The Father Tree

Just outside the maternity ward stands the father tree. In the shade of its broad leaves the Fathers of Sarenga await the birth of their children. It can be a long wait for them so they have to fill their time somehow. They mostly pass the time sleeping, eating, chatting, showing off motorbikes and occasionally getting updates from didima ( grandma ). I love this tradition as I imagine ancient tribesmen may have gathered in the shade to await their own children.

It has been a great day here in Sarenga. Jenni and I have made good progress in our audit. Jenni has mastered the art of cannulating patients. The key is to "soak it in the spirit" (rubbing alcohol) both practically and spiritually. I had another go at suturing an epesiotomy which was good practise. Just this last hour Jenni delivered a baby then immediately after, I delivered another. In both cases the babies were really cute and the mothers didn't need stitches.

We also went to town for some jelabes which are awesome. Imagine a sweet pretzel deep fried in syrup. It has been a busy but exciting day.

Neil

A guava a day keeps the doctor away!

Today has been hectic. Last night a set of twin girls were born. They are very premature as mum was only 25 weeks pregnant. The hospital here is not set up to deal with such tiny babies. They need ventilation to stop them becoming exhausted just from breathing.  As we've mentioned before they don't have a ventilator here. Unfortunately there is no point in sending them to  the big government hospital because neonatolgy is such a new speciality here in india and they also wouldn't have the time or the resources needed. Shubhro is going to give them the best care he can but there isn't too much hope because they are likely to get an infection and won't cope.

I was in the paediatric clinic which was very quiet with only 2 patients to see. A 7 month old boy was in with a viral cold and cough. Interestingly, this boy needed to be resuscitated for one hour when he was born. The guidelines say that you should stop resuscitation if it is unsuccessful after 20 minutes. He was beautiful with these gorgeous big brown eyes staring at you. You could tell that he gave his mother great pleasure and joy. Unfortunately,  his brain was deprived of oxygen in utero leaving him with some spasticity which suggests he has cerebral palsy. It makes you wonder whether it is morally right to stop resuscitation after 20 minutes. Yes this child will be disabled but his mum clearly loves him and wouldn't want him to have died at birth. I know in the uk the issue of inflicting disability and suffering versus allowing a child to die is pretty contentious.

I then went to the antenatal clinic due to the quietness of paediatrics. Here there was one woman just 13 weeks pregnant who had been suffering from intolerable vomiting since the start of her pregnancy.  She has hyperemesis gravidarum (the condition which caused the premature announcement of Kate's pregnancy). She was unwell and had previously been admitted to another hospital 3 times. She needed to be admitted here because she wasn't able to keep anything down. I should mention that the family members provide food and personal care for their relatives  in hospital meaning you need willing family to look after you. This woman's mother, who was with her, couldn't stay because she had to look after her husband at home. The lady's husband was refusing to come to her. It was decided she should be admitted anyway and the husband convinced to come. She only stayed for an hour or two before leaving. Her mother was afraid of being left with a hospital bill. What makes this worse is that her husband has a family government health insurance card. The mother said of the husband "I thought he was a good man before he married her, it turns out he isn't". I don't understand indian marriage! This woman deserves so much better. Women here need to have a husband to look after them but it often leaves them trapped. It makes me so glad that the uk is different.

Wow, so much seriousness today! In lighter news, this guy gave me a piece of guava while I was sitting in clinic. It made my day. What a cutie!

J x

Rainy day crafts

We are truly into monsoon time. Last night the thunder roared and today there it is tipping it down. A fairly quiet morning on the ward with Neil and I trying to look over the 9 new babies before they went to get their bcg jabs.

In the nursery there is a phototherapy machine that is used to treat neonatal jaundice.  The compound that makes people yellow can cross into the brain which is particularly bad in babies because it can cause permanent brain damage. The light is at a certain wave length to break down this compound in the skin reducing the jaundice and preventing build up in the brain.  The babies that go under the lamp need to wear little masks over their eyes to stop any damage. The masks that are here were clearly made by an adult that hadn't taken into account that the gap between the eyes in babies and the size of the head is much much smaller. This meant that one eye would be covered and the gap for the nose would be over the other eye. Also they just didn't fit. I saw this and mentioned to Shubhro and Elisabeth that it could probably be easily fixed by sticking the gap closed. I was given some needles and thread and this morning I set to it. The nursery is empty at the moment and one of the nurses saw me working and joined in. This made everything so much quicker. It is very satisfying to do something that will last even after we have gone.

