An interesting day in pediatrics

Tuesday (June 26) was the last day of the SDM medical students’ posting in pediatrics. Eva and I were scheduled to be there until Friday (June 29). I was a bit apprehensive that once again the faculty would not have any idea what to do with us. However, Wednesday was a pleasant surprise. Not only did I get asked to be an English teacher (presumably because of my complexion) J but we saw some very interesting cases in the Pediatric Out Patient Department (OPD). (One of the patient’s father asked, in broken English, if I would tutor his daughter, who is in 6th standard, in English. I tried to explain that I was in India as a student and not a tutor but I’m not so sure he understood. The conversation ended with me saying, “I no teach English.”)

We saw our first foreigner in the hospital, a Canadian. A white woman in her early 20s brought a young girl (with fever and diarrhea) to the clinic. She is in India working with a NGO at a school about an hour outside of Dharward. It was an interesting office visit… the physician was questioning the young girl in Kannada- the local dialect (which she didn’t seem to understand totally) and then speaking to the Canadian woman in English (which she didn’t seem to understand as her first language was obviously French). The physician prescribed some antibiotics and explained oral re hydration therapy. The physician said later that most NGOs in the area are fairly good at handling diarrhea, dehydration, and parasites.

Shortly after a family came in with their two and a half month old daughter. She was born with spina bifida, a developmental birth defect involving the neural tube (specifically the spinal cord and vertebrae), which was operated on at birth in a hospital in northern India. They brought their daughter to the OPD to ensure that she was recovering properly. The physician had a difficult time assessing this as there were no medical records from the patient’s previous care facility. He later explained to us that continuity of care is hard to come by in India.

After performing a general neurological exam, the physician said that the child most likely suffered from a meningocele. A meningocele is the least common form of spina bifida. In this condition some of the vertebrae are split (do not develop properly in utero) and the meninges are damaged and pushed out through the opening. This appears as a sac or cyst on the infants back. The sac contains both the meninges and cerebrospinal fluid (CSF). Luckily the spinal cord and nerves are not involved in a meningocele and neurologic function is generally normal. (In other forms of spina bifida, when the spinal cord is involved, neurologic function is impaired from the point of malformation in the spinal cord and below.)

Side note- the physician also observed that the patient exhibited the sunset sign (her eyes looked like a sun setting) which results from increased CSF pressure due to an obstruction in the flow- most likely at the location of the operation. (It is exciting when the stuff we have spent hours learning about at the library presents in a patient- makes all the time seem worth it.)

Next we were able to examine a six month old boy who suffered from severe hydrocephalus. Hydrocephalus is a condition where an abnormal accumulation of cerebrospinal fluid (usually due to a blockage in the CSF circulation) causes increased pressure inside the skull leading to progressive enlargement of the head. Infants with hydrocephalus have large heads because the increase CSF pressure has caused the individual skull bones (which have not fused with each other yet) to bulge outward. This child, who at 6 months is expected to have a head circumference of 40 cm, had a head circumference of 55 cm, the circumference expected for an adolescent. This child also exhibited the sunset sign. Compression of the brain by the accumulating fluid (increased pressure) eventually causes convulsions and mental retardation in these patients. The cause of this patient’s hydrocephalus is most likely genetic as he is the product of a consanguineous marriage (his parents are first cousins). The physician informed us that the patient would be admitted for a full evaluation and seen by the neurosurgeon on Monday (which is the day of the week the neurosurgeon is at SDM Hospital).

The treatment for hydrocephalus is surgery. A shunt is placed from the brain to the body cavity (most commonly), where the excess CSF can be resorbed. The shunting of the excess fluid relieves the increased intracranial pressure. It is difficult to say what the prognosis for this patient will be as it is probable that a great deal of neurologic damage has already occurred. There are also a number of shunt complications which can occur (malfunction, failure, and infection). If for some reason a shunt fails, CSF will begin to accumulate again, increasing the intracranial pressure and a number of symptoms can develop (seizures). Shunt failure rate is relatively high- patients often have multiple shunt revisions throughout life.

