Saturday, 17 March 2018

The Bedside Murmurs

Medical Smiles :

The Bedside Murmurs

The medical college is a strange place. Anybody who’s not studying there would like to have studied there. But all those who are studying there wish they were not there . The first year student is faced with an avalanche of information in the form of Anatomy of the human body ,it’s metabolic functions in Physiology and its chemistry in Biochemistry. Anatomy is not half as interesting as made out by connoisseurs of six pack and size zero. It’s all dead and frozen with the soulful accompaniment of the powerful stench of formalin. Many a wannabe doctor would faint in the first day. Yours truly did not, because I never thought of it as human body. It was all leathery and dry. Physiology in our times used to be full of carbon coated drums and croaking poor frogs who were butchered for study. Maneka Gandhi put paid to that and all frogs can breath easy. But the pain of pricking oneself for umpteen blood studies is heart breaking. Not to speak of the feeling when your early college crushes prick themselves. Biochemistry is your only link to the lab as we know from school days . Although collecting and testing urine is not exactly what you thought the guys in white overalls do. Phew.....

Once you enter your second year you’re led in a flock, to the Hospital. Lest you get any ideas ,the junior students are treated with just about the same respect as a doormat. They wander around the wards like headless chicken as one of our leaders once remarked. Once in a while a junior faculty takes pity on them and call them out. When we were third years ,we had a Profesor..let’s call him Zach...who was very sympathetic to us. In the sense he was very reluctant to take classes. But he would lead us suddenly to a patients bed side. The harassed patient would invariably be a cardiac patient . With an additional sound in their heart called a murmur. Zach was fond of these murmurs. So he would put his stethoscope chest piece to the patients chest and disengage the earpiece. He would then invite the students one by one to adorn them and listen to the heart sounds and murmur. He was so confident about our abilities that he never allowed us to place the steth ourselves.

If you ever thought that doctors would hear amazing stuff through their tubes ,you will be cured by third year of Medicine. That year you will actually that  accept doctors are divine because all that you hear will be hush push and lub dub. Zach would be describing a “ pan systolic murmur with a diastolic flow murmur.” You’re even more shocked your classmates, especially the female ones hear them.Later only you realise that all that they were hearing was the cloth rubbing on the chest piece. A Physician..those guys with an MD in General Medicine who perpetually detest the Cardiologists ...once remarked. “ Cardiologists are Gods. Because they can hear things other people can’t hear.” I would second that. It is another matter that the Echo machine deflated many of their egos. I’ve a friend who disagreed with the examiner about a murmur in a PG exam. The examiner was livid and demanded an Echocardiogram on the spot. It was done and lo and behold ,my friend ,the candidate was right. Just as surely he failed that attempt. Such are stuff Gods are made of.

Coming back to bedside ,the only worthwhile stuff junior students do is to study history taking. This is a laborious process . In the first days it takes an hour. I’ve always wondered what’s the point, since what we get in an OPD is all but five minutes . But it’s the custom and we need to follow it. The patient is subjected to a volley of questions starting from his  childhood . By the time he is finished he’ll be too tired to speak and the student would be breathless. But some people, especially older ones enjoy the interaction.

The examination part is hesitant and clumsy when it comes to junior years and the patient smiles through the process . There are experienced patients who tell students “my liver is enlarged 3 cm”. Especially in exams ,these kind of patients are a treasure. Some Examiners are smarter. They instruct the patients not to reveal a certain finding that’s not very obvious. Like a swelling in a private part . The fate of the student is sealed unless the patient takes pity on the junior doctor fumbling around the bedside.

Once the examination is done, in the training period ,one sacrificial goat should present the case to the teacher . This is your training for the exams too..which you realise quite late. Most of us used to avoid this ,pinning hopes on an over eager student . And hoping that your turn never comes . One of my classmates made his turn memorable by stating that the patient has a Past history of suicide. The word "attempt "was swallowed by him with more swiftness than the guy once did  his poison. The teaching Professor gave a quiziccal look and then burst out laughing. The class followed as you’re expected to,in a medical school.

Then there was this guy who was quizzing a teenage girl for symptoms of thyroid disease. The guidebook said 'ask for intolerance to cold ',so he was keen.
“ Do you feel cold without it being cold?” Was the first question.
 The girl said No.( obviously )
He tried again.

