Soman Uncle: Guest Post by Dr. Sheetal

Editor’s note: Dr. Sheetal is an internal medicine physician who is in the initial stages of developing a Geriatrics and Palliative Care Program at Kasturba Medical College in Mangalore. She joined Pallium India for a week of shadowing. She will also be coming to the University of Iowa to shadow the Geriatrics program later this year.

It was almost an hour and a half into my first home visit that I first noticed Soman Uncle, our driver for the trip. He had quite cheerfully made a second trip walking in the blazing sunlight ,around the block of houses where we had parked, searching for the house of the patient. Finally he had found it. We trooped behind him as he led us into the house for what was a bereavement visit, a yet another unique initiative of Pallium India. We sat in the living room , 2 doctors , a nurse and Soman Uncle. We sat in respectful silence, watching the grieving wife. The polished floors and high academics of my Medical College hadn’t quite prepared me for a bereavement visit. As I sat there struggling to strike up a conversation with the lady of the house, I saw Soman uncle easing the patient into a chair , asking her details of the disaster , the funeral arrangements, deftly enquiring about her needs and resources.

Soma Uncle, coordinating the next home visit

Suddenly the melancholy of the room seemed to lift as he made enquiries. The patient very stoically narrated the trauma of the death of her husband and brother in law, in the recent cyclone. The message of Pallium India , to provide care beyond cure was reflected in his easy and confident manner , offering support where needed and making a difference by just being present. His presence and easy manner, worked well to wipe away my own ineptitude in  such matters . My grand confidence as a doctor ebbed away, while I watched in awe at humanity on display. Throughout the next 3 hours as we walked in and out of houses , the presence of Soman uncle, acted to provide the balm of humanity around my cold enquiry of medical facts. I found him making casual talk about the teakwood tree being cut in the next compound or about a recently constructed wall at the house. He had stiff competition from Nurse Seena, who actually went into the kitchen of a patient and asked about the lunch plans for the day, while I limited myself to neurological examination and auscultation and found myself too tongue tied to speak anything else!!

At the end of the day as our van came to a halt at the headquarters of palllium, it didn’t seem like a long day at work, rather like a day spent meeting friends and family of Soman Uncle and nurse Seena.

Chitharal Rock Jain Temple, at least as old as 1300s

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Sr. Dinu: poised, confident and competent. Guest blog by Allie Weis.

In Muttacadu, I found someone who I admire greatly. Her name is nurse Dinu. At first when we loaded up the vans for the day, I was disappointed because since there was not a doctor with us, I did not know what the day would hold. This turned out to be the silliest thought I could have had. Nurse Dinu is poised, confident, compassionate, and competent. There is no need for a doctor to be on this visit today. Dinu communicates with us, asks us our opinions, and teaches us. She makes the day the experience it was. She knows her patients and their needs. She may be small but her presence is large and she is greeted warmly by the patients we visit.

The first woman is in a dimly lit home. She needs a catheter change. Dinu asks the husband for a lantern and begins to prep for her catheter change. I watched her so intensely. There were mosquitoes flying in the home, the cement walls were damp from the humidity. The bedsheet’s discoloration makes it unclear when they were last clean, and an old bench is the only acceptable place to set up sterile field. I’m having flashbacks to my first semester of nursing school. Hand’s drop below the waist? Fail. Turn your back on the patient? Fail. Sterile drape moves? Fail. Incredibly enough, I think my lab instructor would have passed Dinu. Somehow in this unclean home, Dinu does this procedure by the book. I still break a sweat in the hospital trying to maintain sterile field on a mobile patient with plenty of space and light, Dinu makes it look like she could do this in her sleep. I am amazed by her.

Thy notices that the urine is cloudy and the patient is able to verbalize pain in the lower abdomen and back. A UTI is suspected. Dinu respects us as we respect her and she asks Thy what she would do. Thy says that an antibiotic should be started and Dinu agrees. It was such a pleasant feeling to be included on patient care. This was a change from the day before where I felt like more of an observer. Dinu made me feel like we were a team. I think that is what I admire most about her. I love that even though she is intelligent and has a lot of experience, she recognizes intelligence in others and takes their opinions seriously.

I ride in the van with Dinu on the way to the next visit. It is a psychiatric patient. Dinu thoroughly and patiently answers all of my questions I ask about the care of psychiatric patients in India. After completing a psychiatric rotation at UIHC, it is upsetting to me there there is not a specific diagnosis for this patient. She is just labeled as “psych.” I know America still has a long way to go to change how we treat patients with mental illness, but it gives me more respect for the progress we have made.

