The Whole Picture

In 2023, I engaged in a profound workshop dissecting the intricate interplay among doctors, healthcare systems, and wider socio-political contexts. 

This workshop, alongside other experiences during that period, served as a catalyst for a profound shift in my perspective on health.

As doctors we are trained to play within the boundaries of guidelines and pharmaceuticals. With limited time with each patient, it is easy to fall into the trap of treating the reports and images and not the patient, and the person.

As I listen to individuals’ encounters with healthcare professionals, it becomes increasingly evident that doctors often address what they perceive as the issue, rather than considering the patient’s perspective. However, the solution typically resides somewhere between these two viewpoints.Given the power dynamics inherent in the doctor-patient relationship, it falls upon physicians to bridge this gap and navigate towards this middle ground.

Unless doctors in a diverse country like India, with its myriad communities and complex cultural tapestry, tailor treatments that are culturally sensitive and contextually relevant, the effectiveness of the treatment is compromised.

Anyone can write a prescription. In current times, one doesn’t have to be a doctor to do that.The true value of our medical education, expertise, and experience lies in our ability to apply this knowledge effectively within the specific context of each individual patient we encounter.

Merely prescribing iron to someone with an iron deficiency is insufficient. It’s crucial to delve deeper and understand the underlying reasons for their deficiency. We must consider factors such as the patient’s access to affordable supplements, what iron-rich foods are available and culturally acceptable in their environment, and ensure accessibility to these resources.

Health transcends mere medical intervention. Each time we prescribe a drug, we make a choice that carries political implications. While we have the freedom to act as we see fit we should be aware of this dynamic.  

Are we prescribing the drug because its benefits outweigh its side effects? Can the patient afford it? Does the patient’s circumstances allow them to be compliant with the treatment plan? Is it actually solving the problem or just alleviating it for the time being and will reappear once the medication is stopped? Is there a practical, natural, long term solution? Or are we as doctors, unknowingly playing as marionettes in the hands of big pharma and the silent elite and setting the patient up for long term dependence on a product that needs to be paid for? 

As doctors, it’s crucial to question these dynamics, even if it’s not part of our formal training. Our responsibility lies with our patients, not the system. We must open our minds to constantly ask these questions and understand how political policies impact health.

It has also become essential to expand our viewpoint beyond the individual patient and recognize that health has social, economic, political and cultural determinants. Public policy, housing conditions, sanitation, access to clean water, employment opportunities, education, and cultural constraints all exert profound influence on overall health outcomes. Acknowledging and addressing these broader determinants are essential steps towards fostering health and well-being in communities, rural and urban, economically stable or not. 

If our primary concern is the well-being of individuals, it’s imperative to acknowledge that their health, as well as the functioning of the medical system, is intricately intertwined with larger societal perspectives of economy, politics, and culture.

Our primary duty is to prioritise the health and well-being of the patient, which is why we pursued medicine in the first place. Our responsibility does not lie in perpetuating a cycle of pharmaceutical dependence or ensuring profits for large corporations.

Especially in the current political environment, it is not enough to insulate oneself in the sanitised bubble of the hospital or clinic and pretend that we are only concerned with the patient, the lab and the stethoscope. Our ears need to hear the exposure to silica in the mines between the wheeze of lung disease, see the standing water breeding mosquitoes between the rash of Dengue, understand the family dynamics behind a pregnant mothers pallor of iron deficiency anaemia. 

Rather than simply adhering to international guidelines and prescribing medications, our obligation is to address the specific problem that the patient presents to us. If we find ourselves unable to solve the issue, it is our responsibility to be honest about our limitations and seek alternative solutions.

Is it a significant demand on each doctor? Undoubtedly. Is the current system conducive to supporting this ethos? Unfortunately, no. However, does this imply that we can simply relinquish our responsibility? I believe not. At the very least, we should endeavour to contribute to the solution.

This  poster serves as a visual narrative of our collective exploration into the root causes of healthcare crises and the need for a holistic approach to addressing them.

Titled “The Whole Picture” the poster aims to spark conversations about the broader socio-political forces shaping medical encounters and the imperative of understanding the political economy of health. It invites viewers to ponder on the interconnectedness of health with issues like urban development, displacement, and communal tensions.

As a participant of Govern-H 2.2, I am excited to share this poster as a testament to our commitment to engaging in rigorous political study and advocating for systemic change in healthcare. It serves as a reminder of the ongoing journey towards a more equitable and inclusive healthcare system, grounded in holistic principles and collective action.

To reach me for customised illustrations, poster design or concept art please email me at: illustratinghope@gmail.com.

To browse through some of my work please check the following links:

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You can find @illustratinghope’s profile on Freelancer here.

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COVID 19: A solution oriented approach

Dr. Harshit is an emergency medicine physician, working on the floor through this pandemic. He offers an algorithm to help deal with the onslaught we face as healthcare workers on the ground.

Please note that this will help if multiple institutions across cities follow a standardised guideline and cooperate with each other to manage the pandemic.

