What a great way to celebrate national women physician day by saying thanks again to my PCP for picking up on my enlarged thyroid. What a great clinician SHE is! Ironically, I haven’t seen her since that first visit in October and the rest of my doctors have been all men. I actually remember thinking while laying on the OR table before I was given anesthesia, really? All the doctors are men? There were 2 ENT residents, 1 ENT attending, 1 anesthesia resident, 1 anesthesia attending and even the one med student was a guy. How in this day could there be no women physicians in the room? In that moment I wanted to band together with the circulating nurse and surgery tech since they were the only other women around. It was such an odd realization and thought to be going through my head before the procedure. My gender observations aside, I am very grateful for the outstanding surgery team, both men and woman, who took care of me so well last week.
 
That brings me to today, Wednesday, marking one week since the surgery, post op day 7. I have to admit I feel much better than I expected. I wasn’t sure what to expect but I didn’t expect to be this functional so quickly. The pain has been manageable with Tylenol and even that I have spaced out. I do find myself still getting tired a bit easily requiring an afternoon nap but still on the road to recovery. I will have my surgery follow up appointment on Thursday to see how things are progressing. My neck is sooo much better! The tape used to close the incision is visible but really not that noticeable and the bruising and swelling has disappeared. Em's advice to me is always, remember you are FEARLESS, in this case neck scar or not. (She even gave me a shirt to remind me.)

Now the most important thing I need to say is THANK YOU. Yes I mean to shout because I can’t articulate how touching, moving, and essential the support of my family, friends, friends of friends, physicians, and even strangers has been to my recovery. Not only my recovery from the surgery but coping with the diagnosis of cancer, even if it is “just papillary thyroid cancer”.  Everyone has been there for moments to laugh with me, cry with me, distract me, and give me that all needed hug. (I am a hugger and believe a hug can make anything better, at least for a moment.) Special thanks go to my Mom, Dad and Em who made the trek to NYC to be with me. They made sure I was getting out of bed, made sure I showered, made sure I got out of the apartment for fresh air (but not for too long), made sure I was fed, made sure Morrie was fed, and were kind enough to document the whole thing! They were awesome, amazing, and couldn’t have asked for a better team! I love my family!

Happy weekend, everybody! I'll start off by saying this is Emily again (Meg's sister). She is sleeping right now but wanted to give you all a little update. She will likely post something of her own very soon.

​The last few days have been all about getting Meg what she needs and trying to convince her not to do too much. If you know Megan, you know she is a go go go kind of gal! I know the slower pace has been hard for her, but she's listening to what her body needs and I know she's doing her best to be a good patient. 

The thing she keeps talking about is how blown away she is by all the support. We talked about how it feels a little weird to be putting such personal info out there for the Facebook world, but how humbling it is to hear from so many people who care. This is what makes social media so insanely cool. Each of you have warmed her heart and made her smile. I wouldn't let her attempt to respond to everyone because she needs to rest, but please know she says THANK YOU a thousand times over. 

Here's a little bit of how we've been keeping ourselves busy.... 

Restaurant week! This was Thursday afternoon. We went to a place called The Writing Room. (Doesn't she look amazing for 24 hours post-op?!) Unfortunately she felt better on Thursday than she has since then, but this was a much needed bit of fresh air. And we had a great lunch! I was sitting in our cozy booth feeling so grateful to have some QT with my best friend and amazing parents. And then we started talking about politics... ;-)

I've probably been embarrassing Meg by taking random pictures of gallery walls, pretty tiles, and cool lighting. Don't be mad, I'm just a country gal in the big city! The whole restaurant week timing has really been a perk. It's great to check out nice places in her neighborhood (Upper East Side) and see where we might want to revisit in the future. 

A few of Meg's friends stopped by for a visit on Thursday night and it was so fun to meet them and for Meg to be able to do a little rundown of her experience at the hospital. So glad she has found such good people here. And wow, the goodies they brought with them!! She was blown away that her 'fellow fellows' all went in on flowers, sweet treats and of course, wine. What more could you ask for!! We've also had some surprise deliveries that have made for the perfect bright spots when Meg was not feeling so good and in need of a pick me up. She sends a huge THANK YOU to each of you. (My dad is also grateful, as he has been poaching oatmeal raisin cookies and other goodies like it's his job.)

