Blissful Life

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

Author: akshay

  • 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.

  • Why I Write

    Subtracting the dates, I have been blogging for more than 9 years as of now. That is not a big number considering how blogging was mainstream years before I began. Neither have I written a lot by quantity.

    But I have been writing. I do not remember if I had any specific idea in mind on what to write about when I began. I was pretty new to the internet when I began. And I thought everyone who used internet maintained a blog for their personal ruminations.

    I always had things to write about. Be it my take on things happening in the world, be it something new that I learned that day, be it a travelogue, be it a simple new thought. There has been times I was so engrossed in life outside that I have forgotten to write. Or times when I was too tired that I could not write. But never have I not written because I didn’t have anything to write about.

    For a long time, I did not care about the audience. My writings were mostly for myself and addressed at random strangers on the internet. I did not worry about who would be or would not be reading my posts. I was never concerned about the relevance of my posts. Because it was always relevant to me.
    Not much has changed. I now regularly post updates from me on Telegram and WhatsApp (check the sidebar on details how to join) but I am not worried about people not reading what I write. Because even today, I write for myself.

    I consider blogging to be documentation of one’s mind. In addition, I think writing helps clarify ideas for oneself. That clarity of mind is very important for me.

    A simple image I drew in Krita because without illustrations, people tend to get bored with long blog posts.

    I have been inspired by others writing. My favourite blogs had been zen habits, Scott H. Young, Study Hacks, BetterExplained, LifeHacker, Dumb Little Man, PluginID, etc. After my dad and My Experiments With Truth, I think these blogs have exerted the most influence on shaping what I am today.

    Unlike books, a blog keeps coming back at you. You read a book, you are deeply affected by it, and sometimes it stays with you throughout your life. But you start following a blog, the author keeps coming back to you with their ideas and influences forever (till you stop following). For those who read, what they read shapes them.

    And I read. I have read on the internet much more than I have read books. This could be bad. Because to write a book needs much more deliberation and therefore books by definition have more concrete ideas. But that is also a good point for blogs. Blogs are direct unfiltered thoughts from a person’s mind. They do not go through the censorship of acceptability or merchantability.

    And therefore multitudes of raw, sometimes radical, nevertheless vibrant and different ideas have entered my mind and some have stayed back.

    It is in the same spirit that I write. What use is a thought if it has not been shared? I may be redundant and be writing what others have already written about. But the collection of thoughts that I represent in my writings is unique.

    That’s the truth. I write to influence. Thoughts that aren’t expressed simply do not exist. If you care for something, you need to show that you care. And writing is my way of doing it.

  • The Sour Grape

    I have been told by at least one person (and I think many more might have the same idea) that “I have disregard for postgraduate entrance examinations and am working where I am currently working like it is something heroic because I find entrance examinations difficult to crack, because I’m incapable of getting a good rank, and I am just finding excuses that I can’t figure out what postgraduation to do, that I don’t want to lock myself in a garage to learn”.

    To them I would say, maybe you are right.

    Maybe I am an idiot.
    Maybe I barely passed MBBS.
    Maybe I should not have been a doctor on the first hand.
    Maybe I do not have the aptitude to crack entrance exams.
    Maybe I am not even smart enough to do the “right” things in life.
    Maybe I am stupid.

    But, guess what?

    I don’t care.

    My choices are entirely mine. My outlook is formed by my thought processes and I can live with the same. Maybe I don’t fit your definition of success. Maybe I don’t fit your definition of smart. I don’t care.

    It is my life. And I will choose how to tread it.

    If your idea of successful and smart is to eternally run behind happiness in a pattern that is set by the expectations of the community. Pity you. I am happy where I am. And I am confident of being able to find happy places throughout my life. I don’t need your free advice on what is the smartest thing to do.

    Do I sound arrogant? Well, that’s your problem to solve. Because if you feel like you have been smitten, it’s exactly you whom I intended to smite.

    You think I will learn myself? Yeah I will. I might some day come back and write entrance exams. But I won’t be writing it for you. I will be writing it for myself.

    I am in control of my life.
    Don’t try to wrestle that control away from me.

    You can try to unsettle me and shake my confidence.
    Well, thank you. But it doesn’t work on me.

    You know why?
    Because my strength lies in knowing what I am doing.

