On a narrow dirt trail that edged its way through neon green rice paddies, Jinu told us about a young women who lives in the house from which we'd just left, outside the village of Kamasamudram, pop. 1700. She had recently delivered a child at 33 weeks gestational age (of the expected 40) in the back seat of an auto-rickshaw en route to CHAD, the Community Health And Development hospital I've written about previously. The baby survived without complication, but his mother was still in the hospital, having suffered from post-partum hemorrhage and, later, disseminated intravascular coagulation (DIC), a very serious hematological response that can occur as a result of severe illness and that predisposes one to dying. Over the course of three weeks in the intensive care unit, she had stabilized. Jinu's purpose in visiting the house was to better assess their economic status, so the hospital would know how much, if any, they could pay of the enormous medical bill that they had recently issued.
I realized that these CHAD nursing visits to the villages that lie in the 88 village catchment area (I'd previously been told, and written, 69 villages) were about more than the ante- and post-natal visits that had occupied much of the morning, and would occupy much of the afternoon. The community nurses spend 5 days a week touring the villages, working with the assistance of "pitchus" (the part time community health workers) and hospital-trained health aids that oversee them, and to follow-up and prepare for the doctors visits that take place in each village once a month. Today, my last at CMC, we would visit eight villages, ranging in population from 1700 to 114.
Jinu, in her sky blue cotton sari, shielded herself from the bright sun with a black umbrella as she led our group of four to the next home, a mud-brick and thatch dwelling that we could see in the distance beyond a large banyan tree and a herd of contented cows. Behind her was the regional health aid, who assisted the pitchus of the 8 villages, and who wore her faded pink sari with a dignity that matched the severity of the tightly drawn skin of her aging face. Kevin, a very nice medical student from St. Louis, and I followed. The banyan tree was decorated with large cotton satchels hung from its branches and aerial roots. Inside them, we learned, were the placentas of a generation of cows, saved and displayed to increase the yield of the cow's milk that would feed not just the calves but the villagers.
We arrived at the mud home and stepped past the delicately drawn kollam, intricate chalk floor-drawings that sit at the entrance to, and serve to welcome the gods into, the home. A young women with a swollen belly sat on the front step in front of a darkened entrance, her face yellowed from the turmeric powder that I would see on women throughout the day, particularly the pregnant ones. Kevin told me the story of the Tamil prince who'd gone to China, fallen in love with a Chinese woman, and returned home with a new taste in skin color, to which generations of women that followed would aspire. The woman was 26 years old. Married at 16, she'd suffered through 10 years of infertility. Traditionally, women are expected to conceive within the first year of marriage, and I hoped quietly that she'd not been punished by her husband's family for a transgression that was not her fault. We were invited in to do the prenatal visit with Jinu, taking her blood pressure, measuring the height of her uterine fundus, listening for the fetal heart beat. As with several of the 20 or so that we would see throughout the day, we referred her to the hospital for further evaluation of edematous feet and a slightly elevated blood pressure, possible evidence of impending pre-eclampsia. Concerned for this precious child, I'm sure she won't hesitate to seek care.
In Mothakkal, a village of 200 people about 1km from the small country lane where we parked, we met a 25 year old torn between excitement at the birth of his son, a beautiful and healthy child, and worry for his 49 year old mother. Within the past few months she'd been diagnosed with chronic kidney failure as a result of long-standing high blood pressure. The hospital had recommended twice-weekly dialysis, which, at the cost of 5000 Rs per month, was beyond their ability to pay. Even if they could pay, the 2km walk to public transport was prohibitive in her frail state. She looked ill, fed up, exhausted. She will likely die soon. Outside of her clean, brightly painted mud hut a group of grandmothers sorted peanuts and shared gossip, both freshly harvested from the surrounding fields.
As the day wore on, we visited Mothupullam (pop. 900), Chinumothupullam (pop. 114), Kallamburam Kottai (pop. 370) and others. The sun started to fall in the west and we started our journey home, stopping at a busy rural junction for chai. A young boy delivered it from the chai-stand across the road from where we parked. We watched a family of monkeys play on its tin roof, some peering over the edge to stare at the men taking tea.
It was a wonderful final day at CMC, going out to see the village of the families and children that would hopefully stay out of the inpatient wards where I started my month. It was great for the same reason that all home visits are: you understand people's health in the greater context of their lives. You see the fields in which people work, the houses where they make and raise their children, and where they will likely spend their final days. Sometimes all of these things are taking place under the same roof at the same time.
Having been in Vellore for four weeks, some final thoughts are in order. Being in one place has made me think about the difference between living in a place and just visiting. One could easily say that I've just been a visitor here; that is of course true. However, I would suggest that visiting a place requires only a certain level of engagement, one that demands very little of the visitor. Just the other day i sat on a plastic bag on the side of a road as a man replaced the soles of a month-old pair of sandals (or chappals) that i'd already worn through. I made a phone call one day and felt cheated when the man told me to hang up and then demanded that i pay. I refused. He yelled. I yelled back. He slammed his fist on the desk. I stormed out. India taught me several years ago what it is to be angry, what it is to release that anger, and what it is to feel better having done so. Among the places i've traveled, India is unique in that it forces on to respond to the environment in a deeper way. It overloads the senses and waits for one's reply. It pushes one to extremes of rage so that one may know true peace. It forces one to step through filth in order to find its incredible beauty. It makes me feel as if i've lived here, if not now then sometime before, because there are few places in which i felt so alive.
All that said, i'm looking forward to coming home (and to coming back). Thanks for putting up with my daily emails. Knowing that some of you (mom) are reading these has made me look at every experience and every day a bit more closely. Experiences, like food, are better when shared; mine has been made more rich because of you.
Sunday, March 25, 2007
CMC - Day Nineteen
It would appear that my encounter with the horse - which i've been advised, in one of several supportive emails, that i should have bitten back - was merely coincidental in its timing in relation to the flu-like illness that felt so disabling yesterday. Today i feel better - less feverish, less weak - and i've ventured into the hospital to prepare for a talk i'm giving this afternoon on pediatric asthma treatment guidelines. I won't bore you with the details. There is a quotation often (and apparently mistakenly) attributed to Ralph Waldo Emerson and the last line of wich goes something like this: ..."to know that even one life has breathed easier because you have [lectured]. This is to have succeeded." Surely, to lecture on treating asthma is a way to find success.
Today is Hospital Day at CMC and the campus is abuzz with this annual showcase of the hospital and its departments. Set up under three massive and brightly coloured tents in a large parking lot across from the hospital are no fewer than 60 booths displaying the departmental displays, in addition to carnival type games, food stalls, and hospital-associated vendors. The women from CODES, the COmmunity DEvelopment and Society group, a project jointly coordinated by CHAD and the communities to create disposable income for families, are there selling their handicrafts. Reprentatives from the leprosi hospital, Karigiri, are selling their printed fabrics. A large section is cordoned off where medical students are giving free health check-ups for the public. The festive atmosphere and this great display of informational public health lifted me right out of my lethargy.
The department of Pharmacology had a busy and crowded display of posterboards, dioramas, and models depicting pharmacuetical classes, tips for travel and appropriate storage, adverse effects, and routes of administration. A large foam-board image of the front of a man had an inhaler stuck in his mouth, several needles stuck into the foam body, indicating subcutaneous, intraveinous, and intraosseus (into the bone) routes of administration. The adjacent poster depicted a less fortunate man from behind with a large needle jutting out of his painted pink buttock (intra-muscular) and a suppository pushed into his foam bum (rectal). A large foam house diorama sat beneath a foam archway that read, "Keep drugs away from children." Inside the house various acts of accidental ingestion were taking place by little child dolls. Plastic bags of toxic substances surrounded the house, labeled for recognition.
