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

Friday, May 27: Do what you can with what you have

Today was a pretty unique day. We didn't do much medical work, but we had a fun adventure. After showering, morning prayer, and breakfast, we packed up supplies and headed in two jeeps to a rural village. The road to these villages are gated, and you need special permission to access the road. We rode through some pretty crazy terrain, and saw some really beautiful nature. Just incredible to see where all these people were living. Many of these villagers were farmers and herders, and they had very little access to the outside world.

Once we got there, we set up a mini clinic in a school. The children were on summer vacation unfortunately, so we were not able to see as many patients/kids as usual. But the school was very cute. One interesting thing I noticed was the presence of solar powered lamps sprinkled across the village. It's cool to see that they have those light sources during the night time. We got all the medications and stations set up, then patients came. I helped with taking blood pressure before they saw the doctor. I used the oldest BP machine i'd ever seen! It had mercury in it and looked super old!

One incredible thing I saw was psoriasis. It was systemic and seemed to be a severely chronic problem. That was something I had never seen before. I also learned a bit more about cataracts and about some medications. We didn't see a whole lot of patients, but it's  all good, it was more to just witness the villages, the people, and how they live.

We finished early (around noon) and headed for some lunch. Had some good chicken biriyani and parathas from a local restaurant. Bellies full, we rode back to the medical center, where we relaxed for a bit. Emily and I were supposed to see a C-section in the evening, but the patient had bad pain in the morning so they decided to just do it in the morning. We saw these two little girls dancing in the courtyard area, so we decided to join. It was fun! We exchanged a few dances: some Tamil, some American, and even a French one (from Emily)! We were sadly super tired from that, and we eventually had to rest for a bit afterwards. We had our dinner then some of us went for evening rounds, while the other took a break. Although it's been spoken about a lot, the scenery is just beautiful. One thing I think we all learned today is that there is still a very prevalent population who live in secluded areas with little/no electricity, internet, or access to health care. It was very humbling to meet these people and to see a glimpse of their lifestyle.


-Samir

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 We started our day with a short service at 7:30am. After a delicious meal of Idli and chutney, we headed for Dhoomanoor at 9:30 am— one of the protected, mountainous, tribal regions that the Bethany Medical Centre caters to. The drive up the mountain was exciting requiring excellent maneuvering skills and Mr. Walter, who possessed just that, ensured that we arrived safely to our destination. We were greeted at the mountain’s peak with a view that was simply breathtaking.

 Cases seen today include psoriasis which was to be treated with a coal tar-based topical ointment, glaucoma which was being managed with eye drops as surgery was not a feasible option for this elderly patient, elephantiasis which is endemic to tropical regions and tuberculosis which is also prevalent in these areas. I came to understand that tuberculosis was not only a respiratory disease and that it could also affect other areas such as the lymphatic system, brain, kidneys and bones. It was refreshing to see that this medical effort catered to the people of Dhoomanoor and the surrounding villages bringing medical care to the doorstep of folks who would otherwise walked a great distance to have access to quality health care. School was out of session and so there was no teaching session which is typically held for tribal students in addition to the medical care provided. Particularly worthy of note was the doctor-patient relationship I witnessed—one of mutual respect and trust.

 Our eventful day was crowned with a tasty meal of rice, cabbage, grated coconut and beet salad with chutney and boiled eggs. We read on the porch afterwards for about an hour and called it a night.

-Claudia

Thursday, May 26

We had breakfast before morning prayer and then went on morning rounds. Immediately after rounds, Dr. Muralidar drained the man’s cheek that has been massively swollen all week. He administered local anesthetic before making a small puncture with a needle and opening the hole with blunt dissection and a scalpel. The fluid was a thick mixture of pus and blood that Dr. Muralidar proceeded to drain for several minutes, making sure to disrupt all of the pockets. It was quite gross to watch, but the man looked much better after.

After, Annalisa and I worked with Dr. Clement, who is a very interesting person and a great teacher. He does primary care but as an orthopedic surgeon by training, he definitely sees more imaging than Dr. M. Some of the cases we saw were benign prostatic hypertrophy, vertebral cerebellar insufficiency with spondylitis, pneumoperitoneum, and a supracondylar fracture. Later in the day, we went with him to clean the foot of a man who had lost two toes to diabetic gangrene. It should have been incredibly painful even for the daily cleaning, but the neuropathy was his only analgesic. Dr. Clement reminds us that as the foot heals, he will also regain sensation.

