Techknowdoc's Surgical Adventures!

The Killer Indian Sari

2011-12-12T11:21:00.001+05:30

Now that the title had generated some interest in your mind, let me take this one step further. Our beloved Indian Sari, something that all of us see everyday, can cause Cancer! Shocked. So was I. 5 years of Medical School, 10 years of experience and I had no idea.

I recently read a paper on Cancer cause by wearing a sari in the Indian Medical Association Journal regarding the same and I just knew I would have to put it out to everyone outside the medical circle so that at least you know it's possible.

Squamous Cell Cancer or SCC is a very common skin related cancer which can occur virtually over any part of the body. One of the most common reasons for it developing is constant irritation of the skin due to prolonged contact with something causing uncontrolled multiplication of the skin epithelium. SCC of the skin begins as a small nodule and as it enlarges the center becomes necrotic and sloughs and the nodule turns into an ulcer.

Most Indian women who dorn saris tend to tie them really tightly at the waist. The reason for this is not understood by me. Maybe they think it tucks their tummy in, maybe its the way they've been taught to wear saris or maybe it's just worry that it would open up. This, however, causes some degree of trauma to the skin by the underlying elastic cord. This leads to a minor injury in terms of wrinkling of the skin which can be seen at the end of the day when the sari is taken off. Do this everyday and there is some degree of permanent pigmentation so that the skin almost develops a depression or fold at that place. For some unfortunate people, this repeated inflammation of skin may evolve into SCC.

Strangely, an even more common documented cause of SCC is chronic exposure to sunlight and Ultraviolet Radiation. Wearing a sari would tend to decrease direct exposure to sunlight and UV rays, which is paradoxical to say the least. The only explanation I can come up with is that the change would be at the border of the sari waist band thereby having two forces act to cause the change.

The cancer is a slow growing one and if people are aware and catch it early can be fully treatable. In case of ulcer formation, the entire ulcer with a free margin is excised and that is that. People unaware of the possibility may go on treating it as a skin infection or abscess cavity and lose valuable time making the ultimate prognosis less favourable.

This post is purely to disseminate the information I received for the rest of the medical and indeed the non medical world!

My final thoughts on this : If persistent contact with a sari can cause this, think about those aches and pains you get while using everyday items all the time. The most dreaded example I can think of is your cell phone - Long contact times with your ears as well as minimal radiation. It won't be long before we see a case of SCC over the ears due to constant cell phone / bluetooth usage!

Can you trust your Doctor anymore?

2011-10-19T16:08:00.000+05:30

I was reading over some blogs while I came across this one about the writer having a bad (well, really very bad) experience with her Doctor! She's written her heart out and I'm assuming she channeled most of her anger into the blog. However, she made one mistake! She forgot to look at the other side of the coin. I am trying to show a glimpse of that other side if possible in this post. Do both of us a favour and read her side of the story first to understand this post better. She writes at A-Musing.

Can you trust your Doctor anymore? I would think you don't have a choice. It's like politics. You have to vote for someone, so you do but you may not like the person you've voted for. Let me explain. If you can't trust your Doctor, you have but 2 options left. The Internet and God! Here's why the Doctor is a better bet.

The internet, although a vast whorehouse (yes this is intentional and not a typo for storehouse) of information, will only allow you to read what you want. Try it sometimes. If you have something, and are looking for the symptoms, you would tend to read more into what symptoms you have rather than analyse the whole situation. For eg, A fever can be almost anything, but it is most likely to be nothing. Start searching the internet for fever related diseases and the average hypochondriac (all of us are at some level) would probably end up thinking he/she has malaria, dengue, or Mediterranean Tick Fever!!

God, because, you would probably not realise God's helping you, until you're on your death bed and receive a miracle. Get real, no one attributes a cold going away to God being great! At that point, it's just something that would have happened anyway!

Coming back to the Doctor. There are some points I agree about. Specialities and Super Specialities are branching into areas as small as the pituitary gland (a couple of cms at best). How much would I need to study to know all I can about something as large as a pea! To this question, I have one standard answer! As much as you can! Medicine is not a static knowledge base where x and y always have definite values. There is no constant in medicine and no textbook that can highlight what each patient would go through during a particular illness. It's impossible. That's why its called a practice. The more we see, the more we know and I'll let you into a huge secret here....80% of our work is pure INSTINCT! We just know sometimes, that this fever is more than it appears, that this headache would be the last one of your life, that this little black spot on your toe is going to lead to an amputation of your foot, if you don't listen to the advise we give.

The grand old family physician works almost entirely on instinct because he know's your family, your background, what you are prone to getting and what you aren't. I agree with Purba, that this is a dying art, but it's more alive than you think. You're the one's that are killing it. Who runs to a pediatrician when your child has a cold. You think the G.P. can't handle that? What about when you have vertigo. This one's my favourite. Straight to the neurologist we go, when all it most likely is, is ear wax! Even then, we must see an ENT right? Hardly necessary. These super specialists are booming because you are feeding their fire. Post operative dressings can be done by any family physician, but patient's prefer going to the surgeon. He's a surgeon, for God's sakes. He can either operate or devote his time to simple dressings (of course complicated one's go to the surgeon, that's a given) . If you want him to remove time from his operating schedule and dress your wound, he is going to charge you for it. Then, don't wince about the costs!

Coming to the monetary aspect. We charge, overcharge and extort at times. Sure we do. We have homes to run, same as you. Are you telling me that the delicious bar of chocolate that you so relish, actually costs Rs. 30. I know for a fact, that the manufacturing costs, including wrapping, do not exceed Rs. 10 at best! You gladly pay for that don't you. Look at the fuel prices! Do you think our government is losing money on petrol. Now, look at it this way. Out of the 10 years which we study to become specialists, we earn Rs. 0. However, during this time, we treat almost > 10000 patients (and this is a conservative average of 1000 patients a year, almost just 3 a day. I know OPD's that see 45 patients everyday) all for Rs. 0. When we finally get our degrees, after all the fees (of course there are free seats - these just cost Rs. 80,000 in a private college, a paid seat is about 200000), the exam fees (approx 50000 counting exams every year), the registration fees (about 10000), the travelling (because there are not enough medical colleges near home), we're almost 30 by now (assuming you finish school at 16, junior college at 18, MBBS at 23, Internship at 24, Post Grad by 28 and struggle for 2 years to get a hospital job / clinic if you have rich parents). After this, if I charge you Rs. 500 for a consultation (which is how much you would pay for a movie if it was a couple going) is that too much??

