Little rats, rather mice . . .Need help

One of the stories that used to really stir our imaginations during my childhood was that of the Pied Piper of Hamelyn. I used to really think about myself as the Pied Piper who would lead all sorts of animals with different tunes from my imaginary flute.

Well, of late, I really wish I had the powers of the Pied Piper. Because, we have been facing a real challenge with a sudden spurt in the population of rats and mice in the hospital as well as in our residences. Dealing with rats is not that difficult – they are quite large and eat poisoned baits as well as are easily trapped.

The problem is with the small mice. I never thought we had a major problem till last week, when our maid told me that a lot of clothes were being damaged. I was quite busy with work, till she kept 3 killed mice for me to see.

The next day, my fur-phobic better half was after me to clean up couple of old boxes in which we had kept a water hose and some footwear. Well, it was a revelation. In fact, we realized that we were a breeding station for mice.

After that we had a major discussion about how to control these pests. Nobody had much of a clue. I tried to put powdered poison – but these mice did not eat any of those. Suggestions are invited from our well-wishers on how to control these little pests.

Praise and Prayer Bulletin - 20 Dec 2011

1. We praise the Lord for LO and SK, both children with tetanus who made remarkable recoveries and have been discharged.

2. There has been a situation of unrest in the region over the last month. There were about 12 days of total shutdown which affected hospital work to quite an extent. In addition, there were patients like RD who died because of inability to go ahead after referral. Please pray that there would be everlasting peace in the region.

3. Tuberculosis continues to ravage the country, especially our region. As a Tuberculosis Unit, we are looking at new strategies to address this terrible scourge. We praise for the team led by Dr Johnson as well as requests prayers for the future.

4. We have seen a spurt of patients with alleged history of poisoning. Most of them could be successfully saved but there were few of them like CD who did not make it. We are not able to do full justice to most of these patients as the part related to counselling them does not happen many a time. Please pray that we would be able to respond to such cases more positively.

5. We praise the Lord for the 3 very sick pregnant patients whom we were able to save over the last 2 weeks. SDe, who had come in with a very bad eclampsia with pulmonary edema was a miracle. She was in the ventilator for 5 days. She is doing well and would be discharged tomorrow. SeeD also has improved although she has a bad vesicovaginal fistula. She has run up a bill of about 40,000 which I'm definite that her family would not be able to pay. SeeD was also in the ventilator for 3 days. SakD, the patient with the rupture uterus had a very uneventful recovery.

6. Please pray for the families of ND, who died unexpectedly after malaria complicating pregnancy and RD, who had severe eclampsia. There needs to be quite a lot to be done in public healthcare in this region before we can think about preventing such unnecessary deaths.

7. We've been seeing quite a number of sick malaria patients over the last 1 month. It is quite unusual to see such patients during this winter. Please pray for protection for our staff. As well as ability to treat such patients when they come to NJH.

8. We organised a Christmas get-together for our neighbours around the hospital campus, which was well attended. Initially, there was quite a lot of apprehensions about hosting such a programme. We praise God for the response from the local community. We request special prayers as we plan for a more closer interaction with the community we serve.

9. Along with the rest of India, Jharkhand has also been severe affected by severe cold. According to the press, about 50 people have lost their lives in Jharkhand. But, our friends in the villages tell us that it is only the tip of the iceberg. The poor are really hit by the cold. Kindly pray that the cold wave will subside and that there would not be any deaths.

10. The hospital celebrates Christmas on the 22nd December with a dinner and on 27th December with the staging of the Christmas play. Kindly pray for all the arrangements. Quite a lot of staff and families are away during Christmas. Please pray for all their travel. In addition, the hospital functions with skeleton staff. Kindly remember Drs Nandamani and Ango who have been shouldering clinical work since the 17th. Dr Johnson would join work from 23rd December.

11. Last week, we were able to install 2 Multipara Monitors, thanks to a kind donation from churches in the United Kingdom through Dr. Colin Binks. We thank the Lord as well as all the donors. We have already used it well.

12. In response to our wish list for 2012, we've started to recieve quite a few donations. We thank the Lord for all the donations and well as pray that more gifts will follow soon.

The 2nd Maternal Death. . . Many lessons to learn

Carefully read this report of the maternal death, the second one of the previous post on ND. There are a lot of lessons to be learnt especially something which I've been emphasizing in my blog.

RD, a 25 year pregnant lady almost at term had multiple episodes of seizures since Friday night. She went to the nearest health centre which was not a government run health centre - a mission hospital about 135 kms away from our place. I'm not sure of the circumstances of her going straightaway to this mission hospital where there is not much facility for any secondary care - but similiar to us do a lot of secondary care especially in obstetric and malaria treatment.

RD was unconscious by the time she reached the above mentioned mission hospital. And it was Saturday morning.

I recieved a call from one of the main nurses of this place saying that they have referred RD. I was quite busy and told her not to refer as we were having a tough time and I was leaving on vacation. But, it seems that RD had already left. I informed the labour room that such a patient is coming and I should be informed as soon as the patient comes.

I was doing all the last minute clearing up of office work and I totally forgot that this patient would be coming in. I was on leave and it seems that Dr Nandamani had told that he be told of every patient who comes in.

After I entrained, I happened to call up Nandu who told me that a very sick eclampsia patient had come in sometime in the afternoon and he had referred her. I told him that was fine and told him that I had asked the nurses to call me as the patient came in. But, then, they saw me rushing to and fro finishing my work before rushing to catch the train.

