Tuesday, January 3, 2017

Encouraging healthcare workers to admit mistakes without the fear of retribution



Recently, someone on Facebook posted this link. It described a doctor who made a mistake during a procedure and refused to admit it. Later, when he remembered an incident from childhood when his doctor had done something similar to him as the patient, he went back and apologised to the patient. This led me to think about simple mistakes that healthcare workers make.

We all find it difficult to admit our mistakes. It is human nature. However, when there is a possibility of being penalised for the mistake, then the disincentive to admit it is even higher. This can lead to some dangerous consequences.

Let us take an example. A nurse in a hospital has to do a number of procedures ranging from the really simple to some that are fairly complex. Let us say that while opening a syringe, the needle unintentionally touched a non-sterile surface. The best thing to do would be to discard the syringe and use a new one. However, if the hospital had a stringent inventory control process and the staff was penalised or scolded for using excess consumables, then what was the nurse likely to do?

Human nature would make him continue to use the same syringe. Who wanted to be penalised for this? Who wanted to answer questions from the audit team? At the end of the day, the patient would be the one who would suffer the most. This could potentially cause a serious infection depending on what the syringe was being used for.

So, while it is important for the Inventory team to do its job and ensure that operations are run in a prudent manner, hospital authorities need to figure out ways by which situations like the above can be avoided. While Inventory shortages were easy to identify, it is very difficult to identify the real cause of, in this case, an infection. Often, from the point when something like this happened to it actually manifesting itself in the form of symptoms, a lot of time has passed. So many things could have happened in the interim. How can anyone, then pinpoint that usage of that contaminated syringe caused the infection? This makes it easier for the nurse to continue to use the syringe rather than discard it and take a new one and then be reprimanded by the authorities for not being more careful.

What could be the possible solutions?

I think the first thing that needs to be done is to remove any financial penalty on the individual that commits the mistake. This can be the worst way to fix the issue. Assuming that a financial penalty, (especially when the stakes are so high) would cause the staff to be more careful in such cases is wrong.

Hospitals should allow for such instances while putting SOPs in place. Staff should be encouraged to document such instances so that audits can take these into account without any reprimands or penalties.

In some cases, proper training and education can also help avoid repeated mistakes.

Healthcare poses such challenges all the time. There is a very thin line between prudence and foolishness. Crossing this line can harm patients. At times, this harm can be irreversible. It is upon the administrators to identify the ways in which this can happen and fix the issues.

Saturday, December 24, 2016

Encouraging children to develop the ability to think for themselves



My family is from Gujarat. As you can imagine, my entire extended family is a staunch supporter of Prime Minister Modi. A few have become more circumspect recently but I will not get into that for now. Any voice that opposed anything Modi did or said in the past many years would be labelled 'pseudo-secularist', 'MIM', 'Rahul Gandhi fan' etc.

Parents would be so emphatic in their support that children would begin to believe that not supporting Modi, whether they genuinely liked the man or not, was a crime.

I tend to take contrarian viewpoints in any such debate. With a bunch of Modi supporters, I can be rabidly anti-Modi while I could put my family to shame in front of Modi-haters. During family debates, when I find fault with many things Modi did, I find some of my cousins beginning to speak up, even if just a little. It's as if, almost for the first time, their inner thoughts have a found a voice.

I put this down to the unintentional consequences of having strong parents. Children tend to emulate their parents' opinions rather than developing their own.

It is important for parents who want their children to grow into mature individuals to ensure that they also become capable of thinking matters through, from different perspectives, and then forming their own thoughts on any subject whether political or otherwise. By being strong-headed about such things, they would be stifling the child's ability to think for himself or herself.

This freedom to think should also exist in religious matters even though this could result in far more controversial results. Shoving religious beliefs down a child's throat can cause rebellion later in life when even basic tenets of humanity could eventually be rejected. Most religious thinking today is constrained by dogma. Instead of trying to understand the fundamentals of religion, children are taught 'not to reason why, but to do and die'.

I believe that encouraging children to develop a mind of their own by laying before them the facts and your perspective and then strongly encouraging them to think through (and also letting them know that it's always alright if they change their mind) is a much better way to help them grow into complete individuals.