 

Based on the proposed guidelines for Coronavirus response by the Government of Karnataka, we came up with this simple algorithm for better understanding – For the public and healthcare professionals (HCP). Because the first problem lies there itself. Just not good enough understanding of what is to be done by individuals in the system.   

This algorithm is quiet simple and works. If :- 

• Properly followed and involved personnel are trained 
• Issues foreseen and taken care of 
• Enforcement and monitoring continuously that it is being followed without corruption 
• Transparency to the public and accountability by the system 
• Allowing room for expansion as the situation worsens. Because it will definitely worsen before it improves. As we are witnessing in other badly hit metropolitan cities. 

As HCP’s on the frontlines seeing the daily ground reality problems we wanted to outline certain major problem points in this algorithm that need to be taken care of at the earliest.  

*pre-existing co-morbidities like Lung diseases/ TB/ Liver disease/ Heart disease/ Kidney disease/ Patient on dialysis/ HIV/ Cancer/ Patient on steroids or other immunosupressants/ Immuno-compromised patients 

#co-morbidities like Hypertension/ Diabetes/ Thyroid disorders/ Obesity do not necessarily need to be admitted. Left to the discretion of consulting physician 

## The decision of home quarantine or placing a patient in a Community Care Centre (CCC) will be made on assessment based on treating physicians discretion, Living situation of the patient – can the patient isolate, availability of a family member to monitor, etc. 

** Monitor for symptoms like breathlessness, blue-ish discolouration of lips or fingers or toes, chest tightness, altered sensorium, low oxygen saturation <95% on oximeter, etc.  

P1 – Symptomatic person or primary contacts of a COVID positive person not getting tested at the earliest on symptom onset. Most people, out of fear of isolation and quarantine, do not seem to be getting themselves tested. Our advice to people is if you have symptoms please get tested early – this way if you test positive you are in the system. It is the systems responsibility then to monitor you at home or get you a hospital bed if you are in need of it, which currently is the major problem. Do not wait till you get really sick because then getting a bed currently is next to impossible as the system will not take responsibility for you. And the getting tested, getting a report and getting a hospital bed after that might be too late. 

Availability of testing does not seem to be a problem anymore. Capping of prices of the testing from different labs needs to be looked at as this would help the poor get tested.  

 

P2 – You may get tested but due to the load of testing most labs take 48 hours to 120 hours to report your sample. And now the new rule from the government directing labs to not give the reports to the patients, only release it to BBMP. And then BBMP will respond and go to the patient and assess the situation and either decide on home quarantine / CCC/ Hospital. Which again, lets say the report was ready in 48 hours and dispatched to BBMP, but simply due to the load BBMP has to handle they take another 48 hours to 144 hours to respond (this 144hours happened with one of my own family members). 

Let me illustrate this problem to you with a real scenario that happened a few days ago in the hospital we work at. A lady from Chintamani Mrs. M developed fever and cough on 26th of June. Got tested on 27th of June. Developed breathlessness on 29th of June. Went to a hospital but they would not admit her without a report so she went to the testing centre where she got swabbed and they wouldn’t release her the reports and told her to contact BBMP. Which they tried and there was no response from BBMP. She went from hospital to hospital for 2 days and everywhere the same answer – “get us the report and an official letter from BBMP if its positive only then we can give you a bed”. She came to us in Bengaluru on the 1st of July already dead in the ambulance. See the problem there??? 

 

P3 – This on paper is a very sorted out plan with guidelines and everything on when are you home quarantined and when are you taken to a CCC. Reality of it we really don’t know if it is good or bad. But like I said foreseeing the problems that may present is a big part of our success in responding to this pandemic.  

The CCC’s must have HCP’s monitoring patients regularly so if they worsen can be taken to a hospital at the earliest. These HCP’s must be trained in what to assess for and it must be documented. Patients on home quarantine must be assessed and trained properly in monitoring themselves. So should their family members who will play the role of primary caregivers. Proper counseling and monitoring that the patient must not pass on the infection to others in the family or the community must be taken care of. If the patient develops symptoms on monitoring as per guidelines that need the patient to be taken to a hospital, a hospital of response must already be assigned for every home quarantined patient. Monitoring of these patients on home quarantine by HCP’s must be done daily. The startups vs COVID initiative and the apthamitra app can be used for the same.  

 

P4 – Now this is the biggest problem.  

• Hospitals not holding beds for coronavirus patients as much as directed by government guidelines.  

• Government not enforcing these hospitals to release beds for these patients and not monitoring the same.  
• Patients who should be home quarantined or in CCC’s taking up hospital beds by using forces of connections and money. 
• Capping of prices as per government guidelines to be followed strictly and monitored. Beds are being sold off to patients who can afford it and don’t need a hospital bed. Whereas patients who can’t afford it and need the bed are not able to get any. 
• Patients not on ventilators and only on oxygen are taking up ICU beds in private hospitals as they would profit more from it. This makes already scarce ICU beds and ventilators even more scarce because of wrong use of ICU beds.  For some reason government price capping guidelines has allowed a column for ICU beds without ventilator. That should not be allowed in a pandemic of this scale – ICU beds means with ventilator only. If not on ventilator and only on oxygen requiring strict monitoring patient must be kept in High Dependence Units (HDU’s). 
• Maintaining transparency of bed availability to the public in real time. And these hospitals held accountable for not caring for sick patients and sending them away from the door. 

