Today marks my third day on the medical ICU service at Christian Medical College. It has so far been an incredible week with types of pathophysiology that I have only previously read about in textbooks presenting right in front of my eyes.
I'll retrace my steps, briefly, with a description of CMC though after only working here three days I understand some components of it are indescrible. The medical campus is located smack in the center of Vellore. You have to dodge cows, autorickshaws, beggers and the occasional goat to step inside the guarded gate to one of India's best hospitals. The CMC campus is quite large, spanning several city blocks and composed of buildings connected by outside walkways and corridors. Nestled in between all of this is areas of lush gardens and fountains where patients congreate to eat, commiserate their sufferings and joys and fill their water bottles. The most chaotic area is "Casualty", or what we call the Emergency Department. The waiting room is entirely outside and spills back for about a block into the street at a busy time. The services and departments at CMC are quite extensive, really any medical service from nuclear medicine to dermatology to isolation units are present. In comparison to a hospital in the U.S., the facilities might be considered archaic and shabby, but in comparison I have met some of the brightest minds in medicine here that I have encountered thus far in my training.
Back to the ICU. It honestly is very similar to our ICUs in the layout and general composition except there are only two isolation rooms, and the rest of the ICU patients lay side by side in their respective beds. There are white sheets that can be dawn beween beds in the case of a code or other procedures to give patients privacy. I am working with 4 residents of various levels who took a little while to open up to me, but they all embody the warmth and kindness that is so typical of the people here. They offer almost identical kinds of support in terms of treatment and care-ventilators, telemetry, art lines, medications, etc.-and really the bustling atmosphere and efficiency is the same as at home, except the kinds of cases are starkly different. Some of the most fascinating cases I have seen so far are sepsis/ARDS secondary to scrub typhus infection, puerperal sepsis progressing to frank DIC, necrotising fasciitis (can't spell that right because the appropriate key that also won't let me spell sebra correctly doesn't work on this computer (sebra as in the horse-like animal with black and white stripes :), multiple cases of organophosphate poisoning (intentional and unintentional), peripartum cardiomyopathy, Leptospirosis, sepsis and empyema secondary to salmonella typhi, abdominal tuberculosis, tuberculos epididymitis (didn't know it could go there, did you?) and there are so many more. The proficiency and skill with which the attending, Dr. Victor Peter John treats his patients is so impressive. He has trained boh here and in Australia and is completely attuned to the subtleties of medicine here that are so foreign to me.
What's also interesting about the ICU is the meticulous attention to cost. With every administration of medication the nurses are quick to whip out a calculator to tally the patient's accruing bill. During rounds the cost of one certain medication over another is a constant, and diagnostic tests and labs are only performed as a complete necessity and not in the rapid, surefire routine way that they are so often performed in the U.S. Often times empiric treatment or observation will continue for a day or two before performing a test that will most likely be inevitable to avoid the cost to the patient. I understood why this is so vital when Dr. Victor discussed our 55 year-old female patient with multi-organ system dysfunction and ARDS secondary to scrub typhus. He said the doxycycline and asithromycin required to treat her, as well as the supportive care in the ICU would likely come to $2,000 US dollars for the 7-10 days of treatment she would require. (A 7-10 day ICU stay in the U.S. would be astronomical, several tens of thousands of dollars). However, her family was running out of money to pay the bill and she didn't have insurance. Dr. Victor said the unit would continue to give her supportive care free of charge if her family could pay for the medicines, but they couldn't provide the medicines for free because there are so many similar cases and the hospital would cease to function if they did this for every patient. I looked at him with a frown and asked, "So what happens if they can't pay?". He replied that they would pull support and allow her to go peacefully. He told me that the hospital can treat 3-4 ward patients for every ICU patients, so this poses a difficult moral dilemna for him when dealing with ICU patients. He looked at me and asked, "So when an ICU patient is salvageable, who do you treat? I've worked where you have everything and you don't have to make such decisions, but this is not one of those places."
Watching these compassionate and brilliant physicians deal with the difficult social conditions that accompany these unique diseases has been one of the most interesting and heart-wrenching things I have seen in medicine. Dr. Victor spends countless hours each day discussing every aspect of our ICU patients' care, from financial to logistical, with family members. As the 22 year-old mother of 5 children coded for the second time today secondary to cardiogenic shock from peripartum cardiomyopathy, he and the residents tirelessly resuscitated her, adjusting vasopressors and administering medication. He had just come from talking with her mother who was devastated and wanted everything possible done though they couldn't afford much more medication. "She's young. She needs a chance." He said as he walked off to see the next patient.
After spending the mornings in the ICU, I have been attending the tropical medicine symposium that is offered at CMC this week and next. There are several world-renowned Infectious Disease specialists in attendance, and physicians have come from as far as Norway and Japan to attend. They are all paying a huge fee to attend the symposium, and Michael Hood and I are getting it for free! We kind of wormed our way in the first day, but are now chummy with the group and "Dr. House", as we call one of the exceptionally brilliant ID docs from Canada. Several patients are selected each day, and we do bedside rounds in which the patient's case is presented, we come up with a differential diagnosis, discuss the acutal diagnosis, view scans and patholgy and discuss treatment. Now here is where I have really seen the things I've only read about in books! Tuberculous meningitis, hyatid liver and lung disease, rheumatic fever! It's exciting and so much fun to learn in this context, I'm like a kid in a candy store with all of these diseases! Who knows what today's session will bring...hoping to see more wild parasitic infections.
