Indian Medic

2012-07-30T06:51:00.001+05:30

AM 6:43

30 July 2012

I have been taking far too much stress about mu driving abilities.

I have barely logged 9 + 11 = 20 hours. I am a novice by every standared out there.

If I panic in the rush hour traffic of Sion-Trombay road, its but natural.

What I need is to relax and take control of my life. And it all begins with discipline.

And for me the first dictum of discipline means awaking early in the morning and getting to time on work.

And with this 8.30 AM - 5.30 PM gruelling schedule add after that, running errands and winding up with an hour long driving practice daily, I need to be up and about on my toes for 12 hours every day. That demands physical conditioning from hell.

So I started, ok.... restarted for the umpteenth time my morning walk.

And there are so many things that need to be attended to

- I need to drop my check at the bank.

- I need to drop off and pick up my laundry

- There a 4 inch long post it on the fridge with grocery requirements

Cram or Die!!!

2012-02-25T08:22:00.000+05:30

I wonder how I managed to survive 12 years in medicine without mugging things up….???

Its THE norm, the basic, most important skill needed to be a doctor– a excellent memory… for DDXing most importantly!

I have always had this abhorrence for memorizing large tedious lists… I always cut corners, meaning to come back to them, but never did.

It’s really a wonder how I survived 12 years of exams and Vivas if I can’t string half a dozen causes/effects or what not for every known/unknown phenomenon in medicine.

I mean, I knew I had to. I knew it was important. But I have never made mnemonics for anything while studying… EVER! Or borrowed any for that matter… except maybe the one for the carpal bones (She Looks Too Pretty, Try To Catch Her!)

And of course the one for the Cranial nerves I picked up from Eric Segal’s ‘Doctors’.

But other than that, I had no system to memorize long winding lists of things.

I have this image from early in med school, from the reruns of the show ‘ER’ depicting the character Dr. Peter Benton, a driven surgeon, waking at 4 am in the morning and running the treadmill, simultaneously enumerating causes and stuff for things.

That image more than anything drove home the fact that any reasonable, self-respecting doctor should have at least a dozen DDx for any given condition at the tips of their tongues.

But I never could. Memorizing stuff the most tedious thing anyone could have asked me to do.

Give me complicated theories and mechanisms and physiologic-pathologic explanations anytime and I could go into the arcane details of such things.

But a long boring list of disjoint items.. Never!!

Looking back, I don’t know how I survived.

But looks like fate has caught up with me finally.

The Practical exam I need to clear to get DNB certified, is exclusively based on the principle of commit and vomit…

You need to have darn sharp memory and reproducibility skills if you want to make the cut!

What the hell am I gonna do?

Maybe its time to thinks of a career change!!

Control

2012-02-16T12:41:00.001+05:30

I know you can control your life or all the shit that goes down in it.... but you sure as hell should be able to control your body and mind... wont say much about the heart.... that's a stupid organ when it comes to productivity.

Yeah.... that's what I'd like... To be in optimal control of my Mind and Body... To do as I bid, when I bid!!!

The Drawing board

2012-02-16T08:51:00.001+05:30

I have been declared FAIL in DNB Final Practical and Viva examination conducted by the Board in the Discipline of General Medicine in June 2011 session against Roll no 1111111*** – Vide Letter from NBE dated 22-12-2012 Ref no – 1111111***/June2011/NBE/25746.

And what the fuck have been doing since then?

Running? As fast as as I can as far as I can.

But here again … I find myself where it all started… THE DRAWING BOARD.

The very same board where I had charted out the plans and details of my coup of AIIMS…. When I was barely 19.

According to those plans I should have been a board certified Cardiologist by now.

But alas… you know what they about the best of plans…. Failing …. And all….

So instead, 10 years later, I am 29 days, 3 months and 27 days old. And DNB – Medicine Theory passed and First attempt practical failed.

Not to mention 10 kilos heavier than the lowest mark I had hit on the scales over 6 months ago…. Back to binging on chocolates and fried food again, getting really uncomfortable in all my newly bought denims and tops.

And sinking back into a state of deep oblivion, especially so since the result of the practicals….

Am I scared of studying?

I want to say No…. but I am not sure if that’s the right anwer.

Am I scared of hardwork….? Oh God Almighty… YES!!!

Then Medicine and specifically Internal Medicine was the last thing I should have chosen as a speciality.

Too late to look back on the transgressions I have committed to my own life.

Lets get back to the drawing board.

Kids nowadays…

2011-02-11T19:45:00.002+05:30

An obvious part of our DNB training program are regular seminars, case presentations and journal club activities etc. By rotation, this takes up two days in the five-day week (Saturdays are half days). Until a couple of months back as Chief resident, it was my job to delegate topics, cases and such to my colleagues and juniors and keep after to them to make sure the presentations occur as planned. I was directly answerable to the Head if a particular person was not prepped and in his /her stance, I would have to do an extempore discussion. I always had multiple random presentations ready and set to go on my Flash drive under such unfortunate circumstances.

But since the last couple of months my successor at the co-ordination level has not been able to keep up the job. And neither was he prepared to give extempore orations. So we have been having a highly irregular PG activity schedule off late.

Until last week, when the Boss lady gave us all a good dressing down and promised to give us term extensions (meaning Delayed completion certificates on the various disciplines) if we did not stick to the schedule as planned.

Fortunately, however the four final year residents have been exempted from doing the presentations, but we still have to sit on them though. This week it was the turn of first year resident to do a PowerPoint on 'Aplastic anemia and recent advances in therapy.'

First, let me say how well I appreciate the poor general condition of a first year resident, - always sleep deprived, hungry, irritable, tired, exhausted. They pretty much work on the spinal level – in reflexive movements and actions. No time to actually exercise the ticker Gray matter to study and learn new things.

I've been there, done that, so I get it.

So I am very supportive of my first year residents when they are up on the mike, usually taking the questions from the consultants and not firing any myself.

So this chappie, was on call the previous day and was totally strung out. So when I reminded him that he was up the next day for Aplastic anemia, it took him a full minute to realize what I was saying.

'Shit…. I forgot.' A vacant, downcast expression followed.

Pitying the poor fellow, I got someone to cover for him for a couple of hours that night, so he could at least read up a bit.

