SIRI SRINIVAS, 07 Jan 2009 | Citizen Matters
As a matter of principle, we don't like over-achievers around here. But some, we let pass. Rakesh Sharma is currently interning at St. John's Medical College. He will head to Oxford to pursue a D.Phil in Clinical Neurology as one of this year's Rhodes Scholars. Like that were not enough, he manages his own show on WorldSpace Satellite Radio. He also writes a popular blog about the pains of juggling medical education alongside culture clashes. Having excelled in theater, music, writing, and academics and, yet, miraculously managing to retain a sense of humor, he talks to me about pulling off studgiri so effortlessly.
Tell us about yourself.
Regular Jack, with none of the bildungsroman melodrama. Grew up mostly in and around Bangalore. Went to Sudarshan Vidya Mandir, Jayanagar. Chose to make study-hard-get-into-NCJ my mantra. Didn't study hard, got into NCJ nonetheless. Then got into St. John's, which has been fun until now if not mirthful. 'Fun' is such a good fill-in-the-blank word.
Interests have been many and varied. Like most South Bangalore Brahmin Boys, I have done something classical - music in my case. Did Carnatic as a child, and Hindustani much later. But then, I haven't been able to pursue them with as much vigour as I would have liked. Writing is a much loved interest, but one that requires effort and I have been historically known to not put in any. Films I thrive on, and I read about 12 books at a time. And yes, radio! I am with WorldSpace, a job not so much a job as a pleasant musical weekly diversion.
Now that you should ask, I really have no answer. Seemed like the only viable option that would keep me from the noose. I get bored very easily. The mundane-ness of things gets to me far quicker (and much stronger) than it does most people, I guess. To not be a keyboard-clunking-cubicle-animal was thus a foregone conclusion. Medicine, on the other hand, seemed so hands-on, so inter-personal, and at times full of instant satisfaction. It is true that I have vacillated in extremes about this particular choice given how medicine excites and exasperates in as little time as seconds, but no other profession could boast of doing social good while also challenging one academically, and giving you a strong sense of purpose.
When did you first give the Rhodes Scholarship a thought?
Erm, I had heard of the scholarship, but thought it to be one of those urban myths until when I went to St. John's. During my first year, one of my seniors won it. And three years later, one more senior (Amal Isaiah) won it. So that's probably when I first thought of it.
The Rhodes is without doubt the most prestigious award there is in the world for undergraduates, and the many others that have followed in the same mold pale in comparison. What attracted me to it were the selection criteria. I was gladdened beyond belief that the scholarship looked beyond one's marks cards. Coming as I do from a frustratingly marks-oriented academic system, it seemed like there was hope yet for people who chose to be well-rounded individuals as opposed to academic automatons.
How has studying at St. Johns helped in the run-up?
Immensely. Being one of the few medical colleges in the country that lays emphasis as much on clinical medicine as research, a John's undergraduate is exposed to a whole range of options very early on. Our research centre (IPHCR) is doing a great job, the hospital believes in ethical and affordable medical care, naturally making it one of the best in the state, and the college, with its added emphasis on ethics, rural health care, student research etc, is with good reason consistently among the top ten in the country.
Besides, John's has the highest number of Rhodes Scholars for any medical college. Dr. Christoper Mathias and Dr. Salim Yusuf are stalwarts in their chosen fields. Dr. Anoop Sebastian and Dr. Amal Isaiah, our recent Scholars are also doing great. So, the reception to Johnites by the Rhodes Committee is overwhelmingly nice.
So what happened at the interviews?
My nails got shorter.
And when you were told that you'd won?
Right after the interviews. They took about half an hour after all the interviews. Called us in. Said they would announce it in alphabetical order (of surnames). And mine was the last name. I near died.
So what clinched it?
I'd like to say Cheerful Disposition, but that would be lying. I don't know, honestly. The panel is a smart set of people, and to narrow down their choice of a person to a couple of reasons would be to question their smartness. But, as a blanket statement, honesty would be it. They can see right through pfaffy answers.
What happens in A day in the life of Rakesh Sharma?
