Hot tea and chest pain

Mr Ramesh is a good friend and also a patient, a dreadful combination. He came to me complaining of chest discomfort and insisted that it was due to drinking scalding tea that morning. Ignoring his diagnosis, I started asking him the usual questions we doctors ask to exclude pain due to heart disease. Where was the pain, did it go up to the neck and down the arm, was there any sweating, how long did it last, etc.

When I was asking these questions, he sat there giving me a bored look. I knew what was going on his mind. ‘I came here with some trivial problem and this fool is asking these stupid questions’. He looked at his watch twice in those few minutes I spent trying to get a proper history.

Despite his protests, I did a cardiogram. The tracing showed severely compromised blood supply to a portion of the heart. I explained the gravity of the problem, gave him a note for hospital admission, called the cardiologist friend of mine and sent him on his way.

The same afternoon I went to the hospital to see him. I went directly to the coronary care unit. I did not find him there. Then I went to my cardiologist friend to find out what had happened. Before I could open my mouth, he asked me, ‘where is your friend?’ Having made sure that he was not in the hospital and worried, I called his office only to be told by his well-meaning secretary that he was fine but in a meeting and would I mind calling him after an hour or so? The knowledge that he was alive was reassuring but all the same the worry was no less.

I went to his house to apprise his wife about the serious nature of the problem. I found her having her prized afternoon siesta. After I finished my tale regarding her husband’s erratic behaviour, she gave me a splendid piece of advice. ‘Doc, you always worry too much. He gets these pains after drinking hot tea. You have advised him to stop this bad habit [I did not remember this piece of expert advice having been given] and if he does that, he will be OK, you wait and see!’ I requested her to please send her husband to the hospital with out wasting any more time, drank the cup of tea which she had made and returned home thoroughly depressed and worried.

Are you wondering what happened to my friend? He didn’t want to go to the hospital, especially when all the pain had gone and he felt very good. He made an uneventful recovery. His subsequent ECGs showed a small scar and his treadmill test came back negative. According to his wife, he gets no chest pains now because he has stopped drinking hot tea. No credit whatsoever to the poor me who spent several sleepless nights and anxious days looking after an unwilling and, I suspect not very grateful patient! Even now he says he takes the medicines to keep me in good humour!

This true life story I wrote several years back. This episode illustrates the fact that many patients do well despite us doctors.

Count Narayan Rao

Both Narayan Rao and his wife are no more. Count died many years ago and madam Rao a few years ago. They had lived not far from my clinic and as Count had many health problems, I was a frequent visitor to their home. He very rarely visited my clinic and would joke with me,’ If I came there, I would get some more illnesses with all those patients there coughing and sneezing.’ This opinion I shared with him and have often marveled at the very few times I have fallen ill considering the number of times and patients with infections that I am exposed to over the years.

Narayan Rao, when he passed away was in his early seventies. He was related to a classmate of mine and that was their reference to see me. He had retired from a corporate executives’ job, but the habits of corporate life remained with him. To look at, he was a tall fair and handsome man, with a red, florid face. He spoke with naturally accented good English. He reminded me of characters I had seen in the movies and read in Wodehouse novels and that is the reason why I came to call him Count Narayan rao. In the course of our brief association I came to call him simply as count.

I looked forward to the visits I made to his home, because I never returned without feeling good and happy after the visit. The reason was not money. As a matter of fact because of the close relationship I did not take any fees from him. The feel good factor was the man himself. He enjoyed life and wanted to share his enjoyment with others which happily included me. He suffered from diabetes, has had several heart attacks and was in early chronic heart failure. But the disease that bugged him most was Gout. I used to make fun of him that he had a rich man’s disease [Gout affects royalty more than others is the popular notion]. Narayan rao was not rich but he led a rich life. Both of them were socialites of the then Bangalore and often they would be out of home attending this party or the other, despite his sickness.

Out of necessity he had to take multiple drugs and that included anti gout drugs. Like it is now then too, the treatment of acute gout was with either colchicine or Indomethacin.Count did not tolerate colchicine so I had no option but to give him Indomethacin, a toxic drug, especially given his other problems. Naturally my prescriptions were niggardly and never more than ten tablets at a time.

Once Count became breathless and I had to rush and see him. His wife was not at home and count was alone and with great difficulty he came and opened the door for me. Then he went back and lay down on his bed. After examining him I found his lungs filling up and wanted to know how much of the prescribed diuretic he was taking. He said he did not know but directed me to the cupboard where his records were kept. I opened cupboard and found a mini pharmacy there along with my notes in one of the drawers.

