Sunday 29 May 2016

Diabetic foot real challenge of rural India


  Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)

About a man with gangrenous diabetic foot and his fight against amputation

 It was a lazy Saturday evening of my OPD. Suddenly one of my hospital attendant came & told me, “Madam,one OPD patient is waiting for you. Would you like to examine him? He has a bad pus filled, fowl smelling, dirty wound over his one of the foot.” She made a face. But I decided to help him. As I am a primary care physician and helping him is my duty.
I asked my attendant to send him to my OPD. This was my first encounter with Shintre family. I saw one 18 years old young boy was accompanying his 78 years old grandfather who was suffering from left diabetic foot.
It seems he was known diabetic and hypertensive since last many years and was taking treatment from CHC near by because he cannot afford a private physician. He was a poor, illiterate fellow, surviving with his wife in different house. His pension income was 500/- only. The treatment he received from CHC was theTb.metformin 500mg OD and Tb. atenolol 50 mg OD. (Not so preferred combination in old age diabetic person unless indicated).He also had some heart problem (? IHD) in past but no details were available.
The patient was having deteriorating wound day by day even after dressings by CHC staff. The family came to me as they overheard I am a diabetic educator and were hopeful that I will help them in this worsening situation.
This was a tricky call for me. As I have to decide to treat him in my OPD or refer him to surgeon. But family members were not ready for surgical intervention and requested me to do the most needful I can to my best capacity.
I made my mind to take the challenge & win this battle of diabetic foot. I was determined to save this foot as amputation is not the solution .A thorough patient education, family members counselling, appropriate BSL control and wound care is must as treatment.
 I carefully assessed the foot.It was full of pus, slough, dorsum of foot skin was destroyed. Tendons, even some part of metatarsals was visible. The third toe of foot had dry gangrene at distal phalanx and proximal phalanx has developed wet gangrene changes. He has no pain sensation; temperature sensation over the foot. Mild crude touch was intact.
I was worried for changes of gas gangrene and maggots .But to our luck wound has no maggots or crepitus changes.I cleaned the wound and  then washed it properly with betadine, normal saline, spirit and gauze pad. While using gauze pad for dressing I follow one rule taught by my surgery teacher.”Not to use cotton straight on the wound. The small threads of cotton got stuck or attached to slough and margins which delays the wound healing.” Hence I used simple gauze made up of dressing bandage roll. I also immunized him with a tetanus toxoid injection.
I know sending pus culture was a must thing but due to limitations of both my reliability of resources and patient’s economic status I have to cancel that investigation. But I did other relevant investigations like CBC, Sr.creatinine, Sr.urea, lipid profile,BSL fasting & post prandial, ECG, X ray foot.
To my relief X ray has no changes of Charcot joint,osteomyelitis or gas gangrene. But his Hb was low, creatinine, urea, BSL were high.

After evaluation of investigations I switch him to pre-mix insulin, aspirin atorvastatin, oral haematemics and low dose ecitalopam as he was very depressed and anxious about the entire process. I used tramadol and paracetamol as analgesics as since the beginning I was worried for his renal function, hence don’t want to use NSAIDs group drugs (many doctors give diclofenac injection intramuscular quite often as routine without considering renal status.)I also stopped his CHC started metformin and atenolol which has no much role in his treatment now. His blood pressure was 130/80 mm Hg; hence we did not give any antihypertensive with relevant antibiotics.
Slowly he started showing improvement .His pus reduced, wound looks healthy and granulation development was visible. But the third toe was still a concern. It’s the gangrene changes were not resolving. One day during the dressing, the tendon holding the third toe rupture and by next visit the toe was unstable. This happened after 4 months of meticulous dressing.

In this situation I have to take a call of amputation– painful but important. I discussed the possibilities with family and the patient .they gave me the consent for same as by now it’s only a toe they were sacrificing and not the whole limb.:-)

With their permission I did the amputation with a pair of scissors .It bleed profusely post amputation as patient was on aspirin but later after giving a good pressure bandage, stump started healing fast and appropriately.

Initially for almost 2 months we did twice a week dressing.Once wound started healing well we reduced it to once a week. During this treatment anemia correction and use of aspirin works like magic wand. The patient has zero pain, temperature sensation minimal touch sensation over the limb on day one. But as we started regular supervised dressing series he resumed his pain, touch sensation to almost normal level. At times he used to scream, beg and yell for euthanasia .But this pain was worth bearing because birth of new foot has started in his life.Now Mr.Janaba Shintre is doing well. The diabetic foot is almost healed now. He has resumed his day today activities well.


Conclusion
This journey with this patient as primary care physician and diabetic educator taught me a lot. This experience underline few important aspects of patient centered care like good compliance to treatment ,faith in treating physician, role of good patient and family’s education etc.Every diabetic foot does not require amputation. With systematic and periodic care we can save limb from horror of amputation and followed disability.

At the end I thank Almighty for giving me transient healing hands of a physician. Thank you. :-).

