THE LARGER PICTURE - DO NOT HOUND THE DOCTOR WITH A "TELESCOPIC MENTALITY" - DOCTORS SHOULD PROTEST!

     Road traffic accidents are common. The injured persons are brought to the hospital (government or private). Doctors attend. Results are unpredictable. If the results are good, the people feel "Doctors did their duty. So what?" If the results are bad, the people get agitated. They feel that the doctors did not even do their duty. Usually this is followed by manhandling of doctors and destroying the property of the hospital. Doctor is neither protected nor respected.  A weak case is filed against the perpetrators of crime and the sympathies of the public lie with them. The harassed doctor and the hospital get no accolades, thanks or good comments.
     You may say "Why a blog on this common scenario?" I will explain. This, I must remind you is an incomplete picture. A telescopic view of a larger picture. What then is the larger picture? A person buys a bus (Bus owner) without any worry about its quality. A driver employed by him drives it as if he owns the bus and the road. An unscrupulous employee at the RTO certifies it fit even without checking it. Road is made by the unscrupulous elements in connivance with the city administration. In the case of a RTA who then is the main culprit? Your guess is as good as mine. I can say for sure one thing - not in the least the doctor. Why then harass him? Because he is the "soft target in the unorganised sector". What then is the solution? Seeing the larger picture and involving the real culprits. If there is a need for expensive treatment and / or expensive investigations naturally the bus owner and the city administration must chip in. Do not they blame the hospital owner if there is a death? Similarly bus owner must be arrested and taken to task. Why does this not happen? I really do not know
     In case of a food poisoning, the hotel owner, cook, building owner, food inspector, and the city adminstration must be tackled and if at all the doctor must be praised and applauded when helpful. Why should the brunt of the burden borne by the doctor?
     Also, I would like to make a clear distinction between the 'error of judgement' and 'criminal negligence'. Not attending is criminal negligence. There is no excuse. Attending but making a wrong diagnosis amounts to an error of judgement. This is. pardonable
     How shall we tackle these issues? Creating awareness is one thing. Forming a SOP is another. If the item you buy is defective, the onus is on the manufacturer and not the salesman. You cannot shoot a messenger however bad the message is. Doctors have to assert their rights. Creating awareness involves many platforms. Honoring of good doctors, appreciating the good deeds, recording the contributions in disaster management are all important steps. Doctors should proactively take credit by using internet, facebook and other similar sites. Petitioning on the Facebook is another option.
     The whole idea is to get credit for the good acts and expose the real culprit. Service clubs and Professional organisations like  IMA must also help. It will take some time for things to change. A change from the telescopic view to viewing the larger picture is the need of the hour. I hope that it will happen pretty soon!

MEMRIES OF MY FIRST MBBS EXAMINATION - SWEET DREAMS OR NIGHTMARE?

     One of my Professors  used to say "Examination is  a botheration to the population of the Indian nation whose main occupation is cultivation." I would like to make a correction - they are so for all nations irrespective of the occupation!
     The most horrible examination I faced was the first sessional exam after 6 months after joining the I MBBS. It was important to be in the top 40 of the class. It meant an entry into the Anatomy Club which almost ensured a pass in the final exam. I felt this should be a cakewalk, for I was the 13 th in the state in PUC to qualify for an almost free merit seat. The books were bigger, the subjects vaster, but the overconfidence brushed it aside. I worked just as I had worked for PUC. I never realised that was not enough. When the results came, I was in for a rude shock. I had scored just 37! Faced with defeat, humiliation I accepted the result and went to the teachers for advice. One of them encouraged me . He said "You can still try. If you score 105 together in the first and the second sessionals, you will get a direct entry to the Anatomy Club and you will become a Prosector which means  you can teach the  juniors the dissection ( you will get one more chance for some dissections) and also get paid for it. It was a win - win situation and I tried really hard. I learent to draw really god diagrams copying from my friend's uncle's diagrams. I did really well and got 69 out of 100 - just crossing the magic figure of 105 by 1 ( a total of 106). I understood what hard work was.
     The final  examinations were considered to be necessary evil. All appeared, only about 30% passed. Going to the exam hall was like going to the slaughterhouse. No one could predict the outcome. When the son of the Principal of Mangalore college appeared fro Physiology at Manipal, where the Dean was the examiner he promptly failed. Neither the Principal (his father ) influenced not the Dean thought of passing him on terms other than on merit.
     That reminds me of my own Physiology exam. "Effect of Atropine on the Vagus nerve and the Heart" was the task It needed to dissect the tiny Vagus nerve and study the effect of Atropine and get a cardiac muscle curve as the proof. It was an examiner's delight and the student's nightmare. With my limited knowledge of finding the Vagus nerve (a white , smooth, glistening hairlike structure),  hampered by my astigmatism, I could never locate it. After the stipulated 60 minutes one had to face the" firing squad" I mean the examiners! I realized at the end of 55 minutes that I had only 1 option.To kill the poor frog! I had to commit the crime in 5 minutes and that too without leaving a trace. I had to think fast. The only weapon I had was the Atropine.I emptied the bottle of atropine on the heart of the frog. After a series if twitches, the frog promptly died and the curve became flat. I washed up the scene of crime and no trace of atropine was left. The army of examiners came to me.  I was so scared. I was sure I would fail. They asked for the graph. I said "The frog died!" The senior most among them said" I have seen these kind of things happen. I fail to understand how the frog died at the correct moment? How on earth did you kill it? I put up a brave front and said "Sir, it must have had a heart attack!"
I answered all the questions. I just passed. Anything was better than failing!
     Anatomy was another issue altogether. Dissections were the toughest party of the examination. Each got 1 part of the body to dissect - selected by lots. The stipulated time was 3 hours. The one who got to dissect the sole of the foot usually went home straight away - that was better than failing after a 3 hour struggle. Luckily I did not get that!
     Histology though a difficult subject to master, was the easiest exam. There was one George, who trained the students in a unique style. He was very good at drawing and anyone who attended his classes would learn to draw well. He would tell us how to recognise each slide without error.  Cover slip broken on the right side - Heart; Cover slip broken on the left side - Lung; Excess stain on the back of the slide - Testes; Slide broken in the right corner - Prostate..... the list would go on. He would show us these peculiarities repeatedly. He had only one request - "Please do not break a slide!" With this 'foolproof'' training,almost  everyone passed!
     Lastly there was Biochemistry - a part of Physiology. It would boil down to 2 questions in Physiology out of which 1 would be a cycle. There would be a 'titration' experiment in the practicals. One had to carefully neutralise something (usually an alkali to an acid). End point was important. The professor always said  "add half a drop more"! I never understood how to add half a drop. The smallest is one drop! Once when I asked this doubt the professor said " Only a vigilant student can do it well". May be I was not vigilant enough. I never understood the half drop concept anyway.
    I did pass tee first MBBS exam in the first attempt! I even scored well! Looking back, that looks incredible!

ON BEING A MEDICAL TEACHER - MY EARLY EXPERIENCES AND EXPERIMRNTS

     Being a good  medical teacher was my life's ambition I had seen a few dedicated teachers during my MBBS days. I recognised the efforts they put in ; the sacrifice they made and the devotion with which they imparted the knowledge. I did not have to look far. I had zeroed in n my career.
     The day I passed my MD, I applied for the job - Lecturer in Medicine. I was greatly disappointed to know that there were no immediate vacancies. I joined a hospital and patiently waited for the vacancy to arise. While working there, I developed interesting in collecting clinical materials - case details, X rays,
 ECG s etc which were very helpful later as teaching aids and for the books I wrote. I also developed a habit of referring to the books and journals.
    The golden day came on 17 February 1982 when I joined a medical college as a Lecturer. I went with a new apron; new shirt,  and armed with knowledge, capped with pride and arrogance (born out of knowledge). Initial years of ones career are 'power driven' - you 'know' everything. From the knowledge stems arrogance and from that comes a dynamic performance. There are only 2 zones - black and white.
 I was ready for my first clinics.
     What followed was unimaginable - the senior students had already attended a clinic by my chief (Dr. KP Ganesan) and left. 4 students were curiously looking at me. They said they were repeaters. There were no organised classes for repeaters. They wondered whether I could teach them. I had taught such students as an intern and as a PG student. I agreed immediately. I took the class well. They liked it. I was extremely happy. I still remember the names of 2 students - Bipin Patel who later become a Physician in the US and did very well for himself. The other one was one Sandra.  For the next 2 months I took clinics for them regularly and all 4 passed (the pass percentage then was 30%). I was thrilled.
     I have taught many batches of UG s and PG s after that. I enjoy using the black board for the theory classes. There has been innovation and modernization in teaching. Power point presentations have replaced blackboards. I personally feel that the audiovisual aids like power points impart  uniformity. They extend mediocracy. Basically it is an exercise in trasferring image(and not necessarily knowledge)  from the teacher to the taught without either one essentially understanding or mastering the topic. A black board is like an empty canvas. It gives immense scope for the teacher to evolve the subject and develop the concept. It is an exercise in transfer of knowledge with a better understanding by both - the teacher and the student.
     The salary of a teacher was unimaginable when I joined. I took home a princely salary of Rs. 250. Daily wage unskilled laborers earned more. Then it was a matter of pride to be a teacher. To survive one had to practice. That is how and why I practiced. Even now my first and only love is teaching. Practice is incidental requirement which I never really fell in love with except the fact that I met people and I enjoyed interacting  with them.
     One or two things have concerned me. Till recently there was no formal training for teachers who teach at highest level -MBBS, MD, DM, Phd. etc. Also no emphasis is given to the 2 major requirements in any field - communication and decision making. Innate skills of communication have to be honed. Decision should be made on rational thinking and common sense rather than using guidelines and protocols alone.
     The later part of one's career is passion driven. One is aware that there is a grey zone( in addition to the back and white ) and many things belong there. One humbly accepts the fact that one could be wrong or more importantly, the other person could be right. Arrogance born out of knowledge (of the early phase of the profession ) is replaced by humility born out wisdom in the later phase of the profession.
     Probably I am now in  the 'passion driven' phase of the profession. I travel far and wide on invitation to take classes and teach PG s and doctors at many CME s.
     I want to emphasize one important point. A good professional remains a student and a teacher all his life.
One need not necessarily have an attachment to a medical college to be a teacher. Teaching any one else at the work including junior doctors, colleagues, even the patients (patient education) makes one a teacher. What is important is to perform the task well and not the title.
     Looking back, I have no regrets.However, the satisfaction obtained by teaching the repeaters and the so called back benchers  (who really need us and our skills)  was infinitely more than that obtained the day I received my 'good teacher award'.
     

