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!!

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......

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........

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