Let's take insurance. Most Doctor's hate insurance and insurance providers. You want to know why? Most patients claiming insurance request us to present inflated bills, hide previous illnesses, lie about the duration of the disease and more things I can't write about. They also expect the Doctor to help them out in whatever way possible to process their claim. When did we become insurance agents! The OPD insurance registration that Purba talks about is mostly in the big hospitals. You want to know why it's necessary. Some patients calmly walk away without paying many times. Who's the clinic/hospital supposed to catch then?

Investigations! This one can go on for another 200 pages. We prescribe them most often because we need them. Other times, it's because patients are ignorant regarding their health and don't maintain a yearly check on themselves. You want to prevent diseases but don't want to take the steps to prevent them. Studies in the US clearly state that half the number of colon cancers can be cured if detected early. The way to do this is yearly colonoscopies after a particular age. Would you do it? What would your reaction be if you were told you have a tumour? I'll tell you. You would say, but I feel perfectly fine! That's why we order tests! Sometimes, you feel nothing while a disease grows inside. On the other hand, I do agree, that most tests ordered today are over the top and unnecessary! This is a small group though.

Medications. I would love to send of some of my patients with just a simple Crocin. Maybe some warm salt water gargling. Would you be satisfied with that? I can guarantee that this is the correct modality of treatment for certain symptoms, but would you pay me for hearing this. Most patients are dissatisfied with the medication they receive as they expect more. I have actually had people walking into the clinic and demanding injections even when they are not required. What do I say to them? If I don't give it, someone else will and I lose my patient to another specialist!

It's a delicate balance between under doing and overdoing. Neither Purba nor I can decide which is right. It's up to you, the patients. Just leave with this thought though. Blood Pressure can change in minutes. If you have a high reading at a Doctor's clinic, most will tell you to get it checked again. Don't ignore them. At the same time, don't ask them whether they're sure you don't need an ECG / Echo. They will advise you for it if you do! Remember, we get sued for medical negligence if this happens. No one can sue the patient for not following instructions!

Virtual Colonoscopy Anyone?

2011-10-15T13:32:00.000+05:30

I consider myself to be quite tech savvy but sometimes even I am blown away at what we have achieved! One of the few constants as a surgeon is that you are likely to find at least one constipated patient per week, at least one obstructed patient a month and at least one Colon cancer a year.

The Gold Standard for detecting this deadly disease is, and has been for a while now, a Colonoscopy. I fear, though, that this simple, but wonderful examination has finally met its match. Like most things on the cloud now, this is just one more thing that has gone virtual. This is a big leap from the olden days, when even the television monitor wasn't available to the proctologist. This is how he did it then.

Virtual Colonoscopy is here and is here to stay in my opinion. It's just a matter of time before more centers pick up the technology and offer it at a price that would rival the regular colonoscopy exam (which is quite cheap right now). The images are just stunning. The advantages are tremendous.

The regular colonoscopy is a fairly uncomfortable procedure. Imagine, having a pipe shoved up your rear end with a machine pumping air in so as to open up the colon for easy maneuverability. Shudder!! A lot of people have to put up with it though, and they do (or did) for lack of options so far!

Of course there is capsule endoscopy but I don't think that will last. First, it's too expensive and not likely to get cheap. Second, you still have to collect the capsule the next day, after it has passed all through your bowels, which reduces compliance a lot (for obvious reasons)

Virtual Colonoscopy should come as a saviour to people who need a endoscopy and don't want to go through the options above! I haven't been able to fully judge the potential of this yet but am hoping to do this soon. Here's a comparison of images for you to ponder over!

Not another Lipoma!

2011-09-30T10:13:00.000+05:30

The exclamation mark at the beginning of the post is warranted! I have written before about the God's scheming to keep surgeon's on their toes by making sure the intra operative findings completely differ from the initial clinical assesment as was the case during the mysterious hernia here.. I'm quite prepared to give this phenomenon a name maybe Techknowdoc's Law (on the lines of Murphy!)

A 40 something Koli (fisherfolk community) woman presented to us with a swelling over her left buccal surface not visible from the outside but fairly big on the inside. It was bothering her as it would interfere with her eating and brushing. Now that I have mentioned brushing, this lady would not use toothpaste but tobacco powder (an unfortunate but very common occurrence in rural India)

This simple piece of information was enough to make us suspicious and we did the usual palpations and tests.An ultrasound exam revealed an echopoor mass with some solid component and no conclusion was offered by the radiologist on the first exam. She also turned out to be hypothyroid which prompted us to think in terms of an aberrant thyroid mass (lingual thyroid is common too)

She was advised an MRI and a thyroid uptake scan both of which were not done as she was not in a position to afford expensive tests. A repeat ultrasound after 2 weeks showed that the mass was not shrinking after a course of antibiotics, and the neck scan revealed normal thyroid tissue and a reactive lymph node on the opposite side.

She was getting very restless and offered a blanket consent for removal. We decided to go ahead and operate. After preop preperations were complete, she was taken in the OT and was given local anaesthesia with an anaesthetist standby. As soon as we took the incision, a grand yellow soft mass popped out.

Once again, the infamous Lipoma (which has baffled us before - as seen in this post) had surfaced in the most unlikely of locations with the most unusual presentation. This was easily removed and the patient was sent home about 2 hours post the surgery! She walked in for a follow up after a week with the mouth wound completely healed and the histopathology report confirming a simple Lipoma.

I guess the God's were giving us a break with this fortunate happy ending! This case will be prepared as a case report and sent to a medical journal for publication. Hopefully, it should end up published.

A rose by any other name....

2011-09-15T13:48:00.000+05:30

'What's in a name? That which we call a rose by any other name would smell as sweet,'

Famous last words!

