diary as an intern

I’m an intern physician… I’m at PHC Valsang… and it happens to be one of the topmost PHCs in Solapur district. And here are many drugs, I never see in my hospital… though it lacks some fundamental investigation techniques, it seemed to be near perfect to me as a primary health service center… provided that you refer the patients to the necessary higher center when the need is apparent… and this doesn’t sound bad. But…

I hate that ‘but’… but it is there. I don’t want it, but it is there. This polished structure, this cleanliness this cool behavior is now I feel is sheep’s skin worn by bad nasty careless educated wolves…. Enemies of health working as health care workers. I feel it, that these webcams are foolish, morons or idiots… machine things having no IQs….. or maybe I’m an idiot.

As usual today there were many patients, with their usual complaints, and with their own usual theories about their complaints, and with their usual wrong beliefs and wrong health habits. And as usual I try to explain them the things, the importance of minor activities and good health habits and their effect on health… that ‘saline’ (their term for iv fluids) are not energy doses and that (pain killer) injections are not the solutions for every health complaint. And I usually succeed in convincing the patients and making them to understand their health problem at least an outline of it f not in complete… but then I face the complaint of the MO and even of the attending staff and class four servants that I ‘spend’ or ‘waste’ too much time on patients… and the crowd is very big and I’ve to check the patients in fast………..

Today I encountered a cheerful forty year old obese woman, a butcher’s wife (her weight was apparent by her size, though I didn’t actually weigh her). And she was there to tell about the ‘weakness’ of the right side of her body… there was no obvious loss of functions… and when asked about the onset of her weakness, she described an episode of profuse sweating with transient confusion which was followed by the weakness and the weakness had reduced then… she had not consulted any doctor. This was a mini stroke a herald of a catastrophe. I asked her about her blood pressure, and she told me that she was taking one blood pressure tablet for high blood pressure once upon a time which she stopped as someone told her that her BP was normal… I wanted to measure it, and I took her to the MO’s chair. He wasn’t there and I got a chance to examine the only BP apparatus in this PHC… it is fixed to a stand near the MO”s chair. And to my horror, its release valve is malfunctioning! And I got the reason why the MO tells that the BP of every patient I send to him as normal… even that of those having symptoms of angina. I somehow stopped the airflow and her BP was 210/ 150 mm Hg……………… stage two, very high.

I reached the drug store to find some suitable drug for her… only to find out that the ramipril and hydrochorothiazide tablets over here are the dolls decorating the showroom… the pharmacist refused to give those drugs to her. And I asked sir about what to do with that patient, and guess what that lady got- atenolol that too just 50 mg…….. aten 50 for bp 210/ 150??? He said after looking at my shocked face that what’ll happen if our stock of ramipril ends… the patient can’t afford it, so we give this one affordable- atenelol 50 mg! Then why the hell are you keeping that drug in your drugstore… I can’t guess, and can’t understand the logic behind this… the logic behind having the drug and not giving it to the patients who require it. Atenolol blunts the CNS… makes people dull as an adverse effect… and we must give any drug after evaluating its need or benefits and the potential harms it can cause. And if a better drug is available, we must give it instead of some crude one… I really can’t understand the logic behind giving her atenolol when ramipril was available.

And I see them telling a patient to get his forearm massaged at home with a gel after a trauma and when by examination fracture was apparent with no x ray advised and no immobilization was done. And I see infants getting prescription of nimesulide syrups… and I feel what if this’ just a bad dream and I’ll get up and I’ll see that this isn’t true… but it’s not… it is the truth. And I face it, everywhere… everyday and continue to hope that at least at some point of time this’ll change and we’ll live in a healthy happy world.

Am I really mad to dream what I dream? Is it possible to make some improvement? Is it possible to make the health service perfect… to make everyone healthy and happy? Can the world in my dreams exist? I don’t know… but I can’t stop thinking of it and trying for it… as if I don’t think of my dreams, I think nothing! And someone has beautifully told me that dreams can come true, without that possibility nature would not have incited us to have them… and I believe in him.

ideal Vs Real................ ..........!!

