Wednesday 21 December 2011

Humour at death bed

Among us are certain individuals endowed with extra ordinary power to laugh at odds, misfortunes, calamities befalling them and even when death confronting them. Like this time, I was on annual vacation in Kerala in December 2010. What a gulf goers usually do during their vacation, is to pay lightning visits to his friends and relatives to renew the friendship and refresh their memories. Last year when I called at the house of a close friend and former colleague of mine, his wife confided to us the painful story of his hospitalization and admission to ICU where he had to be kept for more than ten days and that all of them were alarmed at the possibility that they would not see him alive once again . I was at a loss how to face him or what to ask him , let alone  console him. When I began to grope for words, my friend who had just been discharged from the hospital intervened and came to my rescue. He shook hands with me and began to enquire about  my children especially about the elder ones who were so close to him while he was living in Doha. With smiling face he began to describe what he had happened to him: “My wife might have told you that I was in the hospital. It is because of the fact that we are sometimes compelled to remind others that there is an organ in our body called heart .I am a heart patient,  and my wife   is diabetic and therefore we are partners even in ill-health”. Since he was laughing when he  spoke to us we shared his “joy”with difficulty. By the grace of God he is still leading normal life with his family at his native place.

The other day we had been to the house of a maternal uncle of my son in law who died of kidney failure. He had a history of struggle with diabetes. His house was packed with mourners from different walks of life.. I knew that he was not a political leader and that the mourners were not there to express their “deep shock at the irreparable loss or unbridgeable gap”. He was a common man who won their hearts  through  his lighthearted approach, simple life and innocent jokes. I know him since 2001 when the engagement ceremony of my daughter with his nephew was conducted. The ceremony had coincided with my eldest son’s admission to Aleppy Medical College. When he met my son during the ceremony he congratulated him saying “ I wish you all success. When you graduate and work as a doctor , I will come to see you with diabetes in my hand”. When I narrated this incident to one of the mourners, he testified that the deceased had always had an unusual sense of humour.

During the marriage ceremony of my daughter conducted after one year from the engagement, he noticed that the electric switch board in our living room was covered with clourful grazing papers normally used for wrapping presentation items. My daughter had done it not to expose the wooden box to the participants in the function. She told us that he had later asked her whether the switch board itself was one of the gifts presented to us on the occasion of her marriage.

When his father passed away a few months prior to his death , the newspaper that carried the death news introduced his brothers as retired engineer, Kerala State Electricity Board employee etc. whereas they had nothing to mention against his name . After reading the newspaper, he commented saying that he should have been introduced at least as a kidney patient.

Once a journalist colleague of my son in law fell unconscious and was taken to hospital where the doctors disclosed to him that he had only one kidney and that was why had fallen unconscious. When he resumed his duties after being discharged from the hospital he told his colleagues who congratulated him on his recovery: “ I have been, hither to, proud of being the owner two kidneys . You know the truth now. In lieu of being proud of having two kidneys, I suggest that all of you undergo a medical checkup. It is possible that some of you may have only one kidney .

The other day when I met a friend of mine I enquired about his younger brother who also close to me. He said that he met with an accident recently and died. Though I was sorry to learn about his sad demise, his brother narranted the incident   in such a way  that one would fee that  his brother had gone for shoppping..


By the father

Sunday 18 December 2011

GOOD MORNING, YOU ARE DYING !!!

PATIENT: “Sat sree akal Ji” (form of wishing in Punjabi)
“Doctor Sahib, Apna reporte ayaa hai” (Doctor, my reports have come)
DOCTOR:“Babaji, thuade Ghale me cancer hai” ( Uncle , you have a cancer in your throat)
PATIENT:”Achha Ji”(Local term for Yes sir, but it comes so spontaneously that what it actually means is that I heard something but I didn’t get any thing)
“Waise teek hai na” (after all that is normal, right)

It is interesting to watch how people receive bad news. During the last two years I have had the opportunity to see patients with bad prognosis day in and day out. Thanks to being in a prime institute of my country, India, I have developed an expertise in spelling out the death certificates to the patients. There was a time when I used to avoid such situations on purpose as I had considered myself emotionally inefficient to deal with such cases. But it was when I had to do my thesis on oral cancer that I developed this touch in spelling out misery.

