December 2008

As the year comes to an end the health centre continues to move on in providing health care for the rural poor.

Outpatient: Total 1865
Below 15 years
Male: 150; Female: 114
>65 years
Male: 101; Female 81
Adults
Male: 537; Female: 882

Income levels (INR per month)
Below 1000: 1006
1000 - 1500: 619
Above 1500: 240

Eye Programme: 108
Glasses: 26
Medicines: 28
Surgery: 07

Antenatal Programme:
New: 07
Deliveries: Home - 01, Hospital: 03 (02 LSCS)
Abortions: Nil

Subhadra, delivered a baby after 07 years of marriage. The look on her face says it all.

You could not have asked for a more proud set of parents.

Apuramu is 24 years and suffers from Epilepsy. The plaster cast on her left arm bears testimony to an injury sustained during an epileptic attack.

She is 04 months pregnant and is under our care. We are hoping that her epilepsy will be controlled so that she can have a normal conception and delivery.

Both Apuramu and Subhadra have been supported by funding from the Village Development Council, London, England

October 2008

Outpatient Total: 1566

Children < 15 years
Male: 127 ; Female: 108
Old Age > 65
Males: 80; Females: 80
Adults
Male: 449; Females: 772

Income Levels of Patients (INR per month)

< 1000 pm: 802
1000 - 1500 pm: 555
1500 - 3000 pm: 209

Eye Programme:
Number Examined: 99
Glasses Prescribed: 26
Medications: 58
Surgeries: 15

Ante Natal Programme:
New registrations: 02
Deliveries: Nil
Abortion: 01

September 2008

Outpatient Total: 1721
Children < 15 years
Male: 171; Female: 126
Old Age > 65 years
Male: 117; Female: 97
Adults
Male: 487; Female 723

Income Levels of Patients (INR per month)

< 1000 pm: 771
1000 - 1500: 431
1500 - 3000: 505

Eye Programme
Number Examined: 95
Glasses Prescribed: 22
Medications: 63
Surgery: 10

Ante Natal Programme
New Registrations: 2
Deliveries: 02 (Hospital 02, LSCS 01)
Abortions: 01

August 2008

Outpatient Total: 1550
Children <>Male: 142; Female: 77
Old Age (> 65 years)
Male: 99 ; Female 174
Adults
Male: 465 ; Female 593

Eye Programme
Number examined: 74
Glasses prescribed: 26
Medications: 34
Surgery: 09

Ante Natal Programme
New registration: 3
Deliveries: 02 (LSCS 01)
Abortions: Nil

Reddi Babu had a severe Viral Keratitis. Malnutrition and local practices like putting milk in the yes aggravated the infection. Fortunately we were able to save the eye with minimal corneal damage.

July 2008

As expected the pace of work picked up in July.

Outpatient Total: 1686
Children < 15
Male: 167, Female: 107
Old Age (> 65 years)
Male: 120; Female: 104
Adults
Male: 405; Female: 782

Eye Programme
Number examined: 103
Glasses Prescribed: 34
Medications: 56
Surgeries: 13

Antenatal Programme
New Registered: 05

Bavaji is a 17 year old boy, who came to us with massive loss of weight. As is apparent from the photograph, he is emaciated and the swelling on the neck is apparent.
He has THROTOXOCOSIS.
Clinically he also had Aortic and Mitral Regurgitation
His laboratory Investigations done here proved this diagnosis and an Echo done at St John's Medical College proved the presence of valvular heart disease.
He is now under treatment at the Health Centre.
His Investigations and hospitalisation was supported by SISHUKUNJ INTERNATIONAL
His medications are being supported by HEART and HAND FOR THE HANDICAPPED.


Kadirappa, is a 65 year old man who came to the Health Centre with a chronic pain in the neck and difficulty in walking.
Clinically his gait was spastic, with brisk lower limb reflexes. Bowel and bladder control were maintained. This suggested a cord compression in the cervical (neck) region.
An X Ray done at the Health Centre, proved this diagnosis.
He has been put on a Cervical Collar and NSAIDs for the pain.
He will require graded physiotherapy and cervical muscle strengthening excercises.
The cost of his collar and investigation were supported by the Village Development Council.

The health centre restarted work on 02 June, a Monday, and sure enough the word of mouth express ensured that the patients were there in full. We have decided to showcase our statistics in a different way which we hope will be clearer.

Outpatient: Total 1382
Children (<15)
Male: 132 Female: 132
Old Age (> 65 years)
Male: 120 Female: 102
Adults
Male: 389 Female: 559
Eye Programme
Total Patients: 66
Glasses: 16
Medications: 37
Cataract Surgeries: 13
Antenatal Programme
New Patients: 01


Every day one encounters a slew of stories, some to do with hard luck, some just defeated by the world, but in all this the very spirit of humanity shines through....
A few of the stories are given below:

Shivaiah, who is 70 years is a Rural Artisan. What that means is that he depends upon traditional art work for his living. He has an only son who is mentally retarded. Shivaiah takes care of him with his meagre earnings and old age pension of Rs 200 pm. Shivaiah himself is a Diabetic and Hypertensive. The health centre provides free treatment to both Shivaiah and his son.
Shivaiah's treatment is possible thanks to a grant from Village Development Council, London, who have funded us for Old Age support.
His son's medicines for Fits comes from a grant from Heart and Hand for the Handicapped, New York

Deena has no parents, both of them succumbing to some illness - possibly AIDS. She is looked after by her grandmother. Deena stays in the Rural Education Centre, through the week. At the REC she gets to eat three meals a day and also gets a few clothes. Weekends she is back with her grandmother.
Subbamma, was hit by her son, because she was too old and was a drain on her family. As youcan see in the photograph, her right shoulder is swollen and distorted from the blow. This is domestic violence aimed at the old. Rising prices and runaway inflation is making life all the more difficult for the rural poor.

