Reflections

Wow, I can’t believe three weeks have flown by! The whole experience at the CMC has been incredible. I’m so excited for the next batch of uthscsa students to come down, I think if anything to really appreciate how fortunate we are in the US to have access to health care and adequate supplies. It’s humbling and inspiring to know that the docs here can all easily practice in other countries if they wanted to, but choose to stay in India to help people knowing their resources are limited.

Quick description of my last week: CHAD consists of a clinic for the villagers to attend, hospital ward to take care of villagers who need to be admitted, and nurse and doctor runs out into over 80 villages around the area to refill prescriptions and see sick patients. The story behind CHAD and the CMC hospital is a really good one, e-mail me if you want it. (I don’t want to give it away for the ones about to come here! Plus, it’s really long and I want to do it justice.)

CODES and SHARES are different groups that each act to serve the community. CODES stands for “community development service” and it employs women to build and make things for the hospital. So, they can make scrubs, c-collars, and also anything metal that needs welding together! Go women! They also have a counseling service for married couples, which seems to really work. SHARES is similar (I’ve forgotten what it stands for) which employs women to make baskets and other handicrafts that are exported. CODES is government funded, and SHARES is independent. Both groups also serve as support for women, and encourage confidence and independence.

I love how faith is universal here. I love how people of the Christian, Hindu and Muslim faiths can pray together in the same room, like in the small building dedicated to worship at SHARES. I also love the respect and patience people have with one another here in the hospital and at CHAD. Today I saw a c-section delivery in a woman whose labor wasn’t progressing quickly enough. At first I was a little apprehensive about the cloth facemasks, surgeons’ caps, and feet covers (we took our sandals off and wore canvas booties.) I was even more apprehensive about the manual BP being taken intermittently during surgery, and man did I wish she had an epidural and not just spinal anesthesia. But the surgery itself was amazing… they used the same sterile techniques as we do, and the actual procedure looked the same with almost the same instruments. Just missing the sleepy med student holding the bladder flap back with a retractor as her arm slowly falls asleep...

The little one came out with the most confused expression on his face, then a healthy cry! I always wonder what babies are thinking. :-) I hope that by the time he’s older, his world will be a better place for him. I’ve had my eyes opened to the problems India faces as a developing nation, and it’s almost overwhelming. Pollution, suicides due to stigmas placed on seeking psychiatric help, alcoholism, overcrowded hospitals, overworked doctors, treatment denied because of inability to pay, and the quickly growing HIV population. Also, because sex outside of marriage is not discussed, nor homosexuality, doctors are not able to help patients prevent transmission of STD’s or HIV.

Some of these are similar to our own problems, but the US is a wealthy nation. I’d have to say though, India is working with what it’s got. It was impressive how explicit one ob/gyn doctor was in counseling her patients about contraception and their relationships with their husbands. She even lectured the male residents on how they should treat their wives! These docs are all here for a reason—for the hope that this will all change. And one day patients will be more educated and able to prevent many of the diseases that they are now being treated for.

I’m so grateful for this experience. Thank you all for your emails and support from the other side of the world—it’s been so fun being able to share this with all of you! Now, I’m heading off to Bangalore to spend some time with my extended family for a month (It’ll be so weird without you brother!! I’ll miss you!), hit up my cousin’s wedding and do a bit of traveling. Oh yeah, and I find out where I go for residency tomorrow. Wish me luck!

I thought that I’d stick in some more pics of the hospital (as if this isn’t long enough…) :-)

Women and Children's building

Old school dryers! (this is how they dry bedsheets and scrubs after they're washed)

Really nice view of the garden by the chapel in the middle of the hospital.

And mystery... SOLVED!!!

The mystery... solved?

I ran into another one of those weird boxes... and to my surprise, this one didn't say "terrestrial magnetism" on it. It turns out that the medical school just had these educational facts on each of these box things. It almost took the fun out of finding the first one, but then I realized that I still don't know: 1) what "terrestrial magnetism" really is, and 2) what's inside the box. Ooooh.

But, another mystery is solved! Frank found Collin! More like Collin found Frank... Collin was the chaplain who found us a place to stay when we found out our hotel was booked. We've been trying to locate him for the past two weeks to thank him, and it turns out he was trying to find us to make sure we were ok! What a blessing he was indeed. :-)

Another bit o' happiness-- Ultimate worked out! There was definite American dominance but Richa, our lone Austrialian friend who made it out actually said Ultimate was a lot like their "Netball" which is basically Ultimate frisbee with a ball and not a frisbee. (It's not like basketball though.) This probably explained why she was so awesome! There's a student from Boston coming today who was requested by the other Boston students to bring an actual Ultimate disc, so maybe tomorrow we can try again. My little pink frisbee was flying all over the place! The kids in the park loved it-- they had a blast trying to take it away from us before their parents pulled them away. :-)

CHAD has been great too, it's the community outreach component of the CMC. One of the docs gave us the most incredible story of the history of the Hospital. I'm so amazed at what people are capable of accomplishing once they set their hearts to it! Next time I'll try and explain a little more of my experience at CHAD, CODES, and SHARES, but now I'm going to hit the sack. Sweet dreamin!

