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What is life if full of care!!
We have no time to stand and stare!!

These are my favorite lines. I feel those lines invariably especially after choosing
to be in the medical profession.
I had been totally unwary all throughout my medical journey which ended up being
an Anatomist. Repeating for getting into the medical profession and then for post-graduation
!! And then still the life is yet to settle!! But, I am always keeping the
hope to get a good opportunity. This reminds lines from the stalwart M. S.
Dhoni, “Kharagpur ki Government naukri mei phas gaya toh aghe kuch nahi ho
payega. Sirf 9 to 5 ki duty karte rehna padega.” (Meaning that,”If I join the
Government as a permanent employee as a ticket collector in the railways at
Kharagpur, then I will have to remain satisfied doing the 9 am to 5 pm duty. I will
be unable to satisfy my inner voice, be unable to fulfill the dream I cherish as a
And now we are not even able to get that. No satisfactory job nor salary!! Post PG
long wait; no result! MPSC was hope, but it was as if wanting to taste poisonous
honey!! It being preclinical subject is given last priority. Later on only to realize
that all preclinical vacancies are being directed to clinical subjects. I really fail to
understand why preclinical subjects are being looked down so much. To add on to
the existing struggle, MCI has reduced the requirement of staff members to be
recruited. Most of the time, pan India vacancies are available, but not where one
stays!! Ab kya pura India ghume? No family life.
But being a teacher, I encourage students. So how do I lose hope? Where there is
a will, there has to be a way. So, just need to keep patience and wait for the right
time to come.
And then by the grace of God a ray of hope is seen.
Job in a private college!! Everyone knows how it is!! Actually, it’s an open secret. But
sometimes to achieve something in life, some risks and compromises have to be
made. One needs to come out of the comfort zone as my husband puts it. It was slightly skirmished
for me. Not used to the local train travels, those fight to get
seats and phone calls to railway helpline numbers and many more. But, then I made
great lifetime friends in due course of time as well. Also, I got to learn a lot from
them. How everyone is struggling and yet so happy!!
I learned a lot as an Anatomist. I have my own innovative and unique style of
teaching. But at the same time, I am eager to learn from students as well. Although
it’s really funny to listen to their answers (entertainment time), it teaches lots
of lessons as well. For example, most of the time students are confused between
the lungs and liver. So, one can stress on this mistake. Thus, in future students can
avoid these errors. Also, if students are aware of the system wise different trays
kept in the examination, they can avoid mixture of two topics. In addition, one must be
aware that for dental students, knowledge on HNF is to be imbibed more.
Exercise science, Occupational therapy and Physiotherapy students, limb study is
to be focused. For MBBS students, mnemonics and stories help a lot to catch
their attention.
Ultimately, one has to choose a profession of our liking or like the one in which he
or she is into. I would like to reiterate on the winning statements of our beloved
MISS INDIA WORLD MANUSHI CHILLER, “Profession is not just about being
paid. It’s the respect and love one gets by doing whatever one has focused on.
Mothers’ life is full of sacrifice and doesn’t expect anything in return. And so that
is the highest paid profession.” And yes, of course, I could better understand
these words as I am because of the sacrifices and struggles of my mother and my
elder brother. Had they not been selfless, can’t even imagine my fate.
In the meantime, one has to be vigilant and look out for the opportunity. It does come
and in a special way unfolds the divine plan of God. Of course our efforts and hard
work matters!! And that opportunity did come thanks to the Modi government. Pan
India Central government is opening new medical colleges.
So, I am feeling positive and hopeful for the future. As Bob Hope rightly says, “I’ve
always been in the right place and time. Of course, I steered myself there.”





The doctor-patient relationship has been and remains a keystone of healthcare in community. In ancient era people would seek medical remedies from ‘vaidya’ and had faith in him. He was family physician for the people. The guidance ,co-operation and to lesser degree mutual participation were distinguishing patterns of doctor-patient relationship.

For medical profession , Hippocratic oath established a code of ethics for doctor ,it also provided ’Bill of Rights’ for patients. The code emphasized the doctor’s attitude towards patient, “The regimen I adopt shall be for the benefit of my patients according to my ability and judgement ,and not for their hurt or for wrong…Whatsoever house I enter ,there will I go for the benefit of the

Sick ,refraining from all wrongdoing or corruption and especially from any seduction,of male or female ,of bond free. Whatsoever things I see or hear concerning the life of men,in my attendance on the sick or even apart there from,which ought not be noised abroad ,I will keep silence thereon ,counting such things to be as sacred secrets”.

Previously doctor would be called as GOD and his word was final for the patients.Patients never used to doubt doctor’s skill and approach towards patient.

Becoming a doctor was considered to be a noble profession but scenario has changed for last two decades. The doctor who was treated respectfully by society is now beaten by that society.People don’t think of sacrifices which he/she made for becoming a doctor.

