Pesticide poisoning . . . A point

The last 2 days, I had a very unique problem with 2 patients. 

The first one was a young lady who had come in unconscious since the last 24 hours and was being managed elsewhere. There was no definitive diagnosis. From the history and examination findings, there were only 2 possibilities. . . It was either a pontine bleed or an organophosphorus poisoning. 

The relatives vehemently denied the possibility of a poisoning. 

As she was not breathing well, we had her intubated in no time. While intubating, we noticed that there was quite a lot of secretions in the airway. 

Nothing much happened initially. We had given the option of a referral which the relatives were not very much interested in.

We weighed the options and started off her on Atropine to which she amazingly responded. By today morning, she was sitting up and it was quite heartening to see the sight . . .

 Later today, a little boy came in gasping, frothing from the mouth and with pin point pupils. He had eaten some poison which was kept on the window ledge. Here, the parents were sure on what was eaten. . . For me, it was pure organophosphorus. He responded to the same management which we gave for the former lady except for the ventilation. 

This is the fourth or fifth time that patients have come in after ingesting poisons accidently (at least from the history). I remember one of them which I thought was homicidal. 

I remember being taught that free availability of poisons is one of the major causes of accidental and self inflicted poisoning in most of the Asian countries where it is common.

When the parents of the boy showed me the sachet of the poison, it was not difficult to realise the reason on why accidental poisoning is something we need to consider seriously when patients come unconscious to our emergency rooms.

Below is the snap of the sachet.

A common practice in India to decrease the cost of purchase of many an item, sachets such as these are quite a dangerous thing. Taken out from their original packing, these poisons are repacked into unlabelled packets. I showed it to couple of our staff who use pesticides for farming purposes. I asked them about the poison. They did not have any idea other than that it was very good to kill houseflies. 

The shiny substance inside the sachet is quite attractive for children. Many a time I've seen liquid pesticides repacked inside empty cough syrup bottles. Last year, we had one young man who claimed to have unknowingly drank Malathion which was stored inside a cough syrup bottle. He was lucky to have made it alive.

In the prevention of pesticide poisoning, one of the concepts being promoted is to ensure that purchase of pesticides be monitored and there is community based storage of pesticides. Of course it is important. However, more important is the need for public awareness not to store it outside their labelled bottles or sachets and not to sell or store pesticides in loose unlabelled packets.

Well, regarding the first patient, the lady - I got a history from her that she was having headache and she had taken some medicine which was given to her long ago. . . She does not remember anything after she took that medicine. My hunch is that she has taken some organophosphorus poison which was kept in an unlabelled bottle. In fact, we had got the history of a headache from the husband . . .from which we had kept the probability of a intracranial bleed -  a pontine hemorrhage because of the pin point pupil . . .

So, any unconscious patient from now on . . . we would be looking at possibilities of poisoning seriously.

The Unborn Girl . . . Murdered

(User discretion advised due to snap of macerated baby)

KB, a 40 year old came to us at around Saturday midnight with a history of term pregnancy, labour pains and loss of fetal movements since one day. Since, Titus, who was on duty, did not get a fetal heart sound, he did an ultrasound which showed a dead baby in a transverse lie. 

He did per vaginal examination was surprised to find a 70 cm long rubber tube coiled inside the uterus. 

There was no fetal pole palpable through the vaginal orifice and there was a foul smell. 

He called me telling about the rubber tube. I felt that something was amiss. 

Considering that KB was in labour for more than 1 day, I did not think it as wise to try a internal podalic version which we regularly do. One of our doctors, Dr Shishir is quite an expert in doing it.  

I posted her for a Cesarian section. 

I was surprised to find out that the uterus looked very much preterm. It looked quite unhealthy too. I was glad that I did not go for the IPV. 

As soon as the uterus was opened, stench of decomposed flesh filled the room. The baby was badly macerated and was at least 3 days dead. The baby was female. . . 

The dead baby and the orange colored rubber tube which we found inside the uterus. . . 

It was not complicated to piece the events together. Someone had helped the family diagnose a female baby. And they had tried to abort it. 

Considering the patient's age, I asked if we could do a tubectomy on her. The family was outright against the suggestion . . . The husband told me that they needed to have a boy. . . 

