Thursday, March 11, 2010

Welcome back to NH blog. This is Dr Kiran. We are in the process of finding something pertinent to our medical lives hidden in some of the known anecdotes.

The following anecdote was quoted by one of my friends. He had read it in a magazine few years back. He found the end very touching and narrated to me.

The story goes like this:

Mr and Mrs Shaw were worried. Unlike other members of their family, their youngest son Rahul was not an academic achiever, despite reaching his fifth standard.
The parents gave him everything a child could desire. Their only motive was to make him an academic success. They wanted their son to top the class, as did their other children. They were telling Rahul the virtues of good academic career. They would quote how his elder siblings are respected in the family for their academic excellence and so on. Not that Rahul was stupid. He was naughty, mischievous, playful, spoke a lot of nonsense, played well, but could not study and get good grades. His teachers were fed up with him. They would often call the parents to school to report him. They advised the parents to seek the help of a counsellor to rule out attention deficit hyperactivity. Many teachers could not just bear his presence in their class. All these were reflected in his report card as low grades. The school authorities threatened the parents of a transfer certificate if they did not get any better of him.
And, suddenly Rahul became better. His grades started improving. His attention span increased. There were literally no complaints from the school for more than a fortnight. It all sounded and felt magical for the parents. They had not done anything from their end, but still, something seemed to work.
This time when the parents were called to the school, they expected another taunt, but were taken by a surprise. The teacher had called them to congratulate on their effort. Rahul had got good grades in the unit test. The parents could not digest this. They started feeling guilty for the appreciation bestowed on them for no effort of theirs.
But the event deserved celebration. Both parents took Rahul for an ice-cream. In the parlour, Mr Shaw asked his son: “How are you doing all this?” He was worried if his son had started copying from his neighbour.
“I did not see anyone’s paper. It is all my own effort” said the lad.
“But how?” demanded Mrs Shaw this time.
“I have got a new friend. She works in my school. I talk to her all the time. I feel great with it”
“In the school?” thought Mr Shaw. “If the effort is done by the school to improve him, why are they complimenting us?”
“Something’s not fitting” he told his wife. “Can you show me your new friend?” he asked his son.
“Of course. She would still be at school. We can go now and meet her” said Rahul with a happy note in the voice.
They turned their car towards the school. Rahul led them towards the library. They found a lady in her twenties, arranging the books in the racks.
“What is her name?” asked Mr Shaw.
“I don’t know” was the prompt response from the son!
They waited till the lady was done with her work and returned to the counter. She saw Rahul and looked happy.
“These are my parents” introduced Rahul.
The lady bowed to them gracefully and smiled.
“Thanks for helping my son. We don’t know how to thank you enough”, said Mrs Shaw gently.
The lady did not say anything. She showed few gestures with her hands, which neither of the Shaws understood. All that they could make out was that she was using sign language used by verbally handicapped.
“Oh my God! She cannot speak?” said a shocked Mrs Shaw.
“Not just that. She can’t hear, read or write either. She is employed by the school to keep the library clean” said the Library in-charge who was passing by.
The parents looked perplexed. Mr Shaw came out of the shock and demanded with his son: “What sort of help have you got from her that improved you so much? She can’t teach you any academics; she doesn’t know how to write. Forget other things – she can’t even hear you.”
Smile could not leave Rahul’s face. “She does far more than hearing, Dad. She LISTENS!!”

We often miss this point. Most of the times, we medical professionals hear or preach. We do not listen. I have a nice recall from my medical school times. One doctor who was considered just mediocre for his medical knowledge was very popular with patients. Similarly, another doctor we used to adore for the clinical acumen and great subject knowledge was a total flop with patients. When this was discussed amongst friends, we would flatly declare that the patients are foolish; they are so ignorant and dumb that they can’t even recognise a good doctor from a bad one. We felt that we knew the definition of “good” far better than the patient.
On the hind sight, now I feel that the patients were not outright foolish. They sought what they wanted and got it. The doctor who was mediocre in our view was good for them, because he LISTENED. Our “great man” either heard or preached. We often witness how emotional catharsis helps the patients in psychiatry. But, we fail to extrapolate the same for ourselves. Many a times, the patients need a soothing soul to pour out their inner self. A good listener. But how many of us can afford to do so in our busy practise? When time becomes money for the professional, where is the scope to be a good listener? But, there should be a way out. There are many doctors who have successfully balanced both very nicely during their entire career. If you ARE one or know one, please communicate with our readership. Let the world “LISTEN” to you this time.

