#pravara

Osobe koje se bore za svoj život u BiH i za koje su pisani brojni apeli za prikupljanje sredstava za pomoć (među njima i djeca), na meti su prevaranata koji pod izgovorom da će im uplatiti novac za liječenje traže uplatu provizije na svoje račune. Iza prevare stoji muška osoba čiji će identitet utvrditi policija, a do sada su zabilježena četiri slučaja. Posljednji slučaj dogodio se u četvrtak, 6.…

On Monday (11.08) I was involved with Directly Observed Treatment, Short-Course chemotherapy (DOTS) for tuberculosis. I learned that 20% of the world’s TB patients are living in India. This is a consequence of poor hygiene and crowded conditions. This is the “Designated Microscopic Center” where sputum cultures are assessed:

Upon finding a New Sputum Positive (NSP), treatment is given under the observation of volunteers from the community. These services are made available within five kilometers of patients’ residences to minimize the burden of travel and time missed from work.

The department head insisted that none of his patients were contagious, but I insisted on wearing a mask in the ward because tuberculosis. We came upon a woman who was diagnosed post-partum, isolated from her fifteen-day-old son. Her baby does not necessarily have TB, a disease that is spread by respiratory secretions, but chemoprophylaxis (medication for the prevention of infection) is necessary.

On Tuesday (12.08) I had the pleasure of working with Dr. Ravishanker, the only man brave enough to work as a plastic surgeon at Pravara Hospital. In fact, his is the only burns unit within a 100-kilometer radius. I stepped into his office to find a baby post-operatively who was put under the knife for extravasation (vessel leakage into surrounding tissues) from her cephalic vein, a complication from the IV antibiotics that she received for septicemia (infection of the bloodstream).

A mother asked about her child, “Have you inserted plastic into her?” A common misconception about plastic surgery.  Plastic surgeons perform reconstructive procedures to correct congenital abnormalities (e.g. cleft lips and palates) or impairments caused by injury (e.g. burns). Of course, some plastic surgeons also perform cosmetic surgeries to alter the appearance of patients, but Dr. Ravishanker does not involve himself in these cases. 

Cleft lips and palates are best treated at three and nine months, respectively, but many families hold out for the prospect of a free procedure. This boy of twelve years still needs a palate repair for this reason: 

Not only was his speech impaired, but he could not walk in without assistance due to untreated burns on his leg. Skin grafting should have been initiated immediately, but two years without proper care have cost him. Although the function in his leg will be restored, the limb will forever remain shorter. Both procedures will be taken up in April of 2015, Dr. Ravishanker’s next available.

The most common “cause” of burns is kerosene stove combustion, though the burn properties may lead the surgeon to believe otherwise. He reports that around 80% of cases are not accidental. Every patient is a medical legal case and requires psychiatric evaluation. Perhaps domestic disputes or unsettled dowries furnish the female ward.

Neglect is often to blame. We came upon a nine-year-old girl who suffered electrical burns. She was playing on a roof when she fell, clung to a 440V cable, and swung into a window.

An eleven-year-old girl presented with a scalded chest and face with cuts on her wrist, throat, and abdomen. She explained that a pressure cooker burst and the lid was ejected toward her head; the edges of the lid cut her neck; she then slipped on water and fell on an open vegetable cutter (vili), perforating her intestine; meanwhile, her wrist struck the edge of a pot on the table. One of the medical interns, Pallavi, was convinced that this incredible set of circumstances did in fact explain her injuries. Others insist that she is covering up a darker truth. I can’t be convinced either way: I don’t have the facts. I only wish that the resources were there to allow for an in-depth investigation in every case. 

Dr. Ravishanker provides comprehensive therapy that prioritizes the patient’s emotional well-being. One of the women under his care has been isolated from her baby due to the risk of infection in the unit; however, he makes an exception for breastfeeding to keep the woman happy, because he knows that recovery depends on the right state of mind.

