Indian Summer: Holly writes a book OR 3144 words you won't regret reading

Location: CHTC Guest House
Written: 7/6/09, 2:45pm (started), 6:10pm (masterpiece completed)

I know, I know, I know. I’ve done a terrible job updating the blog over the past 3 weeks. This is partly due to the fact that I’ve emailed with several of you – so many of you know some of what I’ve been doing. But let’s face it – I’ve just been plain lazy! The 110 degree heat and 80% humidity tend to have that effect. Anyway, prepare yourself for the long, arduous entry ahead. I suggest gathering snacks, coffee, and maybe a pillow for a mid-entry nap. I have the afternoon free and I intend on using it to bore you all.

3 weeks ago: LCECU

We spent the first two weeks of our trip taking a Community Health course with the 2nd year medical students at CMC. Once that course ended, we began weekly rotations throughout the CMC system. My first week (6/15-19/2009) was spent in a special hospital called the Low Cost Effective Care Unit (LCECU). The LCECU is an Urban Health Center located in downtown Vellore. Unlike the government Urban Health Center that I visited during the course, the LCECU is privately funded through CMC.

This unit mainly serves as an outpatient clinic with a focus on family medicine and primary care. The unit has daily general outpatient hours that include diagnosing and treating acute illnesses. Additionally, each day there is a different specialty clinic to manage chronic conditions and prenatal care. These specialty clinics include Antenatal care, Psychiatry, Diabetes/Hypertension, and Pediatrics. The unit is equipped with a small lab, an ultrasound, about 30 inpatient beds, a pharmacy and a labor room. The unit does not perform cesarean sections. These births must be sent to the CMC main hospital (about a 15 minute journey by autorickshaw).

The LCECU treats approximately 150 outpatients each day (if not more!). Patients begin lining up around 6 am where they can expect to wait up to 6 hours before seeing a doctor. Clinic lasts from 8 am until 3 or 4pm. This work is divided between 2-3 doctors, several nurses, and some rotating interns. Each patient interaction lasts about 5 minutes. Usually the doctors do not have time to perform a thorough physical exam. Although the patients seemed happy to get the small amount of time allotted for them.

The patients at the LCECU are the poorest in Vellore. Many of the them live on less than 100 Rs (about 2 USD) per day per family. Care here is provided very cheaply with patients paying only what they can manage. The care is subsidized by the profits made in the main CMC hospital. Unfortunately, care often must be rationed here. Patients may have to raise their own money or wait for adequate funds to be available before they receive expensive treatments.

In spite of the extreme financial limitations, the LCECU is able to provide a good amount of care. They minimize expenses by having patients keep their own medical records and bring them to every appointment. This prevents the need for storage space and a records manager. A doctor told me that patients take very good care of their records (with records only being lost in the extreme case of house fires). Additionally, from 10am-noon each day the city of Vellore has a scheduled power outage. While the main hospital and many area businesses have generators, the LCECU saves money by managing without electricity during that time. As you can imagine, it was quite strange (and HOT!) to be examining patients without lights or a fan. Patients are able to purchase their medications in the pharmacy for a very low cost (for example: $2/month for Metformin, a drug for diabetes). A typical office visit may cost between 20 cents and $1. If a patient cannot be managed in the LCECU setting, they are referred to the main CMC hospital where their status as a limited-income patient is not lost. On my first day in the LCECU, I saw an incredibly scary situation where a woman was having a probable heart attack in the clinic. Keep in mind that if she had had an MI in the LCECU, there would be limited treatment options available (no EKG, no cardiac catheterization, no crash cart, etc). She was given sublingual nitroglycerin and referred to the main hospital for an EKG that would cost her only 50 Rupees ($1 USD). This kind of run-around treatment and limited access is just one example of the many problems that developing countries must deal with daily.

India has one of the highest birth rates in the world. As such, every hospital and clinic treats many, many, MANY pregnant women. One of the goals of developing nations is to increase access and utilization of prenatal care. The LCECU sees pregnant women once per week ("The battle of the bulge" according to one doctor). At least once in the pregnancy an ultrasound will be performed for gestational dating and as a general check up. In an extremely embarrassing situation, I once asked the doctor whether the mother was having a boy or a girl. As it turns out, the determination of gender prenatally is illegal in India. This law was enacted to fight infanticide of female fetuses. Since my arrival, a doctor in a neighboring state has been prosecuted for sex determination and gender-related abortions. Although gender-related abortion is illegal in India, abortions for other reasons are allowed.

Sign about the inability to determine gender in India

The best part of my week in the LCECU was going on house calls with a physician who works there. Dr. Sushil was one of the professors of the Community Health course. He spends half of his time seeing outpatients in the LCECU. The other half of his time is spent going on site visits in the various slums in and around Vellore. I would hesitate to use to word slum based on the connotation – but the connotation is exactly what I’m going for. To call the places we saw villages or neighborhoods would imply that these areas were in anyway a desirable place to live. The slums have open sewage drains that run along side the roads, water pumps that don’t reliably provide clean water, trash and flies absolutely everywhere, small houses where people live on top of each other (without any furniture, refrigeration, or privacy).

