Doctoring Days

Contrary to my initial plans for the year, I've begun working at a nearby hospital until the seat allotment is finalized. While last year, the PG courses began by May 1st, this year has been unpredictable for the most part. I thought it would be a good change to get back into the hospital atmosphere and clinical set up since I've mostly spent the whole of last year on building my theoretical knowledge. The process of applying was fairly simple thanks to the resume building skills provided by my friend Dr. Sanjana! I also realized that even with just an MBBS Degree, it IS possible to get some employment, and that too on a temporary basis!

Chitra and I

After I found out that Chitra was also looking for a similar opportunity, we teamed up and applied together. After an interview with the HR and Dr S, we were formally given a position. Our first day was more of an introduction-orientation of sorts. We were taken around the hospitals, across the various departments and we also met several consultants. Most of them were very friendly and asked us about our plans ahead. They also advised us to take all precautions while examining the patients and briefed us on the existing protocols in place. Since we were working 9-5 on our first day, we spent the day taking histories of the in-patients and filling any details in the case-sheets. Finally, some amazing Corner House Ice-cream with the enthu cutlet genius Chitra brought an end to an interesting day with new beginnings! 

The next day, I got to meet Dr D, a pulmonologist with vast experience and also had a short interaction with Dr A, a budding nephrologist and she told me about the pros and cons of specializing post and MD as well as the increased number of super specialists in a big city like Bangalore. (Fangirl alert!) Day 3 was the morning shift and after the initial lull, cases began to trickle in steadily ranging from COPD cases, asthma exacerbations to anaemia under evaluation. The ward cases had several in the onco department, a psychiatry case, a few ortho post-ops and even an AKI (Acute Kidney Injury) due to ?Connective Tissue Disorder. A visit to the ICU with Dr S revealed a grim scenario. Communicating to a patient's attenders about a poor prognosis and end of life care is never easy and sometimes we must consider all clinical as well as non clinical aspects before taking any decision. Truly, an overwhelming situation for both the one delivering and receiving such information but such is the profession..

We soon got N95 Masks, Face Shields and ID Cards to induct us formally into the setup and glad though I am to have received some protective gear, it is certainly not a pleasant experience to have the masks tightly fitted for the entire duration of the shift and move around too. I also got to see cases in the OPD with Dr S, most patients have been coming to her since the last few years and she has an eye for detail which helps her spot uncommon presentations. There were cases of sarcoidosis, hemoptysis under evaluation, respiratory failure as well as Obstructive Sleep Apnoea presenting in the OPD which were all worked up as required and subsequently treated. There was also the case of young Ms D, born with bicuspid aortic valve, resulting in Aortic Stenosis which prompted a Balloon Valvuloplasty about 9 years ago. She also had anemia and GERD. The patient had new complaints of breathlessness and severe fatigue. After considering her clinical features as well as the laboratory correlation, the cardiologists in the hospital suspected that it coule be a case of Infective Endocarditis and decided that she must be referred to a higher centre and did the needful soon. 

Terrace views. :)

While the evening shift of 2-8 might initially seem to be "free", cases do keep popping in and out, a call from the wards or sometimes the ER too. Be it the case of obstructed ventral hernia that was taken up for surgery on Sunday evening or the post robotic surgery (for prostate cancer) patient who came for a hormonal injection (Degarelix), there is definitely a wide range of cases (baring ObG and Paeds). 

One that I will probably remember for a long time is of Mrs UK who was diagnosed with carcinoma of the gall bladder about six months ago and underwent cholecystectomy and a course or chemotherapy as well. But statistics do not favour the gall bladder cancer which is usually diagnosed only in the late stages and has an aggressive course. While we started a blood transfusion and albumin infusion to correct the anaemia and hypoproteinemia, the renal function was also compromised because of some of the chemotherapeutic drugs and the liver function, too, was deranged. Midway through the transfusion, her breathing became laborious since the ascitic fluid was obstructing her normal breathing. After we explained the situation to the patient's son, we shifted her to the ICU to monitor her vitals continuously and drained the ascitic fluid under USG guidance. While I was familiar with the procedure from internship days, a year's gap made me nervous to handle the "3-way" but I was guided patiently by Dr S2.

While it's important to know procedures, it is more crucial to know when to implement them and using the best techniques (when available). It also made think about how vastly different any theory is from the realities or clinical practice. Often, our clinical findings take precedence to make decisions over what the laboratory values might suggest. Ultimately, there is a cohesion between what we read, how we percieve and diagnose a case and how we explain the condition, treatment and progress to the patient's attenders. All these are three completely different skills to be developed over time in order to provide the best possible care, as a doctor, or should I say, to be a "successful" doctor. I'm also in the process of understanding how the government setup and private set up differ in some of their protocols and standard of care. There is probably no system which is completely without flaws but we must try and do the best we can in the set up we are in. 

It's been a week here and I'm not sure what's in the coming weeks/months but I'm trying to go with the flow and take this as yet another experience. There is always a take-away from everything we attempt and to be honest, my reasons for joining work were also to have a change from home so I'll just take things as they come, for now. :)

Covid Conversations.

Day 1.
Although the lockdown officially began all over India at 9pm on March 24th, I've been mostly indoors, only stepping out for any essentials since March 16th.

Staying indoor isn't something new to me; I spent most of last year either in an AC lecture hall or inside my room, preparing for PG. In fact, I was just beginning to go on long walks to another area, play badminton in nearby courts, attend gym amd aerobics when slowly but surely, a clamp down was enforced, across the city, state and eventually the entire country.

Covid-19 is something none of us planned for, none of us had any leeway for in our airtight plans for life, so it does come as a sudden displacement of all our carefully crafted plans. Promotions, retirements are postponed, competitive exams; the great way of determining the path to be taken by Indian students have been derailed indefinitely and so has every other plan that people have made for themselves. For once, we are at the mercy of a microscopic entity that scientists once fought over as being living or non-living; a Virus.

It makes you wonder, how fragile life really is. But it also makes you realize that life does go on, through deviations, detours and sometimes roadblocks. That's the beauty of creation.
Countries rebuild themselves, economies will slowly but surely rise and families will tide over the crisis with strength of the human spirit.