People react to their disease in different ways. Everyone has their own unique way of defending pain. Some cry, some get angry at themselves (and at the doctor), some deny it all, some defy it,some withdraw into themselves, and some get ready for the fight. This depends on many factors such as whether the patient is a male or female and on his or her educational, economic, religious and social backdrop Therefore as a resident doctor it is very important to assess the mental and emotional capacity of the patient before you spell it out. The trick is to say the truth without provoking the patient, to be tough but without hurting him , emotionally bonded to the patient but within the limit that you never become his or her sympathizer.

A patient once came to my late OPD in the late hours with a CT scan report. As I had already packed up my instruments and was ready to leave I was a bit reluctant to entertain him. But he told me that he had not brought the patient and just needed opinion regarding the CT finding. I saw a huge tumor involving most of his nose, sinuses and nasopharynx. Seeing the amount of destruction it caused to the bones around I could say that it was highly malignant. I told him that his patient had a malignant tumor which was rapidly progressing and destroying his body and most probably was not amenable to treatment with curative intend. He sat there and heard the whole sermon of doom. Then he replies,” I hope everything is all right then”. I sat wondering which part I or he had missed . I told him that we could not cure the patient who asked me whether everything was alright. I told him that it was not the case and that his patient was dying. I asked him to bring the patient and we would explain the rest.

It is extremely difficult to explain the prognosis to women. However informed and educated they may be , they have this inborn character of cracking up in such situations. An old man with carcinoma of larynx in an advanced stage had been coming to my OPD. Each time I sent him for biopsy he got lost and came to my OPD next time without the results. So this time I insisted on him to bring someone from home. But to my dismay, a young lady in twenties had accompanied him. I preferred to explain the prognosis to the old man rather than to the lady. But she told me that she was a distant relative and was a nurse working in a peripheral hospital which comforted me. At least she must have seen patients like this. I sent the patient outside and started explaining the bad prognosis of her uncle’s disease to her. She told me she was expecting this for sometime seeing the smoking habit of her uncle. I told her that the biopsy was just to prove the diagnosis; even though we were 99% sure it was cancer. She was calm and composed. She said she would later break the news to the relative and left. I was sorry for the patient but was happy for my accomplishment of breaking the news to a women and not making her cry for the first time. After 5 minutes she rushed into my room her eyes red and raining with tears. She told me she could not face her uncle being informed that he was going to die. She began to cry loudly and other patients tried to notice. I asked her to calm down and be stronger. Things like this could happen to any tom, dick and harry . I have a fixed protocol of lines to calm patients down. It took me around ten minutes to console her and she left wiping off her tears. I felt a little relieved but still waiting for that woman who can receive the bad news.

We have our own ways not to frighten the patients because majority of patients coming to us are scared either of the disease they have or of the surgery we perform. So one wrong word would make them run and hide at their homes. It is very easy to convince the patients that they are ill . After all that is what they expect when they come to us. On the other hand, it is very easy to make a patient disagree with surgery. Just explain the procedure in layman’s terms and he will never allow you to cut him open. Most of our patients are neurotic which simply means that they are obsessed with disease. The moment you tell them they are normal, they either switch the doctor or keep increasing their complaints and visits. So we try to formulate terms and conditions which would satisfy them. Globus hystericus is the most fascinating among them all. Seen most commonly in women, this condition just means that the patient has a feeling of a lump in her throat but there is nothing wrong. If you tell her she is normal, she would just come again and again. If you tell her the fancy name, she will be happy irrespective of whether you treat her or not. Such patients are very happy with relative gimmicks like diet management, exercise, steam inhalation etc though none of these is a definite treatment. Not all tumors are dangerous or deadly , so it is very important that we don’t frighten the patients and make them count his days. So we have got wordings which would explain to him the disease perfectly. These words are just locally evolved and have the same meaning, but the idea it gives to the patient is different. Like for instance, a ‘Gant’ is a swelling which is benign, a ‘rasoli’ is supposed to be a similar swelling which is more dangerous and everybody understands when we call a swelling a cancer. A ‘sojish’ is a small ulcer or oedema , a ‘chala’ is a similar ulcer but more dangerous and next stage is a cancer. Since the boundaries between these terms are pretty vague, one must use them very carefully or else the patient may get misinformed.

