Sunday, 10 September 2017

Simplicity


Fábio Schwalm

Home visit in the late afternoon
Hi Dona Ana, how is going the hemodialysis
She responds:
Well, at first it was difficult, I had a bad time ... now I'm fine ... I spend the four hours praying
while I pray
And eating?
Better now I can eat more
And how can we help?
She hold a list in her hands:
What is Damascus?

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Fábio Schwalm is a Brazilian rural family physician. He works in Brazilian South in a city called Barão. He is learning to write and grew in a rural area working in the smoke farm. 

Sunday, 27 August 2017

The day that I dealed with death peacefully

 Andressa Cavalcante Paz e Silva


“When the rain falls down / What brings it back? / Opens the resurrected cloud / From white to black / It's a second birth / For dying skin / In my coffin...” 

(My coffin - Jon Foreman)


I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. So, I’m going to tell you a rural success journey story.

My story begins with a young girl going to a home medical visiting in a little rural area called Curuá, in Baixo Amazonas, north of Brazil. This girl was attending Medicine classes for four years in a College School in Rio Grande do Sul, a state located on the opposite side of Curuá, south of Brazil. However, this story is not about her. This story is about the day she understood the real meaning of Rest in Peace. This girl is me.

It started out with a “Hi, good morning, mrs. Maria. Have you called out for our visit? Let me see how Mr. Manoel is going.” and them the medical interview continued.

-Thank you for being here, doctor, he is not so well. He can’t speak anymore and It is being pretty difficult for him to walk. Also, he is refusing to eat since the day he had this strong diarrhea.

- Oh, and how was this diarrhea, mrs. Maria? You see if he is suffering of pain? Tell me more about it. - The student asked.

- It was last week. It’s been 5 days since the only episode. Oh and those black stools were so so smelly as I’d never had seen!! And in the last two days he is totally constipated. We tried so hard to give him food… We even tried to lay down some pasty food and in his lips and mouth, but the only thing he wants is water and sleep. We are trying so hard to give him the medications another doctor prescribed us, as well as those nutritional supplements. Now he isn’t suffering of pain, but we are worried about inappetence.

Mr. Manoel, an elderly man aged 77, was clearly dehydrated, hypotensive (80x40mmHg) and in the neurological exam we found out Glasgow 10. When we touched his belly during the abdominal exam, his face showed heavy pain. In our hypothesis we conclude that maybe Mr. Manoel was having an upper digestive hemorrhage. 

Unfortunately (or fortunately), the medical conduct wasn’t totally accepted by the family. First, we suggested moving the patient to Santarém, a place with a hospital, in which he could do exams to confirm the bleeding and treat specifically. Nevertheless, the logistic for all transportation stuff and maintenance of the patient and the family in Santarém was really difficult. 

Actually, even if there were no problems at all, Mr. Manoel’s family had already decided he would die at home. “We can’t send him to Santarém… A couple of weeks ago when he was a little better he said that If we ever try to send him to another place instead of here, he would come to haunt us after his death for sure!” - they said. In summary, the elderly man was medicated with some Oral Rehydration Solution and referred to the doctor of the city, as I was only in an observership. This experience was really different and meaningful for me. The empowerment of that family caught my attention and I started to think about empowering my parents and my relatives to understand the finite of life and to embrace palliative care too. Mr. Manoel get better in the consequent day after drinking the oral rehydratation solution, but after two days he died at the crack of dawn. 

So, I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. I guess Mr. Manoel’s journey through death was peaceful and I guess he will not come back to haunt his family. 



Photo by: Keith Dalmon Ferreira
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Andressa Paz is a Medicine Student living in the South of Brazil. She loves listening to stories and rural ones are her favorite. She had her first contact with rural and remote Medicine in Kat Kalen - Haiti and then in brazilian Amazon area