Dr. Ravishanker maintains strict standards in his department. He mandates that every patient receive a bath with soap and water daily. His nutrition protocol includes cheap, available ingredients (eggs, butter, sugar, and milk) that provide the nutrients burns patients need at an affordable price. Antibiotics, blood products, and immunoglobulin are only used when absolutely necessary. The amniotic membranes that he harnesses are readily available. Because of his cost-saving measures, a fee of < 100,000 Rs is achieved for these patients. The banking of amnion and skin grafts is an advanced practice, though the rural hospital’s storage conditions may appear primitive:

I visited a woman in acute condition who sustained 60% burns. Her wailing was unnerving, but we didn’t linger. When I inquired about her pain medications, however, we learned that the ER had prescribed none. Tramadol was started immediately thereafter, and the patient’s moaning subsided. Morphine would have been preferred, of course.

Wednesday (13.08) morning was spent in general surgery. In the afternoon, I watched my colleagues present their findings from our visit to Chandrapur for the Health Bank Study. Of the eight groups that presented, theirs was among four selected to present at a symposium. These students’ theatrical presentations strongly appealed to the pathos of the audience. Before describing the poisonous effects of pesticides, the first group asserted that they were about to “blow [our] minds off!” Another group likened diabetes to a tiger: “if you feed it and never turn your back on it, you can live with it; but if you ignore it, it will pounce on you and rip you to shreds!” 

I requested a posting in the psychiatric department for Thursday (14.08). The psychiatric department is entwined with every other department in the hospital, particularly antenatal care, because pregnant women may be depressed by the harassment of in-laws who push their daughters toward over-exertion, and, of course, the burns unit. Here, I joined med interns as they interviewed patients about psychosocial stressors—marital problems, death of family or friends, financial problems, discord with neighbors, legal problems, calamities—in addition to the standard questions involved in taking a medical and social history. 

Because so many people in other departments had indicated that mental illness was heavily stigmatized in rural India, I was curious to know about the psychiatrist’s reality. Dr. Chaudhury explained that the stigma exists in providers only. To demonstrate this, he questioned a presenting couple about their willingness to address mental health: the husband explained that he found his wife talking to herself. She insisted that God was telling her to make a pilgrimage to a distant temple. Having observed similar symptoms in his sister, he didn’t hesitate to seek treatment. She has been stable on anti-psychotic therapy for months now. He has a friend who also receives treatment for mental illness. 

The RGJAY funds do not finance any psych meds, unfortunately. The cost of these medications at Rs 100-200 per month is feasible for most patients. For others, anti-cholinergics may be sacrificed from the regimen. These drugs are normally on board to prevent movement disorders that may result from anti-psychotic medications.

Dr. Chaudhury was involved with the military before he began his career as a psychiatrist. I was curious to know about the extent of PTSD in his comrades and patients. PTSD is not so much of an issue here—which he attributes to a difference in moral justification, among other factors. Soldiers are never deployed outside of India.

The second half of my program is made up of experiences in various departments here at the hospital, particularly looking at how they do drugs. On Monday and Tuesday (04-05.08) I visited the hospital’s department of oncology in the basement. It is located below ground level to protect small children and pregnant women from exposure to radiation, but there I was, standing outside of the radiation treatment center… Sensing my apprehension, the resident explained that a dosimeter continuously measures radiation levels for safety.

We first visited the Treatment Planning Room where the precise dose and beam angle of radiation therapy (RT) are determined. The main tumor and neighboring organs are outlined on the patient’s CT scan results. A cumulative dose volume histogram illustrates what doses these areas will receive, expressed in grays (Gy). For the main tumor, this should be 90%, while surrounding tissues must not receive more than a specific amount. RT is given externally or, in the case of brachytherapy, internally. We saw the instruments used to insert radiation directly into the organ for internal beam RT, like whoa:

We were shown the two RT machines. Some patients undergo RT with manual planning due to financial need: depending on whom you ask, this may mean radiation without an MRI or CT scan. The RGJAY funds assist needy patients in Maharashtra, but some cannot produce the necessary documents to obtain coverage. I wonder how the beams can be manually arranged without compromising precision. A bladder even can vary by 1-2 cm depending on fullness.

I watched five men argue over a women with breast cancer exposed on the table. The energy was all wrong. They were laughing about I don’t know, dropping things. A phrantic fysicist entered the room to hurriedly calculate the times for each dose. I couldn’t help but think of how anxious and vulnerable I would feel if I were the patient. But how did she feel? Did she know her rights as a patient? Did she fully trust her providers? She was tachypnic—breathing rapidly. I later asked the oncologist what they were arguing about in Marathi. A: the placement of dividers to prevent radiation to her brain.