The only time I don’t like my patients is when they become careless and don’t follow my instructions. A patient had cancer in his larynx which was treated by radiotherapy. He had come for follow up after 6 months and had not shown any evidence of disease. I examined the patient and there was still no evidence of the disease. I removed my facemask to tell him the good news but noticed the foul smell of tobacco smoke. I asked him whether he started smoking again. He reluctantly told me that he has been smoking for the last 2 months. I got so furious that I shouted at the patient so violently that even my co-resident, who was an occasional smoker got frightened seeing my hatred to smokers . How could he start something which caused his disease at the first time? He has not understood the gravity of his disease and the extent of damage it could do to him and his family. I was under the false impression that we had conquered the disease while the patient himself was conspiring against me. I threw his card away and told him to get lost. He sat there and stared at me. I told him not to see me again until he quit smoking. I knew this was against doctor patient conduct, but my care for the patient had overwhelmed my conscience. The other patients started explaining to him the importance of quitting smoking and that I was behaving like this because I cared for him. May be the patient would never come to me again, but at least I made my point clear to him.

As a doctor we are often accused of being emotionally blunt. Especially surgeons are considered rogue and emotionally attached to patients. Some say that how can we bond with our patients and later cut them with a scalpel. But the truth is surgeons unknowingly get attached to their patients even if they don’t want to. But we often try to hide this by behaving indifferently because most of the diseases we deal with have bad prognosis and urgent decision making and action is of paramount importance. So being emotionally attached to our patients would really interfere with such a decision making. This reminded me of a joke which floated in the facebook. Physicians and Surgeons go for duck hunting. When the ducks fly over them the physician, the Internist points his gun, but does not shoot. "This bird certainly looks like a female mallard, but I must rule out geese , and swans. A juvenile Mesopotamian sea duck would look exactly the same!" the duck flies away. The surgeon comes,” look it flies,BOOM, then turns to the pathologist and asks , what was that?.



By the eldest son



Thursday 15 December 2011

Singing birds and sweet mangoes.


In this world of ours unfortunately dominated by chaos, confusion, tension and turmoil, every one is looking for a bit of relief , a little space to relax and a ray hope. A singing bird or a melodious music or a beautiful butterfly that seeks  to suck the nectar of flowers fluttering its wings or the fragrance emanating from jasmine flowers is apt to give man what he is badly in need of these days.

Apart from these blessings of Nature there are certain aspects of human behaviour that grant us mental satisfaction and contribute to our peace of mind. The other day we had been to the house of my wife's friend to hand over a book my wife had borrowed from her. I waited on the ground floor of the building whereas their apartment was on the first floor so that my wife could hand over the book and return quickly since it was already 10 P.M as people in Doha are in a hurry, during winter season, to dine and go to bed after wrapping themselves in warming blankets to plunge into sleep induced by the cold weather . My wife did not come back quickly but their eldest son came down telling me that his father was calling me to go upstairs. Though I tried to apologise, he insisted on his request and I had to follow him. While my wife was chatting with her friend I sat in their living room talking to her husband explaining why I was waiting on the ground floor instead of entering their house When the chit-chat between the two housewives went on for while , I began to remind my wife that it was already too late but her friend tried to assure me they were not at all disturbed by our presence and that their bed time was 12 midnight .Despite that they were not expecting us, with in a few minutes two plates of chapattis and a bowl of chicken curry were placed on their dining table. Then we found them literally begging us to accept eat something. Though our dinner was ready at home, we began to eat while both of them stood beside us requesting us to eat more and more. His wife was taking chapattis from our plates and tearing them into small pieces to facilitate our dining. She told me that she presumed that the curry prepared by her might not be as delicious as the one prepared by my wife which could be the reason why I was hesitant to eat . We were like obedient students before them as we could not escape from tight grip of their warm hospitality which had a special flavour unmatched by any item in the menu of any hotel in the world. What mattered were not the dishes on their dining table but their open-hearted approach and extraordinary cordiality that have left an indelible imprint on our minds. It disturbs our minds when we think that we will not able to reciprocate their hospitality when they visit us next time however hard we may try. We believe that God has chosen such persons to be an epitome of those sublime characteristics.
I remember a man who used to invite me to join him for a cup of coffee when ever I passed by the traditional teashop in our village in Kerala he used to frequent. When I apologised, he seemed to be annoyed. My initial reaction was some sort of astonishment or even resentment as I wondered why he was annoyed at my unwillingness to join him as if I had to wilily-nilly obey him and I even thought that he had no right to force me do something I didn’t like . It took me some time to realise the sincerity of his purpose, the selflessness his motive , that his was not a perfunctory act for he expected nothing from me in return and he would gain nought save the pleasure he derived if I accepted his invitation. If I acceded to his request, he was instead going to loose a few bucks .If he had asked me to do him a favour prior to his invitation or thereafter, his invitation would have been tantamount to a diluted version of bribery

