Unpublished novel by Rakesh Biswas for all interested in the science and fantasy of medicine. Not about religion, but a postmodern multi genre combining elements of Science, Fantasy and Romance
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The Medical Grocery shop

 

June is in her teens now (as far as this episode is concerned-Suts). She's a 3rd year medical student and a regular member of Professor Jo's class on holistic medicine, which she's quite enthusiastic about along with her regular medical college routine. She listened as Joatmon began with that faraway look in his eyes.

"As physician healers our only job is to trouble shoot advanced systems and there is a physician healer within all humans irrespective of their technical qualifications. To utilize one's healing capacities one has to learn to be a life long student. The stories we experience everyday tell us how to approach various system problems and how they are solved. Essentially they portray disease situations where macrocosmic expressions of these systems go awry due to peculiar microcosmic interactions."

Having said that professor Joatmon attended to his next customer. He was at the moment a shopkeeper with an aura of a physician. He was a shopkeeper who liked chatting with his customers, listening to their problems taking care not to offer immediate solutions. June thought he resembled the huge tree she had spotted once in the midst of the marshes in Bharatpur his patients perching on him each day like a host of painted storks building nests on his shoulders. He never made an attempt to shake them off but simply filed them in his data-base.

Joatmon began again after having disposed his second customer for the day. "These microcosmic interactions would be different in different individuals as all of us carry within us a chemical cauldron hidden deep in our bodies, the chemicals brewing within our blood. Different molecules with different expressions give rise to our chemical individualities. In the holistic approach we don't treat each and every machine as if they are created equally. We don't type them into disease classes, rather we look at them as individual systems afflicted in a manner that is unique to that particular system. Each and every machine has its own way of adapting to its immediate environment although superficially they may share a statistical similarity. Inside each and every machine if you look into their circuitry is a tree with a pattern of statistical self-similarity (that is very often labeled as a fractal). A fractal structure is present in all our systems, be it a river like branching of capillaries and blood vessels seen on Endoscopy or a bronchial tree on the chest x-ray carrying air to the alveolar rivers for supplying oxygen to the cells. When disease strikes due to a particular machine's maladaptive behavior, the fractal tree is chopped off or scorched, scarred and distorted as a manifestation of the battle within."

The next customer had come for half a kilo of sugar. The grocer professor gently filled up the weighing scales with crystals of carbon glistening as sugar, all the while enquiring about his family, his wife's headache, if he could put his little one to school this time or had the principal failed him again in the parentís interview.

 

 

 

 

 

 

 

 

 

Quest for chemical individuality

 

"To our chemical individualities are due our chemical merits and shortcomings. The factors which confer upon us our predispositions to and immunities from various mishaps which are spoken of as disease are inherent in our very chemical structure and even in the molecular groupings which confer upon us our individualities and which went to the making of the chromosomes from which we sprang." AE Garrod

 

 

 

June watched and marveled at the professor's unique flexibility, his ability to work at many different levels simultaneously and establishing individualized care rather than a blanket protocol. Protocols and decision trees were what June spent most of her days memorizing in her medical school and professor Joatmon's approach struck her as peculiar. At the same time she found this easier and less taxing and began to seriously doubt her medical school texts that treated all patients with one diagnosis in the same manner. "Don't you find this ironic?" She asked her batch mate and best friend Krish (shortened from Krishna). Krish was a tall dark handsome guy frequently spotted with June in the canteen.

"What?Ē Asked Chris, somewhere down the line Krish had been nominally transformed into Chris). He was trying to concentrate on the material for the community medicine exams, trying to memorize the dimensions of a sanitary toilet along with mugging up a lot of info (facts and figures) on strategies for disease prevention on a global scale.†† June continued, "Well, don't you think it's ironic that a profession so very devoted to the care of individuals should care so little about individuality."

As a third year medical student, June wouldn't bother to wait for the bedside teaching to start everyday. That was unlike her other batch-mates loafing in the corridors, presumably waiting for their professor to allot them a case, who would very often be found at the coffee club, busy discussing the latest bit of evidence on the efficacy of a newly launched drug. June would rather allot herself her own cases for the day by simply walking up to any of the individuals lying in their beds waiting for deliverance. "Hi! I am a student doctor and I want to know what your problems are?" she started off with a particularly emaciated man with a distended belly (somehow the most interesting patients appeared to be holed up in the general ward).

