Hello Readers,
Well as most of you know I'm back in Houston. It has been wonderful being back. I'm enjoying the a/c and although it's somewhat hot in my mind I'm always saying "it's not as bad as India". These are some things I'm not missing: the heat, the touts, the traffic, the noise, the smells, the showering with buckets, the wearing bug spray everyday.
Apart from all this the experience was amazing. I loved the buildings, the architecture, the history, the diversity of the people, the colorful saris, the carefree nature of my trip. I had been looking forward to India for such a long time that now I can't believe that I've lived it. It was more than visiting as a tourist, I had the opportunity to live in an Indian city for three weeks and interact with people on a day to day basis. I met wonderful and interesting people. Through my travels the most evident lesson became that life isn't easy for any of us. Whether we live in India or the US; whether we have money or desperately need it we all face challenges. This might seem like a downer to some, but to me it's comforting in a way. It's good to know that people face obstacles even larger than the ones I face and they make it! They do it with positive attitudes and maintain an optimism that inspires me to live a better life. Also, I can't help but think that because of these challenges relationships become so important. It's been through the support of family and friends that I've been able to reach this point in my life.
Well I will stop with all this mushy stuff for the blog but I just want everyone to know how thankful I am for my life. I am truly blessed.
Happy Mother's Day!
Sunday, May 11, 2008
Wednesday, May 7, 2008
The Assignment: Dengue Fever
Dengue is the most prevalent mosquito-borne viral illness. The viral etiology of dengue fever was established in the 1940’s and dengue-like illnesses date back over 200 years. Each year over 100 million dengue infections occur worldwide. It is said that every year 2.5 billion people are at risk for the infection.
EPIDEMIOLOGY
Dengue viruses are members of the family Flaviviridae, genus flavivirus. Four antigenically related but distinct dengue viruses exist. All dengue viruses are mosquito-borne human pathogens that cause an exclusively acute infection. The dengue viruses are maintained through the human-mosquito-human cycle and involve mosquitos of the genus Aedes. Transmission of the virus can occur between mosquitoes and nonhuman primates but no evidence exists that this is an important reservoir for transmission to humans.
Aedes aegypti mosquitoes have many characteristics that make them ideal for dissemination of the virus. A. aegypti usually breed in proximity to houses, laying eggs in water containers. A. aegypti are daytime feeders that prefer to bite humans are frequently unnoticed. They frequently take multiple blood meals in a single breeding cycle. For this reason, A. aegypti mosquitoes are able to transmit dengue virus to several individuals in a small area.
aegypti are widely distributed in tropical and subtropical areas.
TRANSMISSION PATTERNS
Epidemic dengue- this type of transmission occurs when dengue virus is introduced into a region as an isolated event involving a single virus strain. When large populations of susceptible hosts and mosquitoes are present transmission of dengue becomes explosive. In this kind of transmission the incidence of infection among susceptible individuals often reaches 25 to 50 percent.
This pattern predominated the transmission of dengue in the pre-WWII era. Initial introduction of the dengue virus frequently occurred at seaports and port cities acted as distribution points for inland areas. Epidemic transmission currently predominates virus transmission in certain parts of South America and Africa and smaller island nations. The incidence of the virus varies considerably from year to year and the risk for acquisition of the virus for travelers is high during an epidemic but low at other times.
Hyperendemic dengue- this type of transmission refers to the continuous circulation of multiple dengue virus serotypes in the same area. This type of transmission requires the year-round presence of competent vector mosquitoes and a large population base. Arease with hyperendemic dengue virus transmission contribute to the majority of cases of dengue worldwide. The overall risk for acquisition for travelers is higher in these areas.
CLINICAL PRESENTATION
The clinical manisfestation of dengue fever ranges from self-limited dengue fever to dengue hemorrhagic fever with shock. Research has indicated that all dengue virus infections are symptomatic. Age appears to be an important factor in the prevalence of symptomatic disease with children more likely to have asymptomatic disease. Symptoms typically occur between four and seven days after the bite of a mosquito although the incubation can range anywhere from 3 to 14 days. Dengue can be excluded as the cause of symptoms in a traveler developing illness more than 14 days after returning from a dengue-endemic region.
Classic Dengue: Classically dengue fever presents as an acute febrile illness with headache, retroorbital pain, and marked muscle and joint pain. The severe muscle and joint pain has cause dengue fever to be called “break bone fever”. The fever component of the illness typically lasts for 5 to 7 days. The febrile period can be followed by a period of marked fatigue that can last for days to weeks. Physical exam is usually non-specific but may include macular or maculopapular rash.
Hemorrhagic Dengue: Hemorrhagic manifestations are common in patients with dengue fever and are rarely life-threatening. Hemorrhagic manifestations include petechiae, ecchymoses, purpura, hematemesis, metrorrhagia, melena, and spontaneous bleeding. The risk of severe disease is higher in sequential dengue infection. The four cardinal features of Dengue hemorrhagic fever include increased vascular permeability, fever, hemorrhage, and marked thrombocytopenia
DIAGNOSIS
The diagnosis of acute dengue virus infection is primarily clinical. Often patients with dengue fever have a positive tourniquet test, leucopenia, thrombocytopenia, and increased AST level in comparison to patient’s with other febrile illnesses. In developing countries, dengue hemorrhagic fever is frequently diagnoses based upon classification established by the World Health Organization. When dengue virus infection is clinically suspected the patient is treated empirically.
Confirmation of acute dengue virus infection is most frequently accomplished with serology. The most frequently used serologic tests for the diagnosis of acute dengue virus infection are the hemagglutination inhibition (HI) assay and IgG or IgM enzyme immunoassays.
TREATMENT
There is no specific treatment available for Dengue fever therefore it is important to exclude other treatable causes. Other disease that present like dengue include malaria, thyphoid fever, and leptospirosis. Supportive treatments are available for the manifestations of dengue fever. Patients should be maintain their intake of fluids to prevent dehydration. Fever and myalgias can be managed with acetaminophen and aspirin and NSAIDs should be avoided because of the risk of bleeding complications. Most importantly patients should be carefully monitored for signs of complications. The period of maximum risk for shock is between the third and seventh day of illness near defervescence. Plasma leakage usually occurs during this period. Red Flags include severe abdominal pain, persistent vomiting, altered mental status. Other signs include elevation of hematocrit, severe thrombocytopenia, increased AST, and hypotension.
