Triage Talent

As Brian mentioned, we went to Sivananda again last night and spent some time with the kids.  It was so nice to see them again, they are truly inspiring.  Their stories we heard last week made me want to lose my faith in humanity.  How could such innocent children who were given such a difficult fate be rejected by their own families and society in general.  But then I see the compassionate care and support they receive at Sivananda and it renews my hope again.  Despite all they’ve been through they really seem like happy, well-adjusted and optimistic kids.  They were so excited about the festivities last night.  I felt very fortunate to have the chance to witness and even take part in their ritual and learn more of the culture.

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.

Kids’r’us

So as you can tell the med-peds section of CIT2 went to the Government children’s hospital in Hyderabad. From the description provided from Brian, I think that you can all realize that this is a different world here. We saw a lot, but I want to comment on a few of the things that really stood out in my head.

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….

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.