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!!

I started today like every other day but today is my day off.  Normally my day off is packed with errands to run, things to get finished, and time to socialize.  Yesterday I thought to myself, what am I going to do? What I didn't anticipate was socializing today.  In the staff quarters/guest quarters there is an Indian-American woman who is staying here tending to her father, who is ill and admitted to the hospital.  She left the area over 25 years ago and settled in Arizona.  My new friend tried to get her father to move to the US  but he insisted on staying in the land where he grew up and where his circle of support lies.  Now her father is 86 years old and has been hospitalized since January 7.  He was planning to move to the US at the end of March and wanted to get any major medical procedures completed before leaving.  Any surgeries would be too expensive in the US and his insurance won't work there.  He was admitted for an umbilical hernia repair and has had several complications since then.  Doctors found a hair line hip fracture, which they will not surgically repair due to his age, plus a hematoma (a pool of blood in the tissue).  His latest ailment is that he is constipated. During my intern year, I was an expert at constipation. I had a full arsenal of remedies to make the bowels move.  Here however, it turns out the pharmacy doesn't have senna, colace, docusate or Miralax (stool softners and laxatives). The town pharmacy doesn't even have them.  My friend is incredibly frustrated because if she would have known, she could have filled her entire suitcase full of these over the counter medications with one stop at Costco.   

I went to visit her dad today to show him that his daughter has a friend here and is staying strong.   My first surprise was that he is in the special VIP ward which means he can pay the 700 rupee a day charge for a private room (approx. $12).  It is very similar to the hospital rooms at Wake, minus the sailboat picture on the wall, air conditioning, and there is no flat screen TV.  My friend has hired an aid to be with her father 24/7 as an extra measure because here the patient attendants have the responsibility for all the needs of the patient.  There isn't much I did for her father expect offer reassurance and support.  Hopefully he will get well enough soon to make his flight to the US.  

The rest of the day was spent recuperating.  It seems that I have caught a type of cold virus.  Yesterday it started with my left eye watering and a runny nose. Today it progressed to congestion, headache, and a few muscle aches.  Nothing very serious just a bit of an inconvenience.  There are numerous people with the same type of symptoms and I was told it should only last a couple days.  Keep your fingers crossed! 

The guys taking care of me we excited to give me a taste of America today for a Sunday treat, Diet Coke.

I think OPD stands for Out Patient Department.  It is ward number 7 on the ground floor just steps away from the main entrance to the hospital.  (Aside one thing I like about this hospital is that the numbering actually makes sense including the floors as ground 1, 2, 3, 4). Back on track, the outpatient clinic teams for Internal Medicine are rotated on a daily basis.  There are 6 Internal Medicine Teams so therefore each team spends one day a week in the outpatient clinic and causality (the ER).  That is the day they admit patients to their ward service then the rest of the week they take care and discharge until their admitting day rolls around again.  The Professor explained to me how the patients who come to this clinic or hospital are the rural, poor, and very sick.  Those with means or in cities go to the private hospital where they can make appointments and don't have to wait to be seen.  Here, however, that is not the case.  Many of the patients we saw this morning and afternoon were text book illness such as tonsillitis, chronic liver disease, sciatic nerve pain, Rheumatoid arthritis, and low platelets.  Yet the diagnosis and treatment were more like a puzzle and negotiation.  You see part of the diagnosis and treatment is trying to figure out one the means of the patient, two what investigations fit within those means, and three how serious is the illness that you need to push the patient's outside their financial comfort zone. Evidence-based medicine is still the foundation of knowledge and desired practice but in reality if  you don't have the gold to pay for the "gold standard" what value does it have?  