MYSTERY OF THE MEDICAL FITNESS FOR A PARALYSED PERSON OR WAS IT IMPERSONATION?

     In the career of a doctor there are some sticky situations. Insurance Medical examination is one of them. This is mainly because the scant respect the administrators and the agents have for the client, medical report or the doctor.  I really do not understand the logistics of this. The payment for the doctor is still about Rs. 100 - while foreign insurance companies pay $ 250 per report! Cheap labor indeed . Again  I do not understand this mentality particularly when the emoluments of the staff are increased almost on yearly basis for their work(?).
     This story concerns one such medical examination a mandatory requirement before any insurance. A person was brought to me for a LIC Medical examination. I did not know the person though he is supposed to have been a well known person. He was accompanied by the ABM (Asst. Branch Manager) and the LIC agent . I requested both of them to identify the person and sign on my LIC diary for the same. I sincerely examined him. I found him feverish and surprisingly a little bit pale which was unusual as he was coming from a good  family. I even commented about it and he promptly said he was suffering from cold.
     The ABM and the agent took possession of the medical certificate, thanked me and left. I forgot about the episode till about 2 monthes later the agent told me in passing that the client died and that the claim (double benefit 4 lakhs for 2 lakhs policy) was promptly rejected by the LIC. I was not concerned anyway. Later I came to know that the party had filed a suit against the LIC. I did not bother about the details. Only when a person from the LIC Udupi division walked in a few days later for the "inquiry". Even then I did not assess the severity of the situation. I thought it was a routine inquiry because of early death which is a standard procedure. I was shell shocked when the person said the LIC had decided to file a criminal case against me. Why so?
     He gave his version. The man was in a hospital admitted for a widespread cancer with spread to the bone, fracture of the spine and paralysis due to compression of the spinal cord. It was highly impossible that he could have come out of the room in the hospital leave alone visiting my clinic on the first floor. I got the implication. I had examined an impersonator. LIC wanted to file a criminal case against me for 'criminal involvement with the client for gain' . I was speechless. They gave me a week to reply
     . I visited my lawyer friend in the evening and explained the situation to him. He heard me out and cooly said, "These things happen. Say sorry. Usually they leave you!" I was really upset. I had not committed the fraud. LIC officials had. To save them they were trying to make me the scapegoat. I sat up the night and gave it a serious thought at midnight when all is quiet and one can think without distraction.
     I hit upon an idea which seemed to be foolproof. I wrote back saying " The person alleged to be so and so who was examined by me on the said date was indeed medically fit. However, the onus of identifying them lies with the persons who introduced him - in this instance - the ABM and the agent of LIC. So please forward your queries and inquiries to these two who in my opinion are hand in glove with the party and are the perpetrators to the crime".
    The tone, and the content of the letter must have annoyed them. The LIC decided to take a second opinion from Nani Palkiwala. They wanted to silence me. I proactively wrote to them that I would be unilaterally proceeding for defamation charges with a claim of 1 crore for the mental harassment from LIC in order to save the fraudsters who were from LIC. The letter had the desired effect. Nani Palkiwala adviced LIC  to lay off and behave. They apologised.  The case was closed.
     The moral of the story is to be very careful at all times. Fraudsters plan the escape roue in advance. Innocent one gets involved unless one is vigilant at all times!
     

THE STORY HOW AND WHY THOMAS WILLIS (OF CIRCLE OF WILLIS FAME) BECAME VERY FAMOUS

     Thomas Willis was a British doctor who was known for neurology and anatomy of the brain-  best known for Circle of Willis
     He was born in 1621.His research would changer the concepts which prevailed before his era. In the pre Willis era, the teachings of da Vinci, Vesalius and Berangario prevailed and brain was thought to be an organ of purification. Willis did a lot of work on Anatomy of the brain. He worked in collaboration with Christopher Wren and Richard Lower. His research in anatomy of the brain  resulted in findings which were unexpected and very different from the views held then. He became famous. But for his research he needed to dissect human corpses. It was not easy to get them and many a time those were obtained by a 'forcible' donation
     Today's story relates to one such episode where the body for research was obtained by a 'forced' donation - one Anne Green, a 22 year old housemaid who became pregnant by the grandson of her employer. She gave birth to a baby prematurely and hid the infant which promptly died. She was accused of infanticide, tried and convicted and was to be hanged to death for the offense.(This happened on the 14 th December 1650)  This was a public ritual witnessed by many. They pinched her and pulled her down by the legs which was supposed to shorten the process and thereby reduce the duration of agonising asphyxia. Her body was pulled by so many people so violently that the court official was worried whether the rope would break and requested the people to leave the body alone. The body was given to William Petty for anatomy lectures at Oxford . When Petty and other doctors including Willis opened the coffin, the 'corpse' was said to have taken a breath. Willis raised the body to a sitting position the doctors opened the mouth and poured hot drinks down. This caused a cough and the doctors began to resuscitate her by rubbing the hands and feet. About 15 minutes later the eyes fluttered. The doctors began bloodletting and applied compression bandages to the arms and legs to increase the circulation (as it was believed then). They put her body on a bed besides that of another woman whose unfortunate job was to keep Anne's body warm. 12 hours after the official 'execution' Anne spoke a few words. After  4 days, she began to eat solid food. After a month, she was said to have fully recovered. Because her her unique resuscitation, Anne was later reprieved of her crime. Anne moved to the countryside taking the coffin as a souvenir. She married, had 3 children and lived for another 15 years.
     Willis married Mary in 1657 and in 9 years of their married life had 8 children 4 sons and 4 daughters. All but 2 children died. Mary expired in 1666.
     This episode made Willis very famous and his success resulted in jealousy from his colleagues. He had to face a lot of harassment He died relatively young at the age of 54. Willis is best known for his circle of Willis which was described before him and he always acknowledged the earlier claims.
     It is rare to find such an extraordinary story in the history of Medicine - No wonder it made Willis world famous for all times to come!

"DAMSEL IN DISTRESS" - A TRUE EPISODE - WHAT WAS THE REASON? HOW WAS IT SORTED OUT?

     Whenever a lady comes for the complaint of vomiting, I remember this episode of a "Damsel in Distress". It was a usual day like any other day. She had taken an evening appointment. She was working in a software firm and wanted an urgent appointment to consult me.
     She came with her mother. Mother was really concerned to the point of being inquisitive. The complaint was one of vomiting almost after each feed. Mother and daughter lived in different cities. Daughter had come to her mother's house because of the complaint.
     After taking an elaborate history, mother hovered around the daughter during the examination. At every step she would ask "What is the diagnosis?" The daughter was uncharacteristically quiet. She spoke little but co operated for the examination. Those were the days before the ultrasound scan became available. At the  end of the examination, I asked for some blood and urine tests. In situations such as these one discretely asks for the pregnancy test - I used to use a code "Urine for H" (which my regular lab understood )indicating HCG which is the basis of the pregnancy test.
     She came back with the reports. She came in alone and said " I insist you do not divulge anything to my mother. I also insist you help me in solving the problem. I know my rights and I demand professional secrecy even from my mother. Then she went out and called her mother in. The report confirmed my suspicion. She was indeed pregnant! Mother asked me "What is the diagnosis doctor?" I had to think fast. I had to tell her something that would closely mimic the early pregnancy. Something that had vomiting as a component. I said "Urinary Infection". Indeed, ascending infection can be complicated by acute pyelonephritis which can present with vomiting ( and fever which can get masked by the partial treatment). Mother seemed to be  satisfied with the explanation. Daughter kept quiet. Both of them went back.
     Next day the daughter came alone. She demanded, "Now that I am your client, you are duty bound to help me. Guide me to a good doctor for the termination of pregnancy". I suggested some name and she went away.She came back after a couple of days and thanked me. She gave a vent to her feelings. She said a man gets away easily and a woman has to suffer and all this  is very unfair. I agreed with her.  I almost forgot the episode.
     After about 5 years, I saw her again in my clinic accompanied by a man. She had come to consult me for something very minor. Anyway, I did my job professionally and did not show any signs of recognition.She thanked me, went out with her husband. Just after she left I observed her handbag. As I was pondering what to do and how to get her back, she suddenly came in. "Doctor, I am sure you recognize me.Doctor, do you remember  I gave a vent to my feelings and had said the boys get away. After going back to work, I gave it a serious thought. I wanted to punish the guywho did it to me. I married him. What better punishment can I give? I wanted you to know that the whole episode had a happy ending.
     I was speechless! I congratulated her and wished her well. How many girls can do this? More should try to "punish" the person responsible. I could not decide who was in a greater  distress. The "damsel" or the "gentleman"?

