A Medical Whodunit? And A Cautionary Tale

A Medical Who-dunit? Or A Cautionary Tale

This post starts as a medical mystery and ends as a cautionary tale and a general advice column. But before I get to telling you my cautionary tale let’s talk semantics first. When you say you are sick or ill what does that mean? It merely means you have a set of aches or pains or complaints which you go show to a doctor and then he hears them/sees them/checks them and tells you that you are "suffering" from such and such a disease. The Annals Of Internal Medicine has a pithy description of this:

"Illness is what you have, when you go to see a doctor. Disease is what you have, when you come out of seeing a  doctor" 

 So even the American academy of internal medicine agrees that a disease is just a name applied to a group of likely symptoms very similar to those named in a book somewhere. You might have that disease or you might not. It requires, usually, more investigations to confirm or deny. Everything else is an educated guess. Sometimes the only way to confirm that the disease is indeed what you have is to start the treatment and observe. If the prescribed medicines work for you and you get relief from your symptoms (or illness) you are considered cured of your disease. If not, then the process starts again, right from the investigation stage.

But is this all there is to health? Mere absence of any symptoms or illness or disease? If you say No then you are right. And the World Health Organization agrees with you too. The WHO says health is

"Not mere absence of disease,

But Physical, Mental and Emotional well-being"

If you read that again you can see that health is a very simple concept of wellbeing in everything and even a little emotional turmoil is considered sickness. But this fact is not easily accepted by our society for when someone complains of emotional turmoil what does society say to him or her? Chin up, be brave, ride it out, accept it, move on, it happens to everybody. All these platitudes merely cover up the fact that society does not accept anything other than physical pain as illness and visible symptoms as disease.

Say for instance one of you constantly misses his train to work every day because the trains are late or overcrowded or canceled at the last minute and this causes constant emotional turmoil. Would you consider that man as a sick man because of his emotional suffering? Or say someone suffers under impossible work conditions, long hours, bad superiors, unappreciative colleagues and work involving unthinking drudgery, causing daily emotional turmoil in daily work. Would you consider that person as sick and accept that his work which has made him sick? Or would you say that as long as he is able to work normally he is healthy?

And the answer to that question is exactly the cautionary tale I am about to tell you.

The other day I had a call over from a ward to attend a patient who had been admitted for occult blood in the oral cavity. To translate it into normal English, the patient had woken up from sleep to find blood in his mouth and had rushed to the hospital to get admitted saying he was vomiting blood. Now the reason for bleeding into the mouth without any obviously visible injury (like being punched) may range from cancer to tuberculosis and to everything in between. But under the keep it simple stupid principle the most obvious reason to rule out was gum disease or gingivitis as it’s known medically.

The reason for this is that gingivitis (gum disease) is widespread and almost every one of us has at some stage or the other has had it with or without us knowing about it. And its also one of the most easily curable of diseases. You just have to brush with the right tooth paste (preferably an imported one) and gum disease disappears. Or so says the omnipotent doctors (practicing in America or Britain) who act in Television commercials (seen the Sensodyne Ad? Parodontax Ad?). But nothing in life is that simple, especially infections involving bacteria or viruses is not. It’s an almighty hell of a battle inside our body daily- us trying to fight off the bacteria which are trying to live off us.

So even the best brushing with a will - diligent brushing ten minutes a day/three times a day (including nights) might not prevent gum disease. Because, for one thing, the bacteria in the mouth cannot all be eliminated with brushing them away - they can hide in other places like tongue, tonsil and throat and come back again. For another, bacteria develop resistance fast and using the same toothpaste with same medications in it for a long time means the bacteria are no longer affected by the toothpaste's antibacterial action. And finally we come to the one reason no one talks about- stress. Emotional stress or mental stress has an enormous role to play in our body’s immune system and stress can make us weak and easy prey for bacterial infections.  

And so when the patient had complained of blood in the mouth and after they had checked out and dismissed all the frightening diseases (like cancer) first, the attending postgraduate students had diagnosed the patient as suffering from the common disease of gingivitis or gum disease and having told the patient to brush properly had closed his case file and marked him for discharge the next day. But someone else had decided at the last minute that an expert opinion is needed and asked for a consultant's all-clear before finally closing the file.

