Wednesday, July 28, 2010

Dr Kiran hellos everyone. I had a good response for the previous couple of anecdote written by two friends. We shall see another anecdote now, followed by our regular features: Interesting learning scenarios in Pediatric cardiology and the popular “pediatric cardiology pearls”. The anecdote I have written this time was read few years back. I have expanded it a bit, but have retained the first-person narration of the original.

Please read and send your comments:

During my school days, there was a boy who was adored by everyone. He was not the class topper, he was not a champion sportsman, he was not an orator, he did not have great looks, his father was not the richest man in the community, he did not know any music, and he was, certainly, not a celebrity. Yet, he was liked by everyone. For the simple reason that he was good!

I wanted to know what made him so good that he was liked by all. I could sense that I could trust him; I could believe his words for he never lied. I was fond of him because he seemed to have a very simple and honest solution for every problem!

One day, he invited me to his home. I was curious to know where he lived and how his parents were. I went with him.

It was a very humble house; small, neat and clean. The utility of space was evident. I knew that my house was three times as big, but was pretty cluttered.

“Can I meet your parents?” I asked him.

“Both my parents work. They are not back till 6 PM. My elder brother has gone to tuitions and I am alone as of now”, he replied.

I recalled a joke of 10-year-old who answered the door bell of postman with a cigarette in one hand and a beer bottle in the other. “Is your dad in?” asked the postman. The kid laughed and replied, “You are a dumbo. Would you expect me in the house like this if my father was in?” asked the kid! I would have taken the opportunity of solitude to the hilt. Whereas, my friend appeared to be too good for a normal boy!

“You mean, there is no one to watch you over and still you are so good?” I asked him.

“There are certain principles that we live with in my house. They are not rules. There is no punishment if you break them or no reward if you follow them. But, I have experienced that I win applauds by following them. As for getting naughty, yes we do. But it never reaches a stage of destruction!” he replied.

“What rules…er… principles?” I started wondering now.

“Would you like to see them?” he asked doe eyed.

“See the principles?” I wondered.

“Come”, my friend led me towards a wall. There hung a sheet of parchment with neat writing in lines. Almost everyline had a different handwriting.

I read some of them:

 Do unto others as you would have others do unto you
 If you open it, close it.
 If you turn it on, turn it off.
 If you unlock it, lock it up.
 If you break it, admit it.
 If you can't fix it, call someone who can.
 If you borrow it, return it.
 If you value it, take care of it.
 If you make a mess, clean it up.
 If you move it, put it back.
 If it belongs to someone else, get permission to use it.
 If you don't know how to operate it, leave it alone.
 If it's none of your business, don't ask questions.
 If it will brighten someone's day, SAY IT!
 If what you have to say will hurt somebody, DON'T SAY IT!
 If something isn't broken, don't try and fix it.
 If you think you know it all, look around and see how little you really know.

I just kept looking at them. None of those lines seemed great. They were all simple instructions, much like what are written in the operating manuals of appliances. In fact they were nothing compared to some of the “good habits” books I had read. But the simplicity did strike.

“What are these? What exactly these lines have to do with the discipline and good behavior?” I asked him with an element of surprise.

“These are the practical principles that we follow! There is no compulsion of following them. As I told you earlier, there are no rewards or punishments attached to them. But the effect of following them is really rewarding. I do follow them very honestly. You can see what I get from everyone!”

“How do you do it?” was my question, still with the tone of surprise.

“Whenever something good strikes any one of us, we discuss the point during our dinner with all family members. The elders in the family refine the content and make it a single line principle. The person who proposed the principle will get to write the line on the sheet in his own handwriting. Once written, we all try to follow it. As you can see, there are different handwritings on the paper. Every morning, we go to the paper, read everyline with maximum concentration that we can. Even though it is a routine and I know most of them byheart, I try to make this morning affair interesting by analyzing how many of them I have followed the previous day and how many I have broken. When there is a chance for rectifying, I do it honestly. Since they are very simple one liners, we tend to remember them for long time. It has not only won me credits, it has also definitely helped in character building.”

I was struck for a while. I took me sometime to appreciate the simplicity yet the power of routine. “It is so simple to be good, but it is so difficult to be simple” was a bollywood quote I had appreciated sometime back. It seemed to manifest in the simple abode of my friend.

The above anecdote is a true life incident I had read, narrated in first person. “Trifles make perfection and perfection is never trifle” was the life motto of Michelangelo. I felt that not only every house but every workplace should also have such a chart of principles that are practical yet simple. Seeing them everyday would be inspiring and seeing the people follow it may end up whipping the “lazy bums” of the department from their inside. Would you like to have one in your home or workplace?

INTERRUPTED PROBLEMS

We saw a 9-month-old with very complex anatomy. There was a PFO shunting left to right, supramitral membrane, large subaortic VSD, complete (100%) DORV, NRGA, large conus with subaortic obstruction, small bicuspid aortic valve (Z score of minus 3), Type B interrupted aortic arch, severe PAH and large PDA continuing as descending aorta. In a cyanosed crying child, the echo took almost an hour to delineate the anatomy. The mere description of components can discourage the surgeon from any management. How to tackle such cases? It is a combination of Shones complex with complete DORV. The small aortic component does not permit too extravagant surgeries. Is there an option? Can we think of DKS in such cases? Arch reconstruction strategy would depend on what we do proximally. Is there an option of a 2-pump repair in such complex anatomies? Please tell me your opinions on this.

EISENMENGER ISSUE

There was an interesting discussion. Our surgeons maintained that the residual VSD of post-TOF patients, howsoever big the VSD might be, does not develop Eisenmengarization! Physiologically, this statement does not make much sense. But the surgeons maintain their stand, as they have not seen a single case of such physiology till now! Is there any physiological explanation for this? Is it because of the paucity of such cases that it is largely unseen? Let me know your views on it.

TO GLENN OR NOT TO

In a patient of cTGA with VSD with conventional repair (VSD closure to convert it to classical cTGA), is there a role of adding a Glenn shunt if PA pressures are acceptable? One of our senior surgeons felt that a role exists. But, logically, this would offload the MLV. The crux of the issue is MRV which is systemic. The MRV preload and afterload would not change. Why should one add a Glenn shunt in such a scenario? If anyone has any more details on this, please start a discussion.

CUT-OFF LIMIT

Is there a limit for the extent of cyanosis in admixture lesion s as against low Qp? We see huge variations in the levels of cyanosis in low Qp situations. Sometimes, even with good admixture, the SO2 would be low in few. We had a patient of cTGA with DORV and non-routable VSD. The child had SO2 of 65% but the Qp/Qs was 3.8:1! How should such instances be treated? Let me know your takes.

MITRAL PUZZLE

How far the PML mobility characterizes the MV involvement in RHD? We often see children with classical history of acute rheumatic fever with significant mitral regurgitation. Many of them have nicely mobile PML. How should we term them? Should we say that they are a combination of Acute rheumatic fever with non-rheumatic MR? How would the management change? Let me know your opinions.

