Fall of Retail

 I took Carillion Blvd and drove into Carnegie Center Blvd, I had few seconds to decide before I would be at the traffic junction whether to take right turn on US 1 North or left turn to be on US 1 South. Couple of miles on North would take me to Wegmans and Wal-Mart whereas South would take me to Superfresh about five miles away.

US1 - Expway in US

I stayed in left lane to head towards North. I was waiting for the signal, the traffic on US 1 was moderate and impressed me with lots of new cars zooming past the crossing. I felt auto industry was not in that bad shape in US. I turned left and was comfortable driving in the center lane for another 2 ½ miles before I took the Scudders Mill exit. On my right I saw the Princeton Health Center. It was under construction when I visited Princeton a few years back. I was impressed to see widening of Campus Road at next traffic signal to facilitate smooth flow of traffic towards the health center. After driving for a mile and a half I was at Schalks Crossing, I slowed down the car and took free right turn at the signal, crossed USPS (post office) took a right to park my car near McD. I had a surprise in store, the McD was almost gone, couldn't be easily noticed, may be they were doing well but from outside it wasn't prominent as we find it in India. In stead some Mexican joint was more prominent. Anyway I parked my car there and decided to move around.

The place looked so familiar even after little over three years. I could make out in a glance that the Block Busters is gone and Pet shop has come in its place. Block Busters was in keen competition with Netflix. I would frequently visit Block Buster to rent a DVD and to drop back in the box. I felt sad to see the Block Busters go. 

No more CDs, DVDs on rent

In any case recession was not the reason for its closure. It was the technological advancement that had taken the toll of an established business. Online availability of movies and serials, Apple TV, free downloads, iPhones, smartphones etc. all had forced the closure of Block Busters. The changes in technology can impact business and result in zero sum game. Pet shop replacing Block Busters indicated surplus money available to spend on pets in American society. The CVS pharmacy around the corner was still going strong. I proceeded towards the Superfresh and on way found a photo processing lab run by Chinese had downed its shutters. Again it was the technology to blame. The photographic business was not the same after the advent of digital photography. The next door Hallmark was also gone. Blame it again to the technology, social networking eliminating the need of a physical greeting cards. I moved further. The dollar shop of a Pakistani was gone, Dunkin Donuts had its usual clientèle  wine shop run by an Indian was doing better, NYSC gym was replaced by another gym perhaps the change of franchiser. Indian restaurant had a new management and double the space. All looked well. As I came near the Superfresh, I was in for a surprise. Superfresh was closed.

In front of empty corridors where Superfresh existed

Chill ran down my spine. How could it be? I asked a question to myself. The store was apparently doing well when I visited last. I could easily compare it to Shoprite in terms of its size and services. Right from fresh vegetable and fruits section to Parmacy, Superfresh had everything. In fact fresh vegetables and fruits section and its Pharmacy were better than many other similar supermarkets. The salad bar and ready to eat food area with multi cuisine menu was a treat for working executives in the neighbourhood of Plainsboro and College Road. I just couldn’t imagine that it was all gone. Superfresh belonged to A&P group, a leading company in US. The company was in expansion mode till mid 2008, acquiring Pathmark. But it announced closure of its outlets from early 2011 and the Plainsboro Superfresh was closed on Nov 14^th 2012. Competition may not be the reason for the closure. There was no competitor for Superfresh in radius of nearly eight miles. The nearest competitor was Wal-Mart, Wegman’s, Shoprite all of them close to each other. They should have been the one who would feel the heat of competition. It was Kmart that had similar fate like Superfresh few years back. Was recession the reason for Superfresh closure. I personally feel not.

My mind went back to India, Navi Mumbai in particular, the place where I stay. I have seen organized retail closing down. For a change the government policies were not much responsible for such closures. There have been hundreds of hurdles for FDI in retail. The single brand, multi brand has been topic of discussion for politicians. Similarly 100% investment by foreign player was also adequately debated. Many hurdles were created right from city selection based upon population to state government approval. No worthwhile investments have come in this sector. The death of organized retail in India was of Indian companies. Business decision based largely on political situation was seen in UP. Reilance took decision to shut the business there. Strategic decisions going wrong started with Subhiksha. Others did similar mistakes sooner or later. I have seen in my locality closure of few outlets of More, Fairprice, Spinach, Foodland to name a few. In the recent past More mega stores was also closed. In Navi Mumbai two major attractions of yesteryears, Palm Beach Galleria and City Center met an early death. There was a time when these places were responsible for traffic snarls and jams in the area. That was the rush these places attracted. Center One, the first of its kind in Navi Mumbai and the still half vacant Raghuleela Mall are struggling for their survival. All these resulted in loss of thousands of jobs. At the same time the “Gupta Stores” around the corner is flourishing. How do we explain this? No real FDI has come but the retail crumpled and what crumpled was Indian organized sector. And all this happened when the Indian economy was growing better that US economy and was perhaps the second best after China in the world. Explanation for this is too complex.

I shifted my thoughts from India to US and went back to my car. I drove to Nassau Blvd on US1 that had Wal-Mart, Target, Wegmans. All of these were all doing well. A little away Comp USA, a leading computer hardware and software chain stores was replaced by Dollor Tree, but Best Buys selling computer hardware and software was doing well. Boarders, a leading book stores that would satisfy the hunger for knowledge was replaced by Buy Buy Baby a competitor for Babies ‘R’ Us and diversification of Bed, Bath and Beyond. I don’t know if closure of book stores should be blamed to e-books and technological advancement or surplus disposable income available to spend on children rather than buying books?

