Day 0, 1^st February 2009 – 0805h GMT; London Underground, Tooting Broadway to Leicester Square, London

Part Deux

Yesterday was, as all post-transcontinental flight days are, a blur. My mind was still murky as I struggled to carry out the last minute tasks I had to complete before I left London yet again. All I know is that it was great to see Jerome and Michelle again, and that I had a haircut, and in paying for my car insurance, I had swiftly spent more in one day in London than during the entirety of my trip to India. My mind was so warped I couldn’t even play on the playstation properly, and I sit here now on the way to the airport, wondering if I had forgotten to pack something. I think I like to think I’m a better globetrotter than I really am. Then again, I’m still alive and somewhat happy.

I think my point of the rant is that I haven’t really thought of Toronto all that much, except for the excitement of seeing Emily again. This morning in the shower, it hit me a little bit – this week, I’m going to have to be at the top of my game – I am starting my electives, applying for my first ever job in my life, and I’ve got all these written reports to do, and settle into a new city and new home, all the while not trying to freeze to death in the magical -22°C. Maybe I’ll miss India and the fear of cholera that comes with it.

Whatever it is, part two of KP’s 2009 is about to begin, and I cannot wait to see what it will bring, as I cannot wait to see how this entire year will mould me. The stage is set for an evolution…January in India, February in Canada, March in Chertsey, April in Epsom, then the crowning moment of a medical student’s career – clinical finals and hopefully thereafter graduation! If 2008 was consumed by the frightful exams midway through the year, this year the young medical student can finally have something to be excited about. I don’t need resolutions this 2009, just a questioning mind, a loving heart, and bottles of guts!

Day 0, 1^st February 2009 – 1445h GMT -0500; Air Canada Flight, London to Toronto

We’ve begun our approach into Toronto, and are flying through a crystal clear sky. Below us are great white sheets of snow, peppered with the dusky green of trees. This is a view from a plane I have yet to see, and I have seen many views in my fortunate life. It is beautiful. A different kind of beautiful. And I cannot believe that I am here…after watching takeoff from dusty Jaipur and busy Mumbai, and the candlelights of London…now I’ve arrived in the land of the pure.

Day 43, 31^st January 2009 – 0615h GMT; Jet Airways Flight, Mumbai to London

Where the Heart Is

Back in Greenwich Mean Time, our plane crosses the waters past Amsterdam and Brussels and towards London Heathrow. It is 2°C in London, and the frost forms tiny ice crystals on the plane window, as it fights to get to my bones. Suddenly m home-coming doesn’t seem all that grand – it is routine, like all my other overseas trips. It makes me feel as if India meant nothing to me. London is calling me and I know that once I step back onto its soil, it will consume me once again, blindsiding me with friends, food, habit. Will I remember the kindness of the locals I have met? Will I remember the beers shared with the tourist friends I have met? I have traveled so far and yet have not moved at al. I have achieved all and nothing at the same time. I want to remember India – my exhilarations and my frustrations. I need to remember.

Landing in London near dawn, the horizon is painted blood red, which grows more vibrant as the minutes pass – a grey blue contrast just above it. I love the approach to London in the dark. The lights bellows from the lampposts, sleepy buildings are like a thousand candles floating on a dark ocean. And the lights shine like diamonds, jewels on the face of Europe. It is immensely beautiful and it perks my spirits a little. I’ve missed the city. On another weekend, I could have been stumbling off a night-bus with Jerome, Simon and Charan, after a good night out.

Now, the sun begins to stretch his arms after he sleeps and the soft rays hit the wings of the plane, and you can just about make out its entire outline, as it glows a soft blue. I am home, albeit temporarily.

My thoughts still, inevitably, float back to India – now the busrides to and fro from Agra and Delhi – the hours spent, like now, gazing out of the window, soaking in life – trying to grasp an intangible beauty. I can still remember the red sunset…the sun a ball of fire through the mist and cloud, caressing the mountaintops, and melting into the hills like butter…and in the foreground the Sarso plants smile in their fields of millions – yellow flower speckled on a sheet of green. This is the India you want to remember, a nature you don’t get in Trafalgar Square. As the migratory flocks fly up ahead and the casual bright green parakeet flashes across my line of sight, I can almost imagine a gathering of Indian buck deer watching with intent, as a tired tiger, still imposing and majestic, makes his way back to his lair, with the Pariah kites soaring up above.

