Hemophagocytic Lymphohistocytosis (HLH)

I did not really come across any tropical illness that was truly really any interest to me. I did come across two patients that had the above disease so I decided to write my one and a half page blurb on it: HLH is also known as the autosomal recessive familial hemophagocytic lymphohistiocytosis (FHL), familial erythrophagocytic lymphohistiocytosis (FEL), and viral-associated hemophagocytic syndrome (VAHS). Twenty-five percent of all HL H cases are familial and are frequently associated with parental consanguinity. It is a life-threatening disease most often affects infants from birth to 18 months of age. Primary HLH refers to presence of an underlying genetic disorder and secondary HLH refers to HLH phenomenon occurring secondary to another condition (ex viral illness) has caused a great deal of confusion among clinicians. Yet, the clinical presentation and outcome of both are generally the same.

HLH is associated with a many different infections, autoimmune disorders, and malignancies. The different amounts of infections associated with HLH include:EBV, CMV, parvovirus, herpes simplex, varicella-zoster, measles, HHV-8, and HIV. HLH may occur shortly after the initiation of HAART in the treatment of HIV-AIDS. HLH may also correspond wihth some bacterial infections(Brucella, gram negative bacteria, tuberculosis), parasites (Leishmaniasis, and fungal infections.

Autoimmune disorders associated with HLH include lupus, rheumatoid arthritis, Still’s disease, polyarteritis nodosa, mixed connective tissue disease, pulmonary sarcoidosis, systemic sclerosis, and Sjogren’s syndrome. HLH can also be found in patients with immune deficiencies such as X-linked lymphoproliferative syndrome, in renal or liver transplant recipients, or Kawasaki disease.

The basic pathophysiologic abnormality in HLH is cytokine dysfunction leading to accumulation of activated T-lymphocytes and activated histiocytes (macrophages) in many organs. The cytokines that are found in high levels in the plasma of HLH patients include interferon gamma, TNF-alpha, interleukins (IL-6, IL-12, and soluble IL-2 receptor (CD25). There has also been evidence of depressed or nonexistent natural killer cell and cytotoxic activity in HLH patients and family members. Their natural killer cell activity sometimes returns to normal when patients are in remission. Genes on chromosome 6,9,10, and 17 have been reported to be associated with HLH.

The initial symptoms and signs of HLH are similar to common infections, fevers of unknown origin, or hepatitis. Thus the diagnosis of HLH may be made late in the course of the disease or postmortem. In a Swedish study, the following symptoms were found most patients (they listed in order of most common): fever, hepatomegaly, splenomegaly, neurologic symptoms, rash, and lymphadenopathy. Many of these patients have clinical and radiologic findings similar to someone with acute respiratory distress syndrome. Thus alveolar-interstitial opacities and pleural effusions are common. On ultrasound, you may find gall bladder thickening, hyperechoic kidneys, ascites, and hepatomegaly. Patients may also have a mononuclear pleocytosis of the cerebral spinal fluid (lymphocytic meningitis) and evidence of parameningeal infiltrations, subdural effusions, retinal hemorrhages, and hypodense or necrotic areas, demonstrated by MRI of the brain.
On pathology, may see proliferation of normal histiocytes and T-lymphocytes in various tissues. There may also be hemophagocytosis of red cells, other WBCs, and platelets in the bone marrow, spleen, or lymph nodes. Infiltration of the liver and bone marrow with histiocytes and the antiproliferative effects of cytokines leads to damage to these organs. Hepatic failure is a common feature of HLH patients. Such patients may also have hyperbilirubinemia, hypoalbuminemia, and decreased number of clotting factors.

Diagnosis of HLH takes a high level of suspicion. The diagnostic criteria is defined by a set of major signs and symptoms which are as follows: fever, splenomegaly, cytopenia in at least two cell lines, hypertriglyceridemia and/or hypofibrinogenemia, and tissue demonstration of hemophagocytosis. Additional criteria include low or absent NK cell activity, serum ferritin concentration >500 microg/L, and soluble CD25 (sIL-2 receptor) >2400 U/mL. Either the first of these three additional criteria or a combo of the second and third may replace one of the major criteria listed previously.

Treatment of HLH involves initiating immunochemotherapy on the HLH-2004 protocol. This protocol includes induction therapy with dexamethasone, etoposide (VP-16), cyclosporine (started at week 9), and intrathecal methotrexate, followed by pulses of dexamethasone and VP-16 for up to one year. Allogenic hematopoietic cell transplantation appears to provide the best overall cure rate in HLH patients. This therapy is needed in all patients who have homozygous mutation in the various genes associated with HLH, those who have responded poorly to the initial eight weeks of therapy, and those with CNS disease. The protocol should not be used in patients with the following: systemic juvenile rheumatoid arthritis and lupus patients with the macrophage activation syndrome, HIV-associated HLH, and iatrogenically immune-suppressed patients.

References= http://www.uptodate.com/

Pictures:
1)While in Bombay, we drove by a traditional Hindi wedding. This was the groom on his way to get his bride. The ceremony looked beautiful.
2) Me on Marine Drive.
3) This is Jantar Mantar. This is an observatory began in 1728. It is basically a place with a bunch of sundals, compasses, and astronomy stuff. This area has an instrument used to locate your birthday sign. I am standing next to the Gemini section.
4) City Palace is the home of maharaja of Jaipur. The family still lives there, but that area was off limits. The guys in the picture wanted me to take a pic with them then they asked for money. That was the last person I took any pics with that wasn't from the US.
5) In a shop in Jaipur. The guy in the store wanted to show us how to wear a sari. In the Rajasthan area, the women wear a part of the sari material over their head. In other areas of India they just drape it over their shoulder.These fools also wanted me to take a pic with them then they asked for money. That was the last person I took any pics with that wasn't from the US.
6) Erica and I trying on saris at a local shop in Jaipur.
7) This is me and Erica riding an Elephant. This is a professional shot that some guy took for us. I was glad to know that they only make the elephants carry tourist up to the fort 5 times a day then they get to rest until the next morning. I was still bothered by the stick the guy used to beat the elephant into staying in line.

