Home again, Home again

So I have now been home for about a week and have just about gotten my jet lag. For some reason it was a lot worse on the way back.
I wanted to finish narrating my last week in Vellore.
I only spoke of Monday on my last blog.
SO Tuesday I went on Nurses Rounds since the week before when I was on CHAD I did not get to and this was one of things I really wanted to do while here. I was still not feeling so well at this point, so was a bit nervous about going into the villages where there would really be no "bathroom" for me to use, plus being out in the hot sun all day. The last week we were here it got pretty warm on us -- about 85-90. Anyways, I went and started feeling better after having some hot tea one the village woman made for us. I was nervous to drink it, but was glad I did after. It seemed to soothe my stomach.
So Nurses Rounds consist of the Nurse, the Health Care Worker, a driver, a Nursing Student, and us foreigners in a SUV-like truck. The Nurses visit the homes of last trimester pregnancies, newborn babies, and other problems the Aide would like for her to see. They also have to do death reports, and so have to talk to the families and figure out what happened and what the person died of. The first village we visited a newborn baby has died after only a few hours of life, and so they were talking to the mother and rest of the family to see why this baby died.
The second village we visited had been named "Best Village in India" by the Predident. Every person in the village had been educated and they had different programs for the people so everyone had a job to do. I noticed in this village as well, that each home had some landscaping outside the house -- some roses or other flowers -- which was very different that other villages. They seemed a bit more developed and more wealth that other villages.
We visited 4 villages in all. During the day we saw alot of pre-natal visits, did some newborn education to a mother, gave out some medications, among other home visits.
I really enjoy getting to go to the homes and villages, as I got to see the way people live and get a better feel for the culture here. I thinked I learned more about cultural things than medical things on this day - which was awesome.
Thursday was a awesome day. We went to Kerigeri, the leprosy hospital. It treats all things now, since Leprosy is not as widespread as it was in the past.
So the scholarship I came over on is the Paul Brand Scholarship. So who is Paul Brand? He was a hand surgeon who did a tremendous amount of work in leprosy. He was a founding physician at Kerigeri. I have been reading one of his books, Fearfully and Wonderfully Made. Paul is reading the biography about his life and Rebecca ready The Gift of Pain, which I hope to read after this book. It is really neat to read about the same places we are now standing back in history when some things were very different here and some things are pretty much the same.
The hospital here is a great place. Everyone is so friendly. We had to catch a bus at 7 am from the CMC Hospital to ride about 30 minutes out to the hospital. There were many stops along the way to pick up the nurses and doctors and take them out to the hospital. Kerigeri is outside of town - I think this was because when the hospital was built was when Leprosy patients were sent out from the cities.
We spent the morning at the outpatient clinic. There were 4 of us, so we split up and went to different specialties for about an hour and than rotated around.
I first spent some time with a physician who is a well-known leprosy clinician. She had Paul and I go learn what the PT and OT people did -- casting, making molds to take pressure off pressure points where patients' were getting ulceration from not being able to feel. Also we saw how they test the peripheral nerves - kind of similiar to diabetes peripheral neuosensory testing. It was pretty interesting.
We than saw some patients with the physician ( she was a dermatologist). We were able to see the depigmentation that occurs with leprosy, as well as feel many enlarged nerves from the bacteria causing inflammation of the nerves.
This was quite fascinating and something I will probaly never see again.
I also spent an hour with an Opthamologist. I never did opthomology during 3rd year, so this was really interesting to me. She let me look throught the slit- lamp, which was very cool. To really see each part of the eye magnified helped me to better understand what I am looking at when I look through my little scope.
We spent the afternoon at the actual hospital and had a lady from the Relations Department take us around - like our own personal tour. She took us to some of the research areas and were able to learn about some of the interesting research going on here. Including research on resistance to treatment, genetics of leprosy, and using rats to determine of treatment has been successful. Leprosy is not able to be grown in the lab like most bacteria, but it will grow in the feet of rats. So they inject the bacteria in the rats foot and follow the bacteria this way.
We also were able to see the leprosy wards, where they make the special shoes for the patients to help keep them from getting ulcers, as well as visited the shop where the people with leprosy make different products ( table cloths, dresses, and other things).
It was a great day and a nice way to end my time here. It was especially meaningful since this was the work of Paul Brand, who I am here because of.
Now being home and people ask how India was -- so many different emotions flood over me. It is a hard question to answer -- it's different than any other country and has taught me many things - about medicine, about culture, and about humanity.

