Family Medicine that is not in the books

Photo of a mask hanging in front of a rainy day, taken by the author

Written by Karine Kersting Puls

Translated into english by Bianca Niemezewski Silveira

 Posted and edited by Bianca Cadore Morás

(Portuguese below)

The residency ended. Finally, the idealized life of a family physician was about to begin, but it wasn't just anyone. It was not in any specialty. It was not at anywhere. It was the one as a physician, family physician, family and community physician in a rural city. And the dream began. And the plans started. Staff meeting. Planning.  Agenda management. Knowing the territory. Knowing people. Bonds. Touch. Take care. Two weeks: that was the time. Two weeks for such a virus to emerge and catch dreams, plans, expectations, curiosities, take everything on the way and change the route. Change the known. To change.  Pandemic. Individual protection equipment. Do not touch. Do not hug. It is no longer allowed to share the mate. Do not shake hands. Examine what is necessary. Do what is necessary. Do not leave if not necessary. Pandemic. Fear. Confusion.  Standstill. Action.Make the contingency plan. Isolation. Take the test. And that idealization became reality - not the idealized reality, but the true one. And the real world has shown that reinvention is daily. Family and community physican. She learned that being a family and community physician goes beyond books. It goes beyond the residency. It goes beyond idealization. She learned that a family and community doctor is a reinvention, flexibilization, a daily action in the balance between doing and not doing.  She learned so young that in order to be a family and community physician, a pandemic must be orchestrated in the midst of a non-idealized rural community.

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About the author:

Karine Kersting Puls is a family doctor in the interior of Rio Grande do Sul (Brazil), member of Rural Seeds and WONCA Working Party on Rural Practice.

Original text in Portuguese:

MFC que não está nos livros

Foto de uma máscara em frente a um dia chuvoso, tirada pela autora

Escrito por Karine Kersting Puls
Traduzido para o inglês por Bianca Niemezewski Silveira
Postado e editado por Bianca Cadore Morás

(Em inglês acima)

Terminou a residência. Finalmente a tão idealizada vida de médica ia começar, mas não era qualquer uma. Não era em qualquer especialidade. Não era em qualquer lugar. Era aquela como médica, médica de família e comunidade, médica de família e comunidade em uma cidade rural. E o sonho começou. E os planos começaram. Reunião de equipe. Planejamentos. Gestão da agenda. Conhece o território. Conhece as pessoas. Faz vínculo. Toca. Cuida. Duas semanas: esse foi o tempo. Duas semanas para um tal de vírus surgir e pegar os sonhos, os planejamentos, as expectativas, as curiosidades, pegar tudo que tinha pelo caminho e mudar o trajeto. Mudar o conhecido. Mudar. Pandemia. EPIs. Não toca. Não abraça. Não compartilha mais o chimarrão. Não aperta a mão. Examina o necessário. Faz o necessário. Não sai se não for necessário. Pandemia. Medo. Confusão. Paralisação. Ação. Faz o plano de contingência. Coloca em isolamento. Faz o teste. E aquela idealização se tornou realidade - não a realidade idealizada, mas a de verdade. E o mundo real mostrou que a reinvenção é diária. Médica de família e comunidade. Aprendeu que ser médica de família e comunidade vai além dos livros. Vai além da residência. Vai além da idealização. Aprendeu que médica de família e comunidade é uma reinvenção, uma flexibilização, uma ação diária no equilíbrio entre o fazer e o não fazer. Aprendeu tão jovem que para ser médica de família e comunidade tem que se orquestrar uma pandemia em meio a uma comunidade rural não idealizada.

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Sobre a autora:

Karine Kersting Puls é médica de família e comunidade no interior do Rio Grande do Sul (Brasil), membro da Rural Seeds e do conselho do WONCA Working Party on Rural Practice.

Je suis étudiant!

Another intense afternoon at the clinic. Malnutrition and infections are already routine work.

Suddenly arrives a young man of 8 years of age and, well articulated in his words, appears and speaks directly with me, in French: Je suis étudiant!

