ICGME?

Only have time for a quick post.  For people concerned, we’ve all gotten over our “tropical tummies,” but we’re feeling the ill effects of being in a city of 10 million people with no motor vehicle emissions standards.

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.

Throwdown: Zyvox vs. Survanta

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.

 

Random Thoughts from Day #2

1.) Sorry KBA, no “mother’s milk” (vanco/zosyn) here. Empiric antibiotic of choice is Ceftriaxone alone.

2.) India has a pay-for-performance health care system. The patients pay upfront and then then they perform the lab/procedure/imaging.

3.) The second two bus trips have not been as pleasurable as the first one.  I have never been so hot/sweaty/claustrophobic at the same time.

First Day on the wards

Today was our first exposure to patients. After meeting with Dr. U.K. Singh, the chair of microbiology to discuss our objectives, we took a brief tour of the microbiology labs and had a chat with one of the Assistant Professors of Microbiology. They have very few resources compared to the central micro lab at UH, but since they have to bill for all their services, as well as the media and the lab tech’s time, very few patients would be able to afford the services. Blood cultures are done the old way, innoculating them into media, and then visually examining them daily. No fancy Bac-tec machines named after the Jackson 5 here. Susceptibilities are all done by hand, and they don’t routinely run antigen tests since most people can’t afford them. They do have the ability to run ELISAs and Western Blots, but at 3000 rupees a pop (about US$70), it’s out of range for most Indians in the area.

Paras, Alicia, and I then met with the Chair of Pediatrics, who was kind enough to take us on a tour of the hospital. We saw the NICU, Respiratory ICU, and the Pediatric Wards, as well as the outpatient clinic. The NICU was far more advanced than I would have thought. They have monitors, electronic warmers, and modern ventilators. The last ventilator that I saw in South Africa was extremely archaic, and was only used in emergencies. These were state of the art touch screen vents. They do not, however, have ECMO, iNO, or any cardiac cath capabilities for babies. All the congenital heart kids go to Chennai by road–the same harrowing 3.5-4 hour experience we had. Because the families here lack the capability to care for any disable children and will often ignore them as if they were dead, they do not resuscitate below 28 weeks. As such, they have no incubators, and all their beds are open. Their main priorities in the NICU are controlling sepsis and hyperbilirubinemia. What astonishes me is that the microbiologic flora are completely different here than back home. They see almost no group B strept which is the bane of the Mac House moonlighter’s existence. They see more gram negative infections, and their initial choices for coverage are a second generation cephalosporin and amikacin.

We also talked to the chair about the vaccinations. They have most of the regular vaccinations for free, paid by the government. This includes the BCG, Hep B, oral polio, TDaP, and Hib. Others, like Pneumococcoal, Hep A, and rotavirus are paid out of pocket if the family wants them.

It was interesting talking the the attendings here. The big concerns are always cost to the patients and resource allocation. The common thread is that they would all love to have state of the art equipment, but if they can’t use it enough to justify the cost, and can’t bill patients for their use, what’s the point? Money still makes the world go around.

The quick visit to the post-natal wards was very different from Mac House. Every one was co-sleeping, and the earliest discharge day was DOL 3 for a vag delivery. For C-Sections, it’s 7 days. The chief of pediatrics told us that they have the same army of grandmothers that we have in Cleveland out there giving advice on what to do for their grandchildren. So they like to take the extra time to teach the mothers how to take care of their children.

The peds wards have about 30 to 40 beds split amongst general wards, the gastro ward, and the “PICU,” which is still awaiting equipment. So far nothing strange or exotic–pneumonia, febrile seizures, gastro, and breakthrough seizures.

The people here are quite sharp. The NICU attending we talked to was preparing to depart for fellowship training at Sick Kids in Toronto for Pediatric Nephrology. And everyone I talked to seemed to know the western “standard of care” that they would like to see practice, and then compare it to the reality that they know they can deliver and get paid for.

After lunch at “the dive” next to the canteen, which is very fast and efficient with good food, we got to see slides of malaria and microfilaria.

And now, we chill in front of the computers.

Some thoughts after Work Day #1…

Today was our first real day ‘working’ on the wards (its more observing than working, kind of like being a glorified 3rd year med student). The work day in this teaching hospital runs from 9AM to 1PM, no duty hours violations here. Most of the attendings go to their private practices in the afternoon where they make most of their incomes.

Today we rounded with a group of medical students. We saw a patient presenting with a CHF exacerbation, but I missed the diastolic murmur key to making the diagnosis of Rheumatic Heart Disease. I must remember to broaden my differential here.

I asked one of the students who all the people laying in the hall outside the wards were. She told me they were the family members of the patients. She said they are not allowed back into the Intensive Care Units. I asked if they at least get up-dates ont he condition of their loved one and she said “Thats not how we do it in India.” All the family hears are requests to go to the pharmacy to buy another antibiotic or bag of saline. The people seem to accept that this is the way it is. I know when my father was in the CCF ICU, I was at his bedside hanging on every word the team was saying and we were asked to leave due to visiting hours, my mom and I got pretty fired up. Its is probably a good thing they didn’t ask us to wait in the hall all day without any up-dates.

The other case that struck me today was a Temple Priest with pancytopenia and fevers. The resident said that their was a delay in making the eventual diagnosis of HIV (with parvovirus?) because they assumed he would not be someone to get HIV given his profession. It turns out he contracted the virus from a surgical procedure 5 years ago. It seems even in India, doctors make assumptions and value judgements about their patients.