Though late, the South-West monsoon [the main source of Rain for this area] finally have been kind enough to my native state, Kerala.
Until this week, Newspapers were saying that this was the weakest monsoon in recent memory with a 43 percent deficit in rainfall in the first 7 weeks of the season. Power blackouts started [as the major source of Power here is Hydro-electric projects] and fear of failed crops were looming large.
This week everything changed. The sky started pouring and pouring. Even as I type, I can hear the wonderful sound of rain. Newspapers started talking about flash floods and landslips. Let us hope the monsoon will wipe off the rainfall deficit in quick time.
Rain or no Rain,Chikungunya epidemic continues relentlessly. In some families, almost all members are getting affected. I had an opportunity to visit a small town 15 kms away. I went there on invitation of a local Club. They wanted me to give a health education class about chikungunya fever.
When I reached there, the people were not in a mood to listen to a talk. They wanted prescription for medicines so that they can recover fast. Most of them were manual labourers, and the persistent joint pain and swellings were preventing them from working. Some wanted preventive medicines to protect them from the virus. I was helpless. There is no fast cure.The joint pains may last for weeks to months. During that period, they will have to continue taking anti-inflammatory drugs. Also, there is no preventive medicine or vaccine yet. I asked them to take measures to reduce breeding of Aedes mosquito. I also asked them to isolate the patient inside a mosquito net during the time of fever. At that time, maximum number of viruses are there in patient's blood and mosquito bite can easily spread the illness.
My team saw more than 50 patients. Some free medicines were distributed, but nobody was satisfied. As we drove back, my thoughts were on the enormity of physical and economic damage this virus had brought on the society, especially for the poor.
Wednesday, July 30, 2008
Monday, July 28, 2008
Craze for Specialist Consultation
Recently, I had an interesting experience. A-25-year old guy working in a Software Company in Banglore came to me with complaints of lack of appetite, giddiness, nausea and headache of a week duration. He had seen a doctor there in Banglore but the medicines prescribed did not help him.
Just looking at his eyes made me realise he was jaundiced. I examined him fully and came to a conclusion that he was having jaundice probably due to acute viral hepatitis. Before ordering a panel of tests to find out the exact cause of jaundice, I asked him to show me the Banglore doctor's prescription. He gave it to me little reluctantly. To my utter surprise, the doctor he had seen is a senior consultant in Neurosurgery at a posh hospital. The doctor had not spotted jaundice, may be because at that time [6 days ago] it was not as evident as it is now. He had given him anti vertigo and anti vomiting tablets.
I was curious.Why you went to a neurosurgeon? He said his friends told him it was better to see a top most consultant of Neuroscience as they all felt the problem was in Brain. Still why a surgeon? You could have gone to the neuro-physician? The reply shocked me.Only the neurosurgeon in that hospital had an American degree.
This craze for specialist consultation [after self diagnosis] is growing among the upper and middle income groups in India. Most often this leads to delayed diagnosis and delayed treatment. Many doctors also encourage this for selfish motives. The patient with headache go to a neurologist first and the one with chest pain will always go to the cardiologist first. The concerned specialist first rules out all the illnesses that he can treat by a panel of investigations. If all are negative, then only the patient is referred elsewhere.
With tons of medical information available on the Internet, many patients believe that they can diagnose themselves. They also believe that they can chose the specialist they want to consult. Many decides which medicines they will take and which they would not. Is this trend of patient emancipation beneficial to the society? Many believe so but I am not so sure.
.
Just looking at his eyes made me realise he was jaundiced. I examined him fully and came to a conclusion that he was having jaundice probably due to acute viral hepatitis. Before ordering a panel of tests to find out the exact cause of jaundice, I asked him to show me the Banglore doctor's prescription. He gave it to me little reluctantly. To my utter surprise, the doctor he had seen is a senior consultant in Neurosurgery at a posh hospital. The doctor had not spotted jaundice, may be because at that time [6 days ago] it was not as evident as it is now. He had given him anti vertigo and anti vomiting tablets.
