Monthly Archives: January 2018

“What If This Was Your Father, Doctor?”

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“What If This Was Your Father, Doctor?”
© Dr. Rajas Deshpande
 
“Doctor, I want to know about this illness. I want to understand it” she said.
It had taken me an entire medical career and a lot of experience to understand this disease in steps, no neurologist in the world claims to have fully understood it. It was my duty to simplify things for her, but it was impossible to transfer years of knowledge and experience in few minutes. I decided to give it a try. If I learn to understand the patient and relative one step more, I will be a better doctor hopefully. This lady, with her Prada and Dior accessories, also appeared well educated.© Dr. Rajas Deshpande
 
“Your father has frontotemporal dementia, a condition that causes progressive loss of memory and abnormal mentation, thoughts, or behavior. This is because certain parts of his brain degenerate faster.” I started.
“One minute doctor” she interrupted “How does that explain why he starts undressing, passing urine anywhere in front of others, even children or guests? He uses such foul language sometimes”.
 
I hate being interrupted. Especially when someone butts in a second question before I finish answering the first. But I must accommodate the patient’s and the relative’s anxiety.
“That is because we have an area in the brain that controls our behavior, stops us from doing social-inappropriate things. This is why we stop from doing certain things in certain situations, while we retain the ability to do them in privacy. That is called inhibition. When those areas in the brain degenerate, there is thus a ‘disinhibition’, whereby the patient does not know what is inappropriate. Somewhat similar to losing mental control after taking alcohol”.
“So the blood supply is cut off in the brain?” she fired.
“I never said that. I said this is due to degeneration. The cells in his brain die faster. Although at this age loss of blood supply is an additional reason for worsening”. When you know too much of something, it is difficult to not confuse.© Dr. Rajas Deshpande
 
You know, I am no Mangeshkar or Tendulkar myself, but this is like asking Lataji “I want to understand music and sing that song just like you” or telling Sachin “I want to make a century like you right now. Teach me cricket in ten minutes”. What they have learnt in decades with extreme hard work cannot be taught / understood or explained in few minutes. I can explain it in a nutshell, but it is not possible to ensure that the relative or patient “completely understood” everything I knew. But then again, the better this lady understood the disease, the better she will care for her father. So I decided another approach.
 
“Ma’m, I request you to please read about this disease from these two websites. Then write down your questions and please book another appointment. We will save a lot of random discussion then.” I told her.
“Ok Doctor” she agreed reluctantly “But tell me what you would have done if this was your father. I thought that with so many advances and researchers, there must be some good cure by now for such diseases” she said. The hidden disdainful sarcasm didn’t escape me. I ignored it.© Dr. Rajas Deshpande
 
“Now please tell me the list of all medicines that your father is currently taking, and their doses” I asked her.
She emptied a huge bag upon my table, with over 20 medicines from different pathies, some unlabeled, and including some bottled oils. She started asking her father one by one, he wouldn’t reply.
“I don’t know doctor” she said, frustrated. “He lives alone near my house, and takes these medicines by himself. We lost my mom few years ago. I guess some of these oils are for his massage”.
Some of those medicines were past an expiry date. The old man hadn’t a clue what he was taking.
 
“But you just told me he has severe memory problems and cannot understand much” I questioned.
“Yes, but we thought he knew what medicines he was taking” she said.
I did not want to embarrass her further.© Dr. Rajas Deshpande
“Ma’m, wouldn’t it be better if you understood the daily necessities of your father before you questioned anyone else about his disease? You can ask the doctor any number of questions, it is my duty to answer them. But I would definitely not have left my father to look after himself in such a situation.”
“No, doc, we are looking for a care center for him already. I cannot look after him, I have my own family and the kids need all my attention”.
“Then please stop blaming the medical researchers for not finding a cure for everything. Please accept that everyone ages and needs care, the same care that you were provided as a child”.
I didn’t want her to be unhappy, it was also my prerogative to understand her situation. I reassured her:
“Please read about this well, and come back next week, I am sure that at least a few problems can be resolved. I want to help you and him”.
 
