Heat and Dust – adventures in Rajasthan.

In 2015 I was fortunate to have had the opportunity of travelling twice to India as part of Project Hamrahi activities. In June I spent a week with Anjum Joad at the Bhagwan Mahaveer Cancer Hospital and Research Centre (BMCHRC) in Jaipur, Rajasthan and then in October I had a week with Santanu Chakraborty at Ruma Abedona Hospice and the Chittaranjan National Cancer Institute. I would like to relate some of my experiences in Rajasthan.

Anjum Joad is a highly experienced palliative care specialist who established the palliative care service at BMCHRC 17 years ago. BMCHRC is a charitable trust cancer hospital with approximately 250 beds in a city of 6 million people. Over time the service has gradually developed to include two anaesthetic colleagues with palliative care experience who also provide medical input, two junior medical officers and two or three nurses. Apart from consultation liaison and direct care for inpatients, there is a busy outpatient clinic which operates on an open access basis six days a week.

For the last three years, Anjum has coordinated the Jaipur Certificate Course in Pain and Palliative Medicine which is a six week course for both doctors and nurses. Odette Spruyt and Mary Duffy attended the inaugural course in November 2013 and this year I was invited to help. The course is one of several six week courses available in India; currently these are also conducted in Ahmedabad, Hyderabad, Kolkata, Mumbai and of course Trivandrum. This year’s course was notable because it marked the commencement of input from the Indo-American Cancer Association, which is assisting to meet the growing demand for trained palliative care clinicians by partnering with Pallium India to write a clearly defined curriculum for these courses.

With the course being held in the peak of the Indian summer in the desert state of Rajasthan I was initially nervous to accept the invitation from Anjum, but eventually decided to accept this as a challenge to the cloistered life we lead in the air-conditioned homes, cars and hospitals of Australia. As it turned out, the challenge was raised a couple of bars along the way. Firstly, by virtue of the fact that the air-conditioning to the outpatient room which we used as our base had been disconnected for reasons unclear to all – so we had to manage with ceiling and table fans which seemed to do nothing other than blow our papers all over the place and just circulate the stiflingly hot air. Although it was hot – the maximum daily temperature tended to be around 42 to 43 degrees Celsius – the dry nature of the heat made it manageable.

The second additional challenge came with the invitation extended to join Anjum and a palliative care colleague from New Delhi, Sushma Bhatnagar, on a road trip to Jodhpur. Jodphur is a major city in Rajasthan approximately 340 km from Jaipur – on Indian roads this translates to a five to six hour bumpy but entertaining ride. Anjum and Sushma had been invited to present a palliative care workshop for the medical community in Jodhpur and by luck this was scheduled for the day after my arrival in India. Once again, it was an opportunity too good to miss, and it was with great pleasure – and some amusement as I was obliged to be a recipient of assorted felicitations including not just a bouquet of flowers but also a commemorative trophy – that I assisted in the delivery of the three hour workshop to a very attentive audience of 80 or so doctors.

I joined the course in the fourth week and spent a week with a small group of four medical officers and three nurses. I was requested to deliver presentations on a number of topics including the pain management, anxiety and depression, prognostication, communication skills including not for CPR discussions, the management of ascites and brain tumours. As one would expect, this teaching was incorporated into the day-to-day provision of clinical care but this afforded many opportunities for bedside teaching. I was very interested to find out that two of the medical officers were in fact dental surgeons: it seems that in BMCHRC, and perhaps elsewhere in India, it is possible for dental surgeons to practice medicine under close supervision. If Anjum hadn’t told me about their qualifications I certainly wouldn’t have been any the wiser as they certainly demonstrated very good medical skills and knowledge.

On the final day of my Jaipur visit, Anjum had requested that I present at the hospital grand round. Based on my experiences in Jamshedpur, another Project Hamrahi site, I decided to talk about burnout as I had noticed that this was a problem for Indian oncologists. After several days of working together Anjum requested that I perhaps change the topic of my presentation to something of a more scientific nature, or in her words, ‘It would be good if you didn’t talk about pet therapy but rather something to show my oncology colleagues that we in palliative care are real doctors also!’ So it was with that in mind that I chose to present the findings of the ketamine and octreotide studies conducted by the Palliative Care Clinical Studies Collaborative.

All in all I had a very enjoyable week in Jaipur. I was made to feel very welcome, it was a genuine privilege to witness the excellent work being done not only for individual patients but also to increase the palliative care workforce, I hope I was able to make a small contribution to the teaching being conducted and I was able to make a new friend with the dynamic and inspirational Anjum Joad.

– Anil Tandon