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Quality of Life for Tracheostomy Pediatric Patients in Vellore, India (Fall 2018)

by Cara Katzer, MD

CMC in India

From the gracious visions of Dr. Kevin Sykes, Dr. Sufi Thomas, Dr. Shannon Kraft and Dr. Alex Chiu, I begin my month abroad heading to Christian Medical College in Vellore, India as part of the Global Health Track at the University of Kansas Medical Center (KUMC). This research track was established, in partnership with the faculty, by Dr. Sreeya Yalamanchali, current chief resident in the KU Department of Otolaryngology.

CMCChristian Medical College and Hospital (CMC) first opened its doors in 1909 under the direction of Dr. Ida Scudder, an American missionary, as a one-bed clinic to serve women. In 1902, she built the 40-bed Mary Taber Schell Memorial Hospital for women and children. The main hospital moved to its present location in 1924, and treatment was extended to men and children. At present, it is a 2,234 bed multi-specialty, tertiary care teaching hospital with patients from all over the world. Dr. Naina Picardo, Associate Professor of the pediatric ENT unit at CMC and a previous Modale Scholar of KU, has graciously collaborated with Dr. Yalamanchali before me. Now, instead of pioneering this relationship, I am tasked with cultivating it and, for that, I feel beyond privileged.

Through Dr. Naina's vision, we have extended our collaboration to include faculty of Children's Mercy Hospital: Dr. Daniel Jensen, Assistant Professor and Dr. Pamela Nicklaus, Pediatric Otolaryngology Fellowship Director and Associate Professor. Children's Mercy Hospital (CMH) of Kansas City was first imagined in 1897 by the two sisters Dr. Alice Berry Graham, a dentist, and Dr. Katharine Berry Richardson, a surgeon, as a single bed in an existing women's hospital. The first standalone hospital opened in 1904, quickly outgrowing its capacity and moving to its second location in 1917 before moving to its final location in 1970. Currently, it is a nationally recognized, academic and tertiary referral hospital for pediatric patients with multiple subspecialties and 301 beds at its main campus

CMC

Both institutions have rich foundations in missions of mercy and serving patients from all walks of life. This project takes root in these foundations and is under the guidance of two robust ENT departments. Here, we aim to investigate the quality of life of pediatric tracheostomy patients and their caregivers in Kansas City and Vellore, India. This project centers on understanding barriers to tracheostomy education, qualifying the caregiver experience, and identifying methods to improve quality patient care. In this collaboration, we challenge ourselves to grow beyond the tired method of retrofitting Western medical practices to a non-Western country and to understand what patients and medical providers on other side of the world may have to teach us. Though I am mindful that my opinions and observations are colored through my American glasses, that is where this project takes root--that across oceans of culture, barriers of language, and vastly different resources, there remains this unifying drive to understand our patients and change their experience.

I am both eager to get started and anxious of the shoes I must fill. While nothing can be completely accounted for, I remind myself I am not alone on this journey: I have the backing of three departments, all who are working for our success and who are lending their knowledge, expertise and wisdom to this project and relationship. As I journey, I task myself to stay humble; to remember the visions of our founders; to channel the drive of my mentors; and to draw inspiration from our patients. By sharing our perspectives and relying on one another, we are a true collaborative that has the potential to expand beyond my short time abroad.

Vellore Vellore Vellore

First Days: November 1 - 4, 2018

It is easy to be caught up in the whirlwind of India on first arrival: queues pose as examples of organized chaos, and the native language of Tamil sounds like a mumbled flurry of consonants. I feel lost, tired, and confused. In my jetlag, I struggle to negotiate a cup of coffee. In addition to being unable to speak the language, I am puzzled by the strange but infamous Indian head-shake that simultaneously means yes and no, as well as a variety of other interpretations. My taxi from the airport broke down no less than 4 times before I made it to Vellore, stopping periodically at different road-side stalls where my driver is told they have the part, but to come back in 5 minutes (which really means anytime between 5 minutes to several hours), and they never manage to procure even a mechanic. Eventually, I made it to the Bagayam campus of CMC, which offered relief from the crowded and noisy streets encountered on my tour of the various auto-shops along the way from Chennai to Vellore.