"I am hungry." he replied.

 

 

 

 

Listening to patients and teachers alike

 

June realized that a systematic step-by-step questioning approach wouldn't lead her anywhere with this patient. She decided to jump tracks like she had watched Joatmon do on a number of occasions.

"Where are you from?"

"Nepal."

"Well...I am Juneli..."she began and was cut short by the patient who started excitedly in Nepali, "Aae...tapaiko ghar kahan pareo?"

June explained she wasn't Nepali but her father was a Nepal lover who had chanced across this river in Nepal that gave her the name. Ram Hari opened up better after that.

June checked if she had got all the components of the history of present illness in order. The onset and duration of symptoms, course and present status of the illness, the investigations done and treatment received and finally noted specific symptoms that would help to localize the disease to any organ system component.

Samsara had once told her about one of his wild schemes wanting to convert these points in the history and physical findings into weighted numbers. ďLet's assume each of the points in the history are numbers like a1, a2...a'n', b1, b2...b'n' for the general survey findings and c1, c2, cíní for the systemic examination. If we integrate them for each individual patient we can have a number for a diagnosis.Ē

June knew what Joatmon would say to that, ďBy giving everyone a number we assume that all individuals with numbered symptoms are similar in their inner microcosmic interactions but they are not.Ē

Professor Mechanic was scheduled to take their clinical bedside for the day. He preferred that classes even on practical clinical approach to patients be held in the classroom next to the outpatient department, as he didn't like too many students standing and crowding around a patients bed. Also if the students were seated and relaxed the discussion was more enjoyable. Only, it had to be labeled as bedside teaching anyway. The student who had taken the history began...so and so from...came with the chief complaints of abdominal pain and gradual distension since the last few months. The professor along with the whole class listened patiently to the complete history narrated by the student presenting the case with minimum possible interruption. At the end the professor asked one of the students in the audience to analyze it upon which he looked bewildered. As if anticipating this, the professor proceeded to explain it himself.

 

 

 

 

58

 

 

A young Alcoholic cirrhotic

June would visit Ram Hari every morning and collect his story bit by bit during the time most of her friends would busy chatting away waiting for Professor Mechanic to come and teach them.Ram Hari was a 25-year-old man working as a hotel waiter in Bharatpur, Nepal and had come to Kolkata, India searching for a job in a bigger hotel. He landed up in the bed before June however as he had developed a distension of his abdomen while in Kolkata and when he presented to the outpatient department of their medical college a kindly physician admitted him. That was three years back and ever since he had been depending on the hospital for his food, shelter, and intermittent fluid removal from his abdomen. Most of the hospital staff knew him by name.

He had been a regular drinker since the age of twelve. His mother had abandoned him when he was a 6 year old (his father kept saying she had run away with another man). From the age of 12, he was forced to work as a daily wage earner by his father and was employed in a factory manufacturing country liquor. Since then he started drinking 250 ml of spirits daily and would occasionally consume 2 bottles of 750 ml each. At the age of 21, he suffered an episode of massive blood vomiting and tarry stools for which he had been admitted to a district hospital in Nepal where he received 6 units of blood transfusion. Soon after discharge from that hospital he resumed drinking for another year until he was readmitted to the same hospital with a fluid filled belly. He has undergone repeated removal of fluid ever since with needles jabbed at various sites over his belly. He also had a hernia over his umbilicus due to all that fluid in his belly and which burst spontaneously one fine day for which he again had to be admitted for an emergency operation.

June started doing a physical examination on Ram Hari meticulously elucidating the findings as she had often seen Joatmon do.