Parking lots are full even now

The food court in Market Fair has been replaced by high end sit in restaurants that results in increased customer spendings and these too are doing good business. Fortunately Barnes and Nobel is still there though at different location. For a person like me returning to US after over three years the business scenario is different. There is a certain shift in business, I don’t see any decline, parking lots are full, stores are crowded but where and how the money is being spent has undergone a change.

I have no answers for many questions and to the major question if these changes have any logical relation to recession? And will these lead to economic prosperity or downfall? Time will tell.

Retail Pharmacy

Perhaps stars are not favourable for Indian pharmaceutical industry. On one side the vested interests are bent upon to malign the manufacturing industry that provides affordable medicines across the world. The fact that hurts MNCs. On the other side pharmacies are holding the manufacturers and the consumers at ransom, threatening strike every other day and dictating term. It’s painful reality.

The retail pharmacy business dates back to 1860’s. The manufacturing sector emerged in India almost after five decades in mid 1900. Even with the late start the manufacturing sector made a spectacular progress. With government support the manufacturing sector is galloping from 1970 onwards. Ever thought why retail sector could not keep pace with the manufacturing sector? There are many reasons, but just one most important reason has been lack of professional management. Retail never got the right impetus. It lacked professionalism. Unfortunately pharmacy has been an extension of a grocery shop in India and that mentality of owners and consumers hindered its progress. We hardly see any board of Pharmacy. What we see is board of medical and general stores or a chemist. There is tremendous increase in the number of such shops (pharmacies) but there is a lack of quality. There is hardly any pharmacy that can come close to its counterparts even in a nearby place like Dubai. The standards of pharmacies in developed nations are far superior. Unless the mentalities of the pharmacy owners undergo a drastic change, the Indian consumers will always be at receiving end.

One of the most neglected lots of professionals in India is the pharmacists. The poor pharmacy graduates study mathematics and microbiology, pharmaceutical engineering and pharmacology, pharmaceutical management and pharmacognosy, and many other subjects for the graduation. It is a much harder discipline than many other fields, but when they graduate they are offered peanuts by the pharmacies. The diploma holders are not much different. There is a exploitation of this young generation. At many places one finds a ‘qualified person’ is grossly unqualified, but who cares?

The margins for the pharmacies in India are perhaps the best in the world. In addition to medicines the pharmacies indulge in many other activities. Selling talk time of mobile service providers is unique to India. Very often one find a big board of mobile services provider and the name of pharmacy appears in small letters in one corner of the board. Substitution of doctor’s prescription by another product that offers better margin is very common. Some unscrupulous elements also indulge in selling samples. The bonus offers and discount schemes announced by manufacturers never reach the consumers. Some assume a role of clinician and practice medicine. In many places in UP and Bihar, patients are injected by someone in the pharmacy. The pharmacies also make large profits by selling cosmetics and daily necessities, even bread and butter. The claim that pharmacy business is not lucrative is a myth. There are hardly any pharmacies that have downed their shutters. Many of the pharmacies get credit from the wholesalers and do their business with negligible investments in stocks. Date expired and unsold products are replaced by the manufacturer. Pharmacy is one of the most lucrative business in India.

There is greater awareness by FDA. The rules are being implemented. Consumers are getting smarter. There is an increased competition. Availability of more pharmacy graduates and their chances of starting their own business in a professional way and many more reasons make old timers, and the so called leaders in the wholesale and retail sector jittery. The problem is threat to the supremacy of some individuals, unions and associations. All these years the companies are restricted from marketing their products unless they pay large sums to local associations. Unless NOC is obtained, the manufacturer cannot market the product. The word NOC was replaced by word LOC (Letter of cooperation) due to MRTP issues, but the practice still prevails. Long back the chemist association in Aurangabad had decided to restrict number of brands in the market. Just five brands of Ampicillin were allowed in the local market. This practice prevented a local leading manufacturer Lupin from making their Lupilin available in the local market where it was produced. This dadagiri of the chemists association started in early eighties. Sarabhai Chemicals, the leading company in that era had reduced the margins and the association went for boycott of Sarabhai products that lasted for a while. The unity among the pharmacies was about to break. Many of the pharmacies were losing business and were keen to end the boycott. It was the time when Sarabhais decided to go public and had announced their public issue (what we call now as IPO). Fearing the adverse impact on the public issue, unfortunately the management succumbed to the demands of the chemists association. Tiger tasted the blood and eventually became a man-eater. The arm twisting practices by the wholesalers and retailers that started in that era have increased over a period of time. FDA has now stepped in and want the pharmacies follow the rules and provide better service. This is what hurts the leaders who are mentally still in the last millennium. They want to dictate terms on the association members, arm twist them to maintain their supremacy. There has to be end to it.

With the changes that are taking place in the society, and with the diminishing role of family doctors, there is a need for community pharmacists. This is a noble profession, but certain unscrupulous elements are tarnishing the image. Time has come to empathize with the patients, understand their pain and provide them with right medication and advice. The element of social responsibility has to be there. Business ethics must include obligations to the society. There has to be a difference between a person selling paratha for Rs. 200 to a stranded devotee in Kedarnath and the pharmacist. Pharmacists should not hold the consumers and manufacturers at ransom. This is possible only when the pharmacies are managed by professionals and are treated as pharmacies and not as an extension of grocery shops. Running pharmacy should not be a Dhanda, but should be a noble profession. It’s a dignified profession. Act that way, don’t degrade. Will the pharmacy owners realize this and act?