J x

Breast is best!

We all know breast is best. It must be because its good enough for our new prince. It reduces mums' risk of breast cancer, helps them lose baby weight, it improves baby immunity, it's free, reduces tummy bugs, is always the right temperature and makes healthier, smarter and less obese children. In Britain we struggle to get rates of breast feeding high enough. This is not so in Sarenga; here they love it.

On ward rounds if a mother has problems breast feeding our stern, though somewhat incompetent, nurse Tina takes the wheel. She knows what to do and she has done it before. Plunging her hand into the mother's sari she pulls out a breast and squeezes to prove the well is not dry. She then takes the baby and smooshes it face first into the breast. Whether it sucks or not is in God's hands. It's as simple as that. This approach shocked us at first but we have come to accept that this is just how they do health promotion here.

So they love breast feeding here. I went with Elisabeth to see a patient in clinic who presented with secondary amenorea and loss of libido. I thought about prolactin (the hormone which stimulates milk production) so I asked if she had problems breast feeding her only child. She said she got on well and then said more which my bengali would not permit me to understand. Elisabeth's eyes widened and I asked what she said. It turned out she was still breast feeding the child. The child was 7 years old.

It is actually common to see 2 and 3 year old children breast feeding. I find it perturbing when the child can reach into its mothers sari and pull out the breast without the mother taking notice. It strikes me that a child with that level of dexterity can surely feed himself. I say himself as these children are invariably male, as they are most precious and should be breast fed as long as possible. The only male child is exposed to dangerous levels of maternal affection while his sisters are left out. Mothers keep playing the 50/50 odds up to 5 or more pregnancies till they hit the jackpot and get a boy.

We will talk more about the girl/boy disparities in future posts. I just thought this was an interesting cultural observation for an otherwise peaceful day here in Sarenga.

Neil

Monkey business

Following a horrible night of me being unwell, we had a nice quiet day. Very little was going on in the hospital but Neil went and helped with the antenatal clinic (while I caught up on some sleep). All of the women came back with their results at once so there was a mad rush of people waving their results slips- some of them Neil and Elisabeth hadn't seen in the first place. There was a scramble to try and match patients to notes! The concept of a queue is lost on Indian people (wow that makes me sound thoroughly British)!
We've started making arrangements for our travel at the end of our time here and booked our train up to Darjeeling!  It's making us pretty excited.  Apparently the train we are getting is very like the experience in the film the Darjeeling limited.  Neil is looking forward to this. I can't remember the film!
On Fridays there is a weekly study meeting for the doctors and Neil and I presented on one of the cases we had seen. The discussion was good but disturbed by the sight of a monkey outside the room. One of the doctors (who is very loud and insists on calling me Jennifer Lopez) scared him away by yelling before we could get a good picture. Shubhro managed to get one of me laughing at this loud doctor with the monkey in the background.
J x

Some pictures

These are of us enjoying the wedding reception!

Wedding crashers

Last night Jenni and I attended a traditional Bengali wedding. Shubrho and Elisabeth were invited as it was one of the Hospital staffs children. It was an amazing experience and it was unlike any other wedding we have been to. I should clarify that this was not the ceremony but reception 1 of 2 as they have a party for both the bride and the grooms family.

We arrived fashionably late to the party due to a cesarean section. We walked down from the hospital and turned off onto a mud path past the cow tied to a tree. The path followed the side of one of the ponds in the village and was lit with strip bulbs strung up on posts. The sound of tablas grew louder as we approached and would hear the shrill register of Indian music blasting from the sound system.

We were welcomed by the man from the hospital who quickly ushered us into the house. Sandals off we were led down a crowded corridor. He showed us into a room where the Bride was sitting like a deity on a shrine. She was sitting cross legged dressed in colourful saris with lots of jewels stuck to her face. She was surrounded by flowers and the whole scene was lit by a single 1000 watt bulb. We quickly took in the scene and did lots of bowing and namashkar-ing. It was so far very surreal.