Until then, things are changing, yes, but this too shall pass. :')

Day 3.

So how are families as a unit coping with the lockdown ? While it's easy for individuals to busy themselves in social media challenges/ workout sessions and other ways of productivity, when you look at the entire family being together for extended periods of time, you'll begin to realize that it requires a team effort for smooth functioning of day to day activities. We also begin to realize how we depend on so many individuals for our day to day activities; be it the milk man, flower seller, vegetable vendor and pourakarmikas. 

Yes, there is a lot of uncertainty over when things will get back to "normal" again but it's also a time to reflect on how much "In control" we really are. Mankind has always believed in progress and we believe that as the superior species, we have tamed the forces of nature, but clearly, we were mistaken, as is evidenced by the raging spread of this nanomolecular virus.

As I walk across the now empty park to get some milk, I see the growing carpet of dry leaves on the pavement, a layer of flowers lies untended across the park while birds seem to have made a comeback with their daily chirping. While one species grapples with this virus,the rest of the planet, is strangely, re-emerging from the shadows that we've pushed them to. Perhaps, this is a wake up call to care more for the planet that has given us everything.

Another interesting thing is the amount of conspiracy theories, memes and forwards that are bombarding the internet these days. I think my dad has successfully completed a course from WhatsApp University.

And lastly, the Painting that I began almost 3 months ago is finally completed in a way (there are a few more things but that'll have to wait until the lockdown has ended...) and I'm filled with relief, more than anything else. I'd still recommend anyone interested in Tanjore Painting to learn it from a teacher, rather than on YouTube, because all said and done, there's nothing like learning the finer details from someone experienced.

Day 30.

It's been a month of lockdown and we're nowhere near the end of this. While the US and Europe have had larger numbers to grapple with, the economic price we'll have to pay for this extended quarantine isn't hard to imagine. While I sit at home and think about what activity to engage myself in, many others (including my dad), are figuring out how to keep the business running with minimal contact and travel. This hits hard especially on the industries that require human interactions, on factories that depend on manpower and any sector that involves travel and social interaction. 

Nevertheless, "learn as you go" kind of process as most countries learn by trial and error and each others' mistakes while trying to establish an evolving protocol. While the Spanish Flu of 1918 (coincidentally, I also found a reference to this in the British period drama Downton Abbey) surprisingly affected the younger population more, it was also partly overshadowed by the military activities of World War I. The name Spanish Flu does not refer to its Spanish origin but it was more prominently publicized in the Spanish media, since Spain was a neutral party in the ongoing war.

The foreseeable future will probably have us cautiously walking back towards normalcy, at every step, taking precautions that we don't create a resurgence of the untamed virus. Perhaps, this signifies that our efforts need to be better channelized; medical research over nuclear policies, vaccine development over artificial intelligence and affordable healthcare over high-end medical facilities. 

For now, we only know that the curve must be flattened in order to reach a manageable state. Surely, these times too shall pass and we shall look back and wonder how we made it. :)

Day 63

Honestly didn't expect that the lockdown would be extended as far as this but to be honest, is this really a "lockdown"? Most stores are reopening with "maximum safety measures", buses are operating on supposed limited capacity and flights have resumed amidst chaos on the ground! Not far from all this,patients are multiplying everyday while the government resources are being stretched and the private hospitals are charging exorbitant rates to provide a standard level care. Does every individual have a fair chance of surviving the pandemic? The answer is, an uncomfortable but resounding NO!

Why?

Because I've realized not everyone can afford the highest level of care provided by the best corporate hospitals. 

Which would leave a disproportionate number seeking the facilities of the government set up. 

Which obviously is not equipped with sufficient ventilators or support staff to help every sick patient. 

Which would mean they would use their limited resources only upon those that are likely to recover earlier, thanks to their younger age and absence of comorbidities. 

Which leaves an uncomfortable silence about the rest.

The way forward is uncertain but we've got to bounce back, one way or the other. We can't wish the virus away, but we can take caution in our social interactions. In a way, it puts into perspective how "cohesive" our social structure actually is. So bringing about this distancing on a longer term,is a challenge but perhaps we will find innovative solutions to connect despite the distance. :)

The Walk Home.

My father said we were to pack up soon,

A long walk; because I wasn't born with a silver spoon.

I asked if I could bring my bat and ball,

But he said I would get one when they would reopen the mall.

I waved goodbye to my friends at the site,

The construction workers with whom I spent every night.

The mother carried the heaviest load among us,

After all, didn't she carry bricks without a fuss?

My father said we were to walk home to the village,

Yet my blistered feet did not give much mileage.

He said we would work in the fields and harvest,

But I was hungry and in need of rest.

My mother says a virus is here to stay,

To remain indoors is the only way,

But my father asks, what about our monthly pay,

And so I'm walking; to a place far away.

Limitless Love .

Wrinkled with the fine lines of their ripe age,
Peppered with the ills that poverty bring,
Bereft of the love and care of their offspring,
They arrived with savings of their meagre wage.

Immobilized by disease, she lay bedridden
Yet beneath the pain, a coy smile was hidden,
Aged yet agile, he rallied around for her care,
Her infected foot, he vowed to repair.

He pleaded and prodded all day long,
Until even the hardest heart melted at his adoration,
His relentless efforts would make her strong,
She regained her colour with his dedication.

A love so pure they shared,
That crossed boundaries of age and ill health,
Others often watched and admired
That their attachment was their one true wealth.

An ode to Mrs. S and her husband whom I had the opportunity to meet during my surgery postings at Hassan.

Observations in OBG: The joy of bringing babies to life!

As always, with a hint of excitement and ladles of nervousness, we reported to the Department of Obstetrics and Gynaecology just about two months ago. As we were shuffled into the 3 units A, B and C (each withits own unique reputation), Labour room and Casualty, some had Lady Luck on their side while some others knew they had a few more hurdles to cross than the rest.

