Sunday 29 January 2017

The Fever That Never Was

                                                       Dr.B.C.Rao

           Those were difficult days. Difficult in more than one sense. Professionally, there was a trickle of indifferent patients with an occasional house call thrown in. For most of these, I was either the second or third choice physician. Who would come to a young man just out of medical school,working out of an unimpressive single room and most of the time was found either sitting idle or reading the day’s newspapers? Most of them were also drifters whose usual mode of payment was a promise to pay tomorrow. Neither that tomorrow nor the patient would ever come.   
            
         Such was my state when I was called to see an eight-year-old boy at home.House calls those days were welcome as they brought in much-needed additional income. I went with the mother to see the boy. 

         I found him in bed, looking fairly OK except for a fever of 103 degrees. After the usual examination and assurance that all would be well in a couple of days.As I was about to leave when a young voice behind me asked if I would like to wash my hands. 

         A bright and pretty 12-year-old stood with a soap tray and a towel near the wash basin. More to accede to her request than for any real need to wash, I washed my hands and returned home. After two days, the call came again. The boy continues to have fever and would I mind coming again to see him? 

       Racking my brain as to what could be the cause I rushed to his home.Those inexperienced days only the worst and the rarest illnesses would come to my mind and by the time I reached his home, I was prepared for the worst scenario. 

       I found him sitting in bed reading a comic. I examined him and found everything normal except for the temperature which was now 102 degrees and lower than last time but high enough to cause worry. I thought it was time to get a few basic tests done to find out the cause. I asked the mother to get these done and after the ritual hand-washing, ably assisted by that charming sister of the patient returned home.

             The next two days were agony. It is every doctor’s hope when treating these cases that the fever would go away and peace would prevail. This is what I was expecting when the mother came to see me in my clinic.I went through the sheets of lab reports she had brought. They were all normal and she said, ‘Doctor, my boy still has fever of 102 degrees and would you mind seeing him?’ 

       With growing desperation, I reached his home. The patient was nowhere to be found. A frantic search in the house did not produce the errant patient. Enquiries revealed that the boy was playing cricket in the next street. A sick boy with a 102-degree fever of unknown cause playing cricket! That too in the hot afternoon sun! Blasphemy. My heart sank and I sat rather heavily on a nearby chair. The ever-present assistant brought me a cup of merciful water to drink.


        The mother and daughter combination succeeded in bringing the wretched boy home and forced him to lie down on the bed.I examined him.He appeared to be in fine fettle except that he resented this unwarranted interference with his cricket.I took his temperature. It showed 102 degrees! I stood there looking at the thermometer and wondering what to do next. I heard the voice of the sister asking me, ‘How do you know that the thermometer shows the correct reading?’          
        
      Yes how? I quickly washed the instrument and thrust it under the tongue of the young girl. After a minute’s anxious wait.It read 102 degrees!  
      
        It took a 12-year-old girl with an enquiring mind to spot the problem. It was such a relief to know that the boy had no fever that I almost forgot to thank his sister and congratulate her.I asked them to buy a new thermometer,discharged the patient to resume his cricket and with a dancing heart returned home.

        Since that episode the young lady and I have both aged.She went on to do her graduation, post-graduation and has settled abroad. We have kept in touch.When she visits me I see in front of my eyes a chirpy 12-year-old who taught me the home truth that Common sense and an enquiring mind is often more important than knowledge in one’s professional life.

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.






Sunday 22 January 2017

Project Kamal early screening of hypothyroidism & treatment – A determined journey for wellbeing of community


 Dr Smruti Mandar Haval

Project Kamal hum mm. Sounds cool but what does this means? Are you doing any research or building chain of hospitals? Many people asked me this question with lots of curiosity. Well project Kamal is a gift I have dedicated to my grandmother Mrs. Kamal Gopal Palekar aka Nani. She is the dearest person for me on mother earth.

She is a hypothyroid patient from past 30 + years and underwent two major operations in past. She is a true fighter and a jolly lady. With many good and bad qualities she passed on her hypothyroidism to me. With God’s wish at young age of 28 years I got diagnosed. I was expecting this but not at such an early age. I know the pain of taking daily tablets, regular blood checkup, weight fluctuations, mood swing etc but I was determined to fight back and win this battle.
 
