KMC

Today was my first day at Kauvery Medical Center (KMC)!  This is the largest corporate hospital in Trichy and many surrounding areas.  Siva-Sakthi Nursing Home (SSNH) was a private hospital, while KMC is corporate, meaning it is basically a large private hospital.  While at SSNH the doctor who owns it just allowed me to come on in with no questions asked, I had to bring copies of my passport, appcard, and transcript to KMC.  This was to prove to Kauvery Academy that I am who I say.  I also had to bring an official letter from Bishop Heber College to prove that I am training here.  Everything was very official: I was required to wear a lab coat and name tag, and I will receive a certificate after my 15 days to say I trained at KMC.  The reasons for these formalities and document keeping are that KMC is a large hospital and they are there to make money, so they record everything. 

I shadowed the same dietitian today who works at SSNH in the evenings.  She is a very busy woman, working 9:00 a.m. to 5:00 p.m. at KMC, then 5:30 p.m. to 8:00 p.m. at SSNH, taking only an hour for lunch.  She also cooks very traditional food to bring with her each day besides spending time with her family at home.  She works six days a week and only sleeps six hours at night! Her and Dr. Sakthi of SSNH created a diabetic education book together, and it looks very professional.  She is very determined, and I do not see how she is not exhausted.   She took me through the ICU then the IMCU before then taking me to the wards.  I have not done any work in American hospitals, but this seemed similar.  The ICU is the Intensive Care Unit for those who are just entering the hospital.  After they are stable, they enter the IMCU or Intensive Medical Care Unit.  After this they enter the wards until they recover.  The dietitian, whose name is Gayathiri, first writes all the patient information in her charts like their ID number, name, age, etc.  She then estimates their height and weight and calculates BMI.  She must estimate the BMI of every patient because they are bed ridden and cannot be moved to be weighted or have their height taken.  Based on all of the doctor’s notes and what she knows of their progress, she writes out a diet order for the nursing and food staff to carry out.  Even though many patients have been there for a while and, therefore, eat similar things each day, and besides the fact that the hospital has a rotating menu, she makes these diets very quickly.  In about two and a half hours, she made diet orders for 30 patients.  This means she was reviewing these patient’s charts, making these orders, and explaining everything to me while spending only five minutes on each patient. 

The main reasons people were in the ICU or IMCU were diet-related diseases, traffic accidents, and infectious disease (Dengue and other viral diseases).  After she estimates BMI, she estimates calorie needs as well as protein, fat, and other needs.  She then decides the volume of food needed to satisfy these needs and makes up a diet plan.  For people who can eat a normal diet, foods are traditional Indian food like tea, coffee, dosas, chapatti, rice, vegetables, juice, etc.  Some may only eat a soft diet, liquid diet, or clear liquid diet.  The liquid and clear liquid are usually for those with enteral feedings, which is usually a nasal tube routed to their stomach.  I always thought that this was an automatic process with a machine pumping food down (and it may be in the US, I have never shadowed a dietitian at home), but here the food solution was made and held up into the air (so gravity may do its work) while the food was slowly poured into a small tube that was connected to the enteral feed.  Water was also poured through this tube for it to be absorbed in the intestines even though these patients all had IVs as well.  I know that this is important because the GI tract becomes weak if a patient only has an IV because peristalsis will slowly cease with no food to push against.  The only other reason for a liquid diet that I saw was that a woman in a traffic accident had a fractured maxillary bone (jaw bone) and could only drink her foods rather than eat them.  Because she could swallow and was conscious, though, they opted not to do the tube feeding.  For many patients who are starting the tube feeding, especially those who were not eating much before because of the circumstances leading to their hospital admission, she will start them on clear liquids to get the GI tract started again.  She then progresses to regular liquid with more and more food each day.  Some people had soft diets.  One reason for this was an alcohol withdrawal patient.  He was giddy (which here means disoriented/drowsy/not-fully-conscious) because he had low sodium levels and could not put forth the effort and coordination to chew. 

