Every day cardiovascular professionals around the globe are involved in improving and saving the lives of the countless people seeking care for themselves or their loved ones. This is no small feat, given the global epidemic that is heart disease. If this “day job” wasn’t enough, many of these same professionals also volunteer their time to help others in areas where access to basic health care, let alone cardiovascular care, is limited. In April, Sandeep Krishnan, MD, an ACC Fellow in Training and member of the College’s first class of “Emerging Advocates,” went on a three-week trip to the Himalayas in Northern India (Himachal Pradesh). While there, he and fellow volunteers saw more than 3,500 patients and provided them with internal medicine, Ob/ Gyn, pediatric, pharmaceutical and other services, including echocardiography. He kept Cardiology’s editors, friends and colleagues up to date with weekly blog posts and pictures, excerpted here. DAY 1 We traveled to our first campsite just outside Bisalpur, India. We ascended to about 7,500 feet in the Himalayas and set up shop. Our housing situation here is tents spread out over a small campsite. We have pit toilets and two tents for bucket showers. Not quite the Ritz, but it’s doable! DAY 2 We started the day out with a short hike, had breakfast, and then had a 1.5 hour hike all the way down to our first clinic site at a “nearby” village. Apparently, the definition of “nearby” is very dependent on where in the world you live. We were headed straight downhill for 1.5 hours (which meant the way back up was not going to be fun). Everyone here is so active! I think the incidence of atherosclerotic heart disease is fairly low in this population after noting their diet and activity levels. After a hard day’s work in the clinic we spent an hour hiking back to the campsite, which was all uphill, but the views, again, were beyond describable. Unfortunately the photos don't do this landscape justice. When we returned to camp, we had a lecture hour. I came up with the idea to go around the room and have everyone share one interesting case he or she saw or one thing that he or she learned today and then we had a lecture. PATIENT COUNT: 160 ECHO COUNT: 4 DAY 3 Today we walked 10 km – it truly seems that we are walking uphill to work both ways – and set up our clinic on an area of holy ground near a Hindu temple. The patients came in all shapes and sizes, but here were a few observations that I started making: people here look much older than they really are. This is probably a combination of being exposed to sun and damaging UV rays, as well as performing hard labor most of the day. Moreover, they are almost all ubiquitous smokers. Many patients also described symptoms of heart failure. We found that many patients also were quite dehydrated and, most surprisingly, had normal hearts. We, unfortunately, do not have any statins or nitro to give and do not even have the ability to check an ECG. And don’t even mention going to the cath lab. About halfway through the day, the weather took a turn for the worse and our clinic literally got hailed out. One thing I am beginning to realize is how fortunate I am to be around such an awesome group of such diverse people. We have folks from all over the world here and everyone has a different set of experiences and background but we all get along quite famously and we work quite seamlessly together. PATIENT COUNT: 106; ECHO COUNT: 5 DAY 4 Started the day off right – made it all the way to the top of the ridge line! It took us the better part of an hour, but the views were truly amazing. We rushed back down to start our clinic, and I did several echoes in the morning. We had a few interesting physical exams, including a mitral regurgitation murmur and a split S2. The medical students and residents really enjoyed learning more about echocardiography and hearing the extra heart sounds. DAY 5 Our most interesting clinic day so far. Our clinic was inundated with villagers who were coming to celebrate a puja of a local god, so there were probably 1,000 people hanging out. My first true valvular heart disease patient came in this day as well. A 60-year-old man (who looked more like he was 80 years old) said he was having a very sharp pain in his chest. Our medical student in the triage tent astutely noticed this patient had a very wide pulse pressure (150/50) and she heard a systolic murmur but was concerned for aortic regurgitation. After taking a thorough history and appreciating both a systolic ejection murmur and an aortic diastolic murmur with Corrigan’s pulse, we put the patient under the echo probe and sure enough, he had a mixture of a stenotic aortic valve with torrential aortic regurgitation and a dilated left ventricle (LV) . He claimed he was not short of breath but he was extremely cachectic and I fear he did not understand what we were asking him. We referred him for urgent surgery at the nearby hospital and the Himalayan Health Exchange offered to pay for the entire operation to replace his diseased aortic valve. The echo machine is definitely becoming a staple part of the clinic, and now