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Archive for August 20th, 2008

JIPMER, Part One

Posted by Gopal on 20 August, 2008

MGMCRI is situated about 16km from downtown Pondy. It is at the border of a rural area, and is flanked by vast streches of mostly open space, dotted with coconut and palmetto trees. It is the southernmost of the 7 medical colleges in Pondy, and the oldest private medical college. As was mentioned earlier (I think), in private hospitals, patients pay for everything. Insurance in Hyderabad is <1%, and is negligible here in Pondy. MGMCRI is about 7 years old, and its wards are not usually full. It does much better, I am told, than the other private colleges here, because it is more established.

Dr. U.K. Singh, the Head of Microbiology at MGMCRI, kindly arranged for me to meet his opposite number at JIPMER this morning. I got into a car at the medical college, accompanied by one of the tutors (instructor-equivalent at CWRU) as my guide. There were two other assistant professors in the car, headed to Pondy to do some other work.  Halfway to our destination, the front passenger tire blew out, so we had a 20 minute delay for a tire change. As my wife has no doubt already guessed, I concluded that I could have done it faster.  My conversation with my companions was illuminating. Money drives the medical college construction. Completely. There are few patients at most of these colleges. The colleges make their money by charging students exorbitant sums to matriculate and study there.  The income from patients is negligible.  This seems to dilute the quality of care as well as the quality of the medical education here in Pondy at these brand new schools.  A new government medical college is also being constructed. This one should have no problems filling up with patients, however, since it will primarily serve the poorest of the poor. There is no shortage of those persons here. 

The Jawaharlal Institute of Postgraduate Medical Education and Research is oone of the two established government hospitals. It is about 6km north of the heart of Pondy, and is thus situated in a more urban setting. Its sprawling (by Indian city standards) campus is separated from the city by a compound wall. There is lush vegetation between the buildings, and the place is bustling with people, inside and outside.  JIPMER’s capacity is 1000 beds, and it routinely has a census of 2000. Don’t know who is holding that transfer pager. My guide and I entered the main building, opposite the Administrative building, and made our way to Microbiology on the second floor. The hallways have the unmistakable look, color, and feel of non-private Indian hospitals; something the CIT1 crowd, among others, can appreciate. The major difference here is that the anatomy lab is on the first floor, and the smell of formaldehyde penetrates all four floors above it.

Dr. Parija is the head of Microbiology at JIPMER. He came here as a freshly-graduated resident (MD in Microbiology) and is now in his 28th year at the institution. He was not in his office when we were shown in, so I had the opportunity to get to know him first from the things in that room. The room itself was large, maybe 20 feet by 20 feet, and was lined with cabinets and shelves on every wall. Numerous certificates and plaques adorned the wall space above the lower lying cabinets. Dr. Parija was clearly a speaker in high demand. A relief map of Nepal just next to the door suggested his place of origin. His desk was oversized and trapezoidal, with a matching glass top. On one corner was an atlas of parasitology, recently published, authored by Subhas Chandra Parija. The computer was on a desk behind his chair, and sported the blue screen of death. We sat down in two of the four chairs across from his desk and waited. It was abundantly clear that he was a highly accomplished man. In India, as elsewhere, this usually means that a big ego is in tow, and that Gopal will have a rough time of it during talks of collaboration. After about five minutes, he entered quietly and, over the next three quarters of an hour, dispossessed me of my assumptions.

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More musings from Pondi….

Posted by parask on 20 August, 2008

As per the usual, Brian did an excellent job in covering what happened on the Pediatrics side of things here in Pondi. One comment from that… I am not entirely sure why they chose to put the pt on linezolid when the pt failed Ceftriaxone. When I asked the professor he said it was for resistant Strep Pneumo and not MRSA. If they are using ciprofloxacin on the neonates, wouldn’t moxifloxacin/levofloxacin have been a viable alternative??? 

From what I have heard (many voices in my head), the original musings were a hit! Allow me to add a few more and also update you on some of the previous posts…

– I was told to tell you all that “all” of us did not buy drums, only “most” of us did. If any of you can figure out who is happy that he/she did not buy drums, I have a present for you. Please comment below…

– Mustaches are still on, no one has fallen off that wagon yet (Brian never got on). We will have pics up once we are smart enough to figure out how to do that. Also, we have yet to figure out the penalty for the person that gets rid of the mustache first…. so if you got something please let us know….

– Still no signs of Betsy. I think that Betsy caught wind that Tim likes meat (esp steaks) and has yet to grace us with her presence again

– If you are ever in the neighborhood of Mahatma Gandhi Medical College and Research Institute, I highly recommend going to R.R. Caterers (the “dive” that Brain refers to). They have amazing tandoori chicken. This place will now be known as the Official Tandoori place of CIT2.

– The canteen that we go to for breakfast has started using a cash register today. The good thing about that is that we can now double check what we ordered and not get totally surprised with what appears on our plate (see: communication problems). The bad thing is that the canteen has lost a lot of efficiency which means that it takes a long time to get the right order. I’m not sure which is better…

– We had yet another rousing game of euchre yesterday. I believe that we will next be learning how to play pinochle. After that, apparently it’s on with travel Scrabble!!

