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Thursday, May 17, 2018

First PEP - Days 7, 8, 9, 10, and so on...

Well, I lost count.

I didn't miss a single tab. But I have, as usual, missed on writing the experience.

There are indeed some highlights.

First, a house surgeon and his friend from my college came all the way to Nugu and our hospital after reading my posts. I guess I put enough philosophy in his head that he comes back and joins here later.

Then, I'm making good progress in my thesis work, interviewing patients about their perspectives on how they became sick. I have interviewed three patients till today. Each interview gave me a completely different story. I have even moved to Asha Kirana hospital asking permission to interview patients there.

Also, Amazon made three deliveries. My favourite book - The Emperor of All Maladies, my favourite stethoscope Dr Morepen ST 01, and Tripti Sharan's Chronicles of a Gynaecologist. (all affiliate links) 
I started managing my tasks with any.do, and it's going well till now.

Somehow, I'm on a streak!

Wednesday, May 2, 2018

First PEP - Days 4, 5, 6

Days fly by as usual. It's already day 6 and I'm wondering what I did on day 5. (I slept all day).

Day 4 - Monday, 30th April

I had general OPD duty. In essence I was jobless almost the entire day. I sat in the injection room and saw some 10 patients.

This morning I had tried to swallow the LPV/r without any water. It wasn't a very good idea as one of it got stuck to the throat and I almost had to do Heimlich on myself.

It's the day we went to Nugu and savoured garlic bread and churmuri prepared by all the ladies.
Busy kitchen at the ladies' place


Not conspicuous: Ram struggling with pepper powder in his eyes
On the way back Kishan & Suchitra ran out of petrol. So I had to empty a 1 litre bottle of water into my throat and fill petrol in it. Swathi and I went on a scooter ride after about an year today.

Day 5: May day

All I remember of this day is sleeping all day. I tried to get some useful work done after waking up in the evening. But having finished dinner, I slept again.

Ah, ah. I also sent an email to the canteen manager regarding the legality of "cooling charge".

Day 6: May 2, Wednesday

My first shift in the new ED. I spent half an hour with the new defibrillator. Skanray as they call it. Sankar Ray as I call it. Sliding out the adult pad for getting the paediatric paddles was the most interesting part. Still wondering whether the whole machine can act as an AED.

Only 3 cases came to the ED today. One of them was a lady in labour and I sent her straight to labour ward. The lady with fracture of leg? Straight to x-ray. The sad one was the man with MDR-TB, diabetes and cellulitis of a limb, had to send him to Mysore as well.

The computer network in the hospital was in partial disarray today thanks to the lightning and thunder last night. Oh, man! Yesterday there was a bolt of lightning and ear-deafening thunder right outside my window; I thought I died. One can only imagine how the poor electronics must have felt.

The thunderstorm is back tonight. I came to the hospital to finish this blog post as the power supply keeps getting disturbed in my room. And there it goes, another strike on the radio station above us. I sure will need an audiology check-up soon.

Earlier when I was in my bed, I felt my calf muscles ache. Myalgia is an early sign of acute HIV, you see. Had to brush up on the basics of acute infection. Also had to read three studies on the failure of PEP in health care workers. Seems like the right regimen wasn't chosen or there were adherence issues in most of the cases. I might also have been part of a world record by receiving PEP at around 15 minutes which I think is the earliest anyone has ever received PEP.

I might be having some minor reaction to the PEP as I feel abdominal discomfort (in the form of flatulence) and feel like the stools are coming out faster than usual. But apart from that, the pickle in the canteen is making me eat very well.

Sunday, April 29, 2018

First PEP - Days 1, 2, 3

After having done the "Perfectly Messy Prefect" series and "Jog Journal" series, I have now gotten the opportunity to start a new series - on Post Exposure Prophylaxis.

Let's start with the good news. I put a central line in a patient (that's my first time after MBBS and the first time I was confidently doing it on my own).

This patient who's been admitted with Cryptococcal antigen showing 3+ in their CSF needed lots of amphotericin for two weeks. Putting amphotericin in a peripheral venous line is okay, but it can soon lead to thrombophlebitis and both patient and doctor will have a hard time managing it. So we decided that it must go through a central line.

