My Lockdown on blogging

My Lockdown on blogging

Dear Friends,

How are you doing with lockdown (I call it shutdown, computer terminology) in ? Wherever you are, US, China, Canada or Ceylon?

It may be a treat for you to avoid US, China, Canada or Ceylon traffic (I forget most of the landmarks of the world, now)!

? Your better half must be busy replanting ? is it daffodil or is it looking after grand children?

With rain coming I will have a break, let my rooftop garden go wild.

It is only 20 by 30 feet has 5 types of lilies and 25 water plants and many banzai plants.

Mind you the 20 odd palm trees I planted only three survived and are very tall now.

I have some seeds too.

Mind you I do not watch cricket or play hockey.

I keep my one and my  daughter’s hockey sticks as souvenirs.

I lost my billiard sticks and ques.

Somebody had used them as firewood, I believe in my absence abroad. 

You may not be hearing or getting my rants from now onwards.

I am getting bit lazy and lot of typos and grammatical mistakes.

I do not want to kill the queen’s language.

Besides satire has no place in this country.

By the way, keep me posted of life and things dear to heart.

List of Medical Stuff one Needs in an Emergency

List of Medical Stuff one Needs in an Emergency

Things are not good as it is, and I wake up exactly 8 hours after a good sleep without bad dreams.

Nothing else to do, this is a way to ease my pent up anger of incarceration.

No anxiety at all!

But I must thank late Professor Senake Bibile, who was probably assassinated by CIA cohorts and Drug conglomerate of America.

This is dedicated to him.

Having said that, I have met bizarre medical personnel in Ceylon, UK and New Zealand where I have worked for considerable length of time and finally settle downed as a teacher and a research pathologist.

I used to say, I can run any hospital with minimum of facilities and of course, I did not have many when I was managing a D.M.O station with Cholera epidemic in this country.

My memory is failing and I start with a incident in a private nursing home in Negambo.

I had an 84 four year old male admitted to this nursing hospital for last rights by his relations.

I had a good technician who was a navel officer with whom I worked during 1989 in Digana village (IMMI) where the 15 or bodies and body parts scattered DJV guys/ girls dumped by our army, then active.

I did have a camera (as a pathologist I photograph some cases for posterity) but never ventured into hysterical photo record but the local journalists took some photographs and they were the first to appear in daily papers.

I told my private technician (he was not employed to save money) to make a blood film (I generally have a look at them after my clinical rounds) and look at it in detail.

He came running to me to report malaria and I told him not a surprise he had hepatosplenomegaly.

My in depth examination revealed even malaria gametes.

Caveat was he had appendicitis in addition.

 

I went and told the owner of the the institution for approval of intravenous chloroquine which I had to purchase from a local pharmacy.

We did not keep a stock and it has cardiac-suppressant effects.

With a ECG monitor standing by, I infused first the antibiotics (we have decided not to operate him immediately) and then the chloroquine slowly.

To my surprise he woke up from his slumber (he had thought he is going to die) and I asked him what he wants me to do.

He said he wish to go home immediately (to write his will or something to that effect).

I said nothing doing for 3 weeks (good for our hospital account) and I will tell him when.

Then I told him his kith and kin wished him dead already and not to trust them when they visit him.

furthermore, pretend you are in deep sleep (coma to be precise) and listen to them to confirm my above affirmations.

Malaria gone and primaquine (double dose) given to prevent relapse, he was by tenth day full of spirit and his ruptured appendix was forming into an abscess walled off (fat guy with lot of omental fat to ward of septicaemia) by the antibiotic treatment.

If my memory was right I gave a single dose of chloramphenicol which was followed by Rocephin IV.

On a similar note on malaria I diagnosed a malaria case in New Zealand clinically and asked the chief technician blood (malaria) film.

He said no malaria in New Zealand (I did not tell him the patient is a visitor from Malaysia).

I took a bet for a large chocolate slab and won it but we shared the spoils in good spirit.

He was the best technician I have ever worked with in my life.

In a similar case a patient was brought in moribund state (after writing his will) with a rollicking double pneumonia.

We treated him with Rocephin and he started recovering but my basal tests included Serum typhoid antibody titre.

He had typhoid too (confirmed) and Rocehin was enough to cure both pneumonia and typhoid.

I am not sure typhoid causes pneuminia.

He had two doses of chloramphenicol IV.

Mind you chloramphenicol is now banned in Ceylon.

 

In a lighter note all my engineer friends (only one girl) who did the Mahaweli Project including surveying came to me within 9 to 12 months with malaria.

The symptoms were variable (like Dengue) in addition to fever (by the way, not typical of malaria in textbooks).

I had eight Cesarean babies dying in my first month of internship.

We did not have a bacteriology unit and sent all blood and stool sample to Colombo confirmed typhoid epidemic in the hospital.

Thankfully midwife feeding the babies was a typhoid carrier, including few other nurses.

 

Closed the Unit and send the acting consultant guy back to base in Colombo.

I reported to the DHS that he was not in base on duty and was recuperating in Colombo.

MS was also transferred.

These were the times when Public Service Commission had teeth without political intervention.

Coming to my list.

