Poya Day!

Hey guys!  As promised I wanted to share pictures with you from Poya Day.

Poya Day is considered very auspicious by Buddhists. As I said before it is celebrated during the full moon. This is a day of prayers, beautiful lighting, and a day to refrain from drinking and eating meat. Each Poya Day has a different name and some are celebrated in grander ways than others. In Kandy (the cultural center of Sri Lanka) there is going to be many celebrations leading up to the Poya Day in August.

Currently, in Unawatuna (a city about 15 min car ride from me) there is a 7 day festival going on that started yesterday. I am not sure what the festival is for exactly but I know it culminates with a visit from the Sri Lankan President on Monday.

Anyways, here are some pictures and a video from the celebrations!

Leading up to the temple are multiple little shops selling anything from shoes to plastic buckets to decoration for the home to food. These are beautiful clay pots.

These are like wind chimes minus the chiming. I think they are suppose to bring peace.

There are many coffee places around Sri Lanka using the Starbucks logo and fooling me into thinking I may get a delicious mocha! They have various different names.

 My friends! You met Mirna in my other posts; her family is originally from Bosnia. Sean is in the middle: he is an undergraduate student at Hopkins who is thinking about going into Medicine. Xiao is on the left and he is a Global Health graduate student at Hopkins who is originally from China. We are a very diverse group!

 The first smaller temple we passed. They have Buddha on the right (not seen in this picture) and some Hindu Gods that they worship as well. See the video below.

The larger temple on the beach that we walked to. So pretty!

 Drummers lead people carrying rice and sweets to the big temple.

 We stopped for a delicious bite. This is vegetable kottu- vegetables and roti minced on the stove.

 The beautiful temple by the water with Buddha at the top on the right.

Large, simple Buddha statue at the top of the mountain

Finally to end here is a video of the praying a the smaller temple. I don't know if you can tell from the video but the priest (? I think he's a priest) is dancing to the drums while doing prayers. I've never seen that before. Very interesting!

But the video is not loading! Sorry! I tried for 2 hours, and I am sleepy. Will try again later.

Ode to mothers!

I know I have talked a bit about the medical training in Sri Lanka, but I have not told you how the patients navigate it.

Patients are admitted through the ED, directly from other clinics, or transferred from other hospitals. This is very similar to our system in the US. The big difference is that the ED does not really "triage". Everyone who comes to the ED is admitted. The ED only decides where they go (ICU, ward floor, surgical floor, etc). This leads to MANY admissions. At times up to 60-100 in a day. Mind boggling. There obviously aren't enough beds for these patients so sometimes they double up in the same bed. Other times they sleep on the floor or benches around the ward. Every family brings their own sheets while the same mattress covered in plastic is reused (or no mattress for the families on the floor or benches). This definitely saves the hospital lots of money on laundry costs I am sure.

The people I find truly inspirational are the mothers. They are with their children in the hospital 24/7. Many of them have other children at home or live far away but they stay with the child in the hospital the whole time, sleeping in the chairs by his/her bed. They are a valuable source of information as well, reminding the doctors about the medicines just given and holding on to important paperwork; they don't just sit there!

Similarly, the mothers of the interns and residents here keep them going. Most of the female doctors (actually all that I have met) are married to other doctors. Doctors are probably the only ones who would understand and support another doctor's lifestyle, especially in a culture where women are supposed to be the housewifes: cooking, cleaning, and caring for the children. Supporting these doctors are their mothers! Interestingly, in Sri Lankan culture, similar to Indian culture, the couple is supposed to live with the man's family, but they have learned that in old age it is usually the daughter who cares for her parents, so many of these couples actually live with the woman's family. I think the dynamics of that are interesting as most Indian men would probably not tolerate living with their in-laws but the men here don't seem to mind (at least the doctors I have spoken to do not mind). These mothers do the cooking and housework for their doctor children. They also care for the grandchildren and take them to school, though are light on the discipline like grandparents all over the world :o)

I am definitely very thankful for both of my mothers without whom I would not have gotten through medical school or residency. And of course my husband who is not a doctor but always incredibly understanding, a great cook, and a good cleaner!

