Filling you in on the last week…
On Sunday (Valentine’s Day) Eva and I met the two Australian medical students (Dan and Liam) at Hotel Timor for lunch, dessert buffet, some pool time, and the hope of free wireless internet. As usual things did not go quite as planned- lunch and the all you can eat dessert buffet were amazing, we snuck into the pool area and lazed around for hours no problem…. the internet however was of course a myth (thus the delay in the last posting and no new picture). I have realized how much I take internet access (on laptops and iphones) for granted at home.
I returned to clinic Monday morning after basically recovering from dengue (although my legs were still covered in a rash for a few more days). I spent last week traveling to a few mobile clinics- seeing around 50 patients in 2 hours at one Eva and I went to together which was a 3 hour drive west of Dili (the evaluation at mobile clinic is very brief and really serves as a means of identifying those few patients who are very ill needing to be brought into Dili for further evaluation/treatment as well as to ensure these communities feel their health concerns/needs are supported). I was able to assist in/observe a few deliveries this week which was also exciting. I have been a bit disappointed in the amount of obstetrics Eva and I have been involved in… the midwives at the clinic handle the majority of the deliveries and it always seems our days are filled with other tasks- unable to just hang out in maternity.
The malnutrition program continues to function and has been greatly aided by the addition of a pediatrician from Australia. Her name is Maggie and she will be spending several months here in Dili. She was excited to work with Grace and I on the program and (as I have hoped to see other parts of the care provided by BPC) she has basically taken over coordinating the daily efforts. We continue to have a large inpatient population of tuberculosis (TB) patients which has been quite interesting. The advanced stage TB presents in Timor Leste is basically unheard of in the United States. Eva and I are both learning a great deal about the varied presentations, treatment, and prevention strategies. Aside from malnutrition and TB patients there are several cases of malaria, dengue, pneumonia, pylonephritis, urinary tract infection, pelvic inflammatory disease, leprosy, mastitis, and gastrointestinal worms.
Last Monday Eva and I were invited to dinner at Tracy Morgan’s home by Dan (one of the Australian medical students). Tracy Morgan is an expat living in Timor Leste working for an NGO… she is fairly well known due to the length of time she has been active in the country/Dili community and because she owns a large home where she houses many foreigners traveling through Timor Leste (Dan is currently living there). The dinner party was in honor of one of the Irish girls living with Tracy and Dan as she is leaving the country to return to Ireland. It was a wonderful dinner and I write about it only to give some insight into the diverse group of foreigners we have met who are here in Timor all working on various projects. There was the Irish girl working for the UN, an Australian working for the police force in Dili, an Australian working for the education system, an Australian working for Marie Stopes Clinic (a family planning center), a Japanese girl working for the office of immigration, a Tasmanian pediatrician, two Australian medical students, two American medical students (Eva and I), and Tracy who is a lawyer by trade. Needless to say dinner conversation was interesting as we enjoyed pasta with marinara and feta, egg plant, garlic bread, red wine, and mango crisp with ice cream for dessert (definitely the best we have eaten since our arrival). It has been great to interact with so many individuals from varied backgrounds.
Now… for the highlight of this blog… and possible the entire trip!! Eva and I spent the weekend in Atauro, which is a small island about 30km north of Dili. The island is 140 sq-km, has a population that totals around 8,000, and only two small cities with occasional electricity. Dan, Liam, Eva, and I all decided it was time to get out of Dili for a weekend and explore Atauro. We boarded a ferry on Saturday morning for the two hour ride across the Wetar Strait. Upon arrival we walked to our accommodations for the weekend called Nemas. Run by an Australian named Barry, Nemas, includes 5 thatched huts right on the beach. We were fortunate to stay in the largest hut which actually had sleeping space for around 8 people and open air bathroom facilities in back. The other huts were occupied by a group of 3 Australians, 2 Portuguese, and a group with 1 Australian and 2 Portuguese. We all enjoyed each other’s company as we dined together in the main hut where Barry and his extended Timorese family live.
After arriving on Saturday, eating a bit of lunch, and getting settled in we spent the afternoon enjoying the beach, reading in the hammock, and playing a bit of Frisbee on the beach. Dinner was served again in the main hut and then the majority of the guests at Nemas returned to our hut for some music. Dan is a talented guitar player and singer (Eva joined in on a few songs and experimented with the harmonica which was great). It was really the perfect ending to an excellent day.
On Sunday, after breakfast and a café Timor or two (East Timor is known for its wonderful coffee), most of us guest loaded in Barry’s small boat for some snorkeling. Having never snorkeled before I was a bit apprehensive but let me just say it was amazing!!! The coral reefs around Timor are supposed to be some of the best in the world and I was reminded over and over again by the other guests how fortunate I was to have this be my first look at life in the sea. We spend several hours flipping around the crystal clear water looking at all sorts of sea creatures… just long enough for both Eva and I to burn our backsides. The remainder of Sunday afternoon was spent in the same manner as Saturday afternoon. I finished another wonderful book in our hammock, the title being “What is the What” and recommend it to anybody looking for something to read. The only downside of going to Atauro for the weekend is the only way to return to Dili is by fishing boat on Monday morning (the ferry only goes for the day on Saturday leaving around 3 PM- not enough time to enjoy the island). So at 3:15 AM Monday morning the alarm went off, all of the guest from Nemas enjoyed one more cup of café Timor together, and loaded in the back of a truck at 4 AM to head to Vilo to catch our boat. The fishing boat was better than I anticipated (we had heard horror stories of foreigners scooping buckets of water out of the bottom of boats as waves crashed over the edge wishing they had a life jacket). Our boat was much different than the image I had in my head. The majority of people stretched out on the deck and slept during the 3 hour trip back to Dili. I stayed awake, saw a few dolphins and flying fish in the early morning light, enjoyed the ride/breeze, and watched the sunrise over the water and Timor. It was truly a wonderful/perfect weekend- great atmosphere and great company. Eva and I returned to BPC refreshed for another week.
This week looks to be very similar to those previous. Eva and I plan to head out to several mobile clinics after morning rounds and spend our evenings with the friends we have made here. We went to the US embassy this evening as a birthday party was being held in George Washington’s honor- turned out to be a standard BBQ by the onsite pool. Eva and I enjoyed a cheeseburger, Diet Coke (for me), and a beer (for Eva) while chatting with several military personal who are working with the Mercy Ship (a naval boat with first class facilities that travels to foreign countries providing medical care). Turned out to be an interesting evening… the US embassy grounds are almost embarrassingly extravagant compared to the surroundings (not sure what else I expected). On Thursday we plan to go out to dinner, maybe Thai, as both Liam and one of the Australian doctors we have spent time with will be returning home on Saturday. Friday is Dan’s 31st birthday (Australian medical student not Dr. Dan) … the plan was to celebrate, however Dan became ill after returning from Atauro… so we will have to wait and see how he is feeling by Friday. Regardless it should be a good week.
Eva and I have booked our return tickets to Australia. We will be spending some time in Darwin and Sydney both before heading home on March 13th. Hope this message finds everybody well... and for those in Iowa while it is scary to say… I miss the snow.
(PS- I apologize for any typos/improper grammar as I have not been proof reading)
Wednesday, February 24, 2010
Sunday, February 14, 2010
2/11/2010, A few bumps in the road...
