India & South Africa Journal of Events and Happenings

King Edwards & Hlabisa - Last Post

2008-08-01T07:18:00.000-07:00

Hello and sorry for the long delay in posting. As a last minute request, rather than remaining in Durban to do rotations, I went back to Hlabisa for the week. It was rather spur of the moment, thus was unable to get to an internet café for the update. In returning to Hlabisa, I was unable to go to Drakensburg and Lesotho, but for the academic experience of working with AIDS patients, it was totally worth it, as that is why I came here in the first place. Added a few more pics to Picasa, scattered throughout folders. What follows is the blog I had written for Durban as well as the transition to Hlabisa. With no internet in Hlabisa, I would write in Microsoft Word each night. This will be my last post as I am leaving tomorrow to return to the US, and am excited and ready. Anyways ….

Tuesday, July 22nd

Today was the first day at King Edward Hospital, a government hospital and big part of the teaching program at the University of KwaZulu-Natal (Nelson Mandela School of Medicine). It is situated on the outskirts of Durban, and comprises a host of services including OB/GYN, Pediatrics, L&D, OPD (Out Patient Dept, equivalent of an ER in the US), Surgery, Maxillo-Facial, & Orthopedics, just to name a few. It is run in large part by residents as the University of KwaZulu-Natal medical school is situated just adjacent to it.

Upon arriving, the various security additions (that I am getting used to seeing) were immediately noticed. The appearance of the hospital, which resembled a prison, was evidence and symbolic of the huge crime rate in this city. Razor wire surrounds the entire complex. Armed guards check every bag and purse, as well as question visitors about their business, almost like in an international airport.

That brings to mind an incident that occurred this morning with one of the students. While waiting outside her home to be picked up, a car drove up and its occupants held her up at gun point, demanding her cell phone. She gave it to them, and they drove off. Luckily, no one was hurt, and she was ok, and they didn’t get any money (didn’t even ask apparently). It’s really frustrating and sad to see so much crime and no police or government action against such. I say this because I can honestly say I have not seen one police car the entire time I have been in Durban. I did at Hlabisa, Umhlanga, and even the Gandhi settlement, but none here. Guess that explains why everyone has razor wire, electric fences, guard dogs, and barred windows. Anyways, I digress, back to King Edwards Hospital.

I and another student were assigned pediatrics this morning, which was very informative. We rounded with medical students from KwaZulu-Natal, and the Doctor was very good as he asked us questions pertaining to the current disease process and management, as well as provided answers and insight into such. There were only 4 patients, but all were fairly interesting. Two toddlers with HIV and complications of that, one with pneumonia, and one with dehydration. We discussed in depth their management, pitfalls of such management, and testing/procedures necessary to provide adequate care. Very educational! We finished at about 10:30am, had some coffee and walked around the hospital and medical school, had lunch, then I spent the afternoon with a physician who specializes in Ultrasound. This was a good experience as in Lynchburg and Roanoke, the ED physicians are using this to obtain “quick peaks” (FAST) which saves many patients from unnecessary X-rays and CT scans as well as provides immediate information for decision making, so it was very beneficial to be with a physician that took the time to explain the machine, how it works, what organs were being viewed, and the diseases processes as they related to what we were seeing and how they would present in the clinic. Great experience!!

We finished up at about 4pm, then it was off to the internet café for about an hour (as it closes at 5:30), then home (which is the Zulu family I am staying with) for an awesome dinner, and some time with the family watching Manchester United play the Orlando Pirates (Johannesburg) in Soccer. Erm …. Go Steelers!

Wednesday, July 23rd

Up at 7am and back to King Edwards, doing pediatrics again. This morning was good as we saw a new group of patients with different disease processes. They included one month old infant with diarrhea (probable sepsis, observed a spinal tap and bladder tap), a three month old infant with HIV, horrible oral candidiasis, and pneumonia (TB vs. aspiration), a four month old with TB meningitis, a six month old with croup and chronic liver complications (awaiting transplant), and a seven year old with rheumatic fever. We finished up at around noon, had lunch, and then went to Ultrasound again by choice as this is something I still need lots of practice interpreting. Our first patient presented with dyspnea and chest pain, and turned out to have one of the largest pericardial effusions the Doctor had ever seen. We also observed two patients with DVTs (Deep Vein Thrombosis), which I have seen before, but not with ultrasound and color flow patterns. It was a good day.

While there, our coordinator was there, and I asked him if it would be possible to go back to Hlabisa (the rural area I did my first rotation at). He checked for me, and said it would be fine, so that means no internet post again for another week. It is good though because it is a rural hospital where almost all of the patients have HIV and TB, and many of the cases are at their extreme due to poverty, lack of healthcare available in that area, and reliance on traditional healing, which has it’s place here, but not for AIDS. So for me academically, it’s a great opportunity to study that which I have only read about in the US. LB is going too, so it will be a good chance for us to do a rotation together, as we have been split up this entire rotation. Really looking forward to this week. Means no Drakensburg and Lesotho, but means I get a second chance to see first hand how bad HIV has plagued this country and its people, and that coincides with why I came here.

Thursday, July 24th

Back in Hlabisa, and I must say for nothing to do, no internet, TV, or even hot water, it is so nice to be back. This was the hospital I spent my first rotation at, and am glad to have the opportunity to come back. 90% of the hospital admissions are due to AIDS or AIDS related diseases such as TB meningitis, pulmonary TB, Cryptococcal meningitis, Kaposi’s sarcoma, and necrotic decubitus sores just to name a few. The cases that present are unlike anything I have ever seen, as people tend to wait until traditional healers and home remedies have taken effect. This usually ends with no results and the patient presenting with not only the aforementioned afflictions, but the extremes of said diseases, resulting in palliative care for many patients.

Anyways, today was spent stocking up on groceries, unpacking (again), and settling into the apartment. We are housed in the physician’s quarters, and even though there is no TV, phone, or internet, the accommodations are very nice, similar to a modern apartment in the US. I am rooming with two other guys, and LB is a few apartments down from us with two other girls.

Off to bed early thinking about the afflictions Hlabisa would show me tomorrow.

Friday, July 25th

After meeting with the Doctors at the 8am lecture that occurs every morning at Hlabisa hospital, I chose to follow Dr Mahala Buckley in the male ward. She is from Australia, and not sure of her specialty, but she was a wonderful teacher last time I was here, and dare I say, brilliant concerning the complicated management of HIV and it’s associated opportunistic infections. We saw approximately thirty patients, almost all suffering from complications of HIV. Some of the current diagnosis’s included a pericardial effusion (resulting from TB), pulmonary TB, pneumocystis carinii pneumonia (Pneumocystis jiroveci), an HIV + male with TB meningitis and paraphimosis, a middle aged man suffering from lung cancer with metastasis to the liver (CXR was a complete white-out on the L), numerous pleural effusions (as result of TB), COPD (observed three patients who had severe digital clubbing and the classic, hyperexpanded CXR), peptic ulcer, ETOH induced fatty liver, heart failure, renal failure, … you name it, it’s here.

The most disturbing case was a young male with end-stage AIDS. His CD4 count was below fifty and appearance was wasted, cachectic, and with contracted extremities. He was lying on his left side in something similar to a fetal position, and upon performing a physical exam, the physician noticed a dressing on his sacral region. Upon revealing the wound underneath, immediately slapping us in the face was the smell of necrotic, rotting flesh. The wound was obviously infected, as well as necrotic with dead tissue about the size of an egg. The poor man had become septic as a result. The wound was redressed and young patient scheduled for the operating theatre for a surgical debridement.

These wounds are very common in HIV patients, as with a healthy immune system, we fight off staphylococcus bacteria and fungal invaders. With AIDS, there is no immune response, thus the wound behaves like a petri dish used to grow bacterial cultures; the wound is moist, warm, and there is abundant nutrients for bacteria and fungi to thrive on, thus the process of wound infection and tissue necrosis is amplified in AIDS patients.

This was one reason that I liked following Dr. Buckley. She is very thorough in her exams and investigations, even going back to look at not only medications, but when the medications were given and to see if all of the previous orders she had written had been followed. She is very strong advocate for her patients, making it known, without question, what she expects from the hospital staff. At the same time, she is also a great teacher, in that she will ask nurses and aids, “what do you think, as you are caring for the patient as well” and this not only teaches the staff to think and anticipate things, but also to be proactive and involved in the patient’s care. Patients that are this sick require a large amount of time, resources, and man (woman) power, and without everyone working as a team with the common goal of caring for these patients, the system would not work. Dr. Buckley does a great job of making sure her team operates in a fashion that provides maximum benefit to all of their patients.

Spent about nine hours with Dr. Buckley in the male ward, then it was back to the apartment, to see a few of the students off (leaving for the weekend for a game drive) and chill with the remaining two that stayed behind. We watched season one and a small bit of season two of “The Office” (best ever – that’s what she said), then it was off to bed.

Saturday, July 26th

So, woke up at around 7am this morning. In a groove I guess. No clinical time during the weekends, and generally, I would be out sight-seeing or visiting a historical place here, but Hlabisa is about three hours from Durban and Tembe, and one hour from St. Lucia. Not much close to here and it cost a lot for taxis, so the plan is to study all weekend, work on my Hindi (got quite far with it in India, and think it would be cool to learn a second language), and study for a board-style test upon my return and for the national boards. This is basically how I spent my Saturday. LB, I, and Ben (pre-med student) cooked up some fish (Hake) and potatoes, carrots, and onion. It turned out really well and always find it satisfying to attempt a meal I have never made and for it to turn out good. Watched a few more episodes of “The Office”, then it was off to bed. Love me some lazy days.

Sunday, July 27th

Again, another day off. Spent the entire day making medical reference cards for stuff I can never seem to remember (CSF fluid analysis, HACEK organisms, Pre/Post/Intrinsic renal failure, etc) and reading through ‘Current Medical Dx and Tx 2008’. This was literally my entire day. I am boring myself just writing this.

Monday, July 28th

The realization that I will we be home, come this time next week, is a comforting and welcome expectancy. We left the US on May 30th and that, now, seems forever ago. I have enjoyed this experience beyond words, but at the same time, have come to realize how much my family and friends mean to me. Like the ole cliché, “absence makes the heart grow fonder”, I am getting fonder and fonder of coming home each day. Anyways, back at Hlabisa hospital today, this time on the female ward, with Dr Amber Siegel.

Monday’s tend to be busy here as most are off the weekend, and Monday is the day where a lot of catching up needs to be done. We rounded on twenty-seven patients today, with afflictions that included (this is beginning to sound repetitive, I know) HIV/AIDS (24 of the 27 patients were positive), Pneumoniae carinii, Cryptococcal meningitis, pulmonary TB, abdominal TB, TB meningitis, miliary TB (“fried shrimp, boiled shrimp, shrimp gumbo, …”), esophageal candidiasis, HTN, DM, pleural effusions, stroke, & endocarditis just to name a few.

An unexpected aspect of the patient population her at Hlabisa that Mahala (Dr. Buckley) brought up last week was how a majority of HIV infected males where in their forties and fifties, where a majority of the HIV positive females were in their twenties and thirties. In speaking with one of the young male nurses, he stated the reason for this was that many of the younger women go for the older men with the expectation of security and monetary relief. He stated that they also value experience and feel that the older men are wiser in the relationship arena. It is really depressing to see so many of these young women and middle aged men, condemned to a slow and agonizing fate, that will not only take their life, but also their independence, autonomy, and dignity. Yet, many continue to believe that it “Only happens to other people” and “It won’t happen to me”. Even more prevalent than HIV & AIDS in South Africa, is the infection of ignorance among its populace.

