My Uncle's Story of Defeat....

Stories hadn't moved me to an edge for some time now. And then I met my uncle, a very close relative. I surprisingly hadn't heard his complete story till date, although people jibed bits of their own versions.

It was the story of his youth, of fairytale success & crumbling demise of dreams. I knew footballers & musicians who plummeted to glorious fame and spiralled into dark vanquish. But his story was almost my own, of our own family, of my cousins born to him...

I still remember a photo of him in khaki green Army uniform, holding a red headshield right after landing from a helicopter. He looked no less than a protagonist from a romantic english novel,  his life no less than fiction, like undulating seawaves.

Since early childhood, studies weren't his expertise. But he was gifted. He played volleyball & was exceptionally phenomenal at it. He played under clubs. People back home in Gorkha, knew him for his game.

He was perhaps eighteen when he entered Kathmandu, stepping in his elder brother's shoes, who was already a government official. Goverment service was prestigious, highly revered and acclaimed. My uncle had similar big dreams. Given his extraordinary skills, he was offered an army position. He enrolled in sports quota. He had only two hours of service per day
Unlike fellow cadres, he was exempted of arduous army rountine. Other cadres were vexed of the liberty he was granted.

In his glory days, he never lost a game. And that picture of khaki dress with red headshield was taken in one such sunny day....

He was paid very well both by the army and his club. People knew him. No one forgot his name after watching his game. He had the same name as our late King. And he played like one.

Times were promising. And someone advised him to join a bank job. Those days, government and bank jobs were prized. He initially declined but since his army trainings were only two hours a day, he had abundant time for a fulltime job. Little did he know, that it was the herald of an ominous downfall...

He was juggling two jobs, and still playing well when he met another player Hari. Hari was a big bull from Kathmandu valley and reigned volleyball arena of Patan.

He met his nemesis.

Their egoes wrestled, both claiming the title over some verbal spat. The challenge was very serious for both. One afternoon, they confronted each other in a volleyball match.

Like every other time, my uncle won!!

But that defeat stirred fire in Hari's soul. His ego collapsed and he seeked revenge. As they say, you need only one matchstick to set an entire stockpile of straw on fire. Hari was a snowball of venegeance...

He found about my uncle's jobs through some dissatisfied fellow cadres in the army. Someone filed a complaint that he was working two jobs. My uncle didn't know he could be punished for taking dual jobs simultaneously. His knightly castle of armors, badges, stars and brooches suddenly fell apart. He lost both jobs, was fined heavily and even threatened to be jailed. He couldn't play from his club... One angry defeated volleyballer ruined his reputation as well as life.

After some time, army offered his position back as a sportsman. But his sportsmanship spirit was trampled. He was terrified. He succumbed to the illfated twist of time. Too many things changed. Only he can narrate the hailstorm of emotional rollercoster he experienced.

Days months and years passed in unemployment. He found solace in alcohol. His wife and children suffered heavily with and because of him. Children missed schools due to unpaid dues, wife worked through odd jobs to make ends meet and he lost his identity even in front of his family. 

If only he had lost that one game. If only Hari had won. Even Hari perhaps wasn't aware that an act of wrath would devastate many lives. It wasn't my uncle's fault. He was extraordinarily blessed, but with a different fate.....

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So much respect for this man who would've otherwise represented Nepal in International platform. He would've been an Army Major now... and his talented kids would have had a different life!


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Doctors for Society or versus them??

I feel very sad about this bilateral pull between medical fraternity & consumer right advocates. I want to start with my small story. I clarify beforehand that me & my story is just the tip of the iceberg, in terms of medical scenario in Nepal.

I am a married, female, doctor, who lives with her in-laws, with my two kids. Please read about my obligations in between the lines. And I went to China at 6th month of 2nd pregnancy all alone, to a city where I didn't know anyone before, only to learn something called Fat graft. It was something new & something I really really wanted to learn. I chose to go there in such a vulnerable stage of pregnancy because I knew, if I didn't take that opportunity, I probably wouldn't get a second chance.

This is the state of learning or training opportunities in Nepal. I cannot imagine  hardships faced by thousands others, who live in foreign countries for years before completing eight grueling years of medical education until MD degree. And despite that, these same thousands of doctors are working day & night, with monthly income similar to or even less than that of clothing stores, wholesale vendors or slaughter houses, leave aside fashion boutiques, parlors, restaurants, etc. In the United Kingdom, junior doctors, took to the streets, to increase remunerations in the past. In Nepal, if we did the same by talking about wages, it would trigger another moral debate and catch meaty headlines in our newspapers.

