Namaste Hyderabad

Today was our last day in Hyderabad. Before we all left to go our separate ways, we had one last meeting scheduled at Care Hospital with Dr. Krishnamohan. We arrived at CARE at 10:00 and went to see Dr. Krishnamohan in the Cath Lab. Apparently, he had been working all night and there had been two temporary pacing procedures at night and another one early in the morning. He decided to walk us around to see the patients so we could observe how the temporary pacemaker was secured, how the patients were doing, and how their ECG signals looked.

Dr. Krishnamohan also brought us into the imaging room to look at the xrays and fluoro images of these patients. While we were in this room he also showed us some of the leads that the hospital is using and even allowed us to play around with one and see how it felt. This was a really education and helpful experience for us and we really appreciated Dr. Krishnamohan's help with us.

Dhananjay, Dr. Krishnamohan, Erin, and Shruthi at CARE Hospital

Before we left CARE for our last time, we made sure to take a picture and thank him over and over again for all the help he provided us on this trip and over the past few months. We are looking forward to continue our collaboration with him and are hoping to have the chance to come visit again with prototypes later in the spring.

After leaving the hospital we headed a few buildings down the street to Karachi bakery to pick up some Karachi biscuits (cookies), which are famous here in India, to take home to our families. We then made our way back to the Taj Banjara and past our favorite lake for the last time so we could pack our bags and head out. Dhananjay was heading to Mumbai and Erin and Shruthi were heading to Jaipur for the next few days. The car took Dhananjay to the airport while Erin and Shruthi went to visit her families place where they enjoyed a nice authentic home cooked, South Indian meal, and got Mehndi (henna done).

Mehndi on the front of Erin's hands

Mehndi comes in three different styles, Arabic, Indian, and Designer. Both Erin and Shruthi decided to get Indian, which was an intricate pattern completely covering both the front and back of their hands. Each person's Mehndi can take anywhere from 45 minuts to two hours depending on the level of detail and how much of the arm is done. Once the Mehndi has been put on, you are supposed to wait anywhere from 4 hours to 24 hours for it to dry before peeling or scraping it off. Apparently the longer the Mehndi sits on your skin, the darker the color gets. Unfortunately, Shruthi and Erin had to leave for the airport at 4:30 so they were not able to remove the Mehndi until they got to the airport. Luckily, at this point everything was dried, so it came off pretty easily and they were able to have two fully functional and extremely intricate hands.

Erin and Shruthi with their Mehndi and trying not to touch anything

Erin and Shruthi will now be sight-seeing tourists for the next few days with David, who will be meeting up with them in Jaipur. Dhananjay is going to be visiting friends in family in his hometown and Mumbai and will be heading back to America at the beginning of January for our Spring semester.

Until our next global health trip, Namaste and thanks for reading!

A Day With the Village People

Yesterday was our last full day of work in Hyderabad. We decided to visit the peripheral city of Mahabubnagar because Dr. Krishnamohan had a cardiologist contact at a hospital in the town.

We left Hyderabad around 10:30 and set off on our 100 kilometer journey to Mahabubnagar. Knowing that we were going to a peripheral city, we were all expecting a treacherous journey similar to our drive to Baharampu. We were all pleasantly suprsised to find a smooth drive, with nicely paved roads, very little traffic, and only an hour and a half drive. In fact, the ride was so smooth, that all three of us were able to fall asleep on the drive, even when crammed into the back of a tiny car.

SVS Medical College Hospital

We arrived to SVS Medical College in Mahabubnagar around 12:00pm and were immediately brought to the Cath lab. While we sat in the Cathlab area waiting for Dr. Sanjeeva Kumar, a cardiologist and one of the founders of the cardiology department at the hospital, we could not help but admire the facilities in this hospital. Everything was extremely well kept, the entire hospital looked clean, and this was in a place where the majority of the population was under the poverty line. SVS is a private hospital, however, because of the Aarogyasri insurance scheme, patients below the poverty line are able to get free medical care at private facilities such as SVS. 

Paitent shoes outside of the Cardiology department

Anyways, while we were waiting for Dr. Kumar to finish with his patients and a procedure, Shruthi decided to go into the Cath Lab with him and watch. The Cath Lab was very similar to Hopkins: extremely nice equipment, very clean, and the doctor started and finished the angiograph in under ten minutes. 

Authentic South Indian lunch we enjoyed with Dr. Kumar at the hospitals cafeteria

When we finally had the chance to talk with Dr. Kumar and Dr. Narayana, another consulting cardiologist at the hospital, we were able to learn alot about the volume of patients they see here, the struggles they face with pacing procedures, their protocols for both temporary and permanent pacing, and the issues and complications they face as a peripheral hospital. 

Deserted hallway at the government hospital

After leaving SVS, we headed 3 kilometers down the road to a District Government hospital. Much to our surprise, this government hospital seemed deserted and was a complete opposite from what we had seen down the road. When we walked inside, there was no security gaurds, or even patients sitting around, something very uncommon here in India, so we took it upon ourselves to walk around and find someone to talk to. We noticed from the signs on the wall that this hospital did not appear to have a full cardiology department, but that there may have been a cardiologist who generally worked there. 

District Hospital of Mahabubnahar

We finally found ourselves on the second floor of the hospital outside of the Hospital Superindendents office. We knocked, introduced ourselves, and she kindly allowed us to come in and talk. Although she was not as familiar with the cardiac department and cardiology capabilities of the hospital, she did her best to explain to us the problems that there hospital faced and what facilities and things they did have access to. After our talk, we said our goodbyes which Shruthi somehow managed to turn into a 30 minute conversation after realizing that the superindenant was also Tamil and had three daughters our age, one of whom looked like Shruthi and was also named Shruthi.

Shilparamam market in Hyderabad

 After a long day, we got in the car to head back to Hyderabad. Erin and Shruthi, who wanted to get some more shopping in, decided to head out to Shilparamam market for an hour or so before it closed. This was a suprisingly large market with lots of colorful clothes, scarves, and hand-made art work. Erin and Shruthi both ended up buying some things and then headed back to the hotel to get some sleep before there last monrning in Hyderabad.

