Wednesday, October 11, 2017

What does happiness actually mean?

All of us want to be happy. What does it mean to be truly happy? What does it take to be truly happy?

I read this excellent article that talks about the work in this area by Emily Esfahani Smith. She has also done a TED Talk on the same topic. 

This article made a lot of sense to me when I look back upon my life and see the effect of the four factors that she talks about - belonging, transcendence, purpose and story telling.

Monday, October 9, 2017

Dialysis Olympiad Bike Expedition - Doing more with Dialysis kicks off today

We at NephroPlus are organising the second edition of the Dialysis Olympiad on October 29th in Delhi. The event is going to be held at the Thyagaraj Sports Complex. After the stupendous success of this event in 2015 at Hyderabad, the event moves to the Indian capital and enables a lot more patients from the North of the country to participate as well.

As a curtain raiser for the event, a one-of-its-kind bike expedition is being kicked off today from Jalandhar, Punjab where a number of people on dialysis will be participating in a 400 km bike relay to Delhi over four days. This expedition will halt at various towns and cities on the way.

This bike expedition and the Olympiad are in line with our overarching vision to enable those on dialysis to lead a normal life. We strongly believe that dialysis need not prevent you from living a full life. People on dialysis all over the world do things that otherwise healthy people do like work, travel, exercise and have fun. In India however, there is a huge misconception that dialysis is like a death sentence and people are confined to the bed or have to lead sedentary lives. 

Events like this help tremendously to change this thinking and get the patient, the family and indeed, the public at large to understand that dialysis need not stop you from doing what you would like to do. People on dialysis can and should lead normal lives!

Sunday, October 8, 2017

After twenty years, a new home

My parents, brother and I moved into our own house a little more than twenty years ago. We had built that house from scratch. That house has seen many major events in our lives. My graduation, my diagnosis with kidney disease, my brother Prasan’s marriage and my brother Karan going abroad. It also saw the birth of Effigent, the sale of Effigent and the birth of NephroPlus.

However, if you looked at how the twin cities of Hyderabad and Secunderabad were changing, you would be naive not to see that all the development is happening on the side of the newer - Hi-tech city. My primary barometer to judge the development of the city is to see where all the new restaurants were opening. Over the last few years, most of the good restaurants have wound up in the older twin cities and moved to the Hi-tech city area.

So, we’ve been thinking of moving to that side of town for a long time now and have been scouring the area for good apartments. Finally we zeroed in on one and here we are - in our new home!

Our apartment is on the 28th floor and the height offers a beautiful view of the city. I love to sip my tea every morning from the balcony that overlooks the city. Here is a picture I took one morning from the balcony:

 I love our new home. Many people ask me why we moved from an independent house to an apartment? The answer is simple. Our old house was too big for just the three of us. It was difficult for us, especially my mother to maintain it well. Added to that was the fact that the area we moved to was developing more rapidly than the old area. Staying in an apartment also offers some other conveniences - amenities such as a swimming pool and a gymnasium in the apartment complex itself, a store and maintenance personnel on call 24X7 etc. All this is just not there in the old house.

We are going to keep the old house for a while until we’re sure we like it here though!

Friday, October 6, 2017

A scare, then a Transesophageal Echocardiogram clears the air

So, my fistula infection has shown no signs of relenting. Even though there is no fever, there is a persistent ooze from the infected puncture site. There is no collection in the area that warrants surgical intervention. Then from where the hell is this oozing?

Protocol demands an echocardiogram to rule out Infective Endocarditis. This is common in dialysis patients. So, I went and got an Echocardiogram done.  It was not without drama. The cardiologist happens to be a senior doctor and he first went through the motions and declared that there was nothing to worry. As I was getting up, he exclaimed, “Just lie down again. I want to check something else.” I lay down and he put the probe on my chest and then a little lower and as if he had found something unusual, said, “What is this?”

For the next 5-7 minutes he put the probe in various positions and at various angles and tried to make sense of something. In the end he said he could see something that looked like ‘vegetation’ - a term for infection but he wasn’t sure and advised getting a Transesophageal Echocardiogram (TEE) or a PET-CT scan to get a better view of the ‘thing’!

I took the report to my Nephrologist and he asked me to meet another cardiologist and get a TEE done. 

The internet can be an amazing source of information. It is impossible to hide anything from someone who has access to the internet. The article I linked to above had a scary statistic - a 65% 1 year mortality of HD patients who got Infective Endocarditis (IE). I started fearing the worst. As I usually do, I started imagining life with IE. I started thinking about a preparing a will, about work, about my parents.
Today was the day of the TEE. I was asked to have a light breakfast before 7 am and no food or water after that. I had what I would call a heavy breakfast at 6:45 am. Believe me, my ‘heavy breakfast’ is very different from what you would call a ‘heavy breakfast’! I wouldn’t have it any other way as I knew my body better than anyone else and there was no way I would be able to withstand ‘no food, no water’ without a heavy breakfast. I took a nap after that and by around 11:30 we were at the hospital. 

After the customary explanation about the procedure and billing for the test, they sprayed some anaesthetic into my throat that numbed the walls. They then inserted a thick tube coated with anaesthetic jelly. The first few moments were very uncomfortable as the tube was pushed down my throat. But once it was in, it wasn’t bad at all. The doctor looked at the images being generated on the screen. After about ten minutes, they concluded that there was no infection!

I was a relieved man. I would have had a tough time being on the 35% bucket of the post IE mortality statistic!

Now that still leaves the question, “What is causing the freakin’ ooze?” unanswered. I met my nephrologist with the report of the TEE. He said let us stop all antibiotics and wait and watch. The risk of long term antibiotic usage is a fungal infection. Don’t ask me how and why!

So, for now, I have been asked to stop the antibiotics (after almost two months of taking them) and wait.

Saturday, September 23, 2017

An unending fistula infection

In the middle of August, I contracted an infection in my fistula. I have had a few in the past. All of them however would clear with a few days of antibiotics, typically Amoxyclav. This time however, I have been on a variety of antibiotics for the last almost six weeks and though the infection has reduced, it has not gone completely. There is a still a persistent, small amount of discharge of blood from the infected site. I am now on what they call, a maintenance dose of an antibiotic.

I use buttonhole needles and the buttonhole technique has been associated with an increased risk of infection. Earlier I used to have an infection almost every year. But ever since I have followed the double prep method of cannulation, I have managed to keep infections at bay. WEhn the infection came however, it made up for all the missed instances.

If you asked me to move away from buttonhole to the regular, sharp method of cannulation, I would refuse. The advantages of buttonholing for me are far too great to give it up, at least for now. The reduced pain, the ability to avoid aneurysms, the zero risk of cross punctures - all make buttonholing a risk worth taking.

The downside of an infected fistula is that you cannot shower freely as you need to protect the infected site from water. And of course, swimming is on hold! That’s something I miss a lot. Now that winter will set in soon in Hyderabad, I am not sure how long I will be away from swimming.

For now though, all I am hoping is for the infection to go away completely. I am not really sure what side effects such a long duration of antibiotics could  cause.

Saturday, September 2, 2017

A life on the cloud

I was always someone who had everything on his laptop. Email and files would all be on my laptop at all times. I took backups using Apple’s Time Machine and had another Carbon Copy Cloner copy. I used to take two backups almost daily! 

The reason for this was that I used POP for my email and I had set it up so that my mail client (Apple Mail) would delete the copy of the email from the server. If anything happened to my laptop which caused me to lose my data, I would be stranded without my email forever! 

I had this bad experience at one point when both my hard disks crashed and the only copy of all my mail and files was on my laptop. I became paranoid after this incident.

Recently, I decided to put an end to this dependency on hard disks once and for all. I painstakingly moved all my email to IMAP. I had to create folders in the IMAP account and then drag and drop email from the corresponding POP folder to the IMAP folder. This was the worst part of the entire exercise.

