I've spent the past few days this week in the hospital, mostly observing in the OPD (outpatient department) and Casualty (or the Emergency Room as we would call it).
It is quite interesting to see the similarities and also intense differences that exist.
The morning begins at 8:30am with a short devotion service. I was initially very wary of this, but it actually turned out to be quite pleasant. The service is lead by Dr. Philip and begins with songs in Hindi, followed by a brief, but meaningful sermon.
Rounds begin immediately after devotion, led by Dr. Philip, who is then tailed by a contingent of nearly 20 other doctors and students. Rounds in this case consist of every in-patient in the hospital, so you see a wide variety of cases.
Day 1 started in the ICU (which consists of 3 beds), principally with a woman who was sadly on death's door... congestive heart failure, emphysema, and a variety of other issues (apparently she passed later that day). The condition of the patients improved considerably as we wound our way through the patchwork of rooms and buildings that house the patients. We reached the pediatric ward and saw two tiny babies, each only 3 weeks old, both of whom were severely dehydrated from nausea and diarrhea. This seemed a bit odd to me, as you would expect them to be breastfeeding, but perhaps they were not doing so. The poor things were so tiny...
We saw a number of other young children with diarrhea, fever and dehydration, but that is pretty typical around here. Food and water sanitation can be pretty problematic in some parts of the area.
We then came to another adult ward and saw a teenage boy who was complaining of severe headaches and extreme lethargy. My mind went to migraines, but they said they thought he had tb meningitis. Apparently the brain scan had showed "water" by which I think they meant cerebral spinal fluid in his head. They put him on anti-tb treatment and steroids and moved on. He was discharged the next day...
When my Mom and I found this out we were both a bit disturbed. She explained to me that without doing a culture, there is no way they could be sure that it was tb meningitis and not one of several other things. They apparently discharged him because he was more alert and seemed to be doing better, but that was because they gave him a huge shot of steroids to wake him up, not because the tb meds had started working.
I am not writing this to be critical... in general, the hospital does a fantastic job in the context of limited resources, but the difference from how my Mom would have handled this type of case in the U.S. was striking.
Most of the rest of my time has been spent in the OPD with Dr. Parvesh. A nice young Indian doc, he has decided to teach me medicine 101 in the few days I am here this week. I told him we could swap... if he taught me medicine, I would teach him statistics.
The sheer volume of patients they see is mind-boggling, not to mention the complete lack of privacy. Four doctors sit in a row along the length of a room at a desk and patients are quickly seen one after the other. If they need to do an exam, they pull a curtain shut, but for the most part, everyone is basically right on top of each other. It is in pretty stark contrast to the environment created by HIPAA and patient confidentiality in the States, but no-one here really seems to mind. The expectations are just different.
The amount of TB and typhoid seems rather unreal. It was like every other patient had one of the other. Also a lot of other respiratory infections, fever, and diarrhea.
There were however two patients that have stuck in mind...
The first I saw on Tuesday as I was sitting with Dr. Parvesh. He suddenly grabbed a piece of paper and told me to calculate an equation he wrote down. I pulled out my cell phone and started punching in numbers. When I finished I showed him the answer and asked if it seemed reasonable. He said no and I started to get a little red in the face. But then we both recalculated it and got the same answer, so he realized he had written down the formula incorrectly. He hands me the "bible of internal medicine" and told me to look it up. Of course, I had next to no idea what it was I was looking up, as the whole conversation with the patient was in Hindi, but I eventually deciphered that it was a calculation used for chronic kidney disease. Finally, I found the formula and recalculated the number, correctly this time. I got a number of 14.4.
Okay, I said, here it is. Well what are the reference values, he asked? Well how on earth should I know, I thought! So up came the book again (fortunately I remembered the page) and I sifted around until I found a table of reference levels. Stage 5, it said, less than 15 equals full renal failure and dialysis required. I looked at him and whispered, "is dialysis available here"? I had a feeling I knew the answer...
He didn't reply. But when the woman came back later, I caught the word Chandigarh amidst the Hindi. I am pretty sure he was telling her that without dialysis she would die, and that the nearest place to get dialysis was Chandigarh - nearly an 8hr drive away (each way) by car. And I looked it up later and the treatment would cost $200-400 a month, at least. That is a lot of money here, and I suspect was totally out of the range of this family.
