Team South India: Leprosy in Hyderabad, India

by Lucy Sung, c/o 2018

Team South India: Lucy, Nancy, Jason, and Melanie

Resilience one of the most important qualities of a physician. As medical students, we are constantly put under the pressure to succeed, answer questions correctly, be polite and courteous to all people, even if they are yelling at you in rage or in pain. On top of it all, we get lectures from the people upstairs that we need to take care of ourselves and remember to exercise.

It can be a lot to juggle.

But the best way to continue your day while you rub your sore shoulders and resist snacking on more Cheez-its, is to remind yourself that medical school is training. We are training for the best job (IMHO) in the world. We are always told that becoming a physician is a privilege. We are reminded so much that sometimes, the word - privilege - ceases to hold meaning.

This is why I love traveling. It is always about discovering and challenging yourself to adapt to any environment. In other words, increasing your resiliency.

There are two parts that I always look forward to when traveling:

Part 1. Going to the new place.
Part 2. After being at the new place for some time, going back home.

Outside Omani General Hospital, the oldest hospital in India. 

There are lessons learned in every step.

In the first part - Going to the new place - the experience of plucking yourself out of your environment and being plopped into a new one is a privilege in itself. Not everyone has the courage, the finances, and the time, to leave their responsibilities behind at home, and go forth and do something just for themselves. When I leave the airplane at my new destination, I feel nothing but relief. Relief because I have a slight fear of planes, but also because now it is time where I can focus on myself and prepare to learn something new about the people around me and about myself.

This is why I believe that traveling is a great and useful tool for medical students. We will learn by experience during our clinical years how to adapt to the hospital, but that is limited to bedside manners and how to bite your tongue at bully attendings. For our own personal development, traveling teaches you resilience by demonstration of the people that you meet and putting you in stressful situations that cannot be escaped by closing the door. You learn to confront, culturally appropriately of course, and how to share ideas and communicate without words. One of the fondest pastimes when I was a Peace Corps Volunteer in Rwanda was sitting with my neighbors in the late afternoon chatting about life, cows, and the future. But often, we sat in silence and enjoyed each other company while we watched the cows graze. When I was at a market place in Zanzibar, a Muslim grandma slapped my face and walked away because I was showing my shoulders. Did I want to yell and show my anger? Of course. But is that really going to solve anything? Probably not. Although it is not a fond memory, it reminds me that I am still a guest in another person's home, their country, their culture.

Lesson from Traveling #1: Increase your ability to walk in other people's shoes and learn empathy.

After the devastating earthquake in Nepal, the team was disbanded on grounds of safety. Melanie, through some kind of magic, established contact with the oldest hospital in India and invited classmates to join her and her family in Hyderabad, India. In the middle of finals, myself and 2 other students quickly decided to join Melanie and we soon found ourselves with tickets and visas to India.

The team with Dr. Ramesh in surgery 

At Osmania General Hospital, we were greeted by our preceptor, Dr. Ramesh. He loves to laugh and pimped us a lot on anatomy. From one of his residents, we got a tour of the hospital, a 100 year old colonial building that could rival the Buckingham Palace in its esthetic. However, the inside also smelled like it was 100 years old as well. Pigeons flew in the rafters in the four story tall alcove, dark corners were stained with urine, and patients beds were lined side by side like army beds in bunkers. Despite the sharp contrast against the Western hospital whose air is tinged with antiseptic, everything and anything was treated here.

Tuberculosis is very common!

Jason examining a patient with upper lobar pneumonia

The magnificent alcove of Osmania General Hospital

Medical Ward, patients either waiting or recovering from surgery

Our days consisted of either surgeries, receiving lessons and being pimped by doctors in general surgery or medicine, but with special permission and a few phone calls, we had the opportunity to exam three patients with leprosy.

Leprosy!

In a slightly offensive and stereotypical way, I had imagined leprosy to be like the images I had been exposed to of leper colonies. Bandages and isolation, is what the unknowing person like myself imagined. We had a short lesson on leprosy during our immunology course -- TH1 and TH2 imbalances, tuberculoid, lepromatous, and other words that had become a scramble in our brains.