Then came the files. I already had a Dropbox Plus account which gave me 1 TB of data storage on the cloud. I wasn’t using this enough. I took the big decision of moving all my files to Dropbox. I first spent some time cleaning up my files on the laptop. I removed a lot of files that were just lying there without being loved for years. I moved all of them to Trash. I also structured my folders better. Then, I finally moved everything to Dropbox from the laptop. 

There, I was done!

I recently moved to an iPad Pro 10.5” as my primary work computer. To get it all setup, I simply had to setup my Gmail account and my Dropbox account and then in Dropbox, I had to set all my files to “Make Available Offline”. Once this was completed, I was all set.

There are many advantages to this. I can practically work from any computer. I am not tied down to using my own. Even if my iPad goes down, I would not lose a single email or file. The only downside to this is the availability of the internet to sync. But this is not needed all the time since I always have the most recent copy on my iPad. Changes would get synced when the connectivity was restored.

I think moving to the cloud is a great change from the way I used to work. It is very efficient and safe. I don’t have to ever worry about losing any data or taking backups. A life on the cloud is a good thing!

Wednesday, August 9, 2017

Fresenius acquires NxStage: what this means for those who want Home HD in India

In a surprise press release, Fresenius Medical Corporation announced the acquisition of NxStage, the company that produces the world’s only portable hemodialysis machine. I just wrote about NxStage completing ten years a couple of days back.

This acquisition could be good news for patients in India looking to have access to home hemo infrastructure. Why did NxStage not come to India? As I said in my last blog post, this was primarily due to the lack of a large number of patients who would be able to afford a machine like the System One and more importantly the per-session cost of the consumables.

How can that change with Fresenius coming in? Fresenius already has a well-established presence in the country. They are the country’s largest dialysis machine suppliers and they have a decent penetration when it comes to consumables for dialysis as well. Add to that their solid service infrastructure which consists of well-trained engineers and you have an end-to-end dialysis solution. The Fresenius team can theoretically make the NxStage machines available pretty soon in the country. They would need to figure out a way to manufacture the NxStage specific consumables at a lower cost. They can easily get their Indian engineers trained in the NxStage machine. All this would actually make it possible for Indian patients to get access to the NxStage machine!

However, all this is assuming that Fresenius would want to bring the machine to India. That is quite a big assumption. It is rarely the case that patients like me can gauge the real reasons for these multi-billion dollar acquisitions! We might never get to know the real reasons behind the acquisitions. Press notes are drafted to make the right noises. People might make guesses about the real motive. However, no one apart from the people right at the top would know the real reasons.

Anyway, I am strongly hoping that Fresenius will find a way to bring the machine to India and will want to do so. The large population here does have people who will want the convenience it offers. So, to those Indians on dialysis who want better options: don’t lose hope yet!

Sunday, August 6, 2017

NxStage System One completes ten years, no signs of coming to India

The revolutionary portable dialysis machine that has enabled home hemodialysis for many patients in the US has completed ten years. More than a hundred patients recently celebrated their ten year anniversary with the machine. Despite criticisms of the machine by renowned experts especially with regard to the high blood flow rates (necessitated by the low use of dialysate to make it portable), this machine has really changed life for many. 

When you think about it, though home hemo in itself is a huge life-changer, the added convenience of a portable hemodialysis machine takes this freedom achieved due to home hemo to a whole new level. 

For me personally, the inability to travel without the shackles of a fluid and diet restriction is a major killjoy. Who wants to have these sickening restrictions on a vacation? In fact, when you’re used to not having any restrictions at home, having them on a vacation actually makes the outing sometimes feel torturous!

The fact that not one company has been able to come out with an alternative to the System One is quite astounding. Ten years is a long time. Though there are many companies that have a machine in the works, not one has been able to hit the market. 

And what keeps the System One from India? Are we more than ten years behind the US? This is a really sorry state of affairs. I complain about the lack of Soliris to enable me to have a kidney transplant. I have stated in the past that I will stop complaining; just give me the NxStage machine!

Saturday, August 5, 2017

Watching streaming video

I recently got myself an Amazon Fire Stick. It is a very simple device that plugs into the HDMI port in your television and connects to a power socket. Using Wifi and various apps available for it, it can stream a lot of content from around the world.

I have watched a lot of stuff since I got the device - House of Cards, Silicon Valley, Inside Edge, The Crown. Its an amazing device with the simplicity of any Apple product. 

I remember reading about television content that you could watch at your own convenience long, long back in a book. To me, at that time it seemed almost impossible. And here I am actually using such a device. The pace at which technology is progressing is almost mind-numbing. I recently was told about a blog called Wait, but why? In it the author writes some really amazing stuff about how technology is changing our world and the rapid pace at which this is happening. I am going to write a complete post about that some other day.

Back to five nights a week

I have been dialysing for six nights a week for a long time now. I did dabble with various other routines and settled on six nights a week. That worked well for me. For the last year or so. I have been having Carpal Tunnel Syndrome which did not allow me to sleep beyond very early in the morning and I would get up with severe numbness in my left hand. Strangely, on dialysis nights, I could sleep up to 5 am. So, it kind of made sense for me to do dialysis on more nights!

Recently, I got operated for  Carpal Tunnel Syndrome on my left hand and my right hand is getting better with a device under clinical trial. So I am able to sleep till longer. I thought recently that I should try to do five nights instead of six nights and see how it goes. I have been doing that for the last two weeks and find it going quite well. I will be continuing this for some time now.

What, you might wonder, do I like about my nights off-dialysis? Well, who likes to dialyze? Who likes their fingers to be tied with a string to prevent the hand from moving too much in the night so that the needles don’t come off? Who likes needles in their arm, isn’t the first place? Not me! I also like the fact that I am alone in my room. I feel free. Honestly, it is difficult to describe.

I have been putting on less fluid weight recently and that has helped to make this decision. If I know me well enough, the less fluid weight gain is not going to last long. In that case, I will switch back to six nights a week. That is the whole damn advantage of home hemo. You can choose when to dialyse and when not to. You can choose when to start your session and when to end it. You can dictate your treatment without worrying about schedules, about timings, about so many other things. I am so grateful that I have access to this wonderful modality. I so wish many others could do this as well!

Sunday, July 30, 2017

“God doesn't exist. But don't tell that to my servant...”

“God doesn't exist. But don't tell that to my servant because I am afraid he might kill me while I sleep.” - Voltaire

I came across this quote in the book Sapiens by Yuval Noah Harari. It struck me as really profound. The concept of God was probably created to bring some kind of order to society. Think about it. Do you think a majority of the people who do not have the fear of divine punishment would stay away from things we consider ‘wrong’? Granted, there are some people who would not do ‘wrong’ because it is ‘wrong’. But how many such people are there? My thinking is that a vast majority of human beings, sapiens if you will, don’t do ‘wrong’ because of the fear of punishment of some kind - by the law or by God.

Take away the fear of punishment and then the world would quickly descend into chaos and anarchy. People would be doing all kinds of things - murder, rapes, cheating, dacoity, you name it.

Having law was simply not enough. People would be punished only if they got caught and then there was also the burden of finding evidence to prove your guilt. There was something more powerful than law that was needed. God fitted the bill nicely.

The trouble is the concept of God relied on something called faith. You did not need evidence to prove anything. Nobody could question anything. Dogma was the order of the day. This lead to some rather unfortunate consequences: rituals and rules.

I think religion was a good thing that man made. However, the real problems began when layers kept getting added to every religion. With every generation came another layer - a layer of rituals and rules. “You should not do this”. “If you do this, this will happen”. “If you do this ritual, this can be cancelled out”. The rituals and rules became so complex and so irrational that religions today are probably completely unrecognisable when compared to their original forms. And the most important rule was “Theirs not to reason why, Theirs but to do and die.” No questions could be asked. That would be blasphemous. With this came absolute power for the clergy and unquestioned obeisance from the laity.

In the end, religion has become a monster that is being misused so badly that it completely defeated the purpose for which it was created.

