On my Skin

On my Skin

She opened the door of the health unit almost sensing something that morning. In the Rural Health Unit, about 100 kilometers away from the nearest reference center. A newly appointed doctor....and the farmers of the region saw in those hands a ray of hope. "The doctor listens to us."

Maybe this was the beginning of a cry about the future on her face. When she was in the office with another patient, somebody knocked the door, "Doctor, please come fast". The nurse was already gloved, a woman in great pain, laboir pain. Upon touching down the cervix, it was 5cm dilated. Fetal heartbeat flickering and Ineffective contractions.

Labor without progression was sensed. Oxytocin, orientations, everyone entering the small emergency room. Got everyone out of there to take a deep breath and called the 911.

"The ambulance can only get there in two hours, it is in another displacement." The calculation was not difficult... Two hours to come plus two hours to cover the 100km made 4 long hours. Can we handle it? Will the baby be born before that? We ask for priority, but the whole state needs priority.

Deep breathing, medications, salines, change of position, but still it is only 6cm of dilation in the first hour. The Fetal Heart Beat slowed down. They call the ambulance. "I need it for now." It doesn't arrive.

It did not come, it did not happen, it did not progress and it was not born.

Some colleagues would say, "it is her fault that she chose to work where she has no recourse". But is there a way to have a hospital in the countryside? To have an anesthetist team in the middle of the green of the corn? To have a team with obstetrician? Pediatrician? There, where the soy is planted?

Several will condemn "it is the doctor's fault, who went there," but would the unborn child stop herself being born or would the mother stop going into labor because they were in the countryside? Would the countryside stop existing just because there are no qualified professionals in it?

The baby was not born, the baby did not survive. Everyone hears the fetal heartbeat fade away without recourse, no training, no legislation, no doctor adequately trained for more than 60% of Brazil's population living in rural areas. While the ambulance did not arrive, a sigh, a tear.... A fatality? Could we have avoided this?

From birth to mourning. To err is human, to kill and to die is human too. But a doctor in the rural area without training is inhumane.

Warm regards,
Mayara Floss

Review by: Nisanth Menon
Translated into English by: Bianca Silveira

Posted and Edited by: Ana Júlia Araújo

Link to Portuguese text: http://balsa10.blogspot.com/2018/05/na-minha-pele.html?q=mayara+floss

Mayara Floss is a young doctor working in a rural area: Cunha Porã (SC), 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.

Strong determination is half battle won

It gives me immense pleasure to share my feelings from a few days ago. Being born as a girl and growing into women is so challenging. Also nature and almighty gave boon to becoming a mother; most prestigious designation! But the journey is not easy.

Menarche is a very sensitive turning point in every girl's life. I happened to visit a rural area few days ago and with the help of an NGO we conducted a health checkup camp specially for girls and women from ages 8 - 60 years. We started from younger girls and tried to talk in most simple form so that they could feel free to express themselves.

Besides general health problems, most had issues associated with menstrual cycle. To our surprise, majority were not using sanitary napkins, but using clothes! It gave rise to health issues they felt ashamed to discuss.

During camp we showed short animation movies about adolescent health as mass media has better impact. These girls and women were convinced that spending little on sanitary napkins will help in contributing towards positive health. We tried to inculcate in their mind that along with spending on clothes and jewelry, they should save little to be spent on sanitary napkin. They all promised to do so from coming months.

Also elderly ladies complained of anemia and general ill health like backache, hypothyroidism and diabetes. They were advised regular health checkups at district hospital and to take medicines on regular basis.

Many women gave history of very early hysterectomy. This is a practice I have noticed very often in peripheral area when poor women undergo hysterectomy at early age for trivial issues because they lack proper health education and are forced to undergo hysterectomy by wrong professionals. They are thus exposed to osteoporosis and other hormonal imbalances for the life time.

The camp concluded with the message of using sanitary napkins on regular basis, regular health checkups and sharing health issues with community workers for betterment of women’s health; also plans to start a small scale industry for sanitary napkins at a cost which community can afford.

All endeavours need lots of planning, capital and proper implementation. But as said "strong determination is half battle won". Look forward to contribute to womanhood in most positive way. Proud to be a women..Proud to be a mother!

Dr. Sonia

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

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.

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.

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.

__________________________

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