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!


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.


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.


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.


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!!


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 Let’s see how best this platform can be utilised for the purpose of mutual learning.



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