More clinic and weekend fun

Hello!

Friday was OPD day again for pediatrics unit two, so I spent most of my day in the busy clinic. This time the doctor I sat with also had a resident with her, and they both saw patients at the same time. There were also about 5 medical students intermittently coming and going to present other patients, so with all of those people along with the patients and parents there were often more than 10 people in the small exam room at a time. In spite of the crowding and general chaos, I did see some very interesting patients:

1. A girl with megaloblastic anemia from B12 deficiency (hemoglobin 3.9!). I learned, unsurprisingly, that both iron and B12 deficiency are very common in Indian children since most people are vegetarians. I also learned that hyperpigmentation can be a sign of B12 deficiency.

2. A boy with thalassemia, who has already had a splenectomy and requires biweekly blood transfusions. I learned to recognize thalassemic facies (frontal bossing and maxillary hypertrophy from extramedullary hematopoiesis).

3. A baby with hemihypertrophy and hemangiomas, likely due to Klippel-Trenaunay-Weber syndrome.

4. Two kids being treated from pulmonary TB and one recently treated for TB meningitis.

5. A baby referred from Tamil Nadu for further workup after a stroke.

6. Two brothers with severe growth delay being worked up for growth hormone deficiency or other hormonal problems.

A few kids come in just for vaccines, but otherwise there don’t seem to be any “well baby/child” visits – almost everyone we see is actually sick. It’s probably not ideal for children’s health, but it does make for a more interesting clinic than the typical American pediatric clinic! I’ve been very impressed with how well the doctors remember everything (anatomy, drug dosing, detailed pathophysiology, etc) without ever seeming to look anything up.

I won’t go into too much detail about our weekend excursions since Abby and Katherine have already done so, but here are a few pictures:

Nandi bull, Mysore (4th biggest nandi in India, we were told):

Devaraja market, Mysore:

This sign was hung on some bamboo by the bull. A man explained:

"It's because sometimes children pull on the bamboo and break it".

Oh... ok then.

Back to the wards tomorrow. I'm hoping I can go to "unit of hope" clinic (disabilities clinic) on Tuesday or Wednesday. Goa next weekend!

Namaskara! (Karnataka version of Namaste)

Libby

Weekend in Bangalore

Well my week in the ED had to end early. It turns out the sickness I had on Monday night was just a mini preview of what was to come Thurs night. After enjoying The Hungergames for a second time with KJ and Libby, along with intermission dinner of a chicken sandwich and Pepsi, I was propelled into full-fledged  gastroenteritis. It was honestly, the sickest I have ever been in my adult life. I will stop nasty descriptions here. My stupidly unprepared self walked the first time, then crawled the next, to KJ’s (who it was revealed to me later was beginning her own GI ordeal) door for Imodium, Pepto-bismol, and then, finally, Azithromycin. Therefore, I was unable to work in the ED Friday and missed Saturday’s excursion to Mysore with the other Minnesotans as I rebuilt my body’s water supply.

Sunday, leaving KJ and her gastro with the Azithromycin I bought from a drug store counter just down the street from the Annexe, Sasha, Libby, Jill, and I adventured to downtown Bangalore. Of course we opted to jam 4 in a tuk-tuk. This included Cubbon Park, MG Road stores, and Commerce Blvd market. The park was beautiful with Bamboo trees (trees?), walking paths, and groups playing Cricket. MG Road hosts many high-end shops selling jewelry, electronics, etc. At Commerce Blvd Market we came away with some good deals on scarves, jewelry, and sandals. Jill successfully talked a clerk down on 2 very beautiful scarves while Sasha and I joined forces to get 2 less nice scarves for a better deal than 1. I bought some sandals for 100 Rupees ($2) that ended up not fitting but my feet were so dirty from walking all afternoon I couldn’t bring myself to try them on in the store. So, it’s my own fault. Oh well.

Overall, the ED was a fun experience with some very interesting patients I was able to see. There were the usual ED complaints like Gastroenteritis, alcohol intoxication/withdrawal, suicidal ideation, cellulitis, and pneumonia. There were the surprising patients including the patient with an acute stroke who was given tPA thrombolysis within the 3 hour time limit and the doctors weren’t even breaking a sweat as they would in the U.S. Very impressive.  Also, in this category can be included the precipitous delivery of  a healthy baby girl in the ED, which can occasionally be found in U.S. ED’s but is jolting all the same. Finally, there were the many International health-specific patients including the man with abdominal pain, fever, diarrhea, and hepatomegaly on exam who needed to be ruled out for amoebic hepatic abscess (what?) that apparently occurs commonly in alcoholics in India.

