Non-specific

Indian hypocrisy on racism

2009-06-01T04:21:00.000-07:00

The recent attacks on Indian students in Australia have sparked off a major slew of protests down under, which threatens to strain Indo-Australian diplomatic ties. These attacks have taken on a completely different face because of them being labelled as racist in nature. The Indian government has publicly supported Indian protesters in Australia, implying their support of the 'racism' charge.

Strictly speaking, the word 'racism' applies to the concept of a perceived superiority in individuals belonging to one race with respect to individuals belonging to another race. However, independent of semantics, the root cause of this is seated within human nature itself. Since time immemorial, there has always been a need to identify with a community. Probably, communal behaviour led to human civilization itself! As communities mushroomed in various parts of the world, there was bound to be friction, especially in times of scarce resources. And somewhere in history, aeons and aeons ago, occurred the first communal riot. I firmly believe that human beings have not really evolved mentally over the millennia. We are painting a new picture on a new canvas today, but the paints are still the same. Is there even a solution to communal hatred? Is this a nasty side-effect of human civilization? These are all really tough questions to answer.

Anyway, in today's world that strives to be an egalitarian utopia, there exist some rules of morality and equality. While India draws its gene pool from many ethnic groups, such as the Dravidians, Aryans (Europids), Central Asians and Mongols, to name a few, the populace has amalgamated into a union over the centuries. But, as is the nature of humans, there are new differences to manufacture so that each person can have something to identify with.

I believe that, when the union of India was formed, it was a huge mistake to draw state boundaries on the basis of language. It merely gave people another opportunity to be divisive. If you think about it, one's principal language is one's principal identity in India. To compound issues further, there is the plainly visible difference in skin colour between the Northern and Southern Indian people. So often I have heard women advising other women, “Don't be out in the sun too long, you will get all black like a Madrasi!” It is a challenge to even begin criticizing such a remark. Should I first question this woman's intelligence because she clubs the four distinct Southern states as “Madras,” or should I feel utter disgust at her expressed displeasure at being dark-skinned (as though it were some unequivocally detestable fate) or should I rant about the mindless Indian obsession with fairness? We are a brown-skinned people with white-skin ambitions. Implicit in this statement is our acute sensitivity towards skin colour, which itself reeks of racism.

Tweak this with the addition of religion, and then tweak it further with the addition of castes, and finally tweak it even further with sub-castes! You don't really need to be Einstein to figure out the cause-and-effect relationship between caste identity and caste-based discrimination. And caste identity will never cease to exist as long as its active reinforcement remains a part of national policy. Caste information is sought at every educational and employment tier, caste-based benefits are provided, caste-based votes are sought, caste-based political gimmicks are staged (Meira Kumar, GMC Balayogi) and, in countless ways, caste is entwined into the fabric that is Indian life. I never knew my caste till I was out of school, and I never bothered to know my sub-caste till I was even older. I was forced to find out because I was entering a government-aided educational institution. Of course, people like me are probably very few, and mostly urban, because in the semi-urban and rural parts of India, caste is life. “Jo kabhi nahi jaati, wohi jaat hai” (Caste is that which one can never cast away). Let's not forget that India is where the concept of untouchability came about, and still exists in some rural pockets.

Communal tolerance is a dying a slow death in India. Men in power, frequently associated with the government or politics, incite communal tensions and forge communal rifts. Flared tempers and rampant disinformation synergistically turn fordable rifts into impassable chasms. This is the reality of India. Countless communal riots, ethnic cleansing in Kashmir, neglect of the North-East, anti-North Indian campaigns by self-important no-good morons (SNM, perhaps) in Maharashtra, the list is endless, much like government apathy.

The hatred between communities is simmering for so long in India that it takes very little for this black cauldron to boil over and scald everything in its wake. Whether to term this as 'racism' or 'communalism' or 'casteism' is a matter for the academics to decide, but the root cause is singular. A rose by any other name would smell as sweet (and its thorns would prick as deep). Indians should take a look a long, hard, introspective look into their own backyards before pointing fingers at other nations, which have a far cleaner record than their own.

I was in awe, too

2009-05-22T04:13:00.000-07:00

Though I started off on an independent train of thought, it seemed appropriate to link this title to an article I read on Veena's blog. (I hope I don't hear you say “Awe, they are writing coordinated blog posts!”)

Over the years, a large number of trivial entities has been the reason for me being awed. The earliest such event that I can remember happened when I was in kindergarten. I had a neighbour who was a couple of years older than I (a very significant age difference, at that age... one may say 50% older!) who mentioned a certain “double-lined book” in conversation. With all the wisdom and experience of a 6-year-old, she explained that these books are used to write Hindi or Marathi script. So amazed was I at this complex entity (books were either blank or ruled... what is this new variation?) that I accompanied her to the stationery store to see for myself! The store was far, near the edge of my recognizable walkable universe, but I still went. Such is the power of curiosity!

Another such incident that I vividly remember occurred during my standard 1 exams. We had to write our answers on the question-paper itself, in contrast to the standard 2 students (who we shared the bench with), who had separate answer sheets. The teacher supervising the exam would occasionally hand out a “supplement” (one of the longest words I had ever heard back then! Aside: one of the proudest moments of standard 1 was when I spelled the word “umbrella” correctly during a “dictation”!) and students had to tie the supplement to the 4-sided paper they started out with! Wow! You can actually tie papers in an exam? Once I saw the guy sitting next to me perform this magical task. I shuddered at the thought of performing this herculean task the following year... I didn't know how to tie a paper! I knew how to tie shoelaces, but those knots are meant to come off easily too. What if my exam paper comes off? Oh, the stress!

And things didn't just stop with that. If activities of those one or two years older had such a profound impact, you can probably imagine my utter and incomprehensible awe at what my 7-year-older brother did! He went to boarding school for two years, at a time when I was 5 years old. My parents probably wanted me to try out boarding school sometime in the future as well, but to even begin to think of living away from home for a year, with strangers, where the only people looking after you were teachers (evil tyrants, cruel taskmasters, people who give homework – that infernal thing – and shout at us if we don't do it, and prevent us from talking by sternly reprimanding us with “finger on your lips!”) was inconceivably traumatic. I may have considered the possibility when I was a bit older, but the fear I had as a 5-year-old never really went away. It was a reputed school and I enjoyed visiting the place, but I could never think of living there. The day he left for boarding school for the first time, I was probably asleep at the time he left; and I had forgotten that he was to leave that day. I remember searching for him around the house... even under the cupboards and beds (which had a ground-clearance of 3-4 inches... how can a kid get under that, you ask? Well, I guess I lived by Sherlock Holmes' words even then... see the quote in the sidebar).

There were many such incidents at numerous points. In standard 12, my biology professors scared all those who were intending to enter medicine by telling us the size of medical books. Gray's Anatomy is so big that you will never have a chance to read anything a second time, so you have to pay more attention when you read your books, they said! As I compose this post, I see all my medical books sitting in my bookshelf and then I see my degree on the desk that attests that I have read all those tomes, and I smile. I never did own Gray's Anatomy, or read it even once, let alone come back to read something twice!

The fact is that time marches on relentlessly, without heeding one's insecurities. We adapt, we improve and we manage to overcome the situation. It is really not such a big deal. I would wonder if I could go through reading my standard 12 books: measly little booklets of some 300-400 pages each, compared to the 1200-page volumes I was reading a year later, and 2500-page volumes I was reading three years later! A million people, just like you, went through this before you, and so will you. This concept has blunted my awe of things, and I no longer react the way I did growing up. More accurately, it has blunted the negative emotions (the insecurity and anxiety) attached to the awe. And I think that's a good thing.

Much '49-O' about nothing, and other political issues

2009-05-14T14:37:00.001-07:00

I am sure you have received those forwarded emails urging you to go to a polling booth and not register a vote. These emails have been around for years now, and I do remember some newspaper reports of disgruntled citizens who were disallowed from casting such a vote even during the previous general elections of 2004. The famous Rule 49-O of the Conduct of Election Rules, which govern how the process of elections is conducted in India, is what gives a citizen the right to go to a polling booth and register the fact that he/she does not want to vote. It was intended to prevent bogus voting on the said person's behalf, but has found a new use in today's politician-bashing educated society.

I think it's quite dumb to go and cast a 49-O vote at this point. It amounts to a wilful wastage of your vote. This new phenomenon originates from the attention-grabbing email publicity of its existence. The emails go on to add that, if the number of such no-votes registered outnumbers the votes received by the winning candidate, a re-election would be held with none of the current candidates being allowed to contest. However, this is not true. There is no provision to hold a re-election or bar the candidates. See the 49-O info website for more on this [www.49-O.info].

The number of people casting the 49-O vote is so insignificant, even in this election (going by newspaper reports), that even if bogus voting was done in all those people's names, it wouldn't affect any electoral race. There are 543 seats and about 550 million eligible voters, making each seat voted on by an average of 10 lakh (1 million) people. Of these, assume 50% turn up to vote, i.e. 500,000, and the main fight is between 2 or 3 parties. Are the 10 or 20 or even 100 people who cast a 49-O vote in each constituency ever going to affect the results? Well, they may in the odd seat that may go down to the wire. In the 2004 general elections, only 2 seats had a victory margin of lower than 500! And all this is assuming that the 49-O voters' names will be used for bogus voting. So, on the whole, casting a 49-O vote is a waste.

A few days ago, I had a long discussion with a few friends about whether we voted for local issues or with a particular political party at the centre in mind. The group was evenly divided and it made for a very loud, interesting and colourful debate. Of course, it helped that a couple of them were slightly inebriated! In a city like Mumbai, most “issues” candidates fight elections on do not even apply. In a rural area, a population of one constituency (~1 million) would cover at least 500 villages and a few more semi-urban areas. Building roads, constructing schools and hospitals, providing water and electricity, demolishing X's place of worship to build Y's etc. are probably the major issues there. In my constituency, in the heart of Mumbai's suburbs, roads are handled by the BMC or MMRDA, electricity comes from Reliance, schools are run by the BMC and private concerns, and the BMC even provides water! So, the candidate who sits in the central government really has very little to do in my constituency!

In urban areas, where a lot of the basic amenities are available to the populace, we find other issues to talk about, such as the 26/11 terror attack. However you look at it, and even if Shivraj Patil deserved to be sacked, the fact remains that the police, coast guard, RAW and whoever else was supposed to be vigilant, was caught unawares. The incident was the last straw that broke the camel's back for Patil. But how can that one man be held responsible for what happened? Isn't it foolish to use this incident as something to base one's vote upon? The point I am trying to make is that, in urban areas, we have very few local issues that we can justify our vote on. Besides, I feel that the 26/11 terror attack can hardly be referred to as a local issue.

So, the educated urban voter has to usually vote based on national issues, or for the guy that comes from his caste. Surprised? Well, the caste identity is highly entrenched in all levels of society, and education has nothing to do with it. This is a reason why caste-based reservations in India (aimed at giving higher education to “backward castes”) will never wipe out the caste system – the root of the problem. Anything that reinforces caste identity can never wipe out the caste system. Anyway, that was not the point. I am also a firm believer in voting with selfish motives. A great disadvantage of democracy is that everybody's vote weighs the same. So there is no point in wasting your vote based on highly romanticized issues that are most relevant to somebody else. When these selfish reasons get multiplied by 250 million (low voter turnout, you know), we get the collective voice of India. And this voice can be truly representative only if each has thought about himself/herself.

This was the first election that I voted in, despite being eligible in the previous one. (Aside: In my enthusiasm to be the “responsible youth”, I had filled out all the requisite forms, stood in queues and produced proofs to have my name registered, all in vain. The responsible youth had met the irresponsible bureaucracy.) Having put forth my case for voting with the central leadership in mind, I examined my options. Realistically, there are two major players. The first party currently has a very respectable prime minister, but has a tradition of nepotism. The person leading it and calling all the shots (the “high command”) was a bartender in Italy, before marrying an Indian pilot. Oh, but that pilot was plucked out of the sky because he had to become India's prime minister one day... by his mother whose only claim to fame was that her dad was involved in India's freedom struggle. And, yeah, make no mention about the fact that his greed for power probably led to the division of the nation and bloody communal riots. A few years ago, this very party's government passed a law that would severely curtail my chances at pursuing my future education in a field of my choice. [More about this law here]

The second party used to have a highly respectable leader, known for his mild manners and cross-border peace initiatives. With him passing the baton to the new leadership, this party seems like a much less attractive proposition. This party's prime ministerial candidate, and his deputy (a Chief Minister from a Western state), are known to be fiercely communal in their outlook. The deputy will definitely hold a significant portfolio, such as the Home Ministry, if this party comes to power. Workers driven by this party's ideology tore down a religious place in 1992. Riots broke out in major cities, killing more than 2000 people. In 2002, the deputy allegedly supervised and orchestrated communal genocide in his state, in which more than 1000 people lost their lives. (News has it that this loser was denied a US visa on two occasions because of his involvement in such criminal activities!) A leader from this party had openly led mobs during this rampage.

