Oh no! not yet another…...
Dr.Rakas sat down in her chair in the clinic and rearranged the things on her desk. She liked her desk to be neat and organised. Very organised actually!. But she managed to hide or atleast tone down her obsession with organisation while in school and college. Her name was unusual and when anyone asked what that meant, she had a ready reply that she had used from school days. It always caused a few in the crowd around her to break into laughter and that helped. Laughter always helped. The rest of the crowd would wonder and decide to go to their dictionaries once they got home. Either way, it helped! She would say,”As a child, I created such a lot of ruckus, that they named me that.” Of course, that was not why she was named Rakas. Most people realised that and wondered what her name really meant. They would later search on the net and read that it is a finnish word which meant dear beloved. But she was obviously Indian with no trace of any Finnish blood in her. Hmm… She never revealed why she was named what she was. It added to the mystery of who she was. She liked mysteries.
After her MBBS and MD in general medicine, she had decided not to specialise any further. Instead she tried various options ultimately realising that she would be completely in charge of her schedule only if she had her own clinic. So she started her clinic. Named it Dr. Rakas’s clinic. Nothing fancy. She was there most days. She gave herself Friday and Saturday off since she felt Sundays were days when it was convenient for patients. Her practice picked up slowly. Soon she established a name for herself. Oh that doctor who listens, the kai raasi kaara doctor!………..Although she tried to tell her patients that it was her medicines that helped not her kai raasi, those steadfast believers of kai raasi were not easily convinced.
It had been 2 years since she started this clinic. She wondered sometimes about a change. It was on one such day that something interesting happened. She was nearly finished. The last patient, her receptionist announced. She smiled her professional smile at the 50 year old man who was coming into the consultation room. His name was Ramachandran. He started off by telling her about his back pain. Inwardly, she groaned. Oh no! not yet another back pain!. She did not like dealing with problems that did not have a clear cure. People expected that from allopathic doctors and were disappointed when they found out that their awful back pain was labelled as degenerative back pain, that is …….due to old age wear and tear!! What was offered as treatment for this group was limited. Physiotherapy was the cornerstone and if that did not help, it was just pain control with different tablets.
She questioned him to find out if the back pain was due to any other reason apart from wear and tear. There were none. She was always careful about that. A story she had heard one of her teachers narrate made a big impact on her mind. He had seen a patient with back pain and there was nothing specific to suspect anything different. But he was a young man and it worsened and ultimately it turned out that he had an infection. The patient had not bothered to tell him that he had a hole in his heart since he felt it was not related to his back pain and the doctor had been a bit rushed that he had not asked in detail about past medical problems. An infection from the heart had travelled through his blood to the back. He was sued by the patient and it led to all sorts of legal problems but was sorted out ok in the end. But he told this story so that his students would not dismiss back pains so easily……….
So Dr.Rakas asked her patient in detail and then decided.Her diagnosis was that it was degenerative from the history. She started her examination and was surprised to find a tender spot quite clearly painful to touch apart from the rest of the back. She decided to treat as degenerative but keep under review. She asked him to come back. He came back 2 weeks later. Still painful. She decided to do some basic blood tests and an Xray. He came back with results in a few days. The blood results were normal. But the Xray showed a vertebral fracture, that one of the small bones that make up the back bone had been decreased in height. Sort of collapsed a bit. Vertebral fractures do not look like other fractures. She sent him for a dexa scan. a scan that would show how dense his bones were.
As she lay in bed that night, she was thinking about this patient. As most doctors do, she kept going back to that particular patient and wondered what exactly was worrying her. Dr.Rakas lived alone. Once a patient, an old lady, a patti, asked her with the usual disinhibition exhibited by garrulours old paattis, why are you not married? Do you not want to have a normal life? She had smiled. She used to get irritated with people who tried to pry into her private life. But not that day. How could she explain to an 80 year old lady whose times and thoughts were different to hers? Even her contemporaries wondered if she was right in taking such a big decision. How could she explain that to her, her freedom was the most important thing in life? Would she be branded selfish and abnormal? She chose to stay single. It was not a decision into which circumstances forced her. How could she tell the world which was ruled by the majority in any aspect of life which looked at anything different with scorn and derision and fear too?………..Would anyone really understand that her need to be free to do whatever she wants mattered more than the guy she nearly married, the biological instinct to nurture a young child?………Not really…….some did….but she chose to tell the truth to only some………….when she thought there was a chance of the listener understanding………..when the question was delivered by someone she liked…………..but to pattis like this one, a smile sufficed………..they could interpert it any way they wanted…………
The next day dawned as usual. She was seeing her ninth patient, Ms. Rani, 35 years old. Back pain. After seeing eight patients with colds, she welcomed the change with joy! It was only when the same patient came back to her a few days with an xray showing a vertebral fracture, she sat up and took notice. What was happening? A 35 year old with a vertebral fracture??
