Amma Ponnu

It has been about a month that I have been living in anna nagar, chennai. On my evening walks a pair caught my eye. This is a posh locality where spending ability is much more than the average. With affluence comes poverty, as the not so fortunate flock to the temples churches and hotels stores hoping to get some loose change, which can buy them a meal. Euphoria of blowing a couple of hundred or even thousands lasts longer than the taste of Buhari biryani in the mouth. As one walks out a mixed group reaches out for alms. There are elders, single women, specially abled, kids and a microcosm of society earnestly beseeking.

A mother sat quietly accepting the little that passerby handed in. I didnt first see the little figure adjacent to her, who appeared to be a downs syndrome child about 15 years old. Downs syndrome is a spectrum with variable IQ levels. This child was obviously quite low in her mental capabilities. Mother kept her very close and saw to it that her needs were provided for. When the mother begged for alms, daughter joined in repeating the lines she saw her mother use.

As a principle I dont give money to the le miserables. I stopped and observed them. They were dressed shabby, had obviously not washed in a while but looked well nourished. The moment our gaze met, both of them pleaded with me to help. I asked if they had eaten, mother replied in the negative. Daughter chimed in too. I gave enough to buy them a meal for the night. They bought dosa from street vendor and enjoyed the fresh snack. I walked away with some happiness in my heart. Next day they were near a temple. We recognized each other. I helped again.

On christmas eve as I was strolling the decked up street, two of them caught my notice. Both wore a santa claus hat that seemed ironic to me. Even if one had to beg for a meal, the festive season brings joy to all. After the shop shut by 10 pm, saw the two of them going home with mother leading her 15 year old treasure. Both in santa claus hats.

Why does such poverty exist? Is it their fault that they didnt get a chance to study? Why should one beg to get the basic 3: roti kapda makan? What would have happened if they had shiksha sehat? Any decent society should provide free education and health to all. With a basic education, this mother could be taught basic skills to run a micro business that can earn her enough to not beg. Access to healthcare would help her daughter, who with time will need more of her mother. As the two of them trudged along, after a obviously good evening to rest I followed their path with moist eyes.

Merry xmas amma ponnu :)

Health Informatics - how she bewitched me

18 years ago frustrated with the heavy workload in my ED - emergency department in Al Ain hospital, Abu Dhabi (350+ patients/ day) in the single govt hospital where all emergencies were brought and the lack of process or much career progression in emergency medicine I reached a dead end. With clumps of hair falling off in adrenaline driven stress related alopecia areata the writing on the wall was clear; pause or perish. Internet had just arrived in UAE and I was playing happily like a child with a new toy, exploring its new capabilities that it opened up. Once it became clear that this is a new frontier opening up, I dived in with joy. After a hectic night duty with my eye lids half closed, I headed to computer science classes and learnt VB - visual basic and Microsoft Access. Building my website in HTML typed on notepad I came the traditional way into software, not as a fastfood generation that has everything served up on applications. Frontpage, Dreamweaver came much later but when the capabilities of application limited my creativity, it tool a flip to enter the familiar HTML world.