PREVENTION
The greatest risk for dengue virus infection is in individuals living in endemic areas not in travelers. Mosquito control is the most effective approach to prevention of transmission. A vaccine against all 4 serotypes does not yet exist, but it is currently in development.
http://www.cdc.gov/NCIDOD/DVBID/dengue/
EPIDEMIOLOGY
Dengue viruses are members of the family Flaviviridae, genus flavivirus. Four antigenically related but distinct dengue viruses exist. All dengue viruses are mosquito-borne human pathogens that cause an exclusively acute infection. The dengue viruses are maintained through the human-mosquito-human cycle and involve mosquitos of the genus Aedes. Transmission of the virus can occur between mosquitoes and nonhuman primates but no evidence exists that this is an important reservoir for transmission to humans.
Aedes aegypti mosquitoes have many characteristics that make them ideal for dissemination of the virus. A. aegypti usually breed in proximity to houses, laying eggs in water containers. A. aegypti are daytime feeders that prefer to bite humans are frequently unnoticed. They frequently take multiple blood meals in a single breeding cycle. For this reason, A. aegypti mosquitoes are able to transmit dengue virus to several individuals in a small area.
aegypti are widely distributed in tropical and subtropical areas.
TRANSMISSION PATTERNS
Epidemic dengue- this type of transmission occurs when dengue virus is introduced into a region as an isolated event involving a single virus strain. When large populations of susceptible hosts and mosquitoes are present transmission of dengue becomes explosive. In this kind of transmission the incidence of infection among susceptible individuals often reaches 25 to 50 percent.
This pattern predominated the transmission of dengue in the pre-WWII era. Initial introduction of the dengue virus frequently occurred at seaports and port cities acted as distribution points for inland areas. Epidemic transmission currently predominates virus transmission in certain parts of South America and Africa and smaller island nations. The incidence of the virus varies considerably from year to year and the risk for acquisition of the virus for travelers is high during an epidemic but low at other times.
Hyperendemic dengue- this type of transmission refers to the continuous circulation of multiple dengue virus serotypes in the same area. This type of transmission requires the year-round presence of competent vector mosquitoes and a large population base. Arease with hyperendemic dengue virus transmission contribute to the majority of cases of dengue worldwide. The overall risk for acquisition for travelers is higher in these areas.
CLINICAL PRESENTATION
The clinical manisfestation of dengue fever ranges from self-limited dengue fever to dengue hemorrhagic fever with shock. Research has indicated that all dengue virus infections are symptomatic. Age appears to be an important factor in the prevalence of symptomatic disease with children more likely to have asymptomatic disease. Symptoms typically occur between four and seven days after the bite of a mosquito although the incubation can range anywhere from 3 to 14 days. Dengue can be excluded as the cause of symptoms in a traveler developing illness more than 14 days after returning from a dengue-endemic region.
Classic Dengue: Classically dengue fever presents as an acute febrile illness with headache, retroorbital pain, and marked muscle and joint pain. The severe muscle and joint pain has cause dengue fever to be called “break bone fever”. The fever component of the illness typically lasts for 5 to 7 days. The febrile period can be followed by a period of marked fatigue that can last for days to weeks. Physical exam is usually non-specific but may include macular or maculopapular rash.
Hemorrhagic Dengue: Hemorrhagic manifestations are common in patients with dengue fever and are rarely life-threatening. Hemorrhagic manifestations include petechiae, ecchymoses, purpura, hematemesis, metrorrhagia, melena, and spontaneous bleeding. The risk of severe disease is higher in sequential dengue infection. The four cardinal features of Dengue hemorrhagic fever include increased vascular permeability, fever, hemorrhage, and marked thrombocytopenia
DIAGNOSIS
The diagnosis of acute dengue virus infection is primarily clinical. Often patients with dengue fever have a positive tourniquet test, leucopenia, thrombocytopenia, and increased AST level in comparison to patient’s with other febrile illnesses. In developing countries, dengue hemorrhagic fever is frequently diagnoses based upon classification established by the World Health Organization. When dengue virus infection is clinically suspected the patient is treated empirically.
Confirmation of acute dengue virus infection is most frequently accomplished with serology. The most frequently used serologic tests for the diagnosis of acute dengue virus infection are the hemagglutination inhibition (HI) assay and IgG or IgM enzyme immunoassays.
TREATMENT
There is no specific treatment available for Dengue fever therefore it is important to exclude other treatable causes. Other disease that present like dengue include malaria, thyphoid fever, and leptospirosis. Supportive treatments are available for the manifestations of dengue fever. Patients should be maintain their intake of fluids to prevent dehydration. Fever and myalgias can be managed with acetaminophen and aspirin and NSAIDs should be avoided because of the risk of bleeding complications. Most importantly patients should be carefully monitored for signs of complications. The period of maximum risk for shock is between the third and seventh day of illness near defervescence. Plasma leakage usually occurs during this period. Red Flags include severe abdominal pain, persistent vomiting, altered mental status. Other signs include elevation of hematocrit, severe thrombocytopenia, increased AST, and hypotension.
PREVENTION
The greatest risk for dengue virus infection is in individuals living in endemic areas not in travelers. Mosquito control is the most effective approach to prevention of transmission. A vaccine against all 4 serotypes does not yet exist, but it is currently in development.
http://www.cdc.gov/NCIDOD/DVBID/dengue/
Thursday, April 24, 2008
Goodbye Vellore
Hello Readers,
In honor of our time ending in Vellore I have decided to do a picture blog of life in Vellore. It has truly been an amazing experience living in this city for three weeks. It's considered a small city in India but with so many people and animals around I can't imagine. Here are some of my pics. Enjoy :)
This is a picture of our room at Aavana Inn. Not too bad. It has A/C and it's moderately priced. The staff is really nice and they always smile and wave at us. We brought our sheets from home and put them directly on the sheets that were already there. We have a tv and can get room service any time! The room is costing us almost 900 ruppees per day which is $23. This is between the two of us! Not bad!!!
