CASTE CENSUS – SCOPE AND CHALLENGES

 

Now that the story is old and dust has settled over it, it is worth revisiting the issue of caste census with a cool head. One may think that talking about caste in modern day India could re-legitimize, reinforce and reestablish an institution that progress and modernity has rendered irrelevant and the Constitution has made illegal, but honestly, have we ever left it behind as we progressed?

 

Caste is a living reality in India, among all religions and in all states.Yes, Muslims in India too are divided along caste likes. They are stratified into three main castes. At the top of the pyramid are the Ashrafs (literally, the ‘nobles’, who trace their ancestry to inhabitants of the Arab peninsula or Central Asia or are converts from Hindu upper castes), Ajlafs (literally, the ‘commoners’, who are said to be converted from Hindu low castes) and Arzals (literally, the ‘despicable’, who are said to be Dalit converts). Even among Christians, after conversion from Hinduism the stigma of caste stick with them and Dalits become Dalit Christians and cannot marry Syrian Christians in Kerala. Similarly in Tamilnadu Christian Nadar would enter into a marital alliance with a Hindu Nadar but never with a Christian of another caste!

 

There are villages after villages which don't cast their vote but simply vote for their caste. We live with caste all the time. So many family names are caste identifiers. We still are uneasy with inter-caste marriages. Members of subaltern caste still suffer discrimination in villages and at work, even across seven seas. Caste based social oppression, though illegal, is overtly or covertly practiced. 

 

The irony of not knowing the caste numbers is profound. This caste invisibility has produced strange paradox, we debate about reservations from the streets to the parliament without knowing the real distribution of the disadvantaged. We deploy caste neutral tools in deeply stratified society, and well meaning government policies miss their mark because we are unaware of the real numbers.

 

 

Why is a caste census necessary?

So, why do we want to again scratch the old festering caste wound which our society carries? This is a necessary surgery, which can no longer be ignored, lest it turns cancerous. Critics fear that caste counting may harden identities or fuel populist demands of increasing the reservation quota. Such concerns are not without merit, but fear of its misuse cannot justify a National statistical blindness. What the government does to address these problems will depend upon its political statecraft and many such political time bombs, kept safely in the cupboard for many years, have been defused in the past by the present government. 

 

This will be the first caste census of independent India. The main opposition party avoided it like plague in the 65 years it ruled for it was unsure about the consequences. Their model of 'caste blind development ' failed to curb inequalities and Garibi hatao remained a slogan.  But it succeeded in ensuring caste is deeply entrenched in the political system. They feared that caste enumeration would mobilize political realignment and consolidation of depressed caste communities into electorally powerful vote bank, whose aspirations were left unmet. This caste census will be the first step towards understanding the composition of our society and a giant leap towards evidence based inclusive governance. 

 

The results will have to be implemented with care, clarity and purpose, without bothering about the seismic changes it might usher. For decades our planning and development has moved ahead with a critical blind spot. We were all along chasing parameters like GDP but ignoring such an important factor like caste, which continues to decide access to education, employment, healthcare, housing and delivery of justice!

 

 

How will caste census help?

After every census we are able to interpret data under headings like age, gender, geography, language, but not caste! Why did we continue with this huge umbra region in our national understanding? The caste census will offer an opportunity to correct this misalignment. We will know how our society is truly composed, not only their population size, but their social and economic conditions. This caste census will not be about reinforcing identity but about identifying structural inequalities.

 

Caste enumeration is not about division, it is about design. It will help designing a fairer system, target our interventions more accurately and create more inclusive India. Cast census is not about looking backwards but it is about moving forward with a clear and just plan, with wisdom and with eyes wide open. The numbers we gather today will shape the justice we deliver tomorrow. 

 

Expect a seismic change

Political parties, both in government and in opposition, may be out for a rude shock not only in relative numerical strength of a particular caste in a given region but today's leaders may realize that their caste following is much less than they had projected and anticipated so far! Data could reveal presumed armies of caste supporters to be much smaller or much larger than the leaders and followers had assumed. This could lead to a scramble of realignment within and across parties. Who knows whether the Congress President and leader of the opposition will still enjoy the presumed caste dominance in Gulberga, Karnataka after the caste census!