A display at the Obstetrics and Gynecology department depicted the Desert of Gestational Diabetes Mellitus (GDM). Small yellow foam footprints headed in the direction of the road to management, each representing a symptom of GDM: weight gain, hyperglycemia, excessive thirst, and excessive urination. They were placed to aoid the small green foam cacti that represented GDM risk factors: maternal age greater than 30 years, family history of diabetes, recurrent abortions and obesity. A sign in the middle said "Decide Your Path? Which Way?", and signs pointed in the direction of "management" or "complications." On the road to the oasis of management were signs outlining the appropriate steps to monitor GDM - "visit 15 days once till 28 wks, then weekly to term;" "maintain good personal hygiene;" "adequate fluids." Inside a cool blue pool at the end of the management road, surrounded by foam palm trees, one could find "scans" and "drugs" and "investigations." Taking the other route, one found the pyramid of complications, a large Egyptian tomb labeled "macrosomia" (big baby), "congenital malformation," "still birth," "infection/UTI."
One large poster in the background showed the male reproductive system pre- and post-vasectomy. I learned at CHAD the other morning that vasectomy is basically a non-option for Indian males. Not even the women want their husbands to have vasectomies, so powerful is the perception of that certain display of male virility. The hospital is trying to promote it more and more as women are rushing after one or two childbirths to have "tubectomies." This wouldn't be seen as problematic except that so many of the women requesting them are in their early early 20s.
The Department of Cardiology's Planet Heart had row upon row of coloured diagrams depicting the flow of blood through the four chambers of the heart. The Nephrology Department displayed glamorous glomeruli lit up with chains of flashing lights indicating the flow of blood and then urine. The pathologists had their rows of microscopes out for the public scrutiny of various tissue samples. The anatomists had a remarkable display of fetal crania. The dentists had dentures and a smile contest for kids. The operating theatre had a foam diorama that looked like a scene out of "Team America:" a team of puppet size dolls were in the middle of a C-section on a doll that was about a third of their size. "The patient seems awfully small," a young girl pointed out in a beautiful Tamil lilt, before giggling.
A voice interrupted the music: "The 9th grade students of the Ida Scudder school would like to dedicate a song from the film 'Arrop' for their beloved teacher Padmini."
I turned around to see a poster of a women being set on fire, perhaps by her angry inlaws. Such incidents are surprisingly and unfortunately common, even today. The Department of Plastic Surgery depicted how people became burned, the complications of such burns, and photos of their successful repair of the damage. A sign warned in four languages: "No loose and flowing clothes while cooking;" and "never keep the oil lamps and candles near the cot (or) curtains at home when all are sleeping." Next door the department of radiology had a large poster that said, "RADIATION: Friend or Foe?" Flanking this question was one photo of a man being hugged by a large white tiger and, on the other side, a man pointing a gun towards the reader. Not sure what they were trying to get across.
A rather progressive display came from the women of Waste Management, the girls in green saris that can be found on every campus collecting refuse. They had a bucket full of warms displaying thier composting techniques, plastic bags displaying each type of trash collected, and a poster asking us to do our part by not using that plastic bags that are ubiquitous in every aspect of shopping. They are, i'm afraid to say, ahead of their time in India.
Perhaps the most impressive display was a large papier-mache mountain decorated with temples and cities, farms and villages, each depicting a component of the endocrine system. The hypothalamus, a large electricity tower at the top of the mountain, connected to the pancreas, a city full of pizza huts, soda fountains, and ice cream shops. The parathyroid gland - "This is the area of moans, bones, and groans," i was informed by the eager attendant - was a cemetary. Two villages, side by side, represented the hyperfunctioning and hypofunctioning thyroid gland. In the former, skinny farmers rushed about through lush rice paddies. In the latter, lazy farmers and fat cows wallowed around unkept fields.
I've been struck, in the past few weeks, at how alienating it must sometimes feel to be a patient at CMC, the doctors interviewing in the native language but always discussing the cases in english in front of the patient. In medicine we do so much to distance ourselves from patients, from wearing white coats to speaking a language no one understands. To see such a massive outreach to the public in the form of such earnest and elaborate educational tools - in English, Tamil, and other languages - was quite heartwarming. People were learning about what they could do to improve and maintain their health, what the hospital could do in the event that they didn't succeed, and they were having a ball. This was something everyone seemed to be proud to be a part of.
Maybe we need a hospital day back home?
Today is Hospital Day at CMC and the campus is abuzz with this annual showcase of the hospital and its departments. Set up under three massive and brightly coloured tents in a large parking lot across from the hospital are no fewer than 60 booths displaying the departmental displays, in addition to carnival type games, food stalls, and hospital-associated vendors. The women from CODES, the COmmunity DEvelopment and Society group, a project jointly coordinated by CHAD and the communities to create disposable income for families, are there selling their handicrafts. Reprentatives from the leprosi hospital, Karigiri, are selling their printed fabrics. A large section is cordoned off where medical students are giving free health check-ups for the public. The festive atmosphere and this great display of informational public health lifted me right out of my lethargy.
The department of Pharmacology had a busy and crowded display of posterboards, dioramas, and models depicting pharmacuetical classes, tips for travel and appropriate storage, adverse effects, and routes of administration. A large foam-board image of the front of a man had an inhaler stuck in his mouth, several needles stuck into the foam body, indicating subcutaneous, intraveinous, and intraosseus (into the bone) routes of administration. The adjacent poster depicted a less fortunate man from behind with a large needle jutting out of his painted pink buttock (intra-muscular) and a suppository pushed into his foam bum (rectal). A large foam house diorama sat beneath a foam archway that read, "Keep drugs away from children." Inside the house various acts of accidental ingestion were taking place by little child dolls. Plastic bags of toxic substances surrounded the house, labeled for recognition.
A display at the Obstetrics and Gynecology department depicted the Desert of Gestational Diabetes Mellitus (GDM). Small yellow foam footprints headed in the direction of the road to management, each representing a symptom of GDM: weight gain, hyperglycemia, excessive thirst, and excessive urination. They were placed to aoid the small green foam cacti that represented GDM risk factors: maternal age greater than 30 years, family history of diabetes, recurrent abortions and obesity. A sign in the middle said "Decide Your Path? Which Way?", and signs pointed in the direction of "management" or "complications." On the road to the oasis of management were signs outlining the appropriate steps to monitor GDM - "visit 15 days once till 28 wks, then weekly to term;" "maintain good personal hygiene;" "adequate fluids." Inside a cool blue pool at the end of the management road, surrounded by foam palm trees, one could find "scans" and "drugs" and "investigations." Taking the other route, one found the pyramid of complications, a large Egyptian tomb labeled "macrosomia" (big baby), "congenital malformation," "still birth," "infection/UTI."
One large poster in the background showed the male reproductive system pre- and post-vasectomy. I learned at CHAD the other morning that vasectomy is basically a non-option for Indian males. Not even the women want their husbands to have vasectomies, so powerful is the perception of that certain display of male virility. The hospital is trying to promote it more and more as women are rushing after one or two childbirths to have "tubectomies." This wouldn't be seen as problematic except that so many of the women requesting them are in their early early 20s.
The Department of Cardiology's Planet Heart had row upon row of coloured diagrams depicting the flow of blood through the four chambers of the heart. The Nephrology Department displayed glamorous glomeruli lit up with chains of flashing lights indicating the flow of blood and then urine. The pathologists had their rows of microscopes out for the public scrutiny of various tissue samples. The anatomists had a remarkable display of fetal crania. The dentists had dentures and a smile contest for kids. The operating theatre had a foam diorama that looked like a scene out of "Team America:" a team of puppet size dolls were in the middle of a C-section on a doll that was about a third of their size. "The patient seems awfully small," a young girl pointed out in a beautiful Tamil lilt, before giggling.
A voice interrupted the music: "The 9th grade students of the Ida Scudder school would like to dedicate a song from the film 'Arrop' for their beloved teacher Padmini."
I turned around to see a poster of a women being set on fire, perhaps by her angry inlaws. Such incidents are surprisingly and unfortunately common, even today. The Department of Plastic Surgery depicted how people became burned, the complications of such burns, and photos of their successful repair of the damage. A sign warned in four languages: "No loose and flowing clothes while cooking;" and "never keep the oil lamps and candles near the cot (or) curtains at home when all are sleeping." Next door the department of radiology had a large poster that said, "RADIATION: Friend or Foe?" Flanking this question was one photo of a man being hugged by a large white tiger and, on the other side, a man pointing a gun towards the reader. Not sure what they were trying to get across.
