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.

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

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 day that I dealed with death peacefully

 Andressa Cavalcante Paz e Silva

“When the rain falls down / What brings it back? / Opens the resurrected cloud / From white to black / It's a second birth / For dying skin / In my coffin...” 

(My coffin - Jon Foreman)

I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. So, I’m going to tell you a rural success journey story.

My story begins with a young girl going to a home medical visiting in a little rural area called Curuá, in Baixo Amazonas, north of Brazil. This girl was attending Medicine classes for four years in a College School in Rio Grande do Sul, a state located on the opposite side of Curuá, south of Brazil. However, this story is not about her. This story is about the day she understood the real meaning of Rest in Peace. This girl is me.

It started out with a “Hi, good morning, mrs. Maria. Have you called out for our visit? Let me see how Mr. Manoel is going.” and them the medical interview continued.

-Thank you for being here, doctor, he is not so well. He can’t speak anymore and It is being pretty difficult for him to walk. Also, he is refusing to eat since the day he had this strong diarrhea.

- Oh, and how was this diarrhea, mrs. Maria? You see if he is suffering of pain? Tell me more about it. - The student asked.

- It was last week. It’s been 5 days since the only episode. Oh and those black stools were so so smelly as I’d never had seen!! And in the last two days he is totally constipated. We tried so hard to give him food… We even tried to lay down some pasty food and in his lips and mouth, but the only thing he wants is water and sleep. We are trying so hard to give him the medications another doctor prescribed us, as well as those nutritional supplements. Now he isn’t suffering of pain, but we are worried about inappetence.

Mr. Manoel, an elderly man aged 77, was clearly dehydrated, hypotensive (80x40mmHg) and in the neurological exam we found out Glasgow 10. When we touched his belly during the abdominal exam, his face showed heavy pain. In our hypothesis we conclude that maybe Mr. Manoel was having an upper digestive hemorrhage. 

Unfortunately (or fortunately), the medical conduct wasn’t totally accepted by the family. First, we suggested moving the patient to Santarém, a place with a hospital, in which he could do exams to confirm the bleeding and treat specifically. Nevertheless, the logistic for all transportation stuff and maintenance of the patient and the family in Santarém was really difficult. 

Actually, even if there were no problems at all, Mr. Manoel’s family had already decided he would die at home. “We can’t send him to Santarém… A couple of weeks ago when he was a little better he said that If we ever try to send him to another place instead of here, he would come to haunt us after his death for sure!” - they said. In summary, the elderly man was medicated with some Oral Rehydration Solution and referred to the doctor of the city, as I was only in an observership. This experience was really different and meaningful for me. The empowerment of that family caught my attention and I started to think about empowering my parents and my relatives to understand the finite of life and to embrace palliative care too. Mr. Manoel get better in the consequent day after drinking the oral rehydratation solution, but after two days he died at the crack of dawn. 

So, I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. I guess Mr. Manoel’s journey through death was peaceful and I guess he will not come back to haunt his family. 

Photo by: Keith Dalmon Ferreira

--

Andressa Paz is a Medicine Student living in the South of Brazil. She loves listening to stories and rural ones are her favorite. She had her first contact with rural and remote Medicine in Kat Kalen - Haiti and then in brazilian Amazon area

Its just God's miracle, we are just medium...

         Hello friends.Me Dr.Suhas and my wife Dr. Prerna are specialist by degree but generalist by choice.We both have humble rural background and upbringing.Hence after our post graduation we moved to rural set up for practice as we believe we have many dues towards society and community who helped us to be a good doctor.

        In rural peripheral setup you have a new day new challenge.There are many stories till now in one year. 

But the most interesting one is the 28 year female diagnosed with unexplained infertility for 8 long years. She was investigated & treated at several Super speciality setups at Mumbai, Pune, Nasik, Malegaon, Aurangabad. 

     She even underwent multiple times for diagnostic laparoscopy, hysteroscopy, IUI, IVF & her male partner was also treated for low sperm count in last 8 years but failed every time. Spent lacs of rupees for treatment but every time result was unsuccessful. Husband being rickshaw driver, due to mental frustration gave up hope on for not being able to  become a father. 

               Interesting fact is that the couple was none other than our hospital staff worker's son & daughter in law. 

After we started practice in rural setup, the staff told the story about her son & daughter in law. The couple meanwhile consulted us. Selective investigations were done as all the previous investigations were normal. We studied the case very thoroughly and with help of expert opinion of Dr. Prerna the patient conceived within a month. Her UPT came positive for the first time. 

           The happiness which we saw on her face was priceless. After proper care of thorough 9 months pregnancy she delivered a male child on 23/4/17. Staff worker's son literally cried with happiness. He told us that we are everything for him. And we told him its just God's miracle, we are just medium...