Son of the arid land of Ambovombe, the little boy tells me about the difficulty in school because he can not see the blackboard. He struggles but has headaches.

He is the only child who attends school for all the children I attended in the entire first week of work. His case was not the priority and seemed absolutely far from our possibilities at the moment. However, #FraternitywithoutBorders was his and his grandmother's only hope

I took a deep breath. I had to do something. And I did...a modified Snellen test was enough to diagnose myopia. Concerned, I tell the translator..."He needs glasses, but we can not offer."

As we have learned in the FWB, we are many united hands working for Love. Dani, my translator and right arm (and left too!) Showed readiness to respond that we had a chance. The next day, we were all going to talk to the priest who had received a mission from the Catholic Church the week before. We introduced the FSF and we got another partner.

A week later, he and his grandmother return to the clinic. Main complaint: a little hand holding a package, a smile that can not be restrained on the lips and a tight hug from anyone who never loses HOPE to see it happen!

Janaina doing the modified Snellen test with the patient during her work 
in Madagascar

Janaine Camargo is a family doctor and works at the NGO Fraternity Without Borders in a rural area in Madagascar

Translated into English by: Bianca Silveira
Posted and Edited by: Ana Júlia Araújo

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.

Healthcare in Kerala : My observation

....having stayed in kerala during my graduation , I found Kerala to be a society full of paradoxes, rather hypocritical to an extent.

Whereas on the one hand you have the best literacy rates and the wow health standards at par with the developed world, on the other you have almost near zero entrepreneurial ventures no industry very limited opportunities of employment outside the government .

One of the highest suicide rates in the country and almost all families have an earning member overseas/outside kerala sending in the dough.

On the one hand female literacy rates are the highest in the country on the other ladies venturing outside their home after sundown were looked down upon,

On the one hand you have the matriarchial society on the other hand ladies are not allowed in the sabrimala temple ( a place of worship in Kerala)

Whereas on the one hand you will not find any coolies on the railway stations but a good chunk are manual labourers in the society.

Whereas you will find them to be admitting to be less than willing to do anything yet their professionalism specially in healthcare is beyond compare, their dedication , zeal and commitment unparalleled.

Health standards were achieved in my opinion because of exemplary societal acceptance of the role of the ladies in the healthcare field specially in the domain of Nursing and teaching.

Whereas men folk ventured to search for employment opportunities beyond Kerala, i.e in the Gulf, America, Europe, or even in other indian states,the women folk continued to manage the native front and ensured education and good healthcare to their children.

As a result even though the governmental expenditure on health was trivial, the out of pocket healthcare was flourishing.

Nothing succeeds like success! once they had carved out a place for their state in the health standard arena they took upon themselves on a war footing as a matter of immense pride to keep it that way and once achieved the government too started to patronise the healthcare in a bigger manner.

If you have travelled through Kerala you would realise that it is an urban village from the northern most district (Kasarkode) to the southern border (Thiruvananathapuram)with almost universally similar facilities all over.

This was probably due to a paradigmal shift by the policy makers regarding resource allocation to local governing bodies called panchayats around 1996, where almost 40 percent of the states available funds were at the disposal of these local bodies for capacity building and development, as per local needs.

Open door policy viz for education in english and hindi ensured education to kids that was utilisable beyond kerala, at the same time not letting go their tradtional cultural traditions i.e mohiniattam, kathakkali, and their gaanamelas,

Notwithstanding what the world said they continued to use coconut oil for cooking relying on their cultural wisdom,only now the entire world is marketing virgin coconut oil for cooking and as cure for some forms of dementia.

Coconut,coffee,cardamom and rubber which were their cash crops peculiar to the weather there continued to attaract world attention because despite all the mechanisation most of these crops continued to be grown traditionally and had their quality and genepool maintained.

Traditionally they eat parboiled rice which is now emerging as a recommendation for diabetics.

With the IT revolution the beauty of kerala became popular and Kerala an important destination for medical tourism specially for the Maldivians and the Lankans. like begets like !! once the dollars started trickling in the industry veterans pumped in even more to ensure world standards.

