Tag Archive | cancer

India’s Nutty Problem

In India, cancer presentation and care are markedly different than in the United States. It can be attributed to a variety of factors, including poverty, tobacco, alcoholism, and diet. For one, rare in the United States but relatively prevalent in India, are extreme cases of head and neck cancers due to the popular usage of smokeless tobacco. It has been linked to a variety of premalignant oral cavity lesions such as oral leukoplakia, erythroplakia, and tobacco-associated keratosis, which can all result in carcinoma in situ, invasive squamous cell carcinoma (SCC), and verrucous carcinoma. Additional risk factors for oropharyngeal and mucosal cancers include HPV 16 & 18 and poor oral hygiene.

Tobacco is often wrapped in betel leaf and situated in the oral vestibule, the area between the gum and cheeks. They are cheap and highly addictive. Sad to also say the cancers progressive rapidly, first forming precancerous lesions then becoming malignant. Other forms of tobacco use include beedies (rolled up cigarettes in tendu leaf, also known as the “poor man’s cigarette”) and reverse smoking, that is, smoking a cigarette from the lit end.

Bidis Cigarettes

Betel Leaf Wrap

Betel Quid

In Southeast Asia, oral submucous fibrosis is a common premalignancy associated with betel leaf chewing. Areca nut is the potent ingredient in betel quid, often in combination with betel leaf, tobacco, alkaline slaked lime, and catechu (extract of Acacia catechu tree). The quid, or chew, is placed in the mouth, allowing for sublingual absorption. The compound found in areca nut is arecoline, an alkaloid that stimulates salivation and pleasure. Variations of betel quid include pan (fresh quid), gutka, pan masala (powdered quid w/o tobacco), pan parag, mawa (crude mix of areca, tobacco, lime), and mainpuri tobacco (with additional sweeteners or spices such as cardamom, saffron, clove, anise seed, tumeric, mustard).

In the case of oral SMF, the clinical manifestations include restricted mouth movements, oral pain and dryness, glossy tongue and de-papillation, growing intolerance of spicy foods, increased salivation, and hearing loss from stenosis of eustachian tube.

During my surgery OR hopping, I saw a ridiculous number of oral cancers: buccal (cheeks), tongue, gingival, lower alveolar (jaw), floor of the mouth (FOM), larynx, and thyroid. Following removal of the tumor and nearby tissue, a meticulous neck dissection was performed to ensure lymphatic clearance. The sickest and goriest surgery I witnessed involved the lower alveolar carcinoma, cancer of the jaw. Teeth were mercilessly pulled out using pliers. A special metal saw in the form of a thin wire was employed to cut off the mandible. The vigorous oscillating movements looked strangely similar to flossing, except it was obnoxiously, painfully loud and misty dusts of blood and bone hovered in the area between doctor and patient. Another brutal, but less common cancer, was floor of the mouth. What on earth?! I did not know it could happen, but it certainly did in India. Just picture how the surgery would happen, let alone how the doctor would get his hands in the mouth! FOM carcinoma would be a terrible disease because it is located right at the midline, so for the lymphatic clearance, jugular, cervical and other regional lymph nodes from both sides have to be removed.

It’s interesting how cancer surgery is performed in India; it is a blend of general surgery, surgical oncology, and reconstruction. After the tumor excisions in cases of buccal, lower alveolar, and FOM, there will obviously be something missing. Without the jaw bone, it’s just flubbery there. Without a floor to the mouth, there’s no foundation to the oral cavity. And without your cheeks, well, there’s just a gaping hole. What they do in India is a flap, such as a pectoralis major flap. An island of a skin flap is carved out over the pectoralis muscle. The piece of muscle is carefully cut out, like a raw and red beef brisket, and subsequently flipped up and through the neck to its final destination. The flap is sutured in the designated area, whether its the cheek, the FOM, or the lower jaw. Cosmetically it may not be very aesthetically pleasing, but functionally, it works.

