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Just wanted to give all of you a quick summary of our trip back to the US and our first few days back in America. We left Makunda last Wednesday to start our journey home back to the US. Before our departure, the staff at Makunda threw us a wonderful farewell potluck dinner and so we were able to visit with most of the campus families before we left. We were sad to leave so many new friends who have such a passion for serving Christ through medical missions work but we we were consoled with the thought that we will soon be able to return to India to labor with them to reach people with the Gospel. At our farewell dinner we also had the pleasant experience of meeting several medical students from CMC Vellore (the leading Christian medical college in India). All students at Vellore spend time during their third year at a mission hospital with one of their consultants so that the students are able to have more exposure to medicine at a mission hospital which we though would be great experience for many medical students to be able to enjoy during their training.

We started our trip back to the US by first traveling to Burrows Memorial Christian Hospital located in Alipur, Assam. Burrows Hospital is another EHA hospital that is located about four hours from Makunda Christian Hospital. We were excited about getting an opportunity to see another EHA hospital and to see how they approached missions work. We spent from Wednesday to Sunday (one day longer than expected but we’ll get to that soon) at the hospital in Alipur. The hospital in Alipur is primarily a surgical hospital with a few medical patients that are seen as necessary. The doctor there, Dr. Gnanaraj, did his surgical residency and then did a fellowship in urological surgery. Quite a few of the procedures at this hospital are done laparoscopically and so they have a laparoscopic training center at this hospital to train surgeons who want to get more laparoscopic experience. We were extremely impressed by how innovative this hospital is with regard to several patient care initiatives including a fully computerized electronic medical system that was developed there by one of their staff and has significantly impacted how efficiently they have been able to take care of patients at this hospital. All of their lab results and ordering of medicines are done electronically and because of that they have had significant cost savings in prescriptions ordering because the pharmacy is able to order medications automatically when supplies run low and thus they have had to keep less stock on hand.

We were also impressed by their evangelistic focus which starts with daily chapel that all staff attend. What is unique about this chapel service is that at the end of the meeting there is board with all the patient names listed and each staff is assigned two patients to pray for. Then after the meeting, the entire staff go to the patient wards and sing a Christian song in Bengali or Hindi and then each staff sits with their assigned patient and prays for them. What a great way for patients to know that we are praying for them and are concerned about their spiritual care. They have also pioneered a very innovative way to share the Christian message while at the same time generating revenue for the hospital with patient created DVDs. They have a camera and stage set up for patient families where the families can act out scenes from the Bible (they have scripts available) and the video camera records them. Because most people like to see themselves on video, most families will chip together to get the 50 rupees needed to by a copy of the DVD. This generates revenue for the hospital to support their infrastructure costs and gets a Biblical story into the hands of the patients. What an innovative way to share the Gospel!

Another innovative concept that is done at Alipur to increase patient education has been their ability to provide a live feed from the OR to the patient waiting areas so that other patients and families can watch an operation. This has allowed many patients to become educated about common surgical diseases and many viewers who have had similar symptoms as the patient being operated on have subsequently self referred themselves. Another interesting idea that we saw at the hospital was the use of medical camps in surrounding villages to reach the extremely poor. The hospital will travel many times a year to villages within a 200-300 km radius with all their diagnostic equipment and their doctors so that they can see patients who don’t have the money to even get to the hospital for an evaluation. Along with these medical camps, they partner with several other mission organizations who focus on evangelism while the doctors provide medical care. In fact, the medical campus are organized by local pastors so that as people come to know Christ personally, the pastors provide a good network for discipleship and continued community for new believers. Because of their partnership with other mission agencies, many churches have been planted in surrounding communities primarily through the conversion of individuals who were first seen at Burrows Christian Hospital.

We spent three days with one of the campus families who so graciously hosted us. We stayed with Vinay and Rekha John who serve principal for the nursing school and nursing superintendent respectively. We were so blessed by their hospitality, their vision for reaching this part of India by providing high quality nursing care, and finally by the wonderful cooking of Rekha Aunty who spoiled us with some wonderful Indian food. The nursing school at Burrows has been in existence for over 50 years and so they have a long tradition of training excellent nurses. One of the new programs that they are working on is a nurse medical practitioner program (similar to PA or a nurse practitioner role in America) to help meet the increasing medical needs of the Indian population. Their hope is that in their nurse medical practitioner program, that they can train nurses to give spinal anesthesia and to do some of the most common abdominal surgeries so that the patients do not have to leave their home villages for treatment. Karuna and Luke also enjoyed making a new friend with their son, Reuel, who is eight years old.

On Thursday we also got the pleasure of seeing our dear friends, Jodi and Nelson, who serve with Tiny Hands International and run a children’s home (Hesed Home) in Imphal, Manipur. Jodi has been Melissa’s best friend since college and they served together while she was working at Asian Christian Academy. It was wonderful to see both of them again and to spend two quality days with them before we left Assam. We hung out with the Jamirs on Thursday and Friday and Christo spent quite a bit of time at the hospital to see how this EHA hospital ran. Christo’s computer skills even came to good use because he got work with the IT team at Burrows to help them develop a web interface for their insurance registration scheme so that agents can enroll patients that live far away from the hospital without having to return to Alipur to put the data into the central computer. Their new insurance program is an ambitious one which seeks to provide health insurance for 10 rupees a year per person. This insurance would completely cover all doctor/hospital fees with the patient only being responsible for disposable items and medicines. Because the health insurance is so cheap they need to enroll a large number of patients inorder to make this program feasible. Their goal is to get about a million patients enrolled to make this program a reality. This program also provides health coverage to even the poorest individuals because of how affordable it is (about the equivalent of 25 cents for 1 year of health coverage).

Our friends left Silchar on Saturday morning around 5 AM and our flight was supposed to leave at 3:30 in the afternoon and so we got to the airport early at around noon to make sure there would be no problems with our flight from Silchar to Kolkata. However, we suspected something was wrong as we drove into the airport because all the shops appeared to be closed and typically they open up around the time of the flight. Upon arrival at the airport we discovered that Air Deccan had preponed our flight from 3:30 in the afternoon to 11:15 in the morning and thus our flight was long gone by the time we arrived. We were disappointed to say the least and all the more so when we found out that the change had been made a month ago but they had not e-mailed us to let us know of the change…such is life in India. Since this was the last flight out of Silchar for the day it meant one more day in Assam and cancellation of our connecting flight from Kolkata to Delhi on Saturday. So more fees to pay but thankfully when we showed up at the airport the next day there was a flight waiting for us and we were able to safely get to Kolkata on Sunday.

However, when we got to Kolkata and checked in for our evening flight to Delhi we found out that even though we had paid for Luke’s ticket they had no record of it and thus another expenditure of money to help us finally get a ticket so that we could keep the family together on our flight to Delhi. We arrived at Delhi on Sunday night around 11:30 PM and promptly went to sleep once we arrived at our hostel in Delhi. Monday was another busy day in Delhi with a meeting with Dr. Jameela George, one of the central office staff for EHA. We enjoyed talking with her tremendously and about the possibility of working at one of the EHA hospitals in the future. She shared with us several hospitals that focused on teaching and had a clear vision for combining the gospel with medical work which was encouraging for us. She also shared with us a possibility for Christo being able to work with their disaster management unit which helps to provide medical care in disaster areas in the Indian subcontinent. They have responded to multiple natural disasters in India and surrounding areas including the tsunami of 2004, several earthquakes in India, multiple projects in typhoon devastated areas, and most recently they are planning on getting a team ready to go to Myanmar which was recently devastated by typhoon Nargis (it is believed that over 100,000 people died in this typhoon). Christo’s training in emergency medicine and its emphasis on mass casualty medicine would fit in ideally with working as part of this team should we decide to join EHA long-term when we return to India.

After our meeting at EHA headquarters we had the opportunity to visit one of the ministries we support called Anurag which provides training and education for women and children. We have sponsored one of the tailoring students each year for the last two years and so it was wonderful to meet the person we were sponsoring. The staff at Anurag gave us a warm welcome and we enjoyed being able to learn about the many dimensions of this ministry. We were glad to see that the support we were giving was being put to wonderful use to serve people and reach them for Christ. After Anurag it was on to some last minute book shopping in Delhi (most medical texts are considerable cheaper in India as compared to the US) and then dinner with Zarema and Jeremy Dawson. Zarema is the EHA student elective coordinator and she has been a wonderful resource for us during this trip and helped to arrange several things for us while we were in Delhi. We got to enjoy a great homecooked meal with Zarema and her family and give her some feedback about our time at Makunda. Then we made the trip over to the airport for our Lufthansa flight to Frankfurt. Our flight was scheduled to depart at 2:25 AM but didn’t get off the ground till about 3:15 AM. In the process of getting to the airport we also realized that we had left one of our suitcases in Delhi filled with all the gifts we had bought for people back in the US and toiletries. Yikes! So we are now praying that there will be someone that will be returning to India from Delhi that has some extra space so that they can get us back our suitcase.

Our flights went very smoothly and as soon as we landed in one airport, it was time for the next flight and thus we had no layovers on this trip back. One of the members from our church picked us up on Tuesday from Minneapolis and by the time we got home the kids had already fallen asleep.

The last few days have been busy with packing up things for the house, going to several ceremonies for Christo’s graduation from medical school, finalizing paperwork for the sale of our condo, and hosting many family members that are coming into town. It will probably be some time before we can post again because Christo will graduate on Saturday, we will load up the trucks on Saturday night, speak at church on Sunday and then leave for Nebraska on Sunday evening and hopefully we’ll arrive in Dallas to move into our new home on Monday. Please be in prayer for us as we go through a lot of change in a little amount of time and especially for the kids who are still having a difficult time adjusting to the time change and continue to wake up between 3 and 4 in the morning. Please also pray for our safety as we travel the 1000 miles to Dallas and get our new home ready to live in.

We have also put along with this post some pictures from our last weeks at Makunda.

Click on the Pictures to View the Gallery from Weeks 3 & 4 at Makunda

Because of the problems we had with our internet connection, we were not able to put up this post from Melissa. Continue to lift up Luke in your prayers as he has still been suffering from diarrhea. The kids are having a difficult time with jet lag…they were up this morning about 1:30 AM. We hope that they will be able to re-time their body clocks soon. We’ve also put up some pictures from our third week along with this post.

