Wrapping Up

Well, our last day ended a bit anti-climactically: Abby and I were told to meet the van at 12:30 today for afternoon psychiatry clinic, but there was nobody there. We waited and waited, and eventually gave up, so now we have the afternoon unexpectedly free. I thought I’d take the opportunity to write my final blog post of the rotation (although I may write some travel-related posts next week if I have the opportunity).

Abby described the beginning of our week, with the autism survey and health education talk. Below is a picture of the talk, which took place in a village schoolhouse:

On Tuesday, we had eye clinic. Cataracts are a big problem in India, and the majority of the patients were either pre- or post-op cataract surgery patients. The Mugalur clinic has a program that provides cataract surgery, including one night as an inpatient, pre- and post-op visits, and medications, all for 500 rupees (about $10). The same surgery would cost many times more in a hospital (although still much less than in the US, I’m sure), and patients come from far away to take advantage of the deal. It is a wonderful thing for them, since many have little or no vision before the surgery, and most are elderly rural villagers without a reliable source of income. It’s a busy service; I believe the doctor said they do about 10-20 surgeries every Monday.

There are big termite hills like this everywhere in the countryside around Mugalur:

Yesterday I spent the day in dermatology clinic, and Abby was in gyn-onc clinic (really mostly gynecology, not oncology, according to her). Dermatology clinic was interesting, especially since I hadn’t had a chance to do it in the hospital as most of the others did. We saw pityriasis alba (pale patches on the faces of dark-skinned children), chemical vitiligo caused by hair dye, palmar-plantar dermatosis, polymorphous light eruption (caused by sun exposure – plenty of that in India), as well as common things like acne, seborrheic keratosis, psoriasis, and allergic reactions. One lady had a reaction to the kumkum powder used in her forehead bindi; the doctor suggested other kinds of powder she could use instead. The doctor also told me about a plant called parthenium, or congress grass. Apparently, this is a weed native to North America that was inadvertently introduced to India in a shipment of wheat, and has since become widespread. He said that Indians are very sensitive to it and it causes all kinds of skin rashes, as well as hay fever and asthma. He told me it is called congress grass because the US Congress approved the wheat shipment, although something I read says it is because it grows in clusters. Who knows.

Parthenium:

Last night the five of us made the trip into downtown Bangalore to see UB City (a fancy shopping mall full of designer stores – Versace, Jimmy Choo, Louis Vuitton, etc, as well as the ritzy Sky Bar), and to have dinner at the Biere Club, Bangalore’s first brewpub (established in 2011!) We had a delicious shared platter of middle eastern food, and of course a sampling of the beer!

At the Biere Club

Well, that is it for our rotation (and medical school – crazy!) It has been a good experience in spite of the occasional frustration, and I think we’re all glad we came. I had the chance to see things (dengue hemorrhagic fever, lots of TB, Indian rural health care) that I will probably never see at home, and to experience another culture and health care system very different from my own. We got to travel to interesting places and experience life in the center of India’s technology boom.

Tomorrow morning I will catch a plane for Delhi to start the final leg of my India trip. I will be joining a group tour of North India, featuring Delhi, Agra, Jaipur, and Ranthambore National Park. If I have internet, I will continue to post to update everyone of my travels!

Namaskara!

Libby

Community Health Wk 2 & THE END.

As the students who were posted to Community Health our first 2 weeks in Bangalore majorly wrote about the same clinic days we had this week, I will keep that portion of this blog post short. For the rest I will try to describe some of the strange and interesting aspects of South Indian life we probably haven’t posted about yet. I will also sum up my experience in India as I leave in less than 2 days. My fellow MN elective students leave just a few hours after me as well so all of our last posts are on their way.

Two of the days on Community Health this week were spent in activities I do not think KJ, Sasha, or Jill were able to undergo. These were the Autism village survey and a Cancer Health Information meeting. Libby and I spent Monday with a Psychology trainee who is conducting a survey of village children to identify the presence of mental health problems or learning disabilities in children. Specifically, she is collecting data to identify the percentage of children who may have Autism using the CHAT and M-CHAT questionnaire (for those of you who are wondering). Therefore, she has been visiting parents in their homes only in the villages around Mugalur to collect a small sample of the population as a representation of all villages around Bangalore. It was fun and informative to spend time with her visiting homes. All of the families were very welcoming of us into their homes. The older children liked to ask Libby and I our names and even our Mothers’ names which was surprising.

