It’s strange coming back to Medicine as I knew it.  During M&M at the VA, we had a lengthy discussion about TIPS in end stage liver disease.  I remember that very few places in India even have the capabilities to do that.  We’re also back to a point where we get indignant if we don’t get chemistries back in hours, where we can get a C-reactive protein faster than a renal panel, and where CT scans are the norm.

Our ID statements on HIV inpatients include most recent CD4 counts (usually done last week), and we entertain the possibility of micafungin in chemotherapy patients.

In my physical exams, I was much more careful to palpate for nodes, tried to identify the heart lesion causing the murmur, and yes, even looked for peripheral nerve inflammation.

I’m definitely feeling the burden of whitewashing the experiences.  People don’t want to hear every single detail, but everyone wants to know “how was it?!”

And life goes on…

After spending two weeks in Hyderabad, I landed at the JFK airport approximately 12 hrs ago, greeted by severe downpours and traffic delays.  Sight of my apartment, bed, bathroom was comforting and as expected, I am fully awake at 3 AM thinking what would I have been doing in Hyderabad at this time if I were still there.  Finally, being able to access internet (a privilege I have been deprived of) gives me an opportunity to finally share my humbling experiences at the SRH, NIMS and fever hospital.  And as Dr. Anant Reddy from SRH would say, “to speak from your heart and not lips.” 

Days in SRH were spent learning about leprosy, examining patients, physiotherapy provided, attending reconstructive hand surgery.  Absolutely AMAZING work by Dr. Reddy who has put my faith back in surgeons and humanity.  At SRH, they not only take care of medical issues but provide them with housing, food and vocation so they can be independent and live with dignity.  We also learned about the TB and DOT program, visited off site DOT centers around the city, and discussed the obstacles they face, and also talked about PMTCT program briefly with Dr. Venkat Reddy.

Next was the adult 20 patient HIV ward (aka the care and support center) managed by Dr. Rao and Dr. Suguna where patients are never turned away regardless of complexities and complications, regardless of not being able to obtain the diagnostics/procedures, which would eventually be very frustrating for me but to physicians at SRH – they do with what they have. CD4 count is sent out, viral loads are not done anywhere, WBC count is but platelet count is not available, diarrheal cases are seen but cultures are limited; For TB patients, AFB smears are done but cultures and susceptibility testing is done when failure on therapy is suspected with referral to the Chest hospital, isolation but no negative pressure rooms are available. A definitive diagnoses is infrequently made but is presumed as it is solely based on history and exam, and a response to most possible readily available treatments. Yes, we are privileged to have many resources available to us. 

At the Care and support center, besides medical, social support to patients and family is provided, healthier nutritional frequent meals are guaranteed, a referral to government sponsored ART centre to initiate or continue antiretrovirals is given- which if I recall correctly is limited to AZT/3TC/ may be d4T, efavirenz, nevaripine and I don’t think anyone was on a protease inhibitor. But even if the medications are available, travel to an ART centre when patients are ill also affects adherence. It is also a social stigma of seen at these centres that refrains them from being compliant. Resistance, I wonder? Second line regimen, especially if patient has severe complications to the 1st line regimen, is very difficult. What I have learned and practice in US is yet not possible there. Granted the resources are limited, challenges many but still the care provided by clincians is truly inspiring, and brilliant. 

My favorite place to visit at SRH was the children home.  Each child has one poignant story than the other but they seem to be so connected with each other, almost as if there is an unspoken bond amongst all. And a thought keeps recurring  - what would have happened to these innocent children if this home was not there, and what about the children who have not found a home like SRH. I am sure there are many out there, abandoned and left to beg on the streets, suffering the cruelties of our society. One of the mommy’s, as is addressed by children, nineteen-years old, shared that once she was married to a man twice her age, had a baby boy who is healthy and now 3 years of age. Husband was found to be HIV positive and when her test was positive, in-laws and husband disposed of her, took away her child and since her family couldn’t take care, she is now at SRH taking care of children (a teenager herself). Her eyes well up with tears as she showed me the only picture of her son, making sure I was seeing it under light and admired his big beautiful eyes.  Also, the teacher, Mrs. Prasana, likely in her forties has devoted her life to SRH since she was sixteen. She aspires to infuse as much education possible into these children so when they grow up they will be self-sufficient.  She has been teaching the children of the leprosy patient but she feels attached to the HIV orphans.  She is their teacher during daytime, motherly figure around festivals, and at night makes a special trip to discipline them to change to night clothes, take the meds and to be in bed by 8 pm.  I asked her to send me a list of all the birthdays for children, since for a few, birthdays come and go with no celebration or a gift. If anyone interested, please let me know. 