 

Even more significant political fallout of caste census may be the loss of luster of caste and religion in politics and the predominance of performance, decision making and good governance! After all, caste leaders like Sri Lalu Prasad in Bihar and Sri Mulayam Singh in U.P did precious nothing to improve the conditions of their caste and everything to enrich their own families! Armed with caste census, with detailed knowledge of not only their numbers but their education, employment, health, housing and financial status, will there not be a revolt within these family ruled regional parties? After all, this is the true empowerment of the subaltern groups. Raw data from this census will verify or negate the notion that whether mobilization in the name of caste, or for that matter religion, brings deliverance and prosperity.

 

 

The logistical challenge

The logistical challenge of census in India is formidable but including caste will multiply the challenge manifold. Well designed questionnaire to know not only their numbers but their living conditions, their educational qualifications, their employment status, their housing, banking and credit facilities, their position in society and their delivery of justice is a must. The task will be a technical nightmare. 

 

You may be thinking of caste amomh Hindus as 4 varnas- Brahmin,  Khatriya, Vaishya and Shudra. But each varna has multiple castes or jatis and each caste has multitudes of sub-castes or upjatis. There are more than 3000 jatis in India and countless upjatis. Borders between these castes and sub-castes are petty porous for opportunists to slide in and out to get maximum benefits in government schemes and reservations. Add to this the parliament approved EWS or extremely weaker section category and the oft repeated agitation in almost every state for inclusion in OBC category. As if that was not enough, we have the Muslim Dalits, the Christian Dalits, and the Muslim OBC (Pasmandas), once counted in the census do they too get qualified for affirmative actins like reservation? And now you have an idea how gigantic a problem awaits our political system. 

 

 

Caste is not just a part of our past for most Indians, it is a crucial dimension of our present. If we want caste to matter less tomorrow, we must now understand how much it matters today, and draw a baseline. To pretend that caste has become irrelevant is like ignoring the elephant in the room. To exclude caste from the census is to continue policy making in the dark. To include it, thoughtfully and responsibly is to shine long overdue light in this dark corner and solve the problem of delivering education, employment, healthcare, housing, banking, trade and delivery of justice purposefully. It is the real road to last mile delivery.

 

REMEMBERING PROF. K.M. SINGH BY HIS LECTURE ON BENIGN HYPERPLASIA OF PROSTATE

 

 

Prof. K.M. Singh was a Reader in the Department of Surgery, in King George’s Medical College when we were doing our MBBS. He always wore white clothes and a starched apron and was responsible for the teaching of undergraduate students along with Prof. T.C. Goel. He was always smiling and very helpful and was easily approachable. We could go inside his room with any problem and he was always keen to help. He lived in New Hyderabad, almost 3 Km from our Institution and was extremely punctual. His classes were very methodical and they were very easy to follow. For those who found English difficult to grasp, he would translate in Hindi and repeat the subject again and again till the last person had understood the point. This quality made him very popular with the students.

 

During our residency days, posting in his unit was most sought after because of two reasons – he would see to it that surgery was fairly distributed amongst residents and he had started doing cystoscopy and trans urethral resection of prostate for benign hyperplasia of prostate (BHP) and urinary bladder tumours (BT). The urinary bladder endoscopy was newly introduced in the department and only Prof. Harish Chandra and Prof. K.M. Singh were performing it and all residents were keen to learn the skill.

 

An outstanding quality of Prof. K.M. Singh was his respect for his seniors and colleagues. During my residency days, when I was a resident in Prof. R.P. Sahi’s unit, one day I saw Prof. K.M. Singh waiting outside Prof. Sahi’s outpatient clinic, where he was teaching undergraduates. When I asked him that should I inform Prof. Sahi that he is waiting outside he, most vehemently, said no, and waited for the next 45 minutes patiently. Any other staff member of his seniority could have excused himself and barged in, but for Prof. K.M. Singh that was simply unthinkable. His respect for his seniors was only matched by his love for his students. These enviable qualities and his professional skills took him to the post of Head of the Department of Surgery and eventually the Principal of King George’s Medical College.

 

Prof. K.M. Singh had h huge collection of surgical instruments, X. rays and pathology specimens in his room and they were routinely used for undergraduate teaching. I was one of the few residents who could borrow them for my evening ward teaching of students and next day he would always ask how the class went.