Before reinforcing "blind-folded" legal system, create opportunities, scholarships, trainings, promote research, grants. Make doctors resourceful, trained and experts. Create environment for growth & positivity instead of making doctors hunker down for justice. We are breeding a society of distrust, of malice, threat & fury. If patients are consumers, then doctors must be goods that can be bought, things, or materials. I don't understand how to bridge this huge loop hole between doctors & patients.

Yes we are moms!

Motherhood, so sacred and powerful.... yet the world has so little time to glorify it. I cannot speak for all but I deeply admire all women who become mothers. As routine as it may seem, every woman has risked her life and body to nurture another being.... a boy or a girl, both loved and nourished unaminously, before either is received partially by this world. What a pity that a girl child is still belittled, a pregnant woman is still judged, disparaging their worth at work, devalued coz their time is divided between work and child.  The world is blurring into emotionless incompassionate emoticons, where new beings find themselves in the lap of babysitters, because the world couldn't spare their moms at work. This subconcious shift to workaholic robotics, scares me. As a mother of two, a boy and a girl, I love them both. As about my work, its my third child, I love it almost obsessively. But how to find that balance, is complicated. More than often, I struggle to meet two full time jobs. I cannot accomplish both, without pushing myself beyond nerve-wrecking limits.

Another painful truth, moms are again judged insensibly for their bodily changes, prompting them to despise the mirror. This social media whim, singing tales of reverence of zero-sized moms, is inflicting grave hazards on the minds of the young. 

Motherhood is so so beautiful, so divine.. no Shakespeare could scribble words of wisdom about it... coz he is a man. Only that woman, can jot down this celestial feeling. But alas! she's been busy rearing the new one. Thats why there is so less written about it, while there are volumes about another kind of love. Man and woman might have flimsy, superfluous or momentary glimpses of fleeting joy. Parenting is such sturdy feeling with robust roots, that won't wither with time. Its like that untainted lake, that doesn't shrink like a spring river. My deepest gratitude to all women, who are mothers, are reeling thru two full time jobs and finding joys to rejoice and recapitulate thru their lifetime.

Pollution in Kathmandu and brunt on our skin

Unabated pollution and deteriorating air quality of Kathmandu has been in news for all the wrong reasons lately. Due to rapid urbanization, people from all over the country throng to the capital for of education, employment, entrepreneurship etc. With annual population growth rate of 4.7% and motorization rate of 12%, Kathmandu has fast become overpopulated as well as polluted. Contributors of environmental pollution are vehicle emission, open air waste burning, industrial smog, brick kiln smoke, river sewage, construction work, etc. Scarcity of natural sinks such as forests, ponds, grassland and greenery has catapulted this damage in the valley.

In 2017, Kathmandu ranked as 5th most polluted city in the world according to Pollution index survey. In 2018, Environment Performance Index(EPI) had Nepal at the bottom among 180 countries in the survey. EPI was measured considering various indicators such as household solid fuels, sanitation, heavy metal and lead exposure, air quality, water quality, etc. Air quality of Nepal was worse than its neighbouring countries India, China, Bangladesh, etc. Ultraviolet Index (UVI) of major cities such as Kathmandu and P0khara are usually at the worst daily, with scores of 9-10 every day. UV Index depends on ozone layer, cloud cover, environmental pollutants, etc. Pollutants in the air are nitrogen oxide, sulfur dioxide, carbon monoxide, particulate matter smaller than 2. 5 Microns(PM2.5), ground level ozone, hydrocarbons, methane, etc. Amount of particulate matter in the air (PM2.5) has reached more than four times that of WHO guidelines in Kathmandu.

So what are the health implications of such chemicals, indices and scores? Pollution is a major health hazard causing asthma respiratory difficulties, heart disease and cancers. WHO has reported death rate of 0.036% from air pollution in Nepal. Globally, more and more researches are attributed to links between pollution and health. In the same realm, skin health is hugely impacted by environmental pollution.

