Shrink's Views

ramblings of an unknown psychiatrist

Posts Tagged ‘community health’

“Can you please give me some poison?” – Part III

Posted by Dheeraj Kattula on July 10, 2010

It was usual Wednesday morning. Patients on Clozapine lined up to get the investigation request signed. It is a quick process for the doctors to sign a small bunch of slips. The OPD assistant filled in those slips and gets the job done. I looked up for a moment to see the patients. I saw Murugan’s aunt. I had come to know her well by then. You can read the posts “Can you please give me some poison?” and “Can you please give me some poison?- Part II” to get the context.

The first post was about this lady who was the sole care giver for her nephew who had Schizophrenia. She was struggling for long to get him well. It required an admission into hospital to make him better. She had no supports to facilitate that. In that post I promised that old lady that I would visit her village to help her bring her nephew to the hospital.

The second post was about my visit to their village and my encounter with the patient. Though I could not bring the patient that day, the patient came to the hospital for an admission as a voluntary patient. He was started on Tab Clozapine, the most efficacious anti-psychotic drug in the world after a fully informed consent. He improved much and got discharged. The senior psychiatrist of the hospital made a rare exception to Murugan by making hospital purchase Clozapine from an outside pharmacy to be given to Murugan for free. Murugan was lucky.

He was supposed to come every week for a routine blood test. This is because the drug Clozapine is associated with a rare but dangerous side effect in which the blood cells required for fighting the germs decrease badly. In rare instances, it can cause death too. Therefore we are very careful in monitoring the counts of those blood cells every week.

Murugan’s aunt asked me how she could get his test done as he has not turned up. What?!!! A Clozapine patient has not come for the routine blood test. He could die of agranulocytsis, where his blood cells which fight infections get reduced in the blood. The fact of this risk had been explained to both of them many times. They consented to come regularly for blood tests with their thumb impressions. Our explanation should be quite fresh in his memory. How can he not come? How dare this dear lady come and ask for ‘repeat medicines’ like it had been the practice before? I had every reason to be irritated.

I asked her, “OK. Why has he not come? Did we not tell that he MUST come for blood tests? What is he doing at home?” She said softly, “He has gone to the mill.”

“Mill? Did he go for work?” I asked with surprise.

“Yes. He started working last Friday. He gets Rs 120/- per day.”

Oh my God! This guy had not worked productively in any place for the past 20 years. He never earned a rupee. From my experience in their village, I knew that he had potential to work. When I was waiting at the bus stop, I heard a man call him out. Murugan had come with me to send me off. This man told Murugan to be ready by 6.00 am the next day. Apparently, that man wanted help in keeping an eye on a four wheeler for an hour the next day in a nearby village. All that Murugan would have received for that job is a bunch of beedis (rolled tobacco leaves about ¼ the size of a cigar).

I was amazed. Murugan has got a job in a spinning mill. I remembered my co-passenger had asked me if I was looking for such a job in a mill. Murugan has successfully found such a job. I credit Clozapine for such magic. If Clozapine was to continue, then it is mandatory that he came for the test.

I pulled a small sheet of paper and wrote a note to him. “Dear Murugan, I am very happy that you have found a job. Congratulations. Your blood test is very important. Do come and get it done.” I expected them to come the next day, but Murugan came back to get the test done before we closed work that evening. I also had an opportunity to write a letter to the manager of spinning mill to kindly give him leave on Wednesdays, so that he can come for certain blood tests which are necessary for his problems.

Next week I found Murugan had not gone back for work. His aunt prevented him from delivering the letter. She thought I had probably written to the manager mentioning details of his mental illness. She reasoned that such a letter could go against him because of the stigma attached to mental illness. She felt I was uninformed about the status of the real world as I was limited to ‘high society’!

I reassured her and explained to her what I had written. Murugan then informed me that it was not only this fear but the prophet-parrot had predicted that Murugan was in a ‘bad time period’. In India soothsayers/ fortune tellers use parrots to pick cards which are supposed to bear the secrets of the future of the client. His aunt had wanted to shield him away from authorities, just in case they stopped him from work. He was as irritated about her behaviour as me. I gave her a strong dose of scolding. Poor people take even a scolding in good sense, when they think that you are a concerned person. You cannot assume this for the rich patients. The rich though can be deceived by sweet talk even if you are not really concerned.