A rather progressive display came from the women of Waste Management, the girls in green saris that can be found on every campus collecting refuse. They had a bucket full of warms displaying thier composting techniques, plastic bags displaying each type of trash collected, and a poster asking us to do our part by not using that plastic bags that are ubiquitous in every aspect of shopping. They are, i'm afraid to say, ahead of their time in India.
Perhaps the most impressive display was a large papier-mache mountain decorated with temples and cities, farms and villages, each depicting a component of the endocrine system. The hypothalamus, a large electricity tower at the top of the mountain, connected to the pancreas, a city full of pizza huts, soda fountains, and ice cream shops. The parathyroid gland - "This is the area of moans, bones, and groans," i was informed by the eager attendant - was a cemetary. Two villages, side by side, represented the hyperfunctioning and hypofunctioning thyroid gland. In the former, skinny farmers rushed about through lush rice paddies. In the latter, lazy farmers and fat cows wallowed around unkept fields.
I've been struck, in the past few weeks, at how alienating it must sometimes feel to be a patient at CMC, the doctors interviewing in the native language but always discussing the cases in english in front of the patient. In medicine we do so much to distance ourselves from patients, from wearing white coats to speaking a language no one understands. To see such a massive outreach to the public in the form of such earnest and elaborate educational tools - in English, Tamil, and other languages - was quite heartwarming. People were learning about what they could do to improve and maintain their health, what the hospital could do in the event that they didn't succeed, and they were having a ball. This was something everyone seemed to be proud to be a part of.
Maybe we need a hospital day back home?
CMC - Day Eighteen
I'm afraid to say that the most interesting patient i've seen today is...ME! I haven' t the energy to string this into a story about an Indian romance gone wrong, but I had a rather unfriendly encounter with a beautiful young painted horse. I came away with a bruised ego and something like a love bite on the shoulder. The police officer standing by warned that i should get "a shot" or face a fever. Having not broken the skin, and having been up to date on my tetanus, and unawares about any Indian equine fevers, i ignored his advice. I woke up this morning without a fever but not feeling well otherwise. The doctor in the emergency room, to which i was sent by are slightly overprotective hostel manager, said he thinks i probably have a viral illness - feels like flu - that was already on its way. He gave me some antibiotics to prevent a skin-infection where the horse bit me. He also told me to call him at home if it got worse. I'm going to try to be a good patient.
In case anybody (read Mom) is concerned, i'm in the best place possible to be sick in India. I'm surrounded by talented physicians trained all around the world and the best facilities this side of the Kaveri river.
I was supposed to spend the day with CHAD nurses visiting villages. Perhaps i'll have something to write about that on Friday.
I won't write much more than this: health is something we too often take for granted.
I'm going to lie down.
justin
ps. The temple in Vellore's impressive fort, outside of which i was bitten, houses some of the most impressive and intact temple carvings i've ever seen. Highly recommended to those who might otherwise skip over Vellore.
In case anybody (read Mom) is concerned, i'm in the best place possible to be sick in India. I'm surrounded by talented physicians trained all around the world and the best facilities this side of the Kaveri river.
I was supposed to spend the day with CHAD nurses visiting villages. Perhaps i'll have something to write about that on Friday.
I won't write much more than this: health is something we too often take for granted.
I'm going to lie down.
justin
ps. The temple in Vellore's impressive fort, outside of which i was bitten, houses some of the most impressive and intact temple carvings i've ever seen. Highly recommended to those who might otherwise skip over Vellore.
CMC - Day Seventeen
Chettinai is 65 years old with long grey hair in the early matted stages of imminent dreadlocks. I first noticed her huddled in a dark corner, squatting on her calloused and cracked heals in a filthy green silk sari. The carried the strong smell of an infected wound. Without a blouse her sagging wasted breast could be seen hanging near her waist. A woman, a relative perhaps, yelled at her, beckoning for her to move to a proper seat amongst those others waiting for their appointments. Others, employees, tried to do the same. The women shook her head. She had the crazed look of an animal trapped in a corner, one who only wants to find a place to hide.
During my first week of rotations, in an outpatient session for Child Health I, i noticed a sign in the general OPD (outpatient department) building that said Palliative Care Service. I found this surprising, knowing how underdeveloped such services are meant to be in the developing world. From a resources point of view, palliative care is a more efficient way of taking care of people with terminal illnesses but this is a realization that is coming slowly even at home - refer to the unchanging Medicare Hospice benefit. From a care point of view, palliative services are the most efficient at attending to quality of life when life is limited. I should have expected that CMC would have figured that out.
As this is my last week, i have the chance to float around a bit, and i spent the morning with the palliative care service, headquartered in a 10'x10' room in a corner of the OPD. As many of you know, this is a particular interest of mine, and I immediately felt at home amongst this Hamilton, one of two chaplains on the service (the other being his wife) sat me town and introduced me to the service. The three doctors, two nurses, two chaplains, one social worker and one secretary offer outpatient and home based services to (mostly) cancer patients. This is because, Dr. Rina, head of the department is a radiation oncologist and because HIV patients are taken care of by the HIV team at the end of life. Also, those with degenerative neuromuscular disorders ( e.g. ALS, or Lou Gehrig's disease) are taken care of by neurologists. The team sees approximately 30-40 patients per week in the OPD and 30-45 per week on their home rounds. Their catchment area is an approximately 50 kilometer radius from the hospital. On the mondays and wednesdays that they do home visits the might spend the whole day travelling. They only rarely have inpatients, most of whom come for one procedure or another, because most people want to die at home. A Catholic charity nearby is scheduled to open a 50 bed hospice soon, however, and the CMC palliative care service will provide medical care. Hamilton thinks they will have difficulty filling it. Based on what i've seen at home, how desperately the services are needed, i think they'll be full. Istn' it true that "if you build it, they will come."
The soft-spoken and eloquent young chaplain explained that the service has two primary goals, one to provide patient care, the other to educate about palliative care. Since the department opened four years ago they have made great strides in meeting both. Within the hospital they are now a well and increasingly known referral service and their patient rosters continue to grow as a result. As a result of several donations, they are basically able to provide this care for free. It is not preferentially distributed to those who can afford it. On the education front they have institutionalized their efforts in many ways, providing one week of mandatory training to the undergraduate medical students. Proactively, they are currently encouraging the government to make it a mandatory part of medical education in every Indian medical school. Oncology registrars spend one month per year for two years in the service, and they have initiated a one year post-graduate fellowship in palliative care, the first of its kind in India. The team also invites teams of social workers, chaplains, nurses and physicians from smaller hospitals to complete short training courses so that they may start their own services. All of these educational programs will be run from the first floor of the new hospice building, which will also have housing for residents, fellows and visitors from abroad. It sounds an exciting project. Harrison will be renouncing his role as a chaplain and taking over as director of programming, which will add a new dimension to the teaching he does currently on the spiritual aspects of dying and palliative care.
It all sounds great, and yet their optimism about and pride in their service is coupled with a humility that comes from doing a very difficult job. Chettinai is a case in point. The women who yelled at her to be seated in the waiting room is her daughter-in-law, with whom she lives, along with her two granddaughters. Her son, the father of the grandchildren, died some time ago and the daughter-in-law has been left alone to care for her. This is a difficult task. Chettinai has a type of cancer called spindle cell carcinoma, a malignant epithelial cancer that has eroded through the skin under her right axilla (armpit) and grown like a mushroom into a large fungating mass about the size of a small melon. The infected white flesh had a sheen of oozing fluid. The skin that used to cover the mass hangs on if dried pieces. If you think it's unpleasant to read about i can assure you the sight was far far worse. As was the smell. The young, sweet and very competent physicians with whom i worked explained Chettinai's story.
Even when her husband was alive, she was used to being the boss in the family. When he died, not much changed, except there was less money to go around. She, her son's wife, and two daughters were dependent on her son for their welfare. But she was still the boss and, as in many families, expected to be catered to in her old age. When her son died, i'm not sure how, she might have known about this strange growth under her arm, but i'm not sure anyone else did.