And that’s how I ended up being summoned to check out the patient, the last thing pending before they sent the patient home. Which was quite a lucky thing for him as events turned out, for I cracked the real case which the others had dismissed so easily as obvious. But i will get to that. When i first entered and saw the patient i read the case notes top to bottom. But I was not satisfied with the reason given there of the blood being due to gum disease. It seemed too obvious and easy a solution and my Sherlock Holmesian instincts were aroused.

Something prompting my subconscious, I examined the patient again trying to find some other reason till at last I found it on the roof of the mouth. This is an area which normally nobody bothers about so someone had missed it when admitting the patient. But on the roof of the mouth there were many small bleeding spots called purpura from which blood was dripping into the patient’s mouth. And intrigued by this finding when I checked his blood test results again, I found that his blood levels were dangerously low. 

I arranged for blood substitutes and drugs to increase his hemoglobin levels- under the treat first and ask questions later policy and then sat down to talk with him. I slowly got him to loosen up and drew out the following. He told me that he was a police constable in the traffic department and his work consisted of standing still in one spot all day long. And consequently when he came home after the day's work he had severe leg pains and cramps and couldn’t get to sleep easily but spent tossing and turning half the night. He had visited a local doctor who had prescribed him sleeping tablets to help him go to sleep.

It was at this juncture that I made the connection. I asked him the name of the drug and it was as I had suspected. I asked him how for how long the doctor had told him to take it and how long he had continued to take it. The patient confessed that the doctor had specified that it was to be taken for only ten days but the patient had kept the prescription and automatically renewed it himself from the medical shop and had been taking the drug for months continuously. And there was the reason. Some drugs have dangerous side effects when taken long term, especially drugs prescribed for sleeplessness, which can cause bone marrow depression and consequently reduced production of blood cells.

So there was the case in a perfect link -the reason for the patients bleeding in the mouth was a drug overdose, which had caused reduced blood levels, which had caused increased bleeding tendency, which had caused purpura in the palate, which had caused blood to drip into the mouth, which had frightened the patient and brought him to the hospital on a complaint of vomiting blood. Voila. Elementary my dear Watson. Case Closed, I take a bow.

And all this was because the patient had been stressed enough in his job to need sleeping tablets every day. So should we blame this man’s condition on his stupidity in taking a medicine daily for many months without telling anybody? Or should we blame it on the stress on his life which drove him to take it like that? Which is the real culprit here- the medicine or the stress? If we can go back and read the WHO advice again which I have quoted above- it says that health is not just absence of disease but wellness in everything - physical, mental and emotional. So the emotional sickness of a stressful job can really cause you ill health and make you develop un-looked for diseases. And that is the cautionary tale I wanted to share with you.

One final thought to leave with you- self-diagnosis and especially self-medication is playing with fire. And that’s putting it diplomatically. 

The Gift – A Short Story

                                                             The Gift – A Short Story                     

He stood there on the opposite corner of the street watching and waiting as the bank opened up in the morning. He knew he could just stride in there and be the first customer of the day but for his purposes he preferred that one or two others go in before him. After all wouldn’t any bank staff be annoyed if someone came in the first thing in the morning to close down three separate savings accounts and withdraw all the money from them? The money itself wasn’t a huge amount even spread over three accounts- his father’s death compensation money, his mothers saving account from the job she had slaved in every single day since his father died when he was young and his own little checking account his mother insisted he maintain since he first started working part time at a hotel as a waiter at the age of twelve. And today was the day that all that money would finally be used - to pay his college fees.

Impatient as he was he pushed his way into the bank and into the withdrawals line. There was a little bit of argument when he showed the bank staff the three withdrawal slips and informed about closing the accounts. The clerk behind the money disbursal counter had to summon the manager to whom he again had to explain everything in full and insisted he be paid in cash which the manger counseled against. But he had no choice the college had specified the amount be paid in cash only maybe to hide the fee amount of the students behind false accounts to divert the tax authorities. Not his place to question the rules, he just wanted the cash to go pay the college admission fee and he insisted on being paid in cash only, unaware that the ruckus he was making had attracted the attention of two large gentlemen behind him who now flanked him unobtrusively on both sides as he made his way out of the bank.