The Department is one of the busiest at HIMS, notorious for its hectic schedule which reflected upon the interns and staff alike. I was posted in B Unit which initially had the all-male staff of Dr. Rajashekhar Sir (Unit Chief), Dr. Shridhar Sir and Dr. Raghupathi Sir. Later Dr. Nishitha ma'am joined the Unit. On my first OPD day, I learnt the main steps of taking and ANC case including the examination. Now these were things that I could learn well only with time so initially it would take me some time to localize the Fetal Heart Sound (FHS) but slowly, over the weeks, my ears began to get trained to recognize the familiar rhythmic beating, to make an estimate of the gestational age by the abdominal examination and also to assess about the progression of labour based on the PV examination.

A typical duty day involved a quick prerounds of the Post Natal Wards, Immediate and Late Post Operative Wards, Special Ward, ICU and Gynaec Wards after which we had the ANC rounds with the staff and the rounds and follow up of all of the wards as advised by the professors during their rounds. After this we hurried to the ANC OPD to clear the cases and give admission to those in labour. Any emergency case would be taken up for LSCS once all the investigations were in place. By 4PM, there would be rounds by the duty doctor of all the ANC cases admitted during which he/she would decide the course of action: Watch for Progress/ Shift to Labor Room/ Prepare for LSCS or maybe even discharge in case they were not in active labor.

Following this was the tedious process of writing the case sheet (which was later marginally simplified by a book which we had to fill up) looking at any loopholes, any deranged laboratory values or medical / surgical comorbidities. Usually there would be few cases taken up for Emergency LSCS where we were required to assist and close up. The common indications were Meconium Stained Liqour with Foetal Distress, Cephalopelvic Disproportion, Previous LSCS, AntePartum haemorrhage, Pregnancy Induced Hypertension(PIH), Abnormal Lie/Presentation among others. Along with the usual ANC cases, there were several cases of spontaneous/ threatened/ missed abortion or cases who came for MTP or HIV/HbsAg positive which were dealt with in the Septic Labor Room. Cases required strict monitoring of vitals were shifted to the High Dependency Unit (HDU) where PIH, Ecclampsia, Pre eclampsia and GDM cases were monitored by the labor room interns and staff.

One notable incident that occurred when on duty was the case of the 'Tubectomy Meningitis' as I'd like to call it. Two patients who had been operated earlier in the morning, developed restlessness and became disoriented later in the evening even as their vitals remained normal and their laboratory investigations revealed no obvious imbalance. While we monitored the patients all night long in the ICU, the patient attenders were increasingly impatient and we even had to deal with the mob and media attention. They were referred to NIMHANS the following morning where they were said to have 'Bupivacaine Induced Aseptic Meningitis'. Now the patients made a complete recovery but it brought about a lot of changes in the OT and the Post Operative Care of the patient to prevent such instances.

What began with hesitation and reluctance towards this subject gradually changed into respect for this demanding yet equally fulfilling career choice. From the first LSCS assisted to the first baby delivered via normal vaginal delivery, there was a definite surge in my interest and respect towards this department. From bullying irresponsible and intoxicated patient attenders to arrange for blood for their anaemic patient in labour to holding the hand of the sobbing woman who had just had an IUD (intrauterine death) in her first pregnancy, there was something to learn in everyday of OBG.

The Gynaec Ward had its own set of patients who needed to be operated upon for commonly a Fibroid Uterus or  a Uterovaginal Prolapse but I also got to see a gigantic mucinous cystadenoma of Ovary in an otherwise frail woman of 70years operated upon successfully. There were plenty of ruptured ectopic that came our way, especially on the C unit duty days but as Dr. R said it, a "quick in, quick out" approach works best to handle these cases. Be it with the interaction with patients or their attenders or sometimes with the professors, nursing staff and even our colleagues, there has been some real high voltage drama we've witnessed/been a part of.

Towards the end of two months, I did feel relieved that it had passed with no major mishap but more importantly, I also felt like I was actually doing something. Perhaps the posting where I definitely had *some* relevance to the Department even though we were mostly treated otherwise. :')

Labour Room with the Roomie!

Of course, the completion did not pan out as expected and it definitely was a disappointment but nevertheless, irrespective of the outcome of my derailed completion/erroneous extension I will be thankful for everything I have learnt from the professors and nursing staff during my 2 month stint in the Department of Obstetrics and Gynaecology at SCH, Hassan.

Unfulfilled Dreams.

Little ones who did not see the light of the day,
From tiny undefined forms in gray,
To well formed twins in full bloom,
Sat snugly encased in their mother's womb.

For nine long months, she waited with bated breath,
As weeks turned into months, the belly swelled
In hopes of pink and blue, the young mother dwelled,
Alas, she only saw them after their death.

Young and naive, she felt their plea for help,
Day after day, she heard their beating hearts aloud,
She pleaded in vain for them to emerge from her womb,
But alas, she would only see them entwined at their tomb.

In the memory of the unborn twins of S, who could have lived.

Anecdotes from the Medicine Wards... (1)

With much trepidation about the big majors I set foot in Medicine and my first consolation was that I was shunted to Psychiatry for the first 15 days. So I had 9 to 4 psychiatry duty followed by Medicine duty in the casualty on OPD days. A big relief was that I was placed in Medicine D Unit which had professors who were friendly and ready to share their knowledge. I was indeed lucky to have skipped the units with a cranky or an unsympathetic professor.

Though my time in the casualty was restricted to the post OPD hours, there was plenty of work since the cases simply never stopped coming! From accelerated hypertension cases (a cool 240/110mmHg), uncontrolled T2DM, chest pain, acute GE, CVA, fever with chills to alcoholic liver disease, alcohol withdrawal and the ever so common poisoning and snake bite cases, there were an abundance of cases that were constantly rolled into the casualty often giving us not even a moment's respite because there would also be calls from the wards/ICU/ICCU/Emergency regarding any patient who would need immediate attention.

In short, even though we were 4 interns in the unit, the workload managed to keep us on our toes at all times.

Dr. Hoysala, Dr. Muthuraj Sir, Dr. Halesh Sir, Dr. Impana and Dr. Sanjana C (missing in action : Dr. Venkatesh Sir)

An interesting case would be of Aravamma who came with classical chest pain, referred from a smaller government hospital (Belur?) after the ECG there showed what appeared to be Ventricular Tachycardia and her BP was around 180/100mmHg. Her previous history suggested IHD and she had undergone angioplasty earlier. Presently she needed immediate treatment in an ICU facility and since we had one bed vacant at that time, we explained the risks, the prognosis and admitted the patient. 

