Portable Audiometry Clinical Research in Tamil Nadu, India
Global Health Blog: India 2017
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 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.
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.
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 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, 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!
South Indian coffee
Week 2: November 6 - 10, 2017
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.
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 (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 (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 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.
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?
After portable audiometry testing
24 hour emergency room at St Thomas Hospital
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.
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.
Aulina and adopted puppy Belle
Large Banyan tree, the national tree of India
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
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.
Hills surrounding CMC Chittoor campus
Last day at Modale
Learn more about SHOEBOX portable audiometry at https://www.shoebox.md/.