On my last day in clinic, I feel a little strange... maybe out of place. I know i'm leaving and that this is the last time i'll see this clinic - somehow i've already distanced myself. Yesterday I asked Dr. Sunil if the clinic could use some Doxycycline because some previous students have literally left bottles of the antibiotic behind trying to save space in their suitcases. Nobody here at the hostel has claimed it and i'd rather see it go to someone who needs it than sit around and go bad. So I waited out side the wards and dropped off the containers; Dr. Sunil was a gracious mentor and good ambassador to the students who have gone through there. In the back of my mind I feel like there is some sort of professional relationship that could be fostered between KU and CMC to develop new ideas and growth in the area of implimenting primary care with Dr. Sunil... but I can't quite solidify what that is yet, so I say nothing other than thank you for a wonderful experience. For a couple of hours I sat near the treatment room for patients coming in to get their penicillin prophylaxis shot for their rheumatic heart disease. They would first get a test patch on their skin to see if they had a reaction to the penicillin. In the half hour they had to wait to see if they reacted, I got to listen to their hearts. They ranged from barely audible murmurs to murmurs so loud I wondered if they could hear them the way you can hear your own heart pounding in your head sometimes. I was able to distinguish systolic vs diastolic, grade, and location but I realized that I had a hard time picking up the regurge on the murmurs... I need to buff up on my cardiology. It was a brief morning for my last day, but it was a good day. Now i'm back at the hostel packing and washing clothes before I head out on my night train this evening after one last dinner at the Darling Residency (great food ;-> ). Again, it's a weird sensation packing... I feel some nostalgia for leaving but I also realize i've only been here for 3 & 1/2 wks. Should I have nostalgia? Is it nostalgia, or just another wonderbug woking on my gut? I guess i'll find out soon enough. One thing I can say that i'm not going to miss is the ever increasing heat that is here to stay... it's hot now, probably 15-20 degrees hotter than when I arrived.
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Tuesday, February 24, 2009
Mahabalipuram
This weekend I ventured down to Mahabalipuram (Mamalapuram) with David Lee. Another med student that I met on the interview trail. His medical training is somewhat unique though in that he applied to a US program that is based in Isreal. We headed out early on saturday morning and got to our first bus transfer in Kanchipuram. From there we managed to get onto a direct bus that went through Chengleput, but didn't require us to get another bus from their to Mahabalipuram. Overall it took us about 3.5 hrs by bus, not bad. On arrival into town were landed next to a public demonstration against the violence between the Sri Lankans and the Tamil Tigers (Tamils in Sri Lanka who want their independence, if I understand correctly). It was a very vivid image for someone who doesn't speak tamil and can only derive information from facial expressions and other visual clues like demonstrators dressed in black and waving black flags... I thought about taking a picture, but my better judgement won the arguement so I have no visual aid to offer. Next we headed towards the beach to try and find a place fairly close to the shore. By about 1 pm. we were checked in and looking for lunch and we found it by wandering to the beach. After a feast of masala fried fish (deep fried spicey fish), french fries, and fresh lime soda (a wonderful drink i'm only now discovering that involves fresh squeezed lime that you mix carbonated water with sparring amounts of sugar... otherwise you create a momentary volcano, which is kinda fun too), we wondered down the beach in the direction of the only temple we could see. After coming to a fence that surrounds the complex and discovering we had to walk all the way around the fence to get in, we finally got to see the temple up close about a half hour after originally being within 100 ft of it. Instead of plagerizing Lonely Planet, i'll just include a link to a website that explains the temples ( http://www.mahabalipuram.co.in/shore_temple_at_mahabalipuram.php ). An interesting and understandable note, foreigners are required to pay 250 Rs. for entrance to the Shore Temple and the Five Rathas, citizens only have to pay 10 Rs. I was a little confused by the spectacle that I saw throughout the day as we visited the sights... it's my understanding that the temple and the structures like the Five Rathas are somewhat sacred, yet the entire day children and adults alike climbed around these ancient structures like they were a jungle gym. There were hordes of school children on field trips Saturday, so we're not talking one or two kids acting a little unruly. Combining this with locals hawking their goods more zealously than places i've previously visited before, I found my patience and basic trust in my fellow man wearing thin by the end of the day. Along the way toward the end of the afternoon we came across a man trying to sell rock carved pendents. Mahabalipuram is world renowned for their trade of rock sculpting and are still commisioned world wide to work on temples and statues. Almost everyshop in town sells ridiculously ornate rock carvings, so this man selling small pendents while we were trying to sight see didn't have a chance at