By the sea

I arrived in Chennai this evening after a short flight from Hyderabad, thus kicking off the second leg of my India journey. The past three weeks have been an unforgettable experience, but I’m glad to move on from Hyderabad and see other cities and states within South India. As my plane descends into the Chennai airport I notice from above that the terrain itself is distinctly different from that around Hyderabad, even though I’m only one state away. Where Andhra Pradesh is rugged, dry, and scrubbish with giant granite boulders placed gingerly atop small hills and occasional palms dotting the landscape, coastal Tamil Nadu is verdant, richly textured from above by the dense palms, with small, steep mountains coursing like veins across the land.

Traveling alone in India three weeks later is a much smoother and less intimidating experience. I know to grab the required baggage tags at check-in that are never pointed out, I can understand both verbal and non-verbal communications better, and I’m more accustomed to the tenor and pace of business interactions. As the plane taxis up to the Chennai terminal I’m reminded of that painfully long and uncomfortable first night spent in the stuffy, heavily-used portion of Domestic Departures and I can’t wait to escape as soon as possible this time. Mercifully my bag is fourth out of the chute in baggage claim so I grab it, take another look at the address I’d written down for the hotel (knowing now that by far the most important part is the area of town, not the road or address number), queue up for the pre-paid taxi line, successfully manage to box out the Indian businessmen attempting to occupy the six inches between me and the man in front of me, pay the pre-paid fee for Mylapore (about $4), and head out to grab my cab.

As I exit the building aimed for the pre-paid taxi stand a man spots ticket in my hand and grabs my bag. I let him take it…I suspect he’s not the driver but just a poor man working as a porter for tips, but unlike my last visit to this airport I’m confident he’s not here to steal my bags, nor does he expect any large sum of cash. When he sees our young driver at the dispatch table he gestures and makes some grunting sounds. He appears to not speak English or Tamil, and possibly may not be able to speak at all. He spots the designated cab and rolls my suitcase along the line of waiting autos, and I get little surge of excitement as he stops in front of one of the old Ambassadors (“potato cars” as they have been known to CIT3…well, at least to Ben). These cars are everywhere here and just dripping with character but I’ve yet to get inside one. My bags get loaded in the trunk, I give the porter a small tip, and take my seat in the back. There’s no air-conditioning but it’s a nice evening and riding beneath the tufted and welted ceiling upholstery is worth the sacrifice. My young driver is joined by another young guy, both about 20 years old and in matching uniforms, as well as a third middle-aged man. They all three squeeze into the front bench seat, confirm the destination printed on my pre-paid receipt and head out. The two cabbies appear to be good friends. They are boisterously joking and laughing with one another in the front bench seat while chewing and spitting pan (flavored chewing tobacco very popular in India). Of course I can’t understand them, but I do notice that the Tamil they’re speaking has a different sound, even a slightly different meter than Telegu. A few minutes into the trip we pull over by the side of the road and the older man hops out after a quick farewell. As we drive on I lean out the car window to catch a breeze and to see what I can of the city.

Chennai in the early evening dusky light looks to me like Hyderabad in ten years. The streets, even at rush hour, are less congested and chaotic, and we pass several entrances to an underground subway. In segments of free-flowing traffic I notice drivers will even stay in their own lanes if they don’t have to pass anyone. Hyderabad has endless construction projects rising from the rubble and rubbish of the shantied streets, but Chennai appears to be already constructed, with tall, modern, brightly lit buildings glowing up ahead. In contrast to Hyderabad many of the shop-fronts actually have front walls and doors, and there seems to be less garbage in the streets (and buffalo, goats, and dogs for that matter). And the rubble, piles and piles of broken bricks, segments of stucco, and crushed concrete that littered literally every street and alley in Hyderabad are greatly reduced in Chennai. For lack of a better term, Chennai just appears to hold her weight a little better than Hyderabad, but we’ll see what blemished and bulging problem areas are revealed by the light of day tomorrow.

I’m all riced out…

It’s hard to believe, but it’s the end of CIT3.  The bags are packed, the souvenirs are purchased,the ipod is charged, and our last meal of rice and spicy vegetables eaten.  Only thing left is to go to the airport to start our 30+ hour trip home.

