Final Post

Dear Friends and family,
Thanks again for your support and prayers. They were much appreciated. Feel free to check my blog at http://ariinindia.blogspot.com and my photos at http://www.facebook.com/media/set/?set=a.10150635147306019.447711.697836018&type=1&l=dc34de252a. Below I’ll just give a quick introduction t o the people. Then I explore my educational, clinical, and cultural experience, as well as mission opportunities and my spiritual growth.
Dr. Ann and Dr. Vijay are the founders of Makunda Christian hospital. Both are from south India. Dr. Vijay is a pediatric surgeon and Dr. Ann is a anesthetist. Both were called by God to open a mission hospital. Dr. Hasanga, a third year surgery resident from Australia, was visiting for 6 weeks with his wife Nadie, and children Harumi and Himish. They’re originally from Sri Lanka. Their story glorifies God. About three years ago they both came to really know Christ, and just recently God put it on their heart to visit Makunda. Neither Hasanga nor Nadie have had any plans of medical missions, which is what makes their faith so beautiful. The way Nadie says it, “We’re going to have to go home after this and figure out why God called us here.” Dr Rachel (an Anesthetist) and her husband Dr. Anupam (a general surgeon) have recently come to Makunda for three years to repay residency and medical school costs. Dr. Krupa and Dr. Goldey are both junior doctors (ie post internship but pre residency) here for a year. Krupa’s parents are missionaries in India and God has now given her a similar heart.

