I Hate Last Days

            Today was our last day in India! We spent our day at Kovalam Beach, which we just found out will soon be demolished and replaced with an international sea port! :( We will be the last Team Iowa that got to visit! Sad day. During our time at Kovalam, we swam, caught some rays, bought some final goodies, and grabbed a bite to eat.
            After returning from Kovalam, we got cleaned up and had one last oreo milkshake at the restaurant across from our hotel <3 The Pallium India van parade then arrived and took us on a nighttime city tour of Trivandrum. We made visits to a temple, an abandoned 15th century palace, a beach (the cool night breeze off of the sea was amazing), and drove past some other cool places.
            Now, here I am, 3 hours before we leave our hotel for the airport, reflecting on all the incredible experiences I've had here over the past 3 weeks (and trying to figure out how I'll fit all the stuff I've purchased into my suitcases). I won't be too sappy here because I think the rest of the blog speaks for itself, but I'm extremely fortunate to have taken part in this opportunity, and will undoubtedly be a more well-rounded nurse and person in general because of this journey. I've met 15 outstanding other students from the University of Iowa and made some great new friends, and I hope we will all keep in touch.
            Although I am not looking forward to the 18 hour plane ride home followed by a 4 hour bus ride (and all the security checks and small layovers in between), I am excited to see everyone I've missed while I was here. Thank you to Dr. Eland, Dr. Broderick, UI International Programs, Pallium India, and the Capital Hotel for everything! Thank you to everyone who helped make this trip possible for me! And yes, as always, thank YOU for reading! :)

Final Friday: After Class (Veli Lake Tourist Village)

            After our final class day at Pallium, a group of us took rickshaws to Veli Lake Tourist Village before having dinner on the rooftop of our hotel. Here are a few pictures from our mini-adventure :)

An artsy pic, courtesy of Jesteny!

Even though it's only our second to last day, the goodbyes are beginning!

Final Project: Abnormal Posturing

             For my final course project, I have chosen to present a case and do further research on what is known as abnormal posturing. Many of you who are further along in your educational programs may be fairly familiar with this concept, but it was something that I had never heard of when I came across a patient with such posturing on a home visit here in Trivandrum, which is what sparked my interest in the subject.
            The patient was a 47 year old man that had been hit by a car while riding a bicycle 6 months earlier, which resulted in a traumatic head injury that had caused a midline shift and an epidural hemorrhage which required a craniotomy to stop the bleeding and relieve the pressure that the leaking blood was exerting on the brain. When we arrived, the family gathered in the room and the neighbors came to observe through the open window, and you could tell that everyone cared deeply for the patient. Dr. Annama began examining the patient and noticed that he appeared at first to be “awake” but indeed was unresponsive, and that his pupils did not respond to light stimulus. We also saw that he had a nasogastric tube due to the fact that he was unresponsive and therefore unable to swallow, as well as a urinary catheter. His breathing was labored, and was accompanied by a painful moan at times. Abbey explained to me that the man was in a decorticate posture, which is indicative of severe damage to the central nervous system. It was heartbreaking to see such a relatively young man in such a vegetative state, which had one day been imposed on him so incredibly suddenly. That being said, I was fascinated from a medical standpoint in regard to what the physiological reasoning was behind this phenomenon.
            When a muscle contracts in an uninjured person, the antagonistic muscles on the opposite side of the joint resist the contraction to some degree. The damage to the central nervous system results in a total or partial absence of this opposing force, which causes the abnormal posturing. Posturing can occur on just one or both sides of the body, and patients can alternate between different postures as their condition improves or worsens. The causes of these conditions include intracranial hemorrhaging, brain tumors, strokes, encephalopathies, head injuries, and intracranial hypertension. The less severe type of posturing (in relative terms) is decorticate position, which was the position, which was displayed in our patient. Decorticate posture is indicative of damage to the nerve pathway that connects the brain and the spinal cord. A person in this position will have their arms fixed in a flexed position, or bent inward on the chest, their hands clenched into fists, their legs extended and their feet turned inward, as seen in the bottom diagram of the photo below. The more severe type of posturing is decerebrate position. Decerebrate posture is usually indicative of severe damage to the brain itself, and is characterized by extension of the arms and legs, plantar flexion, and backwards arching of the head and neck, as seen in the top figure in the photo below.

