ramadocblog

Do you know what is Ram ventilation?

No! It is not named after me! (delusions of grandeur much!)

Then again this makes the animal ‘RAM’ around!

On a related note! Do you know that there are some living beings who simply have to move all their life! The moment they stop; they die! There is literally no rest for the wicked!

Lets us not Ram around the bush and get to the point!

So Ram ventilation is a method of breathing used by some fish and sharks where they swim with their mouths open, allowing water to flow over their gills for oxygen uptake. This process relies on the forward motion of the animal to force water into the mouth and over the gills, rather than relying on muscular contractions to pump water.

The mechanism involves the animal swimming with its mouth open, creating a pressure difference that draws water into the mouth and across the gills. Now as water passes over the gills, oxygen is extracted and transferred to the bloodstream, while carbon dioxide is expelled.

Some fish and sharks, are obligate ram ventilators while some fish, like tunas, have evolved specific gill and skeletal adaptations to enhance the efficiency of ram ventilation.

But Ram ventilation comes with a price!

The sharks must swim constantly in order to keep oxygen-rich water flowing over their gills, but others are able to pass water through their respiratory system by a pumping motion of their pharynx!

This allows them to rest on the sea floor and still breathe. However, sharks do have to swim to avoid sinking to the bottom of the water column. The ability to move up and down freely in the water column is, in fact, one of the extraordinary adaptations of sharks.

Sharks, do not have a swim bladder like bony fishes, instead, they rely on lift generated by their large pectoral fins, much like the way an airplane’s wings provide lift and also sharks have very large livers that contain a high proportion of oil providing them with additional buoyancy! Of course when there is a species which has something valuable you have humans trying to get it!

Which is why Shark liver oil is in demand!

It has been long used in Scandinavian folk medicine to treat multiple ailments, including wounds, cancer, heart disease, and infertility!

Nowadays, it’s sold as a dietary supplement that promises to deliver these same health effects. Research on SLO attributes its multiple health benefits to its high alkylglycerol (AKG), squalene, and omega-3 polyunsaturated fatty acid (PUFA) content.

Then again you can also learn from the fact that may be the reason why Shark is so fit and strong is because it is on the move all the time! This is just Ram speaking! Then you have Raj speaking or rather Rajkumar! In this case; ShivRajkumar! Do check out his OM and AK47! Movies that is!

Shubh ratri!

Mustard may be one of the most universal things ever! If you like the sauce though then you must thank an ARMS RACE between plants and caterpillar!

The availability of these small seeds determine whether you will be making sambar or palya or not! These small items like the Mustard, some pieces of dal like Urad or chana, turmeric and jeera are the small things which are always in less quantity but you cannot start your cooking without them!

It is so amazing that we use them to test whether the oil is reached a proper temperature or not! The splashing of mustard seeds is the standard mode of operation in every kitchen in india! After a good meal, my mother used to even eat those pieces of splattered mustard! She used to tell that it is a great carminative!

The chutney is incomplete without a tempering of mustard! The same with those amazing pickles or vegetables!
The chief difference at least in my house between Sambar and rasam was the seed! If it is mustard then it is sambar! While if it jeera or cumin seeds then it is rasam! With Jeera though you must not wait for the oil to heat too much since they burn the jeera and do not splatter!

In many parts the oil is the way to go! The oil is an acquired taste though since many may not tolerate the smell. Though you can use a little salt to reduce the odor which is not bad but if you are not used to it then you may not like it!

Then you have the SARSO ka saag! Which is the go to dish in the old movies of the North!

One western Fad which is now everywhere is the mustard sauce! It is also an acquired taste! It is sour and a little bitter! Some swear by its taste though! Many cannot get enough! Since I am not a foodie; I can take a little and that is that!

But it is the lead in the taste! It is a pungent and dominant taste with a little bitterness and sourness to boot!

But did you know that the taste is so strong because plants were developing a weapon!?

The zest taste is a game changer for many and must have! The fact though is that it tastes like that because it is a natural insect repellent!