We then were invited for the food which occurred in sittings until all the guests were fed. We were in a marquee covered in colourful cloth and crammed with red garden furniture. This meal was an impressive exercise in efficiency. Men dressed in green charged down the rows laying out banana leaf plates, water, cups and no cutlery (not needed if you have hands). The food was great and it just kept coming: chickpea, rice, chicken, mango chutney, popadoms, salad. Desert was a local rice pudding and ball of sugar thing served straight on top of any curry you hadn't finished when it arrived. You didn't have long to eat such a large volume of food as the next sitting was hungry and ready to go.

Unfortunately for Jenni the speed and volume of food was just too much as straight after the meal she ran outside and vomited in a corner. I was sympathetic at the time but there is no denying that it was hilarious. All in all a fantastic wedding. I have so many ideas for when I get back and start planning my own wedding.

Also today Jenni and I managed a baby after delivery on our own today. It was apgar 5 at 1 minute but after some vigorous drying from Jenni and some nervous muttering from me we got her to apgar 9 at 5 minutes. We presented the healthy wee girl to a very proud deedima (grandmother) which was just lovely.

Neil

(Non) Pushy parents

I am experiencing one of those wonderful moments in medicine when you realise what an incredible job you get to do. Your study and work has been worth it for you have the honour of partaking in something magical. Sorry I should explain that I have just delivered my first baby! The mother was not pushing well. She kept trying to push her legs down and pull her hips and bottom down. This wasn't her first child so we couldn't quite understand why she wasn't doing it right. The nurses were unable to hear the babies heart so Elisabeth decided to make a small cut in the vagina to allow the head to come out. As soon as there was some more room, he came out pretty easily and I pulled out his body. He cried and was in good condition so we let blood flow through the cord for another minute before I clamped it. I should say men are nowhere to be seen in an Indian labour suite and the expectant fathers wait around a tree outside. Dad did not cut the cord. I then got to deliver the placenta and stitch up the cut we had made. All this was done with a great lot of help from Elisabeth. This was the first time that I'd ever sutured a person so it was quite nerve racking. Thankfully it went well.

During my excitement, poor Neil was in the ward checking all the babies. Just 4 new ones today. All perfect.
We had an interesting time in outpatients this morning. No patients to see but lots of discussion with the doctors. They couldn't understand how our prescribing works as free prescriptions or a standard prescription charge are unheard of here. Drug companies have somehow managed to convince people that if there are 2 identical tablets but one costs 3 rupees and the other 30, the one which costs 30 will obviously work better. It's just plain stealing from people in poverty. A drug rep came round and was trying to convince the doctors that piriton is a cure all medication.  In the UK the cry would be show me the study which proves it! It was really interesting to be able to take time and discuss some of the differences. I feel like we are understanding the system a bit better.

All human life is like a breath...

Wow today has been pretty crazy! We were at a birth this morning but the baby must have been very distressed during the labour. He came out and didn't cry and the liquid which covered him was filthy instead of it being clear as is normal. He'd also been squeezed during the birth processing causing his head to be an odd shape. He was quickly taken over to the baby heater and Neil listened to his heart as I tried to clean him. Our efforts to stimulate him didn't work and so a little mask was put over his face and we breathed for him. Shubhro came and inserted a tube down into his windpipe to inflate the lungs better. The baby was still not breathing on his own. A cannula was put in to his hand and some drugs to stimulate him were given. One and a half hours later and he was still unable to breathe on his own. Everything else on examination seemed ok though. His heart was still going fast like it should do, he was flexing to pain, his colour was good. The father came in and was told of the situation and was asked whether we should stop now. He wanted to keep going. They have no baby ventilator here so the family had to be taught. 7 hours later and they are still going. This is really heartening for us because life is not seen as so precious here especially new babies-they can always make more! In places with a high birth rate infant mortality is not seen as much of an issue by families. It is so lovely to see this love and care for this new life.