What would happen if there was a cure for everything? How many of them elderlies will be taken care of, provided for? How long will their children look after them? In most cases, even the healthiest of parents are considered a nuisance once they have grown up the grandchildren. After that, they become an irritating liability.
Then, the annoyance of having to look after them, the exasperation of even a small illness they may have, and the extreme anger to have to spend time and money for their healthcare / treatment is all unloaded upon the doctor. While we are learning to deal with this in our everyday practice, I have decided to spend an extra minute to educate the family about their own responsibilities in every such case. © Dr. Rajas Deshpande
 
As she left the room she asked “Doc, he is elderly, you must give him some concession”.
I smiled. This wasn’t a medical question. It was my turn not to reply now.
© Dr. Rajas Deshpande
 
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The Proud Indian

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The Proud Indian
© Dr. Rajas Deshpande

“I was a man of action. It hurts me inside when I look at myself now” said the huge gentleman.
It was indeed sad to see the state he was in. Parkinson’s disease not only slows the body, but also makes one quite stiff, as if the body is made of some heavy stone. The side effects of levodopa, the most common medicine used in Parkinson’s disease patients, was also causing too many abnormal movements.I told him that some changes were required in his doses, and that I needed his cooperation and patience. He agreed, then I wrote him a new prescription.

“By the way, Doctor, if any of your poor patients needs any help with treatment or medicines, please let me know. I will arrange” he said once I finished with the instructions. Always needy for this cause, I took down his details.© Dr. Rajas Deshpande

He came over a month later, happy. This time he donated for an orphanage I often wrote about. I was more than happy, and told him he did not have to pay my fees ever.

“Thank you, Doctor, but you must let me help your poor patients” said Mr. Abdulkadar Mulla.

Over a period of time, I came to know that he donates medicines and free check up kits required for the treatment of young girls from interior adiwasi areas. He spends thousands of rupees every year, since many years, to help run health camps for such children, mostly through the BKL Walawalkar hospital at Dervan in Ratnagiri district.

This time Mr. Abdulkadar Mulla came over, I tried to understand why he is going out of the way to help out children from the interior.

“Because most people are interested in the kind of show-off charity. When you donate to famous organizations in the big cities, your contributions are recognized and published instantly. That is one reason, charity does not often reach where it must: the interior, deprived sections of our country”.
He paused.
“I must say this, doctor, please don’t misunderstand. I feel very bad when someone thinks of me less of a patriot just because I am a Muslim. I have served in Indian police, I have been in the elite VVIP security, I have served India as my own country. It hurts me when some people loose talk that all Muslims should go to Pakistan. India is my country too, I was born and brought up here, studied alongside classmates from many other religions, I have friends in almost every religion. I have served the nation honestly in an extremely responsible position, and am now serving the society by contributing in the most impartial way I can. There are limitations to what I can do as an individual to go on proving my honesty to my country. It hurts when people accuse us without even knowing us. From film stars to cricket players, so many Muslims are making India proud, still some people generalise against us”.

I had no answer. I told him that at least doctors are bred to never entertain that discrimination, that no medical student is fit to become a doctor until he / she can see each patient only as a human life without any other tag. Whether it is policemen or criminals, dirty politicians or reporters who paint our profession in the worst shades, patient from this country or that, from one religion or another: we doctors have only one duty: save life, safeguard health. There is no religion to the happiness of a saved life, nor to the agony of a death. There is no religion to the hand that helps. © Dr. Rajas Deshpande

I remembered the many Muslim classmates I had through my school and medical college. In fact, I was so close to one in my medical college, that his mother loved me like her own child, and cooked me delicious ‘vegetarian’ dishes whenever I went to their home. Some of my Muslim friends now have their own hospitals treating patients from all religions, especially poor. One of my extremely religious Muslim friends, a super-specialist, treats hundreds of poor patients from all religions: without any discrimination in his treatment or approach.

