Tuesday, October 13, 2015

"Copies of PAN card and Four Photograaphs Please"

We had a temporary power connection provided for our house in Bengaluru when the construction was in progress and I wanted it to be regularised. I approached BESCOM which takes care of power supply to Bengaluru, rather, power shutdowns in Bengaluru, with a request to that end.
“Submit the application along with  1.Two copies of saledeed  2. Two copies of ‘Khata’ certificate 3. Two copies of ‘Khata’ extract  4. Two copies of tax paid receipt  5. Two copies of plan sanction order and Four passport size photographs .”

I have all the requirements except for the passport sized photographs and will have to get another set. About two years back I had my picture taken and got twenty four prints. I was fifty eight then. I had retired from service, my practice was ten years old and set, my house in Goa had been constructed and occupied, children had completed their education and were employed, my LIC policies had matured, my car loan had been repaid, I had no intention of opening any more bank accounts or taking loan from any agency -  in short nothing that would require copies of ration cards, driving licence, PAN card, photographs so on and so forth. I thought there was no need for so many prints but got them done just because the difference in cost between eight prints and twenty four was almost nothing. I thought that those twenty four may remain with me forever.

They did not last even six months!

You go to buy vegetables in the market and the vendor will ask for your PAN card, voter ID and two copies of passport size photographs. You get into a bus, the conductor will ask for photo ID and photographs. Go to a hotel and at the check in counter you need to provide photo ID and photographs, I register for a conference and have to give the organisers my ID copy and two passport size........  . I have had my picture taken twice after the twenty four that I have mentioned above and right now I have not got a single print with me. If my wife asks for my Photo ID and two passport sized photographs before serving me dinner today, I will have to sleep on empty stomach. Good for health, they say, anyway.

My bank account is thirty years old. They already have my PAN card, voter ID, Adhar card, ration card and what not as part of their KYC programme. Still,  when I go to open a RD “Sir, PAN card and photographs”, I want my mobile number to be incorporated with my SB account “Sir, PAN card and photos”, I want facility of net banking “PAN card and copies of photograph, sir”. I have fought with the bank clerk any number of times and have ultimately capitulated. Me -  “You already have everything that you are asking for under your KYC programme” .  Clerk - “Yes sir, but that file is with the head office and the system does not accept if I don’t scan PAN card and photos”. You can’t beat the system.

Today I went to the sub registrar’s office to register a power of attorney and the sub registrar wanted copies of driving licence, PAN card and two photographs.

The demand for my photographs is never ending.

This time I will have forty eight prints made. I will keep four of them in the bank locker and enter it in my will - to be used only when the attendant at the crematorium says “Adhar card copy and four passport size photographs please.”

I don’t think anymore photographs would be required thereafter.

Wednesday, September 16, 2015

Rain, Rain gauge And Ganesha Chaturthi

When we put up a fabricated structure to cover a part of our compound space, the fabricator had to leave spaces here and there to allow the electric wires, telephone cables and TV cables to pass through.  Rain water was flowing through these gaps and to prevent that we did some ‘Jugaad’ and managed to close most of them.  Still, one spot remained open and drops of rain fell into our portico. I managed it with another simpler ‘Jugaad’, which, in this case, is a bucket placed to catch these leaking drops. This bucket is my rain gauge. I empty it every morning and from the amount of water collected in this bucket I can measure the rain fall on my house as accurately as the meteorological department.  For most of this rainy season the bucket remained dry.  A week back the weather department announced that the monsoon has retreated and that the rain fall this season is deficient 25%. Tomorrow is Ganesha Chaturthi and I have hardly seen a rain free ‘chaturthi’ here. I thought this may be one.

