Friday, June 5th

6/5/15

Today was our last full day as a group. Christine and Keiko went to the government hospital in Kerula with the visiting surgeon yesterday, so today, Kristen, Gina, Derick and I went to the hospital with the anesthesiologist, Dr. Guru.  He came to pick us up at 8:30 am and we headed to the hospital. Dr. Guru told us that the hospital provides care for uninsured tribal members not only for free, but also that they provide free food for inpatient and monetary incentives for coming to clinic appointments so that they will actually come to receive care rather than relying on alternative/naturalistic tribal medicine only. I'm not exactly sure how much funding the hospital receives from the government or how it is sustainable, but I was very impressed by it. It was actually a legit hospital -- more fully equipped than Bethany Medical Centre. After we got there, we changed into scrubs and went to the OR with two orthopedic surgeons. The first case was a guy who had a broken arm from last year and had to have the plate taken out. The surgeons explained everything for us, so it was a good experience. We asked them afterward whether one of us could scrub in, so Derick scrubbed in on the next case. It was a more complicated case where the patient had a huge break in his ulnar bone. Derick got to screw in the plate and also suture for the first time. We got a chance to talk to one of the ortho surgeons and we found out that ortho is also a very competitive specialty in India as well. In India, you don't get to choose your specialty. You take an exam after you graduate from medical school and depending on your rank from the exam, you are given three choices from which you can choose from. To get into ortho, you have to be top of the top in the nation. Interestingly enough though, the other two competitive specialties in India are internal medicine and peds. It's interesting to compare as they are not considered the most competitive specialties in America. 

Another interesting is their sterile techniques. I've had a chance to scrub in on a couple of surgery cases at Rush and know what our sterile techniques are like. Of course, there are only limited resources here, so things can't be done the way they are done in America. But, after seeing the standards taken in America and how things are done here, I'm not sure if I would want to have any surgery done here. It would be interesting to see how things are done at a better-funded hospital in India as well.

On the way back to Bethany from the hospital, Dr. Guru told us that the hospital actually pays the patients to come to their appointments. The tribal population mainly believes in alternative medicine/tribal medicine and does not like coming to the hospital. As a result, the hospital incentivizes hospital visits with actual cash and provides free food and beds for admitted patients. I was very impressed when I heard this as something like this wouldn't fly in America at all. It made me wonder whether the initial cost in providing these monetary incentives is actually less than the cost that would be needed to treat conditions that could've been prevented. I wouldn't be surprised if it is and that's why the hospital has this system for the tribal population.

After we got back, we wrote thank you cards for all the staff that took care of us. It's been especially helpful to have Sanil with us as his English is excellent and he translated for us when we saw patients. He also had us do procedures and made sure to get us in the middle of the night for ER cases (although I woke up only once for this and it was just gastritis). He wants to do a family medicine residency in America, so he's studying for Step 1 right now and has been pointing out high-yield Step 1 clinical factoids from different cases for us. 

In the evening, we sent off Derick, Gina and Jen, and then there were four of us. We'll be heading to Delhi tomorrow to travel for a week before heading back to Chicago. 

Overall, this was a great experience for us and will be a great trip for those who are finishing up their M1 or even M2 year. I personally learned and saw a lot and this trip has reaffirmed my passion for global health. This trip serves as an invaluable reminder as to why I'm in medical school and why I'm studying a lot. I hope that I can gain the knowledge and the skills to be able to one day travel to wherever I am needed and serve those in need. Thanks for reading!

Thursday, June 4th

Today was the day the visiting surgeon came. We went to prayer, ate breakfast, went on rounds and then went to surgery. Keiko scrubbed into the first case which was a laparoscopic appendectomy. The surgeon only charges the patient $100 for the surgery and he bought all the equipment himself. He owns it and he brings it with him in his car wherever he goes. I was talking with the anesthesiologist and I bagged that patient for the entire case. He was telling me how to only use two fingers because it was a two liter bag and the tidal volume was only about 500ml. The surgeon was a great teacher and showed us everything in the peritoneal cavity via the scope. 

The next patient I scrubbed in for. It was an anal fissure that was accompanied by constant constipation. We were there to cut the internal sphincter to relieve the patient. First he had me examine the anus with my finger in the anal canal to look for any polyps. After a negative screening we proceeded with the procedure. We felt the external sphincter and then he made a parallel cut on top of the internal sphincter. Then I took the foreceps and held the muscle body while he cut the sphincter 2/3 of the way through. This was to increase the anal opening so the patient could still have control over bowel movements but wouldn't be so constipated anymore. We didn't sew anything up. Instead, the surgeon cauterized the incision and the fissure. Then we made a gauze butt plug, covered it in lube, and made sure it was secure in the patient for recovery. 

