Crisis!!!

My father and brother have both ingested cyanide.

Please read the info-graphic below while I have a meltdown.

How did this happen? I spent most of this morning pacing up and down... asking myself this question, asking my father this question and yelling this question out to the multiverse in general.

My aunt had sent a food supplement* from abroad... and my dad mistaking it for a fruit snack, ripped open the packet and was liberally offering it to all at home. I declined the first time I was offered, and the second time, my brother told me it tasted vile and was best avoided.

On a chance phone call with my aunt, I find out that this product is actually meant for a relative with cancer, that the active ingredient ("vitamin" B17) is actually cyanide. In addition, there was a warning message on the back of the pack stating "eating 2 or more kernels can cause acute cyanide poisoning".

GAHHHHHHHH!!!!!

By this time my dad has eaten six, my brother two and the Baby's nanny had popped three in her mouth but spat them out because of the taste.

From that moment, I was hyperventilating and in a total frenzy, reading up on the internet, making frantic calls to the National Poisons Centre and blasting my dad for not reading the package or the instructions that they were meant for our sick relative.

Happily, none of them had any acute effects, but I loaded them with vitamin B12 (antidote, usually given by injection) and will be getting their blood tested for a couple of weeks and keep an eye out for nasty effects.

What gives me the shivers is that I could easily have eaten it and it would have passed on to the little Bumtrinket, with disastrous effects. We would have known nothing until she suddenly stopped breathing or her kidneys packed up or something. I was shaking all the time and didn't stop until I burst into tears, hugged her and let all the misery and fear out.

Today's lesson: always ALWAYS check what you eat, especially if it is something new or unfamiliar and keep yourselves safe!

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* I am not naming it for ethical reasons, i.e. someone may be tempted to try it

How NOT to furnish a baby crib

Cuddle overload!

During my baby shopping days, I went a little crazy with the cot furnishings... bumper pillows, bolster pillows, ordinary pillows, quilts, blankets, cot sheets, draw sheets and lots and lots of cuddly toys. A few days after the cot was lovingly decorated, I received an email with the updated guidelines on preventing SIDS - Sudden Infant Death Syndrome.

Although there is quite a kerfluffle about SIDS in USA, Aussie and Europe, we rarely hear about it in Asian countries. There are many reasons for this... all of them worthy of some consideration.

One is that in SL, small babies are almost always with their mother/grandmother and generally under supervision. I feel antsy about leaving the little Bumtrinket alone even when I go to brush my teeth. I would never dream of having her sleep in another room... as it is, her crib is right next to the bed, and she is only a couple of feet away from me. I can touch her when I want to, I can see her movements and I can hear her breathing. Studies have also shown that close proximity to the parent (mother) helps regulate infant breathing. I think there is a cultural/economic aspect here as well since the vast majority cannot afford the space for a separate sleeping area for a baby.

The other, of course, is breast feeding. Now this is also supported by traditional and cultural values and has been the rule rather than the exception in ancient SL. Exhibit B below is a woodcarving from the Ambekke Devale, and stolen from here.

During the 1970's there was heavy advertising by the milkfood companies, promoting infant formula but thanks to research and heavy lobbying by Prof. Priyani Soysa, Prof Dulitha Fernando, Dr Hiranthi Wijemanne and team, legislation was passed not only to ban marketing (Sri Lanka Code for the Promotion of Breastfeeding and Marketing of Breast Milk Substitutes) but also to allow mothers maternity leave in order to feed their kids (Maternity Benefits Ordinance). Since 2005, there has been overwhelming research evidence that breastfeeding reduces the risk of SIDS.

Source : Unicef, 2009

Our traditional choice of bedding is another factor. Babies sleep on mats or in makeshift cradles made out of a saree or bed sheet. No toxic foam, no soft pillows, good ventilation. Also not much chance of being placed face down as in the West... less chance of suffocation.

Unfortunately, several studies have noted an increase in SIDS in Asia, which is attributed to adopting "Western" practices. In Sri Lanka, opinion is divided as to whether the rarity is due to good practices or due to under-diagnosis.

The American Academy of Paediatrics parental guide to safe sleeping can be viewed here.

My safety tips would be as follows

1. Use a coir (kohu) mattress, with a cotton lining. These are natural, no toxic products like in foam mattresses, allows air to circulate and is cooler for the baby. Make sure it fits firmly in the crib.

2. If you're using cot bumpers along the sides of the crib, make sure they are firmly secured (check every day or even more often).

3. No loose bedding or bits of cloth/blankets on the crib.

4. No pillows.

5. No soft toys.

6. Burp the baby well, hold upright for 10-15 minutes afterwards, and then lay the baby on his/her back (not on tummy).

7. Any "tummy time" must be supervised.

8. If the baby is sleeping on your bed, make sure you/your partner don't fall deep asleep and roll over or squish the baby.

9. Breastfeed, breastfeed, breastfeed.

10. Make sure baby's immunization is upto date.

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Edit:

11. Sleep in the same room as baby

12. Supervise constantly

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Sources:

Department of Census and Statistics (2003) Sri Lanka Demographic and Health Survey 2002, Department of Census and Statistics, Sri Lanka: Colombo.

Fernando, R & Abayasinghe, N (2008) Sudden infant death syndrome/unexplained infant deaths in Sri Lanka, Medicine, Science and the Law, 48, 4, pp. 325-328.

Nelson, EAS, Fujita, T, Sawaguchi, A & Knight, B (1998) Is the incidence of SIDS increasing in Asia? International Journal of Legal Medicine, 111, 5, pp. 278-280.

Reid, GM (2006) Sudden infant death syndrome (SIDS): Microgravity and inadequate sensory stimulation, Medical Hypothesis, 66, 5, pp. 920-924.

Unicef (2009) Infant and young child feeding programme review: case study - Sri Lanka, New York: Unicef.

To C or not to C

So yeah, I had a C section. There were many reasons, and I won't be going into them here. It's not easy to decide between a normal vaginal delivery (NVD) and a C section (CS). NVD is the "natural" way to go... but also involves torn vaginal walls, a lot of pain, bleeding etc. Unless you plan on giving birth in a barn, it's not truly "natural" either... drugs such as oxytocin are given to kick start and maintain the contractions, and pethidine or even an epidural is given for the pain. This is because :

a) no woman should be in unnecessary pain (unless she wants to)

b) prolonged labour means loads of risks to both mother and baby

Almost always, an episiotomy cut is done, effectively widening the vaginal passage in a manner that will not affect the muscles controlling the bowel. So you end up with stitches, whether you like it or not.

CS is basically abdominal surgery... you get sliced open, there's a lot of blood and pain once the anaesthesia wears off.

NVD is safer for the mother, riskier for the baby. But it's better for the baby because the brain gets "moulded" and extra water is squeezed out of the baby lungs. CS is riskier for the mum, but the baby is born all pretty and rosy, not having gone through the trauma of being squeezed through a bony passage. NVD is unpredictable, you never know what might go wrong at a god-awful hour when no doctors are immediately available. CS offers a measure of comfort for the control freak.

I know a lot of people think that mothers going for C sections have it "easy". A couple of months ago, some of the Sinhala blogs on Kottu were discussing if mothers who deliver "normally" (NVD) love their children more. This offended me even then... how can pain be a measure of affection? I can't compare the two, since I didn't go through both*, but I can assure you that the C section is by no means easy.

