Awareness of self

When I wrote the story of Mrs A, I said I would write about two of them. This one is the other which I meant to.

She has been my patient for many years and must be in her mid sixties now. With a strong family history of cancer and heart disease she is extra careful with her health and gets her tests done on a regular basis and keeps her twice a year visits to me without fail. Living with another sister who keeps indifferent health adds to her worries. Let me call her Ms M.

When Ms N came to see me when she was not due to see me, some three months ago, it was for another reason. She had severe back and hip pains of few weeks duration. Ms N is a frail vegetarian and when I found that her back and hips were generally tender with no specific localizing signs, I thought she has osteoporosis with add on Vit D deficiency, this despite her taking calcium tablets and a drug named alondrenate which is given for osteoporosis.

Vit D is manufactured by our skin only when there is sunlight exposure. Modern living and fear of sunburn makes people become Vit D deficient which can give rise to many signs and symptoms and aches and pains are some of these. Vit D deficiency was virtually unknown in the earlier years of my practice. Now I see this quite frequently for reasons mentioned above and also easy availability of tests to detect deficiency.

Mrs N was asked to do these tests and come back. The bone calcium density was not bad but her vitamin levels were low. I thought there you are! You have the diagnosis and the treatment is easy. Just give her Vit D supplements and get her to sit in the sun and her pains will disappear in a month or two. Thus reassured, Mrs N went her way.

She came back six weeks later, in acute distress. She was in such severe pain that she had to be assisted into my clinic by her brother. Instead of getting better she had gotten worse. I really cannot blame her for having gone to a specialist doctor in rheumatology [illnesses related to what is loosely called connective tissue]. This doctor had done a large number of tests to detect antibodies against her own cells. These were negative.

Here I must explain the basics of this fascinating aspect of life. We are each of us, unique, in the sense our cells [the ultimate functioning units of our body] are our own and there is an elaborate mechanism which allows our cells to recognize each other as belonging to one person and this mechanism has the ability to recognize something which enters our body as foreign. After this recognition there is an elaborate system of defense [major research area] to counter these invaders. This recognition of self from non self is fundamental to life. Occasionally, for various reasons, some understood and some still to be understood, this intricate system of recognition fails and the resulting clutch of disorders, go by the name of auto immune diseases.

Like we all have a life span [bible limits it to three score and ten, meaning seventy. I should be dead by this time going by this!]. Our body consists of various organs which perform various functions. Each of these organs is made up of millions of specialist cells. And all these cells too have their own life span and it is not threescore ten. Cells lining our mouth have a shorten life span than that of cells of our brain. When a cell dies the innards are released and these find their way into our lymph and blood stream. This dead material when once it comes out of the cell should be quickly disposed off. Or else these become potent antigens [foreign] and the our immune system begins to fight these by forming antibodies and the resulting fight takes place all over but when it occurs in our connective tissue it becomes painful and the illness too is widespread. Connective tissue is the one which binds the various structures and gives shape and structure to us. The resulting plethora of illnesses is called auto immune disease. I have given a rather simple explanation and I may be pardoned by my specialist friends for any error.

Ms N had one of these illnesses. Which one was the issue? The rheumatologist too must have been in this quandary and therefore had given her a non specific drug and wanted to review her after she tries it for few weeks. Why then she got back to me when my earlier treatment gave her no relief?

Sometimes we doctors stick our necks out and sometimes it is to benefit our patients and occasionally we get hung by! This is what I did. While reading about another problem I chanced upon this condition called Polymyalgia Rheumatica and the symptoms and signs fitted to what Ms N had like a glove. It occurs rather suddenly to only those above sixty, three times more common in women, large muscles of the spine hip and shoulders are preferentially involved, and markers of inflammation CRP and ESR will be very high. All of these were true in Ms N’S case.

I made bold to call her. I knew her name and the locality she lives and finding her number in the phone book was not tough. She must have been taken by surprise at my request to see her as soon as possible and she agreed and thus the present consult.

I explained to her the possible diagnosis and treatment. It took some convincing for her to agree to the treatment as it meant taking small dose of steroid [compared to what is given for other allied conditions]. Another motive was the dramatic freedom from pain she is likely to get if the diagnosis is right [sticking my neck out]
She agreed and three weeks ago took the initial shot of long acting steroid followed by oral tablets. Even I was surprised by the result.

