Throat Inflation can initiate to Rheumatic Heart Disease

Throat Inflation can initiate to Rheumatic Heart Disease

Introduction

In day-to-day life, one of the most commonly occurring contagions is a sore throat medically acknowledged as Pharyngitis or Streptococcal infection (strep throat). The cause is almost always by a bacterium called Group-A Beta-Hemolytic Streptococcus. The familiar symptoms are Discomfort or a prickly sensation in the throat, Dysphagia, scrambled voice. Generally, to overcome it many clinicians advise taking bed rest with a soft diet and plenty of fluids intake, in case severe unruly condition the prescribed medicine is antibiotics, analgesic, corticosteroids, and etc. The interesting doubt ascends i.e. why & how strep throat is it related to heart diseases? In general, the heart diseases are classified into various types such as atherosclerotic diseases, heart arrhythmias, cardiomyopathy, and congenital heart defects etc. Rheumatic Heart Disease is precisely triggered due to Rheumatic Fever.

Roughly 97-98 percent of the population can overcome to sore throat infection but for remaining, it can lead to Rheumatic Fever at post-sore-throat infection. This article mainly deals with a sore throat leading to Rheumatic fever. Which further may lead to chronic rheumatic heart disease, and comprises of numerous symptoms of this disease.

Initiation of Rheumatic Fever

Rheumatic fever is a non-contagious acute fever, marked as inflammation & pain in the joints. The word rheumatic generally termed as rheumatism which means inflammation and pain in the joints, muscles, or fibrous tissue stained by disease. And fever is an abnormal rise in body temperature.

All in all rheumatic fever caused to a very small percentage of the population, the prone individuals are children (5-15 years) and is rare after age 35 years. Rheumatic fever is an autoimmune inflammatory process that progresses as a corollary of streptococcal infection. The most significant complication of rheumatic fever is Rheumatic Heart Disease, which usually occurs after frequent bouts of severe illness.

Rheumatic Heart Disease

Initially, the human is attacked with Streptococcal Pharyngitis leading to Rheumatic Fever, typically occurs several weeks after Pharyngitis. Streptococcus cell membrane consists of a protein called M-Protein and the bacteria is highly antigenic to human. The immune system identifies the antigens through macrophages and counter attacks by producing antibodies against the M-protein cell membrane of Pharyngitis bacteria. But these antibodies also attack body own cells consist of M-protein which is similar to foreign body protein (this similarity is known as molecular mimicry) and finally leads to damage of body organs, which is known as the type-2 hypersensitivity reaction. The similar M-protein body cells or organs are myocardium of the heart, joints, subcutaneous layer (skin), Basal ganglia of the brain.

In rheumatic fever, there is a variety of clinical findings Jones’ criteria further classified as major and minor as follows

Minor

  • Fever: the Abnormal rise in body temperature.
  • Arthralgia: Pain in regular joints.
  • In blood, there is an increase in ESR/CRP.
  • The ECG shows a prolonged PR interval in heart-block.
  • Previous repetitive episodes of Rheumatic fever.

Major

  • Migratory Polyarthritis: Multiple large joints Inflammation one after another in a symmetric way.
  • Subcutaneous nodules: These are firm lumps under the lining of the skin made of collagen which is painless and extensor.
  • Erythema marginatum: These are the reddish rash ring formed on trunk and arms.
  • Sydenham’s chorea: It is categorized by rapid or awkward jerking moment primary affecting face, hands, and feet caused by the destruction of basal ganglia of the brain.

The Carditis/Pancarditis caused by Rheumatic Fever

In the main, the heart is affected by auto-immune response during Rheumatic fever known as Rheumatic Heart Disease. This occurs when attacks of Rheumatic fever cause scarring and damage to the heart. Normally heart consists of three layers namely: pericardium, myocardium, and endocardium, these consist of M-protein in their tissue cells. But the antibodies released from immune system cause inflammation to the layers of heart leads to Carditis/Pancarditis. The inflammation is fibers type due to an accumulation of fibrin.

Pericarditis

Inflammation of outer covering of heart is called Pericarditis, leading to sharp localized chest pain and reliefs on flexion of the spine (forward bending). On auscultation doctors can notice friction rub/pericardial rub in additional it weak heart sound is observed. When fever subsites there is no long-term pericarditis issue is seen in future.

Myocarditis

Another effect of Rheumatic Heart Disease is Myocarditis, caused due to inflammation in Myocardium of heart. In Myocardium there is a formation of Aschoff body, it is very small pin head inflammatory lesions and these are the immune-mediated granuloma. It also contains large ribbon-like nucleated macrophages called Anitschkow cells. Myocarditis is the most dangerous and recorded most common cause mortality in children if it is untreated. The Myocardium becomes loose and flabby, unable to contract which may lead to other complications like congestive heart failure. This complication is not a long-term issue.

Endocarditis

The serious and long-term complication is Endocarditis, inflammation of endocardium of heart and attacks specifically on valves of the heart. During fever, tachycardia occurs that leads to rapid closing and the opening of valves. Due to inflammation, there is a rupture or erosion of leaflets at valves. However, ruptures lead to deposition of platelets and fibrin which results in the formation of multiple small vegetation (sterile) on the valves. During post-fever healing occurs but this vegetation leads to fibrosis due to this the valves become fibrotic and distorted.

Above three conditions Pericarditis, Myocarditis, and Endocarditis usually leading light to Acute Rheumatic Heart Disease during Rheumatic fever in children. Whereas Endocarditis leads to severe complications like mitral stenosis, mitral regurgitation, and aortic stenosis and regurgitation in adults because of untreated recurrent episodes of Rheumatic fever which finally result in Chronic Rheumatic Heart Diseases.