Anyways, in discussing some of the patients as we rounded, I learned that one vomited up a WORM last week. They (Dr and nursing staff) agree that it was about a foot long. I have already purchased my Abendazole for a “deworming” when I get home. There was also a patient on another ward who presented with maggots in her vaginal vault. That was all I wanted to hear (or didn’t want to hear) of that. Also rounded on one patient whose CBC came back with a Hgb of 5.1, WBC 2.1 with a neutrophil count via manual diff of 0.92). Another patient, whom we were talking about doing a U/S guided thoracentesis for a small pleural effusion, had a platelet count of 9 (no, not a typo, NINE). Needless to say, no thoracentesis was performed. The sad part is that due to the rampant presence of HIV in the community (and country for that matter), there is not enough viable blood for instances like this. There is no blood at the hospital, and if blood is available (which sometimes, it isn’t), it takes half a day to a full day to be obtained. My hats of to the Doctors who work here, as they manage some of the most difficult cases imaginable in a setting that reflects the poverty and underfunding this healthcare facility receives’. It’s a lot like veterinary medicine, in that many of the treatment decisions are based on the clinical picture and history, as things like CT scans, cultures, etc are unavailable.

Well, off to bed. Three more days here in Hlabisa, then back to Durban for one night, then it’s a two day trip home. The countdown is on!

Tuesday, July 29th – Thursday, July 31st

OK, got a little lazy on the blogs the past few days, so combining the last few days here at Hlabisa. This is all going online at one time as I haven’t had internet for one week, so I guess it really doesn’t matter. The last few days have been spent in the male and female ward at Hlabisa Hospital, and still seeing a lot of the same horrifying conditions. Won’t repeat them all as they are the same as listed above, but it is really a depressing site, as most of the patients are literally waiting to die. The question is how much they are willing to endure and how long they want to prolong the evitable. Poverty here makes it difficult, even for those compliantly following medical advice, to remain healthy. Saw two patients die this week, and that’s from roughly 9-3pm, but rounding on the same unit and seeing empty beds, that were occupied the previous day by terminally ill patients, reveals the outcome of AIDS and its associated comorbidities.

A few ethical things have presented this week, and are worth mentioning. A patient arrived over the weekend, and died apparently hours later. The diagnosis was listed as “abdominal distention”, which I agreed with the physician, is sign, not a diagnosis. The physician was finally able to get in touch with the transferring physician, to get somewhat of an idea of what had happened and what was going on, though this had to be done while the family was waiting for the death certificate. No EMTOLA here, thus no laws or rules were broken, but it would be nice to see, in this situation, responsibility taken for this action. Anyways, based on presenting hx (obtained from the transferring physician), the patient most likely had cancer that resulted in bowel obstruction and ultimately death.

Another difference here is that “DNR” status is not really an option, more of a given. It seems to be accepted that HIV is a death sentence, and all is done physically, medically, pharmacologically, to elude it’s associated afflictions, but once one of these infections take hold, and CD4 counts are in the single digits, resuscitation isn’t part of the medical treatment equation of such a diagnosis. I guess it kind of depends on where you stand, and how you feel based on your own experiences. My own feeling is that it is the right thing given this situation. Seeing the suffering … the wasting that ensues as the body literally feeds on itself, the necrotic ulcers and rotting flesh as a result of being bedridden and immobile, and experiencing this surround by approximately 15 other patients, most experiencing the same hell, … I try to think of the what would be the case if resuscitation was performed, and I think that maybe a mother would have son for a bit longer, or maybe a daughter would have a mother for a few more days or weeks, but then I think too, what would the patient want. Based on what I have seen, the answer would probably be unanimous, and the fact that the hospital is not equipped to resuscitate patients beyond one ventilator, and really no ancillary staff trained (nursing, respiratory, x-ray, etc), this really isn’t even an option if it was chosen to be performed. Anyways, this is all just my opinion … and one could argue that opinions are like assholes, everyone has one and they all stink.

So, I guess this is my last blog post for this trip. I have to admit, I am probably more excited about coming home than I am sad about leaving, mainly to see family and friends, graduate, hopefully get into a neonatal residency program, and … to see family and friends! Did I mention that? :P It has been a really great experience, and the biggest thing that I have learned is how much I take for granted. Things I have never thought of like how much money we make in the US, clean water, internet, air conditioning, modern hospitals / supplies / procedures, the ability to easily get a job (even if minimum wage), community resources (libraries, police, fire dept), paved roads. I am sure reverse culture shock will present for the first while or so being back, but listing this stuff (just the tip of the iceberg) puts in perspective how it will feel returning home.

I have to say I enjoyed traveling to both India and South Africa. To pick between the two though, I would have to say I enjoyed India much more. Some reasons I guess include how friendly and welcoming the people were. Also, how we didn’t have to look over our shoulder every few minutes (not that all of South Africa is unsafe as it’s not, and crime resides in any big city anywhere in the world. We just happen to be near a lot of it at our scheduled rotations). Also, I guess us being so different to the Indian people made us somewhat strangers and interesting, where in South Africa, we look like anyone else, and are treated as such. I found myself really respecting the Indian culture, as from what I gather, it is deeply rooted in family, respect, and not doing things to bring shame upon their selves or their family (Thanks Rima for helping to explain that) and that aspect seems to take precedence over material things as well as exemplifies all people should treat each other. This was all evident by the kindness and warmth that they showed us during our time there.

Well, I guess this is it. Thanks to everyone who read, posted comments, & to those I have kept in contact with via phone, on here, MySpace, and Facebook. It has been fun sharing and therapeutic for me in that it kept me in touch with family and friends. I’ll leave it at that. Thanks again, God bless

Jason

Umhlanga

2008-07-22T07:48:00.000-07:00

Friday, July 18th

Umhlanga (um-SHLONG-a) is a ritzy, well-to-do, beach resort town just north of Durban. It is here that LB and I decided to spend the weekend; away from the city, away from our home stays, away from students, and away from pretty much everything, just to have a nice weekend of rest and relaxation on the beach. She actually found the place, and told me about it, and all it took was an internet photo of the place to say yes. Her room is much nicer with full bath on a platform and separate shower, as well as twice the living room space, but my room is cozy, relaxing, and nice get-away from the previous week.

Upon arriving at Umhlanga at about 3:30pm after finishing up a rotation in Verulam, we both settled into our rooms, met the owner of the place, who scheduled dinner for us at a seafood place called Jimmy’s Killer Prawns. The food was amazing, and the 2.2 pounds of boiled shrimp and mussels proved to be way too much, but leftovers are good. Chilled there for a few hours eating prawns and drinking South African wine (Shiraz, I think), then it was back to our B&B (bed and breakfast), and asleep by 10pm

Saturday, July 19th

We were awakened this morning to a full course breakfast, and then it was off to the beach. It is winter here, but currently 72 degrees. Winter here is more of a term to describe the season rather than the conditions. Stayed at the beach for about 3 hours, where we took in the scenery, read some of my PANCE review book and Current, and worked on my suntan, which would turn out later to be sunburn. The beach was nice as I haven’t been to a beach in a few years, and its ironic how sand and water with nothing much to do but lay there can be so nice.

For the evening, we ate a place called ‘Olive & Oil’, a Mediterranean seafood place suggested to us by the owner of the B&B. She was right on, as the food was amazing. A seafood platter of grilled squid, line fish, prawns, and langoustines, along with salad and wine (Pinotage, I think). We hung out here for about 4 hours, moving to the bar area after dinner to watch rugby and a little of the British Open. Home by 10:30, some internet time, then off to bed.

Sunday, July 20th

It was back to the beach again today, this time with SPF 30 in addition to the SPF 48 I use on my tattoos. Studied for about 2 hours, took some photos, watched the ships at sea leaving Durban (which you can see from the beach), and just enjoyed the fact that there was no work today, and actually kind of happy about the fact I get to come home in less than 2 weeks. Having a blast, and this weekend is amazing, but coming home has been on my mind, probably because it’s close, but also it’s something I am looking forward to.

For dinner, we went to a place called ‘The Butcher Boy’, a nice restaurant known throughout the east coast of South Africa for their meat. I had Prime rib which was a close call for the best that I have ever had (New London Steak House being the other). Amazing! Also, some more wine (some red??) that was very good. I wish I would have written down the names. Oh well. Back to the B&B early for some internet time, chatted on IM (Good to talk to you Rima and Angie), & then off to bed.

Monday, July 21st

Having a 3 day weekend, we used today to pack, and to go to what is labeled as “The biggest mall in the southern hemisphere”, Gateway mall. Took some photos of it as it is a pretty amazing place. Almost every store you could think of, as well as Vegas style fountains shooting water patterns 3 stories high, an indoor wall climbing thing, an outdoor skate park (designed by Tony Hawk I think), and an outside wave machine for surfing. Needless to say, I have to watch my money from here on out as I went a little overboard, but well worth it. Spent about 4 hours here, Sushi for lunch, then it was back to the B&B to retrieve our bags, and head back to Durban.

Tomorrow begins our rotation at King Edward Hospital, which is also where med students from KwaZulu-Natal study, so should be a good experience to see some of the specialties there (Radiology, Pediatrics, and 2 days of Surgery). Looking forward it and will post again, probably Friday to share the experience there. Thanks for reading.

Jason

Verulam

2008-07-19T14:39:00.001-07:00

Thursday, July 17th

So, currently chilling at my Zulu home stay, organizing pics, and packing for the weekend, etc. We have decided to postpone the Drakensburg / Lesotho trip until next weekend (3 day weekend), so this weekend, I and LB (classmate who has been on the trip with me) are going to a place called Umhlanga (that’s fun to say. . . Um SHLONG a) :P It is situated on the Indian Ocean just north of Durban. Sitting on the beach should be nice, and a chance to get some more studying done from good ole ‘Current Medical Dx and Tx 2008’ as it’s board time when I get back.

Today, we visited Verulam Regional Hospice; a non-government funded hospice service that runs solely on private donations. Their mission is to assist those with the challenges and hardships of end of life circumstances. The people they see are end-stage AIDS & cancer primarily, and hospice helps insure that they are educated and comfortable with the life ending process that is going on. They also provide support and education to the families of these patients as well. A great group of people with a cause desperately needed in the face of such death and dying, primarily as a result of AIDS.

Our visit consisted of meeting the people of Verulam, learning about their mission and history, then heading out into the community to meet and check on some of the people they are currently providing hospice to. We drove to a small, poverty stricken village call Zwsleisa to see a lady and her child, both infect with HIV. Both were doing OK at the moment, though ear infxns and illness are already plaguing them, a sign that their progression from HIV to AIDS has begun. Sad story. Next, we traveled to the home of an Indian lady who is battling colon cancer. She welcomed us in, offered us tea, and told us about her story and about the loss of her brother 1 year back. Her hospitality reminded me of how welcoming and friendly the people were in India, and it was sad, yet nice to speak with her, and I think for her to talk and have visitors seemed to make her happy, as it did the Indian people we visited one month earlier. Our final trip was to Osindisweni hospital to visit a lady, HIV +, who has been paralyzed from Spinal TB. She had been paralyzed for 6 months, and has now currently stopped eating due to her bowels not working properly. It’s shocking to see how HIV, rather than just kills people, drags out it’s destruction for such a long period. Another reason that hospice for these patients is vital.

After seeing patients, we ate a nice lunch prepared by the staff, and then it was off to Dr. Naidu’s office to discuss TB & AIDS. He has 3 lectures set up with us, and we spend about 1½ hours with him each. He is the Medical Director of our program here in South Africa, and is very much into education and teaching the world about the current health crisis his country is facing. We discussed a lot about AIDS & TB, but also about how the government here has really hurt the people that it serves. I’ll list a few facts that I found startling, that we have learned since being here and in our discussion today.

