Week 2 In Trivandrum

I was informed on Saturday that the exhibition at the Saphalayam Complex & Mall would continue on Sunday and, if I wished, I could be part of it. Fortunately, I was able to hire an auto rickshaw. The driver said 150, and I agreed, assuming he meant rupees. There were several staff members and volunteers there, and I had wonderful conversation with the volunteers. There was one volunteer— a now-retired engineer — who had worked in the Middle East, and was heavily involved in the exhibition. He bought me a cup of coffee and a few others joined in the conversation.

As they did, I suddenly realized that I do not speak Malayalam, nor am I able to have a conversation in any Indian languages. I must admit, sometimes I may seem to agree with my body language without knowing what the conversation was about! Normally when I come to India, it takes me 2 to 3 months to understand and speak a bit in an accent; most Indians think it is odd. In the hospital during rounds with patients, things are in a similar vein; One of them peering in to my eyes, animatedly explaining his present state. I was nodding as if I was part of the conversation, and it was a bit embarrassing for me. Often, I do simply state that I do not speak the language, in English.

The week was very educational for me and working with caregivers’ compassionate, wise and wonderful communicators was an honour.

On Sunday night, I was told the apartment would have two more guests, as it accommodates three people. While I was working, Dr. Rajashree arrived in the evening. She works in her town as a physician, and helps to evaluate the participants of their CCPPM course during the last week of training. In the morning, I learnt that Sarah, a medical student from Berkley Medical School, who was involved in research with Pallium India, arrived around midnight. It appears she was in an accident had an injury to the foot and several of her friends had to bring her in a wheel chair. Lucky me, I was fast asleep, and missed the commotion!

Come Monday morning, Mrs. Kumari made breakfast for all of us and the driver picked us up on time to drive to the hospital. Sarah had crutches and kind of air-cast to stabilize her ankle and foot.

After the rounds at the hospital, the staff said we were going to lunch at a wedding ceremony. I remembered on Sunday that one of the volunteers had invited me for lunch and said he didn’t know the couple, but I was still not sure what this was all about. I went along to a wedding hall, which was almost across the main road of the hospital. Crossing the road can be hazardous in most cities in India, if you don’t know what you are doing! Despite 6 people crossing together, I had my own anxieties of being hit by a scooter or auto rickshaw. We safely crossed the road and found that the wedding was already over. I followed my colleagues in to a large hall with full of long tables and chairs on one side, which could have probably sat more than 200 people. Already some were eating, so we sat at an empty table. The serving team came with a roll of white sheet of paper and rolled it out and made the table look clean! Immediately after another server came with cut green banana leaf and spread it in front of each guest, which I remember was the “plate”. Next came servers in tandem, with variety of dishes. If I remember correctly, there were more than a dozen delicacies served, one after the other. I could recognize four or five of them including rice. Since I am not often a lunch eater, I stuck to what I know and-using my fingers as is tradition-I was able to complete my meal. After washing our hands, we returned to the hospital. Luckily, Crossing the road this time was a breeze, as there were no vehicles within 20 meters of our crossing.

As we returned to the hospital, I joined Sunil to see a patient for admission in the clinic with pain crisis, with fungating carcinoma of the mouth cavity. His wife was very articulate. After the visit I better understood some of the societal and cultural imperatives; especially for younger women when their husband is at the end of life. Family may associate with them until the death of the husband but it must be a struggle for the wife left behind, in several families.

That afternoon I had a chance to go to the rooftop, where I found a garden; where rehabilitation patients cultivate and variety of vegetables are produced, as part of therapy.

That night, I prepared some ideas for a teleconference the next day.

Cancer patients are seen in outpatient clinics and in the hospital but what surprised me was the variety of neurological patients with stroke, back injuries with paraplegia that were part of the care and rehabilitation. When I started palliative care a few decades ago, it was very much for cancer patients. Patients with AIDS have been part of palliative care the AIDS crisis, and now with triple therapy it has been much better. Now, we see more patients with organ failure, dementia and other neurodegenerative disorders.

That evening’s teleconference included more than 12 participants with interest in advancing the safe use of opioids, and especially methadone education. At the end of the meeting there was consensus to explore few ideas and Drs. Ann Broderick, Dawn Lockman and I agreed to assist. At the end of the meeting personally I felt that I had my “marching orders” to get a few things done while I was in Trivandrum. We did agree to continue collaborating in the best interests of Mother India as we move forwards.

Wednesday morning offered me an opportunity to present to the participants of the CCPPM course on the topic of opioids, including methadone. There was good interaction and I learnt some of the physician practices in India, including how to structure educational material.

Following that, Sunil had a house call for an 80 year old patient and her physician daughter, who was being looked after at home with help. She had respiratory issues, and is probably close to end of life, but is receiving CPAP most of the time. It almost felt like by different interventions life is being prolonged. But she appeared comfortable, even though she is not able take much by mouth. This is not an uncommon theme where I work, we are often negotiating with family & proxy decision makers as to what is appropriate. After speaking to Sunil, we have agreed I will go over the existing TIPS-ECHO material on methadone in the Library, to revise and hopefully by the end of next week share with the contributors and reviewers.

Thursday, mostly I worked on the material and saw Dr. Rajashree engaging the participants of the course in Dr. Bruce Davis Training Centre. Dr Davis’ picture is on the top right hand corner of the photograph below. His donations led to such a valuable centre to train caregivers.

Friday morning as I was going up the stairs, I saw Dr. Rajagopal who stopped me to talk about a patient he was due to see in the outpatient clinic. A man over 65 and had obesity, sleep apnea with severe genu valgum (knock-knee) and a few other co-morbidities. Following several consultations with other caregivers, he had seen Raj earlier and was due to see him again today. At the last visit Raj had seen him and his wife; part of the conversation was not only about care, but the patient was wondering whether ending his life was a good idea. He was not depressed, but life has become a major burden with major disability. It appears that, after conversation with Raj, he was planning to explore surgery and explore other options.

Palliative care is about caring for people beyond cure and disease. In our practice in a tertiary care setting, we are more focused on, or talk about “total suffering” but always consider the disease, person and family. But sometimes we do wonder why we are being consulted! I mean to say that sometimes we have our own definitions of who is the right patient for us to see or not. This gets worse when the workload is high. I felt that the above patient (who I had a chance to see with Raj) is the right patient for palliative care to be involved in any part of the world. He and his wife’s suffering was immense.

That evening, I planned to go to Bangalore to see my sister-in-law Angelika and husband Wilhelm, as we had arranged earlier. After some more work on the educational material, I took a flight. Wilhelm greeted me at the Bangalore airport. We had a fantastic get together for two days and the brunch at the Sheraton went till 4 pm. After the brunch, I was driven back to the airport. We took a picture before I walked in to the airport, and I was back on the plane to Trivandrum.

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