“ Do you feel abnormally cold ?”. The girl giggled but said no.
He wasn’t one to give up easily.
“ When it’s raining the you feel cold?”
The girl went red probably from the imagery of a rainy night coming from the mouth of the guy was a handsome hunk. And she giggled and said “ Yes’

He promptly wrote “intolerance to cold “ in the notes.

Yours truly has had his share of bloopers. One that I remember vividly is searching the Obstetric ward once for a patient named prominently in the front page of case sheet as Rajalakshmi. I reported back to the Staff Nurse that I couldn’t find the patient. She gently pointed out that Rajalakshmi was the name of the treating doctor and not the patient .

The cake goes to the hapless female student who was appearing for her Microbiology exam. She was a chronic additional in Medical college parlance ,meaning she was a repeater many times over. The internal examiner wanted her to pass . The external examiner..the dreaded species in any medical course exam who lands from another university...helpfully agreed to ask a simple question.
“ Can you name a single celled organism?”
The internal suddenly realised the candidate was confused and he stealthily gestured towards the wall where an enlarged picture of amoeba was hanging . As luck would have it another creature of a different species chose the exact time to cross the picture. So our candidate confidently answered.
“ Cockroach,Sir”
It is not known what happened to the examiners but such are the stuff legends are surely made of.

Saturday, 30 April 2016

The Film that Knows Infinity

The Man who knew Infinity

It's tough to make biopics, tougher to be authentic and still tougher to make it engaging ,especially when your subject dabbled with higher mathematics. The Man Who Knew Infinity directed by Mathew Brown based on the life of Mathematical genius Srinivasa Ramanujam pulls off this task with elan. The story of this Indian Mathemetician who was honoured with a Royal Society Fellowship is well known. We already had one biopic in Tamil on him titled Ramanujam. I haven't seen it so can't offer any comparisons. The current movie portrays his life,work and passion with taste  and honesty. Dev Patel acquits himself well in the title role while Jeremy Irons lives his role as Prof. Hardy.Devika Bhise puts in a spirited performance as Janaki,the wife of the genius. The life and times of the great Indian is brought out well by the arts department and the England scenario which is most of the movie ,is also perfect to a fault. The highlight of the movie is that the subject of Mathematics is dealt with seriously ,not dumbed down. The scene where Hardy explains the " partitions " is an example and his comment " even you can understand this " is almost directed at the audience.
Today education is seen as a part of one's job application. A necessary evil that has to be suffered before one settles for a job and a high salary. Employability is a buzzword and the pursuit of  knowledge for the sake of it is considered archaic. This movie is a reminder that pursuit of pure science is a pleasure which should not be denied to our gennext in the guise of making them employable. Science for the sake of science is part of what makes man great. Let's keep it that way at least for the gifted.
For starters how many of us know the Chennai houses two world class Mathematical institutes?

Saturday, 23 April 2016

ഇടക്കുന്നി അമ്മ

ഇടക്കുന്നി അമ്മ

ഇടതടവില്ലാതെ അനുഗ്രഹം ചൊരിയും
ഇടക്കുന്നി വാഴും അമ്മേ മഹേശ്വരി
ഇടയ്ക്ക തൻ തുടി കേട്ടുണരുന്ന ദേവീ
ഇടക്കെങ്കിലും എന്നെ ഓർക്കേണമമ്മേ

കിഴക്കുള്ള കുളത്തിൽ പഴയതെല്ലാം
അഴലും കോപവും കാമവും മോഹവും
അഴിയാ ബന്ധങളഴിച്ചുവെച്ചിന്നൊരു
വഴി തേടി നിൻ മുന്നിലെത്തി നിൽപ്പൂ

പഞ്ചാരി തൻ പഞ്ചാമൃതം നുകർന്ന്
അഞ്ചാനപ്പുറത്തെഴുന്ന്ള്ളുമമ്മേ ഭഗവതി
സഞ്ചിത പാപങ്ങളൊക്കെ ഹനിക്കണം
പഞ്ചപാപങ്ങളെൻ വഴി തീണ്ടാതിരിക്കണം

സർവാഭീഷ്ടപ്രദായിനീ രാജരാജേശ്വരീ
സർവവും നിന്നിൽ സമർപ്പിക്കുന്നു ഞാൻ
സന്തതമെന്നെ നീ കാത്തുകൊള്ളീടണം
സർവശക്തിയും ചേരും അമ്മേ നാരായണ.

