Rural health center pictures

Abby posted in detail about village survey yesterday, so I thought I'd just post a few more pictures.

1. Courtyard of the rural health center in Mugalur. Apparently every medical college in India is required to operate one rural health center and interns have to spend several months there during their training.

2. Inpatient room at rural health center (there didn't seem to be any inpatients at the moment). The health center also has a labor and delivery room, an operating room, and outpatient rooms.

3. Poster on mental health problems. There is a psychiatry clinic every Friday.

4. Poster on nutrition to prevent anemia

5. Street in Seethanayakanahalli, the village where we conducted our survey

6. Village school where we saw one of the children with special needs

Today we spent the day in geriatric clinic in another village close to Mugalur. Elderly patients come once a month to check in with a doctor, get vital signs checked, and get medications refilled. These services are offered at reduced costs since government pensions for the elderly are only about 400 rupees (around $8) a month, and most of the patients have no other source of income. Some of the patients weren't able to pay even 5 or 10 rupees for medications, and most were still given the medications anyway. Tomorrow we will spend our day in maternal child health, which I am looking forward to!

-Libby

Community Health-Village Rehab + Goa

Quite a lot has happened since I last wrote. As you can see from the previous posts Goa was absolutely crazy and amazing at the same time! I’ll put my two cents in although as well.

Goa the beach city we went to was crazy fun. Lots of beach laying and eating out. There was also the night market which, you may have read in Libby and KJ’s blogs, was a strange mix of Indians and older adult European/American hippies. We’ve been told Goa was particularly popular amongst these expatriates a few decades ago as a drug and party location while still being a relaxed and holistic environment, pretty perfect for those living the hippie lifestyle. Hello Mcjagger and Steven Tyler. We also got our seafood fix (minus the veg Sagar) with a very nice restaurant that served us prawns, Kingfish, fish fry and also offered shark, lobster, crab, etc. Goa was the perfect place to offer us a reprieve from the chaotic Bangalore surroundings and rebooted us for the week ahead of knowledge absorption back at St. Johns.

This week is the first of our last 2 weeks  which in Libby and I are spending posted at community health. The first day was actually spent at the Urban Health Center where we learned a large amount about the Indian health system and culture in general. I will defer you to Libby’s post which was very complete and included more than I could have remembered. Mostly in this department, doctors and students usually go to a village outside Bangalore called Mugulore where surrounding village peoples come for care. They have an “Operating Theater” where they can do minor procedures (major if required) including cataract removals which was actually the order of the day today as it was eye clinic day. I did not get to observe any of these procedures as we actually spent the day in a village about a 25min drive from Mugulore. The village had a name I couldn’t attempt to pronounce much less spell.  Here a community health worker had identified village people with disabilities who required screening first at the clinic in Mugulore, and if they were found to require Physical, Occupational, or Speech therapies, were further referred to St. Johns. First, although, we visited the potential disabled patients in their homes to gather their stories and information.

 To meet with the patients, we students, the doctor, and health worker were invited into people’s homes. We removed our shoes as customary in India, and sat in whatever seating was offered: chairs, benches, beds, mats on the ground-because you must always sit in India when visiting. There was an 11-year-old boy who suffered a fall with resultant epidural hemorrhage and temporal fracture at age 8 for which he was hospitalized in the ICU with brain herniation. He did not receive an operation but from the discharge summary we were provided he was exhibiting posturing, asymmetrical papillary dilation, and mental status changes all of which would have led him to a craniotomy in the U.S. He recovered well expect for complete left-sided hearing loss and near-complete right-sided hearing loss. Therefore, we recommended he be evaluated at Mugulore and likely to be prescribed a hearing aid for the better right ear.  We also visited the village government school where the teachers had identified a young girl with a learning disability and speech delay. She was very nice, cooperative, and liked waving goodbye to us, but spoke only a few words. The school was 2 small buildings with joint classrooms where multiple grades were taught. There were various posters on the walls and a chalkboard with mostly English written on them.  There were only a couple of bench desks and some plastic chairs, so it seemed most students and teachers sit on the floor during lessons. There was also a 2 or 3 year-old patient with bilateral knee-ankle valgus deformity imparing his gait. We were quite the novelty at this patient’ s home as we were sitting on a floor mat in the living room and the window and door were filled with adults and children staring at us. I was concerned us being Caucasian and in the village may have been slightly counterproductive to the goal of screening these patients. Tomorrow we got to Mugulore again which has Geriatric clinic so I am excited to see what other pathologies we will experience.

Namaste! Abby

This was a visit to a family with a 7 year-old who was mentally challenged and whom we were screening for likely evaluation at Mugulore and further therapy at St. Johns.