    My future is uncertain. But I’m comfortable with uncertainty.
    My ideas are abstract. But I can think in abstract.
    My philosophy is impractical. But I can make it work.
    You may be right. But dare you say I am wrong.

  • My Idea of a Perfect Electronic Medical Record System

    The COWs are coming to our hospital.

    No, not these. They’re getting more attention than they deserve.

    Our hospital might soon switch to an Electronic Medical Record system. And this will bring in Computer on Wheels, COW as they’re affectionately called in other hospitals.

    More like this

    While that makes me more happy about where I’m working, it also brings back a lot of ideas I’ve had during medical school. I have seen hard problems for humans that are pretty easy for computers to solve. I have seen processes that could be hastened by leaps and bounds if computers were involved even partially.

    The Perfect Electronic Medical Record System

    The perfect EMR does not just record what the physician or nurse puts in. It is an intelligent assistant that does some thinking of its own and comes back with suggestions and autofills for the physician or assistant.

    For example, when a child comes to you and her mother says she has fever, you start entering “fe…” and the EMR autofills fever. Next you can enter the duration from a dropdown menu. Also associated symptoms can be ticked “yes/no”. As you’re done and move to the next row, the computer automatically populates an entry – “Cough? Yes/No”. If you choose yes, it asks you for characterization.
    If at any point you’re in doubt or do not want to characterize a symptom, you can just delete the autosuggestion and move on to the next line.

    Once you are done with the symptoms and exhausted the negative history that the smart EMR suggested for you, you can enter the examination findings. Again the EMR will suggest for you the most important findings you should not forget to look for based on existing data on what the most common findings are for that particular set of complaints.

    Later, the computer will show you a list of provisional diagnoses based on the data you’ve entered about the patient, and the past set of data the computer has, and even the compendium of knowledge that it potentially has access to. You can reorder the diagnoses if you like.

    Accordingly the computer will suggest investigations and management plans with dosages calculated according to weight or dosage adjustments that are required for special conditions.

    The computer will always suggest and ask you for guidance when in doubt. You can always override the computer, but you can also take computers help in not missing important things.

    Such a system might not be useful for an expert clinician, but it will definitely help a new doctor in emergency rooms late night. Most importantly, the system makes sure that an exhaustive history taking and examination has been done. It also helps in making clinical decisions based on data and evidence.

    Impossible?

    Certainly not. I just discovered that Dr Lawrence Weed, MD has been saying this exact thing since years. He might even have developed such a system already. But EMR systems do not seem to have this kind of intelligence integrated yet.

    The accuracy of simple software powered by big data like Akinator is testimonial to the power of computers when it comes to problems like this.

    Clinical decision making is no holy grail and it will soon be heavily relying on, if not replaced by, artificial intelligence.

    Pictures courtesy pixabay.com

  • Joining Swami Vivekananda Youth Movement

    Till yesterday, I had thought that I had joined Vivekananda Memorial Hospital.  But, yesterday there was an orientation session for new employees at this organization. And the events made me realize that I have indeed joined, or want to join, Swami Vivekananda Youth Movement, the parent organization of VMH.

    SVYM’s story is very heart-touchingly written in the blog of Dr R Balu (RB).

    I am not aware of any other organization which has the story of its inception so beautifully and lucidly laid out. RB’s experiences that led him to start SVYM are relatable. And he has made it possible to connect dots from those strokes of inspiration to the concrete structure that exists today.

    But Dr M A Balasubramanya nevertheless described the same in a couple of hours yesterday. Some of his words dug deeper than I expected them to go inside my mind. I was expecting him to speak about how they had to undergo a lot of hardships and struggle to reach where we are. He did. But I wasn’t expecting to shake my mind and say that SVYM now has presence throughout Karnataka and caters to lakhs of people under education, health, community empowerment, research, training, and ultimately development and achieved this growth over 32 years by not faltering even once from its core values of “Satya, Ahimsa, Seva, Tyaga”. It sent depolarizations through some of my old neurons.

    We had a brief on organization policies, accounting practices, etc.

    After lunch, we went on a long trip to Kenchanahalli and Hosahalli campuses where other activities of SVYM happens.

    Kenchanahalli is on the verge of being converted to a centre for socio-economic empowerment program.

