But that doesn't really matter if it happens to be your child with suspected polio.
Yesterday afternoon, I began my rotation with the pediatrics ward team. We were there for about three hours and it was probably the most ambivalent rush of feelings I have had in a long time. It took me sometime afterwards to process it (not sure it's fully processed) and the effort exhausted me. It was a combination of wonder, excitement, frustration, anger, and helplessness. I attended afternoon rounds... what I saw was that more than half the time was spent in discussing payment issues, idle chit chat, or concern over being busy... more on this later...
The hospital smells of formaldehyde. When Carla and I were sitting in the director's office, I turned and asked her, what IS this familiar smell that I can't place? She immediately replied "anatomy lab" and she was right on. We were told to come back in a little while because an attending was still at lunch. On rounds, for the first time since college, I wanted to be an infectious disease specialist... we saw rickettsia (i never knew it could present with skin lesions of the devastating sort that I saw), suspected polio, bilateral bronchopneumonia, multitude of gastric complaints associated with fever, salmonella, possible meningitis, suspected primary TB--all within a matter of minutes of stepping foot into the ward.
The ward made me feel like I was in a time warp. The nurses all wore white sari's with plastic nurses hats. When we entered the PICU, we had to take our shoes off and go barefoot! The attending never washed his hands... in between all these infectious disease patients! I think he heard carla point it out to me, because from then on, he was constantly washing his hands... I don't think carla or I intended for him to hear us, but its better for the patients anyhow--and in my training--i understand the well being of the patient to be the end all be all of the actions. Also, the attending pointed out that when they need to attain urine samples, if a midstream clean catch is not possible (patient too young, contaminated specimen), they routinely do a suprapubic cath! For those outside medicine, this is an invasive procedure involving piercing the lower pelvis directly into the bladder to get a urine sample. We asked, why not just do a regular in and out catheter? The attending said he is "absolutely against catheters. They will inevitable introduce infection." Hmmm. I wonder why that is. The attending was excellent about teaching points and introducing each patient's history for our benefit. At the end, he left us in "pediatric casualty" which is their ER... I saw a patient with 30% third degree burns... I worry every two minutes since I saw him about his infection risk. I feel that there is alot than can be done to improve outcomes just from what I saw in the first few hours. Not expensive changes. Just behavioral ones-the Semmelweis type.
So why the feelings of helplessness... As I was trying to make sense of my feelings yesterday, here is what I came up with. In India, you will see the poorest of the poor, walk by the sickest of the sick, everyday, on every street. This has been true in every city of India that I have ever been in. As you walk by, they will call out to you, drag their bodies, with missing limbs, up to you, with pleading, begging eyes, motioning with their hands, their desire to eat something. I recently read Kurt Vonnegut's "A Man Without A Country", where he points out America is the only country with fat poor people. In India, "scaphoid abdomen" takes on a whole new meaning, as you wonder how long the skin can possibly continue to hold in whatever is left. Sorry to be graphic. But it is very real and it is omnipresent. So, I don't know if this is everyone's immediate reaction, but mine is to put up walls. If I were to process the poverty and sickness with each person I passed, and face up to the complexity of inhumanity, limited resources, failure of government, failure of humans to take care of one another, the gross inequity between my yesterday and my today, I would not make it two feet (or 0.6 meters, depending where you are) without breaking down. And yet, my ability to walk by, is likely the same defense that humankind has in allowing this to go on.
I just kept thinking "positive thoughts". Yes, this absolutely sucks, but I am here to see what is being done about it, so I walk on passing one after another of sadness personified on the street. So you see, when I got to the wards, and heard all this talk about not ordering needed antibiotics or tests due to payment issues, turning away a child without the ability to pay even with the high likelihood of polio at the top of the differential, watching worried mother after worried mother, have to make decisions about feeding all her children, or paying for medication for her sick child, and it goes on--helplessness and frustration overwhelmed me. Many times, the doctors talk in English, make a plan, and do not even inform the parents of the plan or updates on what they think is going on. In the states, I can at least go back and talk to the families if something like this happens. But here, the pathology is beyond what I have seen in infectious disease, and I do not speak the language. I am literally useless.
And being that I am Rupa, I am ambivalent. Who am I to judge a country with such limited resources, or the doctors that dare to take on the challenge? Of course they have to worry about payment if they want the hospital to exist another day. Maybe their defense mechanism for making it through the day is to have idle chit chat to break up the reality or to take pride in the busyness, even if they approach it at their own pace. But in Rupa's idealistic mind...ability to pay should only factor into cost effective use of resources... not life or death decisions. Yes we have the ability to save your child's life. No we will not do it if you cannot pay. Don't get me wrong; do not think for a minute that health care is treated as a basic human right in the United States either... its just that the level of drastic measures that are sought are at a different level in a developed versus a developing nation. Deep Breath.
