CCU and Step Down CCU

Today, I shadowed a dietitian who has only worked at KMC for two months.  She mentioned to me that her pay is about 7,000 rupees per month.  This is so crazy to me, still! I make 7,000 rupees in a day or two, and I do not even have a degree, yet! Apparently, the head dietitian makes around 10,000-15,000 rupees each month.  One admirable thing that this dietitian told me is that she has only two months of experience in a multispecialty hospital because she used to work at a gym focusing on weight loss and gain.  She was actually paid more at that position, getting 12,000 rupees per month.  However, she was bored!  She said she was not learning anything, so she came to KMC despite the fact that her pay would be cut in half.  I would really have to be bored and hate my job to move to another job with half the pay.  It is wonderful that she moved in the pursuit of knowledge and contentment.  Anyways, considering the fact that KMC just hired a new dietitian last week and that they are implementing a hospital kitchen soon, it seems like they are drastically expanding the nutrition program, which is good news!  Unfortunately for me, the dietitian I shadowed today speaks very little English. It is unbelievably lucky that the country I was born in has citizens who speak a language taught all over the world, but it is learned to varying degrees!  This dietitian did things that were very different from the head dietitian, Gayathiri.  There were two problems with this for me: I was in the CCU, which I rarely visit, and this dietitian is very inexperienced.  Combined with her present, yet poor, English skills, I was left confused frequently.  Despite this, I will now report to you the common threads between each cardiac patient.  In general, these patients are served only liquid or soft diets, are prescribed much lower calorie and protein allowances than I would expect, have fluid restrictions, and take food orally with few tube feedings.  An extreme example of the limited food prescribed is one patient with cardiovascular disease who had a heart attack.  She was given 18 kilocalories and 0.6 grams of protein per kilogram of bodyweight.  The standard values for anyone are 23 kilocalories and 0.8 grams of protein.  I have no idea why these values are lower than I would ever expect.  One explanation given to me before is that most cardiac patients are overweight because the same diet that produces heart problems usually causes overweight or obesity.  Macronutrients will, therefore, be restricted to promote weight loss.  However, malnutrition is very common in hospitals here, and this is dangerous even for patients who are overweight.  I need to ask more about this. 

Something I saw today, which I have not seen before, was an Acitrom diet.  Acitrom is a blood thinner, and a special diet goes along with it.  Vitamin K and fat rich foods were to be avoided.  The patient was not served cauliflower, cabbage, any other green leafy vegetable, or coconut. 

After lunch, we visited the “Step Down CCU.”  This is where cardiac patients are moved to after their condition improves.  This ward acts as the intermediary between the CCU and general wards.  The most interesting patient I saw had a BMI of 41 kg/m² (the cutoff for obesity is 30 g/m²).  He had an aortic aneurism and left leg cellulitis.  He was to eat a normal soft diet today, but tomorrow he would begin a high protein diet because he required surgery on his left knee.  His leg was HUGE.  He had a high BMI in addition to the cellulitis.  His skin was peeling and he had ulcers all over.  The dietitian was unsure about what to do with the doctor’s orders.  They prescribed a high protein diet post-surgery, but the man had a urea value of 141 mg/dL and creatinine level of 3.80 mg/dL.  The normal ranges for these blood components are 7-20 mg/dL and 0.6-1.2 mg/dL, respectively.  These values are very high, and excess protein is often broken down, producing ammonia that is turned into urea.  With high urea levels, and with a high protein diet needed to support recovery after surgery, what is a dietitian to prescribe?  She stuck with the high protein diet, but I need to ask Gayathiri more about this tomorrow. 

The last thing to mention about today is that I finally learned to make tea, the South Indian way.  I watched Madhan, our chef, as he prepared tea.  The process goes as follows.  First, you bring milk to a boil over low heat.  This takes about three minutes.  You then add tea powder, one spoonful per cup, and allow it to simmer for a minute or two.  You then turn the heat up and down three times.  Each time, the milk will slowly boil up, nearly coming out of the pot.  Right before this happens, you turn the heat way down low and allow the milk to simmer down.  In a separate cup, you add two spoons of sugar for each cup of tea that you are making.  After the third time that you allow the milk to boil down, you pour it through a strainer into the cup with the sugar.  You proceed to pour this back and fourth between two cups to thoroughly mix the freshly brewed tea and sugar.  The result is a frothy, delicious cup of tea.  It really was more of an art than simply brewing tea.  I will have to practice many times before I can do it nearly as well as Madhan.  Tomorrow morning, he will show me how to make sambar! 