With this, let’s get back to our regular feature: Challenges in Pediatric Cardiology!

VIAGRA CONTROL

It has been few years that we are using sildenafil for the pulmonary hypertension and high PVRI. Indiscriminate use is one of the biggest challenges bothering the congenital heart care. We have seen doctors equating PAH with sildenafil. Despite all the efforts of journals and experts trying to create awareness on judicious use of sildenafil, the misuse is rampant. Is there is any role of Bosentan? How are comparative analogies between Bosentan and Sildenafil? Please let us know if any studies on this comparison are published.

LIMITATIONS OF VALVE

We had a 32-year-old with small subpulmonic VSD, bicuspid aortic valve and moderate AR. The issue was with the valve. No doubt that the VSD needs closure as per guidelines. But, is the valve repairable? If yes, then the effort is worth it. If not, then the patient needs valve replacement. Is the valve replacement worth in a 32-year-old, especially when the hemodynamic effect of VSD is small? What happens if the lesion is left untouched now? Is it possible to close VSD alone and not attempt the valve repair at all? All these questions bothering us, the patient data was placed in front of the surgeons. The surgical team decided to go ahead with the VSD closure and assured that the valve can be repaired. Their analogy was simple. If the VSD is closed with the AR left alone, the natural history of bicuspid aortic valve would be far superior to that with the VSD pulling the aortic valve cusp. If VSD is not tackled now, the patient may deteriorate faster. What is the experience with other centres? How would you tackle this scenario? Please let me know.

CONVENTIONAL CONFUSION

Sometimes, we wonder how fast we forget! Once we reach a level of practical comfort, the theory that was read becomes easily effaced. Same happened during one of our seminars recently. All of us remembered the classification of Tricuspid atresia as I, II, III based on great artery relations and A, B, C based on the pulmonary valve and pressures. Although I am quite fond of history, I had forgotten that the mentioned classification goes with the eponym of Kuhne. Our fellow, Dr Shweta, was presenting the seminar. She told us that the class IA was intact IVS AND pulmonary atresia, class IB was restrictive VSD AND pulmonary valvar stensosis. I wondered if the term AND is correct. The feeling was that AND should be replaced by OR/AND. However, she showed the reference from the text book (Moss and Adams). I was unable to get the original article by Kuhne et al. If anyone has any recall or has the original article, I request you to pass it on for the benefit of others.

LOCATION, LOCATION, LOCATION

I am yet to find a person who has completely understood the VSDs! This simple looking lesion can pose so many surprises, that the moment you get comfortable with it, a new problem, hitherto not experienced, pops up. In one of our discussions, our senior surgeon opined that the outlet VSDs have development of early PVRI compared to VSDs in other locations. The opinion was seconded by others. I could not recall any statement of this sort in the texts. I presumed the probable reason to be the proximity with pulmonic valve. It is likely that the hemophysiology of outlet VSDs simulate AP Windows to a certain extent. Is my presumption correct? If anyone can come with proper explanation with proof, you will be rewarded by a special mention in the blog; your name would be written in CAPITAL LETTERS!!

BLUE OR NOT

We were coursing through some of the interesting cases seen off late. We do have a series of single pulmonary arteries unpublished yet. One of such cases was a hemitruncus with intact septae. The question was: would this patient ever by cyanosed? If yes, why and how? I was emphatic that such patients would never have a cardiac cyanosis. The pulmonary artery exposed to the high pressure would eventually develop high PVRI and restricts the blood flow. The entire right heart output is going to single lung and it may eventually develop high PVRI. Till then, the patient should be pink. After bilateral high PVRI, the patient may have signs of low cardiac output and failure rather than cyanosis, unless the PFO opens up or pulmonary AV fistulae develop. Hence, clinically, the loudness of S2 would determine the status of the patient. Soft S2 shows patient has at least one good lung and loud P2 shows the development of high PVRI in the hitherto good lung. However, there were some arguments against my logic. What is your opinion? We may not have seen such a scenario, but may logically conclude the outcome. Let me know your takes on this issue.

This scenario marks the end of another post. Let me get the suggestions and answers to all these queries. Put them in the comments box or mail them to drkiranvs@gmail.com Let’s see how best this platform can be utilised for the purpose of mutual learning.

