Pages from the Philips Seeking God's leading in medical missions

Week Three

Another week has passed and we now down to less than a week at Makunda before we leave here for Delhi on Saturday and then return to the US on Tuesday. It has been a good week at Makunda with time to talk with other families on campus and to get their perspectives on mission work in India.

Monday was an extremely busy day in the outpatient clinic where we saw 290 patients! Even with the extra help provided by the return of Dr. Vijay and Dr. Ann, we felt that we could hardly keep up with the extra number of patients who were here. I have to think that the patients must somehow know how many doctors will be working on a particular day and tailor the number of people who visit the clinic accordingly. Regardless, I thought seeing that many patients in a day did them a disservice and wore out the staff to the point of sheer exhaustion but it is so difficult to do anything else because how do you turn away so many people who have traveled anywhere from 2-8 hours for the chance to see a doctor? One of the things that we’ve talked with several of the healthcare providers here about was having nurses help see patients as well and then for them to refer more complicated patients to physicians so that the workload would be more manageable and so that each patient would get more than the 2-5 minutes we can give them at the current pace. However, it seems that in India that will require changing the expectations of many people because most patients believe that if they paid the money to be seen by a healthcare provider, they need to be seen by a physician in order to get their money’s worth. But the way that doctors here are stretched so thin because of the sheer number of patients that doesn’t look to be a sustainable model. Even in the U.S., many hospitals have discovered that nurses, PAs and nurse practitioners often do a better job managing chronic diseases and other common complaints than many physicians because they have more time to spend with patients and it is a better use of a limited resource. In many ways, almost 1/3-1/2 of our patients here could be seen and treated by a physician extender because so many patients come in with the complaint of sore throat or cough or stomach pain. Perhaps as the healthcare crisis here grows larger, people will be willing to change their expectations so that more of the population can get access to high quality care at an affordable price.

On Monday we also had a young girl in the ICU who we had admitted over the weekend for diabetic ketoacidosis. She was 11 years old and had spent the last two months being extremely sick at home and by the time she came to the hospital she was totally dehydrated and emaciated. When we did the initial sugar measurement it did not register on our glucometer because it was too high. Only after about 30 units of insulin and a day of rehydration did we finally get a glucose reading of greater than 500. She came from an extremely poor family and thus we admitted her over the weekend to help her family and her learn about her illness and to teach them about the importance of regularly receiving insulin to prevent a relapse of the condition that had brought her into the hospital. I was amazed by the education that this family received and the openness the father had towards the Gospel. Since we had several days with them, we taught the family how to give insulin injections themselves and how to store insulin so that their supply would last them about a month at a time. This family has no refrigerator and thus we had to give them another option for storing insulin at cool temperatures so that it would not be ruined. Here they have found that by using a clay pot half filled with sand and the other half filled with water, that they can store medicines at temperatures close to what you can achieve in a refrigerator. So part of this admission was spent teaching them how to create this refrigeration device so that they could store their daughter’s insulin. The admission along with the medicines she received cost greater than 3000 rupees (almost $100) but all the family could afford to give was 1000 rupees (about $25) and thus the rest of their care was written off as charity. I’m still amazed by how the hospital here is able to make a determination of the truly needy verses people who just claim to be needy so that they don’t have to pay as much. However, it seems that most of the doctors here are blessed with being able to delineate between the very poor and others who can afford to pay for their care (although I still have no clue on how to make that distinction). At least with this family it was very obvious that they were extremely poor because on Tuesday morning when we arranged for their discharge, they asked to be discharged early because they live about 20-30 kilometers away from here over a mountain and the father was going to carry their daughter the entire distance and so they needed time to get there before it got too dark. I could not even imagine a father having to do that for his daughter but they had no money for transportation and we did not have vehicles available to transport patients and thus this man carried his weak daughter for several hours until they were able to reach home. What was also meaningful to me about this family was the father’s openness in wanting hear about Christ because of the care his daughter received here and so we were able to give him a copy of the Bible in his language so that hopefully by the time they return for their follow-up visit in 1 month he will come back with more questions about how he can have a relationship with the living God.

