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Monday, May 1, 2017

VMH - first few days

Getting to Saragur from Mattanur is a tricky business. The shortest route isn't necessarily covered by public transport. My initial plan was to reach Mysore via Virajpet-Hunsur and then take a direct bus to Saragur. But later, I dropped it in favour of what my mom suggested - get down at Hunsur and take a bus that cuts through the corner.

So I did get down at Hunsur. Turns out, in Hunsur there are two KSRTC bus stations. One is for urban buses - the one I got down at. The other, inter-village rural bus service, is where I would find buses to Saragur. Luckily it is walkable distance between the two stations. At the rural bus stand, there was a bus to HD Kote. It's 11 more kilometres between HD Kote and Saragur. But there was no direct bus to Saragur. So I got into the HD Kote bus.

And that was the slowest bus ever. It stopped at every house and couldn't accelerate faster than a turtle. At HD Kote bus stand, there was a city bus going to Saragur waiting for me. This one was faster, yet slow.

Thus, I reached Saragur at 1.30. Half an hour late on schedule. Took an auto to Vivekananda Memorial Hospital. Ms Latha was waiting for me. She welcomed me and arranged my stay in the guest room next to the canteen (on the way to doctor's quarters). Although it is shared accommodation, currently I am the only one in my room. I quickly freshened up and reached hospital.

Said hi to Dr Chaithanya Prasad who was in General Medicine OPD and whom I had met last time I came to VMH a couple of weeks back. He asked me to get introduced to others. So I met Dr Sitaram in Orthopaedics OPD and Dr Sridharan in Paediatrics OPD. I also had to introduce myself to Dr Narendra whom I had met last time. I couldn't find other consultants. Then I reached Casualty were Dr Susan was writing something in a case sheet.

She is also new here. We spent some time seeing patients and talking about the hospital. Later, at 4, there was a meeting of all RMOs. They were talking about mobile units, their functioning, any problems they are facing, etc. Small corrections to duty roster was also being made. I was asked if I could manage emergencies and assigned to Kenchanahalli for Friday night.

After that there was rounds. After rounds, I sat in casualty for some time. Then, when I was about to leave, Dr Susan was taking a case for next day's grand rounds.

Wednesday morning, sharp 8 am. That's when grand rounds begin. All doctors come around a case that is being presented. Today's case was a lady with pregnancy induced hypertension and anemia. Dr Susan presented the case under the mentorship of Dr Padmaja. There was a brief discussion on the management of such case and the failures in ANC.

After the case presentation there was journal club in training hall where various people presented different journal articles. Dr Shreyas presented his own research on obesity and vitamin D levels. Dr Jyothi presented a study on thyroid disorders in HIV patients. Dr Dennis (?) presented on National Health Policy. The National Health Policy topic is so vast that it was not even half finished at the end of the given time.

After the presentations there was an announcement that a community dinner is being planned the next night where we would cook and eat ourselves. I volunteered to bring firewood and start fire, along with John, Eric, and Shubham. Others volunteered for preparing various dishes.

Afterwards there was rounds. And after rounds I went to casualty. I also sat with Dr Haripriya who had asked on the previous day to read the medical log book of an HIV patient to figure out what the striking points of his history was. We discussed this along with Shubham and found various points like the low adherence, the weight variations (or lack of it), etc.

That evening Dr Padmaja, took the firewood volunteers away from rounds to find out a place for the oven. John is an expert in fire making. We found a place close to Dr Prashanth's residence. The group of Bengalis who worked at the hospital was also staying right next to that place. They helped with the firewood and also with setting up the oven.

Then, I got a call from Dr Prashanth who would demonstrate bladder wash on a patient who needed it every day for me. Since Dr Prashanth would go on a 10 day leave the next day, I had to do the bladder wash to make sure this patient's catheter wouldn't get blocked. Unfortunately, this patient's condition worsened the same night and he was referred to KR Hospital because we suspected perforation.

I tagged along in the casualty that night with Dr Susan and Dr Jyothi who were having tag duty. Had late night dinner which Dr Shivambika prepared. Then went back to my room to sleep.

Thursday morning we woke up at around 5:30 so we could complete the 5 procedures that were pending - three lumbar punctures and two pleural taps. I did one of the lumbar punctures.