    And Hosahalli! Hosahalli is a beautiful campus in 24 acres. There is Vivekananda Teacher Training and Research Centre here. And befittingly, the tribal school right next to it. Dr Ramkumar who works there rightly puts it. After years of working in Bengaluru and other places,.  they come here with lots of experience and every day they face a new challenge. The tribal kids have their own culture. Their language is different. Their aptitudes and attitudes are different. There is sometimes more to learn from them than to teach them.

    Challenges like these, and the motivation to work with principles to overcome these challenges on a regular basis is what makes SVYM truly special

    Take this example from Vivekananda Memorial Hospital.

    VK is an 11 year old boy who got admitted with Diabetic Keto Acidosis. We were counselling him and his mother regarding the importance of strictly taking insulin, even while in school. And we were concerned about them being not able to recognize and treat hypoglycemia. The mother was in fact very much aware of hypoglycemia and apparently she used to manage it at home using sugar water.

    “But who will make sugar water for him at school, ma?” we asked her. She gave a blank smile.

    We gave our usual advice. “So, keep a sweet something in his pocket so that even at school when he feels symptoms of hypoglycemia he can eat it”.

    She smiled and said “My boy is just a kid. He will eat the sweet whenever he likes.”

  • Rekindling Ambitions

    On the eve of independence day in 2013, I wrote this post
    which was about keeping ourselves safe from getting involved
    in situations where doing good might be bad. I grew more and more
    pessimistic about life and people around me since then. Going through
    the comments section of any news item would put me in a state of teeth
    clenching aversion towards fellow country men.

    I was not like this. I was patriotic. I called myself ASD of India. I believed in people like Dr APJ Abdul Kalam when they said that it’s possible to do anything if we have a desire strong enough. Swami Vivekananda’s words “Arise, awake, and stop not till the goal is reached!” would make me determined to succeed.

    My schools were the best. They never taught me the meaning of impossible. Everything seemed possible. Everything seemed interesting. Everyone was involved with the same spirit.

    But college was something entirely different. Suddenly, I was exposed to the bad, and sad sides of humanity. Not just in the immediate surrounding. Newspapers suddenly became sources of bad news. In fact, I quit reading newspapers entirely. They were becoming too negative for me. Or was it that I was too weak to face the reality? Maybe. But I could imagine alternate realities (or fantasies) in which people are far less corrupt and far more content. I could imagine spirited colleagues. I could imagine living in a better society.

    For some reason, I assumed that those were just fantasies. I grew too pessimistic. I assumed that honesty will never win and that as time goes on, things will get only worse. I figured that we were doomed. I knew that there was no future for humanity.

    This negativity has contributed more than a little to my decision not to run behind a post graduate seat. I had already grown sick of the education system much before I grew sick of the entire system. I was not going to spend any more time in that toxic environment that’s called “college”. Any college.

    I was clueless on what to do when I joined Vivekananda Memorial Hospital. It took me more than a month, but now I’m finally beginning to understand.

    Yesterday, there was an orientation session here. VMH is run by Swami Vivekananda Youth Movement. The CEO of SVYM, Dr MA Balasubramanya gave a speech in the orientation session. He ran through the history of the organization. The values of SVYM is “Satya, Ahimsa, Seva, and Tyaga”. SVYM does an incredible amount of good work in Karnataka. And it started from two batches of students of MMC. It has taken 32 years for this organization to become what it is right now. And it hasn’t paid a single rupee in bribe to reach where it is.

    The most important thing that he spoke yesterday and that hit me hard was that it was indeed possible for honest people to survive. That it was indeed possible to do good things. That good people do, in fact, exist.

    I have a theory of love. When you fall in love with a person the first time, there is a component of infatuation. Once you grow beyond that, you start to see imperfections in your partner and stop loving them as much. But there is a certain moment in the relationship where you fall in love with the same person again. The difference is that this time, you know all the positives and negatives of your partner and you are loving the whole person. This newfound love is unbreakable. Because you have accepted all the bads of your partner, there is nothing new that can change your love.

    I think I should now apply the same theory to ambitions. Initially we go through the rosy feeling of the entire world being full of possibilities and unlimited potentials. Then there is a rough patch in which you grow tired and weary, and forced to give up. It was only when I had given up and threw my hands in despair that I got help.

