Grace’s guest blog about jet lag

Jet lag is not a joke. I thought I had the perfect plan to beat jet lag. I planned on getting as much sleep as possible during the 24 hours of travel, up until our first morning in Trivandrum. That way, I would wake up Friday morning ready to stay up for at least 12 hours. I slept most of the first flight, probably 10 out of the total 13 hours; I even slept on the second plane. When we arrived at the hotel, I went to sleep for 90 minutes and woke up at 8 am feeling really good. I thought I had beat jet lag. I don’t think I could have been more wrong.


It hit me a little after noon; I had already walked 11,000 steps and I was exhausted. Not even food or water helped. My brain felt dead and I was in zombie mode. I took a two hour nap and still fell asleep at 8pm, fully dressed with my shoes and the lights still on.


The next morning was even worse. I was wide awake at 6 in the morning, but that definitely did not mean my mind was functioning clearly. I brushed my teeth twice because I forgot I had already done so. I shattered a glass at breakfast and was dropping my food on the floor. In general, I felt as though I had no control over my body.


Jet lag is more than just being tired during the day and waking up at odd hours of the night. It is doing and saying things you normally would never do. It is a thick fog over your brain that makes directions so hard to understand. Jet lag is real and I sure hope it ends soon.2016-12-29-05-22-29


Oh jet lag…

The students in the program need to write a short essay about their physical sensations during jet lag.  I smiled when the first 2 essays arrived at 5:30 this morning.  I was wide awake too.  They described the lack of concentration and irritability, and not feeling in control of their body’s schedule. (They had been up for 2 hours).  Years ago, my sister-in-law mentioned that jet lag was the best approximation that healthy people could have of the fog that cancer patients have during chemotherapy.  We thought it would make a good reflection topic.

The essay authors, Janice and Alex, were up and ready to go on a walk at 6:30 this morning. We went to the large city park that houses the zoo and the art museums. The park has a large circular drive where every morning, hundreds of Malayalis walk and run.  We figured out to walk on the left hand side after a time.


And then off we went to Pallium India headquarters at the Arumana Hospital for classes in pain and communication.

We heard that 80% of the world’s population and 99% of Indians have no access to opiate pain relief. (Kaley and Sam were assigned the life time job of changing this inequity in their role as public health experts).  This group quickly caught on that pain is not solely a physical phenomenon.  All pain has an emotional component, and a social impact.  Some pain causes despair or spiritual suffering.  We also introduced a common phenomenon of collusion, where family and health care providers do not share all the medical information with the patient.  All ready for home visits next week!

We finished with a welcome dinner from the Pallium leadership.  Saree and kurti shopping tomorrow for the New Year’s banquet as well as a trip to the beach.


Trivandrum, Day #1

We arrived with all our luggage, 30 hours after some of us left downtown Iowa City.


There is nothing better in  the nervousness of international travel than leaving the airport into a crowd of people and hearing “Dr. Ann!”.  Babu, the senior medical social worker and advocacy director for Pallium India had come at 3:30 AM to wait for the arrival of TEAM IOWA.  Some of us went to sleep for a couple of hours (or more) and others just stayed up, showered and explored the city until our class with Manoj, Babu, Arathy and Dr. Rajagopal.

For me, I was reminded that I explore more when I have  students with me.  Somehow they embolden me to do things that I would not do on my own.  It was great fun to return to my adopted city.  Many people on the staff of Pallium and at the hotel have stopped me to talk about “Jo Madam”–the term of respect for Dr. Jo Eland, my senior colleague on this trip who died earlier this year.

The students explored the city with step counters (over 9,000 steps on no sleep), maps and a scavenger hunt list.  Some of us had lunch on the hotel roof top where there are breezes and views.

I am not complaining about the heat and humidity…yet.

Greetings to you all.

By the skin of my teeth

Now in New York City, fighting jet lag….and missing a Nor’easter)

I almost missed the inauguration of the Oral Health Clinic at Pallium India. This clinic will fill an important need for rehabilitation patients, patients who are chronically ill, and the patients who are terminally ill with painful dental problems. Little did I know that I was selected to cut the ribbon!


Dr. Sreedevi in red sari, as we inaugurate the clinic.

The faculty and staff at the College of Dentistry, specifically Dr Dan Caplan and Marilyn Wessels-Evers were especially generous to gather surgical dental equipment and fluoride that they thought would be helpful. And Dr. Satish Khera donated 20 dozen pediatric toothbrushes and 20 dozen adult toothbrushes. TEAM IOWA-a group of 15 health science students- collaborated by packing all the instruments, the fluoride packets and the toothbrushes in their luggage for their 3 week course at Pallium India. Luckily we did not get stopped at customs. (We had a story all ready about compulsive Iowa toothbrushers.)

IMG_0724 (1)

Sr. Sandhya instructs young patients on the use of the donated toothbrushes.

