Category Archives: India 2013

Head and Neck Surgery at Mazumdar-Shaw Cancer Hospital

(This post is from Zach Chandy!)

We spent the last two days shadowing the Head and Neck Surgeons at Mazumdar-Shaw Cancer hospital, an enormous hospital on the outskirts of Bangalore city and sister hospital to Narayana Hrudalaya cardiac hospital. I spent the first day in surgery and the second day in the clinic. I choose to write about one surgery and the follow-up, which has made a major imprint on me.

The patient presented with a carcinoma of the anterior 2/3 of tongue that was infiltrating the floor of the mouth. The surgeon and the patient had decided to perform an aggressive surgery to remove the tongue, floor of the mouth, and larynx to extend his life expectancy to one year. By the time we entered the OR at 8:30 am, the surgeon had finished ligating the blood supply and was in the process of pulling the tissue out in one swoop. The scene was quite gruesome with the lower lip pulled off the mandible in an ungodly position. I couldn’t comprehend how the surgeon was going to patch up the wound and make it look somewhat like it did before.

The next steps were to remove a skin/subcutaneous flap from the lateral thigh and place it over the neck to close the wound, fashion a new floor of the mouth, and construct a new tongue that was somewhat mobile. I was amazed at how much care the surgeons put into each stitch and movement considering the surgery was estimated to take 14 hours. By the time we had left the OR at 4 pm, the surgeon had connected the skin flap to the skin of the anterior neck and the pulled it through the floor of the mouth to construct a new floor. He was using a large microscope to reconnect the blood supply to the skin. I knew the surgery would continue for many more hours.

The following day, our group went on rounds with the group of 5 attending surgeons. We saw 15 patients that they had operated on in the last week, but I found it hard to concentrate, because my mind was bustling with anticipation to see what had become of the patient from yesterday. When we approached his bed, I couldn’t believe it was the same patient. His jaw area and anterior neck didn’t look unusual except for the small gash in the lower neck where the surgeon had stitched the skin flap to the neck skin. When I peered inside his mouth, the floor of the mouth and new tongue flap looked expertly done. Only when I looked closely, could I tell the tongue and floor of the mouth were made from skin.

As we left the patient’s bedside, the surgeon mentioned the patient would regain the ability to swallow liquid and minced foods. However, he wouldn’t be able to talk and would have to breathe out of his trachea-tube for the rest of his life.

Although I knew the patient’s life would be much different after the surgery, I couldn’t imagine him getting any better care then he did with the doctors at Mazumdar-Shaw. The experience demonstrated how outstanding surgical care has become, and has inspired me to strongly consider surgery as a specialty down the line.

A cup of tea!

(This entry is from Tiffany Cho!)

We had the privilege of visiting a tea estate in Devala today. We learned that the five Adivasi tribes of Gudalur valley collectively own and manage the tea estate. Although our jeep ride up the mountain was rather perilous at times, we were constantly surrounded by beautifully lush greenery at every turn. When we arrived as far as the jeeps would take us, we met one of the ladies who works as a tea leaf picker and got treated to a glass of tea. Because they boil the water over an open flame, we could really taste the smokiness in the piping hot cup of tea. It was rather delicious. 

We then embarked on a two- to three-mile hike down the mountain to the rendezvous point to have our lunch. The hike was simply breathtaking. Leeches were a minor concern as we walked, but we were forewarned :) I believe our vigilance paid off since most of us only found one or two leeches during our “leech check” at the end of our journey. I must admit though that they were rather tenacious. 

After lunch, we continued our tea education by visiting the Woodbridge tea factory where they process black and green tea. During our short tour, we learned the drying, fermentation, sorting, and packing processes involved with manufacturing the tea we can so easily access at our supermarkets. 

It was a pleasure to experience another aspect of Indian culture and experience, in however small a manner, the daily lives of some of the patients we had the honor of meeting this week. 

Blood, guts, a some really big hearts

Words cannot describe our experience at the Christian Medical College in India. Therefore…here are a few photos—

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A few of the highlights over the past few days have been seeing thyroid surgery, an autopsy, pathology museum, and a c-section/vagina birth. The days have been blurred together after having so many new and mind blowing experiences. Never in my life did I ever expect to see an autopsy. The procedures when performing the autopsy are so much different than one would expect. Without going into too many graphic details, I was shocked at the amount of force needed to release the organs from the fascia. Despite the internal mutilation done to the body, the medical examiner made sure to carefully stitch up the abdomen for cosmetic purposes so that the body could be given back to the family. Seeing the fresh organs full of color and form was just so different than what we saw in anatomy lab. I think for anyone even considering surgery, time spent in the autopsy room is indispensable.