Wednesday we were able to accompany 2 physicians and a few health workers to a village near Mugalur to conduct a Cancer Health Information meeting for the village women. It was held in a school, as a lot of village clinics and meetings seem to be, and there were likely 15-20 women in attendance. The discussion was held in Kannada but we were given a short summation of what was covered afterwards. All of the discussion was actually centered around tobacco as a cause of cancer and there was no mention of breast cancer, cervical cancer, or ovarian cancer. I overheard the presenting physician explain that it is not effective to discuss these topics in a village setting as the women would not retain it well. He explained, for some reason, in his experience information on these more sensitive topics are more effectively received in a clinic setting or one-on-one. It is also not very socially and culturally acceptable to discuss topics like sexual health in public, which you must explain if you are going to discuss cervical cancer. During the talk an older adult woman came forward to show she had had a cancerous mass caused by chewing tobacco removed from her left maxillary (cheek) area. The physicians used her experience as an example to the women of how tobacco affects your health. The women did seem to receive the information well and were interactive with the physicians but, as women tend to do, there was quite a bit of chit chatting ;).

Interesting observations about India before I sum up my experience:

Granite and marble must be super inexpensive because we saw multiple homes with floors and walls covered with the material. My Mother is very jealous.

 This may have been talked about, but almost all of the rickshaw drivers have their identifying information and blood types on the back of their seat in case they are in a collision. I’ve never been to New York or in a cab in Chicago but maybe this is also present there??

 Multiple times but not every time we have seen families at restaurants the man is given the menu and orders for the whole family it seems without consultation on who wants what.

It has been strange to see how starkly different the villagers appear from people in the city. In the city, many young people wear jeans, T-shirts, leggings, and few jewelry items. While, in the village there is still a strong presence of traditional clothing including saris with short-sleeve shirts cut at the midriff called a choli or ravika. There is also a lot of jewelry worn including brightly-colored bracelets on both arms of women, silver ankle bracelets with charms on women, little girls, and little boys, gold earrings with small jewels in them, and sometimes large gold nose rings.

In the third-most populous city in India, I didn’t think it would be so interesting for Indians to see Caucasion people. I was surprised but understanding at the stares we receive while outside the medical college complex. We’ve all been saying how disappointed we will be when we return to the U.S. and we’re no longer the object of fascination or photographs.

Again, in the third-most populous city in India, I was surprised to see so many cows roaming the major streets. They’re even in the center of the city!! Goats, pigs, and chickens too!! You don’t need to road-trip outside the city to see wildlife in India like you do in the U.S.

So, to sum it up this has been a fantastic adventure!! My goal to see and learn about international/tropical medicine was met perfectly. I saw and gained knowledge of medical conditions I may have only read about otherwise and may never see again which is, truly, priceless.  I experienced more areas of India than I had originally planned including New Delhi, Goa, and Hampi which was more than ideal.  But, mostly, I saw India. The good and the bad, and that is what it really means to travel!!

Namaste! -Abby

This is a village house outside of Bangalore. It is more traditional as it has a tile, peaked roof unlike the more modern, expensive ones with flat roofs that are brightly colored. You can see the wash bins on the left of the picture. When we drive through the villages there are always women washing clothes and dishes using water carried in these buckets from the nearest water faucet.

This was the path through a banana farm field to reach the famous Mango Tree Restaurant. See Katherine's last post for a picture of a meal eaten at Mango Tree. Superb!!

This is the chaotic bus stop in Bangalore. The bathrooms left a lot to be desired. Squatty potties galore.

These are the elephant stables where the government elephants of the Vijayanagar empire which was centered in Hampi in the 14th and 15th centuries. We imagined the Queen being carried in her fabulous cart/wagon (something like that) by the elephants to her royal Queen's Bath structure below.

Apparently the Queen liked to swim a few miles while she was bathing. Largest master bathroom in the world.

