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...)

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