Beginning of Success to Reach Health Care to Rural Communities with Extremely Low Resources and Access Problems

Shakuntala Chhabra

Social accountability in health care and medical education has been the hallmark of Kasturba Health Society, Sevagram, which runs Mahatma Gandhi Institute of Medical Sciences, Sewagram in Wardha District of Maharashtra, India. KHS also runs a Nursing School, Nursing College and Kasturba Vidya Mandir (School for children) in the same campus. Institute’s birth is also the consequence of social accountability by none other than Mahatma Gandhi, in the form of a 2 bedded dispensary in 1938 in the village Sewagram where there was a epidemic of Cholera and women and children were finding it difficult to get treatment. The sapling has now grown into a blooming tree with nearly 1000 bedded well equipped, Kasturba Hospital at Sevagram village in the centre of country. Expanding health services to Melghat region in Amravati, Maharashtra, is another step towards social accountability in health and education. The step was taken in view of rural communities sufferings.

In view of the problems of high maternal, perinatal, infant and child morbidity / mortality step was taken to help rural community. So government of India and Government of Maharashtra were approached with the proposal for Mother and Child / Multispecility Hospital at Utawali, but delays in the system were worrisome. So it was decided to do whatever was possible. Agriculture land was bought more than dozen no objections were procured and plans of hospital as expansion of existing institute in the nearly district was planned.

Fortunately a Mumbai based charitable trust “Shri Brihad Bhartiya Samaj” came forward with the generous donation for the building and major equipments for the proposed hospital. Before this hospital could be built a beginning was made on first January 2012 by alterations / additions in the existing building of a minihospital constructed by KHS, Sevagram some years back where a physician and ophthalmologist deputed by KHS were working. A make shift birth area, operation theatre for caesarean section, hysterectomy and other surgeries was done. Other needed changes were made in the building and equipments / instruments were procured. In the existing guest house in the campus, alterations and additions were made so that the health teams could stay for 24/7 for emergency services. A nearby hut was converted into kitchenette, dining area cum office. A mini-library and online Maharashtra University of Health Sciences library were made available for every one to remain updated. Sports too were arranged and mobile phones and televisions to make the life of health providers in the hilly forestry region with access problems little easy and to try to reduce the general reluctance of health providers to work in the region. Now since Feb 2016 a reasonably well equipped. Multispeciality Dr. Sushila Nayar Hospital in Utawali has come up with basic facilities available in much better way with reasonability comfortable place for the health provider team in the building. A building with 4 flats and some land have been procured in the vicinity keeping in mind needed accommodation during the development.

With the guidance, support and help of KHS/MGIMS, Sewagram the team of Obstetrician – Gynaecologist, Paediatrician, Anaesthetist, Physician, Medical Officers, Interns, Administrative Officer, Nurses with other paramedical staff have been managing emergencies and day to day problems in outpatient, inpatient and operation theatre, 24/7 days. While paramedical administrative staff has been exclusively appointed, doctors are deputed in rotation from head quarter, the medical institute in the near by district, a dozen doctors are always available. Author as officer on special duty with support of management and a big number of colleagues at base institute are trying since beginning their best, from buying agriculture land to health services now in a reasonably equipped hospital. Caesarean sections, minor and major gynaecological surgeries are being performed in addition to normal and instrumental births. Everybody is trying to give his/her best with whatever available in the given circumstances with limited resources. The very first caesarean section was performed on 21st January, 2012, mother and baby discharged healthy in a week. The first hysterectomy with removal of a uncommon cancer of ovarian tumor ‘Struma Ovari’ performed on 15 February, 2012 and the woman doing well, 6 years. Now services for prevention of blindness complete eye care are also being provided.

Everybody is trying to give his/her best with whatever available in the given circumstances with limited resources.

There is good understanding and cooperation between Sub District Hospital Primary Health centres of Government of Maharashtra and our centre.

While trying to do whatever we could, we have had many challenges, many practical difficulties and have also realised that though. nutrition, anaemia, poor health, are responsible for many problems, their causes are deep, in the social and economical conditions, in the nonavailability of food, in ignorance, when the food is available, gender bias, unemployment, addiction and many other issues. Hindrances also include lack of awareness, lack of resources to seek services at health facilities and their own faith concepts of traditional healing, beliefs and disbeliefs. Sometimes making the patient stay in the hospital for her own good or her child’s good is a tough job, testing the patience, the best of counselling skills and dedication. 

We realized within months of opening the hospital unless Community based services, community motivation, mobilization and behaviour change, were done not much was going to change. So a step was taken in this direction way back in Feb 2013, just a year after starting the services. Now seven nurse midwives provide community based antenatal services, advocacy about intranatal, postnatal, neonatal care in the villages. We started with 52 villages in February 2013 and 13 more were added from July 2013, a total of 65 till recent past. Later 35 more have been added from April 2016 and 40 more in August 2017, making a total of 140 villages. The team visits villages 5 days a week. Medical officers posted under Rural NGO posting scheme of the Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha used to run Community Based health clinics in these villages with the nurses, in rotation while services at base hospital at Utawali. However the current rules of postgraduates medical admissions with national eligibility examination, no medical officers are available. Some laws for some good spoil other good work. So interns of the Institute in the near by District at Sewagram  are posted in rotation for 15 days, task shifting. So while each NM visit their assigned village, once in a month, doctors run clinic in assigned villages by covering 7 villages in one visit by one doctor. Things will change. It needs some time before awareness will come in the tribal population and their many unlisted social and economical issues are really addressed.  