This was our beach hang-out for the weekend. The servers actually learn patrons' names and keep track of what you order throughout the day so you just pay your balance before you leave.

Here is a shot on the hill overlooking the night market. Below are hundreds of huts selling clothes, jewelry, home decorations, drums, flutes, etc. 

We were walking to a restaurant in Goa and saw this elephant just walking down the main road among mopeds, trucks, bicycles, etc. Naturally.

Go-ahhh

As per Katherine’s post, Goa was a wonderful and much-appreciated break from the hectic city life in Bangalore. There isn’t too much to add to her account, as most of our time was spent on the beach and/or eating, but one other interesting experience was the Saturday Night Market slightly north of our beach. The Lonely Planet describes it as “well-organized” and “more relaxing” than the bigger Wednesday market. I can’t compare to the Wednesday market, but the night market was plenty busy, huge, and chaotic for my tastes. There were hundreds of stalls selling the usual tourist stuff as well as some things we hadn’t seen elsewhere, such as vintage Bollywood film posters and more contemporary Indian art. There were also many food stands and a stage with live music. It was quite the experience and we were all glad to have seen it. The vendors (and many of the patrons) are a blend of Indian and aging, mostly European hippie-types. Interestingly, there is apparently a large Russian influence in Goa, and many signs were in Russian. We even heard Indian vendors speaking Russian to customers, which was weird, particularly for Sasha!

This morning Abby and I made it to community medicine in time to get the van to the urban health center. This is located in a large slum near St. John’s. There is another student from BU on the rotation with us this week, and the three of us joined a faculty member from St. John’s at the clinic. Unfortunately, the clinic is apparently not very well known in the area, as we only saw two patients in the few hours we spent there – one of whom was the son of the cleaning lady, who she brought in because he’d had a fever that morning, and one for a medication refill. I was surprised that there weren’t more patients, given the clamoring throngs always present in the St. John’s outpatient department. Appointments at the urban clinic only cost 10 rupees, so you would think people would be eager for this service. Part of the problem may be lack of awareness; while the clinic had a sign posted above the door it was obscured, at least today, by someone’s laundry drying in the window above, and I don’t think there is much advertising of the services elsewere in the slum. The slum itself didn’t seem as bad as I had expected – streets wide enough to drive a car through in most areas, and not too much more trash than elsewhere in the city. The main difference was the rickety corrugated tin structures. The faculty member we were with, Dr. Brem(?), said the government is putting in cement apartment buildings on the edge of the slum to try to attract residents out of the more temporary structures so it can knock them down and put in more valuable real estate. He told us that about 20% of Bangalore’s population lives in slums, and that that is a low figure compared to other big cities in India and much of Asia.

The lack of patients was unfortunate, but it did give us the chance to ask lots of questions about health, health care, and health disparities in India that I’ve been unable to ask before due to the busy schedule on pediatrics. Dr. Brem’s research interests are in prenatal/perinatal care and tobacco, so we talked a lot about those, but also health care in general. Some figures and statistics I found interesting:

-The birth rate in southern Karnataka and Tamil Nadu is around 2.1. It has been decreasing steadily with improving infant and child mortality rates. In northern Karnataka, the birth rate is closer to 3 and further north in India it is even higher.

-In the last five years, there has been a drastic drop in the percentage of babies born at home, due to a new government incentive that gives people a financial incentive for delivering at a hospital.

-Most children in the slums do go to school, many even to private schools. Dr. Brem thinks many children are able move out of the slums when they get educated, but more people keep moving in from rural areas so the slum populations are not dropping.

-Tobacco use in India is a big problem, but smoking cigarettes is only a small percentage of this. The rest is divided more or less evenly into beedies (hand-rolled tobacco) and chewing tobacco. Unlike in the US, smoking is much more prevalent in men (around 15:1 ratio) while chewing tobacco is about equal in men and women, especially in rural areas.

-We also learned more about St. John’s. It falls between the government hospitals and the “corporate” hospitals in terms of cost to patients. A patient pays about 300 rupees per night to stay in a common ward, plus the costs of any lab tests, imaging, treatments, etc. that are needed. To get a semi-private or private room will be 1000 rupees and up. These fees cover all of St. John’s expenses; they do not receive any government assistance. The costs charged to patients are lower than a private hospital, and St. John’s compensates for this by paying its staff lower wages. Unfortunately, that often means good doctors leave for more lucrative positions. A government hospital theoretically provides most services for free, but a patient might have to pay bribes in order to have x-rays done, etc. Also, the care is not as good and a patient might wait for days to see a physician.