I admire the Professor in her drive, negotiation skills, and perseverance when practicing medicine.  To me I feel she has the patient's best interest in the forefront, even if is not something they want to hear. She tells them this is what would be needed and then tells them what is a must.  They trust her and in return, she does what she can to do right by them.  There was a time sitting in clinic today where it was as if I was in one of the resident clinics back in the US, just the surroundings and dress was different.  There have been several times during my residency where a treatment or study has been prescribed but later find out it was not completed due to cost.  I face this problem more and more while practicing medicine in the United States. We often must manage finances, not medicine.  I think the main difference is that here in India there is transparency of the costs for labs and medications.  In the US it isn't until your insurance is submitted that the cost is determined.  At least in India you know up front what your costs are and if treatment will be financially feasible.  Of course that being said, I am impressed with the resources available to patients in the US, if cost IS an issue.  There are community pharmacies and crisis centers that will provide medications without charge. 

Stepping away from medicine, Professor and I spent the downtime between patients talking about the cultures and traditions of our respective countries.  One topic that came up was marriage and weddings.  She was surprised that there are not really arranged marriages in the US.  This to her was the way it should be, marriage revolving around love between two people instead of being told who you are suppose to spend the rest of your life with.  She was also surprised that there is no dowery in the American wedding culture.  We talked about the traditionally the bride's family pays for the wedding and the groom's family pays for the reception, that is as close to dowery and gifts I could come up with. We also talked about Ruby, the new puppy my sister and I gave to my Mom as a surprise early birthday present.  Professor talked about how she never understood American's attachment to domestic animals until she read the book Marley and Me.  She states she was weeping by the end and it made more sense to her how important pets can be.  Still though, she won't go to her brother's house if his dog is there. 

I truly enjoy these chats with the Professor on more of a person level. I came to India as a representative of Project HOPE in the field of Medicine.  However, this journey is more than medicine, it is fundamentally about the people and culture.  The rest is built on those two things. How blessed I am to learn about the culture and people by being immersed in it with such willing teachers.

Below is the Medical College and Dorms.  The view is from a balcony at the hospital near my room.

Today I was mid chart review when an assistant approached me and beckoned me to follow him.  He looked official in his wife uniform so I went ahead and tagged along.  We ended up in the Medical Superintendent's office where Professor was with several other people.  There was pit in the bottom of my stomach, what did I screw up or what cultural faux paus did I make.  Instead, I had the pleasure of meeting several administrative gentleman. I can't remember their names but one was the head of the Internal Medicine Department the other the Head of Surgery and I have no idea who the third was.  They heard I was at the hospital and wanted to meet me.  It was entertaining watching them interact with each other and then trying to interact with me.  The head of medicine gentleman had such a thick Indian accent I had to let the Professor translate for me.  We then spent 20 minutes trying to explain how college and medical school works in the US.  It is confusing in the US to figure out medical school , internship, and residency.  I can only imaging how much more confusing it is for them!  Then they asked me how much medical care costs in the US say for an office visit. Good luck figuring it out. My honest answer of it depends didn't seem to satisfy them. However I don't exact numbers it depends on the region, the hospital, your insurance company, if it's raining outside ( just kidding). Transparency is yet to be a staple of American medicine from my point of view. We had coffee and there were several side conversations that took place.   In the back of my mind I am always wondering, are they talking about me and if they are I hope it is good.   One thing is that I don't find myself dwelling on that aspect, so what if they are talking about me.  Let them talk.

An interesting conversation that did take place was about the passing of law to split Andhra Pradesh (the state in India I am in) into two different states.  In India the land is divided into states based on the linguistics of the area. This new split from what I can gather was based on politics.  The big uproar about the split is that the new state will include the current capitol of Hyderabad.  The people in this area feel they have spent their time, money, and resources to build up the capitol and now it is just being given away to start over anew.   (Keep in mind this is my very rough translation of the events, please correct me  if anyone knows more)  One thing I can say for sure about India, the people are passionate for their country and passionate in their conversations!  There is constant action when talking whether it is the tilting of the head side to side or waving of the arms, it is constant action when carrying on a conversation. I may not be able to understand the words but I stay entertained. 

The now previous state of Andra Pradesh.