The remainder of this week in pediatrics was fairly uneventful (wellness checks and immunizations). Next week we begin our two week community medicine posting which should be very interesting. As far as this weekend goes… we are planning on relaxing and finalizing our travel plans for a world wind tour of India at the end of July. We will be leaving Dharward in just two short weeks, traveling around India (Bangalore, Mysore, Delhi and surrounding area, and Mumbai), and then returning home on August 1st.

Hot Showers, Diet Cokes, and Monsoon!!

Eva and I left Dharward, just the two of us, on Thursday evening for a weekend of independence after a semi frustrating week. While the things we have seen in pediatrics have been very interesting (two cases of malaria, a case of cerebral palsy, and a few new born exams) we stand around a lot and waste time as the unit seems short staffed and unprepared for students. Aside from the hospital, life at home with the family has been a bit confining- both Eva and I are used to living more independently (everybody here is very concerned with our well being- over the top concerned). We headed out of town on an overnight train to Goa on Thursday the 21st around 11:30. Goa is the state neighboring Karnataka to the west and is well know for its beautiful beaches. The train ride wasn’t too bad, we were in a sleeper car and aside from being a little too close to the bathrooms I was able to sleep most of the way.

We arrived at our stop around 7 AM and unfortunately there was no car to pick us up- a bit of a mix up with the hotel. In general it isn’t super safe (for women) to just hop in a taxi here- so Eva and I had arranged for the hotel to pick us up. Well turns out the car went to a different train station, so after a few phone calls, we got in a pre-paid taxi and headed to our hotel, the Sunset Village Resort. Unfortunately, June isn’t exactly beach weather, what with it being monsoon season and all, but we were determined to make the best of our freedom/independence!! Eva and I checked into our hotel early, got some breakfast (cereal w/ cold milk, lots of fruit, and amazing coffee- most American breakfast I’ve had since arriving), and headed back to our room for a nap. Between the air-conditioned room and soft mattress Eva and I had about the most amazing naps ever.

We crawled out of bed in the afternoon and set off to explore Baga and its beaches. We wandered around but unfortunately most of the shops, restaurants, and hotels are closed for the off season and won’t open again until September. We saw a few foreigners and found an open book store. After purchasing some books (we have finished all the ones brought from home) we walked back to our hotel along the beach. The Arabian Sea looked extremely ruff (due to the season) and there were very few people swimming or even in beach attire. (It hadn’t really rained yet… so I was a bit confused about the monsoon business.)

After returning to the hotel, I took a long hot shower, first one since I left home. We only have cold water at the house- of course with how hot it has been the cold water usually feels pretty good. But the hot shower was truly amazing! Eva and I had dinner and drinks at one of the restaurants in our hotel. After which we sat by the pool for awhile… there were two gentlemen playing a mix of Indian and some pretty bad American music. It is so interesting which American songs people cover all over the world. It began raining while we were at dinner and didn’t really stop for the rest of our time in Goa. I have to say monsoon rain is pretty awesome… it just pours and pours and pours.

On Saturday it was still raining, so after another lovely breakfast, we decided to just relax in our air conditioning and comfy beds. I started one of the new books, napped a little, and worked out. Our hotel had a real gym… with weights and cardio machines :) I’m pretty sure the gym hasn’t ever really been used and I definitely got some strange looks while working out but it felt soo good (again I haven’t had a good workout since I left- gyms aren’t easy to come by here and running outside is sort of out of the question for several reasons). In the evening we took a cab to one of the few restaurants which remains open in the off season for some seafood. Dinner was wonderful. It wasn’t so much that the seafood was wonderful (good but not wonderful)… but more importantly there was Diet Coke (my first… and second… Diet Coke since May). Eva and I also ordered 3 desserts to share. YUM! When we got back to the hotel we enjoyed the poolside entertainment once again and then headed to bed.

I woke up early Sunday to work out and take one last long hot shower. After breakfast we checked out and headed to the train station. Despite the complete absence of ideal beach weather, I didn’t even get my swim suit out of my bag; our weekend at the beach was wonderful. Between the hot showers, the Diet Coke, and the gym… I felt spoiled. The train ride home was fairly uneventful. The scenery was beautiful- rolling mountains covered in jungle and fog and a few waterfalls. After about 7 hours we returned to Dharward around 10 PM. I will remember Goa fondly and will have to attempt to return during the high season- around Christmas time.

