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.

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.

Neither burden nor feather

André Silva

This post was originally wrote for the Brazilian Blog of General Practice: “Causos Clínicos”

Attention: The following personal essay is based on a real case, but all names are fictitious. Further, all the story elements occurred in different situations. I saw main story with a wire of my life story. In this patchwork some details are older, some newer. But all are thea background of memories and heart.

As a suggestion please listen this soundtrack to read this story, this is the playlist that I listened when I wrote it. They are songs that made me smile, cry and touch as human in my vulnerability. Good reading!

AppleMusic

Spotify

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 -   You're kidding me! I do not believe in you !! This is absurd !!

I heard the shouts at reception, a woman's voice. All while I was talking to two undergraduate students in their final year of medicine. They were preparing to meet the last person in the morning at that Thursday autumn. It had up a music of Enya which the resident had said that she was fed up of listening it.

I'm going to the front desk, and I come across a lady I had met three weeks ago, Mrs. Matilde. Skinny, black, with hands punished by time and hard work in the fields and at home in their seventies. So slight that it was hard to imagine that she had four children.

-          Doctor, why are you doing this to me? - She said almost in tears.

As she screamed, a short film went through my head: the diagnosis of HIV for more than month and she denying it. The case discussion with the nurse and the difficulty to make her understand. And those cold data on paper: 14000 and few viruses per mL of blood, 350 leukocytes type CD4, numbers that leave no doubt, but Matilde only increased her anguish.

I almost as a reflex, call her to the office, the same that had Enya as background music.

-          Doctor, I couldn’t have AIDS, I am with no man for over 30 years since I husband had died, I did not take blood... what will I become? How much life do I have?

       I ended up stopping the music. I thought it was worse, because it was possible to hear the strained breaths of both students, Bruna, Pamela, and my own.

-          Mrs. Matilde, let's talk calmly. I'm here to clarify all your doubts.

-          Doctor, I'm not with a man for over thirty years, my life was taking care of four children, and just now I met my first granddaughter. Look, you need to wash the chair where I sat, so people will not be contaminated when sit here! – She was sobbing, already standing.

"Hard to believe that today there are still people who think that HIV is transmitted like this." - I thought in my smallness. "I need to act fast, accurately and undressing of my prejudices and my fears."

I turn on the music again. I ask Mrs. Matilde to sit and breathe deeply with me. The students in the corner observing were seedlings.

-          Mrs. Matilde, the main point now is not where this virus came from. What matters is that today we have treatment and we will always be here to care you.

-          But doctor, people will not be able to get closer to me and ...

-          Mrs. Matilde, please give me your hands.

-          But but...

-          Mrs. Matilde, give me your hands. Let's go. - I speak with her more firmly.

I welcome those skinny little hands, and look at that old lady with a scarf on the head.

-          You see? We don’t get HIV like this? Can you see thaat you don’t need to be afraid? You still could play with your grandoughter.. You just need to slow down. You will be able to take the medicine and live quite yet.

-          Doctor, you have the age of my grandson. Aren’t you lying to me, right? I'll even be able to continue to come here, sit in this chair and be cared by everyone here at the Health Basic Unit?

-          For sure, Mrs. Matilde.

-               And I can get my granddaughter on my lap?

-               Of course.

-               And could I hug anyone?

-               You can even hug me, Mrs. Matilde.

Them, the lady opens her arms and wraps me in a hug, weeping. "Thank you," she said. And a new film goes through my head, my poor childhood, the youngest of eight children, the causes and conditions that led me to medicine, family medicine, for living the distance of five thousand kilometers of the city where I was born and raised. The miss of my mother, that great friend the lives over thirty years with HIV, that another friend who has been diagnosed recently, the fragility and richness of this phenomenon called life. And drops a tear inside my being, while I hug that little person.

-          Doctor, so I'm going, much more peaceful. I do not want to take you time. I can come tomorrow with my daughter for you to explain to her how it will work from here on?  The exams... medicines...

-          Please Mrs. Matilde. We will be waiting for you.

  And Mrs. Matilde leaves the surgery, light as a feather. I observe Bruna and Pamela thrilled.

