Week 3

November 14th, 2019 by Kimberly Hall
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This was a week a variety! I was at a new place each day. One was the community center Melakuppam, which was having their morbidity clinic. This is a rural clinic and for comparison, we had 30 patients come to the clinic so ⅓-¼ of the amount we saw in the urban morbidity clinic. The nurses provided a lot of education and there is definitely accountability between community members (aka a couple tattled on each other for not taking meds etc :)). I don’t think I’ve mentioned, there are no rooms in the clinics, just one big room-they have a curtain to pull or clear the room for antenatal visits. So, everyone hears everyone’s business if they try. There is no electricity aka no fan at this location and no bathroom. Because there was no school that day due to a holiday, there was also no running water! We walked to a home that has a huge well to wash our hands before lunch. The communities value the clinics and any limitations are met with a solution by the community!

My husband got to come along for a day this week! We had a long bus ride, so he got to see several of the clinics I have been at as we dropped the nurses off for the day. It was great for him to get to see the community. We toured a government primary health center (Melvisharam). Greeda wanted me to be able to compare the centers and see a center outside of CMC. The nurses clearly knew each other and discussed some community members and their concerns. This facility provides free care to a mainly Muslim population. I could definitely see the differences in dress from what we typically see in clinic (although we see Christian, Hindu and Muslim patients….just mainly Hindu). They have a specific room for the distribution of meds and management of TB, the antenatal clinic line was out TWO doors, a small lab and pharmacy. It was an antenatal clinic day and similar to CMC different clinics are offered on certain days. We also got to meet with the president of the rotary club who was there to discuss remodeling of the buildings with a group. He works with both government and CMC clinics and they wanted a picture with us. I think everyone was in awe of Michael’s height.

I also went to CHAD or community health and development. Chad is physician run and has both inpatient and outpatient services, including an emergency room. Everything looked and ran very similar to RHUSA. We actually went out in a van that was set up for antenatal visits and med distribution. The van was awesome!! We had a table and chairs in the back and would see the morbidity patients out in the shade. The views of the beautiful hills and countryside were phenomenal. The van had four stops and patients knew where the van would come and were waiting for us. Patients are seen and then able to get their medications for minimal cost…once we saw them all, we moved to the next community!

LCECU or lost cost effective care unit was another clinic I visited, which offers both outpatient and inpatient services as well. It is also known as family urban medicine and serves to poorest of the poor in the community surrounding CMC. This branch started in the 80s and has a specific screening process. There is a social worker on site who interviews the family of each prospective patient to ensure they meet criteria for getting care at LCECU. I also learned that when a poll was taken several years back staff identified that they were not seeing nearly as many extremely poor patients which is the mission of the hospital. So, I’m 2016 they shifted their model to add “home visits” and are still learning and developing this. I put home visits in quotes because there still is a station vs actual home visits. But the stations are located in 5 slums, which are very crowded.

I visited on an antenatal clinic day, which looked different than the community clinics. Their visits are more comprehensive with a urine dipstick, blood work if necessary, ultrasound and a room for transvaginal exams. Each service has its own cost. I was able to observe each aspect of the antenatal visits-learning more about ultrasound was my favorite! I also observed rounds and learned about the inpatients on the labor unit. They also have a procedure room which was fun to observe. There were some painful looking wounds and the patients were very tough with very little complaining. In the afternoon I did outreach care home visits.

I spent my last morning with Binitha at Kilminnel. It seemed fitting to spend my last day with her and in the village where I spent most of my time. We went for home visits to patients with mental health disorders. Then, one of the community leaders walked us to the famous nearby Hindu temple which has a miraculous story and was massive. The lake was also being built and Binitha said that people are coming from near and far to see the temple. It was incredible. The community leader was thrilled to take me and show me a part of the community he is very proud of. I was able to meet many people along the way, as he stopped to talk with people. We got back and finished the geriatric club and did some BP checks before heading back to the college of nursing. It was very bittersweet for my time at CMC to come to an end, I am very thankful for all of that I have learned and have no doubt it will impact my practice as a Family NP!

Week 2

November 12th, 2019 by Kimberly Hall
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What a learning week!!