Next week Murugan was back. He had delivered the letter to his manager. His manager was okay with a weekly ‘off’ on Wednesdays. Murugan would regularly come from now on. His aunt wanted a letter to get a weekly ‘off’ from her company too. We gave one for her too. She too would get a weekly ‘off’ on Wednesdays. From now on she can happily accompany him. I am amazed at how much difference a typed letter sent to an employer by the doctor could make to the patient. I would use this method more and check if this makes any more difference than just encouraging patients to go for work.

Murugan’s story is a miracle. It is a miracle because of Clozapine, health care workers, hospital and the spinning mill which employs him. It is thrilling not only to see a homicide and suicide prevented, but also see lives transformed when modern medicine works along with social services and occupational rehabilitation.

Does this old lady want poison, now? May be…to kill rats and cockroaches! 🙂

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Posted in challenge, drug therapy, emotion, indian society, love, psychiatry, schizophrenia, stigma | Tagged: , , , , , , , , , | 4 Comments »

“He will get bed sores and die in about three months. Take care of him. Feed him with what he likes.”: Medical Model VS Family Practice Model

Posted by Dheeraj Kattula on June 29, 2010

He was discussing about his experiences after he came down from the mountains. He was doctor doing medical work in the communities based in nearby hills. He was posted there by our hospital for a couple of months. Of the many things he told that day, I remember this story clearly.

He had seen a 74 year old man with a fracture in his femur in a hilly village. He asked me what he would have done. It was a simple answer for me. I said, “You would have told them to bring him down to the hospital. We could give some charity, even if they cannot pay fully. The bones can be fixed.” There were five competent orthopaedic surgeons in our hospital at that time. He smiled sarcastically. He wanted to make a point, but what he said shocked me.

He had said, “I told them, that he might not live very long. He cannot move here and there because of his broken hip. He will get bed sores and die in about three months. Take care of him. Feed him with what he likes. Let him enjoy the time he has.”

I was filled with malaise. What?!!! How can a doctor say this kind of stuff? I couldn’t control myself. I asked him, “Wasn’t it inhuman? Fractures are treatable. Isn’t it? Then why not offer it. How can we give a death sentence for a treatable condition?”

He laughed at me as if I was talking rubbish. I heard his argument keenly. Probably, it was to rubbish his argument to boost my egoistic ethical pride. He said, “Listen, this old man has a son who is the only bread winner. His daughter-in-law is a house wife. His grandson is now in standard 10. His grand-daughter is in standard 8. It costs about Rs 5000/- to bring him down from the hills in a vehicle. The cost of treatment in the hospital would at least be Rs 30,000/-. They do not have that much of money. If I do send them down, they will have to bring him back after a discussion with a orthopaedic surgeon. In the bargain they would have spent off large amount of money. Just in case they go ahead and treat him, they will have to sell off their house. If they sell it off, then they will have to live in the street.”

I was listening. He went on, “If they spend all that they have, the grandson may not pursue education beyond high school. The grand-daughter would have to discontinue school to add to family income. All this might add one or two more years to a 74 year old man. Is adding a couple of years to such a man worth losing the future of a whole generation?”

It was a tough call. I was a new graduate then. I was trained in the medical model. I was supposed to tell the best medical treatment available to the patients and let them decide what they wanted. I realized this model absolves me of any feeling of guilt. The truth is I do have in my mind what is better, but still I would have done what is ‘right’. My friend’s argument did not convince me.

After about 6 years of that incident I am wondering if that ‘right’ that I would have done is really right?  What would I do if I were in that old man’s position? I am absolutely sure I would rather wish a better future for my grandchild than live a few extra years. I have heard grandparents in India bless their grand children, “Let my years be added to you.” Of course that does not mean that one can assume this sentiment in every case?

The point is that my friend is a family physician. His expertise is not only in managing health problems at a primary level but also in understanding clinical problems and treatment options in the light of socio-economic conditions and the values of the family. His model makes people happier and fulfilled more than the medical model which has the appearance of being more scientific. May be it is time the specialists learn to use the broader model. This can be done when; in addition to eliciting clinical histories clinicians spend some more time with patients in understanding their and their family context and expectations.