8) This is the view from on top of the elephant at Amber Fort in Jaipur. The elephant kept on blowing its nasty boogers on us. That got annoying. But it was still really cool to be seating on top of an elephant.

9)This is the Water Palace in Jaipur. We got to look at it from a distance. I wonder how they built this thing?

Pediatrics and Leprosy Hospital

I spent my last week at the CMC on the Pediatrics ward. I was told to report to the wards on the 5th floor at 8am. I got there on time and of course nobody was available to tell me what to do. So I waited and waited and finally someone from Team II showed up and told me to follow her on rounds.

The ward wasn’t far different from the other floors I had been in. It still had the flimsy curtains with no privacy for the patients. Moms usually joined their children in their cribs since there was no where else to sit. The parents were officially quiet for being in a pediatric ward. You would hear the occasional child screaming in agony but it was a lot quieter than I expected. The moms tried their best to keep their kids quiet as well. It felt like it was almost taboo or embarrassing to them if their child showed any signs of discomfort.

Most of my time on this ward I spent sitting in a corner waiting for someone to make some use of me. The residents were busy running around and not taking much time to explain to me what was going on in the wards. They were not the happy-go-lucky pediatricians I was use to working with in the states. The kids did have interesting diagnoses though. I saw one bed with a kid with a scorpion sting to the cheek, another kid had dengue, and two kids had HLH, which I had no clue what that was.

The team eventually began to round and it was the usual speak fast and soft rounding method. I couldn’t hear anything the residents were saying for the life of me and they spent most of their time directing their presentation to the attending. Occasionally I would realize that the team would get really quiet and look in my direction. This usually met they had asked me a question but since I couldn’t hear them I never knew that they were talking to me. The attending even started pimping me, so I decided to leave since I really didn’t feel like being pimped. Also I wasn’t too impressed with the experience so I was excited to get out of their anywhere.

My 2nd day on the ward wasn’t any better than the 1st. It was probably a bit worse. One of the residents gave a case presentation on meconium-stained birth. It was basically a pimping session where the poor resident had to basically read the attendings mind to figure out what the attending was asking.
Basically my experience on the pediatric ward, which I had been looking forward to during my whole time at CMC was a bit of a bore. It was way too serious and disorganized for my liking.

The next day Collin, Aruna, Erica, myself, Nicolette, Seema, and a medical student from St Louis went to Karigari to see the CMC facility there. This is where Vellore famous Leprosy hospital is located. Before this facility use to only hold leprosy patients. But now it functions as another inpatient facility for patients apart from leprosy patients. I believe the facility was first opened in 1955.

We were all a bit disappointed with our trip to Karigari. We thought we were going to be able to interact with leprosy patients 4and get to see some of the therapy the facility provides for its patients there. Instead, we got a walk and point tour by one of the facilities workers. She showed us the different departments of the facility. We got only a quick glimpse at the leprosy patients. She showed us their research facilities where they work with mice foot pads to grow the leprosy bacteria. We also stopped by a shop run by the facility. There they sell gifts and souvenirs made by leprosy patients who were taught these skills during their stay at Karigari. Profits made by this shop go back to the enhancement of Karigari. I bought some table clothes and pillow cases for some of my friends in the US since I knew the proceeds were going to a good cause.

We then made a visit to Kadapadi, which houses the outpatient facility associated with Karigari. There we were introduced to occupational therapist that gave us a step-by-step demonstration of his diabetic foot care education speech. He stated that patients are encouraged to soak their feet once a day in water for 30 minutes. After that they should use a plummer stone to scrub off all the excess skin on their sole. Then they are told to exfoliate their feet with oil. This method helps prevent dangerous foot ulcers.

1) This is when a autoricksaw driver let Erica drive the autoricksaw.
2) This is a picture from the shoe-making facility at Karigari. These shoes are made out of a special microcellular rubber. They are specially made for both the leprosy and diabetes patients.
3) More shoe making.
4) Examples of the prostheses they make for the leprosy patients that have lost limbs.
5) Us getting a tour of the facility at Karigari.
6) My last week in India was spent traveling through North India. My week of travel began with meeting Neha and Ruchi, two of our classmates, in Bombay. This picture was from a restaurant we went to upon arrival in Bombay. The food there was really good. Probably the best I had during my whole trip to India.
7) During our first night in Bombay, we went to a local club called the Hawaiian Shack. It was surprisingly very fun. The DJ was on point and played a lot of old school rap songs. They also would mix Hindi beats with hip hop beats, which I thought was pretty cool. We left the club when they started playing techno.
8) This is a picture of the Taj Mahal Palace hotel in Bombay. It is one of the most expensive hotels in India. I think it cost about $300 to $500 a night. It was really nice inside.
9) This is me in front of the Gateway to India, also located in Bombay. It was under construction when we went to see. It use to be an import/export port site when India was under British rule.

Weekend in Bangalore

I didn't realize how much of a village Vellore was until I actually took a trip to the big city. This past weekend, Erica and I made a trip to Bangalore (AKA Bengaluru). Bangalore is located in the state to the NW of Tamil Nadu (where Vellore is located) in Karnataka. It is know as the place to go if you are looking for work in the IT industry. Our trip started off on a rough leg since my alarm clock (Erica) woke me up at 7:10am when were surposed to leave for the train station at 7:30am to catch our train that would be leaving at 9:10am. I hadn't packed any of my clothes or taken a shower the night before so I was kind of in a hurry. We made it out the door in time, but it didn't matter anyway b/c our train came about 30minutes late.

Waiting at the train station was an adventure in its self. I was kind of excited about the whole trip since this would be my first time on a transit train. Of course at the train station we were met with lots of stares from the locals. It was kind of cold outside also that morning and it also started to sprinkle a bit. I expected the worse about the actual train ride, but it wasn't that bad. We were in an A/C coach and everyone had their own sits with a portable table in front. I slept pretty much the whole way to the Banglore, which was about 3 and a half hours out of Vellore. Every now and then I would wake up to the sounds of vendors selling bread/egg omelets, dosas, or tea. The food smelled great, but I kept to munching on the biscuits I had in my bag which I knew were safe. The train did not make any announcements about what city they were stopping at so I had to periodically look outside the window to see where we stopped. That was annoying.