Life begins NOW…..

Every year the months of Jun/Jul assume different importance for me. I see so many of my young friends on the threshold of new life. Life begins for them now. This is the time when the results of MMS and PGDM are announced. FB is flooded with the messages and there is a sense of achievement. Yes, it is an achievement, fulfillment of aspirations. The moist eyes of parents and a affectionate hug of siblings enhance the pleasure of this achievement. But these achievements come with a price. The price that has been paid and the price that is to be paid in future, the uncertain one, the unknown one.

MBA adds greater responsibility. As a management graduate one is expected to perform better than others. The mistakes committed by others may be overlooked, but the management graduates are not expected to commit those mistakes. So better application of acquired knowledge is needed, eye for the details is needed and commitment to excel is needed. The maturity levels attained by management graduates help them to mould themselves. Many of management students ask me a simple question. Why should I do this job now after MBA? I could have done it even without MBA. That’s a very valid question. I feel MBA puts you on a different platform that helps to perform any job better and faster than non MBAs. One develops an edge and then over the years this edge has to be regularly sharpened to get better and better results. Management qualification helps to have a better vision. What cannot be seen, anticipated, visualized by others can be done by management graduates. These skills get developed, this may not be a part of structured syllabus, but it comes without asking. Therefore a job that a graduate can perform will be done much better and faster by a MBA.   

Many of my young friends who started at grass root levels are doing exceedingly well. The zeal for achievement, determination and commitment with a pinch of luck has done the trick. Adaptability to so far not known work culture helps a long way, be it a job or own business. My young friends who chose the less travelled path and used their MBA knowledge are also doing well. Developing websites, selling fruits and vegetables online, starting a fast food joint, venturing in to real estate or interior decoration business or just helping father to do better with existing business are the fields where my young friends have done noteworthy job. Taking risk and going on less travelled tracks helps in the long run. But one has to have patience and has to believe in self. MBA helps in this respect.

The world is changing fast. There are plenty of opportunities. These are to be cashed upon. One has to be proactive. Anticipate what will be needed a year later and work on that today. If one starts working on providing what is needed today, it may be too late. By the time one develops and offers something the needs might change, so work for the future needs and offer desired product at right time. MBA helps you do to this. This applies not only to marketing but to every specialization. HR has challenges to manage knowledge resources, finance has to work in challenging times as world economy is delicately poised, operations and IT will have to operate on higher platforms due to rapid changes in technology. Every field has challenges, every field offers opportunities, and if one has vision then one can see through for others it’s like unscaleble wall. Use your MBA knowledge here.

For all those who failed to get the formal degree, remember it’s not the end of the world. But the knowledge acquired is still there. Knowledge is indestructible. It cannot be destroyed. Apply this knowledge to whatever you choose to do in future. Success is certain. Remember one simple principle, knowledge is an advantage acquired, but this advantage can be nullified if not refreshed. No one should relax, strive to update knowledge every moment, be a student for life time. You will learn to succeed.  

Choose the field that interests you. Your interest will help you perform better. And better performance will propel you for the growth. Guide your future yourself. No one knows you better that yourself, so choose what suits you, what interests you. It’s time to begin, take right step forward.

And a final word. Be a good human being. All the wealth, power, knowledge is worthless if one is not a good human being. May God bless you all for bright future.

Indian Pharmaceutical Industry

Slow poisoning is on. It will take time, but end is inevitable. Believe it or not, the world class Indian pharmaceutical sector is subjected to slow poisoning and is under attack by vested interests. The poison is being released into the system aimed at total destruction. It’s a novel way to attack. This sector is relatively small compared to FMCG sector. HUL profits for last year were higher than turnover of Lupin Laboratories. This is just to give an idea of the size of these two sectors. The question is if this sector is so small then why would it come under attack? There are many reasons. Across the world human beings are very sensitive to anything that is related to food and healthcare. India was dominated by MNCs in these sectors. This is now a history. In this sector the top companies in India are of Indian origin and these companies are a threat to the supremacy of MNCs across the world. As far as FMCGs are concerned, their Indian competitors are no threat these giants operating world over. They rule the Indian market. In addition the majority share holdings in these companies are with foreigners. Same is story for auto sector. The market leader Maruti Suzuki has over 56% foreign share holdings and most of the other players are unlisted companies in India making huge profit compared to their Indian counterparts. Electronics is totally dominated by foreign players, be it LG, Samsung, or Sony. Indian manufactures are struggling to survive. Why should these MNCs bother about their Indian competitors? Similar is the story for engineering sector, be it ABB or Siemens. Nestle and Cadbury’s are market leaders in different segments, not Amul. Indian children are growing on noodles, pizza and burgers. Foreign Banking and Insurance operations are growing and have sizable business in India compared to Indian operator’s share in the foreign countries. Indian banks or LIC have neglible presence in the world market, thus no complaints about Indian banks or insurance companies by foreign players. Oil and Gas, IT and Metal sectors also have some foreign players but dynamics of that business is different, and there is no attack on Indian companies. Therefore large foreign holdings in their Indian arm, strong market presence and big profits that are repatriated to country of origin makes India a wonderful destination to operate where their supremacy is not challenged. Why then anyone would bother about Indian manufacturers? The chart below gives a fair idea of foreign holdings of leading listed companies. There are thousands of privately held, unlisted companies who make fortune for the stakeholders that go unnoticed by a common man. Thus there is no cause of worry for MNCs. India is safe heaven for them. But it is not so for pharmaceutical sector, thus it is under attack.