Wednesday, July 26, 2017

Keeping busy is the best way to restrict fluids for those on dialysis

If you asked me what was the toughest thing about dialysis, I would say the fluid restriction. Restricting all fluids put together to a litre a day, which is the typical fluid volume most people are allowed is very difficult. Many people give different suggestions on how to limit fluids. Use a one litre water bottle and drink only out of that, squeeze a lemon in a glass of water and freeze it in an ice tray and then suck on a cube when thirsty, limit salt etc.

These options are great. However, I think the best way to restrict fluids is to keep busy. Working full time obviously, is the best option. If not full time, at least part time. If working is not an option at all, then find something productive to do that keeps your mind occupied. Everyone needs something to look forward to. In the book, ‘Being mortal’, Atul Gawande recounts how adding a vegetable patch and some pets to a home for the aged improved outcomes dramatically for all the people staying there. Everyone started looking forward to doing some work for the patch and the pets. They had something to do. They had something to look forward to.

In dialysis, apart from the mental benefits in terms of being productive, limiting the fluid intake is an added advantage. If you believe it is thirst that is causing you to drink more water, think again. This is completely a mental game. The mind is like a spoilt child. Tell it that you cannot have something and it will crave only that. If you keep it busy with something else, it will forget about what it cannot have.

Most people I know that have survived long on dialysis have been working. It need not be a regular job. It could be anything. It does not have to pay anything either. The mental benefits are far greater than anything else that you may gain from this.

Tuesday, July 25, 2017

How I fixed my non-dialysis day sleep problem

I used to relish my non-dialysis days for a long time. However, the numbness in my left hand  which was eventually diagnosed as Carpal Tunnel Syndrome did not allow me to sleep beyond 2 or 3 am. I would wake up with a severe sensation of pins and needles and pain in my left hand. I would need to massage it and shake it and then try to go back to sleep. I would be able to sleep for a short while and then the sensation would return. Around 4 am or so I would just give up and then wake up completely.

I was operated for Carpal Tunnel Syndrome in June which relieved the issue in the left hand. Strangely, the sensation began in the right hand almost immediately after the left hand was operated upon. You could argue that this looked like it was a psychological issue. Believe me, it was not. 

I was planning to watch for a while and then have the right hand operated too. However, suddenly I got to know that one of our NephroPlus partner hospitals was conducting a clinical trial on a device that cured Carpal Tunnel Syndrome without surgery. The device was invented by a German mechanical engineer who had the same issue and did not want to undergo surgery for it. I got in touch with the hospital partner and managed to get the device.

I have been using the device for two weeks now and I am happy to report that I was able to sleep through until 6:30 am this Tuesday, my non-dialysis day. Inspired, I took even yesterday (Saturday) off from dialysis and was able to sleep through till 6:20 am. I am so thrilled that it looks like this device will cure the issue for me without surgery.

I will post more details about the device here once I check with the team on whether it is ok or not.

Sunday, July 23, 2017

The secret recipe of longevity on dialysis

Recently, I completed twenty years on dialysis  In India, only a few patients complete such a long time on dialysis. I am fortunate enough to know 3-4 people who have completed a long time on dialysis.

Each one, I guess, has his or her own secret to live long on dialysis. For me, it is only one thing - get  as much dialysis as you practically can. I dialyze for 7-8 hours at night, six times a week. I can confidently say that I am alive due to this. There are many people who are on thrice weekly dialysis and have been on dialysis for longer than me. So I guess the magic recipe is different for different people.

Dr. John Agar, a nephrologist from Australia says dialysis is like love making: longer the better, gentler the better and the more frequent the better!

I couldn’t agree more.

When I tell people that I dialyse daily and that too for 7-8 hours every night, they are surprised. They ask me, “You need that much?”

Well, I don’t need that much. I choose that much.

 It is not rocket science honestly. The kidneys of a healthy human work 24 X 7 X 365. No breaks. Dialysis is simply replacing kidney function. So, it is quite obvious that the closer you to get to 24 hours a day, 7 days a week, 365 days a year, the better it is for you.

The best part of getting optimal dialysis is that it allows you to be more relaxed with the diet and fluid restrictions. I pretty much eat and drink what I want and however much I want. Since my body gets such good dialysis, I am able to swim every morning, work full time and travel quite a bit.

Yes, the long term impact of being dialysis is felt from time to time in the form of co-morbidities of various types but those are not avoidable. I manage to deal with them in different ways.

Again, I cannot emphasise enough that each individual is different. You don’t need to be on daily nocturnal dialysis to be able to live long. There are many people who’ve lived longer than I have and are on thrice weekly dialysis at the hospital. This is just my experience. 

The key, however is that the myth in India that you cannot live for long on dialysis is wrong and needs to be dispelled. Individuals can live long, happy, productive lives on dialysis. It’s only a question of how much you want it.

Friday, July 14, 2017

Twenty years with kidney disease

Today, I complete twenty years with kidney disease. Back in 1997, on this very day, I took those vaccines that triggered Atypical Hemolytic Uremic Syndrome, the ultra-rare disease that damaged my kidneys. In a matter of twenty four hours, my life had changed completely. On that day of course,  I had no clue about what was actually happening inside me. The initial symptoms were put down to side effects of the vaccines. Only when the symptoms did not abate after three more days, did we consult my family physician, Dr. Kirit Parekh who ordered some initial tests and discovered that my kidney function was affected. He then put me onto Dr. Girish Narayen, the nephrologist who treated me for a long, long time.

Update: here is a picture of me with him when I went to meet him on the twentieth anniversary of me meeting him back in 1997:

About ten years back, I started this blog and my first post was titled, “Ten years with kidney disease” and in it I had outlined the first ten years of my journey. There have been small ups and downs since then - some neurological issues, a cardiac problem (now resolved), arthritis, Carpal Tunnel Syndrome etc.

On the professional front, of course, the biggest thing that has happened is NephroPlus which has come to change my identity from ‘the guy on dialysis’ to ‘the guy on dialysis who co-founded India’s largest dialysis company’. Not bad eh? Thanks Vikram and Sandeep for this!

For the last twenty years, I feel very grateful. The entire duration has been on dialysis since my transplant did not work. Not many on dialysis have had such a journey. My parents and family have been a massive source of strength and support. Without them I would never have made it so far. Then, Dr. Girish Narayen, the man who put me on daily nocturnal home hemodialysis. I can safely say that I am alive because of this modality. I can also never forget Jayaram Reddy, the Head of the dialysis centre in KIMS Hospital. If it wasn’t for Jayaram, his expertise and and his confidence in his abilities, I would not have begun home hemo.

Where do I go from here? I swim every day, I work full time. I don’t travel as much. I would like to do some more travel. I would like to do more things I genuinely enjoy. I realise the limits of my body but would like to make the most of the coming years.

When I look back at this journey, I see one recurring theme which can aptly be summarised by these immortal lines by Robert Frost:

Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.

Tuesday, July 11, 2017

Everything we hear is an opinion, not a fact

I came across this quote on Whatsapp recently:

"Everything we hear is an opinion, not a fact. Everything we see is a perspective, not the truth."

I couldn't agree more. I did some research on whose quote this was and ironically, this quote is wrongly attributed to Marcus Aurelius all over the internet!

However, this does not take away from the truth of the statement. These days, you get to hear and read such contradictory 'facts' that you are never sure what is true and what isn't. Gone are the days when you could rely on news channels and the print media to deliver to you news, uncoloured by the opinions and leanings of anyone.

Online media has made it even worse. Here there is no pretense of being neutral either. When I browse through my Facebook / Twitter feeds, I very often see completely contradictory claims about the same fact posted by friends with differing loyalties.

People with staunch religious beliefs have an unquestioning attitude towards their religions. After reading the book, Sapiens, by Yuval Noah Harari, you realise that even those beliefs stand on shaky ground. By that same logic, you should not consider everything you read in the book Sapiens, to be factual!

When you realise that many things you have based your world-view upon could have questionable foundations, you feel quite insecure. What is true, what isn't? What is a fact, what is an opinion?