Week Three - Final week

So for the weekend we went to the beach at Mamallapurum. I will not go into great detail about this, since this blog is more for my medical experience. But we had a great time and was very relaxing and refreshing. I swam in the Indian Ocean (well the Bay of Bengal), had a massage, and laid by the pool... oh and also shopped. Week 3 I signed up to do a Dermatology rotation for the week. I actually only ended up not doing so much Derm, but did have a educational week and saw a lot of interesting things. After the trip back from the beach, I was not feeling so hot and my stomach was having issues. This was first time I felt sick the whole trip. I ended up taking a course of Cipro after my stomach continued to have a mind if its own for 3 days. The Cipro and Loperamide helped alot and by Thursday, I was feeling great. So Monday I went to Dermatology Clinic. I loved it! I saw a lot of interesting skin disorders and the Departmental Head doctor would have all the students (the students that go the school at CMC and me) come in to see some rare cases. She would explain the disease and pull out books for us to look at. We saw epidermolysis bullosa, which is a disorder in the skin in which the skin is missing an anchoring protein to hold the skin together. Due to this, whenever the child undergoes mild trauma (just bumping his head and crawling) can lead to bulla to form on the skin. The first child we saw had healing bullae all over his body, but was of good weight. His nails were thickened and narrow. This type of EB was Dowling-Meara ( I had never heard of this before). This is a not so severe type. Another child I saw with the resident I was with had EB as well, but had a congenital dystrophic form - a severe form. This child was very thin, one eye was blue and dysconjugate (not moving together with the other eye) and had severe bulla and scarring over his body. The back of his neck was covered by a scab from the trauma of his shirt collar on his shirt. He also had no fingernails or toenails, part of this disease. He also had contractures of his fingers due to repeated scarring. A very sad site. It was amazing how he was still able to manage buttons and take care of himself with these deformities. Some of the other diagnosis I saw: - tinea capitis ( ringworm on the head) with alopecia (loss of hair) - tinea corporis (ringworm on the torso) - vitiligo - bad staph aureaus skin infection - malasma - leprosy - erythematous plaques covering a man's body who was being worked up for possible Sezary syndrome or other underlying malignancy ...among others. I will write about the rest of the week at a later time. We leave for Chennai today (Friday). I need to go finish packing and try to fit all the things I bought here into my bag. = 0

Scrub Typhus

Note: This is a paper I wrote on a Infectious Disease here in India. This is part of my grade and may not be so enjoyable for those not interested. Just a forewarning.

During my time here at CMC (Christian Medical College) Hospital in Vellore, India, the doctors have talked about a new sort of epidemic over the past couple years of Rickettsial infections. Over the three weeks here, I have seen 4-5 cases of Scrub Typhus in all age groups.
So what is this Scrub Typhus, was my question and may be yours.
Scrub Typhus is caused by a gram negative bacteria, Orientia tsutsugamushi. The name was recently changed from Rickettsia tsutsugamushi, for very important “microbiology” reasons, I’m sure.
How do we get it?
The bacteria’s host is chiggers, which are baby mites. The bacteria are in increased numbers in the chiggers’ salivary glands. Usually the chiggers pass the bacteria on to rodents as the secondary reservoir when the chigger/mite feasts on rodents. However, humans are exposed when bitten by an infected chigger.
The certain type of mite that carries this bacteria populate scrub vegetation, hence the name. However, they have also been found to populate sandy beaches, deserts, and rain forests. People are at risk at getting Scrub Typhus in areas of East and Southeast Asia, India, Japan, and Northern Australia and adjacent islands. These mites prefer rainy seasons and cooler weather, and thus India has seen an increased number of infections during the winter (also the rainy season).
How does a person present?
People can present with many different combinations of symptoms that may cause a rather confusing picture. They may have headache, shaking chills, lymphadenopathy, high fever usually in the 104-105 F range, apathy, anorexia, GI symptoms and conjunctival injection. Without treatment, in 5-8 days a person can start to get a maculopapular rash. The rash starts on the trunk and spreads to the extremities (centrifugal). This rash also helps narrow the differential due to the soles of the feet and palms of the hand being involved, which only occurs with a handful of diagnosis. This rash may also have a petechial look to it, due to the perivasculitis of small blood vessels that occurs causing endothelial injury – resulting in small hemorrhages under the skin or petechiae.
In this same time period of 5-8 days since the start of symptoms, the person may present with an enlarged spleen, cough, and delirium. If not treated, people can die from this infection usually from complications of the infection such as hepatitis, renal failure, shock, or pneumonitis.
The bacteria incubate for 10-12 days prior to a person’s symptoms starting, so a person may remember having been bitten by chiggers 2-3 weeks prior or may still have a bite mark present.
What does a chigger bite look like?
The bite of a chigger or mite goes through different phases as it heals. First the area of skin is red and endurated and enlarges to 8-12mm. It turns into a vesicle before rupturing. Next it becomes dark and necrotic in the center and in called an eschar. This is usually the stage the doctor will see it as and will look for an eschar during the physical exam. How do you diagnose Scrub Typhus?
The Weil-Felix test is a widely used test, due it availability, and being cheap fast; although it will not be positive till the second week of infection and it is not specific for Scrub Typhus. The test causes the antibody to the bacteria in the patient’s blood to react with strains of Proteus bacteria and agglutinate when positive. Another test, the Fluorescent Antibody test, or IFA, is the gold standard test. It identifies the antibody is present in the patients’ blood to Orientia tsutsugamushi. ELISA is another test method that has greater than 90% sensitivity and specificity.
Here at CMC, they use the Weil-Felix test first to narrow and than if positive use the IFA test. However, usually the patient has been treated and responded before this time.
SO, what is the treatment?
Doxycycline 100mg bid for 7-10 days or chloramphenicol is also effective.
Doxycycline can be given if the diagnosis is suspected due to symptoms (often done in Vellore) and the patient’s fever will reside within 36 hours if the diagnosis of Scrub Typhus is correct.
Some History…
Scrub Typhus first made history in the United States during World War II, killing more American troops than any other infectious disease in the China-Burma-India theatre.
It has also recently made the news due to its return to Maldives, which is a popular island resort off southern coast of India. Research was undertaken here due to the bizarre return of this disease. There was no recorded cases in humans on the island since the 1940’s, than in 2002 there was almost 70 people that contracted the disease and 3 people died. People thought it may be due to an influx of rats, the reservoir. So, much money was put in place to correct this problem and guests warned to protect themselves from chiggers. Also, it was seen that in Japan, another common place for the infection, numbers of humans infected would cycle through the years, at times, going 5-10 years without having one case. Maybe a similar cycling also happened in the Maldives.

