This is an aerial picture of the clinic/hospital in Tingriti. The elevation (based off of the tree line) was about 10,000 ft. The mountains on either side of this town go straight up and we climbed a good ways up one of these mountains to get this shot. The yellow tents scattered around are where we have been sleeping the last four nights. As you can tell the hospital here looks quite nice, so why in the world would we need to set up a clinic here? Well nobody works in this hospital. The government built this hospital but there are no staff or doctors to run it! The original plan was to have three clinic sites in this valley but because of flooding and landslides we set up clinic here three days in a row and had people from the surrounding villages (Tindi and Tandi) walk to us.Tuesday, July 8, 2008
Tingriti Clinic
This is an aerial picture of the clinic/hospital in Tingriti. The elevation (based off of the tree line) was about 10,000 ft. The mountains on either side of this town go straight up and we climbed a good ways up one of these mountains to get this shot. The yellow tents scattered around are where we have been sleeping the last four nights. As you can tell the hospital here looks quite nice, so why in the world would we need to set up a clinic here? Well nobody works in this hospital. The government built this hospital but there are no staff or doctors to run it! The original plan was to have three clinic sites in this valley but because of flooding and landslides we set up clinic here three days in a row and had people from the surrounding villages (Tindi and Tandi) walk to us.
Monday, July 7, 2008
Tingriti: Day 3
For the last day of clinic in Tingriti I was stationed in pediatrics with Dr. Reshmi. This rotation is less hands on than the other stations, usually because Dr. Reshmi can speak Hindi so she does the history and exam on her own. She is really good though at keeping you up to date
on what is going on. She would take multiple breaks throughout the history to let us know what she was finding out. Unfortunately there were only about 5-6 children who came to clinic today so we didn't get to see many children. Many parents would bring their children in with complaints of "weakness". Dr. Reshmi said that she had seen a lot of this chief complaint and that the children was usually quite healthy. Usually what it boiled down to was that the mother thought the child was not eating enough and was too skinny. Dr. Reshmi said that she had several patients bring in overweight children with the same chief complaint and reasoning. The little boy to above had a broken elbow that was never fixed properly so that when he would hang his arms by his side his right arm would bend medially, instead of laterally like normal. The only real treatment for him would be surgery to correct the normal anatomy in the elbow. We talked with
Hem to see if we could help subsidize his surgery, but I don't know what ever happened to that. In a previous clinic I saw an injury very similar to this in a 71 yo female. In her case she also had a anterior dislocation of her shoulder that had not been reduced for 20 years! She said she had a cast on her elbow, so she had obviously been to someone to fix it and they must not have set the bones correctly before placing her in the cast. We had a Orthopedistnamed Dr. Ravi along with us so I took it up to him for a consult. He said that reducing the shoulder at this point would provide no help to this lady because all the muscle and cartilage in the shoulder would be so atrophied that it would either fall right back out or it would be in place and just not work. Since she had been coping with this injury for so long and because of her agehe said that surgery was not really an option. The little boy to the left with the cut hat had come in the previous day with lobar pneumonia. He had coarse crackles and wheezing that was loudest in one particular lung. Dr. Reshmi said that even after one day of antibiotics she could tell that he was doing better.
I was hoping to see a case with some worms because the previous day in pharmacy we handed out a lot of prescriptions for albendazole. Most of the children had come in the previous day, including the more interesting cases. There was one child that had what we decided was viral warts all over his hands. I think that we gave him acyclovir to help. I got to see him when he came through pharmacy to get the medication.
Before clinic even started today Chalini tried to open a window by pushing on the glass. The glass gave way and when she jerked her hand back she lacerated the inner surface of her distal forearm and it started gushing blood. The doctors are concerned about the loss of sensation in parts of her hand although they think she is going to be fine.