Regards

Kiran

Tuesday, March 9, 2010

Welcome to NH blog. This is Dr Kiran.

From last post, we decided to put some anecdotes which carry a greater meaning than what meets the eye. In the attempt, I have picked up this small story one of my friends told me once. She also had no recall where she heard the story. It may very well be getting transmitted verbally from many. If this story is in print anywhere, I would be indebted to know the same from the readership.

The story goes something like this:

A board hung on a pet store caught the attention of this young boy of nine.
PUPPIES FOR SALE
Boy slowly went into the shop and smiled at the plump owner.
“How much are the puppies?”
“It would be Rs 300/- each. We have left with only seven more. Have cash or wanna come back with dad?”
The boy meddled with his pockets, brought out some change and counted.
“I have Rs 45/- only now. Can I see the puppies?”
The store owner was a kind man. “Come on in!” he said.
As the boy got in, he found seven cute creamish puppies running hither and thither. A smile laced his face. To his surprise, he found the eighth puppy limping along.
“I heard seven. But they are eight out there!”
The shop keeper looked down the place and said:
“Oh, that’s a defective one. We showed him to the doctor. This puppy has some problem in legs by birth. I have not included him in the list”
“Will he always limp like that?”
“Yes, my boy. Thats why I did not tell you about him”
“I want to buy him!” the boy said.
“No point, child. I don’t even have him in the list. I don’t want to sound cheating a little boy. If you still think you want him, I will give him to you for free.”
The boy’s face grew red. He sounded angry. “Please don’t use the word ‘free’. I don’t want him free. I want to buy him. He is worth the same as all his other siblings. You please keep this Rs 45 as advance and book him for me. I will send my father to pay the rest.”
The shop owner was perplexed. He also had the admiration for this small boy at the same time. He tried to convince the boy.
“I think you should consult your parents before making this decision. You see, this puppy is never going to be a normal, playful one. You will never be able to take him out for fun. There is no chance of you jumping and playing with him.
The boy smiled, “You are wrong”. He slowly pulled his pant up. It showed steel braces around his deformed leg. “It is not about this puppy. Even I can’t run around and jump either. We make a pair because we can understand each other!”
The shop-owner was speechless.

It takes lot of empathy to understand the feelings of patients’ companions. It becomes glaring when the tables turn. I remember our erstwhile boss writing to all of us when her father was in the ICU of a prestigious hospital at Hyderabad. She came back after the demise of her dad and was so full of new ideas about patient care and communication. She could feel for all the parents waiting in the lobby just to hear something about their patient by one of the personnel from inside. She emphasized the need for more frequent, easy and meaningful communications with patient party. She urged the importance of supporting the family at the times of distress and impending death. She conceived the idea of keeping the patient happy till the last moment by creating an atmosphere of solace for everyone. She suggested that we should allow the parents to stay bedside during the last moments of the child and the mutual satisfaction that can be provided when the parents can hold the baby’s hands in those moments. She mooted the proposal of making the end as beautiful as possible for the tender hearts.

Not that our brilliant boss could not have thought of all these issues prior. She probably had in bits and pieces. However, everything got crystallised into a solid structure when she went through the experience with tables turned around. She could empathize with her patients better after her experience with her father’s demise. One example of how a committed person would see the changes around with a positive outlook.

Let me know your views on it. Also, if you have read or heard of small anecdotes, please send them to me. Your contribution would be promptly acknowledged!

With this, let us get back to our regular feature: Challenging scenarios.

IS THIS TRUNCUS POSSIBLE?

I remember sometime back when a cardiologist from a small volume centre presented Truncus arteriosus with intact interventricular septum. We were smiling at the possible embryological nonsense. The shock was on us when we saw a baby with same diagnosis. Our surgical team questioned the well being of cardiology team when we mentioned this to them. We showed them the echo images to stun them. Our enthusiastic fellow, Dr Karunakar had already gone a step ahead and pulled out a couple of articles from his bag on the previous case reports of Truncus with intact IVS! The question was of the management. This 2-month-old was not very well at presentation. The surgeon went through the literature and had a couple of plans for him based on the anatomy on the table. Sadly, the baby did not make it to surgery and expired in the ICU. This is the first time we had come across any Truncus with intact IVS (we have operated 115 cases of truncus so far at NH). Please let me know if you have seen a truncus with intact IVS and how it was managed.

