PHCC posting…

Our medical school has opted CBLE (Community Based Learning and Education) as a strategic approach to make its medical graduates ‘community oriented and advocates of disadvantaged’. (Why so? I will talk about that in my next blog). Recently we 4^th year students were posted in different PHCC (Primary Health Care Centre) of Makwanpur and Lalitpur district for our 6^th CBLE. I am sharing few of interesting experiences during my posting at Chhatiwan PHCC, Makwanpur.

First of all, villagers had wrongly received message that some senior doctors from Patan Hospital are visiting them. Thus we put on our card indicating “MEDICAL STUDENTS” and we introduced our self as same wherever required.

Government of Nepal doesn’t have adequate human resources. This was true in our PHCC too. A medical doctor with MBBS degree was supposed to be there but not even an HA(Health Assistant) was present. The PHCC was run by a team of motivated staffs leaded by a senior AHW (CMA).

There were some admirable tasks done by community. HFOMC (Health Facility Operation Management Committee) had established a laboratory where some basic investigations could be done. This helps up to some extent for right diagnosis and management. DPHO(District Public Health Office) had managed an extra ANM (Auxillary Nursing Midwife) as well. The 3 ANM is still not enough for PHCC services and 24 hour maternity service. Yet they are doing it. I highly admire their job.

Our PHCC was doing somehow fine(?) job for Family planning, Safe motherhood, Immunization, Reproductive health, Curative services etc. But a health facility with limited medications, inadequate lab, no basic facilities like ECG, X-Ray, USG (Video X-Ray) could hardy give proper care to its patients. There were many things unacceptable for me.

I found that patient safety was not cared at all. In the dressing room, the used instruments should be well sterilized. Do you know how is that done there? The instruments were washed with soap and tooth-brush, and rubbed with spirit before use. Amazing!! Isn’t it? An autoclave is not that expensive machine and is easy to use too. Unless it is managed, the instrumented can be boiled in water. But who cares?

Let me tell you, any patient visiting the facility with fever due to systemic illness were given treatment of malaria and typhoid both. Though it was an endemic reasion of these diseases, one of the diagnoses was compulsorily wrong and both might be wrong for some patients. They are receiving over treatment. People are receiving antibiotics not needed to them. Such practice will make organisms resistant to antibiotics we have, and we won’t be able to manage those disease because of unavailability of new antibiotics in future. I was not satisfied, but nothing could be done. This is how these health facilities run. And I was just a trainee there to understand how things are.

I also noticed that such centers are acting like non referral center. They refer very very few patients. Even patients with significant problem requiring visit to higher center were managed haphazardly. I feel that there is serious need to train these health professionals to identify RED FLAG SIGNS and get patients with those signs referred to higher centers.

I remember a patient of mine. An 18 year old unmarried lady visited me with some problem. Her problems were suggestive of Sexually Transmitted Infection (STI). But she denied having a boyfriend or any unsafe sexual activity. Urinary Tract Infection (UTI) was another differential diagnosis, but it was less possible and urine microscopy as well was not suggestive of it. Other investigations were not available. I got confused and consulted my supervisor, the AHW of PHCC. Do you know what he did? He gave medications for both the disease. This lady too got overtreatment.

You have to make a record of every patient, diagnosis and treatment in specified registers of HMIS (Health Management Information System). In the chart provided, COPD (Chronic Obstructive Pulmonary Disease), a respiratory problem, was kept under cardio vascular disease. I wonder how did the experts in ministry made such blunder and distributed all over the country.

During my posting at ANC (Anti Natal Checkup i.e. Medical and nursing care of women during pregnancy) I found that most of the women being pregnant for 1^st time were 15-17 years of age. It clearly shows early marriage in our communities. I asked the age of marriage to those mothers. Most of them answered 14 or 15. Along with smoking, alcohol and drug abuse, we are also worried about problems of premature sex in big cities of our country. But this is socially rampant in rural too. This is definitely going to adversely affect the heath of these mothers and their children too. I asked to all the mothers visiting me in ANC care room about their contraceptive use as well. Almost half of them replied that they didn’t use any, other half said that they didn’t need it because their husbands were in foreign. These examples clarify why our CPR (Contraceptive Prevalence Rate) is stagnant in below 50 % (Source: DHS 2011).