My List

1. Saline and Dextrose saline

2. Blood.

3. Hyperimmune serum

4. Morphine

5. Frusemde and simple oral diuretics

6. Oxygen cylinder with mask to make 20-30% oxygen saturation.

7. Prednisolone

8. Isoprenaline with ventolin nebulizer

9. Insulin preferably with an insulin pump

10. Thyroxin

11. ECG

12. X-Ray

13. Emergency Blood film (malaria, ureamia, liver failure, anaemia, leukaemia and even metastatic cancer)

14. Blood sample for basic investigations virology not included.

15. Blood Pressure apparatus and appropriate treatment.

16 to 20 is optional depending on the initial cues.

That include, cholera, typhoid, hepatitis and now Coronavirus testing kit.

My approach to any clinical problem at hand (POMR- Problem Oriented Medical Records)

My approach to any clinical problem at hand (POMR- Problem Oriented Medical Records)

There is some overlay and interplay of terminology.

Even after going through the list throughly, only 60% of the problems can be sorted out with impunity (40% already known and another 20% solved leaving behind 40% a mystery).

When I see journalists’ questions and presentations, Dr. Sanjaya Gupta is having a torrid time and trying hard to keep abreast but mildly skeptical of political overtures.

I hope this list will give some comfort (40% a mystery)1

1. Aetiology

2. Definitions

3. Classification of Diseases

4. Epidemiology

Incidence

Prevalence

5. Pathogenesis

6. Pathology (after the fact at postmortem or biopsy)

7. Microbiology

8. Virology (globally neglected including WHO)

9. Immunology

10. Clinical Findings

11. Laboratory Findings (relevant and incidental)

12. Differential diagnosis (my specialty of trying to delineate subtle differences)

13. Treatment modalities including life support

14. Complications (disease as well as treatment itself including ventilator support)

15. Prognosis

16. Prevention

17. Research

18. Outcome

19. Outlook

20. Philosophical Perspective (ability to stay calm in adversity and leave no stone unturned nevertheless for ABSOLUTE clarity)

Update on Coronavirus

Reproduction

Update on Coronavirus

This retrospective case series includes adults 18 years of age or older with confirmed Covid-19 who were consecutively admitted between March 5 (date of the first positive case) and March 27, 2020, at an 862-bed quaternary referral center and an affiliated 180-bed nonteaching community hospital in Manhattan. Both hospitals adopted an early-intubation strategy with limited use of high-flow nasal cannulae during this period. Cases were confirmed through reverse-transcriptase–polymerase-chain-reaction assays performed on nasopharyngeal swab specimens. Data were manually abstracted from electronic health records with the use of a quality-controlled protocol and structured abstraction tool (details are provided in the Methods section in the Supplementary Appendix, available with the full text of this letter at NEJM.org).

Table 1. Characteristics of the Patients.

Among the 393 patients, the median age was 62.2 years, 60.6% were male, and 35.8% had obesity (Table 1). The most common presenting symptoms were cough (79.4%), fever (77.1%), dyspnea (56.5%), myalgias (23.8%), diarrhea (23.7%), and nausea and vomiting (19.1%) (Table S1 in the Supplementary Appendix). Most of the patients (90.0%) had lymphopenia, 27% had thrombocytopenia, and many had elevated liver-function values and inflammatory markers. Between March 5 and April 10, respiratory failure leading to invasive mechanical ventilation developed in 130 patients (33.1%); to date, only 43 of these patients (33.1%) have been extubated. In total, 40 of the patients (10.2%) have died, and 260 (66.2%) have been discharged from the hospital; outcome data are incomplete for the remaining 93 patients (23.7%).

Patients who received invasive mechanical ventilation were more likely to be male, to have obesity, and to have elevated liver-function values and inflammatory markers (ferritin, d-dimer, C-reactive protein, and procalcitonin) than were patients who did not receive invasive mechanical ventilation. Of the patients who received invasive mechanical ventilation, 40 (30.8%) did not need supplemental oxygen during the first 3 hours after presenting to the emergency department. Patients who received invasive mechanical ventilation were more likely to need vasopressor support (95.4% vs. 1.5%) and to have other complications, including atrial arrhythmias (17.7% vs. 1.9%) and new renal replacement therapy (13.3% vs. 0.4%).

Among these 393 patients with Covid-19 who were hospitalized in two New York City hospitals, the manifestations of the disease at presentation were generally similar to those in a large case series from China¹; however, gastrointestinal symptoms appeared to be more common than in China (where these symptoms occurred in 4 to 5% of patients). This difference could reflect geographic variation or differential reporting. Obesity was common and may be a risk factor for respiratory failure leading to invasive mechanical ventilation.³ The percentage of patients in our case series who received invasive mechanical ventilation was more than 10 times as high as that in China; potential contributors include the more severe disease in our cohort (since testing and hospitalization in the United States is largely limited to patients with more severe disease) and the early-intubation strategy used in our hospitals. Regardless, the high demand for invasive mechanical ventilation has the potential to overwhelm hospital resources. Deterioration occurred in many patients whose condition had previously been stable; almost a third of patients who received invasive mechanical ventilation did not need supplemental oxygen at presentation. The observations that the patients who received invasive mechanical ventilation almost universally received vasopressor support and that many also received new renal replacement therapy suggest that there is also a need to strengthen stockpiles and supply chains for these resources.

Parag Goyal, M.D.
Justin J. Choi, M.D.