Caroline at CINI

Case studies

2010-06-11T15:03:00.005+05:30

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

2010-06-07T14:16:00.005+05:30

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

2010-06-05T13:46:00.002+05:30

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?

2010-06-02T16:17:00.007+05:30

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

2010-06-02T12:49:00.009+05:30

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?

2010-05-31T20:58:00.004+05:30

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...

2010-05-31T10:47:00.008+05:30

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.

Frustration

2010-05-30T20:56:00.013+05:30

I have to admit, I'm starting to find this place infuriating. I feel isolated and I'm frustrated because I can't achieve what I want to achieve. What do I want to achieve? Hmm, not sure. But I can't seem to do even the smallest things so how can I begin to think about doing good works and, you know, saving lives and that kind of thing? I've been prowling around my room like a caged animal. Reading for half an hour, getting up, drinking water, pacing, looking outside at the heat, standing under the fan, returning to my book. Time crawls along, punctuated by meals and opportunities for cups of tea. I can see why someone would have wanted to invent meditation in these circumstances.

It's the election this weekend and I've been advised to stay on the campus to avoid civil unrest. I hate the campus but I need the campus. I'm well-fed and safe here but I feel so trapped. There's nowhere to go. To get to town requires 3 rickshaws and the metro. And when you take to the road you take your life in your hands.

The area around CINI is desolate. It's a dust road extending back into farmland. I tried going for a run, I said never again because of the heat and the attention, but was so desperate to get out, I did go again. The only place I can go for sanity is the roof in the very early morning.

The first thing I couldn't do is get internet connection.

A barber shop in my street

Further down the road

After the rain

But I managed to get a phone and despite having my number cancelled and having to have it re-instated with a resubmition of my documentation, it is still working to this day, and that is 4 days later, so that is a record.

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Check out the internet cafe, top right of the picture. This is during one of many power cuts which is why the whole street is lit with candles and kerosene lamps.

The internet cafe wanted to copy my passport before I could log on. Do you think they are tracking the sites I visit? Will they notice I looked up last minute flights to the UK? Hmmmm.

Yes and I have taken some really nice videos, and I've tried to upload them but the speed here is just too slow, it won't work.

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Luckily, after a bit of a battle with the librarian, I managed to procure a copy of the hefty Nelson's Textbook of Paediatrics.

Peace in the internet cafe

Clinic

2010-05-28T14:04:00.013+05:30

Hello, I'm pleased say that the daddy decided to agree to support his family and come back from Bombay, so the little girl I told you about last time has been admitted. Here she is with her mum in the emergency ward.

And here's the family, reunited.

Clincs run every morning from 9.30 except Thursday clinics which are free so attract huge crowds, so they start at 8.30 and go on until whenever.

There are hoardes of women with their children who line up, register for 10 rupees, have their child's weight recorded on the growth chart and then wait to see a doctor. There is a lot of variety, and the doctors here are particularly keen to pick up cases of malnutrition. Here are a couple of cases. One the marasmus type of protein energy malnutrition with severe muscle wasting. The abdominal muscle and smooth muscle of the intestine is also wasted, which gives the baby a protruding tummy. The second shows generalised oedema which occurs in the kwashiorkor pattern of malnutrition.

Neither of these were admitted as there are not enough beds.

This two-year-old girl has hydrocephalus, where the cerebrospinal fluid is being made at a faster rate than it is absorbed. So her skull is expanding to house the extra volume, but the extra pressure is pushing on her brain. She already had delayed milestones and was unable to hold her head up, but now her co-ordination is deteriorating. She needs a shunt to be put in, as a permanent fitting, to drain the excess fluid. But it's unlikely her parents will be able to afford this operation.

This boy has cerebral palsy. He will be referred for neurological assessment and rehabilitation.

This is a boil which is draining to the occipital node. First time I have actually palpated an occipital node, so exciting for me, not so for him. He'll be treated with hot and cold compresses, antibiotics and painkillers, and then within 48 hours the boil will have to be surgically excised and drained.

