May 31st - Wedding Festivities, Indira Gandhi Medical College, and Shopping Round 2

        Dr. Jain's niece is getting married next month and today was the start of the various functions that will be happening throughout the next month leading up to the wedding. Before the invitations are given out to everyone the first invitation must be presented to God and that was what today's function was for. The reception hall was gorgeous and we kind of forgot that we were in India for a bit until we realized that everyone was talking in Hindi/Marati and we had no idea what was going on.I wish we were going to be here for the wedding but sadly it's happening right after we get back to Pittsburgh.  

The reception hall. There was a wedding happening in the morning as we went inside

The stage with a picture of Dr. Jain's father. The bride's grandather

The crowd

Lord Ganesha (The remover of obstacles)

The cutest baby in the room. The bride's cousin

All the women in the front row

The bride with aunt (red) and mother (green)

Outside the reception hall with Dr. Jain

       After the function today I went to Indira Gandhi Medical College which is the other government medical college in Nagpur. Dr. Shrikande, the head of the Pathology department attended the Global Sickle Cell Disease Conference in Atlanta this past March and wanted me to help analyze some population screening data to publish a paper. They have screened over a 100,000 individuals in the Nagpur area to determine the sickle cell trait prevalence in the region and among the various caste groups. I spent the entire afternoon with her and her team going over the data and making a plan for what needs to be done. It was super super hot and the power kept going out throughout the afternoon making it even worse. Working in this heat is super exhausting and I don't know how they get anything done here. 

Dr. Shrikhande, Myself, Dr. Amit and Helen

           After finishing up at IGMC, Dr. Jain sent her driver and Amarapalli, one of the MD Pediatric doctors out to take us shopping. We went to Sanskruti, a shop near IGMC to find my sister a chaniya choli. I didn't end up getting a picture of the one that she bought since they kept it to stitch the blouse but the fabric below is one of the ones that she really liked. I bought a few more saris but I only got a picture of one of them but I'll put more up once we pick up the pieces on Sunday night.

Pretty blue chaniya choli fabric

I bought a couple more saris but this was my favorite with the elephants on the border

We found a cow along the entrance to the hospital

Dr. Jain had fresh lychee for us to eat. First time we got to do this. 

Fresh lychee is the way to go :-)

Sister's Blog

My sister has been doing different stuff from me so if you're interested you can check out her blog as well

http://akshayaarjunan.tumblr.com/

May 30th: ANC Clinic and First Round of Shopping

            I spent the day again with Sanjeewani today in the ANC clinic as she counseled the women. Sanjeewani started the clinic by explaining the purpose of the visit to the women that were gathered in the beginning. After explaining all the general information to the group she proceeded to speak with each woman individually about their person and family medical history. There were a few women that tested positive so Sanjeewani asked the women to bring their husbands in so that they could also be tested. None of the men today also tested positive but there was a couple that had come in yesterday that both tested positive. This was their first pregnancy however since the woman was 24 weeks along there was no prenatal testing that they could offer so the couple was advised to deliver here at the hospital in Nagpur so that the baby would immediately be screened as part of the hospitals Sickle Cell Newborn Screening Program. Sanjeewani also advised the couple that should come in for a family planning visit before they decided to have another child.

The husband's wife tested positive for sickle/thal trait so he had to come in and get tested as well.
Poonam the lab tech does his blood draw

Sanjeewani explains to the husband why he has to get his blood drawn

The couple already had a child so he was also tested to see if he had Sickle/thal trait. He was such a champ. Didn't cry at all. 

Sanjeewani explains to the mom that her husband and son are both negative and only she has trait

Another husband getting his blood drawn after his wife received a positive trait test

Sanjeewani talking to the girl about her family and medical history

          In the afternoon I got to see a number of the pediatric ward patients and boy was there a variety. There was young girl that was so severely malnourished that all you could see were her bones. Apparently her mother had continued to breastfeed her and never had given her any other food with the necessary nutrients. We also saw children with Cerebral Palsy, Hyperbilirubinemia, Duchenne’s, and Thalassemia. It seems like the growth of most of these children is stunted and kids that are 11 and 12 looks like they are 5 or 6 years old. I was amazed when Dr. Jain told me the ages of the children because honestly there was no way that I would have known. There are over 46 different wards in the hospital and today was the first day that I got to explore a little bit and see a few of the wards. The picture below is one that my sister took of one of the pediatric wards.

