Typhoid fever, or enteric fever, is not very common in the US as only 400 cases per year are diagnosed; three-quarters of these are in international travelers. In fact, over 70% of cases are seen within 30 days of returning from international travel, often the Indian subcontinent or Latin America where it is endemic. Worldwide, it is much larger concern, with over 21 million cases occurring and 200,000 of them resulting in death. Caused by bacteria, it is often seen in areas and countries where sanitation is not well-enforced. As it is potentially fatal, rapid diagnosis and treatment is mandatory.
Background
Typhoid fever is a systemic infection of the bacterium Salmonella enterica, most commonly serotypes typhi and paratyphi, found exclusively in humans. After ingesting the bug, the Salmonella subspecies invades through the gastrointestinal tract and multiplies in immune cells (specifically the mononuclear phagocytic cells) in the liver, spleen, lymph nodes and Peyer patches. As it travels through the intestinal layers, the bacterium forms protective layers, helping it survive the body's defense mechanisms; it often uses one of the killing cells (macrophage) as a safehaven, traveling and multiplying within the vesicle. Salmonella also enters the bloodstream and surrounding organs, quickly becoming a systemic illness.
Interestingly, Salmonella can withstand acidic environments up to a certain pH. When the pH reaches 1.5 or less, the bacteria die; this is the typical pH of gastric acid. Any patient taking antacids, reflux medication (proton pump inhibitors or histamine-2 receptor blockers), or who have had a gastrectomy or have another illness affecting gastric pH levels are at an increased risk of typhoid fever.
Transmission
People infected with Salmonella carry the bacteria in their bloodstream and GI tract. This is often transmitted to drinking water and food, making fecal contamination of water supplies a significant problem. Also, food from street vendors are often more frequently infected with the organism. About 5% of people infected may maintain a chronic carrier state (excretion of the bacterium for over one year) and therefore unknowingly continue to spread disease.
Clinical Features
Typhoid fever often has an insidious onset of nonspecific symptoms, including fever, dull frontal headache, constipation, malaise, anorexia, chills, and myalgia. Symptoms usually begin after an incubation period that varies based on dose of organism, often ranging between 7-14 days; paratyhoid fever often shows a shorter incubation time.
The incubation ends and symptoms begin as bacteremia develops. Often nonspecific symptoms will appear before the onset of a high fever (103-104 F). Abdominal pain will be the presenting symptom in 20-40% of patients. Diarrhea and vomiting is relatively uncommon in the presentation of typhoid fever although may vary based on geography, perhaps due to changes in diets, strain of organism or other factors; constipation is a more common symptoms, believed to be secondary to swollen Peyer patches causing obstruction of the ileocecal valve.
One unique symptom of typhoid fever includes rose spots on the skinat the end of the first week, seen in approximately one third of patients. This is a bacterial embolic phenomenon and are occasionally seen with shigellosis or nontyphoidal salmonellosis. The rose spots are very subtle and sparse (potentially no more than five spots total) and are described as a truncal salmon-colored maculopapular rash with lesions less than 5cm that blanch. These lesions often resolve within two to five days.
If typhoid fever continues untreated through the second week, the patient appears more toxic. Through the end of the second week and beyond, more severe symptoms may appear, including confusion, delirium, increasing abdominal distention that may lead to perforation of the intestines, and death. On the other hand, symptomatic improvement occurs two days after initiating treatment with the patient markedly improved after four to five days.
Diagnosis
Serologic tests and cultures are the means for diagnosis. DNA assays that identify Salmonella antibodies or antigens should be confirmed with cultures. Definitive diagnosis requires isolation of the organism; this can come from blood, bone marrow, emesis, stool, or urine with bone marrow being the most sensitive for S. typhi although also the most traumatic.
In general, most patients will be moderately anemic with an elevated erythrocyte sedimentation rate, decreased platelets and white cells. Liver transaminases and bilirubin levels are elevated to roughly twice that of normal. Mild hyponatremia and hypokalmia are also commonly seen.
Treatment
When typhoid fever is suspected, a doctor needs to be seen immediately. Antibiotic therapy is the means for treatment and should be started empirically if clinical suspicion is high. Commonly prescribed antibiotics include ampicillin, trimethoprim-sulfamethoxazole, or ciprofloxacin. In addition to antibiotics, adequate fluid must be repleted with electrolytes and nutrition as needed.
Unfortunately increasing resistance to antimicrobial agents, including fluoroquinolones, and this may lead to a dramatic increase in typhoid fever-related fatalities.
If taking treatment for typhoid fever, take the full course as directed by the doctor. It is also important to avoid serving food to others as the risk of spreading the organism is high.
Prevention
Two basics steps can be taken to prevent typhoid fever: avoid risky food and drink and appropriate vaccination before departure to endemic international areas. All water should be bought in a sealed bottle or boiled before drinking. Anything that may have been made with potentially contaminated water, such as ice or popsicles, that have not been cooked should be avoided. Eat only foods that have been properly cooked and are served hot and steaming. Avoid any raw vegetables or fruits that are not peeled before eating, and peel these directly after washing hands properly. Finally avoid food that is sold from street vendors as it is difficult to keep food on the street clean.
A notable decrease in cases has been observed since the mid-1990s with possible correlation attributed to the vaccination. Two vaccination options are possible, either intramuscularly or orally, and are highly encouraged for international travel.
Typhoid Fever. http://www.emedicine.com/med/topic2331.htm July 24,2006
CDC
Sunday, April 27, 2008
Tuesday, April 22, 2008
A Weekend of Many Thanks
Before we left for India, one of the guys going (Dinesh) had a friend who was giving him and his friends a houseboat ride as a congrats for getting into residency. That was this weekend! And what an adventure it was! So Thursday night, after we were done with work, all 7 UTHSCSA people plus 2 Oklahoma people departed Vellore for Alleppey in the southern province of Kerala. Now, it is not advised to travel in India at night. That being said, our options were slim as far as tranportation, so away we went, and we had many a near miss that night. We arrived safely after a long and very uncomfortable ride on Friday afternoon, after watching many a movie including a Bollywood hit Jab We Met (definitely a must see), to get on a beautiful 3-bedroom houseboat. Now words do not do this adventure justice! Kerala is beautiful and this was the most relaxing event I have done in India. Manish, Dinesh's generous friend, met us on the dock, and we boarded, not knowing how wonderful the weekend was about to be. As we sailed out, the staff prepared coconut water and beer as well as some fruits for us. We stopped at a few port stops to pick up dinner, but mainly cruised along, enjoying the locals and tourists both that we passed.
