Image, Event

October of this year, we visited the Norman Rockwell Museum in Stockbridge, Massachusetts. This painting by Howard Pyle gripped my attention. With a sheer force, it thrust my imagination to the horror of the situation. At arm's length, these men are facing each other. Another man of flesh and blood. Horses neighing, alarmed by the clamor, perhaps injured already by whips of terrified master and sharp bayonets of master's enemies. At this proximity, these men perhaps see their enemies' eyes, face. How do they lift their sharp swords or pointed bayonets and shove it into another man's throat or chest or belly? Whoever plants the sword to another's chest must be numb with an overwhelming force. The stabbed one must be terrified as the darkness replaces the light of life. Those who have not yet planted a sword or been stabbed must be scared, terrified, uncertain. This is a feeling of undescribable anguish, horror and terror. 

It is an image that incites an imagination about the event. 

In the past few days, the world has been subjected to an event, that incites an even terrifying image of horror. A young woman in Delhi is lured into a bus along with her boyfriend. Six men assault them with iron rods, rape the girl, and throw them out of the bus stripped naked and unconscious. We learn today that the girl died.  

Who are these men? These six men. How did they decide they will take a bus down the road, lure a woman, rape her, and kill her? What must have happened in that bus? Six lustful evils preying upon a woman. There must have been shrieks, cries, moans. How did these evils' eyes look when they impaled the  helpless woman's belly with an iron rod? This is an image of horror, pure horror. 

Faulty Analysis

Republica had published an editorial regarding failure rates of medical students at Nepal Medical Council (NMC)'s licensing examination. A little irked by shallow analysis I had sent a tad sharp comment online. They decided to give it a space on print edition the next day: 

The licensing exam failure rate of students who went to medical schools in certain countries, namely, China, Russia, is high. I have heard the argument of requiring students planning medical school overseas pass Kathmandu University's medical entrance examination tests, at varied platforms. It might add some safety by helping select qualified individuals, especially if the exam is standardized to test qualities that determine a good doctor (and not just knowledge, as is done now). However, even if this has any significance, it will perhaps be minuscule. The main action will be in what the student gets in her 5 years of medical school. Until we think about assuring a basic minimal quality in those 5 years, any other efforts will be trials with high chances of failure. 

But what we can do immediately is build mechanisms to rehabilitate these individuals who are doing poorly in the licensing exams. For example, we could require anyone who fails twice consecutively to do 2 years of rotating internships at selected academic institutions in Nepal before they can apply for the license. All who fail, either they have done medical school in Nepal or overseas, should be treated the same. This exercise of demonizing students from select countries is a form of bigotry that lumps all grades of students together. It is unfair to diligent students from those places. And it is ultimately going to serve no good. Even these poorly-trained students  have already spent a fortune and ripe youth at these institutions. They are ultimately an asset to health manpower-deprived country. We need to find ways to remedy their deficiencies and give them a proper place where they can  contribute to the care of sick and infirm of this nation.   

A Squatter Settlement

There is a squatter settlement in Maharajgunj, just behind the staff quarter of Institute of Medicine. On my way to and from work, I sometimes take the way through this settlement. There is something about this settlement that gives a positive vibe. 

It is a crowded place. In a narrow strip of sharply inclining land, it is a motley of shanty houses and few sturdier ones separated by tight alleys. A loud whisper is perhaps audible to the settler's neighbor. Wandering chickens and ducks in these alleys, I am sure, find treats at several of the owner's neighbors. 

But this settlement seems cool about the sardined living conditions. In these narrow empty spaces, which are neatly stone-paved, children are jovially playing badminton and hoola hoops. Adult males are engrossed in several groups of carrom board games, back from work and winding down or unemployed and killing time, I do not know. 

Furthermore, the organization of the limited space is quite impressive. All the alleys are paved with concrete. In the slope, there are neat concrete steps in the alleys gyrating down the hill. At the bottom of the settlement, there is a remnant of river, which now flows with sewage composed primarily of  nearby city dwellers' excrement. They have managed to cover the river completely with concrete structure so that the filth is hidden. The only evidence of that horror is the open river, just before the squatter settlement starts. This open disgust snakes up the non-squatters settlement, malodorous and ugly. It seems like no one cares in those turfs. 

