5HT

I am piqued at myself saying this...

2012-01-14T20:04:00.000-05:00

There: "Pair tuta hai na baba....dard thoda to hoga ....sahan karo abhi"

Here: "It is not acceptable for you to have pain...please let us know if your pain medicines are not adequate"

This post has been deleted

2011-12-30T06:48:00.000-05:00

The Ritual by Abraham Varghese

2011-12-29T21:21:00.001-05:00

Am so amused by some of the reactions in the comment section of this video.

The busyness of being busy

2011-12-28T22:47:00.000-05:00

I have always struggled with when lack of novelty threatens sustaining interest in activity. I remember Louis Aledort's comment at MBA's Hematology CME, when I first attended this in Mumbai. Somehow his comments stood above Mammen Chandy's ode to Lorenzo's Oil. They stuck in my impressionable mind. He had alluded then that the redeeming moments during boredom ridden midlife/after-midlife crises are often an interesting patient, a serendipitous catch, a renal bruit you picked, an opening snap that others overlooked, an anion gap you chose to investigate that turned out to be the real thing, that reinforced your way of thinking. That maybe you should just do your thing, give 2 hoots to what people say, write, recommend. Because you are the one who is doing things in circumstances which surround you.

It is important to ask yourself a question, to rejuvenate the juices or the physical exam skills, to sharpen your skill of diagnostication,to invent a way. You could be very good in adhering to guidelines and doing things systematically. But boredom/ lack of engagement will elicit an error in you if callousness or lack of conscientiousness towards the culture of safety does not.

I think it is important to be busy. But it is also important to decide what you wish to be busy with.

Culture Shock..........

2011-11-07T16:16:00.001-05:00

Date Nov 07, 2011.
This was one of the no real planned agenda routine days on my trip to India this Diwali of 2011. The noise of the crackers had died down and the triglycerides had peaked at 260+ , waist fattened on sweets of all kinds, plenty of rice and dollops of ghee and left over chocolates.

What it turned out to be was a revelation.

I am one of the innocent few of my flock trying to cover my naivete in thinking I would be able to return and practice in India as an Infectious Diseases physician with braggadocio, patriotism, thinking big, an exercise in philanthropy, or say what you may. Every time I think this ought to be my punch line for my future SOP for a Fulbright scholarship application or a motivating Carpe Diem kick on the rump when I am too stricken by porn pestilence or Facebook fetish to indulge in useful activity. And I cannot imagine a this picture/situation where I can fill myself in.

MSF- 8 months away from DW?!; WHO- lack of clinical work?!, Consulting with McKinsey- same lack of clinical work which equals intellectual rust; health concerns; frailty of resolve; concern that mutabilities of time might change priorities in life the way it has from say 5 years back to till now. All these play on the mind.

This was supposed to be a trial for what might be.

My friend is an Infectious Diseases Consultant in Pune. Having done an Infectious Diseases fellowship at Hinduja Hospital, he has established a reasonably successful ID practice here in Pune. I accompanied him on one of his 'routine days' hospital-hopping across the city seeing various consults requested of him. My debilitated motorcycle served me well. The weather was bearable, I had relearned all the tricks of 2 wheeler driving in Pune traffic.

We started at Inamdar Hospital, in Fatima Nagar. This came as a real shocker.For one, I thought this might be some small apartment-converted-into-nursing home type gharghuti affair. But the scale of this hospital awed as much as the in-expertise of the nursing staff and lackadaisical manner of things appalled me. The usual sort of ID cases, but drugs missing from the med list, doses and names botched up, a blissfully unaware BHMS type of registrar, nitpicking nursing staff. It may be my limited view of things, but I was unimpressed by the usual Indian/Puneri way of acknowledging and satisfying a need while glossing over the details. The paan stains will come........I thought.

I remembered my friend Jason, from Baltimore, reasoning why we give leucovorin while treating Toxo. How I wished he were here to see this- our land of plenty. Plenty of people, plenty of disease, plenty of infections, plenty of doctors, plenty of money, plenty of poverty, plenty of misery, plenty of inequality, plenty of diversity, plenty of toxo...

A long drive to my birth place. King Edward Memorial (KEM) Hospital in Rasta Peth.I have quaint remembrances of doing my medicine internship here. Of course residency was at the bigger, dirtier KEM in Mumbai, but this KEM was where I thrombolysed my first MI patient on a semi-floor bed naive to the concept of reperfusion arrhythmias, did simultaneous and tandem ascitic taps on noon calls, and had to suture my first bone marrow puncture site which I over-enthusiastically converted into an incision. It was where I diagnosed my first Addison's, and ran my first code on a renal transplant patient spilling OKT3 on my apron, already smelling of NAC. It was where I got my Hep B needlestick, panicked first and then got wiser from the situation. (I don't know if it was the HBIG though which made me wise). It was where I got my medicine mojo.

Fever with rash is always a sticky wicket to play on. Fever with rash in the ICU is even more tormenting. From the days of the Lepto epidemic in Mumbai, I have had hypotheses of scrub/tick typhus, Hantavirus, Crimean Congo, immune storm pathophysiologies to the FART( Fever Associated with Rash and Thrombocytopenia) and FUNDAY ( Fever UNDiagnosed As Yet) phenomena. I admit I had to refer back to Ananthanarayan's textbook of Microbiology to refresh my details on the Weil Felix reaction.

Drug rash we opined- like is usual, ID physicians are first to pick up on even non infectious etiologies because of the general housekeeping sort of job one does in this role.Of course we fornicated on Lepto/Dengue and all those usual culprits, besides typhus, spotted fevers etc.
And continued Tygacil and Meropenem!!! Bloody jaat ka baida maru.........

OPD at Deenanath Mangeshkar Hospital at Nal Stop came with it's bushwhack of the day. An otherwise healthy old lady of mid 60s or so, walks in with her nephew with symptoms of dysuria.No antecedent antibiotic exposure, no prior hospital stay or urethral instrumentation. Some 30-50 pus cells i the urine with an ESBL E Coli in the culture!!!

" This is very common here", my friend explains. He mentions of another friend's mother who grew an ESBL in the urine in similar circumstances. He blames this on the blatant abuse of higher antibiotics and the "spiraling empiricism" among sub-specialists with the authority to prescribe, but no knowledge to guide such prescription resulting in Zosyn or Meropenem being a first line antibiotic for maybe an SBP, Colistin being a staple drug in the ICU, and double and triple Gram neg coverage being a common phenomenon. I am scared at the disconnect between what is taught and what I am practicing now and this mirch masala type of practice.
He reasons that this community acquired ESBL UTI phenomenon is close to 70% of the UTIs he is seeing. He has no data to back this statement apart from his recollection of experiences which he says is not biased. He reasons that this maniac empiricism might be causing the prevalence of ESBLs in the community to be so high that people might be spreading it to each other. We discuss that we should prove/disprove this theory by possibly culturing the stool of these 2 patients or the water supply at their homes.

Our 60 year old lady gets Ertapenem for a week.

A few HIV, and TB patients follow.

But this question keeps nagging. So the NDM scare stories are for real? This really will be a tainted shit hole of MDR bugs,the bugbear of ID physicians of the world? Will we be the biggest prescribers of Colistin the world, like we are possibly for Amphotericin? Will we sink into the grave our GPs have dug?
My naivety suddenly was more apparent than ever before.I had wanted to return to India because I always thought that there was so much opportunity for an ID Physician to carve a niche into, to work to establish norms, to educate, to improve upon. But now it seemed to be like the same plot was a bit trepidatious, even quixotic.Organized chaos might work in business models, but what butterflies are created in this unholy, free for all kaccharpatti, and how they may evolve is something I cannot imagine. ID specialists might be in demand due to ESBLs and KPCs proliferating everywhere, but with neither the drugs to manage them, nor the epi wherewithal to prevent them, we might just be practicing this abhorred empiricism at a higher level.God save us from that anarchy !!!

Small hospital in Parvati zopadpatti area. Few simple TB cases ( so relieved to see pulmonary TB after what seemed like a drought of TB across the Atlantic) and Crypto Men ( Amphotericin again!!)

My fears were confirmed at the Sahyadri Hospital ICU in Erandawane . All three patients we saw had MDR organisms in pleural fluid, CSF and blood respectively. Colistin, Teicoplanin, and Micafungin were running like tube feeds. It dawned to me that it was likely we would lose this battle against the microbiome faster than other countries would. Unless we could export these bugs to a more developed country, there would be no more new drugs to fug these bugs.We would be back to the old days of good air, nourishing food and sanatoriums for the very resistant bug illnesses. Or surgery for recalcitrant infections. More radical or modified radical abscessectomies/ infectionotomies for more or less virulent infections.Maggot therapy, hot coffee therapy.

'Kya aap Acinetobacter positive hai?'

" I am MDR positive, please don't hug me"
" MDR- Jaankari hi bachaav"

" No, you don't get NDM from mosquito bites"

The funny thing was that there is no hospital epidemiologist allied to the ID physician. I guess the incentive in a pay out of pocket system is in people staying longer in hospitals or ICUs. And so no one takes this seriously. Possibly with development of the health insurance system, shorter stays would be the norm with physicians whose patients develop nosocomial infections getting a rap on their knuckles for poor performance. The opportunity would then arise for educating these numbskull surgeons, by disincentivising poor performers.

I really hope that day would come.

Nahi to andher nagri chaupat raja, takiye ser bhaaji, takiye ser khaaja.

This or that

2011-07-10T01:39:00.001-04:00

This was part of a long drive conversation with DW. I have worked in two healthcare models, one of the developed world, and another barely sufficing to meet needs of the developing ( whatever that word means) world. We manage to scrape the surface back home. Manage the one single basic issue really well. But if anything is screwed, complications arise, or things become more complex than diagnosis and treatment of one issue, we step back, become fatalistic and let things take a natural course.

Which is not to say that the plentiful bounteous healthcare dollars available to the American healthcare system have created a mannaland here. Problems of treating a populace that expects too much, and believes itself to be immortal, and a force ready to appease this hunger, are not easy to solve. You would say, what's wrong with that? This is an individualistic society that values the achiever who pushes his chances to the maximum, be that his fight with fence sitters, backscratchers, depression or pesky irritants that threaten his longevity. But, do we need a geriatrician to tell us that one day it is going to all end, and to accept this is not a defeat of the generation?

Are we then better off in the developing world setting, where too much healthcare has not intruded itself into interfering with the daily issues of life, or becoming a part of it? After all, would I care what goes into the making of my TV as long as I am able to watch stuff on it? Or is that a sense of acceptance that since we cannot shape our lives with the limited monies and resources we have, we have to accept what life deals to us, be that the fatal realizations of the frailties of our own bodies?

To be truthful, I do not know. If it were me, I would want the best, ain't I? But, are the countless visits to the doctor's, tests, venepunctures everyday, some numbers thrown against my profile, pills, chills and psychic overkills really the best? I cannot seem to decide without a P<0.05

Homeostenosis

2011-05-08T22:45:00.000-04:00

I met a 83 year old, who once would lift 250 pounds in one snatch,

Now, age, the passing of his significant other, severe heart failure,

I know not which more, makes em puff and sigh so hard,

In 10 pound dumbbells he finds his match.

Echo

2011-04-14T16:31:00.002-04:00

My Q waves wonder why they are there, While,
Physiology, respiratory variations or my lardaceous midriff
Do not explain whether the cold water I drank,
Inverted the Ts in the same views
Of my presenile heart, which must now be viewed
Or so they say!!

Iphone secrets

2011-01-31T01:38:00.002-05:00

I am also surprised as to how well my Bluetooth headsets work with the iPhone. Earlier on with the windows mobile handset , it was a task trying to her the headset to sync with the handset. Listening to the classics on piano by Richard Clayderman..... Soothing with no sound breaks. Wish I had waited for the Bose Bluetooth headset. But the Motorola is good enough.

Tomorrow is a new day.
Hope , I hope is on my way

Shivakumar

Moblogging

2011-01-29T23:38:00.002-05:00

This is my first post from the iPhone blogging tool. Blogger has become an old thing in some ways what with twitter and Facebook. But I prefer freetext to click and enter. Having the iPhone handy is also useful when the thought strikes and pen and paper are not handy, nor is a computer screen.

I have to figure out how to insert an embedded hyperlink in text with this device.

Meliorix

Interview questions and answers tips

2011-01-28T11:27:00.000-05:00

This is for future reference:

8 Websites That Give You Tips On Job Interview Questions and Answers

Motivator: "Tell me something about yourself"

Bodypainthing ...circa std III textbook

2011-01-27T23:40:00.003-05:00

Thought I would never find this ever....

Okee Pokee crack me crown
King of the island of Gulp 'em Down
Was thought the finest young fellow in town
When he dressed in his best for the party.

Okaa Pokaa Ching Ma Ring
Eighteenth wife of the mighty king
Loved her Lord above everything
And dressed him up for the party.

Satins and silks the queen did lack
But she'd some red paint, that looked well on black
So she painted her Lord and Master's back?
Before he went to the party

Crowns and stars and ships with sails
And flying dragons with curly tails
And so dressed Okee Pokee, without a coat or a vest
But yet, in his best for the party..

Let us put the dialysers out of business

2010-12-04T23:49:00.000-05:00

Never occurred to me why when we talk of Heartmate 2 and all that chutzpah, is there no such implantable device for the kidney.

Cleveland Clinic gets $3 million to create artificial implantable kidney

Maybe there might be an implantable MARS system for the lliver too!!

F.D.A. Studies Band Surgery for Less Obese - NYTimes.com

2010-12-04T23:17:00.002-05:00

Interesting read about bariatric surgery in the NYT.

F.D.A. Studies Band Surgery for Less Obese - NYTimes.com

Think of the symptomatics-anyone who is obese and has symptoms- OA I guess is symptomatic obesity, or OSA- which everyone will have. So then suddenly 1/3rd of all Americans, including all those brobdignagian American football stars will qualify. Of course there is no debating the lack of a middle path- weight watchers and surgery are 2 extremes. One often feels stuck when managing obese patients who have no quick fixes than disciplining themselves. Lifestyle change often is a life changing event and not many want or are able to do that.

We know about the effect of bariatric surgery and the resultant weight loss on not just medical problems- I mean imagine coming off diabetic medications-, but also factors like mood- improving depression, as well as paradoxically, an increase in suicide risk!! But have you read the fine print in Love Bailey on dumping syndromes and other miscellaneous post gastrectomy complications?!! People do not appreciate how dramatic the weight loss can sometimes be- I have taken care of people who eat 1 cracker for breakfast, 2 for lunch and a few sips of juice for dinner which consists of a few raisins!!!! And lose 1o0 lbs or so in few months. One of my colleagues once presented a case of Wernicke's encephalopathy in a patient after bariatric surgery- aptly titled as "loss of weight and loss of gait" because the patient would just not eat anything at all. Surgical complications exist of course, and quite often the obese with COPD, OSA, CAD, CHF are poor candidates for surgery anyways given all the end organ damage which has already set in. One is stuck thinking as to where to start to remedy this lardaceous mess. I guess addressing it before it assumes gargantuan proportions is an option....but then...suddenly everyone's in. It is tricky ground..one has to loop before taking this leap of faith.

Technology Can Get Freaky | MakeUseOf.com

2010-12-04T22:47:00.001-05:00

Wonder what wireless fidelity might be?!!

Technology Can Get Freaky | MakeUseOf.com

Classic Gas

2010-09-13T16:15:00.003-04:00

Saw the most awesome X ray I have ever seen- 40 something guy with MR and hydrocephalus who keeps swallowing air. Also gets opiates for an ankle fracture and is immobile from it. So guess what shows: a hugely distended stomach, small bowel distended as well; colon is at least 20 cm in size with a Chiladiti sign.

It sounded like the Rime of the Ancient Aviator:
Air , air everywhere, and all our planes did float
Air air everywhere, watch his belly bloat!!!!

Obviously I cannot reporduce the image due to privacy concerns etc- but it is coming at a journal near your library soon.

equanimates

2010-06-24T00:44:00.003-04:00

How the morbidly obese lady who wore skin hugging jeans 4 inches below her Brobdingnagian rump and ringlets of gaudy colors tearing her pinnae apart ,and wetpaint for lipstick with jello in her hair and 12 inch high heels became a sorrowful, troubled, aching, short of breath person who sighed and panted to breathe her bellows to carpopedal spasm and funny perioral feelings; and sighed and fluttered her eyes, depressed her lateral canthi to convey a 9/10 pain that was sharp and localized to her tender chest wall and came from the heart.

How this transition happened once she wore the peekaboo hospital gown , how she donned the sickness role of a troubled soul whom misery had struck a machete on after disability had sapped the energy off , seemed clear to me when, once "ruled out"- this perversion of American medicine- she got her percocet, dressed up, painted her nails, took her cellphone and hollered, " Sebastian, get your f#@*ing ass here to fetch me."

Simbly put.....

2010-04-25T02:47:00.003-04:00

"How the hell can you see 70 admissions in a day", Debangshyu exclaimed

"Abbe you did medical school in Delhi na?"

"Woh to we used to present cases and get our term completion done through friends. Koi ward shard work nahi kiya"

My first experience at "floors" in a typical hospital in the US was with Dshyu who oriented me to other culture shocks including rounding by the podside and not the bedside, dispo decision making pushed by case managers, the mirth of Dilaudid, the christianity of equating pain management with deliverance from suffering, nursing homers and other gomers.

"You get capped at 10 for the day?" I had exclaimed. Solid maja hai babu.....I had thought. Kaamchoron ka desh hoga.

A couple of years later I was on the other side,dressed in scrubs and an unnecessarily long apron/labcoat, stetho stylishly strung around syringomyelic shoulders, specious wrinkles on my forehead complaining that "no, I cannot take a fifth now"

Dr Terry was amazed too, like Dshyu- how can you take 70 admissions in a day. (As was Gawande when he wondered in his NEJM article about how a general surgeon could see 36 patients in 3 hours)

I had to tell them that admitting 70 patients with one ailment, with one page HPI and one page orders, no 15 line past medical history and EMR to dig records from, other hospitals to get records faxed from, no baby boomers seeking immortality and no oligocerebral nonagenerian grandaunts of HuffPo/Grey's Anatomy educated smart grandnieces with every joint fixed every coronary stented, every nephron dialysed and every orifice scoped into made it infinitely less work than the 10 of the above kind I admit here.