TRUE STORY - HOW THE GREAT NEUROLOGIST BABINSKI WAS DENIED PROFESSORSHIP- DID IT REALLY MATTER?

     It is not possible to achieve all the ambitions all the time. Can one still reach great professional heights and have a good career? an average man's answer would be a 'no'. But I warn you not to draw conclusions before reading the outstanding story of Joseph Babinski, unduobtedly a great neurologist of all time.
     Babinski was born in 1857. He was a faculty of Medicine in France where the faculty was given only part time jobs and allowed to practice. A university career was possible only after defense of thesis. Aggregation (becoming an associate Professor)  was the next step. This entailed complicated exams. The next would be elevation to the post of the Full Professor (which was partly by selection) and gave a status and enabled one to head the department.
     The time had come after Babinski became eligible for appearing for a competitive examination after completing 2 years of residency. These exams started  in 1802 when the success rate was 60%. Babinski appeared in 1877. He did fairly well in Clinicals (anatomy of trapezius 17 /20 ) and treatment (Burns 20 /20). He did not qualify for aggregation and was promoted to permanent post.in 1879.
     After completing 4 years of residency, Babinski appeared for the Gold medal examination which was mandatory. He did well in the written examination (Gastric mucus membrane ). He qualified for the oral exam but could not appear due to the illness. He was not considered for the gold medal.
      He got employed under Charcot a well respected neurologist at that time. In 1886 he appeared again for the Aggregate exam. He scored  16 / 20 (Hydatid cyst) which was not good enough to appear for the orals. In 1887 he appeared again with Gilles de la Tourette and Pierre Marie, scored 16 / 20 for clinicals and 14 / 20 for orals (chicken pox) and was not admitted. In 1888, in a competition held for 3 possible places Babinski scored 27 / 30 and in orals (sclerosis of the heart) he got 26 / 30  - not good enough for the next step. ,
     In 1893, he   competed for the aggregate and  he successfully completed the exam with a score of 30 / 30 for  written part ( Scarlet fever ) and 19 / 20 for orals (diphtheria with paralysis)., 17 / 20 for cliniclas,, and 30 /30 for the case (Syphilis ).  The idea was to find an able successor to the then head of the chair - Charcot. The competition was between, Babinski, Landouzy, Dejerrine, Raymond and P. marie. Babiski was the preferred pupil. Unfortunately, the arch rival of Charcot - Bouchard- was at the chair of the selection committee. Babinski was intentionally ignored. This story was lapped up by the press and the media much to the discomfort of the education minister who was involved by the public in the controversy. Next opportunity was provided in 1895. Babinski never appeared. He vowed never to appear again. He joined a hospital at la p Petie where he worked for rest of his illustrious career.
     Did Babinski lose anything by being unfairly denied of the opportunity? In his own words, "No" is the answer. His only regret was that he could have influenced the career if he had any. He in fact considered it an advantage not having been invited. He could work at his own pace in his own style.
     What is the moral of the story? One does not necessarily have to be a professor to excel in the field of practice of Medicine.
     Dear friends, do not get demotivaed if you do not achieve what you want to. Still you can do well. In fact, Babinski became world famous for his sign even without Professorship. 

A VISIT TO THE DOCTOR'S CLINIC ( AN OFFICE CONSULTATION) PAST, PRESENT,AND FUTURE

     I have very fond memories of  patients visiting my father's clinic for an outpatient consultation in  late 60 s and 70 s. The atmosphere was one of happiness and joy. There was  a high degree of respect given to the doctor. The consultation began with the exchange of pleasantries. An enquiry about a close family member son / grandson / father / grandfather was the opening sentence. This was followed by the usual questions and a clinical examination.  A chest X Ray, and a few basic blood tests were done if really required. Urine sugar helped to pick up diabetes which was then investigated in a laboratory. The consultation ended with a sound advice and a reassurance. The patient was invariably accompanied by many family members wife, sister, mother in law, children and others. This was a sort of a day out for them. Most were coming from out station places like Kasargod, Hassan, Coorg and this was an outing. The consultation was followed by a lunch at a restaurant, and then a movie followed again by some shopping. Then they went home usually by the last train / bus. No wonder therefore the patients liked the visit to the doctor's office and looked forward to it. Obviously an "experience based socially laced medicine" was being practiced much to the satisfaction of the patients. I remember one particular patient of mine, a lady, whom I saw at an institution that I was working at that time. Her son would bring her every month by train for a chronic backache. I would see her and she would go away by noon. On one particular day, I found her waiting for me in the evening - I was really surprised to see her waiting. On asking her why she had waited, she simply said  "Doctor, you did not pat me on the back and reassure  me as you always do!" I then realized the importance of this one simple gesture!
     Then came the changes. There were more investigations available. The whole process became customised and standardised. Less time was being spent with the patients. Slowly the emphasis was shifting from "reassurance" to "cautious observation" and a specific and accurate diagnosis . This probably reduced the satisfaction and trust in the doctors. Consumer courts started and slowly "defensive medicine" started taking over from "experience based medicine". The doctors did not see the writing on the wall.
     I  remember an interesting episode which happened to a senior surgeon of Mangalore. On account of an MS Surgery examination, the doctor who was an examiner for the examination, reached his clinic only by 6 PM though he was to reach by 12 noon. A patient who considered himself important was visibly agitated and gave a vent to his feelings. He rudely said to the doctor "Where were you doctor? I waited for you for 6 hours!" The doctor was naturally a witty one. He coolly said "I waited for you for 30 years. Where were You?"  The patient was speechless!
     In 1990 s, the "evidence based medicine" started taking over. The wit, humor, wisdom, social interaction and trust were slowly replaced by arroganace, cut and dry approach, mistrust, a feeling that the things were being done for a "gain" by the doctor. The distance between the doctor and the patient increased. Doctor shopping began. This was the time when Corporate entities  made an entry into the hitherto sacred and  private space of doctor patient  interaction. Health was converted into a "product" and the doctor, a "service giver"- just like any other service for gain! Naturally the respect of the  patients vanished and doctors were merely performers and service providers for a fee! This trend increased the patient expectations tremendously and a good result was always expected. The costs naturally went up and the satisfaction levels plummeted. We are currently experiencing this.
     What will be the future of the patient's office visit? A survey by doctors at the US showed that the patients did not like to wait for 1 hour for a 7 minute long consultation.Dr. Eric Topol feels that the  Smartphones will have an important role to play in the whole process in future - Eye examination, ENT examination, transmission of metrics like BP, Heart rhythm, respiratory rate, oxygen saturation can be conveniently and easily done using a smart phone without the patient's presence in the doctor's office. Dr. Topol even  expects the hospital visits to happen in a completely different way in 5 years from now. Video links with transmission of data in real time or in advance - a form of virtual office visit may replace most of the  conventional office visits.
     Do not ask me whether the payment for the virtual consultation will be real or virtual  an image of a high denomination currency sent with a thank you note to the doctor bu the patient using WhatsApp! I really cannot tell!

THE TRUE STORY OF SIR RONALD ROSS - "MOSQUITO MAN"- HE GOT EVERYTHING ONE DREAMT OF! -WAS HE HAPPY?