This is a picture of a cow just strolling along infront of CMC hospital complex. This is a very common sight. The other day while we were at the travel agent's office a cow tried to come in the door! They just shooed it away. I especially like the little calfs. They're so cute!
This is a cute little monkey at CMC campus. We were on our way to have lunch when I spotted one of them. Suddenly there were more! I think 7 total. The men that work on the grounds were trying to help me find them all so I could take pictures. I'm sure to them it's not unusual to see monkeys walking around. This one is particularly cute because he's eating and just stuffing the food in his mouth! You can see his little cheeks puffing out full of food.
This is during one of our rickshaw rides to CMC campus from our hotel. Seeing people on motorcycles isn't uncommon, but seeing a woman driving one is. She's probably going to work like us. I like this!
This is one of the main market roads in Vellore. Look at all the people!!! It's always crazy especially when a 2 rickshaws, 3 motorcycles, and 4 bicycles are driving past you at the same time. I wish I had a recording of the sounds to go along with this picture. It's so noisy! It's mostly people yelling and talking and cars honking but it's so much noise!
This is a closer look at the flowers that people sell on the street. Women buy these and make beautiful garlands to put in their hair. The flowers smell so good and are so colorful!
This is a picture at the vegetable market we found in Vellore while walking one afternoon. There are countless stalls with people usually selling one or two different kinds of veggies. After we started taking pictures people were begging us to take their picture. I like this one because the green vegetable looks funny. It's like a cucumber with chickenpox!
Another picture at the market. This one is of chilis. HOT HOT HOT! They looked vibrant. At this store they also sold legumes like lentils!
A picture of a market in Vellore at dusk. There were people selling all sorts of fruit here. Apples, grapes, oranges, mangoes. I really wanted to try the mangoes but I didn't want to get sick.
This is a picture of the temple in Vellore. We were waiting until the temple opened at 3pm and it was so hot! The temple is beautiful both inside and out. It was a very interesting experience going inside. You had to go in barefoot and the ground was very hot! It was made of stone. We ran on tip toes while the Indian people walked calmly. They're very used to walking barefoot. In most stores we take our shoes off before entering.
This is the entry to the temple. You can see all the people waiting to go in. We paid two rupees each to have our shoes watched. One of our friends on a prior trip didn't do so and one of his shoes mysteriously disappeared.
This was taken from the Vellore Fort. It overlooks part of Vellore.
In honor of our time ending in Vellore I have decided to do a picture blog of life in Vellore. It has truly been an amazing experience living in this city for three weeks. It's considered a small city in India but with so many people and animals around I can't imagine. Here are some of my pics. Enjoy :)
This is a picture of our room at Aavana Inn. Not too bad. It has A/C and it's moderately priced. The staff is really nice and they always smile and wave at us. We brought our sheets from home and put them directly on the sheets that were already there. We have a tv and can get room service any time! The room is costing us almost 900 ruppees per day which is $23. This is between the two of us! Not bad!!!
This is a picture of a cow just strolling along infront of CMC hospital complex. This is a very common sight. The other day while we were at the travel agent's office a cow tried to come in the door! They just shooed it away. I especially like the little calfs. They're so cute!
This is a cute little monkey at CMC campus. We were on our way to have lunch when I spotted one of them. Suddenly there were more! I think 7 total. The men that work on the grounds were trying to help me find them all so I could take pictures. I'm sure to them it's not unusual to see monkeys walking around. This one is particularly cute because he's eating and just stuffing the food in his mouth! You can see his little cheeks puffing out full of food.
This is during one of our rickshaw rides to CMC campus from our hotel. Seeing people on motorcycles isn't uncommon, but seeing a woman driving one is. She's probably going to work like us. I like this!
This is one of the main market roads in Vellore. Look at all the people!!! It's always crazy especially when a 2 rickshaws, 3 motorcycles, and 4 bicycles are driving past you at the same time. I wish I had a recording of the sounds to go along with this picture. It's so noisy! It's mostly people yelling and talking and cars honking but it's so much noise!
This is a closer look at the flowers that people sell on the street. Women buy these and make beautiful garlands to put in their hair. The flowers smell so good and are so colorful!
This is a picture at the vegetable market we found in Vellore while walking one afternoon. There are countless stalls with people usually selling one or two different kinds of veggies. After we started taking pictures people were begging us to take their picture. I like this one because the green vegetable looks funny. It's like a cucumber with chickenpox!
Another picture at the market. This one is of chilis. HOT HOT HOT! They looked vibrant. At this store they also sold legumes like lentils! 
A picture of a market in Vellore at dusk. There were people selling all sorts of fruit here. Apples, grapes, oranges, mangoes. I really wanted to try the mangoes but I didn't want to get sick.
This is a picture of the temple in Vellore. We were waiting until the temple opened at 3pm and it was so hot! The temple is beautiful both inside and out. It was a very interesting experience going inside. You had to go in barefoot and the ground was very hot! It was made of stone. We ran on tip toes while the Indian people walked calmly. They're very used to walking barefoot. In most stores we take our shoes off before entering.
This is the entry to the temple. You can see all the people waiting to go in. We paid two rupees each to have our shoes watched. One of our friends on a prior trip didn't do so and one of his shoes mysteriously disappeared.
This was taken from the Vellore Fort. It overlooks part of Vellore.Wednesday, April 23, 2008
UPDATED: Giving Thanks
Vanakam Readers,
As you can imagine while in India I have realized how thankful I am for numerous things in my life. Underground sewers, air conditioning, clean drinking water, clean roadside bathrooms, people who speak my language, reliable electricity, living near my friends and family, paved roads, the absence of farm animals on the roads (no cows or donkeys). Through these past weeks I've continued to realize how blessed I am to have been born into my family. Life would be a lot different if I was born to a village family in India. For one I wouldn't have all the opportunities that have brought me to this point in my life. I'm less than a month away from graduating medical school and I know this is a great accomplishment both for myself and all the people that have helped me along this journey.
Little did I know that through this trip I would experience the gratefulness of just being alive. Of being able to breath and eat and talk and walk. Of being able to speak with my family and discuss menial things with my friends. As some of you may have learned from my fellow travellers' blogs we were in a serious car accident this past Monday morning. Let me begin by saying that we are all doing okay. We were all able to walk away from the wreck and from the pictures you will see in this blog that is truly a miracle!
