WHO BENEFITS WHEN I UNDERGO STENTING FOR MY HEART ATTACK?

     Indeed the question is who benefits when I undergo stenting for my heart attack? I thought the answer is obvious - Me! If the answer is so obvious, I would not have posed this question in the first place.
     To the uninitiated, STENT is a way of making sure that blood flows once again in the vessel (coronary artery supplying blood to a portion of the heart in this instance). This is based on a sound principle that the heart attack is indeed caused by the sudden stoppage of the blood supply to the heart muscle in the first place. (A reduction usually happening slowly not amounting to a sudden block would result in a less dangerous 'warning signal'of  ( the possibly oncoming) heart attack - known as 'Angina pectoris (meaning 'chest pain'). The process of removing the block and preventing a further block is done using 'clot busters' - chemicals that dissolve the clot. However these on their own cannot prevent this from happening again. It is precisely for this purpose permanent measures are undertaken to make sure that  that enough blood flows through the arteries of the heart once again - these procedures are called 'revascularisation' procedures. An angiogram ( dye injection to visualize the arterial tree oft he heart ) is done first. This helps in making sure that there is a block ( or many blocks) in the first place and the size and location of these blocks. Depending on the feasibility, the patients are taken up for the medical procedure of Angioplasty (by which the blocks are removed) and stenting is done  to make sure the vessels which have been opened up are prevented from getting blocked again.There are many  types of shunts available - the ordinary ones wich keep the artery open ; the drug eluting ones  which hopefully prevent the blockade from happening once again by having a small dose of anticancer drugs which are known to slow down the cell multiplication ( the basic principle of treating cancer anyway). These are many times more expensive than the ordinary stents. Then there are the so called 'vanishing stents' which are supposed to merge with the arteries and keep them open longest. These are priced highest - in fact, many times more than the ordinary ones.
     Now we come to the basic point - HOW ARE THE STENTS PRICED? Basically there are 2 priciples of pricing anything - 1. The costs incurred. 2. The exclusivity. It is the neighbour's selling price that often determines the cost of the item most of the times. Thus a logical balance is struck - depending on the demand and supply position. This delicate balance is sometimes offset by EXCLUSIVITY of the product and the SERIOUSNESS OF THE SITUATION. In the case of stents BOTH these factors operate. This gives a free hand for the manufacturers to grossly overprice the product. This is what exactly happened to the 'Vanishing stents' sold by Abbot in India. The customers were royally fleeced to the core because there were no rivals. The worse news is that it has been found that even the so called vanishing stents get blocked many times defeating the basic purpose. Now we come to the point - the unsuspecting client is made to pay for the CONCEPT which has NOT been proved! You might ask me the question how on earth is this possible because even the drugs undergo extensive trials and attempts are made to obtain adequate proof before these are used on the patients. How then the stents get away? Brings us to a glaring fact that there is NO NEED to conduct trials before the DEVICES are used on human beings - and believe me, stent is one such device. How then can we remedy this seemingly iremediable problem where the ABBOT COMPANY MAKES HUGE PROFITS WHETHER THE END USER ( THE PATIENT WHO SUFFERED A HEART ATTACK) LIVES OR DIES OR BENEFITS OR NOT.The Abbott company DOES NOT EVEN MENTION THE MRP which has to be compulsorily mentioned by even products like toothpaste! I discussed this issue with legal authorities and patients who had suffered. I felt very sad after I was made to know that there is NO LIMIT ON THE MRP OF PRODUCTS CREATED BY ESEARCH for which there are no alternatives. I then understood that the ball is in the court of the consumer - the patient and addresssed may fora on this and related topics. No one saw the urgency in the issue till a kit or kin of theirs developed a heart attack and there was no time for these discussions.
     When I almost gave up, I found a good news on the newspapers today that the MRP OF THE DEVICES HAS TO BE COMPULSORILY MENTIONED. Now there is some kind of a hold on the companies like Abbott. I am not for a moment saying that they are the only ones in this dirty game. There are many other devices like pacemakers, intra cardiac defibrillators, artificial joints, ocular implants, heart valves, disposable syringes and many more items manufactured  by many companies. Now some sort of regulations will come int place. It has been also mentioned that attempts are being done to notify these products as drugs and compulsorily bring them under the Drugs and Cosmetics act1940. If this happens, their prices will be monitored and regulated making the whole process fair to all concerned including the stake holder - the patient. Therefore with this single act of the government, there will be more people benefitting fairly when a person undergoes stenting!

THE IMPORTANCE OF "COUGH!"