The last 3 weeks have been an emotional rollar coaster.  You would have to be a robot to not be affected by the poverty you see everyday here.  After each visit to a hospital or clinic at that was almost literally bursting at the seams with people and misery, I would try very hard to focus what the healthcare workers had accomplished, and not on the the seemingly insurmountable problems around the corner.  It’s easy to drown in what is wrong with this healthcare system, but it’s crucial to remember that there are dedicated people trying to change the System.  Somedays were easier than others.

I’m glad we ended our academic portion at SRH touring the HIV ward and the small hospital on the grounds.  Sivananda has such a positive energy and it’s clear that everyone there wants to be there and is trying their best to make it a special place.  The doctor-patient relationship is wonderful to watch.  The doctor knows every patient, every story.  The patients, in turn, are empowered to be in charge of their disease and treatment.  Sivananda may not be fancy like Apollo with flat screen TVs and granite counter tops, but it’s clear that the staff and patients take pride in their institution–the buildings are tidy and airy, the sheets are clean, the paths are neatly marked with white stones.  It’s simple and evident that no rupee is wasted.

As I travel home to my waiting family, I hope Sivananda will continue to be an inspiration to me as I continue my practice.  As an individual, I can’t fix every problem in our healthcare system and I can’t correct the disparities among different socioeconomic and ethic groups.  All I can do is try my best everyday to provide the best care to my patients with the resources available, to know and treat the whole person, not just the disease, and to value the life of every human being regardless of how many rupees or dollars they have in their pocket.  In short, I will try to be like Sivananda.

Favorite Things

Nick perfecting rice and chapati eating with his RIGHT HAND ONLY

Getting a taxi ride across town for $3

Getting our temperatures scanned with a forehead thermometer at the airport

Setting a man, and then a woman straight when they tried to cut in line in front of us

Nora almost getting a massage in the same room as Waqas

Nora being asked if she was from this country

Suresh vigorously shaking his head in disagreement when I tried to wash clothes with the spin cycle

A man and a goat riding in an auto rickshaw through the busy streets of Chaar Minar

A dump truck full of school kids smiling and waving while on their way to school

Raju blowing a kiss to a man on the street to grab his attention

Nick buying a lungi, and declaring it as his new lounging attire

Suresh telling Nick that he needs a white shirt and a brown towel to properly accessorize his new lounging attire

Waqas telling the man at Chaar Minar that him and I are a married couple from Delhi to avoid paying Rs. 100 entry fee

Dr. Gopal Saar meeting Amala

Christina in a TB mask and sunglasses

The daily I spy someone urinating on the side of the street game

Shobha calling Raju and Suresh by each others names

Hoping Suresh did not make bitter gourd each night

Me getting yelled at by the priest for ringing the bell with my left hand at the temple

Rickshaw driver charging us Rs. 350 for 5 blocks

Whiskey gellato

Telugu movies and dance numbers 24 hours a day

Little kids, everywhere

All of us mastering the head wobble…

the perfect ending

Today is my last official day in India. Our flight leaves at 1am tomorrow morning. I am just beginning to get used to the sounds, smell, and the pace of life here, and now it is all going to be coming to an end.

As I reflect back over the time I have spent here, I have had many amazing experiences. Our last day was sepent at Siravananda Rehabilitation Home, which was the perfect ending  to our clinical experiences. When we spent the first week at Siravananda, I had nothing to compare it to. I did not notice that there were screens on many of the windows, I did not notice the cleanliness in which the buildings were kept, or the extent of the organization that was involved in our every visit there.  Only after traveling to multiple government hospitals and smaller community centers, I was able to appreciate Siravananda so much more.

During our last day at Siravananda we toured the HIV ward, and also a smaller ward where HIV patients who were co-infected with TB stayed. The doctor who showed us around knew each of the patients personal stories very well, and  explained how each person’s condition had already improved from the time of presentation. The patients were also very informed about their medical condition, and were even correcting the physician when she told us their CD4 counts. Each patient had their own bed that was in a small room that was shared with ~5 other people. The bedsheets appeared clean, there were no bugs, and the chaos of the other hospitals was non-existant.

Additionally, we saw a new hospital which as has just recently been opened in the past 3 months that sits on the same property as Siravananda. This hospital is under new management, and is offering free medical care to the people who present there. They emphasized that they are trying to focus on quality medical care as opposed to investing their resources to make their facility look flashy and attractive. Finally it seemed like there was a middle ground. We had just visited the Fever Hospital and Apollo the day before which were 2 drastically different institutions.

