JUN-B-6
A FULL “ACADEMIC DAY” AT INDIRA GHANDI MEDICAL COLLEGE
AT SIMLA AFTER A COURTESY CALL ON THE “KING OF KINNAUR”
AND THEN ROUNDS AND PATIENT PRESENTATIONS AT
THE MEDICAL SCHOOL BEFORE THE ROAD TRIP TO NARKANDA
June 15, 2002
I have just arrived at the Hatu Peak room, the top (third) floor “penthouse” room of the Himachal Pradesh Tourist board’s hotel in what I remember from my original visit in 1998 as a ski resort here in Himachal on our way to the Kinnaur Valley. I have had a busy day with a lot of attention focused on me, for which I believe I had to rise to the occasion and get above the sniping from a wannabe team leader who is still holding forth on his vast experience, having made two prior trips to India to do much the same—nothing. Two trips are as many as I have made---last month---to India and half as many times as I have been in the Spiti Valley. But Bill Norton, who is only a couple years older than I but looks another twenty years older than that is still telling the students, that as the leader of this group, he has some good advice to give them from his prior experiences in India. He is not only not the leader, but is the single most useless participant, who is now more than deadwood to be carried but someone who must continuously be corrected. If he would like to take over as the leader, two people in that position are unnecessary and I have other things to do, so maybe he should take over the responsibility for the next 1200 patients and the next two trips as well. Since he has never been qualified to solve a single patient’s problem, he would probably not want to be entitled to that job, so he will assign that to one of his worker bees while he goes about the task of interviewing selected participants for his book he is writing on this expedition, something that has never been done before, he says. He has also been wrong about nearly every other pearl he has imparted to the students from his leadership position at the head of the table at our gatherings, so I may have to public ally shoot him down since he relishes the public forum to announce his close association with Ravi which he seems to think grants him the title to author my book and take credit at all official functions.
Right after breakfast when the HP government’s official driver had picked me up, I was driven up the very steep hairpin switchbacks to the top of the hill we had climbed yesterday to the prominent house on the hilltop which had been built in 1853. It was built by the British for the British administrators of the Raj, and he had to get a special exemption to be the first non-British purchaser. No that he had any trouble proving where he had come from! He is the 132nd in an unbroken line of local Kings over the seven hundred year period of the Kinnaur Kingdom in this area. He is “Bumiputra”, “to the manor born.” He was crowned in the wooden fort with the temple and central place “keep” for the era of the armed bowmen archers in this feudal society ruled by his family for more than half a millennium. As part of the British concession to keep the traditional royalties, they had to agree to tear down the outer ramparts of the fortress, leaving the central keep and the palace and the Hindu temple intact. I had climbed to that area on my second day in Sangla, seat of the Kinnaur kingdom, in 1998. I had remembered seeing posters of the king, crowned now with the emerald green felt of the Kinnaur cap. As the already crowned king of the area, he entered politics, and stood for election to the HP congress party candidate, and was defeated by one vote. The opposition which had charges of corruption then which seem to be confirmed now, had made a coalition with another opposition party regardless of diametrically opposed ideology, and with this unprincipled accession, gathered the one vote that put him out of power. As detailed yesterday in the reading I had down about the VJP party and the current Prime Minister, made out to be a sleepy lush, the VJP will be on its way out at the next December’s campaign and February elections with the March new government, likely to be headed by “Raja Sahib,” as the constituents call him reverently, whereas his full name is “Raja Vir Bhadra Singh.” His nephew, Rajeshwar Singh is out of the royal succession line, as is his daughter and her retarded son Digvijay (ironically meaning "Victory") Singh, whom we examined yesterday in the same house. Since a daughter does not count in the royal lineage, a long line of primogenitor sons---132 generations and still going strong, is a near record with one other princely family in India about the same lineage. .
He is campaigning now and makes frequent tours through his district, holding audiences as often as he is in Simla between ten and one PM each day like a Middle Eastern sheikh in his majlis. He also took about ten phone calls while I was there from petitioners. He is a consummate politician.
