The Buddha Says

Fat patients

2008-04-06T12:08:00.004Z

Are we allowed to call patients fat? Oh no!!! Not anymore.

'Ma-am, I think you maybe a wee bit overweight. Your BMI is 45. Ideally, it should be something like 25. Just a wee bit over the top.' - And, the patient leaves the clinic thinking - 'The doctor thinks I am overweight and HE is going to do something about it.' NO...HE IS NOT!

Last week, saw a patient with a BMI 0f 49. Gallstones.

Patient: 'Niggly pains in my back doctor'
Me: 'Your BMI is high.'

Patient: 'Pains not too bad doctor, just annoying sometimes'
Me: 'You are overweight.'

Patient: 'A scan showed gallstones doctor.'
Me: 'You are morbidly obese.'

Patient: 'I smoke and have diabetes. Do you think that's what's causing the pain doctor?'
Me: 'YOU ARE FAT! So fat that in a few years time your knees wont be able to carry you anymore. That is if you make it to 50 with the diabetes and that smoking.'

Patient: 'I am waiting for an appointment with the Weight Management Clinic.'
Me: 'What are YOU doing about your health?!'

Patient: 'I don't eat that much you know!'
Me (my brain banging itself against a wall that is my skull): 'Well, how much does this pain affect your life?'

Patient: 'I think I will feel a lot better if I had an operation to remove my gallbladder. I can't eat a pack of crisps without these niggly pains coming back you know.'
Me (feeling a trickle down my ear that is my brain melting down): 'You could die in the process. No - no operation for you. Go away and lose some weight. Shoo Shoo...'

Followed by a very emphatic dictation to the patient's GP and weight management clinic, which will be duly toned down by the secretary into Times New Roman on A4.

http://www.dailyrecord.co.uk/news/scottish-news/2008/03/17/doctors-ask-vets-to-scan-fat-patients-86908-20353642/
http://www.thisislondon.co.uk/standard/article-23416709-details/Hospital+floor+can't+take+fat+patients+weight/article.do
http://www.timesonline.co.uk/tol/news/uk/article593126.ece
http://www.timesonline.co.uk/tol/news/uk/health/article712496.ece

Back again - ?wiser ?cynical

2008-04-04T22:42:00.002Z

wtf. Its been a year since I last posted. A lot has happened and a lot more hasn't. I still suffer from verbal constipation when it comes to blogging. Maybe it is the overwhelming desire to post 'good' stuff. But, wtf. A lot has happened and I couldn't care less.

Have turned 30. A big F for that!

Don't have a job after a few months - hey wait a sec - that is not really news is it?

Wikipital has died 'in utero'. RIP naive, 'save-the-world' do-gooder. Have taken up more projects than I have good teeth.

Have not killed a patient yet - but have come pretty close to it once this past year. Someone was watching over the bloody lucky patient or bloody lucky me that day. And did I say 'cynic' somewhere.

And, I cant quite remember why Slashdot is listed on the links on my blog. Cant remember when I last visited it. WTF has been happening in my life.

Anyway, I maybe back at blogging - or maybe not.

Bollywood Movies on Goolge Video

2006-12-07T09:08:00.000Z

I was browsing Google Videos today and clicked on the 'Top 100' link and chose 'India' to see what was being posted by my countrymen. I was very surprised to find two videos that were over 2 hours long at the first and third positions. The first one had 158,314 views and the third one had 33,453 views. They both turned out to be complete Bollywood movies. Now, if this isn't copyright infringement, then what is. Google does not have an easy mechanism to flag a video as copyrighted material. Check out this page for yourself to see what I mean.

One of the videos was posted by a site called megaload.com. (no hyperlink here to save you the trouble. Take my word for it when I say...) It turns out to be a parked domain with only a zillion pop-up ads to boast. Come on guys...if you want to watch a movie, pay for it. But, just look at the number of views and the ratings.

I bet most of these have come from outside India. I live in the UK and it is not very often that you get Bollywood movies screened at a cineplex near you. And, the DVDs are always a year late. But, excuses apart...I think somebody is going to pay for copyright infringement...or do they ever?!