As dusk came, we talked and took pictures and drank a few beers. An hour or so later we had a delicious (yet very spicy) meal, including delicious seafood! Due to not sleeping so well the night before on the van, it was an early night for most. We awoke to a delicious breakfast of omelettes, toast and fresh fruit, and then we packed up for a day on shore and night in Manish's house in Alleppey. We toured an old palace and another temple where the hugging Amma resides (note: there are multiple Ammas all over this country, each with their own set of followers) and saw a beach facing the Arabian Sea (I think). We returned to the house for dinner, also deliciously prepared.
The next morning we awoke for Aruveydic massages, which was quite an experience that I won't go into too much detail here. Unfortunately this took a little longer than expected and we departed Kerala later than anticipated. Thanking the housestaff profusely for their hospitality, we left Alleppey at 4pm for what was a 15-hour drive coming down. Unfortunately, this trip was not as successful--remember how I have talked about how bad the driving is... At around 3:30 in the morning, many of us were restless, and the driver stopped temporarily for coffee and a bathroom break (which in India means peeing in a bush as toilets are a luxury not to be found on a roadtrip!). We all noted how we were having trouble sleeping, but apparently that was not the case. Two hours later, we had quite an abrupt awakening!
All of a sudden, I heard Dinesh yelling at Chris to wake up, that his pupils are blown (which, for the nonmedical types, is not a good sign). I opened my eyes realizing I could not breathe. What I did not realize at this time is that our driver (who had most likely fallen asleep) ran into a hauling truck, which are large and do not move too fast. He hit the truck on the passenger's side (Left side here in India) which Cristina was sitting right behind. Chris, who had been sitting behind Cristina, had slid out of his seat and was unconscious. I do not remember most of what happened initially, and remember only Dinesh yelling at Chris to wake up and me not being able to breathe (I was hyperventilating and apparently delirious I learned later). I quickly tried to make it to the back of the van to get out, where one of the OU students Swamy mentioned that he could not see. This statement knocked me into reality and out of shock (which I think I was in) and I was able to help. I went back to Dinesh to find my shoes and hold Chris's neck stable (he had responded and was slowly making more sense) so Dinesh could go talk to Swamy.
Unfortunately, India does not work like the US in terms of EMS and getting an ambulance took entirely too long. Onlookers were only that--looking on. Thankfully, everyone was okay and stable at this point, although we were still worried about Cristina, who received a very forceful blunt chest trauma, Chris, who had been unconsious and had a laceration in his chin, and Swamy, who potentially had a broken leg and lost his vision. Everyone else, although covered with bruises and abrasions was stable. The ambulance finally came and all 9 of us loaded in the ambulance (EMTs are not trained at all and they did not even have C-collars to stabilze necks--they handed us towels!). We requested to go the 80km to Vellore to go to the CMC, as that is the best hospital in the region and where we were rotating.
We finally arrived at 7:30 (accident happened at 5:30) to absolutely no preparation. Here we got a unique experience amongst the CMC visiting students: Indian health care first hand. No one would see us (Cristina, Chris, and Swamy were the patients) until they had registered and paid. Upon finally registering them, they would not do any x-rays or blood work until we presented a receipt! And they don't give you the order to pay for them together--you pay as you need them, one by one. Seeing the care we got in the ambulance and the response available in Vellore, we were thankful no one was critical or bleeding out! During that day, I stayed with Cristina and went with her to x-rays and an echo (with the receipt in my hand!). Fortunately everything cleared for all 3 of them, and all 9 (10 with the driver) walked away from what could have been a very tragic accident.
I come out of this weekend very thankful for many reasons. First, we had a wonderful weekend of generosity and hospitality by Manish and the housestaff in Alleppey. They completely catered to everyone, making sure we felt at home and had everything we needed. It was an incredibly amazing weekend, and as soon as I upload pictures, you will understand the beauty of Kerala; unfortunately, you will have to take my word on how wonderful the food was! Second, we are incredibly thankful that we are all safe and well. Although today everyone is incredibly sore, we are all able to continue on. Thankfully, when the accident happened everyone was asleep and therefore as relaxed as could be; thankfully the van did not drive head on into the truck; thankfully, we were not going any faster as there was not much more room between Cristina and the truck; thankfully, no one was in the passenger seat. Finally, I am thankful that we have our health care system. Although here, they are incredibly intelligent and I have learned a lot, in the event of a critical trauma, no one would have survived here. No onlooker decided to call an ambulance until someone made them. No EMS was trained for acute care. And for a county hospital, we treat first and ask for money later (I think...). Basically, I walk away thankful for a wonderful weekend in Kerala and a blessed accident where we all eventually walked away (even if Swamy started on a stretcher!). My advice to all the future studetnts: don't travel at night EVER!
I will add pictures later I promise! To see the van post-accident, go to Jami's blog. We are lucky...
As dusk came, we talked and took pictures and drank a few beers. An hour or so later we had a delicious (yet very spicy) meal, including delicious seafood! Due to not sleeping so well the night before on the van, it was an early night for most. We awoke to a delicious breakfast of omelettes, toast and fresh fruit, and then we packed up for a day on shore and night in Manish's house in Alleppey. We toured an old palace and another temple where the hugging Amma resides (note: there are multiple Ammas all over this country, each with their own set of followers) and saw a beach facing the Arabian Sea (I think). We returned to the house for dinner, also deliciously prepared.
