Royal Meal

“What is in a name?”  Famous quotation from Shakespeare’s Romeo – Juliet.  A rose whatever name it is called its fragrance doesn’t change.  But roses are of many colors and hues and there may be variance in fragrance.  But the moment anybody calls a flower rose immediately the different colors of roses come to our mind.  But somebody wants to call a rose by name jasmine because it also has fragrance, it is difficult to imagine and correlate the flower and fragrance. 

Human beings are highly evolved animals.  The ability to communicate by means of language is the most important step in evolution.  Different parts of the world have different languages.  Every language has its own script and expresses words that will be understood by people speaking that language.  People speaking other language will have to learn the language specific to the region to communicate to the people of the region and live in that region. 

We give names not only to the articles of daily use but also different places depending on the activity carried out there. One cannot call a post office a hospital or hospital a railway station as they like.  Establishments in different location are given specific name to be more precise.  So it is very important to have a name and the name cannot be changed according to the fancy of a person.  So a rose should be called a rose and not chrysanthemum. 

The name given to an establishment does not only specify the type of establishment but also conveys the variety of services provided or motto of establishment. Apt name given to a business establishment will definitely boost the business.

This is a photograph taken near Borra caves, Vizag.  This is a thatched house with a big hall and kitchen and a room behind the hall.  There were few tables and plastic chairs for the customers to sit and have meal.  In the front, to the right corner, there is a counter to collect bills.  This hotel is named as Shri Chaitanya Rajula Bhojana Hotel.  Rajula Bhojana Hotel means it is King’s meals hotel.  But below it is also given that it will supply Bengali meals.  I found it amusing to see the name given to the roadside motel given the name suggesting to supply royal meals.  The customer is considered the ‘King’ and the meal provided is “king’s meals’.  After a tedious journey and as the acids in the stomach make havoc hot rice with simple dal will definitely taste delicious and the customer will bless the hotelier.

Sweet Threat

Narayana is worried.  To overcome it he has increased his dose of liquor intake for the past three days.  But that has increased his problems and made him more gloomy and irritable.  The word sugar and sweet is making him feel jittery.  Three days ago in the night he had argument with Bhagyamma, his wife.  Since then his like for sweets has disappeared and now the word sweet itself is raising his blood pressure.

Narayana and Bhagyamma are happily married couple.  They have two grown up children, a daughter and a son.  Daughter is married and son is in college.  The couple works as construction workers, Narayana picking up some contracts of house constructions and Bhagyamma also working in the projects of Narayana.  They have a team of workers under them.  As in construction works male and female labourers work, Bhagyamma supervises women workers and Narayana deals with entire deal of forming a contract and executing it with his team.  Narayana is a high school drop out and Bhagyamma just literate.  Since their marriage twenty five years ago in their teens both lived happily with their earnings and also constructed own house, a portion of which is rented.  They did have their set of problems and differences, but patience of Bhagyamma made their home a sweet home. 

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For the past two years, after the marriage of their daughter Narayana had taken up to regular alcohol intake.  Previously drinking alcohol was occasional.  After daughters marriage on the pretext of hosting parties to daughter’s in-laws frequently he got habituated to liquor.  Now he is almost addicted to it.  Bhagyamma’s request to stop the habit has fallen on deaf ears.  He tried to convince her that small quantity of alcohol is good for health and he knows his limits.  Often he forgets his limits and there will be strong wordy duels in the nights.  Three days ago there was strong protest from Bhagyamma and she gave her ultimatum to him. 

That night he could not sleep.  In the morning when he woke up and remembered the night’s incident, he became restless.  He did not even drink tea in the morning and went to his work.  Bhagyamma was cool and carried her regular work.  He was silent that day.  Next day morning when Bhagyamma wanted to make tea she could not find sugar tin.  She went on searching for the tin in the kitchen shelves, and asked her son if ever he had kept it somewhere.  Her son replied in negative.  Narayana, still lying in the bed heard this.  He slowly got up from the bed and opened a trunk in his bed room and took out the sugar tin and handed over to Bhagyamma.  After she added sugar to tea decoction he again took away the tin from her hands and safely put it back in the trunk and locked and the key was in his key chain that has his two wheeler key and is always in his pant pocket. 

