Cardioplegia... opening hearts...

[ Open heart surgery is any surgery in which you open the chest identify and put tubes to both Sene cava and Aorta , divert the blood away from heart and lung, pass it thorough a Heart Lung machine to maintain oxygenation and blood flow, open up heart chamber and do the surgery. Cardioplegia is a technique by which you use drugs (mainly Potassium Chloride) to stop heart beating while you work. ] 

  When I chose medicine as a profession, I never knew what was lying ahead of me in my future. At every point of time when I look around I used (and most of my friends too often do) compare myself with my non medico friends. I see them heading companies, running firms, doing research. I see the facebook pics of them  posing in Switzerland, South Africa, US, or whichever part of globe u name it. Its often frustrating to sit in a dirty dressing room cutting through an ugly diabetic foot or listening to truly irritating and insulting abuses from seniors and even the local politicians or by standers. Sometimes you feel you made a terrible mistake by choosing to be a Doc. End less years of studies and you never even realize that you are growing old.

  But there are a few times you feel privileged to do what you can and feel proud to be in your profession.

And then,  you feel your heart stands still for a moment.

  I first felt that pleasure when I took the labor for first time. The feel of catching a new born infant and being the first one to handle him/her in this world is hard to describe and share.

  One condition I always loved to diagnose and treat was pulmonary edema. The struggle to take a breath is perhaps the worst thing a man can get. A couple of injections, and may be a little postural adjustment can make life a lot better for a patient in cardiac failure and give a sense of achievement back in your mind.

  Since I chose surgery as my stream, I may not see those patients any more. But I still see a lot of old men with big prostates coming with urinary retention. Some of them not passed urine for days and their bladder will be filling whole abdomen. Put in a Foley catheter and u watch the expression over face , u really feel rewarded. 

  To see a heart going still and then after surgery , it starting to beat again is one such experience which make you feel privileged. Leave aside all the worries ,technical and aesthetic aspects, i believe its one of the greatest achievement of medical technology. The sheer idea of stopping a beating heart with drugs, something which will never stop otherwise from your conception till your death and the courage to attempt that for the first time would have been a great adventure in Medical history. Just being back from Cardiovascular and Thoracic surgery, i once again feel blessed for I would never have other wise touched a real beating heart most of the people around will never know the feeling I had. 

  To all medical aspirants around all I want to say is that this profession is not easy to manage, but despite all odds, many times you will realize that your heart goes still for a moment or two.

     

Escharotomy.. When you realise that you are not naked as long as you are in your skin!

[Eschar is a thick leathery tissue which replace the skin in deep burns patients. Removing eschar is a time consuming pain staking process. Its practically cutting the leathery thing off from rest of tissue. Some times done under general anaesthesia, sometimes sedation and sometimes in our uncivilised setting, "vocal anaesthesia"]
 Burns patients are one particularly frustrating group of patents. For many reason their survival is poor. Anything more than 20% has extremely high mortality, either by fluid loss in early days or late onset infections. Fire to me is fieriest thing on earth. I dont know how people can even imagine about setting onelself on fire. And still an unbeleivable number of people resort to self immolation to "prove their point". Almost every time when a female with burns come, the history will be invariably an "exploded kerosene stove" and for males, a tipped off lamp or attempting to burn wastes. Frequency of stove explosion is so high that you may start thinking if they are making stoves with explosives.
Almost always the patients and bystanders reach a good rapport with the Burns ICU staff in a few days and true history unviels. Sometimes the reality will be more stranger than those soap operas in TV channels. The one who made me write this blog is in our ward now, a 39 year old mother of 3 kids. Did her escharotomy yesterday. She has 55% deep burns extending and now her specimen showed presence of extremely resistant bacteria sensitive only to Imipenam, a drug costing 2000 Rs per day! The history was as usual exploded stove. She had no female bystander and was brought by a guy somewhere in mid 20s. As days passed, the real history surfaced. She left her home husband and kids 2 years ago to live with this guy who is working as a video editor.Neither of families care. Kids are in orphanage. She havent met them for the last 2 years. And as she developed some difference of opinion with him, she was just trying to scare him by trying to burn herself. She never thought the fire would catch up!
 For males its a different story. Its usually the alcohol that does work. Though most of them prefer to pour it on their spouses, some try it on themselves too. To make the matters worse they start having withdrawal symptoms on day 2! One intersting guy came with history of tipped of lamp. 2 weeks in to admission, the eschar came off. This guy used to drink spirits and abuse his wife and kids every day. One fine day his 10yr old son lost his temper and threw the kerosene lamp on his dad. The story was covered up and the guy went home despite his 40% burns. I always think about that boy. I wonder how much he might have suffered and what he will grow to become. I have sutured stab wound on a 16 yr old who works for "quotation" gang and perhaps they need more guys. Ofcourse everyone knows that world we live in is a dangerous place. Still we try to beleive that the soaps and serials are fiction. But as they say Sometimes reality is stranger than Fiction.