These are caused by Staphylococcus, and I have see so many Staph skin infection since I've been here. Either as boils or impetigo or cellulitis. According to Dr Pal, poor hygiene is the cause of more than half of the presentations here. If you ask the mothers, they don't use soap.

I know that clean running water is a problem, and I have seen people washing clothes and dishes as well as swimming and weeing into the ponds in my road, so I'm not all that surprised.

Other problems caused by poor hygiene are scabies and diarrhoea. Diarrhoea of course contributes to malnutrition. With poor reserves, these are the children most prone to suffer from infections in the future.
Children who are sick are given broad spectrum antibiotics, free immunisations and dietary advice.

The medicines being mixed up. In this case Amoxicillin. Respiratory tract infections are very common. Lots of good auscultation practice for me!

Patients who are admitted and treated are thoroughly looked after, fed and educated in how to maintain good standards of nutrition and hygiene. When it is deemed they are ready, they are discharged. Here is Dr Tarique with a family happy to be saying goodbye to CINI.

19 May Seeing patients

2010-05-24T16:31:00.012+05:30

Well, the reason I'm here is to see patients, so that's what I've been doing today, well I've dabbled anyway. First in the clinic and then on the emergency ward, which you can see in the photo here. Ten acute beds. Very different from the emergency ward I had in my mind. The next one shows the nebuliser. A lot of patients who are admitted have lower respiratory tract or other infections because they are so malnourished that they become immunocompromised, so it's in pretty constant use.

Paediatrics is sometimes compared to veterinary science because you can't often get the child to tell you directly what's going on. For me, here, I feel at even more of a loss because I can't understand a word of what their mothers are saying either. I'm sitting with Dr Debjani this morning and just watching really.

TEFL skills come into their own. Their mothers all come armed with a growth chart, on which weight is plotted against age to see if the baby is on the 'road to health', malnourished grade I or severely malnourished (grade II). If someone is severely malnourished, they are admitted to the emergency ward straight away. There they are fed with nutrimix and other good things, until they are back on the road to health, and then they are discharged.

The girl on the left in the photo above, aged 2 years and 8 months, is severely malnourished. She was previously admitted to the emergency ward with malnutrition and discharged home. But her father works in Bombay and doesn't provide a lot of support for the mother who is herself malnourished and unable to care for her children. So the child has returned to CINI. The philosophy here is that in order to solve the problem you must fix the root. So this child's parents have been told that unless the father returns to Calcutta and gives his family adequate support, the child will not be admitted and will die. Harsh decision.

The emergency ward has 10 acute beds, where the mothers and babies stay. The mothers are responsible for cleaning the sheets and area around the bed. They are often prescribed energy dense milk (EDM). This is a mix of milk, Nutrimix, sugar and groundnut oil, prepared by sister. The babies really go for this stuff.

See what I mean? They LOVE it.
In my next blog I'll show you some of what I've seen in the clinic. It's really amazing. I'm a bit behind with publishing stuff, but there have been a few errrrr technical reasons for that. I'll get there!

17 May, the start of the backblog

2010-05-24T15:51:00.010+05:30

This is the street where I live.

17 May 2010

Getting to CINI.

By taxi from Kolkata airport. What are those cars? A fleet of yellow and another of white all zooming over the city.

The drive from the airport took us all through Kolkata to this suburb in the South.

Two kids drove me here, asking passing auto rickshaws for directions. The street scenes as we came here reminded me of Cambodia and Guangdong. It's very much Asian street chaos with each vehicle taking its chance in the driving game of life and death.

So the laws of physics changed with the time zone, and although my driver has no idea where he is going and has even suggested that I get out and go the last bit alone as we are quite near (you have got to be kidding), I know that everything is going to turn out just fine.

And I got to CINI, and it is serene and peaceful.

Dr Subhomoy Pal came and met me, told me to rest today and meet downstairs tomorrow morning for prayers. How intriguing.

