Pictures

Dr. Santosh Gupta's Type I Diabetes Support Group: Anita and Tima are on the left with the Drs. Gupta towards the center; we are surrounded by Dr Gupta's type I diabetes patients.

Post 3: Anita

Leg of dermatitis patient with possible leprosy.

Abdomen with hypopigmented patch of above patient.

Elderly female with MI that we transferred to the ICU.

Post #3:Anita


 Today we saw a couple of interesting cases again. On the inpatient ward, we were rounding with one of the senior physicians when we met a man, a sadhu, who was apparently complaining of odynophagia and hemoptysis. It sounded like he probably did have some oral candidiasis, and was being treated with hydrogen peroxide and an oral antifungal, and the symptoms seemed to be improving. The male head nurse was kind enough to go back with us and interpret for us so we could obtain a more detailed history and complete a physical exam on the patient. It turns out the patient was not having any symptoms of hemoptysis, nor of hematemisis. By the time we saw the patient, his oral candidiasis did look as if it had improved as there was no evidence of infection present. It seemed that his symptoms were improving, but when we asked him why he came into the hospital, he proceeded to show us his legs. Below is a picture of his legs. The patient claimed he had had various bouts of this skin condition for the past 12 years, it used to cover his body, but was getting better. He also had a hypopigmented patch on his torso. We thought this might be leprosy and went home to google pictures on the internet, and came up with a few differentials, but the most likely one seemed to be leprosy. We asked the attending doctor the next day, he seemed to think it was just an unspecified dermatitis, and he noted there was no palpable poplitleal nerve. Neither of us were able to find much out about this physical finding, but it does not seem the lack of such a finding precludes the diagnosis of leprosy. However, in this resource limited setting, a punch biopsy so easily ordered in the US was not possible.

Another interesting case we saw was in the emergency room. There was a 25 year old male the junior doctors said was having an MI with S-T elevations on his EKG and symptoms of chest pain. Upon inspection of his EKG, it turned out he had diffuse S-T elevations. Upon questioning the patient, it sounded like he might have had a viral URI recently, and upon physical examination, he had diffuse wheezes. This was most certainly a case of viral pericarditis, and not a STEMI in an otherwise healthy 25 year old male. We advised the physicians to stop the heparin infusion immediately and explained our reasoning with them. Chest pain in men very quickly becomes angina regardless of circumstances, and shortness of breath is always COPD. Contrast this with another case we saw of a 70 year old woman with known coronary disease (she had had a left heart cath in Delhi showing 70-80% stenosis in her circ and LAD- cath was done for an NSTEMI). Because the patient had known coronary disease, the junior doctor didn’t believe her current symptoms of shortness of breath and chest pressure could possibly be ACS and so she was treated with lasix for a minimal amount of pulmonary edema on her chest xray. When examining her current EKG with prior EKGs from the hospital in Delhi, the patient did indeed have some deepening of ST depressions in V5 and V6, and new depressions in V4. We explained to the physician that a prior history of coronary disease didn’t preclude her from having another MI, but in fact increased her chances of it! We prompted him to start a heparin infusion and proceed with standard NSTEMI medications, and to check a troponin. The troponin assay here is either positive or negative unfortunately; a test strip like a pregnancy test over the counter. There is no quantitation of troponin leak. The patient’s troponin was indeed positive, and she was transferred to the ICU for closer monitoring.

Post 3: Tima

Post 3: Tima

This picture was taken after the ACLS workshop.  I am wearing the white coat in the center, with Drs. JK and Santosh Gupta on the right of the picture.  We are surrounded by the staff of junior doctors.

Haridwar is a very holy city in the Hindu religion.  The holy river Ganges flows through Haridwar, and there are lots of temples and ashrams here.  Every evening on the banks of the Ganges, a special prayer ceremony is held called Har-ki-Pouri (see the video above).  The Guptas took us to see it this evening.  It's a beautiful ceremony attended by thousands of people.  There is music and singing, and lots of offerings are made.  My favorite part is the cute leaves filled with flowers and candles that people float down the river.  Actually, my favorite part is the street food we ate from the market afterward!

The ACLS workshop was a big hit.  The residents seemed to know the basics, but it was clear that they hadn't had any formal ACLS training-- and probably hadn't ever been to a workshop before.  I spent about half the time giving a lecture on the algorithm and the Hs and Ts.  Then we divided all 12 residents into four groups, and each group ran a mock code.  Anita played the dummy and did a great job.  We practiced adequate chest compressions on a couple of stacked pillows.  Apparently the bag-mask was "superinfected" according to one of the residents, so we couldn't demonstrate how to get a good seal on a real person, but we did our best.  They had a bunch of questions at the end which was great!  