Pediatric Ward

          Dr. Jain asked one of the pediatric residents to take us out shopping in the evening which was a lot of fun. Shruti, the resident, had been spending a lot of time with my sister and she was a super nice person to hang out with. She took us to a mall nearby so my sister and I could buy more clothes. (We always need more clothes right?) I got a super pretty sari that I fell in love with J Hopefully I can get the blouse stitched in time.

 

My sari :-) 

One salwar kameez set

And two kurtis :-) 

May 29th: Day Two: Yay for not getting sick :-P

Once again the morning started with Dr. Jain stuffing us. A bowl of cereal cannot compare with the amount of food Dr. Jain expects us to eat every morning. She said she was going to complain to my mom about how we aren’t eating anything and that we aren’t eating healthy since the only thing my sister and I really eat is all the murukku that she keeps buying us :-P Neither of us can resist murukku and it doesn’t help that she keeps refilling the jar.

I spent the day with Dr. Jain in her outpatient clinic. Once again it was a crazy hectic morning but I was really curious to see how patients were treated and what the process was like. It’s a completely different world over here which is really unfortunate because some of the testing that really needs to be done isn’t because the families cannot afford the tests. There was a boy that came in today that was suspected of having Duchenne’s muscular dystrophy. One of the interning doctors came to talk to Dr. Jain about this boy. He just looked at the boy and thought the symptoms might be characteristic of DMD and told Dr. Jain. The first question from Dr. Jain was whether or not a family and personal medical history was taken (which is the first thing he should have done) but he had not done that at all. Dr. Jain did perform a clinical examination and talk to the family about the onset of the various symptoms. She ordered a teat to check the creatine kinase levels on the boy to see if the levels indicated the possibility of DMD. Unfortunately the test was not done because the family could not afford the test. It’s really sad that a test necessary to confirm a diagnosis could not be performed because of money. I know it happens everywhere but the frequency at which it happens here is astounding, frustrating and depressing.

Along the same lines there are a number of children with various metabolic conditions but the high costs of the diagnostic test prevents children from receiving a diagnosis and having a treatment/management plan that can help prevent the onset of symptoms. A simple ferric chloride test is done that can say whether or not five to six different metabolic conditions are present but that’s as much information that can be gleaned from that test. The test will not say what type of metabolic condition is present and the extra tests that are necessary to determine the exact condition are not affordable. We have learned throughout all of our classes that identifying the various metabolic conditions as soon as possible will allow us to help determine a special diet and treatment plan that can prevent the onset of irreversible symptoms but here in Nagpur that is not possible. The hospital can only offer care to help treat and manage the symptoms as they present. There are a number of patients with various genetic conditions in the hospital but the diagnosis is primarily made clinically because the lab tests that are needed for confirmation are not feasible. Family histories can help determine the pattern of inheritance if multiple members of the family are affected but when inheritance patterns can’t be determined through a pedigree, families can only be advised about the possibilities for family planning information and given risk probabilities.

Not a lot of money has been allocated by the government of India towards identifying and treating genetic conditions. Malnutrition and infection are higher on the priority list and the majority of government funding is allocated towards those causes. Sickle cell and thalassemia have received a lot of funding because there is a high prevalence among the tribal population and in recent years the government has been funding programs and initiatives specifically targeting the tribal individuals.

I learned a lot during my trip last year but this the first time that I have been in a government hospital and had the chance to spend an extended amount of time observing. Living in the States we take a lot of things for granted and its being and observing situations like this that makes you take a step back and think.

Today was definitely a better day than yesterday and I learned a lot from Dr. Jain and the other staff members.

Here are a few pictures from the hospital

Walking down a hallway. This was one of the less crowded ones. 