Protinex

I thought that getting care from a dietitian was required for all patients in the ICU and IMCU.  Today, I saw Gayathiri check two patients’ charts, close them, and move on without doing any diet orders or counseling.  She later informed me that the doctor who sees those patients refuses any other person’s care.  He does not accept dietitian or physiotherapist opinions.  He says that the patient is his and that he will give all of the care.  The dietitian approached him about this once, and she was shot down.  It seems ridiculous to me to turn down the care of other professionals.  In the United States, it would be illegal for this doctor to be giving orders that he received no education, degree, or certification to quality him to give.  This is an example of why the speaker yesterday at the Abbot Nutrition Meeting told the dietitians that they must be firm with their profession.  When speaking to patients, though, they are sometimes too firm! One patient’s caretaker informed her that he had given the patient vada, coconut chutney, samosa, etc.  These foods are all either deep fried or high in saturated fat.  The patient had diabetes, though, and these fried foods are not good for her.  The dietitian told them “this person has diabetes, how could you possibly give her these foods?”  This statement feels very judgmental, and this is something we are told not to be when educating patients. 

Today, some patients worsened, others stayed the same, and some improved.  One patient has been receiving crackers at each meal along with all of the food through the Ryles tube.  She is being given these biscuits solely to test her ability to handle solid foods.  She continues to reflux, though, so she cannot progress to a regular diet.  Another patient has gone four days without pooping.  He has been bloating and has abdominal disturbance.  His tube feeding was reduced from 100 mL/hour to 75 mL/hour and he was put back onto an IV.  The dietitian said this stoppage could be from medicine or some other deeper issue.  Hopefully, he resumes his movements soon.  There was one woman who improved drastically today.  A few days ago, she had a CVA, cerebrovascular accident, but she is only 32 years old! Apparently, she is from northern India, where ghee is very popular.  Here in South India, Brahmins consume a lot of ghee, but most other people cook with oils.  In northern India, many people cook all of their food with ghee.  Some families consume 15 kg each month.  This is a lot of saturated fat!  This goes to show you how diet can seriously mess with your health even as a young person.  This woman now has hemiplegia, which is partial paralysis, all because she was cooking with one type of fat over another.  Considerations like these over the long haul can affect you severely. 

Later in the evening, I went to another nutrition meeting!  This meeting was hosted by protinex, a meal and protein replacement company.  The first half was in English, but the speaker gradually switched to Tamil half way through.  One thing that I do want to mention that he said is that, at least in diabetes management, the work dietitians do to change a patient’s diet and exercise habits will contribute 60% to the recovery of the patient.  He said doctors are secondary and that medicines like insulin or metformin can only contribute 40%.  He told the dietitians to make this known to the doctors and to push for diet counseling for all patients.  This seemed pertinent today considering Gayathiri told me that some doctors refuse dietitian considerations.  This view is also opposite of Dr. Siva when he told me, two weeks ago, that diabetes was caused 80% by genetics and treatment was mainly by medicines.  It is nice to see that researchers and companies are pushing for more recognition of the importance of this aspect of care.  Gayathiri also spoke about low glycemic index diets and diabetes management.  One cool thing she mentioned was how diabetic people can eat their favorite, sweet foods.  If they combine these high glycemic index foods with certain things like healthy fats, which slow stomach emptying and digestion, or foods with soluble fibers, which make sugars less available for absorption, their blood sugar will not spike so severely.  After the meeting, we had dinner at this hotel.  I told the BHC driver to arrive one hour and 15 minutes after the scheduled end-time, and this ended up being just enough time. 

Also, I will post pics of this last weekend soon; the internet is kind of wonky sometimes and wouldn't support uploads.  

