tag:blogger.com,1999:blog-6631564144969932072024-03-05T15:18:15.219-08:00Every Town I Lived InThis blog is for my family and friends so they can share in my world adventures that started as rotations in medical school and have evolved into a way of life.Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.comBlogger77125tag:blogger.com,1999:blog-663156414496993207.post-9980776864940762342016-04-12T07:05:00.000-07:002016-04-12T07:05:29.653-07:00The practice of reflection is integral to fully realize the experience.<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif; font-size: x-small;"><i>I am a volunteer for 4 weeks with Project HOPE. All opinions expressed are my own and do not represent the positions, strategies, or opinions or Project HOPE.</i></span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">The end of last week added some additional learning experiences on top of the work I have been doing at the hospital. Last post, I talked about how I have worked on teaching the internship students and medical students while at the hospital. After a day in the hospital, one of the internship students asked if I would like to go out and have a coffee or lunch somewhere in the city. It was a gorgeous sunny day and in the 70s (global warming…) and we went to a large national park within the city of Pristina called Germia. We took a bus which cost 0.40 euros to the park. At the park entrance was a bike rental, tennis courts, and an enormous outdoor swimming pool that is filled and opens in June. We walked through the park along a path that threaded through fields where children were playing soccer and on playground equipment. It was spring break here in Pristina, so the children and their families were taking advantage of the warm weather. On the other side of the path was a large hill with flowering trees and trees starting to bud. We walked along this path and stopped at a bench to enjoy the outdoor weather, drank at the fountain with reportedly some of the best water in Kosovo (at least in the city of Pristina!), and talked all along the way. Some teenagers that we passed shouted out a greeting and asked “Where do you come from?” I responded “New York.” He shouted back “I love America! I was just in New York.” We continued our walk to the end of the path where a large restaurant sits amidst the trees and the playgrounds and had a traditional local lunch of peppers in cream sauce with cornbread and garlic bread to dip as well as fresh salads of cucumbers, tomatoes, onions, olives, and cheese. My friend and I talked about everything - current TV shows and movies, hopes and plans for the future. I asked if she would mind telling me about her experience during the war. She said of course - it is one thing that friends don’t talk about much in Kosovo. Many people suffer from PTSD, and now that the war is over, want to put the past behind them. She says she knows everything about many of her friends, except where they were during the war. </span></span></div>
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<a href="http://3.bp.blogspot.com/-1nwgVyjP6JA/Vw0AesFZiJI/AAAAAAAABTM/soja6PHnc0EvdNvHfKF6OmD1Fv1yvo6rgCK4B/s1600/DSCN0820.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://3.bp.blogspot.com/-1nwgVyjP6JA/Vw0AesFZiJI/AAAAAAAABTM/soja6PHnc0EvdNvHfKF6OmD1Fv1yvo6rgCK4B/s320/DSCN0820.jpg" width="320" /></a><span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">My friend was living in Pristina with her family. She was 11 when the NATO bombing started in 1999. They were initially told the bombing wouldn’t last for more than one week. After 10 days with no end in sight, her family fled south to Macedonia. They spent 5 days sleeping outside at the Macedonian border in a neutral zone then entered into a refugee camp inside Macedonia where they lived for 3 months before being able to return home. She remembers life in the camp to be well organized and structured. They did not worry for food or shelter. The biggest concern she remembers is that her sister was 5 months old at the time they fled Pristina and due to shortages of food, her parents were constantly worried that her sister would not survive. Her sister now has scholarships to study abroad in prestigious universities in the field of her choice. When they returned home, their house was still intact although there had been looting of some of their possessions. They had left everything behind except essential items and passports when they fled for the Macedonian border. I think about the current refugees and migrants sitting along the border in Greece where they are being sent in boats back to Turkey. So many people I have met who were in a similar crisis situation leaving their war-torn country only 17 years ago have been some of the most inspirational people I have met. They are people determined to advance their education and use that education to help improve this new independent nation that the war was fought in order to achieve. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Later that evening I went to the local mall with one of my other friends. There is a 5-D “60’s” cinema that you can pick two short movies to watch. In addition to 3-D glasses, the chairs move so that you feel as though you are in the movie. When it rains in the movie, you get rained on in the theater. It was pretty entertaining. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Due to some scheduling conflicts, plans to revisit the refugee transit center in Macedonia were postpones. Instead, my colleague and I decided to explore the immediate surrounding area of Pristina. We had a fantastic guide, Alban Rafuna (<a href="http://www.beinkosovo.com/"><span class="s2">www.beinkosovo.com</span></a>) who brought along his extraordinarily bright 7-year-old daughter Noliana with him. We visited the predominantly Serbian populated village of Gracanica where one of the best preserved Serbian Orthodox Churches/Monasteries is located. Like many Serbian churches, this one is surrounded by a high brick wall with barbed wire on top of it. The Monastery is still in active use by the Orthodox nuns and is beautifully preserved. We were not allowed to take pictures within the church, but the frescoes inside were breathtaking. It is hard to believe that they are the original frescoes from the 1300s when the church was build by the ruling leader of the time. After this, we headed to an archeological site, the old city of Ulpiana which dates back to the time of the Illyrians - the original predecessors of modern Albanians. Three areas have been excavated within a large area of farmland outside the city. It was picturesque with flowering apple tree orchards dotting the countryside around it. Here we met a beautiful stray dog who fed our scraps of food and spare water to. We traveled a bit father out in the countryside up to Novobrdo Fortress which is in process of renovation. The village below was filled with flowering trees surrounding an old mosque and the ruins of a church that have been many years without use. We had lunch at a restaurant atop an adjacent hill with views of cows and sheep grazing on the green grassland below. We took our leftovers from the meal and revisited the stray dog to feed her our scraps. </span></span></div>
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">That evening on a whim, I went on a drive back to Prizren with some friends in order to see the city at night from the top of the fortress. I hadn’t been feeling all that well the past few days after eating far too much of a milk cake that I think was likely going bad (unfortunately discovered post-consumption in the GI ailment that followed and persisted for days). But, sick or not, I did not want to miss this opportunity! I was not disappointed. The city of Prizren is even more magical at night.</span><span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"> </span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Friday brought along with it another enriching encounter with an inspiring Kosovar who is the executive director of an NGO called Action for Mothers and Children (<a href="http://www.amchealth.org/"><span class="s2">www.amchealth.org</span></a>). I was connected with the director through one of the internship students I met who was on the previous rotation through labor and delivery. This foundation has connections to Dartmouth in the US and she connected with them while spending 3 months studying electronic medical record systems at Dartmouth as part of an exchange program. AMC was originally founded in 2009 in conjunction with USAID with grant money. In 2012, that grant money ran out, but determined to continue the work of the foundation, it became a locally run NGO. Its emphasis is on women’s and children’s health with the original mission to reduce maternal and child mortality rates in Kosovo which was one of the highest in Europe. The statistics are mostly unofficial as there is not a system in place for keeping track. They have multiple projects with the primary aim of education. There are 5 educational resource centers throughout Kosovo which offer classes to women and their partners. Most of the classes are aimed to prepare women for labor and delivery and in prenatal care (nutrition, smoking and alcohol cessation). They also have classes on newborn care. Currently, they are working to establish a national screening program for cervical cancer and to create a national transportation system for babies to be transferred to the only Level III NICU in the country in Pristina when a higher level of care is required (currently, the babies are transported privately by car). The aim of AMC is to provide research and evidence-based information to the people of Kosovo and also to use that information to advocate for policy changes. Some of the advocacy is being done for the health insurance system in development to ensure that prenatal care is included as part of the health insurance package. Prior to AMC’s lobbying efforts, this was not included in the original plans. The main office has 5 employees who all take on a number of projects. They are a group of highly motivated people dedicated to the improvement of health outcomes for the people of their country. </span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-53434872870456994002016-04-07T09:38:00.000-07:002016-04-07T09:38:31.766-07:00Finding my niche<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">This past weekend, my fiancé Michael came to visit me from Germany. It was his first time in Kosovo. Unfortunately, he started not feeling well the day he left and continued to not feel well the whole weekend. Despite having to take it easy and not being as ambitious in our plans as we had hoped, we still had a great weekend!</span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">On Saturday, we took the bus to the city of Prizren. Prizren was the original capital city of the region in the era of the Ottoman Turks. It is strategically placed along a river and within a valley of beautiful mountains. In Kosovo, it is one of the areas where Turkish heritage is best preserved - Turkish is still taught in a lot of the schools and the local cuisine tends to have more Turkish influence than in other parts of Kosovo. The bus ride took approximately two hours and en route, Michael slept and I read about the city and formulated a plan for the day of things we may want to try and see while there. We took a walking tour along the river up to a fortress dating back as early as the 6th century overlooking the city. En route up the steep hill to the fortress, we passed by the ruins of a Serbian Orthodox Church - St. Savior. It is completely enclosed within a metal gate topped with barbed wire and is watched over by a caretaker. This Church was destroyed during riots in March 2004 and is in process of restoration. The church itself was built in the 1300s and some of the frescoes on the wall can still be made out - those that weren’t destroyed in 2004. While wandering through the inside of the now open air church, one can imagine the beauty of it when it was complete. Continuing up the steep hill, we reached the fortress and the view was spectacular. We could see the entire city below and the surrounding mountains. Standing on top, we stood quietly and listened as the call to prayer rang out across the mosques in the city below. We grabbed lunch at a place along the river specializing in Albanian cuisine and happened to be present when a large entourage of political figures came to dine at the same restaurant. The roads were blocked off by police cars. After lunch, we continued our walk through the city. We walked past many of the city’s highlights including the League of Prizren which is considered the original group advocating a nationalist movement for Albanians in Kosovo since the middle ages. We saw multiple mosques and another Serbian Orthodox church destroyed in 2004 and now in process of restoration. Sunday, we took a walking tour of Pristina before Michael headed back to Germany.</span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">I feel as though I am getting into my niche at the hospital. I have had multiple students, residents, and specialists ask me if I have done any deliveries/episiotomies/c-sections and I said, no, but that wasn’t really my primary focus for being here. This is true, and I really do feel like I have an alternate purpose in being at the University Hospital. As I mentioned in a previous post, I am working towards providing educational resources for the faculty (residents, students, midwives, nurses, specialists - whomever!) to have on hand on labor and delivery so that when there is some down time, they can look at evidence-based guidelines and try to make the University Hospital up to international standards of care. I have emailed some PDF files to one of the residents and provided the residents with a brief textbook of Ob/Gyn so that there is at least something to start from.</span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Kids playing outside in a public fountain on a warm spring day in downtown Pristina</td></tr>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">I have discovered two additional roles for myself that have certainly provided me with a sense of purpose, and I hope have contributed positively to the experience of the others I am with on a daily basis. There are many medical students that rotate through labor and delivery. Medical education is difficult. There are many more students than there are positions available to them after the finish their studies. If you are not at the top of the class, the chances you will find a residency program and especially a program that will pay is limited. After completing 6 years of medical studies (this is a bachelors/masters degree), they do a 6 month internship. Afterwards, they must work for 1-2 years as a general practitioner and then can apply to residency. The number of spots are limited within specialties so there is a chance that the specialty one is interested in may not have an available spot at the time you are ready to start residency. A choice is made to start residency in another specialty or to wait. Residency positions within the university or public hospital system are paid but not a living wage (I’ve hear anywhere between 500-700 euros per year) and private residency training is not only unpaid, but requires the resident to pay for the job and training. For Ob/Gyn, residency is 5 years. After that, many physicians do not make a living wage working in the public hospital system and so have private practices on the side. Because of these limited opportunities in training, many students and residents will leave to complete or do further training abroad, many with plans to not return to Kosovo given the limited opportunities here for work. If such highly educated people are not paid a living wage for their work, I worry that an educational drain will exist in Kosovo whereby everyone who can leave, will leave. </span></span></div>
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<a href="http://3.bp.blogspot.com/-fmHeR5IMB3Q/VwaMm48vQdI/AAAAAAAABSI/fj8duD-uBWEmQLMObzQK_gQLML3QSxxgw/s1600/DSCN0779.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://3.bp.blogspot.com/-fmHeR5IMB3Q/VwaMm48vQdI/AAAAAAAABSI/fj8duD-uBWEmQLMObzQK_gQLML3QSxxgw/s320/DSCN0779.jpg" width="320" /></a><span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Medical students very much take on the role of observer when doing their practical part of training (during medical school and during the internship). They are sometimes engaged by the specialists but there is not a lot of teaching that happens at the bedside. Some of the this is the hierarchical culture of the training system but some is just a lack of time - with 10,000-12,000 deliveries per year, there is not a lot of down time on labor and delivery for teaching. I have tried to personally fill in this gap by engaging the medical students and trying to teach things that are applicable to the clinical situation they are observing or to answer any other Ob/Gyn related questions. This is one role I have been trained to do as both a medical student and a resident and I am happy to be able to fill the role of a teacher while I am here.</span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The other role I have made for myself is being the support person for the woman in labor. Since family members are not allowed on labor and delivery, the first time moms seem the most nervous and unsure. Although I do not speak Albanian, the effect of holding a hand or rubbing someone’s shoulder, head or back when they are in pain gives the support I am unable to provide with words. In my normal day-to-day residency work, I often have too much to do to be able to provide this one-on-one support for the patient in labor. In the US, many of them have family members or friends who come to support them and also have awesome labor nurses who are their support people. It has been nice to take that place for the women who deliver at the University Hospital in Kosovo. For me, this role as part of the care of the patient has been invaluable, and I think more meaningful for the patient than if I were the one sitting on the other side delivering the baby. </span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-84277161303457272272016-04-04T05:39:00.003-07:002016-04-04T07:06:24.411-07:00The Halfway Mark<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif; font-size: x-small;"><i>I am a volunteer for 4 weeks in Pristina, Kosovo with Project HOPE. All opinions are my own and do not represent the positions, strategies, or opinions of Project HOPE.</i></span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Those who know me well know that I tend to operate a little more on the glass half empty side of things. When I find that the glass is half full, it is positive; whereas, if my expectations are met, I am no worse for wear. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Kosovar medical students and me after a rousing game of Uno</td></tr>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I would like to approach this moment in my time in Kosovo as a glass half full. Of course, I am amazed that already two weeks have gone by that I have been here, but I am pleased to still have two more weeks to take part as a visiting member of this lovely society in Kosovo. My colleague and I have some working plans for Project HOPE and are looking forward to the implementation phase of our plans. I am getting more comfortable in my physical environment. For example, when I first arrived, the overhead light in the bedroom of the apartment did not work. It still doesn’t work. However, there was a lamp on the desk that does work. The problem is with having enough outlets to charge my electronics. I have a computer that needs charging every night, my personal USA cell phone that I use when I am in a WiFi network that needs charging, my local phone that needs charging, and occasionally a camera battery, iPad, Kindle, portable bluetooth speaker, or iPod. (I realize I’m a bit of an electronics junkie although I will not claim to be an aficionado in anything electronic). When I wanted to go to bed and read, there was no light to use if I wanted my phone to charge, so I read with the backlight of my kindle which often made me very tired and prone to falling asleep prior to 9PM when I first arrived. After a few days in one of the desk drawers, I found an American power strip. This helped the charging problem for all of my electronics except my local phone (which has a European plug) and the lamp. So I could either have a working local phone, or light when it became dark outside. Finally, after two weeks of living here, I happened to wander past and notice the European power strips at the supermarket! So now, I have light AND a charging phone. It’s the small things that can create a lot of joy.</span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">The other issue I have had living physically in the hospital at the end of a patient ward is entering the building and getting to my apartment. I am on the fourth floor at the end of the postpartum unit. There is no way for me to enter or exit the building without going through a patient ward. This isn’t so much the problem as the fact that the front doors of the building are locked sometime between 7-8PM and you have to go through a side entrance. This is also not so much of a problem except for the past two weeks, I have had to literally break into the hospital in order to get to the area to go up the four flights of stairs to get to the postpartum unit and walk through that and show my badge and get to my room at the end of the unit. There is a set of double doors and U-shaped iron bar is placed over the handles to create a lock. With some of the doors, you can open them wide enough to squeeze a small hand through and remove this bar. In one of the sets of doors, this is not possible and I had to knock and wake a sleeping patient or visitor (not sure which) that was lying on the bench on the inside and have her open the door for me so I could enter. Well, when I got back tonight (at 8:40 PM) from dinner with friends, I went through the side entrance, through the doors that miraculously did not have the U lock on them, but found that the other set of doors that I was unable to open wide enough to remove the U lock had the lock on. I happened to see that another visitor who I noticed enter the building behind me entered through a corridor that opened into the main area of the hospital. So I backtracked and discovered this open corridor. My life in the evening has just become 1000x easier. Let me tell you, I have so much more appreciation for freedom of movement in so many aspects of life then I did before. From the limited movement available to Kosovaars with the Visa Problem to my difficulties getting to my apartment where I live, I have a new appreciation for the freedom I have in my life to move from one place to another and would number that as something that should be considered a human right. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Outside the Parliament Building in Pristina</td></tr>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span class="s1">I have thought about this a lot as I have read about the history of the region - I read a book by Robert Kaplan called </span><span class="s2">Balkan Ghosts</span><span class="s1"> that discusses the entire Balkan region and its utterly fascinating history filled with conflict and various authoritarian powers and limits placed on the movement of people within the region. It is also something that was in the forefront of my experience visiting the refugee transit center. The whole reason for its existence being limitations of the freedom of movement. It is something I have only given thought to in passing such as thinking about my most important physical possession - which for me is my passport because it allows me the freedom of movement. All of our human ancestors dating back to the start of the species were nomadic - prior to the advent of agriculture, we all came from hunter/gatherer societies that depended on the freedom of movement for survival. Limitations in the freedom of movement has impacted survival.</span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Speaking of movement, Michael was visiting this weekend and we went on a day trip to Prizren, Kosovo. Unfortunately, he was feeling quite sick after he got here so our trip was not as full as either one of us had hoped it would be, but we still had a great time visiting a new place. </span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-91967818256226901142016-03-31T08:32:00.000-07:002016-04-04T07:06:24.417-07:00Through our conversations we can change the world for the better.<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">The best part of traveling is the people that I meet. My favorite part of the past two weeks has been having conversations with people who were born in a different time, a different place, speaking a different mother tongue, practicing a different religion. Our commonality is that we are meeting in this place and in this time and it is through this shared experience that we both learn more about each other and through each other, learn more about the world that we live in. </span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">Last night I spent the evening with a friend of mine that I met the first day I arrived in Kosovo and had spent Sunday/Monday with in Skopje. We had dinner at a thai restaurant in downtown Pristina, very appropriately named “Thai Restaurant.” We met up with some of her friends including both locals and internationals and sent an evening on the town. I hope to be so inclusive when someone new comes to the place where I live. I was immediately a member of the group and had a great time dancing salsa at the Cuban restaurant (my second salsa dancing at a Cuban restaurant/bar in the Balkans!), talking, and enjoying a beautiful evening out in the city. I’m usually the underdressed person of the group, but this group really put me to shame despite my efforts with the limited clothing I brought with me. It didn’t matter. There was zero judgement. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Dancing salsa at a Cuban restaurant/bar.</td></tr>
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<span style="font-family: 'Trebuchet MS', sans-serif;">The end of my day today, there was a new group of medical students that had arrived on labor and delivery. They were there for a 12 hour shift that they do once every 2 weeks. One medical student in particular immediately started talking to me and asking me questions about where I was from and what brought me to the University Hospital in Pristina. Soon, there was a group of three students an myself discussing what brought us to the field of medicine, how one chooses a specialty, various methods for learning (textbooks, online), and plans and goals for the future. Many of them hope to go abroad to do their residency training. Their English is excellent and many of them are currently studying German as Germany is the place that the majority would like to go to for training.</span><span style="font-family: 'Trebuchet MS', sans-serif;"> </span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">One of the students was born in Germany. His family is from Kosovo but moved during the war the moved back to Kosovo two years after the war ended. He is doing his medical school here but would like to return to Germany for his residency and hopes to live and work there. He went to medical school for a love of science and a fascination for how the human body works.</span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgN6B6LsQezSBpjZ3HotRXKEfGm5kdSn5ESRd0WXuTLIAs8TZSQsdc0jp4pdvQHqvoTtRYGT7Wmdo66g-uPaDrJCRTSrkg08d4L9InJxpxpZw2-XeiETfysjuIbZfYt5FNlSlNicMa4G1Ai/s1600/image-4b9844db6c507acfe016a2c6f775457fb1291d4a5d7d694f1a3e3ec802b154a8-V+%25281%2529.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgN6B6LsQezSBpjZ3HotRXKEfGm5kdSn5ESRd0WXuTLIAs8TZSQsdc0jp4pdvQHqvoTtRYGT7Wmdo66g-uPaDrJCRTSrkg08d4L9InJxpxpZw2-XeiETfysjuIbZfYt5FNlSlNicMa4G1Ai/s320/image-4b9844db6c507acfe016a2c6f775457fb1291d4a5d7d694f1a3e3ec802b154a8-V+%25281%2529.jpg" width="320" /></a><span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">Another female medical student was born in Kosovo and has “never left Kosovo.” Her mother is a doctor and she became interested in medicine because of what she witnessed of her mother’s work and her mother’s satisfaction with her work. She has never thought about doing anything else. She was in Kosovo during the war at the age of 6 and although she was so young, she remembers the time and the fear that gripped her country. She also hopes to go to Germany for her residency training but definitely wants to return to Kosovo. She says that she wants to go to Germany to have better experience and better training so that she can bring that back to the people of Kosovo. There are more doctors being trained here than there are training spots. She has a lot of hope for her country and is thinking about pursuing a career in gynecologic endocrinology or pediatrics.</span></span></div>
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<a href="http://3.bp.blogspot.com/-3HOCteGY-tM/Vv1C1tjR2PI/AAAAAAAABQg/bxGAW6-SxH8c1Bes0g5VP9BXwVbkUgtGg/s1600/IMG_1441%2B%25281%2529.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://3.bp.blogspot.com/-3HOCteGY-tM/Vv1C1tjR2PI/AAAAAAAABQg/bxGAW6-SxH8c1Bes0g5VP9BXwVbkUgtGg/s320/IMG_1441%2B%25281%2529.jpg" width="240" /></a><span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">A third student was talking about how she is fighting some of the traditions of her family. She says that families are proud to have a son become a doctor as he has job security and can provide for the family. Some of her more traditional family members don’t encourage her studies because her role is to get married, take care of the home, and have children. Her response, “I don’t want to do that.” She is one of so many fiercely independent women I have met in my brief time in Pristina.</span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">After talking about our careers and futures, they invited me to their medical student room to hang out. They all pulled out various salty and sweet snacks and we played several rounds of the card game Uno. As has been my consistent experience, they spoke English for my benefit even if it was limited or unsure about words. It was a wonderful way to spend an afternoon.</span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">I have met two other medical students during my time here. One has spent time in the US on an exchange program where she was working with electronic medical record systems. She was offered a scholarship to do a combined MD/MBA program but wants some more life experience before committing to further school. During the war, her family were refugees in Albania and were taken in by an Albanian family. The male of the household was a physician. They were treated with kindness by strangers who saw their needs and took them in, provided them with safe shelter and food.</span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">Another medical student did not have the freedom to leave during the war. Her family stayed. They were isolated with other ethnic Albanians and forced to live in the top floors of apartment buildings during the NATO bombings of 1999. Though she was 9 years old at the time, she vividly remembers the stress and the fear that they lived in through that time. </span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">One of the residents also hopes to bring her family to Germany for more training for herself and also to stay there for hopes for a better life for her daughter. She told me of the challenges of being a working woman with a family and the pressure she is under from her husband’s family to do more at home and that her primary job is to “look beautiful.” </span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">Another resident spoke of the difficulty they have in Kosovo to travel. She wants to see the world but “the problem is the visa.” Since Kosovo is not internationally recognized as an independent country or a part of the UN, it can be difficult for people to obtain visas to travel. There are many barriers - some of which she has overcome as both she and her husband are employed with stable jobs. Some of the countries require a savings of anywhere from 6000-10,000 euros in order to obtain a visa. It is prohibitive for those who want to take a vacation in another part of the world, to widen their global perspective.</span></span></div>
