Experience

This has happened in early eighties.  There is a village, 15KM from a second grade Indian town.  The town bus makes two trips, one in the morning and other in the evening.  The village did not have a qualified medical practitioner until Dr. Sujay had started his clinic.  Coming from a poor family, pressurized to earn Sujay opted to practice in the village so that he can serve and settle down in practice early.  He was welcomed by villagers who were until then were treated by RMP (quack). 

Sujay had to start his clinic in single room.  This is ‘L’ shaped room.  Those days disposable syringes were not known.  Glassvan (glass) syringes were used.  These syringes after use are washed and reused after sterilization by autoclaving (big hospitals) or simply boiling (clinics).  Dr. Sujay had kerosene stove on which he would boil the syringes and wash them with boiling water and reuse after boiling. The doctor has arranged his table and chair in front of entrance.  This would give him a chance of having view of the street and people walking could also see the doctor and inform villagers about his presence.  The doctor stayed for five hours – 9AM to 2PM.  This was extended when patients continued to come.  After 2PM, after the last patient, he simply put down the stove, takes his bag and buzz out to home in the town.

In the clinic there are two benches for patients to sit, if somebody is too weak, they can as well lie down and others would adjust on a single bench or sit down on the floor.  Sujay started his clinic immediately after internship.  He was young, friendly and considerate.  This had made him dear to the villagers.  Many would come tell their complaints and take tablets for relief.  For this they never paid.  In the village practice, doctor is paid only if an injection is given.  Examining the patient and writing down prescription means nothing.  It does not deserve any payment.  Even now this practice continues in villages.

On that eventful day, as usual, Sujay had come to his clinic, all the way greeting villagers, young and old.  People who are waiting told him “doctor I will come after half an hour or I will bring my ---- you will be there no”, and moved along.  By the time he reached his clinic the owner of the room cleaned it and made the patients sit.  She often sits there and watches doctor do his work, chit chats with patients and comforts them with soothing words. She is a widow, aged about 50 years and lives separately from her only son living in the immediate neighborhood. 

As the doctor came in, people started talking.

“What doctor, today you are late”

“I am waiting here for past one hour.  I am the first to come.  So see me first”

“My son has high fever; he did not go to school, please see him soon and send”

Hearing all this Sujay had lighted the stove.  Put the vessel with water on it.  Put few syringes in it to boil.  He adjusted things and medicines in various boxes on his table, took out his stethoscope and BP apparatus, hung the stethoscope around his neck.  As he was doing all this he was responding to patients talk.

“Now, now don’t worry, just two minutes.  I will see you all fast, write good medicines.  Let the water boil.  I can give injections.  Raju missed his school, I will give him injection he will attend school.  Now it’s over.  You said you have come first.  Come on sit here on this stool”.  The stool is just beside his chair.  Behind him is table with stove and syringes boiling.

He examined him gave him some tablets and told how to use.  He asked him to swallow one of the tablets (to observe any allergic reaction) and sit until syringes are boiled.  Then one after other he was examining patients, giving injection and some tablets; sometimes giving tablets to the accompanying person also who complained of symptoms and asked for tablets, refusing any examination to avoid fee, and take tablets one or two freely.

“Saar, I have body aches, give yellow injection.   It works well for me”, Rajaiah a labourer and alcoholic who frequently visits doctor came and dictated his treatment. 

“O Rajaiah, why don’t you stop drinking that arrack?  You need not come to me for these injections.  Instead you can eat eggs or mutton.”  Sujay said as he was examining another patient.

“Saar, I work whole day.  Without arrack I can’t sleep.  Give some tablets for numbness in my limbs”.

 “OK, sit.  Let me see these patients who have come already”.

“Arey Sheenu, what happened to you”, Rajaiah asked a youngster who was already sitting there.  He also sat on the other side of a bench where there was some place to sit.

“I am having fever for the past two days uncle.  RMP Chandranna gave two injections yesterday and day before.  No effect.  So I came to Sujay doctor”.

“Arey what Chandranna knows is nothing.  This Saar is really good.  He has healing touch.  You take one injection.  Next day you will run.”

Sheenu or Srinivas is young man who has studied till 5^th class and took up agriculture.  He generally visits village quack who is his friend.  When that treatment doesn’t work he will visit other doctors.  Now he was suffering from cough and fever. When it was his turn he went and sat on the stool by the side of the doctor.

