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

The McMaster University Physician Assistant program accepts experience in international electives as as long as they meet our program requirements. However, it is the student’s responsibility to find an organization. Two classmates of mine were determined to do an international elective and did extensive research on appropriate organizations. They found the Himalayan Health Exchange which met our program requirements. It is a trekking/clinical medical trip that begins its journey in a small down called Leh in Ladakh, India and ends in Chandigarh, India. The medical team will travel 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 since all of us will be on electives at that time.

I was interested at the prospect of doing an international elective. However, I hesitated. I was debating whether or not to go because:

  1. I have never done something like this before. It will be a four week trip in the Indian Himalayas with limited communication (no WIFI…WHAT?!?)
  2. The itinerary states that participants should expect trekking hours a day to each village and camping overnight in tents. I have camped before so that is not an issues for me. I was more concerned about the 7-8 hours of trekking.
  3. It was not an inexpensive trip.

After discussing it with one of my classmates who have signed up already, 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 after graduating. I’d have the luxury of going with people I know. If I start training now to prepare for the trekking, it should not be too bad. 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 hiking gear
  3. Medications (Yellow fever, Dukoral, Acetazolamide, etc)
  4. Booking flights
  5. Training

Obtaining an Indian Visa was a painless process – we received them within a week of visiting the visa centre in Brampton, Ontario. I had fun looking at equipment and gear but I was lucky I went 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 when 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 Falls 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 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 on the trek

Our days were 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”. We would wake up at 7:30/8AM to empty our bladder, brush our teeth and start packing up our tents and bags for another day of trekking. Breakfast was served around this time as well. We would start trekking, have a break for lunch in between, and stopping ever so often to reapply sunscreen. After hours of walking, we would set up camp. Dinner was served at 6 or 7PM. Repeat! Hot bucket showers were available every 2-3 days. We tried to do laundry on days we camp near near running (COLD) stream water. Camping near a body of water also meant colder nights in the sleeping bag.

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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 I 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 mountains 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 would get a rest day where we explored the surrounding areas (lots of rocks, water, and hills). Otherwise, it’s a clinic day. The clinics were set up in that there is a triage area, several clinic stations with residents and medical students, and a pharmacy tent for medications. There are about 10 clinic days in total and the learners rotate through all of these stations. It was a pretty good pace and we had quite a lot of villagers coming by. Many are road workers. After a few clinics, I realized that the medications we gave them are only temporary measures. With only a 14 day supply of acetaminophen and ranitidine, was what we’re doing sustainable?

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

We had to be 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 stray 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. The night sky was beautiful with all the constellations clearly outlined. Occasionally, we would see shooting stars.

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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 health care access gave me great insight. I started to question whether what we are doing for the villagers had an impact. HHE is taking action to being more sustainable and I like how the organizer attended these trips yearly with the medical team. He also arranged clinics in the closest cities so if any patient needs surgical intervention or imaging, we can direct them there.

I had (a lot) of time to reflect on myself during this trip. One thing I learned is to be to keep an open mind. What allowed me get through those 4 weeks was because I was open to the new experiences. I got to know one of my classmate very well after sharing a tent with her for the entire trip. 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 were trailing behind. However, as I climbed up those steep inclines, 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 remembered was telling myself, “One step at a time” and pushing through the lactic acid building up in my legs. I knew 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 the lessons 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. I highly recommend the Himalayan Health Exchange for your next medical trip. We were the first PA/PA students they took and they 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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