Monday, February 14, 2011

Our Keralan adventure

Our three-day travel weekend to Kerala began with a goodbye to Louella. It was the last time we'd see her since she left Saturday while we were in Kerala, so she, Thanuja and Eileen joined the Oklahomans for dinner at where else?  Darlings! If you tasted the rich and savory curries at this vegetarian restaurant, you'd never eat anywhere else either. Some of my new favorites are bhindi (okra) masala, cashew masala and the vegetable mackenwala. The menu is so immense we have something new at almost every meal. Dinner was a lot of fun with the wonderful Australian girls, and I was sad to hug Louella goodbye. We both agreed that we knew we'd see each other again, and she thinks Landon and I would love surfing in Coffs Harbour, the town that she's in for her rotations. It is a blessing to have met such a truly good-hearted and fun person, and we parted saying we'd keep each other in our prayers as we both continued our journeys.

The four Okies then caught the city bus to Katpadi, the train station in Vellore. We all enjoyed the typical rowdiness of the bus and the music blaring out of the bus radio. We pulled up to Katpadi and walked into the bus station, stepping around  the crowds of people sleeping on the floor. We checked the marquee to confirm our train departure time of 11:05, then perused the station for snacks and bathrooms (the squatting toilets, of course). We watched several trains arrive and leave, headed to Bangalore and other cities and towns. We were glad to see some familiar faces as the Swedes rolled up in their typical long-legged, golden haired trendy European style. Panilla, Victor, Hannah and Ana were headed out of Vellore as well for the weekend, and we bade them farewell and a fun adventure as they hopped on the train before ours.

Our train rolled in a few minutes before 11:05 PM, and we found the correct sleeper car according to our ticket. The inside of the sleeper car was completely dark and completely full. There were several compartments, and each wall had three beds mounted to it, the middle which could fold up during the day hours. We crept as silently as we could through the tiny aisles, careful not to disturb the sleeping passengers whose sandled feet jutted out at all angles from their beds.  We found our beds, and Jules climbed to the top while Mike took the middle, Cristine the bottom and I the bottom on the other side.  Mike's bed was folded up and we struggled with the latch for several moments until the man directly across from the middle bed reached over from the shadows and deftly flicked it shut, securing it and scaring Cristine and I so much that we shrieked, then recovered and thanked him. Thankfully Cristine had had the bright idea to get extra blankets from the hostel, and I was so glad for them to keep me warm from the breeze coming through the window as the train picked up speed, as well as for the barrier between myself and the seat that thousands of others had sat and slept on as well as from the cockroaches that climbed the walls.  Eiik!

I actually grabbed quite a few winks on the way, waking up every now and then to a particularly loud rattle as another train passed us going in the opposite direction or at the stops in the towns along the way. I awoke to sunlight filtering through the window slats and the sound of "coffee!" and "chai" as the man walked along the aisles, toting a large metal container of the hot liquids. I stretched my arms, checked on my sleeping companions and looked out the window to the most beautiful country I have seen yet in India. The dusty red hills of Tamil Nadu had transformed overnight into the shining lakes, flowing rivers and forests of palm trees of Kerala. The magnificent countryside flashed by as we continued on towards our destination.

Michael daringly tried some train food (against Roshan's stern advice), and Jules and I stuck with the coffee since it was boiled first. We decided to disembark one stop early from Allepey in Ernakulam, a town that serves as the ferry departure point to Fort Kochin. We bought tickets for 2 PM to continue onto Allepey, then piled into a rickshaw with all of our backpacks and passed by beautiful city gardens on our way to the main jetty.  At the jetty we joined a massive line of people in a stationary line for ferry tickets. After waiting in the line for about 20 minutes, I went off to figure out why nobody was at the ticket office selling tickets. I learned that once again, as in the way home from Pondicherry, we were being held up by a diplomat. The prime minister was on the island and not leaving for another hour and security wouldn't let them sell tickets until then.  So we've now had the home minister and the prime minister hold up our travels. I feel that we are continually in the presence of Indian diplomatic greatness.

