R&R

The team is off in Mumbai for the weekend. I am told they went to the Elephanta caves today, something I've always wanted to see ever since reading the associated Amar Chitra Katha as a kid. I am taking a day off myself tomorrow to spend with my family here in Hyderabad.

On the gastronomic front, now that I am back on a regular diet (more like soft mechanical with aspiration precautions) we had another dose of Indian Chinese Wednesday night. It wasn't the best, but I am definitely going to miss that stuff when we get back to Cleveland. Have also been having guavas daily. Still in search of the elusive sapota.


I spent some time today with a social scientist who has done some pretty cool work on HIV prevention. This brings my perspectives on HIV care in India to five: a government-sponsored center for antiretroviral therapy, a tertiary care, academic referral hospital where patients pay for everything before its done, a private "corporate" hospital that serves the upper middle to upper class, a non-governmental organization, and today's social scientist. Each perspective has its unique aspects, but there are some themes that cut across organizations. Everyone thinks that the HIV problem here, despite the recent reduced estimates in prevalence, is spiraling out of control. Everyone also agrees that there is a ton of money floating around, but little accountability for how it is spent. I am surprised to see the universally negative feelings toward most NGOs. The glaring exception, of course, is Sivananda. Opinions on them range from: "they are in it for the money" to "they want to convert people to Christianity" to "they are incompetent". Nobody is particularly happy with the government response either, calling it a bunch of hand-waving. For my part, I am happy to have met people both in the government service and in the private sector who are really devoted to the cause.

Another common complaint here is about the brain drain. This is an often devastating problem in Africa as well. It is interesting to see that in India, this applies disproportionately to physicians. The boom in the tech industry has led to IT people who stay here leading extremely comfortable lives. This obviously does not carry over into medicine, so a lot of people are always finding ways to go overseas. Despite this though, we have come across some incredibly intelligent clinicians.
I feel like working with these guys for a month, in a resource-limited setting where you can't just blindly order tests, would be an invaluable, required rotation in an internal medicine residency. For attendings like me too!
Finally, in answer to the query about tea, if you are only getting tea twice a day in India, you are getting shortchanged. We have had tea pretty much 4 times daily here. Plus coffee. Nice.

Lecturing and such

While the team has been seeing cool clinical stuff, I have been spending my time lecturing, networking, and writing concept sheets for grants. Clearly a different experience, but just as educational. It has been an exhausting first 10 days for me, but I am content to know that I have accomplished a great deal in that time. I have given 5 lectures so far, with 3-4 more to go. Being a faculty member, lecturing is certainly not a new concept to me, but maintaining relevancy of my message to persons whose clinical experiences are so far removed from what I see has been a neat challenge.

Now speaking of lectures, today I had to give a talk on HIV drug resistance. Given the state of my exhaustion and some major abdominal pain I have been having, the team decided, on their own, that they would prepare my lecture for me. Over two nights, these guys researched antiretroviral resistance in textbooks and on the Net and put together a pretty impressive talk. I delivered it today with minimal modification and it has easily been the best received of all my lectures so far. So a pat on the back for my peeps here; they are truly the best, and I was very touched at their generosity. More that that, thought, it was fascinating to see the enthusiasm, teamwork, and brain power on display over the past two nights. My fellow travelers have blogged a bit already and have talked quite a bit about the opportunity to just learn, without interruption or any other pressure. Watching them work with such focus, such motivation, and actually seem to have fun doing it was completely unexpected, given that when assigned something like this most of us tend to groan. Now this response from them could clearly be just a reflection of the magnitude of my pathetic appearance, combined with some obviously humanitarian tendencies of this group. Part of me does like to think, though, that they actually learned a lot from going through this self-assigned exercise. I feel like I have witnessed learning in its purest form, driven entirely by the learner. Maybe there is a model there for medical education...

For those concerned (Amma), I have pretty much recovered from my aforementined GI ailment and am back to eating stuff I have no business eating. Today was a banner day, with notable items including avakaya , hot pepper bajjis, and guava. No sequelae to report. Feeling great. Although...I do have two lectures early next week...hmmm...I wouldn't be surprised if I had some more abdominal pain starting Sunday afternoon or so...

