Respiratory Care

 

Respiratory Care Nights

Breathing machine pumping love

Eyes of dying hens

Pierce to depths of turbulence

Needles, blood gas and movement

Brisk sharp and painful

A cascade of alarms, ventilator settings

Causes and remedies

Eventually dropping off to an unusual silence

Mountain valleys, placid waters

Light of dawn and a distant bird song

Waking up to a humidifier alarm.

Barishkar Golpowala (story seller) Twist in the tale 1

A hypothetical twist in the tale 

By Barishkar Golpowala (storyseller) 

Forwarded from another group :

The story so far...

One day in a place not so far far away not that long long ago...more at the link below :

https://www.opindia.com/2022/03/rajasthan-distressed-gynaecologist-was-charged-for-murder-after-a-womans-death-commits-suicide-hospitals-go-on-strike/

The twist/spin :

What if the doctor just disappeared to temporarily escape FIR instead of commiting suicide? Would it have provoked a nation wide movement and brought her tormentors to book? 

The best thing this devoted husband wife couple could have done to escape the current corrupt power mongers would have been to play this game of temporarily and surreptitiously abstaining from "the great game of life" and introducing a chaotic perturbation into it? 

In this information age it would be relatively easier where people are driven more by information than the need to verify it? 

Also people at the bottom of the pyramid (read it currently as doctors) need a sacrificial lamb to put forth their requirements to the powers that be? 

What would everyone think if the person who committed suicide resurfaces again as an associate professor in some medical college in Gandhinagar? 

The law is only supposed to punish people who commit suicide (only if caught alive doing it) but can the law punish her for not committing suicide if she resurfaces again? Imagine the delight of her kids getting to reunite with their mom again? Also would it negate the current movement of the oppressed doctors just because the sacrificial lamb made a comeback? 

This twist in the tale should not dilute the movement for our currently oppressed against the powers that be but it is just a feeler to see how many of us wish this were true. That intelligent doctors wouldn't really have to die to escape the system but give it back in it's own coin?

Barishkar name origin : source Wikipedia licenced under creative commons as fair use with attribution 

Blooms taxonomy and the Panchkosa (tweaked version)

Bloom 1, remembering and understanding is Annamoy kosha, food for thought 

Bloom 2, application is pranamoy kosha (pranamoy is self explanatory) 

Bloom 3, evaluation is monomay kosha, social and emotional energy (from work of Siddhartha Ganguli )

Bloom 4, analysis, is vignanmoy kosha (vignanmoy is self explanatory) 

Bloom 5, is creativity and enlightenment aka anandamoy kosha (again anandamoy is self explanatory) 

More about blooms taxonomy in a past lecture here https://sites.pitt.edu/~super1/lecture/lec54091/002.htm

More about panchakosas in a past lecture here https://sites.pitt.edu/~super1/lecture/lec54621/014.htm

Along with a captured video (starts at 34 minutes) : https://m.youtube.com/watch?v=MmbRbKj-7yE

Research project proposal on "Music and Medicine"

"Music and Medicine" project note (served from a steaming "melting pot" albeit with a few cracks where the light gets in): 

We are looking for people with an interest in "music and medicine" for a new collaborative and performative project. 

Project funding will be driven by performative "music and medicine" pieces on different platforms by the collaborative researcher participants of this project. 

Competency in "music and medicine" is desirable but not essential but what is essential is a desire to learn and perform "music and medicine" in collaboration with the research team. 

Some of the research questions this project is trying to answer are :

Are musical vibrational events (macro-swaras and micro-shruti tones) in a bound time-space (akin to bandish) analogous to "patient event data points" in a lived illness trajectory? 

Are musical "nadas" that join musical vibrational events (macro and micro tones) analogous to "patient event data points" that are the routine events (akin to introns in a DNA strand) in an animate life trajectory?

Assuming that both the scalar and vectoral sequence of tonal vibrational events make up a "raga" are medical diagnosis analogous to ragas? 

