Friday, June 3: The end is here

Our final day at Bethany! What a great 2 weeks it has been. The morning started off a little slow, since it was hard to get up, but morning prayers and breakfast happened as usual. Some nice idli and sambar and chai woke me up, then we were told we'd be going to visit a local school funded by the same base religious organization, Bethany.

We boarded the jeep headed over there, which was technically in Kerala, but was only a 10/15 minute drive. The school was for children with  broken homes aka drunk fathers/orphan children. It is a residential school, and it is  gorgeous. The work the teachers and staff do there is remarkable, and it totally mirrors the care seen at the medical center. The children were very cute, and they had a small assembly for "the students from America". There was a class of small 4 year olds who had just left their families to be at the school. The room was full of crying kids, and I don't think a bunch of foreign faces greeting them made it any better.

We only stayed there for a little while, then had to head back. Once back, I wrote some messages to the different people that made the experience so great, then packed up some stuff. I went down for a last outpatient clinic session, and Emily and I saw that there was a ultrasound specialist here to check out a bunch of patients. He was incredible. The man would go through each body part and section and just say yeah looks fine or no not fine so quickly! I had such a hard time keeping up. Emily, Sheniya, and I would trade off transcribing his words so that proper records could be kept. We saw a lot of pregnant women and mini fetuses which were cute. Also saw some gall stones, kidney stones, and lots of bladders. I don't know if this is completely true, but he said he has done quick ultrasounds of up to 1000 patients a day. That is unreal. He went on and on about ya not enough doctors for the population which was very true.

After an hour of frantic writing, we finished some packing and cleaned things up, then we went around saying our good byes. That was really hard. Everyone was so sad to see us leave, but we reasured to them how valuable they had been to us. Dr. Chakko even said, "don't think of me as a doctor, but more as a mother, or maybe for you a grandmother". Those were such nice words, and it made me think of my grandmas who are no longer here. She is truly an inspiration. Each person I met along this trip has given me motivation to be the best I can be, and whenever I think something's tough/sucks, I will always think about the daunting tasks they go through every day.

We marched up to Sheniya's place for lunch, where we saw an incredible lineup of food. It smelled delicious and tasted even better. Benny helped out too! We had some ice cream as well, then walked back out to finish handing out our cards. We saw Meena, who was super sad to see us go, and we had a little dance party in the in patient hallway haha. We saw the old man who'd been at the hospital the whole time (one of the first patients I saw) step out of his door to say bye. That was truly sweet. He was such a sweet old man and even though he couldn't speak English, we knew he was very genuine and nice. Finally, the nurse who had taken my survey print out ran into me, and handed me back survey responses from 6 women! I was in awe, since I just hadn't had the time or resources to get any responses at all. We strolled back to pack all our things then we said our final goodbyes, pictures, and left.  

We had the usual dosage of crazy Arun driving, and got to the airport. We paid Arun for our stay, then said our good-byes and went for security check. As we passed through I was stopped for having my reflex hammer in my backpack. He was confused about what it was for, and I tried telling him I was a "doctor"... It worked. Our group parted ways at this point, since Therese and Alex were headed to a different destination. This ended our educational vacation, and we were all so fortunate to have this opportunity to have this experience.

-Samir

Thursday, June 2

This morning was quiet; there were few patients to see and I had the feeling that this was the beginning of the end – we leave tomorrow afternoon. Dr. Clement chatted with us between patients. Of note, a man with a severely gangrenous foot was brought in by his family around tea time. You could smell it from Dr. Clement’s office across the hall from Casualty. The foot itself was totally eaten away; it was disfigured, some of the toes were black, and flies would not leave the festering wounds alone. The poor man had been brought in by his family some months ago, but the infection got worse and he is now confined to a wheelchair and overall does not look healthy for his age. Dr. Clement reminded us that the amputation must occur at the level of healthy tissue and bone, which often means removing more than you might expect. It continues to amaze me the injury that people will accept before they come or are brought to the hospital.

Around 2pm, we finished with Dr. Clement and had to leave for our second medical camp. This was much more successful than the first, as school is back in session as of June 1, so we were able to screen all of the children in town. After setting up, we saw patients straight from 3-6pm, first the school children and then the rest of the town, around 150 patients! We got some good practice taking blood pressure in a fast-paced and loud environment. Vickie was helping the pharmacy with drug hand out, Therese with taking body weight, Claudia directing operations, and the rest of us blood pressure and patient flow around the doctors. Dr. Muralidar arrived a little later, which had the effects of both speeding up the clinic and frustrating a lot of people who only wanted to see him. Dr. M has been in the area for more than 20 years and everyone knows him; however Dr. Clement has only been at Anaikatty for a few years.

