7/25 - The Zoo

Our final weekend in India before heading back to the states. We decided to go to Rajiv Gandhi Zoological Park and Wildlife Research Center for a little relaxation and animal-viewing. But first, during breakfast we finally got to meet Dr. SM Dabak (OB-GYN), the doctor in charge of the Maternal & Child Health program (he was visiting the states during the first three weeks). Having taught (according to some of the doctors we have met) around half of the doctors in Pune in some way or form, Dr. Dabak is probably one of the most well-known and prestigious medical practitioners in the city. 

The majestic white tiger.

This was the first White Tiger (Panthera tigris) I have seen in the flesh. Surprisingly, White Tigers are not albinos or a different species; they are simply Bengal Tigers with a recessive genetic trait for white fur. These creatures are extremely rare, so much so that they no longer can be found in the wild.

A butterfly.

That monstrosity of a snake below is known as the King Cobra (Ophiophagus hannah), the longest venomous snake in the entire world. These can grow up to around 17 feet in length, making an angry one capable of viewing you at eye level even from the ground. That, and the fact that they eat other snakes surely make their title quite fitting. The amount of venom from just one bite is enough to kill 20 people and even an adult elephant.

King cobra.

 Went back to the guest house to relax afterwards.

Chilling.

Tomorrow: yoga!!!

7/24 - DMH Hospital (Day 5)

Our last day at DMH.

Today we briefly visited the PICU again before seeing more patients with Dr. Joshi in his office. 

In the office we talked with Dr. Joshi as to why he became a pediatrician. His response was quite simple: it is an extremely social job. We all noticed it during our shifts, but Dr. Joshi absolutely loved to interact with the children and the parents alike. To him, to be a doctor means engaging with your patients and trying to understand them as much as possible. Not only does this keep the profession but going stale, but it helps you enjoy what you do all the more.

After our final shift we decided to see a movie: Minions!

Some interesting observations while about the cinema:

• Very rarely to people purchase their tickets at the door. It is almost always done online. That being said, tickets are extremely affordable. 
• Both Indian and American movies are available. Some have subtitles, others do not. 
• All seats inside the movie theater are reclinable. Quite relaxing.
• There is an enormous variety of snacks to choose from. Sandwiches, popcorn, samosas, ice cream, creamed corn with chutney, cakes, candies, hamburgers, pizzas, etc. 
• In the middle of the film, there is a 5-minute break period for viewers to get snacks or use the bathroom. 

Meet Kevin.

As for the film itself......7/10. Entertaining, but not much going on plot-wise. Sure is nice to hear your name spoken over and over again in a movie.

Our final weekend starts tomorrow!

7/23 - DMH Hospital (Day 4)

Today we did not shadow Dr. Joshi; instead we opted to check out something new: the Pediatric Intensive Care Unit (PICU).

Admittedly what we saw today was a lot harder to swallow than everything we have seen prior. All the children were in very critical condition, and the atmosphere was a lot more solemn than what we were used to.

What I learned about today:

Wilson's Disease: a buildup of copper in the body. These deposits occasionally leave a characteristic golden encirclement around the eye, dubbed the Kayser-Fleischer ring. Wilson's Disease also manifests in the liver of the patient, leading to liver failure and an extreme stage of jaundice.

Sometime during the middle of the shift I went to go see an inguinal hernia surgical repair. Due to protocol only one observer was allowed inside for the operation, so I elected to go. In essence, a hernia occurs when the inner contents of one's body protrude out from where they are supposed to be held. 

Last day at DMH tomorrow.

7/22 - DMH Hospital (Day 3)

Our second day with Dr. Rajan Joshi led us to the Outpatient Department (OPD), a place for patients who visit a hospital but are there less than 24 hours (not "checked-in").

In an earlier post I talked about jaundice, a condition brought about by high levels of heme catabolism product bilirubin in the body. This is a quite common occurrence in children and premature births, as the liver is not always developed enough to remove the excess bilirubin from the bloodstream. As a result, the yellow coloration of the bilirubin causes the characteristic yellow discoloration of the sclera and skin. Due to this common issue, Dr. Joshi has made it an important point to us as one of the major conditions to check for in newborns.