A Little Glimpse Into Indian Hospitality

During our first trip to India I was extremely surprised that when we showed up to our hotel for the first time at 5:00 in the morning, not only was there a person behind the desk ready to check us in, but there was at least eight other staff standing around with smiles on their faces ready to get us whatever we needed and carry our bags up to our room. In America, when you show up to a hotel during off hours you generally consider yourself lucky if you are able to walk into the hotel and not have to press a bell to get a staff member to help you out. That is not to say that hospitality in America is bad, but just that at hotels here in India, they view warm welcomes a little bit differently. 

Also, when I go to a hotel in the US, I consider it to have good hospitality if they offer me free cookies when I check in and greet me with a pleasant good morning when I pass by the counter on my way out in the morning. Although Indian hotels don't generally have fresh cookies waiting for you on your arrival, they do have a fleet of staff there to help you with everything and anything you could need. At first, I thought having this much staff at a hotel was a bit excessive; especially since it seemed like there was always four or five people who seemed to be just standing around. But I guess in a country with 1.2 billion people, having that many staff is not excessive, but simply the hotel businesses way of helping give as many of these people a job as they can.

As mentioned in the last post, before Shruthi left to visit her grandparents, she made sure that the hotel staff new that I was not feeling well and that they should check up on me. I assumed they would give me a call in the evening and if I was feeling fine, that would be the end of it. I was surprised to learn that it was not just one person who had been assigned to check up on me, but at least 5 different people. Even today, after most of them knew I was feeling better, I got two visits to the door, a phone call from the front desk asking if they could bring anything up to me, and a personal chat with the chef who had made me some bland food yesterday asking if he could make me anything specific for breakfast. I'm telling you, the people here are great and really want to make sure your stay is as pleasant as possible.

Later in the day, Shruthi and I went down stairs to the lobby to have a snack and watch as lots of extravagantly dressed people filed into the hotel for a wedding. While we sat in the crowded lobby, the chef came up to us again and asked how I was feeling and if he could get us anything. We both had eaten dinner earlier, so we told him no thank you and decided to just enjoy some of the free snacks they put out on the table. Not even ten minutes later, the chef was back at our table holding a delicious looking plate of sundried tomato and parmesean stuffed chicken with pesto. He put it down on the table and mentioned something about Christmas and holiday spirit, and left us to enjoy this delicious snack (on the house). 

Although I had no idea what people meant when they talked about Indian hospitality before I came here, I have really enjoyed interacting with all the staff and having at least five people wish me a good morning [or afternoon or night] and offer to help me with anything I need anytime I walk through the lobby.

A Mild Case of India

A trip to India is not complete unless someone gets sick. And, seeing as this time the team consists of two people native to India, and one who is not, Erin was the lucky one to get sick.

This morning the team had planned to go to Osmania Medical College to speak with a cardiologist and MBBS students who do temporary pacemakers. They had planned to meet the car around 9:30 so they could get to the hospital by 10:30. Erin had made it downstairs, but had not been feeling the greatest all night and was still not feeling too great this morning, so she decided it would be best if she stayed back for the day. Since Shruthi was leaving later in the day for Chennai to visit her grandparents, she decided to stay back with Erin and make sure she was okay. Also, since she was going to be leaving in the afternoon, she made sure all the staff at the hotel knew that Erin was not feeling well and that they should keep checking up on her throughout the day. And this they did.

Since neither Erin or Shruthi were able to go to Osmania, Dhananjay was on his own with Naresh for the morning. He met with Dr. Imamuddin at Osmania and learned about how they do temporary pacing and the difficulties they have. He also presented some of our potential ideas and was able to gauge his interest and potential willingness to adapt. Because Dr. Imamudin was a little busy, Dhananjay was only able to sit and talk with him for about 30 minutes; however when they finished, he was able to speak with two patients who had received temporary pacing and learn a little bit more about their procedure, their limitations, and how they came to the hospital.

Sunset view from the hotel window this evening

After Osmania, Dhananjay returned to the hotel and checked up on Erin who had been resting and sleeping all morning. Dhananjay was also tired and, since there were no other meetings for the day, went to his room to take a nap. The rest of the day was spent catching up on sleep and relaxing so that hopefully they both felt well enough to go do some site seeing on their day off tomorrow.

Keeping Appointments in India

Friday was set to be another busy day for the team. After waking up and eating an an early breakfast, we walked across the street to CARE hospital for our first meeting of the day.

When we got to CARE, we learned that the cardiac thoracic surgeon we were supposed to be meeting with had ended up having to come in to the hospital overnight to deal with an emergency and thus, had needed to rearrange his schedule and was running a bit behind. We sat outside in the waiting room while he saw the last couple patients he needed to and then made our way into his office.

Dr. Nemanth was a contact that Dr. Krishnamohan had set us up with. He was another very down to earth doctor and gave some really valuable insight into cardiac surgery and temporary pacing. He also was a very innovative thinker and walked us through some potential avenues for devices and procedures that he was familiar with and that we might find helpful. Unfortunately because Dr. Nemanth had needed to switch around his schedule, he had a procedure directly following our meeting and we were only able to talk to him for an hour. However, before we left he told us we were welcome to come watch a procedure and he would help answer more questions (something we are hoping to do early next week).

After our meeting at CARE we were supposed to head over to Osmania government hospital to meet with another cardiologist. Before we left, Naresh gave the doctor a call and learned that he was going to be unable to meet us today. Instead, Naresh suggested we try to go to another hospital, NIMS, and try our luck there. He was unable to get a hold of a doctor right away, but since we didnt have another meeting scheduled until 1, he told us he would keep trying.

Since the team had some time, they decided to go by a nearby street market bazaar, Ghandi Bazaar, to do a little street side shopping. While at the market, Naresh called again to let us know that the two meetings we had at another facility, CARE Nompally, had been cancelled again because the doctors were busy. We decided to go grab lunch and then head back to the hotel to wait for our afternoon meeting which was still on.