“So your name is Sheenu, I think it is Srinivas, what is your age”

“22years sir.  I am having fever sir.  Cough is really troubling me.  Give me something that works fast.”

 The patient was coughing without covering his mouth, droplets polluting entire room.  Sujay turned the patients head to a side and auscultated his chest.  He could understand the severity of infection.  He decided to give antibiotic injection.

In those days penicillin was regarded as panacea for all infections.  It was really a wonder drug.  The main draw back is the serious allergic reactions, sometimes killing the patient instantly.  Whenever penicillin is given, history is taken, whether patient had taken penicillin injection previously.  If they had taken it was given, otherwise when it was essential to give penicillin injection, a test dose is given to know allergy.  If the patient tolerated, it was given.  Sujay asked, “Sheenu did you take penicillin injection previously?”

“Yes sir.  I took it”.

“OK.  Then I will give you that”.

Sujay loaded penicillin in a syringe and gave it into arm. He withdrew the needle and was about to wash the syringe with boiling water.  Just then the boy slumped. 

Sujay left the syringe on the table and bent down to lift the boy. 

“Hey, what happened?  Please you all get up from this bench.  Help me let the boy lay on the table.  Allow some fresh air.  Just move away”.

Sujay understood that it was allergic reaction to penicillin.  He was thinking, talking and doing everything he can and should do.  Patients pulse was feeble and patient was unconscious. Sujay’s pulse was bounding, he could hear his heart beat, instead of lub dub it was just dub dub thumping.  He put a book under the legs of the patient.  With shaking hands he gave corticosteroid injection intravenously as another patient Rajaiah helped him.  He asked another accompanying person to open the IVset from its cover as he took out the saline bottle and fixed the set and connected to the needle already in the vein by giving injection.  He hung the bottle to a nail on the wall.  He watched the pulse again.  It was still feeble and patient appeared unconscious breathing laboriously.  He took the adrenaline vial took 1/2cc of it and diluted with distilled water and gave 1/2cc  subcutaneously.  Watched pulse again.  Patient’s breathing was slowly getting normalised.  He checked the BP.  It was very low.   He again repeated another dose of adrenaline.  Increasing the flow of saline flowing, Sujay wet with sweating once again looked for pulse, though it was fast it was feeling better, BP near recording normal, and Sheenu breathing normally. 

People on the road also came in and started talking,

“What happened?  Injection reaction?”

“Patient will live or die?  Don’t leave the doctor.”

“Doctors are commercial, they just want to give injection and take money, don’t have any service motto.”

“This doctor is good.  He gives injection only when required.  He treated so many serious conditions.”

People talked as they liked.  Rajaiah was trying to help the doctor as asked.  He was doing his best in helping the doctor. 

“Saar asked him whether he had taken injection and then only gave it.  It is not his fault.”

As all this was going Sheenu gained consciousness. 

“Eyy, Sheenu how are you feeling?”  Sujay asked on seeing Sheenu opening his eyes.  He once again checked the condition of patient and knew that the crisis was over.  He gained some confidence, and asked people surrounding to move away and allow fresh air.  He said the boy is fine to all and asked them to move out.  In another 15-20 minutes everything had become normal.  IV fluid was almost over.  Sheenu looked around. 

“Sheenu, you said you have taken penicillin previously.  You had such severe reaction!”

“Previously also I had the same problem after taking the injection sir”, Sheenu answered coolly.

“WHAAAT?  Why did you not tell me?  My god!  It was such a serious reaction.  You are saved.  Never ever take penicillin or any related medicine in future.” Sujay said in a raised voice.

 When Sheenu was about to get up and sit, Sujay asked him to lie down for some more time. Keeping an eye on him Sujay disposed other patients.  Rajaiah was given his yellow injection (B-Complex).  Some pain killers were also given.  He paid the doctor.

“Arey Sheenu, Go home carefully.  If I see your father I will send him.” Rajaiah said as he left the clinic.

After an hour of observation and after checking the general condition, Sheenu was asked to go home. He was given some tablets for fever and cough syrup. By then his father had come.  He was told that Sheenu had serious reaction to penicillin injection and he should never ever take it again in life.