     Many would have heard his name - Sir Ronald Ross - in connection  with the dreaded disease Malaria.He did a lot of research and proved that the disease was transmitted by the mosquitoes. He even got a Nobel prize. He was knighted. He was made the member of the Royal society of Medicine. He should have been the happiest person on the face of the earth. Was he? This is his true story giving details of his life and an insight into his personality.
     He was born in India on 13 May 1857. He loved poetry and music.He passed his exam for the Royal Colllege Of Surgeons of England in 1874. His father's dream was to see him enter IMS in India at Madras which he reluctantly fulfilled. He was not too happy with the way his career was progressing.He  took a year's leave (from 1888 - 1889)  and completed his Diploma in Public Health from the Royal college of England. He became interested in Malaria in 1892. Initially he even doubted the existence of the malarial parasite! He took a long leave in  1894 and met Patrik Manson in 1894 at London. Manson convinced him that the malarial parasite did indeed exist  by showed him the  Leveran bodies in blood ( which were really malarial parasites in the patient's blood demonstrated by Leveran in 1898)  and also showed him  that these can be seen better by staining them. This was to be the turning point in the career of Ronald Ross.
     Convinced by the belief that mosquitoes were in some way connected with the disease (Malaria) a concept proposed by Leveran and seconded by Manson, Ross agreed to do further research in India as requested by Manson. For the 3 years of the study, Manson would be the voice for Ross. He worked Secunderabad while he got an answer for his problem.
     Now, study this scenario - Ross was given a room at Secunderabad hospital. It was a small  hot room with only a window,a  fan,a  table,a  chair and a microscope. His job included catching 7 mosquitoes everyday without harming them and carefully dissecting them ti study their gut - to see if anyone of them had malarial parasites inside their gut. Not even one  mosquito studies was not yielding the result that he wanted. To make the matters worse, he could not even open the window or put the fan on. The dead mosquitoes awaiting the dissection will get scattered. The sweat from his brow would fall continuously on the microscope  thereby ruining the fine adjustment. Imagine the constraints he had - he somehow managed to work.Later when he almost quit, Manson prevailed on him to continue for a few more months.  On the 25 August 1897, Ross had last 2 mosquitoes left to be dissected . and then it happened - Ross found some large, clear cells in the gut of the mosquito the malarial parasite thereby  proving  his speculation that the Mosquitoes transmitted the disease. This was reported in the BMJ 0n 18 Dec 1897.
     Worldwide recognition, name and fame soon followed. He was awarded the Nobel prize in 1902, Knighthood in 1911. He was also made the member of the Royal society of Medicine. Despite all these  Ross was unhappy. Mentally he started competing with his mentor Manson whom he now considered an equal. He had many achievements more than Manson but Ross's private practice  simply could not match the  private practice of Manson who was immensely more popular with the patients.
     This probably started his downfall. He contacted Malaria. He got severe depression. In 1927, he had a stroke from which he partially recovered. He died on 16 September 1932 a sad man.
     In all,  it can be said that the days of his research in India were his' golden days'. The non collaboration and disagreement between Ross and Manson after 1900 seems to have temporarily halted the development and progress of British Tropical Medicine.
     What is surely of interest to the readers of these blogs is the fact that he served at our own Government Wenlock Hospital at Mangalore during his tenure at IMS. We should be really proud to have studied from and worked in a hospital where a Nobel Laureate  had once worked!
     

AN AMAZING TRUE STORY OF A NEAR PERFECT MURDER - "THE ACID BATH MURDER CASE"

     Before I narrate this story, I must set the stage. In 1973, I was studying Forensic Medicine. It was one of the subjects I liked best. A great fan of detective and crime fiction, I was entrhalled by the various stories pertaining to crime. There was a very good reason for it - Professor Laxman Pai - a very well read person with a fluent Shakespearean English and a fantastic skill of narration was our professor of Forensic Medicine. He would narrate the stories pertaining to crime, detection and poisonings which would hold us spell bound. No body would utter a word. Everyone attended his classes. We adored him and his stories. The story I am going to tell is one such which I shall never forget!
     Around 1940 s, the victim, a well to do  Kensington widow was lured to Crawley, shot, stripped of a fur coat and jewellery. An attempt was made to get rid of her body. The law at that time said that if no body was found however strong the circumstantial evidence was, no one could be convicted. The murderer wanted to take shelter behind this rule and walk away scot free. And he almost did. How did he get caught? That is the most interesting part of the story!
     Mr. Haigh, who allegedly murdered the lady, immersed her in a tub of commercial sulfuric acid for some days and then when almost everything got dissolved, he buried the few remains in the surface soil in a yard rented by him. Almost everything was dissolved in the strong commercial sulfuric acid - well, almost everything. The dentures, the gall stones and fragments of a few skeletal bones were not dissolved mainly because the Haigh had impatiently taken out the body a bit too soon out of the "acid bath". The dentures were conclusively identified by a dentist as being made by him for the missing woman. This evidence was not contested. Haigh confessed to 5 other similar murders which he had got away with. He was found to be guilty and hanged.
     It was a near perfect crime. It is one of my favourate stories - the "Acid Bath Murder Case". I have narrated it to many batches of students.This story was invariably followed by a question to the students from me. "What is the poison you would use if you wanted to execute a perfect murder - the poison should have no color, no odour, work fast and be not easily traceable". May did not answer. many were not confident. I used to ask them to look up. Most never did. One particular student once said he could not find the answer in any book - what next. I jokinlgy said "Ask Professor Laxman Pai". In could nor imagine what followed. He went to Professor Laxman Pai and asked him the question - "How to kill someone with an unidentifiable poison and leave no trace?" Now a flabbergasted Dr. Laxman Pai asked him "Who wants to know?" Without batting an eyelid the student said - "Dr. Raghavendra bhat."Now it was Dr. laxman Pai's turn to get surprised - he took the phone (landline in those days) and asked me in a very surprised voice "Raghavendra Bhat, what are you up to?"
     Needless to say I have stopped asking that question after this episode. But the story of "Acid Bath Murder Case" does not stop amusing me -for it was a very cleverly and near perfectly  executed near perfect murder case- almost perfect did I say? A little impatience on the part of the perpetrator of crime sent him to the gallows- a near perfect murder indeed!

A STRANGE CASE OF PATIENT DIAGNOSING HER OWN "MYSTERIUOS" ILLNESS! - TRUE MOTIVATIMG STORY OF KIM GOODSELL

     Many a time patients want to know more about their own illness. Giving them information could be a tricky process. Mistakes happen - in the form of too little / too much information being given. Finally both the doctor and  the patient give up.
     I remember making patient education information files  about common diseases. It helped me immensely in saving my skin in one particular episode where the patient refused angioplasty and the next day died. His immediate relatives who were abroad were very upset. Only when I showed them what was discussed with the patient and  showed them the documented evidence that he had refused the options, they cooled down.
     Most refuse to be told micro details and possible complications. Even when the patients are seriously ill, after listening to all that is told to them, they ask the same question  " no problem, isn't it?" " No other problem, but we are having enough of them to go by" I tell them.
     Then comes a patient once in a way , who is like a breath of fresh air - the one who  asks pertinent questions, understnds the answers, and discusses intelligently - a pleasure to deal with. Like all good things, these patients are rare.to come by. This is the story of one such exceptional patient
     Kim Goodsell in San diego at the age of 30 started noticing ' a strange instability'. That was 20 years ago when she was training for an ironman triathlon. She was diagnosed with 2 rare diseases. One was a disease giving rise to palpitations - ARVC (Arrhythmogenic Right Ventricular Cardiomyopathy)which is known to cause fatal arrhythmias. She got a cardiac defibrillator implanted (as required) and started getting excruciating pains. She could not even hold a fork!The second rare diagnosis came in the form of a neuropathy which caused progressive degeneration of the muscles for which she had to undergo hip replacemen due to a dyspalsia of the hip. . The disease was CMT (Charcot - Marie - Tooth disease) type 2. She gave up the rigorous training and In 2010, asked the physicians at the Mayo Clinic whether her 2 ailments were related.  She was told that the odds for having the 2 diseases together were less than 4 per million that is even lesser than the chance of one being hit by an asteroid! She next consulted the geneticist who tried to dissuade her by saying that it would cost her $3000. But she wanted clear answers. She had found out that she had the  the LMNA gene the mutations of which can cause bone disease, cardiac disease, neuropathy, systemic degradation. She insisted, spent for herself, got the test done and then came the surprise - the test was positive
     This was the beginning - she started to study the molecular pathways of the products of the LMNA gene - She found convergence of lamin A/C and desmosomal proteins. The mutations on the LMNA gene were pertubating the downstream desmosomal proteins. She not only studied  the problem in great detail, she wrote a dissertation on it and even set up her own treatment plan!  She started on a diet that she followed strictly - no excitotoxins (glutamates); no gluten, solanin contained in pepper, tomato, eggplant which she had loved to eat before.
     Her outlook on  life changed  Her health improved, relations with other family members improved and she could walk without support. She could even travel and participate in the outdoor adventure with her husband.She felt she had reversed the disease process.
     Her physician, Dr. Topol, feels that she is a great inspiration for other patients and even the physicians. Physicians are indeed shocked to know that she had deciphered the mystery of her own rare diseases and taken steps on her own which helped her not only to get better but also to revferse the disease prcess!  Of course, the advanced  technology stood by her and helped her. This was impossible 5 years ago.
     What differentiates this patient - Kim Goodsell from others - she had an 'insight' a single minded focus and energy to understand her disease; a gut feeling (born out of research and knowledge) to go ahead with the expensive gene tests despite being dissuaded. She stood to gain a whole lot! She did not waste time on self pity and performance of useless rituals!
     We only wish there will be many more Kim Goodsells! Then the interaction with the patients becomes more interesting, more meaningful and rewarding to both the patient and he doctor!

EVIDENCE BASED LABORATORY MEDICINE ( EBLM) - ARE WE TAKING THE" EVIDENCE" TOO FAR?