Her daughter-in-law looked strung out, her last nerves worn ragged by taking care of a seemingly unappreciative woman as well as her two daughters. Tears fell intermittently from her tired face. Chettinai, ruling the roost, doesn't seem to let her do anything, including change the dressings that she needs to have changed twice daily or work, which she must do to earn money to feed everyone. Her daughter-in-law defies her, working two days a week, leaving her two frightened daughters at home with a women who smells tremendously and acts strangely. She's come home to find Chettinai in the care of her neighbors after this frustrated, pained (because she refuses her pain meds), and increasingly lonely old women laid herself out on the train tracks to end her life. She worries constantly about her daughters and this morning left to chase her mother-in-law - who left for her appointment alone and without warning - leaving them without food for breakfast.
Chettinai mumbles in pain to the nurse who changes her dressing, lifting matted spiderwebs of dirty hair from the unclean and ragged surface: 'No one wants to come near me. They're afraid it's contagious. My granddaughters won't even come close. Why can't you just give me medication to kill me.' And yet she refuses to take the medications and allow the care that might improve these problems. What is worse, the cancer is malignant but hers will likely be a slow death.
They cannot afford their medications, and they are already given concessions. Their is another son, but he remains aloof. He seems to have abandoned them all to their fate. Their is the new hospice, but the mother refuses to move from her children's home. She seems not quite right, like she could use psychiatric care, yet she remains alert, oriented, without delusions. All of this troubles the team and they spend thirty minutes discussing what exactly to do. In the end, there is no conclusion. They will write for new medications, encourage the mother to accept her daughter-in-laws care, and encourage the latter to be patient with her. Caregiver burnout is a common problem in end-of-life care provided by families. Usually there are resources to support these caregivers. In this case their seem to be none. What can be done?
These are the cases that most challenge palliative care services. Fortunately, they seem to be outweighed by those cases in which individuals and families find meaning, find reward, find each other in the process of dying. It is the challenge of assisting families in this way, of finding solutions when none seem to exist, and of caring for people when there is little time but endless space to do so that holds my interest in palliative care.
During my first week of rotations, in an outpatient session for Child Health I, i noticed a sign in the general OPD (outpatient department) building that said Palliative Care Service. I found this surprising, knowing how underdeveloped such services are meant to be in the developing world. From a resources point of view, palliative care is a more efficient way of taking care of people with terminal illnesses but this is a realization that is coming slowly even at home - refer to the unchanging Medicare Hospice benefit. From a care point of view, palliative services are the most efficient at attending to quality of life when life is limited. I should have expected that CMC would have figured that out.
As this is my last week, i have the chance to float around a bit, and i spent the morning with the palliative care service, headquartered in a 10'x10' room in a corner of the OPD. As many of you know, this is a particular interest of mine, and I immediately felt at home amongst this Hamilton, one of two chaplains on the service (the other being his wife) sat me town and introduced me to the service. The three doctors, two nurses, two chaplains, one social worker and one secretary offer outpatient and home based services to (mostly) cancer patients. This is because, Dr. Rina, head of the department is a radiation oncologist and because HIV patients are taken care of by the HIV team at the end of life. Also, those with degenerative neuromuscular disorders ( e.g. ALS, or Lou Gehrig's disease) are taken care of by neurologists. The team sees approximately 30-40 patients per week in the OPD and 30-45 per week on their home rounds. Their catchment area is an approximately 50 kilometer radius from the hospital. On the mondays and wednesdays that they do home visits the might spend the whole day travelling. They only rarely have inpatients, most of whom come for one procedure or another, because most people want to die at home. A Catholic charity nearby is scheduled to open a 50 bed hospice soon, however, and the CMC palliative care service will provide medical care. Hamilton thinks they will have difficulty filling it. Based on what i've seen at home, how desperately the services are needed, i think they'll be full. Istn' it true that "if you build it, they will come."
The soft-spoken and eloquent young chaplain explained that the service has two primary goals, one to provide patient care, the other to educate about palliative care. Since the department opened four years ago they have made great strides in meeting both. Within the hospital they are now a well and increasingly known referral service and their patient rosters continue to grow as a result. As a result of several donations, they are basically able to provide this care for free. It is not preferentially distributed to those who can afford it. On the education front they have institutionalized their efforts in many ways, providing one week of mandatory training to the undergraduate medical students. Proactively, they are currently encouraging the government to make it a mandatory part of medical education in every Indian medical school. Oncology registrars spend one month per year for two years in the service, and they have initiated a one year post-graduate fellowship in palliative care, the first of its kind in India. The team also invites teams of social workers, chaplains, nurses and physicians from smaller hospitals to complete short training courses so that they may start their own services. All of these educational programs will be run from the first floor of the new hospice building, which will also have housing for residents, fellows and visitors from abroad. It sounds an exciting project. Harrison will be renouncing his role as a chaplain and taking over as director of programming, which will add a new dimension to the teaching he does currently on the spiritual aspects of dying and palliative care.
It all sounds great, and yet their optimism about and pride in their service is coupled with a humility that comes from doing a very difficult job. Chettinai is a case in point. The women who yelled at her to be seated in the waiting room is her daughter-in-law, with whom she lives, along with her two granddaughters. Her son, the father of the grandchildren, died some time ago and the daughter-in-law has been left alone to care for her. This is a difficult task. Chettinai has a type of cancer called spindle cell carcinoma, a malignant epithelial cancer that has eroded through the skin under her right axilla (armpit) and grown like a mushroom into a large fungating mass about the size of a small melon. The infected white flesh had a sheen of oozing fluid. The skin that used to cover the mass hangs on if dried pieces. If you think it's unpleasant to read about i can assure you the sight was far far worse. As was the smell. The young, sweet and very competent physicians with whom i worked explained Chettinai's story.
Even when her husband was alive, she was used to being the boss in the family. When he died, not much changed, except there was less money to go around. She, her son's wife, and two daughters were dependent on her son for their welfare. But she was still the boss and, as in many families, expected to be catered to in her old age. When her son died, i'm not sure how, she might have known about this strange growth under her arm, but i'm not sure anyone else did.
Her daughter-in-law looked strung out, her last nerves worn ragged by taking care of a seemingly unappreciative woman as well as her two daughters. Tears fell intermittently from her tired face. Chettinai, ruling the roost, doesn't seem to let her do anything, including change the dressings that she needs to have changed twice daily or work, which she must do to earn money to feed everyone. Her daughter-in-law defies her, working two days a week, leaving her two frightened daughters at home with a women who smells tremendously and acts strangely. She's come home to find Chettinai in the care of her neighbors after this frustrated, pained (because she refuses her pain meds), and increasingly lonely old women laid herself out on the train tracks to end her life. She worries constantly about her daughters and this morning left to chase her mother-in-law - who left for her appointment alone and without warning - leaving them without food for breakfast.
Chettinai mumbles in pain to the nurse who changes her dressing, lifting matted spiderwebs of dirty hair from the unclean and ragged surface: 'No one wants to come near me. They're afraid it's contagious. My granddaughters won't even come close. Why can't you just give me medication to kill me.' And yet she refuses to take the medications and allow the care that might improve these problems. What is worse, the cancer is malignant but hers will likely be a slow death.
They cannot afford their medications, and they are already given concessions. Their is another son, but he remains aloof. He seems to have abandoned them all to their fate. Their is the new hospice, but the mother refuses to move from her children's home. She seems not quite right, like she could use psychiatric care, yet she remains alert, oriented, without delusions. All of this troubles the team and they spend thirty minutes discussing what exactly to do. In the end, there is no conclusion. They will write for new medications, encourage the mother to accept her daughter-in-laws care, and encourage the latter to be patient with her. Caregiver burnout is a common problem in end-of-life care provided by families. Usually there are resources to support these caregivers. In this case their seem to be none. What can be done?
These are the cases that most challenge palliative care services. Fortunately, they seem to be outweighed by those cases in which individuals and families find meaning, find reward, find each other in the process of dying. It is the challenge of assisting families in this way, of finding solutions when none seem to exist, and of caring for people when there is little time but endless space to do so that holds my interest in palliative care.
CMC - Day Sixteen
Amartya Sen is one of India's most famous academics, having one the Nobel Prize for Economics in 1998. His current professorship at Harvard University followed many years as a Master at Trinity College, Cambridge. In his most recent book, The Argumentative India, he expounds on many things, including the profundity of Indian loquaciousness. He points out, as a representative example, that the longest speech ever delivered at the United Nations, at 9 hours, came from the mouth of Krishna Menon, leader of the Indian delegation in the 1950s.