At 3:15, we headed to the CARE outpatient center (OPD). The CARE OPD center is separate from the main inpatient center, but is just about a 5 minute drive from the hotel. At the OPD, we met with Dr. Sridevi, another cardiologist on our graduate committe. Dr. Sridevi was excited to see us and talk in person and was again very helpful with filtering through some of our ideas. She had some hesitations with some of the new ideas we found, because of the difference between Kolkata and Hyderabad, but was very open to sharing some new ideas and how they could and would be adopted. Before we left, Dr. Sridevi mentioned she would be coming to the US in May, 2015 and was hoping to have a chance to visit us at Johns Hopkins, which we were obviously excited to hear about.

We left the meeting feeling good about the direction of our project and decided to take some time in the evening to do some brainstorming and readjusting to our plans to maximize the rest of the trip. Naresh had mentioned that one of the meetings from earlier was going to be rescheduled for the later evening, but this too ended up being cancelled. Nevertheless, we got some really good work done and are prepared to get the most of our last few days in Hyderabad.

During our time here in India it has seemed like a lot of our appointments have been moved around or cancelled. Part of this may be because we are in India were timing and punctuality are not always the most important, but I also think it has a lot to do with these doctors being extremely busy. I imagine that if we were to try and schedule back to back meetings with doctors in America for a week straight, a good number of them would also get cancelled or switched around too do to the uncertainty of scheduling in the medical world. We are doing our best to make use of all the time we have and filling in these missed meetings with additional research, brainstorming, and planning to keep the team on track.

Since we had all had a pretty big lunch earlier in the day, we just stayed in the hotel and ordered a few snacks for dinner before heading out to explore a little more of the city later that night.

Hyderabad Revisited

Although this trip is only about halway over, there are a few key differences I have noticed between this trip and the last one.

First, I have felt a lot more comfortable being in India on this trip. This may have to do with the fact we have been going to a lot of the same places and talking to a lot of the same people as last time, but India does not quite seem as intimidating. 

Second, the hot humid weather we had in August made us a lot more tired and exhausted during our hospital visits and inteviews. This time the weather has been awesome, temperatures between 60 and 80, very little humidity, and very little sweating. 

Third, my impression of Hyderabad has changed significantly. Last time we started in Hyderabad and then went to Kolkata. This time, we did the opposite. I think that my cultural shock from just being in India during our first trip did not allow me to fully recognize the stark differences between these two cities. Since this trip began in Kolkata, which I now realize is much more crowded, much dirtier, and much poorer, I have been able to clearly see why people told us to watch out in Kolkata. Hyderabad is still not the cleanest or most well off place in the world, but I am starting to see more similarities between it and cities in the US.

Now, for what we did on our first full day in Hyderabad. 

We woke up this morning and ate our breakfast at the delicious Taj Banjara buffet. We then braved our way across the street (see our post "Driving in India" from our last trip to understand what crossing the street here involves) to CARE Hospital for our meeting with Dr. Krishnamohan. Dr. Krishnamohan is a senior cardiologist who we met with during our previous visit in Hyderabad and who we have been consulting with as part of our teams graduate committe for the past few months. Him, along with Naresh, a biomedical engineer who helps coordinate CBID groups in Hyderabad, are helping to set up all our meetings and provide us with contacts here in India.

CARE Hospital, our homebase hospital in Hyderabad

During our meeting this morning, the team went over all of what we saw in Kolkata with Dr. Krishnamohan and we expressed what we are hoping to get out of the rest of our visit. It was interesting to hear his take on the things we had heard and seen in Kolkata, because Hyderabad seems to be doing things a lot differently than Kolkata. Dr. Krishnamohan also made some phone calls during our meeting to answer some other questions we had and get meetings set up for the rest of the week. Around 11:30, Dr. Krishnamohan had to go to a procedure, but had told us to go downstairs to the emergency room to talk to a few contacts there about temporary pacing. The emergency staff seemed to be pretty busy, but we were able to talk to a few people and get some insight into how the emergency department at CARE works with the cardiologists and cardiology department at the hospital. When we finished speaking with the emergency medical staff, Dhananjay, Erin, and Shruthi, headed back to the hotel. Dr. Krishnamohan and Naresh had agreed to have lunch with us when the procedure was finished and since we did not have any meetings planned in between, we decided to get some work done while we waited.

When the procedure was almost over, Naresh told us to head over to the restaurant, which happens to be next to the hospital, to meet him and Dr. Krishnamohan. Naresh and Dr. Krishnamohan were a little late because the procedure ran later than expected. Dr. Krishnamohan explained that the procedure, which was scheduled to begin at 12, was not able to actually start til 1 because the Cath Lab was backed up. Because he practiced in England for a long time, he told us that he understands how punctuality does not really exist in India, but that he wanted to do his best for us since he figured we would be.

Authentic Rajistani Thali that we ate for dinner

After lunch Naresh contacted a cardiac anesthesiologist who had agreed to meet with us. The anesthesiologist said that it would be best if we came after 5pm, so we once again headed back to the hotel until Naresh heard back and we were ready to go. Unfortunately, the doctor was unable to clear his schedule for the afternoon, so we instead scheduled the meeting for tomorrow. We all spent the rest of the evening relaxing and then enjoying an authentic Rajistani meal at a restaurant down the street.

New Places and Familiar Faces

Wednesday was our last day in Kolkata. After a quick breakfast, we all packed our suitcases and said goodbye to Rupa and the guest house.

Sign outside the executive suite guest house

Our first meeting of the day was at Shree Jain hospital located in Howrah (near the strain station from the other day). We arrived at the hospital to find out the doctor we were supposed to meet with had forgotten we were coming. Luckily, he was able to put us in contact with another doctor who was at the hospital when we got there.

Interesting sign outside a room at the Shree Jain hospital

We went to the reception counter at the hospital and the receptionest led us to the hospitals ICU where Dr. Saikat Manna was waiting for us. Our talk with Dr. Saikat was extremely helpful and he gave some real perspective for what the patients at this private hospital could afford and what the patients at government hospitals, like NRS Medical college where he had trained, could afford. Dr. Saikat also gave us a good understanding of the use of drugs over device therapy for complete heart block and provided some valuable insight into the costs and perspective of these patients.

After thanking Dr. Saikat, we headed back to the car to go grab lunch. We had a nice quick lunch at a nearby mall and then headed to the airport for our flight. We arrived at the airport around 3 and had an hour and a half to relax before our flight.

