A panting and gasping patient comes to the casualty room.The stretcher trolley still shaking it’s legs.Terrified ,anxious the attendent looked to us with an eye of hope and miracle never seen before.The middle aged man in his thirties have been running with his mother from the start of the day and now it’s stucking 8 pm at the casualty clock.From one hospital to another he has been roaming in relief and solace .With empty stomach ,dirty torn clothes this tea plantation worker has spent all his money in transport -from his nearby primary health centre in the outskrits of dhemaji district to Assam medical college at dibrugarh .He had to transit at four different hospital across the heirchey of Indian healthcare but without a solace.In search of more equipped and more large facility he has been bearing the scorching heat but even after 10 hours of running errands and travelling a distance of around 160 km his mother lies cold lifeless and motionless.
On asking the history after calming him for a while he told his mother has been diagnosed as “pressure stroke” as per local parlance On asking who told him such and asking for ct scan plates as evidence of stroke he answered in negative ,he said this is what has been told from the 1st healthcare care point he visited to the penultimate one before referring here.Frankly speaking a moribud old hypertensive lady having sudden loss of senses can be due to stroke but that is not all.Unconsiousness can have other ingredients too.Before I ask the patient to get a ct scan done the bedside teaching came to my mind.The most common and simple cause should be your first diagnosis ,exclaimed my teacher in a class of hundreds.Taking that dictum to its logical consclusion i asked the intern trainee to check the blood sugar of the patient .Though shocking and to my dismay but not exactly uncalled for ,it recorded 26!!yes u hear me right the blood sugar level is only 26 mg/dl !!a bloody low.For a minute the casualty room became a war field.we hurriedly searched for a vein to cannulate..after about a 5 minute of honey combing operation we could find one.we secured a cannula and gave two bottles of intravenous glucose solutions each bottle costing 30 rupees to the state exchequer.To the utter surprise of the attendent who lost all hope to save her mother their was some life kindled in that corpse like body after about 5 mins .There seemed to be a silver lining for the attendent.As the drops of “amrit” flowed through the veins and to the brain there was some chirping murmers heard from the half opened lips of the earstwhile cadaver.Slowly she could move her limbs and after two bottles of life saving solution entering her flesh and blood ,her soul could once again started making noise.She sat over the stretcher and asked her son to give her a bottle of water.The attendent was stunned as if it’s a horror movie or some magical show,he just kept mum for a while .The patient then in her own ineligible and inexplicable language scolded her son for not giving her water.The attendent slowly still in a shock of belief lend her hand to the mother.This was all going on infront of our own eyes and this was nothing unusual for us.This didn’t moved us too because for us this was normal .we carried on our normal work leaving them to their own world of cacophony .After sometime the attendent came to us and told that her mother wants to go back home.We obliged .Gave him some rudimentary prescriptions and told he can take her health and hearty mother back home.Hearing this the attendent burst in tears,drops rollling down his cheeks .His eyes still glossy and hands trembling he sat on the floor and groped our feet and as an embodiment of some magical powers or respect wanted to thank us from his bottom of heart.For him we were no less than a GOD .Because to him we have given him which he too lost hope ,which he too didn’t expected but for us it’s just hypoglycemia and a 60 ruppes of treatment. We witnessed the mother and son duo walking back from the casualty room chatting in their own affectionate language and waving goodbye to us .A goodbye with a kind of inexpressible gratitude.
The stretcher trolley lies empty in the casualty room waiting for some unfortunate to fill!!
“Dada,why that patient was brought here ,couldn’t it be treated earlier” an innocent questions looms my face
But the answer was not so simple mirked in the display of our dismal healthcare system.
“Low blood sugar” as the Bible of medicine says is a potentially reversible and treatable condition but if not treated could be fatal.
And “time ” is an important factor in successful recovery of such patients.Not all patients are lucky as our one.A prolonged LOW blood sugar level can lead the brain to it’s hunger death.So why on earth a condition which needed to be managed in the earliest of time made to travel the treacherous distance and why on earth the doctors sees the case before has said that the patient was having “pressure stroke”. What is wrong going on?
This may be looming our minds
The answer is simple the doctors earlier has not recorded the blood sugar level of the patients be alone treat it.And as their was no alternate diagnosis to explain the patients condition they may have marked it as “pressure stroke”.The diagnosis of pressure stroke though needs confirmation by imaging but can also be clinically suspected which could not be the case in case of hypoglycemia.Without checking the blood sugar you can’t label as hypoglycemia but without doing ct scan you can say it’s “pressure”.This medical nuance was used to mark the patient as pressure stroke and not hypoglycemia as in both the cases the patient may present with the similar history and look
“How could they miss that” pointed the young intern trying to understand how seniors to him in this medical field dare not check the person’s blood sugar level.He is trying to come in terms how what as a just inductee In medicine could understand could not be understood by experienced seniors.Their comes the answer
“Glucometer ,the device to check the blood sugar level was not available in all the other centres from where she was referred here”
In support of my statement I showed him the referral letter of the previous hospitals where it’s mentioned “BLOOD SUGAR LEVEL -COULD NOT BE CHECKED”
The intern was stunned .How on earth does the the peripheral primary and secondary level hospitals of our country doesn’t have this basic instrument ?