This past weekend we travelled to the state of Kerala to go on a houseboat. This is truly considered a once in a lifetime experience. And is considered to be one of the top 50 things to do before you die. Kinda' erie thinking about that after what happened but the point is that the houseboat experience is truly something unique and amazing!. The houseboat accommodations had been arranged by a friend of another UTHSCSA student. Everything was paid for, but we had to arrange our own travel to Kerala. We tried to get train tickets, but were unable to do so because graduation for the school of nursing occurred the Wednesday before the trip so a lot of students were travelling back home to Kerala. Our other option was to rent a van where we could all travel and drive overnight. For some reason this seemed like a valid idea. Although I was not happy about the 15 hour journey I knew that once we got to the houseboat it would be well worth it.
The drive to Kerala was quite scary. We left an hour later than we had planned. I slept uncomfortably through most of the night and woke up in the early morning. As soon as I woke up I noticed that the driver seemed very sleepy. His eyelids looked heavy and they kept closing. I knew he was fighting sleep, but I encouraged him to stop for coffee and for little breaks. Sometimes I would just ask him a question to try and wake him up. We made it to Kerala later than we had planned and had a great time. I will do another post on that because Kerala was simply amazing. We spent the night on the houseboat and Saturday spent the day at our new Keralan friend's house.
Our big mistake came when we decided to leave Sunday at 4 pm. We had originally planned to leave early Sunday morning, but our friend had arranged ayurvedic massages for us that morning. (I do not hold our friend liable for what happened to us. The whole purpose of the massages and our trip was to give us the full experience of Kerala. He and his family were hospitable and friendly. They did so much for us. I am truly thankful to them for their outstanding hospitality.) We all talked about the decision to stay later and were in agreement that we wanted to do so. Discussing it now, some of us shared our apprehension of that decision. The thing is that no one really shared that with the group when the decision was originally being made.
So when ended up leaving Kerala at around 4pm as planned. We stopped for dinner at around 8 or so and had a nice meal. After that we watched movies in our van. At around midnight most people went to sleep. We stopped again at around 2:30 am. I and others noticed that we had done so and asked the driver why we had stopped. He seemed to plead with us "10 minute sleep". Which was really fine by me.
Next thing I remember is a deep pain in my chest and the feeling that I couldn't breath. I promptly removed my shades that had been covering my eyes and saw chaos all around me. Slowly I realized that we had been in a wreck and saw the cargo truck we had hit right in front of me. With my left hand I reached forward and touched it with my fingers. The steel felt smooth and warm. There was a hissing sound as if gas were escaping from somewhere in front of me. I heard my friends screaming. I quickly put on my glasses that I had tucked in my shirt before going to sleep. Dinesh was trying to wake up Chris who was in the aisle next to me. Chris had been sitting behind me. Anne was standing up and yelling. She was saying she couldn't breathe. I think this awoke something in me. I told her to calm down and breath slowly. Then I knew. I was in pain. An accident had occurred. It was serious. I needed to get out. I tried to figure out how I was going to get out. The door we used to get in was in front of me exactly where the truck had hit. This was not an option. I could only somehow climb out the back. Thankfully my shoes were still under my seat. A miracle considering the force with which we hit! I put them on and grabbed my purse on the way out.
As I climbed over the back seat into the small trunk the doors were open. I could barely see a bunch of Indian men in front of me for I was feeling dizzy. They were all staring and saying things in Tamil which I couldn't understand. I remember being mad because none of them would help me. They just kept staring! I saw it was still dark and jumped off the van. I saw our bags on the side of the road and a man pointing to them as if he was guarding them for us. I needed to sit down. I sat with my back to the accident. I couldn't stand looking at it! It was just too much. As Vida came and sat next to me she started to yell at people to call an ambulance. I think I started to yell too. Together we figured out who we could call to help us. This is most of what I remember until the ambulance got there. I'm not sure about time or how long anything took.
The ambulance got there and we all somehow managed to climb in. Everyone was talking and discussing. And it helped to distract me from all that was happening. I know I ate a cherry jolly rancher (my favorite) someone offered me on the way to the hospital. Thankfully we were only 80 km from CMC in Vellore and we made the decision to travel here. I have to say I had no part in this decision. I was still in shock.
When we got to CMC everyone was staring at us. We had called ahead to arrange for people to be waiting for us, but no one was there. We had to wait to get a wheel chair and stretchers. There were three of us that were seriously hurt. Chris, Michael (Swami), and me. We were also concerned about Jami who had low platelets due to a medical condition. It took a while for us to get seen. The account of what happened in the ER will probably be more reliable from other friends because I didn't really know what was happening. I had been knocked out and I had my glasses on which always makes me feel out of it. The thing I do remember is that before they did anything to me we had to pay. My friends took care of this so I just laid in the stretcher. Before being seen by doctor you must pay. Before drawing blood you must pay. Before getting shots you must pay. Before getting oxygen you must pay. Before getting x-rays you must pay. Before echo you must pay. Also there was no A/C in the ER! It was so hot!!! It just made me feel worse overall.
After everything was said and done I got a tetanus shot, morphine, ecg, 8 x-rays, echo of heart. Everything checked out fine and I was able to go to the hotel that afternoon with a prescription for an anti inflammatory. Since then I have felt okay. It's been two days since the accident and the things bothering me the most are the pain in my chest and headache. My left triceps, ribs, hip are bruised. My right knee also has a nasty bruise.
So these are things I learned/ realized from the experience..........
1. REAL experience of Indian patient
2. NEVER, NEVER, NEVER drive in India at night (especially long distances and overnight trip)
3. If you feel apprehensive about doing something share that feeling with others. Even if it's something small others may share what you're feeling.
4. Trust your gut. Trust yourself.
5. I have been given so much. From material things to people to my life!!!!
6. Miracles do happen!!!! And I am living proof :)
Okay, okay. Here are the pics I have of the accident.
This is a picture of my left upper arm. You can see the large bruise extending almost to my elbow (upper part of pic) to my shoulder. The abrasions were cause by the window that broke next to me. This morning I found a little piece of glass in the back of my head! Right after the accident my arm hurt a lot. I really thought it was broken!!! I could barely move it. Everything checked out okay. No broken bones!!! Miracle :)
This picture was taken by Jami. It's really scary once I tell you where I was sitting. See that crashed in window? You can see a seat in there? That's where I was sitting!!!!! So scary!!!! That's why this is a miracle! I'm so happy to be alive!!!