When she came ten days ago, she came on her own could move all parts of her body, could bend, sit up, walk all without pain. Both her CRP and ESR which were sky high had returned to normal!

Practice of medicine is indeed rewarding. Don’t you agree?

Cure or Kill?

My fading years of practice still provides me with patients whose problems test my skills, patience and occasionally my knowledge. Experience gained over 40 years of practice and occasionally sheer serendipity comes to my rescue. The month of December saw me solving two such problems with the help of a combination of the factors told above and I consider them as the best New Year gifts received even before the old year ended.

It is required that I take permission to tell their stories, especially when they are alive and kicking as in these two instances and I have done so and I must thank them for permitting to do so. Let me begin with the first one, Mrs A.
Mrs A is mother in law of a close friend of mine. She is a well built lady in her mid eighties and spends time living for some months with each of her children and for a long time she was my patient until her elder son retired from the army and came to live in this city 5 years ago. Since then she is being cared for in the army hospital and in a private hospital whenever an emergency arose. With another son living abroad money is not an issue that came into the picture as far as care is concerned.

As it often happens with us GPs, patients leave us to what they think or what their children think, for better pastures, which often is true but not in this case as later events proved. Fifteen or so years ago, when she came under my care, she was an obese, hypertensive, seasonal asthmatic and had fairly well compensated heart failure due to leaking heart valves. She was also severely arthritic with painful hips. Averse to any form of regular exercise and fond of food it was no surprise she kept gaining weight and her hip pains only became worse. We took a risk and got one of her hips replaced and the cardiology opinion was that she was a high risk patient and ideally have her heart valves replaced and the surgeon felt it was not worth doing it considering she is being fairly well managed medically as far as her heart failure was concerned.

Four years ago, when she was not under my care she got her other hip replacement done! She had a stormy post operative period but made good recovery and now she has both hips replaced and was pain free. One would have thought she would exercise and get her weight down but as I said earlier she did not and her weight remained as before and when I occasionally saw her socially [as she is my friend’s mother in law] I felt her weight had only increased. Since last one year her health seemed to worsen and she has been in and out of hospitals for one reason or the other.

Six weeks ago, she was taken to a nearby hospital [with corporate ethos] and was admitted as she was complaining of weakness and was short of breath. Given her heart condition the diagnosis was obvious. She was in heart failure due to leaking valves. The cardiology team of that hospital is good and most of them are known to me but as I was not involved in her care I did not personally check with them as to the details of the treatment. What her son in law and my friend told me was that the cardiologist felt her heart failure was under good control and he advised her increased activity and she was discharged home.

This time the home she came to was the daughters. She continued to be unwell and kept telling her relatives that her end is near, so bad was her feeling! One evening, the son in law [my friend] came to my home and asked me to come and have a look at her before they took her back to the hospital.

I went with him to see her. She was lying flat on bed, a slab of pale flesh with deathly pallor. She looked very ill. She had constant feeling of nausea and was off food for the last week and was barely able to keep fluids. She also felt it impossible to even to get up and sit and the daughter was having a hard time nursing her. Quick examination showed her blood pressure under control, but her heart’s beating was irregular. Her feet were swollen and her lungs showed few abnormal sounds suggesting beginnings of fluid accumulation. She complained of discomfort in the pit of her stomach.

I wanted to see her records. The record keeping had stopped in the year 2006 when she was under my care. Rest were all hospital discharge summaries and prescriptions. I saw the latest prescription. This had 9 drugs. One to stabilize the heart, another to remove the fluid from her lungs, yet another to keep her blood pressure under control, a different one to prevent clotting, another to prevent the possible side effects on the stomach because of all these drugs and the usual masala of vitamins.

