• From Calgary, Canada to Trivandrum, India through Palliative Care

Return To India

It had been several decades since I had been on a motorcycle. I was being brought back to my guesthouse as a back seat passenger, after a videoconference with Drs. Ann Broderick of the University of Iowa, Nandini Vallath, Sunil Kumar and Rajgopal. I have to say that it was an interesting journey through the winding roads of residential Trivandrum, but not a terrifying experience.

After, 32 years of being a palliative care physician in Saskatoon and Calgary, I have the opportunity to be in my native country as part of Pallium India Trivandrum, as a visiting physician.

I would like to thank Dr. Ann Broderick of the University of Iowa, Pallium India, my colleagues in Calgary and my dearest family. If it weren’t for them I would have not been here.

I first heard of Pallium India a few years ago, in an email exchange with my nephew Thomas (Tom) Middlemiss, while he was working in Kerala. He was with Pallium India, and spoke highly of his colleagues and Dr. M. R. Rajagopal. I have been following Pallium India since its inception as a similar organization; Pallium Canada was registered for caregiver educational projects in 2000, I think. Three years later, I saw Pallium India mentioned in one of the international articles.

A Personal Connection To Palliative Care

Tom, originally from Scotland, is now a full-fledged palliative care physician working in New Zealand. He is the middle son of Josephine Middlemiss, who is my wife Margaret Dunn Chary’s sister. Margaret and I emigrated to Canada in the late 70’s. After a stint in Uranium City, Saskatchewan, We moved to London, Ontario to complete our residencies; Margaret in Anaesthesia and I in Radiation Oncology. On the day our dearest son Francis was born through a caesarean section, we found out something was not right in the rectus muscle. That turned out to be a poorly differentiated sarcoma, later labelled as likely “synovial” in origin. In short of three years, the sarcoma took Margaret’s life and I — having planned to move towards combined Surgical & Radiation Oncology after completion — moved away from Oncology.

Then, an opportunity came from my friend and colleague Dr. Paul Savage, and Francis and I moved to Saskatoon, Saskatchewan.

Six months after arriving in Saskatoon, I was walking in the corridor of St Paul’s Hospital when Dr. Fay walked towards me. After exchanging pleasantries she said that I should do Palliative Care. After hearing what was possible, she reminded me that they did not have the money but I would be rewarded in heaven, if I accepted the job! After talking to Drs. George Pylypchuk and Hugh McKee, I became the Medical Director of Palliative Care in the hospital!

My training was in Anesthesia, Surgery, and Radiation Oncology. I became a “family caregiver” at home for Margaret, along with Mary Sweeney my sister-in-law - a trained nurse - who was able to help to look after Margaret at home for a while. At that time, as I remember pain was managed with morphine syrup or injection. A few short acting analgesics - including demerol - were available but not as safe or “strong” as morphine. I could observe several adverse effects but Maggie did put up with them, as the pain was severe and unremitting. Maggie was an amazing lady, physician, friend, wife and mother.

At the time of Maggie’s death in London, Ontario I was blessed with wonderful support of Drs. Aloysius Dunn (father-in-law), Maria Dunn (mother-in-law) and Frank Dunn (brother-in-law), a (now) retired physician hospital administrator, retired Internist doing counselling, and a cardiologist. My colleagues, friends and family were sad like me, but very supportive in every aspect of my loss and grieving. Francis, my son would be three years old in a few months, and went with the flow.

I have been connected with Pallium Canada since 2001 and in 2007 organization became the Pallium Foundation of Canada; I have been one of the three founding directors and chairman of the governance board until recently and now hold the title of honorary chair

Arrival in Kerala and Introductions

I arrived at Trivandrum airport around eight in the evening on a Sunday to be received by Babu, who took me to the guesthouse. The next morning as I was getting ready in the 4th floor apartment overlooking Akkulam lake, the kitchen was busy and breakfast was being prepared. Pallium India had arranged the accommodation, along with meals and transport to Arumana Hospital to join my colleagues to learn and work each day.

The view from my guesthouse
The view from my guesthouse.

As I apporached the entrance of the building, I saw the sign “PALLIUM INDIA”; and below that it read “CARE BEYOND CURE”. I must admit, most of my colleagues feel that a name change away from Palliative Care is inappropriate. But it has a “branding” issue. Most people feel that it is end of life care. The words “Care Beyond Cure” are very interesting and have “branding” potential!