• As the situation gets worse, which it will before it gets better, there must be a plan already in place to expand the current existing number of hospital beds, ICU beds and ventialtors. When the current assigned numbers are already TRULY AND ACTUALLY full.  

All of this gets solved only by two methods. A Centralised Bed Allocation System (CBAS) and a grievances helpline number. There are way too many sick patients running from door to door of hospitals without any help and accountability and dying on the streets. The government has said they are working on a CBAS but how it should ideally work is a different ball game. We will outline that in our next write-up, based on ground reality as no one seems to be asking us what the real problem is but only making PR announcements that all izz well. Well no, all izz not really well.       

 

P5 – These are your SARI patients. Severe Acute Respiratory Illness – not tested for COVID but breathless, and given a pandemic situation all breathless patients must be treated as suspect COVID’s. The government uptill now seems to think they don’t have a responsibility to these patients as they did not get tested. The guidelines earlier released by the GoK to hospitals to reserve beds mentioned only COVID positive patients. Hospitals have been using that technicality to avoid taking patients of SARI and asking them for a report first and a BBMP letter saying this patient is assigned to this hospital. Even government institutes like Bowring and Victoria are exclusively for COVID positive tested and reported patients only. 

Let me illustrate this with another short story. We got a patient yesterday Mr. J who has been breathless since 2 days and been from hospital to hospital (12 of them) for a bed for his breathlessness. Shunted everywhere saying first go get tested and bring us the report only then we can give you a bed. He was pronounced dead in the ambulance itself by us. We tested him after and put the body in the mortuary. It was positive but well what is the point now right. 

The reserved beds must have separate isolation areas for suspected SARI patients and cared for appropriately while awaiting reports. And once report is available shift the patient to the appropriate area of care. These patients should also be able to connect to the CBAS and the grievances helpline number to be able to get care.  

 There are government guidelines been announced and most are very sound. But till we take individual responsibility as patients, government officials, administrators of hospitals and HCP’s – none of it works. Let us all ask the right questions to the right people to make a difference. Transparency and accountability is key. And the ability to expand and adapt as the situation changes. 

Dr. Harshit Mundra

 

Horses, not Zebras

• Dr. Pooja Elizabeth Mishra, writes a short for us.

Every med student has a story about how they took perfectly ordinary symptoms or signs and diagnosed a complex disease. Mine was after a medicine posting when I was practicing what I had learnt on my brother. Very proud that he had “good findings” I jokingly diagnosed him with Marfans. I later discussed this with my Senior Resident (who incidentally took the tutorial) she told me it was highly unlikely. She told me not to worry I was probably experiencing Second Year Syndrome.

Sure, I knew that a healthy 14 year old boy who had no visual symptoms, shortness of breath or back pain would most probably not have Marfans. But he had a lot of the signs – high arched palate, arm span greater than height, hyper extensible joints. What if?

Wikipedia defines Second Year Syndrome as a condition frequently reported in medical students, who perceive themselves to be experiencing the symptoms of a disease that they are studying.

We are trained to look for symptoms and signs in patients so it’s natural we look for them in everyone we meet(ask any student who has finished a psych posting).That’s where clinics comes in, spending time in the wards with patients who have all sorts of illnesses we learn to appreciate the large spectrum of disease. To distinguish between the danger signs and what can be ignored. In OPDs senior doctors can often tell if a patient needs to be admitted just by looking at them. It’s the common sense born of practical experience. There is a look of sickness they say. It could be that they just subliminally picked up the fast respiratory rate, or the pallor or lethargy of severe illness- but whatever it is they are usually right.

House M.D. made diagnostic medicine a relatable term in most homes, but that’s rarely how things are done. We are taught how to come up with a differential diagnosis for a reason, to factor in patient symptoms age, socioeconomic status and age into the equation. We evaluate from most likely to least likely, to arrive at the correct diagnosis. It is something Dr Google or even young med students are not able to do.

So sure my brother could have had Marfans but it was more likely just a growth spurt. The 20 year old with blood in stool and weightloss could have cancer but it’s more likely a fissure in ano. Like a professor in Maryland once told his students, “When you hear hoof beats in Texas, think horses not zebras.”

Dr. Pooja Elizabeth Mishra

 

 

 

Editor’s Note:

On the other hand, for more experienced doctors:

In medicine, the term “zebra” is used in reference to a rare disease or condition.  Doctors are taught to assume that the simplest explanation is usually correct to avoid patients being misdiagnosed with rare illnesses.  Doctors learn to expect common conditions.

But many medical professionals seem to forget that “zebras” DO exist and so getting a diagnosis and treatment can be more difficult for sufferers of rare conditions.