And it was imperative that this happened in the new emergency department that was inaugurated the same day. Dr Ram was around and his guidance is better than the ultrasound guidance he gives.

I will put a better picture of the new ED in a future post


First thing we settled was whether the artery went lateral or medial to the vein. Of course it goes lateral in the femoral canal (NAVY). And nature will never let us have easy mnemonics that apply everywhere. That means artery should go medial to vein in neck. Yet I guessed that it went lateral. Anyhow we immediately confirmed with the USG that the common carotid went medial to internal jugular. The vein was there large and compressible just below the skin.

After pressing the vein some 21 times to get the point on the skin where I had to prick, I pricked a bit lateral to that point. Yet, thanks to ultrasound I could move a bit medial and get into the vein in one go. In went the guidewire, then dilator and then the catheter itself.

Having placed the catheter, I just had to put two sutures on the clips to hold it in place. I don't know what made me choose a round bodied cat-gut. Or I do know - it was the cheapest among the suture materials that were lying around. A round bodied needle never goes easily into the skin. And the way I hold a needle, I do not get enough pressure on the tip. No matter how many times I have tried to correct it, I hold the needle wrong every time.

And the holder slipped just enough for the needle to go through my glove and make a tiny cut on the distal phalanx of my left ring finger laterally. It wasn't deep at all. Maybe one layer of skin was cut out. The direction was tangential. But it left a cut big enough for everyone to see.

And I'm also fortunate to have good colleagues who spoke sense in to me and prevented me from neglecting the prick. I removed the glove and confirmed the prick. There was no blood or anything. Yet I put the finger under running water for more than 5 minutes. And straight I went to the counselling room to get my PEP regimen.

Tenofovir 300 + Lamivudine 300 0-0-1, Lopinavir/Ritonavir 200/50 2-0-2 it would be. 5 pills a day is a lot of pill burden for a person who hasn't had a paracetamol tablet in 5 years. But I was really curious about experiencing PEP.

And within 15 minutes of the prick, I had swallowed the first set of three tablets. There was no nausea or giddiness or anything for that matter. I also got my baseline investigations done. My CBC was perfect except for high eosinophils. I do suspect there are some worms inside me. Maybe I should get an albendazole also, anyhow I'm getting bombarded my antibiotic this month. Creatinine, SGOT, SGPT everything was okay.

I woke up to alarm next day. I didn't want to wait 16 hours before taking the second dose of LPV/r. I took it at 14 hours. I had kept some Bourbon biscuits last day because I knew I would not get breakfast that early. I even had a masala dosa at around 9 am. Didn't feel much of nausea. But my bowel was irritable. I think it was irritable much before all this began. From the day we attended that marriage at Saragur town. Anyhow the masala dosa kept me asleep throughout that morning.

I had kept another alarm for 6 pm Saturday. This one was for the TDF+3TC that I had at 26th hour after the first dose. And then the LPV/r at 8 pm. I don't know if it was gastritis or nausea, but I wasn't really feeling hungry and had only an apple to eat with these.

And then it was today. I woke up at 6 (yesterday's alarm memory?) and slept again. The 7:30 alarm went off and I was actually up when Swathi called me to make sure I woke up and took the tablet. I took the next two LPV/r and went for breakfast.

Right after breakfast I left for Mysuru. Did feel nauseated in the bus that took half an hour to start. Not sure how much of that can be attributed to reading on phone screen in a moving bus. Anyhow, once sleep crept in, there was no other feeling.

At Mysuru I went with a friend to this really nice place called "Khushi". It's a home converted into a hangout cafe. There I had ragi pancake, oats with almond milk, and peanut butter smoothie all without vomiting.

On the way back to bus stand, I dropped in at KR Hospital. Went to the medical ICU to see a patient we had referred here the previous day. Also went to the casualty OT and found it the same level of activity at 2 pm as it used to have 2 years ago - an intern or first year PG struggling to put a catheter in, the ortho intern proud of the slab he put, and patients with tubes running out of various orifices.