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<a href="http://4.bp.blogspot.com/-PA7ir1WW0os/Vv1Chj6yhUI/AAAAAAAABQY/7jm9Gr_12o4Nxe4SpfoSTcPrjUKJTz5EQ/s1600/IMG_1467%2B%25281%2529.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://4.bp.blogspot.com/-PA7ir1WW0os/Vv1Chj6yhUI/AAAAAAAABQY/7jm9Gr_12o4Nxe4SpfoSTcPrjUKJTz5EQ/s320/IMG_1467%2B%25281%2529.jpg" width="240" /></a><span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">After the events in Brussels, I had a conversation with another resident. She spoke of her Muslim religious faith. She was horrified by the events of Brussels and the implications this may have for people who share her religious traditions and faith. She said, this is not Islam. What these people do is not Islam. She also spoke of the Kosovar love for America and Americans the gratitude they have for ending the war and supporting their independence. Every day we have a coffee together and one of these days, we will have one together “outside - out of work.” She is one of the only colleagues I have had that greets me everyday with a handshake or a hug and always when she sees me (even if it is only 15 minutes since I last saw her) how I am doing.</span></span></div>
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<span class="s1"><span style="font-family: Trebuchet MS, sans-serif;">I love a good story and the people of Kosovo are filled with good stories and the courage to share them. I have learned much about the country and its people in my short time I have had here. My most valuable learning has not been of obstetrics and gynecology, it has been learning about this country with all its turbulent history and its perpetually inspiring people. </span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-40468058086602965062016-03-30T06:46:00.000-07:002016-04-04T07:06:24.363-07:00Back at work. <div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif; font-size: x-small;"><i>I am a volunteer in Pristina, Kosovo for 4 weeks with Project HOPE. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.</i></span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I mentioned at the end of last week that I had some ideas for what to do in terms of my work for Project HOPE. One goal listed online for the work at the University Clinical Center was to train all nurses, residents, and doctors in basic life support (CPR). When I arrived, it seemed this was not a very helpful goal for the current situation in the Obstetrics and Gynecology department. For one, there is no equipment to use to help train people. There are no projectors for powerpoint presentations or even any computers at all on labor and delivery. There are computers in many of the offices and internet (although it requires a username and password), but nothing really available for the teaching of BLS. In addition, many people don’t speak enough English to be able to ask questions. Many people understand English but don’t speak it well enough to ensure that the teaching was understood and therefore effective. Also, there are no mannequins to practice CPR on and their are no non-rebreather masks to use to practice safe CPR. Also, BLS teaches about the use of defibrillation which when you have access to it, is what makes CPR most likely to succeed in saving a life. I have not seen any defribillators on the unit. And, most people who require CPR will likely need a higher level of care following resuscitation - higher level of care meaning an ICU. Although I am certain there is an ICU within the University hospital, the hospital is a series of separate buildings and there is not an adult ICU in the obstetrics and gynecology division. I am not sure where it is or how patients would be able to move from here to there in a timely fashion. The only patients who seem to be able to receive higher level of care quickly are the neonates as the NICU is on the same floor as labor and delivery. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">The sterilization equipment on labor and delivery.</td></tr>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">All record keeping is done on paper and there are no computers on the labor and delivery unit. Computers are not just helpful for documentation in an electronic record, they are also helpful as a source of information and learning for residents, midwives, and staff here at the hospital. Without a computer and without any textbooks, there is a deficiency in resources available for the staff to learn from. There is a lot of teaching that goes on especially from midwives to residents and the specialists to the residents and midwives and medical students, but there are no resources available while at the hospital to refer to for management questions or even just for learning to enhance knowledge. Many of the residents are learning German in hopes of going to Germany for further training and possibly to live. There are not as many opportunities here for them. I hope to at least help change the availability of education resources for them, and this is what I plan to work on through my time with Project HOPE. I have started by emailing some PDF files to one of the residents who speaks English. She has been very thankful for these and asked if it would be possible for me to send her more to learn from. Michael is hopefully going to be able to bring a textbook of obstetrics and gynecology for the residents to have to keep in the hospital. One of the residents owns a pocket manual of ob/gyn and another resident owns a book geared toward medical student education published in the UK in 1988. My co-Project HOPE volunteer and I are going to work on a proposal to get a computer on the labor and delivery unit which can be used for education. If they have a computer, PDF files and online textbooks could be accessed by all. We live in an era where so much information is available online and if people are guided where to look for good information, there is so much that can be learned. I hope to help provide some of these resources. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">In terms of practical experience, those who work at the University hospital are not lacking in deliveries. As I mentioned before, during the slow time of year, this hospital averages around 40 deliveries per day and up to 80+ during the busy time of year. They keep a record in a large ledger book of all the deliveries done during the day. Here are the numbers from the past week: </span></span><span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">3/23: 40. 3/24: 42 (7 c-sections). 3/25: 21. 3/26: 15 (really slow day). 3/27: 15. 3/28: 25. 3/29: 36. 3/30 by 2PM: 25 (14 of which were c-section deliveries).</span><span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"> </span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Yesterday, I observed my first c-section delivery at the hospital. It was an urgent c-section for non-reassuring fetal heart tracing. The patient was fully dilated but the head was still high and there is not a lot of access/options for operative vaginal deliveries. She was taken for an “urgent” c-section. I’m not sure that an emergency c-section can really happen in an emergent manner here. Labor and delivery is on the 4th floor. The operating rooms are on the 2nd floor. There is an operating room on the 4th floor but there is no equipment or bed in the OR so it is basically non functional. Anesthesia was via spinal. Reusable cloth drapes are used. The glove sizes available are 7.0, 7.5, or 8.0. The technical parts of the c-section were the same as how we do it in the US. The most interesting part about the whole experience was that the operating rooms are adjacent to each other and all the doors were open - the door between our OR and the neighboring one (which also had a surgery going on simultaneously) as well as the door into the hallway. Betadine is used for skin prep prior to surgery and is used liberally. It is also poured on the dressing before it is applied at the conclusion of the surgery. The patient helps to move herself onto a transfer bed after surgery by pulling on a triangle attached to the top of the bed while the anesthesiologist and resident help pull the patient’s body (on a cloth placed beneath the patient prior to surgery) and legs. Per one of the residents, the infection rate is “high” after surgery. I’m not exactly sure what that translates to in terms of percentages. It was interesting for me to see the flow and see how everyone performs their job in a surgical setting. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">My typical role during a delivery here in Kosovo is to provide support for the mother. As I have mentioned before, no family members are allowed on labor and delivery. I hold her hand, provide water to drink and a wet cloth for the forehead if desired, and talk to her. Even if she doesn’t understand what I am saying, I think she understands my tone of voice and a smile can go a long way. It is a different role than I typically have in the US, but a valuable one and one that helps me feel that I can contribute to the birthing experience for the women here in Pristina. I also helped fold gauze sponges today. Instead of having individually wrapped gauze, they have a large role that gets cut by hand into smaller squares than folded into individually wrapped pieces that are used in the delivery room. We filled two large metal containers with them to prepare for the upcoming deliveries. It was a good day’s work. </span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-49708286449182101292016-03-29T09:03:00.002-07:002016-04-04T07:06:24.370-07:00New Country, New Friends, New Life Experiences<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;"><i><span style="font-size: x-small;">(I am a volunteer for Project HOPE for 4 weeks in Pristina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)</span></i></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Stone Bridge: Skopje, Macedonia</td></tr>
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">On Sunday I took the bus to Skopje, Macedonia. My travel companion was a lovely woman from Kosovo who has worked very closely with Project HOPE as part of her job in Pristina. She is my sister’s age - born at a time of conflict and war in Kosovo and was once a refugee herself. She was interested in visiting the refugee transit center in Macedonia and so we traveled together. In the 1990s, when Kosovo was wracked with war, many Kosovaars fled the country and headed south to Macedonia and Albania. Many of them were resettled in western Europe, the US, Australia, New Zealand. Some of them have returned. My travel companion hadn’t thought of coming back to live permanently here but was visiting on a holiday, got a job, became invested in the work she was doing and a year later, she is still here working very hard to help improve the lives of the people of Kosovo. Much of her work has ties to the University Hospital which is how she came to work with Project HOPE and how I came to meet her. </span></div>
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<tr><td class="tr-caption" style="text-align: center;">One of the many statues of Skopje</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Mother Teresa</td></tr>
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The bus ride through southern Kosovo was stunning - we drove through winding roads through mountains and valleys and small villages. I imagine that when spring comes into full bloom, the hillsides are breathtaking. It was even without the green of spring. It took about two hours to get to Skopje and we were picked up by one of our colleagues from Project HOPE at the bus station. We toured the city - it is a lovely old city with the Kale Fortress overlooking the city that dates back to the 6th century, a stone bridge from the 15th century, and a 66-meter high cross on the highest hill surrounding the city. The city itself is full of statues of famous revolutionaries from Macedonia’s history as well as depicting other historic events of the country. There are also a multitude of memorials for Mother Teresa who was born in Skopje. Fitting to spend Easter at the birthplace of such an iconic figure within the Christian faith. A Turkish bazaar was reminiscent of bazaars in Istanbul. We had a whirlwind walking tour of the city complete with coffee on a touristic boat sitting in the river. This was followed by a spectacular dinner with bread and garlic and pepper dipping sauces, fish soup, rakia, local wine, and entrees of beef, pork, and chicken that tasted even better than they looked. The rest of the Project HOPE team joined us for dinner then afterwards, we headed to a Cuban bar and danced salsa throughout the evening. The apartment we stayed at overlooked the stadium and had an amazing view.</span></div>
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<tr><td class="tr-caption" style="text-align: center;">Refugee Transit Center</td></tr>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">On Monday, my co-Project HOPE volunteer here in Pristina met us in Skopje. We went to the Project HOPE office, had breakfast, then headed out to the refugee transit center in Tabanovtse. There are currently 1500 refugees that are living at the transit center and have been there for approximately one month. The refugees are a combination of Syrian, Afghani, and Iraqi people. Both Farsi and Arabic are spoken in the transit center. The people usually do not stay for as long as they have but due to border closings within western Europe, the cascade effect has been people stuck wherever they made it to at the time of the border closings. The most recent agreement between the EU and Turkey is that any refugees that land in Greece will be sent back to Turkey and Turkey will take them in return for a better relationship and financial incentives with the EU. It is unclear to me what will happen to the people in the transit center. A particular date was set as part of the agreement that anyone who was in Europe prior to that date would be placed in western Europe and anyone arriving afterwards would be sent back to Turkey. The people who are in Macedonia do not wish to settle there. Macedonia, like much of the Balkans, has considerable economic hardship. With a near 25% unemployment rate, refugees are uninterested in competing for an already limited number of jobs. The infrastructures is not strong enough to support the influx of people they have experienced over the past year in transit, let alone to take them in. And the refugees are stuck - they left war and violence and insecurity in the hope for a better life for themselves and for their children. The current refugee population has changed as well. Initially, it was primarily men making the arduous journey and now it is many women, children, and elderly. It is only by fortune that I was born in a place where I have stability and safety in my life and they were not. We are all one human community and we have an ethical and moral responsibility to care for our fellow brothers and sisters in their time of need. The news is filled with horrible stories of terrorists and terror attacks - the refugees are refugees because of the terrorists and terror attacks. They are not leaving their homes, leaving all their possessions, and risking their lives to instill terror. They are leaving to try and save their lives and the lives of their children. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Project HOPE Clinic</td></tr>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">In the transit center, there is a red cross clinic that sees patients and serves as a sort of medical triage. Patients that need more advanced care are sent to the Project HOPE clinic - a one room makeshift clinic with basic medical supplies. One doctor, one nurse, and one logistician work in alternating 12 hours shifts with another team to care for the 1500 people in the camp. They see about 60 patients per 12 hour shift. Most of what they see lately has been children with fevers. It has been a long, cold winter for many of the people living here and they are fighting off disease from living in crowded conditions in a harsh environment. There are between 40-60 pregnant women within the transit center. A local gynecologist comes daily from 3-6 to see these women and provide them with prenatal care.</span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The transit center was well organized and clean. There are multiple single family housing units as well as some larger tent/buildings that house multiple people. Many people were outside - doing the washing, the kids were playing soccer and volleyball and catch. People were talking to each other and to us. I didn’t know what to expect when I went, but I left impressed with the organization and inspired by the people who are working there. There are cleaning groups that come three times a day to remove garbage and clean the camp. People bring meals several times a day to feed all 1500 people. Various organizations have set up children’s centers with toys to play with and to play on. There is currently no school system set up, but as it is unclear how long any of the people will be staying there, it probably will not be set up. The people working there are there for the right reasons - they have been moved by this terrible crisis that has displaced millions from their homes and they are contributing the skills that they have to try and help make the lives of their fellow humankind just a little easier on the way to a better life. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">These two guys asked me to take their picture. It is a picture that could be any two guys anywhere in the world. We are all one human community.</td></tr>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Our visit was short, but powerful and a lasting experience for all of us who came and saw. </span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Our trip back to Pristina was more adventurous than expected - one of our group left her passport in the Project HOPE car in Skopje and was not allowed to cross the border from Macedonia back into Kosovo. The three of us travel companions got off the bus and waited at the border crossing for our friends from Project HOPE to come and rescue us - they had found the passport and delivered it. Not knowing if we would be able to catch another bus to Pristina at the border, we went back to the bus station in Skopje and bought tickets for another bus trip back. We made it back, about 3.5 hours later than planned but we made it safe and sound ready to sleep and to start another day.</span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com1tag:blogger.com,1999:blog-663156414496993207.post-41658101707678202632016-03-26T09:30:00.003-07:002016-04-04T07:06:24.367-07:00When I'm not at work<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">The beautiful thing about an elective is that you don’t have to spend 80 hours a week on average working in the hospital. This would have been true if I stayed in Rochester for my elective or elsewhere in the US. However, if I am able to travel, travel I will. I think it is only when you take yourself outside of the familiar and the routine that you learn the most about yourself. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I spent the week getting oriented at UCCK (University Clinical Center - Kosovo) and starting to understand how labor and delivery works at the university hospital. The first few nights I was here, I was incredibly tired from traveling, being recently sick with a cold, and jet lagged that I went to bed by 8PM or earlier every night except Thursday night. </span></span></div>
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<a href="http://4.bp.blogspot.com/-pYpKJWuxRD4/Vva363iQRhI/AAAAAAAABNA/WgW0zlDH4IAaeqdx2g9JF5Yl2LQPgF-5w/s1600/DSCN0476.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://4.bp.blogspot.com/-pYpKJWuxRD4/Vva363iQRhI/AAAAAAAABNA/WgW0zlDH4IAaeqdx2g9JF5Yl2LQPgF-5w/s320/DSCN0476.jpg" width="320" /></a><span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Thursday, I met my Project HOPE counterpart who has already been in Kosovo for the past 6 or so weeks working in the hospital. She had taken a holiday in Tirana and we met after she returned to Pristina. I saw the essentials - where the grocery store is, where I can buy shampoo, the good restaurants near the hospital, and where to get a SIM card. Now I had coffee, a phone, and items for daily living! She also invited me out for dinner with another friend of hers living in the city - a guy named George who is from Hawaii but whose parents are both physicians that trained at the University of Rochester - small world. We went out for some traditional Albanian food at a restaurant in downtown Pristina. The food was good although more expensive than my usual meal (although I can’t complain about a fancy restaurant charging 7 Euros for an entrée) and then we went to a bar owned by a Scottish ex-pat where trivia is hosted on Thursday nights. We didn’t stay for the whole thing, but enjoyed the time we did have and overall did pretty well as a team. We were certainly contending for the championship with 3 rounds to go. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">For lunch, I stopped at a bakery and had a traditional Albanian pastry filled with meat that was delicious and cheap (0.70 Euros). Tomorrow I will take the bus to Skopje, Macedonia. Skopje is the birthplace of Mother Teresa which is a good way to celebrate Easter Sunday. I am heading to Skopje to stop over on my way to a refugee transit center on the Macedonia-Serbia border on Monday. </span></span></div>
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<a href="http://4.bp.blogspot.com/-41btqHNWJQU/Vva4voUlNtI/AAAAAAAABNY/XzmijU23Q7glw1sDT6uE0Et-1f153mIQw/s1600/DSCN0479.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="https://4.bp.blogspot.com/-41btqHNWJQU/Vva4voUlNtI/AAAAAAAABNY/XzmijU23Q7glw1sDT6uE0Et-1f153mIQw/s320/DSCN0479.jpg" width="320" /></a><span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Living in Kosovo for the past week has been enjoyable and very easy. People are friendly, the food is delicious and cheap (most days I spend less than 5 Euros on food eating out for most meals), and it is a safe place to walk around. Today walking through downtown, the streets were full of people walking together or alone, shopping, eating, drinking coffee. There are a number of stray dogs wandering the streets although fewer than I experienced in either India or Uganda. Smoking is very common in Kosovo and unfortunately the idea of indoor spaces being entirely “non-smoking” is not a reality. Even non-smoking areas are adjacent to smoking areas and the smell has permeated some of my clothing. Most of the people I have met have commented on how young I look. I hear this in the US as well, but not as frequently as I do here. When I tell them that I am 31, they are surprised and say they would not think me older than my early 20s. I have been fortunate to be born in a country that has not gone through recent war on its own soil, where pollution is limited, and it helps that I don’t smoke. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I probably won’t post for a few days as I will not have my computer with me in Skopje and I anticipate a late return Monday night or Tuesday morning. Until then!</span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-54370333352517290822016-03-25T07:37:00.000-07:002016-03-25T08:01:06.733-07:00Learning the Flow when Giving Birth at the University Hospital in Pristina (24-25 March 2016)<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif; font-size: x-small;"><i>(I am a volunteer for Project HOPE for 4 weeks in Pristina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)</i></span></span></div>
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<span class="s2"><a href="http://www.projecthope.org/"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">www.projecthope.org</span></a></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">I am always amazed every time I travel to a new place how welcoming and friendly people are. I don’t speak Albanian, I am an outsider coming in to learn and to find ways to help “improve” the provision of care, and I ask a lot of questions. I feel fully embraced by the staff that I have met in the Labor and Delivery department at the University Hospital and am so blessed to add them to my circle of friends. Sometimes when I get bogged down in the drudgery of my day to day work as a resident in Rochester, NY, I forget why I went into the field of medicine in the first place. Over the past three days, I am starting to remember again why I chose this profession and why I chose Ob/Gyn in particular. I am inspired by the women and men I have met here, their dedication to patient care, and their passion for learning. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">The Obstetrics and Gynecology Clinic is 4 floors with each floor having its own area of focus. Pregnant women who plan to deliver at the University Hospital can come up to two weeks ahead of their due date to wait for the onset of labor. There is a ward in the clinic for these women to stay. There are also wards for gynecology, oncology, and “pathology” - the women who have complicated pregnancies (hypertension, pre-eclampsia, diabetes, etc.). </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">When any of the pregnant women go into labor, they stay on their respective floors until they reach at least 5cm dilation and +/- broken water. At this time, they are moved to the top floor to the labor and delivery unit. There is series of three rooms with two beds per room that I call the “labor corral.” Women are here until it is time for them to start pushing. The labor corral is a cluster of three, three-walled rooms with large windows encompassing the majority of the wall between them, sort of like a fish bowl. The staff room is adjacent to these rooms and all the labor rooms are visible through the large windows. Sometimes there are more laboring women then there are beds available. The women are here alone - no family or friends are allowed on the labor and delivery unit. They bring a bag of supplies with them including clothes for during labor and afterwards, water and other drinks, wet wipes to clean themselves after delivery and for the cleaning of the bed, and clothes and blankets for the baby. The women are each other’s support throughout the labor process. There is a fetal monitor in each of the rooms and doptones are intermittently obtained. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">There is a specialist who checks the cervical dilation of each of the patients at prescribed times throughout the day. The women are walked to a nearby room with small steps leading up to a half table with stirrups. One by one, the women sit at the edge of the table and are examined. The resident sits at the desk to the side and records the exams on a labor curve and also records the plan (continue “passive” labor, stimulation of labor with oxytocin…). The other residents, nurse midwives, other specialists, medical students, and techs are all present for the examinations - sometimes as many as 15 people are in the room for each of the examinations. Once a woman has her cervical exam, fetal heart rate is obtained with a fetoscope and documented, she gets up and walks back to the labor corral. The tech removes the dirtied cloth and places a fresh one down on the table for the next patient.</span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Patients are not just checked at the time of the specialist examination. While in the labor corral, the residents will also periodically check the patients. When a patient reaches full dilation, a resident and midwife bring the patient to a delivery room. The delivery room is already prepared for delivery with the bed broken in half and stirrups up. Pushing never seems to last for very long - the midwives are very active in helping the patient move towards delivery. For most women who are pregnant with their first child, an episiotomy is cut without local anesthesia during one of her contractions. The fetal heart rate monitor is brought into the room, if one is available, for doptones between pushing. If no fetal heart rate monitor is available, the fetoscope is used to assess fetal heart rate between pushes. After delivery of the baby, baby is immediately placed on mom for skin to skin. The cord is clamped and cut and an additional person in the room brings the baby to the scale and weighs it. Afterwards, the baby is wrapped in a series of blankets ending with a thick fleece blanket and either left on the warmer or given back to mom. In the meantime, the midwife administers 10 units IM oxytocin, delivers the placenta, and examines for lacerations. The resident is documenting throughout. After placental delivery, the resident brings up a stool and a light and repairs the episiotomy. 1% lidocaine is used for local anesthesia (approximately 4-5cc). There is only one size suture available for repairs, size 0 braided dissolvable suture. The episiotomy is repaired, the woman is cleaned off with the wet wipes she provided, the foot of the bed is replaced, and she stays with her baby in this room for approximately 2 hours. </span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">Standard Delivery Cart: Top left jar with hand cut and folded mic pads, far left container with scissors for episiotomy, next to that is container with sterile forceps and needle driver, top right fetoscope </td></tr>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">At the public university hospital, epidurals are not available. There are no options for pain management during labor. Although women have been delivering babies for centuries without analgesia, this is so removed from my usual day to day experience in the United States that I find myself in awe of the strength of these women as they deliver their babies with only the support of each other during labor and the support of the health care workers during delivery. </span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Over the past two days, nearly 90 women have delivered their babies at the University Hospital. This is the slow time of year.</span></span></div>