Digitalis is a time honored drug and has a fascinating history. The plant Foxglove from the leaves of which the steroid glycoside Digoxin was extracted, belongs to the family Sacrophulariaceae, was time honored native medicine in Europe for many centuries. It came to widespread use due to an accidental discovery by the 18th century English physician William Withering. A patient of his was very unwell with Dropsy [old name for fluid accumulation all over the body]. After visiting her, Wuthering came back home leaving her to die, so hopeless was her state. Few days later the patient, now recovered, visited him. The surprised Withering found out that she had consumed a concoction made out of the common garden plant, Foxglove! It to his credit that he published his meticulous observations and extract of foxglove, digitalis, came to be used universally in heart failure patients and has with stood the test of time and is in use even to this day.

This wonder drug however, has one major problem. The margin of safety between the therapeutic dose and the toxic one is thin and if one is not careful the drug can become from a life saver to a life taker!. This is especially true when used in the very young and the very old. The toxicity is on the stomach and worse, on the heart. In the stomach it causes severe gastritis manifested as loss of appetite and severe nausea and on the heart with irregular to very fast beating leading to failure, the very illness for which it is given!

Madam A had classical Digoxin toxicity! The drug was stopped and it took 48 hours for her to eat her first solid meal in three weeks. Her heart’s beating returned to normal and the deathly pallor was replaced by a cheerful expression. She began moving around the third day and was able to walk up and down the stairs of her home. Yesterday she made a long car journey to her other son’s place to a town some 6 hours away!

Mrs A escaped from certain death [if she had continued with digoxin].

This story has taken too much of time. Will do the other one sometime next week.

Remembering Bhutto and Thanks giving

I don’t know why I began calling him Bhutto, after that famous India hater Zulfikar Ali Bhutto. Those of you who are interested in the recent history of India and Pakistan will remember that he was Pakistan’s able representative in the UN and later became the country’s prime minister and later was hanged by the military. He excelled in debates and was an effective counter to our own Krishna Menon in prolonged and effectively boring speeches. In one of these speeches he called us Indian Dogs! And this infamous or famous statement must have made me call him Bhutto when he first adopted me as his friend and my home as his. Had I known what a wonderful being he turned out to be, I certainly wouldn’t have called him by this name. But call I did and the name stuck. After all what is in a name, the person is important. So it proved.

Bhutto was a stray dog and must have been a two year old when he came into our home. He was of indeterminate pedigree and as mongrels go, a good looker. He never got fully domesticated and would visit us when his mood took him to do so. He was essentially a street urchin and the street in front of my home was his territory. He never was short of food as he had many friends like me who fed him. But I felt he had a special liking for me.

Deepavali is a noisy festival with nonstop sound of crackers bursting. These days were dreadful days and he took refuge in our home. He would neither eat nor drink and my dislike for the use of crackers as a method of celebration, be it a festival or a wedding goes back to those days when I saw him in absolute dread. He would not leave the house for a few days after and only did so when there was no more of this noise.

Being a street urchin it was not possible to really get him to a Vet to get him immunized but I did try once and he jumped out of the car and ran away. But strangely, when he fractured his leg and was hopping on three legs, I with the help another dog lover friend of mine managed to take him and this time he gave no trouble at all! But the Vet told me that there is no point in attending to him as he would not allow the leg to mend and the cast he is going to put will not stay as he would tear it apart. He felt Bhutto’s days are numbered as he would not survive as a lame dog in the streets. He reluctantly applied the cast and I couldn’t believe that a dog could be so cooperative when the procedure was being done! Even the Vet was surprised. I kept him home for a few hours till the cast dried and after wards let him go.

Next day he came back with yards of plaster of paris smeared bandage trailing his lame leg. He had tried his best to chew the nuisance off and wanted my help to get rid of the remaining. This I did and put a bit of crepe bandage instead. Even this did not remain long. He hopped about for a week or two and then began bearing weight on the lame leg and in a month became normal. Another of my beliefs,’ leave it to nature and often you will see miracles happen’ proved right.

Another time he came when he was ill and took refuge inside the house. He would not eat and only drank water! I opened his mouth and found it full of small eruptions and when I asked my friend he said it was a common viral infection and gave me some pills to try. With great difficulty I managed to get him to eat these pills and in a week’s time when I forced open his mouth there was not a trace of this infection! He was also going out and eating grass and someone told me that dogs do this as a way of healing mouth sores! I don’t know which one did the trick but he became normal and resumed his antics.