Slum in Vellore

Open drainage ditch in a Vellore slum running alongside the entrances to homes

I have added a video I recorded of Dr. Sushil speaking in our Community Health course. Even in the short clip, you can tell that he has incredible dedication to his patients. The clip begins with students guessing the cost of a typical delivery ($1=47 Rupees, average delivery in India is about $80 USD). He talks about visiting the home of a patient who gave birth to a daughter with a meningomyelocele. During one of the slum visits, I saw this patient. She lived with her daughter and husband in a makeshift hut that was about 50 square feet. This story is one example of the extreme poverty, heartache, sadness, and life-is-just-so-damn-unfair which exits in this country (and many others around the world). After my short trip here, I can’t reconcile, justify, or in anyway understand the WHY? of any of these cases. Of course I expected to see poverty and of course I didn’t expect to understand it. Still, expecting to see something and seeing that something are two very different experiences. Many Indians use the concept of karma as a means of explaining the vast extremes. While I completely respect that viewpoint, it simply doesn't work for me.

Two brothers play with stones on their front porch

A small hut rests near the site of a demolished building

We visited two slums during the week. The first slum visit was a general visit to check on the status of current patients as well as determine if any of the community members were not receiving care. Right away we could tell that the patients knew and loved Dr. Sushil. He makes these visits so frequently that the slum dwellers have gotten to know and trust him. We sat down with a man who had a chronic infection and was ultimately cured thanks to treatment at the LCECU. After treatment, the man wanted to repay the LCECU for saving his life. He now is a community activist and works to help his sick neighbors receive treatment. He does this by word of mouth education about LCECU as well as making Dr. Sushil aware of any individuals who are sick but can’t leave their homes. Over the course of the visits we saw many grateful patients. During 1st year, we spent a semester learning about “The Doctor-Patient Relationship.” I must say, that I learned quite a bit more shadowing Dr. Sushil on those 2 days than I did during a semester of lectures. I saw patients who had literally no money offer up their only food to the doctor. Certainly, relationships like that can only develop over time and can’t be learned in a classroom.

Dr. Sushil talking to a patient

The visit to the second slum was to seek out a specific patient. A woman with diabetes was developing cataracts and needed surgery. She was afraid to have the surgery because she didn’t know who would care for her. On the visit, Dr. Sushil spoke with her neighbors and encouraged them to help her recover. A few days later, the woman had decided to have the surgery. The woman lived in a rooftop shack that involved climbing some very steep stairs. I can’t imagine climbing these stairs every day with perfect vision and a healthy body. I don’t know how this elderly nearly blind woman does it every day.

The woman with cataracts lived on the roof of this building

Beautiful girls from one of our slum visits

Following my week in the LCECU, I moved into the main CMC hospital for 2 weeks.

2 weeks ago: The OG

Following the intense week at LCECU, I was excited to spend time in obstetrics and gynecology (“OG” or “Obs and GYNie (pronounced “guy-knee”) as they say here). Just to confuse this entry even more, I’ve added a passage that I wrote 2 weeks ago about my experience in the OG. See! It’s not that I haven’t been writing – I’ve just been holding out on all of you ☺.

The following was written: 6/25/09

Today I saw 2 live births!!! Before my trip, the only concrete goal that I had set for myself was to witness a delivery. I figured that the first delivery I saw should be “the old fashion way” and what better place to see it than a country with one of the highest birthrates in the world.

This week I have been rotating through the OB/GYN ward at the CMC main hospital in Vellore. Due to an annoying sore throat, I only went into the clinic on Tuesday and Thursday of this week. I spent Tuesday observing antenatal check ups for women labeled “high risk” for complicated pregnancies and deliveries. I spent the day with a lovely intern called Hilda. She was great as she let me do the check ups under her guidance. Over the course of about 4 hours we saw approximately 40 patients. If this sounds absurd to you, it should! However, in a country with so many people, there truly aren’t enough hours in the day to give patients the 15-20+ minute visits that we complain about in the US!

The main categories that put women at high risk here in India are: family history of diabetes, hypertension or multiple births, previous complicated pregnancies (including previous stillborn or neonatal death, previous cesarean section, previous baby in breech position), pregnant with multiples, consanguineous partner (common here), HIV positive, and I kid you not “elderly pregnancy”. Elderly pregnancy here begins at the ripe old age of 30.

