Good Enough

Sheelu Srinivas

Consultant ENT Surgeon, Kauvery Hospital, Electronic City, Bengaluru, India

Tara jumped out of her bed as the phone rang; or was it in her dream? Frantically she checked her phone for any missed calls, found none, and went back to sleep.

It had been nine months since she had joined a private hospital as an independent Consultant Otolaryngologist – ‘ENT’ as everyone called her. She was in a teaching college doing middle grade work for a decade. A very aspiring and ambitious surgeon, she wanted to integrate newer ways of approach into clinical care. Encountering a lot of resistance at a teaching institute, she jumped at the opportunity when private hospitals approached her. Her Linkedin profile said all about her and so did her clinical-surgical outcomes. She had turned down many opportunities before, and after lot of contemplation, she agreed to the new job offer.

Having graduated from a prestigious medical school, she had gone ahead to do complete her training- residency- in ENT Surgery at one of the best medical schools in Asia. While in Medical school, she was taught by stalwarts in the field. It struck her that there is a different spark in her mind when the authors of the books she read taught the subjects. This insight drove her to travel across continents to learn skills from various surgeons in her field. As if this was not enough, she enrolled for web-based courses on genetics, read extensively on personalised medicine and scouted for courses that were predicting trends in the future of patient care. She wanted to learn genetics and genomics, from non-other than Eric Lander- the father of genome project. She would update and upgrade not just for professional development but wanted to bring about real changes in patient care. There was a hunger in her belly to devour knowledge and acquire exceptional skills, which both amused and energized people around her. Such was her popularity amongst colleagues and patients that they would consult her even for non-ENT cases.

However, she had this nagging feeling deep inside that whatever she ‘was doing’ was not good enough; and then there was her head of department, who would be pointing out to her that her publication list was slim and make her feel even more acutely that ‘she’ just was not good enough.

Then came the calls, that brought her talents into full bloom.

Tara received a call from cardiac ICU about a patient who was having severe nose- bleed. She rushed to intensive care and learned that the patient was on the blood thinner, Warfarin. She stopped the nosebleed by inserting nasal packs. However, the blood thinner was required to be resumed to maintain optimal anticoagulation which was necessary.

Tara had learned during her personalised medicine course that FDA had approved genomics- based dosing for the blood thinner warfarin to reduce the risk of major side effects and improve drug safety. Warfarin carries a black box warning for serious bleeding. She arranged patients’ samples to be sent for the genes VKORC1, CYP2C9 and CYP4F2.

Tara had discussed with her cardiac colleagues about the recent study on genotype- guided dosing. They brushed it aside saying it adds to the treatment costs for patients. Her argument that the bleeding risk and its complications outweigh the costs of the tests found an ambivalent response!

However, when Tara received a call from her clinical genetics colleague about the genotype of her bleeding patient and placed that discussion on the table the cardiologists agreed to take clinical geneticist’s help for dose adjustments.

It was a hectic day and no sooner did she finish her opd, came intensive care call again

Tara was called from medical ICU for a consult on a lady who was experiencing severe giddiness after receiving Gentamicin. As an ENT surgeon and Otologist, patients with giddiness were the most time-consuming group- each presented with a different story and a unique diagnosis. “Every vertigo is not vestibular,” she would tell colleagues who would dump these patients on her with the confidence that she had the patience to segregate the vertigo into medical, vestibular, neurological, or psychological based on the history alone.

Fellas, diagnosis here was straight forward! She wished to scream – albeit only in her mind.

She had presented studies at the grand rounds about Gentamicin therapy and MT-RNR1 Genotype. In most studies, 100% of individuals with the MT-RNR1 variant developed vestibular symptoms after receiving the first dose. “We know gentamycin associated -vestibular toxicity for decades” commented a senior colleague and the meeting broke for lunch. So much for the whole night she spent on preparation for the talk!

Anyway, Tara spoke to clinical genetics department and arranged for the patient to be tested for MT-RNR1 gene. Thanks to the latest sequencing lab in their hospital, results came next day. Patient was positive for the gene and Tara could insist on stopping aminoglycoside for this patient.

As the day was coming to an end, Tara awaiting a special appointment her secretary had arranged. Tara was looking forward to meeting Ryan’s mom. Ryan was born with profound sensorineural deafness. He was diagnosed at birth, thanks to the universal screening of acuity of hearing she had insisted on, at her institute where only high-risk babies were screened for hearing impairment. That led to timely cochlear implantation surgery and therapy for Ryan which helped to mainstream him in regular school.

Family would visit her to inform his progress or take a picture with her as Ryan loved Tara as his “second-mom”. But, at one consult by the family, Ryan was not to be seen around. On enquiring the reason for the visit, they expressed the good news that the ‘first mom’ was on the family way and wanted to know whether the new baby would also have deafness like Ryan.

Tara congratulated and reassured them that Ryan was doing well and that it’s time they treated him as “normal’. She spoke to her colleague in foetal medicine and gave the family history. She also rung up chief of clinical genetics, her best buddy in the hospital, and requested her for family counselling.

Ryan’s parents visited Tara after a couple of weeks. They had completed their additional consults. Ryan’s blood was sent for deafness-panel genetic tests and the foetus’ samples were also checked by chorionic villous sampling. The results revealed that Ryan carried connexin 26 genes for deafness, but the foetus’s screening was normal. This alleviated parental anxiety. They left after promising to keep their foetal medicine appointments.

The phone rang, it was loud and real this time. Tara jumped out of her bed, smiling at the dream and the three case scenarios she dreamt. She managed the patients exactly how she wanted them to be approached and treated.

At least, in her dreams, the world was really as she wanted it to be.

For now, she would continue her work in the ways of the world. The material world wants and is busy churning out perfect ‘clones’, Tara continues to be ‘good enough’ for them.

Dr. Sheelu Srinivas

Consultant ENT Surgeon

Good Enough

Good Enough

Dr. Sheelu Srinivas

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