Thursday, December 20, 2012

My biggest enemy

We are surrounded by friends and enemies. And we ought to know about them. Not knowing about a friend is a great loss and missing out on an enemy is quite dangerous. I found about one of my biggest enemies, quite close to me, pretty late in life.

It was my dream and an inherent desire since 1999 to do clinical research and publish quality articles in international prestigious journals. I always felt that by doing so, you not only contribute, howsoever miniscule, to the global welfare but you also leave a legacy. If your research is of fair quality, you might be quoted or remembered years after you have gone !

I had no experience or expertise in this field (research).  In 2004, I wrote, rather attempted to write, a case report on a new finding while putting a central venous line. After completing the article, I was keen to send it to Indian Journal of Surgery but couldn’t muster courage to send it. The quality was evidently below par. I even mailed the article  to a friend in PGI, Chandigarh for suggestions to upgrade the quality. The dream remained a dream to be fulfilled  some other day. The article was frozen in a cold store for the next four years.

In August 2007, while I was in Mayo Clinic, Scottsdale, USA as a visiting Clinician, I had a conversation with Prof Jagat Narula, an eminent and reputed Cardiologist in USA. He was the editor of one of the topmost Cardiology journal in the world- JACC (Journal of American College of Cardiology).  When I expressed my hidden desire to learn research, he asked me “ Do you seriously intend to learn research?”. I immediately said “yes”. “Come to me in Irvine”, he said. Dr Narula was Chief of Cardiology in University of California, Irvine. Confused, I asked “But sir, I am a Surgeon and you are a Cardiologist. How would I learn research from you?”. He said with a little smile and a heart capturing style “Pankaj ji, research is research. And human body is one. Come over to me for 4 weeks and you would learn the ‘state of the art’ research”.  Ironically, turning points in life come without knocking but the echo of their knock can be heard throughout the life. So mesmerizing was his aura, so contagious the confidence, so captivating the humility and so instant the connection, I stood there awestruck and my lips could only move in one direction- “Yes”.

On 29th August 2007, Prof Jagat, his deputy and myself were sitting in his office. After much deliberation, 4 projects were zeroed upon. These were to be completed, written and submitted by 26th September, the last date for the Paper submission for American College of Cardiology (ACC) annual meeting to be held in Chicago in March 2008. I was to work with a team of four people (3 medicine residents and one undergraduate student) collaborating with Dr Jagat’s deputy and under the overall guidance of Prof Jagat.

Those four weeks, from 30 August to 26 September, were full of hard work and responsibility. Though a bit stressful yet it was one of the most memorable and enjoyable times of my life. We worked day and night literally and on 26th night, all the four abstracts (papers) were submitted online. I was the first author in all of them.

During the month’s stay, we were always discussing about the well known revered names and  top most journals in the world and submitting articles in these journals.  I also assisted Prof Jagat on a Review article on Vulnerable plaques (the blockages which cause heart attack) which was subsequently published in Nature series journal, one of the top ranking cardiology journal in the world. The whole experience was an eye-opener  as ‘only in dreams’ could I think of publishing articles in such prestigious journals. The biggest realization was that the doyens and stalwarts in any field are not ‘imported from some other planet’ but are very much ‘human. The things that makes them stand apart is uninhibited original thinking, good environment (facilities), dexterity and able mentors. So the goals which seem unachievable or beyond reach are so because of the barricades built by our own mind. Once these are broken, no goal is unattainable.

Two out of the four papers were accepted for presentation in American College of Cardiology, one was presented in American Diabetes Association (ADA) and one in American Society of Cardiovascular Computed Tomography (SCCT) conference in July 2008.

 I came back to India in October 2007 but without the barricades. There has been no looking back since then. In the last 5 years, we could publish more than 30 quality papers in topmost US & European journals. As a matter of routine, we only send articles to US & European journals.  And in 2008, the first article on central venous line, lying in cold store, was rewritten and was accepted for publication in the Indian Journal of Surgery, the only article we sent to an Indian journal.

Yes, I had discovered my biggest enemy- my own mind and the barricades erected by it.

Thursday, November 22, 2012

Water that is not a life saver !

Small observations by great people may lead to great discoveries. As observation of a fall of an apple by Sir Issac Newton led to the discovery of the greatest laws of Physics. I also narrate an interesting story here. However, in this case a small observation by a small man led to a small discovery.