Day 42, 30^th January 2009 – 2145h IST; Jet Airways Flight, Jaipur to Mumbai

The Angry Indian

It is easy to lose yourself in someone else’s story. I’ve been racing through “Slumdog Millionaire” by Vikas Swarup, eager for the headache I picked up in the Jaipur airport to run its course. It is not so easy to form goodbye thoughts when your throat feels dry and your head is aching from a hundred of those same thoughts trying to jam themselves in all at once. My head is clearer now, but I’m still in a disbelieving daze that I am, at last, going home. There is so much to think and write about – my beliefs about the Indian healthcare system, the dozens of faces I have met in this country, my last few days in the hospital, last night’s dinner and shisha with some of my doctor friends, and today.

Today, when I got ready for my last day in hospital, I felt like I was entering a dream. The ambivalence that shrouded my thoughts was dizzying. Was it sadness that I was leaving this home? The trip that couldn’t end any sooner has been for the last few weeks a thrilling adventure that teased and tantalized my senses. Now I am leaving. This is really it! And I will miss Jaipur and India. I will miss my non-English-speaking housekeepers. I will miss the chaos of this place. I would like to think India will miss me a little too. The autorickshaw drivers have somehow ceased to ask for silly amounts of money when I tell them my destination. Perhaps it’s my carefully placed Indian-accented English. Perhaps I look different now. Perhaps Indians recognize one of their own. I would like to believe some of those things…then again, I would also like a big juicy steak.

In these last few days, I found myself often angry with this country for different reasons from before. I asked my doctor friends – “Where are all the angry young Indians?” I maddens me a little that I don’t see the people squirming a little when they see the littered streets and impoverished faces. It maddens me some more when I hear stories of governmental corruption and money-hungry politicians and the scamming middlemen who seem to keep the nation ticking. It really hits a nerve when doctors are happy enough to sit there and hone their skills, then gloat that they have so much more clinical prowess than their Western compatriots. Doctors can’t afford to rest on such fragile laurels, when the population continues to breathe in dirt, drink single-celled organisms and die and rot and hurt and cry. The true test of the medical community in India is ultimately a political one – bridging the rich-poor divide, educating the nation; and then later, a working immunization programme and better sanitation standards. Doctors need to focus on the huge public health issues that are constantly overlooked. Prevention, after all, is better than cure. I wish for change in this country. To be honest, I am angry at others because I too share their same helplessness and it eats me up. Perhaps we are all angry young Indians, pacified by our won need to stay sane in a land we cannot change, a situation we cannot fix. I continue to sit here, unsure of my own justifications, still wishing that there is a resolution along the way…and that when I come back to this country one day, I would be able to taste the water from the taps, public dustbins would exist, and people spit, burped and farted at you a little less.

Truly, India has a long way to go. The educated are chomping at their bits to call their motherland the all-glorious, largest working democratic nation, one of history, culture, religion and art…the best nation in the world… technologically, medically and spiritually developed, superior even…but really, who are they kidding? India cannot call itself a developed nation if the country’s sanitation standards poison the smiles of their children, rabid dogs running rampant, proof of polio and leprosy and malnutrition everywhere you look. It can’t even imagine it if clean water is nowhere to be found and the rich happily rely of water filters and mineral water. It is nothing if the literacy rate that hovers around 60% continues to see a female deficit, and the ‘high-school’ graduates still think like village folk. It cannot be a proud democracy if those who run it do it poorly and the population remains uneducated to know any wiser.

I am frustrated and angry…but only because I care. But of course, don’t take my views as the truth, as they are still half-formed, not fully shaped as really they should be. There is still so much of the world I haven’t seen. It is just a current opinion, and opinions shift like the Rajasthani sands. Touchdown in Mumbai is a few minutes away and a sense of nostalgia hits me. How little I know about what my next six weeks were going to be like six weeks ago. How much I have changed, and also how little…as I sit here, still me, as if no time had passed at all.