I always felt that females especially are not comfortable in discussing this disease in public. There is lot of unawareness about this, no one voice much about this one as we are more busy in educating people about diabetes, hypertension etc.
 
I did my CCMTD course from Chellaram Diabetes Institute in association with PHFI and learnt a lot more about hypothyroidism than what I already know. During my practice of 2 years in area of Sankeshwar I managed to diagnose many hypothyroidism patients. They all were classic cases missed by many physicians.
 
It used to be a lengthy session to counsel the lady about the disease, its progression, compliance to the drugs, regular treatment, follow up etc. Few used to come back few never turned up. There was a strong need to educate the community about this disease and remove the stigma of being a hypothyroid patient. Need of an awareness campaign was there. So one fine day I was thinking about this cause and it clicked me - a name for my dream Project Kamal. Yes it was the most apt name I can think of. It was working as dedication to my Nani. It was catchy and having lot of meaning wrapped in it.
 
Kamal means lotus. Lotus is a flower with lots of importance in various ancient mythologies and cultures. In Hindu/Buddhist/Egyptian mythology lotus is a symbol of love, fertility, beauty, spirituality, prosperity, wealth and peace … in short symbol of life. This symbol was reflecting the kind of work we wanted to do.
 
So we locked the name project Kamal- Early screening of hypothyroidism and its treatment. Now was the time to take next step promotion and awareness campaign. I happen to read about world thyroid awareness week celebration in month of May every year.as I was near to this month I planned an awareness lecture for common people in my area. This year time frame was 23 may -29 may 2016 so we choose 26 May for our celebration and that’s how our journey started. On 26 May we conducted a lecture in a temple and addressed common people. Told them about thyroid gland, how it is important for body to function normal, what are common diseases of it, what is basic relevant treatment etc.
 
For lecture nearly 60 town people came and were amazed to listen to us as it was a new topic for them to learn. Crowd has few ladies who were already suffering from disease. At the end of session we cleared their doubts or myths too. The stress was on hypothyroidism and its treatment compliance. We gave them nice insight that they are supposed to consume thyroxine tablet till they go the heaven. It worked so well that new patients know their status as whether they are hypothyroid or hypothyroid, what best treatment for them is and how they are supposed to take care of themselves. It was a really satisfying day in my life. Followed by lecture we arranged screening camp of thyroid disorders for which 10 patients enrolled and utilize our services.             
 
We have also started Project Kamal Thyroxine Bank where member patient get thyroxine drug at a reasonable cost or discount rate. This whole activity is to make treatment patient friendly, cost effective and improve compliance of patient especially my rural community. In future we are aiming to arrange more awareness camps, screening camps, improvement in case detection rate etc.
 
 So far we have successfully helped 50 + ladies with hypothyroidism. Number is small but this is just beginning. I hope almighty will give us courage and strength for successful implementation of this activity. Thank you.

______________________
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 15 January 2017

Mornai - An Experience

Adrija Rahman

It was the year 1993. I have just finished my house-staff-ship in a tertiary hospital in Kolkata and was desperately looking for a job. I was newly married and my husband Shantanu was my batch mate; so, we were in the same boat. Fortunately, we got a job in Mornai, a remote tea estate in Assam in Kokrajhar district. Without much thought, both of us landed up there.

It was a 20-bedded hospital with an out-patient department (OPD), from where we were catering a population of 10,000 people. Apart from us, we only had another homeopathic doctor in our team. 

Locals were mostly Santhali and Mundari and the garden was owned by the Lutheran Evangelical Church.In the beginning, they were quite skeptical about us (by nature, they had the tendency to resist anything new). Moreover, we were facing extreme difficulty to understand their language.With our limited knowledge and unlimited enthusiasm,we started our job. Gradually those tea garden workers started accepting us and after some initial hiccups we also settled down in that isolated island!

Next year, I gave birth to my only son. For delivery, reluctantly I had to come down to Kolkata fearing about any complication.The nearest secondary care was in Dhubri, which was 6-7 hours drive from the garden. 

I returned to my job when my son was 40 days old.Soon we realized that for his immunization we should take him to Coochbehar, a 4-5 hours drive on an undulated village road.Moreover, the scorching heat in the month of June was unbearable.

