Wednesday, September 24, 2008

What to do if an HIV positive person comes to you for help?

This post is for all health care providers and Social workers in India.
You know an HIV positive person who needs medical help.What to do?
First thing you have to make sure is whether he/she is really 'positive'. Three positive rapid tests detecting antibody is considered confirmatory. These tests are done virtually free of cost at all major Government Hospitals. The person can go directly there to the testing centre and get tested.No need for a doctor to order the test.
If he/she do not want to test in a Government testing centre you can ask him/her to get tested in a good private lab. There the more costly Western Blot test is usually done to confirm the diagnosis.
If the diagnosis is confirmed the most important thing is to reassure the patient that HIV/AIDS is a treatable condition now and the treatment is available free of cost at ART Centres attached to certain major Hospitals. Before starting treatment few other blood tests also have to be done to assess the immune status and overall health of the patient.
It is important to note that all positive persons do not need treatment.If there are no illness and if the person's immunity status is good[meaning the CD4 count is more than 200], treatment is not started immediately.The person needs to follow up regularly to check his immune status.
What do you mean by Immune status?
It is a measure of the ability of the person's body to fight against infections. HIV virus slowly destroys the ability of the body to fight against infections.Such an immune compromised individual can get infections easily.
Why treatment is delayed till the immunity is destroyed?
In early stages of infection especially the first 5 years the body partially win the battle against HIV. Slowly but surely the virus get the upper hand [in most of the positive persons] and the body's immune system gets destroyed. Only at this stage the person becomes ill. We start anti HIV treatment at that time so that we can prevent the person falling ill due to various infections.
Starting treatment before that do not give much benefit.As of now we can only reduce the multiplication of the virus to a minimum.We cannot eradicate the virus. Also the anti HIV medicines have many side effects.There is also chance of drug resistance if the dosages are missed. Considering all this treatment initiation early in the course of HIV infection is not very useful.
It is also important to test the spouse of the person.If the mother is positive the children if any also have to be tested.
If there is a pregnant positive woman, she needs treatment to prevent her child getting infected. This also is provided at ART centres.
Compassion and good advise is what that is needed for a newly detected 'positive' person.

Tuesday, September 23, 2008

Obstinate Patient?

The other day I had a tough time with one of my patient.
She was 54 years of age.She was diagnosed Type 2 Diabetes 5 years ago. Her blood sugar was under fair control with a tablet taken in the morning before breakfast. But for the last 3 months it was high in the mid 300s. I wanted to increase the dosage of her medicine.I told her it will be better to take half a tablet before dinner also.
But her response surprised me.She refused to take medicine in the evening.
'Why'? I asked.
' I am taking an Ayurvedic herbal powder as medicine for Diabetes in the evening' I cant stop that.
I got irritated.May be I was in an irritable mood.
'You first decide on the system of medicine you want to follow.If you want to follow modern medicine you obey my instructions' I shouted.[ I never shouts but my voice was raised].
She was taken back by my raised voice.
'I have been taking that powder for last 3 years'. She pleaded.
'So what?' 'It is not reducing your Blood sugar.So better stop'. My voice was still raised.
She pleaded again but I held on to my tough stand.
Her eyes were red and tears appeared. I did not know what to do for some time.
Then I relented. 'You take your powder in the evening 2 hours before the tablet'.
'If both are taken in the evening will there be any interaction?" She was worried.
I said there wont be any problem. She was relieved and I was able to defuse a difficult situation.
May be I should have proposed that compromise formula earlier.I should not have raised my voice.Some days I may become too irritable.

Friday, September 19, 2008

A Study in Contrast

The other day two of my patients were boys who presented so differently.Their stories were a study in contrast.
The first boy came along with his anxious parents.Both of them were school teachers. The boy was around 14 years and appeared healthy.
' What brings you here?' I asked.
' His urine is frothy'.The mother said.Is he having a kidney problem? They were very anxious as a classmate of their son had Kidney disease.
I examined him in detail and could not find anything wrong.Then I asked for a series of tests of urine and Blood and that too were normal.
I reassured the parents and send them off.