There are dogs and cats that just freely roam the corridors

 

The outside of the hospital. "The Play Area" Look at how rundown everything is

This is not what a hospital should look like

The view of the hospital from across the street

Dr. Jain’s cook decided this morning that he was taking the evening off and that Dr. Jain should take us out to eat so we decided to go to the Venkateshwara temple and out to eat after work. The Venkateshwara temple was gorgeous and reminded me a lot of the SV temple back home. Going to the temples in India always reminds me that temples are what unify Indians from different states. Temples around the country are definitely the monuments that Indians visit when they go to different parts of the country and no matter how many temples you go to you will never find two that are exactly alike. My sister and I have been dragged to our fair share of temples throughout all of our visits to India and when we go to different states in the US because somehow my mom always manages to plan our family vacations and trips so that a temple is part of the itinerary. While going to the same temple gets a bit boring I’ve gotten the chance to see some pretty nice new ones during my last trips. Unfortunately we weren’t allowed to take pictures at the temple and there was a security guard outside so I couldn’t sneak a pic either :-\

By the time we went to dinner it was closer to 9pm and I was both exhausted and not hungry but refusing to eat would probably make Dr. Jain angry so my sister and I forced ourselves to try a little bit of everything. She took us to a Maharashtran buffet so we had the opportunity to try a variety of different dishes. They were a number of different dips and sambars with rice, naan, pappad, uthappam, mango pudding and a variety of other things that I don’t know the names for. All in all it was a great dinner but we were definitely ready for bed by the time we got back. 

May 28, 2012 – SaVe Me, I’m MeLtInG!!!!!

My sister and I were both ready to go at 9:30 this morning. We were going to the hospital to start our days of observation. (Me with genetic counseling and her with the general pediatrics doctors). And let me start this post off by saying that it is currently 48 degrees Celsius (around 117 degrees Fahrenheit) and I am dying. 

 

This is the main teaching building for the Government Medical College

Dr. Jain is the head of the Pediatric division at the Government Medical College in Nagpur. I didn't know this when I was coming here but the Medical College here is the apparently the largest medical college in all of Asia which is pretty crazy. The campus is huge with various buildings for the dental, medical and nursing schools in addition to hostels and the actual hospital facility itself. There is a separate buildings just for infectious diseases which I think is pretty astounding for the city. We haven't had a chance to take pictures yet but hopefully that'll be rectified soon enough. The hospitals in India continue to amaze me. There are just sooooo many people. You can't turn anywhere without running into someone. People are lined up along the hallways, there are some individuals that are napping. People are being rolled around in gurneys and wheelchairs. Some people are walking around holding onto their IV lines. The scene is so completely different from the States that it's hard to wrap my mind around it no matter how many times I go to a hospital here. My sister and I split up this morning to each go and do our own thing. 

I was to be following Sanjeewani today who is the genetic counselor for all the sickle cell and thalassemia patients. Because of the high prevalence of Sickle Cell in the area every pregnant woman that comes through the hospital is screened for sickle cell and thalassemia traits. Each morning around 50-60 women are screened during the Antenatal clinic. They are group counseled in the beginning and given general information about sickle cell and thalassemia. A general family and medical history is taken from each woman and ff the woman tests positive then the husband/partner is then requested to come in for screening as well. And at this time they have a more detailed counseling session explaining inheritance and more details about the condition. Mothers are also offered the option of the having percutaneous umbilical blood sampling (PUBS) or better known as having blood drawn from the umbilical cord and tested to see if the developing baby has sickle cell or thalassemia. Dr. Jain explained that they don’t feel comfortable offering amniocentesis for the purpose of sickle cell screening due to the high rates of limb abnormalities associated with the procedure here and the cost of the procedure.

The Antenatal Clinc (ANC) was supposed to last from 9:30-1:00pm but the heat definitely ended up getting to me because I only lasted till 11-11:30am before getting sick. Great first impression to make but sitting in a room with 30 pregnant women and 1 fan in 118 degree weather is not my idea or my body’s idea of a good time so I ended up excusing myself before I got sick again. But I did have the chance to observe and learn how women are informed about testing and what sort of information is collected from each individual before they get their blood drawn. It is definitely a different atmosphere from what I am used to at Pitt. There is absolutely no privacy whatsoever as the women disclose their medical and family history. And everything happens very quickly as well. Each woman spends about five minutes giving information pertaining to their family and medical history. It is definitely a rushed process but with the amount of individuals that come through the ANC clinic everyday and only one individual to talk to everyone and collect all the necessary information I guess there is no other way to do it.

