The Dalhousie

          So I had my next lone long bike trip. It was more like a retreat from the boring routines in Trauma Center. By the end of three months I was fed up. I was feeling fatigued and brain drained. Although I don't know why. I wanted to run away to a distant place. I wanted to feel the freedom. May be the fact that I am going back to my ward posting has fired up my thirst for freedom.

          When I was doing the wound care of the last patient on my list, I was determined that I am not coming next day. That night I could not sleep well. Next day I woke up at 1200 pm, perplexed what to do, then I saw the email reply from my Madam. She had asked me to explain about the family emergency which I have to attend. So I thought of my imaginary uncle who was traveling to North India suddenly got Acute Cholecystitis and got admitted at Ludhiana. So the destination was decided. I packed my back pack and got on my bike at 2:30pm. It took about one hour to get out of Delhi. Then straight to Ludhiana on the Grand Trunk Road.

        
          My camera will tell the rest of story.

A review of life at Jammu.

       I am twenty five years old now. What have I achieved in my life. Have I done anything out of expected? Have I done anything to become what I really want? How much do I grade myself on my self development ? Have I grown out of my shell? Have I undergone the metamorphosis?

      So many things are undone. Only achievement in my life, something I value to be part of my portfolio is that I am in the course of becoming a surgeon. But thats not the end of it. I want to be different. I dont want to become just a part of swarm of surgeons. I want to identify myself.
 
   I want to be that guy, the one who has seen the world, the content one, the guy with depth in his eyes, the silent guy who sees through, the man who is not owned by anyone. I havent done anything for that.

       I want to do surgery for people who cannot afford the herd of surgeons who operate for a living. I want to do surgery for their cure. I want to do surgery not for my enrichment, but for their life.

      I have took some decisions. After MS, it is either DNB Thoracic surgery or just surgery. I will not marry for fortune but I will not say no fortune either. I dont want to sit in a corner desk and live the life. I want to live young and hard, slow and royale. I want to plunge in to the world. I want to be the man who do.

           In the end I should be able to say ' I had a heck of a life, Lets call it a day'.

Surgical residents, anger management and drinking habits

I have entered my second half of my surgical residency and I think I am mature enough to make my own opinion about the well-known issues of a resident in surgery. In my knowledge, the working environment of residents in any of the surgical speciality is similar. The striking difference between a surgical and non-surgical speciality is the fact that, the surgeons has to perform a well-planned, time consuming procedure  on the patient as the part of treatment while, the treatment by latter specialities mainly comprise of brainstorming, discussions and logical conclusions.

Time consuming is the word that I like to stress here. The usual routine of a surgery unit includes two or three operation days in a week in addition to whatever common things like outpatient day, grand rounds day and special clinics. In a teaching institution the responsibility of working up the patients for surgery naturally lies on the resident, starting from the lowest line of hierarchy. I will never criticize this working model, because it is an inevitable part of surgical training. In my personnel experience, I have found out that the more we talk with the patients, the more beneficial it is.

 Most of the time the residents will not be able to cover the academic topics in a fruitful manner along with the stressful working hours resulting in some mistakes her and there and eventually scolding during operation theatre proceedings or ward rounds. The residents get intimidated by the patients as well. Some patients may consider them inefficient, inexperienced young doctors experimenting on them, while some others over bear them with disrespectful dialogues. The nursing and supporting staff may also sometimes act like residents are invisible.

Getting into a resident ship in a reputable institution under merit is the fruit of long focussed hard training. The UG course itself is a long journey of five and half years. The fresh pass out from a medical school is considered naïve and the chance for a rewarding permanent job is minimal. The same time the friends from precollege times who chose a nonmedical field would have started earning. 

 Anyway my point is that the result of these inevitable pressure put on the residents in surgical specialty has a major influence on their character development as a doctor. The main change is that the threshold for anger come down. But the vent for frustration release is often small. Most of the time the ignorant patient or a newly joined nursing staff will be the prey for unexpected anger venting. The senior staff are usually experienced enough and seen so many residents grow up in front of them. So most of them are resistant to it. From one bad experience the resident will also understand that going into a bull fight with a senior nursing staff is not healthy.