No Tinea solium in here!

It’s been a fun last couple of days! Lots of good learning, and we’ve had a chance to hang out with the other international students, or “elective students” as we’re known as around here. One cool thing to note: People from New Zealand, the UK and Australia are all familiar with Ultimate Frisbee! And, they're all going to teach us Americans how to play Cricket. Hopefully tomorrow we'll all bond over a game of ultimate, made possible with my nice 18 rupee hot pink flying disc. Woohoo!

It’s also been awesome learning about what health care is like in other countries. In Australia for example, they have a lot of outreach clinics there for the Aboriginal population, much like how the CMC goes out to villages here, and how in SA we help underserved areas in south Texas. It’s kind of inspiring, knowing that people all over the world are trying to make it a healthier place.

And speaking of south Texas, some of its areas close to Mexico may actually be in worse shape than the villages we saw here in India. This may be because the CMC has been helping the communities for the past 20 years by funding community health workers and day care teachers for the children. Despite the dust that seems to surround Vellore, its natural beauty is still quite amazing. My dad told me that "Vellore" is a British adaptation of the original name. It roughly translates to “brown sugar town.” So, sugar cane fields are everywhere! Rice fields too!

During nurses’ rounds we traveled to villages around the area and saw how prenatal care was done for expecting mothers. Despite the small size of this hut, inside we found a TV and a large dresser drawer. The temperature was also very cool, the mud must keep out the sun’s warmness. The organization of the program is really impressive—the community health workers keep track of everyone in the village and know who’s sick, who’s pregnant, who’s taking birth control, and who may be suffering from domestic abuse. They then direct these people to get the care they need.

Doctors’ rounds are similar with a giant clinic van traveling to one village, and people coming from all around for medication refills, new complaints, and prenatal care. This was awesome--we learned how to listen to fetal heart tones with our stethoscopes, and how to determine how far along the pregnancy was and where the baby was positioned by using our hands. Ultrasounds are not routine and only reserved for cases with a strong suspicion for a breech pregnancy or other complications.

We also helped the nurses immunize children. For the babies they do two shots at the same time, one in each thigh. I had a fun time watching the little ones have different reactions to the shots. Here they still give the oral polio vaccine and don’t give MMR for children. They don't immunize pregnant women with Rubella either. I was told that MMR and Rubella were being pushed for to be mandatory, but funding seems to be a huge problem here. What really impressed me though was the supply of meds--the clinic was a pharmacy on wheels!

On a side note, earlier this week I attended an awesome lecture on neurocystercercosis (it's huge here!) It surprised me that while most patients contracted the disease from undercooked pork, 30% were vegetarians and became infected by contaminated vegetables or food handlers. This adds another disease to my list of “things I hope I don’t get in India.” :-) All right, time to hit the sack, my CHAD rotation starts tomorrow! YAY!

Neuro Wards!

Wow...neurology has been something else! While in the US adult neurology usually consists of stroke patients with the occasional MS, here stroke patients are managed mostly in the ER (otherwise known as the casualty service, it's more like a ward where patients can stay up to 3 days) or on the medicine wards. So the neurology service at CMC treats mostly demylinating disorders like MS or transverse myelitis. We also have patients in the service being worked up for Guillan-barre syndrome, motor neuron diseases, Creutzfeldt-Jakob disease, and Hanson's disease (more commonly known to us as Leprosy.) Oh, and i forgot the patient with neurotuberculosis and another with a possible mitochondrial myopathy (remember MELAS? well we might have it here...)

It's true that a lot of these patients may not get better, especially the patients with possible MELAS and CJD. But, still it's exciting to see all those things we learned in medical school become applicable in treating these diseases. And the neuro docs are really good, especially about using all that neuroscience we learned back in the day to clinically localize a lesion and narrow down a diagnosis. But technology is definitely not lacking. MRI's, EEG's and EMG's are routinely ordered, and its neat to see the doctors' satisfaction in being correct when the scans arrive later. I've also noticed that while presenting the neurological exam, some docs present by area of the brain... for example "testing of frontal lobe function shows... parietal lobe shows... etc"

I was told that there is actually a child neurologist who sees the kids, but she's away completing her training. So, until she gets back, the adult service sees the kids and does a great job. I love kids and brains!

