Wednesday, January 26, 2011

Another giant goes

On an earlier occasion I had written about Gangubai Hangal and the loss I felt on her death [Death of a Doyenne, 28, July 20009]. Now I am writing about another maestro of Hindustani classical music who passed away three days ago. Collectively as a nation we have not achieved a great deal but have managed to throw up men and women of extraordinary talent and achievement. One such was Pundit Bhimsen Joshi.

Joshi was blessed with a rich voice over which he had extraordinary control. He would hold his listeners spell bound with his mastery over the various nuances of construction and delivery of the various ragas sung in the style of Kirana gharana. Many would be found with tears while listening to him, immersed in musical ecstasy. He was a simple man, who enjoyed life. Liked his drink, food and fast cars. Honors came to him aplenty including the nation’s highest, the Bharat ratna. Last few years of his life were not easy as he was very ill and his last performance was some four years back.

It is worth relating an interesting and unexpected encounter I had with him ten years ago at Mumbai. Four of us, all doctors had gone to Mumbai to attend a medical conference and stayed at a guest house. I was the medical advisor to the company which owned and operated the guest house. The major domo who managed the guest house was a Ghurka [native of Nepal]. When he came to know we were doctors he treated us with special attention and took lot of trouble to make us feel at home. The guest house had three rooms reserved for us for two days and we reached the guest house in the evening and made ourselves comfortable and after some light reading I went o bed. Around 1 am in the morning the major domo knocked on my door. I opened the door and asked him,’ what is the matter? Normally when a doctor is woken up at night there usually is a medical emergency. But this was none of that kind.’ Saab, [sir] some old singer [contempt in his voice] has come, says he has room booked here, office has not informed me’

I went to investigate. I saw the regal [he was a big built guy] persona of Bhimsen Joshi sitting with a glum face. There were flowers and mementoes placed on the next chair. There were few persons standing. These were his escorts who had come to see him safely home after the concert. It must have been galling to be told that the room meant for him was occupied by someone else. I was over whelmed and felt pretty bad that due to some ones error he had to suffer. Apologizing on behalf of the company, I requested him to take my room and I would move out to another one occupied by my friends. He appeared none too happy but I gave him no option and moved my belongings as quickly as possible, woke up my friend and slept on the floor of that room.

It must have been an hour or so later, there was another knock. I was barely asleep. I opened the door to find the major domo again. He said,’ that old singer [gayak] must be mad, he called some chela [disciple, friend] and he has gone away, he has asked me to get you back to the room, saab please come back’ He [Joshi] must have felt bad at disturbing me and had found alternate lodging. Not difficult for him considering the number of admirers he has all over the country. Many would consider it a privilege to host him.

I lost an opportunity of interacting with him at next day’s breakfast. But the ignorant Ghurka was full of apologies and criticism for the company which gives room to all kinds of musical riffraff and wanted me to inform the management not allow this sort of persons in to his esteemed establishment!

Thursday, January 20, 2011

Counting my blessings

It is not always that I am depressed, living in India. With all the faults which I have been enumerating and boring you all with, I have one major reason to be happy. I have freedom of expression. I can say what I want without fear of reprisal. I can also live the life I want to live. Being a born Hindu helps. Neither the state nor the religion forces me to conform. I can dress the way I want, eat what I like, drink what I want, visit or don’t visit a place of worship, I can criticize my gods for their follies and still live fairly peacefully doing what I want to do.

I have Muslim patients/friends who have close relatives in Pakistan. Pakistan is India’s sibling though many in both countries want to deny this fact. People share lot of common features and most of north Indians and Pakistani’s are from the same ethnic stock. India chose the democratic way of governance [or non governance] whereas Pakistan chose Theocracy based democracy. This did not work and over the years the decline of governance and domination of religion over democracy has become overwhelmingly oppressive. Descent is dangerous and nonconformists pay with their lives as it happened to Mr Salman Tasser, governor of Punjab, who was killed by his own body guard. Worse, there were celebrations and the killer was hailed as an upholder of Islamic values. Frightening, isn’t it?

My Muslim friends here are happy to be in India with all her faults. So am I, when it comes to final reckoning.

Loose motions Leela

‘I am your old patient, Mrs. Leela’ the voice said at the other end of the phone line. Here old patient means not elderly but patient of some years standing. Leela is a common name and my practice has its quota of Leelas. I couldn’t place this Leela by her voice. The silence must have made the lady realize that I was finding it difficult to place her. She said,’ I am loose motions Leela’. Here what she meant was that she has had loose bowel movements which I had treated her for some time back and she expects me to remember her. This gamut too failed because I couldn’t remember any Leela who took treatment for diarrhea recently. My memory too is not that great and that adds to the problem. I said so to her.’ No, No, your memory is OK, I came to you three years ago for the problem and you cured me’.