 

After returning from my overseas training I started practicing in Mahanagar. My new clinic was bang opposite Mahanagar Nursing Home and Prof. K.M. Singh would operate his private patients in that hospital. He always wondered why I spent all the money in buying a clinic when I could easily practice from his chamber in the morning when he was in the Medical College. On countless occasions he would send a ward boy to call me to assist him in his surgeries. One day when I referred a patient of acute appendicitis to him he got really angry “Why can’t you operate on appendicitis?” he enquired. I told him that I will only do Plastic Surgery but he was not convinced. “You cannot refuse to operate when you can, it sends wrong message to the society”. He made me operate on that patient that evening and never entered the OT. He later shifted to a bigger and better hospital but his affection for me never waned and he referred all his plastic surgery cases to me.

 

This is an undergraduate lesson on Benign Hyperplasia Prostate that was taught to our class by Prof. K.M. Singh.

Epidemiology

BPH is common with incidence increasing with advancing age. Whilst rare before the age of 40, it affects 30-40% of men older than 50. It is seen in around 90% of men aged 90. Men of African origin are more commonly affected.

Aetiology

The aetiology of BPH is poorly understood. BPH is common with increasing age. It is a hormone-dependent process involving testosterone and dihydrotestosterone production. A failure of normal apoptosis and abnormal epithelial and stromal proliferation have been implicated. This proliferation occurs primarily in the transition zone of the prostate, this leads to restriction of the prostatic urethra and urinary flow.

Clinical features

Features tend to be those of increased urinary frequency, nocturia and incomplete emptying.

• Urinary frequency
• Nocturia
• Incomplete emptying
• Decreased urinary flow
• Dribbling
• Hesitancy
• Retention (acute or chronic)

This condition can cause bothersome problems including frequent urination at night, as well as difficulty completely emptying the bladder, and the urgent need to urinate at inconvenient times. BPH triggers noticeable problems in a third of men in their 60s and nearly half of those in their 80s. In the case of men with milder symptoms, BPH may not interfere with their daily lives much, but if it gets distressing and interferes with quality of life then surgery may be required.

Irritative symptoms (problems with bladder function) include:

• Frequent urination during the day or night
• Strong and sudden urge to urinate, sometimes with involuntary leaking of urine
• Obstructive symptoms (problems with the flow of urine) include:
• Difficulty starting urination
• Straining to urinate
• Incomplete bladder emptying
• Weak or intermittent urine stream
• Dribbling after urination.

Patho-physiology

The prostate gland may begin to grow larger over time in many men. The urethra passes right through the prostate, so it doesn't take much prostate growth to make urination difficult. It is usually the median lobe which obstructs the flow of urine. As the bladder works against the restriction, its muscular walls begin to thicken which can cause problems like the need for more frequent visits to the bathroom and difficulty fully emptying the bladder.

Examination

Digital rectal examination

This is a key component of the examination and allows for assessment of the rough size of the prostate. Irregular enlargement should raise concerns and further investigation for cancer. Evidence of reduced anal tone may be indicative of neurogenic causes of lower urinary track symptoms.

Investigations

Investigations are targeted at confirming the diagnosis, excluding malignancy and accessing for complications.

Urinary

Routine and Microscopic examination of urine is advised. Under the microscope we look for casts, RBCs and pus cells.

Blood

• General Blood Picture
• Blood urea and Serum Creatininr
• Blood Sugar – fasting and post prandial
• LFTs (Alkaline Phosphtase may be elevated in prostatic cancer with bony metastasis)

Additional investigations

Depending on the differentials and certainty of diagnosis, there are many other investigations that may be ordered. These include voiding cysto-urethrogram, urethrocystoscopy and urodynamics (e.g. filling cystometry and pressure-flow studies).

Management

Management is aimed at reducing symptoms and preventing complications (e.g. urinary retention and infection).

Conservative, medical and surgical methods may be used to treat BPH.

Conservative

Consider watchful waiting in those with mild disease and symptoms. Surgery has complications that may be avoided or delayed. In certain circumstances, when patient is not fit for surgery, a long-term catheter (changed every 3 months) is used for management.

Fluid restriction: Patients are advised to restrict the volume of fluids they drink and when they drink to prevent bothersome bathroom visits. Advise them not to drink fluids before driving, traveling or attending events where finding a bathroom will be difficult. Also, ask them to avoid caffeine and alcoholic beverages after dinner or within two hours of bedtime.

Bladder habits : Ask your patients to change the time and manner in which they empty their bladder to reduce symptoms or make them less disruptive.