Next day, at the appointed hour (usually 3.30 pm after a dizzying OPD of a couple of hundred of patients when all the mind screams for is fresh air and some coffee...) we gathered in the conference room.

He started off, and started off well… his slides were good (I was surprised he got any made!).But as he spoke and gestured to the slides, I realized he was just mouthing off what was already mentioned on the slides… except paraphrasing. And the slides seemed disjoint and unhinged. And he was not able to connect the series of slides together and couldn't elaborate any of the advanced stuff on the slides – like genetic correlations, clonal features etc.

I looked around to see if anyone else noticed. A few vacant expressions, a few open-eyed sleepers (all doctors are good at that!) and very few who were actually listing. But no one had the quizzical expression I did… 'Well… maybe they all want to cut the guy some slack'… I thought.

Then came the boomerang… he went on to a case study, pretty elaborately worked up…. it was a good case. But not from our hospital. Ours being a closed populace we all knew the rare cases like Aplastic anemia and such who were regulars in the OPD and the wards.

This case of a 27 yr old male… as the idiot rattled off…. raised a few eyebrows. A consultant even turned to me and mouthed 'Our patient?' I nodded in the negative.

I was on to him, by then, I knew what he had done….

But he gave himself stupidly away, when he came to a slide that read

'The patient was referred to London for second opinion and treated with Eculizumab the cost of which 250K £ per annum'.

DAMN… THE STUPID FOOL… HE HAD DOWNLOADED THE WHOLE PPT FROM THE INTERNET AND DELETED ALL THE SLIDES THAT HE COULDN'T EXPLAIN OR READ OR WHATEVER….

Eculizumab is not yet available in India.

But how thick skulled must he be to present the case as it was… or did he think the audience was thick skulled or what….?

I was angry, amused and indignant all at once. Back 'in the good ol days' we made presentations we made them from scratch, referring multiple textbooks, the internet was only a source of reference and pictures.

Fortunately, for him even if everyone had noticed no one said anything, everyone was too tired to care I suppose. So he got away with it. I did some online research myself and found the whole slide show as it was, except with the background changed and the difficult charts and graphs deleted.

Has this what its come down to… using the internet thus….

I asked around and apparently its quite a common thing. There are whole websites that give out readymade essays and presentations. Even primary school kids with internet know how can come up with the perfect essay.

Ridiculous…. Disgusting….

Later that day, he texted me, thanking me for giving him the two hours so he could 'Prepare' the presentation…

Grand Rounds Vol 7 No. 20

2011-02-09T13:48:00.003+05:30

Grand rounds is up at Suture for a living...

And yours truly got mentioned....

The Green eye monster

2011-02-01T21:19:00.002+05:30

We got a new addition to the department today, a PG RMO or Post-Grad Resident Medical Officer. This is a relatively new concept in DNB recognized institutions across the country. To maintain the accreditation as a centre for DNB post-grad training, we have to have at least one Post-MD or Post DNB doctor on the payroll. Not to be confused with the consultants or attendings. PG RMOs are recently board certified 'Specialists' out to garner some experience in the field. The international equivalent may be a 'Fellow' perhaps.

Well the new addition is a lady with commendable qualifications, not more than 2-3 years older than me. To be very frank, we residents were not really looking forward to getting a PG RMO. She would be our immediate boss, you see and the so-far direct contact that we have had with the attendings would have to be re-routed through the 'proper channel'. The much painstakingly gained trust from the consultants to have a free hand in the wards would kinda go in vain. So far, what the final year residents say goes in the ward (once you run it by the attending ofcourse!), but now we would have someone constantly watching over our shoulders and auditing the often underhanded dealings that are mandatory at the resident level in any teaching hospital.

Simply putting it - my clout as Chief resident would be dampened – There I have said it. I am the trusted one when it comes to deciding rotations and appropriate disciplinary actions for resident on the err. I was the link between the consultants and residents and I liked the perks that went with the position.

I know I sound pompous and all…. But hey I am still human aren't I…?

So finally after a quite a significant delay due to administrative red tape (which we residents were thankful for) we finally got our PG RMO. It was her first day and she had been instructed to conduct rounds in my ward.

Unfortunately for me I was running a good half hour late when I turned up for rounds and was in a sartorial disarray of sorts with my white coat all stained and my pens and penlights flying out of my pockets. I did not quite cut the impressive figure that I would have liked. Nevertheless, I was greeted with the usual 'Good Morning Dr' from my junior resident. My co-registrar introduced me to the New addition as 'This is Doctor Indian Medic'.

And at this she turned an askance glance towards me and said '... and who is he…?'

My juniors passed knowing glances amidst themselves sounding like 'Uh-Oh….!!!"

'The Medical Registrar – Chief resident' I replied in my best baritone...If nothing else I sounded a bit offensive.

And offended I was… no one comes to wards and asks who the hell I am… I mean NO-ONE. I am the self-proclaimed-king of my ward, nothing moves unless I tell it to.

Ok, Ok, I got an ego the size and nature of a Hot air Balloon… but neither of us made a good first impression on the other.

The rest of rounds I chose to stay silent and use the opportunity to size up the competition. She was good, I had to concede, and she knew her stuff. Except that like usual newbies, rather than just taking it all gradually in, she had a lot of pointed questions to ask, putting her in the 'Take command' class of people.

By the ends of rounds, I decided I did not like her…. Truthfully speaking, I had resented her even before she made a physical appearance. Add to that the fact that I am one of those people who always find it difficult to be nice to new people.

That was the extent of my contact with her through the day. But later when I was talking to my colleagues, I realized I had been rather hasty in appraisal. Apparently she had already asked everyone to be on first name basis with her and agreed to provide us (the exam going people) with sets of question papers from the previous years. Moreover, she did have clinically sound knowledge, which could be advantageous to us.

I was apparently the only one with something negative some to say about her…

That's bad… especially with my recent attempts to stem my anger issues and make efforts to lead a 'normaler' life. I had been too hasty with my attitude issues taking precedence, rather than making the poor girl feel welcome.

So I have decided to make an effort tomorrow, be a better person, bite my ego and who knows maybe even make a friend.

The Countdown begins

2011-02-01T20:33:00.003+05:30

Well, the dates are out for my final DNB theory exams - 11 and 12th of June.
As an constant reminder, I have added a countdown timer to that effect on the blog sidebar.