all the staff members have asked me to do echoes on them as well. Every single student wants hands-on echo time, and they are all now considering careers in cardiology! PATIENT COUNT: 226; ECHO COUNT: 7 DAYS 6 AND 7: These days were spent traveling to Manali. After four hard days and nights in the cold weather outside in tents with only occasional bucket showers, we were all ready for a reprieve. A couple of notes on the patients we saw this week: it appeared that the majority of our patients complained of eye issues, and there were several children who had severe cerumen impactions. So far, we have not had any patients with congenital heart disease, but as I type this I realize that we have seen several patients with severely stunted growth, which we were attributing solely to malnutrition. Now I feel it may be worthwhile to do some screening echoes on these patients. Also, many of the kids here have permanent hearing loss from severe, Chronic, recurrent otitis media with complete loss of their auditory ossicles from these infections. So many children had perforated tympanic membranes, and it appears that their ossicles just fell out! Finally, I have yet to see one patient who is volume-overloaded despite the several patients who I noticed had systolic heart failure; in fact, most of these patients were dehydrated. I think this may have something to do with the high altitude and active lifestyle these patients all lead. PATIENT COUNT: 89; ECHO COUNT: 4 WEEK 2: This week we left Manali for our next camp site a few hours away right by the Bias River in Himachal Pradesh. We also happened to be less than 100 feet from the entrance of a Buddhist monastery village. DAY 8: This day was a tough day all around. I started out not feeling so well and then we started getting a cold, torrential downpour on the way to our clinic site. Fortunately, the terrible weather in the morning was followed by clear skies and a beautiful afternoon, which brought some very interesting patients, including an 80-year-old female with complete heart block (HR 41 and BP 250/60) with severe aortic regurgitation (AR) and severe mitral regurgitation. She was sent to Indra Gandhi Medical Center (IGMC) in Shimla for emergent intervention. We also correctly identified a patient with significant tricuspid regurgitation by physician exam, which we confirmed with echo. Finally, we had another patient with severe AR who we also sent to IGMC for surgery. PATIENT COUNT: 226; ECHO COUNT: 6 DAY 9: Our clinic today was situated in a nunnery built on the side of the mountain. It was unbelievable how gorgeous this place was. I even asked around to see if they needed an extra nunnery physician – unfortunately that position was not available. We saw a little over 100 patients today and all of the nuns were in fabulous shape – there were even two giggling nuns trying to get me to compare my biceps to theirs. PATIENT COUNT: 106; ECHO COUNT: 3 DAY 10: Today, we went to a school where we saw a combination of children and older villagers. This was our sickest day of all our clinics thus far. There was a 60-year-old woman with tachypnea to the 40's. She had difficult-to-hear heart sounds, a precordial RV heave, a combined c-v wave, and pulsatile hepatomegaly. The echo found that she had severe mitral stenosis, severe tricuspid valve regurgitation, and a dilated right ventricle (RV) with RV failure and an underfilled LV. She had been referred for surgery before but could not afford it. She admitted to not being able to afford her medications (warfarin, spironolactone and digoxin). I grabbed Ravi, the head of the Himalayan Health Exchange and he offered to pay for her transport to IGMC. I only hope she made it to the hospital on time. We also saw a 54-year-old female with atypical anginal pain with anterior wall motion abnormality and LV dilation. She was medically managed by us in our clinic (without a statin, since we didn’t have those on hand) but also sent for diagnostic cath at IGMC. Students here are becoming very facile with echocardiography and are quick learners. They are now teaching each other. Almost everyone can obtain three of the basic views now on their own. PATIENT COUNT: 250; ECHO COUNT: 7 DAY 11: Today, we had our clinic at a Buddhist monastery adjacent to our campsite. Things started out very calmly and quietly but, by the end of the day, we had seen over 350 patients, done more than 10 echoes, and sent several people to the hospital. What a day! We didn’t finish until almost 7 p.m. and, as if by divine intervention, a puppy ran into the clinic field and made everyone’s day. We all took photos with the cute ball of fur, said our goodbyes to the monks and headed back to our campsite where we had a quick dinner and went to bed. PATIENT COUNT: 360; ECHO COUNT: 15 WEEK 3: I am very tempted to become a monk. So far every Buddhist monastery we have seen has been absolutely gorgeous, with views of snow-capped mountains in the background and breathtaking 360 degree scenery. DAYS 12 AND 13: Started these days off by watching a prayer/meditation chant in the monastery and learned about Buddhism from my new monk