LeFort: RIP

There is some magic in LeFort's operation. It draws some gynecs like honey draws some bees. I remember the time I was a first post resident in Gynecology. My room partner was working as a resident in the other unit in our ward. All residents in that unit were a different breed. They used to post eight major operations on one day, knowing the boss would operate on two of them, which would leave six and the houseman would get to operate on one of them. The boss started performing a vaginal hysterectomy on a patient with alleged menorrhagia. Unfortunately the cervix came off after dividing the uterosacral ligaments, and there was no uterus above it. Then it turned out that the patient had undergone abdominal subtotal hysterectomy in the past. How she had menorrhagia is beyond comprehension. The boss got wild and ordered them to take the next patient, one scheduled to undergo LeFort's operation. After induction of anesthesia, she discovered that the patient had no prolapse at all. How they posted a patient without genital prolapse for LeFort's operation is also beyond comprehension. Perhaps they did not manipulate the OT list very well. That was 29 years ago. I thought things would have improved with time. But today they informed me that there was a very high risk patient scheduled to undergo LeFort's operation tomorrow. The registrar informed me that the patient had second degree uterine prolapse, and minimal cystocele and rectocele. She further told me that I had advised LeFort's operation for that patient. I knew I had not, because my concepts on indications for LeFort's operation are clear and firm, and this one did not fit in those concepts. So I asked them to recheck. Then it turned out that my Assistant Professor and Associate Professor had seen her and advised LeFort's operation. So I finally went to see the patient myself. She had only uterine prolapse, C point at +1 in POP-Q classification. There was no cyctocele or rectocele. "How can you perform LeFort's operation if there is no cystocele or rectocele?" I asked my registrar. "You have to make bladder and rectal surfaces bare and suture them to each other, as we did a month ago on another patient. If there is no prolapse, that will not be possible." "But madam has advised that" she said. "You will qualify at the end of this post. How will you practice gynecology if you cannot think for yourself?" I countered. She had no answer. "I agree that the patient is at ASA grade III for anesthesia. But if a condition is not treatable by LeFort's operation, it cannot be treated by LeFort's only because it can be done under local anesthesia. If at all, you have to perform hysterectomy under local anesthesia." Then I counseled the patient and left her to decide what she wanted, hysterectomy or living with the minimal uterine prolapse she had. Poor LeFort must have been turning in his grave because of what people do with his operation. May his soul rest in peace.

Continuing Medical Education

It was about ten to fifteen years ago. I was a member of the academic committee. I felt that we failed to get educated about what was happening in other specialties after we specialized in one particular subject. So I suggested to the committee that we should get all departments to hold continuing medical education (CME) programs which all staff members should be able to attend. We could then get the education we needed without having to attend fancy conferences in five star hotels. They misunderstood me, and developed a scheme that included finding sponsors for the CMEs. Finally the scheme died, as all schemes eventually die unless they are a part of the curriculum. Now the Medical Council wants all doctors to get 30 hours’ CME credits every 5 years. The scope is not planned. One can get the credits in a variety of ways, including attending conferences, CME programmes, writing scientific articles in indexed journals, speaking in CMEs, and writing chapters in books published by recognized organizations. That does not mean one ends up getting the required knowledge, but it is better than nothing. It is even compulsory for us teachers, who actually teach undergraduate and postgraduate students. I feel a multispecialty curriculum must be planned for every 5 years and that must be made compulsory for all doctors. I hope someone in the council reads my blog. I would have written to the council, but I am discouraged by my past experience of writing to administration, universities and councils – there is no response.

Logical Journal

I had an interesting case of primary abdominal ectopic pregnancy diagnosed early. She insisted on operative treatment rather than observation or medical therapy. So we performed a laparoscopy on her and removed it from the surface of the back of the right broad ligament. Since there is no documentation of such an image in the literature, I sent it to our staff society journal. It is a high tech journal. It accepts articles online. I received a reminder from the editor that I had not responded to his request to correct the reference to required format. It reminded me of municipal working style, where reminders are sent without having sent a prior letter. Anyway I corrected the reference the way he wanted it and sent it. Then the online system told me that I had to send a glossy print of the image to the journal's office because I had sent a revised manuscript. I was surprised, because the journal does not require a print primarily, but only if a revision of the article is required. It has no logic. It seems to be a method of teaching people a lesson when they do not send the manuscript as required. The journal also asked me for an image of ultrasonogram of the patient, when I had not even mentioned it in the text. I think the people on the editorial board have some funny concepts only because they are on that board. They are like our politicians. They get elected in staff society elections, they run the journal using money deducted from our salaries without our consent, and then boss over us. I have half a mind to withdraw the article and post the image on my blog.

More Repairs

We have been away from our wards and offices for one year and three months. I have been forced to sit in the hospital's bill section with the clerk, because there is no place for anyone during the repairs. Now they have started breaking the floor and walls of the staircase and landing of fifth floor where my desk space is. I wonder if there is a transit- transit desk space available for heads of departments sent to a transit desk space when that space goes under repair. I must say they are probably going to make that place beautiful beyond imagination, because it was looking OK before, and they are still breaking it down. I cannot see any other reason for the same. In the meantime, the contractor has taken away our marble in the OTs and put lower priced vitrified tiles in its place. All promises have been like those made by politicians before the elections. The tender term is the contractor will take away all rubble resulting from the repair work. Marble is rubble!

Vacation Arrangements To Water Plants

We were going to be away for about 7 days. We have 15 potted plants in our terrace garden. it would have been great to have a sprinkling system to run at predetermined time every day to water the plants. Unfortunately we don't have one, and I would not develop one only for once a year. So I devised a system that works on capillary action. I placed a big bucket full of water on a table. Then I placed all the potted plants around the table. Then I ran a long piece of string (made by braiding of multiple threads)from the bottom of the bucket to each pot. The idea was to let water pass along the strings from the bucket to the soil in the pots by capillary action until we returned home. I covered the top of the bucket with a plastic sheet to prevent loss of water by evaporation. That was important because no fresh water would be added to the bucket while we were away and that water had to last for 7 days. When we returned 7 days later, the plants were as alive and fresh as when we left. The strings were wet, and the bucket was only 20% empty. I think is beats a computerized water sprinkling system any day.

The Worst Department

"Sir, the inspector from the health university said ours was the worst department in the hospital" our clerk cum typist said. She sounded upset. I would have been upset in her place too, because we all were intensely proud of our department and the institute. "Why did he say so?" I asked. "we took along all the sealed bundles of answer books of students for him to inspect. He did not like that. He wanted them to be open like the other departments had." "But that is against the university rules" I said. "The bundles have to be sealed as soon as the result was ready for each exam." "He also wanted the answer books of each student from all three exams to be put together." "That is not possible because the exams take place 6 months apart, and we cannot break the seal of each bundle, even if he wants it that way" our professor in charge of this matter said. "I explained it to him, and he finally understood it." "But if he is the inspector sent by the university, he should be aware of all the rules" I said. "Yes. Unfortunately he was not" the professor said. The clerk was still upset. "Don't think about what he said. He called our department the worst department because he was inadequate, and believed what the other departments did was the right way, not what is laid down by the university. It was his job to inspect the internal assessment result and go away, not pass judgment on departments. If it is any solace to you, let me point out that he was from an unknown Ayurvedic college. People take admission in such colleges when they cannot get admission in institutes like ours. That the university gave him a job of an inspector that truly busy people do not want does not make him God. His saying that we are the worst does not make us so. We remain what we are - the best. Never worry about what people say about you. Be principle-centered and be happy that you always do the right thing for the sake of doing the right thing, not to please anyone." She seemed happy after that.

Poverty and Obesity

The hospital I work in is a hospital for poor patients. It was my belief that poor people have little money and they cannot afford to eat much. So they would be underweight if not outright malnourished. In recent years I find a different trend. A large number of women especially elderly ones, coming to us for treatment of gynecological conditions are quite obese. It becomes a nightmare to operate on them by whichever route. Vaginally one encounters little of that fat, but the postoperative course can be quite difficult. The trouble begins with having to shift them from the OT table to the trolley and from the trolley to the bed in the ward. The abdominal or laparoscopic route has the additional problem of having to go through layers and layers of fat. The time required for opening and closing the abdomen is quite long. The intraabdoominal fat makes surgery difficult. Wound breakdown rates are high. To find their veins for intravenous injections and transfusions can be a nightmare. Luckily we do not face deep vein thrombosis and pneumonia so often as compared to the US or Europe. I often counsel them to reduce their weight preoperatively, both for the sake of success of the operation and their future health. I am yet to find a single patient who managed that. All of them claim they eat virtually nothing. The diet they describe is virtually nothing. One would believe they gain weight by drinking water. But now I have found out that they consume a lot of coconut, which is not mentioned in the diet unless specifically asked for. Even then many of them avoid answering that question unless one insists on getting an answer. To get a solution to a problem that the patient herself does not want solved is beyond me. 'That is the way it goes' Schultz would have said about this issue, were his characters to bring it up in his comic strip 'Peanuts'.