    If I had ever been able to believe in mythical spirituality, I’d have called it Swami Vivekananda’s infinite power. Otherwise, what can explain the coincidence of my first love of the world be propelled by Swami Vivekananda’s books and now, my rekindled love of the world be propelled by an organization that lives by his name and values?

    Positive thoughts come to you when you are surrounded by positive people. Fortunately, I’ve come to such a place. Now is the time to ride the wave. Expect more.

  • VMH – first few days

    Getting to Saragur from Mattanur is a tricky business. The shortest
    route isn’t necessarily covered by public transport. My initial plan was
    to reach Mysore via Virajpet-Hunsur and then take a direct bus to
    Saragur. But later, I dropped it in favour of what my mom suggested –
    get down at Hunsur and take a bus that cuts through the corner.

    So
    I did get down at Hunsur. Turns out, in Hunsur there are two KSRTC bus
    stations. One is for urban buses – the one I got down at. The other,
    inter-village rural bus service, is where I would find buses to Saragur.
    Luckily it is walkable distance between the two stations. At the rural
    bus stand, there was a bus to HD Kote. It’s 11 more kilometres between
    HD Kote and Saragur. But there was no direct bus to Saragur. So I got
    into the HD Kote bus.

    And that was the slowest bus
    ever. It stopped at every house and couldn’t accelerate faster than a
    turtle. At HD Kote bus stand, there was a city bus going to Saragur
    waiting for me. This one was faster, yet slow.

    Thus, I
    reached Saragur at 1.30. Half an hour late on schedule. Took an auto to
    Vivekananda Memorial Hospital. Ms Latha was waiting for me. She welcomed
    me and arranged my stay in the guest room next to the canteen (on the
    way to doctor’s quarters). Although it is shared accommodation,
    currently I am the only one in my room. I quickly freshened up and
    reached hospital.

    Said hi to Dr Chaithanya Prasad who
    was in General Medicine OPD and whom I had met last time I came to VMH a
    couple of weeks back. He asked me to get introduced to others. So I met
    Dr Sitaram in Orthopaedics OPD and Dr Sridharan in Paediatrics OPD. I
    also had to introduce myself to Dr Narendra whom I had met last time. I
    couldn’t find other consultants. Then I reached Casualty were Dr Susan
    was writing something in a case sheet.

    She is also new
    here. We spent some time seeing patients and talking about the hospital.
    Later, at 4, there was a meeting of all RMOs. They were talking about
    mobile units, their functioning, any problems they are facing, etc.
    Small corrections to duty roster was also being made. I was asked if I
    could manage emergencies and assigned to Kenchanahalli for Friday night.

    After
    that there was rounds. After rounds, I sat in casualty for some time.
    Then, when I was about to leave, Dr Susan was taking a case for next
    day’s grand rounds.

    Wednesday morning, sharp 8 am.
    That’s when grand rounds begin. All doctors come around a case that is
    being presented. Today’s case was a lady with pregnancy induced
    hypertension and anemia. Dr Susan presented the case under the
    mentorship of Dr Padmaja. There was a brief discussion on the management
    of such case and the failures in ANC.

    After the case
    presentation there was journal club in training hall where various
    people presented different journal articles. Dr Shreyas presented his
    own research on obesity and vitamin D levels. Dr Jyothi presented a
    study on thyroid disorders in HIV patients. Dr Dennis (?) presented on
    National Health Policy. The National Health Policy topic is so vast that
    it was not even half finished at the end of the given time.

    After
    the presentations there was an announcement that a community dinner is
    being planned the next night where we would cook and eat ourselves. I
    volunteered to bring firewood and start fire, along with John, Eric, and
    Shubham. Others volunteered for preparing various dishes.

    Afterwards
    there was rounds. And after rounds I went to casualty. I also sat with
    Dr Haripriya who had asked on the previous day to read the medical log
    book of an HIV patient to figure out what the striking points of his
    history was. We discussed this along with Shubham and found various
    points like the low adherence, the weight variations (or lack of it),
    etc.

    That evening Dr Padmaja, took the firewood
    volunteers away from rounds to find out a place for the oven. John is an
    expert in fire making. We found a place close to Dr Prashanth’s
    residence. The group of Bengalis who worked at the hospital was also
    staying right next to that place. They helped with the firewood and also
    with setting up the oven.