The fever hospital seved the poorest of the poor, and treated for the most part all vaccine preventable illnesses. The outpatient facility was bursting to the seams with patients. Our tour guide told us the day before there had been ~2,000 people packed into one of the rooms where rougly 4 doctors were seeing patients waiting to be examined.  Minimal tests are done here, and a lot of the treatment is emperic. The pharmacy consisted of a few people with boxes of medications trying to serve the hundreds of people who were sticking their heads and hands past a metal grate waving their prescriptions.

In stark contrast Apollo seemed like a building that almost did not belong here. The floors and walls were all beautiful granite, and they have special wards that cater to non-resident patients who are coming there to receive their care. The rooms are enormous and one forgets that they are even in a patient room with the flat screen TV with HBO, and the lush bed and granite counter tops in the bathrooms. Here you get care by purchasing ‘packages’. You can literally get any test that you want. If you wanted to get an echo and MRI of your body, there is a package for that. I wonder how many incedentalomas are found there….

Back at this new hospital at Siravananda, there finally seemed to be a compromise. The facility was clean, the female patients whom had just delivered had private rooms with a basinet for their child and seemed truely happy. Other preganant women were there getting their pre-natal care, and there was even a ‘major and minor theatre’ where operations were performed. There seemed to be organization here, and the patients seemed as if they were getting quality care. I hope that this institution will not become over run with the crowds of people that will likely come once the word of this place gets out.

I have truely seen a range of extremes since I have been here. I have been to slums and seen lush hotels and fancy hospitals. In India the people with endless riches truely do live down the street from the most extreme poverty. I have met many individuals who are devoting so much of themselves to making a change here, which is the most important thing. Even though there are many flaws and inherent problems in how some of the medical is delivered, it is a start, and hopefully it will only continue to improve.

Closing Time

Last 3 weeks seem a blur tonight. Each day as if we were in a time machine being transported to the 20th century and then back to the 21st. Each day our emotions went on a roller coaster ride. Feelings of helplessness and sorrow changed to joy and amazement on a daily basis. Here are the images and memories of CIT3

The Patients
As we enter the Leprosy wing at SRH patients start gathering around us. From little boys not old enough to cross the street by themselves, to men and women with wrinkled faces. They looked as though each one secretly hoping that they would be subject of our teaching case.  A young boy falls victim to my newly acquired practical leprosy knowledge. He seems to know what exams I should be doing to test his deficit even before I have a chance to ask him to move his fingers a certain way . I point to the camera and ask with my hands if he would let me take his picture. Before I know it, both the affected and the unaffected hand is up in the air, and a shy smile behind them.
We enter the HIV ward at SRH and predictably enough the patients get up out of bed, as though they were all standardized patients. “No 281” corrects a patient with HIV after the attending doctor presents his case to us and miss quotes the CD4 count.
We enter the doctor’s office, 2 large windows fill the room with light and cool breeze gently caresses the flower print curtains framing each window. We all find chairs, some tables to sit on. There are 6 of us, squeezed in the Outpatient oncology clinic of Dr. Rao. One after another patients come into the room, sometimes more than one patient at the same time. They all have one thing in common, a plastic bag full of a lifetime’s worth of medical records, files, notebooks, hardcopies of xrays, CT scans, ultrasound. And I can’t even get my clinic patients to bring their medication lists.
Scores of blank faces riddled with hopelessness sitting, standing or leaning against walls in various lines at government hospitals.

The Doctors
Just like anywhere else, the entire spectrum can be found here. There are doctors who refuse to treat people with HIV, even if they present with ruptured thoracic aneurysm.  There are doctors who prey on poor people and treat them with medications that has about as much chance working as Penicillin does for Influenza. Then there are doctors who not only restore your faith in humanity but make you ashamed of your own worthless life. There is Dr. Rao who works the system everyday to be able to provide care to his poor cancer patients. He is an unassuming man with a restrained demeanor. His words are limited, as though on loan. But when any one of his hundreds of patients walks through the door, he seems to know everything there is to know about them. First class? Second class? Third class? is usually his first question, trying to gauge how the patient is doing on the sick spectrum. He is not pushing notebooks around, he is talking to them about their schools, jobs, cancer, chemo, and death all at the same time. There is also Dr. Laxmi, who has her finger on the pulse of every microorganism and its host coming in and out of her hospital. You can see the fatigue on her face at times, and just when you think the system will get the best of her she tells you a story of how someone’s life has been changed for the better because of her lab and you are reassured that people like her cannot be beat. Amazing doctors are working here 24/7, when they talk its as though Harrison’s is being radioed to them through a secret microphone. They are passionate about their work and they love these patients. These doctors work under conditions that we cannot even imagine. Every single decision is a struggle. A CBC is not just a CBC, it may represent lack of food on someone’s table for a week. As Dr. Rao said “Life is not ideal, in real life are many compromises”. Standard of care is a luxury to many here.

