Friday, January 25, 2008
Leaving Vellore
Today we are traveling to Chennai. Tomorrow we fly to Dubai. I will write a summary blog when I return home. Till then...happy trails..
Tuesday, January 22, 2008
An attempt at a scholarly discourse on Rheumatic Fever inVellore, India
As with all things academic there comes a time in every great endeavor that one must publish something scholarly. Unfortunately for many of my readers who are not in the medical profession, that time is now. As part of our scholarship and as part of our elective, I must write a scholarly discussion of a tropical disease seen here in India. I have chosen to write about Rheumatic Fever and its devastating sequelae—Rheumatic Heart Disease. While Rheumatic Fever is not typically considered a tropical disease in the truest sense of the term, it is considered a disease of developing nations. As many developing nations lie near the equator, ipso facto, I will consider Rheumatic Fever a tropical disease.
For those of you living in the states with children--esp school aged children as Rheumatic fever is considered a childhood disease occurring at median age of 10-- let me calm your fears that every time your child has a sore throat your child may die of Rheumatic Fever. While at the turn of the last century, there were reportedly 10 cases out of 1000, today the incidence is much less maybe .05 out of 1000 according to estimates given by the World Health Organization. This decline is due to the discovery and use of penicillin and to the fears resulting in untold physician visits by parents like many of you. So relax…you are doing a great job parenting your child. (FYI—as a self professed hypochondriac—I am sure I will be the first parent in line at the doctor’s office.) However, unlike the US, India has not benefited as much from modern practice and Rheumatic Fever continues to claim the lives of many. Worldwide estimates suggest that there may be as many as 30 million children and young adults with chronic rheumatic heart disease and 90,000 die each year from its complications.
It is thought that Rheumatic Fever is an immunologic consequence of antibodies against the M antigenic domain of Group A streptococcus which cross react with antigens present on cardiac tissue. While the exact mechanism and pathogenesis continues to elude researchers, histological evidence suggests this is true. As some of the brightest (and perhaps the most gunner-ish) remember, histological specimens of verrucous lesions on cardiac valvular tissue reveal Aschoff bodies consisting of perivascular foci of eosinophilic collagen surrounded by lymphocytes, plasma cells, and macrophages suggesting its immunologic origin.
But before any carditis occurs, the group A beta hemolytic streptococcal infection must not only colonize the pharynx, but it must also infect. According to many, being colonized by the bacteria is not a sufficient condition nor does it warrant antimicrobial coverage. Once infected by the bug, the child will likely complain of a sore throat although it has been reported in literature that some infections leading to Rheumatic Fever began as asymptomatic infections. Once across the epithelial barrier of the oropharynx, the bacteria incubate for a period of 2-4 days followed by an acute inflammatory response of 3-5 days of sore throat of fever, malaise, sore throat, headache and elevated leukocyte count. Many bugs and viruses can cause sore throats so it is important to document that a Group A Strep infection has occured—the cause of the worry of Rheumatic Fever. To diagnose in the office and at this stage of the disease, one can order the rapid antigen detection test to determine presence of Group A strep. If the patient is presenting some time later with evidence of Syndenham’s chorea and no sore throat one can order anti-streptococcal antibodies such as antistreptolysin-O (ASO) or anti-DNase B as the levels of these antibodies peak during the clinical features of Rheumatic Fever and can signify a recent Group A Strep infection.
In an effort to aid in the diagnosis of Rheumatic Fever, the Jones Criteria was published stating major and minor criteria necessary for diagnosis. However, the diagnosis of Rheumatic Fever can not be made unless it can be documented that Group A Strep infection has occurred as determined by the aforementioned tests. 2 major or 1 major and 2 minor criteria must be present to fulfill the Jones criteria which states:
Major criteria include: carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum.
Minor criteria include: fever, arthralgia, prolonged PR interval on the electrocardiogram, elevated acute phase reactants (increased erythrocyte sedimentation rate [ESR]), presence of C-reactive protein, and leukocytosis.
Rheumatic fever is reported to only occur in .3-3% of cases of Group A Strep pharyngitis. When it occurs, it usually happens weeks after the sore throat has resolved. Penicillin shortens the course of the pharyngitis and prevents future sequalae of Rheumatic Fever and Rheumatic Heart Disease.
