Monday, April 23, 2018

The ruptured uterus dilemma

In most parts of civilised India, a ruptured uterus is unheard of. It's something that is to be read about in text books or to be enthralled by as senior professors tell stories of the occasional patient they have seen with this problem. However, in places like Bihar, it is sadly an all too common occurrence. For however far medical and obstetric care have progressed in the rest of the country, here childbirth remains an extremely risky proposition for both the baby and the mother. (For those not associated with the medical profession, a uterus can rupture in pregnancy when there is prolonged labour or the uterus has been weakened by previous Caesarian sections). In the short time I have spent here, the stories of tragedy during the delivery process have been too many to recount. The worst part of every story without fail is that doctors and quacks all around seem to wait till just past the point of no return before referring the patient to us, by which time even our most strenuous and aggressive efforts prove to be in vain. And the icing on the cake of course, is that the blame and the ire of relatives and even mobs falls on us, rather than the various places they had come from, whose improper treatment had led to the problem in the first place.

From these respects, the story I recount today has a happy ending. It occurred on a day when all my other colleagues were on leave and at about 11 pm at night (the time when patients who have been referred from other places usually reach here), 3 patients came at the same time to the Emergency. As doctors often do when busy, I mentally classified them based on their diagnosis - snake bite, OP poisoning and oh no! Ruptured uterus! The patient was a lady who had not yet reached term but had had two previous Caesarians with one baby dying shortly after birth. She had been in labour for a day and had been undergoing treatment at a local clinic where the doctor had been attempting a normal delivery. However, she suddenly started to pour out blood and had been immediately transferred to our hospital.

The moment I saw her, white as a sheet and lying in a pool of blood on the stretcher, I knew there was very little time. As the sisters (who are an outstanding yet unsung group of people in our hospitals) readied her for the operation, I took the consent and sent the relatives off to try and get some blood. We were in the operation theatre in about 10 minutes (again an outstanding feat given that the OT staff need to come from their homes!) and the baby was out shortly after. To my surprise and delight, he was alive although rather sick and needing to be sent to the neonatal ICU. The reason for the bleeding was soon clear. The uterus had been adherant to the bladder and had ruptured it as well. After closing up the uterus and bladder, I was about to begin the ligation of the Fallopian tubes to prevent future pregnancies and ruptures, when my floor nurse told me the relatives had refused the tubectomy. They wanted another baby!! After 2 Caesarians and a rupture!! I went out to try and convince the relatives, telling them clearly that another baby may kill the mother. But as I have found so many times, a woman's life is not considered important enough to make plans based on her welfare. Risking her life for the sake of another baby made perfect sense in the eyes of the family. I knew that in her heart of hearts, my patient herself was keen for the tubectomy, but she flatly refused to go against the wishes of her family, once she knew they were not agreeable.

And so, for me, the joy of saving the child and the mother was dampened a little. I felt sad that the woman's life had so little value for her own family. I felt angry that crucial decisions about her own body could be made by others and she did not even have a say. I even felt a little guilty that I did not have the courage to go ahead with the tubectomy on medical grounds against the express wishes of the family. It is a situation I find myself in ever so often nowadays. Perched on the horns of an ethical dilemma, not knowing what to do. And always fearing that I have finally made the wrong decision!!

Friday, April 13, 2018

The price of womanhood

The stories are piling up and there's so little time to tell them!! The composition of a good blog post is an art form, but art takes time, unfortunately! So do bear with the brevity and the lack of analyses. The stories are so stark that it sometimes seems abrupt and jolting to leave them without comment. But then, maybe commenting and rationalising will make them more understandable, more acceptable. And that cannot be allowed. In this great country of India, where dwell some of the richest people in the world, where advanced medical care draws people from all over the world to access it, where our scientists are making giant strides at the cutting edge of research and our people are accessing lifestyles that are at par with any developed country in the world, there are still places where the realities of life are far removed from choosing which mall to go to or which movie to see or which joint to dine in. Every day, I am shocked and moved by the stories. Stories that I could not have even imagined possible just a few short months ago.

Today I tell the story of Guddi Devi (name changed). I never knew her. I never even met her. But the poignancy of her story breaks my heart. Her only crime - being a woman in a society where womanhood is a curse. A society where spending money on a woman's health is an unnaceeptable economic burden. I never met Guddi Devi since she never made it to the hospital. But her baby did. He was brought by her relatives, hale and hearty and completely unaware of the deadly drama playing out around him. His mother had been bitten by a snake - an uncomfortably common occurrence in these parts. (The other day we had a krait in our house, but that's a story for another day). The family had taken her to the local witch doctor, who commenced his mantras and spells (or as they are locally called - jaddi putti or jhar poke). While he was doing the necessary charms to remover the poison magically from her body, her baby started crying and she fed him, as any good mother would. And soon after, even before the magician had finished his spell, the dreaded symptoms began. As her eyes began to close and her breathing became more laboured and as the witch doctors incantations increased in volume and fervour, her relatives did the first thing which occurred to them - they rushed the baby to the hospital. After all, this precious boy had suckled at the breast of poor poisoned Guddi and God forbid anything should happen to him if some of the poison had somehow managed to enter him through her milk. As for Guddi, she died quietly, not even a footnote in history, while her little boy played happily in the arms of the relatives whose deep concern for the boy was so terribly countered by their absolute apathy for her fate.