Another condition I learned about today was renal agenesis - a condition where one or both kidneys fail to develop in an individual. If one kidney is present, it is known as unilateral renal agenesis. If neither are present, it is known as bilateral renal agenesis. A lack of both kidneys cause the majority of newborns to pass away not long after birth. On the other hand, if one kidney remains there is no major risk to the well-being of the child as long as said kidney is functioning normally.

Not willing to make the same mistake of waiting to take a group picture on the last day, we took a picture with Dr. Joshi today.

Hooray.

7/21 - DMH Hospital (Day 2)

Today, we got to shadow the consulting pediatrician at DMH Hospital.

Dr. Rajan Joshi practices pediatrics at other hospitals, although multiple days during the week he travels to DMH to contribute his services. He has traveled to the United States frequently, both for professional and tourism purposes. Since his involvement with CFHI, Dr. Joshi has been in close contact with many of the past program participants. In fact, he even acted as the one cloaking a past participant during their white coat ceremony back in Michigan.

This lovely gem of a picture was right above Dr. Joshi's desk.

The majority of the day was spent in his office, watching him treat and diagnose patients. 

7/20 - DMH Hospital (Day 1)

First day at Deenanath Mangeshkar Hospital (AKA DMH Hospital).

This was the first government-run hospital that we shadowed over the course of our trip.

The inside of the main building.

A few general observations:

• Befitting that of a governmental clinic, the hospital is absolutely huge. Almost all medical services are available here. 
• Recently, DMH now is comprised of two buildings: the original hospital and the newly-constructed Super Specialty Hospital (ex. OB-GYN). 
• Available medical technology is state of the art. The majority of all work and patient information is processed electronically. 
• Protocols for sanitation and patient confidentiality are extremely tight here. ID tags were issued to all of us for additional security. 

The entrance to the new building.

For our first day, the three of us shadowed in the Neonatal Intensive Care Unit (NICU), a place where newborns that severely require medical attention are treated.

All the babies seen in the NICU were premature ones, usually in the 30-32 week range of gestational age. There are multiple factors that can contribute to a premature birth, including but not limited to:

• The presence of multiple babies in the womb (i.e. twins)
• Stress 
• A shortened or weaker cervix

As one may expect, a premature birth can be host to a plethora of complications for the newborn. Infants are generally at a greater risk when it comes to visual and auditory problems. In addition, developmental delays become far more common. These risks only become more severe the earlier the child is born. In order to keep the newborn as safe as possible, in the NICU they are usually kept in specialized warmers to monitor their oxygen levels, feeds (nutrients), blood pressure, and temperature. 

Laryngomalacia - Literally meaning a softening of the larynx, it is an extremely common issue in newborns where the weakness of the epiglottis folding in on itself causes airway obstruction. The characteristic sound produced by this is known as stridor. Although surgery is rarely needed for treatment (usually the larynx develops after a while to its sturdier state as the newborn ages), cutting said epiglottis folds can allow for restoration of airflow.

As a final note for this post, NICU services are quite expensive. Warmers cost ~20000 rupees a day (roughly $322 USD). Hospice care is available, but they are currently extremely few and far in between.

7/19 - Sightseeing Around Pune (Day 2)

More sightseeing today! To be more specific, the Balaji Mandir temple in the outskirts of Pune.

A bit more on religion in India:

~78% of the population in India practice Hinduism.

~14% practice Islam.

The remaining ~8% are comprised of other religions/groups, such as Christianity.

The Balaji temple we visited is a Hindu temple. Balaji is in fact another term for Venkateswara, a form of Vishnu. Vishnu, along with Shiva and Brahma, compose the Trimurti (the great trinity of deities in Hinduism). As mentioned in a previous post on Elephanta Island, Shiva is the Destroyer. Brahma is the Creator, and Vishnu is the Preserver.

An overlook we stopped by to take pictures.

The entrance to the temple.

Unfortunately, the temple forbids photography in the interior (which is a shame, because the inside is absolutely beautiful). The temple also requires that one must go in barefoot. Basically, the people entering follow a path from which they can pray to various statues in multiple shrines. After exiting the temple some free sweets are given to visitors to eat. 

Sai really liked to run up to the camera.

Delicious, delicious, bhutta.

Those delicious specimens you see above are known as Bhutta: roasted corn on the cob with salt, pepper, lime juice and chili chutney. There are literally hundreds of mobile bhutta food carts in both the rural and urban parts of Pune. For less than 1 USD, they are absolutely sublime. 

