Archive for January, 2010

31
Jan
10

a beautiful morning

It’s a beautiful morning. The air has a chill to it and there has been a fair bit of snowfall at night. It’s still snowing as I walk in the door. There are no surprises on my ward rounds. There have been no overnight admissions, a welcome rarity, and the nurses are having a slow day. I join them in the pantry to some warm tea, great home-made muffins and a few moments of engrossing shop-floor gossip. I am sure that “all is fine in this fine world.” Till I go to baby A’s room.

Baby A had not started life well. He had been born with hydrocephalus. He had endured severe birth trauma and asphyxia during the delivery, resulting in cerebral hypoxia. His brain was deprived of oxygen for long enough to have permanently damaged it. His cry was feeble, he had to be fed through a tube as he hadn’t really learnt to suckle at the breast yet and he reacted very little while being examined. He has been with us for over a month now.

His mom had known about his condition only during the last months of her pregnancy, when it had been picked up by an ultrasound scan. What was surprising was that Mom A was a nurse; yet she didn’t go for a scan till her third trimester.

Behold! The Medical VIP syndrome: When your patient is a nurse, a doctor, or indeed anyone working in healthcare, or a close family member of any of the above, expect Trouble. With a capital “T”.

They will either present with absolutely unexpected complications or react violently to a perfectly common medication. Or have an obscure syndrome that will take weeks and an eager-beaver intern to diagnose. Or end up with multi-organ failure when all they had come for was to get rid of that ingrown toenail.

Mom A was a community psychiatric nurse and really didn’t seem to understand much about her baby’s condition. The team had tried unsuccessfully to explain the extremely bad prognosis to her on previous occasions and failed. It was like talking to a wailing wall. We felt helpless in front of her tears, her pleas to make her baby better. Baby A’s head kept growing alarmingly.

The neurosurgeons would have nothing to do with him either. He had a badly infected spinal fluid, which meant that they could not operate on him until we managed to control the infection. He had been given all the antibiotics in the book, and then some. He was resistant to most of them, and the ‘safe’ ones didn’t seem to make any difference. We did umpteen spinal taps to relieve the pressure inside his head, and prayed for a sterile fluid. And the labs disappointed us every time.

Mom A is not her usual weepy self when I enter the room hoping to get in a quick exam and get out fast. Things are still running to form; head circumference has gone up by a centimetre over the weekend. Baby A is unconcerned by my probing and prodding, winces a little as I put a cold stethoscope against his chest. Mom is watching all this in silence. I am done in a few minutes and ask the usual questions about bowel movements, urine, sleep, irritability. And then the Big One: does Mom have anything to ask me?

She asks me to sit down, offers me some orange juice. Damn! This is going to be another hard long talk. I decline the juice, sit down in the uncomfortable wooden chair, and wait. She gets up and paces a bit, unsure how to start, turns around suddenly, faces me and asks, “Do you think I am responsible for my baby’s condition?”

Say what? I didn’t see that coming. Her eyes are focused, no tears there, just deep and clear. I look away, thinking of a way to answer her, and she explains. “My husband and I had a long talk yesterday; he wanted me to get the scan in my first trimester, but I thought it would harm my little one. I should have got it done earlier and then my baby would have been fine.” So that’s what it is. Guilt. It happens all the time.

The saddest part of working with seriously ill neonates, for me, is talking to the mothers. Most of these babies are born with asphyxia, cerebral hypoxia and intrauterine growth retardation. At best they’ll need surgery to correct a congenital defect. Many will have learning problems. Some will need lifelong treatment.

All the mothers will live in hope for the rest of their lives. Many will blame themselves for their babies’ conditions. It’s a difficult cross to bear.

I look out the window at the softly falling snow; compose my speech in my head. The scan would not have made him ‘normal’, it would most probably have given the parents the option of not bringing him into this world. Of course there are procedures that are done intra-utero, but not every defect can be rectified. Not every anomaly can be picked up by the antenatal scan either. And Baby A would still have suffered the birth trauma. As I turn to her to explain, I notice the tears. I hear the wretchedly silent sobs. She doesn’t want my ‘expert opinion’. She wants to share her guilt and sorrow with someone. She wants me to understand her.

I hold her hand till the tears run dry, and she smiles at me. One of the many sad smiles I will see on these mothers’ faces over the years. I walk out the room with a heavy step. The day no longer seems so beautiful.

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29
Jan
10

emergency medical services in india

A trip with the neonatology critical care transfer team. Horrible weather, bad roads, poor visibility, agitated driver, blaring siren. Nice and warm inside the ambulance, terrified new intern busy reading up on resuscitation. Bored, random thoughts on the emergency medical services back home in India. Or the lack of them.

The telephone directory at home has a list of numbers to call in any emergency. Police, fire force, ambulance service… There is no universal number like 911. Each service has its own three digit number, which is easy to remember – 100 for the police, 101 for the fire force. Yet I can’t tell you without looking if I call 102 or 103 for an ambulance! Surely that has to be the one that’s more often used? You’d be surprised. You can call the police if you’ve been mugged and they’ll show up in a few minutes, but God help you if you’ve had a heart attack!

Here’s how EMS worked in India – for a very long time. Every city or town council had ambulances and drivers on its payroll. When you called for an ambulance you usually got one, but it was really just a ride to the hospital. The driver did his job – drive. He had absolutely no emergency training and wouldn’t know a cardiac arrest if it bit him on his private parts, but he could drive like a madman. But then so could we all; only the fittest survived on Indian roads. You Gave Way To The Bigger Vehicle – that was the only traffic rule that you had to know. By the way, that’s pretty much still the case in most cities in India and has confused many an international tourist. Check out the latest addition to ‘driving in India’ on YouTube. The terrified hand holding the camera is most likely that of a brick-defecating traveller.