Skin is the largest and outermost organ of the body which acts as a barrier against external harm. It is the first line of defense that fights these chemicals, but ultimately succumbs to their detrimental effects in long term. Skin, hair and oil glands bear the brunt of environmental pollutants, which get absorbed into skin directly or indirectly, causing oxidative stress and inflammation.  Many studies show that skin quality is altered, leading to dry, rough, dull and reactive skin that has redness, itching, burning and stinging. Content of the skin changes. Major studies in Shanghai and Mexico showed decrease in vitamin C, Vitamin E, squalene and linolenic acid content. Pores get clogged causing acne. Decrease in oiliness of skin makes it dry and easily attacked by allergens leading to eczema, itching, sun allergy and rashes. Gases such as nitrous oxide coming from vehicle emission cause pigmentation and black spots. Increased humidity and temperature leads to excessive sweating, clothing dermatitis and flexural dermatitis. Environmental factors also trigger chronic skin diseases such as psoriasis and atopy. Interaction of sunlight with different pollutants cause pigmented spot, keratosis and skin cancers.  UV irradiation coming from the sun can have many effects on skin, most of which are harmful. UV rays reach the earth surface at various intensity during different time of the day and seasons. Compound effect of UV irradiation and toxic gases in atmosphere increase many skin diseases.

Depletion of ozone layer in atmosphere is another imminent threat. Photochemical smog, supersonic aircrafts and gases deplete ozone layer in the sky, increasing UV rays reaching earth surface. For every 1% decrease in ozone layer, there is 2% in UVB intensity and 2% increase in skin cancers.   

Cumulative effect of the pollutants, UV radiation and ozone layer depletion amount to an array of skin diseases that are exponentially rising. Hence urgent measures to curb the pollution and environmental damage in Kathmandu is of paramount importance.

Can we do anything to save ourselves and save our skin from the premature uninvited turmoil?? Skin is a large organ and it isn’t possible to completely cover all areas of skin. Wearing full sleeves can curb the direct exposure to some extent. Since these pollutants get absorbed through exposed skin, washing our face, hands and feet should be a regime. While outside, wearing protective moisturizers and sunscreen  act as barrier as well as fight sundamage. These products form films on the surface of skin and protect from instant damage but not long term protection. A medical study has revealed that Dead Sea minerals rich water (DSW) and Pollustop creams attenuates damage by UVB. They act as physical barrier and protect against carbon and heavy metals induced damage. But they are not readily available in common cosmetic market. Besides these, minimal endeavors can be done on personal front to control health implications of pollution. 

In summary, impact of global warming, pollution and sun damge can be seen on skin as pimples, sunallergy, rashes in short term while wrinkles and cancer in the long run.

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Food Allergy: What are problem foods??

Food allergy is on the rise, and someone with food allergy can present to a skin specialist, physician, child specialist and sometimes even a surgeon. Urbanization, environmental pollution, promoting caesarian delivery, changing food habits, etc. contribute to sharp rise in food allergy in recent past. Being a less discussed entity, patient might be unaware of the actual cause of this distressing health issue.


What is food allergy!
Food allergy is an abnormal reaction to food, triggered by our immune system. Immune system is our body’s defense mechanism against harmful threats such as bacteria, viruses, etc. When this defense system reacts against certain food components, it manifests as allergy. Common symptoms of food allergy are stomach upset, pain abdomen, itchy skin rash, blood in stool, diarrhea, difficulty breathing, swelling of face, unexplained fatigue, irritability, etc.  Symptoms of food allergy usually begins in childhood, but can also start later in life.

There are range of delayed onset food allergies that appear as late as one week after food intake. It is difficult to point at the triggering agent in such situations. Moreover, some people show symptoms without an actual allergy. It is due to intolerance to certain food components. For example, intolerance to lactose component in milk, manifests as diarrhea within few hours of milk consumption. Also, some foods directly produce chemicals such as histamine, mimicking symptoms of allergy. Foods such as wine and pickles cause itchy mouth, sneezing or difficulty breathing promptly. This reaction is dependent on amount ingested. This is not exactly food allergy. Your doctor will be able to tell you precisely.


Foods associated with allergy
Common food allergens in our circumstance are cow milk, egg white, peanuts, fish, wheat, soy bean, dairy products such as cheese, etc. Other allergens are raw fruits and vegetables, tomatoes, chocolate, legumes, lemon, etc. Some foods such as meat, vegetables and fruits can be rendered harmless via cooking, because their allergenic components are destroyed by cooking. Food products such as preservatives, colorants, flavor enhancers such as cinnamon, menthol, vanilla, food additives, wine, dried fruits, pickles, strawberry, etc can directly stimulate symptoms similar to food allergy.


Who gets food allergy??
Small infants and children are more prone to food allergy. Some foods such as cow milk and egg white cause specific symptoms from early childhood. Early introduction of solid foods or formula milk products before six months of life has been associated with development of allergy. Children with history of allergy in family members are at more risk.
Adults can also commonly develop specific food allergies later on.
Generally, someone with one food allergy might also have other food sensitivity. Having said that, all potential food allergens do not cause symptoms in everyone.