And, like any sensible person using Google, the next natural progression was to search for Hindi movies. This is what I found. Google speaks louder than words!!!

All images are screenshots from Google Videos and all trademarks, etc. belong to their respective owners. (Just in case!)

En Route to Ethiopia

2006-10-19T07:27:00.000Z

I am making this entry from an internet kiosk in Amsterdam Airport. I am on my way to Ethiopia as part of a team from the Southern Ethiopia Gwent Health Link. After a month of hectic preparation I am hoping that I can contribute to this visit. I will be teaching health professionals in Ethiopia how to make the best use of computers in medicine. The primary focus is going to be E-learning. We are hoping to get them to interact with us more via the forum that I have created at the link's website. If I get one out of every four attending the course to register on the forum and start posting, then my visit would have been a fantastic success. Well, of all the zillion other problems that they have, I wonder if they will have the time to sit in front of a computer and bother to post to forums. We will know in a few days time.
More from Ethiopia.

Laparoscopic Cholecystectomy

2006-09-18T20:23:00.000Z

My best time at a laparoscopic cholecystectomy yet - 36 minutes flat. My previous best time was 45 minutes. And, no I wasn't racing against time. Honestly. It is always a bad idea to race against time, especially in elective surgery. I just got lucky this time. Like a boss of mine said, the more operations you do, the luckier you get.

Tamil Translation Messages for Mediawiki

2006-08-21T23:24:00.000Z

I have created a new MessagesTa.php for the Wikipital project. This contains a larger number of translated messages in tamil than the default file that ships with MediaWiki 1.7. A lot has been derived from the work done for the Tamil Wikipedia but I have added a considerable amount of stuff. This file, I hope, will be very useful for all Tamil Wikis. Remember to replace விக்கிபிட்டல் with your own project's name or {{SITENAME}} before you install using this file. You can download this file from here. While at it, also check out விக்கிபிட்டல். Please link to this blog to download the file until I upload it to a more permanent location. I don't want people cursing me for a broken link to my googlepages.

தமிழில் விக்கிபிட்டல்

2006-08-21T23:14:00.000Z

Wikipital is now available in Tamil. There are a few issues that I will iron out over the next few days. It took a good deal of work to get the MessagesTa.php file in order inspite of the fact that many of the messages have already been translated for the tamil wikipedia project. The completed file has got a much larger number of translated messages than the default tamil translation file that comes with Mediawiki. I am sure this will be useful for numerous Tamil Wiki projects.Check out my exclusive entry to download this file.

விக்கிபிட்டல் உடல் நலம் மற்றும் மருத்துவம் சம்பந்தப்பட்ட தகவல்களை இலவசமாகவும், கோட்பாடின்றியும் அளிக்கின்றது. கூடிய விரைவில் மற்ற மொழிகளிலும் விக்கிபிட்டல் உருவாக்கப்படும்.

Signs, Signs Everywhere

2006-08-18T00:24:00.000Z

How many signs do we see everyday on average? Little boards telling us where to go, what to watch out for, where to tread carefully and a lot more. Shops, roads, cars, buildings - there is a signboard in every one of them. I work in a hospital and have for the past 18 months taken exactly the same route to the surgical ward on level 3. I am curious to see how many signs my eyes glance at everyday. There are plenty - but have I ever read them?

Let me try and recollect. 'Cosultant Obstetrician On Call', 'Maternity...???', '???Access to Theatres, ITU, CCU Only', a board on the inside of the lifts listing out all the wards and what floors they are on, 'Ward 3/4', '??Access for Staff Only', etc. I am sure that these are only a fraction of the actual number. I will pick up a dictaphone tomorrow and actually read them all into it as I walk the walk.

Oh, and on a completely different note, I completed uploading the tamil version of Wikipital. It is now live at http://ta.wikipital.com. It took awfully long to complete the translation. Thanks a lot to the guys who had already done a lot of the work for Wikipedia.

