Abbreviations

Our resident doctors use a number of abbreviations while writing clinical notes. One of them had used SMS language once, and I had forbid her from doing that again on patients' case papers. She had written 'patient and husband were staying 2gether'. What follows is a list of abbreviations used by them at present. They made this list for me so that I could understand their clinical notes. I suspect this list is by no means complete and is likely to change and/or grow with time. Afeb: afebrile adv: advice ART: antiretroviral therapy a/w: associated with a/w: alive and well b/b: bowel bladder BPV: bleeding per vaginum BHL: block head low C/o: complaining of C/C: chief complaint c: which ˉc: with CM: coming morning do: no disorder d/t: due to : diagnosis D/D: differential diagnosis e/o: evidence of  FM: decreased fetal movements FD: full diet F/S/O: findings suggestive of F/up: follow up G/R/T: guarding/rigidity/tenderness H/O history of I/SOS: inform SOS Imp: impression I/O: input/output Ind: indication i/v/o: in view of K/C/O: known case of Ko/Lo/So: kidney/liver/spleen not palpable LPV: leaking per vaginum MS: married since MC: most common M/Ch: measure and chart NBM: nil by mouth o: degree P/H/O: past history of s: soft SLIUG: single live intrauterine gestation SOS: save our soul S/o: suggestive of T/t: treatment U/S/O: under supervision of uv: uterovaginal w/f: watch for WOG: weeks of gestation

3 Dimensional Instruments in Obstetrics and Gynecology

If you just want to see my 3 dimensional instruments, skip this story and visit the following link..
http://svparulekar.freeiz.com/
The medical students have to be able to identify different instruments used in the practice of Obstetrics and Gynecology. I have written two books on practical examinations, one for undergraduates (Practical Gynecology and Obstetrics for Undergraduates) and the other for postgraduates (Practical Gynecology and Obstetrics). Those books have line diagrams of all instruments, along with detailed descriptions and uses. If the students get to see the actual instruments, the illustrations are not necessary. If they cannot do so, actual video images would be the second best option. But video files are too large to be put on the internet. Most people put color photographs there. I have gone one step further and developed three dimensional photographs of the instruments. The instrument can be viewed through 360 degrees by holding the image with the mouse and rotating it by dragging with the mouse. There are no such three dimensional images of Obstetric and Gynecological instruments anywhere else. Feel free to view them by clicking HERE. You may also access them by pasting the following address in the address bar of your web browser and pressing "Enter" key on the keyboard. http://svparulekar.freeiz.com/

Adjusting Architectural Principles

My hospital is in a heritage building, and they require heritage architects and heritage civil contractors to repair and renovate it. Must be advanced and high quality work. It had so happened that the operation theater had started leaking water freely into my operation theater through its floor; because the scrub area had been build right in the center of the theater rather than along the outside walls where the water supply and drainage pipes were located. One cannot build bathrooms, toilets and scrub areas except at prior designated areas, in any building including heritage building. My theater had to close down for more than two months because of that leak. They couldn’t fix it because they would have to open up the floor to find the leak. They promised to do it during the repair work of the building. Now the work has been going on for about four months. I asked for the architect’s plan again and again received it finally. I noticed that still shows the scrub area right above my theater where it was before. I rang up the architect and explained what he had done wrong. “That was the original location of the scrub area” he said. “But it needs correction. We cannot let it be only because it was like that in the past” I said. He had corrected so many wrong things in the building, he had claimed before. “But they have three theaters and they will lose one if we move the scrub area” he said. “If there is a leak after the work is done, the floor has to be dug up to repair it. Besides that, my theater work will stop too” I said. “We are trying to put the pipes in the walls and not the floor” he said. “Then the walls have to be opened by removing the marble. That is expensive” I said. “It won’t leak for 7 to 8 years” he said. “That is quite a short period. Actually I will retire in five and a half years. SO it won’t leak while I am here. But I cannot let it be as a head of my department. I have to think of the future” I said. “But you signed the plan” he said. “I signed the plan only for my part of the building. I have no authority to approve the plan for some other department. Besides, you refuse to put even a wash-basin in any room if there is no drainage pipe outside it in the original plan. Here you are putting a scrub area right in the middle of the building where it has no business to be” I said. It was a pity that I had to explain architectural principles to an architect who was charging the corporation in millions for doing his work. “I suggest you communicate with the Director. He will arrange a meeting” he said. I wrote to the Director. I hope the error is corrected while there is still an opportunity to do so.