From Princess Mononoke, how I thought leprosy looked like

After getting lost a few times, getting turned away twice, and then eventually talking our way into meeting some patients, we finally had permission to learn about this disease that is not found in the USA.

In immunology, we learned that there are two types of leprosy: tuberculoid (non contagious) and lepromatous (contagious). There are actually FIVE types of leprosy that is along the spectrum of the disease. In order of increasing severity:

• Tuberculoid leprosy (TL) -- strong immune response
• Borderline tuberculoid (BT)
• Borderline borderling (BB)
• Borderline lepromatous (BL)
• Lepromatous leprosy (LL) -- poor immune response

Patients who live in endemic regions and presenting with hypopigmentation patches and loss of sensory dermatones at the patches should be considered for leprosy. 

A and her father with the team

We first met A and her father. A is 13 years old and the cutest, nicest teenager I have ever met. Why can't the teenagers in my life be as polite as her? Last year, she fell down while playing and banged her elbow into the ground. She noticed that the wound turned black and she could not feel any touch, pain, or temperature at the site of the healing lesion. Soon, she noticed patches of lighter skin spreading with the same characteristics of loss of touch and pain. 

Note hypopimentation

New hypopigmentation on the dorsum of her right hand.
Her nails are orange because of henna, a common way to get colored nails in cultures that use it.
A is a typical teenager :)

She and her father visited the local doctor, who then sent them to Osmania General Hospital for treatment for Borderline tuberculoid leprosy. Her treatment includes going to her village's health center to take rifampin under supervision and documented and taking a dose of dapsone daily for 1 year. WHO provides medicine sachets free of charge.

Free of charge by the WHO

Leprosy treatment sachets, one per month. Rifampin once a month and dapsone daily x 24 months.
MDT = multidrug therapy

A and her father must take a 3 hour bus ride to Osmania General Hospital for follow up and laboratory, every 2 months, for the past year. It is a great time commitment, but A and her father were sweet and answered every question we had, even encouraging us to exam her patches. 

Dr. Aradya B. also demonstrated how to conduct a physical exam with a new patient with a possible leprosy diagnosis. In the video below, our patient also has a non-healing ulcer on his foot, a common occurrence because the lack of sensation on the plantar side of feet does not alert the person to sharp objects, burns, or other kinds of trauma. 

Key aspects for the physical exam:

• Note the number and distribution of skin lesions, the borders, and hypopigmentations. 
• Assess neuropathies -- test areas for hypoesthesia such as touch, pinprick, vibrations, temperature, and anhidrosis. This was a great review of the main nerves of the body. 
• Sensory loss is most common, but motor loss and and tenderness can also be found. It is essential to do detect all possible nerve damage. 

Note edema, non-healing ulcer, and adenopathy  

Lesson from Traveling #2: Talk to people, especially the locals. You'l learn so much more. 

The second part -- After some time in a new place, going back home -- is also a welcomed relief. Ready to escape the devastating India summer heat that resulted in over 2000 heat wave related deaths in our region. Ready to go back home and see family and friends. Ready to get a pedicure because my heels are just plain nasty. Our next stop is Nepal where we will be meeting with our community partners to conduct health camps, and where I plan on helping to rejuvenate Nepal's tourism economy by buying all the souvenirs. 

It was over 115F every day...

STEP 1 Recall:

• Leprosy is an infection caused by bacteria Mycobacterium leprae and Mycobacterium lepromatosis. 
• Acid fast, obligate intracellular bacteria, thin rods
• Transmission is from nasal discharge contact
• Two types that we must know: 
• Tuberculoid leprosy: strong immune response that causes a granuloma formation. Characterized by a TH1-type immune response
• Lepromatous leprosy: the immune system is weak and diffuse inflammatory damage occurs. There is low cell-mediated immunity, characterized by a TH2-type immune response.
• Dx: PCR or skin/nerve biopsy
• Tx: TL type: dapsone and rifampin x 6mo. LL type: dapsone, rifampin, and clofazimine x24 mons.