1. In 2005, 5.5 million people (1/5th of the total population) were affected by HIV in South Africa and 1000 AIDS deaths are currently occurring each day.
2. Almost half of all deaths in South Africa, and ~ 71% of deaths among those between 15 – 49, are caused by AIDS
3. The current president of the country, Thabo Mbeki, gave a speech at the International AIDS Conference in Durban in 2000, conveying his belief that poverty, not HIV, was the root cause of AIDS
4. Manto Tshabalala-Msimang is the current health minister of South Africa. In 2006 at the International AIDS Conference in Toronto, she promoted nutrition (specifically beetroot juice) rather than anti-retroviral drugs as treatment for HIV.
5. 50% of HIV infected patients develop active Tuberculosis (which is another problem here as TB takes months to treat, and with poverty, lead to patients not completing their treatment regimens, which in turn leads to resistant TB that carries a < 50% cure rate).
6. HIV rate among pregnant women: at this point, almost 1/3 of the entire pregnant population in South Africa is HIV +
a. 1993 – 4.3%
b. 1996 – 12.2%
c. 1997 – 17%
d. 1999 – 22.4%
e. 2001 – 24.8%
f. 2003 – 27.9%
g. 2005 – 30.2%
7. Jacob Zuma, the Former South African Deputy-President, was found not guilty for raping and HIV + women, but stated he took a shower after consensual sex to reduce his chances of becoming infected (leading by example?  sarcasm).
8. The government only started supplying anti-retroviral drugs in 2004, and to date, only 33% of HIV+ patients are receiving them.
9. AIDS patients are given a small grant by the government (part of the government’s plan to assist I guess) if their CD4 count (a blood marker of AIDS) drops below 200. For this reason, many pt’s, knowing they will die and currently living in shacks with no way to support their family, stop their anti-retroviral drugs, so their CD4 count will drop below 200, just to get this grant.
10. A bill is in the works to make prostitution legal (no joke) by 2010, which is the same year the World Cup of soccer, will be hosted here (HIV +, card-carrying prostitute. That will help how?).
11. Up until a few years ago, blood from blacks was not accepted for donation (because of the expensive cost of testing), so only blood from whites was used. (This is about 20% of the population). Your probably thinking, isn’t all blood tested? Sad fact - Blood from whites underwent very little testing as this was a “black disease”. The ignorance is scary

Anyways, these are just a few sad facts of how AIDS has become such a problem here, coupled with the social and political changes that have occurred here the past 13 years as a result of the abolishment of Apartheid. I had a lady ask me today, “What did you expect to see when you came to South Africa? Wild Animals, jungles?” Honestly, yes, that was a lot of what I thought about. Apartheid ended years ago and it’s a safari here, Right? Wow, was I wrong.

Friday, July 18th

It was back to Verulam Hospice today. Upon arrival, we had coffee, and then left with 3 “sisters” (nurses) and a driver to visit people in the community. The first person we met was a well-to-do retired airlines pilot who was suffering from colon cancer with metastasis to his spine and pelvis. We met with his wife who was in tears from the time we arrived. The sister went in to speak with him and her, and he was unable to even talk. I did not actually go in to see him, by choice, as I felt given the current situation; it was ethically not a “teaching” time. I spoke with the wife and explained to her who we were, and why we were here, told her my prayers were with her and her family, and then went outside to wait. This was prompted by the sister saying we could go in by 2s to see him. I felt that with the emotional state of his wife, and the current circumstances that we were there, that was totally inappropriate. Hospice should be a time for the family to cope and deal with the situation of a sick loved one, and given the man had probably less than 48 hours, this was not the time to “ogle” sick patients. In this case, I was not examining the patient, or even talking with the patient. We were only going to LOOK at the patient, and though I am all about learning and participating, this, I felt, was completely inappropriate for the patient and the family, thus I gave my condolences, and went outside. The other students did view him, but followed suit and left the family to be with the hospice workers as well.

The second patient we saw was a couple, husband and wife. The husband has been suffering from leukemia, and the wife, multiple sclerosis. They were a wonderful pair with such a zest for life. It was as if they were challenging each other to recover from their ailments. Their positive attitudes and optimistic demeanors were very inspiring. They lived in a beautiful, ranch style house, atop a hill overlooking the ocean. Gorgeous! The husband loved to fish, and his main complaint with leukemia was that is was cutting into his fishing time. Upon taking their blood pressures, they challenged each other as to who would have the best. Just a wonderful story of how two people are dealing with potentially life ending diseases. The husband has been fighting leukemia for 8 years, numerous chemo regimens, etc, and it was nice to hear that he had received news a few days ago that his leukemia was in remission. He even showed us proudly his hair under his hat, which he hadn’t been able to grow in many years as a result of the chemo. The husband even invited me to go fishing with him in his boat (which looks like a modified 9 man white water raft). His advice was to “get sick” before I leave, miss a rotation, and come fishing. I think I am going to take him up on it. Awesome people.

After that, we headed back to the hospice center for lunch, and then it was off to Umhlanga, for some R and R for 2 days. Will post again on Monday or Tuesday. Still uploading Tembe Elephant Park pics (have almost 1000 literally), so it is taking forever, but getting a little done each day. Thanks reading and God bless.

Jason

Durban and Hlabisa

2008-07-16T07:08:00.000-07:00

Hello. Sorry for the long delay in posting, but internet is hard to find here, due to the busy schedule we have been adhering to since arriving in Durban and the fact that everything closes at sundown (which is 5pm here as it’s winter for the southern hemisphere).

First off, Durban is a beautiful place, situated along the Indian Ocean on the eastern coast of South Africa. It is a modern city with skyscrapers, restaurants, night clubs, and everything you would expect from a large city. The market is amazing with a vast array of art, jewelry, and crafts that are for sale, and the prices are much better than the tourist places we have visited thus far. The beach is always packed with tourist, locals, and hosts a variety of events from volleyball to professional surfing competitions. Along with all this fun and excitement though comes a large crime rate, which is huge here in Durban. A lot of unemployment coupled with tourist and very lenient penalties for crime have given Durban a reputation for its widespread and large crime volume. We are advised to be in after dark as a result and have been following that advice.

20% of the population here is unemployed, thus crime is a big part of the culture here as a result of the desperation that many of the local inhabitants face. Of course, it’s wrong, but at the same time, desperation leads to many acts that probably would otherwise not be contemplated. Students have been robed here before, and two of the students I am currently doing my first rotation here with were robbed at knife point just prior to the program starting. Luckily, they were carrying very little money and no violence ensued.

Durban – Saturday, July 5th

The first day here consisted of settling into our home stay homes and unpacking. A five hour trip from Tembe and a wait of a few hours at another home stay until my family arrived home from a funeral made it a long day. All of the families we stay with here are Zulu, so it has been really good to learn of their traditions and everyday daily activities. I am staying with the Moloi family and they have been wonderful. Both of the parents are teachers here in Durban, and they have 2 sons who have given us many pointers about this city. It has been really good to just sit and talk after dinner with Mrs. Moloi about culture, politics, religion, or just anything. She is an amazing lady and I feel truly blessed to have been placed here with them.

The food here is wonderful. The diet consists of a lot of meat, which for me, is a big plus as India consisted of primarily a vegetarian diet (which was very good as well). They tend to slaughter a lot of goats and cows for such occasions as weddings, funerals, etc, so the meat is really fresh and very tasty to say the least. Curry is still used here a lot and adds a nice flare to many of the dishes. There is always plenty of coffee and tea (5 roses) available, though I do miss the chai in India.

Durban – Sunday, July 6th

Anyways, on the second day, we had orientation at Bombei (sp?) which is the establishment where Gandhi visited and lived for many years. It is a very poverty stricken area, though having 16 of us in a group with a guide was safe. We learned of Gandhi’s contributions to the area and the South African people as well as the history of the large Indian population that lives here. 20% of the Durban population is Indian as during Apartheid, they were brought here as indentured servants. We were able to visit a museum of Gandhi’s contributions as well memorials and historic landmarks here on the premises.

Durban – Monday, July 7th

We again today visited the Gandhi settlement in Bombei to tour the actual settlement and visit with its inhabitants. As stated earlier, the area is very poor. Most of the homes have no running water, dirt walls, and are held together with sticks, stones, and mud. We had the opportunity to go in some of them, see how the people lived, and they were very welcoming as well as forthcoming about their current situation. As a result of Apartheid, “townships” as they are called, were created to segregate the Blacks, Whites, and Indians. Though this does not exist anymore, the distinct land divisions and distribution of wealth (primarily among the whites, then Indians, then blacks) still lingers resulting in widespread poverty for the blacks of this nation. It was a good experience to meet the people as I can relate a lot of what I see here to racial intolerance that still exist at home.

Durban to Hlabisa – Tuesday, July 8th

Today, it was off to Hlabisa. Hlabisa is a small town about 3 hours from Durban, where we will spend the next week working with physicians at a local hospital. They have an enormous AIDS population which leads to clinics and facilities dedicated to treating AIDS and the opportunistic complications that accompany it.

We left about at about 8am, and arrived at about 11:30. It was a good trip as the last leg of it took us through a game reserve in which we were fortunate enough to see a large bull elephant. He was preoccupied with eating leaves and ripping branches from trees, so no “mock charges” or threats this go round.

Upon arriving, I and another male student settled into a modern style apartment, which is part of a complex that houses the physicians here. The grounds are surrounded by a tall fence and razor wire, with guards patrolling 24/7 so it is a very safe environment, though it makes me wonder what events or activities of the locals led to such an enclosure.

We spent the day checking out the town and grocery store, unpacking, and sitting around having a few South African beers (Castle and Hanza) and preparing for the beginning of our patient contact experience here.

Hlabisa – Wednesday, July 9th

Up early this morning, and off to my first real day of seeing patients here in South Africa. I was assigned to surgery today. Following the surgeon here was amazing and a real privilege. I and a med student from Kentucky witnessed many procedures performed in the “operating theater”, as they refer to it. Plantar wart removal, tumor resection from breast, c-section (lady with twins), Biopsy of thyroid mass, and the most horrible case of ulceration I have ever seen. A 27 year old, HIV + female, with necrotic ulcers in the gluteal region extending to her pelvis and coccyx (you could literally see bone). She then had bilateral ulcers along the region of the head of the femur. It was a horrific sight. She was here to be debrided of necrotic and infected tissue which required a lot of cutting and removing. A truly gruesome sight for sure and equally disturbing was the fact that she was only 27 years old. I have not seen ulcers this bad in diabetic or immobile patients (who tend to suffer from this vary ulcerations and bed sores).

Seems like every other patient we see here is HIV + and is a scary reminder of the horrendous conditions this disease can cause. I have always thought of AIDS/HIV as the disease that kills you, but in reality, it’s the opportunistic infections that take over as a result of the HIV virus decimating your immune system… so you don’t die from AIDS, you die from overwhelming bacterial, viral, or fungal infection, loss of vascular supply leading to necrosis and infected areas of the body, cancer, and really you become susceptible to any and every bacteria, virus, fungus, or absence of cell immunity that you come into contact with. A truly eye-opening experience.

Hlabisa – Thursday, July 10th

Today, I was assigned to the Male ward. The hospital system differs here from the US, in that patients are housed in large rooms (wards), and separated, not by disease process, but by gender (except if they have confirmed active TB, upon which they are placed in the TB ward). 90% of the males here are suffering from complications of HIV. Conditions included abdominal TB, suspected pulmonary TB, stroke, TB meningitis, Kaposi’s sarcoma (which is a horrifying, AIDS related, cancer), cryptococcus meningitis, diabetes, Pneumocystis Jiroveci (Pneumocystis Carinii Pneumonia), AIDS induced dementia, overwhelming candidiasis, & HTN just to name a few. Many of the patients here have these overwhelming infections due to poor living conditions, noncompliance with HIV medications, and poor education about their condition.

I spent about 8 hours at the hospital, then myself and 4 other students here, plus a med student from Kentucky and 2 med students from the UK, got together and cooked a communal dinner of chicken pasta, accompanied by South African beer. The chance to relax and discuss amongst each other the disease entities we saw through-out the day provided a lot of insight into the upcoming rotations I would have as well as the widespread affliction HIV/AIDS has caused here.

