A Breath, At Last.

A baby girl was born in a tiny hamlet;

Tiny and blue, she began her first innings in the ICU.

A frequent visitor; the nebulizer was her healing amulet,

To her, the IV Lines and oxygen masks were nothing new.

Bubbly and bright, she greeted everyone in her sight,

The apple of her mother’s eye;

There wasn’t a treatment they didn’t try,

Yet the little one was always cheerfully high.

A constant worry about the future,

A test was done to reveal the disease nature,

It was a faulty gene they said,

Going on, it would be a rocky road ahead.

Yet another episode came and went,

Each time making a slow but steady dent,

Until her poor lungs could no longer pay this oxygen rent,

Every cell in her body was thoroughly spent.

In delirium she spoke of a happier place,

Perhaps there would be a garden at this unknown place,

She hoped she could breathe at a slower pace then,

And thus retired the brave girl to a heavenly embrace.

Written in memory of Darshini a 15 year old girl, a regular at Cheluvamba Hospital who was a case of Primary Ciliary Dyskinesia. 

Darshini fought bravely until her untimely death. Will always remember her for walking into the PG doctors room and making conversation with us, asking us random questions, with a wide toothy smile. 

Rest in Peace. ❤️🙏🏼

Nights that turned to days.

 3 summers ago was the first of PG duties.

With a fair and reasonable senior to put me at ease.

The night was long and tiring,

And slowly my sleep schedule began its rewiring. 

Since then, innumerable duties have come to pass,

Each with stark contrasts,

Some with adorable kids to play with,

Some with Covid patients and sleep being a myth, 

Some being busy with continuous emergencies

Often while dealing with mortal uncertainties. 

The continual beeping of the monitors soon faded to a distant hum,

To the hard wooden bench, we were comfortably numb.

To the patient's who came from distant villages for care,

We tried our best to treat and be there. 

Often the hunger pangs would begin,

Much to the delivery agent's chagrin.

Snacking on midnight meals,

As we recounted the day's ordeals. 

The early morning coffee to brighten our day

Another day to work and learn on the way,

Crying, grumbling, laughing and smiling through our duties,

We realized there is none better than the patients to teach..

Clinical Correlations.

Everyday is a part of a learning curve and I'm beginning to realise this as I see new cases everyday and attempt to understand how to workup a case. It also gives me the opportunity to interact with consultants, formally and informally and learn a lot about their practice and approach towards patients.

Take the case of Mr L, a 60year old man with uncontrolled Diabetes who presented with cough with expectoration and fever. Suspecting a Right Lower Lobe Pneumonia, he was treated with antibiotics initially but when he did not improve, he was treated in isolation as a Covid Suspect (which thankfully turned out to be negative). The CECT showed that it was a case of necrotizing pneumonia of the Right Middle and and Lower Lobes with partial collapse. The Pleural fluid analysis revealed it to be a exudative fluid and the cell type and ADA helped to exclude Tuberculosis. Furthermore, considering the site of pleural fluid being as high up as the apex of the lung, he was not a suitable candidate for ICD insertion (Intercostal Drain, he was taken up for surgery ( Thoracotomy + Decortication and Right Middle Lobectomy). Several findings could be elicited on examining him such as pedal edema, clubbing, decreased air entry on the right side, woody dullness on percussion and  vesicular breath sounds on auscultation.

Another Patient Mrs K with a pre-existing heart condition (including a valve closure surgery) was admitted for pneumonia and she too was tested for Covid-19. Luckily, her reports too were negative and the following day, I was off in an ambulance (with siren and all) towards Fortis in North Bengaluru where the patient was being transferred to be treated under own cardiologist and team. 

Sometimes, when you're the first point of contact for the patient presenting in the hospital ( either in the OPD or in the ER), you tend to follow up closely, to know how they are doing. Take the case of Mr A, an elderly active gentleman who was brought with history of giddiness and on examination, had elevated BP. He had been having hyponatremia for a while now, although he remained asymptomatic. It was thought to be drug induced by previously seen clinicians. His renal excretion of Na+ was elevated. He was also on the Anti-arrhythmic Amiodarone for "ectopic beats", but a Holter monitor (24hr ECG) revealed that he, infact had Sick Sinus Syndrome. He was suggested for a pacemaker in future, in case of syncopal attacks and his elevated TSH showed that the probable cause for his (euvolemic) hyponatremia  was taken to be his untreated Hypothyroidism. Ideally, he would require to be reviewed periodically if his hyponatremia resolves with the appropriate dose of Thyroxine; if it does not, then SIADH (Syndrome of Inappropriate ADH secretion) would be the alternative cause for his hyponatremia.