Chest Medicine...and countdown to the end of short white coats forever!

As I'm certain you read from Libby's post, a great time was had by all in Hampi last weekend. It is definitely one of the most unique places I have ever been. Despite the heat, its well worth the visit! The photo above is from quite possibly the most beautiful place I will ever eat- the Mango Tree! What a view. And, what a meal. Yum.

Today it's Tuesday, which means we're back in the medical student saddle. Sasha, Jill, and I are spending the week in the chest medicine (pulmonary) department. We've already seen quite a few things and heard some pretty nasty sounding lungs- and trying desperately to remember the differences between ronchi, rales, and crackles. Or at least I am. We're primarily working with Dr. George D'Souza, the head of the department. (who has been to good ol' HCMC!) This morning in clinic, for every patient, he would ask us to diagnose them just by looking at them or auscultating the patient's lungs. Not quite the same as a 30 minute patient chart review on an electronic medical record! Here are some interesting things we diagnosed just on observation:

-Scleroderma: hand findings! Sclerodactyly, and steroid side effects

-SVC Syndrome: engorged, non pulsatile neck veins, facial edema, a little proptosis of the eyes. Most commonly due to a tumor (of anything in the neck), and, historically, TB.

Some other interesting things we saw today:

-lots of TB

-idiopathic pulmonary fibrosis

-pleural effusions, many of which are malignant

-COPD- besides smoking, the most common cause here is from biomass; many patients use wood fires at home for cooking and the indoor pollution results in COPD.

Its hard adjusting to actually looking at X Ray and CT films, as opposed to the large-screened computers at home. We are all still somewhat terrified of beginning residency this June...eeek!

3 days and counting until our last official day as med students, and 4 days until we all depart for home, or further travels! Hard to believe how quickly time has passed.

Looking forward to being stateside in just a couple of weeks!

KJ

Hampi

Well, we are all back safely from the last of our weekend trips. We spent the weekend in Hampi, a ruined city that was a major Hindu capital during the 14^th-16^th century. Again, we took an overnight bus (non-AC this time, which was okay temperature-wise once we got moving but very noisy and bumpy), arriving in Hampi around 8 AM on Saturday morning. We found our guest house just down the road from the bus stand, and our kind hostess Padma prepared us toast, eggs, and real coffee – much needed by all. After breakfast we rented bicycles and set off to see the sights. We happened to walk by the river just as the temple elephant, Lakshmi, was finishing her bath so we got to stand right by her as she climbed the steps back up to the temple.

We spent the rest of the day seeing the sights by bicycle, which worked quite well with the exception of a loose chain on one (requiring a repair by some locals, a process that attracted a crowd of 14 onlookers/participants, not including the six of us):With the bicycle carefully repaired and tested, we set off again, and again the bikes served us well until we set off down a path which we didn’t realize involved many steps up and down the stone riverbanks. This was at the end of the day when we were all hot, tired, hungry, and thirsty, so dragging the heavy old bikes up and down the steps was not pleasant. But eventually we made it back to our hostel, where we showered, changed, and felt much better. We had dinner at the wonderful Mango Tree restaurant, with views over the river and delicious food.

The next day we opted to take rickshaws to a few more sites that we had missed the day before, as we had enjoyed enough bicycle fun the day before. We finished earlier and headed back to the Mango Tree for lunch, since we could enjoy the views better in the daytime. We lingered there for a while enjoying the shade, views, and lassis, then headed back to our hostel to get ready for the return trip.

We arrived around 6 AM this morning, and got back to the Annexe with enough time to lie down for a few minutes, shower, and change for the day ahead – much more leisurely than with Goa last weekend! Abby and I were still tired at community medicine today, but at least we were a bit cleaner than last time! We spent the morning walking from house to house in Mugalur with a psychology student who is conducting a survey on autism in the villages. She hopes to cover around 1500 children in 6 weeks! She is trying to determine prevalence of autism in the area, since the disorder is not well-known in rural areas and many children are simply considered delayed without getting a more accurate diagnosis.

