An introduction to the inner workings

Blogging is tough work!  Again, I must apologize to everyone who expected timely updates but the internet situation, and more so, my inability to properly convey these experiences (at least to the extent that I’m marginally satisfied with their telling) have made it a longer process.  On the plus side, Arun (the head of maintenance and x-ray technician) and I managed to repair the LAN so the hospital is now graced with an internet-equipped computer whose blazing power has drawn information at speeds up to 20 kbps.  So, ideally, I’ll be able to write daily and work out a better posting schedule (though, again, I apologize that this wasn’t able to happen during the first group visit).  Here, instead, is a longer post with many of the highlights since the first group left.

 

About two weeks ago Anil invited me on a three-day trip Anil to tour seven mission hospitals in the region with Rev. Dr. James Vijayakumar, the Global Ministries area executive for Southern Asia.  While it was often fly-on-the-wall observation, there is no better way to learn a game than to be present when the pieces move, and I really got a sense of the big picture in India, in the Christian community, and especially in the mission hospitals.  I could write a volume on just this weekend but for the sake of the blog I’ll just summarize.  We saw many places and met many people, toured established hospitals built up by Anil’s parents, withering hospitals awaiting their time to die, modern and misguided hospitals where the ICU was made as an income stream, deteriorating hospitals in need of fresh leadership, and persecuted hospitals where Christians live inside their walls under the protection of arms.  It was an incredibly educational and unbelievably exhausting journey through the various manifestations of Christian goodwill.  Seeing all these things, I couldn’t help but think about India’s numerous problems.  The biggest and most pervasive issue is corruption.  It seems that everyone will take a skim off the top if they can get away with it, and therein lies another major issue, the inability of the government to enforce its own rules.  This vicious tag-team stagnates development like you wouldn’t believe. 

 

In the same sense, here in rural India, it is incredibly easy to see something that’s been drilled into our heads since childhood as the American Dream, in a different light.  In a nearly feudal societal structure where caste still very much determines the means to life’s end, those born to privilege are the sole holders of opportunity.  And nearly everywhere, it seems, even in the Christian mission hospitals, that gift of opportunity is hoarded for self-promotion and lorded over the miserable masses.  So coming in as an educated and (by local standards) relatively wealthy foreigner, another childhood mantra is stunningly apparent to me:  the power of one.  It’s like the general/governor system in Total War, for good or for ill one well-equipped individual can make all the difference.  The real sticking point is the rare combination of visionary leadership with a focus on serving others.  It is a broken system that was never whole; its fractures swallow the masses while the fortunate stand securely on the pillars of surname. 

 

So how can India repair itself?  That’s the real question.  There is no easy answer, but I can think of a linked issue on a smaller scale:  how can we change the Mungeli culture of last-second caesarians and walk-off deaths?  The cause of the first question is a result of the second and the cause of the second is a large portion of the reason the first is an issue at all.  A roundabout comment on a convoluted situation, but I think I found another analogy that works:  a big bowl of spaghetti and meat sauce.  The spaghetti noodles fall this way and that, tangle here and there, and intertwine where they may.  The sauce poured on top is filtered by the weave of pasta so that most of the meat and much of the sauce stay on top.  So we can think of this spatial representation of Indian society – the noodles being citizens, the sauce education, the meat wealth.  The noodles on top are covered in sauce and meat, but as we move down into the bowl the meat soon disappears and the sauce coating becomes thinner until, soon enough, the bed of the bowl is just a steamy mess of smothered noodles.  That is how today’s dinner is served, and how the noodles with meat and sauce prefer things to be.  The noodles with sauce but no meat will struggle their whole lives through for a chance to touch some, but gravity is not in their favor.  Even if a lucky few do chance to catch a smaller crumb of beef that fell between the cracks, they spend the remainder of their lives hoarding it over their peers.  Now there seem to be three obvious ways to remedy this situation, all of which are the responsibility of the central government.  The first is to cut everything up with a fork and knife to spread the sauce and meat around, but that experiment was done last century and just makes the entire dish cold.  The second is to eat the whole bowl, but Pakistan doesn’t seem that pissed off yet.  The third is to make more sauce, and this is the solution I’ve gotten from every piece of Indian spaghetti I’ve asked.  Education for the lower classes, not just to open the doors to new careers and a higher standard of living, but on a shockingly fundamental basis – to teach people that there are consequences to their actions, to awaken rudimentary analytical processes, and through this, to empower them to hold their elected representatives accountable – for the problem of enforcement can easily be blamed on the government, but in the same way the problem of corrupt government can easily be blamed on the people in whose name the it rules.  Education will lead to a new way of thinking about life, and again I’m talking about the immediate and tangible differences that come from literacy, not from the luxury of tacking on some extra initials behind your name.  Education in Mungeli is something that RMES tries to provide so these children can grow up to a better life.  But there’s the rub, the haughty pivot – “better.”  It’s easy to say that squalor and hunger are bad but it’s less easy to say that power and wealth are good.  But again, that is my judgment on our own social structure – shouldn’t they have the chance to form their own opinions?  Our negligence of humanity’s lethal poverty is not the same as killing outright – it’s like choosing not to save the defecating baby.  Isn’t it better to lose the baby in the midst of the attempt?  The end result may be the same, but the difference is the mental-emotional framework of action grounded in compassion.  There is need and you have the means to a solution.  A solution, one solution, but it is the one we know, and I believe it is, in fact, better.