Yeh kya hai- MI, fir-lepto, uske baad- OPC poisoning, next malaria, next - stroke, PICA; agla- interesting hai- cord case; next- woh bhi clinic ke liye rakha hai VSD/PS. And kone wala HIV as usual with crypto men. He has cutaneous crypto- thats interesting too.

Pneumonia was simple CAP, troponin leaks were probably missed because you don't follow a set and treat initial presentations, cardioembolic stroke from Rheumatic valvular heart disease was at least 1-2 per admission and monsoon masala with Crystalline Penicillin, Artesunate and /or Doxycycline made things so easy.Of course, there's zillions of miles to go- if only there were more resources.There were situations where you just held your hands or grit your teeth in frustration for a life lost and how little you tend to value it, or not give attention to when you have to see such large numbers of people everyday. But as Gawande observed from an outsider's eye,it is still a victory of sorts given the odds. I would like to see what a doctor from the west would have done in Nanded.

Like watching a movie on bioscope I always used to think that one person always had one ailment and there was nothing around that influenced how I as a provider needed to remedy him/her of that single ailment. And then life goes on. I thought that this was an extension of the law of parsimony or Occam's razor to the general way of life and order of things.

But like this case from the NEJM shows, this thought process restricted my vision to within the bioscope. Why would I even look for drug induced lupus when I have temporal arteritis to satisfy my diagnostic nosiness and keep my maaz quiet. Why ever with the former system of tending to the basic complaint would I even bother if an ANA sticks its nose out obnoxiously.

Well if you have the tests to play with, (and the monetary fortitude to order them)- it is a different story. I need to reeducate myself that a person with MAC pneumonia can have Wegener's granulomatosis and HNPCC and liver disease related to HBV which also caused PAN related stroke and a neuropathy, heroin related nephropathy, Arnold Chiari malformation besides a Klippel Trenaunay which is poor last one on impressive the PMH list. All these were diagnosed by different specialists at different expensive insurance/Medicare billed visits- whatever could be upped fixed nipped tucked stapled opened up or closed is done. And now the patient comes to see me!!

If I use what my older system of training taught me- treat what the patient comes to you for, I might get ticked off for ignoring all this excess baggage that the person carries. Billing, after all depends on the number of diagnoses you put in. Again, I need to rule out PE somewhere, rule out MI some otherwhere; have to write a 4 page HPI, get records from other hospitals, contact family, discuss code status, print out ordersets for DM, ACS, heparin ordersets, look at the huge medication list to see what we can keep and what we can omit and finally call all the guys who did the hardware and wiring previously as well to consult.

Thats equal to 10 patients in back home.I think what I want to do- treat what the patient comes in for - should have been done before all this piled up.No one would have faulted me for keeping things simple, so you wouldn't have had to build that big resume of PMH and ordered that ton of investigations and dictated lengthy dictations which one needs to rummage through now.

The wisdom of life consists in the elimination of non-essentials. The consumption society has made us feel that happiness lies in having things, and has failed to teach us the happiness of not having things.It is truly a joy to focus on one thing at a time, not having to build an absurdly lengthy list of differentials and work up to rule out numbers 10-11 and 12 on that list. And it is a joy when life behaves that way . But that is, or may not be the truth. Rules of common things occurring commonly might not necessarily be true when you confront the individual patient who says that chest hurts. It depends on how you want to heed those rules.

Now: House: Each one of these conditions is about a thousand to one shot; that means that any two of them happening at the same time is a million to one shot, Chase says the cardiac infection is a ten million to one shot which makes my idea ten times better than yours.Get a calculator run the numbers."

Chase: "We'll run the tests."

In another world, in another time: "Every human being is the author of his own health or disease" ...so the Buddha tweeted.

To say no....

2010-04-16T14:56:00.002-04:00

Posting a link to a recent article from the NYT. I like the point of giving the people all the information- they are more likely to say no if they know.

It is always so interesting to read the Comments btw.

At the turn of 31

2010-04-16T00:44:00.005-04:00

You sit back wearing your glasses of wisdom, which you think have more than your peers, realize that you have completed half of your productive lifespan, and want to ask "what the hell have I achieved."

Or more importantly where you are in the scheme of things?

I guess the former question applies more to the goal/path/light at the end/nirvana/cause related effect karmically avowed seekers who have always wanted to be cardiologists or MBAs or lawyers or bankers. Where career takes you to the very top of Mt Rushmemore and then life takes over while career shifts to D4 gear mode. Most friends of mine who might be trundling the same side of the 30s are people who have "settled down" thus.

The latter applies to those who are path seekers, more than end seekers. They wish to get to dabble with anysomething jobs, get bored, switch, travel the world, get right brain seizures and take pit stops or change tracks every few years, are sacked, do hemp on the way, play their tennis and panpipe,sleep late wake late, Cheyne Stoke their way to manic hypercreative and depressive ruminative periods. They are a confused protoplasm, feel good/ennui is their guiding gut feeling which drives crucial decisions. Goals are not as important as looking around while getting there.

I had written previously about motivation- what drives one to do what they do. Ismail would slog his ass out at Masjid bunder to get medicines for his chhavi and subsist on vadapav. Of course it was futile because she died eventually. But he did that. There was no goal chasing here. Life took a turn and he had to reinvent goals.

One of my friends wants to keep playing his guitar, trek, powerbike, travel the world, learn new things besides tending to patients. He wishes to adapt the 4 hour work week into being a doctor which of course is number 1 not feasible, does not pay and three, is a logistical nightmare in case you are vainly ambitious. But hell he wants to do all that chutzpah.

Another physician friend took to the villages because he wanted to wake up and feel good everyday about doing his job, in being able to tickle his altruistic conscience the right way; have a good quality of life, not want to earn big dollars and be able to afford small desires while not being consumed by rapaciousness. He would also be close to nature, and seek contentment in small things. It is hard to take that initial step, but he did.

My patient in clinic is separating from her husband of 10 years a month after suffering a stroke . She will need to reinvent herself because she went suddenly from Lionel Messi type focus to Tiger Woods like messed up. She has no goals now except dum vivimus vivamus.

There are some important drivers however which do tend to push one one way or the other. You do tend to feel then like a ch$#ya struggling with a multiple choice question where all answer options seem right the more you mull on each of them.And to say that you are 31!!! And this is not gurugyaan :

Health is a priority. You realize, your body has been kind to you till now. Especially so when 20 some year olds hold their clenched fists to their substernum to confound traditional teaching on age and disease.And climbing 3 flights of stairs or running for codes drains the functional residual capacity out of your lungs. You do want to live well, before you can live life well.

Wish to make Money( yes in capitals), family( how can I be selfish?!), visa status- I wouldn't have put that, but have seen this so much so close and so frequently-all are foghorns which may steer you one way you might not have even thought about.And when you do realize where you are going, common sense means something else to you.

Aiming for stability is what our ammas/appas have taught us , we have seen our brothers and sisters do; what our peers see their brothers and sisters do and want to do. Those three or four things mentioned above are essentially what they mean stability is constituted by. Way later,in your 30s, no one is sermonizing or showing the way. Some do things like they have always been told that they should be done, others call it fate/kismet, forresst gumption, bipolar, recession etc.

What the hell!!

How imperfect.

2010-04-03T12:23:00.003-04:00

ICU call after a month of vacation can be cruel for the mindscape. Then imagine my childish mirth at going through till 5 PM with only one admission to count. And a patient hooked up to the vent with sepsis protocol written for makes life unusually tranquil what with nurses titrating the levophed and neosynephrine and fiO2 and his highness deigning to cast a perfunctory glance once in a while to make sure things are going "in the right direction"- yeah I learned the lingo.

Things looked fine to go, gear shifting into work mode seemed smooth without a migraine threatening to make its ugly head visible. My intern was choosing his poison at the Cafeteria and as languor spread into my synovia and cerebri, I choose to surf cricinfo while on call!!!!!!

Post arrest hypothermia- still cooling, diverticulitis- stable, bleeder- not bleeding, DKA- miles to go for the gap to close, bleeder with MI- not bleeding, not aching; COPD- vented; hemothorax- tube's draining less and less.

"All looks okay", my intern said.

" I concur doctor", I wheedled to humor the dude. Asinus asinum fricat.

Timepass yields to the ultimate timepass of our times-Twitter. I am then directed to George Orwell's essay on Gandhi circa 1949. I am smiling to myself.......

Then shit happens.

I get a page for tachy. My bleeder is bleeding. Instinctively I want to rule out some stuff-MI?PE? - EKG, enzymes, CBC and the works are sent out. We decide to block some mischievous cyclic AMP molecules that are driving the heart whiny with some metoprolol.

Not such a great idea, it turns out. Blood pressure plummets.

Fluids pumped in, blood on the way, pressors pushed into weeny IV lines- she pinks up like a Plumpelina. I am talking to her daughter, some fights between GI and surgery and interventional radiology about who bites the bullet first and plunges into the bloody field first. I am appalled!!

Pressure drops again. This time fluids are followed by levo, neo and then epi drips. She's mottling, holding her belly, looking the way I recognize bodes ill- it reminds me of the picture in Bailey and Love of a patient with pneumococcal peritonitis. It is clear she is exsanguinating faster than we can arrange for her to have any intervention. Sadly a 'code status' discussion makes sense now. I ask," do you want us to operate on you and try........."

I am not sure she heard or understood me. She said, " I do not know....." like she was talking to someone at the end of a long tunnel, each blink of her eye taking away more of her remaining life away. Suddenly she looked every bit of the seventy some years she had managed to hide in her charming demeanor and away from the tar and nicotine and ethanol that also were in her medical facebook profile. I talked to her daughter, and in explaining the "chances" I had to check myself against using colloquial nonmedical words in trying to tell her that her mother's age was a big prognostic factor.

" Is it fated?" , I was asking myself.I was reasoning back like there was an itch in my cerebrum I wanted to scratch out. How could I think so? I could clip, sclerose, inject, coil, embolize, operate. Why was I thinking like a baalu baccha? Or was I?

With all the advances of modern medicine, and all that I have at my back and call, have I got to stop at some point in time and take a breather and say Ohmygawd, what a monstrosity we have created in thinking that we are immortal. and can mend and heal all that looks like a mechanistic peg hole.

" But she is awake ", Jen, the nurse shrieked. "How can you make her comfort care?"

" But she is on her way"

" You can't let her pass this way", she reasoned.

" Even I thought so, initially", I blurted back.

With all my cultural differences, cognitive biases and representativeness heuristics, I felt here, I was the wiser one.

We gave Ms H some Morphine so that she could sleep through the blood flooding her lungs and her heart feebly stammering to a flat line. She looked peaceful as she gave me one long look through her ashen eyes and blinked one last time.

In pursuit of......

2009-12-28T09:37:00.001-05:00

Slideshow on statistics of happiness from slideshare, thanks.

What do we know about happiness

View more documents from www.kapterev.com.

In conversation with Dr Terry

2009-12-20T04:00:00.003-05:00

I was telling him about the Taj Mahal hotel and the latitude comparisons of Florida and Mumbai. How snow happens here, but its a day or two in Shimla in India. How people who lived here for long enough imbibed the American efficiency and thought it was birthright and made similar demands from the system in India when they chose to make the return journey; only to return again to the US and feature neo-enlightened in NYT write ups on the 'reverse brain drain.'

Invariably conversation shifted to how medicine differs in India as compared to the United States. There weren't many moments that allowed, outside the bronch suite, waiting for the patient to be wheeled in. But I wished to tell beyond how health insurance does not exist, and hence people save money for a 'rainy day' and healthcare is separated into government hospitals for the poor and private hospitals for the rich and tourists.

I wished to mention how one system cannot be flawed for being hopelessly inadequate because the demands it makes on it's country's exchequer are miniscule as compared to the Brobdingnagian other; the needs it tends to are so disparate and basic that trying to rein things in seems like a colossal case of Balint's simultagnosia- missing the forest for the trees and doomed to failure like the many Malaria programs we learned of in PSM classes. I wished to mention how micromanagement and backfoot play has become the bane of American medicine- so it seems to someone who has worked in both systems; how people become lists of past medical issues and ideal setups for iPatient scenarios that Abraham Verghese describes again in the BMJ this week; how it is still plausible for a patient to have 17 surgeries and both hips and both knees and shoulders replaced and still crib when the age for beginning mammo screening is moved from 40 to 50; how patient does not know she is on opiods for pain -denies she ever had pain- doctor does not know why pt is on opiods for pain- pt comes in confused and drowsy-screaming-'oh she must be in pain' and pain gets treated as the fifth vital sign of course- and patient is in and out of the hospital, on and off narcan drips, treading the papaver somniferium way to doom.
I also wished to say how I find it odd that everything including duration of hospital stay, courses of illnesses, prognoses can all be stuffed- fitted- normalized according to mandated standards, that deviation from the rule can be scorned upon, hence everything be slotted in some protocol or other and dealt with that way and that insurance and not intelligent thought dictate what approach to take.
Lastly, I wanted to tell him that I would never want to die in a nursing home/hospital, with no family in sight- they got so used to the NH to hospital shuttles ,they did not bother to come see-while some resident desperately dials numbers to find what the code status is, and finally locating a DNR sheet, throats a relieved "allow natural death."

There is chaos here as there is chaos there. Questions need to be asked.There cannot be a Ultimate Turing Machine truth or an answer 42 for all questions.

"You are responsible for your own experience", so the Buddha tweeted.

Knowledge speaks, Wisdom pretends to listen

2009-11-16T00:22:00.003-05:00

Yogi Berra says when you come to a fork on the road, take it.

I am trying to develop a lateral view to things I see and feel everyday- it may involve keeping a distance from all the shindig to develop a 'broader' perspective of things. So I see everything as it happens, feel everything like it should but am not there in participative mode. I am 6 inches above the ground in a holier than thou gear fornicating with my Quasimojo. In this mode, even probing questions can be skillfully deflected with a "depends , on your point of reference" flick off my sleeves- dhamaal invincibility.

I could write nothing for a 100 Q paper and claim it to be my POV, whats my fault, I am diagonally parked in this parallel universe.

You might call me ch#*ya....I could call you something else...but thats besides the point. Somebody has to be the broad boy- and call Carpe diem. If Windows 7 and Ubuntu Linux have to cohabit, someone has to be the wise one.

Because all the world's a stage, and all the men and women are merely players. Each one they have their exits and entrances, and one man in his time plays many parts

But................................ Sheikh Ispiar to ek hi bana na......jo tangdi taang ke je tamasha dekha

And there was one Jesus who said, "God forgive them, for they know not what they say/do"

Abhi ch#*yon, jao chalo karo ch#*yagiri.....

When I should be writing my PS

2009-11-15T02:45:00.002-05:00

I bore through two and half hours of West Side Story and Arundhati Rao's Come September and another reading of 'The Howl's eli eli llama homosexual rantings.

Is it good or bad to be impressionable- each one is affected differently by what is crap for one, kitsch for another, spur to someone else? Is it a harm to be enthusiastic? Should one pretend moral superiority and lose the innocence of the action reaction spiel, and be deliberative and not get the high of now and done- whats next?

I have been trying to think. But conventional ramblings keep me busy.

Dr Druker's interview with the NYT

2009-11-11T10:13:00.003-05:00

Dr Brian Druker was awarded the Lasker science award for developing Imatinib mesylate with Charles Sawyers from MSK and Nicholas Lydon from Novartis.

This is about the magic cancer bullet

With cold coffee at an unearthly hour, after a looong time...

2009-08-29T01:12:00.003-04:00

I always thought writing a paper while doing residency in India was tough and that you would never find the time in the midst of all the emerg/post emerg/pre emerg cycle of actiwitty. I never thought handling 80 patients and seeing consults, doing procedures rat-a-tat-tat-tat was ever an issue then. If yo get free time, you would rather spend it on watching a movie at Sterling or Regal and fine dining at Crystal or Cafe Mondegar or Bhagat Tarachand. And why not wake early, not to do schlolarly activity, but to go to the railway ground to run a couple of three kilometres every now and then, coz you could always take a siesta by the side room after you do the routine ward work.And so when push comes to shove with your theses, you run to DP Singh at TISS or try out trial versions of SPSS really trusting your acumen and luck with the games of trial and error and hoping your p value works out.

I thought writing a paper while in the US would be easy- especially with the fact that residency would not be such a pain in the derriere, time would be at more surplus since management questions wont take forever and clicks of the finger that underlined pages after pages of Harrison would make ailments vanish.

Alas, here 10 patients tire you out. The greatest task at hand seems to be jousting against all the data thrown at you wondering what is relevant and what is non necessary, trying to figure which among the past medical issues needs more digging and which is just another episode in the unending treadmill test that healthcare is viewed as in this developed world.

Not staying in campus- why call it residency then?- cuts you off from working when you like to, and residency becomes a stretched out 8-5 routine where you do a bit extra in form of calls, signouts and all that.

The task of the day is writing a note in the first year, dispo in second year, dispo and managing the census in a smart alecky way in third year. Abraham Verghese's i-patient is very much existent on a busy day when time is at premium and as vitals and I/O are available on COWS- confessions from interns! Work becomes "work" in the true Dilbertamerican way; people judge you, and you need to be mindful of their judgements aware that they have a right to judge you in this 360 degree assessment cumulonimbus thats so pervasive. Uniformity is encouraged as it means productivity, lateralness is frowned upon, protocols are gospel truths.

So when do you sit and analyse what you saw and write abut it? I guess that comes when you do bench work research and stay poor, for the smart ones are seeing more patients in 15 min encounters and making more money!!

Some of my friends who never did clinical work in India do not feel that the emperor's clothes aren't there at all. I guess working in different scenarios gives you spectacles that you can choose to wear or toss, for quite too often WYSInotWYG.

Have a weekend off after some time. Will try to submit something I have been sitting on for some time. Again, I also need to enjoy - when will I have a weekend off again!!

Whats going on.....