Today, we had a different attending. The child with (likely) polio ended up being admitted. We saw an excellent physical exam... with the attending assessing the child's motor movements through play, establishing herself with him, and continuing on. She would do some parent education on rounds, which helped me breath a little easier. I also went to a barium swallow for a child that has had bilious vomiting for 6 days. The pediatric surgeon refreshed my embryology with understanding volvulus and malrotation. I don't think I will ever forget it--i had never seen volvulus before. The surgeon also made me realize that I need to be reading more to keep up with my basic sciences. It has been so easy to get caught up in this love affair with the clinical efficiency of things in the past two years. A little bit of grounding is good every now and then. I have to remember the "why" behind the "what."
The attending today also pointed out that their hospital is private and the poorest of the poor never even make it through the doors. Few and far between. One of the patients I saw today is part of a family of three that lives off 200 rupees a week. That is approximately $5. It is what Carla and I spent together on lunch today. Coming back from lunch, I saw grandmothers asleep on the cool cement floor outside the ward, others eating off the floor. Practically all the mothers are barefoot. I don't know that I could handle poorest of the poor.
We had a clinical meeting at 4pm. There we heard from an American Doctor that had done a research project in Bangladesh. The basic point of his, and his research appears valid and corroborated by others--influenza in the tropics follows a very different pattern than in temerate zones--present for most of the year in moderate amounts rather than the winter peak pediatricians have come to know and "love" in the Northern Hemisphere. Interesting.
I miss Jon. Besides being a good boyfriend. He's my best friend. He's the one that I talk to about all this stuff. and there is so much stuff, but no him to take in the earful.
Well, I am still a victim of jet lag... I continue to wake up by midnight every night. I have some pictures that I have taken while out and about, but I will have to figure it out later. I'm really excited about tomorrow. I hope I can continue to say that forever.
Wednesday, January 31, 2007
Monday, January 29, 2007
permanent brain damage
so last time i wrote was during my first layover in amsterdam.
now i am in vellore, registered for my rotations which begin this afternoon, checked into the hotel and already a market connosieur (don't know how to spell that).
but the times in between then and now... let me tell you...
so during our overnight layover in mumbai (or bombay for those of you not "with it" yet), we were supposed to be able to have a free dinner and lounge at a nearby hotel... there are two airports one is international the other is domestic--well there was no one there to pick us up to take us to the hotel, so we ended up on a shuttle where carla and i thoroughly explored the mumbai airport... found internet, indian junk food, the lounge we got kicked out of cause we are not "elite", and then a restaurant we got kicked out of cause we bought our food at the downstairs counter instead of the upstairs counter.
when we finally got to chennai we got a taxi driver. probably the only one in india that followed ALL the traffic rules. some might like this given the "i'm going to die" feeling i usually have when i travel on the roads in india. but after 48 hours without no sleep, i was looking forward to an aggressive driver for our 4 hour trip to vellore. carla and i just gave each other a sad look everytime someone passed us...cars, lopsided buses, rickshaws, people on foot, cows. i mean seriously, he drove the speed limit the whole way, and even stopped for tea.
so i did not sleep during the entire trip... im just not an airplane sleeper. so after 48 hours of travel time (including the longest layovers of my life) we arrived in vellore and decided we had to get situated. Somewhere in our delerium we decided it would be better to finish errands rather than sleep. so off we went in search of toilet paper, hand soap, a cell phone so you peoples can call us, photocopier for the documents we needed to register the next day, passport photos (oh they are lovely, let me tell you, without having brushed my hair or showered for three days, and now it is on my CMC ID card!) Why we did not go to sleep i do not know. but at some point, carla and i realized we had been waiting for someone that said "be right back" for an hour, and we still had no cell phone and both of us were too tired to realize it! so we decided to go to the hotel.
at the hotel, they first told us they didnt have any a/c rooms with two beds, which we had confirmed they had twice before we left. so carla and i have to get comfy. then, we got to our room to realize there is an elaborate key system that makes it so you cannot have the electricity on while you are gone, not a big deal, accept on hot days where it wuld be nice to be greeted with AC and that oh yeah, if we want to turn off the lights, the ac has to turn off too since none of the switches are actually connected to the light bulb--just to the superkey! we chose the airconditioning and sleeping wiht lights on since we were exhausted. but after a bit of rest, i awoke around midnight to find carla standing on the bed and desk unscrewing light bulbs. she is brilliant! i would have been sleeping with the lights on for three weeks without her. She also said something, but i can't remember what, that made me worry that our staying awake so long had caused permanent brain damage.