Despite humans’ taste for mustard, it evolved as a pest repellent. Mustard plants start by making compounds known as glucosinolates, which in turn produce pungent mustard oils when chewed or crushed.

This was prompted by relentless nibbling from butterfly larvae, but as caterpillars evolved new ways to cut the mustard, plants had to up the ante — thus, growing zestier and zestier over time!

So the next time you add a liberal dollop of mustard just remember that it was rejected by a caterpillar! Now now! Don’t feel bad! At least you are not a castaway!

Which reminds me of Tom Hanks!

Now have some warm milk without mustard and sleep!

Shubh ratri!

Who is a teacher?

Well he or she is anyone who inspires you!

Age and experience are only the added bonus!

If someone is good and wants you to become more good than he or she then he or she is a teacher!

Some teachers are stern; they may not praise much but they know your potential and they want to you get better! While some others praise and encourage you in every step! It is a fine art of balance when an abundance of both is not good for the student!

There have been amazing teachers who themselves have actually not succeeded but then again they know how to fail! So they can teach you how not to fail! Which is why many times you have a very successful student but an ordinary teacher! And then you have those who have reached the pinnacle of success and want you also to do the same! 

In the world of Rat race; when someone is teaching you whole heartedly then he or she is a great teacher and a great human indeed!

On the day of Guru Purnima. I pray to all my gurus or teachers! 

My chief KKR is probably one of the best Otologist in the country with a special interest in Larynx! His discipline and determination has made him a legend! There are thousands of ENT surgeons in the county and the world who have been his lucky students including me!

There are scores of stories about our chief and that can fill a book! Here is one simple one!

One day after a major case we were going for rounds and our ever observant chief saw a nursing student reading a book on tracheostomy care! Chief can do laryngectomy in his sleep and tracheostomy is child’s play for him! But like a curious child he eagerly asked about the book!

The very next day he ordered and got the book for our library! He said that this book for nurses has such amazing details on post tracheostomy care! He told us that we must read it! He of course had finished reading it that day!

That is when we realized how he is one of the best teachers in the country! It is because, he is always willing to learn! 

The best thing is that life and people are always teaching you! All you need to do is be a student for life! Only then you can learn!

On this Guru Purnima I humbly pay my gratitude to all my teachers with special dedication to my dear chief Prof KK Ramalingam! and hope that I remain a student for life.

Mata pita guru devo bhava!

Shubh ratri…

Do you know what is Reilly’s Law of Retail Gravitation?

or optimal positional isochrones?

You have in fact been the ‘victim’ of this science! And much more!

These are rules and regulations for making or constructing a Shopping mall!

Just when you thought that let us just go to the mall and enjoy the cool breeze and the ambience; you are actually falling right into the trap!

Shopping mall design is a science!

Have you gone to such malls and found out a kind person offering you a shopping cart!? That is the biggest trap! You will never buy less now!

But did you know that when it was first introduced, no one took the cart!

Of course the cart was to help shoppers deal with the increasing volume of goods on offer!

Now although a grocery store in Houston had for years been offering its customers the use of children’s wagons with a basket attached to help them manage their purchases, it wasn’t until 1936 when a store owner in Oklahoma City named Sylvan Goldman invented the modern shopping trolley which he called a basket carrier that bulk-buying became a possibility!

Bill Bryson in his book Made in American says how at first, customers showed great reluctance to use the new contraptions. So the clever Goldman came up with an ingenious plan!

He employed half a dozen people to push the carts around all day, pretending to shop! When others saw these ‘customers’ shopping with ease; they in their FOMO rushed to copy and they were hooked!

Now coming to some popular laws!

At their conferences, mall planners bandied about new concepts like Reilly’s Law of Retail Gravitation which is essentially, the mix of stores necessary to keep people moving!

Another such law was called the optimal positional isochrones! This is just another way of saying that the best location for a shopping center is near a highway interchange!