This picture was taken by Claire. This is us in the ambulance. I'm eating the cherry jolly rancher someone offered me. It seemed like a good idea to have some sugar. I'm still in shock here, but happy that we're all traveling together to CMC. Chris is wearing his "C-collar". In the US they normally have a plastic thing not a towel! Chris helped comfort me during the ride there. And held my hand like my brother would have if he had been there. Thank you Chris!!!
This is a picture of me at the hospital. (please excuse the double chin!) I'm already doing better and I'm about to be discharged home. I'm pointing at my IV. It hurt as much as in the US! I'm feeling hot and thirsty and out of it, but also very thankful. Claire had just showed me the picture of the crash and where I was sitting. Happy to be showing off my IV!
This is a picture of me a couple of days after the accident. Still hurting and can't really make sudden movements but doing fine. This is infront of a restaurant we really like because of the yummy food and the picture of the cats with guns! So funny!
As you can imagine while in India I have realized how thankful I am for numerous things in my life. Underground sewers, air conditioning, clean drinking water, clean roadside bathrooms, people who speak my language, reliable electricity, living near my friends and family, paved roads, the absence of farm animals on the roads (no cows or donkeys). Through these past weeks I've continued to realize how blessed I am to have been born into my family. Life would be a lot different if I was born to a village family in India. For one I wouldn't have all the opportunities that have brought me to this point in my life. I'm less than a month away from graduating medical school and I know this is a great accomplishment both for myself and all the people that have helped me along this journey.
Little did I know that through this trip I would experience the gratefulness of just being alive. Of being able to breath and eat and talk and walk. Of being able to speak with my family and discuss menial things with my friends. As some of you may have learned from my fellow travellers' blogs we were in a serious car accident this past Monday morning. Let me begin by saying that we are all doing okay. We were all able to walk away from the wreck and from the pictures you will see in this blog that is truly a miracle!
This past weekend we travelled to the state of Kerala to go on a houseboat. This is truly considered a once in a lifetime experience. And is considered to be one of the top 50 things to do before you die. Kinda' erie thinking about that after what happened but the point is that the houseboat experience is truly something unique and amazing!. The houseboat accommodations had been arranged by a friend of another UTHSCSA student. Everything was paid for, but we had to arrange our own travel to Kerala. We tried to get train tickets, but were unable to do so because graduation for the school of nursing occurred the Wednesday before the trip so a lot of students were travelling back home to Kerala. Our other option was to rent a van where we could all travel and drive overnight. For some reason this seemed like a valid idea. Although I was not happy about the 15 hour journey I knew that once we got to the houseboat it would be well worth it.
The drive to Kerala was quite scary. We left an hour later than we had planned. I slept uncomfortably through most of the night and woke up in the early morning. As soon as I woke up I noticed that the driver seemed very sleepy. His eyelids looked heavy and they kept closing. I knew he was fighting sleep, but I encouraged him to stop for coffee and for little breaks. Sometimes I would just ask him a question to try and wake him up. We made it to Kerala later than we had planned and had a great time. I will do another post on that because Kerala was simply amazing. We spent the night on the houseboat and Saturday spent the day at our new Keralan friend's house.
Our big mistake came when we decided to leave Sunday at 4 pm. We had originally planned to leave early Sunday morning, but our friend had arranged ayurvedic massages for us that morning. (I do not hold our friend liable for what happened to us. The whole purpose of the massages and our trip was to give us the full experience of Kerala. He and his family were hospitable and friendly. They did so much for us. I am truly thankful to them for their outstanding hospitality.) We all talked about the decision to stay later and were in agreement that we wanted to do so. Discussing it now, some of us shared our apprehension of that decision. The thing is that no one really shared that with the group when the decision was originally being made.
So when ended up leaving Kerala at around 4pm as planned. We stopped for dinner at around 8 or so and had a nice meal. After that we watched movies in our van. At around midnight most people went to sleep. We stopped again at around 2:30 am. I and others noticed that we had done so and asked the driver why we had stopped. He seemed to plead with us "10 minute sleep". Which was really fine by me.
Next thing I remember is a deep pain in my chest and the feeling that I couldn't breath. I promptly removed my shades that had been covering my eyes and saw chaos all around me. Slowly I realized that we had been in a wreck and saw the cargo truck we had hit right in front of me. With my left hand I reached forward and touched it with my fingers. The steel felt smooth and warm. There was a hissing sound as if gas were escaping from somewhere in front of me. I heard my friends screaming. I quickly put on my glasses that I had tucked in my shirt before going to sleep. Dinesh was trying to wake up Chris who was in the aisle next to me. Chris had been sitting behind me. Anne was standing up and yelling. She was saying she couldn't breathe. I think this awoke something in me. I told her to calm down and breath slowly. Then I knew. I was in pain. An accident had occurred. It was serious. I needed to get out. I tried to figure out how I was going to get out. The door we used to get in was in front of me exactly where the truck had hit. This was not an option. I could only somehow climb out the back. Thankfully my shoes were still under my seat. A miracle considering the force with which we hit! I put them on and grabbed my purse on the way out.
As I climbed over the back seat into the small trunk the doors were open. I could barely see a bunch of Indian men in front of me for I was feeling dizzy. They were all staring and saying things in Tamil which I couldn't understand. I remember being mad because none of them would help me. They just kept staring! I saw it was still dark and jumped off the van. I saw our bags on the side of the road and a man pointing to them as if he was guarding them for us. I needed to sit down. I sat with my back to the accident. I couldn't stand looking at it! It was just too much. As Vida came and sat next to me she started to yell at people to call an ambulance. I think I started to yell too. Together we figured out who we could call to help us. This is most of what I remember until the ambulance got there. I'm not sure about time or how long anything took.
The ambulance got there and we all somehow managed to climb in. Everyone was talking and discussing. And it helped to distract me from all that was happening. I know I ate a cherry jolly rancher (my favorite) someone offered me on the way to the hospital. Thankfully we were only 80 km from CMC in Vellore and we made the decision to travel here. I have to say I had no part in this decision. I was still in shock.
