The best way to describe my rotations here is that they are simultaneously intruiging and heart breaking. Medicine Team III pretty much had full beds all week, so there was no end to interesting pathology which in many cases, resulted in bad news being delivered as gently as possible to patients and their families. I tried to maintain a neutral facade as I watched our attending inform a son of his very ill mother's infection with pneumocystis pneumonia, the worst of the opportunistic infections affecting her due to her HIV status, and likely the one which will end her life in her frail, decompensated state. She just stared at me, glassy-eyed as I uses my stethoscope to listen to the diffuse, tissue-paper-crinkling I heard in her lungs. The patient that brought me to tears is Mr. Suramanik, a bright-eyed 46 year-old cherub faced man who suffers from severe interstitial lung disease of unknown origin. When we told him the only option he had left due to his financial situation and severity of disease was supplemental oxygen therapy, he let out a cry and hung is head to his chest. Even on several liters of 02 his sats were low, and he understood the severity of his disease. The intern turned to me and I tried to hide the tears building up in my eyes and she said,
"It's okay to be sad. This is terrible."
I pass by his bed several times a day on the wards, and every time I look over to him he is watching me. When we make eye contact I give him a big smile, and he returns it with his sweet one and a little head bobble. His wife is often with him, and she is an emotional rock. I can't tell if she is trying to be strong for him, resigned to their fate, or something more complex. Either way it's not my place to judge her emotional capabilities, but I can't imagine not feeling utter despair at the grave situation her husband is in.
Instead of going to the CMC main hospital yesterday, Michael, Julie, Cristine and I arranged a visit to Karigiri, the leprosy hospital outside of Vellore. We squeezed into a rickshaw a 6:45 AM yesterday morning, and thankfully Julie thought to bring the blanket from her bed to cover us as we drove in the morning chill to our destination. We of course had a coffee break at one of the roadside stands, and we all enjoyed standing and wrapping our hands around the hot metal as we gulped down the sugary, milky coffee goodness. The hospital was about 30 km from the main area of Vellore, and we enjoyed the views as the busy streets of Vellore faded to palm trees and rice paddy fields set against the red and yellow rocky hills. The hospital complex itself covered several acres and was quite beautiful set in groves of trees and huge clusters of magenta, yellow and orange flowers. We met with the director of Karigiri, Dr. Solomon, who welcomed us to the hospital and gave us a brief overview of the history and purpose of the place. The Schieffelin Institute of Health Research and Leprosy Center, also known as Karigiri hospital after the town it is in, was established 55 years ago to care for the leprosy patients in the surrounding areas of Tamil Nadu. The hospital, as well as services for leprosy patients at the national level, suffered a setback about five years ago when previous supporting agencies were unable to obtain funds to be granted to leprosy hospitals on account of the statements by the World Health Organization and other health organizations that the incidence of leprosy had come down in India. Dr. Solomon’s frustration with the WHO’s decree on the fading incidence of leprosy was obvious as he explained that the hospital still sees around 175-200 new cases a year, not to mention caring for the devastating deformities and paralyses left by the disease that disable leprosy patients forever. To be able to continue its work, Karigiri began to offer all outpatient services such as dermatology, ophthalmology, dentistry, psychiatry, general medicine, orthopaedics, ENT, pediatrics and obstetrics and gynecology, in addition to leprosy in order to fund its extensive care and services for leprosy patients. We passed by these comprehensive additions on our way to meet Dr. Bharan, the reconstructive surgeon that we would be accompanying on rounds that day.
Dr. Bharan turned out to be a robust, kind-hearted man who loved his patients and loved teaching medical students. He gave us complete and detailed accounts of each patient’s history from memory as he gently unwrapped the packing and bandages on their extremities that covered the most horrific wounds I have ever seen. Despite the aggressive wounds and deformities marking their bodies, the patients had beautiful smiles as they greeted us with “namastes” and encouraged us to learn from them as well as take pictures. The loss of sensation that can accompany a leprosy infection (though only 20% have nerve involvement, I was surprised to learn) leaves the patients with decreased sensation in their hands and feet so that their joints and extremities are prone to such repeated and severe trauma that they develop inversion of the ankles, resporption of the fingers and toes, and worst of all: ulcers. Many of the ulcers we saw extended completely to the bone, and many patients were recovering from osteomyelitis and cellulitis. Cristine commented that she had never really appreciated the characteristic “fruity odor” of a pseudomonas infection that we are so often taught about in class until we were in the room of several patients with gangrene caused by the bacteria. What amazed me most were the patients that Dr. Bharan had performed reconstructive surgery on. Because many of the patients would get inversion due to paralytic deformity (due to destruction of the nerves supplying the everters and dorsiflexors of the foot), Dr. Bharan had performed posterior tibial muscle insertion transplantations to restore dorsiflexion to their lower limbs and given them the ability to walk in a more normal and less traumatic fashion. He was able to do other incredible reconstructive surgeries to the hands and other areas of the body to give his patients a chance at more normal function and life, since many of them are so dependent on their physical functions to perform labor in the fields and in their homes. Dr. Bharan enjoyed our questions and our interest in his patients, and took multiple opportunities to quiz us on their x-rays and our knowledge of anatomy of the upper and lower limbs.