Just like that ek post dalna tha

2009-08-21T22:23:00.005-04:00

Presented a case from KEM Hospital in Mumbai which we took care of- a case of difficulty weaning which was due to an empty sells syndrome with panhypopituitarism- at the rheumatology challenge at GSH. There was some malaria for lazeez fare and DRK management for laissez faire, chloroquine and artesunate which is like stibogluconate and eflornithine for the C difficult audience.
Was a decent presentation I thought. - gives me some free time now since I am free. Left me with an estomago dolor though, with Chow baba snoring away and food too plenty to eat. I thought of it as a break from the MRSA VRE fluid overload story of daily grind.
Gonna try and keep ready for elective time, long drives and traffic, new places, new people and working towards that letter of recommendation.

I dream meanwhile of the rains in Pune, the greenery of malshej ghat and the beauty of Varanda at its summit, Karjat ghat ,the Bhugaon exit from Paud road and its lustrous wet green vallies and circuitous roads and small hamlets, getting drenched in the waters near the Temghar dam, eating bhaji and chaha on Sinhagad, the bumpy ride to Panshet backwaters- of being able to get drenched and dry your clothes in one single motorcycle ride to Bhatghar dharan, pedalling on rotten pedal boats in sunkissed mist- kya maza hai yaara!!!
Kabhi apna wahan ghar hoga. Mukunda Mukunda Krishna Varanda Varanda

Disco Bombo bulatory

2009-08-17T22:30:00.005-04:00

There is a theory which states that if ever anyone discovers exactly what the world is for and why it is here, it will instantly disappear and be replaced by something even more wierd and inexplicable. There is another theory that states that this has already happened.

As I ambulate, and walk the walk through allergy and immunology and endocrine clinics, I come across Golgafrinchans who have made it to planet earth and then across the Atlantic from Lords and fjords powered by the Heart of Gold to an economy them it can't hold; through internet acquired knowledge and the naive asagacity of putting 1 and 1 as 11, waddling over replaced hips, amputated legs, opiod induced ennui, to few moments of conversations with the Lord of the Syringes and Plasticinated Heart Tubes.

"Appy-polly-logies, I am just a resident, shadowing the attending. Howdy you? Viddy good?"

"Huh huh"

"So what brings you here? "

"Whaddya tinkin? Again cellulitis of the thigh- I always have staph, they always give me Vanco. But now I need the narco. "

"And when did you have the leg surgery?"

"Imawh leg- them done with seben , awd no eight surgeries. 3 amputations on my right leg, 2 on my left leg , 2 hips replaced and 1 knee that has been replaced, but keeps having to have pellets in it"

"You must have had diabetes?"

"Yaya, with the kidney disease,- I am on dialysis , mwa fistula failed 6 times, then had a Hickman done on mwa chester, I also had a kidney taken out for cancer.Then where does it viddy go---yes master , to the heart they say- I had around 5 attacks of the heart, finally they put me a shocker pacer dingi. Someone doc told me I had syphilis of the heart..I always thought it smashes your stinky winky, tut tut.

Then id also viddies your nerves- I have something they call CIDP, with lead toxicity. Ruins in my family.The neuro guy thought it was due to that. But personally the pan galactic gargle blaster does that sometimes to you. They had tested me and found me to have Lupus, so they say. It shows up sometimes, other times it just hides, just like a Gollum following you with round green eyes.I have been on steroids, Coumadin and all that"

"Who thought you had Lupus?"

"I donno. Might be the guy who did the bronchoscopy."

"And why did he do that?"

" My guess is as good as Zaphod Beeblebrox's I guess he just guessed.And then made the gesticulation of aye to me after he called the joint guy on the phone. They gave me something called methotricksstate- it destroyed my liver- had to get that transplanted."

"Any other surgeries?"

" Eight other on my abdomen. Started with a hysterotomy- went to hernia repair and finally adhesions, had gangrene of my bowels, had a colostomy- nice poopy tube for the frontrunners meatinx"

"What medications are you on?"

"28 pills in all a day-I need refills on Dilaudid 10 mg QID and Oxycontin 160 mg BID for now."

"Where is all that pain?"

" I ache all over. My back- from PID,my neck from fibromyalgia, my upper back from osteoporosis. I have rods in my spine from gunshot wound related fractures from the Vogon war at Megarathea.Everytime I cough, it hurts"

" And why do you cough?"

" I had COPD and MAC infection- from all the hookah smoking watching kirkit matches. Thats why I had the bronchoscopy soopid"

" Hmm""

" Whaddya mean hmm....stop hmming...thats not a good sign...just hmming and not giving me some info...stop..aah...Am I going to die?"

"My guess is as good as Zaphod Beeblebrox's"

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------

No reference or similarity to any person living or dead in the above

Uh, no, you got the wrong number. This is 9-1…2.

2009-08-03T22:28:00.002-04:00

Goof ups are universal- like so many I have seen here in the last couple of weeks. People need to collect and acknowledge them and say, perhaps in the larger perspective, 'guys, today is the first day of the rest of our lives', lets get on.Unfortunately someone has to be fall guy and take blame- coz if there is no one to blame, who gets praise, how does the company improve. Corporate humbug.

Oh...how I wish suckers kept to sucking and did not mechanize every bit of life, air, aerosol into stochastic pigeonhole slots.

Anyways ........ am on Tamiflu....as PEP. This is my fifth PEP session. I have had 2 forHIV, one for HepB, one for rabies- and by far the most expensive one here. If I count the countless tabs of Doxy that i gulped down while leptospirae squished along in the lungs of the chappaled mumbai gentry, this would be my sixth.

Medecines do not affect me in the way they might affect many others. I am so convinced about placebo effect and destiny-epiphenomenon axis being major outcome influencing variables that I can challenge a RCT on me and me clones of any whatchamacallitumab drug compared with M and Ms. Nocebo effect you may call that. But the PLOS metaanalysis of antidepressants makes me wonder- why should it not be ethical to prescribe placebo medications just to make someone 'feel better'

Take away your medicines, and what are you? Omniscient nomojo. So despite the fact that you know that they really don't work, you continue to give Paxil and Abilify - why? You are practising placebo medicine aren't you? Do you know you are?

There's so far to go to even realise that there's so much you do not even know. It is a good habit to learn KCP's stylish deflection " I have treated to as much I know, now it it up to HIM"

DD Ads from the 80s

2009-08-02T15:12:00.002-04:00

Have a look. These are the ads we grew up on DD.

Tubaah: Ads by Prahlad Kakkar

Ration card

2009-08-01T00:06:00.000-04:00

The PDS system in India has the 'ration card' system so well entrenched- it is a form of identity proof. I do not think it exists any other country.

"--A hospital bed is a parked taxi with the meter running"- Groucho Marx

Read this article about health rationing in the US.

The PDS system in India has the 'ration card' system so well entrenched- it is a form of identity proof. I do not think this exists any other country.It is something we have grown up with, our few liters of kerosene and few bags of rice to keep it going. Then we had gas stoves and microwaves.

To hear the R word in American commontalk is ironical in this land of the HOV meaning 2 people in a car.For all the talk of having access to the best health care in the world, where it gets spent is apparent to see- 1/2 of all the healthcare you have in your life is in your last year of life. In this year of life, on the day that you die, your average life expectancy would have read out as 6 months more, and so the extra spoon of salt tipped your CHF over, or the strain of jumping over the parapet wall increased myocardial oxygen demand > oxygen supply and infarcted the jeopardized myocardium, and you had a heart attack.

Atherosclerosis started in teenage- after that you are just playing a game of hide and seek. That one will not die, or should not die is an insult to the rules that apply. You cannot fool with Insulin pens and Tarceva and play Tweedledee tweedledum with telomerases that build up as you age.

I come from a different type of healthcare system, and to see young patients die of infectious disease illness, for lack of access to good critical care, while Octreotide is being pumped in day in and out to decrease fistula output in a multiinfarct dementia patient makes me sneer sometimes in irony at the refrain, " whats a life worth"

I would mention-we need to ration moneys all over the world- the apalling disparities are out of sight, out of mind for the ones that demand FULL CODE.

Think of a flu pandemic with acute respiratory illnesses overwhelming the number of ICU beds available.I would think of lives saved, then QAL saved than QALY saved.when deciding who needed to come to the ICU when beds are less.

I found this hard to explain to a foreign medical student who was visiting during my residency in India- we aren't Gods who mete and dole, no one is losing his dignity in being told that it is the end of the road for him and that we do not have anything to offer, or to eat and sleep well and not worry about advanced HIV/AIDS which will kill him one day, for buying medicines for that is 10 times more expensive than his monthly income. My intentions are as noble as Bill Gates', but I don't have a fraction of his chauffeur's fortune.

If I have 10 syringes and 20 pts- I have to decide who needs a test and who does not. If I have 200 syringes and ten patients i decide how many different tests I can run on each patient as 'work up", If I have 20 syringes and 10 patients ( and were in America) I will decide which 3-4 pts need all the "work up", whereas if I were in Canada i will be racking my brain deciding what 2 tests to do in the 10 pts.

She got the drift of it.

Image from original article

What are the chances.......

2009-04-27T18:52:00.002-04:00

That this daily run of the mill random patient that you see in the ER with all the pattern of symptoms that have become second nature to you to slot and eal with, is an initial manifestation of a rare syndrome that you existed only in the small paragraphs of the end of the chapter in Harrison that you never read?

That would depend on the questions you ask I guess. No one comes to the doctor saying I have Langerhans cell histiocytosis or MELAS. You could be very comfortable treating these guys as "COPD exacerbation" or "young stroke with negative work up" and never know for once whats going on. It runs well with your spiel of things- protocol done, rehab worked out, patient feels well, D/C to nursing home.

You could very well put it the other way around and ask, well......WHAT ARE the chances?

Well.....it all depends on the questions you ask.

Full code

2009-04-25T20:31:00.003-04:00

Some day the old guy with multiinfarct dementia with PEG tubes pumping tasteless Jevity 1.5 into his stomach, trach to breathe, multiple aspirations of garden variety flora , MRSA in his maniacal decubiti, VRE in his pee and shit thats C difficult to solidify, will wake up and live his life.

The life where he could get out and smoke some hash , sell some Percocet on the street to add to his income from disability /social security checks , get mugged/shot/stabbed walking home with the booty- all this while battling his chest pain that someone told was from the coke- bah those guys, its the itch from his sternotomy sutures, nothing more- and making occasional visits to the dialysis center, suffering for some stupid genes that his ancestors handled him besides plus size jeans thats family heirloom , battling the stupid BiPAP machine at night when sweet love slept with her own.

That life beckons to him - he craves to get up and move on. It is more than just a sexually transmitted disease, or an accidental collision between sperm and ovum with randomness of Heisenberg or phylogenetic boohah.

You can choose life, choose a job, choose career, Choose a family. Choose a fucking big television, choose washing machines, cars, compact disc players and electrical tin openers. Choose good health, low cholesterol, and dental insurance. Choose fixed interest mortgage repayments. Choose a starter home. Choose your friends.

Or you can choose to live life this way and never die.Because them guys told em all "to do everything."
Just as he did everything man.

Italicised material by Mark Renton from Trainspotting

I am.........

2009-02-20T22:38:00.004-05:00

Mulling over lots of things...........,

Waiting to get some time to myself.........,

Checking lab values on my CCU patients, half guilty to be on Mozilla and Azyxxi at the same time....,

Eating Graham's crackers and snack biscuits with Sumatra coffee to keep me awake...,

Thinking about points of no return and then thinking maybe it is all relative to which direction you are pointed to initially...........,

Wondering where my reading habits went....,

Trying to read end of life care from the UMMC website, arguing with microcerebrate ER nurses, correcting Calcium,Mag,phos on phone-wondering about whether it really matters in the end to have pristine numbers on your metabolic facebook page......,

Still getting a hang of: - living amidst the panicogens of C diff-MRSA-VRE-ESBL than Kochs ; Percocet- Dilaudid-Darvon than Fortwin-Phenergan........,

Waiting for warmer weather, longer days........,

Moving, or trying to...from laissez-faire mode to hitch hiking mode.....,

Wishful I had my own books here, planning my MRCP, also wanting to do a part time masters, struggling to keep up with my research modules..........,

Flipped out at how someone can have a Minnesota tube shoved in for 2 days, have 30 pRBCs and countless FFPs transfused, still bleed like a tap at endo, and finally be made comfort care, never awaken and die......,

mulling over a lot of things..........,

Essentially.

The rest of ......being.....or not being

2009-02-20T22:37:00.000-05:00

Quite as much as I sometimes regret not learning Shakespeare and English poetry from tatha while he was alive- I was weak in maths and needed my dose of Hall and Knight to kindle my left brain too , I also am thankful to some of my teachers who chose to rush through the State board books so that they could teach us some' real stuff'.

I have never met Ms Ramaswamy later, but the pains she took to etch Othello's soliloquy " It is the cause, It is the cause, my soul......" into my memory, or the para by para pauses she took while we painfully trundled through Wilkie Collins' Chandraphattar, or when she let me do my stuff when I differed from what she advised- and ended up hopelessly wrong, all, quite make her the best teacher I have had.

Was reading the rest of the lines after the most quoted lines of Hamlet. We were taught just the first four lines....and I thought that was it. I figured out that the rest was too heavy on existentialist stuff...too much for 8th graders. But then for blogPOST- erity, here goes:

To be, or not to be, that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles
And by opposing end them. To die—to sleep,
No more; and by a sleep to say we end
The heart-ache and the thousand natural shocks
That flesh is heir to: 'tis a consummation
Devoutly to be wish'd. To die, to sleep;
To sleep, perchance to dream—ay, there's the rub:
For in that sleep of death what dreams may come,
When we have shuffled off this mortal coil,
Must give us pause—there's the respect
That makes calamity of so long life.
For who would bear the whips and scorns of time,
Th'oppressor's wrong, the proud man's contumely,
The pangs of dispriz'd love, the law's delay,
The insolence of office, and the spurns
That patient merit of th'unworthy takes,
When he himself might his quietus make
With a bare bodkin? Who would fardels bear,
To grunt and sweat under a weary life,
But that the dread of something after death,
The undiscovere'd country, from whose bourn
No traveller returns, puzzles the will,
And makes us rather bear those ills we have
Than fly to others that we know not of?
Thus conscience does make cowards of us all,
And thus the native hue of resolution
Is sicklied o'er with the pale cast of thought,
And enterprises of great pitch and moment
With this regard their currents turn awry
And lose the name of action.

What was Osler thinking when said....

2008-12-29T13:38:00.002-05:00

"One of the first duties of the physician is to educate the masses not to take medicine."

But engineering or architecture or law?

Whoever coined the word Ambi go US did not know that south Indians mean dude when they call you 'Ambi'...which btw is an infinitely more buddy word than anna or thambi.

Medical innovations

2008-12-24T18:16:00.002-05:00

Cleveland Clinic hosts a medical innovations summit annually where they do a Forbes like listing of a Top 10 innovations for the year.

Plenty of jhinchak stuff.....put especially alluring are percutaneous MVR- imagine the prospects for a country like India where rheumatic heart disease is much more so prevalent than the US ; diffusion tractography- I always was amazed at MR neurography as a diagnostic imaging technique and always thought neuropsych testing prior to neurosurgery was so much a crude way of permitting a neurosurgeon to through the complex jangle bangle of cortex; diaphragmmatic pacing - reminds me of one of my patients whom we had a hard time getting off the vent...pity we get to read about just 10 of the 100 or so ideas submitted.

Also interesting to read is the last page: 'where they are now' Sounds like an alumnus page for some residency program. Some treat!!

Sometime in the past I had posted stuff on more low tech innovative medicine. Such contrast!!
But things do work. As their brochure says..the difference between creativity and innovation is the action that follows the idea in the latter.

Optimus Prime..

2008-12-19T21:22:00.004-05:00

"It's the sense of touch. In any real city, you walk, you know? You brush past people, people bump into you. In L.A., nobody touches you. We're always behind this metal and glass. I think we miss that touch so much, that we crash into each other, just so we can feel something."

------Don Cheadle in Crash

I wonder.......

2008-12-04T23:26:00.002-05:00

How one can play out a Halo3 on streets with real people and blood and gore without hemp in your system, which, you choose to intoxicatedly call the J$#*d.

Paisa Pay Pal Pal

2008-11-25T01:50:00.002-05:00

Ever and againI fear that the amount of money I make/will make, will become what I judge myself on to have been successfull or not.This sends shivers into my nuts and bolts. The American way of things- or at least the desi version of the AWOT-gain leading to wish,and wish leading to gain; credit, credit traps- muddies up the horizon. Like a creatinine clearance curve, it is the initial few steps you take that are critical to get you on or off the Interstate 90 of your life in the US. For once you have the small luxuries sorted out- Toyota Camry, decent house, purchasing power of nonparity- there seems to be no end as to how much you can want or buy.It is excellent if you don't have the monetary means- it only helps build your credit score. It makes me crave for the dirt and mud and smoke of home at times.I feel more comfortable dealing with mud and grime than greenback slime.

ICU meanderings.....

2008-11-25T00:25:00.004-05:00

It has been unusually light this week at the ICU. Have to say thanks for that. I have a loong post thats waiting to be edited and posted....haven't gotten the time to put digit to keyboard for that.Have been diligently enrolled in the mundanities of living the American way. And winter gnaws at the spirit of existence like dementors sucking your souls into their nothingness.Activity peters down to BMR levels( basics mein raada I mean) besides an occassional visit to the gym.The snot that maketh you dries in your nose and your lips shrivel like the leaves whose chlorophyllosophy has been made mockery of by mercury falls and snow flakes.

A slowness comes.......
When thyroxine and cortisol struggle
Against the dominatrix chill
Fat cells fondueplicate, mornings are stiff
Brain is numb,Where's the strife,
This lardaceous life.

Reflective, not reflexive

2008-10-17T15:46:00.002-04:00

Long time since I posted anything on my blog. Getting 'settled' into the rut of things does take its toll I guess. Having got the 'hang' of things I want to look into the mirror , stretch out and relax, with my cuppa.........