I and Shantanu discussed an alternative, whether we could get the immunization done in the garden.Till then, there was no facility for immunization, as the tea garden workers were against any kind of injection to their children. 

How much we tried, we failed to convince them. We started our correspondence with the local health bodies and government officials.Also,initiated some dialogues with the union leaders.The solution was to get our son immunized first and show the local workers that “doctor Sahab’s son” had received the immunization.

Finally, the day came.My son got immunized. He was the first to receive the shot in the immunization camp. 

After that, there was a procession.The union leader led the procession,carrying “the example” on his back,showcasing him to the local workers.The message was conveyed that if the doctor was ready to give the injection to his son,it was important for the others to do the same.Then there was a big queue in the camp and that was the beginning of the immunization in that garden.

The roller coaster of my life took me from one extreme to the other. After practising evidence-based, guideline-driven medicine in one of the poshest practice in the UK, it was hard to swallow the harsh reality of a remote tea garden.

But at this juncture of my life, I can still visualize two young doctors putting their heart and soul to improve the life of a few backward poor tea-garden workers.

Sunday 8 January 2017

Rural agony to smile

 
 Dr. Pawan KB Agrawal

       
We all are bound to experience pain at least once in our lifetime in one form or the other. The severity of pain is subjected to individual experience and determination to tolerate. At times the pain bound us to kneel in front of someone whom we expect to be powerful enough in a hope that we will be relieved. 

Being a doctor, determined to face the rural challenges to bloom a light of happiness in those desperate faces with excruciating pain coming across such helpless yet hopeful patients is a routine.We do grade pain but often we are not able to address the individual experiences adequately.Nevertheless we always thrive amidst our limited resources and destitution of our fellow patients to help them sustain through their difficult times and at times these turmoil carve a beautiful story to inspire courage and hope in a doctor patient relationship. 

A week back I had this patient 32 years in one of the emergency beds during morning rounds.Two hours earlier I was informed by my colleague medical officer about receiving him in agonising pain in his abdomen which started from his scrotum the previous day.The pain had started the earlier morning.Since there were no vehicles to carry him and he could not walk for three hours with the pain, helpless he prevailed throughout the afternoon alongside his ignorant wife and three small children not knowing what was awaiting him. 

Rather than taking him to a religious healer, they preferred him receiving care in a hospital. A wise and often rare scenario in most of our deprived areas where these religious healers are the only prospects.

With the dusk, some of his relatives finally fetched a jeep and a ride of two hours along the bumpy gravelled roads and finally landed him in our emergency ward. Whatever be the reason pain must not happen. This is what we often emphasize to our fellow medical service providers. 

He received some pain killers while he was being examined and investigated. We established the diagnosis of right obstructed inguinal hernia and explained the patient & his relatives that he needs to be operated as soon as possible in order to save the part of his intestine that had come out as hernia and had been stubborn not to go back.

We could not be sure though if the part of his intestine needed to be cut and repaired. As a general practitioner, a generalist, we are regularly operating hernia that goes in spontaneously but a situation like this where a part of the intestine might need to be cut put us in dilemma given limited instruments, anaesthetic expertise and post operative care. 

Another challenge poking us was his referral, a journey of 10 hours by jeep depending on a driver to the nearest higher hospital in Dhangadi,far western Nepal in case the patient party agreed. 

We explained and discussed the scenario with the patient party, scrutinised every option in details. It would have been best if we could refer him in an ambulance with a paramedic to Dhangadi. But it was yet far from happening. 

The turmoil of helplessness,poverty and health care resources in each of us endured the entire night and settled in the afternoon as we, doctors and patient party eventually concluded to put the situation on faith and proceed with surgery in our hospital. 

The patient party agreed that if surgery goes wrong or he dies,they would not raise any claim.A life was on our hands then.How could we not do our best and help him survive was a challenge. 

He was rushed into the operation room almost forty hours later.Together with another generalist Dr. Bikash who is also my mentor since I started working with Possible in Accham two months back.

We put him under spinal anaesthesia and took every precaution available at our disposal. As we explored, the faith or whatever we name it served us with a hope that the part of intestine might survive.It was almost on the verge to die, had we opened him few hours later or had referred him.The anxiety diminished with a sigh of relief. 

