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So much love...!!!

It seemed that he had gone into a persistent vegetative state after a routine surgery. There was no identified toxic/metabolic/anatomic/structural/infectious/rheumatologic cause identified from results of a slew of extensive and sophisticated tests based on every possible near/far fetched hypothesis that could be tossed in the diagnostic process. His brain looked structurally normal with normal electric activity.But he continued to just stare blankly into the recesses of his room, like.... all hope of purposeful life had been sucked out of his existence, as heart continued to pound, blood flowed, lungs bellowed. But... to what end? What caused his neurons to be so benumbed... no one knew. I felt like I wanted to enter into his hippocampi /medial frontal area and tickle and see how they responded .

Only one thing stuck in the story : he had lost his wife to an acute illness a few months before.

I shivered at the thought when I heard the detailed story for the first time. I found it hard to picturize in my mind the fact that this man had slept beside the dead body of his wife for three days without alerting anyone of her death . They called him crazy and schizotypal, but  he had been a 'normal' guy before her death plunged him into craziness.

There was incredible sadness when one entered his room after hearing this story. Like he was one with his wife at last, and we were no one to intrude in to this seeming oneness of two persons. I knew then that he would die soon. I had seen my grandfather shrink into this absurdity of purposelessness without my grandmother had passed. All their lives they had been so passive-aggressive to each other, but in the death of another, the unmanifested love had played out like a gutting opera tristis a la Ivan Illych gradually stenosing all life.

I asked Psych- "Could this be catatonia?"  They said, " NO, please rule out an organic cause." 

I thought, "yeah, sure!!! "

I felt like asking, " could the diagnosis be Sadness? "


They would have called me crazy, I know.


Disclaimer: The details of the above mentioned situation are a figment of imagination only.

The Ritual by Abraham Varghese

Am so amused by some of the reactions in the comment section of this video.

The busyness of being busy

I have always struggled with when lack of novelty threatens sustaining interest in activity. I remember Louis Aledort's comment at MBA's Hematology CME, when I first attended this in Mumbai. Somehow his comments stood above Mammen Chandy's ode to Lorenzo's Oil. They stuck in my impressionable mind. He had alluded then that the redeeming moments during boredom ridden midlife/after-midlife crises are often an interesting patient, a serendipitous catch, a renal bruit you picked, an opening snap that others overlooked, an anion gap you chose to investigate that turned out to be the real thing, that reinforced your way of thinking. That maybe you should just do your thing, give 2 hoots to what people say, write, recommend. Because you are the one who is doing things in circumstances which surround you.

 It is important to ask yourself a question, to rejuvenate the juices or the physical exam skills, to sharpen your skill of diagnostication,to invent a way. You could be very good in adhering to guidelines and doing things systematically. But boredom/ lack of engagement will elicit an error in you if callousness or lack of conscientiousness towards the culture of safety does not.

I think it is important to be busy. But it is also important to decide what you wish to be busy with.

Culture Shock..........

Date Nov 07, 2011.
This was one of the no real planned agenda routine days on my trip to India this Diwali of 2011. The noise of the crackers had died down and the triglycerides had peaked at 260+ , waist fattened on sweets of all kinds, plenty of rice and dollops of ghee and left over chocolates.

What it turned out to be was a revelation.

I am one of the innocent few of my flock trying to cover my naivete in thinking I would be able to return and practice in India as an Infectious Diseases physician with braggadocio, patriotism, thinking big, an exercise in philanthropy, or say what you may. Every time I think this ought to be my punch line for my future SOP for a Fulbright scholarship application or a motivating Carpe Diem kick on the rump when I am too stricken by porn pestilence or Facebook fetish to indulge in useful activity. And I cannot imagine a this picture/situation where I can fill myself in.

MSF- 8 months away from DW?!; WHO- lack of clinical work?!, Consulting with McKinsey- same lack of clinical work which equals intellectual rust; health concerns; frailty of resolve; concern that mutabilities of time might change priorities in life the way it has from say 5 years back to till now. All these play on the mind.

This was supposed to be a trial for what might be.

My friend  is an Infectious Diseases Consultant in Pune. Having done an Infectious Diseases fellowship at Hinduja Hospital, he has established a reasonably successful ID practice here in Pune. I accompanied him on one of his 'routine days' hospital-hopping across the city seeing various consults requested of him. My debilitated motorcycle served me well. The weather was bearable, I had relearned all the tricks of 2 wheeler driving in Pune traffic.

We started at Inamdar Hospital, in Fatima Nagar. This came as a real shocker.For one, I thought this might be some small apartment-converted-into-nursing home type gharghuti affair. But the scale of this hospital awed as much as the in-expertise of the nursing staff and lackadaisical manner of things appalled me. The usual sort of ID cases, but drugs missing from the med list, doses and names botched up, a blissfully unaware BHMS type of registrar, nitpicking nursing staff. It may be my limited view of things, but I was unimpressed by the usual Indian/Puneri way of acknowledging and satisfying a need while glossing over the details. The paan stains will come........I thought.