Yesterday, we traveled to the city of Matara, a local town with few tourists. We traveled using the trains and buses so I am starting to feel more comfortable with them. This is important because there is large cost difference between using public transportation and anything else. It cost us $0.75 to go and come back from Matara which is a 3hour round trip journey. Definitely can't complain about that!

Here are some pictures from the trip:

Sign when we arrived from the train!

 

Views from the streets of Matara. It is said to be smaller than Galle, but I think it looks bigger.

 

Old-timey fans in a place we went to eat by the Matara fort. The place had interesting decorations which did not quite make up for the crazy slow service.

A Buddhist temple on an island we walked to! Note this couple by the water. There were many like them all around the shore and the city. It seems Matara is the city for lovers ;o)

 The temple! Very pretty outside and inside. 

At the top of the temple was this gorgeous view all around. There was also a little moat all around with fishies. Many school children were there too. Unfortunately, my internet is too slow to post more pictures. Maybe when I get back home I can post more.

In honor of mothers, I saw my mother-in-laws name at one of the stores. Sorry the picture is side ways because we were leaving on the bus!

Today is Poya Day (full moon Buddhist celebration) so I have the day off. We plan to go join the celebrations this evening. I will tell you more about them tomorrow!

The registrars!

Hello all! I was hoping to post yesterday but unfortunately my internet has been a bit shotty. I am feeling much better over the last couple of days thanks to a benadryl induced sleep; first time I slept without waking up at night!

As I mentioned at the end of my last post, I wanted to tell you guys about the registrars I am working with. A registrar is roughly equivalent to a resident. The two I am working with right now just started their second year as registrars. They are very smart, like many of the doctors here. This is in large part due to their method of testing that requires the ability to recall details instead of just the ability to identify the correct answer through multiple choice questions like our system. But that being said our system has many other advantages: a focus on evidenced based learning early on and patient centric care, to name a couple. Because of these differences I have found ways to be useful!

I have been discussing with the registrars the differences we have in managing similar diseases, especially in terms of antibiotic choices and sharing various scholarly articles with them. I am also going to work with them on doing case presentations, which they are just starting to do here. I am happy to contribute and even happier that they find my opinions and thoughts useful even if they eventually do things differently. I have in turn been learning a great deal from them.

For example, my prior confusion over antibiotic use. Some of it is Attending dependent, as mentioned before, but I also learned that they are conservative because they want to prevent people from ending up in the ICU of which there are only 5 beds in the entire southern region of Sri Lanka. Also, many people live out in the community and far from hospitals so they want to prevent them from getting sick at home. There are also few epidemiology studies done here so sometimes treatment is based more on experience then evidence. They also have to use stronger antibiotics and have lots of resistance not just due to their frequent antibiotic use but also because the quality and potency of the antibiotics is variable. We owe lots of thanks to our FDA for regulating our system!

One of the registrars is my Sri Lankan equivalent! Here name is Dinesha Magagi and she has the same set of earings as me! I think partially because of our similarities, she has taken me under wing. She frequently shares her meals with me and helps make sure I am seeing the interesting patients, as well as getting a varied experience. The other registrar is Nuwan, and he also helps keep me included and helps me get a sense of how things are in the hospitals around Sri Lanka as he has worked in many different places. I am really enjoying my experience even more and am learning a ton!

Now for some pictures on my day trip to Hikkaduwa today! Rode the public bus for the first time, and it wasn't as scary as I expected! As many things in life :o)

 Sean found an awesome tea shop with the best tea I have had in Sri Lanka! I definitely spent $20 on tea today! The cake store I found when we got off the bus. Really yummy cake for only $1 of which I still have much left over. Cake and tea are a perfect combination!

 I really want to buy a Sri Lankan mask but I spent too much money before arriving here. They are all handmade.

We couldn't go in the water because of the bad tides. Red means stop!

Kandyan Osari!

Sorry for taking so long to update! I do have lots of updates to give for sure but will keep this post short as I am tired and getting sick :o/ Silly viruses I have not been exposed to before.