A day in the life of me would be boring. Mostly hospital stuff, and red stilletos do not an entry make. The life of an intern on Grey's Anatomy/ Scrubs is very far from the life of an actual intern. Very, very.
To chill out, I drink coffee at the canteen. Kapish?
Do little things look different now? Tell us about "vindication".
Heh. For one, I am not giving post graduate entrance exams. They had me a tad worried.
Do things look different?
They would probably, if one chose to sit on a pedestal. But one hasn't.
Vindication is for the vindictive. I am not. See, I'm giving you an interview a good two months later.
Your folks must be really proud!
Yeah, they are. And honestly, a lot of the credit must go to them for letting me be and putting up with all the craziness that's me.
I head to hospital. And quietly hope for a better tomorrow.
8 months, 4 nations & 32,000 miles later – A Snapshot of our International ExperiencesA little bit about us…
We are two fourth year medical students who were granted an extended year of medical school to pursue international experiences. Our journey began with our wedding a week before we left on our 8 month trip. Its been an amazing first year of marriage and we gained a lifetime of memories. Our calloused, bug bitten, now healing feet have touched four nations (not including numerous layovers), traveling over 32,000 flight miles (plus countless more in auto rickshaws, trains, buses, taxis, trufis, carriages, motorbikes, & on foot).
How we decided on where to go…
Our desire was to see and partner with a variety of hospitals and medical service projects overseas. In the future, we are considering work overseas and wanted to explore this long-term vision by taking an extended year prior to residency. We wanted to see what the needs were and see how we could best use medicine overseas in order to guide what course of further training we would need. We decided to contact hospitals and doctors through IMER and on our own. Through the contacts we are able to create a tailored itinerary that would take us to four countries around the world – Nepal, India, Bolivia & Costa Rica working in missions hospitals, academic institutions, public hospitals, and mobile clinics.How our journey began…
Our travels began with >2 days of flights, buses, taxis and not having 3 important checked baggage for several days. Being without toiletries or change of clothes etc. for three days was an unforeseen hurdle to say the least. After a few days of multiple phone calls we received them. The following days brought more drama as a 6 hr bus ride to Tansen Missions hospital turned into a 16 hr trek with road blocks (fires in roads, hostile people with sticks, armed guards, basically a human road block). We were thankful to finally arrive safely to our destination in Nepal.INDIA
Nothing could have fully prepared us for India – the nation had the unique ability to inspire, frustrate, thrill and confound us all in the same day. There's a constant sensory overload with the noise of autos, lorry trucks, cows mooing, scooters blowing their horns and the many smells that test our cranial nerves (some positive, some negative).St. John's Hospital…
Located in Bangalore, India (population 6 million) in the state of Karnataka, St. John’s hospital is a large academic hospital affiliated with the University of Minnesota. We rotated in Community Health for a few weeks and made daily 1-3 hr trips in rugged Jeeps to the rural villages, mainly to Mugalur and Lakhur. Clinics were set up, physical exams done, immunization given, hours of health education taught and numerous diseases were treated. Otherwise, we rotated through OB/GYN, Dermatology, Pediatrics, and the Intensive Care Unit gaining much perspective. The disease pathology and the medical system itself were fascinating (and at times also frustrating) for us to experience. We enjoyed seeing wildlife here daily: monkeys, emus, deer, exotic birds, roosters, goats, lambs... Many of these animals are actually on the hospital grounds and used for pet therapy for the patients.HIV/AIDS Center –
This hospice care and children's home was started to help those with this disease. The patients are shunned by their family, as many people in India still think they can contract the disease through touch. We spent our time rounding with the staff, working with a paraplegic patient doing physical therapy, playing with the orphaned children, and updating the nursing staff and doctors with the latest evidenced
based medicine treatment & management of infectious diseases - TB, AIDS.
San Juan de Dios Hospital located in San Jose, Costa Rica is connected with Universidad de Ciencias Medicas (affiliated with the University of Minnesota). Dr. Hernando Gonzalez helped us set up our experience in San Jose and we were assigned to work with Dr. Monge (extremely hospitable and a great instructor). We rotated through Tropical Dermatology and were exposed to many diseases we had only read about. Living with a great host family (organized by UCIMED) we enjoyed practicing our Spanish, learning more about the culture, and eating wonderful dinners. Our weekends were spent travelling around beautiful Costa Rica.
