The Learner: March 2015

Monday, March 30, 2015

Barsati's Garden - Multiple white roses

There was one white rose bush in our garden which had multiple flowering. It was such a joy for the eye . . .

Thursday, March 26, 2015

Bringing hope . . .

We regularly have patients who give us immense satisfaction at places like Kachhwa. Mrs. PPD was such a patient.

Mrs. PPD came to us in a very serious shape – more serious emotionally than physically. Just 33 years of age, PPD had been diagnosed to have Diabetes Mellitus about 6 years back. She had been running from one doctor to the next since then. She was scared of Insulin shots. Almost all the doctors she met told her the truth - the fact that she needed Insulin to keep her diabetes under control. But PPD was scared.

The depressive nature of PPD brought a sense of doom to her extended household. Her mother-in-law narrated on how the illness seems to have brought a pall of gloom into the home.

PPD came to us about a month back with serious infection. She was depressed and wanted to die. It was a major struggle for us to convince her that she needed insulin injections. Our team did quite a bit of persuasion and prayers to convince her. Initially, she was not ready to self administer the medication.

Over the course of her admission, we discovered that she had bilateral cataract. The issue was about getting the surgery done while the ‘surgery season’ was on. And then there was the spectre of diabetic retinopathy which could dampen the surgery. Of course, someone had went to the extent of telling her that she will not see again that she did not bother to mention about her low vision to us. It was one of our staff who noticed that she was fumbling with things that we realised that her vision was as low as 1/60.

We prayed for her. By God’s grace, from a situation of seriously uncontrolled sugars, the sugar levels were well controlled and she was able to undergo surgery.

Post-surgery, we were all concerned about how much vision she would be able to have. On removing her bandages, we praised God as she told us about how clearer her world has become.

PPD (left with the dark glasses) with her mother in law
(Consent obtained for posting snap)

PPD’s mother narrated on how she has become a lively presence in the house after her treatment. It’s so satisfying to have patients like PPD who appears to have lost all hope for her future. However, we're sure that had it not been for her extended family who was ready to stand with her in the treatment and encourage her, they would not have been able to bring back hope and joy in the house.

Barsati's Garden - The white rose

There are few white rose plants in Barsati's garden. Few snaps of white roses in the garden.

Coming up in a couple of days would be snaps of a white rose with multiple flowers . . .

A different snake . . .

About a week back, we had a young lady of 16 years brought to Emergency Room in a supposedly comatose state after a snake had coiled around her leg. The patient alone had seen the snake and had told relatives before she became unconscious that the snake did not bite her.

There were no obvious bite marks and it was not difficult to come to a conclusion that she was well conscious although appearing a bit drowsy. She also seemed to have a ptosis which on careful examination was not there. The clotting time was normal.

The only issue was a low blood pressure reading of 80/40 mm Hg. We gave her some intravenous fluids and she did not respond to that. And we concluded that this was her normal blood pressure. Later, we found out that there were problems in her family and we diagnosed her as having an acute conversion reaction – a psychological response to difficult situations.

We gave her a small dose of anti-depressant. However, she did not seem to do fine. She continued to remain drowsy. She could communicate when we called her. She could even walk to the toilet without help. She also narrated to us that she was taking some ayurvedic drugs for her psychological condition.

The next day being a Sunday, we could do any investigations. Her condition remained the same.

On Monday, we sent a battery of tests – complete blood count, liver function and renal function.

Her total count came as 1200/cu mm with a predominant lymphocyte picture. Hemoglobin and platelets were normal. The liver and renal function also came as normal.

There were only two major things that we were looking at – either a blood dysgracia most probably secondary to her ayurvedic medications or a haematological malignancy.

We referred her to a higher centre.

This is the second time that I’ve come across a suspected snake bite being diagnosed with something else more serious. The previous time was 4 years back at NJH, when we diagnosed disseminated tuberculosis in a patient who came with an unknown bite.

Wednesday, March 25, 2015

Polypharmacy . . .

It is not uncommon for patients who come to us after going elsewhere, mostly quacks to have multiple medications with them. Most of the time, the medicines will all be non-essential stuff.

Yesterday, I had a patient who sort of broke all records for the number of medicines that he was taking. I counted a total of 21 medications. He has been having fever, cough and breathlessness since the last 2 weeks.

The 21 medicines included 7 multivitamins, 2 antibiotics, 4 anti-histamines, 2 antacids, 2 bronchodilators, 3 NSAIDs and one cough syrup. Interestingly, there was no paracetamol.

Regarding the diagnosis, that would be in my next post . . .

Barsati's Garden - Multiple Dahlias

More snaps of dahlias. This time, 3 or more dahlias in a frame . . .

Tuesday, March 24, 2015

Barsati's Garden - Roses in pairs

More snaps from Barsati's garden. This time, it is roses in pairs.

From the battlefield

This is Sergeant Kuruvilla, reporting from the battlefield in the war against Tuberculosis.

Thank you for your greetings on World Tuberculosis Day. It’s been more than a century since we’ve sighted the enemy, but alas there seems to be no end to the hoards of their armed regiments.

