Dr Nithin PI

Medical doctor

After graduating from government medical college Calicut, Kerala I decided to travel and explore the country. What started in my mind as a gap year became exciting 2-3 years where I was living and working with rural and tribal communities across the nation through NGOs working at the grass root level. These travels have changed the way I live, practise and look at life in general. I have many travelogues and I’ll present one place at a time. This one is about the experiences in Gudalur.

The Gudalur experience

It started off very spontaneously and unplanned as most things would be throughout the year. A nationwide lockdown was announced out of the blue and an email came saying ASHWINI (Association for health welfare in the Nilgiris) is now a Covid -19 empanelled hospital and have vacancy for a junior doctor. I was more than happy to grab the opportunity. The very next day I was in Gudalur, Tamilnadu.

A familiar language, two weeks of quarantine, long phone calls, and zoom presentations with the founders helped me to understand the context and to ease out into rather unfamiliar surroundings. From the very first day I was keen to perceive health from a broad perspective. My medical, gynaecological, and surgical skills improved greatly and soon I was confident enough to manage OP and IP and do minor surgical and orthopaedic procedures in a resource limited secondary care setting.

With time came the understanding that the place and the people were lot more complex and layered. The four tribal communities with distinct cultures, languages, traditions and ways of life, farmers who later migrated from Kerala, Sri Lankan immigrants who came even later as plantation workers and businessmen who came recently to make their living in a growing tourist place – the demography was very unique. A tribal dominant rural area had already transformed more or less into a popular town. The place culturally and historically was part of Kerala and now being a part of Tamil Nadu was posing additional challenges particularly in times of the pandemic when the state boundaries were tightly shut. Tribal communities were moved out of their forests recently and still felt out of place. Most were first-generation learners and the few educated youth couldn’t find adequate job opportunities. Health seeking behaviour was below par. Alcoholism was a major economic and health problem. Mental health issues were more prevalent. Sickle cell disease was endemic. TB, malnourishment and anemia co-existed with lifestyle diseases, stroke and carcinomas.

When I started to spend more time in the community, I felt that although a hospital is needed, but it can’t improve health beyond basic curative services and even to provide contextual hospital-based care a first-hand understanding of the community is an absolute necessity. As a learner I learnt more from the people as they know the most about themselves and their surroundings. Health animators- the mid-level health workers who were all members of the community became my bridge to the community. As I gained their trust and acceptance it became easier for me to work with them. Soon the much formal doctor visits with hospital driver became informal visits on a motorbike and instead of formal referrals I started getting informal calls from the villages whenever they encountered any medical doubts.

Anecdotes from the Land of Blue Mountains

Play it to their strengths..

I was interested in mental health and ASHWINI had a mental health program with a dedicated mental health team comprising of a psychologist and trained community health workers. In-house psychiatrist was no longer available and a visiting psychiatrist was not a viable option in pandemic times. It was understood that most of our patients had multiple socio-cultural and economic barriers in accessing psychiatric care even at our hospital, hence a plan was made to decentralise the whole process. SOPs were made and we were giving training to our mid-level health workers.

Training sessions initially were ineffective, and the message was not going through. Then slowly after a few sessions I came to realise that I was not playing it to their strengths. Though educated and with considerable command over Malayalam and Tamil, those were not their native languages. Most of the words we were using during the training didn’t have a tribal language counterpart. On the other hand, tribal people living in their forests for centuries have amazing pictorial memory and being able to remember whatever they see is an important contextual life skill. Soon all the words in the SOP were changed into stick figures, symbols and colours and our people started to pick up better than anyone would imagine. Sessions were being over in less than stipulated time and trainings becam a joyful activity.

It was a key learning point for me and gave me confidence in taking my work beyond the language and cultural barriers.

To amputate or not to!

A middle-aged man belonging to Kattunayakan tribe came to us with a non-healing wound over his leg of over a month’s duration. He had had a thorn prick and believed that the healing was delayed because the gods were punishing him for his immoral life. He was in a stage of remorse and physical pain and herbal medicines were not working. He wanted the wound to heal and pain to go away so that he can go light a lamp in his forest shrine as an atonement.

The diagnosis of PAD (Peripheral Artery Disease) with infected ischemic ulcer was easy, even femoral pulse was appreciated only on Doppler and the treatment of choice would be an above knee amputation. Being a hunter gatherer and fiercely independent he couldn’t think of losing his limb and his purpose of accessing our care was to save his limb and relieve the pain.

