Diabetes in a village man
A 24 years old man from Enfranze presented 3 month ago within 15 days of onset of polyuria, polydipsia, and generalized body weakness. His blood sugar was 360 and he was started with hypoglycaemic agent at the local private clinic. His condition deteriorated slowly until he lost 10 kilogram (52 to 44 kg) and also his blood sugar level rose to 444, so that he decided to go to the health centre to see the chronic disease nurse. The nurse, after evaluating the patient, concluded that the patient is most likely a type one diabetes and had erroneously been prescribed hypoglycaemic agents, instead of insulin or a referral to the Gondar hospital for workup. He was therefore given instruction about his condition and was referred for further work up and education to Gondar teaching hospital. This must have saved his life. He went home from Gondar to his village, accompanied by his two friends and his mother. Yet again, this patient illustrates the vital part played by nurses who have been trained through the chronic disease programme, where their critical skills save lives.
A 35 years old Diabetic whose sight was saved
A 35 years old young man was sent to Gondar University hospital from a Health Centre after a wound in his right foot has failed to heal for more than 2 weeks in spite of treatment locally with dressings and antibiotics. The nurses team in the polyclinic thought that he had Diabetes Mellitus, which was indeed confirmed by his high blood sugar level. Examination of his eyes showed that he had damage to his retina, with easily seen exudates and haemorrhages which indicated that his disease already had one of the feared chronic complications of diabetes, which could later result in loss of vision. Fortunately, the ophthalmology department was able to give laser therapy so that his sight was saved and he is being cared for at Gondar university Hospital.
The fact that diabetes in this man was first seen when he had advanced disease, because he did not complain of symptoms of disease, apart from the lack of healing of an infection, shows how alert the health team has to be. Such patients will continue to be seen until we have been able to give many more public health messages at Health Centres so that disease can be detected earlier in future. He was fortunate because the high awareness of nurses trained by our Programme in the Health Centre was their reason for referring him al for further investigation; it was they who noticed that the foot ulcer was not healing as expected.
Meeting the health extension workers
Picture 1:HEW from Seka
The Health Extension Workers (HEW) are the community health agents working on health education, prevention and promotion of health in the community. We have used this opportunity provided by the health care system to reach rural people and raise awareness among their community on some of the risk factors of non-communicable diseases as well as identifying symptomatic cases, screening for raised blood pressure and also tracing patients who have been lost follow up at Health Centres. These are early days for our developing the skills of the HEWs; we hope to report on their progress in the community as our work with them becomes more mature. But we are delighted to enlarge the range of care for rural patients; it has never been done before and so is a significant step forward for training.
Picture 2: HEW from Serbo
Semira is a HEW from Shebe catchment area, sitting in the middle in picture no 2. While looking at an educational video of different seizure types she remembered a case from her village. This was her description of what apparently looked like an absence seizure.
‘A 10 year old boy has an attack of absence with looking upward and showing the white of his eyes. He continues to do whatever he has been doing, like walking or eating, but appears to be “absent” and thus he continues to do whatever he has been doing as if never interrupted ’
Picture 3:HEW from Shebe area
The health extension workers are given a three days orientation about features of epilepsy, diabetes, hypertension and heart disease. They are also oriented on how to deliver educational messages on risks, preventive measures and how to deliver lifesaving first aid in case of crisis until appropriate referral can be arranged.
Picture 4:HEW from Omonada area
Picture 5 Community involvement, a new approach for chronic disease prevention and care
Health extension workers in Gondar area are now important and recent members of the team (specialist doctors, nurses, pharmacists, laboratory technicians) caring for chronic disease patients. These are a contemporary health cadre in the Ethiopian health care system primarily engaged in preventive interventions. They are recruited from among their community for a short training and then they return to their home area which is the reason for their high commitment. They have thus been responsible for a number of high impact outcomes in vaccination and in making people aware of their access to health care. Most of them aspire to develop a career in health care such as nursing, pharmacy and environmental health worker.
The HEWs are also be useful for increasing the awareness of the community about chronic non communicable diseases. They can help in early detection, prompt referral and tracing of those who have been lost to follow up. In the chronic disease programs in Jimma and Gondar we are reaching out to HEWs and orienting them on the most important Non Communicable Diseases declared by Ministry of health (diabetes, heart and respiratory diseases) and also in epilepsy. The Health Centre nurse second from far left (brown shirt) would receive referrals from her team of HEWs, confirm diagnosis and start treatment according to standardized protocols and training delivered to her at Gondar University Hospital Chronic disease clinic.
Dr Yoseph, the Ethiopian physician in charge of this Rural Health Centre project, has sent two case studies of the treatment of children with severe cases of epilepsy by a health centre in Maksegnit which is in an isolated area of Ethiopia. The two reports show how the centre in this rural area of Ethiopia is managing to treat these young children suffering from epileptic seizures and as a result bringing positive life changing improvements for them. This would not have been possible without the access to healthcare where it was previously unavailable and these case studies demonstrate that the funding that has been raised through this project is directly benefitting some of the most isolated rural poor in Ethiopia.
The report and photographs included are shown as we have received them from Dr Yoseph himself.
Dr Yoseph, the Ethiopian physician in charge of this Rural Health Centre project, has sent the attached report. Dr Yoseph's work brings him into daily contact with people affected by life changing conditions such as epilepsy. By setting up these Rural Health centres he is bringing access to healthcare where it was previously unavailable. The funding that has been raised through this project is directly benefitting some of the most isolated rural poor in Ethiopia. The report incuding the positive case studies, shows the evidence and value of this approach.
The photographs attached to this report are somewhat distressing but this is how we have received them from Dr Yoseph himself.
We received the attached report, including photographs, from Dr Yoseph. In it he describes the impact of diabetes on young women, in rural Gondar:
EMERGENCIES in Diabetes
A young women from Rural Gondar, farming is type 1 diabetes and on high insulin dose. She had developed hypoglycaemia and came in coma. The health centre nurses were trained in emergency and were able to save her life. Type 1 diabetes is common and patients often develop acute crisis, which is often a cause of premature death unless emergency interventions are possible and delivered promptly.
Patient may miss their meal , or do rigorous farming work ,or take a higher dose of insulin by mistake this will lead them to low blood glucose level which may lead to fainting or at worse coma and if not addressed promptly, this is fatal outcome of treatment. Health education is given to patients to never miss a meal, and always to carry a piece of bread even while working in the farm field
Training of health centre nurses with practical management of emergencies such as the above case saves lives, here discussion is being made the reason why the patient went into coma and how to manage her and whether she needs a referral to hospital. In this case it was concluded she had a hypoglycaemic attack due to high dose prescribed and also rigorous physical activity of the young woman. She was managed with intravenous glucose and after regaining consciousness information was given to her and family on how to prevent such episodes again, Insulin dose was reduced and patient given referral to check with her physician in 3 days to review the dose of insulin administered.
Dr Yoseph Mamo
4 April 2014
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