Day 40, 28^th January 2009 – 1825h IST; Unit 3, JK Lon Hospital, Jaipur

An Indian Ramble

These last two weeks in India have seen such an incredible surge in my learning in the hospital, my experiences outside the hospitals, my thoughts, my emotions…it has been difficult to breathe let alone write about all of them. An entire weekend in Delhi, half-fearing a terrorist attack has gone by, a bevy of new friends have come and gone, and my list of things to read up has literally caused my notebooks to burst at the seams.

In the hospital, I am finally getting some good, old-school clinical teaching sessions, as well as a few tutorial sessions I have shared with the postgrads or registrars in training. My photo log of diseases I have seen here has surpassed a hundred, and my brain hurts a little, from the amount of things I have been desperately trying to pile in before I go. I keep regretting my weeks three and four, when sleep deprivation and ill health and overall jadedness kept me from hitting the pace I am hitting now.

My last few days here have also been occupied with tying up the loose ends of my project, buying gifts for people who have helped me through the six weeks, paying off my debts, and so on…I think I will leave India with the equivalent of £5 in my pocket.

Above all, however, my thoughts have been on this country and my experiences here.

It is strange that I am writing this now – some kind of sum-up of my entire trip. In truth, it feels less like a conclusion because my thoughts and emotions about this place will forever be alive in its dynamicism and they will breathe and grow as a sapling. Think of this as more of a crystallization of thoughts and ideas that have flowed through my head in the recent rush of the tide. I have forgotten some of them already by now, and I feel a tinge of sadness, as I helpless watch them drift away, like silt in the current.

“What is your favourite thing about India. What would you miss the most?” was the question posed to me by a friend in Delhi.

It is funny how such a casual question could flood my senses with a wave of thoughts and feelings, even on a creaking autorickshaw, squashed in a little too tight. The wave hits me hard and fast, crashing upon the rocks, and I was left with a few stutters, then nothing…the disclarity of the froth that gathers below that rock. I try to make sense of my silence, and then the stupidity and simultaneous genius of my answer.

India is the most frustrating place I have ever found myself in. The paradox that seems to govern this country tempts change but breathes apathy. The country has shocked me with it coarsity, poverty and filth. It has angered me with its corruption, apathy and injustice. It has maddened me with the incessant noise of honks, smell of shit and widespread chaos. Yet out of the ashes, it has made me care for a country like I have never before. It has made me care for the world and its people in a way I have never before. I has made me care for the world and its people in a way I have never before. And then I begin to realize, that India has made me…maybe…a better person, the better person I have strived to become but was always too comfortable to stretch for. And the whole reason I get mad with this country, has slowly shifted from thoughts of what the country is doing to me, to what can be done for the country. India is like that family member that annoys you for everything she does and is, but you only let it annoy you because you care. If this is love, then I suppose…I love this country!

My kop-out answer to Marius was that the best thing about India is the me it has made me, forced me to become. It took me a while to think of the answer, and it is not meant to be narcissistic or condescending to the least. It is just personal and true.

“I’ve had some pretty tough times here, but it has taught me a lot about myself – my strengths and my many weaknesses. And I think I have achieved some sort of ‘zen’ that you need to survive in this country. It has given me some sort of peace, believe it or not. It has also helped me see beauty in the world – like how brightly the starts shine over us, and how they remind us that we are under the same sky…And the smiles on the beggar children’s faces…I don’t know. Does that sound like a really stupid answer?”

”It is a good answer,” he smiled.

“Well,” I continued to stutter, “It’s, it’s just…true.”

When I went home, I realized I could have also said the wildlife and nature of India, the picture perfect sunsets and the tangible spirituality that mingles with the spices in my senses. But India has been more than a country of beautiful buildings and less than a country of massive monuments – it has been a personal journey for me, which you would have realized is very much what this entire blog has been about. India has broken me down by removing me from my comfort zone and shredded my complacent sophistication to pieces. It has brought me back to reality. It has taken me down a notch and showed me who I really am or ought to be.