-          Professor, how beautiful was this! But we have a question: a doctor at the hospital told us once that we should never hug patients, neither in private practice, because "gives a lot of freedom" for the patient to ask for more and more things, and it becomes a burden. Do this mean that we can hug?

"I need to be careful with the words," I think as I remember the zeal I learned to have when I do ikebana, those Japanese floral arrangements.

-          But even ICU doctors say that touch helps, what about us, family physicians, doctors of people, of lives, stories and emotions? Hug is therapeutic for patients and for us. And I imagine you have had a good example just now.

-          Undoubtedly teacher. We will bring it to life. Thank you - tell the students at the same time.

So I say goodbye to the students and I'm thinking about it at the office. The clock mark midday, lunch time. I look at the picture of “Lord”, my dog that died few months after 14 years of affection, and I am there, absorbed in my thoughts, in my longing, in my tears, in a vacuum. Moreover, remember Master Dogen, an ancient Japanese Zen master, who said that our practice in life should be "no gain". I think it is. Only family doctor, of people, of lives, stories, emotions. Without any gain or burden, nor feather.

Several months later, after comings and goings of Mrs. Matilde she is "very well". When I was doing another ikebana before dinner during a retreat as I finished the floral arrangement, I remembered Mrs. Matilde and what it means life: a breath, a flower that blooms and withers, a force, the bird flight that leaves no trace, a moment. And ikebana was like this picture. I am grateful to you, Mrs. Matilde. And I found myself not burden nor feather.

_________

André Silva is a Family physician in Brazil and works in a Rururban area located at Porto Alegre within rural characteristics with local creation of animals but the influence of urban problems like drug dealing.

Non indigenous "disease" x Indigenous "disease"

Video with the testimony of Lucíola Inácio Belfort the first Brazilian Indigenous Kaingang to be graduated at medical school she is woking at SESAI (Special Indigenous Health Secretariat) with indigenous communities. She also is a nurse and she is working  on the ground. This video was recorded during the "1st State Seminar of Health of Traditional Communities: indigenous and Maroon - Rio Grande - Brazil‏" ("I Seminário Estadual de Saúde das Comunidades Tradicionais - Indígenas e Quilombolas " - http://www.sinsc.furg.br/site/isesct/ ).

Struggle for health

 

Samir Lopchan

58 years old male from Khung-1, Pyuthan came to our OPD with complains of fever for 2-3 weeks, pain in right side of chest with productive cough. He also had loss of appetite and loss of weight. On examination his temperature was 99° F, pulse rate 92/min and BP 110/70mmHg. On chest examination there were decreased breath sounds on right side of chest. Other examination was within normal limit.

Blood investigations, chest X-ray and Sputum for AFB (for PTB) were ordered. TLC 15,500/mm3 (N73L26E1), Platelet 3,70,000/mm3. Chest X-ray showed opacity in right lung with air-fluid level suggestive of hydropneumothorax/ pyopneumothorax. 

To make sure what is inside I aspirated with a syringe and got thick pus, so the diagnosis was made Pyo-pneumothorax (collection of pus and air inside the lung). For definite treatment the pus should be drained with a pipe inside the chest, it’s called chest tube insertion and drainage and intravenous antibiotics. We all know that ideally money shouldn’t be the issue between the patient and the health worker. But he had only 1-2 thousand rupees with him. This is how most of our patient comes to the district hospital. It is the scenario of every government hospital in rural areas. He even didn’t have any family member to accompany. He had come to hospital thinking he will get some tablets and cough syrup and he will return back. We told him about his condition, what needs to be done and asked him to call his wife to come to hospital. He said, “She has to stay home to look after home and the cattle.”

After taking informed written consent, we gave him Inj. Cefuroxime, Inj. Metronidazole and under local anesthesia, we inserted a 32 no. chest tube in his right chest. A gush of thick pus came, about 550ml of pus was drained and it was attached with a bag with water seal. He was admitted under Inj. Cefuroxime, Inj. Metronidazole, Tab. Levofloxacin, Analgesics, Aciloc. Later his sputum report came which showed positive for pulmonary tuberculosis, so Anti-tubercular drugs were started. 