Next week I am on to Dermatology where I am excited to see illnesses which are only present in a few nations today, India included.

Everyone send your get well wishes to Katherine!!
Namaste!
-Abby

Downtown Bangalore. It is the third most populous city in India and is considered to be cooler as it is at 3,020 ft elevation. But, really the average high temperature is 92F and average low is 70F.

Here is the Annexe III. It is really quite large, this just pictures the front entrance inside the medical college complex.

This is a bamboo bush (bush?) in Cubbon Park. It makes a creaking sounds when it blows in th wind that is so weirdly different from the sound of leaves in the wind.

First week of community med + return of traveller's diarrhea....cue ominous music

We've settled in nicely to Bangalore and, after our first day scavenger hunt for signatures, we have all been on various postings with St. John's. Sasha, Jill, and I elected to do community medicine for our first two weeks here.

Our first day was spent touring an urban government health center, followed by clinic at St. John's urban health center. We were impressed at the follow up and the efforts by the government health center workers with regards to vaccinations and TB medication administration. For children's vaccines, we were shown their cold storage system (they mean business about this, every health center we've been to stresses their vaccine cold storage), and their follow up system. For children that miss a vaccine, workers actually go to the child's home in an attempt to get them caught up. For TB, a patient receives a "kit," stored at the health center, containing their entire duration of treatment, categorized based whether it is new TB or if it is for TB that has been treated before. The patient comes to the center each week for a new supply, and random visits are made to the home to ensure the patient is taking their medications. Following our government health center tour, we opened clinic at the St. John's urban health center, located in one of the many Bangalore slums. This has been open only two years and they are hoping to become better established in the community. The photos above are of St. John's urban health center, and the slum in which it is located.

Our second day was spent at Mugalu rural health center, also a St. John's facility. This has been around since 1992 and is loaded with patients. We arrived during a diabetes education lecture- as it turns out, chronic disease is an extremely common problem here, with type II diabetes on the rise. While Sasha and Jill spent the day in the geriatric clinic, I spent the day with the medical interns in the general outpatient clinic. Its amazing the differences between the USA and India. Patients have much less privacy, and are expected to listen to the doctors before asking questions (Sasha even noticed a sign- listen first, ask later). The visits went extremely quickly, and ended with the intern cutting off a strip of pills from a blister pack, and documenting the visit with a few sentences in a clinic register. I also got to spend some time with the interns discussing the differences between med school in India vs. the USA. Unlike the USA, medical school begins at 18, and is 5 years long. Indian med students spend their 5th year as an intern (like our first year of residency), and then apply for post graduate medical education, similar to our residency. They were quite surprised at my age and that I would not be done with residency until I was 30.

Our third day was spent at a government primary health care center and ENT/vaccination clinic. Our post graduate explained to us the government hierarchy of health care centers in India: the smallest being a sub-center, followed by a community health care center, then primary health care center (with facilities for labor and delivery, and a couple of inpatient beds), a district hospital, and then a referral hospital. There are also many, many private hospitals which patients have the option of choosing as well. There is no health insurance, patients must pay for their health care up front. Even if a doctor is willing to provide treatment for free, patients still must pay for supplies, medications, etc.

This is where our experiences diverge. On Friday, Sasha and Jill went to what I hear was a very interesting psychiatric clinic. I spent my Friday sleeping most of the day, with diffuse myalgias (think flu-type body aches), chills, and a very very low grade fever. I awoke Saturday in decent enough shape to take a day trip out to Mysore with the gang. On returning home, things quickly worsened and I have been experiencing some pretty amazing abdominal pain and GI discomfort...1 dose of Azithromycin is in, 1.5L of water and counting has been drank (drunk? I never know which is right), and I am hoping hoping hoping that I'll be in better shape tomorrow. This makes 2 of us which have succumbed to awful, awful E. Coli nastiness. Another interesting fact: A side effect of Pepto Bismol, which I immediately brushed off as silly, is a black tongue. Lesson learned: side effects actually happen. For everyone's sake I will NOT be posting a photo of my black tongue, just know that I am probably more horrified than you.

Please enjoy a few photos from Mysore:

Sri Chamundi Temple, at the top of Chamundi Hill

Mysore Market- as always, sensory/photo-op overload

Maharaja's Palace, completed in the early 1900s, complete with electricity. There was one built before this that unfortunately burnt down.