When we finally arrived in Banglore we took a ricksaw to our hotel called Hotel Maurya. It was so nice to see paved roads and traffic lights which people actually stopped for. But of course with traffic lights and organization came ridculous traffic. It took forever to get anywhere in this city. It was also nice to see motorcyclist with helmets on, but their partners on their bikes never had helmets on, which bothered me a bit. People also seemed really laid back & friendly in this city and are very willing to help with directions. More people were dressed in western clothing and I looking kind of out of place in my Indian dress. Most people spoke pretty good English that wasn't too hard to understand. Plus the hotel we stayed at was surprisingly nice. We luckily found it on http://www.hostelbookers.com/. It was only about $50 a night and it turned out to be pretty nice. It didn't have sketchy sheets or anything. I actually slept well my first night there without the feeling that anything was biting me throughout the night.

As soon as we set our stuff down in our hotel, we were off to find something to eat. I am not a picky eater and will eat pretty much anything if it tastes decent. My roomie on the otherhand is getting a bit tired of Indian food so I let her pick everywhere we went to eat. We decided to have a curry free weekend and try to enjoy western foods while we were in Banglore. So our first stop was good ole McDonalds. The funny part was that it was more like a Chickfila b/c they only had chicken sandwiches. The sandwich was delicious but very small and the fries were pretty good & a lot less greasy than the stuff you get in the states. Plus they had diet coke, which does not exist in Vellore.

After that we decided to go see a movie. I really wanted to see a Bollywood movie, but soon found out that most of the Indian movies did not have any English subtitles so we were stuck watching only English speaking movies. Our only two choices were: P.S. I Love You and Enchanted. Erica wanted to see P.S. I Love You, but I am not the biggest fan of romance flicks so I was all for Enchanted. I love kids movies; plus it was a Disney movie so there is no way it was going to suck. And of course I was right. The movie was hillarious. I think Erica and I were the two loudest people in the theater.

In the theater, you can get buttered popcorn or caramel. We went with the caramel option, which we soon found out was the better option. The popcorn was yummy. Also during the movies they had intermission. At first we thought that the electricity had gone out but soon found out that it was just a break in the movie for customers to go use the toilet or get more food from the concession stand. The movie theater we went to was called INOX and it was inside a mall. The malls in Banglore were really nice. We went to two of them: one where we ate McDonald's and the other where we saw the movie. The shops had such nicer stuff than you would find in Vellore so we had a field day there.

The next thing on our agenda was to find this company called City Swaps that I had read about them in Lonely Planet. They were surposed to be a double decker touring company that drops you off at 15 different tourist spots around Banglore for only 300 Rupees. We soon found out that they didn't exist anymore and had to look for other options. After spending a good couple of hours walking around the city looking for City Swaps, we were hungry again. We looked through Lonely Planet and found a steakhouse called "Our City Place." I wasn't expecting much especially after the mess we ate in Pondy, but this place turned out to be really good. I don't even really like steak but this food was really good. After eating there we came across a cute little gift shop outside of the restaurant. Erica and I spent about an hour in this shop. I bought earrings, table mats, and costers. From this point on I decided I need to stop buying stuff for me and start concentrating on purchasing stuff for other people.

The next morning, the hotel had free breakfast. This food was not so great. In fact, I thought I was going to throw up after eating it. After breakfast we walked to Banglore's government tourist agency to see if we could get in on a morning tour of the town. The brochure specifically stated that their guides were "...having good knowledge of English," but of course this was not the case. I should have known better from the poor English written in the brochure.

Of course since we were in India, something had to be wrong with our tour. First of all, our bus was not air-conditioned. This was fine whenever the bus was moving b/c we would have cool breeze, but with the crazy amount of traffic we spent a lot of time just sitting in bumper to bumper traffic. Also our tour guide literally sounded like this to me: for example lets say we were stopping to see the Bull Temple, all I heard was "Bangala bangala Bull Temple bangala bangala." Whenever he spoke, I would be like what the hell is he saying? I would look around the bus and everyone else on the bus would nod in agreement to whatever he was saying. Erica and I always looked totally confused. When we would ask the guy to repeat what he was saying he would just say "BANGALA BANGALA" louder and look annoyed at us for not understanding his perfect English. Luckily everyone else on the bus was super nice and very willing to repeat whatever we could not hear him saying. The other people on our tour included two IT guys from South India, a girl from Israel, two families with small children, and a large family from Goa.

Our first stop was at Iskcon Temple. Again we had to take off our shoes and walk through an intricate maze to see this temple. Everyone was chanting "Hare Krishma Hare Krishma Hare Krishma Hare Hare Hare Rama Hare Rama Hare Hare." They gave us a card stating that you surposed to repeat this chant 108 times a day. ISKCON temples are dedicated to Lord Krishna and were built by the Hare-Rama Hare-Krishna cult followers. As we climbed the granite steps there were three small shrines before the main temple. The three idols of Lord Krishna in the main shrine are made of brass. When we returned to the tour bus after this visit, we waited outside the bus by a local village for the other tourists to return from the temple. Pretty soon Erica and I were joined by a group of old men from the village that sat close by and just stared at us. They asked me if I was West Indian and I said no. They really never see Black people in this country. Everyone thinks I am West Indian for some reason. Maybe it is b/c of my braids.

We drove by Vidhana Soudha, which is like the White House of banglore. This building houses Karnataka's state legislature and secretariat. We also drove by Cubbon Park, which is named after Lord Cubbon who is the longest serving Commissioner of Banglore. Please note: I did not get all this information from our tour guide since I couldn't understand what the hell he was saying. I had to google these places myself or ask the other tourists in the buses for specifics. The tour guide then took us to an Emporium for shopping. Why were there only two shops? It was really shady too, b/c the store owners wouldn't leave you alone and were really pressuring me to buy something. I think they had some deal going with the tour guide. Maybe he gets some of their profits. The tour guide even pulled me and Erica aside at one point and told us that he wanted to just take just us two to a special shop for more shopping but we told him no thank you since we were already disappointed with the first stop.

