Indian Medic

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.

ECG pop

2007-12-25T19:59:00.000+05:30

This is a simple but very interesting EKG up for interpretation.

Its got 'multiple dimensions' to it, as one of my colleagues put it.

World AIDS day

2007-12-01T15:36:00.000+05:30

Its World AIDS day today. Sadly though I was the only one sporting the symbolic red ribbon at work. The movement is yet to gain wide popularity and support.

Winter Weary

2007-11-26T15:51:00.000+05:30

This is in continuation to my post a couple of months back, ‘Third time Unlucky?’ I meant to give an update within a couple of weeks of the post, but didn’t quite get around to it.

It so happens for that particular patient, it was fourth time unlucky. She was brought DOA a couple days ago in the ER.
She had a ‘third time’ about a month back, a weeklong stint, luckily enough only in the ward. Apparently, she had been admitted through the Out patient department but one of our relatively ‘not-so-risk-taking’ consultants.

It is a widely observed, but statistically unproven fact, in our hospital that death rates rise in the winter. It’s kind of an annual clearance. Sorry if I sound crude, but a lot of the geriatric patients, including asthmatics, cardiac patients, CVAs, etc who have been in and out of the hospital multiple times throughout the year either suffer one terminal hospitalization or are brought DOA.

When I started observing that this trend was true, involuntarily I counted off a few faces that might show up. This particular lady was one of them. And sadly, she is the fourth patient I have treated in the Wards, to be brought in as DOA. All this with the onset of winter.

It has become a habit to check the Death certificate book maintained in the ICU, whenever we get news that a ‘body’ has been brought to the ER. And then I get nightmares. But the worst part is that if this keeps, there might a few more faces that might haunt me.

Spooked!

2007-11-22T20:44:00.000+05:30

I have been working the ICU for about a month now. A lot many crazy things go on there. This picture for instance...

This Cardiac monitor is on one of the beds rarely used, the one in the farthest corner and used only when all other beds are full. Last week was one such heavy ones with all beds full. We had a Non STEMI coming in and we had to use this last bed.

As soon as the nurse switched it on, it started displaying complexes, which resembled something like V fib. The thing however was that the leads were not connected to anything. In a normal situation, switching on an unconnected monitor displays continuous standardization complexes, like the inverted rectangular ones seen on Electrocardiograms. This monitor however was not doing so, no matter how many times we turned it on and off.

It was a spooky sight; I just had to take a pic off. But even as I was standing there, watching the monitor in an awe of sorts, the 'Heart Rate', which had started in the 120s slowly increased to 400. It definitely looked like Ventricular fibrillation. All the appropriate alarms started beeping, which instantly galvanized the whole ICU team to descend on this bed in the corner, almost as a reflex.

We tried muting the alarms, but couldn’t succeed. We could have just turned the damn thing off and left. But it was a mesmerizing picture in a weird way, which had us standing around, as if waiting for something.

Then it happened. The sudden flat line, with the monotonous continuous beep, which is dreaded by any medical personnel in active critical care. During ordinary circumstances, a full-fledged CPR would have been in progress. But that instance we just stood around, looking at each other’s faces, for a full thirty seconds, before someone had the sense to reach up and turn it off.

No one spoke for a while. I don’t know about others, but I was really spooked by the deal. There were simple enough explainations for it. The electrodes were old and could be responding to some static. But that didn't cross my mind that instant.

It made me acutely aware of the work that I was doing, being the last person to come in contact with the people who leave this world. Having it in my power to save them with timely intervention. At such times, I manage not to think about the families of the person, whom I may be declaring dead soon.

But the two minutes of paralyzed silence, in front of that monitor, brought back thoughts of each and every patient I had resuscitated and lost. It felt as if some one had died there that night unseen by all us. It kind of embodied all those souls that had passed through those doors.

The MI patient came and we all got busy, but somehow there was a respectful silence that prevailed for a long time as opposed to the gay banter that kept the place alive and above the gruesomeness of the place.

Later I heard the janitorial staff discussing something about ghosts and souls still wandering the corridors of the hospital. They also mentioned that bed no seven was an unlucky one, almost no patients who inhabited it made it. I tried not to hear, but then I was really shaken up by the whole experience. I did not need ghosts to worry about.

Even now a week later, walking past bed seven gives me the creeps!!

Milk blooded?

2007-10-04T10:37:00.001+05:30

This is the serum sample of a patient admit with left sided Bell's palsy. Its so bloody lipemic we cant get any biochemical parameters whatsoever!

Third time unlucky???

2007-08-28T18:34:00.000+05:30

There is a patient in our ward, a 60 year old lady with restrictive lung disease, and severe kyphoscoliotic deformity. She has been with us near about 3 months now. She has history of recurrent admissions with exacerbations of her condition, usually mandating a short stint in the ICU with a moderately long one in the ward. But this time, it looks like she is here to stay.She is in a persistent state of metabolic alkalosis and needs continous oxygen. Mostly nasal prongs with regular bronchodilating nebulisations are enough to keep her happy. She had set a routine for herself, a neb each, before and after a poop or a meal.

