PHASE 1: BE THE SPONGE
Be careful with your words. Soak in more often than you speak. Only then can you create something that the people will believe in.
Who speaks more often in the classroom, the teacher or the student? In the beginning, it is the teacher; towards the end of learning (perhaps as a display of mastery) it is encouraged that the student speak. As problem solvers, we must start by absorbing, then responding.
In the same way, despite having written my Fulbright grant proposing the work I believe needs to be done, my goal upon arriving was to begin by learning the things that textbooks and journal articles couldn't teach me while writing my project proposal back in the US. What further constraints are here? How well are the techniques working that they now use? Is it cost, compliance, or inadequacy of the technology that is failing to meets the needs of the patients and clinicians? And during these first few weeks, I've immersed myself in the Indian healthcare environment allowing me to gain insight towards these questions.
EXPERIENCE #1
HIGH RISK FOOT CLINIC
Diagnosis, treatment, and education for diabetics with ulcers that are chronic or at high-risk for amputation
Tuesdays spent observing in the Endocrinology department
Every Tuesday, the CMC Vellore Endocrinology department receives patients who are either on-going cases with advanced ulcers or patients who are new diabetic admittees complaining of sensory loss or wounds on their feet. In each of these cases, the diabetic educator evaluates the health of the feet and any ulcers present. For chronic patients, they will remove the dead skin around their ulcers and rebandage. CMC makes their own soft-soled shoes specifically design to be a certain stiffness to neither be too hard to cause ulcers and neither too soft to allow sharp objects to poke through and harm the soles of the feet. If the ulcered patient is not already wearing a pair of custom-made shoes and the soles of their own footwear is deemed to be too stiff, they will be fitted for diabetic sandals in the hospital's in-house shoe fabrication department.
Below are techniques use to evaluate a new patient. Click on one of the images below to read more about what the nurse is doing!
Things I learned:
Many of these patients are chronic, and despite wearing the proper footwear, they still have ulcers. Not only that, but some ulcers are appearing regions where it's impossible to have high pressure, such as on top of the foot. Dr. Felix agrees that it would be very helpful to have a more robust way of ensuring that the footwear is properly designed and fit for the patient.
EXPERIENCE #2
CLASSROOM OF DOCTORS
Educational diabetic foot care training held at CMC Vellore for doctors attending from all over India and Nepal!
Four day, hands-on class learning the importance of educating patients and providing thorough care
Tuesday through Friday 8am - 5pm, I sat in a classroom and absorbed information on everything from the physiological cause and debilitating progression of neuropathy, to how to debride an ulcer and prescribe proper footwear. The doctors I was sitting amongst were from everywhere across India and exceptionally excited to hear about my project as we drank tea during our lecture breaks. About 50% of the time in the classroom was spent doing hands-on activities interacting with patients or observing nurses and doctors execute treatment.
Click on the pictures below to take a look at some of the things I got to experience!
Things I learned:
All the doctors agree that a large caveat of any footwear (if you can even get the patient to buy it) is compliance in wearing it. Most Indians walk barefoot! So making a sandal to help is not going to work.
I learned that the CMC hospital made something called a "temple sock" which protects the patient's insensitive feet from the burning hot temperatures of the temple's floor stones. It's basically a thin fabric and plastic insert that gets put into the sock such that the patient's skin isn't exposed to the heat. If they're willing to wear this, perhaps we embed our technology in a temple sock?
I learned that even these doctors don't know the value of the pressures that healthy vs diabetic patients exhibit on their feet. I gave some hypotheses of pressure thresholds that may be causing these ulcers, but the doctors agreed that study is necessary to really understand how much pressure is harmful pressure.
EXPERIENCE #3
RURAL ROADSIDE DISABILITY CLINICS
They can't afford to come to use, so we work to bring care to them.
Joining forces with the PMR department, I head out to a different rural village each week
On the days I participate in this social work, my day often starts by waking up at 5am to catch the first bus up to the rural hospital to meet the Chittoor PMR department. From there, we pack up supplies: glucose meters, blood pressure cuffs, stephoscopes, and basic medications. We pile into the doctors' personal cars and drive anywhere from 20 minutes to an hour and a half into rural India. The intent of our time out in the field is not to cure people. It's a matter of making a preliminary diagnosis of disabilities, underlying conditions, or medications that may be of relief to symptoms. They then are referred to a doctor at the main hospital. Each patient leaves with a slip of paper with their current blood pressure and glucose level, as well as a date and time which they can come to the main hospital to see the referred doctor, free of charge.
Typically coming to help at these rural camps as they're called, are Occupational Therapists, Physical Medicine Rehabilitation Doctors, speech therapists, physical therapists, and pharmacists.
In these cases, I have no technical medical knowledge that I can contribute. Instead, I'm simply given the crucial role of "people control." Most times we walk into a Hindu temple and within a half hour, we need to turn it into a working check-up clinic. So I am tasked with deciding where the check-in table should go, where the waiting area should be, where the general practitioners should go, and what room the pharmacy should be sent up in so that patients can get any medications they're prescribed on their way out.
In addition, the first camp I attended, I inherently brought my camera along and the doctor actually requested that I simply spend the day taking pictures of the clinic so he could use the images to convey to other doctors the importance of such social work. So once the clinic is up and running, the doctors and patients alike are enthusiastic about me taking pictures. I always ask a patient before I take their picture, but most times I'm overwhelmed by most everyone tugging at my kurti, asking for me to take their pictures.
Click the pictures below to read their descriptions!
Things I learned
Most patients showing up to our clinics came with no shoes. And those patients who had diabetes and perhaps had been told that they'd need to wear shoes to protect their feet now that they've lost pain sensation would still remove their shoes when entering their home or a Hindu temple. The biggest vulnerability here is actually the floortiles of the temples that get scorching hot in the noon-time sun which will burn the underside of the diabetic, completely unaware to the blisters they've acquired.
CONCLUSIONS FROM THE SPONGE PHASE
From the foot clinic:
Our approach of simply looking at the high-pressure points as being the areas at risk may be inadequate. Many patients had ulcers between their toes or under sandal straps. In addition, we'd like the device to be able to evaluate if the custom-made footwear will adequately protect the foot from pressures moving forward to mitigate the number of chronic patients seen in the ward.
From the diabetic class: Even expert doctors don't know if there is a threshold of pressure that is causing these ulcers. We first need to study a spectrum of diabetic patients to see if there are plantar pressure differences between those who have or haven't had a foot ulcer.
From the rural clinics: If we truly want the device to be a low-cost alternative to expensive pressure mapping mats and Bluetooth insoles, it needs to be accessible to these people. From the power cuts we'd often experience out in the field, we'd need a diagnostic tool that is not dependant on a power source. One that can quickly diagnose areas of the foot that may be at risk for ulceration. At most, the device should be able to run via a smartphone and long-lasting battery. From the patients presenting with diabetes but not wearing shoes, the device must be able to diagnose at-risk areas in barefoot and well as shoed patients.
Time to begin brainstorming!