I was curious.Why you went to a neurosurgeon? He said his friends told him it was better to see a top most consultant of Neuroscience as they all felt the problem was in Brain. Still why a surgeon? You could have gone to the neuro-physician? The reply shocked me.Only the neurosurgeon in that hospital had an American degree.
This craze for specialist consultation [after self diagnosis] is growing among the upper and middle income groups in India. Most often this leads to delayed diagnosis and delayed treatment. Many doctors also encourage this for selfish motives. The patient with headache go to a neurologist first and the one with chest pain will always go to the cardiologist first. The concerned specialist first rules out all the illnesses that he can treat by a panel of investigations. If all are negative, then only the patient is referred elsewhere.
With tons of medical information available on the Internet, many patients believe that they can diagnose themselves. They also believe that they can chose the specialist they want to consult. Many decides which medicines they will take and which they would not. Is this trend of patient emancipation beneficial to the society? Many believe so but I am not so sure.
.
Saturday, July 26, 2008
Alternative Medicine
Can I use this Ayurveda Medicine along with what you had prescribed for me for Diabetes?
Can I use this 'Insulin leaf' for controlling my blood sugar?
Can I use this homeopathy medicine to prevent getting Chikungunya fever?
I hear such questions again and again.The popularity of Alternative Medicine is ever increasing.As long as there are illnesses there will be Alternative Medicine.
Recently I read an interesting article in The Guardian' titled 'A bad week for alternative medicine' by Rose Shapiro.I agree with most of her points. For those who do not have time to read the article in full here are some excerpts that I liked.
Alternative medicine users are apparently prepared to suspend all normal critical faculties when they encounter an alternative practitioner
Quacks often use language that is abstract and subjective but is ultimately meaningless. Words such as "quantum" sound impressive to those of us with only a weak grasp of theoretical physics, but are in fact nothing but pseudo-scientific window dressing designed to lure a gullible public.
Quacks will often tell you that feeling worse is a sign of getting better. Most detox regimes describe symptoms such as spots, bad breath, headaches and nausea as proof that the detox is working. Such a notion is central in homeopathy, which enables practitioners to rationalise away the worsening of their patients' symptoms
The orthodox doctor treats what you have, and the alternative practitioner says you have what she treats
Quacks are flattering and will appeal to your vanity. They tell you that you are unique and extraordinary and not like other people. On the rare occasions that they find nothing wrong they say you need maintenance treatment "in order to keep your energies in balance
Many alternative practitioners sincerely believe in what they are doing and want to help their clients. But there have surely been enough cases now of blatant recklessness if not outright deceit to confirm that practising alternative medicine is very often the last refuge of the scoundrel.
I live in an area of India were ancient Indian Medicine [Ayurveda]have strong roots. Even the name Charakan, I chose in respect of a great ancient Indian Physician called Charaka who lived about 2000 years ago. At that time Ayurveda was one of the most scientific of all medical systems, but it stagnated and went into decay as Scientific medicine within a few hundreds of years. Still, the Ayurveda practitioner used to uphold ethics of high standard. Now in the 21st century, Ayurveda is also fast deteriorating into a money-making business exploiting gullible public like all other Alternative Medical systems.
How do I answer the the above questions of my patients regarding Alternative Medicine?
I just answer 'I don't know'.
Then I explain saying, 'I have not studied Alternative Medicines. And as far as I know they don't have any scientific basis. So if you want to experiment on yourself you may take them.Otherwise don't take them.'
Then they will ask 'as there are no''side effects''what is the harm?'
My reply will be 'I have seen many patients who suffered from severe side effects due to Alternative Medicines.Also such medicines may interact with the medicines I have prescribed.'
Hearing all this most of my patients wont dare to take Alternative Medicine.
Can I use this 'Insulin leaf' for controlling my blood sugar?
Can I use this homeopathy medicine to prevent getting Chikungunya fever?
I hear such questions again and again.The popularity of Alternative Medicine is ever increasing.As long as there are illnesses there will be Alternative Medicine.