We stopped at some sketchy restaurant for lunch. The waiter could never understand what either Erica or I were saying. At the restaurant, I came to realize if you don't speak English with an Indian accent or annunciate your consonants, nobody understands you. Whenever the other tourists would repeat the same thing Erica and I would say, they would magically understand what we had said.

After the tour, Erica and I were hungry again. We found this pizzeria called Giancarlo's Place in a tour book that looked like a nice place to have dinner. It wasn't until we were trying to get a ricksaw to this place that we realized how crooked the ricksaw drivers in Banglore are. In Lonely Planet, it stated that ricksaw drivers are required to use their meters with customers. During our first day, I did not even notice that the ricksaw drivers we used were never using their meters b/c we were so excited to be in the big city. All of a sudden I began to realize that Bangalore is not that big of a city and we were getting charged way too much for wherever we were going. So I started asking the front desk of our hotel how much it should cost to go from the hotel to a certain place. The receptionist would always quote a price that was 1/3 that the ricksaw drivers would give. Our problem was that there was this guy outside our hotel who I like to call the "ricksaw mafia boss" would stand outside our hotel and dictate to other ricksaw drivers how much they should charge us. I would try to go further down the street to get a driver but the ricksaws would still stop in front of him to ask how much they should charge. It got so bad that I had to get one of the guys from the hotel to come talk him into giving us a ricksaw for 50 rupees, but of course when we got into the ricksaw and the guy from the hotel had disappeared, he upped the price to 60 rupees b/c of traffic. What a jerk!

Anyway, after a lot of frustration we finally got to the pizzeria. It turned out to be this really posh restaurant that you have to make a reservation for before coming there. B/c we didn't have a reservation, the owner gave us a sit at the bar which was fine by us. The pizza was really good and the bartender made the best cocktails. He was supposibly voted the best cocktail maker in all of South Indian. He gave us lots of free drinks and was fun to talk to.

That night, I had horrible sleep for some reason: First the back of my right knee (specifically my left popiteal fossa) was killing me. I was convinced the whole night I was experiencing a DVT, which made it even harder for me to sleep. I was afraid I would wake up dead due to a pulmonary embolism. I know, I have issues. I worry too much. It didn't help that our neighbors were incredibly loud the whole night and you could hear all the honking horns and cars outside our hotel in our room.

We left back for Vellore the next morning via train. The trip back was not as nice as going to Bangalore. We somehow ended up on a sleeper train near a family with lots of kids. I love children, but they are not fun to be near when you are travelling and sleeping. These kids were very noisy. They sang songs, played some spelling game, they started dancing, and then I think they were mocking Erica too. One of their family members had asked Erica her name and where she was from. Soon afterwards, I heard one of the kids giggling as she said with a pretend American accent, "Hi, my name is Erica."

Pictures above:

1) This is the food we bought at McDonald's.

2) This is us in front of Mc Donald's. I had to take a pic with Ronald McDonald.

3) This pic is from the second mall we went to. When we walked into the mall, we smelled a familiar smell and realized it was the smell of a chocolate chip cookie. We were so excited when we found the Cookie Man store b/c we have been discussing how we miss having chocolate chip cookies. So we got a sample cookie but they were stale so we didn't buy any cookies. Saddness.

4) This pic is outside Iskcon Temple.

5) This is at Tipu's Palace. This place goes back to the Mughal era. Erica and I had to pay an extra 100 rupees just to enter this palace b/c we are American citizens. At first when the tour guide was only letting the Indian citizens into the palace we thought he was just being shady again. But then he showed us a sign that said American citizens have to pay 100 extra Rupees.

6) This is outside of Tipu's Palace. I decided to join the locals and have a tender coconut. It doesn't taste that great so I don't know why everyone is always drinking it.
7), 8) These are pictures from our stop at the Lalbagh Botanical Gardens. The garden was beautiful and huge. You could spend all day walking around the gardens. There were lots of couples sitting in the grass and on the benches. They were so cute. 7) is of a fossil tree. It is a stump of a tree that has been around for 20+ million years. It is so old that it looks like a stone rather than a tree. 8) is of a flower clock. It is literally a huge clock made out of flowers. It had statues of the seven dwarfs around them which was really random.

9) This pic is from Wilkepedia. It is of the Vidhana Soudha. I couldn't get a good shot of the building from the bus.
10) This pic is also from the web. It is of Cubbon Park. I couldn't get a good shot of this spot either.

11) This is behind the bar at the pizza place. I was attempting to wear of the waiter's hats but it was way too small for my big head.

12) This is the pizza chef. They got him straight from Italy just to make pizza's at this place.

13) This is a picture of Erica in the sleeper train. The train provided sheets in a brown paper bag that read "These sheets have been in a mechanical laundry and if they are emitting a foul odor please ask for new sheets." So I used them since mine weren't emitting any odors so I assumed they were safe, plus it was really cold on the train.

Seizing Baby

My last day at CHAD was on Thursday morning. I did outpatient clinic again. At first the morning was pretty slow and no really interesting patients were coming for clinic visits. I spent most of my time smiling at the cute kids that came in and out of the clinics. One of them even blew me a kiss as she left. She was the cutest thing ever. Then around 10am a young lady came in with a baby in her arms. She had her baby in a big green sweater suit. The intern I was shadowing immediately told her to remove the child's clothes so she could examine the baby. The young woman started describing to the doctor what I came to interpret was that her baby has been having seizures. They were speaking Tamil to each other so of course I couldn't understand what they were talking about but I could tell from the hand motions the young mother was making with her fists that her baby may have been seizing: She clenched her fists and made a jerking motion with them. Then she would roll her eyes back and tilt her head up. It turns out the child was only 8 months old and had one seizure episode this morning after suffering from about one day from a cold & fever. Mom wasn't sure what was going on so she brought the baby into the clinic.