Wednesday, December 14, 2016

Rumour mongering about NephroPlus



I have heard some really crazy rumours about NephroPlus in the last year or so. But the one I heard last night has to top them all.

My mother ran into an aunt last evening. She said that someone told her (strangely she forgot the name of the source) that there was no point in sending kids abroad as in India itself there were many opportunities. Well, nothing wrong with that! She went on to say, "Look at Kamal. He is rolling in money. He now has money for ten generations. NephroPlus received funding from Bessemer Venture."

My, my. How insanely accurate the facts and the perceptions around this rumour are. So, allow me to break this into multiple parts:


  • Bessemer Venture Partners invested in NephroPlus many years back. It was covered widely in the press. Since then, NephroPlus has received two more rounds of funding, one from International Finance Corporation and the last one from Sea Link Capital. All this information is in the public domain and NephroPlus has held press conferences to announce these investments.
  • When an investor invests in a company, however much I would like, the founders don't get a single rupee from that money to spend on themselves or store for generations to come. That money is invested for the growth of the company and give returns to the investors. The money is invested with stringent targets of various kinds.
  • If I had a lot of money, I would rather spend it on myself and not leave it for ten generations. I am not married and also do not have any illegitimate kids for whom I need to leave any money.
  • If I was really rolling in money, would I not get Soliris from the US and get a kidney transplant? The only reason I am not able to get a kidney transplant currently is because I cannot afford the cost of Soliris. I do not like dialysis. I am aching for a kidney transplant. But I cannot for the simple reason that I cannot afford the drug and without the drug, my transplant is likely to fail.
I really wish the rumours were true. But unfortunately, they are not. It is just astonishing how people conjure up such statements. They put two and two together and conclude that the sum is twenty two. Without understanding the background and without understanding the facts, they make atrocious claims and spread them crazily.

My poor aunt was completely fooled by the unnamed source. My mother hurried back worried that I was hiding this huge wealth from her! I had to convince her that these were just rumours and the handiwork of some fools who had too much time to spare.

Saturday, December 10, 2016

A million shades of grey



I had written about this topic back in 2008. Every individual is very complex. It is impossible to classify someone has completely black or completely white. Everyone is somewhere in between - a shade of grey.

Despite realising this, I find myself (and others around me) bucketing people into either black or white. If someone has done something bad, I immediately assume that he is a bad person. If someone has done something good, I immediately assume that he is a good person.

The truth however is that it is merely the action that was good or bad, not the person himself or herself. All of us do good things and bad things. We tend to be less generous of others than we are with ourselves.

This colours our perspectives in very biased ways. If someone whom we have classified as 'bad' does something good, we look for some selfish motive behind that act. On the other hand, if someone we've classified as 'good' does something wrong, we explain it away by saying he or she might have had some compulsion.

We must try to separate the actions from the individuals.

Some people go to another extreme and generalise entire communities, religions and countries in this manner. If they've come across a few individuals from a community doing something, they will generalise and assume that the entire community is like that. At this point, the principle of collective justice is inevitably invoked. For the actions of one person in the community, the entire community must be punished!

In reality, it was one action from among many other actions that caused us to perform this classification. How dangerous this kind of classification can be?

Friday, December 9, 2016

Why am I a huge fan of Peritoneal Dialysis?



I often get asked which type of dialysis is better - Hemodialysis or Peritoneal Dialysis? That question really has no standard answer. It's like asking someone which flavour of ice-cream is the tastiest? It depends on the individual. Some prefer Hemo while others prefer PD.

If you asked me which I prefer personally, I would unabashedly say PD. Why am I such a lover of PD?

I honestly hadn't heard about PD until after my failed transplant in 1998. When I was researching the internet, I actually stumbled across the term by chance. This says a lot about the way medicine is practised in India. "Kidneys are failing, get a fistula made" is the mantra here. When I read about PD for the first time, it almost seemed too good to be true. I decided to ask my doctor about it, half-expecting to be told that it was not available in India or that I wasn't suited to it. Imagine my excitement when he said that I could definitely go for it.

The next six years on PD, as I keep saying to many people I talk to, were the best during my life on dialysis.