On one occasion, the head surgeon was chatting with his assistants and residents, “You know, I would promote tobacco use. Otherwise, I won’t have a job.” A terrible thing to say indeed, but if you think about it, doctors have a job because there are diseases to fight. If talks of prevention are to succeed and more people become healthy, then what will doctors do?! If India is to address and fix the nation’s issue with tobacco use, alcohol, and poverty, then the RCC would run out of business… Doctors would not be running on their feet or cutting out tumors all day. It’s unbelievable to realize that nowadays, chronic illnesses are keeping doctors on their feet and perpetuating the lucrative profession in specialized medicine.

 

Regional Cancer Centre

India was not a free expedition without purpose. Of course, I had a mighty mission in India. Unfortunately, I was not there to cure cancer, as my title may have alluded. Instead, I was there as a rookie medical intern to roam the wards and ORs and see clinical oncology at its finest. Well, not finest; the worst. Cancer is an enigmatic monster yet to be tamed. Lucky for me, I had my first clinical exposure abroad in tropical India. Everything I learned from first year textbooks and lectures has new meaning, something more tangible and practical. It’s one thing to digest mere medical terms and enunciate convoluted anatomical vocabulary. However, it’s a whole new world when I see the melon-sized single lymph node in the neck, the white and warty oral verrucous carcinoma, the blood and gore of surgical dissections, and the hideously painful process behind tumor excision. I had a pumping good time at the medical institution, whether it was watching surgery shows at the head of the table with the anesthesiologists, palpating neck nodes, or simply listening to the doctors teach me. I learn best by hands-on experience, and thanks to my first medical mission abroad, I have returned home with two journals filled with colorful diagrams, clinical notes, and many candid vacation pictures.

The RCC was located less than 3 km from the apartment. Every day, my friend and I took an auto-rickshaw to work. These little taxis are what the Chinese translate to “turtle cars.” They are small, popular, convenient, and cheap gas guzzlers. Each trip was a mere 30 rupees, or less than $1!!! Compared to the NYC metro subway, which is an astonishing $2.25 a trip, it was close to nothing, a mere dent to my wallet. The rickshaw ride took less than 10 minutes, for the roads were rocky, bumpy, and dusty. I had to hang on tightly for the rickety rickshaw ride because driving and riding in India was plain chaotic. It was like China, but worse. Vehicles and motorcycles veered all over the roads, crossed lines without signaling, or cut off other drivers. The streets were sites of cacophonous, obnoxious honking. Sudden braking and lurching forward were constant occurrences, much to my heart and stomach’s dissatisfaction.

Nonetheless, I safely arrived to work and back home in one piece every day. I managed to get a couple of shots of the nearby campus and facilities. Prepare for a grand tour through the RCC and the Medical College in Trivandrum, India:

Medical College entrance: The Golden Jubilee Gate

Through the Medical College

Pretty Ponds Are Distracting

Mother and Baby statue

En route to the RCC: Very beautifully distracting!

Rocks and Rubbles

A Villa Buried Amongst Tropical Shrubbery

Destination arrived: Regional Cancer Centre. The RCC is a specialty hospital dedicated to comprehensive cancer care and clinical research. Since its inception in 1981, the RCC has provided cutting-edge facilities for cancer diagnosis, treatment, palliation, and rehabilitation through surgery, radiation therapy and chemotherapy.

The Busy Street

A Field Across the Street

... Where the Stray Dogs Lounge

 A typical day around the hospital facilities… from the wards to radiation planning to food.

The entrance and hallways were crowded with patients and families. Long assembly lines and crowds of people infiltrated the units. There was very little privacy and personal space.

Pediatrics Ward... Colorful

In India, there is a greater emphasis on radiation therapy to treat cancer. Due to the high influx of patients every day, new and follow-up ones, oncologists there offset the load with quick, rigorous treatment. High-dose radiation in a short period of time is employed, for example, an intense 50 Grays for 3 weeks targeted to a very localized area. There, it is more economical and practical for doctors to deal with patients’ acute symptoms (ex. mucositis, hair loss, skin irritation) and help them manage their complications.

