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!