#IceBucketChallenge #StrikeOutALS

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A long time ago….

I remember visiting my mother’s sister every now and then. She didn’t live very far away. The loving relationship that the two sister’s shared ensured that we kids were also made to spend time with her. “Masi” as we fondly called her was an extremely delightful person with an amazing zest for life.

My childhood has shrunken into vague and distant memories of most events, but there are a few things I remember, vividly. My maternal grandfathers demise after suffering from a fatal MI (heart attack) on my 5th birthday, for one and the memory of my ‘Masi’ sitting on a wheelchair unable to move around as much as she would’ve liked, unable to speak as much as she would’ve liked and unable to carry out her day to day activities.

Mum always told us that ‘Masi’ was suffering from a “ALS”, a medical condition that was going to debilitate her. Not much of what mum said stuck in my head at that age, but these three words did- ALS. That was probably the beginning of a developing interest in the human body and its trials and tribulations.

I’d seen ‘Masi’ wheel chair bound for a long time. Towards the end, she was unable to communicate. I can’t remember the exact sequence of events that led to her passing away, but I do remember my mother being inconsolable for days together. Losing your near and dear ones is always disheartening. I was too young to understand the concept of life and death and was shielded, by my parents, from seeing my Masi after her demise.

 

A few years ago…

I was studying for the under-graduate course in Medicine. As a part of the curriculum, medical students were posted in wards to undergo clinical training for the challenges that lay ahead.

During the General Medicine postings, we came across a patient, Mr. Arnab, a 38 year old male banker, a teetotaller, non smoker, who presented with progressively worsening dysphagia (difficulty in swallowing). He also complained of slurring of speech since the  past few months. Suspecting a neurological disease, probably a Cerebro-Vascular accident (CVA, stroke), a CT scan was arranged for the patient. The report turned out to be normal. The patient improved with symptomatic treatment and was discharged.

However, 2 weeks hence, the patient returned with similar symptoms. Not wanting to take a risk, the consultant referred the patient to a honorary Neurologist at the same hospital. An MRI was performed for the patient. It clinched the diagnosis. Correlating the clinical features with the MRI findings, the patient was diagnosed with ALS.

Facing abandonment from his family and friends, who were unwilling to bear the expenses for the treatment, the patient jumped from his residential building and committed suicide.

 

Amyotrophic Lateral Sclerosis… Very rarely do diseases have names as self-explanatory as this one.

Amyotrophy literally translates into atrophy (decreased bulk) of the muscles, a consequence of the death of the nerves. Sclerosis (hardening) of the lateral tract i.e the cortico spinal tract (more commonly referred to as Motor Neurons), the part of the spinal cord that carries nerve fibres from the motor area of the brain to the various muscles in the body. When the brain perceives the need to move a particular part of the body, the nerves in the motor area of the brain fire an impulse. This impulse travels down the lateral tract to the body to cause contraction of a particular muscle.

Death of the nerves leads to a hardening of the tract and in turn a decrease in the muscle bulk. The nerves which fire the muscles to work, have stopped functioning and so also will the muscle. The individual suffering from this disease will eventually become a cripple, wheel chair bound, unable to carry out activities of daily living.

The exact reason why this disease occurs isn’t known. As a consequence of the rarity of this disease, research work on this subject doesn’t garner the same level of funding as other more prevalent diseases. The only effective drug used against this ghastly condition is Riluzole, a drug that reduces the free radical (toxic chemical) formation in the motor neurons and is partially effective in delaying the symptoms of the disease. However, there isn’t any proven benefit of the drug.

How expensive could such a drug be? 1200$ for a month’s supply. Lack of funding for research and the low profit margins for the pharma companies, due to the rare nature of the disease, being the sole reasons for the unaffordable costs. So expensive is the drug, that most patients who suffer from the disease prefer to die due to the disease, rather than burden their family with debts.

Apart from the cost of the medicine, nursing care at home is also an expensive affair. Manpower, equipment and 24 hour monitors are required for the safe care of such patents at home. No one dies as a direct result of the disease. Complications like bed-sores, pneumonia, pulmonary embolism (clot in the lung vessels), heart attack are very common in patients with ALS.

 

Hordes of peoples are questioning the motives of the #IceBucketChallenge #StrikeOutALS

Why the ice-bucket challenge for a disease such as ALS? Why not use it to create awareness for malnutrition, poverty, maternal and child health etc..? After all, ALS is a disease of the first world countries. We as a third world country must fight the other social ills.