People who twist facts and then spread this alternative reality are doing a lot of harm to the collective conscience of humankind. But then, as much as we would like to believe that this is a recent phenomenon, in reality, this has been happening for a long, long time now. The trouble is the longer the so-called fact has been round, the more firmly entrenched it tends to be in people's minds and the truer it seems to be perceived as.

In the age of the internet, it is very difficult to separate fact from fiction. A few years back, as part of a harmless prank, I managed to convince a colleague that man had landed on Mars by sending him some links from the internet! When even such pages exist, there would obviously be a lot more authentic-looking stuff that would support some selfish narrative.

So, it would do us well to keep the above anonymous quote in mind and not accept everything we hear to be true.

Sunday, July 2, 2017

Health Update

I got done with my surgery for Carpal Tunnel Syndrome on the 15th of June. The surgery was uneventful. I was home before lunch the same day. In the days after the surgery, (19th of June) however, I foolishly tried to move a sofa in my house with my right leg after which I sprained my right thigh badly. I did not realise until the next day however that the pain I was having in my right thigh was due to the sprain. I put it down to the side effects of the antibiotic.

On the 20th evening, when it struck me that it had been a full day since the last dose of my antibiotic and the pain was showing no signs of relenting, I thought about it and figured that the pain could be due to the sprain that could have been caused by moving the sofa!

I went to the orthopedic doctor who did the surgery for Carpal Tunnel Syndrome and was examined by him. He concluded that it was muscular and thankfully not related to the bones. He prescribed a muscle-relaxant and some pain killer. By the end of that week, I was feeling better. By Monday, the 29th, the pain was completely gone.

This week I have started going to office after a ten day gap. From the last couple of days, I have resumed swimming as well. I hit the pool after about three months. I am taking it a little easy to begin with though.

I have been suggested a synovectomy in the left knee to send the synovial fluid for a biopsy to try and figure out the cause for the pain that I have been having for the last 8-9 months there. I have decided to delay it for some time as I have been through quite a lot in the last couple of weeks.

Saturday, June 17, 2017

Augmentin, not nectar

A few days back, I stopped by at a pharmacy to buy some medicines. I overheard two other customers talking.

"Augmentin 625 mg - 10"

"Oh Augmentin. It's a very good medicine."

"You've taken it?"

"My uncle had an infection in his feet. He took this for five days. He was totally cured."

"Ok. I have been asked to take it for a cough."

Well, nothing wrong with that. Except that the second guy's tone was very casual. He sounded like he would take Augmentin for any minor problem.

Many people don't realise the dangers of taking antibiotics without actually needing them. Several studies have shown that bacteria are becoming resistant to several antibiotics. This has a lot to do with indiscriminate use of these drugs.

India, especially has been blamed for allowing pharmacies to dispense antibiotics and several other drugs without prescriptions. Some doctors too are known to prescribe antibiotics where they can be avoided. Patients are happy with the quick-fix they offer.

Apart from having some undesirable side-effects, these drugs could become ineffective over a period of time because they have been used where they need not have been used due to bacteria developing resistance to them.

Scientists would need to go on developing stronger antibiotics which may not always be possible. This, like many other problems of our times is not one that affects us immediately but has disastrous consequences in the long run. We must sit up and take notice.

Here is a very interesting video from Harvard Medical School that demonstrates how bacteria mutate to develop resistance to increasing dosages of antibiotics:

Friday, June 16, 2017

Sapiens by Yuval Noah Harari: Life changing

I came across the book Sapiens when I read a column by its author Yuval Noah Harari in the online version of some magazine. I forget which magazine it was and also what the column was about. The column intrigued me and in the footnote it was mentioned that Harari was the author of the best selling book, Sapiens. I immediately logged onto Amazon and bought a kindle version of the book.

In the book, Harari describes the history of the human species as put together by scientists and anthropologists. Harari first describes what happened after the Big Bang - how Physics began, then how Chemistry began, how Biology began and then finally how History began. Evolution describes the process of how single cells eventually grew into the species Homo sapiens that we call human beings. He then goes on to narrate the origins of the four revolutions that made humans unique: (pasted below from Wikipedia)

1. The Cognitive Revolution (c. 70,000 BCE, when Sapiens evolved imagination)
2. The Agricultural Revolution (c. 12,000 BCE, the development of farming)
3. The unification of humankind (the gradual consolidation of human political organisations towards one global empire)
4. The Scientific Revolution (c. 1500 CE, the emergence of objective science)

All the material in the book is purportedly based on discoveries of various fossils made across the world and theories that explain these discoveries.

Harari's theory of how religions evolved makes for some very compelling reading. It makes you think and question your own beliefs. Is whatever I've been believing in so far nothing but a story of someone's fancy imagination? What is the evidence behind this?

The problem however is not as simple as discarding whatever you've been believing in so far. Science's biggest strength and weakness at the same time is its ever-changing nature. Science has no problem in discarding yesterday's universally-accepted theory in favour of a new theory if facts support the new theory better. Religion, on the other hand, has at its very core a set of unchanging dogmas. Whatever the facts may lead you to believe, religion prefers declaring you a heretic rather than change its core beliefs.

If someone were to discard all his religious beliefs in favour of science, would this decision hold him in good stead forever? What if the ever-changing nature of science cause it to discard some of the basic contradictions it has to religion at some point in the future?

These are some of the many questions that flooded my mind as I read this book. At the end of the day, this decision is up to each of us. This book is one I would recommend to everyone. It is important for each of us to debate the contents in our mind. It is good for us to ask these questions. Sometimes, the answers might not be fully evident. It does not matter. It is good if this forces us to think and not rest our minds in the status quo.

For a quick summary of the book, click here. However, I really recommend that you read the whole book.

Thursday, June 15, 2017

Carpal Tunnel Syndrome

  • I finally have a firm diagnosis for the numbness in the fingers of my left hand
  • It is Carpal Tunnel Syndrome (CTS)
  • I have been having this numbness from late 2015
  • I had consulted a neurologist long ago who somehow missed this diagnosis
  • I consulted another neurologist a few days back, a very senior doctor at Care Hospital
  • He got some tests done which confirmed his initial suspicion of CTS
  • I am scheduled to undergo surgery to decompress the nerve today at around 9 am
  • By the time you read this, I should have been done!
  • Let's hope the surgery helps to relieve my symptoms

When you see something here posted exactly at 5 am... means it has been drafted much before and scheduled to be posted at such and such a date at 5 am.

All my short stories are written completely and then scheduled to be released one part each day typically early in the morning.

Even this post and tomorrow's post have been already written and scheduled to be released at 5 am.

Wednesday, June 14, 2017

Winds of change - 29

(This is the concluding part of a short story which is entirely a work of fiction.)

Immediately after the press conference, the footfalls into the hospital started shooting up. People felt that this was a hospital that stood for the ethical practice of medicine. This was a place they could trust.

During the daily reviews of the numbers, Vasudha and Manav were elated to see the impact of all their efforts coming together. They carefully reviewed all the data to ensure they were not missing anything. They also reviewed department and doctor-wise figures weekly to see if anything was amiss.

At the end of the second month, the hospital showed a very healthy growth compared to the previous month.

This trend continued month on month. Vasudha called a meeting of all the doctors and the Admin team. She shared the results with all of them and thanked them for their co-operation. Without their co-operation, this would never have been possible. The doctors were also very happy. They were earning more than what they were earlier. They felt really nice that all this was possible without succumbing to the unethical practices that had become so prevalent in the profession of late.

Soon, the hospital felt that it was running short of space. They had to regularly refuse patients due to this. They began having a wait-list for procedures and treatments like dialysis. Vasudha decided to expand the hospital, A new block would be constructed. She scheduled a meeting with the old investors and discussed the high level details. Soon, a plan was put together. The old investors decided to fund the entire expansion in return for a further stake in the company.

In under two years, the new block was ready. Swami Keshavanand inaugurated the new block. Vasudha was extremely happy with the progress being made. She realised that what they were doing in Narayana Hospital was breaking new ground in healthcare delivery in the country. She hoped that other hospitals would follow suit in implementing their model.

