Healing The Maladies Of The Mind.

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

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

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

Little ones who buzzed around with abnormal activity,

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

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

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

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

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

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

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

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

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

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

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

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

Lead Kindly Light.

From mounting debts that pushed them off the edge

Through affairs that drove an irreparable wedge,

To the grieving for whom relief was a far fetch,

They chose the untrodden path of no return.

While somewhere a wife grieved for her beloved

Elsewhere a lover regretted hasty words unapproved.

And yet another father repented over love unshowered,

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

Tender care and concern was what they needed

To nudge the fallen spirits that could be reignited

A warm kindling fire of support was all they pleaded,

To awaken the sanguine Phoenix from their ashes.

To save one from the clutches of despair,

Is akin to saving a drowning man at sea.

By giving wings to a wounded man's dream,

Be that social pillar that shall heal and repair.

Suicide is not the answer.

Written in view of Suicide Prevention Awareness.

Keep your eyes and ears open!

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

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

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

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

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

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

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

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

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

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

Roars To Silence.

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

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

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

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

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




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

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

The month of Electives at HIMS

After a month of Orthopaedics began my stint as the CMO. The CMO chair is definitely the "hot seat" as he/she has the overall responsibilities of MLCs as well as to look into every case and start initial treatment and ensure the concerned intern attends to the case. Along with this, the CMO has to look into the brought dead cases and handle them as required.

It was during my CMO duty that I realized how ruthless people can be towards the doctor community. All though a one off event, the temperament of the people definitely put me off at that point. Often it is on those days when you are already loaded with work, barely have a moment to sit down and are dealing with hunger (and hormonal) issues that a patient attenders goes ballistic on you for not giving them enough attention. It's at these moments when there's someone filming your polite request on the phone and threatening to send it to the media (in case something happens to the patient, if not? Well you were just doing what you were supposed to do, what's the big deal in that? ) that you wonder if this is the pathetic respect that doctors get in the society.

But apart from such odd incidents, the CMO duty was one of a kind, it brought me closer to the raw realities in the rural hinterlands; OP poisoning after debts, tablet consumption over broken relationships, assaults in drunken brawls, injuries by factory machineries, teenage pregnancies and RTAs of all sorts (Bike Vs Dog was one among them). The CMO duty might have been hectic but it was indeed a memorable experience to work with the friendly staff and cooperative co interns!

After a week long break, I reported in the Department of Pulmonary Medicine with a lot of trepidation; I had forgotten about COPD and my knowledge of TB required some recollection! But eventually it turned out to be one of the least hectic Departments in the hospital with no emergency calls after 4. The OPD hours were spent prescribing bronchodilators and nebulization or sometimes in conversation and tutoring Deepthi ma'am with her written Kannada.

The patients largely consisted of aged men whose addiction for the nicotine and Bheedis had gotten the better of them. Many of them would clearly come to us with complaints of breathlessness when it was evident they had had their last puff moments before setting foot in the hospital. They would flash a cheeky toothless grin when told to quit smoking, ask for their regular dose of medication and walk away with the satisfaction of doing something about their health. Then there were those who had discontinued their ATT regimen and had now come with worsening symptoms, there were pleural effusions to be drained, pneumonia cases which had to be referred for the loculated effusion, TB +HIV cases with ongoing infection, lung cancer which had been diagnosed but neglected (because the patient looked fine so the attenders didn't consider it worth their time to get him treated at Kidwai) and also a significant fraction of patients walking in asking for Surgery/ Dental/ Medicine/ Dermat departments since the Pulmo department was situated strategically at the centre.

I also realized how the Pulmo was at best equipped to give the patients a 'temporary fix' and not give a long term solution since these were chronic conditions that we were dealing with. Nevertheless it was a fairly free week in Pulmo giving us plenty of time to interact with the cheerful and elegant Dr Deepti, read for a while in the OPD and of course; sleep blissfully at night!

My stint in Radiology was extremely short-lived to actually share any glimpses but in the 2 out of 3 days that I attended Radiology, I got to "see" a lot of CTs and several USGs even though I didn't really follow a lot about it's interpretation.

What began with a lot of preconceived notions were rapidly dispersed once I set foot in the Department of Dermatology.
With a busy OPD and plenty of PGs to learn from, Dermatology has been an interesting, educational experience. From the common Taenias, Ptyriasis, asteatotic eczemas, impetigos, folliculitis, furuncles, psoriasis, vitiligos, lichen planus and herpetic lesions to the filiform warts, erythema multiforme, ingrown toe nails, sebaceous cysts, neurofibromatosis, DLE and more, its been an interesting journey that I never expected to enjoy.