The Fothergill Story

The Manchester Donald Fothergill operation (popularly known as Fothergill's operation) is a very old operation for uterovaginal prolapse. The textbooks we read as undergraduates had a brief description of the same, including the main components only. As postgraduates we never found the original description of the operation in any book. We saw the honorary gynecologists in our institute perform a modified version of the original Fothergill operation and we performed a similar operation ourselves as residents and later as staff members. I wrote a book in 1987 in which I described this modified form because it was the best for our patients. I later wrote an atlas of operative techniques along with my Registrar Dr Shah, who shot all the pictures in the Atlas himself. The technique in that book was also what we did. Now I am about to write a new edition of my book. I thought I should describe the original technique, and started looking for it. I found the original article dated sometime in 1935 on internet. It was available on the site of Obstetric Gynecological Survey for a fee. I don't do net banking and don't use credit cards. I would not pay so much money just read an article for historical interest. I asked colleagues who had worked as juniors in other institutes, and realized that they had different concepts of what the original operation was like, none but one had apparently read the original article, and that one did not put the Fothergill stitch while performing that operation. I finally found the article in my old edition of Shaw's Operative Gynecology. I would not perform it that way myself, but I will describe it in the new edition of my book on Practical Gynecology and Obstetrics, so that students will know what it was like instead of believing a Chinese whisper version they get taught or shown.

Hibiscus on Mango Tree

We have a huge mango tree outside our balcony. I saw something very curious that day. The tree had a hibiscus flower right on top of it, which is about half a story below our window. Since it is a tree growing on the sidewalk, no one has experimented by transplanting a hibiscus branch on the mango tree, and anyway that would not be two and a half storeys above ground level. I have not made that picture using Photoshop or GIMP, because I dislike untruths, and also because I am not good in the use of graphics software of such complex nature. I am putting up the picture for the curious ones, and also in the hope that someone can offer an explanation for the same.

Heritage Keepers

I was on my way from the office to the wards, which are at the opposite ends of the main corridor of the heritage building of the hospital. The corridor was full of people, either going places or waiting. A middle aged guy entered the corridor on my left, walked a couple of paces, turned his head on his left, and blew his nose in the corridor in the general direction of the outside world by pressing on one nostril at a time quite methodically. Then he kept walking in the direction of his destination, and wiped his fingers on three consecutive stone pillars to rid them of the mucus he had so methodically expelled from his nose. “Do you know you have dirtied the hospital building at four places?” I asked him conversationally. He turned toward me with an air of one ready for a fight. There must have been something in my face or appearance that told him I must be a senior doctor in the hospital or perhaps an administrator. “Four...” he said. “Could you not blow your nose outside? All you had to do was to lean out over the railing of the corridor” I said. “.....” “Then you wiped your fingers on three pillars. Do you know that you are spreading disease in a hospital that is meant for treating diseases?” I asked. That should have concerned him, because most probably he was there in connection with a patient related to him. “I have this cold” he said in the way of an explanation for his dirty behavior. “You have to carry this for that purpose” I said and took out a handkerchief from my pocket to show him. He looked at it. He seemed incredulous that anyone would carry a handkerchief in his pocket.

Distortion of Intrauterine Device

“Sir, there is a patient who wants to get her IUCD removed. But the threads are not seen on speculum examination. She has an ultrasonic scan report which shows that the IUCD is in the uterine cavity” my new Assistant Professor said. “In that case the threads have either fallen off, or they are drawn up. If they are drawn up, the IUCD has most probably undergone a somersault” I said. I examined that patient. She had normal pelvic anatomy. There was a mild pelvic infection. “Let us try and get the threads of the IUD out using a brush” I suggested. Accordingly he inserted a cytobrush into the uterine cavity and rotated it around a number of times. Unfortunately the threads did not get entangled in the bristles of the brush and come out. He repeated the procedure two more times, but the threads remained where they were. So I inserted an IUCD removing hook into the uterine cavity and hooked the IUCD out. It came out smoothly at the very first attempt. It was hooked at the center of the vertical limb. It was Copper-T 380. The threads were along the vertical stem. The transverse bars were bent forward at an angle of about 160 degrees with each other. The vertical stem was bent forward at a similar angle at its midpoint. I knew what the problem must have been. So I asked the patient why she wanted the IUCD removed, whether for having another baby or any other reason. “I get intense pain in the lower abdomen and pelvis during and in between menses” she said and grimaced. That confirmed my diagnosis. “What must have bee her symptoms and what was the cause of the distortion of the IUCD?” I asked my Assistant Professors and fourth year resident. Based on the answers given by them, none of which was incidentally correct, I asked the same questions to all Assistant Professors in the department. No one out of 17 of them answered that question, which was a little disturbing, because they all were freshly qualified doctors and were expected to be very knowledgeable. One did not come for the survey, while another opted out after hearing the question. Their reasons for the distortion of the IUCDas follows. 1.The uterus must have been anteverted while the IUCD must have been inserted in a retroverted direction. 2.There must be a uterine fibroid. 3.The uterine cavity must have been distorted. 4.There must be a partial septum in the uterine cavity. 5.The IUCD must have been inserted by the push-out technique rather than by the withdrawal technique. 6.The IUCD must have lost its elastic memory. 7.The IUCD must have a manufacturing defect. 8.The hook must have distorted the IUCD while pulling it out. 9.The tips of the transverse bars must have been embedded in the myometrium. 10.The IUCD must have been embedded into the endometrium. 11.The IUCD is normal. There is no distortion. None of them had any clue about the symptoms the patient must have had. After I completed the survey, I told them the reason for the distortion and the patient's symptoms. “The IUCD may have been inserted into a uterus whose cavity was larger than normal, as after a first trimester abortion. That must have given the IUCD some extra space, so that it was a little malaligned. Uterine contractions trying to expel it out must have caused it to somersault. That would draw up its threads. Repeated uterine contractions would distort the IUCD, and that would cause severe pelvic pain and spasmodic dysmenorrhea. Distortion does not occur often with T-shaped devices due to their slim shape fitting well in the uterine cavity. The rate was much higher with first generation devices like Lippes' loop. This is not my imagination. The medical literature has a large number of such records for those who wish to find those.

Honorary Clinical Clerk

A part of the work of an intern is to write clinical histories of patients attending the gynecological outpatient clinic. It is not very interesting, since most of the interns are not interested in the subject, and those who are d not get to examine those patients. So it becomes a mechanical job. I like writing histories, because I know that a diagnosis can often be reached from the history, and examination is required to confirm the diagnosis. Investigations are required in a small fraction of the total number of women attending the clinic. Sometimes I write histories when there are too many patients in the clinic and the interns and house officers do not seem to be able to cope. When one colleague mentioned that one particular honorary gynecologist in another hospital run by the corporation used to sit in the outpatient clinic and write down patients' histories, I thought the reason must be one of these two. “I used to feel quite awkward when he would sit there and write histories. I was quite junior to him. So I would offer to write the histories myself, and let him examine the patients. But he would not listen to me.” “Why did he write histories himself?” I asked. “He would write histories and then give the patients the address of his private clinic, so that they would go there.” Good grief! The fellow was stealing poor patients from a corporation hospital to flourish in his private practice. Then I recalled the stories that this same honorary used to write scientific papers over weekends using imaginary data, when he was an assistant professor in another hospital run by the corporation. I also recalled the time we were examiners together when one medical student who had refused to accept his private tuition for a fee had been given just passing marks by him as a punishment. I could not do anything about it, because I came to know about it later, and anyway there was no provision for changing anyone's marks given by another examiner.

Reserve a Bed

It was late evening. My doorbell rang. "Hello." He was an old friend of my late brother. "Come in" I said. "Come in" he said to the person accompanying him. Both of them entered and sat down. "This is the uncle of the patient who was under you treatment." "I was the person who rang you up today" the other fellow said. I remembered. I was working in the OT when he rang up and told me one of my old patients was coming to Mumbai. I had told him to take her to the emergency room in the hospital. Now here he was at my residence. "Has she arrived and gone to the hospital?" I asked. "No. She is on a bus. She will reach the hospital at night." "I have told the resident doctors to see her and do the needful" I said. "What do you want me to do now?" "Umm... well. We want you to reserve a bed for her at the hospital." I laughed. "This is not my private hospital that I can reserve a bed for her. My department is under repair and my patients from seven wards are put in 1.67 wards. AT present there are three patients on one bed in the main ward. I am out of my department building and the Boss has given me, the head of department no place to sit. He had told me bluntly that no one would have any office during the repair work. The Deputy Dean has given me desk space in the bill section where I have been sitting to do paperwork and computer work for more than a year. If I as a head of my department has no right to any space, how can I reserve a bed for a patient who has not even reached the hospital. Take her to the emergency room and we do the best possible thing. If you want a reservation, you talk to a politician or administrative boss." They went away. I found the next day that she was admitted at 2:00 A.M. and was sharing a bed with two other women. She was receiving required medical treatment as promised.