He is also diabetic, and has lost control of his sugar frequently, with weight gain and decreased exercise, despite the walking up and down hills of his very vertical district, making his own form of house calls. We offered suggestions about how to decrease his weight and how to work together on the tweaking of his list of medicines to decrease his insulin and to increase his Avandia etc. He had a coronary bypass in Delhi in 1995, and says he is trying to get to exercise into his program for daily activities. I teased him about many things, since royalty or not, he is a back slapper of a real politician, and we could enjoy our meeting together, since we had nothing to request from him. His wife appreciated our candor. Along with a young cardiologist, Dr. Nagy, who is looking after him, as well as after Baldev’s father, I went over his meds with Michael Eifling, who has a vested interest in diabetes control, since ehe is a juvenile diabetic on an insulin pump. We gave some advice on exercise, with the ususal disclaimers from the patint that he would try. His wife preensted me a boc of himacahl cherries as a gift, and we got into the official limo and drove off to the IGMC, where the whole group was awaiting me.
They postponed the grand rounds conference for fifteen minutes more as I sat in the office of Dr. Mawatia, chief of surgery, and we made small talk getting to iknow each other. The very eager “senior registrar”—this is a British training system—took my slides and they fitted them in to a tray to show, often upside down and backwards. They had gathered a large group—three tiems larger than any group in front of which Ravi has ever stood so he got very nervous saying he would have Dr. Glenn do all the talking. So, after florid introductions I launched into a speech on the subject of “Tropical Surgery” although they had expected I might say something about an advertised subject of hypothyroidism—the carrousel of slide that could not fit into my carryon bag with a large batch of the things I am still missing without the bags I left in Delhi and which will probably not appear until after Tabo, as I shiver in the mountains.
They were very interested in the subject, and I played it since they do not have a lot of guest lecturers, and were very attentive and eager. So, the lecture extended well beyond the time allotted as they were still hanging on to the unknowns I had showed them of classic presentation sof the kind of things you only can find in textbooks or in Africa. So, the lecture concluded, they wanted to show me their equipment and their patients, and we made rounds—along witht eh entire entourage, inclding people who had never made rounds before.
I saw a woman with a large hydatid cyst of the liver. They told me that hydatid cyst disease was very common here, including cysts of the liver lungs, and spleen, which they treat with albendazole and then resect it with some kind of scolicide soaked sponges placed around it. There was a grat deal of gall bladder disease, with almost all of them having common duct stones. It was explained to me that the simpler ones were done at the district hospital. The gall bladders themselves are done through a minimal muscle splitting “mini-invasive” operation, not laparaoscopically. We saw several women with advanced breast cancer, including one with a large fixed tumor fungating through the nipple and areolar complex. One womn had a large granuloma in hier neck, since she had been getting “local treatment” by some outside practitioner applying hot irons to a nodue in her nec. This was follicuarl carcinoma, so she was in to get a bit more orthodox thyroidectomy.
Dr. Nagy showed us several patients, including a young woman with rheumatic fever and shortened cords and a stenotic mitral valve, with a good display on echocardiogram. Then he proudly showed us the angiograms stored on CD of a number of coronary catheterizations they had done. We saw one woman who had hypertension after treatment for gall bladder disease, who hade Takyashu’s thyroiditis.
It was a fast tour, but they were delighted with my visiting professorship and wanted to schedule a return trip to do the lecture they had advertised on goiter and hypothyroidism.
We then packed everyone off after luch at the Holdiay Hokme in Simla to go to Fargo, where all of Ravi’s relatives and the Simal Mafioso live Now we had to see theneighbors and relatives who had medical complaingts, and who allhad come to have the “head doctor” examine them in thei make shift setting. Ravi also got me a fleece pullover for the only warm clothijhng I willhave as we now are climbing higher and heading into the Kihnanu Valley. At present we are at the rainy monsoon season height of 2710 meters (9,000 ft) and will be going down to the Sutlej River and following it to get to Sangla over rough switchback roads around avalanches and flood damage from the recent wipeout---said to be sent to India at midnight from China!