CMC in Vellore CMC in Vellore CMC in Vellore

After travel, paperwork, badging, and more paperwork, the following day I make my way to CMC. The hospital has long outgrown its footprint, and patients spill over into every available space. Sometimes it feels like there is no room to breathe, let alone navigate the winding corridors. I meet the unit II (pediatrics) ENT department and my mentor Dr. Naina, which has been a long-anticipated event since our introduction over emails dating back to over a year ago. I am immediately greeted by warmth and excitement from every member of the staff, most enthusiastically Dr. Naina. Then in a manner that matches the urgency and bustle of the hospital that surrounds us, we waste no time in getting started and immediately take action to interview our first patient on day one. We buzz through the questionnaires with an intense efficiency and, then, just as matter-of-factly, we decannulated the patient. In the span of less than 30 minutes, our patient and her family, who over the years have undergone such hardship and sacrifice on behalf of their daughter, were relieved of her tracheostomy. I felt honored to share in this moment of triumph. Though, I think if I would have blinked, I would have missed it. In nearly the same breath, after a rushed hug and unceremonious celebration with Dr. Naina, the family was ushered out to their next appointment, and I was whisked off to rounds, trying not to lose myself in the maze that is CMC. While, so far, the experience has been at times dizzying, I already feel grounded in the work I came to do.

ENT at CMC ENT at CMC ENT at CMC

Week 1: November 5 - 11, 2018

After a restful weekend and some time spent exploring Vellore, fellowship and collaboration weave their way into my work and study at CMC. Between patient caregiver interviews, Dr. Naina and I have strategically organized meetings with faculty and staff from a variety of departments that also care for pediatric tracheostomy patients.

One such provider is Dr. Pragathesh, a pediatric critical care consultant. He shares our concerns about patient and caregiver quality of life and similarly wonders how his own patients fare after leaving the PICU. Dr. Pragathesh has been working with the pulmonology, pediatric, and ENT departments at CMC to start a multidisplinary outpatient service for patients after prolonged respiratory failure for pulmonary diseases such as ARDs (acute respiratory distress syndrome). He is eager to hear of the medical home model our own vent clinic at CMH exemplifies, as Dr. Pragathesh hopes to reimagine the current workflow of the OPDs (outpatient departments) for this clinic. OPDs at CMC provide a single room for the physician, which patients quickly rotate between. Each provider sees upwards of 40 patients with each clinic, and this constant flow of patients is necessary given the nearly 8,000 patients who visit the OPD building each day. Because of this demand, it is infrequent for providers to meet together for a single patient; however, this is not for absence of teamwork at CMC, which seems to be at core of the institution. They host many multidisplinary case conferences and, at the drop of a dime, I will see physicians call or meet with one another for an impromptu consultation.

Pediatric Care at CMC

These spontaneous moments seem to define the energy of the hospital. A brief minute-long hallway encounter leads to an in-depth meeting with me and two skull base surgeons in the ENT department to discuss their work on juvenile nasopharyngeal angiofibroma (JNA) as areas for future collaboration. And reminiscing about Dr. Sreeya Yalamanchali's work with the portal audiometer, SHOEBOX, (read more about her experience below) allows me an invitation to see the progress they have made incorporating portal hearing services into their community health programs! While structure and schedules can easily be dismantled by these passionate but unprompted encounters, somehow, at the end of the day the work is done, appointments are kept (albeit sometimes later than proposed), and new collaborations are founded. While Dr. Pragathesh's vision may challenge the current system, it is obvious that CMC as an institution is constantly imagining beyond their current practices, serving as a model of innovation for healthcare in India.

