DIFFERENTIAL DIAGNOSIS IS A TORTURE STORY!

THREE score and ten decades later I find that growing old and older is really a torture story when it comes to public healthcare and very often private healthcare too no matter how wealthy you and able to afford the moon if it was for sale. This is to say by now I’ve seen several patients come and go as in goodbye cruel world, but there is life and hope that things will improve for the better when it comes to healthcare in India — at least by the time we arrive at amrit kaal or kartavya kaal and whatever euphemistic “kaal” our current high-flying spendthrift government dreams up to make the lives of the very people who vote them to into power again and again — a sorry, shoddy story of nightmares and hells for the last 75 years.
Recently I was with a patient who’s been in and out of hospitals the major part of his life from his 40s onwards, after a severe beating up with iron rods, cycle chains, sticks by local goons, at his neckline where the spine starts (you must understand the spine or skeleton is the scaffolding on which the nervous system is enshrined along with everything else, hence the importance of taking care of your posture lifelong, and nutrition!). In hospital damage control started for my patient but it failed redress the real issues and for the first time the patient heard of something called “differential diagnosis.” Basically, it means the medical folk are not able to certify what really is the root cause of patient’s pain and one treatment after another for a real cause eludes them and this makes life a challenge to survive and live for the unlucky patient.
Doctors too get used to a frequent patient and lose interest because they think in their fast-paced lives there is little or nothing they can do and perhaps want to do if the patient is a senior citizen, feeble and to boot arrogant enough to ask questions – about why this or that surgery didn’t work like he had been assured it would! Most patients I know have this interesting love-hate relationships with their favourite doctors…more or less love or hate mixed up with gratitude if they feel an iota of wellbeing after a treatment is over.
Take the case of a patient I know who was in a public hospital for treatment for a prolapsed rectum which was bothering him from evacuating happily every morning, a case of stomach muscle failure and a previous failed surgery – another rectum surgery was recommended, a spinal injection given, the surgery done to perfection. So perfect that post-surgery, after a few weeks, the situation worsened like never imagined, the patient complained he was barely able to push back his rectum as could do easily before the surgery. So it’s now back to spending whatever energy he has in the bathroom doing his ablutions with painstaking effort…managing himself with various medical formulae to ease discomfort and still manage his body as best as he could.

DIAGNOSTIC TESTING
IN hospital well-intentioned doctors junior, senior, consultants come and go recommending a slew of diagnostic tests, dietary suggestions, et al. Then a bright medical intern will say maybe patient’s got tuberculosis, he is so run down and practically all bones. So all the tests possible to pin down TB are run including needle aspiration, skin biopsy, ultra sound data obtained, sputum and skin tests are the clincher one learns…end result. Nothing positive, no prove of TB, yet the diagnosis is “clinically TB, it is latent TB of the spine or skeleton, a non-infectious variety.” The order goes out to start the patient on standard TB medicines immediately…
You may understand how devastated the patient is! Why should he get TB, TB is something to do with life in impoverished slum conditions and not enough nutritious food and sunshine for anyone! There’s a stigma attached to TB, it’s some kind of a shame, nobody wants to be near you. Never mind that in this case the patient is frail because he has been cutting down on his meals to see if he could sort out his own rectum prolapse issues.
Post-surgery and infection he needs a course of antibiotics which sets him right in the hospital but the TB medicine arrives and a caring staff nurse of the ward cajoles the patient to take it – so what if the tables are huge and a garish pink, she crushed them in water and offers a pink solution to drink. Patient obliges, the medicine doesn’t agree with him, he gets giddy fits and can’t make it to the toilet in time…he has enough gumption to say, “I’m not suffering from TB, I’m feeling well enough now to go home, please discharge me.”
Nevertheless his discharge papers state he is being discharged diagnosed with Koch’s spine C3 C4 C5 verterbrae without distal neuromuscular deficit with neurogenic tumors right thorax under evaluation…etcetera, etcetera. He must take TB medicine at home. The protocol of TB is well laid out now in India for the higher ups want to eliminate TB by 2025 in India and TB patients even get Rs500 per month to feed themselves more nutritionally, the caregiver too gets Rs500 for making sure the patients takes his or her “ghastly” TB medicine!

IT’S NOT TB, THANK YOU!
THE patient refused TB medicine and that’s final. However, to cut a differential diagnosis story short here our patient, still living in a dilemma of collective health issues and how to deal with them, decided to see a consultant neurologist recommended to him, he this consultant neurologist will give him the most conscientious low-down once he sees the patient’s MIR reports and medical history. The appointment was made and the doctor patiently checked the patient out in his clinic with various interesting looking tools and finally, hold your breath: We may rule out TB. His diagnosis is “chronic cervical compression myelopathy in lumber canal stenosis.” This is what has been taking a toll of his nervous system collapsing along with his skeleton courtesy his past medical history
The good doctor prescribed minimal medicines and said patient may do physiotherapy and improve his nutritional intake of food therapy, and “Come back after two months but do the appointment on your way out today itself!” This is a very gentle and no nonsense neurologist and doesn’t even like any husband-wife nasty exchanges in his consulting room, he says, “If you’re fighting, I am walking out immediately and you may go elsewhere.” Well, that’s another thing altogether. But can you imagine the relief the patient gets off his chest when a medical professional rules out TB?
Never mind that the new diagnosis is as dicey a situation as TB! Back home it’s a story of please eat some more, please drink the expensive protein-rich “Ensure,” eat protein bars, eat oatmeal for breakfast or dinner please, get back to proper eating! Find another cook if you don’t like the present one! Nobody dies just because they want to die or they imagine they will be a burden on anyone…sad to say the patient is seriously contemplating euthanasia and donating his wrecked out of shape body to the Goa Medical College & Hospital, “After all they screwed me up right from the beginning, let them have my body finally!”
SO it goes, this is just one patient I am writing about here because he happens to be my hubby. Like I said earlier growing old and older is oftentimes a punishment rather than a reward. Especially if you suffer from any of the degenerative diseases and ailments of our times, and healthcare comes with absurd costing even in a public hospital, where if you choose a private ward room instead of the free crowded ward where toilet facilities are indifferent…it is expensive and you are ruthlessly required to pay in advance in cash (yes, at the GMC).
COMING back to this business about differential diagnosis, this is just to say, never be afraid of doing your homework if you are patient with a tricky medical history. If you feel strongly about a medical diagnosis being wrong (and you’re the patient) sound out your apprehensions aloud for your attending doctor’s ears. I know one man in the police force who after being treated wrongly for something he was not suffering from, he finally suggested to his doctor, please, do you think I have cancer of the blood? They did the tests and lo and behold: It was cancer of the blood and the correct treatment commenced after months of waffling about what he was suffering from!
He was a young patient and together with some serious lifestyle changes (no more boozing and crazy late nights out) he is back to more or less normal active life anew. Take differential diagnosis seriously if you’re suffering from something bothering you for a long time and you are not healing from what you have been officially medically diagnosed. The third largest cause of death today I do believe is medical negligence and errors of judgement.
Also, altogether the healthcare system in this country has a long, long way to go before it grows up and becomes equitable and compassionate for all its citizens. Don’t know about you but I would say any good government’s budget priorities would be public infrastructure, education and healthcare on top of the list. Not going to the moon after the Americans and Chinese have finished going there and Elon Musk is conducting tours to space for overly wealthy clients! India is still very largely a below poverty level country no matter how much Narendra Modi’s government tries to hide it from world leaders in whose league he wants to be!
On that note it’s avjo, selamat datang, poite verem, au revoir, arrivedecci, hasta la vista, vachun yeta here for now.

—Mme Butterfly

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