Laparoscopic Cholecystectomy…

…This morning, we had the fortunate opportunity to observe a laparoscopic cholecystectomy (removal of the gallbladder) performed by a highly experienced and educational physician. The doctor has been a general surgeon for 30 years and has performed laparoscopic procedures nearly exclusively for 20. He said he had performed between 10,000 and 15,000 laparoscopic procedures, and it showed once he began the surgery. I have observed other cholecystecomies at the Washington University School of Medicine, and this surgeon’s work was just as impressive even with significantly older and reusable equipment.

We prepped the OT and observed as the silent patient entered the room, lay down on the bed, and waited for what to him must have seemed like an eternity for the anesthesiologist to arrive. Most patients have a pulse around 150 as they await surgery here, but this man’s was a remarkable 68. To be honest, I would have felt in very good hands under this surgeon as well.

In no time at all, the anesthesiologist had the patient under general anesthesia and the surgeon arrived and was cutting 60 seconds later. Four small incisions (less than 2cm) were made in the navel, about 8cm above the navel, about 15cm right of the navel, and about 15cm up and right from the navel. The abdomen was inflated with CO2 for about 20 seconds and port mechanisms were inserted into the small holes through which an arsenal of tools could be inserted and removed as necessary. Then the surgeon started to really show his expertise. He slid in the scope through the navel and gave us a short tour of the organs. He then positioned the scope to watch as each tool broke through the peritoneum. With four tools now positioned next to the liver, he quickly maneuvered to and positioned the gallbladder. A tool came out as a syringe went in to drain the gallbladder of bile. The syringe came out and more tools went in. In an orchestra of both fine and sweeping movements, the gallbladder was clamped off from the rest of the body and cauterized away from the liver. The port above the navel was removed and the gallbladder was lifted through the remaining hole to the surface. The stone was too big to remove through the small incision, so the surgeon inserted a special tool into the gallbladder to crush the stone and easily extract the entire organ through the tiny incision.


–What is left of the gallbladder on the left and crushed stone on the right–

The fluidity, cleanliness, and proficiency with which this procedure was performed was amazing to watch. In the United States, this procedure would cost thousands of dollars. For nearly the exact same outcome and same minimally invasive surgery, the cost here is about Rs 20,000 – 25,000 ($370-$470). Incredible!

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Appendectomy…

…This evening, we were called back to the hospital to observe an emergency appendectomy. When we arrived, we helped the senior technician prepare what they call the OT (Operating Theater). We retrieved the reusable gowns and equipment from a steaming hot autoclave, descended down ramps (there are no elevators) to the basement, removed our shoes, put on slippers, and entered the OT. The patient was already lying on the table with his IV hanging next to him. He remained silent for the next 20 minutes as dozens of tools, sutures, gowns, and vials were prepared. The anesthesiologist entered next and administered spinal anesthesia through a terrifying looking 9cm needle.

The OT was kept unusually hot for this procedure using portable electric heaters with built in fans. With everything prepared and draped, the surgeon entered and scrubbed in. The procedure was much less invasive than I had anticipated. About a 2 inch incision was made right of the patient’s navel at a slight angle from vertical. We watched as the internal oblique muscle, in an attempt to preserve the strength of the abdominal wall, was split and not cut at a right angle to the first incision. After some pulling and tearing, the appendix and some intestine were brought out of the body where work to close off and cut out the appendix was performed. The doctor generously described each action he performed and educated us at every opportunity.

First Indian Haircut…

…Last night, I had my first haircut in India and left chuckling at the novelty of the experience. To set the tone, it was Rs 50 (about 97 cents). I had seen dozens of roadside open-air barber stands but I ended up going to where the local cricket players and my host father get their haircuts.


–A typical roadside barber setup–

To my complete surprise, the barber shop looked just like a nice women’s salon back home except that it was entirely for men (the female salon was on a different floor). I had expected some rugged virile establishment speckled with rust and dirt, especially after having seen what was offered on the roadside. Instead, I saw masculine men getting facials, shaves, massages, and manicures. The experience became comical, however, when I spotted a nearly bald gentleman reading the paper under one of those spherical plastic drying devices. It almost didn’t seem possible for this to be happening in Faridabad.

Although I asked to keep the length of my hair about the same, and even verified to make sure he understood my English, the barber’s first swipe took hair practically down to the scalp. I just smiled and took it all in, figuring that it would have to grow back at least before I returned to the States.

