USING DIGITAL TECHNOLOGY AS A USEFUL TOOL IN MAKING CLINICAL MEDICINE MORE AFFORDABLE

     There was a time everything was inexpensive and the expectations of the patient were very limited. Patients used to profusely than my father if they improved a little bit. In fact, some were so good in that art that they got away without paying anything! Both the doctors then commanded highest respect and the patients simply adored them.
    Slowly the technology evolved. With that the "costing"  came. Machines were a double edged weapon - they made the diagnosis more precise for the patient and the process of treatment more remunerative for the doctor - still, the things were not expensive! Doctors still commanded respect and admiration.
     Then came the modern digital technological revolution - doctors found it time saving - they could take some short cuts and get away with it - after all, the technology always helped them! This came at an exorbitant cost - naturally the patients expected perfection in diagnosis and treatment and always a cure! The doctors started to get sued because of overlooked diagnosis (what could be easily identified with a good clinical examination can be missed with the best of machines) - giving a drug to which the patient is seriously allergic to without asking him is case in point.
     What then is the solution? Should we shun the new technology ? No , I never said that! Is there a way out? Surely there is. First step is to spend time, take a good history and do a thorough clinical examination. Then comes the surprising part - I refer you to a video gone viral on the internet where the idea is mooted by a foremost invasive cardiologist Dr. Eric Topol - He uses a smartphone ( an I phone) which has a specially made card - the card can be used for 2 tests ECG and ECHO cardiogram by just applying it on the chest of the patient - takes much less time and will cost a fraction of the cost to the patient - an usual ECHO costs $800 and  done using this technology this costs much less( around $ 100). Considering that there are 2 million ECHO s done per year in the USA alone, you can imagine the savings. Dr. Topal has also incorporated  some more things - calorific value of foods - You ask the smartphone how many calories are there in a given meal or a combo promptly the answer comes. It also tracks the blood sugar values depending on a wireless sensor implanted in the abdominal wall. While a patient requiring a continuous monitoring goes home, a wrist bound monitor with the digital screen will help track all the required parameters at home. The best part is all this data can be  collected wirelessly  and forwarded to any computer. All this tracks the patient continuously at a fraction of the cost.
     What is good for Dr. Topol ia also good for us. We habitually ape the west. This is one thing worth aping. We can use the same technology or modify it to suite our needs. Incidentally, Dr. Topol has written a book "Hoe digital revolution will create better hospital care". Such of you who have the time and want to know more can please read it. The link for the original video is here https://www.youtube.com/watch?feature=player_embedded&v=r13uYs7jglg
     I am sure the message is clear - use the digital technology as our slave and not be a slave of the digital technology. This will help evaluation of the patient, diagnosis, management, life style modification and domiciliary treatment even in the presence of  fairly severe illness. It gives us a golden opportunity to do the best and get a firm grip over the  patient care again ! Long live "Digital technology controlled by man!"