The owners actually want you to come but not stay in a place! They want you to move around! They want you to feel that though the mall is large; there is always some rush! In fact in most places benches are built without backs so that people wouldn’t linger on them!

Most food court tables given just enough space and comfort to induce a sense of discomfort after about ten minutes!

To think that one of the pioneers of malls called Victor Gruen had actually envisioned people sitting with cappuccinos, reading newspapers on gripper rods provided by a thoughtful management, or playing chess beside whispering fountains! Of course none of this would be profitable!

The profit is when you come, use a cart, spend and leave!
So next time you go to a mall; skip the cart! In fact the fast track less than ten items was also to make sure that those who spend less can be shown the door faster! Now now! Do not feel cheated or depressed! If you do, then you may want to go to a mall!

Of course you can save some money by treating your sadness with some music like say by P Unnikrishnan!

Try! It’s free! Or is it!?

Shubh ratri!

Do you know what’s 42!?

If you do not know the significance of 42 then you are definitely not a nerd, nor have you read the novel by author Douglas Adams written in 1979 called “The Hitchhiker’s Guide to the Galaxy”, the first in a series of five!

For now if you are worried that this will be a spoiler, well then it is not! The novel is actually a guide within the guide about how to Hitchhike to the Galaxy! Of course the Earth gets destroyed in the novel just so you know!

Now; towards the end of the book, the supercomputer Deep Thought reveals that the answer to the “Great Question” of “Life, the Universe and Everything” is “forty-two.”

Deep Thought takes 7.5 million years to calculate the answer to the ultimate question!

The characters tasked with getting that answer are disappointed because it is not very useful. Yet, as the computer points out, the question itself was vaguely formulated. To find the correct statement of the query whose answer is 42, the computer will have to build a new version of itself. That, too, will take time. The new version of the computer is Earth!

Now Douglas Adams did not think too much when he wrote the number 42 as the  answer but this number is now a part of the GEEK culture with so many theories!

Like even now if you ask your search engine or AI variations of the question “What is the answer to everything?” it will most likely answer “42.”!

The number 42 also appears in different forms in the film Spider-Man: Into the Spider-Verse.

In ancient Egyptian mythology, during the judgment of souls, the dead had to declare before 42 judges that they had not committed any of 42 sins!

The marathon distance of 42.195 kilometers corresponds to the legend of how far the ancient Greek messenger Pheidippides traveled between Marathon and Athens to announce victory over the Persians in 490 B.C. (The fact that the kilometer had not yet been defined at that time only makes the connection all the more astonishing!)

In Mathematics the special thing about this is that it is a Pronic number in that it’s the product of two consecutive integers (6 x 7)!

In the ASCII character set, 42 is the code for the asterisk (*), a wildcard character that can represent any other character or string of characters!

Some even propose that it was chosen because 42 is 101010 in binary code, others have pointed out that light refracts through a water surface by 42 degrees to create a rainbow, and others have commented that light requires 10−42 seconds to cross the diameter of a proton!

Another common theory is that 42 refers to the number of laws in cricket, a recurring theme of the books!

But it must be remembered that these are all simple analysis! It could simply have been the number of girls who had broken Douglas Adam’s heart! Then again; let us wait for some million years to find out the next answer! Just hope it is not 84 though! Or 52! Which is the age of the one with that legendary reverberating voice Kailash Kher!

Listen to his Koun Hain vo and sleep!

Shubh Ratri!

Do you know who was General Andrew Jackson? Now do not tell that he was the son of Jack!

The aim of this blog is communication! You will eventually see how!

So General Andrew Jackson was a prominent figure, leading American forces to victory in several key battles, most notably the Battle of New Orleans. His military successes, particularly against the Creek Indians and the British, earned him the nickname “Old Hickory” and solidified his reputation as a war hero!

All this happened during the American-Brit war of 1812.

In fact Jackson led troops against the Creek Nation, achieving decisive victories at the battles of Tallushatchee, Talladega, and Horseshoe Bend.

But the battle of New Orleans which was in January 1815, Jackson’s forces decisively defeated a larger British army at New Orleans! It was a great victory and moral boosting exercise for his troop!

