Remote Care of COVID 19 : deeply touched, hands free

I am a teleintensivist with over 10,000 hours of experience watching patients in ICU’s from over 10,000 kilometers away for the last 9 years . Today was my second day seeing patients admitted with COVID19 . I have never seen anything like this. It is a testament to human ingenuity, compassion, duty and expertise that patients are getting the best of care in the most trying of circumstances. Nurses and doctors, advanced practitioners and lab technicians, imaging teams and housekeeping-everyone is working and sacrificing their time and energy . It is a wartime effort and this is what true battles are made of-human courage and perseverance. I was unable to sleep well after seeing so many patients with the same illness , all unable to breathe on their own and completely dependent on the miracles of human technology. Nature has given us a challenge to come together and work together . The simplest of instructions to stay home and wash our hands is proving to be a tough task for many of us. We need to make sure that the instruction to stay away from each other to stop the spread of the disease is followed by everyone.

Many of us in this field have been busy with getting our health systems prepared in India. This exercise will definitely help in the coming weeks as the number of cases slowly increases. We have been fortunate-perhaps from a combination of viral impotence along with a sweaty humid climate . Of course the possibility that we have not yet seen the oncoming tsunami of disease is not unimaginable. Reaching out to your source, your God, your core belief seems to be one way to ask for strength as we watch global suffering. A modern jet can get us to the epicenters of COVID19 within a few hours and yet we are not ready to accept that those images could be us. Fate or destiny may still be on our side having given us a solid three months to prepare and benefit from better knowledge, HCQ and maybe even a mutated less dangerous virus. Only time will tell. Time-that elusive elixir that seems to slip away when you need more of it and seems to be in plenty when you are quarantined in your home. Let’s hope that when we think of COVID19 , the Hindi rap phrase “apna time aayega” meaning your time will come,  only indicates our freedom from our self imposed therapeutic distancing . Its quite simple-take a deep breath, suck it up and tell yourself and your loved ones – stay put to stay alive. Have a wonderful Ugadi, the New Year for over 70 million Indians from the Telugu states of India,  and wash you hands and don’t touch your face. With love, Sai.

This was written three weeks ago. Its now Easter. Same story. The world looks for hope from science and peace from mindfulness. Today would be a good time to resurrect our innate unity as a species . We must work together to ensure everyone makes it through with as few bruises as possible. Each one help one.


Doctors Day

What’s it to be a doctor ?

Essays have been penned , books have been written and movies have been made . What’s it really like to be a doctor ? Is it truly another world seldom understood by whoever dons the role of a patient ? Do doctors walk on water ? Can doctors actually be seen at the grocery store ? We are human . It’s a great thing that we are human because to heal we have to reach deep into our own lives , our experiences and our intuition . Our learning shapes our decisions but ultimately it’s our humanity that guides us . It’s fun to be a doctor . In no other profession can you work as colleagues with fifty years of medical school graduates . Seniority creates value by creating a better picture of disease and it’s varied guises . The camaraderie and soldier like group effect is absolutely life changing . Urgency , emergency , scholarship , constant innovation and empathy are the hallmark adjectives that we live our lives by . Juggling , integrating , enjoying our own families and children in the space of minutes stolen from a busy day of patient care and phone calls makes it meaningful . Missed dates , forgotten birthdays, automatic excuse from family gatherings are not what we want but that’s the reality of our chosen life . Despite ideas to the contrary there truly is no five-o-clock shut down shop in this world . Life must go on and saving lives is a full time job . Would I do this again ? Absolutely ! The privilege , the opportunity to shape our own lives through the well being of others , the friendships and trust formed with patients and their families cannot be replicated anywhere else . Financial challenges, professional hurdles , career speed bumps , complex work environments , jagged home interactions , sleep deprivation and physical exhaustion do not deprive the multitude of gracious , graceful , grace filled moments that our jobs give us . Our jobs are not work in the true sense of the word . It’s our life . Proud to be a doctor . We are here to serve always , healing mostly , listening constantly . Your friend and guide for a healthy life.