Resources from
- "Rictkettsial Spotted Fever in Kerala." National Medical Journal of India. Volume 17 #1, Jan 2004.
- "Scrub Typhus." Aracelis, Fernandez. eMedicine. July 14, 2006.
- "Scrub Typhus Reemergence in Maldives." Lewis, Michael; Emergent Infectious Disease. December 2003.

CHAD

Week 2 -- Community Health and Development (CHAD) Rotation
4 of us in our group did CHAD this week along with an Australian couple. CHAD has a clinic where the see the very poor who could not afford CMC pricing as well as the village population. So two days we were able to go into the villages and see the patients there and the other days we worked at the clinic.
We quickly were informed that this was not the best week to be doing CHAD due to Pongal - the Hindu festival of the first harvest of the year. I hear it's like Thanksgiving. From what I have gathered throughout the week, Monday is the day of first harvest. So they bring in the first harvest, make all this rice and pray to the sun gods for thanks. Tuesday is the big deal -- the bulls have their horns painted and sharpened and all the villages get together. I think there is also some running of the bulls kind thing as well. Wednesday is when all the family gets together. So not many people wanted to come see the doctor during this time in the clinic.
Monday Paul and I did Outpatient Pediatric Clinic. It was pretty interesting - lots of seizure disorders here. I am not sure why there are so many people with seizures here, but we saw alot of people this week with this diagnosis.
Tuesday - TB Clinic -- eesh. Most the patients we saw were patients on treatment that weren't coughing. But one lady come in with a hoarse voice and later we looked at her chest x-ray and she had a nice infiltrate (spot in her lung) and the doctor thought she was probably pretty contagious at this point, since she was not on treatment yet. So hopefully I did not breathe too deeply when we were seeing her. We also saw 2-3 patients with Leprosy. It is so sad to see their hands and feet that have been destroyed and deformed as the result of this disease.
Wednesday - Prenatal clinic. Lots of pregnant moms. I learned how to listen with my stethoscope to hear baby's heart sounds. Something I never tried in the states as we just use the Doppler that is just sitting next to the bed. But they cannot afford one here or maybe it is just not vital as they are able to use the stethoscope.
Thursday- Doctor's Rounds. So CHAD takes care of the small villages around Vellore. They have a pretty nice system set up. Each village (which is about 1000 people) has a health aid that is assigned to about 5,000 people - about 4-5 villages. They go to the villages every week ( some go daily) and tend to the villages medical needs. Than there is a nurse who is over 15,000 people. She goes to the villages twice a month and sees all the pregnant mothers in the last trimester and tends to any needs, as well as bringing medications to the village. A doctor is assigned 50,000 people and goes to the village once a month. At any time, they can send a patient to be seen at the main CHAD clinic for further work-up or treatment.
The people pay as they are able to -- the system looks at how poor a family is and decides if the medications are totally free or what price (which is very very small -- less than a dollar for a month's supply of medication).
So Thursday was Doctor's Rounds -- also Pongal day. We went to four villages and went by bus. The bus was the clinic. We would set up a table next to the bus with 4 chairs. The exam table was in the little bus- where the prenatal exams are done. And the back of the bus has a desk for the nurse to hand out medications and give immunizations. Very impressive. We ended up seeing alot of people this day, because the last doctor's rounds were cancelled the month prior due to rain.
I really enjoyed being able to go to the people's homes, see how the live, interact, and understand more about the culture.
They have their bread and butter diagnosis here just as we do at home. They see alot of hypertension, diabetes, and seizure disorder. I think those were the three things we saw the most... oh yes and being pregnant. Overall, a very educational experience.
Friday-- Well Friday we were supposed to go on Nurse's Rounds but I think they overbooked who could go and so were got booted. Scott and I stayed at clinic instead - which was awesome. It was ENT clinic. The doctor we worked with was a great teacher. She would draw a picture of what we would see in the person's ear, for example, and what has wrong and than have us look in his ear. I learned alot from her. The ear is a hard thing to look in and appreciate problems, especially in kids who may give you a split second before totally freaking out. So this was very good for me. We saw some ruptured Tympanic membranes (ear drums), neck cancer, vocal cord palsy, and lots of nasal issues- deviated septums, sinusitis, nasal polyps and such.
And Friday we left for Mamallapurum - a beach city. = )

