Final Days in Dehradun

A lot of stuff happens here—odd encounters, ways of doing things that both baffles and amazes us (as often occurs when one is traveling abroad). On our first auto rickshaw ride to Dr.Vaish’s for instance, we saw a completely naked man walking down the road Bay to Breakers Style. He was acting completely normal and so was everyone around him. It turns out, most of us on the program have “spotted” this local celeb throughout town so I guess this is just his daily uniform.

On this same auto rickshaw ride our driver stopped (more like a running stop) at what can only be described as one of those “water” stations set up during a marathon or charity walk where cups of liquid are handed off to participants as they run by. India-style this consisted of a huge caldron-like pot of bright pink liquid being scooped into plastic cups and handed to drivers and passengers in auto rickshaws and vikram. Let’s just say we passed on the jungle juice.

June 18^th, 2008

Today we got to see a delivery and an abortion. Talk about the “circle of life.” The abortion was actually an evacuation of the fetus in a woman who had a missed abortion (the fetus stopped growing after 22 weeks). Then later in the day we saw a delivery. The delivery was not too much different than what I saw in South Africa. So I wasn’t too shocked by the lack of anesthesia and the violent pushing on the mother’s stomach to get the baby out. I was (and I never thought I would say this) shocked at the lack of basic sanitation techniques including the fact that some people were not wearing shoes, the rest of us were wearing flip flops and only the doctor was wearing gloves. I guess that is pretty much the standard of care here.

After the birth the mother was given some IV pain medications while Dr. Gera finished suturing and then she was not able to see the baby until the sutures were done. When the baby was taken out to see the family no one seemed very happy (and it was a boy—law in India prohibits a couple knowing the sex of the child prior to birth). We told Mrs. Mehta this and she was shocked—she said there is probably some good story behind why they reacted that way.

Because we waited for the delivery, we missed clinic with Dr. Vaish. But in the meantime, some more background on him. He is probably one of the best teachers I have encountered here. He explains everything in a clear and concise manner and has incredible clinical judgment and skills. Not to mention, he loves PA’s! He had a PA work for him for six months and he said she was much better to have around than another MD. Woo hoo.

June 19^th, 2008

Stop the presses. Leigh and I saw the coolest surgery today at Dr. Vaish’s. First at Dr. Gera’s we saw a breast abscess being drained and then another delivery. Then we went to Dr. Vaish’s and saw a premature baby with gastroschisis, which means it was born (they delivered C-Section) with its intestines contained in a sack adjacent to the umbilical cord. The coolest part of the surgery, in which they cut open the baby’s abdomen, was watching the surgeon pull the intestines out of the sack and then like magic they were back where they were supposed to be. I know this seems like it would be straightforward when you think about it anatomically but seeing it in person is a whole other experience. It was one of the craziest, coolest things I have ever seen. There are not words to describe it. The best news is that the baby looked great after surgery and the surgeon says her prognosis is good. She will remain on a ventilator and a special diet but the surgeon said her body should adapt quickly.

After clinic we had a quick late lunch and then went to Dr. Gera’s to get taken to a music/religious gathering of sorts. It was held at a family home close to our home stay. It was really cool. For most of it, since it was in Hindi, I had no clue what they were saying but the music and dancing were beautiful. It was incredible how welcoming everyone was to us. I can’t imagine a group of people being so open to strangers in the U.S.

June 20^th, 2008

Last day in Dehradun. I am very thankful to be here but I still find myself counting down the days until I get home. I am still grappling with this awful cold and the lack of sanitation is still hard for me to take. I understand the system is up against an environment of limited resources but I don’t think it is too much to ask all the people assisting on a surgery to slap on a pair of gloves.

We had our final meeting as a group today at the coffee shop to reflect on our expectations and how they turned out. My expectations were to get as good of an experience out of this trip as I did in South Africa. These were not exactly met. Maybe it’s something about South Africa or has to do with the fact that my program in S.A. was very AIDS/HIV focused (which I have a great interest in), but I felt so much more in need/demand there. Here, limited resources or not, the doctors are able to see an insane number of patients and provide them with great care with an admirable ease. I think the biggest difference between India and South Africa and even India and the U.S. is the respect the people have for their physicians. They trust what they have to say. They typically have a great, positive attitude going into the visit and there is rarely a sense they will question your basic treatment plan. Perhaps this is because they have to pay at the time of service for the lab work they get done so they think twice about running a battery of tests as we often do in the US? I know this definitely has something to do with it, but it is more than that. The people here really try to respect the physician and they seem to have a much healthier relationship as a result.

This weekend I am heading to Amristar with Jen and Val to see the Golden Temple and the Pakistan border. It will be another whirlwind trip but I am sure it will be worth it. I am about to book my plane, etc for the end of my trip, when I will be going to Varanassi with Sarah (who is from Maine). Apparently it is known for its silk and I can get clothes made there very inexpensively. Email me your measurements if you want me to get something for you. Thank you for all the comments. If you want to post a comment just look at the bottom of an entry and click on the comments button.

