Delhi Belly: Part 2 and TAJ

...continued from previous entry

From there we took our very first Indian subway ride. After figuring out the ticketing machine, passing thru security and metal detectors with an automatic rifle aimed at us, and clutching our pepper spray in hand we waited on the platform. A creepy guy followed me and my friend Kelly everywhere we moved on the platform so when the train came we made sure to run to a different car. They do have 1 all female car per train but we were traveling in a coed group and felt it was better to stick together. The train itself ran fast and smooth, hardly jostling us when it came to a stop, but man was it crowded. It was a Saturday and not rush hour and still filled to the brim with people, and an onslaught of more people stepped on when we reached Delhi’s busiest station: Rajiv Chowk.

We got safely to our stop and entered Pahar Ganj which is kind of the grungy, druggy backpacker area of town. We went to a recommended hole in the wall type food place called Sitaram’s Chole Batura and had this wonderful stuffed roti with chenna curry (chenna=chickpea) and spicy vegetables. We were the only white people in the place and stood around our little metal table chowing away.

We then went shopping and with Rohit’s knowledge, I found out that even with my haggling in Pondicherry I had still been charged more than double what my souvenirs were worth. Oh well. You can’t win ‘em all. He helped us haggle for items and then we got some chai on a roof deck pleasantly removed from the blackened air of the market. Afterwards, I got hit in the foot by my first rickshaw and came out unscathed, it was bound to happen sooner or later.

We got cheap drinks at My Bar where people were smoking hash and hookah and cigarettes, there really is no law enforcement unless money is at stake. And a couple brave souls tried street vegetable juice (both fresh vegetables and water are bad ideas for travelers in India...Side note: with eating tons of street food in Delhi, we had to be wary of getting the infamous ‘Delhi belly’ which you can google if you want, but I’m sure you can imagine. A couple of us got a little taste of it unfortunately.)

We took the metro to Connaught Place which is super ritzy and filled with nice restaurants, bars, and markets that could easily be in a Western country. One very interesting thing about Delhi is that each part of the city is entirely unique from South Delhi where our hotel was with it’s posh residents and less dense population, to the east villagey Haus Kaus, to the ritzy CP, the grungy Pahar, and the ridiculously crowded and dirty Old Delhi. You could never be bored living in this city.

We tried some street food--Nepalese dumplings called chicken momos and sweet potato grilled over coals and covered in starfruit juice and spices. All of it delicious and completely unique.

After that our culinary tour continued and we got rolls at Nizaam’s which looked like a diner with red table tops where you order at the counter to a guy grilling in the back. These rolls are like Indian burritos--deeply fried paratha with egg filled with chicken or mutton and spices and vegetables--dripping in grease and dripping in deliciousness.

We took our food coma to a bar where we got many 2 liter jugs of Foster’s beer (even weaker than Kingfisher), hookah, and met up with some friends. We hung out there until late, and when we tried around 12 to go out, the city was closing up. After the gang rape of a tourist in December 2012 brought the rape culture in India to public attention, many previously ignored rules have been taken more seriously including shutting down all bars by 1am. So sadly I never got to experience Delhi nightlife. It was definitely sketchy walking home at that time of night though so I had the boys I was with stand guard as we walked.

The next morning we picked up our driver for Agra that was arranged for us. And we did a whirl wind tour of the monuments we had not yet seen as well as the food we had not yet eaten. We dropped by Lotus Temple for a hit and run tourist pictures.

We went to the DC-esque area where India gate (a tall arc de triomphe structure) stands and tree lined boulevards with houses of government officials and cronies go for 20-100 million USD.

We rode bike rickshaws through Old Delhi where the streets are so packed with people that a car would not be able to maneuver through. Our bikers were very friendly, although we probably could’ve walked faster than they pulled us. We meandered through the narrow market ways usually bustling with wedding markets except for Sundays when we rolled through.

We got lunch in another hole in the wall this time at Parantha Wala Gali where the six of us squeezed into a corner booth and ordered 7 different sweet and savory paranthas (like none other I had had before) rapid fire, all of us going at it with our hands and delicious sauces dripping everywhere and locals amused by our presence.

We hustled through the streets to make sure we tried Indian fried dough (galebi wala), ice creamsicles (kulfi), and pani puri which involved tapping a hollow bread puff, filling it with spiced veggies, and dipping it in spiced mint water. We stopped at a spice shop where the store owner told us all about the spices and teas and had us smell each one of them. Interestingly, a bunch of the spices came from different parts of the same tree, mango is used for sour curries, and turmeric and cumin are the essence of pretty much every Indian dish. Then he struck two rocks together and asked "do you like eggs?" And then we tasted the rock salt, which had that sulfur-like taste of hard boiled eggs.

We finished up the whirl wind tour by going to the largest mosque in India called Jama Masjid Mosque, but between having to remove shoes and us females being required to wear a cloth smock I just watched from the entryway (who knows where those smocks have been!). We biked by the famous red fort, dropped Rohit and the car/driver and booked it to Agra... For nothing. Apparently you needed to send in copies of your passport and visa a week in advance for security clearance to see the taj at night. Would've been nice to know online or when we called multiple times. It was too foggy to see from any hilltops and then poor communication with our driver led us to try and enter the closed gates which led to an angry police man leaning in our car window yelling at us that the taj was closed.

