Neurology at CMC Hospital

Hello all,
Well, this week I'm on the Neurology service, mostly with the N2 service. The wards at CMC are like the old-school kind we used to have back in the US. There is one big room sub-divided into three "halls". Each subdivision is just a big open room with 4-6 beds along each side. Not much privacy, although you can pull drapes when dealing with sensitive issues. The patients are grouped by sex and adult vs pediatric. Most of the kids have at least one parent sitting by their side at all times. These people had to leave their jobs and make the journey all the way here, so the staff trys to make them as comfortabel as possible and get them discharged ASAP. Mixed in with our patients are Neurosurgery patients. One of these is attended at all times by what I believe to be her son. He has not left her side the whole time I've been here, not even changed clothes. I wonder if he sleeps here too? There is also a neuro ICU on our floor. You take off your shoes and put on their flip-flops when you go in. It has a/c! What I noticed in there, though, was how quiet it was. No beeping or booping or other loud alarms like I am used to in ICUs. No ventilators either. Patients that had tracheostomies were on CPAP only. I'm told that the ICU downstairs has vents. Maybe I will see that later this week. The hospital is crowded, but other than the ward set-up and heat, pretty much like other hospitals. All the windows are open and the fans are going, but it is still pretty toasty. I can't imagine what it is like in June when it is really really hot.

The residents stay pretty busy, handling about 10-15 patients each. Several days a week they spend in the OPD, which is the outpatient clinic. They will have two exam tables crammed into a room we can only fit one into, and run through patients as quickly as possible. Because the neuro exam takes a while to do, they may see only twelve patients an afternoon each, but that still means getting out after 6pm or later.

Some interesting cases I have seen so far:
- Cerebral venous thrombosis. Not commonly seen in the US, it is very common here. Occurs predominaely in post-partum women. The residents I spoke to said the etiology is not completely clear, but trhey blame it on local customs regarding childbirthm not giving the mother anything to drink, etc. It presents as a headache with bilateral neurological deficits, and occasionally seizures. This is a diagnosis of exclusion, but is high on the differential list due to the history and physical findings. They rule out Cerebral Hemmorhage because the headache is not as severe, the patient is not so severely obtunded, and the neuro deficits cannot be localized to an arterial source. They also use neuro-imaging regularly, so the MRA helps cement the Dx.
Treatment is similar to a DVT: heparin for several days, then discharge on anti-coagulants for 6 months. Most patients recover well.

- a case of possible Isaac's Syndrome. Isaacs' syndrome is a rare nerve and muscle (neuromuscular) disorder. It may also be referred to as neuromyotonia, Isaacs-Mertens syndrome, or continuous muscle fiber activity syndrome. It's characterized by abnormal nerve impulses from motor neurons of peripheral nerves. These impulses cause continuous activity in muscle fibers. Our patient was in to get an EMG, and the history I gathered was that over a 2yr span, he has developed weakness on one side when trying to run or exert himself. Sometimes when running to catch a bus his hand will clench up in a claw and his foot will suddenly internally rotate due to muscle spasm. He can avoid this if he sees the bus coming and starts to pace a little, "warming up" before he has to jog over to it. The Dx on him is still pending.

- a case of Hansen's (leprosy) vs Myeloradiculopathy. A 63yo male with a history of decreased sensation of tough, temperature, and pain, beginning in his distal lower extremities and progressing proximally up to his mid abdomen (approx T10). He alsso reports recent onset of parethesias and burning, and again greatest in distal lower extremities, gradually diminshing proximally. These have also abated distally as total insensation has set in. Of note, he states the right side is worse in all symptoms than the left. As the Over the past 6 months, also onset of urine retention and constipation. His symptoms have all prgressed to the point where he is bedridden now and dependent on intermittent catheterization. He was diagnosed originally with Hansen's disease at another hospital, and given a course of antibiotics, but these were discontinued after less than 2 months due dermatologic reactions. On physical exam he exhibits significant bilateral lower extremity muscle atrophy, complete lack of sensation to pain, temp, touch, and vibration in both of his legs. He regains sensation around navel level (T10), which is a burning sensation when touched lightly. The jury is still out on him too.