Well, much as I detest the policies of both parties, I had to vote for one of them. Effectively, that is how things work in India. At the end of the day, one of those two parties will form the government. If voting “for” a party doesn't work for you, it is practical to vote “against” the one you hate more. It is way better than casting the insipid 49-O!

No matter how much development comes about in that Western state, I cannot get myself to vote in a leadership that has the blood of thousands on its hands. This was the most important factor on which I based my decision. It is quite ironic that, within a month of the results being announced, I plan to leave for the USA for my further education and I am likely to be there till after the government elected this time finishes its term!

Did the title strike you as odd? '4' looks like 'A', '9' flipped is 'd' and 'O' is 'O'... much ado about nothing!

'Jana Gana Mana': The (Sad) Song of India

2008-12-16T23:32:00.000-08:00

A few days ago, I looked at a video suggested by a friend. The video was an advertisement screened in India to raise awareness about respecting the national anthem. The ad portrays a busy Mumbai street going about its routine, when a sudden downpour makes everyone run for cover. An elderly cobbler coincidentally turns on the radio just as the downpour begins, and realizes that the national anthem is being aired. As people run around about him, he struggles to stand up; as we realize that he is actually handicapped and supports himself on a crutch. The torrent lashes his face but he remains solemnly upright. Three shoeshine boys next to him are the only ones to notice him in the melee, and join in the moment and, half reluctantly and half in shame, stand to (an approximate) attention. Bachchan's baritone concludes the ad with the words “How can you respect your nation if you cannot respect your national anthem?” As he speaks these words, three city kids, probably 18-20, scurry across the scene for shelter.

YouTube video: "Award winning Indian ad, Respect the National Anthem"

According to me, there are numerous things that are problematic with this video. Some minor issues, like the youngsters running across the scene during Amitabh's admonition – is this supposed to imply a generalization that the youth of this country do not respect the anthem? Is standing for the national anthem in the face of a cloudburst (in this case, a perceived adversity) the definitive test for one's respect of the anthem? It's a macabre thought, but what if enemy soldiers simply played the anthem on the battlefront? Should all Indian soldiers (who can safely be assumed to exemplify respect for the nation) stand to attention and become target practice?

The greatest injustice done by the ad, and by many such self-righteous videos in the recent past, is in the singing of the anthem itself. The Indian national anthem is not merely a song – it is a prayer. It was written by Rabindranath Tagore, who had the genius and the foresight to exclude any religious reference, while still maintaining its sanctity as a prayer. In class 7, our Hindi teacher once asked someone the meaning of the anthem, and nobody could answer. It was the girl who used to sit next to me, who took up the unquestionably uncool task of researching it. Mind you, this was long before the internet was freely available. Thanks to her, I could learn that there was something deeper to it than a set of words merely memorized for robotic renditions twice every week.

O! Dispenser of India's destiny, you are the ruler of the minds of all people. Your name rouses the hearts of Punjab, Sindh, Gujarat, the Maratha country (Maharashtra), in the Dravida country (Southern Indian states), Utkala (Orissa) and Bengal. It echoes in the hills of the Vindhyas and Himalayas, it mingles in the rhapsodies of the pure waters of Yamuna and Ganga. They chant only your name. They seek only your auspicious blessings. They sing only the glory of your victory. The salvation of all people waits in your hands. O! Dispenser of India's destiny, you are the ruler of the minds of all people. Victory to you!

According to the Government of India's official version, the song takes 52 seconds to sing. In fact, one of the reasons why 'Jana Gana Mana' was chosen as the anthem, as against its competitor, 'Vande Mataram,' was that it could be sung with gusto and energy. The arguments for and against this issue are numerous, but that is not the point I am trying to make. Over the last few years, spearheaded by the Bharatbala brigade, almost all famous musicians and singers have been involved in some neo-anthem rendition or the other. Some of these versions are regularly aired as advertisements and some are even used in movie theaters before the movie commences.

Without exception, all these new versions have the anthem sung at a nauseatingly slow pace, in a mood that would be melancholic (at best), by people who seem groggy with valium and, sometimes, with pronunciations wrong at places. Again, without exception, each of these is hailed by most people and even moves some to tears. As for me, all these versions are an insult. They become even more repulsive when Lata Mangeshkar starts off with her severely outdated voice. Many of the singers are India's best, many of them are my favourites and all of them, I am sure, respect their nation.

But that does not take away from the fact that these songs dilute the import and subvert the emotion of the 'Jana Gana Mana.' It is quite obvious, from the ovation these songs receive, that a large majority of people see nothing wrong with them. In a nation that is paranoid about the sanctity of even non-entities, I am appalled at the inaction towards (and promotion of) this. It probably just boils down to this – nobody can gain political mileage by correcting the nation's top singers and composers engaged in (a sorry attempt at) singing the national anthem.

Going back to the video in question, if you do not know how to sing the anthem right, how can you claim to respect it?

First three weeks in the USA

2008-05-16T14:18:00.001-07:00

So, for those of you who don’t know, but care enough to know, I have been in the United States of America since the 24th of April. I am here to do an observership in internal medicine, to take a couple of exams and to apply for my residency and appear for my interviews later this year.

I landed in New York on April 24, 2008, after a 16-hour long direct flight from Bombay. The flight was quite pleasant, not as bad as what I had been warned about. It was pretty relaxed and, since I was seated in the exit row, it wasn't too hard on the legs. Of course, being a doctor, the possibility of deep venous thrombosis was always a stimulus for keeping the feet twitching! After landing at John F. Kennedy airport in New York, I had to wait for the Boston flight, which was a good 4 hours later. This was my first chance of observing America and its people. Just sitting there at the terminal, Veena (who was traveling with me) and I had a good time just looking around and observing the goings on of this new and strange country.

The first things that struck me were the neat and organized manner in which things go on, the way there are signboards everywhere to lead you where you want to be, convenient transit systems in the airport (I can’t even imagine how much trouble it would save to get from the Santacruz airport to the Sahar airport if there was a transit system in place!). Of course, the other thing right there to notice is how the cafes dish out such huge servings and its inevitable result on the people that consume them!

On the plane from New York to Boston, the in-flight entertainment TV wasn’t working and, as compensation, they gave us $15 vouchers to use on their airline. I can’t think of something similar being done back in India. This is a prime example of how consumer-oriented the services in this country are! Breaking chronology, I am reminded of the time when, during my observership, I saw one patient who had to be explained how to self-administer an injectable medication. He had to leave the hospital to buy the drug, and it was already closing time. The nurse at the office promised him that she would wait till he got back… this sort of treatment is quite rare back home.

Anyway, so once in Boston, my brother – Satyajeet – and his wife – Shamal – came by to help Veena and I get a bank account and get a cellular phone connection. Needless to say, that was a great help and, more than anything else, something that blunted the anxiety associated with being in a totally new place. It was almost like a fugue… just a few days back I was in such a different environment that it took a few days for the feeling of being here to sink in.

Worcester (pronounced woos-ter), which is about an hour’s drive west of Boston, is the place where St. Vincent Hospital is located. It is also home to quite a few educational institutions, notably the University of Massachusetts (UMass). It seems like a small town but is the second-largest city in the state of Massachusetts (MA). This state is interesting, in that pedestrians have right of way at a zebra crossing. No matter how fast or how many cars are approaching, if you need to cross the road, you can simply walk across and the cars are legally bound to stop for you. Isn’t that simply aMAzing! I am living at a place just outside Worcester, called Shrewsbury, and the picturesque lake Quinsigamond separates the two towns.

In my observership, for the first two weeks I was with an internist – a physician in primary care. It was a tremendous learning experience – much more than I had probably expected! It was my first experience of medical practice in the USA and I could witness the doctor-patient interaction, which is so vastly different from the way it is in India. Well, at least vastly different from that in a large public hospital like KEM, where I have had all my experience. The time spent with each patient is close to 20-25 minutes, the emphasis on preventive strategies, and motivation given to remain on treatment and the involvement of patients in their own healthcare was all worth noting. Patients here are, on an average, highly concerned about the medical decisions affecting them. This is quite remarkable, considering that I have seen much fewer informed patients even in the highly educated sections of society back home. Of course, here there’s the problem of the overly-informed and misinformed patient (thanks to the internet), which makes things a bit more challenging and, at times, amusing!

The variety of patients I saw here in a span of two weeks is considerable. For an observership of two weeks, seeing about 10-15 patients a day, I have seen a disproportionately wide spectrum of patients, which I consider to be the ultimate bonus of being here. Another factor in American patients is that there is a large proportion of older patients and, invariably, they have a combination of multiple conditions which need simultaneous attention, making the clinical decision-making process more interesting. Apart from all this, the guidance in terms of bedside etiquette, patient interaction and the many clinical tips that I got from my mentor all went a long way in making these two weeks both memorable, enjoyable and enriching.

It was Veena’s birthday on the 10th of May and I was in Boston. We roamed around the city on foot, taking in the old-world charm of the place, in addition to checking out the Boston Public Library, the Boston Commons park and the Massachusetts General Hospital (MGH) – one of the best hospitals in the US. The photos, in case you are interested, are posted here.

And it’s taken me a week to write this last line and submit this post. Weird.

Losing Sleep over High BP

2007-08-22T11:33:00.000-07:00

My father recently got me a life insurance policy that has, bundled along with it, a mutual fund investment. Something known as “unit-linked insurance”. As is true for all insurance issues, this came with a requirement to undergo a medical examination. And since I am in the younger age group, it includes only clinical examination, and no tests.

It starts with filling up a detailed questionnaire asking you all kinds of things; and, since I was there for insurance purposes (and being a doctor), I can’t help thinking how each piece of data I give can be used against me by a conniving insurer. There’s a space to write all the pathological tests and X-rays you’ve undergone. Now, honestly, does it matter if I had tests for malaria 3 years back? Or tests for liver function 13 years back? How many people living in a city like Bombay go through 23 years without pathological tests? Is this information sought with a motive or is it just for the sake of well-meaning curiosity? I am already feeling a little uneasy about this whole insurance-health check business.

After I am done with all the writing, I go in for the “examination”. Now the reason for the inverted commas is that the first part of the examination is actually a cross-examination! The doctor cross-checks all the questions as though I had lied on paper. And even if I had, why would I change the story just because she asks me this time? Stupid. She looks surprised that I ticked “non-smoker”. Apparently, my lips are too black. In the US someone might have sued her! I explain that it’s due to the tan I acquired when I was in Ladakh recently. She gives me a skeptical look and moves on. By now, the uneasiness is converting into irritation. Why does this woman refuse to believe me?

Then the examination moves to the clinical examination. She checks my heart and lung sounds, probes the abdomen asking me if it pains. The customary “say aah”, though I really doubt people see much from that exercise. And then comes the clincher. I put forth my arm for the blood pressure measurement. Silence follows. Her face changes as though clouds just gathered suddenly on a sunny day. She looks at me like I am a condemned criminal and asks, reflecting much the same attitude, “Do you know how much your BP is?” What am I supposed to say? She’s the one who checked it! Did they teach her to sense her own BP in her med school? Because they didn’t in mine!

Like it’s a murder conviction, she pronounces “160/100”. Since it’s never been that high in my life, I told her that whenever I’d checked it earlier, it was never over 120/80, which is the normal value. Then came the last straw… she asked me “Why did you find the need to check your BP? I never used to do it when I was in college!” – a question loaded with the implication that I had prior knowledge about my alleged hypertension problem since many months and was now lying to her to get my insurance for a cheaper premium. What is one supposed to reply to a deranged question like that?

I offered her explanations for why the blood pressure could be raised. Firstly, I told her that I had taken a glass of coffee less than half an hour before the visit, which is known to raise blood pressure. Secondly, I had just returned from a course in high altitude medicine in Leh, Ladakh (above 11000 ft.) where we were actually taught about how, due to various physiological mechanisms, there is an increase in blood pressure during the time of acclimatization, which returns to normal gradually. So I told her that it was just 10 days since my return and it might have an influence.

