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.

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. !


 

Case 3 : A draining embarrassment

In one of the chilly months of 2009, one of very close friend rang me up to share something personal. He was very tense and exhausted.

He briefed me that his wife (middle aged around 37 yrs) is having galactorrohea (milky discharge from both the breasts) for the last 5 months. They had consulted a long list of doctors - Gynaecologists, Endocrinologists, Neurologists ....... but to no avail. Needless to say, all the tests possible under the sun were done with reports being in normal range. The medications like bromocriptine had also been tried.

The impact on the psychology and the moral of the patient was understandable. My friend wanted me to find a solution to this peculiar problem 'which he even cannot discuss with anybody'. I was feeling helpless and sad as I couldn't think of a way  by which I could provide relief, even temporarily, to my friend'e wife. And suddenly, I thought that something was being missed and I enquired about the drugs the patient is taking. And yes, she was taking Sumatriptan, which was prescribed for Migraine 6 months back. I could see the rays of hope emanating  from the horizon. I requested her to stop the medicine (Sumatriptan) immediately and planned for reassessment after 2 weeks. For Migraine, I put her on Tab Flunarazine.

After 1 month, she was ecstatic when she told me that she had got rid of the embarrasing discharge (Galactorrohea) and the migraine !

It was an important lesson I learnt that day : Taking medication history (the medicines patient is taking) is as, if not less, important as the medication (treatment) you are going to start.

 

The invincible

While performing a surgery the other day and during normal ‘chats’ in the course of the operation, the nurse who was with me began an interesting conversation. She enquiringly asked me whether the children born by Caeserian section (operation for delivering the baby) were more intelligent than those born in the normal course. Since I was not aware of such a ‘fact’, I pondered over the thought while finishing the operation.

After a while I told the nurse that her information indicated logical thinking. During an operation (Caeserian section), the baby is delivered quickly and so the child has to struggle less. The risk of the child spending time without air (oxygen) is also less. On the contrary, in vaginal (normal) delivery, the child has risk, though rarely, of getting struck in the birth canal and suffering from hypoxic brain damage (damage to the brain because of decreased supply of oxygen to the brain). The nurse was happy because I had provided an explanation to her ‘fact’.

After a while another thought hit me. I told the nurse that this could not be correct since “any man-made process cannot be more efficient than a process designed by nature”. Even though a birth by operation (Caeserian section) might be faster but still it is an artificial procedure developed entirely by humans. All other species on the planet also reproduce and reproduce more efficiently, and they never seem to require any kind of operation! Agreed that operation does come to our rescue at times, but in my opinion such times are not as common as they are made out to be these days.

Man has moved away or, in more sophisticated words, has progressed from tree shades to air-conditioned rooms, earthen pitcher water to chilled refrigerated drinks, walking to ultra-modern cars, etc. But the point to ponder is that have these unnatural additional comforts and pacemakers in life really contributed to our well-being or have taken away their share from the little peace we had? Whenever man is pitched against nature, he can only win small battles. He can never win the war. Nature is invincible. So, why go against nature and not along with it?

This viewpoint was published in the National Edition of "The Tribune" on 7th May, 2012

http://www.tribuneindia.com/2012/20120507/edit.htm#5

The invaluable fees

I saw a 85 year old lady in the office today evening. She was advised an operation (Laparoscopic Cholecystectomy) by a leading Surgeon of Chandigarh a couple of days back. She heard from one of her colleagues in Punjab Secreteriat about 'ethics followed'  at our clinic. So she rang me up in the afternoon to fix the appointment and came over  in the evening.

To my utter surprise, the old lady had just occassional symptoms (mild pain in epigastric region[upper tummy] lasting for few minutes) and ultrasound showed NO stones at all, just a little sludge. The symtoms appeared more like acid-peptic in nature rather than biliary colic. Her latest echo showed that she had Mitral regurugitation, Aortic Stenosis and Aortic Regurgitation (heart was very weak).

After prescribing Esmoprazole (antacid), I reassured the accompanying daughter that she doesn't need any operation as of now and there are 95% chances are that she won't need any ever.

The eyes of the patient's daughter and son were moist, full with gratitute and thanking me generously. I humbly accepted the fees, which was indeed invaluable.

Case 2: A dignosis too near to be seen

One of my good friends Mr Y, a senior IAS officer rang me to fix an appointment for a journalist friend, Mr A, of his. Mr A's 12 year old son had been running high fever for last 42 days. He has consulted almost every physician of Chandigarh region, undergone a lot of tests and received the 'best' of oral and intravenous antibiotics, but to no avail.

Next day, the middle aged couple with their young apprehensive son with an intravenous cannula (a device through which the injections are given) in place on his left hand came to my office.

I asked the history in detail (about the fever and other associated symptoms) and examined him. Going through the 'thick' file, I could see prescriptions of 'all kinds of specialists' and found that almost every possible antibiotic (from amikacin to vancomycin to meropenem) has been pumped into the young body.

After 20 minutes of 'clinical' session, it seemed to me that in pursuit of a 'bigger' diagnosis, Malaria had been a too simple diagnosis and had perhaps had been missed. I told them that for the time being, the child just needed to take 5 tablets of Chloroquine over the next 3 days.

The parents, understandably were not amused and looked towards each other conveying "what a waste of time and effort'. They had come all the way and expected a rare 'big' diagnosis from 'a renowned doctor of AIIMS'. I could read the expressions and reassured them that I am available in the city and would definitely take a relook after 3 days. They just needed to be patient. They agreed on this option as perhaps they didn't have many left.

