A Visit to a Diabetes Clinic

Danielle Wilkins - School for Environment and Sustainability

June 30^th marked the culmination of my first month in Sri Lanka and what a first month it was. By the end I had done what I previously thought to be impossible, survived a Sri Lankan summer without the help of an air-conditioning unit. But we had also started to make strides in putting together a training program for a new form of Medical Assistant specializing in diabetes care and big players like projects funded by the United States Agency for International Development (USAID) were voicing interest in our work.

Admittedly when I first arrived at Grace Home I was a little apprehensive. As I mentioned in my last post, I have a background working on development projects in Sri Lanka, but this was the first time I had undertaken a project focused on medical care, and without the formal backing of one of the big development agencies that generally lead these initiatives. I started out visiting the Diabetes Clinic with the Assistants from Grace who had previously received medical training. These young women (to date no young men have been trained) are to be our front line in the quest to show our new way of caring for diabetic patients actually works. I wanted to see what their working environment was like. It was, in a word, chaotic.

The Diabetes Clinic in Trincomalee General Hospital is held in a room approximately 20ft x 15ft. There are four standard desks with four desktops, four blue chairs, a screen separating a small private area. As I was directly informed when I took a seat in a blue chair, only physicians are permitted to sit in the blue chairs. Each desk has a stool for the patient and three stools are set up in the middle of the room for patients to wait for an available doctor. A nurse guards the clinic door checking to make sure only those with the permitted numbers have access to the room. All other patients wait in a sea of blue plastic bench seats outside.

To date the Assistants are not actually permitted to work with the doctors of the Clinic (we still need to obtain a number of permissions for the Trincomalee Ethics Committee and the Ministry of Health), so they arrived at 6:30am on Monday morning to see patients who arrived early to collect their number. Numbers are very important to the clinic model in Sri Lanka’s public hospitals. Patients arrive to the clinic and line up to receive numbers from the Orderly. The first people in line receive the first numbers and are thus able to see the doctors first. This has significant advantages. These people will also be able to get to the pharmacy first and will have little wait time in filling their prescription. The result is that they are able to get out of the hospital and on with their day quicker than their fellow patients. The early numbers are highly coveted. Or, at least they used to be. More on the change in number policy in a bit.

As the patient’s crowd into the Clinic room to find the Orderly who distributes the small laminated number card, the Grace Diabetes Assistants (DAs) set up shop at one of the doctor desks. The blue chair pushed aside, the Assistants and their patients sit on stools around the desk. They have been coming early on Monday mornings for about a year now. Some of the Orderlies know them and they have a small group of patients, generally older women, who slowly make their way into the clinic to sit and wait their turn. The Grace DAs take their time with each patient. They review their medical book. Each diabetes patient carries with them their medical records. Most of these records are kept in a small notebook. Only doctors are permitted to write in these books and they contain all the notes test results for each person. The DAs perform a quick exam. They check each patient’s blood pressure, their blood glucose, their weight and their feet. The feet of a diabetic patient are very important. Many patients they see do not have great control over their diabetes. As a result, they are at a high risk for neuropathy, characterized by a loss of feeling generally in the feet. Without feeling in their feet these patients are at risk to develop foot ulcers and other lesions that can prove deadly. Monitoring the feet of these patients are just one of the activities in the care model that help the DA collect important baseline information on each patient.

In the midst of their exam the DAs are constantly interrupted. The most frequent interruptions come from newcomers wanting to know where they can collect their number. Other patients want to know what is going on, “are the doctors here?”. The orderlies and nurses are often bustling around preparing the room for the doctors. Through it all the DAs are gracious. They answer questions and return to their patient. They spend on average 15 minutes with each patient, asking about their daily habits and advising them on the need for exercise and an improved diet. Not every patient comes back each month, but a surprising number do.

Around 9:00 the doctors have finished their rounds and are starting to trickle into the Clinic. It is the cue for the DAs that it is time to leave. They have managed to see seven patients today and more of the nurses and orderlies have started to recognize them and offer assistance. Slowly the DAs are gaining acceptance from the patients and the hospital staff.