     There was a time, not long ago, when the clinician diagnosed the condition the patient was suffering from entirely based on a detailed  history,  a thorough clinical examination and a few simple tests. The verdict was accepted without any questions. The possible expected course the disease would take and the expected outcome were discussed. Most of the time, the predictions came true. What was being practiced was "Experience based medicine". It was accepted and had stood the test of time. However when things went wrong, some disappointment was inevitable.Most of the time the turbulence settled down. Litigations were few and far between..
     Somewhere in the 1990 s the experience based medicine gave way to evidence based medicine. Every disease entity was defined. There was a need to fulfil 'required' criteria to conclusively diagnose and start treating the same. Evidence therefore was needed to diagnose conclusively after ruling  out other possible differential diagnoses; to know the stage, severity and extent of the disease and document the same; to prognosticate the outcome and if possible to help improve it. Diabetes mellitus is a case in point - hyperglycemia is a good pointer but exact sugar value gives a rough idea about the current severity. It is every doctor's observation that the patient either eats less or doubles the dose of the medicine on the day of check up to get a better blood sugar value to impress the doctor. Estimation of the glycosylated hemoglobin alerts the doctor as it is an average of 3 monthes' blood sugar values and cannot be 'doctored' by one day's efforts! Ketone bodies if present in blood and urine alert the doctor as the diabetic ketoaidosis is a serious life threatening complication.
     Acute abdominal pain is another scenario - when the surgeon has ruled out all important surgical causes including gall stone colic, appendicitis, ureteric colic and when the physician has ruled out all important medical causes like diabetic ketoacidosis, acute pancreatitis, peritonitis, usually one has to think of acute intermittent porphyria a condition which can  only be diagnosed by a simple urine test for porphobilinogen - a striking example where the evidence based laboratory medicine becomes indispensable. Even to diagnose acute peritonitis, one has to get values of serum  amylase, serum  lipase, serum  calcium and other data. These also help in assessing the severity and prognosis (Ranson's criteria).
     Imagine a scenario where a young athlete  hits her head against a hard surface and loses consciuosness. There are no focal neurologic deficits. The CT scans are normal.. A clinical diagnosis of  " concussion " is made. What is the evidence? Till recently, there were none. Now they are trying to correlate the values of
T- tau protein levels in CSF taken at serial intervals - immediately after the event, 12 hours later, 36 hours later. The first peak  immediately seen after the concussion settles in 12 hours. The second peak comes between 12 and 36 hours. 1 hour values help to decide the time likely to be taken for the resolution of concussion and the time taken by the players to return to the game safely. Hence T - tau is an important' biomarker 'of concussion.
     Then comes the most common and the most important scenario - acute chest pain. Acute myocardial infarction is the most important event to be excluded. There was a time ECG was enough. Then came the enzyme biomarkers. Enzyme CPK came just when I started to practice. It was a sensational discovery! It would not only help pick up the diagnosis but also would help us quantitate the extent of myocardial necrosis. I remember a particular patient referred by a psychiatrist saying "The ECG is normal. His CPK values are 2500. Where is the heart attack?" Truly, there was no heart attack - the extreme elevation was from the skeletal muscles - the patient had Myxedema (hypothyroidism). Soon Isoenzymes came and CPK MB was considered the most sensitive marker of a heart attack . Then came the Troponins - C, T and I of which T and I would help diagnose cardiac muscle necrosis. The problem however was that the elevation was seen even when the cardiac muscle got damaged due to non ischemic conditions as remote as a scorpion bite. Something more specific was obviously  needed. Very recently, highly sensitive cardiac troponin T (hs cTnT) has become available and is now very helpful. The sad news though is that CPK MB has gone out of use and died a natural demise - most f the labs are not doing it any more - thereby showing that there is a 'shelf life' for these biomarkers!
   
     I am sure, we have t understand that the EBLM (Evidene Based Laboratory Medicine) has come to stay. We cannot wish it away. The physicians have to extend an olive branch to the biochemists, use the EBLM  and make the best use of the available options. It will help themselves  and the patients.
     Long live EBLM!
   

THE STORY OF" QUEEN OF BLUE HEARTS" !

     The year - 1930; the hospital - Johns Hopkins; the department - Paediatric; the doctor - Helen Taussig, a specialist paediatric cardiologist rightly considered by some as the "Queen of  hearts".
     Her dedicated team was puzzled by the short lived , strikingly   blue skinned babies which they called the "crossword puzzles" . She could decipher a part of the puzzle - the death was due to lack of oxygen - as revealed by careful autopsies. Obviously, something in the heart was hindering the process of oxygenation - the mixing of deoxygenated and the oxygenated blood at the level of the ventricles was probably the reason.The valve of the pulmonary artery through which the blood  from the heart reached the lungs ( where it got oxygenated and purified) was narrowed.
     Taussig now looked for the possible solution. When no obvious solution was found in the living children, she started to look at the answer for the misery of blue babies in the fetal circulatory system. Ductus arteriosus was a special path to bypass the unnecessary trip of the blood to the lungs ( as the lungs never oxygenate the blood in the fetus).But once the baby began breathing, the lungs start oxygenating  and ductus and other similar paths normally closed.
      Taussig noticed that the blue color intensified when the ductus began to close. She made a clever observation - the children still needed the ductus( for their survival. ) but for a reverse purpose. The normal process of the closure of ductus sealed off the path of the blood to the lungs and virtually killed the baby preventing any oxygenation / purification of the blood. If kept open in the blue babies after birth, the ductus gave one more chance for the deoxygenated blood to get purified. She was thrilled to have found a way to keep them alive longer!
     Now she had to find a surgeon who would agree with her ideas, believe her and do the surgery boldly. No one had thought of this or done this surgery before!  Taussig had heard of a doctor who had daringly entered the hear of a young girl to seal off an improperly closed ductus. If he could seal off one, she reasoned, he could be convinced to create one. She went to Boston in 1940 to meet him. In her own words, she was devastated to find that " he was not in the least interested" in the possibility of building a ductus
     Then it so happened that a nationally known and acclaimed vascular surgeon Alfred Blalock joined Johns Hopkins hospital. She was in awe of him when she witnessed him close a ductus successfully. She said to him " but the really great day will come when you build me a ductus for a child who is dying because too little blood is going to the lungs".
     Accepting here cahllenge, Blalock started experimenting on dogs. After doing so on hundreds of dogs, finally he was ready for the first patient in early 1944.
     The concept involved in the surgery was simple - to choose a major artery stemming from the aortic arch and join it to the pulmonary artery. This procedure sent some of the  blood back to the lungs. The result was spectacular and was there for every one to see!
     "I walked to the head end of the table  ', Taussig recalled of an operation on a young boy "and there he was with  bright pink cheeks and very red lips"! Blalock - Taussig shunt was born and many children got a new lease of life.
      Allthis was possible due to the careful observation and logical deduction by a compassionate doctor - Helen Taussig - "Queen of hearts" indeed!

GOING TO SCHOOL - SOME CHILDHOOD MEMORIES

     I studied mostly in the Kannada medium. I hardly remember what I learnt at the schools but vividly remember some of my teachers and my friends. But I very clearly remember the schools and the process of going to school every day.
     In fact, we looked forward to the activity of going to school everyday. We walked to the school. We would go along with our friends. There were many trees on the way. They belonged to no one in particular. There was a mango tree. We would throw stones at the tender mangoes and sometimes succeed in getting a couple of them. We always shared what we had. We did not have anything to cut with. We did the next best thing - strike the fruit to the floor and share the pieces! That some one got a bigger or a smaller piece did not matter - what mattered was we all got a piece each!
     Then there was a tamarind tree - boys loved the mature tamarind - We would pick the fruits from the roadside and share and eat them. I cannot forget the sweetish - sour   taste of the tamarind from that tree. Friendships were built on sharing the tamarind fruits from other sources. I remember explaining mathematical problems to my friends and getting sweet tamarind in  return!
     There was a ice candy vendor just outside the school. None of us had any pocket money - so we could not think of buying one! When we were thirsty playing in the school, we freely drank the municipal water. And we played every day during the last period. There was a great camaraderie and all enjoyed the games. That we played was all that mattered we did not even bother to see who  won.
     We had to have only 3 vaccinations - small pox, BCG and Tetanus toxoid out of which the first 2 were given in the school. That we picked fruits from the 'dirty' floor, drank 'unclean' water and had fewer immunizations made our immune systems stronger and we got allergy and  asthma less often. Now there is a lot of emphasis on 'very clean' food and water and too many vaccines are given and deworming is done too many times and too often in the pediatric age group resulting in an imbalance between the T2 and T1 immune lymphocytes causing allergy and asthma. There is a move in the west to encourge children to eat from the table tops so that they are somehow exposed to some infection. so that the rising incidence of asthma is reversed.
     In the rainy season, a holiday would be declared if many children got wet. There were no autos and it did not matter when a holiday was declared. On a very rainy day we would intentionally fold our umbrellas and stand outside the school building for 2 to 3 minutes.We would get soaking wet and the headmaster would  take pity on us and send us home. We of course had a different agenda. There were paper boats to make and to be left in streams of water which flowed vigorously during  the rains. It gave us immense pleasure to watch our tiny paper boats travel fast in the steam.
     Then there was the much awaited craft period twice a week. We learnt to make kites and magic lanterns. The craft examination consisted of making a kite - the success was gauged by one's ability to fly the same.  Almost every boy succeeded in succeeded in flying his own kite!
     The day began with a prayer We were taught prayer songs from different  religions. Significance of each day was explained. Each festival was celebrated. Diwali  was celebrated in a unique way - each one would get some crackers and give them to the class teacher. They would be collected and equally shared among all. Sharing equally was the rule - no one objected.
     Then there were yearly picnics - usually to the nearby places in and around Mangalore. The parents of some children gave food, some gave beverages - mostly home made - Some helped by accompanying the children so as to help the teachers in controlling them
     You thought I forgot to mention homework and exam ! Not really! There was no home work! Non at all! All studies were completed at he school. There was no tution. Teachers in the schools gladly cleared  the doubts. Revision classes were held just before the exams. Exams were a routine affair - we were scared of the exam  but were well prepared for it.
     If you ask me did I love my schools, my answer would be "Yes, of course"! But i would shudder at the thought of having to go to school today as a student simply because such schools simply do not exist anymore!

