Author: akshay

This one took a lot of searching. My initial hunch was that the G and the V stood for amino acids. G for Glycine and V for Valine. I thought, maybe, if these amino acids were not substituents, at least they would be the precursors involved in synthesis of Penicillins. I had also heard the word “Penicillin Gold” somewhere suggesting that they could be acronyms as well.

After some searching around, there was a chance discovery of this page on some encyclopedia that said “The different forms of penicillin are
distinguished from each other by adding a single capital letter to their
names. Thus: penicillin F, penicillin G, penicillin K, penicillin N,
penicillin O, penicillin S, penicillin V, and penicillin X”

Now I knew there are more letters and these are chosen just because they are in the alphabet and not because of anything special. So the question became, why these letters? Did they start with Penicillin A and go down all the way till Penicillin V and even X? Is there a list of all Penicillins? Who maintains this list?

After figuring out what Penicillin A and B was, I remembered Alexander Fleming. If Fleming discovered Pencillin, then we should start with him.

So, here’s Fleming’s 1929 paper where he describes the discovery of “mould broth filtrate” which for convenience he decided to call “penicillin” : On the Antibacterial Action of Cultures of a Penicillium, with Special Reference to their Use in the Isolation of B. influenzæ.

He wrote the fungus closely resembles P. rubrum. Some people “corrected” him later. Some then corrected the corrections.

Okay, so in 1929, there was only one Penicillin and it was Fleming’s Penicillin.

Then, for almost 10 years nothing happened. That’s when Ernest Chain and Howard Florey came into the picture. They figured out a way to get good Penicillin. As early as 1940, they discovered Pencillin resistance. An Enzyme from Bacteria able to Destroy Penicillin. If you want to read more about the interesting history of the discovery of penicillin, read this review.

What Chain and Florey synthesised apparently was different from what Fleming discovered and therefore they initially named it Penicillin A and filed a patent. Later, they renamed it to “notatin” to avoid confusion. They also wrote this brilliant article on how they used it on some patients.

Van Bruggen and others in 1943 described another compound from Penicillium which had bactericidal activity and was different from any of the Penicillins till then and named it Penicillin B.

It was soon clear that Penicillin A and Penicillin B were identical. This compound is now called Glucose Oxidase.

From then on, it was mostly about improving on the techniques and therefore most literature is on patent articles. Here is one where Penicillin F and Penicillin G is described. I have no clue why they skipped over C, D, and E.

Around this time, people started producing all kinds of Pencillins.

As I could not find the list anywhere, I decided I will make that list. Here it goes.

Penicillin A – Glucose Oxidase
Penicillin B – Glucose Oxidase
Penicillin C –
Penicillin D –
Penicillin E –
Penicillin F – C14H20N2O4S
Penicillin G – Benzylpenicillin
Penicillin H –
Penicillin I –
Penicillin J –
Penicillin K – Natural penicillin
Penicillin L –
Penicillin M –
Penicillin N – Natural penicillin
Penicillin O – Almecillin
Penicillin P –
Penicillin Q –
Penicillin R –
Penicillin S –
Penicillin T –
Penicillin U –
Penicillin V – Natural penicillin
Penicillin W –
Penicillin X – Natural penicillin
Penicillin Y –
Penicillin Z –

Please let me know if you find the missing items.

On 6th March, Wednesday JeevaRaksha team did the first JLS (JeevaRaksha Life Support) course in an Ayurvedic college in Karnataka at SJG Ayurvedic College, Koppal.

I took Hampi express on the night of fifth and reached by about 9 in the morning and the workshop had already started by the time I reached the venue. The participants were enthusiastically interacting with the facilitators.

Choking was my topic and for the first time I had a “choking charlie” for demonstration. After a small lunch we had the scenario trainings and tests. A lot of candidates became eligible for being trainers.

That evening Ramya, Sahana, and I went on top of Gavisiddeshwara Temple and watched a beautiful sunset.

On Thursday, the training of trainers took place with the candidates who were selected on the previous day. All of them showed real potential to be great facilitators.

The happy picture of the candidates from day 1

If you are a medical student, you know what I am talking about. The PG medical entrance test, called NEET PG, is a proprietary test conducted by National Board of Examinations. You have to sign a non-disclosure agreement to attempt this test. You cannot, according to the agreement, disclose the questions asked to anyone. Neither does NBE publish the question papers anywhere.

How is this fair at all?

