Speech for the BOSE

Dear Fiends! We are the lucky ones to still be around for the 45th reunion of our Batch.
Time has literally flown. On 17th July 1978 when we entered the portals of CMC, the five and a half years for our course, seemed like infinity to me. A senior doctor saar of the ’73 batch put it in perspective, “Dei! When I joined in first year you were in 7th standard!”

Those who have read my blog, and for those who haven’t, on the perception of time.
I had postulated that perception of the length of time is inversely proportional to your age!
At 1 year a year represented your entire life, at 5 years it was 1/5th of your life. As you age that fraction shrinks as the denominator increases, now it’s 1/62 for most of us. Our perception of a year has proportionately shortened.
I have driven down to Bangalore from Calcutta with the King of Calcutta Bong Biswas and his beautiful wife Neena.
We broke journey in Horsley Hills trying to recreate the nostalgia of our class retreats.
The place is unrecognizable with tourist and trash but still retains some of the old world charm of a British hillstation.
We could not locate our retreat centre apparently it does not exist anymore. We searched for the iconic rocks on which most of our old pictures are taken but it was futile.

Bangalore also brings back nostalgic memories of 1976, when our family had driven down in our family Ambassador. That was my first trip south and exposure to the language and culture. Road trips then were a different story then. The cars were not air conditioned and there were limited amenities on the highway.
When we reached Bangalore we were surprised with the cool climate. There were no fans in the place where we stayed, it was considered too fancy!

We were quite amused that a ubiquitous road like Mahatma Gandhi road found in every town in India, was given a modern spin and called MG road! It removed the image of and a bent doddering old man with his cane and instead conjured an image of a modern happening place. Appropriate since MG road was the happening place in Bangalore.

At that time all along MG road there were posters advertising the latest hit Kannada movie, starring the superstar of Kannada movies, Dr. Raj Kumar. The story was based on Shakespeare’s ‘Taming of the Shrew’ and had an apt titled,
‘Bahadur Gandu’.

In Hindi, gandu would loosely translate to an asshole and bahadur means brave. It is logical that a man has to be brave and an Asshole to attempt to tame a shrew, invariably his wife.

While on the subject, I remember the old joke about how all the parts of the body fought for the position of the Boss. The brain the ears, eyes, mouth and nose staked their claim. The anal sphincter aka the asshole also threw his hat in the ring. The others laughed at the anal sphincter who sulked and refused to function. The brain became feverish, the ears began ringing, the eyes saw blurred and the mouth could not eat. They all appealed to the brain, “Let the asshole be the Boss!”.
And it came to pass that the asshole became the Boss.
All the parts of the body functioned perfectly and the asshole did nothing at all, except pass out a lot of shit. The moral of the story is “You don’t have to be a brain to be the Boss, being an asshole is sufficient”.
I recollect a quote by Dean Martin “At my age the biggest satisfaction is having a decent crap in the morning”.
I am sure many of us would concur.

In our vast country with various languages one word may be inoccous in one language maybe noxious in another. For example imagine my hard core Malayali mother in law’s indignation when she knock on a door and the occupants told her, “Kundi khole ke andar aa jao”.

After I completed my MS, I forayed into private practice by necessity. My mission hospital paid peanuts and I had a family to support.
Being a bottom feeder at that time, I was left with, what else? The bottom! All the anal fissures, haemorrhoids, fistulas and perianal abscesses not to forget the fecal impactions came to me. This region people higher up in food chain would not touch with a barge pole because they had the thyroids, abdomens, appendices, hernias, hydroceles and of course the breasts.

Like the motto of a gynaecologist is “Always at your cervix!” mine was “Always at your a____e”, you guessed it right.
I went about my job in earnest and became good at it, remembering the famous quote by Bailey and Love, “If you don’t put your finger in, you will put your foot in.” This must have been told to us ad nauseum during our MBBS.
There were anecdotal stories of the great Puli and his penchant for p.r.s.
A Princess from the Royal family of Nepal admitted in M ward with pyrexia of unknown origin. After taking an extensive history and doing a thorough examination, Puli did his famous p.r. and Eureka! He found a perianal abcess, which was the cause of the fever.
When we were in CMC I remember most of the patients with perianal problems were from across the border Andhra Pradesh. It was attributed to the fiery Andhra food.
In Nagpur we have our own very fiery ‘Saoji cusine’, which is supposed to beat Andhra cooking hands down in terms of conflagration. People have devised an informal grading system for the degree of heat.
Grade 1. Mouth on fire.
Grade 2. Stomach on fire.
Grade 3. Morning after rear end is on fire.
A young adventurous Vellaikara white man visited Nagpur and being either bahadur or foolhardy, he decided to experiment with Saoji cusine.
The moment he took a bite his face turned crimson and he opened his mouth and stuck his tongue out and fanned it with his hand. He gulped down at least a gallon of water and gripped his abdomen complaining of burning. Morning after when he sat on the water closet he passed few hard lumps followed by intense burning. By his description the pain was like passing out a barbed wire! He reached for the toilet paper to wipe himself but the rough paper behaved like an abrasive, making matters worse. He then spotted the hygienic shower and aimed it at the afflicted area. That was an epiphany moment, he realized why Indians wash it rather than wipe it!
He visited me the next day still complaining of a persistent burning. I asked him to strip and lie down in the left lateral position with his right leg flexed. First thing I noticed was a realistic lipstick mark tattooed on his right gluteal region, which seemed to imply either “kiss my ass!” or “my ass has already been kissed”.

On digital examination I felt button hole like abrasion in perianal region, diagnostic of a fissure in ano. He was send off with a prescription of smooth muscle dilators, laxatives and soothing sitz baths.