            Aside from the physiological understanding, there is also a prognostic component to these postures that may or may not be conveyed accurately to the family of the patient by the medical professionals. Abbey and I were concerned, from what we understood during our home visit, that the family of the patient was under the impression that he could essentially make a full recovery. They seemed relatively free of grief, and were reporting that they believed he was making significant progress because the patient would occasionally move one of his limbs, or appear to perk up in response to an auditory stimulus. That being said, the accident had occurred more than 6 months prior to our visit, and the patient was still almost entirely unresponsive, could very likely be in excruciating pain, and had been existing under conditions which severely compromised his quality of life ever since. It was Dr. Annama’s belief that another doctor had previously instilled this unrealistic sense of hope in the family, who didn’t know better. On one hand this is believeable because nobody likes to be the bearer of bad news, but on the other hand, it is utterly unacceptable from a person that has vowed to ensure the beneficience of the patient, in that it has subjected both the patient and his family to a long road of waiting and suffering as the inevitable slowly encroaches. The principle that I will take away from this specific experience will be, in Dr. Raj’s words, to always be sure to restore a realistic hope in the family members and loved ones of individuals who have fallen victim to one of the etiological conditions of these abnormal postures. I will also be sure to educate the family about what causes their loved ones to take on this unnatural and unsettling form and what it means for their prognosis and the life left ahead of them. I am fortunate to have been given this incredible opportunity at this time in my educational career, and will undoubtedly be a more well-rounded nurse in my future because of it.

My Dilemma

            After our final home visit, having seen a great deal of pain and suffering over 6 full days of home visits (as well as during my time as a caregiver with HomeChoice Senior Care), a question was raised in my mind that I just had to ask the doctor we were traveling with. What do you think about human euthanasia? The question had been asked here in India before to Dr. Raj but I had forgotten his response in the heat of the moment, and I’ll go into his response (which I agree with) later, but for now I’ll focus on our doctor’s response, which really troubled me. She told me that human euthanasia goes against everything that the Hindu people believe in. The belief is that karma is responsible for the person’s present suffering, and that this suffering is the only way for the patient to achieve eventual liberation at the time of their death. She explained that it was not our place, nor any human’s place, to interfere with this process. What troubled me most was the fact that this rationale was rather similar to that of many Christians and other people I’ve heard arguments from in the United States, in that this is happening because it’s meant to happen because someone or something or God or the universe or whatever wants it to happen; it’s destiny; it’s meant to be. Now, I wholeheartedly respect the Hindu culture and the ideology of Christians and the rationale of anyone else who opposes euthanasia for these reasons, but this reasoning is entirely too functionalistic for me. Before I got too frustrated, I looked back in my notes from about two and a half weeks ago from when this question was posed to Dr. Raj, and was somewhat pacified by how much it made sense to me and the degree to which I agreed with it.

            Dr. Raj’s response was that he essentially held a 3-fold opinion on the controversy. The first aspect that he considered was that 90% of people who are suffering can have their quality of life improved to the point of no longer desiring death when palliative care is provided. Alright, probably true, I thought. But what about those remaining 10% of people who, no matter what pain meds, counseling, or therapy are given to them, cannot be relieved from their pain and suffering? I wondered, as my eyes moved to the second bullet point of my notes. “However, in the remaining 10%, he sees it as a moral and ethical practice.” YEAH! I thought. See, Dr. Raj, the father of palliative care in India, agrees with me, so I have to be right. But I knew there was that third fold that would throw another wrench into things: “But, before we can even HAVE the argument as to whether or not human euthanasia is ethical on a state, nation, or worldwide scale, palliative care must be made adequately available to all people within that respective area.” Oh… right, I thought to myself. As I was getting all excited that Dr. Raj wasn’t one of those people who blindly oppose euthanasia regardless of circumstance, I forgot the most important part of this viewpoint. While I firmly believe that euthanasia should be an option for cases in which all of these criteria are met, I would find it hard to argue that it would be morally correct to end someone’s life without having quality palliative care offered to them, which is so grossly unavailable to such a large portion of the Indian people, as well as people of the entire world.

