Death - The Best Medicine

Laughter is the best medicine..... or is it? The more one dwells into the abstract, the more one realises that it perhaps isn't.

"How was your MICU posting?" I asked a colleague. I expected he would say things like x number of CPRs or y number of Central lines or something of that sort. But he replied," Kuch nahi..... ABG karo and then around 3-4 am patients start dying. It happens everyday.... 4 -5 to jaate hi hain." Chuckle, and we moved on.

Such is my profession, that we laugh at almost any and every thing. My mother says, especially since my internship has commenced, that I have become very pessimist..... that I do not say 'good' things any more. 'Good things', how do you define good things?

About a year and a half ago, a bunch of us junior college buddies met up. Being the sole medico in a hitherto group of 6 +/- 1 engineers, I tried to keep pace with the conversation and give my inputs as they spoke of Accenture, Infosys, Patni going out of business, fat packages and so on and sultry. Then, probably after a few PJs which made it clear that I was loosing tract, they courteously asked, "So, Jayesh, what do you do? Tell us about the best thing you have seen in medicine."

"It was on Diwali night of my second year", I began enthusiastically. "A diabetic wheeled in. He had gangrene of his foot. Three of his fingers had rotten and we performed an amputation......... We cut his leg just below the knee...." I simplifiied so that they could follow what I was saying, as we chewed on a sumptuous lunch. "I assisted in that procedure. It was beautiful!" 

"God! Jayesh, what's wrong with you! How can you say that rotten feet are beautiful?" They echoed as one choked and the other gagged on their morsels.

Okay, I get it, i don't speak 'good things' any more.

But, while my profession has been making me heartless.... emotionless so to say.... squeezing me dry and devoid of the very aesthetic that differentiates sajeev from nirjeev, it has indeed opened a portal to the mystic and the subconscious. I perhaps understand life a little better now. And nothing helps understanding life more than understanding death.

Death is universal. I probably learnt to spell death in Sr. KG when they taught that the opposite of life is death. Then, when I was around 7 my grandfather expired. As the rituals about the funeral proceeded, I wondered why the ladies in the house were weeping so inconsolably? More elders dressed in white poured in and tried consoling them. All this time, I only wondered, trying to configure what was going on. This is all that I remember of that day.

Then, about a couple of years later, my father rescued a sparrow and it became my pet. I used clean its cage, feed it grains..... and then one morning, it just lay motionless. My dad said, it had died. I cried.... for my friend..... not because it understood what death meant. 

A few years later my grandmother expired. I cried because, I realised I wouldn't get to see her any more. Death, per se, still remained a strange entity. I never gave it much thought.... never pondered over its complexities...... partly because I got too engrossed in my own life and also (luckily) due to the fact that no one else in my family has passed away since. 

In between, my English curriculum in school had two poems, 'Death be not proud' and 'Death the Great leveler', but still I failed to grasp the abstract.

Now a days, people just keep dying all around me. And, I realise that some people are valuable when they are alive and some others after they are gone. There are some for whom you wish they are better dead, some whom you wish, live forever.

A distant relative of mine sent me a MRI for opinion. The report was suggestive of Interstitial lung disease. ILD- one of my hot favourite topics these days in view of my exams. Different diseases causing ILD of upper lobe predominantly and some others of lower lobe predominantly..... their treatments, for majority of which none exist.... and few experimental novel drug..... which I mug up but which in reality will probably never get out of the labs and in clinical practice. But its exams..... pet ka sawal hai.

So, I tried, in my hallmark mask face and expressionless emotionless monotonous voice, explaining that the disease had a very bad prognosis, that there was only one way...... going down and none other that they should NOT believe any ayurvedic or such practitioner who will claim a cure..... ayurvedics claim a cure for everything..... that she has little time left and they should brace themselves for a tough time maintaining her. That it is not cancer and not infectious.

Today, as I was discussing the same with my mother that how bad an end awaited her, it came to my realisation that knowing every disease and more importantly seeing the end, has just made me a bit paranoid when it comes to the health of my beloveds. 

