Syphilis . . . Forgotten foe . . .

Syphilis . . .The very mention of the term used to send shudders in patients and was the darling of medicine professors for quite a long time. It was described as 'the great imitator' by Sir William Osler. One of my professors used to tell that in the olden times, a post-graduate student of Internal Medicine was assessed by how much he knows about syphilis and it seems that the same status is presently enjoyed by HIV-AIDS. 

Well, why I started a post of Syphilis? Over the last week, I had two families diagnosed as having the TPHA test positive. None of the members of the family had any symptom. 

Here are their stories . . . I know there may be quite a lot you may want to comment on them, which I would like to hear . . . 

The first patient was MS, on whom we had to do a Cesarian Section after a complicated trial of labour elsewhere. Before the Cesarian section, MS was diagnosed to have a low hemoglobin and we asked her relatives to arrange blood. The husband had her same blood group and he was ready to arrange blood. Well, on screening of the donor we found out that he is TPHA positive. As a rule, we do not do TPHA on patients who come at term. We do them only for those who come in the first trimester.

Well, by that time the Cesarian was over. We tested the mother and the baby. Both were positive. They very well understood when we counselled them about the disease. 

When I rejoined NJH in June 2010, I had done a re-look at the blood tests we do. Since, almost all of our patients are poor, we were trying to cut down on the tests. We did not find any TPHA positives in any patient for almost 2 years. There were few HBsAg positives and no HIV positives among the antenatal patients. I decided to drop doing TPHA, the main reason being that quacks were quite prompt in prescribing antibiotics and therefore I came to conclusion that this must be the reason that there was no TPHA positive for so long a time. 

However, the protocol was do TPHA in the first and second trimester for all ante-natal patients and drop it for those who come in late third trimester or directly to labour room. 

I was contemplating on whether I should bring back the policy of doing TPHA for all pregnant patients when the next patient arrived. 

One of our antenatal patients who landed up in labour room was found to have a reactive TPHA which was missed in the antenatal period. There was nothing much we could do now other than to re-check TPHA. Unfortunately, the TPHA turned out positive and after the delivery the baby also was reactive. 

I called the father, a man in the armed police force. The fellow looked quite disturbed and a bit drunk. I told him about the TPHA reactive status of his wife and child. He seemed to be hardly bothered. The only thing he wanted was to go home ASAP. I told him that he also needed to get tested. He would have nothing of it. He told me that he had issues to attend to at home and therefore needed to get discharged immediately. 

We tried our best. Ultimately, armed with consent forms on what all will happen and accepting full responsibility if something untoward happens in the future, he was off with his wife and child. 

Questions I have in my mind . . . 

1. TPHA is expensive. Should I do it for all pregnant patients irrespective of when they come - especially when they reach Labour Room straightaway after Antenatal Care elsewhere. Most of the places, VDRL or TPHA is not commonly done. 

2. When I have patients like the latter, what do you do? They are high risk to the community. 

3. Could we have donated blood from the TPHA positive husband to the TPHA positive wife? We had a bit of difficulty getting blood after the husband was refused as a donor. Crossed my brain only now . . . it could have been done. 

2 Happy Families . . . Could have been tragedies . . .

Over the last week, in addition to the tragedy of 3 members of a single family getting burnt, we did have our moments of joy. . .

The first reason for the same was SD1. SD1 came about 10 days back in a terrible state. It was SD1's first pregnancy. There was no antenatal check up. She had turned up at the neighbouring district hospital after being in labour at home for some time. It was sometime before the people there realised that SD1 looked a high risk case.

SD1 had a hemoglobin of 5 gm%. On per vaginal examination, the cervix was edematous with dilatation of 5 cms and there was meconium pouring out. I was in a fix. The referral letter mentioned that SD1 is being referred to Ranchi. We needed blood. There was only one bystander.

I was thankful when the blood matched. But, one pint was never enough. I was sure that the hemoglobin would be lesser than 5 gm%. However, we had to do the surgery. Otherwise, we risked having a rupture uterus and a dead baby.

We went ahead with the surgery. The baby was sick. But, he somehow pulled through. The bystanders were  quite fast is arranging two more pints of blood. It was quite a relief when SD1 recovered soon to be discharged.