In the later half of 2008, over a period of few weeks, I got a spurt of patients in my office suffering from Anterior Anal Fissure.  [Anal Fissure is a condition with severe pain in the anus due to a cut caused usually by constipation. In males, 99% of fissures are on the back side (posterior) side of the anus and 1% on the front (anterior) side]. Initially I ignored it thinking it to be routine presentation but after some time, I was perplexed to note that 95% of the male patients coming to me with fissure had anterior(front) anal fissure (which were supposed to be less than 1% as per the literature). I was wondering as why this change of trend was happening. One of the patients was not getting alright even after being operated by one of my friends. I discussed it with a couple of my colleagues but even they had no idea whatsoever.
I kept on thinking for few days- in every possible direction and every possible cause- as why this could be happening and what could be the reason of this reversal of trend but to no avail. Ignorance turned into desperation was now bordering into frustration. On a routine but eventful day,  one of the similar male patient (suffering from anterior fissure and not getting relief with usual medicines) came for consultation to my clinic. Mentally prepared to listen to him for an hour, I told him  “Tell me everything in detail from the very beginning of your illness”. I was vigilantly listening as he was narrating his story. Suddenly he spoke something that made me rise in the chair and I almost jumped. He said  “I turn on the water-jet and then sit for 10-15 minutes”.  Oh my God ! was it the water-jet which was responsible for all this?

Yes, it was possible because water jet in the toilet seat from behind would hit the front wall of the anus and cause anterior (front) anal fissure. The use of water jet in toilet seats is rampant in North India and this could explain the rising trend of anterior(front)fissure in the population. This would also explain why one of the patients couldn’t get relief even after operation (because he must be using the water jet still).

I took out my out patient register and called all the patients with anterior fissure I had seen in the last few months. No wonder, all were using water jet and that too for a long time. I advised them to stop water jet immediately to which the response was spectacular.

On Feburary 1, 2009, I submitted this research to a prestigious British journal, Colorectal Disease (Colorectal Disease is published from England and is the second highest ranking colorectal journal in the world. It is the official journal of British & Ireland, European and Spanish Societies of  Coloproctolgy) and to my utter surprise, it was accepted for publication on the same day it was submitted (normally it takes 6-8 weeks for the peer review process). It subsequently got published in 2010 June issue

Pankaj Garg. Water stream in a bidet-toilet as a cause of anterior fissure-in-ano: A preliminary report. Colorectal Disease 2010 Jun;12(6):601-2

It was also covered in the leading newspapers of the region from time to time
Hindustan Times- June 9, 2009- Water jet in Toilets may cause Anal Fissures

Aaj Samaj - 5 November, 2012- Jet Spray in Toilet dangerous !

 The Tribune (National Edition)- July 8, 2009- Water jet in toilet behind rising cases of Anal Fissures

Last month, a neuroradiologist and a learned friend of mine from London, informed me that water jet is used in the instrument- Water jet Cutter- a tool capable of slicing into  metal or other materials (such as granite) using a jet of water at high velocity and pressure.

Monday, November 12, 2012

A stubborn blood pressure that refuses to rise !

This was in the winters of December 2008. Mr A, a close family friend of mine had come from Silicone valley (USA) to take care of his father who had been diagnosed and operated for kidney cancer (Renal cell carcinoma) at AIIMS, New Delhi in September 2008.

On that morning, Mr A called me up and frantically said “Pankaj bhaiya, the blood pressure of papa has fallen and is refusing to rise. Its 74/40 since late last night. We called a physician and he has given a lot of medicines and injections. Even after giving 4 bottles of intravenous fluids, the pressure is still the same. He was absolutely alright yesterday evening- eating, drinking, talking and joking. What should we do?”.

I  was surprised and confused at the same time. I had seen him recovering absolutely well after the operation in September and had resumed his normal routine from mid October. I had also telephonically conversed with him two days back and he was quite jovial (optimistic as he always was) and reassuringly fit. So what could have happened so suddenly? Was he in shock (extreme fall in blood pressure most commonly due to bleeding or infection)? But there were no obvious signs of any bleeding or infection.  I also discussed with the physicians treating him but they were clueless as well.

Clueless, thinking in all possible directions. It was a déjà vu situation; a situation I find myself quite often in. May be I welcome, am always happy and available to analyze difficult and complex medical conditions or may be I am too nosy (poking my nose everywhere); whatever it was, my mind was running amok and scanning all the possible causes of hypotension (low blood pressure ) I could think off.

Suddenly, like a flash of light, it struck. Could it be adrenals (glands responsible for production of steroid hormones in the body which play a vital role in maintaining blood pressure); Adrenal failure because of the metastasis (spread) from the operated kidney cancer tumour. Since the patient was not in the condition for a CT scan, I requested Mr A to suggest his physicians to give an injection of steroid (Inj Hydrocortisone) immediately and evaluate the response. Even if the adrenals were normal, one injection of steroid was perfectly safe.

One hour later, I got a call from Mr A. The response was more than dramatic. The patient was sitting and talking with his pressures restored. Mr A was extremely happy and thankful; but I was sad and sorry. My heart had sunk.  I couldn’t muster courage to tell him at that moment of momentary joy that the cancer has come back with a vengeance   and has almost reached the last stage.