At the front, Lieutenants Rifampicin and Isoniazid continue to do a commendable job inspite of the fact that the enemy has designed specific weapons against them called Drug Resistance. Lieutenants Pyrazinamide and Ethambutol continue to serve well, although there are reports of our own troops being injured by them unknowingly during combat.

I understand that new troops with extra fighting capabilities have been identified. It is very essential that they be deployed in our sector at the earliest. Lts. Isoniazid, Rifampicin, Pyrazinamide and Ethambutol have been in the field for quite long and the enemy knows their capabilities quite well. Sometimes, I wonder if the war is going beyond our grip. The new mercenaries of the enemy, MDRTB, XDRTB and TDRTB are ample evidence that we’ve not been diligent. We need the state-of-the-art technology radars available with usto detect these rouges and more potent weapons to fight them.

However, I need to point out issues which our own troops have been guilty of. Quite a few of our troops do not heed to the leadership of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol after some period of time. Instead, they put themselves susceptible to the machinations of the enemy tubercle bacilli. It is quite sad to see this happen.

Meanwhile, there are issues which need to be dealt by the social development wing of the nation. Social determinant issues such as malnutrition, overcrowding and poor livingconditions need to be addressed on a war footing.

Is it true that the enemy is advancing in at least some of our fronts? It is sad to know that even today, in the age of internet and smart phones, people have poor knowledge and attitude about the disease. It pains me to see people spit wherever they want, in spite of the fact that there is evidence of higher spread of the disease because of such practices. Of the last 10 patients, whom I diagnosed to have tuberculosis, more than half of them could not acknowledge and accept the fact that they had the disease. I believe that this is one of the major reasons that there is a delay indiagnosis.

There are quite a lot of the enemy who has infiltrated into our territory without our knowledge. Considering that the private and voluntary sector is the favoured point of contact for a large number of our population, we need to take them into confidence.

I’m encouraged that there is evidence that if standard epidemic control measures are put inplace, we would achieve control on the spread of the disease. We need to follow the basics of public health care. The eight essential components of ‘Primary Health Care’, outlined at the Alma Ata declaration give us enough guidelines to stifle the enemy.

With poor primary healthcare and emphasis on setting up tertiary care institutes all around the battle fronts, this objective is not going to be met. Priorities on tackling malnutrition, rural to urban migrations and overcrowding have to be given priority.

It is sad to note many of our fellow human-beings reap a profit off the victims of the enemy. The government needs to act.

Considering this year’s slogan, I’m sure that there need to be some major changes in our approach to treat tuberculosis. Reaching each of our patients would be a reality only if we allow active detection of cases. The World Health Organisation charter for treatment for tuberculosis has already accepted the superiority of daily drug therapy to intermittent therapy. In India, we need to slowly shift to daily treatment. There is presently no mechanism to ensure that patients remain cured after the completion of treatment. Relapse and re-infection remain hugely unaccounted for.

Unless, we areserious of my above mentioned issues, the slogan for this year – Reach the 3 million: Find, treat, cure TB’ will just be another catchy phrase and an issue to write articles on.

I assure you of my team’s commitment to the control of the tubercle bacillus.

Monday, March 23, 2015

Interesting . . .

Since the lastweek, The Hindustan Times has been doing a feature on the billionaire Indians.

I found this table along with the last article on it.

To have 28 billionaires (18 in pharmaceuticals and 9 in healthcare) who made to the list by making a business out of caring for the sick and dying is a bit disconcerting to me.

I wonder if this statistics bothers anybody else . . .

Barsati's Garden - 2 colors in a single rose plant

Last week, there were 2 roses in a same plant which had different colors. Of course, both the flowers had come up at different times. But, the difference in colors was stark - - -

Saturday, March 21, 2015

Diagnostic dilemma . . .

About a week back, we had a 65 year old man come to outpatient with a history of breathlessness since the last 6 months which increased over the last 2 days. He was so breathless that he could not lie down and it was obvious that he had not had a good sleep since some time. He had a saturation of about 10% which increased to 85% with 5 litres of oxygen.

He was quite confused and made quite a scene on the first day of admission.

On examination, he had bilateral fine crepitations in his chest with a decreased air entry on the right side and other features suggestive of a right sides pleural effusion. On Chest X-Ray, he had right sided pleural effusion and later ultrasound revealed ascites too in addition to dilated portal vein.

His blood examination results are as follows –

Hemoglobin: 10.5 gm%

Peripheral smear: Mild hypochromic microcytic picture with a total count of 15000. Differential count of P87L12M1. Toxic changes present. Adequate platelets.

Serum Creatinine: 0.8

Post prandial blood sugar: 147 mg%

S. Protein: 6.1 gm%

S. Albumin: 3.0 gm%

ESR: 7 mm/hr

We did a pleural tap results of which are –

Total count: 4752 cells

Differential count: L99P1. There were occasional atypical cells with hyperchromatic eccentric

nucleus and blue cytoplasm. ? Plasma cells

Protein: 2.1 gm%

Sugar: 101 mg%

The ascetic fluid was not that much to do a tap.

We treated him with antibiotics and diuretics. He did not have fever and he’s slept well.

He is too poor to go any further. The question is about his further management. We would have liked to do a bone marrow, which we do not have facilities for . . .

Would like feedback asap . . .