Sunday 25 December 2016

About a Diabetic gangrenous foot and negligence in its care with dexamethasone injection




 Dr Smruti Mandar Haval 



Dear readers,

You must have used dexa injection for various purpose in your daily OPD. But a wrong unthoughtful injection of same can destroy someone's life. Hence as a primary care physician it is our duty to educate patients and fellow physicians, AYUSH or complementary medicine practitioners about use of various allopathic drugs.

This is story of mrs.X who came to my OPD on one heavy Sunday OPD. She was a known case of diabetes,IHD,HTN and was on irregular treatment due to unawareness of issues related to its complications. She has a trivial trauma from her footwear and gradually she developed sepsis and gangrene.

Initially they took it lightly and went to a non qualified physician who prescribed her few IV antibiotics and gave a dressing. To reduce her pain and other complaints as a routine practise in rural India yet he gave her one shot of dexa. She got relief for some time but did not understand that her sepsis has flared up. They wasted another 2 days and during that she develop dry gangrene with wet gangrene changes.

With someone's advice they went to a surgeon and later underwent debridement and amputation of 3 fingers of one of the foot. One physician was managing this but as they find it difficult to go to him regularly for follow up they gave up and start visit of one more non allopathic physician.

Things were ok but sugars were uncontrolled and she developed few more patched of gangrene over her amputated part of foot. Mean while due to her pain she gave up her food, was on liquid diet/IV fluids and that too relatives were feeding her in lying down position.(?aspiration pneumonia start).

During this phase they read about my news diabetic foot can be saved in newspaper and they came to me .When she came to me she was hypotensive still on hypertensive drugs, no aspirin for her PVD status, patches of gangrene has set in which require amputation, cough with crepitations, foul smelling but without pus wound cachexic lady.

I did try to talk to relatives, ask them to avoid continuous lying down posture, no feed in that position ,movement of limb in bed minimal ambulation etc. Also I told them about improving nutrition via diet and only glucose or RL IV won’t help.

I also did amputation for her gangrene patches and gave her fresh dressing with antibiotics, insulin etc. She was doing ok for 2-3 days post my visit but on day of her follow up she developed ? MI or aspiration pneumonia as she has symptoms of chest tightness, dyspnea and uneasiness. These symptoms can be of hypoglycaemia too with use of insulin therapy and skipped meal by her last night.

They phoned me but as I was out of hospital I ask them to show other doctor. When she reached there she has vomiting and situation deteriorated then he shifted her to other place for further intensive management .After this I have no news about her.

Conclusion

This case raised many questions in my mind like does a stoppage of dexa injection in time could have reduced her sepsis? Is IV fluid therapy is the treatment for patient satisfaction or small meal counseling to relatives works better? Can intensive insulin therapy aggravate her symptoms or any other cause is there for her health deterioration.


I still feel if she would have come to me early and not wasted her time with quacks she would have been in better position today. I am still hoping that she is doing well and is in safe hands now.

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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: It’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 18 December 2016

Skardu


Dr. Sanam Shah

F lives in a small brickhouse along the river stream. She lives with her husband and an adolescent son. On first instance there is something truly enchanting about her surroundings; im distracted by the sky so blue, tugging at me to get away from my city, 2000 km away near the sea. This is Skardu. It is home to three famous mountain ranges namely Himalayas, Hindu Kush and Karakorum and people reside in the foothills despite the natural upheavels and unrests; enough to lure us there in an instance. Lack of engulfing high rise buildings, the city traffic and general urban craziness would make it an ideal place to retire, I thought to myself. But I am moved by something unsettling about her demeanour. She spoke fluent Balti and conveyed phrases with long pauses. I try to connect with her in Urdu, she nods in reply. However, I wait for her son to return with her bag of medicines that she has been taking for a long time.

I take a breather and admire the lovely backdrop. The clouds hang low and I could almost reach up and try to touch one and the surrounding peaks are draped in the early winter snow, glistening under the rising sun. I almost imagine moving up here in the countryside seeing people like F who have been living in this town since a very long time. A nearby river stream fills the silence.