Things have changed. Slightly. Now most major cities have privately (read ‘corporate social responsibility’) funded EMS, managed by organisations like the Rotary or the local Red Cross. Their ambulances have trained EM nurses and technicians, resus and communication equipment. You may have to pay for their services and more than one EMS in your city will mean more than one phone number to remember. But at least it’s a start.

Then there are critical care ambulance services run by major hospitals, usually under an understanding with the local councils or the police, who will alert them to an emergency. While some hospitals see this as an altruistic service, more often than not these trips end at the hospital that runs the service, even if that means bypassing three perfectly capable institutions on the way. All ethically correct, of course – you’re not soliciting these patients; you’re just providing a much-needed and socially acceptable emergency service. Unless the poor man under the truck happens to be a homeless bum and looks like it. Then time suddenly becomes of immediate essence and the EM personnel will deliver him to the nearest available EM department. He’ll probably get some first aid and an IV drip or two in the EMD, at best an ET tube and an Ambu bag, till he’s transferred to a public-funded hospital, which cannot refuse anybody, the poor sods!

A little by way of explanation how the health care system runs in India. Most hospitals in India are privately run and the patient or his insurance pays for treatment. But the government runs a parallel chain of hospitals, Primary Health Centres, District Hospitals and Tertiary Care Referral Centres, besides Specialized Centres for oncology, neurosciences and so on. All good on paper, and to give them their due, they do sterling work with the kind of resources allotted to them. But these good doctors and surgeons have to deal with a huge backlog of work, are paid a pittance compared to their counterparts in the private sector and are expected to work miracles in substandard surroundings bursting at the seams with patients. Their patients can’t afford private care or pay insurance premiums and hence are doomed to ‘inferior’ health care. Emergency care is afforded the least priority in these institutions. Privately funded hospitals, in contrast, are part of a booming, fast growing and lucrative industry. They have all the latest equipment, good nursing and intensive care, paramedical services and expert physicians and surgeons. They also have efficient public relation departments that will see that you have adequate insurance cover before they lyse that thrombus in your coronary artery.

A few concerned doctors in my city tried to make a difference to this system, a little before my time, by starting the Trauma Life Support Society of India, whose ambitious aim was to co-ordinate EMS among the various private hospitals. Their ambulances would deliver the patient to the nearest ‘member’ hospital which would provide primary trauma care and transfer him to a speciality centre for further treatment. In order to standardize protocols, the society proposed to, and in fact still conducts, trauma life support courses for doctors and nurses. But, as far as I am aware, the project has reached a kind of stalemate in its main aim. Every other hospital in the city has specialized departments and doctors on call. Ultimately it’s a question of money, honey. And of inflated medical egos. Of course relationships exist between different hospitals.

Sure, emergency services in India have to be more organized and streamlined. But that will happen only when the government takes some initiative. Sadly that seems a distant priority as long as lives are seen as expendable in the world’s most populous democracy. We in the medical profession can only do our best. And live in hope.

20
Jan
10

a bit of background

The hospital is the final referral centre for all paediatric specialties in the region. Patients from all the hospitals in the city and nearby towns, besides neighbouring districts. Some even from other countries referred for specialized treatment. Well funded, hence well-maintained. Minimum interference from government agencies.

The Chief calls the heads of different departments to his room, introduces everybody, asks them to make me “feel at home” and assigns me to a paediatric gastrointestinal surgeon, who will be my guide and counselor for two years. And my first thought is, “Why a GI surgeon, of all people? I don’t want to have anything more to do with perforated ulcers or bleeding esophageal varices.”

I have seen enough of them over the years. And made some frantic, yet calmly manipulative phone calls. (The surgeons can sense panic; it’s something they are taught in the operating rooms.) “We have a stable, but possibly bleeding baby, we have IV access and have sent all the labs, her gases are okay, she will need further observation, though. We’ll send her up to you if you’re busy. We know how much you guys have to cope with!” Never mind the saccharine; it’s the specific words that make all the difference in your pitch. Always pays to put in ‘stable’ and ‘IV access’. And the admission is always for observation.

I’m a hardened veteran at this, having worked on the ED floor for almost 10 years now. I have waged pitched battles against the combined forces of severe disease, fatal trauma, unconcerned management, disdainful specialists, unhelpful laboratories, demanding policemen and aggressive relatives. And I still get nervous when a really sick neonate is brought in. Invariably the paediatrician on call is doing something incredibly important at the very moment you try to get in touch with her, so you end up examining the baby. For the record, I know what to do; I know the immediate management – try the paeds’ number again. And I was getting tired of this. I had to get this phobia sorted out, I couldn’t work like this. I have no problem once the baby has crossed the crucial one month line; it’s the neonates that trump me.

So I made the obvious decision. To come to Russia and train in pediatric emergencies and neonatology. Actually I did a lot of research on the available options, about seventeen seconds’ worth. (I had gone to medical school in Russia on a student-exchange programme, you see, which meant that I speak Russian like a native. And it was my home for nearly seven years — the best part of my youth. I was beginning to miss both the country and my old friends, especially after a vacation to Moscow last year.) So I took a two-year break from work, left my wife, daughter (love you both, miss you like hell!) and warm weather (don’t miss you that much) back in India, bought a crate of books on paediatrics and neonatology and a pediatric stethoscope and took the next flight to Russia.

And here I am. Loving it, hating it, persevering with it. And here are some notes from my journey.




January 2010
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