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Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)
 M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med.
Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA
Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine
C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka
Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum
Blog: drsmrutihaval@blogspot.com
          drsmrutimhaval.blogspot.com
Area of practice- Sankeshwar, Dist – Belgaum ,Karnataka


Epidemiology of your area in brief:  I
t’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes,hypertension,asthma ,hypothyroidism etc.

Sunday 22 May 2016

When Arthritis becomes a challenge







On 19th of May, we celebrated the World Family Doctor Day. Thank you all those who are working tirelessly and maintaing integrity and ethical values of our noble profession. Time to remember and celebrate our contribution towards a healthier world. This year smoking cessation was the  theme. Preventive, curative and promoting health are the core areas of primary care physician. We are working to help everyone who wants to quit smoking and to educate all those who are still ignorant about its ill effects. You can quit smoking if you just think to quit. Have a better life..A smoke free life!!! 

Please enjoy the story by Dr. Sumana Datta.


Dr.Sumana Datta

A 30 year old married house wife, lean and thin, belonging to a lower middle class family,residing at a nearby village,came to my clinic an early morning.On entering my clinic before I could offer her a seat, she started explaining her symptoms to me.She was anxious.

I asked her to be calm, take a deep breath,offered her a seat near to me and asked my assistant to give her a glass of water to drink.There were patients waiting outside my clinic but I decided to take my time listening to her with patience.

What I came to know was that This lady had been suffering for the last 1 and half years from generalised weakness,generalised body ache , low back ache and pain in multiple big and small joints including the small joints of hands, occassional episodes of low grade fever.The symptoms were proggressive in nature associated with deterioration of  her general well being.At present she could not eat well, sleep well, remained tensed and depressed.The worst part of the story was that her husband had left her due to her illness.She had no child.She was staying at her parents house.She had been treated by local doctors posted in their rural hospitals with several multivitamins and pain killers providing brief episodes of relief but followed by recurrence.Her blood investigation showed raised ESR.

The lady broke into tears while narrating her story to me.

On examination I found out that she was having  pallor, tachycardia (may be due to anxiousness, may also be due to anaemia and her disease process) and polyarthritis affecting the small joints of hands.The DIP was not tender or swollent at that time but she was telling that she had suffered pain in the DIP s also.A startling finding was that she had dry hypopigmented plaques with white scaling , central clearing and severe itching affecting the lateral aspect of her right cheek extending more laterally to involve the right ear and right side of her neck.When asked about these skin lesions, she said that this was present for long duration,and showed me that there were similar lesions in the anterior aspect of abdomen, lateral aspect of right thigh too.There was no such lesion in the extensor aspects of limbs or near pressure points.Nails were spared.Scalp was also not involved.She was insisting that those were diagnosed to be Tinea Corporis (local language : Daad) and she had been applying several antifungal topical ointments.

To me it clinically appeared to be a typical lesion of DLE (Discoid Lupus Erythematosis) and I suspected that she might have been sufferring from Lupus Arthritis.

I asked her to do a blood test for ANA , Biopsy from the lesion.But thess tests were not available locally and the lady could not afford the price of the tests too.

Based on my clinical suspicion I started her on Hydroxychloroquine 400mg /day along with TCA and Clonazepam, Oral iron supplementation and a Sunscreen lotion.I asked her to protect herself and the lesions from exposure to sunlight.

She came to me for a follow up after 14 days.Luckily,She responded well to Hydroxychloroquine and was symptomatically better.She was happy.

I explained to her what I suspected, what an autoimmune disease is,that it is a multisystem disorder and that ideally she should visit a Rheumatoligist and should undergo regular monitoring.
But she is reluctant to visit any other doctor.

Till now she is doing fine with marked improvement of her generalised well being.Her parents came to me and thanked me a several times.She has started a new life.She is now providing  home tution to toddlers.

What I am trying next is to contact a local NGO and arrange for her treatment in a Govt Tertiary Care centre in Kolkata at least for once where she will be able to undergo a consultation with a rheumatologist and undergo the other necessary investigations free of cost to exclude other underlying systemic complications of the Disease.

I have assured the lady and her family that her continuous care, monitoring and screening for other systemic complications with the locally available cheap baseline investigations will be totally taken care of by me.

Suggestions for strengthening Rural Health Care:
This case has taught me the importance of dermatologic manifestations of systemic diseases. The primary care physicians should be trained well regarding the Dermatological Manifestations of Systemic diseases preferrably with Audio Visual Educational materials which will help them in early diagnosis and treatment of several systemic illnesses based on clinical suspicion where the resource is  limited.

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Area of Practice:
Gangarampur (Sub divisional town) Dist: South Dinajpur, State:WB, Country: India. Epidemiology of the area: It's a small town of about 10km2 diameter with apprx. 50, 000 population.It is located very near to Indo-Bangladesh border.There is  huge inflow of patients not only  from nearby rural areas of South Dinajpur , North Dinajpur, Malda district but also from the rural areas of Bangladesh.Population comprises of people from  both Hindu and Muslim communities.There is also prevalance of the Tribal communities.