The thing, however, is that our hospital is always in a bed crunch and every single bed is essential especially in what we call our emergency cubicle, which is nothing more than a glass walled room with four beds, adjoining the nurses station from where we can keep an eye (literally), on our ‘bad’ patients. And the lady in question has been on one of those beds longer than we care to remember. Frankly speaking, we are not doing much for her, all she needs in strict bed rest, and someone to care of her 24X7.

So about a month back we had planned it out with the family and one of our bolder consultants, decided to discharge her, all arrangements made at her home, O2 cylinders, nebulizers, bed pans, the whole gamut. And not to forget a fulltime, maid to care for her alone. Since there are no nursing homes in India, to take long term care of patients like her, a point I have stressed a lot in one of my previous posts, there really was no other option. It would be prudent to mention here that the lady has a bit of an attention seeking behaviour, and quite often we find it difficult to make out if her symptoms are really as grevious as she states them to be. For instance she complain of shortness of breath every time any of us walks into the room, but all her monitors would be showing perfectly right figures.

Her complaints increased exponentially as the day of her planned discharge grew nearer. We could but only reassure her that she was going to be fine, and even pretend not to have heard her occasionally. ( I know that’s rude, but she could get on your nerves real bad).

D- day - 12. 10 am - I was on call, it was a night as any other, a continous spate of admissions, me in a chronic state of fatigue. Suddenly everything went haywire, all alarms started sounding, we rushed in to the emergency cubicle to find our lady breathless. Initially I had my doubts, but one look at the monitor and I knew this was the real thing. A quick ABG and down she went to the ICU again.
It was hypercapnia like none other I had seen before, 90% PaCO2.

Anyway, she stayed down there for a couple of days, got all stable and came up to reclaim her old bed.

Things moved on again and about two weeks back, when she seemed better, we plotted her discharge again, this time taking care not to let her in on the secret. Her family was in on it though. One fine morning, I walked in and just let her know that she was being sent home that very same day. I was all prepared for a reaction, which could take any possible form, another bout of breathlessness… of protests to let her stay on…. But she took it rather well, and I think even seemed a bit glad about it.

That evening for the first time ever I saw her walk, a few steps from the bed to the wheel chair to be whisked away to the ambulance. She was really short, but then again, with a spine that crooked, she had to be. There were a lot of heartfelt good byes, for a variety of reasons, and the ‘chronic one’ as we used to call her, left for home.

Her bed was duly cleaned up with extra disinfectants and made ready for the next patient who might need the emergency cubicle.

I was on call that night as well. Somewhere in the middle of the night I got a call from the ER to check out a patient with chest pain. If the ER doctor is not able to decide if the patient needs to be admitted, we ward people go down and evaluate the patient. I was just about to leave the ER, when an ambulance screeched into the bay, and a stretcher was whisked in with a patient who was gasping. There was no mistaking the frail frame of my old patient. The ‘Chronic one, was back, and in as bad a state as possible. A few more minutes and she would have arrested.

Four days in the ICU on the ventilator, 2 days off it, and back it was to the ward, the emergency cubicle and bed no 17.

This was two weeks back. We have had no more scares yet. This time too, we residents have started doing the ploting. But this time the consultant who is ultimately responsible for her, is the ‘no risk taking sorts’. So he pointedly ignores it on rounds when we try to suggest that she is stable enough.

I’m sure only one thought comes up in everyone else’s heads, like in mine, every time I enter the emergency cubic. The first time we were to discharge her she got bad, the second time we actually did it, she came back within hours and barely made it.

What would happen if we discharged her the third time???? Would she make it???

Would it be third time unlucky for her???

Breakaway...

2007-08-24T18:52:00.000+05:30

There is no doubt I am learning medicine, loads of hands on practical stuff. But somehow I absolutely don’t find time to corroborate the things I learn with facts mentioned in textbooks and that just wont do in the long run.

Just yesterday our marathon one-month stint of absolutely inhuman calls ended, with my physical breakdown. A colleague of mine and I were on call on alternate days. Somewhere like 36 hrs on call and 12 hrs off. Amounting to more than 140 hours on call in a week. However before my mind gave way, my body did.

Interestingly enough I have not lost as much weight as I would have hoped to. Maybe because of the irregular eating schedule and the innumerable cups of tea and coffee I keep downing hoping to keep my wits sharp.

The flip side however is the I am regarded as a honest and sincere person, by mostly all the consultants, residents and nursing staff alike. This only brightens my chances of landing the DNB seat next year. Till then its scut, scut and more scut.

Needless to say, I am not devoting enough time to the family or my hobbies, which is obvious from the absolute dearth of blogs. I have started collecting interesting x rays and ecgs. I’ve got GPRS on cell phone activated, so now I can pretty much access the internet from my laptop from anywhere for as long as I choose to.

My blogging prospects look bright but I need to step up the studies.

Here’s one more interesting x ray till then.

Its the tracheal calcification that caught my eye! seems perfectly etched out.

What the...?