Ganesha chaturthi is the most widely celebrated festival in Goa. It is a big issue here. From all points of view - religious, social, commercial and political. The bazaar starts buzzing with ‘chouti’ related activities at least a week or two before the festival.  These activities peak two days preceding ‘chouthi.’ There is a tradition of decorating the ‘mantap’ (‘matoli’ as it is locally known) with locally grown vegetables as also wild fruits, flowers and leaves.  In Ponda, the main bazaar road is closed for traffic two days before ‘chouti’ and the street is fully occupied by people selling and buying these things. It is called the ‘matoli bazaar’.  The bazaar began yesterday and it has been raining without break since then.  My rain gauge has recorded 3 cms of rain since yesterday. I hear that people are having a tough time shopping for the festival. The rain, which should have been welcome, is being cursed.

Since I hardly have anything else to do, we have finished our purchases days ahead of ‘chaturthi’ and I am now sitting waiting for my wife to finish her preparations and begin the Gowri pooja. I am the officiating priest and am under strict orders not to leave the room before I finish my task. I am sitting  snug enjoying the rain and using the time to type whatever occurred to my mind.

Goa badly needed rain and I heard that some people performed a ‘Yagna’ at the ‘Brahma’ temple last week.
They should have prayed for rains to begin AFTER Ganesha Chaturthi.


Friday, September 4, 2015

Teaching Dentistry - My Patient Education Programme

Most of my patients think that the ‘gum’ is a block of flesh and the teeth remain stuck in it somehow or the other. A tooth starts paining when a cavity goes deeper and touches the ‘flesh’ below.  A ‘filling’ is something similar to what a mason does. The mason mixes some cement and plugs a hole in the wall and the dentist mixes some cement (many may even be thinking that it is the same cement) and plugs a hole in the tooth. A ‘fixed’ tooth is somehow glued to the gum or tied to other teeth using some wires.  All these may sound idiotic to a dentist but I understand. My knowledge of an electric transformer or a petrol engine or a TV tube would be equally bad if not worse.  I should be least bothered about what my patients think as long as they get the treatment done and pay my fee. But I have a defect. Rather, I have many defects and one of them is trying to make my patients understand what the treatment involves. I spend considerable time and use a variety of teaching aids - a skull and mandible, plaster of Paris working models, plastic exhibition models, extracted teeth and on the spot drawings to achieve my goal. I give detailed explanations about impactions, dentures, RCTs, bridges, braces and what not and at the end, usually receive a bored expression and a blank stare for my efforts. But I persist.

My teaching aids. Ever seen a roadside dentist? His spread on the footpath to advertise his profession is exactly like this.

Recently we had an unusual case in the clinic where in a boy came in for braces to correct his alignment and the x ray showed an impacted canine (unerupted eye tooth stuck in the jaw bone) in the upper jaw. Since it could give rise to complications later in life and since it was mandatory to get rid of it before proceeding with orthodontic treatment (Braces), we decided to remove it. It was a big tooth, and it would have left a big hole in the jaw after removal. It would have taken a long time to close up. Hence, our young surgeon Dr Saurabh suggested that we remove a piece of bone from the chin region (lower jaw) and pack it (graft) in the hole after removing the canine tooth in the upper jaw. The procedure which can be called “extraction of an impacted upper canine followed by autogenous bone graft” was planned.

This is an X Ray of all the teeth in the mouth, known as orthophantamograph. OPG for short. Tooth C is the central incisor, L is the lateral incisor M  is the milk tooth and Ca is the impacted canine. In the normal course this Ca should have pushed the milk tooth out and taken its place. But it changed course, came between the two incisors creating trouble and forcing extraction (removal)

This is a CBCT (Cone Beam Computed Tomography) of the area marked in the other x ray. Something like a CT scan. Gives much more information than an OPG and helps in accurately locating the structures - in this case the canine. Makes the job a little easy for the surgeon.

Opened up the place where the canine is expected to be hiding. The 'gum' is not a mass of flesh. It is a tissue layer about 2 mm thick and covers the jaw bone inside the mouth. Two cuts are made on either side of the operation area and the gum is peeled and pushed up exposing the jaw bone.