(- See more at: http://www.ehlers-danlos.org/about-us/why-the-zebra/#sthash.Gk3UjfuC.dpuf)

What I learnt:  Keep a high level of suspicion for the zebras, but keep the horses at the top of your list. Follow the middle path. Zen works everywhere!

• Dr. Gayatri Sharma

Pravin in Nepal

Each day pours into the next relentlessly, it’s as if there’s only so much that 24 hours can handle. I can safely say that 25^th April 2015 was the longest day of my life.

21–22 April

The bus journey from Varanasi lasted an exhausting 17 hours on treacherous road. We passed through a huge archway which read a curt ‘Indian Border Ends’, and I was finally in Kathmandu.
Suddenly I was acutely aware of the fact that it was finally happening- the lone-traveller-traveling-without-a-plan thing. I was venturing into a foreign country for the first time, about 3000 km away from home.

Kathmandu was warmer than I had expected. The city was colourful with temples and prayer flags. The air was thick with dust. The river carried mostly sewage. But the people were friendly and helpful. They struck up conversations easily, even with me, a total stranger. I fell in love with the place, instantly.
I felt I could spend hours just looking around in the red brick and carved wood Durbar Squares, watching people — old men, college students, families — sitting and passing time.

I struggled to pick up the language, and used the basic phrases in Nepali that I had saved on my phone. When the people I met learned that I was Indian they switched to fluent Hindi; only to be confused to find me still faltering. Being Tamilian, I have only a basic hold on Hindi, and it is as foreign a language for me as any other.

I had planned the trip such that I was to come to Kathmandu back on the last day, to take the bus back to Varanasi. I promised myself that before I went back to India, I would climb the two hundred feet high Dharahara Tower to see the magnificent panorama, and also visit the pretty little temple which I had passed by so often during my walks in the city, the one which no one seemed to go into.

23–24 April

Bhaktapur, not far from the capital, is a UNESCO World Heritage Site with red brick pavements, narrow branching lanes, ancient temples and outbursts of flamboyant woodwork even on the most modest old houses.

 

The traditional Tibetan Buddhist art of painting called Thanka was being taught at many small schools around the square. One could, I thought, spend a lifetime trying to master these intricate art forms. The shop nearby selling these Thanka paintings had a massive yak skin canvas with concentric circles of Tibetan prayers neatly painted on it in gold.

 

I met Gyanu Maya, a 75 year old lady, who sold jewellery that she had made herself. While I bought something from her, she made small talk in Nepali, not noticing that I didn’t understand a word.

 

Each section of the town was meant for different purposes- whole neighbourhoods for people who made pottery, jewellery, carpets, paintings, etc.

I wondered how different life would be if I lived in this town, a cultural hub and an architectural marvel!

 

A bus ride took me to a village called Nagarkot, farther up in the hills. There were few tourists here.

My first glimpse of the distant snow on massive peaks was overwhelming. It was slightly worrying to acknowledge, as a student of Medicine, that just the sigh of these beautiful giants could be therapeutic.

Later I walked through the forest to Kattike, a small village that is accessible only by foot and maybe a courageous driver. I stopped at the first house to ask for water and directions. The father and son there were unwilling to talk. I tried my broken Nepali, and then there was no stopping them! I realised they were just uncomfortable with English, but were actually very friendly people. We spoke about Nepal, its economy, their food and habits. As we drew maps of our countries trying to show our hometowns, they served me their local drinks, chyang and raksi. Nyang Pasang Sherpa, the father, had climbed Mount Everest four times!

How long does it take for three people to become good friends? Three hours and some alcohol, I would say.

25 April 2015

Despite sore muscles, I made up my mind to trek to the foothills on the other side of the valley. I set out for Dhulikel, the next town, with my backpack. After three hours I realised I was lost. A helpful young man pulled up on his motorcycle, asking where I wanted to go.
I could walk on another ten hours from this place to Dhulikel, he said, but instead he could take me downhill on his bike to the direct road. I accepted his offer.

He saved my life.
Nala, the village where he dropped me, was quiet and sparsely populated. Everybody seemed to be out in the fields working. Small children and their mothers were in and around the homes.

Without warning, it happened. I was hit by a sudden wave of nausea and dizziness. It wouldn’t leave! Was this food poisoning? Hypoglycaemia? My knees wobbled, ready to give way. Trees looked like they were being shaken from the roots.

It was a few moments before people started screaming. The mountains rumbled and a cloud of dust began to rise from them.

The earth quaked.

It felt as though a strong force was trying to pin me to the ground with its powerful side-to-side agitation. Flower pots fell from terraces. The road groaned. Bikers toppled helplessly off their machines. Before my eyes, I saw fine cracks appear in the ground.

From a house nearby, two men stumbled out onto the road, only to realise that there were children still indoors. I ran in with them and helped bring out three horrified children.

The ground was still shaking violently, so the only possible gait was a drunken stagger. Even when the shaking subsided, the earth underneath it continued to groan. Later I was told that the earthquake had lasted fifty-five seconds. That was the longest minute I have ever lived through.

Looking up at the hillside I had just biked down from, I saw it covered in a cloud of dust; rock, boulders and sand roaring downhill. I could see no trace of the houses I had passed on my ride down.