Suprisingly, our flight from Kolkata to Hyderabad was the most on-time and efficient flight I have ever been on. I say suprising because we are always talking about doctors not being on time and the overall inefficiency of work here, so the fact that our flight boardered on time in the most efficient way possible, started moving from the gate before 5:00, our scheduled departure time, and arrived in Hyderabad at 7:00 on the dot, was a pleasant suprise.

After getting our bags, we struggled to find a taxi willing to take the three of us with our huge suitcases and eventually had to get a prepaid taxi that was larger to take us to our hotel. We arrived to the Taj Banjara hotel around 8:30pm and we were greeted by many familiar faces that had been here during our last visit in August. We checked in and then headed to our rooms for the night. Although we enjoyed the executive suite in Kolkata, the Taj Banjara was a nice change with the warm water, awesome shower pressure, and fast internet. Also, since we now have fast internet, we were able to add pictures back to all our other blog posts (for anyone interested).

Anyways, we need to go get ready as today we are off to meet with some of the doctors we met last time here in Hyderabad.

An Indian Road Trip

Today began at 5:15am with a quick breakfast and us hustling out the door so we could be on the road and on our way to Baharampur by 5:30am. Baharampur is a peripheral city (suburb) of Kolkata located about 240 km (140 miles) from where we are staying. For those of us in the US, 140 miles would generally mean a 2 to 2.5 hour trip; however, here in India where the traffic is heavy, the roads in the villages are narrow, and the road conditions are horribe, a 140 mile journey becomes a 6 hour journey.

Although we had all planned to sleep during this 6 hour journey this morning, the road conditions on the way to Baharampur did not quite allow us to do that. I would have to say that these roads were by far the worst roads I have ever driven on and we would have probably been more suited in a four-wheeler or a jeep than the mini van which we have been driving in. It is quite impressive watching these drivers navigate through the potholes and sudden change in height of the pavement as they dodge in and out of cars.

Bridge along our route to Baharampur

Anyways, since we had a good 6 hours this morning to sit back and watch the landscape and driving sitatuions, I had some time to jot down some more of my thoughts about roads and driving...

1. People who drive here in India would probably be excellent race car drivers. They are constantly aware of their surroundings, weaving in and out of cars, passing by through the tiniest gaps to avoid hitting other cars and animals, and they all already drive stick shift.

2. It also would not be suprising to learn that stunt drivers in movies are Indian. On our way to Baharampur today we had two incidences where we were passing a car on what would be a two lane road (one in each direction) and just barely moved over and got back to our side before the giant truck speeding down the road from the other side hit us head on. This may sound like I am exaggerating, but there was definitely no more than 1 or 2 feet between us and the car when we veered out of the way. In the US, scenes like this are filmed for hundreds of thousands of dollars. If they came to India, they could probably get this footage a few times a day without paying anything.

3. Indian drivers are probably very good at driving video games. The best way I can describe driving on an Indian bypass (highway) is that it is like playing Mario Kart with traffic signals. However, I noticed this morning than when it is early and there is light traffic, even the traffic signals seem to be ignored.

4. Today we drove on a newly paved road and there were actual lane division lines on the road.

5. Roads are paved in a very mysterious way here in India. We would be driving on an old road and come across a newly paved road every so often. The paved road would never really last more than about half a mile and it seemed like the further away from the city we got, the road we transitioned onto from the paved road got worse and worse. Also, the transition from the paved road to the unpaved road was usually a few inch bump that was worse than a speed bump and was followed by holes and rocks to drive over.

Erin and Shruthi in the flowers

6.  When driving out past the city, you get to see some really cool and pretty things in the landscape. Today we kept driving by these fields of yellow flowers. Shruthi mentioned that these were only found in India and suggested that we stop to take pictures, which we did.

Typical car s with people on top, packed inside, and standing on the back

7.  Indian's are very good at maximizing space. I have never come across so many people stuffed into such small places as I have in India. This includes trains and busses, in which multiple times I have seen people basically hanging out the edges to hold on; cars and autos, which are generally as full as they can be and which people pile onto the top and stand on the sides as the cars go; bicycles, which are usually equipped with a platform for carrying anywhere from 1 to 8 people or a 6 foot stack of some type of food or good; and motorcycles, which are very commonly used as the the primary mode of transportations for entire families.

Baharampur

Outside of Rabindranath Thakur Diagnostic Medical Center in Baharampur

When we finally arrived in Baharampur it was a little before 11:30 and we headed to Rabindranath Thakur Diagnostic and Medical Care center. This hospital is a secondary private hospital catering to this remote village. We first met with Mr. Hogue, the head administrator of the facility. He gave us a tour of the hospital and allowed us to speak with some nurses and other staff along the way. When we returned back to his office, two practicing MBBS doctors came to meet with him. They were there for an interview, but he allowed us to ask them some questions about temporary pacing, their comfort levels with procedures, and there training.

ICU at Rabindranath hospital

One of two operating theaters at Rabindranath Hospital

After this meeting, Mr.  Hogue took us all to a lunch at a nearby restaurant while we waited for the hospitals cardiologist, Dr. Banerjee (apparently Banerjee is the most common Bengali last name), to arrive. When we got back from lunch, Dr. Banerjee had made it to the hospital and was beginning his rounds. We joined him as he went to check on patients and he spoke with us about cardiology and temporary pacing at the hospital. We also had the chance to speak with him abdout some of the problems with peripheral centers and access to permanent pacemakers, transportation, cost, and imaging. His comments provided a lot of new insights for the team and gave some real clarity to the problem these nursing homes and smaller cities face when located so far away.

In order to make sure we were back in Kolkata at a reasonable hour, we wanted to make sure we were back on the road by 3. So after speaking with Dr. Banerjee, we said our goodbyes and headed back in the car and on our way home. This 6 hour drive we were all a little bit more tired and it was dark out, so we were able to catch a little bit of sleep.

Tomorrow is our last day in Kolkata before we head off to Hyderabad, so hopefully we should have better internet connection and can get some more pictures on the blog posts!

Rubber Shoes and Late Nights in Indian Hospitals

Today was set to be a very busy day. We woke up around 8, had a quick breakfast and were headed out the door to meet Dr. Banerjee at Medica. Our first meeting of the day was with a cardiac surgery anesthesiologist. This doctor gave us a completely new look at how temporary pacemakers are being used in India and gave us some real insights into the types of procedures different levels of doctors are comfortable with, as well as some of the key differences between cardiac surgeons and cardiologists thoughts.