Picture Description

So the first picture is Paul and Scott at the table at the Johnson - where we girls now stay. This is where we eat some. When we are on top of things in advance to sign up for dinner the night before - they will bring us dinner here. There is also a TV in this room - with HBO and about 10 other English channels - a very nice thing we found about 5 days into the stay.
Picture 2 and 3 from the top are pictures of the room and bathroom that we were staying in to begin with. This is the New Housing Complex - although not so new. On the left wall in the bathroom is the water heater -- which was very nice.
Pictures below that are the room and bathroom at the Johnson House - we are loving staying here. Again, the shower is not really seperated from the bathroom so we end up getting the whole floor wet when we take a shower. There is a drain in that corner of the room next to the shower head. Now if you may notice all the the big plastic bins. Well the people here don't use toilet paper. Next to all the toilets are water facets and bins. The people will turn the water on and use the left hand to pour water on themselves. No, I have not tried this method. So the left hand is considered unclean in India for this reason and is not used to eat with -- makes sense = ). The shower water is warm, although there is very little water pressure - so it makes it hard to get shampoo out of the hair and such. There is also a plastic bucket here, for Indian people also will fill the bucket with water and wash themselves off this way -- I have done this.
Our room actually has air conditioning although we have not needed it at all and have not even turned it on. Actually in the mornings Rebecca and I are quite cold. The temperatures right now are probaly in the 70's with some days getting up to 80. I am very glad I am here with all the beautiful greenery and without sweating through the day.