Kandakurthi: A story of rolling fingers and tragic pain

A brief glimpse into my day at a screening camp in northern Telangana

August 13, 2017

Long day . Completely tiring but feel energetic . Probably the fact that someone drove me the 200 km each way in a comfortable Innova . I was one of the several doctors who participated in a cancer screening camp spearheaded by Dr Chinnababu Sunkavalli , a dynamic and humanitarian cancer surgeon from my hospital . He runs a charity foundation  honouring his mother and has conducted several such camps . We traveled to the outskirts of the town of Kandakurthi in northern Telangana. It’s not far from the famous Basar Saraswati temple where many symbolically  learn to write their first script . The thought does cross my mind as we drive in the area that perhaps we will need a laptop in the future for those first words :).

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This one was a mega camp with many groups banding together – political party affiliates and cancer charity groups .Dozens of volunteer medical students , interns , dentists, a lung function technician, radiographers, pharmacists , a housekeeping team, nurses and other volunteers helped manage the over 2000 patients who showed up . It’s great and it’s sad . So many people lack organised primary care and screening opportunity from lack of awareness , lack of priority to health and perhaps systemic minimal / convenient support from health authorities . My focus was on the significant bidi workers in the area and smokers / tobacco chewers . We saw about 70-100 patients in my section – we lost count after a while despite trying to be organised . Luckily we were in grade 3 – yes we were in a nice school room that had a giant fan that kept blowing the papers away and was noisy enough to have me shut it off to listen to patients’ lungs.

It appeared that everybody had back pain and knee pain as I have seen in other such settings . The constant bending in farming and the sitting posture for the bidi workers puts a lot of strain on them. In addition we saw several women , many of them in traditional hijab who were current or former bidi rollers . Some managed to roll 1000 bidis in about 10 hours but had serious health effects from this tragic occupation . No one wore masks and no one wore gloves . They knew they had to wash their hands but they lived , cooked and raised children in this same environment. It is well documented that these  workers end up with similar effects as bidi smokers and can even get nicotine poisoning. One woman had  a finger damaged by the little sticks used to make the bidi     (see picture below).

kandakurthi report pic 2

Most had cough , phlegm and the typical wheeze that is seen . They also had difficulty breathing and their lung function was often not normal . I tried to do some education and for the tobacco chewers as well as the smokers tried to assist with quitting . Some promised to do it right away and in dramatic flair with my encouragement managed to fling some of their bidis out the window 🙂 . Hopefully the kids didn’t find them ! There was the usual set of upper respiratory ailments and the assorted rare diagnosis.

kandakurthi report pic 3

 

There is just so much to be done in the form of education . Many of the school kids of the neighbourhood hung out in the camp and many wanted to become doctors !

kandakurthi report pic 5kandakurthi report pic 4

 

Thanks for reading – it’s been a while since I wrote .I found today to be an important experience in my quest to get tobacco out of our lives . It is absolutely wreaking havoc to human life , silently eating away at families , preventing human progress and costing a lot for healthcare . Perhaps we will succeed in this generation .

 

kandakurthi report image 6

 


No Fumar, please 

Dear family and friends
This is a letter from me to you . I am a pulmonologist who has a deep interest in decreasing the harmful impact of tobacco use in my patients . This year on the occasion of World No-Tobacco Day , May 31 , I have decided not to write to my patients but rather to my family and friends . Some of them smoke , many of them are exposed to second hand smoke and all of them know someone who is addicted to nicotine and various forms of tobacco . I write this letter out of love and concern . I completely acknowledge your free choice , the transient relaxing effect that may be derived out of the habit and the possible intrusion into your personal space . It is possible some of you may be angry or distrustful of me for writing a personal letter in the public space . I am willing to face the consequences – for the more I try to look away from the dangers that will affect tobacco users in the days to come , the more I realise I am not being honest . There is no safe dose of tobacco . Every cigarette shaves minutes of a precious life . Every breath of inhaled second hand smoke will increase the odds of lung cancer in nonsmoking sisters and mothers and cousins . COPD , where the lung structure is destroyed will afflict many women who were involuntary smokers . I sincerely do not want anyone to go through the feeling of catching their breath even for the simplest of activities . Several of the people who I spend my time with and who contribute to the fun and enjoyment of my life unfortunately have remained ignorant about the dangers of tobacco use . Many feel hookah is safe but the facts are shocking . While cigarette tips burn about 5000 chemicals at 900 degrees centigrade and create toxic chemicals that cause damage upto the molecular level , hookah does worse in some respects . The average hour of hookah use involves the equivalent of 200 puffs of a cigarette while a single cigarette on average involves only 20 puffs . Even more strikingly , while the average cigarette user inhales upto about 600 ml of smoke with each cigarette , the hookah user will inhale 90,000 ml of smoke in one session. 

