Indian Medic

Kids nowadays…

2011-02-11T19:45:00.002+05:30

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

2011-02-09T13:48:00.003+05:30

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

And yours truly got mentioned....

The Green eye monster

2011-02-01T21:19:00.002+05:30

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

2011-02-01T20:33:00.003+05:30

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?

2011-01-26T10:38:00.003+05:30

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...

2011-01-22T08:08:00.001+05:30

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

2011-01-20T16:20:00.002+05:30

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

Broken Physician?

2011-01-20T13:31:00.001+05:30

After my angry post yesterday, I decided to tone it down a bit. The confrontations mostly and have a more understanding approach towards people who normally bug me. So far, half way into the day, I am doing ok of sorts. But the big test will be tomorrow, when I'll be on call, marathon 36 hrs.

I have to dampen my wild demeanor, or else I'll be slapped with lawsuits left and right once I leave the safety of this institution.

I try to think of myself as a good doctor, rather as 'not a bad doctor'. I care for my patients; I do go out of the way to help. But as I said due to the tediousness of things, I have sorta lost my competitive edge. This will not help my future prospects for subspecialise.

I feel kinda burnt out. And it's just my 12 year in the field of medicine. I am still a rookie by most standards. How can I just give up? I don't want to be a general practitioner. I want to be in pace with the rapid developments that are being made in Medicine every day. I want to be at the cutting edge of things. But not with this attitude I have developed.

Maybe I need a break. A vacation, the last leave I had was in September 2009. For 4 days, so doesn't exactly qualify as a vacation. The one before that was in Jan 2008, for a week. Other than that I have been working every single day, except for the one Sunday a month I get as leave. There are no working hour restrictions for residency in India. I work something like 95-100 hr weeks even today. Does get a bit tiring at the end of 3 years.

Cant give up though can I?

Never have and am not about to begin now.

Will work on things, all aspects of it. Academics, public relations, work ethics, patient's relations everything. Hopefully, the damage is reversible.

Frankly speaking, when I set out a few years back down this road, I did not know there would be so many cross roads. No doubt I have taken a wrong turn, will just have to correct course and get there on time.

Just one thing that nags me though….

Have I turned into one of those Broken Physicans?

An Angry post

2011-01-19T20:14:00.001+05:30

I am in my final year of residency now. Six months before I appear for Final exams. Then I will be a National Board certified Physician. I can practice where I want, anywhere in India. Pursue higher education i.e. Sub-specialize if want.

But often now, there are instances where I think – 'Am I ready to take solo flight?' No consultants to consult, no back up decision maker, no one to take the ultimate blame in shit-hitting-the-fan scenarios.

Especially with my anger issues nowadays. I am angry all the time. The personal stuff apart, there is something frustrating about work. It seems tedious, pointless, and monotonous.

Have been at this hospital almost four years now, first as an ICU Medical officer and two and half years as a resident in Internal Medicine. Initially the challenges seemed…. Well… challenging. Now they are boring repetitive.

Actually its time, I as the Chief Resident get some time off to prepare for my exams. Administrative duties apart, at least the load of clinical work should be lightened up a bit. But unfortunately the following batch of residents, my juniors, are … for the lack of a better word… disappointing. They seem uninterested in the work and the challenge of it. They go around doing stuff just coz they have to. Not coz they are interested.

Well, I suppose from every seniors point of view, juniors always have a lot left to improve upon. But frankly, last time this year, all my senior residents had to do was just show up for grand rounds. We even relieved them of the Outpatient clinics and Emergency On calls in October. Now it's January and I am still trundling off the ER in the middle of the night to interpret 2:1 Mobitz Type II heart blocks, coz my junior couldn't.

Kinda Sucks….

And some of the old shit doesn't change, still have to point out to the Surgeons and Orthopedicians that it is risky to give Gentamycin to patients with a baseline Creatinine of 2.1 mg%, no matter how well you adjust it according the Creatinine clearance.

'Don't refer the patient back to me, when his Creat starts to shot and his Urine output drops!', I savagely shouted at the Surgical fellow, who was telling me about his grand plans to monitor the Creatinine and Urine output stringently.

Anyway, ROMIs – Rule out MIs. Another big issue. Beds are a commodity we are always short of on the Medical wards. We constantly have to borrow beds from other departments in their wards, often in the middle of the night. And with my constantly deteriorating PR relations, beds are hard to come by.

Coming back to the point – ROMIs. Apparently healthy patients with no risk factors for Cardiovascular morbidity whatsoever, presenting to the ER with Chest pain. Well typical ones have the retrosternal squeezing uneasiness, radiating to the left shoulder associated with shortness of breath and sweating etc. If the ECG shows some relevant changes no problem. They get in.

But there are the ones with atypical complaints – Jaw pains, shoulder pains, back pains, epigastric pains, recurrent burps, acid refluxes etc – with Normal ECGs at that. Well they are not exactly diagnostic dilemmas. Textbook says 4-6 hrs observation in the ER, two set of Cardiac markers (CKMB and /or Troponin T or I) and they are good to go. But the problem with our ER is, its not equipped to handle such patients. So they need to come indoor. On an average we have 5-6 patients coming in every night to the ER with such atypical complaints.

It's the job of the resident to screen such patients. Often when I am absolutely out of beds in the ward, I send those patients home, shouldering the whole risk, praying they don't sustain MIs in the next 24 hrs.

What I am trying to say is… well… what am I trying to say…

Just pouring out the frustrations I feel at such times into words. But basically I am getting angrier by the day. Complaints have started pouring onto my Heads table from all sources. Nice lady, she takes care of them though.

But ultimately, my studies suffer.

As I said a angry all the time at my juniors, at my Seniors the consultants – for their often poor decision making, other department residents for calling in my the middle of the night for non-specific stuff, at the nursing staff – when they slacken, at my family coz they don't get it and at myself coz I am not fighting it….

Anyway… bad post to make a comeback with.

Email trial

2011-01-19T14:35:00.000+05:30

Indian Med blogs Directory

2011-01-19T09:42:00.003+05:30

The Indian Medblogs directory has been updated.
Still if you feel your blog needs to be up here email me or leave a comment.

Therapeutic CT scans

2009-10-23T08:09:00.002+05:30

My days in the ward… well are not over, but limited. I have to be present for get rounds presented to me and my co-SRD from the house officers and in turn present to at Grand rounds. Then its off the OPD, where we see patients individually and discuss with the Attendings if needed.

Our hospital, if have not mentioned so earlier caters to a subset of the population whose medical expenses are taken care of by the Government. Its not like Mediclaim or insurance, people don’t pay a penny from their pockets but all expenditure is taken care of up front. I wont go into the details of this scheme but needless to say patients have no clue about the amount of resources the government is spending on them.

The Second factor here is the patients are generally well educated and well informed. So they know what treatment modalities are available for their respective illness and that if it is not available at our hospital then they are aware that it can be made available for them at hospitals on our panel. Well the outrageous things our patients demand… is a topic for another day.

We I have observed in the OPD and the wards both, Multiple cases of Headaches miraculously cured by CT scans.
Interesting huh?

We have our fair share of Migraines and Cluster headaches. Well the clinical diagnosis is migraine is made only after all other differentials are worked up for and ruled out. But the patients I’m talking about have headaches so major, no amount of medication can help their symptoms. But then as part of work up of non resolving headaches, to look for possible Itracranial bleeds or SOLs (Space occupying lesions) we get their CTs done.

And lo and behold, irrespective of the reports the headaches miraculously vanish. Poof!!

99% scans are clean, except for may age related changes etc. But till date I have seen at least a dozen patients making a recovery from getting, what we now call as, ‘Therapeutic CT scans’, almost all of them brain scans. Its quite a joke among us residents, we even make wagers on whether the consultant will ask for a CT or not and whether it will cure the patient or not.

I knows it’s the placebo effect, its psychological …whatever. But our most of our consultants don’t think twice before ordering head CTs for such patients.
What about the money? What about the exposure to radiation?

I have to be in this setup for maybe another 2 years. But when I start practicing in the real world where the patient has to pay out of his pocket, will I order such expensive investigations with such alacrity? Will patients pay for it? Or they’d rather take a second opinion?

Nevertheless the tale of the Therapeutic CT scan has many more editions yet to be added.

The Balancig act

2009-10-05T22:26:00.009+05:30

Finally after a few scattered attempts at posting last year, today I have finally sat down to make any entry on this blog.
Needless to say, I have lost most of my readers (provided I had some to begin with) and the Indian Medblogs directory is outdated.
But I love blogging, it gives me a sense of freedom, to write what I feel like, also the anonymity of it is great to fume out stuff which u cant say out loud , and lastly it helps getting a lot of things that go on my head into perspective.

So Where have I been the past year?
Dutifully carrying out my responsibilities as first year resident in Dept of Internal medicine in my institution, the name of which I’d rather not disclose. Needless to say, the first year of residency is hell, a ‘houseman’ post as it is called in Mumbai. Here in my hospital the schedule is a grueling as anywhere else. I have worked 36 hour shifts on alternate days with only a measly 12 hour gap between the two consecutive shifts, for a year now. The only times I have got days off, have been when my immune system gave into the rigorous schedule and I spiked fevers, probably viral for 48 hours.
I have done all it takes, pulled all nighters, been cooped up inside the dreary hospital for weeks on end without sunlight, poked a zillion arms for blood collection and IV lines, done my share of Pleruocentesis, Peritoneocenteses, spinal taps, Central line insertions. And due to the special privilege of having worked in the ICU prior to landing the DNB seat, I have been perennially on call to interpret ECGs with Blocks and MIs in the ICU, temporary Transvenous pacings and the whole gamut, down in the ICU, which others could not manage.

But I am here finally through the grit and grime, now as a second year resident or SRD (Senior resident doctor). I was promoted a month back, but it has taken me a whole month to get my bearings right. I for one found the transition from JR to SR a bit tough. I remember as the JR I always used to envy the SRs. ‘All they need to do is sit in the on call room and attend phone calls while I sort through the whole pile of shit and keep them informed about the bad eggs in the ward!!’. Boy was I mistaken.

Now I realize as a JR I had only my ward pile of shit to sort through, but now as SR and the honor of being the Physician/Medical resident on call, I have to sort through the whole hospital’s pile of shit, at least that’s what it feels like.
I mean why does a surgeon or an Orthopod need me to get up and put it one paper at 3 am in the night that their patient of so and so condition with a Serum creatinine level of 4.5 mg% should not be put on Aminoglycosides or NSAIDs and that exactly is why his kidneys have failed.
And this on a repeated basis!!

It really does feel like our department goes about wiping up after the other departments in the whole hospital.

I can only right on file so many times that a patient of Ischemic heart disease with CABG done and LVEF of 15-20% needs to have his fluids restricted to less than 800 ml/d, or else he’ll land in Acute LVF. But when he does get ‘well hydrated’ after his TURP and does land in Pulmonary edema, I am the one needed to rush to his bed side first.

Hmmm… do I sound pissed?
I guess I’m pissed, but I love this job, I love the thrill, the satisfaction out of it.

CONFESSION:- When there is a particular tough patient to diagnose, with inadequate signs to provide a diagnosis, but I work him up on a hunch and it does come right ultimately, I feel just great. Am not proud of it, I feel terrible for the patient but the tougher the puzzle, the more gratifying it is. Kind of like House.MD, just not so much drama.

Mind it though, I am still supposed to be on call for 36 hours with 12 hours interim off. But I am supposed to be in many places at all times, I have to attend calls from the ER and all Physician consluts in the other department wards (Physically not only over the phone!!!), oversee the JRs of all Medical wards, take care of the Dialysis unit and still be the back up for the ICU guys, the list is endless. Man was I wrong about the sweet life the SR!!!

I have grown up though, I am a bit more tougher, I take it in my stride when terminal patients kick it, but when the unexpected, apparently young and healthy ones dies, I feel a loss. I have got a bit of an attitude now, I don’t let people take me on rides anymore, especially my colleagues, who have totally used me to get all sorts of leaves for the weddings and funerals in their families the past year.

The one thing I really want to work on now is my studies. I am totally fraught over how I am gonna study so much.

As the famous Spider man one liner goes ‘With Great power comes great responsibility’. I am supposed to know better, know more, to tell the other fellas what to do, take life or death decisions in the wards during emergencies. Even the nurses and residents of other departments want my opinion on their personal family matters. Obviously, my knowledge has not increased by the same rate/ratio as my responsibilities have. And I am struggling to keep up.
Cant make a fool out of myself in front of the juniors or the attendings.

I get sleepless nights, mulling over the implications of having to know all that I should. I mean I should know everything Harrison’s principles of Internal Medicine has to say by now. But I don’t, I just don’t. The more I try, I more it feels like clutching at straws. I have got a thing about studying, kind of a tic. I can only settle down to study if I know I wont be disturbed for the next 3-4 hours ahead. I need my table and chair, my table lamp, my laptop, my music, my cuppa coffee. Only then can I sit at it.

But such times are rare, and rash-hash studying doesn’t make a dent in my brain. I’m always on the edge, like some day soon, people will realize I don’t have the brains it takes to be a SR.
It feels like I’m on a balancing beam, one slip and I’ll fall great depths, lose whatever good impression I have made on people around me. One month in and I have just barely calmed to put my fears down in words. I have to walk the beam until I am really worthy of it. Worthy of being a Senior Resident with so much responsibility. And the only I can do it is study, study and study. To have the knowledge of what do when, when to do.

Plan to keep up the blogging to keep up the spirits, do need the vent.

Indian Med Blogs directory

2009-01-31T20:16:00.002+05:30

The Indian Med Blogs Directory has been updated. Check it out..
If anyone's submission has not been included. Please leave a note.

Grand Rounds 5:18

2009-01-21T20:30:00.003+05:30

Grand Rounds 5:18 is up at MedPage Today hosted by Dr. Val Jones from Get better Health. Check it out...

Clubbed!

2009-01-17T20:14:00.003+05:30

A 68 year old gentleman, presenting with severe breathlessness, Tachycardia with a heart rate of 170/min and running a fever of 104 degrees.

Giving h/o breathlessness, cough with mucopurulent expectoration and low to moderate grade fever on and off since 3-4 years.

Absolutely denied smoking. But look at that clubbing!!!
Differentials were Severe pneumonia, Pulmonary tuberculosis, or Chronic bronchiectasis.