A really nice calendar like pamphlet is designed for pregnant mothers. Danger signs during pregnancy, delivery, peurperium, infancy and Maternal and new born care is well explained there. See  photo below. Since most of the patients are illiterate, PHCC staffs suggest those mothers ask someone to read it for them in home. I don’t think this is going to help. I suggest: the health facility staff should themselves read and explain it to the mothers.

Army officers, coming there for the security of different programs related to upcoming election were staying in new maternity building of the PHCC (not used yet). I remember our last evening there. We went to canteen for our dinner. Different varieties of alcohol are available even in canteen of the PHCC. Some army officers were drinking there and the whole canteen smelled really very bad. We waited outside for long, until they left. Smoking, drinking etc. is banned by Government of Nepal in public places like hospital. As always we have made admirable rules and regulations but failed implement it. I was many times disturbed by bad smell of cigarette as well, by local people (mostly female) even inside emergency of PHC.

Chhatiwan is large VDC. Providing health service to entire VDC is not possible by single health facility. Thus the PHCC runs other SHP in parallel. This is good step for public welfare. The government doesn’t has the provision of keeping two health facility in one VDC. Thus they have divided the human resource in PHCC for two facilities. Single health facility is enough in VDCs of hill with population of less than 5000 population or so. The VDCs in terai are comparatively larger with more than 10,000 population each. I think, running parallel institution, as done by Chhatiwan PHCC could be an option to solve such problem in large VDCs with comparatively more number of population. 

Thank You

The silent husband

Being a medical student in a public hospital is a huge luxury. Luxury in a sense that you can closely visualize your society with wide open eyes. You have the exposure to the real society better than anybody else. People from different community, different social backgrounds come with some interesting stories which can dig your brain, crush your emotions.

I remember a lady whom I met in night call during my obstetrics and gynecology posting. She was not so different case. She had classical symptoms of fibroid uterus which is benign tumor of uterus. Let me tell you, medical students are provided with a long list of question to ask with their patients. The question is about the symptom/problem, about medications, about problems in other uninvolved systems of body which patient don’t have any problem with but something missing can be found some times. And also some social, personal issues are asked along with ideas, concerns (worries) and expectations of patient.

While I reached to the social history, she told me about some of her family problems. She was married for 35 years. She has two sons of 29 and 24 years respectively. How it feels when someone special goes leaving you in trouble, in difficulty, in agony.  Leaving you alone to face it? I guess nobody knows the answer better than this lady. She doesn’t live with her husband now. Her husband lives with other wife (कान्छी श्रीमती). The torturing thing was- her house and the new house of the husband shared common veranda. That is both houses were side by side. And they don’t talk to each other at all. Imagine a lady, who sees her husband daily. The man she was married with, the man whom she gave 25 years of life (from the age of 14 to 39), the man with whom she shared some of the best time of her life, the man who assisted her during delivery of her two babies, the man whom she once thought would give all possible happiness to her. The same man lives in front of her with other woman and even talks to neither her nor the children. Imagine being hurt by someone who once promised to take care. Imagine the tear being brought by someone who promised to bring joy. Imagine the pain given by someone who promised to love… I wonder how she faces all this. And what had been the psychological effect of it in the children?? I, being a poor creature, can do nothing at all other than thinking, imagining, being touched, being hurt…. I think about days before separation. How those might have been? He must not have been able to ask for divorce at once. He must have opted to quarrel and fight in small issues, torture her mentally and physically, abuse by one way or other etc. in the topic of cookery, room, cleanliness, dresses and what not, hoping that she would herself get frustrated and ask for divorce. How patient would she have been in those days of distress? Let’s imagine that, one day she went too frustrated that she replied with anger, ”If you are this unsatisfied with me, or I am this unfit for you, why don’t you leave me?” Obviously, if anything like this was told, he would have happily accepted since he was waiting for it. And even more, how did he purposed or managed another girl to marry him? Did he say that ,"I have a loving wife, two dear children and I am not satisfied and happy with them for such and such reason, so marry me.” Funny, isn’t it? And how did she accept? How did she agree to stay in a home sharing common Veranda with home of previous wife and their children? I don’t know how things happened then. Things are simply unimaginable for me.