The challenge for us was the bill. Because it involved 5 blood transfusions and neonatal care, the total bill was around 20,000 INR. The family was too poor. It did not need much convincing that they would not be able to afford even half of this bill. They paid about 10,000 INR. The rest went as charity. It is a burden for the hospital. But, considering our vision and mission, we have to make such concessions. . . 

The next patient was SD2. Married for 14 years, the family did not have issues. The interesting aspect was that she had a whopping 8 abortions. And the saddest part was that she did not take much interest to do any antenatal check up during the present pregnancy. The delivery was uneventful. It was a pleasure to watch the joy of the family as they adored the new arrival. 

The last one was 2 days back. SS had come with usual labour pains after an uneventful antenatal period. On arrival in labour room, Dr Johnson diagnosed a breech presentation. Since she was a multi, we did not anticipate much problems. But, as soon as the breech was out, Dr Johnson was sure that there was one more baby inside. And yes, she had a surprise twin delivery to add to her already large family of 3 children. 

All the 3 deliveries, especially the first two could have ended up as tragedies. We are thankful that all the babies and mothers are doing well.

Over the last 2 weeks, the 'marriage season' has started in this region. It is very hilarious. Everything revolves around the weddings. Almost everybody in the ward requests for a discharge citing excuse to attend a wedding or to get married . . . We expect quite complicated cases to come in during this period. In addition, we have students from the Christian Medical College, Vellore visiting us for the next 2 weeks. Do continue to follow the blog . . . there should be interesting posts continuing . . . 

Burns . . . Heart wrenching . . .

Well, couple of days back, the last Thursday to be exact, I was called in to help Dr Johnson in his duty. Dr Johnson was operating. And there were five patients coming together into Emergency - quite a crowd for any ER. 

The first two who came were couple of drunk city kids on their way to a marriage function in Daltonganj. They had not seen some road work happening and had skidded over a barrier which was put up. They did not have much problems other than some contusions and minor lacerations. 

Soon came in this family - mother and two children burnt. The culprit - a burst kerosene lantern. Nobody was quite sure on how it happened. The mother, in her late twenties was badly burnt in her left arm. Another girl was burnt a little over the back and buttocks. 

The saddest part was the boy in the house, 8 years old. He was burnt all over - Nandamani calculated 89%. The family was devastated. We thought that he would die soon. It's Monday evening today. He's pulled through so far. We are just managing him symptomatically. There is hardly anything we can do. Nowhere is there any skin to do a graft. 

The worst part is that the rest of the family is that the mother is so depressed that she is not willing for her own treatment. Even Nandamani was in depression . . . 

When I gone for the Burns Retreat in Sylhet, Bangladesh, there was so much discussion about the kerosene lantern - called 'kuppi batti' in that area.  It causes quite a lot of the burns that we see in this part of the country too . . . 

There are crude ones like the one below. Many a time, they are just old bottles with a wick screwed on the top. 

And then there are the better 'safer' ones like the one below. Many people think that they are safer than the above ones. Of course, safer if used properly. I've had many instances of these bursting. Even a personal experience of one bursting in front of me and I getting away without much injuries. 

Well, the problem as far as I realise occur in 3 ways - 

The first one, is a problem with cleaning of the wick and the lamp regularly. Many a time soot accumulates and sometimes some foreign body especially insects get entangled within the soot. If you don't do the regular cleaning, the soot along with the foreign body mixes up with the oil and catches fire - resulting in the lamp getting burst. Almost functions like a Molotov cocktail. 

The second one, is the issue with getting good quality oil. Unscrupulous traders mix diesel or petrol or even old cleaning oil along with the kerosene oil resulting in bursting of the lamp during use due to differential inflammable temperatures of the different oils. 

The last problem and the third one, which is more common occurs due to someone tipping over the lamp, especially when it is kept on the floor. As you can see, most of these lamps come with a small base which tips over fast. . . 

Many a time I wonder why we can't mass produce cold sources of light and distribute them as part of the Public Distribution System of the country. . . We can save many a family from getting burnt . . . 

It is so depressing whenever I see one of the relatives of the family . . . The family is so poor. They cannot afford anything unless the father goes for some manual labour . . . Oh my, oh my . . . Why do I see things like these ? ? ? 