Team India: Overview and Cases

First, Amritsar is a wonderful city.  Gagan, our fearless team leader, set us up in one of the more incredible settings for a global health experience.  The Punjabi people are quite possibly the most friendly, welcoming and hospitable people any of us have ever met. 

We have freestyled our days and it has worked wonderfully. We spent two days at Pingalwara, which literally mean a house or asylum for the disabled, handicapped and crippled.  It was an intense few days in a world we knew nothing of.  It was a very fruitful and emotionally draining experience.  We got to spend time with kids who do not get many visitors and connected in wonderful ways.  It was an interesting insight into some of the troubles that some Indians face.  India is a country of great contrast when it comes to their healthcare. 

Team India also got to give back to one of our UCDSOM administrators.  We set up a clinic in Roy Gurmeet Rai’s hometown of Walipur.  This is a small village outside of Tarn Taran.  Luckily, our paths crossed with a IM doctor, Gaurav, who wanted to join us for the day, and his presence and skills helped create an awesome pop-up clinic.  We took weights, BPs, temps, HEENT, histories and provided a plan.  We saw and advised over 20 patients.  On top of our successful day, we were treated with the previously mentioned Punjabi hospitality.  Roy has an amazing family. 

Now to the most interesting cases we have seen since we have been in India.  We were allowed total access to Fortis Hospital, a top-end hospital in Amritsar.  In our four days, we spent time between ICU, Surgical recovery, Heart command center and the Operation Theatre.  Two cases stood out.

1)   A man came into the hospital two days after a fall.  He came in swollen all over his body.  His eyes were swollen shut.  The doctors took an x-ray, but due to air build-up throughout the body they could not get a clear view.  They proceeded to do a CT and found a pneumothorax.  What was this man presenting with and why did his pneumothorax not present with problems breathing? His picture is below.  

      The patient had surgical emphysema (aka subcutaneous emphysema).  This is when air from the chest cavity becomes trapped in the subcutaneous tissue throughout the body.  It usually occurs due to trauma that causes a puncture of the respiratory or GI tracts.  One of the most common causes is a pneumothorax, which is what happened here.  Interestingly enough, the pneumothorax in this patient was not found because this man’s whole body was still being perfused by the subcutaneous emphysema.  The air trapped due to the surgical emphysema allowed this man to live relatively comfortable with a pneumothorax by providing oxygenated air to the tissues.  

      This will be a memorable case.  We got to touch the patients skin, which was crackling to the touch.  They say it is like rice krispies. There were large, visible air bubbles throughout his body. The man was treated by inserting a chest tube and fixing the pneumothorax. 

2)   We also had the privilege to watch a few open-heart surgeries.   These surgeries were called CABG’s (coronary artery bypass grafts).  They first sawed through the sternum and exposed the pericardium and lungs.  Next, they harvested the LIMA (left internal mammary artery which in the US and our anatomy class is known as the internal thoracic artery) and the great saphenous vein.  The LIMA was expertly released and the great saphenous was cut from the thigh in this patient due to varicose veins in this patients leg (usually it is taken from the leg).  The LIMA was then anastamosed end to side to the diagonal branch of the LAD and then anastamosed again to the LAD to avoid the 80% blockage of the coronary artery.   The great saphenous was then attached from the obtuse marginal artery (known in the US as the left marginal artery) to the aorta. 

This is the great saphenous vein attaching to the aorta.  The great saphenous is the vein in the bottom part of the picture marked in purple to make sure that the vein is not twisted at all.















The

most interesting part of this case was the unique finding on the posterior wall of the heart.  Can you tell by the picture what this finding was? Not a great picture sorry.  The problem is found between the surgeon's finger and the pickups.  Answer will be below.

















Answer: heart aneurysm of the posterior wall of the heart

With love from Team India

DISCLAIMER: Sorry for any grammatical, spelling or medical errors due to the speed in which this was written.  