a sale. In our moment of weakness, as the man sat down in the shade almost as if in resignation, accepting that he was done selling for the day - the man struck up a friendly conversation about where we were from and what we were doing in India and even offered a few tid bits about the history around us. Eventually he somehow became our un-official tour guide for the remaining bits. At the end of which, he invited us to see his rock carving shop... conveniently located at the end of the tour. At which point he confirmed his previous story of being a teacher of rock carving to students that worked at his shop - we saw them in action. We even got to talk to one named Dilip (Indian for Phillip) age 19. The nail in the coffin was accepting the tea and cookies... we felt obligated to buy something, even though we swore off buying anything made of rock as the truly beautiful carvings had no chance of making it on a backpacking trip and the more robust pieces were too heavy. I opted for two small pendents and David chose a simple elephant... only after choosing all the pieces we wanted were we given a price ;-> Ah, I wish there was a way we could have just made a donation... I'd feel better about donating something to a good cause than walking away with our trinkets feeling hosed. After confirming the outragous prices we paid, even after bargaining for a good 15 min., with other street vendors - we chose to BELIEVE that everything we were told was true and that we were in fact helping support kids learning the trade at the local colleges! Later that day, as we were watching the sunset in the park we ran across Dilip once again. This time he and some other boys were flying kites and engaging in the occaisional battle... he stuck to his story and we got to see a spectacle not unlike the magnificent flying scenes from the Kite Runner. Other than the fact that it seemed like 19 was a little old to still be flying kites... I felt much better about my purchase earlier in the day- although I remained a shrewd bargainer for the rest of the weekend.
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L.C.E.C.U. Round 2/23/09
In my final week here in Vellore, I opted to go back to LCECU as I enjoyed my first week there... and partly because I originally had designed my time here to be split up into 2 one weeks rotations and 1 two week rotation. This morning was kinda of slow to get going, as monday mornings usually can be - those in charge not showing up till 8 am. I had a nice chat with a OB/Gyn physician origonally from Detroit who once tried some tropical medicine courses in the Amazon where she met a group of people who were headed to Vellore, she accepted an invitation to travel with them and decided to stay for a while once she got here. She had just returned from a trip to Mysore this weekend and so we chatted about what I should see while i'm there during my travels. She was also the second person to discourage me from going to a wild life park as they aren't designed to allow people to see any wild life. Instead she recommended I visit a nearby town with some old ruins of a fort that she particularly liked. It was a nice chat!
One chore I wasn't looking forward to was asking whether or not in the week that I've been gone, with a friendly reminder this last thursday, if they had managed to get my required evaluation form filled out. I know KU needs some tangeble way to evaluate the month, but it truly is a pain and inconvenience to everyone involved to make it happen. It's hard enough to get evals filled out by our attendings back in the states, let alone a physician over seas that we've only worked with for a week. So, I did ask, and of course nothing had happened. I didn't make a big deal out of it, but it did seem like I had put them at an inconvenience for bringing it up again. Oh well, it finally got done today and what's done is done... I've got my required eval.
On a brighter note, I got to see some interesting pathology with the most classic case of Molluscum Contagiosum that i've ever seen. We also had an interesting talk about how patients manage to keep their insulin useable at home after a lady presented in possible DKA or lactic acidosis from being on Metformin while in renal failure. With insulin it's important to keep it refrigerated or cool, otherwise it starts to breakdown and does not work. So with the lack of refrigeration available to the typical LCECU patient, I wondered how the insulin did any good at all. Apparently by storing the insulin in a small clay pot that is set into a larger clay pot with water and out of the sun... it stays cool enough to have some activity, and they learn to adjust the amount accordingly. It's not the best medicine model, but it is the most effective model for these patients.
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One chore I wasn't looking forward to was asking whether or not in the week that I've been gone, with a friendly reminder this last thursday, if they had managed to get my required evaluation form filled out. I know KU needs some tangeble way to evaluate the month, but it truly is a pain and inconvenience to everyone involved to make it happen. It's hard enough to get evals filled out by our attendings back in the states, let alone a physician over seas that we've only worked with for a week. So, I did ask, and of course nothing had happened. I didn't make a big deal out of it, but it did seem like I had put them at an inconvenience for bringing it up again. Oh well, it finally got done today and what's done is done... I've got my required eval.