The next morning we awoke for Aruveydic massages, which was quite an experience that I won't go into too much detail here. Unfortunately this took a little longer than expected and we departed Kerala later than anticipated. Thanking the housestaff profusely for their hospitality, we left Alleppey at 4pm for what was a 15-hour drive coming down. Unfortunately, this trip was not as successful--remember how I have talked about how bad the driving is... At around 3:30 in the morning, many of us were restless, and the driver stopped temporarily for coffee and a bathroom break (which in India means peeing in a bush as toilets are a luxury not to be found on a roadtrip!). We all noted how we were having trouble sleeping, but apparently that was not the case. Two hours later, we had quite an abrupt awakening!
All of a sudden, I heard Dinesh yelling at Chris to wake up, that his pupils are blown (which, for the nonmedical types, is not a good sign). I opened my eyes realizing I could not breathe. What I did not realize at this time is that our driver (who had most likely fallen asleep) ran into a hauling truck, which are large and do not move too fast. He hit the truck on the passenger's side (Left side here in India) which Cristina was sitting right behind. Chris, who had been sitting behind Cristina, had slid out of his seat and was unconscious. I do not remember most of what happened initially, and remember only Dinesh yelling at Chris to wake up and me not being able to breathe (I was hyperventilating and apparently delirious I learned later). I quickly tried to make it to the back of the van to get out, where one of the OU students Swamy mentioned that he could not see. This statement knocked me into reality and out of shock (which I think I was in) and I was able to help. I went back to Dinesh to find my shoes and hold Chris's neck stable (he had responded and was slowly making more sense) so Dinesh could go talk to Swamy.
Unfortunately, India does not work like the US in terms of EMS and getting an ambulance took entirely too long. Onlookers were only that--looking on. Thankfully, everyone was okay and stable at this point, although we were still worried about Cristina, who received a very forceful blunt chest trauma, Chris, who had been unconsious and had a laceration in his chin, and Swamy, who potentially had a broken leg and lost his vision. Everyone else, although covered with bruises and abrasions was stable. The ambulance finally came and all 9 of us loaded in the ambulance (EMTs are not trained at all and they did not even have C-collars to stabilze necks--they handed us towels!). We requested to go the 80km to Vellore to go to the CMC, as that is the best hospital in the region and where we were rotating.
We finally arrived at 7:30 (accident happened at 5:30) to absolutely no preparation. Here we got a unique experience amongst the CMC visiting students: Indian health care first hand. No one would see us (Cristina, Chris, and Swamy were the patients) until they had registered and paid. Upon finally registering them, they would not do any x-rays or blood work until we presented a receipt! And they don't give you the order to pay for them together--you pay as you need them, one by one. Seeing the care we got in the ambulance and the response available in Vellore, we were thankful no one was critical or bleeding out! During that day, I stayed with Cristina and went with her to x-rays and an echo (with the receipt in my hand!). Fortunately everything cleared for all 3 of them, and all 9 (10 with the driver) walked away from what could have been a very tragic accident.
I come out of this weekend very thankful for many reasons. First, we had a wonderful weekend of generosity and hospitality by Manish and the housestaff in Alleppey. They completely catered to everyone, making sure we felt at home and had everything we needed. It was an incredibly amazing weekend, and as soon as I upload pictures, you will understand the beauty of Kerala; unfortunately, you will have to take my word on how wonderful the food was! Second, we are incredibly thankful that we are all safe and well. Although today everyone is incredibly sore, we are all able to continue on. Thankfully, when the accident happened everyone was asleep and therefore as relaxed as could be; thankfully the van did not drive head on into the truck; thankfully, we were not going any faster as there was not much more room between Cristina and the truck; thankfully, no one was in the passenger seat. Finally, I am thankful that we have our health care system. Although here, they are incredibly intelligent and I have learned a lot, in the event of a critical trauma, no one would have survived here. No onlooker decided to call an ambulance until someone made them. No EMS was trained for acute care. And for a county hospital, we treat first and ask for money later (I think...). Basically, I walk away thankful for a wonderful weekend in Kerala and a blessed accident where we all eventually walked away (even if Swamy started on a stretcher!). My advice to all the future studetnts: don't travel at night EVER!
I will add pictures later I promise! To see the van post-accident, go to Jami's blog. We are lucky...
Tuesday, April 15, 2008
Pictures, Pictures, Pictures
THE MEDICAL
CMC Hosptital is a mega-complex of hostpitals, outpatient clinics, and teaching areas. This is the building for outpatient clinics and the canteen. Here, you start to get an idea of how crazy it is. Imagine the Texas Medical Center with a quarter of the buildings but the same number of people...
CMC Hosptital is a mega-complex of hostpitals, outpatient clinics, and teaching areas. This is the building for outpatient clinics and the canteen. Here, you start to get an idea of how crazy it is. Imagine the Texas Medical Center with a quarter of the buildings but the same number of people...
This is the CHAD (Community Health and Development) hospital. CHAD is similar to a small community hospital that does mainly outpatient and one-day procedures, but it also incorporates a social and educational aspect for its patients. Never worrying about money, the hospital finds a way to treat everyone.
The other component of CHAD is the villages where the intricate setup of part-time community health workers, health aides, nurses, and doctors go to the villages. Here, you can see the health aide in pink and the nurse and nursing student in blue walking through the village street. It is amazing how much the umbrellas can shade someone from the unrelenting summer sun!
Again on nurses rounds, we have arrived at one house to check on a newborn baby. In addition to the nurses and health aide, there is the PTCHW who knows everyone in the village well. This family was one of the first we visited on our day.
This is one of the buildings on the CMC campus. This building includes the computer lab and library. This campus is incredibly green and full of flowers--and very litterfree! It is definitely a nice place to escape the busy-ness that is India!
This is the bus used for the mobile clinic. Here the bus (which contains the exam room and pharmacy) goes from one site in a village to another site in the village instead of house to house like nurses rounds. In this picture, you can see each of the components: in the left open window, the nurse (blue) is manning the pharmacy, the doctor (middle open window, wearing white) is seeing the antenatals with the one exam table, located on the opposite side of the bus, and the health aide (pink in the right open window) is documenting for statistical purposes. Outside, the patients come up to the windows as needed.