All of us have been through this, everyone who truly worships God knows love for other human beings. It is very important to pass this “Indianness” on to the future generations, and not fall prey to lesser thoughts, however loud. © Dr. Rajas Deshpande

Mr. Mulla told me he had had a spinal surgery, during which a surgeon mentioned the charity work at Dervan hospital. “I decided to donate to this hospital at Dervan. This way my hard-earned money reaches where it is most needed” he said. This institute, presently headed by Dr. Suvarna Patil, conducts multiple health-centered activities for children on a charity basis. Many renowned doctors and other professionals from India and abroad participate in their activities.

“Saare Jahan Se Achcha Hindosta Hamara” by the poet Iqbal brings tears to my eyes every time I hear it! I am proud to meet the likes of Mr. Abdulkadar Mulla, who prove by their silent actions who they truly are. I am also proud to belong to the community of doctors, for whom human life is beyond any discrimination.

Jai Hind! Happy Republic Day!
© Dr. Rajas Deshpande
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Beyond Ridiculous!

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Beyond Ridiculous!
© Dr. Rajas Deshpande

A 9 year old child with fits / seizures was taken to a renowned Paediatric Neurologist. He started treatment with one of the most commonly recommended (by almost all textbooks) used medicine in the treatment of seizures: carbamazepine. One of the most effective medicine, used since over 50 years in children, that can cause side effects of rashes in less than 1/1000 cases. Still rarely, the side effects can be very severe, causing extensive damage to the skin.
The doctor explained this to the child’s parents, and then started the recommended doses. Pediatric doctors are the best trained doctors in dose calculation, they are more aware than any other specialty about the side effects in general, because children often cannot even speak and parents may not notice some side effects. © Dr. Rajas Deshpande

Every medicine has side effects. Even vitamins do. Any medicine can potentially cause life threatening reaction, and that’s why the common warning with each medicine: do not use if you are sensitive to this medicine. How will one know whether there will be any allergy / reaction to the medicine without having used it?

Most medicines can cause side effects at high doses, but some can cause dangerous reactions even with the tiniest dose, or test dose. Some medicines (even the one mentioned above) can cause side effects after many months / years of safe use. While the dose dependent (high dose= higher side effect) side effects are somewhat predictable, the ‘idiosyncratic’ (meaning occurring in individual, not all cases, because of the natural tendency of that person) and “allergic” side effects are totally unpredictable, and can be caused by even such common medicines as paracetamol, aspirin, antibiotics or vitamins. Even deaths have been reported after the use of some common medicines, but even in the highly legalized western world, no court holds doctors guilty for the side effects of medicines, if these were discussed and informed to the patient / family. This is against common sense. © Dr. Rajas Deshpande

This child unfortunately developed a rare but well known side effect of this drug, called Stevens Johnson Syndrome (severe skin rashes), had to be admitted and treated, it cost them one lac rupees. While we sympathise with the child and the family, and wish them the best recovery and health, this is hardly the mistake of a doctor.
But the forum, in a regressive decision, held the doctor guilty, fined him 90000 rupees. This is beyond ridiculous. The court observed that “ if the doctor knew that this drug can cause side effects, he should not have prescribed it”. Translated intellectually, that means NO DOCTOR CAN PRESCRIBE ANY MEDICINE! © Dr. Rajas Deshpande

Moreover, what will this court advise for the child now? Every seizure medicine has some rare dangerous side effects. There are no medicines free of side effects. Shall the child be left without treatment now? Which doctor will want to treat such a case? Which court will guarantee that the rarest of the rare side effect cannot happen again in this case, and with such ill-informed forums, the next doctor trying to do good to the child will not be held guilty? © Dr. Rajas Deshpande

Technically, if using a drug that can cause side effects is a crime as per this court, it should hold everyone concerned guilty: the textbooks / medical bodies that recommend this drug, the pharma which produced it, and even the government which allowed it to be sold. Applying the same logic, if some child developed peanut allergy in a hotel or side effects of pollution and dust by travelling on Bangalore roads, will this court hold the hotelier or the city administration guilty and punish them too? Has this forum/ court banned tobacco and alcohol yet, or will it punish the government for the side effects and thousands of deaths caused by these? © Dr. Rajas Deshpande

