Quarter of a Century.

Uncertainties and doubts loom large

But it was time for the annual recharge.

They say nature has the power to heal

With renewed vigour and zeal,

I set off towards yet another climb,

Except this was one was past bedtime!

Through the city we trudged for an hour or so,

And then we began our trek underneath the starry glow.

Puffing and panting, I was breathless in minutes,

Looking down, I could see the lights of the nearby rustic huts.

Why go through this, I asked my sedentary self plenty

But perhaps this is Nature's cashless fee.

As the cold winds taunted us towards the edge,

I knew this was a test I could not sledge.

Settling down into a sleeping bag on the hilltop

I realized there are so many things in Life I cannot stop

But the beauty of the nightsky was mine to cherish

The whizzing shooting stars were mine to wish.

Waking up to an ethereal streak of colour

That slowly grew into shades of pink and amber,

A peacock screamed lustily in the distance,

And Nature thus showcased her brilliance.

In the midst of the uncertainty that lies ahead

Not knowing the upcoming paths I shall tread,

This moment would be mine for eternity

Nature demands, but also unconditionally provides.

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.

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)

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. :)

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!

Learning in Orthopaedics

After the cool confines of the NICU and the dengue filled Paediatric wards, it was time to bid adieu and start afresh in Orthopaedics. 

With no prior experience in suturing/ dressing/ management of Fractures, I had my trepidations regarding this rather male dominated department. Furthermore, I was now setting foot in the new hospital. That is to say, I had so far been a resident of the old hospital which houses the Paediatric Department, Obstetrics and Gynaecology Department and Psychiatry Department while the rest of the Departments, ICU, ICCU are a part of the new massive 4 floor hospital building. (What I'm trying to say is I'm yet to figure out my way through the 4-5 lifts, 4 entrances and ward rooms that all appear the same to my fresh eyes!)

The Orthopaedic department is well organized with two units. Both units function separately and have prefixed OT and OPD days. While unit 1 has specialized interest in spine surgery, unit 2 (under the involvement of the HoD) has a weekly section dedicated to CTEV correction. The Ortho Department has a Male Trauma Centre, Female Trauma Centre and Male and Female Ortho wards. Post OPD, an Ortho intern is expected in the Casualty for all cases that present with Orthopaedic complaints. 

My first day in the OPD gave me a glimpse of the work load and by the looks of it, the number of cases seen by the doctors per day is much more than the earlier department. There is also a CTEV clinic headed by the HoD weekly aiming to correct congenital deformations of the foot. Orthopaedics is about pain management. While in some cases the pain can be eliminated with the right surgery/ slab followed by appropriate exercises, sometimes the original range of movement is not obtained and there is some residual pain. Either way, an Orthopaedic surgeon has his moment when he watches the once bedridden patient taking hesitant steps on his own after the successful completion of a surgery.

It's not just about cutting up and fixing bones. A lot of work goes in before the patient makes it to the OT table. He must be evaluated for his blood counts, tested for seroviruses and often, a physician's opinion is required to rule out any cardiac comorbidities. After this comes the pre anaesthetic evaluation by the Anaesthesia department following which he is said to be 'Fit for Surgery'. In Orthopaedics, there is usage of specific implants for each kind of fracture and this must be procured by the patient prior to the surgery. Sometimes, the patient may also require blood to be transfused prior to surgery to correct anaemia or blood to be arranged in anticipation of blood loss.

My first experience in the OT involved a lot of written procedural work, consent taking and shifting the patients in the order until I was allowed to scrub in. S Sir taught me since it was my first scrub and I was treated more like a precocious kid capable of contaminating the sterile zone. My job was mostly to retract and provide adequate working area for the surgeon. But it was indeed fascinating to watch the theory come alive on the table as Sir observed his work under C arm guidance, fixed the plate, put in a drill to make holes and then put the screws to hold the once broken bones of the trimalleolar fracture in place. Later he closed up and proceeded to operate on the fracture shaft of radius.

My first day in the OT more about figuring out where it exists as the OT complex is pretty much a maze and it had me dejected at one point when I didn't know where I had changed so I thought I'd be stuck in my OT dress until forever. Luckily, I was wrong and I could have a late lunch after meeting the patients post op, giving them the standard instructions regarding NPO, limb elevation and a check XRAY to look at the handiwork of the Orthopaedics. After the rounds with Sir, he dropped us near our hostels (Yaaass) and proceeded to his clinic where a flood of patients awaited him.