I was treated to a similar display this morning by a Mr. Ranjit, an administrator at the Community Health and Development (CHAD) hospital that sits at the southern end of the undergraduate CMC campus, to which I moved from the city this weekend. He spoke for three hours without break on all things CMC and the three of us who sat before him were absolutely rapt. I've spent the rest of the day pondering how I might share as much of what he told us without requiring that you spend all day at your computer. (I think I might have failed in that mission.) CMC's hospital would stand alongside some of the most advanced hospitals in the world, such is their capability to provide the latest care in all subspecialties. However, I am more impressed about what CMC has accomplished in the communities that surround Vellore. I'll share with you why.
First, some background. Ida Scudder was the daughter of an American missionary and physician in Vellore in the late 19th century. She was driven to leave her home and to study medicine in America after events which signaled to her – signs from god, she believed – the desperate need for women's healthcare in India.
Ranjit shared with us the story of the night she was approached by three different fathers requesting her help in their wives' deliveries. Ida, 17 at the time, said that she would alert her father, who would attend to the labouring women. The men refused in turn, prevented by culture from allowing a man to help in labour, and left. Without qualification, Ida would not go on her own.
In India, the beating of drums in the mornings means one of three things: a festival is taking place; a couple is to be married; or a death has occurred. Ida awoke the next morning to, what was to her, the ominous sound of drum beats. She asked her butler to find out what was happening and he returned with the news that three women had died in labour in the night. From this she found the motivation that would carry her through medical training at Cornell University, which would help her to start the first all-female medical and nursing college in India and, subsequently, one of Asia's most impressive medical institutions.
Dr. Ida Scudder had two convictions. First, she would train female doctors and nurses to care for all but to guarantee care to women. Second, this care would take place in the community and therefore she would not build a hospital. Her logic was simple: if good care is provided in the community there should be no need for a hospital. Obviously, this latter goal was successful in its failure to be realized (or was it? – more on that later), and I won't go into detail about how a one-room two-bed ward that was deemed a necessity became a 2,300 bed inpatient facility with over 5000 outpatients seen daily, and all supported by a renowned coeducational undergraduate medical college.
CMCs CHAD program began in the 1950s, in order to better serve the community. They realized at some point that, at the same time the hospital and its sub specialist care was growing, the villages that surrounded the hospital were growing successfully and illness rates were relatively low. Physicians and nurses from CMC, mindful of Dr. Scudder's wishes, went out into the community to learn what was going on. Villages in this part of India, if not others, have by tradition one women who serves as a birthing attendant. She is always the wife of the senior member of the caste of barbers – it may or may not be coincidental that the first surgeons were barbers. The daughter in law – who becomes a part of the family in marriage – was trained in succession. The health care workers who witnessed her work relayed to their CMC colleagues that these women were capable midwives, providing excellent obstetric care. They immediately allied themselves with these women, and started to support their work through CMC. The other providers of care were, they found, men of less rigorous training and more lofty perceptions of their own ability, snake charmers. They distanced themselves (and the patients) from these by (falsely) expressing their admiration for them, acknowledging how busy they must be, and informing them that, as a result, they'd consult them only when absolutely necessary. Probable relief on both ends. They only changed one practice of the barber's wives, who traditionally cut the umbilical cord with any old kitchen knife and then packed the wounds with cow dung. Despite the surprising lack of infection that resulted, CMC provided each women with a sterilized birth kit with gloves, half a razor blade and sterile clamps. That was a great success. The "pitchu" (from Part Time Community Health Worker) can be found in every village pointing out the hundreds (or thousands) of children that she helped deliver. And despite the fact that the government mandates that all births take place in hospitals - because of the continued risk of female infanticide and high-risk births - these women still serve a valuable role.
Being community minded, the physicians and nurses at CMC wanted to keep track of the results of all this and asked the traditional birth attendants to keep records. Being illiterate, most of them, this was an impossible task. So CMC hired and trained health aids, who can be recognized by their pink saris and who track health data for a cluster of 3 villages. There is one nurse to three health aids, one doctor to three nurses and three doctors to cover the entire 69 villages that comprise the CHAD catchment area. Here it is by the numbers: The average village has 1500 people, so each "pichu" covers that many; health aids cover 4-5000 people; nurses ~15,000; physicians 45000. Between three physicians they cover approximately 150,000 people. Remarkable! As is how they keep track. Each individual in this catchment area is given a number, based on their age, and on their village, street and home number. The GPS coordinates for each household are kept by CHAD and, in this way, they can track, using digital technology, the spread of disease in the case of an outbreak. Ranjit told us of a recent case in which a "pitchu" and health aid identified a new diarrheal case in one village. Other reports soon came in and they used the GPS technology to plot a map, starting with the first (index) case, of the spread of diarrhea. They were able to recognize that the illness followed the course of a drain. In the village they found that the water pipe ran through the drain and had developed a leak. They contracted to have the water pipe elevated above the drain and repaired. The diarrhea stopped. This is basic new technology used on a large scale with wonderful results. I wonder if the American public would allow their homes to be plotted on GPS and their health monitored so closely. It feels a bit like Big Brother. But in a country where privacy is a non-issue, such things can contribute greatly to the general welfare, and without a fuss.
Ranjit asked us, when discussing the size of the hospital today, its large patient population, and dedicated physicians of every specialty and "superspecialty" (as they say here), if CMC was a success. It was an open question and he wouldn't say what he believed. The most obvious answer would be yes. However, as Ranjit pointed out, CMC would, perhaps, be a much greater success if it was able to provide the type of care - preventative care - in the community that could keep so many of these people out of the hospital in the first place. "If we were really succeeding in our mission," he asked, "might we not need any hospital at all?" I admire the sort of idealism that his question presupposes.
What he is asking is if it is possible to do the job of preventing illness so well that we are hardly needed at all. Do we have the will, the courage, the selflessness to attempt such a thing?
justin
I was treated to a similar display this morning by a Mr. Ranjit, an administrator at the Community Health and Development (CHAD) hospital that sits at the southern end of the undergraduate CMC campus, to which I moved from the city this weekend. He spoke for three hours without break on all things CMC and the three of us who sat before him were absolutely rapt. I've spent the rest of the day pondering how I might share as much of what he told us without requiring that you spend all day at your computer. (I think I might have failed in that mission.) CMC's hospital would stand alongside some of the most advanced hospitals in the world, such is their capability to provide the latest care in all subspecialties. However, I am more impressed about what CMC has accomplished in the communities that surround Vellore. I'll share with you why.
First, some background. Ida Scudder was the daughter of an American missionary and physician in Vellore in the late 19th century. She was driven to leave her home and to study medicine in America after events which signaled to her – signs from god, she believed – the desperate need for women's healthcare in India.
Ranjit shared with us the story of the night she was approached by three different fathers requesting her help in their wives' deliveries. Ida, 17 at the time, said that she would alert her father, who would attend to the labouring women. The men refused in turn, prevented by culture from allowing a man to help in labour, and left. Without qualification, Ida would not go on her own.
In India, the beating of drums in the mornings means one of three things: a festival is taking place; a couple is to be married; or a death has occurred. Ida awoke the next morning to, what was to her, the ominous sound of drum beats. She asked her butler to find out what was happening and he returned with the news that three women had died in labour in the night. From this she found the motivation that would carry her through medical training at Cornell University, which would help her to start the first all-female medical and nursing college in India and, subsequently, one of Asia's most impressive medical institutions.
Dr. Ida Scudder had two convictions. First, she would train female doctors and nurses to care for all but to guarantee care to women. Second, this care would take place in the community and therefore she would not build a hospital. Her logic was simple: if good care is provided in the community there should be no need for a hospital. Obviously, this latter goal was successful in its failure to be realized (or was it? – more on that later), and I won't go into detail about how a one-room two-bed ward that was deemed a necessity became a 2,300 bed inpatient facility with over 5000 outpatients seen daily, and all supported by a renowned coeducational undergraduate medical college.