The last village of 4 during the mobile clinic was by far the largest and the most populated with elderly people! Here, there is a row of elderly men, patiently waiting in the shade for their number to be called, most for medication refills.THE STREETS
The autorickshaw. This is the Indian way of the affordable taxi. It is similar to the idea of the taxi in NY in that they are everywhere and ready to move...and sometimes a bit dangerous. This is our main mode of transportation--it is brush with death each time, and if we don't almost hit another person at least four times, it wasn't a real ride!
This is often what you see from the front. In case you are wondering where the divinding line is, the white car is on it. To give you a preview of what is to come, that blue car behind comes even further over into our lane, being one of the closest near misses we have had! As I have said, the white line (which can be seen faintly behind the blue car) is merely a suggestion!
Welcome to one of the few stoplights in Vellore. Can't see any lanes here either? Well that is how it works. Much like all lines here in India, it is more of a huddle in an impatient wait for the light to turn green. In fact, there is room for a few more motorbikes and bicycles. Who needs lanes when you can have controlled chaos!
I put this up in honor of the MS150 this past weekend! Here is the Indian version--although this isn't a race, this is just waiting for the green light to go!
THE FOOD
The autorickshaw. This is the Indian way of the affordable taxi. It is similar to the idea of the taxi in NY in that they are everywhere and ready to move...and sometimes a bit dangerous. This is our main mode of transportation--it is brush with death each time, and if we don't almost hit another person at least four times, it wasn't a real ride!
This is often what you see from the front. In case you are wondering where the divinding line is, the white car is on it. To give you a preview of what is to come, that blue car behind comes even further over into our lane, being one of the closest near misses we have had! As I have said, the white line (which can be seen faintly behind the blue car) is merely a suggestion!
Welcome to one of the few stoplights in Vellore. Can't see any lanes here either? Well that is how it works. Much like all lines here in India, it is more of a huddle in an impatient wait for the light to turn green. In fact, there is room for a few more motorbikes and bicycles. Who needs lanes when you can have controlled chaos!
I put this up in honor of the MS150 this past weekend! Here is the Indian version--although this isn't a race, this is just waiting for the green light to go!THE FOOD
Our first breakfast in Vellore! This is dosa and it has 4 different dipping sauces, although only 1 wasn't spicy and 1 was tolerable... From here, we gave into jetlag and slept through the day!
This is egg dosai. This is my favorite breakfast at the canteen--I think of it as the Indian version of a spicy French Toast. My favorite days are when they add less pepper so I can still feel my tongue when breakfast is over! This goes great with one of the many fresh fruit juices they have--my fave is pineapple!
This is a parota! This is my favorite dish in all of India! It often comes in pairs, but I ate the first one before I remembered to take a picture. The empty bowl is the mixed green sauce that is NOT spicy! Also, they have started serving it with an onion milk-type dip--also very good! I need to find me a good parota place when I come back...ideally with tea!
Medicine at CMC
This week I have been on Medicine II at the main CMC hospital. My general impression boils down to 2 observations: they have an insane number of people and some disease are found everywhere.
To start, yesterday Medicine II was in the outpatient clinics all day. Due to the crazy number of people that need to be seen and the small amoung of space, there are 2 doctors (often an intern and upper post-graduate) sharing one exam room with one exam table and one computer...but their own patients plus whatever family comes with them. So in one room you can have up to 8 people! Interns see roughly 30 patients a day and residents 40! Don't they get tired, you may ask--well, dont worry! They take regular tea breaks throughout the day, something I think we should start in the US. It would definitely make me happier!
In clinic, it was a little difficult to follow as they have a crazy number of patients to see, and while speaking primarily Tamil, they dont really have time to translate. Cristina and I tried to follow as best we could but it became challenging during many of the cases.
Today was Grand Rounds for Medince II. Imagine this: around the bed of one patient +/- their family, add 2 attendings, 3-4 interns, 5-6 residents, 7ish CMC medical students, 2 what I think are nursing students, and 6 international students...at one time, there was 27 people around the bed of a patient!! Talk about overwhelming. In addition, people here tend to be soft-spoken. So the 3 American and 3 Singapore students would do our best to put together what we heard--we did pretty well for a while!
During the Rounds (of course with a tea break about half way through), I realized one thing: common diseases are common. Seeing strokes, the attendings lectured on the importance of tight blood pressure control. Seeing meningitis, the attendings asked questions about cerebrospinal fluid findings (often asking the local students, fortunately!). Seeing hemiplegia came questions on upper versus lower motor neuron findings to help identify the location of the lesion. He talked about side effects of antibiotics, need for anticoagulation coverage, and many other topics one would find in Texas. In addition there was some malaria and a few snake bites--and it seemed almost everyone was on anti-TB meds, but overall it could have passed for the county hospital, except I can follow some Spanish!
One rather incredible difference was how they handle terminal illnesses with the patients. One woman had what I believe is a abdominal mesothelioma (details are a bit blurry), but I am not quite sure she was or will ever be told. It seems in India, if the family does not feel the patient should know, that is honored and the patient is not told. A student from Detroit said he saw an elderly woman with gastric carcinoma who was receiving treatments without ever being told a diagnosis. I have heard that this happens, and once or twice, there has been the patient's family who doesn't want us to tell the patient, but it is not honored unless the patient states he or she doesnt want to know. Again the cultural difference is present.
Tomorrow, I believe is a normal day with MedcineII--maybe that will mean less people. Other than that, I continue to assimilate into the culture. More international students came--including 2 more girls from Maastricht!--so we continue to learn about medicine all over the world, another advantage to this trip. It is still hot...and the food is still spicy, even if they say it isnt (although I think I am slowly acclimating my tongue to spicy foods...). This weekend we head to Kerala for the houseboat experience! I will add pictures soon I hope...but for now, go to Chris's blog--pictures a plenty!
To start, yesterday Medicine II was in the outpatient clinics all day. Due to the crazy number of people that need to be seen and the small amoung of space, there are 2 doctors (often an intern and upper post-graduate) sharing one exam room with one exam table and one computer...but their own patients plus whatever family comes with them. So in one room you can have up to 8 people! Interns see roughly 30 patients a day and residents 40! Don't they get tired, you may ask--well, dont worry! They take regular tea breaks throughout the day, something I think we should start in the US. It would definitely make me happier!
