An Autobiography - Prof Dr Hematram Yadav

 

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The things you do...

Powerman Malaysia 2022

SK does not know whether to laugh or cry. If he laughs, it hurts. It is painful when he moves, and he is even afraid to sneeze. Ever since he cracked up a rib in a freak accident, he senses that his naysayers, who have been telling him to slow down with all those extreme sports at this age, are having a field day. They are secretly happy that he is grounded. Short of saying, 'I told you so', he can see the sheer delight in their eyes. Some are even emblazoned to ask, "why this Kolaveri?**"

Yeah, sometimes SK too asks himself, "WHY?" In the same breath, he also replies to himself, "why not?"

Homosapiens, by design, have been made to be agile and mobile. Through many prototypes which failed and multiple disastrous trials runs, Nature has remodelled and re-fashioned Man to be ambulant with such ingenuity. Only over the past 30 years, through the same thinking caps that make Man leap to greater heights, have we become couch potatoes. These prodigal products of Nature, with the boon of cognition, have rewritten the laws of Nature. The glutes, which played an essential role in moving around, somehow lost their purpose. Man now finds more pleasure in accumulating adipose tissue there. It even develops into a fetish by filling it with prostheses that enhance its gargantuan silhouette.  

Yeah, why do people do the things they do? Why do people want to climb a mountain? Why swim across a shark-infested channel to the other side? Why were the Wright brothers fixated on lifting a contraption up in the skies? Why do people write songs or even compose a blog? It is a challenge to push the human body to its limits. This endeavour gives a sense of achievement and immerses the victor in an avalanche of happy hormones. The trade-offs that come from this, the compliments, the honour and the desire to reach even greater heights, are pretty addictive.

There is also a desire to explore the roads rarely walked upon. As humankind learns about himself and the environment around him, he soon realises that so much more that remains unknown. In our short time of sojourn on Earth, a small fraction of eccentric individuals embark upon a journey of self-discovery. Not all will appreciate this.

**the slang lyrics of a popular Tamil song meaning 'why this murderous rage?'' from the movie '3'. It is meant to depict the anguish of a person whose love has been rejected by the girl he is trying to woo. It went on to include an onerous desire to achieve something.

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Burning, burning...

©FG

You tell yourself the citizens of the country sponsored your medical studies. With a fragment of the cost of what you really need to pay, for peanuts, you got a degree. Of course, it was no easy walk in the park on your part, either. All that midnight vigil, the missed outings with buddies and the humiliations at work by seniors later on in life were your sacrifices. You were convinced that your job description would read as crucial as a bomb disposal unit. Your vocation would turn the direction of the country, it seemed. Not to forget the stresses and guilty feelings that haunted you as your patients died in your tour of duty. You can but not complain about your predicament as it was entirely your decision to plunge head in. Some reverence comes with the job, nevertheless.

Those, however, were too few and far between. The same hands that express gratitude to you would be the same ones that point accusatory charges against you. You thought they were placing you on a dais like they do to their Gods, right? When they deified you, they meant you are supposed to be infallible, and when things go south through no fault of yours, they cannot blame God, so they blame you.

If you feel it is unfair to bear the brunt of such responsibility on your tiny shoulders, by all means, move on. They are others who would gladly take over until they, too, burned out.

You are expected to do what you say and say what you do. You are just a spoke in the wheel of life. Others can use you and abuse you. But you cannot. They can be dishonest or lie through their teeth to your face. They can connive to get a big profit out of you. They can make fraudulent claims. No, siree, you cannot do any of that. You are supposed to be the paradigm of virtue. It does not matter if businessmen abuse your good office to enrich themselves. After all, they have their eyes on the money, and you have yours on the soul. So you like to believe...

(P.S. The whole equation gets distorted when the medical studies are self-financed. It is no more of paying back to society but back to the coffers. Sometimes it is an investment. Altruism rarely is in the picture.)

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The lost invisible touch!

Sir Robert Hutchison
Father of clinical methods

A friend, during our stint as house officers, told me about an incident that happened during his medical student days when he was studying in Manipal, India. An American elective medical student had joined the group's ward rounds. The old Professor of Medicine was showing them the correct technique of examining the respiratory system. He laboriously punctuated the teaching rounds by asking basic science questions and snarling occasional sarcastic remarks, for not understanding the basics. He was showing the green medical students the art of inspection, palpation, percussion and auscultation.

The American student, failing to see the point of such a laborious examination of a single patient, raised his hand.