Licensing . . . Easier to Kill than Heal . . .

Well, over the last few weeks, I've been struggling at various fronts about the laws slowly being implemented which would make it quite difficulty for healthcare institutions and providers to be in the service of improving health in the country especially for the common man. 

It is of course true that we boast world class facilities in healthcare such that 'Medical Tourism' has become a very common term for many a corporate hospitals. But, the fact remains that the doctor : population ratio remains abysmally low in almost a majority part of the country. More so, as I mentioned in a previous post, the consultant : population is all the more in a precarious state. 

Over the last couple of years, I've been trying to push the  need for Family Medicine consultants as well as Maternal & Child Health consultants in the country on a larger scale to cater to primary and secondary health care needs of the population. Although the National Board of Examinations have accredited DipNB in Family Medicine and Maternal & Child Health, there has not been much of an encouraging response from the Medical Council of India. 

In fact, it is not very difficult to come to a conclusion that healthcare in India would benefit much from the presence of more Family Medicine and Maternal & Child Health consultants rather than other speciality consultants. 

Just one incident and a thought which went through me when it comes to issue of consultants managing all cases pertaining to a specific speciality. Now, as I had mentioned about this in a previous post, I put my arguments in the light of the high densely populated regions of rural India where even the presence of a doctor with an MBBS degree is a luxury. 

Yesterday, I had a call from our Insurance Provider of RSBY. He wanted reason why we did a Osteotomy Femur of a young man who had been struggling with the condition for almost 5 years. This guy had a accessory piece of bone jutting out from the lower aspect of his thigh. He had multiple episodes of injury. The treatment was to remove it. The problem was that he had gone to couple of orthopedicians and all of them wanted a hefty amount which his family was unable to afford. 

Then, he came to find out about NJH being empanelled under RSBY. He wanted to know if this surgery could be done. Our surgeon, Dr Nandamani was confident that he could do it. The young man underwent the procedure and is doing fine. Now, our Insurance Provider wants to know why we did the surgery without an orthopedician. 

I asked the local fellow on whether he had an orthopedician empanelled under the scheme in the nearby region. The answer was no. The complete truth was that there was an orthopedician who was empanelled under the scheme last year, but he had come to the conclusion that RSBY was not paying him enough and decided not to continue it when the option for re-empanelling arose. 

The other option would be to go to Ranchi and find out an RSBY empanelled orthopedician and get the surgery done. But, that involves quite a lot of overhead expenses which the insurer would not pay. Therefore, he got the surgery done at NJH. 

Now, I thought of doing the same exercise I did for the obstetricians in the last post. The question was about the ideal orthopedician : population ratio. Well, as per my information, there are 3 orthopedicians in the whole of Palamu, Latehar and Daltonganj. 

Now, coming to the thought that crossed my mind last week

I hope all of you know about the Medical Termination of Pregnancy Act of the Government of India. I remembered the clauses which stipulate on who can do an abortion. I could not believe when I contemplated on the same. In addition to an obstetrician, any doctor who has done 6 months of internship in Obstetrics and Gynecology in a teaching institute OR one year of work in Obstetrics and Gynecology department of a hospital OR assisted 25 cases of MTP in an institution recognised for the purpose. 

I had studied this many a time for my graduate and post-graduate examinations. But, did you notice the last part. Just assisting 25 cases of MTP would actually give you the 'licence to kill'. And mind you, you could end up killing both, as a MTP is not without any associated danger to the mother. 

In the light of this, could we look at procedures which heal. Medical graduates without post-graduate training has been doing yeoman service in many areas of the country in rural areas doing procedures which would cause frantic scenes in the Emergency Rooms of many a super-speciality hospital. In fact, there was one generation of doctors who believed in training up willing medical graduates in all aspects of medical specialities as people in rural hinterlands of the country could never think about going to a superspecility centre. 

Unfortunately, very few of our policy-makers are aware about ground realities. They bring in acts like the CEA where you need consultants of different specialities to attend to a simple physiological condition like a normal delivery. 

