The work.

We have been working here for about 2 weeks now...mostly with the home care teams. They have 3 teams that are based out of the MNJ cancer hospital, with 3 vans. The vans are driven by a driver, and the team consists of a social worker and a nurse (ideally).
Each day the social worker does the case management and decides who needs to be seen that day based on priority or who phoned the night before. The driver helps decide according to geographic area. This city is huge and CROWDED. These teams cover anyone within 40kms of the hospital, and 30kms in this city will take 1-1.5hrs to drive! Because of this, seeing 3-4 patients is a full day often. Sometimes only 2 and sometimes if they're close...5.
Last year they had a total of about 90 patients for 3 teams. They now have 120. And since he conference and the advertising that came with it, there has been a HUGE influx of new referrals that want morphine for pain control. You might think this is drug seeking but its not. Most of these patients have cancer and cannot get morphine anywhere else. Pharmacies do not carry any opioid and they must come to MNJ in order to get any. (Which has only been avail for 7-8yrs now). Doctors are scared or don't have the knowledge to order morphine (indian laws could land you in jail on the suspicion of misuse...without evidence). The cancers we see are often late stage and obviously painful.

This has now led to these teams and the palliative clinic and the hospice to be overwhelmed and inundated with patients. But to hear where they came  from 8yrs ago is amazing. The growth has been exponential.

The teams are very knowledgeable of palliative symptom management and the care for these people is astounding.  They work 6 days a week from 0930-1730 (ish...in true indian form) often working well past that. Sunday is their only day off (except holidays) and they are paid a modest monthly salary. (No overtime for those late days). On top of that the counselor and nurse carry an after hours phone for 15 days each and answer phone calls 24 hrs a day. So even if they get called during the night, they come to work in the am. There are no evening or night visits however....as women are not safe out after dark.

The nurses will do just about anything in the homes from injections to ascities taps. The counselors do amazing work with pyschosocial issues as well as communicating medications and procedures and end of life processes. (They are incredible people). One cultural issue that I am having trouble with is that most patients are not told their diagnosis let alone prognosis! The norm seems to be all information is communicated to a family member.  Therefore, the team must ask/seek permission from the family before discussing this with the patient. And if the family says no, the team (including doctor) must find ways to support the patient without saying anything about the real problem! This has made me so grateful for our culture of autonomy as being paramount.

The nice part is that if a family come to MNJ for morphine and cant afford any medicine, they can get it for free. If the family have money, they will pay for their medicine. The teams are also carrying small amounts of medications that they can give inital doses to the patient/family until they can get to the hospital to pick up more.

In India, chewing tobacco and/or beetlenut is a common practice, and we see a lot of head and neck cancers, with wounds like we rarely see in Canada.  The other problem is that most people present for diagnosis very late in the disease process and often have little chance of cure. The team does a lot of teaching of proper wound care but see a lot of problems like infections and maggots related to poor care and poor living conditions. Many people we see live in very simple and poor conditions with little to no education. It proves difficult for teaching families and seeing compliance with care or med administration.  And even with good teaching, access to medications and home support, we see patients in pain, not receiving good care. These teams find this very distressing and disheartening.  And with the huge growing numbers of patients, they also feel spread very thin.

We have tried to support the teams with education, encouragement, friendship, action, and supplies to try to make work more efficient. A major barrier is lack of resources. The hospital does not even have a proper incinerator to safely dispose of waste (aka. Needles and sharps etc). So the staff had let that compliance slide because there was no facility support. We are trying (as a whole) to be creative in finding solutions to solve some of these basic problems that are within the reality of practice here. For example: our best practice is to never recap a needle to avoid risk of sticks by the needle. However, here, a lot of garbage ends up being rummaged through, often by children. (Cause the hospital doesn't have proper disposal) so the team decided to use 'safer' recapping so that at least the needles that end up in the garbage would be capped and not stick someone! (Thankfully the hospice now pays for safe and proper disposal of wastes. So at least the palliative team is doing it right!)

Its humbling to work with these amazing people and inspiring to brainstorm ways to improve, build, support. This entire program runs on an NGO support because the government doesn't see palliative care as part of basic health care services.
Huge shout out to the Pain relief and Palliative care Society  (www.palliativecarepartners.in)
And Two Worlds Cancer Collaboration (www.twoworldscancer.ca)

Please support them if you feel so moved to do so.

The life....