The intern turned around for a second to look up some stuff on her computer about the ill baby. As I looked down at the baby I noticed that she was jerking and her eyes were rolling back. I started to freak out since I have never seen a seizing baby before. I have seen lots of seizing adults but no babies. So I quickly tapped the intern on the shoulder and pointed at the baby. Then I went and got the nearest attending and so they could tell us what to do next. The attending told us to take the baby to a back room and give it a benzo (I can't remember which one she said but I am going to assume it was phenytonin).



So we moved pretty fast with the mother and baby in her arms to a back room. The intern started yelling at the mother because she hadn't removed all the clothes off the child yet. The mom seemed a bit flustered and was having trouble removing the sweater pants off her baby so I helped her out. This amazed me: I was so suprised how calm the mother remained after being yelled at by the intern. She remained silent and put all her trust in the intern who was not relaying back to her what was going on with her baby. The mother did not shed one tear and just had a blank look on her face as the intern ran around the room like a chicken with its head cut off.



The intern than asked the nurse to bring her a syringe with a dose of phenytonin. The intern then administered the dose rectally. Then I thought in my head, how does she know what dose to give? We never weighed the baby. Sadly the baby had lost any form of rectal tone and thus started having a bad case of diarrhea. Thus the dose the intern administered did not stay in so she decided to give another dose and of course the same thing happened again. So me and the mom are busy at the other end of the table trying to wipe (without gloves) all the feces that were pouring all over the baby up with some toilet paper I found. The baby continued to shake on the table, but by this time neither myself or the intern could figure out if the baby was seizing or just cold. The whole time I was thinking to myself, I hope this baby doesn't have meningitis b/c I am all over its body fluids and would be really pissed off I ended up with whatever the baby had.

The attending finally shows up and tells us to move the baby to the ER. When we arrive at the ER, one of the resident finally decides to weigh the baby, which put me at ease b/c I was so afraid that the intern was overdosing the baby. The baby was not moving very much and was breathing pretty fast and I will assume she was in some sort of post-ictal state. The intern decided to start titrating a dose of phenytoin instead by IV, but via a syringe. So we literally had to sit next to the kid with syringe in hand and push only a couple of ccs at a time every so many minutes. The intern had to leave the room for a minute and decided to leave me alone with the baby. She was like "Here, hold this and make sure her respiratory rate doesn't slow down too much." I wanted to be like "Hey wait, what are you doing? I am not a doctor until May 18. Please don't leave me with this baby." But by the time I could say anything, she was out the room. So I did what I thought was most logical. I sat there with the syringe in hand and watched the baby's chest. I figured if the baby's chest stops rising that would be a bad thing. I tried my best to look like I knew what I was doing since the patients were hovering over me still in dead silence.

The intern finally came back and said we would leave the baby in the ER b/c we still have more patients to see. I asked her if she thought that the baby had menigitis or something. She said it was mostly like a febrile seizure. I was relieved to find this out, but still vigourously cleaned my hands with my hand sanitizer. I am not sure what happened to the baby after this, but I know the next plan of action was to perform a lumbar puncture. After the seizing baby, the rest of outpatient clinic was pretty boring so I left early.

Pictures above:

1) This is a picture of a girl outside my hotel in Chennai playing on the roof of a building. The building was pretty high up so I thought it was kind of interesting that someone would choose to play so high up.

2) This is a picture of the flower pot in the lobby of my hotel in Vellore. They are simply flowers cut from the stem placed on top of water. They changed the pot every other day and I think it is kind of pretty so I took a picture of it. I have seen similar displays in other hotels, I am not sure what it means.

3) This a picture of the garden by the girls dorm on the CMC campus. It is gorgeous. The building in the background is a church.

4) These signs are all over CMC. I think they are funny.

5) These cows are everywhere eating trash and in the way. Plus they poop everywhere so you have to watch where you step.

6) These monkeys are also everywhere. They are not very nice either. This one was eating paper on the side of the street. They look like the kinds of monkeys that carry Ebola or some crazy disease. I am more a fan of chimps.

More CHAD

Doctors Rounds: On Tuesday, I went on Doctors rounds with CHAD. Doctors rounds is a mobile clinic that goes to different villages around Vellore every two weeks. Basically the CMC is bringing the hospital to its patients instead of them having to come to the CMC. Many of the people in these villages don't have the money or form of transportation to make to the CMC so it is very convienent for the buses to come to them. On the bus was an intern who dealt with general medicine stuff on a table he set up outside the bus, a registrar (AKA upper level resident) did antenatal checks on the bus along with a health aide nurse, and two nurses in the back of the bus that administered hep B vaccinations.

The health aide nurse wears a pink sari and works with a community aide worker who lives in the village. Together they assesses the socioeconomic status of the families prior to the mobile clinics visits to the different villages. They determine how much each patient can pay for their visit to the mobile clinic. If the family is incredible poor, the visit is free otherwise they pay a very small fee.

I first started my day with the intern. Basically, people would form a line in front of his table. The people who had chronic illnesses had "chronic disease cards" that listed the medications they were on or anything important from previous visits to the doctor. The chronic illnesses for the most part DM, HTN, seizure disorders, and heart murmurs. The intern basically would rewrite their prescriptions or change their meds based on their current complaints. He also saw patients with new complaints and gave them refferals to the CMC if it was anything serious.

Our second stop was fly infested and I had to literally put my fingers in my ears to stop the flys from buzzing past them. The villagers didn't seem to be bothered by the large amount of flies and didn't flinch at their presence. I on the otherhand was ready to pull out my hair. After 3 more stops, we stopped to eat lunch under a tree in the middle of no where. They told me that they always put all their lunches in the middle and share all the food that was brought. They all brought different forms of rices and chutneys and shared with each other. The food looked good, but I wasn't about to get sick eating cold unheated rice. So I just ate my yummy, smoshed, cold butter and jam tosted sandwich. I also had a granola bar in my bag that I munched on, along with some biscuits that I had brought with me.