Hlabisa – The weekend

Everyone is leaving for the weekend to go to St. Lucia to go whale watching, Hippo/croc touring, and a safari drive. Since I and LB spent all of last week doing that, and since my stomach has decided to not cooperate, I chose to stay back and make use of the two days off by studying for boards (National PA Certification Examination - PANCE) that I will take when I get back to the states. It was a very productive weekend. Created a 15 page antibiotic guide, and read extensively about TB, HIV/AIDS, and many of the conditions that accompany it, as well as congenital heart malformations and cardiac disorders. Not much to say about the weekend other than it was very productive, relaxing, and a nice respite from the hectic schedule of the past week and past month and a half.

Hlabisa – Monday, July 14th

Today was probably the most academic and interesting day that I have spent here as a student. Being assigned OPD (Out Patient Dept) allowed me to see so many disease entities, which from an academic standpoint, was amazing, but from a human standpoint, was sad to see. OPD mimics what our Emergency Dept is in the US. Anything and everything comes through the doors.

People came through presenting with hemorrhoids (ok, not the academic case you were expecting), Facial lacerations (very deep and requiring 20+ sutures) from an MVA, pressure sores on a paraplegic patients, GSW to the hand with 4th metacarpal fracture, a lethargic 2 month old who had been treated at home with an “herbal enema” (which I will get to in a sec), Kaposi’s sarcoma of the leg (HIV related cancer), a 3 y/o girl for prosthetic fitting for bilateral ‘below the knee’ amputations as well as bilateral “lobster claw” hands (Thumb and 1 opposing digit on each hand), TB cervical lymphadenapathy, an insect in a girls ear, Pulmonary TB, TB meningitis, TB effusion (which included a thoracentesis as well as admission and chest tubes for empyema), and I could go on and on.

The tragedy of the day was a 15 y/o female who presented in respiratory distress with a hx of cardiac problems related to Tetralogy of Fallot. Upon placing her on O2, writing med/IV orders, and awaiting a bed, she coded. We coded her for 45 minutes before pronouncing her deceased. I was able to resort to my respiratory training and manage the airway as well as suggest pharmacological and physical ideas from PA school and ACLS, but CPR, defibrillation, and cardiac meds proved not enough and she succumbed to cardiac failure. She passed with her mother just on the opposite side of the curtain. The blank stare, stone face, as if in a trance. . . . not even acknowledging that we had emerged from the bedside, expressed the shock and devastation the mother was experiencing, without even as much as a spoken word. I have learned (or accepted) that for some people, death is appropriate as . . . it is their time to go . . . an end to an exhausting journey . . . a halting or cessation that completes the life and death cycle, experienced by all living things. But when it is a child that dies, there is always an awkward feeling . . . that suggest that what you think you know . . . you don’t, and what you think you are prepared for . . . you’re not. Anyways, just some thoughts. Children always bring these thoughts out, as I tend to equate them with innocence and purity. In this case, her death was of no fault of her own. She didn’t use drugs, didn’t smoke, didn’t drink, appeared healthy . . . so when death befalls someone who does the opposite it’s requirements, it’s frustrating, as a health care professional . . . and as human in general. Academically, a good day . . . personally . . . a reminder of why it is that I chose to do what I do.

On a lighter note, 2 healthy babies were delivered . . . and that miracle in itself … the miracle of childbirth … to me … sets right the wrongness of life’s (sometimes) unfair behavior.

As I stated earlier, one child presented dehydrated and febrile after receiving an “herbal enema”. This is very common here and everyone has different recipes, etc, but the result is many admissions for sepsis, toxicity, and infections. Attempts at education are in place, but many of the citizens here remain loyal to old traditions, and this one tends to lead to numerous hospital admissions quite commonly.

Another tidbit I picked up on today was the corruption that plagues the authorities here. We had two people who presented as a result of assault, yet they did not want to involve the authorities. It was explained to me that, with most of the police force being males, may know others (including the perpetrators), and in the many ways that respect and cultural acceptance is garnished here, could lead to even worse consequences (than being assaulted) for the victim. A sad reality that I am sure I will learn more about during my time here in South Africa.

My final “wtf” for the day was how the education differs here. I met some local med students who are currently in their 3rd year of a 5 year program. The doctors here (as well as in many places in the UK) do not have undergraduate degrees, nor are required to obtain such. They go straight from high school into a 5 or 6 year medical program, and emerge as Doctors by the age of 23 or 24. In some ways, this seems like it would limit their knowledge as they lose a lot of education pertaining to the basis of medicine, being biology, chemistry, physics, etc. Then on the other hand, they do not spend 4 years and thousands of dollars on “required courses” (electives and some non-science/medical classes come to mind) and are subjected to a much longer “medical” didactic phase. Anyways, just thought that was a neat fact, and makes a little clearer why many with foreign degrees are not permitted to practice as “Doctors” in the US healthcare system.

Hlabisa – Tuesday, July 15th

After rounds this morning with the physicians, we were taken on a long tour of the hospital and a local clinic just outside the gates by Dr. Adams. He is the head guy here who serves as MD, CFO, and CEO… and basically coordinates this entire hospital system. In speaking with him, he came here as a Doctor, but in an effort to keep the hospital running, due to lack of funds, support, poverty, and not enough help, he has taken upon himself to manage any and everything that needs done here. He is an inspirational man who has definitely left an impression on me and those of this community. He has sacrificed much and given of himself to ensure that the population of 40k here receives health care. The hospital here is 300 beds, and currently is staffed by 7 physicians. 7!! That includes managing the immense HIV/AIDS epidemic and complications, as well as surgery, childbirth, OPD, and chronic issues such as CVD, HTN, and DM. A really amazing organization and the tour this morning gave us a good idea of the numerous challenges and obstacles faced in this rural setting.

Wednesday, July 16

Anyways, k, back in Durban and back to internet :). This has gotten way long. Going to try and upload a few pics, and will slowly upload pics from the game park this week and next (as those are the good ones but have so many). Thanks for reading and will start posting again every few days and in the next day or two as I will be hitting this cafe every day. Also going to Drakensburg & Lisothto (sp?) this weekend for hiking and and site seeing, so should be some pretty cool pics. Thanks again for reading and God bless.

Jason

Tembe Elephant Park

2008-07-05T05:41:00.000-07:00

Elephant pooh….. is very, very big…. and it’s everywhere here…. and serves as an accurate estimate as to the size of these magnificent beast.

Tembe – Day 1

We arrived in Tembe Elephant Park at around 2pm on Tuesday, July 2nd. Upon arrival, they unloaded our massive array of luggage, took us to the bar, and we christened our arrival with an ice cold Castle Lager (which is my new favorite beer I think). After all was settled in, it was 3pm, and time for the game drive. Here at the park, game drives are conducted at 6:30am and 3pm every day, each drive lasting approximately 3 hours. A game drive is a drive in a Toyota Land Cruiser modified to a safari transport, and it takes us many kilometers into the bush, plains, and swamps of the South African reserve here at Tembe Elephant Park. After 1 ½ hours of driving though brush and forest, we stop in open, safe areas and have a 20 minute tea, coffee, and biscuit break in the morning and a cold beer, wine, or beverage in the evening. The Land Cruisers hold 9 people in the modified platform (where the bed of a truck would be), a driver, and one passenger seat with a brush guard mounted seat for when they conduct research and such (not for hunting as there is no hunting permitted in the reserve).

The evening drive was amazing. A true safari through the South African bush. We were privileged to see impala, warthogs, elephants, rhinos, some big elk looking thing which I later learned where called “nyala”, monkeys, and various birds. Upon returning to the camp, the staff led us to the nightly bond fire in the center of the camp, surrounded by a full cabana style bar, rest area with sofas, tables, chairs, and dinning area all covered in straw awnings. We had a glass of wine here around the fire and discussed the drive amongst with various individuals from around the world (20 total this evening though it changes from day to day). We then retreated to our tent (wooden platform covered by a tent, but with all modern amenities inside including beds, dressers, full bath with shower, hot and cold water, electricity, coffee and tea bar, armoire. Check out the photos on Picasa that includes photos of the setup. Kind of like camping in a hotel. Then the drum sounds in the evening for dinner, which was a buffet style setup with soup, chicken, impala, greens, potatoes. A wonderful feast complimentary of the African landscape. Two glasses of Shiraz and it was bedtime for me, in a super comfortable bed equipped with heated mattresses (that you set to your liking). A fitting respite from the experience that is South Africa.

Tembe – Day 2

We are awakened by staff at 5:45am to prepare for the morning game drive. After a small breakfast of fruit, yogurt, and coffee, it was back into the bush. This was a rare drive as we observed almost every type of animal in the park… most of which I have only seen in zoos. Rhinos, an enormous bull elephant, monkeys, impala, wildebeests, nyala, giraffes (way off in the distance though), and zebra…. but the real gift we were granted this morning was to see lions, male and female. They were spotted in the distance, and here in the park, there are only trails and the people here use only specific routes as to not disturb the habitat here. Anyways, before we know it, 5 lions (1 male, 4 females) are making their way to us. Not only up to the Land Cruisers, but crossing in front and behind. At one point, we were actually surrounded by that which is known as “The King of the Jungle”, with these beautiful creatures no more than 10 yards away from our transports. They would stop, look at us, walk a few steps, and look at us again. It was hard to tell if their stare was that of curiosity, intrigue, or hunger. Frightening yet exhilarating at the same time. They continued past us and lay in the shade about 30 yards from the Land Cruisers. If I don’t see another animal the rest of this trip, it would be well worth that 20 minute encounter 10 fold.

The evening game drive proved to be as productive as its predecessor. We traveled to an overlook area built by the park with the view of a water hole. We were graced with the presence or two bull elephants…. unobstructed and just the elephants in their habitat. They move so slow…. methodical …. majestical…. and their sheer size explains such. Our guide whose name was Vusi said that these are some of the biggest elephants in the world, due to the fact of “survival of the fittest” and that only the biggest and strongest take on mates and pass on their genes. Also, these elephants are indigenous to the area and have been here for hundreds and thousands of years. Watching them from the lookout reminded me of Jurassic park almost. Anticipation, excitement, awe, and fear. An awesome experience!!!

During the remainder of the game drive, we saw another elephant, though he would only show us his ass. We also saw impala, nyala (which would be our main course for the evening), zebra, and warthogs. We stopped for a cold beer and a “cheers” between the 6 of us on the drive, and then headed back to the park for wine around the fire which is a nightly event. Dinner was fish and nyala…. Soooo good. Then it was off to lala land in our heated beds. Jet lag is still a factor from the 5 hour time difference from India, but slowly adjusting. Zzzzzz…..

Tembe – Day 3

Today began with a shower in the freezing cold. The water was hot, but being winter here in South Africa and sleeping in a tent means I should start taking my showers in the afternoon. We left on another game drive at about 6:30am. Today, the prize animal seen was giraffes. Very large giraffes... very up close… and 4 of them. We actually saw the first giraffe cross the drive trail (not something you see everyday, a giraffe crossing the road). We were able to get some fantastic photos. Also saw lions again, though they were off in the distance. They were apparently hunting as we saw them shoot into the brush in full dash, then moments later heard a shrill squeal, which our driver told us was the sound of a warthog meeting his / her demise. Morning breakfast for the lions I guess.

The daughters of the family that went with us yesterday evening and today are living in Durban, which is where we leave for on Saturday, so we got their numbers and will hopefully catch up with them in Durban for some local insight into the region. Really nice people and looking forward to seeing them again.

After the game drive, it was back for breakfast which consisted of eggs, sausage, tomatoes, toast, ham, and some very dark meat. As I set eating this wonderful breakfast, a lady across from me (Dr actually, pathologist) says how in her line of work, it makes it impossible for her to eat fried LIVER. I wonder for just a second why she is saying this random thing to me, and then, like the onset of an epiphany, it becomes all so clear as to what the “very dark meat” is that I am eating. Of course, I empathize with her plight not letting on that I too find liver disgusting but not letting my ignorance of my choice for breakfast show. Needless to say, the rest of it sat on the plate as I moved on to finish my eggs, ham, and sausage. From now on, I will be sure to ask the staff if I have any inkling of a question as to what something is. Anyways, two hour nap, then up for lunch and coffee (no mistaking what I was eating this time).