THE STORY OF SANTOSH - A CHEERFUL PATIENT

     In the beginning of the 2 nd year training during MBBS, the students get to see the live patients for the first time. The students have to talk to the patients, examine them meticulously, see the reports, present the case to the teachers and discuss with them. The patient's problems will be discussed with and by the senior doctors and explained to the students. The whole teaching process is called "bedside clinics" and is a much awaited event by the students.
     The attire worn for attending the bedside clinics includes an apron, a stethoscope, and clean and fresh garments. A special feature is that all students seniors and juniors participate together  in this without any discrimination. However, the case presentation is usually done by the senior students who are about to appear for the examination. The junior students observe the seniors and help them in the history taking and get prepared slowly for such experience in future. The whole duration of such activity lasts for about 1 t 2 monthes at a time. This is known as a "clinical posting".
     In this duration students get to see many cases. The best part is interaction with the patients. We went to our first clinical posting with a lot of hesitation and inhibition and expectations. We were afraid of the teachers. We knew our limitations. But we were eager to learn. When we went to the ward on the first day, the first patient we observed was a short  boy of about 18 years who was stunted and looked about 12 years old. He was a cherubic kid with a round face and prominent chest. He always had a ready smile and would cooperate with us freely for the clinical examination. All of us were fond of him and he was fond of us too. He would go out of the way to put the new young students at ease. We asked him the details of his illness s a par of history taking. He gave a fantastic story which was very impressive. He said he is suffering from"asthma".
     Santosh was having spells of cough, breathlessness and wheeze since early childhood. His illness drained his family's meager savings and he was not getting any better. He went from one doctor to the other. And then he went in for herbal medicines - some roots were adviced to be brought from far off forests. He would tell amazing stories of how his"uncles" went to far off land s to get them. We would be awed by the stories and charmed  by his mannerisms. Later the with doctor whom he consulted asked for the tiger's milk. Uncle first had to find a lactating tiger and then get its milk - heroic  indeed! Finally when nothing seems to cure him permanently, he came to the Government Wenlock Hospital where he could consult any good doctor free. In fact he was in the hospital for over a year. When he was well, he would help other patients and also the nurses to distribute food and  medicines. In all he would keep us entertained and informed.
     One day we found him in a bad shape. He was very ill. He was blue and cyanosed. Confused and cometose. His body was swollen due to waterlogging. He was in Cor Pulmonale with Respiratory failure. This was not typical of asthma. Then we asked Post graduate students. We did reading from textbooks and research. We realised that the boy wasnot  suffering from asthma ( an eminently reversible condition)  but from Cystic Fibrosis rare  genetic condition which can involve multiple organs - Lungs (Emphysema, Lung abscess, pneumonia, respiratory failure); Intestine (constipation, failure to pass meconium, malabsorption); Endocrine organs(Diabetes); Altered sweat content and other things. They can eventually go into advanced emphysema (he indeed had a huge chest) and respiratory failure the hallmark of which is Cyanosis (bluish hue). Hypoxia (lack of oxygen) can also produce bluish discoloration, confusion,  headache among other features. Then sudddenly I realised something - the disease was not asthma; it was a much more serious, irriversible disease inherited genetically (autosomal recessive pattern) and the exciting stories s never happened - they were all born out of the Hypoxic state with low oxygen I could not just believe that there were no willing and daring uncles; no tiger's milk; no herbs and roots brought from far away lands! The boy who was always cheerful and always willing to help and cheer up others was very ill and cometose. However, he seemed very peaceful. We stood around his bed feeling helpless. We held his hands, thanked him and assured that we will pray for him and indeed he would be fine by the next day. We had a sense of sadness because he had become a part of our family.  Next morning when we went to the hospital to Santhosh' bed it was empty!