Jackson’s leadership and resilience during the campaign in Mississippi and Louisiana earned him the nickname “Old Hickory”.

BUT! (You expected that didn’t ya!)

Around two thousand people were lost in that battle of New Orleans! The victory came at a price! Sweet but still..

Now, wars do have causality! There is nothing different about this one!

Except the fact that at the time of war, they were no longer at war!

There was a treaty called the treaty of Ghent which was signed before this particular fight! Essentially Americans and Brits had already signed the peace treaty and they were no longer officially fighting! Jackson and the other side did not know this and kept on fighting!

A simple lack of communication led to the death of over two thousand!

This is what lack of communication can do! Be it war or even day to day life! Communication is the most important thing! If you do not communicate properly and on time then it will definitely wreck havoc and create chaos! Lack of proper communication is also the cause most problems in any relationship today! Be it between two partners or even two countries!

Now every time you want to convey a message make sure that you do it properly, clearly and on time! Most importantly make sure your message or communication has been communicated properly to the recipient and he or she has understood the communication!

Simply whispering to yourself will not do! Like in kanthara, make a loud noise and make sure he or she gets it! Which reminds me of Prasanth aka Rishabh shetty!

Now listen to varaha roopam from Kanthara and sleep!
Shubh ratri!

DNB examination especially the practical one is a horror festival! Of course most such examination in a good medical set up is tough and high on nerves but the DNB is specially difficult since it is conducted not in your college or hospital where you have learnt the ropes!

It is conducted in some other place and hospital! In my case it was conducted in a different city and state! None of the professors or teachers may know you and you do not have any familiarity!

Expect sleepless nights to prepare for the unexpected!

The examination pattern is called objective structured clinical examination or OSCE!
Sometimes you will have a healthy patient and all you have to do is ask for history! And if you forget to ask an important point then it’s gone! You are expected to do procedures like AUDIOMETRY test and not believe the technician to do it!

You may be evaluated on how you actually talk to the patient! Getting the diagnosis is a done deal! This goes above and beyond that! How you behave, which instrument you take first, how you assess the patient and how you conduct tests is what is ‘tested’!

The only way to prepare apart from all the theory knowledge is to attend as many mock tests as possible! These tests prepare you to a certain extent!
The tests are usually stations with time interval. Sometimes you need to identify, while in some you need to perform. In many stations you are supposed to simply see and recognize the findings and then answer the questions in the next station!

Rest assured, you can expect questions based on the latest guidelines and trend! During my time we had the SARS pandemic and though it was not direct ENT; we were still asked everything about the SARS virus!

Sometimes the patient is real, while sometimes it is simply a student who has been ‘instructed’ to answer your specific questions! If you ask the correct and proper question, he or she will give you the answer! You not only have to get the answer but also must know the proper question to ask! All when the time is ticking and the situation is super tense!

One such mock test was going on and this station had a CT Scan film! Of course we knew it top to bottom! Being trained in a premier institute, CT PNS or the scan of the sinuses was like child’s play for us! We could get a mine load of info from just a limited coronal cut! And this one had all views!

This film had Sinusitis, mucous collection, a deviation septum and narrow meatus and what not! We could also find stuff like concha and some other cells which one of our faculty used to call the IDK and IDC cells! It means I don’t know and I don’t care! Of course he was an international faculty and he did not have to know or care! But we knew even that!  We did not miss anything! Wrote everything on a piece of paper to answer the questions on the next station based on the CT!

The next station based on the findings of the CT SCAN was of ten vital marks! At the top of my mind I could already imagine more than ten findings! Add the management and further investigation and you have material for even a hundred marks! Let the challenge begin!

There were unfortunately only two questions!

The first was; WHAT WAS THE NAME OF THE PATIENT!? and the second
WHAT WAS HIS AGE?!!

That was the biggest lesson I have ever learnt in a mock test! The raw fact is that you are not just reading a scan! You are treating a patient! A human! He is not just a finding for you! He is a person who has come for getting a treatment!