PEDIATRIC CARDIOLOGY PEARLS

61. In cardiac CT scan, when manually injecting a small dose of contrast, the delay from the start of injection to start of scanning is approximated by a circulation time of approximately 12 to 15 seconds. (Siegel MJ. Multiplanar and three-dimensional multi-detector row CT of thoracic vessels and airways in the pediatric population. Radiology. year 2003 page 641)

62. In the cardiac catheterization, in the absence of a shunt, a step-up of >6% at the atrial level, 4% at the ventricular level, and 4% at the great vessel level will occur in <5% of the time. Variations of >9%, 6%, and 6%, respectively (i.e., three times the standard deviation), would be expected no more than 1% of the time, thus would be highly unlikely in the absence of intracardiac shunting. This is the mark of significant step up in cath data. (Freed MD, Miettinen OS, Nadas AS. Oximetric detection of intracardiac left-to-right shunts. Br Heart J in year 1979 page 690)

63. Shorter refractory periods may facilitate the conduction of very closely coupled impulses and could render the newborn atrium more susceptible to intra-atrial re-entry. This may partly explain the occurrence of atrial arrhythmias such as atrial flutter in the otherwise healthy fetus or newborn infant. (Pickoff AS and others. Atrial vulnerability in the immature hearts. Am J Cardiol in year 1985 page 1402)

64. Even in the current era, congenital heart disease is the most common predisposing cause of brain abscess (Goodkin HP, Harper MB, Pomeroy SL. Intracerebral abscess in children: Historical trends at Children's Hospital Boston. Pediatrics in year 2004 page 1765)

65. Kawasaki disease is a panvasculitis. Most of the morbidity and mortality in affected patients is due to coronary artery aneurysms and associated complications. (Fujiwara H, Hamashima Y. Pathology of the heart in Kawasaki disease. Pediatrics in year 1978 page 100)

That brings us to the end of the present post. Please send your inputs to drkiranvs@gmail.com Since some fresh blood is getting infused to NH team, I hope to give you all something fresh!

Regards

Kiran

Tuesday, July 27, 2010

This is Dr Kiran helloing everyone. I had a good response for the previous anecdote written by a friend. I am presenting the present one written by another friend. Thanks for the infectious zeal! This will be followed by our regular features: Interesting learning scenarios in Pediatric cardiology and the popular “pediatric cardiology pearls”. First - the anecdote: any resemblance to anyone living or dead is purely coincidental!!

Mrs Ana was enjoying her new dress in the mirror. Her husband, Mr Mike had done the payment after much reluctance. “You must dress your age and profession. You work amongst the public; these are too loud” was his argument, but she would not listen.

Mrs Ana started combing her hair, but the image in the mirror did not! She was surprised. She started waving her hand frantically, but the mirror image stood still. She got afraid and wanted to scream, but the voice did not erupt off her throat.

“Cool down”, the mirror image told her. The reflection in the mirror seemed having its own movements. Mrs Ana had no choice but to listen.

“How are your days going?” the reflection asked her.

Mrs Ana hesitated, but told “Fine”. Surprisingly, the voice had become normal.

“You are spending pretty much time with me nowadays!” said the mirror image.

“Well, you see, I am senior in the office now. My husband has come back from his posting. I have some spare time and I am trying to catch up.”

The reflection did not appear impressed. “How about your colleagues and seniors in the office? Do they have equal spare time?”

“They don’t. They still work like mad. In fact the work has increased. I pressurized the boss to hire few juniors. I clearly told him I cannot work more.”

“How is your typical day?” the mirror still did not look impressed.

“I go at around 10 am. By then, my seniors would have done the apprentices’ training session. I hang around for an hour. Then I go to the office gym. Stay there for an hour and a half. Come back and work for an hour and I go to lunch. After an hour of lunch break, I tell the others that I have to go to bank. Spend another hour hanging around at various places. I come back to the workstation by 3.45PM. By 4, I tell them that I have to attend to my family and leave for the day.”

“Very interesting” said the image sordidly. “How about your seniors?”

“As I told you, they work like mad. They start at around 8.30 AM, train the apprentices, start the work, go on till 2 PM. After the lunch, they continue till 5 or 5.30 PM. Few go on till 7 PM also.”

“How do you escape so easily then?”

“You know my previous boss. She was from my own community. My husband was working outside and my kid was young. So, out of sympathy of being a single mother, she gave lot of relaxations to me. She also paid me extra money as my husband was not earning. Both of us together made one of my colleagues a jackass and made him do all my extra work. We kept telling him that I am taking a pay-cut and he gets relatively more money than me. That idiot believed us and did all my work!! Stupid fellow.”

The image started getting blurred and came back. “You know, legally single mother is the term used for divorced or husband-dead ladies with children, unless they are unmarried and have adopted a child.”

“I do, but my stupid colleague did not” giggled Mrs Ana

“Do you justify what you did was correct? What would you have done if someone else had duped you like this?”

Mrs Ana was stern. “First, what I did was entirely wrong. Second, I would have kicked any person who would have done the same to me. After all this, I think I can still get away because I think I have killed my conscience. But the surprise is, why am I telling all the truth to you that I had hidden inside me all these while?”

The mirror image smiled. “Your first assumption is wrong. I AM your conscience. Second one is right. You can cheat the entire world but you cannot lie to your own conscience. The decision to make me reappear guilt-free or to make me vanish forever is left to you.”

The mirror image faded away leaving an awestruck Mrs Ana.

The above anecdote refers to all the black sheep who wish to outsmart their peers with the help of superiors who misplace the priorities. Work culture and ethics are relatively new terms in the western work-front, but are age-old in the Indian systems. There are numerous anecdotes in our epics and history on how an individual should work holding on to ethics and not cheating the final witness: the one’s own conscience. It is secondary whether such people get punished or get their due for wrong deeds in the outer world. It is probably more important to keep our own conscience free of guilt. The problem is in dealing with such people. They become a blemish and bane on the system. Such liabilities bring down the overall morale and work efficiency. When such characters go unpunished, they either simply spread the infection of indiscipline to others or make the honest workers rebel against the system. Once a critical number of such people are reached, the system collapses. It is for the people at power to decide whether such black sheep should be allowed to exist or perish in the system. Let us know how you deal with the “black-sheep” of your firm.

With this, let us get back to our regular feature: Interesting learning scenarios

A BANDED QUESTION

It is maintained that the best time for PA band in any infant with PAH for future single ventricle pathway is by 1 month. Although many surgeons would like to wait for some more time, the general opinion is for 1 month of age. Are there any studies which support this? What is the natural history of infants who were banded for future SV physiology between 1 month and 6 months of age? We often come across such children. One observation is the disparity in the mean PA pressure and ventricular EDP in such children. We generally get a bit liberal with mean PA pressures and plan a BD Glenn for them with the idea that the pressures may come down with the Glenn shunt. Few advocate tightening of PA further. What is the general consensus on this? Please send in your institution policies.

TAKAYASU DI(E)LEMMAS

It was a learning experience. We saw a 12-year-old girl about 3 months back. She had MVP with mild MR and trivial AR. The LV was disproportionately dilated. We did a detailed clinical examination and did not find any structural anomaly. The anemia was evident. Blood investigations showed anemia with dimorphic blood picture. We advised hematenics and follow up after 3 months to see the response. When she came for follow up, we could clearly see the clinical evidence of Takayasu arteritis. The disease process probably had shown some evidence of its presence, but we could not pick up at the inception. By the time we could pick up, the disease had shown its effects. Is there any way we could have diagnosed the problem at the beginning? Please let me know if you have found any methods.

SPINE Vs CEREBRUM

Continuing with the same issue, how effective are the interventions done in patients with Takayasu arteritis with activity in end stage? Although my seniors are optimistic, I am yet to come across any single kid with end stage Takayasu arteritis intervened and made it to another year. It is true that the morbidity comes down for few months, but the mortality factor does not seem to change much. Considering that isolated balloon dilatation is of limited value and cost of stents is usually not bearable by the poor family, it is largely an ethical question. One junior colleague of mine probably had a better expression: “We spend only spinal cord for managing any medical problem of a patient because we would have burned up our cerebral cortex for thinking the financial and social implications of the problem for the family!” Should there be a consensus for the limited finance set-ups for managing the problems whose outcomes are questionable? No one probably has enough time to think of how the family suffered to arrange the finances to treat a fatal condition with negligible outcome. The family would not have understood either the problem or the treatment, forget the chances of success. In a very high-volume centre, where is the time for one-to-one interaction? Such might be the problems of the third-world, but these are the issues which maintain us in the third-world!

