Thursday, October 3, 2013

Breaking Bad

All that you never wanted to know about Anterior Cruciate Ligament (ACL) Reconstruction Surgery

As some of you know, I recently suffered from a ligament injury. This blog post is meant to give some background and update on the injury to the people who know me, and to serve as an informational resource to others who might be going through a similar issue.

Short story:
1998. Boy meets girl, girl meets boy. Boy professes his love to the girl. Girl accepts. Fast forward 15 years. Boy & Girl – now happily married (and to each other!) – go to Switzerland to celebrate the special anniversary. Boy decides to ski in Zermatt, has two bad falls, and damages ligaments in his knee. They complete their trip, come back to India, and the boy then goes through knee surgery. He is now recovering quite well and has started walking. Running, and more importantly, riding his bullet motorcycle are still 6 months away. Much to the delight of one of his friends, who is happily thumping along on the cycle for the interim period.

The Long Version:
I will skip the boy meets girl part – that’s better narrated in-person. :)

Let me start from the fall at the ski resort. This happened in Zermatt – an absolutely gorgeous, car-free town in Switzerland. Zermatt’s ski resort is quite famous – it has Europe’s largest summer ski runs and is one of the most preferred places for professional skiers to practice during the summer & fall months.



(2nd Sep 2013. In Zermatt. Matterhorn in the background. One day before the fall)

Anyway, as I started skiing, fell once, and most likely partially tore one of the side ligaments of my knee (the MCL). I realized after the fall that I needed to pack & go back. I also noted that the only way to go back was to ski all the way down the slope. I started doing that, and as I was navigating a turn, felt a searing pain in the MCL due to which I couldn’t balance myself, and went into a completely uncontrolled fall. Pretty bad one. Once I had stopped tumbling, I found myself howling away in pain on the ski slope. After a few minutes, a nice person stopped by, and we communicated in broken English

Me: “Help. Knee. Pain. No Ski”
“Bring doctor – here?”
“No, no doctor. I go back. To Hotel”
“Ok. I go down, tell office. Ok?”
“Yes, danke. Danke so much!”

15 agonizing minutes later my savior came on a ski mobile. The first question he asked was “Do you have a credit card?” I’ve never been happier with my Capital One card.


(In cable car, on the way back from the ski slope. Notice the bump on the left side of the knee)

About an hour later, I was back at the hotel, narrating the incident to Neha & discussing next steps.  We went to the amazingly nice local doctor, who confirmed that I didn’t have a fracture but most likely had damaged one or more of my ligaments.  I was told to “pay the PRICE and do no HARM”:

PRICE = Protect, Rest, Ice, Compression, Elevation
No HARM = No Heat, Alcohol, Running, Massage

Interesting outcome of this – the doctor told me to take some injection to prevent DVT (blood clots) on the flight back. And since we were going to do a bit of traveling for the next few days, he taught me how to apply the injection myself. We took turns, just for the fun of it – I did it once and Neha did it the second time. That was a new experience that I wasn’t expecting to come out of the Swiss trip!

Anyway, 4 days and 7000 miles later, we were back in Delhi/Gurgaon, where an MRI confirmed that I had
(a)    a partial (grade 2) tear of the MCL,
(b)   a full (grade 3) tear of the ACL

By this time, I had learnt that:

·         Knee ligaments prevent the knee from unnatural movement, such as excessive sideway movement, twisting movement, etc. There are four such ligaments in each knee
·         If there is a large degree of unnatural movement with significant amount of force, the ligaments get damaged or torn
·         ACL injuries are fairly common while playing football (both kinds), basketball, and skiing

Here’s a short (about 5 min) but very informative video on the ligaments, their purpose, what happens when you tear the ACL, and an overview of the surgery


(Note that the surgery example given here uses a graft from the hamstring. The one that I got done used a different graft – more later)

A partial tear gets fixed by itself (as long as you protect it). A full tear can’t be fixed and you have two broad options:

a.       Live with a torn ACL: Usually recommended for the elderly or those who don't live very active lives. The risk is that your knee will keep hurting and can give way with even a minor misstep
b.      Get surgery done to reconstruct the ACL: Recommended for most people less than 60/70 years of age. The surgeon will remove the torn ACL and insert a “substitute” ACL. The substitute could be “harvested” from:
a.       Part of your own hamstring
b.      Part of your own Patellar Tendon (the ligament that joins the knee cap to the shin bone)
c.       From a cadaver