When we got to CMC everyone was staring at us. We had called ahead to arrange for people to be waiting for us, but no one was there. We had to wait to get a wheel chair and stretchers. There were three of us that were seriously hurt. Chris, Michael (Swami), and me. We were also concerned about Jami who had low platelets due to a medical condition. It took a while for us to get seen. The account of what happened in the ER will probably be more reliable from other friends because I didn't really know what was happening. I had been knocked out and I had my glasses on which always makes me feel out of it. The thing I do remember is that before they did anything to me we had to pay. My friends took care of this so I just laid in the stretcher. Before being seen by doctor you must pay. Before drawing blood you must pay. Before getting shots you must pay. Before getting oxygen you must pay. Before getting x-rays you must pay. Before echo you must pay. Also there was no A/C in the ER! It was so hot!!! It just made me feel worse overall.
After everything was said and done I got a tetanus shot, morphine, ecg, 8 x-rays, echo of heart. Everything checked out fine and I was able to go to the hotel that afternoon with a prescription for an anti inflammatory. Since then I have felt okay. It's been two days since the accident and the things bothering me the most are the pain in my chest and headache. My left triceps, ribs, hip are bruised. My right knee also has a nasty bruise.
So these are things I learned/ realized from the experience..........
1. REAL experience of Indian patient
2. NEVER, NEVER, NEVER drive in India at night (especially long distances and overnight trip)
3. If you feel apprehensive about doing something share that feeling with others. Even if it's something small others may share what you're feeling.
4. Trust your gut. Trust yourself.
5. I have been given so much. From material things to people to my life!!!!
6. Miracles do happen!!!! And I am living proof :)
Okay, okay. Here are the pics I have of the accident.
This is a picture of my left upper arm. You can see the large bruise extending almost to my elbow (upper part of pic) to my shoulder. The abrasions were cause by the window that broke next to me. This morning I found a little piece of glass in the back of my head! Right after the accident my arm hurt a lot. I really thought it was broken!!! I could barely move it. Everything checked out okay. No broken bones!!! Miracle :)This picture was taken by Jami. It's really scary once I tell you where I was sitting. See that crashed in window? You can see a seat in there? That's where I was sitting!!!!! So scary!!!! That's why this is a miracle! I'm so happy to be alive!!!
This picture was taken by Claire. This is us in the ambulance. I'm eating the cherry jolly rancher someone offered me. It seemed like a good idea to have some sugar. I'm still in shock here, but happy that we're all traveling together to CMC. Chris is wearing his "C-collar". In the US they normally have a plastic thing not a towel! Chris helped comfort me during the ride there. And held my hand like my brother would have if he had been there. Thank you Chris!!!
This is a picture of me at the hospital. (please excuse the double chin!) I'm already doing better and I'm about to be discharged home. I'm pointing at my IV. It hurt as much as in the US! I'm feeling hot and thirsty and out of it, but also very thankful. Claire had just showed me the picture of the crash and where I was sitting. Happy to be showing off my IV!
This is a picture of me a couple of days after the accident. Still hurting and can't really make sudden movements but doing fine. This is infront of a restaurant we really like because of the yummy food and the picture of the cats with guns! So funny!
Wednesday, April 16, 2008
UPDATED: The One You've Been Waiting For!!!!
PICTURE BLOG!!!!!!!!!!!!!
This is idly. This is my typical breakfast at the canteen on CMC campus. Idly are the little white cakes on the pic. They're made of rice. You eat them with your hand (right if you're Indian and don't use toilet paper) and dip them into the little sauces. I know the white one has coconut and the bright orange one is a little spicy. The juice on the left is sweet lime. So yummy and refreshing in the morning!
This is the front of the CHAD hospital. There is also another wing to the left for the outpatient clinics. We would wait under a big tree (from where I took this picture) for the jeep/bus for nurses'/doctors' rounds in the villages. The front doesn't look bad, but there was an old lady with a naked little boy in front begging. We were told not to give money to the beggars.
This is at one of the homes during nurse's rounds. Here we're sitting at one of the doorways. At this home the nurse (Nancy) standing in the blue sari neds to give one of the women an injection (vitamin B12). We went with her to watch. After the entry way there was a courtyard that led to other rooms. The lady brought out a little straw mat where she layed down directly on the floor. Nancy had forgotten the file to open the vial (in the US you usually don't need one, but it's probaly cheaper to get the vials that use a file). Finally we got it open with a pair of scissors the lady had stashed somewhere.
This is during nurses' rounds. We are walking through the first village for the day. From left to right in the background: Nursing student (her sari is blue with white polkadots), Nurse (blue sari w/out polkadots), health aid (pink sari). The lady closest to me is the social health worker. She knows all the people in the village and represent about 2000 people in the surrounding area. Her job is to know when women are pregnant, if there is a death, marriage in the villages she respresents and to let the health aide know of any social problems affecting the people in her area. As you can tell from the umbrellas it was VERY hot under the searing sun and the umbrellas helped. Anne and I didn't bring one, but the nurse graciously let us borrow hers.
This is us walking to a remote home in one of the villages. The heat was really beating down on us, but as you can tell it was a breathtaking landscape. After we were done with the prenatal exam at this home, her husband cut some fresh coconut for us. They were worried for us because of the heat.
This is a picture during that walk from above. It's just beautiful. It really looks tropical and except for the saris I felt like I was in Latin America.
During Doctor's Clinic in one of the villages. When we arrived on the mobile clinic there were patients waiting for us. More soon arrived. Here the doctor is looking over a patient's chronic health record. You can also see the BP cuff with mercury!!!! I think the little girl in orange with the flowers in her hair is so cute. The doctor was nice, but a bit paternalistic. We saw atleast 200 patients that day!
This is a cute little girl waiting to see the doctor. She had come directly from school and was still wearing her uniform. I love the flowers in her hair! Just lovely. Her parents seemed pleased when I took her picture. I think it might seem like an honor to them.
This is during doctor clinic in one of the villages. We had arrived about 20 minutes prior and the doctors had set up a table to the left of where this was taking place. Here a student nurse (Susan) in the blue sari & white shirt is teaching the women about anemia in pregnancy. She spoke Tamil as she did this and used picture cards to reinforce what she was saying. This is an important part of the rounds bc most of these women are uneducated. You can also see the beautiful flowers many women wear in their hair. They wear them for decoration and bc they smell good!