Is musical cognition as utilitarian as medical cognition? Does musical cognition hold the key to interventional research in "psychoneuroimmunology" that can influence illness event outcomes (aka music therapy)? 

As both "music and medicine" are largely played out in the cognitive mindspace (aka chidakasa), do "musical events" and "medical life events" have similar origins or is music severely limited by a single aural interface while medicine is richer in terms of multisensory event data capture?

Is a medical illness akin to a musical vibrational event trajectory going out of accepted musical scales and causing anguish as well as displeasure if not downright pain and is medical intervention toward improved patient outcomes akin to restoring a music that pleases?

Is the body a musical instrument that plays well largely but goes out of sync when diseased? 

Are environmental forces major players in playing the bodily instrument and the music keeps changing with shift of time and space around it? 

Can one perform both music and medicine events in one presentation platform toward not just aesthetic appeal but utilitarian improvement in student learning outcomes as well as patient illness outcomes? Would this performance begin with a musical composition interspersed with patient illness narratives that would culminate in the identification of the diagnosis (raga) or sometimes discovery of a new raga (if the illness appears to replicate in the populace)? 

While a raga is a gross diagnosis, can one discover newer ragas within ragas depending on individual micro data (akin to microtonal variations in ragas) giving every individual player a different unique diagnosis precise to that player's requirement? 

How does one treat a scale or raga (diagnosis) after its expression is complete? Can one change event vibrations in a given patient (or known past composition that wasn't doing well in the past) from taking a certain trajectory and treat it to steer it toward a desirable and pleasing trajectory thus improving outcomes? 

Can this endeavor to study and perform "music and medicine" scale well among not just beings with an interest in "music and medicine" but in people who are not interested but simply need it anyways? 

What are the implications toward patient privacy and confidentiality and musical copyright? 

This project is an extension of a recent current project on the "scholarship of integration" that is part of a "melting pot" strategy toward making connections with an aim to "unity."

Chapter 80, "The Bronchial Tree"

অধ্যায়--80

শ্বাস বৃক্ষ 

একবার এক্সরে-টার দিকে তাকাও--- দেখতে পাচ্ছো, ঘন জঙ্গল। চারদিকে সবুজ ধানের খেত। একটা গোরু আলস্য ভরে ঘাস খেতে খেতে লেজ নাড়িয়ে মাছি তাড়াচ্ছে। সূর্য অস্তাচলে। একটা দু টো মেঘ আকাশে ভেসে যেতে যেতে পরস্পর মিশে যাচ্ছে। হুম, তুমি ভাল করে তাকিয়ে দেখ, এসব একেবারেই সাধারণ দৃশ্য না? 
অপরদিকে এটা কী দেখত! দৈত্যাকার এক জঙ্গল কাটা যন্ত্র। নতুন অট্রালিকা। কেমন একটা যেন দম বন্ধ হয়ে যাওয়ার অবস্থা না? তুমি কি গাছ নিধন যজ্ঞের আকাশ ভেদী আওয়াজ শুনতে পাচ্ছো? বুঝতে পারছো না, যন্ত্রটা দানবের মতো বিকট আওয়াজ করছে।  
পাওয়ার প্ল্যান্ট প্রকল্প থেকে বিষাক্ত ধোঁয়া বের হচ্ছে। আতস কাচের তলায় দেখার মতোই স্বচ্ছ-- ফুসফুস কর্কট রোগ। একটা ব্রঙ্কোস্কোপি করে দেখে নাও । যন্ত্রটা একেবারেই অকেজো হয়ে গেছে। এইতো ক'দিন আর আয়ু। বড়জোর তিন থেকে ছ'মাস।
সূত্র 

বন্ধুদের কাছে সে দাদা বলেই পরিচিত। চোখে পড়ার মতো তার লম্বাটে চুল, লম্বা দাড়ি। 

লোকে বলে উনি নাকি এই চুলগুলো প্রতিদিন একটা পাগড়িতে বেঁধে রাখতেন। কিন্তু একদিন যেদিন দেশের প্রধানমন্ত্রীকে আরেকজন পাগড়িধারী গুলি করে মেরে ফেলল সেদিন ওর উপরে কলকাতার মানুষ হামলা করেছিল এবং তখন থেকেই সে তার লম্বা চুলটি পাগড়ি তে না বেঁধে খোলাই রাখতেন।