Company	Foreign              Holding                31st March 2013	Last Declared Dividend
Pharma Sector
Sanofi	60.40%	290%
GSK Consumer Healthcare	72.46%	450%
GSK Pharma	50.67%	500%
Pfizer	70.75%	325%
Novartis	75.00%	200%
AstraZeneca	75.00%	175%
FMCG Sector
P & G	68.73%	225%
HUL	52.48%*	600%
Colgate	51.00%	900%
ITC	50.29%+	525%
Nestle	62.76%	125%
Engineering Sector
ABB	75.00%	150%
Siemens	74.71%	300%
SKF	53.58%	75%
Auto Sector
Maruti Suzuki	56.21%	160%
Bosch	71.18%	600%
Cummins	51.00%	400%
IT Sector/Metal Sector
Oracle	80.27%	100%
Sesa Goa	55.13%	10%
Oil & Gas Sector
Cairn	53.66%#	65%
Castrol	71.03%	75%
Source: Published information of/for listed companies *Buyback offer to shareholder to raise holdings to 75% is on (May 2013) +Includes Foreign companies, Foreign nationals and FII #Includes Foreign Promoters and FII There are many unlisted companies operating in India with foreign holdings

Pharmaceutical MNCs are attacking the Indian companies, its guerrilla warfare. Best form of defence is attack. MNCs for their stakes in India cannot go in for direct confrontation, so they have to take help of local gullible persons and institutions, other foreign agencies and even traitors to attack. The corruption in India makes it easy for those who can bribe in hard currency and offer foreign trips, to get what they desire. Attacking Indian pharmaceutical companies is a well thought of, systematic, long-term plan. Attack from foreign entities can be understood. What surprises is the attack by fellow Indians. Some of hospitals from Mumbai and from Delhi have reported to have banned medicines of Ranbaxy. One hospital has asked the company to prove their quality. This reminds me of wolf and lamb story of Panchatantra that mentions a ridiculous justification by wolf to eat the lamb. This is ridiculous; I call someone a cheat and ask that person to prove that he/she is not a cheat, rather than I furnishing the proof of cheating. So any one can charge anybody and the onus will be on the person charged to prove the innocence. The Ranbaxy problems with USFDA are of mid last decade for certain formulations. These hospitals have not used those formulations. If other medicines from Ranbaxy have been used then these hospitals should provide the data of casualties caused by Ranbaxy medicines for last eight years. How come these hospitals woke up so late and are now worried? Is their assessment of patient’s relief/recovery guided by media reports about Ranbaxy? Is it a part of evil design to malign the company image? Unfortunately Indian pharmaceutical manufacturers are turning a blind eye. If one manufacturer is attacked then the others look at it as an opportunity to grow at the cost of the sufferer. Such manufacturers lack foresight. A stage has come when they have to unite and expose the evil designs of multinationals. Showing a top Indian company in a bad taste is no trump card for growth of others. At opportune moment the MNCs will take the joker out of the pack and tell the world that if the top Indian manufacturer is so bad then imagine the condition of rest of the manufacturers. This is dangerous. Not only the top manufacturer would lose the business but it will have a snowballing effect where the entire Indian pharmaceutical industry would lose its credibility and that will take us back to 1960’s. We will be forced to be dependent on MNCs. That will be catastrophic.

What is the genesis of this situation? Lets us take a look at the past. Things changed for Indians in 1970’s when government announced DPCO (Drug Price Control Order). During the same period government brought in some restrictions for pharmaceutical MNCs operating in India. Process patent was in force but not the product patent. All this made the pharmaceutical MNCs uncomfortable and many of such companies either withdrew from Indian market or reduced their exposure. The government support helped the Indian manufacturers to gain strength and they got a chance to prove themselves. The country that was net importer turned in to a net exporter in few decades. World started depending on India for pharmaceutical raw material (API) and finished formulations. Indian manufacturers also went in for manufacturing pharmaceutical equipment and all this has been an eyesore for MNCs.  The MNCs that milked India till 70’s of last century were helpless. Different formulations, innovative fixed dose combinations and penetrating marketing strategies developed by Indian manufacturers left the MNCs high and dry. The hope for MNCs was India’s acceptance to IPR in 2005. There were lots of discussions across the industry to access the future of Indian pharmaceutical industry post 2005. There were different schools of thought. Some felt that India’s dependence on MNCs would increase while others thought the opposite. Post 2005 and even in the era of liberalization the MNCs could hardly do anything. Indian pharmaceutical manufacturers started eroding the bastions of MNCs. Many of them went in for M&A, started their own projects in different countries across the world, gained sizable market share and offered quality products at much lower cost. Many of the MNCs closed their API plants and sourced the raw material from India. And then there was a limit to the patience of MNCs. The overpricing of MNCs was getting exposed. There was advent of generic era that further exposed exploitation by MNCs. Many governments around the world modified their budgets on healthcare because of availability of generics. The profitability of MNCs from yesteryears money spinners plunged. It hurts when you lose the money, it hurts when you see someone overtaking you, it hurts more when you see an Indian company doing this. The MNC profits, their future in the generic jungle is under threat, their ego is hurt. These MNCs are averse to strategic alliances with Indian manufacturers. Their ego prevents them from understanding the reality and taking rational decisions. Such alliances can be a win-win situation, but the MNCs have to keep their aura of supremacy of yesteryears in a closet and then take a step forward. They can’t do it, so attack the Indian players.

