Wednesday, December 31, 2008

Dialysis in India - the 'no choice' problem

(Another Disclaimer: When I refer to a doctor or a nephrologist, it is the average Indian avatar, definitely not all of them. There are exceptions, like the nephrologist who has treated me for the most part during my life on dialysis, Dr. Girish Narayen. I cannot thank him enough for introducing me to daily nocturnal home hemo because of which - I can safely say this - I am alive today.)

When someone is diagnosed with CKD in India, it is treated by many like a death sentence. No one knows what it means. Even established doctors not from the field of nephrology often assume that there is 'no chance' (of survival?).

When the patient is at a stage where he or she requires dialysis, there is absolutely no education on the different modalities available. It is assumed that the patient will be put on in-center hemodialysis twice or thrice a week, 3 to 5 hours each time depending on things like weight, financial position (sad, but true) and physical condition.

The patients don't even know that something like Peritoneal Dialysis exists. And they don't know that it is theoretically possible to do hemo at home everyday. In-center hemo, which is arguably the worst dialysis modality available today, is the default. Everybody is put on this. There is no choice offered, no options presented, no opinions offered.

Only when the patient or his family learns about these other modalities through the internet and through other patients, do they ask their nephs about this. Only then does it become an option.

Why this reluctance in introducing the different options?

It is definitely not commercial. I am sure about this. To me, it just seems to do with the 'comfort zone'. Nephs have been handling hemo for ages now. PD is relatively newer in India and less widely available. Home Hemo is not heard of by even many nephrologists.

Let's talk about home hemo first. I agree to some extent that this cannot be made widely available in a country like India. First, the training is quite complicated. There is no NxStage System One or Aksys here. So, one would have to use something like the Fresenius, the Gambro or the BBraun machines which are much more complex than the System One or the Aksys machines. Training to use these machines is not impossible but it is definitely more difficult. It should be offered as an option to those that are willing to spend the money to buy this machine and are healthy enough to take charge of their own treatment or have a partner or a family member that is willing to help with the treatment. The younger segment of the population should definitely be offered this treatment, maybe a few months into dialysis.

Peritoneal Dialysis, on the other hand, is now widely available. The cost of the treatment is now only a little higher than in-center hemo. The quality of life can be dramatically better. There is absolutely no excuse for doctors not to present PD as a first choice for patients who need to get on dialysis. It should be mentioned in the same breath as in-center hemo. Doctors should explain the positives and negatives of both and let the patient decide unless there are some overriding medical concerns in the usage of either. PD, for me, was a godsend. After my transplant did not work out, if I had to continue on in-center hemo, I would have given up long back. PD gave me my life back.

Well, there are people who prefer in-center Hemo to PD. The only thing I'm saying is involve the patient in this decision. Do not decide for him or her. Present the choices, the pros and the cons of each and let the patient make the decision.

A standard process must be defined and it must be made mandatory for nephrologists to present the different dialysis modalities available and the doctor and the patient should together make the decision on the modality to be adopted for dialysis.

This would be a small beginning towards real change in the dialysis story in India.

Tuesday, December 30, 2008

Dialysis in India - how far have we come?

(Disclaimer: I am no expert on Dialysis, in India or elsewhere. All I'm going to be doing in the next few posts is presenting my opinion as someone on dialysis in India for the last ten and half years.)

Anna Bennett, guest posting for Bill Peckham, links to this excellent article from RenalWEB by Gary Peterson. For those on dialysis or related to dialysis in some way, this is an absolute must-read. An extract:

I believe we are at the beginning of a new stage, or age, of ESRD care. This phase will correct several major mistakes that began a generation ago, yet are only noticed by a few today. A precise name for this emerging stage has not yet been adopted, but something along the lines of “optimal-health dialysis”, “well-CKD5 patient care” (chronic kidney disease stage 5), “high-dose/frequency dialysis” or “dialysis 3.0” seem applicable."

The article goes over how standards in dialysis have changed over the years. While everyone aspired for "adequate" dialysis all these years, we now should move towards a regime of "optimal dialysis". One important measure of the effectiveness of dialysis has been Kt/V or the Urea Reduction Ratio (URR). People generally accepted a Kt/V of 1.2 and a URR of 65% as good enough.

He goes on to say how this should be replaced by a measure of how good the patient feels and the quality of life he or she is having. This makes so much sense. What good is a Kt/V of 1.2 if the patient is feeling weak, drained and fatigued? Especially, when it is medically possible to make him or her feel much, much better.

He strongly advocates use of more human measures like talking to the patients and finding out how they are feeling than simply using 'blood tests' to determine how well dialysis is working. The US medical reimbursement model (a highly complicated system) relies heavily on big corporations who either provide dialysis treatment or the insurance companies which pay for these treatments. This means that their financials often dictate policies.

The Indian context is entirely different. Dialysis regimens are entirely different. The payment model is entirely different. The facilities are entirely different.

Unfortunately, the system in India is such that most patients either pay for their own treatments or are reimbursed by the companies they work for. Arogyasree is a small step towards changing this model but we are still too far away from even beginning to consider the issues brought out by the author of the RenalWEB article.

Sunday, December 28, 2008

The HPS Reunion

We had our school reunion recently at The Hyderabad Public School, Begumpet. There were the mandatory speeches and performances which no one usually enjoys, catching up with friends I was meeting after 15 years and some great food.

The school looked magnificent with all the lighting - something that was never done in our days. I met a whole lot of people I had never hoped to meet if it wasn't for this reunion.

The event was organized pretty well. They gave badges to each person to write his or her name, year of passing out and the house - one among Taxila (green), Nagarjuna (red), Nalanda (blue) and Vijaynagar (yellow).

Just to give you a little background - for those unfamiliar with HPS - these four houses were named after ancient centers of learning in India famed world wide for the quality of teaching and study. Students of the school took their house affiliations very seriously and every member of the house would pitch in to try and make sure that his or her house would be at the top.

Anyway, getting back to the reunion, the badge helped people recollect the names of the folks they ran into.

Most people did recognize me despite my recently cropped hair. There were some instances however when I was far from flattered. I went over to greet someone I remembered with a huge smile on my face. The person would return the smile with a matching enthusiasm. And then slowly, I would catch their eyes moving towards the badge trying to read my name!

But that's all right. I wasn't that famous. I don't expect people to remember me! Anyone who remembered me was a bonus!

The dinner was quite good. They had the regular stuff. But what took the cake was the combination of bread-sambar-cutlet. It tasted just like those from school days! I clearly overate.

All in all it was a great experience.

Tuesday, December 23, 2008

The motivation to swim in winter

Many people are shocked when they learn that I swim every morning even in these cold days. They wonder how I can actually enter a swimming pool when it is so cold.

Well, the answer to this is that I have been swimming almost daily for the last 7-8 months so my body probably gradually increased its tolerance of cold water. And it is not that cold in Hyderabad compared to many other places.

One theory I have is to have a warm or hot shower just before entering the pool. Getting into a pool is shocking the body in two ways - first is the water itself and second is the temperature of the water. By having a hot shower, you remove the first shock in a pleasant way. You only have to deal with the temperature next. Don't quote me on this though. This is only my theory!

More than anything else, however, for me the motivation to continue swimming is the compliments I have been receiving in the past few weeks. Especially from people who have met me after a long time. Everyone seems to think I look much better and much more fit. It is so good to hear this!

I myself enjoy swimming so much that it is not a chore for me to do it. It is the best part of my day. When you like something so much, it is not difficult at all to make the effort. That's what I tell friends who don't exercise. Choose something you enjoy. It will not remain so difficult any more. Sometimes things like walking and running can be quite boring. It may be better to play a game. So, you enjoy the time spent and get exercise at the same time.

And the compliments you receive are like the proverbial icing on the cake. Makes it all the more worthwhile!

Sunday, December 21, 2008

Advice to budding programmers: Write neat code

What exactly do I mean by neat code? We all write code on the computer with a keyboard isn't it? How can code be neat or not neat when you do that!?

Well, let me explain. Take a look at this:

Now, compare that with this:

Exactly the same code. But just look at the difference. All due to some simple formatting. Makes everyone's life so much easier. The programmer's too.

I am not even talking about coding conventions like method and variable names and all that jazz. Just the style of writing code. Some simple rules. Here are a few to get you started:

1. Leave the rest of the line after an opening brace empty
2. Leave a single blank space before and after any operator (=, +, - etc.)
3. Leave a blank line after a related group of statements
4. Indent one level for every block of code. For example, everything inside the for block should be indented one level more than the for statement itself.

Such simple rules go a long way in making code more readable, maintainable and easy to debug.

During my career in the software industry, I have seen the code of two people which are inspirations to me in this aspect - Shanivarapu Ram Seshu Kiran - S R S Kiran in short and Abhilesh Khatri. Both of them worked with me in Effigent. Their code was a pleasure to review. Everything would be so neat. So well written. And they were good technically too.

Another person who has been a guiding light in this respect was Suresh Pai - again ex-Effigent. Suresh was very particular about the way people wrote code. He insisted that everyone followed rules similar to the above.

Some people might argue that these kinds of things are trivial and not important while writing code. I would strongly disagree. Readability and maintainability of the code are extremely important. The author of the code is not always available to maintain his code. And even if he is the one maintaining it, neatly written code is much easier to manage.