Poverty, malnutrition, malaria, maternal and child health are some of the biggest unsolved health problems in this country. However, to propose an ice bucket challenge or something on the same lines, for the aforesaid diseases, is utter folly. The awareness created, not only by the government, but also by the WHO around these issues is phenomenal. I haven’t seen a single home delivery in my year as an intern at Navi Mumbai Municipal Corporation Hospital, a hospital that arguably caters to the underprivileged population. Citizens are being educated and awareness levels are rising.

With ALS, no amount of awareness created is enough. No one cares about a disease which affects two in a lac. No one who hasn’t suffered from it himself, or has seen someone suffer from it. I have seen my own relative suffer from it and have supervised the treatment of a patient who suffered from the disease. Its a death sentence with no date.

If funding and research can retard its course, let alone cure it, why not! Aren’t the 2 people, amongst a lac, who suffer from it human beings? Aren’t those afflicted by it, from third world countries?

The ice bucket challenge is a great initiative.

As for the questions raised by people about wasting clean water.. How many of those who question others motives, bathe under the shower everyday, wasting precious drops of water. Take the ice bucket challenge, use clean water to pour over yourself and avoid bathing on that same day. PRONTO!! Water conserved. Optimism is a great thing. The world isn’t such a bad place after all!

This helps spreads awareness about a disease that not many people (including doctors) know about. It’ll probably reach out to a philanthropist, willing to donate, in a corner of the world, where knowledge of this condition is not commonplace. Funds will be garnered in this manner, research will be strengthened and who knows, with the advances in medicine and technology, a cure may be found. Lets #StrikeOutALS, cause the ones who suffer from it, deserve more!

 

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Path of Life

Seasons come and seasons go,

And the mind wavers to and fro,

There isn’t an answer, there isn’t a plan,

And one keep going back to where it all began.

Life is mysterious and utterly bizzare,

How long it takes to recover from scars,

But there’s always a shining light at the end of a tunnel,

That’ll open it’s arms, so you won’t miss the cuddle.

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Atop the mountains, beneath the sea,

The peace and tranquility makes you feel free,

The loneliness disappears from sight,

And every thing around seems to understands your plight.

The meandering courses across the lakes and streams,

And walks through the clouds, just like in dreams,

Wandering across the country with an uncluttered mind,

To let it out of its dreadful confines.

The path to follow will present itself to you,

Summer, Winter, Autumn or even with dew,

As the seasons change and time flies,

The Golden Path will be the lasting prize.

A New Beginning, or is it?

A company of twelve Doctor’s (Plastic Surgeons) stood in front of Vikram’s (all names changed) bed. The majority of them were residents, a couple of them were working there post-residency and the rest were the bosses. They seemed to be discussing his case very enthusiastically.

Vikram had an accident outside the same hospital, wherein a heavy truck ran over his foot, while he sat with his legs outstretched on his bike, parked by the side of the road. His toes were dangling and his forefoot was crushed. The enormity of the trauma had left him disabled. Vikram was immediately admitted to the Plastic surgery ward, prepared for surgery and operated upon, that very same day. 4 of his 5 toes were amputated. He was placed on a regular dressing schedule to wipe out the infected portion of the wound and allow the healing process to take effect.

2 weeks hence, after the healing process had initiated, Vikram was operated again. This time around, to cover the exposed areas and provide function to the limb. Something that had seemed improbable when he was wheeled into the casualty, after the accident. The graft over his foot had taken up exceedingly well.

Vikram, however, had a problem. He was extremely intolerant to pain. No dressing was complete without Vikram’s screams. This was the way of a public hospital. Sedating every patient for dressings wasn’t an option, due to the abundance of patients in the ward. Vikram just bore the pain, as the dressings were done as gently as possible.

My first taste of my new life as a plastic surgery resident.

At the other end of the spectrum was Rohan, a 25 year old mechanic, who had been burnt by petroleum over his torso and neck, three years ago. Rohan had developed contractures over his axilla (arm-pit), as a result of scarring in the wounds over the burnt area and had undergo surgery to release those contractures. The procedure would allow him to move his arms freely. The restriction in movements due to the contractures had caused him a great deal of social and economic harm.

Rohan, as opposed to Vikram, was extremely tolerant to pain. Burns to 50% of his body and the daily dressings that followed had given him a heart of steel. This was just one of the countless surgeries he’d require to regain full function of his arm. This is the nature of plastic surgery. No single surgery will suffice. It’s a process which requires months, if not years to correct something that had ruined the persons life only in minutes.