We took a small break for lunch and then I joined Sanjeewani as she made her rounds through the different wards. After lunch she typically goes to the delivery ward and speaks with all the new mothers that had not previously been tested for SC or thalassemia traits. Sanjeewani explained that every day there are around 40- 50 deliveries and that she goes and talks to mothers that have not been to the hospital at Nagpur for their prenatal care. Today there were 38 mothers in the delivery ward and 9 of them had not been tested so Sanjeewani had to go and talk to them and obtain their consent for testing. It was definitely interesting going to the ward. All the mothers, new babies and female family members were all crowded in one room. Only mothers that had delivered by C-section had a bed to lie on. The rest of the new mothers just had blankets on the floor that served as their bed and their babies were lying on the floor next to them. In my first day here I have learned that I do not do well standing or sitting in overcrowded rooms. As Sanjeewani was talking to the 9 mothers that she had to test I could feel myself getting faint and feeling like I was going to get sick so I had to excuse myself once more.

I spent the rest of the afternoon with Dr. Jain who in some ways quarantined me to an empty conference room. She was worried that I was overheating myself and wouldn’t let me do anything for the rest of the day which I was actually super grateful for. Normally I try to power through but I could tell that I was drained and exhausted and needed to be in a cool room and not in a hot, crowded, noisy hospital.

We left around 4:30pm to come back to Dr. Jain’s house where both my sister and I ended up crashing and not waking up for dinner or much until the next morning. 

The weather for the rest of the week. I don't know how I'm going to make it. 

May 27th – First Day Here and Already in a Food Coma

            Dr. Jain seems intent on feeding us every minute of the day. She decided to go shopping before we got there and it seems like she bought out a small grocery store because she was worried about what we would eat. She just kept bringing things out for us: cereal, cookies, snacks, fruit, milk, juice, and kept asking if there was anything else we needed. The first thing we did after getting to her house was go to a small puja near her house. Apparently there is a Swami that is coming to talk next week and they have to do a puja at the area that he will be speaking to bless the area. It was nice to walk around but definitely hot. According to the news, Nagpur is the hottest city in the entire country and HOT IT IS, no humidity whatsoever. (~40 something degrees Celsius = over 100 degrees Fahrenheit)

            After breakfast we ended up passing out for a good six hours until we were forced to get up so we didn’t end up staying awake through the night. Dr. Jain’s family lives nearby and her niece is getting married next month so we went to her brother’s house for a family wedding meeting. It was nice to meet the rest of the family. Her two brothers and mother all live within walking distance and it was fun watching them interact. Of course we couldn’t leave without being fed yet again. I think both of us were ready to burst with the amount of food that was forced on us throughout the day. We were exhausted by the time we got back and passed out yet again. One nice thing about working in India is that the day doesn’t really start till 10am but on the other hand the work day doesn’t finish till 6pm. 

May 25-27th: The Travel

             At first we thought our flight to Newark was cancelled which was definitely going to mess up our connections but fortunately it was the 12:30 flight before us that was cancelled and our 3:15 flight was just delayed an hour and a half. We took advantage of that delay and wandered around the airport checking out different restaurants and getting our fill of non-Indian food. Eventually we did reach Newark and we had about an hour to kill before boarding which meant lounging around with the gazillion other Indian people that were waiting for the same flight. This was the first time we were taking a direct non-stop flight to India.

Fourteen and a half hours and we’d be there.

             As much as I hate airports and flights it was nice that we wouldn’t have to stop and have a layover and waste more time. I will say that United has a great movie/TV collection. Food is so-so but for 14 hours on a flight there better be some good entertainment. Four movies and eight hours of sleeping, we finally landed in Mumbai.

           I definitely have to agree with Russell Peters when he talked about landing in India. You’re excited all the way up until the time you get off the plane and realize that it smells like someone took a dump right in front of the plane. You can definitely smell India before you see it.

           We landed around 9:30pm and our flight to Nagpur wasn’t until 6:50am on Sunday so we had a ton of time to kill. This was definitely the fastest that we had gone through immigration though. Our OCI cards took us through a special lane where no one was waiting so it took us 5 minutes to get through immigration and 45 minutes to get our luggage. As always, our luggage was the very last to come out.

           Compared to the international airport in Mumbai, the domestic airport is amazing and clean! Which is great since we had to hang out for 8 hours and I’d much rather sit in a place that doesn’t smell like a dumpster for that long.