As if to reassure me – a “patient” in denial – she said that there have been a lot of young people coming down with high BP, lots of stories in the newspapers (as luck would have it, today’s Times of India has a front-page article on how there are 100 million hypertensives in India!) and how I should “take care from now itself”. She went on to say that she would enter only the lowest reading and I should rest outside for 10 minutes.

The rest didn’t reverse the damage… the reading this time was 140/90 – abnormal enough for her to hand me a diagnosis of a chronic disease, garnished with a smug grin.

Internally, I was repulsed at how this doctor didn’t seem the least bit surprised at this rare diagnosis – high blood pressure in a young, non-smoking, non-alcoholic, non-obese, unemployed (no work, no stress, huh!) person – but proceeded to “counsel” me about it. “Don’t worry, they will give you insurance, but only your premium will be a bit higher.” I was, at this point, convinced that this elevation in BP had something to do with my high altitude sojourn, so I requested her if I could come by around 2 weeks later by when the effects would have disappeared. To this, she bluntly said “You will take a tablet and come so that your BP is normal.” I don’t know what was lower – her intelligence, her tact or her ability to believe people. If I was to pop a tablet, pray tell me why would I want to come two weeks later, why not the next day?

Anyway, I realized that speaking to her would be fruitless and decided to sort the matter with the insurer company’s agents instead, which went off quite smooth.

The fact that I was examined by an idiot didn’t undermine the reality that my blood pressure was quite high. On the way back home, it struck me that apart from coffee and altitude, the more relevant reason was sleep-lack. I had slept just 4 hours that night and that could have certainly raised the BP to this extent. On reaching home, I got a good 3-hour sleep and rechecked my BP.

Lo! And behold! The value stood at 110/70. The medical equivalent of a bull’s-eye. On repeated checks 3 more times during the day, it didn’t budge from that – almost as if it were staunchly protesting the previous hike.

I learnt a lot about how much these so-called minor factors really affect blood pressure. I also learnt how practising doctors know so little about them. The justification for this magnitude of criticism comes from the Times of India article – 100 million hypertensives in India – India is the BP capital of the world. I wonder how many of these are taking pills because they had a coffee one morning, or slept less one night, or were worried about some unrelated thing during the visit or even had an ill-fitting BP instrument cuff! I read up a lot of sources about the potential errors in BP measurement, so that I could share them.

Here are a few tips on correct BP measurement (compiled from various books and online resources), for those of you who are doctors, so that we don’t inadvertently hand an unsuspecting healthy person a diagnosis that will cripple him with a lifetime or drugs, their side-effects and higher insurance premiums!

The mercury sphygmomanometer (not dial or digital) is the most accurate instrument for routine clinical BP measurement.
Inquire about adequate sleep. A single night's sleep-loss can elevate blood pressure.
Inquire about caffeine intake (tea or coffee). BP should not be checked within 2 hours of caffeine intake.
Sitting BP is the universally followed norm, for standardization and to avoid increases or decreases due to standing or lying-down BP.
Support the arm at heart level (not the BP instrument). Improper level can cause an error of as much as 10 mm of Hg.
On the first visit, BP should be taken in both arms, as there is a chance of variability.
A cuff that’s too small will give a falsely high BP reading (I wonder how many large-built people are misdiagnosed because the doctor’s cuff is a bit smaller). The bladder should cover at least 40% of the distance from the shoulder to the elbow and go around at least 80% of the arm circumference.
A cold environment (less than 12 C) and talking can raise blood pressure by 8-15 mm of Hg. The temperature is an American estimate, so it might be higher for Indians.
Watch out for “white coat hypertension” or if your patient is feeling anxious. Anxiety can cause an increase of as much as 30 mm of Hg.
BP is elevated by smoking. In heavy smokers, the BP value in the clinic and the BP during the rest of the day will be different, as the patient won't be smoking in the clinic. It takes 30 minutes for BP to fall back to normal after a smoke.
For diagnosing hypertension, it is better to take values at different times of the day.
Last, and most important, hypertension should never be diagnosed on a single reading.

As far as I was concerned, the rise in BP was due to losing sleep, but there might be thousands of people who lose sleep over their BP every day, probably due to a mistake!

Recommended articles:
ABCs of Hypertension (BMJ): HTML or PDF
Accurate blood pressure measurement (CMAJ): PDF

The Super Cooper Experience

2007-03-24T12:00:00.000-07:00

A couple of days back, when I paid a visit to the dreaded fortress called Cooper Hospital, many old memories were refreshed. My main purpose was to get the signature of the ever-elusive Psychiatry Head; but the walk through the OPD complex and the cacophony raised by the scores of waiting patients transported me a few months into the past.

Cooper Medicine was probably the most memorable posting in my internship. The same OPD where I could see the throng of patients was, in those days, being managed by just a handful of interns. It was our first taste of true medicine. To elicit a history, to examine, to reason out diagnoses, and then, the paramount task of correct prescription – we learnt all these virtually unsupervised. It was like being taught to swim by simply being thrown into the deep end of the pool.

Patients complaining of fever were the norm and anti-malarials would be doled out by the dozen! The slightly more challenging cases were those involving older patients with multiple co-morbidities like diabetes with hypertension, sometimes with heart failure and so on. On the first OPD day of my posting (which was the last day for the resident doctors in the Medicine Department at Cooper), one lady walked in with a BP of 220/120, faint signs of swelling in her feet and moist sounds in her lungs. Though a reasonable suspicion of congestive heart failure would arise, the resident was adamant that I should give her a Depin (nifedipine, a fast-acting anti-hypertensive) and send her home! After nearly 15 minutes of arguing physiology, pathology, medicine, and largely commonsense, somehow the resident relented, managed to “appreciate” the abnormal lung sounds and heeded my advice to admit the poor old lady.

Another interesting case was of a young girl with occasional syncopal episodes (loss of consciousness i.e. “chakkar”). It was quite a task to go through asking all kinds of questions, because of the non-standard nature of the case. Eventually, I settled on a diagnosis of paroxysmal tachycardia, which the Associate Professor agreed would be the first differential. The high of correct reasoning and diagnosis is a rare treat when you learn medicine. I wouldn’t have known what it meant had Cooper Medicine not happened.

Short medicine postings in Cooper were some of the most uninteresting and jobless places in the world, especially after coming out of the ER-esque setting of the ICU, where we were the ones who managed patients from start to finish. Chest medicine is run by the clerk, who thinks she’s deputy to the unit head. So, when he’s not around (4 days of the week), she’s the boss and we obey. In the skin department, we sat around all morning looking at itchy people; while in psychiatry, we sat around listening to the histories being taken and counseling being given. I remember one psychotic patient who told me in great detail about her sons, her neighbours and her imaginary friend. She also asked me about myself, my family and my friends. While it was very amusing to the psychiatrists around me, I think it was an experience worth having!

Cooper Medicine was a place I was warned about. Transfers of unstable patients, angry relatives, volatile circumstances, fiendish residents, stinking ICUs, foul-mouthed sisters and so on! It was none of these (okay, the ICUs did stink!) and I took so many positives back from my Cooper Medicine posting that it will truly define internship (the way it should be) for me.

Most Memorable Incident of Internship

2007-03-24T11:33:00.000-07:00

I was posted in the Cooper Medical Intensive Care Unit (fancily and undeservingly referred to as the Intensive Cardiac Care Unit, ICCU) for a night shift. So there was this 68-year old man, who was admitted the previous day with around 12-15 episodes of diarrhoea, 5-6 episodes of vomiting, abdominal pain and fever. Since the lecturer was present in the ICCU when he came in, he had been started on treatment by the lecturer, and thereafter he was being monitored by us interns.

When I started my shift, there was a constant inflow of patients – some serious, some who had come to hospital just for fun… the usual. This had prevented me from taking a round to take stock of all the patients admitted till much later. At around 11 pm, when I did, the nurse casually mentioned to me “Bed 6 – doesn’t seem like he’ll make it till morning… just look at him!”

He seemed very odd. He was breathing fast, had a pulse of 130 with a BP of 130/80 and was severely dehydrated. The moment I touched his abdomen to examine him, I knew this was big trouble. It was hard as a table! This patient was having a condition known as peritonitis – inflammation of the abdominal cavity – caused, in this case, mostly due to a perforated intestine. Due to this inflammation, large quantities of water were being sucked out of his blood vessels, into the abdominal cavity. Thus, there was a reduction in the volume of blood, leading to his increased heart rate. He was in shock. The nurse was right – he wasn’t going to make it – at least not this way!

The seemingly normal BP didn’t fit in with the increased pulse and dehydration. Then it occurred to me that at age 68, the arteries are hardened and a phenomenon called “pseudohypertension” is known to occur, where there is a falsely high BP reading. Convinced of this fact, I inserted a second intravenous line so that a large quantity of fluid could be administered as quickly as possible. Fluids were started on both sides on full flow so that his hydration could be restored. In cases of severe water loss, the kidneys may shutdown because the fluid reaching them reduces drastically. Thus, conserving kidney function becomes a priority. Antibiotics were started in parallel. The time was now almost midnight.

It’s worth mentioning here that a perforated intestine is a surgeon’s case, since it needs to be repaired by an emergency operation. So I physically went down to the surgery ICU and hauled up the surgery resident (sending a written call in the “call book” would be a foolish thing to do, as it would have been answered long after the patient’s death!). The surgery resident, as I would realize along the way, was an insult to the field of medicine. He first ordered an X-ray of the chest and abdomen in the erect position. The rationale of this is that when erect, air from the perforated intestine floats up under the diaphragm and can be seen as a black shadow under it on the right side.

The X-ray technicians get on the job, shoot the chest X-ray lying down before realizing it’s supposed to be shot erect. So they decide to shoot the abdominal X-ray erect. The plates come back in 20 minutes, and as was expected, the abdominal film shows air under the diaphragm, while the chest film doesn’t. Our great surgery resident now thinks there’s still an element of doubt, and asks me to repeat the chest film, since “In textbooks the classical picture is that in the chest X-ray there is air under the diaphragm.” Okay, so if the same air under diaphragm is seen in an abdominal film, it’s unacceptable! Brilliant!

The technicians are recalled, the chest film shot again – this time sitting up. Another 20 minutes to develop the film, and then it comes back. This time, the air under diaphragm is visible… but now the diaphragm is slightly overlapping one of the ribs. So how can one be sure it’s the diaphragm and not a rib? Bizarre reasoning, but no matter how ridiculous it sounded this is what the surgery resident offered.

The picture was crystal clear – a rigid abdomen, a dehydrated patient, air under the diaphragm on X-ray. Any fool would tell you this was a perforation. But, that night, the patient wasn’t even fortunate enough to have a fool attending on him! After some 5 calls to his senior, it finally dawned upon him that the patient needs to be operated immediately and needs to be transferred to KEM Hospital (Oh, did you know that Cooper has a surgery department, but no anaesthetist on-call in the night?).

And so, there I was taking a surgery transfer to KEM – probably the patient’s last hope at survival. Just in the doorway of the ICCU, it strikes our surgery resident that he is letting go of an opportunity to hone his skills in inserting a central line in this patient! So there’s a further delay and discomfort to the patient, as he struggles and, in his 4^th attempt, manages to achieve success.

The patient, in this entire melee, was surprisingly cooperative. Each time I asked him how he felt, he would always reply, with a smile, that he was fine. I don’t know from where he found the strength to put up such a brave front, but it was commendable how he did! We reached KEM at about 6 am – seven hours after the diagnosis of perforation was made! Since the doctors in the emergency department had already been spoken to, things went on smoothly and an ultrasound, a fresh X-ray and blood tests were carried out and the admission was completed by 7 am.

My job there was done and I was severely deprived of sleep. I took the ambulance back to Cooper, where I crashed in the ICCU till 1 pm. This incident was the closest I came to saving a life, which doctors are supposed to be in the business of doing. I would love to know what happened to this patient, but I am afraid I might never find out.

Very rarely do we get the opportunities where our capabilities are stretched to their limits; and even rarer are the times when we can actually cope with these stresses. My job, that day, was to do my best to save the patient. Not only was my clinical judgement tested; but also my ability to convince (I would rather use the word 'coerce') a senior of my point of view. It is difficult to articulate the feeling of genuine satisfaction at the end of this ordeal. On a personal level, this was the most significant incident of my internship. One of the rare times I truly played the role of a doctor.