I went to the canteen where you can get a fish meal for 14 rupees or a vegetarian meal for 9. I think I had both, with added meat. Then Lara came along. She's volunteering with the social business programme, a not-for-profit, not-for-loss organisation which helps women earn money by selling baby food made by CINI. Funded by the World Bank apparently. She's been here 3 months and can chat away in Bengali – very impressive. She told me that there is a poet, a Nobel laureat called Tagore, whose songs they sing every morning in the assembly hall. Can't wait.

Walked along the road through the village past the rickshaw stop, past the fruit and veg market, left into the main road, past the concrete pipes some people have made into their beds, past the burnt out bus, past the bike shop where they didn't want to rent me a bike, past the beautiful tree in orange bloom, and the little girl in the orange dress all the way to the bridge over the muddy roadworks and then back again.

Have slept. Eaten again. Now need to sleep again so I am all ready for the 9:30 singing session. It's lovely here, going to be OK.

It's all suspiciously easy...

2010-05-16T23:42:00.010+05:30

As we bank over to the left into Delhi airport everything looks dusty and hot. Strong sunshine and hazy sky. It's already mid morning here. I slept in the pink fleece that I take on every trip ever since Nina gave it to me on the Camino to Santiago four years ago. I just know I won't need it once I get outside.

I know this is the calm before the storm but I have been warned so much about the hordes that will be beyond anything I've known, that I'm just bracing myself to be jostled and shoved and hassled and ripped off. Yet the arrivals hall is quiet, calm and smooth running. I spotted one of my bags on the belt and and lunged for it before it went round again but was beaten to it by a member of staff. Someone else then came and took my trolley, checked I was going on to Calcutta and swept off to the coach transfer point, passing various security checks along the way with a discrete nod and a wave. He took me to a large black leather sofa and told me to wait there for my coach which would be here in 20 mins. It arrived in 10. Where's all the waiting around and inefficiency? Oh I know, it will come and I'll look back on all this and laugh. But still...

An hour later...

How can I put this? I can't get any cash. I got to the the terminal for internal flights, thought how lovely it would be to contemplate my fate over a large latte, found an ATM which actually greeted me by name when I put my card in – oh to be recognised in a foreign land – and was then snubbed by the same machine. And all the other ATM machines too. The guy in the information booth told me they don't use chip cards 'here'. I've yet to discover whether here means Delhi airport or the whole country. Anyway, despite being told not to bring any cash as it was a waste of time as cards are so much easier, I did have cheeky tenner on me which I changed into 569 rupees so am after all contemplating my fate over a large latte. Got a bit of a twist to it now though.

And then... ...it got a whole lot worse. Being tempted by the mutton rogan josh after four hours in the departure hall, was that my fatal error? Or is it just my general hormonally unbalanced constitution? Anyway, whatever it was, just as I was heading to the gate I was gripped with abdo pain to die for, had to sit down, the room was spinning, then I was being spun around in a wheelchair as I lost the use of my legs, and sweating and shivering and oh horrible horrible and just as the lovely Jet stewardesses were taking me out of departures to see a doctor (who me?! shhhhhhhhh) I managed to projectile vomit into the queue of people checking in. I know it's awfully cliched but Delhi wanted me to have some belly and it's meant I'm staying here for the night. Jet are very kindly letting me go on their 9.20 flight tomorrow at no extra charge.

And then you start to realise what people mean about us lot being spoilt by the NHS. I mean, I had every confidence in the doctor treating me, as well as the really great nurses, and I picked up some cannulation tips, and no it doesn't hurt. And I felt relieved to be able to lie down and be looked after. But then there was the bill, to be paid in cash there and then - and me without even any useful bits of plastic on me and 120 rupees (just under £2). What if it wasn't one-off abdo torment? What if the problem wasn't cash flow but just lack of any at all. Never been in such a situation before.

Well, what would you do next?

Getting ready

2010-05-07T21:33:00.011+05:30

Just over a week and counting. - furiously praying that Eyjafjoell keeps a lid on it until then.