It’s not an easy task to be a good doctor, especially when nothing is known about many things, no specific treatments are available for many diseases, and many treatments those are available are not reachable to your setting… no diagnostic tools are available, and when patients have bad habits like addictions and false beliefs… I encountered today a patient with fully developed rheumatoid arthritis… with Z thumb, and bent fingers, and lungs shouting fibrosis and COPD, coughing and moaning with pain and with a packet of beedies peeping out of his pocket… and was asking me about the cause of nodules over the back of his elbows, and was requesting me to give some “high quality” drug that would cure him. He was emaciated… I wanted to refer him to higher center (the heck, to my hospital!) but the MO stopped me. Anyway it was a question what they could do for this patient… (I guess nothing other than prescribing a RA factor test and ESR and CRP- what if they were positive… and high) He was a regular patient over there, and was an alcoholic along with being a smoker. I had to give him some analgesics and after him I faced another patient brought by his wife, who was looking like his daughter… he was with full stretched abdomen with ascites of high grade and pitting edema over his feet… and she said that he had vomiting of blood in the morning. And he had same kind of vomiting few months ago… but no swelling. He was having liver cirrhosis (alcoholic) and he was drunk at that time also. And I found that ascitis tapping is not being done here. I searched for diuretics… alas, they were also not available. I ran to MO to ask for what to do, and he told me to send him back with some Tonic capsules (Tonic!!!??? He was as if closer to last stage… I would definitely have admitted him if I were in my hospital). I told her to take him to the causality (the emergency sector) of my hospital in case if some emergency arises… and then I caught the assistant of the pharmacist giving gamma benzene hexachloride ointment to a patient whom I had prescribed betamethasone ointment for atopic dermatitis.

What is going on here…? When are we going to get up and start practicing logically if not ideally? I see steroid tablets being given abundantly because the stock is in abundance, and the nimesulide… and tramadol injections for people with chronic trivial low back ache. I accept opioid analgesics if given after trauma or for severe pain. It’s not something that should be given to each and every patient complaining of pain. And nimesulide is totally unacceptable. And health advices like how to protect lower spine from injuries, and how to take care of spine, and to do exercise are not being given at all. And even if they’re told to do so, the smokers and alcoholics are not going to seize it.

How to change this? Where to make a start? Am I too small to think of that? I don’t know… maybe I’m… or maybe I’m confused. Is my dream of healthy happy world a daydream of a fool? Maybe it is; I never say that I’m a sane person. And I’m going to keep on trying, let me see what the future is going to show me…

me at phc

I’m a human, alas, though I wish to be some angel or demon or something supernatural… so that I’ll be able to do everything I’ve to. I go there, somehow… and encounter a big crowd called OPD patients waiting for me, and the MO raising his eyebrows (as the wall clock over there has been set at a wrong time). I get my own chamber, and I’m left alone to speak to, to examine and to diagnose and then to treat the patients. I do have experience with gynecology, I’ve worked in orthopedics (but it’s really hard to handle patients with injuries and joint complaints without the aids of X- ray films), and in ENT… I know surgery, and little quantity of ophthalmology… but I can’t control sweat gathering over my forehead when I encounter pediatric patients, then patients of deep lung infections and heart complaints, and then a tons of types of fevers and skin rashes and scabies and fungi… here I see everything, and I’m the whole and sole and the responsible person for them… I literally have to dig out information buried in the graveyard of my MBBS school memory. And ironically I’ve to refer patients with something like CSOM or DNS or like IUGR to my own tertiary care hospital… I sign the forms requesting them to do further investigations and do the necessary operations… as those things don’t happen in primary health centre.

The pharmacist insists me to prescribe something in her reach… people try to run away from work, no matter if it’s as small as getting up and opening the cupboard to take out the drugs. And they ask me why the hell I’ve chosen this PHC as it’s defamed for you really have to work hard here. I haven’t chosen it, I’ve been allotted, and no matter how exhausted I get I don’t feel my decision of working is a wrong one. I like experiences, I love patients… and as usual I feel tied because of lack of treatments to some diseases, and the hazards of the treatments I give to them… for some patients I do nothing rather than leaving them to their own luck (or badluck).

Today here was a camp day for laparoscopic tubal ligation operation. And there were maybe more than hundred women or girls (yeah, I don’t know what should I call to them when their average age is around twenty and they have two to three kids) waiting NBM since last night for the Civil Surgeon, and he happened to arrive at around 4.30 in the evening. I was shocked to see the en mass administration of anesthesia and the peon lifting the post operative patients and carrying them in his arms to their bedside (which’ a cloth piece laid on floor) … here are no stretures. But it’s good, that they’re doing family planning… in my hospital I’ve encountered many G4 G5 and sometimes G6, G7…

I don’t know from where I should start to do something that’ll transform the picture to close to ideal one… just trying… I really wish I would be some structure with super power!!! Oh my magic stick, where are you?