Wikipital is Live

2006-08-04T17:38:00.000Z

Wikipital is finally online. Thanks a lot to my brother-in-law, an SpR in Paediatrics, the site is online and content is increasing by the day. I am still working on the translation files for Tamil, my mother tongue. That should go live hopefully within the next fortnight. I have used Mediawiki to do this. More later.

The site is at www.wikipital.com

The Leaking Aneurysm

2006-07-07T22:59:00.000Z

The worst of partialities is to withold oneself,
the worst of ignorance is not to act,
the worst lie is to steal away.

- CHARLES PEGUY
(1873-1914)

A few months ago, I was faced with an exceptionally difficult situation. It was fairly routine to start with. A 68 year old man was brought into A&E with a leaking abdominal aneurysm. He was in hypovolemic shock and I was the surgical doctor on call. It was obvious that he needed urgent surgery and I spoke to the vascular surgeon on call and agreed to transfer the patient to the oeprating theatre while he got to the hospital.

The patient was on the operating table, fully anaesthetised, 30 mins after I first saw him in A&E. And, he was deteriorating fast. The consultant anesthetist asked me if I had clamped the aorta before. I said that I had never done it before though I had assisted numerous aneurysm surgeries and knew how to do it. I said I probably could do it if the situation was desperate. At this stage, I asked the theatre staff to try calling the vascular surgeon again. But, he had already left his home.
I seemed to have little choice left. I opened him up. He had a very large retroperitoneal leak. I dissected to the top of the aneurysm, found what felt like the neck, dissected down to the vertebrae and applied a clamp. However, it was not effective as I would have expected to be. I struggled for a few minutes and then decided to leave the clamp on and just press hard on the aorta!!! ( I don't think that is a particularly effective maneouvre.) The vascular surgeon came approximately fifteen minutes after I had opened the patient. The patient now had a sytolic pressure of 80mm with full inotropic support. He spent 5 mins exploring the neck and it became clear that the quality of the suprarenal aorta was so poor that it would be impossible to fix a graft to it. And, so we decided not to do anything further and the patient died on the operating table.

I had no doubt in my mind that I had taken the right decision to open him up, even though I had never done this on my own before. However, six months on, some of my colleagues insist that what I had done was too risky for my career and they would attempt no such thing (not even an emergency tracheostomy on a choking person in a pub). I have had a long chat with my boss and am none the wiser now. I am not sure what the law says about all this. But, if there was the slightest chance that my intervention would save the life of a patient who would otherwise die, then I will do what is necessary. And, if I am sued for causing 'death by misadventure' then so be it.

WikiDoctor

2006-06-27T21:52:00.000Z

I know there are plenty of wikis around. I got interested in contributing to the wikipedia quite recently. I had another project on my mind - inspired by a friend. A website for Indian patients. The aim would be to provide simple, reliable, evidence-based, health/disease related information in english as well as every regional language of the country. The lack of a strong regulatory body for the medical profession combined with the collective ignorance of the common Indian public results in some very sad situations. I have often been a part of this in the past - a hapless spectator watching the system fail again and again. The surest way forward in my opinion is to empower the people with knowledge. With knowledge comes enquiry. With knowledge comes the freedom of choice. Patients can question the decisions taken by their healtcare providers. The informed patient is a formidable entity who can take on the medical practitioners whop often try to squeeze every last paisa out of a sick patient and his/her family.

This is where WikiDoctor comes in. A wiki in English and every Indian language, providing healtcare information. Eminent and 'honest' healthcare prefessionals will contribute to its developement. The information provided will be simple and evidence-based. Articles will be written to dispose off myths and superstitions using simple logic and common sense. Maybe a few articles about some of the top healthcare institutions in India.

A wiki dedicated to the dissemination of health related information to the common man in the Indian subcontinent. And, I cant wait for the day when a farmer asks me about the complications of a certain procedure that I propose to do on him. I cant wait for the day when patients in India act as a check on fradulent practices and medical incompetence. And, what better way to start off than start experimenting with building a wiki myself.

So, here is where I have got to so far.