Last Weekend

Last Friday, June 24, I felt sick all day!  I think it was just a big old dose of homesickness, though, because after calling my wife then my mom, the nausea I had felt since waking dissipated.  Because of this ill feeling, though, I neglected to write my blog!  On Friday, the difficult patient I discussed before, who refused to eat the food available in Trichy and who could not eat food from home since he lived eight hours away, finally got some nourishment.  His neighbor brought in some food, and he ate happily for the first time in days.  The problem with this, though, is that his “neighbor” apparently lives two hours from the hospital, so his breakfast arrived around noon.  This threw his whole eating schedule out of whack.  Hopefully he can figure it out soon.  Even though he is taking a full diet, the enteral tube was left in his nose because, without eating enough, he may slip back into critical condition.  Because of this, most patients have their tube left in for a few days after fully switching to an oral diet to make sure they adjust well and do not need further support.  Another patient seen on Friday had diabetic ketoacidosis.  Her blood glucose was 384mg/dL, well above the normal 100 mg/dL.  Her creatinine was high, and her pH, CO₂, O₂, and bicarbonate were all low, as well.  This shows that her blood was acidic, had lost its ability to buffer itself, and that her kidneys were not functioning well.  This woman was not in a good state.  She was in such a poor condition that she only received 30 mL of food per hour through the tube feeding.  Stable patients normally receive 100 mL per hour.  The last thing to mention about Friday are the poor and rich wards.  At KMC, there are normal rooms and there are hospital suites for the rich patients; this is similar to hospitals back home.  On the fourth floor, though, are the male and female general wards.  The middle class people can afford a room on this floor, but the poorest are placed in huge rooms with curtains in between them.  The ICU is similar, but there is AC and a lot of staff for support.  The wards for the poorer patients are hot, crowded, and do not smell great.  Before entering these wards, the dietitian I was shadowing that day (a different from Gayathiri, who I normally shadow) took down notes from all of the patient charts.  Because the hospital is so short-staffed, though, she could only see a few patients out of 20.  They rotate on who is seen each day. A lot of her time was spent making records for her reference, which would later be rewritten in an "official" hospital record.  I make joke at the word official because it is a composition notebook in which the dietitians have to use a ruler to make columns.  I feel that they would save time if they just took notes in this record rather than do it twice.  I will suggest this to them in my report I am required to submit to KMC by the end of the week.  

Later that evening, after calling home and resting (thank God my nausea subsided), we left for Ooty!  This eight hour bus trip was not so bad, since it was a semi-sleeper.   There were short periods of rest in between the swerving bus and crazy honking cars.  In Ooty, we hitched a government bus to Mudumalai.  This trip was not so nice.  We took this super cramped bus down a mountain at 2,200 meters above sea-level with 36 hairpin turns.  People kept piling on until we were super-packed.  Finally, we arrived in Mudumalai.  We booked some hotel rooms and rested after our 10 hour travels.  Jess was super sick by this point, so I just sat in a comfy chair outside the hotel, gazed at the mountains, read my book, smoked the Cuban I picked up in Pondicherry, ate all the dried fruits and nuts I bought in town, and just took some needed chill-time.   After this point, we had lunch at the hotel.  Jess was so sick that she only ate a little bit of rice or something and had to go back to lay down.  She had a fever and really could not do much.  After a while, Jess was finally feeling better, and we ventured out and met some guys in town who had come from Bangalore to party.  It was cute that six 26 to 33 year old computer technicians came down to spend time together.  They took us to a dam then back to their place that was very near to ours.  This is an example of how hospitable people can be over here.  They brought us in, let us control the television, bought us snacks, gave us some scotch (that they had to smuggle into Tamil Nadu since the government checks for alcohol at the borders), and started a camp fire.  By this point, though, we were both tired after the long travels.  We headed back to the hotel for a deserved night’s sleep!