I said “thank you, take care” with a heavy voice which he could hardly hear and closed the call.



Wednesday, November 7, 2012

Loss of an acquaintance

In the summer of 2009, who was admitted in a tertiary hospital in Panchkula (Chandigarh,India).an acquaintance of mine, Mr P, called me to take advice regarding his father

Mr P's father was a 78 year old gentleman who complained of difficulty in breathing (dyspnea) and some discomfort in the chest during the previous night for which he was admitted in the hospital the next morning. The emergency physician diagnosed it as due to some heart problem and sought a cardiologist's opinion. The cardiologist also agreed and posted the patient for Angiography (and proceed according to the findings thereafter). Meanwhile, Mr P rang me up for advice.

On initial discussion, the breathing difficulty and the chest discomfort looked a bit atypical. I advised Mr P to take a second opinion but on his insistence, I agreed to pay a visit.

I saw Mr P's father in the evening. As mentioned earlier, the symptoms didn’t seem like to be originating from the heart. On probing, the discomfort looked more in the upper abdomen (tummy) rather than the chest and the tummy also seemed a bit distended (bloated). On further inquiring, it was revealed that the patient had been suffering from severe constipation and had not passed motions for the last 5 days. The distension of the tummy and the breathing difficulty had been progressively increasing since then. I immediately did a per rectal examination and found the rectum fully loaded with tons of motions (fecal matter) ! Obviously, he was suffering from fecal impaction- a common condition in the elderly age group people who eat less fibre and move even less.

I immediately ordered a rectal enema and got it repeated at regular intervals till the impaction finished. The patient's symptoms and distension disappeared. He was sent back home with in 24 hours and was advised high fibre diet and ambulation (walking) on discharge.

I permanently lost an acquaintance that day and gained a very close friend !

A dependable man

Last year, a very senior bank officer Mr A came to me to show his father. His father, 96 years old, was bed ridden and had to be brought in on a wheel chair from the car to the bed in the emergency room.

After taking history and conducting a thorough examination, I suggested that even though an operation would be ideal, but considering his age and condition, I would prefer doing a small procedure which would give him considerable relief.

I just enquired as a matter of fact from Mr A " Is your father  dependant on you?"
(In India, a lot of government offices and banks reimburse the expenditure done by an official on himself and on the people financially dependant on him  such as his wife, children less than 18 yrs and the retired parents.)

Mr A almost instantaneously replied with a light smile " No doc, he is not dependant on me. I am dependant on him".

After standing speechless for few moments, the time it took me to absorb the iconic statement, I smiled back and nodded my head in agreement.

I could conclude at least one thing- a man with such ethics and character is quite dependable !


Friday, October 26, 2012

Case-5 : I operate only on humans, not on X-ray Films !

A remarkably similar experience happened with two different persons from opposite corners of the Indian sun-continent- One from Srinagar and other from Dhaka, Bangladesh.

Mr H, a 55 yr old gentleman, came to me two months back (August 2012) from Dhaka along with his wife  and a young son. Both father and son were pilots in a commercial Bangladesh airline. Mr H was earlier a pilot in Bangladesh Air Force. He was suffering from chronic anal fistula and somebody told him about me and they came to Chandigarh fully prepared for operation.

We were sitting in my office in the evening and after exchanging courtsies, we came to the main issue. He narrated his history in a doctored manner which I patiently listened. I examined him in detail and then studied the MRI which was recently done. Surprisingly, Mr H had no symptoms of anal fistula for the last 9 months, though the MRI showed a tract (fistula). It is a known fact that a MRI can show even a healed tract for years.

I told them that no intervention was needed as there were no symptoms for nine months and a significant (about 70-80%) chance was that his fistula was healed and might not trouble him for the rest of his life. Mr H looked upon me in disbelief unable to hide his disappointment. He apprised me of the difficulties they had encountered (getting an Indian visa for a Bangladeh Air Force ex-pilot was the biggest of them) and the logistics exhausted (expenditure and the holidays) on the trip. He literally pleaded me to operate on him as coming again would be an impossible task for him.

I clearly understood what he was saying and feeling. Empathizing with him, I explained to him that while taking decisions for surgery (whether to operate a patient or not), I only take medical factors into consideration and with great effort, keep all other factors (social, financial, logistic, various pressures etc) out of this process. I always think if my brother/relative is sitting in front of me instead of the patient, what would I advise him. The same advise would be the best for the patient.

It did take some time and effort to convince the patient that when chances of getting alright are quite higher without operation (though not 100%), it is better not to operate. I also requested the family not to take too many opinions because some surgeon may operate on him seeing the MRI report and he would be legally justified in doing so.

