Blissful Life

Category: medical

  • 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.

  • Lessons One Should Learn From Shehla Sherin’s Death

    If you do not avoid news like me, you would have heard about the tragic death of a 10 year old in Wayanad a couple of days ago. You can search the name and find the story on your own, but a few facts are established already.

    1. Shehla Sherin had her foot go into a hole on the floor of her classroom and was afraid a snake bit her in that incident
    2. There was delay in taking her to the hospital
    3. Anti-Snake venom was not administered at the local hospital, and the child was referred to a tertiary care center at least an hour away.
    4. Child died on the way.

    I won’t unnecessarily go into speculations on what other things happened on that fateful day, but having managed emergency department in a rural hospital for over an year, I will use this sad death to illustrate two very important lessons for every doctor.

    Lesson 1: Never take any complaint lightly, even if the circumstances lead you to think otherwise

    There are two ways patients can come in. There are people who exaggerate, and people who downplay. Take all symptoms seriously.

    There are no insignificant complaints. There are no insignificant findings. Whatever the patient tells you has to be taken seriously. Even if the patient asks you to not take it seriously. At the height of experience and confidence you might be able to predict that something isn’t as serious as it sounds, but be really really careful before making that decision.

    I had once a patient come to the casualty with a swollen foot. The patient had intellectual and speech disabilities and therefore there was no proper history. The bystander (who apparently takes care of the patient) told that “someone must have hit him”. My colleague suspected a snake-bite because of the way the swelling looked, but nevertheless ordered a whole blood clotting time test and a foot x-ray to rule out a fracture. My shift was about to start and while I was taking charge from my colleague I inspected the foot of this patient closely (in the x-ray room). I could see two small points of bleeding close to each other – fang marks!

    We immediately told the bystander that this is not “someone must have hit him”, it is a snake bite, and that the patient will die unless something is done immediately. This bystander did not look like they liked the patient very much because they asked me “please do whatever you can here itself, don’t refer us to higher center”. We knew that the best we could do was given anti-snake venom (which we immediately started doing) but the patient might require blood products which weren’t available and required referral. So, we took a stand and sent the patient as soon as the ASV went in.

    There was this other patient who came at noon on a different day with severe chest pain, as if he was going to die the next moment. He was a smoker and alcoholic with a very good chance of having a heart attack. He wouldn’t even lay still for us to get a proper ECG, and whatever leads we could obtain looked like there were ST elevations all over. The MI protocol kicked in, we gave all the painkillers, anti-coagulants, and sent the patient to the nearest cardiology center. News later was that he was just having severe gastritis due to alcoholism. But, we did what we should have done.

    We’ve had a patient with vague headache/chest pain admitted for observation die on us under strict observation. I’ve had a patient with diarrhea go into dehydration and shock. I’ve had a lady who could perceive fetal movements but have no fetal heart activity on ultrasound. We’ve had a person with cellulitis of lower limb go into septic shock and die while we were on rounds. We’ve had a bystander who missed anti-epileptic medication die after getting seizures and aspirating. I’ve examined a kid with high fever who had febrile seizure on the way out. We’ve had a kid admitted for being dull after vaccination die in front of us, despite our best efforts. We’ve had a child in waiting area who wasn’t breathing well arrest by the time they were identified by a patient care worker to be requiring urgent attention. I’ve had a patient with vague thigh pain turn out to be deep vein thrombosis and die next day.

    Always have the worst outcomes in mind when making decisions. Be mindful about patients who you haven’t even seen yet. Communicate a lot. Err on the side of cautiousness.

    Never be afraid to wake seniors up from sleep. When in doubt, ask for help. If you are not sure about something, check it again. If something happens while you could have done something which you didn’t, you’ll regret that your entire life. And that is a pain.

    Lesson 2: It is a privilege to have access to the miracles of modern medicine. When you have the power to use things, please also have the courage to.

    There is always going to be a risk. It is risk that makes the work of a doctor exciting. If you’ve chosen to be a doctor, there is no way you can avoid risk. Even if you become a dermatologist, you can land up in soup. As a doctor, the only way to avoid risk is by quitting professional life and meditating inside a cave.