    Then, I got a call from Dr
    Prashanth who would demonstrate bladder wash on a patient who needed it
    every day for me. Since Dr Prashanth would go on a 10 day leave the next
    day, I had to do the bladder wash to make sure this patient’s catheter
    wouldn’t get blocked. Unfortunately, this patient’s condition worsened
    the same night and he was referred to KR Hospital because we suspected
    perforation.

    I tagged along in the casualty that night
    with Dr Susan and Dr Jyothi who were having tag duty. Had late night
    dinner which Dr Shivambika prepared. Then went back to my room to sleep.

    Thursday
    morning we woke up at around 5:30 so we could complete the 5 procedures
    that were pending – three lumbar punctures and two pleural taps. I did
    one of the lumbar punctures.

    After rounds, had to take
    care of orthopaedic and surgical patients too as Dr Prashanth was on
    leave and he was taking care of them before. I was feeling slightly
    disorganized and tense during this day.

    Later, in the
    night, I went to the community dinner. Fire was already taken care of.
    Cooking was half way through when I reached. Chole was being prepared by
    the Shubhams when it began to rain. And boy did it rain?

    We
    had just gotten things to safety of the guest house next to Dr
    Prashanth’s when the rain started becoming heavier and heavier. Some of
    us had run to the Bengali settlement to see if making Puri would be
    feasible. But by then rain was too heavy and we had to abandon that
    plan.

    When the rain finally finished taking its toll (including several people who slipped and fell in muddy water), we organized in the guest house and started eating whatever we had already prepared.

    It was a merry night with mimicry show by Bharath and training in deadly combat skills by John. The carrot halwa was superb and so was the fruit salad. I slept very happily that night.

  • Joining Vivekananda Memorial Hospital, Saragur

    I joined Vivekananda Memorial Hospital as a Resident Medical Officer, on 18th April, Tuesday, around noon.

    VMH is a secondary care hospital started by Swami Vivekananda Youth Movement at Saragur which is a place almost 1.5 hours by bus from Mysore, but just one hour by private vehicles.

    There is a one year course called Fellowship in HIV Medicine offered by this hospital and educational institution that I plan to join later.

    I had visited this place a couple of times earlier. First as an attendee in a research workshop back in my second year of MBBS and then, in the first week of April, as a prospective student and employee. At both times, I have felt that this place works in a well organized way.

    I am sure this place will help me become a better physician and a better person.

  • Losing an Ear-Tip

    “Which is the most important part of a stethoscope?” asked the Professor.
    “The diaphragm”, “the tube”, “the earplugs”, came answers from students.
    “No. The most important part of a stethoscope is the one between the two earpieces”, said the Professor with a smile. 1

    It was a regular “free” day in Orthopaedics. That means you get to eat either breakfast or lunch. I ran to ward at 8:15, after gulping down a cup of milk shook with the chocolate malt powder that my grandmother lovingly packed for me the last time I went home.

    None of the patients had absconded the night before. Which meant all of the five 70+ year olds with femur fracture where sleeping comfortably on their bed. Only those patients whose perpetual complaint of pain were awake. Even tramadol would not help them. The nurse had just arrived. And I started putting notes, as usual.

    All the patients looked alright. So, there was no need to check their pulse. I checked the blood pressure of a couple of the patients who had surgery just a few days back and entered in the respective notes. Rest of the notes would remain the same as the day before. On one side, all the organ systems would be marked normal and the limb would be marked as having active distal movements. On the other side, the advise for the day. Two antibiotics compulsorily bought from outside even if the hospital supplies the same combination. One painkiller. Paracetamol infusion SOS. And a little something to stop these drugs from punching holes in the bellies of these grandfathers.

    Before I finish putting notes for half the patients the post-graduate students would reach and start dressing. Depending on the mood of the nurse she might join in helping them dress the wounds or stay aloof lost in their own tasks. If a student nurse is found standing still for a second, they’re invariably pulled into the business of taking out “sterile” cotton using a “sterile” forceps and placing them on the “sterile” gloves of the doctor who carefully places them on the wound that has just been cleaned of all the dirty pus and other gross stuff that accumulate in wounds.