The Illness

One would need a daily M&M to talk about the amount of pathology that exists here. The fever hospital is full of diseases that we only read about in medical school like tetanus, diphtheria, malaria. Even the cancers here are different. Head and neck, cervical, gastric and gallbladder cancers cause a big chunk of mortality and morbidity. HIV is rampant, so is TB. And then there is what ails us all, diabetes, HTN and heart disease. As you have already learned from Nora’s post, nosocomial infections and multi drug resistant microorganisms are not strictly a problem of developed countries.

The Setting

There is something for everyone in this country. All levels of care exist here, from the neighborhood pharmacists to government hospitals that provide free of cost care, to hospitals like Apollo where rooms in the International wing would give five star hotels a run for their money. The treatment of you as a person, and your particular illness is directly related to how many rupees are in your pocket. You may be waiting for hours to see a doctor for 5 minutes, or you may purchase “a package” that includes an echo without an indication. The healthcare system often runs thin on resources, not on patients. The sheer number of people is overwhelming.

The society
It is often said this is the land of contradictions. Just when you think the hospitality and warmth of these people cannot be matched you look at a sign posted in the hospital that discourages people from giving bribes. Is the care really free in the government hospitals? People leave their doors and windows open for the majority of the day, welcoming the sights and sounds of the neighborhood. But go out on the streets and nobody will be willing to give you even a car length worth of space. Kids, no matter how sick or poor, always seem to have an infectious smile on their faces. Adults making their living on the streets are so emaciated from poverty that they could be confused for terminally ill. The decision to go see the doctor starts from how much will I miss in daily wages to what will be cost of travel. When your needs are as basic as food, shelter and clothing, health takes a back seat. Every problem here seems to stem from poverty and ever growing population.

These 3 weeks conclude a lesson in disparities in health care. To say that the course objective was met would be an understatement.

Scary bugs

Puja and I got to spend 2 days this week with Dr. Lakshmi of the microbiology department—known to all at NIMS simply as Madam.  In the chaos that is NIMS, Madam’s microbiology lab is an oasis of order and efficiency.  The lab is well lit and tidy.  Everyone appears both busy and content.  We started our days by tagging along with Madam as she did her morning “rounds”.  I was surprised about how hands-on she is the everyday activities of the lab.  In the morning, she sits with the large registry books, which record all the cultures in the hospital.  The lab technicians take turns bringing her their plates so she can check their work.  She makes a few scribbles in the registry and is on to the next Petri dish with a wobble of her head.  Then we move onto checking the sensitivities in the next room.  A computer checks the sensitivities and then Madam double-checks the computer.

Puja and I crowd around the computer with Madam and watch as she goes through the results from the weekend.  The first one is an E coli with ESBL (translation for non-medical = resistance in bacteria to whole classes of antibiotics).  Then another one, then a Klebsiella with ESBL, then acinetobacter.  Madam, most of these cultures are ESBL!  Yes, she replies…very nonchalantly to my shocked face.  I can’t help but imagine how this situation would be dealt with at home.   The infection control team would put everything on lockdown; the Infectious Disease fellow would be drowning in consults.  What do you do when you lack the infrastructure to implement an interdisciplinary approach such as infection control?  There are very few to no single rooms; disposable gloves seem to be a luxury; the vast majority of Purell I’ve seen has come from my backpack; and broad-spectrum antibiotics are available to anyone and everyone, often without a prescription.  How do you manage resistant bacteria and viruses when you don’t have an infection control team and an antibiotic stewardship program at your disposal?  What is going to happen when these bugs become resistant to even more classes of antibiotics?  The road ahead looks very grim, indeed.