MEDICOS Nicaragua 2015: CASE 1 GYN Surgery

CASE 1: GYN Surgery

We arrived to Nicaragua not knowing what quite to expect. With help of our preceptor and GI Surgeon, Dr Lawson, we met the director of Surgery who then allowed us complete access to observing all surgeries at the hospital- that's what we did our entire first week.

Wednesday May 13th 2015:

After observing rounds at 7am, Kristiana and I went down to the surgery wing of the hospital and were very excited to observe what we thought was a c-section.

They made their usual 4 inch vertical midline incision below the umbilicus. They then separated the muscle, pulled the incision open from both sides, shook their heads in awe, and expanded the 4in incision to 7 or 8 inches.

We peeked in and saw what appeared to be a well-vascularized smooth fluid filled mass which we initially thought was the amniotic sack, then we realized they hadn't cut through the uterus yet. Strange. Given how large her abdomen was, we asked if the woman was having twins, "No bebé" the doctor replied. No bebé? Entonces, que es? "es un mega quiste" she replied.

MEGA cyst!

They reached their hands in and pulled out what could only be described as a well vascularized extra large 20 pound water balloon. Impressive.

Take a look at the photos/videos
 below and take a guess as to what kind of cyst it is. Benign or malignant? Teratoma? Serous? Hemorrhagic?

How did it get so large? We were unable to talk to the patient, however, we know that she waited until she was in a lot of pain before coming in. Unfortunately access to care is extremely limited and especially in rural communities. We'll post more about our experiences in rural clinics and house visits soon.

See comments below for the answer. Also, let us know what you think about this case =]

Cheers,

Diana <3

Ps- probably wouldve looked like this google image (but even bigger) on imaging:

MEDICOS Nicaragua 2015

Hooray for the first blog post of the trip! We thought it was only fitting that for the first post we would share some of the thoughts of a first-time traveler of Central America (Rachel). Today's theme: transportation.

We flew into Managua and were greeted by some hospital representatives who so graciously drove us to our hostel in Leon (ps we love our hostel in Leon because we get these pancake-crepes with a whole banana and syrup for breakfast every morning, even when we wake up at 5 am). Within about 20 seconds of getting in the car at the airport, it was clear to me that driving/passengering in Central America is unlike driving/passengering anywhere else. I resorted to closing my eyes at one point to avoid the perpetual state of hypertension that I was experiencing as a result of seeing how close we were to hitting the other cars. And motorcycles. And people.

Also, Central America is HOT and humid. We are pretty much always sweaty and really look forward to cold showers and beaches. On the plus side, lotion is largely unnecessary here. Another plus: I have a newfound appreciation for any kind of wind. We love fans.

On our second day here we took a public bus to UNAN, the medical school in Leon, to meet with the dean of the school who has been great at setting us up in clinics while we're here. The meeting was excellent, but the bus ride was terrifying. I really thought that we were going to tip over - in fact, every time the bus turned I would lean the other way to do my part to help distribute the weight. On the way back to our hostel I stood at the very front of the bus, right over the emergency brake (which I had an urge to pull multiple times). A woman actually sat on the dashboard of the bus with her baby because it was so crowded. Clearly people in the US aren't taking full advantage of space on the bus :)

Okay last transportation story I promise. This past weekend we visiting Playa Gigante, which is a trek off the main road (it was also amazing and if no one writes about it I will soon!). On our way back, we tried to save money by taking one of those retired school buses back to Rivas, the closest large city. When we first got on the bus it was fine, but as more and more people started piling on it got pretty weird. I ended up in an aisle seat with my knees up to my chest (partially because I was sitting right over the bus wheel and partially because I have weirdly long legs). I also had my backpack on my lap and was resting my chin on it. As it started to get pretty packed, one woman decided that the best use of space was to put one arm behind me on the seat back, and the other arm in front of me. She then proceeded to lean forward and rest her breasts on my head...

...for the entire trip (about an hour). I wish I had a photo. Meanwhile, Diana is in the seat in front of me happily playing with a baby the whole time. So jealous.

Anyway, we're loving our time here! It's going by so fast. We can't wait to share more stories with all of you and give you a little taste of what we've been up to. Stay tuned!

Rachel