After a few months got called to the court to explain to a judge why a patient I certified dead was alive. On digging a bit deeper, this perennial problem surfaced again and again. When police found an unidentified person or dead body they either wrote Mohamed or left the name field blank while registering on paper form in the ED. Hence rest of documentation followed as Mohamed. We wrote death report for the name entered in the A&E - accident and emergency registration. I had to give the explanation in writing to the court. CAPA - corrective action was done but I wanted to fix it with preventive action. I went to my HOD Dr Taha Ibrahim FRCS with a proposal to digitize the ED. Dr George Bell a canadian olympian was our medical director who had introduced computers into the hospital in 1997. Except for regular office typing work and printing out discharge summaries it was sparsely used. Dr Taha allowed me to proceed and allotted some funds. I got three PC - personal computers into the department, discovering they lacked networking I got network cards and inserted them myself. We had an intranet of 3 PC. With my VB/Access skills I designed and coded the UI for a simple A&E registration form and deployed it on the intranet. There was a huge waiting list in the ED, even after triaging much of the patients to allow only medical emergencies into the ED. On close study the bottleneck turned out to be in few places viz., registration, clinical documentation and the mandate from MOH - ministry of health that only the treating doctor should fill all lab orders. At a minimum each patient had to get CBC, RBS, Electrolytes, Urine, Chest Xray, ECG which of course increased many fold when other tests became necessary. My answer was to create a label with the mandatory data/ barcode and print it on self adhesive stickers. We printed a set of 10 to begin with and the regsirtation clerk would staple it to the ED one sheeter. Nurse would then just peel of the stickers and affix them on the requests and also sample tubes/ containers. Suddenly the waiting list disappeared in the ED and our patients TAT-turn around time came down dramatically. We were able to count the number of ED attendees with confidence now. On presenting the daily number of patients attended to in ED to management, they refused to believe us. I held my fort and said 'data never lies'. After multiple checks they confirmed the massive numbers we were handling with not a single miss, so far. Next month the A&E workforce was doubled.

This made me think, if I could achieve this by learning technology after night duty in half sleeping mode how much more could I do full time. Being a military school cadet, I was fortunate to be adopted by Prof Khalid Moidu, a legend in the medical informatics world with a PhD from Sweden and veteran from AFMC-armed forces medical college. On his advise I got myself the bible of Medical Informatics written by Prof Ted Shortliffe,  a doctor with a PhD in computer science from Stanford University. His PhD thesis MYCIN in 1950s literally launched the AI - arificial intelligence stream which now is a gushing torrent. Interestingly MYCIN was a proven technology to pick antibiotics in the ICU but healthcare killed it. Nevertheless all other domains gladly adopted AI in telecommunication, banking, finance, insurance, aviation, transportation, energy, media, etc. When I got a chance to meet Ted in 2006, I asked him as to why this happened. His answer is etched in my mind for posterity: 'Human will always be supreme'. MYCIN was compared to highly experienced intensivists decisions, it turned out to be far superior as it was always objective whereas the human was subjective. When it was pitched as replacement for the human, they human killed it. Unfortunately the same mistake continues to be done today with all HealthIT solutions. IBM Watson for all its strength still is frowned upon by humans. All technology should be slave to the Human and never positioned as an alternate. Millions of years of evolution and survival ensures we win, always. After much reading, pondering on a mid career domain shift, deep discussions with family and rearranging finances it was decided to complete a Masters in USA/UK. Next few years went by so fast until I joined GE Healthcare as Clinical Director for South Asia based out of the global star facility JFWTC - John F Welch Technology Centre, Bangalore.

Like Brecon (Brecon Beacons national park) the silent beauty that the welsh have kept a secret for millenia Health Informatics remains an enigma for those who glance at her. If one has the courage to tame this wild beast and ride her, she coyly unravels her secrets. It is left to ones imagination to use her ananth (infinite) capabilities as one pleases. Being an 'Acute Care Informatician' my quest is to have her floating in the skies of my acute care environment (ED-ICU-OT) wafting into every nook and corner like perfume. With her by my side, the acute care environment shall be a much safer, nicer and predictable experience, when patients literally entrust their lives in our hands.                