Rightnow it says 129 days, but I know time flies real fast.
I stil have enough time to hitch up my pants and make a run for it.
Any further delay and I will sure as hell be in a trouble...

So all the best to me...

Who’s the Boss?

2011-01-26T10:38:00.003+05:30

Often a major part of a doctors job is making decisions – ranging from small ones like choice of antibiotics to big ones like DNR. Often it's the decision of the patient and family, but needing the guidance of the attending doctor, who is expected to know the best. When all goes down well – good. But what when the parties have a difference of opinion and some problems crops up. such as in situations where, even after proper guidance and counseling on the physicians behalf, if the family chooses to make a decision in untoward consequences, does the doctor not share any responsibility whatsoever?

Following is one such is incident, which made me ponder – where do you draw the line – of who takes the blame?

We had a patient, a 21 year old college kid, Punit, a couple of months back. He was referred to us from our sister concern hospital in interior Maharashtra, which was basically a secondary care centre. He presented with persistent fever since 2 weeks, high grade without chills and persistent low Total leukocyte counts. He also had history of loss of weights of over 3-4 kg in the past 3 months, but a normal appetite. No other significant history available.

On clinical examination - He was of slight built, vitally stable, with unremarkable findings on Respiratory and cardiovascular system examinations. He had however mild hepato-splenomegaly on per abdomen, with 3 firm, non tender, palpable cervical lymph nodes. No other palpable nodes anywhere else. Other than the fact that he had the mild toxic look of a febrile patient, he seemed fine.

On admission, his Total leukocyte counts were 1700/mm3, with aHemoglobin of 8.7 gm % and Platelet count of 1.25 lacks/mm3. His LFTS were deranged with Total Bili of 2.4 mg%, with a direct fraction of 0.9 mg%, ALT/AST of 56/79 IU/L and ESR – 123 mm. His Widal titers were 1:360 for Typhi H. He was started on broad spectrum antibiotics with anti-malarial cover with our area being pretty much of an endemic zone for malaria.

His Chest X ray showed enlarged hilar lymph nodes and abdominal USG picked up LNs as well.

Initially he seemed to be responding to our treatment with a drop in the fever range and slight increase in the TLC to 2100 /mm3. However a couple of days later it again dropped back to 1500/mm3. He was already into Day 5 of antibiotics here. His tests for Dengue, Leptospirosis, hepatitis, blood cultures came back negative. But the fever persisted, despite change and trial of different antibiotics. An FNAC from his cervical node came back inconclusive as well.

We decided to go ahead with a CT of the abdomen and Thorax with contrast, which revealed discrete sub-centimeter LNs in the thorax and abdomen, occasionally matted but essentially all of them non-necrotic. Sr. ACE levels were normal.

DDs came down to either Koch's which could explain all of his symptoms and signs OR Lympho-reticular malignancy, which could explain all of his symptoms and signs as well. Since Tuberculosis is endemic in India, we immediately started him on an AKT regimen with Streptomycin, Ethambutol and Ofloxacin. We had to avoid the first line drugs – Rifampicin, Isoniazid and Pyrazinamide in view of his LFTs, which had further deteriorated over the week.

Lymphoreticular malignancy was weighing heavily on my mind and I tried talking my attending into doing a Bone marrow aspiration. If it turned out normal well, we at least tried. But she being an old timer of sorts was not so keen on it, saying a trial of AKT ought to put us in a better know how. The debate continued on a daily basis for 2-3 days and finally she relented.

Miraculously however within 48 hours of starting AKT, Punit improved…. Dramatically. His fevers disappeared, his counts came up to 3600 /mm3. He looked and felt much better and also his nodes started disappearing. So AKT it was. We continued him on AKT with persistent improved responses, and in a week's time he was pretty much out of it. Everyone rejoiced.

But not for me the joy of a battle somewhat-easily-won. I harbored misgivings about not having a tissue diagnosis. Well in a place like India, where every 7^th or 8th person had or will have Koch's somewhere in the lifetime, with clinical diagnoses of Tuberculosis – pulmonary and extra-pulmonary, being made a dozen times in our hospital itself on a daily basis, the 'Trial of AKT' concept is more prevalent than pursuing tissue diagnosis as the international textbooks say. Tuberculosis figures as a top differential in pretty much all cases of PUOs or Pyrexia of Unknown origin.

Therefore, Trial of AKT it was for Punit…

However, I convinced my attending for tissue diagnosis. Since his counts had picked up and stayed up, a bone marrow was ruled out. His palpable lymph nodes had disappeared so a LN biopsy was out the window. The only thing left was to do either a CT guided or a Transbronchial Needle aspiration cytology (TBNA). Now came the part of convincing the parents.

His parents were working class people, definitely not uninformed but were not exactly intellectual either. And the boy himself was an engineering student. So we sat all of them down for a heart to heart on the further plan. We or rather my attending spelled it out as explicitly as she could, concluding that even though the AKT seemed to be working for him, Punit might also be having some other occult disease that was getting masked and we needed to seek it out. Then came the pros and cons of the purported procedures, and the risks involved in them. They heard us out, we answered all their questions patiently. The conversation seemed well balanced back then, but in retrospect… well… I'll come to that later.

We gave them a day to think about it. Meanwhile health wise he was doing really well, his LFTs had improved considerably and he was stared on low doses of Rifampicin and INH as well. He was happy, his parents were relieved. Somehow our little chat about an alternate diagnosis didn't seem to weigh as much on their minds. Apparently they even called around and took a second opinion with their family physician before deciding to defer the CT LN biopsy for the present. I would like to mention here that financial constraints were nonexistent in this equation as all charges were being paid for the by the government organization that ran the hospital and employed the father.

Even though I am the chief resident here, I am not allowed to cross the Attending and speak to the relatives after all the pertinent decisions have been made, and I am ok with that. So his AKT was continued and he was discharged, sent back home and asked to follow up after a couple of weeks. All was well…

Till a month and a half later…

He came back to us, as a defaulter. He had stopped his meds since about a week and his fevers came back, as did his Lymph nodes. Apparently Punit had taken up some sports activity which made him miss his meds and his parents had not made a note of it. So back he was in exactly the same condition as last times. Except that this time his Total Leukocyte counts were 1300, his Hemoglobin was 6.6 gm% and his Platelet count was 78000/mm3 – he was pancytopenic. His temperatures were off the charts and his Lymph nodes were more in number and distributions. This time even though we put him back on his AKT, the signs persisted.