After giving him an injection of a diuretic, I returned to the pharmacy. I found lots of drugs which he was taking but not prescribed by me, and also several strips of Indomethacin. How did he get hold of this many tablets and has been using them without my knowledge?

I was very worried not only with the toxic Indomethacin but also the variety of unnamed pills and tonics many of them belonging to the class called herbal medicines. The injection had the desired effect and in a short while his breathing eased off. I asked him, He not only agreed that he took the tablets liberally and stocked them as they gave him very good relief. Sometimes he took three to four of them in a day. Horror! This despite my very clear instructions to the contrary. I was so upset that I had to admonish him, out of respect for age rather gently. He said,’ it is I who gets the pain, not you’. For this, I had no adequate repartee, so I kept quiet. After a while I asked him, how he managed to get the tablets without a prescription? He said it was very easy. He tore a white paper out of his letter pad, cut out the portion that had his printed name, wrote out Narayan rao and age and below which wrote the trade name of the drug and the required quantity. Signed my name underneath! He said no druggist has ever refused him so far! He felt no guilt what so ever! This reminded of my old pharmacology professor who used to say, ‘in this country committing suicide is very easy, you just have to go to the nearest chemist’

I stopped all the herbal medicines and told him how this over dosage of Indomethacin was having an adverse effect on his heart’s condition and his diabetes. He became less liberal in the use of that drug. Whatever may be the reason, his condition improved and he lived a few more years and died ultimately at home with chronic heart failure, in my presence.

Few days before his death when I was there with him, a party of his socialite friends had come to see him. By then the news of his seriousness had spread. When they were leaving, count called me aside and pointing to one of the women, whispered,’ that fellow with her is her third husband; I hope she will not have a fourth one’. His wit never left him, so was his jest for life.

Congratulations Obama

The skinny kid with a funny name has done it! Barak Hussein Obama has become the president of the Unite States of America.

The last time I remember being this happy and excited was when the low profile, utterly honest, sincere, able and who went unsung, our own Lal Bahadur Shastri , was elected prime minster of India some 45 years ago. He was probably the ablest prime minister we have had. That Lal Bahadur lived only for two years as prime minister was a major tragedy for our country.

I wish President elect Barak Obama a long and fruitful life in the service of not only Americans but all of us in this troubled world.

Lastly, to those of you, Americans, who read my appeal in my blog and voted for Barak Obama, my special thanks.

Watch Dog

My friend has a Doberman pet dog. He is peculiar in his behaviour. Unlike the other dogs of his breed he welcomes guests with a whine and a vigorous shake of his head and tail. When he sees any one from the house hold leaving the house he gets upset and starts barking. If you consider my practice as home and my patients as family members and I as Doberman pincer you will be able to follow what follows. Like my friend’s Doberman I too fail more often than not and the reason you will know why if you read the next few lines.

Most of you watch television and newspapers and you meet friends and relatives. Subject of health, doctors and hospitals is a favorite topic of conversation. Morbid details of someone’s illness and death make very interesting topic of conversation as the conversants are not involved. But there is a lurking fear that they would be the subjects of such conversation at a later date. Then how to avoid this fate? Many believe that periodic testing [called whole body testing in their language] will tell them if they are fit or not. Little do they realize that these tests will only reveal that the tests are normal but will not tell them if they are normal or not. Thus this rush to get annual or bi annual tests done is thoroughly uncalled for and it has become one of my primary duties to prevent my patients from indulging in this foolhardy and expensive venture. Am I successful? Sadly, no. The media pressure and the false propaganda by the interested parties are so strong that I am like a Poodle facing of a pack of Pit bulls.

The other fad is running to consult specialists. This is another foolish and unhealthy activity. We call this compartmentalized medicine. The body is divided into several compartments and each compartment has a specialist. Heart has one, brain has one, nose has one, stomach has another and the list is growing every day. As the joke goes, a patient went with a stuck cotton bud in his left ear to an ENT [ear nose throat] specialist. That specialist refused to see him because his specialty was right ear and not left. It is my lot to see these unfortunates after they do the rounds. A person with chest pain would have gone to a cardiologist and finding nothing wrong would then have gone to lung man and then to a stomach doctor [some times stomach illness can cause chest pain] and then to a psychiatrist [if there is no cause that the other specialists can find, then, there must be something mentally wrong with the patient] and then he deems fit to see if he is lucky, a family physician. He may find the cause to be an injury to the chest wall. Supposing he had gone to the family doctor in the first place, if he [family doctor/General practitioner] had not found the cause, he would at least know where to send him. He would have saved the patient lots of money and head ache.