Her lab report

“Doctor, I tried last time as well as today. The nurse does not have my report” the poor woman said. She was seven months pregnant, and wanted her fasting blood sugar report. The resident doctor wants me to do the test again.” “Why? We will get a duplicate report,” I assured her. I got the nurse to write to the laboratory asking for a duplicate report, stating the original was lost. I remembered my conversation with the lab-in-charge, who had stated that she would not give out duplicate reports, since they always sent the originals to the nurse and obtained receipt. They did not have time to give duplicate reports. I had then written to the Head of Biochemistry to arrange to give duplicate reports if required. That letter had not been answered. The patient went all the way to the diagonally opposite corner of the campus, and came back to say, “they said they don’t have time to give me my report”. I rand up the senior Administrative Medical Officer, and asked him to sort out the matter. He took the patient’s details, and rang me back after 10 minutes, telling me that the lab-in-charge was unable to give the report because the blood sample drawn had been of insufficient quantity. When the patient heard this, she said “but they had drawn a full syringe of blood! I even fainted after they drew so much”. Was the lab-in-charge just playing a chess-like game of a countermove for my move? Sadly it was a patient who was the pawn being moved about mercilessly. I rang up the Head of Biochemistry and explained the matter to her, stating that the refusal to give a duplicate report to a patient was resulting in the clinicians filling a new request form, the patient making two visits to the lab- one for getting an appointment, and the other for giving her blood sample, the lab person performed the test again and used up valuable lab resources too, and the patient’s treatment was delayed a lot. She said she was short of lab personnel and could not help it. “OK, I will write to the Director about this tomorrow” I said quietly. “You have the habit of writing to the Director” she said accusingly. Was she referring to the time I had written to the director repeatedly to get my lab technician back that the Head of Biochemistry had borrowed for 15 days and kept for nearly two years? Or was she referring to the time I had got no audiovisual aids for teaching the students in the lecture hall managed by her, and had found that there was no responsible person in her entire department, all allegedly being in a meeting asking for a pay raise? “We are not discussing my habits”, I said firmly, “but management deficiencies at your end. By the way, all my letters to the Director are in the framework of the rules and regulations”. “Yes, all in the framework of the rules and regulations!” she said crossly. “So the patient has to have the test again?” I asked. “Why? We will give the duplicate report,” she said angrily. “But your lab-in-charge says the quantity was insufficient when they drew a full syringe of blood for only a sugar level estimation”. She had no answer to this. “Doctor, I will get the test done in a private lab,” the patient said finally. “I spend a lot coming here anyway, and there is the unnecessary loss of time too.” She did not seem affording enough, but this seemed to be the best alternative to her. I wondered if they believed the primary purpose of the institute was to pay salary to its employees rather than give healthcare to patients.

Delivering a Uterus with a Sigh

I had not really planned to do anything heroic. I usually don’t. Definitely not just after an attack of vivax malaria, with my muscle glycogen stores down to near zero. That patient was obese, weighing in my opinion about 82 kilograms, but the ward scales said 73 kilograms. My associate professor (AP) had diagnosed her to have a leiomyomatous uterus of size of 16 weeks of gestation. She was posted for an abdominal hysterectomy. But she had a lot of central fat, and was at high risk of an abdominal wound breakdown postoperatively, given the overcrowding and contaminated atmosphere owing to building repair work. So the AP suggested we perform a vaginal hysterectomy on her. I never attempt vaginal hysterectomy if the uterine size is bigger than 12 weeks of gestation, and perform an abdominal hysterectomy. But the prospect of opening that huge abdomen, struggling with retraction throughout surgery, closing the huge abdomen at the end of surgery, and possibly dressing and resuturing the broken down wound was discouraging to all. SP finally I did perform a vaginal hysterectomy on her. It took me one hour thirty five minutes. I had to bisect the uterus to enucleate the leiomyoma, which refused to get enucleated anyway because its upper part was beyond reach, and it was degenerated too. The AP jokingly suggested use of a cephalotribe (a destructive obstetric instrument of the yesteryears), and I jokingly told her I was contemplating the use of obstetric forceps myself, but there was no space for their application. I was drenched with sweat by the time I delivered the uterus out, and felt I had run the Mumbai Marathon rather than performed a vaginal hysterectomy. I remember the anesthetist watching my face intently from the head end of the table, holding her breath as I made the final traction, and breathing out with a sigh when the uterus came out and the residents made happy noises. You may wonder how I made out all this while struggling to get the specimen out. Well, after spending 29 years in the profession, I can make out people’s expressions and hear their sighs even when they wear masks.