After that the surgeons invited us to come with them to the next hospital for the rest of the surgeries that day. So we went, grabbed lunch, and headed over to the government tribal hospital for two hydrocele surgeries. Keiko scrubbed into the first one which turned out to be much more complicated than we thought. The testicle was as big as a cantaloupe and when we cut it open, a lot of clearish but yellow tinted fluid came out. However, we discovered he had an inguinal hernia because we also found his cecum in his testicular sac. So the surgeon literally shoved all his intestines back into the abdomen and then recreated the posterior wall with a polypropylene mesh. Then he thought the bladder might be in the testes too because there was another structure there as well. So we threaded a catheter up the urethra and ruled out the possibility of the bladder being in the testes as well. Then he put in drain and sewed the patient up. 

The next case was much simpler, it was a plain hydrocele, but it was just as big. I scrubbed in for it and we turned the testes inside out so the lymph would drain in the future. Then the surgeon put in a drain and stitched the patient up.

We came back to the medical center just in time for dinner. Then we played games, wrote thank you cards, and read before going to bed.

Wednesday, June 3rd

This morning we all got up and went to morning prayer before we ate breakfast. Then we went off to morning rounds. We saw one woman who had hemorrhoids which are pretty much varicose veins of the rectum that are divided into two categories. The first is not painful because the nerves are internal and belong to the upper two thirds of the rectum. The other one is painful and they are external hemorrhoids and they are painful because when the nerves fire for external hemorrhoids you can feel them. You can distinguish between hemorrhoids and intestinal bleeding upon examination after passing a stool. If the blood is mixed in with the stool and is a darker red or black, it is indicative of intestinal bleeding proximal to the rectum and if the blood is bright red it is indicative of hemorrhoids and the blood would not be mixed with the stool, it would be separate. 

Then I went to Dr. Clemets clinic and saw a bunch of patients. One of the boys had eczema and you can distinguish this from measles because measles presents with pustulated rash that starts at the head and spreads down to the feet. It is also usually accompanied by a fever as well. Then we did a I and D, incision and drainage of a man's finger who had felon and once we cut under the finger nail a whole bunch of pus came out. Then we headed over to a c section because the baby was in breach position and fetal distress. When the baby came out it wasn't breathing so the nurses slapped it, poured cold water on it, suctioned its mouth, and started ambu bagging the little girl. After about two minutes of them artificially breathing for her she came to life and started screaming. I've never been so happy to hear a baby cry. 

Then we put it under oxygen and I listened to its lungs to make sure we suctioned enough and the baby was breathing sufficiently. Then we went to have lunch. After that we traveled about an hour to a tribal village in the district of Kerala. The road was really bumpy and once we got there we played with the kids before we started clinic. We had clinic in the school house and I did triage and physicals on all the kids. One kid, a nine year old boy, had a previous corneal abrasion which turned into a corneal ulcer and then a nebula. He also had scabies so I might have contracted that as well...we shall see. After we finished clinic we walked down to the river and took some pictures. When we got back from clinic we went to evening prayer, ate dinner, and then played spoons the rest of the night.

Tuesday, June 2nd

Tuesday, June 2nd

Bethany medical centre 9:32 p.m.

Today was fairly routine, except for the part where we saw A LIVE CHILDBIRTH.

Morning was much of the same - breakfast, rounds, and then we split up into the different OP clinics. Gina and I were on OB/GYN. We ultra sounded a patient who came in with a severely distended abdomen from the level of the umbilicus on down to the pelvis. Our differential included pregnancy and ovarian tumor. Thankfully, abdominal ultrasound revealed a heartbeat. We were able to view the chambers of the baby's heart and the developing spine (notochord? We aren't the best at embryo).

Around noon we got word of a 19 year old mother going into labor (G0P0; I suppose now she's G1P1). Pitocin was administered and then we relaxed for a good stretch of the afternoon while waiting for the cervix to fully dilate. Gina and Kristen observed a D&C in the interim which was supposedly quite bloody.

At 5 pm Keiko and I went down to check on the status of the dilation. We arrived just in time for Ringtu to tell us that the cervix was fully dilated and the delivery was about to happen. We stepped into the room to observe. Local anesthetic with xylocaine was done and an incision made to allow room for the baby as it crowned.

The delivery was much different from what I had imagined. I had always thought the baby would slowly ease out of the canal. That was not what happened.

At first all we saw was the baby's crown. Then, after a few contractions the whole head spurted out. The nurses rushed to cut the umbilicus as it was wrapped around the neck, and then they pulled the whole baby out. It all happened so fast that I barely had time to process what had just happened. 