Without Rohit's help, we ended up at a mediocre, touristy restaurant. We ordered a few good breads and a good saag and spicy mutton but a pretty gross mutton korma which was an unappealing shade of whiteish brown. To compensate we ordered another chicken dish and when it came out looking exactly the same as the korma he explained that no, it was very different, because it had egg in it too. Double fail.

My friend Theresa is the one amongst us with a sweet camera and photography skills. Tragically the night before the Taj, she found out that neither of her batteries were working. We took an adventure to look for the fancy camera battery charger in the dirty, shack filled streets of Agra. We found a small road side stand with cell phones and showed them the battery. The owner  was off on his motorcycle and back in 15 minutes with just what we needed. Noooo idea where it came from though... There's no radioshacks or best buys around!

Our lazy tour guide claimed that the taj did not open until 7am which we found out was incorrect because people were already inside when we got to the line at 650. So me missed the sunrise by a bit but still the second you see the taj everything is fine. It's so majestic and breathtaking and more spectacular than even in photos. It also looks different in every light and even morphed over the couple hours while we were there.

It was built by Shajahan as an ode to (one of) his wives and cost something like 1.2 million dollars (and this was in the mid 1600s)! It was all so romantic. He and the Mughals were also all about symmetry so the building and surroundings are all perfectly symmetric. So much so that the large, elaborate mosque built to the taj's left is replicated to the right and the latter was just used as a fancy guest  house.

The taj is even more intricate and elaborate up close with tons of Sanskrit calligraphy, designs and floral patterns carved into the white marble, and symmetrical architecture within and without. It took 22 years to complete.

After the taj we headed out on our twelve hour journey requiring a 3 hour drive, 2 hour airport check in (just barely made our flight!), 3 hour flight (better in-flight meal and plane conditions on this airline), 1 hour wait to meet our friend Tim, and 3 hour drive to Vellore. Totally worth it though. Such an epic trip.

Delhi Belly: Part 1

In my opinion, a trip to India doesn't really count unless it includes a trip to the Taj Mahal. So a few of us flew up north for a long weekend to see one of the great wonders of the world. We had initially planned to go to a once a month full moonlight viewing of the taj on Friday as I had seen advertised online, but when I tried calling from a hospital phone to reserve tickets the man said "we're closed Friday" and hung up. Fortunately for this situation as well as our entire trip, Rohit, a good friend of mine from growing up now lives in Delhi and with his help (he knows the ins and outs of Delhi and Delhiites, speaks Hindi, and is incredibly helpful.) He called and found out the night viewings were every night that weekend except for Friday--naturally--and rearranged our hotel reservations for us in Delhi and Agra, a feat that would've taken us hours to do. (Of note, all sites, transportation, food, and cultural tidbits in this post are courtesy of Rohit.)

We hired a driver to take the 5 of us the 3 hours to Chennai for our flight. He drove the speed limit, pulled over to make phone calls, and we all had seatbelts... Which we surprisingly found frustrating rather than reassuring and wanted him to pick up the pace a little!

We made it to the airport and struggled through security--we had to check bags to bring our protective pepper spray and this required prescreening them ourselves multiple times and answering questions about the knife we decided to pack for no real reason. We all received pat downs, but the women got our own private rooms for decency as we got felt up by women in uniform.

Past security, we had plenty of time due to delays but no where to eat. We found the only restaurant there which was overpriced and gave us microwave "chicken" nuggets and other delicacies.

Getting on the flight required stamped tags on carry ons, multiple ticket and passport checks, and other annoying unnecessary checkpoints. The plane itself left something to be desired--it was very dirty, seats were torn, tray tables missing, and the food they served was covered in a sauce that looked and smelled like toxic waste. I lucked out though since the plane was half empty with an entire row of 8 seats to myself and slept most of the way despite being startled awake on multiple occasions for service items and trash collection. The Delhi airport is beautiful, by the way, and we were all pleasantly surprised by the toilet paper, soap, and paper towels available in the bathrooms! It’s the little things in life, don’t you think?

We hired a prepaid taxi from the police (to avoid scams) and squeezed five of us into the four seats. The second we left the airport, we knew we had entered a different world. New Delhi is a much more modern and international city, and, as India's second largest, is home to about 22 million people (note that NYC has about 12 million and lacks cows and ox carts in the streets--could you imagine??)

We stayed at a nice hostel called the Moustache Hostel in South Delhi, I only mention it because the name is pretty awesome and the owner was a squat guy with a thick mustache. So we dropped our stuff and tried to grab an auto (aka rickshaw aka tuck tuck) to our first destination--the Haus Kaus Village. I say tried because no one knew where anything was located and of the ones who did, no one was willing to use their meters--preferring to make an unfairly high rate for tourists.

Just outside Haus Kaus, we strolled through Deer Park where tons of deer live protected (and multiplying!) along with peacocks (India's national bird). Then it was Haus Kaus which is an urban village--an old low caste village that was bought up for a shit ton of money and now resembles the east village in NYC--quaint restaurants and bars with terraces touting happy hours and art shops, wall art, and people dressed to the T (not in traditional Indian clothes but western clothes as that demonstrates wealth in a city corrupt with massive amounts of unfairly distributed funds).