Mother's Love

One of staff members is somewhat peculiar, and we always wondered what made him so. When he was proceeding on long leave, we asked him to make adequate arrangement for continuation of his work. He understood exactly how much, and did exactly one third of that. I never anticipated this, but then he is original at times. The concerned clerk rang him up. His old, crippled mother picked up the phone and soundly scolded the clerk for troubling her son who was on leave and anyway out of town. So I had to ring her up to sort out the trouble. I told her I was the head of the department and asked her to tell me how to communicate with her son. “He is out of town” she said. “When will he return?” I asked. “ Um.. I don’t know” she said. That was surprising. He was the only son, still single at a pre-retirement age, so attached to the mother that he wouldn’t go anywhere without her. He had taken her along to stay with him during his residency of three years before passing M.D., and even abroad on a fellowship because there would be no one to look after her. “Where has he gone?” I asked. “I don’t know that” she shouted. “Please do not shout” I said, “I cannot hear you if you shout”. “I have to shout because there is much disturbance here” she said immediately. I could hear no disturbance. Her pat answer reminded me of the pat and schoolboy-like answers her son gave us as explanation for his lapses. “I cannot believe he would go away like this without anyone to look after you” I said. “Oh, a servant comes at night” she sounded like she was smiling when she said this. “Please tell him to contact me urgently” I said “he has gone on leave without doing what he should have done.” “You should have asked him about it before he went on leave” she retorted loudly. “Please don’t shout” I said. “YOU are shouting” she retorted. She reminded me of whatever this must have reminded you too. “He must be aware of the service rules” I said “he has to leave his whereabouts before going on leave’ so that we can contact him if needed”. “He is on leave and you trouble him” she shouted. She used to say the same thing when resident doctors rang him up at night to ask advice on the management of his patients, and would scold them too. “Others merrily take long leave of three months at a time.” So the mother’s boy had been telling stories to mama all right. “You go take action on him. We are fed up with all this. He will resign.” “Please let him” I said as I hung up the phone. Then we would at least get someone who would do his work properly rather than to extract a vengeance on everyone else. I could also see what a mother’s love had done for her son and was still doing it at an age when he himself would have been a grandfather had he married his sweetheart of many years but did or could not.

The Joy of Building a Computer

Computers are expensive. Branded ones are even more expensive, and you cannot repair them yourselves, because their hardware parts are soldered to the motherboard. Computer fabricators have to make a living, so they are expensive too. I have been repairing nonworking computers at home and even in the office when the maintenance guys do not turn up despite repeated calls and work gets stalled. I don’t do chip level repair, and any such repair we have got done from others has not worked anyway. I change rams, SMPS, cables, CD ROMS, hard disks, CPU fans etc. Formatting C-drive and reinstalling Windows is a routine now. So when two of my office computers conked off, and we had already spent quite a bit of money repairing some others, I decided to upgrade them myself. On the advice of our engineer, I procured two sets of Intel’s motherboard and Atom processor, and 1 GB RAM. The configuration may be a bit slow for gamers and programmers, but is adequate for office work. I took the old computers’ boxes, stripped them, fixed the new motherboards and processors inside them, fitted them with hard disks and DVD writers, powered them from the SMPS, and then called the engineer to do the electrical connections. He showed me how to read the circuit diagram given by the manufacturer of the motherboard and fit the wires to the motherboard. Once that was done, the computers were ready. We tested them and they worked. I will not need the engineer the next time for fixing the wires too. And the whole thing cost us less than 8000/- rupees. I was delighted because we had built two computers, with me holding a gynecologist’s degree and no formal training in hardware management. Those of you who wish to repair your own computers and build new ones can also do this. It saves a lot of money, and gives immense pleasure if you are not a hardware engineer.