Recently I read an interesting article in The Guardian' titled 'A bad week for alternative medicine' by Rose Shapiro.I agree with most of her points. For those who do not have time to read the article in full here are some excerpts that I liked.
Alternative medicine users are apparently prepared to suspend all normal critical faculties when they encounter an alternative practitioner
Quacks often use language that is abstract and subjective but is ultimately meaningless. Words such as "quantum" sound impressive to those of us with only a weak grasp of theoretical physics, but are in fact nothing but pseudo-scientific window dressing designed to lure a gullible public.
Quacks will often tell you that feeling worse is a sign of getting better. Most detox regimes describe symptoms such as spots, bad breath, headaches and nausea as proof that the detox is working. Such a notion is central in homeopathy, which enables practitioners to rationalise away the worsening of their patients' symptoms
The orthodox doctor treats what you have, and the alternative practitioner says you have what she treats
Quacks are flattering and will appeal to your vanity. They tell you that you are unique and extraordinary and not like other people. On the rare occasions that they find nothing wrong they say you need maintenance treatment "in order to keep your energies in balance
Many alternative practitioners sincerely believe in what they are doing and want to help their clients. But there have surely been enough cases now of blatant recklessness if not outright deceit to confirm that practising alternative medicine is very often the last refuge of the scoundrel.
I live in an area of India were ancient Indian Medicine [Ayurveda]have strong roots. Even the name Charakan, I chose in respect of a great ancient Indian Physician called Charaka who lived about 2000 years ago. At that time Ayurveda was one of the most scientific of all medical systems, but it stagnated and went into decay as Scientific medicine within a few hundreds of years. Still, the Ayurveda practitioner used to uphold ethics of high standard. Now in the 21st century, Ayurveda is also fast deteriorating into a money-making business exploiting gullible public like all other Alternative Medical systems.
How do I answer the the above questions of my patients regarding Alternative Medicine?
I just answer 'I don't know'.
Then I explain saying, 'I have not studied Alternative Medicines. And as far as I know they don't have any scientific basis. So if you want to experiment on yourself you may take them.Otherwise don't take them.'
Then they will ask 'as there are no''side effects''what is the harm?'
My reply will be 'I have seen many patients who suffered from severe side effects due to Alternative Medicines.Also such medicines may interact with the medicines I have prescribed.'
Hearing all this most of my patients wont dare to take Alternative Medicine.
Wednesday, July 23, 2008
Acute severe joint pain
She was a 30 year old housewife. She was literally carried in to my consulting room by her husband and her mother. She was writhing with agony at each movement of her joints.
She was perfectly all right in the morning.She walked down to the river[which was about 1/2 kilometre away] to bath, came back and made coffee.At that moment,before she could serve coffee her joint pain started with shivering and she had to be carried from kitchen to bedroom.
She had pain in small joints of fingers, wrist,elbow, shoulders,hip,knee and ankles. All those joints were warm. Her temperature was 101F. Rest of the examination was normal.
Yes, this is the classical onset of Chikungunya fever. I send her out in a wheel chair to get admitted.She was given medicines to reduce fever and inflammation of joints.The next day she was sitting happily ready to go home. Her fever has subsided and joint pains less.She will continue to suffer from joint pains for uncertain number of weeks, and thus may need to continue anti inflammatory drugs.
The fever and joint pains in chikungunya infection start so suddenly that some patients are able to tell the exact minute of onset. I still wonder why the onset is so sudden and unexpected.
She was perfectly all right in the morning.She walked down to the river[which was about 1/2 kilometre away] to bath, came back and made coffee.At that moment,before she could serve coffee her joint pain started with shivering and she had to be carried from kitchen to bedroom.
She had pain in small joints of fingers, wrist,elbow, shoulders,hip,knee and ankles. All those joints were warm. Her temperature was 101F. Rest of the examination was normal.
Yes, this is the classical onset of Chikungunya fever. I send her out in a wheel chair to get admitted.She was given medicines to reduce fever and inflammation of joints.The next day she was sitting happily ready to go home. Her fever has subsided and joint pains less.She will continue to suffer from joint pains for uncertain number of weeks, and thus may need to continue anti inflammatory drugs.