A few more pictures from Hampi:

Virupaksha temple and wooden chariot

Huge boulders everywhere

Stone chariot at Vittala temple

Lotus Mahal

Elephant stables

Happy cats at the Mango Tree

We can't believe it's our last week in Bangalore! Trying to get everything done that we wanted to do this week...

-Libby

End of Week 1 Comm Health. AC Please!!

In my last post I wrote about the first 2 days of Community Health where one day we visited the Urban Health Center and the next we travelled to a village to survey for disabled patients who needed evaluation. Now, I will let you know how the rest of the week was. Forgive me if I repeat some information Sasha, Jill, or KJ already wrote about after their Community Health experiences.

Wednesday: We spent the day in a village conducting a Geriatric Clinic. The Geriatric Clinic village was about a 20min drive from the main village clinic in Mugulore. In this smaller village, we used a one-room dwelling to see patients. The day started with a lecture on exercise, nutrition, and diabetes care for the older adults. Us students could not understand the lecture but we could tell it was more of a discussion as the patients gave input and asked questions as well. Afterwards, the patients saw either the doctor or a resident at the front of the room. Here they were asked how they were doing and if they were taking their medications. Almost all of the older adults had one or a combination of Diabetes (called “Sugar” here), Hypertension (called “BP”here), gastritis, cataracts, or hearing loss. The doctor would prescribe them medications which the team brought for an extremely low cost to the patient. The patient then took this written prescription to the nurse at the other end of the dwelling who gave them the medication. The patient was then free to go or stay and socialize if they wished. The doctor working this day informed Libby and I the medication is meant to be paid for a very low cost by the patient but if they could not pay the Community Health Department gave the medication anyway and ate the cost. He said last year the department ended up paying 4 Lachs (4,000 rupees) for medications patients could not pay for.

Thursday: This day we travelled to 3 small villages around Mugulore. One of them was named Gundur but we didn't catch the name of the other 2. Here, we provided vaccination to infants given for no cost by the government, and also conducted pre-natal checks for pregnant patients. Each village allowed us to use one of their public school buildings to conduct the clinic. A desk for a vaccination station would be placed outside or out of view from the section of the building being used for prenatal checks.  Infants received BCG (Tuberculosis vaccination), Tdap (tetanus, diphtheria), and OPV (oral polio virus) vaccination. The prenatal checks involved the woman lying in a floor mat for examination as the buildings had no chairs, much less beds. Gestational age, expected date of delivery, lab results, ultrasound results, symptoms, fetal movement, etc. were recorded in a pamphlet used for government benefits at the time of delivery. If the patient does not have the pamphlet with 4 visits of information written in it they do not qualify for government benefits. We were taught most pregnant women go alone without their husbands to stay with their mothers in their last month of gestation and a few weeks following delivery so they can have help at the end of their pregnancies and with the baby. We did not see any husbands or other adult males accompany the pregnant women at the clinics.

Friday: The last day of the week we travelled to the Anekal Government Community Clinic on the edge of Bangalore city limits to conduct prenatal checks on pregnant patients. These patients also had the government pamphlets to receive benefits at the time of delivery. As I remember the other girls writing in their posts, the women were mostly teenagers and many had been married only a few months. Here, more Mothers and friends accompanied the patients but still absolutely no men. Here, we used a men’s inpatient ward room with 2 rows of beds and a few inpatients in them to conduct examinations of the women.  All patients have a battery of laboratory tests completed at their visit including syphilis, Hep B surface antigen, CBC, HIV, Rh antigen like in the U.S. Unlike the U.S., in India if the patient is Rh negative, the father is tested. If he is also negative the patient will not receive Rhogam but if he is positive she will. This is because Rhogam is over 1,000 rupees. Perhaps in the U.S. we give Rhogam to every pregnant woman who is Rh negative because the ID of the father is not always reliable. Unlike in the villages where every patient was healthy and without pregnancy complications, here there were a few patients with complications including twins, oligohydramnios (decreased amniotic fluid), and fetal bilateral hydronephrosis (kidney enlargement in the fetus). The patient with oligohydramnios was found to be so after the doctor measured a decreased uterine length compared to dates so ordered an ultrasound which was completed within an hour.  Since she was also having decreased fetal movements, she was instructed to see the obstetricians in the clinic for further evaluation and management. This was a very busy clinic as between 30-40 patients were seen in 2.5 hours by 2 doctors and an intern.