Attention Deficit Disorder: 6th Post Syndrome

Residency is of three years for those seeking a postgraduate degree in medicine. It comprises of six posts of six months each. A lot of them take a long time to get adjusted, and hence their abilities as clinicians get restricted in the first six months. But that is because of the pressure of something that they have not experienced before and an inability to cope. It has nothing to do with any deficit in attention. When they start their last post, they develop a syndrome which we call the '6th Post Syndrome'. In this syndrome they are physically present in the hospital, though their minds are elsewhere. There was a time when they used to go on French leave in some units. When we became senior enough to control this, we held a joint meeting and decided that no unit head would permit this. Then they made their juniors function as Registrars just remained present for the rounds, not doing any work actually. That was detrimental to their training. So we stopped that too. Now they work until they can go on leave to prepare for their exams. But their attention is on their dissertations, reading for exams, and perhaps some other things which are not academic. The following example of morning round of the wards should illustrate this point. “Sir, this patient has preeclampsia. Now her blood pressure is under control.” “What are the results of her anticardiolipin antibody and lupus anticoagulant tests?” I asked. “She has given negative consent for undergoing those tests. She cannot afford those tests.” “Why do you not undergo those tests?” I asked the patient. “I don't know which tests” she said. “I have not been told about any tests.” “Sir, her husband was told and she was present there. He said he did not have money at that time” the Registrar said. “But now he may have money. Have you asked again in these many days after her hospitalization?” “Umm... no sir.” she said. I advised the patient to talk to her husband and then tell us if she would get those tests done. “Sir, this patient is seven months pregnant. When she came, she had fever and her Widal test was positive. She received treatment for typhoid, and now her VDRL test is negative.” “VDRL?” I asked. “Umm... sorry sir. Her Widal test is negative.” “OK.” “Sir, this patient has undergone anterior colporrhaphy yesterday morning. Her input was 25000 ml and output was 1650 ml yesterday.” "How did you transfuse her 25000 ml in less than 24 hours?" I was aghast. "Sir?" "25000 ml input is unbelievable" I said. "Umm... no sir. It was 2500 ml." Then I remembered. This same Registrar had once said a patient's input had been two thousand sixteen hundred in 24 hours. “Why is she still on intravenous fluids? Why have you not started oral intake?” I asked. “Her peristalsis are feeble.” “Why did the peristalsis become feeble?” “....” “Sir, this patient underwent a hysterectomy. The one who underwent anterior colporrhaphy is the next one” the Assistant Professor said, to avoid further unnecessary discussion. I examined that patient, gave appropriate instructions, and then moved on to the next patient, who had undergone anterior colporrhaphy. She was also on intravenous fluids. “Why is she still on intravenous fluids? Why have you not started oral intake?” I asked. “Umm... sir, we keep them nil by mouth for 24 hours after major surgery” the Registrar said. I checked her. She had good peristaltic sounds, and that was no surprise because there was no reason for the peristalsis to get affected. I advised to start oral liquids for her. I had taught all of them this point in past, but they seemed not to retain any information given to them.

Rest Room Approach

Rest Room Approach I had read a couple of books that highlight the fact that women and men think differently. I knew it was right, and that was the reason of many marital conflicts. One of the books gave an example which said that it was perfectly normal for a woman to ask another woman “I am going to the rest room. Would you like to go too?” The other woman finds nothing abnormal in that and they happily go there together. It further stated that a man would never ask another man this question, and if he did, the other one and others listening in would think he was crazy. It stated that the woman used this opportunity to talk, empathize, interact on different issues etc. I never could confirm this, because they don't say this in front of men. I am proud to say that my institute has given me that opportunity. They have been repairing the building where my department was. It has been going on for more than a year now, and in the meantime they have given me desk space in the bill section. This room and an adjacent room have a joint rest room for women. The rest room no less unattractive and unclean than most of municipal facilities. There are doors opening into both the rooms. The procedure is that if anyone goes into the rest room, she locks the other door from inside for the duration of use of that room. Thus no other woman surprises her by entering it accidentally. I don't see the purpose of this arrangement, because solo entries into that room are practically unknown. Usually the employees enter this restroom from the adjacent room because in our room there is a male clerk and me, and they probably find it uncomfortable passing in front of us to such a destination. But occasionally the women in the adjacent room lock up their room from inside or outside, and then our room is the only access point for the other women. Usually they go there is pairs. But for the last two days, things have been different. They have a workshop of some sort in the auditorium on the third floor. Yesterday, five women came together and went into the rest room. The noise made by two women is within reasonable limits. One can continue to work though the efficiency is reduced. But five women made so much noise, that we had to stop all work and do deep breathing to control the blood pressure. Today seven women marched in. I wished I had ear plugs. I wonder how they can be so merry in such a small and so unclean a space.

Attack

“Do you have one Dr. XXXXX in your department?” It was my classmate from college on phone. He has a flourishing dental practice. “Yes, what about her?” “She has been maligning me” he sounded upset. “What happened?” I asked. “I had a patient. She underwent a tooth extraction in my clinic and went home. Half an hour later, she fainted. This Dr XXXXX has her clinic next to that woman's residence. So she was called. She saw this and said it was an attack. Then the relatives gathered in my clinic and accused me of negligence so that the patient got an attack.” “What attack?” I was puzzled. “Attack as in a cerebrovascular accident or heart attack” he said. “The word 'attack' means this to these people.” I thought about it a bit. It was too late for being a vasovagal attack. But then I remembered this professor rushing to every one who fainted in the department and calling it vasovagal attack. That clicked. “She must have meant a vasovagal attack” I said. “She has a thing about vasovagal attacks.” “Oh God!” he said. “She should specify that. Now she has instigated my patients against me.” “Explain to them what I said, and everything will be alright.” “But she should not do such things” he protested. “Keep safe distance” I advised. “I do the same thing myself.”

Delayed Vasovagal Attack

My wife told me about a small boy who went to her clinic for a booster shot of a vaccine. He was five years old. His mother and grandfather were with him. The grandfather waited in the waiting room, while the mother took the child into the examination area and put him prone on the table. She moved his shorts down and my wife started giving him the injection. He had not been aware till that moment that he was to receive an injection. So when the needle touched him, he screamed, threw himself in the air, and became uncontrollable in general. So the grandfather was summoned, who helped hold him down and then the injection was administered uneventfully. But the child did not forget the insult easily. He continued to bawl. The mother cuddled him, spoke sweetly to him, distracted him by telling him about other things of interest. He would become quiet for a few seconds, and then remember the whole matter and start bawling again. Five minutes passed like this. Then the bag held by the mother slipped from the mother's hand, the bottle of medicine fell on the floor, her eyes rolled up, and she followed the bottle to the floor. The grandfather panicked and requested the doctor to put some medicine in the mother's mouth. The doctor reassured him, put her flat with her head turned to one side, and sprinkled some water on her face. Then the mother gradually came to. A history of fear of dispensaries was obtained retrospectively. One good thing from the mother's vasovagal attack was that the child's bawling stopped instantly, and did not start again even after the mother was revived.

Spinal Level Work

I started my residency in 1981. The first post I did was an incoming post meant for future anesthetists, for one month prior to regular residency, which I wanted to do because I knew I would get my Registrar’s post after one year of house job, and would not do any allied posts. I wanted to learn CPCR and spinal anesthesia. The Head department of anesthesiology was very kind. He gave me the post even after the last day for application had gone. I owe him. I learnt what I wanted to, and also a bag of tricks that anesthetists believe the surgeons know nothing about. There used to be a guy in anesthesia those days, who used to induce spontaneous GA, but the patient on inhalation agents ventilating self, and go and sit in the anesthetists room while the surgeon performed laparotomy. That was his laziness to give controlled GA, which was a lot of work. These days I find anesthetists who want to give spinal anesthesia for everything, so that they don’t have to give GA. Ventilating patients is a lot of work. They showed me as a reference a line in the footnote of a chapter on anesthesia for laparoscopy, that spinal anesthesia was a possible form of anesthesia for that. Now they give spinal anesthesia for all of our laparoscopies. Some patients scream with pain, because it does not block shoulder pain from irritation of the diaphragm. They ask us to instill local anesthetic into the peritoneal cavity for relieve that. If the patient still howls, they give GA. God help the patient if she develops a complication like a vascular injury or gas embolism under spinal anesthesia. They have a double standard. For laparoscopic sterilization they give general anesthesia, because they are scared of inquiry by a governmental agency if anything goes wrong. A remark in this connection made by a staff member is very amusing. “They give spinal anesthesia for everything except a craniotomy, cataract extraction and tonsillectomy.”

Saviors in Green

People go abroad and visit hospitals. They also watch medical hospital soaps on television. One of the chic things experienced is those dashing hospital personnel going about in scrub suits. Some of them are tempted to do such a thing in their own hospitals back home or at home, as the case may be. It is also more comfortable to wear scrub suits at work, because of higher environmental temperatures, and air conditioners being allowed only for ICUs, operation theaters, and offices of only officers who matter. It is also a nuisance when the people outside the hospital and at home smell hospital odors on one when one works in one's street clothes and goes home wearing the same clothes. That does not happen if one wears a scrub suit at work. It is troublesome to bring one's own scrub suit from home, take it back, get it washed and laundered and then use it again. The hospital does not provide scrub suits for this purpose. So the best way out is to use OT clothes for this purpose. For personnel working in OTs every day, it is very convenient. Those who work in OT only twice a week or so, it is possible at least on those two days. As a result, we see those men and women in green in our hospital wards, labs, and corridors frequently. I wonder if they don't realize that they have to use these OT clothes only in the OTs, and if they go out in those clothes they pick up microorganisms which they carry back to the OTs and contaminate them, promoting surgical wound infections. The doctors and nurses are trained to know this. The other employees have to be told about this by their superior officers, i.e. The doctors and nurses. Either they know and ignore it, or they don't know for reasons unknown, and continue to move around wearing green OT clothes. In the meantime, the unsuspecting public is thrilled to see these saviors in green going about their business, the saviors are happy to bask in the admiration received, and life goes on.