I wonder if she had been aborting like this for sometime since the delivery of her previous 3 daughters the youngest of whom was about 15 years old. . . 

I informed the civil surgeon's office and the police. 

The civil surgeon had informed the press and they were all over the place by Sunday afternoon. 

It is sad. Girl babies are not wanted . . . And they are killed ruthlessly. But, it is not only girl babies who are killed. Kindly read a very good article against abortions of any type.  . . 

The occasions when we've witnessed clear instances of prejudices against the girl child are umpteen. . . And I'm sure that the cold blooded murder which came to light is only the tip of the iceberg . . . 

Serving along with us . . . Prayer Request . . .

It has been quite a hectic week at NJH. As we are pleasantly occupied with serving the people of this region, we've always known that we could do with more help. Of course we have new projects, in disability, RSBY and Climate Change which have been approved and we are looking at the possibility of new people joining us in the Community Health Department.

In addition, we need at least consultants in Medicine and Pediatrics, couple of people in administration, a X-Ray technician and a Pharmacist.

All over EHA, we have realised the need for more people to join us. 

Last week our Director had come out with a letter of appeal for people to consider working alongside us. 

This weekend, could I request you to help us out with prayers that more people will join us . . . I'm sure that with a bigger and committed team we can work wonders and be the 'salt and light' for this region.

Of course, we are thankful for the people we already have, but we need more . . . Please do pass this post to people who you think would be of help to us . . . 

Maybe, who knows? The Lord could be calling you to serve with us . . . 

Prayerfully, Jeevan

Rupture Uterus . . . Double escape

The other day, we had one visitor comment that there was so much happening at NJH more than what was being put up in the blog. Of course, it's become so busy that I have lost count of the amazing miracles that we witness each day. The other day I read somewhere that once you start counting your blessing, you'll loose count. Therefore, I ain't complaining. 

And all praise to my team of clinicians Drs Nandamani, Ango, Titus, Johnson, Shishir and Kumudh who silently labour on without a whimper. The support received from the nursing staff especially the theatre team is amazing. 

Just as I was getting out for a proposed half day leave today, Mr. Selvin, one of our nurses came in with a patient's chart who he thought would require some amount of charity. 

I was stunned on seeing the chart. 

It was of a case of a rupture uterus with a alive baby.

The story . . . It was not even one year since Mr. Gopal Yadav and his wife, Mrs Kavita Devi from Tarhasi village which is about 40 miles from NJH, lost their newborn baby. Mrs. Kavita had undergone a Cesarian section at a private clinic. They are not sure of the indication. The only thing they knew was that the baby was so sick that the obstetrician referred the baby to Ranchi. 

Mr. Gopal did not have enough money and spent almost a day making arrangements. They somehow reached Ranchi the next day, but the baby was dead by the time they reached. 

Nobody told them they should wait for some time before trying for a baby. Mrs. Kavita Devi was soon pregnant a second time and she went into labour sometime early morning of 6th July, 2012. 

The family took her to the same obstetrician who did the Cesarian on her the first time. She was given some injections. However, by around 10 am, she was told that there appears to be some problem and the uterus seemed to have ruptured. 

Someone advised them to rush to NJH as soon as possible.

They reached NJH Emergency at 12:50 pm on 6th July. It did not need much of an examination to suspect a Rupture Uterus. Dr Nandamani was quite fast. The baby was delivered by 1:40 pm. The uterus had ruptured with a hematoma of the right broad ligament extending to the urinary bladder. 

The baby had an Apgar of 2 and 4 at 1 and 5 minutes. The resuscitation was quite good. God's amazing grace and the excellent care at the new NICU ensured that the baby recovered fast. 

The family could not afford the full bill. Thanks to the Grace Babies Charity, we would write off the baby's bill. We wish we have some sort of Charity fund from which we could write off maternity care expenses. 

There have been more unfortunate cases where women end up living terrible lives because of poor obstetric care or lack of care of any sort. However, for Gopal Yadav and his wife, they have been blessed because of NJH. We are thankful that we are called to be a blessing through the service given at NJH. 

(The names and the photographs were put after taking permission from the patient and her family)

RSBY . . . The story so far . . .

It has been more than 4 months, since we were empanelled under the National Health Insurance Scheme - called the Rashtriya Swasthya Bima Yojana. Our parent organisation, the Emmanuel Hospital Association has taken quite a bit of lot of effort that all the constituent hospitals are enrolled under the scheme as well more and more people are successfully enrolled. 