In this post I will tell you about my love and fascination for the Sri Lankan style of wearing a sari. They call it Osari and the style originates from Kandy (a city in Sri Lanka). Here is a picture of it from the Sri Lanka airline air hostesses:



I could not figure out how they wore this because it looks like the sari has three ends but it is worn from the same fabric from which you wear an Indian style sari. Pictured here:


But today one of the interns showed me how to wear one! The key is an extra string that they tie under those upper pleats. Technically you need a specific kind of blouse to wear with a Kandyan Osari (one with puffy sleeves not what picture above), but I think I may try it out with my own sari's at home! I think there is something even more feminine about this stylet. There are other differences in how Sri Lanka's wear their Indian style saris (as they call it) compared to how Indians wear them, but I won't bore you guys with the details.

Let me finish by telling you a few Sinhalese words I have learned (I can't spell so I am going to write them phonetically):
Istuti - thank you
Sudubath- white rice (which I always need because the food here is quite spicy!)
Eta- a generic term for lentils
Daal- a specific term for yellow lentils
Kola- a green leaves dish, not sure which one :oP

You can tell they are mainly food terms and that is thanks to one of the Registrars (aka Resident) who always shares her food with me! I will tell you guys more about her in my next post. Now I must sleep and fight this infection early!

Pictures!

I feel that I have been writing too many words in my blog so this will be a bit of a picture dump post.

Before the pictures though, I want to share some updates on my patients.
- The patient with the neck mass I was telling you all about ended up going for an I&D on Friday afternoon. I will find out tomorrow the results and diagnosis. I am still annoyed that we continued to treat her with amp and gent and called it appropriate antibiotic coverage.
- Another patient with bronchiolitis (2 months old) I saw my first day of starting. The mother speaks English so I became more interested in following his progression. Even the first day I saw him I thought he could be discharged but he stayed 4 more days waiting for his lung exam to improve as well as his chest xray. Then he spiked a temperature from some infection he caught in the hospital (poor handwashing and patients in close proximity) and so is now staying longer! sigh
- Then there is a 6month old with a large ASD who looks like a 1 month old because of her failure to thrive. She is here being managed for bronchiolitis and waiting cardiology consult on when she can be repaired. I was surprised to see the mother giving her so much table food and that more effort wasn't being put in to increase her caloric intake. It has been so busy on the wards, I have not had a chance to ask questions about her management but will try tomorrow!

Despite frustrations I may discuss, I have been impressed by many things, for example how quickly patients get surgeries and needed procedures. This hospital has all the specialists we have in the US but the resources are limited. For example, on Friday, our 8mon patient who recently had repeat pyelostomy developed carpopedal contraction we think we due to hypocalcemia or hypomagnesemia. But we can't send blood work for calcium or magnesium because apparently it gets "lost" in the lab. They gave the patient calcium through a peripheral IV and he developed bradycardia requiring atropine. There was no magnesium for us to give him. It's crazy that a hospital that has so many different subspecialists can't test a blood calcium level. But they still manage and do their best by the patients using their clinical skills and knowledge, which is always impressive.

Hmm I guess I ended up writing too much again. And so much medical jargon. Sorry! It helps me get out my thoughts. Let me compensate with lots of pictures!

 My room! I keep the mosquito net down all the time to keep from being bitten in this rainy season

 My cloest and clothing rack!

 The large window in room, which I like because of the light though it doesn't provide much privacy.

 

 The kitchen I share

The place I eat breakfast every day with my fellow guest housers

Our bathroom! With the always nice hot water geyser!

 

 Me and Mirna in the entrance way before going out to dinner. The windows in the back are windows to my room (thus the lack of privacy). Mirna is graduate student the Global Health program at Duke. I have gotten so dark already! haha

 

Dinesh in our 3-wheeler (apparently only called a Tuk-Tuk in the west). Dinesh works at Leijay and does many jobs like everyone here but he is also one of the primary people to drive the 3-wheeler. He is also always a source of entertainment.

 We went back to Ijaya Beach this weekend and watched fisherman fishing at the beach!

That's it for now. Will update again soon!

So much to learn!

Hello everyone! Sorry for the delay between posts. I am not really used to writing in a blog and was never much of a journal person, so it takes me time to type my thoughts.

And I have so much to learn here that I spend most of my afternoons reading up on what I saw. It's so nice to have time to read, which I found difficult to have in the US because I was always exhausted or had a bazillion other errands to run when not working.