Clearly, when this was penned, people used to name their children after a lot of thought and purpose. Nowadays, it's difficult to tell whether a name is a name or a fruit or a calender month or something discovered by dropping utensils (sorry to all my chinese readers but pin pong whaa is just too easy to poke fun at). Now, I'm no stranger to keeping funny pet names, gosh, I call my own son Toofan (the storm) for God's sakes, but that's a pet name, not a serious, first name / christian name or whatever you want to call it.

An advantage of being a surgeon is that you get to hear all sorts of names coming into your surgery. Not all are unusual but in my opinion most would never get discovered if it was just a medical consult. There it's usually Mr. X or Mrs. Y but no first names or pet names.

My first experience with an unusual name was in Delhi where one of the nurses was named 'Bubble'. If this wasn't enough to tickle my already funny bone, they pronounced it as Buh Buh ll.

As recently as yesterday, we operated on an appendix patient who was named 'Beauty'. Not a name that means beauty or signifies beauty but 'Beauty'!

Can you imagine the torment the poor child would go through in school, college and walking into an interview!
Good Morning Sir/Madam, my name is beauty and I am a team player. Yeah right! It's just difficult to take these names seriously. Sure I may be biased but it's just bad parenting!!

Featured!

2011-08-30T11:59:00.001+05:30

After years of writing and voicing my opinion, I have been featured.
Read the spotlight article at Femina.in on my fight against corruption

Spotlight Article at Femina.in

Remember to share the article and the blog!

6 years and counting

2011-08-24T00:00:00.000+05:30

It has been 6 years to the date since I started writing this blog. I would like to think that much has changed.

Of course, most of that can be attributed to the fact that I went from Municipal Hospital to Private Hospital to Private Practice. I, however, do hope that my writing has changed a bit too.

I was reading some of my early posts and almost had the urge to edit them. I didn't. I guess, it is something that should stay the way it is to remind me of what has changed! Enough with the change bit.

I'd like to take this opportunity to thank the people who have made it possible for me to stay interested in writing this for so long (God knows I tend to get bored with things easily)

Vinita Mulchandani - My best friend, my wife, my biggest reality check, my fashion police, my personal himalaya. She is so many things to me that I would need another 6 years to complete the list. I love you babe!

Toofan Mulchandani - aka Jeehan (Yes, this is the correct order and not the other way round) He will soon become all of the above. As of now, he is just a bundle of joy (no matter how cliched that sounds) He is also the sole inspiration for my other blog 'Taught By My Son"

Samit Malkani - Yes you made it before the rest of my family. Simply because you are almost right up there with the rest of them (and you know it!) If it wasn't for you, I probably would not have been pushed into writing at all. Your blogs are an inspiration (even though I may not be interested in the teachings of the post, the style is great). Read more about it here

The rest of my family - My brother, Gautam, who is my severest critic, who always keeps a check on me and always pretends not to care. My dad, who is surprising everyone with his tech savvy avatar and mom who just loves to read my name anywhere public!

Saanwari Gorwaney Malkani - Yes I wrote your entire name! You have always encouraged me to write on and for that I thank you. You also make sure all of us have some fun which is something we tend to forget with our busy lives. Cheers!

Juhi D - Always will be Juhi D to me! Thanks for believing that I could write for you sometime, even though I have not gotten around to doing it. Coming from you, its a huge morale booster and gives me belief in my writing ability.

Anjum D - Oh God! How I love to fight with you and argue with you. Thanks for reading the post as soon as you get to know about it. You are the most active person when it comes to comments on the blog and I am grateful to you for that. Love your writing too

M.D. - My Meghu Mutter! I know we somehow always miss each others calls but I know you read the blog and enjoy it and you in your own way inspire me! You're a great friend, Thanks!

Sheebs - My rum and coke buddy! How I wish we could have met sooner than we did. Great fun having you around and please keep reading my blog. Can I include Amit in this too since he'd probably not read this anyway until I can somehow get it into a phone call for him!

Bips - You would have been higher mate, but you tend to disappear far too often and I have no clue what you're up to. I would, however, give your reference to anyone who wants to lose weight. I know you read and thanks for that. Cheers!

Nyaani - aka Mental Bua/Aks/Divz/Divya If and when she reads the blog she always has nice things to say. More importantly, I can laugh with you without any reason! Hahahaha

Ok, this is beginning to sound like an oscar speech!

All my other readers! Don't fret because you're at the end. The end is usually the best part. To move to the top, please read, comment, share and care!

Hair Today...Gone Tomorrow...Just came back!

2011-08-22T14:30:00.000+05:30

I read this piece on male pattern baldness this morning where Dr. Phil (yes the one one Oprah) said that 70% men would rather amputate a limb than go bald.

The ultimate fear of some males happens to be baldness. I wonder why? It's not like Samson's story was ever proven to be true. Or even if most politician's (excluding Manmohan Singh for obvious reasons) appear to be bald. What is there to fear?

Some women I know, love the smooth bald feel on their man's head! I think it gives some people character. Agreed, Sehwag and Harsha Bhogle seem better off after their treatments but would you really bother if they hadn't gotten it done? It would not have made an iota of difference to me!

Apparently, there are various new ways of getting the treatment done....Old methods involved literally cutting off the back of your head, where the hair growth is maximum and transplanting it to the front. Nowadays, though, they have hair follicle pick up and implantation over the bald patch (almost sounds like fertilization to me). They have even discovered the gene causing male pattern baldness. Maybe a cure is at hand but it's far from ready now.I know someone working at a hair restoration clinic in Bombay and he swears by the results and the painlessness of it all.

I even got an enquiry from somewhere in Africa for the same. Maybe it's time has finally arrived.Men are looking at ways to prevent baldness and until that arrives, there is always restoration. I'm just pleasently surprised at the number of centres mushrooming up in Bombay for the same.

All the best to my bald friends!

Android, BB, Iphone

2011-08-11T11:11:00.000+05:30

Hi Guys,

I need your help. No this is not Nigerian spam asking for money for me to get back home!

My devil's workshop has come up with an idea to fill the time I have right now and I want to make an application for android, iphone and bb for Dr. Mulchandani's Medical Services

In it's very basic version which I shall start up with, I intend for this app to be a ground level appointment scheduling and rescheduling app with some more features. This is where you guys come in.

