The Rush Continues . . .

(Kindly note that the picture in this blog is a bit gruesome for non-healthcare readers)

The last 3 days of November were relatively manageable at NJH. So, most of us were comforting ourselves that we would slowly be moving into a season of rest and celebration. And, from the second week of December till almost the first week of January, we would not be more than 2 doctors at a time in NJH. So, we would have preferred to remain a bit quiet - enough patients to just keep ourselves financially stable.

So were my thoughts as I walked out of office for the Unit Management Committee meeting yesterday, the 30th November.

However, as I came back, I knew that at least we would not be starting December the same way.

There were 2 patients in labour room. One of them had come in sometime early morning. A teacher in a school in the adjacent district. She had been leaking since the previous day. She was screaming for a Cesarian section. Ultimately to satisfy her, I had to do a examination which was not really warranted - and was almost sure that if she could hold on for another 4 hours, she could deliver.

Then, we had PD, who had been with us for the last week - leaking at 32 weeks. Ultrasound had shown that her baby was just around 1500 gms. We tried our best to refer her but to no positive response from the relatives. Sometime in the morning, we had done an ultrasound which revealed hardly any liquer. In addition, I wondered if she was running a mild fever. Total counts were elevated. We had to induce her, which is what we did sometime in the evening.

As I left the labour room to check on MY, there was one more patient being rolled in.

I reached ACU to find out that there has been a road traffic accident and couple of people who were quite serious has turned up. I met Dr Shishir who was on duty who updated me that one of them had a very bad degloving injury of the foot and he had called Dr. Nandamani to review. The second person appeared to have a blunt injury foot.

Then, there was one more case of poisoning which had turned up - this time, it was organophosphorus poisoning. AK was doing fine so was MY. I wrote for repeat liver enzymes for MY and returned home. As I passed through Labour Room, I enquired about the new patient. I was informed that SD has come in with most probably a dead baby and Dr Shishir was on his way to examine her.

Today early morning as I made to office, I was informed that SD turned out to have a rupture uterus. Her story was so painful. I hope to post it sometime later. She continues to remain sick after undergoing a hysterectomy in the night.

Then, there was PK, a young man - an alcoholic on regular pain medication for non-specific body pain who had come in with quite a bad duodenal perforation.

The theatre team was in hospital overnight. They had arrived at 8 PM the previous night and had returned at 5 AM in the morning. In addition to the two laparotomies, there was the young man with the degloved injury of the leg. Nandu informed me that the unfortunate soul would need a tendon transplant later.

However, I was glad to know that both the other labour patients had delivered normally. The teacher delivered a 2.25 kg girl sometime before midnight and the 32 weeker with leaking delivered a 1.5 kg boy.

Later, there were 4 more deliveries over the day including KD, a G5 with abruptio placenta.

The previous night would have been busier had a primigravida in frank pre-eclampsia with a horrifying blood pressure of 170/130 and a Urine Albumin of 3+ not decide to go home inspite of all our pleadings... It was so unnerving.

However, to compensate for her, today afternoon, we had another primigravida who has come with severe eclampsia at around 7 months pregnancy. By ultrasound, the baby weighs about 1400 gms. We had decided to give the baby a chance by with steroids acting for 24 hours.

SD who had the laparotomy continues to be sick. We request your prayers. Meanwhile, we thank the Lord that MY has survived. His liver enzymes are within normal limits. I plan to discharge him tomorrow.

And to top it all, all this rush on a day when the whole nation is on strike . . . If this continues, we would find it difficult to manage from next week with only 2 doctors . . .

Praise and Prayers - 7 Dec, 2011

(Please go straight to point nos. 10. That has been one of our best praise points for the whole year)

1. Over the last week, the electricity situation in the region had improved. However, since last Saturday we have again started to have long durations of no electricity and we incur quite a large additional expense in running the generator. Kindly pray that we would be able to reach a point where we do not spent unnecessarily on running the generator.

