End of the whirlwind tour...

Bangalore, Goa and Bombay:

We separated from reality for a bit on these excursions. All three of these locations have the resources to make you feel like you are far away from India, in denial about the severity of poverty in some places and in others magnify the divide between the rich and the poor.
We started off with a short drive to Bangalore with an incredibly reasonable driver who even slowed down for pedestrian crosswalks and STOPPED at red lights (Another point learned in India, red lights are merely a suggestion).

We met up with a friend who lives in Bangalore and has a number of different capitalist ventures going on around the world and lives quite a different lifestyle than what we were used to in Vellore. We needed to do some last minute souvenir shopping so did that for most of the day. I think I was a bit tired so I kind of wandered aimlessly although I did go to a store called FabIndia which does a lot of free trade with local artisans and I fell in love with some curtains. However, as I said I was tired so I actually did not purchase anything. After shopping we went out to a posh hotel called the Taj (a chain of super expensive luxury hotels, nicer than any four seasons, ever) for drinks and appetizers. After we went to another bar for more Kingfisher and dancing. The best part about Bangalore is the city has a curfew of 11:30pm so you have to do all your partying by 11:30. This is actually perfect for me because I can go out then go home, go to sleep and still get eight hours of sleep! The next best thing about Bangalore was our hotel had a treadmill! This was the first time in three weeks I got to run. For anyone who knows me this is a huge amount of time for me not to run but I have actually been ok. However, all of our hotels the next three days had treadmills and there were a fantastic treat!

The next morning we sent Vida off to Thailand to meet up with Dustin and we went on to Goa to sit on the beach and do some serious relaxing. The first night we were there we walked down to the beach by our hotel just to check things out. There was trash all over the place, cow dung mixed with sand, lots of men in their underwear (including a group of men playing cricket on the beach in their undies) and sea water that kind of made your skin itch. The cool part about our beach is there is a tanker that ran aground and then was abandoned because no one knew what to do with it. Apparently some groups want it removed but the Indian government does not want to allocate funds to take it apart and therefore it shall remain! The next day we took a taxi with a driver anmed Francis (huge portuguese influence in Goa) to a more quiet beach. We were going to go to Morjim but Francis informed us that it was vacation time for the country and it was not going to be quiet so he would take us to Aswin instead. The beach was perfect! With little straw thatched coverings and beach chairs for rent for $1.25 for the whole day, a restaurant nearby and a clean beach we could not go wrong. We spent most of the day reading, swimming and sleeping and ate some of the most delicious garlic prawns ever (they literally melted in my mouth). We went back to the hotel and then went shopping again! We found another FabIndia and seeing as I was more rested I bought some curtains. I really do not know what I am decorating seeing as I do not have a place to live yet next year but darn it I have curtains! (It's the little things in life).

After Goa we flew to Bombay and stayed at an apartment owned by a friend of a friend that was in a building where a lot of Bollywood stars live ( I told you we saw the other side of India). Bombay had everything your heart could desire. Setup kind of like Manhattan it is congested, dirty, overpopulated, overpriced, and smells a bit like fish. However, it is still India and still has a certain charm about it and I still enjoyed myself. We partook of our last true Indian dishes and also treated ourselves to some gelato (definitely not available in Vellore) before flying to Istanbul. After the India portion of the trip I have to say I had a fantastic time. Each town we visited really has its own unique character, the people are incredibly kind and there is really something for everyone as long as you are willing to find it. It is imperative that you take each day at a time, do not be in a rush because inevitably things will run behind schedule and be willing to try new things.

These are memories that all of us will cherish as we head into residency and for the rest of our lives as we may never have this opportunity or time to allow this kind of trip. All I can say is when you travel to another country rememebr that it is a privelege to be in a foreign country and you should respect that. All too many times I have been in another country and seen tourists take a holier than though attitude with the locals , and usually they are from the US, and it's really embarrassing. When you are traveling you are a representation of your country and because you look and act differently people will take particular notiece of you. So, I just ask you treat everyone with the utmost respect and not be afraid to try new things, practices that are "weird" to us may be daily occurrences for them. I am not saying you need to drink the tap water or bathe in the water drain on the side of the road just be smart and enjoy yourself. Figure out all that such a rich country has to offer through culture, food, tradition and even day to day life!

Mycobacterium leprae

Seeing as I was reading about leprosy and this was Paul Brand’s particular interest I wanted to read a bit more about it and use the topic as my paper for my final requirement of this elective.
Leprosy, a.k.a. Hansen’s disease, is caused by the bacteria Mycobacterium leprae, an acid-fast, rod-shaped organism that affects the skin, mucous membranes, eyes and peripheral nerves. There are two main types of leprosy: turberculoid and leprematous. We saw mostly leprematous form in the hospital so that is what I will focus my paper. The leprematous form is the more severe version, invading multiple organ systems along with the areas mentioned previously. The exact mechanism of transmission remains unknown although it is believed to involve respiratory secretions from infected individuals, human-to-human contact and vertical transmission (from mother to child). The incubation period is about five years, making it more difficult to pinpoint an exact source.

