Sorry! It is Friday. We have had our first five days at the hospital and I am only sitting down to write about it all now! I apologise! My lack of blogging has been due to a) multiple power cuts – average 2 a day, average duration 1 and a half hours! b) Internet not working c) lots going on! But I have made notes in my notebook so I will make sure not to leave out any important details!
I guess I should start with day 1, Monday, our first day at Gudalur Adivasi Hospital.
At the bottom of this post is a picture of the hospital…just in the distance beyond the ambulance up a muddy hill is the doctors quarters where we are now staying and where we eat all our meals – so only a very short commute to work!
MONDAY
Our first day at the hospital was great. We met the two doctors who started up the hospital, Dr Nandukumar and Dr Shyla. They are a married couple who trained in India but who spent a long time working in America. They are both super doctors and really are the foundation of the hospital. We spent the morning in the outpatients department with Dr Nandukumar. I say outpatients, but it’s a small room, which we have found is A+E, plus a theatre, plus outpatients, all rolled into one!
Monday was a very busy day in outpatients and they see everything in all clinics- there are no specific clinics like we are used to – so we saw a huge range of problems in one morning and Dr Nandukumar had such knowledge of everything in order to be able to treat everyone. In the UK, the patients would have been seen by different specialists but they don’t have that luxury here. It was very interesting for us as we jumped from thyroid problems to rheumatoid arthritis to depression to haemorrhoids to sickle cell disease, just to name a few, all in a couple of hours. We also had some teaching on neurological examination in the afternoon from a lovely doctor who everyone calls Abu. He has the nicest, funniest laugh I have ever heard in my life! Teaching was based on a tribal woman in her 40s who had had a stroke. It was interesting to see how differently she had to be managed because of the limited resources available. The nearest CT scanner is about 4 hours away and so they were managing her uncertain of whether it was a haemorrhagic (bleed in the brain) or ischaemic (clot in the brain) stroke. In the UK, a CT would most definitely be done as soon as possible for all patients to differentiate between the two and then they would be managed appropriately as the management is different for each type and also depending on how many hours since the stroke occurred. However, as they were not able to do this due to the distance, expense of sending the patient and also the fact that the patient wouldn’t go anyway, they were managing her supportively and following a watch and wait approach. If she gets worse over the next week they will assume it was an ischaemic stroke and start secondary prevention with aspirin. They do not have any physiotherapists at the hospital but the nurses taught her some exercises to do, as the stroke had significantly affected her left side, specifically her left arm, which she could not use at all.
After our day at the hospital we went for tea and Indian sweets in town with Alice, a really friendly, chatty junior doctor from England who has been working here for 6 months. She did her elective here a few years ago and loved it so much she has come back as a doctor. A patient in the hospital who we have not yet met has had severe full thickness burns to 25% of her body. This is very severe and in the UK she would be taken to a specialist burns unit for sure. Even here they know that they don’t have the facilities to provide her with the necessary care but she is refusing to be transferred to another hospital as she wants to remain in Gudalur with her family nearby. That’s something I learnt today about the hospital actually- there are no set visiting hours and no limit to the number of visitors that each patient can have, as that is one of the many factors why the Adivasi are reluctant to use the government hospitals. So anyway- she wanted to remain in the Adivasi hospital and she needed a blood transfusion. There is no blood bank at the hospital and so the families of patients are often asked to donate blood or the hospital staff donate blood when necessary. They have facilities to screen the blood and it is given fresh. The woman’s husband disappeared when they asked him and has not been seen since, and so Alice very kindly donated a pint (?) of blood as she was a match. She was subsequently feeling a bit shaky, so we went to a café called Lulu Bakes for tea and the sweetest cakes and sweets I have had! I am going to get my blood group tested so that I can also donate blood if they need me to and I think that Mona and Duana will too.
TUESDAY
On Tuesday morning we had some suturing teaching from Dr Nandukumar who was absolutely horrified to learn that we practiced suturing using new and non-expired sutures, here the students use a curved needle and thread! He showed us the sutures that they use for patients and all of them had expired, many by several years. This isn’t necessarily a problem although they do check the strength of them before they use them, but it better explained Dr Nandukumar’s horror!
