Non indigenous "disease" x Indigenous "disease"

Video with the testimony of Lucíola Inácio Belfort the first Brazilian Indigenous Kaingang to be graduated at medical school she is woking at SESAI (Special Indigenous Health Secretariat) with indigenous communities. She also is a nurse and she is working  on the ground. This video was recorded during the "1st State Seminar of Health of Traditional Communities: indigenous and Maroon - Rio Grande - Brazil‏" ("I Seminário Estadual de Saúde das Comunidades Tradicionais - Indígenas e Quilombolas " - http://www.sinsc.furg.br/site/isesct/ ).

Struggle for health

 

Samir Lopchan

58 years old male from Khung-1, Pyuthan came to our OPD with complains of fever for 2-3 weeks, pain in right side of chest with productive cough. He also had loss of appetite and loss of weight. On examination his temperature was 99° F, pulse rate 92/min and BP 110/70mmHg. On chest examination there were decreased breath sounds on right side of chest. Other examination was within normal limit.

Blood investigations, chest X-ray and Sputum for AFB (for PTB) were ordered. TLC 15,500/mm3 (N73L26E1), Platelet 3,70,000/mm3. Chest X-ray showed opacity in right lung with air-fluid level suggestive of hydropneumothorax/ pyopneumothorax. 

To make sure what is inside I aspirated with a syringe and got thick pus, so the diagnosis was made Pyo-pneumothorax (collection of pus and air inside the lung). For definite treatment the pus should be drained with a pipe inside the chest, it’s called chest tube insertion and drainage and intravenous antibiotics. We all know that ideally money shouldn’t be the issue between the patient and the health worker. But he had only 1-2 thousand rupees with him. This is how most of our patient comes to the district hospital. It is the scenario of every government hospital in rural areas. He even didn’t have any family member to accompany. He had come to hospital thinking he will get some tablets and cough syrup and he will return back. We told him about his condition, what needs to be done and asked him to call his wife to come to hospital. He said, “She has to stay home to look after home and the cattle.”

After taking informed written consent, we gave him Inj. Cefuroxime, Inj. Metronidazole and under local anesthesia, we inserted a 32 no. chest tube in his right chest. A gush of thick pus came, about 550ml of pus was drained and it was attached with a bag with water seal. He was admitted under Inj. Cefuroxime, Inj. Metronidazole, Tab. Levofloxacin, Analgesics, Aciloc. Later his sputum report came which showed positive for pulmonary tuberculosis, so Anti-tubercular drugs were started. 

He couldn’t afford the treatment so we did all for free. If we have had relied only on government free supply we wouldn’t be able to manage this case in a district hospital. Chest tubes aren’t available in most district hospitals. Many antibiotics don’t come under free supply. And if we had referred him outside the district either he would have returned back home or he had to sell his property to arrange money for his treatment. I had bought chest tubes, water seal bags from the NSI (Nick Simons Institute) GP fund, few medicines, tapes, sutures from my ‘Poor patient treatment fund’ (for which I collect donations from various kind-hearted donors) and got some medicines from NCCDF (Nepal Critical care development Foundation).

After 3 weeks of treatment, he improved a lot, most of the pus was drained but the entire lesion was not clear. CECT chest was the best option to see the extent and detail of the lesion and obviously a cardiothoracic consultation. But for that he had to go out from the district and he didn’t have money for that and he was not ready for that. So we discussed the situation, explained him and took out the tube and discharged him on Anti-tubercular drugs and other medicines. I know this isn’t the world’s best treatment what he got. People may say why you didn’t do pus culture, why you didn’t do CECT chest to see lesion, why didn’t you send him for the CTVS consultation, what if he develops some complications and many things. But what I am confident about is what I did is the best in this situation, what I did is the best any doctor can do in this settings. We knew that we had limited resources; we knew that we were less specialized. But everything was well explained to him and it was a joint decision to do the best in that situation. This is how we are giving our service; yes definitely compromised, may not be according to the international guidelines, may not be satisfactory to the super-specialized doctors but it is definitely stuffed with lot of warmth, devotion, dedication and right to the situation and settings.

Sometimes we have to act out of our profession and do something extra to provide health service in rural areas. I want to thank NSI, NCCDF and all the donors who believed in me and my work and helped me and my entire team.

 

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Name of the author- Dr. Samir Lama
Brief Description about the author- MD General Practice, working at Pyuthan District Hospital, Nepal
Area of practice- MD General Practice, I see all general cases and do surgeries mostly LSCS, appendectomy, hernia, hydrocele.
epidemiology of your area in brief- Mid-western region of Nepal, hilly area, difficult in transport, nearest referral center is 4-6hrs long drive through the hilly roads.
Introduction of your rural health story
Conclusion
Suggestions for strengthening rural healthcare and Role of WoRSA

Newer technologies and rural health

 Dr.Smruti Mandar Nikumbh-Haval

With new updates in world of bioengineering many firms are introducing various patient friendly gadgets which help them in monitoring of health issues. But in most of the rural areas these techniques are beyond reach. Reasons could be cost, literacy rate, education level to monitor them, maintainace, service centers, easy availability etc. 

 But a primary care physician can judge the need of such techniques well for community. These can bring a welcome change in community health services. He/she should try to search and use them for improvement of rural health. Urban or rural good patient health care should be the aim of every primary care physician. 

Today I will share my experience of one such technology came across few months back. It’s named as Continuous Glucose Monitoring System (CGMS).This is a new technology in market for monitoring of glycemic control of patient over period of 14 days continuously without causing much discomfort to patient. 

I got introduce to this during one of the workshop I attended. One of my colleague there who was type I diabetic using it smoothly to control his glycemic variables. I quite liked that so I searched for the company that provided that in India. My main hurdle was my rural back group .To convince marketing fellow was a task as he was bit reluctant to come to our place, share a demo and training. I assured him that I will personally take him to the venue and arrange transport. Then with lot of yes/no he agreed. One more (?) Bribe I offered him was discovery of an undiscovered market place which will help him in his promotion. That clicked well to him I guess. :-P. 

 We got our demo and I soon mastered the skill. We now have used it on more than 7 patients and it really helped them in their treatment plan modification. My patient range was also variable /we used it in post CABG, post angioplasty, uncontrolled diabetic patients and brittle diabetes cases. We got excellent details from that monitoring. We also ask patient to keep a food consumption chart to correlate readings of glucose levels. 

 We document hypoglycemia unawareness, false alarms of hypoglycemia/ Hyperglycemia, Dawn’s phenomenon. With these variables we could modify there treatment plan and make their life bit stress free as symptoms are gone or in control. This time we know a concrete reason. The patient satisfaction was immense. 

 CGMS really document it better and helps in monitoring of glycemic control. We even saved one patient who was having recurrent severe hypoglycemia and need of Insulinoma workup. With careful history, glucose monitoring and treatment adjustments things are in control, major operative or multiple investigations and psychological stress got saved. 

The only factor that hampers its routine use in rural population of India is cost of device. But I am hopeful in near future it will come down. In primary care one should learn to balance technology and its need as treatment option. We should not depend too much on them. Clinical judgment is a priority. Additional tools like these should be used to improve clinical outcome. 

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Brief Description about the author
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.