Tuesday, February 24, 2015

NEURONS IN UNIFORMS: Neurology at the Indian Armed Forces Medical Institution,New Delhi,India

January 24,2015

Week 2 and Beyond

Salient Aspects of Outpatient Department

India has a "bilingual medical system “patient interviews in Hindi and case presentations in English. Unless absolutely needed the CT scans and MRI were not done emergently and this made my brain exercise a lot in localizing lesions based on clinical presentation alone Neurocysticercosis and tuberculous brain abscess were relatively common in far flunked remote areas with limited access to medical care and these people would then come to us with some classic textbook radiology findings. I also saw many seizure patients and all the drugs commonly used in US were freely available at least in this center. If these patients insisted on following up with local Army hospitals (and not the special 8 Neurology Centers) we had to be more judicious in our medication choice for these patients. This was because there was limited variety of antiepileptic medications available at peripheral smaller medical centers.

Didactics and Conferences
Monday Journal Club comprised of discussing about CHANCE and SAMPRISS trials. Tuesday Chief rounds was an interesting case of Peripheral lower extremity tingling which completely resolved in 4 days and what was left was some ankle weakness and minimal limb girdle weakness. Interestingly the nerve conduction studies, Electromyography, Brain and Spine MRI were all normal. CSF analysis was unremarkable as well. Onwards plan was to repeat EMG. A muscle biopsy was to follow suite. Wednesay Neuroradiology conference was again exciting with a case of ring enhancing lesion on MRI Brain. It was really nice of Neuroradiology folks to spend some extra time with me teaching me about some tips and tricks of reading “films”. There was also a joint Neurology and Medicine case conference on approach to Altered Mental status. A round table discussion about a bed bound patient and its prognosis made us all plunge into article review about prognosis of Coma which then was discussed in resident report of the week. I discussed about an article in Journal of Neurology, Neurosurgery and Psychiatry on Medical Coma Prognosis.

Inpatient and Neuroscience ICU cases.
Vascular Neurology cases (stroke, subarachnoid hemorrhage, intracerebral hemorrhage) were the mainstay in the ICU. There was also a case of Guillain-Barre syndrome. We had some great attending inputs on how lack of long term rehab units or acute level rehab facilities tend to cause prolonged stay of some patients in ICU and floors. An interesting case of refractory seizures with normal MRI and not so helpful interictal (inbetween seizure event) EEG was puzzling everyone.24 hour Video EEG was available but not so commonly used and the patient was referred to All India Institute of Medical Sciences for further care.

Visiting All India Institute of Medical Sciences(A.I.I.M.S)
Army Institution did not have an Epilepsy Monitoring unit and not a very aggressive Neuro Intervention team. They referred complex Epilepsy cases to A.I.I.M.S.So, towards the end of my elective my preceptor helped me connect with this hospital and the Neurology faculty there. It is the best public sector Indian hospital with all sub specialties and a huge patient workload. The Epilepsy monitoring unit was pretty similar to what I had seen at Brigham and Women hospital .I spent the morning rounds on these patients with Epilepsy fellow and attending. There was an interesting case of Frontal Lobe seizures which required sharp eyes to decipher the location of seizure onset on EEG. There was another interesting case of what looked like Non epileptic spells and I was part of a long family meeting and patient counseling on this issue.Similar settings like our Neuropsychiatry team at Brigham talking to patients with similar presentations and etiologies.

The Neuroradiology conference was wonderful and I felt “homely” seeing Centricity Software (used at Brigham) being used to see the Neurology Images at A.I.I.M.S..
Epilepsy Surgery case conference were a treat to attend. The residents told me that the reason they went on so well was that the head of Epilepsy division was married to the Head of Epilepsy surgery division. One can understand the popularity of this institution and the huge patient workload by the fact that the wait time for Epilepsy monitoring admissions was close to 1 year.

The Epilepsy clinics were held each day and were blessed with some of the finest cases from the country. Structural lesions causing seizures (prior stroke or hemorrhage, sequlae of brain infections, tumors) as well as childhood syndromes comprised the majority and for many the cause was yet to be determined. My aim in clinic was to learn and understand the selection of anti-epileptic medications based on age, gender, co-morbidities, seizure type and most importantly (believe it or not) cost and availability at patients home city or village.

The rich and poor paradox in India in Healthcare Sector
On my last day, I decided to spend a few hours at the other extreme of Medical care; A super specialty ultra modern western model of corporate hospital called Medanta-The Medicity(A hub of what is popularly called as Medical Tourism).  It had a completely different patient population. Very well to do families from other Asian countries and also Africa were the major clients/patients here in addition to affluent Indians. My aim of visiting this place was to see how choice of anti-epiletic medication or the approach towards Neurology Intervention procedures/surgeries changes when patients are from super well to do families. 

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