CXR - showed a totally whitewashed right lung. Consolidtion? Tumor?
(Didn’t have my trusty Sony Digicam. The picture was so worth a shot!!)

Workup was negative for active Kochs. Seven days of high antibiotics later the CXR pretty much cleared up, with remnants of what looked like fibrotic sequelae to old pulmonary Kochs at the apices of both lungs.

CT at cinched the diagnosis. Honeycombing s/o bronchiectatic changes secondary to old infections.

Final diagnosis - Massive Rt sided pneumonia in a case of Post -TB bronchiectasis.

Dissertation dilemmas

2009-01-16T20:45:00.002+05:30

As an postgraduate student in Internal Medicine, as is obvious, I have complete a thesis or dissertation on some suitable topic. Without which I won’t get my degree. So far so good.
Finding the topic was hell, my preceptor or thesis guide is a a very strict lady, known to eat residents alive if she feels like.
‘Never cross Dr. K,’ - valuable advice from my predecessors.
Thing is she is a diabetologist, so needless to say my dissertation had to do something with diabetes.

She handed me the topic as well, ‘Something on with Diabetic foot’. How vague is that? Well after almost a months work, amidst torturous work shifts, I managed to come up with ‘Something on with Diabetic foot’. (Am being vague here on purpose!!!)

We need to submit a Dissertation protocol to the National Board of Examinations within a month of registrations. So a protocol it was, with the routine aims, objectives, study design, materials and methods etc.

Went through, numerous papers and abstracts to get inspiration for a study design. Spent endless hours online and in the library and muttering about it in sleep, (according to my mom!)

Ah, it was such a day of relief when I finally got her to sign the draft of my protocol, (after multiple corrections, editing, printing, re-corrections, and re-editing and re-printing).

Except to have it made in clear and very concise terms ‘You do know I won’t be signing your final thesis copy, unless you present two papers for me.’

Shit!!!

I have never done a paper before.

Then came the realization that I had somehow managed to come up with the protocol, now I have to run the theories, and assumptions and tests I had blabbered about in there and prove them!!

Shit!!! Shit!!!

I have no clue where to begin. Except that, I have to somehow got to get my hands on a biothesiometer.

Shit!!! Shit!!! Shit!!!

The worst is yet to begin.

The White Cap

2009-01-15T13:16:00.005+05:30

As doctors, from day one of our medical training we have to work in close proximity with the other major members of the medical profession, the Nurses. They are there in every hospital or clinic or nursing home working diligently by the side of the MDs, treating patients and dispensing the medication.
But do we ever stop to say thank you to them, except as a part of the cursory thanks we mutter at, say, when they have assisted you in a procedure or examination? Do we ever realize that we as medical practitioners, the ones in active medicine at least, are so dependent on the nursing staff that we couldn’t function one day without them? And are we glad enough that we have them?

In general, the budding doctor encounters the nursing faction of medicine, when the clinical rotations begin. The clinical career of invariably every medical student begins with a sense of superiority complex, a snobby attitude and an upturned nose towards the nurses. 99% of them fall flat on their faces in the first few days, when they realize they know zilch and are the most un-needed, superfluous part of the medical team. The wise ones make friends with the nurses and all rotations are smooth sailing for them. You can get invaluable guidance and instructions from the seasoned nurses who where there long before you came and will be there long after you are gone. From blood sampling, to starting and intravenous drip, to passing a nasogastric tube they are the ones who teach you the tricks.

Having been part of the ICU team at my hospital for well over a year now, I am acutely aware of how much of what I do most of the day (and night) is dependent on the nursing staff. We have a team of eight staff nurses and one in charge. It’s as well oiled a team as can be. Each one of them is well trained in the care of critical patients. Not to mention all of them are thoroughly knowledgeable and hardworking. Some with solid clinical knowledge, excellent at interpreting the worst of arrhythmias on EKG and some with an angelic healing touch doing away with patients discomfort in a jiffy and yet some with the keen eye of experience instructing me to watch out for a particular patient, apparently stable that minute. ‘He is not looking good to me, he may crash any minute.’ And they do crash, no matter what their vital parameters or Blood gases or EKGs say!

I know I can rely on them no matter what, can catch some shut eye in the on call room trusting them to monitor the worst of the patients. There is one lady in particular who can pass a Ryle’s nasogastric tube, like no body else can in the worst of old fellas with toothless roomy oral cavities, when no matter what you do, the damn thing just coils up in the recesses of the pharynx, sometimes exiting through the mouth or at times even through the other nostril!!! And I as a resident have no other option but arm myself with the laryngoscope and Magill’s forceps to try and pass the tube under vision and sedation, (if the patient is not zonked enough already). But now I let Sr. M, have a shot at it, before I boot up. Also she can manage to find cannulate veins in the thickest, most edematous of arms around. And good lasting veins at that!! She is truly a God send.

Here in India, most of the private hospitals have done away with the traditional white gowns and white caps of the nurses. But government institutions as is ours, still adhere to the same old dress code. They are all attired in pristine white uniforms, with their hair neatly tied up, white caps, white stocking and white shoes. I can imagine how they must instill some kind of hope in the sick patient’s hearts. They are the ones who are in maximum contact with the patients, often acting as the messenger to inform me of the latest complaint they have.

As doctors, we do the history, the examination, the notes and order writing. But their job is so much more than just to carry out those orders and charting temperatures. Making the patient comfortable, showing them genuine kindness, listening to the patient’s grievances, tucking them in at night and everything. Not to mention the other tasks normal people would find queasy doing for their own family members like sponge baths and bed pans. And most importantly, packing up the bodies of patient’s who didn’t make it, to be handed over to the next of kin.

I don’t know about other institutions, but in our hospital it’s part of the nurse’s job, with the help of the attendants to do the needful when the patient expires. As the doctor, I am there with the patient till the last minute giving CPR or emergency intubations etc with watchful, hopeful eyes on the monitor. If he dies, its my responsibility to break the news to the family, and do the necessary paperwork. But am I there with the patient after they are gone? Most doctors consider it a personal failure when the patient dies on them. I do too. Initially when I came to work in the ICU, the inevitable number of deaths would simply overpower me. it would take a lot of deliberation to go out and declare the patient. Its never uncomfortable on any doctor, but I used to take it extraordinarily tough on myself, almost as bereaved as the family. I would simply walk up to patient, after declaring to the family, say a goodbye and a sorry. Then simply shut myself in the on call room for the onslaught of tears.

But in the later months, I grew tougher, it’s still very upsetting to lose a patient, but the tears don’t come anymore. That I guess is because, I used to think that declaring death was the toughest thing to do. But when I saw my colleagues, the white attired ladies, tending to the mortal remains of the patient after they have passed on, often comforting the relatives at their first glimpse of their departed loved one, cleaning them up, even giving occasional hair-washes to remove the blood and gook (Sr. M, again here), something not expected of their duty, I think to myself, do I really have the toughest job of all? I guess not.

In the government medical institutions, the hierarchy of the nursing division is essentially four tired. Simply put we have the Black belts, the Red belts, the Blue belts and the White belts. Sounds like Karate? Mostly is. The Black belted people are the head honchos, the Matrons, assistant matrons or Nursing superintendents, the Red belts are the ward incharges or supervisors, the Blue belts are the staff nurses doing the main work and the White belts are usually students or novices. Out Red belt or Sister Incharge is a firebrand. Almost sixty, with just about a year left to retire, she is the most disciplined, assertive, person around. She runs the ICU on a real tight leash, but things function so smoothly when she around and there is never any dearth of resources on her watch. She feared by one and all to the point of veneration. She makes it her own personal agenda to train all us fledgling doctors in the needed administrative know-how and forms at everything. As Kim at Emergiblog puts it she ‘babysits’ us all the time, and our head of the department and dean turn to her to get updates on the residents behavior and general demeanors. Everyone in our team is fearing the day, not long off, when our watchful motherly Incharge will retire and we will be left in a soup.

As I mentioned my contact with nurses began early in my medical career as normally does, but I learnt the hard way how decapitated we would be if they were not around. We were having severe shortage of hostel boarding in our Intern year, and we, as interns were technically eligible for boarding neither at the Undegraduate hostel nor the postgraduate hostel. The administration promptly ordered the 35-40 of us out on the streets. As if, we would go down without a fight. We went on a strike, a very vociferous and raucous strike at that, almost bringing the hospital daily working to a standstill, for we had the backing of all the undergraduate and postgraduate students. Consequently, the dean bowed down and we were allotted quarters in the nursing students hostel, which was overcrowded as well, on a temporary basis till something solid could be worked out. Needless to say, this did not go down well with the nurses and they put up a days token strike in protest.

We thought we were shutting the hospital down by our rallies and protests and shouts, we were in for a very rude shock. There were no angry slogans or rallies from the nurses, nothing overt. They just simply did not report to their duties. Man! Was it havoc!!! Wards and OPDs just fell apart, nobody knew what to do. Patients just lay there, with no body to care for them, no medication administered, no treatments carried out. The consultants were so lost, it all transpired into anger at us the interns, for being the root cause of the all that evil. We all got explicit instructions from the dean and consultants, that till the whole matter was sorted out and the nurses came back, we interns would do everything required to keep the wards running, I mean everything. The vitals charting, food distributions, medications, injections, bedpans, dressings everything. Or else we wouldn’t get the necessary rotation completion certificated.

Needless to say, it was the goriest day of my life, for I was posted then in Obstetrics, in the post partum ward. We did it all, with heads high, but am sure our batch will never ever forget that particular day, when the nurses striked. The situation cleared out by evening, when the dean made alternate arrangement for our boarding with amazing alacrity. So I know I can’t function without my nursing support system, even if I wanted to.

The state of affairs in India is changing though, consequent to the occurrences probably in the developed nations. The latest generations of nurses are all migrating out in India in search of greener pastures. International hospitals are luring them away with better pay packets and perks to boot. Its prevailing almost in epidemic proportions now. The US, the UK, the UAE are all running real short of good quality nurses and here in India there is a surplus. So it all fits. The Indian government is getting smarter though, they are trying to stem the efflux by introducing 5-10 year bonds to fulfill before anybody can leave the country. I don’t know how far it has been successful, though.

There is nothing else to say I guess, except that every doctor should make a better effort at recognizing the contribution of the nurses to the medical field. We do need them whether we realize it or not, the White caps.

Dedicated to all the nurses out there… KEEP UP THE GOOD WORK!!!

Current reading

2009-01-12T20:42:00.001+05:30

I have started blogging, should also begin my reading. Currently I’m on Khalid Hosseini’s ‘The Kite Runner’. I like to consider myself a updated reader, but the past year has been exceptionally bad for my hobby of reading. I begun reading the book more than six months ago, but never got around to finishing it, though I have been faithfully carrying it around in my rucksack everywhere I go, as is a very old habit, hoping to chance on reading a few pages while on the bus to work and back.

But again never got around to it.

Well, you know what they say about it being never too late…

I’m back…again

2009-01-12T20:30:00.001+05:30

I’m back. Yes, my last post (my only post in 2008) was titled precisely that. Then where the hell was I? I can give umpteen number of reasons stating ‘I was too busy with the residency grind’, or ‘what little time I do get, is devoted to getting some shut eye’, or ‘there is way too much studying to do, too muck knowledge to accrue’.
Well to be frank none of the reasons are true. They are true, in the true sense. I do slog a lot, and am always badly in need of more sleep, and have been attempting to dedicate time for serious studying. However, this is not why I was absent from the blogging world.

I just didn’t get around to it. There were enough interesting things to say, many fascinating incidents to narrate. But I just simply didn’t get around to it.
So here’s the update as of now.

I’m a first year resident of Internal medicine. Am posted in the ICU, still, for lack of firstly, candidates to rotate and secondly, gumption on the part of the current Head of department to pull down the final year resident to work in the ICU as the curriculum demands it.
I have learnt a lot the past year and when I say a lot, I mean a lot. Mostly critical care, but ours is a general ICU so we see almost all varieties of patients. Have honed my skills at procedures to near perfection. Have earned a reputation as the ‘Dependable one’.

Ok. Enough bragging about things. There have been slip-ups as well. Lost many patients, mostly for the lack of better resources to treat them. Have had particularly tumultuous personal life, something I rather not elaborate. Am not as up-to-date with the studying part as I aspire to be, a constant source of irritation for me.

Almost a fortnight into New Year, not many resolutions. None made, none to break, spares a lot of mental trauma. Except make a better effort at blogging. And to catch up with my reading.

Hope to see more supportive comments, coming my way, as they did when I was an active Blogger in the past.

Happy 2009 everyone.

I'm Back...

2008-09-12T22:13:00.003+05:30

Hello again blog world...

I really have no idea if any body even checking in to see if I am dead or alive.
Well, but its not time to be narcissistic.

The good news is, I am back. From a sabbatical of sorts, from med blogging.

And as of two months now, I am officially doing my post - Graduation in internal medicine. Yesssssss!!! Landed the residency alright, with quite a struggle.

There is a lot more to say, but that will have to wait. The site is in an obvious state of neglect, have some more work to do on it. Then will sit down for some proper blogging.

See ya till then.

ECG pop

2007-12-25T19:59:00.000+05:30

This is a simple but very interesting EKG up for interpretation.

Its got 'multiple dimensions' to it, as one of my colleagues put it.

World AIDS day

2007-12-01T15:36:00.000+05:30

Its World AIDS day today. Sadly though I was the only one sporting the symbolic red ribbon at work. The movement is yet to gain wide popularity and support.

Winter Weary

2007-11-26T15:51:00.000+05:30

This is in continuation to my post a couple of months back, ‘Third time Unlucky?’ I meant to give an update within a couple of weeks of the post, but didn’t quite get around to it.

It so happens for that particular patient, it was fourth time unlucky. She was brought DOA a couple days ago in the ER.
She had a ‘third time’ about a month back, a weeklong stint, luckily enough only in the ward. Apparently, she had been admitted through the Out patient department but one of our relatively ‘not-so-risk-taking’ consultants.

It is a widely observed, but statistically unproven fact, in our hospital that death rates rise in the winter. It’s kind of an annual clearance. Sorry if I sound crude, but a lot of the geriatric patients, including asthmatics, cardiac patients, CVAs, etc who have been in and out of the hospital multiple times throughout the year either suffer one terminal hospitalization or are brought DOA.

When I started observing that this trend was true, involuntarily I counted off a few faces that might show up. This particular lady was one of them. And sadly, she is the fourth patient I have treated in the Wards, to be brought in as DOA. All this with the onset of winter.