We eventually made it to the island of Fort Kochin and enjoyed the trip across the water. It was almost Venice-like, reminding me of taking the vaporetti from the main island to Murano as red-tiled roofs passed by, except that the landscape was simultaneously lush and tropical. We wandered through the streets of Kochin, stopping to visit a spice market where men stooped in the hot sun to spread piles of fresh ginger to dry. We walked into the storerooms where women piled the ginger into burlap sacks and it's spicey scent hung heavy in the air. We sampled several kinds of freshly-brewed tea in the small shop upstairs, then climbed back in a rickshaw to travel to the other side of Kochin because we wanted to see the fort for which the island was named. Upon arrival, we asked several bystanders to direct us to the fort. Each one was completely confused, something we are accustomed to because of the communication barrier. I whipped out our Lonely Planet travel book to find a map, and realized that Fort Kochin was the name of the island and there was no actual fort. Oops. So instead of visiting this imaginary fort, we stood at the shore of the lake and watched the fishermaen operating  the intricate Chinese fishing nets, massive structures as tall as a house composed of numerous poles bent in triangular shapes with nets stretched between them. They stood tall, saluting the blue sky until the fishemen started to climb up them, their body weight forcing the poles and nets into the water as they walked the length of them. They then reversed this methodical dance to bring them up to discover what treasures they had brought up from the water.

We stopped for lunch at the very bohemian and fabulous ex-patriate haunted Solar Cafe where we all had smooth and delicious fruit shakes, fresh lime juice with ginger, French toast with cinnamon wild honey and typical Keralan breakfast food. We then waited in line to get tickets for the 1:20 PM ferry, already a little anxious because we enjoyed our leisurely lunch so much that we had missed the 12:50 PM ferry and we had a train to catch to Allepey at 2 PM from Ernakulam.  After getting our tickets we got in line, aware of the massive crowd of people swelling on all sides of us. People were inching forward, trying to crowd in front of us but Cristine and I dug our feet in and held strong to our positions in the front and center, determined to get on the boat. When the gate opened it was a mad rush forward, and Cristine and I found ourselves literally stuck, jammed shoulder to shoulder with several other people in the mouth of the gate. I literally couldn't move, and she and I were both laughing hysterically as the pressure behind us built until we were popped forward like the cork out of a champagne bottle. We found places as near to the boat door as possible, and leaped from the boat before it was even fully docked as we arrived at 1:46 PM to Ernakulam.  We all sprinted as fast as possible with our bags through the ferry terminal, hailing a rickshaw and telling him to hurry to the train station.  Luckily we arrived with plenty of time to spare since it turns out the train wasn't leaving until 2:20 PM (another communication error), but our transportation adventures weren't over yet. As the clock ticked nearer to 2:20 PM, people began hopping off the train platform amd crossing to the other side of the tracks to be able to get better seats by boarding from the level of the tracks on the opposite side.
Julie laughed and said,
"Hey! They're  Sooners!", to which we all agreed was an appropriate label.
Many of them continued to jump across the tracks, even as the train was chugging along just feet away. We knew that with the enormous crowd still standing on the platform it was going to be tough to get a seat, so I picked a door and grabbed the handle as it passed by, running alongside the moving train and yelling for the others to follow. Even by the time I got in the car, the seats were already filled and people were standing in the aisles. I sighed in frustration until I heard Cristine shout over the noise, "Go up!"  I looked above me and saw people clambering onto the metal mesh luggage racks above the seats, and without a moment's hesitation I planted my right foot in the space between a sitting man's legs (much to his irritation) and swung myself and my bag up. And this is how the four Oklahomans rode for over an hour to Allepey. It was hot, sweaty and our legs cramped in a million places, but at least we had the sweet sounds of The Backstreet Boys and Daddy Yankee playing from a guy's phone on the other side of the luggage rack.

We were relieved to climb down when the train arrived in Allepey, amd we found a rickshaw to take us to the Palm Grove Lake Resort, 2.5 km north of Allepey in Punnamada.  Allepey looked like any typical small Indian town, other than the fact that it had a large waterway running through its center that held boats of all designs, shapes and colors.  We were glad to leave the noises of the town behind as our rickshaw followed the curve of the road to the left and the scenery changed to palm tree forests, small neat homes and brilliant green algae-covered ponds. Our happiness was palpable as we checked in and explored the grounds of the resort. The property ended directly at the backwaters, the water lapping just steps from the front porch of our quaint cottage. Through the thick palm trees we watched the local 'traffic' of houseboats, eleborate covered canoes and one particularly comical man standing in a paddle canoe who chased around 200 ducklings for hours until he herded then back to his yard. We met an elderly Swiss couple who had been coming to Kerala and the Palm Grove Lake Resort for years. They said they had traveled a lot in their lives, but in the past 10 years had just been coming to Kerala for a month in the winter because they loved it so much. They were disappointed to hear that we only had a weekend in Kerala because we had to return to school. The kind woman told us that we had many years until we were their age, but we shouldn't worry about growing old because old age is wonderful and they were very happy to be 'pensioners'.  We slept the night away under the gauzy protection of mosquito nets, enjoying the quiet and cool night.

