Breaking the fast

We all know how humanity has evolved. From stones to tablets, from Astronomy to interplanetary missions, from being hunted by animals to becoming more Powerful than them and from couting travel distance in months to seconds.

In the span of time, even the mode of keeping time has changed. From sun dials or human time keepers, we now have atomic clock accurate to the femtosecond!

Earlier, since no one could keep their own time, there came phrases like sunrise and sunset. Noon meant sun directly above your head.

People still used to keep fast. And to track that time, there must have come phrases like - you can eat after sunrise or after moon rise.

The difference between now and then is that, you can come to know when is going to be the moon rise of when has it already happened at exactly which location in earth. Thus, the practice of waiting for sun rise or sunset is purely customary according to me.

There are people who do not eat until they see the sun or the moon! The fast was meant for specific timing and as far as you can ascertain it, there is no need to wait to see the moon to break the fast. :)

New sphygmomanometer?

If a thermometer has a constriction that doesn't allow rapid fall of mercury after attaining the high temperature, can we similarly make a sphygmomanometer with a constriction such that the rate of fall in BP is always 2 mm/sec, neither more nor less?

Simple thing but will standardize the method of taking blood pressure further since the speed of lowering varies from doctor to doctor and instrument to instrument.

Ethical way of taking history from a patient with a classical case

This is to all the doctors and medical students in the world, let's go back to the days of your medical school...

I joined Seth GS Medical College and KEM Hospital in 2013 and in the last 4 years I have had the privilege of interacting with two good conditions on two separate occasions.

One was Dr Michael Glynn, Consulting Physician, Gastroenterologist and Hepatologist, Barts Health NHS trust England. He is also the co-editor of Hutchinson's clinical methods.

And the other one was Dr Ravi Ramakantan, Director of the department of Radiology at Kokilaben Ambani Hospital in Mumbai.

On two separate occasions of a guest lecture students asked them the question ie:
" When we medical students go to take cases to the clinical wards, we see that lots of medical students gather around the same patient who generally has a good classical history and examination findings and they fail to see the discomfort and inconvenience they are causing to the patient. This is especially true before the practical exams. How do we prevent this or decrease the agony to the patient?"

Frankly speaking this is a very difficult situation. But the two vastly contrasting answers and I got from these two clinicians, has been etched in my mind.

Dr Michael firstly agreed that it is indeed a very difficult situation. He suggested that may be a first person can take a video while the other person is taking a history and eliciting examination findings, and the other person can see the video although he pointed out that watching the video will not be as much educational as taking the history first hand.

However Dr Ravi Ramakantan said, you can go and talk to the patient and develop a special bond with him. You should show the patient how much do you care for him. Of course it is an art to engage with the patient. But once you succeed in doing that the patient with himself or herself tell you the agony that he faces and will allow you to examine him/her.

Disclaimer- these are personal first hand accounts. I thought that sharing these answers with everyone we help thousands of medical students who are facing the same problem. It is in the interest of the students as well as the patient that I have written this. I may not have perfectly reproduced the words and the sentences spoken by them and this is just my interpretation of the same.

In a way, both the answers show the empathy that is needed. The first one tells you should not go ahead when the patient is not at ease. The second answer asks you to understand the same pain that the patient is going through and wait is a patient is ready.

We medical students, still have a lot to learn from the stalwarts of our own institutions, in the field of medicine.

Updates to RNTCP Guidelines

Recent changes in Tuberculosis guidelines 2016

1. 3 new goals – cure, prevent resistance and break chain of transmission.

2. Introduction of daily regime.

3. Definition and treatment of mono and polyresistance apart from MDR and XDR Tuberculosis.

4. Treatment in CAT 1 – 2(HRZE) + 4 (HRE) : Continue ethambutol in continuation phase too.

5. Treatment in CAT 2 – 2(HRZES) + 1(HRZE) + 5 (HRE).

6. Introduction of Bedaquiline as a new drug. ATP synthase inhibitor specifically targets myc. Tb. Indicated in age more than 18 years. Contraindicatef in pregnancy and those taking hormonal OCP. It may be given in patients with stable arrythmia.

7. Definition of presumptive tuberculosis. Duration > 2 weeks etc.

8. New algorithm to diagnose Tuberculosis – pulmonary, extrapulmonary, drug resistant.

9. Introduction of Newer molecular methods like CBNAAT and line probe assay in diagnostic algorithm apart from smear microscopy and chest Xray.

10. Diagnosis of tuberculosis based on X-ray will be called as Clinically diagnosed tuberculosis.

11. Sputum should be around 2ml and preferably be mucopurulent.

12. Follow up – New and previously treated Drug sensitive pulmonary tuberculosis – No need to extend Intensive phase, sputum microscopy at end of IP and end of treatment, weight monthly, chest x-ray if required.

