Kids nowadays…

An obvious part of our DNB training program are regular seminars, case presentations and journal club activities etc. By rotation, this takes up two days in the five-day week (Saturdays are half days). Until a couple of months back as Chief resident, it was my job to delegate topics, cases and such to my colleagues and juniors and keep after to them to make sure the presentations occur as planned. I was directly answerable to the Head if a particular person was not prepped and in his /her stance, I would have to do an extempore discussion. I always had multiple random presentations ready and set to go on my Flash drive under such unfortunate circumstances.

But since the last couple of months my successor at the co-ordination level has not been able to keep up the job. And neither was he prepared to give extempore orations. So we have been having a highly irregular PG activity schedule off late.

Until last week, when the Boss lady gave us all a good dressing down and promised to give us term extensions (meaning Delayed completion certificates on the various disciplines) if we did not stick to the schedule as planned.

Fortunately, however the four final year residents have been exempted from doing the presentations, but we still have to sit on them though. This week it was the turn of first year resident to do a PowerPoint on 'Aplastic anemia and recent advances in therapy.'

First, let me say how well I appreciate the poor general condition of a first year resident, - always sleep deprived, hungry, irritable, tired, exhausted. They pretty much work on the spinal level – in reflexive movements and actions. No time to actually exercise the ticker Gray matter to study and learn new things.

I've been there, done that, so I get it.

So I am very supportive of my first year residents when they are up on the mike, usually taking the questions from the consultants and not firing any myself.

So this chappie, was on call the previous day and was totally strung out. So when I reminded him that he was up the next day for Aplastic anemia, it took him a full minute to realize what I was saying.

'Shit…. I forgot.' A vacant, downcast expression followed.

Pitying the poor fellow, I got someone to cover for him for a couple of hours that night, so he could at least read up a bit.

Next day, at the appointed hour (usually 3.30 pm after a dizzying OPD of a couple of hundred of patients when all the mind screams for is fresh air and some coffee...) we gathered in the conference room.

He started off, and started off well… his slides were good (I was surprised he got any made!).But as he spoke and gestured to the slides, I realized he was just mouthing off what was already mentioned on the slides… except paraphrasing. And the slides seemed disjoint and unhinged. And he was not able to connect the series of slides together and couldn't elaborate any of the advanced stuff on the slides – like genetic correlations, clonal features etc.

I looked around to see if anyone else noticed. A few vacant expressions, a few open-eyed sleepers (all doctors are good at that!) and very few who were actually listing. But no one had the quizzical expression I did… 'Well… maybe they all want to cut the guy some slack'… I thought.

Then came the boomerang… he went on to a case study, pretty elaborately worked up…. it was a good case. But not from our hospital. Ours being a closed populace we all knew the rare cases like Aplastic anemia and such who were regulars in the OPD and the wards.

This case of a 27 yr old male… as the idiot rattled off…. raised a few eyebrows. A consultant even turned to me and mouthed 'Our patient?' I nodded in the negative.

I was on to him, by then, I knew what he had done….

But he gave himself stupidly away, when he came to a slide that read

'The patient was referred to London for second opinion and treated with Eculizumab the cost of which 250K £ per annum'.

DAMN… THE STUPID FOOL… HE HAD DOWNLOADED THE WHOLE PPT FROM THE INTERNET AND DELETED ALL THE SLIDES THAT HE COULDN'T EXPLAIN OR READ OR WHATEVER….

Eculizumab is not yet available in India.

But how thick skulled must he be to present the case as it was… or did he think the audience was thick skulled or what….?

I was angry, amused and indignant all at once. Back 'in the good ol days' we made presentations we made them from scratch, referring multiple textbooks, the internet was only a source of reference and pictures.

Fortunately, for him even if everyone had noticed no one said anything, everyone was too tired to care I suppose. So he got away with it. I did some online research myself and found the whole slide show as it was, except with the background changed and the difficult charts and graphs deleted.

Has this what its come down to… using the internet thus….

I asked around and apparently its quite a common thing. There are whole websites that give out readymade essays and presentations. Even primary school kids with internet know how can come up with the perfect essay.

Ridiculous…. Disgusting….

Later that day, he texted me, thanking me for giving him the two hours so he could 'Prepare' the presentation…

Grand Rounds Vol 7 No. 20

Grand rounds is up at Suture for a living...

And yours truly got mentioned....