I have to say each day I fall into more of a routine and things seem to be improving. I had my morning coffee followed by a cool  shower then breakfast.  I was able to get some Skype time in with Mom and even catch the end of the Mizzou basketball game before it was time to round.  Today on pre-rounds I branched out from just watching to participating.  I went with the House Surgeon (Intern) and examined the patient along side her.  It is interesting to hear the lung sounds and then hear them described in different vocabulary.  It takes me a minute to make the translation.  When I was listening to the lungs of a woman I placed my hand on her shoulder, like I wound any other patient.  What happened next surprised me, her mother every so timidly stroked the back of my hand.  I wish I could have known what she was thinking.  While that was happening the daughter on the other side of the bed was taking my picture with her cell phone.  I caught her in the act so to speak but just smiled for the picture.  Part of me feels like such an imposter because this family was looking at me to figure out the diagnosis.  However, you could be the smartest doctor in the world yet in this situation the socioeconomic factors limited your diagnostic abilities.  There is a strong clinical suspicion this patient has lymphoma yet without solid proof you can't treat her appropriately.   In the end it was recommended she see further treatment at an institution in the larger city of Hydrabad that has a hematology department. We will see tomorrow if the family agrees to this because they are poor and may not be able to come up with the money.  The Professor reminded than that once they get the diagnosis they can come back here to complete their treatment.

Another experience on rounds that stuck with me today was when we were getting pimped by the Professor (this is a form of teaching where the superior asks you questions that you are expected to know and if you don't you are scolded).  She was asking about Dengue Fever manifestations and classifications (luckily I was not part of the questioning on this particular topic because that is not an illness I am familiar with).  The residents did not know all the answers in regards to the pathophysiology, that is when the Professor made this comment "Your eyes see what your brain knows". Implying that if they didn't know the manifestations they wouldn't be able to diagnosis the symptoms if a patient presented with them.  For me this resonated in how true it is.  There are time when I get reliant on resources or smart phrases, watching this morning gave me the urge to buff up on the foundation to better serve the patient's I see. 

After rounds I had the pleasure of my mid morning sit down time with the Professor.  This is the time we go over the topic she assigned me the previous day and really just exchange cultures.  It is fascinating to me how from first glance India and America seem like polar opposite but then after discussing issues I realize that they are actually more alike than I thought.  Yes there are inherent differences due to the population size of India and the variety of cultures, languages, and poverty however, people at their cores are strikingly the same. From the little things like in both cultures as a single woman over the age of 22 there is the barrage of questions about when are you going to get married to society revolving around money as the marker for success to even the lack education and literacy perpetuating the cycle of poverty.  Two different countries but as humans it appears we all share similar traits.

My room that even has WiFi!!

Today I arrived for rounds at 9 am on ward 31.  I looked over the charts, for the most part which are written in English and examined a few patients.  I watched as one report showed a Cr of 2.5 meaning the antibiotic they were using needed to be reduced because the patient's kidney function was decreased.  What I saw made me appreciate and realize how lazy or perhaps efficient medicine in the US has become.  If I need to renally dose an antibiotic I go online to UpToDate or MicroMedX  to find the dosage.  Then if I'm not sure I can call the pharmacist just a phone call away to further clarify to dose.  Here what ensured was pulling the medical information insert out of the box of pills, reading the instructions, doing the calculations, and finally determining the dose.  This entire process took 15 minutes in all whereas I would take less than 1 min, 5 at the max if I had to call. 

This made me reflect how medicine in the US is very instant, we want results and we want them now.  Once the results come we want action to be taken immediately.  It seems like there is always a test or image to follow up on and the care plan for patient's is dynamic changing moment by moment.  Perhaps that is why I struggle when patients, families, nursing staff, administration and even attendings ask when something will be done or when the discharge will take place.  I can give a rough estimate but in reality I'm not very accurate at predicting the future. That being said all I ask for is patience and understanding when I predict the wrong time, the wrong date or discharge a patient past 1 pm.