On a brighter note, I got to see some interesting pathology with the most classic case of Molluscum Contagiosum that i've ever seen. We also had an interesting talk about how patients manage to keep their insulin useable at home after a lady presented in possible DKA or lactic acidosis from being on Metformin while in renal failure. With insulin it's important to keep it refrigerated or cool, otherwise it starts to breakdown and does not work. So with the lack of refrigeration available to the typical LCECU patient, I wondered how the insulin did any good at all. Apparently by storing the insulin in a small clay pot that is set into a larger clay pot with water and out of the sun... it stays cool enough to have some activity, and they learn to adjust the amount accordingly. It's not the best medicine model, but it is the most effective model for these patients.
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Karigiri: Day 4 Mobile Clinic and Orthotic Workshop
Today we went on a mobile clinic to a local village and got to see various dermatological pathology such as tinea corporus. We got a patient with chronic cough for a couple months, so we asked them for a sputum sample to check for TB. One of the most memorable patients was a lady that had a BTK (Below The Knee) amputation because while having a seizure one of her legs flailed into an open fire... we just did a quick check for ulcer's on the stump and managed her seizure meds. All in all a pretty relaxed morning that was mostly consumed by making casual medical conversation with the Dr. for the day.
One of our biggest frustrations at Karigiri has been the very structured schedule that doesn't start on time, but has three to four hr periods of down time between morning clinics and afternoon clinics that hold us hostage. If we could just have a half hour for lunch and knock out the afternoon session right after, we could get a head start on the hour commute back to our hostels and get some other stuff done with the day. As it is now, we get back closer to six in the evening. I know, I know - IST (Indian Standard Time) rules the land ;->
So this afternon when we got back from the mobile clinic we went over to the location for the afternoon session and asked if we could start a little bit early... which i'm glad we did because it turned out to be a really unique experience! Karigiri manufactures it's own microcellular rubber from raw rubber stock produced in Kerala, and then uses it in make custom orthotic shoes as well as prosthetic devices. We got to tour the workshop, rubber mill, and even had the opportunity to purchase a custom fit pair of orthotic chappals (sandals) - for a whopping, wait for it, 450 Rs. ($9)... custom, and they did it in under an hour for four of us! I had read in Dr. Paul Brand's book, The Gift of Pain, about the research that went into finding pressure points of leprosy patients extremities and the long process of creating new ways and devices for combating their ulcers. After wearing my new chappals home from Karigiri, i'm a firm believer that the microcellular rubber disperses the pressure on the bottom of your foot more evenly and thus reduces pressure on the pressure points... you ask how, because the sandals I had been wearing had given me a blister in exactly one of these pressure points that has had me limping for the last couple days. With the new microcellular rubber insole sandals on, I walked without a limp and could barely notice the discomfort. It was amazing to see them work, fast and efficient and doing it for literally pennies on the dollar... yet another example of a low cost efficient system. They could even recycle the scraps of rubber into new batches. The icing on the cake was to see that the hard sole put on the bottom of the sandal was made from used tires! After nearly a month of seeing mountains of trash lining streets and a total disregard for throwing trash into trash cans, these guys are recycling! It was a neat afternoon, and we're glad we started early cause we ended up staying the entire afternoon.
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One of our biggest frustrations at Karigiri has been the very structured schedule that doesn't start on time, but has three to four hr periods of down time between morning clinics and afternoon clinics that hold us hostage. If we could just have a half hour for lunch and knock out the afternoon session right after, we could get a head start on the hour commute back to our hostels and get some other stuff done with the day. As it is now, we get back closer to six in the evening. I know, I know - IST (Indian Standard Time) rules the land ;->
So this afternon when we got back from the mobile clinic we went over to the location for the afternoon session and asked if we could start a little bit early... which i'm glad we did because it turned out to be a really unique experience! Karigiri manufactures it's own microcellular rubber from raw rubber stock produced in Kerala, and then uses it in make custom orthotic shoes as well as prosthetic devices. We got to tour the workshop, rubber mill, and even had the opportunity to purchase a custom fit pair of orthotic chappals (sandals) - for a whopping, wait for it, 450 Rs. ($9)... custom, and they did it in under an hour for four of us! I had read in Dr. Paul Brand's book, The Gift of Pain, about the research that went into finding pressure points of leprosy patients extremities and the long process of creating new ways and devices for combating their ulcers. After wearing my new chappals home from Karigiri, i'm a firm believer that the microcellular rubber disperses the pressure on the bottom of your foot more evenly and thus reduces pressure on the pressure points... you ask how, because the sandals I had been wearing had given me a blister in exactly one of these pressure points that has had me limping for the last couple days. With the new microcellular rubber insole sandals on, I walked without a limp and could barely notice the discomfort. It was amazing to see them work, fast and efficient and doing it for literally pennies on the dollar... yet another example of a low cost efficient system. They could even recycle the scraps of rubber into new batches. The icing on the cake was to see that the hard sole put on the bottom of the sandal was made from used tires! After nearly a month of seeing mountains of trash lining streets and a total disregard for throwing trash into trash cans, these guys are recycling! It was a neat afternoon, and we're glad we started early cause we ended up staying the entire afternoon.
