Water that is not a life saver !

Small observations by great people may lead to great discoveries. As observation of a fall of an apple by Sir Issac Newton led to the discovery of the greatest laws of Physics. I also narrate an interesting story here. However, in this case a small observation by a small man led to a small discovery.

In the later half of 2008, over a period of few weeks, I got a spurt of patients in my office suffering from Anterior Anal Fissure.  [Anal Fissure is a condition with severe pain in the anus due to a cut caused usually by constipation. In males, 99% of fissures are on the back side (posterior) side of the anus and 1% on the front (anterior) side]. Initially I ignored it thinking it to be routine presentation but after some time, I was perplexed to note that 95% of the male patients coming to me with fissure had anterior(front) anal fissure (which were supposed to be less than 1% as per the literature). I was wondering as why this change of trend was happening. One of the patients was not getting alright even after being operated by one of my friends. I discussed it with a couple of my colleagues but even they had no idea whatsoever.

I kept on thinking for few days- in every possible direction and every possible cause- as why this could be happening and what could be the reason of this reversal of trend but to no avail. Ignorance turned into desperation was now bordering into frustration. On a routine but eventful day,  one of the similar male patient (suffering from anterior fissure and not getting relief with usual medicines) came for consultation to my clinic. Mentally prepared to listen to him for an hour, I told him  “Tell me everything in detail from the very beginning of your illness”. I was vigilantly listening as he was narrating his story. Suddenly he spoke something that made me rise in the chair and I almost jumped. He said  “I turn on the water-jet and then sit for 10-15 minutes”.  Oh my God ! was it the water-jet which was responsible for all this?

Yes, it was possible because water jet in the toilet seat from behind would hit the front wall of the anus and cause anterior (front) anal fissure. The use of water jet in toilet seats is rampant in North India and this could explain the rising trend of anterior(front)fissure in the population. This would also explain why one of the patients couldn’t get relief even after operation (because he must be using the water jet still).

I took out my out patient register and called all the patients with anterior fissure I had seen in the last few months. No wonder, all were using water jet and that too for a long time. I advised them to stop water jet immediately to which the response was spectacular.

On Feburary 1, 2009, I submitted this research to a prestigious British journal, Colorectal Disease (Colorectal Disease is published from England and is the second highest ranking colorectal journal in the world. It is the official journal of British & Ireland, European and Spanish Societies of  Coloproctolgy) and to my utter surprise, it was accepted for publication on the same day it was submitted (normally it takes 6-8 weeks for the peer review process). It subsequently got published in 2010 June issue

Pankaj Garg. Water stream in a bidet-toilet as a cause of anterior fissure-in-ano: A preliminary report. Colorectal Disease 2010 Jun;12(6):601-2

(http://www.ncbi.nlm.nih.gov/pubmed?term=19486098)

It was also covered in the leading newspapers of the region from time to time

Hindustan Times- June 9, 2009- Water jet in Toilets may cause Anal Fissures

Aaj Samaj - 5 November, 2012- Jet Spray in Toilet dangerous !

 The Tribune (National Edition)- July 8, 2009- Water jet in toilet behind rising cases of Anal Fissures

Last month, a neuroradiologist and a learned friend of mine from London, informed me that water jet is used in the instrument- Water jet Cutter- a tool capable of slicing into  metal or other materials (such as granite) using a jet of water at high velocity and pressure.  http://en.m.wikipedia.org/wiki/Water_jet_cutter

A stubborn blood pressure that refuses to rise !

This was in the winters of December 2008. Mr A, a close family friend of mine had come from Silicone valley (USA) to take care of his father who had been diagnosed and operated for kidney cancer (Renal cell carcinoma) at AIIMS, New Delhi in September 2008.

On that morning, Mr A called me up and frantically said “Pankaj bhaiya, the blood pressure of papa has fallen and is refusing to rise. Its 74/40 since late last night. We called a physician and he has given a lot of medicines and injections. Even after giving 4 bottles of intravenous fluids, the pressure is still the same. He was absolutely alright yesterday evening- eating, drinking, talking and joking. What should we do?”.