Though Sujay sent the patient home and he returned to his home, he was worried about the patient as he was having abnormally increased pulse rate, the side effect of the anti-reaction injection.  In fact, the next day he was afraid to go the village alone.  So he took his friend along with him for support in case things turned worse.  Fortunately patient had become alright, his fever was less, and was feeling better.  Sujay wrote him some more medicines for further treatment.

Every doctor might face such critical situation many times in their life.  In such conditions if patient could not be saved, doctor feels so depressed as to give up practice for ever.  But once the stress is overcome doctor will again be ready to face challenge with added experience.

After this incident Sujay had made it a practice to ask if patient had any problem after taking any injection or tablet.

Fertility

Sometimes the biology of woman makes her vulnerable to mean criticism.  This is particularly problematic if she conceives within the first month of her marital life.  If the husband and in-laws understand she will have a peaceful life.  Otherwise she will be subjected to mental trauma. 

Once, a newly married couple had come to me.  Parents-in-law also accompanied.  Young bride was shy and sat silently.  Mother-in-law told me that the girl was supposed to get her periods that week but did not get it.  I asked for pregnancy test and pregnancy was confirmed.  Except the girl there was disbelief in all others’ face.  The boy said he is married just three weeks ago and doesn’t want to have children so soon.  He expressed his doubt that how can a pregnancy occur so early and what could be the duration of pregnancy.  I understood that he is suspecting the girl’s fidelity.  He opted for a scan.  The scan was showing early gestational sac, with a fetal node – suggestive of early pregnancy of 5-6 weeks.  Now all he wanted to know if that marriage had taken place only three weeks ago how can she be more than 5 weeks pregnant.  That is a genuine doubt.

In obstetrics we count pregnancy duration – gestational age, in weeks.  This is counted from the first day of bleeding of menstrual cycle (MC).  The onset of bleeding in a MC is clearing of  the old endometrium (inner most layer of uterus which lodges embryo, nourishes in early stages and develop attachment to placenta to sustain fetus until delivery).  New endometrium starts developing along with ovum in the ovaries.  The changes in ovum that is to be released and fertilized, and endometrium so as to provide nutrition in case of successful fertilization and implantation of embryo that happens in the 3^rd week of MC.  The normal MC is 28 days cycle.  It could vary a few days – 26 to 30 days.  In a 28 day MC ovum is released on 14^th day.  If the cycle duration is more it may be delayed, in a shorter cycle it may be early.  In general, in normal MC the fertile period – chance of conception is from 12^th to 16^th day.  The first two weeks of preparatory period is also added when pregnancy dating is done.  So getting married in the 3^rd week of MC and being diagnosed to have 5weeks pregnancy a week after missing periods is perfectly normal.  There is nothing to suspect any mischief by the girl.  Though obstetrician explains the newly weds and their family the biology of conception and dating, few still doubt.   Illogical doubting spoils future togetherness.  It is good to have scientific understanding of ovulation, fertility and dating of pregnancy which will help in future family planning.

The fertility period in a woman with regular MC of 28 to 30 days is 12^th to 18^th day of MC.  First day of bleeding is considered as first day of MC.  Contraceptive methods are used to prevent either release of ovulation (OC pills) or prevent contact of sperm with ovum (barrier methods, abstinence), or prevent implantation (Intra uterine devices, emergency pill).  This awareness of fertility period in the woman helps to prevent unwanted pregnancy and improve health of woman.

Contraception

We all know that prevention is better than cure.  But in practice this principle is followed by few, particularly when it comes to avoiding unwanted pregnancy.  Except the highly educated and living in metros very few couple opt for contraception in the early days of their married life.  The first pregnancy if occurs within a month or two, there will be unending discussions whether to continue pregnancy or undergo abortion.  The girl simply has to oblige wishes of husband/in-law’s family.  This will be quite unpleasant in the early days of marriage. 

Even after abortion and delivery very few couple chooses any contraceptive method.  This is due to lack of awareness and unnecessary apprehensions.

There are many simple methods of avoiding pregnancy – using contraception.  Depending on the couple’s choice, the duration of contraception requirement gynecologists will suggest appropriate method.  As of now except the male condoms all methods are for use by women.  The only contraceptive that can be used by male is ‘condom’. 