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<span class="s1"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">The big question for me is how do I take the observations and experiences of the past few days and use them to contribute to improving the system to provide better care for patients, better health care administration, and better education? I have some thoughts on this, but for now, it is Friday and I am looking forward to exploring my new home. </span></span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-49441682353051074302016-03-24T08:45:00.001-07:002016-03-25T08:01:06.731-07:00A Day in the Life on Labor and Delivery - 23 March 2016<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><i style="background-color: #fff9ee; color: #222222; font-family: Georgia, Utopia, 'Palatino Linotype', Palatino, serif; line-height: 21.56px;"><span style="font-family: 'helvetica neue', arial, helvetica, sans-serif;"><span style="font-size: x-small;">(I am volunteering for 4 weeks with Project HOPE at the University Hospital in Prishtina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)</span></span></i></span></div>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">Despite going to bed at 6:30 last night, I still woke up to my alarm at 6:30 feeling tired. I attribute that to the jet lag. I met with the head of the nursing department at 8AM this morning and also met with one of the Gynecology staff. I was brought up to the “normal” labor and delivery unit which is on the same floor where my apartment is. This hospital is quite busy as one would expect given that the average age of the population is in the 20s and >70% of Kosovaars are less than 27. They average 40-50 deliveries per day in the “slow” winter time and more than 80 per day in the “busy” summer time for a total of more than 10,000 births per year. There are 6 resident physicians who work here during the day (7AM - 2PM). They do three 24-hour call shifts (I think per week although this wasn’t clear) and at night, there are three residents present and three specialists. Once finishing high school, medical school lasts for 6 years after which they spend 1-2 years as general practitioners before they can specialize. Ob/Gyn is a 4 year training. There is not a specific training program per se but instead 4 years of training. They spend about 3 months in a department at a time. </span></span></div>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">The first delivery of the day was a bit of a throwback to my very first day of residency. The woman was lovely. Women have to be at least 5cm dilated and have their water broken before they can be brought to the labor ward. Once there, they stay in a “labor” room with two patients per room and no curtains to separate them. Sometimes they have cervical exams in this labor room and sometimes they are moved to a separate checking room which has a half-bed and stirrups. Once a patient reaches fully dilated and is ready to push, she is brought to a labor room. These rooms are individual. No family is allowed in any part of the labor department. The labor bed is prepared for delivery by already being broken down with stirrups up. A bucket sits below the half bed to catch fluid and the placenta after delivery. The woman pushes, most often an episiotomy is cut, and she delivers her baby. This woman pushed like a champ and her baby came quickly and was placed on her abdomen until the pediatric nurses arrived. The pediatric nurses will dry the baby and weigh it and then wrap it in a series of blankets. In the meantime, the episiotomy is repaired. Epidurals are only available at the private hospitals for laboring women and are not available at this university hospital for normal labors. They do provide lidocaine prior to the repair. I held the woman’s hand as she pushed and watched her face light up with joy after her baby girl was placed on her abdomen. As the episiotomy was being repaired, I started to feel quite light-headed and really wishing I had figured out how to eat breakfast prior to starting my day. I let go of the woman’s hand, grabbed my coat, and walked to the end of the hallway where there was an open window and sat down. Shortly thereafter, several nurses and residents approached me and asked if I was okay. I was, just embarrassed. I sat for a while in one of the nurse’s rooms and received a very kindly lecture on how I just need to tell someone if I don’t feel well as they are more than happy to help me. </span></span></div>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">I met several residents and went to their resident call room where we paused for a breakfast. One of the residents ordered breakfast for me from a local place which was delivered. We had our coffee, I had a chicken sandwich, and we had a leisurely breakfast. Then back to work.</span></span></div>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">The “specialist” (attending) does the checking of the patients at various points throughout the day. Nurse midwives do the deliveries and the residents do the repairs. They do not have enough fetal monitors for all the patients so most women have intermittent monitoring during the labor process. Some will have monitoring if they are complicated or demonstrate non-reassuring fetal status. The records are all kept on paper and like in the US, the residents are primarily responsible for the documentation. They also keep a large book with all of the deliveries from the hospital. They have between 4-6 scheduled c-sections per day and approximately 4-6 unscheduled c-sections. The c-section rate for the country is about 30%. One laboring woman was taken urgently for a c-section for a fetal bradycardia. There were no bells, no obstetrics team, just nurses and residents working very quickly to get the patient in a wheelchair to be wheeled down to the operating theater on the floor below. </span></span></div>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">Many people are in and out of the room during the labor process and each has their set role. After delivery of the placenta, someone comes to mop the floor and replace the placenta bucket. The repair is completed, the foot of the bed is added, and the woman has two hours with her baby in this room before being moved elsewhere.</span></span></div>
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<tr><td class="tr-caption" style="text-align: center;">My Breakfast, Lunch, and Dinner with WiFi</td></tr>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">I ventured out and found the cafe owned by a friendly man who spend several years in Britain. The food is delicious and cheap (2 Euros for a lovely greek salad, 0.50 Euros for a Turkish coffee, and 0.50 Euros for sparkling water) and the WiFi is excellent. The best part is that it is open from 0600-2200 every day except Saturday which means I have a place to grab breakfast in the morning!</span></span></div>
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<span class="s1"><span style="font-family: Verdana, sans-serif;">Mirupafshim!</span></span></div>
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-OYz_cg8nyHc/VvQLAah-ZLI/AAAAAAAABLk/m-jzC-9KdawquGlrkGzZ-ZtqRrBgY8M0A/s1600/DSCN0455.jpg" imageanchor="1"><img border="0" height="240" src="https://2.bp.blogspot.com/-OYz_cg8nyHc/VvQLAah-ZLI/AAAAAAAABLk/m-jzC-9KdawquGlrkGzZ-ZtqRrBgY8M0A/s320/DSCN0455.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">My apartment in the hospital is the closest door on the left. The door to antepartum is on the right.</td></tr>
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<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/-8JwksGgVaZk/VvQK6ipwLAI/AAAAAAAABLc/6ilcjQdP3cMy_DmwVNvPow0PYxgaDgIfg/s1600/DSCN0456.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://1.bp.blogspot.com/-8JwksGgVaZk/VvQK6ipwLAI/AAAAAAAABLc/6ilcjQdP3cMy_DmwVNvPow0PYxgaDgIfg/s320/DSCN0456.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">My room on the inside.</td></tr>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-29914851290043357922016-03-23T07:35:00.000-07:002016-03-25T08:01:06.729-07:00Kosovo - Arrival - 22 March 2016<div dir="ltr" style="text-align: left;" trbidi="on">
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<span class="s1"><i><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">(I am volunteering for 4 weeks with Project HOPE at the University Hospital in Prishtina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)</span></i></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">It is rare that I find myself truly “off the grid” but indeed, this is where I have found myself in Prishtina, Kosovo. After 13 or so hours in the air, I had an overall uneventful trip to Prishtina International Airport Adem Jahari. At Passport Control, my passport was stamped and I was told “welcome.” No questions asked. I was able to access the internet for 15 minutes to let my parents and Michael know that I arrived. My bag arrived also uneventfully, I put it through a security scanner and when I walked out of the baggage claim, Angel from the Macedonia Project HOPE headquarters was here to pick me up. I slept horribly (as usual) on the plane ride over and so was hoping today would not be a long day. We drove to the University Hospital and spent at least 20 minutes looking for a place to park. Hard to believe, but this parking situation may even be worse than Lot 1. </span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">We first walked to the cafe and had a macchiato. Kosovo is known to have good coffee, and I was not disappointed. We then proceeded to the gynecology building where we were to meet with the nursing director. She was not there. Apparently Kosovo time is a bit similar to my experience with Uganda time - the time is more like a suggestion and you can expect people to be late. We then walked up to the apartment where I will be staying the next four weeks. It is at the end of the maternity ward and quite adequate. There is a pull-out couch that serves as a bed, a private bathroom with shower, a couple of small dressers (with some stuff in them perhaps from prior volunteers?) and a television that does not work. There is a desk and another small couch. The WiFi does not work which is unfortunate.</span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The remainder of the day was spent in a series of meetings. I never had time to change out of my plane clothes so spent the entire day wandering around in day-old plane clothes consisting of black Fabletics pants, a Reebok t-shirt with the phrase “we can work it out” on the front, and a Reebok jacket. Way to keep it classy, B. Angel comes to Kosovo about once a week and tries to meet with all the people he needs to on the days he is here to ensure that Project HOPE’s projects are functioning smoothly and to troubleshoot on the ground. Part of Project HOPE’s mission in Kosovo is with supplying essential medications. The health care workers in Kosovo assess what medications they need and have difficulty obtaining and Project HOPE works to get these medications for them. Most of the medications are chemotherapeutic agents for a variety of cancers. They are also working on a project for a medication to treat cystic fibrosis. </span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">The interesting thing about Kosovo is that it is a new nation (independence 17 February 2008), has the youngest population in Europe (average age in the mid 20s with approximately 70% of the population < 27 years), and is working on building infrastructure form within. Prior to independence, it was run by the United Nations, and prior to that, it had experienced years and years of war and was part of a larger nation (Yugoslavia) that ran the infrastructure. One of Kosovo’s current struggles is that it is not uniformly recognized as an independent nation. Major changes are happening in health care policy such as revamping health insurance so that all people will have access to care and that care will be able to be provided. Providing care requires revenue and in the current system, enough revenue is not generated to sustain the health care system. </span></span></div>
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<span class="s1"><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Things I have learned:</span></span></div>
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<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Turkish Airlines is nice. Good food served with real silverware (even in economy class), and they give you a little toiletry kit with slippers, socks, eye mask, toothbrush, toothpaste, and lip balm! They are receiving advertising from the new Batman v Superman movie so all of this came in a batman/superman case. Amazing.</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">There is a reason people dress reasonably well on planes, you may end up meeting with the Minister of Health Financing, and if you happened to wear “athleisure,” you may feel particularly underdressed…</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">People are very friendly and even if they do not know you, they will refer to you as “my friend” by the end of a conversation. Everyone at leasts shakes hands if not hugs upon greeting and parting. I was offered a coffee at every meeting Angel and I attended today (4-5 total).</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Kosovo is pro-American - there is a street that runs through the center of the city named after Bill Clinton with his picture plastered on the side of a building and a statue of him just to the side of the road by a flying American flag. Kosovaars are grateful to the United States for their support in the war in 1999 and in supporting Kosovo’s independence.</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">My sense of direction when I am really tired is truly awful. We went past a cafe with WiFi that shouldn’t be too far from where I am staying, but I couldn’t find it when left to myself this afternoon. Perhaps when I am more rested tomorrow, I will venture around more to try and find it. The hospital complex is a series of separate buildings, and I am not quite sure where the road is that the cafe is located on.</span></li>
<li><span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">I need to turn on the hot water heater at least an hour prior to wanting to take a shower if I want any semblance of warm.</span></li>
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<span style="font-family: "helvetica neue" , "arial" , "helvetica" , sans-serif;">Sorry for the lack of pictures. More to come as I start to learn my way around.</span></div>
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-17253489874538668882016-03-21T06:12:00.000-07:002016-03-25T08:01:06.727-07:00A New Adventure<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Verdana, sans-serif;">It has been a few years since my last post on the blog. Since graduating medical school, I matched into residency at the University of Rochester in Rochester, NY in Ob/Gyn. I have been a busy worker bee working 80ish hours a week with 4 weeks of vacation a year. I spend my vacations traveling, mostly to Germany to spend time with my fiance Michael. I have finally reached my third (of 4 total) year of residency and have an awesome 4-week rotation called "elective." My journey to create my elective experience was arduous and frustrating, but finally worked out. I am working with a group called Project HOPE (all opinions are my own and not those of the organization) and on my way to Prishtina, Kosovo to teach and mentor in the Ob/Gyn department at the University Hospital. I am not really sure what my day to day will look like, but I am ready for a new adventure!</span><br />
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<span style="font-family: Verdana, sans-serif;">I tried to prepare by doing some reading about Kosovo's history and learning a little Albanian. I can say good day (mirë dita), my name is (unë quhem), and goodbye (mirupafshim). I'm not as prepared as I would like to be, but I will learn as I go. I worked up until the day I left and ready to have a change in scenery. I have a long travel ahead - ROC --> JFK --> IST --> PRN and will arrive Tuesday morning at 0830. See you in Kosovo!</span><br />
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<span style="font-family: Verdana, sans-serif;">http://www.projecthope.org/ </span><br />
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Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-40792993560379901272012-05-24T10:31:00.001-07:002012-05-24T10:31:53.024-07:00Arua Rural Rotation (13 May - 23 May)<br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1655.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1655.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />I spent last weekend in Kampala since on Sunday, Renee and I had to leave for our week long rural rotation in Arua - a town in northwestern Uganda near the Congo border. The weekend was pretty quiet. Renee and I went out on Friday night with our housemate Sarah and Lucy - the wonderful woman who runs Edge House. The place we went to was packed and everyone was dancing. Feeling tired from our week, Renee, Sarah, and I were the first to leave the dance party and head home. Saturday morning was lazy as well. I enjoyed sleeping in and relaxing at the Edge House and Makerere Guest House, reading and writing emails. That night we went out to watch football (soccer) at a local pub. We didn't get home early enough for the time we had to get up Sunday morning so the 6am alarm I set was quite unwelcome. Renee and I had a ride coming at 630 to bring us to the bus booking office to book our bus tickets and catch the 730 bus to Arua. It was a bit of an adventure to get our tickets and get on the bus. We were at the booking office by 645 but no one who worked there was around. We sat and waited. The bus to Arua arrived before any of the office workers did. Finally around 710, an office worker arrived and Renee got in line to buy our tickets while I watched our luggage. While she was not making any progress in the line, a man starting yelling "15 minutes until the bus leaves. 15 minutes!" then it was "10 minutes!" then "5 minutes!" Finally Renee made it to the front of the line and as the man was making the final call for bus boarding, we got our tickets, gave our luggage to the guy loading luggage under the bus and took our seats at the back. <br /><br />The journey was pretty uneventful albeit long and not the most comfortable. It is between 7-8 hours from Kampala to Arua and for a bus ride that long, I definitely do not recommend sitting in the back of the bus. I was tired enough to sleep but too uncomfortable to actually get any meaningful sleep on the road. Every time I seemed to fall asleep, the bus would go over a pothole or one of the many speed bumps and Renee and I would be airborne - not so conducive to sleeping.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1660.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1660.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />We made it to Arua a little before 3 in the afternoon and Renee called Dr. Alex, our supervising doctor for our time in Arua. We waited at the bus station for about 20-30 minutes for him to pick us up and take us to our lodging. Our home for the weeks is pretty nice. We are just outside Arua town adjacent to a golf course. We have a clean and comfortable room although there is only electricity for about 5-6 hours a day and although the shower has hot water, the shower head doesn't exactly work so I have to shower underneath the faucet. The restaurant has good food and we get breakfast so I really have no complaints. And it's cheaper than staying at the Edge House for a week. After getting settled and relaxing for a while on the porch outside our room, we ordered dinner. As soon as we ordered, Dr. Alex called us and said he wanted to take us out somewhere. We paused our dinner order and when we arrived, we discovered he was taking us to the hospital for a quick look. Apparently there was some trauma that was coming in and he was called in. It must not have been much of an emergency if he had time to pick us up before going and when we got there, there were no patients. The "emergency" never came in. We left the hospital and instead of going back to our lodging, Dr. Alex took us to his house where we met his mother and a friend of his. We hung out there and watched television - neither Renee nor I had any idea what was going on. Plus we were getting increasingly hungry and tired. After about a half hour, we got back in the car, this time with Dr. Alex's mother and friend and headed further out of town where we picked up some more people then went to the District Hospital to visit a patient who is somehow connected to Dr. Alex personally. It was interesting to see, but not on a Sunday night and after 8 hours on an uncomfortable bus. The best part about the hospital was when we saw a few cows wandering around on the grounds. After an hour, we finally were brought back to our lodging and had our dinner - fish and chips (French Fries). The fish was literally a whole fish, head, tail and all and Renee had to teach me how to eat it. It was really tasty and definitely welcome after not having eaten much all day. We went to bed exhausted and ready to start a new day at the hospital. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1662.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1662.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Monday morning we got up and had breakfast at the hotel. We were supposed to be picked up at 830 but didn't end up getting picked up until nearly 9. We were taken to Arua Regional Referral Hospital to the casualty ward. The hospital had a long queue of patients already waiting and the medical and surgical casualty were full. Renee and I met Dr. Alex and got to work seeing patients. It was nice that we had the autonomy to see patients on our own but then staffed our patients with Dr. Alex. It was nice to have the supervision and feedback. I saw a wide variety of pathology - two cases of malaria, several fractures, a late presentation of congestive heart failure due to mitral valve incompetence, a patient with a 16cm spleen due to liver failure and portal hypertension. It was great to get some exposure to things that I either don't see often if at all at home and to see diseases late in their natural course. At the same time, it is sad that those things exist here and although it is great for my medical education, it makes me sad that people do not have equal access to healthcare resources everywhere. The entire country is pretty resource poor so everyone is equal in the lack of resources unlike at home where we have the resources, but unequal access. After all that I have seen this year and working with so many international medical students who come from countries with healthcare systems that equally take care of everyone, I am more convinced than ever that healthcare should be a human right and everyone should have equal access.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1663.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1663.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />I think Renee and I have gotten quite used to Ugandan time and both of us will have to switch back quickly when we get back home. This morning we were supposed to go to the HIV/TB ward for ward rounds which we were told started at 8:00am. We had plans to try and leave between 7:40 and 7:45 to walk to the hospital. We didn't leave our room until about 7:35 and then when we went to have breakfast, the breakfast wasn't ready. We ended up not leaving until a quarter after 8 and made it to the hospital by 8:30. At home, this would certainly not be acceptable. Here, the doctors had not even arrived on the ward yet. Arriving a half an hour late, we still managed to have time to get a complete tour of the ward with an introduction to all the patients before the ward rounds started. It was interesting to see these patients of which we rarely if ever see at home. They are some of the sickest looking patients I have seen so far during my time in Uganda. The worst part was how young most of them were. It's sad to see people my age or younger wasted away from the AIDS and riddled with TB - pulmonary, meningitis, effusions, spinal...it was all there. The worst patient I saw was on re-treatment for TB after having stopped taking his medicines the first time around. Unfortunately for this patient, he had a severe drug reaction likely to one of the new TB medications causing him to develop horrible bleeding ulcers all over his mouth and gums and his skin to start sloughing off of his feet and legs. This drug reaction can be life threatening and so all TB medications were stopped in an effort to treat his drug reaction. After our morning on these ward rounds, Renee and I decided it was time for lunch before heading back to the casualty ward for the afternoon. When we arrived on the casualty ward, there were no consultants present. There was one nurse who was about to leave for her lunch break and a few nursing students around and that was it. The nurse told us that there was one very sick patient that she thought might have TB and told us to put on masks before we went to see him. Renee and I decided that if we were left alone, we would see patients together because two medical students, even though still not equivalent to one doctor, is better than just one medical student. The moment I saw this patient, I was reminded of the ward where we had spent our morning - he was emaciated, clearly sick, with a cup that was slowly filling with the sputum he was coughing out from his lungs. His BP was low and his heart rate was high so we decided to give him fluid resuscitation. There were no nurses or nursing students around at this point and so I placed the IV line myself. We finished taking his history and doing his exam then went to work on the paperwork to admit him and get him a chest xray, a PPD skin test, and a rapid HIV test. After this first patient, the patients continued to keep on coming. Together Renee and I managed two patients with hypoglycemia, a malaria patient, an acute abdomen, an gangrenous toe with cellulitis, and finally two nursing students who asked for us to consult for them since they were not feeling well. There may have been more, but when things get busy in the casualty ward, I don't always have time to record each patient that I see. The problem also is that the nursing students don't always understand what Renee and I ask them to do. For our two hypoglycemic patients, we gave them both dextrose to treat it. According to my Emergency Medicine Manual, you are to give a 50mL bolus of 50% dextrose then recheck the sugar, and if it's still low, repeat the bolus. The only bags of 50% dextrose we had were 100mL. I drew a line through the middle of the bag and asked the students (who had all appeared when previously when the likely TB/HIV patient was there had disappeared), to watch and stop the drip when the fluid level reached the line. The next time I glanced at those patients, both of them had received the entire 100mL of dextrose. Of course as a result, they went from being hypoglycemic to a not insignificant level of hyperglycemia. At least the body is able to compensate for a transient hyperglycemia better than the hypoglycemia so hopefully there isn't any long term iatrogenic sequelae. The best part about these episodes with both patients is that Renee and I are pretty sure we figured out the underlying cause for the hypoglycemia in the first place - one was probably a medication side effect in combination with not having eaten or drank anything all morning then going out to do physical therapy. The other one most likely has a gastric ulcer - she had not eaten or drank all day and when I asked why she said that for the past month she had stomach pain every time she ate. She also drinks a lot of coffee and was recently on a medication for heart palpitations. This may be the one and only time that I see the initial presentation of a gastric ulcer as a hypoglycemic episode. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1664.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1664.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />After finishing in casualty, Renee and I were invited to dinner at the home of a Minnesota couple (United Methodists from New Ulm) working for the Peace Corps here in Arua. We had a delicious home cooked meal and a delightful time chatting and getting to know this husband and wife pair who have three children all around our ages and decided to join the Peace Corps because "we aren't dead yet." It was nice to be with people having a shared experience of being asked to do things beyond our training and comfort level. It was great to make some new friends. Feeling full after dinner and eating a few local mangoes, we headed back to the hotel very happy and content with our day. We may be extending our stay in Arua for a few days...<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1665.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1665.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />After two long and tiring days of working in the hospital, Renee and I decided that Wednesday would be a short day if it was nice and we would leave the hospital around lunch and head to the one and only pool in Arua for the afternoon. The day was beautiful - perfect for relaxing by the pool. At the hospital that morning we went to the pediatric ward to join the pediatric ward rounds. The doctor was later than we were in arriving and he was alone doing the ward rounds that morning. In one room alone, there were 25 patients. In the first hour, we only got through two of them and this was not because there was a lot of teaching happening, it was because of the disorganization of the files and the fact that many of the patients were new or were supposed to have various testing done and there was a search for results or a search in the record to find out why exactly the child was admitted. The consultant had a lot of work to be done and not a lot of time for teaching. After a few hours, Renee and I had figured out that we were not going to get much out of pediatric ward rounds and decided it would be better for us to leave and relax and recharge for the rest of the week. The pool in Arua is fairly small - not great for a pool workout but I attempted to get at least a long warm up in - but it is quiet and very relaxing and the adjacent restaurant had delicious food. Despite our repeat application of sunscreen, we both left the pool burnt after spending more than 6 hours of our afternoon there. I was able to finish my book (Cutting for Stone - great book!) and both of us left feeling much more refreshed.