Feasts, Holi festivals and friendships-returning to Bihar with Project Hamrahi

Feb 26th - March 2ndDr. Odette Spruyt, Ms Mary Duffy and Ms. Shalini AJ

During the visit, three of us visited four major medical institutes in Patna:

1. Indira Gandhi Institute of Medical Science (IGIMS) (RCC) (Fully Autonomous Body)

2. All India Institute of Medical Sciences, Patna (AIIMS) (Centrally Sponsored)3. Paras Hospitals (Chain of private hospitals in North India)4. Mahavir Cancer Hospital (Hospital run by a Trust)

The objectives of the visit were:

1. Current state of projects (IGIMS) and palliative care units if any2. Continue Hamrahi link with IGIMS3. Capacity Building4. Awareness Raising

Our special thanks go to Dr Khandelwal for his efforts in promoting our visit and liaising with the 4 institutes to help set up the program at each. We were very appreciative of your consistent support since 2010.

1. IGIMS, Patna. Feb 27th, 2018Palliative care has been growing here since the first doctor, Dr Vinod Verma, anaesthesiologist, was trained by Pallium India in 2009. He was joined by Prof Rajesh Singh and Ns Sister Sujata, in 2011. Most recently, 2 doctors (Dr Richa Madwawi and Dr Mumtaz) and 2 nurses (Sister Neelam and Sister Daisy) were selected to receive training at AIIMS, Delhi, under Dr Sushma Bhatnagar, assisted by Dr Cynthia Goh and the Lien/APHN group. Pallium India continue to support palliative care activity through Project Hamrahi and through funding morphine for impoverished patients. In addition, Jiv Daya sponsors medicines, two data operators and two nurses for palliative care. The Institute currently obtains opioids using the outdated licencing process but were keen to adopt the modified rules as soon as possible. There has been great progress in ensuring an uninterrupted supply of morphine for patients, and maintaining clear records for morphine consumption. The total consumption of 5000 x 10mg tablets per month remains low however, given there are approximately 5500 new patients per year and 35000 followup patients*. Most patients present with advanced cancer with a likely need for strong analgesia.

Prof. NR Biswas, Director of IGIMS is very supportive of developing palliative care and is assisting Prof Singh to apply for opioids using the updated processes outlined in the NDPS Amendment Act 2014 and to apply for State Palliative Care Cell status under the National Program for Palliative Care.

The Hamrahi team were warmly welcomed back to IGIMS and requests received for further training, fellowships, and assistance with development of a Department of Palliative Medicine. Pallium India would be willing to support further training and capacity development there as requested.

Picture 1: IGIMS Palliative Care team: From Left to right : Dr. Avinash Kumar Pandey, Ms. Mary Duffy, Dr. Rajesh Kumar Singh, Dr. Odette Spruyt, Dr. Manish (Surgical Oncologist), Dr. Vinod Verma, Dr. Mumtaz, Dr. Richa Madhawi, Ms. Shalini AJ, Sister Neelam

*Footnote:Based on 10mg q4h, 6 tabs per day, only approximately 6% of 5500 new patients would receive opioids at 60mg/day orally

Picture 2: Holi celebration with the IGIMS team

2. AIIMS, Patna Feb 28th, 2018

Dr Pritanjali Singh (Oncologist) and Dr. Chandani (Anesthesiologist) coordinated the program at AIIMS, Patna. We met Dr. Prabhat Kumar Singh, the Director who had been HOD Anesthesiology at Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) in Lucknow when Pallium India had set up a palliative care unit there. We also met with Dr Badhani, HOD Anaesthesiology. He and Dr Chandani had also attended the recent palliative care introduction at AIIMS, Delhi.

We participated in a ward round with Dr Pritanjali and her fellow, assisting with a difficult discussion with parents of a paediatric patient with a poor prognosis. There is an abnormally high incidence of carcinoma gall bladder in Bihar, etiology not yet determined. We saw 2 women with this diagnosis, one an elderly woman whose grandson was a medical student. He remained in contact with Odette on Whats App after return to Australia and until his grandmother died. His love for his grandmother and desire to help her during her dying days was moving for all of us to behold.

In the afternoon, we participated in a CME session. Dr. Pritanjali (Oncologist), Dr. Chandani (Anesthesiologist), Dr. Ruchi Gupta (Radiologist) presented followed by

presentations from our team. The interaction was well received with good discussion about ethical issues in end of life care, and great interest in the work of Pallium India.

We were impressed to learn that there are plans for a Department of Palliative Medicine and for a 20 bed palliative care unit at AIIMS, Patna and that the Institute has established an uninterrupted supply of morphine. While the patient workload is just being established at AIIMS, Patna, there is great enthusiasm and innovation for improving patient care in Bihar. Telemedicine is already operational for patients who live in more remote parts of Bihar.

Picture 3: Banner for the CME in AIIMS, Patna

Picture 4: Dr. Pritanjali delivering her session

Picture 5: AIIMS team outside the auditoriumDr. Pritanjali (Second from left in the front row)Dr. Badhani (Fourth from left in front row)Dr. Chandani (Fifth from right in the front row)

3. Paras Hospital, Patna : March 1st 2018 Morning

Our final day brought us to two hospitals. The first, Paras, is a private or corporate chain of hospitals across India, especially aimed at rural and remote populations.The focus of Paras healthcare is to provide tertiary level care especially in oncology, cardiology, orthopaedics and neurology with the aim of evolving into transplant centres. The hospital in Patna has developed numerous ICU beds but as yet, the palliative care service development remains minimal. As yet, Paras Patna has not applied for RMI status to facilitate the procurement and prescription of opioids. Our visit here included:

Meeting with the Director, Mr. Talat Halim, Dr. Shane Miraz, an Anesthesiologist, and Dr. Shekhar Keshari, Palliative Care physician trained in CMC, Vellore, and Mr Ramesh Murugaswamy, general manager of operations, who coordinated our visit.

CME – Dr. Odette, Ms. Mary Duffy and Ms. Shalini – presented on different aspects of palliative care and Pallium India national projects

Experiences shared by the Nurses with Ms Mary Duffy

4. Mahavir Cancer Sansthan, March 1st, 2018, afternoon

Our week concluded with a visit to Mahavir Cancer Centre. This centre is run by a trust. It provides services to 3 lakh cancer patients each year. Morphine is available but through the old licencing process. The Director, Dr Biswajit Sanyal, spoke passionately about palliative care, having been instrumental in establishing palliative care at his previous hospital. He hopes that a palliative care service will be established at Mahavir in the future and invited our assistance with training staff. Oncologist, Dr Rita Rani plans to attend the 10-day palliative care training course in July this year. He also requested help in obtaining a patient lifting machine or hoist for bathing and other nursing cares. Once again, our visit included meetings with senior staff of the Centre, including:

Meeting with Dr. Biswajit Sanyal, The Director, Dr. Manisha Singh, HOD Chemotherapy and the Associate Director, Dr. Vinita Trivedi, HOD-Radiotherapy, Dr. Rita Rani, Consultant Radiation Oncology

We also held a CME session at which Odette, Mary and Shalini all presented on different aspects of palliative care and Pallium India national projects

Picture 10: The organizing teamFrom left to right – Dr. Rita Rani, Dr. Vinita Trivedi, Dr. L.B. Singh (Medical Superintendent), Dr. Manisha Singh, Dr. Biswjit Sanyal, Mary Duffy, Dr. Odette Spruyt, Shalini AJ.