In summary…

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!!!

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.

Bungee Parenting

Today is a national holiday.  It’s Ganesh Chaturthi, so we had the day off from the government hospitals here in Hyderabad.

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.

Forget Hopkins, try this for reality TV

Today we had the opportunity to watch an artist at work. As you know, Sivananda takes care of leprosy patients: medical care, surgeries, rehabilitation, all for free.

We got to watch two hand surgeries today. My descriptions will not do the surgeries justice (Dr. Beine is much better at it than I ever will be). But over the course of several hours, we saw a deformed hand get reshaped to something functional–tendons were exposed, cut, rerouted, and sutured to their new homes, all through incisions no more than a centimeter long.

Stop and look at your hand. Make a fist. Wiggle your fingers. Pick up a coin or a pencil. The hand is a remarkably complex appendage, and these docs are doing complicated surgeries on patients affected by leprosy so they can have a shot at a productive, meaningful life.

All this out of the goodness of their hearts.

It’s Fantastic………….

So officially I am now staying at the Sivananda Rehabilitation Home in Kukatpally, Hyderabad. Although I have been eager to share my experience by writing, unfortunately the computer access has been very limited here at the home. For those I haven’t talked on the phone, 15 hrs in the plane did go by fast, granted I did watch “finally” – I am Legend and the Iron Man. Ride over from the airport at 3 am, to the place I stayed for a day, believe it or not, was fast yet bumpy. Traffic in Hyderabad or most cities in India is definitely an experience as there are no rules (that are followed), no dividers, 15 different vehicles, honking every 5 seconds along with the pedestrians, cramped together, walking, slithering, all in a rush – one more than the other, buses making left turns from far lanes, motorcycle stopped in the middle of a road to talk on a cell phone or eat an orange, a scooter undergoing a transaction in a middle of a big intersection with a papaya vendor also strolling in that mess with his 4 wheeled wooden cart while rest of the world trying to weave there way around them beeping incessantly, and my shocking observation, not a single loud curse word heard from any of the drivers. To top it, the most daunting task has been to actually cross the road because NO ONE will stop unless you just throw yourself on the road with traffic coming your way at 45km/hr, stick your hand out to stop them, and if you are not run over, you can make it to the other side. Yes, I have a new respect for the yellow cab drivers in NY now.

Anyways, after reaching home, I slept for a couple of hours and was woken up by an aroma of burning coal outside of my window. Yes, it was the IRON MAN (unfortunately not Robert Downie Jr.) but literally a man who irons clothes for a living. My first day was very relaxing, pleasant and beautiful. That evening we drove around Chaarminar, necklace road, a lake with the Buddha’s statue, and finally a temple down the street ending my first day with the delicious home cooked four course dinner.

On August 25^th – I moved into my room at the Sivananda home. Luckily, my roommate from Chicago, there for the last two months, has been fantastic. She made sure that the room was lizard free, I had plenty of water, volunteered to venture out in the traffic with me for “bare” necessities. Just short of knowing telegu and her appearance, she could easily pass for a native as she is able to finesse her way gracefully through many situations, knows everyone, and seems to be everyone’s favorite.

 

August 26^th – My reason to come to SRH, I made my way to the HIV home for the children. The most amazing thirty children, all HIV (+), abandoned by their family or homeless, most of them appear younger than their stated ages, perfectly happy in their own small world yet seeking attention desperately. They greeted me with so much warmth and excitement, wanting to show me their art work, singing songs and addressing me as “akka” a telegu word for a big sister. Their ages, 5 to 15 yrs, in one classroom, one teacher working to give an individual attention, juggling all subjects and grades till the 4^th standard. Honestly, I have never seen as many children together in such harmony with each other. This is and is going to be the most emotional part of my journey and as to even make an attempt to describe my experience would be challenging and unjust.

Rest of the day was social and educational. I finally met with rest of the group from Case and we all shared our experiences, gave/heard lectures on numerous topics/diseases that we were to experience at SRH. To sum it up so far – a perfect weather, perfect food, perfect accommodation and now I anticipate already a perfect company.

 

Aug 27^th– stay tuned