After rounds, had to take care of orthopaedic and surgical patients too as Dr Prashanth was on leave and he was taking care of them before. I was feeling slightly disorganized and tense during this day.

Later, in the night, I went to the community dinner. Fire was already taken care of. Cooking was half way through when I reached. Chole was being prepared by the Shubhams when it began to rain. And boy did it rain?

We had just gotten things to safety of the guest house next to Dr Prashanth's when the rain started becoming heavier and heavier. Some of us had run to the Bengali settlement to see if making Puri would be feasible. But by then rain was too heavy and we had to abandon that plan.

When the rain finally finished taking its toll (including several people who slipped and fell in muddy water), we organized in the guest house and started eating whatever we had already prepared.

It was a merry night with mimicry show by Bharath and training in deadly combat skills by John. The carrot halwa was superb and so was the fruit salad. I slept very happily that night.

Joining Vivekananda Memorial Hospital, Saragur

I joined Vivekananda Memorial Hospital as a Resident Medical Officer, on 18th April, Tuesday, around noon.

VMH is a secondary care hospital started by Swami Vivekananda Youth Movement at Saragur which is a place almost 1.5 hours by bus from Mysore, but just one hour by private vehicles.

There is a one year course called Fellowship in HIV Medicine offered by this hospital and educational institution that I plan to join later.

I had visited this place a couple of times earlier. First as an attendee in a research workshop back in my second year of MBBS and then, in the first week of April, as a prospective student and employee. At both times, I have felt that this place works in a well organized way.

I am sure this place will help me become a better physician and a better person.

Thursday, April 6, 2017

Losing an Ear-Tip

"Which is the most important part of a stethoscope?" asked the Professor.
"The diaphragm", "the tube", "the earplugs", came answers from students.
"No. The most important part of a stethoscope is the one between the two earpieces", said the Professor with a smile. 1

It was a regular "free" day in Orthopaedics. That means you get to eat either breakfast or lunch. I ran to ward at 8:15, after gulping down a cup of milk shook with the chocolate malt powder that my grandmother lovingly packed for me the last time I went home.

None of the patients had absconded the night before. Which meant all of the five 70+ year olds with femur fracture where sleeping comfortably on their bed. Only those patients whose perpetual complaint of pain were awake. Even tramadol would not help them. The nurse had just arrived. And I started putting notes, as usual.

All the patients looked alright. So, there was no need to check their pulse. I checked the blood pressure of a couple of the patients who had surgery just a few days back and entered in the respective notes. Rest of the notes would remain the same as the day before. On one side, all the organ systems would be marked normal and the limb would be marked as having active distal movements. On the other side, the advise for the day. Two antibiotics compulsorily bought from outside even if the hospital supplies the same combination. One painkiller. Paracetamol infusion SOS. And a little something to stop these drugs from punching holes in the bellies of these grandfathers.

Before I finish putting notes for half the patients the post-graduate students would reach and start dressing. Depending on the mood of the nurse she might join in helping them dress the wounds or stay aloof lost in their own tasks. If a student nurse is found standing still for a second, they're invariably pulled into the business of taking out "sterile" cotton using a "sterile" forceps and placing them on the "sterile" gloves of the doctor who carefully places them on the wound that has just been cleaned of all the dirty pus and other gross stuff that accumulate in wounds.

I sometimes do seriously wonder whether it is the over-priced antibiotics and the over-done sterile dressing that help the patient or the innate immunity of the patient themselves.

Anyhow, post dressing, there was rounds. Where each patient is seen and discussed briefly. If you are ever admitted as a patient, remember that rounds is the most important time of your hospital stay and treatment. Almost the entirety of the planning of your management happens during this brief encounter between the doctors and the patient. If there's something that bothers you, you better keep repeating it to yourself to blurt it out during the rounds.

During rounds some orders would be made. Ha, get another X-ray done on this knee. Get the side view. Get the distal joint. Easy enough. The patient can't walk. Sometimes, they can't even sit. So you would need a trolley. But they aren't motorized yet. So you need a worker to push. And that's the most difficult part. You have either one or two workers at your disposal. And they have to do all the work in the ward beginning from cleaning and not ending at making sure everyone's shaved and prepared for surgery. It's largely unknown how they set their priorities. They might help your patient get an x-ray. But that might not happen before noon. Maybe they can be bribed into getting it quickly. But should you pay or should the patient? There are no clear answers. The best way forward would be to tell them and remind them and ask someone else to remind them and then come back and confirm they've indeed done what you've pleaded them to. And that's what I did.