In clinic, it was a little difficult to follow as they have a crazy number of patients to see, and while speaking primarily Tamil, they dont really have time to translate. Cristina and I tried to follow as best we could but it became challenging during many of the cases.
Today was Grand Rounds for Medince II. Imagine this: around the bed of one patient +/- their family, add 2 attendings, 3-4 interns, 5-6 residents, 7ish CMC medical students, 2 what I think are nursing students, and 6 international students...at one time, there was 27 people around the bed of a patient!! Talk about overwhelming. In addition, people here tend to be soft-spoken. So the 3 American and 3 Singapore students would do our best to put together what we heard--we did pretty well for a while!
During the Rounds (of course with a tea break about half way through), I realized one thing: common diseases are common. Seeing strokes, the attendings lectured on the importance of tight blood pressure control. Seeing meningitis, the attendings asked questions about cerebrospinal fluid findings (often asking the local students, fortunately!). Seeing hemiplegia came questions on upper versus lower motor neuron findings to help identify the location of the lesion. He talked about side effects of antibiotics, need for anticoagulation coverage, and many other topics one would find in Texas. In addition there was some malaria and a few snake bites--and it seemed almost everyone was on anti-TB meds, but overall it could have passed for the county hospital, except I can follow some Spanish!
One rather incredible difference was how they handle terminal illnesses with the patients. One woman had what I believe is a abdominal mesothelioma (details are a bit blurry), but I am not quite sure she was or will ever be told. It seems in India, if the family does not feel the patient should know, that is honored and the patient is not told. A student from Detroit said he saw an elderly woman with gastric carcinoma who was receiving treatments without ever being told a diagnosis. I have heard that this happens, and once or twice, there has been the patient's family who doesn't want us to tell the patient, but it is not honored unless the patient states he or she doesnt want to know. Again the cultural difference is present.
Tomorrow, I believe is a normal day with MedcineII--maybe that will mean less people. Other than that, I continue to assimilate into the culture. More international students came--including 2 more girls from Maastricht!--so we continue to learn about medicine all over the world, another advantage to this trip. It is still hot...and the food is still spicy, even if they say it isnt (although I think I am slowly acclimating my tongue to spicy foods...). This weekend we head to Kerala for the houseboat experience! I will add pictures soon I hope...but for now, go to Chris's blog--pictures a plenty!
Sunday, April 13, 2008
Bobbing and Staring in Mammallapuram; Happy New Year!
This weekend, we took a little weekend trip to Mammallapuram, a town located on the beach somewhere between 2-3 hours drive from Vellore (not quite sure as I fell asleep). Renting a car with driver through the CMC office, we were on our way Saturday morning. Mammallapuram is a "world heritage" site where there are the stone carvings dating back to the 6th-8th centuries. The carvings include the Shore Temple, the Five Rathas, and Arjuna's penance to name a few. Basically they are very intricate carvings of ancient Indian history as this used to be an active sea port for the Bay of Bengal. Okay, I will be the first to admit I don't know a lot about the history, but it doesn't take much to appreciate how impressive the stone carvings are.
So upon arriving to the city, which is very different as it is more of a tourist town than Vellore, we checked into the hotel and went to grab a bite to eat. Ordering what the waiter said was not spicy, I immediately regretted my decision--my mouth was on fire! We then got in the car and went to the Five Rathas, who represent five brothers and one lady (whom if I understood the guide right, they all married). Outside the Rathas (like any good tourist town) was a million shops and little stone carvings to purchase. We decided to hold off and went to the Shore Temple, which fortunately was not affected by the tsunami that hit a few years back. Taking some snaps, we then walked through the shops that were between the us and the coastline. And there, the pressures of tourism got us--we started buying. At the second shop, we haggled the lady and her husband down to "reasonable" prices, and she invited Cristina and I to a festive lunch on Sunday as it is the Tamil New Year. She and her husband gave us directions--in Tamil, of course--and we continued on the many shops.
Finally making it to the beach after passing a cow and many many staring people, we dipped our feet in the Indian Ocean and of course subsequently got splashed by a larger wave. We then decided to head to the lighthouse and surrounding carvings. Taking some more pictures of carvings and goats and monkeys, we crossed the street to look in a couple more shops. At this point, our driver was giving us tips as to whether he thought we were getting good deals on our purchases! Most of the time he said we paid too much and crushed our feelings of a successful bargain. Regardless, we were spent and headed back to the hotel for dinner. Unfortunately the hotel is surrounded by shops...
We spent quite a few hours in one shop with the owner who proceeded to tell us about his life, inviting us to his birthday celebration in May in Cashmere (?). After parting with more than we wanted (with good deals!), we finally headed to dinner--much to late for Chris's liking! We enjoyed fresh white snapper on the beach!
Sunday morning we awoke and headed to a few more stone caves filled with carvings and headed out. Stopping at Kanchipuram on the way back to take a few snaps of a few more temples, we finally made it back to Vellore.
At the end of this trip I feel there are 2 things of which to comment: the staring and the head bobbing. Throughout this weekend trip, we really started appreciating just how much staring takes place. Having heard others talk about the incessant and shameless staring, at first we would just smile and try to ignore it. But it does not stop. For example, during the hour we were at the Stone Temple, we were asked to be in a picture of complete strangers and another girl came up and shook my hand then touched my face. Many will ask where we are from, which is completely fine and almost more welcoming; many will just stare until one of us leaves. Incredible. Even as I write this blog in an internet cafe, there is a small child pointing at me at the door of my cubicle with his presumed mother and grandmother sitting and staring. I do not mean this critically (although when it is a group of men, it is a bit unsettling), it is just something a little difficult to get used to.
And then there is the head bobbing. It has been discussed in many a previous blogs, and my trip would not be complete unless I too made note of it. It is part of the culture to answer all questions and comments with a sideways head bob. The answers could mean anything: yes, no, whatever, go away. This is a gesture we have grown to appreciate--and mimic unconsciously sometimes. It seems this bob is likened to our nodding, which sometimes just means that one is paying attention. Often if you watch a group listen to a speech or lecture, you will see many sitting there bobbing their heads. It is quite amusing and now, not quite so confusing!