            One Tree Hill and Friends has definitely been my savior so far. I don’t think I will ever tire of watching episodes of Friends over and over again and that is what I did for our long wait.

Thankfully our flight to Nagpur was short and sweet and we were sitting next to a mom with her 8 month old baby girl who was adorable and I got to play with her for most of the flight.

          Finally landed in Nagpur around 8am, got our luggage and met Dr. Jain and we were done traveling for another week. 

Time to go back to da Motherland :-D

In less than two days my sister and I are going to be heading to India. We still have yet to pack or get anything ready for our 4 week trip which is slightly nerve wrecking but both of us have been crazy busy and I'm still trying to get all my disease summaries and patient write ups completed for my current rotation.

For those of you that kept up with all of my babbling last summer welcome back and for those of you that are reading this for the first time, I hope you decide to come back. I found out last year that keeping an updated blog about what I was doing during my trip was the easiest way to let everyone know once instead of repeating the same story over and over again through skype and gchat. Plus it kept my mom happy to know everything that I did and where I was at every single moment of the day.

I got lucky this year and got permission to go to India for both my optional rotation for my genetic counseling degree and my thesis project. For the first half of the trip I will be in Nagpur, Maharashtra at the Government Medical College & Hospital of Nagpur. I will be working with Dr. Dipty Jain and other physicians at the hospital in the pedis, obstetric and outpatient clinics to observe genetic counseling practices in the hospital. I will have the opportunity to talk to families to learn about their knowledge of a particular condition/disease that runs in their family to learn more about how their entire medical experience to receive a diagnosis. My research with Dr. Jain until this point has focused on collecting data on sickle cell patients to see if we can ultimately determine a clinical phenotype for Sickle Cell disease in India. I will still be working on this project while I'm in Nagpur but I'm also going to get the chance to observe genetic counseling in India and see exactly what hospitals in India consider genetic counseling. Dr. Jain told me that in addition to hemoglobinopathies they also have patients with other genetic conditions that I will be able to shadow and interact with. I will also be visiting another government hospital in Nagpur to work with Dr. Shrikhande on population screening for Sickle Cell in Nagpur. At both hospitals I will have the opportunity to travel to various villages and observe outreach clinics and visit with families. I think I will also be going to Raipur in the neighboring state while I am in Nagpur but we still haven't worked out the details of that trip yet.

For the second half of my trip I am going back to the Ashwini Adivasi Hospital in Gudalur, Tamil Nadu. I spent some time here last year and absolutely fell in love with the place. I had such a great experience that I am super excited to go back. Dr. Nandakumar really wants to increase education and awareness in the area so Akshaya and I have been working on some pamphlets that we are going to print in Tamil to distribute to the families in the area. We are also going to try to put together a video about personal hygiene, nutrition, negative consequences of smoking/alcohol, how to manage someone with stroke, sanitizing water, etc... to play in the waiting room of the hospital so people can become educated as they wait for their appointment. Our trip to Gudalur is mainly to help in any way that we can while we are there. This will definitely be where we will be most comfortable since we speak the language and can understand people without a translator. But another plus is the atmosphere and the people. Both the hospital staff and villagers were super friendly and amazing to interact with. I really did not want to leave during my visit last year and I am really excited that I get to go back while I am here. Since I speak Tamil I will get to directly speak with the patients and counsel them on my own which will be great. Explaining chromosomes to someone in English is a lot easier than explaining chromosomes to someone in Tamil, especially an individual that may not even have the baseline science education to know what chromosomes are but it's definitely going to be a great learning experience.

I started by rotations a week early this summer so I could spend an extra week at home with my family and see my grandmother and grandfather. It seems surreal that I have been able to go to India so frequently in the last two years. As a family we usually only went every 4-5 years and to have been able to go 4 times in the last two years has been great. I'm looking forward to getting to see family and my cousins and all of the new little ones that have been literally popping up over the last few years. It's nice to see them grow up and remember you as opposed to seeing them as a newborn baby and then suddenly they're 4 or 5 years old and have no idea who you are except you're coming from America and probably bringing presents.

I'm going to try to keep this updated on a daily basis which actually worked last summer but I don't know what my schedule is going to be like while I'm there so my sister and I are probably going to take turns posting this time around.