If you had the chance to download this on your smartphones for free, other than the fact that you could fix and change appointments with any of the doctors on my panel, what else would you like there to be.

Off the top of my head I can tell you that there would be a very brief (phone friendly) introduction to Dr. Mulchandani's Medical Services, maps to our locations, specialities (which may be embedded in the app itself or may be a weblink to the main page), contact links, ability to email directly / call directly from the app (no need to exit the app and go to email / dialer)

What else can I put in there in terms of value service.If you had the app, what else would you want from your Doctor's office.

Should I put in some basic disease symptoms and direct where you go / which doctor (specialist) you need to go to

Simple Eg. Nail half broken - Go to the Surgeon (no need to go to the G.P. / Family Doctor)

Any other suggestions would be very helpful. Any ideas I pick up would be credited to your twitter handles / social avatars!

Looking forward to lots of suggestions. If you don't have any please criticize! And Harshly!

If none of the above, just support this and say go ahead and make it.

@Scepticemia Already reminded my about reminders, which I had completely overlooked! Stuff like this is all I need. Nothing technical necessary!

Thanks and Cheers

Life is not fair

2011-08-06T11:30:00.000+05:30

Something terrible happened last month. Something I wouldn't even wish on my worst enemy. It was a tragedy. There are no other words to describe it, nothing that would do it justice. Justice, that's a funny word, because it seems there is no justice in this world. A world that allows the passing of a little girl to the heavens for no fault of her own. Fault can't even come to play a role because what happened was beyond anyone's control, no matter what one says. And what can you say, when a 3 year old girl falls off the window on the 3rd floor. I think this will be written over twice. One would be the Doctor in me remembering what happened. The next one to follow would be me, a father, a friend, a relative, a human recounting the horror!

It happened in Pune. We were informed and left the next day. We reached the hospital (fortune had it that it belonged to someone I know closely). She was lying in the ICU bed. No external injuries. Eyes closed with gauze and sticking plaster to prevent damage to the cornea. All injuries were internal we were told by the attending consultant (also a good friend of mine)

She had multiple fractures of the skull, ping pong fractures and depressed fractures, bleeding in the brain, blockage of the ventricles (which plays a role in absorption of CSF) and was unconscious. The situation was grim and there was nothing much we could do but wait it out and watch for how she would progress.

Over the days, some levels of consciousness were regained. She would respond to her parents calling out to her, hands and legs would move. To a lay person, this meant improvement. To the consultant, he was more practical. He warned me about some levels of spasmodic contraction remaining on the right side. She was moving but how much was voluntary. Her eyes were opening slowly, but were they able to see. There was serious doubts about sight since the haemorrhage in the brain was compressing the optic nerve.Days passed into weeks, CT scans and MRI's were performed. Physiotherapy started. All that could be done was being done. She was on the ventilator, but a tracheostomy was imminent.

The last scan showed increasing pressure onto the brain and a decision for burr hole surgery was made. Tracheostomy was very much in the piping but was postponed to respect the wishes of the parents. It was decided to give the burr hole a chance to see if drastic improvement occured and the need for tracheostomy could be averted.

The neurosurgeon was kind enough to do it in the night itself so no time would be wasted. He infomed me when it was over. However, he was not too happy with the surface of the brain. In his own words, "It's not pulsating as much as it should after evacuation of the CSF". He was not too happy, but was optimistic as was the need of the hour.

Over the next day and a half, she developed respiratory infections. It was time for a tracheostomy, whether the relatives agreed or not. It simply could not be postponed any longer. It was done the next day. Suctioning was carried out regularly. The child seemed to be losing the battle, though.

Then, at 3.30 a.m. the call came. Middle of the night calls are almost always bad news. This was too.

She was no more!

What Next Bombay? (Ported here from wordpress by popular demand)

2011-07-25T10:16:00.003+05:30

I’m not going to recount the episodes that have occurred in the past. I’m not even going to dwell on the 3 blasts a couple of days ago.

I am just going to vent, so if you do not want to hear complaints and anger, get away from this now!

The psyche of people living in BOMBAY (this is how I am going to refer to my city, and anyone who wants to pick a bone with me regarding this, I dare you!) has changed so drastically that now that something even remotely close to tragedy happens, we’re tuned to brush it off unless it has affected us directly. We were called by many people living outside the country, family and friends who are as close as family, all afraid because the BLASTS had taken place in our city. All concerned and rightly so. The atmosphere at home and the clinic was slightly different though. According to them, we were nowhere close.

My wife, bhabi, nephew and son were all at Metro that evening. I was at babulnath. Yet we thought it was fine because we were ‘nowhere close’ to the blasts…It was close enough for people not in the city to call us, but as long as we were a kilometer away, we were far off and not affected. Most people in areas of terror attacks fear for themselves even if they are miles away. It just doesn’t matter to us anymore.

26/11 was frighteningly close to my home. I was at Mondy’s as it happened. Our friends stayed over that night! We were afraid then. Nothing this time. Repeated attacks have either made us really strong or extremely stupid.

The other thing I want to rant about is people blaming the politicians and the intelligence agencies. What do you think they were supposed to do. We live in our city, spit on our roads, litter like there is no tomorrow (or dustbins), get irritated when cops stop us or have a nakabandi because it screws traffic and still proceed to blame them the next time something happens.

I remember the drunk driving crusade that the cops started. I loved it. Used to feel proud when I stopped seeing cops working in the dead of night to prevent people like us who drink and drive from dying. Most of us though, disliked it. Hated them for catching us, if they did. Cried foul when licenses were taken and court appearances demanded. Would you drink and drive internationally….I don’t think so!

You want to live in a safe city, reclaim it from inept politicians. Take your own responsibilities seriously. Stop at the goddamn red light for a change. Even better, get your license legally without a bribe or an agent. There are enough and more rules and laws. All we need is to implement them, and we shouldn’t need the police to tell us or force us to do so. Of late, I have been intentionally driving into people coming down the wrong way in a one way street outside my home. One uncle on a scooter almost fell, yelling at me for doing it purposely and was shocked when I said yes I did. Hopefully, he won’t be riding down the wrong way again. I also picked up some chewing gum a 40 something Aunty spit on the road because the shopkeeper wouldn’t let her use the bin. Small things but it’s a start.

