The Occult . . . The Paradoxes of Indian Healthcare - Part 3

India has always been associated with the occult. And you may be surprised that the myriad religions, the thousands of gods and goddesses Indian culture is associated with has nothing to do with this. Irrespective of religion, caste, economic status . . . people depend on the occult for healthcare . . . 

Today, I came across 3 patients who tried it out . . . and it's usually the case for the conditions involved. 

The first was a young boy who had an acute episode of seizures in the morning. The relatives brought him straightaway to hospital. After the seizures was controlled, the brought in one of the local exponents of black magic to throw out the evil spirit from the boy. Our staff had quite a tough time dealing with the relatives as they were quite well off. 

The second patient was not that lucky. Bitten by a cobra early morning today, the family had been subjecting him to all mumble jumble till about afternoon when they realised that he may do better in a hospital. He arrived at around 5 pm at NJH. There was no respiratory effort. There was a faint heartbeat. From our previous experiences with cobra bites, Titus commenced CPCR . . . then he realised that it may not of any use. The pupils were already dilated. 

The third patient was also a snake bite victim, a young girl with viper bite, who came in more than a day after the bite with a very bad compartment syndrome. Dr Nandamani did a fasciotomy only to find out that one part of the leg was already badly gangrenous. 

We were sure that the chances of her going into a below knee amputation was quite high. We referred the girl. 

Unfortunately, the parents were too poor to take the girl elsewhere. However, I did not want to manage a potential high risk surgical condition without the surgeon around. They promised to take the patient elsewhere next day. Sometime later that evening, I found out there was a commotion in the Acute Care where the girl was admitted. 

It seemed that the family had arranged for a 'witch-doctor' to come and do sorcery on her. I chased them out. Later, I found out that couple of my staff were also involved in arranging the witch-doctor. I called them and asked for an explanation. However, they denied any involvement. I did not have any evidence. However, later, I found out that they had initiated a discussion with few other staff on the reasons why I should have allowed them to do the sorcery. 'The doctors are anyway referring, so what is the big thing about the relatives trying out jaad-phook (black magic) for their daughter'. . . that was the justification. 

It was shocking . . . unfortunate, but true. 

The worst aspect of the use of occult is that  most of the diseases where the populace invokes the witch-doctors are clinical conditions which merit immediate medical attention . . . SNAKE BITES, SEIZURES, ECLAMPSIA . . .the major ones we're concerned about. One more disease for which the witch-doctor is consulted is HEPATITIS. However, since it is not an acute condition, we do not hear much about it. 

The amount of money that these witch-doctors make is enormous. 

Considering that modern medical facilities are very much far away in terms of accessibility, availability and affordability, it would take quite a lot of effort to turn away the common man from these money mongers. Talking about money mongers, the sadder aspect is that modern clinical practice is also very much in danger of reducing it's practitioners to money mongers . . . which is not much different from our 'witch-doctors'. More about that in my next post on the Paradoxes of Indian Healthcare . . . 

Funding . . . The Paradoxes in Indian Healthcare - Part 2

The other day during a meeting, someone commented on how easy and freely available is HIV testing in almost all government facilities compared to other investigations such as hemoglobin, urine albumin etc. Someone suggested that even there are places where HIV testing is available, but a sphygmomanometer to measure blood pressure is not available. 

I'm afraid that this situation is actually true. 

There is quite a lot of funding available for HIV. But, no money for Reproductive and Child Health Care. So, no sphygmomanometers or instruments to measure hemoglobin or urine albumin. Well, I would not need to do explanations on the importance of doing a hemoglobin for a pregnant lady as part of her antenatal care. Or a routine check up of blood pressure. 

I'm not touting for HIV testing to be stopped . . . it is a lifeline for babies who are born to mothers who could be diagnosed to be HIV positive. But, we need to rule out anemia for all our women who become pregnant . . . for anemia is supposed to be the commonest indirect cause of maternal mortality in the world. 

Talking about maternal mortality . . . it irritates me when the Polio Surveillance officer calls me every Monday to check out if there has been any case of Acute Flaccid Paralysis in the hospital over the week. I'm not irritated because I don't like this guy . . . he's in fact a good friend. I'm irritated because there are young mothers dying while giving birth. We fill up the Institutional Death Reviews and send them . . . On October 18th, it will be one year since we've started the reviews. Till today, I've not been called for any meeting related to any of the deaths. 