The evening drive was amazing. First, elephants were observed at the watering hole where they typically frequent in the evenings. Drinking 160 liters of water per day makes it a prime place to find them when other destinations have proven unfruitful. Then, we were off through the bush, and actually found a large bull elephant just along side the trail eating from a tree. An awesome, yet somewhat frightening experience. We turned the truck off in order to view him without disturbing him, and a few times, he turned to look at us, and I’m thinking, by time he charges, we are in for it, but he kept eating and after about 15 minutes of silent observation, we moved on. Next stumble upon kudu, which are like deer the size of cattle. Beautiful creatures, and as it turns out, they were the main course for dinner as well. The blessing of the night was the privilege of seeing two white rhinos, up close and while it was still light (twilight). My camera was unable focus, but LB’s camera was able to capture some photos of this elusive and shy beast. Discovery channel does not do it justice when compared to seeing them up close and in action. They are so big, yet can carry their massive girth so fast. They attempted to elude us a few times, but we were able to position ourselves in a way that allowed for viewing without interrupting their natural activities, though I guess we did as they were attempting to elude us.

Dinner, as stated in the previous paragraph, was kudu, sweet chili chicken, pea and mint soup, mixed vegetables, bread, and for me, 3 glasses of Sauvignon Blanc :P The meals here have been just as much a part of the experience as seeing the wild game. The previous night was warthog and kingfish, preceded by nyala on Tuesday night. The kudu tonight was similar to venison at home, but not as gamey, probably due to the awesome preparation. The dinners are a fitting nightcap to the adventurous experience of the game drives during the day.

After dinner, it was back to the 5 star tent, preheating the heating pad on the beds, talk of the events of the day, and off to bed at 9pm (still a little jetlagged from Indian time).

Tembe – Day 4

I was up at 5:20 for the grueling task of leaving the comfort of the heated bed and suffering through a shower. The shower itself feels amazing; it’s the pre shower and post shower routine in the cold chill created by the current winter conditions that are killer. But all worth it for the cup of hot coffee awaiting me at the bedside status post shower.

The morning presented itself as somewhat warmer than the previous mornings, but draped in heavy fog and mist, which made it impossible to see anything in the distance. We have seen many of the big animals in the park, and thought maybe this morning we would attempt to see the elusive leopard, which frequents an area much less populated than most of the reserve. We had no luck in seeing such, but did experience one of the most frightening … yet exciting moments in my life. We came across a lone bull elephant (estimated by Patrick, our driver, to be about six tons) ripping branches and leaves from a tree along side the trail. As we pulled along side (as we had done during previous encounters) and killed the engine as we usually do to prevent from disturbing the animals, the elephant began working his way to us. “Awesome”, I think to myself, as this will provide for some really good photos. This went on for about 5 minutes with the elephant getting about 7-10 yards from the Land Cruiser. At this point, I am getting a little uncomfortable, but holding on to the belief that this is a common occurrence and all will be fine. It was after this that the elephant stared at us for what seemed like an eternity with what appeared to be intelligent and gentle, yet cautious eyes. Then, with a still calm appearance, he began stomping his front leg, splaying his ears for the appearance of looking larger, and throwing sand on his back with his trunk. At this point, my heart is going 100 mph as this elephant easily out weighs our Land Cruiser. All of sudden, with a powerful burst of all 6 tons, he charges the Land Cruiser. We are all remaining as still as possible, part out of instinct, part out of sheer terror. It was called a “mock charge” as explained afterwards by our driver, in an effort for the bull to show his dominance and that we were disturbing him. He only took about 3 steps, yet was still… for a lack of a better word… petrifying. He continued to stare at us from his halted charge stance, then, as if nothing had happened, he turned, and walked about 20 yards from us back towards his breakfast of shrubs and leaves. With the vehicle being off, Patrick allowed it to roll towards the elephant once more, and this time, the elephant initiates a full gallop charge. With the new distance between us, Patrick was able to start the vehicle and back away in reverse. The elephant displayed his superiority in this ever so convincing manner for the last time, then left the trail and calmly made his way off into the bush. Patrick then explained to us that what we had witnessed was a “mock charge”. The elephant’s ears being flared and truck raised high above it’s head served as a warning us, but not a sign of attack. If his ears would have been tucked back and head down with his trunk back between his front legs, then we would have been in danger and he would have moved us to safe distance (though I question how we would have started the truck in time … ). Definitely one of the most awe invoking experiences of my life. I was glad we didn’t see any more elephants for the remainder of that drive.

Back at the camp, it was a full breakfast with sausage, kudu steaks, poached eggs, ham/bacon, toast, yogurt, coffee, 3 different fruit juices, then back to the tent for some light reading and nap time.

The evening trip was a good finale to this sensational week. Numerous elephant encounters, though no charging this time, Rhinos (white), impala, nyala, kudu, and monkeys just to name a few. We went to where the giraffe tend to stay, but no luck, though it was ok as we had a great giraffe encounter the previous day. The drive back to camp was bitter sweet. A final chance to reflect on the observations, sightings, and encounters that we had been privileged to witness during the week. The sunset was beautiful as usual, and the unusually warm temperature complemented the enormity of thoughts and feelings that imprinted themselves just as the photos I had taken during this spectacular week.

Dinner tonight was fish, and of course it was amazing as usual. The highlight was to have a “bush baby” come and eat out of one of the staff’s hand. I was unable to get photos due to the low light conditions which conflict with my camera’s abilities, but such a fitting conclusion to a wonderful week. Bush babies are a weird cross between cats, koala bears, and squirrels. They are active in the trees at night, and make the most god awful sounds, the likes of a baby with croup screaming at the top of it’s lungs into a megaphone. This is offset though by their koala bear / bat appearing faces, large eyes, and huge bushy tails. Click here for a photo. So amazing! The staff member fed them beer bread, for which it came down the tree just far enough to grasp the bread, then back up the tree with its treat it went. Awesome!!

Well, this has gotten really long, but being without internet has allowed me to formulate this in increments as the week has progressed. It has been a wonderful experience, one I won’t soon forget, and a place that I hope to visit again in the future. My television at home tends to stay on ‘Discovery’, ‘National Geographic’, and ‘The Science Channel’ and this 4 day experience has given me a chance to see African wildlife that previously I had only viewed through an LCD.

We have also met some wonderful people here as well. A couple from Switzerland, many from Durban and Cape Town, a couple from Germany … and meeting all these people has given us the opportunity to explain why we are here and what it is that PAs do. It has also given us a chance to discuss rural health, healthcare, and HIV in general with these people from other nations, and hear, from an indigenous perspective, the troubles, pitfalls, and current healthcare problems these people face. Surprisingly, it sounds as if most have many of the same problems and a very common theme… and that is, those with money receive adequate healthcare, those without don’t. Hopefully, our month here in Durban will provide us with new ideas and solutions that could only come from being in an environment totally different from that in which I have learned healthcare.

Anyways, this has gotten super long, so if you have made it to this point, thank you for reading. The comments and replies that are received from writing these experiences really help for, as fun as this trip has been, there are so many people back home that I miss … and as I have stated in previous post, this helps keep me connected my family and friends, whose absence this past month fortifies the necessity to return home in 29 days and counting. Thanks to all for reading, and God bless.

Jason

*** Cafe closing, so will upload pics tomorrow or Monday.

From India to South Africa

2008-06-30T11:13:00.000-07:00

June 28th, 2008

So, sitting on train bound for Delhi. It is 11:45am, and we departed Dehradun approximately 2 hours ago. Plan is to arrive in Delhi at around 3:45pm, then sit in Delhi airport until 2:25am (Sunday morning). Will be nice though, to just chill, read, and find some Indian food for my last Indian meal here. A fear I have of South Africa and returning to the US is whether all other food will taste bland compared to the spicy concoctions of Indian cuisine. Sooooo good.

So, leaving India. I guess I feel happy and sad. I am really psyched about going to South Africa and all of the new experiences that will accompany that trip, but would like to spend more time here as well, as there is still so much we haven’t seen or done. Oh well, maybe a return trip one day …. Hopefully.

The culture here is nothing like I had imagined. Of course, I read about it prior to coming, watched videos provided by CFHI, and checked out internet photos and resources, and spoke with friends from or familiar with the region, but none of that really prepares you for what it is like to be immersed in Indian culture. The crowds, random animals walking the streets, … peddlers, shop owners, and merchants at every corner and on every on sidewalk .… the wonderful smells of spicy and wonderful delicacies mixed with the not so pleasant whiffs of pollution and human waste, … horns, horns, and more horns resonating from vikrams, auto rickshaws, motorcycles, scooters, buses, and pimped out Tatas (trucks), … the beautiful colors and patterns of the various sarees and scarves, … monkeys moving about with such human similarities, … and probably what sticks out most is the weird mix of poverty and success, … meshed together side by side giving much the sensation of a third world country, tropical getaway, and a technologically advanced society all in one unique conglomeration that is the culture of India.

I will also miss the many friends I have made here as well. These friends are students as myself, whom are here for the medical and cultural experience, as well as the many Indian friends I have made, Doctors, Home stay families, CFHI coordinators. I will also miss the looks of interest we received from many of the Indian here, which upon staring back, would almost always end with a smile and tilt of the head or a praying, hand gesture and “Namaste”. The people here have been so welcoming, hospitable, and courteous to us as visitors. I have to wonder how someone who doesn’t speak the native language (as we don’t here) would be greeted by those in our country if they were to walk the streets, look and smile at most that they met ….

Driving is definitely going to be different when I get home. One, I will not have driven in 2 months, but also, here, they drive on the Left. Also, here, it is as if you are dependant on other people to give you room. You merge without looking; you go through intersections taking a leap of faith it seems … almost as if there is an unspoken communication between those around you. You go into the right lane at times to pass, and the oncoming traffic gives you room. The speed seems only determined by the congestion of the traffic. The horn is constantly sounding, not as a show of anger or frustration with someone (though sometimes it is, along with shouting of obscenities), but to let those around you know your position or your intention to pass. 3 and 4 people on motorcycles are as common as SUVs in the US. Mirrors on bikes and other modes of transportation are folded inwards to avoid hitting objects or people due to the close proximity of room you are given. No stoplights here. Only traffic guards at peak times. Driving will never be the same for me, that I am sure of.

2 days later … June 30th

We’ll, I am currently relaxing in a beautiful room in Saint Lucia, South Africa. My battery died prior to this part, thus was unable to charge for two days, and those days were spent in airports and on flights. To get back to the topic above and move on from my digression of perspective feelings and emotions about India, we arrived in Delhi airport on Friday at around 5pm. We weren’t allowed to check our luggage until 10:45pm, which sucks because Keddy and Will, the other 2 students we spent the entire month with, boarded their planes prior to us being able to get in and say goodbye. Guess I will hit them on Facebook, but still would have liked to seen them once more … back on topic, we boarded our flight at about 2:45am Sunday morning … and what a fiasco.

Our luggage was of course overweight, due to gifts and the additions acquired while in India. The guy wants $300 US dollars, and they didn’t take VISA. Wtf!!! I was able to coax him with the $200 in cash I had, and have a sneaky suspicion part of that went to his personal account. Anyways, that issue was resolved. Then, they say they have no ticket number for LB (student from JCHS that I am traveling with). He allows us to board, but says he needs to keep the E-ticket (itinerary) for security purposes. With no choice, we agree. Bah! We board and land 8 hours later in Addis Ababa, Ethiopia.

When we are leaving the plane, an employee is holding a sign with LB’s name on it. He asks for tickets, which the one for the next flight does not have a ticket number on hers. He says, “You have a boarding pass, this is not a ticket, you can’t fly with this”. Now panic has set in as we have 45min until the next flight from the time we landed. After him talking to his superiors, LB is able to find a paper ticket in her back with the “ticket number” that they are requesting. We just make the flight and another 6 hours later, we are in Johannesburg, South Africa.