We started her on Amiodarone (an antiarrhythmic) at 150mg (1amp) in 100mL of NS over 10mins but she still remained tachycardic (180bpm) so we had to give her a DC Shock and the change in her heart rate was evident immediately. It was a scene reminiscent of a sitcom when I held the paddles (thanks to the guidance of Halesh Sir who gave me the opportunity) and the familiar 'charge' and 'clear' was announced. Although she remained critical after the initial recovery and she had to be referred to Jayadeva Institute, it was a memorable moment that made a lot of difference.

Then there was Gowramma who was admitted for chest pain and pain abdomen under Medicine but collapsed after her pain abdomen which required a CT scan went unattended. In retrospect it appeared to be an intestinal perforation which should have never been admitted under Medicine but under Surgery where she might have had some chance.

In contrast there was another patient who had chest pain and pain abdomen. While we had an ECG and Troponin I to rule out IHD, it was the CT Abdomen which suggested metastatic growth in the liver hence she had to referred to a higher centre even though she appeared to  be stable.

There  was Rangegowda who was a known case of IHD and had a poor prognosis and when he had a second arrest, by the time the ECG taken reached us and by the time it was seen by the duty doctor, he had suffered another arrest and couldn't make it.

Then there was Jayalakshmi who came with bleeding gums and her inital platelet count was around 500/uL. She received about 6 pints of whole blood transfusion for her anaemia and thrombocytopenia but her last platelet count was around 28,000/uL.

After a peripheral smear, the next logical step was a bone marrow biopsy to investigate the cause of thrombocytopenia. After some running around, I coordinated with the Pathology professor who taught me how to do a bone marrow biopsy with a Jamshedi Needle at the sternum. We had a look under the microscope and it appeared to be a case of ITP so we put her on oral steroids (Wysolone) and discharged her after nearly 10 days of admission.

There were a lot of patients who came in with genuine complaints and were admitted only to have no investigation done and were only visited occasionally by their attenders who viewed them more as a burden and hence didn't bother to get the necessary blood transfusion done or even get them the medicines prescribed. Another patient who had severe pitting edema of upper and lower limbs needed a 2D Echo because her ECG suggested a previous MI but it took an angry phone call from my side explaining the seriousness of the old lady's situation to get the absconding attenders who were away due to festivities.

It was disappointing to see how little some attenders cared and at the same time there were exceptions like the 13 year old boy who got his grandmother Arjunamma admitted for fever and anaemia and ensured that she got 2 pints of blood transfusion and a USG Abdomen done and had been the main cause of her good progress and successful recovery.

There was Thayamma who came with weakness of Right Upper and Lower Limb and the CT Reports confirmed the stroke but it was the CBC which caught my eye with an elevated WBC count (149*10e3/uL) and a Peripheral Smear confirmed the probable diagnosis of Chronic Myeloid Leukemia. Unfortunately, even after we explained the need for a bone marrow biopsy and the availability of the appropriate treatment at Kidwai Institute, the attenders and the patient were inclined to go home so there wasn't much we could do.

Probably one of the most heart-rending cases are those of 'Unknown' patients/destitutes who have literally been picked up from the streets after some passerby would have informed the ambulance hotline. Since they had no attenders, it was left to the hospital staff to get the investigations done, ensure her nutrition, hygiene and well being. The sad reality is, when one is not accountable, the entire team begins to take less effort because they know they are not answerable to anyone. 

The (unknown) old woman who was brought in an inebriated state only mentioned vaguely that she had been assaulted by her son while slipping in and out of her delirium and so gangrenous foot required a doppler according to the surgeons who didn't offer any other treatment, the fractured forearm couldn't be put into a slab because of the swelling according to the orthopaedics, her sugars were elevated but there was no Insulin supply in the ward, her Urea and Creatinine were elevated but with all other comorbidities, she certainly wasn't a candidate for dialysis and thus ended the story of a woman neglected by her own kith and kin and subsequently by society as well....

(To be continued)
https://moodymusings95.blogspot.com/2018/11/the-lessons-and-learning-in-medicine-2.html?m=1

 (some names may have been changed)

Healing The Maladies Of The Mind.

Old couples who had warmth and love despite the illness of the other,

Newly weds who looked at each other with fresh excitement but had deep seated issues,

Middle aged men and women who came alone in awareness of their condition,

Little ones who buzzed around with abnormal activity,

Young men who had fallen prey to addictions or who had been betrayed by relationships,

Women who survived the torment in their families but were victims of an innate sorrow,

Old men who had spent their twilight years in a liquid trance and were now facing the consequences,

People of all ages from a 11 year old boy bullied at school to a middle aged mother tormented by obsessions beyond her control, who had taken the extreme step to end their miseries as a lasting solution.

They were all patients in the Department of Psychiatry where I have been posted for 15 days.

I didn't have a lot of expectations since this was a busy government set up with limited facilities but as the days progressed by views were altered to some extent. We had admissions in the Male and Female Psychiatry Ward, follow up of references from the new hospital wing, OPD duties and also ECTs given twice or thrice a week while there are EEG facilities at a low cost, a small vocational activities centre and programs held in view of Mental Health Awareness.

We had a program in view on suicide prevention where we had a few cultural events, poetry and paintings were on display and we were given saplings to mark the event. during the past fortnight there was much to be learnt from Dr. P who was known for giving time to patients and counseling them and also looking into other comorbidities, Dr. B who has been in the hospital for almost a decade now and hence has an established rapport with her patients and Dr. S who always made it a point to explain the scientific basis of the illness to the patient and the attenders and also tried to implement aspects of cognitive behaviour therapy along with medication.