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Karigiri: PBIHC - Day 3
In my attempts to catch up on my entries, arranging travel, and uploading pictures I find myself staying up later and getting up earlier. This morning I was rewarded for my efforts! After spending over two hours last night trying to purchase a flight from Dehli to London without success due to something the website didn't like about how I entered my credit card information, this morning on my first attempt with a different credit card - victory was mine ;-> I even was able to blog successfuly this morning before leaving by 7 a.m. to make it to Karigiri by 8 a.m. I've come to appreciate the small victories even more during my time here!
On to the PBIHC, which stands for the Paul Brand Integrated Health Center. This morning we were designated to attend a diabetes workshop there and I had high hopes due to the fact that this center was named after Dr. Brand. Unfortunately, the clinic was somewhat of a let down and no one offered to explain exactly what the mission of the PBIHC is. After again arriving on time, the clinic began on IST. The Dr.'s in the clinic we began the morning with weren't interested in teaching or translating so I quickly moved on to another station at the clinic that examined the patient's feet, tested and measured sensation, and calculated ABIs to evaluate for peripheral vascular disease that quickly complicates the life of a diabetic. Fortunately these stations, run by the Occupational Therapists and Physiotherapists, were much more interested in explaining their work and translating conversations... I stayed for the rest of the morning. Also at one of these stations, I ran into a Dr. from Bolivia who is here at Karigiri for a 3wk course on diabetic ulcer care. The pioneering research and techniques perfected at Karigiri for caring for and preventing wounds caused by the insenstivity to pain that leprosy patients suffer from, directly translates to diabetic foot ulcers.
Haggling with the auto drivers is a constant chore and a delight rarely, at least for me. They seem to enjoy the sport quite a bit. On the way from the PBIHC to Karigiri Hospital we need an auto and as we were debating rates I swear that I heard the man say "60" to which I said ok. When we arrived I handed the man a 100 Rs. bill to which he gave me 35 Rs. change. After about a minute of debating the 5 Rs. in change and being robbed of my only leverage (money) I decided to wage a sit in. At this point my classmates began to laugh as they informed me that he really did say 65 Rs. I had to swallow my pride and exit the vehicle ;-> It's not the amount that mattered it was the principal of the thing. Yesterday they agreed for a whole trip to be 90 and when we got there we handed the driver a 100... meaning we only needed 10 Rs. in change, an amount any auto driver readily has. Seeing an opportunity to get 10 Rs. more he feigned that he had no change. We promptly pooled our change to exactly 90. After discussing this incident with other students they've had similar experiences, but I like their reaction to the "no change" scam- "so free ride then"... apparently drivers suddenly remember they have change at that point.
The afternoon was rather unproductive as we sat and watched a group occupational therapy session take place in Tamil. It was great to see the hospital addressing the social rehabilitation aspects of leprosy (Socail ostracism leaves scars just as handicapping as any physical deformity). However, the same OT that was so gracious and energetic about explaining his station's role in the diabetic clinic that very morning, let us sit for an hour and a half without explaining what was taking place or translating for us. The language barrier has proved to be a bigger issue than I thought it would.