We completed the day with visits to physical therapy, occupational therapy and the orthotics area where we watched the skilled technicians place patient’s limbs in plaster casts to help protect the healing process and promote mobility by allowing them to ambulate properly. One of the most interesting conversations we had was with the occupational therapist who was doing dexterity exercises with a newly diagnosed patient. After discussing the benefits of the therapy, the therapist informed us that the patient was not informed of his diagnosis of leprosy. I was extremely confused by this, and asked him what he meant. He said that in India, illness and disease are often stigmata that cause great social and emotional difficulties for patients, so they choose not to know their disease and be labeled by it. Doctors in accordance with this belief, do not directly tell the patient their diagnosis, but do treat them for whatever disease they may have. The therapist said that his patient in particular came to Karigiri for a “skin condition” and received his treatment without ever being told he had leprosy or discussing it, because the emotional havoc it would bestow on him was too much to handle. Cristine had told me something similar to this last week when she visited a couple with HIV during her week with CHAD. She was confused because during the whole visit, the doctor and the patients only talked about stomach problems, appetitie, etc., but “HIV”, “infection” and “anti-retroviral treatment” were never mentioned. She asked the physician about it when they left, and the physician gave her a similar explanation as the occupational therapist shared with us. This thought seemed so radical and foreign to me because in the US, as a patient your diagnosis is an indentifier. Something you live and fight. When I think of all the “Race for the Cures” and “HIV Awareness Weeks” there are in the US, I can’t imagine what the majority of Indian people would think of us. Though this cultural belief seems in general to be held by the poor, uneducated people of India, this demographic is the majority of the population so it’s quite a significant number who must feel this way.
We said our goodbyes to the wonderful staff and patients of Karigiri and headed back to Vellore, thankfully in a 4-person rickshaw, and were greeted upon arrival at our hostel by a group of 6 or 7 monkeys scampering off into the trees. The girls and I had another lovely run around campus, followed by dinner at the rooftop garden restaurant at Darling’s with all of the international students and beers downstairs at the bar. I had a great talk with Landon last night, and was amazed to hear that it is snowing yet again in Oklahoma City! He is doing such an amazing job of planning our trip to Indonesia together, as well as when we meet back up with Jules and Cristine in Singapore to travel to Malaysia and Thailand. I can’t wait!
Today was another great day back on Medicine Team III. The morning started off with two interesting presentations on transfusions reactions and organophosphate poisonings. Since organophosphate poisonings are generally quite rare in the US, my knowledge about them has exponentially increased in my time here, as 12% of ICU admits are organophosphate poisonings, and they comprise 29% of all poisonings. They are sometimes accidental, but more frequently a suicide attempt since the chemical is readily available in this agricultural region. Although our usual standard of treatment at home is pralidoxime, patients at CMC are more often treated with a 2 mg IV atropine bolus, followed by 2-5 mg of atropine every 5-15 minutes until atropinization is achieved. I learned that pralidoxime treatment is actually a bit controversial, because one study by de Silva found that its use did not make a difference in organophosphate poisonings, and it actually increased respiratory complications. Since I’ve never seen an organophosphate poisoning at home, I’m not exactly sure how it would actually be handled clinically in the US, but we learned that pralidoxime is the gold standard in pharmacology second year. I do know that CMC plans to do its own trial with oximes in the near future. I am continually impressed by the amount of research and clinical investigations occurring at this amazing institution, and the scientific curiosity that I see in every resident and attending.