General treatment

  • Take bed rest, Intravenous fluids and a healthy diet.
  • Conventional medications such as antibiotics (without carditis up to age 18/21 years, with carditis up to age 25/45 years), anti-inflammatory drugs.
  • In-take of Cardiac drugs on doctor’s prescription.
  • In severe, case surgical treatment of heart is required.

References

http://rhdaction.org/

https://emedicine.medscape.com/article/236582-overview

Rheumatic Fever

https://www.medgag.com/anatomy-10-years-2018-2017-question-papers-1st-prof-mbbs-wbuhs/

What Is Liver Cirrhosis ? Symptoms, Treatment & Causes

What Is Liver Cirrhosis ? Symptoms, Treatment & Causes

What is Liver Cirrhosis?

Cirrhosis is a type of chronic disease (slow processing) that’s relative to the liver. Cirrhosis is identified when the cells of the liver are getting replaced by fibrosis (i.e. fibrous thickening of tissue) or the replacement of normal tissue with scar tissue. Basically, cirrhosis leads to damage to our liver and their functions. The liver plays a significant role in metabolism, detoxifying harmful substances, purify the blood and also including bile production and excretion too. Mostly, cirrhosis caused in alcoholic person and also more chances in a patient of viral hepatitis (B and C).

By examing and performing various experiments the medical science finds out a way to limit the further effects of cirrhosis but still cannot be able to cure. The ultimate way to rescue from cirrhosis is liver transplantation.

Globally, At present, there are more than 1 million cases of liver cirrhosis are.

 

Symptoms of Liver Cirrhosis

  • Joint pain
  • Fever
  • Fatigue
  • Vomiting
  • Abnormal personality
  • Neurologically deprived
  • Hepatic encephalopathy
  • Peripheral neuropathy
  • Asterixis
  • Integumentary
  • Jaundice (icterus)
  • Spider angiomas
  • Palmar erythema
  • Purpura
  • Caput medusa
  • Itchy skin
  • Gastrointestinal
  • Dull abdomen pain
  • Dyspepsia
  • Fetor hepaticus
  • Flatulence
  • Varices
  • Gastritis
  • Gynecomastia’ testicular atrophy
  • Hematemesis
  • Feel like overeating
  • Hemorrhoidal varices
  • Digestion problem
  • Increase size of liver
  • Loss of appetite
  • Hematologic
  • Anemia
  • Thrombocytopenia
  • Leukopenia
  • Coagulation disorders
  • Splenomegaly
  • Metabolic
  • Hypokalemia
  • Hyponatremia
  • Hypoalbuminemia
  • Fluid retention
  • Peripheral edema
  • Ascites

 

Causes of Liver Cirrhosis

  • Hepatitis B
  • Hepatitis C
  • Biliary atresia
  • Wilson’s disease
  • Fat accumulated in the liver
  • Primary biliary cirrhosis
  • Primary sclerosing cholangitis
  • Infection (schistosomiasis, peritonitis)
  • Enlargement of the spleen (splenomegaly)
  • Portal hypertension
  • Esophageal varices
  • Malnutrition
  • Bone disease
  • Gallstones
  • Heart failure
  • Obstructed blood flow
  • Hormonal imbalance
  • Production of toxins
  • Prevent the functions of protein and drugs too
  • Non- alcoholic fatty liver disease (NAFLD)
  • Non- alcoholic steatohepatitis (NASH)
  • Greater chance of Liver cancer

 

Prevention of Liver Cirrhosis

  • Stop or reduce intake of alcohol
  • Focus on the balanced diet
  • Less intake of salt
  • Less intake of sugar too
  • Prevent from taking of non-veg and spices.

Tests to be Performed for Liver Cirrhosis

  • Blood test
  • Liver function test ( ALT, AST, ALP)
  • Creatinine
  • Hepatitis B And C
  • Imaging test (CT, MRI, ultrasound, MRE)
  • Biopsy
  • TREATMENT
  • Endoscopy
  • Medication
  • vaccination
  • Rehabilitation
  • Consume diet with low sodium content
  • Avoiding nonsteroidal anti-inflammatory drugs
  • Hemochromatosis (reduce the levels of iron)
  • By the excretion of copper in urine
  • Liver transplant

 

Conclusion

The liver is the most workable organ within our body, performs various functions relating to circulation too. The liver performs both functions like production and excretion too.

LIVER CIRRHOSIS is the most advanced form of liver disease that’s related to generally drinking alcohol and viral hepatitis B and C. Liver cirrhosis occurs when the liver cells are killed or injured, and after that when the inflammation occurs, the injured want to repair itself by forming scar tissue that consequences in forming new liver cells in clusters form that leads to regeneration of nodules of liver within the scar tissue.

The disease is a part of the progression. It may start with the fatty liver disease, then progress to alcoholic hepatitis, and then to liver cirrhosis.

Liver cirrhosis main identified by jaundice, loss of appetite and fatigue. There are various types of complications occur in liver cirrhosis including liver cancer.

Diagnosis of liver cirrhosis can be started firstly with examing patient history, family history also, the vital signs (physical examination), blood test, and we can also perform complete diagnosis by confirming liver cirrhosis by performing the liver biopsy.