This takes us to the grim reality of the Indian healthcare care system.
The doctors in the primary and secondary health care system are put at dilemmas in every step of theirs when such type of patient comes.As mentioned earlier unconsciousness could be due to low blood sugar or stroke.In absence of instrument to check blood sugar level ,the only option is to give prophylactically glucose solutions .But here comes the catch .If the patient was having actually stroke and we give prophylactic glucose solution that would be detrimental to the patient .So even if u have to give prophylactic glucose solution you need to check twice that the patient is not having stroke.To make it confirm you need to do a CT scan,which is unavailable in most of the primary and secondary health care level and so is the referral.
This whole buisness of referral could have been avoided if and only the simple blood sugar measurement could have been done at the first point of health care.
What’s exactly would have been the cost to do so in the primary health care centres.A Glucometer may cost the state only a hundred Gandhi’s and Glucometer strips fourty.And that Glucometer could be used for a minimum 1000 patients .so only ruppess one for each patient!!
On the other hand to transport a patient from a primary health centre to a tertiary care centre about 100-150 km away may cost the public health transport a whooping 1000-1500 ruppess or more to the patients family if private mode of transport is used.O
Above that crucial time to save the patient may be lost and ultimately may succumb on the way.what a tragedy of sorts!!
And who is at fault??
Many more complications arise in cases of such referrals.Many times we may see the attendents of patients manhandling doctors who have refered such cases and when any such patients succumb before reaching the referal point.The refering doctor could do very little except referring the case in such cases because of such pathetic infrastructure at his level.
It also in turn increases the dependence of patients to tertiary care centres where crowding of patients occur which could have been treated else where.A tertiary care centre built to treat and manage the critical and difficult be cases waste most of its energy in terms of infrastructure and manpower in treating cases which don’t necessitate tertiary care.This in turn lead to a proportionate decrease of attention to the critical cases because the manpower gets weared off.
All this I explained to the intern doctor present with me
She nodded head but with a sense of disappointment and exclaimed “This is a
classic example of malutilization of human resources”
In india the problem which looms the Indian healthcare system is overemphasization on centralisation , disproportionate emphasis on tertiary care system and medical colleges and top to down approach which could be best appretiated by govt overemphasis on opening more and more medical colleges.This top down approach sometimes has popular mandate too . People frustrated with more or less non functioning primary and secondary health care system always urge for opening of more and more medical colleges.This could be seen in cases of increased demand by different comunities
to set up medical colleges in their locality . People fails to understand that opening more and more medical colleges could not be a solution for strenthenig the public health care system.No purpose is served by opening medical colleges in distant far away areas ,at best is acts as an equipeed primary/secondary health care centre and in turn compromises on the very nature what a tertiary care centre should cater to .So what we see is that medical colleges opened in remote far flung areas suffer from lack of faculty members, infrastructure , multidisciplinary coordination and this in turn leads to poor training of medical graduates.The problems In remote medical colleges are bound to arise because you can’t expect a complex neurosurgery to be performed there because apart from medical infrastructure there are logistical and intersectorial infrastructure too. You can’t expect the vest surgeon of the state to perform an operation in that remote hospital by taking up a job there.This is because the super specialist doctors also have their aspirations and tend to stay in the state capital and have a kind of living than to stay in a remote village far flung area.And that is no sin.Every one wants a comfort zone of living and all their hardworks in life have been to achieve that standard living which they aspired for .There may be exceptions but exceptions don’t make a rule. We don’t have army headquarters at the border villages or the state secretariat at the far flung remote area and rightly so because their sphere of work and requirements could be fulfilled only in the state capital collaborating with the capital’s level of development.Same logic applies for health care too .If u couldn’t expect a principal secretary of a state or an army general living in the remote village then how could you expect a professor of medicine do the same? This logic negates the common notion of opening a medical college here and there and thereby implying it to be the solution of all ills .Instead of questioning the political structure of dismantling the primary and secondary health care this clamouring for medical colleges should stop.Opening of a medical college that also with questionable infrastructure neeeded for it’s stature to be is an easy way of the political structure to evade questions if their manhandling of public healthcare
The fundamental nature of development in india is unequal .A state càpital is not the same in development as that the remotest village.And it can’t be so .Even the most developed countries of the world has such inequalities.This inequalities were there and is still there and probably will be there and to think something different is living in utopia.Till utopia is achieved we have to live by reality. This is to not to suggest that only the people of the state capital gets acess to best form of treatment but not the others .But this is to suggest that though inequalities may be there as we move from the state capital there should be a minimum standard of development across the state .The state capital could be far above the minimum standard but the remotest one shouldn’t be below.And based on the local development we need to develop our healthcare system.So a district headquarters may have a district hospital far above the minimum standard of heath care but a remotest primary health centre should not be below the standard level of healthcare.A primary health care system should be able to cater the maximum demands of the community it serves and only the genuine cases needing expert consultation need to be refered ,thus increasing the ease of referal of very low number of cases and also it’s management at the higher level of healthcare as they also need not deal with unnecessary referrals.
