Saturday, November 28, 2009

Passing motions

‘Saar [slr], it is again paining’ he said.
I did not remember seeing him.
I asked him,' when was it that he last saw me’.
He said ‘five years ago’.
‘Have you brought any of my records? I asked.
‘No saar, I lost it’ he said.
‘Where is the pain?’ I asked.
‘Same place as last time’.
So here is a person who expects me to remember the place of his pain that occurred 5 years ago. I told him.
‘Sorry’ he said but won’t tell me the place of his pain.
I insist on knowing.
‘There, where I pass motions’ he said, pointing to his neither region.

This place of motion passing needs some explanation. In the heavily vernacularised English, motions mean moving the bowel and the place where this occurs is anus. So this patient is having pain in his anus.

The first hurdle in this intricate art of history taking has been won.

Now comes the next step of the battle.
‘Do you have the pain all the time or only when you pass motions?’ [I speak his language]
‘What saar?’ He asks.
I repeat he question.
‘Both times’ he says.
So he has it all the time.
I ask him, 'does it become worse when you pass motions? ‘Yes Saar, very very much, I cry and shout with pain, wife comes running.’
This wife comes running part is to impress me the severity of pain.

I am now duly impressed that this man does indeed have severe pain and needs urgent attention.

I ask him to undress so that I can have a good look at the place he is having motions.
‘Saar last time you have seen saar’ he pleads.
This man thinks that I am some super doctor who has the memory of seeing ‘his place where he passes motions’ 5 years ago.
I tell him the need to examine him again
‘Last time you give motion making medicine and I became ok. You give this time also’ [this motion making medicine is a mild laxative given in painful anal conditions and he thinks if he gets a prescription for that he can avoid the unpleasantness of examination].

Like many other young men and women he is shy to show the part. This reluctance is cultural and was much more so in the past than it is now. But I still get an occasional young man like the present one.

A see saw battle ensues with I trying to pull his trousers down and he trying to hitch them up.

Ultimately I succeed and to our mutual relief the consultation gets over and he gets his motion going medicine.

He had anal fissure, a fairly common condition and easily treatable.

On golf ball
My friend and avid golfer, Jnandev Kamath, has sent this poem. I think my golfer readers will enjoy reading this.

In My Hand I Hold A Ball,
White And Dimpled, Rather Small.
Oh, How Bland It Does Appear,
This Harmless Looking Little Sphere.

By Its Size I Could Not Guess,
The Awesome Strength It Does Possess.
But Since I Fell Beneath Its Spell,
I've Wandered Through The Fires Of Hell.

My Life Has Not Been Quite The Same,
Since I Chose To Play This Stupid Game.
It Rules My Mind For Hours On End,
A Fortune It Has Made Me Spend.

It Has Made Me Yell, Curse And Cry,
I Hate Myself And Want To Die.
It Promises A Thing Called Par,
If I Can Hit It Straight And Far.

To Master Such A Tiny Ball,
Should Not Be Very Hard At All.
But My Desires The Ball Refuses,
And Does Exactly As It Chooses.

It Hooks And Slices, Dribbles And Dies,
And Even Disappears Before My Eyes.
Often It Will Have A Whim,
To Hit A Tree Or Take A Swim.

With Miles Of Grass On Which To Land,
Finds A Tiny Patch Of Sand.
Then Has Me Offering Up My Soul,
If Only It Would Find The Hole.

It's Made Me Whimper Like A Pup,
And Swear That I Will Give It Up.
And Take To Drink To Ease My Sorrow,
But The Ball Knows ... I'll Be Back Tomorrow.

Sunday, November 22, 2009

Never say die

You read about Ratnakar Shetty and his heart attack in my last post. This time another incident involving him. As can be surmised by the previous story, Ratnakar is an avid golfer. Once, some years ago while out golfing he was hit on the eye by an errant golf ball. Instead of ducking or swaying this brave man looked straight in the direction of the shout and got hit. Despite it being a half volley the injury was severe and he was taken to the hospital for expert eye care.

I went to visit him in the hospital few days after the incident. He was sitting alone with a huge bandage that covered his injured eye. Doctors had told him of the possibility of his loosing sight in that eye and he looked disturbed. Later it proved that he retained some vision.

I asked him,’ how are you coping’?

‘They have said I can play golf ‘he said!

Here was the true spirit of golf on display. To keep the talk going, I asked him,’ when are they operating’?