The warning labels and the taxes for tobacco in cigarettes have become part of our legislation but alternate forms of tobacco such as hookah or bidis have not . 

I have seen patients drag in oxygen cylinders , use artificial breathing machines , go on chemotherapy with all the suffering that entails . I have seen wives in tears , mothers wailing and fathers distraught . No movie can match the suffering that doctors see and much of it preventable . 

Concepts like social smoking , light smoking , smoking only at parties etc are not ok since they promote the concept of tobacco use as a desirable decision . I absolutely do not want my son or his cousins or my nephews or nieces to endure any suffering from the effects of tobacco use by anyone . It is time for this generation to put a stop for the pseudo economic benefits of the tobacco industry . 

I write this after deep thought – tobacco is addictive , it’s a drug and for some it may create value but the risks are unlike any other human habit . We must pause and take stock . Quitting tobacco is easy for some and hard for others . I am here to help . I hope my family and friends read this .
With love ,
Sai 
Feel free to share and if it will help someone you love make it go viral !

Check out the WHO website for this year’s theme . 
http://www.who.int/tobacco/wntd/en/


$$$ don’t make the Man

Here as promised is a short commentary on one more amazing speech that was hard hitting in it’s simplicity . Zero slides , no gimmicks , almost telegraphic snippets of life experience . Manoj Bhargava the billionaire , the no holds barred champion of honesty and philanthropist was the final keynote speaker . Using Star Trek lingo he mentioned that his prime directive was to not tolerate aggravation from anyone – be it employees or even his best customers . He stated that if someone is not happy with the situation they should find it elsewhere . He spoke about his bicycles which generate electricity and gave a sneak peek at his foray into improving health . His team has developed a new sensor that can get vital signs and transmit for monitoring . He reminded that studying human nature was more important than several other areas of business and that no one was teaching this . He gave an example that there was no such thing as doing business with General Motors – you do business with a human being there . He also said that determination is more important than passion . He spoke about the need for common sense and to have a sense of urgency and of utmost importance was honesty . Doing what is useful is important and that takes discipline . Identify the purpose of something and which of those purposes do you need ? The mother is the model to follow – no frills just pure work and always ask the question – what would mom do ? He exhorted that using common sense there was a higher chance of success than with experts and you would save money .

His ventures have been successful and Mr Bhargava came across as a tough but fair boss to work for . I expect to see great things come out of his ventures .


Sam Pitroda : Master of Connectivity

In my short trip to the US last week had been invited to speak on telemedicine in the global connectivity panel at TIECON Midwest in Detroit. It was a cool experience with Cyrus Mistry sharing his insider info on the workings of Googledom. The message was to think BIG – moonshot big. There were other amazing speakers talking about drones and driverless cars as well as new methods of placing orders for travel . The evening keynote by India’s father of connectivity was a deep look at a man who went beyond imagination for a country where a simple long distance call was an experiment. Sam Pitroda who was the architect for digital connectivity in India gave a beautiful keynote .

His focus is now merging Gandhian philosophy with technology . He spoke about values of truth, trust , sacrifice , unconditional love and peace . His vision is for Happy Cities which are nonviolent and his concept of connectivity goes beyond technology . He spoke about refreshingly about education in the future and stated that truly to learn today we need Motivation , Content and Time . A mentor is needed rather than a teacher .  It was absolute rapt attention in the room . He shared a very personal story of his life . I have tried to capture a short slice in this post .

He shared his experience with Indira Gandhi and with Rajiv Gandhi and his struggles as an American in India and how he gave up his US citizenship to regain Indian citizenship. He spoke about recreating successful businesses and his relationship with his family.

His question to everyone was: How would we redesign the world knowing that the internet is here  ? Not just change but redesign our models of governance and living. There is a need for new conversation he reminded. Connectivity is the biggest event in the history of the world. Everything can be questioned from the way we govern to the way we learn .