Since I am an aspiring cardiologist and love to listen to the sounds a beating heart makes as blood flows through its chambers and valves, I must write a few words about the cardiac manifestations of Rheumatic Fever. Pancarditis is the most serious and second most common complication of Rheumatic Fever (occurring in 50% of cases) according to an article by emedicine. Evidence of carditis includes dyspnea with mild to moderate pleuritic chest pain accompanied by a new murmur and tachycardia out of proportion to the fever. Pericarditis and its accompanying friction rub are also known to occur. Murmurs of acute rheumatic fever are thought to be from valve insufficiencies. Rheumatic fever most commonly affects the mitral valve but it can also affect the Aortic valve as I have seen here in India. Mitral valve regurgitation is appreciated as an apical pansystolic blowing murmur which radiates to the left axilla. During active carditis, one can also hear the Carey Coombs murmur which is an apical diastolic rumble often accompanying severe mitral valve insufficiency. In addition, it is also possible to hear the high pitched, blowing, decrescendo murmur of aortic regurgitation heard during diasystole as well.
I was initially instructed to write only 1.5 pages. I included the details of the heart sounds not because I expect that many of you are at all interested in cardiology, but rather because I want you to appreciate the workings of our heart and the symphony of sounds one can hear. While in India, I have heard both systolic and diastolic murmurs in the same patient. These murmurs are quite rare in the states and it is my privilege to be in India and my blessing to meet these patients.
Finally, I would like to write a few words about the impact of Rheumatic Fever on the lives of people in Vellore. Rheumatic fever leading to Rheumatic Heart Disease (the scarring of the mitral and sometimes the aortic valves) is a great burden to this population. Chronic Rheumatic Heart Disease results in cardiomegaly with left atrial enlargement further resulting in atrial fibrillation followed by exacerbations of congestive heart failure. Over time and after bouts of re-infection of the damaged valves, patients will become so sick and that they will need corrective surgery and valve replacement which so many of these people can not afford. Just last week I met a 24 year old woman with such severe mitral valve insufficiency from Rheumatic Fever that she would die without surgery. Unfortunately, she had no money to afford surgery. She will likely die at a young age leaving her children without a mother. If only she could have received a 10 day course of penicillin when she was initially infected--a simple cure not given in the complicated world of poverty. It makes me sad to think if only she had been born in another place she might have had a different life. She is only one of many individuals I have met suffering from Rheumatic Heart Disease.
There is more to write…such as the treatment of congestive heart failure in acute rheumatic fever…the prophylaxis of recurrent infections of damaged valves… but I trust those of you needing to know this information can review these protocols online. I hope you have enjoyed this discussion and found it somewhat useful. Thank you for reading.
*** with reference of emedicine's article on Rheumatic Fever
For those of you living in the states with children--esp school aged children as Rheumatic fever is considered a childhood disease occurring at median age of 10-- let me calm your fears that every time your child has a sore throat your child may die of Rheumatic Fever. While at the turn of the last century, there were reportedly 10 cases out of 1000, today the incidence is much less maybe .05 out of 1000 according to estimates given by the World Health Organization. This decline is due to the discovery and use of penicillin and to the fears resulting in untold physician visits by parents like many of you. So relax…you are doing a great job parenting your child. (FYI—as a self professed hypochondriac—I am sure I will be the first parent in line at the doctor’s office.) However, unlike the US, India has not benefited as much from modern practice and Rheumatic Fever continues to claim the lives of many. Worldwide estimates suggest that there may be as many as 30 million children and young adults with chronic rheumatic heart disease and 90,000 die each year from its complications.
It is thought that Rheumatic Fever is an immunologic consequence of antibodies against the M antigenic domain of Group A streptococcus which cross react with antigens present on cardiac tissue. While the exact mechanism and pathogenesis continues to elude researchers, histological evidence suggests this is true. As some of the brightest (and perhaps the most gunner-ish) remember, histological specimens of verrucous lesions on cardiac valvular tissue reveal Aschoff bodies consisting of perivascular foci of eosinophilic collagen surrounded by lymphocytes, plasma cells, and macrophages suggesting its immunologic origin.
But before any carditis occurs, the group A beta hemolytic streptococcal infection must not only colonize the pharynx, but it must also infect. According to many, being colonized by the bacteria is not a sufficient condition nor does it warrant antimicrobial coverage. Once infected by the bug, the child will likely complain of a sore throat although it has been reported in literature that some infections leading to Rheumatic Fever began as asymptomatic infections. Once across the epithelial barrier of the oropharynx, the bacteria incubate for a period of 2-4 days followed by an acute inflammatory response of 3-5 days of sore throat of fever, malaise, sore throat, headache and elevated leukocyte count. Many bugs and viruses can cause sore throats so it is important to document that a Group A Strep infection has occured—the cause of the worry of Rheumatic Fever. To diagnose in the office and at this stage of the disease, one can order the rapid antigen detection test to determine presence of Group A strep. If the patient is presenting some time later with evidence of Syndenham’s chorea and no sore throat one can order anti-streptococcal antibodies such as antistreptolysin-O (ASO) or anti-DNase B as the levels of these antibodies peak during the clinical features of Rheumatic Fever and can signify a recent Group A Strep infection.