‘What is your problem now?’ I asked.

‘Same, I have loose motions again.’ She replied.
‘Why don’t you come and see me’ I asked her. ‘You are too far away from where I live and I am afraid to travel’. This is a genuine problem. ‘Why don’t you prescribe some medication on phone which I can try?

I told the name of a commonly used drug which is given for infective diarrhea. ‘Doctor, I have already tried it, it is of no use, she said. ‘Who gave the prescription’ I asked’. ‘Dr S did one week ago’, she replied.

Dr S is a practitioner in her area. ‘Why don’t you go to him and tell him you are no better?
‘I did and he scared me, he wants me to go to hospital and get colonoscopy done [colonoscopy is passing a fibreoptic soft tube up the lower intestine and seeing the innards. Usually done when one doesn’t know the cause. In advising her Dr S was not wrong. I told her that.

‘But you cured me last time, I had the same problem’. She would not leave me in peace.
‘What was the treatment I gave you? Do you have my old case notes or prescriptions? I asked her.
She said, no and insisted that she come and see me.

She gave me no options. I agreed to see her and to see that she does not have any mid journey crisis, gave her a prescription for a bowel slowing drug and asked her to see me next day.

She came in next morning with a put on smile as though she was my long lost friend. Three years is a long time to remember a face for a person whose memory and recall is none too great. I still could not place her. Now she has got me it no longer worried her. She has been having these bouts of diarrhea which lasts from a week to two weeks and she gets better after taking medication with local doctor [meaning the hapless Dr S]. This time however she is not better despite his medication which she took for more than a week. The prescriptions she showed me had most of the common antidiarrhoeals.

Here was a problem. Could she be a diabetic and could this be a rare neuropathy due to diabetes? Sometimes these wild hunches of mine do work. She said she was not a diabetic but she has Gout and takes medications and before I asked her she said Dr M [M is a doctor who specializes in joint ailments] has asked her to take the drug for life. I asked her the name. She said goutnil. Goutnil is trade name of a drug called colchicine given for acute attacks of gout and certainly not to be taken for life. ‘How many tablets a day you are taking? I asked. ‘Three, that too when I have severe pain, when not in pain, I take one and sometimes none’. [Not really following take for life advice]

Here was the diagnosis. Gout causes severe pain and swelling of the small joint of hand/feet. The preferred joint is that of big toe. Colchicine is a very good drug to manage acute attacks but to prevent recurring attacks another drug called allopurinol is given, sometimes for life. Colchicine in many patients causes diarrhea. In Loose motions Leela’s case, likely culprit.

‘Did Dr M tell you to take it for life? I asked her.

She was silent for a while and said,’ Dr M gave me this drug to take for two weeks and then come and see him. It is very difficult to see him, he has a nasty receptionist, and getting appointment is difficult. So I asked my cousin who also has gout. He takes medicine daily and his doctor has told him, it is for life. As I also have the same problem I too thought it is for life’.

The patient who came in for intractable diarrhea ended up getting advice on management of gout. She stopped colchicine and her diarrhea disappeared.

It is six months since her visit and there has been no call and hopefully both her gout and gut are quiet.

Thursday, January 13, 2011

Kidney tray

Some years back, Bangalore achieved the dubious distinction of being the capital of clandestine kidney transplants. New and stricter regulations have made the procedure more transparent now. Those days the kidneys were procured for a price from poor donors. Slumlords were known to even coerce people to donate their kidneys for a commission. There was a lot of hue and cry in the press and surgeons too came in for a fair bit of justified criticism. There were widespread rumors of kidneys being removed from ignorant poor who got admitted for some other reason. This was the atmosphere prevailing then in the city, when this incident occurred in one of the hospitals. The patient was admitted for a minor procedure of draining an abscess [collection of pus].This was being done under local anesthesia in which the patient is conscious but doesn’t feel the pain in the place of operation. The surgeon after giving the local anesthetic proceeded to incise the abscess. No sooner he inserted the knife, a stream of pus welled out of the cut. To prevent spillage, he told the nurse with some urgency,’ quick, get me the kidney tray.’ The horrified patient jumped and ran out of the room. It took the combined might of three attendants and the surgeon to convince the patient that kidney tray is the name for the receptacle and it is not a tray to hold the kidney and to get him back to complete the procedure.

The word went round to all Bangalore hospitals not to mention the dreaded word in front of conscious patients undergoing procedures!