As the eschar falls off, the reality is revealed. Then you realise that you are not naked when you are in your skin.

Tracing an appendix.... till a mayflower tree

[For those who doesnt know... Appendicectomy is one of the basic surgeries. In it, we hook out appendix and trace it to its base before dividing and taking it out] She came in as just another patient, 14 yr girl with lower abdominal pain, clinically a routine appendicitis. As our lab doesnt do HIV screening at night, we asked for the by stander to get it done from outside. A frail old lady came in. Obviously we asked for someone more responsible only to realise that there is no else to come. She was an orphan, second of 4 girls, her father was missing for years and her mother died in Bombay 2 years ago. Old lady was her grandmother. We somehow arranged things for surgery and got it done next day. A beneficiary card in RSBY scheme or a BPL certificate is almost an Aladdins lamp in Medical Colleges these days. She had none. Atleast some certificate from local Panchayath can help. We were trying to find out which area she belongs to. Then I noticed her address. It was just her name, and the name of a bus stop near our hospital. So we asked were exactly and she described precisely.... "ünder the may flower tree there" As i drove through that road today I searched for the may flower tree. There was a shack, or more aptly a tent, covered by tin sheets exactly beneath the may flower tree. I have passed through the same place many a times. Never did I notice such a thing there. Nor would I have imagined a family of 5 staying inside that. Just the thought of an old lady and 4 young girls in such an insecure dwelling is horrifying. Especially when its just half an hour away from where Soumya was torn apart and brutally killed a year ago. On second thought, I know there are many homeless people around. I know its a dangerous world. Still when you cross roads with someone like her , it pauses you for a moment. But i have no option but to proceed with ward rounds! Do I? Tail Piece: When we took her to OT she was asking for my female ward intern. She wouldnt let us induce anaesthesia or do surgery without her. At first I was annoyed, then I felt envious, then I silently prayed for my HS "Oh God, let this profession dont destroy the humaneness in her!"

Scenes from workplace....

Found this suicide note from the pocket of an oldman brought to ER by police. His both legs were bought in seperate bags, apparantly nicely sawed down by wheels of a speeding train. Jumped in front of train clearly with intention to take his own life. I wonder why he failed. Perhaps he didnt like the idea of a mangled head. Or may be he changed his mind too late to get out,but too early from the end he once wished.
And I wonder how he feels now. I presume his life was miserable. Still it wouldnt be any better without both his legs.
Or perhaps it may change for good. Like the patient who rejoined with his family after 15 long years after getting his right leg amputated for severe infection. He had spend 3months in the no by stander bed with an open stump,enjoyed care and hospitality of every charity worker and by stander of nearby patients. I dont know for sure. Let the time prove it.
I know I can find answer to most of question
s just by siting beside him and talking to him. But I cant. Somewhere down the timeline,I guess, I have become a Doctor!

About blunt dissection....

Back to blogging after a long time. Blunt dissection is the art of surgery. Its simply splitting through the tissue planes, the non existent potential spaces, spilling no blood, discovering the hidden. Its a technique hard to learn, harder to master. When you miss the level and plane you loose. You hit a lot of vessels spill a lot of blood. This is an attempt to dissect many lives I see in my work. Exploring, without bleeding...