A Death

Shanaz Bee was only 30 years old when she died leaving behind five children, the youngest being twins aged 08 months.
Why did she have to die at this young age - its is a story of neglect, poverty and probably mismanagement.
She had not been well for over two months, going to some village doctors, who treated her with Injections etc - the usual stuff. Her mother kept insisting that she come to the Health Centre, but she would not or could not - putting off the visit with some excuse or the other - "Who will look after the kids?" "Who will cook food?" and so on and so forth.
Finally her parents convinced her to come and stay with them. By then she was apparently in a pretty bad shape. She went to a private practitioner in Madanapalle, who again treated her with some antibiotics.
She finally came to the health centre on a Friday morning, reaching early to beat the rush. When the staff came in an hour later, they found her quite breathless. They were in the process of shifting her to the Emergency Room, when she collapsed. We tried resuscitating her but to no avail.
Why did she die - no one knows - a post mortem may have helped, but then who has the money to pay the police, the civil surgeons? After all it is one more death in an overpopulated land.
But a death is a death and what of the kids?

April 2008

Well the new year has started without a let up. Patients continue streaming in, more numbers than usual as they know that it is time for our annual vacation!! This much needed break will give us all a breather to recharge batteries, exhausted minds to ensure that we continue to give our best to our patients. The health centre closed on 26 April and will reopen on 25th May. Exactly a month's break.
The numbers for April:

Patients
Children: 46
Adults: 1851

Antenatal
Registered: 02
Spontaneous Abortion: 01. She had an abortion at 10 weeks of pregnancy

Eye Care
Patients 38
Cataract Surgeries: 07

March 2008

As the Financial Year closes, it is time to take stock of what happened the previous year and look forward to plans for the coming year, not that it makes a difference to the patients as any year, day is the same when it comes to illnesses.
March was like any other month, probably busier than others. The review of work is as follows:
Patients:
Children: 104
Adults: 1861


Antenatal
Number Registered: 05
Deliveries: Nil

Eye Care
Patients: 85
Children: 01
Cataract Surgeries: 04

Gowthami - ? Lymphoproliferative disorder

Gowthami, a 6 year old girl, from a village about 15 km from here, was brough to the RHC with a h/o poor apetite and increasing lassitude.
Clinically she was undernourished (as the photo shows), there was pallor and she was very hesitant in answering questions. Her parents had followed the usual route of going to RMPs, Doctors who all have given her injections and IV fluids. Not one of them had done a blood test or examined her.
There was Cervical lymphadenopathy and diminshed air entry on the left side of the chest
Investigations:
Hb: 12 gm%, TC 30000/cumm, P 18%, Lymphocytes 79%, E 02% and M 01%
Peripheral smear showed normocytic, normochromic RBCs with moderate Leucocytosis and atypical lymphocytes. Immunohistochemistry was suggested

The X Ray of the chest showed a fullness of the Pulmonary Bay, suggestive of a mediastinal mass, probably a lymph node.
This made us think of a LYMPHOPROLIFERATIVE DISORDER, ? Hodgkins or NHL.
We have sent her for CT Scan to find out the spread of the disease. We are awiting this report.

February 2008

As usual another busy month:
Outpatient:
Children: 165
Adults:
Total: 1888
Eye Care:
Children: 01
Adults:93
Cataracts Operated: 05
Ante Natal:
New registrations: 05
Deliveries: 02 - Birth Weight (3.2 kg and 0.750 kg)
Still Birth: 01 (0.750 gm - Mother contracted chicken pox in her 2nd trimester and had a still birth)

Our New Generator

As you can see we have a new generator, which has been installed, tested and is now fully functional. This hopefully will help us tide over the ever present problems of power cuts, which, as summer approaches is only bound to get worse.
This Generator was thanks to the kind generosity of Mr Shyamal Purushottam, a prent of Rishi Valley School. We all thank him for his generosity.

Paediatric Camp 16 Feb 2008

16th February is always a date that hangs heavily over us. Dr Ramamurthy, PhD passed away on this date. This year, thanks to his brothers, we were able to organise a Paediatric and Dental Camp for about 100 children of the Rishi Valley Rural Education Centre. These photos are from the camp. Ofcourse analysis of data will take some time.

A New Ambulance for the School

The pictures you see are that of a new ambulance. This has been made possible thanks to class of 1982 of RVS. After buying the ambulance we found a builder in Bangalore who modifies Ambulances. We got it modified to suit our needs with roll on/off stretcher, airconditioning doctors seat, electricalpoints etc, including a placement for an Oxygen Concentrator. We now need to get a Defibrillator and a Transport Ventilator to make the ambulance fully and effcetively functional.

THANKS CLASS OF 82 FOR YOUR GENEROUS CONTRIBUTION

Tha

Congenital Heart Disease - Operated - Thanks to AROGYASRI

The Andhra Pradesh Government had recently launched the Arogyasri programme in which, the poor get access to high end medical care which otherwise would not have been accessible to them because of the costs involved.
Mallika, was diagnosed in the health centre to have a Congenital Heart Disease - most likely a Patent Ductus Arteriosus in early February this year. She was referred to SVIMS, Tirupati, under this schme. The the ECHO Cardiography confirmed the diagnosis and by the 20th of Feb she was operated and discharged by the end of the month - ALL DONE FREE OF CHARGE.
Mallika is now doing well and is quite health post operatively.
Such programmes, if they function well can do a lot of good for the poor,who are as it is hamstrung by the lackof financial resources. May the Arogyasri continue doing good work.

December 2007 and January 2008

A usual the days go by with the constant flow of patients.

December 2007

OUTPATIENT
Children: 150
Adults: 1634
Total: 1784

EYE CARE
Children: 02
Adults: 71
Cataracts: 04

ANTENATAL:
Registered: 07


January 2008

OUTPATIENTS
Children: 90
Adults: 1444
Total: 1534

EYE CARE
Children: 01
Adults: 71
Cataracts: 05

ANTENATAL
Registered: 04

We have a new Doctor

Dr Ramesh, a paediatrician, joined us from the 01st of January. His presence has made adefinite and positive impact on the quality of health care for children. His wife, Jyothi teaches English at the Rishi Valley School and we hope that he will be with us for a long period of time.

Venkataramana - A wizened baby - UPDATE

An update.
Venkataramana barely survived a week in St Johns Medical College, succumbing to his various illnesses.
Loosing a life is always a hard one to take. In this case the mother is also ill with a Congestive Heart Failure due to Rheumatic Heart Disease. We have been counselling the family to avoid further pregnancies as it could prove dangerous to the mother.