The IMA, other medical bodies, Neurological society, and intellectuals should stand by this doctor who has suffered the mental agony. This decision must be challenged in higher courts.
We regret that some patients suffer side effects, no one should, but at the same time, the “side effects of medicine” is not the doctor’s fault, especially in this case where he had explained the parents about such possibility.
We need medically educated forums and judges who can refrain from populist tendencies.
© Dr. Rajas Deshpande
PS:
I respect courts. I respect higher courts more. But I refuse to believe that every decision made by every judge is correct, that every decision is impartial, that it is not affected by pressures. This article is solely based upon the attached news clip. I must admit that this reporter Ms. Meghna Singhania has done an excellent and impartial reporting. Doctors must please stand united against this decision.

https://medicaldialogues.in/side-effects-of-prescribed-m…/…/

Fate and The Fatal Healthcare Gamble

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Fate and The Fatal Healthcare Gamble.
© Dr. Rajas Deshpande
 
In the rush of a local station, a 25 year old man suddenly shouted in a scary way and threw a fit. His eyes rolled up, his body shaked violently, and he fell down. The jerks kept rocking his body and shocked people around him noticed blood stained frothing from his mouth.
 
Some strong person, too eager to be a hero by the demonstration of gym-built strength, kept his foot on the leg of this patient and pulled his tightened hand to straighten it, till one heard the obvious sound of a bone breaking. Another slapped at the face of this convulsing patient, abusing, and telling the bystanders that the ghost holding this patient must be scared off. © Dr. Rajas Deshpande
 
Yet another, with the confidence of experience, thrust a dirty leather footwear under his nose. Someone else shouted for an onion or chilli, guaranteeing that it will immediately stop this voodoo. This too was then applied to the nose of this patient who was still convulsing. The patient had a lock-jaw, his teeth were clenched together. A spoon was then forcibly inserted between the teeth, and so strong was the effort that few teeth broke and blood oozed out.
 
By this time the convulsion had stopped, and everyone who had thus “treated” the patient proudly explained how each of these tricks always worked.
 
None of them knew that an epileptic attack would automatically stop within a minute and a half, that one should not force open the mouth or straighten the hands or legs, because that will only hurt the patient. The excessive electrical discharge in the brain that causes such fits will not stop by doing anything externally. Within a minute, such activity stops automatically as the brain energy and the currents cannot sustain, and the patient recovers consciousness in most cases. Rarely, such fits go on beyond a minute or two, in which case, only the trained medical practitioners must handle the case, preferably physicians or neurologists. © Dr. Rajas Deshpande
 
This patient was still unconscious.
An ambulance which had the “contract” for that station arrived, and the “paramedics” got the patient in. Relieved that all was well, people, as always after whatever happens, carried on.
This ambulance then took the patient to a “contract” hospital far away, even when there were many good hospitals on the way, thus wasting the most precious time. The patient had aspirated: his blood and saliva had now blocked his respiration.
By the time he was taken to this hospital, he was almost gasping.
 
The contract hospital, owned by an organization that had excellent political links, was designed to hide the deficiency of the most important element in good healthcare: well qualified and experienced, genuine specialists. Being the one to provide the lowest cost treatments, it only employed doctors willing to work on the lowest salaries. Poorly qualified, rarely experienced and already fed up with the workload. But in these days of beautiful, colourful signboards and deceptive advertising, declarations of “world class healthcare”, one rarely questions the training, qualification and experience of doctors. © Dr. Rajas Deshpande
 
The patient was taken into ICU, intubated and ventilated. An orthopedic surgeon attended his manmade fractures.
Legally everything was completed and correct. All forms signed. Critical status explained, understood, accepted. Relatives happy about the charges and the behavior, explanations by the doctors and specially appointed PROs. A qualified Neurologist was called in for a visit, who guided the treatment and went away. He was scarcely in a position to advise the relatives that the basic life support systems require great experience in such cases, and this hospital didn’t have that kind of a team. That would be unethical, plus the hospital had enough connections. That’s what got them the contract in the first place. Also, his calls would stop if he spoke beyond what he was called for.
 