The other' boy' came with his father.They were from a village 30kms away. They came with a reference letter from a Local doctor.The ' boy' looked as if he is about 12 years old. When I looked down at the patient file in front of me I was shocked to see the age written as 23.Was it a clerical mistake?I asked the father about the boy's age.Yes it is 23. I read the reference letter.Yes he was referred to me to find a reason for his short stature.
I examined him. His height was 123cm and weight 24 Kilograms. He did not show any features of puberty. He had no hair growth over face, chest, armpits or genitalia.
His penis was small and testicles rudimentary. His voice was like that of a 10 year old child. It seemed as if his body got stuck at 10 years for the last 13 years.
'When did you notice that there is something wrong in your son?' I asked the father.
He told me that once a doctor told him the boy had problems and need many tests to find out the cause,but nothing was done.
Why those tests were not done?
Money was the major problem he said apologetically. 'Also I was sick for several years.So there was nobody to take him to distant City to do the tests.' He added.
He is probably a case of ' Pituitary Dwarfism'. It is an abnormality rarely seen in children.They stop growing early or growth is very much delayed. This is caused by deficiency of Growth hormone . Such children may have deficiency of other hormones also.This may result in lack of sexual maturity as seen in this boy.
Early diagnosis in the childhood is important. Treatment with Growth Hormone Injections usually makes a big difference.But it have to be given before adulthood.By 18 to 20 years the bone plates fuses and further growth is not possible.
Treatment with sex hormones may help this 'boy' to mature.But he will never gain height. He could have gained height if treatment was started when he was around 15 or earlier.
Such contrasting tales I see in my practise regularly. India is full of such contrasts. Over anxious literate and well off parents who know many things and is afraid of all known and unknown diseases attacking their children on the one hand,and the illiterate poor rural folk who accepts everything that is given to them as destiny on the other hand.
India is a land of
Luxury,opulence and high education on one side
poverty,illiteracy and ignorance on the other side.

When will this huge divide go away?

Tuesday, September 9, 2008

Diabetes management in the Third World

He is 32 year old male. He is a poor manual labourer ready to do any kind of job.He is also a Type 1 Diabetes patient for last 7 years.

He lived near the place I worked previously.He presented to me 7 years ago with sudden loss of weight and severe fatigue. His blood sugar was around 500mgs. He was treated with insulin and fluids and he became better.A trial of oral tablets for Diabetes was tried but did not work. He could not afford C peptide estimation or antibody estimation to prove that he is having Type 1 Diabetes. As he responded only to Insulin he was assumed as type 1 and treated with twice daily premixed Insulin.

As I moved out from that area I did not see him for few years. Last week he came to me again. He came for some relief to his severe unbearable ear ache. I asked him about his Diabetes.He reassuringly told me that he is taking Insulin injections regularly twice a day.He was not concerned about his Diabetes.He is having this ear ache and discharge for last few months. I examined him and saw that he had thick pus coming out of his right ear. He also had high blood pressure and severe numbness of his feet.
'When did you check your blood sugar?' I asked.
He was not very sure. 'May be 3 months ago', he replied.
What was the sugar value? I persisted
'May be around 300. It was always around that when i check'. He revealed.
'Do you keep your Insulin in refrigerator'? I enquired. I remembered that he used to keep his Insulin at a pharmacy nearby as he or his neighbours did not have a Fridge.
'No .I keep it in a plastic Mug filled with water'.
'Why not in the pharmacy'? I asked.
His explanation was like this. The pharmacy in which he used to keep his Insulin had closed few years ago.Also somebody had told him that Insulin if not kept in a Fridge, should be kept under water.
Here is a Type 1 Diabetes patient who is storing his Insulin improperly and thereby reducing its potency. He is taking this low potency Insulin and is checking his blood sugar rarely.His blood sugar is always high and now he is developing Diabetic nephropathy and neuropathy.Due to this poorly controlled blood sugar he had also developed acute ear infection about which only he is bothered.
What should I do?
I told him the importance of keeping the Insulin in a cool environment.I asked him to see anyone of his neighbours have a Fridge.If not I told him to buy an Earthen pot, put water and few pieces of ice in it and put the insulin in it so that it is submerged in water.I also gave him a week's course of antibiotics for his ear infection and few anti BP tablets. I refused his offer of consultation fee.
Should I have done more? Should I have donated a refrigerator to his house? Or should I have helped him in any other way?

I don't know.
There are thousands of such Type 1 Diabetes patients through out the third world. Only very fortunate few survive more than 10 years after diagnosis.
Let us hope the future will be bright for such patients. Let us work for more just world.

Sunday, September 7, 2008

Is it AIDS doctor?

A 48 year old man came to my clinic with his brother. The man is working in one of the Persian Gulf Countries. He was in Persian Gulf for the last few years but was not regularly employed.He was staying with and was dependent on his friends and relatives most of the time. 5 months ago he was fortunate enough to get a good job. Finally he started sending money to his family in India.

His illness also started 5 months ago.He began getting loose stools. Some times there was blood in the stools.He lost all his appetite and became thin.His friends asked him to see a doctor. He did not had a health insurance or other benefits.He knew that seeing a doctor there means lot of money.He applied for leave to come to India for treatment,but it was rejected. He continued to suffer and lost around 20 kilograms in weight. Sensing something wrong his boss gave him leave.Thus he presented before me.

