While I was spending time in the TB clinic at the CHAD clinic, I kept hearing about a disease that I had never encountered before in the U.S. Many patients would come into the clinic for sputum sample collections for presumed TB, but one of the residents kept ordering CBCs to work up for a disease entity called "TPE." TPE, as it turns out, stands for Tropical Pulmonary Eosinophilia. He told me that TPE is very common in Vellore and other parts of Asia and this is something they often check for when a patient comes to TB clinic with because the disease is endemic to south India and so prevalent there.
TPE is the result of an immune hypersensitivity reaction to human filarial parasites, Wuchereria bancrofti and Brugia malayi, is characterized by cough, dyspnea and nocturnal wheezing, diffuse reticulonodular infiltrates in chest radiographs, and marked peripheral blood eosinophilia. The criteria used for the diagnosis of TPE are: (1) appropriate exposure history (mosquito bite) in an endemic area of filariasis, (2) a history of paroxysmal nocturnal cough and breathlessness, (3) chest radiographic evidence of pulmonary infiltrations, (4) leucocytosis in blood, (5) peripheral blood eosinophils more than 3000 cells/mm3, (6) elevated serum IgE levels, (7) elevated serum antifilarial antibodies (IgG and/or IgE), and (8) a clinical response to diethylcarbamazine.
TPE) usually affects people living in the tropics, especially those in Southeast Asia, India, and certain parts of China and Africa. However, due to increasing global travel and the migration, this disease is increasinglyseen in the West, where the diagnosis can be easily missed since it is rarely encountered and can mimic many other conditions. Most typically, TPE can mimic acuteor refractory bronchial asthma
Leucocytosis with an absolute increase in eosinophils in the peripheral blood is the hallmark of TPE. Lung function tests reveal mainly a restrictive ventilation defect with superimposed airway obstruction.
Typically, microfilariae circulate in the blood of patients with lymphatic filariasis without significant clinical consequences. In the case of TPE, however, these microfilariae appear to be trapped in the lung on their first pass through the circulation, where they are presumed to initiate an inflammatory response.
In contrast to the majority of people with lymphatic filariasis, who have a downregulated response to the parasites, patients with TPE mount a robust systemic and localized immune response that includes elevations of both polyclonal and filaria-specific IgE and IgG. The very high levels of eosinophils found in the peripheral blood of TPE patients (>3,000/µl) are surpassed in the lungs: levels have been determined to be 12-fold more concentrated in the epithelial lining fluid of the lungs than in the systemic circulation.
A mild form of interstitial lung disease persists in the majority of patients treated for TPE. For the untreated TPE patient, the outcome is more extreme and could lead to a progressive interstitial fibrosis.
Wednesday, February 20, 2008
Tuesday, February 12, 2008
Sweating it out
Ok, so I haven't blogged in a while and have some catching up to do! The past few days have been good, but hot. And by hot, I mean hot. Our hostel dosen't have a/c, which is pretty typical of most accomodations in India. But for some reason this week I am really feeling the heat. I think I am also underestimating how much fluids I am losing through insensible losses, ie sweat. I think beacuse I haven' t been drinking enough water, I've been feeling more tired than usual. So I need to be good about drinking LOTS of water so that I don't pass out.
Let's see, where did I leave off? On Friday, I went to internal medicine rounds at the hospital. It was a little better than the day before because I could hear better and get a better sense of what was going on. But it is STILL hard to hear people here! I like to think that I'm used to what "Indian" English sounds like, but people here speak so quickly. And throw in loads of medical jargon and it becomes worse. This time I went to rounds in the ICU. Again, not too drastically different from what I'm used to in the U.S. The actual number of beds is smaller, and there aren't separate encloures for rooms like back home, so it's more of a "ward" type feel. But they have all the latest in terms of equipment, like ventilators, crash carts, etc. They also, for the most part, use the same antibiotics as we do back home, only they have different trade names because they are marketed through different companies. Because I was in the ICU, I got to see some pretty sick patients, many of whom were intubated. Although the medical issues of the patients was pretty similar to what I'm used to back home, what struck me was how the attending interacted with the family members of the patient. After seeing each patient, my attending would pull the family member into the room and would talk to him about the patient, standing up, surrounded by the entire team. He would tell the family member (usually only one person, designated to be the spokesperson) that their relative wasn't doing well, that the prognosis was dim, and that they needed to start considering how long they wanted to keep them alive via artificial means. He would also ask them if they thought it was worth as much money as they were paying to stay in the ICU. This is definitely something I'm not used to back home. Conversations between doctors and family members are usually done privately, and they are not nearly as blunt or suggestive as far as what should be done with the patient. And another difference here is that patients and family members are so grateful for whatever opinion the doctor gives. It's amazing how much respect doctors command here. In many ways, the doctor-patient relationship is very paternalistic here and patients blindly follow whatever advice they are given. This might be due to the fact that many of the patients seen at CMC are represent very low socio-economic classes and have very little education. But I'm sure this is what it used to be like in the U.S. back in the 60s and 70s, in the era before HMOs, malpractice suits, and having patients self-diagnose themselves on the internet.