Melissa’s Post:
Today we are experiencing life in a uniquely Indian way as there is a bundh underway. It appears to be in protest of the price of petrol or the rising price of rice (we have been told both so we’re not exactly sure what the cause is). A bundh is actually illegal – this one has been called by the BJP – but they happen anyway and basically what it boils down to is that no one is allowed to travel by vehicle. The same thing happens but it is called a curfew when it is both official and legal and is called by the government. Anyway, it amounts to an unplanned holiday for many people and so we are particularly thankful as it is a restful day for us to process our experiences over the past several weeks.

We continue to be struck by the need in India that takes on some many forms – there is a need for both great quantity and quality of healthcare, a need for education (especially amongst the poor), a need for a better quality of life that comes with clean drinking water, quality housing, access and funds for shoes, and most of all a need for Christ and the transforming work that only He can bring about both in the lives of individuals as well as entire communities and countries. It is often the sheer volume that makes these issues so overwhelming – there are over a billion people in India and about 70% of them live in rural villages where it is much more challenging to bring about change – but the diversity of areas that need to be addressed also take my breath away. I was greatly encouraged this week by a quote from Edmund Burke that I came across in some reading I was doing which says, “Nobody made a greater mistake than he who did nothing because he could only do a little.” That is a reminder I am striving to hold steady in my mind – in addition to the amazing thought that God longs to transform our feeble efforts into something that will make His name known among the nations.

Luke in particular has been struggling with illness this week. He is at a difficult age as he is very curious and far too much finds its way into his mouth. Just the other day I was bathing him (using a bucket and cup) and I turned to pick up the towel and in that split-second he had begun using the cup to drink the water that was remaining in the bucket. Of course, this water hadn’t been cleaned or filtered (both of which we must do to get it to a drinkable condition) and so it was one of the last things that he should have been ingesting. Even with Karuna being a couple of years older it was easier for the lesson about all the water being dirty (except for that which was coming directly out of the filter) and for that lesson to “stick”. In that way, it looks like it will be a blessing that the kids will be a couple of years older once we move back here permanently.

This has meant several long days at home with a sick child as well as a lot of time over the stovetop boiling everything that can fit in a pot and that could possibly go into his mouth. This has been much different mission trip for me (Melissa) as I have not felt like I’m doing anything much to advance the cause of Christ but rather am just trying to keep my family alive and reasonably healthy. This is also the case because I don’t know Bengali which has been a strong reminder of how important it is for us to work on learning as much Hindi as we can before we return. It has also been a good trip in that I have been able to spend a lot of time praying for the ministry here – something that it is so easy to neglect when it appears there is so much to do for the sake of the ministry.

The time I have spent at the school has been eye opening. In some ways, they are facing similar challenges to what we faced at ACHS in Tamil Nadu but in other respects the situation here is even more challenging. On the one hand, the students here are also poor and from uneducated families. However, the culture in south India is such that education is highly valued (many of the students I taught during my time in Tamil Nadu are in graduate school now even though they are the first in their families to be educated) whereas here there isn’t a strong vision for education or even much of an understanding of just how much education can do to improve lives for families and entire communities. Many of the students here treat education as a temporary diversion but assume they will eventually end up become paan pickers (paan is an addictive substance similar to chewing tobacco) like most of the adults in the area do. One of the greatest challenges facing Makunda is the need to attract good teachers especially as the school grows both in terms of the number of students they are serving and the grade levels offered. (At present the school is from kindergarten until 7th grade but one grade is added each year and eventually they will be a K-12 school.) We are also still trying to sort out if it would be best for us to serve at a hospital that has a school as part of the ministry so I could help out with teaching or if we should homeschool our kids as this would allow us to serve at a more remote hospital (without a school onsite) that are typically more difficult for EHA to staff.

As our time here winds down, I am getting more and more excited about our short time in Delhi when we will meet with the staff at the central office. We are hoping to get a better sense of the distinctive of the hospitals and projects within the EHA network and move closer to a sense of where we might be able to serve long term. We are probably going to make a trip back here in about four years to visit several hospitals that look to be possibilities and then narrow that list down even further so that we can spend a month working at one or two hospitals before we make the big trip back to move here.

This week has been a blessing for us as we have had relatively consistent electricity. It is amazing how helpful a ceiling fan can be in mitigating the heat. As you might have heard on the news, India is in the grip of a terrible heat wave and so if we don’t have electricity behind inside feels like being in an oven. It has also been a blessing because our neighbor has a TV and so seeing a bit of news has made us feel less disconnected from the rest of the world. Incidentally, as we’ve gotten to know people here I have again been astounded on how “in the know” people are all around the world about what is happening in the US. We are regularly engaged in discussions about the primaries in the US, the war in Iraq, the mortgage/credit crises – and people know enough to discuss these matters in detail. It makes me feel awful to think of how little we know of other countries political systems, economies and current events. I’ve made a note to myself to pay more attention to the BBC!

This will probably be our last email update from Makunda as we are going on Wednesday to Burrows Christian Hospital in Alipore (outside Silchar). This will give us an opportunity to see another EHA hospital as well as meet up with my dear friend Jodi and her husband Nelson who are flying in from Imphal, Manipur. We are so excited to see them and so thankful that they are willing to do this so that we can visit (ironically, we were here in India during their recent trip to the US) in person. We are about an inch apart on our map of India and so I would have been so disappointed to miss out on a visit when we are so close – over course, it’s not an easy inch to travel! Please be praying for us as we travel back to the Silchar area to begin creeping our way back toward the US.

We have learned so much during our time here and are leaving with a stronger sense of what type of ministry we want to be involved with long term so we are also excited to return to the US and get to share with many of you in person about where God is leading us.

Click on the Pictures to View the Gallery from Week 2 at Makunda

Just a quick post to let all of you know that we have arrived safely back in Rochester around 4 PM this afternoon. God blessed us with a good travel experience and the kids did well although they have both crashed for the evening. Please continue to lift us up in your prayers as we get over jet lag, get ready for graduation and move to Texas in the next four days! We’ll write more when we get a little more sleep. Just in case you were wondering…it seems that the server that was hosting our pictures has gone offline and so you might have gotten a page not found error when you clicked on the picture galleries. I moved all our pictures to another server and so they should be working again. Just let us know if you cannot view the picture galleries again.

Another week has passed and we now down to less than a week at Makunda before we leave here for Delhi on Saturday and then return to the US on Tuesday. It has been a good week at Makunda with time to talk with other families on campus and to get their perspectives on mission work in India.

Monday was an extremely busy day in the outpatient clinic where we saw 290 patients! Even with the extra help provided by the return of Dr. Vijay and Dr. Ann, we felt that we could hardly keep up with the extra number of patients who were here. I have to think that the patients must somehow know how many doctors will be working on a particular day and tailor the number of people who visit the clinic accordingly. Regardless, I thought seeing that many patients in a day did them a disservice and wore out the staff to the point of sheer exhaustion but it is so difficult to do anything else because how do you turn away so many people who have traveled anywhere from 2-8 hours for the chance to see a doctor? One of the things that we’ve talked with several of the healthcare providers here about was having nurses help see patients as well and then for them to refer more complicated patients to physicians so that the workload would be more manageable and so that each patient would get more than the 2-5 minutes we can give them at the current pace. However, it seems that in India that will require changing the expectations of many people because most patients believe that if they paid the money to be seen by a healthcare provider, they need to be seen by a physician in order to get their money’s worth. But the way that doctors here are stretched so thin because of the sheer number of patients that doesn’t look to be a sustainable model. Even in the U.S., many hospitals have discovered that nurses, PAs and nurse practitioners often do a better job managing chronic diseases and other common complaints than many physicians because they have more time to spend with patients and it is a better use of a limited resource. In many ways, almost 1/3-1/2 of our patients here could be seen and treated by a physician extender because so many patients come in with the complaint of sore throat or cough or stomach pain. Perhaps as the healthcare crisis here grows larger, people will be willing to change their expectations so that more of the population can get access to high quality care at an affordable price.

On Monday we also had a young girl in the ICU who we had admitted over the weekend for diabetic ketoacidosis. She was 11 years old and had spent the last two months being extremely sick at home and by the time she came to the hospital she was totally dehydrated and emaciated. When we did the initial sugar measurement it did not register on our glucometer because it was too high. Only after about 30 units of insulin and a day of rehydration did we finally get a glucose reading of greater than 500. She came from an extremely poor family and thus we admitted her over the weekend to help her family and her learn about her illness and to teach them about the importance of regularly receiving insulin to prevent a relapse of the condition that had brought her into the hospital. I was amazed by the education that this family received and the openness the father had towards the Gospel. Since we had several days with them, we taught the family how to give insulin injections themselves and how to store insulin so that their supply would last them about a month at a time. This family has no refrigerator and thus we had to give them another option for storing insulin at cool temperatures so that it would not be ruined. Here they have found that by using a clay pot half filled with sand and the other half filled with water, that they can store medicines at temperatures close to what you can achieve in a refrigerator. So part of this admission was spent teaching them how to create this refrigeration device so that they could store their daughter’s insulin. The admission along with the medicines she received cost greater than 3000 rupees (almost $100) but all the family could afford to give was 1000 rupees (about $25) and thus the rest of their care was written off as charity. I’m still amazed by how the hospital here is able to make a determination of the truly needy verses people who just claim to be needy so that they don’t have to pay as much. However, it seems that most of the doctors here are blessed with being able to delineate between the very poor and others who can afford to pay for their care (although I still have no clue on how to make that distinction). At least with this family it was very obvious that they were extremely poor because on Tuesday morning when we arranged for their discharge, they asked to be discharged early because they live about 20-30 kilometers away from here over a mountain and the father was going to carry their daughter the entire distance and so they needed time to get there before it got too dark. I could not even imagine a father having to do that for his daughter but they had no money for transportation and we did not have vehicles available to transport patients and thus this man carried his weak daughter for several hours until they were able to reach home. What was also meaningful to me about this family was the father’s openness in wanting hear about Christ because of the care his daughter received here and so we were able to give him a copy of the Bible in his language so that hopefully by the time they return for their follow-up visit in 1 month he will come back with more questions about how he can have a relationship with the living God.