Educational, Clinical, and Cultural Experience
Educationally I realized I know nothing. My iphone apps stopped working after I shut the 3G off and turned the air plane mode on. Not only did I lose access to my internet dependent apps (ie up-to-date), but also I lost my internet nondependent apps (ie epocrates) which was devastating. I’m dependent on Epocrates for knowing medicines and doses. Instead I had to depend on this International Medicine handbook that Sylvia had gotten for me at the Louisville workshop, even though it wasn’t all inclusive. The other issue with the Meds is that that they have different trade names for all generic names, and that their “drug of choice” within a family of ACE-I for example will be different than ours, and often time I never will have heard of it.
It was humbling but good. In the US we’ve become so dependent on our iphones because we can and it makes us better doctors. In India its less of an option so the Junior doctors we were privileged to work with gave me the desire to have so much more knowledge memorized than I do. Don’t get me wrong, so of the stuff they have to memorize is useless, such as knowing the exact name of the guy who invented all instruments, techniques, etc. But a lot of it is helpful.
During the rotation I was responsible for rounding on the female medicine ward, which always had a few postpartum patients mixed in. I helped when I had time to round on postpartum patients. And part of the time I rounded with the team on the Male ward, pediatric and ICU patients while the team was rounding. I spent a little time in maternity, but I was a little bored with it since I’d been there primarily last year, and I felt God stirring my heart to leave Sylvia there alone to optimize her experience so mostly the time I spent there was while on call. During the day I’d help out in the Out Patient Department where 300-400 patients were seen a day. It’s like a clinic, acute care and ER all in one. Chronic diseases are managed there, acute issues are treated, patients are hospitalized if needed, minor procedures performed as needed, and admitted for surgery if indicated. When I got bored with that I’d go to the ultrasound department for a bit and do prenatal ultrasounds. Also during the day we’d take turns being primary surgeon for the c-sections. Initially Sylvia and I were on call every third night, after a week call was spaced to every fourth night.
In this large spectrum of medical specialties I was exposed to a lot of tropical medicine/infectious disease, advanced diseases due to late presentations, having to make resource limited decisions. I won’t be surprised if my PPD is positive this year I saw so much active TB. We had one patient with TB Meningitis. There’s a high prevalence of eclampsia and preeclampsia in this population. I saw numerous hemorrhagic CVA where I felt helpless to do anything because we didn’t have a CT. One 30 yo female came in 8 days post partum with hemorrhagic and ischemic CVA and with a large midline shift according to the CT film from a larger hospital with a CT. The patients come back because they can’t afford the cost of care at the other facilities. That postpartum patient already had fixed dilated pupils and had lost her cornea reflex. She ended up dying later the next night on my call. I had a STEMI patient with hypertensive emergency present who I was forced to manage medically, because evidently hardly anyone in all of India can afford a heart care. One day by God’s providence, I walked into maternity just as a patient arrived from a small rural health center. The nurse looked at me and said “cord prolapsed”. I raced around the table, and saw about 20cm of the cord hanging out as well as a hand or foot. I quickly instructed the nurse to put her gloved had into the vagina, called Dr. Ann in OPD, raced to OT (operation theater, i.e. OR) where they were waiting. Dr. Anupam had the baby out literally in two cuts, and which point Dr. Ann started the resuscitation, which was successful.
I also learned to treat patients even though you feel half blind. The hospital is self supporting. The patients pay for every medicine, service, study and test we order. Unless they’re about to sell their house, cow, or farm they’re expected to pay. Consequently we do our best to limit what tests we order. Also rather that treating all 20 problems as we do in the states, we try to only address whatever their chief complaint was, in order to keep the cost affordable and realistic based on the extreme poverty in that area.
I learned that my first response to anemia in old or young, male or female, pregnant or non pregnant is Albendazole. I learned that any kid that comes in with a fever pretty much automatically gets a malaria test and a bicheck test. I saw a 11 year boy with Tetralogy of Falot that was found on a 2-D echo I’d ordered due to murmur and presence of a heart murmur. He didn’t end up having endocarditis, but he did end up having Tetralogy of Falot.
Clinically, the physical exam because so crucial. Not only because of limited tests, but also because of the language barriers I was going through to obtain any history. The nursing staff for the most part spoke English. But their English was very broken and the pronunciation wasn’t always the same as ours. Consequently they found Sylvia easier to understand since her ability to speak broken English was better than mine. Then my translators in the OPD weren’t even nurses so I had to go through the barrier of lack of medical background. Then, what they understood they had to explain to the patients in Bengali. And that required crossing the barrier of lack of education. So whatever history I managed to glean wasn’t very helpful, causing me to depend more than ever on my physical exam.
Culturally I had a very diverse experience. The mission hospital served the people of Assam and several surrounding states. Most of the staff and nursing school students seemed to come from Nagaland, Mizoram, and Manipur. Dr. Ann and Dr. Vijay are from the south (from Tamil). Dr. Rachel and Dr. Anupam are from Bunjab. Dr. Hasanga and his family are originally from Sri Lanka, though they’ve been in Australia for like 17 years now. It was a melting pot of cultures. I didn’t plenty of culturally unacceptable things to incur the irritation of Rachel. Both Rachel , Anupam, Dr. Ann, and Dr. Vijay were trained in the postgraduate training in India which is very harsh and degrading. Consequently, it’s culturally acceptable to hit and yell at patients and staff if they’re not doing as asked or as they should. It seems that in the US we’re overly concerned about patient satisfaction (to the detriment of the patient) and over there they’re under concerned about patient satisfaction (to the detriment of the patient). Also it’s a male dominated society, so the male decides whether the patient can have a life saving c-section or surgery or tubal ligation. Sometimes the husband decides for a tubal without informing the wife.

