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Thursday, June 15, 2017

The Sour Grape

I have been told by at least one person (and I think many more might have the same idea) that "I have disregard for postgraduate entrance examinations and am working where I am currently working like it is something heroic because I find entrance examinations difficult to crack, because I'm incapable of getting a good rank, and I am just finding excuses that I can't figure out what postgraduation to do, that I don't want to lock myself in a garage to learn".

To them I would say, maybe you are right.

Maybe I am an idiot.
Maybe I barely passed MBBS.
Maybe I should not have been a doctor on the first hand.
Maybe I do not have the aptitude to crack entrance exams.
Maybe I am not even smart enough to do the "right" things in life.
Maybe I am stupid.

But, guess what?

I don't care.

My choices are entirely mine. My outlook is formed by my thought processes and I can live with the same. Maybe I don't fit your definition of success. Maybe I don't fit your definition of smart. I don't care.

It is my life. And I will choose how to tread it.

If your idea of successful and smart is to eternally run behind happiness in a pattern that is set by the expectations of the community. Pity you. I am happy where I am. And I am confident of being able to find happy places throughout my life. I don't need your free advice on what is the smartest thing to do.

Do I sound arrogant? Well, that's your problem to solve. Because if you feel like you have been smitten, it's exactly you whom I intended to smite.

You think I will learn myself? Yeah I will. I might some day come back and write entrance exams. But I won't be writing it for you. I will be writing it for myself.

I am in control of my life.
Don't try to wrestle that control away from me.

You can try to unsettle me and shake my confidence.
Well, thank you. But it doesn't work on me.

You know why?
Because my strength lies in knowing what I am doing.

My future is uncertain. But I'm comfortable with uncertainty.
My ideas are abstract. But I can think in abstract.
My philosophy is impractical. But I can make it work.
You may be right. But dare you say I am wrong.

Monday, June 5, 2017

My Idea of a Perfect Electronic Medical Record System

The COWs are coming to our hospital.

No, not these. They're getting more attention than they deserve.

Our hospital might soon switch to an Electronic Medical Record system. And this will bring in Computer on Wheels, COW as they're affectionately called in other hospitals.
More like this
While that makes me more happy about where I'm working, it also brings back a lot of ideas I've had during medical school. I have seen hard problems for humans that are pretty easy for computers to solve. I have seen processes that could be hastened by leaps and bounds if computers were involved even partially.

The Perfect Electronic Medical Record System

The perfect EMR does not just record what the physician or nurse puts in. It is an intelligent assistant that does some thinking of its own and comes back with suggestions and autofills for the physician or assistant.

For example, when a child comes to you and her mother says she has fever, you start entering "fe..." and the EMR autofills fever. Next you can enter the duration from a dropdown menu. Also associated symptoms can be ticked "yes/no". As you're done and move to the next row, the computer automatically populates an entry - "Cough? Yes/No". If you choose yes, it asks you for characterization.
If at any point you're in doubt or do not want to characterize a symptom, you can just delete the autosuggestion and move on to the next line.

Once you are done with the symptoms and exhausted the negative history that the smart EMR suggested for you, you can enter the examination findings. Again the EMR will suggest for you the most important findings you should not forget to look for based on existing data on what the most common findings are for that particular set of complaints.

Later, the computer will show you a list of provisional diagnoses based on the data you've entered about the patient, and the past set of data the computer has, and even the compendium of knowledge that it potentially has access to. You can reorder the diagnoses if you like.

Accordingly the computer will suggest investigations and management plans with dosages calculated according to weight or dosage adjustments that are required for special conditions.

The computer will always suggest and ask you for guidance when in doubt. You can always override the computer, but you can also take computers help in not missing important things.

Such a system might not be useful for an expert clinician, but it will definitely help a new doctor in emergency rooms late night. Most importantly, the system makes sure that an exhaustive history taking and examination has been done. It also helps in making clinical decisions based on data and evidence.

Impossible?

Certainly not. I just discovered that Dr Lawrence Weed, MD has been saying this exact thing since years. He might even have developed such a system already. But EMR systems do not seem to have this kind of intelligence integrated yet.

The accuracy of simple software powered by big data like Akinator is testimonial to the power of computers when it comes to problems like this.

Clinical decision making is no holy grail and it will soon be heavily relying on, if not replaced by, artificial intelligence.

Pictures courtesy pixabay.com

Wednesday, May 31, 2017

Joining Swami Vivekananda Youth Movement

Till yesterday, I had thought that I had joined Vivekananda Memorial Hospital.  But, yesterday there was an orientation session for new employees at this organization. And the events made me realize that I have indeed joined, or want to join, Swami Vivekananda Youth Movement, the parent organization of VMH.

SVYM's story is very heart-touchingly written in the blog of Dr R Balu (RB).

I am not aware of any other organization which has the story of its inception so beautifully and lucidly laid out. RB's experiences that led him to start SVYM are relatable. And he has made it possible to connect dots from those strokes of inspiration to the concrete structure that exists today.

But Dr M A Balasubramanya nevertheless described the same in a couple of hours yesterday. Some of his words dug deeper than I expected them to go inside my mind. I was expecting him to speak about how they had to undergo a lot of hardships and struggle to reach where we are. He did. But I wasn't expecting to shake my mind and say that SVYM now has presence throughout Karnataka and caters to lakhs of people under education, health, community empowerment, research, training, and ultimately development and achieved this growth over 32 years by not faltering even once from its core values of "Satya, Ahimsa, Seva, Tyaga". It sent depolarizations through some of my old neurons.

We had a brief on organization policies, accounting practices, etc.

After lunch, we went on a long trip to Kenchanahalli and Hosahalli campuses where other activities of SVYM happens.

Kenchanahalli is on the verge of being converted to a centre for socio-economic empowerment program.

And Hosahalli! Hosahalli is a beautiful campus in 24 acres. There is Vivekananda Teacher Training and Research Centre here. And befittingly, the tribal school right next to it. Dr Ramkumar who works there rightly puts it. After years of working in Bengaluru and other places,.  they come here with lots of experience and every day they face a new challenge. The tribal kids have their own culture. Their language is different. Their aptitudes and attitudes are different. There is sometimes more to learn from them than to teach them.

Challenges like these, and the motivation to work with principles to overcome these challenges on a regular basis is what makes SVYM truly special

Take this example from Vivekananda Memorial Hospital.

VK is an 11 year old boy who got admitted with Diabetic Keto Acidosis. We were counselling him and his mother regarding the importance of strictly taking insulin, even while in school. And we were concerned about them being not able to recognize and treat hypoglycemia. The mother was in fact very much aware of hypoglycemia and apparently she used to manage it at home using sugar water.

"But who will make sugar water for him at school, ma?" we asked her. She gave a blank smile.

We gave our usual advice. "So, keep a sweet something in his pocket so that even at school when he feels symptoms of hypoglycemia he can eat it".

She smiled and said "My boy is just a kid. He will eat the sweet whenever he likes."

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.