Connectivity is truly to lift people from poverty and we must do things for others. He reminded us that our planet has 8 billion people with 8 billion journeys and 8 billion stories. ‘Give them a chance to help’ was his call to action. I had a ‘selfie’ of sorts with him- it was nice to hear a person who had been in the newspapers as I grew up and learn the inner workings of those headline creating events. He lives in Chicago and he has a book out there describing his journey. Look out for one more post from my Detroit experience-this one is about a super rich dude with a super down to earth humility .

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Operatic Transplanted Lungs

If you had a chance to read my post on the keynote address at CHEST meeting it may be clear that the quality of the speakers was exceptional. This next write up is about a truly astounding experience . I was privileged to listen to Charity Sunshine Tillemann-Dick speak and sing. She is a miraculous survivor of two double lung transplants, fighting skin cancer now and still a world class opera singer. She regaled us with her beautiful voice which would perhaps bring tears to even the deaf . Language unidentified- perhaps Italian , perhaps Latin but the tones and the pitch and the other aspects of opera singing which make it a musical science were all there . She shared her tough life story with us and it was clear that we were fortunate to have had health but perhaps unfortunate to not have used our own life experiences to ascend the pyramid of life. Her medical history is enough to educate several trainees and experienced specialists in many branches of medicine and surgery. Her last minute second transplant turned around her life. The courage and encouragement provided by her surgeon were really instructional- the hope they offered kept the patient singing. She even went to a performance in New York against great odds . Her voice box was fortunately saved by her skilled surgeon and she benefitted from the grace of organ donation not once but twice . Look her up and read her story- it surely will show you that life is truly mysterious and completely worth pursuing.

charity-tillemannWill try and post a short video clip on FaceBook.


Find your Wilson

I was fortunate to attend the opening keynote address by Dr Gerard Silvestri, the incoming President of the American College of Chest Physicians in Los Angeles last week. In true Hollywood fashion there was a giant stage and robust acoustics . The grandeur of the venue was matched by the message . It was a message in immense humility . It was a message on the personal care and empathy that was reciprocated between a master physician and a grateful patient. As Dr Silvestri stated, “Go Find Your Wilson” was the call to arms for all health providers to connect at the deepest personal level with their patients and their ambitions and the path they choose for their health . The story began over several decades in the peaks and troughs of FEV1 that occurs in the life of a patient with severe COPD. In fact the family of two sisters and the patient, Mr Wilson all had tobacco induced COPD and Dr Silvestri in cinematic fashion led us through their challenges up to the final day when Mr Wilson lay dying. I was touched and so were others by the beautiful narrative and the joie de vivre that was evident despite dyspnea  and decompensation. It is a testament to faith between the patent and the physician .It is a testament to trust and to truth. Th honesty exhibited by the doctor was equally reciprocated by the patient. The message was clear- we all have a patient who influences and enriches our life by allowing us to become a part of theirs. The overarching lesson was to allow us to become better caregivers. This short writeup does not do justice to the amazing tribute that Dr Silvestri paid to his patient .Yes, we must all go seek out our own Mr Wilson . The final slide summarized what we all know – tobacco kills relentlessly.img_1113


Sepsis : Killing millions for millennia

September 13 is recognized as World Sepsis Day. It legitimizes the war on sepsis just as every other designated day for various diseases creates awareness. Sepsis can kill quickly- in fact so fast that there is no time to say goodbye . Any cut or wound if infected by bacteria can trigger an irreversible cascade of chemical reactions that lead to a drop in blood pressure, shut down the kidneys and mess up the blood clotting system. If not corrected fast and accurately people die. In fact over 6 million new borns and children as well as 100,000 women get septic during pregnancy and child-birth every year . More people die of sepsis than heart attacks . It is a costly problem- over $20 billion US dollars per year to treat sepsis just in the US alone. However it is sad to note that 60-80% of all deaths in developing countries are due to sepsis. Bacteria and even viruses can trigger the sepsis one way trip. The body in all its self preservation attempts releases chemicals that trigger inflammation – this is the same thing that happens when you have a bit of swelling around an injury. White blood cells which fight infection are sent to contain the infected area as well as repair and heal. There are special molecules that make the blood vessels leakier so that healing fluids and cells can slip out of the blood stream and go to the site of injury. Sometimes this well meaning effort goes out of control and too much fluid slips out and the blood pressure drops and other organs are affected as noted above.