Small Group Teaching

I was teaching the medical students in a small group of about 15 'vaginal wall prolapse'. I had to draw diagrams and explain the mechanism of development of the prolapse and its repair. As I sat down drawing the diagram on a piece of paper and they stood in a half circle around me, I happened to look up and notice consternation on the face of many of them. I could make out the reason for that. “I will hold up the paper and show the diagrams to everyone,” I said, “don’t worry”. Their faces cleared. “I had a very traumatic experience as a student”, I said. “There was a lecturer in ENT who was teaching us something to do the ear surgery, drawing a diagram on a small piece of paper. But he kept the paper down on the table and kept explaining with the help of the diagram. Only the three or four students standing in front of him could see that and understand it. I was in the back row and couldn’t see a thing. So I started looking at the ceiling. That must have bothered him. ‘If you are not interested in my teaching, go away’ he said to me. I decided it wasn’t worth explaining my apparent lack of interest, since as a teacher he couldn’t understand the inadequacy of his teaching method. So I turned and started to go away. The other students immediately told him I was a good student, and there was a mistake. So he allowed me to stay, but did not improve his teaching method. I learnt what not to do from his behavior. So I always hold up the diagram and show it to all the students. I hope you will also learn from inadequacies of other people how to be adequate yourselves in your behavior with others.” They seemed to like the idea. And as I held up the paper to show it to all, I realized that it was a better method than drawing in a notebook and holding it up, because I could see my diagram from the back side of the paper too (owing to its translucency) and point out relevant areas while they continued to observe it from the other side. Beats both the students and me looking at the same paper at the same time, when they face me.

3 Idiots

I saw this movie last weekend. Actually, I saw may be 2% of the movie, since I cannot bear to watch moving objects on a movie, TV or computer screen. I sat through the movie with my eyes closed, opening them when I could not understand something. I listened well, and enjoyed the movie very much. My wife and son were there to tell me in case I missed something visual. The story has some parts of Chetan Bhagat’s novel ‘Five Point Someone’, and still it is different. Bhagat did not give any message, while ‘3 Idiots’ gives many very strong ones, about how to learn what one want to most rather than what the parents want one to, how to enjoy learning something new every day, how to excel rather than how to succeed, how not to get into the rat race and try to come out a winner by just learning things by heart to reproduce them in exam, how to think rather than do what everyone has been doing before, how to live life rather than go through life, how to teach things in simple and enjoyable form that would go a long way and educating children. Rancho is a very strong character, and Aamir Khan has done that part very well. In fact, all characters have been well portrayed. I strongly recommend the movie to all parents whose children are getting educated, all children who are getting educated, and all educators. I was emotional too, partly because I am a teacher too, and knew what it was all about. I was emotional also because I am a father whose son has just spent 3.5 years away from home in a prestigious engineering college where students reach through a rat race, and where things happen like they happened in ‘3 Idiots’. Perhaps what was happening in the movie was that part of my son’s life that he did not tell us about, but what we always wanted to see because we were the parents. I congratulate everyone who has been involved with making of this movie.

Fund Raising For Medical Students

A couple of second-year students approached me yesterday. They gave an invitation for the annual cultural program. The studentrs have this program in which there are skits, dramas, musicals, competions, debates etc. There are funds reserved from the budget, which perhaps do not seem sufficient to them. So they asked me, “Sir, do you have any contacts in the pharmaceutical industry, who could give us some money for this program?” I was taken aback. Obviously they had been told to do this either by senior students who had been doing this before, or by their advisors. “There are guidelines of Medical Council of India on not accepting money or gifts like junkets from pharmaceuticals, because it is lileky to influence the prescription habits of doctors and is an unethical marketing practice. You are perhaps being initiated into this unhealthy practice quite early, actually even before you qualify as doctors. Then you will perhaps not think it is wrong to accept such things from pharmaceuticals when you start medical practice.” I thought they would take the advice and go away. But they were persistent. “Sir, in that case will your department contribute any funds for this program?” I give money to my son when he needs it. I did not know why they could not ask their parents. Students had asked us for money in past for such programs, and to support residents' strikes during which a lot of patients suffered from inadequate healthcare, and we suffered because we had to do our work as well as that of the resident doctors. I had resented that, and I still resent it. “Why do you want to blow other people's money on your enjoyment?” I asked. “It is always other people's money that is blown on enjoyment in public functions,” said one of our staff members who happened to be there. “Why don't you ask your parents for money?” I asked. “I know you all are quite rich. What does your father do?” I asked one of them. “He has a restaurant”. “What does your father do?” I asked the other student. “He is a businessman”. “Well, they have loads of money. I request you not to ask staff members for money. I may not have been very pleasant in this discussion, but it was to change your attitudes for better, believe me” I said. They went away after that. I hope I did change their attitudes for better.