This weekend our whole group went on a road trip to Pondicherry. Our trip to get there was an adventure in and of itself. Eight of us crammed into an SUV that was probably meant for 5 people, and our luggage was strapped down to the roof of the truck. And the road to get there (it's about a 4 hour trip) was bumpy, narrow, and poorly paved. Which is the case for most roads in India, but when you're with a driver who is swerving constantly at speeds that are twice what is safe to drive on such a road, you can't help but start to fearing for your life.
Pondicherry is a small city which was a former French colony. And it attracts many western tourists who come there to medidate because of a famous ashram there. There's really not much to do there, except to go medidate or sit on the beach. Neither of which are my sort of thing to do. So a bunch of us basically went shopping. But I didn't find anything I really liked because I didn't think they had a very good selection. Later that evening our group went to dinner at an overpriced restaurant which was not good either. But at least the company was good.
Yesterday and today I've been working at CHAD clinics, which stands for the community health and development program here. Yesterday I was at a family practice clinic, so we saw people of all ages. Jen and I saw one little boy who presented with new onset headaches and vomiting. After MUCH debate, they finally decided to get him a CT scan. In the US, this wouldn't even have been a question. But it makes your realize that finances really do play a role in determining the level of health care people get.
Today I went to the TB clinic. TB patients, in India, are considered "bread and butter" cases. Far from the case back home. Many of the patients had dormant TB, but one woman I saw had MILIARY TB. I'm not kidding. The doctor had pulled up her chest x ray, and said "that's miliary TB." I've never seen a chest x ray like that- it looked like somebody took a pen and just made little dots throughout the film. I assumed it was one of his patients outside of the clinic. But then, this patient walks in and sits down in front of me and I realize that SHE is the one he's talking about! I was amazed that somebody in her condition was even walking around.
The other crazy patient I saw today was a 19 year old woman who looked absolutely emaciated and pale. She probably weighted at most 80 lbs. And there was a good reason why. The doctor pulled up her CBC on the computer and she had a hemoglobin of 4.5! I couldn't believe it. She was basically about to go into high output cardiac failure as a result of her anemia. She had horrible oral ulcers, and pedal edema from her heart failure. She waited this long to come in because she couldn't afford treatment. And today she was in such a bad state that she needed to be admitted. Craziness.
Anyway, this week I'm continuing with CHAD. More stories to follow....
Let's see, where did I leave off? On Friday, I went to internal medicine rounds at the hospital. It was a little better than the day before because I could hear better and get a better sense of what was going on. But it is STILL hard to hear people here! I like to think that I'm used to what "Indian" English sounds like, but people here speak so quickly. And throw in loads of medical jargon and it becomes worse. This time I went to rounds in the ICU. Again, not too drastically different from what I'm used to in the U.S. The actual number of beds is smaller, and there aren't separate encloures for rooms like back home, so it's more of a "ward" type feel. But they have all the latest in terms of equipment, like ventilators, crash carts, etc. They also, for the most part, use the same antibiotics as we do back home, only they have different trade names because they are marketed through different companies. Because I was in the ICU, I got to see some pretty sick patients, many of whom were intubated. Although the medical issues of the patients was pretty similar to what I'm used to back home, what struck me was how the attending interacted with the family members of the patient. After seeing each patient, my attending would pull the family member into the room and would talk to him about the patient, standing up, surrounded by the entire team. He would tell the family member (usually only one person, designated to be the spokesperson) that their relative wasn't doing well, that the prognosis was dim, and that they needed to start considering how long they wanted to keep them alive via artificial means. He would also ask them if they thought it was worth as much money as they were paying to stay in the ICU. This is definitely something I'm not used to back home. Conversations between doctors and family members are usually done privately, and they are not nearly as blunt or suggestive as far as what should be done with the patient. And another difference here is that patients and family members are so grateful for whatever opinion the doctor gives. It's amazing how much respect doctors command here. In many ways, the doctor-patient relationship is very paternalistic here and patients blindly follow whatever advice they are given. This might be due to the fact that many of the patients seen at CMC are represent very low socio-economic classes and have very little education. But I'm sure this is what it used to be like in the U.S. back in the 60s and 70s, in the era before HMOs, malpractice suits, and having patients self-diagnose themselves on the internet.