(The bad alignment of the text above is a bug in Blogger. The Preview shows it properly.)

Friday, December 19, 2008

Advice to budding programmers: Learn shell scripting

Shell scripting to programming is like salt to a meal. By itself it does not count for much. But its contribution is critical. You probably will never have a separate course in a computer science degree on shell scripting. You probably will never have a client who comes to you just for a shell scripting project.

But make no mistake, it is a nifty tool in the hands of developers. You can save hours of frustration with a tiny little script. You can do so many things with shell scripts that you would have to otherwise do manually that it should be one of the first things you learn after you have gained an understanding of your first programming language.

I am not referring to mundane things like 'rename all files that have an extension 'fck' in the folder called Aardvark that resides three levels below your home folder'. These kinds of problems are meant to teach you how to use shell scripts. I am referring to the daily things that a programmer must do.

For example, builds. Daily builds, like Joel so simply puts it are your friend. A lot of pain can be avoided with a process that includes daily builds. I can prove with statistics if someone gives me the money and resources to do so that daily builds in the process can reduce the time taken to deliver a project by as much as 25%.

By having a script that automatically checks out the code at a designated time and compiles the whole body of code, generating an installer (maybe this part in the later stages of the cycle) and emailing out errors to designated persons, a heck of a lot of pain can be reduced.

This is just one example. An entire backup process can be put in place by only using shell scripts. There are just too many uses of shell scripts for a developer not to know them. The mistake which many people make is to think about learning shell scripting when they actually come across a problem which they know can be solved by shell scripts. Too late!

So, dear budding programmers, take my advice - go look for a good shell scripting tutorial in another tab in this same browser window!

Advice to budding programmers: Learn C

In today's world, you can really quite easily get away without learning C. Tch tch. Sad.

The programming languages that are out there being adopted dime a dozen by wannabe programmers these days are so full of abstraction that many of them will never know what memory really means.

C should be made mandatory in all computer science courses. And a prerequisite for applying to software development jobs. Why, you might ask? Why should a programmer worry about allocating and freeing memory when he can leave it to the run time to do? Why should programmers rack their brains trying to figure out pointers when they can get through life without coming across one? Why not focus on solving application problems rather than worry about memory leaks?

Well, you have a point. But then, I am not asking all programmers to program forever in C. I am just saying "Learn C". Know it inside out. For a few months in your programming career (the earlier the better), think in C. Dream about linked lists. Sort an n-dimensional array in your mind. Mull over the beauty of a struct. Wonder about pointers to pointers.

This kind of rugged training to your brain gets you ready for the challenges ahead. You understand exactly why Java screws up big time with garbage collection. You will appreciate the layers put above all the 'low level crap'. You might even be able to resolve some of the problems thrown up by Dot Net.

A good programmer uses the facility given to him. But he does not fumble when the software does not behave as documented. He will go one layer lower and find a way out. This kind of skill comes easily to a person who has gone through the grill of programming in C.

C gives you the power unimaginable in higher level programming languages. But, as we all know, with great power comes great responsibility. It is easy to crash things, mess things up beyond recognition and in general, cause utter chaos!

C also has a way of filtering out the wheat from the chaff, the stars from the also-rans. I know many an aspiring programmer who gave up on their programming career because they ran into C early in their life. They just did not cut it.

Is this fair? Absolutely. For them as well as for the developer community in general.

Thursday, December 18, 2008

Advice to budding programmers: Grow organically

I often see programmers getting lured by the prospect of leading and managing teams very early in their careers. This typically happens in startups and small companies. Programmers with about 2-3 years of experience are asked to lead teams and they happily take on the responsibility thinking that they are growing very fast.

They couldn't be more wrong.

I have seen people grow too fast and then regret this later in life. Growth must be organic, the 'right' way. For people to be able to manage teams involved in technical projects, it is extremely important that they be technically competent too. A manager with superficial knowledge of the technology can never be effective.

So, when programmers have barely started their careers, it is imperative that they gain an in-depth understanding of technology before they start managing teams. I would say, a programmer must have atleast 5-6 years of experience in a very hands-on technical role before he takes on a managerial role.

Even after this, it will be very useful if he or she continues to code atleast for a few hours every day so that he never gets out of touch with the nuances of programming.

It is very tempting for programmers early in their careers to take on managerial responsibilities. There is a feeling of a 'promotion', a recognition of your abilities. This may be true. But in the interest of their career, it would be wise to defer this additional responsibility until they are really ready for it.

Managements of software companies must also realize this. Often they are left with no choice. Senior managers are expensive. Cheaper resources have the ability. So, why not? But in the long run, this is harmful to both. The company also stands to lose because good technical ability cannot be found easily.

By turning a programmer into a manager, you have lost a good programmer and found a bad manager!

Wednesday, December 17, 2008

The grind

My life is really hectic these days. Ever since I took up my new job, I have been running. Running from one place to another, finishing what I am supposed to finish. With no time to pause and reflect on what I am really doing.

My whole day is spent just getting things done. I get up in the morning and have about half an hour of peace when I have my tea and go through my email, blog, visit my orkut and facebook pages. That's it. After this, the mad rush starts. Its one continuous race against time. Temple, swim, breakfast and head out to office. I need to start atleast by 9:20 to have any hope of reaching by 10 which, by any standards, is not early. The commute takes about 45 minutes one way.

The next 8 hours or so are spent in office or related work.

I leave office around 6 and then start the dreary commute back home amidst the chaotic Hyderabad traffic. Another 45 minutes.

By the time I am back I am half dead. No motivation to do anything whatsoever. I have even stopped dialysing on my own. I wait till the tech comes and have him start the session. I am too tired.

Morning comes. The race against the clock starts all over again.

The tough part about the new job is that Saturdays are officially working days. This is really difficult on me. I badly need the two days off to recover. The schedule during the week is so exacting, my mind and body need the two days to be able to remain sane.

When I think about this, I wonder why I am feeling so tired? The work is not yet stressful. The work hours are not longer than what I was used to. Is it the travel? Is it the working Saturdays? I have no idea.

Sunday, December 14, 2008

The all important 'context'

Knowing and understanding the context of any statement, event or happening is so important. The same event in the backdrop of different contexts can have entirely different meanings.

Take my haircut, for example.

A few months back, I decided to shave off all the hair on my head. So, I went to my regular barber's shop and told the barber assigned to me as much. His name was Amba Das. He suggested cropping it very short instead of going the whole hog. I said, "What the heck, might as well try something new." I asked him to do it.

At the end of it, I was quite happy with the results. But I was not at all sure how others would react. Over the next few days, I was quite overwhelmed with the compliments I received. From "sexy" to "suits you" to "tummuchitis (too much it is), keep it like that only", they kept pouring in. The last one especially, from someone that mattered.

Amba Das was a genius.

This was the reaction from people who knew the context of what had happened. They knew that this was intentional. They knew a barber had done it. They knew that it was done at my behest.

Compare this with those who did not know the context.

"How did you lose your hair?"

"What happened to your hair?"

"I never thought hair loss was a side effect of dialysis!"

Gawd! Spare me the horror!

I had to painstakingly explain that I got this done myself. It was meant to be a fashion statement, maybe. Dialysis has nothing to do with this.

"Oh!", they would exclaim. I could read their disbelief quite easily. Wtf, I would think. I couldn't care less. I was happy with it. So were the people that mattered.

But, coming back to my initial point, the context is really important. Famous people are often quoted out of context and I sympathize with them. A single statement, taken without what was asked or what was said before can have a totally different meaning than what was intended.

Saturday, December 13, 2008

Got my two pairs of buttonholes

I had recently written about my problems with my buttonholes. After some back and forth with Gus on the Home Dialysis forums, I finally decided to get another pair of buttonholes.

So, I started alternating the two pairs of sites with sharp needles. The pain was much less since the same pair of sites did not have to undergo the trauma of another cannulation less than half a day after they were used. They got a full day's rest, an opportunity to heal and 'cool down' before they were up and running for another cannulation. Their buddies, the second set of buttonholes would do their bit in the meantime!

So far, it has been all right. I am keeping my fingers crossed. Let's see how it goes.

Thursday, December 11, 2008

Traveling on Dialysis

Bill Peckham writes in his blog "If you've always wanted to see Toronto, dialysis shouldn't be the thing that stands in your way. It can be done but first payers must understand that travel matters."

This was in response to a comment by Anupama from Bangalore who wanted to go see her (Bill, Anu is a lady, btw) brother in Canada. She was wondering if there was a way she could get dialysis when she traveled to Canada. This is one of the biggest problems dialyzors in India face. That of travel.

Traveling within India is possible. You can get get the standard 4 hour treatments without too much of a hassle. Don't expect nocturnal though. Traveling outside the country can be very difficult. The cost is a major factor. With the exchange rate heavily loaded against India, the cost of a single session of dialysis can be more than ten times as expensive as that in India. Every country has very different protocols on dialysis and the units may have problems adjusting to the protocol you're used to.

By and large however, I would say it is very easy for someone outside India to get dialysis in India. The same is definitely not true for countries like the US and Canada. The costs and the logistics are huge barriers.

