Maternal Death . . . The Third One

This is the account of the 3^rd maternal death we had over the last 24 hours.

RKD was brought just in as we were doing the final and last attempts of resuscitation onMD. RKD looked dead except for the faint gasps. We intubated her and had her hooked to the ventilator. Her blood pressure was a whooping 280/175 mm Hg. Urine albumin was 4+.

RKD’s history was mindboggling and spoke volumes of the care available for women as well as about how expensive we were to the common man.

RKD who was about 7 months pregnant with her third child suffered her first bout of seizures sometime on the 29^th of July. As is common, they summoned the local wizard to do the needful. The seizures were controlled and she did well.

She had another episode of seizures sometime on Wednesday, the 1^st of August. Someone advised them to come to NJH, but someone else dissuaded them saying that it is expensive. Instead they went to one of the private hospitals in Daltonganj, where they were asked to come to NJH.

Instead, they went to the local district hospital. The doctors at the local district hospital asked them to go to NJH. They could not make up their mind. On 2^nd August morning, someone told them about a ‘famous practitioner’ in the neighboring district.

The relatives promptly took her to the ‘famous practitioner’ who did his treatment. She did not have any more seizures and she looked better. After that, they took her to the wizard in her village again - just to ensure that she would not become sick again. She looked better.

On Saturday, the 4^th August, sometime in the evening, she suffered another episode of multiple seizures which continued over the night. The witch doctor was again summoned who told them that it was beyond his powers. She was unconscious by morning. They took her again to the ‘famous practioner’ in the neighboring district on Monday morning.

The ‘famous practioner’ also told them that the disease was something he did not have much control on. He recommended NJH.

Thus after all the efforts of running all around the district and the neighbouring district, they decided to come to NJH . . . just 10 kms away from their house.

It was around 2 PM on Monday, the 6^th of August, when they finally reached us.

There was hardly any urine coming out. Her lungs were all clogged out. The conjunctiva was congested and edematous. It was only a matter of time. . . before the rest of her organs collapsed. 

She arrested sometime during the midnight . . .

I don’t know what to say . . . please draw your own conclusions. .. … ….

By the way, I’m going to the nearby village of Piperakala where there was a maternal death couple of days back. .. … They had brought the dead body to us. Shall post a report as soon as I return. . . 

Maternal Death . . . The second one

I came from Ranchi after a meeting on Maternal Mortality . . . I made a promise of writing up about all the maternal deaths I come across. Something that I'm seriously thinking about doing is to find out maternal deaths which occur in the community through our volunteers who are involved in other projects through NJH. Who knows . . . we may come up with quite a lot of revelations. 

It was not even an hour after I had arrived, when a patient was brought dead to casualty. She was pregnant. It was busy otherwise. So, not much of a thought was given and relatives took the body home. 

Later, today morning, Johnson called me up to say that the dead pregnant lady had come from Piprakala, one of our neighbouring villages. It's a shame.  

Sometime around mid-day, there was one more very sick pregnant lady who was brought in. There was nothing much to do. She was gasping. Titus told them to go ahead to Ranchi . . . which they really agreed for.

But, the relatives made a beeline to my office and was soon pleading to do the best that we could. I was caught up with work, but somehow made to Acute Care. 

MD looked hardly 20. She was puffing and huffing. Papery white, with a tint of yellow. There could be only one diagnosis. . . Malaria.

I explained everything to the relatives. We had to get her ventilated. She could collapse any minute. We got a sample of blood for the baselines. And had her hooked to the ventilator in no time. Then, she suffered a cardiac arrest. . . we got her heart working. From the look of her eyes, it was obvious that it was going to be tough. Tough it was as she got into another cardiac arrest. . . And her pupils had started to become unequal.  

Meanwhile the results from the lab came in. Platelets of 14,000/cu mm. And 90% of her Red Blood Cells infested with Plasmodium Falciparum. 

She hardly had a chance. . . 

We declared her clinically dead at 2:30 pm, about 2 hours after she had come in. 

She was being treated elsewhere for the last 3 days. . . Nobody had diagnosed malaria. I wonder how even a quack would have missed out on the diagnosis. 

Thoughts on this maternal death . . . 

- A failure to diagnose malaria. She had been to hospital, but the malaria smear is put as negative. 

- Who knows she may have been treated with anti-malarials. It is very difficult to imagine quacks not giving anti-malarials in fever cases. Maybe, we are having resistant cases. 

Talking about malaria, we are having quite a number of fever patients coming in. As we had suspected last year, we still have a hunch that it's not only malaria that we are dealing with.

Well, today afternoon I plan to visit the house of the lady who was brought in dead. Shall put up a post as soon as we come back. . . 

Marathon Cesarian Sections . . . Cont'd

Over the last week, I've tried to pull your attention to the poverty of this region. In addition, there was the day when we had to do 7 Cesarian sections on the trot . . . all of them, Maternal Near Misses.

They all got discharged without any sort of complications except for the babies of KD and AF. 

Below is the chart once more. This time, I've added 2 columns . . . which shows the final bill and the charity we ended up giving.