Today after rounds I did outpatient clinic with one of the attendings here.  In the US, the average PCP gets about 15 minutes per patient….. so that's about 16 patients per half day?  Here they see 60 to 100 patients per half day.  I timed it at 2-3 minutes per patient.  This includes "charting"-- actually, here each patient carries around his or her own medical record including all tests and reports, and the attending just writes a one or two-line note after the clinic visit.  A universal medical record of sorts.  I actually think this record system works pretty well-- all physicians have all the information on every patient, which is more than we can say for our own patients in the US.  We saw some pretty interesting cases-- tuberculous involvement of the skin which is pretty rare, psoriasis, lots of anemia, and lots of COPD and heart disease.

I had been getting a little frustrated with the clinical care here and I think it was because I wasn't really sure of my role at this hospital.  But we had a good discussion with the Guptas and decided we were going to spend more time in the ER, since that seemed to be where our clinical impact was greatest.  That seems to be working out well.  Having seen patients in the wards, ER, and outpatient setting, I feel like I am starting to figure out how medical care is done here.  Physicians here are incredibly talented at diagnosing and treating infectious disease, and I have learned a lot about the presentation and treatment of malaria, TB, scrub typhi, etc.  But there is a long way to go in the treatment of non-communicable diseases, especially cardiopulmonary disease and renal disease.  It has taken some time to adjust, but I think now we have an established role that includes a lot of teaching.  We are basically giving the residents a simplified core curriculum similar to what we give to our new interns.  Hopefully we will teach something that will last longer than the short month that we are here.

Post 2: Anita

Entry #2 Today we again worked with Dr. Santosh Gupta, this time in the outpatient setting. The first patient we saw was a sad case; a 20 year old male who had had Type 1 diabetes since the age of 11, but had never had adequate insulin regimens to control his diabetes. The patient suffered from polyuria, polydipsia, and clearly malnutrition. This young man, at the age of 20, weighed 31 kg and was 5 foot 1 inches tall, with a BMI of 13. He was in the low-normal range of growth for a 9 year old male in the United States. The patient was being fed an adequate amount of food, but his body could not effectively use it at all. The patient was coming in today to, rather than use 16 units of 70/30 insulin once a day, start a basal/bolus regimen. The problem with such severe diabetes is that these patients are not able to work, impeded by polyuria and extreme fatigue. 

The next patient was a very cute 8 year old boy who had been started on a basal/bolus regimen for about 2 years. He knew exactly how much insulin, and what types of insulin he took. His problem was low fasting blood sugar levels. His family had misunderstood and had been adjusting his nightly lantus dose by increasing rather than decreasing it. He had come with his father to meet with the newly trained diabetic educator to better adjust his insulin regimen.

The last patient we saw was a 16 year old boy who had been diagnosed with diabetes Type 1 at age 11. He has been a success story, keeping his HbA1c levels below 7, being very strict with his insulin. He now has reached his teenage years however, and has become more pre-occupied with playing cricket than taking his insulin. It seems his mother is quite upset about this, but he is fairly ambivalent, and because of this, his HbA1c h as suffered.

Post 2: Tima

Post 2 (Tima):

Today we decided to spend some time in the ER.  Interestingly, there were two patients at once who came in with organophosphate poisoning.  One middle-aged man was poisoned accidentally with insecticide during his work as a farmer.  He had been in the ER for a while and didn't look that bad, except that his heart rate was 140 on the monitor.  OP poisoning here is treated with atropine bolus and drip; pralidoxime is not available.  After doing some background reading on OP poisoning, I realized he was probably over-atropinized and suggested that the ER resident either turn down or hold his atropine.  The other toxicology patient was a young woman who drank insecticide as a suicide attempt after a fight with her husband.  She really looked terrible-- scleral injection and watering, rhinorrhea, the whole story.  Both these patients had family at the bedside, but Anita pointed out the big difference in family dynamics between them.  

I came back later in the evening with Dr Gupta to do an echo on an MI patient in the ER.  We were just getting ready to start when a young woman ran in and cried "Doctors, there's an emergency!"  A few of the residents ran outside.  There was an unresponsive man in the back of a car.  One of the residents got in the car-- I think to check for a pulse.  All I saw was a lifeless hand dropping to the seat.  The resident got out of the car and called for a stretcher.  After what seemed like forever, someone brought a wheelchair.  This guy was probably dead and couldn't sit in a wheelchair, so eventually the four of us carried him into the ER.  Once he was on a bed a lot of busy commotion ensued.  They were trying to hook him up to a monitor.  I was starting to panic because by this time it had been several minutes from arrival and the patient was pulseless, but no one had started chest compressions!  I couldn't tell who was in charge of the code-- because that's what it was.  By this point I was having an internal struggle, because I didn't want to start giving orders on their patient in their ER when there were already three physicians present.  But no one was coding the patient, and time to initiation of compressions correlates with decreased survival, so that won out.  I took over and ordered them to start compressions.  I ordered a bag-mask, oxygen, defibrillator, and IV access.