He was extremely ill looking, thin and emaciated. He said he is having frequent tummy pain along with loose stools.Some times it is mixed with blood, which he attributed to Piles. He was pale and his blood pressure was on the lower side.I asked him to lie down. I examined his abdomen. He had a fairly large and hard palpable Liver.He also had pain on pressing his lower abdomen on the left side.For me the diagnosis was obvious.

I asked him to do some blood tests and an Ultra sonogram of his abdomen and come back to me with the reports in 2 hours.
Both of them went out but the patient's brother returned immediately, came close to me and asked
'Is it AIDS doctor?
I wish it was AIDS. I replied.
His face showed his confusion.I explained. Probably it is advanced Colonic cancer which had spread to Liver. If in operable the chances of survival are very slim.
If it is AIDS I can offer a lot and he will live healthy for long.But......
The Ultrasound scan suggested my impression was correct.He was referred to higher centre. Subsequent CT Scan and a colonoscopic biopsy confirmed the diagnosis.

Yesterday was his day of surgery.It was planned to remove the colonic tumour and to give chemotherapy later for the Liver lesion. His brother called me in the afternoon.He was crying when he said that the colon tumour was in operable as there was adherence to Urinary bladder. They just did a diversion of bowel to abdominal wall so that he wont have obstruction to bowel movements. His days are numbered.

Colonic cancers especially on the left side are slow growing and are diagnosed early because of alteration in bowel habits and bloody stools. When diagnosed early it is a curable cancer.
This patient because of his circumstances delayed seeking medical help which now proved was suicidal.

Saturday, September 6, 2008

Happy News

The type 1 Diabetic I mentioned in A Strange Interview married that guy.I was specially invited for that marriage. It was on a working day and I excused myself.Send a greetings instead. I had 2 reasons for not attending the marriage. The obvious reason is I was busy as all doctors are. The other reason which I thought is some thing entirely different.I am not sure it is correct. Going to a gathering where I am invited because I am the doc treating the bride's illness may highlight the fact of her illness among even those who do not know it. I did not want that.
The marriage was almost a year ago. 10 days ago she called saying her blood sugars are unusually high.I asked her to come and see me. There was nothing wrong on examination.Then I asked her about her menstrual periods. She is late by few days.As her periods were irregular how late she did not know. I asked for a Urine Pregnancy test. It was positive.Yes she was Pregnant. I was happy but also worried that from now onwards extra care have to be taken to ensure a normal pregnancy and delivery. Her HbA1c was 6.9, which is fairly good.I am hoping for an uneventful pregnancy.

Friday, September 5, 2008

Fasting Season

During the last week of August my out patients were mainly Muslims getting ready for traditional fasting during the month of Ramadan.As I was out of station also for some days my hands were full with patients.
Most of them are regular patients who wanted my guidance and approval before starting fasting. They want their blood sugar,Cholesterol and Blood pressure checked. They wanted my advise regarding timing of medication. As they fast from day break to Sunset medicines have to be taken late evening and early morning. Most of them are happy when I tell them they can fast. Some sick old people who may not be able to with stand fasting have to be told no. Some times they insist and then I will say try for few days, and if you feel sick stop.
Some patients I see only just before fasting season. They will be Diabetic or having high blood pressure. They never come for follow up visits even though they are taking medicines. They come during this time because they also want a reassurance that they can fast.Their face will show guilt as I ask where were you all this time. After hearing my lecture regarding the importance of frequent blood testing and follow up visits some may change their habits. But many in this group I am sure will come only next year.
From the experience of last 10 years I know that I cant change everybody.

Monday, September 1, 2008

A mood elevating patient

It was Monday,the beginning of a busy week. My mood as I entered my consulting room was not good.May be the morning blues.Or depressed thinking about a week full of work ahead.
First 2 patients came in and went out.My mood remained the same.
Then walked in[or literally carried in by his son] a retired school teacher.He is above 80. He is a regular patient of mine for last 4 years.He is suffering from Type 2 Diabetes,Benign prostatic enlargement,Osteoarthritis etc etc. Regularly he becomes sick when I am out of station. This time it happened again. He tried to contact me for a trivial cold. He could not as I was away for a week.This made him restless.His sleep was reduced.Then he started running a temperature.The son took him to another doc the next day. Medicines were prescribed.The symptoms were reduced but he was not satisfied.
He held my hand and told me he is so happy seeing me. He said he do not feel good.There is no appetite or sleep. He was afraid he will die before I came back.The son remarked that the illness actually started when his Dad heard I am out of station and now he will become all right soon.
I examined him and then reassured him that he is only having a mild cold.I also told him I won't go anywhere next 2 months. He did not leave my hand for a long time.

The faith and love that the old man had for me made me happy and I began smiling again.My blues were forgotten.