That night she could not sleep properly. She dreamt of vertebrae and her patient being thrown off a building. She woke up with a start and went back to her notes. Yes, she had definitely asked about any injury or fall. Nothing had happened to account for the back pain.
When she saw her third patient with a vertebral fracture, she started worrying. This one was a 80 year old lady though. Mrs. Mariam. So it was probably osteoporosis, thinning of the bones with age.
In a month’s time, she had seen ten patients with vertebral fractures. All their dexa scans showed clear osteoporosis. Their bones were so fragile that they were fracturing.
She spoke to one of her friends, Shyam, a senior general practitioner. He could not help her much but suggested jokingly……..why do you not try a hercule poirot like meeting? Only in this case, all the people you assemble are victims of a disease not a crime and you do not even know why you are having a meeting…………
She wondered uneasily. What was she supposed to do? She referred one to a rheumatologist who just asked the patient to continue the alendronate. She referred one to an orthopaedician who did the same. Was she looking for something that did not exist?
She could not sleep again!…….I have made my diagnosis. Treated them. What more do I want? But, I cannot ignore my instinct that there is something that I am missing here. I am out of options though. Maybe I will just do what Shyam suggested!. Why not? If they think it is silly, they will not turn up. But it may help. Who knows?
So she went back the next day and asked her receptionist to send a letter to all her ten vertebral fracture patients………including…… Mr. Ramachandra, Ms. Rani, Mrs. Mariam.
The day arrived. She had chosen a Saturday morning and asked her receptionist to come in and help her that day. Raja agreed readily. He was wondering what the doctor was planning to do. Were they all alcoholics? Was this like alocoholics anonymous? But he personally knew these patients. There was something else going on……..Maybe he could leave the clinic door slightly open…..
One by one they all trickled in. Dr.Rakas saw interest and confusion in most of their expressions. This was not what a normal doctor did! When all ten had arrived, Dr. Rakas began. She was actually feeling quite embarrassed since she had no idea what she was planning to do. But she had learnt long ago the art of looking confident whatever be the real situation. The patients waited for her to begin.
She smiled and started………I know that all of you are wondering why I have called here today. To start with, I want to tell you that I am going to discuss your diagnosis in this group. If anyone of you does not want me to do so, let me know now and please leave. I will not discuss your diagnosis if you do not want me to.
She waited. No one spoke. Hmm………
She said…….I really do not mind if u walk out now. It is your choice.
It was old Mrs. Mariam who spoke……………Oh I am too old to care about anyone now. You can tell everyone all about my medical problems including my bowels dear!.
Everyone laughed. That eased the tension.
Dr.Rakas threw a grateful look in Mariam’s direction…………Thanks.Now, do any of you want to leave?
No one did. She wondered if it was curiosity that kept them there…….
She said…………I want you all to introduce yourselves. Just names and age.
They all did. Then,
She started with Mariam…………..This lady here has a vertebral fracture.
A startled sound escaped most mouths. So this was a vertebral fracture group therapy session was it? thought Rani………..
Dr. Rakas continued………….I have explained to most of you what that means. It basically means the bone is so thin that it breaks. All of you have had dexa scans which showed osteoporosis.
What you would not know is that it is common in elderly people only. especially women after menopause. when their hormones stop working, their bones become less dense………
There are other causes of vertebral fracture too…………..like fall from a great height…….but that happens with normal density on dexa scan……….
Of the people here, Mariam is the only person who i expected to have osteoporosis and she does………..
But why the other 9? Rani………..you are too young to have osteoporosis. Your hormones should be protecting you still.
Mr. Ramachandran, men’s bones are more dense. So you should not be have osteoporosis…..
Now I just want you all to talk about this.
There was a babble of voices. All wanted to talk at once.
Dr. Rakas intervened.
Mr.Mariam, you are the oldest person. You talk first and we will listen.
Mrs. Mariam smiled. So that is my reward for helping you out earlier.
Again everybody laughed.
She continued………….I feel like Ms. Marple with one of her mysteries. Is that what you think this is Doctor dear? You want to know why these people have fractures? A pity you are not interested in mine!