• Caution them not to hold it in for too long.
• Ask them to empty your bladder when they first get the urge to do so. 
• When out in public, ask them to go to the bathroom and try to urinate when they get the chance, even if they don't feel the need.
• They should take your time when urinating, emptying their bladder as much as possible.
• After each time they urinate, they should try again right away. 
• They should try urethral milking, this will prevent post-void dribbling. 
• Teach them to gently squeeze the base of the penis after urinating and work their way outward to force urine out of the urethra.

Medical

Treatment of urinary track infection – but this may be virtually impossible if the prostate is causing outflow obstruction. Stagnant urine has a tendency to get infected.

Surgical

Transurethral Resection of the Prostate (TURP): is a new procedure in which a resectoscope is used to resect obstructing tissue. There are a number of complications that can occur. Retrograde ejaculation (up to 75%), urinary infection, need for urinary catheter are all relatively common. Occasionally clot retention, urinary incontinence, urethral stricture and erectile dysfunction may occur. A rare but serious early complication is TURP syndrome.

Open prostatectomy: tends to be reserved for very large prostates (> 80-100ml) following discussion of more conservative options. No ejaculate can be produced following prostatectomy and most experience symptoms of urinary urgency, frequency and nocturia. Erectile dysfunction may occur. Prostatic tissue remains and cancer can still occur.

Treatment of Urinary retention

Urinary retention may complicate BPH

Acute retention

Men presenting with acute urinary retention require catheterization. Ensure you evaluate for infection and renal impairment that may complicate urinary retention.

Patients require urological review and work-up (particularly if they do not have an existing diagnosis). Typically on the first occasion, a patient may be catheterized. Recurrent retention typically indicates a need for surgical intervention.

Chronic retention

Men with chronic retention should be catheterized particularly where there is renal impairment or hydronephrosis. Often surgery will be advised, though intermittent self-catheterization or a long-term catheter can be used to tide over a critical phase.

 

That is how Prof. K.M. Singh’s lecture on BHP ended. Those were the days when there were no Ultrasound and MRI, no Uroflowmetry, no drugs like alpha blockers, 5-alpha reductase inhibitors, or tadalafil, which can relax the bladder neck and prostate, shrink the prostate, or improve the urinary flow and those were the days when suprapubic open prostatectomy was commonly done. Under these circumstances when I look at my class notes, I can only wonder how conclusive our undergraduate teaching was and how much effort our teachers like Prof. K.M. Singh took to teach us.

ARE YOU A DIABETIC? LET ME HELP.

 

 

Being diagnosed with Type II diabetes can feel like the end of the world, but it also marks the beginning of a journey towards better health and well-being. And, it's very common these days, so don't panic! Understanding and managing this chronic condition is essential to living a fulfilling life. Outstanding sportspersons like Waseem Akram, Craig  Cummins, Billy Jean King, Alexander Zeverev and Sophie Devine are all diabetic and have achieved the pinnacle of their sporting career despite that. The first steps you take after diagnosis set the foundation for effective blood sugar control, reduced complications, and improved quality of life. From adopting a balanced diet to a brisk walking schedule, to monitoring your glucose levels, each action plays a crucial role.

This blog is for guiding you through those initial, vital steps, and for empowering you to take control confidently and proactively. Embrace this opportunity to learn, adapt, and thrive on your path to managing Type II diabetes successfully.

 

Introduction

Understanding Type II Diabetes

Type II diabetes is a chronic condition characterized by the body's ineffective use of insulin, leading to elevated blood sugar levels. Unlike Type I diabetes, it often develops gradually and is commonly associated with lifestyle factors such as diet, physical inactivity, and obesity. Understanding this condition is crucial as it impacts numerous body systems and can lead to complications if not managed in time.

The Importance of Early Management

Early management of Type II diabetes is vital to prevent complications like heart disease, nerve damage, and kidney problems. Taking immediate steps—such as adopting a balanced diet rich in whole grains and vegetables, initiating regular physical activity, and monitoring blood sugar levels—can significantly improve health outcomes. For example, incorporating a 30-minute daily walk or consulting a doctor  or dietitian to create a personalized meal plan are practical measures to start with. Early engagement with healthcare professionals empowers patients to control their condition effectively, improving quality of life.