‘They have told me that I can play next Sunday’ was his reply

Then on the talk centered around not his eye but on how he was going to play the blessed game and how soon after this unwanted interference in the form of his eye injury.

When I was taking his leave, he asked me.’ Doc, tell me is it true that one eyed golfers put the ball better’? Putting was a weak part of his game.

Another demo of true golfing spirit.

He got operated and returned to active golf some months later. His vision in the affected eye was poor and nothing much could be done to improve.

He met me some time later and said that he was having trouble playing because the image from the bad eye was interfering with the one from the good eye and wanted my advice. On the spur of the moment I told him the best option is while at play he covers the bad eye with an eye patch. ‘Perfect solution’ Ratnakar said.

Then on he was seen on the golf course with a black eye patch covering his affected eye! He looked quite funny with the black patch on his left eye and swinging the golf club.

He was never a great golfer. So his loss of sight in one eye did not male much difference to his game, It however provided his friends some more fun.

Mini miracle
They lived in a duplex apartment. From the base to the first floor there was flight of steps that ran up to 12 ft. On one side there is a protective railing and the other side there was a wall. The mother and her two children, a toddler of three years and a girl baby of 14months were in the upstairs bedroom, when the phone rang. The mother rushed down to answer the phone leaving the children in the bedroom and the door ajar. The toddler quietly followed the mother down. The baby crawled and walked to the railing looking for the mother who was directly below, busy on phone.

She slipped through the vertical slats of the railing and fell on the tiled floor below at the feet of the mother!

The shocked mother took the child to her doctor neighbor who advised her to take the baby to the hospital. While on their way they found the baby playing and smiling and looking quite normal. They turned around and came to see me.

The mother stood with the baby grasping the mother tightly at the chest and shoulder, turning occasionally and giving me frightened looks. The father and the toddler took their seats. The father explained the incident and their fear. By this time the little girl had lost her fear and was playing with the pencil I had given her and was trying to eat the blunt end. She had no pain, was moving her legs and arms, breathing normally, had no bruises or cuts, no bleeding from the nose or ears and had not lost consciousness after the fall.

I examined her. There was no hint of any injury. She was perfectly normal and I had to believe the parents that she had fallen from a height of 12 ft on hard floor and sustained no injuries!

If this is not a miracle what is?

This took place two days ago.

Thursday, November 19, 2009

Lucky and Daisy

Though his name was William Herbert D’souza, every one called him Lucky. I believe he had another name called Stonehead when he was young. How he came to be called by these names is interesting. When he was a schoolboy, while out playing, a coconut [a raw coconut weighs more than a kg] fell on his head and Herbert escaped with a mild bruise and continued playing. This incident made people call him Lucky and also Stonehead because his head withstood the fall of a coconut from that height! In the course of time the name Stonehead came to be used less and less and the name Lucky more and more. Herbert used to say that old timers who met with him after many years still called him Stonehead.

After school he did a stint in college and then like many of his community of Catholic Mangalorians, went to the Middle East to seek his fortune. Not only did he get his fortune in the form of a well paying job with an oil company but also got his future wife Daisy there. After thirty years of life, they came back and settled in Bangalore and became my patients.

Both Daisy and Lucky are no more and I have lost touch with the children. The story relating to the couple however is still very green in my memory. Lucky first came to me to get his pain in the abdomen treated. This problem of pain and burning he has had even when he was in the gulf [common term used when one referred to Middle East]. He showed prescriptions for antacids and acid blockers which he said gave him some relief. Those were the years when we had to rely on careful history and our own intusion to make a diagnosis. The only investigation we had was known funnily as a barium meal study. This was no meal and quite unpleasant one at that. We made the hapless patient swallow the barium liquid and took pictures of the liquid passing through the patient’s entrails. It did show if there was frank pathology like a big ulcer or a growth. More often than not, we missed the diagnosis unlike now when it has become easy to diagnose ulcer disease with wide spread use of flexible fibreoptic endoscopes.

Naturally the examination did not reveal any thing in particular and I told him the same as other doctors had done before. I gave him a prescription for the latest acid blocker and sent him home. He had told me that he was a social drinker and I advised him to go slow on alcohol as it was not good for people who had his problem.

