Bizarre Obstetric Care . . . The Sad End . . .

Sometime around 12 in the afternoon, we declared AD clinically dead. She had been struggling after the surgery. She could hardly breathe on her own and she was hooked onto the ventilator. 

We had trouble maintaining her blood pressure and was on ionotropes. 

Per-operatively, the abdomen was a mess. According to Nandamani and Titus who did the surgery, the uterus was like 'putrefactive minced meat' and the peritoneal was all stinking with dilated bowel loops. There was no way the uterus could be removed as the uterine vault was all necrosed and flimsy. They closed the uterine rent and came out after putting in couple of drains. 

The nasogastric tube was draining all stinking coffee ground material. 

As I sat with the AD's husband to fill up the Facility Based Maternity Death Review, it was very obvious that he had hardly been caring for his wife. Married for 10 years, the only thing he had to say was how burdensome his wife was for all these years. The tone was bordering on how good it was that she died . . . 

It did not need much questioning to realise that he hardly bothered how his wife fared. The first baby born by a Cesarian section had died at birth as the labour pains were happening at home and he took her late to hospital. The next delivery he tried at home and when nothing much happened, he took her to hospital, where she had a normal delivery. The third delivery was again tried at home. 

That was his excuse for trying the fourth one at home . . . there was some problem. So, he took her to hospital. Delivered in hospital where nobody picked up the rupture uterus. They brought her here as she was not feeling good after delivery. Then, we asked for blood. I found out that the husband's blood group was same as that of AD . . . but, he was hardly bothered about donating blood. 

He took her back to the place where she delivered rather than to Ranchi . . . They transfused 3 pints of blood without doing any surgery. . . It was already 4 days after the rupture uterus when she came here a second time. The family told us that they were not willing to take her anywhere else. . . If she dies, she dies . . . 

She died. . . The husband was worried about the children . . . 2 girls aged 3 years and 2 years. . . They would be orphans . . . . more so if the husband remarries . . . 

Talking about girls, over the last week, we've had enough stories of violence related to the female gender. The one which happened in Bangalore was very very sad . . . The second incident which happened near Kolkotta crossed all limits of cruelty one can witness . . . 

And after I had penned this post, yesterday night, I had this unfortunate lady being wheeled into emergency. She was beaten up by her alcoholic husband . . .Bones in both her hands have been crushed into multiple pieces with some foreign body lodged in one of the hands . . .

The unnerving aspect of all such incidents is that one gets the feeling that such incidents are on the rise . . . which is not a good sign for the society. . . When I look at Maternal Health care, I'm quite convinced that things would not improve until we give more respect and value to the women and girl children around us . . . 

Praise and Prayer Bulletin. . .15th April, 2012

1. We thank the Lord for the safe delivery of Dr Angeline. Our third one, Chesed Tabitha Kuruvilla arrived after a very short period of labour pains at 8:35 pm on the 11th April. Please continue to pray for Mrs. Chandrakala and Mrs Kanchan who are also expecting within the next 2 weeks.

2. We praise God for the healing given to BS, who was unconscious for almost a week (We had done a lumbar puncture on him and there is a snap of cobweb appearance). He had to be put in ventilator for a day. It is such a blessing to see him smile as we go for rounds each day.

3. Our RSBY work is going in full swing. We had our first patient with a snake bite who was treated successfully using RSBY Smart Card facilities. Please also pray for the 8 year old girl who has been admitted with the snake bite.

4. All of our obstetric patients who came over the last week have recovered well, including MD have recovered without much complications. We thank the Lord. However, we have yet one more patient AD who is quite a bad shape after surgery today. Please pray that she would make a miraculous recovery. Dr Nandamani did surgery on her. The uterus was very friable with a bad peritonitis. She is on ventilator and ionotropes. 

5. The Clinical Establishment Act is in the process of being implemented in Jharkhand. There are quite a lot of implications for institutions such as ours. We need more staff with qualifications. Kindly also pray that there would be separate regulations for rural institutions such as ours. 

6. Dr Ango is on her way today night to attend to her DipNB Practical Examinations at Nagpur on the 17th April. Kindly remember her and Dr Nandamani as they travel.

7. The electricity problem in the region continues to be in a bad shape. We need almost 150 litres of diesel every week to ensure round the clock electricity supply to the hospital and about 10 hours of supply to the residences. Please pray that there would be improvement in electricity supply. 

8. We thank the Lord that the repairs are happening on the road to Daltonganj. Please pray that the repairs would be completed soon. 

9. Tuberculosis continues to be one of our major concerns. The load of patients whom we see baffles me and I'm quite concerned about what is happening with regard to development of resistance due to partial treatment. I pray that someone will be burdened to develop a Respiratory Diseases Centre at NJH. Considering that we are already a Tuberculosis Unit, there is a huge potential.

10. The Burns Unit construction is going on in a full swing. We praise God for the funds received so far. We are also getting quite a few patients whom we've managed well... We thank the Lord for all of those who have supported us so far. We need more committed staff to manage a full fledged burns unit. Please pray. . . 

Start of the new season . . . Snake Bites . . .

Summer has started and patients with snake bites are back. Over the last one week, we had 3 patients - first one with viper bite, and the other 2, cobra bites - both of them coming over the last 2 days. 

The second patient, and the first cobra bite victim, a middle aged lady who was bitten yesterday night had come sometime early morning yesterday. She was hardly breathing and was in a total neuromuscular paralysis. It seems they had been trying black magic (locally called 'jhad phuk) to remove the poison all through the night. 