     You may wonder what is this all about! After all, what is the importance of cough, such a common happening? Is there anyone who has not had cough sometime or the other? None, I am sure. Then what is this about?
     I am not referring to the 'cough' you are thinking of - cough as a mark of disease. Cough is called a 'symptom' if the patient complains of it and a 'sign' if the doctors discovers that the patient is coughing too much. This happens in various situations some acute like acute bronchitis and pneumonia. and some chronic like tuberculosis or occupational lung disorders. Pneumonia has replaced tuberculosis as the 2nd most important killer!
     The cough I am referring to is a special cough - for example a cough by a girlfriend is a means of attracting the attention of her boyfriend particularly when she is forgotten in the company of his friends!  The cough by  a wife is a even more serious event - it is brake - a remote control even before actual remote control was even thought of - an effective means of telling her spouse "You are talking too much - Stop!". Most of the times, it has a magical effect!
     One of my patients once told me of an event where a patient had a bout of violent cough and fell down clutching his chest - he was taken to a hospital immediately - In all probability, the violent cough had ruptured his lung resulting in the escape of air outside his lung into the surrounding pleural space - a very serious condition called "tension pneumothorax" - a killer. He survived only because of a good medical attention!
     Cough may sometime  be the end point of a crisis! When someone is choked on something - say, a morsel of food, one can try a life saver called Heimlich maneuver - a type of a squeeze below the middle of the chest - which can effectively dislodge the substance blocking the critical airways and throw it out with a cough - a life is saved following that cough!
     Some coughs are telling - Bovine cough a cough resembling a cow's cough is said to suggest pressure on the recurrent laryngeal nerve deep inside the chest - an ominous sign indicating possible cancer. Our generation I am sure, has not forgotten the Whooping cough a dramatic event where a series of coughs in quick  succession  is  is followed by a distinct unforgettable sound of air rushing in - a whoop!This potential killer seen particularly in children has  become a lesser offender now due to vaccination though it is trying to raise its ugly head again!
     There is an interesting neurological condition called Pseudobulbar palsy which results from damage to the higher centres of the brain where the patient cannot cough to order but the reflex cough is preserved!
     Once one of my friends claimed that the best medicine for cough was brandy! In fact he was trying to justify his daily dose of brandy with a plausible medical reason!

" '"DOCTOR IN TROUBLE! "

     Gone are the days when a doctor was considered as God. Later he was revered and adored  though not treated as divinity. He formed a part of the family and was invited for all festivals and functions and consulted for all medical and even social problems. I remember distinctly an occasion when a patient died at home. He was regularly being treated by my father as his family doctor. It was a Sunday and my father had taken all of us to the beach at the evening. All of a sudden there was chaos on the beach. Two people were running, who we later realised, were desperately looking for my father. I was really surprised when I realised that they were looking for my father after the patient  had died! My father explained this phenomenon  to me describing it as a 'bond' between the doctor and the patient. It was imperative that the doctor who has treated the patient must see the patient after death so that 'soul rests in peace'. This was in the mid 60s when I was a primary school student. I was really overwhelmed!
     Later I completed my MBBS and went in for Post graduate studies in Medicine. I saw and treated patients at the Government Wenlock Hospital. It was a very heartening and a satisfying experience. The patients selected the government system knowing full well that it was far from perfect. The doctors knowing this, went out of the way to compensate with compassion and the nurses and the other paramedical staff also did their best. The team work seemed to satisfy the patients who came from far and wide. Of course, some were unhappy, they shifted their patients out to other hospitals. Some patients died - often this event was predictable. Sometimes death was unexpected but doctors were around at the time and shared the sorrow of the patients. The trainee doctors acted as a buffer between the patients and the treating doctors never letting down their teachers whom they held in high esteem.
     Now there is a complete change of the scenario. The patients do not respect the doctors in the same set up. Doctors are 'uncomfortable ,. Patients demand more. Even when they are aware of the limitations, their demands are unrealistic. They expect the senior doctors to be around all the time. It is unreasonable. The doctors belong to a cadre known as Honorary doctors who are not paid anything by the Government for teir services lent to the Government system. On the other hand the they are 'part time employees' of the teaching institution which limited responsibilities and limited emoluments. Obviously they have look elsewhere to make a comfortable living - which is the basic expectation of any professional with 15 years input into training (leave alone the cost). They do some private practice. In any professional system, there is a hierarchy and the system is closely followed. This happens in all government offices including the DC office, RTO, etc.
     Not only the doctors are expected to be present all the  time, they are also expected to solve all problems
medical and otherwise. One cannot expect a 5 star treatment at no cost. Shortage of medicines, non availability of space in the ICU, shortage of beds cannot be addressed to by the doctors. A road traffic accident is a case in point - Death or injury results from an accident. Such a patient is brought to the hospital and the relatives are naturally emotionally upset  Doctors become the target of any shortcomings of the hospital or the system and any adverse outcome of the event. First of all take the larger picture - why did the accident happen at all? Because an unscrupulous person bought a non roadworhty painted up bus and got it certified fit for use by a corrupt officer of the RTO. City corporation officials made a road out of what was left after sharing most of the sanctioned money at various levels. The so called road is a true mutant with many holes. An unsuspecting two wheeler rider who is innocently trying to avoid a pothole and find the road or what is left of it is mercilessly hit and knocked down by a speeding bus often from the wrong side. He is rushed to the hospital and the relatives are not prepared for the event, outcome, or the expenses. In this emotionally charged condition they try to vent the anger on the easily available person  - the doctor! Naturally the doctor who is trying to do his best against all odds gets naturally emotionally upset - after all, he is also a human being and an accidental easy target in the whole show!  Every one is unhappy and the real corrupt antisocial culprits have got scot free! Nothing ever has happened to the bus owner, bus driver, RTO official, corporation road contractor, or road tax collector, DC ever! Only the doctor is targeted. All these culprits should be made accountable - at least they must be given the responsibility of transportation of the patient and must be made to bear the expenses of all the expensive treatment modalities, diagnostic tests and costly medicines and also the cost of treatment in a higher, greater equipped center  if the need arises!
     This is my personal opinion. A beautiful honorary system will die down if the steps are not taken at the right time which is now!
   
