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Shades of Gray

Posted by Gopal on 24 August, 2008

I am back in Pondy, reflecting upon yesterday’s voyage, as Brian foreshadowed. Also, I uploaded some posts I had been working on when I did not have internet access over the past couple of days here and here.

I spent Friday in aunt’s house in Nellore. Nellore, the last major city in southern AP before one hits Chennai in Tamil Nadu, is the ancestral home of my mother’s family, and is where my mother was born and spent some of her formative years. I had not been there in 16 years. I spent about 18 hours with my aunt, including the night stay. Saturday morning, I awoke and bathed. Upon exiting the bathroom, I immediately perceived that the door to my bedroom was now on the floor. This was not entirely surprising, since my aunt had complained on the previous night of the white ant problem in that door frame, and I had already ascertained that the door was had been staying affixed to its frame primarily by the adhesive properties of the white paint on its exterior. I cleaned up the shards of wood, saw none of the offending termites, who had presumable headed off long ago to greener pastures, and, after a quick breakfast of pongal, proceeded to the Nellore YRG CARE clinic at about 11am. I was then apprised of the first of a series of unfortunate events.

Sunil had not come. Although his presence was not required for the tour, which was to be conducted by Krishnan and Vasu anyway, it was essential for my return to Chennai that afternoon. At least, it was according to the plan we had worked out 48 hours previously. Since I had an appointment with the Chairman of the Balaji Trust (the parent organization that started MGMCRI) in Chennai that evening, I rapidly became apprehensive and voiced my concern to Krishnan in a half-crazed, high-pitched tone. His eyes widened and he spoke to me very slowly and deliberately, acknowledging that I must be frustrated. This is exactly what I have been trained to say when dealing with “problem” patients and generally works extremely well. It infuriates me when I am subjected to it. Once he outlined a very reasonable course of action that would get me to Chennai by mid-afternoon, I calmed down and my pulse came back down to the low 120s, which is the baseline I achieved following my volume-depletion after cleaning up the disintegrated door frame in 90 degree weather with the ceiling fan off. Krishnan then cheerfully remarked that Americans such as myself are all so black-and-white about plans. Here in India, there are only shades of gray, but you are not used to that, he laughed, and Vasu looked up from his laptop to sagely waggle his head and laugh in agreement. Yes, I said weakly, shades of gray. Hehe. We headed off for the tour, which Krishnan conducted with supreme competence and efficiency I have now come to expect of YRG staff. I called Mrs. Asha to confirm my appointment with the Chairman. She seemed rather surprised to hear from me, even though she had asked me to call at exactly that time on that day. She asked me to call her back in the afternoon, when she would divulge the particulars of the meeting venue and time. We dined at Murali Krishna’s, a fantastic restaurant serving typical Andhra fare, and tried to call Sunil to gloat but he was not available. Then they dropped me off at the bus stop. I left my water bottle in the car.

I boarded the bus to Chennai and payed about $2.80. My recliner didn’t work, and I was too exhausted to find a different seat. It was 1PM and the heat was unbearable; I could barely wait until the driver started off so that we could turn on the A/C and the TV. Sure enough, within five minutes, we pushed off, and I realized that there was no A/C on this bus and that the TV did not work.

We made about 15 stops in Nellore and picked up about 4 people. The last was a man on the outskirts of the city. I don’t know where he was going, but the driver charged him 10 rupees compared to my 114 fare, so I decided it couldn’t be that far. The man was barefoot, dressed in a blue short-sleeve shirt and a darker blue lungi folded at the knees. He held a basket against his hip and spoke in a gravelly baritone very deferentially to the bus driver, ending all his sentences with “saar”. After paying, he stepped into the main part of the bus and began to hawk his wares in an unbelievably shrill voice, walking up and down the aisle several times before realizing that none of the eight of us passengers was a future customer. For whatever he had in that basket. So he sat down and demanded that the driver turn on the TV, not taking no for an answer. The driver yelled something back at him and he quieted down. Meanwhile, my shirt was slowly being steeped in sweat as we rarely got enough wind coming through the windows, what with the frequent stops. My mind started swimming, just a bit, and I began experiencing mildly paranoid ideation. Specifically, thinking a bit about lungi-boy’s abrupt change in behavior, I imagined that the driver and he were in cahoots and that they would perpetrate some heinous act upon us once we were in a more rural setting. I felt a sharp tap on my left shoulder and looked back to see lungi-boy gesturing to my watch. I started to take it off and then thought briefly and said 3:15. This seemed to satisfy him and, after a while, I managed to fall asleep.