Early yesterday morning, someone suggested that she be taken to NJH for treatment. 

She had to be intubated immediately and started on mechanical ventilation. She responded quite well and was out of the ventilator within 2 hours after having received 10 vials of the anti-snake venom. By evening, she was sitting up and we kept her for observation overnight. She has some local swelling which would take some time to subside. 

Well, she is a milestone patient for us as she has been treated completely free under the RSBY.

The third patient, a young girl with an unknown bite came sometime late afternoon today. The diagnosis was very obvious - either a krait bite or a cobra bite. The clotting time came out normal. Therefore, cobra bite. In went 10 vials of the anti-snake venom and she was soon on her way to complete recovery. 

However, I should tell you a bit more about the little girl. She had been bitten sometime early morning. She came straightaway to the district hospital. She was kept there for about couple of hours although a diagnosis of snake bite was made. And at around 1 pm, she was referred to Ranchi. Someone suggested that they try out NJH. And that's how they reached here. 

It is unfortunate that the district hospital has no facilities to keep ASV, when the prevalence of snake bites are quite high in the region. 

Bizarre Obstetric Care . . .

As I write up about the different patients to come to us for care, I always pray that things get better as each day passes. Unfortunately, it does not seem so. The number of patients with rupture uterus and eclampsia continue unabated. Of course, on and off, we get patients who were saved from certain death because of timely intervention . . . 

But, one lady who came yesterday broke all limits of imagination on how careless and ignorant can people be when it comes to obstetric care. . . 

I was in Out Patient yesterday (13th April, 2012) when at around 2 pm, a lady with a distended abdomen was wheeled in. The history was that she had a normal delivery on 10th April elsewhere following when the abdomen got progressively distended. They also told me that somebody had diagnosed her to have a rupture uterus following the delivery . . . 

The lady has been married for 12 years. . .  and the family did not have children for about 8 years. The first delivery was a tragedy. For reasons unknown, she ended up with a Cesarian section, but lost the baby. . . The next two deliveries were normal . . . and one done at home and the other in hospital ! ! ! In between, she had 2 abortions. 

Then came the fourth one, they tried a home delivery . . . but started to have difficulties, for which they came to the district hospital. She ultimately delivered normally. The baby was dead but she started to become sick. She was brought to us in a terrible shape on 11th April, 2012. So, she was P4L2D2A2. 

It was obvious . . . the uterus had ruptured. Her Hemoglobin was 4 gm%. We asked the relatives to get blood. She had about half a dozen male relatives but nobody was ready to give blood. 

It was fine, if there were no relatives to donate blood or if all the relatives got their blood group checked and then none of them matched. In such a situation, many of us from among staff have donated blood to patients. 

We told the relatives that they better take the patient to Ranchi. They did not hesitate to take her away. 

We had forgotten about her. 

And then they came back yesterday. We shall call her AD. Now, it took some time for me to discover that AD was the same patient who came to us on 11th April, 2012 and was supposedly taken to Ranchi. 

So, I was quite inquisitive to find out what happened after the relatives took her from here on the 11th. It seems they took her to the district hospital in the adjacent district. They told her everything will be fine once blood is transfused. And they managed to get hold of 3 units of blood. . . Nothing else was done. 

It was obvious that the patient was deteriorating. Later, someone told them that this sort of patient can only be managed at NJH or Apollo. And, therefore, she was brought here a second time. 

The patient was obviously sick. The hemoglobin was 10 gm%. She was dehydrated. We were sure that we will operate only if we had at least one pint of blood. Unfortunately, the relatives were not relenting. It required quite a lot of counselling from our side. I'm glad that they arranged one pint of blood today morning (14th April). As I write this, Dr Nandamani would have started operating. 

We pray that she will do well . . . 

Now, major lesson learnt here - lack of adequate medical facilities within the country. I had written quite a mouthful on a new act which is going to be implemented soon. What will patients like AD do when such a act is implemented?

Photo Post . . . 14 April 2012 . . .

A glimpse of happenings at our place over the last week . . . .

X-Ray abdomen showing Sigmoid Volvulus

The same patient per operatively . . . 

Gall bladder with stones . . . 

This man with multiple swellings on his nose has been wanting to get it removed. . .
Recently, he had acquired a RSBY Card. I've promised to review when Dr Hiles comes visiting next time . . . 

Another view of the same patient . . . 

This patient already had tuberculosis treatment three times. As of now, his sputum is not positive for Acid Fast Bacilli. The major problem is that his lungs have been badly damaged. Damaged lungs and its management is one aspect of tuberculosis treatment which is hardly given much importance . . . 

Another patient with tuberculosis

Another patient who came with breathlessness who had anti-TB treatment for about a month about 10 years back . . . 

Miliary Tuberculosis 1

Miliary tuberculosis - 2

The spread of the disease and drug resistance is on the rise because of prescriptions like these . . . 

Pelvis of a young man on whom a murder attempt was made by running a tractor over him . . . Alleged caste violence. . . 

This is how a patient rather 'a dead body' was brought couple of days back. The patient was brought all the way from Gaya in Bihar. From the old treatment prescriptions, it looked like he was suffering from cardiac disease. . . Unfortunately, he died on the way . . . Tells volumes of healthcare in our part of the country . . . Gaya is about 250 kms from our place and has tertiary care facilities . . . . For those who could not recognise the snap, there is a body lying at the front of a mini truck . . .