So yesterday we were invited to a college's house "for a small dinner". So after a long day at work, we grab an autorickshaw, and head to her house.
[Side note: there are no actual addresses around here.... a few streets have names but houses are tucked back into mazes or lanes and alleys with no names. So addresses literally have landmarks such as "across from the sai bubba temple". So we had to get off at the bus stand and wait for her to come and lead us to her house. ]

We arrive at her house, being introduced to all her siblings and mom and their children...had a cup of chai and were entertained by the children with song and dance.
Then we were told to go upstairs to the rooftop where we walked straight into a home church service...in Telugu.  Thankfully the brother who was preaching, only put the spotlight on us for a few mins. After the service we were ushered downstairs again to eat with the children, while the adults all sat kn the rooftop and ate. Huh.
Then as we were leaving to find another auto (which we told our college about 4 times).... there were two young men with motorcycles that she told us to go with. We thought they were just taking us to the main street to find an auto, but nope.....they were driving us all the way back to the hotel. So we got the authentic indian experince of riding on the back of a motorcycle, weaving through crazy night time traffic. I enjoyed myself. ...rosa was hanging on for dear life, but was a good sport about it! Hah!

Ps: yesterday I saw a sign on the highway that stated Hyderabad was the worlds #2 tourist place. Votes?

Pps: to add to my previous post....
I like eating with my hand.
I REALLY REALLY dont like all the garbage. This is a serious problem in so many countries I visit .... im starting to feel a serious need to change things. 

The good, the bad and the funny

I'm starting to see a few sides to India and naturally, there are things I like and don't like. And there are the things I find hilarious!

I love the tiny cups of piping hot chai. I love the sparkling bright colours everywhere. I love the head waggle (and im getting pretty good at it!). I have even come to love the conversation of horns in the street. If you really listen, you can hear what they're saying to each other. "Im right here" - "excuse me, I'd like to pass" - "GET OUT OF THE WAY! !!" - "would you like a taxi? " - "move over!" .....
I love biriyani rice and palak paneer.

I don't much like the leering stares, that swivel heads 360 degrees as they stumble into traffic,  but if its purely curiosity, I've started waving and saying hello. That usually makes it stop. ;) I dont much like the constant and utter chaos in the streets All. Day. Long....but again...I've come to sort of enjoy the ebb and flow and pecking order that are the streets, and have gotten pretty good at weaving through it all too! I don't much like that there are indian prices...and then there are foreign prices.

And then there are things that crack me up!  Like an auto rickshaw full of coconuts, or two camels being walked across a bridge. Or a cow dressed up with a floral halo being walked thru busy traffic on a main st in mumbai. Or a family of five on a motorcycle; toddler usually fast asleep on the gas tank, dad driving, kid sandwiched between dad and mom who is riding side saddle holding and infant. A man reading the newspaper on the back of a motorcycle.  A man carrying a dresser on a motorcycle.  Carrying just about anything or everything frankly. Like a huge bunch of balloons or a huge piece of glass.

This is a land of contradictions.  Of tastes and smells and sounds and colours that all delight and don't.  But all in all...I think we're getting along pretty good so far.

Conference

Our first weekend in Hyderabad was spent attending the International Indian Palliative care Conference. We spent 3 days meeting leaders in palliative care from all over the world, working so hard to bring good palliative care to everyone. The theme was innovate, integrate, and influence. We heard about a lot of new studies, both in evidence for new practice and in where and why the palliative care is most needed. One of the big focuses this year was on new indian legislation, improving the access to opioids (which at this point is mainly morphine). There is still a long way to go and a lot of people fighting for the human right to access of palliative care and pain control. I heard about about pediatric palliative care and its limitations. And why we need early screening and intervention ; cultural barriers here in india . We heard about alternative therapies like yoga and blowing bubbles ;) how to incorporate into critical care and emergency medicine; support for caregivers; symptom management ideas; spirituality(which is hugely important here); palliative care in non malignant diseases....
All in all, it was an excellent gathering of some of the top people in palliative care around the world with poignant things to say, and the most inspiring women!!! A surprising amount of female doctors and other inspiring women making a huge difference in this world!
I feel honoured to have met so many amazing people.

Oh india....