The other recently shocking event was our OBGYN rotation. For the majority of the group, it was the first time we’d ever seen birth of any sort. In one day we were able to witness a vagina birth and c-section. Again without going into gory details, it was quite a sight to see and a lot to take in. But watching a new born child take its first few breaths suspends time and reality for those few minutes. Overall, I think the entire session is quite a special experience and a privilege to be present for.

Beyond all the pathology and procedures we’ve seeing, what has affected me the most was the superb quality of physicians that we’ve been exposed to. They have been kind, patient, generous, and engaging. It’s what you should expect from any physician at a teaching hospital, but these individuals have gone far and beyond. We’ve even had the privilege of having home cooked dinner at a their homes. They are not just physicians that I admire in medical practice, but people that I would like to emulate daily life.

Personally, this India trip has far exceeded my own expectations in what I thought I was going to see. It has been, inspiring, humbling, thought provoking, and delicious (I’m obsessed with their chicken and rice dish). Tonight we leave to another city via train. We leave Vellore excited for the next stage of our adventure.

Kevin Ting

The Art of the Physical Exam

Today is the beginning of our second week in India, and I can’t believe how fast the trip is passing. We are starting to settle into a routine that begins with breakfast of idly, dosa, or omlette, and the most delicious milky chai tea. Then we pack in to the student bus surrounded by CMC medical students, the youngest of whom are only 16! At the hospital we shadowed morning rounds in the endocrine surgery ward with an attending and several residents. These doctors are phenomenal and dedicated instructors; they are willing to spend almost an hour on each case, carefully teaching us the pathophysiology of each condition, from basic anatomy to complex diagnostic classification systems. We are all so grateful for their time!

I think the most important thing I will take away from rounding with CMC doctors is the art of the physical exam. I continue to be impressed with how much diagnostic information they are able to extract through basic techniques of palpating, percussing, and auscultating. While examining a patient who presented with swelling on her neck, our attending thoroughly reviewed head and neck anatomy, identifying each boney landmark and isolating each relevant lymph node (we learned there are around 300 in the head and neck!). He then palpated the swelling itself, evaluated the number of nodules, determined fixation to fascia, and described the consistency. From this information alone he was able to diagnose the mass as a tumor and predict malignancy. Only after making this initial assessment did he need to confirm with cytology, x-ray and ultrasound.

This weekend we were able to take a quick break from the hospital to do some traveling. We visited a seaside town called Mammalpuram, famous for the Pallavan architecture of it’s ancient temples. Two highlights were the 1400 year old Shore Temple, which was miraculously untouched by the 2004 tsunami, and the Five Rathas, a series of monolith temples all carved from a single giant boulder. We ended the day with a dinner delicious fried calamari and whole tandori style sea bass at a beach front restaurant. As it got dark a monsoon picked up out at sea, and we witnessed an amazing lightning show.

I can’t wait to keep exploring and learning for the rest of the trip!

- Tanya

Ultrasound, Medicine, and Endocrinology

Friday, June 28th, 2013

Keeping with the theme of this trip, the last two days have been very busy. Yesterday was the first day of our research project.  We made our way around the ICU in teams of 4 or 5 ultra sounding maxillary sinuses to test the efficiency of detecting it using ultrasound. While my team and I made our rounds around the ICU, the physicians would take time out of their day to teach use the individual cases there were there. We saw a hug number of cases ranging from organic phosphate poisoning to extremely complex cases with multiple disease at work in the same patient. The two cases that were most impactful to me was the 15 year old girl that was suffering from organic phosphate poisoning. According to the physicians, this is an extremely common occurrence due to the need for pesticides and how cheap organic phosphates are. It was hard to witness the girl struggling to breath while the toxin was being worked out of her system. While the patient is expected to make a full recovery, the physician said she will likely be back because she will be reexposed to the organic phosphates in her life. The second patient we saw yesterday was a middle aged man that was on life support with pyrexia of unknown origin. For me this was both interesting and humbling because I was witnessing the physicians work through a differential for fever, something I assumed to be simple. After hearing them discuss the vast amount of conditions, diseases, and syndromes that could be at play within this patient I realized how much of medicine I still need to learn.