There’s much discussion about which kind of ACL reconstruction to go for. Here’s what I have learnt (note that I am by no means a professional – you need to talk to your doctor if you are evaluating this decision):

1.       Cadaver harvesting is less painful. But chances of complications are more, since there’s a foreign body being inserted into your knee. Also, the ACL might give way after a few years and might need replacement again
2.       The differences between hamstring vs. PT harvesting are minor. If your surgeon is more comfortable with one vs. the other, then go with whatever he/she wants to do. PT harvesting does leave a bad-ass scar (4-5 inches), so if you care a lot about that, you can go with the hamstring option

Here’s a great resource with more information: http://orthoinfo.aaos.org/topic.cfm?topic=a00297

My surgeon wanted to evaluate the condition of the knee during surgery and make the decision then between Hamstring vs. Patellar Tendor. I was cool with it. He ultimately went with PT.

Surgery.

I was brought into my room at about 8am. Preparations started in full swing. A battery of tests was done. I was given a good shave of the leg. A big fat arrow was made on my left leg using a marker pen (to remind people which leg to operate upon). I was asked to change into this pink attire:



(Don't mess with me, even if I am wearing pink!)

I was wheeled away from the room around noon, from where I was taken to the pre-surgery prep room. That’s where two questions were asked at least 15 times at different stages:

“Which leg is it”
“When did you last eat or drink something”

I am glad that the folks at Medanta don’t leave any room for error here.

I was then administered regional (spinal) anesthesia. The thing is injected into the spine – it hurt more than a regular syringe, but less than how much I thought it would – what with the needle going into a bone etc. Within 5 minutes, my lower half of the body was completely numb. The surgeon joked that even if I wanted to run away from the surgery, I could no longer do it, given that my brain couldn't control my legs.

I was then taken into the OT, where the operation lasted for about 45 minutes (or so I’m told). The surgery is done using arthroscopy (fancy word for camera-assisted). Here’s a fascinating video of the entire procedure (This is not the video of my surgery, but the operation is identical to mine. Note: Graphic Advisory):



("Glorified Carpenters" at work - in words of my surgeon)

I could hear the drills, the hammer, feel being pushed & pulled, but magically (&thankfully) didn’t feel any pain at all. I wanted to see the operation, but they had put curtains to prevent me from doing it. My surgeon had promised me that he'd give me a DVD of the operation (which I now have!).

The down side of the operation was that half-way into the procedure I started feeling queasy, dizzy, and threw up. This happened multiple times in the post-operative area and later in my room as well. I was told that my body reacted strongly to the anesthesia, and this does happen to a few people.

Post-surgery

Quick notes post surgery:

·         The attendant (Rhea) during my stay in the hospital was awesome. Neha was extremely uncomfortable in leaving me alone, given that I was puking my way to glory. The attendant tried to convince her that she was there at the press of a button, but Neha requested her to stay by me the entire night. And she did! The entire night, she sat inside the room by the entrance, doing her paperwork in the light coming from the bathroom. Once I started feeling better, I told her that she could go back to her attendant station, but she said that she had promised Neha she’d be there by me, and so she wasn’t leaving. I was just bowled over by this dedication. Thanks sister Rhea – I will never forget this!

·         There was pain and discomfort the first night, and I didn’t get much sleep

·         Was discharged from the hospital the next day. The incisions in my knee had been stapled (21 staples in all!!) and the leg was wrapped up tightly in crepe bandage. Finally, a dial-a-loc brace was fitted, that prevented any knee bending. I was allowed to walk using a walker


(Another use for Milton's stapler!)
Note: This pic was taken 2 weeks after surgery, hence the absence of swelling

·         The crepe bandage felt too tight. Apparently the doctor had told my wife (when I was puking away) that when I come back to my senses, I will start complaining about how tight the bandage was, and that is to be expected. That’s exactly what I felt. It all started to feel better after 3 days

·         Pain subsided significantly after the 3rd night, just as the surgeon had predicted

·         I couldn’t lift my leg at all for the first 4-5 days. Getting in and out of bed was difficult – someone had to lift the leg for me

