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.

     

Newer technologies and rural health

With new updates in world of bioengineering many firms are introducing various patient friendly gadgets which help them in monitoring of health issues. But in most of the rural areas these techniques are beyond reach. Reasons could be cost, literacy rate, education level to monitor them, maintainace, service centers, easy availability etc.

                But a primary care physician can judge the need of such techniques well for community. These can bring a welcome change in community health services. He/she should try to search and use them for improvement of rural health. Urban or rural good patient health care should be the aim of every primary care physician.

              Today I will share my experience of one such technology came across few months back. It’s named as Continuous Glucose Monitoring System (CGMS).This is a new technology in market for monitoring of glycemic control of patient over period of 14 days continuously without causing much discomfort to patient.

            I got introduce to this during one of the workshop I attended. One of my colleague there who was type I diabetic using it smoothly to control his glycemic variables. I quite liked that so I searched for the company that provided that in India. My main hurdle was my rural back group .To convince marketing fellow was a task as he was bit reluctant to come to our place, share a demo and training.       I assured him that I will personally take him to the venue and arrange transport. Then with lot of yes/no he agreed. One more (?) Bribe I offered him was discovery of an undiscovered market place which will help him in his promotion. That clicked well to him I guess. :-P.

          We got our demo and I soon mastered the skill. We now have used it on more than 7 patients and it really helped them in their treatment plan modification. My patient range was also variable /we used it in post CABG, post angioplasty, uncontrolled diabetic patients and brittle diabetes cases. We got excellent details from that monitoring. We also ask patient to keep a food consumption chart to correlate readings of glucose levels.

 We document hypoglycemia unawareness, false alarms of hypoglycemia/

Hyperglycemia, Dawn’s phenomenon. With these variables we could modify there treatment plan and make their life bit stress free as symptoms are gone or in control. This time we know a concrete reason. The patient satisfaction was immense.

          CGMS really document it better and helps in monitoring of glycemic control. We even saved one patient who was having recurrent severe hypoglycemia and need of Insulinoma workup. With careful history, glucose monitoring and treatment adjustments things are in control, major operative or multiple investigations and psychological stress got saved.

           The only factor that hampers its routine use in rural population of India is cost of device. But I am hopeful in near future it will come down.

              In primary care one should learn to balance technology and its need as treatment option. We should not depend too much on them. Clinical judgment is a priority. Additional tools like these should be used to improve clinical outcome.

                                

Releasing soon "Common Problems in Geriatric Women"

Dear friends,
      We Sukarmayogi Publishers,Sankeshwar,Belgaum are soon releasing our next book  "Common Problems in Geriatric Women" by Authors Dr. Subhash Nikumbh and Dr.Smruti Nikumbh-Haval.
         The book discuss the various problems a lady face in her geriatric age.The format is suitable for for both common public and medical practitioners.
          The cost of book with postage is 200/- and can be purchased at rural cme with rs.150/-.Looking forward for your warm response. Good day.

High blood pressure? What's that?

            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 loosing a battle as doctor with a businessman but was determined and with God's wish I took the challenge to treat him as out patient ambulatory care.
             Sometimes its better to take calculated risk and treat patients rather than loosing ans send for more doctor shopping at the end lose a life.I did his E.C.G. no major changes of MI was 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 prediabetic 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 wont follow.He  LOL my advice saying doctor I don't like sweet.its 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 hypertensives 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 has begin again and this time chest pain was more severe in intensity.this create a 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 Centred 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.
         Its good at times to black mail patients emotionally for there own benefit.I scold him but same time made him realise 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.Its 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 thee 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 counselling,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.

Project Kamal early screening of hypothyroidism & treatment – A determined journey for wellbeing of community

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, 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 there status as whether they are hypothyroid or hypothyroid, what is best treatment for them 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 7 patients enrolled and utilize our services.              

             To improve adherence of patient to the treatment I planned a package Project Kamal membership. We kept nominal fees for this of Rs 50/-. As if kept free no one realize its importance. After membership patients will get 20/- concession in fees for 10 visits with Rs.50/- concession in thyroid function test results and one additional concession to the baby’s TFT if mother is pregnant and delivered baby in our set up. Like this many more rewards patient will get via their membership.

               We are also in process of starting a Project Kamal thyroxine bank where member patient will 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 25 + ladies with hypothyroidism and 4 members to Project Kamal. Numbers are small but this is just beginning. I hope almighty will give us courage and strength for successful implementation of this activity. Thank you.

Rural primary care physician- By choice?

                            Many people ask me how and why you become a rural primary care physician? Is it by choice or a circumstantial decision? So to get answers to these questions let me share little bit of background of mine. I Dr. Smruti Subhash Nikumbh now known as Dr. Smruti Mandar Haval is a daughter of Dr. Subhash K. Nikumbh & Dr. Usha Nikumbh. My parents are specialist in their own subjects (Obstetrics Gynaecology & Ophthalmology) respectively. They are practising in area named Chalisgaon, Dist Jalgaon a town with population of 1 lakh to 2 lakh now with a good rural area surrounding it. When my parents started their practice 32 years back the population was round 40000 and most of the patients used to be farmers, poor daily wagers with not so good paying capacity. Most of the consultations used to be charity service. The connectivity was also poor then to the town. Patients used to come on bullock cart, cycle, walking. Ambulance service was a fancy thing. Maternal and child mortality was a regular thing. Laboratory facilities were in very primitive stage.

