Blissful Life

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

Year: 2018

  • What Next?

    I am privileged. I was born into a higher middle class family in Kerala. I have not been discriminated against based on my family’s religion/caste/colour/whatever. I am male. My parents are both alive and work in public sector. I even had access to internet at a very early age. I was allowed and assisted to dream.

    Precious copy of my life plan (written after 10th standard)

    My father is a doctor. I became a doctor. Natural. It was not incredibly difficult. I did not have to fight unfair situations. I had plenty of help.

    I think it is because of my excellent background that I am able to even recognize these privileges.

    Consciously or not, much of my life’s philosophy is influenced by this. My obsession with free knowledge, is a good example. I may not be able to erase the advantages I already have, but I try to avoid relying on them.

    There is no point in beating myself too much either. I am not responsible for my privileges. But I am accountable. Having had all this, if I do not make the best out of them, I am wasting them. When life gives you lemons, make lemonade. But what if life gives you apples?

    I have a few straightforward options.

    • Become a specialist/super-specialist doctor. Work in one or two hospital(s). Make a lot of money. Help a lot of people.
    • Go back to SVYM. Help build a resurgent India.
    • Join some other organization/hospital/research project which can benefit from a clinical doctor.

    None of these are mutually exclusive options either.

    Yesterday I was coincidentally discussing with dad a verse from Gita which has many different interpretations.

    karmaṇyēvādhikārastē mā phalēṣu kadācana.
    mā karmaphalahēturbhūrmā tē saṅgō.stvakarmaṇi৷৷2.47৷৷

    Specifically, it is the last part we concentrated on. “You should not not do your duties.” How do you know what your duties are, though?

    Every person plays multiple roles in their lives. They would have multiple roles each inside family, work, society, and any other sphere of their life. There are duties in each of these. Is there any way you can prioritize one above the other?

    I have never been good at prioritizing things in the past. I usually get distracted by the most visible task and forget rest of my duties. I sometimes am able to note them down and come back to them. But this is fixable.

    24 hours is what everyone has per day, on Earth. There are indeed people who get a lot accomplished in that 24 hours. If they can, so can I. I will have to organize my time well and get disciplined. And more importantly, I will have to choose the right commitments.

    That is what we are coming to, aren’t we? Commitments. What are the right commitments for me now? What should I do next?

    I keep reading “A Guide for Young People: What to Do With Your Life By Leo Babauta” now and then. The gist is this:

    The idea behind all of this is that you can’t know what you’re going to do with your life right now, because you don’t know who you’re going to be, what you’ll be able to do, what you’ll be passionate about, who you’ll meet, what opportunities will come up, or what the world will be like. But you do know this: if you are prepared, you can do anything you want.

    Prepare yourself by learning about your mind, becoming trustworthy, building things, overcoming procrastination, getting good at discomfort and uncertainty.

    You can put all this off and live a life of safety and boringness. Or you can start today, and see what life has to offer you.

    Lastly, what do you do when your parents and teachers pressure you to figure things out? Tell them you’re going to be an entrepreneur, start your own business, and take over the world. If you prepare for that, you’ll actually be prepared for any career.

    Is this advice for me? Am I already at that point where I should be knowing what I’ll be doing and who I am? At the end of my final MBBS, I thought the one year of internship will be the time when I finally understand what I will do with my life. But I was wrong. During FHM, I got a few ideas on the kind of life I do want to pursue. I am sure I will not be going back to a university in a few years. And then there are a few preferences.

    I sort of want to do things that create massive impact. That is why I got bored of clinical work. It was the same thing happening every day. Sick patients, some diagnosis, some treatment, some outcome. At the end of the day, not much has changed in the way things are.

    I want to do creative things as well. I do not want to be remembered for things I did. I want to be remembered when people use things I built.

    I love internet. It is a technology that has immense potential. I want to utilize it.

    I love computers. Computers (including the small ones called smartphones) are all over the world. Sooner or later they will take over the world. I definitely want to be a part of this take-over.

    I love teaching and learning. I want to help people learn all they want to. Knowledge should not become monopolized. 

    I believe I am good at a few different skills – programming, writing, clinical care, teaching. I want to do things that utilize all my skills. If I do not utilize all the skills I have, I am wasting those skills. That would be running away from “duty”.

    In fact, I have a few ideas in my mind which are aligned with all these preferences. I want to build free software (free as in freedom) that bring the power of internet and data science to healthcare. I want to enable people (especially the ones in healthcare) to achieve more through the use of technology. I want to make sure this immense power (of technology) does not get accumulated in a few hands. And I want more people like me – I want to ensure there are hundreds of thousands of people with me who do things like me (or better!).

    These can’t happen if I am alone. I need to connect with people. I need to build on collective strength. I already know a few people I would love to work with. Almost all of them are in the Silicon Valley of India. What makes perfect sense for me to do next is – move to Bangalore and start talking to people. That’s what I am going to do as well.

  • Way Forward

    On 30th of June, SVYM organized a one day session on careers after MBBS at Vivekananda Memorial Hospital.