I spotted people who had been working in the fields running back towards the village. So far I had seen no casualties. But the earth wasn’t still. Every few seconds it rumbled and shook, though less strongly.

Rather than move on to Dhulikel, I decided to wait in an open field till the tremors had stopped. I sat there for an hour but the rumbling didn’t stop. My muddled brain tried to calm me down, saying that earthquakes like this were common in the Himalayas. Later I learned that the last ’quake of a similar magnitude was in 1934, eighty years in the past.

I didn’t know what to do, so I continued walking. I passed a small town called Banepa, where the highway showed cracks. People were all standing outside their houses. A few mud-walled buildings had been reduced to rubble, some windows had shattered and the shops were shuttered, but people did not look worried. Some were even excited.

Every time there was a tremor, though, the downed shutters would rattle hard, and the women would squeal in a loud chorus.

I reached Dhulikel four hours after the earthquake. Here too, just a few mud houses had crumbled, but public transport was overflowing with people. I realised later they were trying to get to the hospital. Everybody was out on the streets.

 

I bumped into a pair of Turkish tourists, father and son, who had found a taxi, and urged me to go back to Kathmandu with them. I told myself I could come back once the tremors stopped. Despite a highway full of cracks, it took only an hour to get to Kathmandu.

In the city, broken pavements and streets made it difficult to walk. When I saw the number of people waiting in front of the hospital, I realised that this was a much bigger calamity than I had thought. People were searching for kin in the rubble, ambulances were rushing bleeding victims to hospitals. They were the only vehicles on the road, other than the overcrowded buses.

I got out of the taxi and started walking towards the nearby government hospital. Mobile networks were down and the entire population seemed to be out on the streets, a mass of people sobbing and running around helplessly. Darkness fell, and only the occasional passing ambulance lit my way.

At the hospital, doctors, nurses and medical students were doing the best they could, as they moved from one patient to the next. They were short on supplies. And the injured and sick were still pouring in.

I met one of the staff, told them that I was a doctor and I could help. I shifted patients for scans, took blood samples, then went around adjusting and checking the intravenous fluid lines.

At some point I was assigned to an eight-year-old boy who needed a CT scan of his head immediately. There was only one elevator and it could accommodate only one stretcher at a time. We could not wait, so we piled three or more patients on to each stretcher. The little boy was laid down alongside a frail old lady.

Upstairs in the scan room there were a dozen people waiting on wheelchairs and trolleys. They took one look at our crowded stretcher and let us pass into the imaging room. When the staff asked whether I was this boy’s brother or father, I realised that his mother had been left behind downstairs.

The boy’s scan was soon done, but the old lady still had to get hers. I had to get the boy downstairs, back to his mother immediately, but there was no spare stretcher. Against everything I had learnt in medical school about moving patients with head injuries, I lifted him and carried him in my arms. His misshapen head rested softly against me, and his blood started to stain my shirt. After a few moments he began to get agitated, tugging at my shirt. I stood there helplessly, not knowing what to do and wanting to cry.

Back in the casualty ward I saw another boy, sitting on a bed crying. He was Indian, twelve years old and named Pappai. He was playing near his uncle’s home in Kathmandu when the earthquake hit. A collapsing building had fractured both his ankles. He was brought to the hospital by an ambulance and had no idea where his family was. He was terrified. All I could offer was a little consolation and a few carrots I had in my bag.

I was beginning to wonder where I would go myself. I couldn’t work in the hospital any more. I was near collapse myself and needed some rest, and there were enough medical staff at the hospital. I promised Pappai that I would come back and see him after a few hours and would make sure that he found his family. Luckily he remembered his father’s phone number. His father was in Kolkata.

I returned to the locality where I had stayed in Kathmandu earlier. Everyone was out in the open. I went to the locals, who heard my story and took me in, gave me their water and biscuits and the entire back seat of their car to sleep in. They sat inside their cars all night.

Miraculously, someone’s WiFi was still working! I read frantic messages from friends and family, and managed to send some replies. I asked one friend to contact Pappai’s parents in Kolkata.

The constant anxiety kept us awake the whole night. The car shook for a good ten seconds with each aftershock, even if it was just a brief tremor.

26 April 2015

The next morning I left my luggage at a Christian convent and returned to the hospital. There were still people on the roads, though luckily the tremors were fewer and weaker.

The hospital seemed much less chaotic. There were no more ambulances rushing towards the hospital, and no more patients waiting on gurneys. With difficulty I found the eight-year-old with the head injury; he was in the ICU. The wards were crowded, with injured people in every corner. I couldn’t find Pappai at all, and the nurses had no idea about him.

So I headed back to the convent, intending to set out for another hospital. On the way back, I passed the Dharahara Tower I had so wanted to climb. It took me a while to realise that the tower wasn’t rising above the trees. Someone told me that it had collapsed, killing 180 people. My blood froze for a second, thinking about the people inside who would have been walking up the spiralling stairs and felt the weight of the tower crashing down towards the earth. I could only hope that it was a quick death.

