Elbows are indeed useful devices- the hinge joint that provides so much manipulation to the hand- allowing us to scratch our backs ,dig our noses and daintily deliver morsels to the mouth. A part of the body that can stick out at an angle, rotate back, cross forwards- its uses are numerous. And equally, a joint of damage and destruction – to thy neighbours. Imagine this scenario- short girl (like me) standing in queue at a coffee kiosk- I collect my disposable cup and gingerly make my way out of the queue towards sipping distance when the next in line carelessly lifts his elbows and gets –my-cup. And I get hot scalding coffee over myself and none inside me! He does not even realize his flappy elbow! Walking down a straight corridor- looking straight ahead. There’s a couple of people standing in a corner and talking. As you approach ,one of them casually puts his hand on his hips-elbow sticking out- and (remember me, Iam short,right) the wretched elbow gets me on my forehead sending me spinning, seeing stars! Sitting in a cinema- -I do wish people could keep their elbows within their own spaces ! Sitting in a public hall, aisle of a plane/bus/train- keep your elbows in-else they will poke the unwitting stroller in the passage. And mind you, those things are sharp! So please, my friends- do watch these sharp corners-these elbows and in public places please be aware of where you are keeping your elbows. They can poke, hit, hurt, blind and scald
In a busy throughfare , please do not stand thus- you can avoid morbidity to other passers –by!!! Remember your-Elbow Etiquette!
I studied in a girl’s school that was co-ed until class 5 and then the boys had to leave ! A time in the 70’s when schooling came with mandatory “moral science” classes, “drill” classes, music ( singing) classes and then the handwork class. The girls did stitching & embroidery and I don’t have the faintest clue what the boys did. Strangely enough, that was just accepted. It must have been in the third standard when we did our first stitching project. I still remember it distinctly – we stitched a ladies’ panty! All of us were asked to get some poplin material of specified dimensions , a length of lace and thread and needle . The teacher did the cutting and looking back, I have no idea who it was meant for. I think she chose a panty because it was the easiest cut of them all! She was quite a slim young thing and yet she cut everyone’s panties the same XXXL size. There were two symmetrical halves and we had to sew them together first , so we learnt to hem – and then we had to attach the lace all around. For an expert probably half an hours work , but it kept us busy for the whole year! Learning to thread the needle and keeping in without falling out was a big skill to master. Then doing the stitch without poking one’s fingers( or eyes) or the next kid’s body parts , basically we did a few stitches of the hem per class. And then the lace was another big adventure – holding it in line while stitching it in without closing the holes for the legs – there was a lot of fine motor coordination in that process. At the end the teacher undertook inserting an elastic lining in each waistline. Finally , there would the final PTA meeting where our works would be presented and our classroom had a long line of panties on the wall, proudly presented. I remember mine – a lurid orange ( that must have been my mother’s joke on me) with white lace , all uneven and ungainly hanging in there with the bright reds and the florid yellows and a few simpering pinks. None of them were fit for wearing either in their size, fit or integrity and am pretty sure no parent framed their child’s first attempt at stitching on their walls at home🤭. The next year’s teacher had better aesthetic sense and decided on a cushion cover . We were to find a suitable picture for embroidery and buy a plain cushion cover . Mine was fairly standard – a vase with flowers and we were taught the intricacies of the stem stitch, chain stitch, buttonhole and how to fill in neatly. This was much better and our final products were pulled in and lumpy and protruding in parts but frame worthy for proud parents. Mine in future would grace the makeshift cushion for the kittens Billa & Ranga ! We progressed and there was an entire tablecloth with cross stitch designs in the last year of primary school. By this time I was getting better. Could thread the needle, and measure lengths of thread that were not injurious to myself or my classmates and progress slowly. A family friend , the quintessential Malayali Christian Auntie who was a wizard at stitching, embroidery , fabric painting and whatnot , drew my patterns for me for the cross stitch. I still remember the pale pink material specific for cross-stitch patterns and the various flower patterns in the middle and corners that I managed to complete. At the end while I was pretty proud of my work, when they all were displayed on the wall in school, mine looked very ordinary in comparison to several- and that’s when we heard that many mothers had done their girls’ embroidery for them😁. After primary school we completely stopped embroidery and I dont remember what I did instead. Not drawing because no one could identify what I drew , and I was not really the sports kind ( apart from Palanquin race every year) nor dance ( I think I was considered too clumsy for that) . Perhaps that’s why they kept me in the school choir to keep me out of mischief ! That has however bestowed me with a repertoire of hymns and carols for a lifetime! During internship , a most accomplished classmate of mine ( she aced cooking, swimming and stitching and embroidery and also had the ultimate talent in MCQ exams ) inspired me enough to pick up the thread & needle and thimble again. I embroidered an entire kurta for my sister which of course I inherited from her in due course ( a pink kurta with yellow designs) which probably marked the pinnacle of my seamstress’ career and monogrammed the boyfriend’s handkerchiefs and embroidered a bookmark with his initials when he left for PG to a faraway Northern state. Remember me even when you sweat or sneeze …….., I see friends and colleagues posting their highly professional work these days and wonder- Did they also begin with an XXXL panty?