Numerous times I have regretted for getting enraged with patients or patient attendants. The stimulating issue will be something silly. The patient might have forgot to bring an investigation report, might not have responded to my call etc. I get furious when such negligent acts occur before me when I am frustrated, especially after some scolding from consultant or senior, or during a long busy duty. ‘This doctor is talking to us as if we are animals’- I have heard one bystander of a patient make a comment about me in ED. It is not actually true from my point of view, and it is a well-known fact that the patient bystanders try to provoke staff with all kinds of offending remarks when they don’t get what they expect.

What can be done to prevent clumsy conversations and keep ourselves under control? The first point is that one should voluntarily train and keep some artificiality in conversation and action in front of patients and their attenders. This comes from practice. Speaking with true emotions out of heart may not be advantageous to patient or doctor either. I have seen senior consultants managing difficult situations with versatility of language. This is also known as ‘Soft skills’. Some may have this innate quality. But most of has to develop it.

Dramatization is the key word in learning communication. Start with a facial expression that might communicate the situation beforehand. Spending two minutes on a CAT film as if you are studying it thoroughly, running through the referral letters even if they have written blunders, pulling your lips apart laterally creating a smiling face before conveying a normal result or good result will help more than telling it plainly. Make a sad face or face of desperation before conveying a bad report or death. Try to look at the face of person while talking and get the feedback. Try to be clear and loud enough. Be a good actor.

Try to think for a second before raising the voice. Get the help of nursing staff or guard to raise the voice than getting our own pressure high. If something wrong has been found with the nursing staff never ever raise the voice, smile and make a joke of it. Politely make them know that you will convey the mistakes to the consultant or their seniors if they keep on repeating it. The permanent staff is afraid only of their own superiors and consultants. Better idea is to keep a friendly relationship with all supporting staff and never go on to a straight fight with them.

There are so many surgeons who do not drink. But an equal number of them take alcoholic beverages. From my experience, having a Beer party once or twice a month with resident colleagues is a great reliever of stress. Sharing the experiences, feeling loose and free and good food is actually a necessity for healthy survival in this profession. Not only drinking, having a coffee break with a colleague is also refreshing. Actually it is usual that one get addicted to coffee in residency. Anyone who has done residency cannot forget the freshness of after rounds coffee. It is lucky to have non egoistic down to earth, freely communicable colleague to share the work and fun.

'I am enjoying life'

          [7:58PM, 10/07/2014] My friend: I was pondering over your earlier question...

          [7:58PM, 10/07/2014] My friend: What do u think is enjoying life

          [8:01PM, 10/07/2014] My friend: I think being with friends I love and the man I love...and going for trips and exploring new places...wud be enjoyment for me...

          [8:02PM, 10/07/2014] My friend: Being able to take unplanned leave from work is enjoyment for me...

          [8:02PM, 10/07/2014] My friend: Being able to curl up with a book with nice fried snacks is enjoyment for me...

         [8:05PM, 10/07/2014] My friend: Having couple of drinks and becoming euphoric and dancing a bit wud    be  enjoyment for me...

         [8:13PM, 10/07/2014] Me: Its strange u never mentioned having kids and growing them....

         [8:13PM, 10/07/2014] My friend: How does that come under enjoyment 

         [8:14PM, 10/07/2014] My friend: That wud come under inevitable stress and torture!

Well, I frequently make that above statement in my diary. I want to remember the good times in my life. May be this statement is a sign that I fear that something bad will happen in my life. This is like counterattack thinking. Thinking the opposite possibility of whatever topic. More fruitful would be a lateral thinking. Anyway that is not of my interest now.

The above conversation was made with one of my best friends. I saved it because, it is like an ideal answer to the question. May be later in life I will review this answer. It is fun to see how things, ideas and views change as the years pass by.