In an effort to aid in the diagnosis of Rheumatic Fever, the Jones Criteria was published stating major and minor criteria necessary for diagnosis. However, the diagnosis of Rheumatic Fever can not be made unless it can be documented that Group A Strep infection has occurred as determined by the aforementioned tests. 2 major or 1 major and 2 minor criteria must be present to fulfill the Jones criteria which states:
Major criteria include: carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum.
Minor criteria include: fever, arthralgia, prolonged PR interval on the electrocardiogram, elevated acute phase reactants (increased erythrocyte sedimentation rate [ESR]), presence of C-reactive protein, and leukocytosis.
Rheumatic fever is reported to only occur in .3-3% of cases of Group A Strep pharyngitis. When it occurs, it usually happens weeks after the sore throat has resolved. Penicillin shortens the course of the pharyngitis and prevents future sequalae of Rheumatic Fever and Rheumatic Heart Disease.
Since I am an aspiring cardiologist and love to listen to the sounds a beating heart makes as blood flows through its chambers and valves, I must write a few words about the cardiac manifestations of Rheumatic Fever. Pancarditis is the most serious and second most common complication of Rheumatic Fever (occurring in 50% of cases) according to an article by emedicine. Evidence of carditis includes dyspnea with mild to moderate pleuritic chest pain accompanied by a new murmur and tachycardia out of proportion to the fever. Pericarditis and its accompanying friction rub are also known to occur. Murmurs of acute rheumatic fever are thought to be from valve insufficiencies. Rheumatic fever most commonly affects the mitral valve but it can also affect the Aortic valve as I have seen here in India. Mitral valve regurgitation is appreciated as an apical pansystolic blowing murmur which radiates to the left axilla. During active carditis, one can also hear the Carey Coombs murmur which is an apical diastolic rumble often accompanying severe mitral valve insufficiency. In addition, it is also possible to hear the high pitched, blowing, decrescendo murmur of aortic regurgitation heard during diasystole as well.
I was initially instructed to write only 1.5 pages. I included the details of the heart sounds not because I expect that many of you are at all interested in cardiology, but rather because I want you to appreciate the workings of our heart and the symphony of sounds one can hear. While in India, I have heard both systolic and diastolic murmurs in the same patient. These murmurs are quite rare in the states and it is my privilege to be in India and my blessing to meet these patients.
Finally, I would like to write a few words about the impact of Rheumatic Fever on the lives of people in Vellore. Rheumatic fever leading to Rheumatic Heart Disease (the scarring of the mitral and sometimes the aortic valves) is a great burden to this population. Chronic Rheumatic Heart Disease results in cardiomegaly with left atrial enlargement further resulting in atrial fibrillation followed by exacerbations of congestive heart failure. Over time and after bouts of re-infection of the damaged valves, patients will become so sick and that they will need corrective surgery and valve replacement which so many of these people can not afford. Just last week I met a 24 year old woman with such severe mitral valve insufficiency from Rheumatic Fever that she would die without surgery. Unfortunately, she had no money to afford surgery. She will likely die at a young age leaving her children without a mother. If only she could have received a 10 day course of penicillin when she was initially infected--a simple cure not given in the complicated world of poverty. It makes me sad to think if only she had been born in another place she might have had a different life. She is only one of many individuals I have met suffering from Rheumatic Heart Disease.
There is more to write…such as the treatment of congestive heart failure in acute rheumatic fever…the prophylaxis of recurrent infections of damaged valves… but I trust those of you needing to know this information can review these protocols online. I hope you have enjoyed this discussion and found it somewhat useful. Thank you for reading.
*** with reference of emedicine's article on Rheumatic Fever
Monday, January 21, 2008
Not-so-Infectious Infectious Disease
Last Friday I participated in outpatient Infectious Disease hoping to see a rare ricketsial infection, advanced TB or a rare sequalae of HIV. Instead, I took a history of a man with sexual dysfunction. Apparently there is no such thing as specialty clinics for infectious disease at CMC. They do have a few scheduled clinics for HIV, but due to the extraordinary volumes of patients infectious disease physicians are also expected to see general medicine cases also.