On general examination Ram Hari was visibly very pale and malnourished, had a prominent scalp infection, and his eyes suggested a mild jaundice. Ram Hari's abdomen provided the maximum number of findings. It was distended with prominent veins and fullness in his flanks, an everted and bulging out umbilicus (as if someone had stuck a top over that portion of his belly). She could hear a continuous to and fro sound over his umbilicus with her stethoscope but couldnít figure why there was this sound and decided to look it up later in her books if possible.June could palpate his liver and spleen by dipping her fingers into the organs through his fluid filled belly. She could elicit a vibration of fluid over her palms placed on his belly by tapping at it from a point opposite. It is a sign that goes by the name of 'fluid thrill' possibly given by a thrilled physician first to have discovered it. It confirmed the presence of a lot of fluid in Ram Hari's peritoneal bag covering his intestines.

June took a peek at his file to look up the investigations already done during his hospital stay.

He had a hemoglobin of 5 g/dL, a total leukocyte count of 1800, and markedly reduced platelets on smear suggestive of hypersplenism. His serum bilirubin was 3.6 mg/dL with an unconjugated fraction of 2.4 mg/dL, serum albumin was 2.1 g/dL and globulins were raised at 4.5 g/dL. His HbsAg (Virutex/latex), Anti-HCV (dot blot Assay) and HIV (ELISA) were negative. Ultrasound abdomen showed an irregular liver surface with portal vein measuring 14 mm apart from free fluid.

 

 

 

 

 

 

 

 

Bedside troubleshooting: a systems approach

 

 

Prof Mechanic began, " The approach to clinical problems (or challenges), begin almost always in trying to localize it at a component level, be it in the kidneys, heart, brain or liver. Asking where the problem is gives us the morphologic/anatomic diagnosis. The ability to make a diagnosis would therefore depend very much on our knowledge of anatomy, the intricacies of the machine's internal circuitries. None of you should feel uncomfortable looking at the jumble of chips and maze of signaling pathways that one finds on removing the lid off your machines. You have had sufficient time I hope to learn about it in your pre-clinical years. This learning and your knowledge of anatomy is what separate you from a layperson that is more likely to be your patient. It is also important because the human machine takes a long time in its evolutionary sequence to change in structure. So for most part of your medical career you will find many of the other things that you learn today shall change dramatically over the years but your knowledge of structure/anatomy shall not. Even grossly your machine may not appear to change very much in function at a component level. The kidney will continue to produce urine, the liver bile, and the heart shall continue to supply blood and oxygen to all the tissues, microchips that produce energy from your daily bread and the brain shall continue to think perhaps! This view of the brain was not always there in the past and we have held on to it for quite some time now. However at a deeper microcosmic level the stories may change. This is because, (Quoting Blake)

"The Microscope knows not of this nor the telescope:

they alter the ratio of the spectators Organs but leave objects untouched."

Apart from identifying which component is malfunctioning we have to also answer the question of why it is malfunctioning. If a machine points out or displays chest pain on its LCD screen we can speculate the source to lie in the coronary pipes which may be blocked and not supplying enough oxygen to the central pump, or it could even be something wrong with the aortic valves in the pump, again impeding circulation through the coronary pipes. We can also speculate that it may be due to a host of other system components like the food pipes or lungs or even the muscles or bones of the chest and very often these possibilities would be narrowed by weighing clues offered in the symptoms, the onset, duration, course and exact site of the pain. Assuming that we have narrowed down the problem site to the pipes supplying the heart (fashionably called the coronary arteries) we have to wonder next why, what is happening there? The commonest story in circulation at present to explain blockage of these pipes is the story of atherosclerosis. The story of immigrant lipid moieties settling down in the endothelium, constantly under attack from inflammatory mediators until one fine day the plaque like community fissures and cracks up resulting in a blocked pipe. This is a problem of the present global community, violence and strife everywhere. Our diagnosis generally ends here after unearthing the site and cause of the problem.

 

 

Summarizing livers and rivers within

 

 

 

Prof Mechanic continued, "To summarize then, we have a 25-year-old system with a bloated belly, past blood vomits and altered behavior. This pointís to the liver and its pipes under high pressure as the anatomic location of this problem. This is what we would label as its anatomic diagnosis. Now the exact cause for injury to the liver is also quite clear. Ten years of uninterrupted high dose alcohol consumption, like spilling coffee everyday on your laptop that finds its way into the hard disc. On examining this machine we find prominent veins over his belly a marker of all those displaced liver rivers. And just look at those beautiful red spiders, Wow! Look at that haul on his back! Look how they blanch off and disappear when I press this glass on his skin and reappear when I remove the pressure. Also if you remove his underwear and examine his genitals you shall find both his testes small like that of a kid. There is hardly any secondary sexual characteristics in this 25-year-old you would expect, axillary, pubic hair...hardly any? The spiders-dilated small arterioles, small testes, lack of sexuality is all because of an excess of the female hormone, estrogen in his bloodÖThat estrogen which couldn't be utilized by his ailing liver.