The jaw bone is scraped off with a surgical drill exposing the impacted tooth lying underneath. What is seen is about one third of the tooth called the crown. The root, which is two thirds, is not exposed and is inside the bone.

The exposed part, the crown, is cut, separated from the root and taken out

The root as seen after removing the crown.
Root is pulled down into the space crated after removing the crown and is taken out.
The hole in the jaw after the removal of the tooth

What you are seeing here is the cut made to reach the chin bone. The cut is behind the lower lip in front of the lower front teeth 

The rectangular 'window' seen above the retractor is the place from which fragments of bone are removed for grafting.

Bone fragments (graft) placed in the cavity earlier occupied by the tooth

The cut behind the lower lip is sutured.

The cut made for removal of the impacted canine is sutured.
As a surgery it is not something great but it was the first time that such a procedure was being done in my clinic. I was excited as well as apprehensive. Cutting open the upper jaw was compulsory. Cutting the lower jaw was optional. Patients get jittery the moment a knife comes into picture. We were suggesting an extra cut which was not a necessity though beneficial to the patient.  The parents seemed to understand.  Saurabh as usual was confident. We did the extraction and graft. It took two hours. The boy bore it bravely. The parents were scared to look at the procedure and spent the time worrying, watching TV and napping.  It is a week since we did the case and the boy is fine. I had taken pictures at different stages so that I could explain the procedure to his parents and since I had the pictures, thought of posting them here. There is no reason why anyone should be interested in the gory details of my profession but you don’t know. This is an era where people are interested in gory details of everything. Whatsapp brings you all the gory details of an accident or suicide and TOI is full of a murder which took place three years back. This is far better. If you happen to be one of the interested, and have gone through the post, please let me know if you could make out what was done. That would help me rate my capabilities as a teacher, and if so mandated, put an end to my stupidity of trying to teach dentistry to my patients.

Sunday, August 9, 2015

An Irritation

Usually I try to accept this world as it comes. There are many things that I like and some that I don’t. But there is nothing much I can do about them. I try to appreciate and enjoy what I like and gloss over what I don’t. Some people, some attitudes, certain behaviours, some of the happenings irritate a bit more. I am sure that me and some of my actions are a source of irritation to many. We (I mean all of us in this society) usually share these likes and dislikes with those who have similar views and get it off our heart. I also put some of them down in this blog. They may not merit a mention anywhere but I feel better once I put it out of my head. This was one such irritation. Sorry for a grouchy post.

The referral letter said,

Dr Raghunandan,

Ref  Mr XYZ , with periosteal abscess for needful.  Treatment Given, Baycip TZ 1+1 and    
 Mahacef 200  1+1. 
Sd  Dr ABC

This letter was from one of my medical colleagues and was brought by a patient with a swollen face and tooth ache.

I have great regards and respect for all my medical colleagues.  It is a fact that they have a better qualification, a better understanding of the human body and its functions, and are much more capable in dealing with it.  At the same time it is also a fact that a majority of them hardly have any knowledge of dentistry.

(When I was in my final year BDS, there were a number of my higher secondary batch mates who were in final MBBS.  They were doing clinical rounds in various departments and they had a fifteen days posting in dental college. Usually the dental posting was considered a lean time during their grueling clinical schedule and it provided them with a chance to catch up on the morning shows in the ‘Apsara’ theatre next to our college.)

This patient reported to the doctor with tooth ache and swelling four days back. He was given Ciprofloxacin + Tinidazole. Patient returned after two days with increased swelling.  Cipro+TZ was discontinued and Cefixime started. Another two days and the patient came back with an even bigger swelling and unbearable pain. That was when he was shunted off to the dentist.

 It was an abscess alright but not periosteal abscess. We call it alveolar abscess. And evidently, both the antibiotics prescribed were not at all necessary and absolutely useless.