The actual delivery is like the proverbial piece of cake, but afterwards, the mother has to deal with the contractions of the womb, since it is now going through the process of getting back to size (this happens naturally with NVD and is mostly complete by the time the baby is out). The process is helped by hormones that are secreted in response to feeding.

The difference? After a C section, the womb has a large surgical cut along the lower part... so with each contraction, the raw edges are squeezed tight against each other.... over and over again. For 2 days, every time I fed my child, I could feel the contractions one after the other, pain rippling through my insides in relentless waves. Sometimes it would make me moan with agony, tears dripping down onto the innocent little face nestling at my breast. The nice doctors offered me pethidine, but I refused, because I knew it would make the baby sleepy and make breast feeding more difficult to establish. And there's the pain from the surgical skin cut as well... a burning red gash across my lower belly.

I know it's not a competition, but on behalf of all the much maligned mums who go through a CS, I'd like to place on record that it's certainly not an easy piece of cake to eat!

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* I need to ask my Sis-in-law or my friend T who both went through hours of labour and then had to have emergency CS, yipes!

A relatively short guide to pregnancy for the completely clueless

A couple of my commentors were kind enough to say they learnt a lot about pregnancy from my humble posts, and some even followed up with more questions. I realised that we have access to very few sources about actual health experiences, pregnancy related or otherwise.

When I worked/trained at DMH and Castle Street, I used to spend a lot of time chatting with the mums-to-be and giving them advice on diet, exercise, what to expect in the labour room etc. Quite often though, I'd feel like a complete fool, because it was all "book-learnt" and never from actual experience. In fact, I had a 17 year old girl (let's ignore the underage bit for the moment) tell me off in the labour room after asking me how many kids I had. Her scathing comment went along the lines of "you haven't a clue about what you're talking about and what I'm going through, so be quiet and concentrate on getting this thing outta me!"

So this is one of the Bibles for our Ob/Gyn appointments.

Image from here

So as soon as the test came positive, I blew the dust off my copy and started thumbing through. My reaction was one of deep disgust, since (although it was obvious) everything was clinical and from the point of the doctor, not from the point of the mum. In addition, none of those much revered "Ten Teachers" were female... and the book was summarily discarded.

My cousin then lent me her copy of this.

Image from here

It's a bit wordy, but it became standard bedside reading and it includes chapters on pregnancy planning, week by week update about the baby, labour and best of all bits for the proud papa to read.

I'm not going to reproduce the book here, but just include a few highlights from my own experiences (wow, it feels so good to say that... am not a pregnancy-noob anymore!)

How do you know you're pregnant?

I've mentioned several times that I figured it out a couple of weeks before my period was due. One reason is that I'm frequently invited to do a lecture on the "physiological changes in pregnancy" to nursing students, paramedics etc., so I knew what to look out for!

It helps of course, if you're planning to get pregnant and have thrown your stash of pills/condoms out of the window. There are many ways to time doing "it", including counting dates off a calendar, checking your temperature daily for subtle changes. I personally recommend just getting rid of the... um... preventives and having a lot of relaxed fun with your significant other, but of course, to each his own.

The first thing I noticed that I was uncharacteristically hungry all the time and felt quite bloated. Then my boobs started to hurt (gah!!) and I actually went to work bra-less for a few days (no one notices under a saree anyway). Then came the need to pee all the time. By then, I just knew.

Of course the only way to be completely sure is to do a pregnancy test. The urine test (dipstick) costs between 40-50 rupees at the pharmacy and is simple to use... just stick it for a few seconds (5-15, it varies from brand to brand) and wait for the results. It's good to have a wide mouthed container (e.g. marmite jar) handy for moments like that. Note however, you need to be at least 5-6 weeks pregnant (i.e. about 2 weeks after your period is due) for this to be reliable, so any time before that, you may as well stir your urine with a hairpin.

Image from here

Unfortunately, when my test came positive (yay!) I noticed that the strip had expired (it was a remnant of my days working in the female casualty wards). So we went and got a blood test done the next day. The blood test is a bit more reliable and can read positive as early as 3 weeks after your last period. There are 2 methods, one tests just positive/negative, while the other gives the actual hormone levels, so that the doctor can estimate how far along you are... this is useful if your periods are irregular. The test can cost between Rs. 1500/- to Rs. 3500/-, and if you're doing it, I would recommend one of the more established/reliable labs.

To be 100% sure, an ultra sound scan is needed, and this gives additional information like where the pregnancy is (some conceive outside the womb), whether it's a singleton or multiples (eeek!) and a more reliable estimate of how many weeks the baby is. The test can cost between Rs. 1500/- to 3,000/- depending on the hospital and doctors charges. You'd also probably need a referral or at the very least a positive urine/blood test, before you saunter in and ask for a scan!

Planning for a pregnancy

Of course, it's always better if you can do this (cue flashbacks of all catastrophic-unwanted-unexpected pregnancy movies). If you like, you can have a pre-conception chat with a doctor/nurse/midwife/nutritionist and find out how you can optimise yourself for the baby. This is very important if you have a medical condition needing long term treatment.

This means having a chat with your significant other, checking your blood sugar, blood pressure and haemoglobin, avoiding smoking (even second hand) and alcohol, getting a dental check up etc. It's also good to start on the vits: vitamin B-complex, vitamin C and folic acid. In fact, I'd recommend them to any young female of reproductive age because, apart from being good for the teeny tiny baby, they give you nice healthy skin and shiny hair. You can also take iron and calcium if you like, but this can be saved for later in the pregnancy as long as you have a healthy diet.

AVOID the vitamin A supplements and foods that have loads of it like liver and cod liver oil because it can cause birth defects. Some acne medications contain retinol related compounds and should be avoided as well. The usual amounts of vitamin A obtained from yellow fruits and veggies are perfectly adequate and necessary for mum and the baby.

If you HAVEN'T planned and still find you are pregnant, no need to get all worked up and panicky about bygones... just decide to take it from there... :D

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Hmmmm... I just realised that the "relatively short" in the title is totally misleading. I'm not even sure if anyone wants to read all these details. Anywez, await part 2 soon (unless the Baby arrives, in which case, await part 2 later!)

Snake in the grass!

Literally...!

Image from here

A few days ago, hopping out of the car and striding ahead to the house in front of Mum, I notice a black and yellow shoelace lying on the path. I stooped to pick it up and realised that

a) No one at home wears lace up shoes anymore

b) Shoelaces don't taper off towards one end

I shrieked and jumped back as my brain processed the triangular head with the wicked eyes and the familiar mottled markings of a baby Russel's viper, and my muscles worked on a survival instinct of their own. The fellow was tiny, compared to the monster in the picture above, actually looked more like this.

Panic and pandemonium reigned for a few moments and with the help of the neighbours, the offending critter was hacked to pieces... I didn't watch (too busy with a mini trembling fit inside my room), and although I am all for the sanctity of life and live and let live mindset, I was not in the mood to suggest catching it and sending it to the snake lab of the Colombo Medical Faculty (where the snake venom is milked for experiments).

Daboia russelli is one of the deadliest snakes in Sri Lanka... the venom wreaks havoc on a number of body systems, messes up the clotting, poisons the liver and kidneys, causes dangerous heart rhythms and can damage the nervous system, i.e. you're pretty much screwed. Antivenom is available, but it's a polyvalent antivenom (common remedy for several types of snake bites) that's is imported from India. Although quite effective, it causes unpleasant allergic reactions - fever, chills, rashes, itching, clogged throat, and in about 40%, anaphylaxis, which is life threatening. In fact, a patient once said to me "Doctor, I died and went to hell twice and crawled back. Once when the snake bit me, and once when you gave me the injection".