Indians have pardoned the cola giants when their products were found to contain pesticides above the desirable limits. Indian parents whose children’s life was endangered due to insects in the chocolates or higher radiation levels in milk powder turned a blind eye towards the MNCs manufacturing such products of questionable quality in India. MNCs manage such situations well. Their PR activities pull them out of the mess that they create. Indian companies are unable to handle adverse propaganda. The pharmaceutical companies may or may not have faulted but there is a malicious attack to spread the venom. When there is a price war MNCs cannot show their superiority unless they play foul. Time has come to understand such evil designs of all those who hate to see India prosper, who dread to see Indian drugs curing the billions around the world at low cost and those who want prosper at the alleged failures of fellow manufacturers. It’s time to tell the world the progress of Indian pharmaceutical industry. Stand together for Indian pharmaceutical industry before it is too late. Solidarity is the only way out.

Nurturing Laziness

The political parties are bent upon providing food grains at subsidized price to those under BPL. In fact the limit of income of less than Rs.27/- can itself be challenged. But that is another story. The intriguing questions are, how one can ride a bike and get a BPL card for himself, or how a female may find some time in between her two favourite serials and rush to get the BPL card.

The media has reported that the government might call a special session of Parliament to pass the National Food Security Bill. The ruling UPA claims that it will solve the hunger crisis on the other hand its critics are certain that it will only increase corruption, and that the public distribution system must be wound up and replaced by cash transfers. The corruption in PDS will never get eliminated and on the other hand the cash transfers will open up new avenues for corrupt officials. Today’s print media has advertisements announcing the launch of similar scheme in Madhya Pradesh, making rice available for Rs.2/- per kg and wheat for Rs.1/- per kg. Making food available at such a low price is big threat to the nation. I am not talking economics but conditioning of mind. Out of the basic needs of Roti, Kapada and Makan, government has taken care of Roti by providing food at near zero prices. Governments in many states provide a piece of land and the cash assistance to build the house. The Makan is also taken care of. Kapada is not of great significance and the same is available, either as new or used one at reasonable price. Apart from this the RTE helps in education, various schemes for minorities offer lot of assistance, healthcare, mother and childcare are also taken care of. Incentives for going to government dispensaries for prenatal check up and delivery are already available. Everything provided by the government to its subjects in communist country is understandable. In communist nations a “common man” cannot influence the politburo and cannot change the government. Situation is different in democratic countries. Such schemes are more for creating a vote bank rather than the consideration for welfare state.  If the governments are of different political ideologies at center and at state level then there are chances of competition. One may offer greater benefits than other to appease and this will lead to rat race. There is no end to it. Now the question that bothers me is simple. If one gets everything from government, than why should people work? What is the motivation? Getting dole can be motivation for those above BPL to fall in to BPL. This is not done. Jobs need to be created and fair wages paid so that the citizens can buy the needs form their earnings. Dole, if I can call all these schemes so, makes one lazy. This is not acceptable. India with largest youth population should not be pushed to be lazy nation. If jobs are difficult to create, which can be debated, then entrepreneurship needs to be encouraged. Let people work and earn then spend rather that subsidizing, or giving free. That is bad for the economy and the nation.

Create real jobs. Not jobs on the paper. Fictitious job creation is still more dangerous. I know a sad story of a person who was in fish farming. The labour intensive activity went on for years till one day he found workers abandoning the job on his project. In few months he had no worker to work and was forced out of the business. His enquiries revealed that his ex-employees are on pay roll of some scheme, that provides wages and sad part was the workers may not work if they share the wages with certain individuals and make money even without stepping out of their home. If these kinds of jobs are made available then who the hell will go in for a hard labour on a fish farm? Are we not making the productive population lazy? Work has no substitute. A Latin proverb says, “If there is no wind, row”. Wind will induce lethargy, nobody will row. If one has to reach somewhere, one has to row. Let there be no wind of cheap food, free housing and lots freebies, nobody will row, this will induce lethargy and nation will depend upon the few who work. To ruin the nation nurturing idleness is enough, you don’t need enemies.

The need is for good governance, transparency and no subsidies. The need is to make the population work and not depend upon government dole. If India has to prosper then the politicians have to realize this ground reality. They should strive for the growth and not for just coming to the power. 

Epistaxis II

This is the second part. Cautions for readers are the same as given in the first part. Any critical analysis is for introspection and not to malign image or reputation of any individual, doctor or hospital. Introspection should help all to perform better. No hard feelings. Take it easy. Here we go.....

Shift from Casualty to room was much faster than expected. In the same casualty little over six months ago, I had brought a old lasdy with hip bone fracture. The medical officer forced me to rush to the pharmacy to buy traction. It was indeed needed. I left the patient alone in the emergency, went to the pharmacy and got the traction. For next six hours in spite of repeated coaxing the patient and traction were lying in casualty. Ultimately after a wait of six hours with acute fracture pain the patient was shifted to the room and it took another hour to put the traction in place. With this experience and background, I was happy at my shifting to the room in less than one hour after arrival. The bed had electronic controls for reclining, altering the height of the bed and looked impressive. Unfortunately it was uncomfortable for me as these beds were designed keeping in mind patient’s maximum height to be of six feet. I am more than six two, so fitting in the bed was tricky. I had to sleep diagonally. While in casualty blood samples were drawn, IV cannula was in place at the back of my left wrist and x-ray chest was done. I thought I will have few hours of sleep before I go to the operation theater. However it was not to be so. I just dosed off and nurse walked in to record the ECG. Soon after that a ward boy came with hospital dress. There was a problem again. The largest size available in the hospital was tight for me. With no other option I slipped into what was provided and I was looking like a joker. Pyjamas were three inches short, sleeves were between elbow and wrist, many of the buttons refused to come closer to the button holes. I looked in the mirror and enjoyed my funny look. Then one after other someone kept on coming, from nurses to the anesthetist and surgeon as if there was a conspiracy not to allow me to sleep.

