Blissful Life

Category: fhm

  • The Art of Setting Up Success

    What makes a great surgeon? Do they have long fingers? Or steady hands? Or the heart of a lion?

    I think it is the preparation they do right before they make the incision.

    In VMH, I would be assisting various surgeons, especially Dr MR Seetharam in orthopedic surgeries. MRS is very methodical in preparation for a surgery. Every surgery is different. One might require an expensive equipment, or a team of skilled surgeons. The patient might have severe comorbidities that make post-surgical management difficult. The economics might not work out. Functional recovery maybe more important. There are many factors that go into choosing the right kind of surgery for the right kind of patient. MRS will be thinking of all these as soon as becoming aware of someone who has an issue. But that’s not the preparation I’m talking about.

    Inside the operation theater, with the patient and others eagerly waiting, there’s a final and crucial step of preparation that MRS does. The X-rays are put on the viewer where it can be seen from the operating table. Another look is given at the X-ray to review the approach and the location of the fracture fragments. The fractured part is positioned with great attention to allow the views and manipulations that would be required later during the surgery. Extra tables are brought in if so required. The position of each assistant is decided. All the props are set up exactly where they have to be. The C-arm (A C-shaped X-ray machine that can be rotated around the patient during the surgery to see the bones and the implants near real-time) is brought in and out of the field to ensure there are no hurdles. A shoot is made in each position that the part would be during the surgery to be sure there is no obstruction in the C-arm’s view. All the implants and instruments are reviewed to make sure they’re right. The assistants are warmed up on the procedure and the tools that’ll be used. The success of a surgery is decided before the incision is put.

    That last sentence might sound like this speech by Harsha Bhogle. Or the saying “The more you sweat in practice, the less you bleed in battle”. But I am not talking about the years of dedication one puts in before one becomes a fine surgeon.

    I am specifically talking about the setup. Take this example of a setup for arterial blood draw.

    Depends I think. If you’re crammed between the wall and the ICU bed on an obese hypovolemic patient whose diaper you cannot remove completely and you’re drawing the femoral artery with a plastic syringe not meant for it, should be sufficiently difficult.

    — Akshay S Dinesh (@asdofindia) December 31, 2020

    That is a setup for failure. If one compromises on the setup, they would often have to compromise on the result as well.

    * * *

    What I realized as I was writing this is that I tend to compromise a lot. I don’t know whether I do it as a way to challenge myself so that I feel good about myself if I luckily succeed. Or because I’ve not learned how to negotiate better. Or maybe I don’t know what I need. Or maybe I don’t think. Or maybe I think being accommodating is a virtue.

    Perhaps accommodation isn’t a virtue. Perhaps if you don’t ask for the right working conditions, you’re going to end up being ineffective and lowering the standard all over.

    But you’re never going to have all that you need. “You’re going to have to compromise” is the folk wisdom. It’s difficult to imagine having everything I need. That’s a contradiction.

    Perhaps then my core premise is wrong. It is probably not about the setup. Or maybe it’s a bit of everything. Maybe I’m partly right.

    Maybe you can compromise on the setup if you can compensate with your skill (or luck). Or maybe that’s too much strain on you.

    I don’t know. Maybe I’ll have clarity later.

    PS: I was wondering whether to make the latter section “PS”. But maybe that’s the script. It’s a blog, after all.

  • Lumbar Puncture and HIV

    Lumbar puncture is a fascinating procedure. It is cheap, it can be done in relatively remote places, and it can be learnt easily given access to enough people who need it.

    LP has an incredible role in the management of many complications related to HIV. I’ve heard stories about how there used to be 5 LPs done every day in VMH during the time when HIV was causing rampant destruction in Karnataka and India. When I was there, we would do about 5 in two weeks. Nevertheless, when a colleague asked on Twitter about CSF analysis, I thought I should write down some of the things I believe to know about Lumbar Puncture itself, especially in relation to its use in management of complications of HIV.

    The first many LPs I saw were all done for spinal anesthesia in KR Hospital. Till then all I knew about spinal anaesthesia was a friend’s description of the back ache he had post a “cool” hernia surgery because they had “poked many times for anaesthesia”. I think I hadn’t really thought about it till I was doing my anaesthesia rotation during internship. The first LP I did was also done during the same time – the “pop” and being in the space that you can learn only by doing. (If anyone thinks that all knowledge is codifiable like I do, here is what it feels like. Imagine there is a thick plastic layer laid around a piece of rusk. Imagine your needle piercing through the rusk and then splitting open the plastic layer. Now you are in the space.)