From January to April, 2009 we plan to be overseas again, this time to be in Honduras working at a hospital there, mainly on the inpatient services. We plan to return and begin our residencies in June 2009.
One of the best ways to gain both medical and educational perspective is to travel. We like to explain it by a mathematical equation: a change of place plus a change of pace equals a change of perspective. We cannot go back to our former perspectives after treating a tiger bite, a 75-year-old woman injured after climbing atop a tree in attempts to collect firewood, or having to wait one month to receive results of "routine" lab tests. We have gained understanding of the density of suffering this past year working in health care facilities with extended exposure to impoverished communities. The immense need of the people, the vibrant chaos of their lives, and the variety of costumes, cuisines, and cultures have left us drained. Certain images keep returning with an absolute force: the leprous distorted fingers thrust into our faces, the impoverished woman with AIDS who was outcast by her family, and a child covered with dirt on the street stretching out his hand to offer us the rest of his bread. In the future, we envision ourselves involved with programs that bring not only supplies, but also dedicated physicians to underserved people groups.
A look at the latest products for anesthesia, monitoring and warming.
As a teaching hospital-based anesthesiologist, I'm always interested in trialing the latest technology to see how it will shape the future of the field. So every year I make a point of visiting the exhibit hall at the American Society of Anesthesiologists' annual meeting and reviewing the newly introduced products. Here's what stood out when the group convened in Orlando in October.
B. Braun's Space Infusion Pump System looks like a flexible, easy-to-use, drug delivery option. Its compact, lightweight and modular syringe and large-volume pump units let you station multiple, independently operating infusion sources at bedside with a minimal footprint. The rechargeable-battery-operated units stack together for IV pole or rail mounting, or can be plugged into the portable Space Station housing, which can accommodate and power up to four pumps. The company says the units list for about $2,800 each.
B. Braun also highlighted its Stimuplex HNS12 nerve stimulator, which features the new SENSe (sequential electrical nerve stimulation) software. The new technology builds on traditional nerve stimulation's two short pulses per second with a third, longer pulse for greater sensitivity and improved neural response. This seems like it would make placing nerve blocks quicker and easier. The unit retails for $900.
Teleflex Medical is adding new safety and infection control features to its Arrow StimuCath Continuous Nerve Block Kits. The trays will now include SafetyGlide Injection Needles, SharpsAway II Locking Disposal Cups and StatLock Catheter Stabilization Devices in the name of sharps safety. They'll also now offer a choice of skin preps, including Tinted ChloraPrep Hi-Lite Orange, as an alternative to povidone-iodine.
LMA North America introduced two new advances on the traditional laryngeal mask airway. The LMA Supreme ($25), a single-use device, features a larger, pre-curved cuff that lets you position it faster and more accurately to obtain a good seal without exerting much pressure. It also has a built-in drain tube for channeling fluid and gas from the airway, and a built-in bite block.
The LMA Classic Excel ($319), on the other hand, is reusable up to 60 times. It improves on the LMA Classic by exchanging the aperture bars, which blocked intubation, for a figure-eight shaped epiglottic elevating bar, past which an endotracheal tube can be inserted.
AES has also innovated the laryngeal mask airway with its Ultra Cuff Pilot Valve. The latex-free, single-use airway, available in neo-natal to adult sizes, measures and reports the air pressure in the cuff by way of an attached valve. The colored indicator bands on the valve provide instant feedback to potential changes in placement. It's a small improvement that lets you inject safety into the process. The device comes in two models: The 100 percent silicone cuff and tube version costs $11, while the PVC tube with silicone cuff version costs $9.
