This is Dr Kiran welcoming everyone to the new post. My last post did get me few responses: One of the doctors who read it commented on some of the practical patient management techniques he has been following for past few years. One of which was the use of frozen betadine! He freezes betadine solution in the freezer into small cubes. He uses those cubes to sterilize and prepare the skin before IM injection. The temperature numbs the skin and betadine provides the antisepsis. He says that none of his patients have ever complained of injection pain and no incidence of any injection abscess in the last 25 years! In fact, he claims that he is famous as “Painless injection doctor” in the locality.

“Not everything in medicine needs to be FDA approved” was what Dr Passi had written in his article. It is indeed true. We can innovate; we can change things for better and simple. The above example of using antisepsis is inspiring. I don’t know how many doctors are using the same technique, but I heard this for the first time. Please send me the details of any innovations that you are doing. Let us share them with the readership.

With this, let us start our anecdote. This was sent by a friend and I have retained his own style of narration. Please read this and discuss amongst your colleagues:

Mrs Fragrance was exposed to bright light, but her eyes were comfortable. She did not know where she was, for all that she could see was just bright light.

“Welcome Mrs Fragrance” said a deep, baritone and pleasant voice.

Mrs Fragrance could just hear the voice. The light was so bright that nothing else was seen.

“Where am I? Who are you?” Mrs Fragrance asked in a scared voice.

“You are at the court. This place decides your next journey. It can be the heaven or the hell” said the baritone.

“You mean, I am dead?”

“No conclusions at this place. You are at junction of unknown and uncertainty. Please answer some questions. It will be over soon.”

“OK”, Mrs Fragrance was uncertain.

“You can tell something about yourself.”

“I was working as a school teacher; I taught 4th standard students. I was very pious and God-fearing. I have lived a good life.”

“What subjects were you teaching?” asked the Baritone.

“I was supposed to teach them all subjects – like mathematics, science, history and so on. But everyday, I taught them ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’”

“Only those rhymes instead of all the subjects you mentioned to 4th standard students? Don’t they need better quality than that? It never occurred to you that 4th standards do not need ‘Jack and Jill’ anymore?”

“I did my best. I worked very hard to teach them the rhymes because I could not do any better. Coming to all the other harder subjects, I used to make the trainee teachers working in other departments do those difficult jobs.”

“Was it the duty of trainee teachers to do all these?” asked the surprised baritone.

“No; it was not. In fact, it was very hard for them to do my work. Still, I made them do it. I was very close to the head-mistress. I used that influence to get those trainees do my work. Since the trainees were afraid of head-mistress, they used to do it without much resistance.”

“Why did you not hire a junior teacher to do your work?”

“I could have. But, I wanted to show the administration that I was doing all the work. More so, hiring a subordinate would be sharing my income. I wanted all the profit for myself. Since, the head-mistress was close to me, I could do all this. By the time the head-mistress retired, the trainees had no idea that they were actually doing my job and did everything silently thinking that it is their work.”

“You never felt you were performing sub-optimal?” asked the still surprised baritone.

“I always did my best. I spent hours together in teaching ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’ to all the 4th standard students over years. You know how sharp these kids are. They refused to learn those old rhymes and few even demanded learning other subjects. I scolded them nicely and forced them to learn what I knew the best. But, some of my colleagues had objection. They felt that my teaching is inferior and referred few kids to other teachers. But, I brought this to the notice of head-mistress and penalized those stupid colleagues.”

“Mrs. Fragrance,” said the baritone. “Let me get it correct. You were supposed to teach normal 4th standard students and all that you taught them was ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’. You made poor trainee teachers who did not even belong to your department do all the hard work that was supposedly yours. You used the influence of your head-mistress in the entire wrong doing. Throughout your life, you have never kept the standards. Still, you convinced the management that you are doing all the work. You made all the money without even hiring an able subordinate. Some unlucky trainees were always there to do your work at the cost of their learning. You still think that you were hard working and deserved all the good things that happened to you all this time. Am I right?”

