An Autobiography - Prof Dr Hematram Yadav

 

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Heal thyself!

Undoctored: The Story of a Medic Who Ran Out of Patients 
Author: Adam Kay

There used to be a time when only the crêmê à la crêmê would be handpicked from public examination scorers to study medicine in state-sponsored medical schools. The competition to be admitted as a medical student was so keen. Entrance would mean assured employment by the State, together with the prestige, perks and elevation of social status to the family that came with it. That is what everyone thought, anyway.

A career in Obstetrics used to be considered quite noble. Doing the work of a stork, being there, and bringing joy via new birth was considered honourable. The team did not mind the long hours and gruelling work conditions, as they were muffled by the lustful cry of a newborn and wiped clean by the tears of joy of a parturient mother. 

Again, it is fulfilling no more.

What was a noble and fulfilling profession became a pressure cooker. A patient walks into a consultation room, wanting hassle-free relief from his pre-existing ailment. He wants 100% relief, not accepting that morbidity and mortality are realities of life. At the same time, he is wary that he may be taken for a ride, given a suboptimal treatment, and, if money is involved, be fleeced of his hard-earned money. 

The medical practitioner, on the other hand, considers the patient a potential legal liability. He must ensure all the ‘t’s are crossed, and the ‘i’s are dotted. He must run a battery of tests to ensure nothing is missed or left that lawyers will later accuse of medical negligence. 

In this background, Dr Adam Kay, a doctor in the ward, found the hard way that the system is toxic. It does not bother the practitioners or the attendants. They are left to deal with their own problems, grief and shortcomings. Dr Kay’s partner had a miscarriage, which he had to deal with himself. The system asked him to put his emotional baggage aside and work. 

He left his overalls and stethoscope for a career in standup comedy and scriptwriting. He soon discovered his true sexuality. In a genuinely comical way, laced with lots of sarcasm, he describes all the going on in his life, good and bad, all in one bag of laughs. Sometimes, he goes philosophical about human life and why we are here. A good read. 

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In God's hands?

Bad Surgeon: Love Under the Knife (2023)
Documentary

Perhaps the media is the one that needs to take the blame. It may be people's fascination with the high life and their gullibility. Or the society's rules on the confidentiality of information or the restriction. Some have perfected the art of staying in the limelight to awe others with their stories so tall that they cannot be refuted. These do not make sense, but watching Dr Paolo Macchiarini's shenanigans, they would. 

Dr Macchiarini is an Italian maverick surgeon employed at Karolinska Institute in Stockholm, Sweden, between 2010 and 2013. With a long, impressive CV, including a stint as a visiting Professor at University College London and multiple revolutionary discoveries in regenerative medicine in Russia, he hit the headlines performing groundbreaking trachea replacement surgery using a plastic mould and stem cell technology. 

At the height of his success, he meets journalist Benita Alexander. She is swept off her feet, love blossoms and wedding bells will soon be rung. Everything is going well except for his frequent absence. After all, he is a globetrotting star surgeon flying from country to country, performing avant-garde top-notch operations. On top of that, world leaders like the Clintons, Obama and the Pope have Macchiarini on their speed dial. He is their personal physician.

The wedding is planned to happen at the Vatican itself, officiated by, of all people, the Pope himself. Yes, the Pope also does weddings.

One by one, news of botched surgeries comes to the open. His credentials turned out to be fraud. His colleagues at Karolinka start an investigation. An investigative journalist is roped in. Somehow, because the World Wide Web is in its infancy, the information from one part of the world either does not reach or is falsified when it hits the outside world until ... 

Benito Alexander, the journalist scheduled to marry Macchiarini, catches him having a wife and children. She exposes him in an article in Vanity Fair. Thus came the surgeon's downfall. One by one, Sweden charges him in court. He is presently serving jail in Sweden. Macchirianno used Benito's position as a journalist to springboard his own publicity. 