On the subject of wiping there is the story of a senior anaesthetist in CMC being reprimanded by a white theatre nurse for resting his backside against the shelf containing the autoclaved drums.
“Kindly remove your unsterile backside from my sterile equipment” was her reprimand.
The anaesthetist not short on wit retorted, “Sister we wash it and don’t wipe it”.

The Resident who wouldn’t operate

This satirical essay was written by a former resident describing his journey through surgical residency. He describes his trials and travails with sardonic humour. He prefers to remain anonymous.

Sinbad had done his MBBS from a Medical College in Dakshina Kannada. An average student but often marked out by Professors as someone with ‘great potential.’ It was in internship that he had found his inner calling- Surgery. He loved the smell of spirit and the sight of blood and pus. He was quite eager to dress the burns patients and if ever a resident offered him a lacerated scalp to suture, he would gush about it for the next many weeks. The one time he was told his suturing was better than the residents’, he relived the procedure throughout the night. He enjoyed the company of surgery residents- there was something about them which was different, cool, macho.

The Professors had their quirks but were legendary- to see Dr. Thangam Varghese operating was to see an artist paint, Dr. Sri Ram Bhat’s left hand was spoken of among interns as much as his book was appreciated, Dr.Harish Rao’s diction, Dr. Ashfaque Mohammad’s humor, Dr. BM Nayak’s jogs and intra-op high-fives, Dr.SP Rai’s conduct. He certainly wanted to be a surgeon.

It isn’t clear where he spent the next two years. But he was preparing for the post graduate entrances. His seniors had advised him not to take up any clinical jobs, for they had understood that it was difficult to work and study for NEET simultaneously. As he wrote his first set of examinations he realised a cruel fact. They do not ask you what you should know in entrance exams. It is merely an exam of elimination to aid the filling up of post graduate seats. And so he wrote-ten, twenty, thirty, forty exams and more, across India, in two years and failed in almost all of them, qualified a few but was knocked out at the interview stage in a couple of others. Two years of loneliness, failure, rejection, helplessness and the lack of an identity.

This was when the heavens woke up to his pleas and he found himself a seat in Surgery, somewhere in North India. The years of misery were over. The Promised Land, the land of milk and honey awaited him. And unlike many others, who wanted Orthopaedics or Medicine or Radiology but were settling for Surgery owing to their ranks, he had actually found himself in the field he loved the most. This was going to be tiring but rewarding, or so he thought.

This was what he learnt in Residency.

First Year:

1. Humiliation is a way of life here. Most things you are shouted at for aren’t even your fault. Shouting at you portrays the Boss as a sinless God in front of the patient. Your senior can scream at you in public for his own fault and you shall put your head down and listen.
2. It’s all Divide and Rule brother. All the powers that be need do is make your passing conditional to their approval.That is enough for colleagues to find every opportunity to put another down through three years.
3. Do not trust your own brother if he is your colleague or senior. Nobody is here to learn Surgery the way you thought they would be. In an environment of insecurity, do not expect anybody to keep your secrets.
4. They will be polite to their wives and children for they need to be. They will be polite to their patients, for they are their livelihood. They will never be polite to you. You are the scum of the earth.
5. They will say do not eat till the job is done, but make sure you eat. Especially breakfast. They will not care whether you slept in days or not, but will disturb your sleep at midnight by taking an additional round, merely to feel senior.
6. Hydrocele is your cutting. Unless the Boss decides he wants to teach a beautiful intern what a tunica vaginalis looks like. And this will happen often. If your eyes brighten up at the sight of a hydrocele, teach them not to. Don’t blame the intern, put her to good use. If she can chat up the Boss in OPD, that will save you from a lot of pedal lactic acidosis.
7. Touch feet as often as possible. Even if your back hurts. You touch feet for years and then you get your feet touched for years. It means nothing. Just keep touching. Makes life easier.
8. If a wound gapes, it’s your fault. Seroma, Haematoma, Surgical site infection. All of it your fault. Even if you were not present inside the operation theatre and did all you could to prevent it.
9. Take time out to cry. You need to keep your system light. You might struggle from suicidal ideation, but it is documented that 30% surgery residents do too. So you are not alone. You can always jump off the hostel building like many before you have, but that won’t change the way things work around here.
10. Don’t work hard. Give an impression that you are hard-working. Both are two different things. Work where you can be noticed, when there is maximum possibility of being noticed. Exert yourself completely to the patient who is Boss’ relative/ mechanic/ driver. Your elaborate burn dressings will never be seen, don’t even bother.
11. Curiosity and Spirit of Enquiry is all bovine faeces(bull). Never ask questions. Be a YES man. It’s good for your health.

Second Year:

1. Get a car. Boss has his income. But Boss likes to save. Drive him around. Feed him till he chokes. Your father’s hard earned currency notes are actually confetti meant to be showered on Boss.
2. If he asks you to buy him a brownie, get him ice cream too. If he asks you to buy him a helicopter, buy him a space station. Why? He knows many ways by which he can ruin your life. He is Boss. The medical establishments have no way of assessing and admonishing the dinosaurs in the food chain.
3. Your senior is exam-going. He needs a good impression. Take the blame for his mistakes in the morning. You can always whip the juniors in the evening. Or tear up their files.
4. Hernia is your cutting. Unless the Boss decides he needs to teach an undergraduate damsel how a tension-free mesh repair is done. Or, the Lecturer would be in a mood to finish three hernioplasties under 45 minutes by himself, some silly personal record of his . You will be second assistant forever, or so it will feel. Don’t run throughout the night trying to get the patients fit for surgery. You will get peanuts at the end of it.
5. Lecturers don’t care about you more than they care about their job. And for many reasons they need to be in Boss’ good books. Else he’ll load them with more cumbersome work and stall their promotions. So anything you tell them in good faith shall be duly reported. And if they tell you something personal, they are merely venting. Don’t read too much into it.
6. Humour in Surgery sucks. It is almost always slapstick. Almost always centred around boobs and balls. Few get sarcasm and almost no one will understand a pun. The older they get, the more funny they try to be, the worse the humour that comes out. Laugh anyway. Else you stand out as a sore thumb.
7. Start holding the Boss’ suitcase as he walks in and walks out. Go up to the car. It is all a colonial hangover. It makes absolutely no sense, but do it anyway.
8. Anaesthetists are almost always women. They almost always are in a rush the moment the scalpel or needle-holder is thrust in your hands. She will insinuate your lecturer or boss about how fast things would have gone had he been operating. Your superior is hormonal. He takes her comment as instruction. Walk over to the other side buddy, again.
9. They’ll say how their residency was far busier, far superior and far fetched things like how they did Whipple’s alone in a dark room under local anaesthesia. You’ll wonder why they don’t teach you how to drape, hold a needle-holder, place a suture. Never vocalise it.
10. Flatter. Suck up. You’ve never done it? Well, now’s your time. Flattery always works. Remember, your goal is peace of mind. Nothing else.