No waiting around this time, we went ahead with a bone marrow and open Cervical LN biopsy. Bone marrow was somewhat unremarkable except for a decrease in all cell lines. His LN biopsy however, showed typical Reed – Sternberg's cells…

Hodgkin's…

DAMN….

AKT was stopped and he was referred to Tata Memorial Cancer hospital for further work up.

There was of course one more conversation with the parents, explaining this new turn, a conversation I chose not to be a part of.

It hounded me, a young boy, Hodgkin's lymphoma. So many questions…

Was the delay in diagnosis going to cost us bad? What would have happened had he not defaulted on his medication and the symptoms had been masked for another few months. Should we have insisted that the parents do the biopsy? Should I have gone ahead after the attending was through and talk some sense into the parents and Punit himself? Should we have stressed on the details of the alternated diagnosis while talking to the parents the first time around, in essence scaring them or drilling fear into their heads about the mortal nature of what we were suspecting? May be the doctor should be given sole responsibility to make such decisions, would that have avoided this situation? In retrospect all of these questions were valid, but unanswerable.

Who's fault is it? Who should take the blame if the delay in diagnosis makes a dent in his treatment options? Is the current system of informed decision making as good as it is made to sound? Or is just a roundabout way to split the blame with the patient party when things go wrong?

Even if say, it was entirely the decision of the Punit and his family… can I as a doctor sleep comfortably at night, knowing that my patients decision could cost him his life.

Maybe it's ok, if it's a situation where it's a terminal disorder and the patient does not want to suffer anymore and chooses to discontinue or deny treatment. That would be understandable. But Punit's situation where time is muscle… should we as doctors let the patients and family make such mistakes on the name of informed consent? Is there no way around it?

I was in a turmoil for a whole week after this… guessing and second guessing myself. My attending, focused on the fact that we had been explicit as possible in the discussion with the parents, when they had chose to defer the biopsy, (read – a lawsuit was out of question).

Don't know how to end this tale… well, Punit has been started on Chemo, and is being planned for Anti CD 20 therapy. His future remains dark.

Not a bad day...

2011-01-22T08:08:00.001+05:30

Well, I made it, through one day of no bickering or angry resentment at the workplace, on my on call day at that. Its quite a personal achievement for me. I did not shout at anybody, did not bitch about anybody, did not call any one names, no nothing.

I did my job as well as I could. I even tried to join in on the birthday celebrations of a recently recruited colleague I barely know. Neither did I bare my teeth at the first year surgical resident who came up to me for guidance on his dissertation, which takes off from where mine ends. I gave him the relevant information, in as a patient a manner as possible, even though his apparent cluelessness about the basics of his chosen topic was a bit amusing to me, and I could see that it had taken him a lot of courage and galls to come up to me – The Fire Spewer, for some guidance in the first place.

I did not delegate the simple, unchallenging tasks of Insulin infusion titration of two patients with abnormally high sugars to my interns. I patiently attended all hourly calls from the wards and titrated the sugars.

I finished my thesis today, finally. Supposed to send it to the printers today. Now that’s a relief… have come a long way from the days when I struggling to do ‘Something on diabetic foot…’

Yeah, maybe I was not as smart as I think I was in my initial days. But I did get here the tough way. And I still have a long, a really long way to go.

Liver Cirrhosis - Palmar Erythema

2011-01-20T16:20:00.002+05:30

Palmar erythema in a case of advanced Alcoholic liver disease with Cirrhosis.

Broken Physician?

2011-01-20T13:31:00.001+05:30

After my angry post yesterday, I decided to tone it down a bit. The confrontations mostly and have a more understanding approach towards people who normally bug me. So far, half way into the day, I am doing ok of sorts. But the big test will be tomorrow, when I'll be on call, marathon 36 hrs.

I have to dampen my wild demeanor, or else I'll be slapped with lawsuits left and right once I leave the safety of this institution.

I try to think of myself as a good doctor, rather as 'not a bad doctor'. I care for my patients; I do go out of the way to help. But as I said due to the tediousness of things, I have sorta lost my competitive edge. This will not help my future prospects for subspecialise.

I feel kinda burnt out. And it's just my 12 year in the field of medicine. I am still a rookie by most standards. How can I just give up? I don't want to be a general practitioner. I want to be in pace with the rapid developments that are being made in Medicine every day. I want to be at the cutting edge of things. But not with this attitude I have developed.

Maybe I need a break. A vacation, the last leave I had was in September 2009. For 4 days, so doesn't exactly qualify as a vacation. The one before that was in Jan 2008, for a week. Other than that I have been working every single day, except for the one Sunday a month I get as leave. There are no working hour restrictions for residency in India. I work something like 95-100 hr weeks even today. Does get a bit tiring at the end of 3 years.

Cant give up though can I?

Never have and am not about to begin now.

Will work on things, all aspects of it. Academics, public relations, work ethics, patient's relations everything. Hopefully, the damage is reversible.

Frankly speaking, when I set out a few years back down this road, I did not know there would be so many cross roads. No doubt I have taken a wrong turn, will just have to correct course and get there on time.

Just one thing that nags me though….

Have I turned into one of those Broken Physicans?

An Angry post

2011-01-19T20:14:00.001+05:30

I am in my final year of residency now. Six months before I appear for Final exams. Then I will be a National Board certified Physician. I can practice where I want, anywhere in India. Pursue higher education i.e. Sub-specialize if want.

But often now, there are instances where I think – 'Am I ready to take solo flight?' No consultants to consult, no back up decision maker, no one to take the ultimate blame in shit-hitting-the-fan scenarios.

Especially with my anger issues nowadays. I am angry all the time. The personal stuff apart, there is something frustrating about work. It seems tedious, pointless, and monotonous.

Have been at this hospital almost four years now, first as an ICU Medical officer and two and half years as a resident in Internal Medicine. Initially the challenges seemed…. Well… challenging. Now they are boring repetitive.