Funny story: Thursday the doctors wanted the air conditioning on in the van on the way to Mugulore so shut all of the windows and waited for the driver to turn it on.  The driver refused. On the return drive back to St. Johns the doctors again requested the AC on. This time the driver agreed to turn it on when we got to the main road and only until we got into town. AC is VERY luxurious in India.  I asked if any of the homes in Bangalore have air conditioning. The resident and health worker laughed at me.

Tonight we go to Hampi, a once thriving city in the 14th century, which now has many historical ruins and temples. We will surely report back next Mon/Tues, also the start of our last week in India!! Wow!!

Namaste! -Abby

There aren't enough food pictures on our blog. This is Tali some of us had in Goa. It is like dishes on one big plate! I'm not adept at naming foods but I will take a stab at describing it. There is a chip similar to Papad, Okra, milk-yogurt, and multiple sauces that are spicy, potatoey (Aloo), cauliflowery (Gobi), etc. Oh and rice! You can trust me on that one. Ugh I'm horrible.

Here is a monkey family that was walking right outside the HOSPITAL. Yeah, crazy. There is a baby Monkey next to the first adult. He was quite playful while Libby and I watched him. We can also hear monkey noises outside our windows in the Annexe. 

This is the entrance to the operating room at Mugalur (right spelling this time). We couldn't get all the way in to the room but I thought it was interesting it's called a Theatre.

Tender coconuts and medical oncology

"Please don't bring tender coconuts inside the hospital" The first day at St John’s we noticed this sign at the hospital entrance and it makes me laugh every time I see it. Yet another item on the long list of things that are a mystery to us here. What exactly, is wrong with a coconut – tender ones in particular? And why are they singled out as opposed to all of the potentially more destructive items one could bring into the hospital?

Yesterday however, one of the Oncology residents and I were discussing the differences between India and Minnesota (she really wanted to hear about the weather). When I described a typical winter in Minnesota, she (predictably) gaped at me bug eyed and exclaimed “OH MY GOD! You must be so hot and dehydrated here!!! You should drink a tender coconut! That’s the best thing for dehydration.”

AH HA! “What is a tender coconut and why can’t I bring one into the hospital?!!!” I immediately exclaimed.

Needless to say, she looked at me like I was a weirdo. But explained that tender coconuts are thought to carry tetanus spores. And they are basically just coconuts with the tops chopped off and a straw stuck in it. And they sell them right in front of the hospital. Mystery solved! 

On a more serious note, my week on Medical Oncology has been interesting, as well as frustrating. The oncologist I'm working with completed his Hem/Onc fellowship at the U! He's been fun to work with and great about explaining things to me. The variety of cancers in clinic has been fascinating; hepatocellular carcinomas (generally from chronic Hep B or C here), Ewing's sarcoma (bone tumors usually in adolescents), Hodgkin's Lymphoma, Acute Myeloid Leukemia, Chronic Lymphoid Leukemia, gastric adenocarcinoma, as well as breast, lung, colon, and pancreatic cancer. There have also been patients with anemia (nutritional and autoimmune hemolytic anemia), primary amyloidosis, and idiopathic hypersplenism (potentially secondary to repeated infection-malarial or a long list of others). Breast cancer has been by far the most prevalent, and of note, I have not seen a single case of prostate cancer.

Cost is a huge issue, as chemo is expensive and often paid for out of pocket- patients who can afford it get very similar treatment to home, complete with PET scans and good follow up care. Patients who cannot pay for chemo are generally sent straight to palliative care. I have been told there is only one cancer hospital in India that has the ability to significantly help poor patients with treatment costs and it is located in Mumbai. Travel costs often put it out of reach for poor patients. 

Cost also dictates whether or not patients can follow through on treatment. For example we have seen women with ER/PR+ breast cancers (hormone positive), who have completed chemo and radiation therapy, but could not afford the subsequent 5 years of hormonal therapy generally prescribed. One showed up at clinic with metastases to her lymph nodes. Incredibly sad and frustrating. 