Leave alone maternal deaths, I've had men, women and children coming with symptoms suggestive of viral hemorrhagic disease most probably dengue . . . nobody turned up until someone accidently put it in the papers. Still the response has been quite muted. There were 3 proved cases of cholera in the hospital. I informed the authorities responsible. No response. 

It does not need any brains to explain that nobody is interested in maternal deaths, tuberculosis, malaria or cholera as there is hardly any money in it. There is money in HIV, Polio . . . even cancer. And now, Non-communicable diseases. Because that's what the West is quite concerned of. HIV, polio . . . because they are quite concerned that we will transmit the diseases to them. 

Non-communicable diseases - - - so that they can get back all the expenditure spent on research of drugs which have been proved to be either useless or has side-effects. Recently, I had a mail from one of my elderly friends (not a doctor) who told me how he was 'detoxified' from all the medicines he and his wife had been prescribed by his cardiologist et al in India, after he went to the US to be with his son. He was put on a regular regime of exercises and dieting. He is doing good with no problems . .. ... 

My previous post had been on the pharmaceutical industry. Even for the pharmaceutical industry, there is nothing much in store from maternal or child health and infectious diseases such as malaria or cholera. 

There is only one solution for this issue. Our friends in the Health Ministry needs to realise the pressing healthcare issues of the country and ensure that funds and personnel are available for research on those issues. We have enough research to show that the metabolic functioning varies in cultures and races. Following research, we need to have systems put in place such that the research can be converted into action. Only then, can the real needs of healthcare in India be addressed . . . 

Depending on funds from any organisation abroad would only ensure that public healthcare issues of those regions would only be addressed and we would remain with healthcare issues such as Maternal and Child Health, Tuberculosis, Malaria etc which we have been continuing to grapple with since ages. 

Coming to funding . . . there are more issues. Like the issue of adequate infrastructure not available for Primary Health Centres and other public healthcare institutions to start. And worse than that is the all out dependence on Private Medical Colleges to help us with staffing our Health Centres with doctors . . . Well, that is fodder for another post . . .

Snake Bites . . . A Query

We manage quite a lot of snake bites and the cases that we've been handling have been quite a lot compared to the previous years. Unfortunately, most of our snake bite cases reach us quite late. 

I look forward to answers from experts about our observations with regard to snake bites who come late for treatment.  

When patients come late, more than 6 hours after the bite, we've seen that the chance of having a anaphylaxis reaction to the Anti Snake Venom (ASV) is quite high. In fact, we've got this experience of patients bitten by krait (which is more common here) go into respiratory arrest as soon as the ASV is given.  However, I do agree that when we give it within the first 4-6 hours after the bite, we do not have to face this problem.

Is there any evidence regarding the time interval after the snake bite upto which ASV can be given - when all features of envenomation has set in? By the way, I've heard of hospitals using upto 200 vials of ASV to treat viper bite when the clotting time was abnormal after more than 24 hours of the bite.

As of now, I've 3 patients with krait bite who came about more than 6 hours after the bite. The first person came after about 9 hours of the bite. He was given ASV elsewhere (5 vials). I did not give him any more ASV and he is doing well now. There was another lady who had come in almost 12 hours after the bite. We did not give her any ASV in the beginning. However, one of our doctors thought the next day (almost 24 hours after the bite) that it did not look good. He started off ASV. The next thing I know was that she went into a respiratory arrest. She was in the ventilator for 2 days following which she has recovered. 

The third patient came just about 4 hours back (4 pm) following a bite sometime early morning. He was maintaining the saturation quite well. I was not sure about starting ASV. However, I thought of starting it later. Within an hour of starting ASV, he had gone into respiratory arrest (almost more than 12 hours after the bite). He is on the ventilator now.

We also get late presentations of viper bites.

Below is the gangrenous leg of a boy who was bitten by a viper. He presented to us more than a day after the bite. He did not get ASV as his Clotting Time was normal. However, we had to do extensive surgery on the leg including skin graft.

So, the ultimate questions being  - 

'Is there a higher chance of anaphylaxis on giving ASV to patients who present late after a snake bite?'

'Is there a time limit beyond which ASV would not be of any use for a patient with systemic signs (hematotoxic/neurotoxic) of envenomation?'

The preference for the boy continues . . . 4 stories

There were 3 cases last week, where I was almost sure that the relatives quite well knew the gender of the fetus that the respective patient was carrying. That was when the 4th one came. 

The snap above is that of RD's baby - born sometime early morning today by emergency cesarian section. Yes, you have diagnosed correct. It was a case of Hand Prolapse. She was lucky to have made it alive although sick. However, there was no reason that this baby should have born sick by Emergency Cesarian. 