Upon arrival in Johannesburg, we find that our flight is closed. Have no idea what that means, then they return and say the flight is changed, pushed back an hour. I’m thinking “ffs” to myself at this point, but it’s the last flight, then done with flying for another month. We board, fly, and arrive in Durban on Sunday night at about 6pm … super confused with the time changes and darkness and 5:30pm (it’s winter here). Cab meets us (sweet Honda Nuance) and takes us to St Lucia.

Upon arrival to Umlilo (the hostel we are staying at for two days), we unloaded our luggage. I was standing in the driveway here taking wrap off of my luggage so I could roll it, when a car pulls up behind me, shining its lights away from me. To my surprise / shock / amazement, the aim of the car’s headlights was upon an enormous hippopotamus, approximately 40 yards away just across the street eating grass. “Welcome to South Africa” I told myself.

So, slept for a few hours, then up this morning at 5am for whale watching. Humpback whales migrate along this part of the Indian Ocean and this is supposed to be a prime time for seeing them. We met a monster jeep thingy that took us to the ocean, where we boarded a boat. The whales were literally swimming beside the boat such as dolphins do. Such enormous and beautiful creatures. Saw one jump, and all the others blow water and swim along side us. Getting a video of the trip which I will you tube or post stills. Such an amazing site. We then took naps :P and went for a hippo / Croc tour in the estuary here at St. Lucia. An amazing and relaxing trip on a large pontoon boat along one of the ocean inlets here. Photos and pics are uploading now.

Anyways, off to repack for Tembe elephant park in the morning. Will be there for 4 days, then back to Durban where I will meet the home stay family that I will be with for the next month. If no internet at Tembe, will repost again Mon or Tue of next week, otherwise, will be the end of this week. Thanks for reading and the comments. Miss my family and friends and this helps me stay connected. Thanks again and God bless!

Jason

Dehradun - Week 4

2008-06-25T01:48:00.000-07:00

Hello. It is currently Wednesday, 6/25/08, and I am sitting at the home stay writing which may be my last entry from India. We depart here on Saturday, 6/28 for South Africa which I am super excited about … also sad though to be leaving India as it has been such a wonderful experience, way surpassing any expectations I had prior to arrival. The last week is in Dehradun, where we first arrived. I am rotating with an OB/GYN Dr and an Internal Medicine Physician.

OB/GYN has been with Dr Nisha Gera at the Nisha Nursing Home (many private hospitals here are called nursing homes). We are precepted by her and another physician whom has just joined her practice (name escapes me), both who have been very kind and generous with their time. We typically spend about 3 – 3 ½ hours per day with them, primarily observing as they see patients, then discussing each patient and their condition / diagnosis / treatment regimen after their dismissal. We were permitted to see a D & C yesterday (to remove products of conception after a spontaneous abortion, and not elective as they don’t perform that and I would not participate in such). Similar to how it’s done in the States. Some photos are posted of the OR and such in the “Dehradun” folder. Most of the patients that we have seen the past few days are either prenatal visits or check-ups for postnatal issues.

The other rotation we are doing is with Dr. Mathur, who is a doctor of Internal Medicine. He runs a private hospital as well. It has been an interesting rotation in that we have seen a variety of disease process, including Neurocysticerosis (parasites in the brain, quite common here), malaria, TB, hepatitis, as well as many non-specific things such as N/V/D, chest pain, abdominal pain, etc. He is good at seeing the pt, then discussing the interesting ones with us, such as diagnostic criteria and treatment plan. We get to review the labs, x-rays, ct scans, and such of the patients which as been very beneficial from an academic standpoint.

Some things I have noticed in how India differs from the US when it comes to healthcare are that each patient seems to always bring their medications and pertinent records with them. This is something I have witnessed first hand that the patients in the US don’t do (and very frustrating and many don’t even know what they are taking when asked). Another thing is that each patient pays the physician there on the spot, in rupees (the currency here in India), and it’s usually equal to about 10-50 US dollars from what I have seen, including the test and lab work. There is no insurance, paperwork, or legal stuff. Pt brings his/her own records, speaks to MD, takes a list of instructions/prescriptions (which are picked up at one of the many “chemist/pharmacist”, and the transaction is done. It almost seems like there is so much room for error and legal pitfalls, yet that is another of the big differences here, is that litigation is not a lottery here, and a very, very rare occurrence. None of the physicians we have been with have been involved with nor seemed concerned with it. It just doesn’t really happen. Drugs are so much cheaper here to. It’s not the big business it is in other places (though it is trending that way.) Bought 4 Ondansetron (4mg) tablets here for nausea (for classmate) for 20 rupees ($2 US). 10 of those tablets in the US (know as Zofran) cost approx $244. 10 Cetirzine tablets (active ingredient in Zyrtec for allergies was 30 rupees (little of $2 US dollars) along with Nim which is patent in the US for allergies. 10 tablets in the US = approx $10 dollars (and that’s for the generic for Zyrtec). The drugs here according the physicians are just as good, as the chemist/druggist (reputable ones) will only buy from certain pharmaceuticals here, just without the billion dollar budgets for advertising.

Anyways, just a few of the things I have noticed that really differ from the western medicine I am accustomed to. So, the remainder of this week is a few more rotations, few last minutes gifts, and getting everything packed and ready for the departure from here on Saturday. Currently have a sore throat and chest cold which sucks (but at least the drugs are affordable) and I have azithromycin as well. Will give it a few days and see.

I set up a site for photos on Picasa (it’s linked here, top right just below the photo on the right). Will be adding photos every few days as I take them, and South Africa will just continue here, no new blog site are anything (Guess I need to change the title). So, off for now. Will try to post once more before leaving on Saturday, then probably again on Monday or so. We fly to Durban on Saturday, and should reach Umilio and Tembe on Sunday night sometime. Next week is a vacation spot and a side trip prior to the start of the South African rotation in Durban on July 5th, so should have lots to write about next week as well as some cool safari photos (I hope). Thanks for reading ….

Jason

Week 3 - Than Gaon & Agra

2008-06-21T23:36:00.000-07:00

Hello everyone. Just got back from Agra (Taj Mahal). Long trip and well worth it. Currently at our home stay where we arrived a few hours ago writing this in word so I can cut and paste as this current blog when I get to the internet café (saves time = saves rupees). Will talk about Agra shortly, but will write about Than Gaon now, the village we spent last week at.

Than Gaon was the best part of this trip by far. It is a small village located in the foothills of the Himalayas. It is sponsored by CFHI (the company we went through to do this trip) and consist of bathrooms and showers (buckets and solar powered hot water), an outside kitchen/dinning area (sort of like a beach bar or something), and little cottages housing 4 beds with mosquito nets each (nothing else but a little table by each bed. Then there is Dr Paul’s Clinic. Than Gaon is central to approximately 30 villages (couple hundred people in each village) scattered throughout the foothills of the Himalayas, with no roads, only trials up, over, and around mountains.

We arrived there this past Sunday (6/15) and settled in to our little huts. After a tour, we ate, talked, and relaxed just chilling in the mountains. Monday, we had clinic with Dr Paul. Dr Paul has been here for about 5 years. He has clinic on Mondays, Wednesdays, and Fridays, and hikes to villages on Tuesdays and Thursdays, hitting each village approx once per month; otherwise, they hike to Than Gaon and his clinic. Monday, we saw some really sad things. A 1 ½ year old girl came (as she has been brought by her father ~ 6 km one way) each day for dressing changes on her head. She apparently fell into an open fire 1 month ago, causing 3rd degree burns to her entire scalp. I have some pictures of her. So cute, though she is usually just quiet and stares, as she knows this routine well and that bandages and antiseptic are going to hurt. We would see her every day this week.

Another pt we saw as a 14 year old boy, who had diarrhea. Yeah, not that special. Then Dr Paul shows us a story of a boy who was electrocuted a few km from the clinic, revived, though burns about much of his body. He survived with Dr Paul visiting him and treating him. This was that boy, and no deficits or scars where present. A really amazing story. Those are just a few of the pts that day. Saw about 20. It was raining which usually keeps many away as they must come from km away. No yoga on Monday, as the yoga teacher couldn’t make it. Its way in the hills and Dr Paul, along with the yoga instructor, stay in the village Mon – Fri, then home to their wife and children on weekends.

Tuesday, we did 12 km hike (6km each way) to a village called Khara Khet. Wow, what a hike. 12 km is far, but up hills and through mountain trails was killer … and I’m out of shape for sure, though that is changing a lot … one of the good things about being here. Good food and lotssss of walking. Didn’t see many pt’s at the camp, but it was a good chance to rest, talk with Dr Paul about his many adventures here in the mountains. We made it back around 5:30 pm, and then it was shower, and yoga time. First time I have ever done yoga, but it was great, especially after the long hike. Ohm, ohm, ohm, ohmshanti, shanti, shanti. Ha-ha, fun stuff. (Rima, you can teach me more when I get back  ). After that it was dinner, reading, and then bed. The food here is amazing. One of the cool things about this place is that many herbs, medicinal and culinary, have been brought in and planted here. So much flavor to the food. Each meal consist of rice and dal (lentil preparations), with a vegetable, Alou and matar. (sp? Potatoes and beans) Chai in the am and lunch, and usually mango custard (so good). Breakfast was fresh mangos, eggs, potato pancakes (not sure of name), toast. Such good food.

Wednesday was clinic again. Saw our cute little 1 ½ year old. Don’t think I ever got her name. Saw about 15 pts. Did get to play cricket today with the locals. So fun, and also another good reminder of how out of shape I am. We played for about 2 hours. Yoga in the morning and evening. Fun day.

Thursday was another hike (10 km round trip) to a village called Bolita. It rained so hard the entire trip. I had rain gear which helped, but “pull over cause you can’t see the road rain” for the whole trip, up and back. It is monsoon season here, and in the mountains, it’s especially evident. Rains at least once per day. Made for a cool, albeit wet hike. Saw about 20 pts. The locals at Bolita where great. Made us hot chai twice. I think I am addicted to the stuff. We stayed in the village for about 4 hours. So a horse with a poncho which was funny.

We finished up Friday with clinic, then “herbal education”. This is where Dr Paul took us around the village and showed us some of the herbs and medicines that come from plants. Fresh lemongrass, cloves (the kind people smoke), and kinds of ayruvedic plants that help with digestion, constipation, pain, fever, malaise, HTN, cholesterol. You name it. Many where shipped in and planted. Others were native. Really cool. At about 2pm, we left Than Gaon to go to our home stay, repack, and 3 of us left for the bus station and overnight “sleeper bus” trip to Agra, to see the Taj Mahal.

That Trip there was good. Slept a lot. When we arrived, it was hot as hell. Agra is one of the hottest places in India, and that was evident upon stepping off the Air conditioned bus. We sat around for about 4 hours, had breakfast, waiting on the Taj to open. They have VIPs at times, and today was one of those times. We left and went to see the Agra fort, amazing place. Enormous. We toured this, and got some beautiful shots of the Taj from here. We finally got into the Taj about 3pm, after standing in line an hour. What an awe inducing structure, and the story of it being built by a man for his woman. Very inspiring. Check out pictures. Some really awesome shots but do it no justice. We went inside to see the tombs. Amazing how cool it is inside and the entire structure is built of marble. It was well worth the wait and trip to see it. A wonder of the world, deserving of that title. Dinner and cold beer follow. Then it was rickshaw back to the bus station, and back to Dehradun, where I am at our home stay writing this now.

I will miss Than Gaon for sure. So quiet, no horns, pollution, or hecticness (word?), just mountains and peace. Hope to come back some day, but many other places in the world to see too, so who knows. Dr Paul is truly and inspiring person. Definitely a shining example of the right reasons to be in the profession of helping people, and a real ambassador to his craft. It’s not money for him, it’s helping as many people as possible and helping those that also try to help themselves (one of the frustrating things about medicine, is people who think pills can cure everything…. None of that here). I will miss him and this week.

Well, this is getting long, thus I will conclude. This week, will be in Dehradun with an OB/GYN and an Internal Medicine/Surgeon so should be an interesting week. I have internet this week, so pictures and such should come soon. So many to upload. Well, off to the internet café to post this. Thanks for reading….