Even the age is important as far as any issue is concerned! In fact they are the two most important factors in treatment!

Now this was a mock test so it was ok to score a dud which we did! But some experiences are remembered for life! So next time you read a report; first read the name and age of the patient!

Of course if you are calm and peaceful then any exam is easy! Then again not everyone can be as calm and peaceful as the Holy Dalai Lama!

Shubh ratri!

Back in my days!

My son usually makes some cute and great jokes with this!


“you call those text back in my day we just talk”

“you call that flash light back in my day we call that portable super nova!”

“you call that a microphone nah back in my day we called those portable cave echoes”

Of course all those are creative jokes but this is one of the most scary beginning of speech for any youngster!

If these words scare you then rest assured you are young! Or at least younger that the person starting with the words, Back in my Day!

Why do people start the back in my days prologue!?

Well; when everything is gone the only thing that remains is the memory!

Memory is like that sweet smell of incense stick or the smell of charcoal after a puja or a yagna which lingers days after the event giving you a sweet nascent reminder of the event!

Every generation gets the Back in my days lecture from the previous generation! The new generation has now made it a MEME!

With all the happening in the world there comes a time when you realize that you have done this and done that but there is no one to listen!

Many old timers only need a listening ear! All you have to do is nod along and listen. Maybe put a smile and in between act surprised or pleased as the case may be!

I had a patient the other day and his by stander was his father who was an intelligent and accomplished person. Unfortunately it was peak time and time is, well most precious! I knew that after the preliminary introduction and treatment of the patient, he would start the BACK IN MY DAY or BIMD soon!

So the patient explained his issues in less than a minute and my examination was done in less than five! As predicted though, the BIMD began! It was long and frankly if I had time, very interesting! Since I like history, I do not mind listening to historical stuff! The issue here is that once the movie begins, it is very difficult to stop! A fine balancing act has to be made!

The person delivering the BIMD must be content that his BIMD has been delivered at least to some extent while the person getting the BIMD must balance the time! One way you know that the time is over is when the BIMD incidents get repeated! The moment he or she starts telling the same thing you know that you can put a pause to the delivery! Even putting a pause or even end is a tricky thing which takes experience and patience! You have to use all your composure and talent to slowly stop the BIMD! It is like driving a car on the Highway! You cannot stop suddenly! It will topple or skid or hit some other vehicle! You have to slowly decelerate and then stop!

The deceleration is by slowly turning the attention to another person or to the time or the fact that there are other people waiting for the BIMD delivery! You must also remember that you cannot simply nod! You must repeat some stuff from the BIMD delivery so that the person delivering the BIMD is satisfied to at least pause the delivery for now!

Most importantly though the chief reason why you must accept the BIMD delivery once in a while is because at some point in the future you may be the one doing the delivery!

For surgeons and clinicians and I guess in most profession, the BIMD is routine! Of course when it becomes too much or too long, it becomes a pain! Still when someone is giving his or her BIMD; just hope that it is good and short!

Short and stout but extremely talented though was Shail Chaturvedi  ji! Not much of BIMD there!

Now Back in my days we used to sleep on time! Do that when you wish!

Shubh Ratri!

Nocere is the Latin word for hurt or harm!

One of the first things we learn in medical education has this word at the top!

The term is “Primum non nocere”!

This is the dictum and the first and foremost rule for any medical practitioner!

This Latin phrase means “first, do no harm”.

It’s a fundamental principle in medical ethics, emphasizing the importance of avoiding actions that could cause harm to a patient, even if those actions are intended to help. This principle is a cornerstone of medical training and practice worldwide.

Nocere also comes again in our medical education in the form of Nociceptors which were discovered by Charles Scott Sherrington in 1906.

A nociceptor (“pain receptor”) is a sensory neuron that responds to damaging stimuli by sending “possible threat” signals to the spinal cord and the brain. The brain creates the sensation of pain to direct attention to the body part, so the threat can be mitigated; this process is called nociception!