After introducing myself to my attending, a patient who spoke broken English pushed a medical chart our direction interrupting what introductions my attending and I could have made. Thinking that this patient must be very sick, I pulled up a chair and listened. To my surprise, the patient leaned towards my attending and began to whisper in his ear. Thinking this must be serious, I began to wonder what was spoken. After a few moments, my attending handed me the chart and said... "He speaks English. Interview him and get a full history and physical. Give a diagnosis and suggest a treatment plan." I was a little stunned. I had not been given this kind of autonomy before in India. The attending escorted me and my patient out of the room. "Come... Come... I will find you a private room." After a moments hesitation, while I fumbled with my medicine manual (blue book) trying to find the infectious disease section and hope for some help, I followed my attending.
In India nothing is private. There are too many people and there is not enough room for privacy. My patient and I sat down behind a blue curtain. As my attending pulled the curtain close, he handed me the chart saying, "the chief complaint is erectile dysfunction. Come back to my office when you are done."
It became obvious during the interview that my patient's broken English and my American accent made hand gesturing and pointing to each other's crotch almost essential for understanding. I will spare the details as they are graphic. After what I thought was as good a history as I could get, I did a cursory examination and reported back to my attending's office relieved that the worst was over--or so I thought. My attending was disappointed that I had not done a genital examination. He pointed out the door handed me the chart and said "do a full physical this time."
By now I think my patient knew that I was a physician-in-training and only pretending to know what I was doing. He asked me what happened. "He wants me to do a genital exam." If you have ever had a dog as a pet, you know that when they are confused they tilt their head to side as if to want more explanation. My patient tilted his head and wrinkled his forehead. "He wants me to see your...." I pointed to my crotch and he immediately understood. He then excused himself to the rest room saying that he would return.
I don't know why he left or what he had to do. Maybe he was as nervous as I was. Or maybe he had needed to go for awhile as it had taken us a long time to understand each other. For any reason, I thought it was strange and wished he would hurry back as I wanted this humiliation over as quickly as possible. When he returned I did the exam.
In his chart I wrote, "circumcised male, no lesions, no ulcers. 2 testicles." Final diagnosis: Erectile Dysfunction likely secondary to anxiety. Recommend Counseling. My attending seemed satisfied.
After introducing myself to my attending, a patient who spoke broken English pushed a medical chart our direction interrupting what introductions my attending and I could have made. Thinking that this patient must be very sick, I pulled up a chair and listened. To my surprise, the patient leaned towards my attending and began to whisper in his ear. Thinking this must be serious, I began to wonder what was spoken. After a few moments, my attending handed me the chart and said... "He speaks English. Interview him and get a full history and physical. Give a diagnosis and suggest a treatment plan." I was a little stunned. I had not been given this kind of autonomy before in India. The attending escorted me and my patient out of the room. "Come... Come... I will find you a private room." After a moments hesitation, while I fumbled with my medicine manual (blue book) trying to find the infectious disease section and hope for some help, I followed my attending.
In India nothing is private. There are too many people and there is not enough room for privacy. My patient and I sat down behind a blue curtain. As my attending pulled the curtain close, he handed me the chart saying, "the chief complaint is erectile dysfunction. Come back to my office when you are done."
It became obvious during the interview that my patient's broken English and my American accent made hand gesturing and pointing to each other's crotch almost essential for understanding. I will spare the details as they are graphic. After what I thought was as good a history as I could get, I did a cursory examination and reported back to my attending's office relieved that the worst was over--or so I thought. My attending was disappointed that I had not done a genital examination. He pointed out the door handed me the chart and said "do a full physical this time."
By now I think my patient knew that I was a physician-in-training and only pretending to know what I was doing. He asked me what happened. "He wants me to do a genital exam." If you have ever had a dog as a pet, you know that when they are confused they tilt their head to side as if to want more explanation. My patient tilted his head and wrinkled his forehead. "He wants me to see your...." I pointed to my crotch and he immediately understood. He then excused himself to the rest room saying that he would return.
I don't know why he left or what he had to do. Maybe he was as nervous as I was. Or maybe he had needed to go for awhile as it had taken us a long time to understand each other. For any reason, I thought it was strange and wished he would hurry back as I wanted this humiliation over as quickly as possible. When he returned I did the exam.