It's Saturday morning now and after a low-key Friday, we are about to venture out for some mani-pedis. Not sure my dad will be taking part in that. We'll meet him for brunch afterward. Stay tuned for some very wild and crazy adventures with Morrie the cat!! He and I had a big day yesterday. More details to come. 

Thanks again to all!!
- Em on behalf of Meg

Caption contest for this lovely picture?? Dad is amazed by the trash removal system here. Gotta love him.

Wednesday Night Update: 10:30 p.m.
 
HOME! We are back home. Morrie the cat is snuggling his favorite girl and we are binging on takeout food. Fingers crossed for some good sleep tonight.
 
Wednesday Evening Update: 7 p.m.
 
Meg is out of surgery!
 
She went back at one and six hours later we are still in the waiting room, sitting tight until we can go back and see her.
I (Emily) got to spend about 15 minutes with her in the recovery unit. It took about the same amount of time to get there in this maze of a hospital. Luckily the hallways are color-coded and I had a list of directions—nine steps!! Whew. Meg was awake and alert. Her hair was fanned out on the pillow so she was looking more like Farah Fawcett than a recovering cancer patient. She said her neck is sore and she is thirsty, but the pain isn’t too bad.
 
The doctor had great things to report. It’s clear the medical team is top-notch here. Meg’s program director came by to see us in the waiting area. So thoughtful of her and comforting to know Meg’s work family cares about her as much as we do (thanks to those of you reading this!). Rabbi Edie also stopped by a few times. She shared a beautiful prayer before Megan went in. I couldn’t hold the tears back, but it was just perfect and exactly what we needed.

We feel surrounded by compassion here, thanks in large part to the love so many of you are sending our way. Perspective is also everywhere we look. Many families sitting a short distance away are dealing with much more extensive surgeries and complex diagnoses. (My mom talks to everyone and it’s nearly impossible for this journalist not to eavesdrop.) Megan has been the first to point out again and again that hers is a case with much more good news than bad. For that we are so thankful.

Got a stealth pic while Meg and my dad weren't looking. We call them the twins...both internists, both love old people. Here they are casually discussing the stages of dementia whilst I looked on with nervous energy seeping from my pores. #Geriatrics 

It's been a while since my last post. Life became busy as always. Here’s a flash-forward of what has been happening. I moved with Morrie, my cat, from Winston Salem to NYC. Started a fellowship in Geriatrics and Palliative Care. Took and passed my internal medicine boards and finally now a "real doctor" according to the state of New York. Celebrated with a spectacular girls trip to Greece. Tried online dating and still trying online dating. Worked on research projects and quality improvement projects. Ran my fastest half marathon in Central Park in December. Turned 31 in Jan 2016.
 
I had my first patient truly pass through the entire hospital system as his primary care doctor from inpatient to outpatient to home again to back to the hospital. Then breaking the news his cancer was no longer curable and was going to kill him in a matter of weeks to transfer to the palliative care unit and miraculously making it to home hospice. He died last week and I'll admit it hurt my heart. Yet, I will carry his great big smile and greeting of “Hola Dr. Megan!” with me for the lessons he taught me about being a doctor but also about the lessons he taught me about myself.
 
Now is where is will share some bad news followed by good news. As many of you reading this know I'm a private person, not much of a Facebook feelings poster so this feels a little awkward. However, this is for my family and friends who have supported me, encouraged me, and are willing to drop everything at a moments notice to be there for me.
 
The bad news begins like this. I was feeling great and went to establish care with a primary care doctor because I need to practice what I preach, right. My doctor during the physical exam felt my thyroid (a gland in the neck) and thought it was big. She sent me for an ultrasound that showed two nodules that are not suppose to be there. Due to the size of the nodule, I was sent to an endocrinologist (a specialist in thyroids) to have a biopsy taken. He stuck a needle in my neck to get some tissue and here's the bad news, this tissue showed papillary thyroid cancer.
 