The various methods of contraception are -

Natural methods:  The fertile period of woman, strictly speaking, is only 5 days in a menstrual cycle.  In a 28day menstrual cycle ovum is released on the 14^th day or otherwise it can also be said to occur 14 days before the onset of bleeding – first day of periods.  The life of ovum is 48 hours and that of sperm is 72 hours.  So the possibility of conception is from 12^th to 16^th day is high.  A woman having 30days+/-2days cycle should abstain from sexual activity from 12^th to 18^th day of the menstrual cycle (first day of bleeding is considered as first day of menstrual cycle).  This one week is unsafe and any couple wants to avoid pregnancy should either avoid sexual activity (abstinence) or male should withdraw and allow the ejaculation outside the vagina (coitus interruptus).  The failure rate in this method is high.

Barrier method:  This is the method which prevents live sperm meeting the ovum.  Condoms come in this category.  Male condoms are most widely used.  Condoms not only prevent pregnancy but also prevent sexually transmitted diseases.  Male condoms are easily available, can be carried easily, inexpensive and simple to use by males and when properly used the failure rate is 2-3/100 women years (100x12).  Failure could be due to improper usage or tears in the condom. 

Female condoms are costly and bulky to carry.  Failure rate is 5/100 women years.

The chemical barrier is the use of spermicidal jellies or douches.  The common spermicidal agent nonoxynol-9 is available as ‘Today’, to be inserted in the vagina before the act.  This can prevent pregnancy but not infections.

Hormonal methods:  Hormonal contraceptives are the best means of avoiding pregnancy as their effectiveness is 100% when used correctly.  Hormonal pills or OC pills are available in different formulations using estrogen and progesterone.  When both the hormones are used, it is combined pill.  Combined pill can be available as single or biphasic and triphasic depending on amount of hormones used to mimic normal menstrual cyclic changes in the hormones.  Usually fixed dose pills are used.  Combined pills are generally available in pack of 20 or 21.  These are started on first or second day of periods and not later than 5^th day or as advised by manufacturer.  Once started, pills should be taken regularly at the same time – preferably bed time, till the pack is over.  After stopping the pills bleeding starts within a week.  The pills can be used as long the contraceptive protection is needed. 

There are also pills with progesterone only.  These are in particular useful in breast feeding woman. 

The pill which is presently misused by the young generation is post-coital pill.  This is also called as morning after pill and used as emergency contraception. The pills contain large doses of hormones and effective when used within 72 hours of coitus.  But this is only an emergency pill, and the large dose of hormones in these pills may cause more side effects.

Injectable contraceptives that are estrogen free are also available.  These injections can be taken once in 60-90 days depending on the type of injection.

The important side effect of hormones is thrombo-embolism affecting cardiovascular system.  But the low dose of estrogen in the OC pills, estrogen free pills and injections has reduced this troublesome side effect.  The use of injections is supposed to cause some amount of demineralization of bones which reverts to normal once the usage is stopped.  The other common side effects like spotting can be overcome by using appropriate dose pill. 

There are definitely some beneficial effects of OC pills.  The cycles become regular, pain during periods lessens, bleeding is reduced and helps in reducing anemia.  Also studies have shown that pill use may give protection against benign breast disorders and ovarian cancer. 

Non-hormonal pills:  Centchroman 30mg per day twice weekly for 3 months followed by once weekly is a good non-hormonal contraceptive pill.  The only side effect is delayed periods.  This is somehow not easily availble in the medical stores.

Intra-uterine devices (IUD):  These are the small devices placed in the uterus to prevent pregnancy.  These are made of polyethylene or other polymers.  They are usually ‘T’ shaped. These can be medicated and non- medicated.  The commonly used devices have thin copper wires wound around the stem of the device.  Copper has strong anti-fertility effect.  The medicated device is with progesterone in time release form – Progestasert and Mirena. 

The common side effects with IUD is occasional spotting, increased menstrual flow with cramps.  This will subside within a month or two.  There is chance of infection in women with multiple partners.  The failure rate is 3% in the first year. The progesterone medicated IUD, is more beneficial as it protects women against excessive bleeding and reduces anemia.  The advantage of IUD is once inserted and tolerated it can be left in situ depending on prescribed duration of effectiveness(3-5 years) or removed earlier when woman decides to conceive.