Came across this delightful piece in the NEJM this week: makes me so happy I trained under DRK. His non expressive "I don't know" makes so much sense when you decide to sit back and look at the larger picture . It is like extrapolating the gestalt logic to each individual person. Like: meet Mr Paul: he has a large nose, a few crepitations down his left infraaxillary area and a few nodes in his armpit: and no, he does not have sarcoid please. Thats Mr Paul. A unique person going by that name, not a syndrome Paul but a Mr Paul.And since when did his name become some Wegener something?

Snaps .....iTrip (ati)

2008-06-02T05:29:00.009-04:00

Just back from a back breaking, skin tanning overindulgent trip. Savored every bit of it except an occasional migraine. Needed something close to hold on to before I take the social
lemming- jump into the Indische Ocean across to starting a residency in being non- resident- of- India. So IInd Class sleeper berths and state tourism bus travel was a blessing in disguise. Suddenly I felt like an Amitav Ghosh mated with William Darlymple type of person with a wanderlustful Pico Iyer thrown in for good measure. And the mood, waiting on the fly infested Pune railway station to embark on the "Dadar express" was deliberately Rubaiyat like "ah my beloved fill me the cup that clears...."- I wanna wanna sinfully indulge myself this time like this trip were a juicy hapooos amba that I shall never get to eat again.

I had been reminded some time back by a cousin from a nouveau- riche background that my parents were second class citizens who would never travel by car even if they were to buy one. For once I seemed to be happy with that statement.What with no chakks on the train, lots of laddus and Banganapallis - larger, sweeter and cheaper than the over rated Devgad hapoos- to get softishunderbellied on, backpacking with a Bhavnagri plastic bag through toasty dusty hot AP.......ekdum jhakaasmaal!!!!!!

Some snaps.......

Snap of the main temple at Tirupati. With my 1.3 MP cellphone camera!!!!!!

The sky is my roof, the earth is my playground.Astra Castra Numen Lumen

This is a shot from a distance of the same temple gopuram and the promenade around where folks camp day and night.
The one really great thing in this snap- no, I am not referring to the golden dome inside the temple- is the verdant greenery in the background. If you feel claustrophobic amidst all the sweaty taklu crowd, you can always choose to cool off in the hills around the temple area.

Pushkarni.
Watching the people do their rituals here I thought I got some idea as to why the bathing ghats at Benares are such a draw for folks all and sundry. What could be so interesting about people dunkin themselves in water? Well....come and watch.....

The train rambles along, stupidly, trying to catch up with the sun, as the tracks wind around- sometimes west, running directly into the sun as it arcs into the horizon; sometimes north, disadvantaged by trigonometric inanities of resultant vector and all that stuff.
Life and Times are playing out their parts outside windows with railings like Pozzo and Lucky, while one watches listlessly inert,like an Estragon, as the scenery evolves from verdant green to burnt sienna to orange and magenta to finally pitch black. Only an amber signal light flashes in the distance somewhere.

To the Lord of Seven Hills

2008-05-26T05:25:00.002-04:00

I am taking a break............

Pappu chala Pardes

2008-05-20T13:14:00.002-04:00

Not many posts this month........

......amidst hours spent on Mahabus and the rambunctious BEST no 66- front seat upper level, in Ruby hall Poly OPD and Nair Hospital Anand Bhavan flat 19, wandering through quaintly unfamiliar- now KEM corridors and the disorderly forums on immihelp.com, soothing gadolinum thrombophlebitis and sore Latissmus dorsi, fixing houses and spouse grouses, cycling through Kalyani Nagar Koregaon park Kawde Road Keshavnagar and Kharadi and other heterosexual streets of Pune listening to Enigma, Eagles and Simon and Garfunkel's sweet Mrs Robinson, pushing my petrol budget with experimentations based on the quench effect and 4 stroke faith while the heat burns me amber and pop goes the diesel, doing paper work, more paper work and still more f@#$ing paper work, shopping lemon squeezers, tea strainers, roti belans, kadhais and neck ties, rounding on Kochs, more Kochs and still more f@#$ing Kochs, deciding and undeciding about wasting some time on IPL and finally giving way to inertia , only to be plagued by the guilt of art being long and time fleeting and the muffled drums beating couch po-tick-tack-toeishly................

I didn't get time.

Hope cries
While a moment dies
And time flies
Amidst existential lies

The vegetarian ass

2008-05-01T05:21:00.003-04:00

As an epilogue to the Buridan's ass problem, I give you this........distilled from an argument I had with Sanjivani last week- she is an obligate omnivore, and highly opinionated about the same, and I abhor those who can suck the marrow out of a leg piece and crunch on hydroxyapatite remorselessly.

So here goes........

Suppose two people were stranded on an island, some spaceship from the Aandupaandu galaxy offloaded them there by mistake instead of discharging at the restaurant at the end of the universe. Now this is no Blue Lagoon mannaland sadly.The island is one with the bleakest of landscapes such that nothing grows there- not a weed of andropogon or a tuft of grass or even some poison ivy, no animal has ever set foot there, even the fish swim miles away from the coast of this crazy place. Let's call the island Duravida- hard life.There is just a spring which supplies fresh water, so you don't die of dehydration. Get the drift? Well then......

Now

1) Scenario 1: Person 1 is a carnivore, like my friend. He can tolerate the hunger pangs for a few days. But when desperation and hypoglycemia clouds his senses, he will not hesitate to kill his companion to eat him up.

a) Lets say person 2 is also a like minded bloke, thinks exactly like person 1. So one day both, in compos non mentis due to hunger and their unevolved, carnivorous survival of the
fittest instincts egging them on, decide to kill the other to survive. As one delivers the first
blow, the other realizes he has to fight back and machetes the other, the end result being
that both are lethally wounded and don't make it to their goal to eat some meat.

b) If person 2 were a vegetarian- It is against his .....moral gut instinct we shall say......... to kill and eat. He will never think of killing person 1 to eat him. He won't even realize whats on
person 1's mind when he delivers the first blow. Too stunned to hit back, he will eventually
be killed. If he were quick enough to realize his position and strike back in self defense, may
be he might kill person 1, but he will still not eat him.So while person 1 dies of greivious injury, person 2 dies of starvation!!!

Scenario 2) Persons 1 and 2 are herbivores by choice. So even when hunger gnaws at their very person and ATP molecules pop away into oblivion like goli soda, their determination not to kill each other, or even ignorance of the existence of such an option will send them both packing towards the pearly gates where a Mahatma awaits them.

Dulce et decorum est.........

So - what do we have..............both die, one lives, both die, both die.

Result 1-0 for the carnivores.
Shall we say this is a victory for them? Wait a min....... what happens to person 2 after he has killed person 1. There is no ship in sight, none shall ever touch shore there. Not a vulture to kill and feast on!!!!!! He shall eventually starve to his death too, (or maybe even start to eat himself up?!!!!!)

Kya jholl hai!!!!
(Sanjivani's reply: Kahi hi haan!!!!)

This is not my indignation/malafide mudslinging against those who choose to eat meat or any hosannah or piece of propaganda for believers of vegetarianism. It is just a hypothetical situation arising out of an argument. Needless to say, cannibalism, if and where it exists, is strongly condemned by the author

udderly bored...... some divine bovination from the Holy cow!!

2008-04-20T15:22:00.003-04:00

If you breathe in, you inspire.......If you don't you.... expire

2008-04-15T14:33:00.002-04:00

A yoga teacher had once instructed me to just observe my patterns of breathing while performing ADL, and doing so I had been surprised as to how we take for granted the inflow and outflow of air out of our lungs to occur like it were an irrefutable absolute truth- like it is as true as I am or you are. We exist because we breathe. Since our existence is not doubted, so also that air will move in and out, this cannot be impossible.

To me the COPDs were always the hukkahwallahs, who never went to the chest med OPD despite repeated 'warnings', came shamelessly again and again to the EMS bearing with the grudging and abuses of the EMS staff.....for they came there to regain the ability to breathe. Not all were smokers- a large proportion was of patients with byssinosis- not their fault, some post Kochs bronchiectasis- again not their fault, one with Kartagener's-who cried helplessly, I remember, at being told that his sperms were all dead,some Cushingoid with years of steroid abuse, one mama who said, "kabhi to marna hai, beedi peekay aish karte marenge, kya galat hai". I had never imagined or associated any emotion with them.....a few nebulisations, an antibiotic if needed...and they're off.....till they get an exacerbation again. What could you do anyways? "Fefda kharab ho gaya hai.......kuch nahi kar sakte......dum to lagna hi hai........sahan karo...." The worst I had faced myself till then, was a blocked nose......extremely frustrating. But nothing compared to this- from an article in the NYT.

Ondine's curse was a theoretical entity for me till I managed organophosphorus poisoning patients, whom we had to fight with all night to remind them that they had to breathe if they wanted to live. Neurology registrars laughed at me when I made a diagnosis of central hypoventilation in a patient with recovering Lance Adams. But when the patient died, undiagnosed, I was surprised how they could digest their inability to point to specific reasons.The very thought of needing to remember that one had to breathe, and knowing that if I sleep I shall not breathe, and hence die was too ghastly to imagine in real time. Shaila Vartak was embodiment such a curse, and getting her off the ventilator was an achievement we shall ever be really proud of.

"Myasthenia hai".....the neuro registrar seemed cock sure.I felt something was amiss. She was middle aged Konkanastha brahmin, middle class, coming with a history of fatigue, diplopia and recent onset of weakness. No thymoma, RNS not conclusive enough. Electively intubated and steroid, Azoran and pyridostigmine upped to max levels.......no response. Should we do plasmapheresis? We decided to redo the EMG......and repeat EMG revealed that Shaila was suffering from a muscle dystrophy. So while leptospirosis patients with ARDS waited for ventilator vacancy, we fought with Shaila, fiddling with SIMV, pressure support, low tidal volumes, postural variations, 2 ventilator associated pneumonias, progesterone, acetazolamide and analeptics, countless trials of weaning and sheer desperation. Shaila could walk, but she could not breathe. She could even AMBU herself if someone was busy with some other patient.I never talked to her as she was on trach for a loooong time. But finally when she was weaned off onto a nocturnal BiPAP support...after 2 long months in the ICU, we felt jubiliant that we had achieved the near impossible.

" Jor jor se saans leti hai isliye haat paanv tedha hota hai aur fit aata hai".........me,explaining carpopedal spasm to a histrionic teenager's relatives in the EMS!!!!!!

And I am learning Spanish......

2008-04-13T04:17:00.003-04:00

How difficult it seems then to think of a thought, to form a sentence in English, to translate each word into Spanish based on a presumedly instantaneously accessible vocabulary databank, to check for grammatical correctness and language specific plausibility,to string them together in right order, and to vocalize, all this while maintaining collective stream of thought in a conversation.!!!!!!!

Medical shorthand

2008-04-13T04:05:00.002-04:00

Some more stuff ..I believe from the BMJ.....continuing from an old post - medical short forms.

Buridan ka gadha

2008-04-08T04:35:00.002-04:00

The ass: placed equidistant between two equivalent piles of hay, the ass could not make up his mind as to which to choose to go towards first and feast on, and thus starved himself to death. Had there been just one pile, he would have lived.Don't blame him. He was just being perfectly rational. There was nothing to choose between the two piles in terms of size, quality of hay or the distance they were from him to the smallest measure.But the result was that our rational ass could not make up his mind as mounting hunger kept clouding his ability to do so, and finally died of starvation.

Buridan, had he been there: Above all, it was irrational to starve himself to death. Thus although it would be irrational to choose which pile to feast on based on just one turn of pitch and toss, the ends justified the means in this case.So Buridan tossed a coin, and based his decision on the result of the toss. (Let us say it was a pile of bread, for Buridan is no ass.)

How do we choose which path to take when we know nothing of where either leads us to? Simple. Na?

On a lazy sunday afternoon......

2008-03-23T05:51:00.003-04:00

I was leafing through the first few posts of this blog.

I had also happened to buy the Times of India today after a long time and , starting from the last page as usual , I happened to stop by a snap from a later page of a lagoon in Costa Rica which was supposed to be azure blue due to some chemical reaction between CaCO3 and sulphur in the waters. Now the catch was that this snap was printed in black and white.

Which means:
- The lagoon could really be azure blue and this was a printing error, the TOI put up a b/w snap by mistake.

- The snap was a wrong snap, it really was not azure lagoon in Cosat Rica but some murky green one with moss and weeds in the east.

- If I am color blind to blue, how would I really have made out.Would it have mattered to me anyways?

All these three situations are possible reality situations. The ultimate reality is the existence of the lagoon . But hardly anyone who reads the TOI Pune is going to go to Costa Rica to verify.So all these are realities in their own sense.

We support our inferences in a realm of stochastic determinism of things.The qualities of things is determined by the known quantities that they resemble. The lagoon is blue because it resembles the color of the sky which is known to be blue. But if we come to know of something that does not resemble anything we already know of? Like ..... describing how fortification spectra of migraine look like without really seeing them, or ...something that you will ever have to guess but never know for sure....what does a patient with Wernicke's aphasia think of or dream of if he never understands the environment around him??!!??

Reality is a bit like Heisenberg's principle.
Electrons jump back and forth, atoms and molecules change, the thoughts that are formed of long term potentiation due to molecules at the CA1 region in the hippocampus should mutate if the basic structure of those molecules is relative to the observation moment.

When I surf through the phonebook of my old cellphone handset I am randomly presented with names of people I had known but whom, for lack of presentation to my sensory apparatus had' forgotten'- Chandu, Vilas AKD, Geeta staff, Ankur, Nilima, Sayali, Shridhar, Sunanda, Sushil , Suyash, Varsha Shevgan. As I scroll through, I can conjure the faces, how we interacted, the scenes of interaction, the circumstance. The palette fills in gradually.

We change so much over time- is a cliched reality. But we change relative to what?

It is like alluding to the question of the ship Theseus. When a new ship was recreated from components of the old ship, and a reconstructed old ship stood beside, which was the original Theseus?The new one made from components of the old, or the old one which was the original, but had innards which were all replaced.

Am I the me who cycled the lanes of Rasta Peth on a Tobu cycle at 10, or the random medical student who was trying to romance KD Tripathi and the hernias of other people at 20 or the person I am now? Can I be like a Beautifully American Kevin Spacey shot in his temples visualizing his life from his childhood to his tragic demise in the last few moments in a flashback(or more pleasantly like a sit like a Forrest Gump on some bench in some park at the end of his eventful soiree of a life) and point out that this, whatever it is, was/is my baseline?

Time is potent, and memory fickle. Surfing through older pages of your blog, you will wonder....did I ever really think like this? Why so? And if you never happened to visit those pages, you will never get the answer.

Being aware of all possible situations- the blue lagoon, the mossy green lagoon, and the blue lagoon in black and white makes me more comfortable. Maybe

Innocents aboard

2008-03-19T12:25:00.002-04:00

Amidst the bedlam of the IID course coordinating chaotic case discussions and listening to cute Italian accents, a once in some time incident like the one below provides for much humor as much as it sets you thinking.

"Doctor, मला ना कुत्रा चावला. मी दोन इंजेक्शन घेतले."

"कुत्रा कसला होता? आजुन कुणाला चावला का?"

"नाही हो, घरचा कुत्रा आहे. Palmolin कुत्रा आहे.त्याला पण वाईट वाटला असेल, म्हनून दोन divasa पासून कीव कीव कर तोय. मला ना दोन तीन diwas झोप नही लागली"

" अहो घाबरु नका, इंजेक्शन घेतला ना तुम्ही, कही नाही होणार तुम्हाला"

" मला कसला काय होणार, tya कुत्र्याला majhyapasun HIV झाला की माझा भाऊ रागाव्णार mhanun मला भीती"
!!!!!!!!!!!!!!!!!!!!!

Metamorphosed

2008-03-12T22:22:00.003-04:00

Just a random thought, nothing more:

If Kafka's psychological continuity is not counterintuitive- it isn't, is it?
Then human cloning is not so bad, apparently.
For if mind makes man, then who would mind a Mahatma Gandhi who looks like a Brad Pitt, speaks like a Churchill, waxes oh so eloquently like a Shakespeare, and yet thinks like himself.

And when he dies, he wakes up as a beetle.

How the mighty have fallen.......

2008-02-27T10:30:00.003-05:00

There have been people who've been directed to this blog from google search results for phrases containing the word '5HT'. Folks, sorry....it's just a name that occurred to me while creating the blog.
With the meta-analysis published in the PLoS taking a symbol of hope away from ironically those wanting hope-help-worth, I expect more people to be misdirected to this blog. Sorry again.
But I do feel amazed that the symbolic blue white capsule had given hope to so many who had lost it all, when it was no more than just a placebo.Or so they say.If anything it is a tribute to the powers of placebo therapy. Shrinks will argue about anecdotal cases of miraculous recovery, those who have recovered will swear by it really being the feel good pill.But in the hard unforgiving world of show-me-the-figures, prozac draws a null.

I have always been surprised that drug trials when comparing an outcome between a test drug and placebo always show nonzero results with placebo. The opioid theory is understandable for nontangible outcomes where there is a human element involved or symptomatic relief is sought, but not where there are hard quantifiable objective outcomes.
That placebo is not superior to no treatment was elucidated well in this great piece in the NEJM.The authors however agreed that when subjective or non continuous outcomes were analyzed then placebo did make a difference. Here we can discern the difference between the "science" and the "art" of medicine.For the individual patient feeling good is not the same as a clean coronary on cath. Just as a clean coronary does not mean end of therapy. How many busy cardiologists can claim to successfully treat such a patient? If your jeera goli homeopathy can succeed in that, then all the figures can go screw a hyena.

Ain't I talking like a GP?

Happiness was just about feeling happy
T'was not "not feeling sad"
The they made a pill to make you happy
Now it really doesn't work,..aw!! thats really just so bad!!

This too shall pass

2008-02-25T09:13:00.002-05:00

There was a time when I would spend all my time in just reading. I never felt guilty of not doing anything in life but reading. Then life was not stressed with things like a stable bank balance, settling in life and all that jag. Pages after voluminous pages of Harrison/Nelson were guzzled like some maniac Oktoberfest OCD. Private practice was a sinful abomination, and the GP was then what one should not be like- mediocre depraved cold cough remedier of Multivit A to Z school of medicine, coached by cravatted dumb-em- down Med reps and slaves to the Pharma dementors.

