Wear blinkers and run the race

Just imagine a horse running a race… the blinkers are put on

The literary meaning of blinkers is “a pair of small leather screens attached to a horse’s bridle to prevent it seeing sideways and behind and being startled”.

The analogy cannot be better.

The moment someone is diagnosed with cancer, unsolicited advice pours in from all corners. Right from sugar free diet to herbals, nature cure, toxic effects of chemotherapy and stories of how their relatives had pain etc. There are very few encouraging voices. Sympathy can overpower you and you don’t need it.

I always advise the patients, ‘just imagine that you are running the most important race of your life’. Don’t lose hope. Don’t allow people to discourage you. In fact ask people to mind their business. You have to attend to the most important business – your health and your life. NO free advice please. If anyone still wants to offer advice send them to me , I will handle them.

Put on the blinkers, don’t look look sideways or behind and don’t be startled by all the noise. Just look at the finish line and run wth all your might

YOU HAVE TO RUN AND WIN !

 

 

 

Good ‘Old’ generation!

 

Yesterday was a very interesting day. I saw 4 patients who are over 70. When I started my surgical career, more than 3 decades ago, we had a fairly unwritten rule that above 50 years be careful and after 60 avoid risky surgery. Some of the major surgeries which we performed on the younger patients were not offered to the elderly patients as there was a fear that there would be some complications and they would not be able to stand the complications.

In the west it has been proven recently that even older patients have the same kind of resistance and power to heal  and tt does not really depend on the age.

‘Physiological age’  is more important than the ‘Chronological age’

Mr. Mehrotra came into my room with a spring in his step. The first thing I asked was “Are you really 79”? He said, “Of course I am 79 and I even have great grandsons.”

I generally do not base my assessment on the biochemical values or numbers.

So I asked him “What do you do in a day and what time do you get up in the morning?” He said, “I am up by 5 in the morning”.

“Oh, and then ? “.

“I go for a walk for about an hour”,

I asked, “how much distance” and he said, “about 5 km.”

(I said to myself “I don’t do that”)

He said, “then I come back and may be have some juice and fruit, a bit of yoga and then I have my breakfast”.

I said, “Fantastic routine, what else do you do, can you go up a flight of steps?” He said, “of course I can because when I go for a swim in the evening, I do go up and down the steps.”

So I said,”oh oh, that means you swim also?”

He said, “of course I swim or go to the gym.”

Well this man is certainly great, at 79 he is fit and is definitely not overweight. I look at the people who came with him, his nephew (who well certainly looked pretty uneasy with the whole conversation) because it was clear that he never walked, forget about gymming and swimming and he was easily 10 kg overweight.   I had to do a major liver surgery for him so I said, “there is a risk in surgery”, he said, “so what, I am ready for it.” I think it is not only the physical fitness but also the mental attitude of the older generation which is remarkable.

Second gentleman was again 75, the same story except that he does not gym and does all the things which normally should have been done by someone who is much younger than him.

I had no hesitation in clearing both the patients for both liver and pancreatic surgeries respectively. Yes, there are some risks involved but it depends on how you take care of your body.

Then came a 75 year old whom I had operated upon for rectal cancer. He said, “doctorsaab, can I go for my walks?” I said, “of course, you can.” He said, “what about the treadmill?”

( Oh, I also have a treadmill but I do not seem to be using it much).

“Yeah, why treadmill, why not just go for a nice walk in the lawns or outside?”

He said, “yes, that I do everyday, I used to do for an hour but now it is 1/2 an hour, but in the monsoon season, if it is raining, I still want to do my exercise and that is why I am asking if I can go on the treadmill”

I said, “of course you can do it but just be careful”.

So, in short, when I look at the older generation it is so enlightening. They are right in front of us- they take care of their health. Their physical fitness is far far better than the younger generation. In fact, I feel that the ‘father’ coming from a small town will do far better than the ‘son’ who is a busy executive in the city. In small towns and villages the people have to walk, there are no fancy cars. They have fresh vegetables, fresh produce, plenty of clean air and certainly they are far healthier than their city bred sons who are either stressed out, stuck in the traffic, no exercise and plenty of excuses not to do so.

Are we going to see a kind of reversal of the longevity which we have achieved over the years and have younger people having lifestyle related diseases in their prime. May be yes, unless we take quick corrective steps. There is no great science involved in this. Just see your father. Ultimately it is the genes which determine your own health and see your father and follow his habits and that itself is going to make you a healthier person.

Old is gold is a saying which is worth remembering every time. It is so true!