My younger son was travelling, he was called and asked to take next available flight back home. In any case he would not have made it before the surgery. He booked online and was to reach Vashi by 3.00 pm. I did not call my elder son in US as there was no point giving him the tension and in any case he can reach only when the emergency is over. By 9.30 am my wife and brother accompanied me when I was wheeled in to preparation room next to the OT. The final check was on to move me to the OT. The nursing staff was pushing the stretcher when the anesthetist asked me if I could walk to the OT. I said yes, I accompanied him to the OT. I took a good look at the OT. It was OK. I was in for endoscopy and cauterization. The position of the operation table was away from the monitor and thus the table and shadow less lamps were shifted accordingly. Anesthetist asked me usual questions, if I have dentures, addictions etc. He started Ringer Lactate drip, I saw him adding a sedative and in a moment I was fast asleep. I woke up when the procedure was in the final stage and the ENT surgeon was pushing the packs in my nostrils. In fact the pain of pushing 8 cm long packs in nostrils made me wake up from the deep slumber. The ENT surgeon looked to be happy at the job she did. I spent another hour in recovery room and later on was shifted to my room. The oxygen mask was making me uncomfortable. I did not certainly need the oxygen. I asked the nurse to check oxygen on pulse oximeter, it was 100. I asked her to remove the mask. On discharge I realized the need for the same for the hospital, as they had billed me for the oxygen and also for pulse oximeter. I could bought the pulse oximeter for myself with kind of charge billed. Rest of the day I was sleepy and uncomfortable. Nostrils were packed, breathing was through the mouth. With packed nostrils the post operative secretions, discharge was blocking the sinuses. I had to constantly sip water to keep dry mouth moist but even that was painful as nostrils were blocked. Block your nostrils and try to drink, you experience the discomfort. Lips developed cracks due to dryness. I had a restless night. Next morning some secretions dripped down the nostrils. ENT surgeon came for a round and looked satisfied with the progress. She suggested that packs could be removed after two days and I would be normal.

Things were not destined to be so. By 11^th afternoon I started bleeding again. The difference from earlier episodes and the fresh ones was that I was now getting a forewarning of the bleeding. The packs in the nostrils would absorb the blood and then blood would run down the nostrils. I was taken to the OPD to show her, as she did not respond to our request to visit the room. Now the ENT surgeon was worried. She prescribed me those medicines which she had asked me to stop when I met her first.  I had three episodes on that day. Next day the ENT surgeon was to take a look and see if she could remove the packs. She examined and suggested we should remove the packs on 13^th in the OT, so that if need be the cauterization can be again done. Bleeding was increasing on 12^th. The quantity was high and frequency was more. On that evening my brother saw me bleeding for the first time and then he realized the gravity of situation. The chairman of the hospital was informed of the condition, staff from ICU rushed to my room, we were given a choice to get another ENT surgeon of our choice from anywhere and we also made plans to shift if condition deteriorates. The night went by. Next morning on 13^th, bleeding was more profuse.  I went to toilet and nose started bleeding and once again the blood was splattered everywhere in the toilet to the bed. In between the bleeding would stop but things were taking a serious turn. By noon I was in the preparation room and while on the stretcher I once again bled profusely. That was the first time my younger son saw me bleeding. He could not believe that things could be so bad. I was moved to the OT with ice pack over my nostrils. This time the OT was different, but problems were same. The table had to be moved so it was closer to the monitor. The equipment was attached to the monitor. The cable was loose. It worked for a while and then the monitor went blank. I got reminded of AVG cable connecting the laptop with LCD projector not working in the management school that happened to belong to the same hospital group. The problem was somehow fixed. The air conditioning was on full blast. I requested the staff to increase the temperature. The poor fellow did not know how to respond to my request. I told the anesthetist to increase the temperature. He knew the problem and told the staff to switch off the AC. Apparently the thermostat of the AC was not working. Again it was similar to the problems I had in management school. I was readied for the procedure. This time I was not to be sedated but a mild tranquilizer was given. I was in full senses, local anesthetic xylocaine 4% was put in the nasal cavity and the pain was little blunt. In a short while the ENT surgeon walked in. She ordered IV cephalosporin. I stopped her and suggested that she gives amoxycillin and not cephalosporin. It was more than ten days I was on cephalosporin. She agreed but was tense.  I could sense her nervousness when I was in the preparation room and she was frantically trying to get some additional help, another senior ENT surgeon. She had a tough luck. No one was available at that moment. She called couple of her friends who advised her. Fortunately for me we had requested our octogenarian friend, a highly experienced ENT surgeon to be present in the OT. I was positioned for the procedure. She asked the table to be lowered. Unfortunately it could not be done. Then she asked for a stool, that was made available and then she stood on the stool to start the procedure. Eye drops were put in my eyes so that the vision gets blurred and a head towel was placed and tucked so that I could not see anything. She asked for the headlight, placed over her head and here again the connection was loose. The headlight stopped working. The wires were tightened and she was now ready. Our friend who was supposed to be there had still not come. The traffic jam at Airoli bridge had delayed him.  She asked me if she can start the procedure. I wasn't sure how much time my doctor friend would take and he was only an adviser  so I asked her to proceed. She removed the eight cms. long  packs that were placed little over 75 hours back. There was a friction and pain during the removal and soon after that there was gush of blood. The cauterization that she did on 10^th was disturbed and old wounds started bleeding. She was in a shock. She asked for assistance, ‘get the suction, Txxy, jaldi karo, it’s a profuse bleeding”, she applied the suction to suck out the accumulating blood. Either she was tense or was not used to the procedure, God knows. Ideally she should have put saline gauze over the bleeding surface and then used the suction. This minimizes the damage to the bleeding tissues. Putting suction straight on the bleeders is traumatic. Anyway while this was on, my doctor friend walked in and then I had my comfort levels. She put the endoscope in. I could feel the pain, it must be old model of endoscope as the new ones are just 2 mm in diameter.  This time she used RF for cauterization. It took almost twenty five minutes to finish the cauterization. The tip of the instrument emits high frequency waves and raises the temperature to about 70⁰ C that seals the bleeding points. She would cauterize one point and the bleeding would start from another point. At one point she used so much of force that I felt rupture in septum. This was confirmed later by another doctors when the healing process was on and old blood clots were gone. She was working on my nose as if she was playing a video game. She had to look at the monitor and make moves. The battle was over after nearly half an hour. With all these efforts she was feeling warm; she ordered to start the AC that had nonfunctional thermostat. Once again the blast of cold air swept my body. My doctor friend advised her not to pack but place gel foam, a old time tested dressing. The surgeon was not quite impressed with suggestion of an old timer but couldn't refuse and placed it in both the nostrils. I was wheeled out to recovery room. All looked relieved. The ENT surgeon patted me with assurance that all is well and went for another surgery. My wife, son, brother, doctor friend were around the bed with visible sign of relief. I blinked my eyes to assure that things are OK now. That happiness was momentary. I got the feeling that I am going to bleed. I told my doctor friend and asked the nurse to get the gauze. Before anyone could realize my nose started bleeding. The faces turned worried and helpless. The anesthetist and my doctor friends came close to me, ice was brought and once again my nostrils and face was covered with ice pack. The ENT surgeon was informed but was in the OT operating another patient. The two attending doctors and my brother said that nothing can be done at this stage. All that was to be done has been done. We have to wait and watch. Everyone looked helpless. I was wondering if it was a beginning of an end. Is this the way a healthy person has to meet his end. No it can’t, I said to myself and relaxed. The gel foam that my doctor friend had suggested worked. It soaked the blood and packed my nose. With pressure of soaked gel and it’s forming a film over the bleeding area the bleeding stopped. The cold compression was on. The ENT surgeon came after about half an hour and I am sure she must have silently thanked my doctor friend for his suggestion of gel foam. I was in recovery room for next two hours before returning to the room.