“Heyy!  What is this?  If you lock the sugar in the trunk how Raju will make tea in the evenings?” Bhagyamma questioned.

“I’ll give money to Raju.  He can drink tea outside.  I want to be careful” retorted Narayana.

“This is really funny.  Keep the tin out side” Bhagyamma shouted.

“Now don’t tell me anything.  I know how to control you.  After this sugar gets over, I will never buy any sugar”, Narayana said firmly.

“What nonsense.  Can there be any house without salt and sugar” quizzed Bhagyamma.

“When there is need we shall just buy in small quantities of 50-100gms.  That’s all”, then he turned towards his son who was picking his tea cup and said, “sonny, from now onwards we all shall stop drinking tea.  So we need not have sugar in the house”.

“Nanna, this is simply meaningless.  If some friends or relatives come to our house, we should have to at least give them tea.  How can we run for sugar in front of them”?

“OK.  Then I shall keep only five spoons of sugar in the kitchen everyday”, Narayana said as a compromise.

“Sonny, you go.  I’ll deal with your father”, Bhagyamma said to her son and turned to her husband, “look, if you are locking it inside I’ll buy another tin and a kilogram of sugar and keep it in a secret place out of your reach.  After all, kitchen is my domain”

Bhagyamma warned seriously. 

“You, stubborn lady!  Why, why do you want to trouble me?”

“I am not troubling you.  Just stop that bloody habit of drinking everyday”

“You never allow me to live in peace”, Narayana walked out from kitchen. 

Bhagyamma continued her chores in the kitchen. 

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The next day in the afternoon from their construction place Narayana took Bhagyamma to diagnostic laboratory and got her blood and urine examination done.  That day was her scheduled visit to the doctor with blood reports.  Bhagyamma was diagnosed to have diabetes mellitus a year ago.  Since then she is regularly using medicines and visits the doctor at regular intervals of two to three months.  If Bhagyamma forgets, Narayana reminds her and gets investigations done and visits the doctor.  Whenever they visit the doctor, it is Narayana who always does the talking and questioning the doctor about medicines.  He also takes care to remind her to take medicines regularly.  When the reports of blood sugar are given he compares them with previous reports and if there is any elevation of sugar level by 4-5 milligrams, he will pester the doctor for reasons for elevation in spite of regular treatment.  Bhagyamma simply sits by his side and listens to what doctor says.  If she has any complaints she tells them in a word or two and her husband will elaborate and questions the doctor for such complaints and their relation to her diabetes and the precautions to be taken.

That evening after returning from work, both bathed and wore clean pressed clothes, and together went to clinic.  On the way he collected the reports.  They went to their doctor, Dr. Rajkumar.  They entered the doctor’s chamber on their turn.

Dr. Rajkumar looked at them and smiled, “Oh, Narayana!  How are you Bhagyamma?”

Narayana sat on a chair in front of the doctor and Bhagyamma sat on the stool beside the right of doctor.  Dr. Rajkumar remembers the couple very well as they are his regular clients for the past two years.  He particularly remembers Narayana as a dominating husband who always does the entire talking for his problems or his wife’s.  He will have many doubts and makes him repeat everything twice about medicines and their usage. Bhagyamma talks very little rather her husband interjects when she wants to say something.  Since Bhagyamma is diagnosed to have diabetes, it is Narayana who even before handing over of the reports would tell the blood sugar level in the report and comment on it.  But today in contrast to that he simply handed the cover with reports to the doctor and put the pack of previous prescriptions of Bhagyamma in front of doctor. 