I came back to Saragur in a sunny bus ride and was really hungry. Quickly had my tablets and then a full plate of rice and sambar. The mango pickle these days in canteen is coming closer to real mango pickle from back home.

2 from the big one and one from the small one

Monday, November 27, 2017

Patient Inclusiveness in Rounds, Sex Between Serodiscordant Couples, Role-plays, PrEP, PEP, Anti-Retroviral Drugs, Drug Resistance, and what not!

This weekend was fun! I am grateful to a lot of people for it being so.

It started Saturday morning with grand rounds, as usual. We were joined by Dr Ramakrishna Prasad (RK), Dr Ashoojit, and Dr Praneeth Sai. RK was leading the rounds. And he introduced the concept of patient/family centred rounds wherein we include the family in the discussion and make them feel a part of the process.

That meant I talked to the patient in front of everyone and let him describe his problems in his own words. This allowed gleaning certain facts of his life that were also much useful later in the day while talking about other aspects of care in HIV.

What followed was journal club by Dr Swathi in the training hall. She presented "Living with the difference: the impact of serodiscordance on the affective and sexual life of HIV/aids patients" a topic that greatly interests her.

They interviewed 11 carriers and based on the theme of sexuality after HIV infection between serodiscordant couples found four topics articulated:
  1. Fear of Sexual Transmission to the Partner
  2. Sexual Response Alterations
  3. Sexual Abstinence
  4. Sexual Life Maintenance.
Based on this experience, there was a role-play session where Dr Praneeth volunteered as an HIV positive patient and I as his spouse and Dr Swathi would counsel us about our sexual life.

That's when the groundbreaking reality of U=U was introduced by RK. Apparently, studies like HTPN 052 has shown that when the viral load is undetectable as a result of ART, the virus is untransmittable! This must bring great joy to serodiscordant couples who have been having poor sex life after diagnosis.

With that in mind, the role-play went ahead in letting the couples know the latest science and choose what they like to do going ahead - abstinence, safe sex, or unprotected sex. (Of course keeping in mind that other STIs can get transmitted through unprotected sex).

Then we spent about an hour discussing on thesis topics that we would want to work on for our fellowship using frameworks like the logic model and SMART criteria.

I had fancied the concept of using technology (phone alarm) to improve adherence to ART. Based on that initial concept our discussion took us to a mixed method study on the pattern of adherence, associated demographics, need for adherence support, and factors for poor adherence because we thought there is no answer to these questions in our setting. [I can imagine myself interviewing patients admitted in the ward probably due to an opportunistic infection they got as a result of poor adherence leading to poor immunity, trying to draw themes on the reasons why they don't take medication; and also probably finding correlation between parameters and good adherence]

Next, Dr Swathi finalized that her study would be on the topic of sexual life of serodiscordant couples. She would find out the fears these couples have. She would also take the latest science (U=U) and collect reactions.

Dr Praneeth would be working on PrEP and PEP, how counselling improves the rates of PEP or PrEP, their effectiveness, and so on.

We all agreed on a rough timeline - two months for proposal and ethics clearance. Two months for data collection. Two months for thesis writing. And then we had lunch.

The initial schedule for the evening was theory classes by RK on various topics which he morphed a bit into Feynman technique of learning. We were asked to take up a topic and explain using the white board. And whenever we hit a roadblock he would come up with answers/questions that would help us understand the topic or the lacunae in our knowledge. (One of the many inspiring techniques RK would demonstrate in these two days).

Swathi went on with acute HIV. How does acute HIV look like? Can we diagnose HIV based on symptoms? How soon can we diagnose it? What is the natural history of HIV like? (The graphs we had to come up with showing CD4 count and viral load over time in HIV, merit a post of their own)

Then I had to talk about anti-retroviral medications. I tried to draw the lifecycle and then explain where the various drugs acted at. And then, while trying to give examples for each class, did I realize that I knew very few ARVs. TLE, ZLN, over. There seems to be a world much beyond just these.

On demand PrEP vs Daily PrEP. This was what Dr Praneeth talked about. He's been behind PrEP and PEP for a while as evident from his research interest. While I had no idea about Pre-Exposure Prophylaxis (PrEP), let alone the different modes of administration. Anyhow, here's an article that says on-demand PrEP is as effective as daily PrEP.