The next patient we visit has an NG tube and needs a catheter change. When I walked into the room, I looked at the bed and didn’t even realize there was a person laying there. She was so frail and had contractures of her arms and legs. She is near the end of life. The daughter of the patient wanted the NG tube out. Dinu is great at communication and you can tell her care is centered around the wants and needs of the family. She listens to the daughter about why she wants the NG tube out and what she thinks her mother’s abilities are. Dinu turns to Stephanie. Again, Dinu’s mutual respect is displayed. She asks Stephanie’s opinion and together they decide that the NG cannot come out until it is seen how something like porridge is swallowed.

The last home Dinu takes us to is an experience I’ll never forget. The woman who was a patient had had a brain bleed after being abused by her husband. My whole group was not emotionally ready for this experience. But Dinu stands tall. The best palliative care she gave this family was a listening ear and a shoulder to cry on. This woman, in her 30s, is cared for by her parents. Dinu steps out of the room and listen’s to the father’s concerns while the rest of us sit with the woman and her mother. The mother tells us that her daughter was a successful accountant before her brain injury and shows us pictures of how beautiful and graceful her daughter used to be. I am sad for her. My heart hurts that this happened to this woman, but my feeling of anger is much stronger. I am outraged that the husband is not in jail and that he has their children. I am outraged that he is not facing the repercussions of his actions. But the woman is safe now. The hands of loved ones no longer harm her, but help her to get stronger. Dinu tells us we were “just checking” on this visit, but this is where we spend the most time. From what I can gather the visits to this home are a great source of emotional support. And Dinu is strong for this patient and the family.

I watched Dinu do a lot of nursing procedures today, but that is not what I learned from her. She showed how important it is to therapeutically communicate with patients and how necessary a soft touch is on the road to recovery and comfort in patients. When I think of a good nurse and the kind of nurse I want to be, an image of Dinu comes to my mind.

Editor note: drawings and blog are by Allie Weis.

Brooke’s description of tilapia… er, hum… jet lag

This was my first time experiencing extreme jet lag. We crossed roughly ten time zones, leaving an eleven and a half hour time difference between our new location in India and our home in Iowa City.

I thought due to my travel experience I would transition smoothly with the help of melatonin and sleep! I was WRONG. During the ~13+ hour flight, I slept for roughly 8 hours. The melatonin was handy, but I also spent the flight next to a talkative (and adorable) three-year-old little girl. When we finally got to Abu Dhabi, I was feeling exhausted. My eyes were actually hurting, maybe because they wanted to be closed so badly? I haven’t quite figured that one out, yet. I slept almost the entire second flight, waking up only to eat.

Since arriving in India on the morning of the 29th I have woken up at 4 AM every morning. Even when I feel extremely tired, I haven’t been able to fall back asleep. During the first couple of days I experienced what I can only describe as an extreme haziness. At points I felt so tired, that when someone was talking to me I nodded and ‘uh hu’ed, but I could not take in a single word they were saying to me. It was like trying to listen to a speaker with a blanket covering it. I also noticed I had trouble finding words. Multiple times when trying to describe the rice pudding I liked on the plane I would say ‘tilapia’ instead of ‘tapioca’. I also used the word ‘chair’ when I meant to say I wanted to lie on the bed. This happened to me numerous times where I felt like I said the right word, but it came out wrong.

“Chemobrain” has been described as an experience similar to jet lag. Ironically enough, the term chemobrain was often used around my house as a joke. My brother went through high doses of chemotherapy and radiation after being diagnosed with a rare form of bone cancer at the age of 19. We regularly equated his misuse of words, misplacing of items, and losing his train of thought midsentence to “chemobrain”. We would frequently do this in a joking manner, laughing with him as we sloughed off his mishaps with this word. I never realized what he was actually going through.

I cannot imagine having this haze for an entire year. I felt very frustrated our first few days trying to sort out and communicate my thoughts. Even journaling felt difficult. I kept waiting for the morning that I would wake up and feel normal again. Today was day 4 in India, and I still don’t feel completely back to normal. Chemotherapy not only takes an emotional and physical toll on a person, but this mental toll is something I had ever recognized. I admire chemotherapy patients for their strength in handling not only symptoms such as nausea, vomiting, and hair loss, which I feel are typically associated with the treatment, but also the emotional strength it takes to face a disease and deal with “chemobrain” for months at a time. Simply put, I don’t think I can ever say “chemobrain” lightheartedly or teasingly again.

Editor’s note: pictures show Brooke in a Laurie Baker (famous architect) building, and on the trip to Ponmudi.