Dr. Rajkumar, as he was taking out the reports from the cover was bit surprised with the behaviour of Narayana sitting quietly with a gloomy face.  “May be the sugar levels have come high”, he thought to himself.  But when he saw the reports they were completely normal. 

“OK, Bhagyamma.  Your reports are normal.  Good. Let me check your BP”, doctor proceeded with his regular physical examination and BP. 

“OK Bhagyamma.  You are doing well. You can continue with the same medicines”, and proceeded with writing the prescription.  As he was writing the prescription Narayana said in low tone, “Saar”

“What Narayana?” doctor felt relieved as Narayana started speaking

“Saar, she is threatening me that she will eat sugar and commit suicide”, sadness in his tone was obvious. 

“What?” doctor looked into his face.

“Yes saar, she is threatening me that she will eat sugar and commit suicide.  I am hiding the sugar tin. I am really scared”, Narayana said in low tone, fear has drained his energy.

Doctor burst out into laughter.  He couldn’t control, he laughed and laughed.  It was unimaginable for him to think that somebody can threaten this way, particularly Bhagyamma who appears to be a submissive docile wife. Two persons sitting in the waiting room peeped into consultation room to know the cause of laughter.  Bhagyamma was also laughing.  The persons moved back to their seats.  Narayana stirred in his seat with discomfort.

“What to do Saar.  He is troubling me every night.  Doesn’t give up alcohol.  I have a grown up son in the house”, Bhagyamma explained.

“Well, Bhagyamma, sometimes there will be problems in marital life.  You two together sit and discuss and solve your problem.  You seem to be a patient woman.  Anyway now that who have threatened him with your sweet threat, I think he will try to change”, doctor said with a smile. 

Dr. Rajkumar was really surprised at the intelligence of the lady who picked up his word that for diabetics using excess sugar is like poison and used the weapon on her husband to make him tow her line. 

“You are such great couple; you should talk and come to an understanding.  As alcohol is not good for health, try to give it up Narayana. Her diabetes is under control.  Don’t worry.  Use these medicines regularly, Bhagyamma.  Be happy”.

As he was talking he finished writing his prescription.

“Fine, Saar.  I rarely drink in excess.  Give her some medicines to be active and healthy.”

“I already wrote.  If you don’t drink, and listen to her she will oblige you”, doctor handed the prescription to Bhagyamma. 

 Bhagyamma walked out with a smile and Narayana followed her.  

Woman

Dream - Reality - 2

I don’t think there will be any person who had never experienced dreams in their sleep.  We dream of our fears, our aspirations and some are unexplainable.  I do dream many times, sometimes nightmares, some pleasant ones and some predictions which I could only understand retrospectively.

In the early days of my practice as obstetrician, I had a patient who had a complication of delivery.  It was her first delivery.  Delivery of the baby was smooth.  After the delivery placenta should be expelled within half-an- hour, the maximum period.  As the placenta was not expelled spontaneously I sedated the patient and tried manual removal.  It was adherent to the uterus.  I separated it and removed from the uterus.  When I examined I found that part of placenta – a cotyledon was left behind.  I tried my best to remove it manually under deep sedation but was not successful.  As it was a bit of placenta and more than 80% was removed and there was no bleeding I put her on further medication to not have any bleeding and contraction of uterus which incidentally can help in separation and expulsion of the retained bit.  To prevent any infection I also put her on antibiotics.

The retained placental bits when small are expelled spontaneously and without much problem.  Sometimes it can get infected and patient may have fever and excessive bleeding.  For first 24hrs I waited hopefully, praying god, that it is expelled.  Patient was continuously monitored for any problematic symptoms. After a day I started getting worried.  With increasing time the possibility of complications also increase.  I was remembering all the complications I have seen and read during the course of specialty education.  I was scared of surgical intervention in the immediate postpartum period for fear of infection and bleeding.  I wanted to consult my professor and take her opinion as to the management.  The whole of second day I was just thinking of my professor and when to meet her and request her guidance. 