It is funny that at the dawn of the birth of information technology, we were promised knowledge accessible to all. People would be more empowered to make informed decisions after accessing all sides of the multifaceted monster called truth. Surprise, surprise. Humans can still hoodwink the system and abuse the system to fulfil nefarious personal interests. 

Information platforms further help these people to peddle fake news and whitewash things. Bragging and broadcasting tall stories have become much easier. 

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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 robe and the abacus...

Never trust a man in a suit and tie.

He may hide his evil intentions behind

his haberdashery perfection. In the

same vein, a female who reveals much

more than is needed to hide the 

necessaries may be masking the real 

thing she is hiding. 

It is said that the mark of the fall of an economy or, to go as far as a civilisation, is the disproportionate increase in the numbers of accountants and lawyers in society. Disproportionate to what, one may ask. For a community to propel to higher heights, we desperately need educators, engineers, scientists and health care workers. Educators to teach the young minds, engineers to push the boundary of the mind to explore new frontiers, scientists to discover ways to ease living and health professionals to ensure healthy bodies and minds for continual progress. As society becomes complicated, or the piece of the economic pie gets smaller, there would arise the need to protect or usurp material as much as possible, the legal way. After all, good times do not last forever.

Furthermore, the generation next would not be so resilient or antifragile to handle things given to them on a platter. Still, prosperity has to be continued down generations. Hence, there is an innate compulsion for good times to continue rolling within the family. Finances need to be fixed.

The significant jump in the numbers of lawyers and accountants may also mark the decline of morality. Whether the downfall of society is because of their increase or as a response to the fall, it is a matter of conjecture. When one sees things that used to be settled with a gentleman’s handshake amongst close-knitted friends or relatives now mandates legally signed documents to seal the deal, we know we are going down the rabbit hole of mutual distrust.

Washing dirty linen in public and broadcasting intimate detail to shame the other party is in vogue these days. The accusers think that they could play the victim card by putting all lewd pieces in the open. Little do they know, the public says a free daytime soap opera.

Trustfulness is now a forgotten virtue. When a person used to be entrusted with our monies, we did that not because he could give a beautiful account of our income and expenditure. We knew that there was no doubt about his trustworthiness as he would guard his assigned duty with his life. Now, we want a nicely executed (maybe concocted) Excel sheet with all the 't's well crossed and the 'i's meticulously dotted. Creativity and documentation supersede honesty and hard work.

Honest toiling and passion do not count in this material. All one needs to be successful and marketable in a colourful resumé with skills of articulation Lawyers and accountants help us towards that end. Teachers and medical personnel do not serve to broadcast their deeds. There do it because it is a service to mankind. At least, that is how it used to be.

[P.S. Writers and literary figures are still needed for they need to stir emotion and push boundaries, for we only know our limits when we push them to the brim.]

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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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Carved to perfection?

Under the Knife - A History of Surgery in 28 Remarkable Operations (2018)
Author: Arnold Van De Laar

Most nations in the world are forever looking out to keep their brains within their boundaries. Brains, besides economics, are the main ingredients of nation-building. For this, it needs the services of the top five professional vocations - architects, accountants, engineers, maybe lawyers and doctors.

Critical thinking and thinking outside the box are pre-requisites to unshackle the chains of poverty. Ironically, doctors are not expected to be too creative. They are merely expected to conform and follow the precedence as set by their seniors. No patients want to be treated by a 'cowboy'. New ventures can only be under the purview of peers of high standings. Misadventures stemming from unconventional, novel and experimental modalities will implore the wrath of the society, not praises for innovations.

This book is a collection of about 28 kinds of surgeries and a little of history associated with them. It goes as far back as to a time when analgesia was a long shot of brandy or chewing on some roots. And the removal of bladder stones meant cutting through the highly sensitive and vascular perineal region unanaesthetised and the area was to be left unsutured. Sutured had not been invented yet.

Jan De Vaat, a Dutch surgeon, had the dubious honour of operating on his own bladder stone. The lithotomy position, used by most gynaecological patients, got its name from these operations as it was in that position bladder stones were removed (lith - stone, otomy - cut).