Sunday, 13 August 2017

The Elderly Lady and her Chicken


Dr. Etonu Joseph

It was a usual day on the ward in the rural facility I work in (kapelebyong Rural Health Center,in north eastern Uganda), as I was doing a ward round. Like other normal days it is characterised by children having malaria and usually I review them to make sure the dosages are right and they receive the right treatment.
This particular day I noticed a chicken walking through the ward and of course I was furious(given that infection control is very important) why would a chicken be moving through the ward. Then I chased it out. The African local chicken are quite fast and of course it got away.
Surprisingly after sometime I noticed the same chicken coming back to the ward. This time I asked the nurse on the ward what was wrong with the chicken.
She then revealed to me that the chicken is for one of the elderly patients on the ward. “It has even laid eggs and it must be trying to come back to lay another one”, the nurse added!!!
This made me even angrier. How can a chicken just want to lay eggs in a hospital!!!
I matched to the patient with my eyebrows up and I noticed next to her was an old sink that was not in use, with a box and about 11 eggs. The chicken had already laid 11 eggs!!! I asked her in shock, ‘’why is your chicken laying eggs in the ward?” She replied to me, I was admitted to be in hospital for 2 weeks and unfortunately I stay alone at home. This is the 3rd time my chicken is laying eggs and the 2 previous times I wasn’t home to protect it from the neighbours who stole all the eggs. I am not willing to take any chances this time so I have decided to carry the chicken to hospital with me this time, she humbly replied. I told her that unfortunately chicken are not allowed to live in the hospital next to patients because it could cause diseases and she just kept quiet. She looked at me in confusion as to why the doctor wouldn’t understand her concern.
She put me in a dilemma I couldn’t send this lady back home because we needed to monitor her meds and it was unfortunate that she stays at home alone and all her children had moved to the city, like most of the elderly women.

We ended up having to organise for her a separate empty room to be with her chicken.

I am still wondering whether it was the right decision. What would you do in the same position?


Above you can see the eggs in the broken sink!!


Above you can see the patient’s bed!! Next to the sink!! With the chicken seated on the eggs below!!




--

I am Dr. Etonu Joseph, Junior medical doctor from Uganda 29 years of age, I've been practicing for 2 years in a rural area in Uganda in a county called Kapelebyong county. I Started my work when I was 26 years old in the facility. Iam the only doctor there covering the health of 89,000 people. Being a very rural area very few doctors attempted to work there but so far i am the one who has lasted the longest in the facility..The people I serve are the humble indigenous rural people of Karamoja and also Kapelebyong county..I graduated in 2012 at the University of St. Petersburg Pavlov,the Russian Federation. But i started working in this rural area in late 2014. I ride a motorcycle to work because the roads are soo bad in the rains that sometimes it rains on me! BUT I LOVE MY WORK and I have learnt a lot from the people I serve.

Sunday, 2 July 2017

Its just God's miracle, we are just medium...


         Hello friends.Me Dr.Suhas and my wife Dr. Prerna are specialist by degree but generalist by choice.We both have humble rural background and upbringing.Hence after our post graduation we moved to rural set up for practice as we believe we have many dues towards society and community who helped us to be a good doctor.
        In rural peripheral setup you have a new day new challenge.There are many stories till now in one year. 
But the most interesting one is the 28 year female diagnosed with unexplained infertility for 8 long years. She was investigated & treated at several Super speciality setups at Mumbai, Pune, Nasik, Malegaon, Aurangabad. 

     She even underwent multiple times for diagnostic laparoscopy, hysteroscopy, IUI, IVF & her male partner was also treated for low sperm count in last 8 years but failed every time. Spent lacs of rupees for treatment but every time result was unsuccessful. Husband being rickshaw driver, due to mental frustration gave up hope on for not being able to  become a father. 

               Interesting fact is that the couple was none other than our hospital staff worker's son & daughter in law. 
After we started practice in rural setup, the staff told the story about her son & daughter in law. The couple meanwhile consulted us. Selective investigations were done as all the previous investigations were normal. We studied the case very thoroughly and with help of expert opinion of Dr. Prerna the patient conceived within a month. Her UPT came positive for the first time. 

           The happiness which we saw on her face was priceless. After proper care of thorough 9 months pregnancy she delivered a male child on 23/4/17. Staff worker's son literally cried with happiness. He told us that we are everything for him. And we told him its just God's miracle, we are just medium...