Yes the scary word cancer, however that is also the good news. Papillary thyroid cancer can be removed and cured. The survival rate after removal is 99% at 5 years.  I won't have to see an oncologist, no chemotherapy, and no radiation. An ENT surgeon is going to remove the thyroid gland and since the cancer nodules were caught early I most likely will not have any other treatment. I will be on replacement thyroid hormone for the rest of my life, that’s it. One small pill.
 
My surgery will be Wed Jan 27 (tomorrow) and my family will be able to fly in to New York despite the airport delays to help me heal. I want to use the website as an update page, Em will post updates on the blog and man my phone as I recover. I appreciate everyone's thoughts prayers and good vibes. I'm thankful for the outpouring of love and support during this challenging time from family and friends from all parts of my life.
 
So here’s to 2016 – Harder, Better, Faster, Stronger! Meg
 
https://www.youtube.com/watch?v=lLYD_-A_X5E 
 

On a lighter note, I got the opportunity to go visit a few on the nearby Hindu Temples.  My Tucson friend joined me which was wonderful because she served as a translator and guide.  She practices the Hindu faith giving me insight to the rituals and significance of the temples, offering, etc. The first temple was located in the hillside overlooking the city below.  We arrived as the priests were performing one of the daily rituals which included providing offerings, food, and then cleaning the God.  Once that was complete we were allowed to enter and visit the God.  The God was stunning presented in all gold, covered with flowers and radiating in the candle light.  The God was smaller than I expected, only about 12 inches x 12 inches.  The ritual was performed, a blessing was spoken, and it was finished with giving us coconut water poured in our hands to drink.  I felt awful but I did not drink the water, I dabbed it on my cheek!  That just seemed like a raging case of bacteria to expose to my gut to since I am not used to the local bacteria here.  After visiting the God we went outside where my Tuscan friend lit a fire and placed it outside the alter.  We then walked three laps around the alter to solidify her prayer.  She prayed for health and strength for her Dad who is hospitalized. I have to say I admire the spirituality, devotion, and dedication of the Hindu faith.  The faith of the followers is inspiring. 

We finished our evening with a trip to the local street market. This was fun for me because it gives me the opportunity to see a piece of the local life. Where do the people go to get shampoo? Where do they do their grocery shopping and get their hair cut, the everyday events of life.  There was the main dirt road lined with fruit venders, retail shops, and moto repair shops. There were children, chickens, and pigs running around amongst the locals doing their every day shopping.  It was the hustle and bustle of the village.  I even did a bit of shopping myself. 

Today I had the opportunity to review x-rays with one of the chest doctors. The chest x-rays were of patients who were admitted with tuberculosis and currently receiving treatment. There were classic cavitary lesions and even an image of miliary tuberculosis on the x-rays. I found it pretty cool to see in real life what I have studied in the textbooks. We then went to the microbiology lab across the hall to see an acid fast stain. There were a ton of the bacillus all over the slide, lighting up like green fluoresant stars in the sky!  Next, we attempted to go to the dermatology clinic and see skin cases but the afternoons are pretty slow in the clinics. The way it works here is most patients come in the morning, get seen by the doctor on a first come first serve basis, tests and labs are ordered, the patients leaves to get them done, then returns to the doctor with the results. Only then is the treatment determined. There is no MyWakeOne or I will call you with the results here.

What I was hoping to see in the dermatology clinic was a case of leprosy, the clinic sees several cases each week. The dermatologist was telling me the cases have increased to roughly 50 cases per 10,000 people which is a significant amount. The reason for the surge is several years ago Indian declared that leprosy was eradicated in the country, only 1 case per 10,000 people. What happened then was suppliers, such as aid organizations and pharmaceutical companies, quit providing the medication to treat leprosy. If leprosy was supposedly gone there was no need to keep spending money on distributing the medication. That would have been the ideal situation but that was not the case. So now several years later you are seeing a spike because people who were infected didn't have treatment options available allowing the disease cycle to continue.