Causes of Hyponatremia as per Harrison

Sometimes, there are situations where you really cannot do much. Mrs S, a young woman with a daughter in her 20s, came with complaints of decreased appetite and weight loss. Her abdominal distension due to ascites made it more evident that there was an underlying malignancy. The initial blood work revealed elevated CA-125 and a CT scan showed an ovarian carcinoma but the report ( thickening of the stomach wall) also prompted for an Upper GI Endoscopy which revealed the original Carcinoma of Stomach which had metastasized as Krukenberg Tumour. I did an ascitic tap to drain nearly 2.5Litres of fluid, we started her on multivitamins and other supportive (palliative measures). The late stage of detection did not help either, so neither chemo or surgery were options which would guarantee an improved quality of life.

An interesting case that we saw in the OPD was of Mrs. P, who had been having cough for over 6 months(!). With no co-morbidities like Diabetes or Pre-existing COPD, she was taken through a battery of investigations and had completed courses of antibiotics, none of which, had yielded any answers. She tested negative for Tuberculosis and a bronchoscopy guided biopsy got some specimens which were faintly suggestive of a neoplasm (a second Pathologist opinion only gave an "acute on chronic inflammatory changes"). A PET-CT report said it was a hypermetabolic lesion with SUV 4.5 (Still a bit lesser than the cut-off to consider it a malignancy). Here, the radiologist picked up what could possibly be the "Finger in Glove" appearance of ABPA (Allergic BronchoPulmonary Aspergillosis). While the fungal cultures from Bronchoscopy had not yielded any Aspergillus, it could have been narrowly missed considered how quick the bronchoscopy has to be (extremely uncomfortable for the patient) so she has been started empirically on Voriconazole. Further work up would, in fact, be necessary and this led to a discussion on whether a CT guided Biopsy or Endobronchial Utrasound Transbronchial Needle Aspiration (EBUS-TBNA) would yield better results. D Ma'am then asked to read up on the approach to non - resolving pneumonias and it showed that a step-wise protocol is followed. We also read an article from UpToDate for possible etiologies of non-resolving pneumonia and the differences in their presentation. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644829/

Mrs A, presented with cough without expectoration and with massive pleural effusion seen radiologically. With a history of pulmonary TB in her primary contact, it was not hard to find the cause of her (pleural) Tuberculosis (this is STILL EXTRA-Pulmonary!). But  the conundrum was that her Pleural Fluid analysis from GeneXpert showed "Indeterminate" for Rifampicin. Rifampicin is one of the crucial drugs in the regimen of Tuberculosis treatment as per RNTCP and Resistance to this would mean that it would be considered as MDR-TB (MultiDrug Resistant Tuberculosis). So we inserted an ICD, sent pleural fluid again for analysis (this time LPA too). Only after verifying the resistance would she be started on the whole line of drugs that come under MDR TB treatment, until then she would be expected to continue on the HRZE regimen itself.

There was also the case of Mrs N who was brought to the ER with severe breathlessness. She had grade 4 pedal edema, raised JVP and on further examination, her right lung had decreased/absent air entry compared to left and she had a loud P2 as well. Looking through her previous reports, we gathered she had a history of Tuberculosis as a teenager which has caused the Right Destroyed Lung/Fibrothorax evident on X-Ray, overtime, the increased load on the single functional Left lung leading to Congestive Cardiac Failure. She was immediately put on BiPAP to reduce the carbon dioxide load as shown by an immediate ABG. The sudden need to be put on oxygen, the medications to manage her CCF and her sudden immobility did take her by surprise but we tried our best to boost her morale and give her confidence that she would improve.

Right Fibrothorax/Destroyed Lung

Apart from the battery of pulmonology cases, there have been stroke patients, chemo cases coming in for day care and a Carcinoma stomach operated (for the second time) and almost discharged when he had serosanguinous discharge at the operative site so he was re-admitted and taken up for Emergency OT for Burst Abdomen. There was also a patient who presented with renal colic and was almost shifted to OT for URSL and DJ stenting but backed out in the last minute after his pain was relieved (I'm still not very sure which is the ideal analgesic). There have been cases to ponder over and cases to work up to reach a diagnosis and the availability of the facilities is a big plus of a private setup.