Madam tells us about past infection control and education programs she has implemented with variable success.   It’s a big problem, she admits with a weary wobble of her head.  What can you do except try and educate people?   I am once again overwhelmed with admiration for people like Madam who try again and again to provide good care in spite of extremely limited resources and an endless line of people in need.

“I wonder if Heaven got a ghetto”

I’ll be a Hem/Onc fellow in 10 months; most people still give me a variety of looks when they hear this news: ranging from slightly bemused to exceedingly astonished…really- why would anyone want to be an Oncologist?

We arrived at the MNJ governement institute early monday morning, by now well-versed on the infrastructure or lackthereof in a government hospital. First stop was the pediactric unit. We didn’t fully know what to expect but by now we had basically seen it all

It was a 15 bed ward…there were currently 30 inpatients each with one family member or another..most of the mothers had stayed overnight, but fathers arent allowed overnight: in the past theyve had problems with fathers drinking and abusing the staff

We were greeted by Dr. S, the lone medical oncologist for the entire hospital; she warned us immediately about the Dutch pediatrician who had visited her some time ago and couldn’t sleep for 6 weeks afterwards..without skipping a beat she had to start rounds on her 150 or so patients for the day..

the pace is fast- we see a child with ALL who is on 120mg morphine…unable to fully rely on labs either due to cost or accuracy, the cursory exam consists of a quick check for pallor or petechiae: one child was sent for platelets with a written order and his sterile needle to take to the blood bank- he was 4

The curative rates for ALL in the US is roughly 75-80%; Since the pediatric ward opened there have been 3 survivors out of over 300 patients, less than 1 %; the survival for AML patients is essentially 0 often because nobody can monitor coagulopathies; patients cant afford the travel costs and often complete cycles are missed

a 2 year old child presents with a distended abdomen: we know that there was an anterior mass but we don’t know much more than that-nobody was willing to take a biopsy..our attending admits sheepishly that often she has to give empiric chemo…the reasons are many: either because nobody is willing to make a diagnosis, or the lack of trust on pathology- slides are often mixed up or lost completely, or inability to followup markers: she’ll try something until there is some response… I must have had a dumbfounded look on my face because she quickly reassures me- don’t worry this is off the books, but it’s the best we can do

The kids are sharp and often know more about their treatments and dates than the parents- we hear a story about one child who had scolded Dr. S because she had discussed treatment details with his parents while he wasnt there; they then had a 1 to 1 detailed hospice talk- he was 8

After pediatric rounds we make our way to the adult wards; the Oncologist tells us that she trained in adult Hem/Onc in the US but came back becuase there was the need…as far as the Pediatric training: she tells us that there is a St. Judes hotline where physicians can seek opinions from specialist- this hotline, various textbooks, and on the job experience comprise the extent of her Peds fellowship

As we make our way upstairs patient after patient comes to the Madam for another opinion..they will follow us all day trying to get in a few precious seconds

By now the Madam is rolling, and a whole new set of problems come up.  Still she often has to resort to empiric chemotherapy, whether it is doing anything or not; one patient was on a regimen for 9 months that she had bought from a personal pharmacy- she had barely lost any hair at all that entire time

When a patient is doing poorly they are referred to the Palliative care department- the fees associated with transporting dead bodies is so high that they try to discharge patients home as close as possible to their death so that families can avoid the cost

the majority of the afternoon is a blur..we finally get some time to take a breather in the library- it is her only 30minute solace of the day; we try to reflect but can’t really put into words what we witnessed

Dr. S understands immediately and fills the silence- really…why would anyone want to be an Oncologist?

She doesn’t feel that coming back to the government hospital is saintly, but on some level it is the challenge- academically trying to make the best with limited to zero resources often concocting her own methods in order to offer some palliation to suffering patients

she doesnt convince us and soon enough she realizes that she can’t convince herself…she goes on: she often goes home crying on the brink of leaving her post- but then if she doesn’t do this what else will she do?

she repeats again that it’s not saintly but somebody has to offer these people something..the survival rates are dismal but she argues that 1% survival is 100% survival to that particular patient or child’s parent…with her eyes tearing up as she speaks she goes on: again on the brink of leaving her post- but then if she doesn’t do this who else will do it?