    Interns and/or final year students from Mysore Medical College, Bangalore Medical College, Hassan Institute of Medical Sciences, JSS Medical College Mysore were among the ones who were in the audience.

    After the SVYM video, it began with introductory remarks by Dr Chaithanya Prasad, the director of VMH.

    Then Dr MA Balasubramanya talked about administrative careers after MBBS. The gist of it was that as doctors, we are already administrating. There is no running away from it. We should embrace that reality and go forward with it.

    Dr Kumaran K took the audience through the story of his life in research and thereby had them thinking about how to pursue a career in research.

    Dr Ravindranath motivated the audience to take up surgery as a career and showed various alternatives to the MS degree to become a surgeon – majorly about options in various other countries.

    Dr RK Nair talked about his passion for emergency medicine and how to go about it as an Indian.

    Good lunch in between, and then a snippet on Fellowship in HIV medicine.

    Dr Dushyanth P who is the technical lead of SVYM’s palliative care talked about careers in public health and palliative care.

    Dr Seetharam MR and Dr Kumar GS and the audience brainstormed on the direction where healthcare is headed or should be headed.

    Later the participants were taken on a walk around the SVYM Saragur campus and the interactions continued over various tourist spots in and around.

    Downloads

    The presentations [Powerpoint, Google Drive]
    Recording of Dr Kumaran’s talk [Soundcloud, audio]

  • First PEP – Days 7, 8, 9, 10, and so on…

    Well, I lost count.

    I didn’t miss a single tab. But I have, as usual, missed on writing the experience.

    There are indeed some highlights.

    First, a house surgeon and his friend from my college came all the way to Nugu and our hospital after reading my posts. I guess I put enough philosophy in his head that he comes back and joins here later.

    Then, I’m making good progress in my thesis work, interviewing patients about their perspectives on how they became sick. I have interviewed three patients till today. Each interview gave me a completely different story. I have even moved to Asha Kirana hospital asking permission to interview patients there.

    Also, Amazon made three deliveries. My favourite book – The Emperor of All Maladies, my favourite stethoscope Dr Morepen ST 01, and Tripti Sharan’s Chronicles of a Gynaecologist. (all affiliate links) 

    Finally got a hard copy. Horror stories one after the other. Chronicles of @triptisharan200 pic.twitter.com/0Y3D1LFwLf

    — Akshay S Dinesh (@asdofindia) May 17, 2018

    I started managing my tasks with any.do, and it’s going well till now.

    Somehow, I’m on a streak!

  • First PEP – Days 4, 5, 6

    Days fly by as usual. It’s already day 6 and I’m wondering what I did on day 5. (I slept all day).

    Day 4 – Monday, 30th April

    I had general OPD duty. In essence I was jobless almost the entire day. I sat in the injection room and saw some 10 patients.

    This morning I had tried to swallow the LPV/r without any water. It wasn’t a very good idea as one of it got stuck to the throat and I almost had to do Heimlich on myself.

    It’s the day we went to Nugu and savoured garlic bread and churmuri prepared by all the ladies.

    Busy kitchen at the ladies’ place
    Not conspicuous: Ram struggling with pepper powder in his eyes

    On the way back Kishan & Suchitra ran out of petrol. So I had to empty a 1 litre bottle of water into my throat and fill petrol in it. Swathi and I went on a scooter ride after about an year today.

    Day 5: May day

    All I remember of this day is sleeping all day. I tried to get some useful work done after waking up in the evening. But having finished dinner, I slept again.

    Ah, ah. I also sent an email to the canteen manager regarding the legality of “cooling charge”.

    Day 6: May 2, Wednesday

    My first shift in the new ED. I spent half an hour with the new defibrillator. Skanray as they call it. Sankar Ray as I call it. Sliding out the adult pad for getting the paediatric paddles was the most interesting part. Still wondering whether the whole machine can act as an AED.

    Only 3 cases came to the ED today. One of them was a lady in labour and I sent her straight to labour ward. The lady with fracture of leg? Straight to x-ray. The sad one was the man with MDR-TB, diabetes and cellulitis of a limb, had to send him to Mysore as well.

    The computer network in the hospital was in partial disarray today thanks to the lightning and thunder last night. Oh, man! Yesterday there was a bolt of lightning and ear-deafening thunder right outside my window; I thought I died. One can only imagine how the poor electronics must have felt.

    The thunderstorm is back tonight. I came to the hospital to finish this blog post as the power supply keeps getting disturbed in my room. And there it goes, another strike on the radio station above us. I sure will need an audiology check-up soon.

    Earlier when I was in my bed, I felt my calf muscles ache. Myalgia is an early sign of acute HIV, you see. Had to brush up on the basics of acute infection. Also had to read three studies on the failure of PEP in health care workers. Seems like the right regimen wasn’t chosen or there were adherence issues in most of the cases. I might also have been part of a world record by receiving PEP at around 15 minutes which I think is the earliest anyone has ever received PEP.