When we finished our meeting with the anesthesiologist, we went back down to Dr. Banerjee's office. Dr. Banerjee was in the middle of a procedure, so the team decided to go grab a quick lunch at a restaurant across the street while we waited.

Dhananjay, Erin, and Shruthi in the purple Medica scrubs

As soon as we got back, Dr. Banerjee's assistant told us to head up to the cath lab as there was a temporary procedure going on that we should go watch. The doctors quickly showed us where the scrubs and shoes were and pointed us in the direction of where we should change. Once the three of us had all properly donned our scrubs, caps, masks, and shoes, we headed into the cath lab to watch a placement of a temporary pacemaker. The doctor doing the procedure walked us through every step he was doing and patiently answered all our questions when he finished. After the procedure, we doffed our scrubs and other protective equipment, and went to change.  As we were getting ready to leave we ran into Dr. Banerjee who was heading into another procedure and a breif chance to talk to him and thank him for all the meetings he set up for us.

Shoes in the hospital

An interesting thing about Medica (and most of the hospitals we have visited in Inda) is that everyone wears open toed rubber shoes in the operating theaters (which is what they call ORs here). Before entering the "sterile" areas, you are supposed to remove your shoes, put them on a rack, walk inside barefoot, and take a pair of rubber shoes from another rack to wear inside. We all get the different shoes inside the OT concept, but are still trying to understand why they all wear open toe shoes. Just another mystery of India, I guess.

We left Medica and headed back to the guest house around 5pm. When we got back, we spent some time catching up on work and emails and planning the rest of our evening. After another delicious dinner at the guest house, we headed to SSKM to go speak with doctors, possibly, see some more temporary pacing procedures, and find out what an Indian hospital is like at night.

Outside of the cardiology department when we arrived at night to SSKM

We got to SSKM around 8:30 and went to meet with Dr. Soumik. Dr. Soumik was at the end of an overnight on-call shift, but willingly allowed us to sit down and talk with him. We ended up discussing ideas and the landscape in India for about an hour and a half until it was time for Dr. Soumik to leave. As Dr. Soumik was leaving, he introduced us to another doctor, Dr. Chaudhry. This doctor had no idea about our project before hand, but was super eager and enthusiastic talking with us. After speaking with him for a bit, an emergency case came in and he had to run off.

Patient in the hallway at SSKM

We then went over to the doctors room to wait for someone to tell us about the temporary pacing procedure that was supposed to be happening. The doctors room was a small room that had recently been painted and had four metal frames with 2 inch thick mattresses on top for the doctors to sit. Dr. Soumik had pointed out to us that this was a huge upgrade from what it had been and that it was now suitable for humans. Around 11:00 we decided to head back since no procedures had happened yet and we have an early day planned for tomorrow (5:30am).

Anyways, we are off to sleep and prepare for our long day tomorrow!

Driving in Circles

Day 3

In India, Sunday is known as the holiday. Since most people work on a Monday-Saturday weekday schedule, Sunday is really the only day when everyone has off and time to relax. With our short time in India, we decided it would be best if we utilized our holiday to get some additional field research done. Luckily, we had met a doctor at BM Birla the day before who was willing to meet with us near his hometown on his day off, so we figured we would take advantage of that. Unfortunately, Jay had already made plans with his family for the day, so Shruthi and Erin were on there own.

Before we planned to leave and visit the nursing home (which was between 2 and 2.5 hours away), we had planned to have a lunch at Dr. Saha's home. Dr. Saha, Dr. Acharya, David, and Linda would be leaving later that day for a village and would be staying there for the next week. We used this lunch to say goodbye to all of them (since we won't see them until we are back in Baltimore) and make sure our plans for the rest of the week were finalized.

The Plan
As expected, lunch was delicious, but a little later than originally planned (good old IST). After lunch, it was arranged that Erin and Shruthi would ride to the train station with everyone else so they could keep the car and stay with the driver, Omesh, that they knew pretty well. Also, since Jay and his Indian phone were not with us, and the phone that had been given to us did not have a charger, Erin and Shruthi were planning on using Omesh's phone to help stay in contact with everyone else.

Outside the Kolkata train station

The Execution
Initially, this seemed like a solid plan for us. We would ride in the car with Omesh, drop everyone off at the train station, and then head off to the nursing home in the village. When we arrived at the train station we made our way through the huge crowds of people to the platform where there train was leaving and said our goodbyes. As we made our way out of the train station, Shruthi decided to give the doctor a call since we were running a bit later than expected. Sadly, the doctor said he was going to be leaving about 30 minutes after we were scheduled to get there to head back to the city and recommended that we do not come.

For about thirty seconds after hearing this news we were upset that we weren't going to be able to go, but then Omesh's phone rang and Dr. Acharya was on the line. Apparently the other groups train had been spontaneously cancelled and they needed us to turn around anyways and pick them up. We circled back to the train station, payed another fee to get in (the man at the booth was not in the mood to accept our ticket time-stamped 10 minutes prior) and met up with everyone else. While Dr. Saha and Dr. Acharya went around trying to figure out what to do, the rest of us stood around talking and wondering what was going to happen next. When Dr. Acharya and Dr. Saha came back it was decided that everyone would go back into the two cars, drive to Dr. Sahas and then split up to go on our way. David, Erin, Linda, and Shruthi piled into the small car and headed out of the station. We got right outside the station gate when we realized we did not know where to go or what was going on. Our driver pulled over to the side of the road and waited to hear from everyone else.

A few minutes later we got a phone call that they needed to put another suitcase in our car. The driver started backing up back into the station, but was abruptly stopped by the gaurds. To give a little perspective here, our car was directly in front of the gate out and had literally passed through about 5 minutes ago. The guards did not care and strictly instructed us that we would have to go around again to get back inside. After speaking with the other car, they decided to squeeze everything and meet us outside of the gate. Once they met up with our car, Dr. Acharya and Dr. Saha told Erin and Shruthi that they would no longer be riding in the cars because both cars were going to be leaving directly from there to go to the village. It was arranged that the two of us would take a cab and that we needed to head back down the street to the station to meet the cab.