It is with great sadness that I write about the tragic demise of our sister, Dr. B. Sudha who belonged to the batch of 1981. She was involved in a car accident on 30 December 1999, at Chertala in Kerala in which both herself and her husband Mr. Vijayakumaran Nair expired. They have two sons – Abhishek (8 yrs) and Vishnu (5 yrs). At the time, Sudha was practising as Chief gynaecologist at Nair’s Hospital, Quilon and her husband was the finance manager at Kerala Cashew Corporation, Quilon.
I want to explain in detail as to what Sudha went through in her final hours because I feel that for all of us abroad and at home, it will be an eye-opener as to the reality of Emergency medical care in India.
Shortly after her accident, the three victims in the car were taken to a nearby private hospital called KVM Hospital which boasts of being a TRAUMA CARE Centre and is equipped with whole body CT scanner etc. Her husband was brought in gasping and unconscious and was unresuscitable by their accounts (PM revealed posterior fossa pontine hemorrhage). Sudha was, however, fully conscious and oriented and able to give a brief history and naturally continuously enquiring after her husband. She had, by account of the doctors in attendance, severe swelling of the face and neck including subcutaneous emphysema and was at the time maintaining her own airway and hemodynamically stable, even though there was a continuous ooze into the mouth from a palatal injury. She had bilateral facio-maxillary injuries including fractured nasal bones, fractured both maxillae at several sites, split hard and soft palate, mandibular symphysial separation. A CT head was immediately performed along with skull x-rays which demonstrated the above injuries and NO brain injury. No pain relief was given, no x-rays of chest or neck were obtained, certainly no evidence of having looked elsewhere in the body for other problems. There was one tooth missing (no one knows where it had gone).
Close relatives (non-medicos) had arrived with an ambulance to take the remaining two survivors to Medical Trust Hospital in Ernakulam (about 50 km away). However, the treating doctors claimed that though she was very stable then, she might aspirate and die during transfer, which frightened them, and they sent the ambulance away. Subsequently, they went to great lengths to get hold of a maxillo- facial surgeon (essentially a postgraduate dentist) who arrived and suggested he would perform a simple interdental wiring of the maxilla to keep it together in an attempt to stop the slow ooze. She was taken to the theatre 4 hours after the accident and the surgery actually started only an hour later. All the time she was fully conscious. The actual procedure was performed without any anaesthesia, not even LA. 2 anaesthetists were on standby in the theatre, however, along with a plastic surgeon in tow to perform an emergency tracheostomy should the need arise. The actual procedure took around 15 minutes and shortly following this, Sudha is supposed to have indicated that she was choking. Intubation failed, tracheostomy failed and a subsequent attempt at intubation succeeded by which time she was very difficult to bag ventilate. She was declared dead 71/2 hrs after the accident, i.e. about 7 hrs or so after admission, most of which time she was reported as being fully conscious and ‘stable’.
Unfortunately, my brother Satish (Batch of 1983) who works in Trivandrum was informed several hours after the accident and he was unable to make it in time to help. The third person involved was subsequently taken to Medical Trust Hospital in Ernakulam. He had many problems, but today he is discharged from hospital and doing well.
As a family, we are more than devastated by our personal loss – but as doctors we are horrified and shocked at the total lack of basic emergency knowledge and care in, what we are told, most of the hospitals. I wonder what can be done to prevent such a tragedy happening to someone else?