This weekend our whole group went on a road trip to Pondicherry. Our trip to get there was an adventure in and of itself. Eight of us crammed into an SUV that was probably meant for 5 people, and our luggage was strapped down to the roof of the truck. And the road to get there (it's about a 4 hour trip) was bumpy, narrow, and poorly paved. Which is the case for most roads in India, but when you're with a driver who is swerving constantly at speeds that are twice what is safe to drive on such a road, you can't help but start to fearing for your life.
Pondicherry is a small city which was a former French colony. And it attracts many western tourists who come there to medidate because of a famous ashram there. There's really not much to do there, except to go medidate or sit on the beach. Neither of which are my sort of thing to do. So a bunch of us basically went shopping. But I didn't find anything I really liked because I didn't think they had a very good selection. Later that evening our group went to dinner at an overpriced restaurant which was not good either. But at least the company was good.
Yesterday and today I've been working at CHAD clinics, which stands for the community health and development program here. Yesterday I was at a family practice clinic, so we saw people of all ages. Jen and I saw one little boy who presented with new onset headaches and vomiting. After MUCH debate, they finally decided to get him a CT scan. In the US, this wouldn't even have been a question. But it makes your realize that finances really do play a role in determining the level of health care people get.
Today I went to the TB clinic. TB patients, in India, are considered "bread and butter" cases. Far from the case back home. Many of the patients had dormant TB, but one woman I saw had MILIARY TB. I'm not kidding. The doctor had pulled up her chest x ray, and said "that's miliary TB." I've never seen a chest x ray like that- it looked like somebody took a pen and just made little dots throughout the film. I assumed it was one of his patients outside of the clinic. But then, this patient walks in and sits down in front of me and I realize that SHE is the one he's talking about! I was amazed that somebody in her condition was even walking around.
The other crazy patient I saw today was a 19 year old woman who looked absolutely emaciated and pale. She probably weighted at most 80 lbs. And there was a good reason why. The doctor pulled up her CBC on the computer and she had a hemoglobin of 4.5! I couldn't believe it. She was basically about to go into high output cardiac failure as a result of her anemia. She had horrible oral ulcers, and pedal edema from her heart failure. She waited this long to come in because she couldn't afford treatment. And today she was in such a bad state that she needed to be admitted. Craziness.
Anyway, this week I'm continuing with CHAD. More stories to follow....
Thursday, February 7, 2008
Medical speak
For the past two days, I've had a taste of internal medicine, India style. Yesterday I went to a general medicine clinic. There were a variety of patients with all sorts of complaints, including hip pain, memory loss, persistent cough, etc. I was surprised at how far many of the patients had travelled to get to Vellore. Apparently CMC's reputation is so great that patients (and their families) come from all over the country because it is a tertiary referral center. I saw several patients who came from as far as West Bengal, Rajasthan, and Bihar. They come down to Vellore over a period of several weeks with their family, and many of them get check-ups too since they're already down here. Many of these patients are only Hindi speaking, but luckily my attending was fluent in both Tamil and Hindi and so there was no communication barrier. My comprehension of both languages is at about the same level, that is, very basic. But when I know the context in which somebody is speaking I can get a good idea of what's going on. The medical record system here is quite modern, though. All patient labs, imaging, and discharge summaries are online. This isn't even the case for many hospitals in the U.S.!