The class looked at Professor Mechanic mesmerized by his deft handling of this 25-year-old young machine arriving so very easily at a diagnosis both morphologic as well as etiologic.

"But then...June thought, is getting the diagnosis the central process of clinical medicine?"

The 5 edition of the oxford handbook of clinical medicine that she carried about in her apron most often to the wards also raised the same question and in its own answer submitted, ďThe central process in medicine are: The relief of symptoms, the providing of reassurance or other prognostic information and the lending of a sympathetic ear, all seriously lacking June thought in professor Mechanic who always seemed to be in a hurry doing procedures, giving lectures and advice too often without much listening. He was more like a tree swaying gregariously in a storm shaking off all the birds that dared not build nests on his shoulders. Prof Jo never seemed to be in a hurry, which made you wish you could be with him always.

 

 

 

 

 

 

 

61

Discussing the Whole

 

June emailed Ram Hariís story to Joatmon particularly because she was convinced there must be another level of diagnosis for him apart from the fact that he had cirrhosis of liver (Prof mechanicís morphologic diagnosis) due to alcohol (His etiologic diagnosis).

Dear June, Thanks a lot for this. There is this other dimension of a patientís diagnosis which you have sensed and we in holistic medicine feel is so often neglected by professor mechanicís hardware school. Itís the social diagnosis that lifts this machine from the hospital bed and places him in a wider community perspective. That is why a hospital physician who never practices in the community can hardly ever connect to his patients beyond the mechanical approach, barring exceptions. I would like you to prepare a report of this case because itís important that we tell the world that cirrhosis with all its complications due to alcohol can even occur at this age possibly related to poverty, child labor and easy access to alcohol and we need to keep our eyes open for this cohort of young alcoholics. Give me the complete clinical summary of this case and I shall prepare the discussion. Jo

June browsed through the discussion prepared by Jo. It must have been hard to collect the references sitting in his cave in the jungle but then he had friends in better places that would have mailed the references to him. This patient highlights the social problems posing substantial challenges to health care in the third World. Child labor was forced upon him at an early age and he took up alcohol early also because of easy access to liquor. Inspite of legislative enactments prohibiting employment of children below the age of 14 years (section 14; Civil rights act, 2012, Nepal), the 1981 census, Nepal, showed that 4.5 million or 60% of the child population in 10 to 14 age group of Nepal is economically active1. The sale or offering of alcoholic drinks to persons below 18 years of age is illegal according to legal restrictions on production, sale, and consumption of alcoholic beverages in Nepal2. However, alcohol use has been quite prevalent in Nepal since time immemorial. Social tolerance to alcohol use is quite high and mostly alcohol has not been taken seriously either by the Government or by any social organization. Production, sale, and consumption of alcohol are ever on the increase and it could be taken as the number one problem drug in the country3. These factors contributed to the early onset of heavy drinking in our index case and he developed cirrhosis at the age of 21 years. His dependence on alcohol was such that he didnít stop drinking even after the first episode of blood vomiting and tarry stools. Continued drinking for another year made his social and financial supports give away.

Following this he was converted into a total dependant on the hospital partly for his regular abdominal fluid removal and partly for 2 square meals a day, effectively falling into the vicious cycle of poverty and social-physical debility. The so called Developed countries such as United States have dealt with their alcohol problem with periodic enforcement of strict prohibition like the one, which lasted from 1920-23, and the incidence of alcoholic cirrhosis reached an all time low. The death rate from the condition fell to half its 1907 peak and did not start to increase again until the amendment was repealed4. The time is ripe for Nepal to embrace strict enforcement of its prohibition laws.