There were patients being seen by the Prof for since 6-7 years, patients who had shown tremendous improvement with medication and those who remained in the same level of (dys)function inspite of regular medication. Commonly, there were cases of Alcohol Withdrawal Syndrome, Generalized Anxiety Disorder, Major Depressive Disorder, Bipolar Affective Disorder (Mania), Catatonia, Obsessive Compulsive Disorder and undifferentiated Schizophrenia among others in the wards. The patients were monitored with respect to their medication and many left the premises close to their premorbid personality while some, like Y had to be discharged against medical advice (DAMA) since his religious inclinations had increased and he began to demand to go home. L was a typical case of schizophrenia with bizzare delusions, thematic perseverence and formal thought disorder even as he was oriented to time, place and person. During my ward duties for 5-6 days, the patients became somewhat more cheerful during the evening, some would even joke and manage a smile during my post dinner rounds while for some, the dreaded night only spelt restlessness and craving for liqour.

The OPD sees quite a consistent turnout of patients everyday with a minimum of 20-30 new cases and another 30-40 coming for medications or follow up. Commonly the cases were of dysthymia and MDD in middle aged women, adjustment disorder or sometimes bipolar affective disorder in younger women, generalized anxiety disorder in middle aged males, social anxiety in younger males, alcohol dependence syndrome in males (and even nicotine dependence syndrome) of all ages,
Attention Deficit Hyperactivity Disorder in children and cases of dementia in the older age group.

During my interaction with the patients (we were to take the patient history, vitals and present before the Professor who would then look into the treatment and counselling aspect), I realized that it requires some effort to dissociate the family conflicts, financial crisis or relationship failures (i.e the psychosocial stressor) from the actually illness of the patient. I felt that to a large extent, the individual's symptoms can be improved with treatment but when the stressors persist, it is nearly impossible to guarantee a significant change in the quality of their life. However, while we cannot instruct them on how to lead their life, we can always give our suggestions or better yet, help them to cope with their circumstances with courage and endurance.

The most important skill in this department is listening. While in most other departments, a preliminary examination and relevant history elicited to establish the timeline guarantees a probable diagnosis and treatment, in this case it is more of gently unearthing the relevant facts from the mound of unnecessary detail from not so forthcoming patients until they are ready to share the persecutory thoughts plaguing their mind. Only then can you consider a diagnosis or a sometimes a mixed episode after which you look at other comorbidities and decide on the suitable drugs.

Another indispensable quality is that of empathy. You cannot help your patient of you cannot try and understand how they are feeling. True, you and I know that the voices they are hearing in their head are not real but you need to make your patient feel that they are not alone in their suffering. You will need to educate them that they are not ill fated to feel such strong obsessions or deep seated feeling of sorrow, it is after all an imbalance of neurochemicals like seratonin and dopamine which can be controlled with timely and appropriate medication, support from their family and regular follow up.

Lead Kindly Light.

From mounting debts that pushed them off the edge

Through affairs that drove an irreparable wedge,

To the grieving for whom relief was a far fetch,

They chose the untrodden path of no return.

While somewhere a wife grieved for her beloved

Elsewhere a lover regretted hasty words unapproved.

And yet another father repented over love unshowered,

For they had lost a loved one to a preventable illness.

Tender care and concern was what they needed

To nudge the fallen spirits that could be reignited

A warm kindling fire of support was all they pleaded,

To awaken the sanguine Phoenix from their ashes.

To save one from the clutches of despair,

Is akin to saving a drowning man at sea.

By giving wings to a wounded man's dream,

Be that social pillar that shall heal and repair.

Suicide is not the answer.

Written in view of Suicide Prevention Awareness.

Keep your eyes and ears open!

Here we are at the end of August with 2 months of Medicine looming large. The past month has been spent in the Ophthalmology department and presently in the Department of ENT.

Ophthalmology department worked very systematically and since there were PGs here, there were specific tasks allocated to the interns. We did a LOT of IOP measuring, VT measuring, Lacrimal syringing, conjunctival washes and seeing the OPD cases upto one extent following which the PGs would take over. We even had a seminar assigned to us on a specific topic and thankfully that went without a hiccup. 

The Department is extremely productive; there are OTs almost thrice a week with one of them being a 'Camp OT' where more than a dozen patients would come for the cataract surgery. Apart from the regular cataract surgeries, Pterygium excisions, dacryocystectomy and Trabeculectomy procedures, there was the speciality clinic where they did laser procedures for Posterior Capsule Opacities (PCO: a common post op complication), Testing of Visual Field by the Automated Perimeter, B Scan (when the fundus was not well visualized on Direct Ophthalmoscope) and Fundus Fluorescein Angiography in cases of Diabetic Retinopathy and CRVO and so on.

While some days were interesting with something new presenting in the OPD like a Corneal Ulcer or Nystagmus or perhaps a foreign body, other days were spent in the mundane reality of testing the IOP of patients who simply refused to follow my instructions in spite of the simplest of explanation in the most controlled calm voice possible. Ophthalm duty did not actually involve frequent casualty calls and even when they did, there would be a first year PG to help you with it. The PGs were friendly and the kind you could approach for all the questions that pop into your head.

Following 13 days in Ophthalm (I took two days off and headed home for the weekend. Ah, bliss.), It was time for ENT. The ENT OPD was definitely busy and there were regular admissions for the surgical procedures like Tonsillectomy, Septoplasty under FESS, hemithyroidectomy, Excision of swellings, Tympanoplasty with Mastoidectomy and sometimes even emergency tracheostomies.

 The OT is twice a week so more often than not, due to the heavy load of cases, a patient ended up having his surgery after it had been postponed ATLEAST once. After a 'shakeup' of things regarding the casualty duties, it appeared that we would not have to do duties but of course that was not meant to be so the duties are back on and we keep the PGs in the loop.

While ENT does bring you in close contact with infections, it also brought out the effect of people's habits. Oral submucosal fibrosis was a common presentation after years of tobacco chewing as was a carcinoma of pyriform fossa or a tonsillar malignancy in chronic smokers. One patient came to us with a very obvious swelling in the neck that ulcerated in few days, change in voice, inability to swallow and in stridor requiring a tracheostomy within a few days. While some of the early stage cancers are given RT/CT, the others are given more of palliative care since they would not be eligible for radical neck dissection and RT due to the  widespread growth of the tumour.

