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Tuesday, May 26, 2015

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.  

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