    The first time I saw an LP done for diagnostic reasons was in the medical emergency ward of KR Hospital where a young patient with some sort of neurological condition was being pinned down to the bed by 4 people and the postgraduate resident was dancing with the needle along with the squirming patient. Despite the grotesqueness of the picture, I found it incredible that 20-40 drops of a particular fluid can be so valuable in diagnosis.

    I learned the reasons when I was in VMH. There were many “spot” diagnoses we made using LP:

    1) Perceived high opening pressure in an HIV infected patient with neurologic symptoms – we send for cryptococcal antigen and it is almost certainly positive. (Always use Cryptococcal antigen test. Indian ink looks fancy under the microscope when it is positive, but is not as sensitive)

    2) High lymphocytes and proteins – you can keep your various tuberculosis diagnoses active. But even otherwise, you can’t rule out TB ever.

    3) RBCs and you can suspect sub-arachno… Just admit that you did a traumatic tap.

    But LP was mainly used for ruling out the infections. It is very simple to miss CNS infections in HIV infected patients. For example they will come with vomiting and you will examine their mouth and see oral (and possibly oesophageal) candidiasis written all over it. But rather unknown to you, they might also be having cryptococcal meningitis.

    It might be difficult to treat cryptococcal meningitis because Flucytosine is not something you find easily in India and therefore you are stuck with Fluconazole and Amphotericin B and good luck to you if you plan to give the latter in peripheral venous lines. (I’m not sure if the liposomal variety of Amphotericin B doesn’t cause as much phlebitis). But cryptococcal meningitis is a diagnosis you do not have to miss, if you are doing LP.

    It is a messy thing, but it is a life saving diagnosis. I’ve seen one patient die during the treatment, even though we were doing regular therapeutic lumbar punctures to reduce the intracranial pressure. But I’ve seen almost everyone else survive (including the case where I had to take PEP). I’ve also heard a very inspiring story from Dr Ramakrishna Prasad about a patient whom everyone else had given up on, coming back to life after switching over to the liposomal variety.

    A (thankfully) much rarer thing is HIV CSF escape syndrome. Hearing about this for the first time is when I realized which peak of the Dunning-Kruger effect I was on. You see, the blood brain barrier is a real thing. And not all of the HIV drugs cross this barrier the same way (paradoxic?). And therefore there are patients who can have no virus in their plasma, but if you do a CSF viral load test you will have a real surprise waiting.

    A not so uncommon thing which can be diagnosed through CSF is neurosyphilis. I always have to read the guidelines three times about when to use a VDRL test and how much to rely on it, but this is a test that we used to do as a protocol while doing an LP in HIV infected.

    Things like gadolinium enhanced MRI are becoming more useful than CSF analysis in diagnosis of things like tubercular meningitis. But from what Dr Rahul Abraham once told a group of us about his experience with MSF in Bihar, lumbar puncture will remain with us till the end of the HIV pandemic.

  • 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

  • Patient Inclusiveness in Rounds, Sex Between Serodiscordant Couples, Role-plays, PrEP, PEP, Anti-Retroviral Drugs, Drug Resistance, and what not!

    This weekend was fun! I am grateful to a lot of people for it being so.

    It started Saturday morning with grand rounds, as usual. We were joined by Dr Ramakrishna Prasad (RK), Dr Ashoojit, and Dr Praneeth Sai. RK was leading the rounds. And he introduced the concept of patient/family centred rounds wherein we include the family in the discussion and make them feel a part of the process.

    That meant I talked to the patient in front of everyone and let him describe his problems in his own words. This allowed gleaning certain facts of his life that were also much useful later in the day while talking about other aspects of care in HIV.

    What followed was journal club by Dr Swathi in the training hall. She presented “Living with the difference: the impact of serodiscordance on the affective and sexual life of HIV/aids patients” a topic that greatly interests her.

    They interviewed 11 carriers and based on the theme of sexuality after HIV infection between serodiscordant couples found four topics articulated:

    1. Fear of Sexual Transmission to the Partner
    2. Sexual Response Alterations
    3. Sexual Abstinence
    4. Sexual Life Maintenance.

    Based on this experience, there was a role-play session where Dr Praneeth volunteered as an HIV positive patient and I as his spouse and Dr Swathi would counsel us about our sexual life.

    That’s when the groundbreaking reality of U=U was introduced by RK. Apparently, studies like HTPN 052 has shown that when the viral load is undetectable as a result of ART, the virus is untransmittable! This must bring great joy to serodiscordant couples who have been having poor sex life after diagnosis.

    With that in mind, the role-play went ahead in letting the couples know the latest science and choose what they like to do going ahead – abstinence, safe sex, or unprotected sex. (Of course keeping in mind that other STIs can get transmitted through unprotected sex).

