Pictures!

Baby admitted for failure to thrive because mom was not breast feeding

Clinic day at the cerebral palsy orphanage

Pediatric rounds. 12yr old girl with TB meningitis

Supply closet on the wards

Paul Brand outpatient clinic for leprosy

Food served on banana leaves

Jenna and I in sarees

Village visits at the CHAD

Pregnancy education in the villages. CHAD rotation

Mom and son in village

Farming

The Taj Mahal

The Last Post

So I am currently sitting in the London airport killing time once again which means that my trip is over. I just wanted to fill you all in and reflect a bit on the trip as a whole.

The last day or so of Pediatrics was great. The attendings there really taught more than any other department I was in. I saw some very interesting/hilarious patients. There was one kid who drank a bottle of insecticides. Insecticides are composed of organophosphates which are highly poisonous so we was given the antidote which is atropine. Well one of the phrases every medical student has memorized when studying for their Pharmacology test is in regards to the side effects of atropine: "Hot as a hare, dry as a bone, mad as a hatter...". So on first entering the wards in the morning I see this child (about 11yrs old) flailing in his bed, his mother slapping him because she is freaked out and wants him to stop, he is ripping himself free of the restraints and screaming that "they are coming". Nothing could calm this kid down, that is until he saw the 3 foreigners watching him. As soon as he saw us he became very still and stared a hole right through me as he whispered something to the nurses and staff restraining him. They all burst out laughing and told me that he wanted to know why the cat person was there (ie me and the other 2 foreigners). He carried on for a good 45minutes before the residents finally decided that they would give him haloperidol (an anti-psychotic). The Indian medical system continues to confuse me because the doctor wrote the prescription/order for a haloperidol injection and handed it to the father. The parents were going to have to go down to the pharmacy and purchase the injection for it to be given to the patient. This posed a slight problem as the parents (along with security) were needed to help restrain the child. I have no idea where the logic is in going about giving a medication in this way, nor do I know how it ended as we continued rounding on other patients. Some of the other patients that really made an impression on me were two little babies and a 9yr old girl. The first baby was around 1yr of age and had 'septic dengue'. He looked so sick and was so edematous that it was really sad. The team talked with the parents and they all agreed to sign a DNR (do not resuscitate) order, so sad. The 9yr old girl had meningitis (suspected to be TB) and I have never seen such pronounced and 'by the book symptoms'. I first noticed this girl when she was eating breakfast because she was leaning back on her mom sitting perfectly straight as her mom fed her, kind of odd. Once we came to her on rounds I discovered why. She had absolutely positive Brudzinski and Kernig signs; if you moved her neck at all she just screamed in pain. It was really incredible. The last baby was a failure to thrive patient meaning he wasn't eating and growing like a baby should. It turns out that this was because the mom was not breast feeding for some unknown reason. This patient was memorable to me not because of the diagnosis but the response of the medical team caring for him. The attending actually yelled at the mother and told her that if she did not want to kill her baby she needed to start breast feeding or find a wet nurse. I have never seen a doctor be so blunt and to the point in the US. He did not try to sugar coat anything or listen to her explanations as to why she was not breast feeding he simply told her the cold hard fact that her baby would die if she did not feed him. Very true, but quite harsh.


I cannot believe that my month in India has ended. I really was not sure what to expect when starting out on the trip but it was so much more than I could have imagined. I loved learning about the cultures and religion that are such a prominent part of the Indian identity and daily life. I was amazed at how big of an affect it has on their outlook towards medicine and life in general. I was shocked by the doctor patient relationship and how patients will just walk right into a doctor's room and ask to be seen and how a doctor will often yell at the patient if they are not following orders and can be a bit harsh with them (I should clarify that they came across as harsh to me, an outsider, but that this was viewed as very normal by everyone else). I had been warned that Indians are rude and yet I found them to be the most welcoming and accepting people who always gave more than they actually had to give. I was intrigued by how hard daily life is for many of them and how 'simple' medical problems have much larger effects for them here (having diabetes and a cut on the foot is much more serious when you do not own shoes and walk barefoot through trash all day every day). While there are many programs in place to help those who cannot afford regular medical care to get doctor's appointments and needed medications the system is not perfect and seems to focus on getting paid over helping the patient sometimes (such as the boy above). India seems to be full of these sorts of contradictions yet the people as a whole are so happy and content with their lives. I do not believe that any other country in the world could live with such a huge population without their being constant battles for space and property; while the Indians handle it with minimal upset. I am beyond thrilled with the experience I had in India. I feel that one month was barely enough time to feel as if I gained a basic understanding of the culture and how to get around and live in India. I would have loved to stay longer and really hope that I can return someday.