We stumbled around the ruins in the village which were our first cool Mughalai architectural gems. Then holed up on a bar terrace with kingfishers (India's pervasive cheap beer). We then headed to Imperfecto which was a cute restaurant decked out for valentines day with scented candles, hearts, and really expensive Indian wine (crazy tax to drink in public!)

Rohit joined us in time for us to venture out for street food exactly when a downpour started. Since we were sopping wet, we opted for an indoor restaurant instead and went to a 5 star Mughalai restaurant called Karims. We let him order a spread for the table and we demolished plates of butter chicken (amazing), tandoori mutton (melted right off the bone) and chicken, kebabs, some curries and salads, naan, paratha, and roti. We even risked it and had reverse osmosis water rather than bottled. We were stuffed and surprised when it all only cost about 6600 rupees or about $55 total. From there we went to his apartment and hung out with his worldly roommates and tried a local spiced rum called Old Monk.

The next morning we again struggled to find an auto who knew where humayun's tomb is (it's a unesco world heritage site, so you'd think they'd know) even when we showed it to them on a map, but we did get there and boy was it cold in the morning (after the rain and especially compared to southern India). Even the stray puppy was shivering. Entry for a foreigner was 25 times the cost of entry for an Indian, so I learned the phrase “But come on, I’m Indian,” (especially after my yoga instructor was convinced) in Hindi and tried it out at the ticket counter--to my credit, the guy at least understood me because it only backfired when he asked for some proof of identification.

We explored the tombs and mosques all of which are huge and intricate and impressive. Humayun's tomb was especially impressive and grand with sprawling gardens and fountains (it's kind of the architectural precursor to the Taj Mahal). It was really serene inside until a field trip of hundreds of primary school children came in screaming... Made even worse when they entered the high vaulted tomb that made their voices echo in every direction.

We tried to get an auto from there to our next tourist destination and encountered our first scam attempt. This one driver said he’d take us for 500 rupees and when we countered with 50 rupees (a generous offer for the distance we needed to cover) he said "yes 50 but first we stop at one shopping center." Some drivers drive tourists to stores or hotels (claiming your hotel has unexpectedly shut down) and wait in a nearby room for kickback from the venders. The other scams the guidebook said to watch out for that we didn’t encounter is poop-on-the-shoe and a hypnosis scam, which are fairly self-explanatory.

Next stop was Akshardam, a relatively new temple complex that had sprawling grounds and tons of intricately carved pillars and temples and statues and fountains. There were so many carvings that no plane of any structure was flat, it was all tiny designs carved out of marble and sandstone. We sadly weren’t allowed cameras to document how cool this looked.

While there we saw animatronic and IMAX (incredibly loud to begin with made even louder by the set of headphones we wore that shouted English over the Hindi) productions explaining the formation of this religion. They both involved a young boy leaving home with almost no possessions and becoming a yogi, protecting all living beings, and practicing nonviolence. We missed the first 5 minutes of the first production so it was not until after our visit that we found out what religion Akshardam was built for and in the meantime it felt very cult-ish. We ultimately found out it’s for Jainism, but if any religion, even mainstream ones, were depicted the way this one was, it would definitely appear to be a cult.

Hold tight for part 2!!

Trials and "Trails"

I've been trying to spend most of this first rotation with a particular junior attending (all the senior attendings turned me down when I asked to observe them), named Dr. Krishna (many people go by first names rather than fathers' names), mostly so that someone recognizes me. It's been great though, the more he gets to know me, the more he fills me in on the patients we are seeing and talks to me about culture and asks me questions about America. We discussed Breaking Bad in English while he was working up a Tamil patient. He's only on season two and loves it. He noted though that, "it's easier to be bad in India" and I don't doubt it--the police are great (not really) with bureaucratic paperwork but not so much with law enforcement, not to mention the corruption in all levels of police and government. Maybe I should start a meth business here! It would be quite lucrative.

I also saw in outpatient that some patients were paying full price for labs and medications and some were paying only 25% or nothing at all. I asked who pays when the patient doesn't and apparently this not for profit hospital gets much of it's income through donations from the US and the rest from reinvesting their profits. When I asked if there was any health insurance, he laughed and shook his head saying that people here hardly have enough income to eat let alone afford some luxury like health insurance. I asked about government health insurance and he said there was none-- they deal more with provision of food and shelter to the poorest of the poor.

Many of our outpatients have TB as well and I saw really advanced manifestations (for you med people--Potts causing cord compression and miliary TB with a snowy diffuse infiltrate on chest xray--things I'd only ever read in textbooks). They also see a ton of neurology complaints even as internists--tons of people with headaches and strokes (although unlike the US, many of these people must've had the stroke months ago rather than hours which is too late to do anything..). We saw a patient who was prescribed antipsychotics for depression by her cardiologist aka malpractice in amurrica.

(Speaking of TB I bought some N95 masks and have worn them in the isolation ward despite the funny looks and head shakes I get from the Indian doctors.)

Also, religion, particularly Christianity, plays a big role at this institution. I was surprised when on Monday our day started with devotion--reading out of the bible with discussion and long, uncomfortable pauses for reflection. Also during devotion, I had my big water bottle on the table. A resident asked for some water so I had no intention to drink out of it after (germs!) but she never even offered it back, just drank the rest of it. A random girl on the bus a day later also asked for some but I was so thirsty I had to turn her down. I don't know about you, but I've never asked a random person for some of their water.