The patient spent four agonizing days and a considerable amount of money, which he could ill afford, on consultations and medications which were not at all required in the first place. A daily wage worker, he missed work and consequently the wages for all the four days.

I drained the abscess and I will have to extract the tooth sometime later. If I had seen the case first, I would have removed the tooth then and there and the patient would have been fine within a few hours and with two pain killers, if at all.

The doctor knew that this was a dental infection, did not have the required knowledge or skill to treat it but still attempted and persisted in treating it with medicines which were not at all indicated.

This is not a stray case. I am writing this after seeing many such cases in my clinic. I can understand a practitioner prescribing medications for immediate relief before referring the case to the right person. But I can't understand this persistance.

Why do they attempt/ feel compelled to treat these? It certainly is not ignorance. Is it the fear of losing a patient? Is it because they feel that it is a ‘mere dental infection’ and nothing beyond their capabilities? Is their ego coming in the way of referring the case to a dentist straight away? What is it?

Saturday, August 1, 2015

Nagesh Maharudra Temple at Nageshi, Ponda.

Our swimming pool is closed for maintenance since the last fifteen days and is expected to remain closed for another month or so. Some of us, the addicted ones, now infest the temple pond of Nageshi at Bandora, Ponda. I have visited Nageshi a number of times but the greenery of the rainy season, the overnight rain and the early morning fog had given a refreshing  new look to the temple and its surroundings. I was tempted to take some pictures and post them here.  

The washed road to Nageshi and greenery all around.
Early morning fog covers the hillocks surrounding the temple. The tower seen amidst greenery is the temple of Shantadurga. 

Abode of Nagesh Maharudra. The rainy season grass covers the courtyard, provides a wonderful contrast and adds to the beauty. 
The inviting waters of the picturesque temple pond.

The green surroundings and the fish in the pond provide a break for the pool users from the monotony of the blue ceramic tiles. It is a pleasure to watch the fish swimming under you. The bigger ones which are capable of biting your fingers off  remain stationary at the bottom and stay put till you stretch your hands.

And if you are lucky you may even find a colourful water snake keeping you company. They are supposed to be harmless and non poisonous. (Till they bite you!) My friend Triambak was the lucky one yesterday. 

Another view of the pond

Monday, July 27, 2015

Ashaadha Ekaadashi

One of my friends on FB wanted to know about the importance of Ashadha ekadashi .  I did not know either. I felt that whether I follow our religious practices or not, I should have some knowledge about them. Searched the net, used whatever brains I have and came up with the following information.

A day in the life of gods is a year for human life.  The ‘Uttaraayana’ and ‘Dakshinaayana’ which are of half a year duration for humans are the day and night for gods.  Dakshinaayana is the night part. It begins in the month of ‘Ashaadha’ of lunar calendar. That is the time when lord Vishnu goes to sleep or ‘Yoganidra’. He is in Yoganidra during the first four months of Dakshinaayana  which are collectively called ‘Chaaturmaasa’.

We have a goddess responsible for day and another for night. I believe the goddess of night was unhappy that no auspicious activities were taking place during her time and felt that there was no need for her to exist.  Her sentiments were conveyed to Lord Vishnu. Lord Vishnu felt bad about it and assuaged her feelings by declaring that the benefits obtained by worshipping him during chaaturmaasa would be in multiples of what one would get by worshipping him during other times.  
Since Ekaadashi is considered the most auspicious for worshipping Lord Vishnu, Ashadha ekaadashi, the beginning ekaadashi of chaaturmaasa acquires greater importance.

Wearing the symbols of Lord Vishnnu namely the Shankha and Chakra, called the ‘Mudras’ is a must during worshipping lord Vishnu. Hence the followers of Dwaita philosophy have these symbols put on their bodies from the heads of their respective religious organisations on ashaadha ekaadashi. This process of preparing for the worship is the ‘Mudraadharana’.