In his chart I wrote, "circumcised male, no lesions, no ulcers. 2 testicles." Final diagnosis: Erectile Dysfunction likely secondary to anxiety. Recommend Counseling. My attending seemed satisfied.
Friday, January 18, 2008
Nursing Rounds and Poverty
On Wednesday I participated in Nursing Rounds at CHAD. We traveled to 4 nearby villages following up on patients in the communities who were known to be sick and many others who we discovered to be sick on our rounds. It was a great time to meet people in their communities and in their homes.
Our trip began with two patients who had recently attempted suicide. Sadly suicide has been on the rise here in Vellore in 20-40 year-olds. There are three main methods: hanging, organophosphate (pesticide) poisoning, and drinking the juice of boiled Oleander leaves. Both patients this morning tried to commit suicide by overdosing on anti-seizure medicine. What surprised me most was how open these patients were about their lives. They readily admitted to the their problems when confronted by the nurse. One had problems with her father who had forbidden her from talking to her friends and the other, a 20-something year old male, had an argument with his uncle.
In that same village I witnessed a funeral ceremony. A new mother 5 weeks from delivery had died of a presumed heart attack. It was so sad. She was only 27 years old. Her body rested in a glass casket for everyone to see. Garlands of flowers draped over her casket. Drums, which could be heard everywhere in the village, played to signify her death and to bring her peace in her reincarnation. Men were standing at the periphery. I could not identify a husband or her family. Many women were wailing near the casket and occasionally beating the glass encasing her body. I felt overwhelmed by their wailing. I had never seen tears like that at home.
I wish I could describe in words the images of these villages. The villages were dirty; but, the rice patties were green and luscious. The people were poor; but, every home had a TV. Many were sick; but, they could get sophisticated care from CHAD and from CMC if they were desperate. What struck me most was the lack of progress. I imagine that generations of people had been living on these lands and in these homes and yet they still had sewage ditches in front of their homes and open fires for cooking in their houses. Time had stood still for these families. The modern advancements of ovens, microwaves, etc had passed them by. They had electricity but the only use was for light bulbs and TV. I learned later that they had only received a TV because they were promised one by a political party if they were elected. It was strange. They had a TV but little else. It is hard for me to imagine what images and thoughts these people had when the dreamed. It was a bit of a culture shock you could say.
This weekend I am going to see the Indian Ocean with my fellow students from San Antonio. I've heard the Indian Ocean is beautiful. I am looking forward to a horizon of waves and sun and a respite from the humanity here in Vellore.
Our trip began with two patients who had recently attempted suicide. Sadly suicide has been on the rise here in Vellore in 20-40 year-olds. There are three main methods: hanging, organophosphate (pesticide) poisoning, and drinking the juice of boiled Oleander leaves. Both patients this morning tried to commit suicide by overdosing on anti-seizure medicine. What surprised me most was how open these patients were about their lives. They readily admitted to the their problems when confronted by the nurse. One had problems with her father who had forbidden her from talking to her friends and the other, a 20-something year old male, had an argument with his uncle.
In that same village I witnessed a funeral ceremony. A new mother 5 weeks from delivery had died of a presumed heart attack. It was so sad. She was only 27 years old. Her body rested in a glass casket for everyone to see. Garlands of flowers draped over her casket. Drums, which could be heard everywhere in the village, played to signify her death and to bring her peace in her reincarnation. Men were standing at the periphery. I could not identify a husband or her family. Many women were wailing near the casket and occasionally beating the glass encasing her body. I felt overwhelmed by their wailing. I had never seen tears like that at home.
I wish I could describe in words the images of these villages. The villages were dirty; but, the rice patties were green and luscious. The people were poor; but, every home had a TV. Many were sick; but, they could get sophisticated care from CHAD and from CMC if they were desperate. What struck me most was the lack of progress. I imagine that generations of people had been living on these lands and in these homes and yet they still had sewage ditches in front of their homes and open fires for cooking in their houses. Time had stood still for these families. The modern advancements of ovens, microwaves, etc had passed them by. They had electricity but the only use was for light bulbs and TV. I learned later that they had only received a TV because they were promised one by a political party if they were elected. It was strange. They had a TV but little else. It is hard for me to imagine what images and thoughts these people had when the dreamed. It was a bit of a culture shock you could say.
This weekend I am going to see the Indian Ocean with my fellow students from San Antonio. I've heard the Indian Ocean is beautiful. I am looking forward to a horizon of waves and sun and a respite from the humanity here in Vellore.