13. Follow up – MDR tuberculosis – sputum smear monthly 3,4,5,6,7 months in intensive phase and at 3 months interval in continuation phase 9,12,15..., extend ip phase by maximum 3 months total of 9 months.

Some more additions to it, adding here which might help to pg students.

1)monitoring health status of Tb treated patients (for recurrence of tb) for 24 months after treatment
2) online monitoring of treatment adherence through 99dots programme (currently it is on pilot basis running for tb-hiv patients)
3) intensified tb case finding in clinically, socially and geographically vulnerable population. It's a provider initiated activity.
4) now 'tb suspect' term is replaced by 'presumptive Tb case'.
5) in diagnostic algorithm sputum examination along with chest x-ray is recommended.
6) 'NSP' term is replaced by 'microbiologically confirmed case'
7) NSN and others r called now onwards 'clinically diagnosed tb' case. (terms replaced)
8) definitions of cured, defaulted, treatment completed, failure, failure to respond, loss to follow up are somwhat changed.
9) cat I, cat II, cat IV terminologies r obsolete n replaced by drug sensitive (new or previously treated) and drug resistant tb categories.

Disclaimer:
I had received this message on WhatsApp. I haven't compiled this.

Acute or chronic?

No matter how much clear today's evidence based medicine gets, one thing will be always hazy.

Acute, subacute and chronic are concepts related to time. Thus they relative to each other.

A bout of vomiting that began 1 minute ago is acute, and so is acute chest pain since 1 hour. But when a young man complains of back ache since yesterday, will it cease to be acute?

A look at the dictionary will tell you "acute" can be used in two different ways :
1.
(of an unpleasant or unwelcome situation or phenomenon) present or experienced to a severe or intense degree.
Example-
"an acute housing shortage"

2.
(of a disease or its symptoms) severe but of short duration.
Example-
"acute appendicitis"

Acute is derived from the Latin word "acus" which means"needle", thus auguring well the above two meanings.

Similarly, the meaning of chronic on Google is

- (of an illness) persisting for a long time or constantly recurring.
Example-
"chronic bronchitis"

Chronic is derived from Greek "Khronos" which means "time", again matching with the meaning.

Subacute is vaguely defined as something that is between acute and chronic.

Point to be noted is that - all these three words are "adjectives" and not "adverbs". Thus they describe the noun ie the patient or the disease and not the "verb" or the action that the disease is causing.

Acute Appendicitis tells you that the patient suffered from SEVERE Appendicitis FOR A SHORT TIME. And not that "it progressed quickly".

Similarly Chronic Bronchitis tells you the patient has Bronchitis that recurred many times over a period of time or is present since a long time. It doesn't mean that "there was an episode of bronchitis 1 year ago".

Many doctors use a simple Funda -
Acute - minutes to hours
Subacute - hours to days
Chronic - days to weeks.

However this "minutes to hours to days to weeks" stands for progression of disease and not "how many hours or weeks ago he had that episode".

I hope this clarifies the long standing confusion on this topic.

# whenever in doubt, refer to the etymology of the words #

Second opinion OPD

The OPD naming has evolved over the years to reflect the need of the patients.

For layman, OPD is the out patient department, where doctor examines the patients and prescribes medicines. Most OPDs don't have special names. Some can be broadly divided into new patient opd, where taking detailed history takes a lot of time and follow up patient opd where usually the patient is well controlled on treatment and keeps following with the doctor just to screen and pick up any new disease early or sometimes for dosage adjustments.

But you can also find other OPDs like usual (read 'rich') OPD and poor patients OPD.

But looking at the knowledge explosion, patients consider themselves as "i-know-all". Thus they don't trust the doctor.
Also, increasing mistrust leads to erosion of doctor- patient relationship.

The breed of Family doctors is soon become extinct and everyone wants to rush to specialists and super specialists. Thus, patients End up consulting more than one doctor.

Also with rising affluence, the average Indian wants the best health care to be provided for which he is ready to loosen his strings.

The day isn't far, when doctors will keep separate time slots for second opinion, for unsatisfied patients coming after talking to another doctor - the future of second opinion OPDs!

Does repeated case presentation help a medical student?

My friend in postings, had presented the same case 4 times to various professors during our medicine postings, because other students hadn't prepared their cases. Did he became better each time presenting the same case?
That, the teacher will decide, but he almost learnt the entire case by heart eventually. Ml

So, if someone has presented lots of cases during the years of MBBS clinical postings, does that student become better at case presentations / better clinician or it just doesn't matter??

I think it's a sigmoid curve with a plateau. Initially you'll become better and better at presentation but eventually it will saturate. Then only the right lobe of brain and the flow of thoughts in a person's mind will be helpful in marginally increasing the presentation skills.