Author
Dr. is Dr.Suhas Pawar is (MS Gen.Surgeon) and his wife Dr.Prerna Pawar MBBS,DGO.They run a rural hospital named Saibaba Hospital, Satana,Nashik. Both belogs to humble rural background and are passionate to provide all super speciality services to rural people in there own community.This shall reduce there trouble to cope up with city urban life.



Sunday, 21 May 2017

The police protection

Dr. Etonu Joseph 

It was a usual afternoon at Kapelebyong Health center 4,in Uganda, like everyday during my work I see all patients with different conditions.Some of them are brought by a policeman and this would be because of assault or even rape sometimes.But this day had i saw a police officer,a gentleman well built and strong sitting in the waiting area waiting to see me. As usual because I knew he had other day duties. I allowed him into my doctor's room. I expected him to be accompanying the usual cases of rape or violence but was I wrong.

Entering the room he closes the door behind him and he sat down. So i asked him "What can I do for you?" He replied it is I who needs help, "yesterday night I was attacked by my wife and she was bitting me with her teeth" He showed me all the bite marks on the hands and the back. I felt for him because 1st of all he is a Man! And also a police man. And being in the village many men usually beat their wives and sometimes they injure them so badly. But it was very humbling to notice this policeman keeping himself calm. And he did not beat his wife(Being physically strong He didnot even fight back). I advised him to get help for his wife because he was not safe living with her.

But it got me suprised that if a policeman can seek for help on the abusive nature of his wife.Then that means he loves her and it could also mean that he respects the rule of law.But it also got me thinking as we call police for help, who helps the police when they are in trouble..?

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I am Dr. Etonu Joseph, Junior medical doctor from Uganda 29 years of age, I've been practicing for 2 years in a rural area in Uganda in a county called Kapelebyong county. I Started my work when I was 26 years old in the facility. Iam the only doctor there covering the health of 89,000 people. Being a very rural area very few doctors attempted to work there but so far i am the one who has lasted the longest in the facility..The people I serve are the humble indigenous rural people of Karamoja and also Kapelebyong county..I graduated in 2012 at the University of St. Petersburg Pavlov,the Russian Federation. But i started working in this rural area in late 2014. I ride a motorcycle to work because the roads are soo bad in the rains that sometimes it rains on me!  BUT I LOVE MY WORK and I have learnt a lot from the people I serve. 

Sunday, 14 May 2017

Isolation


Caruaru - Mayara Floss @ruralices

Mayara Floss

I need to call Emergency.
There is an emergency in the rural unit.
"But doctor, there's no phone."

Caruaru 02/17

Mayara Floss 
Undergraduate student of medicine at Federal University of Rio Grande (FURG) - Brazil. She Co-creator of project 'Health Education League'.  She is the creator of the Rural Family Medicine Café to provide a forum to discuss Rural Health – a forum for students, young doctors and experienced professors and GPs from all world. She is the student representative of the WONCA Working Party on Rural Practice. She also co-created with Pratyush Kumar the project 'Rural Health Success Stories' and writes a weekly blog of Popular Education, Arts and Health - the Ferry Street of 10.

Sunday, 26 February 2017

Parsimony


                                                    Dr.B.C.Rao

        I got trained in the old school of thought as far as patient care is considered. There were several dos and don’ts that were dinned into our heads. Some of these were don’t prescribe an expensive drug when an alternative cheaper one is available. The other is don’t investigate unless absolutely necessary. Always listen to the patient then proceed to examine and always try and come to a clinical conclusion. If you have to confirm do the minimum lab and other tests. When you are in doubt get another opinion.


       These principles have stood me and my patients in good stead over the years and saved us lots of headache and money. But occasionally it has backfired to give an example or two.

       
         I am against routine annual medical examinations and investigations to all and sundry and with valid reasons.I consider these a waste of money. But when there is a definite indication to screen a high risk patient I do order the required tests.

      

        In this case the a young man’s company does many tests as a part of the employee benefit and an electrocardiogram is one of them. He knows that I am against routine screening for heart disease in low risk groups and the youngster was one such.He reluctantly came and apologetically asked me to have a look at the reports.The company and done many tests which included an ECG.