    Risks shouldn’t hold you back from attempting something that’s required for your patient. I got this lesson the first time when I was still an intern, and was in KR Hospital’s Medical ICU. I was trying to insert a catheter into someone’s jugular but I was going too superficial. My senior then told me “Always remember, what you’re doing is for the benefit of the patient. You’re only going to harm them by not doing it confidently. The patient will die if they don’t get this line. So you may as well put it in boldly.”

    There is a definite role for experience and knowledge in being able to build the confidence to do things. But neither of that will come unless you want to do those things for your patient. If you are shy of cutting, you can never be a surgeon. If you are scared of side effects, all the pharmacology you know is absolutely of no use.

    Too many doctors think that by not committing something they’re keeping themselves safe. But their fake sense of safety comes at the cost of the patient’s suffering. Laws of medical negligence apply to acts of omission as well as they apply to acts of commission. With all your training you may as well do something and fail, than be a mean coward. That’s what your license is for.

    Use anesthesia (ketamine + midazolam, if you will) when draining breast abscess. Give powerful analgesics when people are in pain (don’t give diclofenac for MI/fracture. Give something like pentazocine). Use second line and third line drugs when the first line fails. Give aminophylline or magnesium sulphate for COPD/Asthma. Steroids and immuno-suppressants are in various guidelines for a reason – use them when indicated. Even newborns may need anti-epileptics. Benzathine Penicillin is the best available cure for Syphilis. “Higher antibiotics” are not reserved for higher centers. Use vasopressors (and for heart’s sake not fluids) in hypotension where failure needs to be considered. Use nitroglycerine to control high blood pressure. Use heparin. Use atropine. Use adrenaline. Use BiPAP. Resuscitate. Use oxygen. Use fluids. Give vaccines. Conduct deliveries. Splint fractures. Suture large wounds. Intubate and bag till the ventilator in referral center. Use all the things you’ve learnt to deliver care. That’s why you’re a doctor.

    And if you feel you’re under-prepared for any of those things even after MBBS, work with sincere people in rural hospitals (like VMH or THI or BHS). Learn the skills. Learn the craft. Understand pain and suffering. Care for other humans. Become a good doctor. Then do whatever you want to.

    Epilogue

    I had a rule when I was working in ED – “Nobody dies when I’m on duty”. The only exception was patients admitted for palliative care. Imagine if every doctor in our country made rules like that for themselves.

  • Meftal-Spas vs Meftal-Forte for Menstrual Pain

    I was recently asked by someone whether Meftal-Forte is a better drug than Meftal-Spas for menstrual pain.

    I hadn’t heard about Meftal-Forte till then. So I looked up. 1mg told me both the drugs are manufactured by Blue Cross.

    The page about Meftal-Spas gives us what I knew already – it is a combination of Mefenamic Acid 250mg and Dicyclomine 10mg.

    The page about Meftal-Forte told me that it is a combination of Mefenamic Acid 500mg and Paracetamol 325 mg.

    Based on this, the quick answer is “No. Meftal-Spas seems to be better suited for menstrual pain in people who find relief by using it. But self-medication may not be the best way to manage menstrual pain.”

    The longer answer is that dicyclomine is an anti-spasmodic that is widely used with anecdotal evidence supporting its use in primary dysmenorrhea. Mefenamic acid is an anti-inflammatory drug that is indicated for use in primary dysmenorrhea. Paracetamol is not really indicated for primary dysmenorrhea. Therefore if forced to choose between these combinations, the one with dicyclomine makes more sense to be used in primary dysmenorrhea. But self-medication is mostly not the right thing to do because a lot of dysmenorrhea maybe secondary to things like endometriosis and maybe better treated by other drugs under the guidance of a family doctor or a gynecologist, and sometimes just mefenamic acid (in the right dosage) might be enough to control primary dysmenorrhea.

