Know Your Antibiotics!

“What are the five commonly prescribed Antibiotics by you?"

I asked. A very unpleasant question this was for one of our residents seated in a room of about thirty odd doctors during today's very pleasant Bangalore afternoon.

“Augmentin…

Piptaz….

Clindamycin…

Metrogyl…

….mumble…

Dalacin”

He completed after a lot of contemplation. For those commoners who lack the knowledge of antibiotics, the third and the fifth one are the same, the former being the generic name and the latter being its brand name. While he was happy that he got his five, I thought it would never hurt to ask more and went ahead with my rapid five.

Me: “So….what do you give it for?” 

He: ‘Blank’

Me: “How many patients do you give it to on an average?”

He: ‘Blank’

Me: “And how many of them recover”?

He: ‘Blank’

Me: “Do you look at the antibiotic policy of the hospital before prescribing?”

He: ‘Blank’

Me: “Do we have an antibiotic policy in the hospital?”

He: ‘Blank’

I could have gone ahead with my minor dissection on his prescription practice and rationale but the general reaction in the room with department heads, senior consultants, residents and interns was a sight to behold. Working with microbes and antibiotics day in and day out I am of the opinion that the most resistant of all are us Doctors, nobody or nothing else. We are way ahead of all the Multi-Drug, Pan-Drug and Extremely Drug Resistant Microbes that we fret about and deal with in our hospitals.

In the periodical class on Infection Prevention and Control that we conduct for consultants and residents wherein we brief about NABH standards, Standard Precautions, Personal Protective Equipment, Hand Hygiene, Bio-hazard Spill Management, Biomedical Waste Management, Health Care Associated Infections, Surveillance Charts, Antibiotic Policy and Post exposure Prophylaxis the most I could do as a Medical Microbiologist and an Infection Control Officer was to share my little knowledge I have about these issues.

Some days there are few consultants with a ‘rock-solid-will-never-change-my-unit-my-antibiotic-my decision-my responsibility-my patient-I-know-better’ attitude and then some days there are only residents with ‘i-will-only-follow-what-my-head-says’ [read: not the head above his shoulder but the unit head] attitude. Some days there are five in the room, some days about ten and some days there are none. And on all days the laboratory doctors are considered ‘para’-medical and not medical because they see samples, not the patients. The samples are from their own patients is something long forgotten.

Despite all this our quest for training and data collection continues. “To measure is to know, if you cannot measure it, you cannot improve it” so said the great Scots-Irish mathematical physicist and engineer Lord Kelvin. It has not been an easy ride and it will never be, likewise for all doctors dealing with Infection Control especially in small health care settings where constraints are not just with resources but also with the lack of awareness and drive amongst our own peers, it has always been so in most of our Indian hospitals with regards to other situations.

Microbes with novel beta-lactamase enzymes have reached the United Kingdom from our capital and are christened with the city’s name too! New Delhi Metallo Beta-Lactamase! If it sounds very cool and you are a health care personnel you should be more than sorry. At the grass root level we still are far away from deciding on whether to check or not on what happens to the antibiotics that we scribble on our prescription pads. Only the kinds of Nipah Virus can wake us up.

Guidelines and policies are slowly falling into place at all levels but there are hundred other institution and speciality specific issues of Antibiotic Resistance and in the way we approach them, we are facing a silent epidemic and we have a long way to go!

Right Choice, Right Route, Right Dose, Right Frequency & Right Duration-the 5 Rs of Antibiotic Prescription apart, a 6th R would definitely do a lot of good to our patients and also all of us who belong to the medical fraternity- RIGHT ATTITUDE.