Besides SRH, my experience at NIMS (Nizams Institute of Medical Sciences) was exceptional. I especially enjoyed meeting Dr. Laxmi, an outstanding microbiologist and Dr. Subbalaxmi, professor of internal medicine, involved with HIV care and in my opinion an expert in infectious diseases (although she doesn’t admit it as ID is not recognized as a separate subspecialty).  We rounded on a few patients with residents in the acute care ward.  Piperacillin-tazobactam seems to be the drug of choice currently and she showed her frustration at not de-escalating therapy and increasing resistance especially the feared ESBL’s at NIMS. The cases we discussed and actually saw– meliodosis, falciparum malaria, suspected leptospirosis, possible disseminated TB (only x-rays and MRI’s).  I plan to continue my correspondence with Dr. Subbalaxmi and to return next year more prepared, organized and with a few lectures relative to the pathology seen in India.

Last visit was at the fever hospital, where we did see cases of diphtheria, tetanus, dengue (suspected) pyrexia ward, malaria but I really wanted to see rabies!!! Perhaps next year 

After delicious lunch on our last day, I finally parted with the rest of the CIT2 gang, all of whom are exceptional and no doubt are compassionate, caring physicians themselves. And off course, thank you Gopal for making this happen for all us. I look forward to CIT3 already!!!

Let’s hear it for vaccines.

The past few days I seem to have acquired an upper respiratory infection.   Is it Bocavirus?  It’s gotten to the point that I’ve started a steroid burst just to make me feel good enough to make it home.  By my calculations, my last dose will be taken in the Frankfurt airport.

So when I get back home and develop a fever 13.5 days after returning, there’ll be a great differential.  With my chronic asthmatic cough and known exposure, could it be TB?  How about Dengue or malaria?  But wait!  I took a course of steroids–could it be related to relative immunosuppression?  How about Avian flu?  I did walk (quickly) by chickens being housed alive in the Pondicherry Market.  What if I have a little bit of a sore throat, and something that looks plaquish…diptheria?

Once again,  reaffirming that I don’t want to become an interesting patient.

This weekend, Goa.  Then a long series of flights home.

I arrived in Pune 15 minutes ahead of schedule last night, and within 25 minutes of landing was standing in my well-appointed hotel room. My host at the National AIDS Research Institute, Dr. Srikanth Tripathi, met me in the hotel lobby an hour later and we headed out for a light dinner of pav bhaji. On the way, he took me to the Maharashtra answer to Tower Books/Records.

This morning, Dr. Tripathi took me to a couple of HIV clinics run by NARI, one at the National Institute of Virology, where he launched his research career, back in the day, and one at Sassoon Hospital. A distinctive feature of both of these clinics, one that I have observed nowhere else save YRG CARE, is the seamless integration of clinical care and research. Unlike most government clinics, these are by no means overburdened with patients. They see 20-30 a day. A pittance compared to the 100-150 they see at Osmania or Gandhi in Hyderabad. Every physician here, however, seems at the top of their game and they all seem to be involved in clinical trials.

After seeing these satellite clinics, we headed to the mother ship. NARI itself. This is where Dr. Tripathi sees patients these days, as well as where he heads up the TB and retroviral resistance labs. He gave me a whirlwind tour of most of the labs as well as the clinic. One of the medical officers, Dr. Sampada, presented a fascinating case of unexplained 6th nerve palsy that progressed, then improved on ART, without any other directed therapy. Then it was time for my lecture and we were off to lunch. Perhaps the most memorable interaction for me, besides the great discussions I had with Dr. Tripathi, was with Dr. Mawar, an anthropologist that is tackling the critical problems of bioethics training and stigma research in healthcare providers. After lunch, I was taken to the airport without complications. Everything proceeded like clockwork. Obviously.