Tuesday marked a day in which a significant change was made in the way that I will work here for the remainder of our time. We found that even though I was somewhat helpful in the outpatient clinic with seeing patients, it often took away time from some helpers in the clinic because I needed them to help me translate for patients with more complicated diseases. So it was decided I would spend my time primarily managing and working up the inpatients and then assist with the outpatient clinic as needed. So far this change of pace has been a good transition because the nurses in the hospital have more time to be able to help translate for me, I get to spend more time getting to know my patients, and with any extra time that I have while in the hospital, I’ve been able to work on developing some standardized treatment protocols for some common diseases that we see here at Makunda. So on Tuesday morning, I rounded on about 30 patients between long ward, male ward and the ICU and then went over case management with Dr. Philip since he is the senior physician on call with us this week. On Tuesday we had a patient in the ICU who was being managed by Dr. Shailini, our OB-GYN, who was pregnant and came in with a ruptured uterus and an intrauterine fetal death because she had labored at home for several days and eventually the contractions cause her uterus to rupture. Thankfully, Dr. Shilini was able to save the mom after she operated on her and repaired her ruptured uterus and removed almost 2 liters of blood from her belly. It is still shocking to me that there are still many moms here who die during childbirth because of lack of access to good medical care and lack of education. I talked with Dr. Ann this week to find out some of her thoughts on why patients wait so long before they finally come to the doctor and she had some interesting insight into this problem. Part of the problem she explained is lack of education regarding basic health literacy. Many of the people in the surrounding villages do not know how to differentiate between a patient who is very sick verses someone who is only mildly sick. A second part of the problem seems to be that many patients will often go to receive treatment from a local quack who masquerades himself as a healthcare provider and only when their interventions don’t work do they finally come to see a physician. By the time that they then come to a physician they are often so sick that there is little to be done except implore God to bring about healing because there is little we can do for them from a medical standpoint. Finally she explained that often women here do not get adequate healthcare because they need permission from their husband before they can come in to see a doctor. Often what occurs is a woman will go into labor and will labor for several days and when she finally decides that to go see a doctor for extra help, she first needs to find her husband (who is often working far from home to send the family money) so she can get permission from him to go/be taken to the hospital. Often women only get in touch with their husbands once it is too late or the husbands say no because they can’t afford to go to the hospital. In many ways the rights of women in rural India are very little in practice even though many rights have been granted to them through the law. For example, in this part of India, a woman cannot choose to have a tubal ligation for family planning purposes unless her husband also consents to the procedure and thus there are many moms who would like to have fewer babies but are unable to do so because their husband will not consent.

On Wednesday we admitted a 26 year old lady who came in unconscious. She is a mother of four children, all under the age of 10, who had been ill for several days when her family finally brought her into the hospital once she became unresponsive. When we first examined her it was very clear that she had some type of central nervous system infection but the problem was in trying to delineate what type of infection she had so that we could treat her appropriately. The two major CNS infections we see here are pyogenic meningitis (bacterial infection of the covering of the brain) or cerebral malaria from severe falcipirum malaria infection. We checked for malaria with a rapid diagnostic test which came back negative but we still ended up treating her with both IV antibiotics for bacterial meningitis and an artemesin derivative for malaria infection because we couldn’t afford to take the risk of the malaria rapid test being negative when she might have really had cerebral malaria. She responded after about three days of IV medications with some minimal movement and response to commands but as she gradually came out of her coma it became clear that she is totally paralyzed on the left side of her body. Seeing that she had a stroke associated with her CNS infection, we had to revise our diagnosis once more to TB meningitis with associated endarteritis. So five days later we were finally able to start her on anti-TB medications. Throughout the rest of this week, she has gradually become more and more awake but the sad reality is that it doesn’t look like she is getting any of her function back on the left side. Her mom has been in tears many times when we have talked with her and I’ve prayed with them asking God for healing. If God does not allow her to regain at least some function back on her left side, we will have a mom, age 26, of four children under the age of 10 who cannot take care of her family because half of her body doesn’t move anymore. Please join us in praying for her recovery and for her family to learn of the love of God in all circumstances through this difficult situation.

Wednesday also brought two of the most difficult and heart wrenching cases I had yet seen at Makunda. A lady brought in her 1½ year old son to the outpatient clinic and from our first look at him we knew that something was terribly wrong. Even though this baby was 18 months old, he weighed a mere six pounds. He literally looked like a skeleton covered with skin. He looked like the many babies you see pictures of from famine stricken parts of Africa who die of starvation. This baby had severe protein energy malnutrition and weighed less than 25% of his expected body weight. He had a condition that we term marasmus. We immediately asked that this mom admit the patient to the hospital because we needed to sort out what was going on with this baby and start refeeding him. After admission, we started to learn more about this baby and his tale of woe during his young life. Two months after he was born, his mom passed away from some sort of infection and thus for the next year his father took care of him alone. His father was completely unprepared for the task of taking care of a baby and didn’t know how to feed him or take care of him well. So over the course of that year he gradually lost weight and became severely malnourished. Then about three months ago, his dad went away for a couple of days for work and left the baby with a relative but his dad acquired some type of fever in the jungle and died also. So finally the baby came into the care of his aunt and for the last three months she had been trying to help him get better by feeding him again but with little success. Finally out of desperation she brought in the baby to see if there was anything we could do for him. This was an extremely difficult patient for me because he was the same age as Luke and I just could not imagine something like this happening to him. This baby can barely hold his head up let alone walk or talk. In the hospital we started the baby on a high calorie refeeding diet and have gradually started to increase his feedings to prevent the complication of refeeding syndrome. Initially the aunt just wanted some medicines to take home with her because she had her own family to take care of. So I talked with Melissa and we agreed that we would take over his care until the time we left if the aunt was unable to care for him. So the next day we made the offer to take care of the baby for her but by then she had realized the gravity of the situation and agreed to stay with the baby in the hospital until he started to regain some weight. There are several issues that came to mind as I’ve been taking care of this baby. One was the realization that he lived less than 2 km away from the hospital and yet his situation still became this desperate. Did the dad not know he could access care at the hospital free of charge if he had just brought the child in? Why did none of the other relatives take an interest in the condition of this baby earlier so that things didn’t have to get this bad? How can we more effectively reach into the villages near the hospital so that we improve their basic understanding of health and more importantly transform them with the gospel so that people realize that lives are important and valuable? The other thought that came to mind with this baby was how desperately India needs some type of child protective service. In India, there is no governmental agency charged with protecting the welfare of children. No matter how poorly children are treated by their parents, there is nothing we can do from a legal perspective to remove that child from that home. Even if we could try to file a case in court, the legal system here takes years to work and thus most of these kids would suffer years of abuse or neglect before something happened from a legal perspective. There is also no system in place to care for children who are removed from their parents home or who have no home to begin with. There is no foster care system or formalized governmental adoption services to provide placement for children taken from families and thus part of the reason for not wanting to take children away from their parents is because they cannot offer a reasonable alternative. The state of child welfare in India is still quite sad because there are literally millions of children here who are orphans (I believe from the last statistic that I read, India has the largest number of orphans in the world – around 22 million) but almost no one to adopt them. India as a society is still very opposed to adoption because of social norms and the influence of Hinduism. There is little sense of social responsibility because according to Hindu philosophy the life that you live now is a consequence of the life you lived in your last incarnation. Also in Indian culture adopted kids are looked down upon because there is the issue of arranged marriage and it is difficult to marry off kids who are adopted because no one quite knows what type of family they came from. For a country with such a problem of orphans and abandoned children, you would think the government would be more willing to allow for things like international adoption but that just isn’t the case here. Because of nationalistic pride and not wanting Christians to adopt Hindu and Muslim babies the government makes it extremely difficult for foreigners to adopt Indian children which is why you see very few adopted Indian babies in America as compared to Chinese, Russian and Central American babies. The one advantage we have with this issue is that because I have retained my Indian citizenship and am of Indian origin it should be far easier for us to adopt children when we come back as opposed to if we were both non-Indians living here. Thus our hope is that once we return to India we can add another 3-4 children to our family through adoption.

The difficult second case was a woman in her fifties who came in with the worst skin condition I had ever seen in my life. She had first come to the hospital three months ago with some type of skin condition that causes blisters to form on her body which would then rupture and get secondarily infected. She refused admission the first time we saw her three months ago and just went home with some antibiotics to treat her secondary infections. She returned for follow-up and you knew that she was very ill and ashamed because she kept almost her entire body covered with her sari. When I examined her she literally had blisters covering her body from her head down to the soles of her feet. My clinical diagnosis was that of pemphigus vulgaris because of the hundreds of blisters she had on her body. It was so painful for her to even walk because of the blisters on the soles of her feet and we pleaded with her to get admitted this time but her family refused again. Her daughter who came along said that she could not stay with her mother during the hospitalization because she had her own family back at home and in order for a patient to be admitted to the hospital at least one attendant must stay with them because we don’t have enough staff to care for patients who have no family members with them. So we sent this lady home on immunosuppressive medications and antibiotics and prayed that she would get better so that they would see the power of Christ at work. I prayed several times that day that God would give me the faith to pray like He did when he or the disciples saw the lepers and just by his touch they would be healed.