Treatment of liver cirrhosis prevents further damage to the liver, liver cancer, other complications related to liver cirrhosis and other adjacent organs from any damage. By suppressing the immune system by prescribed medications like prednisone and azathioprine to prevent further inflammation related to the liver in such as autoimmune hepatitis.

We can’t cure liver cirrhosis, but we can provide treatment to the patient as medication and further types of test like endoscopy. The best recommendation for the liver cirrhosis patient is to liver transplant surgery, still, the medical science working on the curing of liver cirrhosis by medications and some other remedies.

 

Gandhi had a vision towards health promotion of the society

Gandhi had a vision towards health promotion of the society

Introduction

When we think about Gandhi, what are all the things which come to our mind? Father of the nation, fought for independence, non-violence movement, his adherence to truth, etc. we never realized the immense knowledge on health he had. Yes, he had a vision towards health promotion of the society. Though initially, he hated modern medicine, at the end he himself stressed the need for an evidence-based medicine

My life experiences on Gandhi:

My first experience is with our ENT department. In our college ENT department, there will be a quote told by Gandhi. He says, “It is not our patient who is dependent on us, but we who are dependent on him. By serving him, we are not obliging him; rather, by giving us the privilege to serve him, he is obliging us “. The need for a patient-centered healthcare facility is insisted on by him long ago. This quote is also inscribed in the OP suite at AIIMS, New Delhi.

My second experience was in Velammal Medical College, Madurai in a neurology quiz. There was a question called what are Gandhi neurons. I didn’t expect that question. I was like, there is a neuron named after him? They told those mirror neurons, appears to underlie feelings of empathy was named so by Indian born American neuroscientist Ramachandran on 2008

Keys to health:

Gandhi’s book on “keys to health” is one of his most famous writings. He believed in the 5 element concept of human body earth, water, vacancy, air, light.

  • Air: he insisted on breathing exercises, cleaning the nostrils and the importance of sleeping under the open sky.
  • Water: he insisted that everyone have the right to get pure water and proper drainage facility. It is the duty of government to provide that. He also believed in hydrotherapy
  • Earth: he believed that mud has the potential to cure scorpion sting, constipation, boils, etc.
  • Light: he had faith in yoga and sunbath.
  • Vacancy: it is also called Aakash or ether. Gandhi believed that brahmacharya led to a healthy life.

He insists that we should not abuse the body we have. He says” everything in the world can be used and abused and it applies to our body too. We abuse it when we use it for selfish purposes, in order to harm our body. It is put to right use if we exercise self-restraint and dedicate ourselves to the service of the whole world ”.He wrote about his experiences in his publication, ’Indian option’ under the title ‘guide to health’ and some articles on nature cure and five elements and their effects. Those articles were published in Aga Khan Palace in 1942.

His approach towards diet:

Nowadays people are very concerned about their diet. Now we have paleo diet, Atkins diet, etc. Gandhi during his period stressed the importance of dietary habits in the health of a person. He divides people into vegetarian, flesh and mixed and considered vegetarian diet the best. He insisted on the importance of adequate nutritional proportion in food. Regarding sweets, he supported jiggery, yes the only sweet which contains lots of iron content. He insisted to avoid fried food. Gandhi says,” Food should be taken as a matter of duty even as a medicine to sustain the body, never for the satisfaction of palate. There should be self-control as such habits of elders influence children to some extent”.

His approach towards smoking and drinking alcohol:

Gandhi states that ” Drugs and drink are the two arms of the devil with which he strikes his helpless slaves into stupefaction and intoxication ” .At that time people were drinking to get attention from British, social availability etc. police training schools made it compulsory to drink wine and eat meat. This makes the individual health and the community health in question. He starts that prohibition should start from not selling in shops, etc. he asks the women to actively participate against alcoholism.

He opposed smoking explaining the ill effects of it. The British tobacco company humiliated him by selling cigarettes named “Mahatma Gandhi” cigarettes. But he didn’t lose hope. He fought against tobacco throughout his life. He says,” He opposed smoking explaining the ill effects of it. The British tobacco company humiliated him by selling cigarettes named “Mahatma Gandhi” cigarettes. But he didn’t lose hope. He fought against tobacco throughout his life. He says, “if every smoker stopped the dirty habit of making his mouth a chimney to foul breath by making a present of his savings to some national cause, he would benefit both himself and the nation “.

Hygiene and health, the universal principles:

Gandhi made committees in Africa and Ahmadabad to conduct surveillance on open defecating areas and to promote sanitation there. Today around Tanjore we can see lots of villages with signboards promoting construction of latrines in the home and to avoid open-air defecation. Still, we cannot make people avoid open-air defecation and we cannot expect Gandhi to successfully establish that long ago. But we should never forget his ceaseless effort for health promotion.

Though he had a strong belief in God, he hated the untidy pilgrimage practices in India. He incorporated health education and hygiene in his 18 points constructive programmes

His initial disappointment over Western Medicine:

He suffered from digestive complaints while practicing law in South Africa. He took some medicine but they were ineffective. One of his friends gave him a book “Return to Nature” by Adolf. The book told about dietary reforms, mud application over the abdomen, use of wet compresses, etc. he got relief from these. He insisted that such drugless therapy is needed in countries like India where people don’t have access to the healthcare facility. But in this view, I bet to differ from Gandhi. We need to establish evidence-based medicine all over the country. In Tamil Nadu lots of quarks have arisen to provide the cure for jaundice, AIDS, etc. recently a person calling himself healer Baskar promoted the state to practice domiciliary delivery and as a result, a woman from Thiruppur lost her life. He also claims that sambhar vada is the cure for gallstones. We should never promote such evidence less medicine

His later positive attitude towards modern medicine:

In his 50s he suffered from hemorrhoids he first went seeking a solution from naturopathy. Then he went to Dr.Dalai and he underwent surgery and got cured of the illness. He even suggested others suffering from hemorrhoids to go for surgery. In January 1924, in Yerwada jail, he suffered from appendicitis and was operated by British surgeon Maddock. This life-saving surgery promoted his mind the need for modern medicine.