Windows Vista: Surprising Feature

We have Windows Vista on our new computer. We have been using Windows XP all this time and have been quite satisfied with it. But the new system had Vista preinstalled on it, and we had to take it. I found a new surpsising feature on it. I had downloaded some large files and taken their back-up on my external hard disk. Two files were incompletely downloaded, and I downloaded them after 2 days. Then I connected my external hard disk to take back-up, and started looking for the downloaded files. When I found them and went to the folder on the external hard disk containing the previous files, I found these two files already there. The files on both internal and external hard disks had the same date and time stamp, and the same size. They were identical. I was foxed. The files had transferred themselves to my external hard disk. I thought about it quite a lot, and finally concluded that Windows Vista had understood that it was my practice to transfer downloaded files to the external hard disk, and done that by itself. It was something like a macro written by one would have done. I did not find such a feature of the Vista on Internet search. If it is a planned feature, I congratulate Microsoft. If it is accidental, I congratulate whoever is responsible for that accident.

Habits Die Hard

My hospital is gigantic. When it was built more than 80 years ago, it was planned well, for the needs of people at that time. As the population expanded, and as specialties and super-specialties developed, the hospital also expanded. These expansions were wherever space was made available, not necessarily keeping the convenience of the patients in mind. Somewhere near the north end of the building, there is a wall, and there is a stone with the engraving “Women’s Exit” just above of where the exit was. The exit was closed long before I joined the institute as a student 34 years ago. I see it because it is seen from a window near my outpatient department. I wonder if anyone else sees it. The laboratory is at one end of the hospital, the collection center is approximately in the center of the hospital campus, and the outpatient clinic is at the other end of the campus. The sick patient has to go all the way from one end to the other, and many times like that if there is any problem with the collection, processing of the sample, and receipt of the reports by the nurse in the outpatient clinic. I don’t look forward to the prospect of going around the campus even when I am in good health and best of spirit. I suppose the patients do it because there is no alternative. But all troubles of the patients are not due to the improper locations of different services. Some are due to habits cultivated by some personnel. I have tried hard again and again, but the issues have not been resolved. One of them is the chest radiographs. The clarity of the radiographs is about 60% of that of good films obtained in the private sector. I cannot understand why it is so, since they use the same films in both the places. In addition, the radiologists do not report these radiographs. The patient brings the radiographs to us. We see those and then have to send the patients back to the radiologists for reporting, as is required by the law. It is not only two visits to the radiology department, but standing in a queue twice. I discussed the issue with the concerned head of department many times. “Yes, that issue needs to be resolved,” he said every time, but has not done so successfully. I suppose he must have more important things to do. The other issue is that of electrocardiograms or ECGs. When we send a patient requiring an operation to get an ECG, the technician sends them away, saying “come and get it done when you come for admission for your operation”. I explained to the technicians that the ECG was necessary for obtaining fitness for anesthesia, and if it was abnormal, the patient would have to get treated before being scheduled for the operation. So getting it done just before admission to the hospital for the operation was meaningless. That has not made any difference. The ECGs are sent to us without reports. Then we have to send the patients to the medicine department for getting those reported. The head of the medicine department told me that the ECG department was actually under the control of the cardiology department, and the cardiologists should be sorting out the problems as well as reporting the ECGs. The cardiologists do not do any such thing. Another tragic thing is that the medicine and anesthesia outpatient clinics and the ECG department are all situated close to each other, but do not coordinate their activity. So our patient goes there twice to get the ECG done, and then comes to us for further advice. We send the patient for ECG reporting, and anesthesia fitness. If she makes a mistake, she comes back with the report, and we have to send her back to the same area for anesthesia fitness. If the anesthetists do not like the ECG, they send the patient back to get a cardiologist’s opinion. Then we send the patient to a cardiologist, whose outpatient clinic is on another weekday. After a few visits to the cardiologist, the patient is back with us, and then back to the anesthesia outpatient. How they don’t lose their sanity is beyond my comprehension. I will tell you about a carpenter’s mother. This fellow was doing some work in my house, and told me about his mother’s experience. She was sent to multiple places for multiple times, and finally was called for admission for her operation to get a bone tumor from her thigh removed. When she reached the hospital the doctor on duty told her that she was called the next day, and sent her away. When she reached the hospital the next day, the doctor on duty was different from the one who had sent her away. He scolded her for not coming for admission the previous day, and sent her away, asking her to go the outpatient clinic the next week for a new appointment. He refused to listen to her story of the previous day. She went home, and declared that she would live with the tumor rather than go to the hospital again. The carpenter had lost 15 days’ earning because he had spent those days in the hospital with his mother, going around to get things done. She could not sit down and lie down on her back because the tumor was right on the back of the limb. That she should choose to live with it rather than go back to the hospital speaks volumes about how the poor souls are treated. No matter what we do to improve these inadequacies in management, there is no noticeable change. These habits die hard.