References

  1. Children and Women of Nepal, a situation analysis, UNICEF Nepal Publications 1992.
  2. Madira Niyamharu (2033) Nepal Niyam Sangraha, Khanda4. (KA) 2040, Ministry of law and justice, HMG/Nepal, pg 132-8.
  3. Shrestha NM. Alcohol and drug abuse in Nepal. British J of Addiction 1992; 87: 1241-8.
  4. Musto DF. Alcohol in American History. Sc American 1996; 274 (4): 64-9.

The pump that runs our rivers

 

The 5th semester clinical medicine posting was the most exciting time for June with the days going by like a dream. Chris was being extra nice to her as a compensation for being not so nice to her father Samsara whose Baulish ways were getting on his nerves. Professor mechanicís classes went on full swing. ďSystem trouble shooting approaches a patient system by breaking it up into its component parts. Now that you have had some idea of how we deal with the liver we shall move on to the heart. Itís vital to have a pump delivering a constant supply of electrons to run our microchip tissues. This pump that runs our rivers gives the required thrust to the electrons contained within them to reach the interstitial ocean. The ocean of water and its electrons exist not only amidst all of us cells but also within us. All of us individual Earths are made of three parts of water and one part land. In this three-part water of Earthís body there exist plenty of micro-capillaries, arterial rivers bringing our microchips daily bread and at the same time venous tributaries drain their daily excrement. A drain that returns all the water back to the central pump that purifies it by sending it into the lungs, open air, pristine valleys.

 

The machine right now before you is malfunctioning because it is unable to breathe properly. Its activities of daily living have been severely restricted as it gets short of breath even while going to the bathroom. Initially it wasnít this bad when the problem started. It was just that its God noticed the system running slow, files taking longer to open as if fatigued. Then the shortness of breath was noticed on climbing stairs and now this. On general survey you can make out the increased breathing rate and also notice the veins near its collar becoming prominent with a peculiar bulging followed by a collapse, the V-y we call it. Looking at this we can safely assume one of the right heart valves is leaking and this in turn is because of increased pressures in the Lung Rivers leading to a pressure rise in the right heart chamber that has resulted in the right heart valves to come apart. Why has the pressure risen in these rivers, which normally are placid at 5-10 mm of mercury pressure? Could it be an avalanche somewhere up in the snows, a lot of ice melting all at once? From the history we know it was a more chronic process.

The pump in his left side that presently drives the whole system circuit has been failing gradually for some time now. As the left chamber of the pump fails there is an increase in its end diastolic pressure that is in turn transmitted to the pulmonary rivers, which drain the right chambers. As a result the right pump fails because of the failure of the left main pump. So itís not just the breathing difficulty. His whole body is bloating up as the ocean in his interstitium stagnates for want of proper drainage. Now why did the left main pump fail in the first place? It could have been a blockage of its own blood supply due to a sudden traffic jam in his coronaries (quite a common reason actually). Or it could be that the valves in the left main pump are leaking in which case you can easily hear that whoosh-whoosh torrential turbulence with your steth or it could even be that the muscle cells running the left pump with their contractile energy just dried up due to a poorly understood reason.Ē

 

 

 

Behind a failing pump: the ailing person

 