So,what probably started as a mundane chore of life evolved as the feather in the cap of the nation leave alone Kerala .

Regards

Dr Hemant Saluja

Rural Family Doctor

Mayara Floss

Taking care of the patients in the countryside was my way of coming back to rural. I planted tobacco when I was young and today I try to support patients  to stop smoking.

Brazilian South, Jul / 17

The Elderly Lady and her Chicken

Dr. Etonu Joseph

It was a usual day on the ward in the rural facility I work in (kapelebyong Rural Health Center,in north eastern Uganda), as I was doing a ward round. Like other normal days it is characterised by children having malaria and usually I review them to make sure the dosages are right and they receive the right treatment.

This particular day I noticed a chicken walking through the ward and of course I was furious(given that infection control is very important) why would a chicken be moving through the ward. Then I chased it out. The African local chicken are quite fast and of course it got away.

Surprisingly after sometime I noticed the same chicken coming back to the ward. This time I asked the nurse on the ward what was wrong with the chicken.

She then revealed to me that the chicken is for one of the elderly patients on the ward. “It has even laid eggs and it must be trying to come back to lay another one”, the nurse added!!!

This made me even angrier. How can a chicken just want to lay eggs in a hospital!!!

I matched to the patient with my eyebrows up and I noticed next to her was an old sink that was not in use, with a box and about 11 eggs. The chicken had already laid 11 eggs!!! I asked her in shock, ‘’why is your chicken laying eggs in the ward?” She replied to me, I was admitted to be in hospital for 2 weeks and unfortunately I stay alone at home. This is the 3rd time my chicken is laying eggs and the 2 previous times I wasn’t home to protect it from the neighbours who stole all the eggs. I am not willing to take any chances this time so I have decided to carry the chicken to hospital with me this time, she humbly replied. I told her that unfortunately chicken are not allowed to live in the hospital next to patients because it could cause diseases and she just kept quiet. She looked at me in confusion as to why the doctor wouldn’t understand her concern.

She put me in a dilemma I couldn’t send this lady back home because we needed to monitor her meds and it was unfortunate that she stays at home alone and all her children had moved to the city, like most of the elderly women.

We ended up having to organise for her a separate empty room to be with her chicken.

I am still wondering whether it was the right decision. What would you do in the same position?

Above you can see the eggs in the broken sink!!

Above you can see the patient’s bed!! Next to the sink!! With the chicken seated on the eggs below!!

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I am Dr. Etonu Joseph, Junior medical doctor from Uganda 29 years of age, I've been practicing for 2 years in a rural area in Uganda in a county called Kapelebyong county. I Started my work when I was 26 years old in the facility. Iam the only doctor there covering the health of 89,000 people. Being a very rural area very few doctors attempted to work there but so far i am the one who has lasted the longest in the facility..The people I serve are the humble indigenous rural people of Karamoja and also Kapelebyong county..I graduated in 2012 at the University of St. Petersburg Pavlov,the Russian Federation. But i started working in this rural area in late 2014. I ride a motorcycle to work because the roads are soo bad in the rains that sometimes it rains on me! BUT I LOVE MY WORK and I have learnt a lot from the people I serve.

The police protection

Dr. Etonu Joseph 

It was a usual afternoon at Kapelebyong Health center 4,in Uganda, like everyday during my work I see all patients with different conditions.Some of them are brought by a policeman and this would be because of assault or even rape sometimes.But this day had i saw a police officer,a gentleman well built and strong sitting in the waiting area waiting to see me. As usual because I knew he had other day duties. I allowed him into my doctor's room. I expected him to be accompanying the usual cases of rape or violence but was I wrong.

Entering the room he closes the door behind him and he sat down. So i asked him "What can I do for you?" He replied it is I who needs help, "yesterday night I was attacked by my wife and she was bitting me with her teeth" He showed me all the bite marks on the hands and the back. I felt for him because 1st of all he is a Man! And also a police man. And being in the village many men usually beat their wives and sometimes they injure them so badly. But it was very humbling to notice this policeman keeping himself calm. And he did not beat his wife(Being physically strong He didnot even fight back). I advised him to get help for his wife because he was not safe living with her.

