In pursuit of......

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

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

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

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

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...

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

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

I am.........

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

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.