  এই সেই শহর কলকাতা, যেখানে সামান্যতম বাহানায় আদ্যিকালের ট্রামের উপর উত্তেজিত জনতা হামলে পড়ে পুড়িয়ে ফেলে(ট্রামের ভাড়া বৃদ্ধি এর মধ্যে একটা কারণ। )

সত্যি কথা কী, দাদা সেদিন থেকে একেবারেই পাল্টে গিয়েছিল। মৌলবাদীদের ছড়ানো বিষাক্ত ধোঁয়ার ছাপ তার মুখের উপর পড়েছিল। কিন্তু অদ্ভুত ভাবে কয়েকবছরের মধ্যে সমস্ত ব্যাপারটা তাকে সংকীর্ণতার বাইরে বের করে নিয়ে এল।

সে হিপ্পি চুল রাখল। ধূমপান শুরু করে কারখানার চিমনির মতো ধোঁয়া ছাড়তে লাগল(যদিও তার ধর্মে ধূমপান নিষিদ্ধ ছিল। )

মানুষটা একেবারেই পাল্টে গেল। 

হিপ্পি গজাবার সাথে সাথে দাদার মধ্যে একটা নতুন প্রতিভা দেখা গেল। সেটা হল কবিতার প্রতি তার  অনুরাগ এবং চেতনা। এরপর থেকে দাদাকে প্রায়শই প্রেসিডেন্সি কলেজ ক্যাম্পাসে অনর্গল চেতনা প্রবাহের মত কবিতা পাঠ করতে দেখা যেত.

জুনের সঙ্গে দাদার প্রথম আলাপ  হয়, যখন জুন একজন জুনিয়র ডাক্তার এবং দাদা তখন পাঞ্জাব বিশ্ববিদ্যালয়ের রসায়নের অবসরপ্রাপ্ত অধ্যাপক। তার সদ্য শ্বাসযন্ত্রের পরীক্ষায় বেশ কৌতূহলজনক কিছু অসঙ্গতি পাওয়া গেছে। সেটা হল তার শ্বাসযন্ত্রের উপরের ডানদিকে কোনও ক্ষতিগ্রস্ত এলাকা চিহ্নিত হয়েছে। স্টেথো বসালে বিকট শব্দ শোনা যায়। 

আবাসনে থাকাকালীন জুন এই কেসটার ব্যাপারে গভীর ভাবে স্টাডি করেছিল। সে রোগীর সঙ্গে হামেসাই আড্ডা দিত। কিন্তু অম্রিন্দর সিং দাদার ডায়েরিতে লেখা লাইন ক'টা পড়া হয়নি---

গতরাতে আমি আবিষ্কার করলাম, আমার শ্বাসবৃক্ষে আঙুরের মতো থোকা হয়েছে। লম্বাটে বিশ্রী দেখতে। এরা আমার রক্ত চুষে খেয়েছে....এই গাছ  ভ্রমণপিপাসুদেরকে প্রখর রোদে মাথার উপর ছায়া দেয়। আর বেশি কিছু না...পাতা ঝরে, 
প্রতিটা কাশি যেন আমার ভিতরে ভয়াবহ ঝড় তুলে থোকাগুলোকে বোঁটা থেকে নাড়িয়ে দেয়।

More about the translator in the link below :

https://consciousnotebooksequel.blogspot.com/2022/07/amal-krishna-roy-author.html

Original English version :

The Bronchial tree 

"Take a look at this chest x-ray…Hmm dense forests bordering on green rice fields 

A cow munching grass, lazily waving away the flies, the setting sun, and one or two clouds 

interspersed …Hmm looks normal-show the other one. What’s this! A giant jungle mower, Concrete 

new buildings-all cooped up look alike? Hey can you hear the trees crashing!