When we got home, we were surprised to hear that the doctors were taking us out to dinner in Coimbatore. Dr. Muralidar’s favorite restaurant is a Chinese place where we had more rice and noodles and chicken than we could finish. It was delicious. Finally, after what turned out to be a long and exhausting day, we got home at midnight. Tomorrow we will visit the school over the border in Kerala that the Tribal Welfare Trust manages before we start the long journey home.

-Alex

Wednesday, June 1: Life in the In-Patient Wards

1 June: Life in the in-patient wards



The hospital portion of the medical center contains two large open wards, a male ward and

a female/pediatric ward. Each contains about 15-20 beds, of which anywhere from a

quarter to three-quarters are full at any given time. There are no curtains separating the

beds, so privacy is a minimum, as is room for visiting families. Family members can be in

the wards during the day, but only one is allowed to stay overnight (either in an empty bed

or on a blanket on the floor).

The wards aren't air conditioned, so get quite warm during the day. Patients (and their

families) are expected to provide their own food, clothing, and additional blankets

throughout their stay. There aren't any TVs or other sources of entertainment besides fellow

patients. Privacy, due to the nature of the open wards, is minimal; occasionally curtain

dividers will be put up to protect a particularly vulnerable patients, and there are a few

actual singe-patient rooms (as well as a 2-bed isolation ward). Bathrooms are also

communal. For the most part, patients spend their days in bed or, if they're well enough,

taking short walks around the medical center. Several nurses at a time take care of the

patients, distributing medications, carrying out doctors' orders from rounds, and setting up

newly-admitted patients.

The medical center also has a small ICU, used mostly for patients who need machine-

monitoring (the regular in-patient wards are notably machine-free) or who come in with acute

conditions in the middle of the night.

Although the medical center has a X-Ray machine and a basic lab, any patients who need

more advanced imaging or lab testing need to go to Coimbatore, the large city in the region

about an hour away that has more complex medical facilities. However, because Bethany

has limited internet and computer access, meaning that everything has to be hand-

delivered.

Besides all the usual excitement today, Arun, the Bethany manager/logistics master

extraordinaire, invited us over to his house for tea. He, his wife, and two adorable kids live

in an apartment in the medical center that overlooks the hills behind the clinic. Apparently,

the elephant that made an appearance at he center just a week before we arrived walked

right through their backyard! We spent a lovely couple of hours playing with the kids, talking

with Arun and his view, and learning how to make authentic Indian chai tea. (The secret is

extra cardamom!) The hospitality and welcome we've received from everyone in India,

particularly at Bethany, is overwhelming. I wasn't expecting to feel as much a part of the

family as I feel now, after less than 2 short weeks. We've received and learned much more

from this experience than we can ever hope to repay.

-Emily

Tuesday, May 31

This morning me and Vicky did OB rounds with Dr. Muralidar and then continued to see outpatients with her and Dr. Chakko throughout the rest of the morning. We saw many anemic pregnant patients and scheduled two of them for blood transfusions. One patient was two months pregnant, 27 years old, and only 27 kilograms. Another patient we saw was from a tribal village, had experienced two home births years before, and was now experiencing a prolapsed uterus, which we examined with Dr. Chakko. Lastly, one patient was having some pelvic pain and was wondering if she was pregnant. We did a vaginal ultrasound to determine if there was a gestational sac, which we did ultimately see. Dr. Chakko estimated that she was approximately 2 weeks along. Following outpatient appointments, I went and got Alex and Annalisa to see a live birth. Me and Vicky were also able to stay and watch that. After this, we had all seen a birth while here! Afterwards, me and Samir watched a C section. In ways I thought it was more intense than a live birth. Probably because I didn't know what to expect, but once the uterus was cut open it was a very quick procedure to get the child out of the uterus. It was interesting to watch them stitch up all the layers of the abdominal fascias afterwards.  I also had no idea that patients were just given an epidural during these procedures, so it was interesting to have an awake patient.