We decided to admit him and start treatment with antibiotic injections and prime him for a lifesaving amputation. The psychologist and tribal staff were involved but, in a few days, he could only be convinced enough to give away his foot. Couldn’t fault his logic as external wound was only there, meanwhile he began to become febrile. We decided to go for a below knee guillotine amputation and an above knee amputation later when the patient was more convinced. With more counselling things happened as planned, during the above knee amputation we discovered that there was a gas gangrene, the muscles were rotting and he ideally needed a hip disarticulation which could not be done in our resource limited setting.

Referring was not an option as patient didn’t want any more shortening of his limb and we knew no medical college will go the extra mile of convincing him when discharge against medical advice will be an easier option. Our decision was to discharge him on painkillers and oral antibiotics so that he could be in the familiar surroundings of his home. On the day of discharge patient developed signs of DVT due to immobilisation but it was not recorded as I understood hospital stay had given enough agony to him, he wanted no more of it and going back home to light the lamp in the forest shrine was more important to him.

We didn’t want the people to feel that a man who came to heal a wound on his leg, ended up losing that limb, and yet died. So, we went to his village to talk to the people and his family about our decisions and the reasons behind it so that already existent low health seeking behaviour is not affected further.

Behind a Ponseti cast

Once we came across a 3-month-old baby belonging to Paniya community having bilateral clubfeet as a part of distal arthrogryposis. Treatment of choice was serial Ponseti casts every week till the deformity is corrected. The whole process would take 2 to 3 months, has to be completed within 1st year of birth and stopping midway would result in even more deformity. Even after the correction, the baby would need specialised splint and shoes for a couple of years. The family was counselled to make them aware of the long road ahead and to ensure adherence.

It was a first-time experience for me, I learnt to put the Ponseti cast and we went ahead with the plan. After a few weeks patient was lost to follow up and realising the hazardous consequences we were keen to track down the patient and understand what exactly went wrong. Upon enquiry and village visits we understood that lockdown situation has increased the transportation cost to the hospital by many folds as no public transport was available. The family who had seen similar kinds of kids in the village having gross developmental delay were under the impression that their kid also won’t survive beyond a few years and hence didn’t want to torture their child with serial casts.

We decided to administer the cast in the field. I went along with our physiotherapist in a motorbike every week. The child’s parents were taught about developmental milestones and they were convinced that their child has no developmental delay. They understood physiotherapy could address the elbow contracture and serial casts would resolve the club feet and their child could have a quality life.

In the process our physiotherapist learnt to put the cast and me & the child’s mother learnt a bit of physiotherapy. Yet the most important learning for me was to understand the patient better and empower them to take their health in their own hands, work with them around their difficulties, acknowledging that patients always act in the best interest of themselves to the limit of their knowledge and circumstances just like a doctor acting in the best interest of his patient to the limit of his knowledge and circumstances and both are partners in the enabling process of healing.

Curious case of a chronic psychotic

No one knew since when Rema has symptoms of psychosis, but after her marriage because of psychiatric issues her husband left her and took their child along with him. This was a major stressor for her and she soon became a “wandering lunatic”. She then got pregnant on the streets and gave birth to another kid. She is now living with her mother and child. When relatively functional she wanders on the streets and is aggressive and violent when having an acute episode. Multiple times she has been seen at our hospital, a diagnosis of chronic schizoaffective disorder and prescription of multiple antipsychotics hadn’t helped her much due to lack of adherence. The context of she belonging to Paniya community was so relevant that even in her hallucinations she saw her slave masters of bygone era.

It was important to manage a patient like Rema in hospital setting during her acute episode as there was no other option and it would instil confidence in our health workers to carry on with the mental health programme. She was kept in our hospital for about a month and how much ever we tried we could not avoid polypharmacy. We understood that Rema may remain functional but won’t have enough insight to take her medicines by herself. So, a responsible person had to be entrusted with this responsibility. Her mother and 12 year old kid were taught about the need of medicines and trained on when and how to give them.

After about two weeks we made an informal visit to Rema’s house and what I saw made me realise the superficiality of our interventions. Out of boredom and loneliness, Rema’s mother had gone to her relatives house. The child had gone to another relative’s house to eat food. Rema was staying alone, eating and taking medicines whenever she felt like and was almost flipping back into her psychotic self. We addressed the situation by providing separate pill boxes for morning, afternoon and night and our community health worker who was staying nearby was entrusted to go check on her and to put medicines in her pill boxes on a daily basis. Efforts were also put to have a dialogue with her mother and kid to make sure Rema was not staying alone.

Years later despite our best efforts, Rema continues to oscillate between relapse and remissions. Last time when I checked on her, she was worried about her short hair-cut during her latest hospital admission!