He couldn’t afford the treatment so we did all for free. If we have had relied only on government free supply we wouldn’t be able to manage this case in a district hospital. Chest tubes aren’t available in most district hospitals. Many antibiotics don’t come under free supply. And if we had referred him outside the district either he would have returned back home or he had to sell his property to arrange money for his treatment. I had bought chest tubes, water seal bags from the NSI (Nick Simons Institute) GP fund, few medicines, tapes, sutures from my ‘Poor patient treatment fund’ (for which I collect donations from various kind-hearted donors) and got some medicines from NCCDF (Nepal Critical care development Foundation).

After 3 weeks of treatment, he improved a lot, most of the pus was drained but the entire lesion was not clear. CECT chest was the best option to see the extent and detail of the lesion and obviously a cardiothoracic consultation. But for that he had to go out from the district and he didn’t have money for that and he was not ready for that. So we discussed the situation, explained him and took out the tube and discharged him on Anti-tubercular drugs and other medicines. I know this isn’t the world’s best treatment what he got. People may say why you didn’t do pus culture, why you didn’t do CECT chest to see lesion, why didn’t you send him for the CTVS consultation, what if he develops some complications and many things. But what I am confident about is what I did is the best in this situation, what I did is the best any doctor can do in this settings. We knew that we had limited resources; we knew that we were less specialized. But everything was well explained to him and it was a joint decision to do the best in that situation. This is how we are giving our service; yes definitely compromised, may not be according to the international guidelines, may not be satisfactory to the super-specialized doctors but it is definitely stuffed with lot of warmth, devotion, dedication and right to the situation and settings.

Sometimes we have to act out of our profession and do something extra to provide health service in rural areas. I want to thank NSI, NCCDF and all the donors who believed in me and my work and helped me and my entire team.

 

__________________________________

Name of the author- Dr. Samir Lama
Brief Description about the author- MD General Practice, working at Pyuthan District Hospital, Nepal
Area of practice- MD General Practice, I see all general cases and do surgeries mostly LSCS, appendectomy, hernia, hydrocele.
epidemiology of your area in brief- Mid-western region of Nepal, hilly area, difficult in transport, nearest referral center is 4-6hrs long drive through the hilly roads.
Introduction of your rural health story
Conclusion
Suggestions for strengthening rural healthcare and Role of WoRSA

High blood pressure? What's that?

 

Dr.Smruti Mandar Nikumbh-Haval

           It was a busy weekday evening OPD. Various patients were pouring with their multiple problems. I was helping everyone with my best capacity. And then came this middle aged gentleman. Mr. X 40 year old shopkeeper and a known face of the town. He was all OK no complaints as of but slightly panic. Reason a G.P. told him his B.P. was very high. He need lipid profile (?) and physician urgently as his B.P. was 180/130 mm Hg. He went to him for a casual OPD visit of cough and cold. In past he has only faced fatigue, vague chest pain, sweating on and off which was normal according to him as he is on field for work most of the time.

          It was an emergency and need admission preferably intensive care. So many complications came to mind intracranial bleed, MI, target organ damage etc.

         I first noted his B.P. all over again. It was still 180/130 mm Hg. Frightening as I know my resources were limited especially in late evenings as all OPD referral options get close by then at district level. Only option remains is emergency room but this fellow was not ready for admission as next morning he has a big consignment delivery order to handle.

           Human nature money is more important than health. My grandpa always says "Sar Salamat Toh Pagadi Pachas" means health is sound rewards are awaiting for you. Health is wealth.

         I was losing a battle as doctor with a businessman but was determined and with God's wish I took the challenge to treat him as outpatient ambulatory care.

             Sometimes it’s better to take calculated risk and treat patients rather than losing and send for more doctor shopping at the end lose a life. I did his E.C.G. no major changes of MI were there but left ventricular hypertrophy changes were there.

        I gave him usual instructions of salt restriction, diet modification, rest etc along with suitable anti-hypertensive medicines. Also warmed him to come to me for follow up next day as advised.