I remembered my friend Jason, from Baltimore, reasoning why we give leucovorin while treating Toxo. How I wished he were here to see this- our land of plenty. Plenty of people, plenty of disease, plenty of infections, plenty of doctors, plenty of money, plenty of poverty, plenty of misery, plenty of inequality, plenty of diversity, plenty of toxo...

A long drive to my birth place. King Edward Memorial (KEM) Hospital in Rasta Peth.I have quaint remembrances of doing my medicine internship here. Of course residency was at the bigger, dirtier KEM in Mumbai, but this KEM was where I thrombolysed my first MI patient on a semi-floor bed naive to the concept of reperfusion arrhythmias, did simultaneous and tandem ascitic taps on noon calls, and had to suture my first bone marrow puncture site which I over-enthusiastically converted into an incision. It was where I diagnosed my first Addison's, and ran my first code on a renal transplant patient spilling OKT3 on my apron, already smelling of NAC. It was where I got my Hep B needlestick, panicked first and then got wiser from the situation. (I don't know if it was the HBIG though which made me wise). It was where I got my medicine mojo.

Fever with rash is always a  sticky wicket to play on. Fever with rash in the ICU is even more tormenting. From the days of the Lepto epidemic in Mumbai, I have had hypotheses of scrub/tick typhus, Hantavirus, Crimean Congo, immune storm pathophysiologies to the FART( Fever Associated with Rash and Thrombocytopenia) and FUNDAY ( Fever UNDiagnosed As Yet) phenomena. I admit I had to refer back to Ananthanarayan's textbook of Microbiology to  refresh my details on the Weil Felix reaction.

Drug rash we opined- like is usual, ID physicians are first to pick up on even non infectious etiologies because of the general housekeeping sort of job one does in this role.Of course we fornicated on Lepto/Dengue and all those usual culprits, besides typhus, spotted fevers etc.
And continued Tygacil and Meropenem!!! Bloody jaat ka baida maru.........

OPD at Deenanath Mangeshkar Hospital at Nal Stop  came with it's bushwhack of the day. An otherwise healthy old lady of mid 60s or so, walks in with her nephew with symptoms of dysuria.No antecedent antibiotic exposure, no prior hospital stay or urethral instrumentation. Some 30-50 pus cells i the urine with an ESBL E Coli in the culture!!!

" This is very common here", my friend explains. He mentions of another friend's mother who grew an ESBL in the urine in similar circumstances. He blames this on the blatant abuse of higher antibiotics and the "spiraling empiricism"  among sub-specialists with the authority to prescribe, but no knowledge to guide such prescription resulting in Zosyn or Meropenem being a first line antibiotic for maybe an SBP, Colistin being a staple drug in the ICU, and double and triple Gram neg coverage being a common phenomenon. I am scared at the disconnect between what is taught and what I am practicing now and this mirch masala type of practice.
He reasons that this community acquired ESBL UTI phenomenon is close to 70% of the UTIs he is seeing. He has no data to back this statement apart from his recollection of experiences which he says is not biased. He reasons that this maniac empiricism might be causing the prevalence of ESBLs in the community to be so high that people might be spreading it to each other. We discuss that we should prove/disprove this theory by possibly culturing the stool of these 2 patients or the water supply at their homes.

Our 60 year old lady gets Ertapenem for a week.

A few HIV, and TB patients follow.

But this question keeps nagging. So the NDM scare stories are for real? This really will be a tainted shit hole of MDR bugs,the bugbear of ID physicians of the world? Will we be the biggest prescribers of Colistin the world, like we are possibly for Amphotericin? Will we sink into the grave our GPs have dug?
My naivety suddenly was more apparent than ever before.I had wanted to return to India because I always thought that there was so much opportunity for an ID Physician to carve a niche into, to work to establish norms, to educate, to improve upon. But now it seemed to be like the same plot was a bit trepidatious, even quixotic.Organized chaos might work in business models, but what butterflies are created in this unholy, free for all kaccharpatti, and how they may evolve is something I cannot imagine. ID specialists might be in demand due to ESBLs and KPCs proliferating everywhere, but with neither the drugs to manage them, nor the epi wherewithal to prevent them, we might just be practicing this abhorred empiricism at a higher level.God save us from that anarchy !!!

Small hospital in Parvati zopadpatti area. Few simple TB cases ( so relieved to see pulmonary TB after what seemed like a  drought of TB across the Atlantic) and Crypto Men ( Amphotericin again!!)