Now for the part about the casualty. Having no such prior experience, my first time in the casualty was more of an observation than an action packed experience. Patients being rushed in on stretchers and wheelchairs, limping in, walking in and sometimes stumbling in after an intoxicated night. From the fairly calm atmosphere of the Paediatric wards, it took me some time to adapt to the sights (of wounds), sounds (of pain) and smell (of injuries) in the casualty. Furthermore, I still had to figure out where specific instruments and apparatus were located. What amazed me was how, in spite of all the chaos and rush, there was actually a system in place and perhaps, there was a method in the madness! 

The moment a case was brought in, there was the CMO asking for their history behind the injury (assault/RTA/self fall), a surgery intern looking at injuries in the head thorax and abdomen, a medicine intern assessing if he had any other complaints and the orthopaedic intern looking into his injuries to the back and peripheries. Depending on the severity, each injury is addressed and the patient is admitted if necessary treatment can be provided in the hospital.

As an Ortho intern, it was my duty to assess the limb affected for its movements, neurovascular status, provide wound dressing and suturing in case of lacerated wounds, ask for the XRAY of the specified part and then act accordingly (based on the instructions of our duty doctor). In case of undisplaced fractures, often a slab support is given followed by a review in OPD. Some fractures need to be operated upon such as an open fracture or one that is displaced completely hence the patient is put on a slab support and informed about the need for surgery. Cervical vertebrae fractures are usually not handled here because of its coexisting neurological involvement and they are referred to a higher centre just like cases where the vascularity of the limb is compromised requiring a vascular surgeon intervention.

I usually stay till 12AM and then walk back to the Ladies Hostel and attend to any calls between 5.30 and 8.30am (which are less or none in the early hours tbh). The maximum number of cases are between 8.30 to 11.30PM on weekends, especially post rains. As we clear each case, there are fresh ones being rolled in and so it's a constant state of flux in the casualty. The 'brothers' and sisters in the casualty are extremely helpful, especially when it comes to learning any procedure. After my first day where I made several attempts with the help of my co intern, I was eager learn suturing and sure enough, there were plenty of opportunities to learn in a day. On my next duty day, under the guidance of Basavaraj Brother, I managed to suture a lacerated wound by myself even as curious 3rd years wondered if this new person in the casualty was an Ortho PG. It's indeed a moment of joy when you look at your handiwork after unsteady hands managed to coordinate to close a gaping wound. In the course of the day, I managed to close another badly cut open wound at the shoulder with sutures thanks to the guidance of my senior Co Intern.

The next OT day proved to be interesting with me fainting with postural hypotension and then making it back to the OT to put mattress sutures on the patient posted for implant removal. All in all, each day in the Ortho Department brings forth new things to be learnt, new experiences and a sense of excitement over every tiny new thing accomplished. :)

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.

Nefelibata.

Picture Imperfect.

Tell me everything I shouldn't know

The dark stains that refuse to go.

Fill me with the darkness that shall blind,

The answers to the questions on my my mind.

Beneath that fine veneer and sheen

Maybe there are unknown tales to glean.

Fall from that pedestal of glory please

Bestow that starched white with some grease.

Tell me everything I shouldn't know

Anything to let go of that halo

Fill me with dark lies so I may believe

And hope to seek an uncomfortable refuge.

Beneath that chiseled perfection I see

Maybe there are crevices and cracks unknown to me

For now that is all the reason I can live with

To believe that it is after all a delusional myth.

When I'm not swatting flies and seeing inebriated patients on night duty at the Holehonnur CHC, I'm scamming their free WiFi and attempting to relearn how to write poetry.

Working at a PHC for a month and now a CHC has been an interesting experience so far, opening your eyes to the amount of sickness and disease. It also makes you realize how the things you take for granted are privileges to someone else.

During my free time in the day, I've been doing paintings that should probably be torn up into 38372827 pieces yet I still have them probably because they are so stupid they are a little funny. :')

Oh and I'm also listening to some music after what seems like ages! :) 

• Kajra Mohabbat Wala (Sachet Tandon)
• You can be king again (I'm not really into anime but I should thank Medha for this!)
• Nindaraan Diyaan (Amit Trivedi) <3
• Your hand in mine (Explosions in the sky)
• K (Cigarettes after sex)
• What's my name (Rihanna) (I heard this recently after years and I couldn't believe I was a big fan of this once xD

^ A cloud walker. An individual who lives in the clouds of her own imagination or dreams. A person who doesn't abide by the rules of society, literature, or art. 

String Of Flowers.

A string of flowers for her silky strand,
He walked into her life, asking for her hand.
Endless sunsets and misty mornings in mind,
Reality was otherwise, she would soon find.