– For the record, I’m still not married…

– I miss diet coke. The soft drinks that they have (all regular) really do taste like sugar syrup now. Fortunately, some of the restaurants carry diet coke (with 1 calorie instead of 0) so I have tried my best to get my fill on there.

– On our visit to Auroville, we had a “guide” that was no help. In fact, the most he did was attempt to steal a car that he thought was ours. Fortunately, Gopal saved the day and alerted the guide that the car was not his and that he could not have it. Then he sent him to a timeout…. at a meditation center…

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Throwdown: Zyvox vs. Survanta

Posted by brianc79 on 20 August, 2008

I’ve taken a break from blogging for a day or so.  So, I have a little to catch up on.   Yesterday I started getting some GI upset, fortunately not the Cipro-taking kind.  I’m thinking my bland American stomach is being thrown into convulsions from an exclusively Indian food diet.Yesteday we rounded in the NICU.  It’s pretty amazing what they are trying to do with limited resources.  I’m still surprised that first line therapy includes amikacin.  What would that be–a dry martini, shaken not stirred?
Second line includes piperacillin and ciprofloxacin.  In a neonate.  They obviously have not read the literature on beagle pups and cartilage.  We’ll call that infant formula–second best to mother’s milk.

Overnight, the NICU sent a baby out to mom, and then got a SGA pre-term twin that weighed 850 grams.  The baby was intubated, but they couldn’t give Survanta.  Why is that?  Survanta costs 13,000 rupees (US$300)…per dose, which is way too expensive for a typical Indian family.

Out on the wards, the young girl with pneumonia was going home today.  Choice of antibiotics Zyvox (linezolid).  Cost?  40 rupees (about US$1).  Compare that to our cost of US$40…per pill.  We’ll call this fortified mother’s milk.  Or maybe a Rum and Coke.

Also on the Peds Wards today, we saw a case of Duchenne’s muscular dystrophy, calf pseudohypertrophy, Gower’s maneuver and all.  This is one of those cases which we never see admitted to inpatient at Rainbow, though I’m sure it exists.  We also saw a probable case of cerebral palsy/developmental delay.  I thought about how much stuff and resources we would send these parents home with in the US, and wondered what kind of support they would get here in India.
Rest assured, we are not just working.   Yesterday we went sightseeing to Auroville, a eutopian, non-denominational settlement outside of Pondicherry.  It was founded on the principles set forth by Mother and Sri Aurobindo.  In the middle of the settlement is a Banyan tree, and right next to it is a huge, Disney-esque meditation chamber.   Think Epcot center except with gold discs.  It is supposed to be reminiscent of the divine consciousness.  It’s surrounded by brick “petals”, and to get into it you go down a ramp, then up a set of stairs.  Of course they make you remove your shoes and socks, but they also make you put on a pair of white socks which they provide.

You then start your ascent by a ramp that slowly spirals along the outside of the ball to reach the meditation chamber.  The inside of the meditation chamber is all white, with 12 white pillars, white carpet, and a huge crystal ball on a golden stand.  A ray of sunlight shines down from the ceiling.  Even when it’s full of people, when everyone’s quiet, it’s a very cool, experience.

 

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Somebody better call ethics…

Posted by kikidecker on 20 August, 2008

My lack of accessing the internet yesterday has put me behind. Saddle-up, we have a lot to discuss.

End of life conversations are so important in the MICU and at our institution and there are many people who do really amazing jobs at it. So yesterday we were rounding on an 87 y/o minimally responsive trached pt who had initially presented with TB meningitis, been put on steroids, later got an upper GI bleed and had been in the ICU for weeks… Not making any progress. Wait, that sounds familiar, right? So I asked about end of life discussions. The attending said that they don’t discuss it with the family and continue to do everything. He added “the ladies figure it out, and then take them home against medical advice eventually.” In a place where they are paying daily for the hospital stay, I guess the family has some motivation to ‘figure it out’ but I wish there was more communication. I asked him if pts can designate themselves as DNR, but they can’t do that either! One pt we saw earlier who came in with a hemmorhagic stroke, her family couldn’t pay for the head CT (only $20-30 in US currency) so they took her home AMA too.

We noticed the other day when we rounded a sign that said “isolation” in the male wards. Yesterday we got to see our first HIV pt, and he was the one in the isolation room! He didn’t have anything infectious, the guy we saw today with leprosy and tb was in the regular ICU.

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More Random Thoughts

Posted by tfernan0 on 20 August, 2008

1.) In India, they have one tablet that contains the usual four drugs (INH, rifampin, pyrazinamide, ethambutol) in the active TB treatment regiment to increase compliance.

2.) I have not seen one tie in the 3 days of rounding here. In fact, as others have noted, about half the doctors and most the ancillary staff don’t even wear closed toes shoes. Dr. Walsh would not be happy with that, but he should take heart because no wears scrubs on rounds either.

3.) Intracerebral tuberculoma = BAD.

4.) We saw the big golden ball in Auroville yesterday. Its pretty impressive. You cannot appreciate how big the golden ball is until you are inside it. The silence in the meditation room is deafening.

5.) As my mustache grows, so grows my respect amungst my Indian collegues. (Picture to follow once we figure out how to upload one.)

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