The essence of existence then was to dream, close eyes and float spenta amertal on raf kinases propelled nanomotors, hiking through TyKs seeking all that is new and unique, and catchy, perhaps contorted- looking for the rare syndrome, the gestalt agglomeration that stretched the limits of your associative memory – Tore Solente Gole or Rubenstein Taybi , LEOPARD, LAMB/NAME. and all that fancy pansy orgiastic quasi-intellectualism. What was the motivation to hoard so much ‘knowledge’? It was a phase where the more you know/memorise, the more successful you were. The secondary gain ( should be primary gain??-perhaps??) of this cannabinoidated phase of life, was learning how to read, what to gain beyond mere pages of print, how to browse the authors list in a book and imagine the his/her personality, work, workplace- looking at perhaps how to learn to think like the rara avis that dreamed of gene splicing or histone deacetylases or gene sequencing and all that jhakasmaal.

That salubrious cirrus does not however feed the mundane rigmaroles of nine to five (to perhaps nine.) The bottom line being that “No one pays you to just sit and read.”

When I visited the book exhibition last week I really felt like buying every single book I liked and wanted to dirty with pencil underlining and comments and doodles like in days of past. But unfortunately I do not have the money to satisfy my fetish.
I hardly seem to get time to sit and read I tried to reason with myself. When will I read if at all I were to buy Bartlett’s tome or Fishman or Feigenbaum. ?
Amedeo is left undisturbed since Sept 2007, CCO sends me more updates than I can keep track of. OTM by June is a target that seems fuelled by a bit of misplaced enthusiasm. Schlossberg seems to be gathering dust as I seem to be drifting into that private practice mould of work. Surprisingly I do not find myself worthy of all the maaki stuff I used to think this type of functioning merited being called. This too shall pass. Maybe.

Movies have already been hijacked out of the budget of the middleclass mensch by the multiplex mafia. Now we shall have the IPL brand of superfowl larceny. Tickets for 500 and 750 to see your city play!!!!!!
Sharad Power and his BaCChI have demonstrated its testicular/dallar fortitude amply, but the bidding telecast where a Bombay dyer fought a booze badshah and an androgynous filmstar for nonsons of soil was a mockery of the Utappam Dhoni breed of cricketers, not ‘tribute to their merit’ as some moron Suhel Seth would have us believe.

As they say: ‘the difference between men and “boys” is the size/price of their toys’

Ha ha ha....!!

2008-02-17T23:17:00.003-05:00

"
We then simultaneously noticed another pedestrian walking towards us, with the biggest bulge EVER in the crotch area of his jeans. Incredulously, hubby looked at me and mouthed the question: "is that an erection?", to which I immediately replied: "no silly, that's just a huge hydrocele!"
"

From a blog called urostream .

Quid novi ex Pune

2008-02-17T21:37:00.004-05:00

DNA comes as a whiff of fresh air amidst the stench of the Times . No ads apart from classifieds means you do not have an inane full page obit for some peripatetic industrialist's mother who breathed a wretched last breath after a year in the BH ICU on bi pap for COPD, or SITA/SOTC tours' lewd ads inviting a nouveau riche upper middle class for a Thai/European jamboree for " fifty thousand per couple only for 5 days 6 nights in the scenic Baden Baden on the Jungfrauroch, savings galore". Nothing irritates you more than a huge gimmicky full front page ad for an IPO for some real estate company.Thankfully except a single ad in the lower right of the front page, this paper does not have any ads.
Brownie point score:1

The layout is cheerfully colorful, but thankfully does not get cheesy on coverage. (plus 1).
There is some page three nonsense for those who categorize this piddleshit as news.But thankfully that comes as a separate 2 page supplement, unlike the 7-8 page piece of toilet paper that sells as PT.(minus 0.5) It ain't pretentious about the shibboleth of journalistic courage- or whatever they call it- like the IE- c'mon BOFORS was in the time of Chitra Subramaniam, they don't have such a big geese around to cook nowadays, and anyways the television channels break wind breaking news on some "sharmnaak vyakti Shakti or be- imaan swami, khoon se haath rang lene wale doctor" by the hour. Whats new? And frankly who has the time to read' exclusive to the times' anyways.

Coverage is passable, often petite and interrupted, and not extensive like a Hindu. But writers are good. You do not end up missing a Bachchi or Mukul Sharma, certainly not Jug.Sample this interview with Christophe Jaffrelot ( who's that?) His analysis of the Indian middle class is quite novel and interesting. I would have preferred to read something like this on a Sunday rather than Malavika Sanghvi's torture on the emotional upheavals of the so called creme de la creme, or how some Neetu Singh struggled through married life or what Tina Ambani likes for lunch.( plus 2) Local coverage is okayish, but international news and sport lacking in purpose and just copy paste from AP/NYT. They could do with a Sunil Gavaskar or Rashmee Roshan Lall here.

The package in Mumbai was a steal- Rs 220 for the entire year. I do not know the pricing in Pune. But all in all good baby steps ab initio......but I hope it stays this way. For ratings 3.5/5...paisa vasool for Rs2/-.

(Disclaimer: Opinions expressed here are my own personal, and not intended to defame in any way.)

Vulcanised tools

2008-02-10T10:28:00.000-05:00

Interesting debate on whether condoms are the answer to non HIV STDs, or not.
The latter makes more interesting reading.Invoking the Einstein in saying that it is insanity to do the same thing again and again and expect different results, the author seems to take a holistic view of things. He makes an important point that we should not be naive to over rely on one single gurumantra- for experience with life is often counterintuitive on these grounds, and thus there should never be a gurumantra for everything. This de-seeder of sorts, slayer of Jesus juice is a catchy, fashionable slogan for the Bono- Gere brand of humanitarianism, but still seems a tacky band- aid when the statistics of usage and adherence are hammered out. After all, as Dr Telang would say, who would like to eat a chocolate with the wrapper on?! The important tool that should be used more frequently is health education. Till then condoms are no better than water balloons used for holi.

Interesting anecdotal cases that I have seen more than incidentally now are seropositive couples infected with a mix of mutant virus thats resistant( usually the husband, usually alcoholic) and wild type virus thats sensitive ( usually the wife, usually faithful to the spouse) and still preferring to eat the chocolate without the wrapper on, and horror of horrors, ending up pregnant!!Think of how we are falling short here.If you get any answers, you have solved the enigma of the pecker decker.

The A to Z of AIDS control makes for entertaining reading if you go through the entire list (in the first article). When something starts with A for abstinence, you know where you are heading. But fortunately/unfortunately, those are the guys who have all the money. So the no glove, no love slogan will keep ringing in our ears then ad nauseum.

...................

2008-01-24T11:34:00.000-05:00

Immunology, as taught in the MBBS curriculum was always fascinating.I still vividly remember Ananthnarayanan's extremely content intensive Harrison type chapter on the immune response.I was reading about Niels Jerne's antibody idiotype network, Susumu Tonegawa's VDJC splicing, the same time as I was seeing cases of Wiskott Aldrich syndrome in peds wards and was learning about GVHD and TA-GVHD from Dr Apte at his clinics. Same time Jayshree was cured of acute lymphoblastic leukemia. She is doing her patho residency in Mumbai now. Perhaps apart from critical care no other branch of medicine gives you the satisfaction of having gone to the brink with the patient and been back to see the light of day.Hearing Mammen Chandy speak at MBA's hemat CME was another inspiring moment. It was the most lucid and simplistic explanation of the PCR that I have heard. From Dr Chandy's mouth it sounded like music.If there were limits to achievement in the medical field, this was the specialty that was tearing to have a go at them, then I had thought.For everything seemed so intuitively simple- that these guys were playing high stakes of life and death along Kaplan Meier slopes with ingenuity and logic as tools seemed astonishing.

This week's NEJM features an amazing series on kidney- PBSCT co- transplantation and immune tolerance with microchimerism. The case report of the liver transplantation done on the girl with FHF is a perfect example of how perspicaciousness, and perhaps more importantly common sense, creates wonders when serendipity offers you the chance to do so. The decision to withdraw immunosupression when the hemolysis developed was a masterstroke to an amazing turn of events.Even more delectable is Thomas Starzl's editorial on the three articles. Your day is made when you have such pedantry to savor from!!!!!!!!!!!

Cytomegalovirus

2008-01-18T11:38:00.000-05:00

Razzaq was distraught, shitting his guts out trying to strain out threads of mucus from his rectum everytime he had to go. It did his job no good. His life was lived in between embarrassing visits to the bathroom where colon griped and sighed and bore nothing. When finally the poopy tube was passed and his innards illuminated to shed light on the diagnosis, he was left with the question to answer...a lac a month for putting a stopper on the shitty bits? Quality of life was at a premium he could not afford.He asks me why he cannot have ischemic heart disease due to CMV- a chest pain is less embarrassing than a pain that gnaws at your ass and life.

Everyone thought Narhari had Pneumocystis pneumonia. Hypoxia, ground glass shadows, AIDS. Given sulfa/ pyri everyone thought he would improve. But he kept gasping for breath, ashen, cyanosed, wasted, sweating like crazy, tongue furry dry from his panting. He had fucked his way into his present condition, you might say, screwing prostitute after wasted prostitute while wifey dear and kids waited on his drunken tantrums, offered puja to Khandoba for his health, while the HIV virus dick-tocked away at his immunity. Then came CMV. Surreptitiously, like a Salazar Slytherin . No one anticipated, no one even thought of it..... as it ate into his lungs. What to do now?Who will get the Valganci? Fucker!!!!!!!!!

Sclerosing cholangitis is like a death sentence for all UC patients I have seen. AIDS cholangiopathy is a horribler. God save you if it is CMV. The sight of a deeply jaundiced, darkly pigmented, wasted patient with Candida coating his mouth is like a deep visceral queasy sensation of hopelessness tugging at your intestines.Anisa Begum pulled through amazingly. Her husband sold property, land.They mortgaged their house.The family camped in hospital corridors, ate out of her hospital food. After 2 long months finally she succumbed.Lifelong treatment, and, any success at it I have to state truthfully, would have sunk the family into an ineluctable pit of debt and misery. The Lord was merciful, shall we say?Reality can be so grotesquely disquieting.

Pandharinath withdraws 90,000 rupees from his provident fund each month to pay for the Valgancyclovir for his CMV retinitis.He is a teacher, and his savings are not much. His fundus shows burnt out CMV in the left eye with scarring and sclerosed vessels and healing retinitis on the right. Not very great results, but he can read now from a bare perception of light stage 2 months ago. It means a lot to him.

Sultamicillin

2008-01-16T09:52:00.000-05:00

An unusual off day midweek means I am cleaning up my Google reader. I have my Amedeo folder to clean as well. Lots of in things that I got myself in sync'd with: PAF, the Ezetemibe article, new guidelines from the DHHS and ADA,the cortosyn shock conundrum with seemingly decisive remarks. Wish I had a smartphone/PDA sometimes....hmm...but it does not go with my job profile does it:-)

Came across this one from the BMJ( trust them to provide you with your dose of masala) :Also go through the rapid responses if you are in the mood for more. I remember so many more- a journal like JAPI can print such stuff for fun value, if not the BMJ for reason of cultural differences/ monkey business or whatever you call it.These were slangs used by the residents for menial houseman jobs that even mama-maushi would not so/ hospital terminology that was mundane and dull...to spice up the dirty job.Here goes my list from my residency days:

Give Sultamicillin: Discharge ( Patient ko salta ne ka)

Mobilise the patient: Prime the patient's family for discharge. I thought it meant physiotherapy when Andy told me to do so first time.

Memo dena: DAMA( discharge against medical advice)

Sir ke Photo ka Positive/negative: Respectively MRI/CT- when CT was not revealing, to convince the guy to spend for an MR.

Parda lavaycha ahe: To the mama in the EMS. To draw the curtains meant prepare for ether swab administration to a lady with an obvious case of conversion disorder.Seemingly nasty- hence the curtains- but extremely effective for breaking a conversion when the 'lady doth protest too much methinks'. A bhayyanni going crazy all of a sudden is a nightmare if time is at a premium and ether swab is almost magical in the context.

MI Masala/"woh saat things": Asp/NTG/Captopril/metoprolol/Heparin/Diazepam/Dulcolax

FART: Fever with rash and thrombocytopenia.

IM session: Intellectual masturbation session.

Bada Lasix: 400 mg frusemide. Chhota Lasix: 10 mg frusemide.

Bevdology: Alcoholic cirrhosis and complications

Quadruple H: Over aggressive Triple H therapy for subarachnoid hemorrhage causing Heart failure.

Parkie/hypoT (Mandar/Mandakini among college junta): slow responses to questions by a patient.

Hivtaap: HIV medicine

James Bhaand/ All India Boat(finger) Club/PP( Pelvis Presley)/ Catch master: Gynecologists for their 2 finger procedure.I still ROTFL visualizing a handsome effeminate gynecologist holding his 2 fingers in black suit a la Roger Moore.

Anna Shetty/Kashi kings: Anesthetists, for wasting everyone's time making unwarranted referrals for pre op fitness just to save their skin.

Ampho nympho: Cryptococcal meningitis

Macchar/dracula: Intern. Poor fall guy who does all the blood draws, waking patients up at 6 am to prick them in order to finish before the samples go to the lab.

Yama, I see you: MICU, when patient after patient seems to succumb to improbable APACHE scores.

AB masala: Atul Borkar masala which consisted of Diclonac, Rantac, Reglan. Seemingly fantastic cocktail to buy time till reports of investigations ordered for arrive. In similar lines was a diagnostic masala of investigations made famous by EMS registrar- "kuch samajh nahi aaya to ABG, Creat, sugar, lytes karo...kuch nikal ayega"

More when I can remember.

Posts might dry up...am working almost 9 to 9 now.

Routine day in office

2008-01-14T14:05:00.000-05:00

Not to type for fillers:

Amongst other things- a guy with Troisier's sign, another with zero lymphocytes in his peripheral smear and on counter, but with a CD4 count of 3 on FACSScan!!!,

and this:

Triglycerides of 850, cholesterol 279, HDL above 50. On AZT, 3TC and NVP.No PIs!!

Also a revelation on how crucial decisions in life are sometimes made at such a ch#$ya level, especially when there is a doctor in front of you.

Hmm...

2008-01-14T13:41:00.000-05:00

I wish this hospital were as visible/ famous as it is good.

The J1 story

2008-01-11T04:11:00.000-05:00

Found this article about the spectacular success of the J1 waiver in the Washington Post. Shahbash guys!! And in true Gujju tradition they are making sure their precedent is being followed in earnest.

The DHHS( same guys who write the HIV guidelines) estimate whether an area is medically under served based on 4 main parameters- percentage of over 65 population, percentage living below poverty level, IMR and doctors per 1000 population. Based on this a score called the IMU score is awarded to the place from 0 ( most under served) to 100 ( least under served).

Now there's two pieces of stats I wish to bring to notice:

1) The percentage of people who live in a MUA according to state.Note, as you will click on the link, MA and Shah's state MD have a mere 5 and 6% people living in MUAs. DC is surprisingly ranked no 48 in this ranking!! And Mississippi, ranked last, still has less than 30% people living in MUAs. I guess in either case the poverty and DPR values skew the score. (For a family of three the poverty threshold is around $ 20,000 pa. ) And this statistic will be affected by size of state and population density too.

I would argue that the above 65 does not demographically fit well with the rest of criteria-but still Vermont ranks no 2!!

2) Search for MUAs in MA here.
See the number of places in Suffolk, Middlesex and Plymouth counties. I am attaching a county map of MA for reference so that you can get an idea of physical distances.Queire decir : You can be within an hour's driving distance from Boston and still serve in a MUA. I shall be PC and not make any comments. Those wise enough can make their own conclusions.

Decisions, decisions.......

2008-01-06T01:33:00.000-05:00

Times for decisions are tough times. If you want to gamble you can hit rich, but you ought to have a back up. I am playing things even because I have invested too much of money thats not mine- I am in the dumps as far as financial security goes- and time thats so frickin precious, and faith thats a one way road.....and want to do nothing to jeopardize where I stand now. I certainly do not want to live off someone any longer.I would have loved to work with MSF, they liked me too apparently.I would have loved to work at Harvard, JHU...opportunity does beckon. But I cannot afford it now.

Picked this one from a cricket forum:
Bhajji said, " abbe tere Maa ki!"
Symonds thought he heard, "hey monkey!"

Sperms in the peripheral smear

2008-01-04T04:15:00.000-05:00

Healthmap is a very interesting website for epidemiologists and Infectious Disease folks. A little bit like EID and MMWR combined. But I happened to discover, quite fortuitously, an interesting case we had managed in our very unit at SGH while scanning through the website.

Follow the link. Zoom into India using the 'alerts by country' list on the left side.You see a yellow Google maps like icon on Maharashtra. Click on it, and click on the 'PRO/AH/EDR>Trypanosmoiasis -India:(Maharashtra)' link. You will get the details in a pop up window. Of the three cases reported, the water seller from Pune was the one we managed at SGH. He turned out to be a case of Trypanosoma evansii. When the news spread in the department, it had everyone rushing to the pathology room to see the promastigotes squiggling along in the peripheral blood smear amongst RBCs .It was a spectacular sight, one I had never seen before; and credit must go to the pathologist who had the insight to do a wet mount on peripheral blood, and correctly identify the morphological characteristics.It looked like sperms doing a dance amidst innocent aciliate RBCs, playing langdi and phugadi drunk on Brownian potion. It was a sight I shall never forget.

I do not know if I can divulge any details. But my residents, and all others who saw will remember.

( Image is not original. It is for representative purpose only)

Hashimojo

2008-01-02T03:32:00.000-05:00

I always thought Howl was Alan Ginsberg's best poem. It certainly is one of my favorites..... how better can you capture hyper intellectual angst of a misunderstood, precociously overevolved flock than something beginning like this:

I saw the best minds of my generation destroyed by madness,
starving hysterical naked,
dragging themselves through the negro streets at dawn looking for an angry fix,
angelheaded hipsters burning for the ancient heavenly connection to
the starry dynamo in the machinery of night ...