After he was shifted to the ward, we prohibited him to eat and had him keep on intravenous fluids.After two days we started with liquids and had him have usual diet on fourth day. He was then walking happily without pain and discharged on seventh day after we are pretty sure that the complication would not happen. 

Sometimes we do end up with a climax where a family turns upside down with an unexpected helpless death of the beloved on a hospital bed.But to our faith & the conviction of his fellow relatives,this time a life in despair was restored with balance and smile for his new journey back home with his small family.

Sunday 1 January 2017

Fresia - Story of a Mapuche Women


   


Imagene: La ruca (Vivienda Mapuche)

Dr.Rossana Betancur Escobar 

         (Original Story in Spanish. Translated into English by Mayara Floss) 

         My name is Fresia. I am a woman, Mapuche, 68 years old.I belong to a rural community towards the coast of Chile. My ancestors are of origin is Lafquenche*. I live with my daughter Rosa.She is the youngest of my children.I had 4 children. The others men went out to try their luck to Santiago ...There they formed a family. A year ago they returned with their wives and grandchildren to a house next to mine.

      A year and a half ago my health declined.I did not feel very well.I was without courage, nor the strength to go and sell my vegetables to the people or feed my animals.

                                     ... Same time my partner left ... 


      Rosa started to worry. She took me to the Machi** and said it would be good if we go go to the doctor but before we did a ceremony to heal my spirit she wanted to go elsewhere.

       We went to Carahue***. How strange was everything ... I do not remember much that they told to me.I only had many examinations.One of them was very unpleasant - a tube by the mouth.Before the examination I did not want to eat.After the examination I was worse and vomited.

        We went back to the house but my daughter was quiet.Next time we stayed an hour in Temuco with other doctors.They examined me & told that I have a cancer in the esophagus ...The only thing I noticed was the young lady in front of me put her hand near my heart ... that place was hurting me for so long.

        My daughter left me in a chair. Waited to be comfortable and said  "Mommy, I have to talk to the doctor" ...

   
         After a while she came back by my side ... I do not know why, but I felt that she had cried. But I did not want to ask her. “They  can not operate because you are very thin ...”. “Well, dear, I told you ... it will be a long wait”.

       We were in the micro bus to return to our house with my eyes fixed at the window ...

 I remembered how my children were born,I attended my sick mother,left her house to follow my partner,told my children that they will study because I was not going to stay for sowing... and now I realise that they are my seed.

      That night  was the most beautiful one.My partner came in my dream.
He said: "Fresia do not follow me,you have to go back to the doctors,take good medicine and get fat.Children still need you .. Every time you need me, I'll be by your side ...". This gave me strength to fight back.


      Here we went again ... to Temuco. I'm going to take chemotherapy.They say it's for the tumour to shrink. But before they have to put a hose outside of my throat  so I can feed.

     The return to home was different today... I feel happy ... I look in to mirror and found that I have recovered.Who I am ... I AM FRESIA ... AND I AM HERE.

* The Lafquenches or Lafkenches is the name given to those Mapuches who inhabit coastal areas of the region of La Araucanía at the province of Valdivia in the Southern Zone of Chile.

**Machi: Local folk healer

*** Carahue: A city and commune in southern Chile. It is located 56 km west of Temuco on the northern bank of the Imperial River. 








Author:


Rossana Betancur Escobar is a resident doctor in Family Medicine at U de la Frontera in Chile.She started to write this material as a compilation of life histories of her patients throughout her 9 years of work. This is mainly based on rural health and cultural relevance as Mapuche population predominates in the area which she respect and greatly admire. In 2009, she started working in a Health Unit as a family doctor, at Hernan Henriquez Hospital in Temuco, Chile. The unit was responsible for caring the the patients in their homes whether due to acute pathology or terminal cancer. People come from all over the region and from the city.She continue to attend a large percentage of rural population.She is trying to get the attention of her colleagues in other specialities in a hospital of high complexity to raise awareness about patients being cared at home and with the support of their families. So was born this idea to tell patients life stories and how they have experienced the sick. Today she is  working in a rural health centre inserted in the interior of Mapuche communities and she hope to write more stories.