 

Understanding Your Diagnosis

What Type II Diabetes Means

Type II Diabetes is a chronic condition where the body either resists the effects of insulin or doesn't produce enough insulin to maintain normal glucose levels. Unlike Type I Diabetes, it often develops over time and is largely influenced by lifestyle factors. Understanding this is crucial, as managing blood sugar involves both medication and lifestyle adjustments.

Common Symptoms and Risks

Symptoms often include increased thirst, frequent urination, fatigue, and blurred vision. If left unmanaged, risks include heart disease, nerve damage, and kidney issues. Recognizing symptoms early allows for timely intervention. For instance, if you notice excessive thirst or unexplained weight loss, consult your healthcare provider promptly.

There are many misconceptions about Type II Diabetes, such as it being caused solely by eating sugar or that insulin is the only treatment. In reality, a balanced diet, regular exercise, and sometimes oral medications are key to management. For example, incorporating daily walks can improve insulin sensitivity. Educate yourself to separate myths from facts to make informed health decisions.

Watching for Low Blood Sugar

Hypoglycemia (low blood sugar) can occur, especially when on medications. Watch for: Shakiness, Sweating, Confusion, Dizziness and nausea. Keep glucose biscuits, toffees or a small juice box with you just in case.

 

Consulting Healthcare Professionals

Choosing the Right Healthcare Providers

Start with your general practitioner, who can confirm the diagnosis and refer you as needed. An endocrinologist can offer specialized care, and a registered dietitian can help with a tailored eating plan. Choose professionals with experience treating diabetes and with whom you feel comfortable communicating.

Important Tests and Screenings

Diabetic affects certain target organs – heart, kidneys, and eyes. By doing these screening tests we repeatedly test these target organs and see if they are being harmed by diabetes. This is called target organ survey. Expect the following in your first round of evaluations:

·        Blood Sugar 11 hours fasting and 90 minutes PP

·        HbA1c test (measures average blood sugar over 2–3 months)

·        Kidney function tests

·        Blood pressure monitoring

·        Serum Lipid profile

·        Eye – fundus examination

·        Chest X. Ray

·        Foot examination to detect early complications

These form the baseline for your ongoing care plan. Regular investigations that monitor your target organs – heart, kidneys and eyes, when they return normal is not a waste of money, it is a guarantee and a reassurance of the fact that you are doing well.

Setting Up Regular Follow-Ups: 

Initially, follow-up visits every 3 months are common to check your numbers and adjust your plan. Set reminders and don’t skip these—small changes in test results can be a cue to prevent bigger issues later.

Selecting the Right Doctor or Specialist

Choosing the appropriate healthcare provider is crucial after a Type II diabetes diagnosis. Start by consulting your primary care physician, who can manage your condition and refer you to specialists if necessary. An endocrinologist specializes in diabetes and hormonal disorders and can offer advanced care for complex cases.

Initial Medical Tests and Assessments

Your healthcare provider will order several tests to understand your condition better. Common assessments include HbA1c testing to measure average blood glucose over the past two to three months, kidney function tests, cholesterol levels, and blood pressure monitoring. Eye exams and foot checks are also important to identify complications early. These tests form the baseline for your treatment and help personalize your management plan.

Setting Up Follow-up Appointments

Regular follow-up appointments are essential to monitor your progress and adjust treatment as needed. Initially, you may need visits every three months to evaluate your blood sugar control and overall health. Discuss scheduling with your doctor and set reminders to keep appointments. Consistent communication helps in timely identification of issues, ensuring better long-term management of your diabetes.

 

Lifestyle Modifications

Declare you are a diabetic

This should be the first thing you should tell your doctor, if he is a new one. No matter why you are visiting him/her, for a fractured bone, or chest pain or diminishing vision or dizziness, the first thing your doctor must know is that you are a diabetic and the second thing he/she should know is your latest Blood Sugar levels – both fasting and PP and your HbA1c levels. If you hide your diabetic status the doctor stops thinking about a host of diseases that are much common in diabetics, and your diagnosis may be delayed. You can be a controlled diabetic or an un-controled diabetic, but once a diabetic, you always remain a diabetic. 