June 16th & 17th

We are back in DehraDun. It is amazing being able to stay with the Mehta’s again. Mrs. Mehta is like our mom and treats us like royalty. We all felt like we were “coming home” when we returned from Agra. When we told Mrs. Mehta we were going to make no bake cookies (they don't have an oven) for Varyun (our home stay brother) for his 17th birthday on Wednesday we asked if he liked peanut butter since we couldn't get marshmallows to make Rice Crispy treats. Mrs. Mehta said he really only likes American peanut butter, but "that is too expensive." None of us remembered how much we paid for the peanut butter. Everything is pretty cheap here so we aren't usually too concerned especially when it involves buying food like we get at home. When we looked at the price sticker and saw the price was 235 Rupees, about $5.50 (much more than even a very nice meal at a restaurant here) we thought about the price in Indian terms. A typical office visit with a doctor in private practice is 100 Rupees. Two KG of mangoes (or 4.4 pounds) is $1.25. So I guess that makes peanut butter expensive, but really not that different than in the states. It is funny to think of it this way since peanut butter and jelly sandwiches are generally thought of as a great economical meal in the US. This week we are on rotation with Dr. Nisha Gera, an OBGYN who runs her own outpatient and inpatient facility with an operating room. She is a very pleasant, personable, knowledgeable doctor in her late forties. She also offers us watermelon and coffee daily which is amazing. Dr. Gera has a large, primarily female, very capable and friendly staff. We saw several pregnant women today and got to listen to the fetal heart beat with our stethoscopes and see a few ultrasounds. The lack of HIPAA compliance in India is impressive and particularly shocking to be pervasive even in a private practice like Dr. Gera’s. For instance, a woman’s pregnancy test results (granted they were negative) were announced for the entire room of patients to hear. No one seems to be bothered by this. In fact, no one in India seems to be bothered by very much. While working at our second clinical site with Dr. Vaipin Vaish (a pediatrician who runs his own hospital with his OBGYN wife) we witnessed firsthand just how easygoing people here are. A young newlywed couple came in and the wife was complaining of fatigue and malaise, weight gain and her pregnancy test was negative. Dr. Vaish proceeded to tell her husband that she has “anxiety and depression.” During this explanation (medical terms in India are always in English so usually we can understand the diagnosis but not much more than that in a patient encounter unless the doctor translates), the husband, wife and Dr. Vaish were jovial and jubilant as they laughed and said, “Anxiety!” “Depression!” When Dr. Vaish said he would give her medications they rejoiced. Later a young boy (age 10) came in complaining of fever and headache and was unable to move his neck to place his chin on his chest. Suspecting meningitis, Dr. Vaish did a spinal tap. I saw a few spinal taps in South Africa but it is a pretty cool procedure to observe. The boy’s CSF (Cerebrospinal fluid) was clear, indicating it was not a bacterial infection. When Dr. Vaish went to tell the family the good news, he held up the test tube containing the CSF (to be sent to the lab) and everyone rejoiced that it was “clear!” Amidst the heat, honking, pollution, lack of basic sanitation, smells and general difficulty in logistics of living in India, many of us are finding ourselves worn down quite easily. I am surprised at how difficult this trip has been for me personally. In many ways I feel like the clinical portion is the easy part—the part I can control by applying the medical knowledge I have and adding to it the experience and lessons of the doctors here. The challenge lies in trying to survive here without constantly feeling like you are ready to go home and give up. Not too much is easy other than Pizza Hut, Costa Coffee (or Barista here in DehraDun) and the Mehta’s and it is clear how hard life is for the poorest people living here, especially when the divide between the rich and the poor is so great. This wears on you in ways that are difficult to verbalize and manifests in the form of a lack of energy. I keep expecting to wake up one day and LOVE India for the whole day and just be happy. Perhaps this will never be the case. This is hard to accept. There was a lot about South Africa that I found challenging but when I think about going back there I would get on the next plane out of here to work in a TB ward there. But South Africa had many parts that were like America and when you returned from work you could go “chill out” in a neighborhood that looked like Santa Monica. India is much safer and violent crime is not nearly as much of an issue so feeling safe pretty much everywhere I go and being able to walk around during the day alone is a big relief. I can’t help but wonder if the reason why everyone is so jubilant and upbeat here is because of how much it takes for them to get through a day here. Consequently, when their doctor has a solution to their health care concerns they are so happy it was “this easy.” I hope some of this resilience will wear off on me during the next three weeks. I know some already has, just not at the quick pace I would prefer it to.

Agra for the Weekend

We departed at 8:00pm on an air-conditioned overnight (10 hour) bus from Dehra Dun to Agra. Many of us were not feeling well, but decided to be as positive as possible and even made a list of Amazing Race-esque tasks we could complete for points and total them at the end to determine a winner. Ashley scored two points right off the bat when she threw up in the public toilet in the bus station "because it smelled that bad." Before we boarded we visited the Kumar Shop, which sells a lot of American products so we picked up crackers, dried fruit, cookies and Skippy Peanut Butter. I actually screamed (don't worry, not too loud) when I saw the chunky natural peanut butter. The bus ride was interesting…It was freezing because it was air conditioned and we sat at the front of the bus, placing us front and center in the action including a vomiting baby, almost uninterrupted honking and several extended stops (one for over a half an hour because of a "broken bridge"). Not to worry, our ride home made the bus seem like luxury travel. But there were may other goings in the 14 hours separating our two 10 hour journeys. We arrived in Agra at 7:00am to see the Taj Mahal. Admission was 750 Rupees for foreigners and 50 Rupees for domestic travelers. Nevertheless, it was worth the money. It is truly indescribably amazing. We did a lot of fun poses in front of the Taj. It's kind of weird and we haven't been able to figure out exactly why this happens, but wherever we go the local people love to take their photo with us. They LOVE it. Val is in particularly high demand for her blonde hair. We thought at first it was because there are not a lot of Caucasian people living in India but surely there are a lot visiting Agra to see the Taj. I think the strangest part about it is you get the feeling the photo you took with some man and/or his family will end up being framed in some house in India. Does that make us famous?