Today I went to rounds in the E.R. The team consisted of a group of 5-6 interns and residents with one attending. As in the clinic, the patients presented with a spectrum of complaints: myocardial infarction, uncontrolled diabetes, altered sensorium, and even a random snake bite victim. The frustrating part, though, was trying to get a sense of what was going on with the patients. The rounding style here is very different from what I'm used to back home. The presenting resident speaks directly to the attending, instead of the team and speaks very softly and quickly. I don't usually have trouble understanding Indian accents- if anything, I think they are easier to understand because in Indian English the words are articulated very well. But in the setting of a crowded, noisy ER with nurses bumping into you it proves exceedingly difficult to understand what's going on with the patients. After rounds, we had a mid-morning coffee break (this is very common here) and then one of the residents presented a power point on dementia assessment scales. Again, hard to understand...or maybe I just have a hearing problem!
This weekend a bunch of us are going to Pondicherry. It's about a 4-5 hour drive from Vellore. It should be fun. I'm looking forward to having a change of scene for a bit. Even though I've only been here for less than a week, it almost feels like forever. Perhaps this is because I've been to India so many times and this is why it feels less "foreign" to me than other places. But being here on my own has definitely made me more confident about small things, like bargaining with auto rickshaw drivers in my broken Tamil and being more bold when crossing the street (which actually is a very scary thing to do here).
Today I went to rounds in the E.R. The team consisted of a group of 5-6 interns and residents with one attending. As in the clinic, the patients presented with a spectrum of complaints: myocardial infarction, uncontrolled diabetes, altered sensorium, and even a random snake bite victim. The frustrating part, though, was trying to get a sense of what was going on with the patients. The rounding style here is very different from what I'm used to back home. The presenting resident speaks directly to the attending, instead of the team and speaks very softly and quickly. I don't usually have trouble understanding Indian accents- if anything, I think they are easier to understand because in Indian English the words are articulated very well. But in the setting of a crowded, noisy ER with nurses bumping into you it proves exceedingly difficult to understand what's going on with the patients. After rounds, we had a mid-morning coffee break (this is very common here) and then one of the residents presented a power point on dementia assessment scales. Again, hard to understand...or maybe I just have a hearing problem!
This weekend a bunch of us are going to Pondicherry. It's about a 4-5 hour drive from Vellore. It should be fun. I'm looking forward to having a change of scene for a bit. Even though I've only been here for less than a week, it almost feels like forever. Perhaps this is because I've been to India so many times and this is why it feels less "foreign" to me than other places. But being here on my own has definitely made me more confident about small things, like bargaining with auto rickshaw drivers in my broken Tamil and being more bold when crossing the street (which actually is a very scary thing to do here).
Wednesday, February 6, 2008
Laboring away
So after all of the paperwork madness, I finally started work yesterday. Nicolette, Erica, and I went to the "OG" (ob/gyn) wards. We spent the morning hanging around labor and delivery watching the residents and interns do their thing. I got to see a few deliveries. The labor ward here is definitely different from what I'm used to in the U.S. There are no private rooms, only cots separated by flimsy curtains. I got to see a few deliveries. I learned that it is much more common here to do episiotomies and vacuum/forceps deliveries . Ouch. Pain tolerance also takes on a new definition here. Women do NOT routinely get pain medications, and the vast majority labor through their delivery with out any form of narcotics or epidural. Which explains the wailing. Women routinely cry out in pain as their contractions come, and each one is accompanied by their mother or elder female relative at the bedside. No male relatives are allowed.
We went to the OR (aka 'operating theatre' here in India) to watch a c section. I don't know why, but for some reason I expected the inside of the OR here to be drastically different than what it is in the U.S. But it wasn't. For the most part, everything inside was the same: several rooms with modern equipment and technology. Even the way in which the doctors scrub in and the scrub nurse system is the same. The funny part though was the actual scrubs. Nurses wear separate gowns, but the scrubs worn by the doctors here are these huge, clown-like pants which are super short. They reminded me of light blue churidar pants. And the scrub shirts are these huge, long, floppy shirts with drawstring ties on the back. And nobody wears closed toed shoes on the wards- they just wear their regular outside chappals and think nothing of it. And during deliveries, doctors don't cover up their toes. In fact, it is normal for large quantities of blood to be dripping on your feet during a delivery. In the OR, we got these floppy booties with drawstrings on them to cover up our chappals but mine kept falling off so I felt pretty foolish walking around.