BANDING THE HOMOGRAFT!

This one was a real test. We had a 7-year-old who underwent VSD closure with RV to PA homograft about 2 years back outside. Few small additional muscular VSDs were documented and were probably hoped to get spontaneously closed over time. The child was lost for follow up and presented to us one day with failure. The muscular VSDs appeared sizable. On cath, there was a significant step-up. However, the lesion was typically swiss cheesed and there was no single sizable lesion. Together, the hemodynamic effect was significant. How to handle such scenarios? The VSDs were so small that they could not be closed individually. Since it was a homograft, the option of PA band also did not exist. How to deal with such a scenario? Please let me know your options on this.

TERMINOLOGY

How would you classify tricuspid atresia in the setting of cTGA as per Kuhne’s?! The left sided TV would be atretic and the great arteries would be L malposed. Should we call it type 1 or type 3? Although many classifications are accepted for tricuspid atresia, the most used classification does not involve this scenario. Please let me know your take on it.

PEDIATRIC CARDIOLOGY PEARLS

56. In neonatal IE most cases occur in structurally normal hearts. Although relatively uncommon, increasing numbers of cases of neonatal IE have been reported since the 1970s. This reflects the increased use of prosthetic intravascular devices and more frequent insertion of long-term indwelling central venous catheters. (Ferrieri P, Gewitz MH et al: Unique features of infective endocarditis in childhood. Circulation 2002 page 2115)

57. Genetics in CHD have curious angle of research. Investigators from the Baltimore-Washington Infant Study analyzed the rate of precurrence – which is the number of currently affected relatives at the time of birth. These studies demonstrate substantial rates of familial disease and suggest that CHDs may not be as sporadic as once thought. (Boughman JA, Berg KA, Astemborski JA, et al. Familial risks of congenital heart defect assessed in a population-based epidemiologic study. Am J Med Genet 1987 page 839)

58. Although currently an unproven hypothesis, the potential neurodevelopmental advantage to be derived by the affected neonate who avoids acidemia may, in the long run, prove to be the most important long-term salutary effect of prenatal cardiac diagnosis. (Lavrijsen SW, et al. Severe umbilical cord acidemia and neurological outcome in preterm and full-term neonates. Biol Neonate 2005 page 27)

59. Two kinds of atrial receptors have been described. Type A receptors fire during atrial contraction and respond to changes in atrial pressure, and type B receptors fire during ventricular systole and respond to changes in atrial volume. Type A receptors stimulate and type B receptors inhibit sympathetic activity. These stretch receptors provide feedback to the hypothalamus and inhibit secretion of antidiuretic hormone called vasopressin (Little RC, Little WC. The output of the heart and its control. In: Physiology of the Heart and Circulation. Chicago: Year Book Medical, 1989 page 165)

60. The first reported case of autopsy-proven myocardial contusion was in 1764; it described a boy struck in the chest by a plate! (Akenside M. Account of blow upon heart and its effects. Philos Trans R Soc Lond Biol 1764 page 353)

With that, we come to the end of another post. Please let me know your opinions. Send in your comments and contributions to drkiranvs@gmail.com


Regards

Kiran

Saturday, July 17, 2010

This is Dr Kiran welcoming everyone to the new post. My last post did get me few responses: One of the doctors who read it commented on some of the practical patient management techniques he has been following for past few years. One of which was the use of frozen betadine! He freezes betadine solution in the freezer into small cubes. He uses those cubes to sterilize and prepare the skin before IM injection. The temperature numbs the skin and betadine provides the antisepsis. He says that none of his patients have ever complained of injection pain and no incidence of any injection abscess in the last 25 years! In fact, he claims that he is famous as “Painless injection doctor” in the locality.

“Not everything in medicine needs to be FDA approved” was what Dr Passi had written in his article. It is indeed true. We can innovate; we can change things for better and simple. The above example of using antisepsis is inspiring. I don’t know how many doctors are using the same technique, but I heard this for the first time. Please send me the details of any innovations that you are doing. Let us share them with the readership.

With this, let us start our anecdote. This was sent by a friend and I have retained his own style of narration. Please read this and discuss amongst your colleagues:

Mrs Fragrance was exposed to bright light, but her eyes were comfortable. She did not know where she was, for all that she could see was just bright light.

“Welcome Mrs Fragrance” said a deep, baritone and pleasant voice.

Mrs Fragrance could just hear the voice. The light was so bright that nothing else was seen.

“Where am I? Who are you?” Mrs Fragrance asked in a scared voice.

“You are at the court. This place decides your next journey. It can be the heaven or the hell” said the baritone.

“You mean, I am dead?”

“No conclusions at this place. You are at junction of unknown and uncertainty. Please answer some questions. It will be over soon.”

“OK”, Mrs Fragrance was uncertain.

“You can tell something about yourself.”

“I was working as a school teacher; I taught 4th standard students. I was very pious and God-fearing. I have lived a good life.”

“What subjects were you teaching?” asked the Baritone.

“I was supposed to teach them all subjects – like mathematics, science, history and so on. But everyday, I taught them ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’”

“Only those rhymes instead of all the subjects you mentioned to 4th standard students? Don’t they need better quality than that? It never occurred to you that 4th standards do not need ‘Jack and Jill’ anymore?”

“I did my best. I worked very hard to teach them the rhymes because I could not do any better. Coming to all the other harder subjects, I used to make the trainee teachers working in other departments do those difficult jobs.”

“Was it the duty of trainee teachers to do all these?” asked the surprised baritone.

“No; it was not. In fact, it was very hard for them to do my work. Still, I made them do it. I was very close to the head-mistress. I used that influence to get those trainees do my work. Since the trainees were afraid of head-mistress, they used to do it without much resistance.”

“Why did you not hire a junior teacher to do your work?”

“I could have. But, I wanted to show the administration that I was doing all the work. More so, hiring a subordinate would be sharing my income. I wanted all the profit for myself. Since, the head-mistress was close to me, I could do all this. By the time the head-mistress retired, the trainees had no idea that they were actually doing my job and did everything silently thinking that it is their work.”

“You never felt you were performing sub-optimal?” asked the still surprised baritone.

“I always did my best. I spent hours together in teaching ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’ to all the 4th standard students over years. You know how sharp these kids are. They refused to learn those old rhymes and few even demanded learning other subjects. I scolded them nicely and forced them to learn what I knew the best. But, some of my colleagues had objection. They felt that my teaching is inferior and referred few kids to other teachers. But, I brought this to the notice of head-mistress and penalized those stupid colleagues.”

“Mrs. Fragrance,” said the baritone. “Let me get it correct. You were supposed to teach normal 4th standard students and all that you taught them was ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’. You made poor trainee teachers who did not even belong to your department do all the hard work that was supposedly yours. You used the influence of your head-mistress in the entire wrong doing. Throughout your life, you have never kept the standards. Still, you convinced the management that you are doing all the work. You made all the money without even hiring an able subordinate. Some unlucky trainees were always there to do your work at the cost of their learning. You still think that you were hard working and deserved all the good things that happened to you all this time. Am I right?”

“Yes” said Mrs Fragrance. “Even though many in my own department used to joke, I was very honest in teaching ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’ to all the higher class students. I think I have done my job the best way. More so, I always attended churches. I used to apply leave or just scoot out of the job during working hours to attend the prayers and as many places of worship as possible. I must have attended more churches than any other person in my city! I was always pious and God-fearing.”

“Who would see your regular school work on all those days when you attended the places of worship?”

“The trainees. I used my influence with the head-mistress to make the trainees do my regular work. In fact, in my absence, they used to do all my work and the management was not even aware of my absence. I was paid even for my absence. Good terms with head-mistress are very important.”

“Final question, Mrs Fragrance” the baritone said. “Do you think you deserve heaven or hell?”