Can’t make out – over here the mower’s creating a din. Hmm see anything more? 

A lot of alveolar opacities which is probably the smoke from our upcoming power plant… 

Hmm the diagnosis is clear—Lung cancer. Get a bronchoscopy but the prognosis is bleak 

At the most 3-6 months--Sutra"

He was known as Dada to his friends. He had remarkably long 

hair for an Indian along with a long beard. 

They say he used to religiously tie it in a turban once everyday before they attacked him mercilessly one day when the prime minister died, killed by another person with a turban. That day there were countless such victims in the roads of Kolkata. It's a city where outdated Government tram-cars are usually torched by violent mobs at even lesser pretexts (the price hike in the tram ticket being one such routine stimulus). 

Dada was transformed that day not only because of the hideous gash inflicted on his face by a religious fanatic but strangely the whole experience made him very unkemptly irreligious in the years to come. 

He let his hair down like a hippie and started smoking like a chimney (smoking was strictly forbidden in his religion). Another development that was totally unlike Dada in his pre-hippie days was his fascination for poetry. He was a permanent fixture on the Presidency college campus spouting a free flowing stream of consciousness verse that would intimidate even the utmost post-post modernists. 

June came to know him only as a solemn retired professor of chemistry from Punjabi university, introduced to her by the senior resident as one with interesting findings on his chest, a respiratory case that would be surely kept for her ensuing clinical exams if available at that time. Sure enough there was a bulge at the right upper part of his chest that was dull on tapping and there was a hollow sound on putting the steth. A mass lesion is the most likely morphologic diagnosis thought June. She had become quite deft in her handling of cases during her residency years. 

She chatted with her patient as always but couldn’t find time to read what Amrinder Singh 'Dada' had written in his diary. 

Last night I discovered the fruits of bronchogenic carcinoma growing on my bronchial tree. 

Ugly and slimy it tasted of blood and phlegm. This tree…had long been a source of shade for travel 

weary souls amidst sun burnt fields. Not any more…falling leaves, shriveled bark, ugly nodular fruits 

with a slimy sauce. With each and every cough it shakes from its very roots caught in a raging storm.

Image from https://en.m.wikipedia.org/wiki/Lung#

Raga Bahudari case presentation

Work in progress:

Musical Medicine and case based reasoning around Raga Bahudari a lecdem in musical and medical cognition

 

The different cases are contained in this musical melange by Sindhusha 

vocalized by her in an engaging manner here: https://youtu.be/mYkOQ9qccDM

The first... minutes from... to... is alapana aka the introduction to the learning objectives of the presentation followed by: 

Alapana (Introduction and also abstract with learning objectives) 

Aa aaa re ne re naa 

We shall be presenting a few cases that apparently appear to have a common diagnosis where their life events reflect similar frequencies spread out and recurring in a similar scalar as well as vectoral pattern over time. 

The pattern verbalized by Sindhusha is called raga Bahudari and the disease pattern is anatomically round the serosal covering of our abdominal and thoracic viscera that embryologically originate from an intraembryonic coelom and often associated with a notorious and infamous microorganism discovered in 1882 and awarded a Nobel Prize in 1905 around 50 years after the death of Thyagaraja and the first case being rendered by Sindhusha here through Thyagaraja's musical score and lyrics is a classic presentation of the disease. 

All the lyrics of the first case by Thyagaraja is quoted (aka borrowed and stolen) from Mr Shiv Kumar here:

www.shivkumar.org/music/brovabarama.htm

Right after the alapana Sindhusha chooses to sing the anupallavi introducing the case.

"Anupallavi:

Sri Vasudeva! Andakotla Kukshini Yunchukoleda? Nannu"

Literal translation:

"Sri Vasudeva! Have you not absorbed and preserved (“yunchukoleda”) the entire cosmos (“kukshini”) within your stomach (“Andakotla”)

Medical translation:

"Vasudeva, a 60-year-old retired farmer started experiencing gradual distension of the abdomen (andakotla) since last 3 months along with low grade fever and significant weight loss.