·         Key thing during the first few days is to make sure you don’t keep anything (pillow etc) under the knee. Your knee should be perfectly straight. And keep doing the few exercises they tell you to do – especially the one in which you need to tighten your thigh muscles. You can’t do enough of those

·         Garbage bags come in very handy to water-proof the leg as you are taking a shower

·         I had a lot of swelling in my ankle. A lot - it felt like the foot would burst! Apparently its normal. Keeping the leg horizontal helps. Keeping it above the level of the heart helps even more

·         If you feel uncomfortable with the brace and can’t sleep, don’t worry. You’ll get used to it very quickly. The brace is extremely important while you are sleeping – it makes sure you don’t do anything stupid in sleep. Don’t remove it unless your doctor allows you to

·         Having to sleep in one position the entire night was a bummer. I kept getting up a few times every night

·         I started a little bit of work (from home) day 2 post surgery. But couldn’t accomplish much in days 2-5, partly due to the uneasiness & pain, and partly due to headaches that I was getting which were the after effects of the anesthesia. Starting day 5, I resumed work (still from home) with about 80% efficiency. I plan to start going to the office now (2 weeks from surgery), given that I can now bend my knee

Current condition:

I’ve completed 2 weeks post surgery (and 4 weeks post incident). I got the staples removed yesterday and am now allowed to walk using a stick.


(On way to getting the staples removed and knee lock relaxed. Can you feel the excitement?)

I can (and need to) bend my knee as well. Currently I can manage about 45 degrees, but will most likely be able to go to 60 degrees in a few days. 90 degrees will come in a week or so (all of this per my fabulous surgeon Dr. Vivek Dahiya of Medanta, who’s been spot-on with his predictions so far). The walking stick / crutch will go away week 6 post surgery. Driving can start week 8. Running is 6 months post surgery. Intense sports (soccer, skiing, etc) can resume 12 months post surgery. The speed and amount of recovery depends upon how well do I stick to the physiotherapy regime. It might also depend on how much fun I have with all the attention I am getting these days – here are a few examples:



(Foot painting in action. You can still see the arrow mark that was painted pre-surgery)




(I am now a work of art - Guess this whole surgery thing ain't that bad)


So that’s it folks. Thanks to the awesome staff at Medanta. Thanks to everyone for their wishes. And big thanks to Neha for being the most patient wife ever!

Cheers!


Saturday, April 20, 2013

Lazy Indian Advertisers


Aaaggghhhh.....Crappy Ads.....!!

This blog entry is about really crappy ads. When I was in the US, all of us desis would often remember those nice, funny ads that we used to have back in India, and complain about the utter lack of creativity in American ads (please, spare us those 100x zoom of burgers and sandwiches and other edibles!).

Having moved back, I've realized that Indian advertisers have also caught upto their American counterparts. Here's a list of really crappy ads from India that make you want to puke!

1. Let's start with chocolate and candy. And I know that moving from "puking" to "chocolate" isn't a very sensible segue, but its at least more sensible than the ad I'm talking about.

Do you like chocolate brownies? How much do you like them? Would you still eat them if you knew that your head would explode as soon as you've tasted the first bite? That's probably the loyalty test that Eclairs seems to be going for here:



What earns this ad a position in this list? Well, the utterly ridiculous & scary imagery. There's a guy who is completely engrossed in enjoying his candy, soaking in the flavor. There's another woman totally absorbed in playing her musical instrument. And BAM!! Their heads explode into bursts of chocolate. Then there's the bonus dash of sadism that the DJ brings in, when he rewinds and re-explodes people's heads a few more times. Finally, in order to make sure that you never ever try this flavor of Eclairs again, they leave you with a parting shot of another head explosion.

2. Now that you've eaten chocolate, let's get your teeth cleaned. The next one is from Colgate:



By the time you have seen this ad, you probably have a lot of questions in your mind. Where did the woman suddenly come from? This is a frikkin' plane after all. Given that there is food service going on, its fair to assume that the plane is in flight. So where did she suddenly appear from, along with her entourage? Does she go around hiding in planes, waiting to pounce on some unsuspecting poor soul who happens to have a toothache? And why is she so angry? What's up with the sudden barrage of questions? Why are her people clicking the guy's photographs? Why is the guy carrying the box of the toothpaste with him while he is sitting in a plane? (I've never sat in a plane with the toothpaste carton in my lap, but maybe that's just me). After the job is done, why does the woman run away so quickly - where's she gonna go - jump off the plane?