Linear Accelerator for Radiation Therapy

Tea break in India as compared to the luxury of Starbucks at the famed Stony Brook Medical Center. Check out the differences in the coffee shops and portion size. I actually prefer the tiny cups of lemon milk tea over astronomical grande frappaccinos. I love my milk tea, better with bubbles =)

Fuel Up With Caffeine!

Typical Breakfast in the Canteen: Vada with Lemon Milk Tea

Rice Water Soup and Pink Root Water... Hm.

The positive messages that are posted around the hospital, in English… Though South India boasts of high literacy rates, people coming in with advanced diseases are poor common people.

Lol... Cancer the Crab is the RCC Mascot

A Peek At India’s Health Care

After an extensive summer spent in sunny South India, I have made a list of notable observations. Health care and patient management is dramatically different in India than in the United States. Here’s a big picture of medicine in India.

  • Aside from the reality that doctors are overshadowed by IT experts and computer nerds, doctors still play an integral role in patient care. They are flooded with a high volume of cancer patients at the RCC every day, Monday to Saturday. Like an assembly line, one by one, each patient waits in a long line to get follow-up and treatment. Every patient seems very compliant, hinging on the doctors’ orders. Quiet, obedient, and sad-looking, patients listen and follow what the doctors tell them. They get their 5-minutes time with the doctor, then they leave until the next appointment. Most times, patients come in, sit down, talk briefly about how they’re feeling, let the doctors poke them, and walk out without saying as much as a “Thank you.” Or maybe they do, and I don’t catch it because of the language barrier. Simply judging from body language though, they seem to leave without graciously thanking the doctor. It’s less of a personal connection with the doctor, almost more robotic and routine. There’s less patient autonomy and more implicit trust placed in the doctor. In the United States, however, patients are encouraged to ask questions, be educated about their disease and what to do, and work closely with the doctor to get better. It’s all about patient empowerment and dignity. If things go awry, patients and families blame the first person in the line of help – the doctor, the ‘savior’ – and shoot for the Benjamins…
  • Which brings me to the next point:  No malpractice insurance in India. Doctors don’t get sued and drained dry there like it’s a leech-feeding frenzy. Patients respect doctors, and no matter how poor they are, they don’t litigate like its their prerogative. Besides, suing requires money and lawyers; in impoverished states of India, neither are easy to acquire.
  • Doctors are not paid as well as computer/software engineers, who earn up to four times more than medical professionals. At least at the Medical College, doctors are paid by salary, as opposed to a fee-for-service basis. The oncologists and surgeons work mostly a Monday to Friday job, 9 – 5 pm, in and out in a jiffy. Not bad for a lifestyle position in medicine. That also means that doctors choose medicine for the right reasons and not simply for the lucrative profits. If people have an ulterior motive to earn money, computers are the way to go, not medicine. Doctors hold a god-given mission to fight debilitating diseases and heal the people, and not just in India. People who dedicate 10+ years to medical education and training must be highly motivated and compassionate to pursue medicine. Once in a while, the socially inept or money-hungry doctor slips through the crack and somehow waddles through medical school and intense training, but hopefully most doctors of the future will be personable, charismatic, and devoted, like the special doctors I met in India.
  • However, patients are less considerate of their doctors’ personal space and privacy. That is, they see you and come up, interrupting your conversation or coffee break with colleagues and without saying so much as an “Excuse me.” This happened on one occasion, while I was having a tea break with Dr. Roshni. She told me that in England, patients almost never approach a doctor outside an exam room or dare to interrupt the doctors’ personal time. In India, they can come up and start asking more questions about their health and treatment, all while doctors are dealing with other business, taking time off, or walking to their cars.