Vaginal myomectomy: A new operative technique

I had a patient who had undergone a cesarean section in the past, and had developed a leiomyoma in the back wall of the uterus low down. Removing the tumor by opening the abdomen was risky in view of her past operation and the location of the leiomyoma. So I removed the tumor by the vaginal route, dividing the cervix and lower part of the uterus in midline on the back aspect, and then sutured the cervix and uterus back. This operative technique is not described in the literature, though I have written about it in my book, and also in the chapter that Wolter Kluwer have asked me to cotribute to their book: TeLinde's Operative Gynecology. For the technically minded readers, I am giving below my operation notes written on the patient's hospital paper. I must say it reduced the patient's operative morbidity quite a lot and was a satisfying experience for me as a surgeon too. _____________________________________________________________________________________ Vaginal myomectomy was done by Dr. S.V. Parulekar under spinal anesthesia. 1. Lithotomy position was given 2. Aseptic and antiseptic precautions were taken. 3. The cervix was exposed using a Sims’ speculum and held on its anterior lip with a vulsellum. The upper limit of the rectum was defined by per rectal examination, and was found to be posterior to the upper limit of the posterior wall leiomyoma in the supravaginal cervix. 4. 1:300000 adrenaline in saline was infiltrated under the vaginal mucosa above the portio vaginalis posteriorly in the midline. 5. The posterior lip of the cervix was held with two Allis’ forceps on either side of the midline and the cervix was divided upwards with No. 23 scalpel blade. 6. The incision was extended over the vagina and through it into the effaced posterior supravaginal cervix underneath the vagina. The incision was deepened until the pseudocapsule of the leiomyoma was divided and the myoma was exposed. It was held with a tenaculum and a bulldog vulsellum, and was enucleated by blunt dissection with an index finger and the closed blades of stout curved scissors. 7. Hemostasis was achieved by cauterization one bleeding vessel in the bed of the leiomyoma. The bed was occluded with a series of purse-string sutures of No. 1 polyglactin 910 from above downwards. Oxidized cellulose strip was placed in the highest part of the myoma bed which could not be reached with the suture needle. 8. Hemostasis was confirmed at systolic blood pressure of 115 mm Hg. The incision in the cervix was closed with interrupted sutures of polyglactin 910. Vaginal mucosal incision was closed with interrupted sutures of No. 1-0 chromic catgut. A vaginal mucosal tear was found in the right posterolateral part. It was sutured with a continuous stitch of No. 1-0 chromic catgut. Hemostasis was confirmed at systolic blood pressure of 115 mm Hg again. 9. Patency of the cervical canal was confirmed by passage of a uterine sound. Rectal examination was done with one finger to confirm absence of injury to the rectum. 10. 5% povidone iodine solution was applied to the cervix and vagina. A sterile pad was applied to the vulva.