After 72 hours, I received a call on my cell from Mr A and could know what he would say from the tone of his voice. " Sir, you are genius, my son got rid of his fever for the first time in 6 weeks. I am so................". As I was listening to the phone call, the prophetic words of my par excellent teacher, Prof AN Malviya, Head of Department of Internal Medicine at AIIMS, New Delhi in 1990's, echoed in my brain " I would crucify (fail) you if you make a diagnosis other Viral or Malaria in a patient with fever of less than 7 days duration".

Clinging to these lines, I have found myself on the right side so often and so often, have seen physicians making a diagnosis of Typdoid or TB in a patient of fever with only 3-4 days.

Common sense is of paramount importance especially in Clinical science.

The great, Sir Robert Hutchison, wrote in British Medical Journal in 1953

From inability to let well alone;
from too much zeal for the new and contempt for what is old;
from putting knowledge before wisdom,
science before art
and cleverness before common sense;
from treating patients as cases;
and from making the cure of the disease more grievous than the endurance of the same, O Good Lord, deliver us.

Case 1: A missing arthritis

A friend of mine in Chandigarh called me to fix an appointment for a 76 year old father (Mr X) of his friend in Delhi. Mr X was suffering from severe osteoarthritis of his both knees and had been advised knee replacement of both the knees by the two leading orthopaedic surgeons of Chandigarh region.

I was a bit reluctant to call the patient to my office as the diagnosis was already made and I had not much to contribute. But on my friends insistence and satisfaction, I agreed.

The 76 year old weak gracious gentleman walked limpishly with great difficulty into my office taking small steps a time and got seated in front of me. Initially, the thought baffled me that this 'old weak man with trembling hands' would be subjected to a major surgery but then i was relieved thinking that the operation would releive him of his troubles.

The main complaint of Mr X was that all his body was getting 'rigid' and he could barely walk, which was obvious. I started examining him (more so as a formality as he had come all the way to consult me). I requested him to slowly bend the left knee. To my surprise, he could bend 70% of the knee. On enquiring, he divulged that there was no pain in bending whatsoever. The same sequence was repeated on right knee with the same results. The findings puzzled me as the patient of severe osteoarthritis cannot easily bend his/her knees and that too without pain.

My mind started running in every direction and after few seconds, it struck " O my God, the patient has all the three components - Rigidity (he's complaining), Bradykinesia meaning decreased ability to walk and Tremor (I could see)- of Parkinson's disease".
I immediately rang Dr Manish Sinha, a neurologist friend in Alchemist Hospital, Panchkula and briefly told him the history, examination and the diagnosis. He exclaimed " Dr Pankaj, you have made the diagnosis, it must be correct. Pl send the patient to me tomorrow". I felt flattered by the compliment and more by the thought that the old man would be spared an unnecessary operation due to a wrong diagnosis.

Next day, the patient consulted Dr Sinha and his medications for Parkinson's disease were initiated.
 

Introduction 3 : Ethics of a doctor

Ethics in every profession in the society are degrading faster than the speed we are aging. But the degarded ethics in medical profession hurt more and evoke stronger reaction. Why?
It could be because of the following reason. Since several centuries, medical profession has been based on ethics and removing agony from the lives of suffering people. Other professions also perhaps do the same for example lawyers also removes agony from peoples lives. But perhaps there is a difference. A lawyer's client has committed/accused of an act of commission which leads to some loss of sympathy for him/her whereas a doctor's client is almost always 'innocent' and all sympathies are with him/her. This is true as well. So when it is said that medical profession is a nobel profession, it implies that no other profession is as nobel if rightly done.

After my 22 years experience in medical field, I strongly feel that in the long run, an ethical honest and competent doctor is always successful. You may lose a few patients in the the short run but ultimately your reputation as a ethical doctor conquers every heart and would bring even people from faraway places to you. So good ethics is the best policy !

Introduction 2: A complete doctor

An important person required in the society today is "A complete doctor".

What is a ' a complete doctor'?

Somebody rightly said "Specialization (MD & MS) and Super Specialization (DM/Mch) is  knowing more and more about less and less..........and perhaps, ultimately knowing, everything about nothing !!".

This is a major challenge we face today. As the craze for specialization and number of specialists increase, the number of generalists (a general doctor) decrease. This lead to a number of problems in proper diagnosis and treatment.

I often see, right from from post graduation days, surgeons refusing to read ECG's of their patients (saying 'let the cardiologists do so'), ENT surgeons not evening taking history in a Rehumatology patient, Gynaecologist refusing to talk to a patient/relative with an eye problem etc.

The point here is NOT to be a master of all fields; but to ensure that as a specialist, you don't wipe other specialities from your mind. As a specialist you don't have to treat patients of other specialities, but I strongly feel that a specialist should have a fair knowledge of other specialities and should at least be able to make a reasonable diagnosis.

God made only one single body; different specialities are made by us-humans. So no bacteria, virus or for that matter of fact, any illness is expected to restrict itself to the artificial systems and specialities (heart, brain, tummy, gynae etc) which we have made. So it becomes inevitable that a practicing clinician in ANY speciality would come across patients, not too infrequently, when the illness of his speciality presents as an illness of some other speciality which he/she would miss if they are not well acquintated with other specialities.

I daily come across patients who are treated like a 'football' (referred from one doctor to another) for the want of a proper diagnosis; which would not happen if a good 'complete doctor' sees such a patient.

Introduction - Why this blog

I felt the need to create this blog to share my experiences as a doctor (not only as a surgeon which I am).

In my opinion, ETHICS & COMPETENCE are the two pillars for any professional, much more so in medical field. And these are the two most debated aspects about doctors in India and across the world. So through this platform, I shall share my experiences and views primarily about these two aspects of medical profession.