Venkataramana - A Wizened baby

A three month old baby, one of the surviving twins.
The birth weight of both the twins was 2.0 kg (4.4 lbs).
The elder twin was a girl and so the mother did not give her breast milk, leaving the baby to depend on cow's milk. Being born small, the girl had no chance and died within a month of birth.
The younger being a male had the "privilege" of mother's milk. Now, in spite of being three months of age, this one is also struggling for life. Weight at present is 2.1 kg, a scant 100 gms more than his birth weight. The baby also had cough and respiratory distress. The X Ray showed a patch in the left lung suspicious of a Bronchopneumonia. Also worrying us is the fact that the baby has not put on any weight since birth.
It may be maternal malnutrition or more likely that the mother has Tuberculosis (the mother has cough with sputum production for a month now) which has been passed onto the baby.
The baby has been admitted at St Johns Medical College, Bangalore.
Watch this space for updates

An Old Age Story

An old lady, bent at the waist, almost double, using a stick to support her feeble frame, one amongst the many you would pass by on the dusty village raods without a second glance.
She came to us saying that she was unwell and had very little energy. One look at her and Dr Kamakshi diagnosed Anaemia. Sure enough, her Haemoglobin was 3 gm% (normal 12 gm%). No wonder she was tired and fatigued.
We helped her children understand the need for proper nutrition, a roasted mixture of ragi, green gram dhal, rice and chickpeas was suggested as a gruel, with the addition of milk and jaggery. Of course B Complex and Iron tablets were added. Luckily for her, she has children to look after her.
Let us hope that her remaining years on this earth will be qualitatively better.

ANNUAL REPORT 2006 - 07

RISHI VALLEY RURAL HEALTH CENTRE
KRISHNAMURTI FOUNDATION INDIA

ANNUAL REPORT 2006-07

The patient load is unremitting. Day in and out the outpatient is full of the poor seeking succour. During the year, 15,426 patients sought the services offered by the RURAL HEALTH CENTRE, up from 11532 of the previous year. We managed to streamline a few systems and also, we got used to the numbers pouring in. As ever, funding is a constraint and mobilising resources the key to the successful running of the Health Centre.

OUTPATIENT

2004 – 05: 7461
2005 – 06: 11532
2006 – 07: 15426

The average daily workload of the tri weekly outpatient is about 120, with a maximum of 200, which we saw in January.
Since its inception in January 2001, the RHC has treated a total of 61,005 patients.
We are reporting an HIV +ve incidence of 2.94%. ASHA Foundation in Bangalore and the newly opened ART Centres at Cuddapah and Tirupati have helped in extending free Anti Retroviral treatment to our patients.

EYE CARE

This programme continues to do well. Support from SILOAM Eye Centre, (a unit of LV Prasad Eye Institute) and Sathya Eye Hospital, helped us in operating on a number of poor patients.
This year, 187 Cataract surgeries and 5 Glaucoma surgeries were done at these hospitals.
Since its inception in 2001, the Eye Care Facility has examined 5798 patients and has facilitated 748 cataract surgeries in this time period.
But as with any of our programmes, lack of adequate funding remains the biggest constraint. AGAMA India, has been the prime supporter of this programme and we hope that they would continue supporting us in the future.
We are looking for funding for this programme at a cost of Rs 1550/- per cataract surgery.

TUBERCULOSIS PROGRAMME

This programme is funded by the SIDVIM trust. The RNTCP now accepts all cases referred to the PHC, without hesitation. The cases being treated by us are the ones, which do not fall under the purview of the RNTCP treatment protocols.
We started TB cultures in our Microbiology Centre in January of this year and this has proved to be a great boon in the diagnosis and treatment, particularly of Multi Drug Resistant TB.
HIV positives continue to be detected amongst our TB patients, with an incidence of 4 out of the 62.
221 patients have benefited from the TB programme with a cure rate of 92.76%, which compares with the best in the rest of the country.
The data for the calendar year 2006 is given below.
Cases Details

New Cases: 62
Sputum +ve: 19 (31%)
Extra Pulmonary TB: 8 (13%)

Treated at RHC: 34 (55%)
Number successfully completed treatment at RHC: 23 (68%)
Number carried over to 2007 by RHC: 11 (32%)

Treated by RNTCP: 28 (45%)

Old Cases

Number carried forward from 2005: 12
Number successfully completed treatment: 11 (92%)
Number defaulted: 01 (8%)


ANTENATAL PROGRAMME

The antenatal programme is also doing well. There is a greater awareness amongst pregnant women on the need for regular antenatal checks. The ‘lost to follow up’ is probably because of a number of home deliveries, which do not get reported, in spite of our best efforts.
An increasing number of women with multiple pregnancy losses and Bad Obstetric History are accessing our Centre for the following reasons (i) comprehensive work up (ii) personalised guidance and counselling, (iii) close monitoring of the ongoing pregnancy (iv) liaison with Fetal Care Research Centre, Chennai and (v) support of a committed Obstetrician at Madanapalle.

Statistics: 2006

Registered: 40
Delivered: 22
Domiciliary:16
Hospital Normal: 04
Caesarean Section: 02
Ongoing: 11
Lost to follow up: 07

COMMUNITY DIAGNOSTIC CENTRE

A total of 9305 tests were done at the Community Diagnostic Centre. As in any clinical setting, haematology and biochemistry predominated.
The Microbiology Centre, which is the only one of its kind in a 120 km radius, has proved to be highly beneficial in early diagnosis of various infections. The Centre did 150 cultures this year and we hope that more clinicians will avail of this facility.

Statistics:
Haematology: 3274
Biochemistry: 2441
Serology: 313
Urine Analysis: 1802
Clinical Pathology: 87
Endocrinology: 388
Microbiology: 150
Sputum: 379
FNAC:1
ECG: 243
X Ray: 227

HIV: We tested 170 patients using a rapid agglutination test (TRIDOT). Of these 5 were declared positive, giving us a rate of 2.94%, which is comparable to what is reported in the literature.
Endocrinology: This was of a greater surprise to us. 25 out of 110 patients tested (22.73%) showed evidence of Hypothyroidism. This raises the question as to why there is so much of hypothyroidism in these areas.