It was more than 48 hrs and patient was quite normal but has not expelled the retained bit.  That night I could not sleep with anxiety.  I was just thinking about how to manage it.  Continuous monitoring of the patient was getting on my nerves.  Then I saw my professor and I explained her problem.  She said, “Don’t worry. She will be alright.  Nothing will happen”.  Then I woke up and realised it was a dream. 

That morning after examining patient I decided to meet my professor who is also a resident in the same city.  In the morning when I went to see the patient she said, “Doctor, in the morning I expelled a big clot”.

“Really? How big was it?”  I asked. 

“This much”, she cupped her hand and showed me.

“Was there any excess bleeding”

“No, it was normal”.

I examined her and found that uterus was appropriate to the period of postpartum and everything else was normal. 

I was relieved and thanked my professor for her reassurance in the dream and spontaneous expulsion of the bit. I kept her for another day and sent home.

She came for follow up after 2 weeks and found to be absolutely normal.

(In those days ultra sound scanning was not available in our city).   

Sunset

Sunset and sunrise are fascinating.  It appears new everyday.  The changing colors of the sky and lighting at dawn and dusk, the activity in the nature at that time all are ever new. 

Whenever I watch sunset I remember a childhood incident.  I was at my uncle’s place for holidaying.  It was a village.  I, along with my siblings and cousins would go out to visit other friends and relatives in the village.  The age of all of us was in single digit only. We all would go out in the morning and evenings.  In the afternoon, after lunch we have to be at home as it would be hot in the afternoon. 

One day we all went out in the evening.  One of my cousins had a staff in his hand.  This staff has a small scythe tied at one end.  This is used to pull and cut tiny branches with leaves to feed goats or also pluck fruits high in the branches.  We went to the village lake.  There my cousins swam for sometime and later we all started back home.  The sun was on his journey to home and rest.  We kids liked the setting sun in beautiful orange red colors and the sky shining in golden hue.  The clouds were having golden linings.  The sun was round like a huge bright light red glowing ball.  In those meadows amidst scattered toddy palms the glowing sun looked very near and reachable to us.  My cousin said that he will pull the sun down with the staff he had.  We all Okayed and started straight towards the sun!  We ran and ran, until the sun disappeared.  With disappointment, we returned home. 

Whenever I see the sunset in the meadows appearing reachable, I always remember that incident and long to catch sun one day in my hands! 

Blessed Life

Life is precious, invaluable.  As long as we are blessed with it we do not understand its value.  When we know how lucky we are to be born and alive we will use our life in a better way. 

I was just going through a topic ‘fetal wastage’.  I read it previously.  But my understanding was more of scientific approach to deal with it in clinical practice.  Now I have a different perspective.  In a menstrual cycle of 28 days, ovulation occurs on 14^th day.  Fertilization of this ovum can take place on 14^th, 15^th or 16^th day.  After fertilization the resultant zygote will undergo certain changes and divides and redivides to form a ball of cells which will get implanted in the uterus by 20^th to 21^st day.  Once implanted further changes will take place and embryo develops and pregnancy specific hormone, HCG, is released.  The presence of this hormone can be detected in the blood by 27^th day.  The powerful tests can also detect this hormone in urine as early as 2^nd day of missed period.  The detection of this hormone 2-3 days prior to missed period to immediately a day after missed period is indication of pregnancy – biochemical pregnancy.  More than 80% of these biochemical pregnancies are simply eliminated by nature and are not recognized clinically.  In fact, more than 50% of the fertilized ova fail to implant in the uterus and 30% of the implanted ova fail to develop to the clinically recognizable stage.  A woman in her early stage of pregnancy may show a weakly positive pregnancy test but may have bleeding within a week.  If the test is not done it will be taken as delayed periods having normal or a little bit of excessive menstrual flow.  The rest 20% are clinically recognized pregnancies.  From this number another 20% are lost in the early period of pregnancy, between 9^th and 12^th week.  The demise of fetus as early as 8^th week can be detected sonographically as blighted ovum or in later period recognized as missed abortion.  If the pregnancy continues well after 12^th week and live by 16^th week the loss of fetus is about 1%.  But, though the fetus is live and active it is estimated that 3-5% of fetuses will have gross congenital malformations which are incompatible with life.  The recognition of these fetuses through ultrasound sonography and terminating the pregnancy will result in further loss. 

