The rest of the week on ophthalmology working in Schell Eye Hospital was delightful. Surgery patients stay overnight prior to and after their surgery, so I had the pleasure of attending eye ward rounds with the ophthalmologists, something that is almost never done in the United States because ophthalmology is an outpatient service. I watched one of the residents be endlessly grilled about one of the cases, the attendings him pushing himt to the point where he couldn't answer anymore. The more aggressive style of teaching seems normal to me now and I am constantly impressed by both the resident's and physician's bank of knowledge. Because medical students mainly study theory and participate in didactic learning during medical school, I feel that their knowledge base is more extensive than ours in some areas like knowing the appropriate dosages of medications off the top of their head. However, they lack the clinical teaching during medical school that we have during our third and fourth years. It's hard to say what is the best way to educate a future physician, but as my resident Dr. Shilpa said,
"When it's all said and done, we all know what we need to know."
Dr. Shilpa was a fun resident to work with, stopping to explain things and show me findings as she chattered back and forth with patients in several different languages-Hindi, Tamil, Bengali-because the patients came from many parts of India, each with their own dialect. She was shocked to discover that I only knew two, explaining that as a doctor in India, it's necessary to understand many in order to be able to communicate and treat patients. She herself spoke seven.
One of the most interesting ophthalmology patients I saw was a seven-year-old girl with an intra-fourth ventricle grade III anaplastic ependyoma that had caused a bilateral internuclear ophthalmoplegia. Dr. Jeyanthan had me conduct her interesting neurological exam (she also had a right-sided CN VII palsy), then sent me with her and her parents to visit the orthoptist down the hall. With my interest in pediatric ophthalmology I have worked with several orthoptists, but this one had to be one of my favorites! She fixed me with a stern glance when I entered the room, but brightened when I told her I was interested in pediatric ophthalmology and wanted to learn about the management of the little girl's condition. She deftly worked through a series of tests and exercises, making everyone in the room jump when she abruptly banged the old flashlight she used for tracking eye movements on the table because it stopped working. She laughed at my startled response then held the light up for me to see.
"Look! Brighter!" She said.
I was said when the week of ophthalmology was over, but very excited because on our last day Dr. Jeyanthan, our favorite CMC ophthalmologist, invited us to his home next week for tea with his family. We were thrilled to accept and arranged for tea on Tuesday night. I also had the opportunity to speak with several of his optometry students. Dr. Jeyanthan is very dedicated to their education and has helped found a beautiful new school and program for the students. They all looked extremely young to me, and peppered me with questions about how to apply to optometry school in the United States. Michael and I gave them our emails and encouraged them to contact us if we could be of any help.
This week is my final week of medical rotations in India and I am very sad that my time here is almost over. However, I couldn't have ended on a sweeter note than spending my last week at CHAD, the Community Health and Development program run by CMC. The CHAD is its own self-sustaining hospital on the outskirts of the CMC campus (the actual medical school campus, not the hospital in downtown Vellore) that also provides rural health initiatives, public health services and education to the people in Vellore and the surrounding areas. It was nice to be able to just walk to the CHAD after breakfast in the canteen (literally five minutes through the beautiful tree-lined paths of campus), and I started my day off in the OPD clinic (outpatient clinic) with a kind resident named Ashim. He took the time to explain not only the patients' heath conditions, but also the social and financial aspects of practicing not only good but realistic medicine in this patient population. For example, diabetic patients are managed by checking pre and post-prandial glucose levels instead of a hemoglobin A1c, because these measurements are easy to obtain while an A1c costs 150 rupees. Ashim said that if you order these expensive lab tests, the patient will end up paying for them and will then have no money for the medications. I couldn't help but think how at home we order A1c's without thought, even at the free clinic I work out because the supporting lab does it for free. The physicians have to be so cautious in prescribing medications and treatments here, having to assess each patient's resources in order to determine what medical issues and treatments take priority. A barrage of patients passed through the clinic that morning, ranging from severe diarrhea to run of the mill COPD, and mid-morning I wanted to see the other CHAD clinics so I went to labor and delivery.