Next day, as I called up Nandu, he seemed quite disraught. After he had the shock of having lost ND, he had to deal with RD too. It seems that he was quite busy with other patients and RD did not leave NJH for quite some time. By the time her family arranged everything to take her to Ranchi it was late afternoon.

As they travelled to Ranchi, they were stopped by policemen on the way saying that the route was quite dangerous and they would not allow travel. With quite a lot of social unrest going on, this was a common occurance in this part of India. Many a time, travel before 5 in the morning and after 6 in the evening is not without risk.

RD came back to NJH. She was still unconscious and was putting out frothy pink sputum from the mouth. Similiar to SDe on whom we spent quite a lot of our energies, RD was also quite sick. Nandu hooked her onto the ventilator, but she was too sick for attempt of any sort of intervention. RD died by midnight.

Recently, there was some bit of discussion on one of the social networks about the cause of maternal mortality. I've always maintained that health education and social changes are only possible once we have a robust system of healthcare put in place.

Most of the places where the MMR is high has a very poor public healthcare system. 3rd world regions like Sri Lanka and few states within our own country boasts of high standards of maternal and child health indices only after they've had basic necessities of primary and secondary healthcare and to some extent tertiary healthcare put into place before all the other social engineering measures including changes of health seeking behaviour was attempted. (In some places, it was done alongside)

In the region (block level) where we serve, we had run a 3 year programme on reducing maternal and infant mortality. One of the major emphasis that we had given was on taking the patient to the nearest healthcare centre on earliest signs of complications. But, if you had noticed - in most of the maternal deaths and the maternal near misses which I've documented in this blog, almost 70% of them had taken the expectant mother to a government health centre - subcentres, primary health centres and even district hospitals. And there were glaring deficiencies.

Before I finish this post, I need to tell about ED. The story is pathetic. I did a Cesarian on ED on Friday afternoon (16th Dec) for the indication of hand prolapse and obstructed labour. The baby was alive on delivery but died soon after.

ED's pains had started sometime on Thursday morning. It was her 4th pregnancy - the family had 3 girls and social norm demanded that she has a boy. The traditional birth attendant who saw ED had diagnosed the complication as soon as she had done a pervaginal examination. And she had told the family to take her very soon to a hospital . . . Which they did . . . The nearest Primary Health Centre . . . who also diagnosed her complication and had referred her to the District Hospital.

ED remained in the district hospital from Thursday evening till Friday morning when she was told that nothing more can be done there and to take her NJH. Which also they did . . .

But it was too late. The baby was moribund . . .with only the heart beating. The lungs were all clogged with thick meconium. We intubated the baby and tried to suck it out. But, it was too late. . .

ED's family and RD's family did the right things, took decisions at the right moment. But, the healthcare system failedt them. For RD it was more than that.

 

I'm not out on a blame game. What I want to emphasize is that we would not make much progress on all our umpteen health related goals without giving utmost priority to our healthcare system. No amount of health education or attempts at changing social beliefs are going to change health more than serious attempts at ensuring that the three tiers of public healthcare are in place to at least some extent.

Per operatively, it was a difficult case. She narrowly missed a uterine rupture. The bladder was all edematous and there were multiple hemorrhages on the lower segment which was dangerously thinned out. Some part of the lower segment had dehisced out and was like mincemeat. The baby was very badly impacted in the inlet.

After all that had happened with ED, the biggest disappointment for ED's family was that the dead baby was a boy. They wished they had brought her straightaway to NJH. But, they have not realised that it could have been worser. ED still runs the chance of developing a vesico-vaginal fistula.

2 Maternal Deaths . . . The first one . . .

We had 2 maternal deaths on Saturday (17th Dec), the day I left NJH for my vacation.

One of them was quite expected and the other was quite unbelievably shocking. One happened in NJH and the other occured at Medical College, Ranchi.

I had written about ND in my previous post. Clinically, ND was improving. However, I was not confident of continuing to treat her at NJH as Nandamani was going to be alone from 18th December. We had been talking to her relatives about having her treated at a higher centre from the very beginning.

The plan was ultimately to do an Ultrasound of the fetus on the early morning of 17th December and then to refer her to Ranchi. I was on call on the 16th and sometime during midnight, her relatives requested that they be allowed to take her early morning of the 17th without waiting till daybreak for the ultrasound.

The next thing we know is that her dead body was brought sometime in the evening to NJH emergency. It was unbelievable. The story was that she reached Medical College, Ranchi at around 8:00 am. Ultrasound revealed that her 28 week fetus was dead. The doctors started treatment. She was feeling fine. She had her lunch at around 12:30 pm. But, she was found dead on her bed at around 1:30 pm. There was no explanation given.

But the reason for which the dead body was brought to NJH emergency was different. After the relatives reached back to her home at Satbarwa, one of the local quacks gave an opinion that she does not seem to be fully dead and that her heart is still going on. So, they rushed with the body to NJH.

The story is quite a sad one. But, that is how life goes on this region of our country. 

X-Ray Spine Finding . . .

The X-Ray given below is of a 65 year old man who came with severe back pain and evening rise of temperature since the last 2 weeks. In addition to the extensive amount of osteophytes, we just could not come to a conclusion on a faint homogenous opacity jutting out to the left at L3-L4. His ESR is 124 mm.

Kindly throw light if anybody has a clue about what it could be.