 

Compared to the non-squatters, somehow, these people appear to have been able to do something of common good. It is obvious that they have been able to organize things around them. These narrow alleys are clean, they have common space to play, a big water tank with a tap stands upright at about the center of the settlement that everyone can come to collect water, a filthy open sewage is covered throughout the settlement. 

How have they been able to do it? Did some donor do it for them? I doubt it. Are they unified by common predicament that is driving them to work together for common good? Are they unified at all? If so, what is bringing them together? It does look like development. And what does it tell about our constant whining about the lack of funds for development in our communities?

These are some of the questions which a physician who deals with rotten/rotting/degenerating/broken body is perhaps ill-equipped to answer. But the distinction from indifferent settlements surrounding this squatter settlement can not escape his attention. 

Empiric Treatment

She came with her father-in-law. Wasted and pale, she looked withdrawn, dejected, and lethargic. They were from a village in Kavrepalanchowk. Her husband was away for a labor job in a Gulf country. For the past several months, she was having fevers, poor appetite. As it became disabling, she came to our hospital and was admitted for evaluation. Her fevers persisted. The only clue to her disease was the finding of an enlarged spleen. But several diseases can cause enlarged spleen. Even after several days of hospital stay, multitudes of non-invasive and invasive tests, a cause could not be pinpointed. So our hospital team decided to discharge her from the hospital and have the results followed-up as outpatient.

As outpatient, she had several more visits and a battery of additional tests. Her fevers persisted. On this visit, they came with the results of all these tests. I went through each of these tests. They were essentially normal, one after another. I told them that these tests did not tell us what was making her febrile.

At this stage, her father-in-law entered the pleading mode. Help us, please. We have exhausted our money in quest for the cause of the fever. Almost 40,000 rupees have been spent so far. We have been staying in a hotel to have these tests done and fevers haven't budged. We can not afford to stay longer. What are we to do?

Fever is not an endocrinologist's forte. On top of that, one trained in North America. In these shores, where shit infuses drinking water, cattle and humans share abode, almost infinite souls share a crammed room breathing each other's exhaled air, flies cruise feces and foods, mosquitoes camp between man and animals, weirdest of the bugs can cause weirdest of the fevers. A specific diagnosis is a mammoth challenge. Furthermore, my patient is in desperate financial predicament. Any further testing would be adding salt to their sores. What am I to do?

Many of my patients who come with fever also have tight purses, limiting exhaustive investigations. In desperate attempt to deal with these fevers, I have developed my own way of looking at fevers. The way I see it is, what treatment are these fevers most likely to respond to. For this, I put them in broad categories. Are they, for example: 
- Feces fever (caused by microorganisms found in feces)
- Viral fever
- TB
- Tarai fever (caused by several parasites)
- Non-infectious fever, etc. 
Another big category I have invented is doxycycline fever. This pseudo-scientific category includes a whole bunch of fevers caused by atypical organisms that respond to an antibiotic called doxycycline.  

After talking to the patient and examining her, I tentatively put this patient as having doxycycline fever. But as you may guess by my wobbly expertise on fevers, I can never be confident. What if this patient deteriorates? There is every likelihood that I will never see this patient, even if this patient is visiting my hospital everyday, just because of the way disorganization works here. Patients bounce back and forth between departments without someone taking up a responsibility. If she goes home, which she is highly likely to do because of financial issues, who knows what happens in some remote corner of Kavrepalanchowk? So I asked them if they have cell phones. Both the father-in-law and my patient had cell phones. I took their numbers and explained to them that I want to try a medication which she can take at home. I told them they have to come to the emergency room if fevers do not go away in 1 week. Otherwise, I will call them in 2 weeks. I put a diagnosis of ?Brucellosis on my chart and prescribed her doxycycline. 

