Blissful Life

When you apply skepticism and care in equal amounts, you get bliss.

Month: August 2017

  • My Obsession with Free Knowledge

    I have a peculiar attachment with free knowledge – the concept that knowledge should be free of conditions and unencumbered by geographical, economic, cultural, and any other avoidable barriers. This often puts me in a position where I strangely reject certain well meant advices simultaneously appearing stupid and arrogant to others.

    For example, a good friend and fellow citizen once suggested to me that I join Landmark Forum, a 3 day course that helps people understand their hidden biases and become more productive people. I listened to their forum leader speaking about how the course works and the psychology behind it and I was sure it would be a fantastic idea. But, when it came to registering for the course and participate, something prevented me from doing it.

    The other day I asked a pharmacologist friend if she knew any prophylactic treatment for syphilis. She went to UpToDate (or I’m not sure if it was some other similar service) and started looking up the information. I was curious what she was using and whether I could have it in my phone too. She said it would need a subscription, but she was willing to share her username and password with me. I said that I didn’t want access to it.

    Yesterday a close friend suggested Dr Thameem Saif’s lecture series on basic concepts in medicine for me. She said that it was really good and helps to grasp basic concepts really fast, saving a lot of time. I agreed with her on all that and said I wouldn’t attend the lecture series.

    Additionally, I hate the concepts of entrance coaching, tuition, etc.

    The pattern I see emerging is that I have constant disregard for knowledge that is held behind restrictions, especially if tied with a business. I don’t consider making a business out of knowledge evil. But I hold a pet peeve against using that kind of knowledge for my personal benefit.

    To understand this attitude, you need to look at the other things that I value and principles that I care for.

    Free software

    Free as in free speech, not free coffee. Here is an interesting paragraph from gnu.org about free software:

    The idea of the Free Software Movement is that computer users deserve the freedom to form a
    community    . You should have the freedom to help yourself, by
    changing the source code to do whatever you need to do. And the
    freedom to help your neighbor, by redistributing copies of programs to
    other people. Also the freedom to help build your community, by
    publishing improved versions so that other people can use them.

    I have been an ardent user and advocate of free software for the past 8 or so years. The idea that there is collective ownership of software and people being able to make and share improvements on the software with each other thus creating a better product for everyone is addictive. So much that once you subscribe to this philosophy you feel grudge and guilt if you were to use or be forced to use non-free software for any task.

    I can still use Microsoft Word on my parents’ computer running Microsoft Windows to type a letter. But it simply won’t feel right.

    Open Web

    The Open Web is that part of the world wide web which is open for anyone to use, create, and innovate in irrespective of their location, race, gender, economic status, etc. according to me.

    Internet has enabled human dreams far quicker than any other invention. Internet is a great equalizing force. Internet has elevated human life to a higher level. And Open Web is the most important pillar of this success.

    With the Open Web, it is far more easy and quick for people anywhere on earth to share and receive knowledge. Collaboration is cakewalk. Building upon each other’s ideas becomes rule rather than exception. Charles Darwin and Gregor Mendel worked on two critical pieces of the theory of evolution at around the same time. But they never knew about each other’s work. Won’t ever happen in the internet age.

    When I see internet services that are “app-only” or requires sign in for viewing, I wince. They are justified in trying to retain users. But it simply won’t feel right for me to use such a service.

    Open Access

    With internet, the cost of publishing came to almost zero. And so one would think that science literature would become cheaper and cheaper to access. But the opposite is the truth. Scholars expend their lives trying to expand the horizons of science and publishing industry locks down their contributions to select few who are willing to pay exorbitant amounts of money to access this.

    People who fight these are killed. But their spirit cannot be killed. Open Access movement is gaining large amount of followers. When enough academicians hold fast to the promise that they won’t publish in money-thirsty journals, there will be a tilt in the way scientific literature is published.

    Science needs to be set free. And open access to scientific articles is crucial here.

    I’ve not published anything yet. But when I do, it will be open access. And I keep asking the people I have any influence over, to keep their contributions to the knowledge base that humans have built to be open access.

    Free Knowledge

    It is in this backdrop that free knowledge enters.

    Organizations like Wikimedia, Creative Commons, and even YouTube have done a lot to advance free knowledge. “Imagine a world in which every single person on the planet is given free access to the sum of all human knowledge.”

    If you have been reading carefully till now, you know that free culture is my culture. And free knowledge is an inalienable part of free culture.

    From as early as 11th standard, I have been using the internet and all the wonderful resources in it to learn. I fell in love with MIT’s OpenCourseWare. When NCERT textbooks weren’t enough I would run to OERs like CK-12.

    But when I joined MBBS I faced the greatest challenge ever. To date I have not been able to find any good collaborative (or not) open textbook online for medicine or any subject that medical education includes. There have been very good attempts like Ophtho book, Path Bites, Radiopaedia.org, etc. But the information is usually so scattered that it is very difficult to get a comprehensive understanding of the subjects.