For what it is worth, I honour Guddi Devi and the millions of women like her, who live and die quietly, destined to be second class citizens solely because of the absence of the all-important Y-chromosome. May God have mercy on their souls......

Sunday, April 1, 2018

The cost of saving a life - going to jail

This morning a lady came into the hospital. She had delivered a baby 2 days ago and had been bleeding ever since. She was white like a sheet and her blood pressure was barely recordable. Her Haemoglobin was 3 gm. When I worked in Jharkhand 15 years ago, our management would have been simple. Find someone with her blood group, bleed them and transfuse. But things are different now. As in all aspects of medicine, there are strict regulations and guidelines governing blood transfusions and without a recognised blood bank, it is not allowed. A few years ago, two staff members of a rural hospital spent some months in jail for transfusing blood to save a patient without a blood bank licence. So now, even if a patient is dying, we cannot transfuse them blood to save their life without running the risk of going to jail.

A lot of things are like this in our country today. With more and more regulations being brought in by powerful lobbies and highly placed doctors from the large corporates in cities like Delhi, those of us who practice medicine in very different circumstances find ourselves battling with life and death questions like this every day. It is no wonder that doctors don't want to work in rural areas or smaller hospitals. On the one hand, since the majority of our patients are poor, we are never going to get enough money to procure all the expensive gadgets, doctors and facilities that are mandated by the law to practice even basic medicine. On the other hand, we are faced with situations like this where a simple intervention that has very little risk is guaranteed to be life-saving, but cannot be done without breaking the law.

The husband of the patient was sent to the local blood bank and came back with the news that there was no blood. But he had been told of some private clinic where blood was available. I don't know if it a profitable side business of someone from the government blood bank or it is a private clinic who have bribed the powers that be to turn a blind eye. Since bribing is not an option for us, we will always be at a disadvantage if we ever stray even a millimeter from the law. Anyway, we sent off the patient, feeling relieved that our ethical dilemma had been solved by someone else. But the big question remains - will I risk going to jail in order to save a life? I do not know the answer to that question........

Saturday, March 31, 2018

Madhepura!

I got married in good old arranged marriage fashion. One of the tools I used in the whole meet-and-greet process was to tell the prospective bride that I could possibly end up working in a small village in Bihar. Well, I now realise you have to watch out what you wish for, since many years down the line, here we are!! Our caboodle has relocated to a small hospital in Madhepura town, North Bihar after bidding a tearful farewell to our dear friends in Bilga and Ludhiana. The sorrow of the parting still hangs heavy on our hearts although it is a sweet sorrow, since we moved in response to the pull on our heartstrings. And having been here for some time now, it is clear to us that this is where we are meant to be for this season of our lives.

Madhepura is a dusty little town in the basin of the river Koshi. This is its biggest claim to fame as the river floods at regular intervals wreaking destruction throughout the area. Its other claim to fame is being the bastion of the Yadav political dynasties - Lalloo and Pappu Yadav on the one side and Sharad Yadav on the other. Demographically and economically it is in the poorest cluster of districts along with neighbouring Saharsa, Araria and Purnea (1). The literacy rate is 53.7% and the sex ratio is an appalling 914 females for every 1000 males (2). There are a number of Dalit and Mahadalit communities surrounding the hospital with the Moosahars (lit. rat-eaters) being the group among which we do the maximum work. The small hospital where we work is on the outskirts of the town and has many challenges. As many of our patients cannot afford to go to larger cities like Purnea, Patna or Siliguri for treatment, we often are faced with the situation of taking care of rather sick patients without too many facilities. However, we often find that necessity is the mother of invention and things go better than we expect which is very encouraging.

I used to blog avidly many years ago and hope I will be able to get back to some regularity. The main reason I am restarting this blog is to tell some of the stories of our patients. These stories tell the real plight of the people we work with and I hope they will reach the parts of India that I am used to - where things are very different and some of the situations we come across would be unthinkable. Do let me know what you think in the comments or by email. So hope I can keep writing and you all will enjoy reading! God bless!!



(A picture from the blog of a friend of mine which shows the front of the hospital... and a horse, something that is not as unheard of as we would think!!   http://jeevankuruvilla.blogspot.in/2012/11/madhepura-christian-hospital.html)

Reference
1. http://brlp.in/documents/11369/125465/Poverty+and+Social+Assessment+-+A++districtwise+study+of+Bihar.pdf/8a3c0c07-7021-45c8-8dbb-cb5d6190a9e3
2. https://www.udyogmitrabihar.in/docs/dp/madhepura.pdf

Friday, April 17, 2015

The Community Physician's Prayer

Amy wrote this prayer while working on one of her assignments for her MA course with our amazing coach Dr. Stan Nussbaum. I was really moved when I read it and thought I would share it with all of you. The photograph is by Dr. Rajesh Isaac.