"Professor, wouldn't it be better if we just send the patient for a chest X-ray?" he quipped.

That is the state of medicine now. We have lost the art of practising medicine. It is just about diagnostic procedures and laboratory results. Clinicians no longer use clinical methods to diagnose. If it used to be that laboratory and auxiliary tests were used to confirm or disprove our differential diagnoses, now it is the primary modality of the approach of a patient. 

Pretty early in my training, I did an attachment in a Gynaecological Oncology unit. Its head, an old-timer Professor, once was in a dilemma. As part of the staging of cancer in his patients, he would perform a CT scan. This, he would do after carefully performing a complete clinical examination. The outcome of the scan would enable him to decide on the operability of cases. There was this particular cases where he was in limbo. He was unsure of the stage of cancer. After much discussion, argument and reevaluation, he was convinced that that individual patient had an early operable cancer even though scans were reported as otherwise. After much deliberation, he went ahead and assessed the patient under anaesthesia on the operation theatre. It turned out that the old Professor was correct after all. He proceeded with the surgery, and final histopathological specimen confirmed his clinical findings too.

That was how it used to be. Clinical acumen took precedence over laboratory and auxiliary investigations. Now, lab tests take precedence even over a good history taking. The recent Covid-19 pandemic is evidence of the above. Do the swab test first, then the clinician (or perhaps the technician) would decide the next course of action; whether to operate, treat conservatively or even see the patient. Just quarantine and see the outcome later - If he pulls through what was perceived as a death warrant. 

A recent case that came to my attention recently during my work made me realised that perhaps we are too dependant on lab results. Maybe it is fueled by patient expectations of wanting an instant resolution (diagnoses) and fear of litigation. The need for an instantaneous gratification in all human dealings has permeated all social activities. We do not want our results now, but yesterday.

A 30-year-old lady presented with a two weeks delay of her periods. A urinary pregnancy test showed positive findings (i.e. pregnant). The couple presented at their doctor for a pelvic ultrasound scanning. The examination did not reveal much. As she was asymptomatic, she was told to show up in two weeks for reassessment but to return earlier if she felt unwell.

Just three days later, she returned with slight discomfort over her lower belly. HCG levels revealed 2000 IU/L. This time, a vague mass was seen just right of the uterus. A diagnosis of possible ectopic pregnancy was made and referred to a tertiary centre.

Based on the above findings, at the tertiary centre, Methotrexate was administered intramuscularly to medically treat the ectopic pregnancy. 

Follow-up HCG five days later was 5000 IU/L; adnexal mass still present, uterus empty. After the first episode of pelvic discomfort, she had been symptom-free except for the anxiety caused by the turns of events. 

Another three days later, HCG was 3000; still, uterus was empty, and the adnexal swelling persisted. The patient was well otherwise. 

© George Condous

Seven apprehensive days later, i.e. three weeks after her first consultation, much to the puzzlement of everyone, a small shadow was seen in the uterine cavity of what appeared like a gestational sac with a yolk sac in-situ. A diagnosis of heterotopic pregnancy (concomitant intrauterine and extrauterine pregnancy) was considered, and laparoscopic evaluation was considered.

Being confused with the whole turn of events, the patient decided to opt for 'wait and see' policy. A day after that, she passed out blood clots. She was diagnosed as had a complete miscarriage and was monitored periodically. 

So what happened here? Did the clinicians place too much trust on biochemical results over clinical findings? Perhaps not. When the HCG levels are significant, with the presence of extrauterine shadows and an empty uterus in imaging, it would be negligent to just sit on it. Did the methotrexate cause miscarriage? Possibly not. A high HCG with an absence of visible pregnancy is itself a hallmark of abnormal pregnancy, including impending miscarriage.

In anything that the Covid-19 had taught us, it would be that everybody can be an expert. Armed with statistics and articles to support the assertions, anyone can insist on having found the elusive cure for the ailment. Clinicians, who by nature, like to err on the side of caution, had been accused of selling out the whole human race for self-interests. It seems PhD doctors got the panacea for all woes. Their data analyses and textbookish method of approaching disease make them excellent armchair critiques of what is wrong with the medical services in any country. We all know what happens in the field is not what is shown in laboratory experimentations. But still, it is a free world. Anyone can say what they want. The more one delves into a subject, the less he is cocksure about anything.