Waxing in Gynecological Residency

I suppose waxing is a well known method of removal of unwanted body hair. It has its place in the cosmetic therapy of hirsutism. That was the only form of waxing I knew until today morning. But my resident doctors are full of surprises and one of them gave me one today. It was a patient's consent for undergoing a gynecological operation. I had instructed them about the exact words to be used because it was an unusual case. When they showed me the consent before induction of anesthesia on that patient, I found that it was not as I had wanted it. I pointed out the errors, and explained why it should be in a different way. They promised to change it. A little while later I found my senior house-officer doing something I had not seen before. She had cut a 1.5 cm long and 5 mm wide strip of transparent adhesive tape that is usually used for retaining dressings. I could not imagine any use of such a small piece of adhesive tape. So I watched. She proceeded to put it firmly on the patient's case record sheet, and pull it away. She repeated this procedure twice. Then she put away the adhesive tape and wrote on the part she had doctored. Then it dawned on me that she had removed unwanted words from the consent and put new words in their place. An eraser is a thing of school life. An adhesive tape is an essential item for the resident doctors. So if it can be used in place of an eraser, so much the better. The tape pulls out a superficial layer of the paper on which it is applied and leaves a reasonably blank though thinner paper behind, on which corrections can be made. The expertise with which she carried out the maneuver suggested that she had done that many times in the past, and was quite good at it. That perhaps qualifies as lateral thinking.

"Sorry Sir" Syndrome

There is a new syndrome on the block. No matter which institute the students come from, they are affected by this uniformly. It starts in the undergraduate days, and continues in the postgraduate days. "Why did you not attend the teaching session yesterday?" "Sorry Sir." "Why did you run away from your duty in the emergency ward?" "Sorry Sir." "Why did you enter the operation theater without changing into OT clothes?" "Sorry Sir." "Why did you go out of the OT wearing OT slippers? Do you not know that it carries dirt and microorganisms into the OT and contaminates it, increasing our surgical infection rate?" "Sorry Sir." "Saying sorry does not solve the problem. What do you propose to do about it?" "Sorry Sir." There is a great book by Thomas A Harris - 'I am OK, you are OK'. It is on Transactional Analysis. It is a practical guide to using Transactional Analysis as a method for solving problems. As described by that author, I wish my students would respond to my adult questions with adult answers, so that the adult-adult interaction would produce results satisfying to both parties. Unfortunately no matter how much I try, they adopt the parent-child interaction. Then everything I ask is just a 'lecture' on bad behavior, to be suffered silently until it gets over, and the only response is "Sorry Sir." In fact it is I who is sorry, not them, that they suffer from this syndrome.

Laptop Table

I had always used a desktop PC, which I took pride in opening and repairing when it gave trouble. But I needed something smaller that I could put on my tummy while I reclined on a bed, and read my huge collection of books and articles. I wanted to buy an Amazon Kindle ebook reader, but there were no dealers in India, and I did not trust internet transactions with credit cards. So I bought a netbook, and it worked wonderfully. Unfortunately I realized by and by that its fans put out heated air from its undersurface, and it burned my abdomen. When I kept it on my lap, it burned the lap. I also realized that when I kept it on a table or a mattress, the heat would not escape readily, and would heat the surface it was on. I had to leave the undersurface open to let the heat escape. Then I had an idea. We had a folding container for newspapers and magazines. Its sides were of cloth and skeleton of light wood. I have drawn a rough picture to give you an idea. It is much prettier than that :-). I keep the netbook on its upper transverse bars, and sit under a fan. The warm air is easily dissipated. I keep the mouse and USB multihub in the cloth part. It has been working fine for quite some time. I thought about it when I saw an ad in the newspaper today. It was about a USB laptop table. It has two USB fans where the laptop sits. I wonder if those fans actually cool the laptop. My make-shift table cost me nothing as compared to 2100/- INR for this table, and my fan cools me and my netbook very well, while the USB fans of that table would never cool me. My make-shift table reminds me of my religion too. They used to keep their holy books on such tables (or stands) for reading convenience. Perhaps technology has taken me back by a century or so.

Prelunch Hand Wash

I heard that our clerical employees had become health conscious and were using a special hand wash prior to lunch. I got curious, and asked them to show what they were using to wash their hands. One of them opened the steel cupboard and produced the bottle of the hand wash solution. “This is the hand wash solution the doctors use after examining a patient, before examining another patient, so as not to transfer infection from the first patient to the next one” I said. “Yes. The nurse gave it to us. It is on schedule” they explained. “That is all right” I said. “Please read the ingredients of the solution.” So the person who had taken the bottle out of the cupboard took it from me and read the ingredients. “Dextropropoxy polyethoxy ... something, and ....something propanol... and ....” “Those are alcohol based antiseptics” I said. “There is a color added too. Please see if they are safe to be ingested.” So she searched the label of the bottle and finally said “the label does not say the contents are safe for ingestion.” “How long have you been using this hand wash prior to lunch?” I asked. “One month” they said. They seemed a little worried. “So you have been ingesting these chemicals for month. We don't know what are the effects of these on the human body if ingested. Perhaps you are chronically poisoned. Show me your hands” I said. The leader showed me both of her palms. “See these dirt marks? That dirt does not go away with this hand wash. You are ingesting all the dirt you pick up during your journey to the workplace and during your work too. Why do you not use soap and water instead?” “We were using soap and water in the past. But the nurse said ...” Perhaps they were impressed with the technology, which was supposed to kill all germs and resulted in dry hands. “I wonder if the nurse is using the same hand wash before her lunch and if so, for how long” I said. The nurse was not around, so I could not educate her. “Think carefully before you change your health practices.” “Yes sir” they said.

Mock Viva Fiasco

Education of undergraduate students is chalked out by the medical council and health university very well. However what exists on paper and what actually transpires are poles apart. We have these students who want self education or automatic (i.e. without learning anything) education. So they do not attend lectures and practicals. The Boss felt that we have to draw them back to clinical education and he conceived a novel idea for the same. He conducted mock viva for all students. They were put in an auditorium housing 300 students. Mock examiners and students were made to conduct mock viva, which was shown on two giant screens. The program was conducted by the surgery department. We could not do it last year because of H1N1 epidemic. This year the surgery department conducted the program again. I heard they had a bit of a problem getting students to attend. But the captive students doing clinical terms were caught and made to attend. Our program was scheduled after they finished their all clinical postings. We did not raise the money required through kind pharmaceuticals as suggested. We used our laptop, web camera, LCD projector, and existing audio system of the auditorium. The money for the equipment was our own money, not that of the corporation and not from pharmaceuticals. Our Assistant Professors carried the instruments and pathology specimens themselves when they could not find a servant to do it. One professor was program director who spent days planning and organizing the whole thing. I gave them my 3 D images of instruments and photographs of specimens, to be shown in addition to the actual instruments and specimens. We invited external examiners from a sister institute. All of our professors and associate professors turned up for the event. Then the waiting began. We waited for a half hour. Not a single student arrived. After we got tried and left, four students (one of them the class representative) arrived and said they could not get students to attend and could the program be please cancelled? Comments of different people on that occasion were as follows. “But the students are in the canteen, common room, and katta” the custodian said. “Could they not tell us in advance, so that we would not have wasted our time?” an angry professor said. “They are like that. That day there were only 8 students out of 180 for the Director's lecture” said the attendant. “We spent our own money on this. Now that is also lost” said another professor. “And Sir went to Lamingtom road to buy the web camera himself! Can't they understand” said an associate professor. “We are going to be their examiners. Let us be properly strict with them during the exam” suggested a senior professor. “I know that will not happen. The country needs doctors. So all examiners pass almost all the students, unless the students don't appear for the theory exam or keep their mouths shut during the viva. The people's health seems to be OK despite doctors of such quality. So what does it matter anyway?” said a cynic. “We will cancel the program. I will write to the director and inform him about the response to his wonderful idea. We will let the students learn such things only during their clinical postings in future, and if they don't attend that time, so be it” I concluded.

Publishers' Tricks

I had written a book on 'Conversation Games'. I wrote it because a lot of people played a lot of such games with me and that experience was more than enough to write it. The main problem with writing a book begins after one completes writing it. It is to find a publisher. The publishers of my medical books would not publish this book, because it was not a medical book and they would not be able to sell it. Then one day I saw an ad in a newspaper. It was about a psychology book being published by MaiXXXya Prakashan, written by a psychiatrist. I thought they would do, since they seemed to have done something in that field. I called them. After telling the guy on the phone who I was and what was the purpose of my call, he asked me what my book was about. “It is about conversation games. I saw your ad about the book written by a psychiatrist and I thought my book being from a similar field, you would be interested in my book.” “Come and meet me with your manuscript” he said. I met him. I gave him my manuscript. “I will call you with my answer in two weeks” he said and wrote that down on his acknowledgement slip. Two weeks passed and still there was no call from him. I knew the ways of book publishers and I decided to wait. I waited for four months and then I called him. “What is it?” he asked. “It is about the manuscript I gave you four months ago” I said. “Yes. I cannot do that book” he said. “Can I collect the manuscript tomorrow?” I asked. “No. I am a bit busy right now” he said. “That is OK” I said. “We don't have to talk. You can leave the manuscript with the receptionist. I will collect it.” “No. You don't understand. I am busy for 3 to 4 days. I will call you next week.” I could not understand how a fellow with a desk job could be so busy that he could not take out my manuscript from the drawer and give it to the receptionist. The next week passed without any call. Finally the receptionist called in the following week and said she would send the manuscript unless I could send someone over. I requested her to send it by post. I hope she does. When I thought about the whole thing more, I realized the only reason he got hold of my manuscript and kept it blocked for four and half months was probably to keep a book that could possibly compete with his book from being published, to cut down competition. I knew that was most probably the case, because something like that had happened to my son. He wrote two books on making aeroplanes by origami, when he was seven years old. There was a book in market, published by a 'JyXXXna Prakashan'. It was different from an origami book. It had models of card board, which were to be constructed after cutting them out of the book. When I contacted the publishing house and stated my interest, the guy called us, took charge of the manuscript and kept it for many months, before returning it with regrets that he could not publish it. By then he had sold his book well. My son's book were published by another publisher later. But the bad aftertaste of the dealing with the first publisher we had approached has still not gone away.