Again more laughter. Dr.Rakas understood the power of Mrs.Mariam. She was one of those special brand of people who could put anyone at ease.
Mrs. Mariam continued………..since the doctor is not interested in me, i think we will begin with rani…………I know, Ramachandran, you want to talk first. But Rani reminds me of my granddaughter. So she goes first.
Rani spoke…………I have no idea what you want me to say. I just developed back pain. Came to see the doctor and here I am.
Ramachandran spoke next……….Before Mrs Mariam decides that Anvesh looks like her grandson, I will speak up.
Mariam looked comically outraged!!……
Ramachandran continued………….My story is similar to Rani’s. I really cannot think of any reason why I should get a fracture that I should not be getting.
Anvesh picked up the thread…………Are you thinking of something like AIDS doctor?
Oh no! Dr. Rakas hastened to add…………….I just want to know if there is something that is common among the 9 of you or ten even!!………
Mariam snorted………….adding me an afterthought are you dear?
Dr.Rakas wondered………how come she never seemed to miss an opportunity to make a smart comment?…..
She said aloud……….Just think ………..All of you………I can tell you what I thought………..I wondered if any of u were using any drugs………
Can you give an example doctor…………asked Rohit…….
Dr.Rakas replied……….Steroids, drugs used for fits and more……..
Rani piped up……….I have not been taking any medications for any reason.
Others mirrored her answer.
A silence descended on the group. No one could think of anything to say.
Anvesh started talking about his kids just to break the silence…………..My daughter is only 8 years old and already she thinks she is in charge and I have to listen to
her. The other day, she was so kind and nice to me because I had just then had my injection and my arm hurt a bit.
Dr.Rakas looked up…………What injection? I do not remember giving you any injection……………. Oh sorry! I guess you see other doctors as well besides me.
I just assumed that you had seen only me since I have been seeing you on and off for the last two years.
Anvesh hastened to clarify………..No no!We see only you doctor. This was just my booster injection.
What booster injection? Mariam enquired.
Anvesh explained…………Well, one day I was feeling very tired and totally drained. My friend suggested that I get a vitamin booster injection. It seems it helped him.
So I went to see this chap. He is not a doctor actually. He just gives these vitamin booster injections. That is all. I get one done about every 3 months. It has really helped me.
Rani sounded excited…………..Oh yes! I too have been having that for years. It is called Vitboost.
When Rohit called out………..I too have been having it……….., the penny dropped!……..
Dr.Rakas asked…………..Who is this person? Do any of you know exactly where he gets this vitboost or whatever it is called from? Do you buy from any pharmacy?
Rani’s voice faltered a bit as she said…………..No, we cannot buy it from any pharmacy. The man is called Vellappan. He works in a hospital as a ward boy. He
said he has seen many doctors use this and that it is a secret weapon.
When Dr.Rakas asked…………Is there anyone in this group who has not used this vitboost?
Only Mariam replied……….I have not……
The rest of the group sat with pale faces and stricken expressions…………
Rohit said…………I have been having them for quite a few years now………..But doctor, it really helped me. I used to suffer from asthma a lot and then after these
injections my attacks stopped actually.
Dr.Rakas spoke in a kind voice…………The drug could be a steroid injection. A steroid helps for some conditions but its use has to be monitored by a doctor.
It is a very useful substance but has quite a lot of side effects especially if taken for a long time.
I will contact this Mr. Vellappan and ask him about this drug and ask him to give me a sample. One of you give me his address. If I find that this is the cause of your osteoporosis,
I will report him to the police. I advice you all to discontinue using it from now. Also inform anybody you know who has been using it to stop doing so and get themselves
tested for side effects. Actually, all of you please fix appointments with me individually so that I can talk to you and check up your blood pressure, look for diabetes and talk to you
about this episode.
Most of them just nodded. They were just too dazed to take in what was happening.
Dr.Rakas sat down in her chair………….wondering………….I have solved the mystery like Hercule Poirot. But I feel depressed not happy………..
Raja came in……….Doctor, why are you so sad?
She tried to rearrange her face into a neutral expression…………….I suppose you heard a bit of what was happenning………It is quite shocking actually for the patients and me.
Raja smiled………….But you have to be positive. Atleast now these people know and that horrible man will not be able to wreck havoc anymore…….
We may be able to stop a Vellappan here…………wonder how many more Vellappans operate under different names and where……………..