Tuesday marked a day in which a significant change was made in the way that I will work here for the remainder of our time. We found that even though I was somewhat helpful in the outpatient clinic with seeing patients, it often took away time from some helpers in the clinic because I needed them to help me translate for patients with more complicated diseases. So it was decided I would spend my time primarily managing and working up the inpatients and then assist with the outpatient clinic as needed. So far this change of pace has been a good transition because the nurses in the hospital have more time to be able to help translate for me, I get to spend more time getting to know my patients, and with any extra time that I have while in the hospital, I’ve been able to work on developing some standardized treatment protocols for some common diseases that we see here at Makunda. So on Tuesday morning, I rounded on about 30 patients between long ward, male ward and the ICU and then went over case management with Dr. Philip since he is the senior physician on call with us this week. On Tuesday we had a patient in the ICU who was being managed by Dr. Shailini, our OB-GYN, who was pregnant and came in with a ruptured uterus and an intrauterine fetal death because she had labored at home for several days and eventually the contractions cause her uterus to rupture. Thankfully, Dr. Shilini was able to save the mom after she operated on her and repaired her ruptured uterus and removed almost 2 liters of blood from her belly. It is still shocking to me that there are still many moms here who die during childbirth because of lack of access to good medical care and lack of education. I talked with Dr. Ann this week to find out some of her thoughts on why patients wait so long before they finally come to the doctor and she had some interesting insight into this problem. Part of the problem she explained is lack of education regarding basic health literacy. Many of the people in the surrounding villages do not know how to differentiate between a patient who is very sick verses someone who is only mildly sick. A second part of the problem seems to be that many patients will often go to receive treatment from a local quack who masquerades himself as a healthcare provider and only when their interventions don’t work do they finally come to see a physician. By the time that they then come to a physician they are often so sick that there is little to be done except implore God to bring about healing because there is little we can do for them from a medical standpoint. Finally she explained that often women here do not get adequate healthcare because they need permission from their husband before they can come in to see a doctor. Often what occurs is a woman will go into labor and will labor for several days and when she finally decides that to go see a doctor for extra help, she first needs to find her husband (who is often working far from home to send the family money) so she can get permission from him to go/be taken to the hospital. Often women only get in touch with their husbands once it is too late or the husbands say no because they can’t afford to go to the hospital. In many ways the rights of women in rural India are very little in practice even though many rights have been granted to them through the law. For example, in this part of India, a woman cannot choose to have a tubal ligation for family planning purposes unless her husband also consents to the procedure and thus there are many moms who would like to have fewer babies but are unable to do so because their husband will not consent.

On Wednesday we admitted a 26 year old lady who came in unconscious. She is a mother of four children, all under the age of 10, who had been ill for several days when her family finally brought her into the hospital once she became unresponsive. When we first examined her it was very clear that she had some type of central nervous system infection but the problem was in trying to delineate what type of infection she had so that we could treat her appropriately. The two major CNS infections we see here are pyogenic meningitis (bacterial infection of the covering of the brain) or cerebral malaria from severe falcipirum malaria infection. We checked for malaria with a rapid diagnostic test which came back negative but we still ended up treating her with both IV antibiotics for bacterial meningitis and an artemesin derivative for malaria infection because we couldn’t afford to take the risk of the malaria rapid test being negative when she might have really had cerebral malaria. She responded after about three days of IV medications with some minimal movement and response to commands but as she gradually came out of her coma it became clear that she is totally paralyzed on the left side of her body. Seeing that she had a stroke associated with her CNS infection, we had to revise our diagnosis once more to TB meningitis with associated endarteritis. So five days later we were finally able to start her on anti-TB medications. Throughout the rest of this week, she has gradually become more and more awake but the sad reality is that it doesn’t look like she is getting any of her function back on the left side. Her mom has been in tears many times when we have talked with her and I’ve prayed with them asking God for healing. If God does not allow her to regain at least some function back on her left side, we will have a mom, age 26, of four children under the age of 10 who cannot take care of her family because half of her body doesn’t move anymore. Please join us in praying for her recovery and for her family to learn of the love of God in all circumstances through this difficult situation.