It has become a habit to check the Death certificate book maintained in the ICU, whenever we get news that a ‘body’ has been brought to the ER. And then I get nightmares. But the worst part is that if this keeps, there might a few more faces that might haunt me.

Spooked!

2007-11-22T20:44:00.000+05:30

I have been working the ICU for about a month now. A lot many crazy things go on there. This picture for instance...

This Cardiac monitor is on one of the beds rarely used, the one in the farthest corner and used only when all other beds are full. Last week was one such heavy ones with all beds full. We had a Non STEMI coming in and we had to use this last bed.

As soon as the nurse switched it on, it started displaying complexes, which resembled something like V fib. The thing however was that the leads were not connected to anything. In a normal situation, switching on an unconnected monitor displays continuous standardization complexes, like the inverted rectangular ones seen on Electrocardiograms. This monitor however was not doing so, no matter how many times we turned it on and off.

It was a spooky sight; I just had to take a pic off. But even as I was standing there, watching the monitor in an awe of sorts, the 'Heart Rate', which had started in the 120s slowly increased to 400. It definitely looked like Ventricular fibrillation. All the appropriate alarms started beeping, which instantly galvanized the whole ICU team to descend on this bed in the corner, almost as a reflex.

We tried muting the alarms, but couldn’t succeed. We could have just turned the damn thing off and left. But it was a mesmerizing picture in a weird way, which had us standing around, as if waiting for something.

Then it happened. The sudden flat line, with the monotonous continuous beep, which is dreaded by any medical personnel in active critical care. During ordinary circumstances, a full-fledged CPR would have been in progress. But that instance we just stood around, looking at each other’s faces, for a full thirty seconds, before someone had the sense to reach up and turn it off.

No one spoke for a while. I don’t know about others, but I was really spooked by the deal. There were simple enough explainations for it. The electrodes were old and could be responding to some static. But that didn't cross my mind that instant.

It made me acutely aware of the work that I was doing, being the last person to come in contact with the people who leave this world. Having it in my power to save them with timely intervention. At such times, I manage not to think about the families of the person, whom I may be declaring dead soon.

But the two minutes of paralyzed silence, in front of that monitor, brought back thoughts of each and every patient I had resuscitated and lost. It felt as if some one had died there that night unseen by all us. It kind of embodied all those souls that had passed through those doors.

The MI patient came and we all got busy, but somehow there was a respectful silence that prevailed for a long time as opposed to the gay banter that kept the place alive and above the gruesomeness of the place.

Later I heard the janitorial staff discussing something about ghosts and souls still wandering the corridors of the hospital. They also mentioned that bed no seven was an unlucky one, almost no patients who inhabited it made it. I tried not to hear, but then I was really shaken up by the whole experience. I did not need ghosts to worry about.

Even now a week later, walking past bed seven gives me the creeps!!

Milk blooded?

2007-10-04T10:37:00.001+05:30

This is the serum sample of a patient admit with left sided Bell's palsy. Its so bloody lipemic we cant get any biochemical parameters whatsoever!

Third time unlucky???

2007-08-28T18:34:00.000+05:30

There is a patient in our ward, a 60 year old lady with restrictive lung disease, and severe kyphoscoliotic deformity. She has been with us near about 3 months now. She has history of recurrent admissions with exacerbations of her condition, usually mandating a short stint in the ICU with a moderately long one in the ward. But this time, it looks like she is here to stay.She is in a persistent state of metabolic alkalosis and needs continous oxygen. Mostly nasal prongs with regular bronchodilating nebulisations are enough to keep her happy. She had set a routine for herself, a neb each, before and after a poop or a meal.

The thing, however, is that our hospital is always in a bed crunch and every single bed is essential especially in what we call our emergency cubicle, which is nothing more than a glass walled room with four beds, adjoining the nurses station from where we can keep an eye (literally), on our ‘bad’ patients. And the lady in question has been on one of those beds longer than we care to remember. Frankly speaking, we are not doing much for her, all she needs in strict bed rest, and someone to care of her 24X7.

So about a month back we had planned it out with the family and one of our bolder consultants, decided to discharge her, all arrangements made at her home, O2 cylinders, nebulizers, bed pans, the whole gamut. And not to forget a fulltime, maid to care for her alone. Since there are no nursing homes in India, to take long term care of patients like her, a point I have stressed a lot in one of my previous posts, there really was no other option. It would be prudent to mention here that the lady has a bit of an attention seeking behaviour, and quite often we find it difficult to make out if her symptoms are really as grevious as she states them to be. For instance she complain of shortness of breath every time any of us walks into the room, but all her monitors would be showing perfectly right figures.

Her complaints increased exponentially as the day of her planned discharge grew nearer. We could but only reassure her that she was going to be fine, and even pretend not to have heard her occasionally. ( I know that’s rude, but she could get on your nerves real bad).

D- day - 12. 10 am - I was on call, it was a night as any other, a continous spate of admissions, me in a chronic state of fatigue. Suddenly everything went haywire, all alarms started sounding, we rushed in to the emergency cubicle to find our lady breathless. Initially I had my doubts, but one look at the monitor and I knew this was the real thing. A quick ABG and down she went to the ICU again.
It was hypercapnia like none other I had seen before, 90% PaCO2.

Anyway, she stayed down there for a couple of days, got all stable and came up to reclaim her old bed.

Things moved on again and about two weeks back, when she seemed better, we plotted her discharge again, this time taking care not to let her in on the secret. Her family was in on it though. One fine morning, I walked in and just let her know that she was being sent home that very same day. I was all prepared for a reaction, which could take any possible form, another bout of breathlessness… of protests to let her stay on…. But she took it rather well, and I think even seemed a bit glad about it.

That evening for the first time ever I saw her walk, a few steps from the bed to the wheel chair to be whisked away to the ambulance. She was really short, but then again, with a spine that crooked, she had to be. There were a lot of heartfelt good byes, for a variety of reasons, and the ‘chronic one’ as we used to call her, left for home.

Her bed was duly cleaned up with extra disinfectants and made ready for the next patient who might need the emergency cubicle.

I was on call that night as well. Somewhere in the middle of the night I got a call from the ER to check out a patient with chest pain. If the ER doctor is not able to decide if the patient needs to be admitted, we ward people go down and evaluate the patient. I was just about to leave the ER, when an ambulance screeched into the bay, and a stretcher was whisked in with a patient who was gasping. There was no mistaking the frail frame of my old patient. The ‘Chronic one, was back, and in as bad a state as possible. A few more minutes and she would have arrested.

Four days in the ICU on the ventilator, 2 days off it, and back it was to the ward, the emergency cubicle and bed no 17.

This was two weeks back. We have had no more scares yet. This time too, we residents have started doing the ploting. But this time the consultant who is ultimately responsible for her, is the ‘no risk taking sorts’. So he pointedly ignores it on rounds when we try to suggest that she is stable enough.

I’m sure only one thought comes up in everyone else’s heads, like in mine, every time I enter the emergency cubic. The first time we were to discharge her she got bad, the second time we actually did it, she came back within hours and barely made it.

What would happen if we discharged her the third time???? Would she make it???

Would it be third time unlucky for her???

Breakaway...

2007-08-24T18:52:00.000+05:30

There is no doubt I am learning medicine, loads of hands on practical stuff. But somehow I absolutely don’t find time to corroborate the things I learn with facts mentioned in textbooks and that just wont do in the long run.

Just yesterday our marathon one-month stint of absolutely inhuman calls ended, with my physical breakdown. A colleague of mine and I were on call on alternate days. Somewhere like 36 hrs on call and 12 hrs off. Amounting to more than 140 hours on call in a week. However before my mind gave way, my body did.

Interestingly enough I have not lost as much weight as I would have hoped to. Maybe because of the irregular eating schedule and the innumerable cups of tea and coffee I keep downing hoping to keep my wits sharp.

The flip side however is the I am regarded as a honest and sincere person, by mostly all the consultants, residents and nursing staff alike. This only brightens my chances of landing the DNB seat next year. Till then its scut, scut and more scut.

Needless to say, I am not devoting enough time to the family or my hobbies, which is obvious from the absolute dearth of blogs. I have started collecting interesting x rays and ecgs. I’ve got GPRS on cell phone activated, so now I can pretty much access the internet from my laptop from anywhere for as long as I choose to.

My blogging prospects look bright but I need to step up the studies.

Here’s one more interesting x ray till then.

Its the tracheal calcification that caught my eye! seems perfectly etched out.

What the...?

2007-08-07T12:31:00.001+05:30

Paraphernalia

2007-07-31T12:03:00.001+05:30

ARDS

2007-07-30T20:32:00.001+05:30

A pt of mixed malaria suddenly went into respiratory distress and an absolutely clear chest turned into the one above.

Time moves on

2007-07-28T07:16:00.001+05:30

Right now am in the 34 hr of my marathon 50 hr long shift. Just about another 26 hrs to go.

Books

2007-07-28T07:07:00.001+05:30

Galore

Yipeeeeeeeeeeeeee

2007-06-26T20:59:00.000+05:30

Guess who cleared DNB Part I?????

It the one good thing that has happened to me in a long long time!!!!

Now comes the issue of applying for residency interviews all around the country!!!!

Expression of freedom

2007-05-08T20:21:00.000+05:30

If there is one thing I have realized in the past one month of living a life of residency is that there is nothing as sweet as getting out of the hospital after a 36 hour on call shift. Maybe its my shortcoming in a way, that I don’t look forward to being on call. I kinda get apprehensive as the day progresses, especially if there are potential patients in the ward who may crash any minute.

I love my sleep and it’s considered a light on-call duty if you manage 2-3 hours of undisturbed sleep. But even when I am asleep in my room, which is on the same floor as the wards, I find it difficult to get refreshing sleep, irrespective of how long it is. My mind keeps dwelling on the things I could or should have done for a any patient, and I start filing away mental notes. Not for me, anymore, the luxury of falling asleep as soon as hitting the bed. That was in the initial days when I used be exhausted as hell. But nowadays it takes me at least 15-20 minutes to fall into a light doze that can be easily shattered by the first ring of the phone. Consequently, even though the next which technically is called ‘post call’ duty, I am invariably carrying the weariness of the previous day.

My mom noticed that even one day of sleep deprivation brings on the telltale black circles under my eyes. And I have to wait till the weekend to recharge my batteries.

But the sweet sweet, final moments when the duty is winding down, is really pleasant feeling. It’s not something I am proud of, but I genuinely feel glad when I get off call.

What’s with the smell?

2007-05-04T12:23:00.002+05:30

It’s been one month at the job, which is not so new anymore, and I haven’t posted anything relevant. Not that there has been lack of interesting things to relate. Just that I never get around to sitting at the PC for more than a 10 minutes a day, that’s just to check the mail. But to mark the end of the first month, I thought I might as well write something.

I have been allotted quarters in the campus, but I still manage to come home every night, no matter how late it is, except of course when I am on call, which happens once in every four days. If all’s well, I can hand over my patients to the resident on call and get home by 6. 30 pm. The first thing that greets me when I get home is my sister’s screwed up nose. Somehow she finds the very air around me offensive. My mom does too, except she doesn’t display it as overtly as my sister does. Its what they call the ‘Hospital smell’. Initially I thought that having sweated it out 10 long hours in the midst of summer, (our ward are not air conditioned), I must smell real bad. But later I realized that it was not the musty sweaty odor that bothered them as much as the ‘Hospital smell’ I carried home with me.

Frankly I myself am not able to distinguish the particular smell they talk about, but then it is not surprising, considering that I spend all day in the hospital environ. My mom even claims that the ‘smell’ has permanently stuck to my clothes, and permeated into the wood of my closet. No matter how strong a detergent she uses to wash them, the smell stays. I suppose it is a combination of the various spirits we use for different antiseptic purposes. And the occasional metallic smell of blood, which can render the strongest stomachs nauseous.

On most days I dutifully shower before partaking in the regular family routines just to please my sis. But on the bad days, her nose screwed in disgust and two words of abomination ‘You Stink’ drive me into a rage that ends in verbal altercations. And then there are days, when I am just too tired to care and hitting the sack is the only thing I am interested in.

I remember the day, when I took in the air of a hospital as a medical student for the first time and it turned my stomach. I was just one month old in med school, obviously had had no clinical exposure whatsoever. We had all just about got used to the horrible stench of Formalin, in gross anatomy, which we were exposed to for 4 hours every alternate day. A senior of mine, who was to become my best friend in the future, was hospitalized with Renal colic. Our gang was on good terms with her so we visited her in the ICU. It was routine to admit medical students in the ICU for all purposes, as the wards were too grubby.

Within a minute of entering the ICU I felt sick. Smells have a way of bringing back memories associated with them in an extremely vivid fashion. My mind got flooded with images of various times when my mother and father were hospitalized. I felt so giddy, I had to step out and leave without visiting. Over the years I have got accustomed to ‘Hospital smells’ of all sorts. No issues there.
However there are other smells that take me back to various times in the past. It would seem stupid if I go about listing them. But somehow my mind has filed away memories and tagged them with smells, so when I come across a familiar smell, a sense of nostalgia creeps over and for a second I am transported back in time. More often than not this happens with perfumes and deodorants I have used over the years. I try to stick to one perfume or deo, but never manage to.

Most people don’t get it, how certain smells can almost debilitate me if they bring back bad memories. My friends consider a personality quirk of mine how I suddenly, in the oddest of places go about whiffing the air for a fleeting scent.

Hope that my family gets used to the hospital smell soon enough.

Initial impressions

2007-05-04T12:18:00.000+05:30

This was a post I had written within a fortnight of joining the new job. But somehow I never got around to posting it. Since I hardly find the time to put up decent posts anymore, I thought I might as well post this one.

There are days when you just have to marvel the complex manner in which man adapts to his surroundings. My first couple of weeks at the new job has been a mixed experience, as can be expected. Highs and lows, all part of the game.

However the image that managed to imprint itself deeply in my mind is of the elevator operator. A middle-aged fellow of average built. He was seated on a low wooded stool by the console and at first glance looked like he was sliding his fingers up and down the buttons before selecting one. The first couple of times, I rode the lift, I did not notice it. But there were the telltale black spectacles/ goggles sticking out of his shirt pocket.

He was blind, the poor chap.