I also tour the Neuro ICU with sister Mercy Jesudoss, a nurse who visited KUMC in 2013 as a part of the Modale Fellowship along with Dr. Naina. She greets me as an old friend and provides insight into the daily care and discharge education for tracheostomy patients. The Modale Fellowship was pioneered by Dr. Mani M. Mani, Emeritus Professor of the Facial Plastics Department at KUMC and former CMC graduate. Through the KU Office of International Programs, an exchange program between CMC and KUMC Departments of Nursing and Allied Health has been active for over a decade. And, therefore, it is at every turn I find yet another person who was briefed on my arrival. Each extends an offer of coffee (which I can now order independently), a tour of Vellore, or simple advice and encouragement. In the words of one such colleague, once you know one person at CMC, you seem to know everyone. My evening is filled with activities, including: kurta shopping (a traditional Indian garment) with perioperative nurse Anita Jayakumar; a rooftop dinner with the family of Orthopedic consultant Dr. Justin Arckiaraj; and an invitation by the ENT department to their welcome event for new fellows and interns. I also begin to discover the international students on campus who help me find the best restaurants and navigate the public buses. We even have the chance to celebrate Diwali and enjoy the fireworks from atop the College Hill.

While I arrived feeling uncertain, much to my surprise, I seem to have been unknowingly integrated into the CMC family, the sentiment compounded by the practice of strangers and friends alike greeting one another as "brother" or "sister". Next week, more study participants are scheduled, and I will observe how this "family" serves its siblings through the community health outreach programs.

ENT at CMC ENT at CMC ENT at CMC

Week 2: November 12 - 18, 2018

CMC

Among our research participants, one theme consistently reappears in conversations: there's limited access to help outside of the home. Many caregivers have moved away from their family networks in order to be closer to healthcare centers. In some households, the second caregiver (and income earner) travels for extended periods of time for better paying work, thus leaving a single care provider at home with a tracheostomy dependent child. Imagine, sometimes without reliable electricity or running water, when both the care of the child and frequently income for the family, is dependent on one person. With no one else to look after the child at home, cash must be generated from work that must be performed with the child always at your side. Each day there is the constant dilemma between buying food or medical supplies to clean and suction the tracheostomy. Each night is a struggle between needing to sleep verses worrying you will not wake when the child needs immediate suctioning. For many of our patients, they fight these battles without help from family or neighbors. This story of isolation and vulnerability, is not unique to pediatric tracheostomy patients nor to other types of patients in India. It is a common problem for patients with chronic diseases and their caregivers in most countries, including the United States. The question is, how can we better support these families? In the U.S., one solution of paid in-home nursing or care assistants is available to some, particularly those with the right insurance plan, comorbidities, or financial situation. But another model, accessible for patients in Vellore and its surrounding villages, is reliance on a strong community healthcare network.

CMC has been a leader and role model for community-based care, with a variety of clinics and programs centered around this concept including: the Low-Cost Effective Care Unit (LCECU), the Rural Unit for Health and Social Affairs (RUSHA), the Community Health and Development Unit (CHAD) and the Community Health Nursing Program (CONCH). Together, these programs provide basic healthcare to both urban and rural patients of Vellore. Collectively, they provide low-cost care (including subspecialty services such as ENT, Ophthalmology, Obstetrics and Gynecology, Psychiatry and more) as well as healthcare screenings and immunizations. When necessary, they provide direct referrals to CMC for more complex care or additional work-up. More information about these programs can be found here.

This week, I had opportunities to visit the LCECU as well as rural and urban divisions of CONCH. CONCH provides services at community health departments as well as in-home consultations through the College of Nursing. Their area of service includes 22 rural villages with a population of approximately 65,000 people, in addition to 23,000 people living in the urban periphery of Vellore. During our home visits, Jennifer Angeline, an intern in the Division of Audiology and Speech Therapy, has recently renewed hearing screens at these health encounters. Ms. Jennifer was able to provide several ENT referrals for some types of hearing losses; other patients were offered formal audiograms for hearing aids in addition to counseling and reassurance. While this service is largely thanks to the infrastructure of CONCH and Ms. Jennifer's own interest in community-based health, this re-invigoration was partly inspired by the innovative work of Dr. Yalamanchali's research validating a portable audiogram model.