          With so many challenges my parents started their practice and with their good clinical judgement they managed to improve overall mortality and morbidity of patients from that area. Health promotion and awareness was always a part of their consultations. Since childhood I have observed there moves - conservative approach, no unnecessary surgeries, IV fluids, antibiotics abuse as that of today’s era.

                This entire thing nurtured a family physician in me and I learnt to live with people of golden heart. This journey with my parents generate a kind of liking in me for rural health, it’s up liftment, challenges.

              With God’s grace and wish I got family medicine as my post graduate course and carrier. Also I got married to a man who has his work place in a small developing town of population 50000 -60000. For me this new work place is like my own home town  15-20 years back. After looking back at my 2 years of journey of rural physician I feel my challenges are same as of my parents but I love my job as patients I deal here are same as of my childhood pure mind, golden heart with lots of faith in me. They do feel I have healing hands. Their trust act as placebo in my treatment plan.

                For my residency & undergraduate training I have stayed in urban and metro areas. Those 10 years taught me how urbanisation changing human psychology. There I mate various types of patients like Google masters, self-diagnosis specialists, doctor shopping freak etc. This work culture was just not suitable for me. May be I was still a country side gal. Hence as soon as I finished my studies I decided to come back to my roots the rural practice.

              Here I diagnose patients with minimal investigations, cost effective medicines, no much branding of pharmacy companies. This job gives me lots of satisfaction of work and my dues are getting clear slowly towards community I live. I also run few projects or schemes to improve treatment compliance of my patients to their long term treatment.

These schemes are

 1)    Project Kamal Early screening of hypothyroidism and treatment

2       2)   Diabetic Mitra Live healthy with diabetes

          3)SurekhUsha Kavach Early screening of cardiovascular diseases and treatment

             In these activities we charge patient nominal fees and make sure that they will receive best discount on each visit, investigations done by me. Slowly & steadily I am working on up liftment of health of my community.

                 Being a female I can relate well with both male and female patients. Female patients open up about their problems much better & clear so with that I can help them in best way.  I am a proud # Rural Female GP by choice and I am loving it. Thank you Almighty for all guidance & strength.

The dual challenge- Pregnacy with GDM & Hypothyroidism

           This story I have pen down today is about Mrs.P a young lady of mid twenties age.She is a known case as hypothyroidism and on regular treatment. In fact her hypothyroidism got diagnosed during her  work up of infertility.With meticulous follow up and treatment she managed to conceive.(It is a painful journey so far as she meet me every month  with blood report -  poor lady is tired of same).But now she is a pioneer member of Project Kamal and inspiring many more for a good fight against hypothyroidism).
           All was good till one fine day her husband called me and asked for an appointment .Her 7 th month was running and she was suffering from sore throat,joint pain,fever with chills,pedal oedema etc. The joint pain was so severe that it was refraining her from doing her day to day activity.I ask him to see me earliest.Its been an slightly emotional call as I know this couple last 18 months and have seen there struggle quit closely.They are very humble,obedient and compliant with what ever treatment has been offered to them.
           As per schedule she came to my OPD and I did her assessment.Clinically she was suffering from acute pharyngitis with viral fever.She told me these symptoms are there from 4-6 days and she seek treatment for same from a near by doctor who gave her two injections (?) followed by which she had dark coloured urine for 2 days with little relief.We advice her few basic investigations to work up fever cause.
         She came back after 2 hours with them and to our surprise her urine was showing 3 + glucose, her RBS was 348 mg/dl ,Hb has dropped and urine was showing few pus cells.This was a big news as all her last investigations were absolutely normal.To  confirm the findings we probed her more on family details and we got to know that her father was a diabetic and died few years back because of diabetic complications.Her paternal aunt and elder sister are diabetic.So a strong history of diabetes support  current results.
             She got nervous, anxious, emotional all at same time and started crying as she smell that something is wrong with her investigations. The husband and I some how counselled her that no need to worry lets fight the battle.I told her that she is on verge of a disease name Gestational diabetes mellitus a type of diabetes appears during pregnancy and there is treatment for it if she co operates as she always do. She some how mange to balance her emotions and told me please go ahead and confirm whether its  really there in her as  she was really tired of fighting this pricking & draw blood business!
           I did her Hba1c in my OPD and that reading too came 8.4 %.I was  not so convinced with that result as her Hb was also low so there were higher chances of bias or increased reading.We also cross check her urine sample for glycosuria as on dip stick we got 3 + glucose but on Benedict's  test also the urine colour came brick red the same colour I  have seen in my biochemistry classes!
           We admit her control her sugars with MNT and insulin therapy.Her infection has been controlled with intravenous antibiotics. Throughout the process  pedal oedema remains with fluctuations but her BP was normal and no investigations suggesting help syndrome.Now things are under control and we are hopeful for a healthy out come of pregnancy.
           The lesson I learnt from this case is importance of detail history taking ,screening high risk pregnancy and MOGTT in second trimester. Tests like MOGTT are bit costly,time consuming hence not so popular test or investigation in most of the parts of rural India.
             But the primary care physician and obstetricians can use simple tests like 50 gm oral glucose challenge test which is less time consuming and good screening tool along with random RBS. This may help to pick up the DM early in pregnancy as India is one of the capital of diabetes and diabetes is fast treading disease.
              Many guidelines have shown that South Asian females are more at risk of developing GDM hence there early screening is very important. HbA1c can also act as a good tool but in Indian rural scenario  under lying anaemia is a hurdle.Through Diabetic Mitra project we are trying to improve this situation and hopeful that Almighty will give us healing hands.Thank you.