Jason

Dharamsala

2008-06-20T03:20:00.000-07:00

This is my first post in over a week. Haven’t been able to write as we went to Dharamsala this past weekend and upon arrival back to Dehradun on Sunday, we left for Than Goan, where I have been the past week. Set up a Picasa picture post site for all the pictures, so check them out. Will still try to post to Facebook and Myspace, but Picasa retains the quality thus going to try that.

So, Dharamsala this last weekend was quite and experience. I am glad that I went, but must admit, it was the trip from hell. It began in Dehradun as seven of us had planned the entire week on this trip, via taxi. Fourteen thousand rupees total = two thousand per person which isn’t bad considering gas and the distance (twelve hour trip from Dehradun). Well, as we are loading into the taxi, we realize there is room for six, and driver…. Not seven. Grrrrrr. Well, we converted two bucket seats into a bench seat with some ingenuity and a lot of pillows and blankets. Then, we were off. First hour, not so bad, straight roads, good weather … a little cramped, but air condition and fruit loops (found some in a store here), not so bad. About two hours into the trip, we reach the mountains, with literal cliffs on each side, and the driver is whipping around them so fast, that many of us, not only a little scared (ok, a lot), are also getting motion sickness. Well… first girl has to stop and puke. It gave us a break, and she felt much better afterwards. Next, Will and I began feeling very sick like we are going to vomit. After about an hour of feeling like this, we are like, “PULL OVER”. We get out and attempt to make ourselves puke. Sounds gross, I know, but imagine being on a rollercoaster you don’t like or being drunk to the point were you are sick … but lasting another 8 hours!!!! Thus, we attempted to vomit out of sheer misery of being extremely car sick. We explained to the cab driver his driving was making us sick, but I think he just thought we were silly. Anyways, Will pukes... I can’t. Another hour into the trip, I am literally saying, “the next hotel, stop, I’m staying, pick me back up on the way through”. The car sickness at this point is making me so dizzy, closing my eyes makes me sicker, and finally I have him pull over again, and this time I am able to vomit, without any help. Ahhhh. I did feel somewhat better after that. Anyways, we drove through the night (left Dehradun about nine pm on Friday the 13th of all days.

We arrive in Dharamsala at about nine am on Saturday the 14th, and after parking, the driver stays to sleep and we go touring. Once there, it was actually pretty neat. We actually went to Macleod Ganj which is just past Dharamsala, and is the home of the Dalai Lama. Of course, he isn’t there this weekend. But we still were allowed to enter the temple, meet some of the monks, and sit with them during a chanting prayer ceremony. I have to admit, the spirituality of the place was amazing. Actual Tibetan monks praying… it is really hard to put into words. Check out the pictures. They help. We also took some pictures with some of the Tibetan monks and people. Shopping was awesome. Bought a lot of Tibet stuff. It was shocking and a real eye opener to see the images near the temple, of the atrocities committed by the Chinese against the Tibetans. Never really thought that much into it, as from the states, this is all so far away and stuff you see on the news or in the paper. Being in Dharamsala really changed that perspective for me. Long story short, China took over Tibet, forcing them to leave, massacring men, women, and children. The people we met were very nice, peaceful, and the atmosphere in being surrounded by monks and Tibetans make it really difficult to fathom how such a people could be treated so harshly…… Really sad. Anyways, back to the trip.

So, we shop, tour, visit. Of course with how our luck was going, the museum would be closed as it is the second Saturday of the month. Grrrr. Also, It was soooo cloudy that normally snow capped peaks that should be visible were not. Damn it! Anyways, I am still glad we went, even just to see the Tibetan monks and meet the Tibetan people. An experience I will never forget.
So, the ride back is just as crazy, without all the car sickness, the driving was just as erratic. He tells us before departure that he was unable to sleep. Great! He has been up for over 24 hours, and has 12 hours of driving along cliffs of mountains connected to the Himalayas. FFS!!!! Anyways, we drive, and apparently took a wrong turn somewhere, thus 15 later, we arrive in Dehradun at the Mehta’s house (our home stay family). The icing on the cake for this weekend is that all the pictures I took from Friday to Sunday (whole Dharamsala trip) are on a memory card (SD) that for some reason is not reading in any device I put it in. So the pictures are on there (I hope) and hoping I can take it somewhere when I get back to the states and have them retrieved. Grrr. So pissed about that as there are some awesome pictures of us with the Tibetan monks holding Tibetan flags, Dr Joshi (cardiologist), children here. Have another card though so at least that is working.

Wow, this got long. Anyways. It was a rough trip to and fro, but I am glad we went. I actually hope to come back one day in a medical capacity or just to visit, as it is a beautiful place and truly a wonderful opportunity to meet the Tibetan people and learn of their story, which is still ongoing.

Well, that’s it for Dharamsala weekend. Will write about the village of Than Goan next, as that is where we spent week 3 in India, then the Taj in Agra. Thanks for reading…

Jason

Oh.... and got a haircut :P by LB

Week 2 Dehradun

2008-06-13T05:00:00.000-07:00

Hi. Just wanted to write a quick post about the end of the week as we are leaving tonight for Dharamsala and returning Sunday, and leave for Than Goan shortly after arriving Sunday and there is no internet there. So will hopefully post some pics and my thoughts on Dharamsala, but if not, it will be next weekend when we return back to Dehradun from Than Goan.

We finished up rotations. Wednesday ended up being the last day with Dr. Vaish has he had to fly to Bombay for a Neonatal conference :( but it was also good because it allowed me to spend more time with Dr. Joshi (Cardiologist) and attend his cardiac ECHO's (which he does from 1 - 4).

Saw many more pts with Dr Joshi over the last two days. One that really stood out was a 15 years old boy with COPD as you would see in a smoker. He worked the fire in a restruant since he was young, and has already developed the characteristic barrell chest. really sad to see. Another pt we saw had severe malnutrition, to the point where he had to be carried in. He was being managed by another physician for that, but seeing us to assess his cardiomyopathy. He was approximately 5'10'' and wiegyed about 70 pounds.

The last pt I wanted to talk about as a 42 year old male who presented this morning with pedal edema, load systolic murmur, JVD, and DOE. Dr Joshi scheduled him for ECHO today, and I actually got to do the ECHO on him. First one... cool right ..... wrong! No, it was cool, but in looking on the Left side of his chest, there were no real heart findings. After a few minutes, Dr Joshi took over, and same for him. Then moving to the Right side of the chest, what do you know, there is the heart. Grrrr. Na, it was a really interesting case. Dr Joshi was even intrigued. The pt ended up having Dextracardia (heart on the Right) as well as transpostion of the great vessels (Pulm Artery off Left ventricle and Aorta off the R), and has survived this long due to large VSD and ASD. A really interesting case and one that will be a great reminder of my first ECHO. Dr Joshi was a wonderful teacher and I will miss him (even though I have only known him for a week). He gave me his email to keep him updated on stuff which is cool.

Other than that, Getting ready for a 10 hour taxi cab ride to Dharamsala. Will be uncomfortable as hell im sure, but the trains are having issues, and bus is worse, thus 7 of us have hired a cab. We will drive overnight, See Dharamsala and the Dalai Lama tomorrow (Sat), then drive back saturday night, arriving back here (Dehradun) on Sunday about 9am, then leaving for Than Goan at 11am which is about an hour from here. The R & R for a week. Some hiking to sights, but yoga in the morning and afternoon in the woods which should be peaceful and fun.

So if I don't write anymore this weekend, then my next post will be sometime after next weekend, as we are trying to go to Agra to see the Taj next weekend. We'll see. After next weekend though, will write about each and every place and hopefully have some cool pics too. Gotta go get packed. Thanks for reading.

Jason

Week 2 - Dehradun

2008-06-11T07:34:00.000-07:00

It is currently Wednesday, June 11th at about 7pm (9:30am Wednesday there). Pissed because the USB ports on the internet cafe computers suck. grrrr. Anyways, not many pics, but still a few of Dehradun that I wanted to add. This is day #3 in Dehradun, and it's hot as hell (though sounds like it is hot at home as well). Gotten to the point where I always sweat, there are just sometimes less than others. The nivia deodorant is holding up though :P Its been fun though. We are staying with a family here in Deharadun (The Mehta's) and they are wonderful. Mrs Mehta cooks us breakfast and dinner, has purified water always stocked, and is a wonderful cook. The Mehta's have been taking students for 5 years (new students every month .... actually week) so they are able to help us getting to destinations as well as with any questions or concerns we have. Mrs. Mehta is primarily who we see. She rocks. Anyways, I am doing two rotations this week, one with a cardiologist (Dr. Joshi) and with a Pediatrician/Neonatologist (Dr. Vaish). About 3 hours per day with each.

Dr Joshi is our first rotation, meeting with him about 10am every morning. I say "about" because depending no vikrams to get from place to place and traffic varies our arrival time from day to day. He sees literally 70pts by 1:30 when we are done (3 1/2 hours). Given, most are follow-up, or established patients, but its amazing. I think the real key to it though is that there isn't all the paperwork that we have in the states, as suing doctors (or anyone) is not a common practice here unless gross negligence has occurred. He writes notes on a piece of paper, writes out Rx or instructions for pt, and thats it. He has been an amazing teacher, giving us every EKG and challenging us to find the abnormalities, then explaining the findings to us. He also reviews every CXR and Lab report with us. I have learned (and recalled) so much the past 3 days. We have seen STEMIs, Dilated Cardiomyopathies, Stenosises, regurg, etc... you name it. Tomorrow we also follow him to learn how to read Echocardiograms as he does those as well. Great experience so far and two more days to go. First day was a little scary as an unruly patient apparently began being rude or not happy with something (still not fluent with the language), but it ended with Dr. Joshi coming from behind his desk and other patient's getting in between them, and pushing the unruly pt out. Then everyone kinda laughed. Have no idea what it was about (didn't ask) but I had Dr. Joshi's back ......... well ...... pretty far back :P

At 1:20ish, we leave Dr Joshi and travel via bus to Vaish Nursing Home (not what you think). This is a Peds, PICU, and NICU facility started in 1988 by Dr. Vaish. I have to say he is one of the most admirable people I have ever met. He had no nurse upon starting, and spent the night with his admitted patients (1 or 2 beds), and now manages a full NICU (~15 beds), PICU (~10 beds), and Peds, Mother/baby care, etc and still does this as the only physician with many nurses, residents, and students to help. They also have a surgical unit where a pediatric surgeon comes once or twice a week and Dr Vaish acts as anesthesia (airway and paralytics/sedatives). He is literally an Intensivist, Neonatologist, anesthesiologist all in one.

We begin at 2pm with him, seeing outpatients for approximately one hour. Then we round all the units, finishing with the NICU. This is where I will focus as this is my interest and passion. Some things that strike me immediately, is one, we take off our shoes and put on sandles or go in barefooted. Strange, I know. Also, there are no blenders, only O2 and air (blenders are needed in NICU to mix Air/O2 to specific concentrations). So it is a little strange walking around in sandles. During the last 3 days, they have been running oxyhoods, ventilators (SIMV though they have HFOV capability), and NCPAP. What I was really impressed with was that Dr Vaish has a US Army version of Doppler Ultrasound. He actually checks for germinal matrix bleeds, as well as congenital heart conditions and abdominal abnormalities ... and as if that isn't enough, downstairs is a huge Echocardiograph machine (same model as they used at Carilion in Roanoke) that is much more specific, and he interprets these. Yesterday, He actually found what appeared to be Transposition of the great vessels (turned out to be both vessels coming off the L ventricle with a dependent shunt.. weird .. i know). And we had to take an intubated neonate outside to get to the ECHO room (no elevators here). But without his knowledge of using U/S to pick up stuff like this, a lot would be missed, and the nearest surgical place for cardiac annomolies is 8 hours away (Delhi). Their unit also administers surfactant (Survanta). Really neat to see all the similarities and differences. He intubated a child for surgery (6 months) and blew into the ETT to check for placement. That was a little odd I thought, but such is a lot of stuff here. Also, spinal taps (witnessed 2) are done in the same fashion as home, except without gloves (though surgical scrub and prep on the pt was used.