Since the last post my main project has continued to be developing a malnutrition program at Bairo Pite Clinic (BPC) for the children that continue to come into Dr Dan’s office looking emaciated. The hope is to develop a program that can be maintained by the volunteers and clinic staff after we leave here. It sounds like there have been several attempts at this in the past always ending with a similar story- volunteers come, set up a program, leave, and the program falls apart. Candice, the Australian intern, actually helped establish a malnutrition program here on her first trip to BPC over a year ago. I feel a bit uncertain about how to set up a malnutrition program and I also feel a bit uncertain about how to ensure that it will last.
As a general rule here is Timor-Leste, as in most developing countries, infants receive adequate nutrition as long as they are breastfeed and can avoid illness resulting in diarrhea, vomiting, or poor feeding. That being said when children transition from breast milk to whatever food Mom and Dad are eating many run into trouble. Whether it is the frequency of feeds (which need to be more than 3 times a day like the parents), the quality of food/food preparation, the quantity of food, or any number of other factors malnutrition can become a problem quickly. The majority of the children we are admitting with malnutrition also have complaints of diarrhea, vomiting, and in several cases worms.
With the use of several resources, including the WHO malnutrition guidelines, the advice of two Australian pediatricians, the advice of several volunteers, my fellow medical students, and the clinics nutritionist (that’s right there is a clinic nutritionist…. not sure what else she is all responsible for but I question how you can have a nutritionist on staff and have children dying of hypoglycemia… frustrating) I think we have come up with a pretty good system. It is far from perfect; there just isn’t the staff at BPC to monitor the kids and their feedings as closely as should be done. That being said the kids are eating and gaining weight.
One of the volunteers, Grace, a 19 year old who has recently graduated from high school and is hoping to get a scholarship to study medicine outside of Timor-Leste, has been the best of help. She has been our partner in crime. We weight the kids everyday and hand out packets of what looks like powdered milk called F100. The parents just mix the F100 with 100 mL clean water and feed to their kids every 3 hours. The premixed formula is distributed by the WHO and has all the essentials in the appropriate proportions. We have had several children discharged looking a bit plumper which is promising. One of the children passed away during the night. Dr Dan was not informed until I found out when I had one less kid to weigh and asked the other mothers where she was. Again… frustrating and sad. Really… unnecessary. We have several children in the malnutrition ward that would likely be better served at Dili National where they have a well established malnutrition program with the appropriately trained staff but continue to meet resistance when the suggestion is made to transfer these patients. So we just keep suggesting… and hope for the best.
Now for life outside of BPC… at the end of last week I was sick with what I thought was just a sinus infection (of all things). I was congested, had a headache, pressure/pain over my right maxillary sinus, purulent drainage, and a fever. I started a course of antibiotics, which I brought from home, and stayed in bed except to run to clinic to get tested for malaria just to make sure. I was anxious to feel better so I could accompany everybody to Mt Ramelau for our weekend getaway. By Saturday morning, when we were to depart Dili for the three hour drive south into the mountains, I was feeling a bit better so I loaded in to our rented 4 wheel drive with the other med students. The roads were horrible!! I don’t get motion sick but this trip was enough to put both Eva and I over the edge- up and down, winding through the mountains, avoiding pot holes/sections of washed out road, and just about everything else you can imagine.
We arrived in Maubisse mid afternoon and pulled up to the Pousada, a Poutugesse guesthouse, where we were spending the night. The plan was to hang out Saturday afternoon, enjoy the view of the mountains from the Pousada, wake up bright and early Sunday morning, climb Mt Ramelau, and head back to Dili Sunday afternoon. The Pousada was a beautiful guesthouse tucked in the mountains with gardens and great views all around. Unfortunately, I was feeling rather rotten by the time we arrived so spent all day laying in bed. Eva, the Australians, and the New Yorker played Frisbee and foosball. The air was cool, quiet, and clean in the mountains (very different from Dili). We ate dinner at the main house and I again returned to bed hoping to feel well enough to climb in the AM.
Sunday morning Eva, one of the Australians (the other one was feeling ill), the New Yorker, and I headed for Mt Ramelau at 5 AM. We were able to find the trail head with only a few wrong turns and were hiking up the mountain by 7:30 AM. The hike was wonderful, I was feeling better, and it was so nice to be out and get some exercise. The views on the way up were remarkable and thankfully it remained clear the majority of the way. We reached the top around 10:30 AM by which point clouds had rolled in and we weren’t able to see much unfortunately. The top is marked by a 3m high statue of the Virgin Mary- we took in some sustenance (cheese and crackers, oreos, and bananas) in her presence before heading back to our vehicle. Upon returning to the Pousada we ate lunch and again loaded into our 4 wheel drive for the painful drive back to Dili… this time it rained the entire way. Feeling ill once again by the time we got home Eva and I were in bed and asleep by 8 PM.
This week started just as any of the others have… we were up and headed to clinic for rounds at 8AM. Monday turned out to be a pretty typical day. We went to the grocery store in the evening as we were going to have dinner at Dr Dan’s on Tuesday because the New York medical student was leaving on Wednesday. Eva and I went for Monday night dinner at the Indian restaurant across the street and for some reason I wasn’t feeling quite right. I figured maybe I was still recovering from my sinus infection… so showered and headed to bed when we got home. Tuesday morning I wasn’t feeling much better (dizzy, weak) but again got myself together and headed to clinic with Eva for morning rounds. As I put on bug spray that morning for the millions of mosquitoes I thought maybe I was poisoning myself with DEET (turns out I was wrong). While in the maternity ward I started to feel faint so excused myself and took a seat outside. Dr Dan sent me to the lab to again get tested for malaria and this time dengue as well. Surprise… surprise… I have dengue fever.
For those who don’t know dengue fever is a mosquito-borne virus which is relatively common throughout Asia and thus Timor. There is no vaccine available and they only way to avoid it is to avoid mosquito bites- easier said than done here. Symptoms include high fever, headache, body ache, diarrhea, and some get a rash. Check to all of those. There is no specific treatment for dengue- just rest and take Tylenol for the fever. The other key is to have your platelet count checked daily to ensure they are not falling as dengue can become hemorrhagic. So this is what I have been doing all week... (having the true Timorese experience as many have said). I have been laying in bed feeling lousy and weak, taking Tylenol to try and control the fever, Eva has been drawing my blood every morning to have my platelet count checked at the hospital, and the Australian doctors who round with us on Sundays have been doing home visits to check on my every day. For this I am so thankful!! I have been reading some great books during the day when I am awake to keep my mind occupied. I’m starting feel a bit more like myself but being sick in a foreign place really makes me miss home.
I’m not sure what day I will head back to the clinic… hopefully tomorrow if I feel up to it as I am going a bit crazy in our little room. Eva and I are going to try and go to Hotel Timor (the nicest hotel in the country) sometime this weekend as we heard rumor they have free Wi Fi and an all you can eat dessert buffet… I’ll try and post this blog and maybe a picture or two at the time. Hope everybody has a very Happy Valentine’s Day!
As a general rule here is Timor-Leste, as in most developing countries, infants receive adequate nutrition as long as they are breastfeed and can avoid illness resulting in diarrhea, vomiting, or poor feeding. That being said when children transition from breast milk to whatever food Mom and Dad are eating many run into trouble. Whether it is the frequency of feeds (which need to be more than 3 times a day like the parents), the quality of food/food preparation, the quantity of food, or any number of other factors malnutrition can become a problem quickly. The majority of the children we are admitting with malnutrition also have complaints of diarrhea, vomiting, and in several cases worms.