Dr. Asitha de Silva and his team recently published an article in PLoS Medicine, which will revolutionize how snakebite is treated in SL as their method can reduce adverse reactions by over 40%. Hurrah for the doctors who are doing something to take snakebites out of the "neglected disease" category!

According to the Annual Health Bulletin, 39,321 patients have been admitted in the year 2007 to Government hospitals following snakebite. Most are probably from non venomous snakes, but that's one of the biggest problems we face - difficulty in identifying as the snake is often not brought. Of course when they DO bring the snake, that can result in complications as well. I have my share of snaky stories... just like most of the other docs out there...

Once the patient was accompanied by a 3 foot long live cobra in a gunny sack, which was jumping around like crazy and obviously enraged. The relatives kept egging me to peer inside the sack and confirm the identity and I kept saying no effing way. Finally, they killed the fellow and put it in a glass jar and brought it back to the ward... gah!

On another day when I asked "did you see the snake?" the patient signaled to his friend, who promptly dropped the snake at my feet. I screamed and leaped on to my chair before you could say "fatal haematotoxicity"... and then realized that the snake was, thankfully, dead. That is of course no excuse and I swear that incident is responsible for my crop of grey hairs.

Yet another day a couple of teenage rasthi-types walk in holding a jar that had a coiled up krait. Apparently one of them had felt "something" and then noticed the snake. I was quite pleased since we had a suspect, and careful examination (I went over his skin with a magnifying glass) showed that the guy hadn't been bitten after all. I asked him to stay for 4 hours observation just in case (as he said he felt something), but next thing I know, they had disappeared, leaving the snake filled jar on the floor of the corridor, where to my horror, it was kicked by an unwary labourer and went rolling around the ward! Much frantic scrambling later, the snake (still in the jar) and I were eyeballing each other from opposite ends of the doctor's table. It took another 4 hours to find a labourer who was willing (read - not too scared) to hand the snake over to the Faculty.

So what do you do if, gods forbid, you or someone with you is bitten by a snake?

1. do not panic and run around (muscle activity = the venom will be absorbed faster)
2. remember that most snakebites turn out to be harmless
3. do not cut or suck at the wound, don't apply ice
4. wash with soap (if available) and clean water
5. remove anything that might constrict a swelling limb : bangles, rings, watches etc.
6. immobilise the limb, if possible at a level below the heart. If it's a leg, splint/tie it to the other leg, or use anything handy (e.g. an umbrella) as a splint. The victim would need to be carried, which is all the better since that minimises muscle activity.
7. don't tie tourniquets (reduces blood flow to the whole limb and may make things worse)
8. don't give aspirin or ibuprofen; paracetamol may be given if pain is severe
9. take the victim to the nearest government hospital - most are equipped to deal with snakebite
10. don't waste time searching for or killing the snake. Even dead snakes can give a "reflex bite" and you may become the second victim!

Stay safe, all!

Health for all?

I was pretty annoyed recently when I read of a statement by the Minister of Health that alcoholics should be denied treatment by the public health sector. That sanctimonious ... um... person...!!! Who is he to decide who gets treated and who gets denied? And then my second thoughts kicked in. I have been guilty of thinking the very same thing, not once but a hundred times, not just about alcoholics, but also of smokers and several others too.

It's hard to think charitable thoughts when an alcoholic is wheeled in as a "stat" admission, usually semi-conscious, vomiting blood, delirious and uncooperative. I confess I usually suppress a groan of despair at the sight of them... and with good reason. Almost invariably it results in a lot of running around, organising blood, plasma etc. etc. Especially at night where there is only one doctor and two nurses in a ward, this usually means that other patients might get neglected. Drugs and injections are not given on time, and other admissions are not seen to, because everyone is hovering around the alcoholic dude.

You see, the chronic alcoholics are LOUD. They are dramatic - swollen bellies, hallucinations, screams, blood and guts. They are critical - they may go into cardiac arrest at any time. And when (not if) they do, they are so obese, that it is near impossible for me to clamber on to their beds to deliver effective CPR. An additional thing I've noticed is that somehow, the relatives are the most demanding I've come across, the ones who are quick to make a fuss if things aren't done NOW.

And in the melee it is easy to miss the young dengue patient whose blood pressure has dropped, or the guy with the heart attack who has developed a rhythm disturbance of the heart, or the guy with leptospirosis whose urine output has dropped. When we do find out, it's because they too have progressed to a critical stage, when it could have been nipped in the bud. And that's not fair.

Then there is the expense. It's ironic that the patients with chronic lung disease due to smoking and chronic liver disease due to boozing cost the state more that the innocent johnny on the next bed who has done nothing to deserve his illness. Spiral CT scans, high resolution CT scans, ultra-sound scans, endoscopy, radiographically guided biopsies, inhalers, drugs, blood and blood products. Factor in the cost of hospital stay, meals, linen etc., which are also borne by the state. And then the health care sector runs through its allocated budget, and it is the other poor patients that bear the brunt of it. That's not fair.

You have to admit that the diseases are distressing, painful and associated with the hopelessness of knowing there is no cure. Yet because of the whole psychology behind short term rewards vs. long time penalties, very few cut down on their consumption, despite begging and pleading by the mothers, wives and children, and despite dark predictions by their doctors. I strongly believe that addicts must take responsibility for their actions, but there's always that niggling knowledge that for a person who is physically/psychologically addicted to something, the choice to stop is that much harder.

And this is where I blame the people in charge - officials who issue liquor licenses, politicians who extol the revenue brought in by taxing alcohol and tobacco but who are too short sighted to see the costs of a diseased society. I blame policemen who consort with brewers of moonshine in exchange for bribes, and officials who exploit legal loopholes. It has been scientifically proven that increase in taxation and ban of advertising and ban of public consumption are effective measures in controlling tobacco and alcohol. And yet we have this. No perfumes or jewelery; no watches, electronic gadgets or chocolates. Just tobacco and alcohol, sold duty free... thithata matha.

I am no saint. Even though I have never spoken it out for a patient or relative to hear, I have often thought viciously to myself "yes, go ahead, drink all you want, just die at home instead of landing in the small hours of the morning and ruining my sleep" (remember in SL, we don't get the following day off after a rough night on-call). To deny those thoughts is to be dishonest and blind to my own failings.

In spite of all that, we should never lose sight of the fact that we are dealing with human beings. That denying healthcare to anyone - whatever their failings may be - is unethical, unacceptable and a betrayal of the compassion we all need to cultivate within ourselves.

These people, I tell you....!

So some time ago, this guy walks into the hospital complaining of tummy pains and constipation, and is sent over to the casualty unit. After giving the same story to the examining doctor, he reluctantly agrees to a rectal examination. The doctor is quite peplexed to find first a sili sili bag, and then a hard immovable object stuck "up there". Frantic x-trays were taken.

Picture quiz... can you guess what this is?