Ad fad

2006-07-01T14:58:00.000-07:00

This post is exclusively about the new Airtel advertisement that appears so often nowadays. I’ve heard a lot about this ad, overwhelmingly biased towards the positives. Words such as ‘deep’, ‘classy’ and ‘best ad ever’ have been used by various people to describe it. At first glance, I must admit, I was fairly impressed by this one. On subsequent viewings, that opinion changed considerably.

Apart from the captivating, immensely popular and evergreen A. R. Rahman music, there’s really little else to the ad, if one takes a close look. The ad uses a strong emotional undercurrent to mesmerize the viewer. Using Indian icons like Mahatma Gandhi, Lata Mangeshkar and Sachin Tendulkar, along with the equally familiar (late) Nusrat Fateh Ali Khan and a person strongly resembling Mother Teresa, the ad men have (successfully) created a great package. However, just because it looks and ‘feels’ good, it doesn’t mean that there’s any sense to it.

There are several so-called weighty, effective lines used in the ad, which refer to a billion hearts broken by a raised finger and how two raised fingers can win a World War, how a whisper can inspire hope and a touch can instill faith, how millions of candles can end wars and acts of defiance can start a revolution, and so on!

First of all, I will nitpick and bring out several inconsistencies, before moving on to the more significant arguments as to why this ad is quite meaningless.

If candles could end wars, why would we need Churchill to hold up two fingers? Besides, if Churchill's two raised fingers could win a World War, why did it take 6 long years and 2 nuclear weapons to bring an end to it? Isn’t that excessive dramatization?

Now, I come to the more significant argument against the sense in the ad. All the forms of expression that are so sensitively depicted in the ad do not, in the slightest, require a mobile phone. So, in essence, the ad shouldn’t be for Airtel! What it means is that to “express yourself”, you don’t need Airtel – which is the concept the ad is trying to sell your emotionally overcome mind, which will, at this stage, accept anything because it’s labile.

These are the kind of tactics that are selling these days – emotional entrapment and its various congeners. The other ad-man favourite is the use of children in ads. This is quite an old concept that works essentially on one characteristic observed with many parents – pampering their kids. If kids see other kids using some object, they automatically wish they had it too. Then they will nag their parents, throw tantrums and skip meals until they get it; or until they get smacked on their bottoms. Frequently, the parents are the ones that yield and the ad-man gets a contract extension.

As far as the Airtel ad goes, the background score is great and it makes a good example to explain the meaning of ‘transferred epithet’ to a middle-school student. That’s about the only evidence of meaning in it, as far as I can see.

Cooped up in Cooper

2006-06-14T07:42:00.000-07:00

The onus of responsibility for catering to the health and wellbeing of the Western suburban population lies with the Dr. R. N. Cooper Hospital, Juhu. The shambolic remains of this hospital are the grim reminders of an institution that has seen better days. Defunct, worn down buildings, almost about to crash to the ground, stand beside the slightly better-off functional ones. Lush green gardens and a clean concrete road coursing through the campus bear no resemblance to the state of this hospital.

It is here that interns from KEM Hospital get posted for two inglorious months – one each in the departments of Medicine and Surgery. Having survived a month here during my Surgery posting, here’s my experience.

A lot of things about Cooper conflict with the way things are back at KEM. First, there’s a muster that must be signed before 8.30 a.m., failing which the AMO will triumphantly mark the innocent intern absent. Of course, if one manages to reach the muster earlier, by 8 a.m. or so, one can easily manage to sign for a few friends – since the AMO is seldom there so early! At times, we must wait for the doors of the muster room to open… something that can stretch up to 30 minutes!

There being only two units in the Surgery and Medicine departments, emergency duty comes on alternate days. Over a period of 15 days (to be spent in General Surgery), it’s quite easy to lose track of time and be severely disoriented. Most of this time is spent in the Surgical ICU, the smell of which works synergistically to aggravate your disorientation. A complex blend of phenyl, spirit, patients and the “general ICU smell” bombards your senses the moment you step across the ICU door.

The typical Surgery posting consists of few blood collections, plenty of transfers, a surfeit of CT scans and a small opportunity to get one’s hands dirty with some actual surgical procedure. Cooper hospital lacks a CT scanner, and their Sonography machines drowned in the 26/7 floods. So, all patients who require a CT or a USG need to be taken to one of the nearby hospitals – BSES or Nanavati – or to KEM, in case they cannot afford the former two. And, since the BMC is so committed to patient care, the intern, who has no other work, has to accompany the patient to all these places – a punishment for being free.

Taking patients to higher referral centres, namely KEM, also forms one of the principal roles of the intern at Cooper Hospital. We are equipped with an “Emergency Tray”, which we are supposed to employ in our heroic efforts to save the patient’s life; if he/she were to “turn bad” on the way. Instructions on how to do that, of course, are hard to come by. We make do with the nurse’s hurried offering “Atrop, adrenaline, soda bicarb and intubation… Intubation aata hai na?” and shoot off towards the ambulance; silently praying that there should be no requirement of executing those instructions.

Getting the patient to KEM safe and sound is just half the battle won. Convincing the KEM doctors to take the patient in is the major challenge. Cooper transfers witness some of the most legendary instances of “batting” (referred to in one of the previous posts). The ESR registrar first chastises the intern for poor management of the patient (to which the intern conveniently blames the Cooper house officers and registrars) as his opening salvo-cum-greeting. The intern, for being a Cooper-intern, is made to suffer more indignation. The lecturer at KEM adds to the registrar’s comments and makes the intern feel like a worm. Then, the intern, obeying like a servile animal, completes the documentation, gets all the forms filled and does whatever it takes to admit the patient (i.e. relieve himself of this terrible responsibility). One must also remember to take back that “Emergency Tray” to Cooper, failing which one may have to return to KEM after hearing some nasty language from the ward sister.

The ICU side-room has three hospital beds. I say hospital beds because they are made of metal, have a firm mattress and are covered by a white bed sheet. They are fairly wide, so that more than one person may assume a recumbent position on it. Of course, how three beds can be sufficient for two interns, one house officer (Surgery) and another Orthopaedic house officer beats me, especially when one of the two interns is frequently female. Certain Orthopaedics house officers are accommodating and generous, especially to female interns looking for a bed to share; but that’s a different story.

Finding a bed to sleep is no guarantee of sleep, however. There are always life-saving jobs to do in the middle of the night when patients come in, such as collecting their blood, inserting feeding tubes and IV lines. The intern’s absence from such a scenario can be fatal for the patient. So, we mask our frustration with a jovial grin and surrender the sleep for something less deep.

After scavenging 36.43 winks of sleep, the clock strikes 8 and the sun brings joy – the prospect of being home and sleeping for real. At times like these the late-opening AMO office (where we register our presence) becomes a cause for many a peeved intern.

The non-emergency days are spent in the OPD, mainly filling forms. Of course, the lucky ones get to clerk the patient’s history and examination findings – not because of their diligence, but because their registrar fell off a bike to fracture his arm. Hours spent in the casualty department are quite refreshing. A friendly casualty officer (CO) helps, but isn’t a necessity for time to pass merrily. In the mornings, scores of patients line up to take their anti-rabies injections; and this was the first time I was giving intramuscular injections to people! Strange how the defining point of a doctor – the injection – evaded me for so long!

The remaining 15 days of the month-long posting were spent in ENT, Ophthalmology and Orthopaedics departments. They were breezy and involved no night-duties, no stinky ICUs and virtually no work!

Free time in Cooper is a horrible thing, since there are no good places to spend it. The canteen food is pallid and there’s no common room. Food places outside are decent – the main ones being Pappilon and Amar Juice Centre, with Naturals ice-cream and New Yorker being a short distance away.

Cooper was a unique experience for me. The 10 minute bike ride from home, the jovial banter of the two house officers of my unit, one specifically cooperative patient, the abhorrent antics of the medicine house officers in the Medical ICU and the scarcity of work will summarize the Cooper experience during my Surgery posting. Cooper is a place that’s okay to visit; but don’t ever stay there too long as a doctor… you won’t stay there long if you’re a patient anyway.

Logical reasoning on reservation

2006-05-15T04:26:00.000-07:00

The recent furore over the reservation issue brings to the fore the chinks in our intelligence, as a populace, and the ineptness of our Government (intentional or unintentional) over the years.

So many questions have never been addressed and a logical and systematic approach to the problem has never been encouraged owing to sabotage by political interests. The Government of India has been stupendously unintelligent with its approaches at uplifting the disadvantaged – only to be blessed with political gains (which were, obviously, the intentions).

The following is a logical dissection of the pro-quota philosophy.

Equal Representation:
Any society, in order to avoid feeling dominated by those who need not have its own benefit in mind, would aspire for representation in the governing body. Thus is born the concept of equal representation: the backbone of democracy. Thus far, India maintains this in terms of population, such that there are more MPs from densely populated states and less from less populous states. The Government is the first and only place where representation of all sections of society becomes necessary and justified.

During the course of the reservation debate, justifications for quotas include this representation argument. Pro-quota thinkers ask for educational reservation to increase representation of the “backward classes” in educational institutes.

This demand defies logic for the following reasons:

Is education the place where equal representation is needed?
If so, would we tomorrow see one seat each reserved for students coming from each of the 4000+ “backward” castes we have in India?
Why, in their zeal, don’t pro-quota thinkers ask for SC/ST/OBC reservations in the Parliament? Shouldn’t the most important post (that of Prime Minister) be 50% reserved, considering the seats in the best institutions (AIIMS, IITs and IIMs) are?

Therefore, it becomes clear that since there’s no quota for SC/ST/OBC in Parliament (the only place where equal representation becomes justified), the intentions behind asking for quotas do not truly include ‘equal representation’.

Social Justice:
This is one of the strongest pro-quota arguments. After centuries of oppression by “upper castes”, the “lower castes” need to realize their true identity and place in society. And, hence, the best and only way to do so is through reservation of seats in educational institutions.

Unfortunately, the impact of education and bookish knowledge does not erode the aeons-old crust of apathy and disdain that certain sections of society hold in regard to the “lower” castes. The caste-centric nature that both the “upper” and the “lower” castes are guilty of is responsible for the continuing sense of inferiority experienced by people belonging to these so-called “lower” castes.

Education was, till some years back (as claimed by pro-quota thinkers) the sole right of “upper” castes. While this would be quite correct, I would use this point to argue that it did nothing to instill a sense of responsibility and an egalitarian outlook in the minds of the “upper” castes. They were still prey to the historical human vices of dominating fellow men and getting one-up on them, eventually “oppressing” them. In a broad sense, this is the same trait that has probably helped man in his evolution – where equality of opportunity has no room (it’s survival of the fittest).

If one draws a parallel to the concept of superstitions, one realizes that these, too, are irrational beliefs that have carried on since centuries. But, it’s not uncommon to find a doctor or a software engineer turning cold if a black feline crossed his/her path. What it proves is that no amount of bookish knowledge (which is doled out universally under the garb of education) can shake consolidated prejudices in our minds, which are largely immune to text.

Then, how does social justice come about by granting students from the “backward” castes seats in educational institutions? Education cannot change age-old beliefs, which are the root cause of the oppression!

Reservations in Higher Education cause Social Uplift:
It is absurd how many pro-quota thinkers are sold on this idea: hook, line and sinker! No other concept could be more removed from rationality than this one. In a country like ours, where barely a tenth of the general population enters a graduation course, and even fewer enter post-graduate college, what fraction of the society would eventually benefit from these reforms?

On one hand, the Government claims that large sections of the nation’s population are “backward”. On the other hand, it gives reservations in higher educational institutes to the castes to which “backward” people belong. The distinction is very crucial.

The minority of “forward” people, actually belonging to “backward” castes, are the ones that stand to gain with the advent of the new policy. The reasoning is simple: if most of the “backward” castes are indeed “backward”, then they must not be even reaching junior college. In this scenario, how much sense does it make to add reservations in post-graduate and super-speciality courses? Is the Government planning to directly promote these students into graduation as a radical new form of “uplift”?

Reservation Reloaded:
We’ve all heard pro-quota thinkers at some point or the other state that reservations are not enough for a given person just at one level and that they should be made available at all possible levels. First at the entrance point for graduation, during entrance for post-graduation, while getting into super-speciality courses and then, even for jobs.

Assuming that the reservation policy is intended to “solve” the problem of “backwardness” as experienced by the so-called “backward caste” candidate, we shall discuss this further.