  • Speaking of privacy, there are no exam rooms. No clean white walls, no personal exam table, no time, no privacy whatsoever. The medicine outpatient (O/P) clinics had separate areas designated for different parts of the body: head & neck, surgical, GI/chest, breast/brain, and gynecologic/urinary. Rotating through all of the units, I noticed the doctor’s room was a shared space for multiple patients at a time. Smaller units like breast and gynecology had one doctor man a whole morning-full of patients. One small room with a desk, chairs, and an exam table plus curtains. More busy clinics like head and neck consisted of multiple rooms and shared spaces. A large room would consist of three desks for three doctors at a time. Patients sat down in a chair before the doctor. That was basically the examination area, where three patients and families were crowded in, in addition to the doctors, nurses, and two lowly American students. No personal space, no privacy, no windows, no circulation, except for the buzzing fan to my left.
  • The hospitals are congested like your poor nose during a bad winter’s cold. The general pediatrics ward was nearly filled with children. A new, more private alcove was recently painted and completed. Still, the pediatrics ward gets populated with sick, waiting children. Worse, the outpatient clinics are clogged and packed to maximum capacity, especially in the mornings. People come in early, some traveling from far distances, to get taken care of early. But when many people come in early, there’s a major plaque buildup in the inelastic, narrow hallways. Many times, I squeezed and battled through fragile bones, melancholy faces, and oppressing body odor and heat. Air conditioning was a godsend only in three places: radiation simulation room, GI/chest clinic, and surgery theatres.
  • No white coats. Interesting. The only people wearing white lab coats are the nurses, or ‘sisters’ in India. If they’re not wearing white coats, they’re wearing white dresses and sarees. The classic symbol of the almighty doctor is not worn in India, or at least not at the RCC. The professional dress code for physicians in India is a head scratcher though. Men wear the classic black pants, belt, and fancy dress shirt. Slick, clean, and proper. However, women do not dress up in a professional manner. They do not set fashion trends with pencil skirts or Express columnar pants, paired to silk blouses or ruffled tops or belted cardigans. Nono, they dress like every Indian woman on the street: sarees, scarves, long light pants, and traditional dresses. The only ways to distinguish them from other women are the stethoscopes and their English.
  • No proper procedure. Like in surgery, I’ve witnessed surgeons commit procedural skill sins. Take sterile gloving and gowning. There’s a careful way in putting on sterile gloves, but surgeons there end up touching nonsterile parts and gloving on ‘sterile.’ When they finish gowning and spin around for the final tie, they touch the card tag at the end of the string, which is NOT sterile. Only the nonsterile helper is supposed to be touching that tag. The anesthesiologist at Stony Brook would be blubbering in madness if she saw this…

  • Along with the above point, there’s no wasting. That goes for gloves, surgical caps and shoes, papers, etc…  (1) paper is kept under minimal use. When it is used, the paper material is dirt cheap and cruddy. Paper is thin, grayish, and plain. That’s already a luxury in India. (2) When I enter the surgical OR area, I change into area-specific shoes, whether they’re ugly black shoes or flip-flops, shared amongst everyone working there. I hate walking barefoot as it is, but having to share shoes with people really grossed me out. I had to suck it up, since I didn’t bring socks on this summer trip. More importantly, the chief concern is the fact that open-toed shoes are unprotected; broken shoes are worn into surgery! Flip flops! Open-toed! What would happen if there’s a needle prick or spillage of bodily fluids? What if the Foley catheter leaked right onto your precious toes?! To be honest, I failed to comply myself when I worked in the laboratory; I faced dangerous chemicals, and yet, I didn’t let the NYC summer heat and harried run to Penn Station hinder me from wearing short shorts and flip-flops. So why am I freaking out in India?? (3) Likewise, the anesthesiologists make minimal use of gloves unless they have to. That means, when they draw blood, make injections, or fix tubes, they do so without gloving. Now I venture to ask, what about blood bourne pathogens and diseases?!