After stern questioning by the senior doctor, the patient mumbles something about a perfume bottle, and says he was assaulted by rouges (brandishing said perfume bottle) who had also robbed his house the previous night. Various methods were tried in order to get the bottle out... including a pair of obstetrics (delivery) forceps hastily borrowed from the nearby OBG ward, but to no avail. The patient was finally wheeled to surgery, sliced open and relieved of the offending object.

Of course, this account won't be complete without mentioning a famous story by one of my Profs. who never fails to regale successive generations of medical students with his wit and wisdom. Apparently while examining a similar patient, he had noticed a faint buzzing against his fingers... at which point he had asked the patient whether he wanted the vibrator taken out, or whether he simply wanted the batteries changed! After the operation (or so the Prof. claims) the vibrator had gone mysteriously missing. He then goes on to say he strongly suspects the ward nurses to have filched it for their own diversion...! (Of course, all these is said in a spirit of humour, esp. when Ms. A, one of the senior nurses, is present. She usually laughs and shakes her head - I think she has heard the story far too often to react in any other way!)

According to the 25th edition of A Short Practice of Surgery by Baily & Love, "The variety of foreign bodies that have found their way into the rectum is hardly less remarkable than the ingenuity displayed in their removal". It then goes on to describe the discovery and removal of turnips, pepper-pots, glass tumblers, screwdrivers and live artillery shells, just to name a few...

Ah well... and life goes on....

Luck

There was once this guy, a victim of a blast, not too long ago.

As the fatal explosion occurred, shrapnel entered his body, like it did to others around him. Others died.

The biggest piece that entered his body was a bullet casing that went in through his chest, missed the heart and lungs, missed the great vessels carrying his life-blood, missed the gullet and the windpipe and lodged at the back of his throat.

And all the doctors had to do was to make a small slit and remove it from there.

Two ball bearings also hit his face, neatly entering on either side of his right eye and getting stuck in the skull, leaving his eye - and his vision - intact.

Luck? Good karma?

I don't know... do you?

Physician, heal thyself...

I managed to leave the ward by about 5.30pm during last week's post casualty. Post casualty on-calls always suck... the ward is full, half of the patients are after surgery and invariably the number of patients exceeds the number of beds.

Anyway, it was a quick break - rush to the flat, welcome wash and then grab a bite to eat, a banana and a piece of cheese, as it happened. 15 minutes later I felt a horrible burning sensation around and inside my mouth... rushing to the mirror, I saw horrible ugly red wheals form on my lips and tongue... eeeek!

Okie... food allergy (but to bananas and cheese??) Horrible pictures started swimming through my head. Things like angioedema and Stevens-Johnsen syndrome start off like this. There was no one at home, so, mildly panicked, I rushed off to the OPD with the vague uncomfortable knowledge at the back of my head that whatever this was, it could kill me.

The OPD doctor took one look at me and said "admit!!". So there I was, jittery as hell, clutching the admission sheet while my name was being jotted down into the admission book of a medical ward. The doctor there - an intern like myself, let's call him R - took my history, my blood pressure, listened to my lungs and said with interest that the taste buds on my tongue were so swollen that he could count every single one of them.

And then we ran into a problem. One of the drugs I needed, promethazine (also known as phenargen) would knock me out completely - and I was on-call that night! A brief argument ensued. I had every intention of going "LAMA" (leaving against medical advice) after getting the shots I needed. There were a hundred things to do in my ward... there were at least 2 patients who were "bad". Dr. R said in that case, there was no way he would give me the promethazine because then he would have to restrain me in his ward - I would be in no condition to do an on-call.

After a few minutes of roundabout conversation "but I have to go"... "then I can't give you phenargen"... "but I need the phenargen" we reached a compromise. I would get the non sedating drugs and wait in the ward. He would go and have a quiet cup of tea. We would decide on what to do once he came back.

My symptoms improved somewhat, my BP continued to be stable and the horrible itching didn't spread beyond my face. So about an hour later I signed myself out of that ward. I cajoled the nurses into letting me keep the cannula - after all, if I collapsed, there would be a handy pathway for nurses in my ward to give me the phenargen or whatever.

So there I was, doing a ward round, cannula on my hand as large as life and patients giving me odd looks and asking "Doc what happened to you?" Happily my Registrar took a firm stand and said he'd be on-call instead of me so that I could go home and get a good night's rest.

Which brings me to the hypocrisy of it all.

Had it been someone else asking my advice, I would have snapped that they needed in-patient treatment and that the universe will survive for one night without them. But no, doctors are the worst type of patients. They are stubborn, idiotic and know-it-all. As a general rule they take poor care of themselves - irregular meals, inadequate water intake, erratic sleep patterns and not enough quality time with loved ones/family. In short, they (i.e. we) are hypocrites of the worst sort.

Sigh... looks like I fit pretty neatly into the stereotype!

Daily ditties

Sri Lankans frustrate me in general.

Those in my ward are frustrate me in particular.

But they are my daily fare.... my bread and butter, so to speak. Every day I ask patients about their bowel movements and whether they are peeing comfortably. I stick my finger up innumerable back-sides. I poke and prod and tap and listen. I feel sweaty and uncomfortable and sick at times. These days, dehydration is almost a by word. And still, in spite of doing our best, patients don't do what's best for themselves... why do people have so much trouble in taking responsibility for their own health?

Take the guy in bed X for instance. After devoutly fasting for 20 days, he decides to prematurely break-fast by going on an alcoholic binge.... which lasted till sunrise. He then lands in our ward with a ruptured stomach ulcer, bleeding like mad and has to be rushed into emergency surgery. After days of being kept nil by mouth, we cautiously asked him to drink water - and water only - not exceeding 30ml an hour. The next thing you know the guy is found with a huge buriyani in hand! Aaarrrgh!!!

Then there's the fellow who stabbed himself in the stomach with a bread knife. He seems to have wriggled it around a bit also because his bowels were cut and torn in multiple places and he needed 6 hours of surgery in the wee hours of the night, ICU care and constant monitoring after that. After looking disgruntled for a day or two, he starts yelling at the doctors accusing them of starving him to death. After frustrated conversation and repeated explanations that food will kill him if taken too early, our only conclusion was that next time, he should aim slightly higher and to the left. Hmmmph!

My last casualty saw three admissions with bad diabetic foot ulcers. All three patients had delayed coming to hospital by at least 2 weeks after developing what was initially a small sore. This is in spite of repeated verbal and written information by doctors, nurses and medical and nursing students of the importance of foot care and getting early treatment. One foot ulcer was actually swarming with maggots!! (Eeeeuw!!!) They all turned up after 11pm in the night and all had to undergo amputation. Depressing.

Come to think of it, our countrymen and women seem to have a particular affinity for coming to hospitals in the middle of the night for quite routine complaints. I guess they finish up the house work, sort out their accounts and bills and feed the poor and hungry before they come. Almost every casualty has an admission or two where the patient has been constipated for days... sometimes weeks... who then decides that they want to move their bowel at 2 o'clock in the morning! Honestly, if they came at a decent hour that day... they would have got prompt treatment, a date for endoscopy and been sent home quite comfortable... instead of having to sleep on the floor because there are no beds. And probably wouldn't have had a sleepy doctor (virtual pitchfork threatening alarmingly) getting irritated at their complacence.