Outside the bank standing on the edge of the pavement he decided that the money with him would not be too safe on a bus and decided that he was better off taking an auto rickshaw. He lifted his hand to signal one which was making a rapid progress down the other side of the road. As he leaned forward to see intently if the auto would stop and turn his way he was jostled hard from behind and pushed off balance into the road straight on the path of the incoming auto. As he was hit by the front wheel of the auto and was flying into the air and just before he crashed down into the road he remembered that the bag he had held under an armpit, the bag with all that money had been pulled away from him just before he was pushed onto the road. That was the last thing he remembered, the money, before his head crashed into the road with a sickening crunch.

When he woke up all groggy and blinking his eyes the first thing he saw was his mothers tear filled face right beside him. She gave a little scream of delight at him waking up and leaned forward to give him a quick hug before any of the nurses could stop her. "Thank god, thank god, you are all right, i was so afraid". He shook his head to clear it and with a tremor in his voice murmured "mom, mom i lost the money someone stole it". His mother put a loving hand on his forehead to quiet him "hush now, it’s ok, I know all about it, the gentleman who found it brought the bag safely home yesterday and he told me how he had found it on the road near the bank". He couldn’t believe what he was hearing, maybe the injury to his head was serious and he was hallucinating did he just hear his mother tell that the money was back? He couldn’t believe it and stared at her intently. His mother alarmed at the wild look in his eyes spoke rapidly "It’s all right, all right, don’t worry anymore about it, we can go pay the money to the college after you are discharged from the hospital tomorrow. Now close your eyes and rest"

Later that day, when he woke up he heard the rest of the story about how his head injury had almost killed him and how his heart had actually stopped for a few minutes on the way to the hospital and the ambulance people had to shock his heart back to life in the ambulance itself. He also heard about how he had been in a deep coma for the past two days and had surprisingly woken up today. One of the nurses confided to him that even a policeman had come around to check with the doctor and his mother if he had attempted suicide because he had lost the money and in that case they would have to file a criminal case against him for the suicide attempt. The doctor had managed to satisfy the policeman's inquires and had at last driven him away.

So, that night when the doctor made his rounds around the ward he asked him "doctor when will you discharge me? I have to go join an engineering college within this week. My whole future depends on it". The doctor looked at him a long moment and said "Well, your mother told me the same thing this morning. I wouldn't mind discharging you tomorrow but I have some doubts about your condition. I want you to go see a neuro - a brain doctor- tomorrow morning at nine. I will instruct the nurse to take you to the second floor neuro department tomorrow morning and once the neuro doctor checks you and says you are fit to go home, I will discharge you from here tomorrow afternoon". After saying so, the doctor walked away to the nurse and stood talking to her sometime, both of them glancing his way before finally leaving for the day.

The next day as the nurse wheeled him down to the second floor neuro department he asked her in a halting, scared voice "Nurse is there anything wrong with me? Why should I see the brain doctor? Is my brain injured?" the nurse, a large woman, laughed in a hearty voice and said "Son, there is nothing wrong with your brain that’s why we are going to see the neuro. For a man who had a head injury and was clinically dead for a few minutes, your brain scans are all absolutely normal. And that’s why the doctor himself is puzzled and wants a second opinion". She made him sit down on a empty chair in a long line of patients all sitting down and waiting for the neuro doctor to appear, before she went away with a final admonishment to him "Now look, as soon as the neuro sees you, you come straight back to the ward, ok? And don’t forget to bring your scans back with you" as she dumped a large file with the scans onto his lap before she walked away.

After sitting there silently for a few minutes digesting the nurses news he turned over at the giggling sound nearby. It was a young couple seated beside him with a child of maybe four or five years of age held on the mother’s lap and the child was smiling and giggling and making funny noises at her mother. He couldn’t help but smile at that exhibition of childish innocence and exuberance. It did something to his heart, to lift the gloom of sadness from it. He turned to the man beside him and asked "Are you here for the baby?” The man nodded at him and he felt bold enough to go on to ask "What’s the problem with her? She looks so normal" The man hesitated before he replied "Nothing serious, just that a couple of days ago she had a fit of sorts, you know, like epileptic fits and started gasping for breath and suddenly even stopped breathing. Thank God we got her to hospital in time to save her. The doctors said that we were very lucky and she had almost died before she came back to us". As he said that the father leaned over to touch his daughters head protectively at the reminder of almost losing her forever. 