CMCs CHAD program began in the 1950s, in order to better serve the community. They realized at some point that, at the same time the hospital and its sub specialist care was growing, the villages that surrounded the hospital were growing successfully and illness rates were relatively low. Physicians and nurses from CMC, mindful of Dr. Scudder's wishes, went out into the community to learn what was going on. Villages in this part of India, if not others, have by tradition one women who serves as a birthing attendant. She is always the wife of the senior member of the caste of barbers – it may or may not be coincidental that the first surgeons were barbers. The daughter in law – who becomes a part of the family in marriage – was trained in succession. The health care workers who witnessed her work relayed to their CMC colleagues that these women were capable midwives, providing excellent obstetric care. They immediately allied themselves with these women, and started to support their work through CMC. The other providers of care were, they found, men of less rigorous training and more lofty perceptions of their own ability, snake charmers. They distanced themselves (and the patients) from these by (falsely) expressing their admiration for them, acknowledging how busy they must be, and informing them that, as a result, they'd consult them only when absolutely necessary. Probable relief on both ends. They only changed one practice of the barber's wives, who traditionally cut the umbilical cord with any old kitchen knife and then packed the wounds with cow dung. Despite the surprising lack of infection that resulted, CMC provided each women with a sterilized birth kit with gloves, half a razor blade and sterile clamps. That was a great success. The "pitchu" (from Part Time Community Health Worker) can be found in every village pointing out the hundreds (or thousands) of children that she helped deliver. And despite the fact that the government mandates that all births take place in hospitals - because of the continued risk of female infanticide and high-risk births - these women still serve a valuable role.
Being community minded, the physicians and nurses at CMC wanted to keep track of the results of all this and asked the traditional birth attendants to keep records. Being illiterate, most of them, this was an impossible task. So CMC hired and trained health aids, who can be recognized by their pink saris and who track health data for a cluster of 3 villages. There is one nurse to three health aids, one doctor to three nurses and three doctors to cover the entire 69 villages that comprise the CHAD catchment area. Here it is by the numbers: The average village has 1500 people, so each "pichu" covers that many; health aids cover 4-5000 people; nurses ~15,000; physicians 45000. Between three physicians they cover approximately 150,000 people. Remarkable! As is how they keep track. Each individual in this catchment area is given a number, based on their age, and on their village, street and home number. The GPS coordinates for each household are kept by CHAD and, in this way, they can track, using digital technology, the spread of disease in the case of an outbreak. Ranjit told us of a recent case in which a "pitchu" and health aid identified a new diarrheal case in one village. Other reports soon came in and they used the GPS technology to plot a map, starting with the first (index) case, of the spread of diarrhea. They were able to recognize that the illness followed the course of a drain. In the village they found that the water pipe ran through the drain and had developed a leak. They contracted to have the water pipe elevated above the drain and repaired. The diarrhea stopped. This is basic new technology used on a large scale with wonderful results. I wonder if the American public would allow their homes to be plotted on GPS and their health monitored so closely. It feels a bit like Big Brother. But in a country where privacy is a non-issue, such things can contribute greatly to the general welfare, and without a fuss.
Ranjit asked us, when discussing the size of the hospital today, its large patient population, and dedicated physicians of every specialty and "superspecialty" (as they say here), if CMC was a success. It was an open question and he wouldn't say what he believed. The most obvious answer would be yes. However, as Ranjit pointed out, CMC would, perhaps, be a much greater success if it was able to provide the type of care - preventative care - in the community that could keep so many of these people out of the hospital in the first place. "If we were really succeeding in our mission," he asked, "might we not need any hospital at all?" I admire the sort of idealism that his question presupposes.
What he is asking is if it is possible to do the job of preventing illness so well that we are hardly needed at all. Do we have the will, the courage, the selflessness to attempt such a thing?
justin
CMC - Day Fifteen
It was a busy day in the Child Health Out Patient Department (OPD). Their were at least a hundred children to see and only a few doctors to see them, the registrars off to study for upcoming exams. I spent most of the day with Dr. Winsley Rose. The son of two teachers and a Tamil native he's as gentle an individual as his name would suggest. It is a name you're no longer likely to find, even in England, and it's illustrative of that persistent and paradoxical Indian fondness for the days of the Raj (when the British ruled). He's also one of the newest consultants at CMC. In fact, i've been here longer than he has. He moved here with his wife, a community medicine physician, and their three year old daughter, not two weeks ago. Over the course of the last week i've had a chance to get to know Dr. Winsley and to learn from him about India and the medicine practiced here.
A relatively tall and thin man with square wire rim spectacles, a neatly trimmed goatee and a charming smile, Dr. Winsley has a demeanor that the children seem to love. He told me over lunch that, while it was difficult to say what it was that made him go into medicine, he knew the first day of his pediatrics roatation in his intern year that he wanted to work with children. For one, most children overcome their illness; furthermore much of their illness is through no fault of their own. It provides a health working balance between preventative, acute and chronic care. And he seems very good at it. He finds a way of performing the most thorough exam on the most uncooperative child and half the time, in the end, they seem happier than when he began. This is a rare talent. When it comes to teaching, he is able to stretch the residents' and my own knowledge to its limits without making one feel stupid. Furthermore, he seems like a nice guy to be around. He's invited me around to his house next week and I'm already looking forward to it.
At lunch today he told me about his sister's brother, who lives in Allentown, PA. I asked if he'd every been to the states to visit. "It's too expensive for us," he said. "Aren't you able to save money working at CMC, as housing, food and other expenses are covered." "The only way people find to save money is to go work abroad. And at CMC, we don't make that much money." He explained that at the hospital he just left, the boss who held a job that could soon have been his makes 1.5lakh rupees per month (1 lakh is 100,000). Even senior consultants at CMC only earn about 15,000 Rs per month. That's just under $400. He made much more than that before. "So why," i asked, "did you want to come to CMC?" "I don't think," he began, "that you could find greater job satisfaction than by working in a place like this. Not only because of the variety of cases but also because of your ability to do something about them, even in the most severe cases. In community practice you won't find in a lifetime the types of cases you find here in a week. In a government hospital, you will find them, but you won't be able to do much about it." I am impressed with his pure dedication to good medical care in a profession in which the pursuit of money often seems more common.
I understand his satisfaction, especially in terms of the variety. In today's clinic i saw more children with congenital heart disease - 2 with Tetralogy of Fallot, 3 with ASDs (Atrial Septal Defects), 1 with a large VSD (Ventricular Septal Defect) and 1 16 month old with a PDA (a Patent Ductus Arteriosis, not a Palm Pilot) - than i saw in a week of sub-specialized pediatric cardiology at home. One child had a liver so large it could be felt starting somewhere just above his hips - most of ours are hidden by our rib cages. I wonder if, reading my daily emails, many of you have picked up on this fascination we seem to have in medicine with the bizarre, the extreme, the rare. When an unusual case is presented to a team of physicians, here or at home, you'll often hear people say "good case," or something like that.
I think that it says something about our medical education. In addition to all the things that happen commonly we're also charged with knowing the the most bizarre, rare and unusual causes of any given set of symptoms. We call them zebras. Common things happen commonly, they say. And "when you hear hoofbeats, think horses not zebras." Here in Vellore i feel like i'm on safari. And there is some satisfaction in that, maybe only because it allows one to use the small pieces of information that normally seem so impracticle. Today the consultants were collecting cases for next weeks undergraduate pediatric examinations. Dr. Mammen peaked into the room where Dr. Winsley and I were seated: "Winsley! I've got a child here with celiac sprue," a gluten sensitivity that is not uncommon in white populations of northern European descent. He was genuinly excited. What for them is a zebra is for us a horse. And vice versa. The guy who developed the protocol for treating Small Single Contrast Enhancing Lesions (SSCELs), which he proved in an enormous case series to be (almost always) Neurocystercercosis, is here at CMC. Until coming here, i'd only ever seen cases in books. Here i see children with this, and the seizures that often result, on a daily basis. The problem with our education is that this fascination with the 'fascinomas', as their called, is more likely to make us see the illness before the adult or child that suffers from it: "check out the 'liver' in room three." It objectifies, turning people in patients. And yet it is part of what makes our job potentially more interesting. I'm certainly not the first to write about this conflict, and i will not be the last. But it's something about which we must be acutely aware.