Once when I was living as a bachelor in Doha, a friend of mine who was living with his wife in a humble house invited me to dinner. The dish prepared by his wife was handmade pathiri (pancake made of rice flour) and some curry. I asked her why she took the trouble of preparing handmade pancake instead of preparing it using a home appliance called “pathiri press” as other housewives do . Then she told me that during one of their visits to our house in Kerala, when my l mom was alive , my wife was trying to serve them cookies and cakes which is the usual method among housewives to treat their guests even these days as it saves time and requires no efforts on their part . But when my mom saw this , she told my wife that it was not the proper way of treating guests, volunteered to prepare handmade pathiri by herself in front of her and asked my wife to serve them what her mother in law had prepared .My friend’s wife told me that it was from my mom that she had learnt to make handmade pathiri. She added that handmade pathiri was softer and more tasty as its contents include ground coconut as well. Though the financial status of the host counts, it is not the main contributor to the satisfaction of the guests. I remember one of my late maternal aunt who was so loving and affectionate . Her husband was a man of principles who always wore pure white shirt and dhoti which he himself washed until his death. Such persons never think of earning money and hence he was suffering from financial problems throughout his life and trying hard to make both ends meet. But every one who visited their house testified to the fact that what they witnessed there was an atmosphere of affluence bestowed by their selflessness, humility, love and care for their guests. Their financial problems had had no adverse effect on the impression they created in the minds their visitors. On the other hand who ever visited the house of another maternal aunt of mine, whose husband was rich, owned properties and lived in two-storey building in those days complained of a gloomy atmosphere and dead silence in their house.

Our mom taught us not to disappoint any one who knocked at our door even “ if the person came to us on a horseback” .She did not always have a money to give those approaching her as her husband was just a farmer who was trying hard to meet the day to day expenses of his family. Therefore she sometimes gave them the shirts or dhotis her children were using without telling them. When we returned home we found our dress items missing and quarrelled with her.

Our villagers still remember that my mom had hosted whoever visited our house regardless of their financial status . Last year when I was on vacation in Kerala, an ailing person whom I met told me how my mom used give him Kanhi (rice water soup) when he visited our house to purchase fresh mangoes from mango trees grown in the plot of land where our old house stood. Neither those mango trees that gave us different types of sweet mangoes nor my mom who used to care for them are with us today. When I sold the last mango tree to a timber merchant as it stood so close to our house and its branches began to cause damage to the roof , I thought I could plant another one to give us the same type of large fleshy sweet mangoes. But though we have more than three mango trees in our plot of land today none of them is similar to it in terms of taste or shape.

A few weeks prior to her sad demise in 2000, my mom was hospitalised. When her condition worsened, she expressed her wish to see me. By the time I reached the hospital in Kerala where she was admitted she was in the ICU unit .Since the moment she saw me, her condition began to improve and she was transferred to general ward. She soon regained the power of speech she had lost, began to speak to the visitors and even crack jokes with those visiting her. We decided to take her home and look after her with the help of a home nurse. At home she was looked after jointly by my sister and brother’s wife. Her condition seemed to improve and my sister returned to her house. We thought that every thing was going well but a couple of days later all on a sudden when I was having lunch she breathed her last due to cardiac arrest .Even when my only sister hugged me and wept, I don’t know why I could not follow her . It seemed that my feelings were frozen or it might be that one needs to be brave even to shed tears. If one cannot weep even at the death of his mom, nothing else in the world can make him cry.



By the father





Saturday 3 December 2011

Weird facts

On a fine morning she was walking though the coconut grove close to her house in the company of her husband who happened to be a journalist. Being enchanted by the coconut trees laden with green and ripe coconut bunches, adjoined by paddy fields full of lush green rice plants he commented saying " What a splendid sight ". She gazed at him and said "oh, you are thinking on these lines but I am now reflecting on what will be my situation if a coconut falls on my head ".