THANK YOU

To all of you who have supported the health centre, emotionally, financially and in every way possible. The list is big and there is not enough space to thank one and all.

FUNDING
Every bit small bit helps in our endeavours and we welcome any contribution. Please look at www.rvrhc.blogspot.com for our funding requirements.

OCTOBER and NOVEMBER 2007

Dr Kartik was away from mid October to mid November, to Oak Grove School of the Krishnamurti Foundation of America, Ojai, California, USA as part of a teacher visit programme. October was also the month of Deepavalli and the health centre was closed for two weekd from the middle of October to the end of October.
Skeleton staff manned the health centre, by turns, providing basic first aid and emergent medications. The health centre resumed its functioning from 26th Novmeber and right from the first day we were up and running starting with a hundred patients, going up to 150 patients by the end of the week.

October 2007

Outpatient:
Children: 55
Total Patients: 653

Ophthalmic Programme
Children: NIL
Total Patients: 08
Cataract Surgeries: NIL

Antenatal Programme:
Registered: 03

November 2007

Outpatient
Children: 20
Total Patients: 321

Ophthalmic Programme
Children: NIL
Total Patients: NIL
Cataract Surgeries: 03

Antenatal Programme:
Registered: 04

When we look back, we wonder where the vacation went!!!! Just kidding.

AUGUST and SEPTEMBER 2007

It has been a while since I updated this so here goes. August and Spetember were busy months as usual. In fact it seems that we have got inured to the deluge of patients.
Here are some statistics:
August 2007

Outpatient
Number of Children: 103
Total Patients: 1942

Ophthalmic Programme
Children: 01
Total Patients: 112
Cataract Surgeries: 15

Ante Natal Programme
Registered: 02

September 2007

Outpatient
Number of Children: 73
Total patients: 1858

Ophthalmic Programme
Children: 05
Total Patients: 70
Cataract Surgeries: 10

Ante Natal Programme:
Registered: 04

All in all not a bad couple of months work.

Vanaja - Traumatic cataract

Hi all - Sorry that the images are not very clear. Vanaja had a traumatic catarct following a stick injury. The image below represents that.

Here she is post op - dark glasses and all. The parents being emotional and greatful to what has been achieved - all for the princely sum of Rs 1500.00 only.

June and July 2007

We reopened the Health centre on 01 June, after a 4 week break. In the interim we had got some renovations done, added a couple of rooms, a day care centre and worked at streamlining the patient flow. Luckily for us, the patient number started small initially - around a 100 per dya, giving us time to shakedown and sort out the teething troubles.

Statistics:

June 2007:
Patients: 1133
Eye patients: 76
Cataracts Operated: 3

July 2007:
Patients: 1799
Eye patients: 103
Cataracts Operated: 11

By the 2nd week of July we were upto speed seeing 130 - 150 patients on teh outpatient days.
There were the usual mix of cases with Pulmonary infections and Viral fevers predominating in the cold damp weather - yes we have had some rain and it is wonderful to see the fields full of groundnuts growing well. We hope that the rains continue, the tanks fill up and that the crops are good this kahrif season.

Ramalinga Reddy - An Update

Reference to my earlier blog on "TB - two sides of a coin"
We had great hopes that Ramalinga Reddy would make a good recovery - after all he was in the best of hands - being admitted to St Johns Medical College on 21 Jun 2007.
Unfortunately that was not to be.
A week after extraperitoneal drainage of the Psoas Abscess he started passing fecal material from the wound. A laparotomy was done and an Ileo-Caecal Perforation was found. Following resection and closure he started recovering. However on the 3rd post op day he threw a convulsion and was admitted to the ICU. His condition continued to deteriorate and he was intubated, put on aventilator and finally a tracheostomy done on 08July 2007. In spite of the best possible care he did not make it. His relatives decided to tke him home and he was discharged against medical advice on 11 July 2007. He died at home on 12 July 2007.
Cause of death - we can only surmise - poor wound management at home when he put leaves and lime etc in the wound, general malnutrition leaving the body in no condition to fight the overwhelming infection, and of course the dreaded word - POVERTY.
I have no idea what the finl bill would be. Since we supported him we are bound to get a whopping bill. Will anyone in the wide world help?

TWO SIDES TO TUBERCULOSIS

In this blog, I would like to discuss, two patients with Tuberculosis, both males, aged 45 years, but the outcomes were vastly different in them.

The first - Ramalinga Reddy, had presented with a lump in the Right Groin (Inguinal region) in May of 2007. Fortunately for him he went to Tirupati, where in the Government Hospital (SVRR) he was diagnosed as having a TUBERCULAR PSOAS ABSCESS, based on Ultrasound and FNAC of the lump. He was the started on Anti Tubercular Treatment and was transferred back to RNTCP, Madanapalle. He had completed about 8 weeks of treatment, when the abscess busrt to the outside. Then what - the local quacks and well intentioned neighbours took over. The poor man was starved, some leaves, lime and other sundry items stuffed into the wound and it was left to fester.Fortunately, a relative of his approached us and he was brought in a three wheeled cargo carrier to the health centre. He was in a

bad shape - Temp 99 F, HR 120/min, BP 90/60 mm Hg, Respiration 22/min. Looking cachectic and dull.

Well, it looked like septicemia and incipient peripheral circulatory failure. Hb 5 gm%, TC: 7600/cumm, P 78% with toxic granulations, ESR 122 mm, RBS 69mg% all pointed to the above. What could we do here. Started an IV, pumped him with Ciprofloxacin and Flagyl and told the relatives to take him to Bangalore - St Johns Medical College. A taxi driver friend of theirs helped and he reached Bangalore 4 hours later. Two pints of blood and then he was operated the same night. It is now a week, post operatively and he is doing well. Dr Santosh of SJMCH has been of immense support and help.

Now the other one. Venkataramana came to the health centre on 11 June with a classical history of cough, sputum, fever and weight loss. He had already spent upwarsd of Rs 10000, going from one RMP to the other, but never once accessing the Primary Health Centre or a Physician. Many injections and IV fluids later, his weight was down to 32 kg (from I guess a healthy 55 kg) and he could barely walk to the outpatient. Clinically his lungs were full of crepitations and Sputum was 3 + for TB Bacilli, HIV was negative. OK so now we were sure and promptly started him on aggressive Anti Tubercular Treatment. His house was close to the PrimaryHealth Centre (5 minutes walk) and he enrolled with them for continuation of treatment.