Name	Time and date of surgery	History	Final management and comments	TOTAL BILL (INR)	CHARITY (INR)
RtD	20th july, 11:00 am	Previous LSCS, had come for ANC on 20 june, Hb: 8 gm%, never bothered to arrange blood	Boy baby, apgar 9 and 10. Had waited almost a day for the blood	13162	3979
SMD	20th july, 12:36 pm	Obstructed labour since previous day 8 pm	Boy baby, apgar 6 and 10. Almost a rupture	16101	6851
MD	20th july, 2 pm	Primi at 40+6 with labour pain since previous night. Later obtained history of leaking 4 days. Irregular fetal heart.	Girl baby apgar 8 and 10. Well off patient – did not go to Ranchi.	15658	490
AF	20th July, 3:14 pm	Labour Pains since yest afternoon and leaking, short 136 cm, obstructed labour	Sick girl baby, apgar 1 and 4. Died later, Almost a rupture	16541	3109
KD	20th July, 5:24 pm	Prev LSCS  with iud and Hb 8 gm%	Dead girl, Hysterectomy for placenta percreta	17320	6524
RnD	21st July, 2:17 am	G4P3L2D1, pedal edema 2 weeks, headache followed by seizures 2 pm, 20th july	Baby boy, apgar 6 and 10. IUGR	16498	1053
SrD	21st July, 3:30 am	Short primi, pedal edema > 2 weeks, was having laboru pain since 12 pm on 20th July, BP 140/100. Urine alb 3+	Cervix edematous and head high, inadequate pelvis – lscs, boy baby apgar 3 and 7. Gr 3 Meconium Stained Amniotic Fluid	19235	2438
	TOTAL			114,515	24,444

Well, why do I have to show this . . . When some hospital asks for a small amount and people don't pay, they make into the newspaper. I know of quite a number of healthcare institutions who do quite a lot of charitable work and do not even find a mention anywhere. Just imagine, almost 20% of our costs going into charity . . . This is a fraction of a day's work. 

As I write this, I've 2 patients who are in the ward for whom I would have to give full charity. . . 

The first one, NK, who delivered her first baby and was brought to us about 5 days back with a history of seizures after she delivered a baby about 5 days back. We've not been able to bring down the blood pressure. We tried to refer them the first day. But, to no avail. Today, the father came to me. He requested me to discharge the patient as they did not have any more money with them. He told, 'I will take her home and then we would wait for her to die'. I've told them that we shall continue treatment for 2 more days and they need not pay any more money . . .

The second one, RD was operated 5 days back. Stuck by polio at the age of 3 years, she had got married to a blind young man from her village. She had a pregnancy 3 years back - she had a normal delivery, but the baby was dead. I wonder how she delivered with both legs stuck with polio. When she came to NJH, it was not a classical Rupture Uterus. On operating, it was like someone had done a Cesarian section without opening the abdomen. 

The family does not have even one rupee with them. We'll have to write off the entire bill . . . 

The consequences of such charity work can be terrible on an institution such as ours . . . But, then, there is no other option for most of our patients . . . I wish we had some sort of support .. .. .. 

Case discussion . . . Need suggestions

We had a 35 year old lady who came with multiple swellings of the tongue and the oral cavity. Grossly, the swelling looked vascular. Would appreciate suggestions on where she can get this managed. The family is lower middle class . . .

Praise and Prayer Bulletin . . .30th July, 2012

1. We are thankful that the Nursing School selections went smoothly. There was no interference from anywhere. Kindly pray that we would be able to influence each of the students as they are with us for the next 2 years that they will develop the qualities of a good nurse. 

2. We thank the Lord for the major increase in all of our statistics. There has been quite a number of poor patients who've started to access us. Unfortunately, this has brought about quite a big burden of charity given for hospital bills. Kindly pray that we will be able to balance our hospital finances well. 

April-June	Outpatients	Inpatients	Deliveries
2008	6338	876	211
2009	5536	699	208
2010	5611	804	304
2011	5775	731	267
2012	7861	1253	360

3. The region around the hospital has received a fairly good amount of rains. However, we understand that the rainfall pattern in the whole of the region has been very inconsistent because of which there are fears of an impending drought in some of the places. Please pray that we would have some more rains.

4. The obstetric work has increased quite a lot. As I write this, there are 4 patients with severe eclampsia who are fighting for their lives in Acute Care. Please pray that each of them will recover well. 

5. There has been a spurt in cases of acute diarrhoeal disease in the region over the last 2 weeks. Kindly pray that we would be able to control the outbreak soon. 

6. There were over 15 patients who came with accidental or suicidal pesticide poisoning over the last 2 weeks. All the patients have made it. We thank the Lord. 

7. We find quite a lot of discrimination against the girl child which gets to very terrible proportions many a time. Please pray that the girl child will be valued in our communities and families. And that we would be means of helping out families realise the importance of the girl child and improved status of women in the society.

8. The hospital is being patronised by the RSBY card-holders in a major way. We thank the Lord that we've able to cater to the poor through the RSBY. We also thank the Lord that we are part of a project on the community monitoring of the RSBY. Kindly pray that we would able to facilitate the RSBY to reach the poorest of the poor. 

9. There is a major need for more consultant staff to join NJH as well as other units of the EHA. Kindly pray that the Lord will move the hearts of qualified people. 

10. Kindly pray for a patient, Nandu Ram. Nandu Ram was in all the local papers over the last week. One of the local quacks had done an appendicectomy on him which has gown awry. He was taken to Ranchi where the doctors had given a very poor chance of survival. The local MLA requested us to take care of him and do the maximum possible. He's got admitted today morning. We pray that the name of the Lord be glorified as we care for Nandu Ram.