And I will continue to learn and breathe and grow. This adventure is a bigger picture that is the next few months, years, decades of my life. I look to Toronto, then to Chertsey, York and Epsom, I look to exams and graduation and Singapore. I look to life beyond all of that, and I am glad I’ve been reminded to grow, and not just to grow up. This is really not about India after all, but it has been one hell of a journey!

Day 35, 23^rd January 2009 – 1000h IST; Unit 3, JK Lon Hospital, Jaipur

Tales from the Hospital

It’s been a busy week for me, which means I haven’t been able to write till now. The evenings have been taken over by dinner appointments – twice with Barbara, my German friend from Agra, and her two French friends, Anne et Helene; and once with Majid Khan, the nice tour guide from the Night Tour a month ago who invited me to his brother-in-law’s place for what proved to be the best meal I have had in India – delicious mutton curry, roast chicken, rice, roti and some lovely Indian sweets. Then of course, there’s the mundane, like compiling my project data and handwashing my clothes. It is inevitable that my life here gets more interesting as my 6-week tenure draws to a close. And this morning, as I walk through the hospital corridors, I feel a tinge of sadness that I am going to miss this place.

Chai

It is said that India’s society is fuelled by frequent, hearty sips of chai. I for one cannot disagree. I only found out today that I can actually get free chai from my housekeepers whenever I want, and am regretting the tardiness of my discovery. Chai or Indian masala tea, is traditionally made by boiling cow’s milk, tea leaves, ginger, and heaps of sugar. The end result is a delicious hot beverage, served in a smallish glass, and sipped with great satisfaction. It is incredibly sweet with a spicy twist, and it puts dull English tea to shame, especially as the sugar rush hits your head like some kind of diabetic explosion. The best things about chai in the hospital are that it comes at random times without warning – and we gladly accept – as Dr. Mild says, “No one says ‘no’ to chai, tee-kay?”, and that it is always served to the doctors by the hospital workers – no more grumpy British registrars forcing med student to make them a cuppa.

Little Red Riding Hood

Little Red Riding Hood is a ten year old girl who I have seen thrice in outpatient clinics. She was a previous inpatient in our unit, who had presented with a subacute onset of fever, arthralgia and malaise. I think she later became dyspnoeic as well because she went into congestive heart failure. On investigations, she was found to have rheumatic fever with carditis and arthritis (ie. two out of five major criteria of the Duckett-Jones classification.)

Rheumatic fever is still a problem in developing countries. It normally occurs a few weeks after infection by Group A β-haemolytic streptococcal pharyngitis, presenting with fever, carditis, arthritis, rash (erythema migrans), subcutaneous nodule or St. Vitus’ dance (the catchy alias of Sydenham’s chorea). More than half of patients with carditis end up having chronic rheumatic heart disease, which basically means the valves in your heart, the ones that prevent backflow of blood through the chambers they are being pumped from, get either too narrow (stenosis) or functionally inept (incompetence). For the poor patient, this leaves them with a poorly function heart which can lead to other complications like congestive heart failure, dilated cardiomyopathy and infective endocarditis – inflammation of the inside lining of the heart. Many of such patients with valvular lesions will require surgery at some stage to repair or replace the valve.

Rheumatic heart disease is hardly seen in Britain, except in immigrant populations, and for this I will remember Little Red Riding Hood. She sits quietly in clinic, like a child who has seen it all. She looks rather glum, but flashes the occasional smile when her father plays with her. She is a clinical gemstone for an inquisitive medical student. She lies obediently on the bed as I perform a cardiovascular examination on her. The positive findings begin to pile in. Pallor. Bounding pulse. Tachycardia. Collapsing pulse (the elusive waterhammer pulse). Wide pulse pressure. Praecordial left-sided bulge. Visible apical impulse. Displaced apex beat. Palpable parasternal heave and thrills over the mitral region. Traube’s sign positive. Loud second heart sound. Grade 5 (!!! this means that you can hear the murmur even with part of the stethoscope off the chest) pansystolic murmur heard best over the mitral region radiating to the axilla. Early diastolic murmur heard best over the aortic region louder on expiration. Duroziez’s sign positive. *takes a breath* Try doing this in a 5-minute OSCE station! Little Red Riding Hood hops off the bed at the end of the examination, easily comprehending my gesticulations and gruff Indian-style goodbye, and holds her father’s hand as she walks happily out of another Wednesday morning visit to the hospital.