PS: This event happened about 6 years ago. Today, thanks to Chief Minister’s insurance scheme and 108 ambulance services, patients like the one described can get free treatment in our hospital.

Posted in challenge, children, Diagnosis, distress, economics, education, ethics, indian society, medicine, philosophy, social | Tagged: , , , , , , , , | 3 Comments »

“Can you please give me some poison?” – Part II

Posted by Dheeraj Kattula on June 20, 2010

This is the continuation of the life story “Can you please give me some poison?” Please read it if you can, to get the background. It was about a lady who was the sole care giver for a nephew who had Schizophrenia. She was struggling for long to get him well. It required an admission into hospital to make him better. She had no supports to facilitate that. In that post I promised that old lady that I would visit her village to help her bring her nephew to the hospital.

I did not keep the promise. Life is quite busy in Oddanchatram. Four weeks passed and the lady came back as proxy for review. I can never forget the look on her face. It showed how much of expectation she had of me and how I had let her down. I had missed four weekends to do a job I promised. If I had a conscience, I had to do something that week.

On the third day, I wound up my work by 5.00 pm and rushed to the Oddanchatram bus-stand. I bought a large coconut bun as a gift. The bun is usually cut into eight pieces before being sold. It was not very costly. In fact it was the item with maximum volume for a given price in that bakery. I believe volume matters to the poor and price matters to the rich in judging the quality of the gifts. I had filled my mp3 player with psychology lectures, to listen during the travel. I never switched the player on, as I was sooooo excited.

I would fulfil my promise. My challenge was to bring an unwilling disturbed patient, who had never seen me before, to the hospital for an admission. I didn’t have a team to assist me. I couldn’t apply restraints. I was not carrying rapidly acting injectable antipsychotics. I heard from a Public Health practitioner that practicing psychiatry in community is like trying to control a lion in the jungle. Controlling a violent patient in hospital is more like controlling the lion in a circus, he said. I was prepared for the worst. I kept my ID card, so that I can get help from people and police…Just in case…However my plan was to talk the person into a voluntary admission.

 I reached the nearest town in an hour. I had to wait to catch a bus to her village. It was getting dark and cloudy. It could rain at any time. I had second thoughts. Is it possible for me to bring an involuntary patient through this complicated travel back to Oddanchatram in a rainy dark night? Though I could abort my mission at that time, I did not. Could I face that lady again, without keeping my promise? Only God knows if one gets another chance. In about 20 minutes, I got the right bus. I asked the co-passengers, to tell me when the right village came. A teenager told me to follow him as he was to alight in the same village. He enquired if I too was going there to find job of a daily wage labourer in the spinning mills located in that area! This is when I was wearing formal clothes and leather shoes. I consoled myself, thinking I was able to relate with him so much that he identified me as a co-worker. 🙂

Once I got down from the bus, I found a street running perpendicular to the main road. I enquired from people if it was the right place. I asked for Murugan’s *house. “Which Murugan?, they asked. Reluctantly, I said,“Mentally deranged Murugan.” I was not comfortable using such a label to identify him. His aunt had wanted me to enquire like that. She had said, “If you ask for the ‘Mentally deranged Murugan’, even the village dogs will show you the way to our house.” I was told to go near the temple, located deeper the village. It started to drizzle. I walked faster. I found a group of people in a circle, chit chatting and having fun in verandah of the village school. When I asked, they pointed to a man who was engaged in a chat with another group nearby.

 He looked like an average poor man. Thinly built and unshaven, he wore a shirt and a lungi. His lungi was pulled up so much so that it exposed his thighs. As I looked at him and his mannerisms, I understood, he could easily be an object of mockery. It was difficult for me to imagine that he could be stoned to death in the village as his aunt portrayed. He smiled innocently as I introduced myself as a doctor from the hospital where he gets his medicines from.

He was happy to receive a guest. He left his group, as he understood that he had to take me to his house. On the way he said that his aunt had brought the Injection but he could not yet get the shot, as the village nurse was not coming regularly. By then it began to pour. We ran to his house, which was not very far from that school. He was surely not as bad as I thought.