Alms

We were taking ward round when I noticed this guy. He was in his early sixties. He was carrying a plastic bag with packs of glucose biscuits. He was handing over one pack to each patient. The packs were small, probably carrying five biscuits each. What was peculiar was that he was wearing a face mask, as used by surgeons in operation theaters. He was probably afraid of catching some disease while distributing his biscuits. What was more peculiar was that his mask was covering only his mouth, while his nose was wide open. He had probably seen some of our surgeons operating, and thought that was the only way to wear the mask. Perhaps he had seen those monks of a certain religion who wear masks so that they do not harm even microbes. Those monks also wear masks over their mouths only. I tapped him on his shoulder. He turned around. “I am the head of the department here” I said. I want to talk to you.” “Is it about permission to distribute biscuits here? I have …” he said, his hand moving towards his pocket. “No. You must have the permission, or the Sister in charge of the ward would not have allowed you in this ward. I want to talk to you about your mask. You have to cover your nose to make it effective.” So he put up his mask over his nose. “Please do not give biscuits to patients receiving intravenous fluids. They are not allowed to eat anything” I told him. He took back the pack he had given to my patient receiving IV fluids. Then he went about his way distributing biscuits, and I went on to see my patients. Three days later I found him doing the rounds of the ward again, his mask below the nose. My Assistant Professor looked at my face, looked at his mask, and started tapping him on his shoulder to get him to cover his nose. “Wait” I said “don’t correct him. Probably he cannot breathe through the mask. He is wearing the mask for his own protection. His open nose cannot harm our patients. So let him be.” A month later, I found him again doing his thing in our ward. His nose was covered. I wonder who corrected him today. I also wonder if the patients are so poor that they happily take whatever is given to them, or they believe that he is a part of the hospital personnel. I also wonder if they realize that he thinks they have diseases he is afraid of and still have no self respect and take the five-biscuit pack that he hands out free.

Blink and a Lucky Save

That patient came to our outpatient clinic like any other patient two weeks ago. She was 50 years old. She had had abnormal uterine bleeding, and had undergone a D & C operation in a private center. She came to us with a report of severe hyperplasia of the endometrium. I found that she had a six weeks’ size uterus and no other abnormality. “Shall we post her for a hysterectomy, sir?” asked my resident doctor. It seemed a reasonable question. The treatment for severe hyperplasia of the endometrium in a woman above 50 would be hysterectomy. But I had a thought without conscious thinking, like that fellow Malcolm Gladwell had written in his famous book ‘Blink’. “She will need hysterectomy” I said. “But let us be sure that we don’t make a mistake.” “Mistake?” “Let us ask for the slides and paraffin block from her pathologist, and request our pathologists to report the slides.” The resident doctor arranged for that. The patient came back to see me today morning. She had the report given by our pathologists. It was ‘endometrial adenocarcinoma’. “If we had believed that first report, we would have performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy on her. That would have been grossly inadequate treatment for her. Now she can undergo extrafascial total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node dissection.” I told my wife about this and said “was the woman lucky to have a correct diagnosis made before undergoing surgical treatment!” “She was lucky she landed up in your cabin at the first visit” she responded. “Umm…” I said and I think I blushed (at the age of 53!). “Don’t look uncomfortable” she said. “My patients going to public hospitals tell me about their experiences there. What I said was correct, not something said just to please you.” I knew she would never say something just to please me, not after 23 years of married life.

Chocolates to Lower Tempers?

I was busy seeing patients in the outpatient clinic. The nurse called me to say that the building repair contractor had come to see me. So I went out to the waiting hall to see him. He was one of the supervisors of the building repair and renovation work appointed by the contractor. “What is it?” I asked. “I have brought chocolates for you, sir” he said. I looked at the bag he proffered. It was a white nondescript paper bag. “Why?” I asked. “Season’s greetings” he answered. “Oh! I would be happier if you had finished our work in time and that too satisfactorily” I said. “You are six months behind schedule, my patients are being denied adequate treatment because there is no space and no OT facilities. The complaints I had lodged are ignored.” ”We do whatever the architect tells us to do” he said. “So you are connected with the architect, not us. Is that right?” I asked. “Yes.” “Then please give the chocolates to the architect” I said. “I thank you for the offer, but no thanks. You might have a spy camera in place of one of the buttons on your shirt, or another person near the door might be video recording the whole thing as in a sting operation. This bag may be said to contain a bundle of bank notes. I do not want it claimed that I was given a bribe to overlook the deficiencies in the repair and restoration work.” He seemed surprised at that, but thankfully he went away. “Did you really think there would be a sting operation sir?” asked one of our professors when I related the story later. “It was possible” I said. “We are small fish. We are not give bribes on a regular basis like they are said to do to politicians and administrators high up. Giving us chocolates costing 50 to 100 rupees must be enough, compared to 20-50% of the total budget to those who are in control. If we are not appeased by the chocolates, they could always hold the threat of the recording of the sting operation over our heads.” Now I wonder if I was right or just paranoid.

Architectural Wonder in Our Hospital

“I always knew the architect appointed by the corporation as a consultant would be as wonderful as any consultants employed by the corporation” one of our professors said. I was surprised. I did not know for a fact that consultants employed by the corporation were always so wonderful. Furthermore, I was aware of the goof-ups of the current ones, so that I was surprised to hear from one of ours that he was so wonderful. “What happened that you are now convinced that he is so wonderful?” I asked. “He has removed the front wall of our offices. He has put a wooden partition there.” “That may be because there is a shortage of sand. He must not have been able to put a brick wall there” I offered. “There is no shortage of sand now” came the answer. “I think he has done that to make the rooms look stylish. Don’t you know that they have wooden floors in stylish places these days?” “I have seen wooden floors in some posh places. But those were floors. He has put walls” I said. “That is a modern concept. It is a concept of lateral thinking.” I had read de Bono’s ‘Lateral Thinking’. This did not seem to be anything like that. Our professor was being sarcastic, I decided. “But that is not all. He has left a huge open space in the front wall, where he is going to fit transparent glass.” “Huh?” I could not say anything else. Anyone could break that glass to enter that room and steal the contents. If there was a bomb blast (our hospital is on the hit list of terrorists and hence they have closed almost all gates) the glass shreds would kill the people inside. “He has recessed the front wall to make the room smaller. Then he has put a storage cabinet outside the door.” “Outside?” I asked incredulously. “Yes. He says that will be OK. He is putting a lock on the cabinet.” So when we had to get anything from the storage cabinet, we had to out of the room. If anyone wanted to steal anything from the cabinet, all he had to do was to kick the door of the cabinet or break its flimsy lock with a pointed object.” “I agree with you” I said. “The architect is indeed is corporation class.” “The process of selection of such architects must be very complex” said another professor. “Yes. Many factors must be considered in that process besides architectural abilities” I said. “No sir. Let me put it in a correct form. Many factors must be considered in that process other than architectural abilities” said the first professor. “Can we not protest?” asked the other professor. “I have protested enough” I said. The letter has been sent to the chief engineer of the corporation.” “What is the outcome?” “The usual – no response.”

Perks of an Honorary Professor

“Sir, did you know they are putting up a multispecialty hospital at Andxxri and giving very good salary to even resident doctors?” “Yes. It is twice as much as of our resident doctors.” “The faculty positions are also being filled up. There is going to be a medical college attached to it, run by the government.” “Yes, I heard that.” “Do you know who is heading the department of Obstetrics and Gynecology?” “No. Who is it?” I asked. “Dr. XXX, who was honorary professor at government medical college.” “Hmm...” I said “I recall her. How did they land up with her?” “We don't know. But because she is going to head the department, a number of us who had applied for Assistant Professor's post did not go for the interview.” “Why?” I asked. It seemed a bit too much. There must be something I did not know about that person. “She used to expect coconut water kept ready for her when she arrived for her morning ward round.” “Who was expected to do it?” “Anybody.” “Who paid for it?” “Anybody. It just had to be there, or else.” “That sounds familiar” I said. “I recall what she used to do when she came to our college as MBBS examiner. She would arrive a little late, and exclaim 'get me a cold drink. It is so terribly hot.' So we would give her a cold drink while the exam remained suspended. It would start after she finished the drink. A half hour later she would say 'I need hot coffee. I can't examine another student until I have had hot coffee.' So an intern would rush to the canteen to get her hot coffee. One day she said 'I have developed headache. Get someone to get me Sxxxxr oil.' Sxxxxr oil was a rubifacient oil for local application for relieving pain. One intern went to the chemist and purchased it. She took it, but did not pay for it. Finally the examiner whose intern had gone for that purchase reimbursed the intern.' “So now you know the reason for the applicants' not going for the interview” the informant grinned.

