Simbly put.....

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

"Abbe you did medical school in Delhi na?"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chase: "We'll run the tests."

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

To say no....

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

It is always so interesting to read the Comments btw.

At the turn of 31

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

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

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

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

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

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

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

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

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

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

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

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

What the hell!!

How imperfect.

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

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

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

"All looks okay", my intern said.

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

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

Then shit happens.

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

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

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

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

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

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

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

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

" But she is on her way"

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

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

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

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