Badami, Bijapur, and the beginning of Pediatrics

We left Dharward at 7:00 AM on Saturday and headed north. Two aunts, one uncle, Eva, and me (plus driver) jumped into the rented SUV and headed out of town. Roads here are definitely sub par so it was a very bumpy ride. Prior to leaving Eva and I read about both Badami and Bijapur in our Lonely Planet- India book to get an idea of what we would be seeing. (while both of Eva’s uncles speak English rather well there is still a significant language barrier at times- we figured it would be best to do a bit of research before departing) We spent both Saturday and Sunday wandering around Hindu temples and Muslim mausoleums. We toured a few gardens in honor of various Hindu Gods. I took lots of pictures which I will have to share at a later date as we still do not have broadband internet. The weather was particularly hot but we still had a very nice time.

We spent the night in a semi questionable hotel... lots of bugs, no shower, and holey mosquito nets. However, our room did have a window AC unit (first air conditioning since I have arrived) and Star Wars II and III (in English) on TV. Eva and I stayed up most of the night chatting. We were a bit apprehensive about falling asleep and being eaten alive by mosquitoes.

On our way back to Dharward we stopped by the home of another one of Eva’s aunts (remember there are 12 siblings in the family). Eva had not yet met this aunt. Upon arrival we were shuffled into the home, fed more than we cared to eat, and given saris which were locally made. In fact on the drive through town, en route to the home, we could look into the shops and see men making the fabric on large looms- lots of bright colors. The hospitality of Indian families continues to amaze me- stopping in (unannounced) is expected- schedules are rearranged, food is prepared, and invitations for staying the night are almost always made. In fact, if one was in the area and did not stop in it would be considered rude. Before leaving, Eva and I, with the help of the Aunts, put on our saris and took pictures with the family. Then it was back in the SUV for three more bumpy hours.

We began our pediatric posting this week- so far it has been pretty good. The children of India are definitely beautiful. We are the only two students in the unit right now. We will join the other students when they begin their time in pediatrics next week. Being the only students has both positives (we get more attention) and negatives (the staff doesn’t always know what to do with us).

On Monday, we observed a physician for about an hour in the out patient clinic- lots of wellness checks/assessment of development and immunizations. Most children here are small for their age due to malnutrition and suffer from anemia, again the result of diet. The majority of India’s population is vegetarian making it difficult to get adequate protein, iron, folic acid, and other vitamins. Dietary supplements are expensive and generally not a feasible solution. In fact a healthy birth weight of a full term infant by western standards is around 3 kg. The healthy birth weight of a full term infant by Indian standards is 2.5 kg. We then received a short lecture I would entitle, “An Introduction to Pediatrics and ‘whatever I feel like telling you.’” The physician was all over the place- I don’t think he had anticipated we would be a part of his day. Eva and I listened attentively and thanked him- but we were glad to leave when he dismissed us. He did share that the general inpatient ward costs around $1/day, while the more expensive private rooms cost around $6/day. Eva reassured me if I got sick we could splurge for a private room. : )

Tuesday, again we reported to the out patient clinic and observed the physician on duty. He informed us that an office visit at the clinic costs 10 Rupees (about a quarter). Immunizations which are covered by the government are free of charge and additional immunizations cost around 20 Rupees. I am not exactly sure which immunizations fall into which category but the examples he gave were: government funded= DPT and polio, independently funded= Hep. B, meningitis, chicken pox

Wednesday was definitely interesting. We reported to the operating room to observe a pediatric surgery. A 3 year old male was having a congenital hydrocele repaired. (I let you look up the details if you are interested) After leaving the OR we went to the pediatric ward to examine two patients- a 6 year old boy and his 3 year old sister. The children are the product of a consanguineous marriage and as a result suffer from severe developmental delays and a metabolic disorder. Both children looked about half their age because of their small size and had extremely distended bellies. Upon palpation it was clear that both children had an enlarged liver and spleen. The little girl also had fluid accumulation in her abdomen. The physician said that some tests were still being preformed (samples have to be sent to a lab in Bangalore) to determine the specifics of the disorder- most likely an autosomal recessive genetic disorder effecting the CNS as well as metabolism.