THE STORY OF HOW ANTI TUBERCULAR TREATMENT STARTED IN MANGALORE

     Today I am going to tell you a story - the story of how anti T\tubercular treatment evolved with special reference to Mangalore. You may wonder how am I authorised to tell the story -in fact, my father (late Dr. VR Bhat) is the one who started the anti tubercular treatment  in Mangalore. He started his practice at Chitra Clinic  in 1947 and as he was specially trained ( at Madras) in handling tuberculosis, his patients mostly were suffering from tuberculosis / its  / complications /  sequellae /mimics like bronchiectasis.At that time tuberculosis was a dreaded killer.  We (my sister and me) watched it from close quarters. Both of us saw dad work hard and save lives. Treatment was very little in the beginning when no specific anti TB drugs were available - the concept was to give good food and rest to the lungs and offer them good ventilation and fresh air. Sanatorium treatment fitted the bill very well. The worst patients were referred to Perandurai sanatorium at Madras. Artificial pneumothorax to intentionally collapse the lung harboring the lesion having caused life threatening haemoptysis was another modality of treatment which needed immense skill so that air embolism a dreaded complication had to be avoided.
     Almost at that time Injectable Streptomycin became available. Each injection of 1 gram would cost more than a couple of sovereigns of gold! At Rs. 32 it was an expensive lifesaver if the patient lived long enough. The trouble was to get Streptomycin. Being expensive, no chemist would touch it. It had to be imported from London, bought at Madras by paying cash and then transported to Mangalore by train in a cold chain (in ice as was the custom then) and stored in a refrigerator. Refrigerators were hardly available in Mangalore. My dad felt that the facilities for these patients must be provided in one place and therefore, he provided Chest X Rays, facilities for blood counts, for sputum AFB testing all in his Chitra Clinic where he did all of these himself for reasons of accuracy and privacy. After procuring the Streptomycin, it would be stored in a fridge at the Sri Ramakrishna Ashram where one of the swamiji was his close friend.
     Imagine the scenario which was common and which we (the  family) witnessed almost every night. A patient would have haemoptysis and one of the relatives would rush to our house. Dad would ask his address, and ask him to go home. Then he would wake up our next door neighbour - his man Friday for such occasions. Both would go in my dad's Morris minor car and reach the side of the road outside the window of the roomin the Sri Ramakrishna Ashram where the swamiji slept.  They wold throw a stone at the window pane with just enough impact to wake up the swamiji without breaking the glass pane. The swamiji would come out with 1 injection of Streptomycin. Armed with that and other paraphernalia ( a BP apparatus, a stethoscope, sterilised glass syringe, cotton, spirit etc in a handsome Doctor's bag ) they would reach the patient's house, examine  him  reassure him, start Inj Streptomycin and other available treatment. Next day he would be evaluated at the clinic for the proper diagnosis. The best part was the charges levied to the patient - Streptomycin would be passed on at no extra cost. Many patients being poor failed to pay even that partially or completely - dad just forgot and forgave them and moved ahead.  The consultation, chest x ray, blood and sputum tests would cost the patient Rs. 30 (a little more than the actual cost price)!Naturally, we had to get a merit seat to be doctors. But with all that I am grateful to the tuberculosis patients - after all, they are responsible for my food, shelter, clothing and education.
     The newer medicines came later. They changed the entire outcome and the outlook of the disease. The victory over Tuberculosis which at one time seemed to be imminent now looks distant and even impossible.We are already feeling the "power" of  drug resistance. With the emergnce of MDR (Multi Drug Resistane) and XDR (Extended Drug Resistance) and TDR(Total Drug Resistance) looming large, we will be probably returning to the bygone era  of "no drugs" worth mentioning for the dreaded  killer disease! Tuberculosis! 

CASE OF THE "PULSELESS" ASTROLOGER- A TRUE HUMAN INTEREST STORY

     I grew up in Mangalore and continue to reside in the same locality. The immediate neighbors have remained the same and we have very cordial working relationship. Each one knows the others. We interact frequently. We help each other.
     One day, as I was looking out of the window, I found the old man in the opposite house suddenly fall down  to the ground in the compound and get "fits" (convulsions). He had turned blue both the things  indicating insufficient blood supply because the heart was beating very slowly. Pulse rate was very slow - around 30 per minute. This is known as Stokes - Adams attack (due to- complete heart block a problem of conduction of the originated heart beat down as the pulse)- a medical emergency.  The treatment would entail insertion of a pacemaker after complete check up and treating the cause like a heart attack if there is one. I was very well aware of the social  limitations of this patient. Lifelong he was practicing  astrology as a hobby without charging anything to the people. Naturally he would not be able to afford a modern life saving gadget costing around Rs. 1,50,000 then. He was honest and self respecting man  staying with his daughter, son in law and grand children would never ask others for help. There was no heart attack and it was worth helping him as the rhythm disorder (complete heart block was the only problem) and he really needed the pacemaker fast. He however categorically told me that the pacemaker insertion according to his astrological predictions was possible only after 3 weeks if at all it was done!
     What was the alternative? I was in a dilemma. Can such an honest person be left alone because he cannot afford the luxury? My first instinct was to help him. I was figuring out how to. Suddenly I remembered an episode. We had inserted a pacemaker in a patient with OSA (Obstructive Sleep Apnea who had blackouts due to periodic inability of the atria to beat (atrial standstill). When she died, I had requested her son to pull out the pacemaker carefully before the final rites. I phone him hoping it had been done and was glad to know it had indeed been done. I requested him to get the pacemaker. There are issues with reusing the pacemaker- it should be functioning. There is a lead through which the wires thinner than the hair have to pass, This lead was bent and cut! However, I requested  my friend, Dr. Mukund,  a cardiologist, to try and use this pacemaker. The cardiologist understood the situation and cooperated.. On testing the continuity of conduction on the table we were pleasantly happy to observe that the pacemaker was nicely functional despite the lead being cut and bent! A miracle indeed! After all the pacemaker was in use only intermittantly for less than 2 years in the earlier patient and the lithium battery should usually last for around 10 years. Anyway, the pacemaker was working well and there was no reason why it should not work for long! I checked the date - it was exactly 3 weeks after the first episode of fall! It took so much time to arrange the pacemaker and then the cardiologist had  to go out of station for a few days. His prediction had come true!
     It was a very satisfying experience for all of us! WE could help a genuinely needy person for the fration of the cost (entire cost came to about Rs. 15,ooo instead of Rs. 1,50,000. What really made me happy was the observation that many people some unknown to him willingly helped him. The episode reimposed my faith in my firm belief -"the society will always pay its rightful due to the deserving person" - only I wish to see this happen more often! He lived happily for 8 more years and continued his hobby of free astrology consultations all along!