Perhaps the demand for wellbeing makes medical services a lucrative business. If before, in the Jurassic era, the doctors would call the shots in the management of patients and the running of medical facilities. The ever increasing expense and the need for state of the art medical equipment make healthcare revolve around breaking even and paying the stockholders rather than being patient-centred. Law of Attraction dictates that the smell of money draws characters of reputable character. Hence, vultures and hyenas of various ferocity started flocking around. Referring to the clinical practice guidelines as their holy grail, these creatures of the dark forces scream medical negligence or even manslaughter whenever an adverse outcome ensues. In hindsight, everyone has 20/20 vision. They think that treating patients is like cooking chicken vindaloo referring to a cookbook.

Like the 1927 movie Metropolis, everyone is just a cogwheel in the big machinery of modernisation. We are mere technicians doing our designated duties for the greater good of mankind as decided by the powers that be - the businessman. The future is not bright, either. After breaking down and digitising our individual tasks, our jobs may be assigned to artificial intelligence (AI). We will be redundant and irrelevant.

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Corona the vaccine, we the virus.

Swans in Venetian Canal
 Credit @filterjm

Probably for the first time since Man started giving salutations to the feared forces around him, he has been asked to stop all kinds of religious congregations in big groups. For aeons, Man believed that maladies take place because the Divine forces have been angered. In their simple understanding, the only avenue left for them to correct the tragedy is to appease the Divinity by glorifying it to high heavens; hoping that He would throw us His Grace.

Hence, despite appeals by the authorities, practitioners of various faiths continue to put their trusts in the forces above, not in rational thinking and the sciences. They feel that people have been misled for far too long. The way the human race appears to be heading does not assure them of a happy ending. Too many have placed self-interest above salvation to expect altruism to prevail.

There are groups of people who are hellbent in finding scapegoats. In their minds, many if not most germs came from the East. In recent memory, we have heard of SARS, H1N1 and Nipah Virus and their fixation with exotic animals like civet cats and bats. In the 14th century, Bubonic Plague and Black Death arose from the Far East via the Silk Road.

Scrolling through the annals of history, one discovers that pretty much every human pathogen originated from our exploitation of animals. Humanity's dominion over animals has unleashed a veritable Pandora's ark of infectious diseases. Most modern human infectious diseases were unknown before domestication led to a mass spillover of animal disease into human populations. For example, tuberculosis appears to have been acquired initially through the domestications of goats but now infects one-third of humanity. Meanwhile, measles and smallpox may have arisen from mutant cattle viruses. We domesticated pigs and got whooping cough, chickens and typhoid fever, ducks and influenza, water buffalos and leprosy as well as horses and cold virus (Michael Greger, How Not to Die).


Or is our decision to self-isolate against each other is Nature's conniving power play to avenge decades of rape of its sovereignty? Look at the countries which were teeming with excessive human activities and see what lockdown has achieved? China's citizens can finally get fresh air and see the blue sky without being enveloped with smog. One week of an absence of gondolas and visitors, dolphins and swans come out to play. It looks like Corona is the vaccine, and we are the virus of Nature.

Since prayers in large enough groups will not see any daylight in the near future, cries for help from the divine forces cannot happen. I guess we have to depend on our God-given intellects to save us from extinction.

Dolphins have appeared at the Italian coastline after the
shipping lines were locked down due to coronavirus (REUTERS)

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To tell or not to tell?

The Farewell (2019)

I first heard this story as being narrated by Lulu Wang in the podcast 'American Life'. It tells Lulu's story of how her family dealt with the news of her paternal grandmother's diagnosis of terminal lung cancer. It describes how Lulu's parents, together with her uncle's (father's brother) family in Japan, gathered in China, where the grandmother lives, to bid her farewell. The twist is that the whole family decided not to tell the patient, Nai Nai as she is affectionately referred to. The family, from three countries, descended upon Nai Nai's house under the pretext of celebrating Lulu's Japanese cousin's wedding.

Lulu's role is portrayed as an early 30s Chinese American student who goes to China in a soul-searching journey to rediscover her Chinese identity. She learns to appreciate the traditional family values. As their old values dictate that the happy mind would give a healthy body, the family thought that not telling Nai Nai of her disease and its grave prognosis. Still, instead of keeping her happy in the company of the people loves, it would go a long way in prolonging her life.

The trick seems to have worked in the case of Nai Nai. Even though she was given only three months to live by her Chinese physicians (and the diagnosis was agreed by American doctors), she went on to live another six years.

