Clerkship: International Elective

The goal of clerkship rotations is for students to acquire a defined body of knowledge, skills and attitudes necessary for the recognition, understanding and management of the common and unique health care problems. During each core clerkship and elective rotation, the PA student will participate, in a supervised capacity, in the care of patients presenting to the specific health care setting (Emergency department, Clinic, in-patient ward, etc).

International Elective – India 

  • Location: Indian Himalayas
  • Length: 2 weeks (4 week trip)

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Himalayan Health Exchange

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Dusty mountains + UV rays

Our program allows us to go on an international elective but we were responsible in finding an organization. Two classmates of mine were determined to do one and did some research. They found the Himalayan Health Exchange and our program approved of it. It is a trekking/clinic medical trip that starts in Leh, Ladakh and ends in Chandigarh. The medical team travels on foot to remote villages and provide primary health care to the villages. This particular trip was scheduled in August, so technically anyone from my class can go as all of us are on electives at that time.

I was debating whether or not to go because

  1. I have never done something like this. It is a four week trip in the Indian Himalayas with limited communication (we get some mules and sherpas)
  2. The itinerary includes trekking hours a day to each village and camping
  3. It was not an inexpensive trip.

After discussing it with one of my classmates who is going, I decided to go. My rationality was that it is a once in a lifetime opportunity. It would be harder to do something like this once school is over. I have the luxury of going with people I know as well. I have camped before and trekking I thought shouldn’t be an issue if I trained. I had enough money from OSAP to go on the trip, though I would be terribly broke after. The experience would be worth it, I convinced myself.

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Sunseting before dinner

Pre-trip preparations include:

  1. Getting an Indian Visa
  2. Purchasing gear
  3. Medications
  4. Booking flights
  5. Training

The Indian Visa was pretty easy – we got them within a week of visiting the visa centre in Brampton. I had fun looking at equipment and gear but I was lucky I was going with a friend who is experienced with camping to advise me on what to get. This includes a sleeping bag, a sleeping pad, water purifying solutions, etc. We also had to get vaccinations and medications. One important medicine to get if considering going to places of high altitude is acetazolamide (Diamox), as it helps decrease the risk of getting acute mountain sickness. Training wise, I did some stairs at the Chedoke in Hamilton and ran a bit here and there after a clerkship day (yes, this all happened while I was still doing other rotations!). However, I did not train as much as I should have been and I definitely regretted it. I’ll tell you why later.

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The beautiful monastery where we had a clinic for the monks

A typical day

Our days are pretty simple. As my friend said, the hardest decision we had to make on a daily basis was “Should I get another pancake or not”. At 7:30/8AM, we would wake up, empty our bladder, brush our teeth and start packing up our tents and bags for another day of trekking. Breakfast is also served around this time. We start our trek, with lunch in between, stopping ever so often to reapply sunscreen. After hours of walking, we set up camp. Dinner starts at 6 or 7PM. Repeat! Hot bucket showers were available every 2-3 days. We try to do laundry whenever with can with the running stream water.

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You cannot appreciate it in the pictures but this was a pretty steep hill

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Trekking was very difficult the first two days because I did not train at all and definitely underestimated the incline and low O2 saturation. When they were passing the pulse oximeter around, I had the lowest O2 sat and was tachycardic. The guys from Denver were still satting at 95%! So acclimatized! The mountain also had its own temperature swings; it was like going through menopause. 1 minute you’re cold and the next you need to take off all the layers.

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Our team consists of doctors, residents, medical students, PA students, and the HHE staff

Sometimes we get a rest day where we explored the surrounding areas (lots of rocks, water, and hills). Otherwise, it’s a clinic day. The clinics are set up in that there is a triage area, clinic stations with residents and medical students, and a pharmacy for medications. We rotate through all of these. It is a pretty good pace and we have quite a lot of villagers who came by. There was also a lot of road workers too. After a few clinics, I realized that the medications we gave them are only temporary. With only a 14 day supply of acetaminophen and ranitidine, is what we’re doing sustainable?

All students were assigned a clinic topic to present after clinic days. All research and readings had to be done prior the trip (no internet access). We covered topics such as acute mountain sickness, leprosy, rheumatic fever, etc.

We were creative in what we did during our free time. There was no wifi. We played A LOT of card games and monopoly deal. A bunch of our team played cricket with the locals and kitchen staff. Others brought books to read and traded them around. We had a dog who followed us for a day on our trek (and left us when he found another group of trekkers). At night, we would stargaze. It was beautiful, all the constellations you can identify and the number of shooting stars that came down.

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Common medical conditions I encountered during my rotationimg_0055

  • GERD
  • MSK pain
  • Dental hygiene – tooth extraction
  • Visual – pinguecula, pterygium, decrease visual acuity
  • Well child check – lice, warts, otitis media

Interesting cases

  • Pott’s disease
  • Chlamydial Conjunctivitis
  • Pilar Cyst
  • Tinea Versicolour

What I learned

Being in a remote area with limited medical access gave me great insight. I started to question whether what we are doing have an impact. HHE is taking action to being more sustainable and I like how the organizer attends these trips yearly with the medical team. He also organizes clinic in the closest cities so that if any patient needs surgical intervention or imaging, we can direct them there.

I learned big life lessons on this trip. The first one being to keep an open mind. What allowed me go through those 4 weeks was partly because I kept an open mind. I got to know my classmate, whom I shared a tent with for the entire trip, very well. We grew to be very close and comfortable with each other…literally haha. She also kept an open mind on this trip. I am actually so proud of her because she is a very clean person and had never camped before so we were a bit worried. However, she proved us all wrong! She had the most positive attitude and made the best out of every situation.

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I was not the best/fastest hiker. In fact, I was always with a few others who are trailing behind. However, comparing myself to others was the last thing on my mind. If I needed to take breaks, I took them. I learned to take things one step at a time…literally. There were some steep inclines and long tumbles if we made the wrong step. It was difficult to breath as well. All I remember was telling myself, “One step at a time” and pushing through the lactic acid building up in my legs. I know that I would eventually get to my destination but at that moment I really needed to focus on getting there, taking deep steady breaths, putting one foot infront of the other. Along the way, I also learned to stop and take a look at what was around me. The views were breath taking and I am still very proud of myself for getting to the top on my own two feet!

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Overall

1 month, 100+ miles of hiking
8 villages, 540+ patients
1800+ eggs

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It was a great experience and I did not regret going at all! The friends I made and what I learned from them were invaluable. We had the most amazing supervisors and kitchen staff who fed us so well. If I were to do this again, I would probably pick a trip with less trekking and more clinics. It was just that this was the only trip available for August. I highly recommend this organization. We were the first PA/PA students they took and told us that they’re happy to have more of us come to their other trips!

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The kitchen staff made pizza and cake with no stove or oven. We think there is sorcery happening in that kitchen tent!
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