Louder than Words

Vanakkam, hello and welcome to another few snippets of life here on the Indian subcontinent. March is almost at an end and that marks two months of my time here already over. I am being sent beautiful photos of the British springtime which I am missing out on and the air here in my little corner of the Nilgiri Hills is getting warmer by the day. The seasons are on the change! With all the movement of people this week has gone by in a flurry. Also today is exam day for our nurses who are getting their formal qualifications. It’s all go!

The most memorable case in the last week as far as I am concerned is a patient who I saw last Thursday. With my rather ropey Tamil I ascertained that she had been suffering from abdominal pain for the past 3 days, no diarrhoea, vomiting or pain on urination associated with it, and that she was currently having her period which was heavier than usual. Knowing the high pain threshold of my tribal patients and not wanting to miss anything I asked one of the Indian doctors to check my version of events with the patient, could this just be very bad period pain? It seemed unlikely that this woman would have travelled to the hospital just for that. My Indian colleague managed to gain an extra few pieces of info. This patient had previously had a sterilisation procedure (tube tie) and before her current period she had missed one month. The question was there; could this be an ectopic pregnancy? Although our hospital doesn’t have enough money to stock urine dip pregnancy tests we do have an ultrasound scanner. The doctor who spoke to our patient has had training in obstetric ultrasound so she had a look. There it was, right next to the left ovary what looked like it could be an ectopic. Although interestingly the majority of her pain and tenderness was on the right side and we couldn’t exclude appendicitis. The senior staff decided we had no choice but to take her to the operating theatre as an emergency. Under a spinal anaesthetic it was possible to do an open operation to see what was going on. The senior obstetrician/gynaecologist and her husband the senior surgeon both scrubbed for the procedure. The woman was extremely slim so finding the relevant anatomy was not difficult but on closer inspection the fluid filled sack attached to the left ovary was nothing more alarming than a small cyst with a little blood in it. This is known as a haemorrhagic cyst, not usually anything to worry about. We still needed to find the culprit when it came to diagnosing her pain. After a brief rummage with the intestines we found it, a rather angry looking appendix! So there you have it, not an ectopic after all but appendicitis.

What really struck me about the proceedings was the way the patient dealt with everything. These women are so brave, having lived their whole lives in the tribal villages to make the journey to the hospital and put their faith in the care of the doctors here when it is so different from their previous sphere of experience.  Before the operation you could read in her face how scared she must have been. After the spinal anaesthetic, although she was fully awake she could feel no pain from the operation and she started to relax a little. I was not needed to scrub in for the operation so I busied myself preparing things and trying to be useful, I had time to regularly check on how she was getting on. Manually checking her blood pressure and changing the warmed bottles of intravenous fluid. This gave me the opportunity to hold her hand and say some reassuring words in my broken Tamil. Every time I went to check up on her she would give me this huge grin, I couldn’t believe that there she was in this amazingly stressful situation smiling at me.

Post operatively when I went to check up on her again and on the ward rounds before her discharge yesterday she gave me the same wonderfully warm smile. I feel like as well as learning Tamil I am also learning another language, one which I have always known but now need to rely on so much more, a method of non-verbal communication. I use it much more consciously now than I ever did in the UK where I could just say what I was thinking.

Another place where non-verbal communication has become vital to me is the delivery room. While the nurses are sitting their exams this has jokingly referred to as my department. On Monday and Tuesday we had 5 difficult and complicated obstetric cases and I was sitting in the labour ward all day and well into the night monitoring them. I am very proud to say that I delivered four of them, the fifth needed a caesarean section. Developing a relationship with your patient when you cannot make small talk is a very different experience. I find that I am constantly learning to pick up cues as to when the women need their hand held, their brow mopped or their back rubbed and when they need time to themselves to rest.

You can probably tell that I have been busy in the hospital this week as my writing is more clinically orientated. The Knowles family clan are arriving in two days and I will be taking a break from my hospital duty so I have been feeling even more inclined to make the most of my experience before the holiday starts. We will be travelling to the North of India which is both exciting and a little scary for me, a journey into the unknown! Anyway I will try and keep up with my blog and let you know about the travels etc.