She is having a significant medical problem. She is going to have surgery (operation) within few days to remove her uterus, both the ovaries and fallopian tubes. And she is in huge economic problem but he doesn’t care. He is financially stable being in a good position in Nepal Rastriya Bank (NRB). But he doesn’t find it necessary to help his previous wife and his children by any means. How can a man be like this? Not only wife, he also ignored his own children who are growing up in front of him and he hasn’t talked to them since 10 years, just imagine the cruelty. Is the new wife happy with this?? I doubt. I have definitely talked to only one side. The husband also must have his own version of story. But I don’t think any justification would be enough. His wife is living separate alone and taking care of the children and himself living with other women. Isn’t he embarrassed anyway? He had a good job, a wife, 2 children and a home. This is more than required for a common man. What made him destroy his family??
He was not happy with his wife?? Ok that’s fine, but was those two children not a responsibility of him???

This story made me remember an incident in community posting during my 1^st year of medical school. In the last day of our community posting at Markhu VDC of Makwanpur, the rector of our academy, Prof. Dr. Neelam Adhiakri was there with us too see our last day presentation. I talked to her about a poor lady in village who had uterine prolapse (आङ खस्ने समस्या). I also talked how she is abused by her husband, how her husband hits her almost daily. Rector ma’am managed free treatment (operation) of her in our Hospital and also managed lodging and food facility for a caretaker (कुरुवा) whoever comes with her. Talking about the abuse, she said, “All the problems in society are created by males.” I was not satisfied to her. I knew she is talking in a feminist view. Yet I didn’t say anything, probably because she was a senior faculty of us, and even more because she managed the treatment for free to that lady. And I was very happy for that.

Today, after hearing the story of this lady who has such a cruel husband. My brain is again thinking, was rector ma’am right that day? Are male really cruel creature?? Is it us alone who create suffering for others??? Are we a creature with no heart and only selfishness (स्वार्थ)???? Are we, males the reason behind all the problems in society????? Probably not, but unfortunately our society has plenty of such people…. For which I personally can do nothing other than being unsatisfied with….

He might suicide tonight

     कुरै नबुझ्ने साथी-सङी र परिवार लाई छोडेर जादै छु ।
        बाँचनै नदिने यो स्वार्थी संसार लाई छोडेर जादै छु ।। 
   मुख मा राम-राम अनी बगलीमा छुरा हुदो रहेछ ।
           आदर्श छाट्ने यि ढोंगी अनुहार लाई छोडेर जादै छु ।।   

Photo: Google

This is starting lines of a suicide note of a character in one of my story (unpublished yet). Today I am talking about suicide. Specially about identifying the person planning to suicide, and what can we do for them? According to CDC (Center for Disease Control), suicide is the 10th leading cause of death. 1 million people attempts suicide every year worldwide and around 50,000 of them succeed/die. Remember, suicidal attempts are more in nights than in day. Suicidal attempts are about three times more in female than male. But successful suicide (not just attempt) is more in male by five times compared to females. Together we can spread awareness. Stand up and do take action. Start now. Things will slowly improve and finally will get fine.

Can we identify someone who is planning to cause his own death?
Yes, most often. First of all, we have to understand that every suicidal person is a human like you and me. He/She has the same feeling of sadness and happiness like we do. Currently they have something to worry, something to express, but there is no one to listen to them, help them, and stand with them. They are not able to ask for help though they want it, they need it. He do want not to die. He wants the pain to be vanished. He wants the suffering to come to an end. Yes, most of the people who commit suicide don’t actually want to die. They just want to stop being hurt. They must be suffering from something unbearable. They do want to get rid of it but they can’t see any alternative. They are in disgust, are hopeless, are in isolation, are in deep pain and they can’t see any escape other than death. And they mislead themselves thinking ‘suicide’ to be a permanent solution of temporary problems. Thus they choose to kill themselves. What can we do then? How can we identify them? Understand that, a suicidal person needn’t be crazy. Someone in extreme distress and emotional pain can anytime plan suicide. A suicidal person needn’t have any mental problem. Any person planned to suicide can be stopped. People planning suicide mostly give some clue. If you are able to understand the clue and take few steps, you might save a life. They may comment for being hopeless, helpless or worthless. They show anger at self, may have increased irritability, moodiness and aggressiveness. Mostly suicidal person have sudden and unexpected switch from being very sad to being very calm or appearing to be happy. If anyone uses sentences like “you will miss me”, "it would be better if I wasn't here" or “I have no way left” etc., we shouldn’t ignore such clues at all. Someone talking about suicide might not be just trying to seek attention. Take it seriously. A Facebook status indicating final ‘BYE’ doesn’t need your likes and comments. You need to meet them instead. Even if your interpretation were wrong, there is nothing to lose. So do stand up and take action.