New Perspective

Hi everybody,

Hope you all are doing well back home. We're all doing well, and I think I speak for everybody when I say "THANK YOU" to all of you for being so concerned about us. Hearing from all of you has really meant a lot to each one of us.

I think I also speak for everybody on this trip when I say that our experiences over approximately 10 days have really given us some new perspective in a lot of different ways. I think you have all read our blogs from last week regarding our excitement for some of the programs here that really amazed us with their efforts, so I don't need to say more about that aspect of new perspective.

This past weekend, the blasts definitely had their impact. It really is quite a different experience to read or watch the news on CNN each day and hear about the 30 or 40 people across the world who died because of blasts compared to when you're actually in the city where the blasts took place. You see and feel the effect on yourself, the people around you, the city as a whole. This morning, we were scheduled to go to one of the 2 hospitals where a lot of the victims had been taken from the blasts on Saturday night, but the security levels are so high right now, strikes were taking place today nearby, family members are swarming the hospitals, etc. that we were advised to hold off from going to the hospital at least for today. We may be there tomorrow morning, and I can only imagine what things are like right now, especially for the family members of those victims in critical condition. My prayers are with all of them.

Today, we went to NIMS, which is a different hospital here in Hyderabad, and even there, we had a moment of silence and saw a lot of grief on the faces of the medical faculty as one of their doctors had passed away in the blasts. Anyways, I think you all get the idea. Wish we could do something more about it. For now, glad we're alive and well. Let's all pray for the victims and their families.

Continuing along with today, I think we all had quite an educational experience that offered some fresh perspective. We went on rounds today for several hours with one of the medical teams at NIMS hospital. These rounds were GREAT in many ways. Residents (five of them) were not paged or called a single time by a nurse or anybody else for any orders. The attending literally was teaching for 3.5 hours while we were with them, and we left before rounds were over. So how could 3.5 hours of rounds be great for residents with so much work to be done, right? Well, when our group left their group, we also realized that the residents didn't really have any orders to place afterwards, any discharge planning to solve, no to minimal notes (I'm pretty sure none). Only limited things could be done, so there wasn't as much work afterwards. They were just learning from their attending and focused on thinking about their patient's care. After lunch, they had time to come attend lectures (topics included HIV Perspective in India, Candidemia, and Rhinosporidiosis) for a couple of hours (in addition to the one hour conference that we all attended this morning). Imagine if we had 3-4 hours of teaching rounds and 3 hours of lecture/conferences every single day. Obviously, our systems are different - there is only so much that can be done for these inpatients due to the lack of money. Lab tests, imaging, treatment options are all limited due to cost. Before every potential diagnostic test is ordered, the attending discussed the costs involved and whether it would be feasible to pursue further diagnostic testing for these patients. Often times, the efforts were focused on empiric treatment rather than any labs or imaging with the goal being strongly on getting the patient better with what the best clincal diagnosis was rather than using any of the cost on extensive labs or imaging. Not too much focus on evidence based medicine. It really was quite interesting to see. The ward consisted of 20 beds across one huge room (talk about your geographic localization). In this entire room, there were only 2 iv poles hanging - one person getting IV abx and one getting a blood transfusion. Nobody was on nasal cannula. Diagnoses being discussed on these patients included HIV opportunistic infections in the lung (i.e. PCP, pneumonias, TB, fungal infections), malaria, TB, snake bites, leptospirosis, brain mets, lung effusions/lesions, HIV medication complications, DIC, lactic acidosis, etc. Somehow, they all looked fairly healthy. Just an incredibly unique experience.

Not even half way through the trip, eyes are wide open!