EPONYMS IN MEDICINE

     Eponyms( Gk. word Epi = upon; onyma = name)  are names derived from the names of things  diseases/ conditions etc. derived from the name of persons / place / things. We use eponyms in our day to day life without realising it - Diesel engine (named after Rudolf Diesel) , atlas are good examples. Some eponyms come from Mythology - Ulysses syndrome is an example. This reflects unnecessary multiple tests done on patients based on a single abnormal result much like the futility of the tasks done by the mythological Ulysses. Some eponyms are derived from the literature - Pickwckiaan syndrome (from the fat boy in Picwick papers by Charles Dickens); Jekyll and Hyde syndrome consisting of behaviour disorder with multiple personalities mimiking the character from RL Stevenson's story. Framingham study is a geographic eponym. Legionnaire's disease is a corporate eponym. Many eponyms are named after the discoverer - Quick test after the haematologist and Bowmann's capsule after the anatomist. Some eponyms are attributed to the wrong people - Saint after whom the Saint's triad is named (gall stones, diverticulitis, hiatus hernia) never described it! Some eponyms are shorter and more comfortable than the original disease - Paget's disease is better than the official name osteodystrophica chronica deformans hypertrophica. Eponyms liven the medical history and are said to be " one of the vestiges of the humanism remaining in an increasingly numeralised and computerised society."!
     Sometimes more than one eponym describes a single condition - Weil's disease, Fiedler's disease, Landouzy's disease'  are the same condition!Sometimes same name denotes different diseases - Pott's fracture, Pott's gangrene, Pott's paralysis, Pott's puffy tumour are different disorders. There are at least 3 different types of Albright syndrome. Some double barrel  eponyms exist - Chidiak - Higashi syndrome (hyphenated) was described by 2 people ; Austin Flint murmur (unhyphenaed) is one person!  So are the other unhyphenated double eponyms indicating a single person - Marcus Gunn pupil, Ramsay Hunt syndrome, and Bence Jones protein.  Lawrence - Moon - Biedl syndrome is a triple eponym which became famous only after Biedl described it. Charcot - Marie - Tooth - Hoffman syndrome is an example of a quadruple eponym.
     Tashima syndrome is an interesting one where the physician searches for a new disease to attach his name to. Tashima from Houston described it first. Stingler's law says that many times the eponyms are not named after the original discoverer. Stingler feels that eponymy is the rightful reward of the original discoverer. Pott's fracture was not only described by Pott but also suffered by him.
     There is a recent move to drop the apostrophe form  possessive eponmys (that is with an apostrophe) so that what was called Hodgkin's disease will now be called Hodgkin disease . Bell palsy (named after Sir Charles Bell) is another example. Sometimes the word "of" is used - Circle of Willis is an example. Saying a positive Babinski (instead of an extensor plantar ) is a truncated eponym. To say "to Kocherize" is an example of a derivative eponym. Some eponyms are derived not from people but from things (caisson disease - caisson is a pressurised chamber). Some multiple different eponyms relate to different people - Pick disease ( by a German Pathologist); Pick disease (by a Czetch Psychiatrist), Pick Pedricarditis (by a Czetch - Austrian physician). Some eponyms have difficult spellings - Kupffer cell, Kuntscher nail, Papanicaoaou smear are some examples.
     Whatever it is, doubtlessly the eponyms add life to otherwise dull matters and makes learning interesting. Only time will tell whether the eponyms will withstand the modern methods of learning and teaching!