Once the haircut was over, the unexpected and unforgettable head massage began. Instead of a soothing, pleasant massage, it felt and looked in the mirror as if this man was trying to crush my skull. He interlaced his fingers on top of my head and applied as much pressure as humanly possible to the sides of my cranium. This was followed by more bone-shattering work on my back, shoulders, and arms, including popping each of the joints in my fingers. Finally, as I thought the procedure was ending and was ready to celebrate my survival, he pulled my arms straight back and then readied his arms between my elbows and back. I could see that some horrific back-popping chiropractic work was imminent and was forced to cry uncle. With my arms helplessly locked behind me, I just begged for the whole thing to end.

Although I had been slightly upset by the short length of my hair, I was happy to pay and left very content that I had not been broken into two pieces.


–Another of many roadside barbers–

Agricultural Oasis…

…While the female volunteers were observing deliveries today, I was quickly summoned into a vehicle at the hospital. As the driver and technician spoke only very broken English, I was under the impression we were leaving to tend to an emergency or pick up a patient. We were driven as fast as possible (about 15mph) on the extremely rough main road for several hundred meters before turning down a very pleasant and well-maintained street. We meandered through nice homes interspersed with lush farms and buffalo basking in the warm sun. We then turned into an appealing compound where I could immediately tell there was no emergency.

After a few moments of confusion as to why we were there, one of the men I had worked with at the hospital the day before came from around the corner and welcomed us all to his home. Over the next half-hour, his brothers, cousins, and other relatives slowly materialized from the surrounding homes to welcome me and say hello. Now knowing that this was to be a tour, I immediately switched gears and tried to take in as much as I could from this unique opportunity.

My first impressions of this home were its unexpected serenity, lush green vistas, and organized cleanliness that seem to not exist anywhere else I have yet visited in India. I was shown their buffalo (not the North American kind, mind you), cow, sheep, German shepherd, and local peacock. It was the most beautiful property I have seen in India and I felt honored to be able to see it let alone be welcomed so royally to it. Upon the owner’s insistence, one of the men was sent to bring fresh buffalo milk for me to try. He returned ten minutes later, first with chairs, then with a table and cloth, and finally with a tray of cookies, snacks, and steaming hot glasses of the freshest buffalo milk possible.

I’ll admit, I had some reservations at first. Being used to pasteurized cow milk from a sealed and refrigerated plastic container, I felt a little anxious drinking hot milk straight out of a buffalo sitting five feet away from me in the middle of an Indian wheat field. But I was committed at this point and was rewarded by an unexpectedly delicious first sip. I even let down my primary defense of using hand sanitizer before touching anything I eat as I politely took cookies and snacks handed to me. The buffalo milk is much thicker and fattier than cow milk, which is one reason why it is strongly preferred over cow milk here. Milk that isn’t fresh is sold in non-refrigerated cartons here and has a very bitter, almost sour taste. The buffalo milk went down very smoothly but was much more filling than a normal milk and I was fully satisfied. But as soon as I lowered my glass, I saw the next one coming. I had read about this kind of hospitality before and happily started in on what was now becoming a challenge to overcome.

I took the opportunity to battle language barriers in order to learn more about agriculture in India. What I learned was fascinating. Being a farmer here in India is much more of a luxury and symbol of being elite than in the United States. One acre of farmland here in Tigaon is valued at one crore 50 lakh (Rs 15,000,000 or about $286,000)!!! I know this value to be correct because I have heard it from separate independent sources, including the doctors, here and in Faridabad. This family’s farm was 20 acres, one of the biggest I have heard of yet here. They grow wheat from November to March and then rice from April to October. I believe they said they can harvest the wheat every 90 days for a yield of about 1600kg per acre and sell it at a price of Rs 20/kg, by my calculations giving Rs 640,000 ($12,100) per wheat harvest. Here, that is a substantial amount of money.

 

The buffalo are also very valuable and are capable of generating a large income. One buffalo can produce 15 liters of milk per day, which sells as about Rs 40 ($.80) per liter. I obtained the value of buffalo but I will check it and edit the post tomorrow to let you know. My note seems a little high but I think they really are that valuable. The family owned five adult buffalo and five newborns sat right next to us as I enjoyed my milk.

