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

Ruralices

Amber Wheatley and Mayara Floss

The experimental short movie produced by Mayara Floss and Amber Wheatley called "Ruralices" received the award for best original background at the FISFA - International Short Film & Arts Festival during the 15th WONCA World Rural Health Conference, New Delhi with voice of Amber Wheatley and the music of Lucio Yanel and sonoplasty by Mayara Floss.

"My first job as a junior doctor in South West Wales involves a 1 hr and 15 min journey by bus from my apartment in the city centre to the hospital in Llanelli. My colleaguess often commented on how difficult it must be because the public transport in Wales, particularly the most western you go, is notorious for having problems. Make no mistake this is absolutely true but it also provided me with two unique opportunities; 1) I took the same bus as the people living in the community so I understood all too well the issues of getting to hospital when you relied on public transport and 2) I got to watch the sunrise every morning as I moved from an urban setting to a suburban setting. During my commute I had more time than at any other point in the day to be alone with my thoughts and take it what was going on around me. I also used this time to catch up on reading, writing and social media. Before medical school I wrote songs and poetry in my spare time but medical school seemed to kill all my creativity. I was slowly starting to reclaim it when one day looking at a photo from the Ruralices instagram page, I was overcome with inspiration. Dr Mayara Floss started the Ruralices page to capture and share images of the daily life of a rural doctor. Each of the pictures I knew held a story and that story inspired these poems". - Amber Wheatley

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Amber and Mayara are Young Doctors and ambassador of Rural Seeds. They are committed and passionate about rural health, arts and writing. 

The children raising children

When it comes to rural medical practice in Uganda, one of the things that fascinates me is the alarming teenage pregnancies. This leads me to a story of one of my patients who came to the health facility I work in (Kapelebyong health center 4, located eastern rural part of Uganda), a 16 year old girl with her mother in law. (Yes her mother in law, its crazy!!) They came to the facility with the complaint of failure to carry pregnancy, ever since she got married 2 years ago (It means she got married when she was 14 years!!). It had been her 3^rd time miscarrying her pregnancy. And this time they decided to come to the hospital for guidance.

When I first saw them I thought it was a mother who had escorted their daughter to hospital for a consultation. But she spoke out and said this girl is failing to conceive. I was very disturbed, It was already running in my mind that this is a child and marital issues should not be in her mind. In fact by what I could see she needed to go to school or she needed to be in school. Her family had already handed her over as a wife to her boyfriend who is also 16 years but he was in school at the moment. (In this rural area boys are usually favoured to continue with their education because in their understanding when a girl marries she joins the other family leaving her old family behind, so any investment in her would be a waste of time!!)   This angered me more because I knew the parents probably made her marry earlier so as to secure a bride price mainly because of the financial situation they have at home.(Poor families are more likely to marry off their daughters earlier to get bride price and this is just so sad!!)

But given the situation it is a rural area in Africa where the community still thinks educating a girl child is useless because she anyway leaves the home and gets married into another home. And marriage comes with a bride price. 

Of course I advised them to come back to the facility the next time they get pregnant. Starting a battle with them and nullifying the marriage was out of my jurisdiction as a medical doctor in a rural area guided by cultural norms.

But this comes to the main issue, many children in the rural area I work in are raising other children. It is sad but I have seen girls as young as 14 years of age getting pregnant. Sometimes the mother and child come to hospital to give birth at the same time. And it becomes worse because by 20 years, most of these girls have given birth to at least 2 children. So you can imagine when they are 30 years of age? In fact by 30 most of the women have at least an average of 8 children!! This is really sad.

Of course as a rural doctor we have started outreach programs to schools encouraging children to remain in school especially girls. But it has come under a lot of pressure and still many girls are also being put under pressure by other girls (their own peers) who already have children of their own. They usually ask questions like, “why are you wasting time? Do you want to spend all your time in school?”

It is a sad situation but the trend is now showing that a young mother is more like to bring the sick child to hospital more often than an older mother.

It is a battle we are fighting quietly. I am really interested to know if this happens in other countries. Any one who can share with me what they are doing to save their rural girls???

Me with some of the rural children of the young mothers on an outreach!

SOME OF THE OUTREACHES ENCOURAGING CHILDREN TO REMAIN IN SCHOOL. ESPECIALLY THE GIRLS..