Third Year:

1. Do not ask for surgeries. Ever. Somebody in the food-chain above you will wait till you make the smallest of blunders, and then announce it to the whole wide world. This, despite you going out of the way to hide their own errors from them, and others, for 2 years now.
2. If you are complimented for your work, deflect it to someone senior to you present nearby. Some patients will want to tell the world how much you have helped them, make sure they do not reach Boss’ ears. He sees you as competition, not as a disciple.
3. Almost all surgeries in the operative list are supposed to be your cutting. Don’t believe it? Check your logbook. But of course, now that you do not know how to do a hernia well, how can they trust you with a mastectomy or a thyroidectomy. You should have worked harder in your residency. For now, you get nothing.
4. Buy costly stuff for Boss and his wife. Give it to him as a Diwali present. He will refuse. But that is a token refusal. He is an abyss. Coax him till he takes it home. You need your thesis signed.
5. Stop entering the O.T. Boss doesn’t think you need to learn surgery nor does he think you need time to study. He will remember to make you write his wife’s research article days before your university exam. Stay out of his sight, stay out of his mind.
6. It’s a tree of monkeys. Your senior will see only monkeys below him. Your junior will see only Hilton-lined holes above him. The cycle continues.
7. They’ll tell you observation is learning. It is, but it is not. You can observe a hundred perforation closures but still think of it as an insurmountable mountain. It is only when the scalpel and bovie are in your hand do you learn the trade, which you probably won’t till you are here.

Sinbad received a call from his Boss weeks before his University exam that he was going to be failed. Thanks to the insistence of two Senior Examiners who voted against the pre-meditated verdict, he was passed, in his first attempt. The God who saved Peter from drowning had saved him too. He has come to appreciate the few friends that stood by him in residency, the love of his life was a God-sent balm, his parents helped him stay sane with their regular visits and daily prayers. Now he works in the suburbs under a kind mentor- learning to drape, suture, operate. He insists that not all residents are selfish, lazy and lacking in passion. Some lose their passion in residency.

The killer string!

Nylon ‘Chinese’ manja

Tuesday, 8th February 2022 at 5:30 pm NS, a 25 year old photographer by profession, stepped out of his house in Bhim Chowk, Jaripatka, Nagpur. Little did he know what fate had in store for him. Aptly demonstrating the unpredictability of life.

He was rushing for an assignment at a tony Hotel in the city. He was dressed to the nines with freshly coiffure hair, spiffy clothes and a gold chain around his neck. He got on his two wheeler and because he was running behind time, he drove at a fast pace. The route took him through crowded localities with narrow lanes.

A month had passed from Makar Sankranti when traditionally kites are flown but there were some stray kites still flying from the roofs of houses. Suddenly NS felt a sharp piercing pain in his neck. He had been snared by a stray kite string, suspended across the road between two buildings. The string dragged him off the vehicle and onto the ground. The vehicle drove driverless for some distance before toppling over. He put his hand on his neck only to find his hand covered with blood. He could feel a huge gash across his neck which was bleeding profusely. He immediately took out his handkerchief and tied it around his neck. Meanwhile bystanders gathered around and began clicking pictures and videos of the accident. He tried to appeal to them for help but no sound came out of his mouth, only wind escaping from his neck with gurgling sound. The thread had cut through his neck and severed the trachea or wind pipe below the vocal chords rendering him literally voiceless. He was a victim of the killer string, the infamous Chinese Manja.

Cut with the open trachea

Makar Sankranti, Uttarayan, Maghi or Pongal as it’s called in various parts of India, marks the entry of the sun into the ‘Makar Rashi’ or Capricorn. This normally occurs on 14th of January on non leap years and the 15th on leap years. It’s celebrated in various ways, from bonfires, sweets to flying kites.

The cotton string of these kites were traditionally treated with a mixture of rice paste and tree gum as binders, mixed with powdered glass got from crushing tubelights or bulbs, dye and other secret exotic ingredients like the contents of a torch battery. To coat the string with the mixture it is strung between two convenient poles, a lump of the mixture was rubbed along the length of the thread allowing the thread to get coated. To avoid the applicator’s fingers getting cut he wears small tubes on each finger or taped his fingers. This sharp string is called ‘manja’.

All these preparations were for the traditional kite fights. The kites are maneuvered so that the threads of two kites would get entangled in an embrace and rub against each other or ‘pech ladaana’ as it’s known in local parlance. One of the kite’s string would get abraded due to the friction and the kite would float loose. In Nagpur this is followed by a shout in unison by the people flying the victorious kite, “O paar” or “O kaat” depending on which part of the city they’re from, which means the kite is cut. In Gujarat the shout is “kai po che”.