We got out of the car and headed back down the road we came from into the station. Once again, we were stopped in our tracks by the guards who told us we would need to walk around. So after a third fake goodbye, we hopped back into the car and drove with everyone else to meet a taxi a little down the right direction of the road. This time we said our actual last goodbye and piled into a taxi.

The Results
So after a few bumps in the plan, Erin and Shruthi, were left alone, without a driver or a phone, in a taxi, headed to a guest house whose address most people did not know. Thankfully our taxi driver was very patient with us and after giving him landmarks to get us close, found some people on the street able to point us in the right direction. When we finally made it home, we were exhausted but could not help but laugh at how our day unfolded.

Fancy decorated vegetables with Erin and Shruthi's dinner

Apparently, Sunday's should be kept for relaxing and not doing work. Lesson learned.

Political Unrest While Jetlag Strikes

Day 2

We all woke up this morning well before our alarms (thanks jetlag) and ready to start the day. After another delicious breakfast prepared by Rupa, Erin, Jay, and Linda headed off to BM Birla teaching hospital. Shruthi and David had an exam to take, so we decided to swap Shruthi for Linda this morning.

Government vs. Private Hospitals

BM Birla is one of the top cardiac hospitals and research centers in all of India. It has a cardiac care unit (CCU) with 53 beds and was probably one of the cleanest CCU's we have come across so far in India. Compared to SSKM, the government hospital we were at yesterday, BM Birla could be a palace. It is really interesting how the government here in India funds all of these public hospitals, but does nothing to keep them updated or clean. The floors are dirty, everything is rusty, and it looks as though the hospital has been there for 50 years (even if it may not have been). When walking through one of these government hospitals it is almost impossible to find even a simple device, tool, or monitor that we would see at a hospital in the US. Private hospitals, on the otherhand, tend to be extremely well kept and clean. Although they might not have all the bells and whistles that US hospitals have, they generally have a lot of the same types of equipment and monitors which are mostly up-to-date. I wish we had pictures to show the inside of BM Birla, but unfortunately we did not take. However, Shruthi took a number of pictures inside SSKM yesterday, so hopefully we will be able to show some of these to at least give you an idea of the kinds of conditions we are talking about.

...Anyways, back to our visit at BM Birla. Once again, we arrived to a hospital only to fall victim to good old Indian Standard Time (IST). Although the doctor we were meeting was not ready yet, the doctors and nurses let us hang out by the desk in the CCU. Dr. De, who we actually got in contact with through Dr. Dutta (the doctor at SSKM we met the day before), was the first new doctor we had met on this trip. Before we had a chance to begin explaining what our project was, she told us to come with her to see the one patient they had in the CCU with a temporary pacemaker.

In the patients room Dr. De quizzed us about pacemakers and heart conditions as if we were medical students. She started asking us questions that would be asked to med students about what type of complications would we expect if a patient was presenting in a certain way. Luckily we had Linda with us because she was able to answer everything and make us look like we really knew what we were doing. After Dr. De's inquisition, she showed us the controls on the temporary pacemakers. To our suprise, she began to change the controls to show us what happens when you adjust them. Although we all appreciated being able to see that, we all seemed a little taken a back that she was doing this on a real patient.

Private ambulance at BM Birla and the closes one to a US ambulance we have seen

The real value in talking to Dr. De was understanding how a hospital can do things right. This hospital is definitely not the kind of place where our solution is going to be implemented, but Dr. De and the other staff around clued us in on how they are so good at what they do, where other areas are suffering, and where some of the best places for innovation are. After talking with her about some of the periphery hospitals, she put us in contact with a resident she has who works at a nursing home in a periphery setting and he set us up to meet with him there the next day.

After BM Birla we all had a little time before our next meeting. We were going to head back to the guest house to wait, but Dr. Saha suggested that we come into the JSV office (his company) because there was some strikes and political demonstrations that were supposed to be going on in the city. Apparently there was a big scandal among the ruling party in Kolkata that led to the arrest of some extremely high government officials the day before, so people were protesting. We never really got the full story of what happened, but we pieced together the information we got the best we could.

Once it was safe for us to go on the roads again, Dhananjay, Erin, and Shruthi headed back to Medica to meet with Dr. Banerjee,  a cardiologist they had met with for a long time during their last visit. Dr. Banerjee was busy again and was constantly being interrupted by patients, nurses, doctors, and other hospital staff for questions, but he managed to keep listening to us and our concepts. Dr. Banerjee seemed extremely interested in the concepts we generated and even began to share is own thoughts on innovation. Sadly, Dr. Banerjee only had a breif amount of time to discuss our concepts today, so he made sure that we scheduled a longer time on Monday. He also promised to introduce us to some other experts he thought could give us their own opinions on our solution concepts and projects.

We returned back to the guest house around 5:30 and were waiting for plans for Dr. Saha for the evening. However, before we even made it to any of these plans, the jetlag struck again and everyone but Erin fell victim to a nice long nap. I think we all are almost all caught up on sleep, but just to make sure, we are all going to try and go to sleep early again.

Hum Kolkata aa gaye...again

Outside the airport in Kolkata

After about 28 hours of traveling we arrived at our guest house in Kolkata at about 9pm on Thursday. The owner of the guest house, Rupa, greeted us and told us she had an authentic Indian dinner waiting for us. We all quickly showered and changed and sat down to enjoy our delicious home cooked meal. After a long day (or two if you count the time difference) of travelling we were all happy to have a meal in front of us and a bed to lie down in.

Day 1

Outside of SSKM

Our first day in Kolkata was set to start at 10:15. After a delicious breakfast prepared by Rupa, we were on our way to SSKM. During our trip in August we also visited SSKM and learned a lot about permanent pacemakers in West Bengal. This time we had a slightly different agenda and headed to the hospital to meet with the head of the Cardiology department, Dr. Dutta. Unfortunately when we arrived at SSKM Dr. Dutta was in a meeting and was not expected to be ready for an hour. While we were waiting he suggested we go meet with Dr. Soumik, another doctor that we had spoke with last time, and make some plans for the rest of our visit. Dr. Soumik was very busy, but was able to point us in the direction of some patients we could talk to.