Rural Healthcare Rural Healthcare Rural Healthcare


Central to the need for these home visits remains inaccessibility to healthcare and often underlying fear. Many people expressed anxiety with healthcare providers in general, given their lack of exposure; some are isolated by illiteracy, language barriers, or financial limitations; and others still live in seclusion secondary to their disease processes or denial of their own healthcare problems. But thanks to attentive citizens of the villages, these clients (patients) were identified as needing in-home services. Through volunteer village leaders, nurses of CMC and the CONCH program were recruited to visit these homes. While these home encounters utilize a significant amount of two of the most valuable resources at CMC, time and expertise, they provide much more than individualized care. They also instill a sense of trust in the hospital and its providers, as well as the community by encouraging its participants to rely on each other. In this way some of our tracheostomy patients directly benefit from this strong network and are visited by members of the CONCH program during times of need and thus integrated into their community. While in no way do these initiatives alleviate all the care needs of our local families, they do help shoulder some of these burdens.

The core values of community, service, and generosity are evident in the daily work of CMC. They appear in the big moments like the ones mentioned above but also the little ones too such as freshly acquainted colleagues sharing new Indian treats with me (my current favorite being besan barfi) or a physician giving a patient ₹100 to help pay an unexpected bill. These daily reminders provide both moments of reflection as well as inspiration, and I hope to carry them home with me.

CMC for Rural CMC for Rural CMC for Rural

Week 3: November 19 - 24

Questions remain in my mind; how do we break down these remaining barriers? How do we reach our most vulnerable patients? This week marked the 40th year celebration of the mission at CMC's RUSHA (Rural Unit for Health and Social Affairs), and I was honored to visit the ENT OPD with Dr. Vikrem, junior faculty of ENT Unit III (Rhinology Division) during this time. After nearly half a century, the initial visions of RUHSA, have nearly all been accomplished. The directors, while obviously thrilled at their successes, also understand there is still so much progress to be made, and complacency will only lead to a dated and irrelevant health system. With this milestone, RUSHA hosted 2 renowned physicians who have pioneered missions in rural and global health, to help move RUSHA forward. During this consortium meeting, a new mission statement for RUHSA was drafted for consideration and approval at CMC. Knowing that others at CMC are also dreaming of change, brings me hope for our patients and their families. What an inspiring time to make my visit!

RUHSA RUHSA RUHSA

Unfortunately for the rest of Tamil Nadu, the horizon wasn't quite so bright. Cyclone Gaja hit the east coast bringing gale force winds and heavy rains with unexpected flooding. In Vellore, this meant many of our participants were unable to safely travel to CMC. While an obvious disappointment and setback to our study, Dr. Naina and I knew in advance that, given all the hardships our patients face, data collection would have to continue even beyond my brief trip. So in the face of the unexpected, I take a deep breath, hang my shoes up to dry, and keep trudging forward-even if the water is calf high.

On a lighter note, this week I was also able to celebrate Thanksgiving in Vellore. While I missed my friends and family at home, I certainly didn't celebrate alone. I had my CMC brothers and sisters to help me explore new traditions. Instead of pumpkin pie, I shared equally orange rava kesari with the ENT II unit, who decided after I described Thanksgiving to them to refer to the holiday as American Diwali. With my good friend Anita, I ate a delicious Thali meal, which just like at Thanksgiving, is followed by the same satiated sleepiness. Despite being halfway across the globe, I still found my heart - and my belly - feeling full this year.

Diwali Surgery at CMC Rainy CMC

Week 4: November 25 - 30, 2018

Cara Katzer MD in India

As my time in India ends, the insights from our patient encounters, paired with my own knowledge of patient care at CMH, spurred Dr. Naina and I to draft a plan to advance the practice at CMC, emphasizing standardized tracheostomy protocols and a multidisciplinary approach. Not only was I able to discuss our findings and recommendations to the ENT II unit, but I presented to the PICU team as well! Both units were supportive of our proposal and, together, they aim to finalize the goals in the upcoming weeks. It is both powerful and humbling that, in addition to my own transformation, my experience has provided the momentum to institute change at CMC as well.