Another is the health insurance racket. A person who has healthy habits, who takes regular exercise and eats moderately, remains healthy well into his seventies. So why does he have to take insurance? The same premium money he can save up and invest or keep it by instead of loosing it every year to keep the insurance company happy. If you are unhealthy you will not get insurance or there will be an exclusion clause any way. Older people who really need insurance do not get it as they run a high risk of illness and therefore are not profitable for the insurance companies. The whole gamut of insurance business runs on one factor. That is fear.

Recently I have had an occasion to visit a hospital and spent some time at the reception where the patients are initially confronted. One of the first questions asked is whether you have health insurance or not? Why is this question? Will this mean that you get better attention? Certainly not. It will mean you go to a separate bracket where in your charges will certainly be higher. This is my hunch. So I advise my patients to put by some money each month and invest it. When the time comes when you are ill needing hospitalization [which never comes to most as death comes unannounced for many of us who are blessed] mostly in your old age, you have enough to take care of your expenses. Most insurance companies also have a ceiling beyond which they will not pay. In this game the insurer is not the winner; the winner is the insurance company. Do I succeed? You guessed it right? I do not.

I find a large number of my patients swallowing daily, potions of vitamins, tonics, A to Z [there is actually a name like that] minerals, health restorative oils, health foods. Again all of this is utterly useless stuff. But do they listen to me? Yes, they listen but don’t follow.

What is the solution to these problems in the community? Find a good watch dog and look after him and listen to his well intentioned barking.

Sahib's constipation

Before we became independent, the British ruled us. There are many opinions as to the way they managed the affairs of the nation. But it is generally agreed that they did a fairly good job of administering this large country. This is especially true of the young officers who managed the districts and talukas. These men were fresh out of their home country, after the initial training, were posted to isolated places, thrown into a culture and people far removed from their own and yet they managed to serve the population as best as they could. They also wielded enormous powers over the subject population under their care. The following story is that of one such young officer.

He liked the country and the people and enjoyed the reputation for being fair and honest. He had to work hard to know his people and to do this he had to tour extensively. Some towns he could visit in his car but often he had to go on horseback. He would start early in the morning after his breakfast and return in the evening. Often he stayed on the outskirts of a big village in a specially designed tent.

There was one blemish which often ruined his otherwise healthy, fun and adventure filled life. He suffered from constipation. Often, days together his bowels bottled up. Help from the civil surgeon who was a fellow white made matters worse. Consultation with local varieties of doctors of different disciplines too did not help. Each morning the young sahib would wake up and wonder what is in store for him that day? If he had a bowel movement, his day was made, if not he would remain grumpy till the next day and wait.

One such morning after having failed to get his bowels move, he gave up the attempt as it was getting late for his rounds, had a hurried breakfast, and left with his driver, attendant and the office clerk who carried the relevant records pertaining to the villages the sahib would visit. The attendant carried Sahib’s Lunch and other requirements. The journey began. They must have gone a few miles when the Sahib started getting strong bowel contractions. This made him feel good. He asked his driver to stop the car at the nearest water body and urged him to hurry.
Soon they reached a bridge with a stream flowing underneath. Sahib got down and having collected his all purpose mug, hurried down to the bank of the stream. He undid his trousers and sat down for the much awaited evacuation. Alas! The strong and urgent contractions disappeared as suddenly as they had appeared. This was no uncommon experience for the Sahib. He knew that if he waited long enough he would get the contractions again and his bowels would move. So he sat patiently with his trousers down. But he kept his solar toupee on to guard against the sun.

He must have waited for ten minutes when he felt a soft thud on the toupee and a splash of gluey muck which splattered down. He looked up in time to see a native hurriedly scampering down from his perch on the side wall of the bridge. Unmindful of the state he was in, the Sahib shouted,’ catch the bugger, don’t let him go, I come up and take care of him’

The witnesses to this awful spectacle, the attendant and the clerk who were sitting by the side of the car ran and were able to stop the shivering native who by now had become aware of the enormity of his offence. He begged for mercy from the Sahib’s assistants who by virtue of their proximity to the Sahib were in themselves were frightful figures.

By now, the Sahib, came panting up the slope without his toupee and shirt which he had thrown into the stream and washed off the gluey muck off as best as he could. He saw the poor villager being beaten by his attendants. He asked them to stop and went to the shaking and shivering and thoroughly frightened villager who stood with folded hands, fear and despair writ large on his face. No sooner the sahib came near him, looking at the half naked white apparition the villager was overcome with intense fear making him fall on the ground begging forgiveness. Sahib asked him to get up and said, ‘hell with your apology, just tell me how you managed to do the job so quickly’.

Rest of the story is irrelevant.