We awoke to the crisp sunshine of Saturday morning in order to inspect the houseboat we would be renting for the day. Julie, Cristine and I walked to the edge of the water where it was parked and were excited to see that Michael had gotten up before us and was already walking around its deck, accompanied by Audree! Audree Condren is one of our friends from OU med school who transferred to UTSW after her first two years and will be graduating this year as well. She is doing a rotation in Bangalore, and we'd welcomed her happily when she wrote me a message about coming to Kerala with us. We all hugged her and finished looking at the boat, surprised and very happy with how nice and beautiful it was. On the first floor there was a kitchen in back, two bedrooms with bathrooms and side-facing windows (and A/C at night!), and a lovely deck with a table and chairs for dining, an elegantly carved and covered wooden bench in the middle, and padded benches on the sides. The ladder from the front deck led to a top balcony with an area for reclining as well as 4 chairs. The outside preserved the traditional Keralan style of palm fronds interwoven to create elaborate weaves that covered the roofs, and the openings on the sides could be covered by curtains that rolled up so we could enjoy the view. It was quite lovely and looked like a nice way to spend the rest of the day and the night on, so we agreed to the price and the departure time of 11:30 AM. We also met our guides for the trip: Rijo the main captain, Vavachan the skipper, Abhi the public relations man/comedian, Kochumon the waiter/server and Babu the chef.  They were all quite adorable, especially Kochumon who was about 4'11" and 90 pounds.  We then walked to breakfast in the quaint bamboo hut-style restaurant on the property, and enjoyed a delicious breakfast of black coffee (I had three cups), fresh pineapple juice, eggs and toast. Unfortunately Julie and Cristine were feeling quite ill and had been up sick several times during the night. None of us had found our dinner the night before at a local restaurant very savory (seriously the only bad food I've had in India), so we think that may have been the culprit though Mike and I didn't get sick and ate the same food.  Jules and Cristine rested for a bit while Mike, Audree and I went to the little town of Punnamada down the road in search of 7-Up for them to take on the boat. The girls were such good sports because they didn't want to miss out on the houseboat experience that we heard was a must while in India.

We boarded our trusty vessel and were greeted with delicious fruit drinks which we sat and sipped as we made our way towards the lake that fed the channels of the backwaters. We were astounded by the vast expanse of water (Abhi, one of our captains told us it was the largest lake in South India), the beauty of the surrounding countryside and the other boats around us as we motored along. We crossed the lake and tied up on the shore for lunch.  From my perch on the bench I could look out onto the endless emerald sea of rice paddies that hugged the lake. We watched people at work in the fields, trudging in for their lunch. We saw beautiful white birds land in great numbers in the fields, their pristine whiteness accentuated by the deep green.  Fresh fish caught by our guides was served for lunch, as well as other scrumptuous Keralan fare in the form of beets, cabbage and green beans, all accentuated by spices that tickled and pleased the taste buds.  We spent the rest of the afternoon leisurely cruising the backwaters, delighted by the glimpses of daily Keralan life that we were able to see from our watery tour bus.  We passed boats of schoolchildren who waved excitedly and yelled to us, other foreign tourists like ourselves and large groups of Indians whose boats boasted banners like 'Happy Birthday' and 'Happy Anniversary!'. We marveled at the tropical beauty of India here that was so unlike the areas we'd seen so far, and enjoyed the fresh cool breeze that played over us as we lounged on the front deck, drinking chai and soaking it all in.