It was past lunch-time when I finished ward work. So I went to Ruchi mess for lunch. That's the one our ortho post graduate likes. Food is really important in orthopaedics. If you don't eat some chicken bones, you can't fix broken bones. After food, I went back to hostel. Because there was no point going back to hospital in the afternoon anyhow. It is not like any work will get done because you are there. So you might as well go back to hostel and enjoy the rare few free hours you find.

Going to hospital during dusk is comfortable. You don't have to wear shoes. So you don't have to wear the socks that haven't been washed in weeks. You can wear jeans if you like. If you think you'll need it, take a stethoscope. And that's the biggest mistake I did that day.

I took my stethoscope. And I put it in my trouser pocket. And I rode my cycle to the hospital. I was pretty sure the stethoscope was fine when I left. But when I reached, and put the stethoscope around my neck, it was missing an ear-tip. Yeah, the black round cushions at the tip of the steth that makes them wearable. I imagine these preventing a hole from forming on my tympanic membrane when I wear a stethoscope.

So I lost an ear-tip. And there's no wearing a steth without the ear-tip. Without a steth, you can't measure BP. (Not really. That's a myth intentionally spread to make interns feel good about having to measure BP. I am the only one with the steth. Only I can measure BP. I am doing valuable work.)

I knew it was going to be a sad day. Because misfortunes do not come singly. This would be the beginning of a series. I was pretty sure there were more things waiting for me in the hospital.

The hospital was calm. As usual. There were not many people in the ward. At least, none of the patients had a family of 20 around the bed. THat's a good sign. Because if there's a family, there'll always be a family guy among them. And he will definitely have a couple of questions about "is my relative going to get better?", "why is the pain not going down at all?". These are questions that do have answers. But I wouldn't want to give those answers. I would just want my work done.

Turns out the x-rays were all done. I don't know who paid whom. And almost everyone was "fit for surgery with low risk" from medical side. And nobody had any complaint. Nothing was wrong. That means, I can report to my seniors that everything is spot on, and go back to hostel and have a good night's sleep.

If only I hadn't lost the ear-tip. Because I might not have needed the steth today, but I'll definitely need it tomorrow. Maybe I had a couple of spare ear-tips in the box that came with the steth. Hmm, anyhow I didn't have the energy to go to a surgical shop to buy a new set. So the spare set better be in the box. I just cycled back to the hostel.

And on the way, just as I crossed DD Urss road, about 400 metres from the hostel, there was something black on the roadside. I stopped my cycle and took a closer look. It was an ear-tip. My ear-tip. Maybe a few cars went over it. But it's not broken or anything. I just have to clean it with spirit and put it back on, like nothing ever happened. Happy. My stethoscope was happy. I was happy.

 1 This joke probably originated in Trivandrum Medical College because it was my dad who told me this. It's also documented in this article in The Hindu.

Wednesday, April 5, 2017

Disillusionment

After graduation, almost everyone I know went away to different so called "coaching centres" for getting into a preferable post graduation seat. I was uncomfortable with the way health education works at colleges and at "coaching centres". So, I went away to Malki hoping to figure out everything.

Daktre was waiting with a vane to fan the fruit flies away. We talked for an entire afternoon and evening (and the next day morning along with my community medicine professor).

Several trains of thought departed at that station. Here are a few.

Who am I?

I am a self-described narcissist. The question though is, is my narcissism clouding my judgement about my abilities and possibilities? Is it making me go in directions that I would not want to if I were to think clearly without the pressure of having to be "me"? The "me" here is also questionable. Stereotypes are bad. If I have an idea of "me" it means that I've stereotyped myself into something. Stereotypes limit what we consider as possible.

Is my "discomfort" with entrance coaching, medical education, etc stemming from my own sense of me being a person who goes against most of the mainstream things? Am I going against most mainstream things because "I go against mainstream things"?

I think the answers to many of these questions are inseparable from the nature of reality.

