Rambodoc at large

Mounting frustrations with local hospitals pushed this young peasant to seek a second opinion at the nearest Ivory Tower. His complaints prompted a urine analysis for which he was sent to a nearby lab. The lab policy demanded a pre-pay along with the sample! The charge was 20 Dinars. Pissed off and cock-a-hoop with indignation, he whined, "Why so much? In my home town we pay 5 Dinars and we do not even have to give a sample!!"




A new proctologist started his promising business in a small town where there was no match for his skills. Among his first patients was a peasant who believed that a good physician should know what is wrong without soliciting information from the patient! The doctor completed a focused exam and hoped he would put his finger on the problem with the tools of his trade but to no avail. The patient finally revealed his illness, a bad tooth that needed to be pulled out! "But why did you let me dig deep in your butt at that time?" Said the doctor in vain. "I assumed you were going to pull it from the root", the peasant replied!


It was a bad weekend on call for Obstetrics and Gynecology at the Medical City Teaching hospital in Baghdad. Three smaller hospitals were closed due to tetanus. By default, we became the only one taking patients. I remember there were 75 admissions in 36 hours! Patients were laying anywhere and everywhere, beds or no beds. One proud dad came to discharge his wife and his new heir, but....We could not find either of them! After 2 long hours of search, the man spelled out his choice: "Tell you what, give me my wife back and you can keep the baby!"

Remember Million Dollar Baby, a four-Oscar flick, with Clint Eastwood playing the tired old boxing coach picking up a girl (Hillary Swank) as his protegé, seeing her through the boxing championships, till she literally falls to bad luck in the final bout?
Now, the point is that I think the whole world is full of high-powered idiots. Like the guys who awarded the Oscars to this splendid movie. Now, I say this because the scenes in the hospital, which make for the climax, are atrocious. Let me now tell you why. The heroine, who trips and breaks her first and second cervical vertebra (what is otherwise known as a broken neck) is on a ventilator with a tracheostomy. In plain English, she was paralysed and was being kept alive by a machine that pushed in oxygen through a tube inserted in a hole in the windpipe. So bloody what, you ask? Admirable sentiments, I must admit. Much as I hate to carp at an otherwise great movie, the girl keeps talking even though she is on a trach. Now, every doctor will tell you that a trached patient can not speak, because the air doesn't go through the voice box anymore. Why couldn't the director (Clint) have researched this well and avoided a crucial faux pas? Why, he could have called me for any help. My consult rates are very standard: just a thousand per hour. Dollars, of course!
The boxwallahs have goofed up on medical issues all the time. It makes me worried how reliable the other things we learn from cinema must be. For example, biologists must have developed hernias laughing while watching the pseudos in Jurassic Park create new dinosaurs from mummified mosquitoes, or whatever it was at that time! Similarly, the guys who deal with Artificial Intelligence, like Ray Kurzweil, must be getting their stress lines ironed by watching The Matrix, or MI-3. One exception seem to be climatologists who seem to think that movies like The Day After Tomorrow or Al Gore's An Inconvenient Truth are cinematic versions of the textbook truth.
In Bollywood movies, the best of the movies lose their beans when it comes to hospital scenes. For decades now, it seems that a hero with a bullet injury will escape death the moment the bullet is removed from his body. And if he has lost blood, no problem, his long-lost brother will miraculously come forward and we are treated to a great spectacle of modern medicine: direct transfusion from one hero to the other. No cross-matching, no HIV testing, etc. Who has the time, bro?
Similarly, a critically ill patient is rushed into an operation theater and anesthetised with a mask, sometimes even with a red rubber catheter in the nose. Gawd! Them things don't exist no more, guys!
At the rate in which the medical idiocy is profitably progressing, I feel a heartfelt tug to start a medical consultation firm based in Mumbai. Later I could open up an office in Hollywood. Maybe, outsource this to India, has anyone done that yet?

Yes, the Chinese have their own culture, and their solutions, like their legendary torture methods, defy conventional norms of 'civilised' nations. Spurious drugs are a result of lax law enforcement, low level of protection for intellectual property (read patents), and general corruption. The Chinese just decided to say "foggedaboutit" and took a shot at a solution.
Maybe people in India, like Barun Mitra, will have something to say about this.