Weekend Fun

This weekend was pretty nice. It was nice to get to sleep in - I think we are getting used to the music the plays over loudspeakers every morning or it is just not as loud as before. On Saturday, we went to the Vellore Fort which is about a 15 minute ride from where we stay. It was built in the 1500's and is made out of large granite slabs - pretty impressive. It also has a large moat surrounding it, which was filled with water at this time. During the hot summer months, all the water is dried up. The Fort has a pretty long history of Kings and such that lived in it and the British took it over and held the Ruler and his family in captivity here as well in the 1700's.
The Fort has a Hindu temple, a Muslim Mosque, and a Christian Church within it -- very well rounded. We walked along the wall of the fort (picture of Paul and I on the wall) than walked in the temple, but only after being yelled at by a shoe man to come take our shoes to him. We all just went in at different times and had the other person hold our shoes, except for Scott... who decided to put his shoes on the other side of the street and hope the little shoe man would not see. Well after everyone came out, Scott had no shoes. The shoe tender had taken them to his store - Scott had to pay the man for watching his shoes ( and taking them too). Kind of funny ... but I'm glad Scott got his shoes since they are the only pair he brought with him. The temple was very large - and I felt a bit out of place so did not spend too much time here ( this is the large white tower pictured above.
We also walked around the Christian church but it was locked up -- it was very pretty. We than walked over to the museum, which had a large T-rex outside as well as some stone sculptures dating back to the 400's. They were just sitting outside without any coverage from the weather - but I guess they have made it this far. The museum was 4 rupees to enter for the locals, but 250 for foreigners. So we decided to not go in.
We also went to our a hotel to eat lunch (Hotel Darling). This took about 3 hours - very slow - but is was very good and the largest meal I have had since being here. We even had ICE CREAM!! It was so great.
Sunday we hiked up the hill/ mountain that is across the street from the campus. It was not a huge hike, but it was great fun. The young boys of the village come up here, I think to smoke, and like to make fun of us I think. Kathryn went up half way due to her asthma, and the boys kept her entertained while we went the rest of the way up. On the way down, Paul was being all adventurous and ended up spraining his ankle. But he is healing quickly. That is what happens when you try to climb boulders with sandals on.
We also went to a Church service Sunday here on Campus. The chapel here is in the shape of a octagon which I had never experienced before, but it was so nice. And the music seemed to resonant on the walls. It was a beautiful service and very refreshing to me. The speaker that gave the sermon was a guest speaker - he was a Urologist here. His message was very good and I think touched all of us that attended. He spoke of God seeing us as we are and we try to hide, our sins and who we are from others, but God sees us for who we are. And that we should be loving and loving others and not be caught up with the materials or what we can obtain here. He used a depiction of a mouse he was chasing in his house. It was great.
And starting our second week...

A couple cases...and a monkey

I wanted to write about a case or two that I have seen here this week.
First, a child I saw on the Wards.
This was a 4 year old boy who came in due to a 4 day history of very high fever as well as a peculiar papular rash (which means you can feel it when you run your hand over the skin ...aka it sticks up) that started on the head and spread to the trunk as well as the palms of the hands and soles of the feet. Rashes usually do not appear on the palms and soles and there are only a few infections/reasons for such. The rash almost looked like a rash you seen in measles. Small lumps all over his face and body that were slightly red. He also did not look too ill-appearing, although he was very warm to touch.
One of these rashes that are on the soles and palms is Rocky Mountain Spotted Fever. Well here in India there are no Rocky Mountains, which is spread via tick bites kind of like Lyme disease and caused by a bacteria -Rickettsia. Not until this past summer was it found that rickettsia was also a problem here in India -- and there was quite an outbreak with many cases. The Peds program is currently doing research on this and testing children with fever and a rash for rickettsia to assess how prevalent this diagnosis is. Here in India they have a different species of Rickettsia which is called Scrub typhus ... something I have never seen in the states. So the treatment -- doxycycline. Now even patients they are not sure if they have it or not will treat with doxy and if the fever diminishes within 72 hours it is diagnosed as Scrub Typhus. Actually today, I saw another woman who actually had an eshar from where the tick had bitten here and was treated with doxy for presumed Rickettsial infection.
I asked the resident today about these ticks and he described them more as chigger. Scrub typhus is not transmitted via ticks but via chiggers or mites described in articles on it. It will be interesting to see how their study here finds.
A second case...
there are so many patients we see everyday so I will try to share ones that are unique to this country.
In clinic on Friday we had a 10 year old child come in who looked about 5 years old. He was very underweight, malnourished, and very short. He came in just a year prior to be treated due to his poor growth. He was diagnosed with Rickets at that time, or Vitamin D deficiency. This is a pretty common thing they see here. One, because of malnutrition, also due to their dark skin ( one way Vit D is created is vie sunlight in the skin) and the cultural practices of wearing veils and swaddling babies or not allowing much sunlight to reach the skin. I was also reading that many here may not be totally Vit D Deficient but with lower daily intake of Calcium here causes a increased need for Vitamin D to absorb the Calcium -- and causes those with low Vitamin D to become deficient due to increased need by the body.
This child (I will add a picture of him later) has bow legs pretty severely due to this. He also has what is called rachitic rosary, which is where the ribs have bony knobs where the ribs join the sternum. His knees were also very enlarged - this is called walking Rickets. This bone deposition increases at pressure points, so in children that can walk this is at the knees - called walking rickets. And in children that crawl, this is at the wrists and called crawling rickets. Rickets is a disease of children and causes poor bone formation at the growth plates. In adults, after the growth plates are closed, Vit D Deficiency results in osteomalacia ( soft bone).
They were treating the child with Calcium and Vit D, but due to the late period of arrival the doctors did not feel he would be able to catch up on his growth.