The "Labour" department was expertly run by Dr. Divya, a resident in community medicine. Community medicine here is much like our family medicine programs back home, but with the added component of public health and community development. I spent the rest of the morning and early afternoon with Dr. Divya, walking from bed to bed in the dingy rooms with privacy between patients only provided by a thin curtain. She visited each patient every half hour to manually feel the taut, pregnant abdomens for the strength and duration of the contractions, as well as to feel the lie of the baby and to listen to their heart rate with her stethoscope. I couldn't believe that the women weren't on monitors as they are back home, but Dr. Divya said that if they were to use the monitors here, they were unable to distinguish between a contraction and the fetal heart rate, which obviously can have devastating consequences if something goes wrong. She was shocked that often times we watch the progression of a woman's labor on the computer monitor that is updated with infrequent exams. She also spoke of the benefits of manual monitoring of labor in the way that it was a soothing, reassuring tool for her patients. She explained that women in India don't discuss childbirth with one another, even mothers to daughters, so when these young women come in the painful throes of labor, they think they are dying. Thus, the constant presence of a physician laying hands on them is not only necessary for monitoring, but also reassurance. It was quite a different story than the U.S. where we have birthing classes and so many women want the ultimate "birthing experience" complete with music and other elaborate rituals. As I looked at the thin young women, groaning in pain with absolutely no epidural or pain medication, I was acutely aware of this gaping difference between our cultures.
Dr. Divya's one concern with the facilities at CHAD was the difficulty in monitoring the pitocin drip when inducing labor. Because the facility can't afford IV pumps, the pitocin is injected into a hanging bag of saline and the rate calcualted by counting the number of drops per minute on a handheld watch. She said that it happens infrequently, but there are errors which have led to fetal complications.
Today was a complication-free day, however, and I got to assist on the delivery of a beautiful baby boy who promptly peed on me as I toweled him off under the heating hood (which at that time was not working because the power went out, an everyday occurence that happens at least 4-5 times in one day). I enjoyed my time on labor and delivery, and hope I'll get to work with the lovely and brilliant Dr. Divya again this week.
My last assignment of the day was a community visit in which the residents conducted an antenatal clinic and a chronic disease clinic. About ten people piled into the CMC van, and we were off to the site where we'd set up the makeshift clinic. The clinic ran quite smoothly, with one side devoted to pregnancy education and antenatal check-ups, and the other a walk-in clinic for patients that needed follow-up or had new complaints. I spent some time with the resident doing the antenatal check-ups, and he emphasized how important patient education was to CHAD because it could prevent many complications caused by patient beliefs and superstitions. For example, many women in the rural villages believe that drinking too much water will give the baby hydrops, and that drinking too much milk will make a baby too large to be delivered, so many women become dehydrated in their adherence to this superstition, also predisposing themselves to urinary tract infections which can then trigger preterm labor. For this reason and many others, a young nurse stood in her crisp white sari in front of the group of pregnant women gathered outside, reading a colorful book which outlined how to follow a healthy regimen in pregnancy and how to deal with complications.
The clinic concluded after a couple of hours, and we helped pack up the supplies and headed back to the CHAD. It was a fantastic first day, and I am very excited to start home visits to patients tomorrow. CHAD represents a sector of people and healthcare in India that I have not previously seen, and I am grateful for this unique experience after the previous more formal weeks in the CMC hospital.
"When it's all said and done, we all know what we need to know."
Dr. Shilpa was a fun resident to work with, stopping to explain things and show me findings as she chattered back and forth with patients in several different languages-Hindi, Tamil, Bengali-because the patients came from many parts of India, each with their own dialect. She was shocked to discover that I only knew two, explaining that as a doctor in India, it's necessary to understand many in order to be able to communicate and treat patients. She herself spoke seven.
One of the most interesting ophthalmology patients I saw was a seven-year-old girl with an intra-fourth ventricle grade III anaplastic ependyoma that had caused a bilateral internuclear ophthalmoplegia. Dr. Jeyanthan had me conduct her interesting neurological exam (she also had a right-sided CN VII palsy), then sent me with her and her parents to visit the orthoptist down the hall. With my interest in pediatric ophthalmology I have worked with several orthoptists, but this one had to be one of my favorites! She fixed me with a stern glance when I entered the room, but brightened when I told her I was interested in pediatric ophthalmology and wanted to learn about the management of the little girl's condition. She deftly worked through a series of tests and exercises, making everyone in the room jump when she abruptly banged the old flashlight she used for tracking eye movements on the table because it stopped working. She laughed at my startled response then held the light up for me to see.
"Look! Brighter!" She said.
I was said when the week of ophthalmology was over, but very excited because on our last day Dr. Jeyanthan, our favorite CMC ophthalmologist, invited us to his home next week for tea with his family. We were thrilled to accept and arranged for tea on Tuesday night. I also had the opportunity to speak with several of his optometry students. Dr. Jeyanthan is very dedicated to their education and has helped found a beautiful new school and program for the students. They all looked extremely young to me, and peppered me with questions about how to apply to optometry school in the United States. Michael and I gave them our emails and encouraged them to contact us if we could be of any help.