“Definitely heaven. I have sincerely taught nursery rhymes to 4th standard students with best of my ability. I have attended all possible places of worship, even at the cost of my own work and by applying as many legal and illegal leaves as possible. My head-mistress always felt that I was very good. I should not go anywhere other than heaven.”

The baritone started laughing. The laugh grew so loud that it filled the place more than the light. Mrs Fragrance started feeling a bit uncomfortable and …….

……she opened her eyes to the reality.

The above anecdote is written by one of my close friends who got inspired by the previous anecdotes I have been posting in this blog. He is a dedicated pediatrician working in a government hospital. He was expressing his concern about the poor quality of people working with him and how they were misutilising the system by the aid of their contacts with higher up officials. I encouraged him to write a story and he did. It is his first attempt and he seems to have done a good job! The point is, these underperformers exist in every system. Most of such people make themselves a liability for others. They are tolerated either due to fear of their contacts, for respect of harmony in workplace, by exploiting junior people to compensate for their laziness. Such black sheep shamelessly celebrate their mediocrity to pain the rest. One of the highly revered vice-chancellors of Bangalore University, Dr HN told once: “There are 2 classes of people; those who work and those who take the credit for the work! The battle in the second category is fierce. One would do very well in the first category.” Is there any example of how such people were set right? If anyone knows the tactics, please enlighten our readership!

With that, let us get back to the regular feature: Interesting learning scenarios:

A TETHERED QUESTION

We saw a 5-year-old with tethered STL of tricuspid valve. The origin appeared to be from the crux, but the STL effectively started off from 18mm from crux. Till that point, it was finely tethered, which could be made out on a high resolution with zooming. Surprisingly, the ATL was sail like. In a case of isolated tethered TV, does ATL also get involved? Is the ATL involvement a corroborative evidence of Ebstein’s anomaly? Please let me know your ideas about it.

VOLUMES, VOLUMES

It is always maintained that the saturations are not the criterion for BD Glenn shunt. The criterion should be the volume reduction. Hence, even when the baby with single ventricle physiology is saturating more than 90%, it may still be prudent to go ahead with BD Glenn even at the cost of some desaturation. If this is the case, why is SO2 taken as a criterion for Fontan completion? In India atleast, there is lot of resistance for Fontan completion. It is always maintained that the patient should earn Fontan completion than it is being given. SO2 plays a major role in pushing the surgeon for Fontan completion. Should we not have same criteria for BD Glenn and Fontan completion? Are the complexity and the presumed Risk/Benefit ratio the hitch for Fontan completion? Are we still at the learning curve for Fontan? Let me have your opinions on this issue.

COLLATERALS IN EISENMENGARIZATION

We had an interesting scenario for discussion. A middle aged male came with TGA, VSD, PAH. He was Eisenmengarized by opinion and natural history. However, his presenting complaint was hemoptysis. He had bouts of blood being coughed out. Cath study showed multiple collaterals. The pertinent question was: Is collateral formation possible in Eisenmengarised patient? The opinions were divided. Few were categorical that the collateral and Eisenmenger do not go together. Few had an opinion that not all the lobules of lung are equally Eisenmengered and those which are affected less might have developed the collaterals. Few felt that the pathology was different from Eisenmenger and should be evaluated, as proving Eisenmenger in this anatomy was not possible. Cardiac CT led to more complexity, as it gave a DD of sequestration too! However, sticking to the basic question, please send me your ideas on the combination of Eisenmenger and collateral formation. What is your opinion? Do you have a separate analogy or do you agree with one of the explanations offered by our team? Please let me know.

TWO POSSIBILITIES

What do you think is the suitable cut off age for a two-stage arterial switch surgery in those infants who come a bit late? We had a 2-month-old with dTGA, PFO and regressed LV. The option of 2 stage arterial switch is always there. Our surgical team is divided in opinion. One senior surgeon believes that the 2 stage arterial switch is a futile exercise and has not shown benefit in long run. He feels that the Senning palliation would be much superior to the hurried 2 stage ASO. The other senior surgeon has opposite opinion and prefers 2 stage ASO to Senning anytime. What is the opinion of the readership? Please let me know how you have been handling such scenarios.

CORONARIES FOR RESCUE

It is a rare thing for the pediatric cardiologist to chase the coronaries fervently. Barring the cases of tetralogy, TGA, Pre-Ross assessment, ALCAPA, Kawasaki and few more, the coronaries are not the area of interest. It so happened that coronaries came to the rescue. We saw a baby with VSD with two great vessels, one of which was hypoplastic. The orientation of posterior great vessel was towards left. The anterior vessel was hypoplastic with a gradient of 70mmHg. The arch vessels could not be visualized. The PA confluence was absent. We could not see the LPA. Supply to the right lung appeared to be from few AP collaterals. The arch appeared to be right sided with a right PDA. Overall, the picture of anatomy distal to semilunar valves was totally unclear. The differentiation of PA from aorta was largely dependent on the coronaries. We ended up chasing the coronaries to determine the great vessels, keeping the possibility of ALCAPA aside! If you were made to chase the coronaries as fervently as we did, please let me know the reason.

PEDIATRIC CARDIOLOGY PEARLS

51. The echocardiographic findings in boys with Duchenne muscular dystrophy correlate with the autopsy findings of posterior epicardial thinning leading to ultimate dilated cardiomyopathy. Studies have showed thinner left ventricular posterior walls, especially behind the posterior mitral valve leaflet, diastolic dysfunction, contraction abnormalities that progressed inferiorly, and temporally progressive wall thinning. (Goldberg SJ, Feldman L, Reinecke C, et al. Echocardiographic determination of contraction and relaxation measurements of the left ventricular wall in normal subjects and patients with muscular dystrophy. Circulation 1980 page 1061)

52. High-dose IVIG has been shown in many clinical trials to reduce the incidence of coronary aneurysms to <5% when administered for 7 to 10 days of the disease onset. (Newburger JW, Takahashi M, Beiser AS, et al. A single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute Kawasaki syndrome. N Engl J Med 1991 page 1633)

53. Administration of antibiotics during an episode of RF does not alter the course or severity of cardiac involvement. (Tompkins DG, Boxerbaum B, Liebman J. Long-term prognosis of rheumatic fever patients receiving regular intramuscular benzathine penicillin. Circulation 1972 page 543)

54. The most common cardiac manifestation of Juvenile Rheumatoid Arthritis is pericarditis. (Gedalia A, Giannini EH, Brewer EJ, et al. Prevalence of pericardial effusion by echocardiography in juvenile rheumatoid arthritis. J Rheumatol 1993 page 206)

55. Pericardial effusion has been reported in as many as 25% of patients infected with the HIV virus; however, large effusions are rare. (Starc TJ, Lipschultz SE, Kaplan S, et al. Cardiac complications in children with human immunodeficiency virus infection. Pediatrics 1999 page 14)

With this, we conclude this post. Please send your feedback to drkiranvs@gmail.com Your suggestions are welcome. Please narrate your experiences with the scenarios discussed and post some novel things seen by you hitherto.

Regards

Kiran

Friday, July 9, 2010

Dr Kiran welcoming everyone to the present post

This time, I am not writing any story or scenario.

I happened to read something about the creativity and medical education recently and got pained a lot.

Just sharing my feelings with the readership. Please comment. Use the comments box or my email drkiranvs@gmail.com

Please go through and discuss:

MEDICAL FEST A.L.A. IIT FESTS

“Give them any challenge and they are ready to do it” was the compliment given by my erstwhile Boss. She was talking of the IT professionals she has hired for her new IT venture. The glow and pride in her eyes was very evident. “They are too good. There is something in them that is not in….” the continuity was lost as if something stuck and topic was deliberately shifted to something else. I did not miss the point. I could complete the half done sentence. We are trying to dodge the unpleasant and that is not the way life goes.