    I sometimes do seriously wonder whether it is the over-priced antibiotics and the over-done sterile dressing that help the patient or the innate immunity of the patient themselves.

    Anyhow, post dressing, there was rounds. Where each patient is seen and discussed briefly. If you are ever admitted as a patient, remember that rounds is the most important time of your hospital stay and treatment. Almost the entirety of the planning of your management happens during this brief encounter between the doctors and the patient. If there’s something that bothers you, you better keep repeating it to yourself to blurt it out during the rounds.

    During rounds some orders would be made. Ha, get another X-ray done on this knee. Get the side view. Get the distal joint. Easy enough. The patient can’t walk. Sometimes, they can’t even sit. So you would need a trolley. But they aren’t motorized yet. So you need a worker to push. And that’s the most difficult part. You have either one or two workers at your disposal. And they have to do all the work in the ward beginning from cleaning and not ending at making sure everyone’s shaved and prepared for surgery. It’s largely unknown how they set their priorities. They might help your patient get an x-ray. But that might not happen before noon. Maybe they can be bribed into getting it quickly. But should you pay or should the patient? There are no clear answers. The best way forward would be to tell them and remind them and ask someone else to remind them and then come back and confirm they’ve indeed done what you’ve pleaded them to. And that’s what I did.

    It was past lunch-time when I finished ward work. So I went to Ruchi mess for lunch. That’s the one our ortho post graduate likes. Food is really important in orthopaedics. If you don’t eat some chicken bones, you can’t fix broken bones. After food, I went back to hostel. Because there was no point going back to hospital in the afternoon anyhow. It is not like any work will get done because you are there. So you might as well go back to hostel and enjoy the rare few free hours you find.

    Going to hospital during dusk is comfortable. You don’t have to wear shoes. So you don’t have to wear the socks that haven’t been washed in weeks. You can wear jeans if you like. If you think you’ll need it, take a stethoscope. And that’s the biggest mistake I did that day.

    I took my stethoscope. And I put it in my trouser pocket. And I rode my cycle to the hospital. I was pretty sure the stethoscope was fine when I left. But when I reached, and put the stethoscope around my neck, it was missing an ear-tip. Yeah, the black round cushions at the tip of the steth that makes them wearable. I imagine these preventing a hole from forming on my tympanic membrane when I wear a stethoscope.

    So I lost an ear-tip. And there’s no wearing a steth without the ear-tip. Without a steth, you can’t measure BP. (Not really. That’s a myth intentionally spread to make interns feel good about having to measure BP. I am the only one with the steth. Only I can measure BP. I am doing valuable work.)

    I knew it was going to be a sad day. Because misfortunes do not come singly. This would be the beginning of a series. I was pretty sure there were more things waiting for me in the hospital.

    The hospital was calm. As usual. There were not many people in the ward. At least, none of the patients had a family of 20 around the bed. THat’s a good sign. Because if there’s a family, there’ll always be a family guy among them. And he will definitely have a couple of questions about “is my relative going to get better?”, “why is the pain not going down at all?”. These are questions that do have answers. But I wouldn’t want to give those answers. I would just want my work done.

    Turns out the x-rays were all done. I don’t know who paid whom. And almost everyone was “fit for surgery with low risk” from medical side. And nobody had any complaint. Nothing was wrong. That means, I can report to my seniors that everything is spot on, and go back to hostel and have a good night’s sleep.

    If only I hadn’t lost the ear-tip. Because I might not have needed the steth today, but I’ll definitely need it tomorrow. Maybe I had a couple of spare ear-tips in the box that came with the steth. Hmm, anyhow I didn’t have the energy to go to a surgical shop to buy a new set. So the spare set better be in the box. I just cycled back to the hostel.

    And on the way, just as I crossed DD Urss road, about 400 metres from the hostel, there was something black on the roadside. I stopped my cycle and took a closer look. It was an ear-tip. My ear-tip. Maybe a few cars went over it. But it’s not broken or anything. I just have to clean it with spirit and put it back on, like nothing ever happened. Happy. My stethoscope was happy. I was happy.

     1 This joke probably originated in Trivandrum Medical College because it was my dad who told me this. It’s also documented in this article in The Hindu.