With the use of several resources, including the WHO malnutrition guidelines, the advice of two Australian pediatricians, the advice of several volunteers, my fellow medical students, and the clinics nutritionist (that’s right there is a clinic nutritionist…. not sure what else she is all responsible for but I question how you can have a nutritionist on staff and have children dying of hypoglycemia… frustrating) I think we have come up with a pretty good system. It is far from perfect; there just isn’t the staff at BPC to monitor the kids and their feedings as closely as should be done. That being said the kids are eating and gaining weight.
One of the volunteers, Grace, a 19 year old who has recently graduated from high school and is hoping to get a scholarship to study medicine outside of Timor-Leste, has been the best of help. She has been our partner in crime. We weight the kids everyday and hand out packets of what looks like powdered milk called F100. The parents just mix the F100 with 100 mL clean water and feed to their kids every 3 hours. The premixed formula is distributed by the WHO and has all the essentials in the appropriate proportions. We have had several children discharged looking a bit plumper which is promising. One of the children passed away during the night. Dr Dan was not informed until I found out when I had one less kid to weigh and asked the other mothers where she was. Again… frustrating and sad. Really… unnecessary. We have several children in the malnutrition ward that would likely be better served at Dili National where they have a well established malnutrition program with the appropriately trained staff but continue to meet resistance when the suggestion is made to transfer these patients. So we just keep suggesting… and hope for the best.
Now for life outside of BPC… at the end of last week I was sick with what I thought was just a sinus infection (of all things). I was congested, had a headache, pressure/pain over my right maxillary sinus, purulent drainage, and a fever. I started a course of antibiotics, which I brought from home, and stayed in bed except to run to clinic to get tested for malaria just to make sure. I was anxious to feel better so I could accompany everybody to Mt Ramelau for our weekend getaway. By Saturday morning, when we were to depart Dili for the three hour drive south into the mountains, I was feeling a bit better so I loaded in to our rented 4 wheel drive with the other med students. The roads were horrible!! I don’t get motion sick but this trip was enough to put both Eva and I over the edge- up and down, winding through the mountains, avoiding pot holes/sections of washed out road, and just about everything else you can imagine.
We arrived in Maubisse mid afternoon and pulled up to the Pousada, a Poutugesse guesthouse, where we were spending the night. The plan was to hang out Saturday afternoon, enjoy the view of the mountains from the Pousada, wake up bright and early Sunday morning, climb Mt Ramelau, and head back to Dili Sunday afternoon. The Pousada was a beautiful guesthouse tucked in the mountains with gardens and great views all around. Unfortunately, I was feeling rather rotten by the time we arrived so spent all day laying in bed. Eva, the Australians, and the New Yorker played Frisbee and foosball. The air was cool, quiet, and clean in the mountains (very different from Dili). We ate dinner at the main house and I again returned to bed hoping to feel well enough to climb in the AM.
Sunday morning Eva, one of the Australians (the other one was feeling ill), the New Yorker, and I headed for Mt Ramelau at 5 AM. We were able to find the trail head with only a few wrong turns and were hiking up the mountain by 7:30 AM. The hike was wonderful, I was feeling better, and it was so nice to be out and get some exercise. The views on the way up were remarkable and thankfully it remained clear the majority of the way. We reached the top around 10:30 AM by which point clouds had rolled in and we weren’t able to see much unfortunately. The top is marked by a 3m high statue of the Virgin Mary- we took in some sustenance (cheese and crackers, oreos, and bananas) in her presence before heading back to our vehicle. Upon returning to the Pousada we ate lunch and again loaded into our 4 wheel drive for the painful drive back to Dili… this time it rained the entire way. Feeling ill once again by the time we got home Eva and I were in bed and asleep by 8 PM.
This week started just as any of the others have… we were up and headed to clinic for rounds at 8AM. Monday turned out to be a pretty typical day. We went to the grocery store in the evening as we were going to have dinner at Dr Dan’s on Tuesday because the New York medical student was leaving on Wednesday. Eva and I went for Monday night dinner at the Indian restaurant across the street and for some reason I wasn’t feeling quite right. I figured maybe I was still recovering from my sinus infection… so showered and headed to bed when we got home. Tuesday morning I wasn’t feeling much better (dizzy, weak) but again got myself together and headed to clinic with Eva for morning rounds. As I put on bug spray that morning for the millions of mosquitoes I thought maybe I was poisoning myself with DEET (turns out I was wrong). While in the maternity ward I started to feel faint so excused myself and took a seat outside. Dr Dan sent me to the lab to again get tested for malaria and this time dengue as well. Surprise… surprise… I have dengue fever.
For those who don’t know dengue fever is a mosquito-borne virus which is relatively common throughout Asia and thus Timor. There is no vaccine available and they only way to avoid it is to avoid mosquito bites- easier said than done here. Symptoms include high fever, headache, body ache, diarrhea, and some get a rash. Check to all of those. There is no specific treatment for dengue- just rest and take Tylenol for the fever. The other key is to have your platelet count checked daily to ensure they are not falling as dengue can become hemorrhagic. So this is what I have been doing all week... (having the true Timorese experience as many have said). I have been laying in bed feeling lousy and weak, taking Tylenol to try and control the fever, Eva has been drawing my blood every morning to have my platelet count checked at the hospital, and the Australian doctors who round with us on Sundays have been doing home visits to check on my every day. For this I am so thankful!! I have been reading some great books during the day when I am awake to keep my mind occupied. I’m starting feel a bit more like myself but being sick in a foreign place really makes me miss home.
I’m not sure what day I will head back to the clinic… hopefully tomorrow if I feel up to it as I am going a bit crazy in our little room. Eva and I are going to try and go to Hotel Timor (the nicest hotel in the country) sometime this weekend as we heard rumor they have free Wi Fi and an all you can eat dessert buffet… I’ll try and post this blog and maybe a picture or two at the time. Hope everybody has a very Happy Valentine’s Day!
Friday, February 5, 2010
2/1/2010
So… this blog is late but as you will see by the time you get through it Eva and I have been very busy since leaving the States and I have had little time to reflect/write. I will try to start at the beginning and hit the high points. We arrived in Australia in the morning on January 21st. Eva’s first cousin once removed (a stretch I know… but you must be resourceful) picked us up from the airport and was an excellent host for our short time in Sydney. We spent the day cleaning up after the journey, visiting a wild life reserve (so many fun animals in Australia), and having a family dinner with a few other extended relatives. We had a great time with good company. The following morning we flew to Darwin, Australia where we again spent the night before catching our last flight to Dili, Timor-Leste on Saturday the 23rd. Darwin was quite nice… we had “fish and chips” and Australian beer before retiring to our airport hotel (thank you Shiva and Irene). Our flight left Darwin around 6 AM and we arrived in Dili in about 1.5 hours.
As we approached Timor-Leste from the air it was clear we were about to see some beautiful landscape- blue green ocean and beaches surrounding jungle covered mountains. While the island is still largely underdeveloped I don’t see this lasting too long as tourists will surely arrive in flocks at some point. After clearing customs we were picked up at the airport by 2 members of the clinic staff and a medical student from New York who is also working at the clinic. Eva and I were relieved someone knew we were coming… we returned to the clinic in an ambulance to join in on AM rounds.
