Thinking locally and beyond....

Posted by kosishthehospice on April 14, 2013 at 10:45 AM

Dr.Abhijit Dam, MD, FCCP, FPM, Dip Pall Med(Cardiff)

Kosish – the hospice

Email: [email protected]


Jyotsna, 9 years, was detected to have Retinoblastoma 1 year back for which she received radiotherapy & chemotherapy . Since the last six months, she was declared ‘palliative’ and referred to our hospice, the parents residing in a rural area of Jharkand. They had to travel for 4 hours by Jeep to reach our hospice.

She had gone blind in both eyes since last 3 months and was very distressed about it as she could no longer play with her brother & sister. She however enjoyed their company & this filled her with happiness.

She frequently complained of headache, which often used to be unbearable. She was already on Step 2 of the WHO analgesic ladder & also getting oral dexamethasone and Amitryptiline. Her VAS score however remained around 7/10. At that point of time, our hospice had no access to oral morphine. We made the maximum use of locally available resources (oral codeine, tramadol, NSAIDS with proper use of adjuvants).

Figure 1. In severe pain


After discussing with her parents, we decided to start her on ‘Kosish Cocktail’(which we have developed & is a mixture of pentazocine lactate 5mg/ml, ketamine 2.5 mg/ml, midazolam 0.25 mg/ml, ondansetron 0.5 mg/ml & lignocaine 3mg/ml. 1 ml of this mixture given S/C 5 hrly) by the subcutaneous route using Intermittent subcutaneous injections given by the family members through an indwelling SC cannulae. Thus, we made adequate use of locally available resources which were accessible, appropriate, acceptable to the patient & family. We thus empowered the family members to participate in the care process.

Figure 2. Jyotsna happy with the pain relief afforded by 'Kosish cocktail'


She lived on for another 2 months with a good quality of life (pain free, living with her parents & siblings & with good symptom control).

We at our hospice, thought out of the box, when morphine was not available & made good use of locally available resources for symptom control. Just because you do not have access to morphine is NOT synonymous with no palliation.




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