“Stethoscope is the costliest jewellery to wear in the world ,it costs your whole youth”

Currently the scenario changed from GOD to people thinking of him now selfish person. Still many doctors are praised for their service but very little section of society holds this attitude. Doctor used to treat patients on the basis of his clinical knowledge which he acquired through years of practice and hard work and this created good rapport between doctor and patient. Now a days ,due to advances in diagnostic technology ,doctors are relying on tests and advising investigations added to financial burden on patient and this is one of the reason creating bitterness in doctor-patient relationship. After implementation of Consumer Protection Act, doctors included under provisions of act also widened gap in doctor-patient relationship. Communication gap is widening between doctor and patient as less time given to patient’s complete history taking and discussion to create good rapport. Inspite of all efforts if something untoward happens, the relatives hold doctor responsible. People should realise that under certain critical conditions of patients, every patient can’t be saved even by greatest doctor. Sometimes there might be negligence from doctor side but such incidences are very few.

Some political persons or media person also make doctor ,a soft target to get publicity by creating negative picture of medical profession in society. Political or some public comments like doctors are charging at higher rates ,doing unnecessary surgeries, writing expensive drugs widens gap in doctor –patient relationship. Political persons instead of directly talking in public,they should discuss issues with medical committees or governing bodies so that further bitter consequences can be avoided.

Another contemporary effect on doctor-patient relationship has been the exponential increase in the use of internet by patients. Better patient education has obvious advantages for mutual relationship ,there are concerns that information on the internet might not always be accurate and reliable. This poses a new challenge for the medical professional-that of revising any misinformation the patient has found him or herself.

For a community to get good healthcare services, doctor-patient relationship needs to be in harmony .Increasing communication between two sides is an important step to improve relationship. Keeping patient and relatives aware of critical conditions that might occur during disease course will help to avoid unnecessary misunderstanding .Media should project positive and good aspects of medical profession also. If any patient or relatives have complaint of doctor ,then they should approach appropriate authority or governing bodies instead of taking law in hand .There is provision of legal action for misbehaving with medical professionals but it has not created much impact in society. The law should be strictly implemented to safeguard medical profession.

By dispensing information in a manner that maximizes understanding is a prerequisite for more equal participation. Shared decision making between the doctor and patient will determine the most appropriate and best course of action for an individual patient.

Doctor is human being and needs to be treated as human ,not required to be a GOD. Good doctor-patient relationship is need of hour for healthy society.





     Days passed by hearing the sudden death news of Celebrities like Michael Jackson, Sri Devi, Sema Lagoo, Om Puri due to Heart Disease. Heart disease can occur in 2 ways:  One by birth, family history, diabetes mellitus type 1. Second by cholesterol, lack of exercise, overweight, smoking, diabetes mellitus type 2.  Nowadays a heart attack by diabetes mellitus is getting worse. If we think twice or thrice, the common effect for this disease can be the mistakes and discipline of our daily life activities.

Recently, ‘diabetic heart disease’ is the highly ranked disease crawling among the adults with an age of 45 to 55. Sadly, this evil that will be been weaving around us at the youthful age. As laziness and unhealthy diet take a major place in your life, the art of heart disease gives birth in your body.

Every profession got its own way of stress, tension, sleepless tasks in simpler word ‘difficulties’ as an employee pressurized by the boss, as a boss stressed in maintaining company statistics, as a student tensed about career and future, a doctor diagnosing patients’ diseases we cannot blame anyone for this. But by these effects of stress, tensions, staying in a stationary position for extended periods of time, our body will be prone to chronic disease like diabetes. Diabetes mellitus type 2 is the most entertained disease in our body. How about the stress of the work which damages your nervous system, increases your blood pressure, constricts your blood vessels? Have you ever thought that not only the junk in your body but even the stress, fear, tension taken up during the work affects your body in a soothing way?

How Diabetes Mellitus type 2 starts?

You get to work and end up the day with an entire body filled with tiredness. All this time the brain helped in thinking, calculating, decision making; digestive system extracted some enzymes from food which helps the other organs to work in a proper way and energy distributed all over so that you may not faint in the middle of your work, but stress disturbed them. As tension and stress make your heart beats fast soon blood pumps fast and your blood vessels constrict by pressure, as the blood moves fast in your body the organs of your body attempts to work fast. This means the body is working more than needed. Eventually, the pituitary gland (master gland of the body) secretes hormones in large amount which means hyperfunction takes places in the organ. As concerned to the pancreas, sometimes it cannot be capable of secreting insulin and the glucose cannot be converted into glycogen that brings changes to the blood sugar level. By this, you will be affected by diabetes mellitus type 2.

Symptoms of Diabetes Mellitus type 2:

If you have diabetes mellitus type 2 you will have an Increased thirst and frequent urination (Excess sugar building up in your bloodstream causes fluid to be pulled from the tissues), Increased hunger, Weight loss (Calories are lost as excess glucose is released into the urine), Fatigue, blurred vision (If blood sugar is too high, fluid may be pulled from the lenses of your eyes. This may affect your ability to focus), Slow-healing sores or frequent infections, Areas of darkened skin (patches of dark, velvety skin in the folds and creases of their bodies — usually in the armpits and neck. This condition, called acanthosis nigricans, may be a sign of insulin resistance). These symptoms of diabetes mellitus type 2 can affect your heart.