65+

life begins and ends in shoonya. we start as babies fully dependant on others to care for us as our body-mind are still continuing their development till about 5 years. 65+ man returns to where he started, as hindu dharma declares to be a child again. visited a much respected leader who lived as a king, made sure all who came in touch grew to their fullest potential, happiness smiles joy was his gifts to so many, my family including. i saw him now 86 years old, unrecognizable but for the sparkle in his eyes that lit a million lives hearth. sat with him, tried in vain to get a conversation going but all i got was a smile behind which there was sadness. long term memories are retained by brain, so when older topics came up, he lit up. now and the future are not his forte now...past is a time warp in which he is ensconced. his family tried in vain to care for the carer who gave many lives a reason to live and prosper. they cant fathom the deep emotions that must be running in his mind, when eating sleeping or just sitting is a huge task. love is all one asks, few are fortunate to get it..many dont and silently leave with nobody watching. money wealth fame gold food drink entertainment power sex...all that which roared in youth like a hurricane is now a distant memory. mind sails a much calmer sea...eating to live, sleeping to heal and sail, till the day comes to adieu.

as i work in ElderCare for 16 years now, thanks to GE Volunteers who made me medical officer for LSP-little sisters of the poor [ https://www.littlesistersofthepoorindia.org/bangalore-st-joseph ] hosur road, Bangalore in 2005, every interaction is humbling. one learns to see life with respect love compassion as nothing lasts forever. this too shall pass...

healer by heart

when a bunch of kids came together in 1985 to study medicine, little did we realize that long after we started we would forever stay frozen in time here. One of us was the healer with charm compassion and smile on his lips, dr vd umashankar. We all went through the grind of an academic mbbs with minimal skills focus but macaulayean rote learning of mostly old redundant information that was irrelevant in 1985 itself, leave alone today. After acing final year exams it was time to play doctor and we ducklings waded into water guided by many well meaning seniors and teachers. USA UK Australia remain sinkholes for all top talent, a curse India endures to this day. After passing PLAB and IELTS dr umashankar was posted across NHS England to learn the ropes of Acute care medicine. His unique ability to feel his fellow human's pain, be it a patient friend family or total stranger kept him from chasing his other passions. Uma was a polyglot dabbling in Tamil poetry prose drama singing (iyal, isai, nadagam) apart from being an entrepreneur from early on. When we were preparing for pg entrance exams uma opened his first business to explore the market. His native insights kept him floating for a while but sharks ensured his fledgling venture folded. Nevertheless uma qualified as an anaesthetist and worked mostly in some of the largest teaching hospitals in south England. Southampton, Bristol, Merthyr Tydfil, Swansea, Swindon were his training grounds. Uma specialized in cardiac anaesthesia from Cleveland clinic, USA to work in cardiac sciences for two decades. When patriotism brought him back to Chennai in 1996, little did he realize deja vu waiting for him. I had the fortune to sit through many deep dives with him, where he refused to accept that business needs to be profitable to sustain. He built a hospital that was on par with the edifices he trained and worked in while at UK USA. When we attended his hospital inauguration, we could only marvel at his brilliance in bringing India to Bharat viz., best of healthcare to a small town. His patients included many of us, who in his noble eyes were all equal; just humans in pain, to be healed. Sincerety dedication sharp clinical skills and 100% devotion meant an army of fans, of which I am astonishingly one. Which UK qualified intensivist would sleep on attenders cot to bring back a patient from jaws of death, for uma it was just another day. The sharks that ended his earlier venture smelt blood and started circling him. Some of us privy to his work and thoughts saw these sharks and warned him. A mother defended her baby from a tiger with just a stick in Indian folklore. Uma saw his patients as his brood and fearlessly continued his healing mission. When he least expected it, a great white lunged at him taking him out of the water and ending a 54 year old story. Those of us watching from sidelines could do nothing but cry. Dr Umashankar, a legend, the likes of whom are like the kurinji flower, blooming rarely but leave a gash deep in our hearts. Adios my friend, we learnt from you how to have only the patients welfare in mind when confronted with myriad options. Acute care medicine is poorer today uma, your patients lost their saviour. Soldiers give their today for our tomorrow. Doctors sacrifice their youth in training,  for their patients. Dr Umashankar gave his life, till the end remaining a true healer.