The fact that there were PGs was a huge bonus since they were extremely friendly and had a clear understanding of every condition, procedure and also the logic behind why we do what we do. I'm so glad I got to interact with these PGs who, in the short period of our interaction, taught me a lot both within and beyond the scope of the subject.

Unreal reality

Through wails and cries we stride
Amidst the corridors of illness we rush
Through the gloom of death we emerge
For those that survive and breathe.

The newborn energetic cry of life
The struggling yet victorious limp of another
The unparalleled joy as the sick child makes it through the night,
For these little miracles, we strive.

Harsh words that mock our effort
Raging voices and rising tempers daunt us
Amidst the dwindling faith in our kind
The ones that leave us with a smile make it worthwhile.

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.

Amidst the tots, toddlers and teens!

Fresh out of the insulated NICU, I began my stint in the Paediatric department with alternate day OPD and ward duties. This meant that I had about half a day and a night off on the ward days and alternate day night duties.

On my first OPD day I reported on time and when I was on my rounds (prior to the actual rounds with the consultants), the recently admitted patient Kishan, a 11 month old boy on ventilator had no cardia and his family attenders began mourning. We quickly did the emergency resuscitation but to no avail. We called the duty doctor who verified the same and informed the family. It was only later that I realized that it was a case of Retroviral infection also present in other family members that was the main factor leading to all other complications.

There was Umme Kulsum, a case NS1 positive Dengue fever of Unit 1 that I monitored because I saw how she progressed from throwing up over a glass of water to half an idli to a full meal. On my subsequent night duty, she had platelet counts around 40,000 , abdominal pain and hypoproteinemia leading to some edema. Over the next few days, her counts dropped further necessitating transfusion after which she made a gradual recovery. It was indeed a happy moment when this little girl gave a broad smile, a shy thank you and made her way out of the wards. The next such happy moment was when Saniya Banu (who was in the PICU for a while) and her elder sister Hiba Tehreen were also discharged upon recovery and they left after a thank you from their mother.

Dengue cases are on the rise this season and they usually present with the primary complaint of fever, sometimes associated with myalgia and vomiting. The management is not specific but mainly consisting of fluid therapy (Ringer Lactate), regular BP monitoring, daily platelet and haematocrit verification. It's when the platelet counts drop further that the crisis deepens with abdominal pain and bleeding as the next set of manifestations. But so far, the dozen or more cases admitted have all made a successful recovery.

The next case that's worth mentioning is a case of hydrocephalus and subgaleal hematoma that was brought to us for a short stay after which we referred it to NIMHANS for a VP Shunt and further neurocare. There was the standard running around for a free ambulance under NRHM (National Rural Health Mission), some reassurance to the parents that NIMHANS would provide quality medical and surgical intervention at affordable prices and Krushi baby was sent packing.

Along with Krushi came B/o Mani who was brought one afternoon after she had 4-5 episodes of convulsions the previous evening. While the mother was extremely emotional and burst into tears at the slightest question/ explanation, the father was rather demanding and expected 24*7 presence of the consultants. This otherwise adorable cherubic little one also had fever and we got a CT and EEG (Electroencephalography) done which again pointed towards a neurologist for further reference (Query: Viral Encephalitis) but then she aspirated on her feed (probably the mother's enthusiasm after a week of keeping the baby on NPO (Nil Per Oral)) and had some respiratory distress, much to the anguish of the parents. At this point, I was some kind of interface between the NICU sisters who were viewed with hostility and the parents who simply wanted to hear that everything was going to be fine; something we cannot guarantee once a child is brought to the NICU. Luckily enough, she made a satisfactory progress, was shifted to the PICU and then was sent home after she regained her active joyful state. Here's hoping she makes a remarkable progress with no recurrence.