How Diabetes Mellitus type 2 affects your Heart?

By regular fast pumping of the heart, it can become weak and irregularity of heartbeat takes place, which may lead to arrhythmia (irregularity of heartbeat) or dilated cardiomyopathy (heart chambers become dilated because of heart muscle weakness and cannot pump blood properly) sometimes heart failure(insufficient supply of oxygen).

As a foodie, a chicken burger with extra cheese in right hand and a cola in the left hand or trying out new fast food seems to be a magic ‘mantra’ for after work stress-relief. You may enjoy that plate of delicious food and get back to sleep. What about the fat summed up in your body?  There is no way for the calories to burn up!

First, calories pile up and there will be no scope to run out of the body. These tiny calories turn and convert into a thick creamy unwanted layer of fat in the body. The unwanted fat slowly turns into cholesterol and lead to obesity. Some of the diluted fats go around the body and stays at a place like heart, bundles up into cholesterol, mostly in a coronary artery, one of the main arteries of the heart. This leads to improper pumping of the blood leading to coronary heart disease. Sometimes, myocardial infarction (heart attack) caused by a blood clot that develops in one of the coronary arteries and can also occur if an artery suddenly narrows or spasms occur.


Symptoms of Heart Disease:

You should be aware of what is happening in your body.

When you feel an unbearable pain that travels through the body (for example from the chest to the arms, neck, back, abdomen, or jaw) light-headedness and dizzy sensationsprofuse sweating nausea, and vomiting clearly shows that your heart is in trouble. It is not getting enough oxygen to pump up the blood. Immediately run to the hospital.


Medications for Heart Disease:

The main medications in use are statins (for lowering cholesterol), aspirin, clopidogrel, and warfarin, (for preventing blood clots), beta-blockers (for treating heart attack, heart failure, and high blood pressure), angiotensin-converting enzyme (ACE) inhibitors (for heart failure and high blood pressure). The doctor will work to find a medication that is safe and effective. They will also use medications to treat underlying conditions that can affect the heart, such as diabetes before they become problematic.


‘Prevention is better than cure’

The only way to get rid of the disease is proper diet and regular exercise. When you wake up a 5-minute meditation or yoga will give fresh start and calmness to your mind which controls your anxiety, stress, tension for the entire day, regular breakfast, minimum 30-minutes exercise per day, power naps, healthy diet, avoid smoking, avoiding or reducing junk food and soda will be helpful to get a good health. By this, you will be healthy and have a great immunity in your body.




The current situation of doctors in Nepal is one of the major factors that is causing the doctors of our generation to practice medicine in a foreign country. At least we won’t have a fear to be beaten up by an angry mob when the patient dies (even after the doctors did all they could).

This type of situation is highly demotivating and will have an impact on the health sector of Nepal for a long time. Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) in the mind of the young medical students and doctors who don’t see or don’t want a future here.

And when all the competent Doctors leave the country for a place with better job security, job satisfaction, paygrade, respect then the country will be left with lack of manpower and will go through a medical crisis with lack of manpower.

People may argue “Doctors should not work for money, they should do good to the society,” I ask WHY? Does anyone tell an engineer to build houses/roads for “betterment of the society”? OR ask the banks to give away money for the same cause. No!

Then why should we do that? Is it wrong that I would want luxuries of modern society after doing my job to the best I can? If I paid a large sum of money for my education is it wrong that I would like to earn a lot more?

So someone who spends their better part of their life and a large sum of money to be a doctor, why would he/she like to remain in a place with minimal pay, lack of freedom to practice their skills and fear. of getting beaten! And they know they have way better alternatives abroad.

I don’t believe Doctors are next to God, I don’t want to be called that either. The medical profession is like just another profession and we are just like other people. We have our own set of skills and limitations just like any other professionals and people seem to forget this.

I am not denying the fact that there is no medical negligence and some doctors are responsible for the wrong outcomes and they are at fault. But it’s not the angry mob or the saddened family of the patient who decides who was at fault.

We have proper laws and the government and Nepal Medical Council(NMC) to investigate it and decide whose fault was there if any. And one can even be banned to practice medicine for life if any major negligence is found. But No! Here, the mob decides that ALWAYS the doctor is at fault. It’s like saying that if some students fail in exams/do bad then the teachers are ALWAYS at fault! If the student doesn’t study properly then whatever the teachers do that student will fail and it won’t be the fault of the teachers. The same analogy applies in case of a doctor and a patient.

If the situation continues like this we will see a decline in the competent people wanting to join medicine in the first place let alone practice here and the quality of the services will degrade causing more mishappenings and the vicious cycle will continue.



The basic two-way communication between the Patient and Doctor is the prime part of interaction in the field of medical sciences in which patient share his/her complaints and discomforts regarding his/her health, mind, how he/she feels about, without any hesitation and on the doctor’s part that he must talk politely with a smile on his face asking his patient’s problem by creating an aura of faith and gaining confidence of his patient. That is a result of faith bestowed upon by the patient on the doctor, who is seen not only as a healer of one’s medical sufferings but also a counselor on personal and family matters.