Nevertheless, talking to the consultants here has, in itself, been a great experience. Dr M, an reknowned orthopaedic surgeon who practices here as well as outside the country spoke about the need for ethical practice, operate only when absolutely necessary and to earn the respect of the patients by not indulging in fraudulent practices. Sometimes, it is easy to get carried away by the herd, but it takes resilience to go against the tide and stick to our ethics. Here's hoping that these words will mean as much to me in the coming years as well. D ma'am shared her experience of PG days and suggested how important it is to read everyday, even if, only just for a short while. It's important to have a good rapport with your colleagues and seniors even if it isn't always a pleasant work environment (especially if you will need to get chances for any procedures!). Dr S3 picked up that I was nervous early on and asked me the reason. When I said that it was because I was afraid I would make mistakes at my first workplace, he said that I would definitely make mistakes at some point or the other but I'll have to learn from them, as time goes by. It was indeed reassuring to hear this!

Watching the burden of ill-health from close quarters is often worrying. One cannot escape old age but one can hope to live it with dignity. One cannot keep diseases at bay forever but one can definitely lead a healthy lifestyle and prevent illness to a large extent. Beyond this, medical science has made progress to alleviate the pain, decrease the progress of a condition or sometimes, remove the causal factor of the disease. Some other times, what we do, is probably buy more time. 

The terrace door has been locked for some reason. I don't think anyone would have spotted me on the CCTV. :P

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. :)

Attempts of April.

I'm probably not going to find a lot of support in this but I'm managing to get through the lockdown without any frustration. 'Is that even normal?' is a valid question at this point but all I'm saying is, I like how I'm getting this time to do everything I've wanted to do.

• I've watched The Office, Money Heist, (most of) Downton Abbey, Pushpavalli, a few good movies here and there. 
• I've been trying to practice some music everyday and it's great to revisit all the songs I learnt more than 10 years ago. 
• There's also some time for art that I have the freedom to attempt thanks to my mom's supplies. I'm also tinkering around in the kitchen these days and the results aren't too bad. 
• After a year of sitting in front of a study table piled with books and being absolutely inactive, it's a great feeling to get some workout within the comfort of my own home, thanks to Cult! (never thought I'd join the cult of Cult followers but there it is! This has really been a boon during this lockdown) 
• The icing on the cake is the new entrant; the Quarantine Quizzing sessions every night that I've joined since the last fortnight. Although the questions are mostly very difficult and my scores are abysmally low, it's a lot like the quizzes I would attend back in school and there's always some interesting trivia to take away from these. 

I've tried to pick up on my reading habit but its a lot slower these days to be honest and that's probably because of my attention span.

• Tell Me Your Dreams : Sidney Sheldon (A book I had wanted to read for a long time now. Unlikely murders, a mental illness and a courtroom drama)
• Nothing Ventured : Jeffrey Archer (The usual tale of twists and turns about a detective out to expose a suave fraudster)
• Fragile Lives: Professor Stephen Westaby (A British Cardiac Surgeon's experience over the years in his profession)
• A Doctor's Chronicles: Dr. Bharath Reddy (A paediatrician sharing is diverse experience of working with kids)
• The Girl On The Train: Paula Hawkins (This is still in progress but it appears to be a thriller set in Britain. As you can see, it hasn't reached the point of being a page-turner yet.)

I've also tried to write, after what seems like ages and although it's far from perfect, I'm really happy with myself for making a start! After drowning in writer's block for ages, this is a breath of fresh air and I'm happy to be making these imperfect attempts at poetry. :)

What would you be?

If you were the wind wafting across the flowers,

Would you caress the flowers, leaving them quivering?

If you were the sturdy tree in the woods,

Would you give a lost soul a humble dwelling?

If you were the ripples in the blue sea,

Would you clutch at the grains of sands anyway?

If you were the raindrops falling from the sky,

Would you sit gently and shimmer on the cobwebs?

If you were the warm crackling fire,

Would your embers give solace to the hillside vagrant?

If you could just be yourself in this world,

Wouldn't it make a difference in the Universe?

The Procrastinating Bibliophile.

