Hiccups

One of the most non-specific conditions for a physician to treat is hiccups (singultus). They usually have a very obscure cause and at times can underlie serious diseases.

A young man (non-diabetic/non-hypertensive) diagnosed with malaria presented with tiring non-stop hiccups. He was investigated three days back and the peripheral blood smear demonstrated vivax parasites. He was on artesunate along with other supportive care. He came at 11pm in the casualty and complained that his hiccups were non-stop, present since afternoon (post-lunch) and had caused him considerable exhaustion. He had no other complaints.

Luckily, he responded to injectable metaclopromide within minutes.

Another patient presented with features of gastric acid reflux disease and exhausting hiccups. However, his chief complaint was acidity, from which he wanted immediate relief. An intramuscular injection of rantidine allayed his acidity, but hiccups continued. This man was otherwise normal. I thought of giving him dispersible domperidone tablets; his hiccups stopped 10 minutes after keeping the tablet under his tongue.

I read up few papers on hiccups, their cause and treatment. Most of the literature has treatment based on trial and error; others consist of success stories (such as mine) without much backing. There is hardly any paper which does not mention remedies put forth by folk medicine. In fact, this adds spice to the otherwise boring allopathic life.

Folk medicine has described various home-remedies to get rid of hiccups – from ‘gulp down two teaspoons of sugar’ to ‘have someone startle you with a loud boo!’ Indian folk medicine also prescribes various techniques such as drinking ice cold water or pressing one’s eyeballs gently. Pulling one’s tongue has been suggested as a good alternative. They probably have a scientific basis (like pressing one’s eyeballs stimulates vagal activity).

Good old Harrison does not have much information on treatment of hiccups. Adam’s & Victor’s Principles of Neurology (8th edition) mentions baclofen for persistent cases. Bradley Neurology in Clinical Practice does not mention anything specific. Goetz textbook of Clinical Neurology (3rd edition) has arguably the best line of management:

1. Chlorpromazine 25 – 50 mg IV or 50 mg per orally
2. Metaclopromide 10 mg IV or 10 mg per orally TID

Some published papers provide excellent views (historical and current medical) on hiccups. There are charts on various drugs that are effective (including atropine) and many authors have given protocols for treating intractable kind of hiccups. A case study is the most interesting of the lot – it’s about a man who was instantly relieved from persistent hiccups after a sexual intercourse!

Suggested reading:
1. A paper from British Medical Journal – ‘Management of Intractable Hiccups’.
2. A historical note on hiccups.
3. A paper describing various causes of hiccups.
4. A case report describing sexual intercourse as a potential cure for intractable hiccups (wow!).

A Night in Casualty

Night-shifts were a part of our EMR (emergency medicine registrar) posting and we thoroughly enjoyed them. We liked the kind of work that was assigned to us and were also able to understand how patients should actually be managed in an emergency setup. Besides, it was one month of legal 'night-outs' - with very little or no work after 3 am. After 3, it was five hours of complete non-specific gossip and nonstop laughter. Missing those days [:(]

A night in the Casualty is never like that in the EMR. You feel like a hermit trapped in a forest from where you can’t escape. You are doing nothing, just issuing ‘case papers’ and not even remotely concerned with the patient management. This was how life was in the last week:

After a long OPD in the morning where at least five multi-drug resistant tuberculosis (MDR TB) patients coughed on my face, Casualty was next on the list. There are usually two interns at night in the Casualty, unless of course one decides to escape. Luckily, that didn’t happen. We were two of us; the Casualty Officer allowed us to divide and my co-intern went off to sleep at 12 midnight. He was told to relieve me at 4.00 am.

Soon after he left, the horrid exodus began. One after the other, patients arrived and demanded immediate attention. I was examining a kid who was down with fever. Since he was really young, I was dealing with him first as you can never take chances with paediatric patients in the casualty.

There was no looking back – entered a lady with a breathless kid in her arm. The kid was only 3 months old. Rush! A woman with severe giddiness was brought by four relatives. Each relative was holding a limb – they didn’t even care to arrange for a wheelchair. A young married girl entered with a deep cut on her wrist, exposing her tendons. Obviously, I realised that it was a suicide attempt; her scared husband was dangling behind. Hesitation marks around the cut were confirmatory. It was a police case and the Casualty Officer was busy noting down the details thereafter (I had to wake him up!).