We reluctantly left our beach front room to board a night bus to a small town of Hampi.
We arrived at the "bus stop" very early cause we had nothin else to do...and met two pairs heading to bangalore...two different bus companies...but both were due for departure at 730pm. By 8, neither of the buses had shown up. Shortly after the one company's bus rolled right past the stop without slowing down. Thankfully,  the girls managed to catch it. Then the other pair's bus rolled by after 9pm and didnt slow down, despite the dude waving the bus down!!! So then they had to wait until the next bus who picked them up and met them with their proper bus at the next stop!!!
Our experience: several buses from the same company came by but none for Hampi.  Finally an hour late a decrepit looking bus rolls in. The men running the bus didnt seem to have a clue what they were doing. Then a second nicer bus rolls up and then the dude realizes half the people going to Hampi were on that nicer (aka. A.c.) bus. We get to our spots after another couple vacated to the other bus to find two single sized strips side by side to make a double.  No curtain. Bent rail. Drunk russian below us. Excellent.
We did manage to snag same deal but with a curtain across the way but sleeping on a moving bus, crammed side by side did not equal any sleep for me.
Chocking that one up as experience.
But.....we did arrive in a fantastic little location.  A large spread out area of ruins of a hindu nation fron the 16th century.  Amazing stone work and temples galore!  All tucked in among banana fields, rice fields,  and a lovely river running among some amazing monolithic rocks!!
We spent the day wandering these ruins and are now spent! Few more hrs tomorrow to finish it off and we'll be on the train to Hyderabad! !!

Goa

After the business and rush of Mumbai, we headed south to goa. An overnight train on a bunk barely wide enough for a person....but the coffee and chai were readily available and cheaper than chips. (They love to say that here...thank you england for the influence ;)
We found ourselves with a beach front room, literally steps from the water. The room is simple but cheap and the surf puts us to sleep each night.
The water is a perfect temperature and the soft sand is throughout the bay. Sure...its filled with tourists but this bay still manages to be quiet and underdeveloped, with simple beach huts and rooms lining the beach. No high rises or big resorts.
I kayaked out to a small island and along the coast dotted with secluded little beaches a couple of times. We had fresh tandoori fish , dining right on the beach. We swam. we sat on lounge chairs under an umbrella. We basked in the warm sun.

Today, however I did something different.  I hired one of many royal enfield motorcycles and went for a ride into the mountain jungle. It was a narrow winding road where you never knew what you would get around each corner. A lori passing a car on a corner; a brightly painted temple; a couple of cows; people walking with huge piles of wood or water on their heads; a monkey. ...
I stopped at a tower lookout near the top of the mtn, where a van full of men happened to also be taking a break. After a nice view of the valley below I head back to the bike...and have no starter. Within a couple of tries on the kick start, I was surrounded by this gaggle of men jabbering away. With their insisted help, we got the bike started and I was on my way again. Later on down the road, I stop for a cold drink. And the bike won't start again. This time the kick start won't work and I enlisted the help of a standerby to push start the thing up again.
At this point I have lost trust in the bike and head back without another stop. Despite the failed bike, I really quite enjoyed the ride...and even the traffic that doesn't seem to follow any rules other than "bigger is better and gets right of way".
A lovely relaxing spot to chill before we head to Hyderabad to start work. 

First lesson

The first lesson we learned in mumbai is that everything can be found by walking straight; five mins. Every single set of directions, when asked was "walking straight. 5 mins".
Even when it wasn't. 

We have now spent 4 days tramping around the streets and neighbourhoods. We have seen everything from posh new high rises to colonial british buildings to the poorest slums in the world. We watched thousands of men doing loads of laundry in the outdoor washermans colony "Dhobighat". We saw muslim mosques and hindu temples. More colourful saris than we can count!
The city practically vibrates with people,  horns, black and yellow taxis, dogs some goats in t-shirts and a few cows. 

I even got the chance to meet up with a gorgeous couple I met ice climbing on a glacier in alaska (as you do) for an evening out. We had drinks at a local watering hole and a delicious meal with these yogurt filled pastries being the favourite.

We braved the city trains (which ended up being way easier than we expected) to another up and coming suburb to check out some graffiti. 

We took a ferry over to an island with caves filled with ancient carvings of hindu deities.  on the way back however, our motor broke on the ferry qnd we sat drifting for about hald an hour until another ferry came along and pulled us back to the harbour. 

The air never really clears up. The locals walk on the road with all the crazy traffic instead of the footpaths. (We have managed to get pretty good at dodging traffic as we cross these busy streets. )  pedestrians are very low on the totem pole of importance on the roads. But even the constant honking and weaving and zipping around each other on the roads didn't seem to bother us much. The red lights and lane lines are merely a sugeestion and frankly. ...I think I could quite enjoy driving here! ;)

We loved our little restaurant at the bottom of the hotel where the only english speaker was a manager who always took care of us. Chapati bread, boiled eggs and curd (local yogurt) was our breakfast usual. The small cups of chai for 2 pennies is refreshing and delicious and readily available just about anywhere.