Frustration

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I figured it out! There is a local government body called the Municipal Corporation of Greater Mumbai (MCGM), which amongst other things, funds and operates KEM Hospital to serve Mumbai's urban poor. It has allowed the hospital to evolve into the massive tertiary care center that is has become. Cost of care for the citizenry is heavily subsidized by the MCGM, which operates on an enormous budget funded by taxpayers. I suppose this is not unlike how our county hospitals operate under state tax revenues in the USA, but because of the high volume of generic pharmaceutical manufacturers in India, KEM is able to provide cheap medicines that would be enormously expensive in the USA. For example, Zosyn (Piperacillin-Tazobactam), our famous shotgun-approach IV antibiotic, is priced at a mere fraction of the cost here. I would be willing to bet, however, that a number of the generics produced here violate patent laws, but that's just a guess.

I always assumed that patient protection laws were completely absent in India, as evidenced by my liberal digital camera shots. But Indian health care is changing every day. Even in a hospital like KEM, which is a treatment center largely for the indigenous poor, "medico-legal" cases are becoming more prominent. The philosophy of diligent and proper documentation is gaining more and more traction here, and Dr. N.D Karnik is at the forefront of that cultural shift. On rounds, he is very quick to bring up the medico-legal issues about a number of cases, urging (and even pleading, on some occasions) his residents to frame every case as if a lawyer was going to be pining through the chart at any moment. To paraphrase his message, "It means ass if you fail to document properly." And this is a very, very public hospital, mind you. You can imagine that its an even greater focal point at private hospitals.

Lack of preventative health care really shows here. I can't tell you how many patients I have seen in my mere 2 weeks who are admitted into the hospital with end-stage kidney disease, thanks to totally uncontrolled diabetes and hypertension (the 2 chief reasons for kidney failure, not only here but in the USA too. Ranjani, I would love for you to weigh in on this). It seems like every second patient has an AV-fistula for dialysis. And it is not their fault in most cases. So many of the patients here are barely making ends meet. They are working like dogs at their job, and they have many mouths to feed at home. To ask them to follow up regularly with a primary care doctor, check their blood pressure and sugar regularly, and purchase medicines is a fool's errand. What's more, lack of education and distrust of allopathic medicine don't help the cause.

A stark example: A young boy recently diagnosed with Tuberculosis Meningitis was taken home by his grandmother, because she believed natural therapy was all he needed. Also, the boy's income was helping to feed the family. His family could not afford for him to stay at the hospital any longer. This kid got treatment for only 2 days when, in order to treat this disease, he will require 9 months of treatment. And now he's back at home. He is going to die, plain and simple. I nearly pulled my hair out when I found out that he had left.

OK OK sorry for the buzzkill post. Here are some of the interesting cases I have seen in the last couple of days! You can see pictures from some of the cases below!

1) Neurocystercercosis - the parasite Taenia solium is responsible for this infection of the brain. It is actually a tapeworm that usually comes from ingestion of poorly cooked pork. This patient was a Muslim, so don't ask me how he ended up getting this. He presented with adult-onset epilepsy, which is the most common presentation of this. I have a nice picture of the CT scan below. Treatment depends on whether the parasite is alive or dead. Albendazole is the anti-helminthic of choice with anti-convulsants also required.

2) Liver abscesses caused by Entamoeba histolytica. This crafty parasite lives in your large intestine until it decides to burrow into your venous circulation and follow the portal circulation to the liver. The big things you see are fever + chills + significant abdominal pain in the right upper quadrant, and weight loss (sometimes). Bloody diarrhea occurs very rarely and did not occur in my patient. My patient also suffers from alcoholic liver disease, so at this point, his liver is basically useless. Treatment is generally very effective, and Metronidazole is the drug of choice.

3) Malaria - OK, maybe this isn't all that exciting to you, but hey, I never see this at home!

4) Syringomyelia in a kid with Arnold Chiari Malformation Type I - I did not realize that these two conditions actually carry an association. He had the classic symptoms of loss of pain and temperature sensation in his upper extremities. In fact, he even burned himself unknowingly on a number of occasions!

5) Tuberculosis meningitis - as I mentioned above. Apparenly, the BCG vaccine that Europeans get can protect you against this form of TB, although it doesn't work well against the pulmonary kind. Treatment is just like with pulmonary TB.



That's all I have for now! It's election day in Mumbai, and everything is shut down. It's basically a holiday. Take note, USA.



Sunjay

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