The army grounds nearby were littered with tents and each tent was packed with people.

 

It looked as though the staple food of the Kathmandu Valley had changed overnight to biscuits and raw instant noodles. Most people were living in the open.

And then it began to rain.

I remember seeing a young mother and her small daughter hugging each other, crying quietly, as if they had nobody left, nowhere to go.
Now — again! — shop shutters began to rattle loudly, and people began to scream. Another earthquake, this time for what felt like thirty seconds.

I sat down on the road, unable to control my knees.

I watched a four storey building no more than twenty feet away shake wildly, ready to fall in my direction. For the first time I was scared I would die. I don’t remember how I got back to the convent.

At the convent I was given a room. There I sat on the floor and, without warning, found myself sobbing uncontrollably.

 

 

 

 

The Headache Poem

(A poem by Dr Siddharth Warrier)

 

I went to a doctor for a headache; he

After much examination said,

‘It seems you suffer – what is clinically

Known as an aching head.

 

But before one makes such daring claim,

One ensures there’s no mistake!

For a head that ‘hurts’ is not the same

As a head that has an ‘ache’.

 

Your head can burn, your head can break,

It can poke or prick like a pin;

If you knew all the ways your head could ache,

Then your aching head would spin.

 

I’ve known of heads that have been said

To stab, and split and shake.

Indeed, you must be glad, your head –

Does nothing more than ache.

 

Some last for hours, some for days,

Some stay and others spread;

Some aches head off in different ways,

Others quietly lie in bed.

 

The Aam aadmi calls it a ‘sardard’,

The middle class say ‘my head is paining’.

The South Bombay folks love a fancy word!

They announce – my head is migraining.

 

For some, the headaches are a measure –

Of all the tensions in their lives!

Some blame it on blood pressure,

While most others blame their wives.

 

All doctors claim an urgent need,

To name which ache is which.

The only thing they haven’t agreed

Is how to name the bitch.

 

Even the neurologists are peeved,

Is it a symptom or a sign?

As a general physician, I’m relieved

That headache isn’t mine.’

 

‘Stop! This is a miracle!’, I said,

‘And surely there’s no mistake!

You’ve left me so confused, my head

Has forgotten how to ache!’

 

– Dr. Siddharth Warrier

Funes, the memorious

I have more memories in myself alone than all men have had since the world was a world. 

  Jorge Luis Borges was an Argentianian writer of fantasy fiction, and I came across his short story- Funes, the memorious, while reading Oliver Sack’s excellent The Man Who Mistook His Wife For A Hat. 

In some ways, I feel, reviews dehumanise whatever they review, because you are forced to look at the work of art from the reviewers perspective and you miss out on your unbiased experience of it.  Having reached this point of no return, I will continue to talk about this piece of literary genius, because it has affected me deeply. 

The story talks about a nineteen year old boy called Funes, who having become paraplegic in a childhood riding accident, is confined to his home. He borrows some Latin books from the narrator, and when the narrator visits him, Funes tells him his story. 

To Funes, the accident was a blessing in disguise, because, it was after it happened that he felt that he was waking up from a dream. His memory, his powers of observation were heightened to to the extent that, “the present was almost intolerable, it was so rich and bright.” Perhaps this is why the narrator likens him to “a vernacular and rustic Zarathustra”, and says that the verb remember can be only done full justice to by Funes. 

Funes has what we would call an eidetic memory, but Jorge Luis Borges has described it so much better. Funes has “an infinite vocabulary for the natural series of numbers”. This actually means that he has a different name for each number, like calling five as the dancing washerwoman, and seven hundred and fourteen as synthesis. But this is more than a case of vocabulary excess. Funes also has a keen eye for detail, and claims that he can see “the many faces of a dead man during the course of a protracted wake”. 

The narrator is insightful enough to realise that this can also be a curse. Funes’ world consists of such excruciating detail that he cannot comprehend the whole. The back of a dog is completely different from the front of the dog, to the extent that Funes has lost the concept of the dog. He has no abstract thought, no imagination, no assimilation powers. His helpless compulsion to notice details does not let him sleep, because he keeps imagining the shape of the crevices in the house. 

  

We all love a story, especially the ones that make you forget all around you. This tale of Funes hypnotised me to the extent that I forgot it was fiction, and started thinking what part of the brain would be responsible for these excesses of perception. I almost initiated a differential diagnosis algorithm (epileptic focus originating in the hippocampal fold? Nah, that would just trigger old memories. What about hypertrophy…?) when my ICU nurse jolted me back to reality, and I got back to work, still thinking of my fictitious patient, still unable to shake off the melancholia of Funes’ world. 

My philosophy of medicine

    

 
This is it. This is the thought that started this blog. 

One evening, coming back from work with all the self doubt and insecurities that comes with being a freshly passed out doctor being thrust into the unfamiliar surroundings of a new hospital, new guidelines and rules, I realised that I had become ‘institutionalised’. I was too used to following orders, protocols. Sure, I had been taught how to examine, diagnose and treat, but the algorithm of a large 1500 bedded hospital had lulled me into working at an (almost) spinal level. 
As I worked through the first few months of my ICU tenure in this 200 bedded hospital, I learnt that I would have to come up with my own algorithms. I learnt that its not about being right all the time, but being wrong the least number of times. 