After we were sufficiently tired from the sun and heat at the Taj we decided to "explore the city." Cities in India are a bit different from most other cities because it is not always clear to us what area is the "city centre" or "good area". Accordingly, without a map or our guide book we were clueless. Luckily the owner of a hotel took pity on us and gave us a map and pointed us in the direction of Costa Coffee (India's Starbucks equivalent). He told us not to pay more than 20 Rupees for an auto rickshaw to get there. Pretty much anywhere you walk when you are white in India you will get constant honks, yells, etc. of offers for "auto rickshaw"? The drivers are not easily deterred. So when you finally do need a ride several drivers crowd around you trying to figure out where you are going and convince you they should be the ones to take you there. Fortunately this surplus of drivers allows you to barter for the best price. This time around we were all sweaty, tired and not in too much of a bargaining mood. So I threw up my hands in the middle of the crowd of drivers (once they acknowledged they knew where Costa Coffee was) and yelled, "40 Rupees for 2 autorikshaws!" And it worked. Annsley said she wanted me to start over and reenact it to be videotaped.

After a few refreshing iced drinks (made with purified water), we were ready to keep exploring. We went to a few government approved stores to look for gifts and then went to Agra Fort. We called Jade who was back at the Mehta's in DehraDun and had her look up a place for us to go to lunch in the Lonely Planet Guide. The South Indian restaurant served pizza and veggie sandwiches--both of which Jen and I split. Sorry I'm a bit slow on the uptake of loving Indian food for three meals/day.

Lunch was great and our next stop was the outdoor shopping bazaar. We walked outside of the restaurant to be met with a downpour of rain. Yeah for monsoon coming early! The outdoor bazaar was out. We went next door to a movie theater and realized there were no English subtitles and then before we knew it were starting to be encircled by people hanging out at the theater. It was probably one of the first times I really felt unsafe in India. In the middle of this crowd an auto rickshaw driver, who was very interested in getting me to shake his hand, approached me displaying handwritten notes and drawings from former customers trying to get us to take a ride with him. After awhile we decided he wasn't that creepy and when we told him we were looking to hire a taxi to go to DehraDun (no one seemed to know where we picked up the bus and we didn't want to wait for the bus and thought a taxi would be much nicer). Turns out, of course, he knew of just the place! We were taken to a nice store that provided private taxis and buses and negotiated a price for a Jeep for the 7 of us for $25/person (three times more than the bus). We discussed it and decided to go back to Costa Coffee, hang out, maybe get some dinner and then leave Agra so we would get back to DehraDun around 6am instead of 3am.

When we got to Costa Coffee we met a guy named Ned from Minnesota who recently graduated from Yale and has been traveling around Nepal and India for the past few weeks. It was great to exchange stories and also to hear that he thought India was "one of the hardest countries I've ever traveled in." I think all of us breathed a big sigh of relief on hearing this since so many of us felt the same way.

Our spirits a bit lifted we came up with the genius plan of going to Pizza Hut next door and having pizza and beer. Leigh and Val (and later me) did a little shopping and Leigh got a custom-made Sari! I got a few hand-embroidered tops. Beer was $1.50 and a medium pizza $5. Yep, that's right: Pizza for lunch and dinner, in India. In my defense, I got the spicy pizza at Pizza Hut.

We got in the taxi at 9:00pm, completely exhausted as most of us had not slept for the better part of the last 36 hours....and discovered our fare did not include AC. It must have been sleep deprivation that made us all feel it wasn't worth paying an extra $7/person for the air conditioning. Instead we "held our ground" and spent the entire ride with the windows down, wind blowing in our face.

This would not have been so bad if it were a pleasant evening breeze. Unfortunately in India where trash fills entire rivers, lies in bins by the side of the road and lies in piles by the side of the road almost EVERYWHERE, a pleasant breeze was far from what we experienced. The smell can perhaps be understood best by those who have traveled on highway 5 in California and passed by Harris Ranch. Let me put it this way…the Harris Cattle Ranch smells like fresh cut flowers in comparison.

Our driver, Hrinder (yep, another “rinder) spoke ZERO English. This was particularly helpful when we realized he was going through Delhi to reach DehraDun, the exact “dangerous” route we were explicitly instructed to avoid. This wasn’t so bad though until we realized Hrinder had NO clue where he was going. We were literally driving though a ghost town and then what I can only describe as what looked like a skateboarding park with walls on either side of us. We tried calling the owner of the taxi company but he didn’t answer. We got directions (or handy Hrinder who always drove off about 2 seconds before people were finished explaining where to go) from about 6 different people until he finally got on the right road.

The drive continued and without any desire or calm conducive sleeping environment, we came up with ways to deal with the wind whipping our face and the putrid smell. Annsley’s invention was to take her T-shirt and wrap it around her head to get her hair out of her face and to cover her nose. I took this to the next level with my long sleeve Henley by buttoning the front over my nose and using the sleeves to cover my mouth. I don’t think I have ever been so happy to essentially be wearing a burka.

Ten hours later (not bad time considering the detours), we arrived at the Mehta’s. I slept about 2 hrs total during the last 48 hours so I ate some breakfast, showered and did some laundry and then passed out for 7 hours. But it was all worth it to see the Taj. Now we are talking about going to Amritsar to see the Golden Temple next weekend which will include 12 hour journeys each way. Insane? Check.

Than Gaon Continued

June 12th, 2008Today was a short hike to the health camp, which was held in a village directly neighboring Than Gaon. We saw A LOT of anemia. I asked Dr. Paul if this was due to the vegetarian diet that most people here adhere to. He said no, it was more likely due to poor nutrition and hard labor. One of the patients we saw was 100 years old. She was walking like she was 60 years old. Her only living relatives are her granddaughter and grandson who she lives with. Her chief complaint was weakness and her diagnosis was hypertension and anemia. Pretty good for 100.

It started raining really hard after her visit, but thankfully let up in time for us to make the walk home without getting soaked (which is mostly a problem because the sun never seems to be out long enough for our clean laundry to dry so none of us could afford to have anything else wet).