She heard informal reports of hospitals in other cities adapting the so-called ‘Narayana Model’. People were very intrigued by this new paradigm being seen for the first time in the healthcare sector.

Vasudha never felt the need to keep the intricacies of her model secret. She felt that the entire healthcare industry could benefit by moving to this model. She strongly felt that there was space for everyone and not one or two but even a hundred Narayana Hospitals would not be enough to cater to the growing needs of Indian patients. She joined the board of some hospitals which wanted her to guide them to implement the ‘Narayana Model’.

Soon, several such hospitals started switching the way they worked and Vasudha advised many of their founders and owners on running their hospitals.

She kept stopping by at the ashram to pay her respects to Swamiji who always guided her to do the right thing. She believed that the peace she felt at the ashram helped her connect to the ideals of her late husband and this proved to be a very important reason behind her success.


Vasudha was sitting in her cabin one day when she got a call from the PA of the Union Health Minister. Apparently, the Health Minister had got to know about the new model of healthcare that Narayana had adopted. The minister wanted to meet Vasudha to understand the ‘Narayana Model’.

Vasudha flew down to Delhi the following week and met with the Health Minister. They discussed the Narayana model at length. She also discussed the various problems she had encountered, some in her own hospital and others while helping other hospitals adopt the model. The minister was intrigued.

The minister told Vasudha that the PM was very keen on exploring the possibility of rolling out Universal Healthcare in the country. He wanted her to be associated with the project. Vasudha was thrilled. She agreed immediately.

On the flight on the way back, her mind wandered to the day when Sheshu talked about his plan. She felt very sad that she had not allowed it to be implemented for a while longer. The truth, she realised, was that she had never thought it would work and that is why she did not even help in the implementation. Had she thought of all the ideas she came up with when the plan was being rolled out the second time, perhaps, Sheshu would be alive today!

She wiped off the tear from her cheek as she looked out of the window into the clouds.

Tuesday, June 13, 2017

Winds of change - 28

(This is the twenty eighth part of a short story which is entirely a work of fiction.)

Manav ensured that the top newspapers and television channels were invited for the press conference. Vasudha made a detailed presentation on their model of healthcare delivery and how it addressed the ills present in the current models. Then she would bring in how the two doctors tried to thwart an honest attempt at beginning a revolution.

On the morning of the press conference, Vasudha and Manav were extremely tense. This was their one big chance. If the press caught on to the story and gave it widespread coverage, it could mean the success of their plan.

They intentionally did not release the press note that is customary before a press conference saying that it would be released after the hospital representatives spoke. The conference hall soon filled up with journalists and AV crew from the top newspapers and television channels.

Vasudha began with poise. She thanked the journalists for coming and attending the meet. She then went over her presentation. Once she started covering the part about the two dishonest doctors, there was a lot of commotion in the room. Manav noticed people getting onto their cell phones. Soon, more and more journalists started coming in. Manav knew that they had succeeded.

Once the presentation was completed, Vasudha and Manav fielded questions from the journalists present on the finer details of the plan and the action being taken against the doctors.

By that evening, the medical community of Rajahmundry and in fact the entire state of Andhra Pradesh was shaken with the news emanating from Narayana Hospital. The national television channels also gave coverage to the news which was huge as generally, national channels do not cover even big stories from a place like Rajahmundry. The next morning, all newspapers of the state carried this story as the headline. Narayana Hospital, its new healthcare delivery model and the corrupt doctors were on everyone’s mind that day.

The hospital got numerous calls. Vasudha’s cell phone was flooded with congratulatory messages and messages of support. Almost all the doctors of the hospital got calls from people they knew asking about the new model and the corrupt doctors.

That evening, Vasudha and Manav met in Vasudha’s cabin. They reviewed the status of the plan. They discussed the possible impact of the press conference and the wide publicity they had got. They decided to keep their expectations low since they knew how the press behaved. One new story the next day and everyone would forget about the hospital.

Vasudha sent an email to all the doctors and Admin team of the hospital thanking them for the support during this crisis. She encouraged them to go back to their regular work and not get distracted with all the hullabaloo that was caused by the events of the past few days.

The careers of the two doctors in Rajahmundry was finished. No one wanted to be associated with them. Even the hospitals they were engaged with while working for Narayana refused to continue their relationship as it would be a major image problem for them. They left Rajahmundry for good and started their practice elsewhere.

(The story concludes tomorrow.)

Monday, June 12, 2017

Winds of change - 27

(This is the twenty seventh part of a short story which is entirely a work of fiction.)

Over the next few days, each of the remaining parts of the plan got rolled out.

The Vigilance committee got into action. They would pick up the copies of the prescriptions and check. The Departmental Committees started interfacing with the Medical Representatives to evaluate new products and other consumables. The surveys were also rolled out.

The Marketing Campaign was the most visible aspect of the project. Huge hoardings of the hospital were set up in the city’s busy junctions and nearby towns. A TV and radio campaign was also run simultaneously. The goal was to get people aware of the way the hospital was being run and encourage them to try it out.

Vasudha and Manav would review the numbers on a daily basis.

Soon, the first month of the project drew to a close. At the end of the review, Vasudha and Manav did a detailed review of all the numbers. They were disappointed to see nothing much had changed overall. They decided to do a department by department analysis. They found that while all other departments had shown a minor growth compared to previous numbers, the orthopaedic and cardiology departments had actually shown significant dips.

Vasudha asked Manav to get doctor wise figures for these two departments, Manav took a day to drill down further and then reported back to Vasudha. They found that while some doctors in the department had shown better numbers, there was one doctor each in both the departments who had shown huge declines in the numbers. Vasudha and Manav started brainstorming on what the problem could be. They called Dr. Madhusudhan to discuss the findings. It was important that confidentiality be maintained around this in order to be able to figure out the problem and fix it.

Dr. Madhusudhan was instructed to have one person each from his team closely follow each of these two doctors and their activities during the next two weeks. They were asked to be extremely careful in their work so as not to raise any suspicion.

At the end of two weeks, a beaming Dr. Madhusudhan walked into Vasudha’s cabin and presented his findings. The two doctors were regularly sending their cases to other hospitals. One of them had already started performing some surgeries in other hospitals. Dr. Madhusudhan handed over documentary evidence in the form of prescriptions, notes made on rough paper in the doctors’ handwriting, CCTV evidence and recorded patient voices.

Vasudha called Manav over and showed the report to him. Now the question was how they should handle this? Manav suggested that they talk to the doctors in private, confront them with the evidence and give them a last warning. Dr. Madhusudhan, on the other hand, felt that terminating them was the only way they could send a strong message to the entire hospital that they meant business.

Vasudha said she agreed with Dr. Madhusudhan. Termination letters were typed out and sent to the two doctors immediately. The other doctors were also informed about the decision along with the rationale behind the decision. The two heads of departments came to meet her and requested her to give the two doctors another chance. Vasudha refused to listen.

Manav then had a brainwave. He suggested that they hold a press conference and announce the termination. They would also go into the reasons behind the termination. They could cover in detail how they were trying to bring a change in the way healthcare was delivered. That way they would get a lot of publicity  and that too for free!

Vasudha loved the ideal.

Sunday, June 11, 2017

Winds of change - 26

(This is the twenty sixth part of a short story which is entirely a work of fiction.)

All the necessary changes in the hospital software were made over the next few days. All these changes would become applicable on the first of the next month. There was a lot of excitement in the hospital. Everyone was speculating on how things would go. Vasudha and Manav were extremely tense. They met multiple times every day to check how the preparation was going on. They decided to give some time for things to fall in place before constituting the Vigilance Team. They also decided to roll out the project on the first and then over the next few weeks, once everything got streamlined in the operations of the hospital, they could start the marketing. They did not want anything to affect the project in the initial days.

Vasudha visited the ashram and updated Swamiji about the plan. He was very happy that Vasudha had kept Sheshadri’s dream alive. He somehow had a good feeling about how Vasudha was implementing it. She blessed Vasudha and wished her the very best.