After my inquisition and finishing a generous pint of thick hot milk, I was taken on a tour of the fields, where grass is grown to feed the livestock, the product out the other end is set out to dry, and wheat and rice are grown to sell. The crops were remarkably green given the dusty brown surroundings I have become accustomed to here. The cow and buffalo pies were stacked strategically to use for cooking at a later date. The sustainable nature of this farm was especially striking after the disregard for pollution and litter so prevalent in the cities here.


–My generous and hospitable hosts, and owners of a true agricultural oasis–

Rural Birth…

…I amended my previous post (Busy In The Village) after new insight and clarification gained today. Be sure to check out where I have noted the change in the discussion of the caste system’s impact on child and maternal health care.

Today, we went back to the same hospital in Tigaon. I learned that the two doctors, one homeopath, and one dental surgeon here provide healthcare to more than 45,000 people throughout their village and the nine surrounding communities. As soon as we arrived, the female volunteers were taken into the delivery room and observed two side-by-side and nearly simultaneous child deliveries. Unfortunately, males are not allowed to view normal deliveries in India. Even male doctors and fathers are not allowed in the room during labor. I say “normal deliveries” as opposed to Cesarean sections because C-sections fall under the classification of surgeries. I know this to be the case because last Monday, on my first day here, I observed a C-section during which the operating room technician was also male. Although I did not get to see today’s deliveries, I made sure to record a detailed account of what the ladies told me about it after.


–The primary OR in which I observed a C-section on my first day–

Just as in the operating room last week, everyone in the delivery room was required to be barefoot or in simple sandals. The expecting mothers were placed side-by-side and labor was induced in both. One female doctor and three nurses tended to both patients. The volunteers said that, as I had similarly noted during the C-section last week, there was little done to comfort the patients. At times, the staff was shouting at the women forcefully and even slapping them on the legs to work harder. The only protective equipment used by the staff were latex gloves. There were no masks, eye protection, or gowns. Everyone was in street clothes although the doctor did wear an apron because she had an important engagement to tend to and left part of the way through the procedure. The volunteers’ first reaction to the delivery was that “it looked like a crime scene in there.” When I asked what kept the staff from getting exposed to blood, they said simply, “Quick reflexes!”


–The hospital catering to a population of 45,000 people–

The first woman to deliver was the older of the two women who has two daughters and desperately wished for a son. After two hours of exhausting labor that could be overheard throughout and outside the small hospital, she gave birth to baby boy. The doctors and staff do not notify the mother of the gender of the child, however, until the placenta has been delivered and the mother has stabilized. It is believed that some women have died from shock related hemorrhaging due to overwhelming depression of having delivered a daughter. The placenta was delivered and all celebrated cheerfully the birth of her baby son.

The next woman to deliver was 21. It was her first child and labor for her appeared to be much more difficult. She delivered a baby girl. The volunteers noted that upon announcement of the baby’s gender, the mood was much less celebratory and the mother was given consolation as if to say “at least you’re young and it’s just your first child.” She will likely try again for a boy, just like the other mother.

In a similar manner to government incentives for pre and post-natal care, I also learned today about financial incentives related to child raising and contraception. If a mother bears a second female child here, an account for that daughter will be automatically created and the government will place Rs 25,000 ($500) into it to be withdrawn once she becomes 18. Apparently, many mothers and families do not take adequate care of or properly nourish their second daughters, sometimes even leading to death. Condoms and birth control can also be obtained from the hospital for free and the government will actually pay men approximately Rs 1100 ($22) to have a vasectomy. I believe there is also an incentive for women to have tubal ligation, but I do not know what the financial incentive is.


–Men huddled around a fire in the chilly morning fog next to the hospital–

Busy In The Village…

…Today, we volunteered at a public hospital in a small agricultural village approximately 10km East of Faridabad. The hospital serves as a hub for the nine surrounding villages and Tuesdays is the day for pregnant women to receive their pre and post-natal checkups. Checkups are simple, including a basic urinalysis for glucose and protein, a simple hemoglobin test, blood typing, vitals, delivery date estimate, etc. Ultrasounds are available in large hospitals or private clinics, but it sounds like many of the women just do without them. Determination of a child’s gender before birth is illegal in India due to male favoritism. The female volunteers here were allowed to help at the ultrasound clinic last week and found the doctor quickly scanning over regions where the patient might be able to guess her child’s sex. Often, the doctor would know the gender but be unable, by law, to tell her patient.