When any solution is suggested for a problem, one basic rule it must obey is that the problem must be eliminated by the solution. If not, it means that the suggested solution is wrong. So, if reservation is applied as a solution to combat the problem of “backwardness”, it is quite evident that it serves little purpose if the problem is at large at every step on the educational ladder and even at the time of seeking a job.

Reservation as the be-all and end-all:
Pro-quota ‘thinkers’ seem to have given up thinking when they state vehemently that reservations in educational institutions are the only way out. Problems as intricate and with ramifications as extensive as the one of social inequality in India cannot have an effective solution as simple as reservation.

A few simple arguments that emerge are:

Different states have different OBC and SC/ST populations. Then why should there be a uniform percentage of quotas across the nation?
The two principal reasons for social backwardness are oppression and education (illiteracy). Both of these lie beyond the jurisdiction of reservation of seats in higher education. How is the problem to be solved without improving basic education first and taking measures to rid the age-old prejudices? Is caste-based reservation not broadening the caste-divide that should ideally be done away with?
Reminding people of their caste and dividing people based on it is being racist in the truest sense. How can the Government promote this as a State policy?

As one may deduce, pro-quota arguments are either logically flawed or unsupported by data. There has been earnest political effort to market the reservation of seats in higher education as the ideal/singular/omnipotent solution to eradicate social inequality from the nation.

The need of the hour is to bridge the gap between the underprivileged, downtrodden sections of society and the developed sections. To believe that there exists but one solution, and that, too, the one of reservations, is equivalent to shutting one’s eyes and believing that the Sun has stopped shining. We must encourage creative new solutions if we are to morph our medieval mindsets, so as to usher in an era where Indians will not need a supplemental identity conferred by their caste. May all Indians unite to cast away their caste forever!

50% Reservation, 100% Politics!

2006-05-03T07:48:00.000-07:00

This was one of the slogans that scores of students were screaming till their voices went hoarse. The peaceful demonstration at Azad Maidan, VT was launched to coincide with nationwide protests under the common banner of ‘Youth for Equality’, a group that started in New Delhi.

I was fairly relieved at being let off at 2 p.m. from Cooper Hospital (my new posting, which shall give me loads of fodder for a few posts) so that I could make it in time for the 3 p.m. start time of the protest. Interestingly, if a crowd ‘gathers’ at a place, the police considers it a ‘gathering’ (profound, isn’t it); but if that crowd moves from point A to point B, that ‘gathering’ suddenly mutates into a ‘rally’. Gatherings merely require a letter to inform the concerned police station of its occurrence. Rallies, on the other hand, need police permission two days in advance, not only from the place it starts, but also from all the local police stations in whose jurisdictions the rally will course through.

Well, the police issues were, thankfully, settled one day in advance. On reaching there, at just 5 minutes past 3, I noticed a nervous energy amongst the students gathered on the ground. There were quite a handful – at least 150, surprisingly, on time! Men and women bustled around with their microphones and camerapersons. Students greeted one another with smiles – those of finding support for a common cause – and, sometimes, meeting old friends after long and asking the redundant question – “So, how come you’re here?”

The protest started off and continued onward with slogan-shouting and speeches being delivered by some excellent orators from various colleges. Mainly, medicos spoke – those from KEM, JJ, Nair, Rajiv Gandhi, and even one from Yavatmal Medical College! St. Xavier's college was represented by a girl who, too, gave a motivating speech. It was great to have the support of the Indian Medical Association (IMA), whose Haji Ali division president came despite the heat to voice the IMA’s opinion and encourage us.

The most enjoyable part of the afternoon was the entertainment in shouting some creative slogans. There were the protest perennials – “Ek, do, teen, char, Arjun Singh ki hogi haar” and “Ek, do, ek, do, Arjun Singh ko fek do”, along with some inspired from Rang De Basanti – “Inquilab Zindabad”! Some were more specific to the cause, like “Aarakshan toh bahana hai, Lakshya toh vote kamana hai”, “50% Reservation, 100% Politics”, “First the British, now the Govt.: same policy – Divide and Rule” and “India’s future quality, Depends on youth equality”. Of course, the “Youth for Equality Zindabad” slogan ran often to fill in for the gaps. One of the smartest posters we had was drawn by one of my seniors at college and depicted (‘Aaj ka’) Arjun shooting yet another arrow at a Bheeshma (an open candidate), beleaguered with dozens of arrows (cleverly labeled SC, ST and OBC).

With the demonstration drawing to a close, the reporters from the media began their coverage and our spokespersons entered the spotlight. Everyone had been strictly instructed to refrain from speaking to the media so that the mission statement would not get diluted or skewed. Also, contact details were obtained from most of the students present at the protest.

The final count yielded a figure of 350-odd students, which was much less than our expectations, but quite a sizeable number nonetheless. After the event was over, a few of us headed off to Rang Bhavan to take stock of the situation and to look ahead for future solutions.

The same night, we found out that one maniacal bus driver drove off a bridge and one 4-year-old ran himself into a world record, shocking the TV news people so much that they forgot giving our little protest even a half-minute mention. So much for the media! Thankfully, the coming sunrise brought some good news – coverage in major newspapers like the Times of India and DNA, though the Mirror refused to reflect even a word on it and the Hindustan Times made a one-line reference. Personally, my comments, and name, found their way into the Times article (though I firmly believe it was due to a strange coincidence – the reporter was an old acquaintance – one I’d made in an adventure camp way back in 1994!).

This was step one of the Mumbai leg of the protests against the recently passed 93rd Constitutional Amendment Act that aims to reduce merit seats in numerous educational institutions across streams. Our main aim was to make a public statement and to launch ourselves as a body so that others from across the city and state know who is to be contacted for information and support.

Our site: http://yfemumbai.blogspot.com/ and email address: yfemumbai@gmail.com .

Spine, the final frontier

2006-04-07T12:34:00.000-07:00

For the first time in the 1960s, when Gene Roddenberry created the sci-fi magic of Star Trek, people had the chance to drift into fantasy and wonder about what lay beyond the sky. The captivating beginning, with Captain Kirk’s unforgettable lines – “Space, the final frontier…” has been the trademark of the series ever since.

Coming back to the present, where the sky, unfortunately, happens to be a formidable limit, I shall describe the final frontiers in a medical student’s journey. At the risk of sounding like a geek, but proceeding to describe my fascination nevertheless, here goes.

When my ‘Long Surgery’ posting ended, I was quite disappointed looking forward at the month ahead. It was that of ‘Short Surgery’, including Anaesthesia, Orthopaedics, ENT and Ophthalmology postings… not exactly the kind that one expects to learn much out of or expect anything remotely exciting to happen. Along with 3 other batch mates, I was scheduled to undergo Anaesthesia first. A 10-day slumber, I thought to myself. But I was mistaken.

As fate would have it, I was posted in the Orthopaedics and Spine operation theatres, while my colleagues landed themselves into the general surgical, ENT, obstetrics and gynaecology operating rooms. Now, it’s important (especially for non-medicos) to highlight the gravity of this situation, which is integral to the hype built up with the title.

Essentially, bones are deep structures (especially limb bones). Spinal operations are precariously close to the vital spinal cord, which is responsible for all our sensations and movements below the jaw. For these reasons, orthopaedic surgeons prefer not to have too many people in the operating rooms, to minimize the potential risk of infection, which would be incredibly hard to treat, especially in cases where prostheses are inserted in the body. Of course, I like to believe that they minimize student infiltration into the OTs to maintain the sanctity and aura surrounding their field, which is effectively carpentry without bacteria. The bottom line is that undergraduates almost never get allowed into the orthopaedics and spine operating rooms.

So there I am – the ‘sincere’ intern, reporting for a posting universally proclaimed as maaf*. The associate professor in the orthopaedics operation theatre makes the situation clear – “We are very lenient. If you are interested in learning about anaesthesia, you are welcome to attend; or you can sit at home and study, we have no problems with that either.” The prospect of bunking, which would have looked more tempting than Barista’s Dark Temptation to most, was an offer that I had to turn down politely.

Being a person that enthusiastically demeans the science of surgery, I consider these last-in-my-lifetime chances at being in an operation theatre. And when you are in orthopaedics and spine, it’s difficult to deny the urge to give in to the curiosity. So I enter the OT. I am greeted by suspicious eyes, poring through the gap between the mask and cap, to scrutinize the potentially infectious infiltrator, inferring from my innocent looks that I am a servile animal – an intern.

Over the next couple of hours, I perform crucial tasks like: positioning the bin such that it doesn’t get in the way of the surgeon, make labels for syringes loaded with specific drugs, turn on a switch for the cardio-monitor, roll cotton on the patient’s arm so he doesn’t shiver and, finally, the most vital of them all – adjust the anesthetist’s mask, which had mischievously slipped below his nose.

Orthopaedic surgeons, as I saw for myself, are the perfect examples of paranoid people. They go to insane lengths to rid the operating field of things that no one can see. The scrubbing lasts for at least 10 minutes, when Betadine scrub is lathered over and around the planned incision site. Next comes the step of layering the patient under numerous covers. First there’s a polyethylene drape. Next there are two cotton drapes that cover everything except the operating field, including the patient’s head. After this comes a stretchable cloth-like material that covers the entire body, through which the operating field has to be cut out. After this comes a pair of light blue synthetic fabrics, which again cover everything apart from the operating field. And finally, they stick an adhesive, transparent plastic over the small amount of skin that remains exposed after the extensive cover-up operation. Then, they cut.

The next day there’s a tremendous change of heart – the residents ask me my name. They explain to me how the anaesthetist’s trolley is set up. They even remember my name and refer to me by name later (as opposed to the generic – “Intern! Do this.”). They were actually surprised to know that interns get posted in anaesthesia, having never seen one before in their department (dumb Alecs who took up the offer). Hell, they even ordered lunch for me!

My stint in the orthopaedics theatre lasts just two days, because of holidays during the five-day posting. It’s now time to go one flight down to the spine OT from the next day.

Now, if you thought orthopaedics was treated like a high-security zone, spine is doubly so. As a learned resident explained to me, “Agar spine mein infect maara toh patient ki lag gayi.” Dr. J (dot) Asthana would surely not condone the language, but would certainly concur with the wisdom in the sentence.

On day one, Dr. Mihir Bapat, one of the prominent spine surgeons in KEM, was operating. The initial covering and draping occurs as I mentioned earlier. Once the incision is taken, the surgeons start using the cautery** like there’s no tomorrow! There is thick smoke billowing from the patient’s back and this goes on and on. After about half an hour, when they are seemingly done with all the burning, they get down to business – cutting the bone. At this point, I got up from the stool that I had occupied to intermittently check the blood pressure (this was my new responsibility, since the automated BP recording was not functioning). I peeped over the ‘blood-brain barrier’*** to get a clear view of what was happening.

What lay before me was one of the most spellbinding sights a doctor will ever witness. The vertebrae were perfectly visible, since the surgeons had meticulously cleaned all the soft tissues around them with the cautery. A row of spinous processes, with the laminae gently sloping away, were facing the outside world for the only time in their lives.

They then explored deeper, extracting the spinous processes of the vertebrae and breaking the laminae to a certain extent, to reveal the glistening white tube. That was the spinal cord. Well, strictly speaking, it was the tough outermost covering called dura mater. The tumour, according to the MRI, was subdural and, hence, warranted opening of the dura too. On incising the dura, a crystal-clear membrane became visible beneath, trying to bulge out of the gap created due to the incision on the dura. It appeared to be as delicate as a bubble! The clear fluid within was the CSF (cerebrospinal fluid). The tumour appeared as a bulge in the cord and had caused compression on the tracts of the spinal cord, resulting in the paraplegia that the patient complained of. Now, they encountered a problem. This tumour was of dural origin but was obstinately adhering to the cord. The jurisdiction of a specialist is literally separated by the thinnest of lines. This newfound hitch called for a neurosurgical intervention.

So then they call the neurosurgeon. I, on the other hand, am quite glad that there’s this kind of demarcation of responsibility… after all, standing in a spine OT (which is a fortunate thing in itself) I am going to watch a neurosurgery (interns don’t even get posted there!). The neurosurgeon makes a quick, clean job of it and out comes the offending mass, almost as thick as the cord itself! Imagine what a compressive force that might exert, in the claustrophobic confines of the spinal canal!

The surgery finishes at about 2 p.m., having lasted a full 5 hours. I finally leave to get some food down the throat, quite thrilled about the whole experience. One should grab any available opportunity to get into some of these off-limits zones… the experience is always worth the effort. Spine, the final frontier, has been breached.

