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

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."