India Trip: Some Cases and a Fort

FROM 1/14/08:

As stated previously this last Friday completed my time with the Internal Medicine II team. Although there was a lot of time spent standing or sitting around waiting for things that never seemed to take place, a common event it seems here in India, there were a few brief moments of extreme education here and there. I got to see things I'd never seen -- and I'd gamble many physicians in the US have never seen -- in quick one hour spurts during rounds with the individual medicine subteams. I cannot go into great detail unfortunately as much of the time I was not privy to such detail not being fluent in Hindi or Tamil, but I can give you all a taste of what I saw.

For starters, I saw lots of diabetes. This obviously is not terribly different from San Antonio, but I mention it because of how unexpected it was. Much like diabetes type 2 was relatively uncommon a few decades ago in the US, the progressive Westernization and, more importantly, increased processing and access of foods in India has lead to a significant increase in their own incidence of the disease. Many have speculated that, like many subgroups in the Hispanic population, having adapted to a relatively meager diet for centuries the Indian people are particularly prone to developing insulin resistance in response to a surge of refined sugars in their diets. Thus India has been introduced to the world of diabetes. It almost made me feel at home again.

With diabetes of course comes heart attacks and strokes. Not surprisingly Indian heart attacks and strokes are much like American strokes.

Now we get to the good stuff.

DRESS. Never heard of it -- initially doubtful it really existed -- but DRESS (or Drug Rash with Eosinophilia and Systemic Symptoms) is, as its name would suggest, a violent reaction in response to the administration of certain drugs. In our patient's case it was some antibiotic he got from who knows where, and he responded with airway narrowing, significant angioedema, hepatic enzyme elevation, and, of course, a rash. I am still not terribly sure how it differs greatly from a generic anaphylactic reaction, but DRESS does sound much more dreadful. Acronyms are scary.

Scrub Typhus. Ooh, exotic. A rickettsial illness that, like apparently all rickettsial illnesses, cleans up quite nice with doxycycline, and is associated with relapsing fevers and chigger bites. According to the doctors at CMC it is also associated with an eschar (funky looking scab) that 95 - 99% of the time tells you it is scrub typhus. Now that I look at how to spell Rickettsia I have learned that the bug has been renamed Orientia tsutsugamushi. You know, just so there's no confusion.

Typhoid. Typhus would not be complete without its close sounding but completely unrelated friend typhoid and so my patients obliged. We had to go to the isolation ward to see this guy. He was infected with Salmonella typhi, and, well, there really isn't much else to say about it. The problem with not getting much in the way of a patient history on rapid rounds with the doctors is that all the patients have nice name tags attached to their illnesses, but when you look at them they just look like sick people. Being transmitted through the fecal-oral route there were no cool eschars to see so, aside from looking unhappy, this guy did not appear too out of the ordinary. Nevertheless I was thankful for my oral typhoid vaccine.

Last interesting case that I can remember and care to share: organophosphate poisoning. For those not in the know -- and a pity you are not -- organophosphates are major components of many industrial pesticides. Combine this and ready access in developing nations with the compounds' cholinergic affects and you have a great way to attempt suicide. Or so many people seem to feel. Such was the case with this young man. As usual I was not able to get much in the way of a history from this guy as I saw him only briefly during Grand Rounds, but he had apparently ingested a large amount of it and properly gone comatose. We gave him a healthy dose of atropine (an anti-cholinergic) and by the end of the day he was awake and fairly normal again. It is an interesting side note that suicide in India, like many other developing nations, has only increased significantly with its recent industrialization. Make of that what you will.

I also saw some malaria, some tuberculosis, some connective tissue disease and rheumatoid arthritis, but, honestly, I do not care to comment about them. I either did not get enough information to say much or I do not think they make for the best stories.

But this week comes CHAD (Community Health And Development!) I'll go more into this amazing project later -- and like much of the rest of CMC I do believe it is worthy of the adjective "amazing" -- but for now I'll simply wrap up with a short summary of our weekend.

Saturday we went to see the 16th Century fort, if I remember correctly, that came to be occupied over time by a wide variety of Indian kingdoms, empires, and, finally, the British. Eventually like most forts it became obsolete and so has become instead a store house for a wide variety of government programs and buildings including a number of museums -- if I may be so generous with the term -- a university, and a police academy of sorts. The highlight of the museums? The giant, green T-Rex statue out front. They were otherwise like the Dubai Museum but without the mannequins. A few artifacts here and there, but little in the way of descriptions, history, or impressive appearance. There was also a Hindu temple on the grounds, the Jalagandeeswarar Temple, which we were unfortunately unable to take pictures of, but I will hopefully be able to describe in detail in my next post. For now let me just say it was... uhh... interesting? Back to the fort, though. It was big and impressive, but being stripped of most its features there is not much to write about.

Sunday we took a quick hike up a nearby granite cliff. Being around 12 noon it was a bit hot and a bit hazy, but it was about a 25 minute hike at leisurely speeds, and so was not very taxing. It was fun to be outside, though, and the view of the city and surrounding tropical green areas was nevertheless very nice. It looked a great deal like Enchanted Rock outside Fredericksburg in Texas I felt, and I longed for my climbing shoes. Amazing how geography and geology can be so similar thousands of miles away.

The last of the weekend was spent doing the American thing. After the girls moved into the Johnson House (completing their move out of the roach friendly new building) we discovered a television and proceeded to make use of it. There were a surprisingly large amount of English channels, and, as it was late at night and we had nothing else to do, we watched When A Stranger Calls on Indian HBO. For those of you not familiar with the movie it's about an hour and a half of phone calls followed by a 5 minute chase to close the movie out. Even for those removed of a TV for a week it made for a pretty crummy movie night, but it was relaxing, though, and nice to be free temporarily from the constant churning of Indian life.