It brings to the time when JFK was brought to the casualty unit in a Dallas hospital after being shot. The surgeon on-call had to perform a tracheostomy to create an airway, but the President succumbed to hypoxia due to a torn trachea and massive blood loss. JFK may have been saved if he had an airway secured within the 8-minute critical window. Probably that is why now an ambulance with a medical team accompanies any of the President's entourage to institute immediate treatment. A similar situation befell upon George Washington. He had a nasty throat infection for which an age-old practice of blood-letting was established instead of tracheostomy. He lost 2.5 litres of blood in 16 hours.

The practice of mandatory circumcision probably arose from Abraham's phimosis. The scriptures made mention of Abraham having painful erections; hence coitus was avoided, and Sarah remained childless. He sliced off the tight prepuce with a stone, and he was relieved of his misery. Sarah soon conceived. King Louis XVI probably suffered the same ailment, but he was relieved by ointments.

Many of the medical conditions here are explained in simple terms for the general public to follow the discussions. Empress Sisi of Austria's ability to witness a stab wound on her chest was due to the tamponade by her corset.
Obesity was an issue even during the early years of the Papacy. Of course, Popes were old when they were ordained. Nevertheless, the 5-year survival rate of Popes is 54%. Many died soon after installed. The lingering rumour is the allegation of foul play, but lifestyles diseases and obesity predominate.

Pope Paul John II was not so lucky with bullets. He once was shot in the abdomen and ended up with a temporary colostomy. He ceremoniously visited his assailant in prison.

Hammurabi had laid down a code for practising physicians. The patient cannot be charged if he is not cured of his ailment. The author relates the story of King Darius, who had an ankle fracture. Egyptians used to have great doctors, it seems, and one of their doctors supposedly treated it.

Many of the general surgeons' jobs revolve around the fact that we are biped. Ever since Lucy, our first ancestor, started walking erect, homo sapiens have to deal with varicose veins, inguinal hernia, haemorrhoids, disc prolapse, genital prolapse as well as hip and knee problems. Incidentally, Lucy is named such because of the song that was playing in the background when her fossils were excavated - Lucy in the Sky of Diamond.

Even though most people think Houdini died underwater, drowning after failing to escape from a locked chest, his cause of death is actually perforated appendicitis with peritonitis.

A dentist in Boston is credited with the honour of administering ether anaesthesia for a surgeon to operate a patient with neck tumour. The surgeon, so impressed with the technique, uttered the historical line, "Gentlemen, this is no humbug." Their European cousins, the British, thought otherwise. That was until the grand multiparous Queen Victoria, in 1847, a year later, had chloroform offered to her by John Snow. The follow-up was not all okay. Queen Victoria suffered postnatal depression, of course not related to anaesthesia. Biblical scholarly were quick to condemn the act as going against Nature as the scriptures state that women must endure labour pains.

With the royal seal established in medicine, other branches of medicine soon gain traction. The importance of handwashing, donning of gloves, hygiene and epidemiology were appreciated.

Because of the nature of human activities and the absence of antibiotics, gangrene was a common occurrence those days. The need for amputation was appreciated.

It is often said that one can train a monkey to perform surgeries. Still, the true mark of a surgeon is in his ability to deduce a diagnosis based on the clinical observations and to deal with complications if it should arise. Saying that history has shown that even experienced surgeons are guilty of running into trouble and failing to identify complications. A case in point was when pioneering vascular, Michael DeBakey, was requested to perform a splenectomy on the leukaemia-inflicted deposed Shah of Persia. A subphrenic abscess developed to be thought of a little bit too late even though the telltale signs were evident for all to elucidate. The monarch succumbed to the complications following the repeat surgery.

Even though the need and safety of surgery are established, some patients still refuse surgical procedures on personal grounds. Bob Marley rejected the idea of losing his big toe even though he was diagnosed with malignant melanoma. His religion, Raftarianism, is against losing body parts. He succumbed to metastasis.