 

 

 

 

 

 

 

 

 

 

Giving voice to those who cannot speak ! Vocalizer for patient

 

vocalizer

Long ago my uncle, a neuroscientist was admitted in the ICU with a blood clot in the brain. He was alert but had to be on ventilator. He was desperate to communicate with his family and relatives. My father was anxious to know what was in his brother’s mind. There was no way of knowing whether he was in pain or wanted to meet his son and many other questions.

This happens everyday in the ICU for many patients with an endotracheal tube . Intubation involves placing a tube in the throat for breathing which takes away the ability to speak but the mind is still alert as many of them are conscious. It is also true of post surgery cases as normally after a very major surgery, on the first post-operative day, the patient is on ventilator and is perfectly conscious.

How does one communicate in such situation?

Writing with all tubes dangling is difficult and the handwriting is hard to decipher.

It’s difficult to see them struggle just to say “ I am feeling cold” ( ICU for some reason is kept cold at 180 C).

We were thinking of a ‘touch activated figurative communication’ program. None were available.

Fortunately I could identify Tata interactive system who are the leading developers of learning solutions. With the help of ICU feedback from Dr Sanjith, we set out with a set of common requirements and the touch sensitive visual icons. The patient could communicate his simple requirements on his personal needs, medical care and also communicate with the family.

Vocalizer for patients is a free app available both in android and iOS platforms. It may be downloaded on a tablet and used for communication by your near and dear.

Not only in the ICU, it is also useful in situations where elderly cannot communicate effectively or have some other issues like tracheostomy or inability to speak due to neurological disorders.

This was funded by ‘Crusade Against Cancer Foundation’ as a social initiative. This will be improved further by adding more language options.

Hospital ICUs would serve patients better by just enabling ‘vocalizer on tablet’ and also displaying a notice in the ICUs.

Hope to make a difference !

Door to door screening for cancer ??

Today there is an announcement on a door to door screening for Cancer, diabetes and cardiac illness in 100 districts in India costing 250 crores ( 37.5 million dollars) .  I was astonished. I don’t know about diabetes and cardiac diseases, but door to door screening for CANCER ??

Thats not logical or rational nor is it cost effective. I wrote in my earlier blog that screening for cancer is NOT the answer. Sweden is a classic example. Its a country with small population, social health care and all the people are followed up throughout their life. The infrastructure is excellent.

So when mammography screening for population was introduced, it was believed that breast cancer would be detected early. Once detected early, the treatment can be effective and lives  can be saved. It seems so logical and simple. But…

After two decades, the breast cancer mortality did not come down.The women undergoing screening had many false alarms and procedures. Lots of stress and tension and finally NO DIFFERENCE.

Why did this Happen??

There are many biases in screening. Lead time bias is just one of them. Cancer is so much like the human organism and cell. It has finite cycle and also ages. so whether you detect a 5 mm tumour now or a 1 cm tumour after six months, the outcome does not change.

It does not mean that you keep waiting once the tumour is detected. Soon there will be spread to lymph nodes etc.

But screening raises a lot of questions. When to test ? Whom to test? and how frequently should we test?

Pap smear was one such screening  technique and all women above 40 were advised to undergo PAP smear. But logistics of doing a pap smear, once in life time of a lady, are so enormous. It is just not possible.

The cost and the ability to handle doubtful lesions are so much that population based screening like the one planned as door to door testing, is just NOT cost-effective or feasible.

Instead, as I wrote earlier ( Jan 2014) , seven warning signals  can alert us to seek medical attention or undergo tests.

 

 

 

Fearless Crusaders

 

Last Friday was a great day.

In fact I can name it  as the  ‘Survivors’ Day’.

Nearly 10 patients who are long time survivors of 5-20 years came for review on the same day, by random coincidence. It certainly makes one feel happy to see them leading normal lives without any fear

I was particularly happy when Suhasini, a young lady came in with a broad smile. I was very glad to know that she was operated 6 years ago for Colon cancer.

She asked me, “Doctor, can I start my family now”?

I was thrilled as I know that she was single when she got operated.

I said, “Certainly, I would like to meet   the wonderful young man who accepted and married you”. She said he is on the way. “We were courting before I was diagnosed but he never left my side and continued to be my support. After 5 years he convinced his parents and even my parents that he will be with me forever”. As she was saying this her husband walked in. I am genuinely proud of this young man. There are so many instances where engagements are broken after diagnosis not just in a young person but even in their parents. In a society with so many unfound fears and superstitions, this couple stood like a shining beacon. I assured them that everything is fine and they can have a wonderful family.

I do have many instances of such remarkable couples who not only fought the disease but went on to lead their lives with full vigour.