Today, we got to go around the Internal Medicine ward and Endocrine ward. Within the IM ward, we got to test our diagnosing abilities as the physician guiding us around explained the case to us and guided us through how to think clinically about the patient. The first case we encountered was a 24 year old  patient that has had hemolytic anemia since he was 4. This caused a whole host of conditions within this patient including an enlarged heart (twice as big as normal), enlarged liver, and an enlarged spleen (5 times bigger then normal). The case was then further complicated by the fact that the patient was suffering from malaria. As the physician was guiding us through the case he taught us to look at each symptom individually and also to look at them collectively to come to a diagnosis. As we continued through the ward we saw cases of Cushing syndrome (both tumor induced and exogenous), acromegaly, and a superior vena cava obstruction caused by recurring malignant breast cancer. Overall, the day was eye opening to how to think clinically about each patient and how to use the knowledge from previous cases to help you through the thought process of the case at hand. I look forward to the days ahead in India to what we are going to learn next.
-Michael

Tying up the week

It’s hard to believe that our first week in India is over! The days have just been flying by! Dr. Chandy’s colleagues have all been so warm and welcoming. Their passion is contagious and we have left each ward feeling excited and inspired. This trip has certainly been “medicine in action”, and we’ve seen quite a few unforgettable cases (Cushing’s, Acromegaly, meningitis, Grave’s disease, Hypothyroidism, DTs, etc.)

Yesterday (Saturday), was our last clinic day of the week. We spent the day at the dermatology ward at CMC’s main hospital. The morning began with a lecture on leprosy and a discussion on how the different types can be differentiated from each other. We were then split into two groups and led by residents to patient rooms. The residents taught us some of the more common derm terms (macule, vesicle, pustule) and then showed us what each looked like. We saw a few cases of allergic contact dermitis and two more rare skin disorders. One was a rare autoimmune disorder which results in the tightening of the skin and the other was a case of Riley Day Syndrome. Riley Day Syndrome is an incredibly rare hereditary disorder which affects the survival of autonomic and sensory nervous systems. Individuals with this disease are insensitive to pain and are unable to produce tears. It would be interesting to learn how patients train to protect themselves when their body is unable to warn them of harm.

The hospitals we have visited here are quite different from the ones we are used to seeing back home. For one thing, each ward consists of a large hall with rows and rows of beds, situated side by side. Families gather around each bed or sleep on the floor beside it. The halls are sometimes the busiest places in the hospital. There is so much happening at once! Interestingly, none of healthcare providers wear white coats. Instead, male doctors wear nice button-down shirts and the female doctors wear long shirts which extend down to their thighs with leggings/ long pants. In some wards, nurses wear beautiful long, white Sari(s). Unlike California where the main spoken languages are english and spanish, India has many languages. Physicians training in India are expected to know several languages, and it is not uncommon for doctors to go back and forth between languages. It’s amazing!

Our first week has been incredible. I can’t wait to see what happens next week!

-Asal

Neurosurgery

After all we saw yesterday i decided to make a separate entry about today – also busy of course. Today was our first day at the bustling CMC hospital main campus. It’s a sprawling complex, crowded with perhaps several thousand patients and families – much more than UCIMC which is itself a large hospital. To me, it feels almost like its own little city.

The highlight of today was our visit to the neurosurgery operating room. We all scrubbed in to watch the removal of a golf ball sized meningioma from a woman’s brain. Before the surgery started, we were able to look at the images and talk about the procedure with the surgeons. We talked about ideas ranging from the best way to position the patient’s head, to what side effects to watch for following the surgery.Then we stood out of the the way (we all know not to break the sterile field!) and watched very intently as the team covered the patient and table with what seemed like 100 layers of sheets and plastic and tubes so that only a small rectangle at the top of the patient’s skull was visible. We watched as the team removed a piece of skull while also controlling the constant bleeding, and finally reached the brain and then the tumor. We could see the brain pulsating with each heartbeat- very much looking alive, and a very different feeling from what we’d seen in our neuroscience class. It was really enthralling to watch the surgeons’ skill as they differentiated the tumor from the normal brain tissue, cut off its blood supply and protected the brain from further damage as they removed the tumor piece by piece. Although I’m not planning to become a neurosurgeon, I have a lot of respect for the precision and concentration required to operate on a human brain.