A kind request to all my fellow doctors- Know The Antibiotic You Prescribe! If not, we are here at the lab to help.🙂

As you all know we are facing a huge problem of Antibiotic Resistance across the world and India is considered as one of the epicentre of what we call as Superbugs, they are even named after our towns and cities like the famous NDM-New Delhi Metallobetalactamase!🤔

Healthcare associated infections are a huge problem due to antibiotic resistant microbes which increase our hospital stay, they also are a huge expenditure and carry a high risk for mortality.😢

Public perception of the issue is very important in this regard which my doctor fraternity seldom considers for discussion. Since we have to begin somewhere I am carrying out a small survey titled ANTIBIOTIC AWARENESS SURVEY with a few questions to be answered.

If this healthcare issue is of concern to you please participate and help us doctors analyze where we all stand. Thank you, your participation and feedback is highly valuable.🙂

Here is the link :

https://www.surveymonkey.com/r/WN7FKHG

-R.

Perks Of Being A Non-Malalyali Medico!

 Pookalam - flowers everywhere!

Celebrating Onam definitely is one, on the other hand no matter how hard I try Malayalam will remain a language that is impossible to learn in this life. My 'endaveno' is more like' gindaveno'.  When two Keralites are in  deep conversation I stand looking at them wide-eyed and all ears, I try my best to understand and all I get is the speed, so commendable! Every word sounds like a palindrome from all directions.The real problem according to me is that lip reading never works here, all because the tongue is on a roll. Funnily this happens every other moment if one is working in a hospital for reasons known ;-)

 Enters Mahabali- apparently he is one of our ambulance drivers who was sporty enough to wear this royal costume, he has been doing this for the last 9 years!

What also happens during the festive season of Onam is the grand celebration by the staff nurses. We at Apollo Hospitals, Bengaluru celebrated Onam today. Our nursing director mentioned an interesting fact " If need be a Keralite may even sell his property to celebrate Onam!" she said. The crowd burst into peals of laughter on that. On a serious note what is admirable is the sense of commitment that they show to their rich heritage and culture even today,when you watch it your heart swells with joy and pride.

 Pulikali- tigers dance too !

This spirit is totally infectious; the flowers, the colours, the dance and the music can keep one blissful for weeks. I have never witnessed such elaborate preparations and attention to details during any festival ever. So many songs and dance forms, stories and decorations, Pulikali and Mahabali, boats and oars, sarees and dhotis, bananas and coconuts, flowers and lamps, Kaikotti Kali and Kathakali. The list is endless, and ofcourse who can forget the Onam Sadya, slurp!

Sorry I could not share this sumptous lunch :-( I am sharing a video of one of the dance forms-'Thiruvathirakali' which was performed today, such pose and grace, even that's a grand treat to watch :-)

Yo! Apollo family staff nurses! :-)

 -R.

B or P- Issues Raising Blood Pressure

"There are some atypical cells probably" said the pathologist.

The doctor was worried, it was his wife's PAP* smear report after all. After a brief discussion they both decided to go for a Human Papilloma Virus detection just to ensure that the picture does not turn out to be bad. He walked to another section and spoke with the Microbiologist regarding the case, the investigation would be outsourced from there to another laboratory which carries out molecular diagnostics.

A couple of minutes later.

"What sample is required for HPV-PCR** pa?" he called the microbiology laboratory and asked.

"EDTA-sample Sir" a technician replied.

The doctor billed for a HPV-PCR test from the billing section and sent the sample from the sample collection centre as told.

 The EDTA vacutainer reached the laboratory through the house-keeping. Another technician received it and took a printout of the worksheet and kept everything ready for the test to be outsourced.

Now one may wonder what this is all about and what happened after that.Let me tell you what the final report was:

Hepatitis B Virus- Not Detected

Human Papilloma Virus

Eh? B or P, what is in a letter? Definitely a great raise in Blood Pressure! I did fall of the chair when I heard this. Everything is pretty much kicked to Pluto if there is a miss or a change, especially in a health care setting when this happens it is not at all pardonable. I am sharing this because it is a necessary learning, unfortunately I wasn't around when this happened. I heard various versions from the technicians regarding this matter, what I understood was the kind of miscommunication that happen over telephonic conversations. The doctor called asking for HPV, the technician heard it as HBV and advised him to send a EDTA vacutainer, but in reality it is either a cervical swab or cytology fluid that needs to be sent. Well even after that with the mismatch in the bill, nobody really bothered to cross check. The outsourced test was for HBV-PCR since it was an EDTA vacutainer. The realization dawned only when the doctor called asking for the HPV-PCR report after two days. HPV is a virus associated with cervical cancer and HBV is a virus associated with hepatitis and liver cancer, two different clinical presentations and diagnoses. The matter is getting sorted out, and we hope not to have such disastrous events again.