Wednesday also brought two of the most difficult and heart wrenching cases I had yet seen at Makunda. A lady brought in her 1½ year old son to the outpatient clinic and from our first look at him we knew that something was terribly wrong. Even though this baby was 18 months old, he weighed a mere six pounds. He literally looked like a skeleton covered with skin. He looked like the many babies you see pictures of from famine stricken parts of Africa who die of starvation. This baby had severe protein energy malnutrition and weighed less than 25% of his expected body weight. He had a condition that we term marasmus. We immediately asked that this mom admit the patient to the hospital because we needed to sort out what was going on with this baby and start refeeding him. After admission, we started to learn more about this baby and his tale of woe during his young life. Two months after he was born, his mom passed away from some sort of infection and thus for the next year his father took care of him alone. His father was completely unprepared for the task of taking care of a baby and didn’t know how to feed him or take care of him well. So over the course of that year he gradually lost weight and became severely malnourished. Then about three months ago, his dad went away for a couple of days for work and left the baby with a relative but his dad acquired some type of fever in the jungle and died also. So finally the baby came into the care of his aunt and for the last three months she had been trying to help him get better by feeding him again but with little success. Finally out of desperation she brought in the baby to see if there was anything we could do for him. This was an extremely difficult patient for me because he was the same age as Luke and I just could not imagine something like this happening to him. This baby can barely hold his head up let alone walk or talk. In the hospital we started the baby on a high calorie refeeding diet and have gradually started to increase his feedings to prevent the complication of refeeding syndrome. Initially the aunt just wanted some medicines to take home with her because she had her own family to take care of. So I talked with Melissa and we agreed that we would take over his care until the time we left if the aunt was unable to care for him. So the next day we made the offer to take care of the baby for her but by then she had realized the gravity of the situation and agreed to stay with the baby in the hospital until he started to regain some weight. There are several issues that came to mind as I’ve been taking care of this baby. One was the realization that he lived less than 2 km away from the hospital and yet his situation still became this desperate. Did the dad not know he could access care at the hospital free of charge if he had just brought the child in? Why did none of the other relatives take an interest in the condition of this baby earlier so that things didn’t have to get this bad? How can we more effectively reach into the villages near the hospital so that we improve their basic understanding of health and more importantly transform them with the gospel so that people realize that lives are important and valuable? The other thought that came to mind with this baby was how desperately India needs some type of child protective service. In India, there is no governmental agency charged with protecting the welfare of children. No matter how poorly children are treated by their parents, there is nothing we can do from a legal perspective to remove that child from that home. Even if we could try to file a case in court, the legal system here takes years to work and thus most of these kids would suffer years of abuse or neglect before something happened from a legal perspective. There is also no system in place to care for children who are removed from their parents home or who have no home to begin with. There is no foster care system or formalized governmental adoption services to provide placement for children taken from families and thus part of the reason for not wanting to take children away from their parents is because they cannot offer a reasonable alternative. The state of child welfare in India is still quite sad because there are literally millions of children here who are orphans (I believe from the last statistic that I read, India has the largest number of orphans in the world – around 22 million) but almost no one to adopt them. India as a society is still very opposed to adoption because of social norms and the influence of Hinduism. There is little sense of social responsibility because according to Hindu philosophy the life that you live now is a consequence of the life you lived in your last incarnation. Also in Indian culture adopted kids are looked down upon because there is the issue of arranged marriage and it is difficult to marry off kids who are adopted because no one quite knows what type of family they came from. For a country with such a problem of orphans and abandoned children, you would think the government would be more willing to allow for things like international adoption but that just isn’t the case here. Because of nationalistic pride and not wanting Christians to adopt Hindu and Muslim babies the government makes it extremely difficult for foreigners to adopt Indian children which is why you see very few adopted Indian babies in America as compared to Chinese, Russian and Central American babies. The one advantage we have with this issue is that because I have retained my Indian citizenship and am of Indian origin it should be far easier for us to adopt children when we come back as opposed to if we were both non-Indians living here. Thus our hope is that once we return to India we can add another 3-4 children to our family through adoption.