Then the rest of our group showed up and I decided to dip before the placenta was removed - I saw that happen the first day and it's not an experience I wanted to voluntarily repeat. 

Following that we relaxed until dinner playing games and talking, and then we went on evening rounds. Saw a patient with clonus following lesion to his left internal capsule from stroke. Also saw a patient with a distinctive S3 sound.

The others went to Dr. Clemet's house for a little jam sesh as I sit here writing this blog entry. Tomorrow we're going to go on a field trip to one of the local tribal villages. I hope it's a great learning experience.

-Derick

Monday, June 1st

Monday, June 1st

Despite being told that Mondays were usually pretty busy, today was a fairly routine day. We went to breakfast and morning prayer followed by rounds. It’s been a great experience being able to follow patients who have been here since we arrived, and observe how their long-term care is handled. The patients seem to recognize us and feel comfortable with us being there, which makes our time here seem more worthwhile. After rounds Keiko and I sat in the outpatient clinic seeing peds patients with Sanil. We saw a patient with impetigo, a rash caused by strep or staph bacteria that I had only heard of and seen pictures of in my science classes. Just another example of something I had never seen before in the US that isn’t out of the ordinary here. After being here for a few days I’m really starting to feel comfortable interacting with the patients even though I can’t talk directly to them. Sanil let us do a lot of the physical exam components and ask the patients questions while he translated. I think he got a little too confident in us when he left Keiko and I alone in the room to examine whether a teenage girl had a rash on her thighs. Needless to say the language barrier didn’t get us very far on that one, but just like when I was in Haiti it was a humbling experience trying to interact with someone when you can’t speak their language. We saw a few more patients, and then sat with Dr. Clement (probably my favorite physician to work with so far) in his clinic for the rest of the morning. Nothing super out of the ordinary today - a lot of back and knee pain, viral infections, and other typical things you'd see in the US.

We took a break after lunch, and Sanil insisted on googling pictures of Britney Spears to convince us that Christine looks exactly like her (he wasn't very successful). I think our trip would have been very different if it weren’t for Sanil. Since he’s close to our age we’re able to get a good perspective of how life here is so different than in the US. Talking to him has really made me realize how much we take for granted. He always comments on how lucky we are that we can make our own choices as far as what specialty we go into, who we date, when we want to get married or start a family, etc. In India their lives are very planned out for them and they don’t have nearly as many opportunities as we do. But they make the most of their situation which I really admire them for.

Sanil had promised to take us hiking later in the afternoon, but I can’t comment too much on that since Nora and I chickened out and stayed at the bottom after he insisted that there were “snakes and things.” Even without going any higher we could still see how beautiful it was and enjoy the nature that we don’t get to see very often in Chicago. When everyone came back down we took another trip to the Aqua Stop. Apparently we’ve had too much curry and not enough sweets because we loaded up on packaged cookies, ice cream bars, and my new favorite coffee that needs to start being made in the US. The rest of the night was a lot of hanging out, taking showers with lizards, and playing card games, which seems to be our nightly activity for the trip. So today wasn’t extremely patient or medically centered, but I’ve loved being able to have some down time and really get to know everyone here. I'm excited to see how the rest of the week plays out!

Sunday, May 31, 2015

Sunday wrapped up the religious retreat at the medical center. The previous night, several of us were invited to Dr. Clement’s home to practice playing Amazing Grace for the morning prayer. As there were only two available violins, I opted to strangle a few cats (read: play) the night before and let Christine and Nora have all the fun at the actual prayer service. Keiko played the piano while Gina strummed some chords on the guitar. Despite Derick’s angelic, soprano voice, he refused to delight the crowd with his raw talent. Dr. Clement and his wife were incredibly welcoming, sharing something along the lines of Indian lemonade and a snack that reminded me of pakoras (a fried snack: Google it, they’re deliciously addictive). To everyone’s delight they also videotaped our professional-level playing.

At the prayer service on Sunday morning, everyone played beautifully—including Keiko, who did an excellent job of faking on the keyboard (it was stuck on a setting that played synthesized 70’s-like music on half the keys). The prayer attendees loved it.

Almost everyone at the medical center is fairly religious, which is apparent even in their medical practice. For example, when Nora and I witnessed an emergency caesarean section, they actually took the time to sit the girl up before giving her the epidural to pray collectively. I’m not sure how prevalent that is in the OR in the United States, though I think we were both a little surprised. The rest of the day was relatively slow as it was meant to be a day of rest. We attended evening rounds later with Sanil, who was a fabulous friend and teacher during our stay.