It was only after three years and many consultations later I came to know that Lucky was addicted to alcohol. I had to make an urgent house call as his wife Daisy was unwell with a severe bout of giddiness. When I reached their house, I found her in bed unable even to get up because of intense vertigo. Lucky came to help me to make her sit up and he was close enough for me to smell alcohol. At 11 in the morning! How long had he been drinking? Is his chronic gastric pain due to drinking habit? I should ask him when he came to see me next. Third day the couple visited me in the clinic when she had become fit enough to move around. After finishing seeing her I asked him how long he has been drinking. Daisy answered,’ has he not told you? He is drinking for many years and mow he drinks in the mornings also. He hardly eats and gets angry when I tell him not to’.

The pieces fell into the place. The red flushed face, warm hands, muscle wasting and the prince of symptoms, chronic gastric pain. How did I miss the diagnosis for this long? Why did I believe him when he said he drank casually when there were tell tale signs and symptoms of alcohol abuse? I felt very bad that he would go to the extent of lying to keep this a secret. I told him so and asked him why in a pained voice. ‘Doctor, he said, I didn’t want you to join Daisy and father [his priest] in giving me sermon to give up alcohol’.

Here is a patient who doesn’t want to give up come what may. I had to do my duty. I told him the inevitable end and painted the ghastly but true picture of bloody death due to cirrhosis of liver. He heard me in silence and then said,’ I cannot sleep with out my drink’ that was easy enough to solve with a nightly dose of a sleeping draught. I told him if he tries to give up I would give him a prescription. He said he will try. His wife said,’ How many times have I not heard him say this’ he won’t doctor, you wait.’ They left with this pessimistic appraisal by Daisy.

After some months of trial and trabulation, Lucky gave up his drinking altogether! His gastritis disappeared and his liver recovered in about six month’s time.

Things thus stood for a couple of years and it was a pleasure to see Lucky in such good health. Then came the unexpected shock. Lucky came in one day and said,’ doc, please come home with me. Daisy is very sick’ I took my bag and went with him. On the way he was unusually silent which I attributed to his worry. I too did not speak much. We reached home and I went to their bedroom where Daisy lay breathing deeply and in some kind of a semi coma. The whole room reeked of Gin. Who has been drinking? I looked at Lucky, ‘not me, she’, he said’ pointing to the prone form. I examined her and found her in no danger and she would come out of her alcoholic stupor by evening. I told Lucky as much and asked him,’ since when she has been like this?’ He said since his recovery.

As long as he was drinking she was busy looking after him and getting him to stop drinking. After he gave up she had no purpose left and with gin handy she took to serious drinking and never even once came to see me. Was there something more that went on between them that I was not privy to? I don’t know.

I tried my best to get her off the habit. A A, Antabuse, psychiatric help, you name it, and she gave it all a try. She made many promises but did not keep them. The down hill course was rapid. She died of cirrhosis of liver with in five years. Lucky survived her by a few more years and died of a stroke.