We had the rest of the day to hang out and it was beautiful outside. We got a lesson in cricket from the guys who work at Nature Quest. JP was pretty much the only one who didn’t have to have the ball thrown at their bat to get a hit, but it was a lot of fun nevertheless.

A few days ago we caught Dr. Paul at a vulnerable moment and convinced him to let us have a bonfire. Our agreement was that if I could get Rahul, one of our local coordinators, to buy the supplies for Smores we could have a bonfire. Unfortunately due to fuel shortages and the high temperatures in India, marshmallows are no longer a cost effective item to bring to Dehradun. Yes, this is a true story. Rahul and Jade were nice enough to buy us some delicious Lindt Dark Chocolate bars and bananas though so we roasted those around the fire and put them on Digestive biscuits.
June 13th, 2008
Our final day at Than Gaon and our final yoga session. Dvrinder, our yoga teacher told us something very wise about practicing the breathing techniques he taught us during the week, “God gave you breath and you should use it. I know you are busy medical students and when you get busy you forget to take deep breaths. But think of it this way, how do dogs breathe? They pant and take short inhalations and exhalations and they never live more than 10-12 years.” What a great way of thinking of it.

We got to see the little girl with the burn on her head again and her wound is continuing to heal. Val and JP had a good laugh on my part when they said a patient looked just like me. She went behind a curtain so the rest of us couldn’t see her for a few minutes. When she came in to see Dr. Paul she had a visibly swollen eyelid from an infection. This was a comparison to my bug bitten eye on the first day. Thanks guys.

This week was a tough week for me. I loved Than Gaon but I had a fever most of the time that wouldn’t quit and then got an upper respiratory infection. Dr. Paul, our wonderful healer, gave me some Ayurvedic medications (and I took antibiotics) which definitely helped. In some ways I was happy to be sick not from food-related causes, as nearly everyone else on the trip has experience.

After seeing patients Friday afternoon, Dr. Paul took us on a tour of the farmland and showed us all of the different plans and explained their uses in the Ayurvedic medications he makes. It is incredible how many medicinal uses one simple plant can have.

We said our goodbyes and then took the treacherous jeep ride back down to Dehra Dun, which consisted of driving down literally slate rock n a windy road. I came up with the idea of thinking of it like an amusement park ride, a la Indiana Jones and that we were on a track.

Week 2: Than Gaon

June 9th, 2008
Our first day in Than Gaon. We are all staying on the Nature Quest property (which works with CFHI and is based out of DehraDun) in three small "cottages" with twin beds and most importantly mosquito nets. The power is unreliable at best and we eat all of our meals outside, but it is beautiful nonetheless and is like luxury (kind of) camping. Mostly everyone seems happy to be away from the city and the honking.

The clinic where we are working with Dr. Paul is also located on the property. The clinic is fully funded by CFHI and this is readily apparent: The sanitation practices are definitely more widely enforced (Dr. Paul cleans the thermometer after each patient) and there appears to be an ample inventory of medications and medical supplies. The patients who come here receive their care and medications at no cost as a result of the funding from CFHI.

Dr. Paul has been the only practitioner here for the last six years. His previous medical background includes working in every village in the state of Uttranchal where we are staying. At his clinic here in Than Gaon he sees patients from nine surrounding villages, some of whom have to make a 7-10 hour journey by foot to reach him (we are about 1.5 hours drive from DehraDun but most of the people living in this area could not afford transportation to DehraDun let alone the cost of medical care). Dr. Paul practices a blend of Western and Ayurvedic medicine. The Ayurvedic medications he gives to his patients are primarily manufactured using the plants and trees that are planted on the Nature Quest property.

Dr. Paul sees patients in the clinic on Mondays, Wednesdays and Fridays and travels to the outlying villages Tuesdays and Thursdays. He has an in-patient bed in case a patient needs to stay overnight or if he has to deliver a baby. Dr. Paul stays in Than Gaon Monday-Friday and then returns to his wife and youngest child (who is in High School) on the weekends.

The first patient we saw today was a young man (late 20s-early 30s) who had fallen on his face while suffering a seizure. Dr.Paul put him on seizure medications and told us how patient compliance is a problem with patients like this because when they don't have seizures they decide it is no longer necessary for them to continue to take their medications. Dr. Paul typically puts his epileptic patients on these medications for three years. Even though the medications he prescribes can be obtained for free, patient education and follow-up is key. So really, not that much different than in the US!

There were many patients, particularly children who came in with coughs and colds. The monsoon season is starting earlier this year and with this change in season comes an increase in colds. This influx of patients gave the six of us ample opportunities to practice our lung exams!

One woman came in complaining of lower abdominal pain and pain with urination. Dr. Paul determined she had a Urinary Tract Infection and prescribed an injectable antibiotic and lasix (a diuretic). I thought this was interesting, lasix for a UTI? Of course I called my stepdad/physician/professor (along with my wonderful PA mom) and asked if he agreed with this treatment plan after I gave him some background on Dr. Paul. In typical John fashion, he paused and said, "Interesting." He went on to say this was probably a great treatment plan for this particular patient to facilitate emptying their bladder (when the kidneys are not involved) in the face of a questionable availability of clean water. In his own words, "These physicians who are healers and use the combination of Eastern and Western medication to individualize their treatment plans are definitely onto something." So if you see John planting some herbs out back at Aegis not to worry.

It is very interesting not only seeing how a well-funded, well-run free clinic in a rural area can operate, but also how Dr. Paul is able to integrate this Eastern and Western approach to medicine. How incredible it is for him to give his patients medication that he makes himself, furthering strengthening the ever-important bond between physician and patient.