These are known as one of the basic but important and prime etiquettes in the medical profession and ethics, but the picture & scenario is not always the same everywhere in the world.

If we talk about India, the picture of a doctor is somewhat ruined in eyes of the people over the past few years.  There were many talks about the doctor being unethical and become money minded. Someone rightly said that ‘one rotten apple spoils the rest in the basket ’. Not all doctors are fraudulent but actually only a few; due to them the image of every doctor and this holy profession is destroyed.

One of the biggest factors for the creation of this bad image is the entry of the corporate sector into the world of diagnostic research and health care system. The cuts and commissions began from the diagnostics stage and then even in the referrals. Pharmaceutical sector started bribing the doctors to prescribe their products who have their own setups. This weakened the trust of the patients.

But not always doctors should be blamed; there are mistakes on the patient’s side as well. Another biggest factor towards ruining this relationship is patient load in the government and private setups and doctor-patient ratio. In India, one doctor is consulting 3 to 4 times more patients in every day than the number approved by guidelines for the physician due to an increased population which makes the situation even worse.



Patients who are visiting the hospital are frustrated and stressed out and somehow gets angry because of their own health complaints and waiting in longer in a queue for their turn and doctors are also not always available due to sacristy of time to focus only to their problems out of the whole lot of patients and give them more priority as in the eyes of the doctor all the patients require proper consultation, treatment, and counseling. Due to which they (patient) sometimes become intolerant.

Sometimes out of frustration they start arguing with other patients and creating a mess in the O.P.D. The situation in the wards is even horrible.

When a male doctor starts examining a female patient in the examination room without taking consent, that patient sometimes put false allegations against the doctor as he had touch with bad intention or exploited her which may lead to bad picture of the doctor in front of the society, may hurt his reputation and he may not able to practice for the rest of life.

When the life of a patient after a major trauma is saved, the doctor is praised for his excellence with blessings for patients and his family and sometimes treated as an incarnation of God who saved the life.

But on the other hand, during or after any major operation, if any patient due to any complications somehow dies or may not survive for long, the attendants and other family members of patient starts blaming the doctor/ operating surgeon that he is not a good doctor or he had not tried to save the patient or must be money minded and many other things and blurt out bad and insulting words about the him.

In many worst cases, the patient’s attendant came in the wards and slaps the doctor out of anger in front of whole staff and other patient or beat him with some weapon and sometimes security personnel is also not able to control them as they came in a group.

Actually, the major factor for the creation of this situation is a communication gap between patient and doctor. Some time doctor couldn’t hear or give time to every patient due to the sacristy of time and high patient load.


We as a citizen should not forget that Doctor is a highly educated, trained, dedicated, hardworking and efficient person of the health care system and how much pressure they face in hospitals and next to God who heals and tries to saves life of his patient without asking for anything in return and must respect his hard work and how much they do for the social whole day and night.

Patients should not lose their temper and become intolerant to release their anger onto the doctor for not doing what they want.

People must understand they are also human, not computers or robots that do everything correctly on command of the handler and according to them whether they are tired or not. I must mention here that doctors already do their duties more than required.

On the doctor’s part, In my opinion, doctors should be soft and polite while talking to every patient whatever is the situation that they should not feel ignored and disappointed which creates a bad impression in patient’s mind.

While attending any patient, a doctor must ask for the consent before performing an examination or procedure and starts only after the patient’s agreement. If the patient is a teenager or a small child then doctor ask from his/her parents.

While attending or examine a patient especially, female patients in which exposure of the body is mandatory, in that situation doctor must ensure that procedure that privacy of patient must be maintained and should be done in the presence of female nurse for doctor’s own safety.

This same thing applies to all female doctors while examing or performing any procedure on male patients that the examination part should in privacy in the presence of a male nurse or male staff and maintain their confidentiality So that patient should not feel shy while exposing his/her body parts.

The approach to the patient should warm and good so that the patient does not think that the doctor must have exploited him or her.

By doing these small things on a day-to-day basis every doctor can help and contribute himself in improving the status and image of the whole community of doctor and medical profession and bring a smile on faces of every patient.