It is surprising that even though the brain perceives pain, the brain as such is painless! There have been times when there have been huge affliction to the brain with no pain! This is really sad since your biggest friend is pain! Pain is the brake to your speeding body!

If you ask a driver, how fast his or her vehicle can go then an experienced driver would tell that the speed does not depend on the engine power or the road! But it depends on the power of the brake! This is what the pain does to your body!

In simple terms when you have pain, it’s the best thing that can happen to you!
Most of the problems of the body lead to pain which is one of the first indicator of the underlying issue! The pain is also the first symptom we ask to any patient! The elicitation of pain on your body is called eliciting ‘Tenderness’! This is one of the most important clinical examinations in medical practice.

Most of the time all you need to know is to ask the site and severity and duration of the pain to make your diagnosis and treat! The frequency and factors which increase of decrease the pain also further make our diagnosis as well as management more efficient.

In some conditions you do not have pain which is really bad like those with diabetes  which is why it is an issue.

One of the most distressing pains is the pain of Migraine which is actually the body’s reaction to either a skipped meal or a disturbed sleep! In fact the history of pain in migraine is the cornerstone in its treatment in which the most important factor is to avoid the trigger of migraine or pain!

So remember that pain is thus your irritating but actually helpful alarm which is waking you up to face the danger! So next time you have pain, try to find the cause before popping that pill And  reduce stress maybe by watching an old movie!

My recommendation is Mayabazaar especially the scene and song called Vivaha Bhojanambu starring Samarla Venkata Ranga Rao!

It’s a laugh riot!

Have a painless Sleep!
Shubh ratri!

When someone said that life is a race; he or she was not kidding!

It is definitely a race!

It starts the moment you get up! It is a race to get ready, have breakfast, beat the traffic and race to reach your work on time!

Then you have the race to finish the work on time and rush back to home to finish the pile of work at home!

The pile of clothes to be cleaned and folded! Your kid’s home work and assignments to be completed! The bills to be paid, the food to be cooked and the house to be cleaned!

Even if you have loads of money and help to do all these, there is still a race to keep the money flowing! You have to race to catch a flight or to catch an important client!

The race never leaves you! Even in the end; lying down on your bed, all weak and unable to move; you have the final race; against TIME!

In fact the actual term is Rat race!

The term “rat race” refers to an endless, self-defeating, and often stressful pursuit of success, typically in a competitive environment. It is called a rat race because it evokes the image of rats frantically scurrying in a maze for a piece of cheese, a pointless and exhausting exercise that ultimately leads nowhere.

It is a miracle how with all this racing around, many people are so successful! They do so much and continue to shine! Of course that also is a matter of time! The champion of today will be forgotten the moment you have a new one!

So once in a while, just STOP! Take a breath! Take a break! The engine needs an overhaul! Your body also needs rest! Let the time run! Turn off the phone and take a look around! Recharge yourself and get ready to race again!

Luckily we humans can take a break from the race! Nature is not so kind!

A gazelle is given the gift of nature to be consistent. To run for long and to run fast but it normally has a slow start! It is always thus racing!

A cheetah can run fast and be quick! It’s chief power is the element of surprise! The sudden attack and the quick start! But if the chase continues then it stops since it cannot maintain the speed! That’s why the gazelle does not give hope though in the end the one gazelle which does not run that fast or is not persistent or is a little slower than the other gets eliminated! The Cheetah is in the race for food while the Gazelle is in a race for his or her life!

Remember the most famous race of the animal kingdom? Well it is the race between the tortoise and the hare! But the story is not so simple! The tortoise can be slow since it has a hard body! There is less danger! The hare on the other hand has no defense whatsoever! Which is why it has to be fast! As a story you may think how the tortoise won! But in the wild, the hare has to win always! When he or she does not win the race; well that is end game! Now that is a HARE (hair!) raising race!

So stop for a while and breath!

Let the race begin tomorrow! Today just listen to Amit Kumar and relax!!

Shubh Ratri!