During our meal, we had some visitors: Two young ladies showed up out of no where and walked over towards where we were eating. One of them was drooling severly and had very crocked teeth. The registrar asked one of the nurses what the situation of these two children was. The nurse stated that girl that was drooling was "mad" and their dad was an alcoholic. By "mad," I think she meant the girl was severly mentally retarded. She said that they usually give the girl a bag of calcium pills so that she would leave them alone. I handed the other girl the rest of my food b/c she looked very hungry and she said thank you. The nurse looked really surprised and said, "At least they know their manners."

By the time we arrived at out 4th stop, I was really sick of sitting outside with the intern. So I made myself useful and helped the registrar with the antenatal checks on the bus. She didn't speak Tamil and only spoke a lot of English to me, so I was happy. She let me write the physical findings of the pregnant women in their antenatal charts. While I was doing this, I noticed 3 girls outside the bus staring and pointing at me. So I waved at them and they got really excited and came to the steps to the entrance of the bus to talk to me. Our conversation mainly involved sign language and the 3 or 4 words of Tamil that I have picked up. Then one of the girls pointed at the hand santizer that I had hanging around my neck. So I poured some in her hand, but she freaked out b/c she didn't understand the concept of waterless handsoap and ran outside to go wash her hands with water.

Nursing Rounds: On wednesday, I participated in Nursing Rounds. I will say this is my favorite rotation thus far on this trip. Except for the fact that I went through 2 liters of water that day and had to carry an umbrella over my head to block the heat, I thoroughly enjoyed the rounds. I met up with my team at about 8:30amish. Nursing rounds functions a bit differently from Doctors Rounds. With Nursing Rounds, we go to the patients' actual homes; it is like what we call a "nurse home visit" in the states. The nurse goes directly to these patients homes b/c for some reason or another they are not able to make it out to CMC on their own. She does anything from antenatal/postnatal checks, BP readings, or just education on caring for their newborn. The nurse leading our group (AKA the public health nurse) was a recent nursing school grad by the named of Nancy. She was super cute and the first Indian person I have seen with braces. We were joined by one health aide, a chaplain student, one community health aide, and another Austrailian student. The Australian student had been traveling throughout India since Dec visiting different hospitals. It was so nice to meet someone taller than me for once. She was a good 5'11 and she work a size 12 shoe.

The chaplain student that joined us was doing a study on epilepsy and SES factors that lead to lack of treatment of epilepsy in the villages. Consanguinty is rampant in this city leading to many developmentally delayed and epileptic children. He told me how some of the villagers don't see consanguinty as the problem or even believe that their child has epilepsy. Instead of taking them to the medical doctor they find local witch doctors who hit the child and roll them around on the ground saying they are trying to cure them.

Nancy stated that she ventures out to these villages every two weeks. Most of her time on these rounds is spent educating new mothers on the dos and don'ts of mothering. For example, there is a practice here of feeding babies castor oil or plain water, so she spends many hours explaining to moms that this can cause serious diarrhea in their babies and breastmilk is all that a baby needs for the first 6 months of life. There is also a practice of not bathing a baby for one week after birth. She has to explain to the mother that the baby needs to be cleaned daily just like any other person. Some moms also like to put baby powder all over their babies faces b/c they think it makes their babies look cute. The problem is that babies can aspirate the powder and get pneumonia. Moms also like to put castor oil on the umbilical stub of their babies after birth, but this can lead to umbilical sepsis. CMC encourages women to get a tubectomy after their second birth. If they agree to this, the patient can get certain hospital fees waved. The problem with this is that a lot of families want male babies so they will continue to have more children until one is born even if they are living in poverty.

The first lady we visited was 20 weeks pregnant according to her fundal height, but her LMP was 14 weeks ago. We visited her to refer her to a CMC for an ultrasound to better check her dates. Her Hb was also low and she may need to be transfused prior to delivery. Here they do something called a PCV to check women's Hb levels. They take this PCV number and divide it by 3. If this number is less than 10 they consider her anemic and will first attempt de-worm her with medication, but if this value remains low they will then transfuse her.

One of the first things I noticed about the villagers is how nice they were. Eventhough they still stared at me, they had a warm smile when ever you looked in their direction. They were also quick to offer you food or water whenever you entered their homes. I of course could not take anything they offered me b/c these people lived in pure poverty. The size of their rooms was like the size of a big closet for which 4 or more people shared. They had one steel bed with rice bags as pillow covers with clothes stuffed in them. Of course there was no A/C but most people had one celling fan but that didn't mean they always had electricity. The weird part was that everyone had a television. There was no kitchen and people cooked with metal pots on firewood.
When you walked into their homes you had to take off your shoes and walk on the bareground which was mostly hot rocky concrete. My feet are going to be so jacked up when I leave India, I must get a pedicure on returning to the states.

Another lady we saw refuses to breastfeed her 2 week old baby. She stated that nothing was coming out. She feeds her baby cow's milk instead. Nancy tried to warn her against this b/c she isn't sterilizing the bottle properly and the baby will soon develop diarrhea. Nancy made her bring out her breast so she could check if she truly wasn't lactating. With one squeeze she squirted out breast milk and Nancy and the other nurse started scolding her for lying to them. They think this lady is just being lazy and doesn't want to wait for her baby to learn to latch on to her breast.

The stop pictured to the right really got to me. Nancy said this family is probably the poorest of all the people she visits. We visited a family of 5 with a mother pregnant with a set of twins. This young lady already had 3 little girls. One of the kids was about 3 years old and doesn't talk or walk. Doctors can't figure out what is wrong with this child. One of the other kids already had signs of Kwashiorkor with a protruding abdomen and thin limbs. Their father's job is lifting rocks off of a truck. Their mom refuses to walk 2 mins to collect rice protein balls that her family qualifies for b/c she is "too busy." They resort to eating rats sometimes when they have nothing to eat. Her husband refuses to see family planning and sees the new additions to their family as a blessing. Nancy is afraid that this mother may commit infanticide once the twins are born and she finally realizes she has no money to feed her family. Nancy told me how infanticide is rampant here and families will place a grain of rice in their childs mouths once it is born and try to pretend that the child just stopped eating one day and they found it dead.