After work (and soccer!) we stumbled upon a banquet and concert on campus for a hematology symposium being held that week. Despite being sweaty and dust-covered in American athletic apparel, they ushered us in. There was a live band performing rock style Indian music and by the end everyone was up and dancing. They taught us a line that we shouted out in unison and in rounds despite not knowing how to pronounce it correctly or what it meant. Turns out it was a mantra praising god, but it was catchy and stayed in my head through the following day. Then they invited us to join the delicious feast of chicken tikka, ginger fish, tater tots (technical term), vegetable fried rice, some corn based salad, some spicy soup thing you put rice in, dosai with coconut sauce, a cole slaw type thing, and honey ice cream and coconut juice for dessert.

I had ventured into Vellore that day with all it's hustle and honking cars and exhaust (I typically try to avoid this and just go back to campus after I leave the hospital) that day to get 5 simple items, and after 3 separate miserable attempts at 9am 11am and 3pm I gave up because either A) there was no store carrying the product B) the store was closed each time I attempted C) the ATMs were shut down due to a strike and no one would take plastic. It's the little annoying things like this that wear and tear on you.

The next day a huge group of us Americans went for a hike up the bigger mountain behind campus. We had to walk down the dusty, dirt road, a private driveway, past sweaty workers on a roof, through the dust of a quarry rock grinder thing, and up a "trail." I put that in quotes because it kind of was a trail to start and maybe there was a trail because we kept finding and losing it but 95% of this hike was scrambling up rocks, between tall brush with pricklers on them that got stuck to your clothes, and ash that turned all of our legs and arms (and face when we touched it) completely black. Not to mention it was 100F and humid and late afternoon. The group was also really wide ranging in hiking abilities and we quickly got split up.

A girl Alex and I followed what most looked like a path, preferring not to go up farther on an ashy rock slide, because the way down is always worse. We turned on the jams on my phone and hoped for a random helicopter to come save us and journeyed alone along this path that obviously wasn't always there to guide us as the sun started to set. Needless to say we made it down safe 3 hours later and hitched a rickshaw back to campus... Hopefully we didn't encounter any scrub typhus in our journey, but I'll let you know when I know in about two weeks.

Last notable thing pre-New Delhi trip (get excited for the next two posts!), was that we admitted a patient with rabies! Agh!! He's 22 and came in already with brain involvement (hydrophobia mostly for med people) and was agitated and quickly moved to the ICU. He plays with stray dogs and doesn't even remember the bite. Only 8 people in the world have survived rabies treated at this stage, so we really don't have much evidence to go on and are just hoping for the best. He's still in the ICU now (almost a week later, sorry, I'm a bit behind in my posts) and hopefully it will be an exciting outcome instead of just terribly sad.

Pondicherry

Most of India was colonized by England, but there are remnants of other countries carving up the subcontinent--Portugal in Goa and France in the city of Pondicherry in Tamil Nadu. A group of us took a weekend trip to the latter. I arranged a bus with a driver for the weekend. He showed up with a large white and pink van, it had worn brown patterned seats and could hold 14 people. It boasted "business class" on the outside, haha but not quite the business class I'm used to! We piled in after a hearty breakfast of egg dosai and chai tea and began the 3 hour journey to travel the 160km to Pondicherry.

The journey there was pretty comfortable, the van was spacious and air conditioned and the roads, especially the highways were well paved. We put on a Tamil music video DVD collection that covered up the omniscient honking horn. All of the videos were of a male and female fawning over each other with a group of same sexed back up dancers breaking it down in synchrony behind them. The English subtitles at the bottom were confusing and slightly disturbing, "how titillating!" "I want to gestate in you for 10 months" and "you can leave your family and care for me" are some of the gems I can remember offhand. One refreshing observation  was that the women in the videos have normal sized stomachs--I wonder how that translates to body image and eating disorders in this country (although American media certainly makes its way over here).

We passed miles of rice paddies and watermelon fields and coconut trees. We passed small villages and a brand new KFC. We also saw a brick making assembly line from gathering the clay to shaping the bricks to leaving them in the sun to a giant kiln  spewing smoke (which we originally thought was a house fire).

A few hours later we made it to Pondicherry and immediately the architecture had a French feel and the streets were a little (barely) cleaner than vellore. There was more traffic on the main street. It was so tight with our giant van that someone hit our rear view mirror. The drivers pulled over, got out, yelled at each other in Tamil for awhile, and when ours got back in he said simply, "that guy is worthless." And drove on.

We got to our hotel where we had reserved 2 rooms for 6 people each. When we looked in, however, there was 1 double bed and 1 single bed in each. Everyone loves a good cuddle, but without A/C that could be pushing it. We were able to get twice as many rooms though fortunately.

The "white area" and French parts of town were way cleaner and quieter (no honking allowed!) than I've grown accustomed to. There were some streets with hardly any traffic and quaint courtyards with colorful flowers. You could then walk one street over and be on a dirty, busy street with trash-spewn all over and mangy, feral dogs fighting over it.