     

THIS IS NO MONKEY "BUSINESS"

     We (my wife Shobha and me) are just back from a trip to Malaysia and Bali. We were specifically told to watch sunset aat Uluwatu at Bali. On the last day of our trip to Bali we planned this after checking out of the hotel before reaching the airport.
     There are 2 things to see at Uluwatu - an old Shiva temple for which the entry is highly restricted. There is a specific dress code which  we were not aware of and so we could not enter the temple as such. Then however, there was the sunset to watch and it can be watched from many points. You get a good view of the ocean too.
     There are many monkeys at Uluwatu. In fact they are encouraged and pampered. There is an exclusive swimming pool for the monkeys - something I have not seen anywhere. And there are very many monkeys. One an sit and relax in the benches provided from where the sunset is not visible. One could watch from the edge of the wall but it is not possible to sit there. We were sitting on one of the open benches when we net a family of 3 French ladies 2 sisters and their mother. The mother had a bandage on her little finger. On inquiry, she revealed that the injury was due to the monkey attempting successfully to snatch a banana in her hand. In the process he scratched and bit the little finger. She had to visit a hospital meant for the foreign tourists and and was given a shot of tetanus toxoid and one of ARV. The whole thing cost her a whopping 100 $! The monkey's prank turned out to be expensive indeed!
     As the sun set was approaching, I called my wife to stand near the wall so that the sunset can be viewed better. She did so. She was busy talking to me and the people around us. Then she moved back to the open benches saying that there is still more time. 2 guides belonging to 2 other groups were sitting beside her on both sides. Just then in one swift move she felt her glasses being snatched from her face suddenly. Before she could realize it was a monkey, he fled with the glasses and sat above the wall  near which I was standing. On the other side of the wall below the spot where the monkey was sitting, there was the ocean in full glory. There was a patch of grass just beside the wall where I was standing.
     The monkey carrying the Cartier glasses which  indeed was an expensive gift, jumped up and sat exactly above me and started to examine the glasses. My wife was desperate as there was no way we could reach the monkey and get the glasses back. There was very little time and little we could do. I wa about to shout at the monkey when a local man advised me to remain calm. He gave the monkey a small chocolate in his right hand. The monkey gladly took the chocolate, for a while held the chocolate in his roght hand and the glasses in the left hand and examine both. He must have found the chocolate more interesting and therefore threw the glasses down and was busy eating the chocolate. Now came the second hurdle. The glasses fell down into the patch of grass behind which was a cliff leading to the ocean. There was no way we could reach the spot where the glasses lay. The same man helped again. He jumped the wall  and in one swift move retrieved the glasses and jumped back to safety and returned the glasses to us. The whole thing was so sudden that we were stunned. Even before we could recover and thank him or offer him a gift, the man had vanished. All along, a Chinese tourist was video recording the whole thing and he had his dark glasses on his forehead. The monkey came back and in one swift move removed his dark glasses, jumped up to the same high spot, turned round the gasses, had a good look  cut it into 2 parts and sincerely gave one part back to the gentleman and threw the other part into the ocean. The glasses were destroyed forever.
     I shudder to think what would have happened if that fate had befallen my wife's glasses. In fact, my heart was beating in my mouth when the monkey was examining the glasses. It was a stroke of good luck that the unknown gentleman came along and helped us. My only regret was that we could not thank him properly.
     Need I say that we immediately proceeded to the airport without caring to watch the sunset. We proceeded to the airport in a taxi driven by Made Yasa who by then had become our friend. I made fun of my wife all along the way. We reached the airport, completed the security formalities and I found a newspaper and settled down to read it as there was time for departure. That is when  I realized that my gasses with the case were missing. Obviously, the monkey had taken it even without my knowledge! I am not too sure who had the last laugh - my wife or the monkey!