Away from the simple cows and the grazing meadow;
A village belle within four walls and a window.
Away from the friendly folk and rustic lore,
She lay forgotten but for her marital chore.

Bereft of the care and love she craved,
Alas, her first born could not be saved.
Agony and pain seethed through her veins,
In futile hope, she clutched at the remains.

No longer was she the cherished one,
After all, she had failed to beget a son.
A string of flowers she saw in his hands,
But they never made it home to her silky strands.

As the eager wife waited in her desolate tome,
The flowers found their way to another home.
And they wondered why she turned insane.
After all, wasn't he handsome and humane?





//Now I'm writing something after what feels like months. I'm surprised I could even string two words together. This is based on a movie plot that I heard from a friend and a fertile imagination. KThanksbye

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.) 

YOLO

There’s just so much going on lately that there’s been no time to sit down and blog it out  and yet the urge to pen down my thoughts only gets stronger.

I probably can’t provide a detailed account of everything that’s happened lately but here are the highlights:

• Aynur scenes on Manjushri’s Gaadi with Abhi (all because we didn’t want to stay on campus on that particular evening). We went ahead by 13kms and then realized that we’d already crossed Aynur so we drove back and then made our way to Aynur Dam (which doesn’t exist. It’s a lake which was drying up) but nevertheless we had a good time racing on the highway until the gaadi became all wobbly!

                          

 

• Home scenes: I’ve been going home every 10 days or so and things are improving only very slightly. Bheemi is bored at home since Science camp is over, the 3 day outdoor camp is also over and there’s nothing to do other than bug the birds or Ma. I’m not sure where things are headed but I’ve got the knack of filtering out these worries from my brain and feeding new ones when I get back to college. I wish I could spend more time with her given how she doesn’t play with the neighbourhood kids or by herself. The comparisons with the present scenario and the seemingly idyllic childhood that I had only puts more pressure on everyone and I hope once school starts, the usual routine will put everyone back in gear.

• Mama and his Toastmasters:

I haven’t spoken much about the famous Balu Mama (yep, he’s quite famous among my friends) here and this seems like a good time. So being the CFO of Fidelity, he is definitely a busy man but his dedication to his passion is noteworthy. Initially it was music and he made time for it and attended the classes in the midst of tiny tots and improved gradually. Today he sings well during Karaoke sessions at home with other fellow music lovers.

About 2 years ago, he took up Toastmasters to improve his public speaking skills given how he is required to speech to large gathering in his work capacity. I’ve been listening to his speeches and reading his scripts from his early days and I can only marvel at the improvement he has shown over time. The effort he puts in for every weekly speech is noteworthy given how he spends most of his time at office or in transit. These days he is participating in competitions and making waves in the Toastmaster circles. Given how he is now mastering the finer nuances of the art of oration, I can no longer provide any criticism to his speeches.

The other day we were at Cubbon for Di’s mountaineering class and Mama presented his speech. He describes how in his college days, cricket was his passion and in one such match, he was fielding and his arch rival was batting. While the ball came in his direction and he caught in the nick of time, not many knew that it had crossed the boundary line. While that remained within him and nagged him in spite of winning the match, it was only later in life did he face the bigger challenge.

While working in one of the international banks in his younger days, he was offered a senior position if he agreed to certain terms and conditions. On closer looks, he realized what they expected of him was unacceptable and would only land him in a soup later. It was a tough choice and the promise of luxury was inviting but the burden of guilt would be too much and nothing was worth the peace of mind he could have. Thus he left and began working is way up all over again in Fidelity.

Thus, we are often faced with tough decisions in life, sometimes the line between what is right and what is wrong is a thin one and not everyone might appreciate it but as long as you can see the line, you need to exert your will power and do the right thing.

I’m also thankful to him for making a huge difference in the light of recent events. Words cannot express how his timely intervention softened Pa’s stance. I only shudder to think of how things would have progressed if not for him. Whatever he said definitely had an impact and made Pa look at things slightly more broadly.

• Demedcon 2016

So we attended the Neurology workshop and the quiz at Devraj Urs Medical College. BP, Govi and I had a good time.

• Abhi and Avm were in Bangalore in the same week and we all (including BP and Govi) spent some time together. Di and I joined them later at BlueO and we spent time bowling, Di had some Gaadi scenes of her own and then headed home. Di did a lot of photography and turns out she was not half bad. The evening was memorable one but the evening didn’t go along expected lines but maybe hoping for it to was just my foolishness.