Hippocrates had noted that cutting open the abdomen is always fatal, but we have come a long way doing safe laparotomies, laparoscopies and many abdominoplasties. Gynaecologists started the ball rolling with minimally invasive surgery with visualisation of pelvic organs. There is an interesting description of Einstein and his problem with a dissecting aortic aneurysm. Nissen, famous for his fundoplication surgery for acid reflux, wrapped his aneurysm with simple cellophane paper, which was to spur scarring around the vessel.

Castration remains one of the most frequent surgeries performed in the history of mankind. Maybe the word 'rib' in ancient scriptures somehow denotes the part of the penile 'bone'. In other words, a woman is a castrated male - God made Eve from Adam's rib!

This surgical operation is more than just a medical procedure. It has power-play and political implications. In the imperial courts of China, eunuchs play an essential role in handling affairs of the royal household. They were loyal and efficient workers. They were not mere servants but hold a very subtle unseen control of power in the kingdom.

During the barbaric tyranny of fanatic Islamic tribes, castration was mainstream. It remained a sure way to put cessation to the lineage of their non-believing conquests. And their subjects made good slave material to spur the economy. Even in recent times, chemical castration was instituted to homosexuals. Alan Turing was one such victim. Prostatic cancer is probably the only bona fide indication for castration of unaffected testes.

The place of placebo is firmly rooted in the holistic management of an ailing patient. Alan B Shepard, the first American to fly into space failed to partake in Apollo 11 lunar mission because of vestibular dysfunction. A dubious procedure of unproven value was done on him. In 1971, he finally landed on the last lunar landing through Apollo 14.

An interesting coincidence happened when JFK's assassin, Lee Harvey Oswald, was treated by the same surgeon who treated JFK. He succumbed to the single bullet that pierced his abdomen, injuring many vital blood vessels. In his dying moment, the medical team try to whisper to him to spill the beans whether he was indeed the shooter, but he took the secret with him to the grave.

The first medical prosthesis was probably that for a patient with tuberculosis of the shoulder. It was made from hardened paraffin but failed miserably as the bone was still infected with T.B.

From the misadventures of Lenin who suffered from multiple strokes and paralysis, we appreciated the need for smooth laminar flow in the carotids.

Kocher, a doyen in general surgery, was a pioneer in gastric surgery together with Billroth and Halstead. Kocher was the first surgeon to be awarded the Nobel Prize and has many things named after him - instruments, incisions, signs, manoeuvres, points of references and even a crater on the moon. Ironically, he died after thyroid surgery.

What started as an operation on an electric eel in an Amsterdam zoo, electricity finally evolved to be used as a means to coagulate and cut tissues.

The book ends with pop culture references to the job in many famed Hollywood productions. From female surgeon, Dr Helena Russel in Space:1999 to Robot Surgeons in Star Wars, making surgeons superfluous to software (HAL 9000) overriding human commands in Kubrik's 2001:Space Odyssey and doctors reduced to corpuscle size to perform minimally invasive procedures in Fanstatic Voyage, many of the things that were considered to be in the domain of science fiction are now becoming mainstream.



(P.S. Just a tongue-in-the-cheek statement. The book failed to mention the contribution of other nations in the development of surgical skills and techniques. Maybe it is ignorance. The British, with the privilege of eavesdropping and spy watching on their subjects, discovered of an Indian peasant performing rhinoplasty on a British soldier was cut off by Tipu Sultan's Army.

 · 

On 9 October 1794, an operation to replace the nose, 

at that point no longer practised in the West, was 

reported in the Gentleman's Magazine. Cowasjee, 

a Mahratta, who had served in the British army as 

a bullock driver was captured by Tipu Sultan and 

mutilated by having his nose and one of his hands 

cut off. The nose was replaced from a flap of skin 

brought down from the forehead to cover the 

mutilated nose, an operation thought to have been

practised for centuries in India.

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