THE SWEET MEMORIES OF VISIT TO A MOVIE THEATRE

     The day on which all of us were taken to a movie in a theater was a big day. It was a family outing much looked forward to. It was a rare occasion and had its own special appeal. As a young boy maybe in the early primary school, I remember accompanying my dad to a classic - "Benhur". I was awed by the war scenes and the seriousness of the movie what if I understood nothing! The settings were great and I thought that the war scene was real!I also remember going to some Hindi movies with my mother and aunt. The dressed worn by the actress were displayed in the theater. I understood nothing of the hindi movies but felt very bad when almost every one cried in the theater! The movies I really enjoyed were the Kannda movies with Narasimha Raju a comedian playing some role usually with Raj Kumar. I was so fond of him that on a trip to Bangalore when my aunt, a doctor at Bowring Hospital asked me what I would like to visit most in Bangalore I replied "Of course, Narasimha Raju!" She politely told me she did not even know where he stayed and I tried to convince her that maybe he lived on the road they had just named after him! This was during my 7 th standard vacations. Any movie would begin with a "News Reel" a black and white depiction of news. One of the news surely would be about "Rashtrapathi Radhakrishnan". For some reason the black and white news played much faster than natural. I was really impressed by the 'speed' of the old polititians till I later understood that it is a technical problem!
     In the school they would rarely show us some excellent black and white movies. Usually they were about some scientific discoveries or about rockets, space travel etc. I would eagerly wait for that rare day. I still remember some scenes from those movies clearly. My beloved uncle would take us ( my cousin and myself) to some English movies at the New Chitra talkies. Usually they were spy movies. Enemy was always more intelligent than what the hero assumed him to be. However after all the action (usually mindless - ending in a large factory which produced God knows what) the hero always won convinsingly! This was during the high school, PUC and MBBS days. During the Post Graduation I would go to movies with my friend Gurudutt who was studying to be an Ophthalmologist. We would see an English movie on most Fridays. It would cost us Rs. 3.50 each for the balcony ticket (in the front portion). Reaching the theater from the hospital would cost less than a rupee. One packet of Masala ground nut and a cold drink each would be around Rs 2. So Rs. 10 in all saw us through a movie session. We walked home after the movie which was healthy and free.
     I just cannot come to terms with the present day scenario of going to a movie theater. Gone are the days of cheap tickets and simple eats. You are forced to take a huge packet of popcorn and a big coke. Some times one wonders whether people go there to eat or t watch the movie. Movies themselves are insipid. They are made by the people with questionable IQ s for people with even lower IQ s. Rarely we find gems among the muck. 100 crore club probably is another social club like Rotary or Lions nothing to do with the actual collections! However there are no superstars any more. No wonder people do not take the trouble of visiting movie theaters regularly. Any 3 Hindi movies seen in the course of 1 year will give you material and ideas sufficient for that year's releases. Once in a way however, a Lunch Box , a Dirty Movie, a Kahani will surface keeping the hope alive and faith intact. No wonder we hardly remember recent movies and never forget the movies like Lawrence of Arabia, Titanic, Inferno, and the like!