The whole clinic was pretty slow so we finished about an hour early. A few of us hiked up to a Monastery were we where showed around by one of the young monks. We are actually not sure if he was a monk yet. The monk told us all to sit down and he shared with us the Buddha store through a set of pictures. The inside was quite peaceful, but there were many things that to me seemed tacky. There were lights around a framed picture of the local guru the Dali Lama and a strange flashing pixel screen in one corner. Other than that there were large posters of what I guess were the different Buddhas. Outside was a temple/monument that was situated between an enormous rock face on one side and a peak of a smooth and grassy mountain on the other side. It was a cool place.
on what is going on. She would take multiple breaks throughout the history to let us know what she was finding out. Unfortunately there were only about 5-6 children who came to clinic today so we didn't get to see many children. Many parents would bring their children in with complaints of "weakness". Dr. Reshmi said that she had seen a lot of this chief complaint and that the children was usually quite healthy. Usually what it boiled down to was that the mother thought the child was not eating enough and was too skinny. Dr. Reshmi said that she had several patients bring in overweight children with the same chief complaint and reasoning. The little boy to above had a broken elbow that was never fixed properly so that when he would hang his arms by his side his right arm would bend medially, instead of laterally like normal. The only real treatment for him would be surgery to correct the normal anatomy in the elbow. We talked with
Hem to see if we could help subsidize his surgery, but I don't know what ever happened to that. In a previous clinic I saw an injury very similar to this in a 71 yo female. In her case she also had a anterior dislocation of her shoulder that had not been reduced for 20 years! She said she had a cast on her elbow, so she had obviously been to someone to fix it and they must not have set the bones correctly before placing her in the cast. We had a Orthopedistnamed Dr. Ravi along with us so I took it up to him for a consult. He said that reducing the shoulder at this point would provide no help to this lady because all the muscle and cartilage in the shoulder would be so atrophied that it would either fall right back out or it would be in place and just not work. Since she had been coping with this injury for so long and because of her agehe said that surgery was not really an option. The little boy to the left with the cut hat had come in the previous day with lobar pneumonia. He had coarse crackles and wheezing that was loudest in one particular lung. Dr. Reshmi said that even after one day of antibiotics she could tell that he was doing better.
I was hoping to see a case with some worms because the previous day in pharmacy we handed out a lot of prescriptions for albendazole. Most of the children had come in the previous day, including the more interesting cases. There was one child that had what we decided was viral warts all over his hands. I think that we gave him acyclovir to help. I got to see him when he came through pharmacy to get the medication.Before clinic even started today Chalini tried to open a window by pushing on the glass. The glass gave way and when she jerked her hand back she lacerated the inner surface of her distal forearm and it started gushing blood. The doctors are concerned about the loss of sensation in parts of her hand although they think she is going to be fine.
The whole clinic was pretty slow so we finished about an hour early. A few of us hiked up to a Monastery were we where showed around by one of the young monks. We are actually not sure if he was a monk yet. The monk told us all to sit down and he shared with us the Buddha store through a set of pictures. The inside was quite peaceful, but there were many things that to me seemed tacky. There were lights around a framed picture of the local guru the Dali Lama and a strange flashing pixel screen in one corner. Other than that there were large posters of what I guess were the different Buddhas. Outside was a temple/monument that was situated between an enormous rock face on one side and a peak of a smooth and grassy mountain on the other side. It was a cool place.
Tingriti Moonshine
I went into town today with the intention of buying some wine liquor that I had spoken with Ravi about. I had seen some plants that looked a lot like hop plants on the drive to Tingriti but they turned out to be some type of grape and that they used it to make liquor. So a few of us went to the small local store and asked for it. After smiling and laughing a little he said that he could get me some liquor. I also asked it I could see where and how it was made so he had a man take me down and back a little alley where a hunchback man stood under a porch breathing the smoke of a wood fire that had a large kettle on it. Above this was a cool water bath on top and a shoot out the side that was dripping a clear liquid into another container. This I assume was the liquor. Unfortunately I did not have my camera with me so I am unable to upload any pictures into this post. The liquor was actually made from fermented wheat rather than grapes. So I took the canister they gave me back to camp and held onto it for a little while because I wanted to ask Ravi if he new of any definite dangers or stories of local people getting sick from this stuff. As far as he knew no one had but he said to drink it at our own risk. So that night few of us tried it. It seemed to almost evaporate right off the tongue, giving merit to the upper 90 percent alcohol percentage that we had been hearing. It wasn't very good at all. It had a slightly goaty/sheepy aftertaste. I couldn't tell if this was a quality of the wheat or a byproduct of the process. Either way, none of us drank very much and the rest of it ended up getting poured in the fire for the entertainment of all. It is also worth noting here that none of the people that drank it suffered any ill consequences.