Whilst we were in the middle of this suturing session they brought in the burnt woman that I mentioned. Her burns are by far the worst I have ever seen. They were all over the front of her chest and neck, up onto her chin and down her arms. Her nylon sari had caught fire whilst cooking on an open fire. It was so sad and she was obviously terrified. We had no idea what was going on, one minute we were practicing suturing on a tablecloth and the next they were readying the room for a debridement of this womans burns. This is basically where they remove all the necrosed tissue that forms in the healing process. They need to do this to keep the wounds clean so that she can have a skin graft. As they don’t have an anaesthetist here, they were using something called ketamine, which is a sedative, in order to carry out the surgery. It was just so unbelievably different to any surgical procedure I have ever seen. They didn’t wear scrubs or masks although they did use sterile gloves. But they didn’t use sterile gowns to cover her, just her own shawl. In the UK there is no question that there would have been much, much, much better infection control and there would have been an anaesthetist who would have very carefully monitored the patient throughout. The only form of monitoring that the patient had was a pulse oximeter. The reason ketamine was appropriate was a) it doesn’t lower the pulse ox and BP in the way that other anaesthetics can and b) it is very short acting, so if there were any complications with it such as a reaction of the patient to it then these would have been short acting also. However it meant that Dr Nandukumar had only 15 minutes to debride a very large area. Throughout, the patient was moaning and making noises as if she was very much in pain, especially when they were trying to flex her neck which is particularly bad. I know that due to the sedative she won’t remember this but normally in theatre patients are completely unconscious and so this was a very strange experience for us and I think we were a bit shocked for a while after, especially as we had not expected it at all. She currently doesn’t want to have skin grafts, especially as her husband is not there, so all they can do is keep the burns clean and see if she changes her mind. I think they are going to start using aloe vera on them, which both soothes and has antiseptic properties.
Tuesday was also the day of our first yoga class! There is a Ayurvedic doctor named Mahesh who works at the hospital. He is small and has a big moustache and is an absolute legend! Anyway – he is amazing at yoga and when we found this out we managed to convince him to give us yoga classes. We have them every other evening at 5:30 and have managed to get loads of nursing students, nurses and a doctor to come along- he now has a bit of a cult following! So first class was Tuesday and we learnt the ‘sun salutation’ which comprises 12 different movements. I didn’t realise how much breathing was involved in yoga, and also how peaceful it is. I have only ever tried pilates which is a lot more active. I really, really enjoyed the class and am very glad that Mahesh has agreed to be our yogi! However, I did nearly fall asleep when he asked us to lie with our eyes shut and relax each part of our body in turn- I was just so relaxed!
WEDNESDAY
Wednesday was quite an uneventful day. We spent some time finalising the questionnaire which we are going to use to do some research whilst we are here into hypertension in pregnancy. In order to do this, we plan to check the urine and blood pressure of every pregnant woman attending the hospital whilst we are here, as well as asking our questionnaire, which evaluates potential barriers to these women to accessing healthcare. Hopefully it will be interesting and we aimed to start on Thursday, so we had to get that sorted out. We also had a bit of a group meeting to discuss our weekend plans and we decided to visit the Tiger reserve and National park which is about an hour away from here. There are lots of wild elephants there!
THURSDAY
Today we spent our day doing our study, checking the BP and urine of all the pregnant women that came to the hospital. There were quite a few so this kept us very occupied.
We also had yoga class number 2, which was great, except I fell asleep during the part where you are supposed to relax your whole body one part at a time! It was so embarrassing! My supposed friends Mona and Duana didn’t even poke me to wake me up - they just let me sleep. Now all the nursing students laugh at me when they see me!
FRIDAY
On Friday we drove with some of the doctors from the hospital to one of the community centres, which was about an hour and a half away. There are a number of these centres and at each there is a ‘health animator,’ a member of the tribal community who has been trained to recognise signs and symptoms so that they can identify those who need medical attention. They can either refer patients to the main hospital or arrange for them to come back when the doctors are coming if it isn’t urgent. It is really an excellent system because we have found that many people don’t know about worrying features of illness. For example- so far of all the pregnant women we have spoken to – none of them knew of any medical complications in pregnancy. However the health animators are aware of these and can recognise them in the women that they see. I have lots more to tell, but the electricity has just gone - so am off on a candle hunt! I will write again after our weekend at the National Park! Happy Weekend! xxx
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