Then there are the kite runners, consisting of children and even adults, scanning the skies and waiting for a kite to go adrift. They chase the kite armed with long bamboo poles having a dry thorn bush tied to the end, to snag the kite thread and claim the kite as a prize. This is called ‘patang lootna’ or looting a kite. The kite itself has hardly any value but the looting was part of the fun and tradition. Then there are the Sharayati, people who place bets or sharayat on which kite will be victorious. Huge sums of money exchange hands.

Behind this seemingly innocuous sport there is a sinister undertone. In a quest to have stronger and sharper manjas, in last 10 years the traditional cotton string was substituted with nylon string, the so called ‘Chinese manja’. Despite it’s name the Chinese manja is not necessarily from China. It is a desi spun product but given that moniker because it was cheap. The fibres, maybe imported from China. This manja is coated with glass and metal filing and is extremely sharp and unbreakable. This manja is capable of slicing through flesh like a hot knife through butter. Unlike the cotton string it is not bio-degradable.

The kite strings get strewn around trees, between buildings, lamp and electric poles. If it crosses a road and an unsuspecting person on a two wheeler gets snared by it, it’s capable of inflicting deep wounds. Invariably it slides over the body but gets hooked at the neck and cuts through the neck. The traditional cotton manjas were sharp but had a low snapping point. They caused damage but not usually deep. The Chinese manja has a very high snapping point enabling it to cut deep and inflict damages.

The kite runners while chasing kites grab on to kite strings which may cross the road and injury an unsuspecting two wheeler rider. The kite runners are so intent on looting a kite that their are oblivious of the traffic and can get hit by a passing vehicle. They also position themselves on rooftops to have an advantage of height to grab onto the string. Fall from buildings are very common. I have treated a small boy who fell from the roof of a house and his thigh got impaled on the spikes of a gate.

Then there’s the betting by the Sharayatis. Betting is illegal but the authorities turn a blind or Nelsonian eye to it. Because winning involves not getting your kite string cut, the demand for the stronger Chinese manja shot up. Now no one can survive a kite fight without using the Chinese manja because cotton manja stands no chance against it.

The manja being non degradable poses an environmental hazard and to birds who also get entangled in it. The National Green Tribunal declared a ban on this manja. But despite the ban, it’s observed more in it’s breach. The Chinese manja can be easily brought in the black market or it is sold in the guise of industrial use.

There were a sequence of events which saved NS’s life. You can call it fate or an act of God or as the Hindi saying goes ‘jako rakhe saiya, mar sake na koi’ (A person blessed by God, cannot be harmed) .

The first was a friend of NS happened to be passing by the accident site and when he saw NS he immediately rushed to his aid. He hailed a passing e-rickshaw and took him to the nearest hospital, which was Janta Maternity Home and Hospital.

The second event was I normally have my consultation in Janta Hospital at 7 pm but that day I had to attend a meeting at 8 pm. I decided to go to Janta early and see my in-patients and miss my evening consultation. I parked my car near the hospital and walked to the gate. I saw an e-rickshaw coming at speed to the gate and attendants lifting a young man off the rickshaw and on to a waiting gurney. The clothes of the attendant were blood stained and the patient’s clothes were soaked with blood. I was told he is a victim of the infamous Chinese Manja. I immediately went along with the patient to the casualty and shifted him onto the examination table. On removing the handkerchief covering his neck, I was greeted by a gush of blood and a spray of blood mixed secretions from the transected trachea or wind pipe, as the patient coughed.

I thought for a moment, “this is way beyond my league!” and the thought of referring the patient to a higher centre briefly flitted through my mind. But then I saw a young man just beginning life, pale as paper, pulseless and a barely recordable blood pressure due to exsanguination . If I referred him in this condition then death was a foregone conclusion.

I recalled an incident during my surgical residency days, an ECG technician stabbed a Microbiology technician in the hospital campus due to personal disputes. The ECG technician knew the anatomy of the heart and stabbed him just below the left nipple, directly in the left ventricle of the heart. What saved him was he was immediately taken to the casualty and a cardio thoracic surgeon was available. The cardio thoracic surgeon took the bold decision of immediately opening his chest, between the ribs, at the site of the knife wound and controlling the bleeding with a stitch on the left ventricle. Once the bleeding was controlled he could be transferred to the operation theatre for a formal surgery. All done sans anaesthesia but the patient was knocking on heaven’s door and was oblivious of pain. This bold action saved a young life!

In Advanced trauma life support (ATLS) training in trauma medicine, there is the ‘Golden Hour’ concept, it is the period of time immediately after a traumatic injury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death and reduce morbidity. I definitely didn’t have an hour to act so no time should be wasted. I went through the ABC of ATLS, which is airway, breathing and circulation. I asked the junior doctors and nurses to start an intravenous line and rush in fluids, administer oxygen and send a sample for immediate cross matching for blood.

I explored the wound to find the source of bleeding, the external jugular vein which was severed on the left side and was pouring blood. I managed to clamp and tie it. There were other smaller bleeders which could be tied off, luckily other major vessels like the carotids or internal jugulars were intact. Now I had a relatively bloodless field and could assess the damage. The trachea had been almost completely transected and was acting like a tracheostomy through which the patient was breathing. I covered the wound lightly with sterile pads and shifted him to the operation theatre. An urgent call for the anaesthetist was sent. I went out and spoke to the relatives, I told them he has a fifty-fifty chance of survival and I will give it my best shot and the rest is in the hands of the Almighty.

In the operation theatre I injected local anaesthesia into the wound and began suturing without waiting for the anaesthetist. The trachea does not have any sensation, I first sucked out the clots and blood in the trachea with a suction, the patient coughed reflexively. Then I began suturing the trachea, with 3 stitches the transected ends came together. There was no air leak and the patient began speaking. Now he was able to inhale the oxygen which was being delivered to him via a face mask. The first thing he said was that no one came to his aid at the accident site. Next I began suturing close the strap muscles of the neck and followed by the platysma which is a muscle just below the skin and finally the skin. His vital parameters like blood pressure and oxygen saturation improved. We finally felt that he was out of the woods.