Next, Dr Ananth introduced PRIME theory of motivation in the context of smoking cessation and we did a little role-play on a smoker and doctor counselling them to quit.

Sunday morning Dr Ashoojit and Dr Praneeth joined rounds and we listened to the stories of two patients - one who had their son living separately for the fear of catching the disease, and the other who had the story of TB but just not the evidence


Then we had a test.
  1. Sita, 26 y/o F, from HD Kote, presents to SVYM after she finds out she is pregnant (LMP 4 months back). Married 6 years back. Husband: Construction worker. Her HIV ELISA returns as REACTIVE
    How will you approach her care?
    - Key history & examination
    - Investigations
    - Counseling messages
    - Therapeutic interventions
    - Health promotion/disease prevention
    (3 marks for each point)
  2. Her husband, Ravi, is 31 y/o M. Further questioning reveals that he is known HIV Positive, but never told Sita. He says he got it from an older married woman he was sexually active with in the past. He was diagnosed at age 28. Reason for testing: Wt loss (10 kg) (Wt at diagnosis 54 kg), oral thrush. Initial CD4 count: 76. Treated with TLE. Denies alcohol use, reports never missing his doses. <A graph with CD4 count showing improvement in the first year of treatment, till 154, then falling back to 38 by 3rd year. Corresponding fall and rise in weight>
    - Develop a problem list (2 marks)
    - Choose 1 clinical hypothesis that is most likely to explain the clinical picture (2 marks)
    - What investigations would you like to send for? What results do you expect to find? (6 marks)
    - Given your knowledge of the husband's case details, will you manage Sita's care differently? (5 marks)
Here's the much more beautifully laid out original

We wrote answers to these questions in half an hour and self evaluated. A discussion ensued on what each person missed, and what each person wrote. This was fun as well as thought-provoking.

And then, Dr Varsha took the fastest and most interesting 15 minutes of the whole weekend to talk about genetic mutations and drug resistance in HIV.
Screengrab of the Stanford HIV Drug Resistance DB
She was evidently excited about the Stanford HIV Drug Resistance Database and talked about 3 mutations that she wanted us to read about - M184V, K65R, K103N. Her explanation of what protease does, and how NRTIs and NNRTIs act opened my eyes to a whole new world of possibilities.

There is more to write about each things I have mentioned here. Maybe another day. Do reach out to me if you're impatient.

Saturday, September 16, 2017

Documentation in Medical Records

I have documented my love of documentation elsewhere. I blog to document my life.

I'm not perfect at it. Nobody ever can be. Because perfect documentation would take more time than the original act of knowing.

Imagine. If you were documenting a visit to a nearby tourist attraction. How would you document it perfectly? You could definitely write about it in much detail. But how much detail is enough detail? Would you be writing about everything that you saw on the way? Would you be writing about your thoughts on what you saw? Would you document the planning process? Would you care about other sensations like smell, warmth, etc?

Recording a video might capture more detail. But a video can't really capture your thoughts unless you speak into it. Even then it can't capture your reflections unless you reflect loud while shooting yourself. But how much can you videograph? Where do you store these videos

Maybe it's possible to categorize and selectively review any moment from the past using a futuristic memory capture program like shown in Black Mirror. But, seriously, who has the time?

Perfect documentation is not equal to complete documentation. Documenting all the tiny details would not be relevant at times. But sometimes the tiniest detail can be very relevant.

This is especially true in medical documentation. Patient's cousin is a diabetic - relevant. Patient had a day old chicken curry in the morning - relevant. Patient was advised to take so and so medication before food two times a day for 5 days and review if his problems didn't subside - relevant. Patient is anxious - relevant. Patient reached hospital at 9 am - relevant. Patient teaches in an anganawadi - relevant.

Documenting all the relevant information is important.

But, when there is too much information, organization of this information in an accessible manner itself becomes important. Because ultimately, the purpose of documentation is to preserve information for the future so that when one looks back in time, it is possible to accurately interpret history (and avoid controversies. Did Swami Vivekananda's speech at the Parliament of World Religions get voice recorded?)