--

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

Simplicity

Fábio Schwalm

Home visit in the late afternoon
Hi Dona Ana, how is going the hemodialysis
She responds:
Well, at first it was difficult, I had a bad time ... now I'm fine ... I spend the four hours praying
while I pray
And eating?
Better now I can eat more
And how can we help?
She hold a list in her hands:
What is Damascus?

__

Fábio Schwalm is a Brazilian rural family physician. He works in Brazilian South in a city called Barão. He is learning to write and grew in a rural area working in the smoke farm. 

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…

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A love story 

Rossana Betancur Escobar

Image: The couple.

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

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

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

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

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

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

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





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

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

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

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

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

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

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

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

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

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

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.

Rural agony to smile

 

 Dr. Pawan KB Agrawal

       

We all are bound to experience pain at least once in our lifetime in one form or the other. The severity of pain is subjected to individual experience and determination to tolerate. At times the pain bound us to kneel in front of someone whom we expect to be powerful enough in a hope that we will be relieved. 

Being a doctor, determined to face the rural challenges to bloom a light of happiness in those desperate faces with excruciating pain coming across such helpless yet hopeful patients is a routine.We do grade pain but often we are not able to address the individual experiences adequately.Nevertheless we always thrive amidst our limited resources and destitution of our fellow patients to help them sustain through their difficult times and at times these turmoil carve a beautiful story to inspire courage and hope in a doctor patient relationship. 

A week back I had this patient 32 years in one of the emergency beds during morning rounds.Two hours earlier I was informed by my colleague medical officer about receiving him in agonising pain in his abdomen which started from his scrotum the previous day.The pain had started the earlier morning.Since there were no vehicles to carry him and he could not walk for three hours with the pain, helpless he prevailed throughout the afternoon alongside his ignorant wife and three small children not knowing what was awaiting him. 

Rather than taking him to a religious healer, they preferred him receiving care in a hospital. A wise and often rare scenario in most of our deprived areas where these religious healers are the only prospects.

With the dusk, some of his relatives finally fetched a jeep and a ride of two hours along the bumpy gravelled roads and finally landed him in our emergency ward. Whatever be the reason pain must not happen. This is what we often emphasize to our fellow medical service providers. 

He received some pain killers while he was being examined and investigated. We established the diagnosis of right obstructed inguinal hernia and explained the patient & his relatives that he needs to be operated as soon as possible in order to save the part of his intestine that had come out as hernia and had been stubborn not to go back.

We could not be sure though if the part of his intestine needed to be cut and repaired. As a general practitioner, a generalist, we are regularly operating hernia that goes in spontaneously but a situation like this where a part of the intestine might need to be cut put us in dilemma given limited instruments, anaesthetic expertise and post operative care. 

Another challenge poking us was his referral, a journey of 10 hours by jeep depending on a driver to the nearest higher hospital in Dhangadi,far western Nepal in case the patient party agreed. 

We explained and discussed the scenario with the patient party, scrutinised every option in details. It would have been best if we could refer him in an ambulance with a paramedic to Dhangadi. But it was yet far from happening. 

The turmoil of helplessness,poverty and health care resources in each of us endured the entire night and settled in the afternoon as we, doctors and patient party eventually concluded to put the situation on faith and proceed with surgery in our hospital. 

The patient party agreed that if surgery goes wrong or he dies,they would not raise any claim.A life was on our hands then.How could we not do our best and help him survive was a challenge. 

He was rushed into the operation room almost forty hours later.Together with another generalist Dr. Bikash who is also my mentor since I started working with Possible in Accham two months back.

We put him under spinal anaesthesia and took every precaution available at our disposal. As we explored, the faith or whatever we name it served us with a hope that the part of intestine might survive.It was almost on the verge to die, had we opened him few hours later or had referred him.The anxiety diminished with a sigh of relief. 

After he was shifted to the ward, we prohibited him to eat and had him keep on intravenous fluids.After two days we started with liquids and had him have usual diet on fourth day. He was then walking happily without pain and discharged on seventh day after we are pretty sure that the complication would not happen. 

Sometimes we do end up with a climax where a family turns upside down with an unexpected helpless death of the beloved on a hospital bed.But to our faith & the conviction of his fellow relatives,this time a life in despair was restored with balance and smile for his new journey back home with his small family.

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.