How are you supposed to tell a patient that they are going to die, and your sorry but there is no option. The treatment exists, but they won't have access to it. This happens in the States too, but a lot less frequently. The even more striking part was the way the woman and her adult daughter responded. There expressions never changed, they just nodded and responded Acha-cha (good, or okay, I see). And then they left...
Death is different here. It is seen as a natural part of the lifecycle and is accepted in a way that it rarely is in the States. That is not to say that the woman felt ready to die, or that her family would not be upset, but it is experienced in a very different way. I suspect part of it has to do with the belief in reincarnation. If death isn't really the end, there is not so much to fear. And people here are quite religious/spiritual.
Then yesterday there was another case that I did not personally see, but which I heard about and have not been able to get off my mind since.
My Mom was sitting with Dr. Anna (Dr. Philip's wife from America who is also a doctor) when a woman came in with bruises all over her face. She claimed she had "fallen on some rocks." Dr. Anna pointed out to my mom that there were no scratches at all, as you would see if she had actually hit her face on a rock. It was pretty obvious that the woman had been beaten by her husband. Apparently, this happens quite frequently and while the women may come to the hospital, they will rarely ever admit to being beaten. Domestic violence is deeply ingrained in society along with women's subordination to men. Of course, this is not universally true, but appears to occur with a disturbing frequency and is largely socially accepted.
The students happened to have an article on malnutrition in women for yesterday's class which was linked to domestic violence. This produced an interesting discussion as we struggled to understand the context in which physical violence, as well as the withholding of food occurs. I wish I understood it better. This type of violence is in stark contrast to the India I experience and the men I know. Yet, there is considerable consensus in the literature, and in what the hospital sees, that it is very much a common feature of society, and is often not dependent on education or socio-economic status. It really makes me appreciate the life I have, and the opportunities and status I am afforded. While domestic violence occurs in the U.S., it does not seem to be so rampant, and is certainly not accepted culturally. But it also makes me wonder, how will Indians change this aspect of their society? For I firmly believe that that change can only truly occur from within. If India is to pull itself out of poverty on a broader scale, particularly in the rural areas, women must have a stronger position in society and such violence must not be tolerated.
It is quite interesting to see the similarities and also intense differences that exist.
The morning begins at 8:30am with a short devotion service. I was initially very wary of this, but it actually turned out to be quite pleasant. The service is lead by Dr. Philip and begins with songs in Hindi, followed by a brief, but meaningful sermon.
Rounds begin immediately after devotion, led by Dr. Philip, who is then tailed by a contingent of nearly 20 other doctors and students. Rounds in this case consist of every in-patient in the hospital, so you see a wide variety of cases.
Day 1 started in the ICU (which consists of 3 beds), principally with a woman who was sadly on death's door... congestive heart failure, emphysema, and a variety of other issues (apparently she passed later that day). The condition of the patients improved considerably as we wound our way through the patchwork of rooms and buildings that house the patients. We reached the pediatric ward and saw two tiny babies, each only 3 weeks old, both of whom were severely dehydrated from nausea and diarrhea. This seemed a bit odd to me, as you would expect them to be breastfeeding, but perhaps they were not doing so. The poor things were so tiny...
We saw a number of other young children with diarrhea, fever and dehydration, but that is pretty typical around here. Food and water sanitation can be pretty problematic in some parts of the area.
We then came to another adult ward and saw a teenage boy who was complaining of severe headaches and extreme lethargy. My mind went to migraines, but they said they thought he had tb meningitis. Apparently the brain scan had showed "water" by which I think they meant cerebral spinal fluid in his head. They put him on anti-tb treatment and steroids and moved on. He was discharged the next day...
When my Mom and I found this out we were both a bit disturbed. She explained to me that without doing a culture, there is no way they could be sure that it was tb meningitis and not one of several other things. They apparently discharged him because he was more alert and seemed to be doing better, but that was because they gave him a huge shot of steroids to wake him up, not because the tb meds had started working.
I am not writing this to be critical... in general, the hospital does a fantastic job in the context of limited resources, but the difference from how my Mom would have handled this type of case in the U.S. was striking.