We left them in the nursery and headed down to the antenatal clinic. Another eye opening experience.  One of the women (just a girl really) looked no more than 12 or 13 years old! She was shorter than me by at least half a foot and had such a youthful face. Legally they can't get married till 18 and she was claiming to be that old for fear of being found too young. I just can't fathom what it must be like to be married and pregnant at such a young age. Other than that we heard some fetal heart beats today:success! and we are definitely getting better at working out the position.  A very encouraging clinic for us. We are still adapting to the concept of the next 3 patients peering in and watching as you are with a patient.  The one positive is that they know what to expect when it is their turn!

After lunch (which included some yellow coloured oranges) we headed back up to maternity to look over the new babies. 7 babies in one night meant that the ward is overfull. We are out of beds and clean sheets and some of the new mums are under the veranda. This time there was another cold baby. Neil was worried and now he is wrapped up in a wooly jumper and a wooly hat that were brought over from Scotland! He had gone back up to make sure that his temperature is improving.

J x

Baby Taanda

This is the story of one of the babies I checked yesterday which we mentioned in the last post. We checked 15 babies as there were many born over the weekend. I call this one baby Tanda as this is the Bengali word for cold. When I went to check him I found no one in the bed space so I went to the verandah to find the family. I found them sitting outside with the baby so I called them in. I noticed the baby was slightly lethargic when I examined him. His respiratory rate was slightly high and his temperature was 35.9 on my cheap thermometer but he was otherwise normal.

I thought the baby was probably too cold so I explained this to the family with the help of a student nurse. I demonstrated how to wrap the baby and told them it should be wrapped if it is outside. I discussed baby Taanda at lunch with Shubhro and he agreed that he was probably cold.

The next I heard of this baby was 6 hours later when he was collapsed with a distended abdomen. Jenni and I arrived as Shubhro began to resuscitate the baby. He was breathing quickly, his heart rate was falling and he was poorly perfused peripherally. The distended abdomen indicated necrotising enterocolitis which is a devastating condition in the UK never mind Sarenga. Shubhro thought he heard a faint systolic murmur which had been too subtle for me during the check. The temperature was normal at this time. Shubhro gave fluids through a needle in the babies bone enough to allow a cannula to be placed. From there he gave fluids , antibiotics and oxygen. We did not ventilate as there is such limited monitoring here that the baby would be brain damaged in the unlikely event he ever came off the ventilator.

Shubhro told the family the baby was likely to die that night. Culturally the husband and grandfather break bad news to the mother so she was not present. The grandfather was a tiny skinny man who was devastated by the news. He kept bowing and thanking Shubhro and us. After the bad news the grandfather returned with a box from the pharmacy with NG tubes, saline and cannulas in it. He presented these to the nurse by placing them at her feet and bowing lots to show respect. This was a really sad sight for us and made the situation personal and emotional where before we were only focused on the medical problems.

Baby Taanda died 2 hours later. It is likely that he died from a heart malformation but it could well have been infection or a metabolic problem. I felt that I should have been more worried for the baby when I examined it. It is an important lesson in being vigilant of small babies who are slightly knocked off. It can be very hard to spot a sick baby as the signs can be subtle as they were in this case. It is unlikely that recognising how sick he was earlier would have made a difference.

In the UK this baby would have been ventilated and would have likely to hve survived. He would have been monitored so much more closely and kept in a warm clean environment. He may not even have got sick in the first place. We mentioned in an earlier post that mothers often put poo on the babies forehead. This baby was found the day before with poo on his forehead which may have caused the infection. Mothers are poorly educated so they don't know how to care for their babies properly. This baby was too cold, had poo on his forehead, had no mosquito net and his mothers hands were dirty. These are problems endemic in this area and result from poor education ans deeply ingrained cultural practices.