The first of the next month was finally there. Nothing visible changed in the workings of the hospital. Patients came, consulted the doctors, got their procedures and investigations as usual. Some were admitted and were then discharged. Things were going on as usual.

Vasudha and Manav met every morning to review the previous day’s numbers. Things seemed to be normal. Nothing much changed. No visible upward or downward trends were observed.

Now was time for the second phase of activities to begin. The Vigilance Team, the marketing campaign, the department committees and the Patient Satisfaction Surveys.

The main job of the Vigilance Team would be to scrutinise if doctors were referring patients elsewhere for investigations and procedures. Since doctors were on a fixed salary here, other hospitals could offer incentives on such things to get them done there rather than Narayana Hospital. Another aspect they would need to look into was if Medical Representatives were contacting doctors directly rather than through the hospital department committees.

Manav and Vasudha debated a lot about who should be a part of the Vigilance Team and how big it should be. They finally decided to hire a retired Army Doctor who was known to Vasudha. Major General (Retd.) Dr. Madhusudhan was about fifty years old, very fit and stayed in Hyderabad. He was very sharp and intelligent, had ethics that were above board and was looking for an opportunity to work somewhere in a role that fitted his profile. Vasudha talked to him and immediately got him on board. Once he joined, the three of them brainstormed on the composition of the rest of the team. They finally decided to make it a four member team including Dr. Madhusudhan. The other three members would be Management Graduates from the Admin team. Manav was assigned the responsibility of doing the co-ordination and identifying potential candidates. The final selection was left to Dr. Madhusudhan.

Vasudha and Manav also got in touch with the Marketing Agency they had identified. The team came down to Rajahmundry and had a day long meeting with the two of them to understand the requirement. They would go back to Bangalore and come up with a comprehensive marketing plan in a week.

Each Department was asked to come up with the committee that would interface with Medical Representatives. They were to pick one doctor from the department, one member from the Admin Team and one from the Vigilance Team.

Manav worked on the Patient Satisfaction Survey and made it very simple. There was only one mandatory question - “How likely are you to recommend Narayana Hospital to others?” to which patients had to respond on a scale of one to five stars. Rather than have an elaborate set of questions, he felt that asking one simple question would be a good indicator of patient satisfaction. There were other optional questions which asked for more details in case respondents gave a score of 1 or 2 stars.

This next phase was the most critical phase of the project. This was when all the cogs of the wheel would be in place and the real effect would start becoming visible.

Saturday, June 10, 2017

Winds of change - 25

(This is the twenty fifth part of a short story which is entirely a work of fiction.)

On the following Monday, at 9 am, all the Heads of Departments along with the Admin team assembled at the Conference Hall. Vasudha greeted them and started asking for comments on each of the points identified in the email that outlined the plan.

Dr. Samba Murthy spoke first. “Ma’am, this plan is almost the same as that which Dr. Som had piloted. The only difference is that it is being implemented across all departments rather than one department. I am just concerned that when the pilot failed, how will this project, which is an extended implementation of the same pilot, work?”

Vasudha turned to Manav. “Manav you want to take that?”

“Yes ma’am. Dr. Murthy, alongside these changes, we have planned a massive marketing campaign in the entire state of Andhra Pradesh. The problem we faced in the implementation of the pilot was that we did not see an increase in footfalls in the hospital. We were doing a great job from the patient’s perspective but that was not being communicated to the patients. We will be having a special budget allocated for marketing. We will he working with a very reputed firm from Bangalore for this.”

The Head of the Orthopaedics Department said, “The project is very good ma’am. However, one concern we all have is on the Vigilance Team. What would be the powers of the this team? Who would be the members of this team? Would they be doctors?”

“They will not be doctors. Doctors would not have time for this,” Vasudha responded curtly.

“If they are not doctors, how will they understand medical records? We are worried that they would overstep their mandate. They would become a superpower within the hospital and question everything we do.”

Vasudha softened a little. “Don’t worry about that Doctor. We will ensure that proper guidelines are given to the Vigilance Team. Honestly, we have not decided who will form this team. We just realise that we need someone to check that the new rules are not misused.” She needed to make sure everyone was genuinely on board for this plan to work.

Dr. Sampath from Nephrology then said, “Ma’am, there are two points that talk about additional incentives - one is based on the outcomes and the other is based on patient satisfaction surveys. No details have been given on how those incentives would be calculated.”

Manav responded, “Dr. Sampath, these incentives will be pegged at 5% of each doctor’s fixed salary. So, each doctor can earn a total of 10% over and above the 10% additional over your last three month’s average. Let’s say a doctor receives a patient satisfaction score of 90% during a month, that doctor would be eligible for a 4.5% additional salary.”

“What about the outcomes? How would that be linked to the salary?”

Vasudha interjected, “As you know, each HoD is going to come up with a set of outcomes for their department. The proportion of patients who achieve those outcomes would determine the outcomes based incentive. For example, in dialysis, one of the outcomes, I am told, could be the Hemoglobin. If the Hemoglobin target range is 9 to 11.5, the % of the doctor’s patients that achieve this target value would affect the doctor’s incentive. A weighted average of all the outcomes would be used.”

Suddenly there were a lot of murmurs in the hall. People started talking with one another. Vasudha raised her hand, “One at a time please.”

One by one the doctors started raising their concerns about this incentive.

“These outcomes are not solely in the doctor’s control. If patients cannot pay for the drugs prescribed, how can we be blamed?”

“How will they be measured? If patients don’t do investigations, how will the outcomes be measured?”

“If anything is going to be outcomes based, doctors will refuse to take critical cases! Who will be responsible for this?”

Vasudha raised her hand again and spoke loudly this time. “Please, please remember that this is over and above your base salary. If these things don’t work, you will get your base salary.”

“That is not the point ma’am. The system should be fair. If the hospital has a policy for outcomes based incentive, the rules should be fair for those incentives.”

“Let us scrap the outcomes based incentive,” Vasudha said loudly.

“Ma’am, maybe we can delay the implementation until we figure out a fair way. Outcomes based incentives are a great way to link performance to pay,” Manav said.

“Yes, sure, let’s do that.”

Vasudha asked if there were any other questions.

“Let us start with this ma’am. We can hold a monthly review of this group and discuss.” Dr. Samba Murthy concluded.

“Sure. This plan starts from first of next month.”

Friday, June 9, 2017

Winds of change - 24

(This is the twenty fourth part of a short story which is entirely a work of fiction.)

Manav worked hard on the plan. This plan would be much bigger and riskier to implement because it would not be restricted to the nephrology department. Vasudha felt that this had to be done across all departments for it to be effective. Manav wore down the high level points that Dr. Som had proposed:

1. High fixed salary for doctors
2. No incentives for investigations and prescriptions
3. No monthly targets for investigations
4. No referral fees to refer to other consultations
5. OP and IP investigations and drugs to be charged at the same rates
6. Medical Representatives to send all new product details to a common email id which would be screened by a Vigilance Committee
7. Outcomes of the patients being treated to be tracked electronically and monitored closely
8. Patients to take a satisfaction survey at the end of their visit

He thought over each of these items and came up with the problems they had encountered in each of them. He wrote down the set of problems and possible solutions for each problem. He worked without taking a single break except for meals and sleep. After three gruelling days, he emailed the document to Vasudha.

Vasudha took a day to review the document, making notes and adding comments. She called Manav and discussed each of the points. They had several discussions over the next few days and about a week after Vasudha addressed the team in the conference hall, she emailed them the plan. She asked them to review in detail and said that they would meet in three days for a detailed discussion.

The email read:

“Dear team,

I appreciate your co-operation in running Narayana Hospital for all these years. As we discussed the other day, we would like to change the way we operate in this hospital. We would like to make sure that every department here practices in the most ethical way possible. At the same time, we obviously need to ensure the financial sustainability of the hospital and also ensure that any of the stakeholders, especially you are not financially affected. Keeping all this in mind, Manav Sharma and I have come up with a draft of the plan. I am putting down the high level details here for your perusal. Please review this and keep your questions and comments ready which we will review on Monday morning at 9 am in the Conference Hall.