Opioids are a staple in cancer patients in the US; however, India has restrictions on morphine due to its abuse potential. The Narcotic Drugs and Psychotropic Substances Act of 1985 leaves cancer pain largely undertreated here. Morphine is only used 1-2 times per week in this department, usually in cases of bone metastases. Tramadol, diclofenac, ibuprofen and paracetamol will have to do, otherwise. 

Back in the outpatient department (OPD), patients might stand or sit wherever with no privacy or guidance. Residents discuss biopsy results across the table. Patients peer over their shoulders. The residents might retreat without notice, leaving me with questioning patients who speak only Marathi. It is, in a word, chaos. I asked the residents to interpret the patients' complaints when it looked like they had a moment. In the meantime, I studied a physician’s reference book on chemotherapy. Patients maintain their own medical records. This is hugely convenient when the biopsy or lab results from another facility are readily available; this avoids the trouble HIPAA imposes to obtain another provider’s findings. 

The inpatient wards are very public: female and male patients are divided between two rooms, with the exception of neutropenic patients who require isolation precautions. On Tuesday morning, I accompanied the doctors and residents on rounds. Afterward, I watched and winced as one of the residents (Amrita) inserted a nasogastric tube into a patient whose lung tumor was compressing his esophagus at an astonishing 11 cm. By the nurse’s request, she inserted an IV drip into a patient with squirelly veins. She scampered around asking for “spirit.” This is the term everyone uses for alcohol swabs. The residents do it all! The roles of doctors and nurses are so very different here. 

Chemotherapy is administered in the Day Care Ward. The RGJAY funding is huge for locals to receive such expensive medications at no cost.

Wednesday and Thursday (06-07.08) were spent in the department of orthopaedics with Dr. Pushkar. The department comprises four units, with the head of the department leading Unit 1 and the most junior professor in Unit 4. 

In the inpatient wards, we saw X-rays of the stainless steel nails which serve as internal splints in cases of simple fractures. Many patients were admitted to have these nails removed now that their fractures have healed. For compound fractures in which bone is exposed to the environment, however, an external splint is necessary. The majority of patients in the ward were very young or old. While lumbar spondylosis is age-related, the strain of farm labour most likely contributes. There are also the conventional bike accidents, tree falls, cricket-related injuries.

We observed a case of compartment syndrome in which a man’s leg had swollen so much that the pressure had obstructed vascular and lymphatic drainage from his muscles. To prevent tissue necrosis, a fasciotomy was performed, leaving his leg exposed at the fascia layer. Unfortunately, intellectual disability has kept this patient from following the doctor’s instructions to perform active movements, so the function in his leg probably will not be restored. The resident explained that the personal care he needs cannot be provided in the ward. His child of six years is basically his caretaker. His wife cannot speak.

I was invited to sit in on the practical examination of physiotherapy students. It was unlike any practical I’ve ever experienced. The nervous students were ruthlessly grilled by Dr. Pushkar. They were asked to assess a patient case, identify instruments and bones, and interpret X-ray findings. The first chap nervously held an X-ray blatantly backwards, leading him to diagnose a fracture in the wrong leg. Dr. Pushkar explained that the ‘R’ is not for Raju, but denotes the right leg, and he “must have been absent for the surgery and X-ray notes.” Yikes. Another student, when asked to pick up any instrument, reached for a bone. It was difficult for me to watch, but I can’t imagine Dr. Pushkar was pleased with the last six months that he spent teaching these students. Nonetheless, he intends to pass them all. I guess they will never forget the content on which they were interrogated.