I got the information I wanted and should have kept quiet. Now what made me write this and torture you?

Out of a whim, I decided to fast on one Ekaadashi day few years back. (What is so great about fasting for a day? I can as well do it- feeling) I decided to fast for 24hrs, remained without food since morning and was miserable by evening. I could not think of anything other than food.  I gave up, had my food and slept. Then I took it as a challenge but did not have the guts or willpower to try another 24 hrs. So I decided to partially fast half a day. For the past few years I have been successfully following it. It is not a fast actually. Can call it disciplined eating.  I have a cup of coffee and two biscuits in the morning, Some snack at mid day and end it by 8 pm. But strictly no tit bits which I otherwise keep popping into the mouth the whole day. Still it is difficult. I can manage fairly well if I am totally occupied in the clinic or elsewhere. If I have nothing to do it gets worse.

It has been raining since two days and there are hardly any patients in the clinic. And today is ekaadashi. By writing this I could keep myself occupied for more than an hour.  Another half an hour and I am done.  What started as ‘ekaadashi’ has turned out to be ‘Roza’. 

Monday, July 13, 2015

Concern or Interference?

The little girl hesitatingly followed her mother into the clinic.
“She has tooth ache since three days”
I asked the child to sit on the chair and just as the girl attempted to climb on to it, her mother lifted her and placed her in the chair. I went closer and bent down to address her.

“What is your name?”
The child was shy and took time to answer.
“Tell me, what is your name?”
“Her name is Tanvi”  - The mother intervened.
I ignored the mother and addressed the child again.
“Which standard are you in?”
“She is in third standard” Mother.
“Which school do you go to?” I tried to engage the daughter in conversation once more
She began falteringly “ I … I….go to Vidya…” 
“She attends Vidya Vikaas High school” -  The mother

I asked the mother to allow the child to speak. “You tell me” I asked the child again “which school do you go to?”
“Vidyaa Vikaas primary section” came the correct answer.
“Does your tooth hurt?”
The child nodded her head in answer.
“Which tooth?”
Again, the girl took time to reply. The mother could not hold back “See, this tooth” She tried to pull open her daughter’s mouth to show me the tooth.

I called the mother aside.
“Madamme, I can understand your concern but please allow your daughter to interact with me. It is important if I have to treat her.”
“But I am afraid that she may not explain things properly. She doesn’t know what to tell you and forgets everything.”
“That is Ok. I will manage and if I need your help, I will certainly ask you.”

I addressed the child again. “Which is the tooth that is hurting”
The girl pointed to the offending tooth. 
“Does is hurt always? All through the day?”
Now she answered. “No. It hurts only when I eat something”.
“Shall I see the tooth? Please open your mouth”

I examined the child. Told her what I intend doing and asked her if she wants me to treat her.
She nodded again.
“I want you to say it aloud.”
“Yes” came the answer.

Then I fixed an appointment and noted it down in my diary.
Now I asked the mother. “Please give me your telephone number”
“Mobile or land line?”
“Whichever, Some number to contact you if required”
“8873…….  No, 88763……. I am sorry, 88673…….. ‘Che’, 98673……… one minute” she opened her bag and tried to find her mobile phone  “oh, I forgot to bring the phone also.”
The child pulled at the mother’s saree “Mummy it is 8867..”
“You keep quiet, don’t interrupt me now”
 “Forget it” I said.  “Note my number and call me from your phone. I will get your number. Give me the landline if you can.”
“Ok. 2314….. Sorry, 2334…… Oh god, we changed it recently and I .……”
A shrill voice rang out confidently and clearly from her side, “8867345342 and 2314563.”
I looked down. The child was beaming .
“Good” I exclaimed and looked at the mother. With an effort I held myself back from saying “See, she can do much better than you”

“I always forget the phone numbers” The mother tried to cover up, sheepishly, and walked out hurriedly pulling her daughter behind her.