Do something, don’t just rant on facebook and twitter.Also, don’t dismiss candle marches so easily. It may not have got the desired result last time, but it did shake up the government. Libya also started with something as small.

If you think you have the guts to make a change happen, stop the next cop you see riding on his bike without a helmet and ask him where the hell it is. My mom has done it and I have never been more proud of her. Stop the cop riding on JJ flyover when he won’t let other bikers ride there. Yell your lungs out at someone asking for a bribe and watch him wet his pants. They only do what they want because the majority let them.

Lastly, this thing is not about religion. It never was. It’s about making a stand and voicing opinions. They want our attention and they have it. I liked Advani’s point about learning from the US. He, however, did not specify what to learn. Should we learn to give body cavity searches to people in wheelchairs, or learn how to bomb the countries we like least?? Or is it the fact that there has not been another attack there…. You can’t copycat nations. You don’t have an identity if you do that. We wouldn’t be independent and a democracy if we did. We got through the British, we can get through terror. All it takes is a few very angry people from one very angry city to start something. Be it traffic rules, or terror. Do something!!!

Ramesh.......Suresh

2011-06-28T11:48:00.000+05:30

The monsoons are upon us and with it comes the time for all things middle east to settle into the by lanes of colaba and most medical centres. At our day care centre, it's a veritable vegetable market full of rings on heads (keffiyeh) for the men and black burqas with nose and forehead guards for the women.

These people come in vast numbers from their homes to look for quality medical care here in India. They come prepared for all and any interventions necessary to go back healthy only to come back another year. The main purpose of them coming here in these months is to enjoy the rains, something that is missing from their lifestyle.

There is one huge problem in all this though. They are loud, and I mean LOUD!

They will greet each other very very warmly, loudly and without a care in the world as to who is around them. They may be staying not half and hour from each other back home but obviously do not ever meet there (maybe for socially specific reasons) and come down here and meet each other like it has been years since last seeing the other. Sometimes, it appears as if it's the last time they will see each other too! So, just in case something happens, they will hug, give the mandatory 3 kisses on either cheek, some on the forehead of elders, make promises to meet again real soon and then just come back the next year to do the same thing here again!

It's almost like the people who shot the five star commercial with Ramesh and Suresh came to one of our centres, took a look at them and said this is it!

AHMED-----MOHAMMED!!!! KAIF HALEK!! YA-ALLA RAFIQ.......FATIMA-----LAILA!! SHABA KHAIR!!

Crayons Are Meant For...

2011-06-20T12:26:00.000+05:30

A couple of days ago, we started potty training our little Toofaan. Little did I know, it would end up being related to something I would see at work the same day.

A 4 year old child was brought in by his grandfather with a tummy ache. He was very nonchalant about it, thought it was just something the child ate, so he wasn't too worried before this day. He, however, noticed this morning that the child pooped in colour (Eastman / Technicolour).

He then had the good sense to call the mother, since the child wasn't too forthcoming with his misendeavours. It turns out that the kid had eaten an entire box of crayons the day before. Further investigation led to the revelation that he has done this before too, but just not in such great quantity.

The tummy ache was treated symptomatically and the kid is better now, but his family is still not sure how to make him stop chewing on the crayons. I told the mother to show him this picture.

Moral of the story: If you don't want to end up like the child above, Stop Eating Crayons!

Push Button Erections!

2011-01-04T13:20:00.000+05:30

In a world where everything is becoming remote controlled and everything is available at the push of a button, this just could not have been too far behind right?

2011 - The era of push button erections is here. What a boon for patients suffering from impaired erections / impotence.

The system consists of an implant which has 3 components. One part is inserted into the penile shaft and is the cannula. 2nd is the reservoir which contains saline used to inflate the cannula and cause the erection. 3rd is the button literally, the control switch if you will, which directs the saline from the reservoir into the cannula. The older version (yes, its been around for a while now) was a manual pump, but now with hydraulics, the entire system is automatic. Once its use is over, press the button again and return to tumescence (it just should not sound like return to innocence! just wrong, I say)

Now, all those pervs who have happened to stumble upon this blog because of the keywords used, this is not meant for normal people who can achieve an erection anyway. Also, it is a surgical procedure to get it 'installed' so beware. Remember this fair warning.

Future possibilities (entirely my ideas, and I will sue if someone copies this)

1.) Inflatable breast implants. Just imagine. Limitless possibilities.

2.) Inflatable biceps / triceps - for the macho wannabies

3.) Inflatable fake pregnancies - to avoid those annoying arranged marriage proposals! Hah! I love this one

4.) Push button crying - to prove a relative died when you want a holiday and have no leave left.

5.) Implants for push button beer delivery. Never get caught with a bottle!

6.) Push Button lubrication - For those times when he wants it and you just don't! (Sorry girls but it will be invented)

Can you think of some on the same lines??

Kicked by a Horse!

2010-11-16T13:19:00.002+05:30

I'm back after a long hiatus....and kicked about it. All it took to get me back to blogging was a horse! If only this had happened sooner.

I am sure this is common in the wild wild west, but this is the first time I've heard of someone coming into a clinic in Bombay because he was kicked by a horse!

What makes it even more strange is that the patient was a 10 year old boy, who was doing his daily chores when he happened to see two horses 'get into an argument' so to speak! He said the two horses were fighting apparently and he went to try and calm one horse down when the other kicked him in the head.

The kid was hit pretty hard and according to his mother, he was lying unconscious for about 10 minutes. He came around and had a huge swelling over his head and required stitches.

The only good thing to come out of it was that when the time came to take him in the O.R. and suture him, he wasn't the slightest bit afraid of the injections and instruments. What a way to get rid of fright! Maybe next time he would kick the horse back!! (No offense meant to PETA members)

He's doing well now and the wound has healed completely, but I doubt he's going to be riding a horse anytime soon. Maybe he'd just go hide in a tree.

