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!