Monday, January 14, 2008
Starting a new elective and meeting the Amma of Vellore
Today I started a week long rotation at CHAD--a community hospital serving the villages outside of Vellore. C-H-A-D stands for Community Health and Development. It is a local hospital which acts to promote health and social welfare in many neighboring poor villages. It is a smaller version of CMC with only a few beds for general medicine, a small labour and delivery ward and a pediatric ward. Most complicated cases are referred to CMC's main hospital. Today I participated in outpatient pediatrics with Rachel. We saw a few kids with runny noses, one with likely malaria, another with possible TB and a 7 year old boy with new onset tonic-clonic seizures. I enjoyed the children. Children are so cute and innocent. They act the same in any nationality. On Wednesday I will get to follow a physician into the community to do home visits. I am excited for this opportunity to see how many of the poorest Indians live.
After work today Rachel, Scott, Rebeca and I traveled to the Golden Temple in Vellore. It was a surreal experience to say the least. It was built by a person called the AMMA who is the incarnation of 3 Hindu goddesses. He commissioned and raised funds to build this temple covered in 9 layers of plated gold (1.5 tons to be exact) and a surrounding pathway in the shape of a star. People from all over come to this temple to receive energy, to refocus their lives, to reduce their bad Kharma and seek wisdom and blessing from the AMMA. The site was unlike anything we have seen around Vellore. It is so luxurious and somewhat out of place especially considering the poverty everywhere.
While there we met a random Canadian women and her husband. They invited us to meet the Amma. Apparently, it is not often that people get to meet the Amma so we were told and that we were very fortunate to be given the opportunity. After a moments warning about how one receives a blessing from the Amma, I stood before a jolly looking somewhat portly man professing to be the incarnation of three goddesses offering me a spoonful of fragrant water for me to drink. Needless to say I was a little speechless. I accepted his perfumed water into my right hand, pretended to drink it then shower my head with his blessing. It was a bizarre event.
After work today Rachel, Scott, Rebeca and I traveled to the Golden Temple in Vellore. It was a surreal experience to say the least. It was built by a person called the AMMA who is the incarnation of 3 Hindu goddesses. He commissioned and raised funds to build this temple covered in 9 layers of plated gold (1.5 tons to be exact) and a surrounding pathway in the shape of a star. People from all over come to this temple to receive energy, to refocus their lives, to reduce their bad Kharma and seek wisdom and blessing from the AMMA. The site was unlike anything we have seen around Vellore. It is so luxurious and somewhat out of place especially considering the poverty everywhere.
While there we met a random Canadian women and her husband. They invited us to meet the Amma. Apparently, it is not often that people get to meet the Amma so we were told and that we were very fortunate to be given the opportunity. After a moments warning about how one receives a blessing from the Amma, I stood before a jolly looking somewhat portly man professing to be the incarnation of three goddesses offering me a spoonful of fragrant water for me to drink. Needless to say I was a little speechless. I accepted his perfumed water into my right hand, pretended to drink it then shower my head with his blessing. It was a bizarre event.
The events following were just as bizarre. Apparently every good temple also has an elephant for reasons I am still unclear about. This elephant was trained to accept bills by his snout, ring a bell, and bless you by snotting on your head. Not only did we get the blessing but we also were able to feed the elephant portions of bread. He was well trained and friendly. Afterwards, the Canadian took us to a hotel where foreign devotees of the Amma stay when visiting. He told us more about his devotion to Amma, the miracles Amma had performed and the vision of Amma's charity (hospitals, schools, etc..) It was all very strange and seemed cult like. Anyway, if you are interested in learning more and seeing pictures visit the following website: http://www.hindujagruti.org/news/3237.html
Friday, January 11, 2008
Cardiology Conference
Today I am attending a conference on Cardiovascular Sciences. Since I am interested in Cardiology I have had the great fortune of hearing from some preeminent researchers including one Nobel Laureate--Peter Agre. Apparently, the Christian Medical College is one of the finest medical institutions in India and has been host to many excellent symposiums.
Overall, I have been very impressed with the physicians I have witnessed. They are very well read in their fields and enjoy teaching. Unfortunately for them, they are also very busy--seeing many more patients in a day then I believe average physicians at home see. According to one of my attendings, their busy schedules prohibits their ability to indulge in research interests. Publications are rare amongst the attendings.
Not only have the talks been excellent but the entertainment has been good as well. Last night, we were entertained by a group of traditional dancers called "Saptaswaranjali." They performed with an orchestra of traditional instruments. It was fantastic. The dancers wore bells around their ankles and choreographed their dances and the clanging of their bells to accentuate the rhythm of the drums. It was very interesting--unlike anything I had seen before. Tonight we have a concert by the apparently famous Indian performer-- David Pascall.