I hope that this was not too boring for all of you or two chaotic (I know I am a terrible writer and tend to just write as I am thinking versus thinking about what I am writing). I also hope that I was able to get across to you all how incredible and experience this was and that I highly suggest making a trip to India if you are ever given the chance. It is different from any other country you will ever travel to (both a good and bad thing) and if you can accept that you will gain more from the people and the culture than you ever thought possible.

Jacq

Pediatric rotation and Karigiri

So for my last week I signed up to do the Pediatric rotation. This was my first time to be in the actual big CMC hospital and it is really pretty nice. The general hierarchy of attendings and residents is the same and the wards themselves are better than the other hospitals I have been in. The pediatrics unit is really run basically the same as in the states. They round in the morning and then spend the rest of the day either in clinic or getting ward work done. So far I have been to the Asthma and the General clinic as well as wards. I have seen tons of interesting patients and just wanted to mention a few.

- Dengue fever - I have seen several cases of Dengue. There is one baby who came in for febrile seizures and it was determined that he had Dengue or maybe some kind of Ricketsial disease. I also came across another child on the ward (not on the team I was rotating with) who was sitting in his bed with tears streaming down his face afraid to move because the pain was so bad. Dengue is commonly referred to as Break Bone Fever. You have such severe bone pain that you feel as if someone is breaking your bones. Absolutely terrible. I felt so badly for the child and his parents who were standing beside his bed helpless. A resident in clinic was telling me that their general policy here is that if a child is nearing the 6th day of fever they begin investigations for the cause because in many diseases the second week of fever is the dangerous week. For example, in Dengue one's platelet count drops and you can begin to bleed internally, or in Kawasaki you can develop coronary (heart) aneurysms which could burst or in Typhoid you start developing severe ulcers.
- I saw another patient who had sickle cell disease. I found this a little intriguing because in the US we are taught that it is essentially a disease of African Americans so I asked my resident about it. He asked if I remembered why sickle cell disease can be good. I cleared the cob webs a bit and remembered that the sickle cell gene has been shown to protect you from Malaria. He said that up North (where this child was from) Malaria is a really big problem and so the genes for sickle cell are naturally selected for (meaning that those with sickle cell disease don't die of malaria). Very interesting, a fact I learned in school and hadn't really thought about since as it doesn't really pertain to US medicine except for board exams. I also saw a patient with B Thalassemia Major, also a rare genetic blood disease. I was told that there are many many genetic problems and many genetic disorders that are prevalent here because there is a lot of cousins marrying cousins, etc. The attending called me in to see this patient because he had the "typical thalassemia face". I had never learned that these children had a particular face but now I won't forget. I t was exciting, I am not sure I would have ever seen that in the US since I won't be going into a field that deals with such illnesses directly.
- They have a mandatory penicillin allergy test before they can prescribe the drug. I found this fascinating. They are constantly trying not to run tests because they are costly and yet they do a skin allergy test on anyone that they want to prescribe penicillin to (a drug that is prescribed constantly in the US). I brought this up with some other students at lunch and they brought up a good point that I hadn't thought of. They HAVE to check for an allergy because if they give a child penicillin and he has an allergic reaction there is no way that his parents would be able to get him to a hospital in time to get any kind of treatment. It takes forever to travel here and that is if you are traveling in a car which the majority of patients do not have. Practicing medicine here brings up all sorts of social and economic issues that we really don't have to think about in the US.
- Another patient I was called in to see by the attending was an 8yr old girl who was deaf. He told me she was perfectly healthy but that she had a history of meningitis at the age of 1yr. He asked if I knew the correlation, which of course I didn't. She had Haemophilus influenza. This is an illness that we do not have in the states because of our vaccination programs. Again, something I would not have ever encountered.