As there was no sedation, I was expecting a peaceful night, of course with the tension of further bleeding. By 11.30 in the night a resident doctor came and started explaining post operative primary and secondary bleeding. His knowledge seems to be from recent reading from some book. I asked him not to explain and let me relax. At four in the morning I heard some saying good morning, I looked at the wall clock it was about four ‘O clock. I lost my cool and fired the intruder, told him to come by eight. My son woke up to see what’s happening. The intruder left without further advance. In the morning my son told me that the person I gave a piece of mind was non other than the resident doctor. I felt bad, but certainly four in the morning is not the time to take a round. Night was otherwise comfortable. I could at least breathe through the nose. There was no further bleeding.

After the first cauterization I experienced nose bleeding may be due constipation. This time I decided to take complete bed rest and be on liquid diet for next three days and take stool softeners  It worked out well. I was doing well with liquids. On day two of operation, I started moving in the room and gained confidence. There was no fresh episode. I took discharge after two days. The ENT surgeon was pleased with her job, but not I. She asked me to see her in OPD after three days. I preferred not to. Two days after I was back home, my doctor friend came to my place and almost set up his clinic to examine me. We sterilized the instruments, got sterile gauze and dressing and removed the obstructing blood soaked gel foam. Net week onwards I went to my doctor friend’s clinic, who extended great help to ensure that I am comfortable.

I had tarry dark stools for over two weeks. My hemoglobin before this problem was over 15 gms. On the day I took discharge it was little above 10 gms. I lost almost 5 gms of hemoglobin in two weeks. One bottle of blood donation reduces the hemoglobin by about one gram. So was it equivalent of five bottles of blood loss?

Few questions are still bothering me. Why I got epistaxis to start with. It was from anterior region. I do not see any apparent cause. I was normal, did not venture in hot sun, did not poke the nose, nostrils were moist, no rhinitis, no coryza, no allergy, normotensive, no diabetes, no stress, nothing yet the profuse bleeding. A big question mark.  Why did the ENT surgeon stopped the coagulants and vitamin K? I just don’t understand. May be that would have helped.

Why did the ENT surgeon put me on third generation cephalosporin? Was it needed? I had no infection when I met her first. I was on IV cephalosporin postoperatively. I was getting hot flushes and had a feeling that cephalosporin is not suiting me. Was the epistaxis due to overuse of cephalosporin?

Was the first cauterization faulty or the packing was not correct? If the packing is right then there is adequate pressure and the chances of bleeding are remote. I was bleeding profusely even with nostrils packed raises doubt about the way packing was done? Why gel foam was not used after the first procedure? I am at loss to understand.