Gandhi against ancient medicine:

While opening an ayurvedic pharmacy in Chennai, he spoke that Ayurvedic physicians are just living by the glory of their past. The system is less evidence-based than the western system. He wanted the Ayurvedic practitioners to practice research and give evidence for modern medicine practitioners.

The next month he wrote to an ayurvedic physician,” I have faith in the Ayurvedic drugs, but very little in the diagnosis of physicians. I therefore never feel sure about a patient under an Ayurvedic physician if his diagnosis is not checked by a trustworthy practitioner under the Western system “.

My Gandhian views regarding independence for doctors:

As a third-year Medical student, I ‘ve been traveling to lots of colleges for intercollegiate conferences. I’ve seen lots of interesting research papers and case presentation from various Medical Colleges. But when I discuss with them and ask about their ambition most of them would like to join PG in central University in India like AIIMS JIPMER etc or to clear international exams to pursue their career abroad.

Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) ,AIIMS and JIPMER in the mind of the young medical students and doctors in Tamil Nadu who don’t see or don’t want a future here.

I didn’t say such aims are wrong. But I question why a young medic with great rank which would allow him/her to choose their favorite PG course in their own state, where they tend to interact with their patients in their own language, to choose a college where they must learn a new language, culture, epidemiology difference, climatic variations etc.

And when all the competent Doctors our state for a place with better job security, job satisfaction, pay grade, respect then Tamil Nadu will be left with lack of manpower and will go through a medical crisis with lack of manpower.

Let’s see the PG stipend across the country

Sino. state Stipend for MD/MS 1st yr Stipend for DM/Mch 1st yr
1 Tamilnadu 27,100 32,800
2 Central government 86,335 89,634
3 Kerala 43k 47k
4 Maharashtra 53,360 48,413
5 Madhya Pradesh 45k 50k
6 Rajasthan 47k 54k
7 Uttar Pradesh 55,830 62,633
8 Bihar 50k 90,411
9 Goa 60k 71,238

Of course, after a lot of struggle, the stipend was increased to 40k 45k for PG and superspeciality respectively. Still, this is very low when compared around the country.

Across the world, Indian doctors are paid less. Across the country, TN doctors are being paid less. This is one of the reasons which implant the dream of studying abroad in young minds.

People may argue “Doctors should not work for money, they should do well to the society,” I ask WHY? Does anyone tell the society to provide all services to doctors free of cost for “betterment of the society”? OR ask the banks to give away money to all doctors for the same cause. No!

I would tell you an anecdote of myself. I finished my schooling in my hometown which is Mannargudi. I’ve chosen to study at Tanjore MC because it was the best College near my home. I didn’t think of studying in central University or in big cities. I really saw and I really wanted my future here. I didn’t have any calculation to join here; I got an emotional bonding which made me choose here.

I really wanted to join MD pediatry here in our college after I finish my MBBS. But when I came to know about the stipend paid across the country and the situation of TN, my dreams shattered. As a student from the middle class, I would rather sacrifice the comfort of living in my dream College over an increased stipend to support my family economical

So should I choose to join AIIMS or JIPMER? The answer is a big NO. We know the status of TN medical postgraduates in central Universities. Every month we are seeing at least one death news regarding PG death in AIIMS who is from Tamil Nadu. I had a senior friend who joined MD pathology in KEM Mumbai, whose bike was shattered just because it got a number plate TN. We have such a welcome from North Indian states. After all hard work, I don’t want to die in a central University.

The assault on doctors is not restricted to TN doctors alone. These past few years in India have witnessed growing instances of assault on doctors. Many newspaper columns have been devoted to the issue. Recently a doctor in Maharashtra’s Dhulia lost his eye after being assaulted by the relatives of a patient. Assault on doctors by angry patients and their kin is only a reflection of the issues troubling the healthcare system.

Let’s continue my story, where should I pursue my post graduation now? This pushes me to think that I should try writing USMLE. Let’s jump to my statement in the beginning of my essay.

Lack of Professional security, unfair wages are some of the few reasons that implant the dream of USMLE(USA), GMC(UK), AMC(AUS) ,AIIMS and JIPMER in the mind of the young medical students and doctors in Tamil Nadu who don’t see or don’t want a future here.

Do I see a future here? NO. Do I want a future here? NO. But this is my new ambition. This is what I should answer when a stranger asks me what you are going to do after finishing MBBS. I’ve been pushed like the majority of students in TN.

We must accept that corruption has found its way in the health sector too. However, I will be unfair in not adding that majority of the doctors remain committed to the ethics of the profession.

Let’s see another scenario; young Indian doctors are making the country proud through their work in developed countries such as Canada, the US, and many European countries. These doctors are working in a better medical ecosystem unlike doctors in India, who are forced to continuously fight unheeding authorities both for the rights of unaware citizens and overworked doctors.

Only 1.3 percent of the GDP is directed towards healthcare. As per the Universal Health Coverage NHP (National Health Policy) in 2017, four percent of GDP should be allocated for health. This data doesn’t reflect that health is a priority for the country.