There is an entity called "The Final Year syndrome" - it occurs universally to everyone irrespective of age, gender or race or culture- in which Final year medical students read of diseases and start finding symptoms of the same in themselves. Can you imagine, diagnosing yourself with a near fatal disease every single day....... that's why the final MBBS exam is called the toughest exam. And, to the quote the idiom. 'What doesn't kill you, makes you stronger.'

So, as we were discussing, the phone rang with the sad news. "Be happy" I told my mother. "She has actually been spared of a lot of pain and suffering. Imagine, if had lived longer, she would have been confined to a bed, wouldn't have been able to breathe without a ventilator .... her caretakers would have had their personal lives destroyed....... Be happy, that she died peacefully."

She had gone to the village, for a change of air and to pay her respects to the family diety. "If she had been in a hospital, we wouldn't have let her die and she wouldn't have given up a life that wouldn't have been worth living."

Life in a hospital is all about witnessing battles for survival.... brave battles, day in and day out. You feel overwhelmed sometimes by the extent to which humans cling on to life.... till very last bit of it. But then, death is so good.... No pain, no suffering. No worries, no anxieties. Do we live lives? No, we only live worries... some real worries and some only a creation of our minds. We live our ambitions, others' ambitions, we live protocols and etiquette. No where, do we live life.

Death on the other hand is so liberating..... In death at least, perhaps, is a chance living life. Death, should be celebrated, not mourned..... for it is the best medicine!

Am I ready to die? .......... No....... I am mortified by the thought of death. But at least, I think about it....there are so many a ways to die, that one must be just plain lucky to be alive, let alone be  healthy and alive. We all live on borrowed time..... and so, I value life even more......may be understand life a little bit more, EVERYDAY.

                    May the departed soul rest in peace. 

A Saga Of Love

Internship, in a way to put it, is in itself an independent phase of life. An era in itself. You are no longer a student, but aren't a doctor either; you are somewhere in between, and sometimes you wonder, if even that is where you belong? There are many a trials and tribulations in the intern's life, frustrated housemen, frustrating schedules, depressing backlogs and demotivating Government Resolutions.

And yet, just somewhere in between, someone comes around, whose pain supersedes your pain, whose confusion makes you realize how lucky you are, that you at least have a rough idea of what you want in life, someone who you just cant pass off as just another incidence......

It was my 4 th night shift on the trot in the EMS - I can boast of it and I will, but I wasn't particularly comfortable or happy doing it! The three of us were chatting with each other as we mechanically cannulated IVs in the que of patients lined up ahead of us..... a que which had no end till so far as the eye could see...., simultaneous collecting blood samples 2 EDTA, 2 Heparin and 3 Plain bulbs, filling out forms and pausing our conversations briefly as we shouted out the instructions, simultaneously surveying the arms of the next patient for a good vein. This whole routine was so intense that it occurred almost at a spinal level, the only higher function involved was in our conversations.

In this din, trolleyed in a patient- not an occurrence of significance in our part of the world. He was a typical patient, cachexic, dehydrated, semiconscious and accompanied by two cash-strapped relatives. I got up and proceeded to his trolley holding a cannula, a spirit soaked cotton swab in my double gloved right hand and a 3-way attached to a syringe in the left, collection bulbs and a strip of dynaplast in the pockets of my apron. The man seemed to be in his late 60s, was bare chested and only a bermuda covered him below the waist. As I set out to do my job  I was interrupted rather annoyed by his wife who asked me, "Will he die?"

This was annoying for two reasons, one, relatives usually asked if patients will survive, not the other way round and two, for the tone of her voice and the way she kept aloof from the patient. But, ours is a profession where personal beliefs and emotions and prejudices are kept in the locker as the white coat is retrieved from it. I did what I had come to do, and directed her to the registrar for ant further queries..... no intern knows how much his involvement in patient care is supposed to be, so prophylactically, it s safe to keep it at a bare minimum.

The registrar asked her for the history, she annoyed him by her attitude, her obsession with the patient's death and her ever changing answers. No one could afford to spend so much time on one patient, there were 50 others waiting in the que. So, after initiating preliminary treatment the Reg moved on to others, leaving minute intricacies of his history for such later time as would be possible.