 

The value of normalcy

              

Normalcy- It is a difficult term to define. It is a deceptive term. It is as complicated as simple it appears. Actually it took a little time for the mankind to understand the value of normalcy.
Earlier it was the values of king and religion that was considered normal. Then it was the values of general public that was considered normal. Then came the century of enlightment. Philosophers started to think what the meaning of being normal is. The statisticians came with idea of 'curve of normalcy' and standard deviations. So now the modern scientific generation believes anything that is between two standard deviations from median can be considered normal.

                But normal man cannot be satisfied by the normalcy. Everyone aim towards the idealism. The minority. The social elites. Defining normalcy in every realm of life will be a herculean task. So I will like to tell about normalcy which is germane to my field of my interest. WHO could come with a definition for 'health' only after years of brainstorming. The standards of wellbeing varies widely.

For a mechanic with lost little finger, it may not be a problem. But for a craftsman even that tip of little finger may cost much, and for a pianist it is invaluable. For a young man with an amputated leg as a result of an accident, ambulation will be a blessing. But for a diabetic patient, the healing of a chronic ulcer on the foot will be a thing for hope. People with no disease want to have ideal body shape, body that resembles a film star. People become anorexic and bulimic to fit in to that perfect dress.

 For a person with a temporary diverting colostomy, a successful reversal surgery is the day of his life. But a patient with colostomy made as a part of cancer treatment prays his disease never come back. He is totally denied of the dream of colostomy reversal. A good stoma without any complications and discomfort is defined as normal for him. For a person with peripheral vascular disease, pain is a part of life. If his pain is reduced to an affordable level, it is considered normal for him. A woman undergoing mastectomy for cancer, any kind of reconstruction which might feel disastrous, if applied on a healthy woman may be considered normal. Same time a small scar on the neck may be disabling for a teenage girl. A young lady may not feel complete until she gets an augmentation surgery on her perfectly healthy breast.

The values of normalcy can change from one end of a scale to the other end in matter of minutes. A doctor who is rushing to the ED to attend a patient may slip and get a serious head injury. That is fate. It is an inevitable unpredictable issue. And the normalcy is a complement factor of fate.

Two movies back to back

Lol.... this month was awesome. I got to watch two blockbuster action thrillers. Both of them were so good that I want to mention in my notes.

I haven't heard of these guys before, but after watching the movie I became a fan, especially the Rocket. Awesome movie, good screenplay and clarity of action sequences in 3D. The comedy makes the difference. Eagerly waiting for the Tony Stark to join the group.

Oh, Stallone the 68 year old Rocky, Statham...the Transporter, the movie is already a treat for eyes and ears. But Expendables 3 has got all the action heros together in a platter. So much for fun. Loved it. Here is a fan of Expendables series. 

How to cut down your body into what you wish

Having a healthy physique is a result of hard work. Except for some exomorphic persons, maintaining the BMI and waist hip ratio in healthy range is a challenge. Most of us doesn't care much about fitness either due to lack of time or patience. Every person in good shape will have a story of dedication and hard work to share.

Let us breakdown the term ‘overweight’. Whatever we consider as ‘overweight’ is actually the weight of excess fat stored in the body. The pot belly is the result of fat deposition both inside and outside the abdomen with some loosening of muscles. As a surgeon I have seen how much thick the fat layer can be. In obese persons, the fat layer just under the skin may measure half foot in depth.

So why does this happen. It is due to the action of ‘thrifty genes’. These genes are supposed to store available excess energy during the seasons of harvest and good weather, so that this stored energy can be used during the time of famine and food scarcity. These subcutaneous fat act as a long term storage facility for energy. In these modern times we don’t have famines or seasons of food scarcity anymore. So the stored energy in the body does not get an opportunity to get out of the system.