India has only 10 lakh doctors working in government and private sectors. According to the World Health Organization, the doctor to patient ratio should be 1:1000. Which means India cannot afford the migration of young minds abroad.

We must find a way to prevent this migration. I didn’t mean preventing the true ambition of students who really know and want a career abroad. I want to stop the migration of students like me who are pushed out due to insecurity.

Recently the NMC Bill was tabled in Parliament and sent to the parliamentary standing committee. The panel has advocated “bridge courses” for indigenous and alternative medicine practitioners such as Ayurveda, and Homeopathy. If bridge courses could have been a real solution then I want a bridge course for local panchayat leaders to fix the shortage of judges in the country.

Thus we are facing a major crisis in TN of loosing young talented doctors to central Universities and abroad. We need to increase the stipend and salary of doctors here and we must provide a safe environment for the doctors. For this, we need a strong political will and planning to prevent such migration.

The basic concept is – rather than counting on what others can do for you, make your life count

Conclusion:

It is better to die on your feet rather live on your knees. Gandhi is an iconic man the world has ever seen. The time when people believed that war was the only solution, there stood a man against violence and proved to the world that humanity, love, and non-violence can win too. He stood up to his lines “Be the change that you wish to see in the world. “ His life itself was a message. In this essay, I have dealt my best to explain my life experiences and my Gandhian principles and Gandhi’s contribution to medicine.

References:

Gandhi M. K., “An Autobiography or the Story of My Experiments with Truth”, Navajivan Publisihng House, Ahmedabad, India, 1927.

Gandhi M. K., “Keys to Health”, Navjivan Publishing House, Ahmadabad, India, 1948.

Gandhi M. K., “Social Service, Work and Reform” (Vol-1), Navjivan Publishing House, Ahmadabad, India, 1976.

Gandhi M. K., “Diet and Diet Reform”, Navjivan Publishing House, Ahmadabad, India, 1949.

Keywords: Gandhi Health, Health promotion by Gandhi

 

ROADS LESS TRAVELLED

ROADS LESS TRAVELLED

One fine morning as I was going on my routine rounds, my eyes were particularly fixated on an old man. It was onco-surgery ward. A ward so infamous, so notorious for all the gloom it possesses. And among all that dejection and despair filling up the atmosphere of the room, this patient was smiling brightly. I went through each of the patient writing up their notes, plans for the day and as I reached the patient in consideration, he was still smiling. I politely asked him, “Sir, how are you feeling this fine sunny morning?” He replied cheerfully that he was feeling great and more so as he was being discharged that day. I opened up his file and saw that he was a case of oesophageal carcinoma. His oesophagus had been resected but only too late. The cancer had metastasized everywhere and he was admitted with the sole purpose of attempting to prolong his life. I asked the patient again, “Sir do you know why you have been admitted here for these past days?” The patient confidently replied he was suffering from some minor ailment that caused him sore throat and vomiting of blood and now that those symptoms had been less frequent, he had healed and was ready to return to his village. So it was only natural when I asked him who had told him about the discharge and his medical condition. Of course, it was his son. And his son on being questioned why he simply replied that he wanted to see his father happy and he couldn’t gather enough courage to break the news and deal with the breakdown it ensues. So I turned back to the patient again, smiled and immediately regretted for asking that if he had any plans after returning to his village. So unaware of the certain death that lurks him, so hopeful of the future, so full of plans and so full of optimism. I too didn’t have the courage to break his heart right away. I walked out silently with a heavy heart not knowing at that very moment what it was that I should have done.

On another instance, it was this woman in her fifties. She was being wheeled into the operation theatre for a major surgery. The patient party had already given their informed consent after being explained about the whole procedure, its risks, benefits and complications. So during the course of the conversation, the attending anesthesiologist asked her how she was feeling and if she was anxious at all. The woman promptly replied that she isn’t scared at all and she thought that all those preparation and precautions were an overkill for a small injection. She casually said the injection could have been given outside as well and they didn’t need to bed her and drag her into some special place. The anesthesiologist sprung up with rage on hearing it. The operation was delayed and the patient party and the attending surgeon were summoned and inquired about the matter. The surgeon mentioned that the patient party had requested him multiple times to let them be the ones to break the news to their patient. On other hand, the patient party replied feebly that they thought all she was going to remember was an injection of anesthesia before she passed out. In their words, they didn’t want to burden her with such grave news and they couldn’t bring them self to let her know about the dangers she is facing.

These are just two instances which I experienced personally. Most of us might have been through it ourselves too. In a country like ours where a significant portion of the population is still illiterate and yet more unaware about health and medical conditions and even a huge portion of people gullible to what others say, it can very easily be projected that the huge chunk of patients do not know what afflicts them even after a correct diagnosis has been made. Of course it is the duty of the attending physician/surgeon to make a diagnosis and explain it to the patient in an understandable language but when the patient hails from a downtrodden table of society with little or no educational background (which is fairly common in our setting) often the final and the only message that gets delivered across to him is “You are DYING”.

So after a patient comes to know he is dying, a different set of dynamics comes into play. It is a gray area really. Not black, nor white. But a plain shade of frustrating, depressing, discouraging and demoralizing gray.

How do you explain hope and define optimism to someone who has never believed once that life has been fair to them and it will ever be…

OR

How do you lie or let the relatives lie to someone who might have important things as managing his family, properties, making his last will and testaments or fulfilling his final desire and wishes? But with all the researches published that have found out optimism in a patient certainly does prolong the life and bring about favorable outcomes in the patient, you certainly tend to think twice.