Finally there's the guy in bed Z... the bane of my existence. He has multiple anal abscesses caused by constipation, caused by his not taking his thyroxine for 3 frikkin years. The abscesses are oozing pus (eeeuw... why am I in this profession?) and the area needs to be kept meticulously clean with frequent dousings of salt water. And he refuses to wash. Instead he asks for more tablets and pills and injections. Jeez... he frikkin refuses to wash!! (Did I say that already?) And he refuses to go to the toilet - which is the root of all the evil in the first place. The only thing that finally got him to the bathroom was my dark prediction (said out loud and to the ward in general) that unless he does so, his bottom will completely rot and fall off.

Well, that's all for now, folks. I have to go early to the ward tomorrow... there are more back sides that need examining.

Sigh...

The death of rats...

With apologies to Terry Pratchett


Picture from here.

____________________

I'm tired.

A casualty to handle, a week end on-call, and personal emotional turmoil.

But all that's besides the point of this post.

______________________

I walked into a medical ward yesterday... sat down near the house officer (an old friend) and started a random chat. I can't explain the difference I felt... was the air somehow heavier in this ward? Was there somehow less light than the one I worked in, or was it just the generally overcast day?

These musings at the back of my mind were cut short by wails and screams of agony. Over and over again... now high pitched, now low... different voices... different levels of torture ripping through souls. At times a confused babbling.... at times just incoherent moans. Over and over again...

I listen for a full minute, mouth agape... "what is that?" I ask, horrified. My friend looks glum. "Them? They're the lepto patients..."

Leptospirosis.

The farmers call it mee una (rat fever). The spiral like bacteria lives in the kidneys of rats... and when they pee, get passed into drains and canals and paddy fields. Unwary farmers go sloshing around... and get infected through the cuts and scrapes on their feet. The fever sets in and chills shake the bodies of these young, strong, healthy males. Blinding headaches. Uncontrollable vomiting. Delirium. And the complications are killers : inflammation of the heart and brain, liver failure, kidney failure, relentless bleeding tendencies.

It is "Lepto season" again in Sri Lanka. There is an epidemic going on... but I don't have the statistics or the numbers yet. Many many are transferred to Colombo... from all over the country and they die like flies... young men, reduced to moaning shells of their former selves. Women die too... young and old... some who have only stepped into the paddy field to help a friend during the sowing.

There is hardly enough space in the dialysis unit for patients with chronic kidney disease. The unit is full of lepto cases, their blood being fed into machines in a desperate attempt to clean out the toxins that are poisoning them. The wards overflow with the infection... the systematic removal of bodies is only matched by the relentless inflow of even more patients.

Antibiotics can cure... if given early. As soon as there is even a faint suspicion of the presence of Leptospira. Before the complications set in. I believe there's an island wide awareness programme going on. Cut off as I am from newspapers, TV and other mass media that is available to the normal population, I haven't a clue as to what they're saying. But please listen, and take care.

____________________

It was close to 9 pm as I walked to the flat, the full moon radiant overhead. I bump into another friend, moodily making her way to the canteen.

"Heavy weekend eh?"

"You have NO idea. Three early morning arrests today"
(cardiac arrests... not good, obviously)

"How many survived?"

"None."

"Damn! Poor you... hope the rest of your day was better..."

She looks at me... tiredness, and something else I can't define seeming to ooze out of her very being.

"I got a call from the dialysis unit at about 10, a patient had arrested during dialysis. While giving CPR, I got a call from the ward... another arrest."

I didn't have much to say after that. Obviously her weekend was a helluva lot more shitty than mine. I only had one question.

"All lepto?"

"Yup, all lepto."

The penis factor...

...is something I don't think I'll ever understand. I mean, I understand the concept of the penis... and it's biological and ...um... pleasurable necessity. But seriously, isn't it rather disturbing to have an independent appendage that dominates your thoughts and actions and perhaps even your life the way it tends to do?

My first unpleasant encounter was about 5 years ago, during my first clinical appointment. I was examining this guy for varicose veins, and he kept asking weird questions such as whether his VVs had been caused by too much sex, whether the surgery would affect his sex life and how he was very active in that department and how much his wife complained. Engrossed as I was with trying to figure out where exactly the incompetent veins were, I merely made several soothing comments such as "don't worry, no of course not" etc. My clinical train of thought was rudely interrupted when his erection became so obvious that I couldn't possibly miss it. Eeeeuw. Utterly flustered, I snapped "get your clothes back on" and fled the ward.

Since then I've been resigned to the fact that as a female in the medical profession I'm likely to have the random patient drop his pants / raise his sarong in the ward, in the clinic and occasionally even on the corridor, usually accompanied by the words "nona meka poddak balanna" (Ma'm, have a look at this). Last week though was more trying than usual, hence this post.

A well known drunkard from the outskirts of Colombo was in our ward, after being assaulted by a gang of equally inebriated fellow drinkers. So there he was, on a bed, trying to look pathetic and failing miserably... and everytime a female went by his bed, this guy would reach under his sarong and start wanking away. Now, since our ward has 3 lady doctors, 5 nurses and about half a dozen student nurses walking around, this would happen every 10 minutes or so. Finally, after the poor nurse who was giving him injections came back looking absolutely nauseated, I asked a couple of attendants to tie his hands to the bars of the bed. Soon afterwards, his family requested that he be transferred to a health facility close to his home and we were only too happy to comply. Good riddance!

The casualty also saw this guy who for some unexplained reason had tied what looked suspiciously like a pirith noola around his penis! By the time he came, that ridiculous piece of thread had been there for a couple of weeks and the organ was swollen, rotting and stinking to high heaven. Our conversation went something like this...

Me : why did you tie that piece of thread?

Patient : I just felt like it Nona

Me : were you trying to sustain an erection?

Patient : no no, I don't do those bad things Nona

Me : why didn't you come any sooner??

Patient : only now it began to hurt Nona

Me : (silent scream of frustration)

The Registrar took one look and said we'd have to amputate, but as the patient was not fasting, we were told to just take him to the OT and cut the thread off, and prepare for surgery the following day. The pleasant task of breaking the news to the patient and getting consent for amputation of the penis was allocated to me. The thread duly came off and P. Nonis, as he jokingly became known as to the senior doctors, (read - No Penis - pathetic medical joke but it did sound funny at that time), was told to be ready for surgery the next day. Morning dawned and the patient was missing from the ward. Much hullabaloo, calls to the hospital police post and paper work to be sent to the Director's office. Goodness knows what happened to the poor fellow. Hopefully, that thing would fall off because if it stays attached for much longer, he'd get blood poisoning and die.

Finally, a 17 year old kid was admitted in the wee hours of the morning, complaining of pain in his weewee. I came to the ward, bleary eyed and started clerking. Apparently he had had sex with his 16 year old girlfriend 2 days ago, forgotten to pull back the foreskin and was now having pain and swelling "down there". Of course, he had to wait till 2.30am to come to hospital. I was more concerned about the girl. Had they used a condom? No. Did he have any idea what part of the cycle she was in? No. Could she be pregnant? Shrug. Apparently "she is a poor girl and has lots of family problems... that's why I was with her". I failed to understand how a possible pregnancy would improve this girl's prospects.

Getting his foreskin back in place was no picnic. Liberal amounts of anaesthetic gel were used... he thrashed around, arms and legs flailing... reinforcements were called... but in a few minutes, things were back to normal. I waited till morning to give that boy a large and nasty piece of my mind. If he thinks he's old enough to screw around, then he's old enough to be responsible about it.

Hopefully, next week will be more routine and have less ickyness all around. All in all, even you guys out there must admit that I have some justification for my rants! :)

Casualty days... casualty nights...

