was contracting quite violently. Looked like she received an intramuscular pitocin, which is quite common management in many places in India. And the uterus also was looking elongated and very much suggestive of an obstructed labour too.

The pervaginal examination confirmed my worst fears. She was in fact terribly obstructed. However the baby was alive. I wanted to see if the baby had passed meconium – but I could not go anywhere beyond the edematous scalp which was firmly wedged in the pelvis. There were no signs of any fetal distress.

Considering that SD had eclampsia and an obstructed labour, I talked to the relatives about the pros and cons involved in the surgery. Ultimately – telling them that there is a remote possibility that we could lose SD as well as the baby in the process. All done including the informed consent, I set out for the surgery – the first one in an ultimately busy day which saw 2 more cesarian sections.

The initial part of the surgery was uneventful including the delivery of the baby although the liquer was thick with meconium. The baby had a good Apgar score. The trouble started from then onwards. The uterus was refusing to contract. No amount of Prostodin and Pitocin would do the trick.  Ultimately, it contracted.

I somehow closed the incision and came out only to find out that the uterus has once more gone into a state of relaxation. SD was losing blood in enormous amounts. The relatives were running from pillar to post for blood.

By late morning, we realized that we were losing her. We removed her off the ventilator at around 1:30 in the afternoon.

As she was taken off the ventilator, a group of SD’s husband’s friends had turned up to donate blood. They became somewhat agitated. They started shouting at me – telling that I did the surgery without the necessary facilities. I calmly explained to that that all options had been well explained. When I showed them the consent forms – they dispersed without making any more fuss.

Since the meeting on maternal death monitoring, we have been quite prompt in sending the necessary reports to the district level. I had to call SD’s father to find out more details before I fill in the report. One of the details we had to fill in was about the occurrence of any danger signs.

I was shocked to find out that SD had swelling of the body since the last 20 days and has not been feeling very well since then. Nobody had taken it quite seriously. Then came the biggest shock. It was a dramatic moment. I asked SD’s father, if the local Sahiya (ASHA) or the ANM knew about her pregnancy and if she had not told her about the danger signs. It turned out that SD was the Sahiya for the village.

The incident spoke volumes about Maternal health care in the district. I could not initially believe my ears. The lady who was responsible for quite a lot of the maternal health care in her village could not diagnose a danger sign in herself and did not take any effort to present herself to a doctor.

We have miles to go before we can claim any sort of success in the area of maternal and child healthcare. It is unfortunate that SD had gone into atonic post-partum hemorrhage. I do not think that anything could have been done even in the best of centres. However, if an early diagnosis was made of her pre-eclampsia and her obstructed labour at a later stage, SD may have survived.

This is the second time within a period of two months that we were having a maternal death due to uterine atony. Maybe, I should be taking the option of opening a blood bank seriously. There are enormous stipulations to be met before I can even think of a blood bank. I recently heard from one of our sister units how and much more troublesome it is to maintain rigorous stipulations required for a blood bank. However, the paradox is that we have licensed blood banks which supply substandard blood and get away with it.

Prayer request . . .

We have a very special patient admitted in Labour Room today. I had tried all my best to refer her off to Ranchi. But to no avail. They are too poor to go anywhere else.

KD, 23 years old, married for 4 years had already lost 2 babies. She was referred from elsewhere today afternoon. When she reached NJH, she had a blood pressure of 200/130 and was 8 months pregnant with the expected date of delivery sometime in the last week of December.

To complicate matters, she has a platelet of 20,000/cu mm. Her liver enzymes are slowly on the rise. The only consolation is that she is not anemic. I've started her on magsulf and steroids. I hope the platelets will improve and we would be able to do a Cesarian section soon and deliver the baby.

Kindly pray that we would be able to help the mother deliver a live healthy baby and the family will go home blessed.