Because . . . RD had come yesterday sometime in the morning with leaking per vagina. And Dr Ango had correctly diagnosed a transverse lie and had asked the relatives for a Cesarian section immediately. The relatives told her that it was RD's fourth pregnancy and she should deliver normal as her birth canal should be quite large enough. 

They left for elsewhere. The next thing we know is that RD came with a hand prolapse early morning. I'm yet to find out what all happened in between. 

Later, in the afternoon, I had a pep talk with one of the relatives and it was well evident that the family knew the baby was a girl and a Cesarian section was considered too expensive to deliver a baby girl. 

However, I'm happy that they came just in time to deliver a live child. 

The other 3 cases where it was also quite evident that the family knew about the gender of the child are narrated below - - - 

1. 5 days back, some time early morning, there was SD who came with a foot presentation with severe intrauterine growth retardation. SD had been leaking since late night. She had been around for antenatal check ups to quite a number of places - - but the family claimed that no one told them that the baby had growth retardation and had an abnormal presentation. To make matters difficult, they did not have any papers of her antenatal care. The baby was alive . . . I gave them the option of doing a Cesarian section. With much reluctance they gave me permission. The baby came out with great difficulty . . . and was a girl. The family showed no interest in keeping her . . .  Yesterday, they got a discharge against medical advice and left . . . Here again, it was quite obvious from the way the family was behaving that it was well known to them that the fetus was a girl . . .

2. 3 days back, I got a call from Titus who was on duty. There was a very rich family who had come with their daughter who was 8 months pregnant. RS was leaking and was having severe pre-eclampsia. Her husband was working in one of the metros. Titus was trying his best to refer her. In fact, the patient wanted to be referred. Her relatives would have none of it and wanted the treatment to be done here. Her blood pressure was rising and Urine Albumin was already 4+. We gave them the option of a Cesarian immediately. The surgery went well. The baby was in fact term but had severe growth retardation. We offered a referral for the baby, which was not taken was the relatives. However, the husband arrived yesterday evening. Our doctor at NICU, Dr Johnson explained about the baby and he readily arranged for the baby to be shifted to a higher centre. I was glad to see him quite furious with his in-laws for the way they dealt with his wife. 

3. Yesterday, we had a lady who came early morning with labour pains. The doctor on duty decided that the contraction were not good enough and gave medicines to accelerate labour. I reached the labour room at around 8:30 am and was a bit concerned with the extra attention that the patient was receiving from her relatives. I also found the uterus a bit funny shaped. As I was examining her, her male bystanders were making a fuss about knowing her latest status. I decided to do a Per Vaginal examination after which I was almost sure that she had an Occipitoposterior Presentation and there was minimal meconium staining of the liquer. And she had not progressed at all from early morning when she came. I told the relatives of the predicament. I could have waited for couple of more hours as this was her 3rd pregnancy and both her previous deliveries had occurred normally. As soon as I dropped the 'Cesarian' word, the family wanted to immediately have the surgery and get the baby out ASAP. I went ahead with the surgery. The baby was a boy. It was quite unusual for the relatives to agree for a Cesarian section that fast

We are all quite aware about the fall of the child sex ratio in the country. The stories I tell here are only the tip of the iceberg. We've had worse experiences. And there are some hilarious experiences too . . .

I'm not sure on where we are heading with regard to the care of the girl child . . . But, someone has to do something . .. ... The issue of the neglect of the girl child is much more serious than what we perceive . . .

Satbarwa's Niagara

We had gone for a trip to a hostel run by the Catholic Church in a place called Garu. It was quite a hectic day for the team as we had to see through approximately 300 children. There was an epidemic of fever going on in the place since one week and that was the reason we were called for.

After everything was over, the authorities in charge of the hostel asked us if we would like to visit a waterfall nearby. It was just about a kilometer and therefore we decided to visit. And wow . . . it was worth the trip.

Well, the trip was also quite picturesque too. A few snaps from the trip. Unfortunately, I was quite tired after a very hectic week. And was more tired after the camp. Thanks to our dentist, Dr Basil and our engineer, Mr. Dinesh who ensured that we have enough photographs of the trip.

The last picture was the best thing that our kids enjoyed during the journey. We had to cross 10 such sections of the river running over the road during the journey. And Dinesh, who drove us ensured that all those with the windows open got sprayed with the water. The snap would surely make it to the Annual Report next year.

Shall post details of the Medical Camp after I get the blood tests too.