Adopting a Diabetes-friendly Diet

Eating a balanced, diabetes-friendly diet is crucial to managing blood sugar levels. Focus on incorporating whole grains, lean proteins, and plenty of vegetables into your meals. Limit intake of sugary foods, refined carbohydrates, and saturated fats. For example, replace white bread with whole grain options and opt for grilled chicken instead of fried foods. Monitoring portion sizes can also help maintain stable glucose levels. Try to build meals around: Whole grains (e.g., oats, brown rice, quinoa) Lean proteins (e.g., chicken, fish, tofu) Fresh vegetables and legumes.

Remember, fat is more harmful than sugar as it offers twice the number of calories to your body per gram (Sugar 4.5calories and fat 9 calories). So, when you look at you food, think "If I put this on a newspaper will it leave an oil / grease stain?" If the answer is 'yes', then that food is not for you. 

Incorporating Physical Activity

Regular physical activity improves insulin sensitivity and aids weight management. Aim for at least 150 minutes of moderate-intensity exercise per week, such as brisk walking, swimming, or cycling. Starting with just 10-15 minute sessions and gradually increasing duration can make exercise more manageable. Additionally, incorporating strength training exercises twice a week can further support blood sugar control.

Managing Stress and Mental Health

Stress can negatively impact blood sugar levels, so managing mental health is important. Techniques such as mindfulness meditation, deep breathing exercises, and yoga can reduce stress. Seeking support from healthcare professionals or support groups may also be beneficial. Establishing a consistent sleep schedule and practicing relaxation before bedtime can improve overall well-being and diabetes management.

 

Medication and Monitoring

Understanding Prescribed Medications

After a Type II diabetes diagnosis, it is crucial to understand any medications prescribed by your healthcare provider. Common medications include metformin, which helps control blood sugar levels by improving insulin sensitivity. Be sure to follow the dosage instructions carefully and discuss any side effects or concerns with your doctor. Keeping a medication diary or using a pill organizer can help ensure you take your medications consistently.

Remember, the same drug every day will only control you if you consume the same number of calories and spend the same number of calories every day. You cannot be irregular with your diet and exercise and expect the drug to do wonders. So changing your attitude and bringing discipline in your life is more important than changing your doctor. 

Blood Sugar Monitoring Techniques

Regular blood sugar monitoring helps you and your healthcare team understand how well your treatment plan is working. Use a blood glucose meter to check your levels, typically before meals and at bedtime. Record your readings in a logbook or smartphone app to track patterns. Your doctor might also recommend continuous glucose monitoring (CGM) devices for more detailed information.

Recognizing and Managing Hypoglycemia

Hypoglycemia, or low blood sugar, can occur if medications lower your glucose too much. Learn to recognize symptoms such as sweating, shakiness, confusion, and dizziness. If you experience these signs, quickly consume fast-acting carbohydrates like glucose biscuits or powder, fruit juice, or regular soda. Always carry a source of sugar with you, and inform family and friends about how to assist you in managing hypoglycemic episodes.

 

Building a Support System

Informing Family and Friends

Sharing your Type II diabetes diagnosis with family and friends is a crucial first step to building a robust support system. Open communication allows your loved ones to understand your needs, provide encouragement, and assist you in managing your condition. For example, involve them in meal planning or remind them of your blood sugar monitoring schedule. Being transparent helps reduce feelings of isolation and fosters a supportive environment.

Joining Diabetes Support Groups

Support groups offer a space to connect with others facing similar challenges, share experiences, and learn practical coping strategies. Whether in-person or virtual, attending regular meetings can enhance your motivation to adhere to treatment plans. Look for local community centers or hospitals that host diabetes groups, or consider online forums if you prefer flexibility and anonymity.

Utilizing Online Resources and Tools

Leveraging online resources such as mobile apps for blood sugar tracking, educational websites, and meal planning tools can empower you to take control of your health. Many apps offer reminders to take medication and log physical activity, helping to maintain consistency. Additionally, reputable diabetes education websites provide up-to-date information and practical tips, which can complement advice from your healthcare provider.

 

Taking the first steps after a Type II diabetes diagnosis is crucial for managing your health effectively. Embrace lifestyle changes, adhere to medication, monitor blood sugar levels, and seek support from healthcare professionals. Remember, proactive management empowers you to live a healthy, fulfilling life. Diabetes is not the end of the road, and it is so prevalent these days that there are many support groups and organizations ready to help you on your journey to a healthier existence.