He was fond of fried dosa and would know by the smell that this was being made in the house and invariably come to the dining area and sit on his haunches with an expectant look on his face. My old mother who was alive then and who was no great dog lover just could not resist liking him and would feed him one dosa after the other.

For a street dog he was clean, but I felt he needed a bath once in a way. He would have none of these and my attempts elicited a howling response. I gave up using water and would use a brush once in a way but surprisingly did not find much dirt on him despite all the mud he came in contact with on the streets.

Being a street dog, he would get into fights with other dogs especially when the females were in season. Again it was my job to treat him. Many an occasion he would report with injuries and allow me to clean and apply antiseptics and never once did he object and would lie down quietly often licking my hands or giving me small bites when I was cleaning his wounds which must have been quite painful. He knew that what I was doing was for his good.

I remember one day morning when I woke up late, only to see him sitting with an upturned anxious face. Normally he would not come into the bedroom but this time he did and was sitting there god knows how long. None of my family even knew he was there! No sooner I woke up his anxiety vanished and before I could touch him he ran down the stairs and disappeared down the street. Did he think, I wonder, looking at me sleeping form that I was dead and thus the anxiety on his face?
He lived a charmed life of may be seven or eight years and died after eating some poison from the street corner dust bin. He came home one evening vomiting blood. One look at him I knew he was too far gone to be saved. He died a few hours later and we buried him inside our compound.

Normally when a human being dies some rites are performed, priests are fed and poojas are performed to send the soul safely to the other world. The evening when he died, we put some flowers on his grave and lit some joss sticks and stood in silent prayer for a few minutes, just then an elderly man unknown to us came and asked for help. He did not look like a professional beggar. It is considered auspicious to give to charity and no one deserved it better than what I thought this emissary of just departed Bhutto,

Another year has gone by and we are entering 2012 and I thought the best way to usher in the New Year is to pay homage to a soul which left me some 20 years ago, but whose memory is still fresh and even after all these years I still miss him!

Like I did last year this year too I thank all of you, my patients, family and friends who have kept me going and for all the love and affection that you have given me.

Fire test

Our revered epic Ramayana has an episode where in Lord Rama tests his wife's chastitiy by making her walk through fire [even in those days there was no need to test the male's chastity]

So this was considered to be the best way to separate the noncorrupt from the corrupt. The first ones to be tested were the ruling party memebers. One by one they were made to walk through the fire pit.

The first to emerge unscathed by fire was Antony. Next to emerge was Manmohan singh holding his backside which was singed but not burnt.After anxiously waiting for a while Antony tells Manmohan,'I donot think we should wait any more, there is a lot of work that we both have to handle' Manmohan says, ' You go, I will wait, I am sure next one to emerge will be madam!

At the time of writing he is still waiting!

Hazare and the whip

I imagined the scene where Gandhian Anna Hazare is going around the country with a whip in his hand looking for persons who like their drink. What would I do if faced with this spectre? I would humbly request him to taste thimble full of wine before he takes up his whip. I am quite confident of winning him over.

Why is he so anti wine? Easy to understand. He has seen addiction to drink ruining families and thinks flogging is the answer. While not advocating that one should take to drinking, I am totally against this kind of thinking. This kind of puritanical attitude is going to draw people away from his movement to eradicate corruption. Instead he should advocate moderation and educate people not to become alcoholics. There is overwhelming medical evidence that small doses of alcohol is good for health!

The question is how small is small?

Nature’s culling

Authorities in national parks allow hunting of wild life if they find one form of life exceeding the limits. This is called culling. This however doesn’t apply to us humans. We are at liberty to breed and multiply and test the resources of mother earth. This over populating the earth is in a way insulting nature. If you go by this yardstick human life is the most dangerous form of life ever evolved. Is there a scheme of things behind this profligacy? I wonder. There are different theories for the disappearance of earlier life forms. For example the Dinosaurs and the Woolly Mammoth. The dinosaurs became extinct after major upheaval die to meteor hit and the woolly mammoth because of rapid advance of ice age. If we are to believe there is an in built wisdom in nature which is not conditioned to safe guard human life, then I am afraid we are in for some form of correction which may well mean disappearance of humans. From the point of view of mother earth nothing much will be missed by the disappearance of this none too attractive a species. How will this be brought about?