I was on call again on Wednesday night and it was not too busy of a night because I only had to go in once and then just answer a couple of phone calls from home. Morning rounds on Thursday were horrible because of a problem we have in the hospital of a large number of maggots falling from the ceiling onto the male ward, isolation ward and maternity ward. I can take most things in stride but for some reason I cannot stand worms and things that look like worms because in the past I’ve had some horrible allergic reactions when they have touched my skin. So on Thursday morning when I started rounding on patients I got this feeling that something was crawling on my neck and I swatted at it and lo and behold it was a maggot. A couple more minutes went by and then I noticed something moving in my hair and I brushed it off and it was another maggot. I figured then that something was wrong and looked around at the ceiling when I noticed that there were hundreds of maggots hanging from the ceiling on a silk thread that they seem to be producing to facilitate their journey from a nearby tree to the ground. I immediately went outside to see where they were coming from and noticed several trees outside that were covered with thousands of these worms and the webs they had spun in their descent down to the ground. The nurses sure got a laugh at the sight of me jumping each time one of these maggots fell on my hair or down my shirt. By the end of the morning I decided to just round on patients outside the wards because I couldn’t stand it anymore. Thankfully I talked with Dr. Ann about our maggot problem and she promptly took care of it by calling in some workmen to come and cut down the trees with the worm problem. Since then we have continued to have problems with these maggots crawling all over our patient beds and floors for the last three to four days although their number has decreased steadily day by day. They always seem to show up when you are doing something important as well because I saw another one crawling into my sterile field before I was getting ready to do a lumbar puncture and there was news of another one that crawled on Dr. Shilini’s surgical scrubs while she was in the midst of a delivery! I’ve been okay with the lack of running water and electricity but these worms nearly drove me mad! Thankfully the problem seems to be taken care of now by the grace of God. Thursday also marked the day that Dr. Harry and his family went away for a couple of days to a nearby convent for their son’s first communion. Because Dr. Ann and Dr. Vijay were busy doing multiple surgeries on that day we were really unsure as to how we would go about seeing our typical volume of patient with just two or three doctors in the outpatient department but God was gracious and provided two days of bundh (or strike). Strikes are very common here in India and they work much differently that they do in the US. When a strike is called here nothing functions for that day. Thursday was an all Assam bundh which meant that the people who organized the strike would not allow anyone to travel on the roads. This meant that most of our patients who come from far away were not allowed to travel. If someone did try to travel on a strike day, the strike organizers very frequently stop the vehicle and destroy it. Friday was an all India bundh which was organized to protest the high cost of commodities and oil in India. Dr. Philip was telling us that often when they really needed a day of rest after toiling away for days without a break that those would be the days that God often provided us with a bundh so that far fewer patients would show up to the outpatient clinic. I think on Thursday we had about 100 patients and on Friday we had 76 patients. On Thursday evening one of the retired staff members from Makunda who had worked here for almost 30 years invited us to his home and we were able to enjoy some good conversation with them as we learned more about how Makunda ran when it was run by the Baptist Mid-Mission. Apparently a lot more agriculture work occurred on campus here during that time because there were quite a few leprosy patients who lived at Makunda and they were able to tend to the fields and maintain the land here (almost 350 acres). On Thursday evening because we finished with clinic early we were able to walk to the market as well to do some weekly grocery shopping. The markets are open here on Monday and Thursday and most of the local farmers bring in their goods on those two days for sale. I took quite a few pictures from the market and so hopefully on our next post I’ll be able to put up some of those pictures to that you can get a better idea of life here.

On Saturday we caught quite a bit of the backlog from two days of strike and so we had about 180 patients on Saturday, considerably more than the 120-140 patients we typically see on Saturday. We also had two very sick patients come in. One was an 18 year old girl who had started to have severe breathing difficulty around noon followed by four episodes of large volume stools. Her family had tried to have her treated by a local village healer but he wasn’t able to do much for her and so she came into the hospital. By the time we examined her, it was very clear that something was terribly wrong with her. Her heart rate was in the 160s and her oxygen saturation was around 79% even with oxygen going full blast. Her pupils were both constricted down which made us start thinking about whether she had ingested some sort of poison. The two leading causes of suicidal death here are organophosphates (from fertilizer) or rat poison. What didn’t fit with organophosphate poisoning was how fast her heart rate was because we typically expect a slow heart rate with organophosphates and not a fast one unless she had ingested multiple poisons. We repeatedly asked her and the family if she had consumed any type of poison and they adamantly denied it. Then she started vomiting blood and we knew things were taking a turn for the worst. We put in an NG tube and tried to wash out her stomach in case there was any poison remaining and in the process removed about 2 liters of blood from her stomach. She stayed at the hospital overnight and one of the relatives finally informed us that she had indeed consumed some type of unknown poison. The next morning we transferred her to a government hospital because it is the policy of this hospital not to take care of medico-legal patients (like suicides or assault victims) because of the problems that it creates with the government. Often times the government agencies tell the hospital that they are not an accredited center to treat medico-legal patients and when they have cared for them in the past there has been a lot of time that the physicians have had to spend in court testifying and giving depositions. Thus the leadership here made a decision to transfer all those patients, once stabilized, because of the resources they consumed from the hospital staff. Saturday evening was a fun evening because we borrowed the hospital projector to show the Star of Bethlehem DVD (www.starofbethlehem.net) to the staff here. That was a special treat for them because of how few of them ever get to watch movies and so we had a full house for the showing. Some people had trouble with the accent of the speaker but they still got the gist of the presentation and many were encouraged in their faith.

Sunday was a really fun day to relax, rest, and enjoy time to worship with the believers on campus. After the worship service, we had lunch at home and then Dr. Philip and I went to the hospital to round on patients before we returned home to go for a picnic with our families. We picked one of the many areas around the campus to go outside and to enjoy some tea and biscuits with Dr. Philip’s family, our family and Dr. Shailini. Then Dr. Shailini treated us to a wonderful dinner of mushrooms and noodles that she had brought from her home in Meghalaya. While Shailini cooked the meal for us we went into town to call Melissa’s sister, Kris, to wish her a happy birthday and we talked to Melissa’s parents and Christo’s parents and tried to catch them up on life here.

Please join us in praying about several matters during our last few days here:

1. Pray for travel safety as we begin our long journey back to the US. On Thursday morning (Wednesday night US time) we will be traveling to Silchar to pick Jodi and Nelson up at the airport. Jodi is Melissa’s close friend who spent a year with her in south India. Jodi and her husband Nelson now minister at a children’s home in Imphal, Manipur which is about a 20 minute flight from here. We will spend Thursday and Friday visiting with them and seeing Burrows Memorial Christian Hospital, another EHA hospital close to Silchar.  On Saturday we will fly to Calcutta and then on to Delhi.
2. Please be praying for our health, especially for Luke. He has been ill with vomiting and diarrhea for the past few days which have made for long days for both him and Melissa as she cares for him. Please pray for him to stay well during our last few days here and for continued health for the rest of us.
3. Please pray for there to be an improvement in the adoption situation in India and for the government to allowed more children to be adopted into good families.

Sorry for the long post. Our internet access is really limited and so I’ll put all of last week’s post in one big post. There are also some pictures from our time at ACA and in Kolkata that can be found on the bottom of this post.

It’s hard to believe that another week has passed and that we are more than half way through our stay here at Makunda. This has been a challenging week as we have thought much about what medical missions should look like and how to balance the demands of work, ministry and time with family.

Monday of this week was an exciting day because some of the other physicians who work here had come back from their vacation. Dr. Shilini, the OB/GYN doctor returned to a full labor ward and Dr. Harry and Amanda McNaughton (missionary physicians from New Zealand) returned from their trip to Shilong. Dr. Shilini stays in the same house we are staying at and so it is great to have some extra company in the house as well as someone who can communicate with the lady who comes in to help with household chores and meals. We are finally able to communicate with her effectively about things around the house with Dr. Shilini serving as translator. Dr. Shilini also brought along with her a much unexpected treat for us and the kids – strawberries!! Apparently, in Shilong, there is an annual strawberry festival and so she had brought some extra to share with us and it felt wonderful to taste some delicious strawberries again. Dr. Harry and Amanda and their three kids have been here for about four months and are planning on being here until November of this year. They have three wonderful kids, Jillian, Andrew and John who have been great for our kids to have some older kids to play with. Dr. Harry is a neurologist and Dr. Amanda is a pulmonologist. Dr. Harry has tried to work in the hospital and OPD as much as possible while Dr. Amanda spends most of her time homeschooling their children and helps out at the hospital when she gets free time.

With Dr. Harry and Dr. Shilini back along with Dr. Ann and Dr. Rockfuii it seemed like we had so much extra help on Monday! Dr. Harry was the senior physician on call for this week and served as back up to Dr. Rockfuii and I who have taken call every other night this week. Dr. Rockfuii took call on Monday and my first day on call was Tuesday. Tuesday morning also marked the first time we had internet access here and that was quite a frustrating experience to say the least. The man who runs the nearest internet access site lives about two kilometers from here but because it is a government facility, the access to the place is erratic at best. The café is open from 10-4 daily but that time is often the most inconvenient for the hospital staff because we have to be in clinic or in the hospital during that time. The other problem is that even though those are the advertised hours, if you have not made prior contact with him to confirm that he will be there, there is no guarantee that anyone will be there to meet you. The other issue is that this man often takes vacations and thus he was off all of last week except for the hour he came in to let us get on the internet. We did manage to check some of our e-mail and post on the blog but getting to upload anything was maddening because the connection would drop after each picture was uploaded!

During the day on Tuesday we also had a patient who was about thirty and presented with what he thought was a fracture that had occurred apparently eight months ago. He works as a mechanic and while he was walking he suddenly felt his left femur break and because he was poor he just left it alone hoping that it would heal by itself. Finally because the area on his left thigh kept enlarging in size he finally came to the hospital to get an X-Ray. When we examined him he had about a 20 cm mass in his left thigh that was hard as bone. We took an x-ray and it confirmed what we suspected – a very large osteosarcoma of the left femur that had completely destroyed most of the femur and had started to eat away most of his pelvic bones on his left side. We told him about the tumor and that his prognosis was not good at all. There is no one in this area within 300 kilometers that can do a hemipelvectomy and even if it could be done we still don’t know if that would remove the tumor entirely. Besides a man who couldn’t come in for eight months because he couldn’t afford to get care for a fracture probably couldn’t afford the cost of a hemipelvectomy. So at the age of 30, this man will pass away from a tumor that could have been dealt with if he had just presented earlier.

On Tuesday evening we went to greet the McNaughtons at their bungalow on campus. Two of their three kids had already fallen asleep because they had made a 15 hour overnight bus trip the day before and none of them had gotten much sleep on that trip. Getting to talk them was extremely refreshing and it was great to hear their perspective on life here and how they have managed to adjust. They were also able to give some advice on where we needed to go to get some money exchanged since we had run out of Indian rupees and needed to exchange our traveler’s checks. Unlike other parts of India where there seems to be a bank at the corner of every street, the nearest bank where we can get traveler’s checks exchanged is almost two hours away! So the McNaughtons graciously lent us some money to get us through another week before we will finally be able to get a vehicle to take us to the bank so that we can exchange money. I think that is what I find often frustrating about India has been how even the simplest things take a half a day to a day to get done here.