The hustle bustle, the chaos of the daily life, splattered blood on the floor and big blobs of Potassium Permanganate scattered all around –Yes this is the Emergency Room or fondly called the ER. The daily commotion of the ER and its speed of treating patients is what makes it the most critical yet exciting area of the hospital. It must sound preposterous to some, to call a Department or award with critically ill patients as ‘exciting’, but a Doctor’s point of view says much different. The thrill of cut and the joy of recovery – both are felt by the doctor at the same time, Blissful as I may call it. In the ER, you must work then and there –provide the patient with the first and foremost help required and as said by the book of Love and Bailey – ‘The Golden Period decides the quintessential treatment required by the patient  ’.  But is it really all that rosy and sparkly as it seems?  Every cloud might have a silver lining- but every cloud has a time when it bursts too. Same could be said with a doctor – A little delay of the seconds, a little inappropriately the body reacts and whoop- the case becomes critical than ever. How the doctor deals with the patient at that time, how he puts his extreme hard work of medical studies into actual treatment and how he manages to save the patients life is the real ball game. Unconscious, yet aware subconsciously how much pain the patient is going through – the doctors know it all. They might not be emotionally involved with everyone but yet the patient’s pain is their pain and the patient’s anguish is their anguish. And theoretically, everything is laid down on the books – which Medicine is first, which injection is second, when to push your chest for CPR and when to call time of death. And amongst all these battles with life – only one thing remains out of control of the patient –a deterration from the normal and even the abnormal. What if a patient reacts a way not mentioned in any Medicine books? What if the patient shows a symptom or sign never seen before –then what? Do we blatantly blame the doctor or feed our superstitious belief that God has planned so. Patients maybe mum at the time of crisis but the ones who love him/her are the real sufferers here. They want to do so much- and yet are helpless there. And there at that moment all their hopes, dreams, wishes lie on the doctor- and he is wilfully made the God. But also with that, lies the blame, the resentment, and the accusations – and if nature takes a call where the Doctor is unable to do anything even though he tried everything to his best of abilities –he is made a demon.
The ER has a million stories every day, millions of hopes and hues and cries of hurting people. It shows how the doctor rushes to the patients help, it shows what medicines are given during emergencies, it should how a person who has ingested poison can be saved – what it doesn’t show is the Pressure of the doctor,what it doesn’t show is the extreme burden of putting his treatment to use in a way that it shows results,the burden of handling a living human life in hand and most of all,the burden of letting down the patient and  above all –himself.
A doctor isn’t merely a white coat human with a stethoscope. A doctors experience is way more than words can explain. He wakes up early in the morning or possibly after only 2 hours of sleep after a night shift, then gets ready and on his toes for the next 10-12 hours. Crying, mourning and pain is what he sees every day. He doesn’t have a sunlight showing him joyous things all day long.  He doesn’t have flowers and butterflies and wall pictures. What he has is a solution- to heal people’s wounds. To make the best of his potential and treat that ulcer, and cure that chest pain. He works and works till the removes the word PAIN from patients’ dictionaries. He doesn’t mean harm – he only means well and truth. And the truth lies in the very basic fact that – LIFE AND DEATH ARE CONTROLLED BY SOME EXTERNAL FORCE THAT CANT BE ELUCIDATED and a doctor can trade his own life for the life of his patient but that’s all he can do. He can work and work and work harder to heal the pain, the sufferings the torture and turmoil born by the patient and his family – what he can’t do is compete against the undeciphered External Force of Nature and have a victory over it.
Lastly would like to quote – “The highest form of knowledge is empathy, for it requires us to suspend our egos and live in another world. It requires profound purpose, larger than the self-kind of understanding.”
-Bill Bullard.


A doctor is the one who referred as a god, he should be empathetic towards his patients rather than sympathetic. A patient is going to doctor with a lot of hopes and faith; even if the patient is suffering from tormenting pain with an incurable disease, a single heart filled kind word of doctor could give great relief to the patient rather than any palliative care. A doctor has a tremendous and valuable role in a patient’s life, in some cases patient will only trust the doctor than anyone else, the doctor is having the key to the happiness of patient. When a patient enters a doctor’s room, the doctor should receive him/her with a gentle and calm smile. Then try to gain the patient’s trust through friendly chat( by asking name, address, occupation, Hobbies etc) provide a comfortable zone for the patient, make such an environment that the patient will trust the doctor and the former feel open enough to share his /her (physical as well as psychological) issues to the doctor. Then only the doctor will get a proper and crisp history from the patient. After history taking doctor should arrive at a suitable diagnosis; Prescribe proper medicines, exercises, diets etc to the patient. If the patient should undergo a surgery, explain to him/her about the procedures (from anesthesia to suturing), complications, consequences etc. Provide the best post-operative care to the patient until the scar of sutures get mild and reduced. Inform the patient to visit the doctor, if any complications have occurred during this period. Moreover, a doctor should behave as a parent to his patient by providing love, empathy, care, and hopes. Corrupted doctors are increasing in number nowadays throughout the world. Before providing enough care to the patient, the doctor should be loyal to himself, then towards his patients and the world around him. He should follow The Hippocratic Oath until his last breath. Being a good doctor means being a good disciple of God, those doctors will be always close to the beat and breath of god and will be an idol in both earth and heaven.




INTRODUCTION: It is an important element to have a detailed view of the procedure known as Lumbar puncture which is also known as the Spinal Tap.

It is mostly used as a diagnostic procedure by which a sample of CSF can be obtained, (which is known as the Cerebrospinal Fluid, the fluid found in the brain and spinal cord.) which is used for bacterial or microscopic examination in the case of meningitis, as well as providing a way for injecting drugs like in the case of chemotherapy. Anesthetic drugs and antibiotics are also injected into the Cerebrospinal fluid via the Spinal tap. This procedure also provides a means of measuring the pressure in the Cerebrospinal fluid with the help of a manometer.