Sunday, July 6, 2008
Tingriti: Day 2
We woke up in the rain this morning. It was a much lighter rain than the rain storm that had flooded our pharmacy tent the day before. I was stationed in the Med Clinic today and I got to work with a new doctor that just got into town to help the team. Her name was Sarah and she was a internal medicine resident. The other people working in the clinic with me today were Chalini, Josh and Bavana. The first patient I saw turned out to be one of the most interesting cases of the day. The patient was complaining of epigastric pain and I first thought that this was going to be another case of acid reflux. However, on visual examination of the abdomen I saw a small bulge in the area he had complained about. With palpation I noticed a nodule that was about 3-4 centimeters long and was tender. The patient also had rebound tenderness. We ended up sending this patient to get a CT scan. We think that he might have had a piece of incarcerated bowel which can be quite bad if it loses blood supply and becomes ischemic. Throughout the rest of the day were many more cases of arthritis and acid reflux and a few cases where we were concerned about Tb so we all had our masks on. Another case that stands out in my memory was a young guy who had repeated left shoulder anterior dislocations of his shoulder, many times while playing cricket. Even though he was right handed something about the throw in cricket caused his left shoulder to come out of socket. He also had an interesting medical history because he was taking medication for epilepsy. This case was one of several where people wanted us to
do more than we really could. He was trying to get more epilepsy medication from us and he wanted us to make his shoulder stay in place. Of course we couldn't do either. We recommended that if his shoulder dislocations got to the point where he couldn't do normal activities than he could have surgery. Near the end of the day I had a lady who was having pain in her left ear and difficulty hearing from the same ear. It turned out that she had a pile of ear wax that was completely covering her tempanic membrane so I got to do a warm water flush of her ear. I was able to clear most of it and she said that she could hear better so I had a nice sense of immediate satisfaction.I am beginning to feel much more comfortable with my histories and physical exam skills. With most of the pts I have been seeing I really feel like I am able to adequately assess them and figure out what they need. Even if I can't figure out exactly what they need, I feel confident in sending them to someone who will know what to do.
I have no real sense of time here. I would not easily be able to tell someone how long I have been here or even how much longer I plan to stay. All that has really mattered is the rising and falling of the sun. This combined with the busy schedule of this trip has made it seem that I only left home a couple days ago.
A group of us took a hike up the mountain beside us after clinic today. We made it up pretty high and had a great view of the town and the campsite.
Saturday, July 5, 2008
Pills, Pills, Pills
The first day at the clinic in Tingriti I was assigned to the pharmacy tent. We actually only had a pharmacy tent for one day because during the first day of clinic it rained so hard that it flooded the tent. Hem, the guy who runs the clinic, has bags and bags of medicines that lay all around the edges of the tent. When he realized that the tent was flooding and getting all his medicines wet he begain screaming SHIT, SHIT, MY BAGS, MY BAGS, SHIT, SHIT (all with his Indian accent which was really very amusing). He is a really nice guy but he doesn't have much of a sense of humor so we all tried to hide our chuckles. Of course we reenacted the whole thing after he left for a bit.
We have been giving out lots and lots of medicines. One thing to keep in mind about the types of medicines that we have been handing out is that there is no local pharmacy (or chemist as they call it) in most of these villages. Things like ibuprofen and tylenol are really hard to get so we have been giving out a lot of it for minor headaches and various joint and body pains. Other common medicines that we have been dishing out our albendazole (for worms) and a lot of Ranitidine (think Pepcid AC) and a ton (literally) of multi-vitamins. Other than those the next most common medicines would be antibiotics. We have all different kinds and we have given them for a variety of problems including: upper respiratory infections, pneumonia, and sinus infections. From the top picture you can see that things can get pretty crazy at the pharmacy tent. There is no such thing as a line here so people crowd in and around you in every direction. The picture actually shows one of times that we weren't as busy.