Please send healthy vibes in my direction,

KJ

first real days in peds

Hello again!

Well, now I've completed two full days in pediatrics I thought I'd post another update. Yesterday was "OPD" day (outpatient department) for our team, so morning rounds were very quick and then I went down to the pediatric clinic where I sat with one of the doctors while he saw patients. Clinic is run on a walk-in basis, and patients receive a number when they get registered. Then the doctor sees them in order, and immediately upon finishing with one patient he presses a button for the next patient. He completes his notes during the visit as well, so things move very efficiently -- we saw 23 patients in just over 3 hours. Of course, the downside of this is that little time is spent with patients, and the doctor's manner struck me as quite abrupt. He told one mother that she was essentially starving her baby, since she had stopped breastfeeding at 5 1/2 months and the baby was significantly underweight. Another mother was told she was poisoning her baby by giving it water when it had diarrhea. However, while the style was different than what I'm used to, I think he took excellent care of the children he saw and offered good, thorough advice to families.
Today was my first "normal" day on the wards where I attended regular morning rounds. This was a good experience, and with the schedule being less rushed the doctors kindly took some time to explain things to me and paraphrase cases where discussions were not in English. I saw two cases of dengue hemorrhagic fever, one case of probable mumps, and plenty of things that are also common in the US (respiratory infections, gastroenteritis, etc). Apparently dengue season hasn't started yet (it starts with the rainy season), and the hospital is typically flooded with cases at that time.

Below are a few pictures of the hospital and grounds -- the building itself is old, but the grounds are very nicely landscaped. For unclear reasons, there is a small menagerie with spotted deer, rabbits, guinea pigs, chickens, turkeys, and and aviary. There are also the usual stray dogs wandering around and sleeping in the shade.



-Libby

Picture Time

Our blog is looking a bit bare of pictures. So this post will mostly consist of photos from the past week.

First, I will give a quick update on me. I spent a half day in the ED with 2 med students from NY. We attended ED rounds and saw a few patients with residents/doctors. There were multiple dehydration patients, a 14yo patient with anemia (hemoglobin 4.0!!!) presumably due to nutritional deficiency and severe cellulitis of a large ankle lesion, a younger woman who attempted suicide by hanging who came in with respiratory distress and was intubated by RSI, pneumonia, etc. Overall, I was impressed by the advanced technology they had available including vitals monitors, ultrasound and CT in the radiology department, easily accessible ECG machines, and ventilators in their emergency ICU which was attached to the ED. The conditions were still sub-par according to American standards, although. It as also surprising to me how patient presentations were almost identical to the way patients are presented in the U.S. Even the same order and phrases are used.

Today I was not in the ED as I was the first victim of gastroenteritis in our travel group. Multiple visits were paid to the porcelain gods last night and this AM so I wasn't feeling up to standing in the hot ED all day. I am excited to have more Indian medicine experiences tomorrow and will report back!!

Spice Market in Chandni Chowk market, Old Delhi. These are actually nuts but there were really more spice sellers than nut sellers.

We had been seeing pigeons everywhere in our first few days in Delhi and made a comment that someone was going to be pooped on before we left. Well, it happened at our soda stop just outside the Taj Mahal complex. Right on Sasha's foot. We were so excited it actually happened I had to take a picture.

This is our first tuk-tuk ride in New Delhi. As you can see they are not built for 4 people. That's Jill in the blue shirt, Sasha's nose to the right, and KJ holding on for her life as you can tell by her facial expression.

This is our bedroom in the Annexe III at St. John's Medical College in Bangalore. Bare but very nice and clean. We all brought our own sheets as lice can be a problem.

This is our bathroom at the Annexe. No shower curtains as Indians don't actually use shower heads but rather buckets to bathe with. The water does tend to soak the whole room. Again, bare but very nice and clean.

Namaste!!

-Abby

Day 1 in Pediatrics

Hello everybody!

Well, after a very wonderful week of south India travels with my dad, I am getting settled in at St. John's Hospital in Bangalore. As Sasha's post says, today's activities were almost entirely comprised of getting various documents signed by various administrative staff. However, I did eventually meet my pediatrics team (after a little more than an hour of waiting for them to arrive on the ward). I was just present for quick afternoon rounds, so haven't gotten a great feel for how things run yet. Tomorrow I will be there for the whole day so will hopefully get a bit more familiar with things. The hospital is old but seems well-equipped, although everything is done on paper and x-rays are not electronic. The patients are mostly staying in large wards with 10-20 beds, which makes for a noisy, hectic environment. One patient on our team had a private room in another section of the hospital, presumably because her family paid extra for it. We saw several very malnourished babies, some pneumonia and asthma, congenital heard disease, and a child with respiratory failure from motor neuron disease.