In the meantime lots of love and hopefully hear from you soon.

A x

P.S. I thought this would be very boring without any pictures so here is one of the very cute and super destructive toddler who lives in the hospital, (its a long story).

Measles and Moonlight

Hello again. I hope this posting finds you well and enjoying life wherever you may be. Things are generally speaking rather good from my viewpoint. The newness of being in a foreign land is starting to wear off and I have found myself on certain occasions referring to my little nest here among the mountains as home. This is in many parts thanks to the wonderful company of my friends and colleagues here at the hospital and in my wider community. The charity here seems to attract a certain type of person. That is not to suggest in any way that the personalities or outside appearances of members of the team are in any way generic but rather that in their own way they all share a passion, a certain keen desire to help people and also to understand their world better.

There are men and women of all ages and religions from all across India and indeed the globe. All here to try and understand the culture of the tribal population and best help them to become a community which is balanced. Strong and independent, aware of its own special heritage but also able to survive and even integrate into modern India. I wish I could introduce you to all the wonderful people who I have been lucky enough to meet while here. One of the interesting aspects of living here is the constant ebb and flow of people around me.

One person who is leaving soon is the young,  pre-medschool, American research student who I am sure I have spoken about before. She arrived a week or two after I did and we have become firm friends. I can’t deny that her leaving to return to America for med school entrance exams is anything other than sad for me. She is a very, very funny person with a sense of humour which ranges from bone dry to ridiculously silly and I have enjoyed being swept up in the slight whirlwind she creates. She will however be returning in the rainy season (all related to her project which involves leeches, gross huh?) which will be something to look forward to. Also coming to the end of her annual visit is the lovely northern retired midwifery teacher. I will certainly miss her as a companion and sounding board. She combines two vitally important aspects for a good friend, firstly she is a brilliant listener and being somewhat further along life’s journey than I am she dispenses sound advice built on experience. Secondly being British she is always willing to sit with me for a cup of tea!

As I said people here come and go. A new arrival to our group (although she is a regular visitor) is a retired paediatric professor from Kerala. Despite being a little older than most of us she is as sharp as a pin and a brilliant clinician. She is also very fun to be around and had been with us barely more than a few days when she arranged a very sociable Sunday cook off. We all enjoyed the shopping and talking and cooking and eating and I am glad that she will be with us at least until April. It is also brilliant to see her working with the other visiting paediatrician who is an American from a Tamil family. It is inspiring to see them discussing child health and it seems that working together they have a chance to really achieve great things to help the malnourished children here.

In a rather dramatic turn of events this week one of our number got taken rather seriously ill. The American anthropology research student, here on an international scholarship since August last year came down with a fever. Illness being not uncommon in India he didn’t think much of it until day five when he was still burning up and started to develop a rash and a hacking cough. I must admit he scared me quite a bit when he phoned me in the evening to “just ask a bit of doctor advice” and proceeded to tell me he was finding it very difficult to breathe. My expert medical advice was for him to come in to the hospital pretty quick sharpish! The junior doctor on call and I gave him the once over and decided that although we were not sure exactly what was wrong with him it was probably viral and he should stay at the doctors hostel for observation, paracetamol, plenty of fluids and antibiotics to prevent secondary infection. The next morning we got a lot of senior opinions, the doctor who runs the hospital and two senior paediatricians who are visiting. The general consensus was that it may well be measles and he was admitted to the hospital for a day and overnight. Thankfully after a lot of sleep and paracetamol he seems to be looking a lot better today and the exanthema is starting to clear.