* Wiki software research - complete
* Basic understanding of how it works - complete
* Chosen a wiki software - complete (initially chose pmwiki, then switched over to mediawiki for scalability)
* Installed a local mediawiki server on my computer - complete
* Uploaded an experimental wiki on to the internet - complete with pmwik

Pending jobs
* confirm name for wiki - WikiDoctor sounds good
* customise mediawiki
* translate into my own native language first
* design the first page to allow navigation to all major sections of the site
* create several stubs
* choose a good skin
* buy a domain and host the website
* get people invloved

HOLY S*&! - that is a lot of work!

Experimenting with Ubuntu

2006-06-23T22:17:00.000Z

After much persuasion by my boss, I decided to switch from Suse 10 to Ubuntu 6.06. And, like all proper decisions this was taken at 1 am when I could barely keep my eyes open let alone think straight. I have had Suse for over 6 months now. I spent a month installing it. That is right. Just under a month. For a variety of reasons. First and most importantly, it was my first linux install. Then I had to find all the drivers for my Dell laptop bits. I had quite a job getting and configuring Suse to play mp3 and mpgs. And, I am not even mentioning manually editing the xorg.conf file. Phew!

And what a difference Ubuntu is. It is the easiest linux distribution to install. It took me little over 30 minutes to do. And, it is a breeze. It comes with a prepackaged set of software that should set your computer up to do most daily chores. You get OpenOffice, Firefox, photoediting tools, some games and more. There aren't any fancy complex programs as these are all available on the online repositories. It recognised all my hardware with ease . Broadband and Ubuntu is a linux marriage made in heaven. I downloaded EasyUbuntu which is a wizard to install numerous multimedia options. And, I had mp3, wmv, mpg support all in under 10 minutes.

And, as a thank you to the man who recommended Ubuntu to me, I have decided to try and convert atleast one other person to Ubuntu. So, now wherever I go, I carry a Ubuntu 6.06 installation CD with me. Happy converting!

Buying a new computer

2006-06-21T21:49:00.000Z

Is this meant to drive you crazy? I have spent over two weeks now desperately trying to configure a new desktop for under £600. I thought this would be relatively easy. I only had two non-modifiable factors: first, it would be a AMD dual core processor based system and second, it will run only linux on it. I decided to build a system to run only linux for a number of reasons. The most important is out of respect for the man I work for who has taught me a lot - in surgery, life and computers. The next reason is that it will force me to learn and become good at linux. And, this has huge implications when I go back home and start running my own hospital. A linux based network would be infinitely simpler to manage and cheaper.

I have so far decided on the processor (athlon fx x 2 3800+) and the motherboard (an asus one with the nvidia ultra 4 chipset). I am yet to decide the rest of the stuff and hopefully should have ordered all the components before the end of next week. And, for the next 10 days I will spend a lot of time staring at online catalogs. So much for the pleasures of building my own computer.

My first wiki entry

2006-06-15T19:31:00.000Z

Today I made my first entry into the world of wikipedia. I operated on a lady with an irreducible, painful femoral hernia a couple of nights ago. She did not have any clinical evidence of obstruction or strangulation. I chose to use the infra-inguinal approach as this is much simpler and a much lesser procedure. She had a bit of omentum incarcerated in the hernia. I excised this and fixed the hernia using sutures.

My consultant had a little chat (the kind you get when you have done something silly) the next day. He thought I should have used the high-approach, so I would have had better access to the abdomen. This would have been useful if she had needed bowel resection. I was planning on opening the lacunar ligament to get bowel out through the femoral canal. This, he said, was not ideal.

So, I decided to read up and was looking on the internet and came across a wiki stump. And, I decided to add some stuff to it. I hope to add to more medical articles in the coming days.

The Third Arm

2005-09-15T08:34:00.000Z

Plenty of interesting stories that bring back memories of my home and training. I think I was a first year resident when this happened. I was sat in trauma when a young man was rushed in. He had fallen in the path of a train and was extremely lucky to be alive. His arm (I dont remember which side) was amputated at the level of the mid-humerus (that is the bone in the upper arm). All we could do was to stabilise him, tie of the blood vessels in the stump and dress the wound.