The most suprising part was how happy these children were living in these conditions. Their home is shown above. It only has 3 walls with the 4th wall open to the environment. One of the kids was eating a bowl of fly infested rice. She had the biggest smile on her face as she waved and smiled at me. I smiled back and tried really hard to hide my tears. I wanted to give them money but the chaplain student told me not to, b/c he said I would only be helping them for the moment, what will they do after that money is gone.

Pictures above:
1) The purple stuff around the lesion is some sort of indigenous oinment the villagers put on open cuts or abrasions.

2) This is what the mobile clinic looked like on Doctors Rounds. This is the back part of the bus where the nurses were administering hep B vaccinations.

3) & 4) This is a girl we met on the second stop that had some sort of vitamin deficiency. Her skin was pretty much sluffing off her body. They gave her a referal to the CMC. I handed her some biscuits b/c she looked really hungry.

5) Nicolette in the car next to mine on her way to Nursing Rounds with Collin on Wednesday.

6) This is one of the CMC daycares that are in some of the villages we visited on Nursing Rounds. CMC has daycares for 3-5 year olds to prevent malnutrition and help educate some of the kids before they enter real school. These kids were so cute, plus they are my favorite age group. The teacher told some of them to recite their alphabet and numbers for us. It was so cute!

7) This is a picture of a mob of kids that were following me during Nursing Rounds. As soon as I turned around to take a picture they all started running away.

8) See above

CHAD OPD

India is incredibly polluted; thus, my allergies are driving me crazy out here. In the US, the further south I moved in Texas the worse my allergies got. I seriously thought that when I came on this trip, allergies wouldn't be a problem for me. I almost did not bring my meds b/c of this. Turns out I was sadly mistaken. India is super polluted with all the cars, ricksaws, & motorcycles all over the place. Plus it doesn't help that people throw their trash everywhere like it is nobody's business. I refuse to contribute to the pollution of India so I carry all my trash in my bag all day long until I can find a trashcan, eventhough I know the trash will end up in someone's backyard pretty soon. Plus, one of the other foreigners told me he doesn't feel too bad when he litters since some goat, cow, or stray dog will probably end up eating it anyway. I guess it is just for my own piece of mind.

My first week here I was fine, but since monday of this weekend my allergies have been ridiculous. Right now I am taking a bunch of meds just so I can breathe properly and get some decent sleep: I am 25mg of benadryl at night, 10mg of xyzal in the morning, one drop per eye of azelastine twice a day, and 2 sprays of nasonex in each nostril every morning. I was hesistant about adding benadryl to the mix, but sleeping monday night was incredibly hard. I felt like someone was smothering me as I tried to sleep. But with benadryl on board, I sleep like a baby.

On monday, I started my CHAD rotation. CHAD stands for Community Health and Development. It is like an outpatient facility for the indiginent population of Vellore. The services they offer here are even cheaper than those offered at the CMC. My CHAD rotation started in the outpatient pediatric department. I was amazed by the amount of kids we saw that wore no shoes. They would be running about the clinic, but with no shoes on. It really bothered me. I wasn't sure if it was a cultural thing or just a I don't have enough money to even buy my kids some shoes thing. Of course all the kids we saw were super cute. Their parents put jingling ankle bracelets on their daugthers along with a bunch of black bracelets. The bracelets are believed to ward of evil spirits. They also put black dots on the cheeks, mid- forehead, or on the soles of their kids. This was to ward off the evil eye. Hindus believe that when someone gets in the face of their child and praises them and says how cute they look this brings bad things upon their child. So they put these marks on them to ward such things away. Some of them also used an eye pencil to draw in their kids eyebrows but I have no clue what this marking was for.

Most of the kids that came in were similiar to the typical things I see in the US. The doctor spent a lot of time consoling parents about colds or viral syndromes. I got a bit bored after a while since the doctor was mostly speaking Tamil and not talking to me much so I moved on to another doctor. I looked around and found a fellow American doctor with a translator so I went over to his table to shadow him. He was great to work with, but spent a lot more time talking to me than his patients. He was also a fellow Texan and recieved his family practice training in Forth Worth. He stated that he has lived in India for the past two years after being called by God to come do missions here. He has been very appreciative of his time here and enjoys the fact that his patients are so grateful for whatever help he can offer them, which he never really felt he recieved in the states. He stated that he gives each of his Hindu patients (not the Muslim ones) a booklet on the Gospel of John after he takes care of their complaints. He feels Hindus like religious people and are very open to learning about other peoples' religious beliefs. His translator was a convert to Christianity 10 years ago and recently married a Christian woman but was disowned by his family after he did this.

Most of the patients I saw with the American doctor were your standard diabetes and hytertension patients. He kept on telling me that I wouldn't have to deal with such issues as a pediatrician, but I had to remind him that I was coming from the obesity capital of Texas. He also told me about how he had read a recent article about an increase prevalence of diabetes in low birth weight babies and he felt this may be one of the contributing factors to the high rates of diabetes in India. He stated that by the time his patients are diagnosed with DM, they already have signs of neuropathy and ridiculous difficult sugar levels to control.

I was so proud of myself when I noticed before the American doctor did that one of his patients had pityriasis versicolor, but the patient wasn't interested in treatment of this rash since it wasn't bothering him. Another interesting patient was a hypertensive patient whose BP was out of control. The first time his BP was taken it was at 211/110 and at this current visit it was at 180/110. They can't get his BP under control b/c he doesn't take his meds on a consistent basis since he can't always afford to purchase them. He works as a security guard on the CMC college campus and only recieves 2500 rupees a month. This is nothing when I am living on about 500 rupees a day for food and transport which doesn't include my accommodation expenses.

