Sunday, August 30, 2009

Ignorance is bliss

Sometimes patients don’t know the danger they are in and even if it is explained to them. They either are not bothered or not intelligent enough to understand. Four days ago I had this man Satish who works for a friend of mine. Satish developed some discomfort in the chest which he attributed to gas and managed a day or two with antacid tablets. As the pain kept coming back, his boss forced him to see me. There was nothing remarkable in his history except that there was early death of his father when Satish was a child of five years. Satish is now 40.

A blood pressure check was horrifying. This otherwise hale and hearty looking fellow had a blood pressure of 240 over 140, highest recorded in my practice in recent years. His pain chest was due to his heart bursting virtually at its seams against this high resistance! Immediate administration of quick acting medication brought his blood pressure down to 160 over 90 and the tests showed strained heart muscle. His blood lipids too were sky high.

His chest discomfort had disappeared. I interviewed Satish and his wife and spent time explaining the seriousness of the illness and why he should change his lifestyle, take regular exercise, eat low calorie food and take medication. The vacant and rather bored expression on their faces never changed throughout the half an hour they spent with me.

The parting question that was put to me by his wife said it all. ‘Sir, he is very fond of ghee, can I put two spoons of it in his rasam rice?’

If I felt like beating my head against the wall will you blame me?

Friday, August 28, 2009


When I first met Cyril Naronha he was past seventy. That was some twenty-five years ago. He just peeped into my clinic one day and having found no patient waiting, sat for a while chatting. I later realized that it was his nature to be pleasant to everyone around him that included the daily sweeper of his house and the neighbor’s gardener. He spoke Kannada with a delightful Mangalorean accent. He spoke the language out of choice, though he could speak impeccable English when the occasion arose. In contrast his wife, Miriam Naronha always spoke to me in English. Not that she couldn’t speak Kannada. But English came naturally to her and she was comfortable conversing in it. At home they spoke Konkani, a language which I spoke as a child but since have forgotten to speak but can understand very well. This came in handy when there was any conversation between husband and wife in Konkani that they thought was private and excluded the doctor. This occasionally led to hilarious situations.

Mr.Naronha always paid my fee with a new note. He sometimes took the trouble of going to the bank and exchanged the soiled one with a new one before visiting me. His wife had no such compunctions. When they visited me together, she being the cashier of the house would pay. Once she paid my fee and the notes were visibly dirty. An irritated Naronha told her, ‘I did not know of your love for the old and the decrepit, extended to the old notes; do you think our doctor is there to dump your filthy torn notes?’ She would have none of this unjustified criticism, she said, ‘my husband, what can you expect out of a wife who has had to make do with second hand things most of her life, including the husband! [He was her second husband]!

There were other features that made me like Cyril. He was always impeccably dressed. He had braces to hold his trousers up, first time ever that I saw them. He told me that when young with a bulging belly he needed them to keep the trousers up and now that he had lost he midline bulge he needed the braces to keep them slipping down and making him liable to the charge of indecent exposure! He also had a tie on, that had seen better days. In winter he would have a coat on and in summer he would do without. All this meant, given the slowness of age, he took more time dressing and undressing than the time spent in examination, quite exasperating when you have a houseful of patients waiting. But he more than made up for this by his humor I don’t remember an occasion when he went without making me laugh. Though he did not need to visit me frequently he made it a point to come once a month usually during the first week when he still had his pension money to spend as he once said. My guess is that he came any way to spend some time chatting up with my patients and my attendant and then with me and thus to have a good time. It is only after his death that I realized how much his visits meant to me.

He also told me some home truths about us doctors. Once he compared to Church priests. Both spoke in a language that the clients did not understand. The priest said his prayers in Latin and though doctors spoke in English it is as bad as speaking in Latin. The priest took confessions and the patients too did that with their doctors. He had a very valid explanation for obesity. It was his belief that when you diet you put on weight and when you don’t you remain normal! He gave his own experience of weight gain and loss. When in service he was careful with what he ate and drank but still gained weight. But now in his old age he ate everything edible and drank good wine but had lost the weight and felt never better. He joked that in this country when you hold official position of power it not only swells ones head but also one’s belly! He did not much like my habit of not giving medication when none is needed. He once told me that one must always give something even if not required. He said the bitter the medicine the better the patient felt. He was all for the mixtures [name for liquid medicines doctors made up those days] dispensed as part of the treatment. He compared this with the practice of temple priests giving something away to the devotee in return for the prayers offered. That is one way of getting the till filled he said. When I told him the psychological and placebo value of these mostly useless ministrations and the need to educate the patients, he said patients will always remain ignorant, and felt it is good for their health not to know too much!