Dr Thanga Prabhu: Acute care medicine, Health Informatics, Digital Health expert. mbbs classmate of Dr VD Umashankar aka ums aka umasha :(

Jack n Jill

As I walked to Yercaud foothills a nomad passed me with his brood of ducklings, moving as one large amorphous amoeba. Just hatched, probably few days old nevertheless cuddly little fellas cute as all newborn are. I decided to get a pair and after a bout of haggling had Jack and Jill in my hand. It feels nice to hold life in one's hands. Being an ER doc I get to hold the dead many times and it aint easy. Many nights the thought of the cold hand haunts me endlessly, who once would have lived like the rest of us. I quit active practice as I couldn't handle the emotional turmoil of seeing people dead, if lucky in one piece. ER work is battlefield work, nothing easy about it. No matter how much one prepares for the shift, it is annoyingly novel every time. The feeling of a bird held in hand is how foetus moving in the belly of a pregnant mom is described in medical textbooks. Being the unlucky sex, we men can only plant seed but it is left to the female to nurture and grow a life. As I held these two fellas in my hand, it reminded me God exists.

At home a cozy home was identified for the ducklings. An unused bird cage which saw 30 pigeons breeding actively was soon home to our babies. As I walked in to my house Brownie our dachshund was curious to see the contents of the bag I held in my hand. I decided to introduce Jack and Jill to the master of the house Brownie. As I lowered the bag for brownie, he lunged at it as if I was offering a gift to him. I should have recognized the hunter turning on in him, alas it slipped my mind.

After settling into their new home with fresh water to drink and some rice to eat, Jack and Jill announced their arrival with a medley of kee kee kee. The baby sound ducklings make till they learn to quack kept us company for many days. My elderly parents who always bred hens, cocks, pigeons, ducks, turkeys were overwhelmed with joy to hold the lil fellas in their hand.

After an hour there was silence from Jack and Jill. I went to check on their wellbeing. Surprisingly both were missing from the pigeon hole that we had placed them in. Being babies, who are curious and inquisitive by nature they had decided to check out the rest of the coop. I closed the main door of the coop behind me and started looking for them amongst all the stuff that had crept into the coop, serving as a store now. 

Brownie was furious that I had ignored him and not utilized his services to find Jack and Jill. His incessant barking with ears upright and tail pointed straight out was clear he was ready to serve his master, me. Or that was how I interpreted it then. He was actually hunting. In an earlier encounter Tiger his predecessor had sniffed out Nag, a 5 foot hooded Cobra in our garden and ensured my dad came nowhere near it with barking and display of his canine protecting his master. Eventually that snake was dealt with safely. Expecting a serpent I opened the coop door.

Hunter Brownie went straight for the jugular of one of the duckling, grabbed it and ran away. Before I realized what had transpired he had enjoyed the snack and came trotting for second helping. I disciplined him and tried in vain to explain to a hunter the morals of going vegan. 

Dont know if it was Jack or Jill that survived this onslaught but after much searching found the survivor very quietly hiding in a nook. I gently extricated it and shifted to a safer place with strong mesh all around. Duckling was happy though it must have missed the brood that were its siblings and till recently his partner. Brownie was always sitting outside the cage like sphinx in rapt attention watching every move or noise it made. Life went on for the singleton with Brownie the bad boy eyeing it and desperately clawing away to reach it. One fine day there was silence in the cage. I found to my dismay my little baby on her back, probably dying of cold.

Jack and Jill came down the Yercaud hill,
Jack got eaten, Jill survived but in a few days joined him in the yonder.

Life goes on...  