Tuesday evening was also my first night on call and it started out with sadness. We had a four day old baby who was delivered at home and came in extremely apneic and lethargic. The baby looked jaundiced and had a very distended abdomen and barely moved when I examined him. This was the first baby for these new parents and like most of the other people who live in this area, they did not know when to seek proper medical help. Apparently the story was that by around noon of that day the baby had become extremely lethargic and would not feed anymore but they only decided to bring the baby in about eight hours later. I admitted the baby that evening around 8 PM and I was not sure if the baby would make it more than a few hours. We could not get a blood pressure on this baby but the nurses somehow managed to get a peripheral IV line so that we could rehydrate the baby and start the baby on antibiotics. I talked the case over with Dr. Harry and we started the baby on the strongest antibiotics we had (third generation cephalosporins) and I sat at the edge of the bed and prayed for this baby to survive so that his parents would know that God was working in this place and through that they would come to know Christ. But God didn’t answer our prayer this time and by 11 PM the baby had died. I questioned why God had allowed this baby to die but God kept reminding me that I do not know His full plan and that I must trust him. Perhaps it was a lack of faith as I prayed…I don’t know but it was hard to see my first baby that I had taken care of die. The rest of the night was fairly uneventful for me because the nurses weren’t able to get a hold of me on the cell phone that they assign me on the nights I’m on call. The campus phone lines are still not working and thus the only way for the nurses to let us know if a patient is not doing well or if there a serious patient who needs to be admitted overnight is for them to give us a call on the cell phone. However the problem here is that cell phone coverage is erratic at best and most of the times the calls will get cut half way through the phone call. So then the nurses send a driver from the hospital with the vehicle about 1 km to the housing area to bring us the chart and if we think it is serious then we return back to the hospital with the driver. So on Tuesday night because the nurses were unable to get a hold of me, they sent the vehicle straight to Dr. Ann for their consultations.

Wednesday was more of the same routine with patient rounds in the morning, OPD during the day and then some time with the kids and Melissa if I got home early enough. On Wednesday, Andrew, one of Dr. Harry’s children came over with a treat for us – watermelon. I had never truly appreciated how great a watermelon tastes when you feel completely parched after sweating all day. Dr. Harry’s children have been a big blessing to our kids because they come over and read to our kids. Karuna has grown quite fond of Jillian (who is 12) because she reads to her every time they get together. Wednesday also marked the arrival of Dr. Philip and his family from Raxul in Bihar where they had been working at Duncan hospital for the past five weeks. Dr. Philip was our initial contact with EHA and Makunda and he helped us tremendously in arranging the details of this trip to make our journey here possible. We met Dr. Philip two years ago in the US when he was presenting at an endocrinology conference at Harvard. I had met Philip and his family many years ago because Dr. Philip’s dad, Dr. Finny, was the person who led my dad to Christ. Dr. Philip is married to Leeja and they have two children, Vinay,6 ½, and Rohan, 13 months. Dr. Philip and his family have been visiting other EHA hospitals recently to figure out where God is leading them to work next. Dr. Philip finished his specialization in endocrinology before coming here about a year ago. He has a heart for working at a hospital where he can teach and work with junior doctors and thus they have been looking for a larger hospital with a postgraduate training program. It sounds like they will most likely be going to Raxul to work at Duncan Hospital after the great experience they had there. Duncan hospital is the largest of the mission hospitals for EHA and they have a family medicine residency program so that he can continue to focus on teaching while working there. Leeja is also a physician who has finished her training in anesthesiology and they hope that she will be able to work at least part-time to help out at the hospital in Raxul.

Thursday was my second night on call and it was an extremely difficult night for me with three deaths. The first was a 3 month old baby we had admitted in the afternoon who was having significant difficulty breathing. When we felt his hands and feet they were already starting to get cold and pale. We started the baby on the strongest antibiotics we had and we checked a blood sugar and it was over 500. We were not sure but perhaps the baby was in diabetic ketoacidosis and so we sent for urine ketones but when we put a catheter in there was not a single drop of urine for us to do the test. By six PM, that first baby had died. The second baby was a girl who had been sick for several days with respiratory distress and had been treated at a government hospital in a nearby village. She had been at that hospital for four days but was not getting better and so the parents asked to be transferred to Makunda hoping we could do more for this 10 month old. She was initially admitted to the long ward (female) but when I saw her in the evening she looked quite sick and was breathing over 60 times a minute and so I transferred her to the ICU. We tried our best to give her a fighting chance by giving her everything we had available including antibiotics, our oxygen supply which runs at a maximum of 2 L/min, and drugs for heart failure because she had decompensated from the pneumonia. Right after I got home from evening rounds I got the call that she had passed away around 11 PM. The mom was sleeping when the baby passed away and so the relatives requested that we not wake her mom until the morning (the mom had been up for several days watching over her daughter) so that she would have some rest before she found out the horrible news that her daughter had died. Another experience with death. The third one was probably the most difficult for me because I had met this man several days earlier. Two days before in the outpatient department I had met an 82 year old man who was complaining of a cough for 3-4 days. When I examined him then he was quite comfortable and the chest x-ray was not very impressive and so I thought we could start outpatient oral antibiotic therapy for him. He returned two days later very short of breath and tired. We admitted him right away to the ICU that afternoon and started him on IV ceftriaxone. I prayed that this man would make it. As the evening progressed he became more and more short of breath and no matter how much oxygen we gave him and the multiple nebulizer treatments he just was not responding. The nurses finally called me in around 4 AM to see the patient and by the time I got there he was hunched over and gasping for air. I felt totally helpless and tried my best to help him with what resources we had available. There are no ventilators here and so that wasn’t an option. I tried to get a blood pressure on him but it was too low to measure. So I started the patient on dopamine as a last ditch effort to save his blood pressure and hopefully keep him from tiring out further but to no avail. I stood there by him with his wife and son helpless and praying that he would pass away with a minimum of pain. He passed away 30 minutes later but there was nothing I could offer him to decrease his suffering as he died. There is no morphine available here to help relieve the pain and air hunger patients feel near the end stages of their illness. It was tragic to watch this family grieve. His wife wailed with such passion that most of the patients in the ICU woke up. I was at the brink of tears because there was nothing I could say to comfort her because I didn’t know her language. There was nothing I could offer but to stand beside her as she cried. The third and final death of my second night of call.

This experience also reminded me to write about another quirk about this hospital – the lack of narcotic availability. Because opioid abuse is so common in this part of India, the government has put a restriction on which institutions can have access to opioid compounds like morphine or fentanyl for pain relief. In order for a hospital to be able to have access to opioid compounds, they have to apply for a special license from the government. Of course a license from the government requires cutting through multiple layers of bueracuracy and even though they have submitted the application to carry opioid substances in the hospital for pain relief, it is still sitting in the office of some official waiting to be authorized. So for now the most we can offer for even the patients with the most severe pain is tramadaol (Ultram). I guess the one blessing is that it cuts down on patients who are narcotic seekers because there are no narcotics available here. But the lack of access of opioid compounds severely limits the pain relief that we can offer to many of our patients including people with severe burns, postoperative pain, or pancreatitis. Speaking of severe burns, my second night on call also brought with it two adults and a child with burns over about 15% percent of their body from a kerosene flash fire. Even though they came to our hospital we had to turn them away because we didn’t have enough staff overnight to be able to manage their pain adequately and to provide them the fluids necessary for them to survive their burn injuries. We had to ask them to go to another hospital with more facilities which probably meant a 2 hour drive over roads that are controlled by terrorist groups at night.

Friday brought along with it another busy day in the OPD and even though Dr. Philip was back Dr. Ann was away along with Dr. Vijay (who had traveled to Vellore this week to teach at the medical college for a week). I think we ended up working till about six PM to get thorough the patients in the outpatient department on Friday. We had two unfortunate cases of people who had waited long after a fracture had occurred to finally seek medical care. One was man in his twenties who had been injured in a truck accident about two weeks before who came in with an infection of the injuries in his legs. We took an x-ray upon admission and it showed that he had broken his fibula in two places. We admitted him to get IV antibiotics until his infection could cool down. The second was a lady in her fifties who fell at home 22 days prior to coming to the hospital and had broken her leg to the point that her bones had come out through her skin. She didn’t get access to treatment and thus when she came in three weeks later her leg was completely infected, purulent and emitted the worst odor I had smelled in a while. It looks like she will have to be referred to another hospital so that they can do an above the knee amputation since it looks like the limb is unsalvageable.

On Friday night, the McNaughtons invited us for a special treat with dinner over at their house along with Dr. Shilini and Dr. Finny’s family. Harry’s specialty is making bread rolls from scratch and so we enjoyed some freshly baked bread along with fresh lettuce that they had grown in their garden…what a delicious treat. We even got to drink some great tea while we were there. I think what is funny about this place is that even though we are in the midst of several tea gardens in Assam it is almost impossible to find Assamese tea here while we used to find plenty of tea grown in Assam in the US. That evening we all entertained ourselves with charades with their kids and talked about our home countries. Amanda also filled Melissa in on her perspective on homeschooling and especially what challenges have presented themselves as they have taken their schooling “on the road” during their time in India. Did you know that in New Zealand the government gives parents money if they choose to home school them?

Saturday was not a very busy day in the OPD but because we were short-staffed it still took us until about 4:30 to get finished with everything. Thankfully no one died on Saturday night which was a blessing for me because I’m not sure I could have handled another day like the one I had on Thursday. I was called into the hospital twice. Once to admit another baby in respiratory distress who I started immediately on the strongest antibiotics we had available because I did not want a repeat of what had happened the two times before and by the grace of God this baby did survive and was discharged a couple of days later. I also admitted another man who looked like he had evidence of a right sided stroke and so I sent them the next day about four hours away to Silchar to have a CT scan done.

I was pretty tired on Sunday morning after my night on call because I got several phone calls overnight about patients but a bucket of cold water on my head helped to wake me up enough to give the sermon for the campus church that meets weekly. I gave a message about meeting the spiritual needs of our patients when they come in for physical complaints. We used as the sermon text John 4, the story of Jesus talking with the woman of Samaria. It was a great passage to illustrate how Christ sought to take this lady from her physical need for water to her more important need of living water that comes through Christ alone. I came to the conclusion at the end of the sermon that the greatest amount of service to man divorced from sharing the gospel with them is a disservice because we are ignoring the most important need that man has which is his separation from God. After the service we had lunch with Dr. Finny and his family followed by the weekly soccer game at the school playground. This week it was the nursing staff verses the nursing students and the students won 2-0. It seems like there is now a streak of students winning compared to staff…hopefully next week’s match will reverse the trend.