When I awoke some 20 minutes later, sweat was dripping off of my brow and streaming down my face. I reached for my water bottle which was safely in the back of Vasu’s car. My kidneys began to shut down for the afternoon. I realized that there was an argument going on. The driver and lungi boy were yelling at each other. Initially, only the driver was yelling, and lungi-boy was trying to plead his case. The driver felt that he had taken him 10 rupees worth of road. Lungi-boy wanted to go a bit farther. Then lungi boy started screaming. He was agreeable to getting off, but he wanted 2 rupees back. He felt that he had only gotten 8 rupees worth of transport. Some of my fellows passengers suggested that lungi boy get off, so he asked the driver to step outside. They would handle things behind the bus. The driver eventually assented, and they stepped off the bus. 10 seconds later, lungi boy came back to put his basket on the bus. Confidence. 5 seconds after this, the driver came back and left with the basket. Then we heard the argument continuing outside. I craned my head to see across the bus, but to no avail. The villagers were gathering to witness the proceedings, and I began to ponder the potential outcomes of the altercation. For my money, the driver could have taken lungi boy. But what if he couldn’t? Could I drive the bus? Don’t they have gears you need to shift? Would my head stop swimming? Fortunately, the driver came back and we headed off. I relaxed and reached again for my water bottle, which continued to be in the back of Vasu’s car.

I called Mrs. Asha to get the details of my appointment with the Chairman.

Yes, Mr, Gopal, you have to get to Ashok Nagar as soon as you get off the bus.

OK. Then what?

But how will you find Ashok Nagar?

Excellent question.

You do one thing. You call me back in 10 minutes.

I did not understand why finding Ashok Nagar was not on the problem list 4 days ago when we planned this meeting. I also did not understand why Mrs Asha had a phone that could apparently only receive calls. I called back in 10 minutes.

Mr. Gopal the Chairman has left for the day.

Really? He left? This is what transpired in the last 10 minutes? HE LEFT? Was it because of the Ashok Nagar dilemma? Really?

Yes. Really. Can we schedule for Monday?

No.

I have fixed an appointment with him at 9:30AM on Monday, OK?

No.

I will see you Monday. The Chairman wants to meet you. You bring your students. Bye.

I called Krishnan to let him know that I no longer had an appointment with the Chairman, and I would just go to Sunil’s house, as we had discussed. Umm, Gopal, there has been a bit of a change. Sunil’s dog is sick. He cannot meet with you. You can go to our guest house.

I want to go back to Pondy.

Yes, yes, that makes much more sense. My driver will meet you at the bus stand. He will put you on a wonderful bus to Pondy. More gray, hah? Hehehe.

Hehehe. Cough cough. I reached for my water bottle. My kidneys began putting their affairs in order. Talk to you later.

We pulled into Chennai at 6PM, where I was to meet Krishnan’s driver. Krishnan called. Hey Gopal, can you do one thing? Can you find the bus to Pondy on your own? It is just that the driver is waiting outside the stand, and he would need to park if he would come to help you.

Sure. Sounds great.

You can’t miss the bus, Gopal, it’s very easy. Go to Enquiry and ask. OK?

Sure. I eventually found the platform with the buses going to Pondy. All ten of them. I got on one. The one with four conductors waiting outside. Or it could have been two. Or one. I ran my bone-dry tongue across my cracked lips, brushed some uremic frost off my arms, put my backpack down and reached for my water bottle. Then it hit. An epiphany. An inexplicable moment of clarity. I ran off the bus and bought a bottle of Aquafina. The bus took off, I downed about half the bottle’s contents, and took stock of my new vehicle.