Actually its time, I as the Chief Resident get some time off to prepare for my exams. Administrative duties apart, at least the load of clinical work should be lightened up a bit. But unfortunately the following batch of residents, my juniors, are … for the lack of a better word… disappointing. They seem uninterested in the work and the challenge of it. They go around doing stuff just coz they have to. Not coz they are interested.

Well, I suppose from every seniors point of view, juniors always have a lot left to improve upon. But frankly, last time this year, all my senior residents had to do was just show up for grand rounds. We even relieved them of the Outpatient clinics and Emergency On calls in October. Now it's January and I am still trundling off the ER in the middle of the night to interpret 2:1 Mobitz Type II heart blocks, coz my junior couldn't.

Kinda Sucks….

And some of the old shit doesn't change, still have to point out to the Surgeons and Orthopedicians that it is risky to give Gentamycin to patients with a baseline Creatinine of 2.1 mg%, no matter how well you adjust it according the Creatinine clearance.

'Don't refer the patient back to me, when his Creat starts to shot and his Urine output drops!', I savagely shouted at the Surgical fellow, who was telling me about his grand plans to monitor the Creatinine and Urine output stringently.

Anyway, ROMIs – Rule out MIs. Another big issue. Beds are a commodity we are always short of on the Medical wards. We constantly have to borrow beds from other departments in their wards, often in the middle of the night. And with my constantly deteriorating PR relations, beds are hard to come by.

Coming back to the point – ROMIs. Apparently healthy patients with no risk factors for Cardiovascular morbidity whatsoever, presenting to the ER with Chest pain. Well typical ones have the retrosternal squeezing uneasiness, radiating to the left shoulder associated with shortness of breath and sweating etc. If the ECG shows some relevant changes no problem. They get in.

But there are the ones with atypical complaints – Jaw pains, shoulder pains, back pains, epigastric pains, recurrent burps, acid refluxes etc – with Normal ECGs at that. Well they are not exactly diagnostic dilemmas. Textbook says 4-6 hrs observation in the ER, two set of Cardiac markers (CKMB and /or Troponin T or I) and they are good to go. But the problem with our ER is, its not equipped to handle such patients. So they need to come indoor. On an average we have 5-6 patients coming in every night to the ER with such atypical complaints.

It's the job of the resident to screen such patients. Often when I am absolutely out of beds in the ward, I send those patients home, shouldering the whole risk, praying they don't sustain MIs in the next 24 hrs.

What I am trying to say is… well… what am I trying to say…

Just pouring out the frustrations I feel at such times into words. But basically I am getting angrier by the day. Complaints have started pouring onto my Heads table from all sources. Nice lady, she takes care of them though.

But ultimately, my studies suffer.

As I said a angry all the time at my juniors, at my Seniors the consultants – for their often poor decision making, other department residents for calling in my the middle of the night for non-specific stuff, at the nursing staff – when they slacken, at my family coz they don't get it and at myself coz I am not fighting it….

Anyway… bad post to make a comeback with.

Email trial

2011-01-19T14:35:00.000+05:30

Indian Med blogs Directory

2011-01-19T09:42:00.003+05:30

The Indian Medblogs directory has been updated.
Still if you feel your blog needs to be up here email me or leave a comment.

Therapeutic CT scans

2009-10-23T08:09:00.002+05:30

My days in the ward… well are not over, but limited. I have to be present for get rounds presented to me and my co-SRD from the house officers and in turn present to at Grand rounds. Then its off the OPD, where we see patients individually and discuss with the Attendings if needed.

Our hospital, if have not mentioned so earlier caters to a subset of the population whose medical expenses are taken care of by the Government. Its not like Mediclaim or insurance, people don’t pay a penny from their pockets but all expenditure is taken care of up front. I wont go into the details of this scheme but needless to say patients have no clue about the amount of resources the government is spending on them.

The Second factor here is the patients are generally well educated and well informed. So they know what treatment modalities are available for their respective illness and that if it is not available at our hospital then they are aware that it can be made available for them at hospitals on our panel. Well the outrageous things our patients demand… is a topic for another day.

We I have observed in the OPD and the wards both, Multiple cases of Headaches miraculously cured by CT scans.
Interesting huh?

We have our fair share of Migraines and Cluster headaches. Well the clinical diagnosis is migraine is made only after all other differentials are worked up for and ruled out. But the patients I’m talking about have headaches so major, no amount of medication can help their symptoms. But then as part of work up of non resolving headaches, to look for possible Itracranial bleeds or SOLs (Space occupying lesions) we get their CTs done.

And lo and behold, irrespective of the reports the headaches miraculously vanish. Poof!!

99% scans are clean, except for may age related changes etc. But till date I have seen at least a dozen patients making a recovery from getting, what we now call as, ‘Therapeutic CT scans’, almost all of them brain scans. Its quite a joke among us residents, we even make wagers on whether the consultant will ask for a CT or not and whether it will cure the patient or not.

I knows it’s the placebo effect, its psychological …whatever. But our most of our consultants don’t think twice before ordering head CTs for such patients.
What about the money? What about the exposure to radiation?

I have to be in this setup for maybe another 2 years. But when I start practicing in the real world where the patient has to pay out of his pocket, will I order such expensive investigations with such alacrity? Will patients pay for it? Or they’d rather take a second opinion?

Nevertheless the tale of the Therapeutic CT scan has many more editions yet to be added.

The Balancig act

2009-10-05T22:26:00.009+05:30

Finally after a few scattered attempts at posting last year, today I have finally sat down to make any entry on this blog.
Needless to say, I have lost most of my readers (provided I had some to begin with) and the Indian Medblogs directory is outdated.
But I love blogging, it gives me a sense of freedom, to write what I feel like, also the anonymity of it is great to fume out stuff which u cant say out loud , and lastly it helps getting a lot of things that go on my head into perspective.