Peritoneal dialysis, on the other hand offers much more flexibility where travel is concerned. Travel in India is a breeze. You call your supplier and he will arrange for the PD fluid bags to be delivered in almost all the major cities in India.

Some companies also have this facility when you travel abroad. Given sufficient notice, they will arrange for PD bags in any country where they have a presence. And that too, at the cost at which you get the bags in India. This is really great.

That is why I say, where travel is concerned, there's nothing like PD. I have gone on many trips within India when I was on PD. On Hemo, I would have traveled more if hospitals provided nocturnal. That is too much to ask for. Many nephrologists haven't even heard of nocturnal. They wonder why I dialyse for so long! So, to expect them to provide this modality for someone from out of town is a long shot. So, travel is usually restricted to a very short duration. This is not the case with PD. You can travel for as long as you like. This is a huge plus for PD.

Wednesday, December 10, 2008

What's the best way to learn a new technology?

I started learning Cocoa recently. There are so few people who know Cocoa that it is really difficult to find someone to teach you. There isn't anyone I know that offers training in Hyderabad.

Again, is it really necessary to find someone to teach you? Once you know programming concepts, picking up a new technology should be fairly straightforward. All you need is some documentation or a good book to follow.

I started learning Cocoa by using the training material that was put up on the web for Stanford's CS193e course on Cocoa. This was excellent material and they had the instruction slides, the sample apps and some very good assignments. The only problem with this approach is there was no one I could turn to when I got stuck. Sravan, a former colleague of mine helped me out a few times. But he now stays in Noida and the only way I can get in touch with him is by email which is not the fastest form of communication.

I think it is important to have a mentor who is good at the technology when you are learning it. It helps clarify doubts, learn to do things the 'right' way and simply act as a sounding board to bounce ideas off. The mentor does not have to teach you like in a classroom setting but just be there to help you when you get stuck with something.

I found a very good book called 'Cocoa Programming for Mac OS X' by Aaron Hillegass which is fairly hands on and the concepts are taught by making the reader actually write applications. I have since switched to this book from the Stanford material. I will probably get back to the Stanford material once I am through with this book. The best part of the Stanford material is the assignments. They are by no means easy. You have to think through your approach before implementing them. That's where a mentor would have been really useful.

I really wish I had made the time to learn this beautiful technology while I was in Effigent. I had the mentors sitting next to me. Unfortunately, I got caught up in other things. Things I was good at but did not necessarily enjoy.

Tuesday, December 9, 2008

The pool where I swim

This is the swimming pool where I swim. Doesn't it look inviting? The best part of swimming in this pool is that at this time of the year, there is hardly anyone who comes to swim. Especially when there is no one in the pool, the water is so still that it is really great to swim in it.

Saturday, December 6, 2008

The missing milk packets

Every morning, as in thousands of other homes, the milk delivery man delivers three packets of milk to our house. He usually leaves the milk packets outside our door, rings the bell and leaves. He does not wait for the packets to be collected by us.

This morning, we waited and waited. But the milk never came. My mother called the milkman and asked him about the milk. He was quite surprised and said that he had left the packets outside our door just like any other day. My mother said there were no packets outside our door. He then said that he left the packets about an hour back and the red car was also not there in our compound which was true as I had taken the car and gone out early in the morning.

My mother then asked him to deliver three more packets and we would pay for them.

My grandmother, my mother , our lady cook and our domestic help then got into an elaborate discussion about the missing milk packets. The milkman must have come and delivered the packets because he knew the car wasn't there. This has never happened before and our milkman is quite a nice guy.

Then what could have happened?

"A dog or a cat perhaps", our cook helpfully offered. The ladies thought about that for a second but dismissed the suggestion because a dog or cat would have tried to open the packets there itself and we would have seen spilt milk. They wouldn't have neatly taken all the three packets and gone away. With the small mouths these creatures have, they couldn't possibly have held the three packets too.

"Then it must have been a thief", they concluded in unison. My father and I who were haplessly listening to this discussion, unable to comprehend the fuss that was being created over three humble packets of milk, were quite relieved that a consensus had been reached.

But it was not to be.

The four ladies then went into an analysis about how a repeat of this could be avoided.

"The packets must be handed over to a person. That way we are sure that they can never be pilfered."

"That's not practical. The guy comes quite early sometimes."

"Let's identify a secret place which only the milkman and we know. The place should not be visible from outside."

Action Items were chalked out. Responsibilities were assigned. Processes that could easily qualify for CMM Level 5 were drawn up.

I wondered if so much discussion had taken place even after the terrorist attacks at Mumbai.

Friday, December 5, 2008

Buttonhole bothers

I wrote about my problems with buttonholes a few days back.

I changed both my access sites recently. Everything went well for a few weeks. But the pain is back. This morning, an hour before the session completed, the pain was there in both sites. I really don't know what to make of this.

Buttonholes have been touted as the best thing since sliced bread. My experience was great for the first year or so. But I have had problems since then. For a few days everything seems all right. But sure enough, after this initial period of comfort, cannulation is scary. The pain seems to be there throughout. The actual process of cannulation is not that much of a problem probably because of the anesthetic (xylocaine) that I inject. But a few hours into dialysis and the pain slowly starts increasing. And when the needles are removed after dialysis, the pain is at its worst.

I have read on the home dialysis forums that it might be a good idea to have two sets of buttonhole sites and you basically alternate between the two every other day. This gives time for the sites to heal. Sounds promising. I must try this. The only question I have is for the creation of a buttonhole site, you need to cannulate at the same site every day. How can this be done? If I must cannulate at the same site every day so that the tunnel forms, how can two sites be created at the same time? I will ask this question on the forum and try and get some answers.

It is amazing how different bodies react to the same thing in different ways. I have yet to hear of anyone with problems with buttonholes. Then why am I having so many problems? I do not know anyone else that needs an anesthetic too. The whole purpose of using buttonholes is that you can avoid the pain that is associated with cannulation.

There are some people who do not use an anesthetic in center too inspite of having sharp needles used on them. This is a real shock to me. Here I am using an anesthetic even for buttonholes and there are these bravehearts that don't use an anesthetic even while using sharps! Do they have such numb arms that the sharp needles don't pain? Or do they like the pain?!

Whatever it is, I don't like any pain at all. My tech once told me that I should try to avoid using the anesthetic because it is not good to use it over a long period of time. The sites around my buttonholes also start becoming black with prolonged use. The area becomes quite ghastly to look at!

I however couldn't care less about this. I need the anesthetic and I use it.

Tuesday, December 2, 2008

In search of the perfect MLA Pesarattu

I have often wondered how the name of this unique dish came about. A little digging around and I found this. In the canteen inside the Andhra Pradesh Legislative Assembly, an MLA would come every morning for breakfast. He would always have an upma and a pesarattu. He would come late sometimes however and to save time, he would ask the canteen guys to put his upma into the pesarattu so that he could finish off both together!

I have no idea if this story is true or not. So, don't quote me on this. Who cares about the origin of the name however? The combination is so tasty that whoever came up with it needs to be thanked profusely!

The MLA pesarattu is essentially a pesarattu which has some upma filled inside it. The pesarattu is very similar to the dosa except that it is made out of green gram.

The pesarattu by itself is made by soaking green gram for a few hours and then grinding it into a liquid consistency. The upma is made by using 'rawa' or crushed wheat and adding water and other flavors apart from cashewnuts.

An open MLA Pesarattu

The MLA pesarattu is to be had with the regular South Indian accompaniments like chutney and sambar. This can be quite filling.

There are a couple of key things to a good MLA Pesarattu. The quality of the Pesarattu dough - care should be taken to make sure its of the right consistency. Too thick and it will taste very tough. Too thin and it will absorb a lot of oil while roasting on the tawa. The upma too should have the right amount of ghee and should be a little spicy. This gives the combination a great taste.

In Hyderabad, the best MLA Pesarattu, I think, is served by Chutneys. They have 2 branches - one at the Nagarjuna circle and the other at Himayatnagar. Both serve excellent MLA Pesarattu. They serve it with four types of chutneys (like most of the other items served here) and sambar. The MLA Pesarattu is usually had for breakfast, but as luck would have it, Chutneys serves the item throughout the day. A visit to the place is never complete without an MLA Pesarattu!

Monday, December 1, 2008

Emergency medical care in India

One of the biggest concerns I had when I was considering home hemo and which I, in fact, still have today is the possibility of an emergency during dialysis and how I would deal with it.

Recently, I came across EMRI, or the Emergency Management and Research Institute set up in my state and other states in India. You basically call 108 from a telephone and an ambulance equipped with medical emergency handling equipment and a qualified person picks you up and rushes you to the nearest hospital.

This came as a huge surprise. I was not aware of this at all. This is quite comforting as you now know that there is a backup that is available should something go wrong. I am not sure if the person in the ambulance is equipped to handle emergencies arising out of dialysis. But he is usually aware of the treatment to be administered to handle cardiac arrests, strokes and some other emergencies.

A very good first step.

