The call of nature: no leaks please..

By Vivek Hande

The victorious England team recently celebrated their Ashes victory on the pitch at Lords by answering “nature’s call” and chose to water the pitch after some feverish Beer drinking. Not quite cricket and not quite gentlemanly, one might say. But what is a leak amongst friends- when you have to go, you have to go.

Apart from some sniggers and some smirks and suppressed amusement, I doubt if this would really outrage a country like us. For us, no place is really sacrosanct. Roads, pavements, streets, buildings, garages, parking lots, gardens, parks, railway tracks and in more recent times ,even coaches in local trains – anywhere , anytime , wherever on the go :that seems to be the motto.  The truth is that in large measure, the progress of a country has to be determined by its standards of sanitation. The less we speak about the standards of sanitation and hygiene in this country , lesser is the stink raised.

It is a fact that more than fifty percent of the 1.2 billion population of the country has no access to toilets. The governments have spent more than 1250 billion rupees on creating toilets and hygiene infrastructure in the last twenty years. However, open air defecation continues to be the norm and toilets that have come up in many villages and rural areas are located unimaginatively and are used as stores for fodder and grain! These are the facts of a government conducted survey and quite literally, money seems to be going down the drain. 

There are toilets in stations and bus stops but do try using them at your own peril. It is a nightmare which may scar you for life. Roads have improved and we have some glorious highways, but there is very little appreciable difference in the standards of the loos. If you are a lady, you can be sure you won’t forget a road trip in a big hurry. Men can be men and can water plants anywhere along the road.

I don’t think we can qualify to ever be called a civilized nation or a developed one, if we can’t get the basic standards of sanitation accessible to each and everyone.  We can build satellites and nuclear reactors and be the amongst the oldest civilizations of the world, but we still cannot defecate and urinate with dignity.  That is the stinking truth!!!

the patient is alays right!

The  patient is  always right!!

Having spent more than two and a half decades in contact with patients in one capacity or the other, I am convinced of the oft repeated statement that the Patient is always right. Very often, there is a tendency to disregard the complaints of the patient, if one cannot find a straight forward clinical correlate for the symptoms. One often finds the cause of the symptoms after spending much time, money, effort and considerable agony to all concerned. 

I have no doubts any longer that the patient is always right even though at times, the narrative of the symptoms may be bizarre , ridiculous , far fetched or improbable.  Very often what the patient tells you may be beneficial, for reasons other than clinical!

 The patient is always right, that is for sure…

Many years back , when I was appearing for my Medicine Practicals  for my MBBS degree,  Francis , an Anglo –Indian was my patient . It was my first major clinical exam but he was a   veteran of examinations  . I was desperately trying to get my very confused thoughts about the patient in some semblance of order.  Francis was rather amused with my efforts. He told  me , “ I am a case of Cirrhosis of Liver with Portal Hypertension. My Liver is enlarged which is not consistent with a diagnosis of Cirrhosis.  The examiner is going to ask you about the causes of enlarged liver in a case of Cirrhosis. If you answer well  , he will ask you about Drugs which can cause hepatic damage . Don’t waste your time and efforts on other issues. Just concentrate on this and you will do well.”  I took a calculated risk and  focused my thoughts on the matter suggested by him and put the rest on the backburner. Well , as predicted , the examiners were consistent with their line of questioning and I did rather well. Francis was proud of me and I had the fact reconfirmed-the patient is always right! 

Then , there was this patient – Jagadish. He was a tall . well built strapping Jat. He cut a very impressive figure in his  uniform . He used to suffer from repeated  episodes  of pain abdomen. He would keep coming back to the casualty and the Medical and Surgical OPDs. Each time he was evaluated in detail. The examination was always unremarkable. The investigations were always normal. He underwent repeated Endoscopies and Ultrasonographies and CT Scans and Barium  studies , but everything was always normal. Somebody though he was malingering and trying to avoid duties. He was evaluated by the psychiatrists as well, but nothing seemed to work out. He continued to be symptomatic off and on .  During the symptom free periods , he was absolutely normal and would play in Unit games and discharge all his duties well. However ,  the pain would return and a couple of times , it coincided with his being detailed on out station duties. He was branded a poor team man and nobody took his abdominal complaints seriously any longer. He was hospitalized again with pain abdomen and he was re-evaluated in detail. Virtually ,  every cause of pain abdomen in the book was looked up and he was evaluated for the same. He was finally diagnosed with Acute Intermittent Porphyria, a condition which does not produce too many clinical signs and shows up normal on almost all tests except the very specific Blood tests which have to be specially asked for. Jagadish was happy that a diagnosis was finally found – he was actually happier that he would no longer be regarded as a malingerer! The patient is always right!