Outside of the operating room, one of the surgeons was an excellent teacher for us all as he introduced us to several patients in the neuroscience ward. With our first year knowledge, we tackled several cases beginning more or less with a question of “what should we test to figure out what’s wrong?” One patient looked normal to us at first and normal is of course what we’ve learned this past year. However, we were soon able to pick up on more clues-his height, prominent jaw, and a very, very tiny white dot on the MRI image clicked with what we’ve learned this past year. With each of us filling in parts, we honed in on his diagnosis of a growth hormone releasing pituitary tumor which of course we’d only read about before.

Seeing patients in the hospital has me very excited for our rotations and beyond. I love finally applying the knowledge that we’ve learned in lecture and I’m not going to forget the patients that we see during our time here.

- Alex

Home visits and more

We started our day with a visit to the Low Cost Effective Care Unit (LCECU) which was founded to serve the urban poor of Vellore. These are people who may make less than $2 per day and cannot afford to pay for medical care. The LCECU manages to keep costs low by having minimal infrastructure. For example, patients handle their own charts, and labor and delivery of uncomplicated cases is run by nurses. The price of generic medicines is also astronomically lower in India than in the US, which helps keep costs lower. Even though the LCECU has limited resources, I was impressed how resourceful it is at serving its patients and I think we can learn a lot from how they operate.

In India, problems like malnutrition, tuberculosis, and dengue remain significant, but as we learned, diabetes and obesity are becoming increasingly common as people move from rural areas and adopt different lifestyle habits in the city. Alcoholism is also a huge problem here- one estimate found that 48% of men in the area are alcoholics. When we rounded in the LCECU we did see some of the serious effects that prolonged alcoholism can have – one patient was suffering from the neurological effects of vitamin B12 deficiency. Another was in the middle of life threatening alcohol withdrawal – delerium tremens.

One of the doctors who we met today made a good point when he mentioned that despite an obvious need, doctors can’t just go write a prescription to get someone’s brother a new job or to send a child to school. But even if doctors can’t always solve every problem in a patient’s life there are ways to make a huge impact with limited resources as we saw today when we accompanied the outreach team of social workers to home visits with several patients. These patients live in a very small houses – often one room, dirt floor, without electricity or plumbing. Outside, water and waste go into open drains so sanitation is a significant problem. Its also impossible not to mention the many goats walking freely in the narrow streets between houses. For a person in a wheelchair, just getting outside the home could be difficult with an obstacle like open drains.

One patient who we visited in his home was already struggling to provide for his family before suffering a spinal cord injury in a fall. Without adequate help after his injury he was severely depressed and suffered multiple complications. Because social workers and doctors can visit him in his house, they were not only aware of his needs but actually found some successful ways to address them. After seeing how well his wife helped care for him, the LCECU got her a job working in the rehabilitation unit. Their house now has a ramp and most strikingly electricity which allows him to run a business recharging people’s cell phones. And other donations have paid for his daughter to attend a private school. These improvements went far beyond the initial medical care that he received following his injury and actually left his family financially better off after his injury than before. By addressing the patients home environment, not only was his injury treated but the lives of an entire family were positively effected.

After rounding in the LCECU today we also rounded in the spinal cord rehabilitation unit of the hospital which serves an astounding 2400 inpatients and 6000 outpatients per day. Many patients come to the unit following traffic accidents -unfortunately unsurprising if you know what driving in India is like. Since our first year of med school was all about normal physiology, it’s been so fascinating to finally apply our knowledge to real cases. In a patient with a complete transection of the spinal cord at C5, we observed the babinski sign, ankle clonus, and hyperreflexia. In another patient with cerebellar damage, we were able to see the effects on his balance as he struggled to walk in a straight line or perform the Romberg test (stand with his eyes closed and feet together).

We saw much more as well but I’ll leave today’s entry there. It was a tiring but rewarding day- perhaps a preview of some of what we’ll see in 3rd and 4th years during our rotations. I’m especially thankful that we got to participate in the home visits because it gave me a better idea of what home life is like for some of the patients we’ll see here.

- Alex

What do you have in your hand?

Dear Readers,

Today was an incredible day at the Christian Medical College in Vellore, India, where ten of us arrived last Friday. We have done nothing but learning and experiencing this new and exciting place with all of our senses since we arrived. Today, we had the opportunity to learn about the Indian health care system and travel with public health care workers to a community clinic and the homes of a few patients in one of the villages. The community clinic consisted of two tiny rooms in the center of a village, crowded with women sitting on the floor, waiting for their turn to see the doctor. In one room, a physician was evaluating pregnant women for their blood pressures and overall health statuses and in the other room, an intern was writing prescriptions for medications for chronic illnesses (specifically type 2 diabetes, thyroid disorders, hypertension, and depression), which patients picked up at the mobile clinic van parked just outside. Of the many things I learned during this encounter (such as how to determine the exact gestational age of a fetus by simple palpation), I observed the incredible work these doctors do in the community. They are truly missionaries. These patients would not be able to to travel to the health center because they live off of the main road and are unable to pay full price for their medications ( 60% of the population in India is below the poverty line.) These doctors see at least 30-40 patients per day and get paid very little because the majority of the funds go to subsidize the care of poor Indians. 