Yes, it is true that the creative energies of everyone in the world is appreciated other than doctors. In the recent issue of Indian Pediatrics, Dr Gauri Rao Passi had rightly pointed one thing. He was talking of the IIT fest and all the new ideas that got a material form and displayed with pride in the fest. It stood as the testimony of the creative and lateral thinking of the bright student community of future engineers. In entire lifetime, can anyone recall a similar medical fest? All the non-academic happenings of medical college are limited to a cultural event with Anthaksharis ruling the roost.

Where exactly the things went wrong? Till 12th std, all the students of science stream go through the same process of learning. By and large, best of these brains enter the medical field. (It was atleast true till the IT boom) After that? We see the engineering students creating their own satellite launched by ISRO, we see the law students representing the country in international law fests, we see the architecture students winning applauds in international forums for their creative designs and so on. What about medical students? The maximum I can recall any medical student achieving is a prize in an essay writing competition. What happened to those “Best of brains”?

Have you ever been encouraged to do some lateral thinking during your basic MBBS training? Were you ever confident of uttering a novel idea that might have come to your mind? Did you anytime feel some lacuna in the medical curriculum and wanted to desperately modify something? How many times could you do all these in a state of fearlessness?

There are lots of reasons for a decline in the creative thinking in medical student community. Lot of it is realized only on a retrospect. The teachers who teach the basic medical sciences are usually discarded ones. Most of them chose to stick to basic sciences because they did not get a clinical subject for their post-graduation. Their frustration is usually evident. I have seen PGs of basic sciences who tried yearly PG entrance exam throughout their 3 year PG course in the hope of getting a “better subject”. They never concentrated enough on their own subject during the most important formative years of their post-graduation. How would you expect such people to become good and inspiring teachers for the younger lot?

In the paramedical field, the good brains usually have a “good” attachment! A really good pathologist or microbiologist would concentrate more on developing their lab practice than teaching. But, the relative numbers of “better” people are certainly higher than in basic sciences.

By the time a student of MBBS reached the final year, the phobia of exams would surround to such an extent that it is blasphemous to think of anything other than the text book. Although really inspiring teachers may exist, the vision of a final year medical student fails to acknowledge it. For most of the students, a mediocre teacher who can consistently rant out the “Exam questions” or “Viva questions” is a bigger hero than the person who can teach with a systematic and scientific methodology.

In the entire period of MBBS, almost every student finds it difficult to accommodate to the consistently changing subjects, curriculum, teaching, preparation for didactic sessions, written and photocopied “notes” and so on. There is practically no one to encourage the creative thinking. By the time students reach a teacher with a creative bent, their mould would not let them move out of the self/system created boundaries.

Examination in the Indian medical education is no less than a horror. It is time for the students to recall how good or bad they were! It is time for the examiners to take revenge or reward the loyalty. Money, influence, good behavior, non-controversial nature etc find a larger place than the actual talent of the candidate. Passing in the final exam is such a big relief even for a consistent hard worker who knew their stuff well. By this time, their lesser intelligent friend in any non-medical professional field would have got his degree and a handsome 6-digit salary and a vehicle.

MBBS marks the end of a beginning. The actual ordeal starts from now. People with enough money can buy any subject of their choice in a private medical college. What was earlier in lakhs has reached crores now. People with influence can get direct seats from the biggies. Next best would be getting question papers of entrance exams for a price. The nexus is strong and powerful and in India, it takes a CBI enquiry to break the code! The other way is to move through your caste. If anyone can prove that they belong to the caste that government considers as backward, irrespective of any other factor, position or assets, the PG seat belongs to them for free. I have personally seen PG students who obtained their seat by reservation coming to the hospital in a Mercedes. Added to this, the nexus of fake caste certificates is probably impossible for even CBI to crack!!

However, the lesser mortals with no money or influence or reservations will have to go through the hard way. They have to take a “break” of couple of years in prime of their life after MBBS to “prepare” for the PG entrance exams. In this period, one has to sustain on the income of their parents or should do very low paying jobs of a “duty doctor”, which is actually a glorified clerkship in a private hospital. They fill exam forms of almost all entrance exams of the country, travel to the exam centre by a third class sleeper coach (which the Indian railways call second class), stay in cheapest of places to save money, eat roadside as they cannot afford high prices of restaurants and write exams for a handful of PG seats. The competition would be something like 700 doctors for each PG seat! With every successive year’s failure, the potential competition increases, as a new batch of MBBS pass outs would have arrived.

With all these difficulties, few get successful in acquiring a PG seat. Most of the doctors would not achieve the subject they always liked and loved. They end up in such a state that they would take the course which they detested from their core! Still, the life should go on. How long can you feed yourself with the parental earnings? How long would you keep answering the relatives who were jealous of your academic success few years back, but are very happy with you now that you are struggling and their otherwise low-performer son is earning 5-digits a month in a call centre or an IT company? It is time to prove. Success comes with hard work in any field. The PG subject you are studying does not matter as long as you are hard working!!

Right? Yeah! Life is smooth once you have got a PG seat? Yeah! Lot of things change in just 3 months. Bright MBBS doctors are made to feel that they are actually duffers. The first years get to do a peon’s job. They run around to collect the lab investigation reports, chest radiography films, arrange the glass vials for blood samples, store the blood and urine culture bottles in their cupboards for emergency use, make a note of all new instructions given by the bosses, request the proud class III and IV workers for shifting the patients to investigation rooms and so on. “Look at the cobweb in that corner of the ward. You people don’t work!” is the remark that I have personally got from my consultant during rounds in my first year of post graduation course.

Thesis is a source of pain for most of the PG students. Not only the process of conceiving and delivering it is tedious, bearing the idiosyncrasies of the “guide” is hellish. For the people who believe in reincarnation, all the good deeds done in the previous birth manifests as a good PG guide and vice-versa! I had the opportunity of seeing the brutalities in first hand. I know some of my colleagues, who were used by the “guide” to get vegetables for the house, drop his kids to the school, make the PG drop guide’s niece in scooter to her work place and get her back in the evening every day, wash his car and get it serviced, book his air tickets at the cost of PG and so on. It is not necessary to say that all the academic work of the guide is actually done by the PG, whether it is preparing slides for a class or writing a chapter for the text book or publishing a study. Should I mention that the PG gets no credit or authorship or acknowledgement for the work? Worse are the cases that I have heard, in which the female PGs have undergone more inhumane treatment and exploitation. With all this, the moment of getting the thesis signed by the “guide” goes through many more phases of torture and is a relieving moment at the end of it.

Where is the creative energy that was bestowed to everyone? Why our medical education system does systematically suppresses the creative thinking? Why is a person who attempts to talk out of the box is treated as a joker? Why do we behave as if we should not think outside the textbooks? The archival system of teaching medicine, inept or inert teachers, lack of opportunity for expressions, fear of getting jeered by the peer group and so many other issues end up in suppressing the ideas and creativity of every medical student. Our conventional upbringing does not allow most of us to rebel against the set norms.

I discussed this issue with some of the peers. “You cannot crib that someone’s wife is more beautiful”, “We are dealing with human lives; we cannot afford to experiment”, “Mere talk is waste; who is going to find a solution?” “All that you feel is right. But the remedy does not lie in the hands of a single person”, “You are burning from inside; you need vipasyana meditation to cool yourself” were some of the answers I got.