The Green eye monster

We got a new addition to the department today, a PG RMO or Post-Grad Resident Medical Officer. This is a relatively new concept in DNB recognized institutions across the country. To maintain the accreditation as a centre for DNB post-grad training, we have to have at least one Post-MD or Post DNB doctor on the payroll. Not to be confused with the consultants or attendings. PG RMOs are recently board certified 'Specialists' out to garner some experience in the field. The international equivalent may be a 'Fellow' perhaps.

Well the new addition is a lady with commendable qualifications, not more than 2-3 years older than me. To be very frank, we residents were not really looking forward to getting a PG RMO. She would be our immediate boss, you see and the so-far direct contact that we have had with the attendings would have to be re-routed through the 'proper channel'. The much painstakingly gained trust from the consultants to have a free hand in the wards would kinda go in vain. So far, what the final year residents say goes in the ward (once you run it by the attending ofcourse!), but now we would have someone constantly watching over our shoulders and auditing the often underhanded dealings that are mandatory at the resident level in any teaching hospital.

Simply putting it - my clout as Chief resident would be dampened – There I have said it. I am the trusted one when it comes to deciding rotations and appropriate disciplinary actions for resident on the err. I was the link between the consultants and residents and I liked the perks that went with the position.

I know I sound pompous and all…. But hey I am still human aren't I…?

So finally after a quite a significant delay due to administrative red tape (which we residents were thankful for) we finally got our PG RMO. It was her first day and she had been instructed to conduct rounds in my ward.

Unfortunately for me I was running a good half hour late when I turned up for rounds and was in a sartorial disarray of sorts with my white coat all stained and my pens and penlights flying out of my pockets. I did not quite cut the impressive figure that I would have liked. Nevertheless, I was greeted with the usual 'Good Morning Dr' from my junior resident. My co-registrar introduced me to the New addition as 'This is Doctor Indian Medic'.

And at this she turned an askance glance towards me and said '... and who is he…?'

My juniors passed knowing glances amidst themselves sounding like 'Uh-Oh….!!!"

'The Medical Registrar – Chief resident' I replied in my best baritone...If nothing else I sounded a bit offensive.

And offended I was… no one comes to wards and asks who the hell I am… I mean NO-ONE. I am the self-proclaimed-king of my ward, nothing moves unless I tell it to.

Ok, Ok, I got an ego the size and nature of a Hot air Balloon… but neither of us made a good first impression on the other.

The rest of rounds I chose to stay silent and use the opportunity to size up the competition. She was good, I had to concede, and she knew her stuff. Except that like usual newbies, rather than just taking it all gradually in, she had a lot of pointed questions to ask, putting her in the 'Take command' class of people.

By the ends of rounds, I decided I did not like her…. Truthfully speaking, I had resented her even before she made a physical appearance. Add to that the fact that I am one of those people who always find it difficult to be nice to new people.

That was the extent of my contact with her through the day. But later when I was talking to my colleagues, I realized I had been rather hasty in appraisal. Apparently she had already asked everyone to be on first name basis with her and agreed to provide us (the exam going people) with sets of question papers from the previous years. Moreover, she did have clinically sound knowledge, which could be advantageous to us.

I was apparently the only one with something negative some to say about her…

That's bad… especially with my recent attempts to stem my anger issues and make efforts to lead a 'normaler' life. I had been too hasty with my attitude issues taking precedence, rather than making the poor girl feel welcome.

So I have decided to make an effort tomorrow, be a better person, bite my ego and who knows maybe even make a friend.

The Countdown begins

Well, the dates are out for my final DNB theory exams - 11 and 12th of June.
As an constant reminder, I have added a countdown timer to that effect on the blog sidebar.

Rightnow it says 129 days, but I know time flies real fast.
I stil have enough time to hitch up my pants and make a run for it.
Any further delay and I will sure as hell be in a trouble...

So all the best to me...

Who’s the Boss?

Often a major part of a doctors job is making decisions – ranging from small ones like choice of antibiotics to big ones like DNR. Often it's the decision of the patient and family, but needing the guidance of the attending doctor, who is expected to know the best. When all goes down well – good. But what when the parties have a difference of opinion and some problems crops up. such as in situations where, even after proper guidance and counseling on the physicians behalf, if the family chooses to make a decision in untoward consequences, does the doctor not share any responsibility whatsoever?

Following is one such is incident, which made me ponder – where do you draw the line – of who takes the blame?