A good half-hour later, two men came into trauma very agitated enquiring about this patient. I was attending to some paperwork and pointed in the direction of the patient's bed. However, something about one of these men was odd. He had his arms folded across his chest and for a moment I did not realise what was odd about that.

Then it struck me. Folded across his chest were not two but three arms. He was cradling the amputated part of his brother's arm that he had picked up from the tracks in the hope that we would be able to put it back together. But, unfortunately, the train had run over the elbow joint and the arm was missing a good 10cm chunk that was probably stuck to some wheel of some carriage of some train.

I wonder what hopes the man had when he picked that arm up from the dirty tracks.

Daughter, Wife, Mother

2005-09-08T22:16:00.000Z

This is by far the most difficult story to tell. I want to write this someday but I am not sure I am just ready yet.

The Tribal

2005-09-07T21:30:00.000Z

7.45 am Friday 2003
Trauma is usually quiet in the mornings. We were sat at the main desk, chatting. Very excited casualty porters wheeled in a young man, lying on his side on a stretcher. And, nothing excites them. So, this had to be something big. He was of small build, lying calmly on his left side. He had long hair and was wearing clothes typical of tribals. He appeared to be stable. For a second, I and my junior resident wondered what all the fuss was about.

Then, one of the porters removed the large gauze swabs lying across his right chest. And there it was. The largest laceration I had ever seen. His chest was split open from his right nipple to the tip of his right scapula - all the way to his pleural cavity. I could actually see the collapsed lung through that gaping hole. A sight enough to squeeze the juice out of any surgical resident's adrenals.

We got him into trauma OR and started the routine bits. I went to inform my boss ('the lion', we called him) who was reading the morning newspaper in an adjoining room. He, in his typical style, feigned irritation at being disturbed over such trivial a matter as a split chest. He came, took one look at the chap and said: "Well, what are you girls gawking at? Stitch that hole up and don't forget to put a chest drain in. I will be in outpatients if you need me." And, he left.

So, that's exactly what we did. I put my hand into his right chest, guided a chest drain in, washed out the pleural cavity with saline and stitched up the intercostals and the skin in layers. My junior resident (I will call him K) was keen to get some stitches in. But, I was selfish and did not want to share this one with him.

He improved dramatically over the next couple of weeks. However, the idiot refused to have his broken arm fixed by the orthopods (he had non-union due to soft tissue interposition) and instead decided to sought some silly traditional treatment. I saw him a few weeks before I left the hospital, on the verge of tears, his arm in bamboo sticks, with another 'joint' between his elbow and his shoulder. I referred him to the orthpods. .Don't know what happened to him after that. He had a wife and a very young girl child. (And his family upset the nurses on the ward by doing a tribal dance on the ward when he got better!!!)

How did it happen? He was sleeping on the roadside when a sheet of metal came of a vehicle carrying them while turning a corner and landed smack on his chest.

The Beggar Woman

2005-08-21T23:55:00.000Z

I don't know how many people even gave a second thought about this woman. I am sure there were other people who have wondered like I have. She was in her late-fifties or early sixties. Fair-skinned. She looked like she had, at some time in her life, been well-off. It just showed in her face. There was something about her - she looked kind, dignified. In any other setting, she would have easily been a friend's mother - the kind of person you meet when you visit your friend's home and who offers you coffee and snacks.

Only this woman was begging on the streets, in front of one of the busiest restaurants in one of the busiest cities of India. She could not walk. She was always sat there with her legs straight in front of her. So typical of an old Indian woman. She did not have any of the cunning of the professional city beggar. She was not aggressive. She was not demanding. She just sat there, pleading sad eyes, hands that would occasionally rise, driven more by hunger than by her will. There was an indefinable dignity about her. I have been tempted to speak to her so many times, to find out who she was. I was certain that she had been abandoned there by her sons or family. I never got around to speaking to her. It is just one of those things that stick to your memory, because of its incompleteness and because it shows, how all those times when I wanted to talk to her, I have always given myself excuses about other, more important things to do. I wonder if she is still alive. I wonder if her family took her back. I wonder who she was.