Today we got permission from the pediatrics attending to go out to the leprosy hospital called Karigiri. On Monday there was a speaker from this hospital at a program for international students and she invited us to come out and see the facilities since we will be leaving soon. It was really an interesting experience. I have studied about Leprosy in class but I have to admit that I knew very little about it besides the basics since it is not something we see on a regular basis in San Antonio. Leprosy is caused by a bacteria known as Mycobacterium leprae. It is still not known how exactly it is transmitted or why some people get the disease and others do not. Historically Leprosy has been around for thousands of years and was often viewed as a punishment from God and people with the disease were kicked out of their communities. Here in Tamil Nadu (the state that Vellore is in) the incidence in the 1950s was nearly 3%. These patients with Leprosy were kicked out of their communities and left to beg and steal for food. Leprosy is an extremely disfiguring disease. It attacks neurons and the skin leaving large rashes, large skin tubercles (kind of like a very big wart), and leaves affected areas anesthetic (without feeling). Because they cannot feel pain they are continually injuring their hands and feet (the areas it affects most) and often lose pieces of these parts. Many leprosy patients are left with clawed hands or hands that are missing fingers. Imagine trying to get through your daily life without fingers. These patients were viewed as grotesque and no one wanted to be around them. In the 1950s a British doctor named Paul Brand, working at the CMC, collaborated with several other doctors to begin treating these patients. Dr. Brand was an orthopedist and began developing surgical techniques which would restore the use of their hands by rearranging the tendons that go to the fingers. Well, patients at CMC did not want to be treated at the same hospital as patients with Leprosy which created a problem as they were the paying patients and most the lerosy patients were receiving care for free. Dr. Brand set out to build a separate leprosy hospital but the city did not want it within the city limits so they gave him a piece of land about 15km away. Here he developed a hospital dedicated to the care of leprosy patients so that they had a place to come where people would not be afraid to touch them and where they could receive any assistance that was needed. This was known as Karigiri. Through the year the hospital has grown and has several ORs, a new separate outpatient facility, a dermatology department, an ENT and Ophthalmology department and physical rehabilitation facilities all devoted to the care of leprosy. Patients came from all over the country and even further to be treated at this facility where no one would stare at them and people were willing to help them. Through education and new medication treatments the incidence of leprosy is now less than 1% in this area. Besides medical and research advances Karigiri has made incredible social advances for these patients. They invented a new kind of rubber that provides the cushion needed to prevent ulcers but also provides enough strength that a nail cannot penetrate it (which a leprosy patient would not feel if it came into his foot). They have a workshop where patients can learn to weave, paint, make pottery and clothing. You can buy these products in the store to help fund such projects. There is also a village that is just for people with leprosy who have been kicked out of their community and had no where else to go. Here they get the help they need (some are blind or do not have fingers to feed themselves) and are able to create a new community and a sense of belonging. You can find out more information about this at www.karigiri.org. It was a really interesting and touching experience and I am so glad that I made it out there to see.

Those are some of the patients that I thought were the most interesting. We are going to a home for children with cerebral palsy tomorrow which should be very interesting to see what kind of support they get here. All in all I have been very impressed with the CMC and would love to come back and work here some more.

Daily India

So as I am getting ready to leave I am realizing there are so many things that I encounter on a daily basis that I have not relayed to all of you. Its funny because when I first arrived these are the things that I thought the most about but as I have acclimated I have stopped noticing them so much, that is until all the International Students get together and talk about how crazy and fun India is.