“Yes” said Mrs Fragrance. “Even though many in my own department used to joke, I was very honest in teaching ‘Jack and Jill’, ‘Twinkle-twinkle’ and ‘Johnny, Johnny’ to all the higher class students. I think I have done my job the best way. More so, I always attended churches. I used to apply leave or just scoot out of the job during working hours to attend the prayers and as many places of worship as possible. I must have attended more churches than any other person in my city! I was always pious and God-fearing.”

“Who would see your regular school work on all those days when you attended the places of worship?”

“The trainees. I used my influence with the head-mistress to make the trainees do my regular work. In fact, in my absence, they used to do all my work and the management was not even aware of my absence. I was paid even for my absence. Good terms with head-mistress are very important.”

“Final question, Mrs Fragrance” the baritone said. “Do you think you deserve heaven or hell?”

“Definitely heaven. I have sincerely taught nursery rhymes to 4th standard students with best of my ability. I have attended all possible places of worship, even at the cost of my own work and by applying as many legal and illegal leaves as possible. My head-mistress always felt that I was very good. I should not go anywhere other than heaven.”

The baritone started laughing. The laugh grew so loud that it filled the place more than the light. Mrs Fragrance started feeling a bit uncomfortable and …….

……she opened her eyes to the reality.

The above anecdote is written by one of my close friends who got inspired by the previous anecdotes I have been posting in this blog. He is a dedicated pediatrician working in a government hospital. He was expressing his concern about the poor quality of people working with him and how they were misutilising the system by the aid of their contacts with higher up officials. I encouraged him to write a story and he did. It is his first attempt and he seems to have done a good job! The point is, these underperformers exist in every system. Most of such people make themselves a liability for others. They are tolerated either due to fear of their contacts, for respect of harmony in workplace, by exploiting junior people to compensate for their laziness. Such black sheep shamelessly celebrate their mediocrity to pain the rest. One of the highly revered vice-chancellors of Bangalore University, Dr HN told once: “There are 2 classes of people; those who work and those who take the credit for the work! The battle in the second category is fierce. One would do very well in the first category.” Is there any example of how such people were set right? If anyone knows the tactics, please enlighten our readership!

With that, let us get back to the regular feature: Interesting learning scenarios:

A TETHERED QUESTION

We saw a 5-year-old with tethered STL of tricuspid valve. The origin appeared to be from the crux, but the STL effectively started off from 18mm from crux. Till that point, it was finely tethered, which could be made out on a high resolution with zooming. Surprisingly, the ATL was sail like. In a case of isolated tethered TV, does ATL also get involved? Is the ATL involvement a corroborative evidence of Ebstein’s anomaly? Please let me know your ideas about it.

VOLUMES, VOLUMES

It is always maintained that the saturations are not the criterion for BD Glenn shunt. The criterion should be the volume reduction. Hence, even when the baby with single ventricle physiology is saturating more than 90%, it may still be prudent to go ahead with BD Glenn even at the cost of some desaturation. If this is the case, why is SO2 taken as a criterion for Fontan completion? In India atleast, there is lot of resistance for Fontan completion. It is always maintained that the patient should earn Fontan completion than it is being given. SO2 plays a major role in pushing the surgeon for Fontan completion. Should we not have same criteria for BD Glenn and Fontan completion? Are the complexity and the presumed Risk/Benefit ratio the hitch for Fontan completion? Are we still at the learning curve for Fontan? Let me have your opinions on this issue.

COLLATERALS IN EISENMENGARIZATION

We had an interesting scenario for discussion. A middle aged male came with TGA, VSD, PAH. He was Eisenmengarized by opinion and natural history. However, his presenting complaint was hemoptysis. He had bouts of blood being coughed out. Cath study showed multiple collaterals. The pertinent question was: Is collateral formation possible in Eisenmengarised patient? The opinions were divided. Few were categorical that the collateral and Eisenmenger do not go together. Few had an opinion that not all the lobules of lung are equally Eisenmengered and those which are affected less might have developed the collaterals. Few felt that the pathology was different from Eisenmenger and should be evaluated, as proving Eisenmenger in this anatomy was not possible. Cardiac CT led to more complexity, as it gave a DD of sequestration too! However, sticking to the basic question, please send me your ideas on the combination of Eisenmenger and collateral formation. What is your opinion? Do you have a separate analogy or do you agree with one of the explanations offered by our team? Please let me know.