Laparoscopic Surgical Treatment of Pain From Chronic Prostatitis

2010-09-25T10:31:00.000+05:30

Laparoscopic radical prostatectomy is a technical and demanding technique used to remove the prostate. Since the late 1990s, this surgical technique has been used for the treatment of prostate cancer. However, its possible uses may be expanding – in very carefully selected and unusual cases – to include the treatment of chronic prostatitis. Should every patient with pain rush to have his prostate removed?

Some forms of pain are good. For example, pain is good when it forces us to remove a hand from a fire. Other forms of pain are bad. Pain is bad when it chronically distracts us from our appointed rounds. For example, an amputee may have pain in a hand that no longer exists; this kind of pathological pain, which fulfills no apparent constructive purpose, can keep the amputee from concentrating on other things.

Pathological pain can also arise from the viscera: The abdominal contents. Common examples are Irritable Bowel Syndrome and Endometriosis, the pain of which is can be hard to localize and treat. For all intents and purposes, visceral pain is not treated surgically. Should the pain of prostatitis be treated surgically?

Prostatitis falls into two broad and general categories: Infectious and non-infectious. The infectious kind is generally associated with bacteria, causes fever and pain, and is easily treated with antibiotics. The non-infectious kind, which can last for years and even decades, is characterized by episodic pain, fatigue, inability to think clearly, depression, and social isolation. Its causes are not known and the treatments have remained elusive. One theory to explain severe, treatment-resistant, chronic prostatitis is that it is really a psycho-somatic manifestation of neurosis and distress. In other words, the theory holds that severe, treatment-resistant, chronic prostatitis is “all in your head” and should be treated with psychotherapy, massage, and trigger point release.

Beginning in 2007, evidence has been anecdotally accumulating that severe chronic prostatitis may be completely curable with laparoscopic radical prostatectomy. Specifically, a 55-year old man with an 8-year history who had exhausted all other options had this surgery and was instantly cured. Since then, a handful of other men have had such treatment as part of an ongoing, IRB-approved prostatitis treatment clinical trial that follows symptoms measured by the Chronic Prostatitis Symptom Index (CPSI) over time. They seem to be also improving, although the response is not completely uniform, the symptoms are receding at different rates, and a minority appears to be getting little, if any, therapeutic effect.

So why should a man in pain not try laparoscopic radical prostatectomy? The answer lies in the risk analysis. Laparoscopic radical prostatectomy is associated with infertility, which for men at child-bearing ages as is the case with prostatitis sufferers, is a major issue. It is also associated with risk of urinary incontinence, erectile dysfunction, bladder neck contracture, cardiovascular complications, infection, and treatment failure. Given that some prostatitis prostates are embedded in a dense reaction that causes adherence of the prostate to the rectum, there is risk of rectal injury.

Men with severe, treatment-resistant, chronic prostatitis have no good options. It may be that laparoscopic radical prostatectomy can help some of them to feel better. However, the promise of this approach is only in the earliest phases of validation and the risks associated with it are serious and real.

To learn more, readers are invited to follow the Prostatitis News Blog, which will post results of the trial as they come in, as well as information on many other facets of prostatitis.

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Guest blogger Arnon Krongrad, MD is Medical Director of the Krongrad Institute for Laparoscopic Prostate Surgery.

What else could a Lipoma be?

2010-08-07T08:35:00.000+05:30

In a follow up to the post on What else could an Umbilical hernia be? a strikingly similar experience prompts this post.

A fairly large lady of middle eastern descent presented to us with a soft, non expansile, mobile, swelling over her left thigh just about where the groin fold meets the leg. She said she'd had it for years and it gave her no trouble other than cosmetic and she wanted it taken out for that specific purpose.

She underwent a Sonogram which confirmed our clinical diagnosis of it being a Lipoma. Happy with our findings we posted her for surgery under local anaesthesia (which is usually the case) in day care!

We started off, dissected around it, it looked like a lipoma and we dug deeper and higher. Down to the muscle layer, carefully avoiding the femoral vessels. Until we reached what we thought was the femoral canal. She was under local so we asked her to cough. No impulse. Asked her again. No impulse. No luck either as my finger was going all the way up through what was now confirmed as the femoral canal.
This was no lipoma. It was a full fledged femoral hernia!

Luckily the anaesthetist was close by and was able to reach us in 10 minutes. We carried out the repair completely and the lady is doing fine.

I wonder what else a lipoma could be? Until I find another presentation.....

Is English Important To Medicine?

2010-06-29T18:04:00.003+05:30

Language has always been a big issue in India, and more so in Maharashtra and Bombay or Mumbai depending on which side of politics you're on. That it was a big issue in the field of medicine has only just started to receive prominence.I've been meaning to write about this for a long while now, but haven't got that push required. I think this week's post graduate examinations were just what I needed.

A twitter friend of mine is an examiner for Medical Students. The Consultant I work with is also an examiner for DNB (Diplomate of National Board) students. Both these intelligent and hard working doctors give up their precious time and practice to examine students in their viva-voce exams and decide whether they are fit to practice medicine. I always wondered how an examiner felt when coming across thousands of students, some of whom excel at medicine and some who are just about there with medicine but speak English fluently.

I would think that holding a command over the language would give the student an immense advantage over his counterpart who would falter in grammar, no matter where he stood on the knowledge scale of medicine. This comes from personal experience as well. I don't think I was even half as good as other students appearing for their examinations with me, but I could speak English well (almost better than half the teacher's taking my exam) and that gave me an upper hand.

From a patient point of view, the whole thing takes a rather wierd turn. Some people would prefer talking in their native tongue to their doctor and some would cringe if a doctor didn't know how to speak English well.

My view on this is that if the books are written in English and the syllabus is taught in English and the exams are conducted in English, the students must, simply must have a working knowledge of the language. That being said, would it be too bad an idea to have a compulsory cut off for English along with the Sciences that we need after college? Should English as a language be a subject along with Anatomy, Physiology and Biochemistry?

I think it should. Please let me know what you think....

What else could an Umbilical Hernia Be?

2010-06-26T18:53:00.000+05:30

As a Surgeon, every time I settle down and think to myself that I've seen a case like this before and it should be routine, God intervenes and reminds me that nothing in surgery is as it seems. Least of all when you expect it to be.