Leprematous leprosy presents with the pathognomonic sign of multiple hypo-pigmented skin lesions lacking sensation. Severe cases can involve the eyes or nasal septum and hand contractures. Multiple methods for testing for leprosy have been tried but the only reliable and standardized method is a skin biopsy, a simple procedure that is easy to do even in India! In leprematous leprosy one can see giant cells accompanied with epithelioid-lymphocyte granulomas along with bacilli surrounding blood vessels and within nerves. The disease begins first affecting thermal sensation followed by pain and touch while proprioception and vibratory senses are often preserved. In addition, deep tendon reflexes remain intact due to bacilli sparing muscle spindles and large nerve fibers. This denervation eventually leads to compression ulcers of the feet or damage to the fingers, often times becoming infected.

From the time of diagnosis patients are then treated with a multiple drug regimen, in the clinic they largely used rifampin, dapsone, clofazamine and sulfa medications. All these meds were tested in the laboratories housed in the center. These meds were determined to be the most effective and required a shorter duration of use, increasing compliance and improving outcomes.
Knowing the treatment for leprosy the medication regimen is simple. What remains difficult is the education of patients to prevent further damage. Education involves significant effort on the part of doctors, nurses, physical therapists and many others. One thing that Ms. Koshi (the public relations woman) pointed out that was interesting, and something to take home, was the effectiveness of patients teaching patients. The clinic organized sessions of previously diagnosed leprosy patients to come and talk to newly diagnosed patients to educate each other on what works and what does not. Patients do not want to hear orders from another doctor or nurse who has never experienced the disease first hand and does not know about the day to day struggles.
In addition, India has the large task of finding those yet to be diagnosed as 70% of leprosy cases are found in India, Myanmar, and Nepal. With 12 million diagnosed worldwide it remains quite prevalent and with it endemic to Florida, Louisiana, and Texas (one reservoir being our very own nine-banded armadillo) it is something we may see at home.


We are asked to research a topic for our elective on a “tropical disease” but the bottom line is the leading cause of death in India, just as in the US, is cardiovascular disease. This along with cancer, traffic accidents and diabetes, amongst many others, are what plague our patients and stress India’s and our healthcare system. What is the solution? I’m not sure yet Going into Ob/Gyn I have a pipe dream of improving the world and quality of life by making women more healthy and thereby their children, even if it is just one person at a time.

I had the pleasure of reading Atul Gawande’s Better: A surgeons notes on performance which definitely got me thinking about what I as an individual and in turn as an individual adding to the medical community can do to make the system “work.” One thing that he stresses and I must remember is to be open to change. Each person has something they can teach someone else and we all have a lot more to learn, no matter who you are. Being humble and putting aside ones ego could dramatically improve how we deliver care. Because of this we have discovered new methods for delivering babies, laparoscopic surgery, vaccines, new medications, etc. and have turned this information into common practice.

After being in India I have learned that we have excellent healthcare in the US (especially after being a patient myself in an Indian hospital), if one has access to it. However, where India falls short of resources and supplies they excel at physical diagnosis and ingenuity, skills that are somewhat fleeting in the American healthcare system.

You may disagree with me and that is ok as long as this makes you start thinking about how you can improve the world around you. Yes, you might be one person but one person can make a huge difference, especially when working with others.

Going to other countries has always inspired me to continue to make a difference, in my local community and abroad. I have traveled and worked in hospitals in other countries before but never with the knowledge and expectations of the medical system that I now have. India was unforgettable, challenging and inspiring, something completely unique and magnificent all at once. So, thank you to the donors who contributed to the scholarship fund that sent me here, nothing compares to this opportunity and for that I am forever grateful.

Tips for Vellore

Places to stay:

If it is hot get air-conditioning, it costs more but it makes all the difference! There are three main hotels in town that are safe and reliable:

Aavana Inn is directly across the street from the hospital so this will save you money on rickshaws but the rooms are fairly small and you will have to share a bed.

Hotel Surabi (where I stayed) is halfway between CMC hospital and CMC campus (about a 25-30 rupee rickshaw ride in either direction, that's less than a dollar). It is clean, has a good restaurant with incredibly slow service, and the laundry guy is one of the nicest people you will ever meet. There is a party place next door that sometimes plays loud music and sets off fireworks, particularly for weddings, but all parties stop around 10 so it's not much of a problem. There is an internet cafe right next door to Surabi for 15 rupees an hour.

