Sunday, February 19, 2012

Ooty (Feb 3-6)

tea plantation

Friday evening I took my first bus trip in India. I went with several of my German friends - Julia, Kim, Carina, Michael - and another girl from France, Anastasia, who is also studying at St. John’s. I was glad that I had a group to go with because I think I may not have made it out of Bangalore on my own. The place where we had to pick up the bus was really not well marked and there were tourist buses everywhere. I think alone, it is quite possible that I would have missed the bus to Ooty. They have sleeper buses in India which are buses with beds that are supposedly more comfortable for sleeping but we were not on one of these buses. We took a non-A/C seater bus which reminded me again why I had resolved not to do overnight bus trips anymore after my experience taking the night bus to and from Copenhagen. At least the Copenhagen bus had WiFi. I did not sleep very well the entire trip to Ooty and when we arrived the following morning, I was feeling quite tired and sore from my night on the bus. They also don’t have bathrooms on the bus and we only made one pit stop...on the side of the road so all the men were able to get out to urinate, but for us women who actually need to at least find some private place to squat - there was nothing. So by the time we arrived in Ooty, I was tired, sore, and really had to use the bathroom. We found a hotel to stay at for the night, dropped off our stuff, got changed and headed out for breakfast.

Ooty - view from Willy's Coffee Pub
There aren’t too many places listed in the Lonely Planet as far as breakfast goes in Ooty and the ones that are listed are pretty difficult to find. Even though there was a street map of Ooty, the fact that many of the roads lack actual street names makes it hard to really find anything - you know what general direction to head and end up asking a lot of people along the way if they know of the place you are looking for. Often people will give you some direction, but unfortunately there are many times when the directions they give are either completely wrong or impossible to understand like “go straight then left” without any specification of how you will know when it is time to turn “left.” We were unable to find the restaurant we were looking for (called Willy’s Coffee Pub) and so ended up eating at a different cafe that was more expensive then it was worth. After having breakfast, we wandered back to our hotel where we had discussed meeting up with a guide to take us to the good trekking spots in Ooty.

home in the Nilgiri Hills
According to the Lonely Planet, the main reason why people go to Ooty is for the trekking. It is an old British hill station up in the mountains and is cooler then some of the larger cities at lower elevation. In addition to the mountains, the Ooty area is also home to a lake and an abundance of tea plantations. The problem with the Lonely Planet is that it doesn’t really tell you where exactly to go to find this great trekking which necessitates hiring a guide. Our hotel had a guide that they called for us and at around 1pm on Saturday, we headed out. Our guide took us on the local bus to a village about 20km outside of Ooty where we got off the bus and started our trek. We climbed to the top of a hill and had a nice, but hazy view of the surrounding mountains and river. According to our guide (which after the weekend, I am not sure how true/factual the information he gave us was...), this was a popular site for Bollywood movie scenes and also the site for some foreign film scenes as well - although the German and French movies and directors he mentioned were unknown to the Germans and French in our group. He didn’t list any Hollywood films that used that site. From there, we walked through a typical farm and home of the Nilgiri hill people. Although I felt uncomfortable walking through someone else’s yard and interrupting their work to talk, the woman who lived there was quite friendly and seemed happy to show us the incredible weaving work she was doing. 

We continued along the trail following our guide through the hilly forests. Apparently, these forests are the home to lots of wildlife including black monkeys (which we heard but did not see) and tigers. I was one of the few in the group hoping to catch a glimpse of a tiger in the wild but the closest we got were some relatively fresh tiger droppings from a few days back that our guide pointed out to us. The best part about the trek through the woods is that we were able to escape the noise of the streets and other than our own walking and talking, the only sounds we heard were the natural sounds of the forest. It was incredibly peaceful and exactly what I needed. Before I arrived in India, I had planned to take weekend trips to visit the major cities of India. After spending time in Delhi and Bangalore, I realized that what I wanted the most out of my weekend trips was an escape from the city to someplace quieter and less crowded. I was glad to find that in Ooty. After a while of hiking through the woods, we came upon Ooty Lake. It was beautifully set by the hills and was a quiet place for us to sit and relax a while. I would have loved to jump in for a swim but instead settled for sitting on one of the giant boulders by the water and just letting the calm of the water fill me with calm. After our time of relaxation, we trekked our way out of the woods and caught a bus back to Ooty. The six of us stopped back at the hotel before making our way to the Kebab Corner for dinner. After we filled ourselves with food, we stopped by a few of the numerous chocolate shops in Ooty, bought ourselves some dessert, and headed back to the hotel for a good night of sleep.