Immediately after suturing

The next day

Two subsequent days

The patient made a miraculous recovery, he was up about and talking by the next day. He kept in intensive care unit (ICU) and monitored for possible complications like aspiration pneumonia from blood entering the trachea. But luckily his recovery was very smooth.

To quote Shakespeare “All’s Well That Ends Well”. I was lauded for my timely efforts which saved a life. But suppose things went bad? The same people would have criticized me for ‘biting more than I could chew’. The same relatives who touched my feet declaring me a God could have become violent. A patient living or dying is not in our hands, we can do our best but ‘there’s many a slip twixt the cup and the lip’. But ‘fortune favours the bold’ and I got a once in a lifetime chance to save a person’s life. As a doctor and a surgeon that’s what I was trained for. We should never shy away from being the good Samaritan.

News report

One of my classmates sent me this message, “Wow, impressive! Tell us more:

1. How did you manage the airway to prevent aspiration without an ET tube? I see only an O2 mask
2. Why under local? Was there no anaesthesia help available?
3. If you had intubated through the mouth and got the end of the ET tube into the distal trachea and inflated the cuff, could it have prevented aspiration and served as a tracheal stent as well?
4. Could he have been transferred to a higher centre where specialist anaesthesia help was available? Why the decision to repair immediately under LA?”

My reply was : “I work in a depressed area which has mainly a slum population. Luckily I was in the hospital when the patient was brought to the casualty. His external jugular were severed on the left side and he was in shock. Initially I planned only to resuscitate him. I caught the bleeders and started iv fluids. The trachea was lying open and already blood had gone in which I aspirated. The anaesthetist meanwhile had not yet arrived so I thought I’d close the trachea to avoid further aspiration. Once I had done that then I sutured the strap muscles and closed the wound. He was not in a condition to be immediately transferred and he would not have been able to afford a corporate hospital. The government medical colleges are in shambles, so I took the decision of managing him myself after taking the relatives in confidence.”

The wound today

Dream of attached bathrooms in the Mansion of the Gods

As we stepped into Men’s Hostel on 17th July 1978, we were told to meet the Hostel Secretary for room allotment. The Hostel Secretary had commandeered a vacant room and was seated behind a desk. He handed us a form which we had to tick our preference for room, ‘double/single/single with attached toilet/single with attached toilet and AC’. I wisely decided on single though in the hot and humid Vellore climate, AC was tempting but I somehow knew it’s highly unlikely that there were AC rooms.

Later I was grateful for my decision because during initiation those unlucky ones who opted for a single room with attached toilet and AC, had a pipe strapped on his back with a shower head suspended above his head and a bed pan tied around his waist as an attached toilet. An aerosol can was suspended around his neck as an AC.

The dream of an attached toilet was always in the minds of the residents of Men’s Hostel, the luxury of not having to walk down the corridor to the common toilets. It was like having the keys to the executive washroom.

During bacchanal parties, indulgence caused increased diuresis and delay. The urgency was so great that they barely managed to step out onto the corridor, and relieve themselves over the railing, which was at a convenient height. The car of the hostel warden parked in the driveway in ‘D’ Block was a regular beneficiary of these ‘showers of blessings’.

This idea may have been instilled in our minds during initiation, when following our morning exercise supervised by the ‘Field Marshal’ and ‘Executioner’ we were supposed to in batches of 3, lie face down in front of ‘C’ Block store and chant in unison, ‘God! God! Give us rain!’ Our prayers were answered when a bucket of water was poured on us. Then we rolled in the mud and again appealed for rain. During this ritual I felt a thin stream of water hit me which had a warmer temperature, suspiciously close to body temperature. Some seniors shouted, “Don’t piss on the poor buggers!” I went berserk and tried to look up but my head was promptly pushed back into the mud.

A story which made rounds in Men’s Hostel and was part of folklore that there an occupant of supertop who routinely used to relieve himself over the railing, fouling things up for the occupants downstream. No amount of entreaty would make him mend his ways. So the occupants downstream took matters in their own hands. They got an electric stove, the ones which had the glowing coils, placed it on an old badminton racket and tied a bamboo to the racket. The stove was plugged into an extension cord. Then they waited patiently for the nightly flow of effluent. When they heard the pitter patter of effluent hitting the ground they switched on the stove and extended so it was right under the stream. It was the perfect ‘mid-stream clean catch’, the stove sparked, the stream stopped and cry of pain was heard from above. To make a long story short they were never troubled again by the flow of effluent.

Then they were the improvised chamber pots, after all “need is the mother of invention” and the desi jugaad in keeping with “waste not want not”. There were a vast collection of empty bottles from past revelry in the hostel rooms, which were put to good use. They were refilled capped and placed in a hidden corner under the bed. Once in a while the watchman would come to sweep the room. The watchman in his attempt to reach the dust in all corners reached the cache of refilled bottles. He picked one up, shook it, looked at the it and stopped just short of sniffing it. Then gave the owner an incredulous look and asked, “Idhu enna Saar? Urineaa?”

Calcium trouble

Do the past residents of Men’s Hostel, especially Circa 1978-1984 recall the strange malady which befell only the males called ‘calcium trouble’?

The clinical scenario was after vigorous and sweaty physical activity or on a hot sweaty night, the victim goes to the toilet to pass urine but is alarmed that he’s unable to pass urine. Just a few drops emerge with severe burning in the urethra.