Around 5:30 PM our trusty captain pulled in to dock along the shore.  Our boat was approached by a jolly, gray-haired Indian man who looked to be about sixty. He asked if we wanted to go on a tour of the small canals in his canoe, and we all agreed.
"Very small canal! Many beautiful. Very happy!" He said excitedly, waving us over to his rough wooden canoe.
After a confusing exchange about how much the price was (we initially thought it was 5 rupees a person, which turned into it being 500 rupees total), we agreed on 400 then hopped in the canoe. We found out our lively captain's name was Anthony, and he lived just off the main canal with his wife and ran a small guesthouse and paddled tourists through the canals. He was excited to hear that we were medical students, and told us that both his daughters were nurses in northern India. He was intent on learning our names, and repeated each as I pointed in turn and told him our names.
"Joooleeee? Michael? Sara! Sara like the Holy Bible! I like to read it!"
I agreed that it was an excellent book and one of my favorites as well, and he nodded with approval at my comment.  I am sometimes baffled by how many Christians I have met in India, and not just at the hospitals where I expect to (since many of them are funded and founded by Christian organizations).  The interesting mix of Christianity and Hinduism is everywhere, and I saw it juxtaposed in many places.  For example, when I went to the back of the houseboat to grab a glass, I noticed a framed picture of Christ and a framed picture of Ganesh mounted next to each other.  Abhi asked me if I knew who they were and I told him, and then commented,
"And they're right next to each other.  Interesting."
"Hmmm, yes" he said with a shrug, but said nothing more about this interesting blend of faiths all on one houseboat.
Anyways, Anthony was an excellent captain as we set off from the houseboat, and kept repeating:
"Balance keep! Balance keep!" as our canoe rocked back and forth with the movement of our paddles.  He was particularly meticulous about Michael's balance for some reason, constantly moving him back and forth in tiny increments, all the while loudly saying:
"Hello Michael!  Balance keeping Michael!  Hello!"
We turned off the main canal and went under a bridge, then took a small branch to the right and floated down exotic rivulets lined by lush, green vegetation, palm trees and village homes. In some places vines and palm fronds hung low over the water and brushed our heads.  At many places village children ran alongside our canoe, blowing kisses, waving, shouting hello and yelling for 'pens pens!' I had one ink pen in my purse which I tossed to a pair of brothers who excitedly searched for it in the grass and yelled 'thaaannkk you!' as we drifted onwards.  Julie was pretty concerned when we saw a snake in the water, but Anthony assured her it wasn't poisonous.  At one point we all had to duck completely down to pass under a low bridge, and our progress was carefully observed by several curious goats at the water's edge.  We passed by fishermen tending their nets, women washing clothes and children playing. We stopped at the point where the canal opened onto the lake to watch the sun cast a warm glow over the water, making sharp silhouettes of the palm trees and boats against the rosy red and orange of the horizon. We were all sad to turn back around to head back, but we all agreed with Anthony when he said,
"Very happy."

Upon return to the houseboat we climbed the ladder to the upper deck to sit in the last few moments of dusk that slowly faded to night, sipping cold Kingfishers that we'd brought aboard and talking about how we felt as if we'd won the lottery in getting to come to India as one of our last rotations in medical school. It's a life experience I will always cherish, especially being able to share it with such good friends. Kochumon soon called us to dinner below, and we dined on chicken curry, fresh bhindi with peppers, rice, chapati, dahl and green beans. It was absolutely delicious and we ate our fill before Rijo came forward with our evening entertainment.  I had asked him earlier in the day if there was music on the boat that they liked to play, and he told me that he'd get it when we stopped.  The 'music' turned out to be an American MTV English music video DVD that he played for us on the small TV on the wall of the front deck. We found jamming out and dancing to the likes of Britney Spears and Will Smith on the backwaters of Kerala to be quite hilarious, and we couldn't stop laughing at their selection of music once they had gone to the back of the boat. We turned into bed around 10:30 PM, and slept quite comfortably until the morning. The motor started up around 7:30 AM and we motored back towards the town of Allepey while munching on a breakfast of coffee, fresh pineapple, eggs and toast.  It was a special morning not only because we were in Kerala, but also because it was Cristine's 26th birthday!  We are officialy celebrating on Monday night, but that didn't stop us from starting the party early!  They docked the boat to a chain of other boats at the main landing, and we had to precariously cross narrow boards balanced between the boats to make it back to land.  We thanked our guides and bade them goodbye as we headed to find the bus station, planning to head back to Fort Kochin to show it to Audree and selfishly to have more banana shakes at the Solar Cafe.  The bus ride to Kochin was another wild one with swaying turns and the whole thing rattled so hard I thought my teeth would fall out. We spent the rest of our time before we caught the train walking through Kochin and lounging in Solar Cafe, sipping our delicious fresh drinks and listening to Simon and Garfunkel.

We boarded the 3:45 PM train to Vellore (which actually arrived around 4:15 PM...India time :), and settled into our hot and dirty sleeper car for the 10-hour ride back to Vellore.  It was nice to be able to travel back in the late afternoon, because I saw much of the Keralan countryside that I'd missed on the night train coming out.  Thick forests of palm trees that filtered the sunlight would quickly give way to sweeping valleys cut by rivers and lakes dotted by green islands of vegetation, then again to flat fields where cows and goats shared their grazing ground with groups of village children playing soccer and cricket.  The most striking sight was around dusk when we looked to the hills where several fires were burning, giving the appearance of molten lava flowing down a raging volcano.  The sky took on a purplish, hazy color giving even greater contrast to the glowing embers on the hills.  We sat on the lower bench until about 9 PM when its occupant wanted to lay down and thus forced us up to our middle and upper bunks, and I was entertained by the adorable little girl on the upper bunk across from me.  She was probably about 8 years old, and she was intent on copying everything I did as I got ready for bed, and watched my every move with big brown eyes and a cute smile.  I drifted off to sleep for at least 3 hours on and off, drowning out the rattling of the train with music from my iPod, and actually slept well until 1:30 AM when I felt Jules shaking my foot from her upper bunk across the aisle.  We all stood guard from then on since we were due to arrive in Vellore around 2 AM, but there are no announcements as to the stops and really no large signs to warn you of your destination, so we could very easily miss our stop in the dark.  We were all relieved when the train slowed and we glimpsed the small white and blue sign for Katpadi station.  We were all too tired to negotiate much on the rickshaw back to campus, and we were never so glad to see the gates of CMC as we pulled in. 