I learned a lot from this baby about medicine, but I learned more about the Bengali culture and the challenges Elisabeth and Shubhro face on a daily basis. I pray that the mother will learn from this and change the way she cares for her future children. Baby Taanda was one small baby who died as a result of massive problems in Indian culture. I am so thankful for the work of KSN as it lessens the injustice of healthcare, the deficit of education and tries to chip away at cultural problems. It is a huge task and it happens only by the will of God. Neil

A mellow monday

A quiet day in Sarenga. Last night we had another exciting delivery. It is an interesting case because the mother has jaundice. You can get a normal jaundice in pregnancy but this always occurs with itchiness. Not so in this case. Her last pregnancy also caused her to become jaundiced and that time the baby died. We were quite worried that this might occur again. During the last minutes of the labour the baby began to show some signs of distress. Neil and I stood there praying that he would be delivered soon and incredibly he was out and completely ok. He's back on the ward with his mum. Also the woman with eclampsia from yesterday is doing well but she'll be kept in for a few more days to watch for any more seizures. They are more likely to happen after birth but hopefully she'll be fine. We had 15 new babies to examine today. All perfect except a little one who had been taken outside unwrapped and had come back in very cold and more lethargic.  Neil taught the mum how to wrap her baby and told her to keep him warm.

The day of rest?

Thank goodness that we are not Pharisaical in our treatment of the sabbath and that Christ was happy to heal on it! Following chapel and midway through breakfast Elisabeth ran in telling us about a woman who was in labour and was having eclampic seizures. We ran up and helped assist in the management of the woman. Amazingly and by the grace of God the child survived (during a seizure the baby is deprived of oxygen increasing the risk of hypoxic iscaemic injury during the labour process). The woman was  very young, having gotten married at 14. The women here tend to get pregnant within the first year of marriage - Elisabeth thinks that women should start taking prenatal supplements from their wedding day! It was very frantic and there were two other deliveries happening at the same time meaning that there was a reduced number of staff there to help. We returned to soggy cereal 2 hours later. Yesterday was much quieter. I did the baby checks for the previous two days deliveries-10 in total. I'm getting pretty slick at it. There will be plenty  more to do tomorrow. Neil went to theatre to see another c section and we were able to spend much of the day quietly reading. In the evening however, we were up seeing another normal birth and some simple resuscitation of the baby - warming and some help with breathing. So many babies! We keep learning more about the difficulties of practicing here. The hospital is given 2000 rupees for every below the poverty line birth that happens here - the families wouldn't be able to afford it otherwise- but the staff can be wasteful or will steal things, like sutures, that they can get money for. They don't understand that if the hospital runs at a loss it will affect their salary. Attitudes are so very different to what we expected. In India there is a cultural thing of finders keepers and if it is worth something then you are entitled to take it. Elisabeth says that when she first came here she was shocked at this and suggested discipline or firing people but it is ingrained in the way that people are and it would not change and just deprive someone of their livelihood. Now we are enjoying some Sunday peace before something else happens that we need to run for. J x

Bicanna foreheads

Another busy day. We were so impressed by the theatre staff last night because it was so smooth and very like a British operating theatre. There is air conditioning  in the theatre itself but none in the changing rooms which made it very hot. The baby was the biggest we've seen here: 4kg (Bengali babies are small). Today we were both in the antenatal clinic and were looking after the low risk pregnancies.  The women often book much later here - probably because they don't have pregnancy tests. The nearest ultrasound scanner is 14 km away because it is difficult to get a license for the machine because of female foetuside. We saw about 20 ladies and are becoming a bit more confident about determining the position of the baby. On the ward round we saw that one of the mothers had put faeces  (bicanna in Bengali) on her baby's forehead as is custom here. Elisabeth gave her a proper telling off because the baby could eat it, get loose stool, and become dehydrated.  The woman's mother in law was telling Elisabeth not to he scared of it to which Elisabeth said you should be scared the baby could die. It is so interesting to see these strange cultural practices. We both managed to have little naps after lunch- it was too hot to do anything else. Back at the hospital I got to see a delivery.  They have no pain relief other than paracetamol and the mother was incredible.  A 3kg baby and the nurses promised Elisabeth some sweets for correctly guessing the weight of the baby. Neil went back to see the baby with the heart problem and checked his oxygen levels. They were a bit low so he is being transferred to another hospital in Bankura (the main city and the name of the part of west Bengal we are in). Still not used to the heat or the many bites that we both have from mosquitoes.  We are starting to plan out travel for the end of our trip. Every where we are going seems to be described as cool. We are very much looking forward to this! J x

A post from Neil

Hey all. We've had another productive day in Sarenga. I went with Shubhro for paeds clinic today while Jenni went with Elisabeth to do gynae. The clinics are pretty exciting as there are like 30 patients per morning. One poor child had such a high fever he was having fits in the clinic. The Indians queue in a frantic way despite having an allocated order. The next patient usually charges into the room before the previous one has left.