Just wanted to put in some statistics related to the RSBY Programme for the three months of March-May 2012.

Regarding outpatient care, we've been giving free registration and consultation to all patients who come with RSBY cards. The statistics so far . . . 

	Nos. of patients	Loss due to registration (in INR)	Loss due to consultation charge (INR)
MARCH	143	4290	7150
APRIL	251	7530	12550
MAY	291	8730	14550
	685	20550	34250
TOTAL LOSS in Outpatient			54800

Table 1

Coming to the in-patient care, the details are as follows - 

Months	Nos. of patients	Amount blocked (INR)	Received reimbursed (INR)	Actual treatment costs (INR)
MARCH	40	139950	100750	141694
APRIL	40	204000	163780	227443
MAY	43	185325	141625	210481
TOTAL	123	529275	406155	579618

Table 2

If we convert into percentages this is what we have got - 

Months	% of blocked amount reimbursed	% of actual costs reimbursed	% of the actual treatment cost which is blocked
MARCH	72.0	71.1	98.8
APRIL	80.3	72.0	89.7
MAY	76.4	67.3	88.0
	76.7	70.1	91.3

Table 3

Well, the above table (Table 3) tells us quite a lot . . . The major issue is with reimbursement. Now where are the challenges?

1. One of the major issues is the 24 hour clause kept for reimbursement. Let's look at an example. If a patient had come at 8 pm in the evening of 10th July, 2012 and we decide to keep him for 2 days in acute care. If he gets shifted out of acute care at 8 am on the second day (12th July, 2012), we receive only one day of ICU treatment. To qualify for 2 days, we need to keep him in ICU till 8:00 pm and then shift him out - which may not appear practical. The same appears for general ward patients too. 

2. You may notice that the actual treatment costs was very near to the blocked amount. However, later, the situation changes and the actual treatments is almost 10% lesser than the amount which is blocked. The only explanation I have is the following - 

    a) During the first month (March) we had more of cold cases (hernias, hydroceles, cataract surgeries etc). From the next month (April onwards), we had more of emergency cases coming in the cost of care of which are on the higher side. 

    b) Another development during the same period was the increase in medicine cases.

3. Another area where we are loosing money is Cesarian sections. The actual costs is about 12,000 INR whereas the amount allotted is only 4,500 INR. 

4. My surgeon was of the opinion that abdominal surgeries are under-alloted. There is almost always a need for blood transfusions which increase the costs.

5. Many a time, patient is referred before one day is over. In such cases, there should be a rule that we can take the bill from the patient. 

THE MAJOR ISSUES - 

1. We feel that the allowed amounts for blocking in medicine cases are on the lower side.

2. In emergency care (both medicine and surgical cases), the costs involved are usually on the higher side. A hernia coming for elective surgery is much cheaper than hernia coming for emergency surgery because of strangulation etc. 

3. Severe anemia is a common problem in our region and is most often nutritional. Many times, they require multiple blood transfusions which are very expensive. 

4. The rates for abdominal surgeries including Cesarian sections need to be revised. 

SOLUTIONS - 

1. Allot an addition of 1000 rupees for all cases (one time payment per admission) who come into emergency with acute onset of symptoms.

2. Delink blood transfusion costs from the RSBY package. 

3. Increase ICU costs to Rs. 1500 per day and General Medical Ward costs to Rs. 750 per day. 

4. Increase the rates of abdominal surgeries especially Cesarian sections. 

FINAL WORD - 

We are quite happy with the support being provided by Star Health especially the State C-ordinator, Mr. Sarfraz and the district point person, Mr Sanjeev Bansal. 

Considering that the hospital makes a loss of almost 20,000 per month on RSBY patients in the outpatient department, it would be good if the solutions suggested are implemented in some form or the other. 

However, we would like to commit ourselves to the success of this amazing scheme in spite of the losses we've incurred. It goes well with our commitment to the poor and the marginalised. We are proud that we are associated with this. 

The RSBY has already become quite famous for the impact it has brought about in the lives of the common man. We look forward to the day when the enrolment will cover almost the whole of the population and the burden of a imminent illness dragging people into poverty becomes a story of the past. . .