The treatment of ‘calcium trouble’ paradoxically was common salt. The victim would rush to the mess, pick up the salt container placed on the dinning table, go to the water cooler, pour a glass of cold water, add a fistful rather than a pinch of salt. After one or two glasses of this mixture he would return to the bogs. A blissful expression could then be seen on the suffer’s face along with the sound of urine flowing freely.

It was said that due to the high calcium content of the drinking water which caused this form of dysuria, hence the dubbed as ‘calcium trouble’. How common salt relieved the suffering was a mystery.

During initiation after our exercise session we were told to drink water with salt. I always thought this was part of the initiation but later discovered the reason.

After any physical activity in the hostel, the ritual was the players would run to the water cooler with salt and drink one or two glasses.

Luckily I only had an attack once during my tenure in CMC. But there were others who told pitiful tales of painful peeing and implored us to take precautions. Hence it was water with salt on a regular basis. I suspect I can blame my early hypertension to this practice.

Now the water drunk I am sure undergoes, reverse osmosis, filtration, ozone treatment and God alone knows what else. Plus bottled water is the norm, so I suspect this malady has become a distant memory or an idiosyncrasy of the Batches of yore. In those simpler times water was straight from the tap.

The Ch_ tiya Community of Assam

The motto of my alma mater, Christian Medical College, Vellore is ‘Not to be ministered unto but to minister’. This was epitomized in the conduct of our teachers, who were simple, humble and dedicated to their work. They were excellent role models.

After finishing my MS, I was motivated in doing my little bit of ministering for the poorest of the poor. I offered my services for charitable surgical camps. I have operated for 19 years in the Lok Biradari Prakalp, Hospital in Hemalkasa. Also in the MAHAN Hospital in Melghat, the Leprosy Mission Hospital in Kothara, Paratwada and in the Vivekananda Mission in Khapri, Nagpur.

The Lok Biradari Prakalp was started by Dr. Prakash Amte in a Naxalite insurgent area, inhabited by poor tribals living in stone age conditions. He has been honoured by the Padma Shri, Ramon Magasaysay and Mother Theresa awards for his selfless work.

Mahan Hospital was started by Dr. Ashish Satav. Mahan is an acronym for Meditation, Aids, Health, Addiction and Nutrition. This is also a tribal area and infamous for 6000 starvation deaths among the tribals in 2016. Incidentally another Alumnus of Vellore, Eric Simoes, a Paediatrician in Denver Colorado, also visits this centre regularly as part of the Bill Gates Foundation.

I don’t claim to be a saint, social service is a symbiotic relationship and both parties benefit. I got an exposure to a wide variety of cases which I don’t normally see in the cities. These were neglected cases either due to ignorance or absence of medical facilities or both. I have operated in primitive conditions, using a surgical drape the size of a napkin, a bare bulb, a torch and even a kerosene lantern for illumination. I learnt to manage with minimum resources. There are critics who would say we are compromising but the reality was, if we don’t operate, they would never get operated. This honed my skills and made me realize we could do a lot with very little. I also got away from the city and far from the maddening crowds. I visited extremely remote areas, untouched by civilization or tourists. These were very pristine places with a lot of natural beauty. I also learnt about the people, diverse culture and language.

Lush tea estates in Dibrugarh and enjoying lunch in a Dhabha where the seating is in a crystal clear stream.

In 2018 I was invited by the Vivekananda Kendra to organize and operate in a free surgical camp in Dibrugarh, Assam. The patients are tribals, mainly from the adjacent state of Arunachal Pradesh and they have very little access to modern facilities. Some came from such remote mountainous areas, which were inaccessible by road. They had to trek for 5 days in order to reach a motorable road.

Three of us enjoyed time together And operating together. Unfortunately one is no longer with us.

Dibrugarh or ‘Ti-Phao’ meaning ‘Place of Heaven’, as it’s known in the Ahom language. The Ahoms were the dominant dynasty and ruled Assam for almost 600 years. They came originally from China and conquered most of Assam.

Dibrugarh lies on the banks of the Brahmaputra, the only masculine river in India. The two main source of economy in Dibrugarh is tea and oil. It is surrounded by lush green tea estates. The first tea garden was established in Chabua around 20 kms from Dibrugarh.

Oil which was first discovered in India in nearby Digboi. During the construction of the Assam Railways in 1867, the engineers noticed the feet of the elephants employed were soaked with oil. The story goes that the British Engineer W. L. Lakes exhorted the local natives to dig in the ground for oil by shouting “Dig Boy!” Boy was a term by which the British referred to the local Indians, this practice still persists in the old colonial clubs established by the British, where the waiters are referred to as ‘boy’, despite being long in the tooth. Thus the name of the site became Digboi. The first oil well and refinery was established in Digboi barely 7 years after the first oil well in the world was dug in Pennsylvania, USA.

We stayed in a hotel, smack in the business district of Dibrugarh. Behind the hotel was an embankment on the Brahmaputra river. Every morning my friends and I would take a walk on the embankment enjoying the cool river breeze and have tea and samosa in a small shop. The area had offices of trucking companies and plenty of trucks were loading and unloading. On the side of a truck was painted, ‘Owner: Rajesh Chutiya’. This was quite amusing to us as ‘chutiya’ (चुतिया) is a slang used in Hindi and Urdu and means a dimwit or dumb person, when used as an adjective. However it could also be used as a verb ‘chutiya banana’ (चुतिया बनाना), which would mean trying to fool or con someone. You can get away with calling a friend ‘chutiya’ but if you called a stranger ‘chutiya’, he would be extremely offended.

There various theories to the origin of the word. One theory is misogynistic, it refers to the female genitalia and the person is behaving unpredictable like a female during ‘that time of the month’. It a term used by males to describe other males and is considered rude to use in feminine company. I remember a surgeon who used earthy language, used the word in front of a female gynaecologist. She was scandalized and would afterwards tell me “he actually used the ‘ch’ (च) word!”