Spanish version
Fresia
Imagene: La ruca (Vivienda Mapuche)
                   Mi nombre es Fresia. Soy mujer,mapuche,tengo 68 años. Pertenezco a  una comunidad rural, hacia la costa. Mis ancestros son  de origen es lafquenche.Vivo junto a mi hija Rosa.Ella es la menor de de mis hijos.Tuve  4…los demás ,varones,salieron a probar suerte a Santiago…por allá formaron familia.Hace un año volvieron,con sus esposas y  mis nietos,construyeron sus casa junto a la mia.
              Un año y medio atrás,mi salud decayó.No me sentía muy bien, estaba sin valor, ni fuerzas para ir a vender mis verduras al pueblo, o alimentar mis animales.
                                   
                               …Mismo tiempo que mi compañero partió…

                  Rosa se empezó a preocupar.Me llevó donde la machi y ella dijo que sería bueno que fuera al médico ,pero que antes hiciéramos una ceremonia para sanar mi espíritu , que quería irse a otro ladoFuimos a Carahue.Que raro se veía todo…No recuerdo mucho que me dijeron, solo que tenia que hacerme muchos exámenes. Uno de ellos muy desagradable, un tubo por  laboca.De antes ya no quería comer,después del examen hasta vomité.Volvimos a la casa, con mi hija…calladitas.
                 Al tiempo ,le entregaron una hora para Temuco,donde otros doctores.Meexaminaron.Me  dijeron que era un cáncer, en esófago …yo lo único que me fijé era en la señorita al frente mio que se ponía la mano cerca del corazón…ese que me dolia tanto, hace tanto tiempo.
                 Mi hija me dejó en una silla..”espérememamita,tengo que hablar  con el doctor”…Al rato estaba de nuevo  a mi lado…no sé porque sentí que había llorado,pero no le quisé preguntar.”Mamita el doctor dice que no se puede operar, porque está muy flaquita…Bueno hija, le dije…tocará esperar”.
                   Ibamos en la micro de vuelta a nuestra casa, con la mirada pegada a la ventana….recordé cuando nacieron mis hijos…cuando atendí a mi mamita enferma…cuando dejé su casa para seguir a mi compañero….cuando le pedí a mis hijos que estudiaran porque yo no me iba a quedar para semilla…y ahora me doy cuenta que ellos son mi semilla.
                   Noches atrás, fue la mashermosa.Mi hombre, en sueños me vino a visitar…”Fresia no me sigas, tienes que volver a los doctores, tomar buen remedio y engordar.Aun haces mucha falta a los nuestros…Cada vez que tu me necesites, a tu lado estaré”….
                  Aquí vamos de nuevo…a Temuco.Me van a hacer quimioterapia, dicen que es para que el tumor achique.Pero antes tienen que poner una manguera, esta vez por fuera de mi guata, para que pueda alimentarme.
                  El regreso a casa hoy es diferente…me siento contenta..miro y me encuentro…he recuperado quien soy…SOY FRESIA…Y AQUÍ ESTOY.

Author:
Rossana Betancur Escobar es  residente segundo año Medicina familiar en la U de la Frontera. "Este material inedito, es el que he empezado a preparar  y que es la recopilacion de las historia de vida de mis pacientes a lo largo de mis 9 años de trabajo. Este se ha dado principalmente en salud rural y con pertinencia cultural,donde predomina en mi zona la poblacion Mapuche,la cual respeto y admiro mucho.A partir del año 2009 comencé a trabajar  en una unidad a cargo de un medico familiar en Hospital Hernan Henriquez de Temuco,Chile, una unidad que atiende pacientes en sus domicilios, ya sea por patologias agudas o cancer terminal.Llegan personas de toda la region y de la ciudad y sigo atendiendo un gran porcentaje de poblacion rural. Buscando una forma de encantar a mis colegas de otras especialidades, en un hospital de alta complejidad,para que deriven pacientes para ser atendidos en su casas y con apoyo de sus familias, es que nace esta forma de contar sus historias de vida y como han vivenciado el enfermar.Hoy me encuentro trabajando en un centro de salud rural, inserto al interior de comunidades mapuches….ahí se comenzará a escribir nuevas historias…."