<br /><br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1666.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1666.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Thursday we were back at work. We had planned to attend the Under 5 Clinic that morning. On our way there, the Peace Corps nurse from Minnesota caught us and took us around the maternity ward. The nice thing about this maternity ward compared to Mulago is that there are actually curtains between the women so they are not just lying out in the open laboring in front of 20-30 other women. When we arrived at the Under 5 Clinic, there was no doctor there yet and soon we were asked by the Peace Corps nurse to come see a child in casualty who had been referred to Arua from a nearby hospital for severe malaria and anemia and was in bad respiratory distress. The other hospital had told the family that there was nothing that could be done to save the child, but we were asked to take a look and give our opinion. This is definitely not a job for medical students but as again there were no consultants to be found in casualty, Renee and I reluctantly took charge. We put the child on oxygen (miraculously, they had this available in casualty) and started trying to start an IV line and also work to get the child admitted and under the care of the pediatrician who happened to be present on the pediatric ward. <br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1667.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1667.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />After we sent the child straight away to the pediatric ward, we had two unconscious patients. One I'm pretty sure has tetanus (we were also considering cerebral malaria and bacterial meningitis). She was completely rigid all over including her jaw. Apparently one month ago she was given tetanus toxoid (we couldn't get more history than that) and I'm thinking that as a result of whatever happened at that time, she ended up developing tetanus. The other unconscious patient was in respiratory distress. She had delivered a stillborn baby via cesarean section 5 months ago and had had abdominal pain since that time. We didn't come up with a diagnosis for her (my top concern was a pulmonary embolism) and so we admitted her to the ward. We had a couple of really sick kids with malaria and one with measles. I saw a diabetic patient who I'm pretty sure was in renal failure with a huge amount of fluid retained everywhere - lungs, abdomen, legs. There was one other unconscious adult - Renee and I diagnosed malaria again since it seems that is what everyone had here if they have a fever and some other vague symptom. We saw a patient who was oozing pus out his belly button. His abdomen was tense and tender and he had an abscess in the left lower quadrant. He also had a chronic cough with sputum production and was completely emaciated. He smelled like TB/HIV (literally - it has a smell) and so we admitted him and I'm pretty sure he has HIV and TB and who knows what that abscess is - probably TB. I started a few IV lines including one in a child. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1668.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1668.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />There was one patient that really got to me today that I was concerned about and would have felt responsible had something bad happened to her. It was a young woman in her early 20s who that morning had witnessed her father die in a motor vehicle accident. She was hyperventilating in respiratory distress. She herself was not involved in the accident. Her family was really concerned about her - understandably although we could find nothing physically wrong with her. Renee and I were both pretty sure that she was in a state of mental shock had an acute stress disorder at that moment which was why she was in the state she was in. At the same time she was there, we had several other really sick patients and so she just wasn't a top priority after we ruled out everything serious. She would quiet down for a while and then all of a sudden scream and start hyperventilating again. Apparently she had been seen by someone while Renee and I were out for lunch and had been given "an injection" of something. No one there knew what she had been injected with and there was no note. I was guessing that she had been given diazepam but I didn't know. I asked all the nurses and the clinical officer I found in clinic but none of them had seen this patient and there were no notes or records anywhere for her. We had given her a bag to breathe into but that was also not helping. I decided to give diazepam thinking that the vial only contained 5mg and according to my Medscape reference, you can give 10mg in one dose. So I filled the syringe and quickly checked the vial - diazepam 5mg/mL - and it didn't register until after I gave it to her and she quieted within a minute that the vial contained 2mL - 10mg of diazepam, not 5mg. Again, this would be okay except for the fact that I wasn't sure what "injection" she had been given earlier and if it was diazepam, I had no idea how much had been given. So I was terrified that I would put in her in respiratory arrest and we don't have a ventilator (let alone an ICU) and if she died from respiratory arrest because I OD'd her on diazepam, it would have been all my fault. We had decided to admit her to the psych ward and thankfully by the time she was headed there, she was awake and breathing okay and no longer hyperventilating. That was the most terrified I have been yet for sure in Uganda (it even surpasses being left alone in the surgical casualty at Mulago). It also made me question if what I am doing here is really helping the patients. I wonder if I am actually making a difference for anyone...<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1670.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1670.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />The alarm went off Friday morning and as the week has gone on, it has become more and more difficult to get up when the alarm sounds. I laid in bed for an extra 15 minutes before I could get the energy to move. We decided to try and avoid the casualty ward again today and since yesterday was so intense, thought that maybe a half day with the afternoon spent at the pool (in the shade this time) if it was nice outside would be a good idea. It was another beautiful day as we walked to the hospital. When we arrived, we found that again there were no doctors in the Under 5 Clinic so we thought we would try and make our own ward rounds on the patients we had admitted from the day before. If you can imagine, it was really difficult to find our patients. Not only are the wards themselves all in separate buildings and unlabeled, but there is also not often a doctor present or anyone who knows the patients that are on the wards. Plus it didn't help that we didn't have any of the patient names written down - just the diagnoses we had contemplated and the ward we had sent them to. We did find a few of our patients - the woman we thought had tetanus/cerebral malaria/meningitis was actually conscious although she was still rigid and her jaw was still clamped shut. After making our rounds, we decided to see what was happening in the minor operating theater. There were a few procedures that morning that we observed. We saw drainage of a foot abscess, a circumcision on a 1 year-old child, removal of an inguinal lipoma, evacuation of a hematoma, and suturing of a laceration secondary to an assault with a knife. It was pretty interesting although sterile technique here definitely doesn't match the sterile technique either Renee or I was taught at home. The worst of the procedures to watch was the circumcision. There is a big campaign to get men circumcised since research has shown that it can reduce the likelihood of HIV transmission. Unfortunately, most of these circumcisions are done well after birth at an age when the boys or men can remember it happening. This one-year old was supposed to have his circumcision under general anesthesia but because his parents had fed him an hour before, he would have to wait 6 hours for the procedure. At home, I think they would have waited and done it later under general, but here, they decided to just do with local anesthesia and no sedation. They strapped the child down to the table with dad holding down his arms and chest and mom holding down his feet. It was borderline barbaric to watch. The child screamed throughout the procedure and for a while afterwards. Once all the procedures of the morning were done and there were no more patients waiting, Renee and I decided it was a good time to call it a day and head to the pool. We had a beautiful day and I was able to get in a short swim and do some reading and take a nap. It was very relaxing. We are both looking forward to sleeping in this weekend and resting up for our final few days in Arua next week. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1671.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1671.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The weekend in Arua was pretty quiet. Renee and I enjoyed sleeping in. Saturday was rainy but we managed to make it to the market in between the rains. The market is huge and busy and easy to get lost in. There are a lot of fabrics, clothing (new and used), toiletries, electronics...you name it, it's probably in the market somewhere. The adjacent food market is also crowded with vendors selling a whole assortment of fruits, vegetables, beans, bread, grains, meats, and the delicacy fried flying ants. The rest of the day was pretty quiet. We read and lounged and then headed to the Indian Restaurant for dinner. After a delicious meal ending in tea, we headed back to the hotel to watch the Premier League championship match. The restaurant was crowded with mostly fans for Chelsea. It was an exciting football match and we went to bed quite late afterwards. Sunday morning we slept in a little then headed to the pool for some lounge time. In the afternoon we went to a dinner party hosted by some of the peace corps volunteers stationed in the West Nile region, including the couple we had dinner with earlier in the week. It was a great day and a very relaxing way to head into our final few days in Arua.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1674.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1674.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Monday we planned to go to the operation theater but they only operate on Tuesdays, Thursdays, and Fridays in the main theater so we went back to the casualty ward. Dr. Alex was back today after his nearly week long trip to Kampala so there were consultants present in the ED. This seemed to make everything a bit more chaotic as they tried to shuffle patients in and out as fast as possible. Instead of being able to evaluate a patient and consider the diagnoses and management plan, Renee and I mostly ended up just being scribes for the history and physical exam. There was not as much learning because there was not much teaching and we weren't given the time to really consider what we thought might be happening with the patients. Regardless, we saw a variety of pathology including a man with elephantiasis, a woman with a cervical and uterine prolapse, a facial tumor, a throat tumor, TB, infected wounds, and some lacerations that we each got to practice suturing. I sutured my first lip laceration which was good experience. All in all the day was okay but the best part came after we returned from the hospital. During lunch, Renee and I reserved our bus tickets for Wednesday to head back to Kampala. While on our way back from the bus office, we stopped by a sports store and bought a football (soccer ball), a pump, and I got myself a Ugandan Nationals shirt. The football we had played with back at Edge House belonged to some British students who have since left. Renee and I want to start playing again when we get back to Kampala so we bought a ball. We decided to try it out this afternoon and our kicking the ball around was interrupted by a group of young boys heading home after school. They joined us in playing a game where we all stood in a circle and one person was in the middle. The ball was passed around the circle until the person in the middle intercepted it and then whoever lost the ball was the new person in the middle. It was a blast and turned our day from kind of mediocre to really fun. Now we are relaxing again in the evening waiting for a our final day on our rural rotation.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1676.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1676.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />We spent our final day in Arua in the major operating theater. Before going to the theater, Renee and I decided to take pictures of the hospital. Our photo taking continued as we dressed in the very non-matching scrub uniforms that they had us wear for our time in the OT. The surgeons had a variety of operations scheduled. There are two theaters but in general only one is used and the other is reserved for emergency cesarean sections. The surgeons do a bit of everything - general surgery, orthopedics, and ob/gyn surgery. I was impressed by their speed of operating and the room turnover speed as well. They got through the morning's cases very quickly. We saw a variety of operations including two hernia repairs, a cesarean, a thyroidectomy, an appendectomy, and debridement for osteomyelitis. There were a lot of things that were done differently in Arua compared to at home. Like in Haiti, there were a lot of ants and flies in the OT and during the osteomyelitis case, one fly landed on several of the surgical instruments and the surgeon's hand and the surgery continued without spraying the instruments or the surgeon changing gloves...in the best of circumstances, osteomyelitis is difficult to cure, but here it seems like it may be nearly impossible. This operation seemed like a last effort to get rid of the infection before this 6 year old boy will need to have his leg amputated. Both hernia repairs (epigastric and femoral) were done with local anesthesia only. The surgeons injected lidocaine at the site of the incision and down into the tissues and when the patient cried in pain, they would inject some more. After the surgeries were done, the patient was asked to get up off the table themselves and walk out of the OT. They did use general anesthesia for the thyroidectomy and appendectomy but general anesthesia here is with ether gas and there are no monitoring devices for the anesthesiologist to use to measure heart rate, blood pressure, or oxygen saturation. These measurements were not even taken manually during the surgery. Perhaps the lack of monitoring is part of the reason why they use local anesthesia instead of general for as many cases as possible. The anesthesiologist also did not listen to the chest after intubating the patient either - at least the surgeons operate pretty quickly in the event that the tube was not in the right position... The cesarean was an interesting case. The mother had 4 previous cesareans and this pregnancy was complicated with high blood pressure and placenta previa. Because of all these factors, the baby was delivered at 31 weeks - pretty early especially in a setting where there is no NICU. The baby was only about 3lbs but had a vigorous cry after delivery and seemed to be doing okay. Being premature in a place where so many children die before the age of 5 due to malnutrition, malaria, diarrhea, or respiratory illnesses is really a disadvantage. It's hard to be hopeful in a case like this. The thing that I was most happy about was that the mother consented to a tubal ligation with her cesarean - with a 5th uterine scar, her chances of a uterine rupture if she were to become pregnant again would be quite high. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/24/1677.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/24/s_1677.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />After the OT, Renee and I had some lunch then went back to the casualty ward one last time. We saw a couple of malaria patients and got them admitted then took some last photos with the staff of Arua Regional Referral Hospital. After we said our goodbyes there, we made one last stop at the home of Marcy and Tom (the peace corps volunteers from Minnesota). Although it was sad to say goodbye, we were both excited to get back to Kampala. Our bus trip Wednesday morning was uneventful except for when we got to the one bridge traversing the Nile that connects the West Nile region to the rest of Uganda. There is a security checkpoint here as a result of the LRA and Joseph Kony and everyone has to get off the bus, show their ID and have their bags searched. It was nice to get off the bus for a few minutes in the middle of our 8 hour bus ride. The funnies part was the sign that pointed out an animal checkpoint. I'm not really sure what they search the animals for, but apparently even animals are not exempt from the security checkpoint. We arrived safely back in Kampala and were able to celebrate with our friends Sarah and Ruth who were leaving that night and the following day, respectively. It is always hard to say goodbye especially to Ruth who had been with us since the beginning of our time in Uganda. It is the friends we have made while sharing these intense experiences that help to keep us sane and to take a step back and still be able to enjoy everyday.<br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Arua,%20Uganda&z=10'>Arua, Uganda</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-73852687864073286342012-05-21T08:46:00.001-07:002012-05-21T08:46:26.734-07:002 Weeks in Surgical CasualtyI spent the past two weeks at Mulago Hospital in the surgical side of the casualty ward. This is similar to the emergency department at home. It is separated into a medical side and a surgical side and is staffed by medicine doctors and surgeons, respectively. I had heard this was a great place to get some practical experience especially with suturing up lacerations. At first I was surprised at how small the ward was. It is made up of several rooms - one is the main treatment room where most of the patients are seen. There are only 4 beds in this room that is divided by a half wall. Then there is a room for ultrasound, a room for xray, a resuscitation room, a plaster room (for orthopedic cases), and an emergency operating theatre. Most of my time on this service I spent in the main treatment room seeing patients.<br /><br />The casualty ward is a busy place - on some days around 500-600 patients might be seen. The "slower" days average about 300 patients in one day. Despite the small amount of space in the main treatment room, there are a lot of "staff" people crowded in there and unfortunately not many of them are consultant physicians. During my two weeks, I was the only international student on the ward except for one day when my roommate Nicole joined me. There were several paramedical students and nursing students who also often lacked supervision. I often found myself not only in a position where I was without supervision, but I was also the supervision for the paramedical and nursing students. As I had the most knowledge and experience of us students, I was the senior. As a medical student, that is a very terrifying and humbling position to be in. I am very aware of what I don't know and when I need help and to not have anyone to ask when in that position is a horrible feeling. I am getting ahead of myself...<br /><br />My first day on the ward was quite atypical. It was quiet. I was disappointed because I had heard such great things, and my first day I didn't end up being able to do much. I learned how the paperwork was filled out for patients and was able to suture up one patient's laceration, but that was about it. The next couple of days picked up and soon I was seeing and managing a lot of patients on my own. During this time, there was always at least an intern present for me to ask questions and to have check over my assessment and plan. All this changed on Thursday during my first week. The morning was a typical morning - the usual variety of trauma (mostly motor vehicle accidents), acute abdomens, back pain, swallowed foreign bodies, abscesses - I had lunch and then went back for the afternoon. When I arrived, the only staff present was the intern. There were not many patients in the emergency department and I got started on a new one that had come in. Soon after, a child came in with a femur fracture from a boda boda (motorcycle taxi) accident. The intern glanced at the patient and while I was still in the middle of evaluating the patient I had started on, he said "I haven't had lunch yet. You are okay to handle this, right?" Before I had a chance to answer, he left and I was alone with a couple of paramedical and nursing students. No nurses, no consultants. I was the most senior person there and I was in charge. I finished up what I was doing and went to see the femur fracture child. As I started my evaluation of him, two more trauma patients came in - the father of the child with the femur fracture who also had injuries from the accident and a patient with head trauma, several lacerations on his face and scalp and bleeding from his ear and nose. I was in way over my head and I knew that and was completely uncomfortable. Morally, I couldn't leave. Even though I was being forced to manage things by myself without supervision, I felt a responsibility to be there for the patients and try to do what I could to make sure that no one died. That was my only goal during that 1-2 hours I was alone - to make sure no one died. The paramedical students and nursing students wanted to help, but unfortunately they had so little experience that they needed me to explicitly explain what I needed them to do. It was terrifying having that responsibility. Somehow I managed and no one died and finally after being left alone in charge for 1-2 hours, the intern and one consultant returned. I finished up with the patients that had come in and talked with the consultants about them. It was nearly 5 and since that is when the international office closes and because I was exhausted from the afternoon, I left. The worst part about it is that even though I told both the consultant and the assistant to the international coordinator that I was left alone in charge of the emergency ward, the only response I got was, "Well, that's great for your learning." No. No it is not great for my learning to basically be experimenting on patients. I did what I thought to do and yes, no one died and I think I probably did the right things for these patients, but I should not have been left without supervision. I do not have enough training and these patients deserve better. They deserve to have trained professionals managing their emergencies and not an international medical student on her fourth day on the emergency ward.<br /><br />This is one of those kind of days that makes me really grateful for the friends that I have and the support network that I have developed while in Uganda. I told my housemates about what happened, and they were so supportive and reassuring and helped me wind down after such an intense experience so that I could face the next day.<br /><br />On Friday, I made sure to bring my Emergency Medicine Manual in my pocket to the emergency ward. If I wasn't going to have supervision, then at least I would have a text to consult so I had some kind of a teacher. I was very glad that I brought that book and for the rest of my time in emergency, it was my closest friend. Friday morning when I arrived, there were no consultants in the emergency department again. Apparently they were all at a meeting. I walked into a room with a few paramedical and nursing students and three bloody messes. The students were focusing all their time on the least critical of the patients - they saw that patient as an opportunity to learn how to suture. As they approached me to ask if I could supervise them, I asked if they had looked at any of the other patients. They had not. I told them that before I could supervise suturing, I needed to assess and triage the other patients that were there. The patient they were focusing on was stable - no bleeding, okay vitals, although he had amnesia for the event that lead to his coming to the hospital - concerning. The other two were in worse shape. One had several lacerations on his face and scalp and had lost consciousness after he had been in a motor vehicle accident. He had bleeding from his nose and ear and a huge hematoma forming underneath his scalp. The other was the most concerning of all. He had a laceration on his head and an open wound on his ankle and was actively vomiting - a sign of increasing intracranial pressure. Thankfully I was not alone for long before the consultants returned from their meeting and I could relax a little and just focus on one patient instead of three.<br /><br />Mulago is the National Referral Hospital and so cases from all over the country are brought here when they have surpassed the expertise or resources of the smaller district and regional hospitals. It also is the regional hospital for Kampala and so a wide variety of pathology is seen on the wards. Although the surgical casualty wards tends to see a lot of trauma patients, a fair number of other interesting things walk through the door as well. I saw one woman who had a suspected meningioma for the past ten years. One entire side of her face was puffed out from the tumor. Because they don't have any treatment available for her, her tumor just keeps growing. It seems we get a lot of late presentations of cancers. The patients don't seem to come in until something has really advanced and so we see some huge masses or patients who are wasted away from throat cancers who haven't been able to eat for months. We also see a lot of bread and butter emergency room problems as well - I saw many young children who had swallowed coins or batteries or some other object and acute abdomens. The trauma patients often seem to involve boda boda accidents. The worst of these involved three people on the same boda - the driver, an older woman, and her grandchild. All three of the boda riders had right sided mid shaft femur fractures. The older woman also had a right sided humerus fracture. Both the driver and the grandchild had open fractures - the driver's fracture had a huge piece of skin missing and a large hematoma had already formed above the fracture site. All of the fractures are set in the casualty ward before they are moved to the wards. Depending on who is working in the plaster (ortho) room, the patients get varying amounts of analgesic relief before manipulation of their fractures. One orthopedist was really great and made sure all patients had morphine on board before reducing and setting the fractures. Others will do the manipulation when the patient has only received diclofenac (an NSAID like ibuprofen) - you know when these patients are being reduced because their screams reverberate throughout the entire third floor of Mulago. <br /><br />It isn't just with ortho manipulations that pain management often seems a bit lacking. I saw one woman with a peritonsillar abscess. The casualty physician stuck a scalpel blade on the end of a clamp and was poking at the abscess at the back of her throat to try and drain it. I have seen a lot of kids with abscesses. It doesn't seem to matter how old the child is or where the abscess is located, they are all drained in the emergency ward without any sedation and sometimes not even local anesthesia. It's also hard to watch the parents have to pin their children down in order to keep them still so that their abscesses can be drained.<br /><br />The other difficult thing about having so much responsibility for making treatment and management decisions is that I am not really sure what resources are available. Many of my boda accident patients, I have wanted to get a head CT on because I was concerned about intracranial hemorrhages. Of the several that I ordered, I don't really know how many of them were actually done. I found out that there is only one neurosurgeon at Mulago Hospital so even if there was a CT done and it showed a hemorrhage, there isn't a guarantee that a patient would be able to have burr holes drilled in the event of increased intracranial pressure anyway. <br /><br />The lack of readily available CT is also a problem for other patients. I spent one morning/afternoon in the resuscitation room where a man was brought in. His initial complaint was an acute abdomen and he soon became non-responsive. Initially the physicians taking care of him thought that he had a ruptured spleen - there was some story about an accident/fall and after an ultrasound, there was free fluid seen in the peritoneum and so splenic rupture was suspected. We started rapid resuscitation measures but his blood pressure just wouldn't pick up. He was taken to surgery (relatively quickly - maybe an hour or two after being in the resuscitation room) for an emergency laparotomy. When the abdomen was opened up, the surgeons were surprised to find not blood but intestinal fluid filling up the abdominal cavity. The patient had a perforated ulcer, not a ruptured spleen and was likely in septic, not hemorrhagic, shock. Looking at the records after this discovery, we saw that this accident had happened over a week ago. The patient survived the surgery but died later that night. Had the diagnoses been known (better imaging would have helped improve the odds of making a correct diagnosis), the patient would have not had surgery immediately, but would have been treated more conservatively with antibiotics and measures to increase his blood pressure before being taken to surgery to repair the hole in his stomach.<br /><br />Despite the challenges and difficulties of working in casualty, I have become even more sure that emergency medicine is the right field for me. I enjoy the fast pace and the variety of patients that I see. I enjoy the hands on aspect - I have lost count of the number of patients I have sutured. I also think it is a great opportunity to do teaching to improve the care that people get when they come to the casualty ward and therefore improve their outcomes. It's the kind of teaching that you can do to enable the people already here to help make the hospitals less dependent on foreign aid.<br /><br /><br /><br /><br /><br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Kampala,%20Uganda&z=10'>Kampala, Uganda</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-47004903376093035262012-05-13T07:10:00.001-07:002012-05-13T07:10:08.691-07:00The First 3 Weeks - Outside Mulago<br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1165.