Today his wife came and met me. Venkataramana had passed away, 10 days ago. Within a week of starting ATT, he developed high fever and progressive breathlessness. By the time they decided to take him to a hospital it was too late - he was gone leaving behind three children ages 15 years to 9 years. The village has rallied around, but what will become of the children, with their father having gone leaving behind a mountain of debt.

Two men of the same age - luck favoured one and deserted the other - I suppose that's the way life is. It is never easy to face the death, least of all, when it is theyoung and the poor who have suffered.

Thanks for bearing with me in my sadness and angst.

THANKS - DONORS: 2006-07

TO OUR DONORS - MAY YOUR TRIBE INCREASE

I would be failing in my duty if I did not thank all of you, who have contributed to supporting our activities. The number of the rural poor who have benefitted from your generosity, both directly as well as indirectly are enormous.
I would like to publicly thank:
Mr Murali Reddy - a Chemist and a son of the soil of Rayalseema who has encouraged us both financially and more importantly keeping my spirits up through his regular email correspondence.
Sishukunj International of the UK - for supporting child care in tertiary hospitals - may god bless all of you.
Mr Jagdish Dore - an old student, many years my senior who has helped us immensely, year after year with the Tuberculosis Programme, and in the process saved many a family from the brink of debt trap and extinction.
Mr Ashok Singhal - my classmate from school and a friend for the running of the health centre.
Mr Ramkumar Ramaswamy - another old student and a friend for helping us upgrade the laboratory
Ms Priya Kamath - an old student of Rishi Valley - for help in subsidising treatment for the elderly
Ms Chatura Padaki - an old student of Rishi Valley, who with her regular contributions keeps us going.
Mr PV Rao - A philanthrophist who lives very humbly in a village nearby and whose contributions to improving the lot of the rural poor has benefited all of us.
AGAMA India - for helping with the ophthalmic programme

and many many others who have chipped in through the year past.

Both Vidya and I hope and pray that many more will contribute and help us in our endeavour to reach out to the sick and suffering rural poor.

A NEW LOOK HEALTH CENTRE

Its been a while since I have blogged - heh! heh! vacation and all that. After getting back, there was the usual flurry of work, in getting the HealthCentre ready for another year. There have been changes both in terms of infrastructure as well as staffing - No I or my wife have not runa away!

First of all - in the adjoining photograph you can see the extended roof. We cannibalised old GI and Asbestos Sheets to cover our frontage.

Now patients waiting have a shade over their heads and the roof came in just at the right time. We completed the work in the first week of June and promptly thereafter it rained - Boy did the patients bless us for providing them with shelter.

Secondly we got two additional rooms - a Registration room and a room for us to consult in with a modicum of privacy. Oops - sorry no photograph of our consulting room. There are separate sections for the pharmacy, accounts and we have even managed to add a single bed as a DAY CARE/EMERGENCY ROOM.

All this has made the patient flow much easier and there seems to be no rush or hordes of patients peering over ones shoulders to see when their turn comes.

Promise you more photographs as time goes by.

GERIATRICIDE - AN UNHEARD OF EVENT

Maddamma is all of 65 years. She is virtually blind thanks to poorly done cataract surgeries done in a camp many years ago - the thick spectacles being testimony of the same. She has been virtually abandoned by her sons, two of them, who have migrated to towns and cities for better jobs. The lack of rains coupled with poor landholdings has ensured that the family can not survive on agriculture. So what happens to an old woman who is "unproductive" as she is weak, infirm and can not see - GERIATRICIDE.
She was brought to us in a moribund condition - fever for three months, malnourished and we thought so thats it.
Modern antibiotics and good nursing care did the trick. She is now OK. But what about her future. Who will support her, feed her?? Was it ethical to treat and prolong life so that she will continue suffering?
I do not know - I have no answers only a whole lot of questions.

IS THERE A LIFE FOR THEM????

Two photos and they say it all - or do they!

In this age of globalisation, 9% GDP and starting salaries of a crore, does it really make a difference to these two girls????

I wonder. Both of them were unfortunate to have been born girls and to make matters worse to a family that is struggling to survive.

The baby came to us absoloutely dehydrated - medical reason is simple enough - Summer Diarrohea - But the Social Cause - being a girl and that too the 2nd in the family, neither the husband nor the grandmother allowed the mother to bring the baby to a doctor. Why - She is after all a girl. Needless to say my blood boiled - the baby was cured but what about the social evil.

The elder daughter suffers from malnutrition - reason - poverty on one hand and girl child on the other.

What can we do to eradicte this evil. It is pernicious and sucking our society dry. I really wish that social equity was well ditributed so that all could benefit from the so called fruits of a booming economy.

MARCH 2007

So the Financial Year draws to a close - these dates are just tick marks in a calendar - they mean nothing but some symbols of trying to organis nature to suit mans needs. No I am not being chauvinistic whenI use the word man - rather it represents the whole of human kind.
Well the merry month of March marched along - 1697 patients, 83 eye patients seen and 09 cataracts operated. Not bad for two of us slogging it out here.
It becomes increasingly difficult as the days go by try and and achieve a modicum of control. We are constantly being overwhelmed by numbers seeking help and a friendly voice. Many a time I doubt the "friendly" voice as the day goes along I find that I become progressively more irritable and at times do snap at the patients - Not good clinical practice - you will all agree! But whenone is overwhelmed the mind and to a greater extent the physical body can only take so much. What does one do? I really do not have any answers.
All of us here at the health centre are eagerly looking forward to a break in summer when we close for a month - a much needed one to recharge ones batteries and come back with a fresh outlook to life and to try and serve the needs of the needy.

