Santhosh's ramblings

It was yet another regular Monday morning in Duncan. I, walking about with the young and excellent consultants in Medicine, Anesthesia/Critical care and Pead’s, me, not doing much but just being around.  As we walked into casualty, there was this 50-year, obese male, in encephalopathy and taking very shallow breaths. A classic and clear patient with Obstructive airways disease and possibly an additional Obesity hypoventilation syndrome in respiratory failure. Some surgeon in a nearby nursing home had taken the risk of doing a cholecystectomy on such a high-risk patient and now he had come in with respiratory failure. His complex blood gases started of a series of conversations. Should we intubate and ventilate, if we ventilate, would he ever come out, or should we wait on NIV alone? If he does not come out of ventilation what would the next step be? Finally, after much consideration, the Anesthetist turned critical care specialist, dec ided for NIV only. We walked into the I

We see quite a bit a new Hansen’s Disease (Leprosy) at the hospital where we are. Three to four new cases a day, for a disease supposedly “eliminated” in India and across the world! We see new pauci-bacillary, many multi bacillary, and very many with severe reactions. We come across many partially treated, some possibly resistant ones too! For an old disease we hardly have any new answers. The same old treatment since a few decades. Well the purpose of this blog was not to complain about the “neglected tropical disease” but to make another point!   But I couldn’t control my habit of being a complainer when it comes to diseases of poverty! The most difficult decision which I find in treating leprosy is to decide, if the patient still needs treatment or is it a burnt-out case. People come after having taken treatment for a few months, with no bacteria detected in the smear, or broken bacteria seen – are we dealing with a partially treated case or a fully treated “burnt out” case.

It was some time in 1990-91. Working as a junior faculty in the division of Nephrology, I was busy. Setting up a new Nephrology unit with just one senior person supporting, most of my days and night were spend in the dialysis unit, much to the irritation of my wife! Busy with the job of setting up systems of the unit, seeing 8 to 10 patients on dialysis a day, seeing that their vascular access is in place, and decisions for dialysis are taken, there was not much time left over. Very minimal to listen or communicate to patients or families. Calls from casualty or other units of Medicine, where we would go see, diagnose renal failure, look out for indications for dialysis, have a quick chat with the family regarding the need for dialysis, and then rest was all standardized protocols.   Patient comes into the unit, vascular access is put, 2 hours session 1, 4 hours session 2 onward, in between assessment will be done on the long-term plans and rest will be communicated over next few day

It was in 1986 that this happened. It was my first duty as a 1 st year resident. My senior resident had instructed me, if very serious patients whose prognosis is likely to be poor come, do not admit, refer them off, so that we can keep beds for other patients. He used a word - “scheme off” the patient. Having come from a small rural mission hospital where I never had heard this “scheming off’ and prior to that from a state-run Medical college, which was the final place for all sick people, I never had the previous expertise of scheming off a patient. And adding to this was my poor language skills in Punjabi! As I was wondering what all this meant, a patient with a suspected hemorrhagic cerebrovascular accident was brought in. With very low sensorium and a hemiplegia, the prognosis was poor. The senior resident came and reminded me, try sending the patient off since we do not have many beds for sick patients. The unsaid reason was to reduce the work burden for us, the residents.

WHO in its 2017 overview of antimicrobial resistance states that “AMR occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials is accelerating this process. In many places, antibiotics are overused and misused in people and animals, and often given without professional oversight. Examples of misuse include when they are taken by people with viral infections like colds and flu, and when they are given as growth promoters in animals or used to prevent diseases in healthy animals.” http://www.who.int/antimicrobial-resistance/en/ Most of the evidence for this comes from research and stories emerging from the urban centers across our nation and other nations. The Delhi superbug story from 2011 of the Klebsiella strain that was multi resistant, created much hue and cry but was soon recognized as an emerging global Klebsiella resistant strain.   Though now recognized as global issue predominantly from urban studies, not much is known

The Vision of Isaiah  – 1 st  September 2018 As a young person called by the Lord, the first few word pictures and revelation and vision he gets is ,  one of rebellion of his own community. “The ox knows his master, the donkey his owner’s manger, but Israel does not know, my people do not understand”. “They have forsaken the Lord, they have spurned the Holy One of Israel and turned their backs on Him”. “Your whole head is injured; your whole heart is afflicted”. And then God continues to reveal His heart and His desire for His people, Isaiah’s own community – “”Stop bringing meaningless offerings!...Your hands are full of blood: wash yourselves and make yourself clean; take your evil deeds out of my sight: stop doing wrong; learn to do right; Seek justice, encourage the oppressed, defend the cause of the fatherless, plead the cause of the widow.” And then God goes on to “reason together with the nation; Though your sins as scarlet, they shall be as white as snow, though they

Three stories from last couple of days in the hospital…. Story 1 - 65-year-old man came to us with a severe peripheral neuropathy, secondary to a burnt out Hansen’s (Leprosy) and our Junior Medical Officer diagnosed him very well. Put him on just a simple tablet of “Pregabalin” and send him home. He comes back to us 4 months later with a bag full of investigations and a pharmacy. Though from a poor background, his children decided, their father has to be taken to Delhi. Took through multiple centers spend about 20,000/- (or more,) with MRIs and scans finally ended at AIIMS. At AIIMS, a burnt-out Hansen’s with peripheral neuropathy was diagnosed and was send back on the same tablet “Pregabalin”. He returned to us, a few thousands less just to confirm if AIIMS was right. And to check with us – which takat ka drug he should take from the bag full of multiple multi vitamins, of various companies, prescribed by each practioner he saw, each time adding on to his home pharmacy, prom