THE IMPORTANCE OF HISTORY TAKING IN PATIENT CARE

     Basically I am a clinician which means that I  treat patients. History taking is an important part of the clinical analysis of the patient. There was a time this was being done diligently - maybe history taking and clinical examinations were the only 2 skills available to the doctors then. Of course some simple blood and urine tests were possible and were being done if needed. This assured that adequate time was spent by the doctor with the patient giving scope for a good communication, observation and documentation which forms the basis of a good logical diagnosis. A correct diagnosis is essential for proper management of the patient and best results.
      This brings us back to history taking - how important is it in this modern era of advanced technology? Is it not enough if a trained (not necessarily a doctor) person takes the data on a ticking basis saving time for the doctor? Sadly, NO. It is interesting to note that 80 - 90 per cent of the times the diagnosis is made by history and good  clinical examination. All the new technology and the machines only help in refining further 5 - 10 percent!Face to face interaction, eye contact, listening to the patient, physical examination by the doctor ( the doctor's touch) are all important.
      The case in point is a patient I saw on last Sunday. I was requested to see a "restless" patient on the Sunday evening. Restlessness would basically point to a problem in the heart / lung / liver / blood sugar related / nervous system related issues  / alcohol withdrawal  are main causes. The patient was confused and restless. On a detailed history taking from the wife and a diligent clinical examination I drew a blank. Then we do some basic investigations - a chest x ray failed to explain the restlessness. The blood sugar was normal. The ECG taken on  modern machine was reported by the machine as "Abnormal - Suggests heart attack" pressing the panic button among the staff and the relatives. This is a bane of modern technology - report comes even if you do not ask for it! Actually, due to confusion and restlessness, the patient was randomly moving his fingers and hand resulting in random "elevation of  ST segment and inversion of T waves" which technically amount to a heart attack . In a true heart attack, these changes are seen in all complexes in a given lead  always whereas in a patient (like this) with movements, the changes are randomly seen in some complexes sometimes - this is made out only if the doctor observes during the ECG recording or records it himself. There were no abnormalities in the other systems mentioned above. He had not consumed alcohol of late.
     The doctor sometimes has to become a detective. Time had come for that. I had overlooked something for sure. No excuse was good enough for that. I had  to make amends and find out the truth. I called his  wife again. I asked about recent behavioral change - sure enough he was doing double duty indicating manic phase of manic depressive psychosis. Then I asked about "daily medicines" that he takes - the wife suddenly remembered - she brought a strip of Alprazolam ( a benzodiazepine drug working on the brain )  which he was consuming more than 15 per day - which she believed was a tonic - obviously he was addicted to Alprazolam . He had stopped it suddenly - being accustomed to a continuous intake, it resulted in withdrawal features of which confusion, restlessness and abnormal movements are dominant. He had all of these and a correct diagnosis was made by talking to the patient's relatives. This re emphasies the need for talking to the patient and his family and making sure we are not misled by the advanced machines. We should not be the slave of technology - we should be the masters controlling the technology to our benefit  and using it judiciously!