Ganesh Chathurthi kicked off yesterday. In Andhra Pradesh, this festival is also known as Vinayaka Chavithi, and is a pretty big deal. For the past week or so, as we have traveled through the city, we have seen Ganesha statues of varying hugeness making their way around Hyderabad on the beds of autos, trucks, and other conveyances. These machinations, however, are nothing compared to Ganesh Chathurthi in Pune. So I have been informed by everyone from my uncles to Raju, our taxi driver. Apparently, this holiday is the big one in all of Maharashtra, and worshippers go all out. Dr. Tripathi was kind enough to bring me in some sweets that he and his mother rolled last night. They were delicious. Too bad we will not be in India for the dunking of the statues at the end of the 9 day celebration.

Brian, Paras and I went to the Niloufer Women’s and Children Hospital again today.  As Paras and Brian mentioned earlier, the number of patients they care for at the hospital is overwhelming and I’ve also been shocked by the acuity of patients.  They see 200-300 patients per day in the casualty ward (ER) and average 5-10 deaths.  Paras and I rounded in the resuscitation ward of the ER around 11am today and they had already had 7 deaths since 8am.  One of the interns told me that bronchopneumonia and congenital heart disease account for a fair percentage of the deaths they see.  The acuity was dramatically presented to us when we first walked into the resuscitation ward on Tuesday in the midst of a full code on our left with a severely dehydrated, unresponsive child on our right.  Sounds like a routine day here.  They are a tertiary referral center, so many acutely ill patients are transferred from smaller hospitals,  but interestingly the only pediatric subspecialty they have is pediatric surgery.  They actually transfer all of their patients with congenital heart disease to a specialized heart hospital, yet the patients present to Niloufer when acutely ill.  An important part of our intern year is learning how to differentiate ”sick” from ”not sick.”  I imagine here they master their triage skills early on in training out of necessity as their ability to pick out the critically ill patients definitely makes the difference between life and death on an hourly basis.  It has been a very interesting experience to see the government-run side of medicine here in India.  I think Brian and Paras have both mentioned it already, however I have to reiterate how impressed I’ve been with their clinical skills and ability to provide care under the conditions in which they practice.

To pass the time, four of us went back to Sivananda to see the kids and see their pooja, the religious ceremony honoring Ganesh.  I was very happy to see the kids again, today they were dressed in their fresh,  sparkling new (literally) clothes.  They were of course acting like kids-running, playing, and being generally rambunctious.  They recognized us as soon as we walked up, which was touching.  They all said “Happy Ganesh” to us, and one of the girls gave us ledu that she’d gotten.

Then we waited.  Ganesh was apparently running late.  About 45 minutes after his proposed arrival, the sound of drums could be heard coming down the path.  There was a plaster Ganesh being wheeled down the pathway with his exuberant entourage of all ages.

They wheeled him up to the place where he would reside for the next 9 or 10 days, and then there was trouble.  Apparently they didn’t realize that Ganesh would be hard to fit into his new home.  After about 30 minutes of manipulating him, he finally made it to his temporary abode, and then the pooja began.

It was a whirl of adorning, praising, burning incense, throwing rice.  Oh yes, and taking pictures.  I think I will have a stack of photos to send back to Sivananda once I get home.

To an outsider, it was all an incredible spectacle, the likes of which we rarely see at home.   The kids were excited as if they were American kids on Christmas morning.

We had to say our goodbyes fairly early to catch a cab back home.  I’m very glad we got to see the kids again, and I’m again amazed that in spite of the battles that they have to fight–the ones they had no say in fighting in the first place–that they can still be kids.  I feel a little sad and guilty that we’re essentially bungee parents, or even worse, bungee tourists.  It’s one of the regrets I’ve had about this trip, that we haven’t had the time to build the relationships with the kids, and others we’ve come across.

I guess that a whole other trip.