I will write again soon because there is probably lots more news for me to bore you with and I do want to show you some of the pictures that I have been taking. Obviously lots of these photos focus quite heavily on the massive moon that we have all been experiencing. It has been really amazing to behold. Dangling over the mountains without any light pollution to interfere, all of us have found ourselves doing a lot of gazing upwards the past few nights. Last night on one of these household moon gazing events we were surprised to hear that we were not the only creatures to be in the immediate locality. A very strange and rather abrasive noise announced the arrival of barking deer in front of our porch. For those of you who are unaware barking deer look a lot like deer, make a barking noise a bit like a dog and according to a friend of mine who is interested in such things have recently been reclassified into the goat family, you learn something new every day!

So from measles to moonlight with a promise of pictures to follow and that is where I will leave you for now. As always lots of love and thanks for the messages I have received.

A x

p.s.
so yesterday my internet was not working so I didn't upload this, so here it is today instead complete with pictures.

Blue Moon

Sunset

Chestnut headed Bee eaters

Strange fruit

In this week’s missive I want to tell you a few anecdotes about fruit. So to start us off here is a little Tamil related introduction. In Tamil the word for fruit is Parlam, with the “rl” sound made by touching the tip of your tongue at the back of your hard palate and letting it roll forward. As a previous strict Anglophone this is not an entirely easy noise for me to create. I must admit that I have developed a strange habit recently, when I see something that I know the Tamil word for I tend to rehearse it to myself in a repetitive fashion. This is why if you were to walk next to me on the street as I passed one of the numerous fruit stalls in town you would hear me muttering “Parlam, parlam, parlam, parlam”. This is one of the many reasons people look at me funny.

During one of my mobile clinic visits about ten days ago we went through a village inside the nature reserve. We did our usual thing of weighing the babies to check for malnutrition and consulting with the patients who have chronic disease to stock up their medications. As we walked past one tree I noticed some large green fruits, they looked like citrus fruit but I was unsure of what variety. I asked one of the community health workers with us what the name of the fruit was. She didn’t know the English name for the fruit but promptly enlisted one of the local tribal men to climb the tree and retrieve one of the fruit for me to eat. I tried to explain that this really would not be necessary but by then he was already clambering along one of the higher branches. With the man and the fruit both safely back on solid ground I cut through the waxy skin to discover that it was in fact a grapefruit, not quite ripe but very tasty and refreshing on a hot day. This was one of the many times that I have been grateful to have my Swiss army knife with me. It came in very handy carving the fruit into segments to share with everyone. 

This could have been the end of the story but a few days ago we went to a different village, deep inside a tea plantation. Just to the left of the village temple was a large and majestic tree with some familiar looking fruit on it. The same health worker was with us and she immediately decided that I obviously was in desperate need of grapefruit. She called for a young boy in one of the houses and before I could say anything I heard her say quite distinctly in Tamil that the English doctor wanted some of the fruit. I tried to say that really I was fine, the tree was very tall and the boy was quite small and I really didn’t want to have to explain to any family members how their child broke a limb fetching me fruit! But in the blink of an eye the boy was up the tree and three soft thuds announced the arrival of some very tasty looking pink grapefruits. In exchange for his skilful climbing the little boy got to keep one of the fruits (it was roughly the size of his head). My Swiss army knife was pressed into action again dividing one of the fruits between those of us working and the third fruit was sent home with one of the health workers for her family. All in all a good outcome with no fractured bones!

In addition to fruit that is recognisable from English supermarket aisles (apples, bananas, citrus fruit and now the first fruits of the mango season) I have come across some entirely new fruits here in India. One which seems freely available at the moment is Chikku. This soft, round, brown fruit has a rough exterior something like sandpaper. The flesh inside is grainy with a texture not unlike a ripe pear and a taste which is sweet and very rich. There are four seeds which look like large apple pips. I really like the Chikku fruit, which is good because if the cheap price in the market is anything to go by I am fairly sure that it is both local and in season.