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1165.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Uganda so far has been the best overall experience. As you probably gathered from my blog about my Ob/Gyn rotation, I am getting incredible hospital experience both in knowledge and practical skills. I also have had a great time with all the wonderful people I met while living here and have had a blast hanging out in Kampala as well as doing some traveling in Uganda.<br /><br />The Edge House where I live is a busy place. It is usually always full and it doesn't take long after one person leaves before a new one arrives to take their place. Most people tend to stay for anywhere from 4-6 weeks so I will for sure completely switch groups of people in the house once if not twice. The best part is that a few days after I arrived, a girl from the Netherlands (Renee) came and she will be here for the same amount of time that I am. We seem to get along well personality wise and I am excited for the adventures we will have while in Uganda. As I write this, there are 6 people that have already left the house (not including people I met that stayed elsewhere and have left) and another 7+ that will leave at the end of this week. I have had an amazing time with the people I have met the first quarter of my trip and anticipate that each group that comes next will be just as great. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1166.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1166.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />Edge House is definitely the best house. We hang out a lot together and the people that run it - Freddie, Nassa, and Lucy - are fantastic. They even do our dishes for us :) At least a few times a week we go out to dinner together and whenever anyone leaves, the whole house is really good about going out together for a final farewell dinner. Someone always has an idea of a new place to try so I have had Ugandan, Indian, Chinese, Italian, Mexican, and "continental" cuisine. If someone hears about something cool happening on a night in Kampala, they will write a note on a white board that we have and usually there will be a group of people that will go. We went to the contemporary national ballet at the National Theater one night followed by a poetry and hip hop cultural night. I've watched soccer matches on a giant screen at a bar/restaurant called Mish Mash. I've had a massage at the nearby country club and spent two afternoons by the pool. Just last night I went to the Dutch Queen's Party - who knew there were so many Dutch people living in Uganda! I also went to a house party of one of the residents from the UK that I met on rotation with 8 of my housemates. The house party was the coolest house party I think I have ever been to - they had a DJ and a rolex man. Rolexes are great Ugandan street food - a chapati with an omlette rolled up inside (hence the name rolex). We also play games together as a house. We have had a few nights of playing cards, one game of ultimate frisbee, and 2 soccer matches. I don't mind sharing a room and a bathroom and a kitchen and common area with so many people because all the people are really fun to be around. But you can see why I have had a hard time finding time to blog with everything happening around me!<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1167.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1167.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />It's nice to know that I have met such great people while living here that in the event that anything bad happened, I know I would have a houseful of people that would be by my side the entire time. I know this because of an incident we had during our ultimate frisbee game. We were having a great time playing. The score was close and so we were all getting a little competitive. One of the girls on my team was going to catch a pass when a girl from the opposing team tried to block it. She ended up sliding into the girl from my team. The game immediately stopped and we all ran over to see my roommate lying on the ground in pain holding her leg with her ankle clearly dislocated and likely broken. Although the hospital is a great experience as a student, it is not a place I would choose to go to as a patient if I could help it. Everyone playing went on a mission - one called our international student coordinator to figure out what hospital to take our friend to, one went to get her money, ID, insurance information, one went to get transport to take her to the hospital, one got some pain medication that she had brought with her. The whole house came together to help one of our own. On the ride to the hospital, there were 4 of us in the van with her trying to get her leg still. Once at the hospital, 3 more of our housemates came to join us bringing more personal items for our injured friend and money in case we didn't have enough to cover the bill. It was really inspiring to see this international group of students who hadn't known each other for that long really rally together to support our friend in need. She ended up staying in the hospital overnight and then saw some Italian orthopedic surgeons in Kampala. The decision was made for her to fly home to have surgery. She has since had her surgery and is doing well at home. We all miss her and wish she was still here with us!<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1168.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1168.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />I have had three weekends in Uganda since I arrived and have traveled for two of those weekends. My first full weekend here, I went with a group of British students from Birmingham, Renee from the Netherlands, and Audrey - an American medical student I met on my Ob rotation to Jinja to go white water rafting down the Nile River. The source of the Nile is Lake Victoria and the start of the Nile is full of amazing rapids all the way up to class 6 (the highest class). We rafted 2 class 5 rapids and smaller ones as well. Apparently there used to be a lot more rapids and these rafting trips started closer to the source but in the past few years, a dam was built that has destroyed some of the rapids closer to the source. We were picked up on Satuday morning and drove to Jinja. At Nalubale headquarters, we were fed a breakfast of rolexes, bananas, and juice and were fitted for helmets and lifejackets. We then boarded a truck to head to our launch site. Once we arrived at the launch site, we were separated into two groups - one that was going to have the ultra super extreme rafting trip and another one that was slightly more tame. I, of course, wanting to get the full Ugandan experience immediately walked over to the ultra super extreme raft along with 4 of the 5 guys that were with us and 2 other girls. Our guide was from Zimbabwe and had been rafting for the past 15 years on various rivers throughout Africa and Europe. We entered the Nile at a wide calm spot to learn a few things about rafting before starting our trip down the rapids. Our leader taught us the different commands he would give for paddling forwards and backwards and how to keep in rhythm while paddling. He taught us how to "GET DOWN!" and hold on to the raft when we hit the major rapids. We practiced our short swimmer rescues and how to get ourselves back into the raft. We learned what to do in the event that we became long swimmers (too far from the raft to grab onto the rope on the side) and how to hang on to rescue kayaks properly. We were taught to fold up into a small ball when under the water to facilitate being shot back up to the surface more quickly and then once on the surface to back float with your head looking in the direction you were flowing with the current. Finally we practiced what to do when the raft flipped over. We were told to try our best to hang onto the paddle even when thrown off the raft and given some tips on swimming while holding the paddle. Feeling slightly more prepared, we started off. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1169.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1169.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The first rapid we hit was a grade 5 and it was a drop down a waterfall. Our leader told us that we really, really didn't want to flip on this rapid. We hit it just right and went over the falls landing with a big splash and paddled our way out of the falls. We watched as the second group went over. They didn't hit it quite as well as we had and ended up partially stuck under the falls and needed the safety boat to throw them a rope and help pull them out from the falls. We continued down the river and the next rapid we hit was a grade 3. We thought we were doing really well paddling through it and then we flipped. We were all a bit suspicious that our raft leader had something to do with our flip. This was confirmed after watching the video and seeing the photos from the rafting trip that indeed we were sabotaged. This set the precedence for the rest of the rafting trip. Except for the very first grade 5 (we had a second one later on in the trip called "The Bad Place") and one other rapid that was only a grade 3 but had some treacherous rocks that the current was directed towards, I was out of the raft on every other rapid...something like 5 or so rapids. Outside of the two where no one fell out, there was only one other rapid that the whole raft didn't turn over on although I was not one of the ones who managed to stay in the raft. It was a blast! I never once felt unsafe. The rescue kayakers were great at getting to you quickly when you became a long swimmer and brought you back to the raft. Even when I was under the rapid, I had a great time being tossed around by the Nile. I folded myself into a ball and got shot up to the surface relatively quickly although at The Bad Place, I was just sucked back under after getting a good breath of air. Our leader definitely lived up to the ultra super extreme rafting experience as he took us down the path of each rapid that would most likely wind up with our raft flipping and if that didn't do it, he flipped us himself. The final rapid called The Nile Special was great fun - I ended up out of the raft near the start and riding it the whole way down. I swam to our raft far downriver. <br /><br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1170.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1170.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />In between the rapids, we took our time in the slower moving water and swam in the Nile, reapplied sunscreen, and drank some water. We also had a lunch break midday with a delicious sandwich, chips and guacamole, and pineapple. That night we stayed at the Nile River Camp which was a great lodging along the banks of the Nile River. The best part about it was the rope swing that you could swing into the Nile from. That and the hot showers. After a good night of sleep, the next day we went into Jinja and to see the actual source of the Nile. We had heard/read that it wasn't all that impressive, but I thought it was still really cool to see where this famed river originates. The town of Jinja (the second largest in Uganda) was pretty sleepy on that Sunday afternoon but still very pleasant to walk around. After seeing the source and walking around Jinja, we returned to Nile River Camp and took the busy back to Kampala. It was a great first weekend in Uganda.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1171.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1171.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The following weekend, Renee (my roommate from the Netherlands who is here the entire time I am), Audrey (from Seattle - arrive the same time I did and is staying for 5 weeks) and I took the bus from Kampala to Sipi Falls in eastern Uganda near Mt. Elgon, the highest peak in Uganda and near the Kenyan border. We had heard that the falls were really beautiful and the weekend very relaxing and peaceful. We had a bit of an adventure to get there. We left the hospital early to try and get an early afternoon bus to Mbale but the buses were full until 5:30. The drive to Mbale takes at least 4 hours and sometimes as many as 6 hours and then from there, it is another hour by private hire to the town of Sipi Falls. While waiting for the bus, we had a nice lunch in Kampala City Center. The bus trip took about 5 hours and we arrived in Mbale at 10:30 at night. We had not arranged for any transportation to meet us in Mbale and along the route, the manager of the lodging we were planning to stay at kept calling me to see where we were on our journey. Thankfully, the people from the Mt. Elgon Flyer bus service in Mbale were able to help find us a private hire to take us to Sipi Falls. We finally arrived around 11:30 at the Crow's Nest - a place with supposedly a gorgeous view (which we couldn't see because it was dark) and a bit rustic. They use a generator that they only run for certain hours of the day so we had kerosene lanterns to light our way to our dorm room and for light as we got settled and ready for bed. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1173.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1173.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />The following morning, we were not disappointed seeing the view from outside our dorm. We were on a hill overlooking a valley and Sipi Falls. It was breathtaking and so quiet and peaceful. We ordered our breakfast (it takes a while to get it after you've ordered) and got ready for the day. We arranged for a guide from the Crow's Nest to take us on the long hike through the village, farmlands, and hills to the three waterfalls. Seeing the rural way of life in Uganda was so nice. Most people farm and one of the major crops in this region is coffee. I had no idea that coffee beans on the tree are actually encased in a red shell and look a bit like berries. The hike, despite being at a relatively leisurely pace, still made all of us slightly out of breath due to the altitude. It was nice to take breaks and be able to take in the view from the tops of the hills we were climbing. About halfway through our long hike, it started to rain. Thankfully we all had rain jackets with us as the rain became progressively harder and everything not covered by the rain jacket was soaked. In many ways, this made the hike even more fun. The top waterfall was the smallest of the three but still very nice. There was a "swimming pool" at the base of it but because we were already pretty cold and it didn't look all that inviting, we decided not to get in. The second falls was probably my favorite. We started at the top of it then hiked down to the bottom. There were two parts of this set of falls - the main waterfall and an adjacent one called the "shower." I was glad I had my waterproof/shockproof/freezeproof camera with me to take with us as we stood underneath the shower and got some great pictures of the three of us. Finally we hiked to see Sipi Falls itself - a 99m high waterfall that drops down amongst a background of such lush greenery. It was serene. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1203.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1203.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />After our hike back to the Crow's Nest, we were all glad to change into some dry clothing. We went up to the main lodge to read, relax, and hang out before our dinner (which we had ordered that morning) that we had planned for 6:30. Dinner was delicious and after that we played a card game that Renee taught us - a Dutch game called "Beste" (not sure of the spelling). Renee and I are both quite competitive and especially, I think, with each other when we play games. (It is a friendly, but serious competition between us - we both really like to win). A fourth person staying at the Crow's Nest asked to join in our game so the 4 of us played. To win the game, you have to win 5 rounds. Renee and I were neck and neck the entire evening while Audrey and our new friend were sitting with only having won about 1 round each. I ended up winning the game overall :) We went to bed that night relatively early because without electricity, there is not much to do. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1214.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1214.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Sunday morning, we got up and met our guide for our planned coffee tour. We went to the home of a local coffee producer and learned the art of making coffee. Starting from the red encased beans, we broke these open to expose the two pale coffee beans inside. These had to be placed in a large mortar and pestle and ground until the coating came off of these beans. Then this was emptied onto a plate and the beans separated from the coating by blowing gently on them. After this, the beans were placed in a pot and put over a fire for roasting. While constantly stirring, we waited to hear the crackle of the beans indicating that they were finished roasting. These were then emptied back onto the plate and we sampled our freshly roasted beans - delicious! The roasted beans went back into the mortar and pestle and were ground up manually in order that we could make coffee. After grinding the beans, the coffee grounds were placed in a pot of boiling water over the fire and boiled for several minutes. Then this was poured through a strainer into a flask for us to drink out of. It was probably the best cup of coffee I have ever had. The flavor was so rich and bold. Coffee lovers everywhere really should go through this process to have the freshest tasting coffee. Amazing.<br /><br />We went back to the lodge and arrange for a private hire to take us back to Mbale so we could catch the bus back to Kampala. The ride home was much quicker than the ride there and we got back in the early evening ready to start another week at Mulago.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1215.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1215.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The third weekend (right after my last week on Ob), Renee and I spent in Kampala. A few of our housemates were leaving that weekend to go back home and since we had traveled the previous two weekends and were going to be here for a while still, we decided a quiet weekend was in order. On Friday night, I had been invited to a house party of the the Ob/Gyn resident from the UK that I had been working with on the wards. She told me that all my housemates were welcome to come as well. I wasn't sure what the house party would be like and I was nervous that it would be a total bust especially because I wasn't really sure where it was and it took a while to get a hold of my friend for better directions while we were on the road. We finally made it, and the house was full of people. It was probably the best house party I have ever been to - the house was very nice and they had hired a DJ as well as a rolex man (a rolex is a chapati with an omlette rolled up inside - a Ugandan street food favorite). All the beverages were also provided. We had a blast dancing and making new friends and didn't end up coming back home until the early hours of Saturday morning. Saturday morning, Nicole - one of my roommates returned from her rural rotation. We had a lazy Saturday sitting at the Makerere Guest House using the internet and just relaxing. On Sunday, Nicole, Renee, me, and Sarah (a new arrival to Edge House) went to Kabira Country Club to spend the afternoon at the pool. Although it is a little pricey, it is a great pool to swim in and lounge by and they have really great food. In addition to hanging out by the pool, Nicole and I decided to get hour-long massages (only $10!!). It was a good massage but definitely the most full body massage I have ever experienced. I don't know that I will have another while I am here, but the one time experience was very relaxing. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/05/13/1216.jpg'><img src='http://photo.blogpressapp.com/photos/12/05/13/s_1216.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />So that pretty much sums up the first three weeks and as I am writing this and have been in Uganda for 5 weeks, I have a lot more to catch up on in more recent blogs. I hope to write about my experience on the Surgical Casualty ward and my safari to Murchison Falls by the end of this weekend!<br /><br /> <br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Kampala,%20Jinja,%20and%20Sipi%20Falls&z=10'>Kampala, Jinja, and Sipi Falls</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-52771860318995927802012-04-29T07:37:00.001-07:002012-04-29T07:37:00.243-07:00The First Three Weeks - Ob/Gyn at Mulago Hospital<br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/29/1066.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/29/s_1066.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Olyotya! (Lugandan greeting). It's hard to believe I have already been in Uganda for three weeks. I just finished my last day of my Ob/Gyn rotation on Friday and will move on to the Casualty Ward (Emergency Medicine) next week. It has been an incredible experience so far and I am absolutely enjoying every day.<br /><br />I spent the three weeks of my Ob rotation on the high risk labor and delivery ward. At the end of my time, I delivered 9 babies - most of them I did solo and learned how to repair second degree tears. The labor ward at Mulago Hospital has the most deliveries per capita in all of Africa. With the Ugandan fertility rate being 6.7, the hospital delivers on average 80-85 babies per day. The main labor ward of the high risk unit contains around 25 beds. On most days, all of these beds are filled and often there are mats laid out on the floor with another 3-10 laboring women lying on those as well. Most of the women end up delivering when they are on a bed, but on the busiest days, there are a few that end up delivering their babies on the floor. There is no privacy within this ward. Not even curtains or dividers to separate the beds. No one is allowed to come into the ward with the woman - not the father of the baby or family members or friends. It is overcrowded as it is and so no one is allowed inside except for the laboring mothers, a few midwives, a few nurses, the international students posted to the ward, and the doctors, interns, and residents during the rounds. The day typically starts at 8:30am with the morning report. It is really interesting as they report daily the events from the previous 24 hours. For the labor ward, they report how many deliveries, both vaginal and cesareans, complications from the deliveries (stillbirths, maternal deaths, multiple births, breech deliveries, etc.), and go over the pending cesarean cases. There is a lot of discussion that takes place after the report and it is really encouraging because the Ugandan Ob/Gyn doctors, midwives, and nurses are very proactive to try to identify major problems and discuss ways to resolve these problems. The maternal mortality rate is unfortunately high in Uganda and despite the lack of resources and inadequate staff, there is a strong motivation to find whatever way they can to try and reduce this using the resources and the staffing that they have. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/29/1067.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/29/s_1067.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Following the morning report, we head off to our respective ward rooms for rounds. On rounds in the main labor suite, there is a senior house officer (a resident), 1-3 junior house officers (interns), the international medical students, occasionally a consultant and occasionally Ugandan medical students. We go through every patient in the main labor suite - review their case, do an exam, and discuss the complications. The primary purpose of the ward rounds seems to be to make the prioritization of cases for cesarean section for the day. There are always more patients that need cesareans that will get them before they deliver vaginally so it is really important to prioritize the cases from the most urgent to the least urgent. This is difficult in and of itself, but unfortunately on a regular basis, there are patients that seem equally needy for cesarean. One day in particular, there were three women who had all had two previous cesarean sections (meaning that there chance of rupturing their uterus is unacceptably high). One was dilated to 7cm, one to 6cm but with a multiple pregnancy, and one only at 4cm but with signs of possible rupture occurring at that moment. When rounds are finished - often after a few hours and often interrupted by anywhere from 1-6 deliveries - the doctors all leave. Some go to admissions, some to the operating room to start on the list of cesareans, some to the pre-eclampsia/eclampsia ward, and some to the high dependency unit. After this, the only people left in the main labor suite to take care of the 25+ near-delivery mothers are 1-3 midwives and the international students. At times things are quite quiet but it seems that as soon as one delivers and that baby lets out its first cry, then several start to deliver. Some of the women yell (typically you hear cries of "Musawo!" which means doctor in Luganda) as they realize they are about to deliver while others are pretty quiet and I have often found myself turning around only to see a woman on her back with her legs flexed and the head of her baby starting to crown. I throw on my gloves, if I have time (as in the head is just at the introitus and retreats when the mother is not pushing), I will gather the supplies needed for the delivery - a syringe of 10 IU oxytocin, two elastic cuffs from gloves to use to tie off the umbilical cord, and a blade to cut the cord. If I really have time, then I will try to find the blanket that the woman brought to have her baby wiped down with and get the cotton ready. The women have to bring their own supplies for the deliveries - they are supposed to bring cotton to clean themselves with, two plastic sheets to lie on to try and keep the bed clean, bleach to wipe the bed down with after delivery, as well as sterile gloves for the person doing the delivery and for their vaginal exams prior to delivery. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/29/1090.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/29/s_1090.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />I was a little terrified with the first baby I delivered in Uganda. The head was crowning and because another international medical student and I were standing at the bedside, the midwives assumed that we were fine and did not need them. Besides, there was a lot more work to be done elsewhere so if we were not in need of help, then they had a lot of other things to be doing. As the mother was pushing, I realized that head seemed to be too big to fit through the vaginal opening. We don't routinely cut episiotomies in the US, but it seemed in this case that one was needed. I had never cut an episiotomy before in my life and did not feel comfortable experimenting without supervision on a Ugandan woman and had to ask the midwife twice to come over and cut it for me before she finally came over and did it. As I delivered the head, I felt for a nuchal cord which there was one wrapped twice around the baby's neck. I couldn't get it reduced and so stuck my fingers between the cord and the neck to try to protect the baby from suffocating and finished the delivery. Everything turned out fine - the baby was healthy and had a good cry. The mother was so grateful for my help in delivering her baby and kept telling me "thank you, thank you" over and over again. It was a great feeling. After that first delivery turned out well, I no longer felt terrified of the imminently delivering mother. In addition to delivering several babies on my own, I also helped some of the other international students deliver babies as well. Several of them had never delivered a baby before and a few had not even had Ob/Gyn at home yet. It was fun to do some teaching and get some incredible practical experience as well.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/29/1094.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/29/s_1094.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />Unfortunately not all the deliveries turned out as well as my first one. Everyday I saw at least one stillbirth and participated in three of those deliveries myself - one that I did solo. Sometimes the mothers seem to know when they are going to delivery a stillborn and other times, it comes as a surprise. There are also times when the baby comes out not breathing and due to a lack of a well equipped NICU, many of these babies don't make it despite our best resuscitative efforts with the resources we have. The worst stillbirth experience for me was with a mother who knew she was giving birth to a stillborn. The baby was in a breech position and when I walked onto the ward that morning, I saw the woman lying on the bed with the baby half out. She had stopped having contractions and had been stuck like that for I'm not sure how long. I alerted the doctors doing rounds to her predicament and was told to start an IV with 10 IU of oxytocin to try and get her to contract. I did this and as I was standing there, she asked me if she was going to die. I told her no, that she was going to be fine. She asked me if I would stay by her and not leave and I of course said yes, that I would stay with her until she delivered. After about 30 minutes of the IVF running and still no contractions, I again alerted the doctors who told me to add another 10 IU to her IV. They said that when she had her next contraction, I should deliver her baby. I have never done a breech delivery in my life and even though the baby wasn't alive, I certainly did not feel comfortable tackling this one on my own. Again, no one would come to help. The midwives told me to leave her be and she would deliver on her own, but I had promised her that I would not leave her so that was not an option. When the mother seemed to have a contraction, I instructed her to try to push. The baby was completely stuck. At this point it had been about an hour since I had started that IV and beyond this one weak contraction, the mother was not having any. I again asked the midwives to help. They told me to just wait. I asked the doctors to help and they said that they would come back to her when they finished their rounds. I kept pleading and finally a visiting resident from Canada came over and assessed the situation. She agreed with me that this baby was not going to deliver on its own and was able to recruit the Ugandan consultant and intern to come and help with the delivery. Turns out I was right. In order to deliver this baby, the consultant had to dislocate both shoulders, broke one arm and finally got the arms delivered (which had been up above the baby's head). After delivering the arms, the consultant realized that the baby seemed to have hydrocephalus and so the head was way to big to deliver. So, they had to manually drain CSF from the baby's skull in order to shrink the head to get the baby out. Nearly 2.5 hours after I first saw this woman, she had finally delivered her stillborn. Thankfully she seemed stable after this traumatic labor and delivery experience. In the US, breech is an indication for cesarean but here, there is not enough OR space to section all the breech babies so many of them end up delivering vaginally. Of the 4 breech deliveries that I saw and helped with, only one lived through the delivery.