In the eyes of the beholder

I have a close friend living abroad. He did not make a very successful marriage but got along with his wife. They make frequent visits to this country and used to visit me. Whenever I went abroad, time permitting, I too visited them. Often there was trouble between them and knowing my friend, despite trying to be neutral, I tended to take his side. Or so the lady thought. She may not have liked me but managed to be nice because I was her husband’s friend. On one occasion when I returned to Bangalore after spending some time with them, I got an e- mail from her, which read, ‘you were looking haggard and worried’ hope you are alright’
This came as a surprise, because I had never felt better at that time and was in best of my spirits. Then how did she get this impression? I wrote back in all earnestness, ‘looks are in the eyes of the beholder’. That was five years ago. Madam has neither seen me nor has spoken to since. My friend did see me once three years ago, but has not seen or written since then. My mails too have gone unanswered!

Tuesday, January 11, 2011

Irresponsible statement

A gentleman who was my patient and whom I will call Mr D, suffered from high blood pressure and his exercise test for ischemic heart disease was positive at high exercise levels. Every year it was the same. We, the cardiologist who saw him and I refrained from doing any further tests on him and explained to him the pros and cons of doing an angiogram and the option of medical treatment was best for him. He came periodically for his blood pressure check and other sundry ailments. One day he developed prolonged chest pain and over the phone I advised him to seek help from the same cardiologist who had moved to another hospital which was located some distance away. Mr D decided to go to the hospital closest to him and met another cardiologist who correctly diagnosed a developing heart attack and proceeded to an angioplasty and stented the obstruction. So far so good. He did however made one remark which destroyed the relationship between Mr D and I, built over 15 years. He said to Mr D, ’you should have got this done many years ago’!

He [the cardiologist] did not bother to go through the case notes and earlier records made by me nor did he have the curtsey to talk to me [he did not know me then]. The patient who was in distress believed in what was told and not what I have been telling him. Later on, when I came to know this young cardiologist, I told him the damage his remark had caused. He of course was contrite but the damage had already been done. I lost that patient and it is three years since the incident. I came to know of the story by one of Mr D’s friends.

Cut your balls off

Advertently or otherwise we cause problems to others by passing some comments or making some remarks. This happens more often than not with us doctors. Sometimes it is due to difficulty with language and sometimes, due to sheer irresponsibility and occasionally, it is due to how the patients/friends interpret the remarks.

Years ago, when I was a medical student, there was a teacher of surgery. We had a patient who had a painless swelling of his testicle. The surgeon made all of us examine the patient. We were some ten students, and all of us examined him. The discussion that followed was in the language of instruction, English. The final conclusion was that he patient had Hydrocele, a simple problem easily curable by a simple operation. When all this was going on the patient, whose mother tongue was Malayalam [language spoken in the state of Kerala] and who had no knowledge of English, was looking at us with some degree of panic. Seeing him thus, the surgeon who knew some Malayalam told him in a tone of assurance, 'don’t worry, you are going to be alright, I will just have to chop of your balls.’ What he meant was, that he will make a cut and drain out the collected water. But when he said the same in Malayalam, it appeared as though he was out to castrate the poor guy. The patient broke into a sweat and fell at the surgeon’s feet requesting him to do no such a thing and to discharge him and allow him to go home with his balls intact. The surgeon was very surprised with this show of ingratitude. He said again in Malayalam, 'my dear fellow’ why are you so worried; I am just going to cut off’ [meaning make a cut]. At this, the patient began to cry.

One of the students whose mother tongue was Malayalam came to the rescue of both the surgeon and the patient and explained the intent and the surgeon understood the blunder inadvertently made by him.

Thursday, January 6, 2011

The 19th Hole

The game of golf is played over 18 holes and it takes 4 to 5 hours to complete. At the end there is the 19th hole which some call the watering hole where the victors and the vanquished gather either to celebrate their victory or drown their sorrows. Many golfers value the time spent on this hole more than the time spent playing the 18 holes.

Apart from the discussion related to golf the conversation can be on a wide range of subjects and like all sports persons, that too over a drink, the pride of place is for talk that makes one laugh. There are some who are born wits and few other have a big collection of stories and jokes and they can recall and at the appropriate moment. One such is a fellow golfer and 19th hole specialist, Mr B.N.S Reddy senior.

The following is what I heard from him last week end.

The anatomy professor was taking his first demonstration for the new batch of medical students. The fresh and uncut formalin reeking body was laid in front and the prof spent time impressing the students on reverence with which one should treat the dead body which is going to give them so much of knowledge and also the importance of keen observation in learning medicine. Then he proceeded to do a strange thing. He inserted a finger into the anus of the body and put the finger inside his mouth. This act, the students thought, was his way of showing respect to the prospective dead teacher, though a bit strange. But what followed was even worse. He asked the students to do the same one by one. Very reluctantly one by one, all the students did what he prof did.

The professor said after this ceremony of finger licking was over. 'Ladies and gentlemen, as I said earlier, in medicine, observation is very important and I am sad, none of you observed what I was doing. I inserted my forefinger but licked the middle’