    In this scenario, I was forced to resort to traditional textbooks. I made it a point not to purchase expensive textbooks. I’ve scraped all the corners of the internet to find out useful PDF files.

    And at the same time I made a pledge to myself that I will leave the condition a bit better by organizing the information that I find and making it possible for a future student to click on links and get access to various information as required. That is why learnlearn.in was born.

    Now that I have finished MBBS I no longer am under duress to stick to textbooks to avoid prolonged stay at a not-so-nice place. But, in the spirit of pirate philosophy, I continue to access resources that are required even when they’re not free knowledge. But I have set a personal restriction that I will not be using resources that aren’t obtainable from the internet.

    By doing this I am expecting to create a path which can be followed by others. I want success, but I want only reproducible success. I don’t want to be successful because I had access to a particular resource by virtue of my geographical, economic, cultural, or any other privileged position.

    So what about things I learn at VMH? Well, my plan here is to put everything that I learn here online. Also, a point to note is that at VMH there’s no package of knowledge that is sold. It’s all experiential learning that occurs here. And people are welcome to work and learn from here.

    Can’t you do the same with Forum, UpToDate, and Dr Thameem? Well, not impossible. But, like I said earlier about using Windows as a free software advocate, it just doesn’t feel right.

    But more importantly, by striving to learn exclusively from free knowledge resources, I create a demand for free knowledge thereby encouraging creators to produce more content in free domain and also allowing people who come after me to have a road that’s been taken before them.

    Let’s build a society where knowledge is free.

  • Fellowship in HIV Medicine – Interview

    A day before independence day, after the long wait of more than three months, the FHM interview took place at SVYM office.

    I was on duty and was checking on a newborn with tachypnea (probably transient tachypnea of newborn) when they called me upstairs for the interview. I had others fill in for me and ran to the interview room.

    My friend Swathi went in first and sitting outside I could hear them talking about the challenges faced by a clinician and public health worker in managing HIV because of the stigma associated with it and how by consistent effort we can influence at least families of HIV infected people to look at it like any other disease.

    I had practised multiple times the answer to why I wanted to join FHM. I look at it as a course in infectious diseases and India is a country still struggling with infections. My personal interests and career choices are probably going to take me to places where being good at managing infectious diseases would be an advantage. Also, SVYM is a great place to be at. The clinical, academic, and overall atmosphere here is wonderful. The kind of people whom I get to work closely with – no mention. Not to forget, I was never interested in a PG seat (till I started working here, that is).

    The conversation then came to how I should rigorously finish my dissertation, starting early and keeping good quality because Indians can also contribute to the knowledge base that medicine is built on.

    I didn’t mention my unrealistic perfectionism that kills most of my research ideas. Maybe articles like this will help me look past RCTs as the only study worth doing. Wish me great productivity.

  • Do Cats Get HIV?

    Blalock-Thomas-Taussig shunt is a surgical technique used in colouring Blue Babies pink.

    Last week we had a baby who was referred for cardiac evaluation come back with a report saying she had Tetralogy of Fallot and needs a BT shunt. The parents had not gotten it done yet. Still, the baby wasn’t blue. Because she was too anaemic to have enough deoxygenated haemoglobin to be cyanotic.

    I had to watch Something the Lord Made that night. It is the heart-touching story of how B(T)T shunt was developed. If you don’t cry with Vivian Thomas at the end, you should probably check your cardiac functioning.

    In the backdrop, there are dogs. Blalock and Thomas would perform their surgical experiments on dogs. Countless dogs who have lost lives for (human and animal) science. Thank you dogs!

    Talking about dogs, there are cats too. I found this post on reddit.

    The Litterbox Hero

    Cats don’t get HIV – it’s Human Immunodeficiency Virus, for viral Lords’ sake. Or maybe there is a Feline Immunodeficiency Virus! And when you read more about it you can find that FIV and even HIV is used in gene therapy.

    Fucking science.

    On the other hand scientists are marching to protect science. And being rational is increasingly being viewed as treacherous and anti-nationalistic.

    People just can’t understand.

    I had just figured out a name for the problem one of our patients who got his tissues necrosed after an IM diclo injection had. It was Nicolau Syndrome (or livedoid dermatitis or embolia cutis medicamentosa – remember the name that can make you sound really good).

    And there walked in a patient who had worked too much and was having pain in the forearms and knees. He had to get an injection. It didn’t matter to him whether I gave him 3 mL normal saline or 20 mg morphine. They just have to get injected. Good luck talking them out with Nicolau Syndrome or even anaphylaxis.

    When the pleasures and shortcuts are so tempting, why would people prefer the rigour of science or protocols.

  • CPR – To Terminate Or Not To – That is the Question

    Unlike with many other resolutions I figured out that today is the first day of the month only after resolving to be productive today. As a part of that I woke up about an hour early and started seeing my babies in ground floor general ward. (Oh, did I forget to mention, I’m in charge of Paediatric patients since more than a couple of weeks now).