After the exciting afternoon, Dr Clement invited us to his home to play / listen to instruments. He has a keyboard, guitar, recorder, piccolo, accordion, plus I'm sure other instruments he didn't bring out. He played for a while and also taught Vicky and Samir how to play the accordion. At the end, him and his wife sang is a Tamil song that is very dear to them and also showed us pictures of elephants outside his home. Because we spent almost an hour and a half at his house we missed evening rounds, however we were told there was a case of drug-resistant TB in the isolation building and it was suggested we go to the lab to see the bacteria under the microscope.

-Therese

Monday, May 30: The Difference Between Knowing Medicine and Knowing Your Patients

Day 9

Personal Reflection: 

On this day in particular, we saw a large variety of individuals in outpatient with Dr. Clement. Male, female, young, and old, presented with different complaints that reminded us of the glimpse into pathology and medicine we had in our first year of training and how much we must learn in our next. More importantly, as our time passed at Bethany, the amazement of knowledge became overshadowed by the sincere and mutually beneficial relationship between these physicians and their patients. No matter the severity, patients showed gratitude and appreciation to the medical staff; no matter how "trivial," the medical staff provided equal time and attention to all patients. Observing these connections gave me insight into this rural and non-Western medicine, an experience I lacked beforehand. It also increased optimism of my future career, despite associated negatives often given in discourse. 

Clinical Perspective:

This day provided some pearls in medicine. I'll list a few brief patient cases and interesting insight given by Dr. Clement in order to properly assess/treat/maintain patient health. 

Patient 1: This young woman presented with L foot pain after blunt force trauma, however had no fracture on her X-Ray. A ruptured ligament is severe enough to treat as a fracture (complete immobilization for 3-6weeks), however will likely appear as a negative x-Ray. If there is suspicion for ligament damage, a "stress X-Ray" could be performed. Take a normal X Ray of foot and compare to manipulated X ray of foot. For example: if suspicion for lateral ligament tear, turn the foot inwards (intorsion), get image, and assess for increased spaces between tarsal bones. 

Patient 2: 74 y/o female with abdominal pain and previous history of recurrent cholecystitis and gall stones recommended for cholecystectomy. Although the patient was older, she also agreed that surgery would be the most beneficial. 

Patient 3: Middle aged man with PSHx of R inguinal repair presents with L deep inguinal hernia. In our M1 year, we learned this is medial to epigastric vessels and courses through both the deep and superficial inguinal rings. For men, this can enter the scrotum. 

Dr. Clement informed us that hernias are reducible and can reappear after a "cough impulse". Indirect hernias typically course through the deep ring and enter the abdominal wall. 

Patient 4: Older woman with an auto skin graft (taken from anterior upper thigh) to L dorsal foot. On examination it was healing well and the dressing was to be changed. We were told that applying ionized silver compound can promote healing and is applied before a new dressing is placed. 

Patient 5: This man appeared in excruciating pain and we learned he had abdominal complaints. He was grunting and writhing on bed and admitted for alcoholic gastritis. Follow up in other blog posts. 

Patient 6: Older woman comes in for a check up. She has a diagnosis of a carcinoma to the lateral aspect of the posterior 1/3 of the tongue. She refuses any chemotherapy or radiation treatment, but presented with neck lymphadenitis on the same side as the tumorous growth. She does accept antibiotics and analgesics for relief. Dr. Clement told us that it is important to allow patients to have control of their own treatment and health, while being supportive and wanting the best for them. 

Patient 7: a pre teen boy presents with his mother who reports some puffiness of his face. He has a history of acute glomerulonephritis with secondary hypertension and was treated accordingly. These new findings are concerning for other residual problems. On examination, the child had a systolic and diastolic murmur which was suspicious for rheumatic carditis secondary to his previous condition. This change is often associated with streptococcal infections. 

Patient 8: a middle aged healthy appearing woman came in for a wound check up. She had a biopsy of a tumor of the R medial upper thigh. Results showed a hemangioma, abnormal growth of blood vessels which can possibly spread to the bone; however, most patients are typically okay! She had a positive prognosis and was content. 

Patient 9: This woman complained of pain to multiple joints and was diagnosed with polyarthralgia in clinic. Further assessment is Needed before a polyarthritis diagnosis. Dr. Clement ordered an ESR, uric acid, serum creatinine, and rheumatoid factor as tests. 

Patient 10: A mid aged woman complains of chest pain and her EKG showed T wave inversions in all anterior leads. T wave inversions are significant for cardiac damage usually secondary to a previous infarction in that area. Interestingly, on her repeat EKG, these inversions were not noted but other changes were seen. She was given a diagnosis of unstable angina and admitted for further evaluation. 