  

Hepatitis B Virus

What bothers me is the mechanical nature of work that happens in most of the hospitals. This happened with a hospital staff, a doctor, I cannot imagine the scenario if it was a patient. It does happen nevertheless. Nobody talks about it, the matter is hushed up or sorted out by us doctors or dealt by the patient relations section. I am talking about it because this kind of maleficence is something we all need to be aware of, as doctors and as patients. We need to always ensure that abbreviations or short forms are not used for drugs or tests during diagnosis and treatment. After all it is a matter of someone's life or death. There is a thin line, a very thin one. Thankfully this incident was something that could be handled, if it was something else I couldn't have forgiven myself for being a part of such a work team! It sends a shiver down my spine, every time I think of it. "Do No Harm" is sometimes easier said than done.

*PAP Smear- The Pap smear is a screening test for cervical cancer. Cells scraped from the opening of the cervix are examined under a microscope. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina.

**PCR- The polymerase chain reaction (PCR) is a technology in molecular biology used to amplify a single copy or a few copies of a piece of DNA across several orders of magnitude, generating thousands to millions of copies of a particular DNA sequence.

-R. 

Dengue Season Lessons

“Hello, calling from emergency, can you tell us the dengue report of…”a resident doctor asks from the other end.

“Positive for NS1 and IgM…”says our laboratory technician.

Seconds later.           

“Hello, calling from the ICU, SDP* needed for….are they ready?” asks a staff nurse.

“Ready, you can send someone right now” replies a blood bank technician.

At the same time.

“Hello Ma’am, calling from reception, can you please verify the dengue report of…”a data entry operator from the other end.

“We will do it in a couple of minutes…” I reply.

Seconds later.

“Hello, calling from the ward can you run a Dengue IgM ELISA for my patient with the previous sample, his platelet counts are low, I strongly suspect Dengue…”a clinician from the other end.

“No problem Ma’am, we will add it to the run today” one of us reply and agree to do it.

This diagnostic and treatment process runs in the various departments of every other hospital in India twenty four seven these days. All thanks to the ‘Dengue Season’ like we choose to call it. At this point of time, as you are reading this I bet there is at least one person you know who has had dengue this year. The emergency and outpatient department is busy with cases of fever, the doctors with every third patient coming with signs and symptoms of dengue, the blood bank is worked up with platelet transfusions and the laboratory with monitoring platelet counts and serological tests.

Dengue is a serious public health concern, like many other diseases and disorders it turns into a red alert when mortality rate surges. Remember the H1N1 a couple of months ago? Keep that for memory, there could be is always a next. I initially thought of writing a post on the ‘dos and donts’ to avoid the transmission of dengue thinking that would be helpful, and then it occurred to me that most of us know about the Aedes mosquito, water stagnation, sanitation, coils, nets, electric bats, repellents, papaya juice and what not. It is not the lack of this knowledge that causes the dengue outbreak every year in a tropical country like ours. There is more to the picture.

 What bothers me as a laboratory physician is our failure at many levels of health care to handle such a situation. There is a great lack of responsibility from all sides- hospitals, doctors and patients alike. The extreme variability in the standard and costs of testing and treatment has recently grabbed attention in Karnataka. Read this to know more-Government Fixes Dengue Test Rate for Pvt Hospitals. Such measures although put the government in a Samaritan position, the real problem is something else. None of us is bothered about any preventive measures or a long term solution to such vector borne diseases. ‘Odomos’, ‘Good Knight’ and 'Mortein’ can think of new advertisements. Doctors, laboratories and blood bank can think of their work load and price revision. And the government can think of regulating them. Until the same time next year! 