“ It shouldn’t hurt to be a child!” said a young girl with Juvenile Idiopathic
arthritis
The WORD Day has been announced under the auspices of PReS( Paediatric Rheumatology European Society) and ENCA ( European Network for Children with Arthritis) and is a day dedicated towards increasing the awareness of Rheumatic diseases in children among the primary medical professionals they are likely to encounter and also among the families , teachers and society.
The plight of Childhood Rheumatic Disease in India
There is a common misconception that Rheumatic diseases are rare. Juvenile Idiopathic Arthritis has an incidence of 1 in 1000 worldwide ( and much higher prevalence) . Henoch Schonlein Purpura and Kawasaki Disease are systemic vasculitides occurring with a reasonable frequency.
More than 50% of Rare Diseases( diseases that occur in less than 1:2000) occur in children.
The actual problem, however ,is not because they are rare, but that they are rarely diagnosed.
Rheumatic diseases are related to the immune system. They are due to aberrant or variant responses by the immune system triggered often by an external factor(eg-an infection) in an individual who might have a genetic susceptibility to such response. It is difficult to predict in advance which child might develop a rheumatic disease as they grow up, but it is important that the disease is identified early and referred to the right experts for management.
Which are the Rheumatic diseases that affect children?
1)Arthritis-called as Juvenile Idiopathic arthritis is a spectrum of many different types of joint inflammation. Some are associated with fever, some with silent inflammation of the eyes, some with inflammation of the spine and so on. All of them can cause longstanding disability and deformity if not managed early. Children with uveitis can also develop visual loss, glaucoma etc if the right treatment is not given
2)Connective Tissue Disease- The most common are SLE(Systemic Lupus Erythematous) and Juvenile Dermatomyositis and theres are others called Scleroderma etc. These diseases cause changes in skin, muscle, joints and all internal organs and can also have longstanding severe consequences if not treated appropriately
3) Systemic Vasculitis- Vasculitis means inflammation of blood vessels and we all know that blood vessels are everywhere in the body. So this group of conditions can also present with manifestations across multiple organ systems .Some conditions like HSP(Henoch Schonlein Purpura) and Kawasaki Disease are seen musch more frequently than conditions like Polyarteritis nodosa and Takayasu arteritis. There is also an Arabian link in a disease called Behcet Disease that presents with painful ulcers in the mouth and genitals , and involvement of several internal organs which is being increasingly recognised in Kerala.
4)Primary Immune Deficiency disorders can often present with rheumatic symptoms and additional infections can give the clue
5)Autoinflammatory disorders- this is a group of conditions, almost always genetic which present as recurrent fever with other typical clinical features. These conditions have become more clear in our understanding in the more recent times and increasing access to genetic testing has improved our ability to confirm diagnoses.
Though we do not have our own incidences of the diseases in India, looking at the population of India and the predominance of young people brings home the sobering reality that there must be a significant prevalence of all these in our country.
All these diseases require early identification and early referral to trained professionals so that appropriate diagnoses can be made and treatment commenced. In all Paediatric Rheumatic diseases, it is the duration of disease at the point of commencement of specific therapy is what determines the long term outcome . And thus the prevention of disability, death and organ failure .
We are also disadvantaged by an extremely small population of trained health professionals in the field.
A DM Program in PGIMER Chandigarh and 2 Fellowships in Sir Gangaram Delhi and in SRCC, Mumbai have contributed to the growth and progress will continue as more training programs happen.
When should we suspect Paediatric Rheumatological illness?
-The child with persistent joint pain
-The child with very prolonged or recurrent fevers
-The children with unexplained rashes and inflammatory skin conditions
-The child with bone pain
-The child with inflammatory diseases of the eyes
The child with multisystem inflammatory disease
What are the challenges for children who suffer with these illnesses?
Delayed diagnosis which delays onset of specific therapy
Almost all of the pediatric rheumatic disease can be controlled very well allowing a normal quality of life even if some require some form of medication lifelong.
Sometimes, workup and investigation can be expensive
About a third of children with JIA may require expensive medications for a period of 1-2 years for their treatment
Increasing awareness amongst the public, the medical society and all stakeholders is important if we have to get the right treatment to each child.
While every child matters, the charitable help available for children with Rheumatic disorders is negligible compared to cancer or heart disease and some of these conditions are as bad as cancer.
Let us move to work together to get these children a better deal. Together, we can make a difference.
sumarants 