Air Conditioner

“Sir, as a head of your department, you can get an air conditioner for your office” our electrical engineer confided in me. “Other staff members do not have that privilege.” “Well, the previous head of department tried until she retired, but could not get one” I said. The office which I inherited from her measures 10 X 10 X 10 feet, has no cross ventilation, and is extremely warm in summer. “I have a circular that states you can get one” he said. “You put up a letter and we will arrange for you to have one.” “Thanks. But I do not want one” I said. He was surprised. He had probably not met anyone who had not wanted an air conditioner when it came as a perk of the job. “Why?” There were many reasons. It was in my opinion unnatural. It caused a higher risk of respiratory infections in susceptible people. It punched holes in the ozone layer. It added to our carbon footprint and increased global warming. I actually cared, but I did not tell him these reasons, because he would think I was being pompous. But there was a management reason that I thought was much more immediate and I told him that one. “I don’t want one because it creates a divide in my department. My subordinates without air conditioners would feel jealous of me, and our rapport would go down. I want us to work together rather than make them think they have to sweat while I enjoy life.” He went away without any comment. I had a meeting that day with my staff members, and when the topic of air conditioners for their offices came up, I told them only the head of the department could get one. Their body language immediately changed and became a little hostile, or perhaps I imagined it. “But I am not asking for one” I said. Their body language became a question mark. So I told them the reason I had told the engineer. Their body language turned into one big smile. “Actually you should get one,” a professor said with a grin. “Then we all will come to your office and spend a lot of time there.” “That is another reason why I don’t want one” I said with an equally wide grin. They all laughed at that. I don’t know if they laughed because they liked my joke, or because they were de-stressed by the knowledge that I would not become like those big shots that sit in air conditioned offices and apparently distance themselves from others who don’t have that perk.

Mango Fishing

A ripe mango is loved world over. This post is about unripe mangoes. The love for it stems back to my childhood, when we would relish eating it with salt for added taste. My mother would make pickles from it, which would last until the next mango season. As a child I had known the happiness of getting unripe mangoes from trees in my grandfather’s garden. The memories grew distant when I grew up, got busy with my medical work, and stopped visiting the grandfather’s garden after he passed away. But then someone planted a mango tree by the side of the road just below my third floor window. In a period of three or four years the tree grew to the second floor level, and started growing mangoes. School children would get the unripe mangoes by hitting them with stones. Older children and young guys started climbing the tree and taking down the mangoes en masse. No one objected, because it was a public tree, with finders-keepers policy applicable. It was then that I remembered my childhood love and decided to try and get at least one mango myself. I knew I could not climb a tree, and if I tried to throw stones to hit those mangoes, I would end up paying a lot of neighbors for broken window panes without any mangoes to show. That was how I was forced to develop the art of mango fishing. I took a long stick, tied a long wire to its end, tied a polyethylene bag to the end of the wire, and kept the inlet of the bag open with a 1 foot diameter plastic ring. Then I lowered it to the tree level, extended out with the stick. I positioned it under a mango, raised it and pulled it, so that the mango would come off and drop into the bag. I remember the security guard of the adjacent building watching me, and laughing when a mango came off and fell to the ground instead of dropping in the bag. I remember his crestfallen face when the next mango I fished fell into my bag successfully. I collected 5 mangoes that day, and proudly presented them to my wife when she came back from her clinic. She was a little concerned that it was not very appropriate for a person of my social standing to do this when we could have purchased unripe mangoes from the market for 10 INR per kilogram. Then I told her how wealthy people go fishing, when they can easily buy fish. They do it for the fun of it, and I had done mango-fishing for the fun of it. She understood and appreciated. Though I was out of practice for a year in between, I engaged in the sport again this weekend again, and collected 10 mangoes. I even threw the bag around swinging from the tip of the stick, having put a small weight in it to stabilize it in breeze. I am proud to say that my best effort got me two mangoes in one go. For those of my readers who think this is a childish thing to do, I will say “Do it once to experience the thrill. This method has not been described in literature before, but now it is. Feel free to try it. It will work on any other fruit too, provided the tree is near enough, and you are at a level higher than the tree. It would be a wonderful thing as a stress buster too.”