This journey, which started with great uncertainty--uncertainty of the project's potential success, of a culture and place different than my own, and of a medical system in which I have never practiced--has been one of affirmation, but also revelation. It has confirmed my belief in collaboration, through which our successes would never have been possible. I have made more colleagues, mentors, and friends than I could have ever imagined. And I have learned more about myself than I can put into words.

Until I can return to India, the work will carry on, both from afar and on the ground. For now, the real work, the work to finish the research we started and to transform patient care, begins. 

KU ENT at CMC CMC partners CMC partners

Portable Audiometry Clinical Research in Tamil Nadu, India (Fall 2017)

by Sreeya Yalamanchali, MD

Entrance to Christian Medical College
Main entrance to the Christian Medical College campus in Vellore City, India

Week 1: October 30 - November 5, 2017

Ask any international student how they felt on day 1 at Christian Medical College, and unanimously the word is "overwhelmed". Overwhelmed with the large crowd of people, overwhelmed with the number of languages spoken on one campus, overwhelmed with the wide variety of pathology seen in one day, and overwhelmed with the hospitality, patience, and kindness of the staff and patients. But once the initial shock passes, you truly see what CMC is: a melting pot of cultures, religions, languages, and ethnicities all working towards the common goal of providing the best health care possible to each and every individual that enters the campus gates. 

Main hospital building of the CMC campus in Vellore City
Main hospital building on the CMC campus in Vellore City, India.  Lots of rain due to the southern monsoons, hence the clouds

Christian Medical College, founded in the 1900's by an American Medical Missionary Dr. Ida Scudder, is located in the city of Vellore in the state of Tamil Nadu in India. It is a non-profit organization with an emphasis on health care for all, missionary work, education, and research. For decades, it has been ranked as one of the top institutions for health care in the country. Over the course of a day, the CMC campus sees over 8,000 outpatients in their outpatient department (OPD), and has approximately 2,133 inpatient beds. It has two campuses: the main campus is located in Vellore City and the other at Bagayam, approximately 7 km from the main campus. The Bagayam campus is similar to a college campus, consisting of housing quarters for students and doctors (including Modale hostel for International students where I am staying), buildings for undergraduate classes, and the Community Health and Development (CHAD) program that serves the rural, semi-urban and tribal population around the area. With parents who completed medical training in India prior to immigrating to the United States, CMC was always described as the premier destination for medicine in India. Thus, when the opportunity to collaborate with the ENT department at CMC was available, I was excited to experience first-hand the place I had heard so much about.  

Outpatient building block at CMC
The Christian Medical College outpatient building, where over 8,000 outpatients are seen every day

Thanks to the vision of Dr. Alex Chiu, Dr. Shannon Kraft, Dr. Kevin Sykes, and Dr. Sufi Thomas, I was granted an opportunity to help develop a new Global Health/Community Outreach Track for the KU ENT Residency Program. The purpose of the Global Health/Community Outreach Track is to a) support research efforts, b) promote physician engagement in community outreach efforts, and c) build sustainable partnerships with the intent of improving health care delivery in resource-limited settings.  

Students from KU Medical Center's allied health departments such as nursing, occupational therapy and physical therapy departments have rotated through CMC due to the efforts of the KUMC Office of International Programs and Dr. Mani M. Mani, a graduate of CMC and Emeritus Professor in the KUMC Department of Plastic Surgery. Previous visits by Dr. Doug Girod and Dr. Kevin Sykes lay the foundation for choosing CMC as the initial collaborative institution for KU ENT. After months of introductions, meetings, and e-mail communication with the CMC ENT department, we decided to embark on a project to validate a portable audiometer called SHOEBOX in the South Indian population and subsequently put it to use in different rural settings and clinics. Hearing loss is considered by the World Health Organization the most prevalent disabling condition globally. The majority of developing countries have less than one audiologist to serve every one million people, and are usually restricted to tertiary-hospital based institutions or specialized centers found in larger towns. By implementing the SHOEBOX portable audiometer, we hope to provide hearing healthcare to those with limited access. Dr. Ruby, the chair of ENT at CMC, and Dr. Picardo, the Principal Investigator in India, have worked tirelessly on the finer details of the project, from presenting at the IRB meeting and delineating the work space, to designing consents in English, Tamil, and Hindi, all in the efforts of conducting a safe and viable long-term project.