Bairo Pite Clinic, where we will be working here in Dili, is like a small compound all run by one physician, Dr. Dan Murphy (Dr Dan to everyone here). There are about 6 wards (maternity, TB, pediatrics, malnutrition, and two for general inpatient), a basic emergency room, a pharmacy, a lab, a kitchen, and a clinic where Dr Dan sees outpatient consultations all day. All of the facilities are very basic but seem to serve their purpose. In total there are around 30-50 inpatient at any given time and about 300 patients are seen each day in the consultation room. That’s right… its crazy!! In general the clinic/hospital seems to do good work. That said, there have been several occasions where patient care has suffered due to insufficient resources and man power. Patients receive care for free, both inpatient and outpatient. Dr Dan informed me that the clinic and hospital function entirely on donations, which is quite impressive. Currently, there are 5 medical students and one intern spending time at the clinic- Eva and I, two Australian medical students, the medical student from New York, and an Australian intern. We work well together and have been spending what little free time we have together.
Dr Dan came to Dili in 1999, just as Timor-Leste gained independence from Indonesia. He has remained in the country ever since, working at his clinic despite several episodes of civil unrest/violence. He has gained the trust and respect of many people here. I myself am very impressed with his dedication to these people. That being said… Dr Dan is an interesting character and functions very much as an independent physician. He feels strongly that in the majority of patient cases he knows what is best with little room for outside opinion. He is very hesitant to refer patients to Dili National (the government hospital in Dili which is staffed primarily by western trained physicians with many more resources) as a result of poor experiences he has had in the past. However, when you have a group of medical students who have trained in western systems we tend to feel a great many of our patients would be better served if referred to Dili National where more resources are available (x-ray machine, CT scanners, ultrasound, operating rooms, many sub-specialists, and larger nursing/support staff). This obviously leads to many debates within our group when it comes time to develop a plan of action for patients. It has been frustrating and I often feel we are not doing our best to take care of these patients. I try and remind myself that I have only been here for a short time while Dr Dan has been working in the community for over 10 years. I am learning how to advocate for patients, gain confidence in my diagnostic abilities, weigh many options when it comes to caring for people, and develop a working relationship with a “boss” I don’t always see eye to eye with.
Despite the daily frustrations at Bairo Pite, it has proved to be a great learning opportunity- the pathology we are seeing in these patients is quite different from home. Our typical day, Monday-Saturday, begins with rounds at 8 AM for the inpatients. We usually get done around 10 AM at which point Dr Dan begins seeing patients in his office. As students we either sit in with him, go to mobile clinic (load up in one of the ambulances with a driver, volunteer, and box of meds to travel to a surrounding community), work on the long list of tasks discussed on rounds, explore/develop possible diagnosis for puzzling inpatients, or staff the ER performing any number of minor surgical procedures. At around 4 PM or whenever all the students are available we round alone. When Dr Dan has finished seeing outpatients we check out with him and discuss any inpatients we are concerned about. Check out tends to turn into a lengthy discussion given differing opinions about treatment plans and we wrap up around 6-7 PM. On Sundays we just round at 9AM and tend to leave around 12-1 PM. Physicians from other NGOs, Dili National, and several of the embassies show up for Sunday rounds which make them a bit more exciting. Some of the more interesting diagnoses are as follows:
- Malaria
- Tuberculosis (many cases with extrapulmonary disease)
- Malnutrition, primarily in toddlers (I somehow got roped into helping develop a malnutrition program and have learned a great deal in the last week or so)
- End stage breast cancer without the benefit of western medicine
- Abscesses, which I have had the pleasure of draining… along with several other minor surgical procedures
- Marfan’s with advanced heart failure (no cardiothoracic surgeon to operate)
Again, as has been a theme in the majority of my developing world experiences, the pathology seen in patients is always more pronounced as care/appropriate treatment is not as readily available.
So… what’s it like here outside of the clinic??? It’s hot here… very hot especially coming from Iowa winter. Luckily Eva and I have a window air conditioner in our room at East Timor Back Packers, one of the only hostels in Dili. The accommodations are very comfortable- we have a room with a queen bed, mini fridge, AC, common showers and toilets, common outdoor sitting area, no hot water, and a kitchen for making our new favorite dinner (tomato, avocado, cucumber, and hot sauce sandwiches). We are within walking distance of the clinic and several restaurants including a 24 hour gas station which is quite convenient. The people of Timor-Leste are very friendly and both of us feel quite safe. There is a large UN presence here with foreign embassies everywhere which is a bit interesting to see. Dili’s population is about 175,000 people but there are no high rise buildings and the infrastructure is very basic. (I see all of this changing if the tourist industry takes off- currently there are only a handful of hotels in the area)
While restaurants in Dili serve a variety of food (Indonesian, Indian, Western, Portuguese) many tend to be quite expensive due to the large UN/NGO presence. We have been able to find a few in the area that are pretty decent. We also purchased some basics at a local grocery store (primarily food imported from Australia and China) and are exploring the local produce markets regularly (bananas, pineapple, mangos, avocado, tomato, cucumber, etc). I’m pretty sure you could find anything you wanted to eat somewhere in Dili the question would just be price… for instance we passed on a $10 box of granola at the grocery store even though I would kill for a bowl of cereal. We would likely be more creative with our dinner options if we weren’t so drained at the end of the day… a quick sandwich is just so easy.
With all of the ups and downs since leaving the States I think the highlight so far was Sunday’s adventure to one of the many beaches near Dili. The landscape of this country is truly beautiful and I will be sure to share pictures when I return home with those interested. After rounds on Sunday all of us medical students decided to head to the beach for an afternoon of R&R. I ran to the beach from our hostel and everybody else biked. It was a bit farther than we anticipated on a hot day but this made the sea side lunch/beverages all the more enjoyable. We spent the afternoon swimming (the water was so warm), reading, laying around, and chatting. In the evening we went to a local restaurant frequented by foreigners and watched the final match of the Australian open while sipping Indonesian beer. Had to gear up for another week. J
I think we may try and take this coming weekend off to climb Mt Ramelau, which is the highest point in Timor-Leste at 2963 m. On a clear day you are supposed to be able to see both the north and south coast of the island from the top. The five of us students (our Australian intern has headed to Bali) will likely all go together. I’ll write more in the near future and again apologize for the delay.
So… this blog is late but as you will see by the time you get through it Eva and I have been very busy since leaving the States and I have had little time to reflect/write. I will try to start at the beginning and hit the high points. We arrived in Australia in the morning on January 21st. Eva’s first cousin once removed (a stretch I know… but you must be resourceful) picked us up from the airport and was an excellent host for our short time in Sydney. We spent the day cleaning up after the journey, visiting a wild life reserve (so many fun animals in Australia), and having a family dinner with a few other extended relatives. We had a great time with good company. The following morning we flew to Darwin, Australia where we again spent the night before catching our last flight to Dili, Timor-Leste on Saturday the 23rd. Darwin was quite nice… we had “fish and chips” and Australian beer before retiring to our airport hotel (thank you Shiva and Irene). Our flight left Darwin around 6 AM and we arrived in Dili in about 1.5 hours.
As we approached Timor-Leste from the air it was clear we were about to see some beautiful landscape- blue green ocean and beaches surrounding jungle covered mountains. While the island is still largely underdeveloped I don’t see this lasting too long as tourists will surely arrive in flocks at some point. After clearing customs we were picked up at the airport by 2 members of the clinic staff and a medical student from New York who is also working at the clinic. Eva and I were relieved someone knew we were coming… we returned to the clinic in an ambulance to join in on AM rounds.