The next morning, Jess and I went out for a safari.  I have now been told by several people that I am a lucky man because we actually saw a tiger on the safari!  It is not currently the season to see tigers, so it was great luck to have seen one.  It was stalking some deer, and our bus totally interrupted it.  It sprang back into the tall brush and stared at us until we left.  Watching him/her run, and stalk, and move about so precisely puts you in a state of awe.  That was a beautiful creature.  We then went to elephant camp, which was both really cool and kind of sad.  The feeding process was very neat and tidy.  There were hundreds of 10”x10”x10” cubes of different kinds of food-stuff laid out over a 60 foot table.  Each time they fed an elephant, they would sprinkle some white stuff over one of the blocks, then choose one of each color and mash and roll it all together.  They then stuffed it into the elephant’s mouth.  The sad part was that the elephants could not move since both legs were chained, and they could not eat without tons of people gawking at them.  We took a jeep back to our hotel.  This jeep ride was crazy.  The back was a 4’x4’ space.  The front was a bench with only four feet across.  We smashed four people into this space: Jess, me, another passenger, and the driver.  The driver had to reach over one of the passengers to reach the gear shift.  People always tell me that us foreigners cannot handle being packed in so tightly, and they are correct. After this, we caught a bus back to Ooty.  This process started out so uncomfortably.  The bus stand was on a tiny forest road near our hotel.  Jess walked back to the hotel to use the bathroom one last time.  The hotel was only a one minute walk away, visible from the bus stand.  As soon as Jess was inside, though, a homeless woman with a long rod with a scythe attached approached me to beg.  Normally, I can say no and people eventually get it.  She knew, though, that I would not leave because I needed to be there to catch the bus.  She stood very closely and stared at me for a very long time.  Jess finally came back, and she still kept staring.  I gave her three rupees, and she finally left.  She stood about 30 feet away and just stood there looking at the rupees.  Finally, the bus came and took us away.  Despite the horribly uncomfortable, cramped nature of these buses, you cannot beat $0.30 to go to a town 40 km away.  The bus ride back up the 36 hairpin turns, though slower-going than going down, was still jolting.  At every turn, the bus driver blared the horn for about ten seconds to say "I am a huge thing, move out of my way."  Frequently, other cars coming down would go into reverse up the mountain to avoid being hit.  It felt like we were chasing them back up, which was not safe.  Between these crazy turns, the road-side brush would clear and we would see expansive, massive, beautiful mountain ranges.  The ingenuity of the farmers in this part of the word is incredible.  You would see terracing on these super steep cliffs so that farming could occur where it was never intended.  Villages would spring up all of a sudden then cease again.  I am willing to bet mortality from falls is common in these places.  When in Ooty, we first headed to the tea museum and factory.  This was the highest elevation tea factory in the world, and it was filled with history.  We watched tea get dried, crushed, fermented, crushed some more, rolled out, spun, and finally sifted into large bags.  I love tea, and I stocked up on 2 kg of it.  Since I got some really nice stuff, this ended up costing $20; compared to the $100-$200 this would have cost me for quality imported tea back home, though, I am very happy about my purchases!  After this, we hit the botanical gardens.  This was absolutely beautiful, so you will have to check out my pics.  Even in this beautiful place, though, people would rather take pictures with us than with the huge variety of plants and craftsmanship around them.  I have finally found my voice when it comes to just saying no.  We then wandered around the Ooty markets.  They mostly sell tea, chocolate, and cold-weather clothing, so it got old pretty quickly.  I bought food from a street vendor.  As they were showing me the foods, one man picked a piece up and accidentally dropped it on the ground.  He picked it back up and was definitely going to put it back into the pile on his stand but saw our stares and threw it away instead.  This is an example of how the culture seems very different than my own.  I cannot generalize to all people who live here, but many people do not care about their conduct and how others will see them.  People step over the railings and walk past the “Keep To The Path” signs to walk all up in the plants of the botanical gardens and remain after the guards start yelling at them; people throw trash anywhere and everywhere; bus drivers careen around hair-pin turns and nearly smash into other cars; people take pictures of us just because our skin is white, etc.  I have heard the view that we look much different than 99% of the population we see; just how I want to take a picture of a woman carrying bananas on her head, people want to take pictures of me, since I am different than anything they normally see.  However, I do not want to take a picture of the woman with bananas on her head because she has dark skin but because her lifestyle is so different than mine.  In the London airport, three weeks ago, I saw whom I believed to be an African man dressed up in beautiful, traditional, sun-gold clothing.  If people lined up to ask him for selfies, I feel like this would have been very rude.  In fact, if I was in the USA and said some of the things I have heard, I would get horrible looks.  Being a Christian, if I said that Hindus do crazy things and that their cultural sites are not worth visiting because they are different, rude, impractical, unethical, and pretentious, I would be narrowing over one billion people into one stereotype, and I would be labeled judgmental and bigoted.  Most hindus I meet are very nice and willing to party or worship with me.  Despite this, that is what I have heard many Christians say during my time here.  Not all Christians say these things, obviously, but I feel like this view is not uncommon.  Anyways, we made it back to the bus stand and figured out how to get back to Trichy.  More beggars came up to us during this time to ask for money.  The common thing I see is for beggars to rub their fingers together, press them to their lips, press their hands against their stomachs, and say they want food.  When I offer them food, though, they turn it down and ask for money.  I feel so uncomfortable when I firmly say no and this person continues to stand there and stare and ask and plead.  I feel selfish because I know I could give them money, but I would feel uncomfortable to pull my wallet out.  I have been advised by everyone not to give beggars money, but it is so difficult.  I have only done it once, and that was only because the woman stood and stared at me for ten minutes (as I described previously). 