We also talked about government programs to ensure tuberculosis and HIV get treated. There are programs to provide the medications free for both diseases and the tuberculosis treatment is even observed improving the compliance rate.  This has decreased the incidence of TB significantly and decreased drug resistance cases. There still a few cases each month of extensively drug-resistant tuberculosis (XDR-TB). Those cases require hospitalization to ensure the patient receives adequate treatment. In regards to HIV, there is still great stigma attached to the diagnosis. Employers fire people with the diagnosis, families excommunicate the individuals, and they are socially ostracized. This has lead to a dangerous environment for hospital employees and other patients. It is not uncommon for HIV positive patients to be admitted to the hospital and not disclose their positive status perhaps due to social pressures. This becomes very dangerous in a setting where medical supplies are often sterilized and reused. What is the ethical action to take? You have the patient's right to determine what tests they undergo on one side and on the other side you have the patients and staff who could potentially be exposed. This seems to be a tough decision.

Below are pictures of the typical outpatient clinic. The attending sits at the desk with the patient who is currently being seen sitting on the silver stool. Additional patients waiting to be seen are first checked in then sit in the blue plastic chairs to wait their turn.  Most patients admitted to the hospital are admitted through the outpatient clinic. The outpatient clinics here function similar to an Urgent Care Clinic in the US. 

"This town is so small" is a phrase I have heard over and over again since arriving at the hospital. The population of Vijayawada is only 1,491,202 people. This shows how perspective matters.  Winston-Salem, NC where I am currently settled is the largest city I have lived in. The population of Winston is 234, 349.  Imagine how small that city would seem to the people here. Even smaller is the town where I grew up, Washington, MO a thriving metropolis of 13,918.  Yet I wonder if using population is not a reasonable comparison between the two cities. Yes Vijayawada may  have six times the amount of people as Winston-Salem but that doesn't mean the cities have comparable resources or amenities.  Take the average population density of India (364 people per sq km) compared to the US (34 people per sq km).  It seems India has 10 times as many people living in the same sq km as America.  No wonder a town can be labeled small but still have a population over a million.

The population of India is booming and has been one of the assets and pitfalls to the county as a whole.  The population is diverse with a robust culture and traditions leading to an undeniable pride in their country. However, the enormity of the Indian population also results in limited resources with a majority of the people living in utter poverty.  According to the World Bank report in 2010, 32.7% of the Indian population falls below the international poverty line of making less than $1.25 USD a day, while 68.7% of the population lives on less than $2.00 USD a day.   A majority of the people in the area here including the city and surrounding area fall in the category of making less than $2 USD a day.  They are daily wage workers in the agriculture industry, domestic helpers, or stay at home to while the husband works.  That makes affording hospitalizations, medical tests, and treatments difficult, frequently draining the families savings.  Below is a breakdown of just a few of the costs for medical tests:

CBC                                            180 Rupees    $2.91 USD
Renal Profile (Na, K, BUN, Cr)   225 Rupees    $3.64 USD
Liver function test                       300 Rupees    $4.85 USD
Finger stick blood sugar               30 Rupees    $0.48 USD
Urine analysis                               80 Rupees    $1.29 USD
Lipid profile                                 250 Rupees    $4.04 USD
Chest X-Ray                               125 Rupees    $2.02 USD
Abdominal Ultrasound                500 Rupees    $8.09 USD
MRI Brain with DWI                 2,800 Rupees    $45.24 USD

It is a struggle for both the families and the hospital, the hospital gives charitable care but has its limits.  In the end the hospital has to be fiscally sound to keep operating and delivering care.  When a family can not afford the care here at this private hospital their other option is the government run hospitals.  However, I have been told by numerous people on separate occasions these are less than stellar.  At times there are not enough beds for patients so they are sleeping on the floor. Treatments are not available and evidence based medicine is an afterthought.  I'm not saying all are like this but the nearest one here falls into that category.  I guess that is perhaps where I tend to get discouraged.  There are needs that need to be met around every corner and how do you say one is more important that another.  How do you pick and choose? The amount of need is overwhelming and at times can seem like no matter what action is taken is there really a difference being made?  When the medical team receives a smile from a mother who's 16 year daughter has recovered from high fevers and low blood counts I answer yes, a difference has be made.   There may be no definitive diagnosis of which virus caused her symptoms but for that family they have their daughter.  Major change is happening at this institution but perhaps like a ripple in the water we are in the early stages and the difference will take many years to manifest.  That is my attitude, that is my hope and that is my motivation. 