REMEMBERING PROF. M.K. MITRA BY HIS WARD TEACHING

 

Prof. Manoj Kumar Mitra was a Reader in the Department of Medicine when we were doing our MBBS. He was a very methodical teacher with a unique analytical power. His lectures were always very well crafted, to the point and crystal clear. Though nephrology was his passion but he treated a wide variety of patients and his ward teachings were a joy to behold. All the ward beds were allotted to us, the medical students, and we were expected in the evening ward session, to meet the patients, greet them, seek their permission for a conversation and subsequent examination and then proceed to take a detailed history. This would be followed by a clinical examination and we would write down our findings. Then we would ask the resident team a bunch of questions, which, if it was a quiet day, would be patiently answered. If however, the ward was overcrowded and the schedule too busy, we would be brushed aside as unnecessary irritants.

I still remember a tall Sardar ji by the name of Dr. P.P.S. Sethi would be one of Dr. Mitra’s residents and he was a kind hearted senior, who, if available, would answer all our stupid questions. And, if we were bold enough to approach the Senior Residents or the Chief Residents like Dr. Alok Banerjee, Dr. Sumanta Chakraborty, Dr. Pramod Dhawan or Dr. Sunil Sennon then it would be a huge bonus. They were all walking – talking encyclopedia and they could elicit some amazing physical signs and pick up some astonishing heart murmurs. To juniors like us, they were like magicians eliciting shifting dullness, Adson’s Test, Bronchial breathing and Machinery murmurs!

 

All these efforts were made because next morning in the Ward Teaching the physician in charge of our teaching Prof. M.K. Mitra, Prof. A.R. Sarkar, Prof. Mahesh Chandra, Prof. Mam Chandra, Prof. Ashok Chandra, Prof. R.C. Ahuja would go from bed to bed and ask the student, who was allotted the patient, to present the case. This is the description of one such ward teaching, conducted by Prof. Manoj Mitra.

 

The Case Presentation

This middle aged man had a long history of coughing, which he insisted was seasonal and would exacerbate in the cold. He had been to many doctors and had a bunch of prescriptions of different antibiotics, anti allergic drugs and cough syrups. This time his sputum was pinkish in colour, which scared him and so he agreed to get hospitalized. He was finding it difficult to climb stairs of his first floor home and got easily fatigued. Prof. Mitra patiently listened to the history, asked a few questions in Bengali to the patient, and then did a thorough examination. Then he reassured him that they have arrived at a diagnosis and he will be absolutely cured and will be discharged very soon. He also told him in Bengali that now he was going to teach the students about all the medical problems similar to his but it will not be about him. So, he need not unnecessarily worry. Then he turned around to address us, who were all around his bed:  

Most people assume that coughing is associated with a lung or an airway problem. But, an unusual suspect may actually be the heart. It isn't unusual for people who have heart failure to experience significant coughing. In fact, a cough may indicate an important sign that heart failure treatment is inadequate, or, possibly, treatment itself may be causing problems.   

 

1. Heart Failure

Unlike what you may think heart failure does not mean that the heart just stops, that is cardiac arrest. Rather, it means that the heart's pumping ability has been impaired to the extent that the heart is not always able to keep up with the demands of the body. Heart failure can cause a number of cardiac disorders, including

·        coronary artery disease

·        hypertension

·        hypertrophic cardiomyopathy

·        diastolic dysfunction

·        heart valve disease

and several others.

Heart failure is a common disorder. Due to the heart's inefficient pumping ability, blood returning to the heart from the lungs tends to back up, producing pulmonary congestion, which is why people with heart failure are often said to have 'congestive heart failure.' Consequently, with pulmonary congestion, fluid, and a little blood, can leak into the alveoli (air sacs) of the lungs. This lung fluid is what's largely responsible for the dyspnea (a feeling one cannot breathe properly) commonly experienced by people with heart failure because coughing is the body's way of clearing the airway and bronchial passages. Thus, it makes sense that a cough can also result from pulmonary congestion. 

Types of Heart Failure

1.      Left-sided heart failure. There are two types of left-sided heart failure:

o    Systolic failure. This is when your left ventricle isn’t able to contract normally and your heart can’t push an adequate amount of blood into circulation.

o    Diastolic failure. This means your left ventricle doesn’t relax properly due to stiffness and your heart doesn’t fill with enough blood between beats, or the pressure for the heart to function is very high.

2.      Right-sided failure. In right-sided heart failure, your right ventricle loses pumping power and blood backs up in your veins.