Easter celebration

This Easter, the fellowship department of CMC organised a celebration of the life of Christ through music and dance. Here are two songs from the musical. It takes ages to upload so the rest will come slowly. Due to the poor quality of my handicam, you may need to watch these in HD.

Thursday, December 25, 2014

Merry Christmas (and some news)!


This has been a wonderful year for us! We had two new additions to the family - a dog in January and a baby in November! Our cup of joy runneth over and we are grateful to God for all His goodness to us. The arrival of the baby made this year a most blessed one and though there were a number of ups and downs, 2014 has been a landmark year for sure. The highlights of the year for Amy were completion of her data collection for her thesis and the whole pregnancy period and the delivery of the baby. We were grateful to both our mothers who could be here with us during that time. Arpit enjoyed his involvement in the Sunday School and with the students both academically and musically, the highlights being a concert of instrumental music and the musical 'Shrek'. We thank all of you who have journeyed with us in thought, word and prayer and wish you all a Christ-centred Christmas season and a blessed New Year. We look forward to 2015, knowing there may be many new beginnings and value your prayer for all of us in the New Year.

Monday, August 25, 2014

A new addition to the family

There has been some big news in our small family in the last year. After a long time of zero growth, there has finally been some activity! It all began on January 14th when I called my one and only first cousin to wish him for his birthday. (The fact that I have only one reaches significance only with the added information that Amy has 39!!). In the course of the conversation he asked me we were planning to get a dog. I said, no way! We had enough going on without the additional responsibility and given that we are such frequent travellers, keeping a dog would be well nigh impossible. I had already explored this with some of the dog-owners of the campus and after listening to them, had decided that this was too much for us at this point. Maybe, when we were settled down permanently (will that ever happen?!) somewhere, sometime in the distant future…We then moved on to other topics.

That same evening Amy and I stopped at a departmental store to get some groceries and supplies for a meal we were hosting for friends that evening. Right opposite the store where we parked our car was a pet shop. Outside the shop was a cage with 2 tiny Labrador (or Labradog, as it is known in these parts!) pups. Amy and me, both ardent animal fans, went over to look at them and make the usual accompanying noises – Awww, so cute and such like. Unlike usual, we stayed a little longer than we probably should have, making silly noises at the unsuspecting pups, who, of course, reciprocated as all pups in cages would do – with wagging and whines and a general dispensation of ultra-cuteness.

Once the critical limit was passed, the same thought began to form in both of our minds. As we looked at each other, I did not need to hear her words to know what she was going to say – Shall we get one? Having already been befuddled by the dashed pups, how could I then handle the deep pools that were my dear wife’s eyes?!! 20 minutes later we were the proud owners of a tiny pup, a bag-load of accessories that we were told were completely essential and a ton of advice on the various methods of making sure the pup did not die.

I am not used to making on-the-spot decisions. Usually, every decision is accompanied by many hours of research, dithering, pulling of hair and gnashing of teeth. But after January 14th, I think that maybe, being a man-of-the- moment may not necessarily be the worst thing in the world. For bringing home that puppy was one of the best decisions that I have ever made, though it went against all the advice I had been given and my ‘researched’ plans! And so ‘Awesome’ (as I named him over all Amy’s vehement protests!) Mathew came home to spend what would turn out to be a tumultuous day at No.8 Gateway Terrace!!


(to be continued)

Friday, August 15, 2014

CMC chapel choir sings Vande Mataram medley - Happy Independence Day!

Happy Independence Day! As we honour our great leaders who won our freedom for us at great personal cost, I feel happy and proud to be a member of this great nation with its rich and varied heritage. As we worshipped in the church this morning, I was wondering at the magnanimity and openness of our leaders who enshrined the precepts of secularism in our constitution. How easy it would have been for this country with its huge majority of Hindus to declare itself a Hindu state and follow the path of so many of our neighbours into religious fanaticism and destruction. How easy it would have been for our leaders to have won the votes and hearts of the majority of our population with a narrow-minded agenda. How easy it would have been for them to declare - Hindustan for Hindus. But it is a sign of their greatness that we live in this land of freedom in all forms, including religious. Where I am proud to call myself an Indian although I come from a minority community. Where I can follow my own life and path without fear of prosecution or retribution. Where I can join with my fellow Indians to sing together 'Maa Tujhe Salaam - Vande Mataram'


Monday, December 24, 2012

Christmas cantata

This last year has been a really bad one for this poor blog!! Let's hope that the next one will be better!! There are many reasons for the slump, which I think are best left unsaid!! But just to let you know that all is not dead creatively (!!), here are two songs from the short Christmas cantata that Amy and I composed for our institutional Christmas programme performed by the faculty choir conducted by Dr. Jacob Koshy (the wonderful soloists are Christine Joshua and Preethi Paul). Wish you all a very Merry Christmas and a blessed Year ahead.






P.S. There are a few more videos of the Christmas choir and also the Easter musical on the same youtube page - thanks Rev. Stanley.