Mission Opportunities and Spiritual Growth
This was my biggest prayer--- that I’d really develop close relationships with those who would stay behind so that they’d better know Christ. When you’re going through culture shock its easier just to stay busy working than it is to focus on relationships. My one of my three goals of the trip was to know the people and remember names. God answered these prayers. On our last night, the three girls who had been my translator in the OPD were in tears and sharing their hearts. Also my favorite scrub tech was in tears and gave Sylvia and I parting gifts. Also one of my friends has written me on facebook since returning, “My wife - Amen and many people at Makunda loves you a lot (the kids too) - which i wan't aware.” To me to be loved and to be missed means that they felt loved, and the only love I have to offer strangers in so short time is the Lords. So to me, these things show me that God was able to use me to reach the people.
There are three groups of people God allowed me to reach. First are the Christian staff. The work is so oppressing and endless that to love them is to allow them to continue strongly in the Lord’s work. The second group are the people of Assam who are poor and of Hindu/Muslim faith. Though the language and culture barriers were thick, there difference in how I treated and examined the patients in contrast to the Indian patient-physician relationship/interaction demonstrated to them love of Christ. The third group are the English speakers who didn’t truly know Christ. Lokish is one example. He was one of our drivers and of the Hindu faith. As we returned to the airport (a six hour drive), Sylvia and I were able to talk to him about his faith through broken English. He was at the point of thinking that Hindu, Muslim, and Christian faith all share the same God. We challenged him to realize that the God’s of each of these faiths require different things, and it’s not just about getting their blessing. Sylvia and I read a book, Death of a Geru, that was very enlightening concerning the Hindu faith.
Spiritually I think I grew the most just reading that book. Sometimes the simplicity and passion of a new convert helps you appreciate how much you have that most of the rest of the world doesn’t. Just realizing that in contrast to Hindu’s we have a loving God, we have forgiveness, we have peace that lasts longer than meditation sessions. Also I relearned to realize that God has called me to glorify him and make him known and not to be a skilled physician. I will never be a skilled, productive, successful physician in and of myself. God called me to this field because in my weakness his strength is seen. Rather, in the helplessness of the cultural, technological and financial barriers I kept running into, my spirit was humbled and I again took up Christ’s relational yoke of love and walked peacefully and easily next to Him as he shouldered the load.
Thank you and God bless!
Ari

Access to photos

Dear Friend,

We're back with mixed feelings!
I called my dad when I got back, the first time I'd called since I'd left. the first thing he said was "welcome back!" Then in the next breath he accused,"You only posted four times!!!" For that I apologize, but it was out of my control. We only ever had access at the hospital and usually that was only during work hours. So if I was actually working then I wasn't able to use it. Also the internet on the desktop at the hospital was working slower than usual and I was never able to navigate anywhere on that one. so all my posts came from my iphone, and it takes alot longer to type with two fingers as opposed to a whole key board.

I managed to post all my photos to a facebook album that you can access even if you don't have a facebook account at:

http://www.facebook.com/media/set/?set=a.10150635147306019.447711.697836018&type=1&l=dc34de252a

Second, my final update and letter is soon to come.

Thanks again for all your prayer and support, it was definitely felt!

Ari

Heart attack with no resources

Sorry the story got cut off, I was about to miss my ride home from the hospital.
So I had to diagnose the heart attack (mi) by symptoms and EKG alone. No cardiac enzymes available. I dug around to find any cardiac mess since the ones available here are all different than the
"favorite" drugs I have memorized. Also aspirin was out of stock. Fortunately dr vijay had some extra plavix and aspirin combo drug. Also heart catheterization wasn't an option because it's financially out of reach of most people in India. The thing that makes me sick is that so many people abuse the system in the USA to get morphine and dilaudid by complainig of chest pain. Consequently too many of them get heart caths that don't need them. This guy, the thing he needed most was heart cath. Instead we had to just pray and manage him with medicines. He passed away the next day. He was in his early 60's which since being here I've started classifying as "old" in my mind because it's beyond their normal life expectancy. 60 here is equivalent to 90 in the us as far as prognosis and how aggressive we get here.
Otherwise work is good here. I've taken a couple lessons from dr hasanga and the imaginary kris Crawford. I was getting frustrated with the pt's and the language barrier and the cultural barrier and my slowness due to all of them together, plus my lack of experience/knowledge. Following dr hasanga's lead I've been laughing more at the inability to communicate. I no longer expect my self to accomplish anything. And I just seek god in each moment for know why he's called
Me back to Makunda and seek to know what he wants of me in each moment. It's made for a better day and I feel like the people are seeing Jesus more and feeling his love for them so much more now than when I was
Trying to be productive. :)
Sounds like god!
Also my c/sections are getting faster and more controlled and less bloody. I'm also getting better of getting the head out even after it's engaged and pretty far down the vagina. Sylvia too is getting really good too. She had less pre-trainig that I before common here. And today she finished the c/section that she was primary surgeon on in 37 minutes! ( 20 is fast and 45-60 minnie average in USA).