As a result of this law, the pre-natal checkups also include a questionnaire as to the mother’s caste, number of attempted deliveries, number of abortions, number of living children, and the gender of those living children. The government will investigate any suspicious activity regarding abortions. For instance, a mother who has a living female child and who aborts her next fetus will likely be scrutinized.

[The following paragraph has been updated due to a misunderstanding during translation] If you read this post previously, you will recall that I said the cost of pre and post-natal healthcare depended upon one’s caste. I have since learned, however, that it’s the other way around. Mothers are actually paid different amounts depending on her caste. Because education and health care are so limited in rural villages, it has been common for mothers to deliver their children at home (using midwives) without seeking professional medical attention. This has resulted in abnormally high maternal and infant mortality rates. Therefore, the government has instituted the “National Rural Health Program” that actually pays certain mothers to give birth at the hospital. Today, the women were grouped into three caste categories: the General Caste (highest), Schedule Caste (middle), and Backwards Caste (lowest). A woman from the Backwards Caste, for instance, is given Rs 1500 ($30) as an incentive to have three pre-natal checkups, three post-natal checkups, and deliver her child in a hospital. Women from the Schedule Caste receive Rs 500 ($10) and women from the General Caste do not receive any financial benefit because they are believed to be wealthier and more educated.

Furthermore, the hospital staff members and people called “ashas” receive a financial bonus (appx. Rs 500-Rs 1000, or $10-$20) for each child delivered in a hospital. An asha is a person who, from what I understand, serves as a motivator for the proper health care decisions of approximately 1,000 people. He or she keeps records of the people under his or her care and educates people about different health options such as the benefits of going to a hospital to give birth. These are just some of the government’s methods of incentivizing proper health.

I spent the majority of the day determining blood types (AB positive, O negative, etc.), performing hemoglobin tests, conducting simple urinalyses with basic equipment, and preparing samples for tests of malaria.

The most shocking aspects of the day were the frigid temperatures within the unheated hospital, the lack of alcohol swabbing before pricking, and the staff’s handling of blood covered slides and bloody fingers without gloves or even thorough washing. This is not due to any oversight or negligence. It is just common practice here. And for those of you who are curious, yes, I wear gloves that I bring with me.

Santa Comes Early…

…Santa came early this year! Last night, Shri had a small water heater, called a geyser, installed in the family bathroom. Hot water was the one comfort from home I secretly wished for. Someone must have been listening. I can adapt to just about anything, but ice cold showers when it’s less than 45 degrees outside in a home without heat is a bit too invigorating.

However, having a shower at all is the least of problems for many of the people we see here. A rugged looking but gentle woman named Swashiela comes to clean here every day. She lives in the slum we visited yesterday and requested a sweater for Christmas as she does not own one. We went shopping for one today but could not even locate one at the local market. The temperatures reached 4.7 deg C (40 deg F) last night. Twenty-six people have died over the past couple of days in Delhi from hypothermia. My host father is frustrated that the government did not do more to help them, but then acknowledged that if people were given temporary shelter they would never leave.

Showers here are not like showers at home. In most of the homes I have seen here, water is poured out of a faucet into a bucket from which a person scoops water to bathe by hand. There is no tub or shower curtain, just some extra space next to the toilet. It’s a messy way to bathe, but as long as it’s hot you won’t find me complaining.

Slum School…

…This morning, we helped out at a small pediatric clinic in Old Faridabad. I assisted in one of the physician’s pathology lab. Blood tests here are simple and performed manually with records kept by hand in large official books. The main ailments being tested for are Typhoid and Malaria. We have seen numerous cases of Typhoid here already but no cases of Malaria as cases are rare this time of year. Starting IVs and taking blood seem to be difficult processes on the children here. The young kids cry as would be expected with someone repeatedly prodding one’s veins. However, some of the kids are incredibly tough. One boy today stared with enormous eyes at the needle entering his arm. I could tell he was in pain by the tears pooling in his eyes, but he never made a sound or even a grimace.

Today’s real eye-opener, however, came in the afternoon. At 3pm, we made our first visit one to two slum schools founded by our host parents, Shri and Mumta. The slum is only about a ten minute walk south from our home stay, but is drastically different even from the community across the street from it.