  • On Libraries

    Sunil K Pandya asked on NMJI “Are Libraries in Our Medical Institutes Dead?“
    Badakere Rao responded to it with his memories of physical books.
    I had this response:
    The article on libraries and your response to it was a sweet read
    to me. The school in Mattanur that I studied from 1st standard till 10th
    standard had a large library (when I went back last month, it felt
    small. Maybe everything was much bigger when we were smaller). If my
    memory serves me right it had 4000+ books. The most beautiful thing was
    that when any student has a birthday they would celebrate it by donating
    a book (or more books) to the library and their names would be
    announced in the school assembly. This kept the number of books keep
    increasing. Perhaps it became a prestige issue for parents to send only
    quality books with their kids for their birthday, because all the books
    so donated were usually good and new books. From as far as I remember my
    favorite pastime after school (and free hours during school) was to go
    to the library, pick up a book, and read. The competition with other
    students who used to read more books (by numbers noted in the library
    register) only helped propel the habit. When it was time to leave and
    the library teacher would come tapping on the shoulder asking me to
    leave, I would take the book home if it appeared interesting.
    I
    still remember one Sunday when I read The Diary of Anne Franke (C
    edition, I think) from cover to cover at home. Now, this book has an
    interesting side story that makes libraries not just a collection of
    books and something much different from digital book reading devices.
    There are a few sections of the diary in which Anne Frank touches upon
    sexuality. One particular such page which has some graphic description
    (which I do not remember now) was so often read by the library users
    that the page had become dog-eared. In fact, you could open the book
    randomly and there was a very high chance that page would open up. And I
    promise I read that page only a few times. That worn out page perhaps
    was a silent broadcast to all the readers of the book about the
    curiosity in everyone’s mind. There are mechanisms in digital world
    which allows people to “scribble on margins” which can be read by other
    readers on their digital devices. But I do not think any digital
    mechanism can have dog-eared pages.
    When I was
    in ninth and tenth standard, I had become bored of my school’s library.
    Also, I would play football right after school and by the time I was
    done the school library would have been closed. That is when I
    discovered the public library in Mattanur bus stand. More than the books
    there, it was the librarian there who I spent time with. He was
    preparing for IAS examination and would talk to me about Sweden and
    Malayalam literature and so many other things that was happening in the
    world. I took War & Peace from this library once and it was so
    boring that I never read past the first chapter. Finally when I stopped
    going to the library, the book remained in my home’s bookshelf for more
    than an year. I later got a postcard from a new librarian who wanted the
    book back and also made me membership charge for that entire year.
    The
    school I did 11th and 12th in also had the ritual of birthday book
    donation. And the library there was huge too. But somehow I never used
    this library. And of course, there was “entrance coaching” to attend
    after school leaving very little time for actually going to the school
    library.
    Joining Mysore Medical College changed
    a lot of my expectations from “education system”. A library without
    general books was one such new experience for me. Yet, I would frequent
    the college UG library. In fact, Swathi and I have spent a lot of
    evenings in that library sitting across each other and holding hands
    while reading. Sunil’s mention of the pleasure in finding a hidden gem
    is amazingly accurate. Though MMC library’s “gems” were mostly old
    editions of Gray’s anatomy, I particularly remember one physiology
    textbook by Vander which explained some of the concepts in ways nobody
    had ever taught me till then. It was one of those treasures you value so
    much that you would show it to nobody else and try to hide it in some
    corner of the shelf. But fortunately I didn’t have to do any of that
    because not many of my friends were interested in the library, let alone
    a textbook that no teacher had recommended to them.

    My
    favorite book is “The Emperor of All Maladies – a Biography of Cancer”.
    If you ask me, it is a textbook of medicine (especially public health)
    that every medical student should read. But I can make a fairly
    reasonable bet that the college library wouldn’t have that book, even
    today. But, I also know for a fact that it has multiple copies of all
    the editions of a book titled “Companion for 1st MBBS” (and also 2nd
    MBBS, 3rd MBBS, and 4th MBBS). This is a question bank which contains
    past questions asked in the university exam. It is perhaps the most
    widely read book by the undergraduate student in Rajiv Gandhi
    University. And that speaks volumes about what our education system
    prioritizes. Libraries are only victims to the same.

  • Why is Benzylpenicillin called Penicillin G and Phenoxymethylpenicillin Penicillin V?

    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.

  • De Quervain's like Pain After CPR

    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?