This morning, before we went into the field, we had a chance to sit in on a lecture by Indian medical students, interns, and residents at the Christian Medical College. Before the lecture, a prayer was offered. The first thing the speaker said was, “What is that in your hand?” She proceeded to say that too often we waste time worrying about the things we don’t have and focusing on our limitations, rather than doing the best with the resources and abilities that we possess and focusing on fulfilling our own purpose to help others. These physicians at the community clinic are incredible in their ability to diagnose and treat with limited resources. They have perfected the physical exam; when they are in rural areas, they cannot depend on CT scans and X-rays as a crutch, but rather must use their intuition, skills, and experience to help patients. They can ultimately refer them to the hospital if there is a serious problem, but most of the care takes place in the community. I will always remember her words and apply them to any situation in which I find myself.

Being at the clinic made me ponder what community healthcare would look like in America, for there are still so many Americans who have little access to care. Physicians in a time not too long ago would routinely make house calls, especially if their patients were no longer ambulatory. I was inspired today to try to preserve this community-minded doctoring and to support mobile clinics, community health education, and any programs that bring nurses and doctors to patients in need, rather than the other way around. When doctors are part of the community, rather than separate from it in their sterile offices and hospitals, greater trust can be established and sometimes greater care can be given.

We then went to a small village, to the homes of three patients: one with COPD (Chronic Obstructive Pulmonary Disease), a pregnant woman, and a man with tuberculosis. We accompanied one of the village nurses, who sees each member in the village at least twice per month. The village members were gracious and allowed us to listen and touch, just as the nurse did, learning through her and learning by doing (something we have little of in our early medical years). At the pregnant woman’s tiny home (a single room for 6 people) I was able to touch her pregnant belly, feeling for the spine and head of the fetus (who is due July 22nd) as well as listen for the fetal heart beat. It was an incredibly moving experience. This woman smiled so big, so happy that we were there to visit and so thankful to have the blessing of being pregnant with her third child. She had so little, yet she was giving so much. 

We learned that this woman was in a different situation than most of her fellow Indian women; she married for love and her husband is supporting her through a college degree in business. On the back wall in her hut, were  posters of the Tamil and English alphabets, a sign that her appreciation of education is bring transferred to her children. We learned today that the government of India, mostly in the South, has realized that the education level of women is one of the most important determinants of infant health and survival. In places where most women are illiterate and prevented from being educated by overbearing husbands or families who force them to marry at 16 or 17,  the infant mortality rate is incredibly high. This woman was an inspiration for her resolve to value education. I wish her health and happiness and a good delivery of her child! 

After visiting the village, we went back to the wards and observed pediatric patients in the children’s ward. It is so terribly hard to see children in distress (we saw children with pneumonia, hepatitis, typhoid fever, and other infections), but it was so motivating that highly skilled physicians are charged with their care. One thing that will stick with me is the scared look in the eyes of the mothers of these children. I have realized that saving the life of a child is one of the most noble endeavors on this Earth. I hope to be able to do that some day, and give parents relief and comfort. 

There is no possible way to document every single thing I witness. But, allow me to end by saying that here in India, the common greeting and farewell is placing both palms together in the prayer position and bowing in gratitude and fellowship. My advisor explained to me today that it means, “my unity of soul honors your unity of soul.” That powerful greeting demonstrates so clearly the goodness I witnessed today and the good hearts of the village inhabitants in India. They are motivated out of their hearts to help patients in need, not by money. We did learn today that corruption still exists, that government physicians sometimes will leave their hospitals without having seen all of their patients to conduct their profitable private practices and in some parts of the country, families of students who do not get into public medical schools can buy their way in to private medical schools. However, for the most part, this is not the norm. The norm is love and charity and kindness in the face of limited resources and poverty, which I so vividly saw today, and what I will take with me long into the future.

I thank the workers and physicians I met today for teaching us, letting us observe, and for all the good work they do. 

Thank you for reading and I hope you are inspired as well. 
-Jessica