Friday, 22 April 2016

Friendly letter

Been waiting for a moment
Of tranquil peace
To pen a letter to you ,my pal
Since our time started

To tell with joy ,to share and to
Cry without sharing,I kept all those
Memories   in the crevices of my mind
So I can tell you all one day

And I know too that
You enjoy the things that I say

When I see,when I read
Anything and everything
Want to share all those
With you,my friend

When mind reads those golden moments
That we spent talking and knowing each other
I miss you more than ever

Wanted to write a few lines to you
Daily I struggle with words
What excuse shall I use to write
Even if you are before me every moment

Now I realize in a flash
What reason do I need to write to you
Other than the truth that
You are my best friend!

Translated from Tamil original by Srinivasa Raghavan

An Indian Summer

The air is thick with the smell of sweat
Hot winds blow your mind away
You miss the memories of showers of love
Then you realise with a start ,it's an Indian summer

The green acres that covered my morning's walk
Dry and parched as if roasted in hell
The sweet nothings that rain whispered in my ear
Are all silent as if doomsday is near

The green shoot of hope that I lovingly reared
Down to its last leaf as to mock my years
Withered,dry and lifeless lies life
Waiting needlessly for the errant gardener.

In the dusty streets of the cities and towns
Sun is in pursuit of all that's not hidden from sight
To remind us of the endless fury of hurt love
Scorching minds and souls alike with little mercy

Miles and miles of drudgery for a drop of water
The mirage of life that urges you yonder
The long trudge of life is devoid of any green
Then I wake up to the fact that it's a lonely Indian summer.

Friday, 18 March 2016

Doctor in village 4

One of the first things that you learn as you train as a Child Specialist is that the dose of medicines you prescribe is crucially dependent on the weight of the child. Nowadays for many drugs body surface area is used. It is more accurate but difficult to use since you need a ready reckoner. The reckoner will give you surface area from the weight and height of the child. When I started my Paediatric practice therefore the weighing machine was an important instrument that I purchased. By experience you learn to guess the weight from age and appearance especially in busy out-patient departments. But when you have just started to practice you are more scientific .
So when this young woman and ( apparently) her mother walked into my OPD with a toddler hanging on to their hands I understood there was trouble in store. Most parents make their young children stand on the weighing machine ,without realising that they might start crying when left alone. Simple alternative is to weigh both parent and child while the parent carries them,and then subtract the weight of the parent.
When my examination of the child was over , I turned to them and said
" We need to check his weight "
The young woman promptly tried to make the already apprehensive three year old stand on the machine . He promptly started to whimper. Before his whimper turned into a cry ,I told the older woman
" You hold the child. We can take the mothers weight first. Then we can take their weight together and find out his weight"
The young woman hesitated and said
" But doctor ,there is a problem "
" What? " I asked .
" I am not his mother " she said solemnly.
I almost fell off the chair laughing ....

Saturday, 12 March 2016

Doctor in village 3

Doctor in village 3

It was in his forties that my father decided to pursue specialisation in Child Health. When he started practising Medicine there was no need for specialisation to make a decent living. The general practitioner was well respected and derived a lot of job satisfaction. But as years rolled on, the need to specialise increased and there were lots of peer and job pressure on GPs to go in  for specialisation . Being in the Government Health services gave my father the opportunity to pursue specialisation under special rules for In-Service candidates. Admission to this "Service quota " was strictly according to seniority and therefore he was 45 by the time he completed Paediatrics PG course. When he started specialty practice he however continued to see older patients as well. This story is about a hilarious incident in Paediatric practice. It is very important to be able to examine a calm child to make a correct diagnosis . Most Paediatric texts advise that extremely young infants be examined in the lying position. However most toddlers become restless when forced to lie down,so this age group that is from about 8 or 9 months till about five years the children are best examined while they are seated in the mother's or father's lap. Many parents have the habit of placing their two or three year old in the examining chair in front of the Doctor and stand behind them. This is a sure recipe for the child to scream and make the whole interaction unpleasant. So when one afternoon a young mother made the same mistake ,my father gently chided her.
" Please ," he said " keep him on the lap".
" No doctor," the young mother hesitated " it will be inconvenient "
" What ? " he asked incredulously " to keep a child in lap is inconvenient ? "
With a lot of hesitation ,the young mother placed her one year old on the lap ...
...of the doctor!
My father did not know whether to laugh or cry ,but the infant knew. He cried and before his mother finally understood the mistake,had made the doctors lap his urinal.

My father used to say about the incident as an example of how communicating correctly to patients is important .