The next casualty will be my baby. 24 hours from 7am Thursday to 7am Friday, I will handle all the emergency surgical admissions (wince...). It doesn't end there though... I do the post casualty round on Friday morning, and if I'm lucky, get off around 3 or 4 pm to snooze and recharge as I will also be doing the weekend.

The last casualty I did saw 48 admissions in 24 hours...average for NHSL, and thankfully most were not critically ill. It's usually the uncontrolled diabetic with a foot infection, the uncontrolled alcoholic with gastritis/pancreatitis/withdrawal or someone with kidney-stone colic. The latter is the only category I really feel sorry for, as the others, IMHO, ask for it.

Recently, there was this guy (let's call him P, for patient) who was admitted with a painful hernia... something that an ice pack cured. He was asked not to eat and drink and we inserted a nasal tube... just in case. He was doing fine that night, snoozing peacefully, and doing fine when the consultant saw him the next morning. There was just one x-ray that was faintly dodgy... nothing clear cut, but when we looked at one area... it just didn't seem right... it looked as if there was air in the abdominal cavity. Now, air has no business being in there, unless it is in a loop of bowel, i.e. bowel gas. What we saw could be just a bowel loop... and that's what I thought it was. Others just thought it was dodgy.

P suddenly started to deteriorate at about 8.30 in the morning... pulse shot up, BP kept dropping at an alarming rate in spite of the IV drips. Yet he was conscious and rational and talking fine. There was no abdominal pain even though 4-5 doctors of varying experience kept prodding him. He didn't vomit and wasn't running a fever. Blood counts were absolutely normal. The consultant however was taking no chances and P was rushed to the casualty theatre with delay only to order blood and plasma.

"Explaratory laparotomy" is pretty self-explanatory. That's what we do when we have no idea what the heck is going on and open up to have a look. So we opened up and I just couldn't help gasp in horror. What looked like the entirety of what P had for breakfast, lunch and dinner the previous day was inside his abdominal cavity... obviously, part of his bowel had perforated. There's something a little surreal about seeing bits of carrot, kankun and half digested karapincha floating around the liver and sticking to bowel loops.

We sucked nearly 2 liters of intestinal contents out of his abdominal cavity before locating the part of the bowel with the hole in it. A very suspicious lumpy area (? cancer) was resected out and the two free ends were sewn together. And then the washing began... warm saline was poured in and the surgeons patiently washed and rubbed loop after loop of bowel, in a way faintly reminiscent of a Sunlight ad. Thankfully there was an ICU bed available and he was getting the best care available to someone with such a condition. Unfortunately, I guess the stress of the surgery, the infection and the pathology inside his bowel was too much for his system. P went into cardiac arrest yesterday, and could not be resuscitated.

What surprises me was that even with such a lot of muck inside the normally sterile abdominal cavity, this guy was not in pain, had no fever and even joked with the doctors while on the operating table before being anaesthetised. I guess this underlines the fact that in a really old person (ok, he wasn't that old, 67 years), going purely by clinical signs can be misleading and a really high index of suspicion is needed.

It's terrible when we loose a patient... but somehow, it seems less bad when it happens in the ICU. The death happens in spite of the best in critical care, 24 hour one to one medical and nursing care and the monitors and the fancy drugs... there is some sense of inevitability. When it happens in the ward in the middle of the night... there's always sick underlying feeling that something more could have been done... even if the circumstances are such that nothing really could be done.

Mea Culpa...

The other day was my turn at the theater and I was in "civvies" and not the usual saree. I rather liked my blouse, a sort of wrap thingie, mostly in white lace that looked very soft and feminine. The ward round went smoothly but Dr. P, the registrar, seemed somewhat distracted. Several times he asked "what was that again?" which was most uncharacteristic.

After the round, I was at the nurses station filling up some forms when Nurse W (possibly my favourite of them all) came running at me brandishing a large pin as if it were the Sword of Omens. "Look at you child!" she hissed, "Even I am embarrassed... that poor man, who knows what he will cut off when he gets to the theater!!"

I glanced down to realise with shock that the outer flap of my blouse had got ...um... displaced... and that I had done the ward round with the right side of my bosom, (bright purple inner-wear and all) sticking out like a traffic light!

BLUSH

Oh dear... I guess wardrobe malfunctions happen even to the best of us!

5 weeks down

... and 47 to go.

I really don't like this intern business... and apologise to all my readers because this blog is turning into a long drawn out "I don't like my job" whine. Sigh...

A patient almost died on me the other day. The night on-call was seemingly uneventful, I had high hopes of finishing a little early and catching a bit of the Olympics on TV back at the flat. I was almost at the last bed when one of the nurses cam running "Doctor, bed 13 patient A is bad".

Now A was admitted to the last casualty with non specific abdominal pains and had been doing fine so far. The problem was that he was foreign, understood no English or Sinhala and had a "smattering" of Tamil. History was taken using one or two words, lots of arm and leg movements and he was treated on the findings of the physical examination and blood tests. He was a round, jolly looking fellow, eager to tell his story and apparently unfazed that none of us could understand a word he was saying. When I had examined him 30 minutes ago, his tummy was soft but his lungs were a little noisy. Discussed with my senior, who also examined his lungs and we decided to add an antibiotic. What could possibly go wrong in 20 minutes?

I reach the bed to see patient A wheezing, with his chest heaving in the most laboured respirations I had ever seen. Sweat was pouring down his body in streams, his eyes were blood shot and his whole body shaking as he desperately fought to get air into his system. The nurses had got out the nebulizer and the oxygen and we gave him a shot of steroids while I felt for a pulse. Damn... no pulse to be felt on either arm... blood pressure could not be recorded and frantic groping at his neck revealed only a faint carotid pulse. Phew, I thought... this means he at least has a BP of 60. Lungs where full of rales and wheezes.... and his tongue was blue with cyanosis.

A million things were running through my mind... acute severe asthma, ok, we were doing everything required, 20 minutes now, why wasn't he improving? And in the background of the cold clinical reasonings, the desperate voice of a panicked child, please please please, don't let anything bad happen, please don't die.

To make things worse, we don't have a cardiac monitor in our ward. The pulse oxymeter (which is usually held together with a piece of plaster) refused to work. I ran to the next ward to borrow theirs... and before I talked my way through the red tape, an attendant called out that a few good thumps had cause our machine to start working. The readings positively chilled me. Pulse was 210/minute and oxygen saturation was 88%. One look at that and I ran to phone the medical Registrar on call... the patient was dying in front of me and the condition wasn't something I could handle on my own. Dr. N answered the page... and listened patiently as I almost wailed down the line at him. Added one more drug as advised, but the message was "keep doing what you are doing, I will be there soon". My own racing heart slowed down a notch.

Dr. N turned up soon, by then 40 minutes since the attack had started. Patient A was still distressed, still gasping, but his saturation was up to 95% and his heart rate had slowed somewhat. We stood in front of the bed, debating whether to give mag-sulphate or not. This wasn't too safe given the absence of a proper cardiac monitor... but the other options hadn't made much of a difference. Then slowly, slowly, the saturation rose to 100%, his breathing slowed down and A started looking more himself. One hour and 15 minutes after the onset, he was back to his jovial, voluble (but totally unintelligible) self.