The drive into the slum was an adventure in itself. Small fires fill the streets to provide warmth. Despite the filth and poverty, playful children fill the streets as people go about their daily lives. We arrived to find a simple one-room school approximately 10ft by 50ft in size with about 40 students. This school does not receive regular volunteers, so we were given a very warm welcome by the students and two teachers. Shri, who led us in, was greeted with a united and almost militaristic salute from the children, who immediately jumped up from the floor, stood straight up, and threw the back of their right hands against their foreheads.

Shri stayed for a few minutes and then departed. Kids eagerly wrote the English alphabet and waited to approach us to recite it one-by-one. Although lacking many of the possessions you and I take for granted, in many cases including shoes, these children seemed wonderfully satisfied and strikingly normal. In reality, they were more excited to learn and play than the children I taught and tutored in St. Louis.

Once school was out, the children stayed with us and appeared to love having their pictures taken. However, in a manner entirely opposite to our culture, they stop smiling as soon as they pose for a photo. About 20 of the students walked us through the slum toward home. All of them wanted to hold our hands, or at least hold hands with the other kids who were holding our hands. Although the girls dropped away as we left the slum, about 10 young boys walked us all the way home. It was a touching and inspiring experience. I will definitely be back regularly and perhaps put together some more formal English coursework.

Learning Cricket…

…Last Sunday, just a few hours after arriving in Faridabad, a swarm of young men welcomed me into their weekly cricket game. As promised, I returned today at 2pm to join in a couple of games. Each of the men is eager to practice his English and make a new friend. Much of what is said is lost in translation, yet we find things that make us smile and laugh, which mean the same thing anywhere.

Two Weeks In…

…Today marks two weeks since my arrival in India. Now that I have begun to settle in and get a grasp on the culture I want to start sharing my journey over the next 5 months.

Quotidian life here is even more chaotic, filthy, and exhausting than I could have ever anticipated. In a way, it feels like some sort of post apocalyptic society in which a massive civilization has survived but has been left to its own devices. Life is set to an endless din of blaring horns, spewing engines, and overly aggressive shopkeepers. The novelty of it all is fascinating while sometimes also frustrating. As westerners here, we are the center of attention wherever we go. I have been amazed by the lack of tourists, even in the most touristy of attractions and sectors. As I have been told by numerous locals and have learned from experience, “the guest is God in India.” When the caste system was still prevalent here, westerners were seen as above the system entirely. Even though the caste system has been largely eradicated, we still receive special treatment and attention. The vast majority of people are very thankful to have us here and will go out of their way to help us. However, money is the God of Gods here. No matter how genuine and friendly someone seems, it is hard not to question his or her motives. Almost everyone wants something from us, usually money or commission from a place he or she can get us to shop in.

I spent the first week in a city called Gurgaon, which is southwest of Delhi by metro about 45 minutes. It is the “high-rent district” of the Delhi area. I stayed with six other volunteers at the apartment of the program coordinator and his wife. There, I had a week-long orientation on Hindi language, Indian culture, and many of the major sights and attractions of Delhi. We all had an excellent week and became close friends given such a short time.

Last Sunday, I was driven to my home-stay in Faridabad, a city one hour southeast of Delhi by metro plus about a 1 hour tuk tuk ride (total 2 hours). Faridabad has one of the highest concentrations of slums in all of India. There are few paved streets and even fewer stop lights or even signs in this town of over 2 million people. Unlike major Indian cities which have outlawed diesel engines on taxis and tuk tuks, any mode of transportation seems acceptable here. Everything from camel or ox-pulled carts to tractors are common sights. People will latch on to anything that moves. Tiny three-wheeled tuk tuks sometimes carry 16 or more people. Yesterday, I even saw a small scooter with 4 adult men on it. Because of the bone-dry dusty streets and billowing vehicles, the pollution here is visibly and tangibly worse than even Delhi. Honking is also endless, and is to me the most frustrating aspect of the culture. Drivers honk almost for sake of honking. It is horrible. From the room I am in now, I can hear at least 10 different horns with no more than a two second gap between honks. Cows and stray dogs are everywhere and most of them can be found eating garbage that is left in the streets.

I spent most of this week helping give medical checkups and administer medication to the impoverished elderly. I also saw a C section and helped out around a small local hospital. They have much of the medical infrastructure in place, but the quality and sanitation are decades behind US standards. At times, the scenes send shivers down my spine.