Bairo Pite Clinic, where we will be working here in Dili, is like a small compound all run by one physician, Dr. Dan Murphy (Dr Dan to everyone here). There are about 6 wards (maternity, TB, pediatrics, malnutrition, and two for general inpatient), a basic emergency room, a pharmacy, a lab, a kitchen, and a clinic where Dr Dan sees outpatient consultations all day. All of the facilities are very basic but seem to serve their purpose. In total there are around 30-50 inpatient at any given time and about 300 patients are seen each day in the consultation room. That’s right… its crazy!! In general the clinic/hospital seems to do good work. That said, there have been several occasions where patient care has suffered due to insufficient resources and man power. Patients receive care for free, both inpatient and outpatient. Dr Dan informed me that the clinic and hospital function entirely on donations, which is quite impressive. Currently, there are 5 medical students and one intern spending time at the clinic- Eva and I, two Australian medical students, the medical student from New York, and an Australian intern. We work well together and have been spending what little free time we have together.
Dr Dan came to Dili in 1999, just as Timor-Leste gained independence from Indonesia. He has remained in the country ever since, working at his clinic despite several episodes of civil unrest/violence. He has gained the trust and respect of many people here. I myself am very impressed with his dedication to these people. That being said… Dr Dan is an interesting character and functions very much as an independent physician. He feels strongly that in the majority of patient cases he knows what is best with little room for outside opinion. He is very hesitant to refer patients to Dili National (the government hospital in Dili which is staffed primarily by western trained physicians with many more resources) as a result of poor experiences he has had in the past. However, when you have a group of medical students who have trained in western systems we tend to feel a great many of our patients would be better served if referred to Dili National where more resources are available (x-ray machine, CT scanners, ultrasound, operating rooms, many sub-specialists, and larger nursing/support staff). This obviously leads to many debates within our group when it comes time to develop a plan of action for patients. It has been frustrating and I often feel we are not doing our best to take care of these patients. I try and remind myself that I have only been here for a short time while Dr Dan has been working in the community for over 10 years. I am learning how to advocate for patients, gain confidence in my diagnostic abilities, weigh many options when it comes to caring for people, and develop a working relationship with a “boss” I don’t always see eye to eye with.
Despite the daily frustrations at Bairo Pite, it has proved to be a great learning opportunity- the pathology we are seeing in these patients is quite different from home. Our typical day, Monday-Saturday, begins with rounds at 8 AM for the inpatients. We usually get done around 10 AM at which point Dr Dan begins seeing patients in his office. As students we either sit in with him, go to mobile clinic (load up in one of the ambulances with a driver, volunteer, and box of meds to travel to a surrounding community), work on the long list of tasks discussed on rounds, explore/develop possible diagnosis for puzzling inpatients, or staff the ER performing any number of minor surgical procedures. At around 4 PM or whenever all the students are available we round alone. When Dr Dan has finished seeing outpatients we check out with him and discuss any inpatients we are concerned about. Check out tends to turn into a lengthy discussion given differing opinions about treatment plans and we wrap up around 6-7 PM. On Sundays we just round at 9AM and tend to leave around 12-1 PM. Physicians from other NGOs, Dili National, and several of the embassies show up for Sunday rounds which make them a bit more exciting. Some of the more interesting diagnoses are as follows:
- Malaria
- Tuberculosis (many cases with extrapulmonary disease)
- Malnutrition, primarily in toddlers (I somehow got roped into helping develop a malnutrition program and have learned a great deal in the last week or so)
- End stage breast cancer without the benefit of western medicine
- Abscesses, which I have had the pleasure of draining… along with several other minor surgical procedures
- Marfan’s with advanced heart failure (no cardiothoracic surgeon to operate)
Again, as has been a theme in the majority of my developing world experiences, the pathology seen in patients is always more pronounced as care/appropriate treatment is not as readily available.
So… what’s it like here outside of the clinic??? It’s hot here… very hot especially coming from Iowa winter. Luckily Eva and I have a window air conditioner in our room at East Timor Back Packers, one of the only hostels in Dili. The accommodations are very comfortable- we have a room with a queen bed, mini fridge, AC, common showers and toilets, common outdoor sitting area, no hot water, and a kitchen for making our new favorite dinner (tomato, avocado, cucumber, and hot sauce sandwiches). We are within walking distance of the clinic and several restaurants including a 24 hour gas station which is quite convenient. The people of Timor-Leste are very friendly and both of us feel quite safe. There is a large UN presence here with foreign embassies everywhere which is a bit interesting to see. Dili’s population is about 175,000 people but there are no high rise buildings and the infrastructure is very basic. (I see all of this changing if the tourist industry takes off- currently there are only a handful of hotels in the area)
While restaurants in Dili serve a variety of food (Indonesian, Indian, Western, Portuguese) many tend to be quite expensive due to the large UN/NGO presence. We have been able to find a few in the area that are pretty decent. We also purchased some basics at a local grocery store (primarily food imported from Australia and China) and are exploring the local produce markets regularly (bananas, pineapple, mangos, avocado, tomato, cucumber, etc). I’m pretty sure you could find anything you wanted to eat somewhere in Dili the question would just be price… for instance we passed on a $10 box of granola at the grocery store even though I would kill for a bowl of cereal. We would likely be more creative with our dinner options if we weren’t so drained at the end of the day… a quick sandwich is just so easy.
With all of the ups and downs since leaving the States I think the highlight so far was Sunday’s adventure to one of the many beaches near Dili. The landscape of this country is truly beautiful and I will be sure to share pictures when I return home with those interested. After rounds on Sunday all of us medical students decided to head to the beach for an afternoon of R&R. I ran to the beach from our hostel and everybody else biked. It was a bit farther than we anticipated on a hot day but this made the sea side lunch/beverages all the more enjoyable. We spent the afternoon swimming (the water was so warm), reading, laying around, and chatting. In the evening we went to a local restaurant frequented by foreigners and watched the final match of the Australian open while sipping Indonesian beer. Had to gear up for another week. J
I think we may try and take this coming weekend off to climb Mt Ramelau, which is the highest point in Timor-Leste at 2963 m. On a clear day you are supposed to be able to see both the north and south coast of the island from the top. The five of us students (our Australian intern has headed to Bali) will likely all go together. I’ll write more in the near future and again apologize for the delay.
Tuesday, July 10, 2007
Patient Cases at the UHTC and RHTC
The last couple days we have been going to the Urban Health Training Center and the Rural Health Training Center as part of our community medicine posting- we are finally getting to see patients all day every day (and no lectures) : )
Here are just a few of the cases we have seen to give you an idea of the patient population and the health problems they face. Note that most treatment given at these outreach centers is just symptomatic and not necessarily curative.
On Friday at the RHTC I was able to see two elderly women suffering from chikungunya (don’t feel bad if you have no idea what that is- I didn’t until I got here). Chikungunya is a virus which is spread by mosquitoes (similar to how malaria is spread)- the disease was first described in Africa and was very rare until recently. In 2005-2006 there was a widespread outbreak of chikungunya in southern India- after heavy rains and flooding (think standing water and mosquitoes). The virus is generally not fatal although some deaths have been attributed to it. Patients suffering from chikungunya generally present with fever, rash of the limbs and trunk, and arthritic symptoms in multiple joints- can be debilitating. The women I saw both had swollen joints and decreased mobility. The physicians said that the crippling joint pain is the most common and pronounced symptom. The fever generally subsides after a day or two while other symptoms, mainly the joint pain, can last up to weeks or even months (generally longer in older patients). There is no specific treatment for chikungunya- at the RHTC treatment is given for relief of the painful joints- anti inflammatory treatment. (The physicians said that in some clinics steroids are being given.)