Now seven nurse midwives provide community based antenatal services, advocacy about intranatal, postnatal, neonatal care in the villages.

Diagnostic cum therapeutic camps have been made annual event. First camp was held in March 2012 with 226 patients, February 2013 the number was 1036, in 2014 February it was 1107, in 2015 it was1883 and 2016 it was 2197. In 2017 attempts were made to help differently abled and 216 needy were help. In 2018, 3872 Surgeries have been performed on camp days and left over cases are operated within days of camp, some at Utawali and complicated at the institute at Sewagram. Camp for Cleft lip Cleft Palate was also conducted in December 2014. Attempts are being made to help Elderly women and elderly men too for diagnosis and therapy of illnesses, including noncommunicable diseases, (Hypertension, Diabetes and Cancers) vision problems. Research was done with help from US based Global Health through Education and Service, (GHETS) Indo Canadian Institute from Canada. Now Mumbai based philanthropists including Jan Kalyan Trust help in services for elderly. Research about ‘Abortions’ under Indian Council Of Medical Research, New Delhi Disability Detection program was done and Aids, including Wheel chairs provided to nearly 225 people. Now beginning has been made for trying to make adolescent, young school drop outs learn skills to become self sufficient, with support from Jan Kalyan Trust Mumbai. Camps for cataract surgery are being done. 

Research is being done about effects of Bio-fuel mass on health of family specially mothers and new born with plans for providing and Chimneys related to Agriculture status and malnourishment, low body mass index, Anaemia, Vit A deficiency etc. There are plans for Family Life Education Program for Adolescents, Preconception literacy and care also, finding how Wellness can be created for them.

Presently the biggest need is of finances so that in the reasonably equipped, furnished hospital, free services can be provided to the real poor, especially mothers and babies in emergencies. It is not possible for KHS, Sevagram to provide free services to everyone without support. Though services are provided to everyone, who reports, irrespective whether the patient can pay or not, it is not possible to Declare free services due to lack of resources. Also financial support is needed for providing children the needed nutrition at home till the time they are in a position to become self sufficient. Major issues are also awareness of many things, access issues and safe water, working on their beliefs and disbeliefs.

____________________________________

Shakuntala Chhabra is an meritus Professor - Obstetrics Gynaecology, Chief Executive Officer - Woman Child Welfare, Officer Special Duty - Dr. Sushila Nayar Hospital, Melghat. In addition to DGO, MD, Diploma - Advanced International Maternal Health Sweden, Certificate Courses- Maternal Child Health, U.K, Problem Based Learning- Netherlands, others- Logistics Management, Teaching Training, Human Resource Management etc. Receive the awards: FIGO’s Distinguished Community Emergency Obstetrics, Best Teacher, MUHS, Nashik. Short term WHO Consultant, Technical Consultant, Technical Temporary Advisor - WHO. Supervisor for SIDA. Member of Women’s Health Task Force, Network TUFH, USA. Member of World Rural Health Council 2018. Special Interest- Maternal health, Social Obstetrics, Gynaecological cancers, Health Professionals education.

Curated by Ana Júlia Araújo and Mayara Floss

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

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

Diabetic Mitra Insulin Bank - Making Insulin Therapy Patient friendly

Dear friends today I am introducing one of my initiative Diabetic Mitra Insulin Bank to you. It a self funded initiative by my clinic to make life of diabetic patients easy & healthy- treating them well in time, early identification of complications & prevention.

During journey of this project I realise many of my patients were afraid of using insulin as therapy option. Reasons were fear of insulin injection, dependency on same, long duration of therapy, cost & availability of easy devices like insulin pen. Keeping these difficulties in mind we thought of starting a bank where patient will get everything that requires for insulin therapy conventional and modern. This bank give patients option of pre deposit money and book requirement in advance or buy later the requisite things as per need. This move helps patients in crisis time, lack of salary, draught or flood situations. We kept this channel because when patient runs out of money he /she avoids taking proper medication and later land up in severe complications. We hope this can reduce damage to some extent.

This initiative is running on a very positive note and Mr .Manjunath is our strong support like reserve bank. Till date we have 20 plus members utilising our services. Under this initiative we also pay lot of attention to insulin therapy administration counselling. During consultation we spent lot of time with patients, try to reduce as much possible fear about therapy, teach them appropriate way of administration with finger rule.*We also encourage them for self insulin administration. With help of finger rule insulin going intramuscular chances reduces and it becomes almost pain free.

In future we are hopeful for starting patient support fund which will help needy type 1 DM, old age and poor patients who are on insulin therapy but cannot afford to get it due to financial or family problems. We also hope our work will reach to maximum population and we will succeed in spreading message Lets Live Healthy with Diabetes.

 *3 finger, 4 finger, 5 finger rule

While taking insulin over arm patient should keep 3 fingers over biceps and triceps, then remaining area is ideal for insulin administration. They can take it laterally when arm is put in supine position .This helped us to overcome the misconception of injection site-“for any injection is deltoid”. Over abdomen, we asked patient to leave 4 finger area from umbilicus. This leads to sparing of rectus sheath and facilitate administration of insulin more subcutaneously. So here patient can rotate sites easily. Over thigh we used 5 finger rule so patient spared quadriceps and hamstrings. Patient can take insulin over tenser fascia lata or adductor compartment. But here chances of absorption via intramuscular route are higher. Hence it’s not an ideal site.

______________________

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.

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.

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

 Dr Smruti Mandar Haval 

Dear readers,

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

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

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

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

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

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

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

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

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

Conclusion

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


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

______________________


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.