After an initial few awkward days on the ward, I think I am starting to find my place, kind of. Some of the interns and registrars have started to understand my qualifications and will ask me questions if they are uncertain, which is really nice because then I feel useful. Otherwise, I often don't feel too useful as I don't speak the language and sometimes I feel that I am just getting in the way. It's especially hard when patients come up to me talking in Sinhalese and I cannot answer their questions. Some of the patients who speak  English or have been there for a few days understand my limitations but still let me examine their children. That has been the best thing: the respect the patients have for doctors and their willingness to permit me to see their children even if I don't offer anything back.

Now that I understand the system better and am starting to get a sense of the epidemiology of diseases here, I give my input in management decisions. There is one particular case I am becoming very invested in: a 4 month old child with large left sided neck mass. They think it is a cystic hygroma that maybe super infected though the child has no fevers. Oddly though they picked amp and gent to treat, which has poor staph coverage and no anaerobe coverage, but they wanted to continue the same even after 4 days of no change in mass size. And now day 6 the mass is growing and so they sent the child for repeat ultrasound. I suggested CT but they said no, haha. I understand due to child's age and risk of CT but an ultrasound only tells you so much.

But interestingly here, even if the Consultant (our equivalent of Attending) wanted a CT the radiologist may refuse to do it if they don't think it is needed. Also, the registrars here cannot make the decision to do an LP, change antibiotics, or send patient for imaging or special blood studies without the consultant's permission. I understand that this helps to preserve resources  and save costs but it also really delays treatment and tailoring management. It frustrates me because thanks to my training, I do feel comfortable making plans and executing them but am bound by the limits of the system.

I think the registrars lack of autonomy as well as the concern for poor patient follow-up is at least partially why antibiotics are used so freely. But I also learned this antibiotic use is attending dependent (as always!) and some are really better about it. The other problem is many patient's come in on antibiotics so you are stuck treating.

Things are so different here and yet also the same. It's challenging (in a good way!) adopting my knowledge to this system. Also, AAP guidelines are sometimes different from WHO guidelines, and I don't know the latter too well. But now I get to learn! Very exciting.

I must add that I have been impressed by the variety of pathology (ex-31 weekers, CDH, congenital uretral obstruction, myelomeningoceles, neonatal hepatitis, and so much more!) I see here and that despite the apparently cumbersome system care is delivered in a timely manner when really needed.

Anywho, that was a lot of medical talk. Sorry to bore everyone, but I wanted to get some of my thoughts out before I forgot them. No fun pictures today but the weekend is coming up so I am sure that I will have more soon!!

  

First Day on the Wards!

I started my first day on the wards today! It took a little while because I had to meet with the Chief of Pediatrics first and he had other engagements until yesterday.

I don't have a defined role here, which is a bit frustrating because I want to be helpful and not get in the way. The difficulty is that I am not really needed so trying to do independent work really just creates more work for others.

It also took a long time for me to explain who I was and my qualifications and why I was there. Though I kept telling everyone I am from the USA, they all thought I was from India, which complicated the situation more.

In Sri Lanka their medical system is as follows (or so I gathered from multiple discussions): they do 5 years of medical school (MBBS not MD) after high school. Then they do an intern year, which consists of 6months of either medicine or pediatrics and then 6 months of either surgery or ob/gyn. They can start practicing after this year if they want. But many continue to specialize, which consists of two years (I think 2 but maybe more in other specialties) of being a registrar (our equivalent of resident). Then if they want to get an MD they must do this two step process that I haven't quite figures out but it involves exams, a thesis, and spending a year training in the US or UK. So as you can tell it takes a while to explain what I am equivalent to in this scheme of things.

Nonetheless, I am on a mission to learn! And saw some pretty interesting cases of Dengue, measles complicated by pneumonia, SSSS, and post-strep glomerulonephritis complicated by heart failure. And this was just one day! I also saw lots of cases of bronchiolitis and many diarrheal illness from rotavirus and some salmonella. I also saw a very liberal use of antibiotics, which I have also noted in India. I was a bit perturbed by this especially as sometimes the antibiotics did not quite make sense. Maybe there is something I am missing that leads them to be so liberal with antibiotics; I am not sure but I will try to find out.