Apparently a few years back he had been a healthy and hardworking member of the janitorial staff. He lost his eyesight gradually due to progressive diabetic retinopathy. Why he did not or could not get treated for the same I don’t know. I couldn’t help but wonder that had this hospital private concern he would have been jobless as off today.

It never ceases to amaze me, these differences between every aspect of the government and private undertakings in the country. Both have their pros and cons. Unwittingly, there have been multiple mentions regarding these in most of my posts.

In India, more often than not, we cringe about the apathy the government regarding various issues. I know I do. But the perks accompanying a permanent government job are incomparable in their own way. Rest assured there will be no company cars or fully paid vacations. Government jobs in India are synonymous with stability. No matter how meager the pay scale is, there are not many forces on earth can rob a person off it. Its kinda in sickness and in health, till death does apart, or maybe retirement. Then there are the lifelong pension schemes.

As my parents both were government servants, big bucks never held any appeal to me. All my siblings are software professionals and get fat salaries starting from job one, the likes a doctor like me can only dream off achieving, say, 15-20 years down the line, if somehow I manage to put together a massively successful private practice. It’s a paradigm here that no matter how badly doctors work their asses off, it will never be good enough.

Here my thought process broke off, I don’t remember why. I suppose I wrote this post at work, and it got cut off by a patient maybe. Or by a consultant come for rounds.

Job update

2007-04-14T23:20:00.000+05:30

Its been three weeks already, since I started my new job. Can’t believe how time has just flown by. This is the first real breather I have had in all of the three weeks. Forty-eight blissful hours away from the chaotic environment of the hospital, thanks to a government holiday paired with a Sunday. I have caught up with all the sleep I needed and did away with a lot of routine work that had been pending, bills and all. So thought I might as well post something.

The work is good. Its hardcore hands on practical internal medicine, including the mandatory scutwork and paper-pushing. Work amounts to anything between 100-110 hours a week, which includes two 36-hour shifts. Does not seem like much, but there is no slack whatsoever in the pace of the work when the duty is on.

I have been allotted quarters and everything in the hospital itself, but I prefer to come home when I can, no matter how late the hour, just to be with the family. I have adjusted to the strenuous hours, but there are the inevitable complications to putting the body through the paces of residency. Acidity, constipation, occasional insomnia and most of all time disorientation. How many times have I had to double check the dates I write in my post call shift. My mind just refuses to register that a twenty-four hour period with its specific date and day has passed. Days and nights blend into each other and soon its weekend again. Lucky if I am not on call, but if I am, its unparalleled exhaustion.

More often than not when I start on a new job or a rotation, or any endeavor for that matter, which needs me to put in enormous amounts of time, energy and effort, I tend to dream about it all night long. It happened during my internship and during my last job. I would have vivid dreams of whatever happened that day, down to the last detail. I can’t stress enough how realistic these dreams can be. If I wake up in the middle of the night, the disorientation I feel is awful. Bad night’s sleep equals exhaustion and poor performance in the day.

For the initial two weeks of starting this job, I suppose I was too exhausted for the dreams to occur. I would nod off anywhere I hit horizontal. Now that I am coping better, the dreams have started. It’s highly disconcerting. This phase will take at least a couple of more weeks to pass off.

Meanwhile I don’t find much time to study as I had planned. Invariably I am too tired to concentrate, even if I somehow find the time to crack a book.

Things are far from settled. Hope to have something better to report in the next post.

On the receiving end

2007-03-24T23:21:00.000+05:30

One of the things I find most irritating is waiting in a hospital, clinic or medical lab of any kind. I am otherwise a very patient person; I can wait patiently for hours in a queue for Railway tickets or in non-medical government offices, or even in the airport if the flight is delayed. But I just can’t wait for anything related to medicine, when I am on the receiving end. This, I was always aware of in some corner of my mind, but was driven home yesterday when I went in for my pre-employment checkup.

There are some unwritten rules in almost all hospitals when it comes to serving the staff as patients. Broadly speaking, if it’s a private concern, where the patient pays hefty sums from his own pocket, the staff always comes last. Or rather the patient is always right, or patient comes first policy is very strictly followed. This I learnt the hard way last year when I was working at one of the best private hospitals in the city.

But when it comes to government hospitals, it’s the complete opposite. If you are on the staff or even remotely related to someone on the staff, it can help you cut many corners in seeking medical aid. While in med school, we took these things absolutely for granted. So, now when I have to brave certain places where I don’t get preference of any sorts, where my being a doctor on the payroll of the very institution, makes no difference - I get mad.

Actually, it might have been my own indecisiveness that fuelled the annoyance I felt yesterday. The hospital I am going to work at, from Monday onwards can be best described as…hmmm… semi- private. Though the government mostly foots the bill, the patients have to shell out 1% of their paychecks for the health services. Therefore, I was not sure if the personnel’s insistence that they could get to me only when they were done with the patients already waiting for whatever service they were providing, could be transgressed with some insistence of my own. I was uninformed if I should go ahead and barge into the consultant’s room as I would have normally done in my own alma mater, or wait in line for my turn (which I was not sure would come because I had not registered at the OPD registration counter). The HR fellow, taciturn to the point of my wanting to do a PR on him to rule out a stick, had been no help whatsoever. So I waited patiently for half an hour each at the consultant’s door, then at the path lab, then in radiology. After a while, I would decide to be more exigent only to be given the ‘patients need to be dealt with first’ line - then I would vociferously insist until they attended me.

I have admitted previously that I make a poor patient. Other doctors and nurses may understand, but my mom doesn’t. I have been having a rather irritating cough for a couple of months now, which just comes and goes. No fever, no expectoration, nothing major. Last week however, it turned into a full-blown URI - tonsillitis, pharyngitis, rhinitis- the whole package. There was also some earache, but no outright otitis media. My elder sister who lives 800 km away down south also had something similar. She has always has been of, what my mom calls as, frail health. She had TB as a child and has had ‘weak lungs’ ever since. I am not sure what that term means, but she gets hit often with respiratory infections, which take turns for the worse. This time as she always does, she visited a physician who promptly started her on antibiotics and it was all water under the bridge for her in a week’s time.

Here in our household, where I live under my mom’s hawk eyes, I waited for the virus to pass me using only supportive measures life cough medicine and anti histaminics to help. There were a few tired, sleeps-less nights, with the cough and the body ache. The comparisons were obviously inevitable, why couldn’t I start antibiotics and get rid of it like my sister did. She even went to the extent of suggesting that I should probably visit our family physician, Dr. V to get a prescription. Any other time I would have vehemently exclaimed ‘I am a registered medical practitioner, for crying out loud mom!!! If I need antibiotics I can prescribe for myself, I don’t need to see Dr. V for that’. But I didn’t, considering that she had been giving me the VIP treatment that comes with being sick…you know…no chores, tasty dishes of my choice etc. I told her that my URI was not serious enough to warrant antibiotics. She did not buy it.

I should mention here that I have nothing against antibiotics. They are highly crucial weapons in medicine. The current trend of antibiotic prescription however, I believe, is not healthy. Having worked in a private hospital where money is not a factor in play, I have seen antibiotics being used rather injudiciously. It’s the preference of the prescribing doctor, other that the culture/sensitivity which decides what antibiotic is flushed down the IV of a patient. And drug companies with their shove-it-down-the-throat marketing strategies are making the situation worse. Doctors are enticed to use certain antibiotics in settings where they are really not indicated. For instance, when culture sensitivity for pus or urine shows that the organism is sensitive to a variety of drugs including basic ones like gentamicin, as wells as higher ones like third generation cephalosporins, I have seen doctors choose the Cephalosporins over the broad-spectrum antibiotics. To someone like me, who does not have much experience in clinical medicine, and who strongly believes in the tenets set by textbook medicine, this is incomprehensible. What does this mean for the problem of antibiotic resistance? Judicious use of anti-microbials is something that has been drilled into me by med-school, where starting of with Ampicilin and Gentamicin was the norm. Only then, if necessary shifting over to higher and proportionately costlier antibiotics. Luckily enough, the trend of prescribing antivirals for flu and chickenpox has not yet caught on India. Use of antivirals is still limited to serious infections like HIV and hepatitis. Doctors in developed countries may not understand my sentiments, but in a developing country like India, doctors should consider the cost incurred to the government in importing higher antibiotics. It’s all about looking at the big picture.

Also, Dr. V our family physician for over 20 years, is one of those judicious antibiotics prescribing doctors, I genuinely respect. There is more to be said about this problem. But let me get back to the problem at hand.

The worst of my URI has passed but the cough, though having lost its grating quality, still stays. As few days back, after I learnt the job was mine and I was told to come in for a routine medical fitness test, my mom started making doomsday predictions. She’s been saying that the tests, the chest X-ray in particular is going to reveal something I have. Her differentials were pneumonia and TB. She said so jokingly but I knew her fears were genuine. My mom is one of those people who are well informed about everything under the sun, this from reading a lot and watching sensible stuff like Discovery and Nat Geo. For a few moments, I considered the possibility.

There is some serious history of tuberculosis in my family, my sister and both my parents had been through it. Over the years I had tried many a times to locate the BCG mark on my left arm, but the few scars I find, suspiciously look like remnants of the chicken pox. Moreover, BCG does not make a person immune to TB it only decreases the severity of the disease. And when I cough, there is an ache in my side - could it be pleurisy? Pneumonia need not present with a fever and expectorating cough. Constitutional symptoms are not a must for diagnosis. I have seen people with serious respiratory affrications present with less.

A few minutes of wondering, and I knew I was getting ahead of myself. I do have a hypochondriacal streak, a remnant of the famed Medical student syndrome. So when I was told that I will have to wait one full day for the x ray report I tried to talk the technician into giving me a look at the wet film. (Yeah, no digital x-rays for routine chest films). I got back the blood tests in an hour, except for a WBC count on the higher side, everything was within normal limits.

The doctor in me who hates waiting for her turn says the x ray will be clean. The patient in me frets a bit but is willing to defer to the doctor’s opinion. My mom though, I believe, makes a special mention for me in her daily prayers.

“Come off it mom” I say, “It’s just a damn cough! If it doesn’t disappear by the end of the week, I promise I’ll start myself on antibiotics.”

Howwazzat!!!!

2007-03-20T10:08:00.000+05:30

It’s been a while since my last post, not much has been happening. Maybe I was in the ‘no-bright-ideas-for-a-post’ phase.
Then the Cricket World cup 2007 is on. After a humiliating loss to Bangladesh in the first match, the ‘Men in blue’ have made a stunning comeback with their 257 runs win over Bermuda breaking a few records on the way. It was one of the most awesome matches I have ever witnessed. All of them made those sixers and boundaries seem so effortless. And just when I thought it couldn’t get any better, Captain Rahul Dravid, who I never considered to be much of a sixer person, finished off the innings in style with a huge one.

And oh yeah, I’ll be starting my new job any time now. I interviewed for it last week. I am yet to get the word officially but a friend of mine already employed there have me the heads up. The post is of a Junior medical officer, sort of a house job / residency post. The hours are going to be difficult as is the workload. I might not get much time for studying which is in a woebegone state as it is. The pay is only average. The only good thing about the whole deal is that the hospital is part of the DNB programme and if I manage to clear the Primary entrance test, being employed there already might marginally improve my chances of getting in.

What I need probably is a crash course in time-management if I am to concentrate on both the job and the long-term goals.

3.00 pm

UPDATE: - It is official. I got the call this afternoon. I have to go for a medical fitness test on the 23rd and will be employed as of the 24th of March.

Just another movie blooper

2007-03-06T17:05:00.000+05:30

In my earlier post, ‘Paint me red’, I mentioned blood transfusions in old Hindi movies. There have been many bizarre and imaginative portrayals of blood transfusions in those movies. The funniest and most famous however is from a film, which is one of the biggest blockbusters of all times, Amar Akbar Anthony. It pretty much enjoys cult status with today’s generation. It stars none other than the ‘Big B’, Mr. Amitabh Bachchan himself.

It’s story of three brothers who are separated as kids. The father is on the run for a crime he did not commit and mom has left to attempt suicide. Many years later the three brothers Amar, Akbar and Anthony meet each other without knowing that they share the same blood…literally!

The particular goof up I’m talking about happens when the mom, who’s but blind, suffers a vehicular accident. Coincidentally, all three of hers sons are present at the spot and rush her to the hospital, unaware of her identity and each other’s as well. The doctor says she’s lost a lot of blood and needs a blood transfusion and all three of them promptly offer their’s. What happens next is probably one of the silliest moments in Indian film history.

All three sons donate their blood, which is collected in one single bottle. Directly from that single bottle comes out an IV line, which is transfusing the mother. All in one single shot. No blood grouping, no pre-transfusion tests. Maybe the director was uninformed or he thought the audience was stupid. The aesthetic value of that scene made a huge impact on moviegoers 30 years back when the movie was first released. All three sons unknowingly save the life of their own mother…made for a great formula film.

And the message of ‘Unity in Diversity’, which my country is so proud of was delivered with great gung ho. The title is itself is suggestive of the theme, the three protagonists are brought up as per the customs of the three main religions in this country, Amar as a Hindu, Akbar as a Muslim and Anthony as a Christian.

It was a great movie…still is! Except for the blood transfusion scene that never fails to split me up.

Grand Rounds Vol 3. No 24

2007-03-06T16:59:00.000+05:30

Grand Rounds 3.24 are up at Grunt Doc’s blog. This is the fourth time he has hosted the GR since its inception in 2004. Moreover, for a change, this week there is no theme and more than 50 posts have been included. All posts have simply been slotted under different categories, which makes for easy reading.

Catch the grand rounds Volume 3, No 24 here.

Paint me red

2007-03-04T14:02:00.000+05:30

Blood is one of the most important organs of life, though most authorities don’t consider it an organ. It is a body fluid that runs in and out of every nook and crevice of the human body making sure all the supplies necessary for the function of the cells get there in time and takes away all the harmful contaminants to be thrown out of the body. Then of course, it has the function of carrying on pressing responsibilities like transporting white cells to combat infections and platelets and coagulation factors to sites of blood loss. It can be fairly said that blood and blood vessels are the lifelines of the human body.