Dr.Sumana Datta,
MBBS, DNB; Specialist Family Physician;
Life member, AFPI
President,
Academy of Family Physicians of India (WB Chapter)
Ph: 9232610964

Sunday 15 May 2016

Rural health success story, a glimpse from Zakiur’s team, Bangladesh



 
Dr. Md. Zakiur Rahman

Bangladesh is a sovereign country in South Asia, located at the apex of the Bay of Bengal. It has a 600 km coastline with the longest beach in the world and various islands, including a coral reef, home to 700 rivers, most of the world's largest mangrove forest and is one of the most densely populated countries (eighth) in the world. The predominant ethnic groups are Bengalis, along with numerous minorities, including Chakmas, Garos, Marmas, Tanchangyas, Bisnupriya Manipuris, Santhals, Biharis, Oraons, Tripuris, Mundas, Rakhines etc. The state religion and the majority is Islam, followed by Hinduism, Buddhism and Christianity.


Bangladesh

Though we are improving now as a low middle income country, we have a population of over 150 million and rural people comprise 77% and 60% live below the poverty line. Our healthcare infrastructure comprises of 3375 UHFWC, 82 types of district level hospitals and 83 recognized medical colleges. The total number of hospitals in Bangladesh is 1683, of these 678 are government hospitals , where doctor to population ratio is 1:43,660 and nurse to population ratio is 1:8,226. Bangladesh is one of the 6 countries of the IDF SEA region; 415 million people have diabetes in the world and 78 million people reside in the SEA Region; by 2040 this will rise to 140 million. In 2015, there were 7.1 million cases of diabetes in Bangladesh.

My 36 member team of Bangladesh Disease Research Institute ( BDRI) and I have successfully done 5217 diabetes screenings with the help of Novo Nordisk foundation and Biotrade on the occasion of World Health Day and service month of BDRI. My team members had taken so much pain to reach some places where no vehicle was available, even walking was very hard. In April 2016, we did several free health camps in and around Dhaka along with remote villages where the villagers never experienced free health camps; treatment of various diseases handled by family physicians with diabetes screening and limited free medicine provision.



I would like to share one experience of free health camp with the intention to encourage some of you to serve the under privileged and very poor rural people. Most of you will be hearing of Gopinagar for the first time, where we start our rural journey for diabetes screening. It’s about 160 km from the capital Dhaka in Bangladesh under Mymensingh district (to reach there we use bus, rickshaw and boat). People still enjoy radio as their recreation, as no electric supply there and TV is rare, run by battery. Mobile phone is very popular nowadays, almost every home has at least one with limited or no connection with internet. Their health seeking behavior is so poor that they still believe in kabiraj, ojha and quack (unprofessional, slightly educated and wrong learner). They think diabetes is a curse that is for sugar and carbohydrate restriction as he/she finished lifetime sugar and carbohydrate quota. They are not interested to diagnose as well. Although we offered free diabetes screening and consultation, some people did not allow their women for it. After meeting with the village leader and our motivational speech (as family physician) they agreed to help us. Finally we screened 232 people and found 47 in IGT (RBS=7.8-11.1mmol/l) and 12 diabetic (RBS=>11.1mmol/l); among them one DKA(our glucometer failed to read, later confirmed by HbA1C & OGTT). Patients were subsequently managed by endocrinologist in our diabetes center.

We didn’t know that the most memorable scenario still awaited. A 56 year old lady came to us on a handmade ambulance (no engine, rather shoulder of two people with the help of bamboo) where no engine oil is needed. For last two days she was semi conscious suffering from diarrhea and was newly detected diabetes case and on insulin. On quick examination we found GCS not satisfactory; pulse & BP suggested hypoglycemia. Without any hesitation we managed to start a channel for glucose that we had. After 30 minutes patient responded to pain stimulation and finally she communicated with us. This is usual for medical professionals but what a pleasant surprise for us that villagers thought we were second to God. One of the patient’s attendants told us that she was declared dead and prepared for funeral and they came here after hearing the health camp with intention to confirm the death.

That is the beauty of Family Medicine. When, where and how far we are was not important, we only needed love, hope and inspiration to serve mankind. We can see patients any way even in remotest places with limited facilities. Do love Family Medicine and Rural Health. Born out of desire of the villagers, we plan to visit monthly with the vision of rural satellite clinic and to set up rural community clinic in the future if opportunity arises.

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Dr. Md. Zakiur Rahman

Faculty of family medicine, Bangladesh College of general practitioners & Bangladesh Academy of family physicians, Dhaka. Consultant family physician, special interest on diabetology, BDRI. Professor of Microbiology, Monno Medical College, Manikganj. Chairman, Bangladesh Disease Research Institute (BDRI), Dhaka. National secretary, Spice Route Movement Bangladesh. Co-ordinator, Primary care forum Bangladesh. Email : profzakiur@gmail.com Facebook group : Primary Care Forum Bangladesh.