            How’s that for a dilemma to ponder? Thanks for reading.

Home Visits: Day 6 (Muttacadu)

            Today, I traveled to Muttacadu with Aparna, a Pallium doctor, and a Pallium nurse for our final day of home visits in India. It was a bitter-sweet day because I must admit, I’m getting rather homesick as we approach the end of our 3 weeks here, but at the same time, our time here went very quickly and I’ll be sad to leave.

            Our first patient was a younger man with encephalitis. The house was too small for Aparna and I to step into so we watched the chickens as the doctor did the visit. However, when we were leaving, the mother of the patient brought an ulcer on her foot to our attention, that she said hadn’t been healing. When she showed it to us, I couldn’t believe she wasn’t showing more signs of pain. The ulcer was massive, covering almost the entire ball of her foot, and was so deep that you could see her bone. I have no idea how she was still walking on it. Aparna and I were in disbelief. She followed us to the van where they gave her a bandage and some medications, which I believe were antibiotics, to prevent the ulcer from becoming infected and hopefully helping it to heal.

            The next patient that stood out to me was a very elderly woman who was bed ridden due to both old age as well as a cancer that had metastasized to her lungs and her liver. I could immediately tell that she was very near the end of her life, as she appeared to be in delirium as she uttered inaudible, broken phrases among her labored breathing. She no longer responded to her name when called upon, nor to any sort of auditory stimulus. The doctor told us that she had huge pressure ulcers on her back and bottom, the largest of which measuring 15x15 cm. She pointed out the numerous flies that were flying specifically around the patient, and later informed us that she believed that the flies had laid eggs in her pressure ulcers, and that she expects to find maggots (fly larvae) in the ulcers during her next home visit (if the patient lived that long). She would then have to remove the maggots, one by one, and rewrap the ulcers, hoping that the flies wouldn’t be able to find a way inside of the bandages again to lay more eggs. My heart sank at this news, both out of sympathy for the patient as well as frustration that she had no choice but to remain in this environment, which was so inhibitory to her comfort and well being.
            In conclusion, I am very fortunate to have been given this opportunity to go into people's homes in a foreign country to gain a new perspective into the world of palliative care, healthcare, and life in general. In my reflections, I had one dilemma that I could not shake, but I'll go into that more later. For now, here's some pictures from our day in Muttacadu. Thanks for reading!

One of the chickens decided he wanted in on the doctor's visit, so he strolled right into the home of the patient.

Aparna and I discovered this grave in the backyard of one of the patients. We asked the doctor why they would bury someone in their backyard, and she explained that the patient's father was buried there, and that this was a fairly common practice for people who cannot afford to be buried in a cemetery.

Jackfruits growing in a tree along the path into the patient's home.

One of the children I gave a Hawkeye bead necklace to.

Two grandchildren of a patient who were happy to be decked out in Hawkeye spirit with a beaded necklace and a tiger hawk tattoo to support Team Iowa.

Home Visits: Day 5 (Palode)

            Today, I made the 1.5 hour drive to Palode with Abbey, Jackie, and Mara, to work with Dr. Biacin and a team of nurses and volunteers from Pallium India. The day got off to a slow start when I woke up and was feeling pretty crappy, but lucky the Imodium kicked in just in time that I decided to go. We left our hotel at 7:45 am and followed another van with the Pallium team in it, and saw 8 or 9 patients throughout the day.