Another credit to the beautiful red fluid is that it is the easiest organ to transplant, or rather transfuse. Just plug in the IV line and let the blood flow. A wide array of clinical conditions can be amended with timely transfusion. Shock, anemias, coagulation defects, etc, etc. If not whole blood, then platelet concentrates or only RBCs or even only specific coagulation factors. Needless to say, blood has always transfixed me. In the good way, please…

My first brush with the life saving capacity of blood transfusion occurred when I was around eleven years old. My mom had been in a horrible MVA. When we reached the hospital, though she was conscious and coherent, she was still in the red. I remember trying very hard not to cry and to put up a brave front. She had suffered a comminuted fracture of the right tibio-fibula, with a massive concussion and countless lacerations.

The ‘hospital’ was a very small polyclinic, the closest to the site of the accident. They had already transfused her with two units of the whole blood they had in stock. They asked us to arrange for at least four more units of whole blood, they could possible need for surgery. The problem however was that she her blood group was ‘O’Rh negative, which is only the rarest blood group around, maybe next to AB negative. My father was not in town then, so the only people around to help us were our neighbors and mom’s colleagues. Armed with a cross match sample and a list of blood banks in the vicinity a few people set out to get the O negative blood. But they returned soon saying that the half dozen places they had hit in the nearby area did not have O negative blood.

My siblings and I, were huddled near the head of the bed holding onto our mother’s hand. When I heard what the adults were talking about, the first thought that came to mind was “I’ll let them have my blood if that’s what it takes to save my mom’s life.” My eyes met my brother, who was nine at that time, and I could see the exact same emotion reflected in his eyes. My sister however, a couple of years older than me, and a whole lot more sensible, explained to us the concept of blood groups and pre-transfusion testing and that they probably did not take kids’ bloods under any circumstances. And all of us were anyway B Rh positive. My only experience so far with blood transfusion had been what I had seen in the old Hindi movies, where the hero would valiantly offer his blood to save the life. Sufficiently informed, I now prayed to god to devise some means of helping us get the required blood.

By then a few more people had set out to search for it in locales farther away. Among them were mom’s boss and her best friend, we called them ‘uncles’. As the rest us of sat waiting for their return, the chief orthopod came to examine my mother and we were shooed out. Apparently, he also advised that we be taken home, hospitals were no place for small kids. Despite all our protests we were taken home, were we spent the rest of the day sitting by the phone waiting for news. The call came that evening, from my father who had returned by then. The surgery had gone well and mom was doing fine. But I had to know about the blood, to which he replied that the ‘uncles’ had taken care of it.

A week later, when everything had settled down, we learnt that the blood had been obtained from the blood bank of a civic hospital at the other end of the city. And that my mother’s friends had donated their own blood to get what was needed. I was shocked to say the least. What kind of barbaric custom was this, blood in return for blood! Why couldn’t they have just paid in cash? My mom, by then well on her way to recovery, explained to me that blood was so precious a commodity that money was worthless in comparison. If everybody started paying blood with money, where would more and more blood come from? So the practice of donating blood in return for blood, so that someone else could benefit from it some other day. I was never so thankful to god than I was that day. For me it did not matter that the blood donated by my mom’s friends had not been used directly. It was their blood that had saved her life. And I have revered the strength of blood form that moment.

Also, I felt indebted, not to our benefactors, but to God and humanity as whole, I think, if that makes sense.

And I got to repay the debt in medical school. I was eighteen years old, weighed over 50 kgs with no over health problems. Thus having met with the necessary criteria to donate blood, all that was there between me and repaying the debt was my own hesitation. I was scared, I don’t know of what. Not the needles for sure, or of pain, which I knew was not involved. Maybe it was the whole big deal of it. I was going to enter the cycle of human kindness by giving a part of me to save the life of another. It was akin to giving life. In retrospect, I find my thoughts at that time a tad silly. But I was a first year med student, not yet well informed as to how the machinery worked and I was being bowed down by all sorts of altruistic notions. The enormity of it was making me hesitate. But I thought of my mother and I knew it was meant to be. Someone’s donated blood saved my mother’s life. My blood could save someone else’s. It was a simple equation.

The experience was like none other. When I saw the bag fill up with 350 ml of my B positive blood, I felt positively ecstatic. I tried to find out later, for whom my blood had been utilized, but the information was confidential. In return for donating blood, we received a card mentioning our blood group and date of donation. It was a Donor’s card that could be exchanged for one unit of blood of the same group within six months of the date of donation, from any government operated blood bank. Though I was confident that my blood had been utilized, I did not need to cash in the card and it expired. Over the next two years, I collected six more such cards. The official time interval between two donations was four months, but quite a few times, I used to donate within three months after lying to the blood bank officer. Luckily enough, I never suffered any ill effects from doing so.

Our blood bank had a blood in return for blood policy too. But, by then a lot of private blood banks had come up around the city, which sold blood units for money. It was always the patient’s job to arrange for blood guided by the treating physician, and affording patients’ relatives preferred to pay for the blood with money rather than replace it. Also we had no equipment available for emergency auto-transfusions. Consequentially the pool in our blood bank often dried up and we would arrange for blood donation camps. Mostly students took part in those camps and the stocks would be replenished only to be diminished soon. There was also a birthday donor’s club. Students were encouraged to donate blood on their birthdays every year.
Then bizarre policy was issued by our blood bank, which stipulated that blood replaced will have to be of the same blood group as the one issued.

I agree that it was an attempt by the management to store up on the rarer blood groups. But it took a toll on patients. Ones who lived in the city could manage to bring dozens of friends and relatives to get their blood groups checked out and the matching people would donate. But the ones who came from villages and far away places did not have enough donors and had to suffer a lot. This problem became apparent to us during our clinical rotations in the surgical disciplines. To combat the situation, my friends and I came up with the ‘Unofficial blood donors’ Registry’.

We collected the donor cards from as many students as possible and processed the information to make a database consisting of the donor’s name, blood group, dates of donation and expiry of the cards validity and contact numbers. Initially we had planned to retain the cards with us, but people were not willing to part with their precious cards without knowing to exactly what use it would be put to, so we returned the cards back to their owners. Initially it seemed like a very tough task. But I was the prefect of the girl’s hostel that year and exercised all my power to convince people to register their donor card. By the end of the month, we roughly had 60-70 donor card registered with us and the numbers improved as word spread. The idea was that a resident who felt that any of his patient would not be able to arrange for the required blood in time for the surgery or whatever the indication was, would approach us and we would direct him to the people in possession of the cards of blood groups needed. It seems like a tedious approach but it worked out great. The blood bank was a bit reluctant to part with blood units in return for donor cards. But the advantage was that the cards could be exchanged in any of the government blood banks, wherever a blood group, if rare, was available.

We tried to keep the matter as silent as possible, for we were not sure how the management would react. But something that huge could not be hidden for long. Though we were never condoned by the management, officially or unofficially, a few of our teacher’s lauded our effort, unofficially. Of course, there were numerous problems in the endeavor. Quite often cards would expire before being used, and we had to be very judicious as to whom we were giving the cards, for lazy residents had tried to con us on behalf of their patients a few times, and it took a chunk, albeit small out of our study time. We managed the registry for three years, till we were in school. After graduation, we passed it on to the junior class. Last I heard it is still running strongly.

And in final year of med school, when one of my friends met with a near fatal accident, needing a half a dozen major surgeries, we had all the necessary blood units at hand. Guess what goes around does come around.

Over the past seven years, I have donated blood about ten to eleven times. I had to stop doing so a couple years back after an HIV scare, when I sustained a needle prick from an HIV positive patient. That is a story for another day, but for the record, I took the post exposure prophylaxis and have not seroconverted. I can donate blood again, and plan to do so on my mom’s birthday coming up in a couple of months.

The Big (printed) Picture

2007-02-25T22:22:00.000+05:30

Prologue

I think I finally get what’s going wrong with my life. Look at the picture.

I have an HP all-in-one printer that is a boon in itself, for about two years now. I have used it to print countless documents, mostly formal letters for my mother’s use, scan a million photographs and copy a lot of stuff. It’s very special to me.

As is expected, the black cartridge gives way sooner than the color cartridge does. And broke as I am I can’t afford to buy new ones (they are pretty pricey!). So I usually get them refilled at a local stationary store for a nominal amount. Apparently, this is a perfectly acceptable thing to do. So the black printer cartridge has been refilled for about 4-5 times.

Sometime last year, there was a short-circuit in our apartment’s electricity supply and it blew my desktop’s power supply box and took down the printer as well. So many things went wrong with my already ailing desktop that it would be cheaper to buy a spanking new PC than get it repaired. Meanwhile I had bought my notebook, so it obviated the immediate need for a Family Desktop PC. But the printer was very much a needed thing, so I got it repaired.

The people at the HP customer service (after a weeks wait!) informed me that my dear printer was beyond repair and that they would replace it. And they did it for free, I am very thankful for that, coz the warranty period had already expired. But after a couple of months of ‘happily-ever-after’ the not-so-new replaced printer conked out as well. It didn’t completely break down, but works on its own whims and fancies. I tuned into its tantrums and wheedled out as much work as I could. Meanwhile, the color printer blanked out and I got it refilled as well.

Our flat is on the seventh floor and my bedroom faces the road. Consequentially, there is a lot of dust coming in through the windows, which is good neither for my darling Notebook and printer nor for my Allergic rhinitis. Try as I might to protect the dust sensitive gadgets, some particles always manage to find their way into the printer and settle on the cartridges. I try my best to clean them as well as possible, as per the instruction manual. I don’t claim to be tech savvy, but I can find my around and fix basic practical problems.

But the problem has only got worse. Nowadays, even though I know the cartridges are full, the pages come out blank, even though the contraption makes all the noises and motions of giving a perfect print. Today trying to print out an important letter, and receiving a beautiful blank white sheet in return, I got really pissed. I pulled out the dog- eared manual, which I thought I knew by heart and went over the troubleshooting pages for the umpteenth time. I even took out the cartridges and cleaned them with ‘a lint-free cloth, dipped in bottled water after squeezing out the excess water’ as said in the manual. No luck.

Then almost by divine intervention, I chanced to glance upon the illustration. It would be an understatement to say I did a double take. I read the circled lines a dozen times. If I didn’t know better I would have thought that there was some sinister force in play that had changed the instructions.

All these months I had been cleaning the cartridges, the other way around, meticulously wiping the nozzle and carefully avoiding the contacts.

Yes, I am embarrassed as hell. But this thing brought into sharp focus many things in my life, in the past couple of years, that have gone wrong. My studies for instance. I put in a lot of effort into my preparation for my entrance exams but haven’t succeeded. I am not saying that I totally misunderstand, misread, misconstrue, misapprehend or misconceive the stuff in the textbooks. Its like, I do not see the big picture while reading the fine print. Or maybe it’s the other way around…I am not sure. I am not focusing enough; I am just going through the motions of it all. Worried about my own career and future, I have neglected my family and friends. There are many more pressing things that need to be taken care of, but I ignore them.

Now I have totally stopped making sense. I can see a lot of thoughts floating in the reader’s head, “how did someone like this become a doctor?”. For the record, let me state that I am a decent doctor trying to become a good one, and I know I eventually will.

Meanwhile, I can’t live life missing the forest for the tree, or something to that effect. Nor can I read the whole manual and not note the important detail. It’s a balance, everyone needs to achieve for a complete life. And I am going to try my level best henceforth.

Epilogue

I took out the cartridges and cleaned them. This time carefully avoiding the Nozzle and gently cleansing out the Contacts with ‘a lint-free cloth, dipped in bottled water after squeezing out the excess water’. (That is exactly what the manual says!!!)

It still does not work.

Maybe its time I got new print cartridges. Or a new printer…

Frustrating day

2007-02-22T23:06:00.000+05:30

I had one of the most frustrating days possible …
It was one of those days with no overt mishaps, but renders you highly irritable all the same.

I have been postponing the application process for the DNB entrance examinations for almost a week now. And today would be the last day within the too-late limit. 28th of February being the absolute last day for submitting the form. It’s no big deal as such. The form, I had duly downloaded filled out and signed. The only problem was that it had to be verified and attested by a Gazetted officer.

A Gazetted officer is a higher-class employee with the government of India, who is given the right by the office he holds, to verify documents and attest photocopies and photographs and such other dubious material. The reason they are labeled as Gazetted officers is because the government publishes a half-yearly list including the names of these officials and details of their promotions, transfers etc, under the title of the Indian National gazette, or something to that effect. Supposedly, the list includes high-ranking officials of all fields, Magistrates, Medical officers, Law enforcement officials, Lecturers and professors of government institution and the like.

But try as I might to get hold of this ‘Gazette list’ to find a suitable candidate whose services I could enlist to finish my application process, I failed. It makes me look back yearningly at my student days when getting an attestation was an extremely simple process. Our Government hospital, abounded with Government employed Medical officers of all cadres. Somehow, for the past two years finding such a suitable person has been a very disheartening process. I have searched online a lot and posed questions in nearly every suitable forum. but everyone has their own ideas about this curious creature, ‘the Gazetted officer’.

Having no firm evidence and only a faint idea as to who might be a Gazetted officer, I have approached many people to see if they were ‘It’!. Surprisingly even the most well informed people I have approached, though well aware that they themselves were not tagged with the Gazetted label, could not point me in the right directions. They could give only vague ideas amounting to stuff I already knew.

So how do I manage…?

A couple of times, I actually sent all the relevant forms to a friend residing in the city of my alma mater to get them ‘attested’. That was the most desperate, but easiest way out.

I met up with a friend all the way downtown who, all but swore that her immediate senior, a medical officer of unknown variety, was Gazetted!. It worked out fine, that once, but it’s too much to travel an hour and half across the city for a mere signature.

So here is what I understand regarding a Gazetted officer - the type I could easily access namely - DOCTORS...
1) He needs to be employed in a government setup - state or central.
2) He needs to be a M. O or Medical officer in the least ( there are various types - Casualty M.Os, Resident M.Os, Chief M.Os, among many others)

Armed with this knowledge, I charted out the places I could hunt. The options were scarce. There was a government medical college not so far from home, which I knew should abound with M.Os, like my alma mater did. But there was also the risk of running into someone I knew, and I did not need that. Also the post office which was the second thing on my agenda today was vary far from the aforesaid place and it was mandatory that I post that completed forms today to make the 28th February deadline. Secondly, there was a hospital run by the Mumbai Municipal Corporation, also not far from home. I was not so sure if I would be lucky there. But the plus point was that it was adjacent to a Post office which would expedite matters a lot.

So I decided to take a chance and settled on the second spot.