On Saturday we did some shopping, and Sunday we did some touring! We checked out Golconda Fort, which is a really fantastic structure dating from the 1500-1600s, it’s huge and impressive, and the original city in this area! We milled around, listened to our hired english-speaking guide (without whom we would not have been able to appreciate many of the historical nuances) and had an awesome time. There are places you can hear noises amplified from other areas of the fort and some very detailed carving remains on some of the walls. The entire structure sits on natural large stone foundations, walls are nailed in with stone nails, and apparently there’s a secret passage to Charminar, but it wasn’t open to public access. The temple at the top is also amazing, including many large stones balanced on top of each other and the usual Hindu brilliant use of color.

When we were nearing the end of our Golconda adventure, enjoying some ice cream (CIT2 has eaten a lot of ice cream) I was approached by i-news and asked for an interview. I’m not sure who they thought I was, but I consented and it was kind of hilarious. They just wanted to know about my experience in Hyderabad and Golconda. Paras and Tim decided to dance in the background which was really a sight to see, then they got yelled at by the Indian TV crew! Hah! So why me? Some speculation suggests there may have been headlines to the effect of “Pasty American Giant Attacks Golconda!” but we couldn’t find it on TV or the net, so we may never know.

Lastly we went to Charminar which is a monument built to commemorate Hyderabad becoming the capital of Muhammad Quli Qutb Shah in the late 1500s. It’s an amazing four-sided structure that we were able to climb up in and get a great view of the markets and city. Since we’d just been in those markets it was even more impressive how packed they were. What did we get, you’d like to know? Well, in the words of one CIT2 Member “pretty, pretty bangles”. Hint: These were neither Alicia’s nor my words. Paras really busted out the Hindi and got us some good deals in the negotiation process which we really appreciated.

Taking nothing away from what we have to go through in residency (patient care, paperwork, etc), it is amazing what the do here. For 5 residents to admit 130-140 kids in a night is both amazing and ridiculous. That averages to about 25-30 admissions per resident which is likely more admissions that some teams get at RBC (ahem, green team).

The casualty ward (ER) and resuscitation wing (acute emergent care) was equally amazing. When we first walked in to the resuscitation wing (which was about 20 beds and 40-50 kids), we saw a group of people resuscitating a child. Interestingly, once they stabilized the intubated child (aka got a pulse), the medical staff turned their sights to another child. That left their parents to bag and ventilate the child as there was frankly no one else to do that. Even though I don’t have any kids, I’m not sure that I could be bagging my intubated child as I would be an emotional wreck seeing my child in that situation.

During the resuscitation, the assistant professor told us to turn around and see the child that they had just brought in. This patient was severely dehydrated with sunken eyes and profound skin turgor. I have never seen this severe of dehydration in my life. This was the definition of lethargy. Before I could turn to my ABC’s and think about how they would get central access or an IO line in the child, the nurse put a peripheral line in the hand and was already giving a fluid bolus. Within 10 minutes the child was awake and smiling as if nothing had happened. This was critical care and teamwork at its finest.

Once again, I am amazed at the clinical acumen exhibited by the attendings here. Their ability to do a history and physical to ferret out the diagnosis is unreal. I can only hope to be at half that level when I become an attending.

We saw a case of 6 year old twins that were conjoined at the head (similar to the ones that were at Rainbow last year). The girls share the same venous flow which makes the surgery more difficult and perhaps impossible. For reasons that we are not exactly sure, their parents have abandoned them and now they don’t have anyone in their lives. It is really sad that they were considered to be a burden to the family, but they are making the best of what they have. Also, kudos to the government hospital to help out with the situation as best they can.

I expect that the next visit to the hospital will be equally as inspiring as the 3 of us will split up into the fields of medicine that interests us the most (i.e. HIV management, ER, critical care, general wards). I suspect that there will be more stories then….

We’re at Niloufer Hospital, a large government women’s and childrens’ hospital.  They have 350 peds beds.  However, they have 2 or 3 times that many patients.

Overnight they got 140 admissions.

I detect some duty hour violations.  I don’t think  I’ll be complaining about Blue Team anytime soon.

All the care here is given free of charge, but I suspect that 2 or 3 children per bed is not acceptable to some wealthier Indian parents.  It must make infection control a nightmare.