I'm so glad that we went to Kerala.  It's an incredible place of exotic beauty.  Many of the signs there proclaim, "Kerala: God's country", and I certainly see the truth in that. 

Thursday, February 10, 2011

Finishing up the work week, looking forward to the weekend

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.

Monday, February 7, 2011

Medicine, a Scudder and a sari

My first day on Internal Medicine Ward III was wonderful.  I met my intern Dr. Divya Bala Thumaty, a very beautiful and sweet young woman.  She walked with me to the medicine conference room, where we started the day with the rotating residents and the chaplain for a daily devotional.  Although Christian Medical College is obviously founded on Christian values, I didn't know that the staff had devotional time together, and I found this very neat, especially because of the subject matter we addressed.  The chaplain discussed with us that caregivers are expected to heal pain and suffering, but are often in pain and suffering themselves, be it the stresses of life, emotional health, spiritual health, etc.  In order to provide comfort to others and to our patients, we must let ourselves be allowed to be comforted and healed by God.  The chaplain, who is also a physician, said "Our qualification in this field isn't our degree, it's being comforted by God ourselves."  Although this may be extremely simplistic in theory, it gave me peace.  There have often been times as a medical student when I have been so stressed that I feel like I don't give good care to the patients I am seeing, and I know that as my responsibilites grow as I mature as a person and a physician, I am bound to encounter even more stress, and it's my conscious choice to receive comfort in order to give comfort.  From the devotional book we read,
 "Those who have gone through pain and gained comfort from God can face life more confidently.  In order to become an effective caregiver, we may have to go through brokeness and pain.  It sharpens our sensitivity to other people and their pain.  Since we are comforted by the Lord, we are able to impart that comfort to others.  After all, we are called to be "wounded healers".
I know many friends and family members who have gone through such unthinkable struggles in medical school and life who act as caregivers, and I think this is something inspiring to read. 

After devotional we had a typical medicine presentation on the use of ultrasonography in diagnosing enesthitis in ankylosing spondylitis.  During the powerpoint presentation, the power went out twice, which didn't seem to bother any of the residents and attendings one bit.  They instead took it as time for a coffee break and I had my third cup of the creamy, sugary concoction that is coffee "Indian style".  I enjoyed how easily they laughed together.

Wards the rest of the morning and afternoon were as fascinating as ever.  Hemorrhagic tuberculous pericarditis (got to examine the patient and finally felt pulsus paradoxus with my own hands), tetanus (the patient was in complete opisthotonus) and a medical mystery in a young man with severe bronchiectasis and lung disease of unknown origin that led to heart failure (cor pulmonale).  If I had viewed his CT and known his age and history in the US, I would have had cystic fibrosis on my differential in a snap, but my resident said that in India it's almost unheard of, and she had certainly never seen it.  It was likely some form of interstitial lung disease that had become severely complicated by tuberculosis or aspergillosis.  Either way, his diagnosis was unknown and I got to assist with a bedside supraclavicular lymph node biopsy (yes, bedside).  The resident used local with epinephrine and I draped towels over the patient's face so he couldn't watch. Throughout the dissection the resident and I nervously watched his heart rate on the outdated monitor, nervous that even such a small dose of epinephrine could disrupt the delicate homeostasis that his failing heart had accomplished.  I almost lost it when the resident murmured, "Hmmm, is that lung tissue?", fearing we had dissected into the pulmonary apex, but I maintained composure since the patient was awake and breathing right under my hands.  After the biopsy was done I breathed a sigh of relief and my resident just grinned at me.
"You don't do these at the bedside at home, do you?" He asked.
"Nope!" I said.

Tropical medicine rounds were as fabulous as ever-adrenal histoplasmosis and an enormous splenic hydatid cyst!  The leading attending was a local physician who was excited to meet the American students, which is always nice.  I sometimes feel guilty for attending the tropical medicine symposium since many of the international visiting attendees paid about $2,500 to attend, but everyone has been so welcoming to us during our few hours at bedside rounds that we keep coming back for more!