    But I hadn’t even figured out why Atenolol was prescribed to the child with hepatorenal syndrome and not so high BP when I was informed that I had to cover general OPD in Kenchanahalli hospital today. As I had the experience of missing the van going there for being a minute late last time, I didn’t take risk and ran away after instructing the nurse to withhold Atenolol.

    It was only when I was halfway over the bridge that connects our hospital to the other side of Saragur that I realized that the Atenolol was not for BP, but to control the heart rate – tachycardia and gallop rhythm. I told the consultant paediatrician about how dumb I had been and he said it also helps in relieving portal hypertension which our child had.

    Anyhow, Kenchanahalli is a nice break from the hectic Saragur hospital. Serene, silent, and sleepy. I could spend up to half an hour talking with each patient and understanding their problems.

    It takes only half an hour of talking and a spot capillary glucose reading of 352 to make a grandmother who has been visiting our hospital for as long as I have been alive to confess that she has not been taking the teneligliptin 20 mg tablet for the past one month (along with the glipizide + metformin combination, pioglitazone, enalapril, hydrochlorthiazide, metoprolol, and ecospirin) because our hospital didn’t have it in stock the last time she came (one month ago).

    It takes only half an hour of talking about various reasons to quit smoking, instant and late benefits of quitting smoking, complications of continuing smoking, showing images from Google images of healthy lungs and smoker’s lungs and talking to his daughter and her husband about how they can help to convince a 60 year old who had come with a bidi (which was momentarily destroyed and thrown into dust bin in line with the practice inherited from our consultant physician), a match box in his shirt pocket (which was involuntarily donated to the canteen) and amoxycillin tablets in trouser pockets to quit smoking.

    It takes only half an hour of history taking, examination, and consultation over phone (and whatsapp) with consultant to convince a family (and myself) that their newborn who was vomiting milk through mouth and nostrils and not opening her eyes like she was in shock half an hour before, but opened her eyes and mouth and started crying the moment the ambulance reached hospital, is stable and okay and to learn that Epstein Pearls are nothing to worry about. Another 15 minutes ought to be spent to check on the mother who had Tetrology of Fallot and CCF, to listen to her heart murmurs and the wonderful story of how she had to undergo emergency LSCS because she was a short primi, the adventure they experienced in going to Jayadeva hospital to be declared fit for surgery, and how much money they had to pay to the workers who pushed the trolleys or handed over the just born child to the family waiting outside. All that and I was about to send them home with just a home remedy of preparing saline water and pouring a couple of drops into each nostril as many times as possible to relieve the nasal blockage (because we had ran out of saline nasal drops) and luckily I remembered I could prescribe Vitamin D3 drops for babies or I would have sent them back empty handed.

    Medicine is exceedingly fun (and sometimes horribly sad) when you can spend more time with the patient (and family) than what is required to just figure out the diagnosis. Realizations like these are easy to come by when you walk through the now empty corridors of Kenchanahalli hospital where the soul of people behind SVYM always remains.

    But I did not have time to revel in such thoughts. As a part of being not resolute, I had been postponing the task of drafting a CPR protocol for our hospital. I had to finish it somehow. But wherever I search, I couldn’t find a definite answer to the question of when to terminate resuscitation (or efforts at resuscitation). AHA who is the authority on CPR leaves it at that multiple variables should be taken into account. An Indian CPR guideline didn’t even acknowledge this question exists. Someone in Japan had done an analysis based on survival rates and figured out the factors that coincided with prolonged survival or vice versa and set an algorithm for termination. With no definite answer, I resorted to the diplomacy that everyone seems to be following. My protocol draft says that the team leader should make a decision based on a list of variables and that they should continue CPR if they can’t make a decision (in the hope that something changes to make the decision easier, or help comes in the form of a senior doctor who can then take the decision).

    While returning to Saragur in the Maruti Omni ambulance (this car model is so versatile I want to buy one and set up a mobile clinic in the Himalayas later in my life) I was looking at all the clouds with golden lining because the Orange sun was setting behind them and thinking that I should definitely resume the habit of journaling.

    And my children were all fine except one of them is at the lowest point of Dengue thrombocytopenia and looks so sick he could fall down and disappear if someone didn’t hold him up. And the guy whom I withheld Atenolol for? Seems like there is no way to figure out his exact BP. He is too long for a child so we might be tempted to not use the Paediatric BP cuff, but his arms are so thin that an adult cuff would go twice or thrice around his arm. Not to mention that there are two kinds of machines – the adult one with mercury and the Paediatric one with aneroid technology. Mix them up and you get 4 combinations. And we were getting different values for each of these configurations. Finally, I decided to assume that his BP was not too low because he could sit up without giddiness and I could feel the dorsalis pedis artery inside his grossly swollen foot.

    The decision to terminate CPR or not might not make a huge difference in many cases, the patient would die anyhow with the sorry state of our health facilities and infrastructure. But a doctor is forced to be iron minded and make tough decisions every day. Wish them great luck.