Saturday, August 30, 2014

Where less is more…

In my three months of tenure in Lakhnadon I have but lost one patient truly .There were two young kids with aluminium phosphide poisoning and one lady who was brought in decerebrtating ,a case of hanging which I would not count because they were expected to die anyways,we do get extremely sick patients reffered to higher units by our colleagues from the government hospital and local nursing homes. I have been severely restricted in my patient management due to lack of equipments. In my earlier tenures I have seen aweful iatrogenic faux-pas in well-equiped places which have given me restless nights. Having talked to a physician colleague who works in a critical care unit in a research institute and her observation that patients actually do better in a peripheral set up because we are less invasive ,I wonder if she is right.She was talking about how elective intubations expose patients to nosocomial infections and the pneumonia resulting greatly increases the cost for the patient because of need for higher antibiotics ,etc.Often the bystanders choose to take the patient home. Most of our centres do not have a good microbiology back up so less might actually be more in our set-ups. Thank you Lord for the small mercies.

Friday, August 22, 2014

Uncomfortably comfortable.

Today,I stand in a strange place. I do my rounds of the hospital ward and I wonder where I am . I have two ladies who have undergone total abdominal hysterectomies,one gentleman who has undergone resection anastomosis who has just started liquid diet,one gentleman who had his obstructed herniae released and underwent a herniorhaphy with a mesh insertion,two ladies who delivered by caeserian section,one lady with a breast abscess who underwent incision and drainage,one patient post-snake-bite who underwent skin grafting,one patient who has come for exploration of the sole of his feet for probable foreign body.One gentleman who has presented with a bad wound infection post-electrocution for wound debridement. I also happen to have a lady with unstable angina,a young kid on ambu ventilation for snake-bite ,a few patients with fevers and acute gastr-enterites. By the grace of God they all are doing well. These past few weeks I have seen a lady with a haemoglobin of 1.7 gm% with a GCS of 6/15,stranded in the village for two whole days in that state for a lack of vehicle recover and go home.I have seen a tiny baby rejected by the government hospital brought in gasping for breathe sheet white,slowly coming back to life while all of us awaited for the life to go out of him.The same baby the next day during the morning prayers sat on his knees with his hands folded together while we prayed .He was all of two and a half years. I have seen a young boy in his late teens pushed away by a local nursing home in acute respiratory distress and septic shock saying in between gasps of breath that he did not want to leave our hospital.We safely transported him to a higher centre in Jabalpur in our ambulance and a nurse-aid for a PEEP. I stand here ...suspended....,it seems in mid-air,uncomfortably comfortable in Lord Jesus' grace.

Thursday, August 14, 2014

CAN YOU HEAR ?

Malti was brought in with snakebite. A tribal from a village in Seoni ,was not talking,drowsy and had labored breathing. We pumped in ten vials of anti-snake venom ,gave her neostigmine and atropine, intubated her and taught the relatives to ventilate her with an ambu-bag. She needed ten vials more but financial constraints on the part of the hospital and the relatives did not make it possible. At ten in the morning the nurse anaesthetic after consulting me decided to extubate her.However, on extubation, her breathing stopped.I was busy attending to another patient ,so the nurse anaesthetist intubated her and she was back on ambu bag.The whole village it seems were keeping a vigil in the vicinity of the hospital so there were no dearth of hands to bag her. We had given them some tips about watching the saturation et,al. At around ten–thirty at night I received a phone call from the nurse asking me to attend to the patient immediately as she was bloating everywhere.I rushed to the emergency care to see her struggling frantically and four big men holding her down as an enthusiaistic man was happily bagging her into a balloon. I asked the relatives to vacate,silently prayed that she had recovered spontaneuos respiration and extubated her.The tube was blocked with secretions completely.Her saturation dropped down to forty.I was worried but opted for oxygen mask and put her on a full flow oxygen and waited as her saturation picked up to above 95%.I got one of the nurses to get a suturing set and put small nicks in the subcutaneous tissue and milked out the air.It was half an hour before she was truly settled and I was confident enough to leave the emergency unit. Next morning when I went for rounds I saw that she was spiking a fever. She was already on antibiotics and if I had had to hike the antibiotic they would not have been able to cover the cost.I talked to the father who by now had been won over after the initial hostility they had showed the staff about the cost of the anti-snake venom.I shared my delimna with him but told him that we would wait and watch. He gratefully consented.In the evening when I went for my rounds there was no fever.The patient remained afebrile after that. Next morning she started talking to us and smiling at us but would not eat beyond a few spoons we coaxed her to during the rounds. It took another day before we could get the catheter out and get her to finish a whole bowl of porridge and with much joy in my heart I could bid farewell to what seemed like an entire village . She should be coming for her follow up in a week’s time. A few questions remained in my mind. 1)If we had had a ventilator it would have run an alarm and we would not have had the ordeal we had at that time. 2)In this day and age in a country like India should financial constraint be a reason for compromising on optimal quality care for a patient? The last forty thousand of our money went towards paying for forty vials of ASV on that day.The suppliers refused to send us the vials without the payment. 3)Did the patient have an option ,I am not sure considering the status of the patient at the time of presentation,I guess not. Malti survived by God’s grace,but what about other Maltis ?