Ek machar kaafi hai, par ek soch nahi :-P

Picture Courtesy

Do share your opinions and experience.

*SDP-Single donor platelets

-R.

Beauty And The Beholder

"This is beau...uuuutiful" I exclaimed looking at this culture plate.

"Ma'am, doctors like you can say that,not the patient" remarked the technician in my laboratory.

And we exchanged smiles, this was during one of those culture plate reading session which starts every morning half an hour past eight. From arranging these plates, making smears of bacterial colonies and doing biochemical reactions and filling up antibiotic sensitivity forms, not to forget attending the incessant calls from the clinicians and nurses from the wards asking for preliminary reports, well these and a lot more are done during these bustling hours which sometimes runs till noon. A few of my non medical friends tell me that there is no point in asking me how is work, things must be always busy. I do agree it is busy, but it is beautiful.

What keeps us doctors on the move? When my technician said that, I knew he was speaking out of some sort of general impression about the fraternity. Everyone around us has an opinion about us, an expectation that needs to be met.Most of you who have sworn the oath would agree with me, there are many people who would remind you of your responsibility in a way or the other, I tell take it when they do. In fact, one of the data entry operator told me last week "Patient is God" I somehow  succeeded in stopping myself from giving her the look of 'Thank-You-For-Letting-Me-Know-After-Ten-Years-Of-Medicine!' One of the professors in my postgraduate days had told  the class once "Being a doctor is more of an art than science". I stand by it, dealing with people is definitely an art.

When I looked at this culture plate, I thought of the bacteria that caused the arrow head golden hue due to hemolysis like you can see in the picture, what we call Streptococcus agalactiae. I thought of the pus sample from which it was isolated, I thought of the patient who was having an infection, I thought of the clinician who was treating her, I thought of helping him aid the diagnosis. I thought of the antibiotic that can be given. I thought of the possibility of the patient being cured, I thought of her not having to visit the hospital ever again. I had a series of beautiful reasons to call it 'BEAUTIFUL'. 

A surgeon with a scalpel, a radiologist with a scan probe or a dentist with a drill will know what I am talking about. We find beauty in the most absurd things, don't we? A lot of medical drama television programs make it appear like a classic adventure or a stress filled drama but in reality it is much beyond that. To make it all normal, to live that every moment of hope, of being of help to an another human being requires much more than having some empathy and compassion. Every patient teaches us something which helps us help another, that is how this amazing scheme of things works. We are like anyone else, inquisitive and eager about what we do. This is beyond an average man's understanding,probably and most importantly because we are one of those few professionals who find beauty in the pain of someone else. The next time I see something interesting, I shall be careful with my choice of words ;-)

-R.

Swine Flu- Lessons From The Lab

“Tring…tring…triiiiing”

The phone rings for the nth time in the laboratory while everything and everyone are up to something, all are doing their duty to help the patients of the hospital which I can vouch is always more than their individual capacities. 

One of my technicians picks the call.

“Hello Namaste, Microbiology” she says.

While the machines run and beep continuously, a technician receives samples, another processes samples, and an another attends an another call on the other telephone, a few patients wait outside for reports, a housekeeping staff of one of the wards waits inside for reports, a clinician calls for reports, a reporting desk assistant enters some reports, and I one of the microbiologists verify some reports, in the midst of this routine she comes to me with the cordless with quite a dreary look.

“Ma’am please speak to this patient, she is asking for her H1N1 report”

I take the call.

“Hello how may I help you?” I ask the patient out of habit.

And the rest is to be swallowed, in the name of the Hippocratic Oath.