So what is it that we really should do???

To go against the wishes of the patient party who suggest you to not disclose the news or to do what is ethically right and let the patient know and decide how they want to deal with the disease. In the present context, in our setting not complying by the wishes of the patient party might invite a whole new set of problems with risk of physical, social and psychological trauma for you. But even after you reveal the despairing news to the patient they might opt to abstain from any forms of treatment to save money and not become a burden for his family. They might give up all hope on life which might adversely affect at any chance of having a better prognosis. But this issue can be very much be ameliorated by a slight change in our approach to one aspect of medicine we rather choose to ignore, “counseling”. From what has been extensively researched and from what is being practiced by our counterparts on the other face of the world, counseling itself is a major factor that determines the entire outcome of the treatment.

With suitable and effective counseling, the view of the patient towards the disease and treatment process can be exceptionally altered. It is better if you let the patients know that they are not alone suffering from the disease and share the experiences of how others coped with the situation. You could always suggest picking up yoga, meditation or any other means to calm the mind. How they should utilize the time they have tying up any loose knots. And if needs be how you are always there to support him with any palliative care they may need. With a proper counseling, the compliance and adherence of patient to treatment increases, optimism in patients rise to new heights and the overall prognosis and outcomes have favorably fluctuated.

The disease the patients are suffering from is a truth, its prognosis/outcome also a truth, right to information of a human being and your responsibility to respect his sovereignty also a truth and what I firmly believe is only the revelation of this truth and a competent counseling and treatment course will be in the best interests of the patient and the treating physician/surgeon himself. And only then can we rise from the ranks of common people and truly be what the people expect us to be…

“An ethically and morally impeccable human being”.

A Doctor’s View on Doctor – Patient Relationship

A Doctor’s View on Doctor – Patient Relationship

MBBS (Bachelor of medicine and bachelor of surgery ) the most inspiring and attractive word for me throughout my whole childhood. But it becomes toughest on 5th June 2015 when the first time I was successfully failed to get an eligible rank in my West Bengal joint entrance examination for medical. Though the word inspiring was existing in my life for MBBS. I desperately accumulate all my courage and restart my preparation to crack the same examination for the next year.  And that time I successfully able to get the entry in my childhood wish. I was started my journey as an MBBS student at the BURDWAN MEDICAL COLLEGE, WEST BENGAL and from the beginning of that, I was an active part of the world medical association.

‘Doctor Babu ‘when I heard the word indicating to me for the first time it was such a pleasure to feel that astounding feeling. In the first year one day I went to visit the hospital for the first time with my white apron. Then a short height, an unhygienic man came towards me and ask for ECG room. But at that time I was not able to help that man because I also didn’t know this. As a doctor, my duty was to help that man.

A healthy doctor patients relationship is the most important part of treatment. Healthy means professional. Some foremost characters should have to be developed to become a successful doctor. At first, a doctor must have to be helpful towards his patients but obvious within his professional limit. Secondly, justice with patients, equality among patients, and equal division of limited resources only and only based on priority need and next one is fidelity means the ability to truths about our each and every action because mistakes are forgiven but lies are strongly punishable. We must have to be understood that patients are not help-seeking rather we are the help provider.

Doctor patients relationships are of different types. One may be doctor-centric in which doctors are superior and patient must have to follow doctors advice and another one is patients centric in this doctors are flexible in their point of views and they give opportunities to his patients to choose their options.

A doctor can play different roles in appearance to influence his patients. We must have to be flexible in our behavior and it will be the strongest ladder to achieve effective care. The term ‘placebo’ is a substantial term conjoin with the medical profession. Sometimes we have to use strongly directive approach to make better treatment. Some pessimistic patients are not aware of their health so they ignore the treatment process. It is our duty to strongly put our advice and make the better health of the patient. But as besides this, it is also important to remember that the right to refuse is the personal choice of the patient. We can’t pressurize them in any aspect rather we can motivate them. As a good doctor, we have to use tremendous politeness and respect during the treatment of geriatric patients and it is an appropriate doctor-patient relationship.  Another one is protectively paternalistic approach and this is maximally used in pediatric treatment. A doctor can advise his patients by gathering kindness, protection, strength, and patience. Because pain is the fearest foe of a child and as a doctor, our responsibility is not to destroy the fear but to achieve the power to fight against it so that he can tolerate it in his upcoming life. Some other aspect is the supportively directive approach. In this type, doctors believe in patient’s choice along with providing reassurance and guidance. Another example of the perfect doctor-patient relationship is the relationship between doctor and female patients. Most of the female patients always choose female gynecologists for their treatment but as a male doctor also our duty is to provide equal safety and security to them so they can trust us . A doctor can play an active role in the treatment of terminally ill patients. As a doctor, our responsibility not only in cure purpose but also provide the hand in care. In the case of terminally ill patients, we can’t stop our treatment by accepting upcoming death but it is our duty to provide a peaceful death to our patients.

Relationship means the mutual connection between two peoples. So both sides effort is necessary to make a relationship healthy. Patients also have to believe in the doctor to make the relationship more trustworthy. Some people told that feel your patients as your family members but I think rather it is important to feel our family members as our patients when they suffer from disease because a professional relationship can handle effective treatment rather than a coherent relationship. As besides the importance of establishing relationships, it is also important to perfectly terminate our relationship with our patients because we can’t expose us as available and as sympathetic so that we become emotional during termination.

As a future doctor, I will definitely maintain these in my working phase and I wish my other co-workers who are reading this may also influence through my words.