Cerebrospinal Fluid is a clear colorless fluid produced by the choroid plexus and assisted by the ependymal cells. It contains inorganic salts like chloride, glucose few lymphocyte cells and trace amounts of protein. The pressure range of cerebrospinal fluid measured by the manometer is said to be about 60 – 150mm water and the rate of the production of cerebrospinal fluid is 0.5ml/min. (Snells Neuroanatomy)

The basic function of cerebrospinal fluid is to cushion or protect the brain from any mechanical trauma. It also provides buoyancy to the brain due to the increased density of the cerebrospinal fluid. The fluid also acts as a source of nourishment for the underlying nervous tissue and also acts as a pathway for the pineal secretions from the pituitary gland.

Method: The patient, on whom the lumbar puncture is to be performed should lie in a lateral Recumbent position i.e. on the side or even in a prone or sitting position depending on the preference of the health caregiver or a clinician. The vertebral column should be well flexed and the lamina in the lumbar region should be opened to the maximum.

There is an imaginary line which is obtained by joining the highest points on the iliac crests and when joined passes over the fourth lumbar vertebrae. From L3 to the lower border of the S2 vertebrae the subarachnoid space filled with cerebrospinal fluid is accessible and safe to penetrate as the spinal cord in an adult already terminates at the level of L1 and L2 vertebrae, thus making the lumbar region an ideal site to perform the Spinal tap.

The physician then uses a careful aseptic technique and the patient is provided with local anesthesia. The lumbar puncture needle that is the Quincke spinal needles 22G which may be of size 1.5 for infants and newborn, 2.5 for children and 3.5 for adults, fitted with a stylet is passed through anatomical structures like the skin, superficial fascia, Supraspinous ligament, Interspinous ligament, Ligamentum flavum, areolar tissue (which contains the internal vertebral venous plexus), Dura mater and the Arachnoid mater, ending in the subarachnoid space which contains the cerebrospinal fluid. It is from here that we are able to aspirate a sample of cerebrospinal fluid. The needle will pass through these structures to a depth of 1inch (2.5cm) in a normal adult and less in a child, however, in the case of an obese patient a depth of 4 inches is required.

When the stylet is withdrawn and if few drops of blood are seen, it is then due to the fact that the needle has only entered the internal vertebral plexus and might still be in the areolar tissue. The patient would experience a fleeting discomfort in a muscle or a dermatome if the nerve roots of the cauda equina were stimulated. If the needle is in the lumbar cistern and the stylet is withdrawn the cerebrospinal fluid would start flowing and escapes at a rate of approximately one drop per second. The cerebrospinal fluid’s normal pressure is about to 60 -150mm of water and if the subarachnoid pressure is high then the fluid would escape out as a jet.

Anesthetic drugs are also given in the extradural space and in the subarachnoid space in order to anesthetize the nerve roots of the lumbar and sacral area, which is helpful in operations of the pelvic and the leg. The patient is advised to be in an erect position during these surgeries as if the patient is in a recumbent position then the anesthesia would be only effective unilaterally and if the patient is in a head-down position the anesthetic could pass cranially and affect respiration.

Some of the complications include Post-dural puncture headache, infection, cerebral herniation, bleeding and back pain. It is contraindicated when there is an increased intracranial pressure, thrombocytopenia or any brain abscess.

Types of equipment used:

Sterile gloves

1% lidocaine solution

22G or 25G needle

5ml disposable syringe

Sterile drape

Spinal needle with stylet

Manometer with 3 way stopcock

A labeled sterile specimen container

Sterile bandage




I’ve dealt my experiences and knowledge with WHO’s this year theme Health for all

Let`s define Health for all-“Attainment of a level of health that will enable every individual to lead a socially and economically productive life”

When wealth is lost nothing is lost

When health is lost something is lost

When a character is lost everything is lost

Last year WHO stressed on the character aspect that too in individual level through the topic, ”Depression-Let’s talk”. This year we are dealing with the health aspect in community level and the wealth which is needed to establish the health system

“WHO was founded in 1948 to make health a human right and not as a privilege. We’ve crossed 70 years and still the conviction is as strong as ever”, these are the words of WHO director Dr.Tedros

As a third-year medical student, PSM is the subject which gave me the most joy as it dealt with health in community level. Health is something which is to be learned at a community level for the overall health promotion. Health is the only thing which is needed by the richest and also the poorest in the country without any compromise. It would be ruthless and barbaric to put an option like health or food/education/basic needs among the poor. That’s why this year WHO insisted on Health for all everyone everywhere

Now I’ll tell you my real life impact on community health during my 3rd-year ward posting. 8 year old female named Dhivya came to the pediatric OPD with chief complaints of respiratory distress. She is a known case of spastic cerebral palsy who had lost her mother during labor and father to an accident. She is now under the care of her grandmother. On head to foot examination, we found severe pediculosis affecting her scalp and eyebrows. We asked her caretaker to maintain proper hygiene by providing her regular bath and prescribed her ketoconazole shampoo to be bought outside (as it was not available in the hospital pharmacy). But she didn’t take the prescription and wept about her poor socioeconomic status to buy the shampoo which costs Rs.180. This patients history raised me questions in my mind. Why should the innocent girl suffer this? Is this any incurable medical condition like malignancy or AIDS? NO INDEED. Then there is no point in her suffering. The entire humanity should feel ashamed for her suffering as we are spending millions in finding and drug and testing it by clinical trials. Yet this Rs.180 made pushed the therapy to an unreachable altitude.