Isometrics in Cesarean Section

Somehow I don't cease to be surprised by new trends in obstetric practices of resident doctors. We had a patient who underwent a cesarean section. She had developed fetal distress and cesarean section was performed by residents of another unit. She developed hypotension and shock in the postoperative period. She was explored by our Associate Professor and resident doctors. She was found to have extraperitoneal hemorrhage staring from the rectus sheath and dissecting underneath the peritoneum. It was behind the posterior peritoneum too. On questioning it was found that the residents had stretched the edges of the abdominal incision. The method was to grab the side of the incision with both hands, one resident on either side of the incision. Then they would stretch the incision with their body weights by falling backwards with their upper limbs held extended. "Do you not understand that this barbaric method is likely to tear the recti and even extend the incision irregularly? That may produce extensive damage, as in this case." "...." "Do you do this in our unit too?" I asked. "Yes sir". "Will you stop it with immediate effect?" I asked. "Yes sir" they promised. "Do our assistant professors who have come from three other institutes in this city do the same?" I asked. "Yes sir" they said. "Stop" I said. "Yes sir" they said. There was another case undergoing cesarean section in our OT today morning. Our junior resident doctors had changed three days ago. The operating surgeon was a local candidate, while the first assistant was from Down south somewhere. Before I realized what they were doing, they grabbed the sides of the incision on their respective sides and stretched the incision by leaning backwards. "Stop stretching the incision" I said. They looked at me uncomprehendingly. "Do not stretch the incision by hanging onto its edges" I said. The stopped. The senior resident who was the first assistant apologized later. I explained the reason for not indulging in that practice. Then I asked him where he had learned that technique. "In our college during postgraduation" he said. I was intrigued. How bad practices without scientific evidence of their usefulness spread all over the country was beyond me to understand. I wonder if they use 'Facebook' or 'Twitter' or any other social networking site for this purpose.

Carry Your Own Slippers

I thought getting slippers for labor ward and operation theaters should be a simple matter. Keeping adequate stock and placing orders to supplier well in time should also be fairly easy, since the turnover is known. Well, things are not simple in a corporation hospital. There had been a time a few months ago, when almost everyone had started going into the labor ward wearing street footwear because there were no slippers. I had to do a lot of work do get the concerned persons to do their work to get a supply. After coming back from vacation last week, I found out that there were few slippers in the labor ward, and one had to enter the ward bare foot. I talked to the sister in charge of that ward, who pointed a finger at the stores clerk. I managed to find the stores clerk (the act deserves accolades!) and asked her the reason for the short supply. “We have placed an order and the supplier will supply the slippers in due course” she said. That was a standard 'babu' type answer. “But this is not a municipal ward office” I explained “where a delay in moving files is the rule and it does not perhaps matter very much. This is a hospital for patient care, and we cannot afford to have no supply of essential items. Buy some in open market and supply urgently.” “I will speak to Dr. XXX, the Assistant Dean and see what can be done” she said. That meant nothing. It was another stalling tactic. It is a tragedy that a tertiary level hospital doctors are forced to do something like this to ensure that they get slippers to enter the labor ward or operation theater, while the concerned clerks and Assistant Deans go through life sitting in comfortable chairs in comfortable offices, not concerned about anything much.

Final Diagnosis

“Sir, we have a case for discussion in today's maternal mortality meeting”. “OK. Is there anything unusual?” I asked. I had been on vacation and had just joined. So I did not know about any maternal deaths which occurred in my absence. “Yes, sir. The patient was transferred to our hospital in a bad shape, with systolic blood pressure of 70 mm Hg and semiconsciousness. She had had a convulsion before being transferred. Her fetus was alive and well at that time. She deteriorated despite all supportive treatment. The next day the fetus died. Then she died too.” “What is the point of discussion?” “The pathologists have given the cause of death as disseminated intravascular coagulation in a case of intrauterine fetal death.” “Did she have DIC?” “Yes, sir. Her coagulation profile was abnormal on admission.” “OK, I will discuss it in the meeting.” The pathologists were present for the meeting. I asked them why they had given that diagnosis. “Well, the fetus was dead and she had DIC” said the pathologist. “When you say DIC in a case of IUFD, it implies that the DIC was due to IUFD. But in this case the patient had DIC on admission, when the fetus was alive and well. It died the next day. So the fetal death was due to maternal illness including DIC rather than the cause of it” I explained. “Stating the diagnosis in the way you have done is like saying 'DIC in a case of vitiligo or leukoderma'. There should be a cause-effect relationship if you want to put the two together in the cause of death.” They seemed to have understood that. “The minutes of the meeting will be sent to higher offices, including state and central government. The people who will see the report may not be active clinicians and they may feel a woman with IUFD was not treated in time and hence developed DIC. That is the reason I want the diagnosis put correctly.” They promised they would do it that way in future. I hope they tell their colleagues too, because it is beyond me to tell all pathologists myself.

Ego Crash

That fellow was about ten years older than me. He stayed in the same building as I. He knew my academic career very well, and also my professional career. He became a dentist and set up practice in a nearby place. He moved to another place, but kept visiting our building periodically because his brother stayed there. I met him today when he was there on one of his visits. "So how are you?" he slapped my back. "Very well, thank you" I said, "and you?" "OK" he said. "So what are you doing now? Where are you working?" "I am still at KEM Hospital" I said. "I am not going to leave at this age." "Which department?" he asked. I was all shaken up. If he had asked this question thirty years ago, it would have been understandable. But his asking it today meant all my achievements and contributions to the subject I loved were so insignificant that he did not know about them." "I am shocked you asked this question" I said lightly. "I am an obstetrician and gynecologist. How do you not remember, especially when you had brought your sister to me for treatment, and she had got well with my treatment?" He seemed surprised. "It must be loss of memory due to aging" he said jokingly. "But I said 'hello' to you. That is something." "I think I better leave now" I said. "I will write about you on my blog." "Yes, please do that. I will read your blog" he said walking away. I am wondering how he will read my blog, when he does not know the web address of my blog. I wonder if the blow to my ego was intentional, accidental, or he has got Alzheimer's disease."

Thrombocytopenia due to Menorrhagia?

"Sir, I want to inform you about this patient" my Registrar said in the outpatient clinic. "What is it?" I asked. "She has menorrhagia for the last 3 cycles. Her pelvic findings are normal. Her hemoglobin is 5.2 g%, and platelet count is 35000/cmm." "So what do you think?" I asked her. "I think her hemoglobin and platelets are low because she has been bleeding." I was aghast. "Low hemoglobin is understandable if she is bleeding and does not have iron and folic acid replacements" I said, "but why platelet count should be low?" "Because the platelets are used up in the bleeding" she explained. "Do you think it is the other way round?" I asked. "Could she be having menorrhagia because she has a low platelet count due to whatever cause?" "Yes, I think that is the way it is" she agreed. I wonder what she has learned in last 2.5 years of residency, and what she will do in her MS examination after six months. Checking bleeding time, clotting time, and platelet count is a part of the investigations of every abnormal and excessive uterine bleeding in our unit. Why she would keep doing it and still not understand it is beyond me. I dared not ask her that question, because I could not stand the usual answer: "Sorry sir" with a semi-negative shake of the head.

Being Back To Work

A thirteen days' break rejuvenated half of us who joined duty today, while the other half went away to get rejuvenated. At least that is the way it is supposed to work. Here is how it went today. "Sir, we have a patient of Tetralogy of Fallot for MTP." one Registrar reported. "Is she cyanotic?" I asked. "They have not written that on her paper" she answered. "Is she looking cyanotic" I asked patiently. I had indeed been rejuvenated. A fortnight ago I would have got exasperated. "Umm... no Sir." "We will give a low spinal to this Tetralogy of Fallot" said the senior anesthetist. "We don't want to give her general anesthesia." "If she is unfit for anesthesia, we will do it under local anesthesia." I offered. "She can get further pulmonary artery spasm if she gets pain. I prefer low spinal anesthesia" she said. "We did a second trimester MTP in another unit that day like this." "How?" I asked. "We gave her an epidural block. Then they put extraovular something." "And then?" "Then we kept her in the OT under observation" she said. "She aborted at 8:00 P.M." I was stunned. "They abort 24 to 48 hours after extraovular instillation of any agent" I said patiently. "You cannot occupy an OT table to observe a patient until she aborts." My nerves seemed to be taking the usual shocks well. Then there was a case of postmenopausal bleeding undergoing a hysteroscopy and fractional curettage. I looked into the hysteroscope and found her to have a flat polyp arising from near the left tubal ostium. The endoscopic system was nonfunctional, because of viruses in the system, they said. So I held the endoscope focused on the polyp and let all of the lecturers and resident doctors peep in to see what it looked like. The last one was a first year resident. She came along, held the eyepiece with her bare hands and looked it. "Hey!" shouted the others. Then I realized what she had done. I discarded the endoscope which was contaminated. Then I just smiled when she went away sheepishly. She actually had no business adjusting the eyepiece because then the focus would have moved away from the polyp, and she did not have adequate training and experience to focus it properly. She should also know about surgical asepsis and antisepsis. Before vacation I would have scolded her thoroughly. But today I took it in my stride. There were a few more episodes today that elicited a reaction from me quite different from my usual reactions. Either the break had done me good, or I had matured unbelievably in those 13 days.