But it got me suprised that if a policeman can seek for help on the abusive nature of his wife.Then that means he loves her and it could also mean that he respects the rule of law.But it also got me thinking as we call police for help, who helps the police when they are in trouble..?

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I am Dr. Etonu Joseph, Junior medical doctor from Uganda 29 years of age, I've been practicing for 2 years in a rural area in Uganda in a county called Kapelebyong county. I Started my work when I was 26 years old in the facility. Iam the only doctor there covering the health of 89,000 people. Being a very rural area very few doctors attempted to work there but so far i am the one who has lasted the longest in the facility..The people I serve are the humble indigenous rural people of Karamoja and also Kapelebyong county..I graduated in 2012 at the University of St. Petersburg Pavlov,the Russian Federation. But i started working in this rural area in late 2014. I ride a motorcycle to work because the roads are soo bad in the rains that sometimes it rains on me!  BUT I LOVE MY WORK and I have learnt a lot from the people I serve. 

Grief and resilience on a remote Pacific Island

Dr Nini Wynn

I worked as the sole doctor for five years on one of the outer islands of the Southern Cook Islands, a Pacific Island Nation. The hospital with eight-beds had basic facilities and diagnostics only.  We could not provide advanced Cardiac Life Support because there was no Defibrillator. During my stay on the island, I met a family of five: father, mother and three children – two daughters and one son, who faced three deaths in 4 consecutive years.

The 8 year old boy became ill and when it became apparent that he was not improving he was transferred to Rarotonga, the main island, an hour’s flight away. He was found to have an abdominal lump and was referred on for further investigations and management to Auckland, New Zealand, which involved a 4 hour flight and crossing a national border. 

He was diagnosed there with Nephroblastoma (Wilm’s Tumor). Prognosis was very poor and he died at the Auckland Hospital, far from home. The whole family was devastated and shattered. His body was brought back from New Zealand to the Cook Islands to be buried. Blessings were received after this boy passed away and his mother gave birth to another son. They were all so happy to have a new member in the family. However, a year later, one of their daughters was killed in a motor vehicle accident; she fell off the moving car on the way back from school, sustained a severe head injury and was killed instantly. She was brought into the hospital with no sign of life. The parents were informed and they arrived at the hospital hoping against hope. Her mother held her tightly in her arms and said that she loved her so much - she did not even get a chance to say a few words before her daughter’s last breath. Her father was quite a strong man and we did not see him crying, but we all knew that he must have been crying in his heart.  

Bad luck came in a row to that family –the following year the father became sick. He was 54 years old at that time he presented with epigastric pain and weight loss. He had had the pain for quite a while but did not seek medical attention. Clinically, no positive findings were found and he was referred to Rarotonga for further investigation. There is plain X-ray and ultrasound at Rarotonga hospital but no complex imaging i.e no CT scan or MRI. A gastroscopy was done which showed gastric outlet obstruction and a diagnostic biopsy came back as ‘normal gastric mucosa’. However, his condition did not improve and serious discussions followed with the patient, family and the health team. The possibility was that the biopsy taken might have been insufficient and missed a pathology. There were some issues and controversies during the process of his referral, which caused delays in sending him to tertiary care. When he was finally transferred to Auckland, New Zealand he was diagnosed with inoperable carcinoma of stomach and he died six months later in NZ. He was not well enough to travel home. 

I was amazed at the wife and the mother who had faced three deaths in a row - she was so strong and she dealt with her grief with a real will, whilst taking care of the rest of the family- herself, her eldest daughter and the last born son. She had faced expected and unexpected death. She travelled twice to Auckland and spent precious time with her late son and late husband during the last days of their lives. She respected her husband’s wishes to get treatment with traditional medicine for his cancer, because he believed that it could heal him. He was in a denial stage. As the breadwinner of the family, he had a strong will that he must live on. His priority was his family. He did not want to leave his wife and two children. Even though his wife knew the reality-that her husband was living in his last days, she never argued or went against his wishes. The small community of Cook Islanders based in Auckland, gave her and the family help and support in different ways; psychological, spiritual and financial, during her difficult times. His family accompanied his body back to his home island where he was buried close to his ancestors and his daughter.

