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.