Friday, July 4, 2014


    I have often heard the debate on the health care.We in US feel that there is rationing of health care with HMO or by any insurance company or by government. But we are unaware of the medicine that is 'practiced' in other countries.Again the things have changed in many countries especially India .But many years ago when I was in India it was very different, if not difficult.Please note I am talking about the time when there were no CT scans , or PET scans or even ultrasound examination, not even in US.So the medicine was more clinical and certainly local . In India for example the commonest cause of iron deficiency anemia was Hook worm infestation (and excessive menstrual blood loss),and not gastrointestinal blood loss from cancer of colon or bleeding ulcer like in this country.The commonest cause of fever with chills was Malaria and not other infections . There were limited X-ray plates available for use and not a unlimited quota.So the decisions were made clinically and treatments were also not as advanced or as good as it is today . So I still remember some patients that created' hole ' in my heart RAMILA is one such patient.
    I was working in medical ward.We had admitted a young girl , about 14 or 15 years old ,with abdominal pain.She was cachectic looking and probably weighed may be 50 lbs.She was not eating for last 3-4 months as she was nauseous and when she was forced to eat she would throw up.Her examination showed 'clear' lungs.Examination of belly was interesting. It is called "doughy "feeling . This is reported in Tuberculosis in the intestine or belly. This is not seen in countries where milk is Pasteurized.But in many parts of India people get milk from cow directly and not from dairy . So if the cow has TB,the TB organism will be in milk and are nor killed and can infect the intestines of the human beings that consume the infected milk.Ramila got it.
    We started her on treatment . In those days , the treatment of TB was with 3 drugs in pill form and one injection daily. Ramila had no muscles , but she needed the shots. So we continued them . The pills were of 3 kinds . The dose of one of the medicine was 3-4 grams 4 times a day . These are big pills and you have to take such a dose 4 times a day . Even the patients with TB of the lungs , who do not have any stomach problem or nausea , vomiting , also don't like this drug and have problem with taking it.Ramila had hard time and would vomit.She continued to be treated with some success.After being in the hospital for almost two to two and half month, she was discharged.I had hard time convincing the father that his daughter was ready . She had gained may be 15 lbs.She was able to eat.I told the father that if she had any problem he can bring her back and I will take care of her.
   We use to see patients in ER one day a week . There were 6 other units that were taking turns on taking the ER rotations.About a month after discharge, I saw him in the ER .He had brought Ramila . She was throwing up and could not keep anything down.She looked dehydrated. Her eyes were sunken.I was not too sure as to what I could do . But he wanted me to admit her . He told me that' he was not going to take her home '.He told me that 'she is your daughter and you MUST help.'Think about it. I was 23 years old and he was may be 35 years old . He wanted me to do 'screening'.Since we did not have enough X-ray films, we used to do fluoroscopy , which was called screening.I did the screening or the fluoroscopy.It was surprised me .I saw what is called 'air-fluid levels.'This was indicative of intestinal blockage. I had to admit her , but not under medical unit , but under surgery unit. She was going to need surgery , if she did not get better within 24-48 hours.With her abdominal TB , the hope that she was going to improve was low.
    She was admitted to the hospital. I had personally spoken to the surgical resident I had told him to call me when she would be going for surgery. The first 2 days after the ER call are very busy ,especially since we had no limit on how many patients were admitted . We used to have floor beds.Which meant we had beds in between the two cots . There was award system and there were limited number of cots or beds . If we had more than that number , we would put a mattress in between the two beds . Once we discharged enough patients , which usually occurred in next 2 days , every one got the regular bed.So I got some time to see Ramila after 2 days . I had not gotten the call from the surgical resident, So I had presumed that she must have improved . But when I saw her I was surprised. She was still quite sick and still had abdominal distention.The X-ray had shown that she was blocked . So I was not sure why she was not operated. I spoke to the nurse and then to the doctor. The father HAD REFUSED THE SURGERY. I was shocked. I told the nurse to call me as soon as the father came to see her. I got call that evening . I went to talk to him . He asked me if I was sure that she was going to be cured or we were going to go through the same problem of nausea, vomiting and loosing weight.I was speechless . Only thing that I could 'promose' him was that the blockage was ' likely ' to get better. There was no guarantee with her abdominal TB . He told me that the girl had suffered enough and if the GOD wanted her to 'live' she would come out of this without the surgery. With the passing time I was not too sure as to if she would survive the surgery now or we would just prolong the inevitable.
                                  Ramila died in next 36 hours.
                        Nothing that I could do would have saved her.

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