suddenly the door opens and we see a line of patients forming..they found her- the tears disappear, she gathers herself and at least for one more day, MNJ will have its Saint on duty

according to ones own guidelines

For the past 2 days I have been at Nizam’s Institute of Medical Sciences observing an Endocrinologist. He also sees many patients in a day (around 70 to be exact in roughly 5 hours). Patients do not need to make an appointment to see the doctor at this hospital, if they have time to come that particular day, then they make the visit. Like all of the other patients that we have seen interacting with their doctors, the patients here are responsible for keeping their complete medical records and bringing it with them to all appointments. The doctor whom I met with told me that he checks fasting and random blood glucoses on patients monthly, A1C’s every 3 months, lipids and urinary microalbumin every 6 months, and ECG, CXR, and retinopathy screening annually. I asked him why they were checking CXR’s on their patients, and he said that TB is the leading cause of mortality in diabetic patients in India, surpassing cardiovascular disease by far. As the morning rolled on, I quickly saw that there were many differences in the way that these patients were cared for as compared to the patients that I am used to seeing back home. For example, all of the patients had their BP checked, however nothing was really done about it. Additionally, many of the patients had significant dyslipidemia, however the Endocrinologist told me that he does not believe in statins, or aspirin for that matter. Many of the patients were on metformin, sulfonylureas, and the only insulin that is used at this particular clinic is NPH. Also, most patients do not check their blood sugars very often.  They are instructed to check a fasting blood sugar and one at bedtime, if these readings are ‘normal’ they are then told to check 2 x/week, and if these readings are normal, they are told to check once a month. Moreover, they are actually discouraged to bring their glucometers with them to their medical appointments due to there not being enough time to plug the machiene into the computer to get a print out. Actually, for this reason the equipment needed to import the data from patient’s glucometers has not even been purchased, and the advertisement still sits on the desk.

In addition to seeing patients in the outpatient setting, a driver was sent for me today to bring me to the research department. Several clinical trials are currently underway, and this lab is looking at some interesting things. These researchers are working in collaboration with some individuals in Portland to develop a tool to check for glycosylated urinary protein and use it as a surrogate for checking A1C’s. If this tool was reliable and cost effective, it would mean  that patients would not have to come back to the hospital 2 times (first give the blood sample and then to get the result), it would also provide information to patients in more rural areas in the country as well as abroad whom may not have access to a laboratory at all. Additionally, this lab is doing a lot of work with people whom have impaired fasting glucoses and seeing if yoga,in addition to other things can prolong the onset of DM.

All in all what I have seen is very interesting, and my eyes have really been opened that even with the prevalence of DM increasing in India, it is not beening aggressively treateted in all places. Widespread guidelines do not seem to exist or are not enforced here, and the physician has a lot of autonomy to practice according to their paticular beleifs.

“Wishes are children…”

It’s raining this evening. The drought that has plagued Hyderabad and the entire subcontinent for months has been broken, the monsoon at last arrived in a wild and unrelenting rainstorm that paralyzes the city and floods the streets. The rain falls so fast that even the inclined on-ramps of the fly-overs hold almost an inch of water. In low-lying areas the water collects into rushing rivers that feed into deep, turbulent pools that threaten to consume the cars and auto-rickshaws that attempt to ford them. Despite the predictability of the rainy season, the city, with its piecemeal and rapidly expanding urban plan, has no gutter or sewer system to carry the water away. The traffic comes to a grinding halt. Motorcycle riders that usually fill the road are forced to either carry on in the soaking rains or pull over and join the crowds of pedestrians huddled under the narrow shop awnings lining the streets.

The rain pounds the top of our car while we sit motionless on the road. During the breaks in conversation my mind continues to revisit the sights I had seen earlier in the day while observing in the Ob/Gyn department at Ghandi Hospital, the largest government hospital in town. I knew enough from the past two weeks to expect the place to be over-burdened by the sheer volume of patients, with not enough resources or time to go around. I also knew to expect the differences in procedure, to slip on sandals before entering the OR, and to not be shocked at the lack of patient privacy or autonomy. The hospital is only 8 years old but the interior is dark with cracked and mildewed plaster walls that are covered in tobacco stains near the floor and cob webs near the ceiling. It has the feeling of a much older and heavily worn institution.

