BY MICHAEL DAUM, MD
I had the wonderful privilege of visiting three different cities in India for 16 days during my third year of residency. My original impression of India was, "Wow." This country could not be any more different from what I am used to.I am just a small-town boy from southern Indiana, but my medical training has given me the opportunity to visit poverty-stricken areas and witness different medical practices in Honduras, Guatemala, and Haiti. But India was just different. Name anything. From the obvious — language, food, population density, climate, dress, and religion — to the not-so obvious — cleanliness, body language, hospitality, hospitals, patient acuity, and where health care priority fits into government.
India is roughly one-third the size of the United States, but it has roughly four times more people. It is home to 17.5 percent of the world's population, and has 53 cities with more than a million people (the United States has 10).
I went to three southern India cities: Bangalore (also called Bengaluru), Chennai, and Madurai. Each city had its own character. Bangalore was the first city I visited. George Washington University made my trip possible, and the hospital with which it partners is BGS Global Hospital. Dr. Samir Mohammad was the program director. I helped administer oral boards to residents the first two days and lectured the next two days. Fortunately, I had prepared six different hour-long lectures prior to arrival and many cases from my own experience in residency to use for case-based teaching. I used all of them because the residents in all three of the cities were so enthusiastic about learning. It was very evident that they were very well-read but not up to date with the new, ever-changing knowledge and clinical practices in emergency medicine. Their knowledge is almost solely built on textbooks like Tintinalli and Rosen. I had not realized how much FOAMed, UpToDate, and podcasts shaped my education.
The ED had three "trauma bays" that doubled as acute care rooms. They had approximately 10 beds total, which is large compared with other hospitals in India.
I visited BGS Global Hospital-Chennai next, where Dr. KR Ram Mohan was the program director. I spent a majority of the four days lecturing and doing bedside teaching. Almost every patient I assisted required intubation, cardioversion, or some other emergent necessity.
One of my favorite experiences was when I rode on the back of a resident's motorcycle to a World Heritage site one hour south of Chennai called Mahabalipuram. It was quite exhilarating to ride through chaotic traffic with seemingly no traffic rules. The monuments we visited were carved out of bedrock in 700 AD. I also visited a beach, and was amazed at the hundreds of people present and what they were wearing. Women were fully clothed and did not enter the water, while the men wore jeans and would play in the water.
I flew to Madurai after Chennai. It is is a city in the state of Tamil Nadu in southern India. The hospital was called Meenakshi Mission Hospital, and Dr. Narendra Nath Jena, the program director, is quite famous for his pioneering role in emergency medicine in India. He gave me a warm welcome, and his excitement for teaching and passion for the specialty was contagious.
The emergency department was the largest, nicest, and by far the most organized of the three I visited, and it was evident that it was because of the diligent work of Dr. Narendra Nath. I lectured here for three days and took one day to dedicate to clinical skills such as intubation, central line placement, ATLS, and ACLS cases. The residents here absolutely loved the one-on-one clinical teaching, especially using the dummies to intubate and do case reviews.
One of the residents took me to one of the largest Hindu temples in the world called Meenakshi Amman Temple, which forms the heart and lifeline of the 2,500 year-old holy city of Madurai. It is considered one of the "New Seven Wonders of the World" and was truly a sight to see.
One common theme that persisted in each city and hospital I visited was the wonderful hospitality. I was greeted with such warmth and kindness by the program directors, residents, and staff. The program directors in each hospital would constantly ask if they could do anything to make my stay and experience better. One even had the hotel chef prepare a different traditional south Indian dish every meal. And the respect shown by the residents was amazing. They would all stand when I entered the room, and would always say, "Yes, sir" or "No, sir," something I would never expect (not even when I am 65 and ready to retire).
The acuity of patients presenting to the emergency departments at each of the three hospitals were quite different from here in America. We generally see anywhere from 93,000 to 100,000 patients in our ED every year. We admit approximately 23 percent of our patients to the hospital. An even lower percentage are admitted to the stepdown unit, and even fewer are admitted to the ICU. The staff at Meenakshi Mission Hospital and Research Centre, however, sees approximately 14,000 to 15,000 patients per year in the ED, and they admit more than 50 percent to the ICU. These numbers were pretty similar at the BGS Global Hospitals in Bangalore and Chennai. The patients present with much higher acuity in India because they do not have great access to health care and because they often attempt to treat ailments with home remedies and prayer.
I could not be more thankful for the opportunity to participate in such a wonderful experience. I know it could not have been possible without the partnership of the Palmetto Emergency Medicine Residency Program with the GWU International Medicine Program. Most notably, I would like to thank our program director, Dr. Thomas Cook, whose championing involvement in global health, international travel, and its unbelievable life-impacting potential proved 100 percent true. Also, I would like to thank Dr. Heather Brown and Dr. Kate Douglass who helped make this all possible. I will never forget this great experience.
Dr. Daum is a third-year resident in the emergency medicine program at Palmetto Health Richland in Columbia, SC, which is under the direction of Thomas Cook, MD.