For the next three hours that followed, the female ensured that she was noticed by everyone in the EMS by her mannerisms and high pitched quarrels with a semi-conscious husband. It was becoming very irritating for all present..... when we were racing against time to save lives, she was one we could do without.

Finally, at around 5 am the que ended, the reg began interrogating her. She enjoyed every bit of feeding us mis-information and backtracking on her previous statements. By now it was clear that the patient has acute renal failure and would require dialysis for the near foreseeable future. Even if we are a government set-up, procedures such as these cost money, howsoever less that it may be. And she replied, "I don't have the money. If you don't give him dialysis, will he die?" We left it at that, your patient, your decision.

With that had to be asked asked, with all that had to be explained explained, the reg moved on to covering up other formalities. "What is your relation with him?" the Reg asked. The obvious two answers could be sister or wife. And this is where the mystery unfolded. She answered, "Wife...."

And then after a few seconds, glanced back at the patient, her eyes lit up with a resolution and she murmured  as she tried to control a sort of a wicked smile..... "Friend...."

With a startle, the Reg asked, "Wife or friend? Make up your mind."
"Friend" she confirmed.

"Is he married?"
"His wife stays here only, In Elphinstone...." she answered, "but he come to me when ever he is sick."

"Give us his family's address".
"Why? Why do you want his family's address? I have brought him here, I have given my address..."

"If he dies, we have to inform his family."

"Ah.....!" That wicked smile smile finally broke through. 'He dies' - this is what she was waiting to hear for so long.... this is why she was pestering us since the time they has wheeled in.
I think, she had received  a very straight forward answer for her question, no element for ambiguity. But may be, she had some other calculations in her mind. "One minute..." she said. And walked to the trolley which was barely a meter away. I thought, she wanted to whisper something into the patient's ear. But, she echoed, "Doctor is telling you will die. Who will take your body?"
"My wife" he answered, with a smug.
"Why? She does not take care of you. Who will take your body?" she echoed again.
"My uncle's son" he answered in the same demeanor.

At this point, our irritation had been blown away so beyond the roof- added with the exhaustion- that this whole incidence started appearing entertaining, so to say. Both of them were past 60, yet they quarreled like newbies in love exchanging sweet little nothings. The question was not of life-death-suffering, it was of establishing authority.

It was 8am and the next intern came to relieve me. As much as I wanted to stay back and audience this conversation till its end, all my senses were overwhelmed by the prospect of a good shower and the much deprived sleep that would follow.

On my way home I thought over the conversation and the female's obsession with death. It was a very Barbarian emotion that she harboured. Greed - to get what she wanted, at what ever cost it came or closure, that she finally got the recognition she deserved?.

His dead body, a trophy symbolizing her victory in the war, where she had lost every battle or, a conquest over what had been stolen from her? Till death did others apart, but he would be her's even after his death!

This is the beauty of medicine, it isnt just disease and treatment and minting money out of it, it is taking the understanding life and its various aspects to a completely different level. It is understanding the human behaviour- Human behaviour with all its simplicity, with all its complexities, with all its benevolence and malevolence. An opportunity to understand human psyches and emotions.

A skeptic like me will describe her emotions as extreme possessiveness, at it lowest, sickest level.
A die-hard romantic may counter it as eternal love, an epic romantic tragedy  - A Saga Of Love !

STATUS DIPLOMATICUS

(The author wishes to thank the voices in his head for continuously guiding and inspiring him and their help in writing this article)

Status Diplomaticus is a condition of unknown aetiology, characterised by extremely sweet behaviour, inability to speak ill about others and perpetual Risus Sardonicus. The condition is strongly associated with the Type A personalities.

Historical Background:

Status diplomaticus though being described in literature for the first time has been known to the mankind since ages. It is widely believed that many Egyptian Papyruses dating back to 2500 BC have described the condition, but the claim cannot be ascertained as no one has, however, been able to decipher them.