He suffered from stable angina and lived with it for several years. The basic investigation those days was the two-step treadmill, and it was strongly positive. They had just begun doing angiography in few centers and no one did it for a seventy plus person. They were destined to be treated conservatively with the mainstay drugs, the nitrates. Cyril did very well with three four tablets of these a day. I visited him on one of those occasions when he had just recovered from an attack of chest pain. He was not sure where the pain actually was. Was it located in the upper abdomen, lower chest or both? This kind of confusion was not unusual and we had no way of knowing whether the patient has had an ischemic episode, a full-blown infarct or just an episode of hyperacidity. We relied mostly on the resting ECG, the patient’s history and our past knowledge of the patient. I found the ECG no different from his previous ones; his blood pressure and pulse were stable. I reassured him and joked that he will live to a hundred and came home.

That night Cyril died in his sleep. They realized it when he did not wake up in the morning. I was now sure that the previous day’s pain was the beginning of a heart attack yet to show in the ECG. I felt terribly guilty not having sent him to the hospital. Instead I had assured him 100 years of life! I went to his place feeling terrible. There was a somber atmosphere with the body laid in the main hall. The parish priest had just left and I went to his wife and couldn’t help apologizing. She said, ‘doc, it is good you did not send him to the hospital, he died peacefully with no suffering, thank you very much for all that you did for him’

Few years later, Miriam too died. Their son, from Cyril’s first wife, comes periodically to Bangalore to visit his mother in law who lives here and drops in to see me. Except for the central bulge he is a replica of his father.

Thursday, August 27, 2009

Spell check

Many years ago, in the early days of PCs, I got this one from an unknown source.

Eye halve a spelling chequer,
It came with my pea sea.
It plainly marks for my reviue
Miss steaks eye khan knot sea

And an apt rejoinder from Jeff Aronson, who wrote [still writes?] filler for BMJ, follows.
Eye have run this filler threw it,
I am shore your pleased to no.
Its letter perfect all the weigh
My chequer tolled me sew

On growing old

The foot less prompt to meet the morning dew,
The heart less bounding at emotion new,
And hope, once crushed, less quick to spring again.

Mathew Arnold

Clinic capers

Loud annoncement heard over the public address system in the patients waiting area of a hospital's gastroenterolfy clinic. 'Mr Ramakrishnan, please come for your enema'

A patient told my doctor friend that he [patient] has been having wireless fever for which he has taken kerocine [Crocin].

Sunday, August 23, 2009

Incence and Asthma

25 years ago I used to make many house calls. I do hardly any now. Those days the emergency care in out of office hours was provided by us general practitioners and a large percentage of these calls were from those suffering with acute asthma. Asthma then as it is now is a serious disease and our visits meant a great deal to the patients and often was life saving. They were also the days when there were no inhaled bronchodilators and corticosteroids which have virtually eliminated emergencies of the kind we saw then. This city as it is now even then had a high incidence of asthma. There were also fewer institutions and doctors to provide emergency care. It was thus common place those days to drive 20 kms and back after making a house call. It was not difficult to drive as the traffic was thin and road users were less aggressive. I cannot imagine doing the same with the chaotic traffic of today.

This was also an essential part of our lives and these house calls helped us to get to know our patients better. It begets a special relationship when you share a cup of tea with the patient’s husband/ wife/ father after the visit before you started back on your lonely drive back home. You could also subtly assess the economics of the household by the way they lived. Though what the patient paid or could pay fell far short of our expectations, the indirect professional rewards made these house calls worth making.

When the call in question came, it was past 11 pm and I was just drifting off to sleep. It was the frantic voice of my friend and patient Arif that I heard, he said, ‘doc, my wife is having an attack of asthma, if you don’t do something quick she will die’. I asked him to give her a tablet of Alupent [a popular remedy those days]. He said he had already given that and it has had no effect and he stressed the need for me to hurry.