Well, the first world has woken up to air travel spreading lethal bugs across to susceptible populations, even as countries like India and Africa sleep in blissful disregard. You can read the story of the TB guy at this site.
Now, if a doctor has to be posed the issue of confidentiality versus the duty to prevent spread, should he warn the State everytime a case of a contagious disease is detected? What happens to patient privacy then?

an old news article when people were not bothered by the acronym

From today till as long back as the Emperor Nero (immortalized by his playing the fiddle while Rome burnt) man has used glasses to see better, whether for watching gladiatorial contests or for reading the fine print of The Telegraph. The normal lens of the human eye is a soft pliable gel that changes its curvature depending on how far or near an object is being focused upon by the individual. This is called accommodation, a process that helps a man watch a movie screen and his ticket number in a second’s gap without blurring or squinting. As man ages the gel like material in the lens in his eyes becomes stiff and fibrous. In that state it cannot change shape and accommodate to near vision. This is why the elderly need glasses for reading. These, say forecasters in the web portal Futurepundit.com, will soon be historical curiosities.
Scientists at the University of Michigan have developed a tool that uses 'ultrafast' lasers that create microbubbles inside the lens of the eye that soften the age-stiffened fibers. This allows the doctor to detect stiff fibers (those that resist the softening process). These are then removed with the help of lasers. The lens becomes softer and gets back to normal. After this non-invasive procedure, normal vision is restored. Voilå, no glasses!
The microbubble is now the froth of Sonoporation, a process that is the research darling of biophysicists all around the world today.
What exactly is Sonoporation about? How is it going to change the world of health care?
In this revolutionary technology, microbubbles of perfluorocarbons are coated with a shell or coating of albumin, gold or a polymer and injected into a vein of the body. When the microbubbles reach the target organ, like the heart or brain for example, they are targeted by ultrasound energy from an external machine. The ultrasonic waves cause these microbubbles to explode instantly. This causes holes to form in the membranes of cells of the organ, allowing delivery of drugs or other agents into the specific desired site. The entire process is done without putting in instruments or tubes inside the body, unlike current modalities of treatment.
Take the example of a common disease like a brain stroke that is usually due to a block caused by a clot in one of the cerebral arteries that supply oxygen to the organ. Using the technology, scientists in Hospital Vall d’Hebron in Barcelona dissolved the clots in 71 percent of patients, almost double the success rate of the conventional clot dissolution with a drug called tPA. The potential impact of this therapy in stroke management is awesome with earlier and more complete recovery from the crippling disease, says Carlos Molina, lead author of the article that appeared in a leading journal. A randomized trial for evaluation of the technique is now in progress.
Similar results are expected in the treatment of another common disease caused by an arterial clotting process, the heart attack. Blocked coronary arteries that cause damage to the heart muscle can be opened up using microbubbles. This could potentially reduce the numbers of invasive procedures like angioplasties and bypass surgeries in the future. Cardiologists, however, can take solace from the fact that their patients who develop re-stenosis (narrowing of the coronary arteries, a failure of treatment) after angioplasties can be successfully treated with sonoporation.
A very impressive characteristic of the microbubble is its ability to carry drugs into places that are inaccessible through normal means. The best example is the brain, where the blood-brain barrier prevents most drugs from reaching the grey matter. The use of Sonoporation is opening up enticing prospects for drug treatment for incurable diseases like Alzheimer’s, as evidenced by research in the University of California Davis. In this disease, treatment options have not developed because of the frustrating inability of drugs to reach the affected grey cells.
In the erupting research on gene therapy and molecular biology, microbubbles are being viewed as excellent vehicles of non-invasive treatment. In patients with Type I diabetes, the pancreas lacks the ability to produce the glucose reducing hormone insulin. Paul Grayburn at the Baylor University in Dallas has used UTMD (Ultrasound Targeted Microbubble Destruction) to deliver insulin genes carried in microbubbles to the rat pancreas. Says Grayburn, “Not only was their blood sugar lowered, but there was no evidence of any damage to the pancreas”. The implication for diabetics is a cure from the disease, without the need to take daily insulin injections.
With more and more complex diseases appearing to be curable in the near future, biophysicists seem ready to open the bubbly to celebrate. After all, alcohol can cross the blood brain barrier easily!