Modern History:

The attention of the author was drawn to this condition when during one of his surgery OPDs a few years ago when he was still learning his clinical skills, that someone happened to ask, "Are you the CR because of your good PR skills, or do you have good PR skills because you are the CR?" (The author urges the readers to kindly read, understand and most importantly imagine 'Public Relations'.) The lone study was conducted by the author for which no ethics committee permission was deemed necessary and barring a few unsuspecting humans, no animals were involved.

Pathophysiology:

The precipitating event is usually an involuntary involvement in a conflicting situation usually in early childhood. Each situation precipitates the next. The condition progresses slowly until about adolescence, when it becomes prominent and is characterized by a shift to voluntary involvement (involvementohphilia). It is characterized by periods of remission during which no such voluntary activity is seen, probable mechanisms being fatigue of the CNS pathways or proximity of an examination. It recurrence may be precipitated by involuntary involvement or may be spontaneous. Complete remission is never seen.

Signs and Symptoms:

The individuals usually present as very informative, friendly and accommodating. They are usually resistant to heat and pressure upto 100 friendPascals. Some variants are non-compromising in varied amounts. They are reliable. Most of them are very non-committal. Workoholism may be seen in most. They usually have "freshness of ideas" and "risk taking behaviour". They have a very strong past history of similar events and though it may appear to be easy, it is quite difficult to predict the occurrence of next precipitating event. Inability to divulge clinically significant information is pathognomonic of the condition.

Laboratory diagnosis:

1. Demonstration of high titres of self-interest protective antibodies. However, it doesnot have any detrimental effects on the well being of those associated with them.

2. Any demonstration of any iota of commitment in any sample of conversation strongly rules out the diagnosis. It may rarely be false positive.

The Differential Diagnosis:

Differentials though few, are very important because misdiagnosis can lead to improper categorization of the individual which can have far reaching social and mental consequences.

1. The chameleon:

Though the initial presentation is similar, they can be differentiated easily whenever a conflicting situation arises. In some lucky cases however, no such condition may occur for years together and they may be well treated.

2. The opportunist:

The condition is characterised by periods of over friendly behaviour, alternating with periods of extreme aggression or selective mutism. Individuals are usually of good nature until a clash of interest develops. This is one condition which is relatively easy to diagnose. They usually have a past history of similar episodes. One interaction with an opportunist will definitely provide understanding that lasts almost a life time in about 95% of the general population.

3. Chaatooism:

In India a special type of population is identified. The term 'chaatoo' roughly translates to 'lickers'. A current study is underway in which extracts from chaatoos are being administered to individuals with Sjogren’s syndrome. 

Diagnosis:
i. Tailing and trailing are two important signs that are easy to pick up and are pathognomonic of Chaatooism.
ii. Excessive drooling of saliva, actual or apparent, in the absence of identifiable causes such as Downs Syndrome, Mental Retardation, Cretinism, etc. must raise a suspicion of this disorder.
Complications: 
Though no fatalities have been recorded as of yet, they are a high risk population for aspirating and choking on their own drool and a strong theoretical concern prevails.
Treatment:
Vaseline is preferred treatment of contact/friction glossitis which may be seen in some cases.
Nystatin is the Drug of Choice for oral thrush.

4. Vaccardia (Latin; vacca-cow):

This is a very harmless and benign and innocuous condition. It is again easily differentiated by demonstration of diminished power in the challenging situations test. The power gradually diminishes on consequent exposure to challenging situations. It is usually an acquired condition.

Multiple conditions may co-exist in the same individual and may manifest themselves in response to varied precipitating conditions. Vaccardia and Status Diplomaticus are pure forms and no association with any other condition has been identified.

Treatment:

Isolated attempts at treatment have been made in the past by administering electrical shocks, psychotherapy in the form of threats and the 'pinching' technique. However, in the author's personal opinion and experience, such drastic modalities need not be attempted. Tender love and care are sufficient.

The Future:

The author wishes to start a support group for individuals with Status Diplomaticus and their caretakers. 
He hopes to receive a Nobel Prize for his contribution towards the understanding of the condition and also hopes that International Diplomaticus Day be celebrated on 24th November, which happens to coincide with his Birthday.