Dr. N wrote out what to do next and left instructions that if an attack occurs again, to rush the patient over to the medical casualty ward. Once he left, I went to the lecture room, locked the door and had a mini breakdown. After the dry retching had finished and my shaking hands had settled a bit, I washed my face and went to complete the rest of the ward round.

I didn't sleep that night. My mind was churning, trying to find out possible causes and I kept looking at my phone every 10 minutes just in case I had gone suddenly deaf and missed a call from the ward. I think I fell into an uneasy doze around 3 in the morning.

The next day the nurse told me that the attack had come soon after she had given the antibiotic. I went next to patient A (who was, thank goodness, looking hale and hearty) and after waving my hands about and yelling "penicillin ooshi" at him several times he started nodding and said that penicillin was "bad" for him.

OMG!!! The drug we gave him wasn't penicillin (only distantly related) but it easily could have been. If it had been penicillin, he would probably have died within minutes in spite of our best efforts. What I had dealt with was anaphylaxis, a retrospective diagnosis that gave absolutely no comfort. I should have given adrenaline but I didn't know his allergic history and for all intents and purposes what he had seemed like acute severe asthma. All that would have been inexcusable, to my own conscience if not anyone else, had the worst happened.

All in all, I'm really really happy that I'm not on-call this weekend. I think I need a little break.

Update

Greetings, gentle readers, after more than a month of silence, and sparse blogging before that. Not much time today, either - but just enough for a quick update. :) The past four weeks were hectic... many things going on... some nice, some nasty.

1. My blog turned one year old last April. And I didn't even notice, till early July and couldn't blog about it till now. Happy Birthday Angel - my alter ego, my stress buster, and the only means I have of actually putting my thoughts down.
   
   
2. Darling and I got a place of our own - sort of. We've officially moved from the nest, taking clothes, furniture and the 3 rice cookers we got (each a different size, as you never know when or how many guests you'll have to dinner). To be honest, it's not that much of a change, except that now I have to think up of innovative dinner ideas. So far we've been alternating between noodles and pasta. And bread, when I don't feel like boiling the said noodles / pasta. promises to darling of Darwin like cooking have not been fullfilled, yet!
   
   
3. I started the dreaded internship... eeek! Day after day I question why the heck I'm in this field of work. I'm in the ward by 6.30am, sometimes don't get home till past 10pm. I feel constantly sleep deprived. My feet developed blisters, which cracked and bled, in spite of me wearing what I thought were my most comfortable shoes.
   
   It's not that the work's not enjoyable... it is. But it's different from a clinical problem in a textbook that can be leisurely analyzed and solved. We work with living, breathing human beings, in a dynamic state of flux, who develop different, unique and occasionally mind boggling problems every day. It's also coupled with the horrible feeling knowing that you're responsible for someone else's life. Being responsible for one's own is bad enough. To be honest, it's not really a happy job. the "oh but you're making people better" argument is inherently weak as people who get better will do so anyway (natural history), and the people who don't, suffer unbelievably and then die. :(
   
   I did my first solo casualty last week and got through it safely (with all patients alive and ticking, phew!) It doesn't seem so scary now, but still do feel apprehensive as the next one looms up.
   
   The last 24 hours were like a scene from ER... with about half the staff and none of the fancy equipment. Three (three!!) emergency laparotomies, and rushing a patient to a theatre to be ventilated because there were no ICU beds available. Hours of running around organising blood and plasma and platelets and fancy drugs. The emotionless announcement that there had been a death at one ICU and that we had first booking for that bed. How pathetic. One man's death opens the door to life for another. One family's bereavement is the source of relief to another family.
   
   
4. Theatre. The surgical type. At least 10 days of the 28 spent in icy cold, sterile surroundings, wearing draughty green scrubs, face hidden behind a mask that smells a little weird. The stench of the diathermy device as it cuts through tissue and fat. This is why I don't like BBQs... the smell reminds me of burning human flesh. Yech!
   
   
5. Bad news. Something I hate to deliver. Over the last 4 weeks I had to tell 5 families that the situation of their loved one was serious and that while we were doing our best, chances are slim. I watched their eyes tear up, watched grown men cry and rant and rave. I had a lady 15 years older than me kneel at my feet and beg me to somehow save her father. I felt like yelling "there's nothing I can do... I'm only a house officer, the most ignorant and incompetent of the team... even the seniors have done all they can, I cannot do anything more, I am not God!". I felt like kneeling on the floor next to her with my my arms around her shaking shoulders and reassuring her, however untrue and hollow those reassurances would be. I didn't do either. Just followed the protocol we had been trained to follow : asked her kindly, yet clinically, to calm down, wash her face and not to let the patient see her distress.
   
   I wrote out a death certificate for the first time that week. Not a nice experience.
   
   
6. Off day. Much anticipated opportunity to put feet up and consider something other than bread and an omlette for dinner. Darling convinced me that Kung Fu Panda was worth the effort of dragging self out of bed. Totally loved the movie... cuteness re-defined! Cheese kottu from Pilawoo's and early to bed. Bliss!
   

I guess I can't complain that my life is uneventful... stay tuned for more rants... and take care, all!

Monthus Horribillius...

...or is it mensus horribillius? Pardon my Latin.

Anyway, that's what the coming month is promising to be. Hot on the heels of the car crash, my poor father falls ill and needs to be hospitalised. Severe respiratory infection with a suspicion of low cortisol response. Icy cold peripheries, dehydration, fever at 104F and low BP. Dispropotionately low pulse (low 60's). All this had Mums and I scratching our heads and trotting back and forth between the ward and the lab. Happily, the drugs worked and he's back at home and on the mend. Phew!

Yesterday was another scare as around 7.15 am Brother's girlfriend calls to say there's been a bomb in the train she was travelling in! She was thankfully unhurt but quite naturally shocked... and was now walking along Galle road, avoiding crowds and she felt jumpy whenever there were more than a few people around her. A few hours after dropping her home, I read Dinidu's post on the subject... and got to thinking of how many people were nervous about loved ones... real panic beats on the edge of your mind while another part of you keeps chanting "okay, it's going to be okay..." over and over again like same manthra.

And now, the Ministry of Health announces that Internship will be starting on the 1st of July. Now, this means we get an overlap and save 3 1/2 months of waiting but aaaaarrrrgh! I've gotten used to this cushy lifestyle and I don't wanna go! Clinical oriented though I am, the thought of doing casualties, clinics, ward rounds and on calls bloody sux! :(

I need comfort food.

Oh gosh!

(Warning : medical gobbledygook ahead)


I recently met a senior colleague of mine who is attached to the ETU (Emergency Treatment Unit, a.k.a. A&E) of a big hospital in Colombo. Little beads of sweat dotted my forehead as I listened to his experiences there. The trauma scenarios he described were horrifying, even though I have had a decent training at NHSL.

A few weeks ago, a youngish guy had been admitted following a road traffic accident (RTA)... a nasty collision with a train during the wee hours of the morning. While the rest of the body was ok, he had severe injuries to the head, including facial fractures that were a combination of Le Fort II and III. In other words, his facial bones were in 4 fragments... (shudder).

My friend and his team had been trying disparately to intubate the patient, as that was the only way to secure the airway and ensure he didn't aspirate from the torrential bleeding. Every time they tried to insert the ET tube, part of the face would move forward or backwards or sideways....making the task next to impossible.