Some interesting things I've learned: 1. the most common cause for adult-onset seizures here is neurocystercercosis and Tb. 2. Phenobarbitol is super cheap, and as a result lower-income patients with seizures are often on this med for years despite its horrible side effects. I saw a patient who was on it for 5 years and looked so cognitively impaired, it broke my heart. I also saw a pregnant patient who was still taking phenytoin. Ahhhhhh. Anyone up for starting a massive movement to improve seizure management and patient education in developing countries?

Oooh and I learned about Hiramaya's disease. It's when the dura in the cervical region is thicker and shorter posteriorly, so that everytime the patient flexes his neck forward it pinches the spinal cord. This eventually leads to a muscular atrophy of the upper limbs, you can totally see the wasting of this man's interosseous and thenar muscles. The radiologists diagnosed this in a 30 year old man, and we were confirming it. Treatment is to have him wear a C-collar that extends his neck back for a few years so that he doesn't bend his head forward as much. (This must be tricky-- I always have to look down here to see where I'm stepping!)

That's all for now! Hmmm... and here's a question to ponder. Say you have a restaurant with incredibly delicious indian food. And then say you have two mice running around and an ant that landed inside your friend's tea. Do you still eat there? Maybe with close-toed shoes...

A Weekend Escape

This weekend the five us of uthscsa med students visited Pondicherry, which was founded by the French and still quite international. My dad told me that when I was a baby, our family went down to Pondicherry, but I had an ear infection, cried the whole time and had to stay back at the hotel while everyone else went out and explored. I have no memory of this, thankfully. :-)

This time, I was miraculously healthy... I'd like to give major props to the Purel Hand Sanitizer people... that stuff works! We stayed at the Park Guest House, which was an ashram founded with the intent for meditation, and finding inner peace. I'd say that inner peace was found when we stepped into our room that faced the sea and I felt the cool ocean breeze. I went on some great morning runs as the sun rose, and had fun exploring the town's restaurants and specialty shops. Pondicherry was known for paper (produced in a nearby town called Auroraville originally founded with the intent of making it a utopia of sorts) , and incense. I'll post pics soon!

I also had my first yoga lesson! The girls and I went to this place suggested by our guide book and enrolled in a class. At first it was pretty fun, later I began to realize that this yoga instructor guy was a little um, intense. I was doing the serpent pose ok (where you keep your hips on the ground then curl your upper body and head upward) then he had us flex our legs at the knees and raise our legs upward... then he was like "ok now touch your toes to your head!" Suuuuuure... I kind of half tried, then he comes behind Amy and I and then knees each of us in the back! I then realized that I am much more flexible than I thought. And he did too because he said "look! only six inches between toe and head. you will touch." Then he proceeded to try and pull my toes to my head. At this point all I could think about was disc dislocation or spinal cord impingements or... what if my spine just cracked in half? You never know these days. I politely declined (in a falling over in pain "I give up" sort of way.) I think I'll save that for yoga lesson number two...

Thankfully my back is no longer sore. Amy, Sarah and Edna assured me that yoga usually isnt this brutal, but aside from being whacked at occasionally it was surprisingly very energizing! But, for now I'll stick to my running and rocks. :-)

I later learned that this part of town (The east I think) was called "white town" as I noticed very few Indians around who were not tourists. The west side was where the Indians lived and no doubt had more restaurants more affordable to them. This made me wonder about how different things may have been if the Europeans didn't try to take over the world. This might be something to read up on also, I know a lot of good came out of it, but also a lot of things the Indian governement still has to overcome. For example, I've heard corruption in India is pretty rampant still, but I haven't witnessed any yet, only incredibly friendly people.

Another thing... what is going on with the US? More troops in Iraq? And air strikes over Somalia? And no protests in America over this? The majority surely cannot support this. I wonder if Americans could see how the rest of the world lives and how privileged we are in comparison, if they would feel the same about the actions our country is taking. Just a thought.

Day 5-6: Does an embryo have a soul?

I’ve learned that the doctors on the pediatric service like pimping students. But, their pimping is quite different. The first such adventure I had was when a doc held out a little girl’s hand to me and said “ok what is the diagnosis?” To his credit, he did say that the girl had recently undergone a bowel resection and whose CBC showed anemia. But, all I could think was “wow that girl’s hand looks really normal!" It turned out that her knuckles were actually hyperpigmented, as were her lips, which are common signs of Vitamin B deficiency. He looked quite pleased that he stumped the American medical student who has never seen it before, but I plan to redeem myself… somehow.