At 2 weeks, I called her. She sounded perked up, and rather overwhelmed that I called. She said she was doing very well. Fevers were gone, her appetite was up, she felt that she was back to her normal. 

It was a big relief. Based on the results, this might sound like a wise decision but it is hardly that clear at the time of decision making. We call this empiric treatment. A treatment decision made based on hunches without hard evidences. Especially in academic setup, like the one I work at, this is frowned upon. Primarily because we see patients everyday who are indiscriminately put on many medications without compelling reasons. We emphasize to our students and trainees that there should be evidences and compelling reasons to make treatment decisions. 

Yet, when you face social and financial constraints to do expensive investigations you will have to make decisions on empiric treatments based on your clinical judgement. It is a fine balance of how much to investigate and when to treat empirically. For short term illnesses like these febrile illnesses, I am getting much more inclined towards empiric treatments. It's hardly relevant to the patient if the fever was caused by Brucella or Leptospira or Mycoplasma. If the fever goes away and they can get along with their normal lives, structure of the cell membranes of these micro-organisms hardly disturbs their dreams.

As everything else in life, diseases do not always submit to clarity. This demands for an approach which is equally fuzzy. Perhaps this is when the realm of the art of medicine starts. 

Horrid Butchery

Samuel Gross, a trauma surgeon from the 19th century, had this opinion about thyroid surgery: Horrid Butchery. Thyroid is a very important gland in the lower part of the neck. Several maladies can ail this organ. Some of which, for example, cancer, require surgical treatment. But this gland is enmeshed with blood vessels; there are precarious nerves, large blood vessels, tiny but important glands, and airway in vicinity which make surgery quite tricky. From 19th century's Horrid Butchery, this operation has evolved to quite a safe surgery in trained hands. But risks are still substantial, especially if the operator is not well-versed and surgical safety protocols are not properly followed. Where I trained, we had national pioneers in endocrine surgery, and we endocrinologists felt safe to send our patients for surgery at a relatively low threshold if there was a reasonable indication for surgery. But I have had to leash my natural inclinations for my lack of sufficient knowledge about available expertise and facility for thyroid surgery in Nepal. I remind myself, this was once a Horrid Butchery, until I get a good confidence about our surgeons I will send patients to surgery only as a last resort. 

At clinic today, an intern came up to me to discuss a patient that she was seeing. The patient was sent to medical clinic from surgical department to get blood sugars controlled before surgery. This was a 69 year old woman from Saptari. She noticed some pain in the neck nearly 6 months back. When evaluated at Biratnagar, she also got an ultrasound of the neck which showed two small swellings in the thyroid gland. They biopsied these swellings. There was no evidence of cancer. She was given thyroid hormone with an idea that it may help shrink these swellings. But she continued to have some vague pain in the neck and was referred to Kathmandu for further evaluation. 

At Kathmandu, she underwent a repeat imaging of the thyroid gland which again showed those same swellings. One was described as complex (had areas of fluids separated by solid tissues) another was less than a centimeter in size. The radiologist, reported it as having a possibility of cancer based on the "complex lesion" and that it needed a biopsy for evaluation. She underwent a biopsy of these swellings: this did not have enough tissue to make a diagnosis. On the repeat biopsy, it was reported as not having any evidence of cancer. But the surgeon who saw the patient was worried about the report of possibility of cancer on imaging studies. So he decided to have patient undergo surgery. She was admitted to the hospital. But her blood sugars were out of control. Surgeons hesitate to operate when blood sugars are high because it increases the risk of wound complications. They consulted medical team. Medical team started her on insulin but blood sugars were still not controlled and surgery was cancelled. She was transferred to medical ward for blood sugar control and after a few days, since her sugars were still not controlled, discharged home with instructions to follow-up at OPD to adjust insulin dose gradually. 

Having been trained in the problems of thyroid, I looked at each of these investigations. The description of the "complex nodule" and also the printed pictures of the nodule was something called "spongiform nodule." For the size of the nodule that the patient had, it is recommended not even to biopsy spongiform nodules because the risk of this being cancer is very low (99.7% of these nodules are not cancers). So the radiologist had over-called the finding. The surgeon relied on a misleading interpretation. By this time, the patient had spent several days away from home in Kathmandu, many of those in hospital bed, scared she had a neck cancer, ready to have neck slit open, forget about the rupees than vanquished in this anguish. 