 

 

Five Years of My MBBS Life

Five Years of My MBBS Life

I had joined the medical college with all the excitement that is humanly possible. Getting merit-based scholarship and not having to pay a single penny as a donation to college, I had made my parents proud. Not that I had always wanted to be a doctor. Being a doctor is the epitome of success academically in our society. The toppers of the country would choose to be a doctor. More than me, my parents were happy that I was studying Medicine. What more could I do than to make my parents proud. Not that I was forced to study medicine. Personally, I was indifferent. I wanted to go through the tough road that elites chose. Deep down inside, I still wanted to explore passion in life. But I was far too lucky (and thinking now maybe unlucky) that I got my name in the successful candidate name list in the MBBS entrance examination.

First year: Crushed euphoria

I was so happy to sign in the admission forms and submit all my certificates. More than that I was happy to see my dad’s smile while I was signing. Getting my hostel room key and filling a small sheet of paper for college identity card filled me with utmost pride.

As classes started, the happiness curve went down. All my expectation of med school became upside down with the reality. As happy I was to get the key to my hostel room, I was more disappointed to open the room of the hostel that was located 3 kilometers away from the hospital right next to the public bus park. Unlike the photos are shown on the website of the college, the hostel was a temporary rented hotel, with zero facilities. The hostel corridor had a leaking terrace and in the monsoon flooded our room if we opened our door for long. The soaked carpet smell mixed with our own sweat smell during the power cuts was in the air. Love definitely wasn’t in the air.

Second year: Exams

Literally, the second year was nothing but the exams. We had monthly big exams, and countless small posting examination. The syllabus was vast and time very limited. On top of that, we would hear about the terror of HODs of departments during practical Viva examinations. Our only aim was to pass every internal examination so that we would not be barred from giving board examination.

Third year: Honeymoon year

We were posted in the hospital. We had our first share of exposure to the patients. Only two subjects whose exam would be there. Taking history and learning physical examination. It was far different kind of learning compared to learning from the cadavers of first-year anatomy class. For the least, all we had to do was to maintain our attendance to 80 percent.

Fourth Year: Minors

We had already spent a year in the hospital wards and OPDs. The place felt familiar and we had been quite familiar with the history taking and physical examination. Watching POP casts and slabs in the Orthopedics OPD was exciting. Learning to use an Otoscope and be able to visualize the perforated eardrum gave all of us some happiness of sorts.

Final Year: The real exams

We were the same as the third year and our posting was the same. But the way our teachers treated was entirely different and that increased the fear. They would constantly remind of us being the ‘exam giving batch’ and that we had to cover each and every topic. Everyone was seriously studying except for the legends who still got time to flaunt the new bike they had bought.

Time passed in a blink of an eye. There was so much to study and so less of time. Nothing except the syllabus mattered. The frequency of mom and dad calling to ask about my whereabouts decreased. Going out for parties were almost nil. Birthday parties got postponed.

Internship: Three Ds

Dressing. Discharge. Daru (alcohol). The dressing of wounds and especially of the burn patients was really difficult and time-consuming. Making discharge sheets of patients who were admitted for delivery of babies was hectic as hell as the number many a time crossed half-century. And a chilled beer once in a while was the answer for releasing the frustration of doing ‘clerk-type’ work every day.

Right now, I am almost halfway through my internship. The days are so varied. Some days, we get all the time in the world to talk about all the things that are shitty in this country. Other days, we are so tired we fall asleep right as we close our eyes. The way we are treated also varies greatly. Some patients treat as if we are magicians wearing white gloves applying elixirs in their wounds and heal them. Other patients treat as if we don’t even exist there.

Final Note:

With all the free ‘no-need-to-read-compulsorily’ time that I have got in the internship, I get plenty of time to introspect. I think about the situation in the country. I talk with the residents and learn about the things I could do during my internship days to make the future a little bit easier when I would be working in a hospital far from cities. And some nights when I am alone in my room and it is raining outside, I wonder with one question on my mind:

Would I be a good doctor?

” SISTER, BP CUFF! SISTER, GRABS! SISTER ROUNDS! “

” SISTER, BP CUFF! SISTER, GRABS! SISTER ROUNDS! “

Med school! Hospital!!
Everyone in chaos. Sisters, interns, residents, consultants. Everybody in a constant race. Each one of them has their own story.
“sister, bp cuff!  Sister, grabs! sister rounds!
Gosh! Sister, why the hell isn’t this monitor working?? Sister, this! Sister,  that! Omg!! The sisters are a way too clumsy man,” utters the intern.
And here the sisters are in hustle always. Continous running, loading medicines, withdrawing samples, dressing, preparing for dispatch, doing everything in the permitted time. Too much of rush.

Interns,  the beginners, super fresh in their carrier are not much in less haste. Within a week of joining,  get completely used to the new world. The day starts in a haste to reach the rounds without a time for breakfast. After finally finishing writing progress and collecting reports and even before feeling a bit glad to have skipped breakfast for their service, it’s a time to get a complaint about not being responsible towards patients. “Omg! Interns like these kill the patients, says your consultant. When I was on your phase, I solely looked after the ward and opds too”, adds the resident. Interns are under the constant pressure from almost every one,  starting from sisters to consultants. Sometimes more of a paperwork make them forget their profession. Running the entire day, they wanna get through every procedure. But their hard work and sleepless nights are always overruled by the silly mistakes, immaturity and the little ignorance which is definitely not acceptable in our beautiful world of healing. Neither the Residents are free of this vicious cycle. Well,  they are at the top to have the uncountable number of mishappenings and acquaintances at the end of residency. PG’s, the fastest runners of the medical marathon, responsible for every misshapenness and aberrations in their respective wards, from the cleanliness of ward,  infrastructures, patient progress and many more. Never too prepared for the rounds,  always sort of knowledge which seems and is definitely very basic to the consultants. In spite of daily learning,  insistent practice, hard work, they are still miles away from getting pro. On their attempt of getting more serious,  they often land up in misunderstandings with residents of other departments. Their best decisions for their patient are most of the times mistaken irrelevant and inessential investigations or consultation or expert opinion to the counter residents and vice versa.