February 2007

Another month goes past and summer is slowly but surely on us. We had a sudden cold snap in Mid February with temperatures dipping to 9 degrees Celsisus. Wow that was colder than the winter just past. Unfortunately there have been no rains and the valley is drying up - the trees have started shedding their leaves, the earth is dusty and parched awaiting the firsy showers. With UGADI around the corner one hopes for some rains and that too soon.
None of this however makes any difference to our patient load - 1626 patients, 108 eye consults, 11 cataracts, 1 dacryocystectomy and 1 trabeculectomy. One feels happy that all this was possible thanks to some money which accrued over the last month.
We have also had a number of "difficult" diagnosis to make and here the power of the web is immeasurabale. Google and particulalry Google scholar have helped in at least pointing out a reasonable path to follow.
As ever money continues to be at a premium. HELP!!!!!

Another Tough Call

Venkataramana, 55 year old male a farmer by profession presented to the health centre with c/o sudden onset pain in the Thoraco lumbar region. There was a history of lifting weights. So sudden onset low back ache with a positive h/o of trauma - acute lumbago - treat with NSAIDs and Bed rest??? Standard treatment.
Well examined him:
Spine: Marked tenderness from D(T) 10 to L2 levels. Paraspinal spasm and worst of all there was pitting oedema in the same area and with deep palpation there was a suggestionof a boggy swelling under the lateral spinous ligament.
Peripherally: Absence of fine touch from the D10 - L1 dermatomes. Diminished Knee jerk and superficial abdominal reflexes.
There was no bladder dysfunction.
So what does one do next. Here the "cut system" of private practice works in our favour. Since we do not take "kickbacks/ cuts" from laboratories/ diagnostic centres we were able to get an MRI spine done fro Rs 2500/- Quite reasonable in today's age. That the MRI was in Tirupathi (120 km) and patient had to be transported there was another matter.
MRI Spine:
1. Shows a Destruction of D9 vertebral body and posterior bony elements with spinal cord compression.
2. Destruction with soft tissue mass lesion at D12 to L1 with mild compression of Thecal sac ? Metastatic
3. Disc bulge at L4-L5 and S1 with bilateral nerve root compression.

No we were in trouble and the only option was a neurosurgical intervention. Managed to get the local MLA to write a letter to SVIMS, a super speciality hopsitla run by the TTD, and hey have promised all help and concession.

Luckily, the patient ahs some money and since both his sons earn, they have sold a cow for approximatel Rs 15000 to meet the expenses.

As i write this, the patient is on his way to Tirupati for admission.

Let us hope and pray that the selling of the cow was worth it.

I will update this in due course.

A Tough Choice

Habeeb a 50 year old smoker, migrant worker by profession presented on 09 Feb 2007 with a 2 month h/o cough, whitish frothy sputum, occasional haemoptysis. There was associated loss of weight as well as anorexia with evening rise of fever.
Clinically:
Pulse 90/min, BP 110/70 mmHg, Clubbing Gd 1, No pallor.
RS: Trachea central, diminished movements Left Inframammary and Infraxillary regions. VF and VR were also diminished, percussion being impaired. There were a few fine crepts.

He was investigated with a suspicion of Tuberculosis;
Investigations:
Hb 12 gm%, TC 6500/cumm, P 76, L 20, E 04, ESR 32 mm 1st hour
Sputum for AFB x 3 times was negative
X Ray Chest showed a mass lesion LMZ.
After this we did
HIV (Tridot) which was negative, Random Blood Sugar was 70 mg%, Mantoux was -ve.
We were fairly sure that we were looking at a Malignancy but decided to give him a month's trial of ATT with Rifampicin, INH, Ethambutol as well as Pyrazinamide. ATT was started on 14 Feb 2007.
He was reviewed on 13 March 2007 with repeat XRay chest.

On the Photograph, the one on the right is the recent (12 March) and on the left is the older one (12 Feb).

As you can see there is no difference between the two films.

We are now trying to convince his sons (2 of them) to raise Rs 1500 for a CT scan which in all likelihood will give us a diagnosis.

Then the struggle to find a hopsital and funds for further treatment.

This is a daily struggle at the health centre. One feels a sense of impotence to be able to detect diseases but then what? Plead helplessness!

Diagnostic Conundrums - Neurology

A 56 year old male presented on 27 Dec 2006 with c/o vague pains all over the body. He gave h/o fever with chills about a week before onset of these symptoms. Clinically there was no significant abnormality and an initial diagnosis of Viral Fever (? Chikungunya) was made. He was treated with Tab paracetamol (acetaminophen) 500 mg tid with Tab B Complex daily.

He came back to us on 16 Jan 2007 with (i) Pain and swelling in the small and medium sized joints, with early morning stiffness (ii) Parasthesiae in the lower limbs (iii) Mild breathlessness.
Clinically: Vitals were within normal limits. There was marked swelling of the Interphalangeal and ankle joints.
Investigations: Hb 12.5 gm%, ESR 10 mm, Total Count: 5000/cumm, P 70, L 27, E 02, M 01, Random Blood Sugar 90 mg%, VDRL - Non Reactor, RA Factor - non reactor
The diagnosis now looked like Sero Negative Polyarthritis.
He was started on Tab Diclofenac 50 mg bid, Tab Folic Acid 5 mg od.

0n 22 Jan 2007 he was reviewed and his condition had worsened - (i) increased pain all over (ii) Unable to walk or lift hands above the head (iii) increasing tremulousness.
Clinically - All joints were swollen and movements of all limbs were sluggish. This prompted me to do a CNS exam:
Power UL - Grade IV, Lower limbs Gd III - IV, Deep Tendon Jerks Bilaterally diminished, absent ankle jerks. Plantars were flexors.
Sensory - Fine touch was absent till mid chest. There was patchy loss of pain and vibration sense over the legs and upper arms.
This got my suspicion up and I thought of an Acute Cervical Cord Lesion.
NIMHANS being the closest and most affordable we sent him there. By the time he reached NIMHANS, about 150 km over bad roads, he had developed acute retention of Urine and needed to be catheterised.
MRI showed:
1. Extruded disc material and superior migration/ Extradural lesion at C5 C6 levels causing focal compression and thinning of cord.
2. Cervical Spondylosis with myelomalacial changes.

Just putting up this as a reminder that what is apparent may not be the actual facet of the illness. We need to keep our eyes and ears open for the most unexpected. After this I did a search using both PubMed and Google Scholar, but really found no such progression described.
Any comments from the Neurologists/Physicians/Neurosurgeons??