We went to a Indian / French cafe and man is the food there delicious! I got chappatta (like whole wheat flat naan) and warm dhal (lentil based) and a diet coke (a rare find in the developing world!) and it was delicious and comforting. I also got to split chocolate chip pancakes with rich cream sauce. They were like little chocolate cakes! It was especially wonderful because the chocolate items I've tried so far have been uniformly terrible. (Fortunately our campus store carries Nutella!) There was a white woman with a French accent (there are tons of French ex-pats in the city), so I got excited to use my French and ask her about the Hindu temple. Turns out she didn't speak a word of French and just picked up the accent from living here. They had a home made artisanal shop attached so we shopped around the clothing, jewelry, handmade paper items, soaps, and incense.

From there we moseyed to a church--Notre Dame des anges-- which only resembled it's namesake by the two spaced towers. It was instead peach pastel colored and the interior was a pastel blue with stained glass. The disturbing thing was the group of young boys sweeping it out. They didn't look happy and I hope it wasn't child labor, since I know that is still a problem in this region.

We then went shopping because this city has tons of cute shops, and walked along the canal. (The canal is a sewage stream down the center of town.) And made our way to the hindu temple where a very sad and sick looking elephant with tons of gold bling and white paint took my rupees in his hairy and slimy nostril in exchange for a pat on my head as a blessing. We then had to shed our shoes to go in the temple itself. Hindu temples are full of images of many deities (often with many heads or limbs) and colors and incense and statues. Did you know Hinduism has 330 million deities? Can you tell I had time in the van to read the culture section in the guidebook?

That night a few of us did yoga in India, which is super exciting. We didn't get to do a full out ashram experience because that requires a 3 week to 6 month commitment, which we didn't really have time for, but we did have time for a 2 hour session on a rooftop lead by a local graduate of the famous ashram in Pondicherry.

The tough part was doing yoga outside at dusk not having been smart enough to remember bug spray. Here we are trying to do some meditative forms of yoga while I'm slapping and swatting away. Regardless, it was so relaxing to distance myself mentally from the car horns I could hear in the distance. We did some mantras, some breathing, some sun salutations and the like... I don't do yoga enough to appreciate the differences from the US but the girls who went that do it a lot found it unpleasantly different.

The guy leading the class never got my name, but called me "Indian" instead because apparently I could pass for a North Indian. He'd be like "Hey Indian, straighten those arms!" We finished off the night at a classy restaurant on--you guessed it--a rooftop, and then strolled along the Promenade that was closed to cars every evening. The sea breeze did wonders for dispersing mosquitos.

The following morning a friend Alex and I stumbled upon a cute, outdoor cafe and got French crepes--sweet and savory. It was incroyable!

Then we all boarded the bus to check out Auroraville which is this self-sufficient community near Pondicherry and has inhabitants from all over the world. They have this giant golden golf-ball looking dome that has a white room with a perfect crystal in the center for unadulterated meditation, but we were not allowed to go inside unless invited by The Mother. Oh yeah, it's kind of a cult with a divine being--The Mother-- and searching for divine truth. They also share everything, don't use money (then why were the pastries and gift shops so expensive?) and cook organically.

Me and another girl had called a PADI diving place ahead of time to squeeze in a dive in the Indian Ocean, and the guy on the phone said no problem, come by around 2. We got there at 1:57 to find that they never dive past 11am. Fail. You almost come to expect these types of things here. Instead we went shopping and I got a meditation bowl among many, many other things. En route back to the bus we saw a guy lying on the sidewalk who was clearly dead and there were flies eating his face. It was one of the more disturbing things I've ever seen and I don't know why no one was attending to it. In lighter news, the driver didn't show up to the meeting place, but somehow he was parked next to the shop I was in and when I knocked he woke up, ready for the drive home! We all wished we were based in Pondicherry instead of Vellore.

The Grandest of Rounds

(^ view of vellore from the top of the hospital library)

The next day at the hospital was "Grand Rounds." In the US, that generally involves a speaker standing in front of an auditorium of exhausted housestaff picking at their free coffee and bagel educating about their research. Very different in India. This was all 3 sub-teams of my giant medicine 1 team rounding together on ALL 45 patients (that's about 5 times the normal team patient load). This started around 8 am, and had I stayed the whole time, ended after 4 pm. Straight rounding, if you're not in medicine you may not truly appreciate how brutal (and holy crap, inefficient) this is, especially since we were rounding with a team of at least 20 people from bed to bed.

As before I could hardly understand (or hear) anything that was being quietly mumbled, which is incredibly frustrating. Then I turned around and saw a random middle-aged white guy with a back pack. He was accompanied by a middle-aged Indian guy. Turns out the former is the head of an ID department back in the states doing research in a disease fairly prevalent in India and was just there to observe for the week. The wonderful part about this is that it upped the ante for rounds. That Indian dude stepped in (he must be the top dog of the department) and snatched rounds from the director who had been leading them up to his arrival. He spoke loudly and clearly and even told the presenting resident to "speak up so people can hear you," amazing-- it's the simple things. Sadly that won't last. Also it turned into more typical rounding as I'm used to, with the residents being pimped and studies being cited, etc. He trained in the US apparently and it showed.