Stare: to look fixedly with one's eyes wide open

I'm not sure how staring developed, but it seems to be part of human nature. Here in India, I have gotten plenty of stares. I stick out; I have blond hair, blue eyes, and pale skin. I am not wearing the traditional clothes. The staring doesn't offend me, to me it simply expresses curiosity. In the United States, Ms. Manners tell us it is rude to stare. But why? It makes my day when the little kids are running around and all the sudden they see me.  They stop in their tracks, jaws drop (literally), and stare. My response is to smile and wave. To me, if I ignore them or frown at them I give the wrong first impression. Why not show them we are the same on the inside? We tend to be scared of the unfamiliar and but why not seize the opportunity to settle those fears? Curiosity reflects their eagerness to learn, to gain knowledge and I want to oblige. 

Doesn't medicine revolve around curiosity at its core? Diagnosing a symptom or illness is really just a process of trying to figure out why. Why is the patient is having headaches... is it a migraine? meningitis? vision problems? cancer? stress? Today we had several patients who wanted an answer to this question. As health care professionals, we try to answer this why question the best we can so we can go to the next step: fixing it!  Day in and day out this is what we do, it's the bread and butter of medicine. Curiosity is an innate trait we all share and we should embrace it. That is how discoveries are made and society advances. Let's advance together, from the daily wage worker to the college graduate to the Nobel Peace Prize winner.

On another note, I went out to town for the first today. I went with the Professor and got to try on a few sarees. We also stopped for some fresh veggies, it was a full rainbow of colors.

For those reading this you probably know I tend to be a fairly independent lady. I tend to set my mind to something and continue until the task is finished.  This trip though has taught me a few things about what happens when one loses that independence. It is an extraordinary adjustment, it is uncomfortable, and can be terrifying.  These feelings came to the surface when I met a woman today who was admitted for a new stroke because I imagined she was having those feelings.  You see in this area TPA, the medication used to bust the blood clot causing the stroke, is not available.  It doesn't matter if you show up 20 minutes or 20 hour after the first onset of symptoms the treatment will be the same, supportive measures and no reversal of symptoms.  This is the reality of limited access and resources.

As part of the initial supportive treatment, this woman had her hands tied down to prevent her from dislodging the IV lines, a Foley catheter was in her bladder and a feeding tube placed in her nose. None of these treatments, which are necessary, are pleasant for the patient.  Worst of all she was aphasic from the stroke, meaning she could think thoughts but was unable to articulate or speak them. I imagined she felt similar (but worse) than I did the first day arriving at the hospital.  I could talk but no one understood.  I didn't know where I was going, who I was meeting, what time I was suppose to be ready in the morning, how to get the power outlets to work much less the internet or a phone to call home.  The frustration over loss of control was palpable and the inability to express my self left me feeling helpless.  My normal role as caregiver was reversed, I was useless.  For me one for most difficult things was to sit back and let things happen, unknowing of what events were going to take place.  I have traveled quite a bit and enjoy being spontaneous and going with the flow.  The difference is I normally have the ability to express myself if desired, that first night for me was an epic fail as seen by the knock on my door every 15 minutes for 2 hours after I tried to say I was going to sleep.   Obviously I should have brushed on my Telugu, the local language, before traveling.