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/29/1099.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/29/s_1099.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The other really traumatic delivery I helped with was for a woman with severe eclampsia who had major mental status changes because of her eclampsia. She was agitated, anxious, and almost seemed to be in a psychotic state. Her baby was stuck and because there was no space for her in the OR, the decision was made to try a vacuum delivery. A third year resident from the UK that I had been working with for two of the weeks I was on the ward took charge of this delivery. This resident was the best part of my Ob rotation - she was an incredible teacher and provided the perfect amount of supervision and autonomy. She really cared about each and every one of the patients and we teamed up on many deliveries which I think made the whole process go much more efficiently and better overall for the mothers we delivered. Anyway, this particular mother due to her eclampsia and her mental state was aggressively uncooperative. We sedated her with diazepam and it still took four of us holding her down to be able to deliver her baby by vacuum. Thankfully, the baby came out alive but needed immediate resuscitation and so the resident and two of the other international students left to work on that. The Ugandan midwife and doctor who had also been helping disappeared and so I stayed with the mother who was lying in a pool of blood from the episiotomy that had to be cut to deliver her by vacuum. She was continuing to bleed and I was concerned about her stability since she was bleeding and had been given sedation. I watched her respiratory rate and kept checking her pulse and watching her bleeding. One of the midwives stopped by and looked at the patient, shook her head saying "that was not the right way to cut an episiotomy - what a mess" and walked away. The UK resident returned and between her and the three of us international students, we tried to hold her down to repair her episiotomy. The mother was still fighting us despite her sedation and we asked the midwife to come and help hold her down. It seemed like all she really had to contribute was criticism - for the episiotomy and the "slowness" of the repair and for the fact that I was leaning over the patient, trying to hold her down and subsequently was getting blood on my clothes. I said that I could wash the blood out of my clothes later and the resident told her that she should show her how to do a fast repair. The whole scene just felt wrong - four people holding down this poor woman while someone tried to suture her and stop the bleeding. It was a sloppy job, but it seemed to work to stop the bleeding. At the morning meeting the next day, I found out that the patient and the baby were both stable and the mother was in a better mental state than the previous day.<br /><br />Every day was a complete adventure on the labor ward and if I wrote all the stories I had to tell about my experiences, it would be a short novel. It was incredibly hard and difficult but also equally rewarding. I felt like I was learning so much and at the same time was able to give back and help others. Even though at times it seemed like people didn't care or moved too slowly when you needed something NOW, they really do an amazing job with the resources that they have and for every person that seems to not care when something terrible happens, there are at least two that really do care. I was also so inspired by the motivation of the staff to identify problems and try to brainstorm ways to fix them to decrease their maternal and neonatal morbidity and mortality rates. I am sad that my time on Ob is over, but I am excited to start something new - Emergency Medicine!<br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Kampala,%20Uganda&z=10'>Kampala, Uganda</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-38931536916865870672012-04-10T10:10:00.001-07:002012-04-10T10:10:47.514-07:00The Beginning of the End - Arriving in KampalaSo I may get back to my India blogging, but then again, now that I am in Uganda, I may just forget writing about the rest of India and just move on to my last and final location of my world wide medical student tour. <br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/10/1291.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/10/s_1291.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br /><br />I flew out of Minneapolis on Friday, April 6 at about 3 in the afternoon. My mom and sister brought me to the airport after we stopped and had lunch with my brother in St. Paul. When I got to the airport, my one checked bag was 6lbs overweight. Even though I was given 2 free check bags each 50lbs which means I should have gotten 100lbs of weight to bring, Delta was going to charge me $90 for my 6lbs overweight bag. I refused to pay that and I didn't have another bag to check, so I unloaded my shampoo and conditioner and some other liquid things that I had planned to bring and got my bag down to 50lbs. Going through security was a breeze and I sat at my gate for a little over an hour before we boarded the plane for Amsterdam. The flight to Amsterdam was entirely uneventful as all good flights are. I ended up sitting next to a girl around my age who works for the CDC and was also headed to Uganda for 4 weeks to do a project here. The slightly less than 8 hour flight went by relatively quickly and we made it to Amsterdam. I didn't sleep at all on the flight and was quite tired by the time we arrived in Amsterdam. The airport is not very conducive for sleeping, but as I was tired, I still managed to sleep for an hour on the tiled floor. <br />I boarded the plane to Kampala with a stop over in Kigali, Rwanda and the flight was relatively empty so I ended up with a row to myself. The guy sitting in the row next to me was a really nice guy from Texas who was going to Uganda for the second time to do some military training for the Ugandan soldiers. He has been to Africa several times and has loved all of his trips. It was great to get a bit of insight prior to my arrival especially with regard to trips to take on the weekends! This flight was also uneventful and I made it to Kigali and then to Kampala without problem. On this flight I only slept for about an hour as well.<br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/10/1292.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/10/s_1292.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br /><br />Once I arrived in Entebbe (about 35km south of Kampala and the location of Uganda's international airport), I was quickly able to retrieve my bag and get my Ugandan visa ($50). The whole thing went so smoothly and as I walked out of the baggage claim area, I saw a man with a sign with my name on it who I presumed was the person sent from the school to pick me up. He and his wife welcomed me warmly to Uganda and we got into the Makerere University van. It was unfortunate that it was night (10:30 or so) when I arrived so that I couldn't see the scenery on my ride from Entebbe to Kampala. But I was quite tired and ended up falling asleep on the ride to Kampala. I was brought to my housing - the Edge House - on the Makerere campus and was greeted again very warmly by Lucy and Nasser who run the house. None of my housemates were around as the Easter weekend provided for a long holiday weekend so everyone was gone. I was okay with that as I was really tired and after unloading my things, I fell asleep and slept until nearly 11am on Sunday morning.<br />Sunday was a very relaxing day. I wrote my blog about Goa, did some reading, took a nap on the outside porch, went shopping for some groceries and the toiletry items I was forced to leave behind in Minneapolis, and enjoyed being in my new home. One of my housemates, Cecilia from Sweden, returned from her weekend trip with her boyfriend and it was really nice to meet the both of them. Cecilia has already been here for 4 weeks and will be here for another 2 months so we will get to know each other quite well I think by the time she leaves at the beginning of June. Sunday night Nasser took me to get a SIM card for my phone and also get some data so I can connect my phone to the internet. It was so easy - we just asked for a SIM card and got it. Then I bought the airtime and it worked. So easy.<br />Monday morning I slept in quite late again and was woken up by Lucy when a Makerere medical student arrived to take me on my orientation tour. I had to quickly get ready and then headed for my tour. Along with me were two other medical students from UCLA who had also just arrived. We first met with the international student coordinator, Susan who was very friendly. Then we took a tour of Mulago Hospital where we will do our clinical rotations. Finally, our orientation ended with a tour of Kampala itself - the city center and downtown. It was really cool to see some more of the city and kind of get some idea of the layout. Kampala is a much cleaner city than Bangalore and the sidewalks are actually walkable. It's definitely not as crowded nor is the traffic anywhere near the level it was in Bangalore. So far, I am really loving it here. The only bad thing that happened on our tour was that near the taxi park in downtown, a man tried to steal the necklace off of one of the other medical student's neck. He did not succeed and she was okay, but it definitely raised all of our heart rates a bit and made us keep a little tighter hold on our bags. <br />When I returned to Edge House late that afternoon, I met the rest of my housemates and my roommates. The group is fairly international although the majority of students are either from the US or England. We have one from Sweden and one from Holland. It was one of the American's birthday on Monday so 12 of us that are living in the house went out for dinner together to celebrate. Everyone has been so friendly and welcoming and I feel like I am at home already. I am so happy to be hear and think that this will for sure be the overall best of my experiences yet.<br />I am writing this on Tuesday after my first official day at Mulago but I will save the going-on of today for the end of the week when I can recap my first week of Ob/Gyn at Mulago. <br /><br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Kampala,%20Uganda&z=10'>Kampala, Uganda</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-30602187929616482682012-04-08T11:08:00.001-07:002012-04-08T11:08:46.103-07:00Goa (Feb. 24-28)<br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/08/2177.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/08/s_2177.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The weekend before I started Ob/Gyn, Kim and I talked about taking a trip to Goa. She had been to Palolem Beach with Michael, Carina, and Carina's boyfriend Noti the weekend of my birthday but had heard about a beach party happening at Morjim Beach in north Goa that she really wanted to go to. I just wanted to go to Goa so we decided to try and make that happen the following weekend. During the week, our group going to Goa grew - it started out just Kim and me and then Carina, Sonja, and Julia all decided to join us as well. The problem was that we tried to buy our bus tickets very last minute. We went to the travel agency on Wednesday afternoon to buy bus tickets for the weekend. We had decided to go for a long weekend and leave on Thursday night. We had a horrible time trying to get bus tickets. We spent around 2 hours at the travel agency with no luck. There were tickets showing up on the website, but for some reason we were unable to book them. Then we each tried to buy tickets online on our own computers but were again unable to book bus tickets. This was the only time during my time in Bangalore that the bus ticket websites (we tried several) would not accept my American credit card. Just when we thought there was no way we were going to be able to make it Goa, our magic friend Mahesh came through for us. He got on the phone with someone and suddenly we had bus tickets for all of us on a sleeper bus leaving Thursday night for Goa. Unfortunately, we could not get bus tickets to return on Monday morning so we ended up having to change our return to Tuesday morning. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/08/2178.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/08/s_2178.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Thursday night we headed to the bus pickup point and made it on our bus with our handwritten paper tickets. We were not confident these tickets were valid since none of us had had handwritten tickets before this. Thankfully, they worked without a problem and we boarded our bus to Goa. The difficult thing about being on a sleeper bus with 5 people is that often the beds are shared between two people. Since Julia was the last person to decide to join us on the trip, she ended up sharing a bed with a stranger. This actually worked out to our advantage. The guy Josi was an ex-pat living in Morjim Beach. He knew a guy with a car that would be able to pick us all up from our bus drop off point and bring us the rest of the way to Morjim Beach (about an hour away) for a very cheap price - 700Rs for all 6 of us (about $2 per person). He also knew the owners of a group of beach huts and was able to get us a great deal on our accommodation as well. We paid 450Rs per room per night which split between two people was less than $5 per night. They were clean huts with a great location. There was a common shower and toilet that everyone used, but for $5 per night, none of us could complain. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/08/2180.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/08/s_2180.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />After arriving at our huts, rearranging our bags, showering, and changing into our beach wear, the 5 of us headed out for breakfast on the beach. The place we went to - Fish and Feni - ended up being our breakfast place for the duration of our stay. The food was delicious, the service great, and the prices very, very reasonable. The fresh fruit and the fresh fruit juices were amazing as were the omlettes. After breakfast, we headed down to the beach and began our weekend of relaxation - napping on the beach, reading, swimming in the ocean, and of course eating. Late afternoon on Friday we decided to head over to this party that Kim had found and have lunch in that area before checking it out. We went to this Italian place on the beach. The food was good but it took 2 hours for us to get it. To make up for their incredibly slow service, they brought us two pitchers of sangria. Even though we didn't have anywhere we needed to be, we were all starving and a little frustrated at having to wait so long for our food. We finally did eat and then headed to the party next door. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/08/2181.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/08/s_2181.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />I have never been to anything like this party. The music was loud and the place was packed with people - mostly Europeans - who were all dancing, sometimes very crazily, to the beat of the music. I think a lot of the people were on some kind of drug but it was great for people watching. Julia left to meet up with Josi and Carina and Sonja left soon after because of the crowdedness of the place. Kim wanted to stay and although I am sure she would have been fine on her own, I didn't really want to leave her by herself so I stayed as well. After a couple hours of dancing and a ton of sweating, we walked out of the party to get some fresh air. It was a little after 8pm and the sun had set. We still had our swimsuits on and so to cool off, we decided to jump into the ocean. We set our stuff a little ways down the beach - our clothes, flip flops and put our wallets, phones, and my camera buried within the clothes. We jumped into the ocean and played around in the surf for no more than 10 minutes and when we got out and went back to our stuff, it was gone. After searching up and down the beach area and asking anyone nearby if they had seen our stuff, we headed back to our huts in our bikinis to put on more clothes and get a flashlight to look for our things. We were sure it was stolen, but as the clothes really had no value, we were hoping to at least find those thrown somewhere. When we returned to the huts we had an additional problem. I had used my own personal padlock instead of the one provided to us by the hut to lock everything up and the key had been inside my wallet and the spare key in Kim's wallet. We had to have the staff break into our room my removing the bolt on the door (which definitely needed replacing anyway) and replacing it. We got dressed, grabbed our flashlights and as we were heading back down the beach to the party, we ran into Carina and Sonja. We told them what happened and both tried calling our cell phones from Carina's phone. They had both been turned off. We did not find anything when we returned to the party to search for our stuff. We told the bartender at the party about our stolen stuff and asked if anyone turned anything in, if he would let us know. We walked back to our hut and decided to call it a night. Thankfully the flip flops were cheap and I had other sandals, the sarong I had on I bought in India which was no great loss, I didn't have any ID or credit cards in my wallet although I did have all the cash that I brought with me to Goa in that wallet (stupid, I know...), the camera was several years old and actually the back-up camera that I brought and only had pictures from that night on it, and the phone was cheap. The bad thing about losing the phone is that getting a SIM card in India was such a pain and now I would have to go and get another one. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/08/2182.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/08/s_2182.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Saturday morning I woke up early and couldn't get back to sleep. I decided to go for a run along the beach to burn off some of my frustrations of getting my stuff stolen and to also look in the daylight to see if any of our things of no value had been ditched. I ran back to the location of the party and did find both of our pairs of flip flops but nothing else. It was a beautiful morning so I decided to bring the shoes back to our hut and continue my run along the beach. On my way back to the hut, a young-looking Indian man in a white running outfit whom I had seen on my run to the party beach ran up to me and started running next to me. He asked me what I was doing and I said "running." He asked if he could join me and I said "No. I want to run alone." Then he asked where I was staying and I responded vaguely "On the beach." He then asked if he could go to the place I was staying with me. And again, more forcefully I said "No." As if somehow he thought I was not getting his intention, he then reached over and grabbed my crotch. Completely startled, I stopped pushed his hand away and yelled "Don't do that!" Thankfully at that point he turned and ran away. I continued running toward my hut and before I turned in, I checked to make sure he was not around before going in. I brought our sandals back and told Kim what had happened. I still wanted to continue running as now I had even more frustration to burn off and so Kim got dressed and went with me. After my second run with Kim, we went back to the huts and saw Carina. Carina had wanted to go for a run as well so I went on a third run with her. After all of my runs, I went back to the hut, rinsed off, changed into my beach stuff and went to the beach. Julia wasn't feeling well that morning and so didn't join us at our breakfast place for breakfast.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/08/2184.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/08/s_2184.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />The rest of the weekend was much improved from the first 24 hours. I finally had a chance to relax and enjoy the weekend with great friends. We laid on the beach, swam in the ocean, ate good food, read (I finally finished the book Curry: A Tale of Cooks and Conquerors and read a great book that I highly recommend especially if traveling to India called The White Tiger), slept, and had great conversations. I'm so glad that I was there with such great friends since the weekend would have been a miserable disaster if all that had happened and I had been alone. I am very thankful that nothing worse happened with that guy on the beach and that I had good friends to help me out and make sure the rest of my trip was enjoyable. Monday night came all too quickly and soon we found ourselves back on a sleeper bus and heading back to Bangalore.<br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Morjim%20Beach,%20Goa,%20India&z=10'>Morjim Beach, Goa, India</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com1tag:blogger.com,1999:blog-663156414496993207.post-33478762977439218652012-04-07T00:40:00.001-07:002012-04-07T00:40:46.045-07:00Ob/Gyn (Feb. 17 - 24)<br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/07/77.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/07/s_77.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />After finishing my two weeks in Emergency Medicine, I spent the weekend in Bangalore. A few of my German friends who had been spending the last several weeks traveling were going to stick around for a weekend in Bangalore. Unmotivated to go traveling somewhere by myself, I opted to stay in Bangalore as well. On Friday evening, I went out with my friends Kim and Ruby and we met up with one of our Indian friends Prash and several of his international friends out at the Skyye Bar (Skye Bar is spelled with two k's, y's, or e's but I can never remember which letter they double...). The bar is really cool and like most of bars/clubs I visited while in Bangalore, was really upscale and per usual, I felt terribly underdressed. The bar is located on the top floor (14th I think) in UB City - a shopping center with all designer label stores. The best part is that the bar is partially on the rooftop and outside with a really cool view of Bangalore below. I think this is the best view of Bangalore I saw while in India and from the rooftop of the bar, it doesn't look like such a dirty, crowded city like it does from the streets. We had a great time that night with old and new friends and at 11:30 when the bar closed, went back to the Annex 3 satisfied with our evening and all of us looking forward to not having to get up the next morning. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/07/78.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/07/s_78.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />Saturday I slept in then spent some of the afternoon shopping on Commercial Street with Kim. Commercial Street is one of the major shopping areas of Bangalore and is nothing more than a main street and several side streets with a variety of stores including some Western-style stores and Western brands of clothing and shoes as well as stands along the sidewalks of the streets selling all sorts of clothing, shoes, jewelry, and bags. After returning from shopping, Kim, Michael, and I went out again with Prash, this time to the Ice Bar. This bar was of course upscale as well and was built up by a hotel and surrounding a swimming pool. A group of Swedish students who arrived during my last week of emergency medicine and were doing their pathology course at St. John's also met up with us at the bar. We had a good time although I think both Kim and I agreed that the previous night at the Skyye Bar was more fun. Sunday was again spent relaxing and gearing up for the week ahead.<br /><br />For the start of my second half of my time at St. John's, I decided to spend a week on Ob/Gyn. I decided to only post myself there for a week and see how it was and if I liked it, I would stay for another week, otherwise I would switch to a different service. I brought my posting letter to the department office and was instructed to wait in the labor and delivery room for the head of the department. I introduced myself to the interns on labor and delivery and asked if they could tell me when the head of the department arrived. The only problem was that they had all just started on the service and none of them knew who the head of the department was. Within the first hour of sitting in the labor and delivery room, I saw my first vaginal delivery in India. It was fairly traumatic for me as an observer which means that for the pregnant woman delivering, it was probably even more traumatic. The non-private labor room had about 10 beds for pregnant women. When a woman seems ready to deliver, she is brought back to the delivery room where she is transferred to a delivery bed and her feet placed in stirrups. The first traumatic thing I learned was that in India it is common practice to cut episiotomies on all women. I was told that this is because the pelvis of Indian women is typically unfavorable for delivery even though Indian babies tend to weigh less than American babies. Regardless, this was the first episiotomy I have seen cut and although I have nothing to compare it to, it seemed to be quite a large episiotomy. After the episiotomy, one of the consultants and one of the residents both climbed up on the bed with the patient and started pushing down on her abdomen. It didn't seem like they gave her much of a chance to push at all before they decided to help physically push the baby out from up above. Again - I don't know the history of this patient and it may very well be that they had a good reason to start pushing so hard down on her abdomen, but I have never seen anything like this either. The baby was delivered successfully and seemed to be a healthy newborn. I floated between watching the pediatricians do their newborn exam and watching the resident deliver the placenta. Not long after the placenta was delivered and the baby was cleaned up, the baby was brought to the mother and placed on her breast to try and start breast latching to facilitate breastfeeding immediately. This seems to be a common practice as well. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/07/79.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/07/s_79.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />Unfortunately the excitement of this first hour was the highlight of the day. I had high hopes for this posting after such an exciting start but found the rotation to be overall disappointing. Sometime during the delivery, the head of the department had shown up but I missed her. After the delivery, I was told to go look for her on rounds and I searched all of the obstetrics wards as well as the gynecology wards. I found only one group of consultants and residents that were doing rounds and the head of the department was not among them. I did finally find her after all the rounds were done and the first thing she said to me was that she wished I would have found her earlier so that I could have joined her rounding team that morning. I explained that I had been waiting in the labor and delivery room and saw the delivery which is why I hadn't found her sooner. She then told me to go observe in the labor and delivery room and then left. That was the first and only time I saw her during my time on Ob/Gyn. I got very little other instruction as to what I was supposed to do during that week - where I should report, what clinic I should observe - actually, I got no instruction for what I should spend my week doing. After spending the morning on a search mission, I returned to the labor room and read for a while. After nearly 2 hours of reading and only 1 patient in the labor room in latent labor, I decided my time would be better spend outside the hospital and I left.<br /><br />I returned Tuesday morning to the labor and delivery room and started my day of waiting. I rounded with the Ob docs on labor rounds and after they were through, I went to the operating room and saw a cesarean section for a patient with pre-eclampsia. The C-section was very similar to ones I have seen in the US. After the C-section, I stuck around in the OR and watched part of a hysterectomy and then left after about an hour of not really being able to see much of anything of the procedure. I went back to labor and delivery and again there were no patients in active labor so I decided to go get some lunch and do some independent learning outside of the hospital. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/07/80.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/07/s_80.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />On Wednesday I reported to labor and delivery and found out that it was the clinic day for the labor rounding team. I spent the day in clinic with one of the senior residents. Her clinic was a little slower paced than that of the consultants. I didn't see as many patients as I would have seen with the consultants, but the major bonus to being with the resident is that there was time to talk about the patients between their visits and this was by far the best learning day I had on the whole rotation. I learned that the Ob/Gyn residency is only 3 years long and there is not any sub-specialization within the field after residency. I learned that at least at St. John's, the consultants will not perform speculum exams or bimanual exams in unmarried women. If a patient comes in with a complaint of a white vaginal discharge, she is treated with a cocktail of medications to treat any of the possible causes - Chlamydia, Gonorrhea, Candida, and bacterial vaginosis - without having any cultures or lab tests to find the cause. In clinic, I did see my first patient with leprosy. She was in the Ob/Gyn clinic for other reasons, but as this was my first time ever seeing leprosy, I found that to be the most interesting part of her history. One of the more disturbing patients that came into clinic was a first time pregnant woman who was married to an HIV positive man. There have been a few HIV negative women married to HIV positive men that I have seen in the hospital. The disturbing question that I have is since arranged marriage is very common in India, are any of these women knowingly married off to HIV positive men? I really hope that this is not the case...