1. Fixed salary for all doctors: computed as average monthly income from hospital for last 3 months plus 10%
2. No incentives would be paid for prescribing investigations, pharmacy products and procedures
3. No additional fees will be paid for monthly targets for investigations; no monthly targets would be set
4. All referral fees for other consultants would be scrapped
5. IP investigations and drugs would be charged at OP rates
6. A Vigilance Team would be created whose job would be to ensure and monitor adherence to the new plan
7. A committee would be formed for each department which would consist of the head of the department, one member from the Admin team and one member from the Vigilance Team
8. Medical Representatives would need to send details of all new products to this committee which would then pass on the information to the doctors based on the merits
9. The Vigilance Team would be authorised to conduct checks on patient prescriptions and medical records
10. Each Head of Department would come up with the list of outcomes to be tracked for various conditions and these outcomes would be tracked on a regular basis. Doctors would get an outcome based incentive
11. A Patient Satisfaction Survey would be administered to most patients from time to time using a mix of paper based and telephonic surveys. Doctors would get incentivised based on the results of these surveys

All these points are open for discussion. Please come up with questions and comments and we will discuss on Monday.

Vasudha Som”

Thursday, June 8, 2017

Winds of change - 23

(This is the twenty third part of a short story which is entirely a work of fiction.)

Three days later, a meeting was called of all the Heads of Departments and the Admin team at 9 in the morning. Vasudha addressed them in the Conference Hall.

“Good morning everyone. Thanks for taking the time out and coming in for this meeting. Our hospital has gone through many tough phases but none can compare, at least for me at a personal level to that we have just faced. When Dr. Som and I started this hospital, we really thought we could bring quality healthcare to Rajahmundry and the surrounding areas. This was lacking and we thought we could fulfil a real need.

We raised money from many people who had faith in our capability. Over the years we have built a solid team. We are doing fairly well for our age and our size. Somewhere down the line, however, I got a little paranoid about the financial viability and sustainability of the hospital. In that process, certain compromises were made. I now realise how dangerous even a single compromise can be in healthcare.

We all should never forget that the lives of our patients is in our hands. For us, the death of a patient merely becomes a statistic. A number in an Excel spreadsheet somewhere goes up by one. However, when you think, of the impact on the patient and his or her family, this means a lot, lot more than that spreadsheet number. The patient’s life is over and with it, all her dreams, all her ambitions also die. For the family, it could mean a tumultuous change. They could be faced with uncertainty over their future. Many families lose their sole breadwinners. Imagine their plight!

Healthcare companies and especially hospitals like ours should never lose sight of the overarching goal of providing and sustaining life. Everything else is secondary. If we put financials above life, then we are doomed to fail. Unfortunately I have realised this a little late.

Dr. Som had a vision - quality healthcare at affordable prices. I am going to work towards achieving that vision at this hospital from this moment onwards. He had come up with a plan a few months back which I and many of us in this room had felt was not sustainable. We tried a pilot which failed and was scrapped. I have decided to reinstate that pilot. It was not a perfect plan. But at least the intent was right. We need to work together as a team and iron out the kinks in the plan and make it work.

We have lost Dr. Som. Whether we had control over that or not is a matter of debate. We still have his ideals. Whether we lose them or not is completely in our control. I need the co-operation of each and every individual in this room. Without that we will fail. I will be sending a detailed plan over email. This is, by no means, a final plan. This is for your thoughts and inputs. Please go over the plan in detail and get back to me with your thoughts by the end of this week. We will meet again on Monday to discuss specific aspects of the plan and your suggestions. Rollout will happen on the first of next month.

And yes, Manav Sharma will lead the implementation of this plan. Thanks all of you.”

Many people in the room had become a little emotional. Some felt their eyes turn moist. They all got up, came and wished Vasudha and then left one by one.

Manav was the last person left. He walked up to Vasudha and said, “Ma’am, thanks so much for doing this. And thanks for putting your faith in me. I promise I won’t let you down. I will work hard to make this plan a success. I promise you, you’ve done the right thing.”

A tear rolled down Manav’s right cheek. He was embarrassed. He quickly wiped it and left the hall.

Wednesday, June 7, 2017

Winds of change - 22

(This is the twenty second part of a short story which is entirely a work of fiction.)

The next morning, Vasudha got ready and came out of her room quite early. Her mother who was already awake, asked her, “Where are you going?”

“I’m going to the ashram ma and then to the hospital.”

“Ashram is ok Vasudha but you should rest for a few days. What is the hurry to go to the hospital?”

“No ma, I will feel worse if I stay at home. Going to the hospital will keep my mind busy and I will not think about this.”

Her father hearing the discussion came out of the room and said, “Let her go. She is right. Her mind needs to be busy. She will feel worse sitting at home.”

Vasudha reached the ashram and went to the cremation site. She spent a few quiet moments there and then headed towards Swamiji.

She bowed before him and said, “I need your blessings Swamiji. Make me strong. Bless me that I do not break.”

Swamiji said, “You are strong Vasudha. I know you are. Obviously, my blessings are always with you.”

Vasudha left the ashram and drove straight to the hospital. The staff there was surprised to see her. She took a round of the wards and the various OTs and ICUs and then headed towards her cabin. She checked her email and responded where needed and then called Manav.

“Manav, can I see you now, please?”

“Of course, ma’am. Coming there.”

Manav knocked at the cabin door and opened it. Vasudha asked him to come and sit. He was quite surprised that she was back at work.

“Manav, can you put all the plans and analyses you and Dr. Som did for the pilot and send it to me? Every single file, every single dataset.”

“Sure ma’am. I have everything in one folder. I can send that to you very soon.”

Manav went back to his table and quickly pulled out the folder and sent it in an email to Vasudha. He was wondering what she was planning to do. The pilot had failed so badly. Could Dr. Som’s passing have caused her to change her mind?

Vasudha called the head of procurement, Sateesh Kumar to her cabin next. She asked him to stop using the catheter that had costed Dr. Som his life. She also asked for a complete review of all consumables. She asked him to come up with a complete list of brands being used at the hospital grouped by department and consumable.

The Head of Finance was the next person to be called. Vasudha asked him for a one page snapshot of the company’s financials comparison since inception, year on year. She wanted this by the end of the day.

The entire hospital was agog with all the happenings. “Maybe she is going to close the hospital?”, said one. “No, she might be thinking of selling it off to someone”, countered another. “Maybe she is planning to become a sanyasin at the ashram. She went there this morning!”

Manav heard all this and thought, “What bullshit! People just need an excuse to gossip. She is definitely not going anywhere. Why would she ask for the pilot files? She may not implement the pilot because it failed. But she’s not going anywhere. For now at least!”

Tuesday, June 6, 2017

Winds of change - 21

(This is the twenty first part of a short story which is entirely a work of fiction.)

The cremation was to take place at Swami Madhavanand Ashram, by the banks of the River Godavari. Swami Keshavanand was going to supervise the cremation. Both, Vasudha’s and Dr. Som’s parents had already arrived. Several other close relatives had arrived. Everyone was in complete shock. Vasudha had not yet come to terms with Sheshadri’s death. She was going through the motions of the cremation and accepting condolences of various relatives and friends who had gathered. For a moment, she would wonder where Sheshu was? And then the next moment, her eyes would fall on his body and her heart would become heavy and she would realise what had just happened.

The cremation was performed by Dr. Som’s father who was completely broken. They say, the biggest burden a father can ever carry is that of his son’s dead body. The elder Dr. Som could barely believe that his son, whom he was so proud of was no more. Vasudha was standing beside her parents. With no tears in her eyes, her face was almost lifeless. It was as if she had no clue about what was happening.