I’ve appreciated the teaching here so much. Even though the docs have so many patients to see, and even though most of the patient encounters occur in languages I can’t understand, they always seem to make it a point to teach me something. And in incredibly nice ways. Like the doctor at the HIV clinic today who started mapping out the different stages of infection, and what the CD4 counts mean at different ages in between seeing patients. Or the Resident who always makes sure I understand what the disease is before she continues to explain the patient’s plan.

The Doc at the Pediatric HIV clinic pimped me too. He asked me "Does an embryo have a soul?" Of course I didn't know (again) and then he said to check out this lecture that afternoon, which I did. It was fantastic, it was led by an endocrinologist from Singapore who taught ethics, and compared the views of world religions toward stem cell research, and the use of embryos. It was the most unbiased ethical talk I've been to, and I really appreicated the neutral and enthusiastic attitude of the speaker. The discussion afterward was fun too, with surprisingly strong opinions surfacing and good questions being asked. But, now I definitely feel more informed and understand why there's so much conflict going on in the US about the issue.

One patient we saw yesterday had Pierre-Robin Syndrome, which I’ve read about but never seen before. I took a pic because I thought he was the cutest kid ever! He looks a little unhappy in the picture, but right after I took it, he blew me a kiss!

Today I had the chance to do the RUHSA clinic, which is CMC's rural outreach program. We went to the outpatients clinics, and my resident saw a ridiculous amount of patients... it must have been close to 40 in a few hours. And, on no sleep. Here the residents take call every other night and admit patients overnight twice a week. Last night she admitted 14 new patients and didn't sleep at all. They don't have post call days here... so she was still at clinic, and as the senior resident was helping the other interns with difficult clinic cases and just as pleasantly as she was when I saw her yesterday. I'm still in awe. I don't think I could ever complain about q4 call as an intern again... wow. I've included a few pics of the clinic here too.

It's been fantastic on Pediatrics, and I'll be sad that tomorrow is my last day. But, after a nice weekend lying on the beach with the other uthscsa med students in Pondicherry (did I spell that right?) I'll be starting neurology! I wonder if they do the hop on one leg exam thing here too. :-)

Day 4: Vodai for breakfast!

I've been to India a fair amount, but I definitely feel like a foreigner each time I go. Which in some ways is a little frustrating. I wish I could speak the language, be able to explain certain customs, and know what certain dishes are called, especially when in the US people usually think of me as Indian. Which, I am... just a very um, foreign kind.

It's kind of neat being here in Vellore because of the international student population. I've met exchange medical students from New Zealand, the Netherlands, and even Boston. The most surprising thing happened when we went to take pictures for the student registration. The store owner took my picture and when I wrote down my name he exclaimed "oh! that's an Indian name!" I should have said "because I am Indian!" but then remembered that, technically I'm American, not Indian since really the US is just a mix of cultures. Then I wondered... aren't we all American in the US? Why classify us into different ethnic groups when in reality we all would feel like foreigners when we went to those countries?

But, that doesn't change the fact that I love it here. I loved being able to wake up in the morning and have... VODAI! (pronounced wuh-duh, but very quickly, and with conviction.) And, we went to the CMC campus, which was beautiful... so many flowers and very quiet. The students actually have a weight room, I was impressed! we didn't get a good look, but I'm guessing it just might rival UTHSCSA's gym. And check out the box marked "terrestrial magnetism." Ooooh.

Hmm... patient stories. The hospital is really awesome, I'm amazed at how the docs are such great teachers. I think it also takes a real skill to be able to work with such little resources that are available to still treat patients. It must be frustrating too, to know what needs to be done for patients and not be able to do it.

I learned that here at the CMC they don't prescribe antibiotics until at least 5 days into an infection, especially if the patient is stable. This is partly because usually the infection tends to be viral, and also to prevent resistance to antibiotics. Apparently outside physicians in India may be quicker to start them. I thought this was pretty cool, but did question it when I saw an 11 year old boy on the ward with meningitis for the past 3 days and splenic lesions (awaiting a CT) who wasn't on anything yet. But, he was stable...

I also learned a bit about infant nutrition, and how sometimes mothers who can't breast feed are told to use boiled cow's milk with coconut oil to help digestion. I wonder how that would work in SA as well, with the parents who can't afford formula and dilute it with water (which is really bad for babies.)

Hmm... that's about it for now. It's been kind of interesting being the only one that doesnt really need to "adjust" to the culture shock of a new country. For Frank and Edna's stories, check out their blog site! All right... more later!