"This is not kindergarten."

Banana Beach Bar

I have to say that although things move quite slowly here in India, the time is going by rather quickly. I have already been in Bangalore for nearly 2 weeks at this point and have done a terrible job keeping up with my blogging. I spend the day in the hospital on my elective rotations then go back to my room and usually eat something and do some of my laundry via handwashing. I discovered that handwashing clothes takes a long time (maybe it’s because I am never quite sure how to tell when they are clean...) and the best way to approach laundry here is to do a little each day and hang it out on the line to dry. Since we do not have a kitchen in our housing accommodation, I go out to eat a lot. It’s pretty cheap to eat out depending on where you go, but I usually spend about $2 or less per meal. The main problem I have with going out to eat deals with my first statement - things move quite slowly here in India, including the food service. It is not unusual for a meal out to take a full 2 hours starting from the time we start walking there to the time we get back to the Annex. I do have some snacks in my room for when I just really don’t feel like going out. Walking around is always an experience as there don’t seem to be any traffic rules and as a pedestrian, I really feel that I have no right-of-way even if the traffic signals say I do. The sidewalks are in pretty lousy condition as well. As a result of all this, by the time I get back from dinner, it is time to shower and get ready for bed. 

Life in Bangalore:

There are a lot of places to eat around Bangalore. The city is home to about 8 million people and as a result is rather large and crowded. There are several good restaurants within walking distance from the hospital and these are the places I typically eat. Sukh Sagar is a favorite of mine and of the German medical students that I have gotten to know since arriving in Bangalore. Monday night, two of the German students wanted to go eat at a place called Food Street. I don’t know if that is the actual name of the street, but it is a place known for it’s street food. Vendors come out in the evening with a wide range of Indian cuisine made fresh before you for you to enjoy. It’s a great place to go with friends because we are able to sample several different things. This was definitely my favorite food experience in India so far.

mango corn at Food Street

I have been very thankful for my new German friends and have benefitted greatly from their knowledge of Bangalore since most of them have been here since the beginning of December. They always have places to try and are so inclusive. The downside to that is that I wind up spending a lot of my evenings out and don’t get back very early to get some reading or blogging done before I have to get ready for bed. The upside (and the upside definitely wins) is that I am making some great friends and getting to experience more of Bangalore than I think I would have on my own. Some of the other places I have enjoyed going out to with them include the Banana Beach Club (a really cool bar with a beach theme and some of the tables are actually little islands that you have to step across water in order to sit at them), The Egg Factory (known for it’s European/American menu - sometimes you just really need a taste of home), and the Chocolate Room (yes, a restaurant devoted to all things chocolate). 

Another great thing besides the friendship and the food experiences that I have had with my German friends is that they included me in their plans when we were kicked out of the Annex 3 on January 27 due to the arrival of a lot of Catholic bishops who were very clearly more important then the foreign elective medical students. The alternative accommodation offered to us was truly unacceptable - a hospital about 20km away (which would probably take 1 hr by car or 2 hrs by bus each way just because of the traffic) that really didn’t have much surrounding it. We would have seriously been stuck. The Germans were instead able to arrange for us to stay at the Annex 1 which is another lodging on the St. John’s hospital grounds. We have to share rooms, but at least we don’t have to commute 2-4 hrs per day to get to the hospital. 

general hospital ward room

The Annex 1. There really is not much good to say about the place. It’s on the hospital campus and right across from the hospital canteen. My internet works better here than at the Annex 3. And that’s about all it has going for it. My room is equipped with an Indian toilet: a porcelain-lined hole in the floor that you have to squat over. For those of us not used to toilets like this, it is uncomfortable and difficult to use. For me with my broken hip and limited hip abduction and flexion abilities, it is a real challenge. All I can say is that I don’t think I have ever spent so much time washing my feet :( Continuing with the bathroom - there is no shower and no hot water. I fill a bucket with cold (not freezing, but cold) water and take a bucket shower every morning. At least it wakes me up I guess. Now those things are uncomfortable, but manageable. Even the rock hard mattress would be tolerable in addition to the bathroom issues. Even the fact that the walls are paper thin and I hear everything out in the hallway which for some reason seems to be a popular hang out around 5 in the morning could be tolerable. The thing that really puts the Annex 1 as the worst place I have ever lived in my entire life is the cockroaches. Disgusting, scurrying cockroaches. Also, the room just does not seem to be all that clean. I am counting down the days until I can leave. I fully plan to harass the Annex 3 as soon as the bishops leave on February 10 to get my room back in place that is at least clean and has the bonus of a hot shower, a relatively soft bed, and a normal toilet. Thank goodness I have plans to be gone for a few weekends of the Annex 1 experience which cuts down on the time I actually have to spend here. 