A mother and her two sons came to the RHTC- all were patients. The mother had malaria and was given quinine tablets for treatment- she presented with fever and chills for days. Her 3 year old son had a terrible case of scabies and an upper respiratory tract infection. He was given antibiotics, skin cream for the scabies, and advised to take an antiseptic bathe. Her 13 year old son was unable to walk or sit in a chair without assistance. This was the first time he had been brought to the clinic- the mother wanted to know what was wrong and what could be done. After a very brief physical exam and patient history the physician suspected muscular dystrophy. The mother reported that her son developed normally until the age of 7- after which he just got worse. Aside from his physical disability his mental function is normal. He is the product of a consanguineous marriage. The family was referred to SDM hospital- orthopedic department for further care. However, the physician was skeptical as to whether or not they would actually take their son to the hospital (due to a lack of transportation, money, etc.).
Side note- in the past few days I have asked a few physicians about consanguineous marriages in India and why they appear to be so common. Here is what I was told… primarily people don’t understand the medical problems that can result in children that come from a consanguineous marriage (congenital abnormalities). They reported however that the number of consanguineous marriages has decreased to about 50% overall- definitely more common in the villages and rural areas than in urban settings (this is down from about 60-70% 10-15 years ago- the result of education about these congenital abnormalities). The reasons given for arranging a marriage between family members were as follows. Since most parents arrange the marriage and since children generally take care of their parents in old age- parents figure that if both members of the couple are family both have some personal stake in taking care of the parents in old age… thus, the parents are guaranteeing that they will be taken care of in the future. Also, if both members of the couple are individually related to the parents this makes certain that any inheritance will be kept within the family. When the parents die whoever (husband or wife) inherits their land, money, or other property is sure to be family.
Maybe the most disheartening case was one I saw at the UHTC. A 19 year old female came in complaining of loss of energy and fatigue. The patient was clearly anemic and malnourished. In taking the patient’s history this is what the physician found out… the woman had recently lost an infant and complained that her in-laws (whom she lives with- it is customary for the daughter-in-law to move in with her husband’s parents) were giving her a hard time about being an unfit mother. She reported that the family was not giving her any food- she said she had eaten dirt she was so hungry. She said her child died because the family was not giving her enough food to produce sufficient milk for the infant. She said her husband, who works in the field during the day, is not sympathetic and sides with his parents. The physician treated her with antidepressants, nutrition supplements, and advice on free feeding programs in the area.
Along with the above cases there was a woman who presented with fatigue and appeared anemic. After a blood test she was found to have a hemoglobin of 5 (should be around 14). There were countless children with skin infections (the result of poor hygiene)… most of them had scabies and due to scratching the skin had been broken, increasing the risk for secondary infections- which most had (presenting as skin boils averaging 1-2 cm in diameter). Oh and a family of 5 all suffering from gastroenteritis- mother, 7 year old son, 3 year old son, 2 year old daughter, and 7 month old daughter. The physician treated them with antibiotics, oral rehydration solution, and a stress on personal hygiene. And on a more positive note today a 98 year old woman came in to the RHTC, after walking 2 km from the neighboring village, to inquire about getting some new glasses. She had broken hers and wasn’t able to see very well with the old pair she had found at home. Aside from the glasses request she was healthy (and probably the cutest old lady I’ve seen- Eva and I took her picture) : )
Our days spent at the UHTC and RHTC have been an amazing opportunity to learn about medicine, about healthcare in India, about treating a patient population with limited resources, and most importantly about compassion. I feel fortunate to have been able to see and learn from patient cases that are not likely to appear at the University of Iowa Hospitals and Clinics.
Here are just a few of the cases we have seen to give you an idea of the patient population and the health problems they face. Note that most treatment given at these outreach centers is just symptomatic and not necessarily curative.
On Friday at the RHTC I was able to see two elderly women suffering from chikungunya (don’t feel bad if you have no idea what that is- I didn’t until I got here). Chikungunya is a virus which is spread by mosquitoes (similar to how malaria is spread)- the disease was first described in Africa and was very rare until recently. In 2005-2006 there was a widespread outbreak of chikungunya in southern India- after heavy rains and flooding (think standing water and mosquitoes). The virus is generally not fatal although some deaths have been attributed to it. Patients suffering from chikungunya generally present with fever, rash of the limbs and trunk, and arthritic symptoms in multiple joints- can be debilitating. The women I saw both had swollen joints and decreased mobility. The physicians said that the crippling joint pain is the most common and pronounced symptom. The fever generally subsides after a day or two while other symptoms, mainly the joint pain, can last up to weeks or even months (generally longer in older patients). There is no specific treatment for chikungunya- at the RHTC treatment is given for relief of the painful joints- anti inflammatory treatment. (The physicians said that in some clinics steroids are being given.)
A mother and her two sons came to the RHTC- all were patients. The mother had malaria and was given quinine tablets for treatment- she presented with fever and chills for days. Her 3 year old son had a terrible case of scabies and an upper respiratory tract infection. He was given antibiotics, skin cream for the scabies, and advised to take an antiseptic bathe. Her 13 year old son was unable to walk or sit in a chair without assistance. This was the first time he had been brought to the clinic- the mother wanted to know what was wrong and what could be done. After a very brief physical exam and patient history the physician suspected muscular dystrophy. The mother reported that her son developed normally until the age of 7- after which he just got worse. Aside from his physical disability his mental function is normal. He is the product of a consanguineous marriage. The family was referred to SDM hospital- orthopedic department for further care. However, the physician was skeptical as to whether or not they would actually take their son to the hospital (due to a lack of transportation, money, etc.).
Side note- in the past few days I have asked a few physicians about consanguineous marriages in India and why they appear to be so common. Here is what I was told… primarily people don’t understand the medical problems that can result in children that come from a consanguineous marriage (congenital abnormalities). They reported however that the number of consanguineous marriages has decreased to about 50% overall- definitely more common in the villages and rural areas than in urban settings (this is down from about 60-70% 10-15 years ago- the result of education about these congenital abnormalities). The reasons given for arranging a marriage between family members were as follows. Since most parents arrange the marriage and since children generally take care of their parents in old age- parents figure that if both members of the couple are family both have some personal stake in taking care of the parents in old age… thus, the parents are guaranteeing that they will be taken care of in the future. Also, if both members of the couple are individually related to the parents this makes certain that any inheritance will be kept within the family. When the parents die whoever (husband or wife) inherits their land, money, or other property is sure to be family.
Maybe the most disheartening case was one I saw at the UHTC. A 19 year old female came in complaining of loss of energy and fatigue. The patient was clearly anemic and malnourished. In taking the patient’s history this is what the physician found out… the woman had recently lost an infant and complained that her in-laws (whom she lives with- it is customary for the daughter-in-law to move in with her husband’s parents) were giving her a hard time about being an unfit mother. She reported that the family was not giving her any food- she said she had eaten dirt she was so hungry. She said her child died because the family was not giving her enough food to produce sufficient milk for the infant. She said her husband, who works in the field during the day, is not sympathetic and sides with his parents. The physician treated her with antidepressants, nutrition supplements, and advice on free feeding programs in the area.