We decided to sleep in the following morning since none of us had slept very well on the bus and we were tired from the day of trekking. We took our time getting ready and after checking out of the hotel, we were able to find Willy’s Coffee Pub where we had a nice long breakfast. We then met up with our guide from the previous day to go for another trek before we had to catch our bus back to Bangalore that evening. We again took the public bus and got off at the base of Doddabetta Lookout - the highest point in the Nilgiri Hills. The best part of Doddabetta was the hike up the road to the top. The trees along the road had signs posted on them with messages like “let nature be your companion” and “it’s sad when flowers refuse to smile back at you.” The view from the top would have been much more impressive if it were not for the omnipresent haze that seems to cover all of India. The pictures I took from the top were pretty disappointing as they all looked fuzzy from the haze. Instead of going back down the way we came, our guide took us past a rock ledge that is apparently a major suicide spot in the region (morbid, I know - we all felt like that information was completely unnecessary for our tour) and had us crawl underneath a fence into the woods. Our trek through the woods on Sunday was much more rustic and less well marked than our trek the day before. For some of us, it added to the adventure and for others, it was a pretty miserable hike. I was very thankful I was wearing long pants and had decided to bring along my long sleeve shirt so that I could protect my skin from the some of the sharp plant stems that frequented our path. We finally made our way out of the woods and found ourselves in one of the nearby villages that is home to some of the tea plantations of the region. Although from the tea plantation, you could hear the noise of the streets, this was probably my favorite trek that we took all weekend. The plantations were vibrant green and it was very relaxing to meander through the plants. By the time we walked through the tea plantation, it was time to head back to Ooty to collect our bags and have some dinner before catching the bus back to Bangalore. We ate at a hotel recommended by the Lonely Planet although I think we were all a bit disappointed and wished we had returned to Willy’s Coffee Pub for our final meal in Ooty. We boarded our bus around 8pm, had another very restless night, and arrived back in Bangalore Monday morning shortly before 7am - just enough time for a quick nap before starting my posting in Emergency Medicine. Namaste.

local bus

up Doddabetta Lookout

2nd day hike through the woods

Sunday, February 12, 2012

2nd Week of Ortho @ St. John's (Jan. 30 - Feb. 3)

Indian toilet

My second week of ortho was just as interesting as the first week. The clinic days were busy with us often seeing 40-50 patients in one clinic day. The clinic days here are shorter than at home - it doesn’t usually get started until 9:30 and is typically finished by 2pm. Of course, when there are two physicians sharing one clinic room and each are seeing patients simultaneously, a lot more patients get seen. Since almost all patients come to the clinic without an appointment and are assigned a number in the order in which they arrived at the clinic, some end up waiting quite a while before they get to be seen by a physician. This was the situation I experienced with the ortho clinic in Haiti as well. The major difference here in India that I have noticed is that patients will often try to move ahead in line. It is not unusual to have patients coming into the clinic room and as soon as the current patient is done being seen (or sometimes they don’t even wait for that and interrupt the current patient!), they will sit down and start telling the physician their complaint. The docs are aware of this and their first question is almost always, “What number are you?” When it is clear that the patient is trying to move ahead in line, they are sent out from the room and told to wait in line for their turn. Of course this isn’t always the case and knowing the right people can help you to move ahead in line. Any friends of the physician are usually seen ahead of their turn as are any people affiliated with the Catholic church - nuns, priests, and friends of the priests also seem to be allowed to budge in line.

patient with snake bite after amputation
There were several interesting cases (interesting in the sense that it is something I would not see at home - often being labeled as “interesting” is not a good thing for the patient) that came into the ortho clinic this week. One was a young boy who had a fracture of his humerus that should have been treated with surgery but was not because the family was poor and could not afford the surgery. According to my attending, this boy developed a bad infection (osteomyelitis) of his humerus because of the fact that he was not treated appropriately. I saw a few patients with tuberculosis of the spine and one with tuberculosis of the peritoneum. A woman came with osteomalacia due to severe Vitamin D deficiency that was caused by her religious dietary restrictions. Sometimes vitamin and mineral deficiencies are due to poverty, but there are a larger number that are due to strict religious dietary restrictions from both the Hindu and Muslim religions. 