Hotel Darling is the most expensive but also the nicest. It is basically across the street from Surabi and has free internet access for its guests. (It also has excellent food, just a warning though anything that you think is an american treat will have some type of indian flavor thrown in, i.e. pizza with a dash of curry...) Otherwise internet is down the street at iWay or other internet cafes around town. You can also get internet access through the campus library. You pay for the whole month and get a username and password. It allows you to use internet on campus or in the library by the hospital.

As for food all three hotels have good food, all have veg and non-veg restaurants, we usually went with non-veg and ate our share of meat, just don't touch the beef! The other places to eat are at baby residency down the street from Surabi, Chinatown across the street from the hospital or another restaurant with good food that is across the street from the hospital is in the basement of a building. The entrance usually has a guy selling samoses or cheap toys out front and there is a drawing of four cats all holding guns with the letters K-I-L-L written on their backs (promise it's good food though). There is also food at the campus and hospital cantinas and everything at all these places is only a few bucks.

There are two grocery stores near Surabi and Darling one called Harish Zone and the other is called Nilgiris, both on the way to iWay and within walking distance of Surabi and Darling. I personally love grocery stores so these were two of my favorite places. Try out new snacks, the Milki Biiks (cookies with vanilla cream in the middle) are delicious and there are some special spiced peanuts which we referred to as "fart nuts" which taste delicious but smell like... well, like the name we gave them. This is also a good place to get big bottles of water and an occasional ice cream treat. Nilgiri's has a better toiletry section if you forgot something or just want to buy stuff when you get over there.

The Gift of Pain

After our rude awakening with the accident our last week in Vellore was a little disturbed. We took about a day to recover from our bumps and bruises before returning to work. I ended up visiting the Paul Brand Leprosy Clinic this week seeing as that is the namesake of the scholarship I received and what originally made this area well known in the medical field. Dr. Brand was an English surgeon working at CMC in Vellore in the 50s and 60s. He would research patients with leprosy at the end of each day to try and piece together the reason the patients had such severe deformities. What they discovered was that even in mangled extremities there remained normal, healthy tissue. Because of this discovery Dr. Brand was able to perform highly successful reconstructive surgery and subsequently also revolutionized the way the world thought about healing ulcers. We now use a number of similar techniques for our diabetes patients in the US, believing that tissue can, in fact, heal if given enough time and if the insult to the tissue is stopped.

With the discoveryabout the tissue Dr. Brand had a huge influx of patients coming for reconstructive surgery and treatment, flooding the CMC hospital and causing problems with the other patients. Leprosy was a highly misunderstood disease with most people believing it occurred due to a curse from God for unpardonable and unmentionable sins. To make matters worse the disfigurement that ensued from the damage was horrific. With necrotic ulcers, missing appendages, and a hole in the middle of the face after losing a nose no one wanted to come close to a leprosy patient. So in conjunction with the help of Dr. Robert Cochrane CMC was given a large piece of land, about 250 acres, near Karigiri Village (30-45 minutes from Vellore by rickshaw and many bumpy roads, not so much fun when you have to go to the bathroom).
The men's ward.
At the time of the purchase, the property was a vast wasteland, something the government found to be suitable for leprosy patients (sarcasm) and figured no one would want to live in that area thereby completely avoiding the social stigma attached to the disease. What developed after obtaining the property and what one see today is absolutely incredbile. As we arrived on our autorickshaw we drove up to a lush paradise with green trees, flowers blooming and an overall peacefulness, rarely found elsewhere in India. We met up with Ms. Koshi, the public relations person, who kindly took time out of her day to give us a private tour aorund the facilities. The design of the center was to fully treat leprosy patients, perform research to further improve care and provide support for the patients and families (physicially and spiritually).

The disease is caused by bacilli that infiltrate nerves causing severe damage causing patients to lose sensation. The bacilli preferred cooler climates and would thus migrate to the coolest areas of the body: the hands, feet, nose, ears, etc, making these locations the site of the most injuries. In turn, individuals would develop deformities from repetitive damage followed by healing or ulcerations, all due to a lack of sensation. To give an example, in Paul Brand's book The Gift of Pain he describes what happens when someone twists their ankle. A healthy person, like you and me, has a signaling mechanism for when you step on the edge of a sidewalk. In the split second you lose your balance a message goes to your brain telling you that you are about to fall on your face or break a tendon or bone. Your brain sends a signal to the appropriate part of the body telling it to compensate for the fall and therefore not injure yourself. A leprosy patient has none of this. Upon stepping on the edge of a curb a leprosy patient will continue to put his or her entire weight on the foot providing enough force to snap a tendon then continue walking as if nothing happened.

You may wonder why this clinic is still around seeing as we have treatment for leprosy now but Ms Koshi informed us that the definition of an eradiacted disease is 1:10,000 (something I have to check is correct but you will see my point in a sec) therefore by definition leprosy is eradicated but due to India's population being so humongous that comes down to about 20-25 new leprosy diagnoses per month (yes I said month)! In addition, the clinic has turned into a large treatment center for diabetes, particularly the treatment of ulceration with the use of casts, new shoes, antibiotic treatment, education and proper dressing changes.