In the upcoming weeks I'll work in ophthalmology, the medicine wards and in the community health and urban development section. So thrilled to be here, learning so much every moment.
I'll retrace my steps, briefly, with a description of CMC though after only working here three days I understand some components of it are indescrible. The medical campus is located smack in the center of Vellore. You have to dodge cows, autorickshaws, beggers and the occasional goat to step inside the guarded gate to one of India's best hospitals. The CMC campus is quite large, spanning several city blocks and composed of buildings connected by outside walkways and corridors. Nestled in between all of this is areas of lush gardens and fountains where patients congreate to eat, commiserate their sufferings and joys and fill their water bottles. The most chaotic area is "Casualty", or what we call the Emergency Department. The waiting room is entirely outside and spills back for about a block into the street at a busy time. The services and departments at CMC are quite extensive, really any medical service from nuclear medicine to dermatology to isolation units are present. In comparison to a hospital in the U.S., the facilities might be considered archaic and shabby, but in comparison I have met some of the brightest minds in medicine here that I have encountered thus far in my training.
Back to the ICU. It honestly is very similar to our ICUs in the layout and general composition except there are only two isolation rooms, and the rest of the ICU patients lay side by side in their respective beds. There are white sheets that can be dawn beween beds in the case of a code or other procedures to give patients privacy. I am working with 4 residents of various levels who took a little while to open up to me, but they all embody the warmth and kindness that is so typical of the people here. They offer almost identical kinds of support in terms of treatment and care-ventilators, telemetry, art lines, medications, etc.-and really the bustling atmosphere and efficiency is the same as at home, except the kinds of cases are starkly different. Some of the most fascinating cases I have seen so far are sepsis/ARDS secondary to scrub typhus infection, puerperal sepsis progressing to frank DIC, necrotising fasciitis (can't spell that right because the appropriate key that also won't let me spell sebra correctly doesn't work on this computer (sebra as in the horse-like animal with black and white stripes :), multiple cases of organophosphate poisoning (intentional and unintentional), peripartum cardiomyopathy, Leptospirosis, sepsis and empyema secondary to salmonella typhi, abdominal tuberculosis, tuberculos epididymitis (didn't know it could go there, did you?) and there are so many more. The proficiency and skill with which the attending, Dr. Victor Peter John treats his patients is so impressive. He has trained boh here and in Australia and is completely attuned to the subtleties of medicine here that are so foreign to me.
What's also interesting about the ICU is the meticulous attention to cost. With every administration of medication the nurses are quick to whip out a calculator to tally the patient's accruing bill. During rounds the cost of one certain medication over another is a constant, and diagnostic tests and labs are only performed as a complete necessity and not in the rapid, surefire routine way that they are so often performed in the U.S. Often times empiric treatment or observation will continue for a day or two before performing a test that will most likely be inevitable to avoid the cost to the patient. I understood why this is so vital when Dr. Victor discussed our 55 year-old female patient with multi-organ system dysfunction and ARDS secondary to scrub typhus. He said the doxycycline and asithromycin required to treat her, as well as the supportive care in the ICU would likely come to $2,000 US dollars for the 7-10 days of treatment she would require. (A 7-10 day ICU stay in the U.S. would be astronomical, several tens of thousands of dollars). However, her family was running out of money to pay the bill and she didn't have insurance. Dr. Victor said the unit would continue to give her supportive care free of charge if her family could pay for the medicines, but they couldn't provide the medicines for free because there are so many similar cases and the hospital would cease to function if they did this for every patient. I looked at him with a frown and asked, "So what happens if they can't pay?". He replied that they would pull support and allow her to go peacefully. He told me that the hospital can treat 3-4 ward patients for every ICU patients, so this poses a difficult moral dilemna for him when dealing with ICU patients. He looked at me and asked, "So when an ICU patient is salvageable, who do you treat? I've worked where you have everything and you don't have to make such decisions, but this is not one of those places."
Watching these compassionate and brilliant physicians deal with the difficult social conditions that accompany these unique diseases has been one of the most interesting and heart-wrenching things I have seen in medicine. Dr. Victor spends countless hours each day discussing every aspect of our ICU patients' care, from financial to logistical, with family members. As the 22 year-old mother of 5 children coded for the second time today secondary to cardiogenic shock from peripartum cardiomyopathy, he and the residents tirelessly resuscitated her, adjusting vasopressors and administering medication. He had just come from talking with her mother who was devastated and wanted everything possible done though they couldn't afford much more medication. "She's young. She needs a chance." He said as he walked off to see the next patient.
After spending the mornings in the ICU, I have been attending the tropical medicine symposium that is offered at CMC this week and next. There are several world-renowned Infectious Disease specialists in attendance, and physicians have come from as far as Norway and Japan to attend. They are all paying a huge fee to attend the symposium, and Michael Hood and I are getting it for free! We kind of wormed our way in the first day, but are now chummy with the group and "Dr. House", as we call one of the exceptionally brilliant ID docs from Canada. Several patients are selected each day, and we do bedside rounds in which the patient's case is presented, we come up with a differential diagnosis, discuss the acutal diagnosis, view scans and patholgy and discuss treatment. Now here is where I have really seen the things I've only read about in books! Tuberculous meningitis, hyatid liver and lung disease, rheumatic fever! It's exciting and so much fun to learn in this context, I'm like a kid in a candy store with all of these diseases! Who knows what today's session will bring...hoping to see more wild parasitic infections.
In the upcoming weeks I'll work in ophthalmology, the medicine wards and in the community health and urban development section. So thrilled to be here, learning so much every moment.
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