I was back in Kilminnel to start the week. One of my favorite aspects of this particular clinic is that there is a geriatric club. The elders (60+) of the community gather, one reads the daily paper to everyone, they play games, we lead them in range of motion exercises and provide a nutritious snack. A couple other clinics offer this as well. It is fun to see the elders interact and build a community. Some live with their children and others live alone and the program is meant to combat depression and make check up visits easy.

Another program the nurses started in the community is school visits with different educational topics about every month and I was able to observe the Masters students do a presentation at the school. One of the Masters students did her thesis on transportation safety in India so she led this lesson. She covered travel and road safety and had handmade picture cards for the students to view. So they reviewed road signs, how to wear a helmet, not to use your phone while bicycling etc. the children were primary school students from several classes. After the kids wanted to hear who I was and why I am in India. They all said very enthusiastic goodbyes! A similar program occurs at the weekly morbidity clinics, where sometimes 100+ patients come through the clinic, and the nurses prepare a skit or song or presentation to deliver before the clinic starts and patients fill every corner of the clinic.

School presentation & pre-clinic skit

I visited the Kannigapuram Outreach Clinic which is just outside Vellore. This campus is very close to where CMC is building a massive new hospital. Apparently, the community members were upset that the building of the hospital would use their resources (water etc) and protested that they should be given a free clinic that also would provide jobs for community members. So, CMC rents a home that they have turned into the Kannigapuram Clinic. The clinic is not free for everyone, but if the patients are in a certain socioeconomic class, the care is free. This clinic is different from the community clinics and is a place patients are often referred to from Kilminnel, Pattutakku etc. It is closer than the hospitals and offers more services. There is a pharmacist and physician on site. The more basic clinics have some meds and dressings etc, but this clinic has many more. The nurse run clinics are meant for monitoring and the first step for patients to get guidance. The pharmacist, receptionist and physician all have computers for charting, while the smaller community clinics record on paper.

Outpatient record…patient brings with them to each visit!

I also spent a day at RUHSA or the Rural Unit for Health and Social Affairs. Wow. The things they are doing in this rural community are amazing. The communities I have been going to are rural, but closer to a bigger city than RUHSA. In essence RUHSA provides level 1 & 2 care and actively combats social determinants of health. There are 23 outreach clinics across 18 communities and the inpatient + outpatient facility. They have education programs that cover the lifespan, a community college on campus that provides vocational education at a reduced rate and provide targeted education during school years. For example, they took a poll at the local school of all girls in their early teen years asking what things they would like answers to that they do not feel are covered at work/home. The top 3 answers were their menstrual cycle and feminine health, “how to handle the opposite sex” (do we actually know the answer to this?!) and how to apply for college/what careers are available. So educational sessions and resources were provided on the female reproductive cycle, managing interpersonal relationships and college workshops. Due to cultural beliefs in the area, one parent was required to attend the college informational meeting to help reduce pressure and bias to choose a certain profession from the parent based on outdated or misinformation. The program was so outrageously popularl the school requested that the same be done for males as well. What an opportunity for health education! They also have self-help groups for women which teach about proper financial management and provide 0% interest loans. I can’t remember the rest, but they have many awesome programs that are showing measurable results.

I was able to observe inpatient rounds and saw several perplexing cases as well as many “typical” cases for this area (COPD, diabetic complications, work related injury). I also toured and sat in on outpatient, PT and ophthalmology appointments. Different specialists come in from the main hospital on different days and today ENT was present. It was a very busy, encouraging and enlightening day!

Map of RUHSA’s clinics

I provided a presentation on the basics of global health this week as well. I am in KU’s global health course and since I am doing my DNP project looking at international scope of practice for NPs, they really wanted to hear more. I feel like I am still learning a lot, but it went well! They are knowledgeable on the sustainable development goals and social determinants of health, but we had a healthy discussion about the differences in these between the USA and India. We also had a wonderful talk about culturally competent care including scenarios where we may have personal bias, what that can look like and how we overcome it to provide the best care. Primary care is often not as glamorous as a lifesaving surgery or treating a superbug, and we discussed the struggles with nurse recruitment and the potential impact of improved preventive health measures.

I was overwhelmed with knowledge and had a wonderful week!!