We had a lady who presented with a fairly simple small swelling just around her umbilicus at the lower edge. She had had it for about a year. She was keen on getting it out and got the relevant investigations for the surgery ready.

We took her into the O.T. and gave her the necessary sedation and local anaesthesia and proceeded with the usual 'smiling' umbilical incision. On dissection, we noticed a very well circumscribed localised blob of fat = Lipoma. Could it be?? As simple as a Lipoma? No way.

We dissected further. It wasn't extending beyond the subcutaneous plane. I had not even reached the rectus sheath and it was almost out. I was just about ready to call it a Lipoma and then I reached the rectus sheath. It seemed to be growing out of it. I had to really dig deep into my long forgotten medical school knowledge bank kept at the back of my head somewhere in the pits of my cerebrum.

I showed it to my senior. He confirmed. It was a 'Fatty hernia of the Rectus'. Strange, I thought. That's something I've heard in relation to the Linea Alba. Extraperitoneal fat in the epigastrium is known, but paraumbilical at the rectus?? Anyway, that's what we left it as since there was no sac, so it couldn't be a hernia and it was only fat and the defect was less than a cm in size.

Strange!

Doctors and Parents!

2010-06-14T11:36:00.000+05:30

I am intruding on my son's space but this blog is the first amongst many things I intend to share with him.
There are countless books on parenting telling Mom's what they should do. Very few focusing on what the dad should do, or even feel. Numerous books on what to expect, what Mom will be feeling, how to cope with those feelings, how its normal to be emotional etc etc.

Dad's are expected to wing it. Go to work, be the breadwinners, be practical, sensible anything but emotional. Well, we feel it too. Unfortunately, all those books on motherhood and babyhood are written by women. I suspect its because Dad's don't get the time to write or just can't get down to doing it (peer pressure??). Don't close this window just yet...I'm not about to write a book.

This is what I felt in the weeks leading up to the delivery.

When he kicked for the first time - Mom was elated. I felt joy. Immense joy. Not because he kicked. Because she was elated. At that time, he was still a foetus to me. Something I had studied in medical school. The kicking was something we took for granted because we saw pregnant women all the time. But my wife was glowing....and I felt Joy. Immense Joy.

When she started getting Braxton Hicks Contractions - Mom was elated and confused. She had tons of questions. It started to sink in. This was my child. Something I had helped make! My flesh, my blood, possible looks like me. We talked about the contractions. Explained to her it was normal. It's just your uterus getting ready. I am convinced it is an act of God, not to help the uterus get ready or the mother, but for the Dad to realise he's having a baby.

She gets backaches - She felt tired and hassled. It hurt! I said I know. I had no idea. It's impossible to know what kind of pain someone is in unless you've suffered it before. No matter how much you say you know. It was her uterus getting bigger and ready.

She dropped her mucous plug - I was the doctor that my brain is conditioned to be. "It's ok", I said. It's part of the process. I completely missed the fact that this was the first sign of progressing into labour. Of course, it takes days after this for labour to begin, but I am not a gynaec and I missed it. The dad in me began to stir.
I drove slower, much slower. I watched signals with more concentration than ever before. I chose roads according to her convenience. It should not hurt her back. No chances with traffic snarls and accidents.

She was lying in pain when I got back - I realised this was labour. Dad had kicked in. Spoke to Mom. She was our gynaec. She's the quick thinker in the family. Said lets waste no time. We're off to the hospital. I remained calm. Medicine training kicked in involuntarily. Wife asked can you believe we're in labour. I said yes. It didn't register. She stayed at the hospital from then till delivery. I didn't. Mom did. She would decide progress. I wouldn't.

I went home that night and checked my emails. I had one saying June 20 is Father's day. I thought, "What shall we get dad for this one?"

Then it hit me. Smack in the face. By June 20, I too would be a father. My own child. That I had to care for and worry about. I don't usually worry about things. I'm cold like that. But I melted that night. I believed we were in labour. I understood that I was having a son. I knew that I would do anything for him to be born healthy. It kicked in.

This was the first lesson my son taught me. Better than any book could ever explain! Better than any other parent could tell me what to feel. Better than my wife knowing before I did. My Son!

Grand Rounds Vol.6 No. 36 - Let the Lol's Begin!

2010-06-01T06:30:00.005+05:30

I've had a rather interesting time compiling this post for this edition of Grand Rounds. I must say the motive for the theme being humour and laughter was purely selfish. This is the first time I am hosting here and I knew that if I had to keep up the good work of the previous hosts I would have to be totally involved with the selection process of so many many fantastic entries that this event brings on! The only way to screen them would be to enjoy reading every bit and what better way to do that than over a laugh.

So, in no particular order, here are this week's lol posts!

Every doctor would remember the first day in Medical school for various reasons. In my case it was finally wearing the crisp white apron and carrying around a stethoscope for all the world to see that I was a doctor. Fortunately, for me the first day back home wasn't complicated by a medical question like the one at John's Glass Hospital - The Magic Curtain. He bravely answered questions at home and got hands on into Medicine early in his internship.

Insurance is more often than not thought of as a necessary evil. In a country like mine, where insurance is just starting to rear its ugly head, we are just about bracing ourselves for the impact it would create on Doctors. Unfortunately, InsureBlog has this burden of pointing out something that the doctor's should have noticed even with their eyes closed. Prompts me to say "What a bunch of arses" Avoid the NHS and travel abroad is my say on the matter!

A simple but sweet reminder - Mother is always right! Grandmom's even more so. Clearly this ATS Speaker was given a mouthful before leaving home that morning when she went on to announce the simple golden rules to Care for ICU Patients Successfully. Grandma Protocols almost makes me feel like employing it at my surgery!

Maybe we should all use the Grandma protocols to deal with difficult patients. On the other hand the list given here is almost always bound to take care of those particular cases where the patient is just not going to be happy no matter what. Dr. Woodward’s Checklist is the ultimate how to guide for dealing with difficult patients, be they yours or some other Physicians!

Everyone likes a good reception and waiting area. At ACP Internist, this adorable but albeit serious message of COPD grasping our lungs is nicely displayed over the Exhibit area with Exhibit Hall Silliness.