On Sunday, Dr. Shilini, Dr. Harry and Dr. Amanda went to a tea garden nearby here to provide healthcare for the workers there. Dr. Shilini’s response after going to provide medical care for the workers in the tea gardens was that if we thought the patients in our hospital were poor, they now looked downright middle class compared to the workers in the tea gardens. Most of the workers there are given about 150 rupees a week (about 4 dollars a week), one or two kilograms of rice, daal (lentils) and some vegetables. Because of their limited food supply they are often extremely malnourished and because of the working conditions they are often very sick by the time they get to the hospital. Dr. Shilini said there were many moms who were already well into their pregnancy who had never had an antenatal checkup and almost none of them were on iron or folic acid even though almost all of them are anemic. We had just admitted a man from the tea gardens about four days ago who had a hemoglobin of 3 (normal is 12-14 in a man) almost completely from just iron and B12 vitamin deficiency! Dr. Harry and Amanda are trying to also identify patients in the tea gardens with malaria before it becomes severe to the point of causing cerebral malaria. To facilitate this they have learned to look at peripheral smears for malaria and thus are able to make the diagnosis without a serological test which then allows them to care for patients that have almost no money for testing. Sunday evening marked the end of one more week and we are very glad for our time here in learning about medical mission work in India and how we can best prepare ourselves to return. Dr. Rockfuii and I had a teaching session on Sunday evening to help us learn some more about medicine here and we are hoping to have sessions like that every other day to help us learn some of the intricacies and nuances of practicing medicine here.

Thank you for your continued prayers as we have worked here. Please be in prayer for us as we continue to praise God for not letting us or the kids get sick and as we get ready to return back to the US in about two weeks time. Please also pray for us to have a very productive meeting at EHA headquarters in New Delhi on May 12th so that we can better learn how to prepare ourselves for work in India during residency as well as develop a stronger sense of which direction the ministry is moving and what hospital(s) might be a good fit for us long term.

Along with this post, we’ve put up some pictures from our time at ACA and from the time we spent in Kolkata. We’ll try to have more pictures up from Makunda when we get a little bit more time on the internet.

Click on the Pictures to View the Gallery from ACA

Click on the Pictures to View the Gallery from Kolkata

We have not had internet access for more than a week (for that matter no electricity or phones) and so I’ve been journaling every couple of days and now that we have are at an internet café I’ll post the journal entries under the day they were written and thus you’ll see several entries from the last week…just didn’t want to confuse anybody. You can start reading the new entries from the one titled “ACA” and then work forwards up to the latest entry titled “The Weekend.”

On Friday we conducted the OPD in breakneck speed as usual and topped the 215 mark. We had several TB patients admitted on Friday including two patients who had been having fevers and night sweats for over a month. Both were young patients: a man in his twenties and another in his thirties. They had both lost a lot of weight in that time and when they arrived at the hospital they were gaunt and frail. We started them on a direct observed therapy protocol and will discharge them in a couple of days once their fevers recede and they can be followed up by a health care provider in their local villages.

On Friday we also admitted a nine year old boy who had diarrhea for two days and then suddenly developed flaccid paralysis of his upper and lower extremities. Originally we thought it was polio but the parents were sure that he had received a full course of the vaccine. Our next working diagnosis was Guillain-Barré syndrome because of his history of weakness. About 20% of the acute flaccid paralysis cases at Makunda are Guillain-Barré syndrome and the rest are polio. The parents were understandably shaken and in tears almost any time we talked with them. We decided to run some basic electrolytes which showed severely decreased potassium levels. By the next day, after we had given him potassium, he was like a completely different boy with full ability to walk and move around. Praise God for a great recovery for this child!

One of the other things I’ve been so surprised by during our time here has been the frequency at which I’ve heard patients ask the physicians here for an abortion. Of course, Makunda does not do abortions and the physicians counsel the mom to deliver the baby and then give the baby to us and we’ll provide the baby with a home. Abortions are illegal in India but there are apparently still quite a few doctors that do it for money that is exchanged under the table. In India it is also illegal to inform the parents of the sex of the baby because so many families here choose to abort if the baby is a girl because of the lack of value for females within Indian culture. Yet it still happens and there are more boys born than girls in India. I guess the one difference that I see between the US and here in terms of abortions is the types of people that ask for abortions. In the US most of the abortions tend to be unmarried, single females while here they tend to be married women. Usually these are women who already have several kids and do not want to have another one. I’m not quite sure why these moms don’t choose to get a tubal ligation rather than wanting to abort when they get pregnant but perhaps it is partially due to lack of education and partly due to the fact that in India there must be consent from both the wife and husband before a sterilization procedure can be done.

My role in the outpatient department and hospital has also started to change. Because of the sheer volume of patients I’ve started seeing patients with some help in translation from either another physician or nurse. This experience has made me realize how much I rely on obtaining a good history to determine the diagnosis. I’m learning to be better at my physical exam because that is often my most reliable source of information to help me understand a patient’s condition. I’ve also started taking a more active role in the hospital and now frequently round on 30-45 patients with the help of the nurses and try to make treatment decisions for the patients whose cases are uncomplicated and then filter out the very sick patients so that Dr. Ann can round on those when she gets done with her other responsibilities.

On Friday night, Dr. Anand and his wife invited us for dinner. We enjoyed some great Indian food and Karuna and Luke enjoyed playing with Hannah and Deborah, their children. We also got to spend quite a bit of time talking about the history of Makunda, how Dr. Vijay and Dr. Ann ended up here, and about EHA as an organization. It was good to hear about EHA’s emphasis on reaching the poor and marginalized with good quality healthcare while at the same time not separating it from the good news of Christianity. We were also excited to hear about the many different types of hospitals in EHA’s network that all seem to focus on different areas of ministry and work with different people groups. There are hospitals that focus primarily on rural work with an emphasis on pioneering missions and other hospitals that are larger with multidisciplinary practices that allow for postgraduate medical training programs. We are still praying about the type of practice we’d like to join once we finish residency in emergency medicine but it seems like EHA has the right vision for reaching India. We are eagerly looking forward to meeting with some of their administrative staff when we travel to New Delhi on our way back to the U.S.

Saturday marked the departure of Dr. Ancily who returned to Tezpur to continue her family medicine training there. She will be sorely missed because of her great attitude, patience and willingness to teach. She had come to Makunda for two weeks because our OB/GYN doctor and a neurologist were both away during that time at other hospitals. Before starting her training at Tezpur she had worked for seven years in several other North Indian hospitals and so it was great to get her clinical insight into many difficult cases. Because of her departure, the clinic on Saturday felt even busier than normal even though there were only about a 150 patients. The clinic goes for six days a week with only Sunday off. On Sundays, there is no outpatient clinic but we still go in to round on all the hospital patients and take care of any new admissions.

We had three c-sections on Saturday afternoon along with another case of cerebral malaria. This man was infected by both strains of malaria (Plasmodium falciparum and Plasmodium vivax). He was delirious and agitated when he arrived at the hospital and so we had to give him quite a few sedatives and physically restrain him to keep him from hurting himself. We also had another patient admitted to the ICU with extremely high fevers who was negative for malaria infection. After further testing, it was discovered that she had typhoid fever…the first case I’ve seen since starting medical school.

Melissa and the kids walked up to the hospital on Saturday afternoon because we were hoping to be able to get to a nearby village to get internet access. However, we found out that the internet connection was not working because we’ve not had electricity for more than a few hours for the past week. In some ways the lack of connection with the outside world has been probably the most difficult adjustment we’ve had to make during our time here. We have no idea what is going on in the rest of the world. We have not been able to call our families since we arrived here because on our first night here there was a bad storm that had taken out all of our phone lines. In some ways the lack of connection to the rest of the world has also been a blessing because there are no phones to answer, no e-mail to check, no news to find out about. It has given us more time to do other things but it has definitely been an adjustment.

Sunday was our first partial day off. In the morning the kids went to the Sunday school at the school with the hostel students while I went to round on patients. Around 10 AM we started the campus chapel service. It was good to hear about how God has been working in the lives of the staff and to hear the message about God’s love in Christ Jesus. Later that afternoon was the weekly soccer match. The last two weeks the hospital staff had won against the school staff. This week that was not to be so. The school staff which mainly consisted of sixth and seventh grade boys and a couple of teachers thoroughly put the hospital staff to shame and beat them 2-0. Christo played for the first half of the game but after sweating like he had never had before decided to call it a day and let someone else substitute for him. The game was well attended with almost 200 people watching from the sides! Apparently it was quite a bit of entertainment for this area because many cars and bikes that were traveling on the road next to the field stopped to watch the game! We think the school team definitely had the advantage because the boys from the school had way more stamina than the 20-40 year old men playing from the hospital staff.

After the game we walked to the nearest village to see if we could get phone access to make an international call and to our delight the phone exchanges were functioning again after the power had returned. We got to talk with both Christo’s and Melissa’s family for about 10 minutes each and they were both glad to hear from us. Christo’s mom and dad had tried repeatedly to get in touch with us but because all the phone lines had been destroyed in the last storm there was no way for them to get in contact with us and thus they were so glad to hear that we were doing well here.

Prayer Requests:

1. Praise God for keeping us from getting too sick so far. Please pray for continued good health especially for the kids because they keep getting bitten by every type of bug.
2. Pray for the staff at Makunda who are under incredible pressure to care for a tremendous number of patients. Pray for God’s grace and strength for them.
3. Pray for us as we fit into our role here. We would like to work on some tasks here that will hopefully allow them to streamline the way in which the hospital and school runs.
4. Pray for the patients that many who are animists, Muslims, or Hindus would see the love of Christ in the staff and seek spiritual healing as well.

Along with this post, we’ve put up some pictures from Makunda.

Click on the Pictures to View the Gallery from Makunda

Today was another typical day at Makunda during which we saw 203 outpatients and performed two surgeries in the evening as well as a couple of D&Cs.  We admitted another baby overnight into the ICU with pneumonia.  The baby was quite fussy throughout the day but hopefully will turn the corner soon.  Unlike the baby we admitted the day before with pneumonia, this baby does not seem to have heart failure as a consequence of her pneumonia.