Now the code was running-- but the chest compressions were about half as vigorous and fast as what I would consider adequate, and the resident ventilating didn't have a good seal to the mask-- I could hear an air leak.  By this time the patient's family had told us that he had been unresponsive for at least 20 minutes--so I knew we probably would not be able to bring him back.  But I thought, what the hell, we should still try, and I might as well use the opportunity to show these residents how to run a code.  I demonstrated proper chest compressions and got those going.  Then I showed the resident how to get a tight seal for ventilation.  The monitor showed PEA but we still didn't have IV access to give epinephrine.  No one could get a peripheral IV and I found out that the only central line kits were up in the ICU (and they don't use them in codes-- and they don't have a crash cart).   So central access was out-- but finally someone got an IV and we pushed epi.   

We ran the code for about 25 minutes before I called the time of expiration.  I briefly went over points at which we could have done better with the residents.  My first lecture is in a couple days and i had prepared a talk on ACS-- but I just decided to change it to an ACLS workshop.

Anita: Post 1

21-year-old male with diabetes: a success story.  He is showing Dr Gupta how he gives himself insulin shots in his belly.  On the bedside table are Diabetes posters in Hindi (he is also a community educator).

21-year-old female with diabetes: still a long way to go.

Entry #1 (Anita):

Today we worked with Dr. Santosh Gupta and spent time seeing two patients that had been admitted to the hospital specifically for diabetes control: one case is a success story, the other one unfortunately is not. The first patient was a young man, age 21 who had begun to have symptoms of diabetes at the age of 17. The patient, having been married at the age of 14! was able to recall when his symptoms began because that was the year of the birth of his first child.   The young man suffered from polydipsia and polyuria, keeping 5-8 liters of water by his side during the day and then also the night, and urinating every 10-15 minutes. Despite eating everything his family was able to feed him, his appetite was insatiable, and his energy level very low. He stated that none of his neighbors wanted him nearby because of the stench of his urine. The young man was seen by some local physicians who initially gave him 70/30 premixed insulin. This might have been fairly effective, except he was told by another local “physician” that he was too young to take insulin, that it was bad for him, and that it was addictive. As it is prudent to believe what an elder tells you, especially a “physician”,  he was “weaned off” insulin. The patient is quite small for his age, and had been unable to maintain weight because of his uncontrolled diabetes. He finally came under care of the physicians at RKM hospital here in Hardwar 2 years ago. Dr. Santosh Gupta was able to provide him with basal/bolus insulin (lantus/regular) and the patient has been doing very well since. He is able to have enough energy to work rather than relying on his wife to provide for the family. He has gained weight, and he is so committed to taking care of his health, and feels so well that he has become a spokesman and educator in his neighborhood. It seems to be very important to have patients go back to their neighborhood to educate other members in the community about diabetes, particularly because so many myths surround this illness. As mentioned before, it is rumored that insulin is addictive and bad for you. People also feel like diabetics are damaged human beings because of the illness, and they feel that diabetics (especially children and especially girls) are often better off dead. 

The other patient we saw today has a story with a less than happy ending. This patient, a young woman, also 21, had originally been diagnosed with gestational diabetes when she had her first child around the age of 15. She was told after the pregnancy that she no longer had diabetes, and all treatment was discontinued. The patient was married at the age of 14, and her husband committed suicide soon after. The patient’s in-laws offered their younger son to marry her, and indeed they were married, but because he was in love with another woman, he left her. The in-laws offered to pay her parents money to take care of her and their grandchild, but her parents took the money and took the patient. This obviously caused a rift between the families, and the in-laws ended up keeping the grandchild, the patient’s parents ended up kicking their daughter (the patient) out, and the patient has been an orphan ever since. She came into RKM hospital about a month ago, basically in DKA. It is unclear if she is a Type 1 or Type 2 diabetic, or if she ever really “got over” her gestational diabetes. After 1 month of care in the hospital, and extensive education for the patient to use a basal/bolus insulin regimen, the patient did not really seem to be motivated to care for herself.  Unfortunately, the patient no longer had medical indications for inpatient treatment, and it was time for her discharge. The patient was supposedly staying at an orphanage, but when taken by a hospital worker to the orphanage, it seems it was just a dirty plot of land. The patient was brought back to the hospital for further social discharge planning. The patient was given about 1 month’s worth of insulin, and when checked on again, had run away. It is certain that this patient, without social support, without a home, without a job, without anything really, will be unable to care for herself and her diabetes. It would seem this would be the least of her worries when she has to concentrate on putting food in her belly. 

It has been interesting to see diabetes care in a resource-poor setting. There are patients at Barnes-Jewish hospital that are like the first patient; poor, uneducated, but willing to make a change and take charge of their health. These patients are self-motivated, but they also usually have some social support. Other patients are like the second patient; because of their social situation cannot or are not willing to care for themselves, and bad outcomes quickly follow.  

Tima, Post 1: Ramakrishna Hospital, Haridwar, India

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!