Next: DMH Hospital!  

7/18 - Sightseeing Around Pune (Day 1)

The weekend has finally arrived, and that means fun. Time to explore the touristy sites of Pune.

First stop is the Raja Dinkar Kelkar Museum, home to a wide variety of ancient Indian artifacts. Here are just a few of the displays I thought would be nice to share:

Rawr.

 The lion-esque figures in the above photograph are mythical creatures known as Yali. Bestowed with absolute supremacy in the animal kingdom, you will commonly find these standing guard in and around temples in South India. Yali are usually carved upright, with some demonic head under their feet - a symbol of all evil spirits or thoughts entering a holy ground being crushed.

A kumkum box.

What exactly is a kumkum box? Simply, it is a holder for kumkum, A.K.A. kumkuma. By grinding tumeric or saffron into a fine powder (which is subsequently dyed), kumkum is used as religious markings by people throughout India.

A cutout used for shadow puppetry.

Next stop is the Shaniwar Wada, an 18th-century fort built in the middle of the city by the Maratha Empire. Now, it is a popular tourism site.

The most photogenic people I have ever met.

Shaniwar Wada courtyard.

Our last stop of the day is Aga Khan Palace, an incredible piece of architecture built in 1892. Mahatma Gandhi was imprisoned here during the Indian independence movement in 1942. Gandhi's wife, wife Kasturba Gandhi, passed away in the palace in 1944.

Overlooking Aga Khan Palace. There were also fish in the fountain.

Feeling fabulous...

....and then some.

Next post: Temples and religion! 

7/17 - Jiviraj Children's Hospital (Day 3)

Last day at Jiviraj Children's Hospital. Luckily both Kim and Daschel were able to accompany me.

During our tea break, we had a chat with Dr. Kothari about the current state of patient care. We also asked why, like the other private hospitals we have seen thus far, are camera monitors kept in the doctor's office.

First, as mentioned in a previous discussion with Dr. Dugad, the infrastructure of the health system in India is undergoing a great amount of change. With each passing year the number of individuals receiving health insurance is increasing. However, the overall percentage is still extremely low in the grand scheme of things. That is not the only changing paradigm; the number of patients filing lawsuits against their doctors are also on the rise. In regards to the camera displays, Dr. Kothari explains that over the years failure to treat certain patients have been met with rage. Relatives and close friends of the deceased would bust into the clinic and beat the physician with sticks for his failure. As a response, the state of Maharashtra issued a law of 3-years confinement for assault of a doctor. This offence is non-bailable. The cameras are installed as an extra comfort.

The next day, we planned to join Dr. Kothari and his wife for a morning walk in the park (supposedly filled with peacocks). Unfortunately, he had to cancel at the last minute. Which also meant no group photo.

):

Later in the day, Dada and his family took us to Ranka Jewellers for some shopping. To be more precise, shopping for the girls. The quality of jewellery in India is quite high and quite affordable by US standards, although one must have a keen eye for authenticity among the hundreds of small stores dotting the city. Luckily Manisha was able to show us what was what. 

The outside of Ranka Jewellers.

Next round of weekend fun coming up!

7/16 - Jiviraj Children's Hospital (Day 2)

Today I returned to Jiviraj Children's Hospital with Kim.

Saw a good amount of patients again, but because this was a morning shift there were far less children.

Fun fact of the day: a lot of the younger babies made it a point to try to discover the flavor of stethoscope. This is known as oral fixation, the stage at which babies just like to....well, put items in their mouths.

During our tea break we had a nice chat with Dr. Kothari, where we talked about education. As one can imagine, in India the process of becoming a doctor is quite different.

In the United States:

1. Upon completing their undergraduate (or at least the ~3 years required to complete course requirements), an individual can apply for medical school.
2. Medical school lasts for 4 years, during which an MD or DO degree is awarded which allows practice upon completion of a residency program (which a medical student applies for during their last year).
3. This is typically followed by (during the last year of medical school or the first year of residency) a 1-year internship.
4. Next up is residency, in which time spent varies from speciality to speciality. For paediatrics it is 3 years. 
5. A 1-3 year fellowship could also be done after residency, where an individual specializes even further in their residency choice. 
6. Upon completion of the above and passing the examinations, an individual finally becomes board certified to practice. 