We got on a bus headed for Tirupur.  We were told we could catch a bus to Trichy from there.  Randomly, four hours into our trip, not yet in Tirupur, everyone told us to get off the bus.  We did, and another bus came around, and the cashier yelled “Trichy!”  We hopped on and made due for another four hours.  These seats are seriously awful.  If you ever come to India, do more research than we did, and hire a driver or take the train.  While more expensive, it would be so worth it.  I was more crowded than I may have ever been, and I am not exaggerating.  People were standing around and laying in the aisles of the bus because five to six people in each row was too much to fit any more. We got off in Trichy at 2:30 a.m.  When we got off, I spotted a man doing something very strange.  Sometimes, I see people hunching or limping around. I assume this is because a medical issue occurred, and they could not afford treatment.  The dude I saw at the bus stand was side-step crab-walking quickly across the parking lot in jerking motions.  When he reached the two-foot high curb where the ticket stand was, he looked ridiculous climbing up.  I am sure the man was not doing that by choice but because of bodily limitation.  At any rate, this is something I have never seen a person do before, and the strangeness of it after traveling ten hours and being slap tired just put me in a strange mood.  I never really feel unsafe here, but I was glad when the guards at BHC closed the gates behind us.  It is a nice feeling that they stand about 24/7 and keep the riff-raff out. 

Today, I went back to start my last week at KMC.  The hospital environment was depressing this morning.  More people than I have heard on any other day were crying out in pain.  Nurses were taking blood or administering shots, and no one was having it.  One man with renal failure could not stop moaning.  He just kept repeating “Ooooowww, Oooohhhhhhh, Ahhhahhahhahh!”  It was difficult to listen to.  Another man persistently told me to unstrap his arms. The dietitian told me to do no such thing, though, because he would pull all of his IVs/tubes/needles out.  While we were recording patient information, a worker was using a drill, hammer, and handsaw to construct some kind of base for computers.  Like I said last week, I love to apply my knowledge and see unique cases, but the suffering and bustling is too real.  I know that a hospital is also a place of hope, but it puts me in despair.  One woman today, who was admitted the first day I was at KMC two weeks ago from a traffic accident, had finally been shifted to the general wards in a stable and recovering state.  She had a bad head injury, though, and was not fully oriented.  She kept asking where her son was, either not knowing or not accepting that he had died in the accident. 

There was one case that was at least somewhat humorous.  The dietitian and I shared a discreet smile, which you have to do sometimes when the others cases are sad.  This man had went out drinking last night, and, as he drove his two-wheeler home, he crashed into a cow.  It is unfortunate that he broke his arm, but he was not in as serious a state as most other patients, so it was nice to exchange a smile. 