I think it would be prudent to mention here why am so psyched about this whole affair. As a doctor, I know I have an ego, which is larger than it should be for my plain M.B.B.S status. Secondly, recently having lost out in the rat race to get a post-grad seat, the ego has been sufficiently bruised to not want to run into people who might express condolences in any manner. This includes friends and family alike. Even a Gazetted Medical officer, in good faith might inquire when I had finished my basic training in medicine (it has not been that long, trust me!) is bound to make me feel like a failure.

At 12.30 PM, with all sorts of apprehensive feelings running through my head, just when I was about to leave home for the mini-adventure, I received a phone call. I would have reacted to it differently on any other day. It was a call for a job offer, from one of the best hospitals in city. It was a ‘plain post’, or a contract based house job, or house officer post. They wanted me to come for an interview at 2.00 PM, today. But the task I had set out to do was more important, finishing it up and making it to the interview by 2.00 pm would be cutting it real close. For I second I thought about postponing the forms matter and going for the interview. But I had already psyched myself to finish that unpleasant task today, before it was too late. And the job they were offering me was in General Surgery. I have never had keen interest in Surgery. Moreover, not being a resident doctor under any training problem I knew there would not be any ‘cutting’ involved, I’d pretty much be relegated to tending pre-op and post-op patients.

My mom tried to talk me into going for it. But I found myself tending towards the negative. Had it been a job in internal medicine, I would have pounced in it. So I decided to leave it to fate, if I could make it to the interview by 2.00 PM, I would give it a shot. If not…well…then it wasn’t meant to be.

So when I left home my mind was whirling with all sorts of depressive thoughts stemming from the insecurities of my future career. The last thing I needed was bureaucratic bullshit. And that’s just what was waiting for me when I reached the Municipal hospital.

In India, it is common to run into bureaucratic red tape in all places. I was not new to it. Being rest assured that the rest of their career and life is secure, Government officials tend to become highly complacent. Corruption is rampant in all tiers of the hierarchy. Getting any job done from a government office of any sorts is a very big achievement in itself. What I ran into was not frank bureaucratic corruptive bullshit like bribery or anything; but the other end of the spectrum - being shunted from one place to another, form one official to another with no avail.

Armed as I was with insufficient information as to whom I should approach, I found myself approaching even peons to point me in the right direction. I had to stand outside offices for 10 minutes, waiting for the ‘Medical officer’ who occupied it to bid me in, only to be told that they did not do such stuff and I should approach Dr. So-N-So for the same. Three such disappointing encounters and four times scaling the four-floored building, later I found myself in from of the Medical Superintendent’s office. Here it was a twenty-minute wait to be seen. Somehow, I found myself feeling hopeful, if a medical superintendent, the head of a State government run hospital is not a Gazetted officer, who could be? But I was in for a disappointment.

He point blank refused to cross sign my form and attest my photographs, after learning that I was not employed there. When I requested him to consider it as a favor (ok, I said please sir!!), he told me to get my original certificates verified from one of his subordinates, another medical officer, before he signed. I knew it was a lost cause, as I was not carrying my originals with me. Rather than groveling in front of that unhelpful fellow, I left.

Needless to say, after spending an hour in futile attempts to cut the shitty red tape, in a an already flurry mental state, I was seething with rage when I left the building. And as it was always does, when I am overwhelmed with anger, a few tears escaped my eyes. This has always been one of my weaknesses. Nevertheless, the job was still to be done.

I had to fall back on the other option and got the job done. By then, however, it was too late for the interview. It took me a few hours to compose myself after returning home. But mom whom I did not relate the above occurrences, thinks I missed the interview on purpose. I am calm now but still irritable.

Tomorrow is another day and I have more things to do, the topmost on the list is hunting for a job.

The 8 Queen problem

2007-02-17T22:49:00.000+05:30

My sister is studying computer engineering and she gave me this puzzle to solve. It is called the 8 Queen problem and apparently they write algorithms to solve this puzzle, as a learning tool.
Here it is…

Consider a regular chessboard. The puzzle is to place eight Queens in different spots, such that they don’t cross each other out. It’s known that a Queen in Chess can move in all eight directions, so no tow pieces should be in the same row linear or diagonal. It is a very simple puzzle and some concentration can get it done. There are quite a few such combinations. But figuring out one from scratch is a bit daunting. So the puzzle I have posted here already has three pieces in place. Try to figure out where the remaining five go.

It might seem like a stupid task, but not being facile in anything remotely puzzling, I managed to do it!
I will post the answer here in a few days time.

For those who can’t wait that long. This is the answer.

Please let me know, if you crack it.

This too shall pass…

2007-02-16T09:12:00.000+05:30

It is true that one thing that your heart wants more than anything else, eludes you the most. For me it is a chance to make a successful career. For which as I have expounded before, I need to get admission to a Post - Graduation course of my choice in a reasonable good institution.
But this year too, destiny has wielded a fatal blow to my aspirations of achieving any of the above. The results of the few entrance exams I appeared for are out and I did not make the cut.

I am terribly disappointed, yes. But there is no time to mourn. I have to plan what I will be doing next. The options are, but few. I wait it out for another year and strike again. Meanwhile I do a plain post job somewhere, which will give me time to study.

Or I could appear for DNB (Diplomate of National board) which is a degree equivalent to MD/MS, but is done in private hospitals and is a tad more difficult to finally emerge from, I hear. This may be a done deal in six months, but I am unsure as how to go about doing it. Of course there is another entrance exam I need to get out of the way for entering DNB!!!

The whole deal sucks. No wonder many of my colleagues are escaping this almost tyrannical system of my country to study and practice in countries like the US and UK where you are what you are worth! But I am sure there is a whole other side to that coin, I have no idea about.
I am sorry if I sound bitter. But 2007 was supposed to be my year. Well now it doesn’t look like it is meant to be.

Well but I know this not the end of the story here. If anything, my resolution is only firmer still. I will crack the damned exam and set forth on the career course I have charted for myself, if that’s the last thing I do.

I am not superstitious, hell, I am not even devout. Neither do I believe in stuff like ‘Karm’(Karma). But I believe in something that’s above everything else - HOPE. And I know in my heart ‘This too shall pass…’

Grand Rounds, Vol 3. No 21

2007-02-13T16:33:00.000+05:30

‘Grand rounds’ is being hosted this week by Chronic Babe at Chronicbabe.com. And it being Valentine’s day tomorrow, Jenni has come up with a ‘Give me some sugar’ theme. It would seem that not many posts may live upto the theme, but she has beautifully managed to blend it all in and come up with a sugary sweet edition of Grand Rounds.

And yours truly has managed a mention in it, with the ‘Catch me’, post.

Check out Grand rounds here…

And Happy Valentine’s day!!

Love is in the air…

Doctors as patients

2007-02-07T10:19:00.000+05:30

Being a doctor means shouldering many fold responsibilities - to your patients, to the community, to your family and to yourself. What happens if a doctor falls sick? It is a tenet in medicine that doctors make the worst patients. Is it because they know too much and know what questions to ask the treating physician? Because they know too much and consequentially are more scared? Or maybe because they know too much and are well aware that the best of doctors can make mistakes? The bottom line is that doctors make poor patients because they know too much.

When does a doctor seek medical help (from someone else)? How much is too much? All doctors practice some form of self-medication or the other. The degree they hold gives them the right to. But what differs is the scale in which they prescribe to themselves. That I assume, depends on their level of specialization and experience. For instance, being a non-specialized plain MBBS doctor my self-medication spectrum ranges from paracetamol to Cetrizine to simple broad spectrum antibiotics. No anxiolytics, no sedatives or such other drugs. Luckily enough I have ever needed more than that. But I know a few peers who do prescribe stronger stuff like Tramadol and Alprazolam to themselves when needed.

And as far as seeking outside medical help is concerned, mostly doctors approach others only when they have extinguished their quiver of arrows. Or when the symptoms are dramatic enough to warrant it. But if it can be avoided doctors tend to avoid it. This is speaking from experience.

As a kid, I never had any major health issues, except for chickenpox and the occasional cut needing stitches. A couple of years into medical college, which was in a place that faces extremes of all climates, I developed Allergic rhinitis. Allergic tendencies run in my family, my grandma is an asthmatic. But considering that I had never been sick before, I was overwhelmed with this simple but taxing affliction. I used to sneeze, I used to sneeze, and I used to sneeze all day long. The first thing I did on waking up was sneeze uncontrollably 20-30 times. My eyes would go red, my head would start aching and it would feel like my nose was on fire. It was like having a cold forever. The slightest of temperature changes or breezes or dust could bring on a massive paroxysm of sneezing. A senior med student gave me some Antihistaminics, which did help but also made me rather drowsy. I spent the whole of six months in this manner, and if I was a nuisance to my friends and roommates, they sure didn’t say anything.

Then one day my nose started hurting. The lightest of touches would send searing shots of pain into my head. I took all manner of over the counter analgesics but to no avail. The sneezing only escalated in frequency and it seemed like my perpetual cold was getting worse from not being able to smell anything. After a fortnight of suffering, I visited the ENT department. It was not just the pain that pushed me to do so, I was scared. We were studying ENT that semester, and I was scared that I would develop Atrophic rhinitis. It’s a condition where all the nasal mucosa and turbinates shrink and undergo atrophy, leaving a very roomy nasal cavity with permanent loss of smell. The treatment was a procedure called Young’s operation; it consisted of closing away one or both nostrils with skin flaps I admit, it seems like classic Medical student syndrome (a form of hypochondriasis) but the pain was for real.

That’s when I was officially diagnosed with allergic rhinitis, and the nose pain was from vestibulitis, an infection of the outer and lower part of the nose. A course of antibiotics and some serious nasal douching later I was back to normal in a week. You would have thought that I learnt my lesson with that. Nay….

Later that very year, I came down with a serious case of tonsillitis. It went off, only to return in a month’s time. Summers are excruciating in that part of the country and we were heavily into chilled drinks and ice creams to keep cool. Even though it is a myth that drinking or eating cold foodstuff causes cold, URI (upper respiratory tract infection) is aggravated by cold foodstuff, because they lower the temperature in the oral cavity allowing the bacteria to thrive. So my tonsillitis returned with a vengeance every time I went on an ice-cream binge. The odynophagia (pain during swallowing) it caused however was something that was amenable to NSAIDs and I ploughed on.

When I came home for the holidays that year my mom made me visit an ENT specialist, who tagged me with the diagnosis of Chronic follicular tonsillitis. Though she didn’t suggest that I get my tonsils removed, she did advise that I steer clear of cold stuff, something my mom made me swear to do.

Now that I am a registered medical practitioner, I know how to handle my idiosyncratic afflictions. Though occasionally I do indulge myself with some ice cream, I manage to have not more than four attacks of Acute on chronic tonsillitis in a year, as that then would become an indicator for tonsillectomy. My mom, though, keeps haranguing me to get it done.
But tonsillectomy, with General anesthesia, with the ET tube down my nose…no way… I can’t even begin to count all the things that could possibly go wrong there. So as a doctor if I am a poor patient that’s because I know what to be scared of.

My ‘illness’ is a very simple matter, I chose to write about it because I can be subjective and truthful about it. But I do know of a few colleagues who in spite of having a lot of dangerous symptoms didn’t seek help till it was too late.

One of them had abnormal menstrual cycles with occasional abdominal pains which kept getting worse. One day she collapsed during rounds and was diagnosed with twisted ovarian cyst. She had to go under the knife for that one.

Another friends had been passing blood in stools for a while. He thought he had piles and was embarrassed to get help, but turns out it was a fissure, which had progressed to a stage where it had to be excised.

Agreed, the above two conditions are about potentially embarrassing situations. My friend in Med school had occasional shooting pains in her right arm for a really long time. We kept telling her to get it seen. She was in the habit of writing out stuff to memorize it, she over did herself before our second year exams. She could hardly hold her pen straight on the first paper because of the pain. An x ray taken that evening revealed a cervical rib. Luckily enough she managed to scrape through in that paper and did not have to lose six months.

I have a few more of such examples, but the gist has been given. Most doctors are narcissistic, they have super egos, but they are still human. Physically they are as vulnerable as everyone else is. But does having first hand knowledge of the ways of the human body and the millions of things that could go wrong with it, in a way hinder their willingness to seek medical help for themselves?

Catch me…

2007-02-03T12:41:00.000+05:30

Yesterday, I happened to read a very interesting post on one of the most popular medical blogs around, Fingers and Tubes in every orifice. I myself am a huge fan of that particular blog and of the author’s excellent style of writing; he can make you feel like you were present at the spot when things are happening. In his latest post A. McGyver, MD he enthralls us with an occurrence where he was forced to improvise in the face of lacking medical supplies to treat a case of Pneumothorax. A particular point where he says there was only one single sterile glove available, brought back memories of an incident during my OB/GY posting in internship, which was one of the first emergencies I had to face on my own. Even though it occurred well over two years back in my internship, one would think that the details would be a bit hazy, but I remember everything as if it happened yesterday. I suppose, it is one of those things you remember for a lifetime.
Here is the tale…

As Angry medic succinctly put it in his comment to my previous post ‘India IS after all one of the most densely populated countries in the world, and it's only natural that health problems are going to arise from that’, it is understandable that OB/GYN in any hospital is one of the most overworked departments. For an intern, it was the most taxing rotation; one and a half months of sheer exhaustion. We used to work over 100 hours a week including two 36 hr shifts. Social lives spiraled down to nil and any available time was spent in catching up with sleep. It would be easy to spot an intern currently posted in OB/GYN from his/her zombie like looks.

I was never particularly interested in OB/GYN as a career choice, as I did not want to spend the rest of my life ‘wicket keeping’ (as in Cricket!)for other people’s babies, as it was known in the intern world. But a couple of days into the posting and I was hooked! The sheer pace and activity of the place was like a drug that got me high. There was always something or the other to do, never a dull moment, it seemed like there was Adrenaline rushing through me 24x7 and the experience was totally hands on and invaluable. Considering that there was, as always, a staff shortage, interns got a lot of practical things to do, other than just scut work. We could assist in surgeries, mostly Cesarians sections and conduct uncomplicated deliveries under supervision. But what transfixed me the most was witnessing the birth of life. The babies who made it, came in all sizes from healthy 3kg ones to tiny 1.5 kg ones. And it gave me immense pleasure to see the rows of tiny human beings bundled up in the nursery. I was so hooked with the rotation, it was all I thought about and talked about and even dreamt about every night.