When her husband narrated this incident to her father, the latter tried to convince him that she could not be criticized for such a mentality since it is a question of "genetic disorder", because she had imbibed such a characteristic from her father only. She is , fortunately, an exact replica of her beloved mom in terms of her physical features or else it would have been rather hard for her parents to find a groom for her and her husband , a handsome gentleman, who has now tolerated her for a number of years, would not have accepted her as his bride. She should have inherited at least a little bit of courage and confidence from her mom and but has instead absorbed pessimism, anxiety and irrational fear straight from her dad, an epitome of such feelings. Her dad is so delicate and touchy that when there is a very slight leakage in the water tap at home he gets upset; when he goes meet a person he speculates that he will be absent ; when he drives his car he thinks that the car next to him is going to hit him; when he waits for some one he imagines that the person will never arrive; when he goes for shopping he expects that the item he is looking for will be out of stock ; when his children are late to reach home, he imagines that some thing wrong has occurred and so on , so forth.

He remains a passive spectator, let opportunities pass without seizing them and then cries over the spilt milk. He is aware of the fruitlessness and absurdity of such behaviour but cannot help it. He is notorious for his lethargy and laziness. His friends say that it is his wife’s dedication and loyalty that has made him so inactive since she spares no efforts to keep him healthy and happy. She does everything for him including those chores expected of him as a man let alone as a husband and when ever he extends a helping hand to her, she begs him not to do so since he never does anything properly and therefore her work load will increase and not decrease. Every day at 6 am his breakfast is ready on the dining table; she never forgets to remind him to take fresh gooseberry along with turmeric powder prior to his breakfast to control his blood sugar ; when he returns home from his office lunch along for with plates, knives, forks and bowls will be waiting for him, he has just to eat it and wash his hands and that too he does not do properly and the result is that she has to replace the towel hung close to the wash basin frequently as it is always full of oil and stains; his wardrobe is all the time full of ironed shirts and he is very often perplexed as to which dress he has to put on; when he goes out she ensures that has buttoned his shirt properly and advises him not to rush while driving .Last year when they were on vacation in Kerala, a doctor told her that her husband looks younger as she looks after him very well.

He always looks gloomy, moody and tense as if some misfortune is going to befall him. However he may try, he finds it difficult to smile at others when they smile at him .Though he has seen his friends patting and some of them even hugging their wives and children while coming home after a long absence he could never do so. He was shy even to kiss mother when she was alive. Only once could he do so, that too when she had been hospitalized during the last days of her life. But before kissing his mom, he remembers how he ensured that none was watching him and when he did it at last he behaved like a thief trying to steal something.

Once at Kochi airport while his wife and children were waiting to receive him, he came out of the airport, spoke a few words to his children , loaded the luggage in the taxi, got into to it and did not even bother to look at his wife who was there waiting for him . She was naturally very sorry and told her children that she should not have waited for him at the airport. Such a situation has the potential to provoke any women however humble and sincere she may be, but she continues to be loyal and serve him as if nothing unpleasant has happened..

While living as a bachelor , he used to tell his friends that he did not like to invite some one to join him in his life journey just to share grievances and suffer as he could foresee the trouble and turmoil in the offing. He knew that his cousins younger than him had already married. But he forgot the fact though he was physically fit for marriage, he was fiscally unfit for marriage especially his house at that time was an old one badly in need of urgent repairs. On the occasion of his sister’s marriage , a lady belonging to groom’s family who attended the function had pointed her finger to the wooden roof frame of his house being eaten by termites and announced that his home was unsafe. More over his mom was ill and it was very difficult and tiresome to look after her.

A couple of years after his arrival in Doha he traveled to Kerala after borrowing some money to get married at a time when he was drawing a low salary that could just support his parents at home after meeting his expenses in Doha . She should have had the common sense to think that marriage was not a joke and that he should not violate his own promise not to let any girl suffer by joining him as a life partner in such a situation.

His parents especially his mom used to pray to God in tears to take care of this timid toddler of hers as her maternal instincts would have told her that her son was so inept that he could be easily fooled by any Tom, Dick and Harry. Therefore God has been so benevolent to him and rarely does he face obstacles in his life save those created by his own thoughtlessness and stupidity.

Here he is celebrating the 33rd anniversary of his wedded life and living in peace and happiness with his loving and caring wife and children. What else doe he want and why he is restless? These are the two questions, he is yet to find an answer.

The Father