So Where have I been the past year?
Dutifully carrying out my responsibilities as first year resident in Dept of Internal medicine in my institution, the name of which I’d rather not disclose. Needless to say, the first year of residency is hell, a ‘houseman’ post as it is called in Mumbai. Here in my hospital the schedule is a grueling as anywhere else. I have worked 36 hour shifts on alternate days with only a measly 12 hour gap between the two consecutive shifts, for a year now. The only times I have got days off, have been when my immune system gave into the rigorous schedule and I spiked fevers, probably viral for 48 hours.
I have done all it takes, pulled all nighters, been cooped up inside the dreary hospital for weeks on end without sunlight, poked a zillion arms for blood collection and IV lines, done my share of Pleruocentesis, Peritoneocenteses, spinal taps, Central line insertions. And due to the special privilege of having worked in the ICU prior to landing the DNB seat, I have been perennially on call to interpret ECGs with Blocks and MIs in the ICU, temporary Transvenous pacings and the whole gamut, down in the ICU, which others could not manage.

But I am here finally through the grit and grime, now as a second year resident or SRD (Senior resident doctor). I was promoted a month back, but it has taken me a whole month to get my bearings right. I for one found the transition from JR to SR a bit tough. I remember as the JR I always used to envy the SRs. ‘All they need to do is sit in the on call room and attend phone calls while I sort through the whole pile of shit and keep them informed about the bad eggs in the ward!!’. Boy was I mistaken.

Now I realize as a JR I had only my ward pile of shit to sort through, but now as SR and the honor of being the Physician/Medical resident on call, I have to sort through the whole hospital’s pile of shit, at least that’s what it feels like.
I mean why does a surgeon or an Orthopod need me to get up and put it one paper at 3 am in the night that their patient of so and so condition with a Serum creatinine level of 4.5 mg% should not be put on Aminoglycosides or NSAIDs and that exactly is why his kidneys have failed.
And this on a repeated basis!!

It really does feel like our department goes about wiping up after the other departments in the whole hospital.

I can only right on file so many times that a patient of Ischemic heart disease with CABG done and LVEF of 15-20% needs to have his fluids restricted to less than 800 ml/d, or else he’ll land in Acute LVF. But when he does get ‘well hydrated’ after his TURP and does land in Pulmonary edema, I am the one needed to rush to his bed side first.

Hmmm… do I sound pissed?
I guess I’m pissed, but I love this job, I love the thrill, the satisfaction out of it.

CONFESSION:- When there is a particular tough patient to diagnose, with inadequate signs to provide a diagnosis, but I work him up on a hunch and it does come right ultimately, I feel just great. Am not proud of it, I feel terrible for the patient but the tougher the puzzle, the more gratifying it is. Kind of like House.MD, just not so much drama.

Mind it though, I am still supposed to be on call for 36 hours with 12 hours interim off. But I am supposed to be in many places at all times, I have to attend calls from the ER and all Physician consluts in the other department wards (Physically not only over the phone!!!), oversee the JRs of all Medical wards, take care of the Dialysis unit and still be the back up for the ICU guys, the list is endless. Man was I wrong about the sweet life the SR!!!

I have grown up though, I am a bit more tougher, I take it in my stride when terminal patients kick it, but when the unexpected, apparently young and healthy ones dies, I feel a loss. I have got a bit of an attitude now, I don’t let people take me on rides anymore, especially my colleagues, who have totally used me to get all sorts of leaves for the weddings and funerals in their families the past year.

The one thing I really want to work on now is my studies. I am totally fraught over how I am gonna study so much.

As the famous Spider man one liner goes ‘With Great power comes great responsibility’. I am supposed to know better, know more, to tell the other fellas what to do, take life or death decisions in the wards during emergencies. Even the nurses and residents of other departments want my opinion on their personal family matters. Obviously, my knowledge has not increased by the same rate/ratio as my responsibilities have. And I am struggling to keep up.
Cant make a fool out of myself in front of the juniors or the attendings.

I get sleepless nights, mulling over the implications of having to know all that I should. I mean I should know everything Harrison’s principles of Internal Medicine has to say by now. But I don’t, I just don’t. The more I try, I more it feels like clutching at straws. I have got a thing about studying, kind of a tic. I can only settle down to study if I know I wont be disturbed for the next 3-4 hours ahead. I need my table and chair, my table lamp, my laptop, my music, my cuppa coffee. Only then can I sit at it.

But such times are rare, and rash-hash studying doesn’t make a dent in my brain. I’m always on the edge, like some day soon, people will realize I don’t have the brains it takes to be a SR.
It feels like I’m on a balancing beam, one slip and I’ll fall great depths, lose whatever good impression I have made on people around me. One month in and I have just barely calmed to put my fears down in words. I have to walk the beam until I am really worthy of it. Worthy of being a Senior Resident with so much responsibility. And the only I can do it is study, study and study. To have the knowledge of what do when, when to do.

Plan to keep up the blogging to keep up the spirits, do need the vent.

Indian Med Blogs directory

2009-01-31T20:16:00.002+05:30

The Indian Med Blogs Directory has been updated. Check it out..
If anyone's submission has not been included. Please leave a note.

Grand Rounds 5:18

2009-01-21T20:30:00.003+05:30

Grand Rounds 5:18 is up at MedPage Today hosted by Dr. Val Jones from Get better Health. Check it out...

Clubbed!

2009-01-17T20:14:00.003+05:30

A 68 year old gentleman, presenting with severe breathlessness, Tachycardia with a heart rate of 170/min and running a fever of 104 degrees.

Giving h/o breathlessness, cough with mucopurulent expectoration and low to moderate grade fever on and off since 3-4 years.

Absolutely denied smoking. But look at that clubbing!!!
Differentials were Severe pneumonia, Pulmonary tuberculosis, or Chronic bronchiectasis.

CXR - showed a totally whitewashed right lung. Consolidtion? Tumor?
(Didn’t have my trusty Sony Digicam. The picture was so worth a shot!!)

Workup was negative for active Kochs. Seven days of high antibiotics later the CXR pretty much cleared up, with remnants of what looked like fibrotic sequelae to old pulmonary Kochs at the apices of both lungs.

CT at cinched the diagnosis. Honeycombing s/o bronchiectatic changes secondary to old infections.

Final diagnosis - Massive Rt sided pneumonia in a case of Post -TB bronchiectasis.

Dissertation dilemmas

2009-01-16T20:45:00.002+05:30

As an postgraduate student in Internal Medicine, as is obvious, I have complete a thesis or dissertation on some suitable topic. Without which I won’t get my degree. So far so good.
Finding the topic was hell, my preceptor or thesis guide is a a very strict lady, known to eat residents alive if she feels like.
‘Never cross Dr. K,’ - valuable advice from my predecessors.
Thing is she is a diabetologist, so needless to say my dissertation had to do something with diabetes.