-Medical schools habitually sell seats to students. St. John’s has to fight with the government every year not to let them allocate any seats. Since it is a Catholic institution and considered a minority organization, it has some special privileges and has so far gotten away with not giving any seats to the government, however most medical schools do not have full control of their admissions process as the government gets to decide a certain number of the placements.

Anyway, that is a long post – here are some pictures from Goa to reward you if you are still reading!

Happy to have my first Tuborg since Denmark!

Ayurvedic medicine stall at night market -- not sure what "appetizers" means in this context

Fruit vendor on Calangute beach

Katherine’s pedicure attracts a crowd

-Libby

Weekend in Goa!

Calangute Beach, Goa

We've arrived fresh back from an awesome weekend in the state of Goa, India, a tourist destination for beaches and seafood! Our intent for this weekend was 2 things: 1. Beach and 2. Reeeeeelax, which was certainly accomplished by all.

Our journey to Goa almost didn't happen- our bus pick up site was at a stop 10-11km from St. John's, and we thought leaving an hour early (6:30pm) via tuk-tuk would easily get us there on time. One tuk-tuk made it with about 15 minutes to spare, but only Abby had her ticket. Fortunately, tuk-tuk #2 made it there literally 5 minutes before the bus left. Phew! We all enjoyed (sort of) our successful overnight bus ride to Goa, with 2 stops in 13 hours. Hold your bladders, friends!

We stayed at the Jewel Inn and Spa (3 whole stars of luxury!!!) complete with AC!!! TV!!!! and, super soft beds which we all appreciated after staying at the annex. Our routine was beach, eat and drink on the beach, eat dinner, repeat. I think its safe to say that despite sitting in the shade and multiple applications of sunscreen later, we're all still a little burnt. But relaxed, and ready for another week at St. John's! (after a less than pleasant overnight bus ride back to Bangalore....motion sickness is not fun)

Some interesting observations over the weekend:

1. Jockey underwear (boxers, briefs, or otherwise) all constitute appropriate bathing apparel for Indian men, while Indian women all wear full saris while at the beach.

2. White caucasian women in bikinis, despite TONS of advertising, media, etc, are still a sight to behold on the beach and we continued to have an absurd number of people attempt to take our photo/video on their cell phones. Definitely not enjoyable.

3. "Male is separate?" -quote from beach vendor at the cafe we frequented. Sagar, the sole male on our journey raised many eyebrows while travelling with 5 other girls. It proved for a number of hilarious comments from merchants and beachgoers alike.

Sagar, overjoyed to be one of a select few Indian men invited to the Euro-hippie parties at one of Goa's largest tourist attractions, the Saturday Night Market, just north of the beach we were at.

Sasha and I started dermatology today, Jill has started medical oncology, and Libby and Abby are on community medicine. Hard to believe we're on the 2nd half of this rotation and we'll all be home in 2-3 weeks!

Best diet coke ever.

Path from our hotel to the beach...though beautiful, the sand was EXTREMELY hot. Ouch!

Unit of Hope

Today I attended “Unit of Hope”, a multi-specialty clinic for children with disabilities. The clinic has a developmental pediatrician, two orthopedic surgeons, a gastroenterologist, a psychologist, occupational therapist, and early childhood therapist. A family might be there all day (everyone arrives at the same time in the morning and the last patient left around 5), but at least they can see all the specialists they need on one day rather than coming to on several different days. This is particularly helpful for some of the patients who come from outlying areas. Unlike regular pediatric clinic, patients need an appointment for a specific day to come to Unit of Hope. We probably saw about 10 patients all day, far fewer than in a typical pediatric clinic day, where the total is usually between 30 and 40 in a half-day clinic. Like the regular pediatric clinic, Unit of Hope was chaotic and noisy, with two or three patients being seen at the same time. However, I was impressed with how well it was run, and it seemed that families got the chance to ask questions and discuss their concerns in a more relaxed manner than in the regular pediatric clinic.

I saw some interesting cases today. India has quite a bit of cerebral palsy due to lack of access to obstetric care, although today there was only one child with CP in clinic. There were several with clubfoot, some of whom also had other anomalies. I saw a child with the rare disease hereditary hyperphosphatasia, a painful and deforming bone remodeling condition. I also saw a girl suspected to have Rett’s syndrome, a disorder I’ve never seen before but which is frequently tested on the USMLEs since it occurs almost exclusively in girls which is unusual for developmental disorders. Another child had suffered from HIB meningitis at six weeks of age; he recovered fairly well but has learning and behavioral problems now at seven years. Sadly, he got meningitis shortly before the HIB vaccine became routine in India.