And again,  cutting off some of them with an intention of helping out your copartners would again label you a negligent one. You are always in a hit to be so incompetent to the duty. They complete the entire residency in chaos and even at the end,  they are labeled as not very compatible.
Completing postgraduate doesn’t even ease you out or relieves you of pressure. Rather you ought to be more responsible and handle your juniors. Entire hospital is in your hand and you can’t afford a slight carelessness towards the patient. What you call little creates a huge difference in the treatment protocol.
Finally,  its all about life. Its all about healing and curing. You do your level best,  keep running and yelling and complaining and blaming to finally be a better healer,  better soother. You shout at others cause you to feel your way of healing is better and vice versa. All of us are on a single journey with one single motive but with different roads. It’s not easy to know others journey without walking on their shoe. Let’s complain less, be more kind and only a little more understanding. Afterall, all of us have a single aim. Better healing and curing!!!
IS BASIC SCIENCE TOO BASIC??

IS BASIC SCIENCE TOO BASIC??

 

Finishing two years of basic sciences and really looking forward to the clinical years now I am thinking as many a time I did in the past, whether the basic sciences course taught us in Nepal are not updated as per the need of now.

What I am saying is that the information we learn now should be learned either to make a base for learning and understanding the clinical medicine or knowledge that can be utilized in the clinical side.

Let me give you an example:

Why do we have to learn “all” the names of enzymes and memorize the steps of a biochemical pathway? I am saying “all” because some steps are there where the pathology lies(deficiency or overactivation) or the site for drug action and these are crucial to understanding to learn about the disease and the treatment but some steps are there without any significance in clinical application( they may have importance in research but we are learning medicine not researching about everything) . And our syllabus expects us to remember those rather than concepts that are vital.

It may sound like a cry of a lazy student but I say lets put the same time and effort to learn other concepts and applicable things. I am not undermining the importance of the basic science subjects or the curriculum but I feel that if the students are taught from the very beginning to be clinically oriented they will retain the information better and be a better doctor.

If students know that they need to learn the path of this tract in CNS because it signifies the appearance of clinical signs and symptoms according to the site of damage then they will want to know and will understand it better then just learning the path.

Best of all will be integrating the basic science subjects’ concept to give their clinical application. For example, knowing about the location of the pancreas(anatomy) gives me the idea that carcinoma of the head of the pancreas(pathology) can block the hepato-pancreatic duct thus obstructing the bile flow. Knowing about the formation and function of bile(biochemistry and physiology) I can know what will happen in the obstruction vs infection(microbiology). I admit all the times the subjects can’t be integrated but I feel more integration is needed.

Latest approach by Kathmandu University to introduce more clinical insight to the basic sciences is done by the inclusion of a subject named Introduction to Clinical Medicine(ICM) and it is very appreciable and fruitful for the students. It integrates the knowledge of the basic sciences to explain signs and symptoms and management. But one subject is not enough.

I hope that in the next revision of the curriculum the integration and clinical use will be given more importance than just facts and numbers that won’t be clinically applicable.

 

THE IMPACT OF CURRENT HEALTH CARE SITUATION ON MEDICAL STUDENTS AND YOUNG DOCTORS OF NEPAL

THE IMPACT OF CURRENT HEALTH CARE SITUATION ON MEDICAL STUDENTS AND YOUNG DOCTORS OF NEPAL

 

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.

INSPIRATION

INSPIRATION

It’s just been two years since I joined medicine. Finishing up my pre-clinical years now and I feel these two years changed me a lot as a human being. Doing hard work and working under pressure is there but with that, the feeling of my role in the society has recently evolved in me. Before joining it was a profession for me that I dreamed of, I did not know it meant a lot more than just a profession. I now feel that I will be able to make an impact on the society in the future. I feel that “yes I can change lives” and change for a better future for many people. Being just a second-year medical student these things may sound like idealism, “just another inspired fellow who will lose this feeling later when he’ll have to deal with ‘LIFE’.

 

But I ask why not to inspire medical students constantly? Apart from the vast knowledge and skills we are acquiring, I think a little bit of inspiration now and then will make the students push a little harder each time. Make them feel that what they are building up is not merely a way of living, rather it is a way of life.

 

As per my personal experience, the feeling that ‘I need to get to a certain level such that people will believe me and trust me so that I can make an impact on the society’ is something that gives a boost to go on during difficult times. It helps me to go through that biochemical pathway, the late night work on the practicals, the missed wedding of my sister, the party I could not go to and on and on goes the list.

 

We may not realize how much of an impact our words have on people. Maybe because you said the boy next door wanted to be a doctor, maybe because of you someone became more generous to the needy.

 

 

 

 

 

 

So, why not inspire people so they’ll thrive towards greatness rather than settling for “OKAY”.

 

Why not create a feeling in people that they can impact the society and their contribution means something to others?

WHY NOT INSPIRE?

 

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