Another interesting aspect of cancer care here is that patient's families will frequently request the patient not be told the diagnosis. This morning in clinic I watched the fellow shoo a female patient with breast cancer outside of the room, than explained TO HER HUSBAND the chemo treatment plan for her following her mastectomy. I was infuriated for her. However he later explained to me (this had all been done in the local dialect) that the patient's husband has requested she not be told she has cancer. Ever. And there is a lot of fear associated with the word cancer here- he said as an unspoken rule they generally avoid ever saying it to patients. As has been mentioned before, definitely far less patient empowerment here. 

Jill 

A little of this, a little of that

Happy Thursday to all! Its hard to believe that week 3 at St. John's is nearly complete, and that we only have one week left to go!

Sasha and I have really been enjoying our week in dermatology- and have been seeing many cases that we rarely see at home or never expected to see. For our medical friends, here are a few things which have stood out to us: (hopefully this is not an exact repeat of what Abby has posted)

-Measles in an adult: If this occurred in the USA, a patient would be placed in isolation in the hospital, and the media would be eating it up! Terror would ensue, and then who knows what would happen. Unfortunately, measles is just a really contagious virus without any treatment anyways, so the patient we saw in clinic was just told to go home and rest.

-Leprosy/Hansen's disease: like Abby has mentioned in her dermatology posts, it is something that is much more common here. One of the patients we saw had every complication imaginable, from corneal ulcers, to having braces on his hands due to muscle weakness, etc.

-Neurofibromatosis type 1: Sasha and I diagnosed this patient right when he walked into the room. We decided maybe it was worth remembering after all.

-Pemphigus Vulgaris: a really terrible blistering disease with a spectrum of severity. We have seen these patients in clinic as well as hospitalized. According to Dr. Madhurkada, our attending we have been with all week, most hospitals do not treat these patients due to complications of the disease (infection), which is why we have seen so many at St. John's.

This week in the hospital has also made us realize the harsh reality of finances and health care in India. Patients are required to pay for their services up front, and health insurance is not a common thing in the country. Patients who cannot afford medications will not receive them- for example, there was a severe pemphigus vulgaris patient who looked more like a burn victim with, blisters and open wounds from head to toe. (If he was at home, he'd be in a burn ICU with a PCA pump filled with morphine, as opposed to his current place on the general wards with only 4mg of morphine each day) His condition is declining and it seems as if he is developing an infection. The discussion today was not whether or not to switch to a stronger antibiotic, but rather whether or not the patient would be able to afford it. Its something that is hard to see, but this is how the system works.

Clinic is also quite different than at home. Rather than each patient having their own room, a patient comes to the doctor after their number is called. The doctor may be sitting in a room with another doctor running another clinic. There are no computers, and visits seem to take all of 5 minutes- Doctors can see around 30 patients in 4-5 hours. Patients generally do not ask questions, and the doctor/patient relationship here is certainly more authoritarian. According to Dr. Madhurkada, there is a movement towards more documentation, but he is concerned that he will become less efficient and not earn his salary. Despite these hyper-fast visits, he has taken time to describe each patient and important physical findings on them- its been a highly educational week!

While at lunch today, Sasha and I came up with a little list of foods we're missing:

-peanut butter

-salad

-bacon

-beef

-sushi

And a list of things we are excited to return to:

-A/C

-laundry machines

-crossing the street without fear of death

-the ability to eat whatever kind of food whenever we want- don't get me wrong, curry is delicious, but heavy...so its getting tough to do every day...

Oofta, that was long. Thanks for reading! Please enjoy a smattering of pictures from our Bangalore neighborhood.

Ok, this little guy was actually at one of the village clinics a week ago. Oh, how I wish I could actually play with him without fear of rabies...

Spit bin at the Bangalore botanical gardens. Because everyone needs a good spit from time to time.

Another day, another cow hangin out with the traffic. Turns out they know to go home to their owners (who the owners are, we have no idea) at night. Just behind him is our trusty ING bank, our dollar/rupee exchanger and ATM site of choice.

Namaste,

KJ