The traditional wisdom in modern medicine is that the patient has the right to know his or her disease. By understanding the extent of his illness, he is in a position to go all out to combat his ailment, especially which is chronic. This is especially so in cases where the prognosis is uncertain, like in cancers. A patient's attitude and resolve towards fighting the sickness and one-mindedness in battling cancer may actually alter the final outcome.

A person in the terminal stage of her infirmity may want to step up his preparations for the ethereal world. He may want to tick off the items in his bucket list (pun unintended). The content of his will may need alterations and many more.

In many Indian families too, I have noticed that the family would collectively decide that bad news, especially of the medical kind, would not be made known to the elder members. Are the family members worried that breaking bad news may trigger a cardiovascular and emotional meltdown that would be more devastating?

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Overconsumption is the problem.

The Game Changers (Documentary, 2019)

I grew up trying to ward off suggestions from animal-loving vegans who tried their level best to convince me that structurally humans are supposed to be herbivores. They justified their assertions, with seemingly scientific support about our dentition. I would tell them that if we were born to eat just plants, our facial structures would look a goat's. And that I loved my animals too much that I eat them every day. 

In the late 19th century British India, Sikh and Muslim soldiers were favoured over the Hindus to serve the Crown. Apparently, the Hindu soldiers, being mostly vegetarians, lack the prowess that made a bloody thirsty sepoy. Meat consumption had always been linked to muscle power, athletism and aggression. Now what this documentary is saying is that we have got it all wrong. All the things that we thought about being vegan are actually just the opposite. Consuming plant-based products and avoiding meat, fish and eggs are the sure way of health, endurance, recovery and even building muscle bulk in athletes of all categories including wrestlers, footballers and weight lifters. When compared to meat-eaters, plant-eaters are claimed to be more virile.

In the documentary, the gladiators are hailed as the ultimate warriors, respected for their dedication to the blood sports. Archaeological discoveries found their bones to have high strontium levels indicative of them living on nuts and cereals. And they had solid bones. Of course, they had strong bones because their lifespan was extremely short. They were not fearless warriors bur rather fearful captives fighting for their dear lives. These slaves were not fed on a special diet but were hurled skimpy discards before being thrown into the arena to defend against fearsome soldiers or jungle beasts. Their life expectancy was less than 30, hardly any time for osteoporosis to set in. 


This is the first sign that something is not right in the delivery of the facts. The rest of it had to be taken with a pinch of salt. There are plenty of cherrypicking in highlighting the agenda that they are putting forward.

The film goes on arguing the merits of staying vegan, i.e. avoiding animal products altogether - no meat, fish, poultry or eggs. The plant kingdom has it all, nutrients, vitamins, proteins and all. There is no need at all for animals in our food. Towards the end, the film refers to many highly controversial studies. To put the seal of approval to these, they resort to name dropping. Arnold Schwarzenegger, a bodybuilder who won all his medal as a meat-gobbling athlete, now calls to go vegan. Jackie Chan and James Cameron appear in the credit roll. To support their hypothesis, they showcase the performers of many renowned international record-breaking athletes, ultramarathoners, Grand Prix racers, weight lifters, cyclists and more.

For every point that they put forward, there are as many counter-arguments against it online. 

The documentary seems to postulate that glucose is the only form of energy consumed by the brain and muscles. Basic sciences tell us that we can use energy from carbohydrates, fats and finally protein in extreme conditions. Glucose (stored as glycogen) is the primary source of energy while fat is an efficient second line of defence. It is agreed in the scientific community that with the widespread of simple carbohydrates and sugars in the modern diet, our body's ability to burn ketones as fuel is dwindling. We are addicted to sugars for the instant rush. Hence extreme sportsmen like triathletes have to train their bodies via intermittent fasting to prepare the body to burn fat and not to depend too much on glucose. The brain also uses ketones.

The excessive carbohydrate intake regime, as advised by the film, will only build up visceral fat. That is a marker of morbidity which may predispose individuals to coronary artery diseases, stroke and metabolic diseases. Never in the film is fat discussed as a form of energy.

Endothelial damage is assumed after observing a cloudy blood sample. It is a too simplistic an indicator of ill health. Conclusions cannot be made after short intervals of change of meals.

It is suggested that our digestive tract is too long for us to be carnivores. Carnivores typically have shorter tracts (as compared to the body height) and herbivores longers ones. But the acidity of our gastric juices is high, just like carnivores. In my mind, it explains perfectly why we should stay omnivorous. 

Anti-oxidants are high in plants. Some researchers posit that the anti-oxidants are to protect plants, not us. Regarding the controversy about plants being able to provide all forms of proteins that we need, the meat camp disagrees.

