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.

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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.

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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.

Adolescent health challenge - Type 1 DM

Dr.Smruti Mandar Nikumbh –Haval

About a young boy and his journey with diabetes mellitus type 1

One evening when I was busy in writing for my next publication my father in law called me when is my next OPD day.He was dealing with a young 17 year old boy who approached him for his complaints of weight loss (8 kg in 3 months),polyuria,polydypsia,hair fall,easy fatigue and vague abdominal discomfort.He advised relevant investigations and to his surprise his random blood glucose was on higher side 456 mg/dl. Now that was alarming as we were about to diagnose a type 1 DM patient who was a adolescent boy.

Adolescence or teen age its a age of weird ideas,dreams,ambition of career ,sports, unpredictable twists and turns .But this was a life changing twist.

 That high value of blood glucose alert us to investigate him for diabetic ketoacidosis though he was clinically stable.To our relief kidney function was normal but the fasting and post postprandial values were high and HbA1C was 14.2 with glycosuria. He was having UTI and urine ketones were 3 +.

 Now the next step was encounter with the family and most importantly patient himself.As expected the boy was anxious,irritated and nervous about the whole thing.The emotion was clear on his face Why me?

  He was also feeling sad that now he has to give up his favourite sports.But on other side parents were worried that why there son only got this.Both of them are not so far known diabetic neither any close family relatives were  diabetic.

 It was quite challenging for me to handle so many emotions at the same time as a young physician with little experience in this. I set my conversation priorities and told parents that let us thank God that in spite of such a hight sugar he is not in severe DKA. But now we know the root cause of his symptoms now its time for us to work as team and create a strong path for his dreams and a healthy life.

  Parents were feeling sorry that they did not stopped him from drinking excessive sugar cane juice or eating lots of sapata. I told them not to feel sorry as its not the food gave him this stage but its his genetic body that lacks insulin to maintain normal homoeostasis of blood glucose.We can achieve this now with insulin only as OHAs wont work in his case keeping a strong future for him in mind.Slowly as they were understanding the base of the disease and the way they are suppose to tackle  their anxiety was reducing.

Now the next step was fright of daily insulin therapy and pain associated with it.I gave them pen device advice but they chose conventional one.The boy was very anxious as he was feeling like a gunnie pig.Not to forget he was a science student.:P. But this problem to got solved with my Favourite finger rules.That demo reduced there fear of insulin therapy and now one more hurdle crossed.

  This entire process was easy as he was a science student and parents were really co operative and receptive.We gave him lifestyle modification,relevant pharmacological advice.

I know I should have admitted him but his exams were going on hence admission intracath would have increased his stress followed by sugars.So we took challenge and told them warning signs.If any of them appears  to contact us.

 I reviewed him after 5 days.As I always like my patient coming back to me with a big smile.He was from that cadre. Reports were fine,sugars were improving.Most importantly he was feeling much better and his symptoms has reduced .He was trying to learn the art of insulin administration. This was just a beginning. Long way to go. I know I should have done investigations like C peptide level, GAD Antibodies etc but I have some resource limitations. But will get them done soon.

  This case thought me a lot about adolescent patient's psychology, there challenges.

Thank you Almighty for helping us diagnosing him in time and save one life from falling in trap of intensive care.thank you.

Finger rule: 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 facilitates 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.

Conclusion

This case thought me a lot about adolescent patient's psychology, there challenges.

Suggestions for strengthening rural healthcare.

To create database or educational materials which will help primary care physician in rural area all over the world in awareness of diabetes type 1 and its complications. Can arrange awareness and screening camps in schools and colleges.

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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.