Another theory could be chyuta (च्युत) in sanskrit means fallen, failed, declined, degenerated, deviated, uprooted (from a higher state), or unseated (from one’s seat of power). In contrast ‘Achyuta’ (अच्युत) means infallible and it’s another name for Vishnu. In the Bhagvat Gita, Krishna is called Achyuta or ‘the infallible one’.

But why would someone put the suffix of chutiya willingly against his name? Well I remembered reading in the papers some time in 2012, a complaint by Jyotiprasad Chutiya, General Secretary of the All Assam Chutiya Students Union, “Facebook had blocked all accounts of community members with the surname ‘Chutiya’, thinking the names are false and fabricated. They’re ignorant of the fact that Chutiyas are an ethnic tribe of Assam, with has a rich historical background in the state history.” The report goes on to say,” the slang ‘chutiya’ in most of North India, would loosely translate into ‘As_hole’. The move was done by the Indian team monitoring Facebook but it’s obvious that even Indians don’t know enough about India! What with 438 spoken languages and more dialects it’s not child’s play or Zuckenberg’s play to monitor content.” Facebook rectified it’s error and now if you search you will find the accounts of individuals with that surname restored.

I got interested and did some research on the subject. Dibrugarh was part of the Chutiya kingdom until 1523 A.D. when the Ahoms annexed it during the weak rule of the Chutiya King Nitipal. The Chutiyas were the earliest settlers in the plains of Assam. They were supposed to have come from Southern China with their own religion. However with contact with Vaishnavites they adopted Hinduism but still retained some of their original unique practices. Their language is now only retained by the priestly sect and the rest speak Assamese. During the Ahom rule they were inducted into part of the government and their language which at that time was the only written language was used for governance. The Ahom rule ended after the East India Company annexed Assam. Today Chutiyas inhabit upper and central Assam and number 2.5 million.

The origin of their names again has various theories. One theory states that it’s from ‘chu’, which means pure in their language, ‘ti’ which means water and ‘ya’ which means dwellers of the land or Natives dwelling near pure water.

The other theory states that they’re also known as ‘Chutika’, ‘tika’ means origin or people of pure origin.

The final theory is that because they’re original habitation was on the mountain tops or ‘chut’, thus the name Chutiya. However this cannot be true because chut does not belong to their language or any other dialect spoken in the region.

So this was education for me on the diversity of our country, where a slang used as a derogatory adjective or verb in one part of the country is a respected proper noun in another part.

Longevity

I was going through various scientific journals, where they study longevity. Surprisingly exercise does not feature. The most important reason for longevity is genetics, independent of any adverse habits.

There are people who are over 100 who have smoked heavily for at least 40 years of their life.

Genetics play a major role in negating the adverse effects of a bad life style, from reducing the cholesterol, chances of heart disease, hypertension, diabetes or malignancy.

Paradoxically malignant cells demonstrate the ability for unlimited division which healthy aging cells lose due to a genetic make up which limits the number of divisions, hence aging. If genetic engineering is done to enable unlimited division in normal cells it would also increase the propensity of it to turn malignant.

Unlike what is commonly believed a vegetarian diet does not have a major role to play. Various diets like increased antioxidants, vegetarian and vegan have limited role.

Vegetarianism or more specifically veganism is a for a sustainable planet as we use more resources raising livestock and poultry and feeding them fodder than we use growing plants for our own consumption. The amount of land cultivated is greater when we are feeding our livestock, poultry and ourselves. Depleting natural cover for farmlands.

The diet which has some role is a calorie limited diet. Where reduced calories to extent of starvation is followed. This could be due to A reduced oxidative damage to the body by breaking down food and converting it into usable nutrients. However whether such diets can be followed lifelong is doubted.

A positive belief in an higher power is also instrumental in longevity. This helps alleviate anxiety and the feeling of helplessness. There is the comfort that there is someone above looking after you.

Exercise can increase your life span by only an average of 5 years.
But it’s always better to add life to years rather than adding years to life! We can survive to a ripe old age but be bedridden and demented.
What would be the quality of life?
It’s better to live limited years healthy and independent rather than limp to a 100, bedridden and dependent on care givers. Hence the importance of exercise.
A disclaimer, I have merely quoted research and none except the last sentence is my opinion.

Running a steeplechase on Indian roads

Running on the roads in our country is as good as running a steeplechase. Since the lockdown I have a fixed circuit starting from my house and looping back.

My usual circuit

Initially it was peaceful but suddenly the authorities in their wisdom decided to cement-concrete a perfectly good road. So half of the road was closed to traffic.

I started running on the functioning half of the road but it was too nerve wracking with a narrow carriageway, to and fro traffic honking and narrowly missing me. So I started running on the closed side.

Initially I had to negotiate a mound of gravel placed to block off the road and then enter a dug up road. Once the cementing started, I was running on the sidewalk across encroached entrances of shops, narrowly missing customers.

Then they dug up the sidewalk and yesterday I was jumping between the freshly cemented road and the sidewalk. Then suddenly my left foot hit an object and the momentum brought my centre of gravity way forwards and trajectory towards the ground.

I took a couple of frenzied steps attempting to bring back my centre of gravity over my legs but gravity one and I was sprawled over the gravel. I my hands elbows and knees bore the brunt but thankfully besides my pride there was no serious damages.

My run cut short by falling on my face.

The skid marks on my tee shirt!

My grazed knee!

My elbow with gravel and abrasions!

Aging a choice!

Aging a choice!
We sometimes don’t appreciate the importance of fitness until we lose it with age.

Losing is a very gradual process almost imperceptible. Initially it maybe just walking a little slower. Acceptable for advancing age but acceptable only if you accept it! Then preference for using a lift rather than the stairs.