Diagnostic Conundrum - ? Budd Chiari

A 24 year old lady presented to our centre with c/o vague abdominal pain, acid eructations and poor apetite. She was seen by doctors in Madanapalle and treated with PPIs as well as Antacids.
A G3 P3, 1st child born through LSCS.
O/E: General Exam - was normal.
Abdomen: Tortuous dilated superficial abdominal veins, with hepatic flow. (The pictures below show you the location and size of the veins)

There was a 2 cm soft hepatomegaly, no splenomegaly or free fluid.

USG: Mild to moderate hepatomegaly, abdominal varices, prominent mid hepatic vein with absence of right and left hepatic veins.

Whats the Diagnosis and how will you proceed? Please help????

Our First TB Culture

Hi all
In this not so clear photograph, you can see the yellowish cream colonies of Mycobacterium Tuberculosis, grown in our Microbiology Laboratory.
The patient is in all likelihood a case of MDR TB, due to multiple, ill advised, irregular Anti TB Therapy instituted at various times.

Diagnostic Conundrum (1)

A 26year old male presened to the RHC with a 6 month h/o

(i) Progressive inability to lift both hands baove shoulder

• (ii) Weakness and wasting of shoulder muscles

He denied any h/o substance abuse, trauma, fevers, convulsions, or exposure.

Clinically: Pulse 78/min, BP 110/70 mm Hg. No lymphadenopathy, icterus or pallor.

CNS: Higher mental functions were within normal limits. There were no cranial nerve anomalies. Spine was normal - no deformity, tenderness or gibbus.

Bilateral symmetrical wasting of shoulder muscles (see photo) with clearly defined bony prominences.

Power at shoulder joint: Shoulder shrug V/V, Abduction O/V, Adduction III/V, Extension III/V, Flexion III/V, Ext Rotation III/V. Unable to lift hand over the head but when he moves his upper limb at a rapid pace he is able to lift his hands over the head.

All other muscle groups power was V/V. Deep tendon jerks unaffected.

There was no sensory deficit.

Investigations: Hb 10 gm%, Total and Differential Counts: WNL, ESR 20 mm 1 st hour, Urine analysis : WNL, HIV (Tridot) - ve.

We could not do CPK due to lack of facilities.

SO WHAT's THE DIAGNOSIS? I put it as FASCIO SCAPULO HUMORAL DYSTROPHY or some other Muscular Dystrophy.

The biggest problem is that this young man is the sole earning member of his family, ekeing out a living on daily wages, and as he can not work, or rather no one is willing to give him work because of his disability, he has been reduced to abject poverty. I am trying to raise funds to send him to Bangalore to at least get a diagnosis. Even with a diagnosis, there is really nothing one can do for him, I suppose and that is the saddest part of it all.

January 2007

The New Year opened with a bang in many ways - what with festivals and patients our cup was rather full.
January is also the month of festivals, with Pongal/ Sankranti being celeberated with great enthusiasm here in the south by one and all, irrespective of caste, creed or religion. This is the harvest festival and it is a very important one. Traditionally a pot of rice, milk and jaggery are cooked together and the pot has to boil over signifying a year full of cheer and bounty ahead. The cattle are all bedecked as they are the ones who actuually provide the work force around here. Tractors still being too expensive and the fact that tractors can not provide milk(!).
So also ID was also celeberated with great fervour. We had to refuse any number of invitations to partake in the feasts as both of us are vegetarian.
Just to see the spirit of the people celeberating these festivals is, as always, an eye opener to me about how people live together in peace and harmony.
January also ushered in the new year and the republic day. We decided to close for these days and fortunately/unfortunately these days happened to fall onour OPD days. Not that any one was cribbing.
Well, started on 03Januray our first working day with a 184 patients. Whew ! at the end of the day Vidya and I were staggering. The relentless pressure kept on and in spite of only 9 OPD days we ended up seeing 1571 patients. January ended with 188 patients and we are desperately hoping for a respite or someone to help us.
We finally also started work on an extension to the building, a waiting room for patients and a water point. I will be publishing these photos soon along with what we plan to do with the extra spaces we have created.
Watch out for Diagnostic Conundrums being published soon.

October to December 2006

Hey Guys forgot to put up the statistics for these months - rather amiss of me. The patient load is never ending and we have had trouble in keeping up with the load.
So here goes:
October 2006: 1036 patients, 63 eye patients, 23 cataracts done at Madanaplle. We worked only three weeks this month before pushing off for a break.
November 2006: Repoened the Health Centre on the 10th of November and in the first week, we did refresher traing for all our staff on basics of health care and management of emergencies. It really paid off because soon after reopening we had a lady who had a convulsion at our door step and the staff were able to handle it without resorting to "nails" etc.
We saw 518 patients, 54 eye patients of which 7 of them were operated for cataracts.
December 2006: Boy, this has been a tough month. 1776 patients blew us away, 82 eye patients and 16 operated. We could have operated more but for a shortage of funds. We raelly are struggling to make both ends meet and are hoping that some of who read this would contribute to our Health Centre.

November - December 2006

Hi All

Into the new year and may it bring cheer to all the people of the world especially the old and the poor.
The December monsonns have failed us and so we look "forward" to a hot and dusty summer. As it is the experts are proclaiming the year 2007 as the hottest one in history. One hopes that this hot summer along with the El Nino phenomenon does not play havoc with our monsoons. There is barely any water left in our open wells and tanks and soon it will only be a marsh land only to dry out to a hard baked clayey surface.
We had gone on a two week vacation in November and had closed the health centre. After our reopening, the centre continues to be as busy as before. Patients keep pouring in in droves stretching our resources to the limit. It seems almost impossible to keep up ones concentration at the end of the day. Mistakes do happen. At times we are forced to undertreat and call the patient back the next day just for want of time and the fatigue of seeing more than 120 patients of all sorts.
Funds continue to be a problem, though some alumni of the school have promised some money. One hopes that we get some soon.
We are looking for donors as well as any doctor who might be interested in working in a rural setting.
Bye one and all