Moving on rounds this morning were incredibly brief.  The woman with pancytopenia, fevers non responsive to antibiotics, and now crackles with associated hypoxia on room air is still ill.  She refused to go to the bigger city, Hyderabad, for a second opinion on her bone marrow.  The marrow read here was reactive but her clinical symptoms and lab studies seem to be consistent with a hematological (blood) malignancy.  That leaves the Professor with a tough decision on calculating her next move.  More to come on that tomorrow.  The remainder of the 7 patients were seen quickly with new changes in management (except the dose decrease in the antibiotic).  

After rounds the Professor took me to the Cardic Cath lab where her husband is a cardiologist.  I was able to observe and interact with the cardiologist to see how evidence based medicine is modified under socioeconomical restraints.  The hands of the physician's are tied when it comes to their degree of practice, they have the ability to perform what the guidelines say but if the patient can't afford the medication after the procedure the "gold standard" is obsolete.  The case I observed was an elderly woman with three vessel disease and an EF of 20-25%.  The CT surgeons AND the patient were not willing to accept the risks of bypass surgery.  This left the cardiologist to at least perform a palliative stent to the RCA to help with her symptoms. The stents they use are bare metal stents.  When a patient gets the procedure the government will pay for the procedure and one year of medications. After that the patient is on their own.  Another fascinating aspect of the cath lab was when I walked into the back room to put on the lead jackets to avoid radiation exposure, there were woman on the floor with medical equipment spread on a blanket.  There were syringes, catheters, guide wires, and instruments.  Then the explanation followed...due to cost they have to reuse the medical supplies 4-5 times each.  In the US the supplies are discarded after the procedure even if they weren't use.  This is due to reducing the risk of infections.  However here supplies are limited and valued.  These woman spend their days cleaning and sterilizing the materials in order to give the patient's to opportunity to have a cath performed.  The cardiologists use more femoral approaches than radial because the supplies for the femoral access can be reused 4-5 times instead of 2-3 like the radial supplies.  Perhaps the risk of infection is the chance they have to take to survive.  Who I am to judge.  Although when I was in the OR, people were wearing open toe sandals, masks below their noses, the x-ray operator was on his cell phone, and the cardiologist "sterile" gown had a hole in the sleeve. I'm sure the infection control people from the US would have a heart attack had they seen this procedure suite.

Map of Hyderabad

I was up and ready to start my first day on the wards to meet the "professor medium" aka attending and participate in rounds.  I returned to ward 31, which is the female ward where the team is stationed.   I observed the morning pre-rounding and waited for the professor medium to arrive.  What I saw was the "House surgeon" aka intern seeing her various patient's and she was the one responsible for taking their vitals.  There is this blood pressure cuff box which the top flips open to become your gauge and the cuff is inside.   Then she uses her watch to count the pulse.  There is no dynamap to roll from room to room or even individual BP cuffs for each patient. Also there is no hand sanitizer between each patient's bed.  The house surgeon simply turned around to the next patient.  It really is amazing what you can learn from simply observing.  

Not too much longer I was directed to the office of the Professor Medium.  Her office is  a small room with a desk and plastic chair which I sat in.  Much to my relief she spoke English and an understandable English at that.  My first impression was that she was a fierce, intimidating woman who knows how to be in charge.  However, I have to say my first impression, as most first impressions are, was incorrect. Yes she is perhaps a little more blunt that I'm used to when meeting people for the first time but I really like her.  The meeting started out with explaining what year in residency which takes a good 10 minutes because the training tracks are much different between the US and India. After that the really interesting conversation took place.  She explained to me her passion for medicine and why she is at this hospital. Professor explained that this is a private tertiary medical center where the sick come when they have exhausted their other means of treatment.  She explained how India is a spiritual country and there are many different paths of seeking treatment besides allopathic medicine.  There is homeopathic medicine and Ayurveda (Indian Herbal medicine).  Professor isn't a fan of most of the Ayurveda practitioner's, her name for them is Quacks because she feels they take what little money the poor people have then when they get the money they want they refer to the hospital for treatment.   By the time they are referred to allopathy their diseases are far advanced. The poor patient's aren't educated so therefore they don't their rights.  They lack civic sense for example they see 7 children as 14 working hands but really turns into hungry mouths to feed.  These children are then the slum kids, whereas if they only had one child they could be ok.  Most are daily wage workers so each day in the hospital means no money for their families to get food therefore many times  the patient's state their discharge date. In regards to fees the hospital doesn't charge for admission but they have to charge for investigations (labs, test, imaging) that are expensive.