If the legislature can give the license of kill once a medical graduate observes 25 MTPs, I'm certain that it would be unethical not to give the license to practice any speciality of medicine to a doctor who passes out with a MBBS degree. But, of course - the patient should be well aware of who he is going to. In places like ours which are umpteen in 3rd world countries, a couple of well qualified and experienced medical graduates would be more worth than the hoard of quacks who populate the area. 

The fact that there are quacks who freely practice modern medicine including surgeries without any sort of qualification should deter the government from being upfront in demanding that only specialists manage the corresponding disease condition concerning their specialities and nobody else do anything with them. 

A common refrain that we here at many of the mission hospitals including NJH. . . 

Doctor saab, humlog yeham thak bahut ummid ke sath aye hain . . .Hamare liye ye bahut bada baat hai. Hum aage nahim leke ja sakte. . . Jo karna hai, aapko hi karna hai . . . (Dear doctor, we have come till here with great faith in you. Coming till here is a big achievement for us. We can't go further. Whatever needs to be done, has to be done by you.)

The last one to give me this dialogue was the parent of a little boy for whom we could not come to a diagnosis. Most probably, he had a brain stem tumour. I asked the parents to take him home. He was referred by someone we knew - he died at home 2 days later. . . 

So food for thought for the weekend . . . If we can obtain the license to kill our unborn without much difficult, why all the fuss being made about need for specialists especially when you have so few of them . . . more so, when it comes to under-served and remote areas of the country. . . 

Doctor Shopping . . .

3 days back, I had a young man in Emergency with fever for a duration of 7 days. Quite an expected event with the advent of summer. Last year I had written quite a lot on the umpteen number of fever cases that we ended up managing. 

The interesting aspect was that NJH was the 5th healthcare provider his family has taken him to. The unfortunate part was that NJH was more close to his home than the rest of the other providers if you exclude the village quack to whom he had gone initially. 

He had already received almost all the common high end antibiotics that is available in the market as well as all anti-malarials except Quinine. And he was from a well to do family with some amount of education . . .

I counselled his parents and told him about the futility of getting treatment like this. I was not at all interested in taking the young man in for treatment. The family was well off, they could afford to take him to Ranchi and a continuous fever of 7 days duration was not something trivial. 

Armed with a high risk consent, we started to manage him. On examination, we got a suspicion of meningitis. But, the lumbar puncture was negative. The blood tests were negative for malaria. There was lymphocytosis with increased polymorphs with toxic changes and a shift to the left. Renal and Liver functions were within normal limits. 

I covered him with high dose antibiotics and anti-virals. For 24 hours, there was no respite of the fever. Then, I started him on intravenous quinine. His high grade fever has come down. But, he again had one spike, although a smaller one in the evening. I hope that he'll become better and I was most probably dealing with a partially treated malaria. 

Now, Doctor-Shopping is a major problem with the sort of healthcare we have in India now. 

With almost 70% of actual healthcare happening in the private sector, patients are on the run searching for the magician who will get rid of their sickness. The competition between doctors and healthcare institutions makes things more worse. . . In the modern era of evidence based medicine, there is not much of a choice in varying treatments. The impetus is on making a good diagnosis. 

Rather, by doing Doctor-Shopping, patients put themselves at a high risk of getting multiple types of antibiotics and medications. Of course, things become difficult when there is a challenge in getting investigations of your choice with assurance of good quality. 

The quality of medical education only makes things worse. 

Recently, I came across a colleague working in obstetrics in a big hospital in the city. I came to know that his department routinely prescribes intravenous Ceftriaxone for all Cesarian patients irrespective of the indication for a total of 7 days. It was pathetic. He told me that nobody wants to take any chances. It was so unfortunate. It was done so that patients would not go doctor-shopping. But, at what expense. 

Drug resistance in almost all the spheres of microbiology is a major challenge to healthcare. Doctor shopping is something which would built up drug resistance. 

Protocols for diagnosis and treatment prepared by different agencies on various disease conditions and symptoms are available for almost all major diseases. A strict adherence to the algorithm almost always helps in the correct diagnosis. It is cheaper and easier process to go through. 

Now, the question is who will adhere to protocols. This is the situation where a family practice consultant would be of benefit to the patient, especially when he/she is poor. Another point in favour of introducing family practice consultants in a big way in the Indian healthcare scenario . . . I hope the concerned people lend a ear . . .