TRUE STORY OF TYPHOID MARY - DID SHE DESERVE TO BE MADE A VILLAIN?

     Typhoid fever was a dreaded disease. It could spread easily through food and water , make the victim very ill, and could even kill them in large numbers before a treatment was discovered for it. This story of Typhoid Mary dates back to the early 1900 s 1906 - 7 to be precise.
     How would you feel if you are shadowed, followed. chased and arrested when you feel you have done nothing wrong? That is exactly what happened to Mary Mallon, who later became famous as Typhoid Mary.
     In the summer of 1906, Charles Henry Warren, a banker, took his family on a vacation to Oyster Bay where he rented a cottage from one George Thompson. All was well till August 27. Then one by one starting with one of Warren's daughters followed by 2 maids, then the gardener, and then the other daughter - all became very ill due to typhoid fever. Thompson was worried that no one might rent  their cottage and so wanted to investigate this in detail. He knew typhoid spread through food and water but could not guess how so many could get the disease at the same time. He therefore hired George Soper, a civil engineer, to find out the truth. Soper believed that the cook was responsible in some way as the disease spread mainly through food and water. It so happened that Mary Mallon was the took and he took note of that fact. Now the problem was to prove it and the main stumbling block was that she was completely healthy and the concept of a "healthy carrier" was not yet known.
      So, Soper did the next best thing - he traced the employment history in detail back to 1900. He found that typhoid outbreaks had followed wherever she had worked. He found that, in all, 22 had devoloped typhoid fever and 1 young girl had died from 1900 to 1907. A good detective work indeed - this is called an epidemiological survey - a sort of fact finding. He felt it was more than coincidence. He wanted to meet her where she was presently working as a cook - the house of Walter Brown. She did not like the idea one bit - she chased him away with a kitchen knife. Not an easy one to get rid off, he came back with a helper (Dr. Bert Raymond Hoobler). Both were successfully chased away by an enraged Mary. He then involved the health department and Dr. S. Josephine Baker was sent to investigate. This time she saw a team approaching from the health department and staged a "vanishing act" - she was nowhere to be seen and later was traced to the hidden compartment at the basement of the neighbor's property which she accessed after running away jumping over a fence and entering through the secret  trapdoor. She was forcibly taken to Wilard Parker Hospital in New York. She was investigated and was found to harbor typhoid bacilli in her stool. She was later forcibly transferred to an isolated cottage at the North Brother island near New York.
     She seriously believed that she was wronged. She questioned the wisdom and purpose of arresting and isolating her - a healthy lady who according to her had done nothing wrong in her life. She failed to understand why she was being hounded, chased and arrested and kept in isolation.
     The government promptly quoted 2 sections to justify their act - sections 1169 and section 1170. which said  the the board of health shall use all reasonable means for ascertaining the cause of disease or peril to health, and for averting the same throughout the city. It was also considered that  the fact that she was healthy made her more dangerous as a source of such a serious disease which no one would suspect her to be the source of. Hence her imprisonment and  isolation were  justified. She fought a lone battle saying there was no proof that it was she who had spread the disease. In 1909, the case against the state was taken up by a judge who did not agree with her. It was argued that even people infested with the typhoid bacillus could pass the disease from their infected stool  onto food  via unwashed hands. Cooks and food handlers were the people most likely to spread the disease in this fashion. Mary Mallon , by now famous as the "Typhoid Mary" was sent back to confinement.
     In 1910, she was allowed to go free as long as she agreed never to work as a cook again.  She hurriedly accepted these terms to regain her freedom, gave an assurance by affidavit that she would never work as a cook again and would take stringent measures to prevent any further spread of typhoid by regular washing of hands. "Typhoid Mary" walked free.
     What do you think? Was she indeed a villain as made out by her sad story? 

MYSTERY OF THE "HIDDEN ENEMY"!

     She was a brilliant student. Her father, a banker, was worried about her  cough and evening fevers. She ate less, would tire easily and had lost weight. A careful history, examination , a chest x ray and blood and sputum examination confirmed it as Tuberculosis of the lung. She took the treatment, followed the advice and recovered fully. In the bargain her father became my good friend.  He mentioned another daughter of his who had settled in Maharashtra after her marriage.
     After about 2 years, he came back with the other daughter. She was almost looking like her younger sister. She was feeling tired nowadays and had come to her parental home for a few days. She wanted a check up. Nothing particularly was complained of. On a thorough examination, I discovered mild fever and  a lymph node mass with a  few enlarged lymph glands sitting on the right Carotid artery in the neck. It felt like a tubercular lymph node mass (with features of matting) . Ideally a Fine Needle Aspiration or a biopsy was required to prove the suspicion. The location being tricky and the finding classical, I deferred this step in the interest of the patient a decision I regretted   later. However, I explained the whole thing to her father and made him feel the gland mass so that he understood my dilemma of avoiding the procedure of Fine needle aspiration/ biopsy to avoid a possible damage to the major artery which was a more serious matter. I started her on standard doses of anti tubercular medications and monitored her temperature and weight on alternate days.
     She was to go back to Maharashtra in about 2 weeks and she was much better by then. Fever had settled and she had gained about 2 Kg weight (as expected). Her father was very satisfied. She returned to her her home without any issues and started leading a normal life.
     After about 5 days, she started having fever. They phoned me. I asked her to rule out Malaria which was rampant in Mangalore at that time.  There was no evidence of Malaria. I asked her to contact a local doctor. What followed was unbelievable and gave me a rude shock. The local doctor on examination was able to feel lymph gland mass on the left side also and wanted a biopsy of that. It was far away from the Carotid artery and therefore it was very safe to do so and it was done. The nightmare followed. The report came as Papillary Carcinoma of the thyroid gland - a variety of thyroid cancer. The doctor even went to the extent of telling her father that the original diagnosis was indeed wrong and cancer was missed and was treated as tuberculosis, an unpardonable mistake. He phoned me and politely told me so.
     Now it was my turn to get seriously upset. I had entirely depended on my "fingers" for the diagnosis - my chief always told me after 10 years of my training I was ready for the "bare hand combat" and  should always trust myself. I had indeed believed him and trusted myself. I could have done at least a ultrasound scan or a CT scan of the neck and the mediastinum and picked up the "hidden enemy". Did I entirely miss the track? How could I make amends?
     I suddenly realised that the whole thing depended on the biopsy done on the left side. Why not do a biopsy on the right side? Why not a CT scan to know the extent of the disease? Indeed, why not? I requested the father of the patient that they must get a CT scan of the chest and mediastinum and do a lymph gland mass biopsy on the right side also. It took me a while to convince them I also asked them to consult the senior most physician in town and lay all the cards on the table. Let him give a verdict.
     The CT scan showed involvement of multiple groups of lymph glands in the neck, chest and the mediastinum. The biopsy from the neck glands on the right side revealed the presence of Tuberculosis! I was right! What was the message? There were 2 different diseases on two sides - Tuberculosis on the right  side and cancer on the left side! A rare and a deadly combination indeed! The other  lesson take home message was to avoid a short cut whatever the reason  is. A scan would have revealed the other glands and prevented all embarassment.
     There is a little more to be added. The senior physician who saw the patient and the reports thoroughly appreciated my approach for being patient friendly and using good brands of the drugs, following up the patient systematically withou admission and keeping the patients informed of everything at all times. He even advised the father of the patient to thank me. He promptly did so and we became friends again!
      A hidden enemy indeed!
     

MYSTERIOUS CASE OF THE "MEDICAL MURDER"?

