Case studies

Here's the link to my project about the cases I've been following. Yasmiri was actually re-admitted to the Emergency Ward today for treatment of her respiratory problems.

https://docs.google.com/fileview?id=0B_mhuHpg4nPROTQwNDk4ZjYtZTI4OC00ODQ5LTlmYjAtMTI0YzMzNDQyMzM0&hl=en

Farewell from Kolkata. Thanks to everyone I have met here for the insights you have shared. Unforgettable!

another sad story

This 20-month-old came into clinic this morning having lost 2kg in the last month.

He's been separated from his mother for the last six months and is being fed on just milk (cows'?) and no supplementary feed.

He's 5.8kg now and severely malnourished with recurrent fever and vomiting. This is his grandmother who will be his carer during his stay at the emergency ward here.

He's being energy dense milk (EDM-I) 90ml 8 times a day for the first two days, then EDM-2 which is richer in fat and protein once his appetite has recovered. Giving protein and fat rich foods too early puts a strain on the liver, which has often undergone fatty changes in malnourished patients. He doesn't have an enlarged liver, but autopsies have shown that fatty changes occur even without enlargement.

He will also be given broad spectrum antibiotics and a source for the infection will be sought.

There are obvious social problems to uncover and solve, but how much CINI can help with this side is hard to say.

Let's see his progress over the next couple of weeks. Weight now is 5.8kg.

Sitarrrrwawhhwahwahwhaaahhhh

So I went to seek sitars and sarods a couple of weeks ago and only found a sad shop full of rusty out of tune guitars and a mandolin less strung and more strung up. The shop keeper just said, no problem, you like? So I was a bit disheartened, but, but but today I found, with the help of a fellow sitar seeker, a whole street full of musical instrument shops, and workshops. They are hanging from the roofs, their gourd bodies waiting to be planted in the laps of people like me, providing yet another excuse for acquiring variously shaped orange cushions and taking up a yoga pose.

I'd heard the scale is awfully difficult, quarter tones even being further divided into discrete notes on a completely different scale. But actually it's set out in a western scale and you can just produce the other notes by bending strings. Easy! Even better, the guy provided me with mijrabs, contorted paper clip-like devices you wear on your fingers which act as false nails.

And they aren't that expensive either....oh no! The mijrabs, well they are 5 rupees. The sitars range from 6000 or so upwards. I really didn't think I'd be tempted, but...it was very nice to sit there and play, gently hypnotising myself. (Anyone complaining it sounded like a cat being strangled could move into the next room where they wouldn't hear a thing.) But I pulled myself back from the brink. After all, without a student loan coming in, just a meagre salary, I can't justify these kinds of purchases...it's a topsy-turvy world we live in.

I did get some mijrabs and a pitch pipe though, to add some spice to my mandolin playing, as if it needed it, and to bring it boringly back into tune. Ah, no worries, if I miss that dissonant twang I'll just bend strings in keeping with the new-found sitar style.

What's this?

Two nights ago a 21 day old baby came to the emergency ward with blistering all over his body, which he'd had since birth. Dr Tarique prescribed co-amoxiclav, Betadine (povidone-iodine) ointment and fusidic acid cream. This morning I saw the baby, who was purple because he'd been soaked in gentian violet (of Gram stain fame).

The thing is, nobody knows what's wrong with this baby. I said pemphigus or Staphylococcal scalded skin syndrome! He clearly thinks Staph but claims not to know. He asked me to go and find out so I welcome any help.








Oh and I should say, his pulse was 130 - normal, chest was clear but breathing was fast and he felt really warm.

All hail Rabindranath Tagore

We stand before this great world. The truth of our life depends upon our attitude of mind towards it - an attitude which is formed by our habit of dealing with it according to the special circumstances of our surroundings and our temperaments. It guides our attempts to establish relations with the universe either by conquest or union, either through the cultivation of power or that of sympathy. And thus, in our realisation of the truth of existence, we put our emphasis either upon the principle of dualism or upon the principle of unity.

...For us the highest purpose of this world is not merely living it, knowing it and making use of it, but realising our selves in it through expansion of sympathy; not directing ourselves from it and dominating it, but comprehending and uniting it with ourselves in perfect union.