And continuing hysterically nakedly capturing, like no one could, a homo- non- erectus beatnik generation gloating on the evolutionary superiority that their Hash- toxicosis supposedly gave them.

I read this poem right after I had seen a documentary on Baba Amte's Bharat Jodo cycle rally of 1985. The contrast of emotion was startling. A generation looking for a fixation beyond the oral/ banal - confused on purpose of getting up and living another day, comparing it ever to the ethereal surrealism of last night's high.Drudging through the monotony of morning and afternoon, passing into evening and then the orgiastic revelry of night, till tiredness creeps in.

And another equally confused generation, wondering how cycling through Kashmir to Kanyakumari would convince an ultra radical militant to stop hating, nay start loving, a politician to be sincere, or even make the country a better place, all the same driving morning though afternoon passing into evening when tired legs rested and weary minds chatted about life, poverty, illiteracy and all that which sounds so cliche in this day, now that we hear it from the mouths of any goddamned Akhthar, Akshay and Anupam. And one young boy said , "I don't mind the strain or the monotony of just pedaling all day, for the high I get in the evening talking to people like me, with education like I have, parents like mine and houses like ours speaking a language thats so different, from a place thats so far, but from a country thats ours,with worries like I have makes it all the more worthwhile." These might not have been exact words, but that was the gist of it.

Anyways, Ginsberg says somewhere else that Kaddish and not Howl is his best work.I had never read the poem before. But when I did( it is about his mother Naomi's struggles with insanity) I couldn't help notice where his Insulin, Metrazol incantations came from( repeated again in Howl). How well he documents the frustration of preserved insight and the craze of its absence is realized when you contrast the two poems.So many great writers have chronicled medical conditions in such beautiful detail.W Somerset Maugham was the doctor who wrote knowledge fully.But Dickens was no medico, yet chronicled in accurate detail Steele Richardson syndrome and Pickwickian syndrome decades before these entities were scientifically described. Tolstoy almost goes through Elizabeth Kubler Ross' stages of realization of impending death in The Death of Ivan Illych, while his description of the menace of Syphilis in those times is reasonably accurate in medical terms, as is the picture he creates epidemiologically similar in some ways to the HIV epidemic of today, with all the moralistic intonations, however untenable they might be in this PC world. I would rather not go into the Robin Cook genre or the representation of medicine in literature, thats a vast topic and there are references aplenty, even an entire section in the Archives of Int Med.But would suffice to repeat what one teacher taught us long back....

"to be a good doctor, you have to be a good observer."

He must be kidding!!

2007-12-28T00:21:00.000-05:00

I am reproducing an article from The Tribune dated Dec 13. It is a report of a summit held earlier this month where members of the American Association of Physicians of Indian Origin( AAPI), IMA and MCI were in attendance. As much as the reporting is Shahmbolic- "Ministry of Overseas of Indian Affairs?!!"- I am also left wondering why a VC of Datta Meghe Inst of Medical Sciences has to be a spokesperson for an MCI sponsored event. Sharad Power?

I shall highlight some of the startling Rimes that this Cub Mariner has to tell us. I almost decapitated myself laughing my head off.Here's how you, me and even Dupree can get their articles published in a newspaper, and why we shouldn't.( Comments in Italics mine)

New Delhi, December 13
The United States has said India’s recognition system for undergraduate medical courses is at par with theirs, an achievement that could facilitate mobility of doctors from here to the US.

( Makes that sound so official....made to sound as if Dr VM, VC is spokesperson of the US Gov dept of education , na)

The National Committee on Accreditation in the US, highest statutory body in the US responsible for foreign accreditation, has granted parity to the recognition system in India for undergraduate medical courses, Dr Vedprakash Mishra, vice-chancellor of the Datta Meghe Institute of Medical Sciences University, said at a news conference convened to brief on the Indo-US health summit starting tomorrow.

This is the link to the NCFMEA, the agency that reviews accreditation systems. Mind you, this does not mean it accredits by itself.
"The role of the NCFMEA is to review the standards used by foreign countries to accredit medical schools and determine whether those standards are comparable to the standards used to accredit medical schools in the United States"
Neither does it mean that you can bypass the USMLE exams that even the US graduates have to go through, and avoid getting the ECFMG certification( did anyone have that thought btw?). The purpose of the review of accreditation is for US students who want to pursue medical education abroad and want to avail educational assistance in form of Federal Family Education loans. So Dr VM, VC's statement is probably more so to attract children of Indian immigrants to come and pursue their medical education at institutes like the Datta Meghe Inst and not the reverse as Cubbie boy would like us to believe.The MCI's evaluation system has been reviewed already in 1997 and 2003. Quid novi Dr VM?

The parity has been granted for two years. The parity does not give automatic passage to the US or any other country. But the standards of education will be treated at par with the US which will enable students’ mobility to the US, said Dr Hemant Patel, president, American Association of Physicians of Indian Origin (AAPI).

Finally someone who makes sense!!But Dr Patel, have I misread? 1997 is ten years past!

The parity status was given on six parameters-curriculum, teaching, method of evaluation, extension, research and impact of education processes.

Research? Extension?

The first-ever Indo-US healthcare summit is being held here on December 14-15, Robinder Sachdev, a spokesman of Indian American doctors announced today.
Over 125 Indian-origin doctors from the US will be attending the summit, marking the largest ever gathering of NRIs from the US in New Delhi. This summit is being organised in partnership with the Indian Medical Association, the Medical Council of India and the Ministry of Overseas Indian Affairs.
The objective of the summit is to hold a dialogue and discuss specific steps about healthcare in specific states in India and strategies to mitigate the incidences of such diseases.

Which states? Which diseases? Is the AAPI a new GFATM or PEPFAR? If you have the money,please donate to improve the medical colleges in India. Folks like Dilip Walse Patil are least inclined to do so. They would rather fill their coffers recovering bond monies.And please, Wren and Martin is not an expensive buy.

Finally the coup de grace:

The Association of American Physicians of Indian Origin (AAPI), the moving spirit behind the summit, has signed an MoU with the Ministry of Overseas of Indian Affairs to provide rural healthcare in targeted states in India. Doctors from the US will be coming and delivering voluntary services in rural areas as per the MoU.

Show this to Dr Ramadoss please. While us medicos are unwilling to go to rural areas and serve the poor people- besides serving the MOs chicken and khamba every week of course, the genteel APIes have shown us the way with their PIOusness ...we deserve a rap on our Patel-las for fleecing for the poor cash strapped government which pays millions for our education and then choosing not to serve.Bad servers we are. Maybe the AAPI can help him in his hour of need.

My PJ: What did Ramadoss say to the AIIMSonians after Venugopal was evicted?

" Venu, vidi, where is he?"

Creativity.......again, and some shit

2007-12-26T00:42:00.000-05:00

I had a discussion with Gotya recently about creativity and how it might manifest in his profession, as well as mine. He has an argument that I wasted whatever creativity I had in going into medicine which...probably..... is a killer of creative thought in all the protocol based management, memory intensive curricula with no scope for laterality, and all the legal ramifications of possible 'therapeutic misadventures' that creativity needs allowance for.

I was leafing through some of the paintings which his father had made and was amazed that so much creativity flowed through the hands of someone you might not even notice as anyone beyond what he appears..simple/prototype middle class mensch. Conversation drifted to a statement that creative people with poor hastakala skills ( I am making this word up for paucity of any suitable) make it as abstract artists. And that creativity is in thought, it is an idea..which manifests in a abstract painting or a photograph or a innovative program or entrepreneurial breakthrough idea.Where could you possibly fit in medicine in this?Did I really kill whatever iota of creativity I had- I can't draw like Gotya's dad, nor click a great photo nor sculpt, and my bestest poetry was at best freshlimesoda.com stuff, (which is lost with that website going off webspace)- coming into medicine?

Which brings us to a question which I have answered many people while interviewing , but never asked myself when I entered medicine.
" What attracted you to medicine?"
Good marks?!!
People say, or are told to say that they recognized a trait in themselves which they nurtured through their career.Thats kosher interview stuff. Many of us are never so far sighted unfortunately.We never understand the ramifications of what a career in medicine might mean when we take it up after Std XII, when angst, puberty, peer influence and Erikson's stages are wreaking havoc on thought process . Which is not to say that no one should take medicine. But which is to reinforce that you need to recognize and follow what is innate in yourself.For which you need time to inflect.Which is why the American system is not all bad....premed for 2-3 years, then med school. Gives you time to ripen your thought.

Taunts like Gotya's do make me ponder.When we are at crossroads again....after MBBS, after MD, after DM...do we use our faculties well and choose? Or get down to mugging MCQs , then shall choose depending on our rank.Then issues like a DGO in a big hospital versus a MD in rural hospital factor in....how sadder can it get. My friend who did Ob/Gy from BJ , and was a very popular lecturer till recently, rebelled against his wishes for a lost cause of group based practice and took up the subject when he could have well gone in for Medicine,which he liked.
Another friend won't come to the US for a course longer than two years because he has commitments to 'settling into life'.Living for your ideas is selfish, so they tell me.

Now that we have made a jump and are well into 'the system', lets also look at how Gotya is wrong. His argument would mean that doctors are uncreative people. Which is as atrocious an assumption as mine in even believing him for a minute, and coming up with the above. A creative medicine person will diagnosticate without tests,s/he will recognize patterns, s/he will ask himself questions and research for answers.I had written earlier on this blog about creativity and the physicia n...I had also mentioned about low cost innovative technology that people used in an appropriate setting and tasted remarkably successful results. People remain what they are. Creativity doesn't die.It manifests differently.Each circumstance offers an opportunity to use your creativity in a setting appropriate manner.You can always stretch the limits on this, you just have to have to want to do it( and not feel guilty about it).
Nothing sums it up better than the formula that Harvard cognitive neuroscientist Joshua Greene proposes (in the image above)

FECAL TRANSPLANTATION

You could have better terminology for this. Is it just getting some yucky stuff to sound fashionable?Anyways...Aas, Gessert et al have done it for C difficile infusing stool through a NG tube, others have done it through enemas, the logic being resurrecting the gut flora balance.They could not prove whether it was the Vanco pretreatment or the stool feeds( !!!) which cured relapses. But imagine...calling yourself a transplant donor when all you have to do is poop...and having a stool harvester team - what do you call them- FillThee PassTurds.
Hope it catches on in a more appealing tablet form or so.

Anyways..among other stuff, do read Medvalley High's rants about what he calls the 0.7% challenge

Might go on an outing this week....posts might dry up a bit.
Adios.

Feliz Navidad !!!

2007-12-24T15:03:00.000-05:00

Gold, frankincense and myrrh

2007-12-21T10:38:00.000-05:00

It is a small world...an Airtel ad will exhort.It indeed is. You do get an occasional stare of exclamation from the guy sitting ahead of you in the bus when you are talking to your friend in the lines of " abbe woh HongKong se call aaya kal, and Philadelphia call karna hai yeh week"
But it is a small world. When a filthy rich Dr Patwardhan can travel to Pune just to attend Sawai!!Small world when news comes first from the USA about events in Indore or Bangalore.And you have Gtalk at hand always.

I reiterated to myself that I am a good diagnostician when the MRI proved what I had suspected for long. And seeing kids who once huddled over PJ Mehta in the wards while twas residency days, now as uppity residents who mete and dole with self anointed righteousness gave me a nostalgic been there- done that kick. And twas reiterated to myself again why private practice exists....you can never get the attention you seek from a busy physician who has an OPD to finish, students to teach and zebras to pick and fetish upon.

It is snowing in Boston....Ananya looks like an adorable Magi doting over babies Priya and Nikhil, .... I wish I could have been for the Reading get together. Christmas is in Pune as Diwali was in Boston. You can't dash through the snow on a one horse open sleigh through Lakshmi road possibly.

But they say it's a small world.

Oh the weather outside is so 20ish
And I am so bored mugging my Spanish
And since we have no place to go
Let it snow! Let it snow! Let it snow!

Job to do

2007-12-14T10:49:00.000-05:00

Steve Jobs said in his speech at Stanford in 2005, where he talks about three stories of his life,( I searched out this transcript specifically for Ramu...he might have read it already though) that,

"If today were the last day of my life, would I want to do what I am about to do today?"

And that he had read somewhere that if you live each day like it were the last of your life, someday you will most certainly be right.

I remember Dr Deshpande, our teacher in Physiology, a cute looking lady ( I detest the word, but she was ...cute) - who used to tell us, while we grappled with the weight of Guyton and Gray's anatomy on our 'guide' mo(u)lded brains, to "keep an attitude to 'studying' in medicine which is unlike what your colleagues in engineering or in any other course might have. Imagine you have an exam the next day...... everyday. For every patient is an exam, and you cannot be caught unawares or afford to fail."

In hindsight I feel thats one of the lessons that medicine teaches you which you can extrapolate( I love the word!!) beyond the corridors of the hospital.To want to do each thing so well that you want to justify the title you prefix your name with, something your engineering friends cannot do .And there are no measuring scales, no standards here....but a desire to live upto.....what- Schweitzer? Capecchi?Kotnis? Farmer? Bang? Sudarshan? Hegde? Arole?Patch Adams? yourself?

So often we fall hopelessly short of this standard!!!

Jobs' idea seems difficult to imagine. My friend told me once that " kranticha vichaar kshanabharacha asto"- a revolutionary thought stays for some time.You have to cherish it and grow on it. Those who work on it as a way of life end up as the names mentioned above( except the last) When faced with a situation where you do not know blue pill or red pill , do you play it safe, or do you aim for something more?

There is another take to it( Krishnamurti / Bertie ?...don't remember) ...many years down the line, when you sit back on your easy chair and think about how you did, beyond earning and spending, beyond loving and being loved, beyond being 'successful in life' - often in other people's opinion more than yours, think if you gave your best shot even if you did not end up the best. And a smile lights up your face when you realize you did. This is a fictitious moment.It might never come, it might never be. But can you live up to the expectation of that moment?

Just do it....

2007-12-11T02:02:00.000-05:00

I was leafing through Tagore's Gitanjali. I have a really old copy published in the 30's that I picked form a raddhi bookshop sometime. I had made some really funny notes the first time I had read the book.Like a Nike logo next to this verse...one of my favorites.Since the book is already losing leaves, I thought I shall keep a e-note of this.

I must launch out my boat. The languid hours pass by on the shore
The spring has done its flowering and taken leave. And now with the burden of faded futile flowers I wait and linger.
The waves have become clamorous, and upon the bank in the shady lane the yellow leaves flutter and fall.
What emptiness do you gaze upon! Do you not feel a thrill passing through the air with the notes of the far-away song floating from the other shore?

I used to make mental pictures to understand poetry- figure out scenarios that would fit the words.( I had an equally funny one for Ozymandias)To remember this scenario I had created a story- in drawings - of an oarsman who had traveled across an endless Gulf to a surreal island with exotic flowers to get his ailing kid an orchid which he dreamed would cure his child of his illness. This at the cost of his daily wages he earned ferrying goods . He must locate it before winter causes the plant to lose its exuberant bloom, and its heavenly fragrance.He searches all over the island ,as fall/winter chases his footsteps, hunger gnaws at his determination.He searches out a lonely spot at the other end of the island where he finally spots the elusive flower.But winter has begun to tickle his bones..he smells the flower...it is barely what he was told it would be. He trundles hopelessly back to his boat, sobbing his heart out. He sits on the banks, watching across to the horizon as the sea stretches along endlessly, hoping that his child would not see him in his misery. In his sobs he does not hear the flautist play and the courtesans sing , as music fills the atmosphere and the chill and mist seem to vanish in the healing notes that waft through.

He cries out, " Lord, I have failed. Carry me, for I have no will to go and see my child die."

And his Lord whispers, from across the ocean into his ear....."despair not....your love has carried you thus far, and further shall you go. Launch your boat, so what if the flower has lost it's fragrance, you carry the fragrance in your heart.Love gave you your motivation till you came here, now faith will."

"Just do it dude"

The rest... of being ......or not being....

2007-12-11T01:19:00.000-05:00

When you hear hooves...hmm....ask Google

2007-12-09T09:21:00.000-05:00

Well, the googleblog categorically mentions that Larry and Sergey would rather not prefer that you use the word Google as a verb. I tried to mull on a PC title for this posting ....obviously the verb 'googling' was out. Putting the word in capitals as 'Google it' was softer, but all the same fiendish as a Modi.So, disclaimer: I am not cocking a snook when I write"ask Google." It is for shortage of ideas. Ask.com has a much more friendly interface, but not a 'Google scholar' or 'pages from India.' I use Scirus and Healia, but Google has not disappointed me for medical queries. They even ante dated Stumbleupon with 'I am feeling lucky' button.

There was an article in the BMJ about Google getting the answers to problems posted in Case records at the MGH from the NEJM 58% of the time. We all know BMJ publishes junk research from time to time - the romance in the ER one was a ludicrous example.But come to think of it logically, how frequently would you hit something like Muckle Wells syndrome depends on how the person who asks the query enters the search item. He has to look at the rash and fever and look for cognitive shortcuts. He has to know whats important to add to the search list and what to discard.He has to know that the scenario fits sarcoid more than amyloid. We know of this as an anchoring heuristic- a familiar point which he/she knows and builds the case diagnosis from there. It is impossible to know every bit of information that exists about every condition in medicine.Google does all that for you...it keeps your Harrison handy on your laptop, it has the mind map like circuitry, and it can put your a+b+c together like Greg House would.Some of us like to do such syndrome hunting- e+g+h is Whipple's or Prader Willi or other such Gestalt stuff. But guys, to carry French's index of differential diagnoses and Wallach for interpretation of diagnostic tests and do it manually you would waste a hell of a lot of time reaching anywhere.

I do not see using Google for this as being wrong, or as an insult to anyone's intellect.For reasons: a) The possibility that you will arrive at a wrong diagnosis seems faint given that you are entering true factual data of positive findings that you have elicited.The issue is of sensitivity not specificity. b) Since you cannot present this as Evidence based hypothesis testing, you would obviously investigate further to test the biological plausibility of the idea before choosing to intervene on a 'hit' given by Google. c) In all cases you would follow the traditional iterative process of forming hypotheses while asking history and conducting exam, use the other two cognitive short cuts- representativeness heuristic (Spot Diagnosis method) and availability heuristic (past experience), and ask Google only when you are clueless at the end of your interrogation.