During our afternoon break I got to take a nap. I don't remember the last time I took a nap in the middle of the day! We ended the day with evening yoga with our yoga teacher, Dvrinder (who lives in Rishikesh--where we were last weekend). It was so relaxing.

June 10th, 2008
We started our day with yoga at 6:30am for a more rigorous yoga session than last night's relaxation yoga. Poor JP, the only guy who is in our group was having some trouble with his flexibility (and with having to be surrounded by 5 girls all day), but he was a trooper and hung in. The rest of us did well, struggling mostly not to fall asleep during the visual relaxation portions of the yoga session.

After breakfast we went on a two hour hike to the village of Numiyas. It was only about a 1.5 hour hike but we had to stop frequently to allow the man carrying the medical supplies (around 50kg in a backpack) to rest. It was an incredible hike. The views of rolling green hills, farm land, cows, goats and even a 2.5 foot long lizard made the journey unforgettable.

There were not a lot of patients to see, but it was a learning experience nonetheless in seeing how a travelling medical clinic is run. There were a lot of children with a build-up of ear wax--so not too different from Aegis.

We were served tea and cookies and packed lunches of chapati (kind of like tortillas) and masala dosa, yes we are spoiled. When we returned home Jen and I had a chance to sit down with Dvrinder, the yoga teacher, and pick his brain about where to travel and what not to miss. This weekend we will be going to Agra to see the Taj Mahal!

After dinner Dr. Paul announced that one of the workers (Omrinder) is celebrating his one year wedding anniversary and we had soda (Coke and Limca--kind of like Sprite) to toast the occasion. Somehow we got into a discussion about how everyone's name at Nature Quest has a "rinder" in it. We could not stop laughing, not only because probably 90% of the time we pronounce every name of everything wrong, but also because we started coming up with all different ways to use "rinder" as a name...."mmmmmmrinder" "grrrinder" you get the point. Dr.Paul caught on and started to name off all the "rinders" in the village including "Omrinder, Dvrinder, Mrinder, Grinderrinder, Hrinder." At this point Dr. Paul had introduced everyone other than the cook so we asked him what his name was. Dr. Paul responded, "Him? That's Baboo." Our laughter was uncontrollable, however this seems to be status quo around here with Dr. Paul's elaborate stories and phrases.

For instance, on Monday Dr. Paul had a patient come in complaining of right shoulder pain. Dr. Paul told us how the man had an 8 foot long snake wrapped around his leg and how he killed it. He explained the man was plowing a field and felt something near his abdomen and looked down and snake was wrapped around his entire leg. He proceeded to use a piece of the plow (unclear which piece) and use it to stab the snake and kill it. Of course we didn't believe him for a second so we asked Dr. Paul to ask the patient to show us with gestures what happened to him. Sure enough he acted it out and later the story was confirmed by another worker. We asked him why he was here for shoulder pain when he had fought off an 8 foot snake. Dr. Paul responded, "This is man, not Tiger." We all could not stop laughing. This proved to be one of many Dr. Paulisms that were quoted throughout the week.

June 11th, 2008
Today we were back in clinic and got to see a few patients we had seen on Monday. One was a 1.5 year old girl who had fallen into the fire while her mother was looking away to tend to her other child. The girl's parents took her to a clinic closer to their village and paid for the burn (which included most of the back of her head) to be dressed and treated. It was not done correctly and got infected. It was so bad according to Dr. Paul that when he first saw her all he had to do was press gently on the wound and pus came squirting out. The girl's father now makes the 3 hour each way journey to see Dr. Paul every two days for dressing changes. Her mother is nine months pregnant. The girl's wound is still extensive, but looks impressively better than it did on Monday and appears to be healing well.

Dr. Paul had a wide variety of patients coming in today: People with diabetes for medications, fungal infections, anemia, a family with an allergic reaction a plant "in the jungle" and a boy with flatulence. Dr. Paul's response, "Gas is expensive in India."

We had a chance to ask Dr. Paul more questions about Indian culture. In particular we asked him about the marriage practices. He told us the marriage age of women depends on their education background. If a woman is well-educated she will most likely not get married until age 25 when she has finished school and "got settled"/started a career. If the woman is uneducated (and likely to live in more rural areas) they get married as young as age 15. The legal age for marriage in India is 18 for women and 21 for men, but if they are younger and living outside of the city as Dr. Paul says, "Who is there to report them?" Then he told us about marriage practices in Rajikstan and how women as young as 10 years old are "promised" for marriage. He also told us how in Rajikstan when a husband dies his wife must be cremated with him "by the river." We are not sure if this is the case, but it's pretty crazy to think about either way.

After lunch Jen, Val, JP and I decided to walk with one of the workers to the "river." I don't know if it is an American thing but the four of us were picturing this easy river stroll. This was not the case. The stroll consisted of 30 minutes of hiking on an almost entirely steep downhill, single track, rocky pathway for half an hour. But the river and the huge rocks we got to sit on and cold, clean water were well worth the effort. Val and I both felt a bit sick we think mostly due to the heat. I don't think I have sweat so much my entire life as I did these last few weeks.

More to come tomorrow...

Wednesday-Sunday

I just returned home to Dehradun from being away in Rishikesh for the weekend and of course forgot my notebook, but this is a brief catch-up of the happenings here in India:

Wednesday:
Today while reviewing EKGs with Dr. Joshi he noticed a piece of paper Dr. Gandhi had written on with drawings of ST elevations. He recognized Dr. Gandhi’s signature fountain ink pen writing and asked, “Did Dr. Gandhi give you that?” I think he was a little jealous so he proceeded to make us drawings throughout the day, ensuring we held on to them…duel away my friends, it is only to the benefit of Leigh and I!

