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

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