Most amusing was the verbal beat-down that my attending gave to the pharmaceutical reps that came in after morning conference. As they presented their colorful medication books with pictures of wealthy-looking Indians beaming about how great their new insulin pump was, she blistered them with difficult questions about each drug and actually told several not to ever come back unless they had something useful and affordable for the patients. The rest of the day was spent on the wards, following up on some of our previous patients and admitting new. The patient with tetanus was started on a chlorpromazine drip and is not having spasms, but continues to have autonomic storms. Since cardiac arrest caused by this autonomic dysregulation is the most common cause of death, he is being monitored carefully. I think my attending is extremely worried about him because he has not improved despite penicillin, intrathecal and intramuscular tetanus toxoid, diazepam infusions and baclofen and a month has passed since his symptoms began. His wife breaks my heart as she is constantly at his bedside, stroking his tense body and looking pleadingly at us as we continue to make adjustments in his treatment. I was saddened by a patient with aspiration pneumonia, a result of a self-hanging in an unsuccessful suicide attempt. My attending discussed his pneumonia and recurrent empyema with a detached manner, commenting that he had brought it all on himself. I at first thought her insensitive, but also realize that when she has so many patients with unfortunate diseases that are non self-inflicted, and so little resources to help them, she is probably angry with a case like this. My attending, Dr. D’sa Shilpa Reynal is a beautiful, thirty-something brilliant doctor with a manner that often comes off as insensitive and brisk, but I know she truly does care for people and her patients in the way she meticulously goes through their case and grills residents on every aspect of their care. She almost lost it when she told one of my fellow students to go examine a tuberculosis patient, and he started the examination by auscultation with his stethoscope. She berated him for a good 5 minutes, telling him that the good clinical exam begins with simply observing the patient at the bedside, then starting with the most minute of things-the fullness or emptiness of his veins, the color of his skin, his breathing pattern. It’s only after careful observation do you touch with the hands, and only at the end do you actually use your tools. She is a difficult but excellent teacher. She carefully picked out patients for me to examine today, and I heard classic mitral regurge in a patient with rheumatic heart disease as well as distinct crackles and rhonchi in a patient with community-acquired pneumonia.
Today was my last day of work this week, because tonight we take the 11:05 PM train to Allepey in the state of Kerala. We have been waiting to take this trip since before coming to India, as we have heard that Kerala is an exotic, beautiful place of natural wonder. We will arrive at 7 AM tomorrow and plan to stay in a cottage by the backwaters, then hop on a houseboat to drift through the backwaters and enjoy passing the villages and beautiful backdrop of lush jungle. Getting the train tickets was quite an experience (had to go through an intricate and complicated process I’ll write about later in “Everyday India”), and I have heard that trains in India are a whole experience in themselves. Nonetheless, very excited for the weekend trip and to celebrate Cristine’s birthday in a new, exciting and beautiful place. Some of the international students who have been here for awhile are starting to leave, and I'm particularly sad to say goodbye to my new and wonderful Australian friend, Louella. She is a truly wonderful person, and I will miss her when she's gone, but as Landon commented the other night, "Well now we have even more of a reason to go to Australia!" I feel so blessed to not only be in India, but to be here with wonderful new friends and the incredible ones that came with me from Oklahoma. Missing everyone back home and wishing you could be here to enjoy it all with me.
"It's okay to be sad. This is terrible."
I pass by his bed several times a day on the wards, and every time I look over to him he is watching me. When we make eye contact I give him a big smile, and he returns it with his sweet one and a little head bobble. His wife is often with him, and she is an emotional rock. I can't tell if she is trying to be strong for him, resigned to their fate, or something more complex. Either way it's not my place to judge her emotional capabilities, but I can't imagine not feeling utter despair at the grave situation her husband is in.
Instead of going to the CMC main hospital yesterday, Michael, Julie, Cristine and I arranged a visit to Karigiri, the leprosy hospital outside of Vellore. We squeezed into a rickshaw a 6:45 AM yesterday morning, and thankfully Julie thought to bring the blanket from her bed to cover us as we drove in the morning chill to our destination. We of course had a coffee break at one of the roadside stands, and we all enjoyed standing and wrapping our hands around the hot metal as we gulped down the sugary, milky coffee goodness. The hospital was about 30 km from the main area of Vellore, and we enjoyed the views as the busy streets of Vellore faded to palm trees and rice paddy fields set against the red and yellow rocky hills. The hospital complex itself covered several acres and was quite beautiful set in groves of trees and huge clusters of magenta, yellow and orange flowers. We met with the director of Karigiri, Dr. Solomon, who welcomed us to the hospital and gave us a brief overview of the history and purpose of the place. The Schieffelin Institute of Health Research and Leprosy Center, also known as Karigiri hospital after the town it is in, was established 55 years ago to care for the leprosy patients in the surrounding areas of Tamil Nadu. The hospital, as well as services for leprosy patients at the national level, suffered a setback about five years ago when previous supporting agencies were unable to obtain funds to be granted to leprosy hospitals on account of the statements by the World Health Organization and other health organizations that the incidence of leprosy had come down in India. Dr. Solomon’s frustration with the WHO’s decree on the fading incidence of leprosy was obvious as he explained that the hospital still sees around 175-200 new cases a year, not to mention caring for the devastating deformities and paralyses left by the disease that disable leprosy patients forever. To be able to continue its work, Karigiri began to offer all outpatient services such as dermatology, ophthalmology, dentistry, psychiatry, general medicine, orthopaedics, ENT, pediatrics and obstetrics and gynecology, in addition to leprosy in order to fund its extensive care and services for leprosy patients. We passed by these comprehensive additions on our way to meet Dr. Bharan, the reconstructive surgeon that we would be accompanying on rounds that day.