At the end of the day, we saw quite a few echoes done. This time there was a baby with Down’s syndrome and a few patients with rheumatic heart disease (caused by a strep infection that can infect their heart muscle). One patient even did a non-pharmalogical, stress (or treadmill) echo. Leigh and I were quite confused after Dr. Joshi said a few words to the patient and the patient proceeded to jump off the exam table and briskly walk up and down the hall of the ICU for about 10 minutes. It took us five minutes to realize this was the Indian version of a treadmill echo. Just yet another example of “Green”, cost-cutting Indian healthcare.

Today is Leonard’s birthday. Yesterday a man told us that he wants “Anan Fam” (unsure of spelling) which in Hindi means “quick and easy death.” Leonard lived an incredible life and left this world as peacefully and beautifully as he entered it. Happy birthday, Leonard.

Thursday
One of the many differences between the US and India is the fact that, as I stated before, 99% of marriages are arranged. This really seems to make a difference in the management of healthcare in India. There is almost a calmness around a family conference involving a medically-complex patient, as if the people here are secure they will be taken care of. One of the best examples of this is the previously mentioned baby with Down’s syndrome: Her parents were almost proud of her, telling Leigh and I, “She is weak” and smiling. There is so much less stress about how a person will be cared for, perhaps in part due to the intricate family network. It is very humbling that a population of people who work so hard and endure beyond difficult living situations are so at ease with one another.

Friday
Today while waiting for Dr. Gandhi to finish up with a few patients in the ICU, Leigh, Valerie and I had a chance to sit down and talk with two of Dr. Gandhi’s patients who were also waiting for him. The husband and wife both spoke English very well and were eager to hear our thoughts on Obama and the differences in the healthcare systems of the US and India. They could not believe how much it cost for us to get lab work, x-rays done and were astonished by the monthly costs of our healthcare premiums. In India you can get a CT scan done for less than a $100. We were all joking that we should get a full body MRI just to see what it would show. They seemed indifferent about Obama and were more interested in our thoughts on the matter. Of course I am thrilled, but also skeptical of what November will hold. Here in India the concern seems to be more with the US’ trade relations with India so that this country can be more of a competitor to China.

Today we had our weekly meeting with the other 8 students who stayed in Dehradun this week. The reports from most people included their surprise at the lack of sanitation in India. Leigh and I have not had a chance to see any real procedures but we were surprised to note that we have never seen the doctor’s wash their hands in spite of the hundreds of sick people they come in contact with everyday. Others spoke of wearing flip flops in the exam room, the reuse of gloves or the overall lack of wearing gloves (including during a delivery of a baby) and rarely if ever seeing anyone wash their hands. This is definitely a difficult sight to see considering all of the patients we see who have conditions caused by exposure to infection, not to mention what stark contrast this stands with the somewhat obsessive practices of the US (which aren’t always that great either). That said, we are all here to see how a medical system can function in a large population with very limited resources. Perhaps this is one of the ways they are able to do it.

Saturday and Sunday
We left Saturday morning for Rishikesh and took a public bus, which cost less than $1 for a two hour bus ride. It was so crowded it was incredible. I can’t wait to put the photos online! There were 14 of us who went there so it was quite the crowd of white people. Rishikesh is more of a tourist town so there were more white people, but that didn’t seem to cut down on the number of stares or the amount of people asking to take their pictures with us.

We got to go river rafting down the Ganges River, some of the rapids were even class 4! It was so much fun! We all got out of the raft and body surfed down the river and jumped off a cliff. It was incredible. For dinner we were fairly sick of India food so we found a “Health Restaurant” where this man cooks all of the food and I had vegetable PIZZA (!!) and other people had home made spinach pasta with veggies. We went there again this morning and had buckwheat pancakes.

We got to attend a Hindi religious mass at 6:00pm where there were a ton of people because some prominent politician was in town. It was a huge crowd of people all pushing to take photos, but it was gorgeous to watch and hear everyone sing (even though we had no clue what they were singing about). In true American style (and my style) I completely embarrassed myself. People were passing around these gold three-tied plate things with a handle that had literally fire balls in them and people were sticking their hands in the fire to “purify” them. I touched the gold handle and before I knew it, it was handed to me. I didn’t know what to do so I tried to hand it off and in the meantime one of the balls fell out and this guy goes to pick it up and then stands up and knocks the gold thing and balls of flame go everywhere. Excellent. Always good to keep it low key and not stand out in a crowd. Right.


This morning we went on about a 3 hour hike to waterfalls in Rishikesh and it was so beautiful. For awhile we were the only ones there so we actually got to swim a bit and take off our t-shirts and be in our swim suit tops which felt so good. Women here do not wear shorts or tank tops, in fact there were women going rafting in their full sari outfits! So in 95 degree weather it gets old quickly wearing pants and t-shirts with sleeves.

Okay I have to sign off, but next week when I have internet I will write more. Today I am off to ThanGaon to work with Dr.Paul and trek to local villages to provide health care. We also have daily yoga at 6am. It will be a nice change from the fast past of Dehradun (and an escape from all the honking!).

Miss you all lots.

Happy 25th Birthday to Me

Happy 25th birthday to me! Thank you all for your calls, cards, e-cards (sorry I couldn't open them, the computers are outdated here) and emails! Yesterday I tried to post this blog and the internet went out for "10-30 minutes" which in India time means it may not come back for hours so I lost everything I typed and probably won't be able to look at emails until this weekend or week after next...I will try to keep up with my blog though. Next week I won't have any Internet access FYI...onto my blog:

We started the morning with Dr. Joshi in the ICU on his rounds. The way he distributed medications consisted of taking pills out of plastic boxes sitting, unlocked, at the nurse's station and giving them to the patient. We saw a patient in the ICU who had an MI (heart attack) the day before. I asked Dr. Joshi if they had a cath lab, he responded, "Only in Delhi" (a 10 hour bus ride away).