I learnt that there is a big district hospital some distance from this place serving two districts in this town and a bunch of smaller clinics serving this town of approximately 700000-800000. The number of doctors practicing there remains short. The hardest hit are women as they are compelled to see male doctors due to few female doctors serving the area. The doctors themselves are overworked in these challenging circumstances.

So the son finally arrives with a big white plastic bag that I empty on the table before me. To my astonishment there are numerous strips of Levofloxacin that she has been consuming for the last two years that apparently has not made her any better anyways. I look up at her quizically and reconfirm her history that is clearly pointing towards asthma and allergic rhinitis. I dramaticaly ask the family to discard any remaining strips and to avoid using in the future. I write a prescription of anti asthmatics and hand the son with my number in case of any questions and concerns in the future.

This is just one family I chanced to see during my last travels and I begin to think about the other families that make up approximately 800000 population in this town. Its probably just wishful thinking but I pray about having graduate programs in these locations in context of the needs of the local population and someway of retaining health professionals here who often prefer urban centres due to myriad instances like lack of facilities; public-private partnerships that can address the health care challenges and perhaps someday see the establishment of a medical school here!

Five days later when I moved back to work I still thought about her and the numerous challenges meted out by nature both complex and multifactorial. I felt guilty of the urban comforts and started to look at life from perspective of people residing without them on less than 5 dollars a day income. Even after three months of returning, I think about them and their smiling faces and I twinge to return and serve the people and enrich my life with the real stories of life and living in the real world of rural and remote health care. Thats when I think about the neccesity of primary care in developing countries and the need to mobilise a strong workforce of ancilliary health workers besides doctors and nurses. A part of me is there that will cause to return and I would be happy to succumb as long as I can.

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Sanam Shah - Editor of the Blog Rural Health Success Stories
WONCA South Asia Region

Sunday 11 December 2016

Crying to give happiness

By. Dr. Bikash Gauchan


Mother in law, sister in law and a husband of 23 years old female brought her in the emergency department of Bayalpata Hospital in rural Nepal for labor pain at 9 months of pregnancy. It was very sad to know that she had lost her previous baby at 8 months of pregnancy because of intra uterine fetal demise (IUFD). When we examined her, she was in true labor pain, her cervix was 30 % dilated and membrane got ruptured on the way to hospital. Another bad news was revealed lateron, her baby was in breech presentation. We confirmed with obstetric ultrasound and we explained the difficulty of normal delivery and probable need of c-section delivery. The husband stood up and said, “She would need to work and if we do surgery it would be difficult for her.” Family doctor explained the breech delivery of baby might happen normally and might not lead to any complications. As the membrane was ruptured, the baby has less amniotic fluid. As soon as her husband heard us about the probable need of c-section, he ran away not to be found in the village and not to be contacted by mobile phone. His family members shared with us that he might have gone to India because he could not bear the stress. We waited her labor to progress. We waited till another 8 hours, monitoring her in between. Finally we had to diagnose as a case of Breech presentation with obstructed labor. It was very challenging to get the consent for c-section. Finally, mother in law and sister in law gave consent for c-section. After preparing well for anesthesia and giving medications she was rushed to operation theatre (OR). There was the presence of only one Family Doctor at that time. The only anesthesia assistant was on leave. The family doctor quickly gave spinal anesthesia and requested one of the medical officers to monitor for anesthesia. The family doctor scrubbed, painted and draped the lady. He started the c-section and delivered a baby who was passing meconium and little was found inside baby’s mouth. The circulating nurse and medical officer took care of the baby and the baby finally cried to give happiness to the lady on OR table, family members and whole medical team in rural hospital in Nepal. This story highlights the importance of family doctor in saving the lives of mother and neonates in rural regions. The is significant importance of training family doctors for c-section so as to reduce maternal and neonatal mortality globally.   