Next morning, Mr H and his family flew to Srinagar to spend the rest of their vacation.

I was caught in a similar situation 3 years back when Mr Z came to my office with his father from Srinagar. Mr Z is an editor of a leading weekly magazine in J &K (Jammu & Kashmir). His father was suffering from a Recurrent anal fistula and was advised an immediate operation after a MRI showed a fistula tract.

On detailed consultation, the 70 yr old gentleman (Mr Z's father) had no discharge or symptom for the last 16 months. As mentioned in the above case, I advised them to sit back and observe and not to go for an operation. The patient looked at his son in a disapproving manner as if saying " where have you brought me, my lad?". Without any effort, I could read them with ease. It took me about 20 minutes to explain them the risks of operation especially when it is not needed and the chances (more than 75%) of his getting alright without surgery. Mr Z asked " Agreed that my father is alright, what about the MRI which shows a fistula tract?". "I operate only on humans, not on X-ray Films !" was my candid reply. While departing, the old gentleman tried to touch my feet acknowledging his gratitute. I escaped this  embarrassing situation by  jumping back and folding my hands in respect.

Mr Z sends his magazine regulalry to me by post which I accept with great happiness and pride.

Thursday, October 25, 2012

Case 4 : Past is important

I received a call yesterday from Mr J, son of an ex-minister of the state that he wanted to consult me and we scheduled a meeting today.

Mr J, a young handsome gentleman (of about my age) came to my office today afternoon with his wife and a small cute baby, 3 yrs old. He had come to consult regarding his wife who had developed varicose veins ('swollen veins and lumps') over her leg. She had developed these about 3 years old, around the same time of her pregnancy.

On examination, I could see some prominent (hardly significant from medical point of view) veins over her left leg around the knee and even fewer around the ankle. They hardly fitted into anything like varicose veins (long sephanous or short sephanous systems). I assured them that these were just prominent veins which are commonly present in some people and are best ignored.

Then she pointed towards a lump present behind her left knee. It was 4 x 4 cms soft compressible non-tender lump present in the popliteal (knee) fossa. To me it looked like a Baker's cyst (swelling of bursa) or a lipoma ( fat swelling) [Bursa: A bursa is a fluid filled sac/pouch that provides a cushion between bones and tendons and/or muscles around a joint. This helps to reduce friction between the bones and allows free movement. Bursae are filled with synovial fluid and are found around most major joints of the body]. I again reassured that if the swelling is asymptomatic and is stable for the last 2.5 years, then nothing has to be done apart from observation.

At this, she drew my attention to similar swellings behind her both ankles and knees. On examination, they all looked liked bursal swellings. Now, I was thinking as what could possibly cause multiple busral swellings Earlier I had thought of referring her to an Orthopaediacian (bone doctor) but now I changed it to Rheumatologist (doctors who deal with autoimmune diseases like Rheumatoid arthrits, SLE etc).

But I was wondering what could perhaps cause multiple bursitis and subsequent bursal swellings ? All detailed history about fever, oral ulcers, hair fall, small joint stiffness, muscle weakness etc ( symtoms of athritis/ Rheumatological diseases) were negative. So could it be pregnancy because the swelling started around that time only (about 3 yrs back). I was as confused as earlier.

I decided to probe further. That's what make clinical medicine so interesting. My teacher used to say "Every patient (even suffering from the same disease) is different and a good clinician should always  be alert and smart like Sherlock Holmes to unravel the mystery and identify the culpri. Thats why computers and robots can never replace human brains as far as clinical medicine is concerned. In medicine, 2 plus 2 can 3, 4,5 or even be 7 ".

On further probing, she divulged that she had also suffered from high fever and joint pains 3 years back and she was diagnosed as suffering from Chikungunya. I wondered whether an episode of Chikungunya could be responsible for all this. I knew that Chikungunya causes arthritis but was not sure whether it could cause bursitis and subsequent bursal swellings. I explained this to the patient and opened internet on my mobile. I checked a couple of trusted sites and also came across a paper on Chikungunya in Indian Journal of Dermatology from Dr Alladi Mohan, an old trusted learned physician from AIIMS , in which the disease was described in detail. And yes, Chikungunya can cause bursitis in multiple joints and residual bursal swellings even years after.

The patient and her relatives were reassured once again and no doubt all of them were extremely happy.Mr J was quite impressed and wanted to interact more. And so, we kept on talking. Mr J had done PhD in international economic relations from John Hopkin's University, USA and was quite knowledgeable and intelligent. We talked about everything and anything and to our utter surprise, it turned out that both of us were together in Campus School, Hisar (Haryana, India) during our schooling from 1985-1989. Mr J turned out to be my brother's classfellow, who was one year my senior.

Wow, its a small and wonderful world. !