We had another patient with malaria admitted yesterday as well.  Malaria season is just starting in the area because the rains have begun (we’ve been getting torrential downpours every 1-2 days and thus we still have not had electricity for more than a few hours since we have arrived).  Because of the rain, there is plenty of space for mosquitoes to breed and thus the higher incidence of malaria over the next few months.  Dr. Vijay Anand and Dr. Ann have worked here almost 16 years with no malaria prophylaxis and have not gotten malaria yet and so we hope that we will be able to get through this month without acquiring this disease since we’ve also been taking malaria prophylaxis with mefloquine.

Today Dr. Ancily helped walk me through my first D&C.  This was a lady in her twenties who came in with bleeding for three days.  She was about five months pregnant and had expelled the fetus in the morning but because of continued bleeding finally came into the hospital.  When we checked her hemoglobin on admission it was 4.  Again another severely anemic patient due to excessive blood loss.  I praise God again and again that this hospital is here because many of these women would have died at home if this hospital was not there to take care of them.

We have another patient on service who has a tragic story.  She is 25 years old and recently began to have rapidly progressing nephritic syndrome.  For those not in the medical field, nephritic syndrome is a condition in which the kidneys start to lose massive amounts of protein from the body through the urine and thus these patients become severely protein malnourished and thus develop generalized swelling over the body, a condition called anasarca.  What is tragic about this lady is that ever since she developed this condition, she has been deserted by her husband and now she lives with her parents who help to take care of her.  We have nothing to offer her except prayer and if God does not intervene soon she will pass away.  I think working here has made me see how often we have to turn over things to God because for many of our patients there is just not much we can offer them.  The same I think is true in the US but we tend to turn to God later on in a disease because we try a multitude of treatments until they all fail.  Here most of the time if the first line therapy does not work that is about all we can do for them medically.  For many of our patients with terminal diagnoses it has been refreshing to see the physicians address the deeper spiritual problem because even though their life on earth is short, an eternity apart from God is much longer.  Many of the doctors here routinely pray for our patients on rounds for God to provide healing and they pray with the patients before each surgery to let the patients know that the outcome is totally in God’s hands.  I just wish I had the faith of Jesus or Paul who could just command the lame to “get up and walk” and they would…wouldn’t that be an amazing way to show God’s incredible power to heal and save?

In the outpatient department we had another sad case of a completely preventable illness.  A three year old girl came in with her parents because for the past nine days she had suddenly been unable to walk.  Prior to this she was completely healthy and had met all her developmental milestones but this sudden paralysis was completely devastating to them.  The diagnosis was polio, the first I’ve ever seen but something that is still present in this area.  When I examined her and filled out the Indian government form for reporting polio, I discovered that not only was she very weak in her legs but her arms had lost their strength as well.  How tragic that this was again a completely preventable disease with vaccinations but now she will most likely go through the rest of her life as a cripple.  Seeing diseases present here like polio, diphtheria, tetanus, meningitis that are completely preventable through a simple vaccination has made me appreciate vaccinations so much.  If you look at major advances in the 20th century, vaccinations alone have significantly impacted the health of entire populations.  I know there are some parents in the US who don’t want to vaccinate their children because they are worried about autism (the link which has been disproven in study after study done in large populations) or other side-effects that might occur.  But if only they saw what some of these completely preventable diseases did to you, then maybe they would see that the risk of side-effects is well worth avoiding being mentally retarded from meningitis, being crippled by polio, or dying of never ending muscles spasms in tetanus.

In the afternoon we did two more surgeries – one was a C-section that I assisted with and the one in which I did my first tubal ligation and the second was a benign thyroid tumor.  Melissa and the kids continue to get used to life on campus.  We have decided to enroll Karuna in the school here in LKG (lower kindergarden).  She has been thoroughly enjoying spending some time with kids here in school and it has allowed her to start picking up some Bengali and Hindi.  Melissa has been using her time to get to know some of the other campus staff and figuring out how to get food supplies for us.  Several of the nursing students came over in the evening to walk with Melissa and the kids to the market so that it would be safer for them to go out.  There is a nursing school on the campus here that offers a two year course in which 20 students enroll every year.  They have been a big help in keeping things running at the hospital while we are in the outpatient department or overnight.  Melissa will also soon starting working with the teachers in the school here to help them develop lesson plans since none of the teachers at the school have a formal degree in education.  She is also helping out with some of the 6th and 7th grade English classes both to give the current teachers ideas on how to help the students develop their language skills as well as give the students a chance to hear English from someone for whom it is a first language.

Wednesday was another interesting day at the hospital.  The OPD was relatively slower compared to the number of people we saw on Tuesday.  We probably saw around 150 patients on Wednesday.  We’ve been trying as hard as possible to learn Hindi/Bengali/Tribal Languages but it has been difficult because we’re learning some words from each language and some patients only know one out of the three.  Both of us continue to see how important it will be for us to learn the language once we return to India so that it can facilitate our ability to talk with patients, students and neighbors alike.  Especially when it comes to explaining the great news of Christ to our patients, it is so much more effective to communicate in their heart language rather than having to rely on a translator.  So it seems most likely that when we return we will spend the first year in intensive language study so that we can communicate fluently.  I’ve also been praying that God would give the gift of tongues or at least make it easier to pick up several more languages since that is such a necessity here.

Because of my limited understanding of the language, I’ve become more aware of how important a good physical exam is to help diagnose the problem because I often don’t have the clues from a patient history that are typically there to help me come to a diagnosis.  Before coming here, I had never listened to fetal heart sound with a stethoscope, instead it was always with a Doppler probe.  But with all of our antenatal checkups, we have no Doppler probe and thus a new experience was for me to learn how to listen for the fetal heart with a regular stethoscope – something that I’ve had a difficult time hearing well.

We see a lot of skin diseases here because Makunda has become quite famous for their dermatologic diagnostic abilities because of some telemedicine.  Whenever we see a skin condition that we are not quite sure of, Dr. Ann takes a picture of it and then e-mails it to a friend at CMC Vellore who is a dermatologist who takes a look at it and tries to make a diagnosis based on the photograph.  So far this week I’ve seen several patients with leprosy, tinea versicolor, atopic dermatitis, psoriasis, and multiple other infections/dermatitis of unknown etiology.

What has also been interesting to observe has been how the OPD also functions as an emergency room.  Seriously ill patients are carried into the OPD and the families often lay them on the floor until one of us is able to come and take a look at the patient.  We had a patient who was quite delirious from cerebral malaria come in to the OPD today.  Another patient came in screaming in pain from what appeared to be an acute abdomen – later an abdominal ultrasound showed acute gallstone pancreatitis.  Another patient came in who looked completely emaciated with severe muscle wasting and a blood pressure of 80/40.  It looked like either an AIDS patient or someone with a very large tumor burden but as of now it is still an unknown etiology and thus we admitted them for a further workup.

Probably the most distressing case today was a 13 year old boy that came in with chronic mastoditis.  This boy had been complaining to his family about ear pain for three months.  The family initially ignored it but then did homeopathic treatment for several months before finally traveling 100 km to get examined at the hospital once the left mastoid area had ulcerated out and pus was leaking out of the side of his head.  This poor boy was so embarrassed about the ulcerated mass behind his left ear and the large mass behind his right ear that he wore a handkerchief around his head to prevent people form seeing his ears.  By the time we examined him, he had completely lost hearing in both ears and needed to be operated on by an ENT surgeon to just debride the pus and granulation tissue out of his mastoid air cell and the rest of his inner ear.  What was tragic about this was that this was completely preventable had the family sought appropriate care even one or two weeks after he started complaining of ear pain.  A simple course of antibiotics could have prevented his horrible complication and now this little boy will never hear again.

We also had a little girl of about six who came in today with vaginal bleeding.  A couple of days ago she was playing in a local pond with her friends and in the process a leech had entered into her vaginal vault.  She had then bled for several days because of this leech and by the time she came to the hospital she was anemic from this blood loss.  Thankfully the leech had fallen out by the time she came to the hospital and thus we admitted her to replenish her fluids and to observe her to make sure there was no further bleeding.

Even though we got done with clinic early around 4 PM we still had to several more operations in the evening and thus I got finished with the day around 9 PM.  The first case was a hernia repair that went very smoothly.  The second was a lady with a rupture ectopic pregnancy who had bled out about four units into her abdominal cavity.  Her hemoglobin was seven by the time she got to the hospital.  We resected both of her fallopian tubes (she did not want to have any more children) and removed several liters of blood from her belly.  We then had two more c-sections.  One was for a lady that was brought in urgently from the village because she had lost about 500 ml of blood vaginally and the mom was 34 weeks along.  When we removed the placenta we saw a large retroplacental hematoma – good thing we did the c-section that night rather than waiting one day like we had originally planned.  The other was an uncomplicated c-section.  For those of you reading the blog, if any of you have access to an old fetal heart rate monitor / tocodynamomometer please let me know because the hospital has been looking for one for several years but because of the expense, they have not purchased one yet.  It would be really useful in situations when we have to decide on when to c-section or not and when we need to keep a better eye on how the baby is doing while still in the uterus.

If there is one word that can describe the amount of work that has to be done here it is overwhelming. I keep being amazed by the sheer number of people that we see daily in the outpatient department, the several operations we perform, and the number of deliveries that are done daily. Even with four physicians working this week, we seem to go at breakneck speed just to get through the number of patients. I guess it has made me appreciate all the more the all sufficiency of Christ and how He gives the strength necessary to complete the work.

Unfortunately our second day at Makunda was filled with much death. The reality of death is something that is ever present here because there are many diseases for which, no matter how good our therapy, there is little hope of the patient surviving. One of the patients who had been here for thirteen days suffering from tetanus died around 2 AM because of respiratory failure. We had managed to keep his seizures and constant muscle contractures under control for several days with barbiturates but apparently that wasn’t enough and he passed away. He had been isolated in a room that was completely dark because patients with tetanus will go into spasm if there are any loud noises or bright lights. It was tragic because it was so easily preventable since a tetanus vaccine is available here but still many people never get it because of a lack of health literacy. He was only in his twenties and it all started because he had a small cut on his leg.