TWO POSSIBILITIES

What do you think is the suitable cut off age for a two-stage arterial switch surgery in those infants who come a bit late? We had a 2-month-old with dTGA, PFO and regressed LV. The option of 2 stage arterial switch is always there. Our surgical team is divided in opinion. One senior surgeon believes that the 2 stage arterial switch is a futile exercise and has not shown benefit in long run. He feels that the Senning palliation would be much superior to the hurried 2 stage ASO. The other senior surgeon has opposite opinion and prefers 2 stage ASO to Senning anytime. What is the opinion of the readership? Please let me know how you have been handling such scenarios.

CORONARIES FOR RESCUE

It is a rare thing for the pediatric cardiologist to chase the coronaries fervently. Barring the cases of tetralogy, TGA, Pre-Ross assessment, ALCAPA, Kawasaki and few more, the coronaries are not the area of interest. It so happened that coronaries came to the rescue. We saw a baby with VSD with two great vessels, one of which was hypoplastic. The orientation of posterior great vessel was towards left. The anterior vessel was hypoplastic with a gradient of 70mmHg. The arch vessels could not be visualized. The PA confluence was absent. We could not see the LPA. Supply to the right lung appeared to be from few AP collaterals. The arch appeared to be right sided with a right PDA. Overall, the picture of anatomy distal to semilunar valves was totally unclear. The differentiation of PA from aorta was largely dependent on the coronaries. We ended up chasing the coronaries to determine the great vessels, keeping the possibility of ALCAPA aside! If you were made to chase the coronaries as fervently as we did, please let me know the reason.

PEDIATRIC CARDIOLOGY PEARLS

51. The echocardiographic findings in boys with Duchenne muscular dystrophy correlate with the autopsy findings of posterior epicardial thinning leading to ultimate dilated cardiomyopathy. Studies have showed thinner left ventricular posterior walls, especially behind the posterior mitral valve leaflet, diastolic dysfunction, contraction abnormalities that progressed inferiorly, and temporally progressive wall thinning. (Goldberg SJ, Feldman L, Reinecke C, et al. Echocardiographic determination of contraction and relaxation measurements of the left ventricular wall in normal subjects and patients with muscular dystrophy. Circulation 1980 page 1061)

52. High-dose IVIG has been shown in many clinical trials to reduce the incidence of coronary aneurysms to <5% when administered for 7 to 10 days of the disease onset. (Newburger JW, Takahashi M, Beiser AS, et al. A single intravenous infusion of gamma globulin as compared with four infusions in the treatment of acute Kawasaki syndrome. N Engl J Med 1991 page 1633)

53. Administration of antibiotics during an episode of RF does not alter the course or severity of cardiac involvement. (Tompkins DG, Boxerbaum B, Liebman J. Long-term prognosis of rheumatic fever patients receiving regular intramuscular benzathine penicillin. Circulation 1972 page 543)

54. The most common cardiac manifestation of Juvenile Rheumatoid Arthritis is pericarditis. (Gedalia A, Giannini EH, Brewer EJ, et al. Prevalence of pericardial effusion by echocardiography in juvenile rheumatoid arthritis. J Rheumatol 1993 page 206)

55. Pericardial effusion has been reported in as many as 25% of patients infected with the HIV virus; however, large effusions are rare. (Starc TJ, Lipschultz SE, Kaplan S, et al. Cardiac complications in children with human immunodeficiency virus infection. Pediatrics 1999 page 14)

With this, we conclude this post. Please send your feedback to drkiranvs@gmail.com Your suggestions are welcome. Please narrate your experiences with the scenarios discussed and post some novel things seen by you hitherto.

Regards

Kiran