Most of the rest of my time has been spent in the OPD with Dr. Parvesh. A nice young Indian doc, he has decided to teach me medicine 101 in the few days I am here this week. I told him we could swap... if he taught me medicine, I would teach him statistics.
The sheer volume of patients they see is mind-boggling, not to mention the complete lack of privacy. Four doctors sit in a row along the length of a room at a desk and patients are quickly seen one after the other. If they need to do an exam, they pull a curtain shut, but for the most part, everyone is basically right on top of each other. It is in pretty stark contrast to the environment created by HIPAA and patient confidentiality in the States, but no-one here really seems to mind. The expectations are just different.
The amount of TB and typhoid seems rather unreal. It was like every other patient had one of the other. Also a lot of other respiratory infections, fever, and diarrhea.
There were however two patients that have stuck in mind...
The first I saw on Tuesday as I was sitting with Dr. Parvesh. He suddenly grabbed a piece of paper and told me to calculate an equation he wrote down. I pulled out my cell phone and started punching in numbers. When I finished I showed him the answer and asked if it seemed reasonable. He said no and I started to get a little red in the face. But then we both recalculated it and got the same answer, so he realized he had written down the formula incorrectly. He hands me the "bible of internal medicine" and told me to look it up. Of course, I had next to no idea what it was I was looking up, as the whole conversation with the patient was in Hindi, but I eventually deciphered that it was a calculation used for chronic kidney disease. Finally, I found the formula and recalculated the number, correctly this time. I got a number of 14.4.
Okay, I said, here it is. Well what are the reference values, he asked? Well how on earth should I know, I thought! So up came the book again (fortunately I remembered the page) and I sifted around until I found a table of reference levels. Stage 5, it said, less than 15 equals full renal failure and dialysis required. I looked at him and whispered, "is dialysis available here"? I had a feeling I knew the answer...
He didn't reply. But when the woman came back later, I caught the word Chandigarh amidst the Hindi. I am pretty sure he was telling her that without dialysis she would die, and that the nearest place to get dialysis was Chandigarh - nearly an 8hr drive away (each way) by car. And I looked it up later and the treatment would cost $200-400 a month, at least. That is a lot of money here, and I suspect was totally out of the range of this family.
How are you supposed to tell a patient that they are going to die, and your sorry but there is no option. The treatment exists, but they won't have access to it. This happens in the States too, but a lot less frequently. The even more striking part was the way the woman and her adult daughter responded. There expressions never changed, they just nodded and responded Acha-cha (good, or okay, I see). And then they left...
Death is different here. It is seen as a natural part of the lifecycle and is accepted in a way that it rarely is in the States. That is not to say that the woman felt ready to die, or that her family would not be upset, but it is experienced in a very different way. I suspect part of it has to do with the belief in reincarnation. If death isn't really the end, there is not so much to fear. And people here are quite religious/spiritual.
Then yesterday there was another case that I did not personally see, but which I heard about and have not been able to get off my mind since.
My Mom was sitting with Dr. Anna (Dr. Philip's wife from America who is also a doctor) when a woman came in with bruises all over her face. She claimed she had "fallen on some rocks." Dr. Anna pointed out to my mom that there were no scratches at all, as you would see if she had actually hit her face on a rock. It was pretty obvious that the woman had been beaten by her husband. Apparently, this happens quite frequently and while the women may come to the hospital, they will rarely ever admit to being beaten. Domestic violence is deeply ingrained in society along with women's subordination to men. Of course, this is not universally true, but appears to occur with a disturbing frequency and is largely socially accepted.
The students happened to have an article on malnutrition in women for yesterday's class which was linked to domestic violence. This produced an interesting discussion as we struggled to understand the context in which physical violence, as well as the withholding of food occurs. I wish I understood it better. This type of violence is in stark contrast to the India I experience and the men I know. Yet, there is considerable consensus in the literature, and in what the hospital sees, that it is very much a common feature of society, and is often not dependent on education or socio-economic status. It really makes me appreciate the life I have, and the opportunities and status I am afforded. While domestic violence occurs in the U.S., it does not seem to be so rampant, and is certainly not accepted culturally. But it also makes me wonder, how will Indians change this aspect of their society? For I firmly believe that that change can only truly occur from within. If India is to pull itself out of poverty on a broader scale, particularly in the rural areas, women must have a stronger position in society and such violence must not be tolerated.
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