Sometimes I get inspired by watching medical series like HOUSE MD and got inspired by the American health care system. But after doing research regarding that I came to know that the health insurance companies only cover those people who are in good jobs. What about the homeless old man wandering in their streets? Does their insurance companies think that is a life not worthy of a medical care? We need a policy from our leaders which establishes equity among people. This year is the time to ask our leaders our basic right, OUR HEALTH.

For a good health care facility, we need people, services, products, finances and information and everything is needed especially in times of an outbreak. A good example of our health care system can be explained by the Nipah virus outbreak in Kerala. This is a deadly virus an too difficult to establish a diagnosis in index and primary cases. But our health care facility was able to tackle the situation and saved millions in spite of losing a few.

Here we are providing health care free of cost and health insurance also free of cost. As a medico from a government institution, I came across a lot of people from low socioeconomic class (as per modified Kuppusamy scale) seeking medical attention and they were given excellent care under free of cost. Few cost expensive services like MRI are covered under their insurance scheme. But still, we are not providing some advanced services like bone marrow transplantation, gene therapy, etc. which are provided by corporate hospitals. This is one milestone we need to achieve.

When we went to field trips to PHC, ICDS, Health sub-centre during field visits, I can see that at least essential health care is accessible to all individuals and families in an acceptable and affordable way with their full participation. We have launched a sustaining primary health care by formulating national policies, strategies, and plans of action as per Alma-Ata-conference. In spite of inequality among education, social status, economic status, etc, Healthcare is the only this we`ve tried to establish some equality and equity among people.

Regarding the inspiring 2018 theme of WHO I came to know that half of the world`s population don’t have access to a proper healthcare facility. Millions are pushed to poverty due to money spent on food. WHO insisted the need that No one should have to choose between health and food/education/shelter. Then what is the solution? The answer is to establish affordable health services for EVERYWHERE, EVERYONE. This universal health coverage can be achieved if and only if the political will is strong. WHO is calling leaders this year to make universal health coverage a reality for everyone, everywhere.

The very special 2 things in 2018 universal health coverage concept:

  • First, this stresses the importance of nurses and midwives in the health care system. Generally, they are underrated. They are the pillars of our health care system. I’ve seen a Nurses strike in my college. The whole hospital was stranded. They have the number and knowledge for our health infrastructure.
  • Second, universal health coverage stresses the importance of healthcare for older people. It considers their health issues in a novel approach. WHO does not want them to seek a doctor for their diabetes another doctor for arthritis and another doctor for hypertension. It wants them to have a health coverage in such a way that they can whatever the services they need in a single institution with their health-related data and treatment history being synchronized among different specialties.

Countries with universal health care include

Austria, Belarus, Croatia, Czech Republic, Denmark, Finland, France, Germany, Greece, Iceland, Italy, Luxembourg, Malta, Moldova, the Netherlands, Norway, Portugal, Romania, Russia, Serbia, Spain, Sweden, Switzerland, Ukraine and the United Kingdom.

There is a very peculiar thing about this list of countries. Have you noticed any South East Asian county on the list? The answer is a big NO. In South East Asia over 800 million people don’t have full coverage of essential health services. 65 million people are pushed to poverty because of the health costs. We cannot accept or afford a world like this. Especially as a South Asian Country, India cannot accept this atrocious state of us and our neighborhood. That’s why we should make health services universal so that these people do not suffer from financial hardship. By tracking who is not getting health care and who is being improvised by health care, we can make policy to establish this system. This would pave a way for a fairer and healthier world.

Health is a human right. No one should get sick and die just because they are poor or because they cannot access the health services they need. 97 million deaths can be prevented worldwide when the global community makes the right investments in the right health care system. This is quite a big number. The SDG or Sustainable Development Goals insists on making the right investment in the next 15 years to prevent this death. The SDG price tag in 67 countries which has 75% of the world`s population is 3.9 trillion dollars for the 15 years. These countries don’t have the economic source to pay the price tag (India is not one of those countries we have enough resources). But most other countries have the fund to make an investment in these countries. By giving economic assistance is theoretically proven that SDG can be established worldwide. This could add 535 million extra years of healthy living to the world’s population.

People-centered care:

Recently a lot of money invested in health has been wasted due to unnecessary investigations etc. To avoid this year WHO insists on people-centered care. People-centered care means health services are ensured to people’s needs and provided in partnership with them rather than simply given to them. It means the care where people, community, and families were respected informed engaged and treated with dignity and compassion. This improves the trust, experience, and outcome from people and gives confidence and job satisfaction among professionals. This would also improve the quality and efficiency of the healthcare system

Let’s take a look at these facts by WHO:

  • 5 million people don’t receive treatment for TB
  • 17 million people do not receive treatment for HIV
  • 20 million infants are not vaccinated against DPT
  • 204 million women do not receive adequate family planning
  • 1.1 billion people are living with uncontrolled hypertension
  • 2.3 billion people lack basic sanitation

What do we infer from these points? All the above-mentioned care is available now that’s what we are thinking, isn’t it? What is the whole point in developing a care that is not reaching millions and billions of people? We have the good knowledge I accept but we need to make this knowledge useful to the community. Otherwise, all these knowledge are vain.