As he looked at the child, she smiled at him inexplicably and crooking a finger beckoned him nearer. He had always got along well with children and so with a slight smile he got up and went on his haunches before the mother and child to come to head height with the kid. She smiled widely at him and said “Uncle did you get your money back like that Grandpapa said?” Puzzled at her unexpected bombshell he asked “What money? What Grandpa?” She smiled at him knowingly and said “You know when you were crying there about your money bag and how your mother will be so sad about you losing your dads money and you can’t go to school. And I felt so sorry for you I pulled that white Grandfathers robe and told Grandpapa to help you and he smiled and said he will send your money back when you come down here. Did you get it back?” He was shocked to the core about the things said by a child who had never known him and never seen him till this instant. How? How could she know? And as he thought over what she said, straining his brain to try to remember, he felt a sudden bliss descend on his heart, a feeling of joy and everything felt all right with the world in a minute. As he looked into the child’s eyes which had the same bliss of pure joy he leaned over and murmuring “Yes, yes, he kept his word, I got the bag back” he kissed the child on the forehead lightly “Thank God for that”.

P.S. This may not be a true story and then again it may be. I don’t know. But I have written it the way I heard of it and like you I have absolutely no clue who that old man in the white gown was. But a lot of patients who survive Near-Death Experiences do describe a kindly old man in a white robe. Now who could it have been? Any ideas?

Professional Back Biting

Professional Back Biting

 

The other day one of my patients gave me a shock, a massive shock, with of all things a few dozen complimentary words praising me. If you are as surprised as i was, let me explain from the beginning. This was a 45 year old diabetic patient who had suffered from a variety of ailments for the past few months without suspecting that it was all linked together due to a single cause- her uncontrolled blood sugar levels. Early into listening to her recite a litany of complaints I suspected her of diabetes and told her get her blood sugar checked and meanwhile started her off on drugs for her current problems.

When she finally came in with her test reports confirming diabetes i had counseled her on having her blood sugar levels within accepted range at all times and then had referred her back to her family physician for further care. And promptly forgot all about her. Consider my surprise when she turned up again in my room after a few months. She had cajoled the nurses to let her in out of turn, walked straight in, sat down in front of me and said in an inappropriately loud voice "DOCTOR, I am so happy. I told my family members, I told people all over my street and I told everyone that I am now completely cured, that you have cured me of my diabetes".

I flinched from the shock of the unexpected blow and glanced around to see who all had overheard this emphatic denunciation. Relieved that none of my colleagues could have possibly heard it, I decided to prevent her from continuing in this same vein of unbridled enthusiasm and pushing myself up straighter from my customary slouch in the chair and told her in a firm voice "Madam, I did no such thing, as I told you before you cannot cure diabetes, you can merely control it". "But, but" she stammered "I checked my sugar level and it’s all gone".

With a sigh borne out of exhaustion at repeating the same thing for the 50th time that day, I slouched back again in my chair and went over the same grounds again "Madam, diabetes is a lifelong disease, you have to keep taking drugs all your life to keep your sugar levels under control. If not they will rise again". She nodded her head and seemed to have at last got the message. I concluded my lecture by telling her "So what has happened with you is that your blood sugar is normal only because of the medicines and will be normal as long as you continue taking them daily. Leave alone me, no one can cure diabetes, so if someone says he can please don’t believe it" and with that parting piece of advice I sent her on her way.

Now to explain why i was shocked at her emphatic appreciation on my skills in curing diabetes was because I remembered the times I have been part of a crowd of doctors who laughed over these absurd advertisements on curing diabetes published by quacks (fake doctors) in vernacular newspapers. The way these fake doctors cured diabetes is to convince a normal person (healthy/disease free person) that they have diabetes, take a blood sample for testing, switch it with a diabetic patients and show the gullible patient the false result.