 His house had tiled roof and brick walls. It had three compartments. One was the corridor, right in front of the door. On the left was an elevated area, which was used as a kitchen on distal end and store area on the proximal end. On the right side there was another wall which had a door in the middle. The door led to a bedroom. That room had a cupboard, a chair and a trunk. Few clothes were scattered on the floor. His aunt was cooking rice at that time. She was excited when she saw me. She hurriedly cleared the scattered clothes and ordered Murugan to get me a ‘colour’. I figured out that she meant a cool drink. I told her not to bother as it was cold and raining. I had the magical thinking that rain would stop soon. Aren’t some of us are extreme optimists, especially if we take some action?

They spoke in a language called Kannada. I asked about their roots and how they came to Tamil Nadu etc. I then moved to the business of getting Murugan back to the Hospital. I knew the journey was long and difficult. I did not mind the cost of throwing the half cooked rice away to get back to Oddanchatram as fast as possible. I gave the coconut bun. Murugan was happy to take it. He asked me if it was cake!

I gave Murugan the Flufenazine shot that was due to be given. I explained the reason for my visit to Murugan. I asked his aunt about what she wanted to do. Murugan listened to everything. At last he asked me if I would be there in the hospital, if he came. It was as if he said, “If you are there, then I will come.” I got excited. At least some rapport has got established.

In my heart I was keen on taking him personally. I cannot believe judgement of a psychotic person. It could change anytime. His aunt told me if Murugan said something, he would do it. She said, “Now that Murugan knows you and likes you, I will not have any difficulty in bringing him to the Hospital.” I thought I would leave the issue at that point. This was more so because of logistic problems.

The rain showed no inclination to stop. It was already dark and getting late. If I delayed any further, could miss the last bus passing through the village. I packed and secured my mobile and mp3 player in a plastic cover. I walked to the bus stop in the heavy rain after bidding good bye. Murugan also walked right beside me. He wanted to give me a ‘send off’! I enjoyed getting drenched. The tiredness of the day got washed away, as I walked with the hope that Murugan would come to the Hospital after many years.

Three weeks later, Lo behold! Murugan and his aunt came to the hospital for an admission. We had already decided that Murugan’s aunt need not pay any money to the hospital for the in-patient care. There was an arrangement made to procure free food for him too. We explained the possible side effects of Clozapine and the need to come to Hospital weekly for a blood test, before we started him on Clozapine. He and his aunt agreed to the contract. On Clozapine, his behaviour started improving. Before we reached the full dose, I had to go to another part of the country for some work. So I did not see him at discharge. I heard that he improved much by the time of discharge.

What a joy it is to be involved in people’s lives to change it for the better. In the trip to his village I learnt much. The label of being ‘mentally deranged’ transcended even love. Even his dear aunt used it. It was not as bad as I thought. The stigma of mental illness is less palpable in villages, as people did relate with the patient. They chatted, played and smoked with him. After all, he was their friend who got ‘mentally deranged’. The picture was different from what his aunt described. Anyway, what I saw was a snap shot. I might understand these issues more in the future. Murugan comes regularly for follow up, now.

What happened after Murugan got discharged? That would be covered in a future post.

———————————————-

* Name changed

 ‘Murugan’ is a very common name in Tamil Nadu

Posted in challenge, distress, drug therapy, indian society, psychiatry, schizophrenia, stigma | Tagged: , , , , , , , , , , , , | 15 Comments »

“Can you please give me some poison?”

Posted by Dheeraj Kattula on March 7, 2010

She came closer and asked in a soft voice, “Can you please give me some poison?”

I tried masking my shocked spirit with a layer of professionalism. I enquired “Why?”. I avoided her eyes, so as to not threaten her with my piercing look. I conviniently flipped through the medical records. The records belonged to a man who was in his late thirties. She had come proxy for the patient. She was in her late sixties.

She had been coming like this for the past 6 years. She took medicines and gave them to her ‘son’, whenever it was possible. She reported that he liked injections! Thank God for it. Every two weeks, he got a shot of Injection Fluphenazine Decanoate, a long acting drug which controls mental illness. I heard her sob. She was in tears. Why on earth would she need poison?