We wish Dr. Sreedevi and Dr. Amirtha great success for the clinic! It will be great to have this resource for Pallium patients.


Dr. Sreedevi and Dr. Amirtha checking out the dental hygiene on a patient

Oral health is one area that is not covered well in the medical school curriculum. (I have felt grossly deficient in wound management as well). In my practice in an academic center in Iowa,  I frequently “outsource” medical care to other specialties.  I refer all wounds to the wound nurses, all oncology to oncologists, all oral health concerns to dentists, and rehab concerns to physiatrists.

Outsourcing medical care is not always an option in a low resource country. Referrals to specialists may be logistically or financially impossible in a system where patients pay cash for care, and live at a distance from specialty care.   While I am grateful for the new Oral Health Clinic, it reminds me how much I want to ramp up my knowledge base in wound care, mouth pathology and basic oncologic care.

Perhaps, in my return to a high resource country, I can simply ask the question: What would I do if I did not have a specialist to ask?
I am a general internist after all.

And now for the moment of beauty: (I thought I worked for a living until I saw these fisherman pull in the nets at Samudra Beach).


Getting from here to there in Trivandrum

One of the greatest day to day challenges of getting to the hospital to volunteer was transportation to and from the guest apartment. There was not really the option to walk, or bike for 8 kilometers. I tried auto rickshaws,IMG_5384 an easily maneuverable three wheeled vehicle—it is quick but usually requires price negotiation with the drivers. My apartment mate, Anne, was good to take me on the buses when she was in town or when we left the hospital at the same time. The bus is clearly my preference.

But how to determine which bus is mine when Anne is not with me? The buses are not numbered, and Malayalam bus placards did not have a recognizable word for me.


Malayalam, Hindi and English script

At first, I just got on the buses with a notebook –with my destination written in Malayalam. That did not work, as I usually got on the wrong bus. The conductor sucked his teeth (a universal communication tool) and had me get off at the next stop.

The next strategy worked like a charm. I should have known that “relationship” is the key. Anne had been very social at the bus stop.  I smiled at these bus friends at the bus stop and asked them, with my destination written down in Malayalam to make sure that I got on the right bus.  As long as I am out there by the 8:05 AM bus, I was in the chips.


Inbound bus friends: Dhanya, Punyia, Anne, and Revi

It worked well. One time, the conductor tapped my shoulder to have me get off at a hospital on the way, and there was a chorus from my bus friends seated distantly from me that he was mistaken about my stop. Then Revi looked for me every morning.

Getting home was more challenging but equally charming. Chaithanya Mohandas, (a web designer with Leonine Info Solution located right at West Fort) was very happy to help me get on the crowded 5:15 bus. Once, through mass motion only understood by a bus passenger, I got moved toward the front of the bus away from the door. When it was approaching time for me to get off, I started to move toward the door with my yoga mat catching on everyone’s clothes and purses. Amazingly I got off that bus, rumpled but intact. The next time I got the bus with Chaithanya, she parked me right where she could guard me against movement down the bus aisle.


Outbound bus stop friend, Chaithanya

Why do I prefer to take the bus? In part, it is the higher viewpoint, away from the exhaust. But more important, it is the connection with the every day, the unexpected, the hilarious. I am more apt to see the fruit stand, the cricket game, bananas sticking out of a rickshaw, regular people on their way to work looking fresh in saris…6 days a week. From that vantage point, I see whole families on motorcycles (not hilarious). And then there is the time that an elephant went by in a truck.

It is a little restrictive to ONLY know how to travel back and forth at a certain time. I decided to take yoga-which is only offered at 6:15 AM and 6:15 PM. I like the 6:15AM yoga-doing the sun salutation with 30 Keralites on a rooftop is a peaceful way to start the day. Along came Vijay-a rickshaw driver who was willing to come at early hours to get me to yoga on time or pick me up at night. No haggling—he had a set price for going the 8 kilometres—a price that was worth it to make it to yoga.


Vijay drives so smoothly that I can drink coffee

In international stays, it takes a while to make life work. Sometimes it starts working just before it is time to leave. Which means I will have to come back!

Thank you to my friends—Anne, Dhanya, Punyia, Chaitanya, Revi and Vijay. You made life work.

Oh, and happy leap day birthday to my childhood friend, Andy Tuthill, who has had 15 birthdays.



Yoga at Kovallum Beach (I am not there…yet)

An outward expression of grief

The Taj Mahal is my husband’s favorite place on earth. He always wanted us to go together because he found it so spectacular in different lights. Last year, we celebrated 30 years of marriage and tomorrow, February 15th, will be the 31st anniversary of our engagement. We decided, earlier this month, that seeing the Taj Mahal together was a good anniversary gift to each other.

We arrived on a Thursday night to Agra after an easy drive from Delhi. The Taj is closed on Friday. But that did not stop my husband from enjoying the Taj Mahal. We saw it on Friday from the massive Agra Fort,
IMG_5409 and then again at sunset from across the river.
IMG_5443Even the guide joked that my husband wanted to make sure it was still there. We got up early to see it in the early morning light on Saturday.