<br /><br />Thursday I saw my second vaginal delivery on the rotation. An episiotomy was again cut but at least no one jumped on the bed to push the baby out for this delivery. There was a large audience for the delivery, however. A group of 8-10 medical students on their Ob/Gyn course stood around and watched the delivery of the baby and the placenta and the suturing of the tear and episiotomy. The rest of my time that day I spend looking through the large birth registry that they keep at the hospital. Every delivery is recorded with detailed information about the mother and father including age of the mother, occupation, level of education achieved, literacy, number of previous children, and number of years the couple has been married. These logs were really interesting to look through. The majority of women had "housewife" listed for their occupation and those that were not most often had the same occupation as their husbands. Also, I noticed that many of the women were quite young (18-21) when married and when having their first children. <br /><br />Overall, my week on Ob/Gyn was not the greatest. It seemed pretty disorganized, and I very much felt like absolutely no one cared that I was there and wanted to learn. I saw a couple of vaginal deliveries and felt that the experience I had that week were enough to get a sense of Ob/Gyn in India. I decided the rotation was not a high enough yield learning experience to spend more than one week posted there and made the decision to spend the next two weeks with pediatrics. <br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Bangalore,%20India&z=10'>Bangalore, India</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com1tag:blogger.com,1999:blog-663156414496993207.post-50647739573232725002012-04-01T17:24:00.001-07:002012-04-01T17:24:22.855-07:00Emergency Medicine (Feb. 6 - 17)<br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/01/3205.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/01/s_3205.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />It has been a long time since I have blogged, and I am sorry for my readers that follow and have been waiting in anticipation for the next installment of my great epic tale of my adventures abroad. Now I am writing this weeks after the fact sitting and enjoying US comforts with my friends and family. India was such a mix of experiences - there were times when I really loved it and at least an equal number of times where I really hated it. Overall, it was a great learning experience and I came away with a lot of amazing new friends. It was difficult to blog while there for several reasons: 1 - bad internet connectivity (it's difficult to get connected and when you are, the connection is not always great) 2 - social life (this was a good reason for not blogging - I was busy spending time with my new friends instead of sitting in front of my computer writing) 3 - it's difficult to write about a difficult situation when you are in the middle of it. So - this is why it has been nearly 2 months since my last post and I will do my best now to catch you up on what happened in India. <br /><br />My second two weeks at St. John's I spent in the Emergency Medicine Department. The ED is a busy place that sees a whole range of complaints a day including trauma. I saw a lot of things in the ED that I had never seen before and are uncommon in the US including 2 patients with snake bites, tuberculosis of nearly every region of the body, fulminant hepatic failure resulting from a hepatitis A infection, a patient with unretractable seizures, and a pregnant woman with previously undiagnosed rheumatic heart disease. I also saw things that I have seen or will see in the US although I think the approach to the care of these patients is very different on the opposite ends of the world.<br /><br />The emergency department was a great learning experience for me. Out of all of my rotations at St. John's, it is probably the place where I was able to do the most as a medical student. Since the ED was busy and oftentimes the staff and residents had their hands full with patients which meant that I was able to do more to help out. This mainly came in the form of placing patients on heart rate/blood pressure/O2 saturation monitors and periodically checking on them to make sure that they remained stable. The emergency department had fairly new monitoring equipment which is great except for the fact that a lot of the staff did not know how to or were comfortable using these monitors. For stable patients, this wasn't really a big deal. Unfortunately, this was a very scary situation for patients that were unstable including the many trauma patients that came through the ED. Kim (one of the German medical students who was in the ED with me during my first week) and I took it upon ourselves to hook these patients up to monitors and to watch them and alert the staff if the patients' vital signs took a turn for the worst. In addition to keeping track of patient vital signs, I was also allowed to help with some minor procedures - the highlight of which occurred on my birthday when I got to suture a scalp laceration. <br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/01/3206.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/01/s_3206.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />The emergency department was also the place where I saw three of the worst things I have ever seen in my life. These three experiences are probably the main reason why I stopped blogging when I did and are also part of the reason that I have made the decision to specialize in Emergency Medicine when I finish medical school. The first of these experiences occurred on my first day in the emergency department. At least in our area of Bangalore, burn patients are brought to the ED. I'm not sure if specialty burn centers exist, but if they do, not all patients are brought to them. This patient had extensive superficial and deep second degree thermal burns on his face, upper body, and arms from a gasoline fire that occurred at his place of work. Since burn patients are brought to burn units in the US, I had never seen a burn patient before. The burns themselves looked painful and uncomfortable, but the worst part was not just looking at the patient. The worst part came when one of the ED residents took the patient back to the minor operating theatre in the ED and started to peel the blistered skin off of the patient's body before administering any pain medication. These are the first screams that have haunted my thoughts since. Kim and I asked and soon after begged the emergency resident to wait until the patient had adequate pain control before continuing but we were ignored. The resident told us that he "didn't have time" to wait for the patient to receive pain medication. Lesson #1: the most important things at the hospital in decreasing order of importance are COST, then EFFICIENCY, then the patient. Until that point, that was the worst thing I had ever seen.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/01/3207.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/01/s_3207.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />In between my first and second weeks in the emergency department, I decided I needed to get out of the Annex I since it was my birthday and I refused to spend the night of my birthday in with the cockroaches. I booked myself a room at a nice hotel in Bangalore with a pool and a fitness center and a free continental breakfast buffet. The night of my birthday after having a great day in the ED after suturing up a scalp, I went out to dinner at The Chocolate Room with my German friends that were still in town for the weekend. Several of my German friends had headed to Goa for the weekend the day before so it was a small group to celebrate my birthday. We had a delicious dinner and it was a great continuation of my birthday until about 10 minutes before I had arranged for a taxi to pick me up from St. John's and take me to my hotel. I received a text message saying that due to some technical error, my taxi would not be coming to pick me up. Irate - because this is so typical India - I started to cry and complaining about all of the infuriating things about India. Thankfully, one of our Indian friends Mahesh - a psychiatrist at St. John's that I really believe may have magical Indian powers - called someone he knew and taxi was there in 30 minutes to take me to my hotel. Along the way to the hotel, Mahesh kept calling to driver to check on my progress and to make sure that I made it to the hotel okay. Once I arrived, I was given a fresh juice and my things were brought up to my room. Soon after settling in, I received a phone call from the front desk wishing me a happy birthday. They asked if I liked wine, and if so, could they bring me a bottle in honor of my birthday, complimentary from the hotel? Of course I said yes. After the taxi fiasco, it was a great way to end the night of my birthday. The weekend was exactly what I wanted it to be - I was able to work out in the fitness center, swim, eat some good food, sleep in a clean and comfortable bed and returned to check into the Annex 3 on Sunday totally recharged.<br /><br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/01/3208.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/01/s_3208.jpg' border='0' width='210' height='281' align='left' style='margin:5px'></a><br />My second week in the emergency department brought the second and third worst things I have ever seen with each one being worse than the first worst thing I ever saw in my first week in the emergency department. The second worse thing I ever saw was a trauma patient - he had been hit by a truck and when I saw him in the ED, I saw the entire anatomy of the bottom 2/3 of his right leg. His knee was completely disarticulated and he had an open tibia/fibula fracture near his ankle. The muscle and bone were exposed. Miraculously, his vasculature to his foot was still intact so it looked like the patient had a chance to keep his leg despite the severity of his injuries. Like the burn patient, it wasn't the injury itself that made this the new WORST thing I have ever seen. No, it was the treatment that made this the new worst. The same resident that had managed the burn patient was in charge of this trauma patient and with no regard for patient comfort, the resident began washing out this huge open wound with saline in the emergency department before the patient had received adequate pain medication. The patient had received some, but it was clearly not enough as again the patient was screaming with the aggressive washing out that this oblivious resident was doing. At least this patient was in the main emergency ward room and so the senior consultants stopped him and made him wait for more pain medication before continuing. After washing out the wound, the resident was going to change the dressings underneath the patient's injured leg. If I had not stopped him, he would have lifted the leg (which was in three separate pieces - above the knee, the knee to the distal tib/fib fracture, and the foot/ankle) by himself holding the foot and the thigh and leaving the middle piece free. The middle piece with sharp broken bone fragments and a tenuous blood supply that was barely palpable left free to move about. I actually yelled at the resident at this point and directed him to lift holding the foot and the distal end of the middle piece while I held the proximal part of the middle piece and the thigh and counted to lift and to set the leg down. It took 4 hours from this patient's arrival in the emergency department for him to be taken up to the orthopedic ward. And I'm not sure how long after that he was able to go to surgery. The following day I switched to the afternoon shift to avoid working with this resident and to try and give myself a little break from seeing the WORST things I had ever seen.<br /><br /><br /><a href='http://photo.blogpressapp.com/show_photo.php?p=12/04/01/3209.jpg'><img src='http://photo.blogpressapp.com/photos/12/04/01/s_3209.jpg' border='0' width='281' height='210' align='left' style='margin:5px'></a><br />The third worst thing I had ever seen which definitely tops the charts in WORST things actually didn't happen with my least favorite resident in the emergency department. This was another trauma patient who had been crossing the street when she was hit by a car and the car drove off. She was brought to the emergency department unconscious and bleeding from her chest. The emergency department was very busy that day and I became involved in her care when I noticed that someone had put the person that brought her into the hospital in charge of bag ventilating her. There are no ventilators in the emergency department so since she was intubated and not immediately brought to surgery or to an ICU, she had to be manually ventilated in the emergency department. I will never forget seeing the man's face who was put in charge of her breathing. He looked scared - I saw his mouth move - one, two, three - then his hand squeezed the bag - one, two, three, squeeze. I went over to him and told him that I could take over. Relieved, he handed over the bag and so began my 1.5 hours of breathing for this patient. As I breathed for her, I watched her shaky vitals signs. I watched her saturation levels drop to the 70s% and watched as I told the consultants and nothing happened. I watched her heart rate rising then falling. I watched her blood pressure start to fall. I watched the jar attached to the chest tube fill up with the blood draining out of her chest. I told the consultants and nothing happened. I went with the patient to have a CT scan of her head and her chest and stood with a falling apart lead apron covering me and no protection for my thyroid and continued to breathe for her. Finally, 1.5 hours later, the head of the department of emergency became aware of this patient and her tenuous status and brought her to the emergency ICU where she was finally attached to a mechanical ventilator. Her hemoglobin was finally measured - it was down to 2.9 from all the bleeding from her chest. The cardiothoracic surgeon was called. There is only one at St. John's and he was in surgery and he is the only person who can open up a chest and stop a bleeding pulmonary artery. Even though she and her family had the money to pay for the surgery, she couldn't have the surgery she needed to save her life. So my patient, a young woman who just moved to Bangalore for a new job, the woman I breathed for for 1.5 hours, bled out of her chest and died that afternoon. That was the worst thing I have ever seen. <br /><p class='blogpress_location'>Location:<a href='http://maps.google.com/maps?q=Bangalore,%20India&z=10'>Bangalore, India</a></p>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0tag:blogger.com,1999:blog-663156414496993207.post-16924707689153176602012-02-19T00:17:00.000-08:002012-02-19T00:17:52.249-08:00Ooty (Feb 3-6)<div dir="ltr" style="text-align: left;" trbidi="on"> <br />
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<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-PHQwor01WSI/T0Cu-6k4cII/AAAAAAAABDI/K4hZdbUHMiY/s1600/IMG_3598.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://3.bp.blogspot.com/-PHQwor01WSI/T0Cu-6k4cII/AAAAAAAABDI/K4hZdbUHMiY/s320/IMG_3598.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">tea plantation</td></tr>
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<div class="p1"><span style="font-family: Verdana, sans-serif;"><span style="color: #274e13;">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.</span></span></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-8pF7D7wlH9I/T0CuW4n8WzI/AAAAAAAABCo/Ql1rVKKYIzQ/s1600/IMG_3548.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://3.bp.blogspot.com/-8pF7D7wlH9I/T0CuW4n8WzI/AAAAAAAABCo/Ql1rVKKYIzQ/s320/IMG_3548.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Ooty - view from Willy's Coffee Pub</td></tr>
</tbody></table><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;">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.</span></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-H7zEC56vg8c/T0Ct44mxFbI/AAAAAAAABCQ/paKJBx42PlA/s1600/IMG_3518.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://2.bp.blogspot.com/-H7zEC56vg8c/T0Ct44mxFbI/AAAAAAAABCQ/paKJBx42PlA/s320/IMG_3518.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">home in the Nilgiri Hills</td></tr>
</tbody></table><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;">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.</span><span style="color: #274e13; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-53oORp8ZGck/T0CuEDdTEgI/AAAAAAAABCY/0ABnq6R110Q/s1600/IMG_3523.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="http://3.bp.blogspot.com/-53oORp8ZGck/T0CuEDdTEgI/AAAAAAAABCY/0ABnq6R110Q/s320/IMG_3523.JPG" width="320" /></a></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;">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.</span></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEP_AFexXMhPQHVor5I3TxtfiVB5Dt-_bNYJ4FlasMEhTNWvm2h5rHI33zE4uXGmENIHTLw07Foiqu9egHAZfNYK-Z_X2sz5daGc4ah8CqSCSHxr9qEq78LP75Wp1R0wF9ICK1e0QClpfi/s1600/IMG_3536.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEP_AFexXMhPQHVor5I3TxtfiVB5Dt-_bNYJ4FlasMEhTNWvm2h5rHI33zE4uXGmENIHTLw07Foiqu9egHAZfNYK-Z_X2sz5daGc4ah8CqSCSHxr9qEq78LP75Wp1R0wF9ICK1e0QClpfi/s320/IMG_3536.JPG" width="320" /></a></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;">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.</span></div><div class="p1"><span style="color: #274e13; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://4.bp.blogspot.com/-q5-pG9Uc5BA/T0CuezWsIBI/AAAAAAAABCw/tkK50NFZz1Y/s1600/IMG_3552.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://4.bp.blogspot.com/-q5-pG9Uc5BA/T0CuezWsIBI/AAAAAAAABCw/tkK50NFZz1Y/s320/IMG_3552.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">local bus</td></tr>
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<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/-IQEW3pTiyCE/T0CurDxVvYI/AAAAAAAABC4/FmvgSZ9k0n0/s1600/IMG_3555.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://1.bp.blogspot.com/-IQEW3pTiyCE/T0CurDxVvYI/AAAAAAAABC4/FmvgSZ9k0n0/s320/IMG_3555.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">up Doddabetta Lookout</td></tr>
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<tr><td style="text-align: center;"><a href="http://4.bp.blogspot.com/-g3Q5vtDtgts/T0Cu4aI2m6I/AAAAAAAABDA/UO-hvorLtmY/s1600/IMG_3567.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://4.bp.blogspot.com/-g3Q5vtDtgts/T0Cu4aI2m6I/AAAAAAAABDA/UO-hvorLtmY/s320/IMG_3567.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">2nd day hike through the woods</td></tr>
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</span></div></div>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com1Ooty, Tamil Nadu, India11.411828 76.69535599999994711.3780055 76.654414499999945 11.4456505 76.736297499999949tag:blogger.com,1999:blog-663156414496993207.post-30029673638811962442012-02-12T09:26:00.000-08:002012-02-12T09:26:38.685-08:002nd Week of Ortho @ St. John's (Jan. 30 - Feb. 3)<div dir="ltr" style="text-align: left;" trbidi="on"> <br />
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<tr><td class="tr-caption" style="text-align: center;">Indian toilet</td></tr>
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<div class="p1"><span class="s1"><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span></span></div><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-9nwt6IskRRw/Tzf0EaKKDnI/AAAAAAAABBU/edeqjUi2LfI/s1600/IMG_0070.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://2.bp.blogspot.com/-9nwt6IskRRw/Tzf0EaKKDnI/AAAAAAAABBU/edeqjUi2LfI/s320/IMG_0070.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">patient with snake bite after amputation</td></tr>
</tbody></table><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span><span style="color: #0c343d; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/-4r1J0V4aWEM/Tzf0GpmxSrI/AAAAAAAABBc/Cg4c4A4BLLs/s1600/IMG_0089.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://1.bp.blogspot.com/-4r1J0V4aWEM/Tzf0GpmxSrI/AAAAAAAABBc/Cg4c4A4BLLs/s320/IMG_0089.jpg" width="276" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">TB abscess seen on xray</td></tr>
</tbody></table><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span></div><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjA3cUgkJZNfYMDL4uqygnC7pXdGmR3na17ojlTTEP0GpZwbg3diAgoREWNnPssDL__6GmyNpOC7Jm7AG-wKmmXE9ycQc4v0URkY735ECuOIftL8kYTSWaVWaUC75cwm5kycNV9D3REho2i/s1600/IMG_0094.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjA3cUgkJZNfYMDL4uqygnC7pXdGmR3na17ojlTTEP0GpZwbg3diAgoREWNnPssDL__6GmyNpOC7Jm7AG-wKmmXE9ycQc4v0URkY735ECuOIftL8kYTSWaVWaUC75cwm5kycNV9D3REho2i/s320/IMG_0094.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">tuberculosis pus from abscess</td></tr>
</tbody></table><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span><span style="color: #0c343d; font-family: Verdana, sans-serif;"> </span><span style="color: #0c343d; font-family: Verdana, sans-serif;">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...</span></div><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-eRcSsS9WJQw/Tzf0O6f9OnI/AAAAAAAABBs/fhg4hS1Y61k/s1600/IMG_3499.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://3.bp.blogspot.com/-eRcSsS9WJQw/Tzf0O6f9OnI/AAAAAAAABBs/fhg4hS1Y61k/s320/IMG_3499.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Julia, me, Kim @ Love Shack</td></tr>
</tbody></table><div class="p1"><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span><span style="color: #0c343d; font-family: Verdana, sans-serif;"> </span><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span><span style="color: #0c343d; font-family: Verdana, sans-serif;"> </span><span style="color: #0c343d; font-family: Verdana, sans-serif;">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.</span></div><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-Sn6antXAJNQ/Tzf0yiyfGII/AAAAAAAABB8/SiMW1LPkQDM/s1600/IMG_3502.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://3.bp.blogspot.com/-Sn6antXAJNQ/Tzf0yiyfGII/AAAAAAAABB8/SiMW1LPkQDM/s320/IMG_3502.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">bucket shower</td></tr>
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-iv3U6GSQKuQ/Tzf1H6DWWlI/AAAAAAAABCE/zWDHpLiNg5Y/s1600/IMG_3503.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://2.bp.blogspot.com/-iv3U6GSQKuQ/Tzf1H6DWWlI/AAAAAAAABCE/zWDHpLiNg5Y/s320/IMG_3503.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">cockroach roommate (a small one...)</td></tr>
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</span></div></div>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0Bangalore, Karnataka, India12.9715987 77.59456269999998312.7518902 77.342821199999989 13.191307199999999 77.846304199999977tag:blogger.com,1999:blog-663156414496993207.post-53622736485792224432012-01-29T04:04:00.000-08:002012-02-07T04:43:46.192-08:00Hampi<div dir="ltr" style="text-align: left;" trbidi="on"> <br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-9DCDKGwj9oc/TzEY9lS4laI/AAAAAAAAA_g/VW-r280uLAo/s1600/IMG_3210.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="http://4.bp.blogspot.com/-9DCDKGwj9oc/TzEY9lS4laI/AAAAAAAAA_g/VW-r280uLAo/s320/IMG_3210.JPG" width="320" /></a></div><div class="p1"><span class="s1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">During my first week of rotations at St. John’s, I met a group of American and American/Israeli medical students that are at St. John’s for 6 weeks of an elective course. The 5 of them are all doing the same rotations but two are from Columbia in New York and the other 3 are Americans that are going to medical school in Israel that associated with Columbia. Since most of the Germans were going away for a long weekend, I decided to join 4 of the Americans in a weekend trip to Hampi. I definitely felt the need to get out of town after moving into the Annex 1 (see previous blog). Hampi was once the site of a large Hindu empire in India. It is thought of as the home of the monkey Gods. It is a city of ruins from the temples and height of the Hindu empire that once ruled in the area. It is also a nice break from the big city life of Bangalore as the city of Hampi lies along a river and the scenery is a mix of rice paddies and giant boulder hills. </span></span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-datHTaXFeTU/TzEZM7N7SjI/AAAAAAAAA_o/bVWaWP5iVcE/s1600/IMG_3214.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="http://2.bp.blogspot.com/-datHTaXFeTU/TzEZM7N7SjI/AAAAAAAAA_o/bVWaWP5iVcE/s320/IMG_3214.JPG" width="320" /></a></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">The American students arranged the transportation and the lodging which was very nice for me since I was able to just join in without having to do much of the planning. After traveling for a while on my own, this is a welcome break. We were picked up from the Annex 3 at 12am Friday night/Saturday morning by a hired driver. We rode semi-comfortably in a Toyota SUV for 7+ hours to Hampi. Unfortunately for me, I ended up in the front co-pilot seat which meant that at every toll stop (which seemed to occur about ever one hour), I was woken up by the driver to pay the toll. Of course this meant that by the time we arrived in Hampi, I was not feeling very rested. We made our way to our accommodation - Shanthi Guest House - dropped off our bags and cleaned up before heading out to start seeing the sights. We only had 1.5 days to see Hampi which from what I had heard from the Germans is not nearly enough time as the pace of Hampi is very relaxed and once you get there, you don’t really feel in a rush to leave.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZbzSm9MUQ1VTY_cXiBikBpxqWmEUTNdPuggRFP3wQAq5vhyphenhyphen7-T199rZIqcPAWvMVOGgW-nspNAvdWhtP5yh-RkS2kmykwMZdxeMA_lQf1jkLBM_EwUmMzqCPXpl0AGqFv8Db8doCfJWDL/s1600/IMG_3204.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZbzSm9MUQ1VTY_cXiBikBpxqWmEUTNdPuggRFP3wQAq5vhyphenhyphen7-T199rZIqcPAWvMVOGgW-nspNAvdWhtP5yh-RkS2kmykwMZdxeMA_lQf1jkLBM_EwUmMzqCPXpl0AGqFv8Db8doCfJWDL/s320/IMG_3204.JPG" width="320" /></a></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">On the recommendation of the German students, I suggested we rent bicycles to bike around the rice paddies and see some of the temples on the other side of the river from Hampi Bazaar and the same side where our guest house was. I was overruled by the other American students who really wanted to rent mopeds (even though they were much more expensive and didn’t include a helmet and to me felt much more dangerous to ride around on the rule-less streets of India). I closed my eyes, took a deep breath and sent out positive thoughts for my safety. I didn’t ride my own since I had never driven one before, I didn’t feel comfortable driving one myself. In retrospect, I’m not sure if that was the best idea although I did make it through the day in one piece and we only fell over one time - a very low speed fall to the side which helped us to learn early on that I needed to get off the bike when we were turning around.</span><span style="color: #134f5c; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-Yk6TWFk0JMM/TzEZYoOg6YI/AAAAAAAAA_w/UFdB0QF3Oog/s1600/IMG_3224.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/-Yk6TWFk0JMM/TzEZYoOg6YI/AAAAAAAAA_w/UFdB0QF3Oog/s320/IMG_3224.jpg" width="240" /></a></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">It was a beautiful day and was incredibly peaceful riding through the rice paddies and the boulder hills. I would have preferred being on a bike not only for my own safety, but also because bicycles seemed to fit the atmosphere of Hampi much more than a moped. I guess this is what happens when you travel with a group - I don’t have the same independence as when traveling alone and when people differ on what they want to do, someone ends up not getting to do the things they want. I still had a great time and really enjoyed Hampi, so I can’t complain although if I had to do it again, I would go about it differently.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><a href="http://4.bp.blogspot.com/-xqD62N0jz7U/TzEZwlZ2RiI/AAAAAAAAA_4/kAuZcdP74bk/s1600/IMG_3233.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="http://4.bp.blogspot.com/-xqD62N0jz7U/TzEZwlZ2RiI/AAAAAAAAA_4/kAuZcdP74bk/s320/IMG_3233.jpg" width="240" /></a><span style="color: #134f5c; font-family: Verdana, sans-serif;">We visited a few different Hindu temples recommended by the Lonely Planet although several of the temples have similar names and the maps are not all that great so we ended up going to one temple that we discovered later was not the recommended temple to visit - this was the first temple we visited which I did not find all that impressive. The best part of the first temple were the children that were wandering around the temple grounds. They were dressed up in very colorful clothes and were quite friendly and wanted to take pictures with us which is always a joy.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">The second temple we visited was really cool not because of the temple itself (after a while, a lot of them start to look the same...) but because of the landscape it was situated on. After walking past the temple, there was a small canal/well that provided a great photo opportunity. When we walked a bit further, we ended up in these cave-like structures created by the piles of boulders. Inside was much cooler than standing outside in the sun and was a refreshing break. Continuing through the caves, we could climb up a sort of rock scramble stair case to the top of the boulder hill and had a great view overlooking the landscape of Hampi. From here, we could see the river, the rice paddy fields, and the monkey temple which was on a higher boulder hill and from where we planned to see the sunset.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/--IIdciUYjis/TzEZ38LZ5WI/AAAAAAAABAA/WYaLF5ANyZ4/s1600/IMG_3251.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="http://1.bp.blogspot.com/--IIdciUYjis/TzEZ38LZ5WI/AAAAAAAABAA/WYaLF5ANyZ4/s320/IMG_3251.JPG" width="320" /></a></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">We left this temple and had lunch at an Indian restaurant that served only one thing - the South Indian Thali. We each got a metal plate with a palm leaf on it and had several different gravies (curries), breads, and rice piled on. It was delicious. After lunch we made our way on the mopeds to a reservoir lake that one of the girls had heard about from a rickshaw driver she started talking to when we got into Hampi that morning. It took a while for us to find the reservoir but we did find it and a large group of people from all over Europe that were swimming and cliff jumping off the boulders into the lake. Hot, sweaty, and dusty from the night of traveling and the day riding around on the mopeds, getting in the lake sounded heavenly. Of the 5 of us, 4 of us joined in the cliff jumping and were rewarded with being submerged in cool water.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-Y2S0Xz4uEr8/TzEaCh9rU7I/AAAAAAAABAI/MHza8HS024A/s1600/IMG_3259.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/-Y2S0Xz4uEr8/TzEaCh9rU7I/AAAAAAAABAI/MHza8HS024A/s320/IMG_3259.jpg" width="240" /></a></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">Refreshed after our brief swim, we took the mopeds to the monkey temple. To reach the top of the monkey temple requires a climb of about 570 stairs. It was a long way to the top but on the way, I had a gorgeous view of the surrounding countryside and was entertained by several monkeys playing on my walk up. It was nice to sit and relax at the top while waiting for the sun to set - relaxing until a snake crawled out from between two of the boulders and slithered right in front of my feet. In my state of fear, I somehow remembered that with a snake, you should stay very still which I somehow managed to do and the snake slid away. Thankfully the sun set soon afterwards and we made our way back down the 570 stairs to the mopeds and back to our hotel.</span><span style="color: #134f5c; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">Our hotel was a collection of individual huts that to my great satisfaction had 24hrs hot water. I took a much desired hot shower and after we all felt clean again, we had dinner at the hotel restaurant. Exhausted after our day, we all went to sleep early.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td class="tr-caption" style="text-align: center;">Hanuman (monkey) Temple</td></tr>