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On to the PBIHC, which stands for the Paul Brand Integrated Health Center. This morning we were designated to attend a diabetes workshop there and I had high hopes due to the fact that this center was named after Dr. Brand. Unfortunately, the clinic was somewhat of a let down and no one offered to explain exactly what the mission of the PBIHC is. After again arriving on time, the clinic began on IST. The Dr.'s in the clinic we began the morning with weren't interested in teaching or translating so I quickly moved on to another station at the clinic that examined the patient's feet, tested and measured sensation, and calculated ABIs to evaluate for peripheral vascular disease that quickly complicates the life of a diabetic. Fortunately these stations, run by the Occupational Therapists and Physiotherapists, were much more interested in explaining their work and translating conversations... I stayed for the rest of the morning. Also at one of these stations, I ran into a Dr. from Bolivia who is here at Karigiri for a 3wk course on diabetic ulcer care. The pioneering research and techniques perfected at Karigiri for caring for and preventing wounds caused by the insenstivity to pain that leprosy patients suffer from, directly translates to diabetic foot ulcers.
Haggling with the auto drivers is a constant chore and a delight rarely, at least for me. They seem to enjoy the sport quite a bit. On the way from the PBIHC to Karigiri Hospital we need an auto and as we were debating rates I swear that I heard the man say "60" to which I said ok. When we arrived I handed the man a 100 Rs. bill to which he gave me 35 Rs. change. After about a minute of debating the 5 Rs. in change and being robbed of my only leverage (money) I decided to wage a sit in. At this point my classmates began to laugh as they informed me that he really did say 65 Rs. I had to swallow my pride and exit the vehicle ;-> It's not the amount that mattered it was the principal of the thing. Yesterday they agreed for a whole trip to be 90 and when we got there we handed the driver a 100... meaning we only needed 10 Rs. in change, an amount any auto driver readily has. Seeing an opportunity to get 10 Rs. more he feigned that he had no change. We promptly pooled our change to exactly 90. After discussing this incident with other students they've had similar experiences, but I like their reaction to the "no change" scam- "so free ride then"... apparently drivers suddenly remember they have change at that point.
The afternoon was rather unproductive as we sat and watched a group occupational therapy session take place in Tamil. It was great to see the hospital addressing the social rehabilitation aspects of leprosy (Socail ostracism leaves scars just as handicapping as any physical deformity). However, the same OT that was so gracious and energetic about explaining his station's role in the diabetic clinic that very morning, let us sit for an hour and a half without explaining what was taking place or translating for us. The language barrier has proved to be a bigger issue than I thought it would.
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Karigiri - Surgical Rounds and IST
Rush to get there by 8, then IST strikes again. But amazing surgical rounds and got to see surgery! Again, a quick summary of the day. Yesterday we vowed to be on time, which is no easy task because it takes about an hour of public transportation to get there. There is a CMC bus that goes there every day, but for some reason this bus is strictly for staff and no students are allowed to ride... so instead we foreigners stumble our way through a new bus route that takes about 45 min and then take an autorickshaw from there about 12 km to the Karigiri Hospital. Fun times. The afternoon bus ride back is especially awful as the heat boils a metal bus packed full of people as it bounces back and forth down the road. But that's besides the point. So we busted it this morning and made it to Karigiri by 8:00 a.m. on the dot, cause that's when our printed schedule said that surgical rounds began. When we walked in to ask where we should go for rounds, we got a puzzled look and the reply that rounds don't start til 9:00 a.m. Ah, kharma ;-> Despite the frustration, surgical rounds were well worth the wait. We got to see more chronic wound pathology, abcesses, and writhing maggots in one morning than I had seen in my whole pathology course! The message in Dr. Paul Brand's book was really driven home for me to see, both leprosy patients and advanced diabetics, suffering from complications of painlessness. Of course, not all of the wounds we saw were from painlessness. No, Karigiri has adapted it's services as Leprosy has declined. What they learned from their pioneering work with leprosy, applies to chronic wound care regardless of the etiology. We saw a patient with frost bite from Nepal. We saw a local gentlemen who had fallen over with his motorcycle and suffered a severe 3rd degree burn to his calf muscle. We saw about as many non-healing diabetic ulcers as we did ulcers from complications of leprosy. I believe Karigiri will continue to provide a great service to patients in the years to come... diabetes is becoming quite an issue here in India, and posed to be every bit the epidemic that it is in the U.S. The morning of gruesome sights as bandages were removed reminded me how far I've come from my first anatomy labs... instead of being repulsed, I was intrigued by the science, anatomy, and care of each wound. We finished by around 11:30, which was a good thing - once we got back outside in the fresh air we all realized we didn't have much of an appetite just yet ;-> But by the time 12:30 rolled around and the canteen opened up, we welcomed the meal.