          The ECG was abnormal. Though the rhythm was alight the rate was very high. Even if one gives margin to the fear of doctors and machines many have with the resulting increase in the heart rate, this kind of increase was a cause for concern.The report just said sinus tachycardia and the physician who signed it had not bothered to see the patient. There was also a marginal increase in the levels of thyroid hormone.On talking to him I realised he had lost weight, had been having some diarrhoea and when I examined him he had a heart rate of 130 beats per minute. A repeat test for thyroid function revealed he had increased activity of thyroid gland and this was duly treated.

      Had he not done the annual tests would he have come to see me? Probably not immediately but would have because he was concerned with his loss of weight. He would have come much later when treating him may have become tougher than it did.
   

        Another patient this time a friend of mine, who by nature a thrifty sort of a fellow [there is a very thin line between thrifty and miser].He tries his best avoid consulting me [read paying me]. He also treats himself with some success. He had symptoms of hyper acidity a year ago and as his usual antacid failed to help he sought my attention and I advised him to take a course of different class of anti acid drugs and get back after six weeks. He got better and did not get back to see me. When I met with him on the golf course he said he was well but once in a way he has to take the medicine. This worried me as at his age one should not have recurring symptoms like this. As the golf course is not the ideal place for a professional consultation, I asked him to see me in my chambers. This he did when his wife came to see me, he sort of hitched a ride.


             I found he has been taking the medication prescribed and managing.Though there was nothing much detected on physical examination I told him to get an endoscopy done to have look at what his stomach looks like [this meant going to the hospital and getting a flexible tube thrust down the throat right up to the stomach, a not very pleasant procedure but was needed]. He said alright and went away. He did not go to the hospital. He came three months later with worsening of symptoms. I had no doubt about the diagnosis. He had cancer of the stomach and further tests including the endoscopy showed the cancer had spread all over. He does soon after.

         Looking back I feel guilty for not having insisted that he get the tests done.I could have told his wife and she would certainly have succeeded in getting the tests done.Would he have survived had the tests been done six months earlier? Yes he would have.

          There is a saying that you can take the horse to the water but you cannot make it drink it. Sometimes it is difficult to force the issue. But difficult or not I should have done it and he would have probably few more years of life. Now I am carrying this burden and it will be with me and his face will keep coming to haunt me, may be, till I die.

         Another patient and another time. This person was a medical shopper. He saw many doctors and I was one of them. He had painful sensations on the skin of his thighs extending down to the calves. Only sensory involvement of pain sensation carrying nerve fibers may be due to many causes and cancer is one of them. He was a smoker and on testing he was found to be a diabetic. I was happy because diabetic neuropathy is very common and good control of diabetes will help. He was told the diagnosis. He appeared happy that a cause was found and went with the diet sheet and prescription. For three months I did not see him. When he did come he had with him records of three other doctors, one of them a homeopath. His diabetes was under control but his neuropathy [pain] had worsened. A neurologist who had seen him had done a scan of his spine and brain with no abnormality. Now he also had weakness and loss of weight which was attributed to diabetes. What is this patient’s illness?

      I expressed my worry about cancer to the patient and told him to get a PET scan [an expensive test but will reveal cancer activity] of his whole body. After much deliberation and visit to another doctor [fortunately he too advised the same] this test was done. A tumor was found in the patient’s intestine [ceacum]!

     Though nearly six months had elapsed from the onset of pain in region far removed from the place where the cancer was, it was found to be operable. The patient lived few more years but died due to recurrence.

       Here again if we had forced him to do this test and the diagnosis had been done early, may be, he would have lived his normal span of life. All of us [many doctors whom he went to] thought that diabetes is the cause when all the time it was cancer. This episode too has remained in my memory but does not haunt me as the other one does.

       Despite this experience I stick to the principle of investigating only when necessary. But as you can guess, I have started forcing and even threatening them with dire consequences if they don’t follow my advice. Once bitten twice shy that is what I have become.

        Medicine is in many ways, a cruel profession. You may be right 99 times out of 100 but you remember the 100th because willy nilly you were responsible. And to the patient who suffered it is 100 percent.


Author
Dr. B.C. Rao is  73 year old family doctor with varied interests.He is still in active practice though only for limited hours now.He actively guide young aspirants of family practice.