Musings

They come from far, they come from near, the old and the young, the infirm and the diseased - all seeking succour at the Centre. How many people, how many ailments, all clamouring for help. At times just seeing the mass of huamnity waiting at the doors makes the heart sink. The need to be constantly alert, particularly at the end of a long day, takes its toll. The aged and the poor have their own insecurities, many a time a kind word, a smile is all that it takes to reduce the twin burdens of age as well as poverty - one can do nothing much about either - at best some palliation - some placebos - knowing that these medicines will not harm them.
An old man walks, rather limps in. As one talks with him, I find that he is my age. Relentless poverty, a harsh environment and the daily struggle for livelihood have aged him. Clinically he has moderate to severe osteoarthritis in both the knees - we all know the cause factors - poor nutrition, overuse of joints etc. Anti-inflammatory as well as analgesics will only help him up to a certain point. Then what - knee replacement!!!!
He breaks down, he has a son, who is bright and doing well in school. The boy wants to study further, the father says "who will support the family? I can not work and there needs to be food in the house". There is no answer to this conundrum.
Coming to the health centre is a double whammy - loss of a day's wages (about Rs 50) as well as havng topay for the medicines (Rs 10). How does one recompense that? So many questions at all times. At times I wish I had a million bucks everyday to help out the needy but thats just a dole.
Health can never improve without some improvement in the economic status of the poor. That is a big challenge which faces each and every one of us. The healthy GDP does not reflect in the lives of the poor in this country. Economic policies are possibly skewed. Yes setting up SEZs are good for the country - but why take prime fertile land? Why can not these be set up in arid "unproductive" land?? Not that any land can be considered unproductive take Ralegaon Sidhi as an example.
These are just some thoughts that keep coming up in my mnd. The public forum seems an ideal place in which to share these thoughts.
Bye one and all
Kartik

Venkataramanama - An Update

What a smile - Venkataramanama after six months of Anti Tuberculosis Treatment. If you all remember, she had Disseminated TB necessitating admission in St Johns Medical College at Bangalore. (see post "Case of the month - June 2006)
She has been a regular visitor the Health Centre and her smiles seem to light up the the room. She comes from a little hamlet about 30 km away, changing three buses on the way. Quite remarkable considering that she is only 10 years old and barely literate. Her parents are too poor to accompany her all the way to the health centre and therefore our instructions to her have to be very simple and straightforward.
One of our most cooperative patients, she has helped us learn about fortitude and courage.

Sunita - A Girl Child

Sunita is a 11 year old girl studying in our Rural School. An alert teacher noted that she was having difficulty concentrating, falling off to sleep and was not eating properly. The Teacher spent some time with her parents and found that they had also noted the same problems. So he sent her to us.

After examining her, we found that she was quite severely malnourished - Grade III - the cause - Worms and the misfortune of being born a girl!

Treatment was simple, but the time spent with the parents counselling them was very productive.

The teacher is very happy with Sunita's progress and he has told me that she is now active in class, interested in her subjects, active and mixing well with all the others.

The teamwork and close cooperation between the health and education centres has been able to help out this poor girl child.

September 2006

The merry month of September has gone past in a whizz leaving us all quite breatless and tired. The sheer numbers are quite overwhelming:

• 1729 patients seen in the OPD
• 26 Cataracts operated in Madanapalle - "Words can not express our gratitude to Dr TN Krishna Reddy and Dr Shobha Naveen, who operate on our patients at minimum cost."
• 2 Deliveries: Thanks to Dr Asha Neeraja at Madanapalle - one of whom had Pregnancy Induced Hypertension, Intra Uterine Growth Retardation as well as prematurity - the mother and kid are doing fine - that both survived is a testament to the skills of the doctor as well as the nursing staff and to top it all guess how much it cost LSCS + Incubator care = Rs 6700/- only. Can you believe it - who says that quality health care can not be provided at low cost.

The end of September was also a time to reflect and take stock of what had transpired in the past 6 months - a 6 monthly review of sorts - while our patient numbers are impressive (7202 patients from April, 113 Cataracts operated upon, 8 deliveries, including 2 LSCS, no Infant or Maternal deaths), the fact is that we are struggling financially.

A 100,000 rupees in the red, god knows where the money is going to come from. Also we desperately need money to build a waiting room for the patients - the trees providing the only cover at present. That is going to cost us another couple of lakhs. Anyone willing to help???

Bye one and all

Kartik

August 2006

Another month goes by and one is confronted with patients of all types, some near the end of their thether, having gone from pillar to post seeking succour,mostly in vain. In spite of having been in this profession for more than 20 years, disease and death are not easy to get used to.
The poor flock to our centre, seeking professional advise and possibly the right kind of treatment - Iatrogenic Poverty is a major issue with ruthless practitioners out to fleece the poor, ignorant public of what little money they have. So also inappropriate therapy, treatment modalaties, unnecessary surgeries all in the guise of medicine and serving the sick - Whither art thou Hippocrates???

Well the health centre goes on - We saw 1441 patients, did 17 cataract surgeries and 2 Dacryocystectomies and delivered 2 babies both above 2.5 kg. Considering that we started with 1.8 kg, this is quite an achievement.
In the adjoining phot you can see a child being nebulised in our centre. I am sure that the paediatricians would say - it is not the mostideal of circumstances - I agree - but something better than nothing.
Anyway, this child went to a "paediatrician" with c/o fever of less than 2 days duration. No investigations were done and the "good doctor" started him on - hold your breath - Inj Amikacin, Inj Cefatoxime and Inj Metrogyl - wow - should take care of everything!!!!
Well the child did not recover and having spent a couple of thousand rupees and in debt with an interest rate of 4% pm (48% pa),they came to us. Examined the kid and found Heaptosplenomegaly with a Hb 7 gm%, Pl Vivax, TC 6200/cumm, S Bilirubin 2.8 mg%, with conjugated hyperbilirubinaemia - Simple - Treat with Chloroquin 10 mg/kg and child was afebrile in a day and was doing well.
Unfortunately Child developed Hyperactive Airway Disease with LRTI and is now on treatment for the same. Am sure that the child will recover at the soonest.

Take care all and see you soon

July 2006

The busy month of July came to an end and boy did we struggle.

1551 patients - in 12 working days - work that out!
Ouch just looking back at it makes me dizzy.

32 Cataracts and operated upon in July - that itself is some sort of a record.

Of course we are desperately short of Funds - Please help

kartik