During the initial days of my starting home hemo, there were quite a few instances where my blood would leak around the exit site. I wouldn't classify this as an emergency that required me to be rushed to a hospital. This too stopped after I started tying my arm with the fistula with a string to my bed so that the movement was restricted. With nocturnal dialysis, the chances of an emergency are generally lower than with hospital hemo because of the gentle nature of the treatment. However, the risk is not eliminated and having this kind of a fallback is quite reassuring.

There is also an extension to this facility. You have an option of installing a button at home which when pressed, automatically calls the call center and they get the location details automatically. This way an ambulance can be send much sooner to your house.

This is indeed a giant leap for emergency medical care in India.

Friday, November 28, 2008

My new job

I took up a new job this week. Its a startup. Called Grene Inc. After eight long, and by no means uneventful years in Effigent, it feels a little strange to be working in another company.

There is currently a very small team and the team is being built slowly. Reminds me of the first few months of Effigent. We had started operations on September 4th, 2000 with 4 people in an apartment at Begumpet in Hyderabad.

The work that I will be doing is pretty exciting. It will be on the Mac. The company is also involved in home automation which has been a dream area for me to work on. Hopefully I can get involved in that at some point in the future.

It is quite surprising that the technology for some very cool and efficient home automation features is already available and is being implemented. The key is to decide what is really useful and worth implementing. A lot of features sound very cool when you first hear about them. But if they are implemented, the novelty quickly wears off and after a few months you think if it was really worth buying those features.

For the longest time, I was immensely facinated by the possibility of bluetooth enabling my computer to call out "Hi Kamal" when I entered the room it was placed in. I got the software, a bluetooth enabled phone and then got this to work. For a few times, there was a great sense of achievement. Very soon, I tired of it and disabled it.

The key to a good feature apart from the 'cool' factor is the usefulness on a long term basis. Grene Inc. will be greatly successful if we are able to identify these features and implement them.

Wednesday, November 26, 2008

That's my cubicle!

In the swimming pool I go to for my daily morning swim, there are separate changing rooms for men and women on either side of the pool. In the men's changing room, there is a line of about six cubicles with a half length door each. The door covers you from neck to knee if you are of average height. You basically use these cubicles to change.

I, for some reason, like the second cubicle from the left. Don't ask me why. Its just that I am more comfortable in this cubicle. All of us have these quirks, I guess. At the dining table at home too, I always sit on the first chair to the left. Always. If anyone else in my family sits on that chair, I politely ask them to get up. Even when guests come home, I make sure I go and stand next to my chair so that it is not usurped from me. If I don't sit on that chair, I become upset and cranky. The food tastes weird and I get very restless.

Coming back to the swimming pool, I really need that cubicle. I go to all lengths to make sure I get my cubicle. If someone has occupied that cubicle, I temporarily put my things in another cubicle and then wait for him to finish changing. Once he's done, I take my cubicle.

Yesterday, I entered the changing room and saw that no one was there in my cubicle. The door for some reason was closed. Happily, I opened the door of the cubicle. To my utter horror, there was a man of about fifty changing and he had bent down to put on his swimming trunks because of which I could not see him from outside. I was terribly embarrassed. I exclaimed, "I am so sorry!" He was not unduly perturbed. He said, "Its all right" and continued changing. I quickly closed the door and went to the next cubicle.

I thought to myself however, "Serves you right, old man! Next time don't use my cubicle!"

Monday, November 24, 2008

In search of the perfect Undhiyu

The Undhiyu is a Gujarati vegetable dish. It is a heady concoction of vegetables, spices, masalas and 'muthiyas'. It is probably the most elaborate dish in the Gujarati cuisine. Surat is very famous for its Undhiyu.

The traditional method of making the Undhiyu is to put the ingredients into an earthen pot, put the pot into the ground and cook it with wood fire from the top. Once done, the pot is emptied into the serving dish. It is made 'undhu' - upside down in Gujarati, and hence the name!

As with most other food, the Undhiyu is rarely made this way these days. LPG and microwaves have robbed our palates of the true flavors of food and we have to make do with the quicker and easier alternatives.

Many people feel they can add whatever vegetables they feel like in their Undhiyu. They couldn't be more wrong. The vegetables must be chosen carefully. One wrong tasting vegetable and you can be sure to ruin the dish. The most important vegetable is the 'valor' which is broad beans in English. Apart from that, cabbage, cauliflower, beans, raw plantains and brinjals are added.

The 'muthiyas' are what differentiate the Undhiyu from the plain mixed vegetable curry. The 'muthiya' is basically gram flour (besan) and methi leaves rolled into a dough, turned into small balls and deep fried. These 'muthiyas' are added to the mix of vegetables and the whole mixture is cooked.

The Undhiyu can be eaten with pooris, rotlis (phulkas) and it tastes great with rice and Gujarati dal too.

It is quite difficult to find really good Undhiyu. Traditionally Surti families (families hailing from Surat in Gujarat) probably make great Undhiyu but you must be able to take the sweet flavor that goes into every dish that is made in Surat!

The best Undhiyu I've ever had was the one made (rather supervised) by an elderly Gujarati aunt from Chennai when she had come down for a wedding in our family many years back. There was a big family lunch and she took it upon her to make (or rather supervise the making of) the Undhiyu. The attention she gave to detail was evident when she asked a bunch of kids (yours truly included) to remove the skin of the seeds from the 'valor' or the broad beans. She insisted on this because she believed that the skin comes in the way of relishing the Undhiyu! The effort of course, was worth it. The resultant Undhiyu was heavenly.

Isn't that the key for all food? Tremendous care and attention to detail. No short cuts. A lot of people make the Undhiyu but it tastes good only when made the correct way. A warning: don't try making the Undhiyu by looking up a recipe on the internet. Take it from me. It won't work. This is an art that is mastered by first learning it from an experienced chef (the female kind mainly) and then making it three to four times before you have mastered it!

Saturday, November 22, 2008

iPhone Tech Talk

I'm off to Bangalore tomorrow for the iPhone Tech Talk which is on Monday, the 24th of November.

Tech Talks are a great way to get to know about the technology from the experts themselves. It is really nice that Apple has started putting India on their map for these kinds of events. I remember going for the Mac Tech Talk at Bangalore a few years back with Kartik and Ravi. That was a one day event with about a hundred attendees. Most of the people were into the development of device drivers and came because their work involved creating drivers for the Mac. We were probably among the very few that were into application development and probably the only folks doing WebObjects development.

I expect this year to be very different. With the buzz around the iPhone, a lot more people have gotten into Cocoa and Cocoa Touch development (the former because of the latter!) and you see a lot of people aware of these technologies than you did just a few years back.

The situation for WebObjects has become more dismal than ever before. Unfortunate! It is really hard to fathom why such a beautiful technology continues to languish. WebObjects is really poetry in bytes! The architecture of the frameworks, the intuitive paradigms and oh, that ethereal Enterprise Objects Framework, when shall we see such a technology again?

I would really love to get back into WebObjects. I am learning Cocoa these days. Luckily a lot of the philosophy is shared between the two including the whole foundation framework.

Anyway, I hope to have a great time at the Tech Talk on Monday. I'm going a day in advance, hoping to grab some excellent food at MTR, Woodies and heaven-bless-them Nagarathpet.

Wednesday, November 19, 2008

A big mistake

Yesterday, I made a huge mistake while starting dialysis.

There are two injections that I need to use while starting dialysis. One is Xylocaine which is an anesthetic that I usually take in an insulin syringe, about 0.35 ml, and inject a little in the arterial and venous sites to help reduce the pain while cannulating myself. The other is heparin of which I take about 2 ml, dilute to a total of 12 ml with saline and then put the syringe in its place in the heparin pump. When dialysis is about to start I give a bolus shot of 6 ml of the diluted heparin and then for the rest of the treatment the pump injects heparin at the rate of about 1 ml per minute. This is primarily to prevent the blood from clotting.

Yesterday, I had finished injecting the Xylocaine and did the cannulation. Both the bottles are always next to each other on my bed next to which I start my dialysis. The next step was to take 2 ml of heparin. I was not focusing on what I was doing. My mind was on the new job I was about to take up. The different options in front of me. The pros and cons of each.

Instead of taking heparin, I took 2 ml of Xylocaine!

I did not realize this at all. I diluted the xylocaine to 12 ml like I would do with heparin and put the syringe in the heparin pump and also gave a bolus shot of 6 ml.

I continued the rest of the process. However, when the dialysis session had started, I was putting the bottles and other stuff back into the trolley that is meant for all my supplies. At that point I noticed that the heparin bottle was full. I was shocked.

I then realized that I probably took xylocaine instead of heparin. I was terrified. I broke into a sweat. I shouted out to my brother. I asked him to give me my cell phone from which I called my tech and asked him what to do. He asked me to empty the syringe that had xylocaine and take 2 ml of heparin as usual and ignore the fact that I had used xylocaine.

I removed the syringe from the heparin pump and then took 2 ml of heparin. But the line I used to draw saline from usually had blood in it because dialysis had already started. So, to my horror the heparin syringe now had blood in it because I used the same line to draw the saline. I panicked further.

I anyway gave the bolus shot of heparin and the dialysis continued.

When the tech came, he checked everything and said it was all right. The blood would not clot even in the syringe because it was anyway mixed with heparin. I was worried about the xylocaine that mistakenly went into my bloodstream. I called my aunt who is a doctor and checked with her about it.