When the cremation was completed, the family was wished by the hundreds of visitors. At the end of it all, the family sat around Sami Keshavanand. Swamiji explained the ethos of the Bhagavad Gita and the concept of death according to the Hindu scriptures. He stressed that though Sheshadri’s soul had left his body, it was by no means dead. By remembering that, they all had to keep in mind what he stood for and what he believed in. He advised them to continue the good work that he had done in his lifetime.

“Think about what he wanted to do. Think about what he wanted to accomplish. Was there anything he left undone which he wanted to do? Work towards achieving that. That would be the best way of remembering him.”

The rest of the family bowed to Swamiji and walked towards the car. Vasudha stayed back for a few more moments. She addressed Swamiji and said, “I know what you mean Swamiji. It was I who had stopped him from achieving his dreams. I was the one responsible for his death. The catheter that broke - I, I was the one that fought with him to use that catheter in our hospital. Who knew that this would happen? Who knew that my decision would be the one that would kill poor Sheshu?” Tears started gushing down her cheeks as she said these words.

Swamiji calmed Vasudha. “Don’t blame yourself Vasudha. When someone’s ayushya is completed, only excuses are needed for death. So, if it wouldn’t have happened because of the catheter, it would have happened in some other manner. What is important is for us to realise what is right and what is wrong and then act accordingly. There really is no point in putting the blame on anything or anyone.”

Vasudha nodded and wiped her tears. She stood up and bowed to Swamiji and headed towards the car.

Once they reached home, the family rested for some time. Sheshadri’s parents would leave the next morning while Vasudha’s parents decided to stay for a few weeks to support her in recovering from the trauma and coming to terms with her loss.

Vasudha could barely sleep that night. She kept tossing and turning in her bed. Swamiji’s words kept ringing in her ears.

“Think about what he wanted to do. Think about what he wanted to accomplish. Was there anything he left undone which he wanted to do? Work towards achieving that. That would be the best way of remembering him.”

Monday, June 5, 2017

Winds of change - 20

(This is the twentieth part of a short story which is entirely a work of fiction.)

Dr. Som was rushed to the CT scan room. They hurriedly shifted him to the platform and strapped him to begin the scan. The team was watching anxiously from the monitoring room. The radiologist started the process. One by one, he checked different areas of the body. At one point, he felt like he spotted something. He signalled to the other doctors to see. They quickly ruled that out. Where could the needle piece be? Finding it was the first step. If they found it in a difficult place, the next step would be much more difficult.

They saw images of the brain, the heart, the arms, legs, the stomach. Nothing at all. They repeated the whole procedure again. The entire team was intently watching the screen throwing out images one by one. Vasudha was pacing up and down the room. She could not make out the images. She stopped to look at them at times but it did not help at all. After a while she sat on a chair. When she heard  a murmur from the radiologist, she got up with a start and looked at the doctors for any hint of success.

During the second round of images, when they were seeing images of the heart, suddenly, the radiologist spotted the needle piece. It was unmistakable. He pointed to the screen. To everyone’s horror, they noticed that the piece had pierced one of the valves of the heart and blood was gushing out of the tear. They looked at each other and rushed into the room where Dr. Som was kept. Dr. Murthy shouted out, “Dr. Som! Dr. Som!”

Dr. Som did not move. “Quick, get the stretcher. To the ICU.”

Two boys brought the stretcher that was kept aside and placed it right next to the CT scan machine platform. They got hold of the bed sheet that Dr. Som lay on and carried it along with Dr. Som and placed it on the stretcher. They ran with the stretcher towards the elevator. The entire team ran behind them. They had to stop the blood somehow. All the time, the doctors tried waking Dr. Som up. He did not move one bit. They feared that the continuing blood leak was reducing his Blood Pressure. They had to get him to the ICU and push in enormous amounts of saline immediately to prevent the heart from failing.

They reached the ICU within minutes. One of the doctors had already called the ICU and informed them of the situation. The team there had the bed and the saline bottles and the infusion set ready. As soon as they reached, one nurse connected Dr. Som to a bottle of saline and began the infusion. Another nurse connected the vitals monitor. Dr. Murthy was shocked to see that the Blood Pressure of Dr. Som was a dangerously low 80/50. The heart rate was dropping as well.

The saline was not making too much of a difference. They then decided to give an injection of Adrenaline. The syringe was filled and a shot was given directly into the heart. There was no improvement in the Blood pressure and heart rate. The intensivist brought a defibrillator and took the two plates and thrust them on Dr. Som’s chest. Dr. Som’s upper body jumped up in the air and landed back on the bed with force. No improvement in the Blood Pressure and heart rate.

Blood pressure was now 50/30. Heart rate was around 45. One more try with the defibrillator. The body went up in the air and back on the bed.

The line on the monitor was now straight. They tried the defibrillator one more time. The body went up in the air and back on the bed. The line on the monitor remained straight.

It was all over.

Sunday, June 4, 2017

Winds of change - 19

(This is the nineteenth part of a short story which is entirely a work of fiction.)

The next morning, Dr. Sampath came to the ICU by around 7. Vasudha was already up and was sitting beside Dr. Som. The plan was to put in a temporary catheter into the jugular vein to enable quick dialysis. A permanent access for dialysis called an Arteriovenous fistula takes about 4-5 weeks to mature and be usable. A temporary catheter is often used to enable the patient to get dialysis immediately.

Dr. Sampath had a nurse assist to him. He requested Vasudha to wait outside. Vasudha readily complied. He opened the catheterisation kit and the catheter. He told Dr. Som that he was giving a small injection which was  local anaesthetic which would numb the area and allow Dr. Sampath to put in the catheter comfortably. Dr. Som had done hundreds of such procedures himself. He felt it weird that it was he who was now at the sharp end of the needle!

Dr. Sampath had also done this procedure many, many times and tried hard to not feel any pressure and treat Dr. Som just as another of his patients. That way he would confidently complete the procedure in a few minutes. He inserted the catheter into the site and tried placing it into the right position. He felt some resistance to the catheter. He nudged a little. No luck. Dr. Som started getting anxious. But he did not want to say anything and disturb Dr. Sampath. He could not see what was happening. He had to surrender completely to Dr. Sampath at that time. He knew something was amiss. The catheters generally just go in without any problem.

Five minutes passed since Dr. Sampath tried to insert the catheter. He tried nudging and pushing. The catheter wouldn’t budge. Dr. Sampat became tense. He could feel droplets of sweat form on his forehead. At one point, his hands started shaking. He did not utter a word. After another few minutes, Dr. Sampath decided that he would give up and remove the catheter. He told Dr. Som, “Sir, there seems to be something blocking it. I am withdrawing.”

Dr. Som was surprised. “Ok”, he said.

Dr. Sampath began withdrawing the catheter. When he was gently pulling the catheter out, he felt something snip. As he pulled the catheter out, he realised to his horror, that the tip of the catheter had broken and the piece that broke was left inside. By looking at the catheter, Dr. Sampath figured that the tip that was left inside was about an inch long. He started shivering. His hand was on a thick piece of gauze that he had placed on the site to prevent bleeding. Dr. Som asked, “Why are you trembling Sampath?”

Dr. Sampath started sweating profusely. He had no clue what to say. He felt the floor slipping from under his feet.

“S…sir….. The t…t….tip of the c….c…..c…..catheter broke and is left inside.”

Dr. Som closed his eyes in disbelief. Dr. Sampath quickly fixed a plaster to the site tight to prevent bleeding and rushed out of the ICU to tell Vasudha and the other doctors. Within minutes, the senior doctors all assembled in the ICU.  They all had an eye on the vitals being thrown out on the monitor attached to Dr. Som. The worry was where the needle would go and what damage it would create. They had absolutely no control over this. They had to now do a CT scan to determine where the needle was and figure out a way to remove it.

Dr. Som could not utter a word. Vasudha was dazed. She pulled Dr. Murthy and Dr. Sampath aside and asked, “Should we shift him to Hyderabad?”

Dr. Sampath had regained composure by then. “Risky, ma’am. We should try to see where the piece is now. After that we can decide.” Dr. Murty nodded. “Let us do the CT and then decide.”