For me the situation was and is temporary.  I met those around me who spoke some English and I have been able to communicate, which makes all the difference.   The power of language is priceless and a gift I take for granted.  I will take what I have experienced here, both the medical knowledge and my feelings of frustration and helplessness I felt with loss of independence, to relate to patients and incorporate them into my practice. A reassuring pat on the hand, a hug, a smile, and taking that extra time to explain what is happening to a patient I believe can make just as much of an impact as any prescription I can write.  In the age of computers it seems easy to get lost in the instant labs results, the ICD codes, and checking boxes off your to do list.  I'm guilty of this just as much as the next resident.  However, what has happened in the past is in the past and I can strive to make changes in the future.  I will continue to make mistakes but that I how I will grow as a physician and how my patients will teach me.

Picture of Ward 31 which is all women patients with a 30 bed capacity and picture of the code cart.

Rounds were busy on this Monday morning with two patients in the ICU, seven in the men's ward and ten in the women's ward.   All were admitted on the previous Saturday most from the outpatient clinic.  That seems to be a large difference between this hospital and US hospitals (at least the ones I have worked in). In the US patients get admitted most from the emergency department and occasionally a few from clinic.   Perhaps part of the reason is that the outpatient capabilities in the US are much broader with greater access  to studies, tests, and healthcare facilities in general.  There is a Walgreens on every corner, labs in clinics, and patients can call a provider day or night if something is concerning. Safety nets are in place for patients to be treated in the outpatient arena.  There are also incentives for patients to save money by attempting outpatient treatment first.  In this area of India it seems unlikely the daily wage workers would be able to call a provider in the middle of the night and ask for a prescription or even if told to go to the ER that would require waiting for the next bus to stop in their village. All that being said please keep in mind I am speaking of the patient population treated in this area which is mainly the underserved with very limited means.  There are those with substantial means who obtain their care at private hospitals where access to health care is different if you can pay for it.

Now back to rounds.  I was excited to finally have more patients to see but my excitment was shortly replaced with a bit of frustration.  I only am able to get about 40% of what is going on with the patients because of the language barrier.  Some of the patients I knew because I saw them on Saturday, others I was able to read their charts before rounds to get a general idea.  However, those who I was meeting for the first time on rounds were next to impossible to get the entire picture.  I had to rely on my physical findings to give me a general clue of the problem, even then I needed the patient history to put the exam findings in context.  I truly believe that a majority of the time the key to unlock the diagnosis is found in the history.  When listening to a patients lungs and hearing abnormal sounds the context matters in order to narrow the differential and determine the cause, therefore directing your treatment. I was at a loss for the history resulting in broad differentials and lack of treatment course. 

This afternoon my Tuscan friends stopped by to take me to go visit her Dad. He had success in the constipation department and now is having diarrhea.  She is very concerned about the diarrhea however I'm not sure what she was expecting after feeding him laxatives for the past two days.  I considered it a success, uncomfortable in the moment but the constipation was resolved.  They wanted to give him a bunch of antidairrheals which made me pause for a second because before you know it he will be constipated again. In medicine at times we are quick to give medications in order to feel like we are doing sometime when time is what is needed.  The father seemed genuinely happy to seem me because he saw his daughter had a friend.  She has been away from her family and life in America for a month now with no support or friends.  They were also comforted and reassurance when I simply examined him.  There was nothing magical I did or change in medical care I made.  I simply touched the patient with my bare hands and listened with my stethoscope.  I heard a regular heartbeat, not too fast, clear lung sounds, and bowel sounds rumbling away.  His mouth looked wet and skin was pink, all good signs.  The daughter was concerned he was in shock, at least I could say no he is not in shock. With a promise to stop by tomorrow we left her Dad to rest and decided to adventure outside the hospital for some sunshine.  

Neither of us had been out so we took advantage of our new friendship to walk over to the medical school and take our own tour.  As we walked in the front entrance there was the gorgeous shrine to the goddess of knowledge, Saraswati. The building is four stories of beautiful cream colored marble and deep forest granite floors with flower gardens in the middle of the open air concept courtyard.  There were no students around because they were taking their practical in the hospital or have already completed their exams and were on holiday. Another amusing sign we stumbled up is pictured below, Prohibition of Ragging, act 1997. I wonder what events conspired to have to place such a policy then wondered what would happen if that was posted in the US, for both staff and patients.

PS Happy Birthday to Momma Rau!!