     Some patients are persistent. He was one such. He was a bank manager who had intestinal tuberculosis 5 years before he contacted me( in 1988) and was treated at AIIMS for the same. The diagnosis then was confirmed at AIIMS using a barium meal which was then a standard procedure for evaluating esophagus, stomach and small intestine. He had all records with him running into well over 100 pages and later he was successfully cured. 5  years later, some of the symptoms like  abdominal pain returned and he consulted me for the same. The clinical examination was completely normal and the picture did not suggest intestinal tuberculosis. So I tried to convince him that  we shall get an abdominal ultrasound instead and think of the barium meal. He was not willing. He insisted on a barium meal saying that it was that investigation that had picked up the right diagnosis at AIIMS. I wrote out some blood tests and a barium meat and forgot about it.
     A weak later, I had a strange phone call from the radiology centre telling me that a patient of mine had devoloped intense abdominal pain after a barium meal and was very uncomfortable. They wanted to know whether I wanted to see him or he could go home instead as somebody else from his town was willing to take him. I insisted on my examining him and on examination found that he was very ill and having abdominal tenderness and rebound tenderness suggesting peritonitis. A peritonitis due to leakage of barium is a serious matter as 9 out of 10 patients are likely to die despite an attempt to treat them well. The puzzle was if he had indeed devoloped a leakage of the barium from the intestines, how did this happen as the intestinal wall is quite thick.
     I admitted him and involved a surgeon to help the patient. The surgeon was the best I saw in my career but due to some health issues, his career was seriously cut short. He also was equally curious and took the bold step of exploring the abdomen to know the truth. On exploration, a sizable amount  of barium was found in the peritoneal cavity. The surgeon did the detective job and found a small hole in the intestines from where the barium had leaked. On a careful scrutiny he found that there was a small abnormal looking spot on the liver. He was intelligent enough to take biopsy from both the sites (intestines and the liver). He went an extra mile in that he stayed 3 nights in the hospital in the patient's bedside to take care. The relatives were highly appreciative. They understood the predicament and the cremation was over in a few hours.
     The next week, I had an unexpected visitor - a "cousin" of the patient from Bombay. He told me just 2 things. One that I was responsible for the death of the patient which he called a "Medical Murder" - he was referring to the fact that we had got a barium meal without indication when abdominal ultrasound was available! The other thing he told me was that he had called a press conference the next day so that he can appraise the press and the public of this human interest story and successfully ruin my career. It was then the seriousness of the whole thing struck me. I was speechless! I had to think and act fast. I tried telling him that I had ordered a barium meal at his request and that depended on the fact that the intestinal tuberculosis was picked up at AIIMS with that investigation. He flatly denied that the patient was treated for any disease earlier. He had destroyed the records!
     I understood what he wanted. He wanted money. He spelt out the amount. I could not even think of paying it - I felt there was no fault on my side.Nor could I afford to pay it.  But I had to have  some concrete proof..  I did the best possible thing under the circumstances - I asked for time and he gave me 1 day!
     I went home, sat alone and thought about the whole thing. Was I responsible for the "medical murder" directly or indirectly? If not, how could I get out of the mess? Suddenly I realised that there was indeed a way out - to get the histopathology reports of biopsies  from the 2 sites -  intestines and the liver. I personally went to the place to have a look at the slides. What I saw was something unbelievable - Intestinal malignancy with secondaries in the liver!
     It did many things - It gave us the truth; It explained the hole in the intestines ( the cause of  the peritonitis), It saved my practice and reputation. I did not have to worry about the threats. I could fully justify my actions ethically.
     The remaining story is indeed short. The "cousin" could not believe his bad luck and I could not believe my good luck! When he came the next day as he had said he would, I congratulated him for solving the "Mystery of the Medical Murder"!

THE STORY OF THE STETHOSCOPE - "HALLMARK OF THE MEDICAL PROFESSION?"

     The stethoscope is one thing which each medical student waited eagerly to possess. A hallmark of the profession it was the passport to the clinical years. Pre clinical years were dull and drab. It was very difficult to learn a subject like Anatomy but very easy to fail. With great difficulty when one almost lost faith in oneself and all interest in the subject and all hope of passing, one would pass and got into the clinical side. This desperate individual got  to possess the stethoscope - the transformation was  almost unbelievable and magical . The same student  would be looked upon as a "senior" by the students then in the pre clinical years and would be the cynosure of their eyes! The stethoscope also brought the student closer to being a "real doctor".

     What is the story behind such an important invention? It can be said that this invention was born out of child'splay! Rene Theophile Hyacinthe Laennec saw 2 children transmitting scratching sounds through a roll of folded paper to each other. This was the first stethoscope! It avoided the direct contact of the ears to the body (which had to be done till then). When he reported his invention in a journal, it was immediately taken up and translated widely. This invention (in 1819) made Laennec immortal. He became more famous than Auenbrugger who had become famous for his invention of percussion as a modality of clinical examination. Sadly, later Laennec succumbed to Tuberculosis. 

       Laennec not only invented the stethoscope but also named the lung sounds so heard (sibilant and sonorous rales); and was the origiantor of the terms like egophony  and whispering pectoriloquey. It was also found to help in the auscultation of the heart. Naturally it became popular with the practicing doctors and medical and nursing students.
     I clearly remembering possessing a basic model of the stethoscope. It cost Rs. 30 at that time. Better models like Littmann were expensive , lot more than Rs 1000 and were beyond the reach of common students. They were also the target of theft. I clearly remember the commotion caused by the theft of a Littmann stethoscope of one of the students from Malaysia. Everyone's bag was checked; it was never found. Once my ordinary stethoscope was stolen. I was wondering what to do. The next day, it promptly came back to the place where I had left it! Indeed, the thief had a class and he showed it! It was customary for the professors to demonstrate the main findings to the students - this included the auscultatory findings also. On one occasion, a senior professor, known for his sarcastic humour, reprimanded a student
saying that the student's father should not be stingy and should buy him a better stethoscope so that he can hear the findings better. Everyone started giggling hesitantly for the student was none other than the professor's own son!

     No wonder this instrument held the sway for almost 200 years. It seemed to be irreplacable to generations of medical students and doctors. Doppler ultrasound  and ECHO gave it a big blow.ECHO was more reliable in some situations. The postgraduate thesis done by one of my PG students proved this. There were some situations where the stethoscope still proved superior. It has been observed that the Cardiologists are using the stethoscope less ans less.
      Now HHUS (Hand Held Ultrasound ) is giving the stethoscope a serious competetion.  Though expensive (about $10000 a piece), it may be more objective and more accurate. There is no evidence that the stethoscope improved the patient outcomes in its early years though it helped in better diagnosis of Congestive cardiac failure and some other potentially dangerous situations. The lives were saved only after the better drugs like diuretics became available. HHUS on the other hand can do much more. With the basic training, even the non doctor peripheral workers can pick up  dangerous conditions like Cardiac failure and Pulmonary Embolism and save lives. Rural health workers can be made to diagnose abnormal fetal positions and fetal distress early and inform the doctors thus helping save lives. With mass production and encouraged sharing , the working cost may also come down.
     Will we see the sad demise of a legendary icon of the medical profession shortly? Only time will tell. Let us wait and watch.

     

THE STORY OF THE APRON (WHITE COAT) - HOW MUCH WE ADORED IT!

     Our entry into the clinical side after clearing a major ordeal of passing I MBBS (Anatomy, Physiology + Biochemistry) was publicised by two eagerly awaited events - wearing of an apron (white coat / lab coat) and the stethoscope for the first time. Those things gave some recognition to the clinical students and brought the students closer to being "real" doctors. I remember even the public giving importance to these. It was highly fashionable to wear them to a movie! Even the students who rarely attended classes, invariably wore them while going to a movie theater or a restaurant. There was one particular photo studio which had an apron and a stethoscope  and anyone could get themselves photographed wearing an apron and putting the stethoscope around the neck! One of my relatives who was not educated beyond the high school had his own photo taken in this fashion and that photo occupied the place of pride in his house! A third year medical student going on a Yezdi motorbike with his girlfriend wearing a stethoscope around his neck and an apron (mostly borrowed)  was indeed a sight to watch!
      The real use of a white coat was in the biochemistry lab - How can we forget the yellow stain which devoloped when Nitric Acid fell on it? Trousers or shirt would have been ruined but for it. Pockets allowed us to keep our instruments and papers. Sometimes small holes devoloped in the white coat due to sharp objects. One could "diagnose" where the student is posted by the prevailing smell of the apron. A strong smell of formalin meant that he was doing Anatomy, a horrible smell of gangrene meant he was in the Surgical posting. A clean  apron was much in demand thing during the exams!
      Now, a little bit of the history of the white coat. The first time the was coat was allowed by the law to be worn was in 1699 in France.- it was then referred to as a "long robe". The Columbia University medical school founded in 1767 was the first one in the USA to award the Doctor of Medicine degree (MD). It was also the first medical school to have the "White coat ceremony".
      What happened to the white coat? Many professions other than the doctors started using it to gain respectability - laboratory workers, people in the food industry, barbers to name a few. What is the perception of the current generation about the white coat? What does the research show?
      For one thing, the doctors still feel it is important and they like it and prefer to wear it to work. The patient's perception has however changed. The patients feel that the apron does not invoke the same satisfaction or confidence as it did earlier. They would be as comfortable with a doctor who does not wear it. So a white coat does not form a part of the formal attire any more!
      Is ti safe to wear white coat? We are not talking about the safety for the doctor here but about the safety for the patients. Now come the surprising findings of research - Risk of infection is probably INCREASED by the white coat! They are talking about the BBE scenario - which means Bare Below Elbow.- no wrist watches, no rings, no bracelets, no bands. A strict "Wrist hygiene" has to be practiced to avoid bacterial contamination from  cuffs, sleeves of the apron / shirt. A strict Hand hygiene is required  during the insertion and care of invasive devices - urinary catheters, intravascular shunts. White coat contamination by the bacteria (staphylococci of various types) is now widely known. The remedial measure of removing and hanging up the white coat before entering the patient's immediate environment is suggested and practiced.
      How often  a white coat has to be washed? How best is cleaned? The best way is probably to launder it. Best method is to send it to the hospital laundry. However, if one decides to launder it at home, using a hot water wash cycle with a bleach is probably the best option. Along with the white coat, the other things to be suggested to be regularly  decontaminated include cell phones, ID Card, purse, bags and  jewellery.
      What does the future hold for the white coat? Dos any one care?