Still kicking

Sorry for the sparse posts. Been living by the golden rule of the jungle "be flexible.". Everythings good. We've be keeping busy. Dr Ann and dr Vijay arrived back at Makunda last Thursday. They'd been biasing one of the satelite hospitals and Also on vacation. Also here are a family originally from Singapore though most recently living in Australia. Dr hasanga is a general surgeon. He brought with him his wife nadie and his two kids: harumi and himish. They're visitig for 6 weeks and helping out. Dr Rachel (an Anastasist) and her husband dr anupam (a general surgeon) have recently come to Makunda for three years. Dr krumpa and dr goldey are both junior doctors (ie post internship but pre residency) here for a year.
It's been fun enjoying all of them as well as the many nurses and ancillary staff.
Sylvia has been primarily been helping out in maternity and I in the medicine wards. We've all been taking our turns being primary surgeon on c-sections. And we all help out in Opd (ie clinic/Er) as we can. Initially Sylvia and I were on call every third night. Now we're on every fourth night, which is a bit nicer.
Saturday night I was on call. In the early morning a gentleman came in with Stemi. We have EKG here but

To work we go

So we hit the ground running. Saturday we started with work. Deliveries, rounding on maturnity, female ward, ICU, NICU. Sylvia scrubbed in on a c/section. The surgeon asked her how many she'd assisted. She said 4. So he handed her the knife and said "cut." I helped out in opd (out patient department) which is like a urgent care/ER. Challenge #1: I had had a translated her could barely understand my English and then translated the bengali the patients spoke to me. challenge #2: they didn't have a copy of the medicines they had there, and many of their medicines had different names or were different types. Challenge #3: diagnostic tests were even less available than at good Samaritan clinic. For instance I treated pid by just looking at the discharge and pelvic pain.
All and all we stayed busy! Keep praying. I can see their results.
The staff have been very welcoming and hospitable here. Several of the doctors have just arrived. So it makes it much easier than last year to make friends because every one is new, learning their way and their roles and in the same spot as us.
God bless ! :)
Oh! My greatest most wonderful moment yet was my morning run Saturday morning! :) It was the first time I had run in five days. It's been years since I've gone that long without running. The air was cool and fresh and it was exhilarating to be free and fly!!

We've arrive !!

So from tues morning until Friday night we traveled to Makunda and finally arrived. We lost 12 hours, spent Wednesday night in new dehli airport, and spent Thursday night in a hotel in gwahati. It was nice to lay flat and to wash our hair but that's all I have to say. It was dirty and in the middle of a crowded loud city. All our domestic flights within India where short (1-2 hours) and all were delayed 2-3 hours. Because of that we had to plan for such long layovers between flights. Also most flights were only once a day. And it's common for them to get canceled. After the final flight we landed in silchar and then took a 5 hour drive throug the beautiful green country of north east India.
Logistics is not my strong suit. I had a mental list of everything I had to do be for I lost phone and Internet. It wasn't until I wasin the air between minisota and holand that I realized I'd not Written down any of our domestic indian flight info. Nor contact numbers for dr vijay and dr ann and the hospital where we were going. Nor had I'd confirmed arrival times with them in over a Month when I sent them our domestic flight info. God answered my prayers though. In holand they had free Internet in the airport. I wrote down the infor and sent an email. But I think the email bounced. But as we stood out side the final air port praying that some one would see a white person and be there for us. And so it was. Our driver from Makunda walked up And introduced himself. As sylvia sunk into the front seat she exhaled and said "oh I feel so comfortable now!!!"

India here we come!!

Hey friends!
This is were I'm going to try to post updates and pictures while in India.
Sylvia and I leave tomorrow morning at 11:30a.
Please be praying for our safety and ease of travel!

Thanks,
Ari