A hefty middle-aged man arrived with a towel covering his ear. The towel was soaked in blood. He had a fight with a guy in his neighbourhood sometime back. The fellow with whom he fought took a knife and chopped off half his ear. A lady in her forties came with a deep gash on her palm. She claimed that she cut herself while peeling an onion. I couldn’t believe her story because I did not find any reason why a female should peel an onion at 2.00am. Anyways, there was no time to argue with her.

There was a loud noise outside. It was the siren of an ambulance. Correction – there were three ambulances carrying accident patients. Within seconds, there was a flurry of footsteps and wheels of a trolley were heard clearly. A man was brought with multiple fractures on his left leg and a head injury. As I got up to examine him, another trolley was brought in, with a woman in a really bad position. She was trolley no. 1’s wife. As soon as I saw her vomiting blood, I handed the police ‘pink slip’ and she was immediately escorted to ESR (emergency surgery registrar).

‘Pink slip’ is given by the Casualty doctor to any patient needing immediate attention. For patients who are really critical, where one can’t waste time issuing a ‘case paper’, pink slips are used.

Next second, another wheelchair was dragged in the casualty. It was the third accident patient, involved in the same mishap. He was bleeding profusely from his skull. A young boy, around 17 came with his friends. He had fallen from a staircase and an iron rod made a 3 – 4cm hole in his lower back. A girl hurt her eye while playing with her friends. Her friends threw a stone that hit her left eye causing a grievous injury.

At 4.15am, I couldn’t sleep. I was in the hostel room with darkness all around…

[…looking forward to ESR where I’ll play a role in patient management. I hope I get the same (/kind of) co-interns like in EMR.]

The last Laugh

Some people can really get on your nerves. They can be so uncooperative and selfish that you feel like digging a hole in the ground and pushing their heads into it. Worse still, you feel like giving them an injection of rabies virus intracranially.

I was good with them initially. They started taking undue advantage. Now begins the fun. Some people deserve a taste of their own medicine. It’s going to be a nice week ahead, with six of us hell-bent on making their life miserable. Heh heh… you uncivilised asses, you’ve had it.

Don’t trouble trouble, till trouble troubles you.

Few Good Things…

This week in EMS was better than the last.
1. I managed to put an intravenous cannula in almost all patients in one prick. Even in a person who was convulsing.

2. I almost put a central line. Of course I needed help.

3. I managed to avoid needle stick injuries. That reminds me – I’m yet to take my booster for hepatitis B. Shit.

4. I’m lucky I have good co-interns. We divided the work and so that each one of us could sleep for at least an hour every night in the side room of EMS.

5. There was a huge raada in the casualty one night. The next day, there was a fight amongst the interns posted in paediatrics and EPR. Its fun to watch people fight.

6. I learnt (read: memorised) few sentences in Marathi. “Arre gap bas. Ek sui lavaychi aahe.”

7. We agreed to teach a police security guard how to collect blood. In return, he promised to save us in case an angry relative decides to wring our necks. However, the deal didn’t materialise.

8. We learnt how to use the police walkie-talkie. It’s a fun thing.

9. I’ve had at least a kilo of ice-cream this week. EMS is cool!

10. A friend of mine agreed to pole dance on my funeral, whenever it happens. According to her, that will attract at least some people to attend the ritual.