Tomorrow I start at CMC, possibly on the medicine team, possibly not. I find out tomorrow morning.
So upon arriving to the city, which is very different as it is more of a tourist town than Vellore, we checked into the hotel and went to grab a bite to eat. Ordering what the waiter said was not spicy, I immediately regretted my decision--my mouth was on fire! We then got in the car and went to the Five Rathas, who represent five brothers and one lady (whom if I understood the guide right, they all married). Outside the Rathas (like any good tourist town) was a million shops and little stone carvings to purchase. We decided to hold off and went to the Shore Temple, which fortunately was not affected by the tsunami that hit a few years back. Taking some snaps, we then walked through the shops that were between the us and the coastline. And there, the pressures of tourism got us--we started buying. At the second shop, we haggled the lady and her husband down to "reasonable" prices, and she invited Cristina and I to a festive lunch on Sunday as it is the Tamil New Year. She and her husband gave us directions--in Tamil, of course--and we continued on the many shops.
Finally making it to the beach after passing a cow and many many staring people, we dipped our feet in the Indian Ocean and of course subsequently got splashed by a larger wave. We then decided to head to the lighthouse and surrounding carvings. Taking some more pictures of carvings and goats and monkeys, we crossed the street to look in a couple more shops. At this point, our driver was giving us tips as to whether he thought we were getting good deals on our purchases! Most of the time he said we paid too much and crushed our feelings of a successful bargain. Regardless, we were spent and headed back to the hotel for dinner. Unfortunately the hotel is surrounded by shops...
We spent quite a few hours in one shop with the owner who proceeded to tell us about his life, inviting us to his birthday celebration in May in Cashmere (?). After parting with more than we wanted (with good deals!), we finally headed to dinner--much to late for Chris's liking! We enjoyed fresh white snapper on the beach!
Sunday morning we awoke and headed to a few more stone caves filled with carvings and headed out. Stopping at Kanchipuram on the way back to take a few snaps of a few more temples, we finally made it back to Vellore.
At the end of this trip I feel there are 2 things of which to comment: the staring and the head bobbing. Throughout this weekend trip, we really started appreciating just how much staring takes place. Having heard others talk about the incessant and shameless staring, at first we would just smile and try to ignore it. But it does not stop. For example, during the hour we were at the Stone Temple, we were asked to be in a picture of complete strangers and another girl came up and shook my hand then touched my face. Many will ask where we are from, which is completely fine and almost more welcoming; many will just stare until one of us leaves. Incredible. Even as I write this blog in an internet cafe, there is a small child pointing at me at the door of my cubicle with his presumed mother and grandmother sitting and staring. I do not mean this critically (although when it is a group of men, it is a bit unsettling), it is just something a little difficult to get used to.
And then there is the head bobbing. It has been discussed in many a previous blogs, and my trip would not be complete unless I too made note of it. It is part of the culture to answer all questions and comments with a sideways head bob. The answers could mean anything: yes, no, whatever, go away. This is a gesture we have grown to appreciate--and mimic unconsciously sometimes. It seems this bob is likened to our nodding, which sometimes just means that one is paying attention. Often if you watch a group listen to a speech or lecture, you will see many sitting there bobbing their heads. It is quite amusing and now, not quite so confusing!
Tomorrow I start at CMC, possibly on the medicine team, possibly not. I find out tomorrow morning.
Friday, April 11, 2008
A couple days in the villages and a meeting with Amma
Hello again! So as this is a medical trip, I will start there (all who want to bypass, feel free--although there wil be some culture thrown in as well):
This week I am in CHAD (community health and development), a setup that includes a community hospital, a rural network of nurses, doctors, and health aides, and a social network of training, education, and support. This is a rather amazing network, allowing for those who cannot afford care to receive it in a rather resourceful way. Started back around roughly 1900, it was a single-bed hospital; now it can hold around 110 beds (including a small ICU and operation theatre) and visits 68 villages through part-time community health workers (PTCHW), health aides, public health nurses and doctors in a heirarchical fashion to where the PTCHW sees only about 2000-3000 people and sees them all whild the doctor can see between 45,000 and 50,000 people, but not as often.
The first afternoon, I spent in HIV/TB clinic, which although interesting to see the differences, the intense amount of patients and language barrier prevented too much learning. On Wednesday, I went on nurse's rounds though the villages, which was such an awesome experience. The health aide, dressed in pink saris, would identify the people that needed to be seen and the nurse, dressed in blue saris, would come every 2 weeks to see them (this includes all antenatal and postnatal visits, acute concerns, and social concerns). As we went from home to home (sometimes from concrete room to thatched hut), these people, often pregnant women and some ill children as the men were out working, would bring us into their houses and offer whatever they had to eat or drink; unfortunately, due to our naive American stomachs, we often had to decline. They would pull out plastic chairs or mats for us to sit on and turn on the single fan to help cool us off. During the antenatal visits (pregnant women), the women would lie on a mat during the exam. If the husband was home, he would leave as it was "women time" (men are just now starting to be allowed in the delivery room during labor, but even that is a rare occurrence). During the exam, the fundal height would be measured and the baby's heart sounds would be checked with a stethoscope alone--no Doppler was used (incredible!).
While we walked, we began to see how these families lived and just how resourceful they were. A home may be just a single room, with a corner designated as the kitchen and the bed (the single mat) rolled up and propped against the wall. There was no furniture other than potentially a chair. Many had chalk drawings outside the doors to ward off evil spirits and different items hanging above the door, all protecting against something different. Due to the heat of south India, many were able to use it to their advantage: chili peppers, peanuts, tobacco leaves, incense, and cow patties (of course!) used for feul were all left out to dry. Only pictures can truly help see how amazing these families were (which I hope to upload soon!). As we went from house to house, the nurse helped explain the culture and customs of the villages. This really was an experience I hope never to forget, and one I hope to see applied to some of the colonias throughout Texas. The similarities (although too lengthy to get into now) are astounding!