Sunday, November 15, 2009

Lucky escape

‘Can any one have a heart attack and recover with in an hour?’ Ratnakar Shetty asked.
I did the mistake of telling him no.
‘I have’ he said.
This was becoming interesting. I asked Ratnakar who has been a friend and an occasional patient of mine for many years, ‘How do you know?’
This Ratnakar Shetty has a number of close relatives who are doctors and he gets free advice and treatment.
He rarely has to consult a doctor out side this immediate circle. When ever he does so it is for either third or fourth opinion and I am one of these.
‘The doctor told me’ he said.
‘Which doctor, you nephew?’ I asked. I knew one of his nephews who practices close to his house in the other end of the city, to whom Ratnakar usually goes. I thought he would have gone to him.
‘No, No, not my nephew, this happened in the middle of the night and I phoned him [his nephew] and that fool told me to go over to the hospital and see a cardiologist. He said it is a waste of valuable time coming over to see me.
‘So what did you do?’
I drove over to the hospital he said.
‘You drove? I asked him, a bit surprised that a patient who was having a heart attack could drive.
‘Yes, who else will drive and take me at the dead of night’ he said. ‘Why did you not call an ambulance?’ I asked. ‘I wanted to save time’ he said.
This of course was true but I still could not stomach his driving to the hospital in pain.
I asked him, ‘did the pain not bother you’?
‘No, there was no pain, by then Brufen had taken affect and I was pain free’. His wife had given him Brufen, a pain killer, as soon as he complained of pain.
‘So you went to the hospital.Then?’
Then what? One young fellow [young doctor] made me lie down took an ECG [electrocardiograph] and took some blood and told me that I have had a heart attack and wanted to admit me.
‘Did you?’
‘No, Don’t I know you doctors [I did not like him including me] I told him no admission gidmission for me, as I was feeling good’.
What did that doctor do? I asked
He was insisting and wanted to call a cardiologist to put a tube into my leg artery [a procedure called angiogram] he said pointing to his groin. ‘I told him I am going home’ Ratnakar said.
He [the young doctor] would not let me. He wrote a letter, ‘discharged against medical advise’ and made me sign and then he let me go.
‘So, you came home’.
‘Yes I drove back home and slept nicely and next morning I went to office’
.Then why did you come here? I asked
‘All because of that nephew [doctor] of mine’ he said.
‘What did your nephew do’, I asked
‘He took me to a cardiologist after three or four days and that man wanted to again admit me and do this test [putting up a tube into his groin artery]’.
‘And you refused,’ I asked him
‘Yes, I did’
‘Because I felt well and I had played golf the previous day,’ he said.
Now even I began to wonder whether the doctors were right. How can a person who has had a heart attack two days earlier, go and play a full round of golf?
I asked him why he did that.
‘Why not? I already had fixed the fourball and did not want to let down the partners, I am sure you too would have done as I did [again he included me against my wishes]. Knowing how crazy golfers are and the important place this game occupies in their lives, I could understand him going to play but not when you have just had a heart attack.
I told him so.
‘That is why I have come to see you. You look at these reports and tell me what the truth is’.
I had a look at his reports. There was no doubt about his having had a hear attack. A fresh ECG done showed an infarct well on its way to healing. I saw no point in restricting his activities ten days into recovery.
I told him that he was one of the lucky few who did well despite the doctors.
He came four weeks later and the stress ECG showed good effort tolerance and he did not really need any further intervention. He did well and it is nearly ten years since that episode and he has had no heart related problems.

Wednesday, November 11, 2009


Perisamy Gounder was not a regular patient of mine. He came to me when his own doctor, a senior general practitioner in the same area of my practice was not available. This doctor, Dr G was in his sixties when I began my practice and was well known and I would spend time with him when ever I found some time. Though I did not get any value from the point of improving my medical knowledge, I gained a lot by the way of improving my patient management skills from him. He too came to like me and after few years he told his patients to seek my help when ever he was out of town. That was how Perisamy came to see me. The first encounter with Perisamy was memorable in more ways than one.

This middle aged well dressed person asked me as soon as he came in, by the way of confirmation that he has come to the right doctor,’ Are you doctor Rao, Dr G’s friend?’ this he did in Tamil. I said,'yes' in the same language. ‘I need to take this injection’ he said, placing the vial on my desk. I looked at the injection vial. It was 400,000 units of penicillin. I was curious to know why he needed this injection and I asked him. This irked him a bit and he said with obvious irritation,'nee chumma kudayya’ [you can interpret this Tamil sentence as simply give it to shut your trap and give the injection]. Seeing me hesitating, he said Dr G gave him this and he has come here because he was asked to by the old doctor. This meant many things. One is that he would not have otherwise come to me and gone elsewhere to a more senior GP who did not ask stupid questions to that by hesitating I am not sincere to the old doctor’s advice.

I thought it better to give the injection as advised by my senior friend and ask him [the doctor] on his return why and what of this. I loaded the syringe and gave him the shot. Perisamy became very friendly and jovial after this and appreciated the old doctor and told about his friendship with him of over twenty years and took my leave with the parting advice that as a young doctor I was lucky to have won the confidence of the senior man. The fee he paid for that small service was more than what I made from seeing five patients!

Dr G duly returned from his holidays and I made one of my periodic visits to him. I asked him about Perisamy, the injection and his reluctance to tell me why he was taking the injection. The good doctor let out a loud guffaw and said,'keep this to yourself, this Perisamy is a wealthy industrialist from Coimbatore and comes to Bangalore fairly frequently. When ever he is here he sees a woman and spends time with her. The reason for taking the injection is prophylaxis [prevention] against Venereal Disease but he is a good man', the old doctor said as an after thought.

So that was Perisamy’s secret. I could now understand his reluctance to share this secret which he had shared with his own doctor of many years. As I grew older and [wiser?] I too became privy to many such secrets and learnt to keep them to myself and also became less judgmental.

Both Dr G and Perisamy are no more.