            The very first patient had undergone a leg amputation due to a vascular disease and diabetes. The man appeared to be in high spirits, and was laughing and carrying on with his son and neighbors that sat in on his appointment with us. He informed us, however, that he had applied for a disability pension from the government but was denied, leaving him without a stable income. One of the nurses explained to him that he has a right to know why he was denied under the “right to information” act or something to that effect, which I believe he was going to check into. I think that’s a testament to the fact that Pallium doesn’t just plug people full of meds and move on like sometimes happens elsewhere and even in the U.S, but takes it’s time with each patient to ensure well-rounded, holistic care.

            The next patient that stood out to me was a woman who had been diagnosed with cancer of the buccal mucosa (cheek), who was tearful when we entered and was very visibly in a lot of pain. She had undergone a partial mandibulectomy (had part of her lower jaw removed), and her tumor had grown and spread to both sides of her mouth. One one side, she appeared to have a blister or abscess of some kind which appeared to be infected, and on the other side, the tumor had broken through the skin and began to ooze. The woman had great difficulty talking, swallowing, and finding comfortable positions in bed which prevented pressure from being applied to her cheeks. The Pallium team prescribed her some pain medication to make her more comfortable, as well as an antibiotic to reduce the infection in her abscess. I can’t imagine living with something as painful as that must have been, but it was some consolation that she had a daughter that took very good care of her, and a small grandson to cheer her up.

            The next patient was an elderly man whose family was in the process of building a new house, and they were essentially living in a tent in the front of their new property while it was being build. Both of his legs were becoming gangrenous, and Dr. Biacin wanted to admit him to Pallium’s hospital for treatment, but the family refused because they were focused on building there house, and could not delay the process any more. Keep in mind, the family was physically building their own home, not a contractor or anything like that. Nonetheless, it was hard to see a family that didn’t understand the importance of getting their loved one medical treatment, despite encouragement from the Pallium team.

            The last patient that I won’t forget was a very elderly woman who lived alone in a small house in the forest. To be honest, I couldn’t even understand what her diagnosis was, but I don’t believe it was anything incredibly terminal. What really struck me was that she told us that her only son had gotten married 6 years ago and hadn’t come back to care for her ever since, which left her alone in a very remote house with no doors to fend for herself. The Pallium team had previously mentioned the option of selling her home and having her move into a home in the city, which she was somewhat open to. They made some phone calls today and discovered that it was her son who would have to take her to into the home and fill out the paperwork for various legal reasons, and she was convinced that he would never do this, because it would mean he likely wouldn’t get the money for her house and land. I was incredulous at the cruelty and selfishness of the situation, but attempted to refrain from passing judgment, as Dr. Raj had warned us that we must remember that we know very little of their backstory and family dynamics. The Pallium team then decided to call the police department and ask them to come out and assess the situation, as it could be considered abuse or neglect of a dependent person, in which case the woman could be taken to the nursing home and the need for the family to fill out legal paperwork could be overridden. I truly hope the police department arrives quickly and is able to help this woman out, because I can’t imagine living even one night in that home all alone when you can’t even get out of bed.

            After the home visits were through, we stopped at one of the volunteer’s family members’ restaurant for lunch, but I stuck to drinking water as I was beginning to feel pretty crummy again. The ride home thankfully went quickly, and I immediately went to bed to take a nap. I feel slightly better now, a few hours later, and am hopeful that I will have made an even bigger comeback when tomorrow morning rolls around so that I can be physically and mentally present for my final day of home visits. Until then, have a fabulous day, and thanks for reading!

The living quarters of the family in the process of building the new home.

This patient had used her clothes line to hang her IV.

The grandson of one of the patients. He was very playful and excited to see us!

Bidding our farewells.

Dr. Biacin examining a patient.

A rubber tree. The tree bark is cut around a portion of the trunk, and the sap (the thick white liquid) drains down into the cup. The sap is then mixed with a chemical similar to acetic acid and is layed in the sun to dry (see below).

Rubber sheets in the process of drying. The individual will then take the rubber to market and sell it for money.

Our team for the day!