Hats off to such fearless crusaders.

Focus on each mile stone and you will reach the destination

 

Last week I operated on a complex Pancreatic Cancer. After completing the 6 hour surgery I was very happy that everything went well and the surgery was successful. I came out of the theatre and called the family and said that the surgery is successful, the whole tumour has been removed with all the lymphnodes etc. Instead of being happy, one of the relatives kept asking me about the recurrence. I was a bit frustated. I do understand the reason for anxiety but the patient was not even out of recovery room.

You have to realize that cancer treatment is not like a cough and cold with about 4-5 days of antibiotics. It is long drawn and involves different types of therapy. It is important to remember that this is a journey and our destination is potential cure. The journey has many milestones exactly like your own journey on a road. When we travel we only look at the milestones, perhaps we cannot even see a milestone which is more than ½ km away. But each milestone, once you cross, takes you closer to your destination and that is exactly how we need to approach the treatment of cancer.

First , during surgery there should not be any unpleasant surprises, the disease should be localized so that the surgeon can do a good surgery. So, successful surgery is the first milestone.

Second the patient goes to the intensive care unit for a day or two, so the second milestone is a shift from intensive care to the regular ward which means that all the systems are functioning normally.

Then the third milestone is discharge from the hospital. The surgeon does a lot of plumbing and joining the intestines and tubes and ducts together. Everything takes time to heal and once it heals the patient would resume on a diet and is discharged so that is an important milestone – Discharge from the hospital.

Then comes the pathological reports which are important for staging of the disease, also gives an information on how the further treatment has to be managed. This is when you can have a detailed discussion on the options of treatment, the usual fear about chemotherapy is unfounded. If necessary ‘Yes’ chemotherapy would be needed for preventing or lessening chances of recurrence. Chemotherapy might involve a little longer treatment on a periodic basis, so one should approach this positively. I had written earlier and will write again as to how you can handle chemotherapy if necessary.

Then comes the follow up of periodic examinations and tests. Generally if a period of 2 years is crossed most of the chances for recurrence come down but in some of the tumours recurrence can be as late as 5 years or even longer. But this is all part of the journey.

Yes it is tough. But anyone who embarks on this journey with a positive attitude, willing fight to reach the destination, has a lot more chance of making it to the destination i.e. complete eradication of the disease.

Remember , “Focus on each milestone and then you will reach the destination.”

Elderly parents and NRIs

 

Sharda Joshi is around 70 years. She was diagnosed as rectal cancer about 3 years ago and underwent surgery with a permanent colostomy. She is a remarkable lady, a literary critic,   managing her stoma and continues to lead a very productive life. She lost her husband nearly 10 years ago. Her only son has moved to California. He did come for the surgery but as many other NRIs, has work pressures and finds it difficult to come to India to see his mother. Obviously he is pressing her to come to California to spend time with the family.

Sharda talked to me and expressed some genuine concerns.   She was worried about long flights and concerned how she would manage the stoma.

“I want to go and see my grandchildren but, everyone is going to be busy with their own lives, school and homework. Weekends also turn out to be a busy time with the activities, additional things to do, groceries and other chores.”

She said, “What am I going to do while they are at work or in school and even when they get back they are going to have their own friend circle. Why should they even bother about an old lady sitting at home. Here I have my friends. I can talk to them, call them over and even go to some cultural activities and plays”.

” If I fall sick in a foreign health care system , I have  no insurance cover.”

So she said, “Doctor, can you give me a certificate stating that I am not fit to travel to California ?” This was rather unusual as many patients ask for ‘fit to travel’ certificate.

The more I thought about it, the more I realised that though there is some emotional guilt on the part of the children, the parents are better off in their own homes and environs. I see a lot of elderly couples or many single elders managing on their own with some help but having more social interaction here in their country.   It is really unfair to uproot them from their familiar surroundings and make them feel isolated in a foreign country with practically no social interaction.

I looked into the factors that really gives you happiness. The socio-cultural interaction becomes an important issue. Yes, we are going to see ageing population and perhaps lonely, and the big challenge is not just to attend to their basic physical needs and medical needs but try and be in touch with them and encourage social interaction.

I know of a family, Mr. Ramakrishnan, whose three sons were senior software professionals in the US, who took turns and  come here in rotation for 3 months. It will be  difficult for many others to do it.

It is fine to allow their parent/s to have a support system and a friend circle.

This is not just a reflection on NRIs but also in many of the families even here in India, the children stay in far away metros and parents stay in their village homes. This is the same story and the same message.

Allow the elderly their space and the freedom to make their choices.

They want their independence and want to be useful.