Anyways, enough boring medical talk. Here are some more pictures. Tomorrow I will post pictures of my room and other such exciting things.  Right now it's pouring: I love the monsoon rains!

A great place to sit and read and relax!

A couple trying to take wedding pictures at the fort and a crowd of people surrounding them

 Cricket!

Kites!

"Adventures"

So I have never written a blog before, but I had promised many people that I would so here it goes...

This first post will be a bit longer as I have so many days to catch you up on.

As some of you may know from my posts on Facebook, getting to Sri Lanka was a bit of an "adventure". I put adventure in quotes because I have found in my travels that what is called an adventure in retrospect is really a stressful annoyance (or worse) while you are experiencing it. Maybe one day I will be able to laugh at a situation while it is occurring instead of when I look back at it. One day... :oP

I was lucky to not have any admissions in the PICU the night before the drive to Maryland. I was also lucky that that everything leading to getting to the airport went off without a hitch. The flights themselves were a different story. I sat in my plane at Dulles for 2 hours because of the bad weather, which isn't so bad except that it cut into the time I had with my cousin, Gayatri, and her husband, Ritul, in Dubai. I had a 7.5hr layover that I wanted to take complete advantage of! This turned into a 5hr layover in Dubai during which I was constantly stressed about not making the next flight! My cousin and her husband still managed to show me the highlights of Dubai: the tallest building and largest mall (my cousin's favorite place!). I got back to the airport in time but sat there for an extra 2 hours with many other confused foreigners headed to Colombo. The flight was okay but wrought with frustrated flight attendants trying to communicate with people who did not fly much, and with me trying to have some personal space as the lady next to me kept trying to climb over me when going to the bathroom instead of waiting for me to get up. Needless to say, it was an exhausting journey during which I slept little even though usually sleeping on flights is my specialty. It was made worse by me realizing that my baggage had been put on the flight from Dubai coming the next day! Thank God for mothers and traveling experience that lead me to pack plenty of underwear, enough clothes, and other important accessories in my carry-on bag! I received my bag the next evening with everything inside, though, so I can't complain much (in retrospect)!

Leijay is wonderful. The whole guest home is kept beautifully just like in their pictures: http://www.leijayresort.com/Yvonne/Sri_Lanka.html  I am so thankful for how clean everything is and there are no bugs other than mosquitoes! Anyone who knows me knows how much I can't stand bugs and that I have had awful experiences with them in India and Malawi. I did have one large spider that got into my room one day :o/ But luckily the people I am staying here with are wonderful and killed it for me!! I am staying with an undergraduate student from Hopkins in one house in the compound. And in the two nearby houses is a graduate student from Duke and another from Hopkins. It's a great group of people! I have also been lucky that the weather is pretty cool so it has been no problem not having air conditioning.

Sri Lanka is also a really beautiful country. People have been very helpful and welcoming throughout my travels so far. The country itself is a clean, greener version of India. I imagine it is what India looked like while my parents were growing up. Maybe due to the color of my skin (lighter than the locals) or my dress or the way I carry myself (likely all of the above), I stand out more than I expected to. I don't stand out too much in India, especially not in Bombay. But what surprised me more is how fascinated the people are by me. I expect them to be fascinated by the Caucasian and Chinese friends I have made, but I am surprised when they ask me 20 questions and want to know where I am from. Partially due to this and mainly because I don't speak the language, Sri Lanka doesn't feel like home the same way India does. Though maybe this will change over the next two months!

I will be start working in the wards tomorrow morning now that I have met with the chair of the department today. I am really looking forward to the experience!!

I think I will start rambling if I talk much more so here are some pictures of what I did
during my free weekend:

 Eating a traditional Sri Lanka breakfast my first day here: string hoppers with sambol and daal

"Pink coconuts"- sweeter than green coconuts

Reading my kindle by the pool!

 Chillin at Ijaya Beach

Waking around Galle Fort!

Chillin at another beach whose name I don't remember

Eating a Sri Lanka roti or one type of them: this one is like a crepe stuffed with yummies