A lot can happen on a hike in the Western Ghats…

Many years ago, I worked at a secondary school in Suba, a small town outside of Bogotá. The headmaster of the school felt strongly that all students from 1st grade on needed to go on a one week hike. The Andes Mountains provided ample opportunities for varying levels of difficulty. The Spanish headmaster had hiked Pyrenees mountains during Franco’s rule in Spain. He thought that students had a chance to reflect and learn about themselves and others in that week.

And so, after a semi-cluster of problems last year, we elected again to try the Brymore to Ponmudi climb. We started at a tea plantation that was abandoned by the British at the time of independence. On our drive there, the cool temperatures made it clear why the site was so appealing.

We gave the option for an alternate hike this year and this gave students and faculty a chance to do self assessment. I found myself in admiration of both groups but wondered how my Type A personality would handle going on the less strenuous activity. Similarly, during the hike where I was positioned in the group was a topic in my thinking. “What if I started dragging the group?”

Then the awe started settling in. Awe generates amazing peace for me.

And then relief that we made it, and Stephanie kept the bus up at the top waiting for us. The guides do this trip in sandals in 1 hour. We did it in 2.5 hours.

Thank you Iowa. I am a new person again.

Happy birthday Emily and Elly

It was a full New Years weekend for everyone including the two women with birthdays. We all got up and got to the beach early, ate fish, played in the surf, and listened to the lifeguard tweets to move us to less rough waves. The sun felt great.

Then we came home to the hotel to get in our saris. It took Arathy and Lakshmi 15 minutes for each student to help students and 1 professor to get wrapped in the saris. But they looked spectacular!!

And the men looked great too:

Stay tuned for pictures from New Years Day from the Western Ghats hike…

Pallium India

We arrived in Trivandrum! For me, this is a return to friends and colleagues and “family”. This year I have two very skillful and talented friends and colleagues joining me, Kashelle Lockman from the College of Pharmacy and Stephanie Gilbertson-White from the College of Nursing. We share a commitment to interdisciplinary education. We have been collaborating all year with Pallium India, in various projects, including our decision to bring a record number of students (I am sure Jo Eland will send me a message if I am wrong). The students are from pharmacy, radiation therapy, social work, nursing and pre-medical students.

Their first assignment is to write about jet lag, which has so many manifestations. One student wondered why she said tilapia instead of tapioca-not once but twice. My sister-in-law said years ago that jet lag is the best approximation of “chemobrain”.

You will have guest blogs from the students in the coming days. But for now, enjoy the arrival picture.

Fires, fires and fires

Yesterday, many women…over 2 million in fact, celebrated the Attukal Pongala festival in Trivandrum, Kerala where I just spent just over 2 months.  I do not fully understand the story of the goddess who is being celebrated.  The largest impact is that huge numbers of women line the streets of Trivandrum, Kerala in a large radius around the Attukal temple. Each woman has set up a cooking fire with a terra cotta pot, with bricks supplied by the temple.

She has brought the raw ingredients for payasam– rice, jaggery (unrefined sugar in blocks), coconut, cardamom powder, cashews, raisins, ghee (and maybe bananas).  Each woman waits for the flame, which is delivered from the  from the temple.


Then the ingredients are added in step-wise fashion, and boiled until a certain consistency.  This is most notable because 2 million other women are doing it at the same time.  And for a week after this festival, Malayali men will offer visitors and work mates their mother’s payasam as the best in the district.

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These fires and the sheer quantity of them, and the image of 2 million women bent over these cook fires prompts me to write about other fires that affect the health of Indians.  Women still cook with firewood in India, more in the rural areas than in urban areas.  More concerning is the disposal of household waste (including plastics) and brush from plants and trees with burning.  It would not be unusual to have a brush fire going around the hospital where patients already have difficulty breathing.  Walking the 3 blocks from yoga to the hospital, I notice all the street sanitation workers who are burning the leaves that they have collected in a small pile.

India has a rapidly increasing difficulty with smogRecent recommendations have suggested vitamin D supplementation for India’s population because people cannot get the 10 minutes of sunshine needed to make vitamin D in the skin.  What would happen if households or districts used composting–using either worms  or microbes to accelerate the decomposition of household and yard waste to fertilizer…without burning?  Could this be an employment  project with an district entrepreneur paid by neighbors to take the household non-plastic waste and yard waste and make fertilizer?

Burning as a method of waste disposal is a health issue.  Some day, the Attukal Pongala festival could also be a celebration of the triumph over smog and will be one of the few  times open air  fires are used.

There are people in Kerala who are champions for composting. I did not get a chance to visit with the Kerala compost champions on my recent trip.    Next time!

For now, I will just go back to Iowa and love my pet worms in my composter.

And now for your moment of Zen:

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Barrier Free Trivandrum Mural, painted by Pallium patients and staff