This is the emergency room waiting area at the large CMC hospital. You can see the countless people just waiting in the heat! During midday it gets to about 97 degrees or more. In the shade it does feel a lot better, but still HOT HOT HOT. The large CMC hospital is really more like a medical complex with many facilities. They have CT scan, MRI, operating rooms, out patient clinics (lots), library, leprosy rehab clinic, etc.
This is idly. This is my typical breakfast at the canteen on CMC campus. Idly are the little white cakes on the pic. They're made of rice. You eat them with your hand (right if you're Indian and don't use toilet paper) and dip them into the little sauces. I know the white one has coconut and the bright orange one is a little spicy. The juice on the left is sweet lime. So yummy and refreshing in the morning! 
This is the front of the CHAD hospital. There is also another wing to the left for the outpatient clinics. We would wait under a big tree (from where I took this picture) for the jeep/bus for nurses'/doctors' rounds in the villages. The front doesn't look bad, but there was an old lady with a naked little boy in front begging. We were told not to give money to the beggars.
This is at one of the homes during nurse's rounds. Here we're sitting at one of the doorways. At this home the nurse (Nancy) standing in the blue sari neds to give one of the women an injection (vitamin B12). We went with her to watch. After the entry way there was a courtyard that led to other rooms. The lady brought out a little straw mat where she layed down directly on the floor. Nancy had forgotten the file to open the vial (in the US you usually don't need one, but it's probaly cheaper to get the vials that use a file). Finally we got it open with a pair of scissors the lady had stashed somewhere.
This is during nurses' rounds. We are walking through the first village for the day. From left to right in the background: Nursing student (her sari is blue with white polkadots), Nurse (blue sari w/out polkadots), health aid (pink sari). The lady closest to me is the social health worker. She knows all the people in the village and represent about 2000 people in the surrounding area. Her job is to know when women are pregnant, if there is a death, marriage in the villages she respresents and to let the health aide know of any social problems affecting the people in her area. As you can tell from the umbrellas it was VERY hot under the searing sun and the umbrellas helped. Anne and I didn't bring one, but the nurse graciously let us borrow hers.
This is us walking to a remote home in one of the villages. The heat was really beating down on us, but as you can tell it was a breathtaking landscape. After we were done with the prenatal exam at this home, her husband cut some fresh coconut for us. They were worried for us because of the heat. 
This is a picture during that walk from above. It's just beautiful. It really looks tropical and except for the saris I felt like I was in Latin America.
This is me with the healthaide. Her job is to keep statistics of the villages she represents (5000 people). She also helps in identifying problems in the villages and in setting up meetings to solve these problems. She knows all 5000 people personally! She has been a health aide for 25 years. After taking this picture she commented on how dark her skin was compared to mine. I think she looks beautiful!
During Doctor's Clinic in one of the villages. When we arrived on the mobile clinic there were patients waiting for us. More soon arrived. Here the doctor is looking over a patient's chronic health record. You can also see the BP cuff with mercury!!!! I think the little girl in orange with the flowers in her hair is so cute. The doctor was nice, but a bit paternalistic. We saw atleast 200 patients that day!
This is a cute little girl waiting to see the doctor. She had come directly from school and was still wearing her uniform. I love the flowers in her hair! Just lovely. Her parents seemed pleased when I took her picture. I think it might seem like an honor to them.
This is during doctor clinic in one of the villages. We had arrived about 20 minutes prior and the doctors had set up a table to the left of where this was taking place. Here a student nurse (Susan) in the blue sari & white shirt is teaching the women about anemia in pregnancy. She spoke Tamil as she did this and used picture cards to reinforce what she was saying. This is an important part of the rounds bc most of these women are uneducated. You can also see the beautiful flowers many women wear in their hair. They wear them for decoration and bc they smell good!
This is the emergency room waiting area at the large CMC hospital. You can see the countless people just waiting in the heat! During midday it gets to about 97 degrees or more. In the shade it does feel a lot better, but still HOT HOT HOT. The large CMC hospital is really more like a medical complex with many facilities. They have CT scan, MRI, operating rooms, out patient clinics (lots), library, leprosy rehab clinic, etc.
Tuesday, April 15, 2008
Internal Medicine
Yesterday and today I got the opportunity to see what the Internal Medicine service is like at the CMC hospital. Yesterday we had clinic. The clinic is located on the second floor of the non-airconditioned hospital. To get to the OPD (outpatient department) area we had to pass large waiting room areas. For every two rooms that made up the Internal Medicine Team II area there seemed to be at least 40 people waiting. This area was quite warm and stuffy. I'm sure the patients were thankful for the chairs. This part of the OPD is organized with six examining rooms on each side with a small inner hallway connecting the rooms. Doctors use the small inner hallway to get into the rooms because the waiting areas are very crowded. Each examining room is probably 12x12. Two residents share the room. They have two small tables facing each other against one side of the wall and they sit facing each other. Their desks are crowded with charts and other forms. They share a blood pressure cuff that looks like it was from the 1950's. It actually uses mercury! There is an old wooden examining table on the opposite wall. The only thing dividing this table from the rest of the room is a worn and dirty curtain. Aside from the dirty walls, scarce air, and minimal space the examining room looked much like the ones I'm used to. There were small bulletins informing doctors of clinical trials and a computer with the most recent lab results.
The two things that stood out the most to me were that the residents shared an examining room and saw patients at the same time. You can imagine that if the patient was there with a family member (usually the case) there would be at least 6 people crowded into this little space (without counting Anne and me). Forget HIPAA. There was very little privacy in this environment. The other thing that stood out is the number of patients seen by the residents each day. During a typical full day in clinic a CMC resident sees 40 patients!!!! This is compared to the 10 or so an American resident sees during a half day of clinic. What was more incredible is the number seen by the interns (first year residents). In the US it's usually 6 at the most (half day) while in India it can get up to 30 patients in a whole day!!! I can't even imagine having that kind of pressure on me during my first year of training.