 

The hospital in Mungeli is the only real corporate producer to be spoken of in the town, and it is the key to unlock the heavy gate of progress.  This hospital exists because a missionary doctor named Rambo thought caring for the needy was important.  Today it is the nucleus of betterment in Mungeli, providing higher quality care at less than half the cost of hospitals in Raipur, regular employment for both staff and day laborers, opportunities for career advancement through sponsorship of nursing and doctoral students, and education to the area’s children through RMES.  Establishing infrastructure and education are the first steps towards sustainability.  But to sustain here there must be a reason to come back.  Why would the educated choose to work here?  Even nurses only stay out of obligation.  Life is hard, poor, and small; nearly a monastic existence of medical labor and Christian reflection.  And here is the main problem in the mission hospitals – the lack of dedicated doctor-leaders who are willing to take responsibility for others at the price of irrationally high opportunity costs.  The solution to this problem is also not easy, as it requires irrationality towards popular social virtue, a trait that pops up maybe once in a million. 

 

On his last day in India, Rev. Vijayakumar delivered a wonderful message at morning chapel in Mungeli.  He spoke about a passage in Revelation in which the crystal waters flow and the servants of God wear His name on their foreheads.  One of his most important points was one that we’ve all heard before, but, at its core, is really the fundamental challenge of being a Christian.  He asked us whose name is written on our foreheads, because all of ours say “prestige”, “success”, or “comfort” from time to time.  It is easy to get caught up in life to the point of enthrallment, a term I’ve grown to love since it’s meaning was explained to me by a Kenyon professor in a course on Paradise Lost.  Enthrallment is enslavement, but it is not an imposed dominion, it is our own willing submission to something that is unworthy of our devotion.  But looking deeper there is more:  the control of our desires and our attempt to life God-centered lives really is our true, and really only, means to express love within our gifted structure of free will.  But after facing that, there is more: these words are of our own penmanship, not in the sense that we directly put ink to skin, but in the way we script our lives.  His name is worn on our faces for others to see, and it is obvious but not overbearing; it is a brand and not a banner. 

 

Here I’ll change course and talk a bit about my experiences at the hospital.  First though, another observation: the power of touch.  Removing sutures, sitting in crowded cars, eating with my fingers – the proximity of life creates a different sort of connection, one in which life here is very personal.  This is no less true in OT, and one I first found to be almost overwhelming…  The next few sections are written mostly in diary immediately after I had the experiences.  I could easily flush them out but for desire to get up another post I hope you enjoy them as they are.

 

A patient came in complaining of chest pain, his X-ray showed his left lung was completely filled with fluid.  Sudeep sat him on a stool and made an incision in his side to feed in a soft plastic tube which became the outlet of a spectacular foamy cascade of 3 liters of yellow fluid.  It looks like dehydrated urine and splashed on my open toes.  That was shocking.  Just up the hall I went to check on a moaning woman who I thought was in labor, but her legs were covered with abscessed injections and the surgeons were working their fingers in her wounds in search of puss. 

 

Chest tube guy has been here for about two weeks and I often see him walking around outside, tube in tow.

 

Rushing around one morning round we ran into Sudeep who had a difficult case to discuss with Anil.  A 29 year old woman, pregnant with her fifth child, one previous caesarian, ready to deliver but only dilated 1.5cm.  We headed over for a visit to the ultrasound.  After some time, Anil probing her insides, it struck me that there were six people in the room, but no, there were actually seven, one of us still hidden in our first nest.  Three of us, two of her family and myself, were staring blankly at the ultrasound display, not understanding the grainy images rolling around inside her belly.  Here too the language barrier held me at bay, Anil and Sudeep consulted in serious tones, Sudeep filled out some paperwork and questioned the family members who were no more nervous looking than any others I’ve encountered, Anil called in a nurse with some gloves and performed a digital exam and again consulted with Sudeep.  Then he turned to me before talking with the family to let me know that there were only six of us after all…                                                     

 