Sarosh Patel

Some weeks ago, I wrote about my primary school teacher who was responsible for some of the interests I developed later on in my life. Sadly the next fifteen years including the five years I spent in medical school, none of my peers, teachers and professors included, made much of a positive impression on me. Many of them were good teachers but none really enjoyed teaching or helping us out to understand the relationship between illness and patient. May be I am biased, but it was truly a disillusionary period, those five years were, in my life. All my ideas of nobility and sacredness attached to this profession disappeared when I saw firsthand what was happening in the hospital and college. Add personal, emotional and financial difficulties to this and you realize the dismal life I led.

I only realized what a fascinating profession medicine is, when I got out of medical school and began working in the wards as a houseman, directly involved in patient care. I was extremely fortunate in having a rare human being as my mentor. He was late Dr Sarosh Patel. Sarosh was only a few years older to me and worked as a junior doctor preparing for his post graduation in medicine. He was a hugely built man, fair as Parsees go, already balding and had a regal air around him. I was reedy, pale, and ill dressed, always ill at ease and thus we made a contrasting pair. I was fortunate that Sarosh took me under his wing and taught me the basics of patient care. He was a contrast to the boring teachers who made teaching disease centric where as Sarosh’s methods were patient centric. It is from him, for the first time I learnt that the patient was not a collection of organs, that he is ill not for our benefit and that every illness had a socio psychological background to it. Punctual, hard working, he still found time to teach me, sometimes late into the night when both of us were on duty.

He had a very bright future ahead of him. But he did not live long. Within a year of my coming to know him, he died of a brain tumour. I was told even when he was a patient at the Tata memorial at Bombay he would help in the treatment of other patients. Such an extraordinary man was Dr Sarosh Patel. My contact with him was a brief one year but I rate him as one of the finest doctors and human beings I have come across, and now after a lapse of forty-five years, I still grieve at the untimely loss.

Injection mania

Over the past 35 years the attitude of patients to illness has changed. Much of this is towards the better. They now realize the importance of diagnosis and don’t insist on immediate relief. They also have realized the importance of investigations in the management of illnesses. Many have taken to exercise and prevention of disease has its due place in patient care. Despite all this, one obsession remains strong. This is the love for getting injected. The belief that medication given in the injection form is better than oral form still remains strong. This is more so with the lower socio economic sections of the population though an occasional educated upper class patient surprises me by requesting an injection.

This reminds me of an episode which occurred more than 30 years ago. The middle aged man came in supported by his son. The complaint was pain in the low back radiating down the leg. Diagnosis of disc prolapse was fairly easy. Those days we made the patient’s life miserable by confining him to bed for three weeks with the additional insult of taping the leg and attaching a weight which dangled from the edge of the bed. This we thought provided the required traction and imagined the disc would slip back into place.

We also gave liberal doses of pain killers and the prince amongst these was a drug called ergapyrin [butazolidine], a highly toxic drug but quite an effective pain killer. Adding insult injury we gave this drug in the injection form which meant a house call every day. This kind of activity took most of our time. I tried to be an exception and told this patient the illness takes three weeks and he can be managed with oral medication. He would have none of this and insisted that I give him an injection to relieve his pain for the moment and later he will try my oral medication. Very reluctantly, I prepared an injection of butazolidine and proceeded to inject this into his hip. The patient stopped me and asked what was I doing? I explained. He said that is not the place to give the injection but to his leg [he showed me the calf muscle] where there is maximum pain. My reasoning that the best place is the buttock muscle fell on deaf ears. He said his own doctor always gave the injection to the part where it hurt most and it had produced the best results.

My refusals made him tell his son, ‘let us go back home and wait for Dr----- to come back’. I lost another patient. Those days I lost two patients to every patient gained because of my methods were contrary to prevailing practices. Situation since then is better but the love for injections still remains.

Taking people for a ride

I have on occasions written about the futility of yearly screening for healthy persons. But the practice is becoming more rampant as the years go by, screening must be selective and the physician should decide who should be screened and who should not be. Young fit men who have no history of heart disease are subjected to a variety of tests which includes a hemogram, urine test, Liver and kidney function tests, blood test for lipids and sugar, Lung function test, a treadmill ECG and a resting ECG, Echocardiogram and chest X-ray. Package deals are touted in the lay media and even on television. The latest gimmickry is the laboratory/ Hospital going to the person’s residence/ office to do these mostly useless tests. If you don’t come to me I will come to you seem to be the approach? In any case they will not let you go without these tests! Needless to say that there is active connivance of the medical profession and the HR departments of companies in this money wasting [making] exercise.

Screening for disease is important for some and this should be left to the physician to decide.
Going once a year to ones doctor and taking his advice is far better and cheaper way to health than getting inveigled into these unnecessary tests done by the unscrupulous investigative agencies.