Seen all kinds of stuff from TB, Typhoid, and malaria, to a young man with agonal respirations who got drunk and tried to hang himself (a common way of committing suicide here), umbilical hernia repair (surgery), meningitis and pts ranging from ages 27weeks (gestational age) to 70 (sees a few adults).

I could go on and on, but this is getting long, and I need to go get some food. Both physicians have been wonderful to work with and I will hate for this week to end (especially because I want to specialize in neonatolgy and being in a unit here I would have never thought). The Mehta's are great as well, and we will stay with them again after next week for OB/GYN and something. Should be fun.

I hope to post one or two more of these before Monday. This weekend we are trying to go to Darmsala (home of the exiled Dalia Lama) and Sunday, we leave for Than Goan which is a small village in the mountains that apparently locals here don't even know of, which means no internet next week (i think unless we can somehow get back to town in the evening). Should be a good rest though. We actually have to hike from that village to other small villages to administer meds, see pts, etc. Very rural as these people live off the land, and have no means of getting to civilization to hospitals and clinics. Really looking forward to it. Got my Deet, hiking shoes, and backpack ready. Hopefully will add some more pics in the next day or two. I have tried two computers here, and the USBs wont recognize my flash drive. grrrrrrrrrrr. Anyways, until then, thanks for reading and thanks for the comments. Its good for me to get alot of this out and share and its nice to see comments to as it helps keep me in touch with everyone at home. Not homesick like in want to leave, but do miss seeing everyone and I haven't had a beer or steak or salad since i left. It's all good though, as this experience has been great, and the people here are really cool (nice and welcoming). Until next time (day or two), thanks for reading.

Jason

Week 1 - Mussoorie and Rishikesh

2008-06-08T00:45:00.000-07:00

Currently writing from an internet cafe in Rishikesh, awaiting a bus to go to Dehradun. It is hot hot.

Finished up Mussoorie on Friday 6/6, and was really sad to have to leave Saturday morning. What a beautiful place. The week ended good with actually getting to see a surgery. Many simularities, but many differences. We had to take off our shoes and wear sandles (open toed) which was kind of wierd. Watched Dr Samuel perform a cystourography (sp?) in an attempt to remove 2 large kidney stones (seen on KUB view). Upon flushing the bladder, large amouts of mucus presented, which was concerning. The stones were crushed, but he opened her (transverse incision just superior the suprapubic region), and allowed us to see inside the bladder which revealed a large posterior malignancy. Very interesting. Otherwise, the surgery was typically like I have seen it in the west. Sterile tech seemed to be used at all times (though the flip flops where a little strange. A neat experience and grateful for the oppurtunity to have had the chance to observe.

Friday, we traveled to a Tibetan refugee camp (~ 4000) with Dr Jacob (who was an awesome teacher) and saw about 30 Tibetan pts with a full range of disease processes including active TB, facial (preauricular) abscess, and Typhoid to name a few. It was a very humbling experience though. They (the Tibetans) were all so nice, wanted their pics taken with us, and were always smiling and noding. There was a Tibetan monk there as well which was pretty cool to see. Kind of hope to learn more about the whole Tibetan / Chinese thing while here as there are a large number of Tibetans in north / east india.

Saturday morning, we left for Rishikesh for a 26 kilometer Rafting trip on the Ganga (Class 3). It was an amazing experience. I had a crappy camara (Not yours mom ;) ), hoping to get some pics, which i did, but it got wet. bah!! It was amazing though. Took about 2 1/2 hours, almost flipped once. We had a great guide who has actually been on expiditions with Discovery channel, and he really made the trip a blast, with stories, and hyping us up. We did end up in the Ganga "body surfing" (feet foward in the rapids) but it was way up top in an area considered "semi clean" above all the temples and shrines, so hoping no problems (parasites, infxs, etc - that would make a great story :) . We came back after rafting and our guide served us tea (which I'm so hooked on now). That night, we all went across the river (see pics) to a religous ceremony along the Ganga (Aati I think) which was beautiful. Lights and the dress of the particpants was very colorful, and the singing and drums were amazing. Afterwords, we ate with some other students and called it a night. Such a spiritual place and a wonderful vibe about the area.

Today, we went touring and sight seeing, checking out the temples, shops, and the area in general. Lots of pics on Facebook if interested (If can't see, send me invite). See lots of, for lack of a better word, hippies here. It is a very spiratual place, but all the white people I see here look the same. Not really tourist, but dreads, tye dye, .... and non of them seem to acknowledge us which is kind of funny, so we have made it a point to jump in their face and say "HI, HOW ARE YOU". :P Anyways, just thought was kinda strange. Many of the indian people here though have asked us to take pictures with them, which is always a blast. Sadly, I have taken none with my camera, so from now on, gonna try to get some of those for myself. Everyone here has been so kind, not a single hostile event to speak of, not that I was expecting any, but as many smiles and "namaste's" as we get, its really a welcoming feeling. Anyways, enough rambling.

As stated, currently awaiting two other students to return from a hike, then catching a bus to Dehradun where we begin our next rotation tomorrow, with a cardiologist and pediatrician (few hours with each Mon-Fri). Really looking forward to it. We will be staying with a homestay family for the week which means home cooked indian food. Soooooo can't wait for that. Thanks for all the comments on here, facebook, and myspace. It's good to hear from friends and family at home and stay connected. Keep them coming. Will post again in a few days, til then, thanks for reading.

Jason

Week 1 - Mussoorrie (Day 4)

2008-06-05T04:13:00.000-07:00

Trying to upload pics now as a right this. Been kind of a challenge as everything seems so slow. grrr. Anyways, Worked along side a pediatrician today which was awesome. Saw many things from possible malaria to hep A to 2 active cases of TB (complete with lymphadenopathy the size of an egg and chest x-rays). Guessing I'll probably have a positive TB test when I get my next PPD. Oh well. It was a great experience though as I have never seen many of these disease processes, only in text. Yay, some pics finally loaded. Going to upload all to facebook and myspace so check there to see all. These are pics of a monkey, which are in the 100s here. Also a pic of the Hospital we are staying at (Landour Community Hospital), and the mountain pics are looking down from the hospital, One of them from a place I try to spend and hour or two reading good ole Current and "teach yourself Hindi" (which hasn't worked out to great :P ). Tomorrow I will be in peds clinic again with Dr. Jacob, then we are meeting him at a Tibetan refugee place to screen children. There are many Tibetan people here that have fleed from Chinese rule. Here and Darsalaa (sp?) are the two locations of the Tibetan refugees, Darsalaa being the current home of the Dalia Lama and where we go next weekend. Anyways, hope everyone is well. Probably won't post again for a few days, as we leave tomorrow night for Rishikesh for temple seeing Saturday and Rafting on Sunday, Then get settled into Dehradun with a homestay family (whom we stayed with on the first night) for next week, so probably Monday. Going to post pics now on myspace and facebook. Thanks for reading..

Jason

Week 1 - Mussoorie (Day 3)

2008-06-04T03:48:00.000-07:00

Hey, thanks for the replies. Yes, blast so far. Today was really good. Saw a pt with German Measles, one with Typhoid, and a disease called Neurocystercosis (parasite that deposits in the brain). Really scary. Other than that, Drinking Chai and eating all kinds of strange, but good spicy foods. Will post some pics tomorrow. Been trying but this computer is way to slow, thus i will bring my laptop. Think i got a few to upload on Myspace, but taking an eternity (fast internet, slow computers). This has a limit so more will be on my facebook and Myspace site tomorrow. We are going to see some temples this weekend in Rishikesh, and next weekend have planned to go visit the Dalia Lama which should be amazing. We were hoping to see the Taj but there is still some turmoil in that area so we may have to miss that, but will see towards the end of the trip. Again, thanks for the replies and I'll post again in a few days when there is more to tell. Off to haggle for some goods :P

Jason

Week 1 - Mussoorie (day 2)

2008-06-03T04:04:00.000-07:00

Sorry so long for the delay in posting. No internet service till now, but at least i know where to find it now. We left at 7pm Friday night from Roaonke to Dulles, then 3 hour layover until departure to Heathrow (London), then 11hr layover until departure to Delhi, then 10 hour bus ride from Dehli to Dehradun where we stayed the night with one of the host families. The driving here is amazing. No stoplights, lines with no purpose, pedestrians DO NOT have the right of way. It's great, a little scary, but amazing. Saw lots on the bus ride up from animals, to huts, to skyscrapers. It is really a wierd mix of technology and old ways of doing things. Anyways, finally got to sleep in a bed Sunday night, and Monday morning we left for Mussoorie. Having Chai tea every morning for breakfast is something i'll have to figure out how to pull off when i get home. This is probably the most amazing place I have ever seen (You were so right Kinnari). Atop mountains above Dehradun, it is a winding road of merchants, services, food, gifts, crafts, hotels, bars, ... you name it. Truley amazing. We were taken to Landour Community Hospital as that is where we are spending this week shadowing physicians and seeing pts with them. The food has been incredible, though I can't pronounce most of it, though I think my stomach is handling it ok so far (Thanks Rima ;P) . During our free time (afternoons), we have been walking up and down the streets trying to go a little further each day. 7-8 miles so far round trip (though its verrrry hilly). Other than that, I am rooming with Will (Starting 1st year med student) and LB is rooming with Keddy (2nd year med student) and it has been a blast. Currently at an internet cafe, but going to try and load pics onto a flash drive, and load them on here that way, other wise, we return to Dehradun for a week next week. Everyone here has been so kind and more than hospitable. The hospital we are currently at is a christian hospital that has an ER, male and female wards (similiar to vietnam movies), surgery, and peds. The doctors are more than willing to teach, and the pts seem to not even mind us being there. The nurses have been espcially helpful and generous, giving us pointers, grabbing us when there is something good. Everyone has been great. Anyways, k, enough for today, ill post more tomorrow or Thursday and hopefully get pics in a day /or few days. Thanks for reading.

Jason

Hello

2008-05-27T02:45:00.000-07:00

Hello, and thanks for stopping by. My name is Jason Feyerherd I am currently finishing up Physician Assistant school, with graduation being 8/8/08 (In case you want to send money :P ). A fellow classmate and I have chosen to do our last two rotations (electives) in India and South Africa. This blog is to hopefully (pending internet availability) be a journal of our experiences there as well as pics and thoughts about being immersed within the Indian and South African Culture for a month each and to keep in touch with family and friends. The organization we are going through is Child Family Health International in case anyone is interested.

Our trip begins on June 1st with arrival in New Dehli, India, and will consist of visiting three locations during the duration of the program. Two weeks will be spent in the capital city of Dehra Dun (where many patients have come from rural areas), one week in Mussoorie, and one week in Than Gaon. The location is at the foothills of the Himalayan Mountains and the focus is on Rural health within that region. We will stay there with in hostels as well as with host families.

We depart from here on June 29th, and have a 7 day break before beginning the next rotation, so it's off to Tembe, South Africa to spend two days at the Umilio Lodge for a Whale / Hippo / Croc watching tour on the South African Eastern coast, then 4 days at Tembe Elephant Park. Should be awesome.

On July 5th, we leave Tembe and arrive in Durban, South Africa, where we will begin a one month rural health rotation with an HIV focus. The rotation consist of seeing pts in various hospitals in the region and seeing how they are coping with the HIV epidemic that boast one of the highest infection rates in the world.

Though both of these rotations are about healthcare, the experience also focuses on how medicine is practiced in other parts of the world, from traditional to holistic, and how it differs from western medicine. The other focus of the program is simply to be immersed in a different culture, and the experience all that comes along with how different cultures experience life.
Anyways, this first post is to make sure this works, and should begin with entries the beginning of June. Thanks for reading, and bye for now.