        He agreed as I was not spoiling his next day deal. We had few periodic sessions of regular follow up and things settle down. Eventually we did his 2 D Echo, TMT to my relief it came normal. We also gave him prophylactic aspirin keeping his lifestyle and high risk nature. He was found to be pre diabetic range with HbA1c 5.9.His father is a diabetic so told him relevant advice in terms of lifestyle modification which I was sure he won’t follow. He LOL my advice saying doctor I don't like sweet. It’s that I am a jaggery sell & dealer during my stock purchase I have to eat it as part of my bread and butter. Nice excuse that was. :P

          We worked as team for next few months & things were under good control. We tried step down therapy but his body was more hungry for anti-hypertensive so we have to maintain 2 drugs with him.

             But after couple of regular visits he disappeared again. I sent so many reminders personally, through friends but he did not turn up for 3-4 months. Till one fine day he came as his old symptoms have begun again and this time chest pain was more severe in intensity. This create panic in his family. His mother and adolescent son brought him back to me. I assessed him. We were back to square one with B.P. 180/130 mm Hg.

               It was my turn to get angry bird now as he had stopped all medications 3 months back due to some family problem and was under assumption that now things are under control. I felt very bad as his old age mother and son was accompanying him but he was so careless for his own health.

I learnt a family medicine principle all over again Patient Centered Care. I was a religious follower of same but this time I forgot to stress on one important element of it - Role of Family and Friends. So vital it was.

         It’s good at times to black male patients emotionally for their own benefit. I scold him but same time made him realize if he still want to take care of his parents in old age, don’t want wife to get widow in middle age and son to lose school education and continue the family business he has to stay healthy. Health is real wealth. It’s not maintenance free you have to take care of your own health. This scold gave him a insight I felt. As I can see his heart weeping silently. Some after load reduction.:-).

            He promised again that he will remain compliant this time onward. Lucky he was as there were no fresh changes in his E.C.G. fresh changes.

            Gradually his B.P. came down, aspirin worked for his chest pain and other cardiac evaluation came normal. But his HbA1c has increased to 6.2. Now his journey towards diabetes has begun all thanks to his own negligence. Ironically this patient's younger brother is also a hypertensive but except once he never came for follow up.

           From this case I learnt that good counseling; compliance won't work long term if we don't involve family and friends in long term management of chronic diseases.

           With my Project SurekhUsha Kavach we try to improve life of many such Mr or Mrs X,Y, Z. It cost 1% knowledge at times and 99 % human emotions in treatment of chronic diseases. Awareness campaigns against hypertensive disorders are very much essential as common man need to know about importance of blood pressure control, regular treatment and complications associated with it if ignored. Thank you. Almighty bless us all.

___________________________________________________________________

Brief Description about the author
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 young couple and their fight with stigma of infertility

 Dr.Smruti Mandar Nikumbh-Haval

About a young couple and their fight with stigma of infertility

              Hypothyroidism is a kind of under diagnosed disease in rural area unless or until it reaches to the goitre stage. Biochemical diagnosis is an easy way to diagnose it in early stages. Good and reliable labs is a big challenge in rural area.
              Mrs. Patil is just one such patient for me.She was dealing with her primary infertility 2 years post marriage.She and Mr. Patil are a happy go lucky couple where Mr. Patil  is a project manager where Mrs. Patil  is a house wife .
             Before coming to us in month of march Mrs .Patil was suffering from sudden onset of weight gain ,irregular menses,change in voice,facial puffiness,lethargy,depressed feeling - all classical symptoms of hypothyroidism but due to lack of knowledge about it she never approach any doctor.
              Irregular menses was a regular complaint for her since menarche but no one ever investigate for her actual cause.Afraid of developing neck swelling and changed voice she approached my mother in law who is a practising OBG consultant and a generalist practitioner too.In rural area female patient still prefer a female doctor as they find more comfort with them.
              We at Rukmini Hospital,Sankeshwar diagnosed many cases of hypothyroidism in last one year as we find few symptoms are hypothyroidism are very common in this area.
              But Mrs. Patil  was a classical case hence she immediately ordered a thyroid function test which showed her TSH > 150.
             As I deal with many hypothyroid patients now post my successful CCMTCD course from CDI,Pune my mom in law send her to me.The couple was very anxious when they mate me as they saw a young doctor sitting next to them.They were in doubt whether to continue with me or not as one of there fear was we practice in a family set up.Just to retain patient in set up my mom in law sent them to me.
            Appreciating there anxiety I stated my discussion with them and made them understand that its not a major disease but if we don't treat in time it can cause some complications .Also I  made them understand that what ever symptoms she is suffering now are all because of hypothyroidism and once we correct that with thyroxine they will reduce.
           We started her with 100 mcg thyroxine daily and advised repeat follow up TFT after 8 weeks.After 8 weeks her voice was clear,facial puffiness was gone and her weight has also reduced but menses were still absent.We did few modification in dose and decided to wait for another 2 months as HP axis may take some time to adjust but still amenorrhoea persists.
           She happen to mention then that she usually resumes menses only when she used to get hormonal supplements from experts for same.Then I thought of PCOS and refer her back to OBG consultant to rule out PCOS  and hormonal regulation of menses along with ovulation induction if indicated .To God's grace she did not have PCOS and  responded well to HRT and ovulation induction.She is carrying now and hope will deliver a healthy baby.