The Hospital:

As I mentioned in my previous blog, I am spending the first two weeks of my elective time at St. John’s in the orthopedics department. Medical students in India are apparently not allowed to touch patients so my experience as a student is limited mainly to observation. This was also my experience for the most part in Sweden as well. The nice thing about observing in India is that there is a lot to see. Everyday I encounter patients and cases that are things unique to the tropics and to the developing world. It is a fascinating learning experience. I also look at it this way - India is preparing me with theoretical learning about medicine in the tropics and in the developing world so that when I arrive in Kampala, Uganda in April, I will be ready to apply this knowledge in practice since I believe my experience will be much more hands-on there.

The orthopedics department is a very busy place. Our morning rounding list in the hospital is between 35 and 40 patients. In clinic, we see 40+ patients in a half-day. Even though an orthopedic surgery residency in India is a short 3 years, those 3 years are packed with experience. Residents (at least interns) only get 1 day off per month. In the morning, the resident/intern will present the patients that were admitted to the service the night before. Even if they had spent the night on call, they are expected to know everything about the patient, the patient’s problem, and the theoretical knowledge behind the approach to that problem. I have never seen such intense pimping in my life. When the resident/intern didn’t know the answer, the staff would tell him to write down the questions and read up on it later to find the answer. At one point after several questions to which the intern did not know the answer, one of the staff started to tell him the answer. He was stopped by a more senior staff member who said, “This is not kindergarten. He needs to learn it for himself.” Yikes! 

OR scrub sink

It’s always interesting to see how a hospital is run in another country. I can’t generalize and say that how it is at St. John’s is representative of all of India, but it at least gives me an idea of the hospital system in place here. I’m not sure if this is because it is a Catholic hospital, but the nurses are all referred to as “Sister.” I don’t think I have once heard a doctor use a nurse’s actual name - they are all just “sister.” I also haven’t seen any male nurses, but the male staff in the OR are sometimes referred to by “brother” and sometimes referred to by name. In this system, you do not need to have a referral to see a specialist. Any patient can see any type of doctor they want and at least at St. John’s, most of them don’t have appointments beforehand. The hospital has limited resources. I don’t think this is the case for all hospitals but St. John’s serves a poorer population because it is a Catholic mission hospital. For the prevention of pressure ulcers, they use gloves filled with water and place them under the patient’s heels. The beds in the general wards are not adjustable hospital beds, so in order to elevate the foot or the head of the bed, concrete blocks are placed underneath the bed legs. It works. I have seen a lot of family members staying with patients and if they are not rich enough to afford a private room that has a bed for family, the family member will lay a mat on the floor beneath the patient’s bed and sleep on that. In the OR, they use a lot of reusable items. The scrub gowns are cloth as are the drapes and I noticed that some of them have holes. There seem to be a lot of people that wander in and out of the OR - mostly OR staff. They tend to sit in a room off to the side of the OR and chit-chat while the surgery is going on. It kind of reminded me of Haiti when the interpreters would all congregate in a clinic room and socialize even if a patient was in the room. This sometimes meant that they weren’t doing their job which is also the case here at times.

hospital bed with the foot elevated

I have seen a lot of interesting cases during my time on the orthopedic service so far. There is a lot of trauma at the hospital which is similar to the trauma seen at home. Tuberculosis is very prevalent here and there are a lot of patient’s with TB infecting nearly any part of the body. Thankfully, only the pulmonary TB is ultra contagious and I have yet to see a case of that. I have seen patient’s with TB of the spine, abdomen, hip, and lymph nodes. I have seen a couple of patients who suffered fat embolisms after long bone fractures because they were not treated promptly after their injury. In peds clinic, I saw two children with radial club hand - a congenital deformity which has increased incidence in consanguineous marriages resulting in the absence of the radius. The forearm tends to be short because the ulna bows and the hand is deviated towards the pinky. The thumb is also hypoplastic and basically non-functional. The surgical correction sounds pretty cool - the first procedure is an ulnar centralization where the ulna is moved to the center of the forearm to help straighten out the arm. Then in a second procedure, the index finger is rotated so that it can function as a thumb so the child will be able to grasp objects and write. Although the hospital is able to help kids like this, there are an unfortunate number of patients with orthopedic problems that do not get to a hospital early on and a result have a huge morbidity from their injuries. There are a lot of neglected cases that end up with the patient having some permanent disability because they were not able to receive proper care early on. Although I wish I could participate more in the care of patients, I have been really interested in the things I have seen and have been really motivated for independent study. I think this will be a valuable learning experience medically and personally and after my first week, despite some of the challenges, I am glad to be spending time in this incredible place. Namaste.