Why do we think of an improbable end point and stop a beginning? Who is asking anyone to radically change the treatments? There are so many innovations that can occur in teaching, learning, patient examination techniques, diagnostics, assessment pattern and so on. Why not involve student community in these? Just to suggest, why can’t we dedicate one hour every week for listening to the students? Why not a session for them to talk in an open forum to present their ideas on innovation? If someone is shy of presenting himself on the podium, why not keep a box in which he can drop his idea in writing, which can go through a set of understanding and sympathetic senior doctors? In every institute, there are few extra-ordinary and respected, out-of-the-box thinking doctors. Why not they form a group and encourage the student community in catering a creative angle to thinking? Once we dare to change a bit, we can think of changing this ignoble way of conducting our curriculum and assessment patterns.

There might be lot many ways of inculcating the innovation and creativity of the budding doctors during their formative years. “I was treated badly by my guide and now it is my turn to be bad with my students” is the hallmark of a wretched brain. How can such people make good doctors when they are not even good human beings? Isn’t there a need for changing this system somewhere? Till we think of solving these issues, we cannot think of medical fests with new ideas coming from “best of the brains” in the community.

Regards

Kiran

Monday, July 5, 2010

This is Dr Kiran welcoming everyone to the new post of the blog. As we have seen, the primary objective of this blog is dissemination of genuine interest in Pediatric cardiology to all those who have got smitten by this charming bug! I had the opportunity of writing a lot of historical details about the subject and drugs used in this field. For the past few weeks, I have been writing a few short anecdotes which may touch the readers somewhere and may bring back some memories. None of these stories are my own. Most of them are heard, read or sent by the friends. It may seem personal if there is lot of relevance, but that is purely coincidental! With this disclaimer, I am moving on to the following anecdote which was sent by a friend. He did not specify if it is his own. But, the quality of story was worth sharing. Please go through:

Ram was 14 years old. His adolescence was more visible on his recent “don’t care” attitude. He was fond of science classes in the school and was quite good at it. He would often tease his father with the question, “Dad, what is relativity?” His accountant father was probably unaware of who Einstein was! Father used to just smile and keep quiet.

A new circus company had campaigned in their town. Ram wanted to see the circus. It was almost the month-end and his dad did not have spare cash for the new expense. Somehow, after taking a hand-lone from a colleague in the office, the father-son duo went for the show.

They were standing in the queue. A parallel lane was buying tickets from another counter. There was one group in the parallel lane. It was a big group with eight children, all under the age of 12. Ram felt that they didn't have much money. Their clothes were frayed but clean, and the children were well-behaved all of them standing in line, two-by-two holding hands in back of the man who had brought the kids. They were jabbering about the clowns, elephants and other acts they would see that evening. Ram, who had gone to a circus a couple of years back, could sense those kids had never been to the circus before. That evening looked like a highlight of those young lives.

Ram and his dad were behind a couple of people in the line when the children’s group reached the counter. “One full and eight half tickets, please” the man said. The lady in the counter told the amount. The man opened few notes of currency from his pocket and counted. His face fell sad. He counted the money again. “How much did you say the amount was?” he asked the counter lady again. He was turning pale with the answer.

Ram and his father were witnessing the scene. Suddenly, Ram’s dad pulled up a note of Rs 100, dropped it on ground and told the man in the opposite lane: “Sir, you have dropped this note. It fell from your pocket.”

The man looked at Ram’s father. His eyes were filling with tears. He meekly accepted the note and bought the tickets. He came towards Ram, held the hands of his father and told in a choked voice, “I don’t know how to thank you. These are the children from the neighboring orphanage. What the donors pay is just enough for food and clothes. They were dreaming day and night about the circus. As their caretaker, I could not resist bringing them here. I got some of my money and asked for some from my friends. Still, I fell short of some. Bless you, Sir; can’t repay your kindness.”

When Ram reached the counter, they did not have enough money for the tickets. They just walked away from the counter. After few yards, Ram’s dad held hands of his son. “Can we just postpone our programme by a week?” he asked Ram.

“No problems, dad”, Ram said. “Three things, actually. First, I can wait for a week. Second, I can do without too; I have seen the circus earlier. Lastly, today you have taught me what relativity is!” Ram said with a glee in his face.

Ram had found a new meaning for life that day. Moreover, he decided never to tease his father again.

The above anecdote is quite touching, especially for people who empathise. The community of Doctors probably has highest chances for empathy. One of the doctor friends, who does community service told me about her experience with patients wherein she had to make decision for them imagining herself in their shoes! It is a tough experience. The relativity of the issue probably depends on how many tough situation we have passed through in our life. There is the story of a man who was cursing God for not having footwear till he saw a man without legs! The cursing suddenly got transformed to praise. The quantum paradigm shift in this instance is evident. Life is relative and the meek ones need to know this well before they decide on something drastic. Understanding who is right is probably not as important as what is right. This is the biggest aspect of effective leadership, management, parenting, teaching and coaching. It's amazing how much we can accomplish if we simply focus on leaving everyone we meet in better shape than we found them.
With this, let us get back to our regular feature: Interesting learning scenarios

RIGHT PARACHUTE

We can all recall a number of parachute mitral valves. When the papillary muscle of left ventricle is alone, the entire chordae end up getting inserted to the same site and the physical picture is of a parachute with the pointing end at pap muscle and the balloon at the annulus. This is possible for the mitral valve where the site of insertion is well defined. How about the tricuspid valve which sends its chordate over a wider area? We saw a 9-month-old with all the tricuspid chordae getting attached to a single pap muscle. On searching the literature, we found the existence of such an entity. Anderson et al had reported this in a setting of TGA and Aziz et al for TOF. In our case, it was a large VSD and a small ASD. If anyone has any data on this entity, please let us know.

ATRIAL OUTLETS

Another interesting variant of tricuspid valve was seen by us. We have seen a double orifice mitral valve. However, a double orifice tricuspid valve is a rare variant. We had such a scenario in a 6-month-old wherein the TV had two openings on either side of interventricular septum. This was associated with a large inlet VSD and a small RV. The entire MV and one opening of TV were to the MLV and the other opening of TV was to the small MRV. It was an eventual single pump repair. The literature shows the existence of this condition without any other heart lesions. If you can recall any instance of noticing such an anatomical variant, please put up your experience.

PARTIALLY TRANSITIONAL

What would you term a Transitional AV canal defect in which the VSD has closed by a septal pouch? What is the terminology to be used? It is taught that the inlet VSD does not close. However, we have often seen a small inlet VSD of transitional AV canal defect closing spontaneously over a period of time and becoming a partial AV canal defect. Should we continue to call it transitional or change to partial? Tell me your views.

RIMS AND LOCATION

Of late, we have been largely successful in eliminating the need of Transesophageal echocardiography for ASD device closures. Our transthoracic echos have been found sufficient for ASD devices. In this process, we often find that the IVC rims being unsteady. Many times, the defect is not visible at all when the IVC is opened in the subcostal saggital view or in the short axis view. In such cases, we have found a mixed success rate. Is there is fool-proof method in the TTE for this problem? How many centres have actually dropped the TEE for ASD device closures? What are the experiences in those places? Please let us know.

SIDE TO SIDE!

Continuing the problems with devices, we have seen few muscular VSDs which look perfectly OK for device closures during echo evaluation. However, on the table, the LV side of the defect would be much larger than the RV side. Not only crossing becomes a problem, the size of the device to be used is also an issue. Since the muscular VSD devices are symmetrical, the LV side of the device may be too small for the defect and the RV side may be correspondingly big. Our experience with the VSD devices is not as extensive as our PDA and ASD devices. How are the other centres managing this issue? Please let us know if there is a way.