TB abscess seen on xray
The ortho wards also continued to be very busy with our team rounds (I think there are 3 teams total - so we only see a fraction of the entire ortho service at the hospital) consisting of 30-40 patients. Like in clinic, on the wards I saw several patients who had delays in treatment or no treatment at all due to their lack in ability to pay for the surgery that they needed. Patients are required to pay for their surgery in full before they have it even if a delay in the surgery would likely worsen the outcome for the patient in terms of post-op morbidity. There were at least two cases that were nearly cancelled the day of surgery because the patients had not paid for the entire surgery. One was a patient with a femoral neck fracture and the other was a patient with severe TB of the spine resulting in paraplegia. Before the TB patient was able to pay for the entire operation that was scheduled, the surgeon contemplated only doing the part of the surgery that the patient could pay for - he needed a spinal decompression with implants placed to support his spine were his bone had degenerated due to the TB. The surgeon considered only doing the decompression with an anterior rib graft placed and skipping the posterior implants which could have resulted in significant morbidity for this patient. Thankfully, the patient was able to round up enough money to pay for the entire surgery which would give him the best chance at recovery with the least loss of function.

tuberculosis pus from abscess
On our operating days, I did not stay for 11 hours like I did the previous week. There were fewer cases on the schedule so I got done much earlier.  There were two really interesting cases. One was a patient that I had seen twice in clinic - a boy who was a victim of a snake bite that became infected and gangrenous which resulted in the boy having part of his foot amputated. The amputation resulted in a deformity of his foot that was causing him pressure ulcers since he was putting his weight over uncushioned bone. I observed the surgery for the correction of this deformity - a wedge of his bone was taken out and what was left of his foot was brought forward so that the new weight-bearing part of his foot would be the calcaneal heel pad. This boy also came from a poor family and so instead of having screws placed to fix his foot in position, he only had k-wires to hold the correction. He won’t be able to bear weight as quickly because the fixation is not as strong. Hopefully, it will heel well and the boy will be able to have a relatively normal life. The second really interesting case was the TB spine patient. I didn’t stay for the entire case mostly because I couldn’t see - there were 4 people scrubbed in so I couldn’t see at all - but also because it made me nervous to be in the surgery. The patient had a really large TB abscess next to his spine which was opened during the surgery and we were all only wearing regular surgical masks, not the special masks that we wear in the US with any patient with even suspected TB. The one TB surgical case I saw in the US, we basically worse space suits for the surgery that had their own air supply so we wouldn’t breathe in any potentially aerosolized particles of TB. Of all of us in the OR, I seemed to be the only one really uncomfortable with breathing in the presence of an open TB granuloma...

Julia, me, Kim @ Love Shack
In terms of my social life, it continues to be pretty happening with the German medical students. One evening I had dinner at Little Italy - yes, Italian food in India. The food is nothing special, but when you are craving something not Indian, nothing special tastes pretty amazing.  We went to this newly opened Beer Garden that brews their own beer. Not as good as WI and MN beer, but still pretty decent. Unfortunately, I couldn’t really enjoy my beer because over the course of a couple of hours, I developed a fever (101.5 F) and felt pretty miserable. I have no idea what the cause of it was. The next morning, I felt better but since I wasn’t sure what was wrong, I stayed home from the hospital and took it easy. And believe me, a day of rest in the Annex 1 is not all that restful nor is it preferable to being at the hospital because at least at the hospital there aren’t cockroaches (at least none that I have seen). After I felt better, I went to a Bollywood movie with Julia and Michael which was one of the most entertaining experiences I have had so far in India. The movie was in Hindi so I didn’t understand a word of the dialogue, but the plot was pretty simple to follow and we all felt like we had a good understanding of the movie without knowing what was being said. The biggest problem was that none of us knew what the names of any of the characters were except for the main character so when we talked about it afterwards, it was all based on description. Bollywood movies are quite long - typically 3-4 hours and they include an intermission. They also have several big musical numbers with dancing which is also quite fun to watch. The audience gets really into the movie and will often cheer when the hero appears. They also aren’t so good about turning off cell phones - the guy sitting behind us answered his phone twice during the movie... Probably the funniest part of the movie was when one of the characters lit up a cigarette and the only line in English flashed across the bottom of the screen: “Smoking is harmful to your health.” I think Julia, Michael, and I were the only ones that were laughing at that. Wednesday evening I went to a bar called the Love Shack with Kim, Julia, and two of our Indian friends - Mahesh and Prash. It was karaoke night and Mahesh, Prash, Julia, and I sang Wonderwall. It was a fun night but a late one. Although bar close is 11:30 which would have been a decent time to go home and get some sleep before going to the hospital the next day, we ended up at an after party which really wasn’t all that much fun. I was getting really tired and was very glad to get back to the Annex to get some short sleep in.  Thursday, I was tired from the busy social life week I had been living and didn’t feel like going anywhere beyond walking distance. I had dinner that night with my German friends (Kim, Carina, and Michael) and my American friend Jonah at our favorite close-by Indian restaurant Sukh Sagar. Friday was the last day on the ortho service and I finished relatively early - enough time to pack up my stuff for my upcoming weekend trip with my German friends to Ooty. Namaste.
bucket shower
cockroach roommate (a small one...)