After clinic monday, Kathryn, Collin, Nicollete, Erica, and I decided to visit the Golden Temple. This the temple I spoke about in my 2nd or 3rd blog posting that is a big tourist attraction here in Vellore. It is only a couple of years old and is a multi-million dollar project. Sidenote: Spending so much monery on a temple didn't make much sense to me since so much poverty surrounds India. Developing countries never have have their priorities straight. Anyway, this gold plated temple was built to honor a 31-year-old godman who calls himself Narayani Amma. He is believed to be a incarnation and embodiment of the spiritual Divine Mother, the Goddess Narayani. It was amazing to me b/c tons of people worship this man like he is a saint. They journey from all parts of India just to pray to this man. They believe him to be a healer as well. Some western doctors have moved to Vellore just to practice in the presence of Amma. Some people shave off all their hair in sacrifice to him when they make the pilgramage to see this man.

I will say that this temple is a site to see and is hard to describe on paper. They would not allow us to bring cameras, cellphones, or anything with us when we went to see it. We also had to take off our shoes and walk through an intricate star-shapped maze just to get to the middle to see it. Messages by 'Amma' were laid out along the path to the temple with writings from the Gita, the Bible and the Quran. It was a very calming and unusual experience.

Pictures above:

1) A picture showing the dots parents put on their kids' faces.

2) This is a pic of Kathryn and Collin in the ricksaw next to me as we were off to see the Golden Temple.

3) This is a pic of us on the roof top of Hotel Darling after our trip to the Golden Temple. If you look closely we all have red dots mid-forehead which means you visited a temple. They put it on your forehead as you leave the temple.

Pondicherry is so overrated.

This weekend a group of 8 of us decided to drive up to Pondicherry for the weekend. Pondicherry is about 4 hours outside of Vellore and is an old French colony. It is a very hippie, tourist beach town with a 3rd World New Orleans twist. It is near the ocean and was hit hard back in '04 by the tsunami. Five of us in the group were from UTHSCSA; the other three girls were two Sri Lankan girls from Austrialia and one American from St Louis. The Austrialian girls were super helpful b/c they spoke Tamil and helped us in booking the car. They specifically rented a car with a driver for 5000 rupees for our weekend trip.

Renting a driver was a hassle in itself: When the driver shows up, we had specifically asked for a spacious car for with A/C but he shows up in a small 6-seater car with two bootleg chairs in the back to seat 4 more. So that was a problem number one. Then he decides to tie all our luggage to the top of the car, which I was deathly afraid would fly off during our ride to Pondy. When we finally get on the road, the driver starts saying he has to turn off the air b/c we didn't ask for an A/C car. Then their is this big hoopla between one of the Austrialian girls and the driver's manager. The manager insists that we never asked for a A/C car and states that he will add 1000 rupees to our journey's fare. The manager also states he will not give us a full refund if we cancel. He also had the nerve to tell the Australian girl that she spoke crappy Tamil. What a jerk. After lots of harsh words were exchanged for the shadiness of the whole ordeal, we finally bargain for only 800 rupees in addition to our 5000 rupees.

30 minutes later our journey finally began. I thought I would be able to sleep through the whole trip, but that wasn't the case. Our driver drove like a mad man. I was seriously scared for my life at some instances. The ride was super bumpy and he kept on swerving to not hit other vehicles. Yet, we made it to Pondy safely. Then we had to find a place to stay since we could not make any reservations prior to the trip. We found a sketchy place called The French Guesthouse for 1000 rupees per night. The sheets were gross and we had no covers. So me and Erica used our towels to cover ourselves when we slept. We ate dinner that night at some fancy French restaurant. The other girls were adamant about having wine with their food and were livid when they found out they only had 3 glasses of white wine left in the whole restaurant. I wanted to tell the girls to calm down and realize that we are in an area where people aren't big on drinking and they will just have to wait to be back in the US where linquer is at your finger tips. The food at the restaurant was way over priced and didn't taste very good.

The next day we had breakfast at The Hot Bread, which was a French bakery next to our hotel. The food was very filling and good. Then we split up for our shopping excursions. In Pondy, you do not have to dress as conservative as Vellore and I don't get stared at as much as in Vellore. I was able to show my ankles in capris without getting all the stares I would have recieved in Vellore. This town is use to tourist and are rather friendly towards us. I think they thought I was French b/c they kept on saying Bonjour to me. I wasnt too impressed with the selection of the stores though and only bought one purse b/c the strap to the purse I brought with me broke. Aruna keeps on telling me to save my money for North India since they have better selection.

Shopping in Pondy was fun at first, but then it just got really hot and annoying. It was like Texas heat but a little worse. Plus it started to rain and then you just felt even more sticky. We stopped shopping for a while and tried to do indoor activities. We took a tour of a meditation house, which was interesting. You had to enter barefoot and be very quiet. I really didn't understand what was going on, but it was an experience. Then we got 40 minute massages from this sketchy man reccomended by a guy we knew from a local hotel. Massages in India are not like the relaxing kinds you get back in the states. There is no concept of draping and it is basically a oil rub down. You are susposed to be butt-naked and you do them with a member of the same sex. We had a guy do ours and stayed in our bras and underwear. The oil is surposed to be a medicated herbal treatment of some kind. Afterwards I felt like I just paid someone way too much money to rub a smelly oil all over my body and I was more tense than before I got the massage. Plus the guy called me fat during the massage and said that my tummy stuck out. He said I needed to weigh about 70kg, which is about 145Ibs. He said he had some medication he could give me to help me lose the weight in 2 months. I told him no thank you.

Three other students from UTHSCSA met up with us in Pondy (Collin, Jenn, and Seema). They had gone to another local town the day before then made their way up to Pondy. We all went to another fancy French restaurant for dinner that night. The restaurant was on the roof and very nice, but the food was awful. It had no seasonings and it took a good 2 hours to come out. The chef looked like he was working really hard in the back to cook us something amazing but the food came out tasting like crap.

The next morning, Aruna, Erica, and I rode back with Jenn and Seema in their car. This was such a better experience than the crackhead driver that drove us up to Pondy in the first place. This guy was so much more mindful of his passengers and I did not have any close encounters with death this time.

Pictures above:

1) & 2) Are pics from our first night in Pondy.

3) This is on the roof top of the restaurant that took 2 hours to bring out our food.