THE EPISODE OF THE MAN WHO SWOONED

     I reach the HOD office of Medicine department at 9 AM. today as usual. After meeting the people, signing documents and dictating a few letters and communicating digitally with some people I was driving to the teaching hospital .
A narrow road leads to the hospital. Usually vehicles are parked on the left side of the road and that makes the road even narrower. To make the matters worse, some two wheelers come on this narrow one way road from the opposite side. This forces the pedestrian to walk virtually in the middle of the road  exposing himself to all the vehicles. A car stopped. An elderly man got out of the car and even before closed  the door, swooned and fell. Another car passed him and possibly grazed his head. I was 2 cars behind this and saw it happen. As it was an unexpected event and there were people around, I was not too sure whether the man's head was hit by the door or the car that passed. The man who fell down started to bleed from his forehead just above the right eye. I was in 2 minds. I parked the car on the side of the road, got down came to that car and watched. The man driving that car also was an elderly man. He was shaken by the episode. People gathered around and started to ask questions. "What is the color and make of the car that passed by?" asked one person. Her blamed the driver for not noting the number. The driver was trying to put the man inside the car into the back seat and was struggling to do so. No one of the 50 or so people gathered around helped. One scooterist came from the opposite direction and blocked the door to ask some stupid questions of gossip value. He had to be shooed away to make way for the patient to be put inside the car. I helped the old man to do this. Then I volunteered to accompany them to a hospital leaving my car behind. I left the hospital only after making sure that the person was stable and his daughter arrived.
     Whatever happened to our civic sense? Why do we hesitate to help people in distress? Is it the reflection of "me" attitude rather that "we"? Maybe like the nuclear family. We are distancing ourselves from serious problems - "As long as it is not me why should I bother" is one reason. "Why should I get involved in a police case?" is the other one. How on earth do we expect these people to help us in our crisis?
     By helping them I got delayed elsewhere. I do not know whether I am right or the other 'wise' people are right. I am sure there ate more questions than there are answers. Sometimes the answers may be obvious and some times the answers may not come at all.
     I suddenly remembered my childhood days when we were a big homogeneous group unconditionally helping each other. If a boy fell from a tree and got injured, we would stop playing, attend to him, give him water, take him to the nearest doctor who usually did not charge, get medicines take him home and tell only the mother (underplaying the seriousness) and avoid the father and disappear. We pledged to remain so for all time to come and help each other and other people also. I wonder whatever happened to the pledge!

THE CASE OF THE "WRONG CALL"

     It was a very tiring day. I went to bed at about 11 45 and slept off immediately. I had to get up at 4 45 next day to be able to go to the gym. At about 12 15 I was woken up by the shrill ringing of my mobile phone. I picked up the call almost immediately
     The caller, obviously a lady was inconsolably crying. I was surprised but all the same decided to continue the call as the caller was obviously in distress. After a while of sobbing and actual crying, the caller introduced herself as a PG in Pediatrics. A baby had died in the ICU of her institution and the relatives were threatening to manhandle her and her co PG both ladies in the first year of training. Obviously it was the wrong call. I am heading the department of Medicine at a different  institution. The first thought was to say so and softly encourage her to call her HOD. I asked her whether the higher authorities have been informed. She replied saying that she tried to but they refused to take any responsibility saying that only imparting education was their responsibility. I immediately understood the seriousness of the situation. I surmised that the person must have saved the number as HOD and dialed  it. Still it beat me why she dialed me! By the time she realized that I was not the person she wanted to speak to and promptly disconnected. I tried calling her back and she did not pick the call.
     I like mysteries - I always liked to read the novels based on mystery. I always thought that the problem can be solved by logical thinking and action. Now I got an opportunity to put these into action. The number, named of the caller and the institution were the only leads available. Were they enough to solve the puzzle at the dead of the night? Was I justified in helping a PG from another institution? I have 2 daughters who are doing their higher medical training at different institutes. I would have appreciated someone going out of the way to help them. Then I should also do the same!
     I had to some quick thinking. Maximum number of the seats this time went to PG s from Andhra. So, logically no harm thinking that this girl is also from Andhra. I have always found PG s from Andhra quite resourceful and closely knit. So I decided t wake up an Andhra PG and gave him the number and name of the PG and the institution. To the credit of all Andhra boys, they tracked the identity of the person in next 15 minutes! The phone belonged to one of the PG s from our institutes who had stored my number as HOD. He gave the phone to his wife who was working in that institution and in turn, she had lent it to her friend during the hours of duty. This solved the mystery why she had called me.
     Then came the appropriate action. The PG whose wife was having the mobile went to the spot. He was surprised by what he saw. The ladies were hiding inside a small room in ICU. There was a commotion outside the ICU. It was pathetic to see that the management security or the police did not take it seriously. The doctor who went successfully escorted the lady PG s out of the ICU  and took them to a safe place.
     This case is another eye opener. Do we have to wait for something to happen before helping the ladies in distress? Where is the chivalry? It is nauseating to see the people not even doing their own duty for which they are regularly paid. I feel only making people liable for their inaction will be a good answer. There should be stiff fines based on the duration of inaction. Repeated offences should lead to successive demotions and dismissal altogether after the last possible demotion.