- Food: I LOVE the food here. I have never had such flavorful food. Each dish is completely different from the next and has so many spices its incredible. Luckily, I like spicy food. There are many people here from Sweden, the UK, Germany who are dying because they think all the food is hot. They have ended up eating cheese sandwiches three times a day, everyday. They are really missing out. I think I have had meat maybe twice since arriving. Its not that you can't get it its just that they have so many incredible vegetarian dishes. If you are a vegetarian in the US it seems that you are pretty limited in options and your meals are pretty bland, but not here. I could totally be a vegetarian if I lived here. I hope to bring back some spices and recipes to share with all of you.
- The Head bob: I have not quite figured out why but everyone bobs there head side to side when you are talking to them. This gesture can mean 'yes', 'no', 'sure', 'yes I hear you', 'yes I agree,' basically anything. When we first got here it drove us nuts. We would ask someone a question and they would just bob their head and not say anything. What did this mean? Does that mean "yes, there is a bathroom here" or "no, the temple is closed to visitors". However, now we have all noticed that we have adopted the head bob, apparently its contagious.
- Bathrooms: oh what an experience. You are lucky if you find a western toilet here, most bathrooms are what Jenna and I have come to refer to as 'squatters'. Basically they are the same ceramic or porcelain or whatever our toilets are made of but they are in the ground. You must squat over them. They do not flush and there is not toilet paper (thank you mom for sending me with several rolls of toilet paper), this made for a very interesting first week. We also could not figure out why bathroom floors were always wet. It took a good week (until we were no longer staying in hotels catered to foreigners) to realize this was because there is no real shower like we have, there is just a shower head in the bathroom, the entire bathroom is the shower. This made us much more comfortable when we realized this is why the floors are all wet.
- They clean everything here with formaldehyde. This may not mean much to most of you but to all of us that have gone to medical, dental, PT, etc schools we know that smell way too well. It is the solution that we use in the US to preserve dead bodies. So imagine our horror when we walked into our room the first night and took a deep breath and had flashbacks to gross anatomy lab.
- Indians are seriously the friendliest people. I had been warned before coming that they were not nice and to be prepared; however, I have not found this to be true at all. Everyone wants to come up and talk to you and find out where you are from. If you don't know which bus to get on to go where you want to go just ask anyone. Most Indians speak English and if they don't they will take you to someone that does. Today, for example, we went to the Golden Temple after work. We walked to the bus station and climbed on a bus that was in the general vicinity of where we had been told the correct bus should be. We asked and the bus driver did the head bob. We assumed this meant we were in the correct place. We asked a few more times and he gestured to us that he would take us there. As we were approaching the stop the driver called for us and told us this is where we wanted to get off. So nice.
- There is no such thing as privacy here, especially in regards to medicine. We have strict rules in the US: you cannot give any identifying or health information to anyone without the patients consent, you may not discuss a case in any public areas, all computers must be secured. This is not the case here. Patients all crowd into the room together. In fact, they don't exactly like to wait for their turn so many will just mosey into the exam room and try to move their file to the front of the stack or will just thrust their child in the doctor's face so that they will be seen first. With all these extra people in the room the doctor will continue to discuss the patient's ailment with him or her and will continue with his physical exam all with a crowd of people watching. HIPPA would die.
- Identity: this is something that has intrigued me here. In the US we are divided by race, by our backgrounds. Here people are divided by which state they are from, what religion they practice, and what community (caste) they belong to. A child is not given a name until 90-180days of life, before that they are referred to as Lakshima's baby (the mother's name baby). Since the child will have received medical care before they are given a name all of their medical forms identify them as their mother's child. Also on the chart it will list what state you are from, I assume so that the doctor knows which language you speak. However, I have noticed that for those patients who are Muslim it just states Muslim, not what state they live in. I know that many of the Muslims speak their own language (Urdu I believe) but they also speak the local language so I am not sure why that is ignored on the forms.
- Indians are extremely efficient: I have been amazed by the amount of goods a person can fit on a bicycle, an auto rickshaw, an ox cart, a truck, etc. I saw a man driving down the road on a motor cycle with 5 sacks (like potato sacks) full of something sitting in front of him. I saw another man riding a bicycle with probably 60 chickens hanging from it. If there is an inch of room anywhere they can fill it, if there is a piece of plastic or metal on the ground they will find a use for it. It is truly impressive

These are just some of the everyday things that I pass on the roads and thought I would share with all of you. I have really fallen in love with this country and hope to return one day to see all the other parts that I was not able to visit on this trip. Some of what I had been told was true but as a whole everyone has been incredible welcoming and kind and India is a beautiful country full of wonderful people.

The Weekend

Hello. So this weekend we headed out of Vellore (it is a pretty small town with not a lot going on) and caught a train to Chennai (about 3hrs away). The train was an interesting experience. We were in general seating which means that it is a free for all and you cram as many people on a bench as possible. I sat next to a nice Indian man who works in Bangalore during the week and lives in Chennai on the weekends and had my oh so nice classmate Reid on the aisle to protect me from other random men who may have wanted to sit next to the blond white girl. There is no air conditioning in the car we were in but there are lots of portable fans (the kind you used to talk into as a kid cause it made your voice sound funny) none of which were on but luckily it was night time so it was cool without the sun and a nice breeze coming through the open window. I had an interesting conversation with the man next to me about astrology and general ideas on religion and how to live a good life. I tried explaining that astrology isn't really that prevalent (at least not to the extent it is here) in the US so I couldn't really say that I believed in it and lived my life accordingly but he did really understand that so I finally just gave in and said, 'Yes, of course I follow astrology'. I happened to be reading the book Eat, Pray, Love (picked it up in the airport last weekend) and was on the section where the author was studying in an Indian Ashram so I guess that is why my train friend decided to strike up this conversation with me. For those of you who have seen Slumdog Millionaire the train was pretty much just like you see in the movie. All these little kids were walking up and down the aisles trying to sell flowers and necklaces and basically everything. I have been shocked by how true the movie was proved to be during my travels through India.