One other interesting note is that we met a beautiful young girl who completely lacked any sensation of pain. She was being treated for a recent foot ulcer and was scooting herself around the hospital in her little wheelchair behind our group. Dr. Brand talks about a similar case in his book where the little girl would bite the tips off of her fingers and use her blood to paint on the walls, fingerpainting quite literally!

The young girl is in the wheelchair.
Now the medical staff knows so much more about these diseases they focus largely on prevention and protection. There is a shoe factory on site that makes the soles of the shoes with special rubber and each pair is specifically made for each patient. They also designed gadgets to assist with everyday activities: fastening a button, combing hair, brushing teeth, writing, etc. All of these things we take for granted, do not even think about having to do each day but each task is a challenge for each of these patients. Another wonderful aspect of the center is they taught weaving techniques and designed tools so that even those patients missing fingers could still participate in the design and creation of something. This reminded me a lot of the women's prison in Nicaragua; the simple act of believing an individual can do something and contribute to society makes such a huge difference in peoples lives. They currently make wavings and do block printing, a very popular Indian art. The blocks are made out of wood and carved into different shapes then dipped in ink and stamped onto fabric. They can then leave the fabric in its natural creme color or they dip it into a liquid (what that liquid is I don't know, we will call is magic liquid) that changes the colors, the fabric and the ink prints. All in all this is quite impressive because they do all this without any fingers.
Making protheses.
We also got to visit the wards to talk with the leprosy patients currently being treated. I often times feel bad being an observer of sick indivuals and especially felt this way with the leprosy patients. Yes, I enjoyed meeting them and talking to them and yes, I learned a great deal from them but I can not help but feel I was invading their privacy in some way or making them feel like they were on display. However, I must say the patients did not seem to mind and actually seemed thankful to have us around after we told them we were medical students from the US. They were willing to talk about their treatment and their ulcers and let us take some photos. The patients on the male ward actually reminded me of VA patients, talking about how long their ulcers have been around and their various ailments, but I also have to say that the patients in India were quite a bit cheerier than those at the VA in San Antonio. At any rate, I wish I could come back and work here but there does not seem to be much demand for OBs. They are in need of dermatologist, ophthalmologists, orthopedeists, general surgeons and ancillary staff. Ms Koshi said we were welcome back any time and that there was lodging there if students wished to do a week long rotation in the future.

We head to Goa, Bangalore and Bombay this weekend to complete our whirlwind tour of India before flying to Istanbul. Hope everyone at home is doing well!! (as usual, pictures to come when I get to a computer that has all parts working properly!)

The crash

"He jests at scars who never felt a wound" ~Shakespeare

I woke up this morning to screams. I thought I was having a bad dream. After a weekend of having our driver drive around like a maniac I thought that I dreamed we finally crashed, but when I woke up it took a couple of seconds to realize it had, in fact, come true. I looked up and directly above me was the roof that was supposed to be above the front dashboard, cold water was dripping on my legs from the air conditioning unit that was pushed up over the passenger side seat. As I slowly got my bearings and stood up to look around the car seats were scattered haphazardly. The immediate action by all was to make sure everyone was OK. We moved some of the chairs to free Anne from her seat and found Chris, unconscious, lying in the center aisle with blood on his face. I have to admit the terror surged through my body as I yelled "Chris" and he did not respond. Dinesh, being trained as an EMT and having seen accidents like this went into triage mode. He attended to Chris as my thoughts turned to "get the hell out of this car and find help."

The driver who had fallen asleep at the wheel had already climbed out of the front door and as I tried to squeeze behind the front seat he closed the door in my face. I yelled at him to open the door but I think he was in a daze too and did not turn around. (He was also very young, and a tad reckless and more than likely had no idea what to do in a situation like this). I was able to reach the door handle and squeeze behind the chair. Once out I felt like I could not catch my breath and started feeling light headed. A villager was directing traffic and told me to get in the median and out of the way. I sat in the grass for a few seconds trying to catch my breath and wrap my head around what had happened before I stood up to go behind the van. Vida was sitting on the ground and saw me stumbling around and yelled at me to come and sit. Vida and I both began yelling to call an ambulance and one villager who understood English stopped a jeep and told them to call the hospital. We began extricating people out the back door of the van and by this time Chris had come to and was answering questions appropriately, even joking sometimes like his usual self, as Jami held c-spine. We got all our stuff and all the people out of the van except Chris, Jami, and one of the guys from OSU traveling with us who was having vision problems, in retrospect due to vasovagal reasons but we held c-spine for him as a precaution.