* Maaf: Otherwise meaning “forgive” in Hindi, this word has come to be synonymous with unimportant, dispensable and easy
** Cautery: The electric instrument used to burn soft tissue to get it out of the way

*** Blood-brain barrier: The orthopaedic surgeons suspend a transparent plastic sheet (a.k.a. poly-drape) to wall-off the anaesthetist section from the operating section. The anesthetists like to call it the blood-brain barrier… the blood is on one side and the brains are on the other.

An Old Granny's Tale

2006-04-01T22:53:00.000-08:00

It remains to be understood whether the things that stand out amongst the others do so purely by their own virtue or due to other similar things occurring in quick succession so that one may establish a link and remember better.

Anyhow, it is surely strange how some of these things do, so often, come close on the heels of similar occurrences. Wednesday was the day I had a brush with a few old people.

Debuting at the ‘Casualty department’, a fancy word for the medical traffic policeman’s booth, I was feeling quite important about the fact that my writings will circulate throughout the hospital, since I was the first person to see patients in the hospital! I actually referred a patient to the Rheumatology OPD for his chief complaints of backache. Of course, this was after inquiring a bit about joint pains, blurred vision, symmetric small-joint involvement etc., all based on the initial clue that I was dealing with a young male with backache (think of stuff like ankylosing spondylitis and other such Rheumat-type joint afflictions).

In the Casualty department, there’s a simple rule of triage: when a patient is brought in on a ‘trolley’ (a stretcher on wheels), leave everything at hand and attend to the new entrant. So then there was this lady on a trolley. I abandoned the Bihari blabbering about some non-specific* complaints to rush to evaluate** the new case.

She was an old, frail woman lying in pain, contorting her lower body, presumably in a vain attempt at alleviating the discomfort, and mumbling deliriously. At this point (if you have seen the footnote), I was confused whether I should shunt her off to medicine, orthopaedics or surgery! Her niece, who was forthcoming with a few details, alleged*** that she had been hit by a cycle in her native place and had fallen to the ground, following which she had injured her hip. Having cracked the problem at hand, I proceeded to the table to record this clinching evidence – I would now send her to orthopaedics!

Because Casualty is the first place patients come to (in cases of emergency), it is our job to record their details like name, age, sex, address, religion and so on. Of course, we just record the name (only the name, not surname), age and sex. So I ask the niece the old lady’s name and age. Hazarding a guess, I say to myself – “Why do I bother confirming all these things? As if the management is going to change if she’s 70, 75 or 78!” And then the niece, having verified with another man who has accompanied the duo, but has remained silent heretofore, yields the number – “Hundred”. I am jolted, I reconfirm to be a full 100% sure… the number is unchanged.

With childlike glee, I exclaim to the Casualty officer (who usually has a haggard, unexpressive look) that what we have here is not a part of the daily grind. I exclaim to the two random people who have come to visit the casualty officer for his precious signature (COs are authorized to attest document photocopies) and, in the moment, almost forget to do my job of a responsible traffic pandu. Now the bonehead orthopaedicians shall have a moment of surprise in their drab lives.

And in just a little while, it was the CO’s turn to get one of those ‘good ole’ surprises… here was this lady who had developed pregnancy-induced hypertension at the ripe old age of 42. Needless to say she was expecting a baby for the first time in her life (PIH is usually a disease of first-time mothers).

My duty was over soon and, in less than an hour’s time, I was to be at the college Gymkhana meeting (hopefully for the last time, considering it was long since my term was over). The members in attendance entered the Dean’s office. At first, we didn’t seem to mind the wait: the mind sees immense comfort in the air-conditioned environs that the Dean enjoys through the day. But, after a while, we were wondering who this person was – who saw there’s a group of people waiting to start a discussion with the most sought-after person on campus, but was refusing to end his discussion with her, despite this cognition. When he finally left, the Dean offered an explanation. This man, a Dr. Gandhi, was an alumnus of my college and was last seen here the day he passed out, having secured his MBBS degree. That would be somewhere in the precincts of 1958, she offered. Wow! He finished his course about 50 years prior to when I hope to finish mine!

She explained how he was reminiscing about how different the entire college looked back then and how much has changed. It’s something akin to how relatives remark “You have grown so much, when I saw you last you were a baby!” when they meet you after long. Everyone has heard similar lines from their aunts and uncles sometime or the other. But, isn’t is natural to marvel at how something grows and becomes drastically different, especially over a time period as long as half a century?

In a span of a few hours, three people came by and redefined old for me. The oldest human I’ve seen, the oldest primigravida (first-time mother) and my oldest collegemate! Now, what are the odds that all these examples of 'long durations of time' would come by me in as little as 3 hours?

* Non-specific: scroll to the bottom for an explanation
** Evaluate – What we call traffic policing in Casualty:
Abdominal pain, wound, accident – Emergency Surgical Room
Fever with chills, paralysis, altered consciousness, chest pain, breathlessness – Emergency Medical Room
Fracture, dislocation, twisted joints – Orthopaedics
Anyone less than 12 with surgical complaints – Ward 3 (Paediatric surgery)
Anyone less than 12 with non-surgical complaints – Emergency Paediatric Resident

*** Alleged: We are supposed to be very skeptical about any trauma cases – recording the patient's version as an "Alleged history of..." rather than taking it as absolute truth.

Simon says...

2006-03-22T11:16:00.000-08:00

When it comes to cricket matches, the range extends all the way from the super-duper riveting to the mind-numbingly, bordering on genocidal, boring. The duller extreme of the spectrum is sometimes enlivened by the non-playing members of the match. So, in really boring and disappointing test-matches, one finds interest in what the crowd is cheering, who they are booing, what are the umpires’ expressions and so on.

The last day of the India vs. England test at Mumbai was one such match. Initially, slithering slower than a snail with paralysis, Dravid was blocking away like there’s no tomorrow. The defensive outlook, triggered partly by some tight English bowling and by the Indians’ lethargy to think positive, was perfectly effective in drowning me into deep sleep.

A sudden howl by the Brits shook me from my siesta to take notice. Heart-in-the-mouth moment for the Indians, as a powerful appeal had just been turned down.

What transpired in the coming hours was sheer brilliance. The performance was virtually unparalleled in world cricket. The man was in immaculate form – demonstrating consummate poise, accuracy and judgment. In my book, he was the ‘Man of the Match’, since his was the only performance that truly stood out today.

This might sound strange to you and you are probably wondering which cricketer fit that description. Well, it sure was a cricketer – a retired one. Umpire Simon Taufel, of Australia, arbitrated several appeals for Leg-before-wicket (LBW) during his stint at the non-striker’s end. One had to witness the degree of doubt that could have arisen during the shouts, coupled with the intensity of the English entreaty, to believe it. But, time after time, Taufel turned out to be right – whether the batsman was out or not – as proved by the Hawkeye simulation software that the television channels use to clarify LBW decisions.

This has led me to propound a theory on his accuracy. The Hawkeye software was probably manufactured in Australia and Mr. Taufel holds a major financial interest in the firm and, hence, the software is tailored to his decisions. The Australian manufacturers, via wireless signaling technology (?), message the TV channel’s computers (having the software) when Taufel umpires a contest so that his decisions, whether in favour of or against the batsman, are always ratified by Hawkeye.

This covert operation, as was notified to me by a few underground cricket sources, is code named (as you may have guessed by now) “Project Simon Says”.

Of course, it’s entirely likely that this theory may be a little off-target. There’s an alternative theory to back up a possible failure. It is ridiculously simple – Simon is brilliant!

Simon Says: A game we played as children where there's one leader - Simon - who commands "Simon says everybody must do ..." and the kids follow. Those who can't do the action are out. The one who stays till the end wins. A game infinitely less complex than cricket.

Moments in History

2006-03-21T00:11:00.000-08:00

Every once in a while we do things that either we have long forgotten about or never done at all. The purpose of this post is to recognize the fact that three such incidents occurred over a short span of time for me recently.

The first of these momentous moments is about a daily act that one does to groom oneself – in order that no one refers to him as a broom. I am talking about using a serrated polyvinyl chloride object to uniformly orient the keratinous appendages of the epidermis. Combing. I was invited to Veena’s parents’ Silver anniversary and thought to myself that the casual (usual) hasty hand-strokes given to my hair each morning will probably not suffice at a formal occasion. For probably more than at least 18 months, my comb has been out of sight and, certainly, out of use. The reasons had nothing to do with grooming – because I hold no reservations about the use of shampoo – but the fact that I am quite oblivious to “the way they look” and so any look is just fine. Hence, why waste time and effort with a comb when a few quick strokes with the hand are good enough? Valid, isn’t it?

The next incident occurred when I was posted in the Emergency Surgical Room (ESR) for a 24-hour shift from the 16th to the 17th. A patient had had his endotracheal tube for more than 3 days and it was time to perform a tracheostomy*. The ENT surgeon called on to perform the procedure (which is done as properly as a surgery) needed an intern (and I volunteered) to assist him. The ‘surgery’ was to happen on the patient’s bed itself, located in the ICU of the ESR. ‘Washing-up’ with Betadine-scrub at the basin nearby, I donned the variegated green gown and double gloves. Out of curiosity, I asked the ENT surgeon what the procedure is going to be like, because I had never seen a tracheostomy before. The registrar began explaining the procedure in detail, to the extent of actually instructing me on what I would be doing at all these points of time to come. Apart from feeling very important (being assigned actual work during the surgery, as opposed to the usual mopping and retracting), I also felt, for the first time in a long time, glad to learn something from a person. In medical college, there are very few people who elicit such reactions – because teaching gives very few people happiness. And my efforts were put on paper (as I am gradually realizing is the protocol) since the assisting surgeon’s name too must be recorded in the patient’s file.

The last, and the most hair-raising of the adventures, happened yesterday while I was serving time in the Minor Surgical Operation Theatre (MSOT). Serving time simply because the 7-hour shift at the place has work worth just about one. One of my juniors had come in for a dressing change on a furuncle** on his leg, which had been drained. If you are an intern, all new cases are learning experiences. Making friendly banter with the mamas*** helps one learn even more. So my friend, philosopher and guide looked at the wound and grimaced. “Sir, thoda sa shaving karna padega!” Saying that, he hands me a scalpel. My junior and I look equally bewildered at the mama; but with the helpless acceptance that we shall have to proceed with this bizarre experience. And then I started, with all the care I possibly could offer, with a razor-sharp (duh!) scalpel to raze the tender, friable skin around his wound! Soon it was done and we both heaved a sigh of relief. I had shaved a man’s leg; I could die as a content being right now and have no more demands from life!

Now this paragraph is what I call "saving the best for after the last". Actually, I had forgotten about this event and, hence, not written about it when I originally posted this article. I had been asked, by the JAM magazine chief editor, to write an article describing an intern's experiences during the recent Resident Medical Officers' (RMOs) strike across Maharashtra. That article, "Carry on (Trainee) Doctor", was published in the current JAM (March 15-29) and on their website (here) and also on my website (here).

* Tracheostomy: A surgical hole made into the trachea (wind-pipe) in order to insert a tube to give artificial breathing. An endotracheal tube (inserted from the mouth to the trachea) causes damage to the vocal cords and surrounding structures if left in place for too long (>3 days). Since the tracheostomy tube is inserted from a hole made below the level of the vocal cords, it does not cause damage to them.
** Furuncle: A skin infection that develops a collection of pus, caused by bacteria that reside on the skin itself. The furuncle is treated by incising it to drain the pus.
*** Mamas: These middleaged guys have much to talk about, an opinion on everything and, some, are exponents of the art of using expletives. They are the OT workers who know many surgical procedures on account of their years spent watching them. They are ‘instrumental’ in helping the young interns learn the ‘ropes’ of surgery (suturing, etc.).

A Forgotten Tune Plays Again

2006-03-19T02:15:00.000-08:00

I form a part of the club of unabashed Michael Schumacher supporters. Somehow, ever since 1994 when I first began watching Formula 1 races, this sportsman has stood apart. Back then, at my place, my parents thought F1 racing was a dull affair, with cars merely going n number of times around the same track “in circles”. Watching a full race – taking up 2 hours on the common television – was a feat I had first accomplished in 1995, during the Spanish GP. Subjecting my mother to the agony of the circulating cars, I watched with fascination how Schumacher, in his Benetton, was stuck in 5th gear through a large portion of the race. The consequences of being stuck in 5th (at that time F1 cars had 6 gears) is that the engine revs are very low in the slower sections of the race – giving less speed – and the car can never achieve its top speed because it doesn’t utilize the 6th gear. In short, major handicaps in a fast-paced race like Spain.

