A mother dies.

 

 

A mother dies.

 

Dr. Shantanu Abhyankar,

Modern Clinic

Wai, Satara,

Maharashtra, INDIA

PIN 412803

Mobile no. 9822010349

                      

She was wheeled into my OPD and hauled over to the examination table and she passed away. She died, there and then. It was obvious that she was moribund. She was convulsing all the while, frothing at mouth, breathing noisily, sturterously but just about. There she laid pulse less, bloated all over, edematous from face to feet, with a nine month tense, shiny, belly bump in between.

She stayed somewhere beyond Mahabaleshwar, in the Tapola woods, across the Koyna backwaters. She had had her first convulsion early in the morning. She was carried in a hammock, the party trekking for two hours to reach the road. An hour’s wait by the roadside finally got them a Jeep. Driving up the ghat to Mahabaleshwar and then rolling down to Panchgani and Wai. It had taken seven hours to reach my hospital.

 

She died and I was left busy filling up the numerous papers and forms. Not that I objected. My objections were meaningless, anyway. Her death was now a part of a national problem. It was ‘Maternal death’. It will now be investigated. Reports will be sent up and queries will descend down. Papers will pile up. There will be meetings, inquiries and discussions. I felt sad and dejected. This death will pervade my thoughts all day long. I will keep seeing the unfortunate face.  Any death pains a doctor but this one was even more painful. A young mother dying just for want of timely intervention, one feels so helpless, so inadequate. This was her fourth gestation. What happens now to the three motherless children? How will they manage?

 

Four months passed and one morning I received a call from the district collector’s office.  A rude voice ordered me to be present for a meeting the next day at 11AM sharp. Eleven was the most inconvenient hour. I had scheduled appointments. It was impossible to reschedule them all at such a short notice. But I had to fall in line. One can’t fight with the powers that be.

I was uneasy but attended the meeting. An inquiry into such deaths was important. Not to point fingers but to identify the weaknesses in the system. 

She had sought help at three places on way and at all three she was simply asked to go ‘ahead’.

Her postmortem report wasn’t ready yet. The standard remark reading, ‘viscera preserved, opinion reserved’, stared back at me from the papers. This was another of routines. All the viscera are removed and examined in the forensic laboratory, just so that a homicide, an illness, or a poisoning isn’t missed. This wasn’t at all necessary in her case.  The cause of death was obvious from her history. The government doctor just wanted to be extra sure or rather wanted to shift the onus of the final opinion. 

She was carrying, had high blood pressure, which was neglected, had convulsed due to eclampsia and went into what’s called status eclapmticus, a state of continuous convulsions; she died. Eclampsia literally means a bolt of lightning. The disease strikes suddenly.  This is the consequence high blood pressure in pregnancy. She was seen by three doctors on way. All had made the same diagnosis. They were there too. I was the fourth.

A delayed post mortem report meant another sudden call from the district office, another get together, another meeting… missed appointments. I was about to vent my frustration with the system when it was announced that the civil surgeon will arrive late for the meeting but he has the report with him. That was a relief!  

Then began, what’s known as a, ‘verbal’ post mortem. I had certified the death but that was just incidental. I had had no chance to treat or even examine her. But this was my chance to have a ringside view of the government’s working.

Everyone was being cross examined. Who visited her hut? Which sub-center did her village fall under? Which ASHA worker was entrusted with the area? Why were the visits not made?

The district collector was a doctor who had later opted for the civil service.  He felt for the loss. With pointed questions, sparing no one, he was dissecting out the flaws in his own administration. Identifying every weakness in the chain, he was giving instructions, passing orders to overcome issues.

The deceased had not been seen for the past four months. The ASHA worker never visited her since.  According to her, ‘the people in the locality were uncooperative. They just ignored the health workers. The men are mostly drunk, are busy bootlegging and the women too are into moonshine.  The medical officer in-charge, a woman, too keeps away from this area. One is worried of hooligans and molestation. The ASHA worker prior to my appointment hadn’t reported a single pregnancy. I have dutifully registered her name. I have done my duty. Done what I could.’

The medical officer of the sub center, a woman, was asked as to why she wasn’t staying in the locality. ‘I don’t, but even if I were staying there, I was on leave on that very day.’ According to her, she had to rush back to her home town as her father in law suddenly took ill. She had evidence along with her. She produced  the old man’s death certificate and the recording of the phone calls with her superiors asking for emergency leave.

The patient was taken to a small dispensary on way. The elderly doctor manning this place was present. He had examined the patient in the Jeep. The relatives were put off because he didn’t even bother to record the blood pressure. ‘Feeling the pulse is enough for me to diagnose such a high blood pressure’, was his explanation. The collector looked at me. ‘Her GC (general condition) was very poor’, the elderly doc continued, ‘there wasn’t the need to waste time in recording the BP. I don’t have the necessary injections any way. I don’t keep them. There was no point of any detailed examination    since I don’t treat such patients. I simply asked to reach the hospital as soon as possible. I did my duty. I did whatever was possible.’

He wasn’t wrong. He had practiced ‘triage’. On a battle field one concentrates on the soldiers one can save and simply ignore the ones beyond help.  If one attempts to salvage all, then the ones better of worsen and die too. He had rightly sensed that this complication was beyond his abilities and refused the patient.

The next stop was a bigger, better, well equipped hospital. The doctor there had the necessary injections, knew the doses but hadn’t bothered to offer even first aid. He had just directed the patient to me. The collector was incensed. Here was a clear case of negligence. But the doctor was calm. He said, ‘by this time the patient had deteriorated further. She was in status, had vomited and aspirated the vomitus, there were audible rales all over her chest, her lips cyanosed and her breathing was barely discernible. In short she was sure to die within minutes. Any ‘first’ aid would be her last. I didn’t want to risk treating her!!!’ he said. The collector’s brow furrowed. The doctor explained, ‘the people from this locality had notorious reputation. Just a week ago they created a scene at the hospital next door. Their patient was well but disgruntled about the fees they had ganged up, threatened to shatter the place, paid nothing and left!’

There was an awkward silence. Finally the doctor continued, ‘The woman was to die despite my injections. But the relatives would have shattered my hospital blaming the injection for her death. At that hour neither your police nor your law would have been of help, would it? Had I been 100% sure that my hospital will not be targeted, I would have given the injection, knowing that it was futile to do so. But do you guarantee my safety? I have saved and protected my hospital, my staff, myself. It’s been four months since the death. You have summoned me today to explain my position. I have just this to say, I have safely delivered 160 women since. Saved as many women and children. I have done my duty. As far as could. Haven’t I?’

There was again an awkward silence. The civil surgeon hurriedly entered and joined the meeting. He cursorily asked for permission to speak and began narrating the report.  ‘It’s a fact that she was full term,’ he said, ‘it’s a fact that she had high blood pressure. It’s also a fact that she had convulsions. But, but, the convulsions were not due to high blood pressure!....The convulsions came and persisted due to a cerebral bleed!!....The bleed in the brain had resulted from trauma!!!...The trauma had resulted from her husband banging her head against a stone and… this punishment was meted out to her because the curry she had cooked was too bland!!!!’

A stunned silence descended on the room.

My cell shrieked rather outrageously. I had a call from my hospital. There was a woman, pregnant and convulsing. I took leave and started sped back to my place.