I feel like I am settling into life here in Vellore. Already, I have developed some daily habits. I eat egg and cheese sandwiches every morning around 7am. I ride a bus twice a day to and from the hospital often seeing the same people onboard each morning. I eat chicken Masal with a coke most days for lunch at a nearby chinatown restaurant. I return home in the afternoons to relax with my roommate and fellow students before dinner. I am usually in bed around 9pm. This weekend my fellow students from the states and I plan to tour Vellore and eat some of its cuisine. I am looking forward to getting out of the gates of the Christian Medical College.
In case you are wondering.... my appetite remains healthy and have not felt sick---knock on wood. More to come.... Adios!
Overall, I have been very impressed with the physicians I have witnessed. They are very well read in their fields and enjoy teaching. Unfortunately for them, they are also very busy--seeing many more patients in a day then I believe average physicians at home see. According to one of my attendings, their busy schedules prohibits their ability to indulge in research interests. Publications are rare amongst the attendings.
Not only have the talks been excellent but the entertainment has been good as well. Last night, we were entertained by a group of traditional dancers called "Saptaswaranjali." They performed with an orchestra of traditional instruments. It was fantastic. The dancers wore bells around their ankles and choreographed their dances and the clanging of their bells to accentuate the rhythm of the drums. It was very interesting--unlike anything I had seen before. Tonight we have a concert by the apparently famous Indian performer-- David Pascall.
I feel like I am settling into life here in Vellore. Already, I have developed some daily habits. I eat egg and cheese sandwiches every morning around 7am. I ride a bus twice a day to and from the hospital often seeing the same people onboard each morning. I eat chicken Masal with a coke most days for lunch at a nearby chinatown restaurant. I return home in the afternoons to relax with my roommate and fellow students before dinner. I am usually in bed around 9pm. This weekend my fellow students from the states and I plan to tour Vellore and eat some of its cuisine. I am looking forward to getting out of the gates of the Christian Medical College.
In case you are wondering.... my appetite remains healthy and have not felt sick---knock on wood. More to come.... Adios!
Wednesday, January 9, 2008
First Impressions
I have been working in the Neurology wards these past couple of days. The service is full and there is a 2 week wait list for routine admissions. Our team consists of 2 junior faculty individuals who are called lecturers and 5 fellows who are called registrars. We have an attending who is also the chairman of the department who rounds occasionally.
Today, we had grand rounds which means that we walk as a team to see each patient and discuss them with our attending--the chairman of the department. Rounds here are very similar to rounds in the states except for the fact that there appears to be less autonomy given to the junior faculty. Our attending wanted to hear about every case and discuss them in detail. We rounded for ~ 6 hours today and we saw almost half of the patients. Our service has >50 patients which is almost 2x the size of similar teams in the states. These MD's are impressive--they seem tireless and very thorough.
Unfortunately for me, the physicians on my team speak with soft voices that I can not understand even when standing shoulder to shoulder. Even though I am only able to pick up bits and pieces of conversation, I can generally figure out what is going on. They are also very kind in answering my question which I appreciate very much. Our patients are very sick. I have seen more in these past few days than I would have expected. Here is a brief list of the patients I have seen:
Guillain-Barre syndrome
Fabry's Disease
Wilson's Disease
Plasmacytoma
TB Meningitis
Spinal Cerebellar Ataxia
Multiple Sclerosis
Duchenne Muscular Dystrophy
Transverse Venous Sinus Thrombosis
This morning my luggage arrived! I was so excited to see it as I was about to give up hope that it would be returned. Unfortunately, it appears that my toiletries were missing. I can't believe anybody would want my toothbrush or shaving cream. My stethoscope, which is more valuable, was not stolen--very strange.
If you are interested in learning more about the Christian Medical College and its founder Ida Scudder please paste the following address in your browser: http://www.cmch-vellore.edu/pages/?id=scudder. It is a great story about a women physician and her efforts to change lives in Vellore, India.
I am taking lots of photos, but unfortunately it has been difficult findig a computer that will accept my USB card. When I find one, I will provide some images.
