Anecdotes from the Medicine Wards... (1)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 (some names may have been changed)

Healing The Maladies Of The Mind.

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

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

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

Little ones who buzzed around with abnormal activity,

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

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

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

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

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

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

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

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

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

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

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

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

Lead Kindly Light.

From mounting debts that pushed them off the edge

Through affairs that drove an irreparable wedge,

To the grieving for whom relief was a far fetch,

They chose the untrodden path of no return.

While somewhere a wife grieved for her beloved

Elsewhere a lover regretted hasty words unapproved.

And yet another father repented over love unshowered,

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

Tender care and concern was what they needed

To nudge the fallen spirits that could be reignited

A warm kindling fire of support was all they pleaded,

To awaken the sanguine Phoenix from their ashes.

To save one from the clutches of despair,

Is akin to saving a drowning man at sea.

By giving wings to a wounded man's dream,

Be that social pillar that shall heal and repair.

Suicide is not the answer.

Written in view of Suicide Prevention Awareness.

Keep your eyes and ears open!

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

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

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

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

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

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

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

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

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

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

Roars To Silence.

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

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

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

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

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




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

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

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.