Doctors are shrewd aren't they! Here's a story about an Ob/Gyn who would be in a win win situation as regards the gender determination of an unborn child. Find out how he was always right in determining the gender with this maybe true, maybe not story at The Sterile Eye - Hedge your bets. Just to add, in India he would be arrested as it is illegal to determine the sex of the foetus due to the rise in female foeticide.

Laika has a wonderful story to tell regarding the perspective of little children towards doctors - even the one's that are PhD's. In this adorable post, the poor Doctor was reduced to a guinea pig's healer by his young daughter. A Strange Doctor Indeed.

Dr. Charles almost got me reliving my comic book days before I became a Doctor. The batman in each of us is so well described here that I feel it should figure in all medical schools and teachings as an inspiration to all medical students ready to start of their lives as healers.

In India, the art of living is taking on big proportions. In this delightful video blog from Life in the Fast lane, The Art of Sloughing, they highlight the plight of the poor ER doctor reporting to his attending. Also, check out the UCEM - Utopian College of Emergency for Medicine (yes that is not a typo) and the numerous link in there. All worth many clicks and laughs!

Inside Surgery - A medical information blog carried this rather strange piece of news read on the news wire posted by the FBI - Help wanted by plastic surgeons. I really want to know if this is really possible. Inside surgery also has many step by step procedures lined up - Anterior Cervical Fusion being one of them.

A late but brilliant post is this staunch Diabetic Mommy Kerri lists the things that make her a diabteic mommy with such humour that it is impossible not to leave this blog smiling! Her tag line for the blog reads 'Diabetes doesn't define me, but it helps explain me. She explains herself by that wonderful smiling photo in there. That according to me is the best way of tackling Diabetes. Smile!

Sticking with Diabetes, Diabetes Mine ( Read as Gold Mine for Diabetes) compiles this awesome list of glucose logging software for the mac even though she is now a self confessed PC person. Just a wealth of information here.

Just to end on a very funny note - this is something that happened very close to me. Its equivalent to the great Indian Rope Trick for Colds....

Hope you had a smiling time. I hope this edition was even close to expectations as I can barely claim to have matched the greats who have hosted before me. Meanwhile, keep a lookout for next weeks edition and happy blogging.

Call for Submissions - Grand Rounds Vol. 6 No.36

2010-05-27T11:53:00.001+05:30

Hey!

First of, I would like to thank the creators of Grand Rounds for such a wonderful feat and giving me the honour to host this next edition.

With the last edition topping the charts at 33 Charts I would certainly have to pull my socks up and pull of the rounds with at least 50% near perfection that Dr. V did.

Without further ado, lets get into submission mode. I'd like to keep the theme for this edition as Humour in Medicine. This may not have to be restricted to doctor patient but may extend to anything happening in and around medicine with a funny end to it!

Submission can be made either here at the comments section or at my email - Techknowdoc

I am on twitter with the handle (Techknowdoc) and would accept DM's there too

Deadline for submissions would be 30th May - Sunday!

Looking forward to hosting a colourful and hopefully smiling edition!

Cheers

Follow up of the Condyloma Accuminata

2010-05-25T21:32:00.000+05:30

In continuation with my previous post about the giant anal wart that turned out to be cancerous, this is the same patient after 10 days follow up post surgery.

In case you are wondering what it looked like before the surgery, you can check out the photo here or go through my last post Giant Condyloma Accuminata!

That is a pretty descent job if I may say so myself. The only thing is to now, somehow, convince him that radiation is absolutely necessary for complete cure of the carcinoma. He is quite reluctant though. Also, e had about 50 smaller finger sized warts on his bodice and neck and face which he now wanted removed because he was afraid he would get cancer in them too. Took about 1 hour but we got them all!!

He's about ready to go home in a week or so to consider radiotherapy.
Until I hear more from him....

Giant Condyloma Accuminata

2010-05-20T11:16:00.004+05:30

For all the non-medical readers, the title is not something I made up just to arouse your curiosity. Unfortunately, we had a patient of middle east descent recently who presented to us with a large growth in his perineal area (close to the anus).

He had been harbouring it for 10 years. When it started it was about the size of a pea. At present it was about the size of a soccer ball. This is the actual photo. No kidding! What must have started at the anal region as a simple wart was now extending upto the anal cleft behind and the groin in front! What provoked the man to keep it in hiding for all this time eludes even his brain. Somewhere in this mass was his anal opening. Can you even imagine the logistics of hygiene!

Well, we had the honour of having to operate on it and excise what we could while trying to save his sphincter functions. No sooner had we started that we realised that this most likely has undergone malignant change (become cancerous). Every portion we touched would bleed like crazy. The condyloma had become so vascular that it was very like that it had progressed to squamous cell carcinoma as is bound to happen after such a long period of having it. We excised what we could and tried to suture his skin back in place while sending the specimen for histopathological examination.

As it turned out, it was squamous cell carcinoma but the margins could not be identified, meaning we didn't know if we got all of it or was some element left in situ. We asked him to go for an Oncologists opinion for radiotherapy.

He refused! He still is resistant to go there and is thinking of going back to his home country.

God help him!

How soon can we drink after surgery?

2010-05-12T18:00:00.000+05:30

Modern medicine has been breaking bounds in the new era. Every year we come up with new and fantastic methods to fast track recovery after a surgical procedure. The entire day care surgery concept is based on this fact. Sometimes, however, our patients push us to the limit.

The gentleman we were operating upon for a bilateral hernia under day care surgery was a very good candidate for surgery. Medically fit, cooperative, not pain sensitive, motivated for day surgery, ready to walk back to his hotel room in the evening after surgery. He was given local anaesthesia in the inguinal region and we were operating upon him. We finished the Right side and went on to the left. All was going well until suddenly the patient decides to ask us a very interesting question.

"Can I have a beer as soon as the surgery is done?"

We were quite shocked and asked him to say that again. I think he realised what he said because he then tried something else. " I can smell beer in the OT. Can I have some. I can smell it in the oxygen tube" Maybe he thought it was an excellent way to recover early from surgery?

Now wouldn't that be a novel way to get drunk. Inhale some alcohol vapours! Superb absorption!