There were roughly around 40-50 deliveries conducted in our labor room in a 24-hour period and around 7-8 of them would be by LSCS or Lower section Cesarian sections. Our Unit comprised of one senior resident, 4 junior residents and 3 interns. However, our unit was famous for the number of ‘Cesars’ performed which were invariably double of what other units managed on their worst days, rouchly 12-15. Our Senior resident or Lecturer, I feel, did not believe much in the concept of Trial of Labor. Though she was an astute diagnostician and good surgeon, she had a penchant for sending patients to the OR for Cesarians for the slightest holdups in the delivery. The indications more often than not used to be from the ‘relative’ indications listed in the textbook. She would breeze into the labor room, conduct quick exams on all patients, and decide which ones could deliver on their own and which ones needed to be operated upon. Consequentially there used be a line of surgeries occurring in quick succession through out the day and by dinnertime, the labor room would be almost empty, which was a good thing. Residents operated and Interns assisted. We used to take turns assisting, but invariably the one who went into the OR wound up assisting 2-3 Cesareans at a stretch. Each surgery used to last for 45 minutes to an hour but if it were the lecturer performing the C-section, it would all be over in under half hour. She holds the record for the quickest LSCS conducted in our hospital, a mind numbing 21 minutes, from the incision to the final suture.

My tale happened on one such on-call nights. The labor room was virtually empty except for half dozen ladies, part of the late nite crowd who stagger into labor room after dinner around eleven PM and weren’t expected to deliver until dawn. It was around 2.30 AM the leanest time, activity wise. We had one on call room with two beds where all the female residents crashed including the lecturer. We interns managed to sleep where we could, including on tabletops and gurneys.

That shift, it was my turn to stay up in the later part of the night to monitor fetal heart sounds at half an hour intervals of the 6 odd patients who were scattered in the 4 delivery rooms in the labor ward. The Resident who had pulled the short straw was dozing behind nurses’ counter. It had been a hard day for me and after having assisted in a record 7 cesarian sections back to back in the afternoon I could barely stand straight on my feet. That was why I had opted to rest for a couple of hours in the earlier part of the night. Sleep, though, was out of question with the cacaphony of the labor room winding down for the night.

But at 2.30 AM there was a still silence in the ward occasionally broken by a moaning patient or a newborn whimper from the adjoining nursery. It was a calm between two storms. I walked around checking on the patients, taking vitals and checking the FHS (fetal heart sounds). After writing notes I sat down behind the nurses counter and put my head on my arm. Just when I was about to doze off I was abruptly woken up. For a second I thought I had heard some noise. But the deep silence prevailed. Though I told myself to relax, I decided to check the patients out. Maybe it was intuition or maybe I had heard a sound after all, I walked to the delivery room farthest down the corridor. One look into the room and all my tiredness and exhaustion vanished.

The lone occupant of the room was a 34 year old female G3P2L2, i.e she was there to have her third child. Just about ten minutes ago, I had left her comfortably sleeping on the standard issue metal bed with a U shaped cut at the foot end, after having ascertained a good strong FHS. But now she was perched at the edge of the table, her face contorted in pain, her brow glistening with sweat, still not making any sound but obviously experiencing a massive contraction. One look under her dress and my worst fears were confirmed. The Baby was crowning.

“Somebody, get in here”, I yelled into the corridor.

What followed after that, seems like it was played out in ultra slow motion with dramatic music in the background, or maybe it was only my heart thumping wildly in my chest.

Dismissing the routine of wearing a plastic apron over my dress, I rushed forward to the supplies side table and opened the metal bin to get a pair of gloves. But to my chagrin, there were none. Another look at the patient and I could see that the labor was progressing very rapidly - the baby’s head was out. Going to another room for a pair of gloves was out of question I rapidly decided, just when I saw a rolled up glove in the corner of the table wedged under a kidney tray. I snatched it up and jerked it open…it was single. Another glance at the patient…the baby’s torso was half out…and I made the decision in the next split second.

I dropped the glove and lunged for the patient. I was not a second sooner. The baby was out followed by a gush of amniotic fluid, which spattered all over my dress and feet. I caught the baby in mid air with my bare hands, centimeters before it hit the metal bucket placed under the foot end of the table to collect the afterbirth. However, the split second in which the baby had hung by the umbilical cord had torn it and blood started gushing out from the torn ends.

Somehow I managed to hold on to the slippery baby with one hand and pinched the baby’s end of the umbilical cord between thumb and forefinger to stem the bleed. There was not a sound from the baby, but it was not fully flaccid either nor was it cyanotic.

By then people had come into the room and miraculously all of them were gloved. The Baby tray emerged from somewhere and I carefully placed the newborn on it, still holding onto the cord while the nurse tied it with a sterile string. While one resident waited to deliver the placenta, another took the baby to the nursery to resuscitate it.

What followed next does seem a bit hazy to me now, like a dream. The baby was resuscitated with partial success and transferred to the NICU. The neonatologist was saying something about it having lost some blood. Personally I feared I might have caused it some injury while handling it - Erb’s or Klumpke’s palsy, but that was not the case. Since the disaster had been averted, no blame games were being played but I received a few slaps of kudos on my back. It was only when someone pointed it out, that I realized that my dress was soaked in amniotic fluid and my shoes were making sloppy noises as I walked. We didn’t have scrubs in the labor room, and I wasn’t given permission to go back to my dorm to change. I had to spend the remaining four hours of my duty wearing the amniotic fluid soaked dress, which I had tried to rinse of as best as I could, and which later dried to form a stiff canvas. Luckily enough the amniotic fluid was not meconium stained (that’s fetal poop!) But I didn’t mind, after all I had saved a life that night. Nevertheless, it was the most thankful shower I ever had, when I finally got around to it the next morning.

As I said, no blame games were played, but the story of how I caught a baby with my bare hands and got showered with amniotic fluid in the process, spread all over the campus. I checked in on the baby about half a dozen times the next day in the NICU. Though he was severely anemic, underweight and struggling to breathe, he seemed to be improving; I even got to name him. His mom was all gratitude for my having saved her little boy. I named him Aditya, which means ‘Sun’ in Sanskrit. However, it soon became clear that little Aditya was fighting a losing battle. The third morning, on my way to work when I went to the NICU, I was told that he had died of respiratory failure in the night. I said a quick prayer for his soul and went off to bury my sorrow in work. The tears did come though, later that night.

I hold this experience close to my heart, coz I not only had faced my first emergency but also had lost my first patient in essence.

Indian Med Blogs Directory

2007-02-01T14:20:00.009+05:30

As I strongly feel that Indian Doctors are underrepresented in the blogging community, I am trying to list them all under one directory - Don't know how far I'll succeed. But there is no harm in trying.

So if you are an Indian and you have a blog even remotely related to health or medicine and if want to list it here, please leave its link in the comment's section or email it to me directly at indianmedic@gmail.com

Also, please feel free to upload one of these buttons onto your own blog and promote the directory, by simply copying and pasting the HTML codes below the buttons to your blog template.

The Indian Med Blogs Directory

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A Canary's diary - A simple happy yellow bird...

A rookie doc's rants and raves

A Nice place - A thought is an awareness... Awareness is knowledge...
Knowledge is power... All begins with a thought.

A Medico's diary

A Philosopher's diary

All sounds to silence come

Arvind Poswal's blog

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Break free - hey its all about idiosyncrasies...scientific crap...read at ur own risk...criticize do whatever u want! well but I will not stop this even if u find it pakau coz its my blog---n I' l do what I think-- it's rite to (w)rite...right?

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Cochin blogs

CoNFessioNs oF ConFuseD ConFuCiuS - cudn care less though...

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Dr. Nizam Raj Banerjee

E
Evincere

Et Cetera

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Godyears... - There's a fly in my soup again, Mr. God!!!

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Indian Medic-An average Indian Doctor’s stories of everyday occurrences, some sad, some humorous and some simply nonsensical. There are hardly any blogs available by medical practitioners from countries like India where diseases like polio and TB still thrive. So just thought, people may be interested in learning how medicine is practiced in such places…among other
things of course!!

Into the land of thoughts and wisdom...- .an insight into the mind of a self proclaimed litterateur

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Med Tape - Medical and Health information infused

Medical Knicknacks - Some of the stuff Medical Post-Grad aspirants in India are expected to know....purely for academic reasons...no particular format...just blogging stuff as it goes into my head!!! Dunno if it'll help.But hey I gotta try...

Musings of a life less thought about -less thought -> less confusion -> better life -> musingsI am not all knowing as the less knowing claim.I only know more than everyone else...

My Life - As I Know It... - Where I torture myself until I confess the truth

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Non Specific - An effort at remembering the little details of life

O

Orthodoc - (Delhi)I am a young orthopedic surgeon from the mystic land of India. Its about me, my
life, my profession, my country, my evolution and a lot moreeeeeeeee!!!!!! Everybody is welcome to my place on the net.

Ortho Doc - (Chennai)

R

Random rambling

Reflections - Doctor Bruno's Blog. This is my little world.

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S

Scan man’s notes- random noise, nebulous views & artifacts

Shrinked Immaculate

Spot Diagnosis - Radiology images, cases, quizzes and other relevant radiology information

Sumer's Radiology Site

Sundae with Shiva... Blog by an Intern. With a Difference.

Simply Ridiculous - “What distinguishes modern art from the art of other ages is criticism.” -Octavio Paz

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T

Tejas's space

The mystery of the missing person

The Singularity

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Y

You just gotta keep livin' man, L-I-V-I-N - From almost law school to poker player to Medical Student. What an interesting road its been. If your here for the first time I'd recommend reading this from the beginning, not only will some of it make you laugh but you might end up learning a little bit about poker as well.

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Polio - Battling on the frontlines

2007-01-30T10:15:00.000+05:30

One of the most striking aspects of practicing medicine in a developing country like India is the whole wide range of medical conditions we get to see. Not only diseases like Polio and Whooping cough which are termed exotic in the developed nations but also their share of scourges in the form of modern epidemics of diabetes, hypertension etc which were hardly seen when India was just a farming nation. We see and study the whole spectrum of diseases even though major international textbooks limit the diseases that have been already eradicated from most of the world to a page or two at the most.

Having been trained in India, in a General hospital I have been intimately aware of the battle we have been raging with Polio with guidelines provided by the WHO. It’s a matter of disgrace for my peers and me that India is one of the four countries that have yet to eradicate polio while the rest of the world has succeeded in doing so. The other countries in the list are Pakistan, Afghanistan and Nigeria. These four countries are described as Endemic for Polio while there are a few more countries with importation Polio problems. It can be argued that it is because of the abundance of the wild poliovirus in these regions, three of which abut geographically. But there is more to this saga than that.
India was one of the signatories to the WHO declaration in 1988 to eradicate polio by the year 2000, which was later extended to 2005. Even though we have stepped into 2007 the goal still eludes us.

Polio is not a killer disease. If you are lucky enough it will pass you as nothing more than a flu, but one in 200 cases develop Acute Flaccid Paralysis which on resolution lead to atrophy of muscles and residual paralysis. There are three types of Polio viruses of which Type 1 causes most epidemics. The Vaccines currently being used to immunize children against polio are of two types OPV and IPV.

OPV or Oral polio vaccine is the weapon that is being primarily used to battle polio in India. Following is the salient features of the Eradication strategy
1) Routine Immunization - Three routine OPV doses should be received by infants at ages 6, 10 and 14 weeks.
2) National Immunization days - Conducting Pulse Polio Immunization (PPI) programme by providing additional OPV doses to every child aged <5>
3)Surveillance of acute flaccid paralysis (AFP) to identify all reservoirs of wild poliovirus transmission.
4) Mopping Up- intensive house-to-house, child-to-child immunization campaigns are conducted over a period of days to break the final chains of virus transmission.
Add to this Ring Immunization in which when a case of polio is detected all children less than 5 years of age within a radius of 5 km are immunized within 48 hours.
When all this is added up, an average Indian child may receive upto 20 doses of OPV by the time he turns five. The Eradication strategy has made a tremendous difference in bringing down the incidence of Polio from almost 40,000 in 1981 to 300 in 2006. Still it has not succeded…

One of the most purported reasons for the apparent failure of the eradication strategy is the non-maintenance of the Cold chain. Cold chain is essentially the series of machines employed in keeping the OPV at the recommended temperature of 4 degree Celsius, which includes Walk in freezers the district levels to small refrigerators at PHCs and the ubiquitous Ice box taken into the field. More often than not, it is failure to maintain the highly sensitive OPV at the specified temperature that causes it to lose potency and eventually leading to ineffective immunization. Introduction of Vaccine Vial monitors or blue indicators on the vial itself, which indicate if the vaccine is viable or not has rectified the above said problem to a certain extent. (see inset picture)

The other major argument is over the choice of the vaccine itself.

OPV or Sabin vaccine has been selected as the mode to eradicate Polio for a variety of well-established reasons. It is cheap (which goes a long way in its favor), easy to administer (just two drops in the infants’ mouth are enough), it produces Systemic immunity as well as local intestinal immunity (which prevent re-infection from wild viruses), antibody production is quick and the person excretes the vaccine virus, which infects other people propagating Herd immunity. Thus, it is also useful in controlling epidemics.
The points that go against it are stringent storage conditions required as mentioned above and the small but potential chances of Vaccine induced paralysis since a live virus is being administered.

The counterpart of OPV is the IPV (Inactivated Polio Vaccine) or the Salk vaccine, which though not popular in India has its own merits and demerits. It is a costly vaccine, difficult to manufacture and administer (given Subcutaneous or Intramuscular), gives only systemic immunity and does not prevent reinfection, also no role in epidemic control. The good part is however is that being a killed vaccine there is no risk of vaccine induced paralysis, is easy to store, has a longer shelf life and is hundred percent effective after the second dose. In addition, it can be combined with the DPT vaccine ( Diphtheria, pertussis and Tetanus) and given as a quadruple vaccine without changing the current National immunization schedule.

Most of the countries that have successfully eradicated polio have done so with the help of IPV or a combination of OPV and IPV. Considering that the cost factor is one of the major determinants in the usage of OPV alone in India, experts say that the mass administration of IPV may work out cheaper than the 20 doses of OPV that an average child gets. The current National immunization schedule is as follows -

Age - Vaccine
At birth - BCG and OPV - 0 dose
At 6 weeks - DPT 1 and OPV 1
At 10 weeks - DPT 2 and OPV 2
At 14 weeks - DPT 3 and OPV 3

At 9 months - Measles
At 18 months - DPT and OPV boosters
At 5-6 yrs - DT (only Diphtheria and Tetanus)
At 10 and 16 years - Tetanus toxoid boosters.