Dr. Bharan turned out to be a robust, kind-hearted man who loved his patients and loved teaching medical students. He gave us complete and detailed accounts of each patient’s history from memory as he gently unwrapped the packing and bandages on their extremities that covered the most horrific wounds I have ever seen. Despite the aggressive wounds and deformities marking their bodies, the patients had beautiful smiles as they greeted us with “namastes” and encouraged us to learn from them as well as take pictures. The loss of sensation that can accompany a leprosy infection (though only 20% have nerve involvement, I was surprised to learn) leaves the patients with decreased sensation in their hands and feet so that their joints and extremities are prone to such repeated and severe trauma that they develop inversion of the ankles, resporption of the fingers and toes, and worst of all: ulcers. Many of the ulcers we saw extended completely to the bone, and many patients were recovering from osteomyelitis and cellulitis. Cristine commented that she had never really appreciated the characteristic “fruity odor” of a pseudomonas infection that we are so often taught about in class until we were in the room of several patients with gangrene caused by the bacteria. What amazed me most were the patients that Dr. Bharan had performed reconstructive surgery on. Because many of the patients would get inversion due to paralytic deformity (due to destruction of the nerves supplying the everters and dorsiflexors of the foot), Dr. Bharan had performed posterior tibial muscle insertion transplantations to restore dorsiflexion to their lower limbs and given them the ability to walk in a more normal and less traumatic fashion. He was able to do other incredible reconstructive surgeries to the hands and other areas of the body to give his patients a chance at more normal function and life, since many of them are so dependent on their physical functions to perform labor in the fields and in their homes. Dr. Bharan enjoyed our questions and our interest in his patients, and took multiple opportunities to quiz us on their x-rays and our knowledge of anatomy of the upper and lower limbs.
We completed the day with visits to physical therapy, occupational therapy and the orthotics area where we watched the skilled technicians place patient’s limbs in plaster casts to help protect the healing process and promote mobility by allowing them to ambulate properly. One of the most interesting conversations we had was with the occupational therapist who was doing dexterity exercises with a newly diagnosed patient. After discussing the benefits of the therapy, the therapist informed us that the patient was not informed of his diagnosis of leprosy. I was extremely confused by this, and asked him what he meant. He said that in India, illness and disease are often stigmata that cause great social and emotional difficulties for patients, so they choose not to know their disease and be labeled by it. Doctors in accordance with this belief, do not directly tell the patient their diagnosis, but do treat them for whatever disease they may have. The therapist said that his patient in particular came to Karigiri for a “skin condition” and received his treatment without ever being told he had leprosy or discussing it, because the emotional havoc it would bestow on him was too much to handle. Cristine had told me something similar to this last week when she visited a couple with HIV during her week with CHAD. She was confused because during the whole visit, the doctor and the patients only talked about stomach problems, appetitie, etc., but “HIV”, “infection” and “anti-retroviral treatment” were never mentioned. She asked the physician about it when they left, and the physician gave her a similar explanation as the occupational therapist shared with us. This thought seemed so radical and foreign to me because in the US, as a patient your diagnosis is an indentifier. Something you live and fight. When I think of all the “Race for the Cures” and “HIV Awareness Weeks” there are in the US, I can’t imagine what the majority of Indian people would think of us. Though this cultural belief seems in general to be held by the poor, uneducated people of India, this demographic is the majority of the population so it’s quite a significant number who must feel this way.
We said our goodbyes to the wonderful staff and patients of Karigiri and headed back to Vellore, thankfully in a 4-person rickshaw, and were greeted upon arrival at our hostel by a group of 6 or 7 monkeys scampering off into the trees. The girls and I had another lovely run around campus, followed by dinner at the rooftop garden restaurant at Darling’s with all of the international students and beers downstairs at the bar. I had a great talk with Landon last night, and was amazed to hear that it is snowing yet again in Oklahoma City! He is doing such an amazing job of planning our trip to Indonesia together, as well as when we meet back up with Jules and Cristine in Singapore to travel to Malaysia and Thailand. I can’t wait!