While it didn’t occur the same day, the c-section was certainly one of my most memorable experiences during the trip and as such, I think I should do it justice. Previous to this, I had never witnessed a live birth, but following the case, Nora and I left with the impression, “I think I’ll consider adopting” (joking).

But really. The experience was certainly the most violent thing I have ever witnessed. Something along the lines of the movie Alien (you know that scene where the alien baby comes out of her stomach? Yea, like that). The baby was breeched and in fetal distress, making the situation urgent. Nora and I were called out of Dr. Muralidar’s primary care office to witness it. In the OR, Dr. Chako—a feisty, 80-something-year-old woman who would rival any Bengal tiger or US surgeon in the stereotypical attitude (sorry Nora and Al-Faraaz)—was the main surgeon. Without sparing a moment after the prayer and scrubbing-in, she squarely planted her flip-flopped feet, took her attack stance and dove in. Dr. Chako made a huge incision across the entire abdomen, with more urgency than precision from our viewpoint, and as she could not get a firm grasp on the baby without it slipping back inside (this occurred several times), she reached in up to her elbows to pull the baby out from underneath. This still proved rather difficult, and eventually, the baby came out, one leg at a time, bloody, blue, completely limp and not breathing. She immediately started compressing(?) the baby, shouted to a nurse who rushed in and immediately put it under oxygen. About 5 minutes later, to everyone’s relief it started breathing. Nora and I hoped the baby was not left with any significant brain damage, though I’m not certain at this stage of our education how long it takes for something like that to occur.

At any rate, it was truly an experience. Upon my return to Rush, I asked a few doctors if c-sections are typically so “violent,” and it appears that this experience was not so incredibly different from the norm. Who knew? It certainly left me with a lot of compassion and respect for women. 

How can I sum up my parting thoughts on this trip? Impossible. It was such an incredible experience, from both a cultural and medical perspective. To anyone thinking of going on a trip in the future, do it. It’s highly independent, difficult at times and you’re required to leave your American ego and luxuries at the airport door—squatting shower when the water is actually working, no AC (so I nearly feinted once from the heat; I’m no worse for wear), fans when the electricity works, rice and curry for days (even when it’s good, 3 times daily every day is a bit much) and spiders, bugs and lizards to keep you company at night. It’s character building. But working in the mountains with rural villages, contrasting how medicine is performed on the opposite of the world where resources are low, and discovering an entirely different culture, it’s the experience of a lifetime.

- Kristen

Saturday, May 30

The weekend we spent there was not particularly medically oriented but I felt it gave us a great insight into the cultural aspect of what the people in the community do on their spare time. On Friday night, a pleasant couple from the UK arrived to lead a Christian retreat. They explained that they are missionaries stationed in India and had spent the last few years preaching there. I found it fascinating that they were so efficient at eating with their hands (a task I was never able to  master).They told me that it definitely took them a few years to get used to it but that now it felt strange to use utensils. 

Saturday morning, we woke up and headed to breakfast. Breakfast was my favorite meal of the day simply because of the amazing chai they prepared (they also have beans for breakfast sometimes, which I loved). After that, we headed to the church that was located uphill. The retreat was very interesting. The missionaries did not speak Tamil so they used an interpreter. I found the topics of the retreat to be pretty liberal but somewhat culturally insensitive. There were very bold statements made about differences of family life in America compared to family life in India that seemed to be very black and white. I could see how it would send the wrong message to someone who had never been to America but did somewhat clarify for me the reason behind misconceptions that some villagers had about life in the US. Overall, I felt the people of the community really appreciated the messages the missionaries were delivering. It seemed to be a great way to meditate and give them a break from their weekly routine. 

After the service, Christine and I decided that we really needed some more Dark Fantasy. Dark Fantasy were these amazing cookies that we were hooked on the entire time there. As we were going to the store, we also decided that we needed to get a ball, then quickly realized that sending Christine and I out alone was a bad idea. We knew we wouldn't stop until we found a ball and ended up walking to Anaikatti to purchase a ball and a bigger cup for me to drink chai out of. Anaikatti was great! It was a small village in the middle of nowhere with everything you could possibly need (except toilet paper). We knew that this was where we could find a ball so we asked around and were directed to a small store where we got two balls and I purchased a Disney princess sippy cup. We suddenly realized that we were running late for "band practice" so we quickly headed back with our balls and princess cup. 

