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!