Paul
Today, we had grand rounds which means that we walk as a team to see each patient and discuss them with our attending--the chairman of the department. Rounds here are very similar to rounds in the states except for the fact that there appears to be less autonomy given to the junior faculty. Our attending wanted to hear about every case and discuss them in detail. We rounded for ~ 6 hours today and we saw almost half of the patients. Our service has >50 patients which is almost 2x the size of similar teams in the states. These MD's are impressive--they seem tireless and very thorough.
Unfortunately for me, the physicians on my team speak with soft voices that I can not understand even when standing shoulder to shoulder. Even though I am only able to pick up bits and pieces of conversation, I can generally figure out what is going on. They are also very kind in answering my question which I appreciate very much. Our patients are very sick. I have seen more in these past few days than I would have expected. Here is a brief list of the patients I have seen:
Guillain-Barre syndrome
Fabry's Disease
Wilson's Disease
Plasmacytoma
TB Meningitis
Spinal Cerebellar Ataxia
Multiple Sclerosis
Duchenne Muscular Dystrophy
Transverse Venous Sinus Thrombosis
This morning my luggage arrived! I was so excited to see it as I was about to give up hope that it would be returned. Unfortunately, it appears that my toiletries were missing. I can't believe anybody would want my toothbrush or shaving cream. My stethoscope, which is more valuable, was not stolen--very strange.
If you are interested in learning more about the Christian Medical College and its founder Ida Scudder please paste the following address in your browser: http://www.cmch-vellore.edu/pages/?id=scudder. It is a great story about a women physician and her efforts to change lives in Vellore, India.
I am taking lots of photos, but unfortunately it has been difficult findig a computer that will accept my USB card. When I find one, I will provide some images.
Paul
Monday, January 7, 2008
38 hours later...
After 38 hours of flying and driving I have safely arrived in Vellore, India. However, my luggage did not make it. Despite my mother's admonition of such circumstances, I failed to pack any extra clothes or toiletries in my carry on. This is one of many painful lessons I have learned from the wisdom of my mother. Otherwise, I am doing well. My luggage should arrrive tomorrow if all goes according to plan.The flight from Houston to Dubai was long ~15 hours in duration. Thankfully I was plenty entertained by the 600+ channels offered by Emirates Airlines. Rachel and I were tired when we arrived in Chennai. Unfortunately, we had to wait another 10 hours for others from our group to arrive. I slept on the marble ground while Rachel sat in a chair next to me watching our stuff and occasionally flicking mosquitos off of my sleeping body. After three hours, I woke up semi-refreshed and ready for our next adventure.
Chennai is about 2.5 hours from our final and current destination--Vellore. Our journey by taxi from Chennai was in a word...terrifying. I think we must have nearly avoided almost 4 potentially fatal crashes as well as almost killed multiple pedestrians and families riding motorcycles. Apparently, the traffic according to the locals is unregulated, and people drive as they please whether that means going the wrong way against oncoming traffic or pushing others out of the way. Not only do we need to avoid other cars and trucks but also cows which are either grazing or relieving themselves on the roads. However, our driver seemed unamused and unimpressed by the driving hazards so I felt some confidence that he had driven in these conditions before.
My friends and I are staying on the campus of the Christian Medical College. It is a safe haven from the bustling city of Vellore. We are surrounded by trees and lovely gardens. I share a room with Scott my current roommate from the states which gives me some comfort of home. Our room is great and better than expected. We have a screened-in porch!! Unfortunately, the ladies in our group were not so lucky and live in a room infested by cockroaches (which they have affectionately named Jerry, Larry and Tom). Our room is sans insects for now...
We start our rotations tomorrow. I am "posted" for Neurology, Community Health, Leprosy Clinic and Infectious disease. I will write more later. Next time I write you I hope my luggage will have arrived and that I will be wearing something other than what I have had on for the last 3 days.
till next time... cheers!
Friday, January 4, 2008
Packing for my trip
Welcome to the first of hopefully many blogs I will write on my trip to India. Today, I am packing to go. I leave tomorrow afternoon. I think I have packed everything I will need: passport, travel alarm, enough clothes to minimize laundry duties and most importantly anti-malaria pills and a few courses of cipro in case I get a little "tummy ache."
Interestingly, there has been much debate about which anti-malarial pills to use as prophylaxis. Being on a tight budget I opted for the less expensive Doxycycline. Some of my traveling partners have spent more money and are using more effective prophylaxis. Stay tuned to see if I save money or get sick.
Once I am in India and settled in, I will write more about what I will be doing there and why I decided to apply for this international elective. For now all you need to know is that I will be working at the Christian Medical College in Vellore, India. Hope you enjoy my blogs. Tomorrow I fly...
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