She asked me how long it was since this happened. I told her it was about half an hour. She said if nothing has happened in half an hour, it should be ok. And, she recollected, they did give xylocaine IV sometimes in arythmia or irregular heart beats in some patients.

Well, I'm writing this today, so everything was ok in the end.

But this whole experience was really scary. The problem was not the error. This kind of an error could have been committed by a dialysis nurse or tech too. The problem was that I did not know how to recover from the error. That is what scares me.

What I really need is good training for home hemo. Which is not yet available in India. I need to be trained to handle these kinds of situations. When will this become available? Not very soon, I'm afraid. There are hardly any people doing home hemo on their own. This is not a priority for the medical community. When there are people who die due to the lack of dialysis itself, expecting the system to have training for home hemo is not realistic.

Monday, November 17, 2008

My problem with Dostana

I saw Dostana yesterday. It was a good film.

I have one problem with it however. There is a scene in the film where Abhishek Bachchan asks Priyanka Chopra if she is ok with the whole gay thing. Is she comfortable with the fact that Abhishek and John Abraham, who are going to be staying in her house are gay? Priyanka then replies saying that of course she's ok with it. 'Its your choice'.

This is one misconception that people have. They call being gay a 'choice'. It is not a choice. It is how people are made. Their genetic make-up. When you like something, it is not that you consciously decide to like it. You just like it.

Similarly when people are attracted to others of the opposite sex or the same sex, it is not a conscious decision they are making. It is just a part of their system. Their genes are just wired that way. Its not as if at some point in life, a person decides which sex he or she is going to be attracted to.

The worst possible reaction of course, is to think that gays are perverts and that something is 'wrong' with them or that they are 'diseased'. This is ridiculous. But attributing this to a choice that they have made is wrong too.

Another common misconception that people have about gays is that they are always effeminate. Bollywood has constantly portrayed gays as effeminate. Well, some gays are effeminate but definitely not all. Nobody can make out that a person is gay just from physical appearance. In an attempt to burlesque gays and raise some laughs, Bollywood has been severely guilty of this faulty depiction.

It is high time we moved away from such stereotypes and mistaken notions.

Friday, November 14, 2008

Miracles as an aid to faith

There is a saying in Hindi, "Jahaan chamatkar, wahaan namaskar". Which roughly translates to, "Where there is a miracle, people will bow".

What is it about a miracle that attracts people?

People look up to people who are able to perform miracles because of the supernatural element. Something above the ordinary. Something they cannot do themselves. Something beyond the realms of science.

This is really unfortunate. Do we really need a miracle to be able to believe in something? Will we believe in something just because the person who propounds it can perform miracles? If a person can perform miracles, then do we believe everything he or she says?

This is really something we should think about.

Whatever I believe in is based entirely on logic. It should make sense. I will not believe in something just because the person who said this could perform supernatural acts.

What we define as 'defying science' is actually 'defying science as it is today'. Science is ever changing. Yesterday's theories are disproved today. Today's theories will be disproved tomorrow. What constitutes a miracle today could be consistently reproducible in the lab tomorrow.

I cannot base my beliefs based on what someone who can perform miracles says. These people could have vested interests. I need my beliefs to be backed by sound reasoning and rationale. Not vague concepts further obfuscated by the clever use of words.

I am not referring to any particular religion or person. This is a phenomenon that exists across religions and cultures. 'Godmen' frequently use miracles to attract devotees. People are so gullible that they easily fall prey to these people.

When people take to a person as a 'guru' or someone who they really admire and respect, it should be because of his or her purity and definitely not because of an ability to perform miracles.

A true saint is someone who does not do things to become popular. A person who does not do things to attract devotees. A person who is so selfless and free from ego that people will naturally come to him or her without any effort. A person who is pure and free from material desires.

Not someone who needs the crutches of a miracle.

Thursday, November 13, 2008

Understanding a patient

In my eleven odd years with CKD, I have come across quite a lot of doctors. Believe me, they came in all varieties.

You have the grumpy old men who feel the patients are there for the sole purpose of irritating them. They will talk with a condescending air. Then there are those that think they're God's gift to mankind. They have egos as big as their paychecks. Any hint of a suggestion from the poor patient on the treatment course and they will go totally berserk.

On the other end of the spectrum, you have the doctors who genuinely care for their patients. They understand the agony of what they're going through. They are gentle and affable. Easy to approach. Easy to talk to.

Patients need to have that comfort level when they visit their doctor. They are after all trusting the doctor with their lives. It can be quite disconcerting to be in the hands of someone you can't even discuss your situation openly with.

I have had instances where I would ask the doctor about the possibility of using a particular line of treatment because I might have stumbled across it on the internet and the doctor would blow his top and ask me if I wanted him to treat me or to follow what I suggested. I really have a problem with these kinds of doctors.

On the other hand, it is so comforting to visit a doctor who discusses things with you, explains the rationale behind the treatment modality he is choosing and takes your opinion, answers your questions and we come to a conclusion together.

Wednesday, November 12, 2008

Peripheral Neuropathy

For the last month or so, I've been having some numbness in my left foot. I ignored it for a while because it was not too bad. However, when it persisted for this long, I went and met with my nephrologist, Dr. Girish Narayen a few days back.

He sounded very worried and said we should not take chances and should investigate this thoroughly. When I asked him what he was thinking this could be, he said these could be early symptoms of a stroke. He asked me to consult with a neurophysician.

It would be three days before I would see the neurophysician. I was actually very scared. The things I read up on strokes on the internet and what I had heard in the past made me visualize myself in all kinds of situations and my mind was imagining the worst.

On Monday, I met Dr. Srikant Jawalkar, the head of neurology at Yashoda Hospital. He did a preliminary examination and asked me to get a brain CT scan, a carotid doppler and Nerve Conduction Studies done. The same day I got all these done.

Yesterday I went with the reports to Dr. Jawalkar. We had the diagnosis. The CT and the doppler were normal. The Nerve Conduction Studies showed some damage to the nerves in my feet. Thankfully, there was nothing that showed a risk for strokes.

This damage to the nerves is called Peripheral Neuropathy. It is often seen in people on dialysis for a long time. It does not happen to all but it is seen in some people. So, obviously I had to have it!

He put me on some medication and said there was nothing to worry. We would review after about a month.

I was really relieved that it was not serious.

The problem with the human body is that it is designed to function as a symbiotic whole. When anything goes wrong with one part of it, it sets off a gradual chain reaction in almost all other parts of it. It is not like your good 'component' based design in software where one component should function independently of the other components! If a change is made to one component, it should not affect other components. Someone needs a course in good design principles!

Monday, November 10, 2008

Gossip monger

"What are the three most effective forms of communication?"

"Telephone, Television and Tell-a-woman!"

So true!

Some women make very good gossip mongers. Anything remotely scandalous and they will suffer from indigestion unless they talk about it to every person in sight. And if you want it to spread really fast tell her not to tell anyone.

A few years back I had to pick up something from an acquaintance's house. So, I parked my car in the parking area of the apartment complex he stayed in and went up to his flat.

As it turned out, he was not at home. His mother was however there. I asked for him and was told he had gone out. I asked her to tell him that I had come to collect such and such a thing.

She said she would. As I turned to go back, she beckoned me over. I turned to face her. She said to me, "You know what? The girl in the opposite flat ran away with her boyfriend."

I was shocked. What did that have to do with me? I neither knew the family nor the girl. I had probably visited that apartment for the first time in my life. I figured the lady must not have met anyone from the morning and was dying to tell someone. She ran into poor old me. So she had to tell me!

"Oh!" I muttered as I hurriedly left the place. Through the corner of my eye, I caught her looking pleased and relieved.

Sunday, November 9, 2008

'Everything will be all right'

I've heard this baloney quite often. It is the ultimate universally reassuring statement. Whatever happens, don't worry. Everything will be all right.

It can be very irritating sometimes. What will be all right?

CKD has taken away the best years of my life from me. It has brought a host of other problems with it. But don't worry, everything will be all right.

Do these words really help? Do you think they offer comfort? They are really easy to say. Easy to utter. And people think they have done their job by saying this.

I understand that the intent is to ease the agony with the hope of a better future. But honestly, they don't help at all. I know what I have. I'm not that foolish to think that there is going to be a day when I will not have any medical problems at all. I'm stuck with this for life. I know that.

Don't get me wrong here. I am definitely not depressed. I am totally composed. I deal with this very objectively. I am handling this quite well. It is very easy to give up. Pavan Joshi did. I am not going to. Not so soon anyway.

But making such silly statements is totally unnecessary whatever the intent.

One other piece of advice I have for people going to visit someone in a hospital. Never discuss the problem. You never know enough to offer advice. Visit and discuss something totally unrelated. Politics, films, work, whatever. Never ask the patient or the family about the problem. Your visit should be an opportunity for them to get away from the problem. They have discussed this enough.

I have had totally ignorant people coming to visit me (years back when I was in hospital) and ask me what the doctor said. How does that bother you? You know what he said? He said I should not tolerate nosy visitors. Never mind what the doctor said. Let's hear what you have to say instead.

Sorry for ranting so much today.