That's when they decided on a radical approach, one I had never heard of before. They created an emergency tracheostomy and inserted the guide-wire of a CVP line upwards through the larynx and out of the mouth and then guided the ET tube down the wire!! I was open mouthed with admiration at whoever came up with this maneuver. Thanks to their quick action, they were able to get the patient stabilized on a ventilator.

I'm not sure what happened to the poor guy, but I hope he survived.

My applause goes to all innovative doctors out there.... for their clear headedness in the face of the seemingly impossible - a trait that saves lives.

Terrible weeks... one truly terrible month

Hello world...

Apologies for the long silence over here at Angel's pad. As the title hints (ahem) the past few weeks have been one big suckfest. And I can't even blog about most of the things that happened. Sigh. I warn my gentle readers... this is NOT going to be a very happy post...

At least today I came home at a decent hour after submitting the newsletter (1 week late - what's the point of a March newsletter that comes out in mid-April?) but thankfully didn't have to take any more flak than was my due. Tomorrow may be another story as I'm having a lecture in the morning (eeek, have prepared nothing!) and then MedEx duty... with an estimated crowd of close to 20,000! Feet, please forgive me... pedicure and foot massage, soon... I promise!

Last week is hazy... what happened? I remember being yelled at. Oh yeah, I've f**ked up big time and lost a load of invoices from our last workshop. Worth about 15,000/- .... which I will probably have to fork out of my own (meagre) pocket. Last week was spent running around like my tail was on fire going damn! damn!! damn!!! while I went through every single bloody file in the office... TWICE!!! The annoying thing is that I remember thinking, "Girl, if you lose this, you're in deep shit" after I had pasted, labled and stamped the invoices with the Director's seal. So anyway, I gathered up my courage and told the big guy... and his response was more or less, Angel, it's your baby... deal with it" Sigh... If I find the congenitally syphylitic cretin who stole my file I swear I'll chop him up into little pieces and feed him to the snakes in the herpetarium.

The week before that was slightly better with only the SLMA sessions on the calendar. Of course these HAD to be scheduled for the 20th, 21st and 22nd... the LONG WEEKEND! AAArrrrrghh! For once, Darling was off-work on a public holiday but I had to be stuck at frickkin' sessions. In saree. Dealing with irate (and scary) judges, annoyed participants and a hotel management that charged the earth for a couple of photocopies. The food sucked too... and since I repeatedly lost the tiny little chitty with "tea" and an ugly picture of a teacup on it, I had to go without the said tea several times, in spite of the large red tag saying "staff" that was around my neck like a noose.

The worst part was that I missed almost all the sessions I wanted to attend, including the ones on Parkinson's disease, Wilson disease and a symposium on patient safety. This was because some judging session or the other was ongoing and the powers that be wanted the marks entered, tables added up and classified immediately! Unlike Darwin I find powerpoints on topics with long names quite interesting... and these were some top notch international researchers and clinicians. Sigh...

The week before that, my pet died. My first and only pet, unless you count the 2 goldfish I briefly owned when I was 8. Chuti was an abandoned baby squirrel that I rescued and fed on milk for 6 weeks. The fellow was on the cold hard tiles of Brother's room and was found by self while sweeping... and immediately tipped into a shoebox when discovered to be alive. I didn't realise how attached I was to him... feeding him with carefully prepared milk, first thing in the morning... every two hours... last thing at night. He'd run around the box, squeaking with joy when I brought the milk and would follow me in little leaps and bounds around the room or in the garden. The horrible thing is that I think I killed him. He was off his food for a couple of days so I used the feeding tube given by the vet to alternatively give him saline, dextrose and milk. I think the milk went in too fast, because he asphyxiated... he gasped for breath on my palm while we rushed him to the vet and then writhed in terrible pain and died. I've watched people gasp like that... I've seen babies with birth asphyxia... but at least then I could do something other than watch helplessly while waves of guilt crashed over me. Chuti deserves a post of his own... so now you know what the next one will be.

The same week was the quality asurance programme in our faculty. This is a process that takes place once a year in every medical faculty in SL to ensure the curriculum is upto par. Reviewers from the UGC and other faculties spend about a week going through papers and books and files and getting all worked up if something was missing. I was somehow convinced to be a "coordinator" and I had to take an incredible amount of flak for things I wasn't responsible for. I had to dive into mountains of never-before-seen files and come up with specific documents, I had to call up departments for lists of this and that, I'd get defensive when things were criticized, then criticized for getting defensive. There were others who ran around with me... but I for my sins, was the one to get yelled at. Honestly, those reviewers were really rude sometimes, though honey-sweet when the senior staff were around. I have to totally thank my workmate M for covering for me when I had to go off taking Chuti to the vet. But they somehow found about him and made fun of that too... the sickos.

This is just a taste of what the past few days/weeks have been like. The days were occasionally punctuated by visits to blogosphere. I find Half-Doc, my articulate colleague has been compelled to delete his blog for merely stating his thoughts about a drunken party. E-mail has piled up since the connection is mind numbingly slow at office. I suspect it's because some nerds at the CAL lab are downloading flicks.

Anyway I feel too drained to type anymore. Adios, amigos. To Dinesh, Justin, Azrael, Priyanga and the many others who expressed help and support to Samitha, I profusely apologise for the delay in communication and will be in touch as soon as possible.

An update : Samitha Samanmali

Samitha is now in a ward at the accident service of the NHSL. She lies on the bed, her lower body motionless, and gazes out of the window. Blue skies with fluffy clouds. Mara trees bedecked with red and yellow flowers. Crows wheeling across her field of vision.

Friends hover around her, trying to anticipate and meet every need. Major trauma, major surgery and major change of life... in the face of these, Samitha remains cheerful. Tutes are brought to her bedside and she courageously turns pages and refers notes, determined not to fall behind.

What now? The next step is a wheelchair. At present, Samitha can only be "propped up" i.e. kept semi recumbent with the aid of pillows. The injury is at the 5th thoracic spinal level, which means she has poor control over the muscles of her trunk (these are antigravity muscles that help us keep upright). Obviously, a generic wheelchair, purchased from Union Chemists for instance, will be useless. She needs a special, custom-made wheelchair that will help support her comfortably. An electric wheelchair will be ideal as she will then have a degree of independence. Overseas rehabilitation is needed next. There are a couple of wonderful units in Singapore and the UK that offer facilities far far beyond what is available in SL.

Many thanks to all who contributed and continue to contribute to her rehabilitation fund. As yet, only a fraction of the funds needed have been raised, but I feel fairly confident that we may be able to collect the required sum. Things are yet to be streamlined. Arrangements are being made to get her cause registered as a charity. Not only will that give an added incentive for the corporate sector to donate (tax relief!) it will also allow the funds to be handled in the best possible way.

Many friends and well wishers from abroad have contacted us. They're not financial giants... many are students who work part time to pay for their own university education. yet they all want to donate something and this is where we hit a snag. What's the best way. Wire transfer is horribly expensive and not practical for small sums. Cheques run the risk of processing problems when issued by a bank overseas. Someone suggested a demand draft from the bank, but I wonder if this requires a minimum sum. Another friend suggested a paypal account.

Dinesh has kindly offered to develop a website for her cause. Untill he mentioned it, I hadn't realised that there was no official information available online. Maybe the paypal account can be linked to this website. Does anyone know how that works?

Once more, thanks to all for your good wishes and contributions. Will continue with the updates.