To all the books that lie unread,

Purchased once with eagerness,

Yet overlooked for another book instead,

Know that I still love you no less.

To all the books that wait their turn,

Patiently lined up in my shelf,

For a sleek Kindle, I shall never spurn,

Next time, I always tell my lazy self.

To all my books, eager to be read,

Yet, tossed away for a shiny new find,

One fine day, in your path I shall tread,

Until that time, don't you ever mind!

To The White Army.

To my brethren that bleeds elsewhere,

Know that you are precious and rare.

To my comrades without their armour,

Our battles are not one but plenty.

To heal and help we began our journey,

In your recovery, we found our reflected glory.

The nights spent over patients aplenty,

Were worthwhile when they walked out healthy.

While we take on a microscopic enemy,

'Keep Us Safe' being our only plea,

Yet today we stand aghast and helpless,

For mankind can be violent and ruthless.

To my brethren that bleeds elsewhere,

Perhaps not all is lost in despair,

We shall live to see better days,

Humanity shall get through this dark phase.

Jaychu's Kitchen :)

 
 

 

Artistic Attempts :P

 

So that's all for now. Perhaps, there shall be something more interesting coming up in the next blogposts. ;)

A New Decade.

10. Makhna - Drive 

9. Naznina

8. Manzar Hai Ye Naya - Uri

7. Believer

6. Fight Song

5. Hall of Fame

4. A Million Dreams

3. The Fighter

2. Challa - Uri

1. And recently - Malang Malang

And some more songs that gave me a lot of peace. It's almost like a routine to begin the day with some of the invigorating hymns of Shiva/ Hanuman/Durga.

There's a lot uncertainty about the road ahead and it's hard to deal with this cloud hovering above but we can only hope that there's going to be sunshine soon. If not, try to create my own happiness and take what life has to offer with gratitude.

The 2019 was a year that was a challenging transition; from the routine of hostel life to adapting to one at home. It's been a bittersweet experience but one that is perhaps necessary to progress to the next phase of life.

Here's summing up the journey through the subjects that I love and the ones that I have grown to love.

Biochemistry's cycles and pathways have a similar destiny,
Molecules interact within our body with the sole aim of energy.
The hand and foot are an Anatomist's prized tricks,
Leaving us baffled with overlapping muscles and intricate vessels.

Physiology attempts to simplify the complexities of our body,
With flowcharts, formulae and graphs.
While Psychiatry divides the maladies of the mind,
Based on myriad symptoms and specific durations.

Worms and their larva, but some with their operculated egg,
Don't even get me started on identifying mites and ticks by their leg!
Viruses with their myriad shapes and sizes arrive,
Only to be silenced by vaccines; killed and alive.

Through mosquito stats and sanitation facts we sojourn,
While nutrition facts and occupational hazards cause some heart burn.
Through charts and graphs we hope for some reprieve,
But the normal distribution curve has several tricks up its sleeve!

The pathways of disease were dealt in Pathology,
Mechanisms inside the microscopic cell lead to macroscopic changes!
With its artistic histopath slides in 50 shades of Purple and Pink,
Every tissue marker seemed to have a link!

Transporting us to the Labor Room,
OBG thrived on giving us scenarios in the womb.
From interpreting the partograms of obstructed labor,
To staging ovarian and endometrial carcinomas,
This subject surely couldn't be ignored!

What begins with audiograms and tympanograms,
Escalates into a variety of -plasties in tiny orifices.
ENT has its tuning fork tests and hearing devices,
Even as we fumble with the inner ear diagrams.

Cunningly similar, yet subtle differences emerge,
Fundoscopies of the eye have seen a recent surge.
Ophthalm explores beyond the mundane cataracts and conjunctivitis
Into the realm of corneal ulcers, dystrophies and uveitis.

Be it the tall and tented T Waves of Potassium excess,
Or the giant a waves of tricuspid stenosis,
The ST elevations of an MI to its exact artery involved,
Waves of all kinds are always favoured.

If splints and tractions of Ortho fill you to the brim,
Wait for the named fractures of every limb,
In Dermat, you navigate through the many layers of your skin,
Fungal infections and STDs are its kith and kin!

Milestones from a neonate to an unsteady toddler,
Abundant Syndromes like Turner, Edward and Potter.
Facts and figures, scores and cancer stages,
IPCs and CrPCs fill our pages,
A race against time, a chance, perhaps of a lifetime!