Cristine and I went for a lovely run around campus this evening, giggling at the salutes we got from the guards along the paths as we passed by.  Tonight there was a gathering for all international students and staff, and we were given a warm welcome by Mr. Skiel, the director of development for CMC and a transplant from the UK to India for 11 years.  He and is wife, Debbie, were absolutely charming as they gave us a formal welcome to CMC and allowed us to raise our hands to respresent the countries we were from.  By far the largest amount of students are from the US, but there are significant numbers of others-Sweden, Norway, Germany, Singapore, Australia, to name a few. 

He gave us a brief history of Ida Scudder, who is considered the "founding mother" of Christian Medical College. Ida Scudder was an American, born in India to her missionary parents (her father was a physician).  Mr. Skiel explained that for her early life, Ida often hated living in India, and was resistant to her parents' wishes that she become a doctor and instead planned on returning as soon as she was able to the US to marry and start seminary school.  It wasn't until one night when three pregnant women in complicated labor came to her father's clinic seeking help from a woman doctor, but there was no woman doctor, only Ida's father and Ida herself.  The women's husbands refused to let their wives be treated by a male doctor, and begged for Ida's help as she was a woman.  As just a teenager with no medical training, she was helpless to their cries of need and watched them turn away into the night.  She sent a servant into the village the next morning, and found out that all three women had died in the night.  It was then she felt her calling, to help the women and children of India.  She completed medical schoool at Cornell and returned to India and opened a one-room dispensary (that is now the Schell eye hospital here, so cool!), and that was the early and humble beginnings of CMC.  I won't bore you with all the details of the in-between from when she started the clinic in 1918 until now, but essentially CMC has grown from a one-room tiny clinic to an incredible medical institution that is one of the most well-respected in India.  Despite all of this, I can still see the simplistic beginnings in the comprehensive rural health and developement programs that replaced Dr. Ida's initial "roadsides", such as the Community Health and Development (CHAD) program as well as many others offered through CMC.  These places still continue to serve people like the three women who came to Ida that fateful and tragic night.  If you are at all interested, I highly recommend reading more about this amazing woman (you can just Google her, of course :).  She's quite a hero to me.

Lastly, we ended the evening with a lesson in sari!!!  I feel like I have been invited into a secret club, now that I know how to put one on.  I of course volunteered to be the guinea pig/model, and several of the CMC teachers skillfully wrapped me, pleated the cloth and gracefully draped it over my shoulder in about 5 minutes flat.  I tried to replicate the result, but my efforts were not quite as graceful.  The female teachers spoke about how you can tell the region of India where a woman is from by her sari, and that saris have many uses even when they are not being worn (to use like a blanket to keep warm, to suspend a baby in like a hammock, to make curtains, etc.).  They said a decent sari can be purchased for as cheap as 200 rupees, but that wedding saris start around 50,000 rupees!  The reason the weddings ones are so expensive is that they often have actual gold woven into the fabric.  The eldest teacher lamented that the sari is becoming a dying art form in India because the young women prefer the Punjabi pant sets over the traditional garb.  She said only one of her daughters knew how to wear a sari, but that neither actually wore them.  Looking at the teacher who was absolutely majestic in her sari of deep reds, golds and blues that complimented her silver hair, I couldn't imagine why they could do just a thing!  Cristine and Jules were also aghast, and we made a vow to find some beautiful saris to bring home with us from India.

A wonderful day of learning in so many different forms.

Sunday, February 6, 2011

Everyday India III

1) The Power Belly
After only one week in India, we have all noted a phenomenon that Cristine has coined the 'power belly'. The power belly describes the large, round abdomens that protrude from the saris of select Indian women, most commonly middle aged and elderly women. Usually the said women are quite thin everywhere else but the belly.  In a country where showing even a bit of ankle is considered risqué, it seemed strange to me that this belly baring was kosher, but it not only is prominent everywhere but also quite an asset. Power bellies are helpful in boxing out one's personal space on a crowded bus, cutting in line, or just in making one look powerful and strong. I actually quite admire them, and am working on one myself with all the fantastic Indian food I am eating everyday.

2)  Man love
Man love is the term that Michael has used to describe the physical affection displayed in India between men. We first noted it on one of our early rickshaw rides when we passed men on their motorcycles, each driving with one hand and holding hands with the other. We were a bit bemused by this, but throughout the week we have seen acts of man love' everywhere, and it's honestly quite beautiful. They celebrate their kinship by walking hand in hand down the street, long embraces and openly displaying their kindness and love to one another. Living in America where it's ingrained that this behavior would be deemed as homosexual, I am perhaps more hyper-aware to their interactions though it makes me happy to see men celebrate their friendships as openly as women do theirs.  Guys, have you hugged your buds today?