And I made my own rules. As I’m nearing the end of my ICU stint, and going into more unfamiliar surroundings (again!), I realise now more than ever that what I need to take with me, apart from my knowledge of medicine, is my philosophy of medicine. 

This is how it goes:

1. First, do no harm. 

2. Do not prolong life when chances of survival are bleak. 

3. Involve family on ventilator decisions early. 

4. History, history, history. 

5. Constantly read. Ask for help. Choose only after knowing the available choices.

6. Empathize. But don’t let it cloud your decision making.

7. Worry. About patients, treatment decisions and how much of what you’re doing will work. It helps.

8. It is necessary to be impatient to get work done fast and get fast results. But it also necessary to be patient in order to give the patient time to respond.

9. Consider this. You are imposing western standards of practice, western philosophies of life, family and social norms on an environment which may be of eastern mindset or western mindset or a mix of both. So take your time. Learn how to go about things the cautious way, the aggressive way, the respectful way, the minimalistic way, the least painful way.

10. Make your own protocols. 

11. Put the patient’s wishes above that of the family’s.

12. Question everything. Patients, colleagues, current medical guidelines, the sensibility of medical decisions, and the rationale behind applying textbook (or trial) conclusions to individual case scenarios.

13. Think about what you don’t like in the current medical scenario you are working in and what you want to do to change it. It is as important to know the solution as it is to know the problem.

Fifty Shades of Brave

Every backache has a story. 

Actually, this is only a partial truth. Every patient has his or her story of their affliction. But its the ones with the low backache, where both diagnosis, and treatment are dependent on listening. 

So many of them are women. Some actually have medical causes for their pain, like a vitamin deficiency, or osteoporosis. But the treatable cause is only a fraction of the problem, and there always is the real, yet abstract element of loneliness, or a diminished feeling of self worth, or world weariness, that manifests itself in these very nagging, painful symptoms. It is an established fact that depression, a disease of the mind, can have signs of the soma (body). 

  

There will the old Mohameddan lady who has ‘bone breaking back pain, mungi (pins and needles) sensations down her legs, and constant thakaan (fatigue).’

There will be the otherwise sprightly maushis in my hospital who keep asking me what’s wrong with them, why do they keep getting tired, why are they plagued with this backache?

And I know, when they come to me, that my most important job is listening. Tales of children now grown up and busy. Their experience of the daily drudgery of existence. Stories of domestic violence, of a life spent in seva- of the in laws, the kids, the husband. How they handle two jobs and whatever other hardships life throws at them.

So I listen. At times like these, I am thankful for my dual roles of being a woman, and a doctor, because both these roles bring with them that very essential quality- patience. 

And I wonder. Can being a woman be such a thankless job?

A Neurosurgeon’s Fix

Guest writer, Baba Yogesh reviews Paul Kalanithi’s ‘When Breath becomes Air‘

We breathe. We inhale air, with gases in proportion to those in local atmosphere, and we exhale breath which is the inhaled air but with a little less oxygen, some more carbon dioxide, humidified, and cleansed of all particulate matter. This process of breathing results in a personalized change in the quality of air that we breathe out, our breath. From a medical point of view, at no point in one’s life can breath become air. Then does the title imply the breath under scrutiny belongs to a person whose life has ceased to be? But then, how can a person who isn’t alive breathe? This latter pedantic quandary notwithstanding, the original motive of the author, Paul Kalanithi, who wrote the book titled such, probably was to signify death. Death in general, and his impending one in particular.

Paul was a neurosurgeon-scientist. He studied medicine at Stanford, and his research involved electrical stimulation of brain regions with intracerebral electrodes. Paul started college with the question, ‘What makes life meaningful?’ a philosophical timeless Gordian knot we all have wrestled with. Quite unlike many, Paul sought answer to it with literature.

“I had come to see language as an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, into communion.” He saw literature as a fertile source-material to study life. He felt that only the vague intricate complexity of classical writing can encompass the similarly qualified concept of life and its meaning. He majored in English and Biology. He further went on to do Masters in English literature on ‘Whitman and the medicalization of personality’. But after masters, he felt caught in a catch-22. In his words,“If the unexamined life was not worth living, was the unlived life worth examining? ”

Convinced that to truly answer what makes life meaningful, one needed to experience life at the crucial juncture where it could possibly be stripped of meaning, he turned to medicine. His transition into neurosurgery is well-reasoned and captured in,“Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?”

In this book, Paul writes about his life as a surgeon and how he grappled with the complexities involved in patient-care, informed decision, long work-hours, and the unfortunate objectification of patients. And its written with a personal touch such that at no point does it get preachy or overtly verbose. And in the second half, Paul writes about his descent from a care-giver, to a patient diagnosed with stage-IV lung cancer, grappling with the reality of being struck down in his prime when he was at the peak of his surgical career, with life looking up bright ahead. Paul writes about how he dealt with it, accepted it, curiously went through the Kubler-Ross model for 5 stages of loss in reverse, and faced his own mortality and the question of the meaning of his life, up close.