Speaking of arcane knowledge...the exams for medical students and residents here are brutal. For the medical students, a child like one identfied today is brought before them and a panel of four physicians, one from CMC and the rest from outside. The student is told to examine the patient and is then subjected to a barage of questions about the physical exam findings, the differential diagnosis, the probably lab findings, the medications for treatment, etc. The residents' exams are similar, if more difficult. On our morning rounds the other day I saw what exactly these exams can be like. As the rather shy resident stood their shaking...."What is your diagnosis? Why? How can you differentiate between an empyema and a bronchopnemonial effusion? What bacteria is most likely to cause this illness? How do you identify this bacteria? What shape is the staphyloccus? What does the "aureus" in "Staph. aureus" mean? Who described it? What test distinguishes catylase positive and catylase negative bacteria? How do you perform a gram stain? Do you stain with an acid or a base? Or neither?" It was a battery of questions that spanned an entire medical education, including a history of medicine to which i was barely exposed. I can't imagine having an exam like that. It is no wonder so many of the physicians here seem to have encyclopedic knowledge. They have to. If the students or residents fail the test, they cannot start work again and must spend the next 6 months studying until the next exam period comes around. Theirs is an impressive and daunting task. I'm quite grateful for our relatively humanistic (and humane) education, even if i can't wax poetic about gram staining.
I had dinner this evening with some new arrivals, two medical students from the U.S. and another from Australia. As so often happens among people away from home, the discussion made its way in the direction of the restroom. The discussion began with the pros and cons of eating with ones (right) hands, as they do in India, versus eating with a cutlery. James, the australian, noted that a rickshaw driver refused to take money from his left hand, that being the one that is generally used to clean oneself post toileting. It's problematic for him because he's left handed. He went on to declare his disgust at the idea of cleaning oneself with one's hands, and not toilet paper. Kevin, from St. Louis, admitted his ignorance about how the Indians do it, with just a bucket of water and their (left) hands. Thad, from Kansas, couldn't understand it either. In a pinch, Kevin had found himself in a hospital bathroom with only a squat toilet and a bucket. In the end, he sacrificed his sock to the toilet. Laughs all around at that one. An Indian would find that ridiculous. James wondered, if he were in a similar situation, if he would be tempted to use the Indian currency, given its relative lack of value. The others chortled in understanding at his quandry. I may look back someday and think i'm being oversensitive, but i find that kind of talk intolerable, even angering. Ten rupees to us may be a quarter, but for many here it's a days wages. When my proposal that "when in Rome..." was rejected by the three, i informed them that the Indians find our use of toilet paper disgusting. "So what do you think about that?" They didn't think much at all. I have to say that i carry my own toilet paper around in my pocket, or in my bag, because i know it's not likely that i'll find it when i need it. But that doesn't mean i should !&%# on someone else's notion of personal hygeine.
Another weekend arrives. My first and last one in Vellore. I'll be out shopping for the things to bring home. Any requests?
justin
A relatively tall and thin man with square wire rim spectacles, a neatly trimmed goatee and a charming smile, Dr. Winsley has a demeanor that the children seem to love. He told me over lunch that, while it was difficult to say what it was that made him go into medicine, he knew the first day of his pediatrics roatation in his intern year that he wanted to work with children. For one, most children overcome their illness; furthermore much of their illness is through no fault of their own. It provides a health working balance between preventative, acute and chronic care. And he seems very good at it. He finds a way of performing the most thorough exam on the most uncooperative child and half the time, in the end, they seem happier than when he began. This is a rare talent. When it comes to teaching, he is able to stretch the residents' and my own knowledge to its limits without making one feel stupid. Furthermore, he seems like a nice guy to be around. He's invited me around to his house next week and I'm already looking forward to it.
At lunch today he told me about his sister's brother, who lives in Allentown, PA. I asked if he'd every been to the states to visit. "It's too expensive for us," he said. "Aren't you able to save money working at CMC, as housing, food and other expenses are covered." "The only way people find to save money is to go work abroad. And at CMC, we don't make that much money." He explained that at the hospital he just left, the boss who held a job that could soon have been his makes 1.5lakh rupees per month (1 lakh is 100,000). Even senior consultants at CMC only earn about 15,000 Rs per month. That's just under $400. He made much more than that before. "So why," i asked, "did you want to come to CMC?" "I don't think," he began, "that you could find greater job satisfaction than by working in a place like this. Not only because of the variety of cases but also because of your ability to do something about them, even in the most severe cases. In community practice you won't find in a lifetime the types of cases you find here in a week. In a government hospital, you will find them, but you won't be able to do much about it." I am impressed with his pure dedication to good medical care in a profession in which the pursuit of money often seems more common.
I understand his satisfaction, especially in terms of the variety. In today's clinic i saw more children with congenital heart disease - 2 with Tetralogy of Fallot, 3 with ASDs (Atrial Septal Defects), 1 with a large VSD (Ventricular Septal Defect) and 1 16 month old with a PDA (a Patent Ductus Arteriosis, not a Palm Pilot) - than i saw in a week of sub-specialized pediatric cardiology at home. One child had a liver so large it could be felt starting somewhere just above his hips - most of ours are hidden by our rib cages. I wonder if, reading my daily emails, many of you have picked up on this fascination we seem to have in medicine with the bizarre, the extreme, the rare. When an unusual case is presented to a team of physicians, here or at home, you'll often hear people say "good case," or something like that.
I think that it says something about our medical education. In addition to all the things that happen commonly we're also charged with knowing the the most bizarre, rare and unusual causes of any given set of symptoms. We call them zebras. Common things happen commonly, they say. And "when you hear hoofbeats, think horses not zebras." Here in Vellore i feel like i'm on safari. And there is some satisfaction in that, maybe only because it allows one to use the small pieces of information that normally seem so impracticle. Today the consultants were collecting cases for next weeks undergraduate pediatric examinations. Dr. Mammen peaked into the room where Dr. Winsley and I were seated: "Winsley! I've got a child here with celiac sprue," a gluten sensitivity that is not uncommon in white populations of northern European descent. He was genuinly excited. What for them is a zebra is for us a horse. And vice versa. The guy who developed the protocol for treating Small Single Contrast Enhancing Lesions (SSCELs), which he proved in an enormous case series to be (almost always) Neurocystercercosis, is here at CMC. Until coming here, i'd only ever seen cases in books. Here i see children with this, and the seizures that often result, on a daily basis. The problem with our education is that this fascination with the 'fascinomas', as their called, is more likely to make us see the illness before the adult or child that suffers from it: "check out the 'liver' in room three." It objectifies, turning people in patients. And yet it is part of what makes our job potentially more interesting. I'm certainly not the first to write about this conflict, and i will not be the last. But it's something about which we must be acutely aware.
Speaking of arcane knowledge...the exams for medical students and residents here are brutal. For the medical students, a child like one identfied today is brought before them and a panel of four physicians, one from CMC and the rest from outside. The student is told to examine the patient and is then subjected to a barage of questions about the physical exam findings, the differential diagnosis, the probably lab findings, the medications for treatment, etc. The residents' exams are similar, if more difficult. On our morning rounds the other day I saw what exactly these exams can be like. As the rather shy resident stood their shaking...."What is your diagnosis? Why? How can you differentiate between an empyema and a bronchopnemonial effusion? What bacteria is most likely to cause this illness? How do you identify this bacteria? What shape is the staphyloccus? What does the "aureus" in "Staph. aureus" mean? Who described it? What test distinguishes catylase positive and catylase negative bacteria? How do you perform a gram stain? Do you stain with an acid or a base? Or neither?" It was a battery of questions that spanned an entire medical education, including a history of medicine to which i was barely exposed. I can't imagine having an exam like that. It is no wonder so many of the physicians here seem to have encyclopedic knowledge. They have to. If the students or residents fail the test, they cannot start work again and must spend the next 6 months studying until the next exam period comes around. Theirs is an impressive and daunting task. I'm quite grateful for our relatively humanistic (and humane) education, even if i can't wax poetic about gram staining.