Sunday 4 December 2016

Emptiness

 Mayara Floss

“(…) Now one of you says to me, "But Grandpa: does time you are counting as was his boyish life, in the fields And now you start talking about emptiness ..." Then I explain: "It's the fields it is where the emptiness is large. the city is the place where emptiness is small. " In the city we look out and eyes just hit a building, a wall, automobiles. In the city we see short. In the fields, because the emptiness is large, the eyes see far, far away: the fields, the woods, the mountains on the horizon, the sun dies, the moon rises, the stars ... What a beautiful thing to see the white curtain rain is coming ... When emptiness is big world grows. (...)“ – Rubem Alves

I met him in the green cold and welcoming emptiness of Connemara. At night it is possible to see all the stars and in the distance his house near to the mountains is visible. It is necessary to cross a bridge and drive some Kilometres  to get there. When I met him I did not know he was a painter, he came into the Surgery with allot of smiles and jokes and a red nose. He had a obvious cough, sounded chesty and after an examination it was suggested that he take an antibiotic. He declined with a shake of his head saying that it would probably make him  more ill and cause him to be unable to work. His GP and myself a Medical Student gave some medication options but he was kindly sceptical.

While the Doctor spoke on the phone I got a chance to sit behind him and explained with a drawing all about Pneumonia, Bronchitis, emptiness and fullness. He raised his eyebrow and said you have made it very clear, now with your drawing I understand he said.

He accepted a prescription for medication but his GP and I felt that he was unlikely to take the medicine. Before he left the surgery with his prescription the doctor changed a big paper clip for a smaller one and he jokingly chided the doctor for being a penny pincher.

We laughed and I went with him to his car to be greeted by his Labrador, “ I never leave home without her".

The Doctor told me about his patient and friendship and the long life of difficult negotiation with medications. Sometime later we went to visit him which was more a social visit than a House call. The Labrador was on the road waiting for us before we turned in the dirt road. She already knew when the doctor was coming. According to the painter she feels the doctor coming and runs and waits in the ground to welcome him. He recounted how he happened to arrive in that place which he called his spiritual home. Back then may years ago there were only 2 or 3 houses and he described the enchanted emptiness of that rural island.

He was in the process of painting the local landscape, the greenery and lakes outlined with geometrical figures which he painstakingly re altered depending on the view he utilized . His little triangles and squares of paint were repeated thousands of times to get the colour and light exactly right so that he could produce the right green emptiness. His house and structure had evolved over the years based on previous adventures and alliances. Everything there had his personal touch, little pulleys  to close doors, solar panels to provide light, a fireplace strategically constructed in the middle of the house to heat bedrooms behind it and the living room in front. His house spoke his personality and was like a painting of himself. He invited us to sit at a table and sample food including Soup a routine played out often between him and the doctor that I was lucky to be part of on this occasion. Where the doctor sat an envelope with his name which on opening the GP found a chain of paper clips all that had been given by the doctor to the painter in the previous years. We all laughed at his reinforcement of the doctor as a penny pincher. Many people choose to be city dwellers where things are full, less empty, places where there are many things to do a lot of structure for treating diseases and a lot of everything. I learned with a bowl of soup some clips ink and people that emptiness is what could fill myself.

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 Mayara Floss is an undergraduate student of medicine Federal University of Rio Grande (Universidade Federal do Rio Grande - FURG) in Brazil. She is the co-creator of project "League of Education in Health" based on the freirean principles and co-empowerment of communities and students (Blog in Brazilian Portuguese: www.lesfurg.blogspot.com ). She was Fellow of the Science Without Borders Program at the National University of Ireland, Galway 2014-2015. She is the creator of SUS Series ( https://www.youtube.com/channel/UC7p_rNpzJmlIQp2xFMMtk_g  ), a video Series about the Brazilian National Health System. She created in 2015 the Rural Family Medicine CafĂ© (https://sites.google.com/site/someambassadors/familymedicinecafe ) and she is coordinating the recently created Word Rural Medicine Student Network (WRMSN). She also co-created with the Indian Dr. Pratyush the project "Rural Health Success Stories"  and writes weekly for the Blog of Popular Education, Arts and Health - the Ferry Street of 10 (www.balsa10.blogspot.com - in Brazilian Portuguese ).