• There are plenty of thoughts running in my mind but I don’t think they deserve the importance of me brooding over them. Nothing is constant. It’s all about priorities. Happiness is a choice, a conscious decision and once you make it, it's not about the circumstances you are in. It's about the way you choose to react to it. A wise frog once said, react to yourself and not for others. It's best to deal with your thoughts within your own cranium rather than expecting others to understand. 

• I participated in the 5K Speakathon on May 1 which was to raise funds for the speech and hearing centre in Shimoga. A good number of people turned up and several of our professors were all set for a good jog on a Sunday morning. So Shobith was also participating in the event so he picked us (Akkamma, Varsha and I) and we registered and got our Tees. It wasn't all that tiring and we jogged/ brisk walked for the most part and got our certificates. After the mandatory photo session we all parted ways. It was a good start to the day and definitely a great initiative in Shimoga. I wish I was fit enough to participate in the 10k! Maybe next year :)

• And the countdown begins! I’m thrilled to bits about the upcoming trip and can’t wait for this vacation. After all the uncertainty and confusion in the past 2 months, all I want to do is explore new territory and get lost in the midst of nature! I’m going to stay off the radar (hopefully) and do some much needed soul searching. Paediatric postings are at stake but then, you just can’t let go of some opportunities…. :P  

ENT internals are coming up over this weekend but all I can think of is what lies ahead. It’s about time I get back to Semicircular canals and turbinates.

Retrospective Study.

Sometimes, the smallest things take up the largest place in our heart. –Quote along similar lines by Winnie the Pooh.

Truth is bitter and there is nothing more disagreeable than hearing it from the very people who you thought would defend you. When your worst fears are confirmed by the one you trust the most, you really don’t know yourself anymore. I am not who I was, I don’t like who I am but I can’t seem to understand when did I even change. It’s like cancer, growing within you insidiously, destroying you surreptitiously from the inside until one day you wake up to see that you’re no longer who you were. The question is, how much has this cancer progressed? Can I really get back to who I was? My problem is why do I believe so much in the goodness of “who I was”? Maybe I’ve had the flawed gene for a long time now…

Dad studied in Suratkal for 5 years and he describes his hostel life as one of the experiences that taught him a lot about life. One of the reasons (other than the gaadi) for his reluctance on me shifting out of campus was his belief that staying in would teach me a thing or two about people skills and also give me a lot of memories of hostel life. It’s been over 30 years and he still has a connection with some of them. Question is will you be remembered 30 years from now? Career, life, family and everything moves on but we always remember how people made us feel

Once you’ve recognized that there is a problem at hand, you need to figure out a way to eradicate the problem by the roots. I don’t know where or how to begin and honestly if it would make a difference but I will have to make an attempt. It feels like broken glass can’t be pieced back together but to know that I’m no different from the very people I wanted to differ from makes me want to try harder. Giving up on people is easy (and that’s the convenient route I’ve been taking) but the challenge lies in trying to set things right even when you want to walk out. I’ve been saying that school and college friends know me well and they are all the friends I need, but is that an excuse? I guess not.

In the end, we all want to be happy doing what we love with the people who matter to us and being there for the people who mean everything to us. Is that so hard? It actually is when you aren’t sure of what you’re doing AND you don’t know anybody anymore!

Along happier lines, MaPaDi were here over the weekend since Di’s done with her final exams (and I wasn’t really making any headway with my internals preparation). We did a short trip to Jog falls and it was good. It is also likely that the highlight of 2016 will be in the month of May. I can’t say much until it’s all finalized but I’m super excited to be traveling again!

Movie Marathon:

1. Deadpool (Profanity Fest! A witty and sarcastic take on a superhero movie instead of the usual glorification)
2. Scent Of A Woman (a 90s classic, Al Pacino plays a blind man out to fulfil a few of his last desires and to help him in his quest is a young boy with troubles of his own)
3. Flipped (Probably one of the cutest movies I’ve ever watched in the most non cheesy way because the protagonists are still kids. It also makes you think because there is a lot of truth in what’s said…)

I’ve been cycling lately (thanks to VP’s cycle and Liki managing to get it to campus) with Abhi and BP and it’s a lot of fun! :)

On the academic front, last week was my disastrous Ophthalmology seminar and I clearly didn’t put enough time or effort into it and hence suffered the consequences for the same in front of my 90 classmates. ENT postings are coming to an end and not a day passes without the juniors piping up with the answers whether it’s related to Pharmacology or Anatomy. The good thing is that in spite of the shortage of cases in this season, Lohith Sir explains every case and tries to give us an orientation about ENT.

Toodles :)