  • Let me respond to my outburst of questions with a personal account: One day, I was at the foot of the operating table observing an abdominal Whipple maneuver. I had a clear view of the show where I stood, the omentum and intestines exposed beautifully. I idled where the sterile tools lay. The nurse assisting stood to my left, next to the head surgeon. She was wringing the bloody gauze and when she squeezed it a certain way, blood gushed and squirted to my right. The blood splattered onto the ground, just fingerbreaths from my feet. Lucky my Hidden Tiger, Crouching Monkey reflexes kicked in! By instinct, when the nurse squeezed the gauze, I somehow, instinctively foresaw the projectile blood droplets. I immediately jumped aside and watched the blood’s parabolic trajectory down to the ground. One of the spectating doctors watched this scene unfold with me. He looked up at me and said “Be Careful” and walked off. Whew! Close call…

  • See, danger does linger in the surgery rooms! I have plenty of reasons to worry more abroad. It’s because I do not want to get a disease in a foreign place. Coming out here, I had a checklist of vaccines and diseases to avoid, and that was plenty to plan (and pay) for. It’s also the reality that I am in an OR and people are sick. One of the doctors told me that patients get screened for blood bourne pathogens, such as hepatitis B virus (HBV) and HIV, and hence, the lackluster procedural adherence. When hospitals can save, they save on equipment and materials, even at the expense of occupational safety.

INDIA!!!

I spent the past 5 weeks of my final summer vacation in India before I become a slave to boards and clinical years and get buried alive by books. It was also my first time traveling abroad and navigating independently, away from the clutches of my Asian mom and dad. At first, I was anxious about traveling by myself, to a foreign country outside of my comfort zone. I was entering malaria-mosquito-beggar ridden-poverty-typhoid fever-contaminated water territory. I’ve been warned consistently about not drinking the tap water there. I’ve had to get drugged up with expensive medications that my insurance refused to pay for because they were prophylactic; my insurance would only pay for meds if I get sick with the disease. How ridiculous is that??!! Paying for sickness but not prevention huh? I left the country with mefloquine, an expensive anti-malaria drug, some antibiotics for Montezuma’s Revenge (lol), nothing for typhoid fever vaccine because it was taking a hit to my butt pocket, and without MedEx, a health insurance program covering medical expenses in case things go awry abroad and repatriation in case of a disaster. I was treading shark-infested waters, while trying to save on incurring expenses. Going to India I was crossing my fingers (and toes),  hoping I would not come down with dysentery, typhoid fever, animal bites, rabies, dengue fever, weird tropical diseases, accidents, lost limbs, or lost head. Ok, I’m going over the top, but India was a foreign land far far away so my imagination could not be blamed completely for wandering to Pluto.

In the end, my trip to India was still worth it. Dirt cheap as hell and living the simple life, what more could I ask for? With $1500 funded for me, I had my plane ticket and most of my tuition covered. That meant I lived in India for a mere $500 for a good full month: apartment, cheap utilities, cable TV, travel channels, endless round of movies, traditional Indian cuisine, continental food with a tikka twist, desserts, gelato, cocktails, smoothies, milkshakes, assortment of fruits, MANGOES, coconut trees, beautiful beaches, seaside resorts, waves, sun, seafood, elephants, crocodiles, wildlife, waters, mountains, backwater cruises, rickshaws, and much much more.

Of course, my purpose was not just fun in the sun. I was there on a study abroad program with Stony Brook University, working as an intern rotating through the Regional Cancer Centre in Thiruvananthapuram (what a mouthful). There, I had a unique experience from surgical oncology to radiation therapy to crowded outpatient clinics (head and neck, chest, breast, gynecologic, gastrointestinal, pediatrics). I saw whacky clinical cases and worked with amazing, personable doctors. I stood next to mighty surgeons, watching their every dissection, chatted with otherwise bored anesthesiologists, and sat back and absorbed what the kind doctors were teaching me. A spark went off and now I have a renewed appreciation for anatomy, radiology, stitching, and much much more. Stay tuned for an educational course through the clinics of India.

Get VERY envious now, because I’m going to write a series of blog posts documenting a very luxurious, eye-popping time in Kerala, India, one of the greenest and most scenic places in South India.