So what do I tell her? 

I explained to her what I thought of her problems and investigations so far and that her chances of having cancer is extremely low. I told her, if I were her or she was my mother, I would not have the surgery. She looked very relieved by this conversation. But she did ask, "Why did I have to go through all of  this?"

I do not know. I can not put blame on any one person. Radiologist over-called it, but it was not a mistake. They try to be safe than sorry. You do not want to miss a cancer but in this process you have some false positives. Surgeon was also not wrong to plan to take out the gland for a concerning radiology report. But what patient went through was a real hassle and a real risk. 

For me, this has been a lesson. A lesson in the backdrop of the debate on specialization. There is a rigorous debate about patient outcomes and specialty care. Studies are divided, some studies show patient outcomes are better with specialist care. Others show equally good or better, yet cost-effective care by generalists. So there are believers in specialist care and proponents of generalist care. Although I am a specialist, I have had warm feelings for generalist care. Especially in the context of resource poor Nepal. That is one of the reason I have been doing more of internal medicine at this public hospital, than my specialty of endocrinology. Besides, our public healthcare systems are so rudimentary and rooted in crisis mode (doing patch work for crises that come along) it just does not seem conducive for specialty care. 

However, with the event like above, it seems to me that specialist care will be profoundly important for Nepal. What this patient went through was a totally unnecessary hassle with an incredibly high risk. It could have been prevented if a trained endocrinologist had at one time evaluated the patient. It is not the same Nepal, from 8 years ago when we finished our medical schools. At 4000 rupees you can now get a CT scan and it seems like there are more Nepalis now who find paying few thousands of rupees not a very big deal. Multinational laboratory chains have made it possible to get any lab test you want done for few extra bucks. The volume of investigations patients go through is astounding. Perhaps done unnecessarily many a times, driven by profit motives, in many of these for-profit institutions and private practices where they get financial remuneration for ordering lab works. Accordingly, complexity of information available on the patient's illnesses and lab findings is growing massively. This gives an opening for misinterpretation of these lab and investigations results. There has to be someone who can focus on specific areas and build expertise to interpret these complex results.

Study data on specialists vs. generalists may be one thing, but when I think about this patient, and ask myself, instead of me if any other endocrinologist had seen this patient, would they have prevented this hassle and risk? The answer is a solid yes. These are basic stuff in our training. 

There must be several other patients who are getting their sugars controlled right now. They will undergo a Horrid Butchery with splendid sugar levels. Knowing that these patients did indeed need surgery would be nice. Wouldn't it?

Manufactured Success

"Kidney transplantation at Bir Hospital is world-class," declared an article in Kantipur. Perhaps elated by this apparent achievement, it even published an editorial praising the success. 

Great!

It sounded like something to celebrate. Especially when we are working in such resource-poor setting with several limitations. Such success should be morale-lifting for anyone working in the field. 

But the news sounded too good to be true to me. Primarily because of extremely sloppy care my patients had received when I sent few with advanced kidney disease to the same folks that tout these results. My earlier sympathy for a fellow public institution has faded and I have stopped sending them patients.

Are they doing such superb job? Maybe I had misunderstood them. I do not have access to their original data. But going by what data have been given in these newspaper articles, it does not actually look very celebratory. 

The only data that I could make sense of was transplant rejection rate. It says Bir's kidney transplant rejection rate is 11% compared to global average of 20%.  I assume this is annual graft rejection (the transplant program seems to be just 4 years old to give a longer-term outcome. And 20% global outcome data is for 1 year graft rejection rate based on my non-expert search of web. The range was actually 10-20%). 

All these transplants are living donor kidney transplants. So the 1 year graft survival rate is 89% for Bir's program. Corresponding data for whole of the US is 96%. This seems to be a huge difference from a claim of world-class outcomes. Perhaps it could be claimed that Bir's outcomes approach that of global average. But being closer to global average does not mean being a "world-class" in the usual sense of the word. All this hoo-ha appears to be self-congratulatory chest-thumping from statistical white lies. 