It wasn’t as fancy as the other one, but the TV worked well enough to blare a 45 minute tape of Ilayaraaja‘s selected hits repeatedly over the next four hours. We made about 10 stops in the city of Chennai and the bus was packed by the time we hit the east coast road. There was standing room only, and not much of that. I fell asleep (lost consciousness) for some 10-15 minutes. When I awoke a blurry toddler was staring up at me from the floor. I stared back at him through my dry, opacified contacts. He was wearing a shirt, nothing below, and lying in his mother’s lap. I then realized that she was sitting on the floor of the bus, breastfeeding him. She glanced up at me and glared. I jerked my head up violently to look in another direction. Any direction. My head hit an object behind me and to the left. It was a man’s posterior. He was sitting on my left shoulder. This explained the excruciating pain just left of my spine. I straightened up and heard something crack in my spine. I glared at him much in the same way the lady on the floor continued to glare at me. He smiled broadly and started singing along to some of Ilayaraaja’s greatest.

This continued for 3 hours before I saw the familiar mien of the Pondy Chief Minister on a billboard. I had had intermittent contact with my aunt and with Brian via text message. The team was waiting for me at the Ajantha hotel. I got off the bus at the Pondy Bus Stand at 9PM and hailed an auto. The trip to Ajantha took another 10 minutes. The team waited patiently for me as I consumed my dinner and brought them up to speed on my activities. We walked out of the restaurant, Satsanga, and saw two autos parked outside. We quickly agreed on a price of Rs. 250.00 per auto and set off for MGMCRI. Tim, Alicia and I talked in our auto about some slum related issues. Then it stopped. The auto did. It just stopped. No petrol?, I asked the driver. He gave me a winning smile, produced a Sprite bottle with an amber-colored liquid, and disappeared behind the vehicle. A minute later, we were full speed ahead. Until we go to the edge of town. Then we stopped again. This time, he had no extra bottles. Fortunately, his friend up ahead realized we were not right behind them and came back. As they conferred with each other, 3 dogs approached us. I proposed that we hitch our auto to these sturdy specimens, but the other auto driver then pulled out his own sprite bottle and we were off and running again. until we were well into the dead space between Pondy and the campus. The first auto came back. There was no backup any more. The three of us joined Brooke and Brian in their auto and we sped off again. My muscles had already adapted to unusual postures thanks to the man that sat on me for 2 hours. Brooke, however, lost feeling/circulation in her right leg after a few minutes. This proved to be reversible once we arrived at the hostel, and the only thing left to do was explain to the auto driver why we would not be paying him 500 rupees. This only took about 20 minutes and was assisted by translational help from the security guard, who spoke only Tamil and no English, and two student passers-by, who spoke a lot of English and Malayalam but little Tamil. That went almost as well as one would predict and we settled on a sum of 400 rupees. I left the driver muttering to himself, no doubt planning his revenge. Some 13 hours after I set out from Nellore, I walked into my room. Never did I expect to be so pleased to see that place. I called home, spoke to Toohie, heard Geethanjali’s voice, and the gray lifted. I slept well.

Posted in Pondicherry | Tagged: , , , , , , , | 8 Comments »

Last Thoughts from Pondi

Posted by parask on 24 August, 2008

We are all nearing our last day in Pondi and I think that there were some overriding feelings that I wanted to share with you all… I apologize if my posts came out as negative, that was not what I was meaning… indeed I am amazed at a few things that are going on here:

– I think that the physicians here are clinically gifted. Their ability to ferret out a diagnosis with just the history and physical is amazing and something that I wish to have one day. I think that I am very technology dependent and tend to use lab values and radiological evidence as my main force with the history and physical to follow. Often times, I look at the labs and radiology before I even see my patient. This is quite the opposite here as the patients can’t afford the necessary technology.

– I am very impressed that some of the patients that are brought for the “CPC” like lecture are some of the poorer patients who can’t afford the necessary diagnostic procedures to help with therapeutic options. Since they were there as “educational subjects”, they can get these procedures for reduced rates or even for free. I wish that happened more in the hospital, but at the very least it is still happening.

– I also liked the community medicine and they way they taught there medical students. More about this can be seen in Tim’s previous post. What I wanted to add about this was that the Community medicine department opened up 2 clinics (one in the city and one rural) to help with preventative medicine. There, they tried their best to teach about diet and exercise and about the dangers of diabetes and hypertension. As Tim said before, it is better to stop the problem before it is started.