Once the patient believes that they have the disease, these quacks go onto prescribe medicines made of secret ingredients which they will guarantee to cure diabetes and after a proper interval challenge the patient to go to any lab and get a sugar test done. Naturally their blood sugar level would be normal and when the patient sees the normal result they immediately believe that the secret medicine has cured their diabetes- which they never had in the first place. So a simple sleight of hand trick like magicians do is behind all these fake diabetes cures. Which is why I didn’t want to be labeled as one of them people who can "cure" diabetes.

Whenever we doctors get together and relax - like in the changing rooms of operation theatres between patients- we do tend to gossip a bit just like others do. And sometimes the gossip is about the way innocent patients get cheated by other doctors. Most of this gossip would be just unsubstantiated urban myths - like the one about how people who go to fertility clinics advertising 100% guaranteed child- often go home with someone else's kids because the sperm used has been switched with a healthy donors sperm- a very persistent myth you keep hearing often. But mostly it’s about the different ways unscrupulous doctors rip off patients- some of them wholly original inventions.  But all that talk is in the dressing room only- rarely do doctors wash dirty linen in public- like all other professions the medical field too maintains a distaste for exposing other doctors wrongdoings to outsiders. But things are changing. Doctors have started talking to their patients about other doctors- especially their previous attending doctors. And unsurprisingly whatever they tell patients about their previous doctors is mostly uncomplimentary and all about fault finding – or so says a new study.

The Journal of General Internal Medicine (May 2013 ed) has an article which analyzed the number of times doctors talk to patients about other doctors- the results were 29% of positive comments, 4% as neutral and 67% as negative comments critical about other doctors. As surprising as this fact is, I guess its happens more often than we think or acknowledge. Some doctor’s exhibit this instinctive need to breast beat their prowess when compared to their patient’s previous doctors. While others merely offer on or two cutting comments on the line of treatment or choice of drugs previously given by other doctors. None of which is wrong ethically but still a frowned upon practice under the dictum- thou shalt not speak ill of a fellow physician. But doctors are not the Sicilian mafia- there is no code of omerta and hence such doctors who constantly criticize other doctors rarely feel the need to temper their criticisms unless one or more of their patients goes back to confront their previous doctor and says flat out "my new physician says like this, like that, that what you did for me was wrong and you must be stupid" at which stage a battle royal ignites followed by a feud for generations.

Anyway, unlike the previous example of American doctors criticizing other doctors publicly, most doctors in India are wiser (or more discreet) and rarely (never) tell their patients outright that such and such a doctor is bad. It’s all mostly winks and nudges when a patient asks about another doctor. It ranges from “well, I have not heard anything of him till now – which really means- anything good till now” to “why don’t you try someone else, I heard his success rate is not good- which really means half is patients die so why take the risk” all of which is trying to pass the message as subtly as possible that “although I would love to share the horror stories I have heard of the doctor you are asking about, I can’t come right out and say it because my professional ethics forbids me”. Some patients are wise enough to understand the subtle hints and knowing winks. Others are not. So the next time you ask your family physician about another doctor- please watch out for those tell tale signs and subtle winks.

The point of this post is - like all professional relationships the doctor patient relationship is based on trust and it works only if there is absolute trust both ways – second guessing leads to a lot of avoidable tragedies. Hence unnecessarily back biting colleagues and bad mouthing other doctor’s to our patients leads to an overall collapse of trust in all doctors, in the medical profession itself, which would be a tragedy for both patients and doctors. Likewise doctors have a duty to prevent their patients from getting bad treatment by incompetent doctors. But there are ways to do this properly- constructive criticism rather than negative criticism is the way forward. It helps if doctors keep gossiping about colleagues to a minimum- but I guess that we are all human and apt to slip up now and then. So the only way to do this ethically – is for doctors to directly call the other doctor and query him/her if they feel that their patient has received sub-standard care rather than badmouth to the patient. Both as a doctor and as a patient I would appreciate this gesture as it would lead to a solution rather than just blame. So what do you think? I would love to hear your views on this sensitive topic.

And to conclude- I can advice, counsel, prescribe for diabetes- but I cannot cure it and neither can anyone else at this point of time, ok?