before we went to bed, carla and i decided to order food. poor delerious carla on the phone, lets just say that after a 20 minute conversation and four clarification phone calls on trying to order two items and two drinks... we got, half our food, he informed us the rest was still cooking. then he brought in the next order ten minutes later and the bill. then he brought the change 15 minutes later. then he came back to get the dishes. they don't like to knock here either.
now if we can just figure out how to get the hot running water they promised us...i think we will be okay.
okay, so it might sound like im complaining, but in my delerious state, i actually was enjoying the craziness of it. carla and i were giggling the whole time. when we first hit vellore it felt overwhelming, usually i get in "travel mode" when i get to another country but lack of sleep and food, made everything seem a bit surreal. its just about a different way of life, coming from someplace with a certain way of life and integrating, quick like, just takes being with it. but even if i usually consider myself travel savvy... a few things i learned... prioritize the basics when new someplace... sleep and food. they you can figure out the fancy stuff later...
but so far, today has been a blast. we both registered for our electives. This week, I am doing pediatrics. Next week I will be doing home visits and hospital rounds at the community health and development hospital. The following week will be at a rural location! i am really excited. everyone here is really nice, not just at the hospital, but also in the city. sure they want to sell you their stuff, but they are also willing to help you find something if you are lost, even if they don't speak your language or understand anything about you. Mostly, i would just describe the folks here as "curious", just like us. Even if they are staring at us, taking us in... we are staring back and taking it all in. in the end, its all the same. I keep my guard up, just like I do anytime I'm in a city, whether its New York or Belo Horizonte, but this is probably the most comfortable I have felt in a city. I'm excited to make this place home for three weeks. its very managable.
Well, this blog just came out as a regurgitation of events, not quite what I wanted, what I really wanted to do was tell you my thoughts on all these actions. my thoughts on dressing in indian clothes, being ethnically indian, but inherently american and here in this country as foreign to me as any other. but i think this blog came out the way that my first day felt, just event after event. so i'll get to the good stuff in the next one i suppose.
now i am in vellore, registered for my rotations which begin this afternoon, checked into the hotel and already a market connosieur (don't know how to spell that).
but the times in between then and now... let me tell you...
so during our overnight layover in mumbai (or bombay for those of you not "with it" yet), we were supposed to be able to have a free dinner and lounge at a nearby hotel... there are two airports one is international the other is domestic--well there was no one there to pick us up to take us to the hotel, so we ended up on a shuttle where carla and i thoroughly explored the mumbai airport... found internet, indian junk food, the lounge we got kicked out of cause we are not "elite", and then a restaurant we got kicked out of cause we bought our food at the downstairs counter instead of the upstairs counter.
when we finally got to chennai we got a taxi driver. probably the only one in india that followed ALL the traffic rules. some might like this given the "i'm going to die" feeling i usually have when i travel on the roads in india. but after 48 hours without no sleep, i was looking forward to an aggressive driver for our 4 hour trip to vellore. carla and i just gave each other a sad look everytime someone passed us...cars, lopsided buses, rickshaws, people on foot, cows. i mean seriously, he drove the speed limit the whole way, and even stopped for tea.
so i did not sleep during the entire trip... im just not an airplane sleeper. so after 48 hours of travel time (including the longest layovers of my life) we arrived in vellore and decided we had to get situated. Somewhere in our delerium we decided it would be better to finish errands rather than sleep. so off we went in search of toilet paper, hand soap, a cell phone so you peoples can call us, photocopier for the documents we needed to register the next day, passport photos (oh they are lovely, let me tell you, without having brushed my hair or showered for three days, and now it is on my CMC ID card!) Why we did not go to sleep i do not know. but at some point, carla and i realized we had been waiting for someone that said "be right back" for an hour, and we still had no cell phone and both of us were too tired to realize it! so we decided to go to the hotel.
at the hotel, they first told us they didnt have any a/c rooms with two beds, which we had confirmed they had twice before we left. so carla and i have to get comfy. then, we got to our room to realize there is an elaborate key system that makes it so you cannot have the electricity on while you are gone, not a big deal, accept on hot days where it wuld be nice to be greeted with AC and that oh yeah, if we want to turn off the lights, the ac has to turn off too since none of the switches are actually connected to the light bulb--just to the superkey! we chose the airconditioning and sleeping wiht lights on since we were exhausted. but after a bit of rest, i awoke around midnight to find carla standing on the bed and desk unscrewing light bulbs. she is brilliant! i would have been sleeping with the lights on for three weeks without her. She also said something, but i can't remember what, that made me worry that our staying awake so long had caused permanent brain damage.
before we went to bed, carla and i decided to order food. poor delerious carla on the phone, lets just say that after a 20 minute conversation and four clarification phone calls on trying to order two items and two drinks... we got, half our food, he informed us the rest was still cooking. then he brought in the next order ten minutes later and the bill. then he brought the change 15 minutes later. then he came back to get the dishes. they don't like to knock here either.