She was a widow. Her husband had passed away when she was relatively young. She has a son. He is married and settled. He lived less than a kilometer away from her, but did not care for her. She lives with her ‘son’, who was in fact a nephew, son of her sister. She too was a widow. When she was on her dealth-bed, she took a promise from this lady.The promise was that as long as she was alive she had to take care of her son. Truly, she kept her word. Every time the clinical notes were written, it said “Proxy- Mother”.

The old lady was bent with age and was getting weak. She is afraid that she might die at any time. She felt that if she were not alive, her ‘son’ get stoned to death in the community because of his behaviors. His behaviors were abnormal as his disease was not controlled.  His disease was not well controlled because of non-compliance. He was non-compliant, because he was severely psychotic. He was still severely psychotic, because his treatment was not complete. To break this cycle, he required a hospital admission. That could make him slightly better. If he became slightly better, his compliance could improve furthur and then his outcome could improve even more.

Why is he not admitted then? He hated to come to the hospital. This old lady cannot force him to come by herself. Her own son is not bothered about her or her ‘son’. How could she bring the patient? She therefore reasoned that it was better to poison him painlessly rather than leave him alive to the fate of a difficult life.

I did not know what to say. I held her trembling hand. She sobbed harder. I asked her if could visit her village and help her bring her ‘son’ for an admission. She agreed. I took her address. I feel the pressure now. It is uncomfortable to be the only earthly hope for someone. It is that discomfort that leads us to put in extra effort. It is that extra effort that makes the world a better place.

Posted in challenge, distress, love, psychiatry, schizophrenia, social | Tagged: , , , , , , | 12 Comments »

“Divide and Serve”

Posted by Dheeraj Kattula on December 29, 2009

I worked in a Hospital associated with Leprosy work for quite some time. Few months ago I went back to my parent hospital and my own specialty. I returned few weeks ago to cover for absence of a doctor for a period of 3 weeks. Dr Johnson, the doctor whom I have relieved was also here for a short term replacement only. I went with him to the Leprosy home for a routine visit. I found that the whole atmosphere there has changed. Patients were more involved in care for themselves and also for others. This came as a shock to me. I have seen them for years. I found them indifferent to their own problems, not to speak of problems of others.

 Dr Johnson organized games after the clinic was over. I was overjoyed to see the participation of the inmates. I was curious to know, what magical spell he had cast that the whole culture had changed in a span of 6 weeks that he was here.

The problems that patients faced were usually reported to the paramedical staff. Those staffs were responsible to settle the problems and refer appropriately to the hospital. The paramedical staffs are also responsible for arranging food, supplies, accounts etc. They were not answerable to the hospital administration directly. Their broad job descriptions and not being in span of authority of anybody on a daily basis gave them freedom. The patients suffered. Hospital could only help when hospital staff visited the Leprosy Home or when patients came themselves to the hospital. My predecessor and I tried to change the organizational structure for the better. We failed. So, we reduced the target of quality and tried the best that we could do instead of looking at the best that patients could get.

Dr Johnson changed the system without changing organizational structure in any way. He divided the patients into groups of 6-8. He selected young, intelligent persons within their group to the group leader. He divided the groups in such a manner that each group had a balance between young and old, fit and disabled etc. So there were groups among men and groups among women. He selected one representative from men and one from women. The group leaders are supposed to meet these representatives everyday and report the problems faced by individuals in the group like who has got fever, who pricked her/his foot with a thorn etc. These reps were senior inmates who have received some medical training. They knew when a patient could wait for the next visit of paramedical worker/ nurse/ doctor and also when a patient needed to be moved to the hospital.

Within a short time the groups became alive. They met regularly. They knew each others problems. They started to help each other in other ways as well. Their attitudes changed. Initially, they had to report their problems to STAFF. Now they had to report their problems to their OWN people, which is much easier. Dr Johnson taught me the principle of decentralization in a novel way. The paradigm that patients can care for each other is also new. The beauty is that it also works. There is another lesson. Individuals, as weak as they could be can become more self-reliant in groups. Leprosy home visit would remain memorable for many reasons.

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