When I look back at her story, some questions arose in my mind; would there have been any difference in survival and prognosis of this man and his son if they had lived in a big city with specialist care and advanced modern medical technology? Would the man have survived if the referral had been done more urgently? Is this an example of the health inequality/disparity for people living in rural remote areas? If it is so, could there have been a huge difference to this woman’s life?

What shines through is the resilience shown by the family – the very strong sense of belonging to a place – their island - wanting to be there whether in life or death. This love of their home and their people is perhaps the most important.

About the author

My name is Nini. I live in the Cook Islands, a small Island Nation in the Pacific. My work is in the Outpatient and Emergency Department at Rarotonga Hospital. Rarotonga is the main island of the Cook Islands. Prior to that, I worked in a small hospital on one of the Outer Islands which provides primary health care for the local community.

Currently I am working in a rural hospital in NZ to complete the two six-months placement as a part of the newly established Cook Islands General Practice Training Programme. This programme started in 2014 and was developed by the Cook Islands Ministry of Health in partnership with the University of Otago and the RNZCGP. Before this doctors in the Cook Islands had no Family Practice training pathway."

My story is based on a social and cultural concept on death and dying in rural and remote community – from the time I was working on the Outer Island.

A love story

Una Historia de amor 

Rossana Betancur Escobar

Translated into English by Mayara Floss

Imagene: La pareja.

Con Felipe nos conocimos en el barrio. En un cumpleaños de su hermana.El es 3 años mayor que yo.Nos gustamos apenas nos miramos…empezamos a pololear  a escondidas.

Yo tenia 16 años y el 19 .Pasaron dos años y quedé embarazada….yo me di cuenta que queria ser mamá, pero que era como una ilusión de niña-mujer,de sentir que algo nos unía…Poco a poco  mi guatita creció y mi mamá empezó a preguntarme cosas, sobre mi regla, que por que estaba tan palida…yo traté al máximo de que no supiera, hasta que me puso entre la espada y la pared…no me quedó mas que contarle.Asi que empecé mis controles,a llevar a Felipe a la casa…el mas duro en aceptar  fue mi papá…yo era su regalona..dijo algo asi como que la vida iba a ser mas dura …yo no le hice caso y seguí adelante con la ilusión de tener a mi hijita…ahora ya sabíamos que era niñita…yo me la imaginaba jugando,saliendo al parque , haciéndolo que ella la hiciera feliz,en fin.

Llegó el momento del parto y nos fuimos al hospital…debería haber sido  un momento de alegría..pero no no fue asi…un trabajo de parto largo..una bandita en la guata que mostraba los latidos cada vez  mas lentos de su corazón..la matrona corriendo a avisar el doctor…pasaron las horas mas largas de mi vida…cesárea de urgencia…Felipe y yo nos mirábamos,cual de los dos más asustados….se acercó el doctor de los recién nacidos y nos dice que nuestra hijita viene con un problema…que su cerebro no recibió el suficiente oxigeno…que está como dormida…que necesita una maquina para que no se le olvide respirar…no sabria describir que sentí…mezcla de miedo, rabia,dolor ….pero pensaba…tranquila está viva….

Pasaron los días, y quedó así…como una plantita, conectada a maquinas…que gracias a ella podía seguir viviendo…pasaron muchos meses…tenia una sonda para alimentarse, un tubito en la traquea para respirar,un ventilador , lmonitorizada las 24 horas.Todo estos nombres raros  los aprendí con el tiempo, gracias a la enfermera que la cuidaba , que antes de cualquier procedimiento me contaba lo que le iban a hacer.