Author

Dr. is Dr.Suhas Pawar is (MS Gen.Surgeon) and his wife Dr.Prerna Pawar MBBS,DGO.They run a rural hospital named Saibaba Hospital, Satana,Nashik. Both belogs to humble rural background and are passionate to provide all super speciality services to rural people in there own community.This shall reduce there trouble to cope up with city urban life.

Isolation

Caruaru - Mayara Floss @ruralices

Mayara Floss

I need to call Emergency.

There is an emergency in the rural unit.

"But doctor, there's no phone."

Caruaru 02/17

Mayara Floss 

Undergraduate student of medicine at Federal University of Rio Grande (FURG) - 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.

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…

-----------------------------------------------------------------------------------------------

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 ...

-------------------------------

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.

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.

Fresia - Story of a Mapuche Women

   

Imagene: La ruca (Vivienda Mapuche)

Dr.Rossana Betancur Escobar 

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

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

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

                                     ... Same time my partner left ... 

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

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

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

        My daughter left me in a chair. Waited to be comfortable and said  "Mommy, I have to talk to the doctor" ...
   
         After a while she came back by my side ... I do not know why, but I felt that she had cried. But I did not want to ask her. “They  can not operate because you are very thin ...”. “Well, dear, I told you ... it will be a long wait”.

       We were in the micro bus to return to our house with my eyes fixed at the window ...
 I remembered how my children were born,I attended my sick mother,left her house to follow my partner,told my children that they will study because I was not going to stay for sowing... and now I realise that they are my seed.

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

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

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

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

**Machi: Local folk healer

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

Author:

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



Spanish version
Fresia

Imagene: La ruca (Vivienda Mapuche)

                   Mi nombre es Fresia. Soy mujer,mapuche,tengo 68 años. Pertenezco a  una comunidad rural, hacia la costa. Mis ancestros son  de origen es lafquenche.Vivo junto a mi hija Rosa.Ella es la menor de de mis hijos.Tuve  4…los demás ,varones,salieron a probar suerte a Santiago…por allá formaron familia.Hace un año volvieron,con sus esposas y  mis nietos,construyeron sus casa junto a la mia.

              Un año y medio atrás,mi salud decayó.No me sentía muy bien, estaba sin valor, ni fuerzas para ir a vender mis verduras al pueblo, o alimentar mis animales.

                                   

                               …Mismo tiempo que mi compañero partió…

                  Rosa se empezó a preocupar.Me llevó donde la machi y ella dijo que sería bueno que fuera al médico ,pero que antes hiciéramos una ceremonia para sanar mi espíritu , que quería irse a otro ladoFuimos a Carahue.Que raro se veía todo…No recuerdo mucho que me dijeron, solo que tenia que hacerme muchos exámenes. Uno de ellos muy desagradable, un tubo por  laboca.De antes ya no quería comer,después del examen hasta vomité.Volvimos a la casa, con mi hija…calladitas.

                 Al tiempo ,le entregaron una hora para Temuco,donde otros doctores.Meexaminaron.Me  dijeron que era un cáncer, en esófago …yo lo único que me fijé era en la señorita al frente mio que se ponía la mano cerca del corazón…ese que me dolia tanto, hace tanto tiempo.

                 Mi hija me dejó en una silla..”espérememamita,tengo que hablar  con el doctor”…Al rato estaba de nuevo  a mi lado…no sé porque sentí que había llorado,pero no le quisé preguntar.”Mamita el doctor dice que no se puede operar, porque está muy flaquita…Bueno hija, le dije…tocará esperar”.

                   Ibamos en la micro de vuelta a nuestra casa, con la mirada pegada a la ventana….recordé cuando nacieron mis hijos…cuando atendí a mi mamita enferma…cuando dejé su casa para seguir a mi compañero….cuando le pedí a mis hijos que estudiaran porque yo no me iba a quedar para semilla…y ahora me doy cuenta que ellos son mi semilla.

                   Noches atrás, fue la mashermosa.Mi hombre, en sueños me vino a visitar…”Fresia no me sigas, tienes que volver a los doctores, tomar buen remedio y engordar.Aun haces mucha falta a los nuestros…Cada vez que tu me necesites, a tu lado estaré”….

                  Aquí vamos de nuevo…a Temuco.Me van a hacer quimioterapia, dicen que es para que el tumor achique.Pero antes tienen que poner una manguera, esta vez por fuera de mi guata, para que pueda alimentarme.

                  El regreso a casa hoy es diferente…me siento contenta..miro y me encuentro…he recuperado quien soy…SOY FRESIA…Y AQUÍ ESTOY.

Author:

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

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.