Today was another great day back on Medicine Team III. The morning started off with two interesting presentations on transfusions reactions and organophosphate poisonings. Since organophosphate poisonings are generally quite rare in the US, my knowledge about them has exponentially increased in my time here, as 12% of ICU admits are organophosphate poisonings, and they comprise 29% of all poisonings. They are sometimes accidental, but more frequently a suicide attempt since the chemical is readily available in this agricultural region. Although our usual standard of treatment at home is pralidoxime, patients at CMC are more often treated with a 2 mg IV atropine bolus, followed by 2-5 mg of atropine every 5-15 minutes until atropinization is achieved. I learned that pralidoxime treatment is actually a bit controversial, because one study by de Silva found that its use did not make a difference in organophosphate poisonings, and it actually increased respiratory complications. Since I’ve never seen an organophosphate poisoning at home, I’m not exactly sure how it would actually be handled clinically in the US, but we learned that pralidoxime is the gold standard in pharmacology second year. I do know that CMC plans to do its own trial with oximes in the near future. I am continually impressed by the amount of research and clinical investigations occurring at this amazing institution, and the scientific curiosity that I see in every resident and attending.
Most amusing was the verbal beat-down that my attending gave to the pharmaceutical reps that came in after morning conference. As they presented their colorful medication books with pictures of wealthy-looking Indians beaming about how great their new insulin pump was, she blistered them with difficult questions about each drug and actually told several not to ever come back unless they had something useful and affordable for the patients. The rest of the day was spent on the wards, following up on some of our previous patients and admitting new. The patient with tetanus was started on a chlorpromazine drip and is not having spasms, but continues to have autonomic storms. Since cardiac arrest caused by this autonomic dysregulation is the most common cause of death, he is being monitored carefully. I think my attending is extremely worried about him because he has not improved despite penicillin, intrathecal and intramuscular tetanus toxoid, diazepam infusions and baclofen and a month has passed since his symptoms began. His wife breaks my heart as she is constantly at his bedside, stroking his tense body and looking pleadingly at us as we continue to make adjustments in his treatment. I was saddened by a patient with aspiration pneumonia, a result of a self-hanging in an unsuccessful suicide attempt. My attending discussed his pneumonia and recurrent empyema with a detached manner, commenting that he had brought it all on himself. I at first thought her insensitive, but also realize that when she has so many patients with unfortunate diseases that are non self-inflicted, and so little resources to help them, she is probably angry with a case like this. My attending, Dr. D’sa Shilpa Reynal is a beautiful, thirty-something brilliant doctor with a manner that often comes off as insensitive and brisk, but I know she truly does care for people and her patients in the way she meticulously goes through their case and grills residents on every aspect of their care. She almost lost it when she told one of my fellow students to go examine a tuberculosis patient, and he started the examination by auscultation with his stethoscope. She berated him for a good 5 minutes, telling him that the good clinical exam begins with simply observing the patient at the bedside, then starting with the most minute of things-the fullness or emptiness of his veins, the color of his skin, his breathing pattern. It’s only after careful observation do you touch with the hands, and only at the end do you actually use your tools. She is a difficult but excellent teacher. She carefully picked out patients for me to examine today, and I heard classic mitral regurge in a patient with rheumatic heart disease as well as distinct crackles and rhonchi in a patient with community-acquired pneumonia.
Today was my last day of work this week, because tonight we take the 11:05 PM train to Allepey in the state of Kerala. We have been waiting to take this trip since before coming to India, as we have heard that Kerala is an exotic, beautiful place of natural wonder. We will arrive at 7 AM tomorrow and plan to stay in a cottage by the backwaters, then hop on a houseboat to drift through the backwaters and enjoy passing the villages and beautiful backdrop of lush jungle. Getting the train tickets was quite an experience (had to go through an intricate and complicated process I’ll write about later in “Everyday India”), and I have heard that trains in India are a whole experience in themselves. Nonetheless, very excited for the weekend trip and to celebrate Cristine’s birthday in a new, exciting and beautiful place. Some of the international students who have been here for awhile are starting to leave, and I'm particularly sad to say goodbye to my new and wonderful Australian friend, Louella. She is a truly wonderful person, and I will miss her when she's gone, but as Landon commented the other night, "Well now we have even more of a reason to go to Australia!" I feel so blessed to not only be in India, but to be here with wonderful new friends and the incredible ones that came with me from Oklahoma. Missing everyone back home and wishing you could be here to enjoy it all with me.
No comments:
Post a Comment