SOME MORE FACTS ABOUT THE HISTORIC LANDMARK - GOVERNMENT WENLOK HOSPITAL

     I am overwhelmed by the response for the blog on Government Wenlock Hospital. It is indeed a landmark in the city of Mangalore. It started fuctioning in 1848 - I gave it as oversight as 1948 - vigilant readers(DR. Ashok Kumar was the first one)  have corrected me. I am grateful to them.The date is significant because only a few hospitals and medical colleges started before that in India (Madras General Hospital in 1772, Calcutta Medical school in 1824, Grant Medical college in 1843). That was also the year of "gold rush " whre people rushed to  to California. People of Mangalore valued the hospital as much as gold!
     The public of Mangalore were desperate to have a hospital for themselves in Mangalore and therefore submitted a memorandum to the government. In response, the East India Company board of directors issued an order to start a Military Hospital in Mangalore in 1848.It was located in the place where the Lady Goschen Hospital is now situated. This was a rented building with a monthly rent of Rs. 14. This is the list of the limited saff and the salaries paid to them --- A doctor (Rs. 50 / month); a dresser (Rs. 24); a cook (Rs. 7); Aa peon (Rs. 4 and 8 annas); a scavenger (Rs. 3 and 8 annas); a  watchman (Rs. 5). . A year later, the IP were 45 and OP were 1447 (in 1849). In 1851, it was shifted to its own building. The first local surgeon was appointed in 1852. (whose salary was Rs. 100)  who would treat people and help the district surgeon. In 1861, the people of Mangalore decided not to take help from the government and to run the hospital on their own with the local donations!In 1861, the local administration took over the hospital and ran it. In 1871, 165 IP s and 3898 OP s were treated. 1870 s saw people accepting the "hospital culture". New hospitals were started in Puttur (1872), Udupi (1887) and Karkal (1890). In 1893, the then Governor Lord Wenlock visited the hospital and Dr. Bannerman was the medical officer. In 1919, the Madras Presidency took over all the hospitals. A new building was constructed at the present location and the hospital was shifted there and it was named after then Governor, Lord Wenlock.
      In 1903 Janghen, a trade from Hong Kong visited Mangalore  was impressed and donated Rs. 500 for the Operation Theatre Complex. The ambulance, a long felt need was fulfilled by Kudpi Bhujanga Rao from Bombay. In  1920 s and 30 s new wards were started and the Police hospital was amalgamated. 1948 saw a double celebration for Mangaloreans - Hundredth anniversary of the Wenlock hospital and first anniversary if Independence. The it had 110 beds.
     1955 saw a great PPP (public private partnership) of post independence era take place in the form of KMC joining hands with the government in running the hospital and permission for its use in teaching medical students. This was possible due largely to the vision of Dr. TMA Pai, the founder of Kasturba Medical College. What followed  was truly a golden era - a unique win - win situatuion for the govermnent, the public and the medical students and the medical college benefitted. The specialities started around 1955. The hospital was extended with the addition of speciality wards around 1963 - the foundation stone was laid by then CM Veerendra Patil who through the government donated a sum of Rs. 9 lakhs. In  1966 ,  613 IP s and 1086 OP s were treated. Private sector contributed to its devolopment in a big way- Mangalore Medical Relief Soity donated ICU and Cardiac ward. Lions Inernational donated Artificial limbs centre, Pediatric ward, Dialysis unit, Burns ward, Neonatal ward. Rotary donated the Physiotherapy centre. Infosys donated the state of the art Paediatric care facility RAPCC. Speialised machines followed - CT scan, Endoscope, Laproscope became available to the common man. Today in its 167 th year of  its existene, this landmark hospital is proudly serving many  districts of Karnataka (South Kanara, Udupi, North Kanara, Hassan, Coorg, Chickamagalur, and also some of the neighbouring states of Kerala, Tamil Nadu and Andhra Pradesh. Good service despite resource crunch has been the hallmark of this hospital. Thanks to dedicated service from the doctors(KMC as well as the Governmnet doctors), nurses, paramedical and adminstrative staff the hospital has suceeded in delivering what is expected of it.Long live Wenlock Hospital !