The patient had suffered damage to the brain due to the delay in starting the treatment. He remained unconscious. Then in a week he developed septicemia: infection from the lungs that spread via blood to all his body. © Dr. Rajas Deshpande
The relatives were explained everything, except the fact that the team was inexperienced, ill qualified to treat. They were broken when the patient passed away., blaming their ill fate
It was indeed the fate of that patient to have a fit just there, just then. A young man who could have come back to normal health in few minutes was killed.
 
Or was this fate alone?
 
This death was preventable: a fit generally needs no treatment while it is happening. In this case, people had broken his bones and teeth, forced dirt in his nose, and caused bleeding. The ambulance, due to the obvious “loops”, wasted precious time reaching the “contract” hospital rather than the nearest hospital, the contract hospital took the case in spite of not having well qualified expertise and team to handle the situation, and the relatives did not care much beyond the financial implications. All equally guilty. This was a murder with multiple murderers.
The only thing one can do to help a patient having a fit is to make sure their head does not bang upon a hard surface, remove any sharp objects upon or near the patient, and turn the neck gently to one side, so that the food / tobacco/ anything that the patient has in the mouth comes out and does not block their respiratory pipes. Simultaneously, call an ambulance. © Dr. Rajas Deshpande
 
Remember the 6×6 feet supermarket that sells everything, in the corner of your lane? Something similar is happening with healthcare now. One wants every specialist in the nearest location, with cheapest competitive rates, and so long as their advertisement is good, people are happy when quality takes a backseat. A specialist is a specialist, so long as he / she has any degree, so long as the govt. approves, and especially if they offer concession, nobody cares about tomorrow.
 
The extensive training that goes into making of quality doctors is now replaced by many options: some low quality private medical colleges run by those in power, where money buys almost everything and merit/ hard work doesn’t matter, cross pathy and bridge courses, allowing too many unscientific treatments to take center stage in the country’s healthcare, defaming those who try to improve the system , projecting the philosophy that “all healthcare that is cheap is alone good, costly means corruption” etc. © Dr. Rajas Deshpande
Who suffers when inadequately qualified doctors with poor merit, experience and dedication treat the patients? Who suffers when those who have made their career based upon political support or corruption, treat the patients?
The worst gambling in India is in healthcare. People happily stake their lives to save some money.
 
God save my dear India in this healthcare crisis.
Jai Hind
© Dr. Rajas Deshpande

Are You Respectable, Doctor?

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Are You Respectable, Doctor?
© Dr. Rajas Deshpande
 
“Send in the next patient” I told the receptionist.
As no one came in for a few moments, I opened the door. A trembling, shuffling old man in his eighties, standing with the support of his son and daughter in law, was fumbling to remove his sandals outside my door.
“Let it be, it’s ok” I told him.
Smiling, embarrassed that he was unable to move fast, he folded his hands and said ”Namaskar Doctor! You are like a God and your room a temple for me. You give life to so many. I don’t wear sandals in a temple. Let me remove. I am sorry, please give me one minute more”.
It was my turn to be embarrassed. Do I deserve this respect from a stranger just because I am a doctor? © Dr. Rajas Deshpande
 
Mr. Wamanrao, who was a teacher before retiring decades ago, walked in. After examining him, I explained to him and his family that he had a degenerative problem of brain that caused imbalance and stiffness. The concerned family asked some questions earnestly.
 
“Tell them I am old and must leave this world now” said a smiling Wamanrao.
 
Pausing to think for the right words, I explained them the condition, and told him “At present I do not see a reason to worry. I don’t find anything life threatening in your examination, we will also do some tests. But there is no need to think about an end at this time. You should improve, let us try. And yes, it is very fortunate and enviable that your family loves you so much”. It was impossible for me not to remember my own father.
 
In tears, he folded his hands, then blessed me by keeping his hand upon my head, and left.
 