On Thursday I had the amazing opportunity to observe a hemiarthroplasty—the head of the patient’s femur was replaced after its fracture. Here is the original:

I wondered how the surgery compared to my dad’s hip replacement back in the States. I hope that none of the surgical assistants for his procedure slipped on a glove after it had fallen to the floor (I took this to be an individual rather than system error). Orthopaedic surgeons are essentially carpenters for tissue and bone. They hammered into an undernourished leg as I stood in the corner concerned with the clanking sounds. The cauterizer was the hardest for me to tolerate, though. The smell of burning flesh permeated the room. That dizzy feeling of consciousness fading never came up, though. Maybe I’ve become desensitized. It's whatever:

On Friday morning I visited the Health Bank in Pimpri Loki. Here, the ASHA provides first aid, antenatal care, screenings (blood pressure, blood sugars, pregnancy), nutritional supplementation, rehydration, and contraception. If needed, patients are referred to the hospital for skilled care at no cost.

I revisited the blind and deaf students, this time for the SHAPE program. It was a delight to find that one of the deaf girls (Neetan) remembered me from nearly a month back. The posters displayed easy-to-follow visuals while the teacher translated in sign language. 

On Monday (21/07) Leonard and I returned to the Rural Health Center in Rahata. Here we observed an obstetric examination and afterward Sorabh explained the components of the antenatal care interview. Pregnant women are asked about any hereditary diseases: beta thalassemia major is a common recessive hereditary disease in this population that is characterized by a severe form of anemia. Consanguinity is also a part of the interview: ‘caste disorders’ prevail due to incest despite government advocacy of intercaste marriage.

During my time at the clinic I was on call for any and all intramuscular (IM) injections. While administration into the deltoid muscle is standard in the US, malnourished patients lack muscle here, making the more invasive gluteal site the preferred route. Syringes are disposed of at the clinic only after placing the needles in a burner.

On Tuesday (22/07) Sachin, the lab technician, showed us the labs performed for pregnant patients at the Rahata clinic. A dipstick was used to reveal urine glucose and albumin based on color change: abnormal findings are suggestive of gestational diabetes or eclampsia, respectively. Blood samples are divided amongst three plates where anti-A, anti-B, and anti-Rh antibodies are added. A clumping response reveals the patient’s blood type. Blood samples are combined with hydrochloric acid and left to react for a few minutes. Distilled water is then added until the sample matches the reference colour on the Sahli haemometer, and the resultant volume is indicative of the patient’s hemoglobin level.

I thought it would be great fun to put a sample of my own through these tests despite my precarious history with blood. I turned my head from Sachin and his masterful finger-sticking technique. O+ as I already knew, me and the rest of the world. Hemoglobin was twelve, low-normal. As I sat and processed everything that went down, I got that old familiar feeling of dizziness and darkening vision. The plain sight of me in a chair, legs suspended, is pretty ridiculous I guess, so I moved rooms to be ridiculous in private.

On Wednesday and Thursday we were involved in the Targeted Intervention to Migratory Workers for the Prevention of HIV/AIDS. On a rainy Wednesday (23/07) the mobile clinic made its way to Shrimpur to be visited by factory workers. Once I came across the mobile clinic’s drug supply I busied myself with inventory management while we waited for patients...

I sorted out cups that held a smorgasbord of different drugs and arranged the drugs by category (allergy/cold, pain/inflammation, stomach, infection). I had to pretend I didn’t see the syrup-coated measuring cup.

Once patients’ blood samples were collected for HIV/AIDS testing, Dr. Jitendra K. Patil addressed any complaints that they might have had. Notably, allergic bronchitis was seen as a result of working in a dusty factory.

The mobile clinic’s next stop was a five-star hotel in Shirdi on Thursday (24/07). Complaints of lipomas were the trend in these hotel workers. The physician prescribed ciprofloxacin for a patient’s acne, though my first recommendation would have been doxycycline. Welcome to the complex concept of ‘clinical judgment:’ medical professionals base their recommendations largely on personal experience in addition to their assessment of the patient’s unique problem at hand. It is an artful science.

Giby, the medical intern, explained that if Leonard and I were not present, there was no way the hotel owner would have given us all a tour of the place. We saw the hotel’s reproduction of the Shirdi Sai Baba temple, the spa on the fifth floor, the rec room, the kitchen—even the employee break room. Honestly I was pretty indifferent to it all, but the owner’s pride was totally endearing.