The end of a wonderful and wild weekend

What a time in Pondicherry. After our delicious breakfast on Saturday we strolled through the French quarter to get our first glimpse of the Bay of Bengal. We three gals had naively put on our swimsuits under our kertas in the hopes we might lay out in the sun. After arriving at the beach and watching women clad in full saris wading in the water, we realized three American women in bikinis would cause something equivalent to a riot with all the stares we were already getting from the young Indian men prowling the beach for glimpses of skin. Instead we walked along the rocky beach, watching groups of schoolgirls spalshing in the waves, their hair in braided pigtails wearing soaking  wet saris and baseball caps.

We then set out to find the shopping area for gifts for friends and family back home, but soon got overwhelmed by the crush of people and heat. Like an oasis, I spotted a sign that said "A/C. Cold beer.  Snacks.", and the group was immeadiately sold. Not only did they have those treasured conveniences, but delightful 80's music and a clean bathroom to boot! We sat and had two rounds of icy cold Foster's and some tapas while discussing our first week in India, people back home and our plans for continued travel in India. We finished our afternoon with some purchases made at the open air market, then stopped for pre-dinner fortification at the finest of Indian dining  establishments...Pizza Hut. In our defense, both Roshan and Krishna had told us back in OKC that we must try the Chicken Tikka Masala pizza from Pizza Hut while we were in India as it was superb. We were quite pleased with the flavor and it was the perfect blend of the comfort of home and the delicious spices of India.

We took some much-needed showers at Les Hisbiscus, followed by a late-afternoon nap. I was awakened by loud music and chanting from the street below, and opened the wooden shutters to catch sight of a large funeral procession below. An elderly woman chanted as a flower-adorned altar with pictures of the deceased was bourne aloft by several men.  We dined in a palm-frond covered hut at the Bamboo Garden that night, and fell asleep to the quiet sounds of a night in the French quarter.

Sunday brought another beautiful day, and we enjoyed our fresh watermelon, papaya, pineapple and black coffee (yes!!!) in the breakfast room, filled with scent of incense and sunshine filtering onto the red tiled floor. We bid farewell to Bascarane and went for another walking tour of Pondicherry. I was approached by a young girl who introduced herself as Lakshmi, and asked to take a photo. She thanked us after we arranged ourselves for her photo, then shyly asked me,
"Now just one of you Madame, please?"
I couldn't help but giggle a 'sure' as I smiled for her camera, but she still wasn't satisfied with the arrangement.
"Madame, can you please make a stylish pose?"
This brought a fit of laughter from Mike, Cristine and Jules as I placed one hand on my hip and jauntily leaned on a nearby pole with my ankles crossed.
"Thank you Madame, you're so cute." Lakshmi beamed as she head bobbled.
I did my own little head bobble, told her she was cute as well, and we continued on away from my litle papparazzi friend.

We searched for the ashram and found the area where it was located near the ocean. An old man was seated on the curb outside, and I greeted him with a "hello" and a smile, and asked him if we were indeed at the right place.  With hands pressed together in the Indian greeting of gratitude, he said,
"Yes Madame, namaste. I know that you have much compassion. Namaste."
I repeated his gesture and namaste, and felt grateful for his blessing and kind words, hopeful that what he saw in me is how I truly am.  The ashram was so serene and peaceful, seemingly miles away from the screech of horns and din of daily life outside it's white-washed walls. We were asked to leave our shoes outside and were then permitted entrance to the peaceful realm. We walked along the path lined with some of the most enormous and vibrant flowers I've ever seen. The closest flower I can relate them to are zinnias, but these were of brilliant fuschias and oranges, and the size of dinner plates.  We paused in the area of the alter, a white marble rectangular structure on the ground. The top of it was completely covered in religious mosaics made entirely of different flowers. I tried to be as silent and unseen as possible, because there were people all around the alter praying.