The difficult second case was a woman in her fifties who came in with the worst skin condition I had ever seen in my life. She had first come to the hospital three months ago with some type of skin condition that causes blisters to form on her body which would then rupture and get secondarily infected. She refused admission the first time we saw her three months ago and just went home with some antibiotics to treat her secondary infections. She returned for follow-up and you knew that she was very ill and ashamed because she kept almost her entire body covered with her sari. When I examined her she literally had blisters covering her body from her head down to the soles of her feet. My clinical diagnosis was that of pemphigus vulgaris because of the hundreds of blisters she had on her body. It was so painful for her to even walk because of the blisters on the soles of her feet and we pleaded with her to get admitted this time but her family refused again. Her daughter who came along said that she could not stay with her mother during the hospitalization because she had her own family back at home and in order for a patient to be admitted to the hospital at least one attendant must stay with them because we don’t have enough staff to care for patients who have no family members with them. So we sent this lady home on immunosuppressive medications and antibiotics and prayed that she would get better so that they would see the power of Christ at work. I prayed several times that day that God would give me the faith to pray like He did when he or the disciples saw the lepers and just by his touch they would be healed.

I was on call again on Wednesday night and it was not too busy of a night because I only had to go in once and then just answer a couple of phone calls from home. Morning rounds on Thursday were horrible because of a problem we have in the hospital of a large number of maggots falling from the ceiling onto the male ward, isolation ward and maternity ward. I can take most things in stride but for some reason I cannot stand worms and things that look like worms because in the past I’ve had some horrible allergic reactions when they have touched my skin. So on Thursday morning when I started rounding on patients I got this feeling that something was crawling on my neck and I swatted at it and lo and behold it was a maggot. A couple more minutes went by and then I noticed something moving in my hair and I brushed it off and it was another maggot. I figured then that something was wrong and looked around at the ceiling when I noticed that there were hundreds of maggots hanging from the ceiling on a silk thread that they seem to be producing to facilitate their journey from a nearby tree to the ground. I immediately went outside to see where they were coming from and noticed several trees outside that were covered with thousands of these worms and the webs they had spun in their descent down to the ground. The nurses sure got a laugh at the sight of me jumping each time one of these maggots fell on my hair or down my shirt. By the end of the morning I decided to just round on patients outside the wards because I couldn’t stand it anymore. Thankfully I talked with Dr. Ann about our maggot problem and she promptly took care of it by calling in some workmen to come and cut down the trees with the worm problem. Since then we have continued to have problems with these maggots crawling all over our patient beds and floors for the last three to four days although their number has decreased steadily day by day. They always seem to show up when you are doing something important as well because I saw another one crawling into my sterile field before I was getting ready to do a lumbar puncture and there was news of another one that crawled on Dr. Shilini’s surgical scrubs while she was in the midst of a delivery! I’ve been okay with the lack of running water and electricity but these worms nearly drove me mad! Thankfully the problem seems to be taken care of now by the grace of God. Thursday also marked the day that Dr. Harry and his family went away for a couple of days to a nearby convent for their son’s first communion. Because Dr. Ann and Dr. Vijay were busy doing multiple surgeries on that day we were really unsure as to how we would go about seeing our typical volume of patient with just two or three doctors in the outpatient department but God was gracious and provided two days of bundh (or strike). Strikes are very common here in India and they work much differently that they do in the US. When a strike is called here nothing functions for that day. Thursday was an all Assam bundh which meant that the people who organized the strike would not allow anyone to travel on the roads. This meant that most of our patients who come from far away were not allowed to travel. If someone did try to travel on a strike day, the strike organizers very frequently stop the vehicle and destroy it. Friday was an all India bundh which was organized to protest the high cost of commodities and oil in India. Dr. Philip was telling us that often when they really needed a day of rest after toiling away for days without a break that those would be the days that God often provided us with a bundh so that far fewer patients would show up to the outpatient clinic. I think on Thursday we had about 100 patients and on Friday we had 76 patients. On Thursday evening one of the retired staff members from Makunda who had worked here for almost 30 years invited us to his home and we were able to enjoy some good conversation with them as we learned more about how Makunda ran when it was run by the Baptist Mid-Mission. Apparently a lot more agriculture work occurred on campus here during that time because there were quite a few leprosy patients who lived at Makunda and they were able to tend to the fields and maintain the land here (almost 350 acres). On Thursday evening because we finished with clinic early we were able to walk to the market as well to do some weekly grocery shopping. The markets are open here on Monday and Thursday and most of the local farmers bring in their goods on those two days for sale. I took quite a few pictures from the market and so hopefully on our next post I’ll be able to put up some of those pictures to that you can get a better idea of life here.