For comparison, all the JEE advanced question papers from 2007 are put on the official website of JEE advanced. The USMLE website has content description booklet, plenty of sample questions, and practice tests. While the NBE’s website proudly writes everywhere that their exams (not just NEET, all of them) are “proprietary“.

This would not have been a problem if NBE was some private body which conducts test for the sake of individuals. But NBE is not that. NBE is an autonomous body under the Ministry of Health & Family Welfare. NBE is not a private entity.

How come they are doing this then? Well, turns out they have been doing this for years and nobody dared to ask. The DNB exams have been happening the same way from the beginning. Candidates take DNB exam with no knowledge of what they will be assessed on. Professor Suptendra has written about this in this IJME article titled “A farce called the National Board of Examinations“.

I have filed an RTI yesterday with the following content:

I, as a citizen of India, hereby exercise my right to information granted under sec (6) of RTI Act, 2015 by requesting the following.

1) Please provide me with the questions asked (including answer options) in the NEET PG Entrance exam held on Jan 6, 2019.

2) Please provide me the answer key of the above questions.

3) Please provide me with the questions asked (including answer options) in the NEET PG Entrance exam held on Jan 7, 2018.

4) Please provide me the answer key of the above questions.

5) Please provide me with the reason why there was a non-disclosure clause at the beginning of the NEET PG entrance test held on Jan 6, 2019.

The information may be emailed to my address: asdofindia@gmail.com

Thank you

This was addressed to National Board of Examinations. I’m sure the response will be “proprietary test”. Also remember that NBE makes 30 crores profit on NEET PG registration alone with no sanction from MoHFW.

What are students supposed to do to prepare for NBE’s proprietary examinations? Go to entrance coaching institutes? Read textbooks and continue working? The atmosphere around entrance tests is so tense that students are scared to prepare on their own. They are forced into joining medical entrance coaching centers.

But why? How can a test that decides who gets access to the very few postgraduate seats in India’s medical education system be made proprietary? Are you saying that only students who have the time and resources to go to entrance coaching centers should be able to prepare and score well? Should only people with time and money be becoming pediatricians and gynecologists?

What will that mean to India’s health system?

Yesterday I was demonstrating CPR in a life support workshop. Today, I have pain in the left radial styloid process area.

What could it be? Searching took me to two pages of interest. One is AAFP’s page on diagnosis wrist pain. This page talks about many things including Finkelstein’s test which is grasping the thumb with other fingers and then ulnar deviation of wrist. It was negative for me, and I definitely did not have De Quervain’s tendonitis.

But it could be the same tendons. What are the tendons involved in de Quervain’s? The extensor policis brevis and the abductor policis longus which both go through the groove lateral to the radial styloid process. Maybe there was some microtrauma?

The other article was about wrist injuries in emergency service providers. It does not look like I have a scapholunate ligament injury. So I decided to read more about de Quervain’s.

I found an article – Walsh and Miller: Pain about the Styloid Process – which beautifully captures the history of Fritz de Quervain’s initial case descriptions and then Finkelstein’s reviews and so on. The original articles by de Quervain are probably in German (Because Google Translate detects the title so. I initially thought they were in French because I had once enrolled to learn French in Alliance Francaise and it looked similar to what I was learning then). You can, though, read translations in English if you, like me, can’t tell between French and German – references 1-4 on this article.

Especially the one “on a form of chronic tendovaginitis“. When you read this you find out how chronic inflammations of tendon sheath were “rightly, increasingly being seen as tubercular”. And then de Quervain going on to describe a chronic inflammation due to repeated use. The people who see beyond what they are taught to see indeed get diseases named after them.

Wait a second, where did “vagina” come into picture? Why is it tendovaginitis? Well, as it turns out, vagina means sheath in latin (and the sword (gladius) is kept inside) and since the inflammation here is on the sheath around the tendons, de Quervain (who obviously is a master of language) named it tendovaginitis. In fact, I see all reference of tendovaginitis going back to de Quervain’s disease. [Side note: Do you still want to use the word vagina to refer to vagina? Are you sure you are talking about vagina, and not labia or vulva?]

After all that research, now I am now thinking it is the skin over the forearm that is giving me pain as the pain increases when I am softly rubbing over the skin. Maybe it is just a friction burn I got when handling my bag?

Disillusionment. It happens to the best among us. It has happened to you? Welcome to the club.