Another patient I followed up was Eshwaraiyya who came to us with uncontrolled epistaxis. He had earlier undergone ligation of the sphenopalatine artery at St. John's as well but the problem had reared its ugly head again. He had a history of cerebrovascular accident few years ago and was on ecosprin since then. He was also a known case of hypertension and had been passing blood in stools for some time now which had caused his Hb to drop to alarming levels of 5gm/dL. After transfusion of 3 pints of blood his Hb improved but that didn't solve the root of the problem so we referred him to the surgery department where they scheduled him for a colonoscopy to find out what could be causing the bleeding.

ENT was a memorable posting thanks to the interaction we had. Some of the professors were friendly and explained more on the procedure and the case at hand, the PGs were approachable and I was excited to find a fellow bibliophile in Sana ma'am and also, it was good to have more interns join us making the work load lighter, fun times more frequent and many light hearted moments during the course of these 15 days!

The next 6 months are the 3 big majors starting up with General Medicine which includes 15 days of psychiatry. I have a lot of trepidation about the coming days but hopefully they will be eased once I get into the thick of action. Here's hoping I can do my best, deliver to the best of the facilities available and assimilate as much as possible from my experiences. :)

Roars To Silence.

A formidable figure in the past,
Among others he stood tall and strong,
With a commanding presence that would last
He marched to the tune of his own song.

Against odds he rose to a eminent stature,
For years he was at the coveted pinnacle
A man revered and feared for formidable nature
His baritone created ripples along the rural folk.

But Fate moved the dice one fine day,
For none can forever keep illness at bay,
And thus began the decline towards doomsday
Ravaged by the insidious tumour, he would sway.

Alas it was a cruel trick upon him,
As his deep voice hollowed into a ghostly whisper
And his frame melted Into bony nothingness,
His dignity was shredded forever.

His spirit battled against his frail frame,
As he accepted his inelegant mortality,
His lost glory he could not reclaim
Yet with stoic grace he walked to his finality.




To the 80+ old man with a Carcinoma Larynx. He can't talk. The tumour has invaded his pharynx as well. So he can't swallow either so he needs a jejunostomy. He is shrunken and shrivelled up and his eyes are hollow. More than that it's the feeling of helplessness that he can't control the drooling and cant express anything verbally. You begin to wonder that when someone says they are 'alive' there are different degrees of being alive and this is also one kind of living.

On further interaction with the patient's attenders, I gathered that he worked as a revenue officer across the state and that he was a well read man. I saw for myself when I received a note in English from the patient for a complaint he had. :)

A month through sutures, plasters and splints!

As the days passed, my gallery was filled with badly photographed X rays, deep gaping wounds or case sheets that I would forward to the professors on duty for further guidelines on management.

While the 9 to 4 time frame was filled with ward follow ups or sitting through a clogged OPD, the real deal was after 4 when cases came to the casualty and we had to assess the severity of damage and provide necessary treatment/ refer.

During the course of 1 month in Orthopaedics, I had ample opportunity to suture in the casualty and I think there was definitely some improvement from my first day to the last day. We also tried our hand at reducing a dislocated shoulder after watching a couple of videos and also after watching our professor effortlessly do it without causing pain to the patient.

During the course of ward work, I realized (and I was also enlightened) that it's not enough to just come on time, do your work and go. You need to improvement in both knowledge and skill and neither can substantiate for the other. Doing what you're told to do is all good but doing what you aren't told to do is sometimes expected of you. I don't know if I make sense but all I'm saying is it's not enough if you diagnose that the patient had IT fracture, put him on skin traction and get all the relevant investigations required preoperatively and get the health scheme approved for free implants for the patient. You still need to make the time to read up on IT fractures and know about its similarities with neck of femur fractures and how they differ in other modalities.

This is one example but that's the general idea. One time, we had a case of self fall with complaints of pain in the back. Usually one has to rule out a spinal injury in such cases. Based on the presenting feature (respiratory difficulty/falling BP/ paralysis etc one must try to localize the site of lesion. That day we had a 'class' in casualty by S Sir where he explained what to in case of a spinal injury right from the immediate care at the residence to logrolling to the meticulous examination of the patient making sure not to inflict more damage upon the patient.

During the course of ward duty, I came across myriad personalities; from Kishore Naik, the bubbly 12 year old who had a fractured shaft of femur while playing Kabaddi at school to Roopesh who was treated at KMC Mangalore for an RTA with external fixation and later rather unceremoniously left in the rains after being asked to vacate the hospital bed. He came to us infection in the leg and after some conservative management we had to refer him to a higher centre for skin grafting. While he had backlogs from his SSLC, his injury left him dejected about the delay in his career so it took some counselling to tell him that he could still read for the exams, clear them and continue his studies. Apart from asking if they've taken their medicines and for their blood reports, it's also important to tell them that an accident cannot change the trajectory of their life. Then there was Munna who was literally picked up from the streets after being hit by a vehicle. Treated with the goodwill of the hospital and the kindness of the ward boys, he never failed to annoy his fellow patients with his messy littering and incessant grinning in spite of all the complaints hurled in his direction. While Navya, the 7 year old with a femur fracture was operated with TENS and treated with 'Munch' as a reward, Spoorthi, the 6 year old was treated more conservatively with a Thomas Splint. Part of your job is to allay the fears of the patients about the operation, advice the attenders to provide better care, urge, goad and sometimes scold them till they run around to get the relevant investigations done.

During the casualty, some cases were treated conservatively but those where there was vascular injury ( such as the little girl with a supracondylar fracture and also feeble radial pulsation) are immediately referred in order to salvage the limb. There was also an RTA case with polytrauma ranging from pelvic fracture, both bone fracture, urethral rupture and diaphramatic hernia which again was referred after the attenders did not give High Risk Consent. In case of extensive crush injuries, the risk of losing the finger/toe was explained and after necessary treatment, the patient was either discharged or referred.

One of the things that affected me during these postings was the lack of awareness in the patients and their attenders to do as directed. While most of the facilities in the hospital are free for those with a BPL card, one has to put in some effort to go to the respective rooms, give the blood sample, collect it at the stipulated time, collect the form for free scheme and so on. While they all wanted to be cured at free cost, not everyone could grasp the simple instructions that I repeated to them, their relative and finally that one person who had the capacity to get the work done (who, coincidentally would show up at the last minute).