2007-08-07T12:31:00.001+05:30

Paraphernalia

2007-07-31T12:03:00.001+05:30

ARDS

2007-07-30T20:32:00.001+05:30

A pt of mixed malaria suddenly went into respiratory distress and an absolutely clear chest turned into the one above.

Time moves on

2007-07-28T07:16:00.001+05:30

Right now am in the 34 hr of my marathon 50 hr long shift. Just about another 26 hrs to go.

Books

2007-07-28T07:07:00.001+05:30

Galore

Yipeeeeeeeeeeeeee

2007-06-26T20:59:00.000+05:30

Guess who cleared DNB Part I?????

It the one good thing that has happened to me in a long long time!!!!

Now comes the issue of applying for residency interviews all around the country!!!!

Expression of freedom

2007-05-08T20:21:00.000+05:30

If there is one thing I have realized in the past one month of living a life of residency is that there is nothing as sweet as getting out of the hospital after a 36 hour on call shift. Maybe its my shortcoming in a way, that I don’t look forward to being on call. I kinda get apprehensive as the day progresses, especially if there are potential patients in the ward who may crash any minute.

I love my sleep and it’s considered a light on-call duty if you manage 2-3 hours of undisturbed sleep. But even when I am asleep in my room, which is on the same floor as the wards, I find it difficult to get refreshing sleep, irrespective of how long it is. My mind keeps dwelling on the things I could or should have done for a any patient, and I start filing away mental notes. Not for me, anymore, the luxury of falling asleep as soon as hitting the bed. That was in the initial days when I used be exhausted as hell. But nowadays it takes me at least 15-20 minutes to fall into a light doze that can be easily shattered by the first ring of the phone. Consequently, even though the next which technically is called ‘post call’ duty, I am invariably carrying the weariness of the previous day.

My mom noticed that even one day of sleep deprivation brings on the telltale black circles under my eyes. And I have to wait till the weekend to recharge my batteries.

But the sweet sweet, final moments when the duty is winding down, is really pleasant feeling. It’s not something I am proud of, but I genuinely feel glad when I get off call.

What’s with the smell?

2007-05-04T12:23:00.001+05:30

It’s been one month at the job, which is not so new anymore, and I haven’t posted anything relevant. Not that there has been lack of interesting things to relate. Just that I never get around to sitting at the PC for more than a 10 minutes a day, that’s just to check the mail. But to mark the end of the first month, I thought I might as well write something.

I have been allotted quarters in the campus, but I still manage to come home every night, no matter how late it is, except of course when I am on call, which happens once in every four days. If all’s well, I can hand over my patients to the resident on call and get home by 6. 30 pm. The first thing that greets me when I get home is my sister’s screwed up nose. Somehow she finds the very air around me offensive. My mom does too, except she doesn’t display it as overtly as my sister does. Its what they call the ‘Hospital smell’. Initially I thought that having sweated it out 10 long hours in the midst of summer, (our ward are not air conditioned), I must smell real bad. But later I realized that it was not the musty sweaty odor that bothered them as much as the ‘Hospital smell’ I carried home with me.

Frankly I myself am not able to distinguish the particular smell they talk about, but then it is not surprising, considering that I spend all day in the hospital environ. My mom even claims that the ‘smell’ has permanently stuck to my clothes, and permeated into the wood of my closet. No matter how strong a detergent she uses to wash them, the smell stays. I suppose it is a combination of the various spirits we use for different antiseptic purposes. And the occasional metallic smell of blood, which can render the strongest stomachs nauseous.

On most days I dutifully shower before partaking in the regular family routines just to please my sis. But on the bad days, her nose screwed in disgust and two words of abomination ‘You Stink’ drive me into a rage that ends in verbal altercations. And then there are days, when I am just too tired to care and hitting the sack is the only thing I am interested in.

I remember the day, when I took in the air of a hospital as a medical student for the first time and it turned my stomach. I was just one month old in med school, obviously had had no clinical exposure whatsoever. We had all just about got used to the horrible stench of Formalin, in gross anatomy, which we were exposed to for 4 hours every alternate day. A senior of mine, who was to become my best friend in the future, was hospitalized with Renal colic. Our gang was on good terms with her so we visited her in the ICU. It was routine to admit medical students in the ICU for all purposes, as the wards were too grubby.

Within a minute of entering the ICU I felt sick. Smells have a way of bringing back memories associated with them in an extremely vivid fashion. My mind got flooded with images of various times when my mother and father were hospitalized. I felt so giddy, I had to step out and leave without visiting. Over the years I have got accustomed to ‘Hospital smells’ of all sorts. No issues there.
However there are other smells that take me back to various times in the past. It would seem stupid if I go about listing them. But somehow my mind has filed away memories and tagged them with smells, so when I come across a familiar smell, a sense of nostalgia creeps over and for a second I am transported back in time. More often than not this happens with perfumes and deodorants I have used over the years. I try to stick to one perfume or deo, but never manage to.

Most people don’t get it, how certain smells can almost debilitate me if they bring back bad memories. My friends consider a personality quirk of mine how I suddenly, in the oddest of places go about whiffing the air for a fleeting scent.

Hope that my family gets used to the hospital smell soon enough.