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.”

Saturday, June 3, 2017

Winds of change - 18

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

“Dr. Murthy, we need to change things around here a little. It was probably good that I had to spend some time here. I got to see things from a patient’s perspective.” Dr. Som said excitedly.

“Yes of course.”

Vasudha asked the doctors whether the reports were ready. Dr. Sampath nodded. “Sheshu, let me just take a look at the reports and come back.” Vasudha had this uneasy feeling suddenly by looking at the doctors’ faces.

“Sampath, what’s wrong? Tell me. I am a doctor in case you’ve forgotten.” Dr. Som began to get a little anxious.

The two doctors were in a quandary. How could they tell him? On the other hand, how much longer could they hide from him? He was a nephrologist, after all!

Dr. Murthy came and stood next to Dr. Som’s bed. He said, “Dr. Som, you need to be strong now. Being a doctor, I am not going to hide anything from you. But you need to understand that if you are not strong, it will be difficult for everyone, most of all, for you.”

“What is it? Just tell me!”

“Your creatinine is 8.4.”

“What? 8.4?”

Dr. Som felt his heart becoming heavy. Vasudha felt her eyes moisten.

“We’ve repeated the entire set of tests. Your kidney function is compromised Doctor.”

“How can that be? I have had no symptoms. Nothing at all. There must be some mistake. Somewhere. How can it be?”

Vasudha held his hand. “Be strong Sheshu.” She could not stop the tears rolling down her cheek.

“Show me all the reports.”

Dr. Sampath handed over the entire set to Dr. Som. Dr. Som went over each one of them. Once, twice, thrice.

Dr. Som just could not believe what he was seeing. It seemed like he was going over the reports of one of his patients. But every now and then his eyes moved to the name of the patient on the report and the name “Dr. Sheshadri Som” stared back at him. He kept thinking back to see if there was any symptom of kidney disease he could recollect. He couldn’t remember any symptom. The reports could not be wrong either. They had repeated the samples. What should he do now? Should he treat himself? Rely on his team? Move to Hyderabad? No, that would be ridiculous. That would send a very bad signal. Also, he trusted his team. They had good experience. They were efficient. He needed to have confidence in his team. He needed to have complete faith in them. He had to surrender to them.

Dr. Som gathered himself. “So, what’s the plan Sampath?”

Dr. Sampath was a little startled. Would he be treating his own boss?


“What are you planning to do now? I am your patient. Please forget that I am a doctor. Please forget that I own this hospital. Please treat me like a new patient. Let me know what you are planning to do now?”

“Y…yes sir. Please excuse me sir. I will be back in a few minutes.”


Dr. Sampath hurried out of the ICU and went to the nephrology department. He called the doctors for a meeting. It wasn’t a very big department. Dr. Som and Dr. Sampath were the only nephrologists by qualification. There were two other MBBS doctors, Dr. Rahul Kumar and Dr. Suhail Ahmad who were being trained for the last couple of years. Both were quite sincere and hardworking. Dr. Sampath gave them an update on Dr. Som’s diagnosis and told them that they all together needed to offer the best possible care to him.

They brainstormed on the plan. They decided to plan a kidney biopsy in the next 2-3 days. They also decided to put in a temporary catheter the next morning for dialysis which Dr. Som would need immediately.

Dr. Sampath headed back to the ICU. He informed Dr. Som about the plan. He added at the end, “Any thoughts, sir?”

“No Sampath. Sounds good. You go home and get some rest. It’s already midnight.”

Dr. Sampath called out to the nurse on duty and asked her to call Dr. Rahul to the ICU.

“Vasudha, you go home as well. Get some rest. You can come back tomorrow morning.”

“No Sheshu. I would like to stay. I will not be comfortable at home.”

They argued for some time on the subject. In the end Vasudha had her way. She would sleep in the doctor’s cabin within the ICU.

In the meantime, Dr. Rahul came to the ICU. Dr.Sampath instructed him to be stationed in the ICU the whole night and watch over Dr. Som.

Dr. Som then tried to sleep. It was a very tiring day, a life-changing day. Dr. Som began to understand what his patients felt when they were initially diagnosed with kidney disease. He felt uncertain about his future. He had no clue how this would turn out? What would the biopsy say? Would he need dialysis or a kidney transplant? Where would the kidney come from?

Friday, June 2, 2017

Winds of change - 17

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

When the two doctors entered the ICU, they saw Dr. Som was asleep. Vasudha was sitting next to him. She sprung up as soon as she saw them and asked them what the matter was. They signalled to the ICU Duty Doctor to look after Dr. Som and they ushered her into a chamber.

Vasudha was anxious. “What do the test results say, Doctor?”

“Ma’am, Dr. Som’s creatinine is 8.4.”

“What? How can that be? He did not have any signs of this until now? Suddenly? How can it be? Send a repeat sample.”

“Already done ma’am.”

“I’m sure there is something wrong.”

“Let us hope ma’am.”

The Serum Creatinine test was one of the basic tests of kidney function. The normal range is between 0.5 to 1.2 mg/dl. Dr. Som’s was about seven times the upper limit of normal.