100 New Medical Colleges

It is true. I read in the newspaper that the medical council has eased on the norms to start new medical colleges, and recommended starting 100 new ones at district hospital level. It seems it will be a profit sharing public-private partnership. It is expected to fulfill the need for doctors in this country. It will indeed be a wonderful thing when that happens. But the council has not suggested any measures to keep these doctors in the villages where they are needed. If they will all flock to the cities for a better practice and good life, as seems very likely to happen, the woes of patients will not end, and woes of existing doctors will increase due to added competition. Perhaps that will increase the existing cut practice. Perhaps it will introduce newer methods of unethical practice. I also wonder where the teachers will be procured. The existing medical colleges are being derecognized owing to lack of teachers, and I hear some of them move teachers from college to college for inspection by the council. Getting teachers, nurses, technicians for 100 more colleges will be a Herculean task. I pray they can manage it.

Vacation Calls

"Call me if there is any problem and you need help" I told my Associate Professor before proceeding on my thirteen day vacation. "OK" she said. But I knew she was capable and would not have to call me. Well, she did not, but others at the hospital did. On the very first day, the Boss' personal secretary called, and gave me a message. I told her I was on vacation, and to call the person looking after my work henceforth. Then I called the hospital and got the appropriate person to do that work. She called me again the next day. I requested her to comply with my request made the previous day. She called as soon as I put the phone down and said the Boss wanted to speak to me. I spoke to him, gave him the information he wanted, and he promised to get to the person who was handling my department in my absence. The third day the person himself called and took advice on some matter, after saying he was sorry to disturb me. A couple of days went by without any further calls. Then the telephone operator called to say the meeting scheduled for the next day was postponed. That was the first time I learned that a meeting was scheduled that day. I told him I was on vacation and would he please call the next person in command. he said he would. For two days after that there have been no calls. I am quite upset there are no calls. I miss the hospital and the people there. I used to go to the operation theater once a week during my vacations in the past, to assist with operations so that work would not suffer. I cannot do that any more because there are a large number of jobs waiting for being done, and they will remain until the next vacation if I go to the hospital only because I like it. The resident doctors will also be unhappy, because the Boss' vacation is a sort of vacation for them too. The office staff will be unhappy, because they probably feel obligated to be present at prescribed times when I am around. Vacation is a time to stay home and study, so as to get ready for work again" one additional commissioner had said. I wonder where he got this management principle, and whether he applies this to his own vacations too. As my favorite management Guru Stephen Covie puts it, it is the time to sharpen the axe, to recharge, to rejuvenate, and not doing what that additional commissioner said. Fortunately no full timer took him seriously.

Take a baby Home or All Your Money Back!

I received a brochure from an ART center. It was different from the usual ones in that it had an astounding offer. It said all couples who did not get a baby to take home after treatment at that center with assisted reproduction would get 100% money back. It means they have a 100% take home baby rate (which is as yet not reported in any center, nor has this center claimed that), or it is more than 50%, so that they still have some money left after refunding the dues. But will that be enough to meet all expenses and then make a profit appropriate for the investment. There was no * next to the full refund promise with a footnote at the bottom saying 'conditions apply' next to an *, as is found in commercial ads of consumer products. Perhaps it was there in a print far smaller than what I can read. I am sure every one on the mailing list (which is the member list of the obstetrics gynecological society) must have received this brochure. reports will start coming in, and I will post what I gather. If it is 100% genuine, all ART centers in the country and abroad will either have to follow suit or close down.

Partogram: Update

A partogram is a tool that graphically represents cervicographic progress during labor. This tool is recommended for routine monitoring of labor to provide an early warning system. The partograph helps the care provider to identify abnormal progress in labor early, and to initiate appropriate interventions to prevent prolonged and obstructed labor. A number of partograms have been described before, the earliest being that by Friedman. The progress was recorded in centimeters of cervical dilatation per hour. The resulting graph was a sigmoid or an S-shaped curve. However it could not be applied to a woman who did not present at the beginning of labor, since it always began at zero dilatation, and if applied to a woman with greater cervical dilatation, there would be a great delay in making a decision to intervene. Philpott modified this partogram later, starting at the active phase of labor (3 cm cervical dilatation) and added two lines, alert line and action line. The “alert line” was a straight line. It represented the mean rate of cervical dilatation of the slowest 10% of primigravid women in the active phase of labor. It had a progress rate of 1 cm per hour. The purpose of the alert line was to aid the midwife in a peripheral unit, or house surgeon in any hospital to detect at the earliest possible moment the abnormal labor. If a woman's cervical dilatation progressed more slowly than 1 cm per hour, it would cross this alert line and arrangements were made to transfer her from a peripheral unit to a central unit. The “action line” was 4 hours to the right of the alert line. If the patient’s partogram crossed this line, action needed to be taken.This allowed “time to transfer the patient without impairing the success of the essential active management. Later this line was shifted two hours to the left. This was better than Friedman’s partogram, but still could not be applied to women who predented in labor with greater than 3 cm cervical dilatation, as that would result in an error causing delay in getting alert or taking action. Studd modified this partogram and drew stencils for women presenting with 0-2, 2-4, 4-6, 6-8 cm cervical dilatation. I have developed a composite of two stencils for parimgravidas and multiparas presenting in different staged oa labor. The partogram presented here is drawn by studying the mean cervicographic progress of 700 normal primigravidas in labor, presenting at 3, 4, 5, 6, 7, 8, 9 cm cervical dilatation (100 in each group), and similarly for 700 multigravidas. Thus there are two lines, the one on left for primigravidas and the one the right for multigravidas. These are stencils. When a woman presents in labor, her cervical dilatation is checked. The stencil for her is drawn on a blank graph paper, the time zero hour beginning at the point the transverse line for her cervical dilatation crosses the cervicographic progress line for her. Thus only an appropriate segment of the stencil is used for her. This partogram does away with multiple stencils for different women as with Studd’s partogram. There is no error since the partogram meant for her begins at the same dilatation as she has. Whenever her cervicographic progresses two hours or more on the left of her ideal partogram, appropriate action is taken.

Age of Retirement

The Government found that a lot of Professors would retire soon, and there would be such severe shortage of Professors that the medical colleges would be derecognized by the medical council. Instead of appointing new professors by promotion or selection, they decided to increase the age of retirement from 58 to 65. Some time in between that came to be. Then the teachers in corporation hospitals realized they could also benefit from this. Letters were written, appeals were made, administrators were talked to, and the proposal was submitted to the commissioner, and rejected. Some Associate Professors were against this move, because their promotions would be delayed. They did not realize that the whole thing was just being advanced in time, and they would get to work and earn for that much longer. Then it seems the commissioner was told that the proposal was as per UGC and was binding. So he permitted it. That does not mean it happens immediately. It has to be passed by the standing committee and then the house. The age proposed is 62 and not 65. While this was happening, people who were going to retire very soon were praying. Those who were atheist suddenly started believing in God. Those who were to get promoted when someone retired started praying that the proposal got delayed just until after the retirement of the senior concerned. Those of us who were keen to see someone incompetent or lazy go started praying for appropriate delay too. Those of us who knew God would do the right thing anyway just waited for the right thing to happen. In the meantime, someone said that the medical council had recently recommended that the age of retirement be raised to 70. I don’t see that happening in the corporation colleges. Instead of putting off the inevitable by four years, they should increase the salaries of the medical teachers so that there would be no difference between the earnings in private practice and in teaching jobs. At the same time they should also ensure that the teachers are not harassed by silly things but allowed to do what they are meant to do, teaching, patient care, research and scientific writing. It may come to making some of them actually do these things, since allowing them to do so does not mean they actually do those things. I wonder how many of us remain physically fit beyond 58 to work as before. I hear they do not pay dues after retirement in time, such as provident fund, and pension, in case someone retires prematurely. If that is true, a lot of people who might opt for retiring at 58 instead of going on to 62 might not do so, whether they can actually work or not. I heard someone say that teachers will join private medical colleges after retirement from corporation job, since they will be eligible to be teachers up to 70. I hear the medical council wants about 300 more medical colleges to come up soon. I cannot understand where they will get teachers required, since there is already a shortage. Will they then adopt maneuvers more energetically like showing teachers who exist only for council inspections, or moving teachers from college to college depending on where the inspection is being held?