We befriended an intern who was rotating through the OG service this week. He was pretty friendly, and probably made the most effort out of anybody there to make us feel included and involved in the patients. He was also curious and asked us many questions about the U.S. medical education system. In India, students go directly to medical school from high school and our "M.D." equivalent is known as the M.B.B.S. degree here. After 5 years of medical school, they do a one year internship (similar to us) but this involves rotating through every single medical specialty (unlike us.) After this they do their post-graduate medical training, which we call our residency.
Anwyay, enough medical speak. I am convinced that I am going to double my body weight while I'm here if for no other reason than for the fact that I am on a purely carb diet. Idly for breakfast, rice for lunch, dosa for dinner. Gotta love south Indian food. No wonder this country has such a high incidence of diabetes.
My other MAJOR peeve is the mosquitoes. They seem to attack me en masse, especially when I'm in the computer lab. And they have a predeliction for my ankles and feet which I don't really understand. But it's frustrating to have to keep bending down and itching my feet every 5 seconds. Plus it just looks wrong.
We went to the OR (aka 'operating theatre' here in India) to watch a c section. I don't know why, but for some reason I expected the inside of the OR here to be drastically different than what it is in the U.S. But it wasn't. For the most part, everything inside was the same: several rooms with modern equipment and technology. Even the way in which the doctors scrub in and the scrub nurse system is the same. The funny part though was the actual scrubs. Nurses wear separate gowns, but the scrubs worn by the doctors here are these huge, clown-like pants which are super short. They reminded me of light blue churidar pants. And the scrub shirts are these huge, long, floppy shirts with drawstring ties on the back. And nobody wears closed toed shoes on the wards- they just wear their regular outside chappals and think nothing of it. And during deliveries, doctors don't cover up their toes. In fact, it is normal for large quantities of blood to be dripping on your feet during a delivery. In the OR, we got these floppy booties with drawstrings on them to cover up our chappals but mine kept falling off so I felt pretty foolish walking around.
We befriended an intern who was rotating through the OG service this week. He was pretty friendly, and probably made the most effort out of anybody there to make us feel included and involved in the patients. He was also curious and asked us many questions about the U.S. medical education system. In India, students go directly to medical school from high school and our "M.D." equivalent is known as the M.B.B.S. degree here. After 5 years of medical school, they do a one year internship (similar to us) but this involves rotating through every single medical specialty (unlike us.) After this they do their post-graduate medical training, which we call our residency.
Anwyay, enough medical speak. I am convinced that I am going to double my body weight while I'm here if for no other reason than for the fact that I am on a purely carb diet. Idly for breakfast, rice for lunch, dosa for dinner. Gotta love south Indian food. No wonder this country has such a high incidence of diabetes.
My other MAJOR peeve is the mosquitoes. They seem to attack me en masse, especially when I'm in the computer lab. And they have a predeliction for my ankles and feet which I don't really understand. But it's frustrating to have to keep bending down and itching my feet every 5 seconds. Plus it just looks wrong.
Monday, February 4, 2008
Around and about
So today being my first "official" day I (along with others in the group) went to the prinipal's office and got registered. So I'm now officially a visitng foreign student at CMC. Luckily, Kathryn, who was here last month, has decided to stay on for another month so she was around to show us the ropes. Which was a big help, because trying to navigate the ins and outs of where to go in the hospital would have been pretty difficult without her! So for this week, I'll be rotating through the ob/gyn wards. They refer to it as "OG" here and if you say "ob/gyn" they have no idea what you're talking about. This applies to many things you say. I find that every time I come to India, I have to make a serious effort to de-Americanize the way I speak English in order to make myself understood. Today, I started to try speaking English with an Indian accent which means articulating every syllable of every word and this seems to help some, but not entirely. We also met some very friendly foreigners who work at the development office and informed us that there will be a get together for international students tonight. Next week I'll be doing internal medicine and the following week I'll be doing the CHAD (community health and development) rotation where we ride with nurses on vans into the rural villages to provide health care to the villagers. But so far, everybody seems very friendly and accomodating toward foreign students, so that's a good sign.