Saturday, November 8, 2008

Technical versus Managerial

I'm at the crossroads of my career. I need to make some important decisions which will stay with me for a long, long time.

The most important decision at this time is whether to choose the managerial route or the technical route.

The 'normal' career path of many people in the software industry is that they start off as programmers, testers etc. and learn the ropes, so to speak, for a few years and then either continue in the technical area by graduating to design and architecting or slowly get into a managerial role where they lead teams and are responsible for delivery.

Due to my rather unique circumstances, however, I did not get a chance to spend enough time on programming in my early years. I had to take on a managerial position pretty soon. I like to believe I did well.

Now, when I have some time on my hands, I find myself inclined to the technical side. I am focussing on learning Linux on the one hand (shell scripting, how Linux works, the different libraries etc.) and Cocoa (building desktop applications for the Mac) on the other hand.

I enjoy this thoroughly.

On the other hand, some of my friends feel I make a good manager and dealing with people is my forte. Also, some people have suggested that I should now aim to handle an independent software unit rather than manage single projects. This is because I have been doing this for the last few years and doing some technical stuff or managing single projects would not be a step that could be construed as 'growth'.

This is the dilemma I must resolve. And do it quickly.

Friday, November 7, 2008

Swimming in the cold

Its getting a little cold in Hyderabad these days. The minimum temperature is around 16 degrees celsius. When I started swimming regularly earlier this year, I often wondered if I will be able to continue this in the winter months.

It is early November and I am glad that I am still swimming daily. I think the body adjusts to circumstances quite well. If someone who has not been swimming comes one of these days and gets into the pool, it will be quite a shock. But since I have been swimming for a few months now, my body is gradually adjusting to the cooler temperatures.

The place I go to has two pools. For some inexplicable reason, the water in one of the pools is always slightly warmer than the other. The water is not heated at all and the pools are next to each other. Inspite of this, the temperature of the two pools is different.

Until now, I have always been swimming in the cooler pool but a few days back I've switched to the warmer one.

I really don't want to stop swimming. It keeps me fit. I've lost a few kilos. My waist has reduced by a couple of inches. And the best part is - I thoroughly enjoy that time. What more could I want?

Wednesday, November 5, 2008

Late night encounter with a traffic cop

Last night, after a very stimulating discussion on different things (more about this in another post) with some very conscious people over dinner, I was heading back home when there was a posse of traffic cops on the left side of the road arbitrarily stopping vehicles and doing some checking.

You see this happening quite often in Hyderabad these days. A group of traffic cops on one side. The junior guys stopping vehicles at random and checking on things like seat belts, license, registration book etc. The senior guys standing a little distance away leaning against their vehicles writing out the 'challans'. They pick on a spot and then set collection targets - over the table and under the table!

I myself have been accosted quite a few times recently for not wearing my seat belt. Which might be a good thing. I usually pay a fine and leave. Some of the more brazen cops suggest that I can hand them a hundred bucks and I will not have to pay an official fine. I have guiltily acquiesced on more than one occasion. Well, I have my shortcomings.

So yesterday, one of them standing right in the middle of the road signaled me to pull over. I did. He came up to me and came so close to my mouth while asking, "Alcohol piye?" that I thought he had an inbuilt breath detector that could guage the level of alcohol in my breath. "Nahin", I answered.

"License?" I opened my dashboard and started sifting through the innumerable papers in there. I was certain I would not have it. I almost gave up hope when suddenly the red colored bound license caught my eye and I hurriedly pulled it out and showed it to him.

"Ye aapka hai?" What kind of a question was that? "Haan mera hai." He was probably surprised to see my license because it was one of those old non digital licenses, the ones that are the size of an A4 paper and have all the details written manually in the worst possible handwriting. Not the swanky new ones which are the size of a credit card.

"RC?" The cop was now getting agitated. He was trying everything to get his hands on a hundred rupee note or maybe more.

I had gained in confidence by then. I found the RC in a second and gave it to him.

"Oh 2004 ka registration hai?" he exclaimed as if he was surprised that he had actually found a car registered in 2004. How could a car be possibly registered in 2004? That was the tone of his voice. I said "Haan, kyon?" He shook his head in response.

By now, he could sense that I was winning the battle. He then took out what he thought was his trump card. "Pollution?", he said with a smug look on his face. I could almost hear him say to himself, "Got him finally".

"Not so soon buddy", I almost blurted out. Without a word, I pointed to the green pollution certificate on the back of my rear view mirror. I was totally covered.

"Ok" the cop sighed, the feeling of defeat engulfing him totally. He signaled me to carry on.

I never felt as good as I did when I drove away from the place.

Monday, November 3, 2008

How do you determine the exact weight gain?

I'm on nocturnal home hemodialysis. So I start my dialysis usually immediately or shortly after dinner. This means that my weight just before dialysis will always show a little more than what it actually is. This makes it very difficult to know what exactly has been my fluid weight gain between two treatments.

The extra weight that shows up because of the food you just ate is never constant. It depends on what you ate and how much and there is no way to tell the exact amount.

So, you never know how much fluid you need to pull of during a dialysis session.

For example, a few days back, my closing weight after a session was 78 kgs. At night, just before my next dialysis session, my weight was 81 kgs. But I had just had dinner. I usually remove 1 kg to account for dinner. So, I assumed my actual weight was 80 kgs. So, I set the ultrafiltration amount to 2.5 liters (to account for the 500 ml of water that I usually consume during dialysis). So, in effect the nett fluid removal would be 2 kgs.

But, in reality it is never so straightforward. The 1 kg that I assumed is the tricky part. It is very difficult to guage the exact amount.

Yesterday for instance, I assumed the 1 kg and ended up pulling off a lot more fluid. The first half of the day I felt like someone had squeezed me and put me up on a line with hangers to dry. I felt giddy, weak and totally drained. I had to drink a glass of fresh lime water and another glass of Thums Up to even begin to feel better.

Now that's the good part of getting too dry! You get to drink a lot of fluid!

I really wish there was a mechanism to measure the exact amount of extra fluid in the body that was not dependent on the weight. Maybe like measruingt he density of the blood? That should be fairly simple to integrate into the dialysis machine itself. But then, that wouldn't account for the extra fluid in the tissues which could be a significant portion.

Solutions, anybody?

Friday, October 31, 2008

My experience with buttonholes

The buttonhole method is widely acclaimed as 'the thing' for daily dialysis whether short or nocturnal. The needles that are used generally for dialysis have sharp ends so that they can make their way through the tissue and reach the artery or the vein.

The downside to using them is that there is pain during insertion and often during dialysis because of the sharp ends. A little Xylocaine is often used to reduce the pain. Also, a different pair of sites for the arterial and the venous accesses is used for each dialysis session. This is called the step ladder method.

In the buttonhole method, blunt needles are used instead. For the first 4 or 5 days, sharp needles are used at the same pair of sites. This makes a 'tunnel' at the two sites. From the next day, blunt needles are used. Since there is already a tunnel in place, the blunt needles go in easily and you don't actually need sharps.

This is less painful and also safer since if you're dialysing at night, like I do, there is a possibility of moving your arms and sometimes the needles may move so much that if they have sharp ends, they might actually pierce the walls of the artery or vein and cause bleeding. This is rare, of course, but nevertheless, a possibility.

I started using buttonholes a little less than three years back. To start with, things were really excellent. At that time, the tech who initiated my dialysis would do the cannulation. There was absolutely no pain. I remember making a comment to my vascular surgeon, Dr. P. C. Gupta that if I turned the other way while the tech was doing the cannulation, I wouldn't even know when the needle was inserted!

After a few months however, there was pain during cannulation. I had to start using Xylocaine. But I noticed that after using Xylocaine for a couple of weeks, I did not need to use it. But again, after a few weeks of not using it, I would need to use it!

I then changed the location of my buttonholes and found that the pain was much less. So, I am quite confused about the whole buttonhole methodology.

I have only seen one person on the home dialysis forums saying that she needed to use an anesthetic like Xylocaine inspite of using buttonholes. I was quite relieved to see that post actually because I was wondering why I seemed to have pain while others were so happy with this technique.

Each individual's body is different and what works for one may not necessarily work for another. I am still using buttonholes but I'm really wondering if I should switch to sharps. Especially since I need to get the buttonhole needles from the US. They are not available in India.

Again, I am not sure. I have used sharps only on a few occasions in the last three years. Maybe the possible risks are higher. Buttonholes have shown to improve the life of a fistula. I don't want to take any chances. So, maybe I will continue to use them for some more time.

Wednesday, October 29, 2008

The alternate medicine hoax

A large number of alternate medications are available these days for every medical condition imaginable. Practitioners claim to have prevention and cures for things ranging from cancer to AIDS to chikungunya. How true are these claims?

The biggest problem is that the entire alternate medicine industry is not regulated. So, you can actually be selling plain water and claim that it can cure cancer and nobody can touch you. A large number of gullible people are taken in by these claims and spend fortunes on these medicines with no results.

Medical problems are such that you like to take a shot at anything that has some hope of solving your problem. Especially chronic problems. There are many conditions for which modern medicine only has supportive treatment. There are no cures available. These are usually the conditions which these alternate therapies claim to cure.