Modale Hostel for international students
The Modale Hostel was built by Dr. Mani and his family to host international students from around the globe

After orientation on Day 1 in India, I missed the college bus that is strictly for CMC students which shuttles between the Bagayam college campus and the main CMC hospital campus. I was thus instructed to take the city bus that stops right outside of the Bagayam campus, whose route includes CMC hospital. The conductor announces the stop, in Tamil of course, a language that I can barely comprehend, and is not at all similar to my native language Telugu. My family is from Hyderabad (a city in a different state in India), which is one of the most industrialized cities in India. I've travelled to India almost every year, but always to the city, and when traveling around India, I was always with family. Thus my experience in Vellore is quite different for me: living in an Indian village town by myself and unable to speak the native language. However, the beauty of India is, strangers treat each other as family, referring to one another as "brother" and "sister".  After getting on the bus (which, by the way, only rolls to a stop and you must fight your way up the steps before it gains momentum again), I realized the CMC stop was not clear, and I could not understand a word the conductor was saying. As the bus started getting crowded, I turned to the lady sitting next to me, and only said the words CMC with a questioning look. She did not speak any English, yet everyone in the town of Vellore knows CMC. She motioned to me that CMC was also her stop (somehow we understood each other even though she spoke Tamil and I was speaking English), and when the time, she grabbed me by the arm, helped me fight the crowd to exit the bus (again jumping off while the bus was still rolling), crossed the street with me, showed me the gate to CMC, and then continued on her way down the street. If it were not for her kindness, I probably would have been on the bus all day.  

Campus library at CMC
Campus library at Christian Medical College in Tamil Nadu, India

A typical patient day at CMC consists of an initial consultation with the doctor in the morning. Based on the assessment, pertinent tests and imaging are ordered by the doctor and completed by the patient throughout the day. Once tests are completed, the patient is seen again in the afternoon, or the following clinic day, to review their workup and a recommended treatment plan. The majority of patients travel far from all parts of India and from even outside the country (most notably from Bangladesh) to be seen by the CMC physicians. Patients stay in Vellore city for a few days up to a few weeks to finish the workup and treatment prior to returning home. With an already busy patient day, I was somewhat apprehensive that our project would disturb the clinic flow of the physicians, the staff and the patients. Each attending sees an average of 40 patients on their clinic day, while the residents have their own clinics during which they may see even more. However, the culture of India is such that everyone is a willing participant, no matter how busy they may be. The audiology students are working as my translators (in between their own educational and work demands) and, in fact, some of them have even learned to use the SHOEBOX portable audiometer themselves! Staff and patients are ever so gracious, enthusiastic, and thankful in giving up their time on an already busy clinic day to a project that does not personally benefit them in the short term.  

Strobe room at CMC
Strobe room at CMC, which is serving as Dr. Yalamanchali's clinic room for conducting audiograms using portable audiometry

After an initial adjustment period, Week 1 has been a success so far. We've not only easily enrolled numerous patients into our portable audiometry study, but I've also been effortlessly engulfed into a health care system and resident educational system different from my own. (The constant availability of South Indian food is definitely a plus.) More updates on the project and in-action pictures to come next week!

Modale Hostel for international students College canteen South Indian coffee

Modale Hostel

College Canteen

South Indian coffee



Week 2: November 6 - 10, 2017

Entrance to St Thomas Hospital and Leprosy Center in Chetpet
Entrance to St. Thomas Hospital and Leprosy Centre in Chetpet, India