now if we can just figure out how to get the hot running water they promised us...i think we will be okay.
okay, so it might sound like im complaining, but in my delerious state, i actually was enjoying the craziness of it. carla and i were giggling the whole time. when we first hit vellore it felt overwhelming, usually i get in "travel mode" when i get to another country but lack of sleep and food, made everything seem a bit surreal. its just about a different way of life, coming from someplace with a certain way of life and integrating, quick like, just takes being with it. but even if i usually consider myself travel savvy... a few things i learned... prioritize the basics when new someplace... sleep and food. they you can figure out the fancy stuff later...
but so far, today has been a blast. we both registered for our electives. This week, I am doing pediatrics. Next week I will be doing home visits and hospital rounds at the community health and development hospital. The following week will be at a rural location! i am really excited. everyone here is really nice, not just at the hospital, but also in the city. sure they want to sell you their stuff, but they are also willing to help you find something if you are lost, even if they don't speak your language or understand anything about you. Mostly, i would just describe the folks here as "curious", just like us. Even if they are staring at us, taking us in... we are staring back and taking it all in. in the end, its all the same. I keep my guard up, just like I do anytime I'm in a city, whether its New York or Belo Horizonte, but this is probably the most comfortable I have felt in a city. I'm excited to make this place home for three weeks. its very managable.
Well, this blog just came out as a regurgitation of events, not quite what I wanted, what I really wanted to do was tell you my thoughts on all these actions. my thoughts on dressing in indian clothes, being ethnically indian, but inherently american and here in this country as foreign to me as any other. but i think this blog came out the way that my first day felt, just event after event. so i'll get to the good stuff in the next one i suppose.
Saturday, January 27, 2007
my first layover
is in amsterdam where I am currently writing from. carla and i are sitting at opposing computers at 8am (we just paid 6 euros for very little internet time. i dont even know what the conversion rate is right now, ive really been in hiding)... really 1am in United States superpower time. Being awake right now really reminds me of being on call, you know, that slightly loopy, giggly feel.
so when i was packing i was weary of travelling anymore, after my interview trail of fire, but I woke up really excited. i finally get to work in the medical field in another country! i've been waiting forever to get to this point. I think i am also excited because this trip marks being done with my interviews, rank list, and all that. so i just have to wait till march 15th. this will make time fly!
so many people assume that because I am ethnically Indian, I will know what is going on. From my brief prior experience vacationing in Kerala 3 years ago, I can tell you that south india is basically a whole different world than the north india that I know from relative visiting, etc. Different language, culture, food, dress, religion, roads. So we will see if chennai and vell;ore are similar. We arrive in bombay next and have a 6 hour layover. before flying to chennai and then taking a four hour taxi to vellore. you want to talk about post call giddiness? this will be a whole new level of silly rupa.
I packed very light. A few pairs of pants and shirts and basics. I am going to dress in traditional indian garb while working. i brought my bro's digital camera (no i have not given up on film, just taking a break)so perhaps i'll post some pics. carla's travel blog is mytravelbabble.blogspot.com... for additional pics.
will write again when something exciting happens!
so when i was packing i was weary of travelling anymore, after my interview trail of fire, but I woke up really excited. i finally get to work in the medical field in another country! i've been waiting forever to get to this point. I think i am also excited because this trip marks being done with my interviews, rank list, and all that. so i just have to wait till march 15th. this will make time fly!
so many people assume that because I am ethnically Indian, I will know what is going on. From my brief prior experience vacationing in Kerala 3 years ago, I can tell you that south india is basically a whole different world than the north india that I know from relative visiting, etc. Different language, culture, food, dress, religion, roads. So we will see if chennai and vell;ore are similar. We arrive in bombay next and have a 6 hour layover. before flying to chennai and then taking a four hour taxi to vellore. you want to talk about post call giddiness? this will be a whole new level of silly rupa.
I packed very light. A few pairs of pants and shirts and basics. I am going to dress in traditional indian garb while working. i brought my bro's digital camera (no i have not given up on film, just taking a break)so perhaps i'll post some pics. carla's travel blog is mytravelbabble.blogspot.com... for additional pics.
will write again when something exciting happens!
Friday, January 26, 2007
tomorrow im off
i'm packing minimally, and yet travel preparations are always ardous.
i know i've only just finished my interview trail in the states and here i'm off again!
exciting!
driving to houston in the morning to meet up with carla. hope you enjoy sharing my adventures!
i know i've only just finished my interview trail in the states and here i'm off again!
exciting!
driving to houston in the morning to meet up with carla. hope you enjoy sharing my adventures!
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