This was also great because I learned what all of our patients were in for! And man, it was all the stuff you learn about for board exams in medical school and never see... dengue, malaria, and chikungunya (yeah, I've been wearing DEET like white on rice), and more rare infections like listeria (though I'm still eating tons of unpastuerized dairy here 'cause it's delicious), leptospirosis (transmitted by rat urine in water supplies, mmmm), mucormycosis in a diabetic (textbook.), spotted fever, scrub typhus, etc.. Really sick patients with these diseases, but it's medically interesting to put a face to all of these diseases.

(^ internet whenever we can find a wifi signal)

I'd heard from students who had been here in the past that the local medical students play soccer every evening. I didn't have any more details than that--ie where or when--but I asked around for the "oval" and after crossing the street outside the campus gates I found a brown, dusty "field" surrounded by a brown, dusty "track." There was a cricket game and some kids playing soccer shooting browned balls into a holy net, though attached to a sturdy metal frame. The people power walking around the track were dressed in their normal day clothes--saris and sandals for women, button downs and pants with sandals for men. Clothing which is not super conducive to exercise, but I was impressed with their efforts regardless.

A shot through the holy net made it's way over to me so I passed it back and began approaching the group of 20 male Indian med students... I was both the only white person and the only female. One nice student introduced himself, his name was Jonathan, and once I had the in I was able to easily join. I was afraid to take off my jogging pants and play in shorts despite the oppressive 95 degree heat, especially with all the women around in saris. But it was too hot, so shorts it was. (It's disrespectful to show shoulders or knees although midriffs--no matter how fat--are allowed. I also don't think it helped that I was wearing only shorts when I accidentally kicked the ball into an Indian woman's face. Not my fault that the field and track overlapped and there was vulnerable passerbys though, am I right?).

We played full field in the dirt as the sun was setting. Every time the ball was kicked there would be a cloud of reddend brown dust that blew right into my eyes and mouth and made it difficult to breathe.

The guys had impressive foot skills, one was even playing really well in flip flops against others in cleats! Sad story about that guy though is that he is only in vellore while his brother is in rehab from a motor vehicle accident that paralyzed him from the waist down. But on a lighter note, despite being unable to see or breathe it was tons of fun and given that they have no expectations for girls playing sports, I earned their approval.

They continued to play as the sun went down and the ball became increasingly harder to see. As the sun set over the trees there was prayers on loudspeakers nearby and a flock of hundreds of bats started flying over the field. It was pretty magical.

Isolation Ward

My second day in the hospital was spent with the medicine/infectious disease team on the wards. Actually, it started in the morning with journal club where the huge team of interns, residents (called registrars here), and junior and senior attendings (called consultants;..I'm still trying to figure out the logistics and hierarchy here). All the cases presented were mid-30s and mid-40s year old patients all of whom died, and it took me about 5 of these cases to realize it was actually morbidity and mortality rounds and not journal club, so fortunately contrary to what I thought for about an hour, not all young patients die here, whew!

The residents and attendings here are surprisingly intelligent (I'm awful to assume they wouldn't be, I know, but I thought their training wouldn't be as rigorous as in the US), and also practice somewhat evidence based medicine, although adjusted for this resource limited setting and different patient demographics. The M&M was similar to that in the states as were the rounds that followed. Everyone is really friendly, but the hierarchy is still very strict here--lots of "sir"'s going around and no one challenges the bigger guy.

Then we did rounds on the inpatients. The med 1/ ID team is so big that there are 3 separate sub-teams within it and I joined the one that rounds only on the female patients (which unfortunately means that I had twice the load of patients as the 2 teams who split up the male patients). It's odd that they're separate though since the majority of the residents and all the doctors are male anyway.

Rounding is fortunately done in English at the bedside, although with the low-pitched mumbling and heavy accent, I still can only glean about 40% of what is said (40% more than Tamil though). The computer in the ID ward wasn't working well (by the way, I was impressed they have a hybrid medical record system with labs and scanned documents electronically and just notes are handwritten--kind of like how it is at Tufts!) so we went to the isolation ward where they keep the patients with proven active tuberculosis (TB) to use the computer there.

The funny thing about the isolation ward is that the nurses wear only regular masks (not effective against TB) and the doctors don't wear any. When asked about the n95 masks (that actually protect against TB transmission), the intern said you have to go out and buy your own if you want it, but they don't bother because they assume they are already infected -- something like 40% of the Indian population has TB infection, which is almost 1 in every 2 people, so she's probably right. Oh, and they also don't have negative pressure rooms like in the US to remove the TB droplets from the air, just open windows and ceiling fans --which I assume just spread the aerosolized droplets around? Oof.

(^nurses in white saris!)

Rounds were pretty interesting because damn these patients are sick, and even though they're so sick they're not in the ICU. We had a 19 year old female patient with chronic ITP (rare autoimmune disease) with malnutrition and anemia, who was SO malnourished that her THIGHS were the size of the cardboard part of a paper towel roll. She has big, beautiful eyes and a full face but the rest of her body is like a pile of sticks, it was so sad to see it made me tear up.

(^ I tried to crop out her face to protect her privacy, but you can still see her arm)

There was a patient with a heart murmur from rheumatic heart disease (preventable if antibiotics are given for strep throat) so loud that you could hear it before the stethoscope was placed on her chest and you could visibly see it shaking her body. There was a woman who had a blistering, pus-y skin manifestation of likely spotted fever so all the skin on her arms and legs was sloughing off (it was purpura fulminans, something I'd never seen before in the US).

