Calories and Fluids

Today, as I again saw that most patients received the same diet as yesterday, I realized that Monday really was a rare day with so many new patients.  Of the few new patients who came in, most had an enteral feed, and their diet was pretty much the same as the other tube feeding patients.  The main difference here is a calorie and fluid game.  For healthy people, calorie and fluid needs are based on weight, height, muscle and fat mass, activity level, age, and genetics.  For people in the hospital, it also depends on their condition.  Yesterday, I mentioned that as patients improve, they get more fluid from food and less from the IV. The opposite is true, as well.  One of the patients who was in an accident and had a head injury worsened overnight.  The fluids were reduced in the tube feeding while the IV fluids were increased.  I also found out that patients in worse conditions receive more artificial sources of energy.  This is because they receive more IV fluids than fluids from food, so the food must be supplemented to supply the necessary calories and protein.  Critical patients need the most protein and calories, but they can handle the least amount of food.  This is why they will receive more artificial protein and meal replacements.  Some natural sources of protein here include egg flip (egg white plus milk), rice porridge, and daal.  One thing that Gayathiri asks every family is whether or not the patient is vegetarian.  She will either ask security to let the family back to the ICU so that she can ask, or she will call them if they are not at the hospital.  I tried to ask what she does if the family could not be contacted, but she did not understand me.  I think that here, in India, no one is ever really alone, so most people's families know when a loved one goes to the hospital.  If a patient receives enteral support and is vegetarian, they will receive artificial protein because natural proteins will not be able to provide enough. Another consideration in calories and fluids is the reason that the patient is there.  Patients on dialysis because of kidney disease will receive a high-protein and low-fluid diet while a cardiac patient receives a low-calorie and low-fluid diet.  

At KMC, I get to see many patients improve.  The patient with OPC poisoning from Monday was moved to the IMCU early today, and was moved to the general wards while I was there.  It is nice to see patients improve.  Some patients, though, are absent from the ICU, IMCU, and the general wards, leading me to believe that they passed away.  I am not sure how to find out what happened to them, but I cannot imagine where else they might be.  

There was more patient counseling today.  Some of the patients were actually brought to counseling rooms that were air conditioned and private.  I do not understand why some patients get this nicer treatment.  Some of the other counseling patients I saw were in the same cramped, hot, public room.  The diabetic diet counseling here seems very repetitive.  Though I cannot understand Tamil, I have began to recognize the words and patterns the dietitians progress through as they explain the diabetic diet to patients.  While each meal is expected to be similar since there are not as many options as in the US, this process would be boring to me if I was a dietitian.  She usually asks what the patient eats on a day-to-day basis, but it seems that she does not take this into account when she educates them.  An example is a mango and banana farmer who came in.  He is 80 years old and has farmed bananas and mangos for his entire life.  Despite this, the dietitian told him to limit banana and mango consumption to one or two servings per day.  High fruit consumption, especially fruits with high glycemic indexes, probably exacerbates his diabetes, but this could not have lead to diabetes in absence of other factors. At Siva-Sakthi nursing home, Dr. Siva emphasizes quality of life over all other aspects of patient care.  I think Dr. Siva would have told him to keep eating as mangos and bananas as he pleased, as long as he fixed other key areas.  However, Dr. Siva said that he believes that diabetes is caused by 80% genetic and 20% environmental factors.  On the flip side, my nutrition professors tell me the opposite is true.  Dr. Siva said that, in order of importance, risk factors for diabetes are genetic, stress, then diet and exercise.  I would argue that diet and exercise play the largest role in diabetes development.  He said that diabetes runs in families, which is true, but I believe this is because families share practices with their offspring, leading to similar lifestyles and risk factors.  

Dr. Siva is a very cute man.  He asks me many questions about what I learn here, and he gave me a homework assignment for tomorrow.  He told me to look up how glycemic index is measured and the differences between jaggery, cane sugar, and palm sugar.  Hopefully I can impress him tomorrow.

I ate with the dietitians again at lunch today.  Again, we all shared food.  The "caring-is-sharing" culture here is widespread.  After I left KMC for the day and went back to the international hostel at BHC, I decided to go out to a bakery nearby for coffee and cake.  Because all of the BHC students start school tomorrow, many of them moved into the hostels today.  This meant that all of the surrounding businesses and restaurants were packed.  At Arasan bakery, I ended up sitting at a table with three people I did not know.  Two of them were related, but the third was also a stranger to both of them.  We were all table-mates, as one of the women put it.  This is much different in the US.  The owner of the bakery asked the people at the table to shift around so that I could squeeze in.  Also, when I asked one of the Indian women, whose daughter is attending BHC this year, what food she ordered, she let me try all of it.  This is insanely generous!  I cannot imagine walking into Starbucks, having the manager come out to ask people to make room for me, and then have the customers offer me their treats.  Because I contrast so strongly to every single person here with my light skin and different language, and because everyone probably assumes that I am rich since I am a white foreigner, I maintain an awareness of my surroundings.  However, I feel very safe.

This is called Family Cake, but no one here really knows what that means.  I realized that people who go to this bakery know the Tamil words for each of the sweets, so when I repeat the words posted on the signs and receipts to other people, they have no idea what I mean.  I am sure Tamil for Family Cake sounds much different.  Anyways, I will try to post at least one picture of unique foods each day because KMC does not allow pictures of their patients.