It is no exaggeration that acute asthma can kill if not relieved urgently and it was experience of many of us to have witnessed such deaths. I pulled a pair of trousers over my pajamas, told wife where I was going and not to expect me for another two hours [the house was 15 kms away], took the ever-ready kitbag containing all the essential equipment and went to the car. Took the car out and came on to the main connecting road.

Here I must describe how this extension was 25 years ago. The main road which is now a bustling wide road and the commercial hub with traffic round the clock was a barely motorable road which became narrower at both ends where it met the high way. There were no streetlights worth the name. The houses on either side were few and far between. Now if you add to this scenario a constant drizzle very few would venture out. It was November and Bangalore was colder then than it is now. This was the scene when I went out to make this house call. A km down the road I felt the characteristic wobble of my car indicating a burst tire. I had a car that went by the name of Gazel, a version of the popular standard herald car of those days. For a doctor, especially a GP, his car is his best friend. But I cannot say this to my Gazel. The amount of trouble I had with this car, no enemy [even imaginary one] could cause. That is another story which I will narrate some other time.

I had to take the car to the side of the road for an inspection. The rear tire was indeed flat and I had no option but spend some precious time changing the tire. They were pre cell phone days and I had no way of getting in touch with Arif to give the news of my delay. The best way is to change the tire as quickly as possible and be on my way. This was not as easy as it sounds. For one it was pitch dark, there was a cold drizzle and I had only a flickering torchlight to go by. There was no choice. I went back, opened the boot, took out the tire wrench and the jack and turned. That was the first time I noticed the presence of the Dog Doberman. The dark shape merged perfectly with the background. Unlike the other breeds Doberman attacks first and barks later. This dog fortunately just stood there staring at my torchlight and my hands that held the tire wrench and the heavy jack. I let go the jack which fell to the ground with a thud. The sound brought out the fighting instinct in that dog; he let out a huge bark and jumped. At the same time I also jumped and took a swipe with my wrench. Fortunately both of us missed the target and he landed on the car and gave a painful yelping bark and I hid behind the other part of the car away from him. He started sniffing the fallen jack, satisfied that it is no enemy and finding none else he let out another howl. This brought out a chorus of barks from all the dogs in the neighborhood, both strays and the domesticated. I also could see several strays running into join the battle. Thankfully for me the strays were friendly to me but were hell bent on attacking the Doberman. I could now safely retreat to a distance and watch the battle in the dim light.

The commotion brought the lights on in many houses and one of them realized that it was their dog’s cries of anguish. Mongrels [stray dogs] are good fighters and the Doberman was outnumbered. Out came the gentleman of the house calling out, ‘tiny, tiny, where are you, come in my pet’. The dog retreated into the compound and both the master and the dog went in, completely ignoring me and my predicament. This did not bother me, as I knew how my upper class countrymen behave in such times. Seeing only a hapless human, the canine pack quietly retreated leaving me to do my tire-replacing job. With the slippery conditions, placing the jack at the right place was no easy task, and must have taken much more time than usual. With grimy hands and anxiety in my heart I drove the distance to Arif’ s house.

I found him restlessly pacing up and down the verandah of his house. ‘What took you so long? you left the house an hour ago, I called your home and bhabhi [sister meaning my wife] told me you had left, she must be worried, I will call and tell that you are OK’, Without waiting for me to say anything he went to call my home. I knew she wouldn’t be upset but the thought of her waking up once again was not pleasant. I went into the house.

There was a pungent smell coming out of the patient’s room that had spread to the whole house. My tired nose started twitching and the irritating fumes made me cough, by then Arif arrived having assured his bhabhi that her husband is safe and at his assigned job. I asked him,’ what is this obnoxious smell?’ He said that is his mothers doing, after waiting for you so long she went and put something into the fire and this smelly vapor is supposed to help my wife’. Here I must tell you a bit about Arif ‘s mother. Being a mother of 8 children and innumerable grand and great grand children, she is the matriarch of the whole clan and her word is the law in that home. We have a love hate relationship, having crossed swords many a time with the same intention of healing the sick, she her way and I my way. Now, this way of effusing pungent fumes in an asthmatic’s room is tailor made to worsen the asthma. Those days I had even shorter fuse than now and my encounter with the Doberman had made my mood foul. I couldn’t help making some acerbic remark about the old lady little realizing that she was standing just next to the door we were entering. She said to me without mincing words, ‘ are you going to stand there making unwanted remarks or are you going to see the patient and give her some relief, you have taken your time to reach here, Allah ka marzi [thanks to merciful Allah], she is still alive’. Though angry enough to give a fitting retort, I held my tongue, as the patient was indeed very sick. There was much labored breathing with wide spread fine ronchi [sounds made when there is obstruction to the free flow of air] in her lungs with a tinge of blue in her tongue indicating insufficient oxygenation. The fast heart rate was due to a combination of breathing difficulty compounded by the thumping dose of alupent.