Today we went to grand rounds with our team. This basically consists of the whole team rounding on each patient. Our team has 40 patients and it took over four hours to finish rounds. This includes a 15 minute tea break for the attending doctor. Our team was made up of residents, interns, medical students, nurses, visiting attending. 27 people in all!!!! As in the states the resident presents the patient to the attending doctor (head honcho) and then a discussion of the case ensues. This commonly involves the attending making suggestions and helping with the diagnosis and management as needed. The attending also asks the medical students questions (called "pimping" in the US) relating to the patient being discussed. This was much like it is done in the US except for a few minor differences.
The teaching during this time was excellent. I saw patients with many of the same conditions as in the US. Meningitis, pneumonia, thyrotoxicosis, stroke, diabetes to name a few. We also had two patients with snake bites! During Grand Rounds the topic of funding for the patient was openly discussed. I felt that these discussions weren't done with the purpose of withholding treatment. Rather it was done more as a realistic issue of which the family must be informed. Many times in the US it's seen as something taboo. Something that shouldn't by the doctor specially upfront.
The two things that stood out the most to me were that the residents shared an examining room and saw patients at the same time. You can imagine that if the patient was there with a family member (usually the case) there would be at least 6 people crowded into this little space (without counting Anne and me). Forget HIPAA. There was very little privacy in this environment. The other thing that stood out is the number of patients seen by the residents each day. During a typical full day in clinic a CMC resident sees 40 patients!!!! This is compared to the 10 or so an American resident sees during a half day of clinic. What was more incredible is the number seen by the interns (first year residents). In the US it's usually 6 at the most (half day) while in India it can get up to 30 patients in a whole day!!! I can't even imagine having that kind of pressure on me during my first year of training.
Today we went to grand rounds with our team. This basically consists of the whole team rounding on each patient. Our team has 40 patients and it took over four hours to finish rounds. This includes a 15 minute tea break for the attending doctor. Our team was made up of residents, interns, medical students, nurses, visiting attending. 27 people in all!!!! As in the states the resident presents the patient to the attending doctor (head honcho) and then a discussion of the case ensues. This commonly involves the attending making suggestions and helping with the diagnosis and management as needed. The attending also asks the medical students questions (called "pimping" in the US) relating to the patient being discussed. This was much like it is done in the US except for a few minor differences.
The teaching during this time was excellent. I saw patients with many of the same conditions as in the US. Meningitis, pneumonia, thyrotoxicosis, stroke, diabetes to name a few. We also had two patients with snake bites! During Grand Rounds the topic of funding for the patient was openly discussed. I felt that these discussions weren't done with the purpose of withholding treatment. Rather it was done more as a realistic issue of which the family must be informed. Many times in the US it's seen as something taboo. Something that shouldn't by the doctor specially upfront.
Sunday, April 13, 2008
Creature from outer space
Do you know what it feels like to be stared at? I mean unabashedly studied as if you were an alien or some foreign creature. Well I do. I am that foreign creature. Before this trip I knew that I would stick out. In the States I stand out because of my height, but even so I look like many of the people around me. Sometimes people are surprised to learn that I speak Spanish and that I look.....well.....white. Here in Southern India the color of my skin sets me apart from 99.9% of every other person on the street. While strolling through the bustling streets I always feel the weight of eyes on me. It's funny to see little boys and girls giggling at you. Sometimes it's like we're the amusement for these people, some sort of entertainment. Parents point us out to their kids so they can see what a light skinned person looks like. Sometimes they timidly come up to us and shake our hands saying "How are you?". Then they scamper away while giggling with their friends.
At other times it's more of an expression of confusion pasted on their faces. Their puzzling eyes wondering what in the world we're doing in their little town. They want us to hold their babies and have even asked me how I get my skin so white. A lady even brushed Anne's face in wonderment as we waited at a temple. People ask us to take pictures with them and sometimes even without them. It's like they want to show their friends back home that they did infact see a white person. It's not just a tale; now they have proof. At times I feel like I movie star. At other times I mumble under my breath "yes, I'm white. You're not seeing things".
I don't mind waving at the kids and smiling at the families, but what I do mind is when men stare with THAT look in their eye that makes you feel uncomfortable inside. Today while having lunch at a hotel this young guy (probably in his mid 20s-early 30s) kept looking over at Anne and me. And by looking I mean constantly staring. A staring that annoys and disgusts at the same time. I guess part of it is the way we were dressed. We were wearing sleeveless shirts!(uncommon in this part of India other than Mamallapuram). Well being the way I am I stared back and then rolled my eyes at him as I shook my head. I probably wouldn't have done this if I hadn't been with our classmate Chris (guy) and at a place where the waitstaff knows us. The guy proceeded to introduce himself to Chris and only talk to him about why we were there. It's hard being in this kind of culture.
I am enjoying myself and although at times it is an annoyance I don't much mind. Most people are friendly and find it an honor to talk with us. I hope that in some ways they can that we are humans just like them.
At other times it's more of an expression of confusion pasted on their faces. Their puzzling eyes wondering what in the world we're doing in their little town. They want us to hold their babies and have even asked me how I get my skin so white. A lady even brushed Anne's face in wonderment as we waited at a temple. People ask us to take pictures with them and sometimes even without them. It's like they want to show their friends back home that they did infact see a white person. It's not just a tale; now they have proof. At times I feel like I movie star. At other times I mumble under my breath "yes, I'm white. You're not seeing things".
I don't mind waving at the kids and smiling at the families, but what I do mind is when men stare with THAT look in their eye that makes you feel uncomfortable inside. Today while having lunch at a hotel this young guy (probably in his mid 20s-early 30s) kept looking over at Anne and me. And by looking I mean constantly staring. A staring that annoys and disgusts at the same time. I guess part of it is the way we were dressed. We were wearing sleeveless shirts!(uncommon in this part of India other than Mamallapuram). Well being the way I am I stared back and then rolled my eyes at him as I shook my head. I probably wouldn't have done this if I hadn't been with our classmate Chris (guy) and at a place where the waitstaff knows us. The guy proceeded to introduce himself to Chris and only talk to him about why we were there. It's hard being in this kind of culture.
I am enjoying myself and although at times it is an annoyance I don't much mind. Most people are friendly and find it an honor to talk with us. I hope that in some ways they can that we are humans just like them.
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