Courtesy: Some CS Professor (Reddit)
I once saw my consultant Orthopaedician write the timeline of a patient's visits to hospital and management in her case sheet. This was not really necessary for him to document because none of the information was new or not available elsewhere. Her discharge summaries and OPD case record had all those details. But what the consultant did by summarizing all that in a single page is make it easier for recalling everything at a single glance. The timeline itself added value to the documentation.

Elsewhere, A Country Doctor writes in his blog:
Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.
This was an eye-opener for me. I am used to knowing patients' name by their case record and calling them by their name. But many times than not, I would never know the name of the person accompanying the patient, let alone their children or pets.

Documentation is an art. It can be perfected only when you know the subject deeply. And when it comes to medicine this amounts to spending quality time with the patient and getting to know them rather than just their illness(es). Like artists, make your documentation picturesque. And people will enjoy it.

Tuesday, August 15, 2017

Fellowship in HIV Medicine - Interview

A day before independence day, after the long wait of more than three months, the FHM interview took place at SVYM office.

I was on duty and was checking on a newborn with tachypnea (probably transient tachypnea of newborn) when they called me upstairs for the interview. I had others fill in for me and ran to the interview room.

My friend Swathi went in first and sitting outside I could hear them talking about the challenges faced by a clinician and public health worker in managing HIV because of the stigma associated with it and how by consistent effort we can influence at least families of HIV infected people to look at it like any other disease.

I had practised multiple times the answer to why I wanted to join FHM. I look at it as a course in infectious diseases and India is a country still struggling with infections. My personal interests and career choices are probably going to take me to places where being good at managing infectious diseases would be an advantage. Also, SVYM is a great place to be at. The clinical, academic, and overall atmosphere here is wonderful. The kind of people whom I get to work closely with - no mention. Not to forget, I was never interested in a PG seat (till I started working here, that is).

The conversation then came to how I should rigorously finish my dissertation, starting early and keeping good quality because Indians can also contribute to the knowledge base that medicine is built on.

I didn't mention my unrealistic perfectionism that kills most of my research ideas. Maybe articles like this will help me look past RCTs as the only study worth doing. Wish me great productivity.

Friday, August 11, 2017

Do Cats Get HIV?

Blalock-Thomas-Taussig shunt is a surgical technique used in colouring Blue Babies pink.

Last week we had a baby who was referred for cardiac evaluation come back with a report saying she had Tetralogy of Fallot and needs a BT shunt. The parents had not gotten it done yet. Still, the baby wasn't blue. Because she was too anaemic to have enough deoxygenated haemoglobin to be cyanotic.

I had to watch Something the Lord Made that night. It is the heart-touching story of how B(T)T shunt was developed. If you don't cry with Vivian Thomas at the end, you should probably check your cardiac functioning.

In the backdrop, there are dogs. Blalock and Thomas would perform their surgical experiments on dogs. Countless dogs who have lost lives for (human and animal) science. Thank you dogs!

Talking about dogs, there are cats too. I found this post on reddit.

The Litterbox Hero
Cats don't get HIV - it's Human Immunodeficiency Virus, for viral Lords' sake. Or maybe there is a Feline Immunodeficiency Virus! And when you read more about it you can find that FIV and even HIV is used in gene therapy.

Fucking science.

On the other hand scientists are marching to protect science. And being rational is increasingly being viewed as treacherous and anti-nationalistic.

People just can't understand.

I had just figured out a name for the problem one of our patients who got his tissues necrosed after an IM diclo injection had. It was Nicolau Syndrome (or livedoid dermatitis or embolia cutis medicamentosa - remember the name that can make you sound really good).

And there walked in a patient who had worked too much and was having pain in the forearms and knees. He had to get an injection. It didn't matter to him whether I gave him 3 mL normal saline or 20 mg morphine. They just have to get injected. Good luck talking them out with Nicolau Syndrome or even anaphylaxis.

When the pleasures and shortcuts are so tempting, why would people prefer the rigour of science or protocols.