Mis padres dejaron de estar ariscos conmigo…hablamos mucho…lloré…me abrazaron…con mi madre nos turnábamos para cuidarla…

Habían pasado varios meses….Felipe no tenia un trabajo estable…empezaron las discusiones..yo estaba tiempo completo para mi hija…no quería pensar en ninguna otra cosa…cuando el decidió alejarse…estuve de acuerdo…eso generó rechazo hacia el de mis padres..pero yo entendí su situación…demasiado jóvenes para comprender lo que estaba pasando.

Mi hija no habla…no se ríe…pero yo se lo que le pasa…ya creo que es mejor irnos a casa.

Nos envían gente del hospital para seguir ayudándonos…algunas cosas las manejo yo mejor que ellos…pero están dispuestos a ayudarme y aprender , cuando tienen dudas me lo dicen , se comunican con su pediatra o los médicos de la unidad…yo lo agradezco….me empiezo a reconciliar con el hospital…no es que yo crea que hay algo malo ahí…solo que cruzar su umbral,vienen todos los recuerdos a mi mente, me falta el aire, empiezo a sudar…

Ya a un año de nacida..me dicen algo sorprendente….ya no hay mas insumos…empieza a fallar el viejo ventilador mecanico….viejo porque no tiene repuestos..pero mi hija sigue viva!!!...sigo peleando con quien sea y donde sea…voy donde el señor donde mandan a mantención las maquinas…invento repuestos…reciclo…vuelve a funcionar….voy a la muni…me dan ayuda económica…estoy agresiva  con medio mundo,incluso en la casa…..me siento angustiada….mi hija está mas inquieta,las maquinas pitean …comprendo que no puedo seguir asi…me visita la kinesologa del hospital….habla con la doctora y ella le pide que me visite la psicóloga….tengo rabia…he luchado tanto y siento que todos me miran diciendo… para que?....como que para qué!!!.....es mi hija …ella me necesita y seguiré luchando por ella…se que sus días son pocos ,pero mientras ella respire, manifieste su dolor, cambien los parámetros de su maquina…..aqui voy a estar….

Ha pasado el tiempo…estoy asumiendo un poco mas mi vida…volví a estudiar…descanso algunas horas….cuando me visitan me traen los insumos, eso es un viaje menos  y un día mas con mi hija...cuando tengo alguna duda los llamo y me siento apoyada…hay una paramédico que se sentó un dia conmigo a conversar y me hizo tan bien.

Hace unas semanas vino Felipe, hablamos , nos perdonamos…le hablamos a la hija…que la amábamos mucho y que aceptábamos su destino….estuvo muchas semanas muy bien..si hasta a un cumpleaños la llevamos…. Con ventilador y todo!.

…Nuestra hija falleció hace unos días…ella fue el regalo mas hermoso que me dio la vida.... pudimos darle la mejor vida que su condición permitió, en su casa, con su gente…superando una  sobrevida , que nadie imaginó!

Estoy embarazada…me fui a vivir con Felipe…tenemos dificultades..como cualquier pareja…pero estamos viviendo nuestro amor con nuevas energias .Sabemos que nuestra segunda hija será única y que no viene a reempalzar a nadie y que nuestra primera hija vino a enseñarnos muchísimas cosas que esperamos poder practicar…

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A love story 

Rossana Betancur Escobar

Image: The couple.

I met Felipe in the neighbourhood on his sister's birthday. He was 3 years older than me. We just started to look at each other. We started sneaking around.

I was 16 years old and he was 19. Two years passed and I became pregnant. I realized that I wanted to be a mom, but it was like an illusion of girl-woman, to feel that we have something in common. Little by little my belly grew and my mom started to ask questions; about my periods, why I was so pale; I tried to show that I did not know nothing until she put me between the “sword and the wall”. I had nothing more to tell her. So I started my rituals; brought Felipe home. The hardest to accept this was my dad. I was my father's favourite. He said something like life was going to be harder. But I did not pay attention and I went ahead with the illusion of having my little girl. At that point we already knew that it would be a little girl. I imagined her playing, going to the park and making her happy, in any way.