After all, who wouldn’t be disappointed? You could have become anyone – an architect, an engineer, a teacher, a scientist, a mathematician. Yet you chose to become a doctor. Of course it was your calculated choice. What a fantastic profession is it, after all? When a doctor talks to a patient, she is a teacher, an artist; when a doctor is diagnosing an illness, she is a detective, a scientist; when a doctor is communicating, she is a writer; when managing an emergency, she is a leader; in her career, she becomes an administrator, a guide, a policy analyst, a visionary. A doctor’s profession is an incredible melting point of careers. Unique, interesting. And above all, serves humankind like nobody else.

And what did it all come to? Running around like a dog completing errands passed down to you in the strictest hierarchy ever. (It is called dog work, did you know?) Maybe learning a bit of medicine here and there, but if it is up to me, can I really handle a pregnant lady with eclampsia? Or a polytrauma? Will I be able to diagnose appendicitis in time? Am I doing the right thing even? What am I doing to patients? Does this hospital have anything? Are patients really being treated like shit or am I feeling so because I am treated like shit? What about IAS after internship? If this is how it is going to be, why would I even think of a post-graduation in medicine? Ah, I wish I could be in my bed. When did I last sleep? Should I really have taken an ECG on that guy before putting an NG tube like my PG asked me to and killing him? What salary do people in other states get when they do compulsory rural service? Heck, do they even do compulsory rural service? Will I ever get laid? If I eat this biriyani, will I be able to lose the weight after internship? Dude these 5th term students suck. They answer everything. Where did I keep that guy’s X-ray? What is the point of this education system? Am I mad? Is this life? Please stop this.

It is the system. The horrible horrible system. It needs to change. People need to change. India will never improve. Horrible corruption. There are only 20,000 PG seats for 65,000 graduates every year. And then there are foreign graduates too. Life is going to be a rat race. Everyone is behind money. Have doctors always been like this? “Noble profession” it seems. LOL. When there are so many patients, there is no way things can be better. Patient load has to decrease. Examination system has to change. It is just this one year of internship. If I survive this somehow, that would be the end of all pain. Well, maybe 3 years of PG also. But why do PG? What is the point? Does it stop anywhere? They say MD Pediatrics is not enough because “it is saturated field”. Super specialization. Super super specialization. And to do what? Or like my friend, I should also try to go outside the country. They say Australia has too few doctors for their population. One thing is for sure. This system sucks. I don’t want to be anywhere near it.

Woah, woah! Hold on for a moment. I thought this letter is going to be an answer to my confusion. I know what the problems are. Do you have an answer? If no, please ***k off so I can move on with my ***king life.

             *        *         *

Dear Intern (or medical student),

Hang in there. You have done so well. You will keep doing well. Don’t forget, you have a gift – you think!

Let me quote you Kabir.

सुखिया सब संसार है खाए अरु सोवै।
दुखिया दास कबीर है जागे अरु रोवै।।

Now I don’t know what Kabir meant by it. But what I read is this: “The entire world is happy – ate well and slept; but Kabir (you) is sad – up and crying”

Woken up and crying. That’s what you are. And guess what? That’s the first step of enlightenment. Gautama Buddha was a happy prince in a palace till one day he went out and saw suffering in his kingdom; Gandhi was sitting in first-class before he got kicked out; Greta Thunberg should have been in school this Friday, but she saw wildfire in Sweden this summer.

Woken up. Different people get woken up at different times in their lives. Devi Shetty apparently after meeting Mother Teresa. Steve Jobs had Zen Buddhism on LSD. Some don’t wake up in their entire lives. So what if you are in medical school? You have been woken up. And now there is no going back to sleep either.

I have got some very good news for you.

The first good news is that you are at the lowest point in your life. How is that good news? Well, because the only direction you can go from here is “up”. And that is where you are going to go.

The second good news is that you are not alone. There are not many people like you, but there are people like you. They are variably called as “crazy”, “whack ass”, “visionary”, “odd”, “interesting. hmm.”, “crazy”, and so on (depending on who is talking about them). There is no easy way to find them though. They could be in your batch, in your college, among your professors, in a forest, sitting at home, they could be anywhere. They could even be writing blog posts to their juniors.

It is difficult to find them, but if you find them, you are family! There is very little need to talk about what you are going through, because they know what you are talking about. And they can feel your pain. And they want you out of it as soon as possible. And out you will be, shortly. Because there is a better world out there.