Many patients came in that day, and I kept on thinking: that most of them, especially the illiterates, poor and elderly came with a lot of respect, behaved politely, and followed the instructions well. Some came in bitter with their experiences with some other doctors and hospitals and confessed the reason of their angst. The young, rich and highly educated mostly walked in with a paranoia and refusal to trust. But these were very few, mostly because I don’t dance different for the high class patient. The most difficult class to handle were the uneducated rich and the politico poor, who think everything can be bought, threatened or manipulated, including a doctor. © Dr. Rajas Deshpande
 
This last class offends and frustrates most doctors who work with a feeling of dignity for their profession. Not because they ask too many questions, but because they misbehave, are too arrogant to tolerate, and cannot trust anyone. The last thing that a doctor wants is a trustless patient: it means trouble in future even if the best is done for such a patient. Even if saved from a coma, they will belittle the entire profession and file cases for bills. © Dr. Rajas Deshpande
 
We always claim that some doctors are bad and the good ones bear the brunt, then we must also understand that some patients behave bad, but most others suffer the consequences. The “On-Guard” new generation doctors have now started to become too ‘legally correct’, talking in terms that lack feelings. They are not always wrong, because the law of the land, the crass class of media and many administrators openly badmouth this noble profession that carries the entire healthcare of this country upon their shoulders.
 
However, we as doctors must also think if we always behave respectably. There still is an inherent respect for the profession, in the minds of most. But if a doctor thinks that he / she should be treated like God just because they have a degree, there is a grave misunderstanding. One must be proud of one’s merit, but the patient shouldn’t have to pay the fees for that pride. © Dr. Rajas Deshpande
 
Many doctors are usually well behaved, but we also see very rude, “head in the clouds” type of doctors. A little success, a little affluence, and a ballooning ego is a common picture. Such doctors then refuse to acknowledge the patient (or even their own junior) as another human being to be treated as an equal, with dignity and respect. They will crowd their waiting rooms, make patients wait unnecessarily while they chat / entertain “rich and influential clients” etc. They will behave high handed and rude with patients and juniors, pretend to be in a hurry when the patient starts asking questions and even walk out to see another patient in another room. Many quite senior big doctors actually classify the patients financially, so that the assistant filters out and treats a certain class of patients.
 
Some doctors talk “only the legal” language to patients who are emotionally disturbed, in a state of shock or grief. The other end is the “Always smile and keep the patient in a state of false hope till they can pay bills” type of doctor, who disappears once the patient cannot pay or takes a bad turn of health. Some doctors do not even follow the common decencies of respecting elders and women. Manners and etiquette are fast disappearing among doctors, it is time to remind ourselves that a doctor is one of the highest respected intellectual in our society, and just like the heroes upon the big screen, many, especially children emulate the good behaviors of doctors too.© Dr. Rajas Deshpande. It is sad that our media, movies and comedy shows take pride in belittling Indian medical profession, considered one of the best in the world, but it is also true that some doctors indeed provide them with a reason to do so. © Dr. Rajas Deshpande
 
No one will salute a doctor just for his / her degrees, experience, post or affluence. If a doctor wants to be respected, he / she must carefully learn to respect others, use the right language, and follow manners and etiquette at his end. There indeed are a minority who will mistreat a doctor, who will take advantage and misunderstand manners as weakness or an inferiority complex. Give them a sincere chance to change their opinion. If they are still paranoid, arrogant or rude, then a doctor must move on, politely refusing to see them again. © Dr. Rajas Deshpande
 
In absence of any support from the politicians or media, we must learn to cultivate a positive doctor-patient relationship culture rather than ourselves becoming paranoid. We must learn the new language of “legally correct yet compassionate” medical talk. Patients are an inseparable part of our profession, success and daily life, we cannot be at war with them just because of a few imbeciles.
 
I myself am not free of mistakes, and I want to continue to improve, for the day that I think I cannot improve anymore, that I am the best, I can no more be a good doctor.
 
For my birthday tomorrow (07. January), it was necessary that I reminded myself what my parents and the best of my teachers taught me. The best gift life has given me is the ability to be a doctor, and I must take in stride everything that comes with it.
© Dr. Rajas Deshpande
 
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