Lying on the beds next to Rohan were Ghulam and Shaikh. Both victims of oral cancer, the commonest malignancy in the country. Both of them chronic tobacco chewers. Both of them had undergone surgery to remove the tumour, leaving their face disfigured. Both their faces had been reconstructed using skin, muscles and bone from their legs. Both had a tube running down their nose into their stomach to feed them.

But, while Ghulam had recovered fantastically and was to be sent home soon, after removing the feeding tube, Shaikh had a more tumultuous recovery. Infections, bleeding requiring transfusions and poor healing of the wound over the leg had hampered his recovery.

Lying on the bed opposite them was Mr. Thamim, a elderly male, who also suffered from cancer of the oral cavity. His mandible (jaw bone) had been excised along with the tumour and a similar flap, consisting of the fibula (non weight bearing bone in the leg) had been placed over the facial defect. It had been 2 years since his surgery. The result was remarkable. This was the work of a genius. No ordinary man could’ve guessed that this person had undergone a reconstructive surgery.

Mr. Thamim had been admitted for removal of the plate placed over the grafted bone, in order to stabilise it. Plates were usually removed after two years. The same man who’d hide his face from the world, was now walking around the hospital with the same confidence, he had so cruelly been deprived of, due to the tumour.

Besides him lay Mr. Jagannath, another elderly male with a tumour of the teeth (ameloblastoma) which had been excised. The bone over the left side of his face had been excised along with his teeth. The attempted reconstructive procedure had failed, as the flap placed over his defect had blackened, due to a clot in the blood vessels supplying the flap. The flap was not salvageable and had to be removed. The defect looked ghastly, with the left side of his face depressed inwards and asymmetrical.

On just my second day, as I stepped out of the ward to dine at the canteen, I ran into Mr. Jagannath. He had a scarf covering the left side of his face. He didn’t escape the attention or the ridicule of any passerby. “Doctor, this is quite normal for me.” He said.

“I feel most comfortable in the plastic surgery ward, as I don’t have to face society. No one understands our plight. Everyone stares at us, making us feel abnormal.”

Jagannath was a teetotaller, had never smoked or chewed tobacco and had a very frugal albeit healthy lifestyle. 3 months back, the dental surgeons had diagnosed him with a cancer of the tooth.  One which requires a mutilating surgery. The cruel irony of life. The plastic surgeons had given it their all to salvage his flap post-surgery, but had failed.

“I’ll now leave this ward and hospital only after the reconstruction.” Jagannath vowed.

Armaan, a perky sixteen year old, came to the out patient department, the next day, with a broad smile over his face. 2 months ago, the story was very different. Armaan was born with a depressed nose tip. Only the tip of his nose had a cartilage defect. He had just entered Junior College and was the object of ridicule amongst his peers. Unable to afford private care, Armaan pursued his luck with the Plastic Surgery department at our institute.

A minor procedure under local anaesthesia was all that he needed. Fat was injected into the depressed part of his nose with a strapping placed over his nose for a few days.

2 months post-op and Armaan’s nose was as good as new. He couldn’t stop smiling. Armaan had become the cynosure of all eyes in college. He could now concentrate on enjoying his time in college and studies. The attention on his nose and its defective shape had been diverted to more meaningful things.

This was the impact of plastic surgery on people’s lives. When I decided to pursue higher education in the field of Plastic Surgery, I was scoffed at.

“Why do you want to specialise in surgery on the skin?”

“It’s a frivolous profession, one which requires very little skill”

“What satisfaction will you achieve in this profession”

These were some of the many questions asked of me.

And the first day in the Ward 25 answered all these apprehensions that people had planted in my mind. Plastic Surgeons may not save lives, they may not even perform emergency procedures, but they create magic. They allow people to lead a normal life. They allow patients to feel comfortable in their own skin. But, beyond all that, they play such an important role in the lives of patients scarred by previous experiences, be it burns, acid attacks or malignancies.

They rid their bodies of the physical scars related to the traumatic experiences. Once the body is rid of the scars, which are a sequela of such trauma, the mind is more willing to shelve those ghastly experiences and focus on opportunities that lie ahead. Plastic Surgeons heal not only the body, but also the mind.

As newer and more exciting opportunities present themselves to me, I may not pursue Plastic Surgery in future. My mind, nevertheless will always be inclined towards this sub-specialty. Whatever the case may be, I have developed a new found respect for all Plastic Surgeons. One that’ll never wane.