2. Regular bandhs continue to very badly affect the functioning of the hospital. Over the last 15 days we've had 7 days of not much work happening on account of bandhs. Kindly pray that we do not have interruptions of our normal work days.

3. We suspect that unethical practices such as bonded labour aimed towards the suppression of the oppressed minority people groups especially the tribals happen in our region. We do not know how to go ahead in this. Kindly pray that justice will prevail.

4. We are thankful for LO, a 8 year old boy who was admitted with quite bad tetanus. He made a remarkable recovery and was discharged today. We thank the Lord for his recovery. As we discharged LO, we recieved in another young girl with tetanus. Kindly pray that she will make an uneventful recovery like all the others.

5. Last week we had a very bad case of endosulphan poisoning. He was quite sick, but has made quite a remarkable recovery. We are thankful that he is alive and discharged.

6. Kindly remember SD in your prayers - SD, a mother of 5, had a rupture uterus and she reached us 2 days later. After surgery, she remained in the ventilator for about 5 days, before she could be weaned off it. However, we are almost sure that her urinary bladder has most probably sloughed off. She would need more invasive procedures.

7. We thank the Lord that we could almost complete making our hospital environmental friendly by changing over incandescent bulbs to energy saving Flourescent Lamps. Now, our maintenance department is involved in putting in fluorescent street lights - all the efforts ultimately saving quite a lot of energy. We are thankful to EHA-United States who partially financed the efforts. May the Lord bless each of the individual donors.

8. KDA, the mother with pre-eclampsia who delivered a baby weighing 1.3 kilogram has done well. The baby is also doing well and putting on weight. SDA, who also delivered a preterm baby weighing 1.4 kg - the baby has done well, although he struggled the first couple of days. KD, the mother who was in her third pregnancy after 2 previous intrauterine deaths at term, who also had severe Pregnancy Induced Hypertension also delivered a 1.3 kg baby who has since been discharged. As I finished typing this off, I recieved a consultation from Labour Room for a newborn who is 5.5 kgs (12 lbs 12 ozs). Kindly pray for this baby as the family is quite poor to afford for a specialist consultation.


9. Please continue to pray for CD, the 65 year old with one of the worst cases of self-poisoning I've ever seen. She continues to be on Atropine - we have already pumped in about 150 vials of Atropine - and I suspect that she would need more. Yesterday, I had the initial discussions with her on her poisoning. It seems that she was fed up with her insomnia. There was no other reason for her being depressed. And she is glad that she is alive. We thank the Lord for her amazing recovery. Please continue to pray for her as we manage her to a total recovery and especially heal her of her possible depression and insomia.


10. And the ultimate praise point. Yesterday, Dr. Nandamani and Dr. Ango had left to Delhi for Ango to write her DipNB theory exams. We were concerned that Ango had not got her admit card for the examination. Both of them went to the DipNB administrative office in Delhi today morning and found out that Dr Ango had cleared her examination during her last attempt. I'm still not sure of the details. But, we are ecstatic about this news. Please pray as she prepares for her practical examinations.

Unusual Poison . . .

Just now, we had MY, a 25 year old man who was brought in by his parents with the history of poison ingestion. On examination, he was frothing, had an almost pin point pupil and pulse was around 45 per minute.

As is the usual diagnosis with poisoning in a rural area, we started him off on a bolus of Injection Atropine in response to Organophosphorus poisoning.

He responded well but then he started shivering. As I sat to write the inpatient chart - I casually asked them if they knew the exact name of the poison. The father told me 'Endosulphan'. He was absolutely sure. It seems that it is very much used as an insectide in vegetable cultivation around us.

I searched quite a lot for any literature on the management of 'Endosulphan Poisoning'. I even called up my colleague in Madhepura Christian Hospital. I got some reading material which has almost helped me in planning the furthur treatment.

However, considering into fact that endosulphan is quite a dangerous poison and is in the process of being banned all over the world, it is a bit concerning that it is very freely available even now. Interestingly, Sr. Deepti who is managing MY comes from that part of Kerala, which has witnessed the horrific effects of endosulphan poisoning.