Cardiology ward in SSKM

We spent the next hour going bed to bed in the cardiac ward talking to patients and understanding how they got to the hospital, how they were feeling, and what happened during their procedures. Since we were on our own this time, communicating with the patients was a bit more difficult. SSKM is a government hospital and most of the patients who go there are not as well educated as some of the private facilities. This means that most of the patients only speak the language of West Bengal, which is Bengali. Since all of us don't know Bengali, we were forced to find other people to help us communicate. This proved to be pretty easy since the three of us walking through the male cardiac ward with bookbags and notebooks seemed to draw attention and interest from everyone in the room.

Patient with temporary pacing tied to the hospital bed

While Erin stood around the patients bed pretending to understand what was being said, Shruthi and Dhananjay asked questions in Hindi to family members and other people standing by. These people then translated the question to Bengali for the patient. While this may not have been the most efficient system, it allowed us get some valuable information and insight into these patients treatment and conditions.

After talking to patients we headed to our meeting with Dr. Dutta and spoke with him about his opinions on the temporary pacemaker space. Despite the numerous interruptions from people and phone calls, a common occurence during meetings here in India, we wrapped up our conversations and were on our way to Medica for our next meeting with Dr. Banerjee.

We arrived at Medica, made a quick pitstop for caffeine, and then headed over to Dr. Banerjee's office where we were told to take a seat and wait. After about an hour and a half of waiting, his assistant told us he was going to be another hour or two, so we decided to head back and reschedule our meeting. 

When we got back to the guest house the jet-lag set in and we all ended up taking naps. When we woke up, David and Linda were back from their day and we all went to Tolley Club (the club we stayed at during our last trip) for dinner with Dr. Saha, our host in Kolkata, and his wife. Following a delicious meal and interesting conversation, we headed back to the guest house and off to sleep.

The Brady's Take on India: Part 2

Namaste again!

Our team is back in India once again to continue doing field research for our project. Since there are lots of people wondering what we are doing here this time, we have decided to chronicle our trip again with our blog.

So what have we been up to for the past three and a half months?
For the most part we have all been busy working on our two or three projects, taking classes, and fitting in the occasional time to sleep. At some point during this time we narrowed down the focus for our global project and realized that there was still more research we wanted to do in India. Luckily, we were able to work with our Medtronic partners and our CBID advisors to plan another trip to India, so here we are.

In order to maximize our time in India, we all decided it would be best to leave as soon as possible following our final presentations of the semester. For some of us, that meant that we left before we could take our finals, but thankfully our professors were all understanding and have worked with us to figure out how we can take them while over here. So after some logistical planning and ensuring that we had places to go and stay when in India, we booked our tickets for December 10. Unfortunately, Maddie had already booked her ticket home to Australia for our winter break, which is Australia's summer break, so it is just Dhananjay, Erin, and Shruthi back in India and ready to learn more.

Back to India

Linda, Dhananjay, David, Shruthi, and Erin at the airport. Linda and David were also going back to India to work on their global health project, so we all got to travel together.

Our flight was scheduled for 10:00am on December 10. Naturally, we all wanted to sleep on the first 13 hour leg of the trip, so we all decided to pull an all-nighter the night before in hopes that we could crash on the plane. For some of us this worked out and for the rest we are stil working on recovering from jet-lag. Nevertheless, we made it to Dubai, had a not-so-quick 5 hour layover, and then headed on our next 4 hour plane ride to Kolkata where our trip begins.

Day 20: Everyone in Kolkata

21^st August, Thursday

We went to SSKM today, which was a government hospital in Kolkata. SSKM turned out to be much different from Osmania General Hospital (Hyderabad) in terms of patient volume and quality of education and ranked very high as a tertiary care government hospital. It had 300 beds just for cardiology, was well equipped and had the highest number of pacemaker implantations in the country. 

Outside of SSKM Hospital Cardiology deparment

Dr. Shoumik, a 3^rd year resident explained to us about how hard it was to get into SSKM to post doc in cardiology and that it was regarded highly for its education programs. It was also very interesting to learn about ‘Fair Price Shops’ where all medical devices could be availed at a whopping 67% subsidy from the government of West Bengal. 

Later that day, Erin, Jay and Adam observed the implantation procedure for a dual-chamber pacemaker at Medica Hospital that Dr. Banerjee had kindly invited the team to observe. The facilities there were state-of-the art (seemed comparable to those at Hopkins) and the procedure was very efficiently done with all the best practices. An interesting thing to note was that this procedure was done under local anesthesia with no sedation whatsoever!

Jay and Adam in their purple scrubs before the procedure.

Our day ended with a reunion party, where everybody from CBID in Kolkata got together for dinner and drinks. This included the Brady Brunch, the mHealth team (Brian, March, Sriram, and Trent), Anant, two our TAs; Kevin and Michael, Dr. Acharya, Aditya, Dr. Saha, Adam, and Idara (the 4th member of the Medtronic team who had arrived earlier in the day). It was our last day with everyone together in India as Michael and Kevin left that evening for a tour in Northern India (Darjeeling and other places) and Anant was heading back to Baltimore early the next morning. We all enjoyed out time talking about our projects and experiences in India thus far.

Day 18 - Hum Kolkata aa gaye!

August 19th 2014

August 19th was an early morning for Team Brady and Adam. We all woke up around 2:30am to catch a cab to the airport for our 6:30am flight to Kolkata. Kesavan was leaving later in the afternoon from Hyderabad, so he stayed back at the hotel and slept in.

Throughout our time with Kesavan we have been writing down all the funny quotes he says. Since this is our last post with Kesavan, we figured we should share our list of Kesavan quotes:

"It's okay, the rat was scrubbed in"

"So is boneless chicken like seedless grapes, they are just born without them?"

When someone asked why Kesavan was so serious: "I'm serious cause I'm eating serious food"

"I have 2 's'. It's a Samsung. I'm not up to 5s's yet"

Hum Kolkata aa gaye! (We arrived in Kolkata)

Our flight arrived in Kolkata around 8:30am and after the quickest exit from the airport and luggage retrieval (under 20 minutes) we made our way outside to the cars waiting for us. Two hours and lots of Kolkata traffic later, we arrived at the Tolley Club hotel. We had a meeting scheduled for 12:00 am at
Medica Superspecialty hospital, so after a quick turnaround change and a carb-loaded snack, we were ready for our first day in Kolkata!