More here:

https://casereports.bmj.com/content/2009/bcr.08.2008.0625

"Pallavi:

Brova Bharamaa? Raghuraama!

Bhuvanamella Nivai Nannokani"

Literal translation:

"Raghurama! You are the omnipresent Prop (“Neevu”) of the sprawling (“ella”) world (“bhuvana”). Will protecting (“Brova”) this frail (“nann Okkani”) Tyagaraja prove an intolerable burden (“Bhaaramaa?”) on you"

Medical translation:

Vasudeva starts looking inward at another of his anonymized virtual avatars called "Raghurama" and asks the avatar for his support to resolve his current problem. 

Charanam:

Kalashaambudhilo Dayato Namarulakai Yadigaaka

Gopikaalakai Konda Lettaleda ? Karunaakara Tyagarajuni

Literal translation:

Did you not kindly (“dayato”)  to support the Mandara mountain under the ocean on behalf of the celestial (“Namarulakai”) during the churning of the ocean (“kalashambudhilo”)  for nectar?

And did you not (“leda”)  lift (“Letta”)  the Govardhana hill (“konda”)  to protect Gopis and cows. Ocean of mercy!

And did you not (“leda”)  lift (“Letta”)  the Govardhana hill (“konda”)  to protect Gopis and cows. Ocean of mercy!

Medical translation:

 He was investigated and an ascitic tap initially revealed straw colour fluid with ascitic fluid biochemistry, suggesting an exudate, and ascitic fluid cytology revealing lymphocytic pleocytosis.

He was sent home on presumptive antitubercular therapy with an official document that would help him to receive directly observed therapy (DOT) from his local health centre. He was lost to our follow-up and on recent questioning admitted that he had not taken antitubercular therapy as his ascites had subsided spontaneously. However, he admitted to a continuing low grade fever. When he finally returned 2 weeks later he related that he had developed sudden abdominal distension one week previously. Repeat ascitic tap revealed a milky fluid.

An ultrasound done soon after revealed multiple enlarged rounded mesenteric lymph nodes, few of which were conglomerated. Ultrasound guided FNAC from the lymph nodes showed acid fast bacilli on Ziehl–Nielsen stain. The patient was started on antitubercular therapy again with the DOT program and this time we will follow him up more meticulously to ensure compliance.

The Story of Glomerular Injury

This is an extract taken from chapter 92 of "The Conscious Notebook" (full text here and table of contents here

The Story of Glomerular Injury 1-7

Glomerular Injury 1

It has been long since June met Professor Joatmon in his limestone cave of holistic medicine full of stalactites and stalagmites. At present if you move these curtains you can spot June looking smart in that suit, standing on the pulpit with a laser pointer in her hand. From a lecturer she has quickly become an Assistant professor now, teaching in the Macchapucchare College of medical sciences, Nepal. She’s at the moment presenting a paper on preventing and managing glomerular diseases in the community. You can stay on if you’d like to view her presentation.

June starts off with, “May we have the first slide please?”

Slide 1. Macchapucchare teaching hospital, Pokhara, Nepal.

The first slide is a picture of Macchapucchare teaching hospital, Pokhara, Nepal where I live and work. To talk on renal diseases their impact and strategy for long-term solutions I am going to begin by relating a story, which has been synthesized from the stories of a number of our patients and doesn’t necessarily reflect any real life patient. Prem Bahadur Khadka (not his real name) is a 25 year old boy who hails from a remote village near Jumla, Nepal and had never seen a bus or car in his life before he left his village for higher studies.

Slide 2.

This is his village where the only means of travel was an airstrip apart from the other option of a few days of walking.

Slide 3. Professor Joatmon’s village.

Prem was intelligent and soon after he finished his 10^th grade exams he decided to leave his village for higher studies.

Glomerular Injury 2

Slide 4.

He came to Pokhara, enrolled in a good school and saw proper roads and vehicles for the first time.