The fever and joint pains in chikungunya infection start so suddenly that some patients are able to tell the exact minute of onset. I still wonder why the onset is so sudden and unexpected.
A positive feedback
I had a pleasant phone call the other day. The caller was the brother of the patient with acute leukemia in my earlier post.
He said his brother is much better now and has been discharged from the Hematology Centre after a month of hospitalisation. Chemotherapy course have to be continued for a year.He thanked me profusely for diagnosing the condition fast and sending them to that centre. It seemed the doctor there also commented that they reached there well in time.They reached there the next morning itself. The patient is still not out of danger,but chances of survival is more.
I shared the news with the lab team and the pathologist and we all felt good. I started smiling more at my patients and took more time to answer their seemingly silly doubts.
Such positive feed backs help a lot in raising your morale.
He said his brother is much better now and has been discharged from the Hematology Centre after a month of hospitalisation. Chemotherapy course have to be continued for a year.He thanked me profusely for diagnosing the condition fast and sending them to that centre. It seemed the doctor there also commented that they reached there well in time.They reached there the next morning itself. The patient is still not out of danger,but chances of survival is more.
I shared the news with the lab team and the pathologist and we all felt good. I started smiling more at my patients and took more time to answer their seemingly silly doubts.
Such positive feed backs help a lot in raising your morale.
Saturday, July 19, 2008
Thank you Chikungunya
You might be thinking that I am thanking Chikungunya virus for increasing my work and thereby my income.
No you are wrong.
Most people never care to visit a doctor, or check their blood sugar and blood pressure until they get some disease. I am thanking the virus because it helped in detection of type 2 Diabetes in many patients. Also, it helped a few who had undetected high blood pressure.
I know, the patients themselves may not have the same opinion. The pain and suffering they have to endure in Chikungunya fever is enormous. Still there is this compensation of detecting a chronic but manageable disease like Diabetes early before it can produce any serious organ damage.
I am amazed to find that most children of Type 2 Diabetics have not checked their blood sugar even once disregarding the strong family trait for Diabetes. India is now considered as the Diabetic capital of the World with about 40.9 million people estimated to be affected with type 2 Diabetes.Every fifth Diabetic in the World is an Indian.I feel everyone in India should check their blood sugar once every year after the age of 20.If the child is obese or have some other endocrine problem it is better to test even earlier.
Let me end with a happy note. The old lady who stopped insulin on her own and got admitted at 3 am with a blood sugar of 800[DKA ] came for review with her 2 hr after meal Blood sugar value of 170.She is on 30/70 premix Insulin.She promised me never to do that stupidity again.
No you are wrong.
Most people never care to visit a doctor, or check their blood sugar and blood pressure until they get some disease. I am thanking the virus because it helped in detection of type 2 Diabetes in many patients. Also, it helped a few who had undetected high blood pressure.
I know, the patients themselves may not have the same opinion. The pain and suffering they have to endure in Chikungunya fever is enormous. Still there is this compensation of detecting a chronic but manageable disease like Diabetes early before it can produce any serious organ damage.
I am amazed to find that most children of Type 2 Diabetics have not checked their blood sugar even once disregarding the strong family trait for Diabetes. India is now considered as the Diabetic capital of the World with about 40.9 million people estimated to be affected with type 2 Diabetes.Every fifth Diabetic in the World is an Indian.I feel everyone in India should check their blood sugar once every year after the age of 20.If the child is obese or have some other endocrine problem it is better to test even earlier.
Let me end with a happy note. The old lady who stopped insulin on her own and got admitted at 3 am with a blood sugar of 800[DKA ] came for review with her 2 hr after meal Blood sugar value of 170.She is on 30/70 premix Insulin.She promised me never to do that stupidity again.
A smug smile
You might have seen doctors having a smug smile on their face while they look at the investigation results. The patient sitting opposite may think that the Doc is going to tell them some good news. The patient may expect the doctor to tell that the result is negative or the illness is cured. But most often it is the opposite.