Two Teleflex Medical products seek to reduce cross-contamination in laryngoscopy, says the company. The Rüsch EquipLite laryngoscope blade, available in a full range of Miller and Macintosh sizes, offers the strength of metal, but in a single-use blade. It's compatible with conventional handles and includes an LED light source. The Rüsch TruLED laryngoscope handle features a removable, rechargeable, autoclavable battery cartridge for repeated use. Another Teleflex product, the Rüsch TruView EVO Infant, features a hybrid Miller and Macintosh blade coupled with a prism and lenses to allow a view into the smallest patients without having to hyperextend their necks. All three Teleflex products are scheduled for January availability and have not yet been priced.
In an effort to serve patients of all sizes, Verathon Medical showcased its addition of a GVL 5 blade, for morbidly obese or bariatric patients, to its line of reusable GlideScope video laryngoscope blades. The company also offers a single-use Cobalt 1-2 Video Baton for its GlideScope Cobalt pre-term/ neonatal video laryngoscope. The pre-existing systems list at about $10,000 to $11,000, say company representatives, with blades costing about half that.
One way to improve airway management is to ensure you're dealing with healthy airways. In the exhibit hall of its own show, the ASA promoted its "Be Smoke-Free for Surgery" campaign (www.asahq.org/stopsmoking/provider). Since smokers have an increased risk of perioperative respiratory, cardiac and wound complications, and since quitting reduces those risks, the campaign suggests that patients scheduling surgery should quit smoking, and that anesthesia providers, being respiratory specialists, can effectively advise them to.
A non-invasive, immediate and continuous hemoglobin count is now available as a function on Masimo's Rainbow SET technology platform. The measurement, which once required a needlestick and a trip to the lab for a delayed snapshot of a patient's hemoglobin situation, now employs a fingertip sensor and light absorption to produce numerical results on a monitor screen. This means no drawing of blood and no waiting for lab results. If you have a Masimo pulse oximeter (which costs about $4,000), adding the hemoglobin software and license costs about $4,000.
In some orthopedic cases, such as rotator cuff surgery, a patient who is anesthetized and ventilated in the supine position then moved into the beach chair position will experience significant oxygen desaturation in the brain. With CAS Medical Systems' Fore-Sight Absolute Cerebral Oximeter, providers can non-invasively and continuously monitor the O2 sats of a patient's cerebral tissue and take action against hypoxia if needed. Disposable sensors placed on the forehead — and sized for infants as well as adults — beam infrared light through the scalp and skull to deliver the results. The system costs $35,000, says the company.
Smiths Medical has miniaturized end tidal CO2 monitoring with its BCI Capnocheck capnometer. The pocket-sized, 2.1 ounce device connects to a mask, endotracheal tube, LMA or other airway conduit and delivers its data on an LED digital display. It runs on two AAA batteries and can even be worn on a lanyard. The sensor body itself costs $1,000 and the single-use airway adaptor tube $10.
Sometimes elderly patients are dehydrated or otherwise show low blood volume. Hospira's Voluven (6% Hydroxyethyl Starch 130/0.4 in 0.95 sodium chloride injection) is a plasma volume substitute intended to effectively treat hypovolemia so you can safely anesthetize them. The substance costs $45 per 500ml IV bag, and is sold 15 bags to the case.
Smiths Medical says its CADD-Solis Ambulatory Infusion System, which lists at $4,500, lets you program your best practices into a mobile pump. The compact device, whose software lets you establish standard pump protocols and hard and soft dose limits with safeguards and visual alerts, features onscreen graphs and trend reports for intuitive auditing. An ergonomically designed remote control for dosing is also available.
The advances made in implantable neurostimulators for chronic pain in recent years have been impressive. Medtronic's RestoreUltra is palm-sized and 9mm thick. The percutaneous leads that plug into it are programmable to treat specific areas of pain management needs and are adaptable if pain patterns change. The company says the unit can run for nine years if the battery is charged once a month, which the patient does by wearing a recharging harness for about an hour. That shouldn't be too much of a burden. The RestoreUltra lists for about $20,000.
A conventional anesthesia mask is strapped on top of the patient's face and can easily be displaced. The Sedation Mask from Sedation Systems, on the other hand, fits under the chin for stability. The single-use mask, designed by a board-certified anesthesiologist, aims to improve the quality and safety of monitored anesthesia care. Its inflated cushion seals in anesthetic agents, and a separate port below the breathing circuit port for continuous end tidal CO2 monitoring allows the mask to stay on throughout the procedure.