Yesterday we on doctor's rounds, which include a small bus that has been divided into an exam room and pharmacy. As the group (health aide, nurse, 2 nursing students, a doctor, and intern, and the driver--oh and 3 medical students from TX) started out, the goal was to see 4 different villages at a common site. The intern and nursing student set up a table outside for acute problems and chronic disease (often med refill), and the doctor and health aide saw the pregnant women inside the van. The nurse and other nursing student ran the pharmacy at the back of the van. This was incredible--as the day continued, each site promised a larger crowd. As we rotated through the different areas, we played with the children (all amazed with our paleness), smiled with the older patients, and tried to understand what all is put into these days.
Okay, now for everything else (quickly):
food: so everything is spicy, even when they say it isnt! I love the parotas, which I always get with this amazing mixed greens gravy, and the naan (like a tortilla but soooo much better). And the tea I could drink forever--although they alwasy offer us the Westerner version, we always take the Indian one: it is HOT and so sweet. Despite the spice, I am not starvign by any means!
weather: yes it is hot! But amazingly, most of the rooms are not. They do a great job of making the most of a breeze, and although I am sitting in an un-air-conditioned room now, I am quite cool. We are staying in an A/C room to sleep though (come on--it is like a 100+ degrees outside!).
international flare: So we have met people from everywhere: Singapore, Maastricht (!), Malaysia, Germany, Texas (not with us), Canada... and it goes on. Everyone is so friendly. I am getting a nice introduction to other countries...and continuing to whet my appetite to travel more!
Amma: this morning we went to the Golden Temple outside of Vellore and met Amma. She is a person whom it is believed is the vessel of God. Having predicted different miracles, she started having ceremonies and blessings at the age of 16. Planning on only seeing the Golden Temple, built recently and quite impressive, we walked into this gift shop-esque room, and was asked if we would like to meet her. We said okay and were whisked away to see the initial ceremony that was open to the public. Chris, unfortunately, was wearing shorts at this time, and had to wait outside the gates. As Amma was leaving the ceremony, she stopped and asked how Cristtina and I were, what brought us to India and if we would like to go to another blessing. At first hesitant as Chris was waiting outside, we declined. But then Chris arrived sporting a dhoti (Indian sarong for men), and off we went to the ceremony. At the end, Amma invited us to breakfast at the guest house. Throughout this event, we learned about the beliefs and symbols of the culture, with 2 guides: the man from the gift shop who initially asked us if we wanted to meet Amma and another woman from Australia, who abandoned her job as a pharmacist to follow Amma. Although I kept waiting for requests for tithing, they never asked for money and just wanted to show us their way and beliefs. It was another eye opening experience!
Okay, I am leaving many things out, but as this is long enough, I will quit. If you are still reading, what a trooper! I will try not to wait a few days again and therefore keep it shorter!
This week I am in CHAD (community health and development), a setup that includes a community hospital, a rural network of nurses, doctors, and health aides, and a social network of training, education, and support. This is a rather amazing network, allowing for those who cannot afford care to receive it in a rather resourceful way. Started back around roughly 1900, it was a single-bed hospital; now it can hold around 110 beds (including a small ICU and operation theatre) and visits 68 villages through part-time community health workers (PTCHW), health aides, public health nurses and doctors in a heirarchical fashion to where the PTCHW sees only about 2000-3000 people and sees them all whild the doctor can see between 45,000 and 50,000 people, but not as often.
The first afternoon, I spent in HIV/TB clinic, which although interesting to see the differences, the intense amount of patients and language barrier prevented too much learning. On Wednesday, I went on nurse's rounds though the villages, which was such an awesome experience. The health aide, dressed in pink saris, would identify the people that needed to be seen and the nurse, dressed in blue saris, would come every 2 weeks to see them (this includes all antenatal and postnatal visits, acute concerns, and social concerns). As we went from home to home (sometimes from concrete room to thatched hut), these people, often pregnant women and some ill children as the men were out working, would bring us into their houses and offer whatever they had to eat or drink; unfortunately, due to our naive American stomachs, we often had to decline. They would pull out plastic chairs or mats for us to sit on and turn on the single fan to help cool us off. During the antenatal visits (pregnant women), the women would lie on a mat during the exam. If the husband was home, he would leave as it was "women time" (men are just now starting to be allowed in the delivery room during labor, but even that is a rare occurrence). During the exam, the fundal height would be measured and the baby's heart sounds would be checked with a stethoscope alone--no Doppler was used (incredible!).
While we walked, we began to see how these families lived and just how resourceful they were. A home may be just a single room, with a corner designated as the kitchen and the bed (the single mat) rolled up and propped against the wall. There was no furniture other than potentially a chair. Many had chalk drawings outside the doors to ward off evil spirits and different items hanging above the door, all protecting against something different. Due to the heat of south India, many were able to use it to their advantage: chili peppers, peanuts, tobacco leaves, incense, and cow patties (of course!) used for feul were all left out to dry. Only pictures can truly help see how amazing these families were (which I hope to upload soon!). As we went from house to house, the nurse helped explain the culture and customs of the villages. This really was an experience I hope never to forget, and one I hope to see applied to some of the colonias throughout Texas. The similarities (although too lengthy to get into now) are astounding!
Yesterday we on doctor's rounds, which include a small bus that has been divided into an exam room and pharmacy. As the group (health aide, nurse, 2 nursing students, a doctor, and intern, and the driver--oh and 3 medical students from TX) started out, the goal was to see 4 different villages at a common site. The intern and nursing student set up a table outside for acute problems and chronic disease (often med refill), and the doctor and health aide saw the pregnant women inside the van. The nurse and other nursing student ran the pharmacy at the back of the van. This was incredible--as the day continued, each site promised a larger crowd. As we rotated through the different areas, we played with the children (all amazed with our paleness), smiled with the older patients, and tried to understand what all is put into these days.
Okay, now for everything else (quickly):
food: so everything is spicy, even when they say it isnt! I love the parotas, which I always get with this amazing mixed greens gravy, and the naan (like a tortilla but soooo much better). And the tea I could drink forever--although they alwasy offer us the Westerner version, we always take the Indian one: it is HOT and so sweet. Despite the spice, I am not starvign by any means!
weather: yes it is hot! But amazingly, most of the rooms are not. They do a great job of making the most of a breeze, and although I am sitting in an un-air-conditioned room now, I am quite cool. We are staying in an A/C room to sleep though (come on--it is like a 100+ degrees outside!).
international flare: So we have met people from everywhere: Singapore, Maastricht (!), Malaysia, Germany, Texas (not with us), Canada... and it goes on. Everyone is so friendly. I am getting a nice introduction to other countries...and continuing to whet my appetite to travel more!