Jenni also catheterised a patient with urinary retention after giving birth. This is really important as the urine won't come out without the catheter.

This afternoon jenni and I did a few more baby checks on happy healthy babies. We then headed into town ans I bought bicuits and fizzy juice. They love sugar here which is great for me.

There is a ceaarean section heppening this evening so we are resting before.

There are some pictures in this post so you can see what we look like here. We are the same colour as the hospital.

On the maternity ward

Today was day one of experiencing medicine here. The ward round started at around 8.30 and just finished at 1! This is not usually the norm though because Elisabeth has been in Britain for the last month so didn't know the majority of the patients. It was strange to compare some of the nursing practice to the U.K.. Some patients had intravenous lines that had been in for 5 or 6 days- in the U.K. they must come out after 3. Also they don't have many of the blood tests that we rely upon. They can't measure electrolytes here and in most wards at home people would have them checked daily! This is particularly difficult because they still prescribe drugs that damage the kidneys with no way of measuring toxicity. We were also amazed (Elisabeth too) that so many of the new mums had not been taught how to breast feed even though the babies were days old. Supervised feeding for everyone! Once the ward round was done with all the tubes removed Neil and I began the mammoth task of doing post natal baby checks on all the children in the ward. 16 babies later and we are finally done. Neil spotted a heart murmur that Shubhro came to check we think is a fairly common newborn heart problem. At the end of the day I can introduce myself and ask whether baby is peeing, pooing and feeding in Bengali. The student nurses were great and helped us a lot. I am exhausted but it has been great to be of use! J x

Anti first world problems

We went into town to day to get some clothes for working in but also Shubhro needed to buy some new shoes - the rats had eaten them while they were away. Being at the bazaar was incredible. You can fit at least 4 shops into one British high street shop! It is very hot so we are sitting on the porch in our Indian clothes.  We've tied our trousers incorrectly so Shubhro and Elisabeth have been laughing at us! It is nearly dinner time and work starts tomorrow so I'll go. Hopefully I'll be able to update daily :D Jx

The Journey

We made it! It seems like it was ages since we left Glasgow. I'm lying in my bed which is engulfed in a mosquito net as I write this. So much has happened already. We've had 2 pretty long flights which caused my legs to swell up like crazy and Neil to lose his affection for long haul travel. On the flight to Kolkata we experienced our first glimpse of Indian culture as 5 people gathered to join in an argument about the seat numbers. A lot of ticket waving and two distressed flight attendants later and the matter was resolved. Once in Kolkata we drove to Shubhro's parents' house (he is the paediatric doctor that we are working with). The noise on the road is incredible as everyone honks their horn to indicate their presence. The smells of spices and food and dust and exhaust combined with the heat and jolty driving made me feel sick. First vomit of the trip! We've seen all the classic Indian sites: 30 people riding on top of a bus, man squatting in a gutter, bikes cycling the wrong way on the motorway, a motorbike with more than 3 people on it and cows walking down the street. Once at the house, we were treated to wonderful hospitality. Shubhro's mother kept bringing out more food and forcing us to eat it. We spent some time there talking and learning some Bengali and about their lives. Shubhro's niece decided that I look like a doll so his mum called me Dolly! This stuck so much that when she prayed over us as we were leaving she prayed for Neil and Dolly. Another long drive and we finally made it to Sarenga at 9.30pm. I am exhausted but we are getting to sleep in tomorrow! J x

India!

Hello!

On Sunday, Neil and I begin our long journey from Glagow to Dubai to Kolkata!  He is very excited at the prospect of a long haul flight. Having finished with exams today I am filled with a mixture of relief and a new form of anxiety at the prospect of traveling half way around the world! We will be spending 6 weeks working in KSM hospital in Sarenga, west Bengal and then will try and see a bit more of northern India. I am going to do my very best to keep this up to date and let people know what is happening. I may even let you see some pictures of things!

Please keep us in your prayers!

 Love jenni x