Once in Chennai we headed to our hotel and basically stuffed ourselves with a buffet and passed out so we could get up in the morning and head to Mahabalipuram. This is known for being a lovely beach town and a big tourist destination. I can honestly say that I saw more white people walking around this town than I have during my entire stay in India. We first went to the Shore Temple, a beautiful temple dedicated to the god Shiva (the destroyer) on the beach. It amazingly is carved out of 1 massive rock (I feel that mountain is a better term for this). There are no joints at all, it is literally all one piece. Stunning. From there we went to the Five Rajas which are more massive carvings that are meant to look like chariots and a large elephant. It was amazing to see such incredible artwork. I have no idea how someone can approach such an enormous hunk of rock and have the vision to see what it can become.

After visiting these sights we headed back to our car to head to the beach. On the way to the car I was forced to see yet again how terrible poverty is here. There are beggars everywhere. I hate to say it but I have become somewhat immune to it and don't notice it so much anymore, however, some of them you cannot help but notice. There was a small girl (probably 7yrs old) that followed us around for a good 5-10minutes asking for money. Her arm had been broken into an inhumane shape so that her hand was essentially always in a begging position. What I mean by this is that while her shoulder was at rest at her side her elbow and wrist were broken so that her palm was facing up (for money to be placed in) and was about even with her shoulder. Absolutely terrible. I have also seen some blinded children as well as people with their legs broken into a permanent sitting position. It creates such a horrible predicament, I mean what do you do? You feel so terrible for these people and want to give them money but you know that the money you give them is going to go straight to their boss who will see that the gimmick worked and will then break another child's arm or blind another boy. Gowri informed us that this is a huge business in India. That these men who exploit the children (make them beg) also run drug cartels and have immense power in the country. Its so sad.

After the sightseeing we went to enjoy a lovely lunch on the beach. We all realized that we have really acclimated to India when we scoffed at the specialty dish being 400 rupees (about $8 US). It was a nice feeling to realize that you aren't a complete tourist anymore. Although, just when we were feeling so great about fitting in we were ripped off on buying gifts. We found these excellent gifts which we bargained and purchased on our own (meaning without a local person haggling the price for us) only to be told later by Gowri that they had charged us nearly 2-3x what they are worth if an Indian buys them. Darn. So we returned the goods and hit the road. On the way home we made a few stops. First we stopped at a crocodile and snake farm. I am not really sure why but Gowri said we must go and I am glad she did. The number of crocodiles they had in this place was sick, they were literally lying all over each other. Apparently they are going extinct so this is a farm to ensure that they do not do so. We also were able to learn about how snake anti-venom is made. Gowri informed us that snake bites used to be a huge killer in this part of India. Over the years this farm has developed several anti-venoms for different snakes and now supplies immense amounts of anti-venom all over India and other countries making death from snake bite much less common. Also, along the way back to Chennai we stopped at an artists village. It is a huge commune where artists from all over the world gather to study. They had some amazing pieces of art.

The rest of the weekend in Chennai was spent shopping and eating. We collected the last of the gifts we wanted to bring home to people (get excited everyone) and continued to explore Indian cuisine. Gowri has made it her personal mission to be sure that we have tried all the dishes that belong to the different states and communities in India. She also took us to a grocery store so we could buy some of the flours and spices to make some of our favorite dishes when we return home.

I cannot believe that my time here is almost over. There is so much in India that I have not gotten to do and there are so many areas of the hospital that I would have loved to see. I am working in Pediatrics this week but I am hoping that one day I can head out to the Leprosy hospital for a bit. There is so much more to tell you all about daily life here in India and the functioning of the hospital. I am hoping that I will be able to have time and write so more blogs this week before I forget everything.

I hope that everyone is doing well back at home and I cannot wait to get back and share all my pictures and stories with you!