Quick snack before heaidng out for the day

At Medica we met up with Dr. Acharya who came with us to meet Dr Banerjee (leading Senior Interventional Cardiologist, and his colleagues; Dr Moitre and Dr Goupta. We had a quick introductory meeting with Dr Banerjee, followed by further educational sessions from Dr Moitre and Dr Goupta. During this conversations we also had some time to speak with patients, patient families, a medical device distributor and medical device rep.

Maddie speaking with a patient and their family

Shruthi speaking to a device rep

After the educational sessions, Dr. Goupta led us to the outpatient clinic to see the diagnostic tests and facilities at Medica. Adam volunteered to try out the Holter monitor and the nurses and assistants helped guide us through their process for diagnosing bradyarrhythmias.

Adam getting the Holter monitor put on while Shruthi was taking notes

Exhausted from the travelling of the day, Adam, Erin, and Maddie took a car back to the Tolley Club to get some sleep. Meanwhile, Shruthi, Dhananjay, and Dr. Acharya headed over to a secondary hospital, Apex hospital, to see their facilities and speak with the cardiologists and GPs there. It was definitely a long first day in Kolkata, but we found out some really great insights and spoke to a number of key stakeholders for our projet. 

Day 16: Separation Sunday

August 17, 2014

Our third Medtronic engineer, Adam, joined us early on Sunday in Hyderabad. The morning was filled with breakfast, conversation, and bringing Adam up to speed. After official planning in the morning, the team split up to have a relaxing Sunday. Shruthi and Dhananjay visited family while Erin, Maddie, Kesevan, and Adam left to visit a famous museum.

Shruthi visited her aunt and uncle in Hyderabad and Jay went home to Indore where he also met with Atul Sethi, the Managing Director of Shree Pacetronix Pvt Ltd. Mr. Sethi shared some great insights about the Indian healthcare system and the medtech industry in general, apart from the pacemakers space. Shree Pacetronix is one among a handful of medtech companies in India that are doing well. Mr. Sethi’s father is a cardiologist in the US and they, together 20 years ago, decided to enter this industry and make pacemakers available to the middle class Indian at an affordable cost and yet good quality.

Erin, Maddie, Kesavan and Adam spent their day looking at artwork in the Salarjung museum and doing some shopping. Kesavan, in particular, was very interested in Raja Ravi Verma’s paintings since he himself was an artist. You can check out Kesavan’s work here: http://www.kesavanpotti.com/

  

Sign for the Salarjung Museum

Outside of the Salarjung Museum

Excited to get some Indian clothes, the girls steered the group to MG Road to buy authentic Indian clothes but unfortunately, most of the shops were closed because of the festival of ‘Janmasthmi’ (Lord Krishna’s birthday). Overall, Sunday was relaxing and helped the team recover from the hectic week.

Pretty fabrics found when shopping!

Reflections on the Indian Medical Education System

16th August 2014

"Today I made a new friend that I hope to keep for a long time coming. For now, I'll call her Priya. Priya is an intern at Osmania General Hospital, a government hospital in the heart of Hyderabad, and she is in the process of completing her fifth and final year of her MBBS degree (Bachelor of Medicine, Bachelor of Surgery). A very intelligent young woman, her angst and emotion towards the Indian healthcare system are such that she no longer wants to work here, nor does she feel prepared to start practicing as a GP if she doesn't pursue her MD next year. [To provide some context, an MBBS degree in India is the first level of training required to become a licensed general physician, and the MD program provides the next level of specialization in Internal Medicine].

Priya dreams of doing her MD residency in a place like the US. She has a passion for oncology - pancreatic cancer in particular - but over coffee today she explained that the chances available for distinction students like her to make it to specialist level are slim when they have to compete against a large population, with limited infrastructure, and politics disrupting the system. She attributes this solely to the way medical education programs are structured in India, and this was with her background of studying at a private facility. For me this conversation exemplified why education and healthcare now go hand-in-hand as two of India's highest focus areas for development. It spoke to me about the underlying systemic changes that need to be achieved in order to increase awareness about bradycardia and its symptoms, amongst patients and the general physician population. This is especially true in areas where there may be limited contact with practitioners, or in facilities where there may not be the infrastructure to allow for accurate differential diagnosis.

For GPs, training and education can become limiting factors for two reasons. Firstly, the immense competition faced by thousands of students for admission into MD programs after completing their MBBS degree means that many GPs are practicing straight after their MBBS final year internship, with a breadth of knowledge but not much depth into the area of cardiology. Priya explained that her only experience in cardiology throughout her MBBS degree was in her fourth year, where her class studied one chapter of a textbook on cardiac conditions. She is highly motivated, so a lot of her extra knowledge about bradycardia diagnosis and treatment methods came from self-learning, but for those who may not be as inquisitive as her, the same knowledge may not be reached, or could be misinterpreted. She learned how to read an ECG under senior guidance during her internship, but this wasn't taught to her; she had to seek this knowledge by driving her own interests.

Secondly, there are few programs in place to maintain up-to-date dissemination of medical knowledge at the MBBS level, at least in the parts of Hyderabad that we spoke about (there are various programs around the country that are available in some areas but not others). This means outdated practices are commonly used and diagnosis is often based on clinical symptoms, or it is assisted with suboptimal tools. This has been confirmed by a variety of healthcare professionals, and seems to be one of the contributing factors towards unwell but asymptomatic patients being missed or misdiagnosed. However, GP awareness is not the only reason for this; accessing adequate care also relies on the patient being aware of their health and choosing to seek treatment in the first place. A sense of complacency is often seen due to age, financial constraints or both, which means the importance of regular check-ups for screening is undermined.

After two hours of eye-opening and humbling conversation, I left the café feeling very grateful to have met Priya and heard her story. It is connections like this that I feel can make a difference, whether it be on a personal level or on a larger scale, and I look forward to being a part of that change."

- Maddie.

Patients and families at the entrance of the OGH Outpatient Center