Sunday, December 21, 2008

Dudh malai, kukkar shukkar, ghar ghar burger shurger OYE!

Today is the first official day of winter. As if on cue, there is a snowstorm raging outside. The evergreens are shaking, snow whirls up into thick flurries and the ground is calf-deep in white. I wanted to drive over to the mall to watch Slumdog Millionaire but inclement weather discourages the plan. Instead, I stay at home and try to write. This is how far I get.


It's been a busy couple of months. I learnt how to drive, got a car, got a house. To furnish that house, I got in the car and scoured the land for furniture to fill the empty space. On one or two occasions (more, if you're not a family member reading this blog) I almost got myself killed due to inept driving. But that's all in the past. I am now sitting in the house with the new furniture watching snow fall on the car. Or almost the car, as the carport protects it from the ravages of the storm. I drove into the carport last week.


When people ask me what's new, I usually have very little to tell them. My days, and every fourth night, are usually spent at work. Whenever I'm home, I'm usually asleep or watching TV. I didn't imagine it would be like this. When I was younger I had resolved never to buy a TV because it epitomised the death of the imagination. Instead, I would live in a house filled with books and cosy yellow light. The floors would be decorated with warm rugs, art would hang off the walls and the whole atmosphere would be incandescent with an aura of intellect. This would be my life, a lambent expression of the state of my soul.

Last night I spent two hours on the couch watching a Cosby Show Marathon.

Saturday, December 13, 2008


(I'm writing this not so much for the blog as for myself, in an effort to remember.)

When you're interviewing for residency people often ask you to describe a memorable patient, someone who made an impression on you and changed the way you thought. When I was interviewing, I had Salma, a plucky eight year old I took care of in one of Karachi's inner city clinics. She used to wet her bed and every morning would be predictably beaten by her mother for it. We did some tests and found out she had recurrent urinary tract infections. There was a pro bono referral to a specialist, some antibiotics and the bed wetting and beatings ceased. It was almost mathematical in its progress from diagnosis to cure.

As you progress through your career, your list of these patients grows. You may remember someone for their resilience, how they fought and recovered. Or for their kindness, their patience with you as the fledgling physician. Or even for your failure, how you were unable to help someone. The practise of medicine isn't as mathematical as all our algorithms would suggest. There are, of course, guidelines and standards of care but the patients, or diseases, don't read textbooks and there are times when a diagnosis is elusive and difficult to make. Sometimes you can make the diagnosis and the pathology doesn't respond to the treatment. Other times the disease is so widespread that treatment is redundant. The new age of genetics and molecular biology may make our knowledge of science cutting edge but the practise of medicine, and more importantly, the care of patients, still remains for the most part an adaptible combination of both knowledge and humanity, or the art of medicine as people like to call it. To dissect one out from the other is to do the patients a great disservice.


I was on the Hematology Oncology service last month. The general perception people have of cancer medicine is that it is a very depressing field. How can anyone spend their days watching children die. In truth, it's not actually like that. Pediatric cancers are, for the most part, a different species from adult cancers and a lot of them respond very favorably to treatment. Acute Lymphoblastic Leukemia, for instance, has a cure rate of more than 80% and most children are expected to survive. In the month that I spent on the service, there were no fatalities.

And yet, throughout the month, I found my eyes uncomfortably moist. It is difficult watching children suffer and a lot of that comes from the treatment of the cancer itself, the chemotherapy. I'm not going to describe the individual details but it's an experience that, even as observer, takes you outside of yourself and sharply puts things in perspective. Often I would sit and talk with the parents and the specialists, trying to cull, for my own consolation, perhaps, stories of their experience with the disease. It is those stories, more than anything else, that both humble and embolden you as a physician. Like the boy who didn't have hair. Or the family who, after the death of their teenage son, adopted the clinic and made sure that all new patients receive a basket of toys or anything else they might need. Or the man who, even when he found out at the time of transplant that he wasn't the father of his daughter, still took care of her. Her own mother abandoned the child but this man stayed with her, steadfast until the very end. The girl died in his arms.

It is humbling to be around such people. I cannot say how I would react were I to be placed in their situation and, frankly, I am grateful that I am not. But having met them and having been acquainted with their example, I think that I am a better physician and a better person. They set a precedent for me for how to behave under what can only be excruciating circumstances and for that invisible gift I am grateful.

Baby Doctor

I was on call a few weeks ago when we admitted a young boy with fever. He had a short history of severe muscular aches and pains and difficulty walking. As part of the preliminary workup we decided to get viral cultures to try an isolate a pathogen. One of the ways this is done is by collecting a sample from nose. You take a sterile swab, a thin plastic instrument that resembles a long Q-tip, introduce it into a nostril and gently rub it along the walls. Once you think you have a good sample, the swab is removed and snipped off, inoculated in a tube of transport media and sent off to the lab for analysis.

I went into Bryan's room with the test kit. He was laying in bed, tired from all the bloodwork that had already been done. I showed him what I was going to do, told him it wasn't going to hurt and asked for his permission. He looked at me and then at the paraphernalia I carried in my hands.

"What's it for, sir?" he asked.

"We want to make sure there are no bugs, or viruses, at the back of your nose." I simplify it for him.

He looked again at the swab I was holding. It was about the length of a tongue depressor and probably as ominous as a spear to the child.

"Don't worry, not all of it is going to go in your nose. Only a small portion, just enough to get get some bugs," I reassure him.

He looked at me hopefully. "Is it OK if I just sneeze on it?"

Sunday, December 07, 2008

Home Sweet Home

I have a cousin back home who recently graduated from medical school. She's quite a few years younger than I am and over the years we've kept in touch sporadically over MSN. I remember when she was a first year student, struggling with anatomy and biochemistry. We used to talk about what texts to read and how to cope with exams. She's an intern now, a house officer, just done with a three month rotation in OB-GYN. It's amazing how quickly time passes. From a fledgling first-year student to a house officer, it's been six years. Her self-confidence has increased remarkably. She now manages her parents' medications herself. They are both severe diabetics. Her father has heart disease, has had a coronary bypass in the past. Aliya takes care of them both, adjusting the doses of the medications, taking them for doctors' visits, gently shaming them into controlling their diet - her father has a particularly incorrigible sweet tooth. Aliya's brothers are both abroad. She lives alone with her parents.

It makes me think about my own parents. They are both getting older, moving imperceptibly into a frail age. Like Aliya's parents, they too have their own chronic illnesses that they live with. There must be hundreds of families like ours, scattered throughout the country, dependent on their children, this natural role reversal that mimics the gifts of childhood. Unlike a lot of them, our parents are lucky in that they have someone to take care of them. What about those families where nobody has stayed back? Financial circumstances sometimes make these decisions incumbent. Children have to leave home to be able to support the family. The nest is emptied. What then of the parents?

It's hard to make a decision, to balance exigencies against a vacuum of imminent loneliness. I know why people leave. Just from observation I know how dramatically the life of a family improves with remunerations sent from abroad. I also know how sometimes you have to go away to be able to restoratively come back. But, really, how far can you go when heart is tied to heart?

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