The ambulance arrived and short of having c-collars were fairly efficient. They took the OSU guy out on a stretcher as we made make-shift c-collars with towels for Chris and him. Chris was hand carried by the two ambulance drivers to the back of the ambulance. Cristina, who was sitting opposite to me in the vehicle, had gotten hit in the chest with the front passenger seat and the TV above the front windshield had been pushed down and hit her head. She was having difficulty taking a deep breath so we decided to pile everyone, plus luggage, into the ambulance and drive the 120 kilometers home to Vellore. The van driver had a good head lac above his right eye but was completely coherent so we left him with the van and to wait for the next ambulance to take him to a closer hospital.

We spent the rest of the day in the hospital as Chris and Cristina got pan scanned and the OSU guy got x-rays taken of his legs. The rest of us were fairly banged up with scratches and bruises but all walking and talking. No one was hospitalized overnight and all scans, x-rays, echos, etc. checked out just fine.

This seems to be another lesson in India. I have been talking about the chaotic driving that occurs here and how I don't know where the car accident victims end up, I have come to the conclusion that they rarely make it to the hospital. The ambulance consists of two guys who own a van and a cloth stretcher similar to those used in WWII. Without a backboard, c-collar, any type of medical supplies it is a wonder that anyone makes it to the hospital. When things like this happen you begin to wonder what could I have done differently, what if we had left our initial departure site five minutes earlier or later, what if we had forced the driver to stop and get coffee after he refused, what if he had napped two minutes longer or slept during the day as we asked him to do. Bottom line is when you have a sense of doubt or danger or impending doom lingering n your gut listen to it. We were all uncomfortable with the drivers erratic driving and Chris had remarked on the way to Kerala that his driving was like rolling the dice and at some point you have to lose. We made it to Kerala safely and we should have found another mode of transportation home whether it had meant more money or being late for work Monday morning. But hindsight is 20/20.

We don't know who it was but we all decided someone was looking out for us. Being in India we thought maybe Ganesh, the god of luck, or perhaps Shiva, the destroyer. Shiva destroys in order to rebuild, maybe destroying our car to remind us we are mortal and not take for granted the people we have in our lives, the privileges we are given by being in the medical field or in the position in society that we function. Whomever or whatever it was we figured we would cover all of our bases tomorrow and visit the Hindu temple, the Christian church and the mosque down the road and be thankful for all having each other and thankful that we were all able to walk away.

I also say this because for some reason we all seemed to be in exactly the right position to not get seriously injured. Also being asleep probably helped. They say drunk drivers survive car accidents because their bodies go limp and they do not sustain as serious injuries, we figured sleeping was pretty similar. Jami, who had gotten car sick on the way to Kerala and was sitting in the front passenger seat was asleep in one of the chairs in the back, leaving the passenger seat empty (the site of primary impact). Because she was in the backseat Vida was then not lying across the row and was not hurt as badly when the seats were shifted all over the place. I was sitting in the front seat, behind the driver with a clear view of the road in front of me (due to my own motion sickness)and nothing between me and the front windshield. At the time of the accident I was thankfully lying down and the front of the car was pushed down above me and I barely rolled anywhere. Anne was sitting behind me and as we crashed she hit the back of my seat, stopping her from going anywhere and again because I was lying down the seat bent over me rather than pushing me forward.

We all made it safely to the hospital and got to experience the trauma bay from the inside (one rotation med students are not allowed to do). Once to the hospital we were treated very well. We were taken care of by the head nurse who had trained at the Mayo clinic in the US. Dinesh got his facial abrasion cleaned by a very friendly guy who later turned out to be the janitor, but that's India for you, using all your resources! India is also smarter than the US making you pay up front for everything (procedures, supplies, lab tests) before anything is done. Everything is obviously considerably cheaper than in the US but it still makes you think about all you are spending and what is absolutely necessary.

We stayed there most of the day then went back to the hotel to relax. After no breakfast or lunch and being incredibly dehydrated I ate like I had never eaten before and I was never going to eat again. I devoured my paneer naan, anything that is a fresh baked bread product with additional cheese is ALWAYS good. A few of us ate dinner together for somewhat of a debriefing meeting and treated ourselves to some much deserved ice cream sundaes.

As I said before everyone is doing alright. I have a few scrapes and bruises on my legs as do the others but we are all thankful that we walked away. This is just a clear message to never travel at night, make sure you tell your friends and family you love them as often as possible and live life with no regrets! There are too many things that are left to chance in this world, things that can happen in a split second, that could be irreversible. We see it happen to our patients and begin to think "this could never happen to me," only to wake up one morning to your worst nightmare. We have to remember we may be physicians but we will forever remain mortal.

much love to all! Pictures to come...

Houseboats and Relaxation

Sunset

After a painfully long overnight drive from Vellore we arrived in Alleppey, found in the south-western state of Kerala. Known for houseboats, the peaceful serenity of its backwaters and its 100% literacy rate. We met up with a friend from the US who is originally from Kerala who was kind enough to treat us to a houseboat and introduce us to various local customs.