Too many questions...

3. Another crappy chocolate ad - this one is from Choc on. This ad is being bombarded on us at an average of 3 times during every movie screening in the hall. I utterly fail to see the point that the marketer is trying to convey here. Maybe the overall thought goes along the lines of "Katrina is pretty, and we will show her in 3 pretty dresses. She is also fairly expensive to hire, which means that we have done our bit of spending a lot of the brand owner's money. Now will you please buy their chocolate?"



The only saving grace of this ad is that we are not subjected to Katrina's heavily accented Hindi. But that's about it. The connection between the blue Katrina, the white Katrina, and the red Katrina is not very clear in my mind. Then of course there are some puzzling questions around why the blue Katrina is roaming around in what seems to be an abandoned haveli, coming right out of a horror movie. Are the other two Katrinas real or are they imaginary? What's with the wolf/dog? How did the blue Katrina suddenly get a Choc on in her hand, as soon as the white Katrina got one? And finally, why should I eat Choc on? Will I start seeing two more versions of myself once I've had the chocolate bar?

In any case, this is one crappy ad, and I have vowed to never eat Choc on in my life, as a matter of principle. They gave me one for free when I was in PVR last week - its lying around somewhere...

4. Not a great Idea Sirjee!

Idea ads have always been pretty pointless. This one takes it to heavenly heights.




I don't think I need to add too much commentary here. Apparently Idea will change not just my life, but my after life as well, one app at a time. How you ask? Through the use of Google Googles!
And the watchman at the heavenly gates is a Gurkha/Nepalese guy. I guess he couldn't escape from the lowly job, even in heaven.

What comes to mind about the creator of this Sir-G ad - that he was "lay-G" (read lazy)...or that his experience & degree is completely "fur-G" (aka fake)...or that he should be sent back to standard LK-G...Anyway moving on...

5. Fair and Lovely - Poor impression

You want to get a job - first go and apply Fair and Lovely. Earlier, only women could use this short-cut, now the smart scientists at Hindustan Lever have invented a concoction that works for men as well. So you don't need to talk about your experience, your educational background, or any of the other nonsense that might prove how valuable you could be to the firm. Once you've spent enough money on Fair and Lovely, you can just walk into an interview where there are 15 people ready to interview you, but apparently you do all the questioning. One interviewer will do all the answering. And everyone else will nod and give you the job. Simple.




6. And now coming to the crappiest of them all - from J K Cement:

This one packs the entire laziness and nonsense into a short burst of 10 seconds. Enjoy!



(Sorry about the poor quality of the video)
Another one of those ads where I don't need to add any commentary. The pointlessness is fairly...revealing, should I say?

So that's a quick round-up of some really crappy, puke-inducing ads that I've come across these days.
Not wanting to leave you with a bad taste in your mouth, here are a few refreshing ones:

1. Maruti



Funny, very Indian, amazing reaction of the girl, and great connection with the product & its USP.

2. Airtel



Once again, hilarious and quintessentially Indian. Blends well with the Airtel theme of "har friend zaroori hai".

3. Idea - bunny



Catchy tune. And connects with the product pitch.

4. Axis



I find this ad to have a lot of warmth. Great example of trickle down economics. The story comes full circle at the end. And its all related to products of the brand. Very Indian too. Well done.

The ad reminds me of another great ad that Amex in the US came up with in 2009:



Superb music, great positivity, and a warm fuzzy feeling that will connect with every entrepreneur.

5. Camlin



Really funny, in a setting which seems anything but. Again, very Indian. And with an extremely witty connect with the product. Take the last few seconds out, and no one would have guessed that this is a Camlin ad!

6. and two of my personal favorites - Seagram





Great music in the background, superb acting by both the guys, and a hilarious twist at the end.



Hope you enjoyed the post! Remember to rate this post using the options below.

Cheers!


 

Monday, April 8, 2013

Whats yours is mine and whats mine is my own



I am back! And with a lot of material / nonsense / thoughts / experiences to share. Let's start with an exciting topic - taxes!