Thankfully we found the correct bus to Vellore at the bus station, no easy feat considering the amount of buses with no identifying destination on the front and nobody seems to be able to direct you where to go when you ask. Again it was full beyond capacity with people standing in the aisles for the several hour trip home. I was thankful for the woman in the brilliant blue, gold and red sari standing beside me, because the scent of fresh flowers in her hair masked some of the pungent scents of India that tend to be almost everywhere in the cities.  Taking public transportation in India is always an adventure, and this time was no exception. Julie, Cristine and I exchanged several wide-eyed terror-stricken glances as the bus leaned precariously as we bumped down dusty dirt roads, and at one point we were at a standsill in traffic for one hour. Many of the people got off the bus at this point to relieve themselves (directly in the line of sight of the bus, I might add), and I asked a man standing beside my window what was going on. In broken English he explained that the Indian home minister was being inaugerated in Chennai, and that was the reason for the traffic where we were. Though I couldn't see how this was  completely plausible since we were still many miles from Chennai, I just smiled and thanked him for the explanation. The traffic jam caused us to take some 'back routes' which were in even more dire shape than the ones before, but the bus driver didn't seem to slow his break-neck spped one bit. Although we could have hired a car and driver roundtrip for 5,500 rupees for the weekend as many international students do, we wanted to travel like locals because it's one way to experience a part of real India. Round trip bus fare to Pondicherry: 96 rupees.  The experience of sitting on a grimy bus with adorable Indian children crawling in your lap, people vomiting on your shoes (poor Michael), horns blaring, people hanging off the sides of the bus and feeling the bus sway as if it will tip any second: Priceless.

Other than the bus ride being completely chaotic, the journey was scenically beautiful, and from my window seat I enjoyed the firey blaze the sun painted across the sky as it passed lower and lower and finally disappeared into the dusk. It left behind soft streaks of pink, orange and sienna that wove together to make an endless tapestry more beautiful than any of the incredible colors I've admired here in womens saris. I was fascinated by the numerous small temples and altars I saw in the rural areas, sometimes even in the middle of the field. Ganesh in all his many-armed glory seemed more appropriate next to the beautiful countryside than in some of the extravagent temples where I had also seen him in the cities. I feel closest to God in nature, and maybe the people here have similar feelings with their gods as they worship.

Tomorrow I start my second week at CMC on the internal medicine wards and I am so excited. On Wednesday Mike, Cristine, Julie and I will visit the leprosy hospital outside of Vellore. It's sure to be another week of new experiences and lots of fun.  Just hope I don't have to take another bus any time soon....:)

Friday, February 4, 2011

Pondicherry: La vie en rose

We left Vellore yesterday afternoon and rode the packed city bus 4.5 hours to Pondicherry. It was a wonderful drive as we passed the brilliant green of the rice paddies and the colorful stands in the bazaars of the small towns we stopped in along the way.  Many of the locals stood the entire 4.5 hour ride due to the amount of people on the bus. I could not stop smiling at the darling little boy who was halfway in my lap most of the way due to the crush of people behind him. 

When we first arrived in Pondi, it appeared similar to the hustle and bustle of Vellore, but as we rode in our rickshaw to the Les Hisbiscus hotel in the French quarter, the architecture turned more to the white buildings of a quaint French neighborhood and resembled something entirely different than the India we know. Wisps of conversations in French drifted our way as we disembarked from the rickshaw and greeted Bascarane, the gentlemanly proprietor of the utterly charming Hotel Les Hisbiscus.

Much to my delight we found REAL red wine last night, and had crepes for dinner. I think we all felt a bit like we were cheating on India, but the food was excellent. We just finished a European style breakfast, croissants and black coffee, meanwhile listening to Miss Cami Stinson croon sweet melodies on Julies iPod. We are headed out to explore this quirky town where elegant French culture meets vibrant Indian life, hoping to do some shopping, visit an ashram and relax on the beach. Even though I feel like I am on an exotic adventure everyday in Vellore, Pondi really feels like vacation.

Ciao, or should I say namaste....?

Everyday India II

Cutting in line
In India, lines seem to be a mere pretense at organization, just a suggestion of order but not something to really obey or participate in. It doesn't matter what the line is for-ordering food, washing your hands, the bus-people ignore your very presence and pass in front of you. At first I assumed I was getting cut in line because I was a polite foreigner, too passive to say anything, but then I saw Indians cutting other Indians just as frequently. In many of the restaurants and cafeterias on campus, you order at a cashier's stand, pay and then take the receipt to the kitchen for your food to be prepared. These scenarios are particularly maddening because this presents multiple opportunities for cutting. However, luck was on my side one day last week when I was in line with an Indian man who was as frustrated as I was about being cut in line by a man and his son who handed their tickets over before I could even form a frown of injustice. The man behind me let the little boy hand his ticket over, but when the father did there was a rapid-fire exchange in Tamil between the man behind me and the kitchen worker taking the tickets. From the gestures and facial expressions that followed, it was obvious that the cutter had been tattled on and was being sent to the back of the line. My ally and I exchanged smug, victorious glances as he stalked off and we handed our receipts over for our veggie meals. I was so inspired by this incident that I stood my ground the next day when another person tried to cut me. I blocked his pass but smiled sweetly as I held my ground. He backed down and in celebrating my success I didn't even mind that a family of five had snuck in front of me and was now ordering. Little victories.