I have never been athletic in my youth but once I finished my MBBS, I looked around me and saw life style ailments in my patients. I also saw my own father who had prematurely aged.
He discovered he was hypertensive only when he developed a nose bleed.

He had only one of his original teeth left. He was born in a time where dental care was in a nascent stage in India, so the treatment for dental caries was extraction. My mother jokingly commented that getting his teeth extracted has become a hobby with him. She also recounted an incident where the dentist mistakenly extracted a healthy tooth.
In those days in Uttar Pradesh you had itinerant dentist, invariably of Chinese origin, who set up a roadside stall with a barbers chair for a dental chair. The diseased tooth was identified by tapping and eliciting pain. The extraction would be sans anesthetics. People of that era were more stoic and had a high threshold to pain.

There is a classical description of a tooth extraction in Mark Twain’s ‘Adventures of Huckleberry Finn. The boy would complain of toothache and the mother would identity the tooth and tie a string around it. Then she would tie the string to the foot end of the bed and take an embering log from the fire place and bring it near his face. Defensively he would move back and out would pop the tooth.

As a result of not having teeth his cheeks and lips caved in because the lack of support from the teeth. He used a full denture which he removed in the night.

Towards his last days he was never satisfied with his denture despite having it refitted numerous times. He felt it poked his gums or palate. His past time was to file the denture with a nail file to smoothen the protuberances.

He was also unable to sit astride as a pillion on my scooter and had to sit side saddle.
All this made me firm in my resolve to remain active and at least slow down aging if not arrest it.

First in my actions was to give up smoking and it’s been 36 years since I’ve touched a cigarette.

There was a fitness wave abroad and the media promoted at least half an hour of aerobic activity for cardiovascular health. I started with running followed by skipping, then swimming and finally gyming and running.

I may have had cardiovascular benefits from running, swimming and skipping but gyming and weight training made me realize the benefits of muscle training and flexibility.

We visited Manas National Park in Assam and went for an elephant safari. Unlike in other places where they balance a ‘hathi howdah’ on an elephant’s back and you can sit comfortably. They were more humane here and we had to sit astride on the elephant’s back. The elephant is extremely broad in the mid section and this meant doing almost a complete split! I realized how stiff I had become. The mahout was comfortably perched on the elephant’s shoulder and neck and did not have to perform such contortions. I recollected the difficulty my father had sitting astride on my scooter.

One of my classmates who visited the Great Wall of China, sent a photograph to the class group with a comment we should visit these places when we can. Implying physical disabilities later would impede us.
I have run two half marathons in Ladakh, hiked upto Tiger’s nest monastery in Bhutan. In Tawang, Arunachal Pradesh we went to the Bum La pass on the China border at an elevation of 15200 feet. Many from the group experienced altitude sickness. I guess I had got accustomed to altitudes.
Age is only a number and you are only as old as you feel. If I compare myself with my father I’m definitely in better shape. I recollect that how old my parents seemed to me when they were the same age as I am now. I go with the attitude that nothing is impossible if I set my mind to it.

Thoughts after completing the Ladakh Marathon in 2017

In 2017 on this very day I finished the Ladakh Marathon. I am reminiscing my feelings.

Facing early morning sun and running uphill in the ‘cold dessert’ terrain of Ladakh.

“After finishing 21 kms at an altitude of 11500 ft above sea level, it is but natural that there will be soreness and stiffness. One begins to wonder whether it’s worth propelling a 56 year old body or whether it is doing me any harm. I guess it is not accepting any limitations and believing you are only as old as you feel.

During these marathons you come across amputees, polio afflicted, blind and other differently abled people who are not willing to let their disabilities drag them down. In my case I had bad knees and was told 17 years ago I would require knee replacement in 5 years.

Every orthopedic surgeon worth his salt advised me to choose exercises which would not stress my knees. Initially I tried those exercises like swimming and water aerobics. But didn’t find any improvement in my knees. Then I took the decision 8 years ago that if knee replacement is inevitable then I might as well go out with a bang!

I joined a gym kept a personal trainer and never told him about the pain I was experiencing on doing exercises like squats because I knew then he would not make me do it. I also started running on the treadmill something which I never had done earlier. I discovered because of the pain we experience the movement at the knee joints get limited and along with it movement at other joints like hips. We are no longer able to sit cross legged or use an Indian style toilet. The muscles also undergo disuse atrophy. As the saying goes “if you don’t use it you lose it.”

Physiotherapy involves improving range of movement and strengthening muscles. I was ultimately doing physiotherapy on my knees albeit in an extreme form. I’ll warn anyone who plans to tread my path that things became worse before they improved. My knees would get swollen up, a synovial bursa ruptured, the shin would be extremely tender and the muscles especially the calves would be stiff and painful. Rather than having an athletic gait I had more of a gait of aged person.

Any consultation with an orthopedic surgeon and I would be given advice on how to go easy on the knees, use a lift instead of stairs and plan my work in such a way that I would not have to go up and down the stairs often. What I never told them is actually how much stress I was subjecting my knees to. It was kind of a stubbornness and a belief that I was doing the right thing.

Very slowly things began to fall into place. The range of movement on my knees improved and I could sit cross legged or in a squatting position. Then I decided to add a further stress to my knees, start running on the road and for distances. This must have been 3 years ago when I used to run a 1 km stretch and another discovery I made, along with the stiffness of the knees we also develop stiffness in the small joints of the foot. You tend to run flat footed with the entire foot slapping on the ground.

Gradually after working on my form I managed to achieve the desired forefoot then heel strike. Nothing comes easy and no pain no gain but the most important thing is to be consistent.
Now touch wood! My knees feel like new and recently got them checked up. The orthopedic surgeon was surprised when he reviewed the x-rays that how healthy my knees looked.

I discovered amongst the runners circle that there are many other people with similar stories like mine. Even scientific evidence also shows that running with the correct form improves the knees.”