She handed me the topic as well, ‘Something on with Diabetic foot’. How vague is that? Well after almost a months work, amidst torturous work shifts, I managed to come up with ‘Something on with Diabetic foot’. (Am being vague here on purpose!!!)

We need to submit a Dissertation protocol to the National Board of Examinations within a month of registrations. So a protocol it was, with the routine aims, objectives, study design, materials and methods etc.

Went through, numerous papers and abstracts to get inspiration for a study design. Spent endless hours online and in the library and muttering about it in sleep, (according to my mom!)

Ah, it was such a day of relief when I finally got her to sign the draft of my protocol, (after multiple corrections, editing, printing, re-corrections, and re-editing and re-printing).

Except to have it made in clear and very concise terms ‘You do know I won’t be signing your final thesis copy, unless you present two papers for me.’

Shit!!!

I have never done a paper before.

Then came the realization that I had somehow managed to come up with the protocol, now I have to run the theories, and assumptions and tests I had blabbered about in there and prove them!!

Shit!!! Shit!!!

I have no clue where to begin. Except that, I have to somehow got to get my hands on a biothesiometer.

Shit!!! Shit!!! Shit!!!

The worst is yet to begin.

The White Cap

2009-01-15T13:16:00.005+05:30

As doctors, from day one of our medical training we have to work in close proximity with the other major members of the medical profession, the Nurses. They are there in every hospital or clinic or nursing home working diligently by the side of the MDs, treating patients and dispensing the medication.
But do we ever stop to say thank you to them, except as a part of the cursory thanks we mutter at, say, when they have assisted you in a procedure or examination? Do we ever realize that we as medical practitioners, the ones in active medicine at least, are so dependent on the nursing staff that we couldn’t function one day without them? And are we glad enough that we have them?

In general, the budding doctor encounters the nursing faction of medicine, when the clinical rotations begin. The clinical career of invariably every medical student begins with a sense of superiority complex, a snobby attitude and an upturned nose towards the nurses. 99% of them fall flat on their faces in the first few days, when they realize they know zilch and are the most un-needed, superfluous part of the medical team. The wise ones make friends with the nurses and all rotations are smooth sailing for them. You can get invaluable guidance and instructions from the seasoned nurses who where there long before you came and will be there long after you are gone. From blood sampling, to starting and intravenous drip, to passing a nasogastric tube they are the ones who teach you the tricks.

Having been part of the ICU team at my hospital for well over a year now, I am acutely aware of how much of what I do most of the day (and night) is dependent on the nursing staff. We have a team of eight staff nurses and one in charge. It’s as well oiled a team as can be. Each one of them is well trained in the care of critical patients. Not to mention all of them are thoroughly knowledgeable and hardworking. Some with solid clinical knowledge, excellent at interpreting the worst of arrhythmias on EKG and some with an angelic healing touch doing away with patients discomfort in a jiffy and yet some with the keen eye of experience instructing me to watch out for a particular patient, apparently stable that minute. ‘He is not looking good to me, he may crash any minute.’ And they do crash, no matter what their vital parameters or Blood gases or EKGs say!

I know I can rely on them no matter what, can catch some shut eye in the on call room trusting them to monitor the worst of the patients. There is one lady in particular who can pass a Ryle’s nasogastric tube, like no body else can in the worst of old fellas with toothless roomy oral cavities, when no matter what you do, the damn thing just coils up in the recesses of the pharynx, sometimes exiting through the mouth or at times even through the other nostril!!! And I as a resident have no other option but arm myself with the laryngoscope and Magill’s forceps to try and pass the tube under vision and sedation, (if the patient is not zonked enough already). But now I let Sr. M, have a shot at it, before I boot up. Also she can manage to find cannulate veins in the thickest, most edematous of arms around. And good lasting veins at that!! She is truly a God send.

Here in India, most of the private hospitals have done away with the traditional white gowns and white caps of the nurses. But government institutions as is ours, still adhere to the same old dress code. They are all attired in pristine white uniforms, with their hair neatly tied up, white caps, white stocking and white shoes. I can imagine how they must instill some kind of hope in the sick patient’s hearts. They are the ones who are in maximum contact with the patients, often acting as the messenger to inform me of the latest complaint they have.

As doctors, we do the history, the examination, the notes and order writing. But their job is so much more than just to carry out those orders and charting temperatures. Making the patient comfortable, showing them genuine kindness, listening to the patient’s grievances, tucking them in at night and everything. Not to mention the other tasks normal people would find queasy doing for their own family members like sponge baths and bed pans. And most importantly, packing up the bodies of patient’s who didn’t make it, to be handed over to the next of kin.

I don’t know about other institutions, but in our hospital it’s part of the nurse’s job, with the help of the attendants to do the needful when the patient expires. As the doctor, I am there with the patient till the last minute giving CPR or emergency intubations etc with watchful, hopeful eyes on the monitor. If he dies, its my responsibility to break the news to the family, and do the necessary paperwork. But am I there with the patient after they are gone? Most doctors consider it a personal failure when the patient dies on them. I do too. Initially when I came to work in the ICU, the inevitable number of deaths would simply overpower me. it would take a lot of deliberation to go out and declare the patient. Its never uncomfortable on any doctor, but I used to take it extraordinarily tough on myself, almost as bereaved as the family. I would simply walk up to patient, after declaring to the family, say a goodbye and a sorry. Then simply shut myself in the on call room for the onslaught of tears.

But in the later months, I grew tougher, it’s still very upsetting to lose a patient, but the tears don’t come anymore. That I guess is because, I used to think that declaring death was the toughest thing to do. But when I saw my colleagues, the white attired ladies, tending to the mortal remains of the patient after they have passed on, often comforting the relatives at their first glimpse of their departed loved one, cleaning them up, even giving occasional hair-washes to remove the blood and gook (Sr. M, again here), something not expected of their duty, I think to myself, do I really have the toughest job of all? I guess not.

