Diary of a podiatrist
The following are extracts from Vicky Elliot's fieldwork diary - a Podiatrist working at our center in South Nepal
Monday 3rd October 05
Aurahi
In Aurahi we saw Hansa, he was lying outside his home on a mat. His daughter in law was helping to take of him. He had a fever and heat from his left heel wound. The wound was painful inside and had a watery discharge; a deep sinus was evident and had been there many years.
We were able to advise his self-help group member to get antibiotics for him. We checked his legs and feet, and found he had mild foot-drop of the left limb. We advised simple muscle stretches. The previous heel surgery had not improved the condition of the ulcer. I advised a spring and the patient agreed to wear it. He has experienced no stigma in Aurahi and many neighbours gathered around to look. His grandson was copying my Nepali and saying, "wound", people laughed at this, and there was a peaceful atmosphere.
Although he was sick, he smiled and listened to our advice about clean, salty water for soaking and insoles for his flip flops. A motivated patient, with family support, and an understanding community.
Positive impact of community team work.
Kapileshwor
A fairly large group had assembled before we arrived. There were bowls of clean water and patients were soaking their feet. A small discussion was held and names taken of members. The atmosphere was a little depressed and few people spoke up. One of the members has recurrent wounds and did not join in with the others to soak his feet.
A young girl was there with large simple wounds, and flattened arches of both feet. We advised rest, as the facilitator had previously. She was had not been looked after by her father. The authority and influence of the cell facilitator was not enough to change the situation.
A patient named Rahaman had a left foot drop and needed a tarsal platform. We needed to take four measurements for flip flops from this group. Kiswari has a left heel wound of duration four years. We were able to take a measurement for leather sandals, and the feet had severe neuropathic bone damage and swelling.
Tuesday 4th October 05
Loharpatti
A large group of around twenty members were actively doing self-care when we arrived. The cell leader was a helpful, smiley man who encouraged the members. A good sight to see was the presence of members with foot deformities and scars, but fewer ulcers in this group among the males.
Again names were recorded and a small discussion held in the beginning. Sadly we found out no clean water is available to this group for soaking their feet, they only have access to lake water. We asked the leader Muslim about the pump, he informed us it had been stolen. Our fieldworker suggested they discuss a plan of action to obtain a new pump. There appears to be a good relationship between the Health Post and the group leader.
Patients appeared more motivated in this group and were pleased with their "wound free" feet.
One patient Pulo well known to Lalgadh, was still suffering from a recurrent ulcer on the right foot, we suggested and measured for a tarsal platform. One member who does not come regularly was there with a maggot-infected wound. Jamati was also well known and a bit of a "trickster". He was begging in Patna (India) for work and used his disabilities to that advantage. We suggested him to go to the local Health Post and receive ulcer care, but if any deterioration of the wound to come to Lalgadh.
We were able to discuss with patients about the use of flip flops compared to shoes; it was good to see these group members freely speak up and chat well with each other. A sign of a good leader.
Sahida a lady involved with independence training was there with a simple right foot wound; we took measurements for a tarsal platform.
Another good outcome from our visit was the discovery of a recent lady member who had no protective footwear but had anesthetic feet. Our fieldworker without hesitation took a flip flop measurement to bring to Lalgadh's footwear department.
The community department's role in visiting is essential for all groups to add new information, to collect member’s responses and encourage self-care. Within the hospital environment clients are not in their home comfort zone and cannot freely discuss their concerns.
Monday 17th October
Haripur
This is a fairly new group, with around twenty members. Many of the members have been given start up loans in goat keeping and small scale farming, through the Community Department. The members are from Thapa castes and hill groups. On our visit there were a mix of disabled, marginalised and Leprosy affected. This mixing of peoples has helped greatly in the reduction of stigma. Our community worker from LLSC, was explaining how the situation in that area has improved, with all the members helping one of the most disabled of the group with his house building.
One client Min has deformity of his hands and feet, on checking his feet there were dry cracks around the heels. This visit enabled us to re-emphasise the need of "self-care". Encouraging to hear were the comments from other group members about their experiences of being cured of Leprosy. All helped tell Min to take more care and apply oil every day.
Min had already received a leather spoon belt (the belt fits around the palm of the hand where the fingers have become dysfunctional) to help him eat, from the footwear department at LLSC. The "Self Help" group also had a fund to cover costs like oil for self-care purposes. Binod explained that Min's condition was already improved with no open ulcers on his feet. I felt encouraged with the outcome and hope Min remains ulcer free.
Another useful effect of the visit was that we found a client Bhakta, who had a swollen Ulnar nerve on his right arm. Bhakta had been on MDT for six months and in the last weeks was suffering from discomfort in the nerve. Without meeting up in that way, we may have missed that early nerve problem, leading to future clawing of the fingers. We recommended that he come to LLSC for a second opinion from the Doctors. He may need to take a course of medication to reduce the nerve swelling.
Follow up visit in Kapleshiwor
Previously I had seen a young girl of nine years old, Purnam. On the first visit I was able to prescribe multi cellular rubber sandals for her ulcerated feet. At that time we instructed her father to give her rest, in order for her foot wounds to heal. Sadly her one foot had deteriorated and was now infected and swollen. Other clients knew very well about her situation and explained that her family was very poor and needed her to cook and clean for them. The group was well aware of how her hand blisters had come and the fact that rest is needed to heal leprosy foot ulcers. Her future looks bleak without help from LLSC's Community department. Her hand blisters are simple, but soon the infections will lead to bone damage and digit loss. A young girl with damaged hands and feet from Leprosy has few opportunities in Nepal. We discussed her situation and thought the family should be consulted once again to encourage them to look at the long-term dangers of her working so hard with damaged hands and feet. There may be a possibility of sending her to a school in Kathmandu. She is a quiet girl, but very capable of learning given the chance.
Another member of the group had been given special insoles, but was still suffering from heel wounds and forefoot problems. The follow-up visit gave us the chance to tell him to return to LLSC for rocker insoles and woundcare.
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