Earlier that day we had been asked to play "Amazing Grace" for the Sunday morning service so we headed up to the doctor's house to practice. He had 2 violins, a guitar, a keyboard and an awesome accordion that he was really good at. We practiced the song a few times and I still thank Nora for her patience with my lack of musical skills. It felt really good to play the guitar in a group again and especially because it seemed to make the doctor really happy to have us over to play music with him. We practiced for a while and then it was dinner time. We had dinner, some of us went on evening rounds while others showered and then went up to practice again to get ready for the next morning.

Friday, May 29th

It's day two and I'm almost certain that everyone woke up this morning at 7 am thinking "Wow, what have I gotten myself into?" followed immediately by the realization of "Man! My back is killing me!" The modern luxuries of living in a developed city like Chicago are now a thing of the past. There are no stand up showers, just a bucket of water and a pail to rinse. We have to use our toilet paper sparingly as we fear we may run out before the end of the trip and the local shops do not carry more. We're lucky if our mattresses (more like mattress pads) are more than 2 inches thick on an uncomfortable, completely flat metal platform. This is jungle life amongst the Irula tribal people of Tamil Nadu and Kerala and all of the patients treated at Bethany Medical Centre are subject to these same conditions, if not worse. They are usually all smiles though when we round in the wards, especially the younger gentleman in the corner of the male ward (yes, wards are separated by gender) with a diabetic ulcer on his amputated left foot that never seems to heal fully who is a permanent resident at the hospital as he has no other place to live. I am amazed at how Bethany would make an exception to let this differently abled patient with no home or family live full-time at the hospital; I doubt that would ever happen in the US. Now it makes more sense to me why he is always smiling.

As we round, I'm deeply humbled by how the patients and their families stay overnight for days in the wards in these extreme conditions of 95 degrees Fahrenheit and 95% humidity. There is no A/C, no fans, no privacy, limited personal space and certainly no entertainment. I seriously wonder how they manage to pass the time day in and day out. My mindset quickly changes as I tell myself, "If they can survive this, so can I." It's experiences like these that remind me of the tenacity and power of the human spirit and exactly why I wanted to go into medicine. The human body is amazing and capable of so many more things than we know of. I can only hope to elucidate a few of these things in my future career as a doctor.

Being here feels a lot like summer camp, where many of my favorite memories from childhood live. We wake up and get breakfast at 7:30 in order to make morning prayer by 7:45. Bethany is a Christian hospital and prayer is a part of their daily schedule. Morning prayer is a new yet familiar routine for many of us, but a far stretch from our normal lives as students. We briefly take a break for some masala chai and then attend rounds at 8:30. When you first step into the wards, there is a distinct, overpowering icy-hot, menthol-like smell. Unlike a lot of other noxious stimuli, however, this smell never lets up and is oddly comforting. It then becomes immediately apparent that all eyes are on you. As you walk through the wards, each patient looks longingly as if the fate of his life or death lies in your hands. We are definitely not used to this kind of attention back home as lowly first-year medical students, and we feel a bit overwhelmed by the true lack of real clinical knowledge we have to help treat all of these patients. But much like the leap of faith I had to make during each of my summer ropes course classes, we dive in and finish rounds without a hitch, learning at least 10 new things that morning. For instance, we witnessed a positive Hoffman's sign in a man with thalamic pain syndrome after having a thalamic stroke. A Hoffman's sign is often described as the Babinski sign of the upper extremity, but is more so an indicator of hyperreflexia and corticospinal tract disease. Another woman who ended up staying at the hospital the entire time we were there was thought to have Munchausen syndrome as she would seemingly make up symptoms to fit what the doctors thought might be going on or claim she had various new symptoms every day likely to receive more medication and care at the hospital. There is such an interesting dynamic between the patients and Bethany, especially with Dr. Muralidar. Patients come in from sometimes 40-50 kilometers away just to see him, demonstrating the tremendous respect he has gained in this community.

After rounds end, Jen and I report to Dr. Clemet's outpatient office, where he sees at least 20-30 patients a day. Complaints ranged from injuries due to a door shutter falling on a patient to third degree burns on a patient's face and arms due to a road traffic accident. Later, Jen, Derick, Gina and myself briefly observe an ultrasound radiologist that comes to Bethany every other week to scan typically pregnant women or any other case that may require ultrasound.

We then eat lunch and take an afternoon break from the sun. Eventually Derick, Christine, and I take a walk up to a former volleyball court and search for some peacocks. We also try our hands at makeshift baseball and cricket before getting eaten alive by mosquitos and calling it a day. After an hour of rest and sudoku, we go to evening prayer again and eat dinner. We then attend evening rounds and are finally ready for a much needed night of rest. The days are long, but we seem to get an incredible amount of work done. I can't wait to continue this adventure tomorrow.