With amazing skill, he stayed the charging Mika Hakkinen (even then driving for McLaren, which bore the old red-white colour scheme), who was closing in on him like a cheetah stalks an injured impala. Fortuitously for Michael, he could hold on till the end and Mika wouldn’t have gotten past even if his engine had not blown on the penultimate lap. The Michael-Mika rivalry probably took off from here and reached epic proportions during their classic duels in ’98, ’99 and 2000.

One of the spellbinding moments of F1, by my reckoning, was at the 2000 Belgian GP (Spa Francorchamps = fron-ko-shon). The scene was almost identical – Michael was leading Mika by a slim margin, Mika had the faster car (’98, ’99 and 2000 were the years when McLaren were ruling the roost with the speed of their Mercedes Benz engines) and there were just a few laps to go. Michael, having negotiated the Eau Rouge corner, entered Kemmel straight (more than a kilometre long and with a steady incline) and had the back-marker Ricardo Zonta (BAR team) ahead of him. Hakkinen was closing in with every passing yard. Zonta, much slower than his two pursuers, was slightly to the right of the road. Michael tucked in behind him to benefit from the slip-stream effect*. Mika tucked in behind Schumacher to also benefit from his slip-stream. As Michael passed Zonta, he exited the slip-stream but Hakkinen continued to remain in it, this time, Zonta's slip-stream. That extra benefit pulled his McLaren an extra bit more than Michael and he gained the position from Michael and went on to win the race. Though heartbreaking for a Schumacher fan, this overtaking move ranks amongst the top ones for its sheer intensity.

The picture on the left shows the Spa-Francorchamps track of Belgium, notice the twisted Eau Rouge corner leading to the long (and inclined) Kemmel straight. The picture to the right shows the orange car of Zonta, the red car of Schumacher and the grey car of Hakkinen. Hakkinen benefits from the slip-stream effect following Zonta and emerges ahead of Michael even though he was earlier behind him. The video below shows, in the first half, how Hakkinen tried an overtaking move on just the previous lap at the same spot but was brilliantly defended by Schumacher, and in the latter half, the move that's being described here. Amazing driver's-eye-view of the situation!

Michael’s probably endured the most number of rivals in F1! Ever since he started making a mark, he was rubbing shoulders with the greats – Ayrton Senna and Alain Prost. Next was the Brit Damon Hill (McLaren), followed by another McLaren driver Mika Hakkinen. In 1997 occurred the controversial Jacques Villeneuve-collision episode which won him a lot of flak and eventually the championship went right down to the last race at Suzuka, Japan where the Canadian took the honours. After 1997 the Hakkinen rivalry came to the fore once again, as Villeneuve faded away. With the retirement of Hakkinen and McLaren hiring another flying Finn, Kimi Raikkonen, the German’s McLaren rivalry continued. The entry of the swashbuckling Juan-Pablo Montoya (for Williams) promised to be yet another contest to watch out for. The latest amongst the contenders for Michael’s place has been Spaniard Fernando Alonso, the current world champion. He’s climbed up the ranks at a breakneck pace indeed!

One may recall a certain Alex Yoong, the only Malaysian to have ever competed in Formula 1, who resurfaces every now and then to give race info etc. He was actually the 19-year old Fernando Alonso's teammate in their debut 2001 season. Alonso's talents, though not covered on television due to his lowly standing - in the Minardi team, were being heeded elsewhere in the F1 world. He quickly found favour with Flavio Briatore, the head honcho of the Renault team (Renault took over the same Benetton that Schumacher won his first championships with), and was hired subsequently. The rest, as they say, is history.

Now, if you are wondering how all this seemingly irrelevant history is relevant to the title, read further.

In the late 90s, when the Benetton team was well and truly in the doldrums, Giancarlo Fisichella (Italy) and Alexander Wurz (Austria) used to drive for them. The team went racing purely from the point of view of getting their machinery tested in the real circumstances. Their hardware at the time was so far behind the front runners that they couldn’t hope to compete in the same league. Invariably, they would end up languishing amongst the Minardis and Arrows. Fisichella, understandably tired of wasting his talent, sought a move out and joined Sauber Petronas. His former team was taken over by the engine manufacturer – Renault and that is when the tide changed for the team. They were amongst the points and slowly, but surely, threatening to reach the top.

With the recruitment of Alonso in 2003, they started their march towards realizing their dream of championship glory in both categories – the drivers’ as well as the constructors’ titles. In 2006, Giancarlo Fisichella has returned to the team that he has played a major (albeit silent) role in developing. 2005 was Renault’s season – partly because of the precocious brilliance of Alonso and partly because of the Ferrari machinery letting them down.

Today Giancarlo Fisichella (who considers himself the best driver in the business after Michael Schumacher) won the Malaysian Grand Prix, and the Inno di Mameli (Italian National Anthem, composed by the poet Goffredo Mameli) played in Formula 1 after almost an eternity. At one time, when Ferrari and Michael Schumacher were routing the opposition, winning a record 13 races in 2004, many people thought that the Italian and the German anthems are the usual musical pieces played at the end of every race!

It was refreshing to hear that forgotten piece of music once again. Thanks, Fisi for winning that race!

* Slip-stream effect: When a formula-1 car is at high speed, it creates a partial vacuum immediately behind it because the air it displaces due to its motion takes a split-second to fill back up. If another car is following very close, it gets sucked into this partial vacuum, thus going faster than the car ahead. This effect explains the way cars are overtaken on long straights.

Performance Anxiety

2006-03-09T06:31:00.000-08:00

This term usually denotes the condition most of us undergo just prior to exams, prior to interviews and other such encounters where the fear of the outcome overwhelms us. One such attack of PA occurred on the 7th of March.

Contrary to the previous posts, there was some work in the ESR. Three patients had been brought in almost simultaneously. Two of them were “unknowns”, both having suffered a head injury; and the third was suffering from abdominal pain. The excitement of seeing patients in the ESR generally incites all the interns, otherwise languishing on their chairs, to spring up and rush to insert various tubes.

As if that much excitement was not enough (normally, vast amounts of time elapse without a new patient), in walks the Dean, followed closely by the Head of the Surgery Department, who was, in turn, followed by a coterie of cameramen and reporters. The HOD went about bragging to the reporters about how they are proceeding largely unhindered despite the strike, emergency operations are being carried out, the Emergency ICU is functioning to full capacity and – the punch line – how this is being made possible because of the “dynamic young doctors who are working 24 hours” (pointing at us interns, who were proudly exhibiting black ribbons on the apron pocket). He then went on to pose with another senior surgeon, apparently pondering over a CT scan placed on the view-box (like they show in the movies; thankfully it wasn’t as bad as Munnabhai making a spot diagnosis of lymphosarcoma of the intestine on looking at a skull X-ray). The Dean added her bits, towards the end, but the reporters were still hungry for a few more bytes.

In the meanwhile, us dynamic youngsters had expeditiously IVed, Foleyed, RTed and collected one of the two unknowns and were proceeding with our armamentarium towards the other unsuspecting unknown. While at the trolley where all the needles and the swabs are kept, one of the reporters (one must admire his audacity) politely requests me “Doctor, could you please act as if you’re doing some work?” The look he got in return amply conveyed my displeasure at his lack of observation, and he rephrased himself to “Could we please film you doing some work?”

So, there I was – in the spotlight. The IV cannula, a syringe attached to the 3-way and a swab wetted with spirit are all taken to the patient’s bed. With the flair of a rank amateur, I rip open the Nulife 7.5 Sterile Latex Gloves pack (one must dispel the myth that public hospitals care nothing about asepsis). The senior intern (actually an extern from Russia) compresses the patient’s hand proximally, to make the veins more prominent. I clean the area with spirit. Lo and behold! There she is – an object of rare beauty – a fat green vein screaming out “Prick me!” The stakes are high, I must get this IV line otherwise I shall be a failure across national television (well, at least to the small minority of people who waste their time watching fringe channels like CNN-IBN). A bead of sweat forms on my brow. With trepidation, I insert the cannula. Nothing. A little further. Still nothing. At this point of time, the procedure is on full zoom and something’s got to give. The situation is as tense as the moment before ‘pappa’ pockets the cover for the queen in the game of carrom in Munnabhai MBBS.

The situation culminated in an anticlimactic finish and the vein blinked first, a catastrophe was averted. The world watched in awe how the young dynamic doctors saved the day.

Epilogue: (1) The authorities are projecting a false picture before the media regarding the functioning of the hospital. Interns, as you could make out from that over-hyped description of the IV insertion, are doing the job of technicians and do not, by any means, affect patient care by their so-called “dynamic” nature.

(2) The nail-biting IV-line insertion was aired on Wednesday 8th March at night on the CNN-IBN news channel.

Glossary: IVed = insert an intravenous line; Foleyed = insert a Foley's urinary catheter; RTed = insert a Ryle's Tube - a nasogastric tube; collected = collect blood for testing

Signs of Support

2006-03-09T06:16:00.000-08:00

Three days back, while whiling away the time sitting in the ESR (which has been explained in ample depth in all the previous posts), two friends – Harini and Meera – and I decided to start a signature campaign in our college to support the cause of the resident doctors’ strike. The letter was addressed to the MARD President and categorically mentioned the demands that we thought were justified; and we made sure we stayed away from the controversial issue of joining the strike. The letter was merely one of support. Here’s how it read:

To,
The President,
Maharashtra Association of Resident Doctors (MARD).

Dear Sir,

We, the interns/students of Seth G. S. Medical College and K. E. M. Hospital, Parel hereby express our support to your demands to the Government, namely:
- Increased security for resident doctors
- Better working hours for the residents
- Improvement of the doctor-patient ratio
- Improved residential facilities
- Increase in the stipend to bring it on par with that of Class II Medical Officers
- Reduction in tuition fees for residents
We also support your demand that no disciplinary action should be taken against the striking doctors.

Yours sincerely,

[List of people with signatures]

We have, till date, managed to get more than 75% of all the batches to sign the letter. I managed to hand over this idea and the letter to one of my friends who is an RMO in the ENT department in Sion Hospital, who is trying to get a similar campaign going in LTMMC too. This would concretely put on paper the support the residents have amongst the student population. Hopefully, this can be carried out in other colleges as well.

'Continue All'

2006-03-04T05:00:00.000-08:00

It was one of those days where I did pretty much nothing more than sit in the ESR minding my own business, waiting for the next batch of interns to come to relieve me. My state of thoughtlessness was violently interrupted by Dr. OSR (Head of Unit) who shook me and asked me to run up to Ward 6 where Dr. Pinky had some work for me. I tried asking him the cause for the sudden need of an intern, considering our 3-day experience; but he wouldn’t offer an answer and pushed me with urgency.

So with that bit of urgency in my step I climbed the stairway to the first floor where the surgery wards are located and entered ward 6 looking for Dr. Pinky. The ward looked deserted, all patients were comfortably lying on their beds and Dr. Pinky was entirely absent. Assuming that she may be in one of the side-rooms, I proceeded into the ward but was halted halfway through it by one of the nurses who promptly whisked me behind a screen.

On the bed there was a patient lying still. His hands were cold to touch. The nurse informed me that he was alright just a few minutes back and the relatives had suddenly run up to her to inform her that something was wrong. Since there were no residents in the ward, she was compelled to make a call to the ESR. Now, I thought to myself – what I was supposed to do? Having never attempted cardiopulmonary resuscitation (CPR) on anyone before, I was quite flummoxed by the situation.

Here is where being calm in a crisis really helps. What one has learnt in the past suddenly starts, inexplicably, talking. I asked the nurse if adrenaline and atropine had been administered, to which she answered in the affirmative. Something like “look, listen and feel” suddenly struck me and I attempted to check for the pulse and respiration. Next, I instructed the nurses to quickly bring the bed to the flat position (it was propped up at 30°) and I asked one of them to manage the Ambu (Ambulatory Manual Breathing Unit) bag and told her that for every 15 chest compressions there have to be two breaths. In hindsight, if this ratio had been asked to me off-hand, I am sure I wouldn’t have a clue.

On starting the CPR, two problems emerged – the air was escaping between the face mask and the face; and, probably as a consequence, there was very little chest expansion. Here, I realized I had missed out one vital step – to tilt the chin to straighten the airway. I also instructed the nurse (who was a trainee) to apply the mask closely to the face to prevent escape of air. This proved helpful in getting a good chest expansion.