But, I did not have a minute to talk to her then, so why ponder now! It is just the strong emotion it evokes every time I think about her. It makes me think of everything else in my life that are important enough for me to pause and take in but never do.

Two young men and One green venflon

2005-08-19T22:11:00.000Z

I had just started my third year of training in surgery and my friend and colleague was nearing the end of his training. We were covering trauma that Friday night and it was 3 am. A van driven by a drunken driver had ploughed into a group of young men (possibly drunk as well!). Two had died on the spot, one was dead on arrival and we got two badly injured men in their early twenties. Both had similar injuries – head trauma, pelvic and femoral fractures. And, both were in hypovolemic shock. It was difficult to say which one was worse. I took one patient and my friend took the other and we set to work.

Right, airway- happy for the moment; breathing – ok; circulation – zilch. Neither had a recordable blood pressure. ‘Wide bore cannula, please!’ And we got one green venflon and a handful of blue venflons to go with. If you have ever been punched in your stomach and kicked in your balls at the same time, you will know exactly what we felt that day. Two young men in shock and one 18G venflon!!! Well, my friend’s patient showed some signs (I don’t know what they were) of being better than mine. So, he got the cath and shoved it into his external jugular – because that was the only access available. While, I started a series of futile cut-downs. (We did not have any CVP lines, either – in case, you were wondering) I still remember clearly how a anxious + curious + tired + awestruck house officer held a torch light to my patient’s groin as I cut down to the long saphenous vein to pass a large drum catheter into his femoral vein. (I don’t think many surgical trainees these days have seen a drum catheter at all. It is a wide bore tube that is wound on, well, a drum. It is used as a peripherally placed central line.) We weren’t thinking whether it was worth the effort or if this guy was going to make it. We didn’t care. We didn’t want him to die because we hadn't tried hard enough. But, by the time we got fluids and blood into him, he had been hypovolemic and hypoxic long enough to go into irreversible shock.

He died within the next hour. And my friend’s patient died a few hours later. And both were men in their early twenties. And the next day morning we found a stock of central venous kits in one of the cupboards and the duty nurse had not known where to look. F^$#!

Trauma

2005-08-19T21:36:00.000Z

Just back from work. Had a 70 year old chap involved in an accident. His motorcycle was bumped off by a car. But it was great to see everybody work so efficiently....organised chaos was what it was. He has got some really major injuries. I hope he makes it. I have worked in trauma before..In one of the busiest hospitals in India. Has always made me realise that everything in one's life can change in a snap. We have seen distraught families, wifes, daughters, mothers and husbands, sons and fathers devastated by accidents. The story is typical. Somebody goes to work. Doesn't come back in time. And the family gets a phone call(if they have a phone) or a kind autorickshaw driver calling at their home to tell them that their son/whoever has been in an accident and has been taken to such and such hospital. I would have expected 3 years of such experiences would make one numb to the emotional side of things...But it never does. One can only do so much to hide emotions and to appear strong. Clinical detachment it is called.

And my first picture

2005-08-19T06:32:00.000Z

Still experimenting!!!

Now on RSS

2005-08-18T22:27:00.000Z

Now on RSS feed

Have just managed to put the whole thing on RSS…I am not entirely sure why I have done this! Well lets c if it works

Here we go....

2005-08-18T17:19:00.000Z

My very first blog.....who is going to read this....just me, i guess. I suppose most blogs start like this. But honestly, how would I know. I haven't really read that many blogs.

I am a surgical trainee. From India. Now in the UK. Do you get the idea? Well, before you go 'tsk tsk', let me tell you that its not as bad as some think it is. (And, i am already assuming that somebody is reading it!)

7 hernia ops and an equal number of endoscopies in one week. Fully satisfied appetite and i am now like a huge python or an anaconda that has just swollen a deer whole. Most starved surgical trainees will know what i am talking about.