While it may be very healthy to celebrate success, however small, this propensity to manufacture delusions to feel good might be rather detrimental. From what I see everyday working at a public hospital, humility and self-reflection to rectify and improve our dismal healthcare delivery system is more important than ego quenching from such manufactured successes.  

Bags of Medications

The way health care operates at public hospitals in Nepal offers very little opportunity for outcomes based improvement. We do episodic cares. If the patient is admitted to the hospital, care is targeted to the acute illness. Once the patient leaves hospital, fate alone determines if you will see this patient ever again. On the outpatient care, where a long-term patient follow-up should be the rule, our clinics are so disorganized, patient hardly ever sees the same doctor on subsequent follow ups. In essence, our outpatient care is also episodic. So our doctors rarely get to see the outcomes of their deeds. While it deprives the doctors an opportunity to improve based on outcomes, provide continuity of care to the patient, I think it also contributes to an epidemic of of cocksure, megalomaniac doctors with god complex in our society.

Unfortunately, heroic enunciation of a well-read doctor does not seem to be enough for a good patient outcome. Well-written prescription alone does not suffice. Small detail can make a huge difference. I am witness to these differences as I see patients everyday at the outpatient clinic. 

I so often see patients with heart failure who come to the clinic bloated and breathless. They have been off medications for several days to weeks. When asked why they were off medications for so long, they say they ran out of medications they got at the last visit and they were not due for next visit until now. I am surprised by how often they think medications outside Patan Hospital don't work and that they can get medications at local pharmacies by showing their current medications without a prescription. A simple conversation would have perhaps helped. 

This demands of a thoughtful doctor. But that might be the next level. More concerning is the plethora of medication error. Sometimes a medication is missing. At others, a medication that was started for short-term is being continued indefinitely for no good reason. Unable to trust what is written in the charts, these days I have made a habit of asking patients to pull out their medications and tell me what they are doing with each of them. Some of what comes out of this exercise, while exasperating, is also heart-wrenching. 

For a large number of patients with breathing problems we use medications that are inhaled. The types we commonly use in Nepal come in hard capsules. Patient has to put the capsule in a device which twists and breaks them releasing medications to inhale. The patient I had the other day was from somewhere remote. She was breathless and cachectic. As I unpacked her plastic bag with medications, the twisting device was nowhere to be found. But she did have those breathing capsules.

Are you taking these medications? Yes. How? I am eating them in the morning and the evening. 

She had no idea that these medications were to be inhaled using a separate device. It is not just errors that I have encountered during these bag inspections, some are moving improvisations family do trying to help their loved ones. 

A mother-daughter duo from remote Nepal came to me a few days back. The mother had liver failure from excessive alcohol use. In addition to medications, we had instructed her to  absolutely abstain from alcohol. As I was going through her medications one by one, at the end, her daughter also pulled out a Mountain Dew bottle. She was boiling Mountain Dew and giving it to her mother in hopes that it will satisfy her cravings for alcohol. 

 The simplicity of our patients begs for aggressive meticulousness from our doctors. 

Patan Hospital Protests Updates: A Mess

The Prime Minister, also the chancellor of Patan Academy of Health Sciences (PAHS), decided to suspend the newly appointed vice-chancellor of PAHS. He reversed his decision [ultimately he is the one who appointed this controversial vice-chancellor (VC)].

But the tale does not find its coup de grace there.  This VC has decided she wants to fight back legally. We are told she is taking help of some star lawyers. The court has given a stay order. So the sacked VC is officially still our VC. 

With this, we have officially joined the typical mess our larger political system is in. In this mess, a rich philosophical discourse can be conducted in purely technical/philosophical terms about what is right and what is wrong. 

In the court, perhaps an intense debate will happen. Who is right? Who is wrong? What is right? What is wrong? What are the evidences?