The professor spoke how the patients view her as a "God-like" figure.  What she says goes and they don't question.  Therefore it is her job to best determine how she can treat them.  The core of her practice is "ask, ask, ask" because the answer lies within the patient and not always on the investigations.  She asks the patient's their professions so she can gauge what they will be able to afford and perhaps what they can't.  She has a list of labs she wants to get but has to prioritize which are imperative.  If she spends their money on labs they won't be able to afford the treatment.  She could go work in the bigger cities and treat those will money who can afford the studies and medications but will also question her every move.  Yet she chooses to stay here with the poor because they too need an advocate and treatment.  Her view is that her God blessed her with the capabilities to treat the "children of the lower God". 

My morning coffee which is really sweet and tastes more like a mocha. Not a bad way to start off the morning!

I got up in time after a long restful sleep to attempt a "shower" which means turning the heater on for 5 min then filling a bucket with hot water.  I tried that and ended up filling my bucket with luke warmish cold water instead.  It still worked the same just not quite as enjoyable, it actually felt kind of nice given it's warm here. I used my new bug soap bar and even a shampoo bar both of which I am impressed with how well they worked.  I barely got out of the shower and dressed before there was a knock on my door.  There was coffee waiting for me and breakfast soon after.  The coffee here is sweet sweet sweet especially for a girl who is used to black coffee.  Breakfast was made american style and consisted of scrambled eggs and french toast. Both were again sweet but delicious. I appreciate the gesture towards familiar foods.  The awkward thing was that I was sitting at the table alone and hosts just stand there watching me. I guess they want to make sure I am enjoying to food, I'm just not used to all the attention.  I finished getting ready then it was time for the introductions to begin.  

I was to meet the medical superintendent of the hospital and some other staff.  It was a strange encounter because the medical superintendent  wasn't sure what role I am to play.  It was like this was suppose to be planned out for me not the other way around.  He didn't even know I was a resident.  I had to write out a mini resume for him to get that I graduated from medical school.  Then off to the wards which was a bit scary at first, I'm not going to lie.  

The assistant professor who picked me up spoke English to me which was great.  The only problem with that is she doesn't speak English to others so I still have very little clue what is going on.  The carts are written in English which allows me to under stand what has happened to the patient's at least.  I can figure out the general disease and treatment plan.This afternoon was pretty much just watching and observing how things worked.  

Patients are divided man and woman then admitted to the appropriate gender specific unit. We were a general medicine woman only ward.  There are just single beds lined up in rows with small stools next to the beds.  The stools are for patient attendants which are comprised mostly of the patient's families.  The attendents are not employed by the hospital and are relied on for the patient's basic care including toileting, bathing, feeding, walking, ect.  When the doctors see the patient they give the attendants a prescription which they then have to take to the pharmacy to get it filled, cost paid up front.  The attendants are the physical therapists, the nursing assistants, and the patient advocates.  The "orders" placed in the morning are recommendations for the attendants.  That being said there is a woman who from what I gather is employed by the hospital.  She is in charge of sweeping the concrete floors then mopping them with a rag.  The floors are clean after she is finished.

Orientation was a world wind of activity and I'm not sure how much orienting I received.  I was able to find my way back to my room which was a big achievement for the first day. Tomorrow will be the start of rounds at 9 am and meeting the Chief doctor for the unit.  I have my fingers crossed because I'm not sure what to expect.