UNANSWERED McGOON

This has been a perpetual question that might have haunted generations. Probably, I have posted it earlier also. When one of the pulmonary arteries is far smaller than the other and the McGoon’s ratio becomes acceptable, what is the approach to be taken? We often see the surgical and cardiology teams split on the issue. What are the opinions from other centres? Please let me know your expertise in it.

WHOLE OR HOLE?

We had an eight year old with DORV, d-malposed great arteries, VSD, pulmonary atresia and intact IAS. This child saturated 78%. Although there were 2 good sized ventricles, the VSD was not routable. The question was whether to create a BTT shunt or to go for a BD Glenn shunt. The house was spilt on the decision. One half felt that the BTT shunt might be better, as BD Glenn has long term issues. The other half felt argued that the volume load on the ventricle by a BTT shunt would be detrimental on a long run and BD Glenn would serve more than one purpose. It was decided to measure the PA pressures on the table and go with BD Glenn if OK; otherwise to settle for BTT shunt. The other interesting question was – whether an ASD would be required in this case? Since the aorta was more committed to RV and VSD was just reasonable subpulmonic type, should this baby have an ASD to compliment mixing? This was a tough question to answer, as the surgeries proposed were off-pump and to create an ASD, one need to go on-pump. The surgical team could not recall any similar situation from their kitty of experience. Neither was the cardiology team sure of the answer. If anyone had such experience, please enlighten us.

BEHAVIOUR: BEFORE AND AFTER

We had a couple of children with VSD, PS, small RV and had gone through BD Glenn shunt few years back. Now, they returned with progressive restriction of VSD and symptoms. RV was suprasystemic on cath study. The RV EDP had gone up beyond the permissible level for Fontan completion. Although the Glenn shunt was still partially functioning, it was probably a matter of time. How should one go about such situations? Creation of a larger ASD may serve them for few more years and not a long term solution. Is there anything like enlarging or creating a VSD? The surgical team quoted “Prohibitive risk”. Is it the final word? Is there anything that can better such situations? Please tell us about your experiences.

ORTHOTOPY Vs HETEROTOPY

An interesting observation was quoted by one of our senior cardiologists, Dr PV Suresh. Amidst his ever-flowing OPD patients, he had observed the natural history of pulmonary homografts in Rastelli Vs Ross procedures. His observations showed that the Ross homografts behave far superior to the Rastelli homografts. He was seeking the possible explanations for this. The surgical team was represented by Dr Shekar Rao, who has exhaustive experience in both the procedures. Apart from the individual magnitude of both procedures and patient selection, Dr Shekar Rao quoted the advantages of orthotopic positioning of Ross homograft and possible disadvantages of heterotopic positioning of Rastelli homgrafts. The discussion was interesting for senior group and eye-opening for the freshers. We ended up understanding the hemodynamic variations of a 3-D angulation of cardiac structures. It is always emphasized that we cardiologist should have a mental 3-D reconstruction of anatomy with the 2-D data what we get from conventional imaging. This time, we could gauge the 3-D physiology also! We are indebted to both our senior consultants for the new light. Not to boast of ourselves, that’s probably what makes NH a sought after place for students!!

END OF AN ERA

After going through a series of emotional tides, the NH team is settling now. Dr Sunita Maheshwari, our beloved “Boss” decided to quit her post from NH to make space for her dreams. The decision was greeted with surprise, anguish, shock, anger, sorrow and mix of emotions from other team members. The Fellows were not very happy with the development, although it does not affect them on a long term. Such was the gravity created within. On the day of commemoration of a decade of Pediatric cardiology in NH, we also witnessed the handing over of charge to Dr PV Suresh. Although Dr Sunita has promised to come once a week for teaching, we know it is not long term happening. Personally, I feel that Dr Sunita’s achievement lies in the fact that she has prepared the department for her absence. It is no doubt the sign of a leader with a positive vision. Now, it is left for the team to honour her by achieving greater heights despite her absence. That’s one way I think we can thank her. We all wish for an uninterrupted flow of her creative energies and scaling of greater heights she is ever capable of. Adieu.

That brings us to the end of another post. I am yet to receive any comments for the new effort. Please let me know if it is worth continuing. Come out with any better formats for presentation. Put them in the comments box or mail them to drkiranvs@gmail.com I shall consider them seriously and get back to the readership. I hope to get more frequent henceforth.

Regards

Kiran