This week is my final week of medical rotations in India and I am very sad that my time here is almost over. However, I couldn't have ended on a sweeter note than spending my last week at CHAD, the Community Health and Development program run by CMC. The CHAD is its own self-sustaining hospital on the outskirts of the CMC campus (the actual medical school campus, not the hospital in downtown Vellore) that also provides rural health initiatives, public health services and education to the people in Vellore and the surrounding areas. It was nice to be able to just walk to the CHAD after breakfast in the canteen (literally five minutes through the beautiful tree-lined paths of campus), and I started my day off in the OPD clinic (outpatient clinic) with a kind resident named Ashim. He took the time to explain not only the patients' heath conditions, but also the social and financial aspects of practicing not only good but realistic medicine in this patient population. For example, diabetic patients are managed by checking pre and post-prandial glucose levels instead of a hemoglobin A1c, because these measurements are easy to obtain while an A1c costs 150 rupees. Ashim said that if you order these expensive lab tests, the patient will end up paying for them and will then have no money for the medications. I couldn't help but think how at home we order A1c's without thought, even at the free clinic I work out because the supporting lab does it for free. The physicians have to be so cautious in prescribing medications and treatments here, having to assess each patient's resources in order to determine what medical issues and treatments take priority. A barrage of patients passed through the clinic that morning, ranging from severe diarrhea to run of the mill COPD, and mid-morning I wanted to see the other CHAD clinics so I went to labor and delivery.
The "Labour" department was expertly run by Dr. Divya, a resident in community medicine. Community medicine here is much like our family medicine programs back home, but with the added component of public health and community development. I spent the rest of the morning and early afternoon with Dr. Divya, walking from bed to bed in the dingy rooms with privacy between patients only provided by a thin curtain. She visited each patient every half hour to manually feel the taut, pregnant abdomens for the strength and duration of the contractions, as well as to feel the lie of the baby and to listen to their heart rate with her stethoscope. I couldn't believe that the women weren't on monitors as they are back home, but Dr. Divya said that if they were to use the monitors here, they were unable to distinguish between a contraction and the fetal heart rate, which obviously can have devastating consequences if something goes wrong. She was shocked that often times we watch the progression of a woman's labor on the computer monitor that is updated with infrequent exams. She also spoke of the benefits of manual monitoring of labor in the way that it was a soothing, reassuring tool for her patients. She explained that women in India don't discuss childbirth with one another, even mothers to daughters, so when these young women come in the painful throes of labor, they think they are dying. Thus, the constant presence of a physician laying hands on them is not only necessary for monitoring, but also reassurance. It was quite a different story than the U.S. where we have birthing classes and so many women want the ultimate "birthing experience" complete with music and other elaborate rituals. As I looked at the thin young women, groaning in pain with absolutely no epidural or pain medication, I was acutely aware of this gaping difference between our cultures.
Dr. Divya's one concern with the facilities at CHAD was the difficulty in monitoring the pitocin drip when inducing labor. Because the facility can't afford IV pumps, the pitocin is injected into a hanging bag of saline and the rate calcualted by counting the number of drops per minute on a handheld watch. She said that it happens infrequently, but there are errors which have led to fetal complications.
Today was a complication-free day, however, and I got to assist on the delivery of a beautiful baby boy who promptly peed on me as I toweled him off under the heating hood (which at that time was not working because the power went out, an everyday occurence that happens at least 4-5 times in one day). I enjoyed my time on labor and delivery, and hope I'll get to work with the lovely and brilliant Dr. Divya again this week.
My last assignment of the day was a community visit in which the residents conducted an antenatal clinic and a chronic disease clinic. About ten people piled into the CMC van, and we were off to the site where we'd set up the makeshift clinic. The clinic ran quite smoothly, with one side devoted to pregnancy education and antenatal check-ups, and the other a walk-in clinic for patients that needed follow-up or had new complaints. I spent some time with the resident doing the antenatal check-ups, and he emphasized how important patient education was to CHAD because it could prevent many complications caused by patient beliefs and superstitions. For example, many women in the rural villages believe that drinking too much water will give the baby hydrops, and that drinking too much milk will make a baby too large to be delivered, so many women become dehydrated in their adherence to this superstition, also predisposing themselves to urinary tract infections which can then trigger preterm labor. For this reason and many others, a young nurse stood in her crisp white sari in front of the group of pregnant women gathered outside, reading a colorful book which outlined how to follow a healthy regimen in pregnancy and how to deal with complications.
The clinic concluded after a couple of hours, and we helped pack up the supplies and headed back to the CHAD. It was a fantastic first day, and I am very excited to start home visits to patients tomorrow. CHAD represents a sector of people and healthcare in India that I have not previously seen, and I am grateful for this unique experience after the previous more formal weeks in the CMC hospital.
No comments:
Post a Comment