Apart from this natural losses and elimination by selective process, there can be another 5% loss due to maternal disorders, pregnancy and delivery complications, and fetal anomalies.  Another factor to be considered is voluntary abortion, which is practiced legally or illegally worldwide.  A woman voluntarily or forcibly subjected to abortion, and the new life is eliminated in the early stage.  Now considering various factors, calculate the percent of lucky chance you had to live your life. 

Standing against the test of nature, facing various genetic, environmental hazards, being live and healthy is once a life time opportunity.  Once we understand the Nature’s blessings we respect our life, value it more and live to accomplish it.

Mother

Elderly woman of average built and height, slightly bent, appearing to be from middle or lower middle financial status and widow entered my room.  As she entered took out my prescription and put it on table.  I asked her to sit and looked into my prescription. She is Lakshmamma, 57 years old and that prescription was given to her a year and half ago for abdominal pain, backache and body aches.  There weren’t any serious complaints or symptoms and signs noted then.  She sat in a chair in front of me.

“What is your problem now, Lakshmamma? I enquired. She put forth list of general complaints she has – body aches, occasional abdominal pain and general weakness. 

“For all this you could have consulted a family physician or general physician”, I said.

“Last year I came and your medicines kept well till now. That’s why I have come to you again.  Examine me and write some good medicines, amma.”

I examined her.  I found her anemic; there was no other obvious problem on clinical examination. 

“You are weak and anemic.  You need to take rest.” I told her.

“How can I take rest amma?  I have to work all the day”, there was agony in her tone.

“You have children.  Don’t they take care of you? I wanted to know.

“I live with my son.  He has a kirana shop.  All day I have to clean the grains and pack them” she said as a matter of fact.

“You can take rest an hour in the afternoon and sleep early in the night.  So that your back ache will be less”, I advised her, afternoon nap can really help the elderly woman and keep her active rest of the day.

“That rascal won’t allow me to rest in the afternoon, amma.  He takes care of the sales and I have to do all this”, a bit of anger in her tone.

“Why don’t you ask your daughter-in-law to help you?”  I wanted to know what her daughter-in-law does and how she treats her.

“Poor lady, she has to take care of domestic chores and look after three kids.  She is ever busy with her work”, she appeared sympathetic to her daughter-in-law.

“Don’t you have daughter?  Why don’t you stay there for few days?”  I was inquisitive.

“My daughter is kind”, a streak of happiness and smile in her face, “but my son doesn’t allow me to stay there, amma.  If I go to my daughter and stay for more than two days he will come to take me.  Says don’t you feel ashamed to stay at daughter’s house, and brings me back home”, helplessness in her voice.

“If you are sick you should tell him and stay at home”, I advised her.

“No amma.  His survival is on the kirana shop only.  If I am not there who will clean and pack.  He won’t engage any worker.” She seems to have understood her fate.

“OK.  Then I will write that you are sick.  I will write some blood tests.  You are saying you are having frequent abdominal pain, you are post menopausal, better get abdominal scan done.  Though clinically you are ok I don’t want to miss any thing”.

“Please don’t write any tests amma.  Just write some good medicines”. She told me.

 “Show this to your son.  He will get these tests done”. I insisted.

“Why amma.  Just write some good medicines. Last time you wrote, for more than a year I had no problem.  My son is a poor man.  He has to bring up three children.  If there is any problem, I will come to you again.  Write some good medicine for good health”.  She requested me.

 I wrote medicines, gave few samples I had and also handed the list of basic investigation required for her.  Bowing to me she walked out.  She left the requisition written for investigations on my table.