A bit more concerning was the circumstances of the poisoning. It seems MY and his father was threshing wheat with the help of bullocks. In between the bullocks were not behaving well and the father pulled up MY for not keeping the bullocks under control.

Off went MY in a huff into his house and drank the contents of the pesticide bottle. Later in the day they came with the bottle of the pesticide and so we were ultimately sure.

The next 12 hours is going to be critical. It is not even one year since MY got married. Kindly pray that MY will recover well. None of us have any experience of managing 'Endosulphan poisoning'. We welcome suggestions and advice. . .

Another hand-prolapse . . . but luckier . . .

SB never thought that she would end up in this state. It was her second baby. She had an uneventful home delivery 3 years back.

SB's pains had started on Friday early morning and she was from near the hospital. She realised that something was amiss by late evening. However, her relatives insisted that she wait for some more time before going to hospital. And to supplant the patient's efforts, one intramuscular injection of oxytocin was also given.

It could have been a dangerous wait - at around 10 pm, plopped out the hand from her birthcanal. Her relatives understood that this was quite dangerous. They knew that she had to rush straight to NJH. Although her house was not much far from hospital, they could reach only at around 12:30 pm.

As usual, after a quite busy day I was getting into sleep mode when the call came. The nurse informed me that she was not sure about the fetal heartbeat. After the last patient who had come with hand prolapse I was sure that this was also not going to be much different. I was wrong. As I kept my hand on the abdomen of the patient, I felt I got a kick from the fetus.

Yeah, the fetal heart beat was present. And quite well. Everything happened so fast after that. The baby had a poor APGAR score but the theatre staff did a good job with resuscitation. This was the second baby over the last 3 months who came out alive after a hand prolapse. In fact, the previous one was quite fresh in my mind. As was expected, the hand was quite edematous. But, it has settled over time.

We did quite a good job with using the improvised CPAP for this baby too. And we thank the Lord that he has done good.

Bonded Labour . . . Do we still have it . . .

(Kindly note that this post is written on the basis of an incident which happened in hospital today. I have enough reasons to believe that what I think has happened is true - but I do not have any solid evidence to prove anything)

SD had delivered about a week back by Cesarian section for a dead baby with a hand prolapse. We had discharged her today. We knew that she was quite poor. Unfortunately, we had sent the chart for billing and the family was informed about the bill.

Sometime around mid-morning I had a local well off person who came in saying that he was helping out to pay off her bill and that he would need some charity. Dr. Nandamani asked him why he is interested in paying the bill. He replied that the family works in his house and therefore he wants to foot the bill. Dr Nandu smelt something fishy and told that unless a male member of the house comes, he would not do anything.

The well off guy came to me and I sent off for the chart. The chart was in Dr. Nandamani's hands. Nandu called me and told me what he is suspecting. It was then that I realised that there is something major happening here which has missed our attention. The patient was from quite a far off place (Leslieganj). The fact that one of the relatives mentioned that the family works at the house of the well off guy sent alarm bells ringing in both of us.

It is quite a common practice that we see at NJH where well off local people pay off part of the very poor's bills and comes on their behalf to get some charity. Many times, we had ignored it and we were also told that such payments were made with the help of donations taken from local people.

I called a male relative of the patient who told me that whatever payment was being made is wholely from the side of the patient. I asked the relative where the money was. He told me that it was with the well off person. I asked him how they were able to mobilise such an amount. They told me that they pawned a cycle, few jewellery and some of it was given by relatives.

The bill was 11,0000 Indian Rupees. The family told us that they will pay 8,000 Rupees. I told them to pay Rs. 4000 Rupees and wrote in the chart. Later, as I asked the cashier on how much was paid -  I was astounded to find that the well off guy had insisted that he takes Rs. 8000. It was obvious. There was more to the payment that was done than a mere help to a needy patient.

Or is it just wild and wishful thoughts ? ? ?