Recently I posted a quick comment on Facebook about quirky corporate tax laws in India, and sensed that there was some interest. So this piece talks more about a few specific issues on corporate taxes, advance tax withholding.


Before I get into the specifics, let me share some interesting background. A friend asked me what the corporate tax rate in India was. In order to answer that question, and provide some comparisons, I have plotted the corporate tax rates for a few countries:



(Click the picture to see a larger size image)

Some interesting takeaways here:

  1. US, the bastion of capitalism and free markets, has the highest corporate tax rates in pretty much the entire world (40%). It was awarded the first position when Japan dropped its tax rates to about 38% last year (March 2012)
  2. I used to think that the US and UK have similar policies towards openness, free markets, government involvement, etc. The corporate tax rates suggest otherwise: 23% vs. 40%
  3. India is at 32% - definitely on the higher side. China is at 25% and Hong Kong is at a paltry 17% - roughly half of India's. Yes, we have finally beat China on some dimension! :)
  4. Another surprise to me was that some of the European nations that I thought were nanny states & would charge higher taxes - France, Belgium, Sweden, etc - don't actually have very high tax rates (relatively speaking)
(Clarification: The knowledgeable might respond back by saying that the US tax rate mentioned above is nominal, and that the reality is different due to tax shelters and tax havens. This is true. But my goal here is to compare the tax rates as imposed by the government. How organizations react to it is a different mattter)

Anyway, now getting back to the interesting intricacies of the Indian tax system that I wanted to write about:
 
India has a concept of TDS (Tax Deduction at Source). This was adopted to prevent non-payment of taxes. The overall scheme is straightforward - every business is required to hold back 10% on all vendor payments and is required to deposit these to the government as advance tax on behalf of the vendor. The vendor can then account for these appropriately when it files its taxes at the year end. The Indian government also charges 12.36% Service Tax on all services rendered by organizations (similar to sales taxes charged on products). This is where the fun starts:
 
Say you are a consulting company that is raising an invoice of $1M. Your client will pay you only $900k and will deposit $100k as advance income tax (TDS) on your behalf. You will also have to deposit service tax of $110k immediately. So you end up getting $790k in your hands. Note that this is before you have made any profits or accounted for any costs. Now say you are a growth stage company and you planned to reinvest the $1M completely. This means that you end up with a loss of $110k (due to the service tax). You are still ok with it and file your taxes at year end, asking the government to return your $100k of advance income tax, since there wasn't any income. The fun thing is that the government will take its own sweet time to return this money (we are still waiting for our return from last year). But it tries to be good, and promises to pay you a 6% interest rate on the delay. You decide to ignore the fact that the delay is not counted from the day when the TDS was deducted, but from the end of the financial year (Really? So you are going to enjoy the float on my money?). Then the government tries to generally start messing with you and slips in the fact that this 6% interest will be taxed as income (WTF!). Add to this the fact that inflation in the country is 11%, so effectively the 6% return is a -5% loss in real income anyway. By the way, if you are a start-up, you know that your real cost of funds are orders of magnitude more than 6%, so that $100k getting delayed by a year kinda hurts. Anyway, you hope that life would be fair and that any delays in your tax filing would be treated similarly. Ha ha ha - hard luck - apparently when money is owed BY the government, it will pay you 6%, but when it is owed TO the government, you have to pay them 18%. By this time, you give up and utter that phrase that most Indians speak when they hit a brick wall with the system - "Mera Bharat Mahaan"
 
So that was the interesting tidbit I wanted to share. Before I wrap up, another juicy fact related to taxes. Recently, I found out that the Municipal Corporation of Gurgaon was sitting on about Rs. 650 Cr (~$130M) of surplus corpus from previous year. What did the MCG do with this money in the last 12 months? Did it put this sizable money into developing parks? Or maybe they improved the road light situation. Who knows, they might think of improving the roads. No, no, and no. Our local government, in all its wisdom, decided to put the money into fixed deposit saving schemes, earning 9.85% interest rate. Remember that 9.85% is less than inflation, so the real return is negative / close to zero. This is absolutely criminal - the MCG can think of no useful way to use this surplus cash to make the lives of the residents any better!
 
This coming year again they expect a surplus of some Rs. 300 Cr or so. Guess where that's going.
 
Mera Bharat Mahaan!
 
More later. Let me know what you think about the post.