On Saturday we caught quite a bit of the backlog from two days of strike and so we had about 180 patients on Saturday, considerably more than the 120-140 patients we typically see on Saturday. We also had two very sick patients come in. One was an 18 year old girl who had started to have severe breathing difficulty around noon followed by four episodes of large volume stools. Her family had tried to have her treated by a local village healer but he wasn’t able to do much for her and so she came into the hospital. By the time we examined her, it was very clear that something was terribly wrong with her. Her heart rate was in the 160s and her oxygen saturation was around 79% even with oxygen going full blast. Her pupils were both constricted down which made us start thinking about whether she had ingested some sort of poison. The two leading causes of suicidal death here are organophosphates (from fertilizer) or rat poison. What didn’t fit with organophosphate poisoning was how fast her heart rate was because we typically expect a slow heart rate with organophosphates and not a fast one unless she had ingested multiple poisons. We repeatedly asked her and the family if she had consumed any type of poison and they adamantly denied it. Then she started vomiting blood and we knew things were taking a turn for the worst. We put in an NG tube and tried to wash out her stomach in case there was any poison remaining and in the process removed about 2 liters of blood from her stomach. She stayed at the hospital overnight and one of the relatives finally informed us that she had indeed consumed some type of unknown poison. The next morning we transferred her to a government hospital because it is the policy of this hospital not to take care of medico-legal patients (like suicides or assault victims) because of the problems that it creates with the government. Often times the government agencies tell the hospital that they are not an accredited center to treat medico-legal patients and when they have cared for them in the past there has been a lot of time that the physicians have had to spend in court testifying and giving depositions. Thus the leadership here made a decision to transfer all those patients, once stabilized, because of the resources they consumed from the hospital staff. Saturday evening was a fun evening because we borrowed the hospital projector to show the Star of Bethlehem DVD (www.starofbethlehem.net) to the staff here. That was a special treat for them because of how few of them ever get to watch movies and so we had a full house for the showing. Some people had trouble with the accent of the speaker but they still got the gist of the presentation and many were encouraged in their faith.

Sunday was a really fun day to relax, rest, and enjoy time to worship with the believers on campus. After the worship service, we had lunch at home and then Dr. Philip and I went to the hospital to round on patients before we returned home to go for a picnic with our families. We picked one of the many areas around the campus to go outside and to enjoy some tea and biscuits with Dr. Philip’s family, our family and Dr. Shailini. Then Dr. Shailini treated us to a wonderful dinner of mushrooms and noodles that she had brought from her home in Meghalaya. While Shailini cooked the meal for us we went into town to call Melissa’s sister, Kris, to wish her a happy birthday and we talked to Melissa’s parents and Christo’s parents and tried to catch them up on life here.

Please join us in praying about several matters during our last few days here:

1. Pray for travel safety as we begin our long journey back to the US. On Thursday morning (Wednesday night US time) we will be traveling to Silchar to pick Jodi and Nelson up at the airport. Jodi is Melissa’s close friend who spent a year with her in south India. Jodi and her husband Nelson now minister at a children’s home in Imphal, Manipur which is about a 20 minute flight from here. We will spend Thursday and Friday visiting with them and seeing Burrows Memorial Christian Hospital, another EHA hospital close to Silchar. On Saturday we will fly to Calcutta and then on to Delhi.
2. Please be praying for our health, especially for Luke. He has been ill with vomiting and diarrhea for the past few days which have made for long days for both him and Melissa as she cares for him. Please pray for him to stay well during our last few days here and for continued health for the rest of us.
3. Please pray for there to be an improvement in the adoption situation in India and for the government to allowed more children to be adopted into good families.