In spite of Dr. Joshi's heavy patient load, he took the time to go through how he treats the hypertensive patient. He explained the different classes of anti hypertensive medications and when they could be used, the side effects, etc. At the end of the day he let me do an echo! Obviously with his help, but still I got to hold the probe and do it myself.

Dr. Gandhi was in a much more talkative mood today. We spent over an hour with him talking about his childhood, medical school and the evolution of his clinic. He grew up in a one room house with 5 siblings and his parents. He told us how he preferred life on the street to reading and doing his school work and therefore received low marks in school. As the eldest child his father was upset about his poor academic performance so he asked him what he was planning to do with his life if he continued on this path. Dr. Gandhi answered that he would probably wait tables in the morning and evening so that he could nap during the day and make enough money to make ends meet. The next morning he woke up to a vegetable cart outside of his front door. His father asked him if he wanted to sell vegetables instead of going to school. Dr. Gandhi, eager to be allowed to miss school said yes. This infuriated his father and he proceeded to beat him up. When Dr. Gandhi started to run down the street his father threw a pair of scissors at him and punctured his lung. When they arrived at the hospital his father was crying and said he was upset that he was throwing his life away. At this point point he took a step back to evaluate why his father was acting this way and decided to give school a try. He improved so much in school that his teachers thought he was cheating! He then decided to go to medical school. The school he applied to had 1.5 million applicants and 110 seats. He started the clinic/hospital he runs six years ago. At the time it consisted of a single exam room where he did everything and also where he slept at night on newspapers on the floor. Today he has a staff of more than 15 people, 16 in-patient beds and he is planning on opening an Operating Room and Echo room in the next week.

Dr. Gandhi said his secret to practicing successful medicine is ABC: Availability, Behavior and Competence (in order of importance A being most important). He gives all of his patients his cell phone number so they can call him anytime of the day or night. He told us this is half the battle of providing good care. According to him, most of the time a patient just wants to be listened to so if you are available and your behavior reflects active listening they will feel better. He said often times when a patient comes to him for a second opinion he does not change their plan of treatment he merely reassures them to give the medication or lifestyle changes time to work. Lastly, Dr. Gandhi emphasized that your gut is better as a diagnostic tool than your brain so competence is not the most important aspect of practicing medicine.

We asked him how his wife felt about his hours. He said she comes to the clinic for a few hours in the afternoon and then they have dinner together (around 1:30-2:00AM). His marriage, like 99% of marriages in India was arranged. He said most of the time these work out not only due to a bit of luck, but also because of a little patience on the part of both the husband and wife. Perhaps this is the way to go...just kidding.

On to the birthday celebration...Jen bought a cake, Indian sweets, heart-shaped balloons and a Dora the Explorer hat (with the help of J.P. and Leigh) to mark the occasion. An uncle (Shylender) was visiting from Delhi and he apparently LOVES birthdays, in his own words, "365 days is too long in between birthdays, I wish it were more like 165 or even 125 days!" He speaks very good English and has two children who attend college in the US. The party started with the singing of the Indian Birthday Song which consisted of singing and blowing out one candle and cutting the cake. Then a piece of cake was cut off by Uncle Shylender which he proceeded to feed to me, then I had to feed a piece to a friend (Jen). More singing ensued and then more feeding people cake and then the last candle was blown out. My Mom and Dad, who called in the middle of all of this celebrating, can attest to the joyousness of the occasion as I could barely here them on my phone.

After the cake was eaten and sweets were tried, Uncle Shylender insisted we "get the party started! We must have more Whiskey and beer!" He insisted we start dancing and then asked us if we wanted to listen to a CD had in his car of "90s hits from USA". We agreed, but did not realize this involved going outside to his car to listen to the CD...He proceeded to turn on his stereo as high as the volume would go (this is at around 11pm) and shouted: "Dance party, dance party on the car!" I thought Mrs. Metha was going to have a heart attack. We convinced him to bring the music inside after Leigh showed him how to eject the CDs. These CD's consisted of a three disc set by the name of "College Hits" which had a color photo of a pint of beer on the front and included songs like Karma Chameleon, Crazy Little Thing Called Love...

When we got back inside the dining room table had to be moved to make way for a dance floor which then moved to dancing on the chairs: "Don't worry! If we break the chairs we will buy a new set! We must have a dance party!" Mr. and Mrs. Metha joined in on the dancing and I even convinced their son to dance with me for a few seconds. Uncle Shylender then wanted everyone to dance on top of the table, but was appeased with only me getting on it for a minute. It was really a memorable birthday.

Jen, Leigh and J.P. all agreed that they were glad it was my birthday so they could witness such a celebration.

First Day of Clinic: Dr.Joshi & Dr.Gandhi

Today Leigh abnd I worked with two cardiologists. We spent the morning (10:00am-2:30pm) with Dr. Joshi, a cardiologist at Government Doon Hospital. To get there we took a Vikram which is like an auto rikshaw (tuk tuk) except it seats "8 people"--or sometimes 12. It is a cheap way to get around, costing 4 Rupees one way for a 30 minute ride (40 Rupees= $1).

Dr. Joshi is a very nice man in his mid forties. During the three hour period we saw patients in the OPD (Outpatient Department) he probably saw more than a 100 patients. By his estimations, he sees around 250 patients per day. Talk about a man with multi-tasking skills. All of my knowledge from Dr.Morelli, Kate and John was really put to the test. One of our first patients was a 22 year old female with cardiomyopathy and aortic stenosis that radiated to her carotid artery. It was an incredible case for me to see and hear, as well as for Leigh who is entering her senior year of undergraduate and is an EMT, on our first day. This was one of the many patient who we saw who had cardiomyopathy. Dr. Joshi joked that if we wanted to be heart transplant surgeons, we would never be in need of work in India due to this prevalence of cardiomyopathy. We didn't get much other explanation about why there is such a high incidence in India but I'm sure we will by the end of the week.