In general use of contraception protects women against unwanted pregnancy and abortion with it attendant complications.  Abortion subjects women to more physical, mental, social trauma and financial liabilities.  Any woman who wants to use contraception other than barrier or natural methods should consult a gynecologist and use appropriate method as per her health and requirements. 

There are other forms of contraceptives like diaphragms, vaginal rings which are not commonly used and hormonal implants that need implanting tiny rods with hormones subdermally and removed after the scheduled period or as required.

This is simplified information about contraceptives.  This is to encourage women to protect them from unwanted pregnancy and abortion with its attendant complications.  Abortion contributes to 13% of maternal mortality.  Most of it occurs in the developing world.  Contraception will prevent 218 millions of unwanted pregnancies, averts 138 millions abortions with its morbidity and mortality in a year.

All the contraceptive methods have their effect only when they are used.  They do not affect future prospects of pregnancy or have effect on the progeny. 

For a healthy, happy family life the couple should adopt convenient contraceptive method early in the marital life and later for spacing childbirth.  The permanent method of contraception is ‘tubectomy’ in women and ‘vasectomy’ in men.  

New Life

The other day I had one young patient, just 20yrs and married a month ago.  She had come for some general complaint.  I asked her whether she would like to have children early or want to postpone for a certain period.  She said she did not think about it.  She wants to ask her husband and elders.  But then, she asked me the right time to have children.  “When you couple decide to have it”, I said.

After that girl went out I was just thinking about the right time to plan conception – child birth for a couple.  Each may have a different time, for the reasons best known to that couple.  A couple should not try to beget child just because someone in their peer group have given birth to a child or parents and relatives on either side are frequently asking for ‘good news’ or for some such reason compelled to prove their fertility.  Child birth should be happy occasion, and the couple should welcome its arrival in blissful joy of companionship.

To bring a new life into this world the physical and financial health of the couple is of prime importance.  As for the physical health, more importance is attached to the health of the woman – would be mother.  A healthy mother begets healthy child.  The fertility of woman is at its peak between 20 and 30 years age.  This is also the period when the incidence of pregnancy complications is low.  After the age of 30 years the fertility decreases slowly, and after 35 years the incidence of ‘Down Syndrome’ increases gradually.  The possibility of health problems arising after 35 years age will also contribute to increase in congenital anomalies in the fetus and increased incidence of complications in pregnancy.  But in the present day with improved medical care women are conceiving even at the age of 60, delivering healthy grand children (surrogacy).  

Even in young age (20-30 years) some women may  have health problems.  Prior to planning pregnancy, it will be good to consult an Obstetrician and have a general health check-up and basic investigation like hemoglobin percent, blood grouping and Rh typing.  Anemia is most prevalent; almost 50% of women are anemic.  This should be corrected.  If there are any other health problems like heart disease, epilepsy, hypertension, diabetes mellitus, they should get advice from the physician who may advise change in medication.  In case of infections like tuberculosis or any other infection it is better to wait until the due course of treatment is completed.  Hypothyroidism is another endocrinal disorder which is common and sub clinical hypothyroidism can only be known by blood examination only.  Appropriate medication should be started.  Taking these precautions will help in healthy pregnancy and child birth.

With increasing consumerism and commercialisation of all fields it is essential to consider financial aspects of bringing in a child into this world.  People of every status have their own level of care facilities.  As per the status of the couple the finances, not only of the child birth, but the upbringing of the child also should be considered.  The coming generation is very demanding.  From the day of conception till the child evolves into an adult and carries on its life needs parental care, guidance and financial assistance.  Keeping the rising costs of education and all logistics essential to carry forward the generation in view, the couple should also plan their finances and support systems.

Support systems are particularly essential in bringing up the child.  Money doesn’t provide love and emotional support to the child.  It is the parental care that makes all the difference in the life of a child.  Quality time devoted to the child makes it strong mentally and goes a long way in social and spiritual health of the child. 

Procreation is a natural phenomenon.  Without any planning or thinking a new life can start on this earth naturally and live to its destiny.  But in these days of striving for brands and designs, it is appropriate to plan and prepare oneself for the task of bringing in new generation that can make this earth heaven.