Our boat.

We traveled all around the canals and got to see the little towns that are along the jetties. It was great seeing how people lived but was a little uncomfortable as were basically in their backyard where they do the dishes, take baths, etc. The boat was fantastic. We ate (which I have been doing a lot of), got to sit down and read books, oh and I finally got some fruit and vegetables, one thing that seems to be lacking in Vellore as mangoes are not in season on the east coast. We drive back the fourteen hour distance tomorrow after seeing some temples and a palace today and an ayurvedic massage before leaving in the morning. I am just going to post a bunch of pictures because it's hard to explain, that and mostly what we did was relax...

This looks like a lobster but it is actually the biggest shrimp I have ever seen in my life!

Amazingly I am about to start my third week of India, the time is going by so quickly and I am doing my best to take it all in. If you have never been to India it should be put on your to do list. The culture and way of life, although overwhelming at times, is so incredibly rich and unique you will never find anything like it anywhere else!

Below is Captain Chris Patton at the helm and Queen Anne Cioletti enjoying her siesta.

See! We're in someone's backyard!

Things I learned in India

1) The cows that wander aimlessly through the streets are owned by people but they are allowed to roam free during the day. They then know to return home at 4pm each day (so says one of the locals). Cow hanging out outside the hospital.


2)A vespa is the new minivan: a family of four can comfortably ride to whatever destination desired. The new and ultimate soccer mom vehicle! In general more people can fit on a vehicle than I would ever think possible.
This is a jeep. Our driver said it normally seats four but in India it seats 35.


3) It is absolutely ok to relieve yourself on the side of the road if you are male, pooping is optional.

4) There is no such thing as a lane or a one way road. The rules of driving are "every man for himself" or the bigger vehicle always wins.*



*No doubt this list will be added to.

C.H.A.D.

Community Health and Development is what CHAD stands for. This is the rotation that everyone seems to love. It gives us the opportunity to go around to the surrounding villages and see patients to determine whether they need to go to the hospital or if they can be given meds out of the supply carried in the truck. There are doctors rounds, nurses rounds, and clinic held at or for CHAD which is next to the CMC campus. The doctors rounds are in a large van/bus that goes around to the villages to see patients. I will tell you about nurses rounds because I thought they were more interesting.

On nurses rounds we went out into the villages in a four-wheel drive SUV so we could maneuver over the potholes and dirt roads. Luckily it has been dry and hot so I did not have to push any trucks out of the mud like I did in Kenya! Nurses rounds are done either before or after the doctors rounds to work up a patient or follow-up with a patient. There was one nurse, three medical students, the driver and we picked up a local health aid worker in each village who was supposed to know where all the patients lived and if they were home. All of this works beautifully in theory but when it comes to reality things start to fall apart. Without the modern luxuries of cell phones, landlines to the huts or email it's difficult to communicate with the patients and remind them the health workers are coming. I don't know about you but if I could go to work in the fields to make money and feed my family or sit around and wait for medical care at home I would probably go to work too! We wonder why it takes so long for people to come and seek help for their ailments but when you break it down to a matter of life and death I would pick life and tolerate the pain then deal with the consequences when the time comes.

The truck.

The people we did find and take care of seemed like a social visit more than anything. We would go to the home to seek out the patient, would subsequently hear about the rest of the family then the neighbors would come over and talk for a bit then everyone would leave feeling like something was accomplished, just continues to prove the power behind a good listening ear. We saw mostly foot ulcers secondary to diabetes. The nurses also collected death certificates of the recently deceased, checked on any pregos and newborns, which I was excited about. However, the two pregnant ladies we went to check on had left that morning to go to the hospital and deliver (Both had healthy baby boys, fyi) so we didn't get to see any of them.

Little girl in the school with nutritional supplement in her hand.

I have to say the best part of the day was visiting a little school house that had kiddos from ages 1-5 and they were all busily writing on chalkboards when we first entered. We went to deliver some nutritional supplements which was some sort of peanut butter based block of stuff (highly technical term, I know, but I don't know how else to describe it) with additional glucose and vitamins. We tried some and it was a little too sweet for my liking, needed more peanut butter, but it was definitely filling and the kids liked it. Before leaving the kids all got up and sang a song and jumped around dancing, imagine twenty screaming kids in a small concrete building jumping up and down, it was awesome!

Little girl at one patient's home that was terrifed of me, blue eyes are not very common in India, but she really wanted to eat the peanuts.

All in all it was a lot of fun wandering through these little towns and seeing where people lived and not feel like we were there as tourists but as people providing a service and something they were appreciative of having. It was definitely hot, once again, but we lived through the day and ended at a health clinic and shared a cup of tea and friend plantains with another nurse and her family.