PEDIATRIC CARDIOLOGY PEARLS:

46. Sildenafil seems to be beneficial in the management of Primary pulmonary hypertension. Acute vasoreactivity studies in PAH patients suggest that sildenafil may have greater acute hemodynamic effects than inhaled nitric oxide and may further reduce pulmonary vascular resistance. (Michelakis E, Tymchak W, Lien D, et al. Oral sildenafil compared with inhaled nitric oxide in PAH. Circulation. year 2002 page 2398)

47. AHA guidelines on IE prophylaxis extend to HCM. Bacterial endocarditis appears to be virtually confined to patients with the obstructive form of HCM, with a prevalence of <1%. Vegetations most commonly involve the anterior mitral leaflet or septal endocardium at the site of mitral valve - septal contact and less commonly the aortic valve. ( Spirito P, Rapezzi C, Bellone P, et al. Infective endocarditis in hypertrophic cardiomyopathy. A good review is done by authors. Circulation. year 1999 Page 2132)

48. Levosimendan is a calcium-sensitizing agent that has been evaluated in adults with acute decompensated heart failure and in patients with chronic heart failure. One pharmacokinetic study has been performed in children with congenital heart disease. There is no increase in myocardial oxygen consumption or arrhythmias. (Turanlahti M, Boldt T, Palkama T, et al. levosimendan in pediatric patients evaluated for cardiac surgery. Pediatr Crit Care Med. year 2004 page 457)

49. In cases of myocarditis with congestive heart failure, digitalis may be used and has effected dramatic improvement in many instances. However, during periods of acute inflammation, the myocardium may be hypersensitive to digitalis, so rapid administration to achieve therapeutic levels should be avoided. (Parrillo JE. Myocarditis: Good review article on treatment. J Heart Lung Transplant. year 1998 page 941)

50. In Pediatric restrictive cardiomyopathy, beta-blocker therapy was suggested to blunt rapid heart rates in their patient population in whom significant ST-segment depression was noted at higher heart rates. However, tolerating the therapy is the chief caveat. (Rivenes SM, Kearney DL, Smith EO, et al. Sudden death and cardiovascular collapse in children with restrictive cardiomyopathy. Circulation. year 2000 page 876)

With that, we come to the end of another post. Please send your views, opinions, criticisms either by the comments box or by email to drkiranvs@gmail.com I shall post them on your behalf. I am preparing the list of books about which I can talk in next few posts. Till then, I shall continue with the anecdotes. If you have any interesting short stories to share, please mail them to me. Your contribution would be acknowledged.

Regards

Kiran

Friday, July 2, 2010

Hello everyone, this is Dr Kiran welcoming you to the new post. The objective of the blog is to develop an interest in Pediatric cardiology for curious. We learn few interesting facts and discuss few scenarios on practical issues. As previous, let us start with an anecdote which carries a greater meaning in life. The following anecdote is what everyone goes through in life. Please quote your views on it.

Mr Ray was a worried man. His peace was disturbed due to some problems at his office. He was not willing to discuss it with anyone, for he was afraid people may trifle his problems and start talking of their own. He was of the opinion that no one else could understand the significance, quality or gravity of his problem.

His wife, Mrs Ray could not tolerate the downhill condition of her husband. They had a common cousin who was a motivational speaker and well known “agony-uncle”. She sought his assistance and the man agreed to casually visit the Rays for a non-formal session.

Mr Ray did not know of these arrangements. He welcomed the cousin and both of them started talking. Mrs Ray took this opportunity to re-inform that the cousin was a well known advisor and specialized in solving problems in the work environment.

Mr Ray got interested to know the qualification. He hinted that he had a problem in his office. The cousin acknowledged the hint and told, “Would you like to discuss the problem with me? I can try and help it if you don’t mind.”

Mr Ray took the opportunity. His frustration had been piling up for a while. He thought of shooting it off.

“I don’t know if my problem sounds silly. But, it is killing from inside. I am a very principled man who sticks to discipline. If somebody breaks it, I get very frustrated. More so if I have no control on the person doing it. It multiplies if I get victimized in the process of someone else’s indiscipline”, Mr Ray ranted out.

“You cannot be abstract if you want a solution. Get me the facts straight”, his cousin told with a smiling but straight face.

“I have a colleague”, Mr Ray started. “I don’t want to name him. He was an apprentice when I joined, but he got promoted to the same position as mine in few months of my joining. He did not have the qualification for the post, but the Boss took special interest. Probably because they are from same community.”

The cousin nodded. He knew the rule: Do not break the chain of thought!

“It does not bother me. After all, they manipulated the rules of the firm. In a private firm, the rules are flexible if the Bosses agree. What bothers me is the attitude of the person I do not want to name.”

His cousin interrupted. “Let us call him ‘Nameless’. That will solve the problem of expression.”

“OK”, Mr Ray continued. “Nameless is an opportunistic and lazy person. He quoted his family problems and was scooting off from work. Later, he started quoting the health problems. After sometime, he took off for acquiring new training and qualification. Even now when he has got promoted to a higher position, he continues to do the same. His problems seem to be perpetual and he poses as if no one else in the world has any problems. He wants everyone to share the burden of his problems and there is absolutely no help from his side when the other people have problems”, Mr Ray was increasing his tone of anger and was getting breathless while saying all these.

His cousin was simply nodding. He also took some notes in a piece of paper as Mr Ray spoke.

“The biggest problem is on me. I have to bear all the unfinished work of Nameless. He simply gets up and goes home at his will, well ahead of the closing time of office. I have to stay back extra time to complete his incomplete business. When there is some extra work few days, he simply orders the peon to get all the files and leaves by the time files arrive. All those files get dumped on my table. Of course, the other colleagues also chip in, but I have to take the maximum brunt. I have complained to higher authorities many times, but somehow, they are very sympathetic towards him. They kept telling me that since Nameless does not work full-time, they are cutting a portion of his pay. My earlier Boss who was of the same community as Nameless was so moved by all the pathos uttered by Nameless, that he always gave an out-of-the-turn bonus for him! I recently found out that there was never a pay-cut either for him and my Boss used to present a white lie in front of me to keep me silent. Since then, my anger is burning me from inside.”

His cousin’s face did not show any emotion; neither he gestured any noises of sympathy. He kept jotting up something occasionally.

Mr Ray took a gulp of water. His catharsis was evident. His tone was returning back to normal slowly.

“The problem continues even today. Nameless hardly does any work and gets paid the same amount of salary as I do. Nobody cares on how his work gets transferred to others for completion. For the sake of the office pride, we silently bear the burden and finish the work. My burden is heavier nowadays and I cannot even say a word. I often feel like doing the same thing what Nameless does. I am seriously thinking of going scot-free. I will also do half jobs and put the rest on someone else. Anyway, when my boss is tolerating him, he will have no other option other than tolerating me too.”

Mr Ray took another gulp of water and kept silent.

“Any other people in your office? Any other person with similar nature as Nameless?” his cousin asked Mr Ray.

“There are lots working in my office, but as of now, only Nameless is the exception. Others are hard working. Few, in fact, keep very high standards in work. Few people are really inspirational.”

“Can I tell you a small story?” his cousin asked.

“Sure”, Mr Ray said.

“What I quote are from the Vedas - the divine Hindu scriptures. There is mention of a bird called Vyoma, whose sole aim is to reach the sun. It keeps ascending. It lays its egg en-route its journey. The egg keeps dropping all the way, but since the mother bird was at a very high altitude, the egg has to travel a long distance to reach the earth. Still on its journey down in the sky, the egg hatches and the baby bird is delivered. The baby bird starts of its ascent immediately and starts moving towards the sun. The mother bird continues its journey to sun till it burns off in the way due to the heat. As the Sun is described as a ball of fire and the bird also catches fire and burns out, they become essentially one. Do you find any message in this story?”

Mr Ray was silent. Obviously, it was above his head.

His cousin continued: “The story, as any other story from Vedas, is symbolic of life. It should not be taken in literal sense. The sole pursuit of life is to reach the excellence. It should be so powerful that your progeny picks it up as an inborn, innate nature. No external influence should affect the journey. You should rise so high that what other people talk of you should not even fall into your ears. For, people who stop their journey to talk are simply wasting their life. People with a high objective in life have only one way.”