At the end of this week our clinical time is half over- two more weeks of pediatrics and two weeks of community medicine. My time here is going very quickly. This weekend we are off to Hampi for another site seeing trip with the family.

Last Couple Days in OB/GYN

Our time in the obstetrics and gynecology department will end Friday (June 8th). Next we will move onto pediatrics. The posting as a whole has been very interesting, with the last couple days being the best so far. I am still not sure if this is the specialty for me- but I can say I have enjoyed my time with the department. The physicians, staff, and other students have been extremely helpful and Eva and I are very appreciative. As in the States, OB/GYN is female dominated specialty. We have only encountered one male physician in the department.

On Tuesday, Eva and I reported to the OR (operating room) at 8:30 to observe a laparoscopy assisted vaginal hysterectomy. I wasn’t sure what to expect… but can say now that it was definitely one of the coolest things I have seen. The patient was a post menopausal woman who presented with intermittent vaginal bleeding. After examination and biopsy it was determined that she had a large uterine fibroid and potentially uterine cancer. The treatment selected for this patient was total hysterectomy (uterus, fallopian tubes, and ovaries- are all removed). The decision was made to do a laparoscopy assisted vaginal hysterectomy (the uterus is removed through the vagina after its internal attachments are cut) rather than an abdominal hysterectomy (the uterus is removed through an incision in the abdomen) because it is a less invasive procedure. Here is the play by play… (or at least what I understood)

• the patient was first put under general anesthesia
• 4 small incisions were made on the abdomen (a camera with light was inserted in the incision near the umbilicus and various instruments were inserted in the others- two lateral and one midline but inferior to the umbilicus)
• carbon dioxide was pumped into the abdomen to slightly inflate the abdomen (this gives more room to work and a better view)
• then with the use of a cauterizing tool and scissors (which were inserted into the two lateral incisions) the superior attachments of the uterus were severed
• a instrument which looks like a wand with a small corkscrew at the end (which was inserted into the inferior midline incision and screwed into the fundus of the uterus) was used to move the uterus from side to side stretching the attachments- this made it possibly to identify, cauterize, and cut them
• in a similar fashion both of the ovaries/ fallopian tubes were unattached from the inside (they remained held in clamps which were inserted in the lateral abdominal incisions until they could be removed through the vagina)
• the carbon dioxide was then let out of the abdomen and the physician proceeded to perform the vaginal hysterectomy- first the uterus was removed then the ovaries/ fallopian tubes
• after suturing was complete near the vagina the abdomen was inflated one more time
  the physician used the camera with light to visualize the inside- check for bleeding and suction out remaining blood/clots
• the instruments were removed from the abdomen and the 4 small incisions were sutured

The surgery took around 3 hours and was pretty amazing.

Today, June 7th, was an equally amazing day. We reported to our posting at 10 AM and it didn’t appear that the students we had been accompanying knew where we were supposed to be. Eva and I decided to check the labor ward as we still had not seen a vaginal delivery here (we saw a c-section last Saturday). The labor ward is two rooms, one for women in the latent phase of labor and one for women in the active phase of labor (again no private rooms- just large rooms with multiple beds). As soon as we walked in we heard some moaning/yelling from the active phase of labor room. Eva turned to me and said, “that sounds promising.” We have been trying to see a delivery all week long and have had no luck. Between 70-90 babies are delivered per month here and we just happen to miss all of them.

One of the physicians we have followed on a few occasions told us that one woman was in active labor (7 cm dilation) with her first child and would likely deliver shortly. Another woman was at 3 cm dilation but was failing to progress much. Child birth in India is very different than child birth in the US-

• epidurals are not used (in part because of a shortage of anesthesiologist and partly because children are considered a gift worth experiencing pain for)
• no family members/friends are allowed in the delivery room (it is just the patients and staff)
• normal delivery at a private hospital costs around 2000-3000 Rupees (40 Rupees= $1)
• c-section at a private hospital costs around 5000 Rupees

The woman delivered a healthy baby girl (with a bit of a cone head) after a lot of hard work, vacuum assistance, and an episiotomy. A pediatrician was present upon delivery to examine the infant. The delivery went well and the physicians did a wonderful job caring for the mother and fetus… but I still can’t help but think I hope I deliver my children in the US w/family in the room and maybe an epidural. :)

The physicians decided to take the other woman, who was failing to progress, to the OR for a c-section. They told us to go have lunch and meet in the OR in half an hour. Eva and I saw our second c-section… this one a little faster than the first as the baby was showing signs of distress. The woman had a healthy baby boy. Turned out to be a very exciting day!