Allopathic medicine (a term not used by allopathic practitioners) or the regular stream of medicine which is widely used and practiced is governed by stringent rules, approvals and peer reviews that make it very difficult for false claims to be made. This is not the case in most alternate streams of medicine.

I am not making the case that all these alternate streams of medicine are hoaxes. But I definitely believe that most are. Without regulation, they take innocent people for a ride.

It is not only the financial aspect that bothers me. Take a person who is afflicted with a chronic disease. He will clutch at every straw that is available. When he comes across an alternate therapy that people claim can cure his condition, his hopes are raised. He follows the strict diet regimen that usually accompanies these therapies and he starts dreaming of a 'normal' future. Only, within a few weeks his hopes start dwindling. Just like the last thing he had tried a few months back.

The mental aspect of this can only be understood by someone who has gone through this.

The general public is usually more sympathetic towards practitioners of alternate therapies. The methods are never questioned. The educational background of the 'doctors' is never verified. Most 'doctors' are anyway not qualified to treat patients. The treatment they give is also not backed by any formal education in the subject.

Most people decide to try these therapies based on hearsay. 'Someone became totally ok after just two weeks of that treatment'. That sentence is enough for them to go rushing to the 'doctor' to try out the same treatment.

It is entirely possible that alternate therapies like Ayurveda or Unani medicine might actually have some benefits in certain diseases. Even yoga could help in some cases. But the claims which are made these days by quacks without any basis needs to be checked immediately.

Then there are things like Reiki, Pranic healing, faith healing and similar crap. These people claim to cure chronic diseases. Like fuck they will. By putting their hands on my stomach or by moving their hands in the air, do they really think they are going to get my kidneys to start working? Am I an imbecile?

Regulation is really, really required. This is an area where government is required. Arrest people making such claims. Advertise against these people. Educate people and prevent them from falling prey to such unholy practices. This really must stop.

Tuesday, October 28, 2008

In search of the perfect Diwali mithai

Diwali is often synonymous with eating sweets. This is a time when everyone is exchanging 'mithai dabbas'. Even if you just taste a bite of everything that comes home, you would have put on quite a few extra kilos by the end of the season!

Very often, the sweets that are gifted are made of dry fruits like almond, cashew and pista. They come in a gamut of designs and colors. But the taste is pretty much the same. After eating a few of these, the novelty wears off. You get tired of the taste.

This is however not true of the sweets traditionally made at home. Take the 'mohanthaal' for example. It is a traditional Gujarati sweet usually not available in sweet shops. Made with 'khova', wheat flour, ghee, sugar and broken almonds, the 'mohanthaal' is an all time favorite. You can eat it for days and yet not tire of it. A good 'mohanthaal' is soft and coarse and has just the right amount of sugar.
Another favorite is the 'ghughra'. The 'ghughra' is basically a layer of wheat dough filled with either a coconut or a 'khova' based stuffing , rolled over and deep fried. The 'ghughra' is also rarely available in shops and is usually made only at home.
There is something about homemade sweets that is missing in sweets that are bought from shops. You can eat much more of the homemade stuff than you can of the stuff bought from shops.

One problem of Diwali though is the amount of fried stuff you eat. Everything that is made is usually deep fried! For example, the 'pakvan' which is wheat dough arranged in layers with some ghee to hold the layers together and then deep fried in ghee. Even while writing that sentence, I put on about a kilogram! You can imagine what would happen if you actually ate a 'pakvan'.

But I guess its all right. This is one time of the year when it is ok to indulge. I guess I will make it up by a few extra rounds of swimming.

Happy Diwali!

Monday, October 27, 2008

Teaching kids about religion

"Religion should never be forced on children", I have heard this quite a few times. I totally agree. Never force kids to accept your religion. Never force them to perform rituals or visit the place of worship etc. But does that mean you don't teach them about religion? I don't think so.

Children are like a piece of white paper. The first few strokes on that piece of paper are always drawn by the parents. They dictate to a large extent what the painting is going to eventually look like.

I believe that parents need to teach their kids about religion like they teach them so many other things. Parents don't say they're not going to force their kids to go to school, do they? They make sure they go. Similarly, parents should make sure their kids are exposed to the religion they're following.

This should be done till a point the child is big enough to decide on things for himself or herself. At this point, let the child make the call on religion too. But let the parents not make this call so early in the child's life that he or she does not even know about the option so that a decision can be made later in life. By teaching kids about religion, the child is given a choice on whether to follow it or not. It is too unrealistic to expect the child to discover religion without any such exposure.

Religion often offers a way of experiencing peace. However unscientific it may be, it gives a means to achieve 'closure' on many of life's problems. We don't have to prove or disprove anything as long as it gives us peace of mind. Spending time in a temple or with a 'sadhu' often gives us respite from the daily grind.

This opportunity should be given to a child. Parents should not snatch this away forever from a child's life. Teach them about religion. But don't force them once they're big enough. That, I believe should be the mantra.

Wednesday, October 22, 2008

Abhishek Bachchan dances to Appadi Pode Pode

Have you heard the song Appadi Pode Pode? Its an awesome song. The beat is just too good. And in the most trying of circumstances it will have you sway your head with the rhythm.

And there is an ad featuring Abhishek Bachchan where he dances to this song in the bathroom. The ad is also hilarious. It was taken off air for some reason only a few times after it was shown. I would really like to know why. However, there is a video on You Tube that has the ad. Here it is:

Tuesday, October 21, 2008

Custom ringtones on the iPhone - solution, well, sort of

I had posted about the problems I've had with creating custom ringtones on my iPhone. Aditya suggested trying out iPhone Ringtone Maker.

After downloading the Mac version, I had a few problems that were fixed after I wrote to their support. I tried creating a couple of ringtones. They were much better than the ones made by GarageBand.

They were not what I would have liked, however. The quality is still not 'perfect' - something you would expect from Apple. But it is vokay.

I went ahead and bought the full blown version yesterday - not bad at $7.50.

Monday, October 20, 2008

In search of the perfect Khubani ka meetha

No true Hyderabadi meal is complete without the Khubani ka meetha. The taste of this dish is quintessential Hyderabad. If the Charminar had a taste, it would be this!

The basic ingredients are dried apricots and sugar. The apricots are soaked for five to six hours in water and then blended. Sugar is added and the mix is cooked slowly over fire till the apricots turn dark brown.

The apricots have seeds which when broken reveal an edible nut that is used to garnish the meetha. A spoonful of cream is often added as a topping.

Some people add a scoop of vanilla ice cream to the meetha. This is nothing but sacrilege! The pure flavor of the meetha should never be spoilt by having it with ice cream. The best way of course, is to have it plain. Cream, if you wish. Never ice cream.

I stay in Hyderabad and have a really good choice of places to taste the Khubani ka meetha. Quite a few restaurants serve it. Utsav in Secunderabad really makes good Khubani ka meetha. The Parivar Dhaba close to the zoo also makes really good Khubani ka meetha.

But the best place to try the meetha is a muslim wedding. You get the dish prepared by some of the most experienced chefs in the city. You sometimes wonder what could be different with such a simple recipe? Don't wonder. Try it. There is something in the hands of these chefs that adds that element of magic.

Especially to things like the Khubani ka meetha.

Friday, October 17, 2008

Of roads and cheeks

Lalu Prasad Yadav is known for his rustic humour. Recently he became more famous for turning the Indian Railways around. So much so that he was invited to one of the IIMs to do a guest lecture!

Many years back, however, when Lalu became the Chief Minister of Bihar for the first time, one of things he promised was that he would make the roads of Patna as smooth as Hema Malini's cheeks!

The roads of Patna never even came close to the cheeks above.

Down south, roads have been a constant problem in many of the state capitals. Hyderabad, however, boasted of really good roads during the reign of Chandrababu Naidu. A friend traveling by bus from Hyderabad to Bangalore once commented that he could tell when the bus had crossed over at the border from Andhra Pradesh to Karnataka. The bus ride would suddenly become extremely bumpy!

After the change in the government and especially in the last few months, the roads of Hyderabad have deteriorated terribly. The rains have totally spoilt most of the roads in the city. In fact, they now remind me of a set of cheeks too - that of actor Om Puri! Sample this: (with apologies to the great actor!)

Thursday, October 16, 2008

My home hemo journey - Epilogue

The best part about nocturnal daily home hemo is that there are no dietary and fluid restrictions. Since you are getting 7 to 8 hours of dialysis, you can remove a lot more. 3.2 kgs should be very comfortable. Because that is what the body can easily tolerate. Not many people can drink more than that in about 16 hours.

16 hours - that’s the time you are not on dialysis. So, however much you try, you cannot build up too much fluid and toxins that can make you feel bad.

I have felt 100 times better than what I did when I was on hospital dialysis. There are no ‘crashes’ because there is no rapid fluid removal. My energy levels are much better. I am back to work full time. And I put in about 8 to 10 hours of productive work every day.

I go for a swim every morning and do 10 lengths. That’s the best part of my day. This was something I missed when I was on PD too. I am so glad I am able to swim now.

My hemoglobin has drastically improved. My need for erythropoetin has reduced. I had left ventricular dysfunction before I was on daily dialysis. That has improved considerably and my cardiologist was pleasantly surprised to note this and was thinking it was due to the daily dialysis. He hadn’t seen this at all in his entire career!