So the CPR went on for a few minutes, with intermittent checks for heart sounds and the carotid pulse, both of which were, disappointingly, absent. The exercise was becoming pointless and after a while, the nurse advised me to discontinue it. She also told me that since I was the only ‘doctor’ around, I would have to explain the event to the relatives.

It’s worthwhile to mention here that the ongoing strike of resident doctors was initiated by an incident involving breaking the news of a patient’s death to the relatives, following which the doctor was assaulted by the relative.

Obviously, I was extremely apprehensive about the situation, but there was no other choice. I had interacted with this patient for just about 10 minutes – after his death. I had no idea of his disease or the likely cause of death. I had never explained anything as grave as this to patients’ relatives before! Well, there was always going to be a first time, I thought to myself. I asked the nurse for the patient’s file.

He had suffered a fall and injured his head, leading to a Sub-dural Haematoma (SDH) – a collection of blood below the outermost covering of the brain (dura mater). I conjectured, at this juncture, that the increase in intra-cranial pressure may have compromised his vital centres in the medulla. The relatives were soon there to take a look. With extreme caution, which probably reflected in my manner of speaking, the relatives were ‘explained’ this probable cause of death and that ‘we had tried our best’.

Almost as if on cue, Dr. Pinky entered the scene (like the police in the movies) and shot me with the question – “Explained, na?” to which I offered a passive, non-committal nod (how was I supposed to know whether that’s the complete ‘explanation’ to be given to relatives?). She took over, informing the relatives about the future course – that an autopsy will be required and the death certificate will be issued subsequently and that the body will be stored in the morgue etc. That done, we both left the ward.

On my way out, the incident was slowly being digested by my mind. Thoughts like whether there was anything that I could have done differently, whether he should have been intubated (again something that I’ve just seen but never done), whether it’s right to haul up an intern to ‘show the patient’s relatives that we’re doing something’ and so on, were buzzing through my head. But the only two thoughts that stayed back with me by the time I reached the ground floor were that this situation could have easily been averted had there been a qualified resident doctor in the ward (as is always the case) and that there’s nothing more ironical than reading a dead man’s file with the next day’s orders (Ct all, continue all) already filled in. The residents’ strike had claimed a life.

Let down by the Library

2006-03-02T20:36:00.000-08:00

The library in my college shuts early now-a-days as the annual stock-taking is currently in progress. For the very few people like me, in this college, this would be an excellent excuse not to study; but that’s not the case with the majority. This is a good time to observe how resourceful GSites can be in finding a place to read.

A lot of people adopt the kattas around college as their homes at such times. Invariably, the ones near the Pathology museum and opposite the WPM board are occupied through the day. The one on the first floor near the small stairway ascending from opposite the LCR is also a hot favourite - probably due to its excellent ventilation and the view it offers of the happenings on down below. Of late, I have noticed groups of people studying outside the BCR too - two on the katta and one on a chair whisked out of the BCR out of a carrom player's sight.

Non-katta solutions to the problem of "space to study" are ingeniously devised by a few, using motorcycle seats or the ones in the canteen. Either way, the person needs paramount concentration to achieve his/her goal.

Students can also be found in the 'fistula' connecting the library and the college buildings - sometimes sitting around and sometimes sprawled over the floor. This place, too, is excellently ventilated and offers great light; but it's also the point closest to the library where adequate Hutch reception is obtained! Hmm... probably this is the place gossip mongers like to be at.

I have frequently seen people studying on the benches in the Anatomy department, which receives ample sunlight. Now, this provides a lot of light but also requires a high heat tolerance from the occupant of the bench. On the contrary, the 'bats' (as I call them) haunt the benches outside the Pathology lab, which receive little or no sunlight. Whether or not these people really read their books or absorb their content through sonar (?) is open to question.

Another place that’s never seen empty during library stock-taking is the seating outside the MLT and the bench near the college entrance near MLT. The seating area outside the MLT is probably the area with the worst network coverage (at least for Hutch) in college. After the natural light has faded and the kattas are plunged in Shadow, this place, the area outside the upper entrance of MLT and the steps of the college entrance near Gate 1 are thronging with people who utilize the select tube lights that provide light enough to read. At the same time, the office window between the WPM and Gymkhana notice boards becomes a comfortable singleton’s place, once the window panes have shut.

It’s quite remarkable that so many people are willing to take such pains to read their books. Laziness helps at times like these. Necessity is the mother of invention (and resourcefulness). I have managed to find an excellent place for reading – the ESR side-room. And the fact that I am posted there at the moment is a total boon. The side-room has ample lighting, a fan that works and a sofa-cum-bed to relax on. And my co-interns wonder why I report to the ESR three hours before my shift starts!

Two days in the ESR

2006-03-01T12:40:00.000-08:00

Securing passing marks at the final MBBS exams is a mighty relief. This emotion is, however, unique to the near-sighted or the uninformed ones who have not, as yet, been forewarned about the horrors of the year that is to lie before us – the year of ‘internship’.

Of course, the initial five days are supposed to be like the calm before the storm (the ‘calm’ referring to the peaceful sleep one is entitled to on account of attending the ‘orientation programme’). Having tolerated the lectures, comprising mostly of mundane details about irrelevant things (viz. blood bank procedures, how waste is handled once it leaves hospital, and so forth) for two days, my plan for day 3 was similar, though I had some photo reprints to sort out for my friends. That was supposed to be the highlight of the day – giving people their respective prints, as they had requested, and recovering the money I had spent for them.

Onward I trudged towards the third floor, huffing and puffing into Theatre 4, reminding myself that had my trip near Uttarkashi included more of a trek I would be much fitter and wouldn’t have had to contend with the paunch that had developed over the past few months. Anyway, the day’s highlight was soon to be changed – to be replaced by front-page-news-worthy stuff… there was a resident doctors’ strike that had begun the same morning and the hospital needed doctors to fill in for them.

At this point I would like to mention the status of interns in a hospital like mine is somewhat like a bonded labourer. Unless you work the way they tell you to, you don’t get a completion signature. Okay, that wouldn’t be such a problem – unless you take into consideration the fact that our batch, having started internship in late February, has to attend each day in order to have enough months of completed internship to qualify to take post-grad entrance exams later in the year! In short, since they know this, they could very well ask us to sweep the hospital and we would have to be most obliging.

We were forced to digest the news quickly and proceed to the PSM (Preventive and Social Medicine) department, which handles the unenviable and plentifully sadistic responsibility of managing the interns’ postings. They needed about half an hour’s time to formulate, print out, photocopy and display the postings, so they said. And we waited. And waited. And skipped a meal, just in case we have to report immediately. Yup, and we waited. About four hours later I was to learn that I am posted in the Emergency Department, on the surgical side.

I make no bones about my dislike for surgery. I find it crude when it’s at its best and inhuman when it’s at its worst. However, the ESR (Emergency Surgical Room/Resident – used interchangeably whether referring to the location or its contained staff) is a good place to learn a few procedures, which one usually plans to become proficient at, at the end of the internship. Feeling fortunate about the turn of events, I head in to face my apprehensions!

In the meanwhile, those posted in the surgical wards are seen frolicking around, running off home and generally feeling very happy about themselves. In a little while, they would be called back from their way to the railway station, canteen and wherever else that Hutch’s network follows, to report to the wards and do some much-needed clerical work. Nothing holy about it though! Their task was to copy out the orders and medications written by the resident on the previous day in each and every patient’s file (colloquially known as a “Ct all”, continue all). Copying journals is an easier task, any day! When I was helping some of these hapless clerks, I had to seek the assistance of one of the nurses in decoding the heavy-duty encryption on that paper! Sometimes, for people, life is a file.

Back after my humanitarian gesture (very few people share work with fellow interns, especially when they have no benefit from it), the ESR was like a placid track (like the ones in Pakistan) where the masters Sehwag and Bradman were at their best. This phenomenon is known as ‘batting’ in our lingo. Any and all patients were being sent off, after providing adequate justification, of course. I witnessed two attempted suicide cases in a matter of less than 5 minutes. An excerpt of the episode:
· Woman with kerosene burns on at least 40% body surface (20% is the criterion for hospitalization). Patient rapidly redirected to the plastic surgery department, after the lecturer heaves a sigh of relief – “Thank God no one had written on that paper, otherwise it would have been an ESR admission!”
· Man with a cut-throat injury brought in a semi-conscious state. Lecturer examines the wound, comments on the subcutaneous emphysema (air in the subcutaneous plane) and tries to get the patient to talk something. After some mumbling, he comments “He’s got hoarseness… it’s an ENT surgeon’s case. Intern, please refer him to ENT.”

We were given a piece of advice by the lecturer: 4 interns sitting for 6 hours is less boring per intern than 2 interns sitting in 3-hour shifts. We jumped at the idea, and off went two, to come back later. The remaining time at the ESR was nothing worth mentioning, unless time spent in the futile search of the ideal posture in the uncomfortable ESR chairs is taken into consideration.

So thus ended one day at the ESR – thoroughly eventless and largely boring.

We figured that the next day would be equally passive. The PSM department thought otherwise. They brought in interns from unrelated quarters such as the ones posted in rural hospitals to help in the ‘work’ at the ESR. No interns had actually gone to the rural health posts, but were living peacefully under the notion that they won’t have to until the strike gets called off. At times like these one realizes that PSM also means ‘Punishment for Surviving Medicine’. All this under the premise that there’s ‘work’ in the ESR. On the contrary, the Bradmans and Sehwags were replaced by equally dexterous Sachins and Dravids… the interns, as usual, stared at each other, gossiped about the strike with the lecturer (who was proudly narrating his own boisterous antics during his resident days, when he had instrumented a strike), solved the ridiculously simple Mid-Day crossword, had free snacks brought by a Medical Representative (MR) and tried to read little handbooks in the intervening time.

And then chaos struck. In comes a patient with a Sub-Dural Hematoma (SDH). The lecturer yells “Intern! IV, blood collection – send R, B, E, grouping and cross-match, Hb, CBC and then put in RT and Foley’s!” Before we could get our gloves on, another stretcher enters the ESR, carrying a hit-and-run victim – a patient of poly-trauma. Similar instructions are shouted again, disorienting us. I, after filling the labels for the blood vials of the SDH patient, try to make myself useful in this newfound emergency, and run to put the IV line in the newer patient. In the process, I mess up the job and finally the sister does the needful. The lecturer now yells – “Sumedh, what the hell are you doing with that patient? You fill labels for one and collect from another! All four interns divide the work properly.” All this because one daft co-intern couldn’t read that I had finished filling up the labels for Mr. SDH, before shooting off for Mr. Poly-trauma, and had made the mistake of asking the lecturer what to fill up.

The hit-and-run patient was in a sorry state. An old man on his way to the bank was slammed by a fast-moving van; he sustained an open fracture of both leg bones on the right side, a few rib fractures and gaping wounds on his chin and clavicle. As he was being managed by the lecturer, I observed as the senior intern used a wound stapler to appose the gaping edges with metallic staples and an orthopedic stabilized the fracture using a plaster-of-Paris slab. His relatives were being explained why they would need to move him to a private hospital. In the meanwhile, a third patient was brought in, which raised an unbearable stench all over the place. Here was an old man who had developed a huge bedsore on his buttocks, which had subsequently got infected and necrosed. Surprisingly, nothing much to be done (well, at least in the given situation). The lecturer told the senior intern to just clean it with betadine and dress it with compression bandaging.

Before this job was completed, a fourth patient entered. A 24-year old man had undergone an operation for a perforated duodenal ulcer two weeks back and had now presented with abdominal pain. On opening his bandages, we found a huge gaping incision wound, probably because the suture materials were digested by bacterial action. Well, again nothing much to be done – we applied a new dressing and sent him to a private hospital.

After so much work (on regular days, this would be about fifteen minutes’ work), on a day that we were supposed to while away like the previous one, we finally had a chance to sit back and note how patients sometimes come all at once! Just two more patients arrived until my duty finished that evening: I got to suture one CLW of a woman who had been struck by her mother-in-law, and one gory degloving injury (a man’s hand had gone through a machine and the skin had got peeled off his hand).

One cannot help but sympathize with the residents, who handle many times the stress we interns undergo on emergency days; but, at the same time, one cannot help but see the inconvenience and danger patients face in being turned away from a hospital. Therefore, medical personnel need to realize what their actions might lead to when they strike work, whatever may be their demands.

Thank you!

2006-03-01T11:26:00.000-08:00

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