I loaded the syringe with Aminophylline and began the slow IV. After this was over, gave her dose of Betamethasone again IV. Now was the time to wait and see what relief one would get or what side effect I was going to produce with the aminophylline, a dangerous drug at the best of times. No immediate adverse reaction to the drug occurred in the first ten minutes and I heaved a sigh of relief. Now I could take stock of the surroundings. I noticed the closed windows and the stuffy and smelly air in that room. I went and opened the windows and let in some fresh air. By now the son and the mother had removed the Chula [earthen stove containing burning charcoal] with the dhoop [name of the incense] to some far corner of the house and the smell became considerably less. The matriarch was nowhere to be seen. I waited another ten minutes. The patient was significantly better and was actually able to smile at me. The atmosphere was much less tense and I could feel relief all-round. Another ten minutes of wait Syeda [Arif‘s wife] quietly went to sleep virtually free from the terrible spasm. The relief was so spectacular that it was difficult to believe that she was the same patient whom I saw 45 minutes ago.

Now I made my preparations to go. It was now the turn of the matriarch. She had already heard of my ordeal on the way, had seen the near miracle of her daughter in law’s recovery. She said in chaste Urdu, ‘doctor saab, I consider it a favor if you stay and have a cup of tea with us’. I was not that crass as to refuse this peace offer. We had a cup of much deserved hot tea and after thanking the old lady, I returned home to wake up my wife, the fourth time that night.

Sunday, August 9, 2009

Doctor as the detective

The call came again from Mr. Devarajan’s apartment. I had gone there the same afternoon and found him fairly alright though his arm was still twitching a bit. He was able to swallow food and was comfortable and even spoke to me with some optimism which had cheered me. Now, comes this call of distress.

Devarajan was a senior executive in one of the top food processing companies with its head quarters in Bangalore. When this incident occurred some fifteen years ago, I was the company’s medical advisor and would visit twice a week in the afternoon. The company had built apartments next to the office for twenty odd senior officers with all in built amenities, befitting a successful company. Devarajan and his family were occupying one of these. My practice being close by, I got not very infrequent calls from these in house families whenever there was an illness that needed to be attended to at home. Lately calls from Devarajan had become frequent and urgent and what was worrying was that I had not been able to find out what was wrong with him.

I saw him sitting hunched up with head held up. There was uncontrollable twitching of the face and lips with drooling of saliva. His jaws were clenched tightly and he could open the mouth with great difficulty. Neck was held rigidly at a tangent. Lower limb, abdomen and trunk muscles were less affected and he was able to walk without any difficulty. Hands and arms were also rigid but not to the same extent as muscles of the face, jaws and neck. He was not able to speak with any degree of coherence. Going by the past experience I gave him an injection of Diazepam and oral clonezepam with baclofen [all are muscle relaxants].He settled within a few minutes and I was sure he would be ok at least till morning.

Devarajan began having these problems a month ago one evening. Though certain that these were caused by unopposed motor impulses from the brain I did not know the cause. Other conditions which cause rigidity and spasm like Parkinson’s disorder and Motor neuron disease have a chronic course and there is usually a history of many years. Another factor was that he was too young to have any of these. A brain scan did not reveal any abnormality. Elaborate blood studies, opinion from two well known neurologists did not produce any result except the prescription which controlled the acute symptoms as described above. There was even a suggestion for a psychiatric consultation! I wondered how a person can voluntarily bring on these painful spasms just to mimic an illness even if he did have some psychiatric disorder.

The management was worried as the man’s work was suffering and he could hardly attend office as he was doped most of the time [thanks to my ministrations] though during the day his problems were manageable. Devarajan’s misery had me worried and puzzled. Worried because of his suffering and no long term solution in sight and puzzled because I was unable to find a cause even with all the expert help that was available.