Today, I was posted in the labor ward. There are two rooms (one for high-risk deliveries and one for low-risk deliveries). A neonatal resuscitation room separates the two delivery rooms. There was also an operating room for Cesarean sections. The labor room was somewhat of an organized three-ring circus. Each side had about 15 beds and they were both full! When a woman began active labor, a flimsy green curtain was pulled around her bed for “privacy,” that or to prevent the other women from witnessing their fate! During the delivery there were two nurses who job it was (it seemed) to tell the patient to push and help her hold her legs up in what can only be described as the most vulnerable and exposed position a woman can be in. There was also a nurse who Alicia and I lovingly call “The Catcher.” She has what I think must be the best job on the planet. Once she gets the baby and the cord is cut, she cleans the baby up, weighs and measures it, and swaddles it. She is the first person who sees the baby all spruced up and the first person to hold the baby. There is also, of course, the doctor who is running the show and helps get the baby out, and in the case of both of the deliveries I saw: performs and repairs an episiotomy. NOTE TO ALL MEN READING THIS: You don’t know pain, you will never know pain, you are not tougher than women, stronger than women, or in anyway more resilient than women. If you in anyway doubt me, YouTube “episiotomy done with surgical scissors.” Okay, feminist rant over.

I was really nervous to see the deliveries. I have been known to get queasy at the thought of blood (I know – I’m going to be a doctor blah blah blah). Up until the moment the head was crowning, I was still very nervous. But, once you could see the actual baby, my viewpoint completely changed. It sounds so corny, but everything they say in the movies about childbirth is true. It’s a beautiful, wonderful, incredible, natural, and happy event. I’m not saying watching a delivery is for everyone. But it was definitely the best moment of my trip – and way up there on the list of top 10 coolest things I’ve ever seen. Both mother’s delivered healthy baby boys. Alicia and I tried to stay calm, cool, and collected. But I was unsuccessfully holding back tears. Amazing amazing amazing.

Unfortunately, I also saw a mother go into labor at 26 weeks gestation. She gave birth to a stillborn boy. This is far enough along that attempts at resuscitation are often successful (the baby was struggling to breathe for about 5 minutes before dying). I asked a nurse why the baby was not resuscitated and got a disturbingly honest answer. The parents of the baby were very poor and would not be able to afford the care involved in treating a premature baby. The exact quote was “unfortunately in India we have to make medical decisions based on finances.”

The rest of the entry written on: 7/6/09

One week ago: Pediatrics

Last week Mike, Alicia, and I were in the Pediatrics ward. Obviously this was incredible because we got to see cute kids all day long. Our first day began with a morning bible session. Once each week, each department at CMC has a discussion about a passage in the bible and how it applies to the practice of medicine. This weeks’ conversation was about the role of the Husband (next week is the role of the Wife). There is a discussion book that has 52 discussion topics over the course of the year. This book had quotes about the husband being a provider, the head of a household, and the figure of authority. Looking forward to next week showed the wife as the caregiver and also as being subservient to the husband. Using my better judgment, I decided to nod and smile while keeping my respectful disagreement in my head!

We spent the mornings going on rounds with Dr. Rikki. She is an amazing clinician who turns out to be Dr. Sushil’s wife! We saw several interesting patients with asthma and/or respiratory infections. It was exciting to hear the rales/ronchi/wheezes that I spent so much time learning about this past year. The care in the Peds ward is extremely high quality. We also got to see several patients with congenital heart defects post surgery. They seemed to be doing very well.

We saw several babies who were suffering from malnutrition. They were so small and beginning to develop peripheral edema (Kwashiorkor). Malnutrition in infants here usually is caused when mothers don’t breastfeed their babies. This can be due to choice, lack of milk production, or HIV+ status of the mother (breastfeeding is not recommended).

On Wednesday of last week, we observed the pediatric infectious disease outpatient clinic. All the patients that we saw there were HIV+. We shadowed Dr. Valson who was absolutely incredible. He took so much time to teach us about the various stages of HIV disease as well as the limitations and challenges of treating HIV in India. In India, most HIV is contracted through heterosexual transmission. The “typical” story is a man contracts the disease through a sex worker. He then passes the disease to his current or future wife. Although legally, HIV status must be reported to all sexual partners in India – enforcement is difficult and prosecution is rare. Many women do not find out they are positive until their first prenatal check up when a rapid test is performed on all women. It took a lot of effort and self control to not be angry at the father’s of these children. As a physician, you have to learn to keep your own biases and opinions out of the office. But looking at an emaciated 12-year-old child with stage 4 disease, I definitely wanted to blame someone. I was left wondering how much the child knew about his disease and if it would be best to keep the mode of transition hidden from him or tell him the truth.

Thursday was spent in the general outpatient department. This was a great way to end the week. We saw patients who were there with tummy aches, earaches, and for general check ups. After an intense week of seeing some very heavy things, it was nice to see generally healthy and happy kids with their happy and healthy parents.

I have much more to write about, but I think if I write anymore right now I’ll lose your attention forever (or at least get a wicked case of carpal tunnel!). Coming up next: my trips to Bangalore, Chennai, Mamallapuram, and Dehli/Agra; My week at the Community health and development hospital (CHAD); my completely American July 4th celebration; and more.

For those of you who made it through the in one sitting, congrats! I’m sorry that my 3-week blog absence resulted in your eyestrain. Unfortunately, I’m not doing an ophthalmology rotation here so you’re out of luck. As a consolation prize, please accept this montage of various members of the animal kingdom that I’ve encountered in India.