It was incredible how much respect the patients had for Dr. Joshi. As we walked the hallways, people would clasp their hands together and bow their heads as he walked by. In addition, on the whole, patients were extremely patient and waited their turn one by one to see the equivalent of the M.A. and then the doctor. This usually looked like about 15 patients all in a room smaller than the room at Aegis waiting and then Dr. Joshi at his desk and Leigh and I sitting next to him. And we thought Aegis was crowded and chaotic! Luckily, patients carry all of their own medical records/charts in plastic bags with them which really cuts down on that whole filling process we seem to get bogged down with in the states. Did I mention HIPAA? It is definitely not in existence here as most of the patients are privy to other patient's encounters with the doctor.

One of the biggest challenges Leigh and I faced were the language barriers: Not only that the patients primarily speak Hindi, but also that Dr. Joshi has a thick accent and the inflection and stress of vowels and consonants is completely different so a lot of the time we would say what we thought we heard, he would shake his head and then say exactly what we said with a different order of words and inflection. In addition, many names for diagnoses in India are different than in the states. For instance, one patient had A.N. or "Anxiety Neurosis". Dr. Joshi explained that this is what they call "depression" because "if you tell a patient they are depressed, they will be depressed. No? Instead you tell them they have a nervous problem in their stomach and they feel better."

Something that did not differ from the US was the prevalence of pharmaceutical reps: They were the same well-dressed, good looking people they tend to be in the US. The difference is they come into the crowded room, flash some fliers at the doctor and then leave samples on his desk. The only problem is, all of the drugs have different brand names and they rarely write down the generic so trying to figure out a patients med list is nearly impossible.

At the end of OPD, at 1:30, we decided to stay and watch Dr. Joshi do echos...yep he does them himself. We saw a patient with dilated cardiomyopathy who had gross aortic dilation on echo. Dr. Joshi said he had never seen such gross dilation of the aorta in his practice. He explained this could be either due to a congenital defect or a symptom of syphilis.

We took a vikram back home and as usual it was an interesting ride. Not only are the number of people on the street incredible, but the sights and smells are definitely like nothing I have ever seen before. These include heaps of garbage with pigs eating it, cows walking along the road, "rivers" full of trash, stores of all kinds--wood working, steel shops, repair shops, fruit stands...talk about sensory overload.

We started with Dr. Gandhi at 5:00pm in the hospital/clinic which he runs. He is also a cardiologist but because he is the only doctor in charge of this 16 bed hospital and clinic he sees a lot more than heart problems. His typical day runs from 8:30am-2:00am. Many people travel more than 10 hours to see him. Our first patient encounter was definitely interesting. A family consisting of a grandmother, two daughters, a son in-law and a grandson came into the office to discuss the health of the grandmother. When this was done, the rest of the family proceeded to have "their" visit with Dr. Gandhi. Dr. Gandhi explained later that this was common practice, often the choice of a doctor is on an entire family basis. In Dr. Gandhi, the cardiologist's own words, "It is difficult to be a specialist here (in Dehradun). Maybe in Delhi you can be one."

We stayed with Dr. Gandhi until 9:00pm. He said he would be seeing patients until 11:30p.m.

When I returned home, I received a phone call from my Mom informing me that a wonderful, kind-hearted, intelligent, talented, Renaissance man, Leonard Prossor passed away. Leonard meant so much not only as the love of my grandmother's life, but also as a grandfather to her grandchildren. He had such a big heart and sharp wit and he was such an incredible writer. My blog is dedicated to you Leonard, I know you are reading it from a much nicer place now. Tell Greaty I say hi.

First Day in Dehradun

Not sure how long I can write for because it is getting late here.

Last night I met up with the rest of the students at the Airport Hotel. On the way, my taxi got a flat tire and we were stuck on the side of the freeway for over an hour. Nevertheless, I made it back safely to...ummmm...the airport hotel. All of the people on the program are very nice--but it makes me miss all of the people I was in Durban with! During the middle of the night my roommate for the night, Will came in from his flight and at this point I realized I had a bug bite on my eyelid. I woke up this morning to my eye being completely swollen: So now I will be known as "that tall girl with the swollen eye." Of course the one medicine I forgot to bring was Benadryl...oh well.

Benadryl would have been helpful on the 10 hour bus ride from Delhi to Dehradun today though. We left at 5:30am on a bus--all 24 of us and 10 hours later reached our destination. We saw so much of the country side, it was incredible. The roads were basically okay most of the time (AKA paved) and a bit sketchy when we were going up the mountain, but passable for a bus so clearly not that bad.

Myself and three other students are staying in one homestay in Dehradun and another four are at another homestay. The rest of the group are at other clinical sites. This week I will be rotating with two cardiologists (my favorite first!) with a pre-med student Leigh (who is also an EMT).

The family we are staying with is very nice and tonight we had an excellent dinner of rice with vegetables, spicy green beans, chick peas in a curry, cucumber and watermelon (because those have a peel and the knives are sterile). It was amazing. I am not sure what to expect tomorrow at clinic, this will be quite different from South Africa in the lack of focus on HIV/AIDS health care but I do not doubt it will be just as interesting.

My 25th birthday in on Tuesday, if anyone wants to call me in India we are 12.5 hrs ahead and my number is 091 931 909 6146 or of course an email would also suffice. Miss you all, thanks for the emails and comments.