I also saw a few interesting cases in regular clinic yesterday -- neurocystersarcosis, several cases of glycogen storage disorders, hemophilia A, and Fanconi Bickel syndrome. I've been surprised at how many rare disorders I've seen here!

Tomorrow will be my last day on pediatrics and then the six of us head off on a long overnight bus ride for a weekend in Goa! We are all excited for a relaxing weekend away from the urban clamor of Bangalore!

-Libby

Dermatology, Week 2 in Bangalore

I have spent my second week here at St John’s Hospital in Dermatology. In the morning we start rounds on inpatients at 9AM. We round with the interns (actual 5th year Med Students), a resident or 2, and faculty seeing patients assigned to Derm as their primary team as well as patients they are consulting on. On Monday we saw severe Psoriasis, Pemphigous vulgaris, a curious case of vasculitis with muscle weakness?, and the most severe case of septic shock in the ICU I have seen in my short medical career. It was though this last patient was suffering from Staph aureus toxic shock syndrome which only occurs 10% of the time in males. On rounds, the faculty heavily “pimp” the interns and residents on pathophysiology, signs/symptoms, and treatments of dermatologic diseases. They don’t ask us questions but are happy to answer any we have for them. It is actually quite difficult to understand what is going on with most patients as the interns/residents speak very quietly, it is a loud hospital, and although they use English there is still a thick accent. Also, on rounds I have seen the newly built air-conditioned section of the hospital for which patients pay an extra daily fee to stay in. It was pretty empty when I saw it. One day we had sit-down rounds that made me feel like I was in a movie like Shutter Island, or A Beautiful Mind. The patient was brought into a closed room and told to sit down in a chair in the middle with us surrounding them. We then talked about the patient usually in English which the patient may or may not have understood and asked them to show us their backs, stomachs, legs, or even to walk across the room while we assessed their gait and skin. Very strange, but the patient was informed of the plan afterward if there were any changes and they were always very willing to show us their skin findings.

In the afternoons, after a team coffee break, we are in outpatient Derm clinic. There are 5 clinic rooms assigned to Derm. Some have 2 physicians seeing patients simultaneously so HIPAA is not in strict practice here. In 4 hours, one of the physicians saw 22 patients (5.5 patients an hour) which she stated was a “slow day”. You can compare this with the Family Med I worked with in MN who saw 37 patients in 10 hours (3.7 patients an hour) which was considered the maximum amount a doc at that clinic could see. Therefore, it is extremely efficiently run with the Derm docs knowing within 1-2min of the patient entering the room what the diagnosis was and usually being able to write a prescription and finish with the patient and the note within 10min. The docs have a keyboard of sorts on which they press the number assigned to the next patient to be seen. This number appears with a beep sound on a screen outside the door so the patient knows he or she is up next. I have seen multiple times patients entering without their number appearing and being quickly ushered out back to the waiting area. I have also seen the docs become inpatient multiple times and continuously bang on the beep button until the patient comes in. Things must run quickly here!! At the same time the doc is seeing one patient, a previous patient who was sent to the lab for a blood test or to buy a prescription will return to the doctor and interrupt the new patient’s visit to sort out his business first. This all sounds extremely chaotic, and it is, but really it is controlled chaos.

At the end of the day, clinic is over at 2PM, drug representatives come in one by one to present information on their latest drugs available for patients. This would absolutely never be allowed in the U.S. Here, the docs may not always want to hear what the reps have to say but they are always very attentive and open to listening. Also, sometimes they get free samples which can be given to patients. So there’ s a plus too.

Thus far in clinic I have seen: Hansen’s disease (Leprosy), Eczema of all severities, multiple skin sun reactions, arsenic keratosis from arsenic poisoning, contact dermatitis, psoriasis, pemphigus vulgaris which is closely followed for some reason, Tinea, pityriasis versicolor, cellulitis, acne (everyone hates acne), and skin graft follow-up. I have been very excited to have the opportunity to see some diseases I may never get to the chance to see at all, or to the severity I have here, again.

This is the glass house at the Lalbagh Botanical Gardens a short tuk-tuk ride from the Annexe. It was a very beautiful and quiet garden area, popular for families, and with trees from around the world. It was actually pretty large with a man-made lake as well.

Here is a type if Ficus. Apparently both Sasha and my husbands like the word Ficus so I had to take this picture.

We are off to the world-renowned beach destination of Goa tomorrow. It is an overnight bus-ride starting tomorrow to our 3-day mini-vacation on the beach and we are ecstatic!! We have Fri off as a religious holiday so no, we are not skipping out ;)

Namaste!! -Abby

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