Diplomate Struggle

“Sir, I have come back.” My lecturer had been on leave for a couple of days. “How was your exam?” I asked. He had gone to appear for the National Board exam. “It was OK” he said. “I had a bit of a problem on the ward round session.” “Huh?” I said. Our patient load and our evidence based approach to patient management were such that any one who had worked at our institute would always do well in patient management sessions. “The examiners were upset when I said a patient who undergoes a cesarean section has a Foley’s catheter in the urinary bladder.” “What do they do?” I asked. “They put a simple rubber catheter preoperatively, and remove it before starting the operation.” I was surprised. Some people do follow this method. But to criticize an alternative method was not very good. That was a couple of weeks ago. He called me yesterday. “Sir, I passed that exam” he said. “That is wonderful” I said. It was indeed wonderful. I hear the examiners are instructed to pass only 5% candidates. My lecturer must have done very well. That discussion did bring up old thoughts. The National Board invited people to be examiners without any qualifying criteria. So the usual people who are examiners for MD or MS examinations end up being examiners for this exam too. They end up asking the same questions as in the MD and MS exams. They have the same whims and fancies they have when they conduct either exam. Because they have to fail so many candidates, they end up failing those who do not fit their ideas. Years ago, one of our lecturers had gone for this exam. They failed him because he showed them the correct method of holding an episiotomy scissors, with the angle facing outwards. The examiner was quite angry. He said the scissors should always be held with the angle towards the patient. I wonder if that examiner ever makes an episiotomy, because I tried to visualize and failed how he would do it with the handles digging into the patient’s buttock. He went on to criticize the institute where this practice was learned. This candidate went on to be a professor at our institute, and a fine one too. I don’t know what happened to that examiner. I also thought of our professor who was asked to conduct this exam in our college. She got slides of endometrium for showing in the exam. She got the senior scientific officer to label them as proliferative and secretory so that she would know which one was which during the examination. She also got a list of patients kept for the examination from the Registrar, with their clinical findings and diagnosis written against their names. She failed a good candidate because the candidate said the uterus was 16 weeks’ size, while the Registrar had written it was bulky. Had she bothered to just palpate the patient’s abdomen, she would have realized her mistake. I do not know what the National Board achieves by appointing such persons as examiners. When my residents and lecturers want to appear for that exam after their MD/MS qualification, I wish them luck, but ask them why they want to appear for that exam when the examiner could be such a person and fail them. Failing for all the wrong reasons is something quite difficult to live with. In fact, it is insulting to be examined by failed by a person who is wrong and you are right. They still appear for that exam, probably because by that time they have already paid the fee. Most of them learn the hard way what I want them to learn from history and my advice. Well, that is life!

Attitude 11

“Sir, the first half of vacation begins from tomorrow.” “I know, I am on vacation too.” I said. “Did you hear what Dr. XXXX said?” “What?” I asked. It had to be something very interesting. I had had a couple of interesting interactions with him in the last few hours on the same topic. “Today’s is his unit’s emergency. He told his boss that he would take calls only up to midnight, since a new day starts after midnight, and he will be on vacation from that point.” I was aghast. He was known to show that he would be at the hospital for as short a period as possible. He would arrive on the last second permitted every day, never on time, and definitely never early. He would leave at 4:00 P.M. sharp. He used to come much later and leave much earlier in the past, but the biometric attendance system has changed him in this regard. He would not take calls on phone claiming his phone was out of order, but would claim the telephone reimbursement from the hospital anyway. After severe reprimanding by a previous Dean, he started taking calls on his emergency days. Even then, his mother would pick up the phone and scold the caller for disturbing her son. But not to want to take calls until the emergency ended was a new height to his inclination to avoid work. “The boss agreed?” I asked. “Yes. But now it is past 3:00 P.M. and he is busy working!” “That is expected. His Boss told him to finish all work and then proceed on vacation” I said. “Even I told him to finish work first. I reminded him that he had run away on vacation last time without completing all vital work, and when I called his residence, his mother took the phone, said he was away to an unknown place for unknown period without a contact number or address, and that we should get all work done by him before he went on vacation.” “I know!” Actually the whole department knew. “I instructed him to leave his address and contact number for the duration of his vacation, should the hospital need his services for an emergency like resident doctors’ strike.” “I know that” she said. “He was extremely angry with that. Getting a vacation is his right and no one can interfere with it, he said. He said he would throw his resignation letter on your face.” “He did not do that” I smiled. “He wrote his address and phone number down on that notice I had taken out. He is even completing his work before going on vacation.” “That must be because his mother said so on phone to you, not because that is the right thing to do.” She suggested. “He will not resign” I said. “Of course not. When he was heard to threaten he would resign, all of us volunteered to type out his notice of resignation. He just walked away.” That was a bit unkind on him. But I could not blame them. They all were tired of him, and justifiably so.

Placenta Previa: Who Changed the Definition

Considering that all our Assistant Professors gave varied answers to the question about the distance of the lower edge of the placenta from the internal os to be called previa, I did a survey of a number of postgraduate text books of obstetrics. I realized there was no consensus on what was placenta previa. For unknown reason some books have changed the definition and classification of placenta previa, while a few have stuck to the old definition and types (I to IV). A summary of my findings is as follows. Williams Obstetrics: new classification in the form of total, partial, marginal and low lying (the last one in close proximity to the internal os, but no specific distance), no sonographic criterion for the last type. Obstetric & Gynecologic Emergencies: Pearlman et al: somewhat similar to Williams, but the distance for the last type is < 2 cm. Current Obstetric & Gynecologic Diagnosis and Treatment: 2 cm. Current Clinical Strategies: Chan Johnson: 2 cm. Some books mention that if the edge of the placenta is more than 2 cm from the internal os, there will not be antepartum hemorrhage (e.g. Obstetrics & Gynecology: An Illustrated Color Text: Pitkin et al.) Some books mention that if the edge of the placenta is more than 2 cm from the internal os, there will not be difficulty with vaginal delivery (e.g. Clinical Obstetrics: The Fetus and Mother: Reece – Hobbins.) Obstetrics & Gynecology at a Glance: Norwitz - Schorge: no mention ABC of Antenatal Care: Chamberlain - Morgan: no mention Management of High Risk Pregnancy: An Evidence Based Approach: Queenan Best Practices in Labor & Delivery: Warren - Arulkumaran Anesthetic and Obstetric Management of High-Risk Pregnancy: Sanjay Datta: no mention Clinical Protocols in Obstetrics & Gynecology: Iforma Practical Obstetric Problems: Ian Donald: 3 inches or 7 cm. Unfortunately someone edited this book after Dr Donald passed away and removed all such information and released the book for distribution in our and perhaps nearby countries only. I hope he does not come to know about it, wherever he is (may his soul rest in peace). I found that in some books the sentences in this connection were identical. It is difficult to decide if they copied one single source, or someone copied one book, then someone else copied this copier, and then a chain reaction started. What emerges from all this is that someone made a non-evidence based change, which many copied, and finally the science has changed.

Trafficking Women

The training of interns is meticulously spelled out in the curriculum of medical students. However they are often given jobs that are out of this curriculum. It may be said that sometimes whatever work that no one else can or will do is handed down to interns. I myself avoid doing that any time because I understand that they are doctors (in the making) and also human beings. I never tell them to do anything that I would not do myself, and I never do anything that a doctor should not do, except in an emergency with no personnel to do that job. This particular intern was posted in the unit of a colleague. There was a big crowd of women patients. The layout of the outpatient clinic left much to be desired, and women were getting easily confused. So this intern was asked to stand in the middle and guide the patients to appropriate rooms to facilitate a smooth flow of patients and work. The unit head arrived, found him standing in the middle of the waiting hall sending patients in different directions, and got perplexed. “What are you doing?” she asked him. “Madam, I am trafficking women” he answered. “Trafficking ….?” She was aghast. It was a justified reaction. We read about women-trafficking in newspapers. But to hear an intern saying he was doing that was too much. “What do you mean?” “I am guiding them like a traffic police” he explained.

Ethics Fee?

It may be a public hospital for poor patients, but that does not prevent it from charging fancy sums for services given to its own staff members and students. I received a letter from the institutional ethics committee telling me the revised charges for submission of research proposals to the Ethics Committee were revised to rupees 40000/- for pharmaceutical sponsored research (compared to original rupees 25000), rupees 5000/- for government sponsored research, and rupees 500/- for self sponsored staff members’ research (compared to original Rs. 100), students’ proposals for postgraduate dissertation proposals etc. The massive hike in fees was to meet increased cost of stationery, computers and need to employ more administrative staff. What used to be in house work is now so sophisticated that they charge so much for it, and still find multiple faults with the proposals they receive and scrutinize. One would expect to have one’s proposals passed quickly if they charged so much! (That was a PJ). Seriously, they must be considering to buy one computer per research proposal, if they need rupees 40000/- to scrutinize each proposal. Perhaps even hiring one person to do office work for scrutiny of each proposal. I hope they improve in the scrutiny at least. The last time they had asked my student to change the title of the dissertation from “Laparoscopic oophorectomy plus vaginal hysterectomy” to “Laparoscopic Abdominal Vaginal Hysterectomy (LAVH)”. It was the first time I had heard anyone undergoing laparoscopic, abdominal, and vaginal hysterectomy at the same time. The only reason I could not laugh till my sides ached was because I had a sense of dread for the institute, considering the quality of work done by a body meant for improving the quality of proposals of research. That dread has not left me yet, and I am afraid it may never leave me. We are academicians as much as clinicians. A part of our job description includes research, as the medical council and university believe, I believe. It strikes me as funny that we have to spend our own money to do our work, for which we should be paid, not charged. Pharmaceuticals are not interested in original research in hospitals. They just want clinical trials with reports in support of their products that they want to market or promote in the market. Original clinical research in the field of one’s interest should be sponsored by the institute. But here the institute is actually charging the staff members and students for that. I am not surprised that original research is dismally low at present, and will plummet to an all time low with this hike in the charges. The amount charged is not exorbitantly high, but the attitude is all wrong and extremely discouraging. I have a feeling that soon they will put water meters on our taps, electricity meters for our offices, bill us for the water and electricity, and even start to charge us for the use of the loo too.