Mr Ray was not convinced. “Is this advice practical?”

“Of course, yes” his cousin continued. “It depends on where you keep your vision. You can either be the anecdotal Vyoma bird to keep you vision high or you can be a vulture, which keeps flying high but always has its vision fixed on the dead bodies lying on the earth. Here, you are always watching Nameless and getting the vision of a vulture which probably befits the Nameless; not you. Why not keep the vision of some other person in office whom you admire? Why not simulate him? Why not try and get the standards that the other person has achieved? Why not excel and set a standard for others? Why not do the inevitable extra work as a learning experience and gain more out of it? Why should you ever think of going the way Nameless has gone? Would you tolerate yourself if you become what you detest?”

It was hard-hitting for Mr Ray. He was expecting sympathy. What he got was more than what he sought.

“So, how do you think I should rectify the mistakes in the office? Is it not my duty to set it right? Is it not correct to demand my rights for equality and peace of mind?” he asked meekly.

“As a matter of fact, it is not your duty” his cousin said curtly. “You have done your best by bringing it to the notice of your superiors. What they do is not your business. Yes, we all go through phases of injustice in life. It is true that Nameless does not deserve what he is getting. But it happens to almost everyone and almost everywhere. It is neither unique nor rare. If you keep thinking and cribbing about it, you are getting stalled in your journey towards excellence. You are wasting your time by underachieving your potential. You are a creative man. You can be of greater pertinence to the world. Only that you have to think in the correct direction.”

Mr Ray was speechless. He took sometime to digest what he heard. Slowly, he got up from his chair, shook hands with his cousin and said, “I may not agree with all that you said, but seems to make sense in a way. I shall try to implement and let you know the results”.

This anecdote is symbolic of what happens in everyone’s life. In every working place, a certain percentage of people are found who live a parasitic life on others. We used to call it 80:20 principle in the government run hospital I worked earlier. Overall, 20% of honest staff did 80% of all the work, but those 80% staff was struggling hard to get all the credit for the good work not done by them. The scenario may not be much different in any private set up either. There are always people who make a living by sycophancy; they just need a gullible boss! There are people who think being smart is better than being honest. There are people who allow their conscience to collect their full salary without working for it. There are people who are first to attend the meetings with higher authorities and take lead in presenting data for which they have not even contributed. There are people who believe in getting their work done by others by any hook or crook. Such people may present as witty, jovial, smart, wise-cracking and popular with everyone except for their colleagues who actually end up doing the pending work of such characters. But all those apparently smart qualities are largely to hide their lazy self. It is a frustrating experience to be colleagues of such kind. The above anecdote shares one way of dealing with such people. Such breed is so common that each one of us can recall such a character in our working place. How are your experiences in dealing with such people? How do you make yourself compatible in such situations? Please share your experiences with other readers. It is really good to have some solace from every possible corner!

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

SMALL INTO LARGE: POSSIBLE?

We had one year old girl with Tricuspid atresia IIB with disproportionate branch PAs. The LPA was far smaller than the RPA. This baby also had bilateral SVCs with LSVC far bigger than the RSVC. Cath data showed suitability for Glenn shunt. Now the problem was attaching the big LSVC to small LPA! We have seen BTT shunts that cannot exceed the size of the native ipsilateral PA. Is the rule applicable to Glenn too? Is it possible to attach a 10mm SVC to a 5mm PA? How are the dynamics different? The surgical team had a split opinion on this. Please let me know your take on it.

IMPROVEMENT IS PROGRESSIVE AND VICE-VERSA!

This one was learning experience. We had a two-year-old single ventricle- DILV. Cath data for Glenn suitability showed a mean PA pressure of 18mmHg. It was above the comfort level of our surgical team. We were about to negate the possibility of surgery when one of our senior surgeons (who is otherwise very conservative) opted to do the Glenn in this baby. It was a matter of surprise and we wanted to know the basis for his opinion. He explained in very simple terms that Glenn will take off about 30% of his systemic venous input into the heart and about 15% of total cardiac output in this baby. So, post-op, the PA pressures are likely to come down by about 15%, bringing it into comfort zone! It was an eye-opener for mathematically challenged people like some of us! But the logic appeared very appealing. The offloading concept of ventricles is the basis for Glenn shunt. When the criteria are made, is this mathematical calculation already incorporated? That is, do we fix a mean PA standard after making correction for the post-op reduction or not? I could not find an answer. If anyone knows this, please let me know.

LOCATION LOGISTICS

I had brought up this question earlier. In Ebstein’s anomaly if there is a communication between LV and atrialised RV, can we call it a VSD?! One more facet came up this time. It was a 6-year-old girl with Ebstein’s anomaly with the communication between LV and atrialised RV low down and had an aneurysm of STL projecting up and partially covering the defect! Can we call this “restriction of VSD”? Here, neither the term VSD nor the direction of STL limiting the flow is semantically confirmed! Can STL send the aneurysm towards the direction of RA and be still called by the same name? Let me know your ideas on it.

HOW EARLY IS EARLY?

It is tough to picture the cause/effect relationship in retrospect. We had a 2-day-old newborn with Tetralogy – absent pulmonic valve complex. It came with respiratory distress. On echo, the branch PAs were dilated. The chest radiograph showed pneumothorax on the right. The condition deteriorated in a couple of days and the neonate was intubated and electively ventilated. The repeat chest radiograph showed a pneumonic patch with no evidence of pneumothorax this time. The question is: Can absent pulmonic valve complex produce respiratory symptoms so early? Is it beneficial to get a cardiopulmonary CT scan? What is your experience of early presentations in such entities? Please let me know your take on this.

CAUSE – EFFECT

We had a 7-month-old with heart pushed to right. Echo revealed TOF with small RPA. The return from right sided pulmonary veins was minimal. Chest radiograph showed a totally collapsed right lung. CT chest done outside was reported as hypoplastic left lung. Is the lung status acquired or congenital? Is the small RPA the cause of right lung hypoplasia or vice-versa? Is there any way of determining the cause-effect relationship? Please let me know your opinion on this issue.

PEDIATRIC CARDIOLOGY PEARLS:

41. Reporting echocardiography in a systematic manner conveys meaning for management. As per the norm, right-sided and left-sided structures at each level are evaluated according to their morphology, their relative positions, their connections to proximal and distal segments, and the presence and location of shunts, obstructions, and valvular regurgitation. (Edwards WD. Congenital heart disease. In: Schoen FJ, ed. Interventional and Surgical Cardiovascular Pathology: Clinical Correlations and Basic Principles. Philadelphia: WB Saunders, 1989:281-367)

42. The only prospective control trial of Carvedilol use in children with heart failure was published by Shaddy et al in 2007. The trial showed an improvement in children less than 24 months on echo parameters. However, on composite end points of study, there was no significant benefit. (JAMA, 2007, page 1171)

43. Shepard et al in 1991 reported that 1 in 40 patients with tuberous sclerosis may die as a direct result of cardiac rhabdomyomas. (Mayo Clin Proc 1991;66:792-796)

44. When cardiac myxomas obstruct the semilunar valves, patients experience symptoms while bending forward or lying down, with relief of symptoms when standing. (Robertson R. Primary cardiac tumours: Surgical treatment. Am J Surg 1957;94:183-193)

45. Rheumatic mitral stenosis severe enough to result in symptomatic heart failure may occur in the first two decades of life in developing countries. (Agarwal BL. Juvenile mitral stenosis in developing countries: Problems and challenge. J Assoc Physicians India 1986;34:141-144)
With that, we come to the conclusion of one more post. I am really interested to know if there are any readers of this blog other than me! Please send your inputs via the comments section or to my email id drkiranvs@gmail.com The purpose of this blog is to make it interactive. Hope someday it happens!

Regards

Kiran