Conclusion:
         Take home message I learnt from this patient is patient education,counselling and in time diagnosis is very important.Only treating the symptoms superficially is not the only thing but going to the root cause is equally important. If prior physicians would have thought of hypothyroidism in her adolescent age she could not have reached this stage of severe presentation. Every patient is a new lesson to learn which we may not be able to learn in our medical school.
       At last thank you almighty for giving me transient healing hands and power to counsel, educate patient correctly. Also I am thankful to CDI team for teaching me right principles of management of thyroid disorders.:)  

Suggestions for strengthening rural healthcare and Role of WoRSA:To create database or educational materials this will help primary care physician in rural area all over the world in awareness of about hypothyroidism. Our south East Asia belt is more prone for this as our soil lacks iodine. Good regular biochemical and clinical screening can help to reduce its prevalence.WoRSA can grant some screening programmes in rural area to improve rural people’s health.

___________________________________________________________________

Brief Description about the author-
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.

Life..Just before Death..But not Less

 Dr Sonia Singh

Hello friends,  I am Dr Sonia Singh, in charge of the multi drug resistant tuberculosis (MDR TB) ward at Indira Gandhi Institute of Medical Sciences in Patna.

I would like to share my experience about MDR TB patients who have the right to get treated and cured like other patients, but many a times they are devoid of their rights as a patient and as a human!

I write about a student of class 12. He acquired MDR TB infection most likely from the hostel. He was admitted in MDR TB ward and we started treatment after pre treatment evaluation. His general condition at the time of admission was fair so he tolerated medicines well. To our surprise, he was not accompanied by any family member or relative and he did not call them when asked. Finally he confessed that he did not want anybody to know about his disease else they might boycott him at every level; in the family, society and the school. We counselled him nothing like that would happen and that the family is meant to give all kinds of support at hours of need.

He had high blood pressures, so along with MDR TB drugs antihypertensives were planned. Then the patient said that he was afraid to see the nurse and we thought about the possibility of white coat syndrome. He was finally discharged after 7 days. We counselled him again; although he was suffering from a difficult condition , if he adhered to the drug regime he would be totally cured and would be a healthy person in the society. At the same time we advised him to use mask to avoid spreading infection to others. He left our ward happily and is coming for follow up in OPD along with his parents .The best part was that he continued to study throughout his stay in the hospital and was very much concerned about his future and career. (Picture: the patient reading a book )

I conclude my story with mixed feelings. When I was  appointed, my fellow colleagues discouraged me from joining such an infectious ward but my family supported me. They said being an FP I should not turn away from my duties towards society as MDR TB is a new threat to society.I read detailed literature about MDR TB and MDR TB wards and found that health professionals were prone to get infection. So I presented the design of MDR TB wards with adequate ventilation, Ultra Violet Germicidal Irradiation Techniques (UVGI), use of N-95 respirators and also trained nurses to work with full safety. Rest I leave to Almighty!

Some patients often complain that they are ill treated by DOTS-PLUS supervisors and counsellors. We approach them and request not to hate patients but to help them.

We also advise yoga, meditation, positive thinking, listening to music etc. to patients so that they are able to cope with tough situations of life with ease.

I know, it is not so easy but at least a full attempt should be give to Lives..just before death!