The afternoon gave us the opportunity to watch the surgical debridement of a foot wound that had begun tracking along the synovial sheaths that line the tendons of the foot... again the anatomy and science intrigued me, although I was still caught off guard by the way some things were done. For example, we all wore open toed flip flops into the OR. We didn't handle any instruments so I wasn't worried about my own safety, but it still made me uncomfortable after being conditioned to a specific model of surgery in the US. Pain control was given after the fact if the patient was able to feel it, and then it was only a local anesthetic. But they get the job done, they do it well, and they do it for a population of patients that 50 years ago wouldn't have dreamed of such care. An attitude I have discovered to be a good way to experience another culture - it's not wrong or right, it's just different. Regardless, it was an amazing opportunity and made the morning wait worth the trouble!
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The afternoon gave us the opportunity to watch the surgical debridement of a foot wound that had begun tracking along the synovial sheaths that line the tendons of the foot... again the anatomy and science intrigued me, although I was still caught off guard by the way some things were done. For example, we all wore open toed flip flops into the OR. We didn't handle any instruments so I wasn't worried about my own safety, but it still made me uncomfortable after being conditioned to a specific model of surgery in the US. Pain control was given after the fact if the patient was able to feel it, and then it was only a local anesthetic. But they get the job done, they do it well, and they do it for a population of patients that 50 years ago wouldn't have dreamed of such care. An attitude I have discovered to be a good way to experience another culture - it's not wrong or right, it's just different. Regardless, it was an amazing opportunity and made the morning wait worth the trouble!
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Karigiri - The Gift of Pain
The mad rush back to Karigiri on day 1, then hurry up and wait. Brisk welcome. This pretty much sums up what was left of our day by the time we made it to Karigiri at 11:00 a.m. When we got there we were promptly asked why we were late and we replied in part truth, we got lost... cause we actually did, but it didn't account for 3 hours. After sitting down and filling out paperwork for 20 min. or so we got an olive branch in the form of chai tea. Then we waited for another half hour or so until the head Dr., Dr. Solomon, briskly asked one of the girls who, had just momentarily risen from her chair to look at a calaneder on the wall, to sit down. After that, he actually had a fairly warm welcome speech to deliver. After the formalities had been taken care of we wandered over to the canteen for lunch and to await the 2:00 p.m. afternoon start time for our tour of the Dept. of Laboratories. The tour was actually quite interesting. Mycobacterium leprae is actually quite hard to grow in a labratory setting. The only medium that has been found that can grow cultures, is made from the footpads of mice. Karigiri has it own mice factory and research center where they follow the resistant strains they find in patients. It was interesting to see this kind of research going on in the middle of the very arid, rural, countryside. With the tour completed we headed back to Vellore making plans for tomorrow and vowing not to be late two days in a row!
As a side note, Karigiri is of special interest to me even more now that I am reading a book by Dr. Paul Brand "The Gift of Pain". It chronicles his life experience of dealing with and treating pain. It takes a unique view point that without pain, we would destroy our bodies because we would have no warning system... and therefor pain should be looked at, to a degree, as a blessing and not a curse. He then expounds on this concept and how it applies to today. He actually worked at CMC in Vellore and then helped start Karigiri. So this week is of special interest, to see in person what i'm reading about in the book! This book came highly recommended to me, and I would highly recommend it as well! The link for it at amazon.com is below.
http://www.amazon.com/gp/offer-listing/0310221447/ref=dp_olp_used?ie=UTF8&condition=used
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As a side note, Karigiri is of special interest to me even more now that I am reading a book by Dr. Paul Brand "The Gift of Pain". It chronicles his life experience of dealing with and treating pain. It takes a unique view point that without pain, we would destroy our bodies because we would have no warning system... and therefor pain should be looked at, to a degree, as a blessing and not a curse. He then expounds on this concept and how it applies to today. He actually worked at CMC in Vellore and then helped start Karigiri. So this week is of special interest, to see in person what i'm reading about in the book! This book came highly recommended to me, and I would highly recommend it as well! The link for it at amazon.com is below.
http://www.amazon.com/gp/offer-listing/0310221447/ref=dp_olp_used?ie=UTF8&condition=used
Windows Live™ Hotmail®…more than just e-mail. See how it works.
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