Heme iron (of animal origin) is portrayed as the bad guy responsible for a myriad of ailments including coronary diseases, stroke and cancer. The counter-argument to this point is that anaemia, caused by iron deficiency is a bigger problem affecting the functionality of millions.  

With the labelling of Alzheimer's disease as Diabetes Mellitus Type 3 as a result of insulin resistance, perhaps we should relook at their suggestion to increase carbohydrate consumption. 

Finally, environmental degradation perpetrated by cattle farming is proposed as a good enough reason to be vegan. Meat eaters, on the other hand, blame big companies for the blatant use of synthetic hormones and mismanagement of wastes for the pollution. They quote instances of smallholder rearers who have zero carbon emission in husbandry and cattle industries. Even in the cultivation of crops, mega conglomerates are guilty of indiscriminate use of fertilisers and failure to rotate crops for soil health.

We must be very wary when celebrities with little scientific knowledge recommend certain products. They probably have more to hide than their botox-treated crow lines. When they rekindle the story of a 'long lost treasure cove' as the panacea of our woes, I would be worried. I smell a business pitch here.

I wonder if all the virtue of being vegan has anything to do with the laboratory-grown cultured meat that was seen in the media recently.

Rather than concentrating on the type of food that we consume, we should instead try to curb overconsumption. Just about 50 years ago, during our schooling days, we noticed that there used to be one oversized student in the whole form. Now, it is almost impossible to find a normal-sized child in any class. Overeating is the problem. 

It is the converse of the Malthusian theory. Malthus, the English scholar, had predicted, in the late 18th century of a world of famine as a result over exponential growth of population overgrowing its arithmetic increase in food production. Time has proven him wrong, but now, we are stuck with a different set of problems.

Dr Sten Ekberg reacts to 'The Game Changer'. His is one of the counter-arguments against the proposals in the film

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Something to talk about when I am old and grey.

Time is cruel! © DKLA

At the pinnacle of their career, the Beatles must have had an existential crisis. McCartney and Lennon must have wondered how they would be at 64. Their vision of a 64-year old man, from the lenses of a person in the 1960s, must have been quite depressing. With bad teeth, bad eyesight and bald, it must be a picture of melancholy.
 Luckily, growing old in the 21st century is bearable. The 60s is the new 40s. One can still lead a productive life in the senior citizen / geriatric age group provided the bus does not come to pick you up prematurely.

After completing 633 km of cycling from Seoul to Pusan in 5 days, we had a couple days to unwind in Pusan. Immersed in the euphoria of completing our gargantuan task, we thought that our feat must be something that we, the seven of us, would be talking for a long time including reminiscing about it in our twilight years. We would probably be savouring each photo that we took along the way, trying to remember each story attached with it; trying to tell it to anyone who would listen.

At the end of their voyage, if life had been kind, people would have many accomplishments to ponder as their moments in time.

I know a few who talk about a time when they were stoned drunk as their memorable bits to justify their existence. They would brag about their inborn ability to hold their drink and drive home safely with their alcohol levels hitting the ceiling many times over. Or perhaps boast in the glee of a lost weekend of intoxication.
There was once a lady's man who had the charm that would put James Bond to shame. He allegedly had bedded so many women in the prime of his youth. This, he told me unashamedly with pride with a gusto of a record-breaking marathon runner. He even boasted of having two dates on a single night in the same town. Living in the fast lane, walking on eggshells, he ended his night bedding both of them, separately. That must be the zenith of his raison d'être.

Others may find pride in satisfying their gustatory cravings. They claim pride in knowing the tastiest of dishes and culinary servings. They may narrate with passion, their food trails, their exotic spread of palatal teasers and perhaps some unusual delicacies. Well, whatever makes them happy.

I bet these photos may one day carve a smile at the angle of my mouth if ever I were comatose or unarousable.

Serenity max ©FG

Another bridge ©FG

Nature's palette ©FG

Peaceful easy feeling ©FG

Misty taste of Korea ©FG

Shades of blue ©FG

Sunset in Korea ©FG

Picture perfect ©FG

A bike motel ©FG

Busan finishing line ©FG

Our hideout in Busan ©FG

I see you ©FG

Korean garden ©FG

Atop Busan Tower ©FG

Jagalchi Fish Market - can see the original features of the Koreans.©FG

Songdo Beach ©FG

Sunset over at Sangdo ©FG

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