So, due to a case of "thats how it has always been done", the neurology service also gets every attempted suicide by hanging. They don't want them, provide no psychiatric treatment, but still they get them. I saw a resident advise a patient to next time try to drown herself, as it is less traumatic. I think he's pretty sure she'll try it again, but if she fails he doesn't want to have her on the service again.

Also of note, the CMC is apparently not a public hospital. Patients come up to the residents throughout the day complaining of their bills and their inability to pay. I've seen this handled relatively well by the younger residents. The upper levels, who have been dealing with this for years, have not patience. I saw one yell at a woman to sell her bad and her house, do whatever it takes, but pay the bill. Pretty brutal.

Ok, thats all the medical stuff for now. Will post again later.

Electrical panels of CMC college campus

First off. let me tell reiterate how amusing India is. I'm sitting here in a cybercafe listenning to honking of rickshaws, high-pitched hindi music, and over this comes the call to prayer from the local mosque. This place does not let any of your senses rest for a minute!




Ok. Even on the CMC campus it is very entertaining. On the college campus, all of the electrical panels are dedicated to some scientist or other. I'm trying to catalog them all, but here's just a small sample.

Mamallapuram and Kanchipuram

For the weekend, Anne, Cristina and I hired a car (with a/c) to take us to Mamallampuram, on the coast. This is an ancient city, and listed as a UN World Heritage Site. The sculptures and temples here defined a style that then spread out over the rest of India and beyond. Probably the most photographed temple is the Shore Temple, dating from the early 8th century.

We also got to get our feet wet at the beach. Indian Ocean? Check.

Here is a guy selling food (fried fish) near the temple. All along the temple, and all over town, were sculptors. Stonework is the #1 industry in the town 9other than tourism), and you hear the "clink clink" of chisels ringing out all over. I bought a bunch of stuff (yes, rocks), and felt great about bargaining the stoneworkers down to less than 50% of their asking price. Until I showed my driver and he laughed at how much I overpayed. I will not show him anymore stuff. Still, my black marble dancing Pravati and red marble Shiva are something to behold. I have absolutely no idea how I will get these home intact.


About 1.5km south of the village center is a "plaza" containing the 5 Rathas. These are all carved out of solid stone, dating from 630-670AD.

Here we see the largest and tallest, the Dharmaraja, and Anne and Cristina resting inside it and listening to our guide (Rs100, a pretty good tour).

This is the Dharmaraja again.

Here's a view of the plaza. On the left is the Nakula and Sahadeva Raja, named after two brothers. Just to the right of that to that (tough to see) is a life-size stone elephant. On the mid-right is the Draupadi, apparently based on the design of a straw hut (note the roof). And on far right again is the Dharmaraja.

We stayed a pretty good little hotel (Rs1200) with a/c. The girls got mosquito net, I covered myself in deet and braved the malaria. The town is definitely designed with tourist in mind, but its is so hot that the season is winding down and there was almost nobody there. although definitely more westerners than in any other place so far. The ladies shopped with a vengeance, I picked up some stuff for friends. I also got a great little box that you can plug into the wall. It play 18 different mantras over and over again. I will drive my neighbors in the hostel crazy with this thing. We ate at a restaurant right on the beach, fresh seafood!

In the morning we got free breakfast, and then headed over to see the rest of the stuff.


This is a giant bas-relief called Arjunas Penance. The story goes that Arjuna did penance on the bank of the Ganges in the hopes that Shiva would part with his favorite weapon. Shiva eventually materialized and picked a fight with Arjuna, and basically kicked his behind, but eventually gave him the weapon as a reward for trying in the face of inevitable defeat. Arjuna is on the left, the elephant is on the right, and the cleft in the middle represents the Ganges.