-I am also surprised with the amount of OP poisoning that is prevalent here. Some of the studies that I had seen in the past mentioned that approx 45% of MICU admissions were secondary to OP poisoning but I suspect that number must be conservative as it seemed that there were multiple admissions daily.

Tomorrow, we embark on the journey from Pondicherry to Hyderabad by way of Chennai. Lets hope we make it to everything on time….

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Our days off in Pondicherry

Posted by brianc79 on 24 August, 2008

As Brooke mentioned, we saw another case of organophosphate poisoning yesterday on rounds. Of course it had to be, because it seems they need to have a census of at least 2 OP poisonings in the ICU at all times.

Yesterday those of us who were in town and were feeling well enough came into Pondicherry to hang out, and either do work or explore the Indian quarter. Tim, Alicia and I wandered around to find the Grand Bazaar, a large more or less open-air market, although everyone tried to build as much of a roof over their stalls and aisles as possible. Think of this as the West Side Market, but on steroids. Row after row of vegetables piled up in baskets or on the ground, hundreds of bolts of fabric in every color imaginable, and a very fresh chicken. As in still breathing. This is the India I was expecting when I came.

Added to the list of things I wish I had brought: Tamiflu.

The three of us attended services at the Catholic cathedral in town last night. We were hoping the mass would be said in English or French. Instead it was in Tamil. About 20 minutes into what we thought was a homily, we decided we’d had enough and made a quick exit to pick up Brooke for a very leisurely dinner.

I use the term leisurely to mean slow service. But at least we finally got to have our dinner overlooking the beach and Promenade.

Gopal made his way back into town last night. I’m sure that will be the subject of another post shortly.

We’re all looking forward to the Indian food dinner that is being prepared for us at Coffee.com #2 tonight. I am sure we will not be disappointed.

Posted in Pondicherry | Tagged: , , | 2 Comments »

Mustaches!

Posted by brianc79 on 24 August, 2008


DSC_0218

Originally uploaded by BrianC1979

And for the moment everyone’s been waiting for…Mustaches on the beach!

Posted in Pondicherry | Tagged: | 6 Comments »

Yes, we all can fit in one (1) auto-rickshaw.

Posted by kikidecker on 23 August, 2008

It’s been really interesting seeing how medicine is done at the MGMC & RI, and we are especially grateful to Dr. Hanifah teaching us so much during rounds in the ICUs. Here’s a group picture of all of us on our last day, the man on the left is the PG, or resident, on service. Ladies, please note the mustache.

Today we saw another case of organophosphate poisoning, this time given via injection! It turns out they can get syringes very easily at the pharmacies without a prescription, which I guess shouldn’t be surprising to us since they can get all the azithromycin they want too, maybe sometimes they want to get it IV? Anyway, his arm didn’t look too good, we didn’t linger in the RICU today as it was stifling-hot in there, but I hope he was on some abx, because I don’t think he used medical injection-grade organophosphates. Per the admitting doctor it was another case of “love gone wrong.” It’s sad how many suicide attempts we’ve seen in our few days here.

As Brian mentioned we ran into two Americans, Matt and Chris from Dalit Solidarity, who seem to be doing a lot of the stuff we were talking about the other night. I don’t want to belabor the point, but I really am just so happy that we found someone doing what we all agreed was the most important, which is improving the basics, including providing PCP-like care! You know I love my ID peeps, but before we can have good efficacious HIV treatment we need these people to have the basics that allow them to take that medication and avoid other infections, and prevention! They even taught us a little Tamil, which is too bad we’re leaving soon!

And since you wanted to see some pictures of the ‘stashes, here is a cute group photo. Alas, the facial hair is still sparse in this picture, but I am confident in a few days they will really be very nice. In the background is the Auroville dome which you can’t really see on account of glare. Also maybe Brian’s camera had too many options for the man whose meditation we interrupted to have him take this photo. Perhaps when Dr. Yadavalli rejoins the group tonight or tomorrow we will get another group picture. Oh man, speaking of that… I better work on my presentation…

Posted in Pondicherry | Tagged: , , , , , , , | 3 Comments »