The second death happened around nine in the morning. It was a lady Christo had helped to admit the day before with Dr. Ancily who had suffered a massive stroke. She was the patient that had presented unconscious with a dense right sided hemiplegia. Our guess was that her stroke was due to some type of massive intracranial bleed and thus the mass effect on her brain stem must have cause her death. The other two deaths today were two fetuses that died. One was a lady in her twenties who came in with thirty days of vaginal bleeding. She was about three months pregnant when the bleeding started but did not seek treatment until she was so weak that her family finally brought her in. When we checked her hemoglobin initially it was 4 (normal is around 12-15) and her blood pressure was 80/40. She was the palest person I had ever seen. We did a dilatation and curettage to remove the infected products of conception and stop the bleeding. She was also able to find someone who matched her blood type and thus we were able to give her one unit of blood. We don’t have a blood bank available at the hospital and thus we rely on patients to find a compatible relative/friend to provide the blood immediately before transfusion. We have the ability to check the blood for blood borne illnesses but because of the difficulty in finding donors, it is hard to get more than one or two units of blood per patient. The fourth death was a lady that had an intrauterine demise at around 5 months of pregnancy. We delivered the stillborn baby and on examination it appeared as though the baby had been dead for several days before the mom had come in. Frequently many women who had retained dead fetuses died from infection because they had no access to healthcare prior to Makunda coming into existence. Even though it was tragic that these two babies had died it was good to see that their moms did not die along with them.

On the second day Christo observed and then assisted on a couple of operations after our outpatients were seen. The first operation of the evening was a lady with two large 5 cm bladder stones. I had seen kidney stones before but this was the first bladder stone I had seen and they were huge. The looked like two large eggs that were crowding out most of the bladder. Because the stones had been present for such a long time and due to the subsequent chronic inflammation it also appeared that a tumor had formed in the bladder and thus we took biopsy specimens and sent them to a bigger hospital to have them read to help us decide how to proceed in the future. The second operation was a C-section that I got to assist Dr. Ancily with. The mom came in with arrest of labor due to cephalopelvic disproportion. Getting into the uterus was fairly easy but extracting the baby was not. Because of how long the mom had been in labor, there was significant molding of the fetal head as it engaged the pelvic inlet. Thus we ended up using forceps with the C-section to pull out the head and finally get the baby out. Mom and baby both did well. Because it had been a long day, I decided to go home around 7:30 PM while Dr. Ancily and Dr. Rockfuii performed another C-section that evening that got finished around 10 PM…another long day.

After finishing at the hospital, Jonathan, the hospital administrator and his wife Lydia invited us to their home for dinner. It was wonderful to get to know them and their heart for missions and commitment to the work at Makunda was readily visible. Jonathan has worked at Makunda for about six years as the hospital administrator and he married Lydia about 2 ½ years ago. They have a one year old baby, Kenneth. Both of them are from the state of Tamil Nadu and since college had felt a deep burden to reach India for Christ through mission work. We found a little bit more about what had happened to Jonathan a couple of weeks ago when he was assaulted by some villagers. The land that the hospital is on was granted to them by the government many years ago because they took care of leprosy patients. Over time, the land owned by the hospital has been illegally encroached upon by villagers. Most recently, there was a dilapidated structure located on the edge of the property that was illegal constructed. Jonathan and some of the other workers here had gone to remove that structure after getting the proper legal paperwork and because the person that claimed to own that land was not happy about it, he and some other villagers beat up Jonathan and the other workers and cut his arm with a knife. Thankfully even though Jonathan had several bruises and the cut on his arm, he recovered quickly and the villagers have left him alone since then.

We write this after our first full day at Makunda Christian Hospital.  To say that the world in which we live in now is 180 degrees different from the life we lived in Minnesota would only capture a little of life here.  We left the hotel in Kolkata around 9:30 in the morning having learned from our prior airport stop in Bangalore to leave much more time so that we wouldn’t end up nearly missing the flight again.  If any of you will be traveling to Kolkata sometime consider staying at the O2 hotel there…we had a great experience with them and the day at the hotel really helped to rejuvenate us before the last leg of our journey.

After arriving at the airport we were pleasantly surprised by how easy it was to navigate our way through and arrive at the right location.  Although then we found out that our 1 PM flight was delayed by almost an hour and a half and thus we had quite a long wait at the airport.  However, both the kids loved playing with the luggage carts and put on quite a show for the rest of the passengers waiting in the airport terminal.  Our Indian Airlines flight from Kolkata to Silchar was notable for a good lunch meal (in a flight that was about 1 hour…when was the last time we saw a meal being served on such a short flight in America?) and one of the worst landings on our trip so far which made us very thankful to be on the ground again.

Silchar airport has one terminal – really a glorified room (for all of us who are amused at how small of an airport Rochester has, we stand corrected!) and thankfully the driver from Makunda was easily able to locate us from the crowd departing the airport.  Our driver was so gracious because he had actually arrived a day earlier looking for us because some information got miscommunicated and so he had been looking for us on each flight that arrived there!  We then began the 120 km journey from Silchar to Bazaricherra where Makunda is located.  This drive took us about four hours because several parts of the road are nonexistent and there were tons of border patrols throughout our journey.  The road from Silchar to Makunda runs very close to the Bangladesh border so there is a big problem with border crossings and especially with terrorists that cross over into India through this area.  Thus most of the women get some type of army escort when they travel because it is not safe for them to be alone due to terrorist activity among the local tribes.  Also during the rainy season the highway is often completely flooded over and thus roads can be completely closed for several months at a time.  Just as a side note, the difficulty with highway travel makes it hard for pregnant mothers to get to a larger hospital and thus deliveries at Makunda have increased significantly since it is easily accessible to a large number of local patients.  Our driver was excellent and helped us navigate this treacherous journey and helped us arrive safely at Makunda around 8 PM on Sunday night.

The hospital administrator, Jonathan and his wife, Lydia did a great job in getting some living quarters ready for us and thus we were thankful that we could just work on eating dinner and getting the kids to bed.  The building that we are living in was built in the 1950s but the place reminds us of how things must have been a hundred years ago.  There is electricity available at our home but it is periodic at best and there is no running water (the wells have run dry and thus water now has to brought up to each of the buildings daily and stored in some large buckets for use throughout the day).  Our first night was a little harrowing because the rainy season has begun here and there was a horrible storm during the night that sounded extremely loud because our building has a thatched bamboo roof that is covered by a tin room.  Even though we couldn’t sleep very well overnight the kids were so tired that they slept with no problem!  Praise God that He kept us safe through a bad storm.  Because of the storm, several trees fell over power lines and from what we have found out it will now take several days for the electricity to come back again.

Monday morning was an early morning.  The sky starts to lighten up here by about 4:30 to 5 AM and because we live in a forest the birds start talking around the same time and thus we have gotten up much earlier that we were used to back in the U.S.  By about six AM, a lady who comes to help another doctor who lives in the same compound as we do came to help us with breakfast and lunch.  She speaks no English and we don’t speak Bengali or her tribal language and thus the morning was filled with much gesturing and empty looks.  However, she did make us a wonderful breakfast and helped us with washing laundry and cleaning around the house.  One of the biggest things our kids have had to get adjusted to has been the lack of a refrigerator.  It is one of those appliances that we so took for granted in the US but now don’t have that luxury anymore.  Here we cook meals one at a time because most food will spoil in the heat here.  It has also meant no milk for the kids until we find out a way to get milk daily since there is no way for us to keep it from going bad.

Christo’s first day in the hospital was an eye opening experience and one in which he learned much.  Mornings at the hospital start around 8:30 with morning rounds with the 90 patients in the hospital wards before moving on to start the outpatient clinic.  It is amazing to see how efficient the doctors are here, especially Dr. Vijay and Dr. Ann, his wife.  We probably saw all the patients and made treatment decisions in about 45 minutes.  The hospital is one of meager means and there are no private rooms available for patients.   The goal of being able to serve the poor at a low cost is very clearly apparent and they do a wonderful job.   During rounds we saw three patients with cerebral malaria, one school aged girl with diphtheria, several post-op patients (ranging from perforated duodenal ulcer to C-sections to a uretero-vesicular anastomosis and recreated anus for a baby with imperforate anus).  There is also another patient on the wards who currently has tetanus.  There is another patient that has a 5 cm bladder stone and many more with your everyday pneumonia.  On the maternity ward there is a patient who just had a C-section who we just found out has severe dilated cardiomyopathy with an ejection fraction of 32%.

After morning rounds we started the outpatient clinic which typically sees between 150-250 patients a day.  There are currently the two senior physicians (Dr. Vijay, a pediatric surgeon; Dr. Ann (Dr. Vijay’s wife), an anesthesiologist; Dr. Anchily, a resident in family medicine on loan to Makunda from Tezpur Baptist Hospital; Dr. Rochfuii, an intern).  Dr. Anchily and Dr. Rochfuii have just been here a few day and thus all of us are trying to learn a new system and a new language.  Today was a fairly non-busy day because quite a few villagers were not able to get to the hospital due to the storm the night before.  During the day as we see patients in the OPD, serious patients continue to come in.  This day we had a lady in her sixties come carried in by her family.  From what we understood she stopped moving the right side of the body the day before and within a couple of hours had become unconscious.  However the family only decided to bring her in the next day – something quite typical here.  By the time we examined her there was just withdrawal to pain on the right side and she was unconscious but still breathing.   We explained to the family that this was a very serious case and that she could die within the next 48-72 hours and that she should go to a bigger facility where they can do a CT scan to see if there was active intracranial hemorrhage.  The family did not have the means for that and thus they signed a high risk consent and we admitted the patient.

The days here are also interrupted multiple times by deliveries both normal and C-sections.  Today we had three vaginal deliveries and in the evening Dr. Vijay did one more C-section.  We also admitted several patients with preeclampsia, something that seems to be fairly common here.  Late in the day another toddler came in with severe tachypnea and fever.  Chest X-Ray showed complete opacification of the left lung and thus he was admitted for treatment of pneumonia.  Our hope is that we can ultrasound him the next day to see if there is a fluid collection in his thorax and if so then we can tap the fluid to get a better idea of what type of infection he has.  In the OPD we also several patients with tuberculosis since that is very common in this area especially TB with multi-drug resistance.