</tbody></table><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">Sunday morning we got up fairly early to check out, drop our bags off with our driver, and see the sites on the other side of the river before heading back to Bangalore. We took the ferry across the river and dropped off our bags. We then hired a couple of rickshaw drivers for a half-day tour of Hampi. We started out at the Royal Centre of the city where the ruins of the Hindu royalty as well as a giant elephant stable were located. After visiting the Royal Centre, we made our way to the Queen’s bathtub which is more like a swimming pool in size. I can imagine that if I were the queen, I would not leave my bathtub. Our final tour stop was at the Vittala Temple which is the main highlight of the Hampi tour. It is a very well preserved Hindu temple that reminded me a lot of the new 2005 temple built in Delhi. I liked this one better just because it was older. It was just as exquisite with the entire temple carved with spectacular Hindu figures. There was also a large stone chariot in the center of the temple that at one time actually carted people around.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td class="tr-caption" style="text-align: center;">view from Hanuman Temple</td></tr>
</tbody></table><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">Satisfied with our tour, we went to the Mango Tree Cafe for lunch. It was a fantastic cafe with an incredible view and even better food. We enjoyed our meals slowly before boarding the SUV for the ride back to Bangalore. I again sat in the front seat on the way back but thankfully we arrived in Bangalore in time for me to get an adequate (well, as good as it can be in the Annex 1) night’s sleep before starting my second week of orthopedics. Namaste.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td class="tr-caption" style="text-align: center;">AM Ferry Crossing</td></tr>
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-gjKTmcj1hHQ/TzEailFQ7tI/AAAAAAAABAw/_4rOwuL0eA8/s1600/IMG_3335.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://2.bp.blogspot.com/-gjKTmcj1hHQ/TzEailFQ7tI/AAAAAAAABAw/_4rOwuL0eA8/s320/IMG_3335.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">elephant stable</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">queen's bathtub</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwVbyVyGW4pKrcbchP_PIvAuv6MZ4ET4iWi4CYywN8DOnQTl-gPR353lCccQhtXfZCkJ4BL-GQ2WLzwX-z00-cBb1gddscdDOTm_m3iL4YV1qgvgNVgZYLntf9WVU1GJiJMQ51X2_IyT45/s1600/IMG_3429.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwVbyVyGW4pKrcbchP_PIvAuv6MZ4ET4iWi4CYywN8DOnQTl-gPR353lCccQhtXfZCkJ4BL-GQ2WLzwX-z00-cBb1gddscdDOTm_m3iL4YV1qgvgNVgZYLntf9WVU1GJiJMQ51X2_IyT45/s320/IMG_3429.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Vittala Temple</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Vittala Temple</td></tr>
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</span></div></div>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0Hampi, Karnataka, India15.333333 76.46666700000002915.329559 76.459573500000033 15.337107 76.473760500000026tag:blogger.com,1999:blog-663156414496993207.post-69633292893187962222012-01-27T03:50:00.000-08:002012-02-07T09:05:47.064-08:00"This is not kindergarten."<div dir="ltr" style="text-align: left;" trbidi="on"><br />
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-X_VqnCIpS5U/Typ3k5-f15I/AAAAAAAAA_M/Tif66IqcWgw/s1600/IMG_3179.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://2.bp.blogspot.com/-X_VqnCIpS5U/Typ3k5-f15I/AAAAAAAAA_M/Tif66IqcWgw/s320/IMG_3179.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Banana Beach Bar</td></tr>
</tbody></table><br />
<div class="p1"><span class="s1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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. </span></span></div><div class="p1"><b><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></b></div><div class="p1"><b><span style="color: #783f04; font-family: Verdana, sans-serif;">Life in Bangalore:</span></b></div><div class="p1"><span class="s1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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.</span></span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://4.bp.blogspot.com/-H6kUwOFM_C0/Typ3fUA0NpI/AAAAAAAAA_E/bMZqmv4wPmc/s1600/IMG_3172.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://4.bp.blogspot.com/-H6kUwOFM_C0/Typ3fUA0NpI/AAAAAAAAA_E/bMZqmv4wPmc/s320/IMG_3172.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">mango corn at Food Street</td></tr>
</tbody></table><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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).</span><span style="color: #783f04; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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.</span><span style="color: #783f04; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://4.bp.blogspot.com/-HcZx9Geh7L4/Typ3Ph9HbeI/AAAAAAAAA-8/rHfk9Nc07RI/s1600/IMG_0049.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://4.bp.blogspot.com/-HcZx9Geh7L4/Typ3Ph9HbeI/AAAAAAAAA-8/rHfk9Nc07RI/s320/IMG_0049.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">general hospital ward room</td></tr>
</tbody></table><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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.</span><span style="color: #783f04; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><b><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></b></div><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-0oMzpS8mHNc/Typ3JHyp65I/AAAAAAAAA-k/S9vfcyesGmg/s1600/IMG_0029.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/-0oMzpS8mHNc/Typ3JHyp65I/AAAAAAAAA-k/S9vfcyesGmg/s320/IMG_0029.jpg" width="240" /></a></div><div class="p1"><b><span style="color: #783f04; font-family: Verdana, sans-serif;">The Hospital:</span></b></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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.</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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!</span><span style="color: #783f04; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-9aRpbmRZZ3c/Typ3LJIsPkI/AAAAAAAAA-s/9THv96YsIBA/s1600/IMG_0030.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://2.bp.blogspot.com/-9aRpbmRZZ3c/Typ3LJIsPkI/AAAAAAAAA-s/9THv96YsIBA/s320/IMG_0030.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">OR scrub sink</td></tr>
</tbody></table><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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.</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLFB2upgLsAbKC-tH14FOGdpYVxMR54WD3ZFjYH06gICsDQLg7VidvY0mIym8ahsUTXYtfUhubizRsAoeloSWg5bDdtzfyaeEakOU1AufuIlWMF5-sX6GMCkeU8YowQVemebJl4BI8xwPc/s1600/IMG_0048.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLFB2upgLsAbKC-tH14FOGdpYVxMR54WD3ZFjYH06gICsDQLg7VidvY0mIym8ahsUTXYtfUhubizRsAoeloSWg5bDdtzfyaeEakOU1AufuIlWMF5-sX6GMCkeU8YowQVemebJl4BI8xwPc/s320/IMG_0048.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">hospital bed with the foot elevated</td></tr>
</tbody></table><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">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.</span></div></div>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com1Bengaluru, Karnataka, India12.9715987 77.59456269999998312.7518902 77.342821199999989 13.191307199999999 77.846304199999977tag:blogger.com,1999:blog-663156414496993207.post-18080863523079327392012-01-23T04:06:00.000-08:002012-01-23T04:06:33.716-08:001st Official Day - Orthopedics at St. John's Medical College<div dir="ltr" style="text-align: left;" trbidi="on"> <br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-qJ-bou2AIxQ/Tx1Lz5q-VvI/AAAAAAAAA-E/PGJ2mr4Pifo/s1600/IMG_0021.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="http://1.bp.blogspot.com/-qJ-bou2AIxQ/Tx1Lz5q-VvI/AAAAAAAAA-E/PGJ2mr4Pifo/s320/IMG_0021.jpg" width="240" /></a></div><div class="p1"><span class="s1"><span style="color: #783f04; font-family: Verdana, sans-serif;">This week I started my elective training at St. John’s Medical College in Bangalore, India. I have decided to start with two weeks of orthopaedics. The morning started out with breakfast at the hospital canteen with Julia and Sandhya. For 30 rupees (about $0.60) I had tea and toast for breakfast. (I ate a banana before heading to breakfast for some fruit). The other German students joined us at the canteen and we walked to the Annex I where we are hoping to relocate during the two weeks we are kicked out of the Annex III due to the Bishop’s conference. As expected, it took way longer than it should have and was this complicated process to view the rooms then arrange for our two week stay. It seems like everything is set for us though and Friday I will be moving to the Annex I. It’s not as nice as the Annex III and we will most likely be sharing rooms and I am not sure if there is hot water. But at least we are on the hospital campus. And it’s only for two weeks. If it’s really miserable, I’ll be sure to take a weekend trip between the two weeks for a break!</span></span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://4.bp.blogspot.com/-Ssp7Vf422bg/Tx1L4T7o_kI/AAAAAAAAA-M/esMbxG6YLPA/s1600/IMG_0024.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://4.bp.blogspot.com/-Ssp7Vf422bg/Tx1L4T7o_kI/AAAAAAAAA-M/esMbxG6YLPA/s320/IMG_0024.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">clinic exam bed</td></tr>
</tbody></table><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">I was worried that I would be late for my rotation. I got the orthopaedics office shortly after 9:30 and was told to go to the outpatient department (OPD) to meet with the head of the department and observe him for the day. When I arrived at the OPD, there were tons of waiting patients but no doctor. I asked if this was the place and was told to wait - he would arrive shortly. About an hour later, the ortho surgeon I was to observe arrived as well as one of the senior residents (ortho residency here is only 3 years after 5.5 years of medical school which is started immediately following high school). Clinic was completely crazy. Both the staff and the resident were seeing patients in the same room and I sat in a chair between them so I could observe both and get a sense of every patient. The two doctors were sharing a desk and there was no divider between the patients that each one was seeing. Privacy seems to not really exist here. Things were moving at a quick pace and I asked questions when I could get them in but mostly I just took it all in. We stopped for a coffee break about an hour and a half into the clinic. I finally got a chance to talk some with the staff doctor and tell him a little about myself and what I was hoping to get out of my time on the rotation. I said that I was hoping to get a sense of medical practice in India and see a wider range of pathology than I am exposed to in the US. I also said that I was hoping to improve my clinical skills. Both the staff and the resident were really helpful in showing me different exam techniques they used when evaluating orthopaedic patients. The clinic ended about 1:45 after seeing 41 patients. It really reminded me of the craziness of doing ortho clinic in Haiti...</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">Very few patients have an appointment – only 4 of the 41 patients seen today were scheduled. The rest of the patients walk in in the morning and are given a number in the queue then wait until their turn to be seen. The patients bring their own records to the clinic.</span><span style="color: #783f04; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://4.bp.blogspot.com/-OJdKvRQD19Q/Tx1M97UDpiI/AAAAAAAAA-Y/c2uMSRQHTt0/s1600/IMG_0025.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://4.bp.blogspot.com/-OJdKvRQD19Q/Tx1M97UDpiI/AAAAAAAAA-Y/c2uMSRQHTt0/s320/IMG_0025.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">clinic room</td></tr>
</tbody></table><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">I was not disappointed in what I observed in clinic. There was the usual bread and butter ortho - back pain and arthritis - but also the unusual stuff that comes in the tropics and an unfortunate number of neglected cases that were not treated properly at the start due to lack of access and poverty. Tuberculosis is a big problem in India and is in the forefront of the differential for many clinical presentations. We had one patient today with TB of the spine. The other really interesting patient today was a boy who had been bitten by a snake and wound up with necrotizing fasciitis. He then had a mid-tarsal amputation of his foot to get rid of the infection. Now he has developed an equinous deformity due to unopposed plantar flexion from the achilles and is getting a pressure ulcer at the stump site. The staff surgeon is planning on correcting his deformity by removing one of the bones in his feet to bring the calcaneus and the calcaneus heel pad forward so that the weight of his body concentrates on that heel pad.</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">Speaking of interesting patients, I forgot to mention one other patient I met last Friday at the outreach clinic. It was a patient with Wilson’s disease which I have not seen before in the US. He had the classic Kayser-Fleischer rings in his eyes and a dystonia due to the copper deposits in his cerebellum. Great clinical findings to be able to make a diagnosis and treat him!</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">At the end of clinic, the staff invited me to the resident’s seminar at 2:30. Residents are responsible for giving lectures and are horribly pimped during their presentations in a very harsh way. The presentations are picked apart by the head of the department. I felt so sorry for the presenting resident. He seemed so nervous before the presentation started and was stopped on most every slide and asked a range of questions that he was expected to know the answers to, even the really obscure questions. At the end of the presentation, the head of the department told him what he should have also included and how he should approach his next presentation. His final conclusion - “It could have been better.” OUCH!</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #783f04; font-family: Verdana, sans-serif;">I came back to my room after the lecture and did some more handwashing of my clothes. I plan on reading up on TB tonight and am looking forward to a new day at the hospital tomorrow. Namaste.</span></div></div>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com1Bengaluru, Karnataka, India12.9715987 77.59456269999998312.7518902 77.342821199999989 13.191307199999999 77.846304199999977tag:blogger.com,1999:blog-663156414496993207.post-5109443147824296112012-01-22T08:01:00.000-08:002012-01-22T08:01:46.659-08:00It's All Part of the Experience...<div dir="ltr" style="text-align: left;" trbidi="on"> <br />
<div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-5vaZ4SNgjuU/Txwx5QGdV0I/AAAAAAAAA9g/4klPPBc35aA/s1600/IMG_3165.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="240" src="http://4.bp.blogspot.com/-5vaZ4SNgjuU/Txwx5QGdV0I/AAAAAAAAA9g/4klPPBc35aA/s320/IMG_3165.JPG" width="320" /></a></div><div class="p1"><span class="s1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">First off, it is a complete nightmare to try and get connected in India. I have never had to jump through so many hoops or be so persistent to get something done in my life. Things here seem to run on phones so having an Indian phone number was a must especially since I am going to be here for a couple of months. Also, in order to get internet (which is most easily done with a 3G USB stick), you have to have a verifiable Indian phone number. Even to use WiFi in a cafe/coffee shop (which there aren’t many that have WiFi available), you have to have a verifiable Indian phone number. To have an Indian phone number, you have to buy a SIM card. In order to get a SIM card, you must have a passport size photo, a copy of your passport and visa, and a proof of address. On Friday morning, I met with the foreign student coordinator to fill out some paperwork, discuss my postings at the hospital, and to get a proof of address letter. My frustrations started early in the day on Friday. First of all, I sent in a payment to the school to do elective training here. When I arrived, Patima informed me that I still owed money to the school. Apparently because I sent in a cashier’s check in USD, some conversion fee was extracted to change it to rupees. So my $620 check to the school was only worth about $520 and I had to pay another $100. Of course no one tells you these things in advance. I feel like money is leeching out from me on a regular basis which just adds to the constant feeling of being drained that I have had since I arrived in India. After I paid my fee and gave her a passport size photo to put on my ID badge, I was brought to Dr. Sanjiv who is the physician in charge of the international students. He was in the middle of clinic but it didn’t seem to matter to be interrupting his patients for me to talk with him. Privacy doesn’t seem to really exist here in India. As we were discussing my electives, patients were brought into the clinic room to sit and wait until we were done with the discussion. The nice thing about electives at St. John’s is that they are very flexible. I can do pretty much whatever I want for however long I want. If I start a posting and don’t like it, I can switch after a week to something new. I told him that I was interested in doing emergency medicine, orthopaedics, ob/gyn, community health, and pediatrics. As soon as I mentioned orthopaedics, Dr. Sanjiv got all excited and asked what I was doing the rest of the day. Apparently there was a specialist outreach clinic that was traveling to a nearby village to provide a peds ortho clinic. He called the pediatrician on the team and got me a spot in the van to head to the village. </span></span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://3.bp.blogspot.com/-yfYqkWapVS8/Txwx19ItmEI/AAAAAAAAA9Y/jIM7P5TybmA/s1600/IMG_3159.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://3.bp.blogspot.com/-yfYqkWapVS8/Txwx19ItmEI/AAAAAAAAA9Y/jIM7P5TybmA/s320/IMG_3159.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Julia and me</td></tr>
</tbody></table><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">It was a really great experience to spend part of the day at this village hospital. I saw several things that day in clinic that I have never seen before in my few years of clinical experience and things that I am not likely to see in the US. The first patient of the day was a child with (very obvious) rickets. Vitamin deficiencies are a major problem especially for poor people in India. I then met a child with dystonic type cerebral palsy that has affected his arms more than his legs. The child had taught himself to use his feet as hands and showed me how he could unwrap and eat candy and write with his feet. I then saw an adult with an amputated arm. This guy had been in a farm accident a few years ago and broke his arm. He didn’t have access to a hospital or medical facility so the local “medical” expert had him wrap his arm very tightly in bandages. This led to ischemia of his arm which then necrosed and became gangrenous. As a result, the patient had to have his arm amputated. A simple fracture that because of a lack of access resulted in the patient losing his dominant arm. I saw a child with isolated growth hormone deficiency - 12 years old and less than 3 feet tall. I saw an 11 month old baby with vitamin B12 deficiency (mother was breastfeeding but was B12 deficient due to being a lifelong vegetarian). And finally I saw a woman in her mid-30s with a post-polio residual palsy. Mid-30s and had polio. It was a great day for learning and seeing some really interesting medicine and on the drive back to St. John’s, the frustrations seemed to take a backseat to my excitement for this incredible learning opportunity.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://2.bp.blogspot.com/-Pi2uLmLMYFg/TxwxgXqHfGI/AAAAAAAAA9Q/s0m_DfaJiuA/s1600/IMG_3157.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="216" src="http://2.bp.blogspot.com/-Pi2uLmLMYFg/TxwxgXqHfGI/AAAAAAAAA9Q/s0m_DfaJiuA/s320/IMG_3157.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Sandhya and me</td></tr>
</tbody></table><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">After arriving back at the hospital, I went to Patima’s office to finish up my paperwork. She gave me my name badge and my posting letter for ortho to start on Monday. My proof of address letter still needed to be signed so she asked me to stop by Saturday morning to pick it up. I walked back to the Annex III and ran into a couple of the German students that I had met the night before. They were going out shopping and then to have dinner with the rest of the German students and a Nigerian student that was leaving on Saturday. They invited me to join them. I spent the rest of the afternoon with my new friends Julia and Sandhya who showed me around the neighborhood, where I needed to go to get a phone and internet, and had a blast! We ate dinner at a restaurant nearby the hospital and I met the other students. It was a great evening that ended with making plans for Saturday: lunch, more shopping, and an evening out at one of the clubs in Bangalore.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="http://1.bp.blogspot.com/-0fLaxRu7XOY/Txwx99qmxCI/AAAAAAAAA9o/wItrnvTRQdk/s1600/IMG_3168.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="240" src="http://1.bp.blogspot.com/-0fLaxRu7XOY/Txwx99qmxCI/AAAAAAAAA9o/wItrnvTRQdk/s320/IMG_3168.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">my room in the Annex</td></tr>
</tbody></table><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">Saturday morning I went to Patima’s office to get my letter. When I walked in, she told me that it wasn’t ready and that I could pick it up on Monday. I told her that it takes a few days to get a working phone once you submit your application for the SIM card and I really couldn’t wait until Monday to get the process started because everything in India seems to require a working phone. She then checked at the dean’s office and...surprise, surprise...the letter was signed. She had not checked prior to my arrival that morning as she had claimed. I have learned that I need to be insistent and persistent bordering on rude in order to get things done. I took my letter and walked to the Airtel store that Julia had said to go to to get a SIM card. I was anticipating the worst at the phone place and was pleasantly surprised. The woman who helped me filled out my application for me to be sure that it was filled out correctly. She asked me for the names and numbers of (Indian) friends in Bangalore. I told her I had just arrived and didn’t know anyone. She said she just needed one name and one phone number. I pulled out my piece of paper with Dr. Sanjiv’s phone number written on it and wrote his name and number down. I also found my piece of paper with the guy I met on Thursday who bought my coffee and wrote down his name and number. She told me my SIM would likely be working by Saturday evening. I bought a simple Nokia phone and had the SIM card inserted and crossed my fingers that my application would be approved.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-Cm7Yp0HieK4/TxwyQj5QhOI/AAAAAAAAA94/SQ_Mb5FjrPA/s1600/IMG_3170.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-Cm7Yp0HieK4/TxwyQj5QhOI/AAAAAAAAA94/SQ_Mb5FjrPA/s320/IMG_3170.jpg" width="240" /></a></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">I walked back to the hospital and met Julia, Sandhya, and another German student Ruby for lunch at the hospital canteen. We then left for shopping on Commercial Street. Getting a rickshaw to take us to Commercial St. was a process. Some of the drivers didn’t want to go and others refused to use the meter. After about 10-15 minutes of failed attempts to find a rickshaw that would use the</span><span style="color: #134f5c; font-family: Verdana, sans-serif;"> </span><span style="color: #134f5c; font-family: Verdana, sans-serif;">meter (which they are required by law to use), we finally got one and made it to Commercial St. It is a busy shopping area with a combination of western and Indian stores as well as roadside stalls for market bazaar type shopping. Like everywhere in India, it was crowded with people, cars, and dust. Every store we walked into, we were immediately accosted by salespeople who stand uncomfortably close to you and try to help you shop even when you politely decline their help. There is great shopping in India but it really is an exhausting experience. Needing some comfort, we went to McDonald’s for lunch. I never eat at McDonald’s at home, but after being surrounded by the unfamiliar, I needed something familiar. I treated myself to fries and a Fanta orange float. While we were out shopping, I received a text message informing me that my application was approved and my phone was now working! We stopped for coffee at a Cafe Coffee Day and I was excited to try out my phone. I asked for an internet login after ordering (the sign on the door said free WiFi) and was told that they didn’t have WiFi. I started arguing - I mentioned that the sign on the door said there was WiFi. I was then told that I would have to pay 27 rupees for an access card to use the WiFi. I argued again stating that the sign said the WiFi was free. Not getting anywhere, I told the coffee shop worker to forget it. For every good experience, I have at least 3 frustrating ones...</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">After shopping, we headed back to the Annex III with the same frustrating arguing to find a rickshaw to bring us back to the hospital. We had about an hour before we needed to head out to meet up with Julia and Sandhya’s friends at the club. </span><span style="color: #134f5c; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjv7d_opBdaMUDKCIyYtYYJTNka63rAZ4-zQZ05jql4dlyZ-cEpZQWW0koA44bW6C-zqja40wkNxkG3Dx9c9ia7O7Gi8sVX76W6sN-ZUgwsbKtAGQ1QjnpYqRb6pfa5YJmmIelEIGI_EV7G/s1600/IMG_3169.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjv7d_opBdaMUDKCIyYtYYJTNka63rAZ4-zQZ05jql4dlyZ-cEpZQWW0koA44bW6C-zqja40wkNxkG3Dx9c9ia7O7Gi8sVX76W6sN-ZUgwsbKtAGQ1QjnpYqRb6pfa5YJmmIelEIGI_EV7G/s320/IMG_3169.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">handwashing clothes :-/</td></tr>
</tbody></table><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">The club we went to was a sports bar and there were soccer matches playing on every tv. The really nice thing about the bar is that they actually had free WiFi - WiFi that you didn’t need a password or a verifiable Indian phone number for! I did what I hate seeing other people do and immersed myself in my iPod - I checked emails, started sending IMs to people through messages. It’s amazing how dependent I have become on the internet for being connected. It makes it so much easier and I just feel closer to my friends and family when I am connected to the internet. After a while, I stopped being rude and enjoyed the company of my new friends. We had a great night. Bar close in Bangalore is 11:30pm which meant we got back to the Annex at a reasonable time and could get a good night of sleep.</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">This morning (Sunday), I decided to tackle getting my internet. I walked to the store in the Forum Mall that Julia told me to go to for getting the 3G internet stick. I was a little worried because I had foolishly given my only copy of my proof of address letter to Airtel the day before for my phone. Airtel was closed on Sundays so I was unable to get the letter back from them. Julia had not needed her letter in order to get the internet, so I was hoping that it would be the same for me. For 1000 rupees ($20), I could get the TaTa DoComo internet. At first I was told that I didn’t need the letter - that my passport copy, photo, and verifiable phone were enough. Then I was told that I needed the letter and would not be able to get the internet stick. I explained that I gave my letter to Airtel and that they were closed on Sundays so I could not get the letter back from them. I also explained that the person I needed to get another letter from at the hospital was not working on Sunday so I probably could not get another letter until Tuesday. I asked if there was any way around it. The sales clerk told me that if I got the Airtel 3G stick and paid 1500 rupees, I would not need the letter. Fine. More leeching of money. But it is oh so worth it to be connected to the internet in the comfort of my room!</span><span style="color: #134f5c; font-family: Verdana, sans-serif;"> </span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;"><br />
</span></div><div class="p1"><span style="color: #134f5c; font-family: Verdana, sans-serif;">Final note for any of you traveling to India. When you go out to eat, you have to look at the menu because oftentimes large parts of the menu are unavailable at certain times of the day. Tonight Julia, Sandhya, and I went to eat at 5:30. Over half the menu was not available between 3:30 and 7. Also, it is not infrequent to go to a restaurant and try to order something only to be told that they are out. As Sandhya likes to say, it’s all part of the experience... Namaste.</span></div></div>Bethhttp://www.blogger.com/profile/06680637961207457902noreply@blogger.com0Bengaluru, Karnataka, India12.9715987 77.59456269999998312.7518902 77.342821199999989 13.191307199999999 77.846304199999977