Patient Safety: JC, NABH, NABL

JCAHO has officially been renamed JC. Short and sweet to remember. All stakeholders from patients to healthcare providers can now benefit from the easy to use, simple guidelines. I like the Patient Safety  area very much. [ https://www.jointcommission.org/resources/patient-safety-topics/patient-safety/ ]

Quality in healthcare delivery is not an option but essential. Even the healer can be a patient at times and that is when it hurts really hard. Medical equipment, technology, software are tightly regulated to assure 'Primum Non Nocere' - physician do no harm. Quality is a mindset beautifully exemplified by Toyota corporation with their TQM-total quality management philosophy. For a Japanese company to learn automobile technology from USA and Europe and replicate it in the Japan of 1945 that was emerging from the second world war with a clean reset was a moment. The Japanese penchant fro perfection be it in the art of tea making, ikibana (flower arrangement) or calligraphy flowed into industry. Quality was the single big factor which took Japan to world stage and compete with the likes of GM-General Motors, Mercedes Benz, BMW, Audi renowned car makers. TQM ensures quality assurance throughout starting from sourcing components from many OEM-original equipment manufacturers, to shop floor assembly, delivery and service. Medical equipment have top quality, does the system have even a fraction of that? Fact is no. If we get to bottom of the issue, it truly turns out to be gordian knot.

JC [https://www.jointcommission.org/], QCI-NABH [ https://www.nabh.co/ ], QCI-NABL [ https://nablwp.qci.org.in/ ] accreditation assures the end user of TQM in healthcare.

Life can be so ephemeral - Death and beyond

 A few days ago I got a call from a person whom I hold in high esteem. His adult daughter had just passed away at 0230 hrs early morning. There was history of diarrhoea for three days after consuming hotel food, delivered by a food delivery company. Few questions kept popping up in my mind, after helping him face this unbearable loss and navigating a quagmire of unnecessary and repetitive processes. Corruption rears its ugly head to benefit from an emotionally labile condition that prevails. Looking at the workflow involved from the time death is suspected, multiple points of improvement were obvious to improve, all the way to support for grief.

1. Role of emergency services
2. Can food poisoning or Cholera kill in a short time (few days)
3. The Death identification, confirmation, certification process in India
4. MLC - medico legal case implications for death at home, autopsy procedures
5. Funeral arrangements
6. Grief/ Bereavement counselling

FHIR-fast healthcare inter-operability resource

FHIR came from Australia out of the frustration of complex HL7 ver 3.0 and RIM-reference information models. Fast Healthcare Interoperability Resource would allow a dunce like me to plugnplay. All complexity hidden from me, why do I want to know how many people built my car...all i want is my chevy. UI is also moving in this direction, so much so mommies play nursery rhymes on tablet/smart phone and jr soon knows where to dribble or soosoo to stop the annoying nursery rhymes. God it is bad enough being born to working parents, they expect jr to do all they dreamt but failed. IIT to start with....So when a baby can use tech, it should put people to shame saying hum pichle zamaney ke hain. Drs r famous for being technophobes but for anaesthetists whose danda runs on knobs and gases. FHIR is a God send but Graham the inventor probably is afraid of the big HL7 mothership and says it is still beta. We have HL7 India leaders in IAMI, guess they have had a chance to peek under the sheets. Pls share what u see or don't see, need to know both.

Hearing from folks on the field that the basic 'Z segment' tail continues to wag the HL7 dog in FHIR too. It is just a easier way to talk to systems using API calls and SOAP-XML but the basic HL7 design has to be revisited. RIM was an approach to get design out of the equation in creating a reference information model. Problem is it turned out to be a bigger monster that layety found difficult to grasp.

Only good thing that has happened is CDA-clinical document architecture. It is Case Record clinically high fidelity with XML running under-hood for system to system communication. CCD-continuity of care documents builds with CDA to create an EMR that can be strung together as a EHR.  

community citizenship

Hindu culture segments life into 4 phases; Baliya,  Brahmachari, Grihasta and Sanyasi. Upto 12, 25, 50 years of age you progress to renounce physical world and live a life of detachment beyond 50 years of age. Notice the doubling and the fact that 50% of life should be for community/society. All great men have done this viz., Jesus, Buddha, Mahavir, Guru Nanak, Ramanujam, Shankara...Simple life with great thinking marks the few from ordinary mortals.