There are cases of the obsessive compulsive, patients who Google too much- the recent TIME article on one such patient is a good example.I have had an encounter with an acquaintance who waxed eloquent about her not being a vaccine person what with all the "autism going around", and defended her argument saying that "the evidence is there, you cannot deny it". I hadn't seen the evidence she alluded to, and had to take a step back there.But having seen what she was referring to, I wish I could have told her then that the most viewed videos on Youtube aren't exactly what you would call Evidence. I do share Jay Parkinson's frustration when my half read misinformed relatives choose to harp on a antediluvian dichotomy of allopathy Vs homeopathy/ ayurveda, and the latter being 'holistic', 'attacking the root cause of illness' , and choose to base their ideas on word of mouth or vague search results. But do you get confrontational with such people? I would disagree. It is better to be a facilitator in care of such patients, but to care to correct them when their enthusiasm veers them into wrong directions.

Moral: Let's accept Google as a useful tool.
But then, a fool with an idea is still a fool.

Came across this assortment of postings on the use of Google in medicine on the Clinical Cases blog.

Everybody's at home

2007-12-08T02:14:00.000-05:00

Strange stuff.....appa does not work anymore, amma is recuperating at home, my gran is too old to work, she anyways hasn't ever worked in her long life . I am not working right now. Everybody is at home. And no one is bored!!

Have you ever fed someone with your hands? It is a deeply satisfying act. I mean hmm...beyond just the act of delivering a morsel of food to someone who can't him/herself.....Beyond the neuroticism of feeling short on time all the while....and thrusting a granola bar and coffee hurriedly into your own mouths, as you feed your own ego with low cal fattening stuff, do your own job, love yourself, even love others coz you love them loving you back..quite unlike all that ersatz ......just a bit of languorous timelessness to it.
There's also a feeling of giving to it...at an individual level.Of appeasing the hunger of someone else.I guess cooking for someone is also somewhere there in terms of satisfying your Giver instincts.I never wondered when my mother would go through all the trouble of cleaning, cutting, cooking to make us a huge bowl of Sunday evening 'tiffin' while she herself ate little or none of it.Lakshmi...your khane ka khazana is no less appeasing to you than it is to us I guess?

My readings

2007-12-05T14:59:00.000-05:00

For suckers like me: Quail and manna. List of free articles on Pubmed.

And Dale Carnegie's mantra for MRs: How they win over and influence doctors. This is from the PLoS. Particularly interesting are the tables.

And finally....a directory of medical bloggers from India. Maintained by Indian Medic.

Happy reading.

Rabbit run. Rabbit stop.

2007-12-05T11:53:00.000-05:00

Taking a step back and observing things as they happen. Jumpy cousin, woozy aunt, crazy Dani, helpless mother, restless rabbits, pati peripatetic, wishy washy sistahs, loads of money, Kaka's antipathy, some Spanish. Go fish.

Activity beckons.

Floydian philosophy: (with my distortion.):

Run, rabbit, run
Dig that hole, forget the sun,
And when at last the work is done
Don't sit down, its time to dig another one.

For long you live and high you fly
And smiles you'll give and tears you'll cry
And all you touch and all you see
Is all your life will ever be.

Clutter of sorts

2007-11-28T02:57:00.000-05:00

There's a shock bubu in my sensory cortex. There's too much happening with a deafferenting of sorts.There was way too much travel. My Nashville trip merged into Boston, Reading, Mumbai. I interviewed with Mickey and Farhat for the MSF job.It was a fun thing- given real life situations to work on and stuff to manage. Felt more like an MBA assignment- to deliver food sorties to a camp in Nigeria and manage a depressed health worker, a theiving local mechanic, a broken down truck, an impending strike,ambitious plans to establish another feeding center,a disgruntled warlord who feels ignored. Made me want to start stat. But the fact that my limited period of availability would mean that only a miracle would ensure that I get to go on a mission was a bit of a dampener.Maybe I get to work with them in Mumbai.I should know from them folks soon. But then, the shock bubu - I did not feel so bad to brood on it. In other circumstance I would have. But amma has a surgery tomorrow.

Mhatre ajji died. If anyone had to know what loneliness means...man, it cannot get lonelier than it was for her.She sort of made it into oneliness with Krishna.The ISKCON people came with their drums and cymbals and sang sad bhajans. It seems unreal for me sometimes that someone can crave death so much, and not commit any hara kiri but wait patiently knowing that age or ill health will smite you on the head with the fatal blow one day...and each passing day is not the glory of sunshine and the newness of opportunity, but a long parched longing wait.

Again shock bubu ensured that my ADHD assailed senses did not want to make me mull on this, but to ponder a moment and move on.

Have things piled to do. But they can wait for now.

May the surgery go well.

Life goes around in circles

2007-11-07T16:37:00.000-05:00

DC, Hartford, Nashville, a probable Albany, Mumbai.

If you are on a large circle, you never know when you are making a turn.

The earth is spinning while you've been running
You're gonna get back where you've been
While I've been dreaming about the real thing
My reality chases a dream.

Transformer

2007-11-05T17:29:00.000-05:00

This was lying in the posts to edit for a long time.
Disclaimer: If you have better things to do( I did not when I started out writing this.) don't read this.If The Matrix is your Gospel truth and you look upon Bladerunning as a possible future career, read on.

Happened to read some stuff about transhumanism some time back, when time ran drearily, and disuse atrophy threatened. Seemed oddballs and kooky initially- a movement that proclaims to help people do 'better than well.'

I had a sticker stuck on the cover page of my school diary- it read, in Comic Sans MS font, "Good is not good where better is expected."I remembered.I read on.

Wikipedia ( funnily Citizendium, for all its refinement has no entry) puts it as "international intellectual and cultural movement supporting the use of science and technology to enhance human mental and physical abilities, and to ameliorate what it regards as undesirable and unnecessary aspects of the human condition such as stupidity, suffering, disease, aging and involuntary death."

I am piqued.Who are these guys? Surely they aren't aiming at sculpting a philosopher's stone?! I mean it is good to aim to improve. But how do you itemize it into a protocol or menu?That seems Riddikulus...get some parallax for gossakes.

The World Transhumanist Association defines it as "the intellectual and cultural movement that affirms the possibility and desirability of fundamentally improving the human condition through applied reason, especially by developing and making widely available technologies to eliminate aging and to greatly enhance human intellectual, physical, and psychological capacities."

Wow. So PC!!
Abstruse. As PC stuff usually is.

They aim for convergence of Nano, Bio, Info and Cognitive technologies. I was looking for hard examples. Came up with fancy shmancy names: Extropianism ( proactive evolution), Immortalism( technological immortality), Abolitionism ityaadi. Nice to read. But does not form links beyond sounding sexily vague.There are no examples to see. There is no bamboo microscope or AI based prosthetics for cripples, no Deep Thought on brain mapping for Psy illnesses, rather Bootstrapping on boozed up bombast.

My take is that as a transhumanist you could write a great bestseller, or script a hit TV series/movie.Tarsem Singh ...Cell. Remember? Feed the public on such neuromancing with the quaint, put in the CIA, a Jason Bourne and a rumpunctious hotbod like JLo, plenty of intellectual masturbation ( 'IM', as the surgical twats acronymize) with some of the above words, and you have a pseudoPhodu cheez.

Go through the WTA website, you realize it is really an idea of bringing together all progressive thought into one scaffold of improvement.It is as vague as it is ambitious. Because people never set out to eat and drink to build a beauteous fat cell 2.0, and prefer simple non intellectual fornication to IM. How can you call it a movement?Its rather a way of thought, life maybe.

There are ethical angles ad infinitum. It creates a world akin to the alpha beta Omega craziness of Huxley's Brave New World. A caste system of sorts, of those who want to stretch the limit versus those who want to make two meals a day.

All in all: Keep the font Comic Sans MS on that.Not serious are you?

If I had time to waste, I would have written more. I don't, and hence I end here.I want to use the time to evolve pro actively.

Dance to the music in eternal sunshine of the spotless mind

2007-11-02T14:59:00.000-04:00

I used to laugh out uproariously every time I saw his photograph.
Until I came to this Ubuntuised country. Now I respect the philosophy that everyone has a right to be an asshole.I am the wise one( ass hole to somebody else) because there is an asshole like this.Respect everyone, however BORATic he might be.He is the one is responsible for who you are.

I clicked this while we were in Melghat, some 6-7 years ago.Came across this snap( have I posted this already before?) while I was going through old files I had saved on my iPod. It goes like this: Melghat has never had electricity. The last time electricity poles were erected was in the 1980s when Indira Gandhi came visiting.But when she went back, the two warring State Electricity Boards of Maharashtra and MP went back to their pehle tum bickering as to who should be responsible for providing electricity for these suckers.

With all the malnutrition deaths taking up news, the NGOs came to Melghat. They provided solar panels to the villagers.

But you can't, well, give a bushman a fork and knife and expect him to use it the way you do. So what do they do with the solar panels: Watch:

Btw the song they played was Bagh aga bagh sakhe kasa bugu bugu laag tay ..........

Brain waste, funny taste

2007-10-31T13:18:00.000-04:00

An article I came across in the JAMA on health worker migration alludes to what they call " Brain waste"- skilled migrant workers are unable to find work in theirarea of expertise and end up working in unrelated low-payingjobs.

Exotic sounding word.No neurons being tossed into the bin.But compelling on the idea of why people mix up career and life.People have very quaint ideas when they make the switch.

While I must admit at forth that I am no sage on this, I have heard mixed views.
For people like DRK, working in resource poor areas was a brain waste.That its no use working for excellence when you are fighting with red tape and cost cutting all the time. It is funny, none of my teachers have given me negative feedback on that.Not Dilip Mathai, not DRK, not Kaka.
Hardik was honest to admit that its all about money.
One friend of mine, now an intern in MI told me that he came here with romantic notions that what he saw in western movies about a open country and 'promiscuous' lifestyle was true.
"Tab life mein aish karne ka aise lagta tha"

There's a whole bunch in KEM and BJ who think the Mah government is going crazy on bond issues, trying to bulldoze its way through on its supposedly moral high ground, and count it as wise investment to rather spend time and money in making it to elsewhere.

Abhijit said he wants to learn interventional pulmono skills.Charudutt said the same thing when he first came.Learning skills.Lot of things have changed since.

Lifestyle is a major draw.But I presume that means cleaner roads, more taxes, being distanced from near and dear ones,loneliness, nice big cars,safety, subtle racism. It is a mixed bag, really.It is about making choices based on priorities.As Dhiraj says," i would rather be a first class citizen in a second class country than be a second class citizen in a first class country."
No one person is right or wrong here.Just that 'results might vary based on experience.'

Many medical students seem to do so because it is a fashionable thing to do.All the batch toppers are doing it.It catches on as a trend in places like MAMC or AIIMS, where Ramadoss has to address the convocation thus:" don't go away. And if you do, please come back."In my MD batch I am the only one who chose to give my USMLE. In the batch after mine, half the batch is already interviewing.

Renita gave me a totally new perspective: of parents of unmarried girls equating getting married to someone in the US and going there as being an indicator of success in life. I got registered on shaadi.com, just to test the waters and am already put off and shall be deleting my profile.

These are individual anecdotal experiences, a bit colorful,but unsupported by sexy stats.For a more detailed discussion read the WHO fact sheet on this. But I gather, at least from the Pinoy experience, everything starts with an individual experience, an anecdote, a word of mouth, which people tend to trust.Then when things get big, people become numbers, more reliable.

If anyone does read my blog, your experiences are welcome.

Yeah...Mukesh Ambani is the richest man on the earth......so?

2007-10-29T17:10:00.001-04:00

Territory size shows the proportion of all people living on US$10 purchasing power parity or less a day worldwide, that live there.

And the Sensex touched a sexy 20,000.So?
More such maps and great stuff at worldmapper.

To give you a sized perspective of things>>>>

2007-10-27T15:57:00.000-04:00

Watch the video here....amazing stuff!!!

http://www.micro.magnet.fsu.edu/primer/java/scienceopticsu/powersof10/

LoveER

2007-10-26T18:45:00.000-04:00

Believe me or not. If you plan to work in Emergency Medicine, there is a high chance that romance will strike you sometime or the other, more so if you are tall, muscular, with chiseled features and had suffered personal tragedy in the past.

Brendan Kelly from Department of Adult Psychiatry, University College Dublin does a study where she studied 20 randomly selected medical romance novels. And published her results in................... the Lancet !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!( Lim-> 1/0)

Lance my conservative heart, you blokes. Holy whatchamacallit!!

And the conclusion:
These novels draw attention to the romantic possibilities of primary care settings and the apparent inevitability of uncontrolled passions in the context of emergency medicine, especially as practised on aeroplanes. These novels suggest that there is an urgent need to include instruction in the arts of romance in training programmes for doctors and nurses who intend working in these settings.

Get me some beer please.

The new Harry....expectations

2007-10-26T17:06:00.001-04:00

We all have grown up on this book figuratively, and literally speaking- ventured through the 14th while looking up to seniors who read the 12th and 13th, snacked on titbits from the 15th( the most extensive edition to date) ravaged the 16th with pencil underlinings and dogs ears and sticky notes, sweaty forearms and contemptuous doodles...and finally here comes the 17th. Waited a long time for this!!

The 16th was probably the one with the most mistakes- 'non caseating granulomas in TB', holy mackerel!!- as also the most monoclonal antibodies. It was a colorful cousin come visiting, but we hoped for short time.The editing left a lot to be desired - GI and immunology had a lot of unnecessary chapters, the cover was unimaginative and the colors looked as if they were splashed all over with childish glee, the mistakes were atrocious, and I still like to have an atlas- it is what makes OTM a pleasure to read when line after line of text get to your rods' nerves.

The 17th will be out March 2008. Priced $199 on Amazon. From what I can see it seems it is packaged as one book.I hope I am wrong, carrying it along will be a pain. And the middle chapters will be a pain to read with print going down into the central gutter.We want to hypertrophy the gyri, not the brachii.

Dr Loscalzo joins the editorial board. That had to be, given that so many of Harrison's authors are from BWH :-)
The promotional video says there's a 40% increase in content. This valuable new collection includes even more great depictions of pathophysiological processes, decision-speeding algorithms,( we never needed an overdose of that guys, least of all for something like osteoarthritis, probably the worst flow chart in the 16th. And the emergency medicine section had hardly any!!There's always Fred Ferri for flowcharts guys. Butt I have to hand it to you on this, endo flowcharts rock!!) clinical photographs, essential radiology images, an atlas of EKG tracings ( thats a great addition), and full color depictions of key pathological specimens( again, I hope this doesn't get too extensive)

There's 40 new chapters- including Health Disparities," "Quality and Safety in Patient Care," "Hospital Neurology," "Electrophysiology in Neurological Diagnosis," "Clinical Management of Obesity," and "Approach to Heart Murmurs" . All good additions I would agree.

There's a new section called regenerative medicine ( fancy name!!) which includes Stem Cell therapy, tissue engineering and the works. This had to come I guess. So they take some tonnage out of the outlandishly heavy on content Genetics chapters.

There are three great additions I feel:
1)Paul Farmer makes his debut in a chapter called Global considerations in medicine. All chapters will have a Global Considerations icon, which identifies important epidemiological, diagnostic, and therapeutic distinctions between global regions to aid in the diagnosis and management of specific diseases. This will help Harry shed the America specific image it is perceived to have, and enter the league of OTM. A big round of applause for this one.

2) The classic Introduction to Clinical Medicine section features new e-chapters addressing Patient Safety and Quality, Ethics in Medicine, and The Economics of Medicine; Health Disparities, and more.

3) Bonus content in a DVD, as eChapters. This includes 37 chapters spanning some 300 pages , 90 videos and include content such as an atlas of CTs and a chapter on radiography of the chest,atlases of renal pathology and urianalysis, neurology, vasculitides among others.

Harry also has taken a leaning to putting factual information into procedural approach with the 'approach to the patient' boxes since the 16th.They push the pedal on this one with extra additions in form of symptom management. I do not know the details, but this is again a welcome addition form an internist's POV.

Fact is Harrison is the most popular medical textbook all over.It is a humongous task for the editors to even attempt to cater to all their reader base. But this edition seems to be a great first step.I look forward to March 2008.

Gandhi the UnNoble

2007-10-25T10:52:00.000-04:00

I found this engrossing piece on Gandhi on the nobelprize.org website. Ovyvind Tonneson, the editor of the official site from 1998 to 2000 writes, quoting from personal diaries of the members of the Norwegian Nobel Peace Prize Committee. Nominated 5 times in 1937,38,39 and 1947 and 1948, each time the Nobel Peace Prize Committee shot down for reasons as varied as Chauri Chaura, partition, the rioting that followed, and also the fact- in 1948, when he strongest candidate -that the Nobel Prize had never been awarded to anyone posthumously till then.In fact in 1948 the Nobel prize for peace was not awarded to anyone, the official statement from the Committee being that there was 'no suitable living candidate'

The earlier committee( 1936) had harsh words about Gandhi, Jakob Worm Muller, an advisory to the Committee had these words to say:
"He is a freedom fighter and a dictator, an idealist and a nationalist. He is frequently a Christ, but then, suddenly, an ordinary politician." There are many hate sites which say Gandhi's fight in South Africa was restricted in that he took up cause for the Indians but not the blacks.

Muller probably misinterred on Gandhi's philosophy including his message of shunning cowardice for violence as being inconsistent on his principle of non violence.It is important to remember that Gandhi was a soul keeper who chose to be truthful to himself more than a politician. When confronted with making a choice between being truthful and being practical, he would choose the former, thus infuriating many of his colleagues, who chose to play the politics game upfront.He was the writer, thinker, Nehru was the orator. Many of the things good or bad that are ascribed to him are actually the INC's decisions.Besides Gandhi himself accepts that he made mistakes. He accepted to be a part of the British Empire initially.