An example from my internship tales still stoke my mind .Patients with breathing difficulty was the everyday guests to our rural hospital .Now apart from other reasons two most common reasons could be due to heart or due to lung cause .Though it’s a bit complex to differentiate the two and clinical judgement plays an important role the ECG could be an important part of our clinical consideration .Because if it is respiratory it could be managed somewhat in our rural health care centre but cardiac cases needs to be invariably referred .But due to the non availability of ECG ,a very primitive compared to today’s advance of medical science,no doctors would take the risk to clinically differentiate between the two.So do u think for a 30 ruppess ecg to be done we need a medical college but due to the lack of ecg unvariebly all caess ,be it lungs or heart used to be refered even though we had the facility to treat somehow respiratory cases.
Another thing this referral system somewhat aids is to acknowledge some doctors as god and some as devil’s.From our first experience it could be seen that in the eyes the son of our patient we became gods but all other doctors who referred her mother there were all devil’s .It also made him believe that we have some magical powers.We need to demistify this holiness of ours and treat all doctors as humans not as god nor as devil and make it a point to the society by pointing that we don’t have any magical powers too and what we do is based on science and available infrastructure available.We could give back her mother life not because we have magic but because we followed science and we luckily had infrastructure to our disoisal .Our collegeus in previous health centres may not be so lucky to get so.
Stating all these it’s also imperative to remember the decision to refer or not refer could not be bounded by some administrative ,or beureacratic or semi scientific directives .It should be kept under the discretion of the treating doctor .Because he/she is the best judge to clinically asses and decide for referrals.Govt need not create directives for referral but should create infrastructure based on which they can take a balanced and nuanced decision.By infrastructure we mean not only the medical or technological infrastructure but also logistical such as referral ambulancanes and above all security so that they are not intimidated to refer patients because due this prolonged dependence on tertiary heath system and lack of trust on primary /secondary level by the people due to its non functioning nature some sections of population may not trust this new change and may force the doctors to refer their patients in case the patient doesn’t gets cured .Cure or not cure could not be a criteria to refer.A disease may be incurable in nature be it in the primary health care or the apex centre .Criteria should be that does the patient need extra skills be it clinical /technological which is not available there and which can only be available in the next care of heirchey .if so referral should be done and that too with prompt.
What all these meant to us is that the govt needs to focus more on strenthenig the primary and secondary health care centres than the tertiary centres and this more funds needs to be pumped to the lower rungs of the health care .This could be the only way to revolutionize the Indian healthcare.In times of pandemic and outbreaks the success of be health and prevention policy could always be attributed to a robust primary health care system.In any epidemic or pandemic such as covid 19 from contact tracting ,sampling ,screening all could be successfully coupled with a robust primary healthcare .This primary and secondary health care systems could also be used to admit ,observe ,manage asymptomatic ,mild to moderate covid patients .This would lead to less clogging of tertiary health care and thus pave more beds , manpower to those who actually need it .Thus only severe cases requiring icu care or with severe comorbidites should only have it’s way in a tertiary setting .Instead of that we see patients referring from primary or tertiary level only because they need oxygen support or because they need the triple therapy drug (remedesvir,low molecular weight heparin and methyl prednisolone ) started to them.This is because of central procrurement of this drugs and non functioning oxygen delivery system in secondary levels.This is no brainer that even these drugs and oxygen could have been given in secondary healthcare settings thus reducing workload in tertiary care centre and also the costs incurred by the public ambulance services in referrals.only patients who are not responding to these therapies need to be referred.Coupled with this the govt should have a prompt, accessible, available transportation system from secondary level to the tertiary one .
Thus the argument of a robust tertiary care setting for having a successful healthcare system falls flat and it’s the other way round.
Federalism and decentralisation needs to be followed in letter and spirit in health care system to have a successful one but sadly this seems to be a distant dream and lost hope!!