Amma: this morning we went to the Golden Temple outside of Vellore and met Amma. She is a person whom it is believed is the vessel of God. Having predicted different miracles, she started having ceremonies and blessings at the age of 16. Planning on only seeing the Golden Temple, built recently and quite impressive, we walked into this gift shop-esque room, and was asked if we would like to meet her. We said okay and were whisked away to see the initial ceremony that was open to the public. Chris, unfortunately, was wearing shorts at this time, and had to wait outside the gates. As Amma was leaving the ceremony, she stopped and asked how Cristtina and I were, what brought us to India and if we would like to go to another blessing. At first hesitant as Chris was waiting outside, we declined. But then Chris arrived sporting a dhoti (Indian sarong for men), and off we went to the ceremony. At the end, Amma invited us to breakfast at the guest house. Throughout this event, we learned about the beliefs and symbols of the culture, with 2 guides: the man from the gift shop who initially asked us if we wanted to meet Amma and another woman from Australia, who abandoned her job as a pharmacist to follow Amma. Although I kept waiting for requests for tithing, they never asked for money and just wanted to show us their way and beliefs. It was another eye opening experience!
Okay, I am leaving many things out, but as this is long enough, I will quit. If you are still reading, what a trooper! I will try not to wait a few days again and therefore keep it shorter!
Sunday, April 6, 2008
A lot of everything...
So I made it to India (after almost missing my connection in London) and have to say the whole trip from Houston to Vellore went rather smoothly. Upon arriving to Chennai, we were greeted by fairly long lines at Customs, a "security check" at the baggage claim where no one actually watched the monitor, and our luggage! We exchanged some money into Rupees, where we were asked "who was more popular in the States: Michael Jackson or Eminem?" to which we replied neither. We didn't meet up with Chris as he missed his connection due to layover issues and proceeded on to the mob of people and cab drivers outside the airport.
And this is where I realized that in India, there is a lot of everything! People are everywhere, cars are everywhere, trash is everywhere, cows, dogs, bicycles...the list goes on. But it seems to be a very make it work environment. Let me explain. After waiting at the airport for a while to ensure our drive Chris in fact was not coming, we started our drive to Vellore. Now if you think the drivers in San Antonio are bad... There seem to be absolutely no laws on the roads in this country. The middle line is merely a suggestion and you can feel free to cross at anytime, especially if you just think you might want to pass the car/motorbike/bicycle/pedestrian/animal in front of you. Needless to say, I have never wished for a working seat belt more in my life. Once we made it out of Chennai to the highway, more of the same continued, just at faster speeds as we were now on a highway. But rest assured, communication with others took place as our driver laid on his horn upon seeing anyone else on the road. Amazing experience.
As for the environment, I was so impressed with how many people really are everywhere and how resourceful everyone is. Whatever they have, they make it work. For example, if you have a motorbike and need to take plastic chairs, your wife, and some groceries down the street, you pile them on the motorbike and you take them. If you need a ride but have no vehicle, you stand where you are and wait for someone to pick you up. If you need to go to the bathroom and are on the highway where there are no washrooms, you stop and you...well, I think you understand.
In Vellore, we checked into the Aavana Hotel and are staying in a pretty nice room. The shower is interesting as it involves a bucket and pourer... But the hotel room was perfect as yesterday we slept off the jetlag. As most things are closed on Sunday, we fell asleep at 10AM and made ourselves go to dinner at 7:30PM...
As for today, we have officially registered at the CMC. There is a group of roughly 30 students here from Singapore registering (as students and not observers...) as well; after talking to them about their country, which is roughly the population of Houston, it sounds rather intrituing--when do I have time for a trip to Singapore... They let us know about an international party or something this afternoon, so we will see who else is here. Tomorrow I start the CHAD rotation (a rural medicine rotation). I will explain more when I figure out the details. For now, that is enough...
And this is where I realized that in India, there is a lot of everything! People are everywhere, cars are everywhere, trash is everywhere, cows, dogs, bicycles...the list goes on. But it seems to be a very make it work environment. Let me explain. After waiting at the airport for a while to ensure our drive Chris in fact was not coming, we started our drive to Vellore. Now if you think the drivers in San Antonio are bad... There seem to be absolutely no laws on the roads in this country. The middle line is merely a suggestion and you can feel free to cross at anytime, especially if you just think you might want to pass the car/motorbike/bicycle/pedestrian/animal in front of you. Needless to say, I have never wished for a working seat belt more in my life. Once we made it out of Chennai to the highway, more of the same continued, just at faster speeds as we were now on a highway. But rest assured, communication with others took place as our driver laid on his horn upon seeing anyone else on the road. Amazing experience.
As for the environment, I was so impressed with how many people really are everywhere and how resourceful everyone is. Whatever they have, they make it work. For example, if you have a motorbike and need to take plastic chairs, your wife, and some groceries down the street, you pile them on the motorbike and you take them. If you need a ride but have no vehicle, you stand where you are and wait for someone to pick you up. If you need to go to the bathroom and are on the highway where there are no washrooms, you stop and you...well, I think you understand.
In Vellore, we checked into the Aavana Hotel and are staying in a pretty nice room. The shower is interesting as it involves a bucket and pourer... But the hotel room was perfect as yesterday we slept off the jetlag. As most things are closed on Sunday, we fell asleep at 10AM and made ourselves go to dinner at 7:30PM...
As for today, we have officially registered at the CMC. There is a group of roughly 30 students here from Singapore registering (as students and not observers...) as well; after talking to them about their country, which is roughly the population of Houston, it sounds rather intrituing--when do I have time for a trip to Singapore... They let us know about an international party or something this afternoon, so we will see who else is here. Tomorrow I start the CHAD rotation (a rural medicine rotation). I will explain more when I figure out the details. For now, that is enough...
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