This weekend we are headed to Badami and Bijapur, two cities close by, with Eva’s Uncle and Aunt. Both places are supposed to have some pretty amazing architecture- temples and mosques. (hopefully I can get some pictures and fingers crossed... we will get broadband internet at some point so I can post them) On Monday we will report to our pediatrics posting.

Trip to Gokak

On Thursday (May 31st) Eva, Shiva, Uncle, and I traveled to Gokak. Gokak, where Shiva and his 11 siblings grew up, is a city about 60 miles from Dharward. However, being as India moves at a different pace than the States (the trip one direction takes about three hours) we left early in the morning and returned late in the evening. The roads were bumpy and busy with buses, cars, trucks, and wagons full of sugar cane/corn pulled by cows, motorcycles, scooters, bicycles, people, goats, sheep, and a few dogs. I was able to see a great deal of Indian countryside and a few small villages on the way. Transportation here is a bit crazy but we arrived to Gokak safely. After a cold drink (the car has no AC and India is hot) at the Gokak Resort (a story all its own) we visited a temple up in the mountains. The “mountains” remind me of the badlands of South Dakota rather than the mountains of Colorado or Alaska.

To get to the temple we had to climb many steps, Eva and I were a bit concerned about Shiva and Uncle. On the trek up we were accompanied by lots of monkeys :) Uncle brought some coconuts and various things for puja (prayer/offering). The monkeys being rather clever and accustomed to guests bringing food snuck up behind Shiva and actually ripped a bag of rice open. Before we knew it a whole gathering of monkeys were feasting on the steps. When we reached to top we explored the temple a bit, took in the view, looked at all the monkeys, and observed puja.

After the temple we continued to Adubathi- the village closest to the farm owned by Eva’s family. The road was dirt and washed out so we walked most of the way. Once in the village we again visited the temple so Uncle could make an offering. I’m not sure how many people live in Adubathi or how frequently they have visitors (especially white visitors) but we developed a small following of children on our way through town. The homes were modest, with cattle in what I would call the front porch, and little kids everywhere. In the river near the temple women were washing clothes on rocks and some little kids were swimming/bathing. I took some pictures of the children and showed them on my digital camera- they laughed.

We walked down another dirt road to the farm house Eva’s family built in 2000. Her family still owns the land but has hired a family to farm it. We sat with the family living there for a bit. It appeared to be a man and his wife, their son and his wife, and the son’s children. The farm was peaceful and a drastic contrast to the hot car and crowded streets we had come from. After a short visit and some pictures we returned to Gokak for lunch and a visit to the home Shiva grew up in. On the way we got stuck in a traffic jam = sitting in a hot car for 45 minutes with the sun beating down and lots of Indian men yelling in a language I don’t understand :) We then went through the market where vegetables, fruits, and all sorts of spices are sold by weight. The streets were lined with local farmers who had brought their goods to town in large bags and spread them out in the street- Thursday is bizarre day in Gokak.

The home was built in 1900 by the family and Shiva’s eldest brother’s wife lives there with her children and grandchildren. The house was about 4 rooms w/an attic where everyone slept. Shiva shared storied about growing up there with his 11 siblings. Shiva and all of his siblings were delivered at home- he showed us the room (just next to the kitchen). The crib, which was used for about 40 children, is still in the house- it is wooden and hangs by hooks and chains from the ceiling. Shiva said it was not uncommon for mother and daughter/ daughter-in-law to be delivering at the same time- I suppose if one woman has 12 children. We had tea with Eva’s cousin as her Aunt had left for a pilgrimage up north and not yet returned. Then it was back in the car for the journey home- we took a different route this time and thankfully it was a bit smoother.