There are many reasons I liked PD:

  • Less diet and fluid restrictions: I was not asked to restrict anything. I did four exchanges a day compared to many PD patients who do only three exchanges these days. This was a welcome relief from the severe diet and fluid restrictions I was asked to observe while on HD.
  • No needles: Who does not hate needles? The very thought of two thick needles in my arms is even today,  a huge put off for me. The best part about PD was that there was no need for needles.
  • No thrice weekly hospital visits: PD is almost always done at home. The whole effort of going to a hospital thrice a week for about five hours each time was physically and mentally draining, not only for me, but also for my family.
  • Independence: I did my exchanges and exit site dressing myself. This was very different from HD when you showed up at the hospital and surrendered completely to the centre staff. In PD, I had complete control. This does put a lot of responsibility on you. Some people like this, others don't.
  • Freedom to travel: On HD, I can travel only to places where there is a good centre. Also, five hours at a hospital, every alternate day, does not appeal to me on a holiday! With PD, I could travel easily. All I needed to do was to order the PD fluid bags to a place close enough to where I was travelling. The rest was a breeze. 
I was told later that PD worked best when you had some kidney function remaining. I had zero kidney function during my entire PD tenure. It worked beautifully for me. I think the big difference was that I did four exchanges. That is probably why it worked so well for me.

If there was a way for me to go back to PD today, I would close my eyes and take it.

Thursday, December 8, 2016

Why is the new blood donation technique invented in 1977 still not being used?

A new blood donation technique that was invented in 1977 in India is still not being used. I am not sure why. Lot of the challenges we face today have been overcome in this invention:

  • No pump needed to draw blood, blood can flow against gravity
  • Blood from multiple donors can be mixed together and then donated to one recipient
  • No screening required for viruses etc.
  • No anti-clotting agents needed
We should popularise this technique. I am sure many other applications of this are possible. For example, currently, pumps are needed to pump out blood from a dialysis patient's arm. This is just one of the many areas where this can be used.

Here's a video that first demonstrated the technique: (note that there's an audio that plays in the background that says "Yeh sirf kahaani nahi" which undoubtedly proves that this is not just a movie but reality)


Tuesday, December 6, 2016

My non-dialysis day



I dialyse six nights a week, for seven or eight hours each night. No, I am not in a dire condition that I need so much dialysis. I dialyse so much because it allows me a good life. I am able to lead a pretty normal life. I don't need so much dialysis. I choose so much dialysis.

I used to skip dialysis on Sundays earlier. The tech, Jayaram, who used to come home to help with my dialysis had his weekly off at work on Sundays and so, that felt like the right thing to do. It wasn't any scientific decision. It just happened. When Jayaram left because his day job was keeping him too busy, I got a couple of folks from NephroPlus to help with my dialysis.

Somewhere around that time, I decided to change my weekly night off to Tuesdays. Why Tuesdays? Well, I was swimming at a pool that was closed on Wednesdays. What has that got to do with my dialysis weekly off?

Honestly, I am about as non-compliant as they make dialysis patients these days. On a good day, I put on at least 3 litres from morning to night. On a bad day, don't even ask. So, when I skip a day, the fluid weight gain is at the very least 5 litres. I find it a little uncomfortable to swim with too much fluid inside me. Play the fool in a pool - sure. But not rigorous swimming.

So, if I continued with the Sunday dialysis weekly off, I would miss two days a week for my swimming - Wednesdays, because the pool was closed and Mondays, because I was fluid overloaded (sort of).

By coinciding these two days by not dialysing on Tuesdays, I needed to skip only one day in the pool.

Today is Tuesday. My weekly day off from dialysis. I am feeling good today. The thought of not having dialysis seems appealing. No, it's not that I hate dialysis. My regular dialysis keeps me healthy and allows me to eat and drink whatever I want and however much I want. But still, one day off gives me a nice feeling. I have me to myself. No machine, no needles, no timing.

Today, I actually made some progress on my new short story. I have been having writer's block. I don't claim to be some great writer and all to be able to justify calling it a block. But I have just been unable to write more of the story I'm working on currently. I have been stuck at the same point for months!

Why couldn't I take two nights off if I liked it so much? I tried it. I didn't like it. I felt too constrained. I had to watch my fluids too much. And that's the worst feeling anyone can have, IMHO.

So, I will let you go now. Just wanted to share my joy of not having dialysis today. See you soon!