My dad has always lead by example, I am one of his chelas. Sharing your joy with others, that too those less fortunate who are neglected, alone, hungry and deserted multiplies it manifold. My decade with GE taught me the power of education, there can't be a nobler charity than teaching. He distributes food and clothes but I insisted on reading/writing material. While shopping in Vashi Hypercity was approached by college students volunteering to raise money for a cancer child patient. Gladly helped them. Crossword and Landmark setup shop offering learning pack for Rs 100 (colouring book, pencil, eraser) once paid for by a patron to distribute amongst Kamatipura children. Kamatipura is famous for prostitution, the book pack is for their children who came into this world as a byproduct of someone's pleasure. Life is difficult for these poor souls who earn a pittance for working 18+ hours 7 days a week with constant fear of sexual disease, violence and exploitation. I donated willingly to help these children who grow up hearing and seeing their mothers being abused daily. Went on a shopping spree for my young brood, picked up colouring books, crayons and a cap with India flag. Dad distributed rava laddu and samosa, I gave out books and crayons. My gift will last a long time and of the 30 many will become IAS, IPS officers, DRs, teachers who will remember the uncle who gave them these gifts. I want to bring digital education, oops before that English, Maths skills so they confidently walk tomorrow's stage.

With my dream growing we left, content 30 children will snugly tuck into bed with hope, knowing there are still a few left in this world who are happy in giving rather than taking.

Tamil Nadu - Healthcare role model

My heart swells in pride to shout at the top of my voice that TN-Tamil Nadu (where I was born) has been declared a ROLE MODEL for Healthcare by WHO circa 2014. [http://www.deccanchronicle.com/140808/nation-current-affairs/article/tamil-nadu-healthcare-role-model-world-who] The reasons behind this success are uniquely Indian, which I dissect here. What happens in TN can/should happen in the ROW-rest of the world too. The load is heavy but with each of your shoulders we will lift healthcare, locally then globally! 

Centrally purchasing drugs with a robust IT system in place gives purchasing power to drive down costs. Enforcing quality generic drug usage within the system weeds out corruption and unholy nexus between prescriber and manufacturer/supplier. Local empowerment and ownership makes the PoC-point of Care autonomous. Local manpower have sense of ownership, which anyway is high in rural settings. Urban living unfortunately forces strangers to live side by side. Participatory leadership with everyone clearly seeing the cathedral that is getting built means there is pride in the work done. Banavaram [ http://www.thehindu.com/todays-paper/tp-opinion/a-model-that-delivers/article4477096.ece ] and Nandivaram [ http://www.thehindu.com/news/cities/chennai/health-centre-near-chennai-achieves-over-100-rise-in-births/article5437244.ece] are examples of such work. 

Tamil values system put in place in ancient times, effectively reinforced (by the likes of Tiruvalluvar) at frequent intervals has given the Tamil a unique rigmarole of living a disciplined life. Modern distractions do swing aam aadmi away to frivolous pursuits such as fast food, malls and never ending wants to keep the market based economy humming but the values are there, if one wants to uncover. I believe in the uniquely Indian-Hindu concept of life in 4 stages - balya, brahmachari, grihastha and sanyasa. If man lives a 100 years 12, 25, 50, 100 are the milestones for which one has to prepare in every stage. Notice how the periods double but the thing that caught my eye was that you should renounce worldly living by 50 and spend half of your life for Society. True wisdom emanates from one who has no want...Buddha, Mahavira, Jesus, Gandhi are all examples of this. This was practiced by all in ancient times, even by the Great Emperor Chandargupta Maurya, Emperor Ashoka's grandfather. He renounced his throne to come and live in Sravanabelagola (in Karnataka today) where a hill is named Chandragiri after him. How much discipline it must have taken for one to give up an Emperor's throne to live the life of a mendicant?