My fears were confirmed at the Sahyadri Hospital ICU in Erandawane .  All three patients we saw had MDR organisms in pleural fluid, CSF and blood respectively.  Colistin, Teicoplanin,  and Micafungin were running like tube feeds. It dawned to me that it was likely we would lose this battle against the microbiome faster than other countries would. Unless we could export these bugs to a more developed country, there would be no more new drugs to fug these bugs.We would be back to the old days of good air, nourishing food and sanatoriums for the very resistant bug illnesses. Or surgery for recalcitrant infections. More radical or modified radical abscessectomies/ infectionotomies  for more or less virulent infections.Maggot therapy, hot coffee therapy.

'Kya aap Acinetobacter positive hai?'

" I am MDR positive, please don't hug me" 
" MDR- Jaankari hi bachaav"

" No, you don't get NDM from mosquito bites"

 The funny thing was that there is no hospital epidemiologist allied to the ID physician. I guess the incentive in a pay out of pocket system is in people staying longer in hospitals or ICUs. And so no one takes this seriously. Possibly with development of the health insurance system, shorter stays would be the norm with physicians whose patients develop nosocomial infections getting a rap on their knuckles for poor performance. The opportunity would then arise for educating these numbskull surgeons, by disincentivising poor performers.

I really hope that day would come.

Nahi to andher nagri chaupat raja, takiye ser bhaaji, takiye ser khaaja.

This or that

This was part of a long drive conversation with DW. I have worked in two healthcare models, one of the developed world, and another barely sufficing to meet needs of the developing ( whatever that word means) world. We manage to scrape the surface back home. Manage the one single basic issue really well. But if anything is screwed, complications arise, or things become more complex than diagnosis and treatment of one issue, we step back, become fatalistic and let things take a natural course.

Which is not to say that the plentiful bounteous healthcare dollars available to the American healthcare system have created a mannaland here. Problems of treating a populace that expects too much, and believes itself to be immortal, and a force ready to appease this hunger, are not easy to solve. You would say, what's wrong with that? This is an individualistic society that values the achiever who pushes his chances to the maximum, be that his fight with fence sitters, backscratchers, depression or pesky irritants that threaten his longevity. But, do we need a geriatrician to tell us that one day it is going to all end, and to accept this is not a defeat of the generation?

Are we then better off in the developing world setting, where too much healthcare has not intruded itself into interfering with the daily issues of life, or becoming a part of it? After all, would I care what goes into the making of my TV as long as I am able to watch stuff on it? Or is that a sense of acceptance that since we cannot shape our lives with the limited monies and resources we have, we have to accept what life deals to us, be that the fatal realizations of the frailties of our own bodies?

To be truthful, I do not know. If it were me, I would want the best, ain't I? But, are the countless visits to the doctor's, tests, venepunctures everyday, some numbers thrown against my profile, pills, chills and psychic overkills really the best? I cannot seem to decide without a P<0.05

Homeostenosis

I met a 83 year old, who once would lift 250 pounds in one snatch,

Now, age, the passing of his significant other, severe heart failure,

I know not which more, makes em puff and sigh so hard,

In 10 pound dumbbells he finds his match.

Astra Castra Numen Lumen

Echo

My Q waves wonder why they are there, While,
Physiology, respiratory variations or my lardaceous midriff
Do not explain whether the cold water I drank,
Inverted the Ts in the same views
Of my presenile heart, which must now be viewed
Or so they say!!

Iphone secrets

I am also surprised as to how well my Bluetooth headsets work with the iPhone. Earlier on with the windows mobile handset , it was a task trying to her the headset to sync with the handset. Listening to the classics on piano by Richard Clayderman..... Soothing with no sound breaks. Wish I had waited for the Bose Bluetooth headset. But the Motorola is good enough.

Tomorrow is a new day.
Hope , I hope is on my way

Shivakumar

Moblogging

This is my first post from the iPhone blogging tool. Blogger has become an old thing in some ways what with twitter and Facebook. But I prefer freetext to click and enter. Having the iPhone handy is also useful when the thought strikes and pen and paper are not handy, nor is a computer screen.

I have to figure out how to insert an embedded hyperlink in text with this device.

Meliorix

Interview questions and answers tips

This is for future reference:

8 Websites That Give You Tips On Job Interview Questions and Answers

Motivator: "Tell me something about yourself"

Bodypainthing ...circa std III textbook

Thought I would never find this ever....

Okee Pokee crack me crown
King of the island of Gulp 'em Down
Was thought the finest young fellow in town
When he dressed in his best for the party.

Okaa Pokaa Ching Ma Ring
Eighteenth wife of the mighty king
Loved her Lord above everything
And dressed him up for the party.

Satins and silks the queen did lack
But she'd some red paint, that looked well on black
So she painted her Lord and Master's back?
Before he went to the party

Crowns and stars and ships with sails
And flying dragons with curly tails
And so dressed Okee Pokee, without a coat or a vest
But yet, in his best for the party..