After I left KMC for the day, I headed to a nutrition meeting that Gayathiri had invited me to.  I should have known that time runs by Indian Standard Time (IST) and that I should have arrived 30 minutes late (an Indian man called it that, so I do not feel bad saying IST).  The BHC driver, Raja, dropped me off at what I thought was the Dimora Hotel, the location Gayathiri told me.  The richest and lowest classes coincide so closely here that it is stomach churning.  I was dropped off at a nice building complex with an up-scale men’s clothing store at the first floor.  I got on the elevator to go up to where the meeting was to be held.  No one was around, though, and a beggar cornered me in the elevator.  She stood in the doorway so that it would not close and just looked at me.  She did the same thing as I said before.  She said she was hungry, put her hands to her stomach and mouth, and stared long and hard at me.  I said a resounding “NO” several times.  She wouldn’t accept that.  I just had to breeze past her to take the stairs.  She literally chased me up two flights until she saw a guard and left me alone. Raja dropped me off at the door of this building, but he is definitely escorting me all the way up next time.  When I got to the top, I had a tiny moment of panic that I was in the wrong place.  The guard told me the place was closed and that it was the Dimora Fine Dining Restaruant, not hotel.  Someone who spoke English finally came around, and I told him I was there for the meeting.  He took me inside, but I was surprised when I arrived right on time and only one other person was in the conference hall.  Again, I thought I was in the wrong place.  He told me he was the presenter from Abbot Nutrition and that I was in the right place!  This was one of the nicest places I have been while in India.  The conference hall had lighting inlaid into the walls, the chairs were covered with silky red fabric, and the presentation stand was decked out with electrical equipment.  After 40 minutes (40 minutes after the official stat time), the meeting started.  The man explained many myths and common, out-dated practices that occur in hospitals in this area.  He also explained that the dietitians need to be very assertive because doctors often do not listen to them.  The presentation style did not seem to facilitate input from the audience.  When the man asked how many people did something a certain way, and waited for them to raise their hands, he would tell them they were outdated and needed to change.  It almost seemed rude.  There was some good information, though.  He discussed current research in use of NPO, using bowel sounds to decide when to initiate feedings, nasogastric decompression, gastric residual volume, diarrhea, dilution of meal replacements, and blenderized foods.  It was all very interesting.  One thing he mentioned about diarrhea was that it is over-diagnosed.  Nurses are the ones who are having to change the bedpans and clean the patients, so they complain if one patient is having movements too frequently or messily and will tell the doctors/dietitians that the patient has diarrhea and needs a lower quantity/frequency diet.  After this, patients have their IV fluids increased and food reduced.  He gave specific definitions for diarrhea, though, and told the dietitians to be more direct and make sure patients really do need less food.  NPO diets are dangerous for patients in the long-term.  The longer a patient is NPO, the more complications result.  Examples include bacterial infection, muscle wastage in the GI tract, and others.

Afterwards, we were served dinner at this fine establishment.  They brought out trays of charcoal that were mini grills and placed skewers of tandoori chicken, prawns, and fish over them.  We were served starters then lined up at the buffet.  The food was delicious; I have never had better cream of mushroom soup.  By then, the BHC driver was super annoyed because I told him to pick me up at 6:30 p.m., and it was 8:15 p.m.  However, how was I to know that no one would even arrive until 45 minutes past the official start time (thanks IST)!?  There is another meeting tomorrow, and I will tell the driver to bring me 30 minutes after the scheduled start time.  The dietitian told me it starts at 6:30 p.m., but that it really starts at 7:00 p.m.  It is strange that everyone accepts tardiness, but I am getting used to it! 

Last note: as I was getting into the BHC van to bring me back to the hostel, a beggar started bothering me the moment I stepped out of the building.  He followed me to the van.  The driver took about 30 seconds to unlock the doors, so he continued to stand there and wave balloons in my face and kept asking for money.  When I got into the car, he pawed at the window and continues staring and just calling to me.  This is something I will never be comfortable with. 