This was the state of unsatisfactory affairs when Devarajan had to go to Chennai on some errand for a week. He called me soon after his return. I went to see him. He was not home. I went to his office. He was busy with work and welcomed me with a big smile. He was completely fit and there was no evidence of any illness at all and it was so since a week! Devarajan said when he was at Madras he went to see a doctor who practiced Ayurveda [Native medicine] and since he started the medication he has become free from all the symptoms that has been bugging him for the past one month. He just wanted me to see him free of the spasms and share the good news with me. I don’t know who was more relieved, the doctor or the patient.

I have on occasions, though rarely, come across such cures. Though there is no evidence that alternative approaches have cured a particular condition which we, allopathic practitioners have been unable to cure, the cure itself is most welcome. Though how the medication brought on the cure was a puzzle, I was relieved that I no longer had to worry about Devarajan and see his misery.

This happy state of affairs did not last long. A week later he called me again as the problem had recurred and a telephonic consult with the Ayurvedic practitioner ended in doubling the dosage with no relief. This was the time I started looking for causes other than are normally known. Reference to a text book on advances in neurology made mention to acute onset of symptoms such as experienced by Devarajan, in persons exposed to pesticides, who have a genetic predisposition. But how is Devarajan, living in the well appointed flat, be exposed?

The flats are treated once a month for vermin with insecticides. Could this be a cause? But why is he having this problem almost daily? Then it occurred to me. The possible cause could be the clouding that is being done almost daily to the whole campus to ward off the mosquitoes. The poisonous [to the mosquito] cloud contained organochlorines and there was indeed a reference that these can cause the symptoms.

I saw to that he stayed out of the campus. That cured him. He was one of those rare individuals who had a genetic presdisposition to develop acute Parkinson like syndrome when exposed to pesticide spray!

Before writing this story I did a net search and found hundreds of references! Had there been this kind of connectivity, fifteen years ago, Devarajan’s [and mine] misery would have been short lived!

Tuesday, August 4, 2009


This is another story from the past. 40 years ago, when this lady and her family became my patients this area which is now considered a posh up market locality, was ill served even with basic civic amenities. The roads were ill lit and badly surfaced, commuting to the city was tough with very few buses coming into the extension and shopping had to be done with a few poorly stocked stores. There were few villages around though, which had existed probably for centuries and my clinic was one of the very few which provided the basic medical services.

The lady whose story I am writing is now past 70 years. Then, 40 years ago when I first met with her, she was a strapping fecund woman in her early thirties, happily producing children. [She ended up having six boys and one girl]. The first encounter was a house call which ended as a surgical emergency, diagnosed in fading light one grimy rainy night with no facility even for a proper examination. The clinical diagnosis of gall bladder infection proved correct and a surgical removal of her gall bladder cured her.

This episode made her my patient and later my friend for life. Except for her husband, the whole of the family and later on even her grand children became my patients. The family has done well financially over the years.

In addition to the ravages of age, she has developed hypertension, a leaking aortic [heart] valve, severe diabetes with neuropathy and seasonal bronchial asthma. Needless to say, her visits to me have become more frequent now than before.

When she visited me some months ago, she was not looking good and after the consultation was over, she said very diffidently, ‘Doctor, I will not be able to pay your fee’, and then broke down with fits of huge sobs. I keep quiet in such situations and allow the person to finish with the crying. I have learnt that they all come out with what they have come to say and then it is easy to manage. After a while she wiped her tears and said, ‘my husband says I spend too much money on doctors and visits to the hospitals and it is better that I die’. This took me by surprise. Here is wealthy family which has a palatial house with assistants, cook and two cars with drivers and an ongoing flourishing business. And this woman who is the lady of the house has been told to die because her medical expenses are unaffordable. Surely there is some mistake somewhere. I told her as much. She said, ‘Doctor, you don’t know the truth. What I have had to put up in the last fifty years with that man. Never was a day he has asked me what I wanted or how I am doing, even now my illness is an irritant to him and he really feels that I should die as I have lived beyond my utility to him and his children’. I said a few words of sympathy and told her to come as long as she wants and not to worry about paying.

That was some six months ago. That proud woman who used to come every month has not turned up since. One of these days I will hear the sad news of her natural or unnatural death.

End piece

Some say with a smile,
Some with flowers,
Some others with fruits,
Most others don't have words to say.
All are your patients.
You are, my dear GP,
A fortunate man.