June followed up professor mechanics patient with the failing central pump after he got admitted into the ward. She worked on collecting his life event data that she was finding increasingly fascinating thanks to Professor Joís holistic approach along with the equally fascinating mechanisms of disease thanks to professor Mech. The man with the failing central-pump with slowed rivers and a flooded interstitium was originally from a village near Sirmour in Himachal, India. Dharampal, that was his name, had three mothers from his single father. His first mother wasnít his own but gave him two elder brothers. His second mother was his own who bore only one child from his father and that was he. This was likely due to the fact that she died of a febrile illness when he was 3-month old. He spent most of his childhood with his first mother after his father married a third woman who gave him 4 more brothers. He never went to primary school but spent his time cutting grass and grazing cattle in the valleys that were in the lap of the Himalayas. During 1952 when he was 23 years old he went to get enlisted in the Indian army. He participated in the Taken hill fight near Mismi, Arunachal, something that June was unaware of having ever taken place. It was not mentioned in her school history text books. He said their strategy for taking over the Mismi tribals was to gun down a few, inflicting non fatal wounds so that they could later offer them first aid and win them over. He was a great athlete and footballer from what June could gather from his account and when his unit moved to the Nathu La pass in 1962 against the Chinese aggression he missed all the action as he was playing league football for his army team as a captain. In 1971 he spent his time in the Indo- Bangladesh war against Pakistan in airdropping supplies for the Indian forces. In 1977 he was sent to Sri Lanka as a part of the peace keeping force and had road duty in Trincomalee, patrolling and clearing roads. In 1980 he returned victorious to his village. He had been never hospitalized in his 37 years of service and this was his first hospital visit. He had been married at the age of 27 years, the girl having been arranged by his first mother. He used to visit her in the village once in 2 years and she bore him 4 kids. However in 1976 he married again, he said because he was irritated with his in laws. His second wife was 32 year old whose husband had deserted her. He continued to live with his first wife and clarified noting the look of alarm in Juneís eyes that both his wives were quite ok about it and in fact even after a year of his second marriage his first wife bore him another son. His second wife bore him 2 more children in the subsequent years.

Dharampal had already recovered from his shortness of breath before June met him in the wards and collected tit bits of information from his life event data in between examining him daily. Professor mechanic had confirmed his hunch of the morphologic diagnosis being in his left pump chamber by doing an ultrasound-echo examination in the out patient department itself. He also concluded that the problem was a blocked pipe to the pump, as particular walls of his left pump chamber were not contracting properly. Dharampal went home with only a mild residual breathing difficulty. The pump chamber pressures had been relieved with drugs that removed fluid through his urine. However he came back a week later with severe chest pain and breathing difficulty and died shortly in the ICU. It had been a sudden complete blockade of his pump pipes professor Mechanic concluded.

 

 

System trouble: A yellowed display virus

 

 

June was regular in attending Professor Mechanicís clinics as she found his mechanical approach strangely exciting. Inspite of her beliefs about holistic medicine, strangely she didnít find the two incompatible. Even Chris pointed out, ďLook machines are not really similar and have an individual adaptability so even if we approach humans as machines we need not fall into the typological trap of equating all humans as one. Human bodies can still be thought of as machines that need to be approached individually. Most of our problems stem from the fact that we canít separate human consciousness/God from their machine like bodies.Ē

At professor Mechanicís liver clinic June not only saw more machines with fibrosed livers with blocked inflow pipes she had found in 25-year-old Ram Hari but also a lot of other interesting problems like pipes bringing bile from the liver into the intestines getting blocked and bile spreading into the blood circuits as a result coloring the display a golden yellow. It was fun watching professor Plumber introducing wires with balloons into those pipes and removing stones and muck or putting in smaller stents (pipes) into the bile pipes if the block was due to those obnoxious looking schizoid growths many machines seemed to be increasingly getting afflicted with as age advances. There were other causes of the LCD going yellow due to bile in the blood circuit, like at times the liver cells would simply be swollen due to viruses infecting the system either coming in through floppy drives, the feco-oral route or slipping in through emails, the daily sex routine that most Godís couldnít resist. Sometimes they would even seep in through infected needles that might have been jabbed into it in the past like software programs given with intent to treat but unfortunately themselves containing viruses due to faulty sterilization techniques. Once inside the system these viruses usually would manifest as acute system malfunction with a yucky appetite and yellow eyes for some time. The systems gradually recovered as their immune software tackled the virus. However for some systems infected with real bad viruses like B or C the inbuilt immune software had a real tough time (in eliminating the virus B in 10 out of 100 people and C in 80 out of 100 inoculated). They may have been helped with artificial software like interferon alpha or Lamivudine, which at best eliminate the virus in only 30 to 40 of hundred systems already inoculated. Most of the other systems un-helped by artificial software go on to develop what professor mechanic would label as a morphologic diagnosis of Cirrhosis of liver but here unlike Ram Hariís the etiology would be viral hepatitis be it B or C.†††

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Unpublished novel for all interested in the science and fantasy of medicine. Not about religion, but a postmodern multi genre combining elements of Science, Fantasy and Romance