Thursday, July 3, 2008
Gondhla Clinic
After working hard indoors all day you tend to forget where you are and exactly what you are doing. Then you walk outside and you see this view... and remember that you are helping people in a truly amazing place. The triage tent is on the bottom right and the building behind that is the hospital.
This clinic was about 14 kmn from our campsite near Sissu. Instead of using all tents like we did in Kaksur we used the local hospital for several of our clinic rooms. I began the day in OB/GYN and finished the day in the Ophtho clinic. There were not many OB/GYN patients so many of our pts were general medicine pts taken to relieve the burden on their tents. One pt that I had was complaining of arm pain and a couple other things. On examination I noted limited range of
elbow flexion and extension as well as limited ROM at her shoulder. Apparently she had dislocated her shoulder and broken her distal humerus 20 years and had never gotten them fixed. Her arm had healed improperly and her shoulder muscles atrophied. We had an Indian doctor who was a Orthopedist with us who said that even if we reduced the shoulder now it would not help her b/c she wouldn't be able to move her arm. He said a shoulder prosthesis would be possible but was not probable b/c it wouldn't benefit her much either. The picture to the right is the Ophthalmology clinic. The clinic today was set up in the hallway right next to the two medicine clinics. Having a clinic this visibly open is not the best idea because everyone who walks by thinks they need to have there eyes examined, not just the people who really need it. This was one of the busiest afternoons the optho clinic had. In the picture from top to bottom are Vipul, Dustin, Sarika, and then our translator/driver.
Outside the clinic site there was a cool 800 year old fort. After clinic I walked around it and tried to pier inside, but I couldn't see much. There was a couple young boys who were also playing around the fort and trying to throw rocks into the higher open windows. There was a rock on one side that the kids would surf/slide down. I gave it a try and busted my butt. They enjoyed that very much.
This clinic was about 14 kmn from our campsite near Sissu. Instead of using all tents like we did in Kaksur we used the local hospital for several of our clinic rooms. I began the day in OB/GYN and finished the day in the Ophtho clinic. There were not many OB/GYN patients so many of our pts were general medicine pts taken to relieve the burden on their tents. One pt that I had was complaining of arm pain and a couple other things. On examination I noted limited range of
elbow flexion and extension as well as limited ROM at her shoulder. Apparently she had dislocated her shoulder and broken her distal humerus 20 years and had never gotten them fixed. Her arm had healed improperly and her shoulder muscles atrophied. We had an Indian doctor who was a Orthopedist with us who said that even if we reduced the shoulder now it would not help her b/c she wouldn't be able to move her arm. He said a shoulder prosthesis would be possible but was not probable b/c it wouldn't benefit her much either. The picture to the right is the Ophthalmology clinic. The clinic today was set up in the hallway right next to the two medicine clinics. Having a clinic this visibly open is not the best idea because everyone who walks by thinks they need to have there eyes examined, not just the people who really need it. This was one of the busiest afternoons the optho clinic had. In the picture from top to bottom are Vipul, Dustin, Sarika, and then our translator/driver.
Outside the clinic site there was a cool 800 year old fort. After clinic I walked around it and tried to pier inside, but I couldn't see much. There was a couple young boys who were also playing around the fort and trying to throw rocks into the higher open windows. There was a rock on one side that the kids would surf/slide down. I gave it a try and busted my butt. They enjoyed that very much.
Wednesday, July 2, 2008
Glacier Hike
The night after the clinic day in Kaksur several of us went on a hike to try to get up near a glacier that was near our campsite. We had to cross the river again and we then tucked up a little side valley. On the walk up you could see the glacier hanging off the rock face but the further we went the less you could see of it. It was a spectacular hike. Much of the trail that we walked on was actually an irrigation ditch that had been dug from a pseudo-lake much higher up. It was an incredible piece of work.
Subscribe to:
Posts (Atom)