The book ends abruptly. Paul died, in February, 2015. And in the end of the book is an epilogue by his wife, Lucy, who remained by his side all along. She writes how its possible to love a person, as deeply as before, even when the person is no more. Its a book thats personal, humane, and heartrendingly tragic. But then, so is life, often times. If you are a doctor, or anyone who was ever interested in what life and living is all about, here in this book is a perspective that will remain with you for a very long time.

There is no Routine

My ongoing affair with Emergency Medicine has been what I love most: an exponential learning curve. It is almost constantly unsettling. It forces you to keep moving, on a thin edge, keep thinking; Is there anything else I can do for the patient, is there something I’m missing, is there anything more that I can bring to this situation, or learn from it? It is a study in human behaviour, and one in adaption. The second I begin to get used to one kind of protocol, or one pathway of an algorithm, or settle into one kind of daily routine, Emergency Medicine flings me out of my comfort zone, and teaches me a lesson.

 

One of the biggest lessons that the ER has taught me is that I cannot be afford to be complacent.  I cannot blindly AND peacefully follow any seemingly obvious pathway without understanding the rationale behind it, otherwise my patient, and therefore I, will eventually have consequences to bear. It has taught me that there is no such thing as ‘routine’. All protocols,  guidelines,  drug indications, indications for investigations are guidelines based on studies done on similar patients. But our job as physicians is to apply our knowledge of these guidelines to the specific patient and his or her particular scenario. It is simply inadequate to follow the ‘routine’ and put the patient through an investigation ‘package’. The whole point of us being there,  is that we acquaint ourselves with the ins and outs of the patient’s history and circumstances, enabling us to do just what will help us treat the patient optimally. As much as is possible in the amount of time we have with the patient.

This is, of course, idealistic. In India at least, we often do not have enough time with the patient. But in the time that we do have, I think it is unforgivable that we should do so mechanically.

By this, I mean, let’s not miss out on things, let’s not ignore a finding in the hope, that its insignificant. If I’m unsure that what I heard were some crepitations in the left side of the chest, how can it possibly harm me if I ask a colleague or a senior to confirm the finding.

But I also mean, why do anything extra, just because ‘it’s what’s usually done‘. It always makes more sense to me that I should know why its usually done. Either I’ll learn the reason behind it, and I will have learnt something new. Or I will find out that it is not required. Why waste precious energy, money, time and resource in doing something that is without logic. But for any of this processing to happen, I have to think about what I’m doing, and ask questions. Irritating, persistent, nagging questions that are often considered stupid, and irrelevant. Frankly, I’m always a little afraid of asking them, because, shouldn’t I already know this? Do I really want to risk sounding stupid, when I have finally begun to make a good impression on my senior? Will it really be noticed if I do or don’t do this one investigation, or give or not give this one antibiotic? What if my question gives away my vast lack of knowledge, that I am simply not reading enough? These are the weakest thoughts in my head
I realized, that all these questions were centered around me. Its selfish.

Really?

And here’s another thing the ER has taught me. It is dangerous for me to be selfish. I cannot afford to be worried about myself, and as trivial a thing about my appearance, because my action or the lack of it, will not have a direct effect on me at all. There is another person, the patient, involved in the equation.  It may not be a life or death question, it may be just less pain or more pain or just a bit more emergence delirium. I may never even know if it made a difference or not. But my only job, is to make the situation better. And if I have to look a little stupid for a while in order to do so, then it is an infinitesimally small price to pay.

Doctors, for a lot of reasons, especially young doctors, (and in Medicine, young does not refer to chronological age), are riddled with insecurity. It is the root of a lot of mistakes we make. There will always be someone who knows more, who has done more, who has read more about any given subject. I have learnt that I have to channel this insecurity to push me to learn more, so that my knowledge is rooted in firmly established facts, and any treatment I prescribe is rational, and effective. What I have usually found is that, it is sometimes, that one question, that someone fearlessly asked, has changed the diagnosis or prevented a gross error, if not saved a life. It is in fact much safer to ask the question.

I do not mean for this post to sound preachy. These are just things that I have learnt, that I am still striving to do, things that I end up not doing on a busy shift or a day that I lack motivation.

I also do not think, that any of this, is exclusive only to the ER, or as a reader pointed out, even to my profession. If we love what we do for a living, we must learn to find a way to lose our insecurities, and raise questions where they arise.

It is again, clich-ed, but I love what Tagore said,

 

“Where the mind is without fear and the head is held high

Where words come out from the depth of truth

Where tireless striving stretches its arms towards perfection

Where the clear stream of reason has not lost its way

Into the dreary desert sand of dead habit

Where the mind is led forward by thee

Into ever-widening thought and action

Into that heaven of freedom..”

 

I never want to have anything to do with dead habit. What I want, is clear thought, and knowledge, to set me free.

 

As always, please feel free to comment, fight me on this, teach me something new!