Villages

To start the day off, I went to KMC.  One thing I noticed were some patients with enteral feeds eating food by mouth.  This is done to see if patients can tolerate taking food orally.  It is sometimes obvious that patients can start a soft or normal diet and come off of the tube feeding.  This is seen when their vitals improve drastically, when they are conscious, talking, and laughing, and when their blood levels return to normal.  Some patients are not so obvious.  One woman who had received a tracheostomy had severe pain in her throat.  She had a very poor prognosis last week, and she looked just awful whenever I saw her.  This week she was more responsive, and all her lab values normalized.  Because of this, the dietitian thought she was ready for a normal diet but that the pain may not allow her to chew and swallow.  She will take only one spoonful of food at each meal with the majority of her food coming from the tube feeding.  This will let the dietitian know if she can handle eating orally.

A few patients were admitted because of frequent, loose stools and some kind of disorientation.  Most patients who are in critical condition will receive a mixture of IV fluids and enteral feeding.  When patients are in critical condition, they usually need a high protein diet to help rebuild body tissues and to help prevent muscle wastage.  However, whenever a patient has loose stools, no artificial products will be prescribed.  This is because the artificial products are all powders that are mixed into liquid before being administered, and this can upset the digestive system.  For a patient who already has frequent, loose stools, this could increase the problem and cause the patient to lose to many fluids.  So, despite the fact that their high protein needs may not be met without being able to consume protein supplements or natural proteins like meat, they will be given an all natural, easily digestible diet.  The dietitian also took some people off of the tube feedings today and prescribed a normal diet.  Their protein intake automatically decreased per kilogram of bodyweight because patients cannot eat enough foods to equal the high-protein supplements. Because natural foods are better, though, they will accept this loss in protein. One other random thing I found out about tube feedings is that egg flip will only be prescribed to enteral feed patients.  This is simply because this food tastes nasty and has an awful, slimy texture.  It is, after all, egg white and milk mixed together.  This usually induces nausea, so it is only for tube feeding patients.

One thing I always ask the dietitian when a patient's condition improves is how she knows.  She always tells me that the IV fluids are reduced and natural food intake is increased when the condition improves.  That phrase is so vague!  Today she explained that a patient with renal failure who had been on dialysis had lower blood levels of urea and creatinine.  This, she told me, means that the kidneys are functioning properly along with the help of the dialysis machine.  Because of this, the amount of fluids he was able to tolerate doubled.  With more highly functioning kidneys, he can now absorb and filter more fluids.

Some things I saw today I already knew, so it was cool to see the dietitian do what I expected.  An example is a patient with Chronic Obstructive Pulmonary Disease (COPD).  Depending on the type of COPD (chronic bronchitis versus emphysema) people with COPD usually need more calories and protein because they are expending so much energy to breath.  Additionally, people with COPD cannot do very much because they cannot deliver oxygen to their cells to power work.  Because of this, muscle wastage is common.  Sure enough, she prescribed 1.7 grams of protein per kilogram of bodyweight (normal  is 0.8 g/kg) as well as high calories.  Another example I saw was a woman with a UTI.  I figured the most likely reason this older woman with a UTI was in the IMCU was that she developed sepsis.  Sure enough, she had.  She also developed acute gastric encephalitis.  Because of this, she was on a clear liquid diet so that no food residues would upset her GI lining; most of her nutrition will come through the IV.

I also briefly learned about coconuts.  I learned that tender coconut is very healthy and beneficial for the average person.  Not surprisingly, as it always goes, this healthy food is more expensive than its less healthy alternative.  Tender coconuts are young coconuts that are full of water, vitamins, and minerals.  Coconuts are the same thing as tender coconuts, but they are older, have less water, vitamins, and minerals, and have more saturated fat.  Tender coconut water is common to prescribe since it is packed with needed fluids and nutrients, but it will never be prescribed to a diabetic patient because there is too much sugar.  For one patient, the dietitian changed her diet prescription when she saw that her urea, creatinine, and blood glucose were all high, signaling possible diabetes and kidney disease.  She changed the diet to include fruit rather than fruit juice and milk or water rather than tender coconut water.

Another thing I saw today, which I have not seen before, were two tuberculosis cases.  One person had pulmonary tuberculosis, but they were in the general wards.  I assume this means that they were in recovery, but I still did not want to be in the same room as this person with this kind of infectious.  Another case I saw included intercranial tuberculomas.  This is when the bacteria Mycobacterium tuberculosis attacks a location other than the lungs.  Because it attacked her brain, she had a poor prognosis with an estimated time of death only three hours into the future.