This explains the answer to the question, how to lose a major chunk of weight from the body? Make use of the ‘thrifty genes’. Cut down the calories to minimum or nil for a short period of time. Create an artificial environment of food scarcity. Human body has got a wonderful phenomenon called ‘homeostasis.’ It is like auto weather control in air conditioning system. It will make use of the available resources and maintain the inner supply of energy even if the intake from outside is zero.

The basic method to limit energy intake is restriction of carbohydrate and fat in the diet. Proteins and vitamins along with minerals have to be supplemented. Protein supplement is necessary to compensate for the muscle mass loss. But a little loss in muscle mass can be gained later by having a little excess protein and workouts. Usual carbohydrate in diet comes from the grains and their products. Sugar juices and soft drinks also add to it.

Let us see what is left in diet after removing carbohydrate and fat. Fruits and vegetables. Fruits contain sugar which is fructose and vegetables have very less caloric value. Among fruits itself the ones with more juice are the best, like orange, pomegranate, grape and watermelon. Among vegetables what we like to have is cucumber like things and green leaves. Tubers e.g.: potato, are high energy sources which has to be totally avoided.

So a model diet will go like, one to one and half kilos of orange a day as and when hungry, 2-3 cucumbers with lemon juice, salt and chilli. Watermelon or some other melons, 3-4 pomegranates, one full papaya, 5-6 apples are other choices. Boiled or grilled chicken wings or legs once in a week. Try to avoid banana.

Hydration is the key point in any dieting regime. Drink lots of water. One has to take minimum 3 litres per day. Juicy fruits and vegetables can contribute to hydration. The idea is basically to starve the body. The fruits and vegetables are just to fill up the stomach and keep the digestive system running smoothly. Taste buds will also need to be satisfied while dieting. Also having a fruitarian diet may make one feel cold. So to satisfy the taste buds and to keep the core fire alive, one will have to add some salt and spice of choice to the fruits or vegetables as necessary. 

Workout is also a part of this regimen. Minimum half an hour of aerobic exercise will accentuate the weight loss. Rather it will act as a benchmark for your performance. Normally this dieting regimen will not be a hindrance for the energy level one need for half an hour running or elliptical trainer. But feeling constantly deficient in energy level for minimum workout calls for relook into the dieting regimen and halt if necessary.

A major side effect of having a fruitarian diet depicted in literature is pancreatitis ( usually a self-limited  inflammation of pancreas associated with excruciating mid abdominal pain that may prolong up to one week, but needs hospitalisation for diagnosis and early treatment). Actual incidence is not sure, but not in my experience. Another minor but frequent problem is tooth related issues. The fruits contain lot of acids that can easily cause teeth damage. So mouth washing and brushing will be of utmost importance while following a fruitarian diet.

The results are seen within two days of starting a strict diet plan. Loss of weight can be expected up to 3-4 kilograms in a week. After a rapid fall of 10-12 kilogram, there may be a plateau. But maintaining the course will ensure further loss. Aim for two kilos more than the required target line. Once that is attained gradually change to normal diet. Do not overfeed. The change in your habitus will be pronounced and easily notable, that people start to recognise the difference. The appreciation you receive and the improved confidence about self-image will be sufficient to make sure you don't over feed.  Reading on how your favourite film stars and models maintain their shape can also be motivating.

Binge eating or partying once in a fortnight is also recommended with this regime. It can also be avoided if you think it is a hindrance to the divine course of dieting. But in my opinion this will help to be in control and make sure that you can resist the pressure of over feeding once the target line is touched. Once the excess fat has been churned out of the system, you can start pumping in muscles with some extra protein supplements. Still one has to make sure that the carbohydrate and fat intake is not out of the limit.

This article has contents which may be described as ‘pro-anaemic’ or ‘pro-bulimic’. Most of the film stars and models who maintain a great physique had followed at least a part of this regimen. Nobody is born with muscles defined to each fibre or body shape for size zero. This is a choice to be made, a choice that can change your life. Before I finish I have to remind that having a great body is not a reason for ultimate happiness nor defines a successful life.  It is all about the person and how much good at heart you are.