After rounds, I didn't have much to do because as an observer I can't really work with patients. Silly international laws. So I went into town, struggling around people, rickshaws, goats, sewage, and street goods, to find some tunics and leggings to wear for work. I found a nice family-owned shop, had to take off my sandals to get inside, and asked the girl (who didn't speak English) which tops she recommended for me. I paid her father (husband?) up front and hoped for the best that the tailored outfits would actually be there for me the next day.

That night we again went out to dinner as a group of 30 (there is a weekly dinner outing on Wednesdays), but this time it was at the fanciest hotel in town, also on a roof deck, and since it's weekly, it was handled much better. On the way there, most of us took the public bus and a local guy on the bus kept shouting "Darling" at us, which is the name of the hotel, I assume it's because every Wednesday at 7pm a bunch of white people get on the bus for that very same reason. We all tried to rush off the bus as it was driving away at our stop. Then crossing the street to the hotel at night was an adventure, but I protected myself by surrounding myself with other people.

The dinner was tasty, and a little pricey--mine cost 200 rupees or about $3.50 USD. For schezuan chicken noodles and a mango lassi (a yogurt based drink). Meals are typically 30-50 rupees or less than a dollar (exchange is ~60 rps: 1 USD). Southern Indian food has been quite tasty, but it's basically fried dough or fried rice or fried potatoes with chicken or egg and a variety of curry/spiced dipping sauces to be eaten with the right hand only (don't use the poop hand!) and no utensils. This is the deal for breakfast lunch and dinner, but fortunately I'm not sick of it yet!

Assembly Line

The first day at the hospital was quite a culture shock. After navigating the streets--which I should mention, although filled with haphazardly moving objects are surprisingly well-paved--this time in the CMC student shuttle, we made it to the CMC hospital. It's a compound with tons of buildings and people... patients laying all over the ground in front of the "casualty" area (aka emergency room) and rushing between buildings around security guards blowing their whistles and trying, unsuccessfully, to do crowd and traffic control.

Thousands of patients and their families were mulling around in and out of the buildings. Of note, this is the equivalent of a tertiary referral hospital and gets patients sent to it from all over India and some neighboring countries. CMC is a 2700-bed hospital receiving 1.9 million outpatients and 120,000 inpatients annually, to give you a reference, Tufts in downtown Boston is a 400 bed hospital, so CMC has about 7 times the capacity.

My first clinical rotation is on the internal medicine and infectious disease service. As you may or may not know, I'm somewhat of a germaphobe so this is kind of diving in head first to some serious infectious disease, for you budding psychologists out there-- this is extreme exposure therapy. The first day wasn't as bad as future days in this regard though since it was in outpatient clinic.

And man, I have never seen an outpatient clinic quite like this one! It was like an assembly line! They have so many patients that the resident I sat with sees 50-70 patients PER DAY, again for perspective to non-medicine people - a typical clinic day for a resident in the US is 8 in the morning and 8 in the afternoon if they're pushing it AND they're a senior resident or attending. It was insane. I was sitting in a room observing a senior resident go through patient after patient, calling them into the room via a microphone like a bank teller.

They had 2 doctors per room each seeing 2 separate patients simultaneously (no divider between them), and, of course, every patient brings at least 1 family member for support, if not more. That meant a minimum of 7 people in the room at all times, so it was nice and cramped. In addition to that, patients from earlier would barge back in to show a slip of paper or ask another question while the next patient was being seen. Patients waiting would also peak in the doorway uninvited, I assume just to make sure the doctors were doing their work.

There was also the constant background noise of the hundreds of waiting people chatting, as there are no roofs to the patient rooms. There's also no doors on one side, and there were windows between the patient rooms -- which was good for me since me and my friend Tim were in neighboring rooms and pretty bored by hour number 8 of patients we couldn't understand.... but definitely bad for patient confidentiality, I have a feeling HIPPA doesn't exist here.

The patient encounters themselves were very regulated and rushed too. I got out of it what I could, mostly through body language though, as I don't speak Tamil or Hindi or any of the other languages the patients were speaking. There was no handshake (although I don't think there ever is in southern India) then are you the correct person? Yes? Here's a list of yes/no questions regarding your complaint. Okay, now we have a diagnosis, here is the treatment plan, take this receipt with you. There's no discussion of the disease, the treatment options, or anything--it's very paternalistic and all business. There were hardly any physical exams either except for an occasional pound on the back. Blood pressure was always taken though, with this ancient machine shared between the 2 doctors.

The diseases that came in weren't too exciting in the outpatient clinic (from what I was able to understand) -- more diabetes and hypertension than I expected, and of course everyone has tuberculosis.. but I'll get more into that later. The differences were interesting though, like how they use a different blood pressure medication than we do because of poor follow up or how the female doctor had to come in to do the breast exam for a male doctor's patient.

By the way, this is me at lunch in a tunic eating my veggie fried rice with creamy curry sauce with my (right) hand in a hospital. I gotta find me some spoons for next time though because this was less than sanitary.

