Today, I traveled to Murukkumpuhza with Dr. Eland and a
group of 3 other students for our second day of clinicals with the Pallium
India team. We made the hour long drive to the city and arrived at a day clinic
that Pallium India was providing in a local building, at which patients in the
area could receive free visits and medications and not have to travel long,
expensive distances to the hospitals in Trivandrum. We saw 18 patients in the
morning at the clinic, followed by 2 home visits in the afternoon. I’ll outline
a few of the cases that stood out to me in the following paragraphs.
The first
patient was a 58 year old man who had had a bout with throat cancer, which had
gone into remission, but not without chemotherapy and radiation treatments and
the placement of a tracheostomy. Following this, the patient was having trouble
swallowing, so to reduce the risk of choking and to make him able to eat again,
a nasogastric tube was attempted and failed, so a PEG tube was placed directly
through the abdominal wall and into the stomach to feed him. As one may
imagine, the chemotherapy, radiation, and these somewhat infected stomas left
the patient in a lot of pain. He was given a small supply of morphine by the
cancer treatment center, but it was not enough to last him until his next visit
with them. The Pallium team wanted to supply him with more, but the morphine
tablets we had were sustained-release and therefore could not be crushed up and
given through his PEG tube, so they had to prescribe just an antibiotic that
would help to take care of the infection (and, thus, some of the pain) that
could be given through the PEG tube. It was troubling to see a person who was
clearly in so much distress because he could not talk (his wife accompanied him
and communicated his situation to the Pallium team) and could not enjoy food
like we all take for granted. The quality of life in this individual had been
severely compromised.
The next
patient that stood out to me was a man that had previously been turned away by
Pallium India because his only conditions were diabetes and hypertension, which
are extremely prevalent in India (about 80% of the patients we saw were
hypertensive diabetics), and because drugs to treat these conditions can be
obtained for free from the government hospitals. He came back, however, because
he informed us that he is unable to afford to travel to the city (most people
don’t own cars, so he would have to pay for a rickshaw) to obtain the free
medications. He told us that his children had moved out of the area to get
married, and that they did not support him or take care of him in any way. To
some of you this may not sound like such an uncommon thing from a US
perspective, but this is very uncommon in India, as people believe strongly in
personally caring for their family members. Furthermore, he was unable to work
due to his old age and health condition. He told us that he had no income, and
was only able to eat because of a government program that allowed him to
purchase one serving of rice for one rupee, and if that wasn’t available, he
didn’t eat. Because of this, the Pallium team chose to treat him even though he
wasn’t in dire need of palliative
care, which I was glad for. It is difficult for me (and most of us in the US)
to imagine this level of poverty.
The last
patient that I wish to discuss was a man with a motor neuron disease, who was
able to come to the clinic due to the help of his teenage grandson. He was
unable to extend (straighten) some of his fingers, had general weakness, and
had trouble breathing and swallowing at times. We were informed that his
daughter was a nurse, and so him and his family were well aware that his
condition would progressively worsen and ultimately cause his death within the
next year or two. He had been prescribed theophylline (for his shortness of
breath) by an uninformed doctor, which disappointed both Dr. Eland and the
Pallium doctors, as this drug is old, ineffective, and just as costly as other,
more effective drugs. This case really just stood out to me because of the
inevitability of his death because of the fact that we have yet to develop any
way at all to combat this type of disease, as well as the fact that he would
die a slow, drawn out death as his ability to breathe gradually deteriorated.
The Pallium team wished to speak with his family at his next visit in order to
discuss a plan of action to take once he becomes unable to breathe on his own,
which would give them one of two options: to allow him to stop breathing and
die, or to have a tracheostomy placed and to have him put on continuous oxygen.
The family would almost certainly be unable to afford the latter, but the conversation
was necessary in order to ensure that the patient’s wishes be known before he
is unable to express them.
Overall, I
think today was more of a heavy-hearted day. Although we didn’t see anything
extremely shocking compared to yesterday, I think the initial anxiety of being
in a clinical setting in a foreign country had worn off, and I was more able to
absorb the reality of the situation for the patient and their families. I
definitely learned a lot today, and I look forward to continuing to do so over
the next week and a half that remain. As a footnote, I was also able to purchase a new pair of eyeglass frames and prescription lenses at optical store next door to our hotel, all for the equivalent of 50 U.S. dollars, and which only took 1 day to get ready. What a deal! Thanks for reading! :)
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| Removing one's shoes is customary before entering many homes, businesses, and places of worship in India. |
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| One of the women we made a home visit to see. |
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| "One's destination is never a place, but a new way of seeing things." -Henry Miller |
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