There are times such as these when we get to hear from patients the most absurd things possible to a point that they question the credibility of a doctors duties and what I understand of such difficult situation is this, if there is someone who has to show a great deal of patience it has to be the doctors. It can be nobody else.

With the ongoing H1N1 epidemic we have lessons to learn, and believe me when I say 'A LOT'. If you were to pick up a newspaper and read about ‘swine flu’ which I am sure has more than one column nowadays, you may find information on these lines:

Picture Courtesy

‘Death toll rises to….’

‘.....city’ has ‘x’ number of positive cases, and ‘y’ number of deaths

The fear is but obvious. I wish we paid attention to reverse of the coin as well. The working of Indian health care system, especially our preparedness with dealing such an epidemic, the availability of antiviral drugs and vaccination-the pros and cons; when to take them, why to take them and who should take them. The problems, more so solutions to the problems, these are the issues that need to be addressed. Even if they are, the point is that they are not very precise. As a result the pressures and forces acting upon the health care providers are more of social nature than medical due to this trepidation created. We are letting this run us as if we do not have a judgement of our own, well until the next epidemic.

Diagnostics and therapeutics are central to the working of a hospital and no doctor would risk his patient’s life by delaying a test. H1N1 testing is a molecular test, done by a method called Polymerase Chain Reaction and only a few laboratories have the setup and authorization to run this test, thus the logistical problems. Although automation and technology has reached the highest level possible in diagnostics there are areas which are new to us doctors as well. When the workload reaches a threshold, the maximum that a laboratory can do is increase its working capacity through various means, that’s exactly being done in the testing centres across the country. This scenario was quite unexpected in these places too. It is relatively easy to put the blame on the working of a system although some complaints will have the truth in them, thanks to the commercialization. 


We must not forget one thing, a diagnosis that would not have been made otherwise is now scientifically understood and medically treatable. There is no sensibility in hitting the panic button for the wrong reasons. This all the more gives us a good opportunity to confront the reality of the influenza virus. A common cold may not be a common cold after all. The antigenic shifts and drifts, the pandemics and epidemics are not for history, they are here to stay. Let us face it together!

“Tring…”

The cordless on the table rang again.

“Namaste, Microbiology, how may I help you?” I asked.

“Doctor, I wanted to know my daughter’s H1N1 Report” came a query from a father at the other end.

I remembered his voice, the same man who had called at least five times the last evening. How could I forget the fear and anxiety in his voice, and that of the mother’s whom I could hear from behind? I searched for the status of her report as eagerly as him. Doctors are definitely humans, at the end of throughout the day.

Picture Courtesy

I am doing mine, are you?

-R.

Of Waters And Boats

“Good morning Ma’am, kaise ho? Breakfast kiya?”

 

He asks ritualistically while I verify reports of patients in the laboratory every morning. We call him ‘Tasleem’, a young lanky boy of seventeen from Assam who is quite the songbird. There is no tune that he is not familiar with; there is no Hindi song that is not in his playlist. When I hear him sing, I get perturbed thinking about his job as a housekeeping staff in the hospital, such raw and beautiful talent in the wrong place.

Yesterday when he wished me so, there was a subtle change in his tone. I looked at him and smiled.

“What happened Tasleem, everything fine?” I inquired. His reply was something that made me think there is more to this boy’s charm beyond his adolescent silliness. 

“Bina paani ka naav jaisa hai mera life Ma’am” he said and smirked.

I thought about it all day. There are a hundred wise sayings and quotes about boats on shore and how they need to be sailed. But what Tasleem told me was beyond all that. At times we learn from people whom we least expect to teach us. I am grateful to him for that, of course he does get a word or two from me every other day on how he needs to grow up ;-) We all need water, don’t we? Something to use our oars against. While most of us at some point cry and complain of the battles of routine, there are some who find it difficult to find even that purpose in life. What if there is no water, no battle, no purpose? Eerie feeling!

Hope you all find enough waters to sail, a merry good weather and lots of sunshine. And do take care of your boats. Have a good day :-)

-R