As a part of Ortho B, I was once again fortunate to have professors who were mostly patient, friendly and were clear in their instructions. They also made Orthopaedics an interesting branch with their dedication, involvement and explanations. 

We were 3 interns working together and would communicate and share our work more or less equally so despite the busy schedule, we would finish up with the OT, post OT rounds and then head for a late lunch around 4 or there have been days in the casualty when the evenings were busy leading to a late dinner around 12.

Perhaps I realized many of my deficits during this month but there have been many good moments in Ortho such as when you neatly suture a wound and the patient leaves with a thanks or when a ward patient is discharged and thanks you or when a follow up patient comes to the OPD and looks to meet you or that moment when the ward patient requests that you continue to check on them even after you tell them that the new intern will take over from the next day. :)

So the next leg of this journey is as the CMO (Casualty Medical Officer) and it's got paperwork and procedures that take up most of my time but more on that later!

A month in the world of little ones.

The final days of Paediatrics saw a surplus in the case load as the dengue season had kicked in. On some days we had as many as 24 admissions in a day including the ward ones in NICU, PICU, Special ward and the general paediatric wards.

One particular evening there was a case of Paraquat poisoning which was brought to us and we promptly shifted her to the PICU. Now, Paraquat, unfortunately is one of those chemicals which have no specific antidote. The chances of survival are modest when the patient is immediately given activated charcoal based elimination, hemodialysis and hemoperfusion which are just technical terms for us here since we don't have those high end facilities. While B Sir explained the bleak outcome to the family, they had their hopes pinned on a miraculous survival despite the fairly large amount consumed by the teenager over a trivial fight. However it was the following day when M Sir saw the patient and immediately made arrangements to shift the patient out to a private centre where they had some hope of receiving the specified treatment. 

Yet, it was not meant to be since the private set up only squeezed their dwindling funds and sent them packing. At this point, the whole scenario; ( the inconsolable mother, a helpless father, a girl consumed by pain from within as the chemical corroded her from within even as she was in grief over her decision, doctors having their own limitations..) had me in a state of turmoil that couldn't be explained. We sent them packing to Indira Gandhi again in a free ambulance and all I could do was sit and cry as I wrote discharge summaries of moderately sick patients. Never had I seen poverty cripple a family that they are helpless to save their child. The anguish in the father's eyes as he watched his daughter struggle with the tubes attached to her even as he knew that a government facility was the best he could give. 

In the course of my postings, I saw several other girls between 14-17 brought with a history of phenol/ organophosphorous/ calamine lotion/ Harpic consumption and what concerned me was how these children had decided to take this drastic step after any altercation/ failure/ disappointment. Perhaps it has something to do with parenting as well. If only these girls could talk to their parents about what they were going through, if only the parents had the presence of mind to gauge the emotions of a teenager and react accordingly; tomorrow's adults will be a stronger lot who face challenges head on. 

There was Hemavathi from Bangalore who stayed with us for over a week since her typhoid fever was one that did not respond to the usual antibiotics. Initially her parents voiced their concerns about the treatment but in time, they had faith in us and left in a happy state. There was also a case of caecal volvulus with the complaint of abdominal distension. Here again, there was little that we could do since it was more of a paediatrics surgical intervention that was required. It was later that it surfaced that the infant had been investigated in the past and they were aware of the child's precarious condition yet had not taken any proactive steps on it. While some parents are examples of neglect and lack of concern, others are obsessed with every action of their child and promptly notify us about the child's food/sleep/bladder and expect adequate response from us for the same.

Mohammed Fizul was another 1 month 1 week old baby brought to us with an NS1 positive report and a falling platelet count. Overnight, he received transfusion so that he shot up from 9000/microL to a respectable number in the next few days. In the midst of discharge summaries, fresh investigations, rounds and OPD, when the father comes and thanks you for your involvement, you feel a wave of happiness wash away your tiredness, you smile and get back to your work with a burst of motivation.

There was Jeevan, a 1.5 year old who came to us one evening with respiratory distress and a low oxygen saturation. His XRAY did not look good and the underlying pathology remained undiagnosed but he was put on treatment to improve his saturation and general status. His brownish tangled unkempt hair and pale look spoke of his living condition but the concern in his mother's eyes revealed how they regretted that they had neglected his illness. The following day, an ICD was inserted by the surgeon Dr B to drain what appeared to be pus and pockets of air. His condition improved and we got a CT scan done at the hospital which showed a synpneumonic effusion of infective etiology. My shift ended before his discharge but I was told that he made gradual progress in the following days. 

There was Mohammad Hamdan who was brought gasping to the OPD and immediately rushed to the PICU. HE was eventually put on the ventilator and given a dose of antiepileptics and sedatives but he remained restless through the night long ordeal. The following morning, M Sir did an LP and drained CSF which I again rushed towards the virology lab along with the usual investigations. He was extubated subsequently but it is these cases, where you don't know why a particular symptom is occurring that you are worried more because you have a list of possible etiologies to rule out.

The last days of Paediatrics were busy but memorable. Be it the short talks with my P2 professors and ma'am enquiring about my welfare and making sure I had enough food/ sleep, the friendly banter with the sisters who made sure I didn't go hungry on my last day and shared their meal, the rushed breaks and the intermittent sleep, the moments of joy as you hold a chubby little toddler in your arms and look into its innocent eyes even as it doubtfully evaluates your stethoscope to the moment when a parent says it was good to have you as our doctor, Paediatrics was a journey I hope to relive.

Monologues.

I see two possibilities. I'm either going to blog with unwanted frequency or I'll close the blog and call it a day.

As ugly as within

Currently listening to:

• Neenillade (Ondu Motteya Kathe)

• Just Like Honey (the one from Lost In Translation)

• Lag Ja Gale : different versions by various singers but come back often to the original by Lata Mangeshkar (I am a boring old woman who listens to the same songs on repeat until they ferment in my brain)

I'm also glad that I finished reading:

• City of Joy (definitely an interesting read, an eyeopener into the lives of the slum dwellers of Calcutta, the happiness amidst the suffering and the ray of hope amidst illness and poverty.