In India: 

1. Grades up to 12th grade (the equivalent of senior year in a US high school) are referred to as standards. 10th, 11th standard, etc....
2. Once a student completes 12th standard, he/she goes straight to medical college. This lasts for 5.5 years (1 of these years is an internship). Upon completion, the student then receives a Bachelor of Medicine, Bachelor of Surgery degree (M.B.B.S.). 
3. Individuals can then choose to pursue a postgraduate education. This lasts 3 years for a diploma. 
4. Upon completion of the above and passing the examinations, an individual finally becomes board certified to practice. 

Interesting, no? 

Final day with Dr. Kothari tomorrow!

7/15 - Jiviraj Children's Hospital (Day 1)

Finally back to the guest house and the daily medical rotations. Next up on the list is Jiviraj Children's Hospital, a private pediatric clinic run by Dr. Dushyant Kothari.

This was the first and only late-night shift taken over the course of the trip. Unfortunately, I was alone. You see, although my stomach is made of the highest grade industrial steel, Kim and Daschel were not yet totally acclimated after a week's worth of Indian cuisine. Thus, I had to go this one alone.

Jiviraj Children's Hospital.

Some initial observations on the clinic:

1. The clinic, minus the lobby and waiting room is split into 3 separate patient rooms. This includes the doctor's office.
2. In the short time I was there (around 3 hours), I must have seen around 100 children. Dr. Kothari usually spent no more than 2 minutes on each one. Nurses bustled back and forth between the narrow entrances to prep each child before they were seen.
3. There was a lot of crying.
4. There were also a lot of adorable children in adorable outfits. 

Because the previous clinics dealt with OB-GYN cases, I now find it most appropriate to discuss what I learn in each pediatric clinic. First up: Vaccinations, as I saw Dr. Kothari give A LOT of them.

As in the United States, newborn children are prescribed a series of vaccinations for their active acquired immunity. Here are just a few:

At Birth:

BCG - To prevent tuberculosis. 

OPV0 - To prevent polio. In India, most polio vaccinations are in the form of oral drops. They are cheaper in comparison to needles. 

Hepatitis B - To prevent liver infection caused by HBV. One prominent risk in newborn children living in India comes from failure in the liver, which then escalates into jaundice. 

6 Weeks:

Pneumococcal Conjugate Vaccine - To prevent pneumonia. 

Rotavirus - To prevent severe diarrhea in newborns and young children. The rotavirus is the most common cause of this. 

6 Months: 

Flu Vaccine - To prevent flu. The 2nd dose is given after 7 months. 

Others:

Measles/MMR + Vitamin A - Given after 9 months. 

Typhoid (TCV) - Given after 10 months. 

Anyhow, it was an interesting experience. We will be returning tomorrow, so there will be much more to learn!

7/14 - Mumbai Trip (Day 2)

Day 2 in Mumbai.

Woke up around 7:00 AM in order to catch the ferry to Elephanta Island. No; there are no elephants on Elephanta Island. All three of us asked Dada the same question. The name came from the Portuguese when they found an elephant structure around the 18th century upon arrival. Said structure is now on display somewhere in Mumbai.

Now, the main grab of the popular tourist attraction is the cave temple(s) built to honour Lord Shiva, the Destroyer. So, after one extremely shaky and seasick-inducing ferry ride, we finally reached the island.

So tranquil. Besides the roaring tourism.

A happy(?) family. 

The first thing I did in a car when I touched down in India was search for monkeys. Besides the dead one we found during our morning hike, Elephanta Island was the first spot where we saw live ones. Actually, we saw at least a hundred of them. Notorious for stealing from shopkeepers and tourists alike on the island, we were told to steer clear from all monkeys. That, and numerous dark red spots all over their body that led me to believe that getting bitten would be a bad idea. Funny story: a few years back one girl from CFHI had her purse (with her passport within) stolen by one of them. 

The 120-some steps leading up to the cave temples.

The caves. A lot more impressive in person.

One of the numerous sculptures found inside.

 These were the first ruins I have ever visited. Quite impressive!!!

Alas, after that our trip in Mumbai came to an end. We picked up some Starbucks (Yes, that is everywhere) and started on the long road home.

Sorry!!!

I had little to no internet for the remainder of my trip. Now that I am back in the good ol' U S of A, posts on this blog can resume. Stay tuned!