So far everyone seems to be doing okay. Vida's bag finally arrived completely intact and there have been minimal GI issues along the way. This weekend we are going to Kerala to get on a houseboat and relax for a few days. Next week is Ob/Gyn, woohoo!

The Taj

Over the weekend we had a fantastic trip to Jaipur, Agra and Delhi. We started by flying on Spice Jet from Chennai to Jaipur and were picked up from the airport by Colonel Singh. He served for the Indian army for 23 years and fought in the Pakistan-India War in 1971. His wife and the colonel own a kind of bed and breakfast called Shahar Palace, kindly recommended by Colin and Nicolette when they came to Jaipur. It was fully equipped with AC (our one requirement) and good food. The best aspect of the place was how peaceful it was. We slept without honking cars, yelling and loud music and were awoken by the rooster crowing in the main courtyard as opposed to the marching band that seems to play at sunrise every morning in Vellore (why? I don't know but I do mean real marching band complete with drums and horns).

The monkey that ate breakfast with us at Shahar.

We started early the next morning by touring Jaipur, "the pink city" and capital of Rajasthan, which has its own unique charm. The buildings on the main street of the old city are all painted pink (the color of hospitality) and the city has maintained a majority of the old architecture. The streets remain chaotic, true to Indian culture, but included in the chaos are camels, horse drawn carts and elephants waiting at stop lights and hauling cargo.

Our first stop was at Amber Fort. Erected in 1592 by Maharaja Man Singh this was a huge palace on the top of a hill that used to house the maharaja, his numerous wives, concubines, eunichs and children. The steep incline to the top was made a bit easier by taking an elephant ride to the front entrance. This being my first time to ever ride an elephant I was quite excited. These are huge animals! They are each beautifully painted and you sit on top of a platform on their back as they lumber up the hill. Once on the top we were hounded by people selling various items and telling us they "have the best price for you!!" We quickly ducked through the entrance into the main courtyard where our tour began. Each millimeter of the place is ornately decorated and I can not even imagine what it looked like when it was in use. The walls used to be painted with real gold and with gems inlaid into the stone. Paintings and carvings of the gods were placed in every possible location and the views from the front door were breathtaking. The main meeting area once housed the largest carpet ever to exist and above it hung a 15 foot chandelier sent from Czechoslovakia (thought Lizzy would appreciate that). Since the fort is no longer in use most of these items were moved to the City Palace museum, or stolen. The design of the palace, however, is in and of itself impressive. The maharaja had separated the palace into summer and winter sections. The summer part is made of white marble that has small canals where water was pumped out from under the ground and circulated throughout the main rooms to provide a home made air-conditioning system. The winter portion relied on good old fashioned fire! Using curtains to hang along the outside of the buildings the inside of the rooms were carved then painted with a silver finish that would reflect whatever small amount of light was present in the room and retain all the heat.

The elephants waiting to carry us to the top.

After the fort we went to City Palace which was where a later maharaja moved after he got bored with his fort (it's really not surprising there are so many poor people here when they spend all this money on their palaces). We did a bit more sight-seeing, visited some tombs, did some shopping and got henna done on our hands then called it a night. The next day we drove to Agra and stopped at Fatehpur Sikri. Fatehpur Sikri was built by emperor Akbar between 1571 and 1585. This too had the ornate decorations, which I am sure used to be incredible. The interesting notes about Akbar was that he wanted everyone to be accepting of all religions. In turn he had a Hindu wife, a Muslim wife and a Christian wife (along with 233 concubines). He has a separate house built for each wife but throughout the fort the resounding theme is the intermingling of these religions existing within the same space and melting together peacefully into one entity.

The other note about Akbar was with all these women in his life he was unable to father a child. He visited the Sufi saint Shaikh Salim Chisti in Fatehpur who predicted the birth of an heir to the throne and when the prophecy came true Akbar built this city at the home site of Shaikh. Now, being medical students and witnessing our own share of gossip at university hospital, we are not sure how he was suddenly able to have a son at this time and never father a child again, but that's history now! At any rate, the Hindu wife had the son and she coincidentally got the largest house.

From here we headed to Agra, a dismal and disgusting town with the perpetual stench of sewage in the air, to see the Taj Mahal. As one of the wonders of the world I do have to admit it was breathtakingly beautiful. After studying about the construction and the story behind it in high school art history class it was amazing and humbling to actually be standing in front of the actual structure. For those who do not know the story behind it I will tell you, as Ms. Russell told us in high school. It was built by the Emperor Shah Jahan in 1631 as a memorial for his wife, Mumtaz Mahal, after she died during childbirth. The building and designing of the structure was a fantastic feat. Individuals from India to Europe helped in the process and the final product is a perfectly symmetrical structure of white marble stone inlaid with gems and carvings set before a reflecting pool. It is a rumor that when the emperor died he was going to build an identical building in black marble directly across from the Taj Mahal, also perfectly symmetrical, for his own tomb. However, the emperor was overthrown by his son and sent to jail for the rest of his life. When the emperor died his son buried him in a tomb next to his wife completely throwing off the symmetry of the Taj, I think it was to spite his father.