• Marley and Me (can I please get a doggo now?)

• Oliver's Story (Finding love after the loss of your loved one. A sequal to Love Story by Eric Segal)

Anyhoo its back to college and I'm once again in surgery postings. This time we've been divided into 3 units of 10 students. So yesterday we saw two different stages of presentation of the same condition: Carcinoma of the Stomach.

First we saw an elderly female patient with history of abdominal pain since 20 days. Apart from this, she gave history of passage of dark colored stools. Examination did not reveal any findings. Based on the age and the complaints, the professors suspect an advanced stage of gastric cancer and have requested for endoscopy for correlation.

Next we saw a case of a 35 y/o female from Shimoga who was operated for gastric carcinoma. She had initially come with pain in the abdomen after meal and complaints or regurgitation of food. Suspecting PUD, endoscopy was performed. Here, ulcers were detected and the biopsy confirmed H.pylori infection and dysplasia.

After treatment with Anti H.pylori regimen, the patient did not experience relief of symptoms. A repeat biopsy was done and a second opinion was sought which confirmed the gastric carcinoma. The patient was operated at Kidwai Bangalore for a gastrojejunostomy and had come for a check up with the tube. A mother of a young girl, this lady will now require chemotherapy once her lab reports are complete and satisfactory.

Life often throws us into unexpected turns. And there isn't anything we can do about it but to face it head on. Which is why, when the road is clear, the path is straight; keep going and don't dawdle.

Today I saw the surgery for varicose veins for the first time. Its called the Trendelenberg operation and they ligate the tributaries of the GSV and then introduce a stripper, ligate the perforators and then remove the stripper (along with the shrunken vein) in one Strong tugging movement. It went on for quite some time because according to Gopinath Sir, 'It was a jungle inside with fibrosis and inflammation'. 

When the OT goes on for far more than your stomach can wait, your stomach decides to protest. And loudly, the rascal. In fact, today was the orchestra of several hungry stomachs singing in unison. The best way to deal with this is look straight ahead at the table with such conviction that even the ones next to you will believe that it possibly the patient who is hungry and not you!

Watched OMK with Abhi and had Dinner at Anmol midweek. I think I would like that to be the highlight of my week. I just remembered this thing that we had learnt in programming/ JAVA during high school. Something about memory allocation. 

I don't remember it well enough but when you delete one value and add another instead, it occupies the same 'space'. Or something along those lines, I can't get the exact words. I don't think we can do that. You cannot erase a memory you wish to forget by creating new memories. Hah! Life is not so simple that you vapourize an unpleasant experience with a poof!

You accept it, you acknowledge it and you rectify it for what it's worth. You can move farther ahead by acceptance than by denial. Sometimes. :)

Tata!!

Summertime Soliloqouy.

The bird that was meant to soar,
Shall only pause in the summer shade;
It's wings that cannot be chained,
Shall only rest awhile in the storm.

The freedom of the open skies shall prevail,
For nothing could hinder a ship that has set sail,
Perhaphs this was how the journey was meant to be;
In her own strength, with the choice to be free.

Unbound yet with deeper bonds she flew,
In the memories of the past, she grew;
Cherished within were stories untold,
But the beating heart remained it's own.

Every cloud has a silver lining 

This Or That.

They say I think in binaries. 0 or 1. Black or White. Good or Bad. Necessary or Unnecessary.  I see no in between, no intermediate entity. I have always had clear cut definitions. I don’t like blurriness; be it in my vision or in my perspectives. This is how I’ve always been. Do I want to change that? I don’t think so. That perhaps explains the uneasiness that gnaws within me.

There is so much I want to do. Am I really working in that direction? Or am I just working and waiting for everything to miraculously materialize? Ugh, I don’t know where this is stemming from but I’m feeling a lot of discontentment about myself. Is it probably inversely proportional to how ‘happy’ I momentarily feel?

I pride myself for my ability to not be influenced by the choices of those around me. It is one trait I hold close to myself hence, I’m pondering if I am consciously responsible for my actions or have I been influenced by those around me, willingly or unwillingly. 

Gokarna, March 2017 with Abhi and BP.

I don’t have the answers to any of these. I know I think too much, trust me, I don’t like it either that my brain keeps churning out such inane rubbish in the midst of an Aortic Aneurysm and I tuck away these thoughts in a tiny cubicle in my brain, assuring it that I will open the Pandora’s Box once I get the time to blog about it. :)

I want to talk a lot more but I don’t know if this is the medium to unload all my burdens, but it makes sense to reflect to oneself instead of somebody else because you will eventually hear an opinion, an advice, a suggestion or better still, a similarity in thought. All of which is unnecessary when all you need is a mirror. A plain mirror to lay the bare truth in front of your eyes; with all its ugliness, its scars, bruises and perfect imperfections. And that cannot come from anyone but me. (To cut a long story short, I find it as important, or probably more important to understand myself, consolidate my thoughts and be a whole person by myself than anything else. 

Or is this defensive attitude stemming from my fear of being influenced by new ideas and thoughts? 

What is nice may not be necessary and what is necessary may not be nice. 

In the end, nothing matters except what you believe in, what you stand for and what you do.

Subtleties are always better. I could write a million lines on everything I can imagine, which a far more powerful tool than reality is. I want my imagination back. I find much more beauty in metaphors, in an indefinite entity than in the raw face of reality. 
Maybe. 

And that reminds me;

http://scienceblogs.com/mixingmemory/2006/07/17/the-cognitive-science-of-art-r/

Read under ‘Perceptual Problem Solving’. I remember reading those very lines in VS Ramachandran’s Emerging Mind.

On an unrelated note, the marriage seems to have bitten the GRS family cousins as 2* more have fallen for the trap and wedding bells shall be ringing throughout this year. 

Jogging everyday hasn’t helped in physically (Let’s be honest :P ) but it certainly elevates my mood and automatically trashes all the clutter that I tend to attract with a magnet. -_-

Can’t wait to meet my super-achieving Minnulli over this month end (hopefully). :)

Bye Bye Old Faithful :)

(Trust me I’m not a raving lunatic who fondly addresses a virtual entity and distances actual people who listen to her. I just like me more.)