For some reason, none of this seemed real until my mosquito net arrived. It came in an intriguing black toggle bag, which I put away in the India bag, now the only part of my very full room which is not set to be packed up and taken to Cornwall on Thursday. Yes, I am moving out of London. That’s another story… Also in this bag have gone: REPEL 100 for persistently interested mosquitos and P20 once a day sunscreen, ideal for individuals who burn easily. That's me.

I received an email from Dr Pal today, who confirms my internship will begin on 17^th May and has arranged for me to be met in Kolkata next Sunday night. I'd asked if there was anything I could bring, and he said a good stethoscope. So, in that went too.

I had my jabs a while ago, but still had to get my anti-malarials from my GP. The practice nurse in Poplar, where I’m still registered with the GP, had recommended chloroquine (previously vaguely known to me as a rheumatoid arthritis drug).

I was meant to start it two weeks before my departure and continue for a month after I got back. But before I actually collected it form the chemist, someone I met at a barbecue told me that when she went to Africa she didn’t bother taking anything, as the side effects were so awful. Hmmmm, this got me thinking. I looked it up in the BNF. Side effects: gastro-intestinal disturbances, headache, convulsions, visual disturbances, depigmentation or loss of hair…enough already, my hair has a hard enough time of it as it is without inflicting 10 weeks’ chemical assault on it. I know, I know, look up any drug and the list of side effects will make you prefer the disease. But, somehow, something was not quite dragging me over to Poplar to pick up this stuff. And by then I was into the two-week pre-departure window, so would it work anyway?

As it happened, I started my final student placement at a delightful GP surgery in Hackney this week. I ventured to ask the advice of the GP tutor there, and he said, oh, you don’t want that – take doxycycline. I’ll sort it out with H… - and he very kindly did! Apparently all I need to be careful of with this one is a bit of photosensitivity, or as he put it, ‘a better tan’.

Well, from the vanity perspective this one sure beats chloroquine.

Interestingly, when I got home and looked on the CDC website, it said:

Note: Chloroquine is NOT an effective antimalarial drug in India and should not be taken to prevent malaria in this region.

Well, how interesting…

The interactive map is quite cool too. Look: http://cdc-malaria.ncsa.uiuc.edu/

Now, feeling my preparations approaching completion, I decided to open the India bag and review all the bits I’ve accumulated so far. Including the mosquito net in its toggle bag. No longer able to resist, I decided to see what would happen when I opened it. And it didn’t disappoint. It unfurled into something so enticing I just had to get inside it.

Next update soon!

Welcome to my blog!

2010-04-10T16:15:00.005+05:30

Hello and thank you for reading this blog! I was amazed by your very generous response to my sponsored fast appeal in December 2009, and I promised that I would keep you all up to date with the progress of my project. CINI asked me to raise £500 for them, but with the matching scheme and after giftaid, your contributions raised £1410 - an impressive total which will be of enormous use to those working at CINI.

Between December and now I have been buried in my books, preparing for my final exams. But thankfully they passed without too much of a hitch (that's not quite how I remember it - ed) and I am now fulfilling some final obligations for my course here in London before I head off to India for my elective.

To give you an idea of where I'm going and what I'll be doing, have a look at this: http://www.youtube.com/watch?v=aajK2xAA0EQ

That's one of the Thursday morning clinics at CINI in Kolkata. Looks pretty hectic to me. I'll be helping out in these clinics as well as working on the acute ward with children who are unwell with malnutrition.

In the afternoons I will be working on a research project, looking into the underlying causes of malnutrition. This will build on the work of two medical students from UCL who did their elective at CINI last summer.

I also hope to get to know the local area and people as far as is possible in six weeks. I know some of you reading this have spent time in Kolkata, so if you can offer any suggestions of things to take, places to see, language resources or friends to contact while I am there, I'd love to hear from you.

I feel very privileged to be involved in this project and would like to share it with as many people as possible, so if you know of anyone who might be interested, please pass on this link. I really appreciate your support, and welcome any comments, suggestions or requests for information, pictures etc. You can either leave comments on this blog, or email me at caro_dexter@yahoo.co.uk

The dates of this project are May 17 to June 25 2010.

Many thanks and hope to hear from you soon,

Caroline Dexter