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...

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!