Another Indian fruit which is new to me is the Nungu. I was introduced to this fruit while on a field visit to a tribal village. The jeep stopped by the side of the road where a man was stood surrounded by cannonball sized dark fruit. The tribal health workers were thrilled to see it and I get the impression that this is a fruit less readily available on the local stalls. The fruit seller took his large curved knife and hacked into the thick husk separating three jelly like segments. He repeated this a few times, each time with me trying not to wince too badly as the sharp blade came down right next to his unprotected fingers! Soon we had a bag full of the fruit segments to taste. It is very difficult to adequately describe the taste and texture of Nungu. I would say the outside of the segment has a texture a bit like lychee but with a much more delicate flavour. In the middle of each segment there is a pool of liquid which is very refreshing and tastes a little like the water from a tender coconut, not surprising as I have been told the fruit is a relative of the coconut itself. I will post a picture of the fruit seller on the roadside when I get a minute.

Pictures as promised.

Wow this is a very long post about fruit, perhaps I should make more of an effort to write about my work in the hospital next time? Just to reassure you I am still working and learning new things every day about medicine in rural communities and tropical climates. I am getting plenty of experience in the outpatients department, working in the field and in the last week I have been spending more time in the Labour ward which I am enjoying a lot.

Again I want to thank people for keeping me updated with goings on it the UK. Six weeks in and I must admit I am getting homesick. Lots of love to all and hopefully catch up soon.

A x

King of the road

So last week I certainly did not let the grass grow under my feet here in India. I was out every day in the field, the Mobile Clinic and the Area Centres. Many many bumpy Jeep rides and beautiful views of the scenery! So as a result I was very very tired!! The travel and the heat of the sun combined with trying to converse in my extremely poor excuse for Tamil has worn me out.

Therefore you will not be getting my usual long monologue, (please try and hide your relief at this news). Instead using the magic of photography I will try and convey my adventures to you. As they say a picture speaks 1000 words.

The river where they wash Elephants in the nature reserve. There are 3 tribal villages nearby.

One of the new area centres where we have outreach clinics.

A lizard, put in for no reason other than it was a cool lizard.

Walking to a rural village

Still walking....

Tribal house.

Tea plantations

O.K. well you asked for more pictures so this is what you get!! I will try and write more next time when I have recovered from the travelling.

Love to you all,

A x

Coffee flowers and Lemon cake

Now that the rain has finished the coffee plants have erupted into these delicate white blossoms. The bloom will be for only two or three days and this only happens once a year. The wet weather triggered the flowering and if the dry weather can last until the blossoms fall from the bush then it will ensure a good harvest. I have been informed that I am very lucky to witness such a bountiful explosion of these flowers and having experienced it I don’t doubt this to be true.

Today we went out in the jeep to an area centre on the Kerala border and the smell of the coffee plantations was powerful. If you are like me and have never smelt coffee flowers before imagine the smell of the Jasmine flower but more intense. The fragrance is beautiful but certainly not subtle and as predicted by one of the local doctors who was driving us it very soon gave me a fuzzy floral headache. The outpatients clinic was busy but not jam packed and I am managing to see patients in a more independent fashion now, although I still frequently need to call for help with some of the Tamil vocabulary. I am always relieved to see patients who are attending for routine pregnancy related check-ups because I have a set selection of question which I can ask in a confident tone of voice, followed by a BP check, abdominal palpation and a prescription for iron tablets and calcium, it is basic but it just makes me feel happy to be able to finish a whole consultation without needing help.

Last night we were invited to the home of the two senior doctors who are in charge of the whole operation here. They are a very lovely married couple of approximately the same generation as my parents and it is always an absolute pleasure to be invited for dinner at their house. The party was a good one with all of the women folk invited and told to bring a dish. My brief was to provide something savoury and preferably that would go well with the rice dish and stuffed paratha that was already planned. I wanted to try and bring a European dish, mainly because the concept of trying to feed my Indian cooking to a room full of Indian women who could in all likelihood cook much better than me seemed daunting to say the least. After a stroll through town looking at the veg on offer I decided to make Ratatouille. I was ably assisted by a friend who is also a volunteer from the UK and some serious chopping of vegetables ensued! Thankfully despite me being unable to find basil or oregano in small town India, it turned out rather tasty (if I say so myself). It seemed to be a hit among the Indian party goers, although I was asked a number of times if it was a dish named after that animated film with a rat in it.