Do not mistake the horse for the cart

But we don't need to answer many of those questions. There are people who follow the crowd and do great things. There are people who don't follow the crowd and do great things. There are people who follow the crowd and do meagre things. There are people who don't follow the crowd and do meagre things.

Doing "great things" is my cart. That's what I want to do.

How I do it, is just the horse.

And it doesn't matter which horse we are riding.

What do I want to do?

It is funny I haven't defined "great things". Because I don't know what I want to do. I want to do good. I want to be remembered. I want to make life simpler for a lot of people. And I want to satisfy my own intellectual curiosities.

Monday, March 27, 2017

Bye Bye Mysore

An incredible journey has come to its natural end. I started this blog more than 5 years back while waiting in college for my admission procedures. The things that transpired in these 2048 days, I could never have imagined.

The journey doesn't end here though. I am going to continue writing about the funniest things that happened during college, especially during internship. And I'll be writing about all the new things that happen in my life as a doctor.

Now, it's time to move on from the hostel. Bags are packed.

Sunday, December 11, 2016

What's up?

It's been a busy 9 months of internship. So busy that I had to take a casual leave to update this blog. No, just kidding. The CL was just a coincidence. (I couldn't finish this post on that day. I'm now writing this in the free time at psychiatry department). It is just my incredible inability to do more than one thing at a time that's keeping me from all my extracurricular "responsibilities".

It has not gone waste though. I have been carefully considering the lifestyles that various specialities in medicine would afford me. Such as the busy anaesthetist surrounded by his monitors who can get an adrenaline rush by adrenalizing a collapsing patient or the pulmonologist in his roomy consultation room auscultating chest after chest after chest.

Blessed is the radiologist who can sit on his computer all day. But imagine being an obstetrician inserting his finger into the unseen insides of strange vaginas day after day.

I know my priorities. I want a lot of free time (which will go to the web). I also want scot-free holidays (for travelling and attending events). I don't want a career which ties me down in a robotic routine.

Psychiatry sounds interesting. So does community medicine. Not to forget radiology.

But at the same time, I don't want to settle for a comfortable routine of mediocrity. I have been led into believing that human beings are capable of doing great things.

What if there is a future for computers in health care? What if there's something that could be unlocked only by a doctor who understands the possibilities of programming?

What if the next breakthrough in artificial intelligence has to come through an intimate understanding of the mind - both normal and abnormal. We could be thinking about our minds in a completely wrong way and maybe that's why we think consciousness is a hard problem to solve.

If I end up as a regular doctor, who will ask these questions? If someone has to ask these questions, why not me?

Maybe I should hook myself up to the ECT machine behind me and jolt my brain into senses. Maybe I already make sense.

Monday, March 28, 2016

Surgery - the rush

Wednesday: OPD

 My first OPD.

Showered and left early to the ward to finish work there and be at the OPD on time. It was a continuous rush of patients from 9 o'clock till the time PG asked me to go have lunch.

There was everything - Road Traffic Accidents (RTAs), healing and non-healing wounds to be dressed, deep gaping wounds to be sutured, pain abdomen of various kinds.

My first sutures were on the leg of a patient. Neat 3 of them (or 4?). Dr Mayank encouraged me saying "You're a surgeon, ha?" But those were the easiest sutures that day.

While we were incising and draining abscesses, dressing more wounds, etc. a serious RTA patient came, unconscious. The PGs took direct laryngoscope and intubated him, called up ICU duty doctors for emergency, gave a slew of drugs, gave CPR multiple times, etc. But he couldn't be saved. I was pressing on the AMBU bag for a while and I don't even remember when I handed it over to someone else.

Nothing would stop more patients from coming in. The rules of work applied quite strongly here. Nobody else would do our work and we had to do them sooner or later.

After lunch, the rush mellowed a bit. But there was still work for everyone. Students filled in holi colours needed suturing. Quite close to the eye. I was scared to touch the temporal artery. Left it to PG.

While debriding a wound in another patient there was a bleeding artery. And the PG just ligated it in a second.

Evening came in quite soon. We had one patient with pain abdomen and history of typhoid fever that we had to do an emergency OT for (for intestinal perforation). I went to the OT, submitted the list. There was an orthopaedic surgery going on from 3 apparently which was still going on to go on till 8. Our patient would have to wait for that to be over.

