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.