After this came two cases of mesenteric lymphadenitis presenting with pain in the right iliac fossa and some vomiting. The management involved initial NPO, fluid therapy, antibiotics and fat free diet. There was also a case of what appeared to be paraphimosis which I promptly referred to the surgery department. Samarth was born out of a precious pregnancy and was brought for complaints of breathlessness and cough. He recovered in time but M Sir asked for an Echocardiogram which revealed TAPVC (a type of congenital heart disease) and the cardiologist contacted me citing that he needed further intervention because he was likely to go into right heart failure in the near future. He was referred to a higher centre while his family remained apprnehensive and distraught upon hearing this news. Perhaps he is now at Jayadeva receiving the right treatment. Then there was Deekshitha with multiple enlarged infraclavicular lymph nodes which slowly regressed with antibiotic therapy and Rizwanoor, a four month old with bright kajal lined eyes who had been fed 'Nandini Milk' by her foster parents who spoke nothing but Hindi and Assamese and here I was trying to communicate with them with my not so fluent Hindi. Well, it did lead to some heated moments but nevertheless, she too made a satisfactory recovery.

Probably a case I will always remember is that of Prarthana, a 4 year old from the interiors of Arsikere who was referred here for focal seizures. She presented in status and had been given a diazepam earlier. I was in the ward when she was brought in so I asked for her to be started on Eptoin stat and left to contact Sir. The seizures continued so he started her on Lorazepam and then Gardinal followed by Eptoin again. She remained disoriented after which she began feeds, small conversation and was on her feet after a few days. We got the necessary blood investigations and CT scan and somehow her progress wasn't satisfactory since she was still not completely oriented and had some motor incoordination but since they were insisting on a discharge, M Sir did a Lumbar Puncture and we sent the CSF samples to the Micro, Patho and Biochem department and the reports were not obvious but suggestive of albuminocytologic dissociation. I did tell the mother (her father had met with an accident and was admittedly elsewhere) the need for further monitoring and that she was not completely okay yet and this was only a Discharge on Request. Probably because the little girl addressed me as 'Akka' or because she actually responded to me or that the mother was expressed her gratitude that 'Jayashree Doctor' helped them, I wanted to see Prarthana back to her playful state. I sincerely hope she too makes a complete recovery. It's only upon seeing cases like her and others that I've realized the extent of poverty in the patients here. While most of the services are at very nominal rates, it is still a dent to many families. God forbid, when we tell them that the child needs further treatment at a higher centre in Bangalore, I have literally seen the fear in their eyes as they imagine the exorbitant cost of treatment in Bangalore. It requires much reasurrance and restoration of faith before they muster the courage for the next step.

Several cases not in my unit but noteworthy of a mention are a snake bite (cobra) that was promptly treated with ASV (Anti Snake Venom) and he made a complete recovery from near nil saturation and cyanosed state back to his naughty brat state, a case of Acute Flaccid Paralysis (GB Syndrome?) that presented with classic ascending paralysis, late involvement of respiratory muscles and bladder dysfunction. Their vague history and travel history from Mangalore initially created a Nipah scare that was duly dismissed and he was then referred to a higher treatment for specific treatment (IVIg) and cases of cerebral palsy that also have seizure disorder.

When I'm not prescribing drugs after (struggling and) calculating the pediatric dosage, I've given stomach wash, learning cannulation in little ones which can be especially tricky when the concerned patient is a fidgety yelling kicking toddler who will glare at you and screech at the top of his voice for hurting him. So I'm currently practising on the older variants and will hopefully work downwards. There are nights when the duty is fairly uneventful with just a few admissions giving you atleast 4 hours of undisturbed sleep  and then there are nights when every complicated case ranging from poisoning to respiratory distress to febrile seizures lands up at regular intervals making sleep an inevitable myth. 

Now, I'm in Unit 2 and I have some really good professors who are friendly and are very clear in their instructions. They also respond to all queries leaving no room for ambiguity. There is A ma'am who is approachable and always responds in case of emergency. She has an advantage with the language and hence communicates better with patients from different communities. B Sir is probably the earliest to appear in case of crisis, also responds even when he is not in charge, calm and composed in all emergencies, never takes risks when it comes to a critical case and ALWAYS makes it a point to explain the prognosis to the patient attender. M Sir is probably one of the sought after paediatricians in Hassan with people coming from far specifically to see him. His speed of consultation is actually terrifying. His ability to detect something abnormal in a short period of inspection and auscultation is truly something inspiring.

So with a week more of Paediatrics to go, I have nothing but interesting experiences to share, memories of parents gratitude, anger and frustration are things you will have to become accustomed to. When you've seen many cases with the same illness, you will know it's an uneventful prognosis but to the parent, it is the first and hopefully the last time their child is afflicted with this illness so they will need all the reassurance that in due course of time, their child will get better.