Remember Thomas Edison? Wrongly thought to be the inventor of the electric lamp, but actually the creator of the electric grid? Or Graham Bell, who rang in the first telephone? These men created products that changed civilisation. These, amongst some others, were disruptive technologies: technologies so outrageous that they are considered daring, provocative, and extraordinary. Today, we are on the threshold of possibilities so outlandish that science fiction sounds pretty ho-hum.
Nothing exemplifies this as fundamentally as the field of ‘disruptive’ medicine and, arguably, nobody in the field of medicine understands the future of this ‘outrageous’ medicine as well as Richard Satava. ‘Rick’ Satava is a Professor of Surgery at Washington University Medical Center, Seattle and has written several books and articles on futuristic ‘disruptive’ medicine. Apart from being a surgeon of world repute, Satava was part of the team that developed the first robotic and Virtual Reality systems, before joining DARPA (Defence Advanced Research Projects Agency), the brain bank of the US military. He is soon to take over as the Chief Scientist of theUS Army Medical Research and Command. It is here that he will be funding and overseeing more outrageous medical research. So, what earth shaking developments are afoot in the world of medicine?

A NEW AGE

Satava starts off, “A glimpse of what the future might become was given by Alvin Toffler in his 1976 book ‘The Third Wave’, in which he described the three different ‘ages’ – the Agriculture Age, the Industrial Age, and the Information Age. There appears to be a new age emerging – tentatively called the Biointelligence Age.” But one thought the Information Age is the future? He says, “The Information Era is here and is getting over. Over the past 20 years, there have been no new discoveries. The cell phone, computer, etc. are fundamentally the same as they were 20-30 years ago, the only difference being their level of sophistication and add-on features like small size, Internet access, cameras, etc."
The Biointelligence age features a slew of radical technologies that are set to change the entire way of treating health and disease issues. We examine some of the main issues here.

THE IMPOSSIBLE FUSION OF LIFE AND MACHINE

Scientists have implanted sensors and radio transmitters in bees and cockroaches to control them. The cockroach can be controlled with a joystick, allowing a possibility for cameras to be implanted in the creature for use in the detection of earthquakes and tsunamis. Bees fitted with sensors for biological weapons can transmit the information to the military. This is the beginning of the man-made fusion of living and non-living.
In man, brain implants are promising enormous hope for patients of paralysis, epilepsy and Parkinson’s disease. John Donoghue, a neuroscientist who also owns a biotech company called Cyberkinetics in California has begun implanting the Braingate device in the heads of patients that allow them to mechanically move an attached robotic arm with the power of electrical impulses generated by thought. The brain’s electrical impulses generated from thinking of an action go to a robot that then interprets these signals and performs an appropriate action.
How realistic is it to expect intelligent machines to perform radical functions in place of diseased body parts? Says Ray Kurtzweil, a global authority on science and future technology, “The latest generation of the implant for Parkinson’s disease (a slowly paralysing nerve disorder) is not an experiment, and it is an FDA approved therapy”. Rameez Naam says in his book ‘More Than Human’, “In Lisbon, Portugal, there is a group of blind men and women who can now see. In place of eyeglasses, they wear cameras connected to electrodes implanted in the visual parts of their brains. Some of them were blind for twenty years or more before the surgery. The same research that gives them sight could beam images from one person’s mind into another. “
Aubrey de Grey, a world-renowned scientist at the Department of Genetics, University of Cambridge, says, “There are non-biological organs such as cochlear implants already, and rapid progress is being made on more advanced things like artificial hearts. What will be more dramatic is when we start to be able to make machines that can replace some parts of the brain. For well-understood parts like the hippocampus (the part of the brain that stores memory), this may be only a couple of decades away. At that time we may wonder if ‘non-living’ is really the right word - non-biological, yes, but performing a living, cognitive function.”
de Grey looks even farther: “If we end up being able to replace the hippocampus with a machine that works just as well, there's no reason why we couldn't replace it with something that does more than the natural one. One additional function could be to use it as a knowledge base, an inbuilt Internet. In the more distant future we will probably understand the cerebral cortex well enough to start replacing parts of it too, and that is possible.”