    I might be having some minor reaction to the PEP as I feel abdominal discomfort (in the form of flatulence) and feel like the stools are coming out faster than usual. But apart from that, the pickle in the canteen is making me eat very well.

  • First PEP – Days 1, 2, 3

    After having done the “Perfectly Messy Prefect” series and “Jog Journal” series, I have now gotten the opportunity to start a new series – on Post Exposure Prophylaxis.

    Let’s start with the good news. I put a central line in a patient (that’s my first time after MBBS and the first time I was confidently doing it on my own).

    This patient who’s been admitted with Cryptococcal antigen showing 3+ in their CSF needed lots of amphotericin for two weeks. Putting amphotericin in a peripheral venous line is okay, but it can soon lead to thrombophlebitis and both patient and doctor will have a hard time managing it. So we decided that it must go through a central line.

    And it was imperative that this happened in the new emergency department that was inaugurated the same day. Dr Ram was around and his guidance is better than the ultrasound guidance he gives.

    I will put a better picture of the new ED in a future post

    First thing we settled was whether the artery went lateral or medial to the vein. Of course it goes lateral in the femoral canal (NAVY). And nature will never let us have easy mnemonics that apply everywhere. That means artery should go medial to vein in neck. Yet I guessed that it went lateral. Anyhow we immediately confirmed with the USG that the common carotid went medial to internal jugular. The vein was there large and compressible just below the skin.

    After pressing the vein some 21 times to get the point on the skin where I had to prick, I pricked a bit lateral to that point. Yet, thanks to ultrasound I could move a bit medial and get into the vein in one go. In went the guidewire, then dilator and then the catheter itself.

    Having placed the catheter, I just had to put two sutures on the clips to hold it in place. I don’t know what made me choose a round bodied cat-gut. Or I do know – it was the cheapest among the suture materials that were lying around. A round bodied needle never goes easily into the skin. And the way I hold a needle, I do not get enough pressure on the tip. No matter how many times I have tried to correct it, I hold the needle wrong every time.

    And the holder slipped just enough for the needle to go through my glove and make a tiny cut on the distal phalanx of my left ring finger laterally. It wasn’t deep at all. Maybe one layer of skin was cut out. The direction was tangential. But it left a cut big enough for everyone to see.

    And I’m also fortunate to have good colleagues who spoke sense in to me and prevented me from neglecting the prick. I removed the glove and confirmed the prick. There was no blood or anything. Yet I put the finger under running water for more than 5 minutes. And straight I went to the counselling room to get my PEP regimen.

    Tenofovir 300 + Lamivudine 300 0-0-1, Lopinavir/Ritonavir 200/50 2-0-2 it would be. 5 pills a day is a lot of pill burden for a person who hasn’t had a paracetamol tablet in 5 years. But I was really curious about experiencing PEP.

    And within 15 minutes of the prick, I had swallowed the first set of three tablets. There was no nausea or giddiness or anything for that matter. I also got my baseline investigations done. My CBC was perfect except for high eosinophils. I do suspect there are some worms inside me. Maybe I should get an albendazole also, anyhow I’m getting bombarded my antibiotic this month. Creatinine, SGOT, SGPT everything was okay.

    I woke up to alarm next day. I didn’t want to wait 16 hours before taking the second dose of LPV/r. I took it at 14 hours. I had kept some Bourbon biscuits last day because I knew I would not get breakfast that early. I even had a masala dosa at around 9 am. Didn’t feel much of nausea. But my bowel was irritable. I think it was irritable much before all this began. From the day we attended that marriage at Saragur town. Anyhow the masala dosa kept me asleep throughout that morning.

    I had kept another alarm for 6 pm Saturday. This one was for the TDF+3TC that I had at 26th hour after the first dose. And then the LPV/r at 8 pm. I don’t know if it was gastritis or nausea, but I wasn’t really feeling hungry and had only an apple to eat with these.

    And then it was today. I woke up at 6 (yesterday’s alarm memory?) and slept again. The 7:30 alarm went off and I was actually up when Swathi called me to make sure I woke up and took the tablet. I took the next two LPV/r and went for breakfast.

    Right after breakfast I left for Mysuru. Did feel nauseated in the bus that took half an hour to start. Not sure how much of that can be attributed to reading on phone screen in a moving bus. Anyhow, once sleep crept in, there was no other feeling.

    At Mysuru I went with a friend to this really nice place called “Khushi”. It’s a home converted into a hangout cafe. There I had ragi pancake, oats with almond milk, and peanut butter smoothie all without vomiting.

    On the way back to bus stand, I dropped in at KR Hospital. Went to the medical ICU to see a patient we had referred here the previous day. Also went to the casualty OT and found it the same level of activity at 2 pm as it used to have 2 years ago – an intern or first year PG struggling to put a catheter in, the ortho intern proud of the slab he put, and patients with tubes running out of various orifices.

    I came back to Saragur in a sunny bus ride and was really hungry. Quickly had my tablets and then a full plate of rice and sambar. The mango pickle these days in canteen is coming closer to real mango pickle from back home.

    2 from the big one and one from the small one