When I was first escorted to the Delivery unit and introduced to the residents I scanned the room. It’s a large open space with a desk and chairs in the middle. Three walls are lined with stainless steel tables cubicle dividers separating them into pairs. Women are lying on the tables, some motionless, some moaning with labor pains, some with a family member, most alone. It’s strange to see them lying completely flat with not even a sheet beneath them and none of the enumerable monitors typical of a laboring American woman. Just as I step in the room a woman on the right delivers. A resident is assisting the delivery and sort of slides the baby out onto the steel table, suctions the nose and mouth, then tends to the cord and the mother. Rather than placed on the mother’s abdomen or swaddled for warmth the baby stays on the table for at least another three or four minutes. From a distance I notice another woman who has ace-wraps over the length of both arms, and the women next to her is in four-point restraints. I long to know the stories and pathologies of all these patients but I’m resigned to the fact that they will likely remain a mystery to me.

Later on that day I’m back in the delivery room. There are a few new patients, and a few have remained. A couple of residents walk over to examine the woman with the ace-wrapped arms. She is motionless and appears sick, possibly unconcious. She has a single IV in her hand with an empty 500 mL bottle of fluids hanging on the pole at her feet. As I approach the table I see that the skin across much of her face, chest, and abdomen has been disfigured. As one resident listens to the patient’s heart with her stethoscope the other resident informs me that the woman was 30 weeks pregnant. She was admitted four days ago to the plastic surgery service for severe burns covering 70% of her body, but was transferred to Obstetrics one day prior because of fetal demise. The patchy burns covering her face and chest are deep, but appear oddly dry, old, dull. The yellowish subcutaneous layer visible from beneath the thin remaining layer of dermis creates an eerie greenish effect.

With no ado the senior resident performing the exam drapes her stethoscope over her neck, places her hands over the woman’s chest, and nonchalantly begins chest compressions while the junior resident casually grabs a bag and mask to ventilate. Realization rushes over me as I watch the scene unfold, and I’m thankful for the surgical mask I’m wearing as I try to keep my face from betraying the horror I’m feeling inside. Is this a code? Does this woman have a pulse or a rhythm? How long has she been in this condition? Where is the urgency, the frenetic chaos usually associated with codes? The lack of available information is terrifying, and suddenly the status of this woman’s condition sharpens in my mind. I’m acutely aware that this pregnant victim of severe burns, status post intrauterine fetal demise, is lying on a steel table in Labor and Delivery of all places, with one IV, no fluids running, not intubated, and no monitor to even confer the presence or absence of a pulse.

The senior resident continues what can hardly be described as chest compressions. The table itself is quite high, and the resident is standing on the patient’s left, sort of softly thrusting her arms at the patient’s chest at a 30 degree angle, elbows not locked, shoulders barely moving. There doesn’t seem to be any kind of a system either, just a handful of compressions, then a few breaths, and so on. At times the compressions halt completely as the resident leaves the patient’s side to tend to other business before returning a minute or two later for another round. As I watch from the side I notice cockroaches scurrying over the cubicle divider to my right.

A few nurses have gathered in the area. One brings a blade and tube in the event that the patient will be intubated, but they’re never opened. Another brings three vials of meds. I can’t see what they are, but she administers one of them. The rest just stand silently out of the way, watching, coming and going after seeing their fill. Two younger women in colorful saris wander into the mix, and I presume they are family. One of them approaches the patient’s side, opposite the resident. She asks a few questions, observes the scene, gravely nods to the other, and soon begins to weep. She stands there at the patient’s side alone, unconsoled, her despondent cries overpowering the moans of the woman laboring feet away on the other side of the divider. She looks at me, heaving, wailing, clearly seeking answers to why this happened. I feel so helpless, unable to respond, this language unfamiliar, this patient unknown to me, and only my eyes uncovered to try and express my empathy for her situation. Another cockroach darts across the foot of the bed unphased by the surrounding scene.

Eventually the fray dissolves. The family members are escorted back outside, the compressions stop for the last time, and the nurses disperse to their other patients. I approach the woman alone and cast my eyes over her still, disfigured face as questions crash over my mind like a tidal wave. How or why was this woman burned? Why wasn’t she in an ICU? Why wasn’t she intubated already? Why didn’t she have more venous access? Why weren’t they dumping fluids into her? Why didn’t she have any monitoring? Why did her fetus die? Why weren’t they delivering her more aggressively? What caused her death? Shock? DIC? PE? How long was she dead when someone finally bothered to check? This woman did not die on the street, unable to access healthcare – she is lying in the largest tertiary care hospital in the state! I’m confused and angry, and I badly want to turn and scream my outrage at the residents now preoccupied by other tasks. This poor woman suffered terrible injuries, and I have no idea what her ultimate fate could have been, but I’m positive that in America she at least would not have died today. The collision of sights and thoughts overwhelms me and I have to step into the unoccupied “suite” beyond the opposite divider to escape. I face the wall, and for a moment I am overcome with emotion, wishing I could crumple into the corner, to bear the burden of this tragic scenario.