The grand and glorious Taj!!

We saw a few more sites in Agra then left as quickly as possible. I really have to say the pictures of the Taj do not do it justice. The two dimensions presented in the photos can not capture the reflection of light or the vibrant colors and intricate detail of the marble inlay work but you can probably close your eyes and imagine!

We made it back safely to Vellore again after a stop at McDonald's in Delhi (moment of weakness) and a quick plane ride. Tomorrow I start CHAD and get to go see some of the villages and where all the patients live!

PICU and SICU

We made it safely to Vellore after spending a comfortable night in Chennai. I started my rotation this week on pediatrics, following a team around the PICU. Vida and I started on rounds with the attending and three residents. Past visitors to CMC mentioned the whispering rounds and they were not kidding! With the kids crying, the sound of overhead fans, honking cars outside and everyone else on the ward talking I could not hear very much. The attending seemed a little better than the residents and actually explained some of what they were talking about and pimped me a few times but I ended up taking the liberty of going around and looking at dignoses and talking to the patients and their families. There seems to be an uncanny number of kiddos with congenital heart defects and I also met a little guy with rheumatic heart disease, something that I would never see in the USA. It seemed we spent most of our time on rounds discussing fluid management for varying degrees of dehydration, something I am guessing is a larger problem here where the hospitals are not air-conditioned and patients probably lose considerably more fluids during their hospital stay than they would in a nice AC room in the US. I know I lost a lot more fluids on rounds in the morning than I would usually at University Hospital in San Antonio!

Changing dressings in the SICU. This was the first obese person I saw in India and the docs were trying to figure out why.

This is the everyday scene in San Antonio but 300 pound men are VERY rare here.

We met up with some of our other classmates a bit later who were on the SICU rotation who said they got to see quite a bit and had somewhat meaningful interactions with the residents and attending. So I went to the SICU today. The SICU takes care of any surgical patients that are not neuro or cardiac care patients. It runs very similarly to SICU rounds in the US with looking at xrays first of all the patients for the day then going around to each patient. Anesthesiologists run the show in the SICU. They do all the dressing changes on top of pain and medication management. The general surgeons come in for brief periods of time, eye ball their patients and maybe put their two cents in before going back to wherever they emerged from. The SICU rounds felt a lot more beneficial to the American students than the PICU rounds were. The attending and residents were more excited about explaining what was going on with the patients and what were current methods of treatment in India and how those compared to treatment in the US. There were a huge variety of patients in the SICU, from transplant patients to those with septic complications from amputations. Surprisingly there are not very many people from car accidents, we are not sure where all those people go but if I figure that out I will let you know because I am sure they are being sent somewhere!

This is the crash cart, but like most things in India nicely colored, i.e. makes for a good photo.

I will have to write more later when I get a bit more free time. India is fast paced and I feel like my senses are just totally overwhelmed as I adapt to the culture. From all that I see, hear, smell, feel and taste it seems there is so much thrown at you at once it is hard to take it all in. The country is beautiful yet harsh, peaceful yet chaotic. I have rare moments to sit and think and contemplate all that is around me. Currently I am just taking each day at a time, getting accustomed to the heat and getting over the jet lag. We are looking forward to a great trip to the Taj Mahal this weekend and an elephant ride at some point along the way! Hope everyone is well at home!

Made It!!!

Just a quick update and more to follow later when we get to Vellore. So far 6 out of 7 have arrived in India and 5 of our bags made it all the way. We were welcomed in London by snow flurries and freezing temperatures. Jami and I had a leisurely layover in Heathrow and partook in a delightful boiled English breakfast. Vida, on the other hand, sat on the runway waiting to get to a gate only to have thirty minutes to run from one end of the terminal, catch a bus and get on the flight to India with us. She, thankfully, made it but her backpack sadly did not...
We are spending the night in Chennai tonight and will head to Vellore tomorrow morning to start work at the Christian Medical College. First impressions of India: bordering on chaos, and apparently today is a holiday so I am guessing this is calmer than normal (?). The driving is probably the scariest part, there are no lanes, I don't think checking one's blindspot was part of the drivers ed teaching and driving on the left hand side of the road and obeying one way streets is optional. We decided to go exploring this morning and found walking and crossing streets on foot brings you face to face with death every two minutes. I suggested we start taking an autorickshaw to cross the street, currently still being debated as to whether this is the safer option. This afternoon we are on a mission to find clothes, a travel agency and a much needed nap! Hope everyone is doing well, more to come soon!

Here is a picture of the street we had to cross which in retrospect is a quiet, calm road. Add forty more motorcycles, a bus, and three bicycles and you might get a better idea...