But for a novice physician like me, who saw an overnight transformation in energy and work ethics of care providers in the hospital from a political appointment, fundamental questions will be: Why did it happen? What did it do? 

High-Rises

High-rise buildings like the one in the middle of the picture are growing in this city. Amid the shabby concrete houses of this city, their grandeur stands out. When the darkness of the night wraps the valley, unruffled by our perpetual load shedding, these buildings glow with lights perhaps generated by backup power systems. The contrast at night is sharper. They are the survivors in this city where night favors darkness.

They must be the lucky ones who get to live in these buildings: ones who do not have to depend on the electricity that the national power grid supplies. The power grid that is raped by scarcity, incompetence, corruption and ruthlessness. I hear you have to pay millions of rupees to buy these apartments. But if you own that fortune, you do get a chance to escape the darkness of this city.

These glowing buildings at night are the epitome of power structures in Nepal.

If you have enough money, you get uninterrupted electricity (fair enough) and water . If you know somebody at a public hospital, you do not have to wait in line to be seen. But be prepared to let those people in front of you, even if you have waited in line since early morning, if you are a nobody. Hospital beds can be emptied if you hold some power (political office, connections,... you know it). But be prepared to be shoved out to another hospital if you are a nobody. Even if you are paying a substantial sum, do not expect to get a reciprocal quality of care if you are a nobody, either at public hospital or private ones. Be prepared for endless tomorrows to meet the government regulatory requirements if you are a nobody but everything can be done from home if you are in the power structure. 

Let me give you an example: our government gives a subsidy for hemodialysis to patients who have kidney failure. For that, they ask you to get photocopies of citizenship certificate, few passsport-sized photographs and a statement from VDC stating that you need financial assistance. If you are an illiterate peasant from Sankhuwasava, imagine your ordeal. Do you have a citizenship certificate at the first place? How are you going to go to Sankhuwasava to get a VDC statement while you are lying breathless in a public hospital floor? But if you are a local political somebody, you will make a call to the VDC secretary on his mobile phone and have a villager hand-carry the letter to you the next day.  

I get a sense that the plight of powerless is growing. Our government is growing and so are the ones with access to power. Our intellectuals have run out of imagination, their only solution to all of our woes is additional regulation. Our oligarchs are ecstatic about bringing any new regulation. It creates an opportunity to exercise power and extort money. In this game, ease for those with power is still secured but life for the regular folks becomes tougher. 

It seems to me incompetence of our institutions is a bigger issue than a lack of elaborate regulation. Unfortunately, our incompetence and corruption is growing and these institutions are getting larger.

Stones

In my relatively rare taxi rides, I have found our taxi drivers chatty, in a good way: an unusual attribute for our service providers. This might be just a coincidence or perhaps they are primed by potential return in tips by this exhalational exercise of vocal cords.

Today's was a master of them all. His oration that spanned a ride from Tripureshwor to Maharajgunj would have convinced a novice that this bloke was the most knowledgeable person in the area of kidney stones.  Let me summarize:

Our conversation started with me pointing out dust in the air that was made more apparent by the bright car lights at night. You know, he began, the dust can make kidney stones. It makes 10% stones. If you live in Kathmandu enough, with all this dust, you are bound to have kidney stones. The smoke, chewing tobacco, all of them get deposited slowly and make kidney stones. Tomato is the most notorious one, it makes 50% stones. Another one is palung (spinach) that makes 20% stones. I learned all of this from a book that a bideshi (foreigner) gave. 

Was it in English? I ask. 

Yes, he says, it was both in English and Nepali. 

You need to drink 5 liters of water after each meal not to have kidney stones. Stone is a huge, huge problem he perseveres. 

Have you had a kidney stone? I ask. 

Yes, he says, himself and his wife. His wife got operated 2 days back for a kidney stone. It was this big, he shows me with his fingers. I used this same taxi to bring her back home from Dhulikhel Hospital yesterday, he declares. Then he veers off to a lengthy praise of Dhulikhel hospital; how they did operation with a total cost of Rs. 23,404 when at private hospitals they were estimating Rs. 150,000........