On Friday (23/07) all of us international students joined a group of BDS (Bachelor of Dental Surgery) and physiotherapy interns and nurses for the school, health, hygiene, and environment program (SHAPE) in Bhandardara: the dental interns—Aanchal and Aarathi—reviewed brushing technique and cavity prevention with the schoolchildren, while Kalyani of physiotherapy covered wrist and neck exercises and the nurses covered personal and environmental hygiene.

We visited the region’s two Rural Health Centers, which were very similar to the clinic in Rahata. Bhandardara was different from any other village we had seen, however. It is stunningly gorgeous, in the middle of mountains and meadows.

Leonard and I were given the amazing opportunity to take part in a multi-diagnostic camp on the Sunday before last (20/07). The Institute’s dermatology, ENT (ears, nose, throat), general medicine, dentistry, ophthalmology, internal medicine, gynecologic, orthopedic, and physiotherapy departments set up makeshift OPDs at these camps in prearranged villages every month or so.

We were on board… on one of two packed buses at 7:30 AM, taking care to sit at the very front to avoid a rollercoaster ride at the back. The most obnoxious horn you could imagine blasted an unsuspecting me while Leonard drifted to sleep. I was pleasantly surprised when we arrived at the village of Nepani Vadgaon after only fifteen cacophonous kilometers, having been briefed about a 100-kilometer trip.  Our nutella and kayli (banana)-filled selves were also not expecting a breakfast of carb-heavy pohe to be provided. The only thing I've come to expect is discrepancy here. I'm improving my flexibility sans yoga.

Twenty minutes later, flocks of nurses, residents, and department heads were buzzing on breakfast while I stood with Leonard and Mangesh (of the CSM) to the side—but not for long. I approached the nursing students who were obviously laughing at us, and spoke infantile Marathi at them. They ushered me to a masala tea party where I tried to add to my growing Marathi dictionary, but their foreign phrases were left untranslated. I’ve found that, as a rule, the nursing students of Pravara are not fluent in English.

In the ladies’ restroom of Nepani Vadgaon I finally experienced a squat toilet. Look at the not-so-private stalls that changed my life:

Before long, the camp was inaugurated. Villagers sat Indian style (naturally) and watched as the hospital’s department heads were presented with coconuts and bouquets. Mangesh pointed out the sarpanch (head of the village)—a woman dressed in a yellow sari. Many of the towns in the district of Ahmednagar are headed by women.

Once the clinics were opened up in the surrounding schoolhouses, the villagers lined up outside to be seen. I dropped by the skin clinic first, where I saw cases of tinea corporis (ringworm), lipomas (fat tumors), allergic reactions to kumkum (a powder used to mark the forehead), hyperpigmentation, eczema, vitiligo, and neurofibromatosis. I asked the residents what treatments these patients had tried for their skin conditions, and learned of the population’s lack of health literacy. Medical records are not maintained. Prescribed treatments are blindly taken, if at all. Non-adherence commonly leads to fulminant and recurrent disease patterns.

In the ENT department, we observed a patient whose right tympanic membrane was perforated from a recurrent upper respiratory tract infection that had migrated via Eustachian tube. Surgical reconstruction was in order, but first the infection would need to be controlled with antibiotics.

In the mobile dental clinic, basic minor procedures were under way, including scaling (deep cleaning) and uncomplicated tooth extractions. ‘Mishri’ is a form of tobacco that is rubbed on the teeth and gums, while ‘bidi’ is smoked. These habits lead to teeth staining and palate issues in this population.

To manage illiteracy, the ophthalmology department assesses patients’ abilities to count circles from a distance in contrast to the traditional Snellen letter recognition.

In the pediatric department we heard about children who suffered pesticide or kerosene poisoning. During monsoon season, poisonous snake bites surge as burrows become uninhabitable. Snakes are regarded as the “farmer’s friend,” but venom can be neurotoxic or hematotoxic from a provoked krait or viper.

At lunch, the locals ran around offering jalebi—sweet rings of deep-fried flour. I asked one of the internal med residents how I might say ‘no, thank you,’ and he was dumbfounded. He explained that there is no need, that there is a mutual understanding. These patients do not thank him for the services he provides.

In the orthopedics department, the residents were worn down by the many knee osteoarthritis cases, and so I enthusiastically counted exercises out for patients (ek, don, tin, char, panch...).