And then there was this very astute clinician ,  much senior to me. He had a very sharp clinical mind and was rather proud of his clinical abilities. He developed a pretty chronic cough and he diagnosed himself to be suffering from Allergic Bronchitis and treated himself for the same. His cough persisted and his colleagues pointed out to him that he was losing a little weight. He assured himself and his colleagues that it was due to his strict dietary regime that he was losing weight. He was confident about his diagnosis and refused to show himself to  anyone . One day , during ward rounds, one of his patients , a grey haired veteran of several hospital admissions and the proud owner of many morbidities told him, “ Doctor  Saheb, get your blood tested and get an X -Ray. You have Diabetes and I am pretty sure you have TB!”  The Clinician scoffed at the suggestion and moved on. But later in the day , when he was having his second cup of extra sweet coffee, the words of the patient kept ringing in his ear. He thought back about his symptoms and his problems. The next morning he gave his blood samples and got an X-Ray. His Blood Sugar was 385mg/dl and he had a   cavitatory lesion on the X-Ray. He responded to Anti –Tubercular therapy and his sugars gradually came under control with medication. Yet   again , in a manner of speaking , the patient is always right!

In our clinical practice we see all kinds of cases and all kinds of patients. It would always do us good to remember two things-Primum Non Nocere-First do no harm !  Also ,  the patient is always right!!!

a matter of wife and death

A matter of wife and death !

                                               

This is a tale of tangled webs and avoidable crossed connections. I have a friend Vikram; handsome , highly qualified ,eminently eligible and not so very young anymore; a bachelor. Somehow, marriage did not work out for him. Initially , perhaps a case of missed opportunities and later time just kind of  slipped away. His mother, Mrs.S,  a genial , affectionate soul , tried for a long time to get him married and then after many years gradually started stepping down her efforts. 

During earlier days, she would seek alliances through her extensive network of friends, relatives and colleagues ,but at some point in the course of events , she gave up. Her affections and energies got transferred to Victor, her prized , pedigreed Labrador. 

Enter Mrs. R , who  still considers my friend a good catch and is keen to get her niece married to the gent in question. She is not aware that Mrs S is now focused only Victor, the Labrador. Incidentally ,  Mrs S, having shifted her attentions from her son to her pet is rather keen to acquire a mate, of appropriate pedigree for her canine to ensure a handsome litter and that is currently uppermost in her mind. The conversation that followed could have many tongues and tails wagging….

Mrs S( looking fondly at Victor): He is getting old , you know.

Mrs R(thinking fondly of  Vikram): Come , come , he is still very youthful and attractive.

Mrs S: I want to see little babies running around and yelping around the house.

Mrs R: How many babies would make you happy?

Mrs S: At least half dozen and they should have his lovely skin and beautiful brown eyes.

Mrs R: Half dozen? Well , whoever it is , she will have a real tough time!

Mrs S: I am looking around . She should have good pedigree and preferably she ought to be mating for the first time.

Mrs R( taken aback ): I can assure you, we come from a very good family and our children are brought up with the highest values.

Mrs S( interrupting with excitement): I don’t want to waste any time. He is in heat and I want the mating as early as possible. Let us arrange it for this weekend. It will be more convenient at our place. You just give her a good scrub down and bring her across.

Mrs R(convinced that this was definitely not the place for her niece): I better get going.

Mrs S: Let us have some sweets to celebrate . I just can’t wait for the weekend!

Well, Mrs. R beat a hasty retreat and decided to try her luck for her niece in a more restrained family. Mrs S was disappointed over the weekend but has not given up her efforts to find a suitable pedigreed mate for Victor.

 My friend , Vikram remains a bachelor and incidentally , has always hated dogs!