I compose myself, and as I turn back to the center of the room I notice that plastered on one of the columns is a poster of a bunch of cute, pudgy, smiling babies photographed in soft lighting with an accompanying message of some sort for new moms – similar to something one might see in a Pediatrician’s office. It feels ironic and out of place here, a celebration of joy and new life in this dark, impersonal ward that will today serve as at least one woman’s final resting place.

***

It’s morning now. The sun is out and pedestrians and men pushing produce carts have come out from under the awnings to once again fill the shoulders of the roads. As my cab passes beneath the train bridge on the way back to the hospital, I glance out the window at the spot where the deepest eddying pool of water lay last night. This morning it’s completely dry; only a thick, dusty sandbar remains as evidence of the previous night’s torrent. As I survey the scene, a flood of memories of the monsoon the day before washes through my mind, but unlike the water in the roadbed, those memories will take much more than one morning’s sunlight to dry completely.

what more to see…

There is immense suffering and extreme poverty in India. Pediatric oncology is a tough field of medicine, but pediatric oncology in INDIA is medically challenging and emotionally draining. Despite dramatic improvement in mortality of a child with ALL in the rest of the world, survival rate remains <1% in a government hospital we visited today in Redhills, Hyderabad. We observed about 20-25 children with skeletal structures having neck masses, distended abdomen, limb masses, proptosis, skull lesions etc. all co-inhabiting a single ward with 14 steel flat beds, a foot apart from the next with white covers. There are is nothing uplifting about the surroundings with dingy and flaky walls, some parents inside, others outside on the floor trying to collect whatever food they have to provide for their sick child.

The ward is full of AML, ALL, Wilms’s Ewing’s, Hodgkin’s, Non-Hodgkin’s, neuroblastoma, langerhans histocytosis, unknown diagnoses and the list goes on. Dr. Sinha sits on the corner as one by one a child accompanied by a parent makes her/his way on to the stool.  Some are to get a cycle of chemotherapy, some need a transfusion if mucosa is too pale, some to get platelets if have petichiae, some on empiric broad-spectrum antibiotics for fever, some morphine for pain.  Work- up is negligible and treatment assigned solely on a very limited physical exam as none of the parents can afford to pay for tests unless absolutely necessaryy. All are to be seen by social worker who stands behind the counter, so they can get some sort of assistance in getting today’s assigned treatment. Some children are actually handed a needle with a cap to take to the laboratory if blood needs to be drawn and return with the report. No there is no phlebotomist. Even the ward was non-existent until 6 months ago when Dr. Sinha finally was able to get staff together and convince the need for it to the administration.

Dr. Sinha herself is a US trained ADULT oncologist, learning pediatric medicine on the job. She is fully aware of evidence based medicine and novel treatments that change the outcome from 60 to 80%  to 90% but it stops there as she is battling herself with the limited resources. She continues to apply for grants, contacting experts at St. Jude’s hospital in US for protocols, making worksheets to better document, empowering the nurses and parents at the same time to improve childcare.

Before we know it, we quickly swift through the adult inpatient ward and off to the outpatient around the corner. There again, Dr. Sinha went through mounds of chart one by one seeing around 50 patients in all in 2 hours.  Patients named were called out loud, they made their way inside, barefoot, some chose to stand only or sat on the stool for 2-3 minutes as the history was quickly reviewed and treatment assigned – either a cycle of chemotherapy, transfusion, palliative care or surgical referral. There is no patient confidentiality as one patient elbows the other out of the way – they all want to be seen and cured.

We eventually head out to look for our taxi. On they way, we pass a number of people with meager belongings, who have come from far villages, now living outside on the premises of the hospital, hallways, streets, under the shade of a temple to receive radiation treatment. They will stay outside until treatment is finished, tolerated or afforded. With today’s monsoon’s pouring down heavily, I wonder where they must have gone.