Some other interesting things I found out included a patient with a seizure disorder and hypocalcemia.  Milk was a large part of her diet to restore her calcium levels, but because coconuts are so common here and are full of water and minerals (including calcium), tender coconut water is another part of the regimen to supply calcium.  Another thing I learned was from a woman with stage IV liver failure (the last stage of the disease before death) and many gall and kidney stones.  I figured this was from a genetic disease or from alcohol intake, but the woman had consumed no alcohol at all.  Her liver failure was from poor diet alone, including a high oil consumption and many non-veg options (high fat meat and dairy options).  It is also rare for a family to allow a patient to die here because of most families’ Hindu beliefs about killing.  Even though the ICU does not allow visitors, this woman’s family was there because she has a very poor prognosis.  This case brought up some details about alcohol consumption.  In general, no women consume alcohol here.  After the dietitian mentioned this, I realized that all of alcoholics at SSNH that I saw were males.  Apparently, it is not that women won’t be served but the fact that it is just not culturally acceptable, so women choose not to drink.  If I understood her properly, Gayathiri has only had one drink in her life, and she is in her 30s.  Another weird thing about alcohol is that in some large cities, like Maduras, Chennai, etc., women will be served alcohol and it is acceptable, but only with their husbands present.  On the flip side, these locations often require a man’s wife to be present before he will be served, as well.  I am not sure about the reasoning behind this. 

The doctors at SSNH, as well at Gayathiri, mention that patients often do not listen when they are told to change their diet.  One reason is that some cannot afford to.  Another reason is that many people are stuck in their ways and do not want to change.  Another thing that I think lowers compliance is the hospital environment.  In the US, we have learned about confidentiality and patient behavior during counseling.  It is better to find a quiet, private, and safe room to counsel a patient, especially if it is outpatient care (one usually cannot do much to change the environment for inpatient care because the patient is laying in a hospital bed).  After the rounds in the ICU/IMCU/wards, she did some outpatient counseling, mostly for weight reduction (obese patients).  This room where I observed counseling was 92ºF, so it was not comfortable at all.  Most of the hospital is hot besides the ICU where there is A/C.  Also, the door was left wide open, so the huge crowd in the waiting room could hear anything we discussed.  There are always huge crowds in every part of this hospital, as India is experiencing a shortage of health care workers.  This room is also tiny.  KMC owns at least five separate buildings throughout Trichy that I have seen, each being several stories.   I believe this is because they could not buy enough land in one place to build one huge hospital, so they settled for several very large hospitals.  So, there is one office for four dietitians, and it is about 30 square feet (and this might be an overestimate).  So these patients are hot, in a super compact room, and have an audience while they are counseled to lose weight.  I believe this is not conducive for behavior change.  One last thing about counseling: many husband and wife pairs are both obese, and they receive counseling together, which is kind of cool.

The hospital does not let me leave in the day for lunch because, as a trainee, they take full responsibility for me and only let me leave at the end of the day when it is time to go back to BHC.  Because of this, I ate lunch at the hospital rather than at the mess for the international hostel at BHC.  This process kind of grossed me out.  I really like eating with my hands, but doing this in a hospital just does not feel sanitary.  I used hand sanitizer beforehand, but I still felt gross.  Other than this gross feeling, the hospital food was good, and I was eating with four dietitians who were all eating with their hands, so it felt normal.  They also let me try some traditional food they brought from home like some spicy lady’s fingers, curd rice with potatoes (which is SUPERB), and some chicken.  This chicken, like most food here, was very fresh.  In fact, it had been alive yesterday.  I have only had chicken this fresh once before, and it is a special experience always, though it is common here.  I will say that it is difficult to eat this chicken as there are many bones. 

In the evening, I returned to SSNH where I mainly just talked to the staff and read through a nutrition book Gayathiri and Dr. Sakthi produced.  As always, there was not much for me to do there because they are more of an endocrinology consulting office.  Now, I am super exhausted, and it is time for bed!!!