    Then we spent about an hour discussing on thesis topics that we would want to work on for our fellowship using frameworks like the logic model and SMART criteria.

    I had fancied the concept of using technology (phone alarm) to improve adherence to ART. Based on that initial concept our discussion took us to a mixed method study on the pattern of adherence, associated demographics, need for adherence support, and factors for poor adherence because we thought there is no answer to these questions in our setting. [I can imagine myself interviewing patients admitted in the ward probably due to an opportunistic infection they got as a result of poor adherence leading to poor immunity, trying to draw themes on the reasons why they don’t take medication; and also probably finding correlation between parameters and good adherence]

    Next, Dr Swathi finalized that her study would be on the topic of sexual life of serodiscordant couples. She would find out the fears these couples have. She would also take the latest science (U=U) and collect reactions.

    Dr Praneeth would be working on PrEP and PEP, how counselling improves the rates of PEP or PrEP, their effectiveness, and so on.

    We all agreed on a rough timeline – two months for proposal and ethics clearance. Two months for data collection. Two months for thesis writing. And then we had lunch.

    The initial schedule for the evening was theory classes by RK on various topics which he morphed a bit into Feynman technique of learning. We were asked to take up a topic and explain using the white board. And whenever we hit a roadblock he would come up with answers/questions that would help us understand the topic or the lacunae in our knowledge. (One of the many inspiring techniques RK would demonstrate in these two days).

    Swathi went on with acute HIV. How does acute HIV look like? Can we diagnose HIV based on symptoms? How soon can we diagnose it? What is the natural history of HIV like? (The graphs we had to come up with showing CD4 count and viral load over time in HIV, merit a post of their own)

    Then I had to talk about anti-retroviral medications. I tried to draw the lifecycle and then explain where the various drugs acted at. And then, while trying to give examples for each class, did I realize that I knew very few ARVs. TLE, ZLN, over. There seems to be a world much beyond just these.

    On demand PrEP vs Daily PrEP. This was what Dr Praneeth talked about. He’s been behind PrEP and PEP for a while as evident from his research interest. While I had no idea about Pre-Exposure Prophylaxis (PrEP), let alone the different modes of administration. Anyhow, here’s an article that says on-demand PrEP is as effective as daily PrEP.

    Next, Dr Ananth introduced PRIME theory of motivation in the context of smoking cessation and we did a little role-play on a smoker and doctor counselling them to quit.

    Sunday morning Dr Ashoojit and Dr Praneeth joined rounds and we listened to the stories of two patients – one who had their son living separately for the fear of catching the disease, and the other who had the story of TB but just not the evidence

    Then we had a test.

    1. Sita, 26 y/o F, from HD Kote, presents to SVYM after she finds out she is pregnant (LMP 4 months back). Married 6 years back. Husband: Construction worker. Her HIV ELISA returns as REACTIVE
      How will you approach her care?
      – Key history & examination
      – Investigations
      – Counseling messages
      – Therapeutic interventions
      – Health promotion/disease prevention
      (3 marks for each point)
    2. Her husband, Ravi, is 31 y/o M. Further questioning reveals that he is known HIV Positive, but never told Sita. He says he got it from an older married woman he was sexually active with in the past. He was diagnosed at age 28. Reason for testing: Wt loss (10 kg) (Wt at diagnosis 54 kg), oral thrush. Initial CD4 count: 76. Treated with TLE. Denies alcohol use, reports never missing his doses. <A graph with CD4 count showing improvement in the first year of treatment, till 154, then falling back to 38 by 3rd year. Corresponding fall and rise in weight>
      – Develop a problem list (2 marks)
      – Choose 1 clinical hypothesis that is most likely to explain the clinical picture (2 marks)
      – What investigations would you like to send for? What results do you expect to find? (6 marks)
      – Given your knowledge of the husband’s case details, will you manage Sita’s care differently? (5 marks)
    Here’s the much more beautifully laid out original

    We wrote answers to these questions in half an hour and self evaluated. A discussion ensued on what each person missed, and what each person wrote. This was fun as well as thought-provoking.

    And then, Dr Varsha took the fastest and most interesting 15 minutes of the whole weekend to talk about genetic mutations and drug resistance in HIV.

    Screengrab of the Stanford HIV Drug Resistance DB

    She was evidently excited about the Stanford HIV Drug Resistance Database and talked about 3 mutations that she wanted us to read about – M184V, K65R, K103N. Her explanation of what protease does, and how NRTIs and NNRTIs act opened my eyes to a whole new world of possibilities.

    There is more to write about each things I have mentioned here. Maybe another day. Do reach out to me if you’re impatient.

  • 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.