In week 2, the monsoon rains have finally passed, and the sun has peeked over the stagnant rain clouds. On a bright sunny day, I was granted an opportunity to visit St. Thomas Hospital and Leprosy center in the village of Chetpet, approximately a two-hour drive from Vellore. In the company of Dr. Stanley, an OMFS consultant who makes the trip weekly, we started at 9:00 am on a very serene drive away from the hustle and bustle of Vellore. St. Thomas was a hospital built in 1960 mainly for the treatment of leprosy and continues to this day to be managed by 13 Sisters whose hospitality goes above and beyond (home cooked breakfast and lunch!). Now with leprosy on the decline, it is a multi-specialty hospital catering to the surrounding villages, with multiple services such as Internal medicine, orthopedics, ENT and dental. The ENT clinic sees anywhere between 5-15 patients in one afternoon. Providers attempt to manage patients with the limited resources, or otherwise refer to CMC if medically necessary. 

Laryngology Fellow Dr Kavin Kumar during Outpatient Clinic at St Thomas
Dr. Yalamanchali and Laryngology Fellow Dr. Kavin Kumar during outpatient clinic at St. Thomas Hospital

During our afternoon, we received an inpatient consultation for hearing loss in an 80-year-old admitted for fever evaluation. We put the SHOEBOX portable audiometer to use and performed a bedside audiogram on the sweet old lady, a service otherwise not currently available. She had bilateral severe sloping sensorineural hearing loss and may potentially benefit from hearing aids. In that specific area, a program currently exists for the dispersion of hearing aids after objectively proven hearing loss. We now hope to provide her with hearing aids-a service she was not eligible for before!  

Entrance to Rural Unit for Health and Social Affairs Campus
Entrance to Rural Unit for Health and Social Affairs (RUHSA) Campus

In this same week I also travelled to the CMC RUHSA campus (Rural Unit for Health and Social Affairs), approximately 30 minutes outside of Vellore. Developed in 1977, the objective was to develop a model rural health care center promoting health through provision of affordable medical care. This was an opportunity that developed in passing while talking to one of the junior ENT consultants who identified a need for portable audiometry services at RUHSA.

Inpatient ward and ER at RUHSA
Inpatient ward and ER (known as Casualty) at RUHSA

RUHSA is a campus in and of itself with inpatients wards, emergency services, and outpatient services. Audiology services here are also rare. Over the course of a Saturday morning, local villagers stroll into clinic, most commonly with ear complaints due to the high prevalence of chronic ear disease. A mother was very concerned about hearing loss in her 8-year-old daughter, and with the SHOEBOX portable audiogram we identified a mild conductive hearing loss in the little girl. With that information we were able to better counsel the mother and provide her with re-assurance, which made all the difference to her. 

Dr Divyan during Saturday morning clinic at RUHSA
Dr. Divyan hard at work during a Saturday morning clinic at RUHSA

While the first week I learned the importance of gratitude, this week I learned the importance of collaboration and thinking outside the box. A casual chat with Dr. Stanley led to an in-depth brainstorming session on future project ideas, outside of just hearing loss. A ten-minute informal conversation with Dr. Divyan in the hallway of the hospital led to my experience at RUHSA. A brief coffee break with Dr. Naina led to discussions on improving patient quality of life post tracheostomies (imaging sending home a patient with a tracheostomy to an area with frequent electricity cuts). Inspiring conversations such as these occur on a daily basis.

Courtyard of the outpatient building at RUHSA
The courtyard of the outpatient building at RUHSA.  Beautiful concept!

Everyone here is committed to improving the community in some shape or form. This is an eye-opening lesson during a stage in my training where my sole focus has been education and training. How can I bring back that level of servitude to Kansas City, both for the present and for the future?

Young patient after portable audiometry testing 24 hour emergency room at St Thomas Hospital Bagayam campus
After portable audiometry testing 24 hour emergency room at St Thomas Hospital Bagayam campus

CMC Chittoor campus
CMC Chittoor campus

Week 3: November 13 - 17, 2017

In week 3, I visited CMCs campus in Chittoor, which is in the neighboring state of Andhra Pradesh, about 32 km away from the main campus, where the local language is Telugu, my native language. It is a quiet campus nestled in between low-lying hills. It is a relatively new extension of CMC and is exponentially growing. A sound treated booth exists in their ENT clinic with readily available audiology services via an older portable audiogram which requires electricity and connection to a sound booth. We tested the SHOEBOX portable audiometry outside of the sound booth in patients requiring conventional audiograms and obtained accurate results. At CMC main, having to continuously converse with patients via an interpreter put a damper on the physician patient relationship. I would get frustrated knowing that what I was saying was not being translated as accurately as I wanted. Thus, being able to talk to patients in Telugu at the Chittoor campus and truly connecting with them was reinvigorating. While I may need to brush up on my Telugu medical terminology, I realized the true importance of being able to connect with my patients. 