Unlike hospitals in the states where doctors and medical students wear white coats, dress clothes or scrubs, and closed toed shoes, the dress code here is saris or tunics for women and open toed sandals for all. The nurses wear all white saris too. I feel like the scarf of a sari is even more likely to spread disease between patients than a neck tie does in the states, but I could be wrong. It's also harder to tell who is an employee and who is a patient!

Later that night, I squeezed into a rickshaw -- which is kind of a 3 wheeled electric bike taxi of death with a shell exterior, with 2 other students I hadn't yet met to go out to dinner with about 30 people for someone from the previous rotation's last night in town. We squeezed 6 long tables together on a rooftop, and put in orders--some of which weren't filled for over 2 hours. They had alcohol though, which is a pretty rare find in India.

I'm excited (but way too tired) to tell you about infectious disease on the inpatient side, so there's your cliff hanger for my next post!

Arrival and Velloretown!

After a 48 hour journey from Boston to Chennai, India (via Dallas/logical and Dubai) I arrived in the airport to find my baggage late and destroyed and spent enough time searching for it and trying to fix it that I feared my cab driver would leave without me. Luckily, by the time I staggered out of the airport, still half asleep, there was only one cab driver left waiting (others said it was a mob scene with tons of cabbies with placards shouting at you) and since my classmate Rob was joining us as well I felt safe enough that I left my pepper spray unopened.

The 3-hour ride to Vellore started off interestingly with our little taxi weaving in and out of the many headlights that were followed by buses and rickshaws and mopeds and bikes and pedestrians and sleeping cows and rabid dogs blocking both our side of the road and the right side of the road that we kept swerving into to pass the same. Holding your breath works best in situations where the only thing between your headlights and the oncoming ones is a loud honk on the horn. Despite the constant threat of death and incessant loud horn, Rob and I were so exhausted from the travel and jet lag that we passed out for most of the trip.

We got to the Christian Medical College campus around 11pm (10.5 hour time difference from Boston). We lucked out last minute with on campus housing which is pretty pimped out with an A/C unit, western style toilet, and ethernet cord, so I can't complain.

The next morning we met the rest of the Tufts students (there's 9 of us) and students from U Illinois and other countries and schools for orientation after a breakfast of idli = puff bread dipped in spiced sauces with chai tea (you'll note that I can't remember 95% of Indian names and words I learn because reasons but I looked that one up on wikipedia). See, I'm in Vellore, a small city in Tamil Nadu, to do a 1 month rotation at a renowned teaching hospital in India. The orientation ended up taking 2.5 hours, with only 2.5 minutes of instruction (none of which we could understand anyway through the mumbled English thick with Tamil accent). I guess I'll have to adjust to India time.

We had the option of going straight to the hospital or resting for the day, so we rested (#4thyearmedstudents), which involved exploring the medical campus which is filled with dirt roads and aggressive monkeys and well-dressed students in matching saris. We went to the college store to get water, soap, and toilet paper--the essentials. This is when I first noticed that lines don't exist in India, which took awhile for me to catch onto until I realized I wasn't getting any closer to paying.

Then a bunch of us took a public bus (still going into oncoming traffic blasting the horn, but this time the other vehicles had to budge) downtown with the door wide open, which was really just non-existent.

The woman of southern India were decked out in intricate, boldly colorful saris and tons of gold jewelry -- necklaces, rings, toe rings, earrings, and nose rings -- and with colorful and curiously varying bindis. The men mostly wear cotton collared shirts, with short cut hair and unfortunately mustaches are pretty popular.

The most curious thing is the head wobble, I totally thought it was an offensive thing in movies just to mock Indians, but it's REAL. After my neuro rotation, I thought it looked like a tic. It doesn't really make any sense... doesn't quite mean yes or no but it can mean a little of both or neither. Huh. But regardless, my head doesn't know how to move like that.

We checked out the fort which hosts 3 different denominational temples, and happens to be the only attraction in Velloretown. We had to take off our shoes to enter the Hindu temple, which was gross, but worth it. There were statues of Hindu gods with burning incense, a clarinetist with a drummer, dancers, and plenty of barefoot, colorfully dressed worshippers.

We then ventured through the bustling, dirty market. The spices were neon though and there were tons of flower parts. There were cattle, people, goods, raw meats, trash, silks, fruits. It makes it a terrifying adventure to even cross the street. After bargaining for some fresh hot paratha, in the wrong direction-- for some reason this guy thought it worked to start low and work his way up, we hopped again on another public bus.. this time literally because it hardly stops moving, and I was sardined in between a tons of wonderfully smelling individuals.

Came back after registering with the police to the employees cleaning the hostel. You know how certain smells are inextricably connected to past experiences? Well, this one reminded me of anatomy lab. Can't understand why they use formaldehyde as a cleaning solution here, unlike our dear bleach, this one is already a proven carcinogen, but I digress.

We had a meet and great that night with some of the other international students and got to see traditional Tamil dance (apparently in Indian dance all of the hand movements are symbolic and tell a story, but one that I will never understand, I don't know why I didn't already know that) and learned the history of CMC. It was founded by an American girl in 1900 after she was unable to help 3 pregnant woman who died in childbirth when a female doctor wasn't available to treat them (male doctors could not see naked females), and so she went home to train as one of the first female MDs at Cornell and returned to Vellore to start this school that is now one of the country's best.

I'll write about the medical side of things soon! The hospital is another world.