Week 1

October 1st, 2019 by Kimberly Hall
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Hello! My name is Kimberly Hall and I am a Doctorate of Nursing Practice student specializing in Family Medicine at The University of Kansas. Back in 2013, I traveled to Vellore, India for an undergrad clinical rotation at Christian Medical College and fell in love with the country and its people. I jumped at the opportunity to return with a different focus. It is wonderful to be back in the land of constant honking and the “yes” “no” combo head nod that it took me forever to understand!

I am only able to do 15 clinical days, so week 1 I hit the ground running. Nurse Practitioners are not recognized as a part of the nursing profession in India, but work is in progress to open educational programs. The main push back is from physicians, I saw this in research prior to arrival and have had it confirmed in person. India practices in a more traditional hierarchical care model as opposed to the team based care we now see in the US. I had a great conversation with a medical student who came for a residency interview at CMC, he loved the idea of team based care but stated that is definitely not how things work in the current system.

I have done daily “word vomit” journals, as I call them, because I feel I am taking in a ton of information each day. The community health program here is huge. I am going to do my best to organize the highlights!

I am spending most of my time in a branch of CMC called the College of Nursing Community Health Department, or CONCH which is completely nurse run/managed. I was given a presentation all about CONCH, but I did not take notes, so here is what I remember which should be pretty close to the facts. Vellore is split like a grid into blocks and CONCH covers two of these blocks, which includes ~25 communities and over 60,000 people. They have both urban and rural communities and have a standing set of orders from which they are allowed to provide care. They mainly provide first aid, monitoring of chronic disease, screening for tropical diseases and provide appropriate referral (to CMC or government facilities) for community members. These are considered primary centers, secondary centers are essentially outpatient clinics and tertiary centers are hospitals. The primary centers hold different specialty clinics (chronic disease, eye, antenatal etc) throughout the month as well as being open for drop ins and doing home visits daily.

This week I visited two rural clinics in Kilminnel and Puttitakku and an urban clinic in Ramnayakapalayam. The nurses loved trying to get me to say that last one right! I settled on Ranaya-papaya 🙂 In each place I was given a tour of the community including the churches, temples, gathering area, preschool or Balwadi’s and primary schools. The children were adorable and so much fun to interact with. I learned about government nutritional support for children, and even got to taste biscuits made with the fortified mixture they use. This is given free to mothers, but they sometimes have trouble with the parents selling it instead of giving it to the children. The children are weighed weekly and health education is provided in group meetings for parents. Government education is free and if families have more money, they often send their children to private school as they are viewed as superior.

Home visits are a highlight for sure. The nurses say this is how they learn about the community and form strong bonds with families. They keep a book information on each community including the number of men, women, children, community leaders, resources, typical occupations etc. Everything is handwritten and I am very impressed with their systems. When we go into a home we often see at least two family members, as it is very common for multiple generations to live together. Generally we see hypertension, diabetes and antenatal or postnatal patients, but there are many other conditions as well. On Saturday we visited a home with a down’s syndrome patient because the nurse, who has a school age child, thought he would love to enter the drawing contest and brought him the papers. The family was thrilled to see her and we were able to check in on 4 other members of the family too.

Every family tried to feed and give me coffee/tea. I hear “you sit” constantly and honestly, my bum is sore from the bumpy bus rides/constant sitting! I do not want to be rude, though, so I at least sit and occasionally enjoy some food/drink. I am often sitting in the only chair and we do most visits on the floor. One visited homes was on a the start of the Tamil month (I believe) which is a special day in Hindu culture. One family gave me the honor of witnessing the ritual they do which includes getting special food and ringing a bell/praying as it is being carried to the house. Then, they pray over it and eat. She made us some sort of fried dough from scratch (also super cool to see) and we played with her 7 month and 2 year olds. I had 3 other families try to get me to join for the ceremony, lots of yummy snacks, got flowers put in my hair twice and got to see lots of children (no school). Needless to say….I think I got a lot more out of that day than our patients!

Finally, I was able to reunite with Naina, who helped us on my last visit to India and studied at KU. She and her family invited Michael (my husband) and I to a Harvest festival. We ate a traditional meal and got to watch the kids play many different games. It was a great time!

Introducing Myself

August 21st, 2019 by INMED
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Hello! My name is Kimberly Hall. I am a nursing practitioner student at the University of Kansas and I’m starting my INMED service-learning experience at Vellore Christian Medical College and Hospital in India beginning September, 2019.