Along with the above cases there was a woman who presented with fatigue and appeared anemic. After a blood test she was found to have a hemoglobin of 5 (should be around 14). There were countless children with skin infections (the result of poor hygiene)… most of them had scabies and due to scratching the skin had been broken, increasing the risk for secondary infections- which most had (presenting as skin boils averaging 1-2 cm in diameter). Oh and a family of 5 all suffering from gastroenteritis- mother, 7 year old son, 3 year old son, 2 year old daughter, and 7 month old daughter. The physician treated them with antibiotics, oral rehydration solution, and a stress on personal hygiene. And on a more positive note today a 98 year old woman came in to the RHTC, after walking 2 km from the neighboring village, to inquire about getting some new glasses. She had broken hers and wasn’t able to see very well with the old pair she had found at home. Aside from the glasses request she was healthy (and probably the cutest old lady I’ve seen- Eva and I took her picture) : )
Our days spent at the UHTC and RHTC have been an amazing opportunity to learn about medicine, about healthcare in India, about treating a patient population with limited resources, and most importantly about compassion. I feel fortunate to have been able to see and learn from patient cases that are not likely to appear at the University of Iowa Hospitals and Clinics.
Sunday, July 8, 2007
Just a few thoughts…
So… this post is just going to be lots of things about our summer here in India and a little bit about our posting in community medicine (more to come later).
I knew coming to India that most Indian marriages are arranged… however I was totally unaware of the process behind arranging a marriage. While times are changing and more and more young people in India are meeting their mates in their own way- opting for “love” marriages (especially in the large urban areas) – here in southern India the majority of marriages are still arranged. Eva’s aunt and uncle are currently helping their nephew interview prospective brides. This past week Auntie and Uncle, as well as, mother and father have traveled three separate days to cities around Dharward to interview girls and the girls’ families. We inquired about the process and this is what I have found out….
First the parents of the man consult a matchmaker to learn of possible brides. They then set up meetings with these girls and the girls’ families for a sort of interview process. There are generally multiple meetings before a decision is made. If the families agree that the couple is a good match they then consult a fortune teller. The fortune teller must check the horoscope of both parties and give the union an “all clear” before the couple can be married. In some cases dowries are still given in the form of money, gold, a car, etc. (of course all situations are a bit different… this is just what I have gathered thus far). If it is decided that the couple is a good match it is at this time that the future bride and groom are able to communicate- get to know each other (alone).
Eva’s uncle explained that not only must the woman and man be a good match (caste, horoscopes, height, beliefs, future plans, etc.) but the families must fit together. Generally, after the couple is married the wife will move in with the groom’s family (most homes here are multiple family dwellings). She will assume the household tasks given to her by her mother-in-law. I don’t know a lot of details about the actually marriage ceremony (it is supposed to be quite the production- generally between 1,000- 2,000 guests)… Eva and I have been invited to attend the wedding reception of one of the physicians from the hospital. The doctor is in forensic medicine and will be getting married this Sunday. It should be an interesting event- we will be wearing saris to the reception.
Now I mentioned above that part of a couple being a good match is being members of the same caste. The caste system is the basic social structure of Hindu society and although it is not as strong today as it once was… it is definitely still present. For example, here at the house there is a girl, about 12 years old, named Lakshmi who helps Auntie with the house work. She is actually the daughter of the family who farms the land owned by Eva’s family (if that makes sense). Lakshmi lives here at the house and attends school in Dharward (which is a better school than the one she would attend growing up on the farm)- she helps cook and clean in exchange for room and board you could say. Even though the family likes her very much, she is a member of a lower caste and thus eats off of different dishes than we do and sleeps on the floor near the stairwell (even though there are about 6 empty beds in the house). Our driver, who takes us to and from the college everyday, is also a member of a lower caste and thus takes his tea out of different cups than we do. It is all very strange to me.
I, being totally unfamiliar with the details of this system, did a little reading in Lonely Planet… here is what I found out. In Hindu society there are 4 castes and below these 4 main castes are the Untouchables or Dalits (menial laborers- sweepers or latrine cleaners). The castes, from top to bottom, are as follows- Brahmin (priets and teachers), Kshatriya (warriors), Vaishya (merchants), and Shudra (laborers). It is thought that if one lives a moral life it is more probable that one will be reborn into a higher caste with better circumstances. Again, in India today the caste system is definitely weakened and far less rigid… but its presence can still be felt.
Eva and I have been enjoying Indian television in the evenings… there are about 3 channels in English. The channels actually broadcast some descent shows… Seinfeld, Friends, Scrubs, Arrested Development and some alright movies. However, more fascinating than the shows are the commercials. It is interesting all that can be learned from a society’s advertisements. For example, there is a commercial (which airs repeatedly) for men’s face wash… and what makes this face wash special is that it whitens your skin. It is called Nivea White for Men (sp?). So…. while Americans are spending loads of money trying to achieve that sun kissed summer glow… Indians are spending money on face soap that will make their skin whiter. There are similar advertisements for women’s face wash. Whiter skin is desirable because it says something about your social status- if your face is light you must work indoors and make more money than the dark skinned man who works in the sun as a laborer.
Onto the next topic… Eva and I have noticed a difference in the maturity level of the second year medical students here at SDM and the second year medical students at the U of I. For instance, the other day we sat down the in a classroom in the Department of Pediatrics with the batch of second year students we were posted with. Eva and I sat in the middle of the second row. Instantly all of the students moved their chairs behind us and one another so that they would be in the back of the classroom, farthest from the professor. Come to find out the medical education system is a bit different here in India… making the age of the students a bit different. In the States, after completing 12th grade, one must earn a bachelors degree (4 years), then attend medical school (4 years), and then complete a residency program in a particular specialty (minimum 3 years)… after this you are a full fledged doctor. In India, after completing 10th grade, one must attend college-11th and 12th grade-(2 years), and then medical school to earn a bachelors degree in medicine (5.5 years including internship)… after this you can practice medicine. There is the option in India to do a postgraduate degree in order to become a specialist (three years). What this basically all means is that at age 23 (my age), I would be practicing medicine already in India, rather than having at least 6 more years to go in the States. At home we must attend 11 years of education (minimum) after 12th grade to become a doctor. Here in India it is just five and a half years after 12th grade. So our fellow 2nd year medical students at SDM are on average 18-19 years old… this would explain the boys punching each other in the arm while the girls are trying to interview a patient : )
We are nearing the end of our time here in Dharward and are in our last posting- community medicine. While it has been a bit of a struggle conveying to the department that we want to spend as much time seeing patients as possible (and as little time in lecture as possible- the Head of Department designed a two week lecture schedule for Eva and I specifically) the posting has been very interesting so far. The Medical Council of India requires that all medical schools in India provide an opportunity for their students to learn about community medicine by establishing and staffing an Urban Health Training Center (UHTC) and a Rural Health Training Center (RHTC). These centers are basically outreach clinics which provide extremely affordable healthcare to the citizens of the lowest socioeconomic class. Patients pay 10 Rupees a month (a quarter) for unlimited treatment at the UHTC and 5 Rupees a month at the RHTC. While the clinics are by no means all encompassing facilities… they do both have 2-3 exam rooms, a small lab (to do blood and urine tests), a pharmacy (all meds are free after the monthly fee has been paid), and immunization programs. If a patient requires further care and is unable to afford the services of SDM Hospital (it is a private facility) they are referred to the free government hospital in Hubli. Each center is staffed by about 15 people (5 doctors) and serves a population of about 30,000 people. The centers are open from 9 AM – 1 PM (6 days a week) during which on average between 80 and 120 patients are seen. The UHTC is located near the slums around Dharward. The RHTC is located in Wayadad, a village of about 3,200 people about 40 minutes drive from Dharward.