PHC continued......

Wandering is not new to me, but searching some address in a completely strange environment, at a place not given in details in google maps was a bit challenging. With some anxiety and some fear and tons of loneliness and kilotons of curiosity, I reached Walsang- The village of the PHC which has been allotted to me by the DHO. I was walking like a fool, looking at any slightly big house as the PHC… and people were looking at me as if a strange funny fast cartoon character was marching before them. The village was the same as where I’ve spent my childhood, with only few houses with more than one floor and the school and some little private clinics, and open gutters and garbage and pigs. But I encountered about three medical stores which was a bit surprising to me.

And when my legs were about to give up walking, after asking few times to the locals, and after spending almost one hour in searching, I reached a place they were calling as PHC. It was open, and crowded… “Who’s that girl,” I heard a woman asking to a man…

I work in a tertiary care hospital, that too aligned to a medical college- Govt. hospital Solapur… so my idea of primary health centre was something with a standard far below than that of my hospital. And that’s why I got shocked to enter it- the PHC at Walsang… in contrary to my hospital, it’s computerized, and is extremely clean and webcams are recording the behavior of doctors and nurses with the patients… and finger print machines are used for attendance recording… I was pinching myself repeatedly to examine whether whatever I was seeing was true. And I was to have a heart attack or may be a stroke due to excitement when I visited the drug store…

Along with Amox and cipro here septran and tetracyclines like tetracycline and doxycycline, cephalosporins like cefalaxine and cefixime are also available. Of course, higher antibiotics are not always necessary and can cause resistance and toxicity is high especially with the tetracycline group… but they are must when strains resistant to routine antibiotics are encountered. Here in my hospital we pray that the strain shouldn’t be resistant and if it is, we are left with no other choice than telling the patient to purchase it from nearby private medical.

Antihistaminic drugs like cetrizine are also there… but chlorpheniramine maleate stock is in abundance. I don’t understand why they go for CPM when cetrizine has far less CNS side effects… diclofenac and paracetamol are available in my setting also… but diclofenac is sometimes out of stock, here that’s not the case. I almost shouted to see Diclofenac gel in their cupboard. I never see such things in Solapur. I wondered to see a tablet with serratiopeptidase as a constituent… but the other constituent of it- nimesulide disappointed me. Why the hell government is providing something as toxic as nimesulide when it is banned in many countries? One more thing that bothered me was the needles… according to new agenda we use a new needle for every patient, but here the needles are used in ancient manner repeatedly for many patients after boiling it for sterilization. This seems dangerous, when I remember the long queues of patients and relatives waiting for ART drugs in my hospital. And yes, vitamin B tablets are out of stock here, same as in my hospital…

But I liked this PHC… at least the first impression is good. It would be an ideal health center if only few drawbacks it has were removed. It’s as if it’s very close to the health service in my dream world… of course higher facilities like x rays and CT are not available… but still it’s good as it’s just a primary health center. Why my hospital lacks these things like the webcams and the attendance recorders and the cleanliness and the friendliness, why so many drugs are not available here? How can a tertiary health center lag behind some primary one in many things? Why other PHCs are not like this one… why are many of them closed for almost all the time?

I don’t know management much and economics was a big challenge before me when I was a high school student… but it would be very pleasing if I could answer my own questions… I’m here to learn and to use whatever knowledge I have for the patients over here and I’ll do it. But I can’t stop myself dreaming an ideal health service serving the whole world… I want my dream to come true.

PHC... and me

I fear sometimes to do something that others don’t… to be an intern that others don’t expect. I’m not a heroine, a Hercules… a fearless monster with extraordinary strength. I’m a normal human, fragile many times due to some unknown inflammation… who’s unable to give up something that her mind calls as being honest to her job! And my job is to be an intern on a way of being a capable independent physician… I must and must do the things and to use the sources as what a good and ideal physician does. I feel there’s nothing wrong in me to wish to expose myself to the extremes of medical practice.