Keep in touch,

Vijay

Rainy Saturday afternoon in Hyderabad

I figured since I hadn't posted anything for about a week that I should probably do so, even though I don't think I'm going to reinvent the wheel with my blog after reading everyone else's from this past week. As everyone else has said, we are having a great time with each other and have quickly set up what can probably best be described as a very dysfunctional family away from home. One of the attendings from NIMS (Nizam Institute for Medical Services, where Dr. Y has been spending most of his time) who had lunch with us, was quoted as saying we were "interesting" and found us amusing, which Dr. Yadavalli says she meant in a good way, but I think the jury may still be out on that one. We've had terrific Indian food all week and as Jess said are seldomly left without a cup of tea in our hands or our bellies empty(in response to Dr. Armitage, I think tea at conferences and available somewhere at 4pm would improve resident morale tremendously, if nobody else's then at leaset mine).
Currently, I'm sitting in the internet cafe downstairs from our apartment, listening to the rain falling and with every good intention to work on presentation I'm giving this upcoming Thursday on C. diff, which surprisingly is said to not be a very big problem in India. Earlier in the afternoon it was a beautiful day, but now its been raining for about the past hour. Since getting back from a morning of lectures and briefly rounding with a hematology team and discussing a few cases, we've been playing this as a typical lazy Saturday afternoon with a good deal of napping and lounging. Bindu's having the most excitement as she is (finally) Sari shopping with one of Sujan's aunts. This morning, Dr. Yadavalli gave a talk to the internal medicine department at NIMS (Nizam Institute for Medical Services) and then one of the professors in the microbiology department gave us talks on the Chikungunya and Dengue fevers.
As everyone else has said, this week has been a tremendous experience with our exposure to the Sivananda Rehab Home. I was most amazed with their coordination of medical and social services for the leprosy patients, first by treating them (antibiotics and correcting disfigurements secondary to their illness) and then providing vocational training so that they can return to their homes and be able to be provide for their families and be an active member in their community. Ultimately the best part of these services is the restoration of pride in these people who may have been shunned by those around them because of their condition as there is a great deal of social stigma in India regarding the illness.
As everyone else has said, the leprosy care is just one aspect of the work done at Sivananda. They are involved in the national TB program, which Bindu previously described and are expanding their work on HIV, including a new program dealing with reducing mother to child transmission.
The one thing I have to add to everyone else's comments from this week and I have found interesting is the difference in the differential diagnoses here. From speaking with the residents on rounds this morning and from our experience with the TB program, much of what the internist sees is infectious and their primary causative bacteria are completely different from ours (for example on rounds this morning we saw aplastic anemia secondary to what they thought was an unidentified hepatitis virus, malaria and leptospirosis). Their first thoughts to cases are often such illness as tuberculosis, malaria and chikungunya, illnesses we only have a very limited exposure to or none at all. I asked a resident this morning how often he sees cases of malaria and he said usually one to two every other day and speaking of chikungunya, this area had 8,000 cases (I think, it may have been 80,000, but I thought best to underreport) in a recent epidemic in this city of 4 million estimated. If you think about it, in our most notable insect-borne illnesses we have seen about 2000 cases of West Nile and 20,000 cases of Lyme disease per year in the entire US population, compared to just this one locale (and its outlying areas). Pleural effusions here are looked at as tuberculosis first, anything else second. Well its about 5:30 here now and we're planning on starting our evening on the town in about half an hour so I'm going to get going. Guess I'll get to working on the presentation later. Hope everyone is doing well, keep us posted on what's happening back at home. See everyone back at Case in a couple of weeks.

Indian Chinese

One of the greatest gastronomic experiences for me each time I go to India is the consumption of Indian Chinese food. It is very difficult to describe what this is to someone who has not had it. It is not Indian food at all, but it is not Chinese food in terms of what is available in the US. Never having been to China myself, I can't say what is more "authentic". Neither is probably close to the real deal. We sampled a large number of dishes last night: sweet corn soup, manchow soup, Szechuan noodles, spring rolls, paneer satay, and, of course, the greatest of Indian Chinese vegetarian dishes, Vegetables Manchurian (see picture). Very satisfying.

We got to do another favorite activity of mine today as well: Carroms. None of us is particularly good, yet, but playing carroms is way fun.

The first week of the trip, to be spent at Sivananda Rehabilitation Home and NIMS, is pretty much set. We have one more day of R&R. Hopefully, we can catch some sightseeing before the learning starts in earnest, bright and early Monday morning.