Tuesday, February 24, 2015

Neurons in Uniforms: Armed Forces Medical Instituion in New Delhi,India

January 10, 2015

Week 1 Day 1: The Beginning
Finally, after an 18 hour flight and a new year eve somewhere in the skies over the Arabian sea,i joined the Neurology team at Army  hospital. Day 1 was exciting, challenging, demanding and surprising all at the same time.

Monday was a busy outpatient clinic day. No appointments are needed and patients can just show up on Monday, Wednesday or Friday mornings. Together with 3 other residents, I was supposed to see a long queue of patients waiting outside the room. It took me almost 30 minutes to interview, examine and make notes of my first case; what looked like a case of mononeuropathy multiplex. With a list of 40-50 patients (old and new) and limited time(close to 3-4 hours to see all of them) the residents would usually write very small notes and do a quick focused and limited exam. The patient population comprised of Armed forces personal (serving and retired) and their family members. With only 8 defense forces Neurology centers all across the country, the outpatient department gets interesting referrals from hundreds of smaller base hospitals. The clinics were followed by Journal Club on Oral Medications for Multiple Sclerosis. I also shared my experience about the Partners MS Center Clinics and our most current practices.India, although a largely warm country does has its share of high altitudes in Himalayas and Multiple Sclerosis cases are found in this belt. The rest of the day comprised of inpatient bed side rounds which are usually lightning fast on Outpatient Clinic days.

Day 2 and beyond
Day 2 began with a case presentation of distal myopathy. I had presented a similar case of Titin mutation anterior tibial compartment myopathy at Brigham neuropathology conference in 11/2014 and I felt really excited to see a similar case on the other side of the globe. The highlight of Day 2 was my first exposure to their bed side rounds. There is just one team that rounds ED Neurology, ICU Neurology, inpatient consults on other services as well as Neurology inpatient. A typical daily census is 5-6 new floor admits, 3-4 new consults and 1-2 ICU admit daily on Neurology service. In absence of acute rehabs and virtually no step down units, the inpatient stay is usually longer than what it is in US. Also there are lots of outside hospital transfers from smaller district level centers. It took almost 5 hours to round on approx 50 patients. The residents (including) me were asked management pertinent questions and given an assignment during rounds which was discussed the next day. An interesting case i saw was Tubercular Transverse Myelitis which helped me revise Spinal Cord anatomy and syndromes in fine detail.

Day 3 was again the outpatient day. Now i was well versed with the system. Soon i realized that Migraine, Sciatica, Carpal Tunnel Syndrome, Diabetic and Vitamin B12 peripheral neuropathy are the flag bearers of Neurology outpatient cases all over the world. I saw plenty of follow-up intracerebral hemorrhage cases and it is exciting to see CT scans and MRI on “films” rather than computers. Didactics comprised of a presentation on Visual Evoked potential and Brain Stem Auditory evoked potential by a senior resident.

By day 4, I began to appreciate a very strict hierarchical system in the Armed Force Medical wing."Sir" and "Madam" were supposed to be used strictly for anyone senior to you and most of the times also for your colleagues. Among the new admissions overnight the most interesting was a cardioembolic stroke in the left middle cerebral artery territory who presented with right face, arm and leg weakness. He was given IV thrombolytic (tPA) and NIH stroke scale improved from 10 to 5. I realized that intra arterial therapy (tPA) or even mechanical clot retrieval was not well developed in this center and in spite of presenting within 2 hours of presentation a CT angiogram was not pursued emergently.  I gave a brief talk and discussed how intra-arterial treatment was pursued in our system.

Day 5 was again the outpatient clinics. I was more inclined to develop expertise in reading MRI and CT films so requested the Clinic manager(who doubles up as EEG tech in afternoon) to direct all patients who have films in their hands towards my room. It was great discussing all these cases with my attending who shared some very useful tips about these reads.

On Day 6, I decided to ditch my car and took the local Metro train to make it to a Neuroradiology conference. The cases comprised of space occupying lesions, intractable epilepsy and some spinal cord pathologies. It was a completely different cup of tea to look at films and appreciate subtle deficits. I missed our PACS, CAS and Centricity (Computer software based Radiology image viewers) so badly.

Overall, my intial days helped me understand a system which has immense patient load and limited radiology support but lots of clinical marvels to learn Neurology.

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