In the government medical institutions, the hierarchy of the nursing division is essentially four tired. Simply put we have the Black belts, the Red belts, the Blue belts and the White belts. Sounds like Karate? Mostly is. The Black belted people are the head honchos, the Matrons, assistant matrons or Nursing superintendents, the Red belts are the ward incharges or supervisors, the Blue belts are the staff nurses doing the main work and the White belts are usually students or novices. Out Red belt or Sister Incharge is a firebrand. Almost sixty, with just about a year left to retire, she is the most disciplined, assertive, person around. She runs the ICU on a real tight leash, but things function so smoothly when she around and there is never any dearth of resources on her watch. She feared by one and all to the point of veneration. She makes it her own personal agenda to train all us fledgling doctors in the needed administrative know-how and forms at everything. As Kim at Emergiblog puts it she ‘babysits’ us all the time, and our head of the department and dean turn to her to get updates on the residents behavior and general demeanors. Everyone in our team is fearing the day, not long off, when our watchful motherly Incharge will retire and we will be left in a soup.

As I mentioned my contact with nurses began early in my medical career as normally does, but I learnt the hard way how decapitated we would be if they were not around. We were having severe shortage of hostel boarding in our Intern year, and we, as interns were technically eligible for boarding neither at the Undegraduate hostel nor the postgraduate hostel. The administration promptly ordered the 35-40 of us out on the streets. As if, we would go down without a fight. We went on a strike, a very vociferous and raucous strike at that, almost bringing the hospital daily working to a standstill, for we had the backing of all the undergraduate and postgraduate students. Consequently, the dean bowed down and we were allotted quarters in the nursing students hostel, which was overcrowded as well, on a temporary basis till something solid could be worked out. Needless to say, this did not go down well with the nurses and they put up a days token strike in protest.

We thought we were shutting the hospital down by our rallies and protests and shouts, we were in for a very rude shock. There were no angry slogans or rallies from the nurses, nothing overt. They just simply did not report to their duties. Man! Was it havoc!!! Wards and OPDs just fell apart, nobody knew what to do. Patients just lay there, with no body to care for them, no medication administered, no treatments carried out. The consultants were so lost, it all transpired into anger at us the interns, for being the root cause of the all that evil. We all got explicit instructions from the dean and consultants, that till the whole matter was sorted out and the nurses came back, we interns would do everything required to keep the wards running, I mean everything. The vitals charting, food distributions, medications, injections, bedpans, dressings everything. Or else we wouldn’t get the necessary rotation completion certificated.

Needless to say, it was the goriest day of my life, for I was posted then in Obstetrics, in the post partum ward. We did it all, with heads high, but am sure our batch will never ever forget that particular day, when the nurses striked. The situation cleared out by evening, when the dean made alternate arrangement for our boarding with amazing alacrity. So I know I can’t function without my nursing support system, even if I wanted to.

The state of affairs in India is changing though, consequent to the occurrences probably in the developed nations. The latest generations of nurses are all migrating out in India in search of greener pastures. International hospitals are luring them away with better pay packets and perks to boot. Its prevailing almost in epidemic proportions now. The US, the UK, the UAE are all running real short of good quality nurses and here in India there is a surplus. So it all fits. The Indian government is getting smarter though, they are trying to stem the efflux by introducing 5-10 year bonds to fulfill before anybody can leave the country. I don’t know how far it has been successful, though.

There is nothing else to say I guess, except that every doctor should make a better effort at recognizing the contribution of the nurses to the medical field. We do need them whether we realize it or not, the White caps.

Dedicated to all the nurses out there… KEEP UP THE GOOD WORK!!!

Current reading

2009-01-12T20:42:00.001+05:30

I have started blogging, should also begin my reading. Currently I’m on Khalid Hosseini’s ‘The Kite Runner’. I like to consider myself a updated reader, but the past year has been exceptionally bad for my hobby of reading. I begun reading the book more than six months ago, but never got around to finishing it, though I have been faithfully carrying it around in my rucksack everywhere I go, as is a very old habit, hoping to chance on reading a few pages while on the bus to work and back.

But again never got around to it.

Well, you know what they say about it being never too late…

I’m back…again

2009-01-12T20:30:00.001+05:30

I’m back. Yes, my last post (my only post in 2008) was titled precisely that. Then where the hell was I? I can give umpteen number of reasons stating ‘I was too busy with the residency grind’, or ‘what little time I do get, is devoted to getting some shut eye’, or ‘there is way too much studying to do, too muck knowledge to accrue’.
Well to be frank none of the reasons are true. They are true, in the true sense. I do slog a lot, and am always badly in need of more sleep, and have been attempting to dedicate time for serious studying. However, this is not why I was absent from the blogging world.

I just didn’t get around to it. There were enough interesting things to say, many fascinating incidents to narrate. But I just simply didn’t get around to it.
So here’s the update as of now.

I’m a first year resident of Internal medicine. Am posted in the ICU, still, for lack of firstly, candidates to rotate and secondly, gumption on the part of the current Head of department to pull down the final year resident to work in the ICU as the curriculum demands it.
I have learnt a lot the past year and when I say a lot, I mean a lot. Mostly critical care, but ours is a general ICU so we see almost all varieties of patients. Have honed my skills at procedures to near perfection. Have earned a reputation as the ‘Dependable one’.

Ok. Enough bragging about things. There have been slip-ups as well. Lost many patients, mostly for the lack of better resources to treat them. Have had particularly tumultuous personal life, something I rather not elaborate. Am not as up-to-date with the studying part as I aspire to be, a constant source of irritation for me.

Almost a fortnight into New Year, not many resolutions. None made, none to break, spares a lot of mental trauma. Except make a better effort at blogging. And to catch up with my reading.

Hope to see more supportive comments, coming my way, as they did when I was an active Blogger in the past.

Happy 2009 everyone.

I'm Back...

2008-09-12T22:13:00.003+05:30

Hello again blog world...

I really have no idea if any body even checking in to see if I am dead or alive.
Well, but its not time to be narcissistic.

The good news is, I am back. From a sabbatical of sorts, from med blogging.

And as of two months now, I am officially doing my post - Graduation in internal medicine. Yesssssss!!! Landed the residency alright, with quite a struggle.

There is a lot more to say, but that will have to wait. The site is in an obvious state of neglect, have some more work to do on it. Then will sit down for some proper blogging.

See ya till then.