We had a patient, a 21 year old college kid, Punit, a couple of months back. He was referred to us from our sister concern hospital in interior Maharashtra, which was basically a secondary care centre. He presented with persistent fever since 2 weeks, high grade without chills and persistent low Total leukocyte counts. He also had history of loss of weights of over 3-4 kg in the past 3 months, but a normal appetite. No other significant history available.

On clinical examination - He was of slight built, vitally stable, with unremarkable findings on Respiratory and cardiovascular system examinations. He had however mild hepato-splenomegaly on per abdomen, with 3 firm, non tender, palpable cervical lymph nodes. No other palpable nodes anywhere else. Other than the fact that he had the mild toxic look of a febrile patient, he seemed fine.

On admission, his Total leukocyte counts were 1700/mm3, with aHemoglobin of 8.7 gm % and Platelet count of 1.25 lacks/mm3. His LFTS were deranged with Total Bili of 2.4 mg%, with a direct fraction of 0.9 mg%, ALT/AST of 56/79 IU/L and ESR – 123 mm. His Widal titers were 1:360 for Typhi H. He was started on broad spectrum antibiotics with anti-malarial cover with our area being pretty much of an endemic zone for malaria.

His Chest X ray showed enlarged hilar lymph nodes and abdominal USG picked up LNs as well.

Initially he seemed to be responding to our treatment with a drop in the fever range and slight increase in the TLC to 2100 /mm3. However a couple of days later it again dropped back to 1500/mm3. He was already into Day 5 of antibiotics here. His tests for Dengue, Leptospirosis, hepatitis, blood cultures came back negative. But the fever persisted, despite change and trial of different antibiotics. An FNAC from his cervical node came back inconclusive as well.

We decided to go ahead with a CT of the abdomen and Thorax with contrast, which revealed discrete sub-centimeter LNs in the thorax and abdomen, occasionally matted but essentially all of them non-necrotic. Sr. ACE levels were normal.

DDs came down to either Koch's which could explain all of his symptoms and signs OR Lympho-reticular malignancy, which could explain all of his symptoms and signs as well. Since Tuberculosis is endemic in India, we immediately started him on an AKT regimen with Streptomycin, Ethambutol and Ofloxacin. We had to avoid the first line drugs – Rifampicin, Isoniazid and Pyrazinamide in view of his LFTs, which had further deteriorated over the week.

Lymphoreticular malignancy was weighing heavily on my mind and I tried talking my attending into doing a Bone marrow aspiration. If it turned out normal well, we at least tried. But she being an old timer of sorts was not so keen on it, saying a trial of AKT ought to put us in a better know how. The debate continued on a daily basis for 2-3 days and finally she relented.

Miraculously however within 48 hours of starting AKT, Punit improved…. Dramatically. His fevers disappeared, his counts came up to 3600 /mm3. He looked and felt much better and also his nodes started disappearing. So AKT it was. We continued him on AKT with persistent improved responses, and in a week's time he was pretty much out of it. Everyone rejoiced.

But not for me the joy of a battle somewhat-easily-won. I harbored misgivings about not having a tissue diagnosis. Well in a place like India, where every 7^th or 8th person had or will have Koch's somewhere in the lifetime, with clinical diagnoses of Tuberculosis – pulmonary and extra-pulmonary, being made a dozen times in our hospital itself on a daily basis, the 'Trial of AKT' concept is more prevalent than pursuing tissue diagnosis as the international textbooks say. Tuberculosis figures as a top differential in pretty much all cases of PUOs or Pyrexia of Unknown origin.

Therefore, Trial of AKT it was for Punit…

However, I convinced my attending for tissue diagnosis. Since his counts had picked up and stayed up, a bone marrow was ruled out. His palpable lymph nodes had disappeared so a LN biopsy was out the window. The only thing left was to do either a CT guided or a Transbronchial Needle aspiration cytology (TBNA). Now came the part of convincing the parents.

His parents were working class people, definitely not uninformed but were not exactly intellectual either. And the boy himself was an engineering student. So we sat all of them down for a heart to heart on the further plan. We or rather my attending spelled it out as explicitly as she could, concluding that even though the AKT seemed to be working for him, Punit might also be having some other occult disease that was getting masked and we needed to seek it out. Then came the pros and cons of the purported procedures, and the risks involved in them. They heard us out, we answered all their questions patiently. The conversation seemed well balanced back then, but in retrospect… well… I'll come to that later.