All hail Waldo E. Nelson MD

The clinical pattern of typhoid fever in infants ranges from a mild gastroenteritis to a severe septicaemia. Vertical transmission may be responsible for neonatal typhoid fever that begins within 72hr after birth. Vomiting, abdominal distension and diarrhoea are common. The temperature may be variable but can be as high as 40.5 degrees C (106F). Seizures may occur. Hepatomegaly, jaundice, anorexia and weight loss can be marked.


A little guy staying in the NRC bit my finger a couple of days ago. Well he's hungry, which is why he's here, so it didn't shock me that much. Anyway, he's one of the patients I am studying in my project, so I was interviewing his mum at the time. A while later I asked if he had had any childhood infections. Dr Debjani said, yes, typhoid. I said, oh, when? The answer - Now. The Widal test came back three days ago. He's being treated with antibiotics at the moment. Interesting. I stopped playing with my hair and...no, I wasn't playing with my hair. But I did check to see if the bite mark had gone through the skin and then sloped off to wash my hands. And then read up all about typhoid fever, as you could say I have developed a personal interest.

Anyway I checked out my vaccines and typhoid is in there so I should be OK.

As for Tagore, he's the local hero in these parts, and it is his songs they sing every morning to a squeeze box. I gave up going after a week, oh me of little faith, but when I found the amazing book stall territory, the complete works of Tagore was the first thing to leap out at me, and I bought it. So I've been reading what he has to say, even if I don't do the full-on worship thing in the assembly hall. He grew up around here and spent a long time just communing with the trees and the birds. He then decided to teach children, and eventually he set up a university which is going strong, about 300km from here. He was awarded the Nobel Prize for Literature in 1913.

So it turns out the campus is not a prison but a haven, the area is not desolate wasteland but verdant farmland, the oppressive heat will soon give rise to the monsoon and four more weeks, far from being interminable is far too short for me to learn all the things I need to learn about tropical diseases. And how to become serene.

Poverty = Frustration?

Maybe that's the whole point. I'm just experiencing some tiny tiny version of what it means to lose control of your life. And it really is very frustrating. But when I look around me it becomes apparent that I've got a whole lot more freedom than most people here.


I spoke to some of the women I'm using as subjects in my project today, with Dr Debjani translating. They left school at ten, were married at 14 to people they didn't choose, and had children at 17. Now they are here because they don't know how to feed their children properly. Their husbands earn 1000 Rupees a month, which equals less than 15 pounds. They live in one room mud huts.

They are also incredibly warm and lovely. They put a bindi on me today, I didn't know they were doing it until it was done. And then they started stroking me and got me singing. Well, once I realised how much attention they were willing to give, I just carried on, of course. They sang me Bengali songs and got me to repeat them, then they begged me not to leave. There may not be open mic nights here, but I think I've found an acoustic platform with built in audience. Wait til I get the mandolin out!

Another morning, another burst water mains...

CINI's generator

Half way through my shower the water mains went off and then there was a power cut. The generator cut in as usual.

It's OK, I feel better now I've come clean, bring on the hassle, I can face the world with renewed vigor.




The lovely lady in reception agreed to make copies of my questionnaire, and then she did it. Result.

When I went to print off the master questionnaire I mentioned to Urmidi that I was interested in the growth chart CINI uses, and she referred me to the WHO resourcesd. http://www.who.int/childgrowth/en/

Hooray! Finally! It's all there. CINI changed over from an Indian version this April, to the WHO worldwide standard where there are separate charts for boys and girls but not for different ethnic groups or nationalities. So the sample population is taken from all over the world. Apparently the differences within groups are more marked than between them. This is great, I feel like I am getting somewhere at last.

So in CINI terms the so-called road to health (green!) is actually from the mean to 2 standard deviations below the mean. Malnourished (yellow) between 2 and 3 standard deviations below the mean, and severely malnourished (errrr...red?!) below 3 SD below the mean. It might not sound exciting but it's made my day. And it's only 11am.








Two local residents









Dr Debjani is going to translate for me and help me interview my patients for my project, so I can write up some case studies, following six patients from admission through to discharge and back into the community. I think this will be really useful material if I can do it well.



I met the librarian over the tea pots and I think she scowled at me.

But I'm still keeping Nelson, if only to beat myself over the head with.