As per recommendations by experts IPV should replace the OPV shots at 6 and 10 weeks and five doses of OPV should fill in the slots at zero, 14 weeks, 9 months, 18 months and 5 years. This dual pronged approach could well be the answer for India’s problems with Polio eradication. This change of track in Polio control must be implemented as soon as possible to tip the scales in our favor and win this battle.

Along with the above mentioned major possible causes for the faltering Polio eradication there are the omnipresent social causes that plague India that invariably play contributing roles in almost everything that goes wrong here - Over-population, Illiteracy, Unemployment, Corruption etc.

I know first hand what Polio can do to an individual and a family, my aunt suffered form Polio as a child and now has a major residual defect in her legs which in spite of various operations and prostheses never let her have a semblance of normalcy in life. As an eager medical student on National immunization days I was always overtly vociferous (much to the surprise of my friends) in rallies and door and door propagandas for promoting immunization. Even now, I do volunteer work in immunization drives.

Nevertheless, every time there is a case detected, anywhere in the country, I can’t help feeling disappointed. For the lack of a better analogy, to me it feels like, Polio is an abnormally strong springed Jack-in - the Box, every time with utmost difficulty we manage to push it back in the box and just when we are about to close the lid it springs back again.
The Day when India is declared free from Polio will truly be a red-letter day. I am so looking forward to that day.

The Geriatric tale

2007-01-19T23:09:00.000+05:30

Geriatric medicine in India is the least known form of medicine. Becoz no one practices it, because no one gets trained in it. Presently the focus of the health administration is still on decreasing the IMR (infant mortality rate) to less than 30 per 1000 live births which right now, in India, is 54.63 per 1000 live births. It is one of the factors in determining the PQLI - Physical quality of life index in the country. PQLI is determined by the follwing
- IMR
- Life expectancy at age 1
- Literacy rate

If you notice, Life expectancy is also a determinant and presently the Life expectancy in India is 64.71 years (male: 63.9 years female: 65.57 years). That is pretty ok, so it will be a while before Geriatric medicine training is introduced into the mainstream health education. However, I am basically writing this post to string together my experiences with the elderly population.

There is no doubt most of the ailing people who are admit chronically in hospitals are about middle aged. Here I am talking about routine cases like CVE, IHD, Uncontrolled Diabetes and Hypertension and of course Cancer patients. And often instances come where there is nothing much you can do for them. I’ve come across such patients being described as ‘Gomers’ in a few Robin Cook novels. They take up hospital beds and resources that could be more effectively used otherwise. There is a solution possible for this in the form of Nursing homes and Recovery homes and such.

But there are very few such nursing homes and recovery homes in India that will take care of such patients for optimized economic disbursals. And the burden falls on mainstream hospitals. There are often scenarios played out, especially in Government run hospitals, where the doctor takes the family aside and tells them that there is nothing much they can do for their patient, so they can take him home if they wish to. There is no ‘all we can do for him is to keep him comfortable’ (as in pain relief). It’s different when a patient chooses to die in the familiarity of his home and it is different when due to lack of facilities in the hospital or due to the financial situation of the family the patient is taken home to die. Medical insurance is still in its primitive form here and government subsidies for the elderly are limited to separate Qs at railway stations and such.

This is a sore point with me becoz I lost my grandfather in exactly the same way. He was diagnosed with Carcinoma prostate and on diagnosis, his PSA levels were approximating 40 ng/ml with bone and lung mets and it was too late for any modality of treatment to be effective. He was taken to one of the better Cancer hospitals in India but after running tests and treating him for a week, the doctors promptly told my relatives to take him home, as there was nothing much they could do for him. I was 17 and a first year medical student then in the midst of exams, so I could not go visit him. But I was appalled when I learned that instead of keeping him in the hospital in pain relief, my uncle chose to bring him home. My grand father died at home, one and half months after his diagnosis amidst his family in, god - only - knows how much pain. Now after a few years of experience I realize that this should not have happened. My grandfather, 78 when he died, had been complaining of prostatism and acute body pain for 3-4 years. But as is the plight of most elderly who have to depend on their offsprings for getting them medical attention, my grandpa waited and my uncle kept dismissing it, till it was too late.

I am not sure whom to blame, the government which doesn’t make better facilities available for the elderly or my family who didn’t help him in time.

Please note, that most of all this applies to people who are not so affording, though there are the occasional odd rich examples .It’s the norm in India for the kids to look after their parents in their old age. But there are way too many people who think of it as a burden to take care of people who have practically spent their whole life looking out for you. Its only recently that people have started saving for themselves in their retirement and old age, rather than give it all away to their kids and expecting them to fend for them in their bleak years. Also more and more old age homes are coming up in cities and many of the about-to-age populace, including my mom, have decided to live there (and die) in dignity! About my mom, its remains to be seen, as it’s a constant debate between us with me saying I won’t let her!

Examining the other side of the coin, I should mention what is being done for the elderly other than separate senior citizen Qs and concessions. The hospital, where I studied, was a tertiary Government hospital meaning that most of the difficult cases were referred there from the peripheral districts outside the city. The department of Internal medicine conducted weekly clinics for Diabetes, hypertension and Ischemic heart disease, which basically consisted of a bunch of doctors refilling prescriptions of patients and ordering tests as required. The medicines were free as were the tests. And yes, there was a geriatric clinic too, which was in conjunction with other relevant departments like surgery and orthopedics, but that was mostly prescription refilling too.

However my personal brush with elderly patients happened in two particular places. The first was in the Ophthalmology department as in intern. The most common cause of blindness in India is Cataract. In my hospital an average of 40-50 cataract extractions were done a day, and it was the interns’ responsibility to get all the relevant tests out of the way before admitting the patient. That meant giving the patient a list of tests that needed to be done and making sure they went to the right departments to get blood tests and urine tests etc done. Trust me when I say that it is one of the most challenging things to explain to an elderly, illiterate, unaccompanied lady who walks leaning on a staff and is invariably hard of hearing too, the various directions to the get her tests done. Dozens of times I have wound up taking them around for their tests and ultimately depositing them in the Ophthalmology ward, which, unfortunately, was on the fourth floor with no elevators. I suppose it was one of those times that I promised myself that my mother will never suffer a lonely older age.

The other place where I came across multitudes of geriatric patients was during my rural posting, which is a three-month long stint in one of the government run Primary Health Centers or PHCs in rural areas. Apart from the Obstetric patients who came in hordes to avail the Antenatal facilities, (India does have one of the highest populations and population growth rates in the world!), the major bulk of patients were geriatric females and occasionally males. The hypertensives and diabetics aside, they invariably came with complaints of generalized weakness, body ache and joint pains. Osteoarthritis at such a grass root clinic could hardly be treated with HRT (hormone replacement therapy). We had to resort to the NSAIDs (aspirin, Paracetamol etc) along with antacids for treating their symptoms and giving them a week’s worth of calcium supplements and Multivitamin tablets which were free of course. As per protocol, we could only prescribe a week’s worth of medication, but rest assured they returned every week.
As a Primary care physician, I could not bring myself to prescribe virtually unlimited supply of NSAIDs to any patient, over and over again, for fear of giving them Gastritis or Ulcers. Initially I tried to teach them exercises to keep the joints supple but they were more interested in the painkillers.

Then there were those who demanded injections. Not for the pain but for the weakness. It’s a habit in PHCs to give intramuscular injections of Vitamin B12 to anemic patients. The illiterate patients call them ‘Strength booster shots’ or ‘Red strength shots’ as the solution is light red in color. It’s a common for patients suffering form easy fatigability to visit such clinics and demand for ‘Strength shots’. And so used are they to them that when in shortage of Vitamin B12 injections a placebo like distilled water helps as well.

I think I have been rambling too long in this post. I will conclude by saying that much needs to be desired in the practice of Geriatric medicine in India and hope that things change soon for the better.

Medical studies in India

2007-01-16T14:34:00.000+05:30

I have been working on creating this blog for about a week now. However, I haven't been able to come up with a fitting first post for the blog. There are a few unshaped ideas in my head but they will take some time.

So I was thinking, maybe, to start off, I'll write about medical studies in India.

Ok, so the journey of a typical medical student in India starts at the tender age of 17. If u want to be a pre-med you have got to decide so in your final year of high school i.e. HSC or Higher secondary certificate year also known as 10 + 2 STD in many states. A few states offer a choice of completely dropping mathematics in your HSC so you can concentrate on the three main subjects for being a Pre med i.e. Biology, Physics and Chemistry. Whether or not you get into medical school at 17 depends upon your score in the various PMTs (Pre-Medical Tests) conducted by all states and one by the central government. Here too there are exceptions in the form of states that prefer to conduct the admission process based upon your scores in the HSC exams without an entrance exam. It's difficult to say which is the better procedure, but the lack of uniformity most certainly produces discrepancies in the whole system. Add to it confounding variables like caste reservations, minority reservations and a lot many other reservations. There is much to be said about that facet of the admission process, especially the caste reservation, but that would be fodder for another post.

Once you enter into the medical field, you are one of the privileged, coz being a medical student is an honor in its own way, as I am sure it is in other countries. Medical school or medical college as it is called in India consists of four and a half years followed by one year of Internship. The four and half calendar years are divided into three academic years of one, one and half and two years each, coving pre-clinical, para-clinical and clinical subjects respectively. This pattern too is subject to much variation in the different states.

The first year of pre-clinical subjects is spent entirely in classrooms, laboratories and dissection halls, obviously in study of Anatomy, Physiology and Biochemistry. From the Second 'prof' or professional year starts the real fun. Mornings are spent in clinical rotations learning hands on clinical medicine. It might seem odd that students are exposed to real patients even before they cover in theory all the clinical stuff, but that's how it is. Second prof covers Pathology, Pharmacology, Microbiology and Forensic medicine. Final year is similar to the second, except that now there is sync between the classroom study and study at the 'Clinics'. All three 'profs' culminate in exams of their respective subjects. Moreover, if a student fails in any one of them, he is set back by six months and so on until he or she manages to pass the examinations.

Then it is on to internship, 12 months of total unadulterated clinical experience. The fledgling doctors are shunted from discipline to discipline and trained in the basic technicalities of practicing medicine. At the end of each rotation, there is a performance evaluation and if needed one might have to repeat the rotation or if lucky enough, get away with an extension. Even though internship is one of the most crucial elements of any doctor's education how much a person gains from it depends upon the individual. What I mean is that there are always a handful of students who manage to play hooky during their internship days and devote their time in the pursuit of activities, which will ensure their further ascent in the hierarchy of the medical world. They prepare for the Post graduation entrance examinations. We will get there in a bit

After the completion of the compulsory internship and registration with the Indian Medical council or the State medical council where they plan to practice, students officially become doctors or RMPs - Registered Medical Practitioners. The degree bequeathed on them is MBBS, which stands for Bachelor of Medicine and Bachelor of Surgery. All this by the approximate age of 23 or 24. We can practice basic medicine, have a family practice; work in hospitals and clinics or as Medical officers for the government in rural areas. However, for most of us that is not enough.

A couple of decades ago, when the onus was more on family practitioners and not on specialized medicine, MBBS was a highly honored degree. Now trends have changed drastically, so much so, that the MBBS degree is only considered as a checkpoint in the spectrum of medical education. If you want to be a successful doctor, you have to specialize. The catch however is that the transition to being a specialist is by far the most challenging task. Another series of Entrance exams need to be cleared and depending upon your performance you to get be a candidate for either an MD or an MS. MD covers all the non surgical specialties like Internal medicine, Pediatrics, Psychiatry, Anesthesiology etc and MS covers all surgical branches like General surgery, Orthopedics , Ophthalmology and Otorhinolaryngology. OBGY however has the dubious honor of being an MD specialty rather than MS even though it is practically all surgery.

Believe me when I say, the entrance exams are tough. Even though the pattern is multiple choice and the subjects comprise all subjects of undergrad, it is very difficult to crack it. The problem is lack of facilities for specialty training. There are far few seats and far too many candidates. And as the backlog keeps mounting so does the competition, and the exams only get tougher. So far, there is no solution in sight for this problem.

But for those who do make it, it's an unparalleled victory. Not matter how grueling you residency might be, only after setting foot into the sacred territory of post graduation does one feel that he/she has arrived in the 'Promised land of Medicine.' Three years of post graduation training and after that the sky is the limit.

This in a nutshell is the journey of an Indian Medical student from the age of 17 to being a fully qualified 'specialist' doctor. Could take from anywhere between 9 - 12 years. I have another 3-4 years to go before I set foot in the 'Promised land.'

2007-01-15T21:42:00.001+05:30

Indian Med Blogs Directory

2007-01-15T10:53:00.001+05:30

GO TO DIRECTORY

Indian Medic

Kids nowadays…

Grand Rounds Vol 7 No. 20

The Green eye monster

The Countdown begins

Who’s the Boss?

Not a bad day...

Liver Cirrhosis - Palmar Erythema

Broken Physician?

An Angry post

Email trial

Indian Med blogs Directory

Therapeutic CT scans

The Balancig act

Indian Med Blogs directory

Grand Rounds 5:18

Clubbed!

Dissertation dilemmas

The White Cap

Current reading

I’m back…again

I'm Back...

ECG pop

World AIDS day

Winter Weary

Spooked!

Milk blooded?

Third time unlucky???

Breakaway...

What the...?

Paraphernalia

ARDS

Time moves on

Books

Yipeeeeeeeeeeeeee

Expression of freedom

What’s with the smell?

Initial impressions

Job update

On the receiving end

Howwazzat!!!!

Just another movie blooper

Grand Rounds Vol 3. No 24

Paint me red

The Big (printed) Picture

Frustrating day

The 8 Queen problem

This too shall pass…

Grand Rounds, Vol 3. No 21

Doctors as patients

Catch me…

Indian Med Blogs Directory

Akshay Sharma - Pages from an Intern's log book..

A(n)nals Of An Idle Mind - Rambles of an intellectually constipated mind.

Dr. Nizam Raj Banerjee

Et Cetera

Pulsatile life - Unveiling of my life

Trial & Error - Read on, either over a peg of vodka or a mug of coffee. Drinks on the house!

Polio - Battling on the frontlines

The Geriatric tale

Medical studies in India

Indian Med Blogs Directory