We have 50 more of these photos.  Invite us for dinner!

The Makrana marble reflects light differently, and the inlaid stones and carving are an artisan masterpiece.

It is very symmetrical except at the site of the graves of Mughal emperor Shah Jahan and his wife Mumtaz Mahal whose graves are not identical.

You might recall that I was able to parlay a visit to Death Valley National Park into a blog about palliative care. It might seem a stretch that I will make a blog about the Taj Mahal into a palliative care topic. But read on…

Mumtaz Mahal, (“the jewel of the court”), the 3rd wife of Shah Jahan was a Muslim from Persia. She married the Mughal emperor Shah Jahan in 1612 when she was 19 years old. She was his favorite wife and companion. But in 1631, she died during the birth of their 14th child. The emperor’s grief was profound, and he ordered the court to remain in mourning for 2 years. He promised her he would never remarry and that he would build a memorable mausoleum in her honor.

Shah Jahan enlisted an architect, and 22,000 laborers who worked along with 1000 elephants for 22 years to build the Taj with semi-precious and precious gemstones and Makrana marble from Rajastan. Shah Jahan spent 32 million rupees in 1632-1653, which is the equivalent of $1,062,834,098 (yep, a billion) in today’s US dollars. His son deposed him soon after the Taj was built. Shah Jahan had started to build a second black marble Taj when his son placed him under house arrest (to stop this expenditure?). Shah Jahan lived in the Agra Fort (in very regal quarters), where he had a view of the Taj Mahal. At his death, he was buried at the side of his favorite wife who predeceased him by 35 years.

As a palliative care professional, I certainly encourage grieving family members, friends, (and health care professionals) to have some outward expression of their grief- a letter, a bench in a park, a memorial fund. It allows the mourning to be shared with others in a symbolic and externalized way. If I had been part of his bereavement team, I might have discouraged Shah Jahan from spending the empire’s money in this way, worried that it was driven by guilt and might cause some complex family emotions. But hey! Full employment for 22,000 people could be considered a good thing.

And for the love of my life and me….we are very glad he showed his love and grief in this way. Happy anniversary Stanley.


Notice the silly man on the right…I would never do that!


Above the sound of the call to prayer in Murukkumpuzha, a group gathers and chats in the public library on the second floor. Wednesday is outpatient day and those who can climb the stairs come and visit with the Pallium team– nurse, doctor, social worker and volunteer. Here, they will get an assessment of their social situation, their symptoms and refills of their medications.


Sarath takes a social history


Dhanya, a geriatric trainee, looks up during a break

Many healthy appearing women are in clinic on this day. Their husbands or fathers have been injured through accidents either in India or in Gulf countries. Or the menfolk have had strokes and cannot make the trip to clinic. The women serve as “proxies”—reporting symptoms and getting some support for the hard work that they do at home, in addition to their wage earning jobs.IMG_5319

The volunteer, Francis Ernest, bustles about the library , answering his cell phone and talking to patients and families while they wait. About 8 years ago, he retired from his


Mr. Ernest

government job. In retirement, he saw a need for a community organization to meet the health needs of home-bound patients. He asked Dr. MR Rajagopal, the Chairman at Pallium India for some training for 20 interested community members. At Pallium India, the volunteers receive training to be the case managers and frequently the first contact for patients and potential patients in the community. They learn to do follow up for patients who are seen in clinic, receive referrals for Pallium India, and do initial visits after referrals.

Those 20 volunteers, under the leadership of Francis Ernest and Patricia Paul started the SNEHA Palliative Care Society for Murukkumpuzha. “Sneha” means love in Sanskit, very close to the word in Malayalam for love-“sneham”. Now, 8 years later, 4-5 of the original volunteers are still strongly involved.

There was another striking part of this morning’s clinic. A quiet and dignified man sat in his dhoti next to his daughter waiting for his turn to visit with the doctor. His diagnosis is motor neuron disease, which is amyotrophic lateral sclerosis. (I wondered how he possibly made it up the flight of stairs). He was having increasing problems with swallowing and has some regurgitation through his nose. He was losing weight and feeling short of breath. His fingers were developing contractures. He had pain. His daughter, a nurse, elaborated on his narrative. Everyone listening, including this patient with his erect posture, knew that his disease was progressing. Pallium India provided medications for his pain and shortness of breath and he and his daughter went down the flight of stairs…slowly.

My admiration may have ended right there for this patient, except that I peeked out of the second story window and saw him climbing on the back of his daughter’s scooter, his contracted fingers on her shoulders. They must have felt me looking, because they looked up. My hand went to my heart-and we smiled together. They seemed to enjoy my surprise. A week later, he is still in my heart.

And for your eye candy…


Black pepper roasting in the sun at the side of the road