Dr. Bootlick

There are nice doctors and there are not-so-nice doctors. Dr. Bootlick is one of the latter. Thankfully he doesn’t work on my unit – I would have to kill him or myself if I had to deal with him every day. Dr. Bootlick is a short man, with a geeky haircut and a nervous twitch about him. Although he is closer to 40 than he is to 20, he weasles around like a little child in an oversized white coat, and sniffs around for arses to lick.

“When you see sir, you must respect!” he nudges me with a greasy paw, and stands ramrod straight to show me what his skewed perception of respect is. “No hands in pockets! Sir is best paediatrician in Rajasthan!” His statements simmer with typical Indian pride. When he sees ‘Sir’, he shoots straight up into his meerkat look-out mode, whiskers bristling, and then bends over to touch their knees – a sign of ultimate respect in India. He makes me feel like an unappreciative snob from London, which I assure you I am not!

Dr. Bootlick gives a nervy presentation, reading off his slides word-for-word, his hands shake as he quakes in his shoes. I almost feel sorry for him – I see that nervousness in myself too when I have to do public speaking. He yearns so much for love and respect even from his peers – you’ll think that he’s going to start hugging them and screaming in semi-orgasmic cries of affection. During the clinical rounds, he tries to push his way to the front and mutters answers even when the consultant isn’t asking him anything. I think the other doctors are annoyed with him too. He tries to make banter with them as the teaching proceeds – I don’t see any respect in that! – and mostly gets a few uncomfortable laughs, a few ‘shhh’s and general disregard.

Dr. Bootlick is the epitome of what I never want to become as a student or a doctor. He is a groveling child who yearns for attention and respect, yet earns none. He treats his juniors with disdain and almost outright contempt, and arse-licks so much one fears for his oral hygiene. A true test of a good doctor surely, is his relationship with his patients and also his colleagues. So many lessons are learnt from great doctors and teachers, but a good number are learnt from the bad ones as well.

“Charm the Mum, Mild the Child”

Dr. Hero explains to Dr. Petite (one of my unit’s 2^nd year residents) and me in his slow, articulate manner, that when a child is between 6 months to a year of age, you should try not to start the consult by looking him or her directly in the eye. They find this threatening, like dogs do when you stare at them. At around 7 months of age, babies get this thing called stranger anxiety – a normal stage of a child’s social development, where he starts careful differentiation of familiar faces from unfamiliar ones, and he will often seeks his mother’s comfort in the presence of strangers.

“Um, sir, then were do we look?” I ask, sitting there looking stupid, which I seem to do pretty well.

They both laugh.

“Look at the mother and talk to the mum first. The entire time, the child is watching,” Dr. Hero’s eyes look up and switch from side to side like he is watching a tennis game up in the air, “When mum smiles, the child is comforted. Then only do you start by touching the child by the hands first, and playing with him, still avoiding eye contact. If he pulls away, he isn’t ready yet. If he plays along, you can start developing a relationship with him.”

It is the simple tricks that make good doctors great. These tricks are learnt by experience and perfect by habit. I love simple tricks – like the best way to feel a pulse, or the distraction tactics used to do a quick neurological assessment of a child. A good paediatrician is one who has completely examined a child with the child not even realizing it, thinking the entire time he was playing a game.

My respect for Dr. Hero is huge. If ever I find a doctor role model to learn from, it must be him. He is not motivated by money, and is as genuine as he is intelligent. His soft “kyaar wah”s and “achar”s put both parent and child immediately at ease. However, I am not one to hero worship. It is not easy to find heroes in medicine. Different individuals have qualities that I admire, and I wish to soak in all these qualities to make myself some kind of superhuman amalgamation of the lot. This is, of course, a pipedream. I am limited by my own flaws and personality traits and innate programming. I am too edgy to ever be like Dr. DJ, too laidback and lazy to be ever like my ex-surgical F1. I can’t wait to start AHOs – I can’t wait to see what kind of doctor I can eventually evolve into – that metamorphosis from student to physician, from learner to healer.