I had dinner this evening with some new arrivals, two medical students from the U.S. and another from Australia. As so often happens among people away from home, the discussion made its way in the direction of the restroom. The discussion began with the pros and cons of eating with ones (right) hands, as they do in India, versus eating with a cutlery. James, the australian, noted that a rickshaw driver refused to take money from his left hand, that being the one that is generally used to clean oneself post toileting. It's problematic for him because he's left handed. He went on to declare his disgust at the idea of cleaning oneself with one's hands, and not toilet paper. Kevin, from St. Louis, admitted his ignorance about how the Indians do it, with just a bucket of water and their (left) hands. Thad, from Kansas, couldn't understand it either. In a pinch, Kevin had found himself in a hospital bathroom with only a squat toilet and a bucket. In the end, he sacrificed his sock to the toilet. Laughs all around at that one. An Indian would find that ridiculous. James wondered, if he were in a similar situation, if he would be tempted to use the Indian currency, given its relative lack of value. The others chortled in understanding at his quandry. I may look back someday and think i'm being oversensitive, but i find that kind of talk intolerable, even angering. Ten rupees to us may be a quarter, but for many here it's a days wages. When my proposal that "when in Rome..." was rejected by the three, i informed them that the Indians find our use of toilet paper disgusting. "So what do you think about that?" They didn't think much at all. I have to say that i carry my own toilet paper around in my pocket, or in my bag, because i know it's not likely that i'll find it when i need it. But that doesn't mean i should !&%# on someone else's notion of personal hygeine.
Another weekend arrives. My first and last one in Vellore. I'll be out shopping for the things to bring home. Any requests?
justin
CMC - Day Fourteen
It is getting hotter by the day here in Vellore. I find myself wandering around outside in a bit of a daze, wondering what it could be that's making me feel so lethargic. It's the heat. Hot drinks are as good as cold for keeping one cool ('cause it makes you sweat) and i had a chai just now before seeking refuge in the library, with its cool pale aquamarine walls, its rows of flourescent bulbs and whirring fans. Ice cream is good in this heat. But when i bit into a frozen cone filled with chocolate icecream yesterday afternoon, i felt an ache, a sensitive pang, and it snapped me out of a growing denial. I've been having a tooth problem. Part of this denial is circumstantial. First time I came to India five years ago I saw something on the street that i'd never expected. On the occasional street corner, laid out on a dusty mat, one would find a "dentist," with his tooth extractors, some extracted teeth, some gold replacements, and no anesthetics. Yikes! Perhaps it's the first impression of dental care in India that has caused me to avoid seeking care for a "sensitivity" that i first noticed a few weeks ago. Ok, so i have saught dental care in India already. On the advice of an atypically enthusiastic English woman i met in Kerala, I sought out her dentist for a cleaning. She'd had gum transplants there on two occasions and was very pleased with the results. For 500 rupees (again, at 45Rs to the dollar), a teeth cleaning was a steal. I found myself in a somewhat dimly lit room with water- and mould-stained walls and took my place in a dental chair that was only slightly more antiquated than one i would find at home. I saw the autoclave and prayed that they used it. She, the dentist, pulled out a vibrating metal scraper, not the cleaner i was used to, and "cleaned" my teeth. It was at this time i noticed the sensitivity. I tried to hide my flinching smile whenever she passed over a certain bottom left tooth. When she asked, at the end, if i'd felt any sensitivity, I smiled and shook my head in a vigorous lie. I wasn't going to push it.
So over the past few weeks, with brushing, with cold water, i've pushed my dental dilemma out of my mind and imagined that I could take care of it when i get home. The problem is that it's just so expensive in America. You'd expect that medical students would be offered dental coverage, teeth being an important part of one's health, but no such thing exists. Not institutionally, at least. We do get (barely adequate) medical insurance. I wonder if it's the opposite for dental students. In any event, i've had to rely on my parents to cover my dental care - thanks mom and dad! As I get older, though, i feel more and more guilty about it. Last Christmas they bought me a fancy electric toothbrush, hoping, i imagine, that it might in some ways curb their dental expenditures. It was my favorite present, one i thought, given the current state of affairs, might have failed me. Seeing as how i'm in a relatively sophisticated Indian medical center i decided yesterday, after that provoking popsicle, to ask around for a recommended dentist. Dr. Mona immediately suggested Dr. Santosh Koshi. Having failed yesterday to arrange an appointment, i called this morning at 9:20 and was given an appointment at 9:30. I found my way to the dental outpatient clinic and encountered in the waiting room a rather compact, thin, and carefully dressed Dr. Santosh. I thanked him profusely for seeing me so quickly and, assuring me it was nothing, he quietly ushered me back to the a small cubicle and seated me in the dentists chair, this one no different from what i'd find at home. What we passed through on the way there seemed less a dental office than a dental factory. From three rows of cubicles i could hear the sounds of chisels, drills, and painful moans as the consequences of all that sugar consumption - Indians being the largest consumers of sugar in the world - were realized. Okay, so nobody was moaning. Young female dental hygeinists in clear plastic aprons shuffled about, room to room, delivering to hunched-over dentists sterilized instruments plucked with metal tongs from metal trays.
He sat me down, asked what my problem was, checked my teeth and noted that two of my fillings had fallen out. "Shall i schedule an appointment to have them fixed...i know you're very busy." "No, no no....we'll do it now." And so it was that not five minutes later i was staring, unanesthetized, at the sharp end of a dental drill bit. My fingers gripped the chair until they were drained of blood. Every muscle in my body was tensed. "Relax," he said. And he started to drill: whiirrrrrrrrrrrrrrrrrrrrrrrrrr.
And it didn't hurt. Not one bit. Dr. Santosh knew exactly what he was doing and as he drilled away at the bits he wanted to get out of the way, i wondered if, after all these years, my trips home from the dentist with a numb, asymmetrical feeling lip was really necessary. Mind you, i'm not going to ask them to withhold the anesthesia next time, but i wonder. He repaired my fillings within 10 minutes. "That's it," he said. "You're free to go." I asked him where i could pay. He said i needn't worry about it. I said i felt bad, so many people couldn't afford to pay but did. He said not to worry about it. I think that fixing the fillings was easier for him than explaining to me how to become an official patient at CMC. Most people have to figure it out on their own. So, in the end, i had excellent and free dental care in India. And i can highly recommend it to each of you.
I had a meeting yesterday with a Family Medicine doctor from Tufts, in Boston, Wayne Altman. He's here for a three day conference on starting Family Medicine as a specialty in India. I made a gaff at one point and said Family Practice. He corrected me: "It's family medicine. We're no longer practicing; we're good at what we do." It's a marketing decision made by the American Association of Family Practitioners (AAFP) last year. As an aside, how twisted that, in our health care system, different specialities have to make marketing decisions. Currently there are Family Medicine doctors in India. A handful of them. They get their qualification not through a residency, but through something like a fellowship. Dr. Altman (or Dr. Wayne, here) has been working with CMC to start a residency in Family Medicine, as well as a department in the undergraduate school. It would be the first of its kind in India. "For CMC to start a program like this," he said, "would be like Harvard Medical School starting a new department. Others could be expected to follow." Primary care is so desperately needed here and such a development would be, the conference concluded, a wonderful way to improve the overall health of Indians. With a residency program and a regular turnout of well trained family physicians, one could imagine the development of more community health centers, efficiently run by those who can care for adults, children and labouring mothers.
It also might help to deliver vital preventative medicine. I heard on CNN-IBN (India Broadcast News) this morning a report on Indians and heart disease. Indians have four times the risk of developing heart disease than any other race. Thirty percent of the cardiac patients in India are under 35 years of age. This is pretty shocking. Many speculate that this is due to a phenomenon called famine theory, or thrifty gene theory. Basically, a race adapted to famine develops a certain amount of insulin resistance. Fats and cholesterols were more easily stored in case food was not forthcoming. With a change in lifestyle, a secure food supply, and much of it rich in fats, this is a setup for heart disease. This is a growing health problem for India to contend with and better public health delivered by family physicians might be one part of the solution.
I don't want to think about fat foods anymore. I just had some delicious pistachio ice cream...and my teeth felt great!
justin
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