friend, Tenzing. We went to a local school and performed many wellchild checks. We also did several echoes, with two revealing at least moderate aortic stenosis (one was severe) and both with AR. Both had excellent physical exam findings and the medical students were able to pick up on the physical exam findings without an echo. One had perfect pulsus parvus et tardus. These past weeks have really seen the ultrasound machine become an integral part of the clinic. I’ve also started an echocardiography lecture series after dinner for an hour or two, three times a week. The other awesome part of being here, in addition to helping all these patients (over a thousand so far!), has been having the opportunity to interact with so many enthusiastic learners. We work hard and play hard. Being a physician interested in clinician-education, this is a very cool environment to be immersed in for a few weeks. PATIENT COUNT: 222; ECHO COUNT: 5 DAY 14: Went back to the same school today. I saw the largest goiter I have ever seen and also the largest dental abscess with preseptal cellulitis and spread into the maxillary sinus. We did an echo on the cutest 80-year-old grandma, who turned out to have severe aortic stenosis and moderate AR. She wanted us to take her photo, and we ended up giving her some aviator sunglasses, which she rocked. Her family was very involved with her care and wanted to take her for a surgical opinion in Shimla. I also got to do some echoes on children who we were concerned had congenital heart disease. Fortunately they checked out normal. PATIENT COUNT: 205; ECHO COUNT: 6 DAY 15: Had a crazy thunder and lightning storm overnight, and the camp got flooded. Thus, we decided it was safest to cancel clinic and have a free day. We traveled to Kullu in the afternoon, where we spent most of our time trying to find a café with functioning WiFi, after visiting a beautiful Hindu temple in the morning. DAY 16: Today we went to a clinic site in-between several villages, high up in the mountains surrounded on all sides by vertical cliff faces and ice-capped peaks. It took us about an hour drive to reach the site from our monastery guest house. I started out the morning by diagnosing two patients with aortic insufficiency, but neither were severe enough to warrant surgical intervention. We also had an interesting case of ichythiosis in a child, as well as a 30-year-old male who came in complaining of shortness of breath with a largeBlood pressure differential between arms but no femerz-ocarotid delay and strong bilateral femoral pulses. I did an echo, which also happened to show that his ejection fraction was down to 20 percent which was news to him. Fortunately, he was well-compensated, so we did our best to start him on whatever medical therapy we could and advised him to follow up with the nearest cardiologist (who is five hours away). The highlight of the day was a 65-year-old woman who came in accompanied by the cutest little sheep that followed her around everywhere. The woman left triage and went down to the medical tent. When the poor sheep noticed that it’s owner was gone, it freaked out and rushed down the hill and ran all around the medical camp saying “Maaaaaa, Maaaaaa!” PATIENT COUNT: 170; ECHO COUNT: 8 DAY 16: This was a travel day. We traveled to our campsite in Barot and were surrounded by cliffs and mountains on all sides. Tomorrow is our long half-day hike up at least 1,000 feet to reach Bir and then later Dharmsala – the home to the 14th (and current) Dali Lama. DAY 17: We hiked from Barot to Bir today which involved a vertical climb and fall of 2,500 feet, respectively. The hike lasted a little over 20 miles and was gorgeous but tough. Being as adventurous as I am, I decided to round out the hike by opting to hike the rest of the way down. Big mistake – it was worse than the uphill climb! Both us and the mountain goats were falling and slipping as the forest ground was covered with very slippery, dried leaves. We made it back in one piece, but I am exhausted as I type this and sore from head to toe. It was totally worth it, however! DAYS 18-20: These three days had us visiting a local branch of the Tibetan Children’s Village (TCV) Clinic in Bir, India. The TCV is one of the largest amalgamations of Tibetans outside China. Tibetans send their children to these boarding schools where they are taught the Tibetan language, in addition to English and Hindi. They are steeped in Tibetan culture, in addition to learning the usual school subjects. I noticed a few interesting things while here. There is a high prevalence of Hepatitis B in this population. The head nurse asked me if I could ultrasound livers on over 40 of the 1,000 people on campus. I also saw a 5-year-old who was post-atrial septal defect repair with an 18 mm Amplatz device four months prior. On our final day of clinic, some of the wonderful Himalayan Health Exchange staff asked me to do echoes for them as they were very curious about the machine and wanted their hearts checked. PATIENT COUNT: 1,003 (OVER THREE DAYS) ECHO/ULTRASOUND COUNT: 60
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