When I got back to Bishop Heber College, Jess and I, along with Raja, our driver, and Ravi, who is in charge of all social outreach programs here, drove out to some nearby villages!  Ravi explained to us that BHC has such a high rating by the government partly because it does so many social exchanges.  Examples include the 11 villages they sponsor and all of the international students they host.  In the villages, BHC students donate their time to the villagers, the idea being to gradually educate the citizens and dissolve the caste system.  We visited two of the villages that BHC sponsors.  One of the villages we visited is where Raja lives, the other where Ravi's family lives.  Ravi is the only one of his village to receive a degree and move out.  He now works and lives at BHC with his wife.  Part of the reason I believe he could leave was that he only lived in the village for a short time, and that he married a woman of a higher caste.  This is rare for lower casts, but Ravi was a good friend of his wife's family, so they granted permission.  The first village was pretty nice, with large houses painted in nice colors.  It was larger, there were more people, and the people were of a relatively high caste for villagers.  The other village, Pulivalam, had citizens of one of the lowest castes.  Many people lived in shacks they constructed of dried coconut tree leaves and support posts.  Others lived in small buildings paid for, in part, by the government.  Apparently, if the villagers can provide one lakh, the government will provide one or two to build a house.  The houses were small with a tiny kitchen, a traditional cook-fire stove, and a living area with storage shelves near the ceiling.  For some reason, the government also provides televisions.  There were several burial grounds located right next to each other.  They were separated by caste for the backward caste, the second caste, and the third and highest caste among the villages.  This burial ground separated by caste, but located in the same complex, is a perfect example of how separating people by birth is arbitrary.  Sure, the people in lower castes have fewer opportunities and are, therefore, less educated and less able to make money and contribute, but this would not be the case if they were not separated at birth.  Some villages were less than a kilometer away from each other, but being born 1 km away could make a world of difference.  Anyways, we got to see three or four small temples in Pulivalam.  One was the town's temple, and the other ones were family temples.  Ravi said he was pretty much related to anyone who walked by, so they were all family.  However, some were more closely related than others, and family temples were built by those who were closely related.  We saw some young children that Ravi was related to, though he could not say through whom.  The only really nice house in the village belonged to the village leader.  He was the only one with a car and had a fence around his house.

We also got to see a government elementary school near the village.  Children from different villages drove to attend this school.  A few students were even from Trichy.  Students receive materials, lunch, and classes for free.  The only difficulty is getting students to the school, which is a problem for families who live far away.  However, Pulivalam was right next to the school, so these children usually did not struggle to attend.  Painted on the outer wall surrounding the school was a mural of a boy working, with a basket on his head.  As he was working, a thought bubble popped up above his head with him walking toward a school.  This mural demonstrates that schooling helps lift children out of having to work and into more opportunities.  As we walked into the school ground, it instantly exploded with children and their voices and activities.  They basically attacked us.  I have never shaken so many tiny hands in such a short amount of time.  They were so cute and all practiced their English by asking our names and other formalities.  We got to meet the Mistress of the school who basically runs everything, including the 140 students and eight teachers.  The teachers are appointed to different schools by the government, and after a few years, the good teachers are moved to the struggling schools to help build them up.  Subjects taught include sciences, social sciences, math, history, Tamil, and English.  When we left the school, children crowded the van to the point that we almost could not move for fear of running them over.  They ran after the bus for a long time.  They were very cute and wild. 

Farming is ingrained into the culture of the villages we visited.  An example includes banana trees.  Tamil Nadu is huge for bananas, and there is a banana research centre in Trichy.  Each part of the banana tree is used, making it very important.  The banana is edible, the leaves are used as plates, the inner pulp is squeezed for the juice that has medicinal properties and rids the body of kidney stones, and the outer part can be used for cook-fires.  We got to try the juicy pulp of the inner tree.  Each year, banana trees are planted in June and July, and they take about a year to mature.  After a year, the banana branches are cut from the tree and loaded onto a lorry for shipment.  After this, the banana trees are cut down, and other crops are planted over the remains.  Banana trees are delicate, and even if they survived more than one year, the wind would destroy them before they could produce another crop.  There were huge piles of bamboo sticks that were used as braces for the trees against the wind.  Each banana tree produces a small baby tree that grows from the base of the larger tree.  This is dug up and planted in a newly prepared field with irrigation ditches dug.  This small tree will grow and produce a "baby", continuing the cycle.  There are specific Tamil words for this process, and when people get married, this banana tree phrase is repeated to them to represent their family growing for generations.

We saw rice paddies in different stages.  Some were empty fields with small walls and pathways built up around them to hold water when the rice is planted.  These fields were being given rest so that the soil would not be depleted of nutrients.  Another rice paddy we saw had been recently harvested and all of the million of stalks had been left behind to compost.  We also saw some sugar cane and coconut tree fields.  Unlike bananas, coconut trees are left to grow for 30 to 40 years.  They all grew to an angle that was not quite perpendicular to the ground because the wind buffeted them for years.  To harvest coconuts, farmers climb these 40-foot-tall trees and knock the coconuts down.  We also got to see cotton plants.  The young cotton bulbs were sealed with cotton developing inside.  We peeled and popped these pods open and actually ate the cotton, which was a wet, lumpy mess.  While the banana tree pulp we tried tasted like watered down banana, the cotton did not taste like anything.  The mature bulbs pop open into a display of dry cotton while the younger seeds are wetter as they mature.  Seeing all of these different crops for the things I have always used but never seen growing was so wonderful.  You may sometimes think of the farmers who grow your food, but today I got to see them at work, which is always a grounding experience.