.

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.

Skills with the Scalpel and Beyond.

January began with the excitement of nearing the end of our internship. After the debacle that was the NEET PG exam, I began with my stint in the Department of Anaesthesiology.

While most of the time, I was involved in having a look at the Pre Anaesthetic Evaluation of the patient, shifting the patient to the OT and monitoring the vitals, there was also the opportunity to intubate the patients either in the OT or in the ICU and also in giving spinal block to patients being posted for LSCS. Less often, there were also epidural anaesthesias given and Central Lines inserted. The 15 days in the Department involved elective OT, Emergency OT (which was followed by a day off) and ICU duty.

Another thing about the Anaesthesiologists in the Department was how they were always so full of questions! I particularly had an interesting time discussing with Dr C as well as Dr H who were open to all kind of answers and also provided interesting points to ponder upon.


Following this stint in Anaesthesia, it was time to get my hands dirty in surgery! And literally so; With diabetic foot debridements aplenty and the casualty bustling with head injuries, there was never a dull moment in this Department.

Although I was initially very apprehensive about my non existent surgical skills, I was extremely fortunate to be in what I would consider the best unit in surgery. Headed by Dr K who had a huge patient pull (never a day passed without patients turning up saying they were related to him and thus demanded VIP care) and with Dr N and Dr V  who were good spirited and encouraging to the interns, it made for a moderately busy unit with good surgical exposure for an intern. Particular credit must be given to Dr V who almost ALWAYS made it a point to involve the interns in any decision making and gave ample opportunity to do the procedure (skin to skin). At a time when our incisions are still unsteady and prone to fishmouthing, Sir had the confidence to give us a chance to learn. We initially had Dr K as our JR who was well informed and guided us in the casualty for critical cases and later we had Dr P who was also a friendly guide in the wards and the casualty.

As a surgeon, While Hernioplasty, Lap. Cholecystectomy, mastectomy, BK/AK amputation, Trendelenburg Procedure (for patients with Varicose Veins) and cyst excisions remain the elective bread and butter, the emergencies like acute appendicitis/rupture, hollow viscus perforations are the emergency cases which would require early preparation of the patient and an operation at the earliest. Of course, there are a host of local procedures which also come under the jurisdiction of surgeons such as local cyst excisions, incision and drainage of abscesses, suprapubic catheterization, foreign body removals, excision of ingrown toe nails and many many more! Basically a general surgeon has a lot on his plate!

One of the important things I learnt in surgery is that the operation per se is only one part of the treatment provided by the surgeon. The pre operative care as well as post operative care are as important as the procedure itself and goes a long way in deciding the prognosis of the patient.

There were patients who had fairly uneventful surgeries but developed complications post operatively owing to their preoperative comorbidities such as COPD or uncontrolled Diabetes.

A particular patient I will remember is the HBsAg positive Mr. GN who came to the casualty with pain abdomen at night. When his USG happened only the next day afternoon, it revealed a case of intussusception which was operated upon the following day after ensuring he had received some nebulisation in view of his chronic smoking history. While the patient recovered quickly post operatively, he returned soon enough with abdominal wound dehiscence and swab cultures showed sensitivity only to colistin.

Mrs. S was another long term occupant in the Female S/D ward who only had her old and wrinkled husband caring for her relentlessly. Day in and day out he followed us until we made arrangements for free blood transfusion for her, until we had posted her for a below knee amputation that eventually gave her some relief.

Being a part of her OT was another memorable experience altogether with the Gigli saw!

There were a few interesting cases such as a pancreatic cancer in advanced stages. She presented with obstructive jaundice so a Triple Bypass surgery was done with a palliative perspective. There was the patient with open skull fracture who came to our casualty one evening. The contents of the cranium were clearly visible and were palpable. The patient was surprisingly stable so a quick wash and some stay sutures later, we had him rushed to NIMHANS but I had my doubts on his prognosis. Imagine my happiness when I returned after a few days leave and saw the same patient referred back from NIMHANS after an anterior cranial fossa repair and moving around normally!

Thus, after 2months of learning in the Department of Surgery, after even giving a seminar on post operative management of a surgical patient, with some wonderful memories with my co intern Sanjana, with the new junior interns, it was time to bid adieu to the last leg of my internship at Sri Chamarajendra Hospital, 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.