Such smile comes on a doctor's face when the diagnosis he thought of is proved by the test result. The smile becomes bigger if some other doctor or doctors had missed the diagnosis.
I also had smiled like that many times especially early in my practise.Now a days I smile only if the result meant it is a curable or treatable condition.
Today I had a reason to show my smug smile.
She is a 65-year-old woman. She was admitted one year ago for altered behaviour and drowsiness following an episode of severe gastro-enteritis [diarrhea and vomiting]. Lab tests showed her Sodium level was well below normal. This was attributed to lose of salt due to vomiting and diarrhea. She was re-hydrated with sodium containing fluids and she recovered well.
I did not see her till last week when she was admitted for extreme tiredness,lack of appetite and vomiting. Her son told me that after last year's admission, she was not keeping good health. She needed frequent hospitalisation for various ailments.
When I examined her, she looked pale and swollen up. She was not listening to me properly and was very lethargic. Her sodium was again low, but other routine tests were normal. I did a Thyroid function study suspecting low level of hormone production from thyroid gland. The result showed I was right, but surprisingly her thyroid stimulating hormone which is produced by the pituitary gland was also low. This meant she is having Central Hypothyroidism and there is something wrong in the pituitary gland. When I did a series of other hormonal tests to evaluate pituitary function the results were equivocal[not helpful to reach a diagnosis].
So finally I ordered an MRI Scan of the pituitary gland.It was while reading that MRI Scan report that I broke into a smug smile.It showed an empty sella meaning pituitary gland is not visualised as it had shrunk in size.
As there is no tumour or injury visible in MRI, it meant that this is not a life threatening problem. She needs only replacement of hormones that is deficient. So I could smile liberally.
I gave the prescription for hormone replacement tablets. I also gave a reference letter to an Endocrinologist in the near by City so that a second expert opinion can be taken.
Many times I have got excited at the possibility of rare and exotic diagnosis.But immediately I try to curtail my excitement and try to think about it in the patients view point.
For this cute old lady the smile meant good news but for many others the news wont be good.
Such smile comes on a doctor's face when the diagnosis he thought of is proved by the test result. The smile becomes bigger if some other doctor or doctors had missed the diagnosis.
I also had smiled like that many times especially early in my practise.Now a days I smile only if the result meant it is a curable or treatable condition.
Today I had a reason to show my smug smile.
She is a 65-year-old woman. She was admitted one year ago for altered behaviour and drowsiness following an episode of severe gastro-enteritis [diarrhea and vomiting]. Lab tests showed her Sodium level was well below normal. This was attributed to lose of salt due to vomiting and diarrhea. She was re-hydrated with sodium containing fluids and she recovered well.
I did not see her till last week when she was admitted for extreme tiredness,lack of appetite and vomiting. Her son told me that after last year's admission, she was not keeping good health. She needed frequent hospitalisation for various ailments.
When I examined her, she looked pale and swollen up. She was not listening to me properly and was very lethargic. Her sodium was again low, but other routine tests were normal. I did a Thyroid function study suspecting low level of hormone production from thyroid gland. The result showed I was right, but surprisingly her thyroid stimulating hormone which is produced by the pituitary gland was also low. This meant she is having Central Hypothyroidism and there is something wrong in the pituitary gland. When I did a series of other hormonal tests to evaluate pituitary function the results were equivocal[not helpful to reach a diagnosis].
So finally I ordered an MRI Scan of the pituitary gland.It was while reading that MRI Scan report that I broke into a smug smile.It showed an empty sella meaning pituitary gland is not visualised as it had shrunk in size.
As there is no tumour or injury visible in MRI, it meant that this is not a life threatening problem. She needs only replacement of hormones that is deficient. So I could smile liberally.
I gave the prescription for hormone replacement tablets. I also gave a reference letter to an Endocrinologist in the near by City so that a second expert opinion can be taken.
Many times I have got excited at the possibility of rare and exotic diagnosis.But immediately I try to curtail my excitement and try to think about it in the patients view point.
For this cute old lady the smile meant good news but for many others the news wont be good.
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