Slide 5.

As he was a good student he got into engineering and after finishing his degree, arrived in US as a software analyst. However he felt miserable there as he kept missing his relations and his mother’s cooking (among other things). He was actually relieved when he got the pink slip and lost his job after the economic slowdown.

Slide 6.

He came back to his village (and his mothers cooking) but found that by now he couldn’t adjust with his brothers who knew more than him about farming and all his knowledge of software was of no use in the village (which didn’t even have a single computer).

Glomerular injury 3

Slide 7.

While all this was happening to Prem our protagonist in his macrocosm, quite unknown to him or anybody else a major war had already started inside his kidney where his glomeruli were being attacked by a lot of inflammatory cells.

Slide 8. A cell in Prem Bahadur’s glomerulus.

This is a cartoon borrowed from Harrison’s principles of Internal Medicine, which shows in molecular detail the happenings inside a cell in Prem Bahadur’s glomerulus. You can see how the antigens are processed and finally parceled into an endosomal compartment containing the MHC class II molecule .The antigen settles down into the groove of the MHC and sets off a chain reaction stimulating a clonal proliferation of hordes of inflammatory T cells.

Glomerular injury 4

Slide 9.

This is the strong inflammatory response inside Prem Bahadur’s glomerulus as a result of which we expect to see a lot of protein and RBCs in his urine (if only we could have examined it earlier). However Prem Bahadur didn’t notice anything wrong with his urine. His neighbors noticed him growing plump day by day and complimented him on this sign of prosperity. At first Prem Bahadur was also happy that he was getting fat but later noticed that he was unable to enjoy his mother’s cooking due to a feeling of extreme nausea. This too was ignored by him until one day he developed extreme breathlessness and had to be rushed to our hospital in Pokhara.

Slide 10. Our hospital in Pokhara.

This is a picture of our hospital on a stormy night. When I saw him in our casualty (for the first time) I found him gasping for breath, his lungs were full of crepitations which we quickly treated with Lasix and referred him to Katmandu for dialysis. At Katmandu they dialyzed him for fluid overload and a urine analysis subsequently showed 3+ proteins and plenty of RBCs suggesting acute glomerular injury. He was immediately treated with high dose steroids and a renal biopsy was done.

Slide 11. Renal biopsy.

The biopsy showed focal areas of glomeruli that were sclerosed in segments.

Glomerular injury 5

The fire was too severe to be quenched with steroids and it was already too late to prevent Prem Bahadur’s kidney from blowing up in smoke.

Slide 12.

He received a few more dialysis from Kathmandu and spent whatever money he had earned over the past few months. His brothers came forward to donate their kidneys for transplantation but that would mean selling off their land and cattle to go to one of the hospitals in India and Prem Bahadur wasn’t keen on that. The next slide is a Haiku sequence, which was mailed to me by a friend right after 9/11.

Slide 13. Haiku sequence.

Glomerular injury 6

The last I heard of him was through one of our medical students also from the same village. Prem was spending his last days in deathbed with his family praying for him daily and it would be a matter of days or months before death would take him.

Slide 14. Summary of the story of glomerular injury.

This is a summary of the story of glomerular injury taken from Harrison’s principles of Internal Medicine which describes how it’s initiated by breakdown of tolerance leading to reactivity of antibodies with planted glomerular antigens which in turn generates a chemical cytokine mediated response leading to proliferation of inflammatory cells and subsequent irreversible renal damage (in a substantial number of people).

Glomerular injury 7

The key word here is tolerance and (next slide).

Slide 15.

Tolerance is fast becoming popular in transplantation research but we need tolerance urgently before the need for transplantation arises to save our native kidneys (before the inflammatory cells attack them). As much as we need tolerance to save this Earth before a full-fledged war breaks out. That is the problem of glomerular injury for we don’t really know why this breakdown of tolerance occurs. We don’t even know why hypertension or diabetes occur (for that matter). Our present strategy is only to control them in the hope of slowing the progression of renal disease.