sepsis-imageFortunately there has been a ton of research lately and we have found that early treatment can definitely save lives- in fact in some places it has doubled the lives saved. Intensive care is  critical for managing sepsis and simple principles like giving enough fluids to keep the blood pressure up ( about 30 ml/kg body weight ) initially and also starting the correct antibiotic within an hour or sooner can mean the difference between life and death. It is vital to find the source of infection – pneumonia in the lungs or a urinary infection may be common problems. It is also very crucial to monitor parameters like lactic acid which is a measure of metabolism . If the level does not improve with ongoing treatment something is not right- either inadequate resuscitation or the infection is not identified or getting under control. People with diabetes and the immune problems are at risk for worse outcomes from sepsis. Vaccines can sometimes prevent some forms of pneumonia like influenza and may be useful in certain groups. So in summary be afraid of sepsis but early treatment can save lives. As education about sepsis spreads there is optimism but like all good things it is just not enough. What can you do about sepsis ?  Wash your hands, clean any wounds, stay healthy and actively manage any chronic illnesses like diabetes. Do not ignore early signs of infection and see your doctor early.

You can look up http://www.world-sepsis-day.org/ or http://www.cdc.gov/sepsis/ for some great information on sepsis. Of course https://en.wikipedia.org/wiki/Septic_shock is a good place to start reading up on sepsis.


Viral Run

   Its been a month since the high energy tobacco control training that I attended . Fortunately the inspiration from that Johns Hopkins education has not dissipated . We are all in touch on Facebook and WhatsApp. Life’s routines have returned- family, friends,work and the like. As normalcy is a misnomer for life for anyone, change is inevitable.

   First it was the feeling that you are coming down with a cold. Then it was realization that someone who just had a viral infection gave you their ailment for free. The fever and the stomach issues followed. So why would I share this here ? Turns out this was going around town and many a strong personality had been felled in its wake-just for a few days but people were actually taking time off because of the severe symptoms. No name was given to this anonymous leveler. Luckily it gets better in a week or so and thanks to plenty of ibuprofen and fluids am on the mend. The problem though was that it completely stopped any physical exercise.

   I had ventured boldly to sign up for the Airtel Hyderabad Half Marathon on August 28 and after forgetting to pay the registration and going through hoops and requesting favors managed to register through the charity route which was fortunately still available. I was thankful it was for a good cause- the money is used to directly take care of the hospital bills of sick kids in the city by an organization called Heal the Child. I had managed to even run a 10 km on a treadmill- something never done before by this body. I had run 10k twice in a local event but not as a routine. My training schedule was pitiable compared to many who were serious about running. That being so, I still was able to run a few times a week but the virus stopped me in my tracks literally. With great disappointment I made plans to possibly not do the half marathon but there was some part of me saying that I had a good excuse. Spent time searching Google for ‘running a half marathon without training ‘ and found that quite a few had done it ! Never to take no for an answer, I decided to go for it anyway. I tagged along with my relative who is an avid runner and gave me super tips- like wear nipple protectors to prevent chafing, walk-run-walk, don’t run down bridges, use the Gu gel he generously shared . The run was fun . I managed to even finish it ! I could have gone faster but I deliberately told myself no looking at the clock on this one .

   For those of you interested in statistics some technical stuff below- for me it just means that I could do better.

ahm stats 2016.001

   The best part was the sheer number of runners of several ages, the superb pacers and the wonderful cheering crowds of kids, adults, older people and of course the high intensity music. Motivating slogans like ‘Go go go it s not too far’ or something like that and ‘There is hope yet for India’ were really nice to see. After three hours of constant forward movement and going right past the area where I live ( with the temptation to just snuck home and sleep !) , the Gachibowli stadium was in sight and once we finished ,thankfully there was a nice breakfast ( pongal, kesari, idli, chutney :))  and lots of water. I hitched a ride out of the stadium on someones bike and took an Uber home . The pain is still there – the muscles are sore. The knee hurts. Yet it feels really good to have done it. 21 km is a long distance for me -more in mind than in space. Gearing up to see if this is for me -planning to do the same again sometime in the future . Maybe better prepared and a bit stronger. The basics of running are quite simple- pace yourself and you will see benefits .It is a very healthy way to begin taking fitness seriously.  Don’t overdo your own limits if there is risk of injury .Hydrate well with water and salts . Ok then lets catch up on the next one!