3.      Congestive heart failure. The term heart failure is sometimes used interchangeably with congestive heart failure.

Left-sided heart failure causes blood to build up in your pulmonary veins that carry blood from your lungs to your left atrium. This buildup of blood can cause breathing symptoms, such as:

• trouble breathing - dyspnea
• shortness of breath
• coughing, especially during exertion
• shortness of breath when lying down - orthopnea 
• sleeping on extra pillows at night

Right-sided heart failure leads to blood buildup in your veins, which in turn may lead to fluid retention and swelling. The legs are the most common area to develop swelling, but it’s also possible to develop it in your genitals and abdomen.

Common symptoms of right-sided heart failure include:

• palpitations
• chest discomfort
• shortness of breath 
• fluid retention, especially in your lower body - oedema
• weight gain

 

2. Cardiac Cough

Coughing caused solely by heart failure can take several forms. A wet cough produces frothy sputum that may be tinged pink with blood, tends to be quite common with heart failure. Heavy wheezing and labored breathing may also accompany spells of coughing, along with a bubbling feeling in the chest, or even a whistling sound from the lungs. Coughing symptoms like this usually are a sign that heart failure has become substantially worse, and such a cough is usually accompanied by a general flare-up of heart failure symptoms. These symptoms are likely to include

·        Dyspnea

·        orthopnea  or shortness of breath when lying down

·        oedema swelling in dependant parts of the body

·        paroxysmal nocturnal dyspnea or waking up from sleep in the middle of the night, gasping and coughing.

However, people who have this severe form of cardiac cough are generally sick enough to seek medical help without much prompting. 

A cardiac cough can take a much less severe form. Some people with heart failure will develop an annoying, more chronic, drier cough that may produce a small amount of white or pink frothy mucus. People who have this less severe form may assume it to be due to some other cause, attribute to their smoking habit, and thus may fail to seek medical assistance. In doing so, however, the symptoms of heart failure are likely to become substantially worse. So patients should not ignore the onset of a cough even if they consider it to be mild. 

 

3. Medication-Related Cough

Beta blockers are prescribed to lower the heart rate and blood pressure in hypertensive patients. These also target beta receptors throughout our entire body, including the lungs. This may trigger an asthma attack with symptoms such as coughing and wheezing. 

Calcium channel blockers treat heart conditions such as hypertension and coronary artery disease. While uncommon, they too may indirectly cause a drug-induced cough in some people. 

Coughing is also a side effect of a new class of medication that is being tried in patients with heart failure: angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors. These are helpful for heart failure because they dilate the arteries, thus making it easier for the heart to pump blood. These drugs, in trial have shown to produce a cough in about 4% of the test subjects. The cough they experience is generally a dry hacking cough which does not produce sputum.

This is how in 45 minutes this bedside teaching session ended. He encouraged the student presenting the case and urged him to keep up the good work. He then turned to the patient to profusely thank him for his cooperation in the teaching programme and the group moved on to the next bed.

 

These bed side teachings were the heart and soul of our teaching programme in King George’s Medical College. These sessions would improve our’ history taking, examination skills, and knowledge of clinical ethics. It taught us professionalism, and fostered good communication and role modelling skills. These educational sessions would integrate theory, practical skills, and patient contact to make the educational process as realistic as possible, and allow us, the students to develop empathy with the patients. Teaching small groups in the presence of the patient allows trainees to be closely observed and taught clinical practice and medical examinations.

 

Rather than only listening to a presentation or reading from a blackboard, learners have the opportunity to use most of their senses—hearing, vision, smell, and touch—to learn more about the patient and his or her problems. I experienced this during the early years of my training with the first patient I admitted as a resident of surgery with pancreatitis—the smell of alcohol on the breath, the dry tongue, and the decreased skin turgor. By the bedside, I also learnt about the pigmented spots around the umbilicus in severe haemorrhagic pancreatitis and Rovsing’s sign in acute appendicitis. These experiences create hooks upon which a great deal of clinical learning can be hung. 

Although it is known to enhance a student’s learning experience and improve patient care, the use of this type of teaching is unfortunately in steady decline. Absence of quality teachers and the litigations that teachers fear to get entangled in after such teaching sessions are doing immense harm to medical education. Prof. Mitra is still in active practice and stays in New Hyderabad in Lucknow. He chairs several ethics committees and is always ready to help all his students and patients.