I was able to meet Dr. Sunil Kumar, and after introductions joined his team for the patient rounds. The manner with which the transition occurred, made it clear that I was not the “first visitor”. Everything was very smooth and professional, obviously having occurred several times before. At the end of the rounds tea and coffee was served in steel glasses. For me it was a bit tricky to hold the cup at the right spot and drink coffee without spilling or hurting myself. Sunil took me for lunch at the Udupi Hotel Restaurant. My colleague Dr. Brad Hunter in Calgary, knows very well my normal lunch, which is cold water! I did enjoy the lunch in a wonderful vegetarian restaurant. However as I spent more time there, I began to remember my childhood stories. My father’s family a few generations ago came from Udupi, Karnataka, which at that time was Mysore State.

“Care Beyond Cure”

Outpatient Clinic

Following lunch, Sunil held the outpatient clinic which had similar flair as the Tom Baker Cancer Centre in Calgary. I conduct a Complex pain and palliative care clinic there on Tuesday afternoons. At the end of the clinic, tea was served. I am becoming proficient in holding steel glasses with hot beverages.

It was very interesting to note the patient population’s diagnoses being cancer and non-cancer in equal numbers. The enthusiasm and professionalism of the staff was incredible. Dr. Sunil introduced me to Manoj, CEO of Pallium India, a soft spoken, attentive and enthusiastic individual with variety of goals, including administration and advocacy.

At the end of the day I went back to the guesthouse. I sometimes complain of traffic flow in Calgary, but after the ride to the guesthouse, I am not sure whether I am impatient or have hidden “road rage”. In Trivandrum, (as in most of India, I guess) if your “vehicle’s nose” is ahead you go forward and, unless someone or another vehicle is crossing your path, you always speed up!!

Musical Therapy

Before I left for the hospital the next day, I had realized that there was no mirror for shaving in the bathroom. It dawned on me that I could use my iPhone camera, which was a success. My son Francis would be very proud of my technical prowess.

The next morning started with breakfast and ride to the hospital. In the middle of the patient rounds I was suggested to go to Music therapy, a floor below. It was amazing; a wonderful vocalist was singing and rehab patients were totally immersed. After a couple of songs, one of the patients was able to sing his repertoire, which was exceptional and he appeared oblivious to his symptoms and thoroughly enjoyed it.

I was told that the next day individuals with paraplegia, and who use wheelchair for mobility would have a public awareness project in a shopping mall. Dr. Sunil also mentioned that on Thursday morning, I would conduct a workshop on safe use of methadone for pain with participants at the CCPPM training course.

A Special Article “Civil Society-Driven Drug Policy Reform for Health and Human Welfare-India” published in the Journal of Pain and Symptom Management this year, is testament to Pallium India’s involvement in improving palliative care in India. Methadone has been in use for “harm reduction” for 6–7 years, and is now being released for pain management in India.

A videoconference was arranged with Drs. Ann Broderick, Nandini Vallath, Sunil Kumar and Rajgopal who could join for a short time at 5:30 pm using Zoom, and discussed how to structure present educational material for safe use of methadone in India.

Following the videoconferencing, I took my exciting ride back to the guesthouse on the back of a motorcycle.

Public Awareness and Workshops

Next morning, went to the hospital and before lunchtime driven to Saphalayam complex & mall, where Pallium India was assisting the sale of goods prepared by paraplegic patients. There were presentations by the staff and patients and a very good public awareness campaign along with the sale of goods at the exhibition. We did return to the hospital and I was able to spend time in the CCPPM training session that afternoon.

The next morning it was my turn to present a workshop. It was an inquisitive, interprofessional & multidisciplinary group. There was a good discussion and participation was excellent. I was a bit nervous before the start but audience helped me to catch up with their discussion.

I had a chance to meet Dr. Rajgopal in his busy schedule and had met him in Canada couple of years earlier. He epitomizes devotion, motivation and persistence especially in relation to Palliative & End of Life Care in India. It is Dr. Rajgoal’s vocation and not a job. We exchanged pleasantries and he reminded me of Tom my nephew; Tom’s bicycling legacies with Pallium India and of course his work in rural Kerala.

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