What was Osler thinking when said....

"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

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..

"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.......

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

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.....

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

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)

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

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

Pappu chala Pardes

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

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!!

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

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......

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

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

Buridan ka gadha

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......

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

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

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.......

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

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....!!

"
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

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

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.

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

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

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

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

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...

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

The J1 story

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.......

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

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

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."