CMC - Day Two

The average Indian, i've been told, consumes 10-15 portions of milky sweet tea per day. It's called chai, and anyone who has had Indian chai will know that there's nothing like it. To ride a train in India and to hear the chai wallah bellowing deeply, "CHAI...CHAI...CHAI" is music to the ears. In Vellore, like most Indian cities, there are chai stands everywhere and it is the first order of duty each morning to pull up a plastic stool, order "ek (one) chai", and watch the morning go by. One chai costs about 2.5 Rupees,(at 45 Rs to the dollar). An avid coffee drinker at home, i'm trying to take a holiday from the black gold; chai is an excellent substitute. That said, i wasn't sure how much chai i would need to keep me awake during a morning of rounds on the paediatrics ward.

This morning i met Dr. Valsan - Drs get called Dr. [first name] here. He is a paediatrician and ID specialist here at CMC. I realized very quickly that i wouldn't need much tea to learn from this excellent teacher. Dr. Valsan's style of teaching is, unfortunately, a dying art. At least in my experience. Bedside rounds are more than just a name given to a quick presentation of patients and review of the night's events. Rather, each patient is a course in and of itself. A child with persistent pneumonia became a foil to learn not just about the typical (and atypical) causes of persistent and recurrent pneumonias, but also the rates of respiration which predict pneumonia in a given age group (observed and reported here at CMC and now adopted by the World Health Organization), the clinical course of obstructive pneumonias, the common complications of pneumonia in a child, and the treatments for each. Symptoms and radiologic findings were correlated with physical exam findings. To see a physician put his head close to an 8 month old childs chest and percuss (tapping to listen for characteristic sounds) the entire chest for the slightest difference in sounds is something of which the physical diagnosis textbooks would be proud. It is also rare. The radiography was correlated with the laboratory work was correlated with the physical exam in an elegant performance called clinical medicine. Questions were asked of the students and the residents in a way meant to encourage learning, not to reflect hierarchical bullying. To be fair, i've never felt bullied at UVM, but one hears about it elsewhere.

For the medical folks, we examined children this morning with ketotic hypoglycemia (presenting with seizures), autoimmune hemolytic anemia, bacterial meningitis, post-streptococcal glomerulonephritis, Henoch-Schonlein purpura., Methylmalonic acidemia, and a snake bite. Dr. Valsan spoke at length about each of these conditions, including in some cases the history of their discovery, how the condition affected the child at hand, and how we would treat the condition. Importantly, he was always aware about how the cost of care for one child would impact his ability to care for others. As the consulting/attending for the department, he, and not a hospital administrator, decides who's care the hospital will pay for. Therefore care must be cost-effective.

He gave as an example a child with mumps, a disease rarely seen in the U.S. 60% of all children with the mumps get an aseptic meningitis. So, when the mother of a child with mumps comes in saying that her child has had changes ni mental status, coordination, whatever, rather than run all the tests to confirm that the child has a meningitis, you can tell the mother to give the child a paracetemol/tylenol and be pretty comfortable that the child will be just fine. This type of medicine is practical, cost-effective, and, in the U.S., rare. In the U.S. he might get an LP, an MRI, and a bazillion other tests to confirm something that is a known statistical likelihood. Unfortunately, few American families and even fewer Indian families can afford that type of "care." The threat of litigation is part of the problem. The structure of our healthcare system is a bigger problem. Don't get me started.

One child was a case-study in why preventative medicine is so important. Vaccinations are a relative success for medicine in America' one of them prevents measles. We saw this morning a 9 y.o. boy with subacute sclerosing panencephalitis, an incurable complication of infection with the measles virus. What began as myoclonic seizures when the boy would walk had progressed to spasticity in the muscles that would leave this boy a spastic quadraplegic. While antispasmodic drugs might help, this boy will be, according to Dr. Valsan, "deaf, blind and dumb," a grim prognosis. The boy's mother sat with him in her arms and rubbed his limbs and joints, hoping, i know, that it would all go away. The bad news is that such complications are tragic. The good news is that they are rare. The better news is that they are completely preventable. If we can understand one day that exercise, a healthy diet, and no tobacco are as important as vaccines, and that the complications of foregoing them are almost as awful as what this boy is experiencing, then perhaps we will learn to fund healthcare differently, and we will be, as a society, much better off.

The walls of the hospital wards are dirty, the beds ancient and in places rusted, and the facilities appear, by our standards, outdated; but the care that is delivered within this hospital appears first rate. It is practiced with the mindfulness not only of one child's health, but with the health of all the children potentially served by this hospital (that's the whole subcontinent). And the population as a whole will benefit.

I had an excellent morning, experience the kind of teaching i had come here to find. I'm looking forward to a great few weeks.

best,
justin

ps. in the Paediatric ICU, one wears special ICU flipflops that have been sterilized. I have photos to prove it.