Closeup of Arjunas Penance.

There were many other temples and bas-relief around, and we saw almost all of them. Mamallapuram was awesome, and I'd love to go back again. It was hit pretty hard by the tsunami, but has recovered well. Our dinner restaurant had a pic of how it was before it hit, and they definitely rebuilt well. The wave actually uncovered a bunch of new structures previously unknown, now being excavated. There will be even more stuff to see when I come back!


Then we got in the car and headed home. On the way is the town of Kanchipuram ("Golden City"), known for 2 things: 1) it is the silk capital of India 2) it has some serious temples.

We stopped off at the Varadarajaperumal Temple. In this lagoon, under the gold thingy, is a statue of Shiva. They drain the lagoon and take it into the temple once every 40 years (next time, 2016). Apparently 4million pilgrims will descend on this town then. Good luck townspeople!


Inside the temple is the 100 Pillars Hall, a wedding hall with intricately carved solid columns, many with risque scenes from the Kama Sutra.











More from the wedding hall.

View from main entrance in. The hall is out of site over to the left. I could not go any further as a non-hindu. And my feet were starting to sizzle on those hot stones. Native Indians don't wear shoes a lot, so they're tough. They laughed at me as I ran from shadow to shadow, but it is really really dangerously hot out there.

Closeup of one of the pillars

Another temple we passed (pretty darn tall)

A third temple we peeked into. All in all, a great trip. The car and hotel were incredibly good deals, and I'll just pretend that I made out like a bandit with my rocks! Maybe I'll post some pics of them later.







Whew. I think I'm all caught up now. Feel free to post comments or requests.

Teaser

Update: I now have posted CHAD day 2 andf more, so go back and check. We're going to a World Heritage Site town called Mamulampuran this weekend, so I think I will be spending a lot of time when I get back uploading pics (see CHAD day 1 for samples).

In the meantime, here's a tidbit from this afternoon:

Poor quality video, but finally up!

Here is a street corner in Vellore on a rather slow day. Watch the far corner at 37sec in for a common sight on the sidewalk. I like how it acts like this is "its" block. (audio works too). And a pic of possibly the same pedestrian.

I met a living god, was kissed by an elephant, donned native attire, saw monkeys at the hospital and more!

Friday was a really big day for me. We went to the Golden Temple, just outside of Vellore. I don't have any pics of my own, since no cameras are permitted and they search you, but I've included some from when it was being built to give you an idea. So, we pay our Rs100 and start in. The temple itself is in the middle of the most beautiful and cleanest grounds I have seen in this country so far. There is a covered walkway in the shape of a 6-pointed star that you wander along around the perimeter, with the temple itself in the middle. During the walk you pass many signs with deep quotes from someone named "Amma", basically a lot of nice common sense stuff, while relaxing chanting is played on the speakers overhead. After this 1.5Km walk, you reach the end, and walk straight up to the temple. The pricey tickets get to go up to it, the cheap ones (me) get to get real close and walk around it. It is ridiculous. Probably the shiniest thing ever. Very nice.

This site: http://www.sripuram.org/ has pics rotating through on the front page and some stuff about Amma.