How would we know if someone is planning suicide?
There might be some clear reason for pain or sadness. Some failure in exam, unemployment, economic problem and loans to pay, recent breakups or divorce, bad family relationships, family violence etc. can be the cause of suicide. Remember recent suicide by Bollywood star Jiya Khan, who explained break up to be the reason of her suicide, in her six page long suicide note. Similarly, patients of psychiatric problem like depression or schizophrenia, victims of physical and sexual abuse, an alcoholic or drug abuser etc. attempt suicide more than others. Thus these are alarming factors. If someone has attempted suicide earlier, be careful, he can again attempt and may succeed to kill himself this time. Recent suicide by a family member is also a risk factor. Suicidal usually lose interest in day to day activities. Do try to pick up such clues. Many suicidal talk about killing or harming themselves. They may write about death, sometimes even in social networking sites or so. They may bid a good bye through facebook statuses or telephones. They might be collecting things like rope, suicidal drugs, poisons, guns etc. to use for suicide. Talk to them about their problems. Deep sadness, Loss of intrest (दिक्क लाग्ने), trouble sleeping, eating getting worse etc. for more than two weeks are common problems in suicidal. If you find any of such clues, you need to be alarmed.

American Association of Suicidology developed a mnemonic "IS PATH WARM?" to help identify key warning signs for suicide-

• Ideation — Talking about or threatening to kill or hurt oneself; looking for ways to kill oneself, talking or writing about death, dying or suicide
•  Substance abuse — Increased substance use 
• Purposelessness (व्यर्थता)
  
• Anxiety — Anxiety, agitation, or changes in sleep pattern
• Trapped — Feeling like there is no way out 
• Hopelessness 
• Withdrawal — Withdrawing from friends, family, and society 
• Anger 
• Recklessness (लापरबाही/खतरा प्रती ध्यान नदिने) 
• Mood changes

If you see any of above risk factors in any one, get alarmed, they are most likely planning suicide. They need help. You need to take action.

How to help?
Talk to them. If you have seen any of clues as mentioned earlier, you can directly talk about their suicidal thoughts or plans. “With all the depression you've been dealing with, have you ever had the thought that you'd be better off dead?” or any question like this could be asked. Show that you care. Don’t worry, there is no harmful outcome. You can't make a person suicidal by showing that you care.
You came to know about his intentions by phone or facebook? Go to meet him immediately. Talk to him. “I was being worried for you.”, “The way you bade me good bye today was not usual.”, “Your facebook status shows that you are in some trouble.” Etc. can be some sentences to start with.
If he comes up with any tendency like suicide, Ask “when did he begun to feel so?”, “what the real problem was?”, “how can he be helped?” etc. Do show support. Say- I am here for you. Once, I too was in similar situation. Things will be fine. Suicidal feelings are temporary etc. such sentences will help to build up his confidence. He would probably let his feelings come out in front of you and make himself calm. Giving a suicidal person the opportunity to express his or her feelings can provide relief from loneliness, and thus it may prevent a suicide attempt.
Listen to whatever he says calmly being non-judgmental. Let his feeling and sadness come out. And be careful- you should never argue with his thought. Don’t give a lecture on value of life. He doesn’t want to hear it now and it doesn’t help as well.
We should neither over act. He is in distress, he isn’t crazy. You shouldn’t say artificial things. Words are not that important. If you are concerned, your voice, manners and non-verbal communication will show it. Just be yourself.  Ask when has he planned to suicide (time set). If time for suicidal is set, then it’s more severe problem. Inform people nearby to take care of him and do involve doctors/psychiatrists. They can help better. If you think, things are not enough to prevent the suicide than you can inform the police as well.

Let’s unite against this cowardly act. Together we can spread awareness. Let’s stand up for humanity. Let’s attempt to decrease suicide attempts.