CHANGING LIFE’S BUILDING BLOCKS

Conventional medicine looks at organ systems and deals with disease at the macro level. The dizzyingly fast developments in nanotechnology and genetic engineering are set to make this obsolete, if experts are to be believed.
Nanotechnology deals with molecules at the scale of a few nanometers, and banks heavily on the creation of an atomic ‘assembler device’ or molecular machine: a concept of scientist Eric Drexler that pertains to a group of molecules arranged to perform the functions of a machine or even a computer. Says Kurtzweil, “The golden era will be in about twenty years from now. The real Holy Grail of nanotechnology are nanobots, blood cell-size devices that can go inside the body and keep us healthy from inside.” Molecular machines can clear out clots in arteries, go into cells and correct abnormalities, and kill germs or cancer. Kurtzweil reiterates, “If that sounds very futuristic, let me point out that we’re doing sophisticated tasks already with blood cell-size devices in animal experiments.
One scientist cured Type 1 diabetes in rats with a nano-engineered capsule that has seven nanometer pores. It lets insulin out in a controlled fashion and blocks insulin antibodies. This is what is feasible today. MIT has a project of a sub-cellular nano-engineered device that is capable of detecting specifically the antigens that exist only on certain types of cancer cells. When it detects these antigens, it latches onto the cell, and burrows inside the cell, where it releases a toxin that destroys the cancer cell. This is a sophisticated nano-engineered device in that it is created at the molecular level. So that’s what is feasible already.”

CHANGING GENES OR SPECIES?

The era of transgenic animals is upon us already. Michael Crichton’s latest book 'Next’ deals with apes that speak Dutch and French, because of experiments in crossbreeding with humans.
Genetic engineering can prevent inherited disorders, but more radical is transgenic genetic engineering. Satava cites the example of rhodopsins (color detecting eye pigments). Man has four rhodopsins for vision of which he uses only two. The pit viper snake has one of the same rhodopsins that is unused by humans, and which gives the snake the ability to seek its prey in infrared. He asks, “ Should we genetically engineer our children to give them such abilities, so they can see in the dark? Should they have abilities that others do not have, giving them an enormous advantage? Moreover, who will decide which children can be ‘enhanced’? Are we on a threshold of designing our children to a point where there will be a whole class of enhanced individuals?”
Troubling questions, these! The ethical issues of genetic engineering are being debated fiercely in scientific and political circles, with more questions than answers.
With the establishment of ‘intelligent’ prostheses that function even better than a normal body part (as in amputees who can climb mountains or play), and with all possible organs (except the brain) being replaceable with biosynthetic ones, it is possible to conceive of an ‘enhanced’ man with 95% of his body replaced by artificial ones. “Would such a man be ‘humanoid’ or human?” asks Satava.
Talking of humanoids, a parallel development has been the creation of intelligent robots that help impaired patients. Satava remarks, “Advanced programs such as fuzzy logic can help the robot or computer to learn from tasks. This meets the definition of ‘thinking’. There are machines with life-like robotic faces which can answer verbal questions and attempt to make facial expressions that show six specific emotions”. Robotics is expected to be a $50 billion industry by 2025, with countries like South Korea set to become leaders in domestic multifunctional robots (with a target of one domestic droid for every home by 2013). Companies like Microsoft are working on the same lines. With such research, a thinking and emoting robot is not going to be mere science fiction. It is already reality in research!

WILL MAN HIBERNATE AND REJUVENATE?

American scientists have new insights into the phenomenon of hibernation, with stunning implications for medical care. Animals like the Arctic ground squirrel can turn their entire system off, effectively living with minimal heart rate, breathing, and circulation, owing to a molecule that blocks energy generation in the hypothalamus of the brain. Scientists have been able to create a block in mice such that they are put into a state of suspended animation for about 6 hours – no respiration, heart rate, blood pressure, ECG, EEG, and even no activity on functional MRI of the brain. After 6 hours, they are awakened and they behave normally. Satava points out “while this is an early experiment, it points to the possibility of using these molecules or drugs for anesthesia. If successful, in surgery a patient could be put to ‘sleep’ with no heartbeat, no bleeding when incised (bloodless surgery), unaware of pain and unable to move. When the surgery is over, he can be awakened.”
Drexler confirms, “It is possible to discover a drug that causes biostasis (putting life in pause). A method of producing reversible biostasis could help astronauts on long space voyages to save food and avoid boredom. In medicine, biostasis would provide a deep anesthesia giving physicians more time to work. When emergencies occur far from medical help, a good biostasis procedure would provide a sort of universal first-aid treatment: it would stabilize a patient's condition and prevent molecular machines from running amok and damaging tissues. 

But no one has found a drug able to stop the entire metabolism the way anesthetics stop consciousness - that is, in a way that can be reversed by simply washing the drug out of the patient's tissues. Nonetheless, reversible biostasis will be possible when repair machines become available.”
With much research involving other areas like human cloning, prolonging longevity of man, and tissue synthesis modern science is helping evolve a new breed of professional: the scientific ethicist.