So, we walk around, I ring the bells a few times, and start heading out. Stop off at the "gift shop" and a nice guy there starts explaining the layout of the temple to us. Tells us all about Amma, how when he was 16 years old, he got a calling, and it was revealed that he was the personification of the god mother of all. So he goes by "she" now, and started an ashram. 16yrs ago. The golden temple just opened less than a year ago. Anyways, he asks if we would like to meet Amma. He has to call ahead to see if its ok, and then we walk across the street to their old temple complex and we are about to go in but I am stopped. I have shorts on, not permitted. So he takes Anne and Cristina in, and I stand there thinking I may have missed out on a chance to meet a deity. After about 10min, I'm resigned to this fact, and an elephant walks out and passes not 2 feet from me. Well. This made my day. It was all decorated and pretty and nice. And then a random guy comes out and gives me a dhoti (like a sarong, the skirt that Indian men wear). So I wrap it on and go in. There are a bunch of temples, and people are all over the place praying, but they lift up the ropes for me and let me past them back into the VIP section, where all the actual faithful are not allowed (not my fault, hindus, sorry). The girls already met Amma, and he's busy now, but my new Indian friend tells me I can join and watch Amma perform a puja, which is a special ceremony. So I follow him into a big room where about 10 people are sitting, a band is playing, 3 women are chanting constantly, this guy keeps ringing a bell, and on the other side of the room is a very decorated cow just lying there. Amma comes in, and starts adorning the cow further with flowers and incense and gold dust and sacred oils. The cow has all kids of decorations, and he drapes her with a bejweled blanket. Spends a lot of time with incense at the rear end, which is probably a good idea. As it progresses, the music goes faster an faster and the bell rings more and more, and they chant louder and louder. The cow, the whole time, looks very unimpressed. For being the mother of all India, she's pretty chilled out. The high point for her is when he (sorry, Amma is a "she") feeds her some fruit. She likes that a lot. They even hold a golden tray under her mouth to catch any drippings. Seriously. Then its over. That is the biggest deal I have ever seen made about a cow. Everybody apparently is thrilled to have gotten to see this, especially my new friend, who says its only because he brought me that he was permitted in here, so I have a great honor. Amma comes over and asks my name and where I'm from, and tells my new friend to take me to the guesthouse and feed me. He/she speaks perfect English, and is about the same age as me, looks like you average hairy bearded sweaty dude. We go and scratch the cow some and she likes it. Nice cow. I mean, all-mother. Whatever. Anyways, so we wander around the temple complex some more, and I keep getting to cut in front of real worshippers to enter temples and stuff. And there's another elephant! This one gives me a kiss in the face and taps the top of my head with its trunk as a blessing. My new friend says it likes me. Then I go and buy one of the nice gold dhoti's everyone one is wearing ($5, a decent deal). My new friend helps me put it on right. OK, what happened was that a man I'd just met helped me put on a skirt and then he told me he loved me. Anyways, after he says "Chris, I love you", I say "Thanks, you are a nice friend". He gives me a red dot on my forehead. The the two ladies, my friend, and an Australian lady name Zoe who now lives there go over to the guesthouse for food. We chat for a bout an hour. They used to work in engineering and pharma, but are much happier spending time with Amma at the Golden Temple now, and want to do this forever. Then we said goodbye. Wow. No $ requests, no recruitment. Just the original price of admission and my $5 skirt, and we got the deluxe 5-star tour and a free meal. Pretty cool.

Later that day we went to the old fort here in Vellore, which is where these pics were taken. There is an old temple there we went in. You have to take off your shoes, and the stones were really really hot. And there were monkeys (see pic below, it'll enlarge if you click on it)

All - in -all a pretty busy and fun day. Just the kind of stuff I was looking for. Saw a golden temple, a living he/she god, blessed by an elephant, donned a dhoti and a red dot, saw monkeys. I could go home now and be content.

More to come though.....

Random Vellore/CMC Observations and Pics

Just a few random things that don't fit into other posts but that I still want to show you.

Yellow flowers blanketing a building on the college campus.

A leprosy rehab clinic at CMC hospital (don't see those in the US)




A flower vendor on the street. The women apparently buy their fresh flowers the night before. These were just picked.

Turtle mountain. Can't deny the resemblance.

A temple I found down a side alley in Vellore. These this are incredibly intricately deocrated. And there are many many many of them all over.

Ahh, tea. Done the Indian way. Sweet, hot, and delcious. Probably averaging 4 cups a day.

Anne and Cristina's "deluxe" hotel room has a great view! But at least they have a/c.