50 Questions

(More meaningful posts after 6th April – this is just to keep the blog alive)
1. ONE OF YOUR SCARS, HOW DID YOU GET IT?
I don’t have any

2. WHAT IS ON THE WALLS IN YOUR ROOM?
Nothing. I like it clean

3. DO YOU KNOW WHAT TIME YOU WERE BORN?
Yes. 8.15 am. Breakfast time!

4. WHAT DO YOU WANT MORE THAN ANYTHING RIGHT NOW?
Direction

5. WHAT IS YOUR MOST PRIZED POSSESSION(S)?
Family

6. HOW TALL ARE YOU?
179 cm

7. DO YOU GET CLAUSTROPHOBIC?
Nope

8. THE LAST PERSON TO MAKE YOU CRY?
My dad

9. WHAT'S YOUR WORST FEAR?
Being there all alone

10. WHAT KIND OF HAIR/EYE COLOR DO YOU LIKE ON THE OPPOSITE SEX?
Black eyes.
Black hair.

11. COFFEE OR ENERGY DRINK?
Umm… Coffee

12. FAVORITE PIZZA TOPPING?
Can’t decide…

13. IF YOU COULD EAT ANYTHING RIGHT NOW, WHAT WOULD IT BE?
Strawberry with cream

14. FAVORITE COLOR OF ALL TIME?
Red

15. HAVE YOU EVER EATEN A GOLDFISH?
Never. Yuck.

16. WHAT WAS THE FIRST MEANINGFUL GIFT YOU'VE EVER RECEIVED?
When I was a newborn. My sisters chose a very tiny and a-traumatic rakhi.

17. DO YOU HAVE A CRUSH?
Yes

18. FAVORITE CLOTHING BRAND?
Express

19. WOULD YOU FALL IN LOVE KNOWING THAT THE PERSON IS LEAVING?
Yes

20. SAY A NUMBER FROM ONE TO A HUNDRED:
4

21. WHAT’S YOUR WEAKNESS?
A smile

22. MET ANYONE FAMOUS?
My grandmom

23. FIRST JOB?
I’ve been forever jobless

24. EVER DONE A PRANK CALL?
Yes... long time back

25. DO YOU THINK EVERYONE OUT THERE HAS A SOULMATE?
Of course

26. HAVE YOU EVER HAD A SURGERY?
Yes, once. It was many years back.

27. WHAT IS THE BIGGEST TURN OFF OF THE OPPOSITE SEX?
Superficiality

28. WHAT IS ONE THING YOU LIKED ABOUT HIGH SCHOOL?
We had a kind of food fest called Anand Bazar. Annual day used to be great fun too. Pai sir’s lectures were amazing. Wow. I can go on and on.

29. ANY BAD HABITS?
I think too much

30. DO LOOKS MATTER?
Yup

31. HOW DO YOU RELEASE ANGER?
By going into a shell

32. WHAT'S YOUR MAIN GOAL IN LIFE?
To live for people close to my heart

33. WHAT WAS YOUR FAVORITE TOY AS A CHILD?
Cars. I loved to drag them around.

34. HOW MANY NUMBERS ARE IN YOUR CELL PHONE?
More than 300

35. WHAT DO YOU LOOK FOR IN A GUY/GIRL?
Gentleness, humility, looks and above all, enough grey matter

36. WHAT'S YOUR FAVORITE ICE CREAM FLAVOR?
I love all, without nuts

37. DO YOU HAVE A COMPUTER IN YOUR ROOM?
Yes

38. PLANS FOR TONIGHT?
I can’t enter so much data in my brain

39. THE FIRST THING YOU NOTICE IN THE OPPOSITE SEX
Panache

40. FAVORITE THING TO HATE?
People who push others with their elbows

41. WHAT DO YOU LIKE TO DO IN YOUR SPARE TIME?
I waste it doing nothing

42. FAVORITE SEASON OF THE YEAR
Rains

43. WHAT ARE YOUR NICKNAMES?
Ani

44. FAVORITE SUPER POWER?
Umm… does Dexter count as one?

45. HAVE YOU EVER REALLY AND TRULY HAD A BEST FRIEND?
Yes, I do

46. WHAT IS YOUR HAIR COLOR?
Dark Brown

47. EYE COLOR?
Jet Black

48. WHO WERE YOUR GOOD FRIENDS IN HIGH SCHOOL?
Aaron, Adrian, Leo, Talwinder, Dino, Ankush, Glen, Tejas, Anjali, Mayur... the list isn’t complete.

49. KISSES OR HUGS?
Both :)

50. RELATIONSHIPS OR ONE NIGHT STANDS?
Relationships