So just stepped out of OT where I was invited to observe a laparoscopic removal of a kidney stone, unfortunately it was too compacted to extract so a stent might help the patient do the job on her own.  Towards the end of the surgery a woman came into the other OT screaming and shouting and thrashing causing a big scene.  She was pregnant and her baby was due and was also forcing her blood pressure to dangerous heights, pushing her into an hysterical deliria.  Six nurses and attendants fought with her wrangling extremities while Sudeep calmly and cleanly went about his work – he had the baby out in thirty seconds.  I’m not sure exactly why, perhaps because of the baby, perhaps something to do with her BP, perhaps because she was so difficult to control, but they used local anesthetic to take the baby and then had some difficulty sedating her afterwards because with her uncooperative demeanor they weren’t able to get a main line IV, instead opting for her hand, which being a perfectly constructed agent of acceleration (think Frisbee throwing) was also not an ideal site for an injection.  Be that as it may, she needed diazepam so Sudeep would be able to properly close and wow, it was chaotic bloody mess.  Eventually Anil and a couple nurses managed to make it happen and it fell to me to hold her bloodied and writhing arm to prevent her from ripping out her IV catheter.  The most important thing is that she and her baby boy are ok, but wow – I’m still kind of amazed at what just happened; that was A.W.E.S.O.M.E. 

 

I went home for lunch that day and, for the first time in my life, washed someone else’s blood from my hands.

 

On the 21^st Sudeep again invited me to get my hands properly dirty and I scrubbed in to “assist” him in a hysterectomy.  Again, he explained the steps he was taking and answered my questions along the way, assigning me small tasks during the surgery to keep me engaged and actually help, too.  At the end came the kicker as after watching thousands of stitches he figured I would be able to put in one of my own.  When he told me to come on the other side of the table to finish the last stitch it was like being called onstage at a rock concert, total tunnel vision and a nest of butterflies, the forceps and clamp felt unfamiliar and so did piercing flesh.  But with a little instruction I was able to complete a stitch, and thanks to Sudeep’s willingness to teach, will never forget how to make that suture.  Being inspired by this intense personal engagement, I spent the whole day in OT.  Dr. Sona explained a hernia repair and I got really excited, to the point that I’ve borrowed an anatomy book to start learning about the things we see every day.  Surgery is like the ultimate puzzle, you have to take things apart in such a way that after you’ve rearranged some of the pieces, you can put everything back together again.  It’s also an amazing performance of well-planned execution, my favorite part of which is before the first incision when all the doctors fold their gloved hands and take a few moments to pray over their patients.  Later that afternoon came another experience, which at the time was more bewildering than anything, but in hindsight is top 5 coolest things I’ve ever done.  Sudeep and Anil had me scrub in for a caesarian.  In this case, racing to get the baby out, I was keenly aware of how out of my element I was.  I understand all the basic protocols well, but the job of an assistant is to task manage equipment so the doctor can focus on the patient, and I am still quite inept when it comes to which clamps are needed when, which needles are used on which tissue, and how to properly pass instruments.  So, of course, for this one there was another, real, OT nurse assisting.  Another element that made standing at the table a little more difficult is the fact that all the nurses speak only in Hindi and choose to use subtle head nods or looks with their eyes to point out the important things I need to be doing.  This mode of communication feels very casual compared to their intent so that I often totally fail to grasp the fact that they are talking to me!  Also, Sudeep is a gentle guy and speaks softly, but speaking softly with what I hear as a strong accent, behind his mask where lip-reading is right out, I sometimes don’t understand all of his instructions either.  Hahahaha seriously, how do they let me in there, I can’t believe it either.  But surgery is also very intuitive, there’s obviously a huge knowledge barrier as to the what but a little less with the where, and less so with the how.  Open in layers, manage blood supply and enervation, deal with the issue, close in layers.  It’s really neat again to have this perspective, totally on the outside of the theory, but able to recognize, and even perform, some of the practice.  Anyhow, I was actually assigned real tasks during the caesarian and stood with my hand on the patient’s belly as Sudeep extracted the cord-bound baby.  The feel of that birth-motion is forever burned in my mind.

 

End of diary section

 

Ahh heres another fun story – how I became the third victim of the roads.  Anil, Teresa, one of their uncles, their two pugs, and I made a trip to Durg a city southwest of Raipur, to partake in a family celebration of two matriarchal birthdays.  I was already feeling a bit woozy that day and was napping when Anil called to say we were leaving (this woozy feeling later developed into a three day challenge of my intestinal fortitude), so I quickly wolfed my lunch, a pot of ramen-type noodles flavored with tomatoes called Maggi, and headed out.  About fifteen minutes into the drive, just as we passed beyond the craterous roads of Mungeli I got a wave of nausea accompanied by some serious worries.  But I managed to suppress it and was fine for the next half hour of rocky country roads.  At that time we had taken the dogs out of their cages to roam around the back seats, and one of them, Bozo, was squirming on my lap and continually poking me in the stomach.  This was the uncomfortable first factor.  The second was a fully-cranked, almost violent guitar riff on an album of Santana’s greatest hits.  The third was one bump too many.  These three combined for an incredibly fast and overwhelming wave of nausea that was more than I could contain, and before I could even properly alert Anil, I sent three fantastic streams of ketchup-flavored Maggi juice all over the floorboards.  Hahahaha there’s nothing like meeting half the family with your clothes covered in your own vomit, and also nothing like watching your president’s inauguration from India, in an acquaintances’ relatives’ house with your clothes covered in your own vomit.  I must pay respect where it is due:  Barb and Nancy, well done, it was only afterwards that I realized the window control button was literally under my thumb. 