Many centuries ago Rev Malthus propagated a theory that natural calamities like famine, fire or floods will correct the balance and the population gets naturally culled. This may still happen if you go by what is happening in Ethiopia where millions are dying or going to die if the rest of the world sits back and watches. A more likely event will be mutation of a run of the mill virus into a killer with widespread deaths uniformly spread throughout across all nations. Next possibility is nuclear explosion which will kill selectively and therefore unjust!

Going by the life span of stars and planets, earth has few more million years left before it gets blasted to smithereens. Therefore when doom is inevitable why worry? Get on with our wasteful ways and hell with coming generations of life forms.

Corporatization of health

Indian government seems to have washed its hands off of providing health care to its citizens. Going by the evidence of measly allocation of funds in the budget for health and its acceptance of corporate hospitals to provide health care to its employees, the trend is firmly set that we are going the American way. What then is going to happen to the existing health infrastructure, the vast network of primary health care centers and secondary and tertiary care hospitals? If the present trend of encouraging corporatization of medicine continues it is inevitable that these institutions will gradually go to seed and one day will altogether disappear. Imagine the situation where in excellent institutions like AIMS [Delhi] PGI [Chandigarh] NIMHANS and Jayadeva at Bangalore deteriorating and becoming places where only destitute go!

Nations are spending a considerable percentage of their GDP on providing health care. As the population ages health care costs are going to go up and India is no exception. But neglecting government run institutions and encouraging private clinics and hospitals run by corporate and health management funds is the right way of providing health care?

Far from it, it is the worst way, especially for a poor country like India. Some you who are not Indians may wonder when I use the word poor to describe India. What you read or hear about India in the news and electronic media is all about the doings of the 5% of Indians who have done well for themselves.

This 5% is what the corporates are interested in. This 5% consist of the upper middle and the rich. Our politicians [even the grass root ones], beurocrats belong to this class. These are supposed to use the health facilities of the government. Hardly anyone does this and all of them with rare exceptions make a beeline to corporate hospitals when they fall sick or even for their routine health checks. If the top echelons of the government have no confidence in their own institutions how can one expect the ordinary citizens to have any confidence? They too will and have to go to these privately run institutions.

With increasing play by the private sector, falling ill has become a risky proposition. Let me explain. As the private players are mostly businessmen/venture capitalists/health management funds, the end point of their venture is to make money. They are not doctors who are supposed to think of patients welfare first and money next [many doctors too are becoming money first and health next thinkers]. They think of maximum and quickest return on their investment. If the investment is on building they will look at how much a square foot of the building will earn, if it is bed how much a bed will earn, or if it is human in the form of a doctor how much this doctor will earn for them. That is how they look at each item as money earners. Let us say the expected return on a bed is x amount in a year and the year end sees that bed earning is less, then the hospital administrator is pulled up and he in turn will pull up the doctor. The doctor who is so pulled up for not providing the hospital with enough business will either has to quit or adopt methods which his famous Hippocratic oath forbids him to. Most doctors are not in the real sense businessmen to begin with but they become one due to this kind of pressure. So what happens is this. When a patient goes to a corporate hospital and sees the doctor the first likely thought that comes to the doctor is how much I can get out of this patient and not what might be wrong with the patient. This attitude I am sorry to say is widespread and leads to lots of unnecessary investigations and procedures and needless hospitalization.

The sucker is the hapless patient. If he belongs to middle or lower income group, these institutions will make them feel that death would be preferable than the torment of raising sufficient resources to meet the expenditure that a hospital stay brings on.

This fear has led to the mushrooming of health insurance industry. This is another sordid story. Between corporate hospitals and insurance companies there appears to be a cozy relationship. It is not uncommon to hear the hospital reception asking the victim whether he is insured or not. If he is uninsured the smile of the receptionist is likely to be replaced with a frown. This is because you are likely to opt for less paying bed and at the time of discharge haggle, ask for concession, create a scene or as it happens occasionally, simply abscond!

So what is the solution? May be in the next write up.