In the afternoon, we took tea before returning to Dr. Clement at 4pm. After seeing a couple of patients, Claudia came in with news that the surgeon would be around for a ruptured appendix removal, so I left to prep for that around 5. It was a very quick laparoscopic procedure, maybe a half hour, that Samir, Emily, Vickie, and I watched on the monitor. The surgeon quizzed us the whole time and seemed kind of eccentric, talking loudly and managing another emergent case all while probing for the appendix. He spoke with us more post-op, remembering Christine and last year’s group of Rush students, and telling us about the medical training process in India. It is interesting to hear about the variations in these health systems and health training, even while the actual practice is largely the same. It is a product of patient needs, historical legacy, and a highly diversified demographic.

After the surgery, we walked up the hill to see the sunset, which is always colorful. Abhishek’s family arrived to drop him off: he will be staying at Bethany for two months while he waits to start medical school. Their family was very nice, and offered that we visit the school for children with special needs that they run in Kerala.

-Alex

Wednesday, May 25

Today was an absolutely fantastic day!  After another delicious breakfast of itly and morning prayer, Alex and I headed to OBGYN where we were informed that two C-sections and a D and C were scheduled. We then changed into the hospital’s scrubs and sterile flip-flops, put on our caps and masks, and headed into the OR for the first C section.  This C-section was complicated by the fact that the patient had severe uterine adhesions from a previous C-section. Dr. Chakko stated that the severity of the uterine adhesions was due to the previous surgeon not sewing up all of the abdominal wall layers. She wanted us to make a note of this because they would take care to sew up both the visceral and parietal layers of the peritoneum, a step which is often over looked, after the birth of the baby to prevent more of these uterine adhesions. While the uterine adhesions made the surgery more difficult, the birth of the baby went smoothly overall and was amazing to witness. One second you were still looking at the placenta and then all of a sudden there was a crying, healthy baby in the OR with us! After the C-section the surgeons performed a tubectomy. Dr. Chakko told us that in the tribal population of patients who have limited to no access to transportation that would allow them to quickly get to the hospital, a third pregnancy that requires delivery via C-section would put the mother at extremely high risk, so the physicians counsel these patients to receive a tubectomy after their second delivery via C-section. This procedure also went well, and we learned that to ensure complete sterilization the tubectomy needed to remove the portion of the uterine tubes that contains the fimbrae.

The next procedure that we saw was a D and C. Here the patient came in with a chief complaint of excessive and irregular bleeding, so the D and C was checking for malignancy. Once the uterine and cervical samples were collected, they are sent to a lab in Coimbatore to be tested and the hospital should receive the results one week later. We then had a brief tea break of orange fanta and cookies with Dr. Chakko before the second C-section scheduled for that morning. This patient was also undergoing a second C-section; however, she did not present with the same severe uterine adhesions that the first patient did. This did not mean that this second C-section presented with no challenges because half way through the surgery the power went out and the generator didn’t kick in for 2 minutes! However, this challenge in no way alarmed the surgeons. They remained calm and asked me to turn on the flashlight given to me by one of the scrub nurses and hold the light over the woman’s abdomen, so that they could continue with the C-section. After 2 minutes, the generators kicked in, power was restored, and another beautiful, healthy baby was delivered shortly afterwards. They performed a tubectomy after this C-section as well.

All of the surgeries were completed at 1:30pm, so after we changed back into our own scrubs we sat down to another delicious lunch and had some down time until rounds at 8pm. Alex and I decided to play card games during some of that down time, which mainly consisted of us trying to remember 2 person childhood card games. After rounds from 8-9pm, we joined up with the rest of the group to have dinner and then it was off to bed. But what an exhausting and exhilarating day! It was both amazing and inspiring to be in the OR of an 80-year-old woman, and this showed me how the passion and dedication that we need to bring to our practice of medicine in an effort to increase our patients’ quality of life should have no age limit.

-Annalisa