I would say I sleep about 80% on weekdays when I am on dialysis compared to perfect sleep on Sundays when I am not on dialysis. But its not bad at all. I feel completely rested.

Travel is an issue. Now that I am doing daily nocturnal, I completely abhor regular 4 hour sessions. So, when I travel, I cannot dialyze. That restricts travel plans to being away from home for a maximum of two nights. Well, theoretically I can be away for more nights but I will need to do one or more regular hospital dialysis sessions when I am away. I don’t like these sessions at all. And I doubt if hospitals and dialysis centers will allow me to dialyze the whole night. So, currently I am limited to 2 night vacations.

Overall, my life has improved dramatically. No one can say I am unwell without actually knowing about my medical condition (except of course if they happen to see my fistula which can give nightmares to kids!).

This has been entirely due to nocturnal home hemodialysis. I must really thank my nephrologist, Dr. Girish Narayen who advised me and encouraged me to try this when so few (maybe no one else?) people were on this modality in India.

Wednesday, October 15, 2008

My home hemo journey - Part 4

Its been more than two years since I started nocturnal home hemodialysis.

I have come a long way indeed.

I slowly started learning the ropes. At first I just learned how to mix the bicarbonate solution that is used in conjunction with the acid solution that forms the dialysate. This was a piece of cake. You just needed to get the proportions right. Then I learned how to prime the dialyser and tubing before dialysis. This was not rocket science either. For a long time, I used to prepare the bicarb solution and finish the priming before the tech came and he would come and do the cannulation and start dialysis.

I read on the internet that the best thing a dialyzor can do is to cannulate himself. This offers a great advantage. You can actually feel the needles in you so you know exactly how to put them in. So, gradually I gathered the courage to do this. And within a few days I was cannulating myself! This was a great leap for me.

I then also learned to start the whole dialysis myself. Preparation of the bicarb solution, priming, cannulation and then starting dialysis by actually connecting the tubes to the needles and starting. This was great.

From the last month or so, I start off and am into an hour or more of dialysis before the tech comes. He is pleasantly surprised.

The toughest part about starting dialysis is putting the tapes on the needles after cannulation. You have only one hand to do this since the other arm is what you are working on! But I manage somehow.

This is a little risky however since there could be an emergency which I may not know how to deal with. I need to read up on this. But I do it inspite of this because I love the independence this offers. I can start dialysis whenever I want and not have to wait for the tech.


Tuesday, October 14, 2008

My home hemo journey - Part 3

I did some research about the dialysis machine and the RO plant, the two main pieces of equipment required for home hemodialysis.

The best option would have been a portable hemodialysis machine, something akin to the NxStage System One that many people used in the US with great results. I for one, love to travel. And travel would be restricted to short weekend trips with hemodialysis. But the NxStage machine was not yet allowed to be sold outside the US. Moreover, even if I bought it there and brought it here, servicing and repair would be an issue.

So, I decided to go with the Fresenius 4008 S, a sturdy machine used widely in India. I also bought an Ion Exchange RO 100 liter/hour plant. The hemodialysis machine was setup in my bedroom. The RO plant in the terrace of my two storey house. The necessary electrical and plumbing work was done. An RO water connection was given to my bedroom for the HD machine and in my bathroom for the cleaning of the tubes and dialyser after dialysis.

Everything was finally ready by May 13th, 2006.

I decided to go for short daily to start with and then when things settled down to switch to nocturnal.

My first short daily session was good. The tech did everything. I dialysed in the evening for two hours. I continued short daily (except Sundays) for about 20 days. I then thought things were going well enough for us to switch to nocturnal.

The tech would come in around 10 in the night. He would start me off and he would sleep in the same room to take care of any alarms and any other problems that came up. I slept fairly well.

There were hardly any alarms from the machine. Most of them needed a ‘Reset’ button press to take care of.

There were however some other problems. Sometimes, blood would ooze from my arterial and venous sites. The tech was very well equipped to handle these emergencies. These incidents were due to my moving my hands in my sleep that would cause the needles to move around and cause the oozing. We then decided to tie my finger in a manner that would allow some movement of my arm but not enough to cause any oozing.

Once we did this, the oozing stopped completely.

One important thing we did was to use the buttonhole technique. You can find a lot of information on the buttonhole technique on the internet. But in this technique, the regular sharp needles are used for four to five days in a row. Cannulation is done at exactly the same sites (as opposed to the step ladder method) and the same angle. This causes a tunnel to develop. Once this tunnel has developed, we switch to blunt needles. And then cannulate at the same sites using the blunt needles everyday.

This helps in two ways. One - the pain during cannulation is reduced greatly. Two - the needles cannot puncture through the artery and vein in case the arm is moved too much and this protects against bleeding etc.

Part 4

Monday, October 13, 2008

My home hemo journey - Part 2

Dr. Girish Narayen, my nephrologist suggested I try daily home hemodialysis. I started looking it up on the internet. I found a lot of positive comments about this. I started digging deeper.

I could not find any references of daily home hemodialysis being done in India. However, I did find out that there were a very small number of people doing dialysis at home. But only the regular twice or thrice a week sessions.

Also, in the US, apparently, there is an entire infrastructure set up to manage emergencies. In fact, some centers also have online monitoring of the dialysis treatment performed at home.

Here, in India, of course, no such infrastructure is present. That was one of the risks. But I thought I could get a dialysis technician to come home and do the treatment for me. The dialysis technician at the hospital I was undergoing dialysis in was very good at his work.

I thought this through completely. I thought about the pros and cons. I had to rely a lot on the posts in mailing lists and forums on the internet. It was abundantly clear that daily nocturnal dialysis - 7-8 hours every night, 6 to 7 nights a week offered the best outcomes in terms of well being, longevity, minimizing co-morbidities (side effects of kidney disease like heart conditions etc.). The next best was short daily dialysis (2-4 hours every day, 6 to 7 days a week). The worst was the 4 hours thrice a week regimen.

There was no one I could contact who was doing daily dialysis in India. So, I could not get first hand, the experience of the Indian situation. This was quite unnerving.

I was clear about one thing though. I did not want to continue the way I was. I could not tolerate this at all. I needed a better life.

I decided to go for it.

Part 3

Sunday, October 12, 2008

My home hemo journey - Part 1

(Cross posted from Home Hemo training in India)

After the tsunami, in less than a year I was off PD and back on hemo in the hospital. I hated hemo in the hospital. Here's why.

Hemodialysis in a hospital is done twice or thrice a week and for each time between three and five hours. Compare this with the functioning of a kidney. A kidney functions seven days a week and 24 hours every day! So, this kind of dialysis is woefully inadequate.

Because of this intermittent cleansing of the blood, dialyzors (I prefer this term to ‘patients’) undergo a yo-yo effect. Continuous ups and downs. Once a dialysis session is done, your blood is somewhat clean and the excess fluid is removed. But until the next dialysis session, life is a constant struggle. Drink less water. Watch your potassium. Don’t have too much fruit.

The energy levels are horrible. After a dialysis session, dialyzors feel a ‘crash’. This is a term loosely used to describe the horrible feeling after dialysis. You feel weak, tired, listless. Completely drained. I could not do anything after dialysis. I had to go and crash on the bed and doze off.

I had a full time job during this period. But I could not do much. I spent less hours at work. Even when I was there, I would not feel like doing much. It was really terrible.

I am that kind of a person who does exactly what he is advised not to. I guess many of us are like that. If the doctor restricts our fluid intake, fluids are all we want to have. I suddenly started craving fruits and liquids like crazy.

My weight gain between treatments would be a minimum of 4 kgs. Removing 4 kgs in a span of 4 hours can be pretty taxing on the body. The maximum rate of removal of water from the body that can be tolerated by us is 400 ml/hour. There are a number of sites which explain this in more detail. But when you’re removing water at the rate of 1 kg/hour, it can be very bad. The ‘crash’ after dialysis is chiefly due to this.

I understand doctors asking us to limit our fluids. But believe me, dear doctors, this is not something we’re doing intentionally. This is all about human nature. The human mind craves what it is forbidden. Please, please try this out yourself. Just for the heck of it. Just so that you understand what your patients are going through. For a week, restrict your fluids to a liter a day. And then see what happens. Don’t even undergo dialysis. Don’t even restrict your fruits and other things that we need to restrict. Just try the fluid restriction for a week. Let me know how it goes.

The dialysis process itself was horrible. Lying down in the bed for 4 hours without having anything to do can be very frustrating. With every passing minute, you feel worse because fluid is being removed at such a high rate. All around, you see people feeling miserable. The whole experience can be quite distressing.

I would be lucky if I got an hour or two of sleep. And the rest of the time would be just waiting for the whole damn thing to finish. Continuous looks at the watch. Time would move so slowly, it was almost as if the whole world has slowed down.

And I had to go through this torture just to be able to live. What kind of a life was this? Is this kind of a life really worth living?

There is a fellow dialyzor in the US called Stacy (without an ‘e’). He described it very beautifully when he said that dialysis had killed a part of his soul. This is so true. That is exactly what I felt.

Part 2