After we finished rounding, I went across the street to get a 3G stick so now I have internet in my room -- so far it seems to be working very well. It's nice to feel more connected!

The photo shows the "glass house" at the botanical gardens in Bangalore -- a very pleasant place to spend an hour or two, with various local and exotic trees and plants.

Home sweet Bangalore

A hearty hello to all our friends back home! We've made it to Bangalore incident free and begin our rotation in 2 days...

First a little bit of filling in. We spent all of yesterday trekking around New Delhi, navigating the metro, and seeing more monuments and historical sites. Our day started with our always delicious free breakfast at Hotel Tara Palace, which has served us well for the past 4 days- it turns out that very few tourists stay in Old Delhi, so hooray for going a teeny bit off the beaten path!

We made our way to the closest metro stop- and were pleasantly surprised to find an extremely clean, modern, and efficient metro system that took us to pretty much anywhere we wanted to go. Between the posted maps, and 2 different tour books, we successfully found a number of great spots. Our first stop was the Qutub Minar, an old Islamic Ruin build in the 1100s- we are continuously impressed by how people are able to build these almost perfect structures with such intricate detail by hand.

Our next stop was another from the "top 10" of Delhi book (thanks, Abby!), Humyan's tomb. It was a little bit of a walk from the metro stop and required a gas station snack/water/coffee/cold beverage visit. Once arriving at the tomb, we were pretty impressed with how similar it appeared to the Taj, minus the astounding white marble. Humayan was buried here after inadvertently falling down a flight of stairs to his death...yikes! Buried with him are approximately 160 of his family members, as well as his barber. (Hopefully the barber lived a long, lovely life prior to his burial with Humyan...) While wandering around the balcony of the tomb, we noticed a number of visitors, locals and tourists alike, being SWARMED by bees, almost reminiscent of a plague of locusts. Despite visitors' efforts to make the bees dispersed, they walked out of the tomb with ~20+ bees completely surrounding them. Needless to say, it looked like something out of the X-files or the Twilight Zone. Eek. We ended our day with a harrowing tuk-tuk ride (Jill has an amazing photo of this) to Connaught Place, the center of New Delhi. What is a tuk-tuk you ask? We theorize that it is a moped, with a body placed over it (open on both sides), with a small bench in the back. It was more than a tight squeeze- we had a death grip on the tuk-tuk and each other to prevent falling out of the sides and/or getting hit by another car/moped/bike/donkey/cow/person....

Our last night in Delhi ended with dinner and a "local" (or rebottled something) at Q'bar, supposedly the 15th best bar in the world. We all felt a little underdressed but it was delicious and refreshing nonetheless.

This morning we awoke bright and early (3:15am!) to get to the airport by 4:30 for a flight to Bangalore. We arrived without a hitch and checked into the annexe III of St. John's Medical College- we each get our own room and our own bathroom. There are med students here from Sweden and England, and quite a few from all over the US. We are really looking forward to meeting some new people and seeing medicine from a few different perspectives. It was wonderful to finally unpack and try to feel a little more at home (I really wish I had some kind of poster to hang on the wall...its a little bare...)

A quick first impression of Bangalore- very modern, and seems to be much more manageable than Delhi. A little calmer (not quite the same as home, but calmer), and LOTS of western influence, and LOTS of huge companies over here...we're 5km away from 3M, and IBM and Dell are even closer.

After unpacking we propmptly realized we were responsible for our own toilet paper. We ventured out into our neighborhood and found TP, some fruit, shampoo, soap, etc. We also found a new favorite hangout, Cafe Coffee Day, which advertises free wi-fi internet. (And air conditioning!!!)...we eagerly packed up our computers and prepared for skype/facebook/photos/etc only to find the internet was down. Sigh. Currently all four of us are sitting in an outdoor internet cafe, paying 10 rupees (20 cents) per each half an hour. The monitor I am looking at appears to be older than me. Hopefully our coffee shop of choice gets its internet up and running and we'll be able to post some photos for you all...

Tomorrow....we're going to see the Hunger Games!!! Its going to be great.

Oofta, that was a novel...

Namaste Friends!

KJ