Vellore cuisine
Exploring Vellore cuisine with other international students

One of the highlights of the trip has been living in Modale International Student Hostel. Students from all over the world travel to CMC for rotations in various departments. Meeting students from Malaysia, England, Australia, New Zealand (did you know a nickname for someone from New Zealand is a Kiwi, their national bird), Poland, Scotland, and US adds to the melting pot of cultures that CMC truly is. It also creates a sense of community as we lean on each other; each week a new group of students arrive, and the older students take them under their wing, teaching them how to maneuver through life in Vellore. We filled the weekends with local activities such as attending the college rendition of fiddler on the roof, visiting the Golden temple, hiking, Zumba classes, evening walks around campus, and at night we would meet for dinner in the college canteen to reflect on our day. It even became a custom for all of us to plan a dinner in Vellore city prior to each student's departure. I thank each and every one of them for making my experience a special one, because without them, I truly would have been lost.

Goodbye dinner Aulina and the puppy Belle Large Banyan tree at CMC
Goodbye dinner Aulina and adopted puppy Belle Large Banyan tree, the national tree of India

My Amamamma and her friends
My Amamamma (Mom's Mother who raised me for the first 6 years of my life in India) and her friends

Week 4: November 20 - 24, 2017

The saying that time flies has never been truer than this last month. Just as I was becoming accustomed to life in Vellore, it is already time to pack up and head back to reality. Our research project was successful and we met our enrollment quota for the SHOEBOX portable audiometry clinical research project! Yet, I still feel there is more work to be done, and to be continued. This last month was truly inspiring, and I feel even more inspired to continue that work back in Kansas City.

Navigating through the initially overwhelming crowd now seems effortless. The sounds of the autos and the cars honking have become commonplace background noise. I used to wish for quietness, but the vibrancy of India becomes an addicting soundtrack. Saying goodbye to everyone at CMC, and Dr. Naina in particular was tough. Not knowing if I would ever see any of these amazing teachers again, from whom I feel there is so much more to learn, makes leaving CMC very difficult. With each goodbye, I promised myself this would not be my last opportunity at CMC. This place has truly changed my outlook on medicine (during a time in my career when I'm inundated with the nuances of residency), my outlook on teaching, on being a mentor/mentee, on being a student, and on life itself.  All the physicians at CMC want to leave the world a better place than how they found it, and that is the contagious energy of CMC, something I truly will miss. 

Dinner with Dr Naina and her family
Dinner with Dr. Naina and her family

Prior to leaving, I visited by family in Hyderabad. When my family heard about my project, they all lined up to have hearing tests. One day, all my Amamamma's (mom's mother) friends stopped by, each wanting their hearing tested. I used one of the bedrooms for testing hearing with the SHOEBOX portable audiometry while the others waited in the living room having a good time with each other and gossiping about their results. I started out this project with my Amamamma in mind.  She had refused to get a formal hearing test in a sound booth, stating that she hated hospitals and that it was a waste of time. Now I brought the portable audiometry service to her, and she was none the happier. Seeing the smile on her face was the perfect end to a life-changing trip.

My Amamamma Hills surrounding CMC Chittoor campus Last day at Modale
My Amamamma Hills surrounding CMC Chittoor campus Last day at Modale

Learn more about SHOEBOX portable audiometry at https://www.shoebox.md/.

Last modified: Dec 03, 2018
Contributors

Cara Katzer MD

Cara Katzer, MD


Sreeya Yalamanchali

Sreeya Yalamanchali, MD

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