Just like that ek post dalna tha

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

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"

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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.

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

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

Tubaah: Ads by Prahlad Kakkar

Ration card

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.......

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

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