Things like these and it was night quite soon. I stayed in the OT to watch the laparotomy and saw the surgeons closing the ileal perforation. They biopsied the edge of the perforation which I sent for evaluation. I went straight to a hotel from there to have dinner. It was 10.30 in the night by then.

Back in the OPD there were only occasional cases coming in. By now, the casualty OT became the place for Ortho, ENT, and surgery. We had a few more road traffic accidents and assault later in the night.

There was a child who had a scalp wound and there was a lot of blood draining and turns out you can stop bleeding and suture all in one.

There was a goonda gang in which one person got hit by a wicket and had a wound on the scalp. I had to suture it and the scalp was pretty thick but somehow I managed to get one suture through. The rest had to be put by the PG. I would later realize that I should have been locking the needle holder every time I hold it for better control. The entire gang came in to take photos while I was dressing this guy up and I had to ask them to go outside (because they were scaring me).

Around 12, the PGs gave us an algorithm to manage cases that come up in the night. Mostly pain abdomen. We then started taking turns to sleep. I slept from 12 - 4 in the Unit Chief's room (where there were 3 others sleeping, including one on the table).

After 4 there were only three patients who came in, with pain abdomen. I managed them and it was morning by then!

Thursday: Dressing

 At 8, Abdu would come back from sleep and let me go to hostel to become fresh. I rode my cycle slowly, took a shower walking like zombie, and came back. I had to go to the endoscopy room to write down the reports. Saw the duodenal opening of stomach and ?Ca esophagus and things like that.

Joined dressing after that.

If I remember correctly I gave a blood transfusion today for a patient with lipoma in his forearm and low haemoglobin.

Friday: Good Friday 

There was no OT today because "Good Friday". Went to JK grounds in the morning for our second match in Kreida '16 football. The first match was on Wednesday morning which we lost 0-1 to 2k14. Today we drew 1-1 with 2k15 and our only goal was on technicality (the defender touched the ball while it was a goal kick and we kicked it into the goal and something along that line).

Today I had two work after dressing. One was to monitor hourly the abdominal girth of a patient whom we are suspecting intestinal obstruction. And the second was to give blood transfusion to a patient who was losing blood in stools and had grown pale.

The latter guy didn't have any attender but I took his consent and started blood transfusion. The sister scolded me a lot for this because apparently if something happened to him the question that would be asked would be "Why did you do blood transfusion without having an attender? Whom did you ask before doing so?" etc. Apparently, patients can't make decisions for themselves here. Weird world. Anyhow I've decided no more blood transfusions without permission of the entire family.

The former guy also needed a Contrast Enhanced CT scan so we could confirm it is intestinal obstruction and figure out a cause too. I was supposed to talk to the radiology department and get it done on an emergency basis. His creatinine, urea, etc were normal so there was no contraindication for using IV contrast. But it was 1 o'clock by then and they asked me to come and convince the next day's staff.

Saturday

This day from morning my work was to make sure to get the CT done. I managed to convince today's staff even though they first said that surgeons should be bold to open the patient since the X-ray showed clear signs (multiple air-fluid levels) of obstruction. Nevertheless, they fixed 2pm as the time and asked us to be punctual or forget the CT. We got it done and there was indeed obstruction and some free fluid in the peritoneum with nothing much except these in the report.

Sunday

We did emergency surgery for that person today and saw that there was a perforation which led to peritonitis which led to ileus which lead to obstruction and distension of abdomen. There was a lot of suctioning of fecal matter to be done before the abdomen was closed.

Monday, the 28th

Major OT. Meanwhile the patient with blood in the stools got esophageal banding done in the endoscopy room. Now the esophagus can't bleed any more. But he still has to find an exchange donor for the blood I transfused him.

In the OT we had a lot of cases. Goiters, Thyroglossal cyst (sistrunk's operation), the lipoma in intramuscular plane in forearm, Ca Breast, Appendicitises, Haemorrhoid, and a hernia.

By the time I took the case sheets from the anaesthesia PG the rounds were over and there was no work left.

In the night some of us went to Kalamandira to see this drama called "Top" (in Kannada) which nobody understood (even Kannadigas).