The exact reasons, deliberations of the Committee are not cited. These are Tonneson's conclusions. Statute 8 of the Nobel Foundation states, "the deliberations, opinions and proposals of the Nobel Committee with the award of prizes may NOT be made public or otherwise revealed."

The irony is that eminent personalities, who based their own actions on the pattern of Gandhi's teachings, were themselves awarded the Nobel Prize in later years — Albert Luthuli in 1960, Martin Luther King, Jr. in 1964, Mother Teresa in 1979, the Dalai Lama in 1989 and Nelson Mandela in 1993.The irony is that Yasser Arafat and Henry Kissinger can be awarded the Nobel prize for peace by the same people who prefered to be holier than thou with Gandhi!!!

Visual acuity six by sex

2007-10-24T22:54:00.000-04:00

This is an uproariously funny Snellen's chart for testing your acuity of vision!!LOL.No one will be 6/6 on this I guess!!

E-gad-o !!

2007-10-24T13:28:00.000-04:00

Came across this website in the WSJ health blog. Kevin MD does a great job really Digging up stuff from every known place on the www. Well here's the news: Siemens is offering a 1.5 T MRI scanner to the hospital which comes up with the best video detailing its reasons why it deserves to get one free of charge. Some of the videos are outright hilarious- watch the granny one.I don't know if it's intended.

I wonder.......,WTF....., I bite my orbicularis oris....

When we got an MR machine at KEM, it was the first MR machine in a municipal hospital in Mumbai, and one of the best in the city. It stood packed in huge boxes for some time because they could not carry it to the first floor where the MR console is now located. So they had to demolish a part of the wall, use a crane loader to lift it to first level, and then rebuild the wall.Of course, the KEM building being of some heritage value, the paperwork took some time coming through.
And there used to be such a long wait period for MRs in the initial months, this being the place all other hospitals would refer their patients to, people would have average wait periods of 2-3 months!! And getting an appointment for an indoor patient was an equally painful experience. Of course as we started reading MRs with the MR team, we came to be acquainted with each other more. I always had it easy referring a patient for an MR, coz them guys knew my referrals to be genuinely indicated, unlike some other colleagues of mine who had a tough time getting the job done- hehe!

My HP nearly cooked the goose on that one:
I had a patient with a double valve replacement who developed an ADEM like condition after an exanthematous fever. My houseman scheduled an MR, and sure enough Darshana/Yogesh obliged promptly. While rounding in the evening I asked my HP where the patient was. He said, " woh to MR ke liye gaya."
"What??!!!" , I stared back as if the great God had smote me down with a huge scimitar, too bewildered to shoot an abuse even. Primum non nocere( first,do no harm) is a cardinal rule we learn on the first day of medical school.

"You"....I fumbled..."bloody murderer". That was all I could manage for all the venomous upsurge.
" The valve will rip through his chest in that magnetic field"

( Some of you medically educated guys might have got the plot already. Others, come over to edge of your seats and read on as to how the motivated medicine resident saved the day.)

I shat my pants running down to the MR room trying to see if he had got in the gantry already, hoping that a flying Medtronic Hall valve hadn't damaged the machine besides of course ripping his chest apart.That I presumed was a foregone conclusion. 'I hope his sutures held strong.God, my license....weird thoughts buzzed through my brain randomly.

I was done. He was inside, with the queer humming sounds emanating from the room.

" Chalu hai?" I asked with bated breath.
" Fir kya?!" Yogesh said.
" Nothing happened I hope", I asked, biting my lips. "Valve hai uske mitral and aortic position mein"
" Abbe c#%@ye !!! Bataya kyon nahi " he howled at me open eyed, perspiring fast.Something similar had hit him too probably. Suddenly I felt in my HPs unenviable position, expecting the murderer word to come any moment.
" Idiot, isn't it your job?" I asked, knowing that it was a weak hit back, but I had an ass to save.

Then it struck both us pathetic retards simultaneously- if it hadn't happened till now, it wouldn't happen from now.Man, is it not a great feeling when the heart, that has sunk to your bollocks rises up relieved, beating like a wretched hummingbird!!! We researched and found out that the valves are MR compatible. The patient was discharged a week from then, with around 70% recovery, his valves safe and clicking away merrily. Subkuch TickTock hai.

Another MR story....... to get some dil ki bhadaas out...I mean WTF...a free machine...: a free machine!!:
Anyways:

There are people who work in the BMC who wear the BMC badge all so proudly!! These are the folks who are actually never found at work. They hang out in groups at the canteen sipping chai, gossip, go to 'aunty's' and get drunk in daytime, abuse nursing staff, look out for opportunities to strike work at smallest provocation to their mojo, ally with notorious corporators, act as recommendation guys-" saab, isko dekh ke lo haan, apna dost hai!!"- at OPDs, and make a buck out of it.They would prefer this mode of work to what the BMC pays them for: sweep or mop corridors, ferry patients, help in the wards.
And they will break lines in the OPD and thrust their paper in your face saying, " Shtaff hai!!"To which I have suppressed many a frustrated "so what motherf@#$er" under gritted teeth and murderous expression.One similar aayabai association chief from Nair Hospital comes to our OPD one busy Monday.
" Saab, MRI karne ka"
" Kyon?"
" Magaj mein dard hota hai"
After I get through a history, I conclude that this lady with a tension headache needs no imaging.So I go, " karne ka garaj nahi hai."
" Pan mereko karne ka hai na. Maine NAir mein Shitti scan kiya, Usmein kucch nahi dika. Roj magaj thanthanaata hai. Kaam ko bhi nahi gayi ek mahine se. "( Gasp)
"Kuch to fault hai"( yeah, u have your ass and brain in the wrong places, lets do a bilateral hemispherectomy!!) "Aur mein shtaff hai na, mufat mein ho jayega, aap chinta mat karo kharche ka."( Gasp, gasp!!)

I refused to write an MR for her. To which she said she knew the Asst Dean. I said I didn't know him...I said that sacchi.Pronto, the bitch goes to the Asst Dean, a glorified idiot who decided to quit academic pursuits after MBBS was too much for him, and I get a call.
" Karun taak ki. Kaay problem aahe?"
" Sir mala vaatat nahi tila laagnaar."
" Tujhya seniors la vichaarlas ka?"
" Yes sir" ( you filthy bastard!!)
" Kaay ahe, hi loka nantar khoop problems detaat. Press valyankade gela tar problem hoil re.Asha conditions madhe apan karun takaycha." ( Yeah yeah, teri bhains ko anda maru...)
" Theek aahe, sir pathvun dya tila"

And then I cocked the ultimate snoop.Dawg!!Vaibhav, my friend was registrar at the 'headache OPD'- a recent flight of fancy method by Dr Mehta to waste a resident's afternoon of good reading. I told her," udhar magaj ke special doctor baith te hain. Unka final hota hai. Woh bole to haan, nahi bole to naa. Chalega tumko?"

'Bade doctor' Vaibhav gave her TCAs and a fit to resume duty certificate. no MRI. I did the MR guys a favor. I never got an MR request refused. Thats why!!

Gautama smiled....

2007-10-24T02:02:00.000-04:00

CABGs from India

2007-10-23T19:37:00.000-04:00

I had briefly referred to medical tourism in an earlier post, speculating about how the nitty- gritties would work out.
I recently read a fabulous article by David E. Williams. from healthleadersmedia.com on the future of medical tourism from an American perspective.He makes five important predictions he feels will be relevant to the future of medical tourism. I shall reproduce some of his comments.

( Words in Italics from the original article. Rest, my inputs)

1) Medical tourism will cross over to the insured population in 2008: Insurers are beginning to get requests to cover medical tourism from multiple sources: employers and their benefits consultants, foreign hospitals and governments, medical tourism facilitators, and individual members who want to receive coverage overseas. There are important initial steps in this direction. For example, Blue Cross Blue Shield of South Carolina has added Bumrungrad Hospital in Thailand to its hospital network. Jaslok Hospital has tied up with Cigna.If you thought safety and standard of care were issues, the Joint Commission International has accredited over 100 foreign hospitals.

2) Mini-med plans and small employers--not big health plans and blue chip companies--will be the early adopters: Williams argues that though the big spenders will initialize the process, close to half of Americans work for organizations with under 200 workers. Only 60 percent of employers with fewer than 200 workers offered health insurance in 2006.Smaller employers look at insurance differently. Many are shifting to so-called "mini-med" or "limited benefit" plans that cover day-to-day expenses such as doctors' appointments, but not surgery. I wonder how they can commodify a medical service offered?Surgery, or a procedure is easier to. A $50,000 angioplasty in the United States costs less than $6,000 in Mohali, India, according to GlobalChoice Healthcare. Yes thats gains of around 42,000 counting airfare and stay.But with mundane spiels like the annual physical,or a pap test, will it be financially prudent to make a 10,000 km trip to Hyderabad?These would form the major bulk of doctor visits by employees and I don't think thats going to come to foreign shores.Unless you are driving from California to Mexico.I would reason that pathology or radiology would be major gainers here for obvious reasons.

3) Opposition to medical tourism by U.S. physicians will be modest: At the community level, over 25 percent of physicians in the United States are foreign-born. They are familiar with the level of professionalism and training in other countries. U.S. patients are also accustomed to getting their care from foreign physicians. He also draws attention to the fact that a shortage of physicians means the US physicians will be willing to share their work burden with their colleagues abroad.Well said, but the outsourcing juggernaut does whip jingoistic passions among the misinformedly sentimental. There might be patients who will refuse, this has to be factored in.

4) State governments will begin to embrace medical tourism by 2010: Rising healthcare expenses require states to shift funding from other programs or raise taxes, both of which are unpalatable. He gives the example of NY having half a million Dominicans. Santo Domingo, which has some excellent cardiac surgeons and low prices, is a 4-hour nonstop flight away. Why wouldn't New York at least explore the possibility?Possible. But you never know how politicians think.

5) The emergence of medical tourism won't have a major, direct impact on U.S. healthcare costs, but the secondary impact will be substantial: If every U.S. resident who could go abroad for treatment actually went, the savings on total medical costs would be about five percent. That's still a big number, especially compared to other initiatives that are available. But to look at it another way, if healthcare costs are increasing by 10 percent per year, taking full advantage of medical tourism only buys us about half a year.For a country like the US, with the most expensive health care system in the world( around $210billion!!) this might not translate into a very big gain, true.Considering that a major part of this expense is not a public spending, but out of the common man's pocket, the gains will accrue to demand supply equation that the provider and customer share. Queer are the dynamics of health care in this country, where fair market capitalism dictates that need supersedes want. Of course, no one is aiming for great shifts in any hard indicators of health care. (The US health care system does not figure in the first ten or twentys of the WHO list despite being the most expensive.) It would be ridiculously naive to expect anything more than a drop in the ocean. But for the person who feels the pinch most, a dollar saved is a dollar gained.

Subspecialities, not superspecialities

2007-10-22T18:07:00.000-04:00

I have grimaced with utmost condescension at the many times people who go into specialties tend to act as if they have forgotten the medicine they learned before they stepped into the specialty. Like Sagar looking at an EKG of LBBB and saying it looked scary because he did not know what it was, or getting consults for fever from cardio, or the GI resident folding hands saying he didn't do intubations anymore since he was a specialist .

Let me be clear( to myself as well) I love Cardio- I did not quit Cardio because I did not like it. As a subject it is fabulous to learn and practice.In terms of outcomes- satisfaction of cure- it is Hearteningly leagues above say, Nephro or Neuro. The next generation in India is going to be one of the bards of lard, the centrally obese affluent who will come to ERs clutching at their chests while at the peak of their productive lives.Call it thrift gene theory, diesel exhaust related or whatever you choose to- we will be the Type II Diabetes capital of the world.And that translates into serious business of the heart. Whatever one has to say about the number of cardiologists passing out, and it being a market of sorts, them guys are never going to be found without work.Its what more and more people should be doing.

But what pisses me off is that the whole practice of Cardio seems to shift focus onto getting stents into improbable and really unnecessary areas.Into milking the Interventional cow to obscene levels. And it is not an isolated event - its ground situation everywhere. And you would be questioned if you wanted to practice preventive cardiology, if you elicited a plantar response, if you put someone on medical therapy for CVD or chose draw a blood culture.At a certain level, the scopist or Interventional Card guy provides a service- hence can be called a technician doing a 9-5 Cath Lab job- and is paid for the level of skill he can show. To be away from the "human touch" has its advantages too in a overtly litiginous society.

One cannot completely blame this state of things- one cannot be an expert in every given condition which the human body suffers from, and yet be fashionable in the way he/she slides a Cypher into the LAD.If you will be seeing ARVDs and Fazio Londe day in and day out, how would you possibly be wrong if you did not know the treatment of malaria off hand??!!

I am including an extract from Jerome Groopman's book How Doctors Think:

The narrowest subspecialist, the reasoning goes, should also be able to provide this [broad] range of medical services. This naive idea arises, as do so many other wrong beliefs about primary care, because of the concept that doctors take care of diseases. Diseases, the idea goes on, form a hierarchy from simple to difficult. Specialists take care of difficult diseases, so, of course, they will naturally do a good job on simple diseases. Wrong. Doctors take care of people, some of whom have diseases and all of whom have some problem. People used to doing complicated things usually do complicated things in simple situations--for example, ordering tests or x-rays when waiting a few days might suffice--thus overtreating people with simple illnesses and overlooking the clues about other problems that might have brought the patient to the doctor.

Which probably is a reason I am trying to pick on Pulmo/Crit Care or ID as subjects to specialise in. Of course this is not the only motivation...there are many more. But these retain the 'common touch'( why am I quoting Kipling so often, so outofcontext?!) with the broad motherlanguage of medicine while still providing you with the qualification to "earn more than the chaiwallah" as Dr Anand puts it.

There is an algorithm that I saw on someone's Orkut profile about making a choice of which subject to choose after medical school based on your traits. I think in choosing a subspeciality one has to look beyond traits into what your expectations are, what you want to acheive, or what will keep you going when down the line you can manage things at purely a spinal level.This is an algorithm I have come up with. Sorry for the patchy work. But inputs, if any, welcome.

CABG - heartily enjoyed

2007-10-22T17:50:00.000-04:00

Do you want to practice doing CABGs in virtual space?

http://www.abc.net.au/science/lcs/heart.htm

Nice timepass. Wonder why Zapak.com dosen't add it to its list!!And when you botch up, see the message you get!!

Power of a theory!!!

2007-10-20T17:44:00.000-04:00

TPM,Ethical practice, Lamarckism and other things

2007-10-20T14:44:00.000-04:00

"Say what you will about the sweet miracle of unquestioning faith, I consider a capacity for it terrifying and absolutely vile!"
-----Kurt Vonnegut.

Read the story in the link for some more questioning of faith:
http://www.tpmcafe.com/blog/drmatt/2007/oct/18/us_health_care_system_lessons_learned

There is how everyone wants to be in the beginning - never going against what they believe to be basically Good.We are all born with no morals, logic.Where the lesson of adaptive synthesis happens varies.Call it epigenetic, in the way it moulds your perceptive ego, it is scary.We learn our lessons from experiences that made an impact on us.

How true it is: If you ask the wrong questions you will get wrong answers.If you ask what do I gain from cut practice instead of what you stand to lose, you will never know when you changed directions. People carry this right/wrong lesson with them for life. They hesitate to ask ourselves the question why as much as how and what.They don't ask these questions because the uncertainty of not knowing the answers is not comfortable.

Then a desensitization process sets in. It doesn't hurt that much later because everyone is doing it. And if it continues to prick your conscience then you are an aberration.Someone like the protagonist in the movie Dombivili Fast.Not that all the other people are bad/evil. But if they left living on a day to day basis, I do not know how they would survive with all the guilt they carry.

Btw, I loved the name TPM cafe. Was flashback to TPM's rounds at KEM. Accepted, he was unapologetically brash, but his lessons stick around like Boomer chingam on your limbic cortex.

" RaviKiran,you can make mistakes because you are in KEM, which is like being in Fort Knox. If this patient were to sue you, then you, your grandfather and your grandfather's grandfather can spend the rest of your lives mopping the floors of the hospital paying the damages!!!!"

" You are the treating doctor, not Sai Baba!!!" (Thats such a TPM special....)

" Would you do the same if your father was the patient?!!"

Making notes....

2007-10-20T12:43:00.000-04:00

Read this in the Med Economics blog. Making my notes...

Over the years, an increasing number of jurisdictions have taken the position that a resident, even one just starting out, will be held to the standard of a fully trained physician.

A recent New Jersey case, for example, found that residents—regardless of their specialty or years of training—should be held to the level of expertise required of established physicians

It did so, in part, based upon a number of federal court decisions that said that residents—and other medical caregivers with even less training—must meet the same standard as fully licensed physicians. The defendants presented themselves as doctors, the court said, and should be held to the standard of care they claimed to possess. Anything less wouldn't comport with the care patients expected and were entitled to receive.

" I don't want to make the wrong mistakes"

Whoager !!

2007-10-15T13:20:00.000-04:00

Shall be traveling mid week to Baltimore.

One of the many disadvantages of not having a laptop:being disconnected- you sit twiddling thumbs or staring at Cipherspace or write unfashionably in scraps OF PAPER at airport waiting areas and friends' places while all around you are typing ferociously onto screens you can't peep into, wondering sometimes if people are really half as intelligent( or even fertile with those hottie hot toppings on their laps) as their embellishments make them seem to be.
Ah...two/three years back I would count my hours being connected rather then being disconnected!!
Someone have a laptop to donate/sell cheap?

Travel is fun.
But preparing for travel and waiting in transit are a PITA.As is carrying important documents with you during travel,especially when you have to go to the loo and the file is tucked under armpit or the bag staring at you while you are in the evacuation mode.As is the TSA. As is traveling to and from the airport.
Pretty stupid moral of the story: travel is fun, sometimes funny.But not if you are the involved party.

Things that are pending: the statin post is due for editing, one on transhumanism for completion.Need to sort out the links issue.

I hope to sign the contract and get done with things. Inactivity is killing, so are near null bank balances.
Wish me luck.