I  was surprised and confused at the same time. I had seen him recovering absolutely well after the operation in September and had resumed his normal routine from mid October. I had also telephonically conversed with him two days back and he was quite jovial (optimistic as he always was) and reassuringly fit. So what could have happened so suddenly? Was he in shock (extreme fall in blood pressure most commonly due to bleeding or infection)? But there were no obvious signs of any bleeding or infection.  I also discussed with the physicians treating him but they were clueless as well.

Clueless, thinking in all possible directions. It was a déjà vu situation; a situation I find myself quite often in. May be I welcome, am always happy and available to analyze difficult and complex medical conditions or may be I am too nosy (poking my nose everywhere); whatever it was, my mind was running amok and scanning all the possible causes of hypotension (low blood pressure ) I could think off.

Suddenly, like a flash of light, it struck. Could it be adrenals (glands responsible for production of steroid hormones in the body which play a vital role in maintaining blood pressure); Adrenal failure because of the metastasis (spread) from the operated kidney cancer tumour. Since the patient was not in the condition for a CT scan, I requested Mr A to suggest his physicians to give an injection of steroid (Inj Hydrocortisone) immediately and evaluate the response. Even if the adrenals were normal, one injection of steroid was perfectly safe.

One hour later, I got a call from Mr A. The response was more than dramatic. The patient was sitting and talking with his pressures restored. Mr A was extremely happy and thankful; but I was sad and sorry. My heart had sunk.  I couldn’t muster courage to tell him at that moment of momentary joy that the cancer has come back with a vengeance   and has almost reached the last stage.

I said “thank you, take care” with a heavy voice which he could hardly hear and closed the call.

 

 

Loss of an acquaintance

In the summer of 2009, who was admitted in a tertiary hospital in Panchkula (Chandigarh,India).an acquaintance of mine, Mr P, called me to take advice regarding his father

Mr P's father was a 78 year old gentleman who complained of difficulty in breathing (dyspnea) and some discomfort in the chest during the previous night for which he was admitted in the hospital the next morning. The emergency physician diagnosed it as due to some heart problem and sought a cardiologist's opinion. The cardiologist also agreed and posted the patient for Angiography (and proceed according to the findings thereafter). Meanwhile, Mr P rang me up for advice.

On initial discussion, the breathing difficulty and the chest discomfort looked a bit atypical. I advised Mr P to take a second opinion but on his insistence, I agreed to pay a visit.

I saw Mr P's father in the evening. As mentioned earlier, the symptoms didn’t seem like to be originating from the heart. On probing, the discomfort looked more in the upper abdomen (tummy) rather than the chest and the tummy also seemed a bit distended (bloated). On further inquiring, it was revealed that the patient had been suffering from severe constipation and had not passed motions for the last 5 days. The distension of the tummy and the breathing difficulty had been progressively increasing since then. I immediately did a per rectal examination and found the rectum fully loaded with tons of motions (fecal matter) ! Obviously, he was suffering from fecal impaction- a common condition in the elderly age group people who eat less fibre and move even less.

I immediately ordered a rectal enema and got it repeated at regular intervals till the impaction finished. The patient's symptoms and distension disappeared. He was sent back home with in 24 hours and was advised high fibre diet and ambulation (walking) on discharge.

I permanently lost an acquaintance that day and gained a very close friend !

A dependable man

Last year, a very senior bank officer Mr A came to me to show his father. His father, 96 years old, was bed ridden and had to be brought in on a wheel chair from the car to the bed in the emergency room.

After taking history and conducting a thorough examination, I suggested that even though an operation would be ideal, but considering his age and condition, I would prefer doing a small procedure which would give him considerable relief.

I just enquired as a matter of fact from Mr A " Is your father  dependant on you?"
(In India, a lot of government offices and banks reimburse the expenditure done by an official on himself and on the people financially dependant on him  such as his wife, children less than 18 yrs and the retired parents.)

Mr A almost instantaneously replied with a light smile " No doc, he is not dependant on me. I am dependant on him".

After standing speechless for few moments, the time it took me to absorb the iconic statement, I smiled back and nodded my head in agreement.

I could conclude at least one thing- a man with such ethics and character is quite dependable !