Ramakrishna Mission Hospital, Haridwar, India: Post 1: Tima
This blog was created to document our experiences during our global health rotation in Haridwar, India. My name is Fatima Karaki and I am a PGY-2 in Internal Medicine at Washington University in St Louis. Anita Sarathi, an Internal Medicine PGY-3, is also on this rotation and will be leaving posts as well. We are working at Ramakrishna Mission (RKM) Hospital in Haridwar, India for one month as part of the Global Health Scholars program at Washington University in St Louis. Our program became involved with this site via Drs. JK and Santosh Gupta, a cardiologist and pediatric endocrinologist, respectively, affiliated with the university. After retiring several years ago, they chose to devote their time to providing underserved care at RKM Hospital through their foundation, the Manav Seva Foundation. Dr JK Gupta is involved in quality improvement at the hospital, and Dr Santosh Gupta has established a diabetes program there. Through this blog we hope to convey some of our incredible experiences in underserved care, tropical medicine, and Indian culture during our time here. This blog reflects our personal experiences only, and we apologize in advance for any inaccuracies or omissions it may contain.
Each morning, we make rounds in the inpatient male and female wards and in the ER-- but the medical conditions we see here in Haridwar could not be more different from those we see in St Louis. For example, this morning during rounds we saw patients with P. falciparum malaria, amebic liver abscess, scrub typhi, and tuberculous meningitis. Clearly this is a world removed from the chest pain, CHF, COPD, pneumonia, cellulitis, etc that make up the bulk of admissions in St Louis. There are certainly patients here with similar conditions to those we see in the US, but their treatment falls far short of our standard of care. For example, we saw an elderly woman with a huge MCA CVA, but no physical or occupational therapy is available, and she is left with devastating hemiparesis and no chance for rehabilitation. A middle-aged man who presented with difficulty walking was diagnosed with cord compression on plain film, but since there is no orthopedic surgeon he is being treated only with a C-collar for cervical spine stabilization. Since RKM treats the poor and underserved, and is itself understaffed, the hospital is full of similarly devastating cases.
Today I was seeing one of my patients in the ER when I was distracted by an elderly patient in another bed who was moaning and agitated. It was clear that he was dying. One of the interns told me that he was admitted under a diagnosis of acute MI, and out of curiosity I opened his chart. He was a 70 year old male who had presented to an outside hospital about a week earlier with chest pain, with a large anterior STEMI on EKG. He did not receive fibrinolytics at that time and there was no nearby cath lab, so PCI was out of the question. Over the next several days his condition deteriorated, and by the time he was transferred to RKM he was in florid cardiogenic shock. When I saw him, his blood pressure was 80 systolic and he was oliguric. He was on an epinephrine drip at 5 ml/hr, dopamine at 30 ml/hr, and lasix at 10 ml/hr. He had received aspirin and a plavix load, but was not on a heparin drip. His labs showed an elevated total CK, but a troponin had never been checked because it was too expensive (500 rupees for a troponin, compared to 50 rupees for a CK). He had no central access and there were no plans to transfer him to the ICU. Interestingly, since arriving at RKM, his creatinine had risen from 3.5 to 5.0, but he was still on a lasix drip!
It was clear to everyone involved that this patient was headed in the wrong direction. We suggested to his attending physician that the patient appeared dehydrated, and requested discontinuation of the lasix drip along with a small bolus for rehydration. We also suggested discontinuation of the epinephrine drip and initiation of a heparin drip for ACS. Of course, coming in as an outsider and making management suggestions on another physician's patients can be a thorny business, but luckily our host Dr Gupta is well-known at RKM and was able to act as a mediator. We checked on the patient before leaving the hospital for the day, and his BP had recovered to 150s systolic; his dopamine was being titrated down.
I don't know if this patient will survive; it's possible that he will die of his massive MI regardless of our interventions. But what I found interesting was the attitude of the physicians at RKM. The attending physicians are clearly extremely astute and experienced, but there are only two attendings with an MBBS degree (MD equivalent). The rest of the physicians have a BAMS degree (Bachelor of Ayurveda Medicine and Surgery), which is a degree in holistic Ayurvedic medicine. A young BAMS intern was caring for this patient, and during all the action, I asked her opinion:
Me: What do you think?
BAMS: What do I think about what?
Me: What do you think about the patient?
BAMS: What do I think about the patient… what?
Me: What do you think about the patient's condition?
BAMS: ….. I think it's bad?
Me: What do you think we should do?
BAMS: ….
It's going to be an interesting month!
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