KMC Training, Day 9

Nothing too crazy happened at the hospital today.  So, I will just list a few things that I saw/learned.  Most patients have the Ryles tube, the tube for enteral/tube feedings, inserted through their nose down to their stomach or intestines.  One patient I saw today had the tube coming out of her mouth. Because she is unconscious, her movements sometimes yank on the Ryles tube.  They have straps to hold patients' arms down if a particular patient has several mishaps like this.  For some reason, no one secured this patient's arms to prevent her from yanking on the tube.  Several times, the patient pulled the tube nearly all the way out of her nose.  When the tube is pulled out, a new one must be put in.  Because she did this so many times, in a jerking fashion, she irritated her nose to a great degree.  She developed a nasal infection, so they had to put the new tube into her mouth instead.  This brought up the ER patient I saw last week whose caretaker took her home with an enteral feed.  This caretaker will be preparing and administering all of the food.  However, my suspicions were confirmed, today.  Many patients who go home like this accidentally pull the tube out.  In these cases, a doctor visits the home to install a new one, or the patient comes back in for one to be installed.  Infections are common for patients who go home with tube feedings.  Additionally, my other fear was confirmed that many caretakers do not make food of the correct consistency, and they end up clogging the tube.  The dietitian informed me that cost is not a problem for most of these patients; it is merely the matter of not wanting to be at the hospital.

Another patient showed dislike for being in the hospital.  This patient hated the tube and always begged for it to be taken out.  When his condition allowed it, he then started complaining that all of the food he receives is nasty.  Because he is not accepting the enteral feed or oral diet, he is not eating enough! This is deadly for a patient in the IMCU because their calorie and protein needs are already very high, and muscle wasting is common.  He demanded food made from his home.  The only problem is that there were no good hospitals near his home town/village, and KMC is famous, so he drove eight hours to get to Trichy.  Without ice or refrigeration, which is expensive, there is no possible way that this man can have food made at home and brought to him without it spoiling.  The total use of restaurant food that I mentioned in yesterday's post exacerbates this issue because the food is always the same.  Many hospitals at home have rotating menus, but he is served the same, bland foods every day.  No wonder he does not want to eat!  Luckily, his neighbor is in town this week and, with coordination with the dietitian, will start making and bringing food to him.  After the neighbor leaves town, I do not know how this difficult patient will get any nourishment.  I also found out personally why patients are served bland foods, even if they do not like the taste.  Every time I eat very spicy foods at lunch with the dietitians, I cough every so often after the meal.  I notice that mucus production increases.  This would be bad for a patient lying on their back all the time!

Today, I saw a patient prescribed 2.1 grams of protein per kilogram of bodyweight.  Normal people need 0.8 to 1.0 grams per kilogram.  This is the highest prescription I have seen, and, today, I saw why.  This man had been in a RTA, road traffic accident, and had a severe HI, head injury.  Today, I saw him for the first time without bandaging.  There was a huge dent/impression in the left side of his head.  At first I thought it was the sunken look of severe malnutrition, but, when I walked on to his right side, there was no dent.  It looked like a bowling bowl sized impression.  No wonder he needs so much protein; his brain and skull need to heal!  He also cannot do very much activity with that much trauma, so muscle wastage is a huge issue for him.

In the PICU, many children are admitted for common things like fever or vomiting.  These patients will receive breastmilk if they are young or a normal diet if they are older.  However, babies in critical care, like the ones on ventilators, cannot nurse.  These patients are given artificial milk through a Ryles tube.  The nephrotic syndrome case that I saw a few days ago had made no improvement.  Because his eyes kept falling open and he needs to rest, his eyes were taped shut.  This was on top of all of the tubes and machines hooked up to him.  This is a sad case.

I found out we are going to Mudumalai and Ooty this weekend, two places with many forests, wildlife reserves, safaris, elephant camps, and shopping.  Tea is only 300 rupees per kilogram because there are many tea farms in the area.  In the US, I have paid the rate of 8,500 rupees per kilogram.  Because the rate was so high, I only bought a few ounces.  Here, I can buy several kilograms! Hopefully, I can fit it into my luggage.  I am so excited to see elephants and tigers and sloth bears! Oh, my!

One last note: I feel as if I suggested that nurses are incompetent in my post, yesterday.  My point was that they make many mistakes when it comes to feeding patients.  Despite these mistakes, the hospital would not run without them.  They are a huge workforce, and patients would receive no care if there were only doctors, therapists, and dietitians to prescribe care that they could not carry out on their own! Nurses are very necessary and perform many skilled tasks that are critical for patient care.  Thank you to all of you nurses out there!