Social media and mass media: Boon or ban for HEALTH FOR ALL:

Everyone will think that social media and mass media will be useful in spreading knowledge and improving the concept of health for all. But my point is they are better in collapsing the health care system rather than promoting it.

A good example is the MMR vaccination program last year. It was a great program to prevent 3 deadly childhood diseases Mumps, Measles, and Rubella. But it was a failed program. Because of fake what’s app message telling about researches in which they’ve proven that this MMR has lots of ADR?

My cousin refused to vaccinate her child with MMR.

I’ve shown her the researches about the vaccine in PubMed and yet she insisted on that wapp message and ignored me. In the history, there were a lot of failure programs due to mass media also.

. Universal health coverage is more than just health insurance, more than just health care. It means people can get quality health services where and when they need them without suffering financial hardship. Half of the population have no access to healthcare and millions are pushed to poverty due to health expenses. Universal health coverage is the solution to all this problem. Evidence and experience show that all countries at all income levels can make progress with the resources they have also show us that there is no single path to Universal health coverage. All countries must find their own way in their own political social and economic circumstances. Let`s take Ghana and Rwanda as examples,

In Ghana, a remote household receives support from community healthcare workers. They help people to receive relevant health care. I’ve read an interesting story about a 16-year-old boy, Shaibu, who was found to have a deadly skin disease and was spotted during such visits. He was referred to hospital to get specialized quality care. Ghana`s National Health Insurance provides free health services for children under 18. Since 2003, this health insurance covered over 6000 patients.

In Rwanda, Dr.Olushayo Olu WHO representative in Rwanda really wanted to create a community where everybody has a good access to health care, basic services like water and sanitation. He developed a system in which financial barriers are removed. The main problem is lots of their people were working in the informal sector. Generally, health insurance schemes focus on people who are working. So the government decided to create different categories called “UBUDEHE”. This classified people according to socioeconomic status and to know who needs assistance and what level of assistance they need. And the Community based health insurance scheme was rolled out. Now they have a coverage of over 80% which by African standards and by any standards represent a great number and they are now progressing towards 100%.

In India, states like our Tamil Nadu have the glory of having a state government implemented a government insurance scheme. Now the central government also made an initiative, Ayshman Bharat which could be the world’s largest health insurance program.


Universal health coverage not only improves health. It reduces poverty, creates jobs, spares inclusive economic growth and increases gender equality. Strong healthcare systems based on the foundation of primary care are also the best defense against outbreaks and other health emergencies. Universal health coverage and health security are truly two sides of the same coin. Now it is the time for all countries to invest in universal health coverage.

It`s time to talk about the best ways to get health services to all.

Time to remind the world leaders “Health is a human right”

It’s time to have the Right care in Right time in the Right place.

Story of Multiple Epiphyseal Dysplasia

Story of Multiple Epiphyseal Dysplasia


A very rare disease which you will misdiagnose most of the times.

Let’s me introduce you to this skeletal system disorder called Multiple Epiphyseal Dysplasia.

I have a Friend of mine who has a deformity in both of her legs and being a medic I had a very simple diagnosis in my mind which of course I never discussed with her. But suddenly a few days back she was very depressed and she wanted my help so she said to me. Hey, can you suggest me some simple ways to prevent it from getting more deteriorated?

That was the moment I was stunned and I started to go into the depth of my ignorance.

In a curious manner, I asked her what is the thing that you feel is getting worse. She replied to me that now she cannot sit on a motorbike because the distance between her legs was getting lesser with time and she has a waddling gait. She also said that she cannot even squat and many of the body postures which we do so subconsciously aren’t possible for her and is the reason for her depression. She added that her younger sister had even worse symptoms which also included pain along with postural defects and bowed legs.

Later I discovered that it was a disease which ran in her family and they inherited it from their mother who also had the same disease. So it was her mother and my friend with her younger sister and a younger brother who had the same condition known as Multiple Epiphyseal Dysplasia.

It is a rare disease so not many physicians know about it. People suffering from this disease have very fewer chances of getting a proper treatment in time as it is apparent only after 10-12 years that this becomes physically appreciable in the manner of bowing of legs towards outside and associated knock knees most of the times.

The diagnosis of this condition is very difficult as it requires sophisticated multidisciplinary setups with a facility of Genetic and Molecular Testing.

There are not many treatment options available as many it is claimed that the disease cannot be cured completely but only a few modifications can be made surgically to avoid the daily life problems related to sitting and posturing. Surgeries might include arthroplasty and joint replacement to correct the deformity.

The best approach is to reduce the effects of deformity by regular physiotherapy, weight control, and Psychological Counseling.

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