It was time for the delivery and we went to the hospital. It should have been a moment of joy, but it was not like that; a long labor, something around my belly showed a slower heartbeat and the midwife ran to warn the doctor. The longest hours of my life passed. I needed an emergency cesarean. Felipe and I were looking at each other. I did not know which of us was more frightened. The paediatrician approached and told us that our little girl came with a problem, that her brain did not receive enough oxygen, that she is asleep and needs machines to not forget to breath. I do not know how to describe what I felt, a mixture of fear, anger and pain but I thought to relax as she was alive.

The days passed and she was like this- a little plant connected to machines. Thanks to it  she could continue to live. Many months passed; she had a tube to feed, a tube in the windpipe, a ventilator and monitored 24 hours. All these strange names I learnt over time, thanks to the nurse who cared for her, who before any procedure told me what they were going to do.

My parents stopped being angry with me and we talked a lot. I cried and they hugged me. With my mother we took turns taking care of her. 

It had been several months now. Felipe did not have a stable job and the discussions began. I was full time for my daughter and I did not want to think about anything else. When he decided to leave I agreed but that generated a rejection from my parents. But I understood his situation, we were too young to understand what was going on.

My daughter did not make any sound, she did not laugh but I knew what happened to her and though it was better to go home.They sent people from the hospital to continue helping us; some things I managed better than them. My parents were willing to help me learn, when they had doubts they told me, they communicated with her paediatrician or the doctors of the unit. I appreciated it and I began to reconcile with the hospital, not that I believed there was something wrong there, it just crossed the threshold; all the memories came to my mind, I felt I did not have air, I started to sweat ...





Already a year after her birth and they said something surprising; there were no more supplies, the old mechanical ventilator started to fail because it had no spare parts but my daughter was still alive!!! I continued to fight. I went to the lord, where they sent maintenance to the machines, I invented spare parts, I recycled and it worked again. I went to the major, they gave me financial help. I was aggressive with half the world, even in the house I felt distressed. My daughter was more restless and the machines made loads of sounds. I understood that I could not keep going like that. I visited the physiotherapist of the hospital and I talked to the doctor and she asked me to visit the psychologist. I was angry. I had fought so much and I felt that everyone was looking at me saying fighting for what? .... what!!! ..... She was my daughter, she needed me and I would continue to fight for her. I knew that her days were few, but while she breathed, manifested her pain and changed the parameters of her machine, here I would be ....

Time had passed. I assumed a little more of my life. I went back to study; I rested some hours. When they visited me they brought me the supplies, it was one trip less to get the supplies and one more day with my daughter. When I had some doubts I called and I felt supported. There was a paramedic who sat for a day with me to talk and it made me feel so well.

A few weeks later Felipe came. We talked and forgave each other. We talked to our daughter; we said that we loved her a lot and that we accepted her destiny. We had a good many weeks , she even had her birthday, with her ventilator and everything !

Our daughter passed away a few days ago. She was the most beautiful gift that life gave to me. We were able to give her the best life that her condition allowed, in her house, with her people, surpassing a survival, that no one imagined!

I'm pregnant now. I went to live with Felipe, we had difficulties like any couple but we are living our love with new energies. We know that our second daughter will be unique but she would not replace our first child, our first daughter came to teach us many things that we hope to practice ...

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Rossana Betancur Escobar-resident doctor in Family Medicine at U. de la frontera in Chile. 

I started to write this material as a compilation of life histories of my patients throughout my 9 years of work. It involves mainly rural health with cultural relevance, as Mapuche population predominates in my area, which I respect and greatly admire.

In 2009, I started working in a Health Unit as a family doctor, at Hernan Henriquez Hospital in Temuco, Chile, the unit was responsible for caring for patients affected by acute pathologies to terminal cancer, in their homes.

People come from all over the region and from the city and I continue to attend a large percentage of rural population. I try to get the attention of my colleagues in other specialties, in a hospital of high complexity, to raise awareness about patients being cared at home with the support of their families. So was born this idea to tell patients life stories and how they have experienced sickness.

Today I am working in a rural health center, located in the interior of Mapuche communities and I hope to write more stories.

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.

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.

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.