 

After the celebration as we were making our way through the darkness outside of Durg, we were chatting and laughing about the chances of another epigastric incident when we came upon a man splayed out in the road alongside his bicycle.  We stopped and turned around to check on him, he still had a pulse and was breathing, and Anil called in to the police.  This was a personally risky move, because often when accidents are reported the police will assume the person who called is the responsible party.  In this case, however, they had already been alerted and were on their way.  We waited around while darkened pools head-drawn blood thickened on the tarry asphalt, and we were about to move him off the road when a bike arrived with two men and a flashlight – the police.  After some debate with Anil, the three of them decided we would bring him back into town to a government hospital.  So the seats were folded down to make a temporary bed and the policemen lifted the injured man inside.  Everyone squeezed in around him and we made our way to supposed safety to the haunting rhythm of a deteriorating airway.  At the hospital the police ran in for a stretcher onto which we placed his wilting form, and while they hurried him in to a doctor I wiped his blood from the seat-back with a handful of Teresa’s tissues.  On our second trip out of Durg that evening, Anil adopted his passive tone, which I’ve learned to interpret as strained, exasperated, upset, helpless and is used all too often when talking about other healthcare centers.  The doctors he left the accident victim with were nearly inept and entirely unwilling to take responsibility for his care, immediately referring him off to a ward where he would be assessed and referred to two other hospitals before ending up in Raipur, if he survived that long.  

 

From a conversation I’d had earlier that night with Dr. Joseph, an ophthalmologist who we met on one of our hospital tours in Deepdipur, I learned that applying to medical school in India is quite different from the process in the States.  Admission depends entirely on one exam.  GPA, extracurricular activities, exposure to healthcare, and, perhaps most importantly, motivation to become a doctor, mean nothing.  You take an exam, receive a rank, and the top ranked people are admitted until the number of allotted seats are filled.  There are no essays, no drawn-out applications, no interviews.  And the education is similarly non-personal.  The whole thing feels a lot like a class at Tech – you get your gtg number you sit in lecture, or not, you learn the material, or not, but as long as you perform well you are rewarded.  This system has its merits, but when it comes to healthcare, and especially difficult or risky cases like our bicycle accident guy, Indian doctors seem more likely to wash their hands of a life than risk tarnishing their reputations by losing a patient in the attempt to save him.  The major prestige professions here are engineering and medicine, and from what I’ve gathered so far during this trip, many, if not most, of the doctors here look at their profession simply as a prestigious way to make money.  Speaking as someone currently going through the application process in the States, the painfully obvious missing factor in all of this is care.  The medical incentive structure here is misaligned, and the way to fix it is at the beginning – screen for students who would become good doctors, not just those who have a good grasp of theory.  It seems so easy.  Too easy.  For change means upsetting the entrenched elite of medical education, who are happy with their own prestigious positions and not at all inclined to disturb the festering mire of the normal.  Sill further back comes this idea of normalcy, the ideas of honor and prestige, the societal focus on education, and the cultural focus on self.  As I took off a vomit-stained shirt (that white collared shirt you left me, Nancy) now streaked with the blood of a man I’ll never see again, I realized that all these factors play their role in creating the uncaring physician. 

 

Something that’s been ever present in my mind over the past couple weeks is the privilege of perspective, and how it is quickly it retreats behind normalcy’s steady advance.  I’ve realized I find it more difficult to see great things as great or amazing things as amazing.  I just watched a sixteen year old girl have an abortion, yet somehow it was almost routine.  Perhaps I’ve been desensitized…perhaps, but life and death happen, and here is a place that stands in between.  I know this post is a bit more reflective, perhaps even pessimistic, but life is not performed in a rosy glow on the far side of the world.  Gravity still applies, the plants are still green, and people are still just people.  It is good to come and see something different.  It is good to shake up perspectives and think about the way we live our lives, for it is too easy to hide from ourselves, and each other, in the cloak of the other, promising that things will be better with distance, change, or time.  But being alone in a foreign land, it is hard to hide from yourself…

 

~ by packerk on January 28, 2009.