GROWING UP WITH CRICKET

     It was a Sunday -  a bright and sunny Sunday. India was playing a test match against Australia. We had a group of friends who were in love with cricket. We wanted to" watch" the match. There was no TV those days. We however had  a willing neighbor who had a huge Murphy radio. All of us would sit  around  the Murphy radio. There would be about 15 of us of different age groups. The oldest one sat with a A4 size paper and a pen. We would listen to the radio commentary - usually by the likes of Vijaya Merchant. He would describe the scene so well and one could visualize the whole thing  as if it was happening right in front of one's eyes. That was the clarity of language and communication!
      Mr. Vijaya Merchant would start "This is Vijaya Merchant from Brabourne stadium Bombay; the sky is clear, the batsman is ready, the bowler is looking around at the field placements; 3 slips, 1 gully, 1 mid on , 1 mid off ......" We would draw the field on the A4 paper, mark out the fielder positions, and track the ball as it was being bowled and played. Another boy would be the "score marker". We would indulge in this for 3 hours before lunch and then reassemble after having food in our respective homes. This was a very satisfying experience. Doubts would be cleared by the older boys. Every one got a rich experience of almost "being there". However, this was possible only on Sundays and holidays.
      On all days we would assemble in a  compound of a government school whose compound wall had fallen down. At the evenings we would  play cricket from 5 PM to 7 PM on all days including the days of examination. There boys of various ages would meet and play together. The youngest (between 6 to 9 years) would be only allowed to stand in the periphery and watch. After maybe 1 year, they would be allowed to pick balls crossing the boundary line and then throw it back to the bowler. Boys who were a little older would be allowed to field. Later, batting and bowling would be permitted. The best ones played competition matches. The others stood watching and cheered hoping to play  sometime in future. There was no scope for misbehaviour and cheating. The punishment  for cheating would be to get thrown out of the peer group which none wanted and therefore everyone obeyed.
     Looking back, these things helped us a lot in shaping our personality. We had seniors to look up to and ask for help. 3 of the boys got selected at various  IITs for education. Some became engineers. A couple of the boys became doctors. Some became bankers and one boy in particular did exceedingly well and went on to become a director in the bank in which he worked. One person became the correspondent of the Sri Ramakrishna Vidyashala at Mysore and later went on to become the President of the Mysore Ashram which he still is.Many years ago,  he did a ground breaking research on cloning of plants from the leaves in a small, ordinary laboratory at Mysore Vidyashala. He would have figured on BBC had he been in UK.
     We were unified by the game of Cricket which we grew up with. We had role models among our own friends and peers. They led by example. We had working models of leadership, camaraderie, sharing, give and take, respecting seniors, accepting verdicts and decisions which may not have favored us, losing a game, and above all, fairplay and truthfulness. I remember one episode when a boy threw a stone at another boy who had lied. The boy got hurt in the head by the stone and bled a little. When the parents asked him how it happened, the boy simply said "hit by a lie!" He recovered uneventfully and such a thing never happened again. 

EXAMINATIONS THAT WE FACED - A NECESSARY EVIL?

     One of my favorite medicine teacher used to describe examinations in general  as "a botheration to the population of the Indian nation whose main occupation is cultivation". Examinations during MBBS are no better. Most of us still get nightmares about appearing for the examination. The general pass percentage those days was 30% which meant 2 out of 3 students who appeared failed; only 1 passed! One therefore, we appeared  for the examination expecting a failure! Those who cleared all subjects in the first attempt without failure naturally were the best and could clear any examination national or international they chose to appear later.
      This brings back some memories of examinations we faced during the MBBS course. We had theory and practical exams. Theory exams consisted of 5 questions of 16 marks each (essay questions) where long answers wee expected. The 6 th question was for 20 marks which was subdivided into 3 or 4 short note questions. For those who had prepared well there was not enough time to complete the paper. Those who had read little, there was nothing to do for 3 hours - either way this was complicated! If one  answered all questions, he  barely manged to pass - it was always possible to find out what one missed! There were a few students who would habitually appear for the exam every 6 months and fail. They were "super casuals". During the exam, I was surprised to find  one such person writing continuosly for 3 hours. He failed! When I asked him for the reason, he said "didn't match"! I asked him "what didn't match?" He said he randomly wrote 6 answers( he had prepared only that much) without reading the question paper hoping these answers would match the questions-  and unfortunately it did not match with the question paper! Then, there was this guy who brought ready made answers to expected questions in various parts of his body - folded chits hidden in collar, folds of shirt, below the belt, inside the socks etc. Why did he fail then ? He lost the master index slip telling him where he had hidden each piece and so could not locate any paper!
       Clinical exams were a different ball game - students have to examine patients and diagnose them. Better students go by the clinical findings. The others go by the incidental clues -  Red lungiwala has Mitral Stenosis. On one occasion, the patient had a bath and changed his lungi before the exam with disastrous consequences! Worse still, a patient visitor came wearing a red lungi and he was told by a 'super casual' that he surely had Mitral Stenosis. When the person strongly objected the student persisted the official list says so "But  you are wearing a red lungi!" The tuberculosis patient had no slippers  - so said the list - the day before the exam a philanthropic organisation donated slippers  to some poor patients. The patient of tuberculosis was not diagnosed properly because of that! Another clue was the bed number. The patient on bed no 7 was supposed to be having anemia due to malnutrition. To the bad luck of students the patient went home the previous night and the new patient was fat and well fed. Despite the obvious, the student presented  this case as thin and undernourished much to the dismay of the examiners!
       As a part of the examination some specimens were kept. One part of the liver was kept in a jar of formalin. The professor asked the student "What do you think would have happened to the owner of this liver?" meaning thereby what disease he might have suffered from-was the student in a position to tell by looking at the given specimen? The student coolly replied " I should be able to answer your question after a few days". Perplexed, the examiner asked him why so, for which the student replied "I expect him to be alive as he has he remaining part with him. He therefore will surely come looking  for this part too!"
       The cake was taken by a clinical exam in Surgery. A student was appearing for the 6th time. The examiner took pity and  and decided to pass him on one  condition - he cannot practice Surgery and that he has to promise the same keeping his hand on Bhagavat gita. The student did so and he passed. Everyone including the examiner was surprised to find him join MS Surgery the next year. The examiner asked him why did he not keep up his promise. The student replied " I will do my MS sir - that is for getting a fat dowry. With that money, I will build a good hospital. I will never operate. In fact, I was wondering whether you could join after your retirement"!

A MYSTERIOUS CASE OF THE" UNCONSCIOUS "PATIENT - A TRUE HUMAN INTEREST STORY

     I was really impressed by the old man when I saw him in my clinic. A crisp, spotless white dress; clear thoughts; good ability to communicate stood out. He was always in control. He came with his wife looking less than half his age - a very young wife indeed. He made it very clear that he had come for one time consultation for  a thorough check up and advice.
     He had no specific complaints. The check up after a thorough clinical examination showed that he had aged gracefully and had no major illness, in fact not even diabetes! Only thing I was not clear was his occupation - he simply said that he was a "trade union leader" at Bombay and had made some enemies in the course of his career.
     After about a month, his wife requested for a house visit at their flat  for what looked like a bad bout of respiratory infection. I obliged considering his age. He recovered promptly. On my way out of the building, I met an old friend of mine who also was residing in the same building. He was shocked I had visited his house. "Be careful", he said, "this man was a supari  hit man in his prime at Bombay"! I was indeed surprised and slowly forgot all about it. He had mentioned that his children were studying in a residential school far away and I now seemed to understand why - In his old age he had become a toothless tiger and ( he along with his  family) was therefore vulnerable to attacks from his enemies.
     About a year later, his wife phoned at the dead of the night . She said that he was very ill and requested me to come immediately. It was raining cats and dogs and I was not very eager to go. I tried telling her to take  him to a hospital. My wife then reprimanded me saying how can  a lady alone get her husband to the hospital without help. I went ahead  to his house.
     Imagine the scenario - Dead of the night and it was raining very heavily. The old man had fallen unconscious at the entrance of the bathroom - his head and part of the trunk inside the bathroom and remaining part of the trunk and the legs outside. He was unconscious and breathing heavily. He did not respond to his name or to the painful stimulus. I  knelt down in the dampness and checked him - BP was normal and he did not have any stroke. The question that bugged me was why indeed was he unconsciuos?
     The first step in any treatment is a good diagnosis. There was none here. I had to be very careful now. Just then the wife said " Now that you have seen him  you may go. Tomorrow I will come for the death certificate". I was shocked. I told her I had not completed my job. She coolly told me she did not expect me to! I was in a dilemma. whether to leave him alone or to diagnose and treat him. I had to think fast. I looked around and checked what I had hitherto ignored - the drugs. To my dismay, I found a strip of a strong anti diabetic tablet with 3 tablets missing. He was not a diabetic. The diagnosis was obvious - he had been given 3 tablets of a strong anti diabetic medication causing a low blood sugar (hypoglycemia) enough reason for explaining his unconsciousness!
     I decided to save him as it was an eminently reversible condition - ran out of the flat, woke up the next door neighbour who happened to my  same old friend whom I had met earlier, shifted him to the hospital with his help. You should have seen his wife's face. If  looks could kill, I would be dead on the spot.  He recovered fully and went home.
     I slowly sorted out the remaining par of the mystery. His wife wanted him dead to claim his wealth and property. The hit man almost tasted a generous dose of his own medicine!