Our last day at SDM will be Thursday, July 12th. On Friday Eva and I will take the train to Bangalore. We will be spending the weekend with her uncle in Bangalore… and possibly taking a day trip to Mysore. On Monday, July 16th we will fly to Delhi for a North India Highlights tour (visiting Delhi, Varanasi, Agra, Jaipur, Jodhpur, and Udiapur). The tour will end in Mumbai on July 26th. We will then do some sightseeing in Mumbai (hopefully take in a Bollywood movie or two) before flying home the night of July 31st. I am not sure what the internet access will be like at our various destinations… and seeing as we are moving cities almost every other day… I can’t guarantee updates on my Blog… but I will try : )
I knew coming to India that most Indian marriages are arranged… however I was totally unaware of the process behind arranging a marriage. While times are changing and more and more young people in India are meeting their mates in their own way- opting for “love” marriages (especially in the large urban areas) – here in southern India the majority of marriages are still arranged. Eva’s aunt and uncle are currently helping their nephew interview prospective brides. This past week Auntie and Uncle, as well as, mother and father have traveled three separate days to cities around Dharward to interview girls and the girls’ families. We inquired about the process and this is what I have found out….
First the parents of the man consult a matchmaker to learn of possible brides. They then set up meetings with these girls and the girls’ families for a sort of interview process. There are generally multiple meetings before a decision is made. If the families agree that the couple is a good match they then consult a fortune teller. The fortune teller must check the horoscope of both parties and give the union an “all clear” before the couple can be married. In some cases dowries are still given in the form of money, gold, a car, etc. (of course all situations are a bit different… this is just what I have gathered thus far). If it is decided that the couple is a good match it is at this time that the future bride and groom are able to communicate- get to know each other (alone).
Eva’s uncle explained that not only must the woman and man be a good match (caste, horoscopes, height, beliefs, future plans, etc.) but the families must fit together. Generally, after the couple is married the wife will move in with the groom’s family (most homes here are multiple family dwellings). She will assume the household tasks given to her by her mother-in-law. I don’t know a lot of details about the actually marriage ceremony (it is supposed to be quite the production- generally between 1,000- 2,000 guests)… Eva and I have been invited to attend the wedding reception of one of the physicians from the hospital. The doctor is in forensic medicine and will be getting married this Sunday. It should be an interesting event- we will be wearing saris to the reception.
Now I mentioned above that part of a couple being a good match is being members of the same caste. The caste system is the basic social structure of Hindu society and although it is not as strong today as it once was… it is definitely still present. For example, here at the house there is a girl, about 12 years old, named Lakshmi who helps Auntie with the house work. She is actually the daughter of the family who farms the land owned by Eva’s family (if that makes sense). Lakshmi lives here at the house and attends school in Dharward (which is a better school than the one she would attend growing up on the farm)- she helps cook and clean in exchange for room and board you could say. Even though the family likes her very much, she is a member of a lower caste and thus eats off of different dishes than we do and sleeps on the floor near the stairwell (even though there are about 6 empty beds in the house). Our driver, who takes us to and from the college everyday, is also a member of a lower caste and thus takes his tea out of different cups than we do. It is all very strange to me.
I, being totally unfamiliar with the details of this system, did a little reading in Lonely Planet… here is what I found out. In Hindu society there are 4 castes and below these 4 main castes are the Untouchables or Dalits (menial laborers- sweepers or latrine cleaners). The castes, from top to bottom, are as follows- Brahmin (priets and teachers), Kshatriya (warriors), Vaishya (merchants), and Shudra (laborers). It is thought that if one lives a moral life it is more probable that one will be reborn into a higher caste with better circumstances. Again, in India today the caste system is definitely weakened and far less rigid… but its presence can still be felt.
Eva and I have been enjoying Indian television in the evenings… there are about 3 channels in English. The channels actually broadcast some descent shows… Seinfeld, Friends, Scrubs, Arrested Development and some alright movies. However, more fascinating than the shows are the commercials. It is interesting all that can be learned from a society’s advertisements. For example, there is a commercial (which airs repeatedly) for men’s face wash… and what makes this face wash special is that it whitens your skin. It is called Nivea White for Men (sp?). So…. while Americans are spending loads of money trying to achieve that sun kissed summer glow… Indians are spending money on face soap that will make their skin whiter. There are similar advertisements for women’s face wash. Whiter skin is desirable because it says something about your social status- if your face is light you must work indoors and make more money than the dark skinned man who works in the sun as a laborer.
Onto the next topic… Eva and I have noticed a difference in the maturity level of the second year medical students here at SDM and the second year medical students at the U of I. For instance, the other day we sat down the in a classroom in the Department of Pediatrics with the batch of second year students we were posted with. Eva and I sat in the middle of the second row. Instantly all of the students moved their chairs behind us and one another so that they would be in the back of the classroom, farthest from the professor. Come to find out the medical education system is a bit different here in India… making the age of the students a bit different. In the States, after completing 12th grade, one must earn a bachelors degree (4 years), then attend medical school (4 years), and then complete a residency program in a particular specialty (minimum 3 years)… after this you are a full fledged doctor. In India, after completing 10th grade, one must attend college-11th and 12th grade-(2 years), and then medical school to earn a bachelors degree in medicine (5.5 years including internship)… after this you can practice medicine. There is the option in India to do a postgraduate degree in order to become a specialist (three years). What this basically all means is that at age 23 (my age), I would be practicing medicine already in India, rather than having at least 6 more years to go in the States. At home we must attend 11 years of education (minimum) after 12th grade to become a doctor. Here in India it is just five and a half years after 12th grade. So our fellow 2nd year medical students at SDM are on average 18-19 years old… this would explain the boys punching each other in the arm while the girls are trying to interview a patient : )
We are nearing the end of our time here in Dharward and are in our last posting- community medicine. While it has been a bit of a struggle conveying to the department that we want to spend as much time seeing patients as possible (and as little time in lecture as possible- the Head of Department designed a two week lecture schedule for Eva and I specifically) the posting has been very interesting so far. The Medical Council of India requires that all medical schools in India provide an opportunity for their students to learn about community medicine by establishing and staffing an Urban Health Training Center (UHTC) and a Rural Health Training Center (RHTC). These centers are basically outreach clinics which provide extremely affordable healthcare to the citizens of the lowest socioeconomic class. Patients pay 10 Rupees a month (a quarter) for unlimited treatment at the UHTC and 5 Rupees a month at the RHTC. While the clinics are by no means all encompassing facilities… they do both have 2-3 exam rooms, a small lab (to do blood and urine tests), a pharmacy (all meds are free after the monthly fee has been paid), and immunization programs. If a patient requires further care and is unable to afford the services of SDM Hospital (it is a private facility) they are referred to the free government hospital in Hubli. Each center is staffed by about 15 people (5 doctors) and serves a population of about 30,000 people. The centers are open from 9 AM – 1 PM (6 days a week) during which on average between 80 and 120 patients are seen. The UHTC is located near the slums around Dharward. The RHTC is located in Wayadad, a village of about 3,200 people about 40 minutes drive from Dharward.
Our last day at SDM will be Thursday, July 12th. On Friday Eva and I will take the train to Bangalore. We will be spending the weekend with her uncle in Bangalore… and possibly taking a day trip to Mysore. On Monday, July 16th we will fly to Delhi for a North India Highlights tour (visiting Delhi, Varanasi, Agra, Jaipur, Jodhpur, and Udiapur). The tour will end in Mumbai on July 26th. We will then do some sightseeing in Mumbai (hopefully take in a Bollywood movie or two) before flying home the night of July 31st. I am not sure what the internet access will be like at our various destinations… and seeing as we are moving cities almost every other day… I can’t guarantee updates on my Blog… but I will try : )
Friday, June 29, 2007
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.
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.
Monday, June 25, 2007
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.
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.
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