Respironics, now a division of Philips Healthcare, has innovated its PerformaTrak non-invasive ventilation masks with the CapStrap headgear system. For patients who depend on continuous positive airway pressure machines, the new feature — which lets you flip the mask open and shut so that patients may be fed, hydrated or medicated — means that providers won't have to remove and replace the mask several times a day. The single-use mask retails for less than $30.
The Hot Dog Patient Warming System looks like a high-tech, purple electric blanket. Using low voltage and a semi-conductive polymer fabric, it provides the patient with even and precisely controlled warmth throughout the perioperative process. The company, Hot Dog International, says that its product holds a number of advantages over forced air warming, including that it's silent, it's reusable, it uses less electricity and it won't blow airborne contaminants around the patient or the OR. The system, which consists of a controller and the blanket, costs about $2,500.
LMA North America's PerfecTemp Patient Warming System aims to protect patients against hypothermia and pressure injuries at the same time. It's a viscoelastic foam OR table pad that incorporates a heating element for uniform and monitored warmth from beneath the patient. It's quiet, radiolucent and leaves the surgical team with access to all areas of a patient's body. The system, including the pads and a pole-mounted control unit, list for about $9,800 to $10,000.
Patient warming is undoubtedly important, but surgical staff members get cold, too, especially over by the anesthesia cart. Arizant's Solor Vest offers a solution without cords or hoses. The machine-washable fleece vest, available in five sizes, incorporates a rechargeable battery-powered lumbar heating unit. When worn beneath a scrub shirt, the vest can keep a chilly clinician warm for up to six hours. The vest, with battery pack and charger, costs $225.
GE Healthcare's LOGIQ e system combines ultrasound technology with a touchscreen interface to offer users real-time clinical images and controls on the same flat-panel monitor.
The system is operable via a laptop device, but users can also control the imaging, change parameters or annotate the image without looking away from the touchscreen. An articulating arm offers flexibility in the viewing angle. The company says the instrument lists at $50,000 to $55,000, depending on its configuration.
Pajunk's SonoPointer, recently approved by the FDA and scheduled for U.S. availability this month, uses ultrasound to orient and guide the anesthesia provider to the puncture and the precise placement of the cannula for accurate nerve block administration. Determining the exact location and angle for the puncture point with an ultrasound monitor isn't always easy, but the SonoPointer projects a crosshair on the patient at the site indicated by the ultrasound transducer.
I was born and raised in India, primarily in Bangalore. I went to medical school at St. John’s Medical College and subsequently immigrated to the United States of America. I did my residency in General Psychiatry at the Nebraska Psychiatric Institute and the University of Nebraska Medical Center. During my residency I took time to go to London and get training at Guy’s and Maudsley Hospitals. I then completed a Fellowship in Consultation/Liaison Psychiatry and Psychosomatic Medicine at Boston City Hospital and Boston University School of Medicine. I subsequently became a faculty member at Boston University and Tufts University Schools of Medicine. I then left Boston and joined the John A. Burns School of Medicine in Honolulu, Hawaii where I am a Professor of Psychiatry. It was here in the multi-ethnic societies, I develop my interest in cultural psychiatry.
I am board certified in General Psychiatry, Geriatric Psychiatry, Psychosomatic Medicine, and also have certificates in Clinical Psychopharmacology and Neuropsychiatry. I was also certified in England as a Member of the Royal College Psychiatrists, and subsequently elected as a Fellow by the College.
I am currently a Distinguished Fellow of the American Psychiatric Association, and a Member of the American College of Psychiatrists. I am a member, and the former Chair of the Ethnic Minority Elderly Committee of the American Psychiatric Association. While I am primarily a clinician-educator, I have researched and published in the areas of Cultural Psychiatry, Geriatric Psychiatry, Consultation/Liaison Psychiatry, Neuropsychiatry, and Psychopharmacology.
Dr. Iqbal “Ike” Ahmed