Sunday, February 3, 2008
Exploring Vellore
So today I woke up around 7 am, unable to sleep due to jet-lag. Nicolette and I wandered over to the canteen which is next door and enjoyed a nice south Indian breakfast. We had dosas and chutney, and hot tea. I don't mind regular Indian chai, but the regular hot tea they serve at restaurants here bugs me. For some reasons, Indians believe that it is necessary to flood every cup of tea with massive quanitites of milk and sugar. Which I don't appreciate. But it's tea, so I drink it.
Then we took an auto rickshaw over to the CMC hospital campus, which is about 10 minutes away. The four of us wandered around Vellore, but most of the stores here are closed on Sunday. We ventured into a few clothing stores, where we were thoroughly unimpressed by the selection. And we got plenty of stares along the whole way. Which brings me to another subject. The Indian art of staring. Anytime a foreigner walks down the street here, they get stared at. Even though there are a decent number of foreigners here, since CMC is an internationally renowned medical school. Even I, who am dressed in traditional Indian clothing, get stared at. I think it might have something to do with the fact that I am physically bigger than the average Indian man. :-) And, since coming here, I've been approached (on more than one occasion) by locals who will start speaking to me in Hindi. One guy asked me if I was a medical student from north India. In Hindi, no less. My Tamil and Hindi language skills are both pretty broken so I can't respond the way I want, so this frustrates me.
But I digress. My family returned to Chennai today. So the rest of the day I will spend wandering around here. If I'm brave, I might venture out to the fruit stand and buy some fruit. I'm craving sweet, healthy food. That is not diarrhea-inducing. But it's hot and humid and all I want to do is languish in the comforts of a/c. So we'll see how far I make it.
Then we took an auto rickshaw over to the CMC hospital campus, which is about 10 minutes away. The four of us wandered around Vellore, but most of the stores here are closed on Sunday. We ventured into a few clothing stores, where we were thoroughly unimpressed by the selection. And we got plenty of stares along the whole way. Which brings me to another subject. The Indian art of staring. Anytime a foreigner walks down the street here, they get stared at. Even though there are a decent number of foreigners here, since CMC is an internationally renowned medical school. Even I, who am dressed in traditional Indian clothing, get stared at. I think it might have something to do with the fact that I am physically bigger than the average Indian man. :-) And, since coming here, I've been approached (on more than one occasion) by locals who will start speaking to me in Hindi. One guy asked me if I was a medical student from north India. In Hindi, no less. My Tamil and Hindi language skills are both pretty broken so I can't respond the way I want, so this frustrates me.
But I digress. My family returned to Chennai today. So the rest of the day I will spend wandering around here. If I'm brave, I might venture out to the fruit stand and buy some fruit. I'm craving sweet, healthy food. That is not diarrhea-inducing. But it's hot and humid and all I want to do is languish in the comforts of a/c. So we'll see how far I make it.
Friday, February 1, 2008
Finally here!
So I'm finally in India! I managed to make it here in one piece. Our plane landed at about 2 am local time, so we headed straight to the hotel from the airport. The place we're staying at is Beverly Hotel (www.beverlyhotels.com)
and it's pretty decent. I was happy about my hot shower this morning. :-)
We ate breakfast here and now I'm about to go investigate the cell phone situation. My aunt and uncle live 5 minutes from here so I'll meet them, then pick up my classmates and head out to Vellore. It's supposed to be approximately 2 hours from here, so hopefully there won't be too much traffic. More when I get to Vellore!
and it's pretty decent. I was happy about my hot shower this morning. :-)
We ate breakfast here and now I'm about to go investigate the cell phone situation. My aunt and uncle live 5 minutes from here so I'll meet them, then pick up my classmates and head out to Vellore. It's supposed to be approximately 2 hours from here, so hopefully there won't be too much traffic. More when I get to Vellore!
I am in Frankfurt now! The keyboards here are a bit funny and the ys are where the zs normally are so I am having a hard time with that. Anyway we made it in one piece here from houston, although we were on the runway for an hour before we took off. that seems to be the trend for me these days! It looks like our flight to India is leaving on time though, and we got here with just enough time to spare. Now we're hanging out waiting for our flight. It is ugly and gross out here in Frankfurt...I am glad to be leaving here! I am going to go hunt down some free business class lounge food now. More from when I get to India!
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