We gave them a day to think about it. Meanwhile health wise he was doing really well, his LFTs had improved considerably and he was stared on low doses of Rifampicin and INH as well. He was happy, his parents were relieved. Somehow our little chat about an alternate diagnosis didn't seem to weigh as much on their minds. Apparently they even called around and took a second opinion with their family physician before deciding to defer the CT LN biopsy for the present. I would like to mention here that financial constraints were nonexistent in this equation as all charges were being paid for the by the government organization that ran the hospital and employed the father.

Even though I am the chief resident here, I am not allowed to cross the Attending and speak to the relatives after all the pertinent decisions have been made, and I am ok with that. So his AKT was continued and he was discharged, sent back home and asked to follow up after a couple of weeks. All was well…

Till a month and a half later…

He came back to us, as a defaulter. He had stopped his meds since about a week and his fevers came back, as did his Lymph nodes. Apparently Punit had taken up some sports activity which made him miss his meds and his parents had not made a note of it. So back he was in exactly the same condition as last times. Except that this time his Total Leukocyte counts were 1300, his Hemoglobin was 6.6 gm% and his Platelet count was 78000/mm3 – he was pancytopenic. His temperatures were off the charts and his Lymph nodes were more in number and distributions. This time even though we put him back on his AKT, the signs persisted.

No waiting around this time, we went ahead with a bone marrow and open Cervical LN biopsy. Bone marrow was somewhat unremarkable except for a decrease in all cell lines. His LN biopsy however, showed typical Reed – Sternberg's cells…

Hodgkin's…

DAMN….

AKT was stopped and he was referred to Tata Memorial Cancer hospital for further work up.

There was of course one more conversation with the parents, explaining this new turn, a conversation I chose not to be a part of.

It hounded me, a young boy, Hodgkin's lymphoma. So many questions…

Was the delay in diagnosis going to cost us bad? What would have happened had he not defaulted on his medication and the symptoms had been masked for another few months. Should we have insisted that the parents do the biopsy? Should I have gone ahead after the attending was through and talk some sense into the parents and Punit himself? Should we have stressed on the details of the alternated diagnosis while talking to the parents the first time around, in essence scaring them or drilling fear into their heads about the mortal nature of what we were suspecting? May be the doctor should be given sole responsibility to make such decisions, would that have avoided this situation? In retrospect all of these questions were valid, but unanswerable.

Who's fault is it? Who should take the blame if the delay in diagnosis makes a dent in his treatment options? Is the current system of informed decision making as good as it is made to sound? Or is just a roundabout way to split the blame with the patient party when things go wrong?

Even if say, it was entirely the decision of the Punit and his family… can I as a doctor sleep comfortably at night, knowing that my patients decision could cost him his life.

Maybe it's ok, if it's a situation where it's a terminal disorder and the patient does not want to suffer anymore and chooses to discontinue or deny treatment. That would be understandable. But Punit's situation where time is muscle… should we as doctors let the patients and family make such mistakes on the name of informed consent? Is there no way around it?

I was in a turmoil for a whole week after this… guessing and second guessing myself. My attending, focused on the fact that we had been explicit as possible in the discussion with the parents, when they had chose to defer the biopsy, (read – a lawsuit was out of question).

Don't know how to end this tale… well, Punit has been started on Chemo, and is being planned for Anti CD 20 therapy. His future remains dark.

Not a bad day...

Well, I made it, through one day of no bickering or angry resentment at the workplace, on my on call day at that. Its quite a personal achievement for me. I did not shout at anybody, did not bitch about anybody, did not call any one names, no nothing.

I did my job as well as I could. I even tried to join in on the birthday celebrations of a recently recruited colleague I barely know. Neither did I bare my teeth at the first year surgical resident who came up to me for guidance on his dissertation, which takes off from where mine ends. I gave him the relevant information, in as a patient a manner as possible, even though his apparent cluelessness about the basics of his chosen topic was a bit amusing to me, and I could see that it had taken him a lot of courage and galls to come up to me – The Fire Spewer, for some guidance in the first place.

I did not delegate the simple, unchallenging tasks of Insulin infusion titration of two patients with abnormally high sugars to my interns. I patiently attended all hourly calls from the wards and titrated the sugars.

I finished my thesis today, finally. Supposed to send it to the printers today. Now that’s a relief… have come a long way from the days when I struggling to do ‘Something on diabetic foot…’

Yeah, maybe I was not as smart as I think I was in my initial days. But I did get here the tough way. And I still have a long, a really long way to go.

Liver Cirrhosis - Palmar Erythema

Palmar erythema in a case of advanced Alcoholic liver disease with Cirrhosis.