COW MILK PROTEIN ALLERGY

Cow milk protein allergy is common in developed world, while it is rising in our part of the globe. It is not always diagnosed as we do not suspect food allergy frequently in our scenario.

It usually begins within first year of life, and occurs within a week of introducing foods containing cow milk protein. Children typically present to a doctor with diarrhea, vomiting, bad stomach ache or blood in stool within few hours of consuming cow milk or formula feed. Other symptoms are crying inconsolably, irritability, skin allergies, such as itchy hives and eczema, swelling of eyes and lips, shortness of breath, etc.

Children who are not exclusively breastfed for at least first four months of life are at more risk. Components of cow milk protein are present in common formula feeds available in the market, affecting children who are put on these feeds. Cow milk protein is also present in skimmed milk, butter, curds, cheese, yogurt, beverages, burgers, etc. Older children may have eating difficulties, avoiding certain foods, poor weight gain, etc. Do not force your child to eat foods he denies or refuses consistently. Children are often unable to express the discomfort or symptoms accurately.

A doctor makes a diagnosis based on patient’s complaint, previous episodes and careful examination of the patient. Tests such as skin prick tests, specific blood tests (IgE antibodies) help in confirming cow milk protein allergy. These tests are available in few hospitals and laboratories in Nepal. It is not always mandatory to have tests for the diagnosis.

Treatment is avoidance of the food trigger. Exclusive breastfeeding for at least 4 months, and preferably 6 months seem to be protective. In circumstances where exclusive breastfeeding is not possible, it is important to choose formula feed vigilantly. Common formula feeds are not recommended. Partially hydrolyzed infant formula or “hypoallergenic” formula milk should be chosen. Soy formula or litho can be a reassuring alternative in our scenario. However, 10-30% children with cow milk protein allergy also cross react to soy proteins. Replacing cow milk with goat or sheep milk isn’t recommended. On brighter side, cow milk protein allergy generally improves by 6 years of age. But there is no specific age for reintroducing cow milk in diet.

Other food allergies common in childhood are egg white and peanut allergy. While peanut allergy is a menace, children might develop tolerance to egg whites similar to cow milk. Doctors usually advice patients to avoid problem foods, however, a recent study showed that exposing young child with small amounts of culprit foods, eg peanuts, help them develop tolerance to that specific allergenic food.
Another aspect of food allergy is whether we can predict them before they happen. The answer is no, except in few instances, where parents or other family members have similar problems. Children with dry skin, reactive skin and asthma have increased likelihood of developing allergies as adults. But no one can exactly anticipate it before it happens. Parents have to be alert and cautiously follow their child’s relevant symptoms in relation with food intake.
Hence, food allergy is less commonly discussed, not so uncommon health problem.

Birth of a girl child...

After five beautiful years with my daughter, I was in operating room again, ready to bring my second borne into this bittersweet world.
He was borne at fifteen hundred hours, as the day was exhausting into soothing twilight...  An anesthesist friend brought him to me, as I lay in OT table. I noticed his nose, similar to mine. I smiled. My pediatrician husband then took charge of the baby.

I was taken to postoperative room for the night. Two patients were already there, I was placed on the third bed. I was well acquainted with pain, from my previous caesarian section. As a doctor, I also knew I could comfortably rely on analgesics.  However, other two ladies were winching, carefully fidgeting, so that any movement wouldn't throb their raw wounds.

Midnight passed. I was dozing off to sedative-induced drowsy sleep, when a wheeler rolled in. It carried a teenage newmom, after emergency operation. Her babygirl was put to her side. Some hospitals bring baby to mother's side immediately after operation, while others wait 24hours.

As the newborn started crying out of hunger, her mother didn't seem keen to feed her. At first, I thought it was probably because of pain and apprehension immediately atfer operation. Her mother in law was summoned for help. It was then, that I was astonished beyond words. Both women started cursing the newborn. They were so upset that it was a girlchild. They called her names, in harsh cruel offensive language. Mother-in-law angrily vanished out of the room into the darkness, blabbering all the while..... I sank in my bed in horrid disbelief. I found it brutal, close to barbarious. But it was kind of routine for caretaking nurses and obstetric staffs. They didn't react.

The baby was still howling, unaware of the harrowing cruel world she just came into. All she wanted... was her mom's suckle and granny's snuggle or her father rocking her to sleep.... :(

Nursing staff fetched the father in, hoping he could assist the new mom. This first time father was just a boy, perhaps in his late teens. He gently asked his wife to feed the child, but she started ranting again, vehemently. He seemed more level headed than both the ladies. He sat silently for few minutes. It seemed he wanted to help but had no idea what nursing or breastfeeding meant. Their first born was wailing all the time. But her mom was deafmuted to maternal emotions. After few requests, he gave up attempts of coaxing his wife and walked out of the room.