The doctors went back to the lab to personally supervise the testing.

Vasudha returned to the chair. She remembered the bits and pieces of her conversations with Sheshu about kidney disease. She remembered him saying that Kidney Failure was almost always progressive. It started slowly when there would be no symptoms. Gradually the symptoms would build up and the kidneys would lose more and more of their function. She tried recollecting if there was anything unusual with Sheshu’s health over the past few weeks. She couldn’t remember anything out of the ordinary. “There must be something wrong with the report. It cannot come suddenly like this. Maybe its just exhaustion. Once the report comes and he becomes stable, we should go for another holiday. Hospital be damned. Health comes first. This has made me so scared. What is the point of all this?”

Sheshu opened his eyes again. “Vasudha, I want some water.” Vasudha signalled to the nurse. The nurse brought some water and gave it to him.

“What is happening here Vasudha? Where are the doctors?”

“They are at the lab. Just getting the reports. Once they come and everything is ok, we can go home.”

Even though Narayana was their own hospital, Vasudha felt suffocated inside the ICU. She just wanted to be back home with Sheshu. She could not bear the sight and feel of the place. Monitors beeping, an eerie silence otherwise, Sheshu on the bed lying like a patient, various probes connected to him. The entire feeling was terrifying. Even though she had come numerous times to the ICU in the past, for the first time in her life she was experiencing it as a patient’s attender. She would do anything to get out of there as soon as possible.

Sheshu looked around him. He was also experiencing the ICU for the first time from a patient’s bed. He saw the nurses attending to the other patients. He noticed the probes attached to his finger, to his chest and the monitors beeping next to him. He felt quite intimidated. He had walked into the ICU multiple times every day to check on his patients. He felt completely weird being on the receiving end. He started wondering what he could change about the setting to make it more friendly and less scary?

Maybe, the beeping of the machines could be muted? Maybe the lighting could be brighter? The probes, what could he do about the probes? Maybe a television? He needed to give this place a makeover! He discussed his thoughts with Vasudha. He asked her to pull out her phone and take some notes. “This is a great opportunity Vasu. Let’s note down what all we can change here!” Vasudha played along. He dictated and she typed out into her phone. They had about eight or nine items on the list when the doctors returned from the lab.

Thursday, June 1, 2017

Winds of change - 16

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

Dr. Som got back into his daily routine soon after the project so close to his heart was shelved. This was the best way he could help get over the heart-break he suffered. Within a couple of weeks, things were all back to normal between the couple and at Narayana Hospital.

One evening, after a particularly gruelling day at the hospital, as Dr. Som took off his shoes and socks at home, he noticed that his feet were swollen. He thought it was due to the long hours he spent on his desk without walking. He made a mental note to walk around his room every hour or so. The next day, during his OP hours, he got up every hour between two patients and took a walk in his room. He felt a little tired within a few steps. He found that weird. He ignored it however and just stood up, took a few small steps and then continued to see the patients.

This went on for a few days. He however felt that his discomfort was getting worse. One evening, as he completed his consultations, he got up and as he was going towards the door of his cabin, he suddenly felt a huge rush of blood towards his head. He felt suffocated. He reached out to hold onto something. He felt his vision becoming blurred and then totally black. Within a moment, he lost consciousness and fell onto the floor.

Hearing the noise of his falling, the office buy rushed in. He was shocked to see Dr. Som on the floor, lying motionless. He rushed to the intercom telephone and called the ICU. Within a few minutes,  Dr. Som was rushed to the ICU and the intensivist attended to him.

Dr. Som opened his eyes after about fifteen minutes. He was surprised to find himself in the hospital ICU, Vasudha looking over him anxiously and almost all the senior doctors of the hospital surrounding his bed.

“What happened?”

“Sir, don’t worry. You must relax. Your BP was high and you collapsed.”

“What? My BP? High? How much?”

“Sir, please don’t worry.”

“What, don’t worry? Tell me. What exactly happened to me?”

One of the senior most doctors who was to his right responded, “Sheshadri, it was 210/110. You collapsed. We have put you on…”

Dr. Som drifted to sleep again.

The next time he woke was after about an hour. By then the doctors had drawn samples of his blood and sent them to the lab for testing. This time, only Vasudha was by his side apart from some nurses. He asked her, “What’s happening Vasudha? Where is everyone?”

Vasudha responded, “Sheshu, you are fine. They have drawn some blood to get some tests done. Dr. Murthy is at the lab and he will be back with the results soon.”

At the lab, Dr. Murthy couldn’t believe what he saw in front of him. Dr. Som’s kidney function was severely compromised. For the first time in his life, he had encountered a doctor, and that too a nephrologist with kidney failure. He was at a loss now. How would he explain this to Dr. Som and his wife? What would he say to them? How would they react?

Dr. Murthy immediately called a meeting of the senior nephrologists in his cabin and updated them about the test results. He assigned the senior most among them, Dr. V. Sampath, the chief duty of treating Dr. Som for the moment. They decided that the two of them would go to the ICU and talk to Vasudha first.