The very nice midwifery teacher from Scarborough made lemon drizzle cake and I have never been so happy to see a homemade cake in my life. 24 hours later and I am still in a cake induced good mood. Because an oven is not considered to be a vital piece of kitchen equipment here home baking is not usually an option. Luckily our hosts have a small oven and a cake was created! This I must admit has helped to soothe at least one aspect of my home sickness, for now…

I am of course missing you all greatly and looking forward to seeing you when I get back to England or even sooner for those of you who are visiting me out here.

As always lots of love,

A x

P.S. here are some pictures I took today of the coffee flower and the view from the area centre. 

Rain and religion

So I hope these topics are not too heavy for you. It just seems that they have both been important themes in my little sphere recently. The town here is a big cultural and religious melting pot and recently I have been asking around to discover what people believe and how that affects their way of living. To put this into some kind of perspective for those of you who don’t know my personal opinions on religion they fall very much into the category of rather relaxed, but certainly not disinterested. I have been trying to write this entry for about a week because it sort of seemed important. I hope it has not ended up as too much of me talking nonsense. In the end you will have to decide that for yourselves.

Since arriving in India I have spent time talking to people of Hindu faith, Christians (including south Indian Roman Catholics of which there are many), Muslims, people from mixed faith cultural backgrounds and people with very little or no religious beliefs. My patient population itself is from as wide ranging a selection with the addition of the less structured tribal religions. These can vary from being just a branch of Hinduism to something altogether different involving primarily the worship of nature and the forest itself.

So why do I have this sudden interest in Religion? I think it’s partly just me being naturally inquisitive (or nosy to be more accurate). I would like to learn a little more about the belief systems that were not part of my upbringing. Another part of this whole process is purely that I like the stories that go along with religion and I want to hear more.  Also I want to try and understand a bit better the way in which faith and culture might influence the way in which my patients and their families make decisions about their health and medical care. I also like the way religion is a topic which sparks debate, as long as that debate is a friendly and open minded discussion.

It seemed quite fitting that after a week of being slightly preoccupied by religion and wet weather I should decide to take an evening walk up the hill at the edge of town. At the top of the hill is a Catholic church, a Hindu temple and a Mosque. I was walking with three of my friends from the hospital, two of whom are catholic. We should have known to expect precipitation, at the beginning of the walk that the sky was not looking too appealing. The clouds were heavy and brooding, sitting possessively over the tops of the surrounding hills. As we reached the very top of the hill (where the Catholic Church is perched) the skies opened. Big fat drops of rain were coming thick and fast. The church door was open wide and a mass was taking place. It seemed the sensible thing to do to take shelter and I was keen to investigate. I have never seen a catholic mass and I have certainly never seen one in India. I slipped off my sandals at the door, leaving them with the neatly paired rows already congregated. Noting that most of the other women had their heads covered I pulled my shawl up over my damp hair and I stepped inside.

The inside of the church was overwhelming. Like many temples in India it was a riot of colour, all in rather unnatural neon shades. The life-size statue of Jesus above the Altar was wreathed in bright red fairy lights and the walls were painted with murals depicting rolling green pastures. The mass was all conducted in Tamil so to be honest I didn’t understand much but it was a really unique experience, made all the more atmospheric by the thudding of the heavy rain on the roof above. I had been hoping for an opportunity to visit the church at the top of the hill and I was grateful for the weather creating an excuse to go inside. 

When the rain eased up and the congregation rose for communion we made our retreat.

 I have attached a picture for you of the church from the outside. I hope you find it as imposing as I did.

Anyway the rains have all dried up now and the blue skies are back and I have been far too busy to ponder for long on religion. Today I was back on the road doing outpatients clinic in the mountains and the coffee plants are all in flower. I will tell you about it properly in my next blog.

Love to you all,

A x