Was the ENT surgeon casual? Generally epistaxis can be a OPD matter. Maximum one day hospitalization if needed. I was in for six days. Was she not gentle in performing the procedures? I could feel her harshness many times during the procedure. Was the equipment not latest? The procedure has destroyed nasal villi. I will have to live with it for rest of my life.

With adequate knowledge of medical science, medicine and surgery, with adequate resources, with fair amount of doctor friends and some standing in the society, I have experienced the treatment related problems. What would have been the fate of common person on the street had this problem occurred to him/her?

I am limping back to normalcy. I am not supposed to bend down, exert, and lift weight etc for a while. Life will be normal again, but it was a phase of loss of mental peace, tension to family and friends and financial loss. The phase of fighting with mediclaim is on the cards, as they are paying only for two days of hospital stay whereas I was in for six days and there are many other unjustified deductions. This is the sad part of being ill.

Epistaxis

Epistaxis, nose bleeding is common in about 20% population, more common in children. A condition that’s considered harmless, easy to treat and simple can turn critical. There is a need for good clinician to understand the problem and then to handle accordingly. Wrong diagnosis or treatment or surgical procedures can be detrimental and patients condition can turn critical. Given below is account of my recent experience. There might be some dramatization due to selection of certain words. Those who do not like to read about medical conditions should not read further. In this first part I am giving the preoperative situation that was experienced. Next part will offer some description of operative procedure, post operative complications, and recovery. The write up on hospital stay and the services offered can be a good material for management students to understand gap analysis. Those in service industry can have some value addition. If you are comfortable then read further, the first part of Epistaxis.

For the third time in my life on April 10^th 2013, I was admitted to the hospital for an emergency. The first admission was on Oct 18^th 1955, when I had a fall from tree resulting in multiple fractures. Second one was on April 9^th 1984, when the scooter that I was riding was knocked down by a speeding car resulting in injuries and multiple fractures. These events were cyclic and took place in cycle of 29 years. I know the astrological reasons and planetary positions of those days, but it’s not the scope of this article. It all started on April 3^rd 2013. I shut down the desktop by 10 in the night and decided to retire. As I was changing I noticed trickle of blood through my nostril. I dismissed it as minor incidence and attributed the same to hot climatic conditions. In few minutes the trickle turned into a gush and there was blood everywhere from bed to bathroom. I packed my nose with cotton gauze, placed crushed ice over the nose and waited for a while for bleeding to stop. My wife in the meantime checked my blood pressure and it was absolutely normal. I called my cardiologist brother and a surgeon friend but no one could figure out the cause. The common cause at my age can be high blood pressure, but I always had normal blood pressure and there were no issues, physical or emotional that would surge the blood pressure. Bleeding stopped in short while. My throat was experiencing irritation due to trickling down of clotted blood. I involuntarily coughed and this time gush of blood started. When looked at myself in the mirror over the wash basin, I couldn’t believe, I was looking like a vampire without protruding canines.  I repacked the nostrils and decided to held the head straight above the level of heart to reduce the blood supply towards the nose. It worked and the bleeding stopped. I spent a restless night. Next noon I had an appointment with the ENT surgeon. I explained to him what all had happened. He was shocked. He suggested not to remove the pack and prescribed vitamin K injections, some coagulants and nasal drops.  He thought it was posterior bleeding, I thought it was anterior. I volunteered to remove the pack so that he could examine. He was unwilling, yet I removed and asked him examine the septum and internal parts of the nose. Everything looked normal except the raw areas which were bleeding last night. I also got my bleeding time, clotting time and prothrombin time tests done. They all were normal. No injury to nose, no high blood pressure, no headache or dizziness, no infection, no alcohol consumption yet nose was bleeding. 

A day went by with sporadic bleeding. The medications were on.  Next day I decided to have second opinion and went to another ENT surgeon. She was more bold than earlier doctor. She prescribed me an antibiotic and for some unknown reasons asked to stop the medications prescribed by first ENT surgeon. I followed her advice. Due to the blood that had gone down the throat, I had dark tarry stools. This was on  April 5^th 2013. Next twenty four hours were ok, but from subsequent day my nose started bleeding again. I was confined to indoors as the bleeding would start anytime without any forewarning. I was feeling weak with loss of blood. Each episode would result in minimum half a cup of blood loss. It was frightening for family members. My wife being bold handled every episode with care and utmost courage. The female ENT surgeon was repeatedly assuring that the bleeding will stop and we need not worry. On 9^th night I again had a profuse bleeding, just like the one I had on 3^rd. There was blood everywhere, the pillows, the bed sheets, the floor. I packed the nose and kept crushed ice over the face. It stopped in while, but I had a premonition. I could not sleep, I was very restless. There was a constant feeling that something serious is on the cards. Midnight passed by, I was tossing in the bed. By 3.30 early morning I could sense the bleeding and before I could act there was a gush as if tap has been opened. I woke up my wife, she was aghast to see the way blood was pouring out of my nose. I struggled to pack my nostrils, kept my head under the cold shower. It took about 10 to 15 minutes to get the situation under control. I asked my daughter in law to call my cardiologist brother, surgeon friend and the ENT surgeon. They were explained the gravity of situation and we decided to get admitted in hospital. My surgeon friend drove me to the hospital, my brother was already waiting there for me and the ENT surgeon had given instructions to the casualty staff. It was about 4.30 in the morning of April 10^th, the Amavasya day, I was admitted. The procedure was scheduled for 10 am same day. Operation theater was booked; it was available as there were no planned surgeries being Amavasya on that day. From casualty I was moved to the room and the preoperative check up were initiated.