Meanwhile, baby seemed exhausted from crying. Her shrill screams became whimpers and then periodic sobs. Morning was less than hours away when she sobbed herself to sleep.

As the dawn pierced the gloomy dark night, bringing in pale yellow rays through the curtains, I woke up. To my surprise, my fellow mate was feeding her child. Even the granny had mellowed down a bit. She was spreading the light meal hospital allowed for the patient. It was as if the soft morning breeze had lightened their hearts. I understood they had finally amicably accepted the birth of a girl child. Then I heard the teenage mom talk to her child, a hint of tenderness in her voice. Love had sprouted amid the bitterness, anxiety and laments....

My heart crushed for them all. They were mere victims of a mindset, of social preference for a male child.

Why I didn't gain weight??

Everyone has been asking why I haven't gained weight after delivery or during pregnancy.
Its actually a long story, that I didn't wanna whine about in social media. Yes, our lives aren't exactly what we potray in facebook n instagram. We don't look as good as our pictures. I have dark circles, bags and perhaps much more. I haven't slept more than two hours in one stretch of a time in last two months, coz that's how frequently I need to feed my newborn.
Coming back to weight gain, my pregnancy and puerperium were more stormy than I ever imagined.
Pregnancy pukes were so horrible, I landed in ER and took IV drips. I had ketonuria, ie frequent vomiting made me pass glucose in urine. I had hyperemesis for first 4 months.
 During last 3 months, I had severe iron deficiency n anemia. In my final month, I was bedridden coz of my preexisting illness, fibromyalgia. I couldnt eat, I couldnt sleep.

At 36 weekd, a random ultrasound showed that my uterus was just about to erupt or dehisce. Uterine wall thickness was less than 4 mm.  I had to rush for emergency caesrian section. Operating gynecologist ma'am later informed that my uterus was plastic thin and baby's hair had already protruded out of the defect. I was rescued right before uterine rupture threatened both me and my baby's lives. Hubby told me later that day, that it was my second life.
But it was only the beginning of my countless sufferings....
My baby was taken to neonatal ICU for first 24 hours for TTN. My hubby informed me that my boy had heart murmur, a suspected VSD. I was petrified. Amidst so much pain,  all I could think of, was my little boy's VSD. I cried, whined, sobbed and prayed. An ECHO revealed that the defect was small, which would most likely, close spontaneously. But only time would tell.

On the 3rd night, while still in the hospital, I got fever from breast engorgement. Severely painful milk expressions, day and night, for 4-5 days, and it dwindled a bit, only to be followed by wound infection, urinary tract infection and uterine wall infection. There was fluid collection(seroma) at wound site, which was drained via syringe.
At the end of second week, my wound hurt so bad that I couldnt empty bladder or bowel. It went on for a week before a senior gynecologist at Grande Hospital detected the source of infection. I took my third course of antibiotics. I was so weak, I couldnt eat or sleep well.
Just when the wound infection abated, and I thought all was well, I woke up in the middle of the night with fever, rigors and excruciating breast pain. Next day, I was told I had second bout of breast engorgement involving entire lower zone and risked forming an abscess. There I was, getting IV antibiotics again, fourth course. Running to hospital four times a day, as I refused admission coz I couldn't risk exposing my baby to hospital acquired infections. I was five weeks postpartum by then.
As that episode subsided, I had vestibulitis along with aphthae and dental impingement. I couldn't eat, again. My dose of antibiotics were escalated, as they feared my nasal infection had risks of passing into the connecting brain linings. With treatment, my swollen nose and eroded tongue was beginning to wane, and I had severe gastritis, forcing me to stop all antiobiotics.
Between all this, my wound pain had revived. And my gynecologist said I had scar adhesions, probably connecting to the uterus. He was apprehensive that I might need laparoscopic surgery for breaking adhesions if my pain won't subside. Maybe after 6months or so. But for me, any more surgery sounded like death sentence. I had suffered so much, any surgical intervention scared me.
Thankfully the wound pain vanished. And now, my baby is two months old, thriving well, with remarkable weight gain. And his murmur has disappeare. He has embraced my genes wholeheartedly, his light brown eyes, sharp nose, full lips and the dimples that light my world when he smiles.

During all the chaos, my baby's healthy weight gain was my only pride. And I learnt two things, pain is a constant, yet nothing lasts forever. I survived and I conquered.