Overall, this day was super informative and I enjoyed the mid paced nature of seeing a variety of patients in one setting, but being able to give them adequate time for their needs to be met. 

P.S. There was a spicy coconut-curry-cabbage medley that was so delicious. We all ate that day with such ferocity. A picture is below! 

-Simi

Sunday, May 29

Today was our first non-medical and rest day. We started our day by attending Sunday mass with the Bethany Medical Center workers. It was a beautiful ceremony with hymn singing, quotations from the bible, and testimonials. We contributed a collective testimonial of our time thus far in Anaikatty and sang “Amazing Grace.” (Later on, we were to discover that the M1’s last year also performed an instrumental version of “Amazing Grace” at Sunday mass—how coincidental!)

We then spent most of the day relaxing—reading, napping, eating. In the hours before the sun went down, we took a walk down the main road, into the main village of Anaikatty. Since it bordered the state of Kerala, we walked across the bridge and over the state line! Some of us came back with fruit or souvenirs, and most of us came back with some more sun and exercise. Then, we feasted on mangoes and called it a night.

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Since I wasn’t able to give my testimonial during mass, I will comment here on what this trip has meant to me. While much of my time in India has mirrored our collective testimonial—of being welcome into a family and community openly, of witnessing great care for patients’ medical and holistic care, of being adaptable and dedicated to learning—one of the greatest lessons I’ve learned thus far has been that the same care and dedication must be applied to our home, not just in international situations.

Coming to Bethany Medical Center, I have admired the care that our doctors have given to their patients. They have given their careers, and some their lives, to care for the health of the rural and tribal communities. They have expanded their specialty knowledge into the much needed primary care field. Spending time with these physicians and watching them provide much needed care has encouraged my long-desired goal to emulate their path and serve internationally. However, I have also realized that, for them, they are serving domestically and caring for their people at home. Within this short time, I have seen similarities between the rural and tribal areas of Southern India and the poor rural and urban areas of the United States. I have come to realize that these areas need medical workers to care for them with the same passion and dedication that I have witnessed in India. And that whatever my future plans, my duty as a medical student now is to take what I have learned and apply it to my own communities in need.

-Vickie

Saturday, May 28

Again, we took breakfast after morning prayer. We had dosa and some kind of split pea soup. Annalisa, Claudia, Simi and I took a short break while Emily, Samir, Therese, Vickie, and Abhishek went on rounds with Dr. Clement. Dr. M had the morning off, as there were only a few outpatient visits, and Dr. Chakko was out for the day, so it was shaping up to be a quiet day at the hospital. It was very cool today, maybe 70 or 80F in the morning.

We played with some of the kids until teatime at 11, and even convinced them to try it. After tea, Vickie, Claudia, and I worked with Dr. Clement, who had a number of interesting cases. One patient presented with acute abdominal pain, and he explained how to diagnosis either renal colic or tuberculosis by urinalysis (it turned out to be a kidney stone). Another patient had an ulcerating cellulitis on the foot, where the ulcers had healed but there was now chronic edema. Physical exam findings turned Dr. Clement to lymphatic filariasis, a disease we shouldn’t see in the US. Other conditions included bacterial, viral, and fungal infections, and a recovering stroke patient. We also had the chance to listen to a systolic heart murmur, with the same patient also potentially having a septal defect.

Before leaving Dr. Clement, he showed us pictures and a video he took a week ago of the elephant that broke through the fence. It was right outside his house! We went to Rajeev’s after lunch to get water for the trip to Coimbatore, and of course they insisted on feeding us – vada and chutney – always delicious.

At 3, we left for Coimbatore with Walter, meeting Arun at the CSI All Souls’ Church. We had tea and banana bajji across the street, and then Samir and I went next door for haircuts; Arun took the girls to a shopping part of town. We had some time to explore the area a bit before Arun returned to pick us up, but by the time we got back to the meeting point, the girls were gone! We had no way of contacting them, so it turned into a search party in the dark in a strange city with huge crowds…not encouraging. Finally, after Arun located them by simply asking doormen at various stores along the street where this group of girls had gone, we rejoined and headed to one of his favorite restaurants. As we waited for a table, we went to a neighboring shop to buy fruits and vegetables. We had a huge dinner of chicken, fried rice, shawarma, mutton soup, naan, and parotha, and Samir, Emily and I finally got some ice cream. By 10, we were on the road home.

-Alex