I’m not a studious medico kid who prefers thick stereotyped books over the live experiences in the hospital. I’m not a time saver kid running before the clock to have one more MCQ paper solved in a day’s 24 hours. I run behind the experiences… I just can’t refuse to go to the incomparable monthful of experience of attending a PHC… no matter what and where the PHC is, no matter even if it’ll cost me my hours and make me to travel by bus everyday for a month… My friends tell me, then yell on me, then beg me for not doing this- to break trend of escaping PHC service with the shining notes with Mahatma Gandhi imprinted on it… then they give up and I’m left alone to express my fear to this dead machinely computer screen. The clerk in District Healthscience office doesn’t like me, and I get the PHC far far away from where I live. And then I’m left in complete darkness about the status of it… whether I’ll encounter a live human there or whether there’ll be a big rusted lock telling me some corrupted tragedy… and I feel I’m not prepared to face it. Still I’m going there without knowing the outcome… tensed…. I wish how happy it would be if everything were normal, uncorrupted, like something in my sweet dream world. But this isn’t the dream world and I crave for some live hand on my shoulder telling me that what I’m doing isn’t wrong… I know I’m not wrong.
Let me see what is there…

Let them to say what they want………..

They say it’s in vein
To spend hours… in teasing your brain,
To play with words to haunt minds,
To think of the world… existing only in hearts

They say it’s utterly madness
To try to find something…
which maybe completely fruitless
And to consider the world… which affects you not

They say it’s a big flop
To spend your life in searching…
Answers to the endless ‘whys’
And in attempting things… which may cost your life

They say it’s a severe bad luck
To be unable to be practical…
In this ‘Practical’ world
And to foster dreams… those sound irrational

But this madness has its own reward…
What others say doesn’t bother a mad!

She lives life like the spring
Bringing blossom to every mind she meets
Buds are bound to flower…
It’s exciting to watch flowers born as thorns
It’s really funny to live for a cause
No matter, even if it costs you your life

i insane

I’m not a good student… I don’t sit in the library and mug up MCQ books. I don’t know which common questions they ask frequently in the entrance exam, to be honest, I don’t even know exactly how many and which subjects they’re supposed to ask questions on, what I try to read is everything available about the diseases I encounter in the OPD and my beloved neuroscience. I don’t plan, and I don’t want to appear for that exam. I don’t want to be a physician… don’t want to spend my life in the hospitals trying to offer already available treatments which may or may not be effective, and in trying to fight against the disorders disabilities tragedies and curses with maybe partially useful or totally futile or guess based regime weapons, and in trying to be satisfied for offering the treatments to needy ones no matter what the results say…

I don’t hate doctors… really, and I do salute their contribution in the health care system, because if we remove doctors the system will be totally paralyzed… but I don’t want to be one. A doctor has to be practical (yes, I’m speaking of an ideal doctor… and not about the money making robotic machines devoid of their own brains and alas, also of hearts!). She can’t be enthusiastic- the doctor, can’t be drastic… can’t cross the boundaries. She just can’t be curious beyond a certain limit. And she’s helpless; she has to adjust with the scanty diagnostic facilities and primitive like treatments even though she’s working in a most advanced setup (leave apart something like what I experience here)… she has to see failures, she has to face conditions where there is no treatment… there are diseases with no cure, and there are people who get them, and come to her with great hopes… like a machine, she has to take consent and has to convince the patient about the scant regimes and potential hazards of those regimes, and to tell that to the disease there is no treatment.

When she decides to go beyond the limits and to expand the boundaries, to question the regimes and the pathological conditions and mechanisms in physiology, wants to seek something better and safer…, she’s not a doctor, she’s a scientist. I know a doctor is not supposed to play the god though some people still do call her a god, neither a scientist an idol. But… but… but why to accept the limitations, why to surrender the pathological processes and traditional treatment regimes when you believe that something better can be found out? Why to spend life in prescribing VDRL and then ART to thousands of AIDS patients rather than trying to defeat the HIV in total…? Why to go for AMP or nailing and plating and working on live human’s bone/s as on a piece of wood rather than finding something that’ll deposit natural bone where it was and how it was before the accident? Why to give something as hazardous as steroids or cytotoxic drugs to control inflammation? Why is in cases of fights and crimes, MLC papers and signs and signatures and proofs and photos more important than the fact or facts why the heck their brains became so violent? Of course, there is some answer/s to every why, but alas, none meets my satisfaction…

And I, like some unsatisfied wandering spirit keep on thinking of research while working as a doctor in my hospital… and my mind keeps on hovering between the reality and my dream world…