Negligence

Log 2-1-2009 Mrs. Suntanni Pika undergoes a cesarean delivery at a civic hospital. Log 9-1-2009 She recovers well and is discharged from the hospital. Log 12-4-2009 Mrs. Suntanni Pika suffers from excessive menstrual bleeding in two successive menstrual cycles and presents to the same civic hospital. She is prescribed tranexamic acid and hematinics. Log 24-12-2009 Mrs. Suntanni Pika hears about a free gynec camp in a nearby center. She is OK, but wants a free check up anyway. Though the civic hospital was also free, she decides to give this camp a go. They check her up, find a 1 cm diameter fibroid in her uterus. They advise her to undergo a laparoscopic hysterectomy. She likes the idea. They advise her to undergo tests for fitness to undergo anesthesia and surgery. She does that. Log 1-1-2010 Mrs. Suntanni Pika gives consent to undergo laparoscopic hysterectomy, and if required, vaginal or abdominal hysterectomy. They perform the procedure. After breaking some bands of adhesions laparoscopically, they start vaginal hysterectomy. They find some difficulty and perform abdominal hysterectomy. There is some injury to the urinary bladder because it is firmly stuck to the uterus. They call superspecialists who repair the injury. The patient is wheeled out of the operation theater after 11 hours of surgery. Log 19-2-2010 Mrs. Suntanni Pika is discahrged from the hospital alive and well, after having undergone extensive treatment with medicines, and repair of wound breakdown and finally skin grafting on the raw abdominal wound. Log 26-2-2010 Mrs. Suntanni Pika files a case in a court asking for a hefty compensation in a case of alleged negligence by her treating doctors. She also writes to the chief of the civic hospital to get her an expert opinion on her past treatment, thinking that will bolster her case. Log 28-2-2010 Mrs. Suntanni Pika is seen by a gynec in the civic hospital. There is nothing wrong with her except that she has a scar on her lower abdomen and no uterus in her pelvis. Her old records do not show any evidence of negligence. The consent had been proper. The procedure was as per established norms. The best of available doctors at the time had treated her. Complications are unfortunate, but not necessarily due to negligence. The report is handed over to her. Actually the court might have asked for the report directly. That would have been fair to both the parties. Anyway, no one criticizes the court. There must be legal reasons for asking the complainant to get the report. Log 1-3-2010 Mrs. Suntanni Pika writes to the chief of the civic hospital, and sends copies of the letter to the civic chief and a host of others. She complains that the doctors have given a false report in favor of the accused doctors. She demands review of her case by a panel of doctors in the civic institute under the chairmanship of the chief of the hospital. The chief is on vacation. The stand-in chief sends the letter to the concerned doctor for remarks. The doctor is upset because he has given a neutral and unbiased opinion. His boss is upset, because there are false allegations by the patient, and they had never been involved in the patient's treatment in any way. The civic hospital is not bound by any law to give any opinion on existence of any negligence. It is for the court to decide if there is any negligence. The civic doctors have to take out time from their work of treating patients to satisfy an unhappy patient, who is anyway unhappy about a third party. Now she is unhappy with them too because they do not give a report as she wants. This letter is sent back to the stand-in chief. Log 15-3-2010 Mrs. Suntanni Pika's letter to the civic chief reaches the civic hospital chief, asking him to provide necessary information about the complaint. The hospital chief asks the concerned doctors for an explanation. He has not seen their first response received by his office in his absence. So they hand over a copy of the original document. When he understands the whole situation, he gets the papers sent back to the civic chief and tells the concerned doctors to do nothing further, including worrying. The concerned head of department has learnt two lessons. One is how to handle a situation like this in future. The other is lawyers who advice such clients are of the worst unmentionable type.

Psychiatric Maladies

“Sir, Trishi has done it again” my Registrar complained. “She was woken up by her roommate at 6 a.m. for going to the ward. She got up, got ready and went back to sleep. The roommate woke her up again at 7 a.m. She left the room and never reached the ward. She is not reachable on her cell.” Trishi was one of my house officers. She had troubled us a number of times. She would not attend night calls, and the patients would suffer. She would run away from duty without informing anyone, and the co-residents would be burdened with her work. This time looked similar. One of us called her parents, who stayed in another part of the state. Her mother informed that Trishi had reached another city in one of the southern states where her brother stayed. It seemed she had left in a trance, and when she came to, she found herself at the airport. So she just boarded a plane and went to her brother’s place. When she came back a few days later, our chief psychiatrist saw her and diagnosed something beyond my comprehension, warning us that she was likely to commit suicide too. I never knew air-travel was so easy. I myself always needed an agent to book my ticket well in advance. The story Trishi’s Mom told me was different. She told me Trishi had told her that her current post was quite heavy. She had to just get through this post, and she would be all right once she began her next post, which was in a very light unit. After joining duty, in a week’s time Trishi had another breakdown, and the psychiatrist advised her rest for 15 days. Her Mom took her home for rest. But my residents had another story altogether. “Sir, Trishi has gone home to get engaged.” Trishi came back after 20 days, and indeed she had got engaged. She told me it was not planned at all, and her parents had forced her to do so or something to that effect. One week later Trishi was found asleep in her room and she wouldn’t wake up. It was found she had consumed an unknown number of sleeping pills. They rushed her to the ICU, where she made a recovery so dramatic, that when our people went to see her, she was found to be absconding, and was later found to be in her hostel room with her fiancé, in perfect physical health and best possible mood. Trishi went through these cycles of joining duty and absconding or taking sleeping pills, until that post ended. She joined a new unit with very little work, and indeed she had a total recovery. Not once did she remain absent or take a single pill for committing suicide. Her psychiatrist would call this a remission of whatever she was suffering from, but Trishi had known about the time of her remission a few months in advance, and had told her mother the exact date when it would happen. “Sir, you are very naive” said my ex-Registrar who knew Trishi very well. Trishi has not submitted her topic of dissertation to the University until after the beginning of this post. Now she cannot appear for the University exam at the end of her 3 years of residency. There is a rule that there must be at least one year between the time of submission of the topic and the exam.” “But why?” I said. “Does she not want to pass and do whatever she plans to do afterwards?” “She has her reasons. She needs an excuse to give to her in-laws for postponing her wedding by another six months.” I wonder if Trishi’s psychiatrist knows all this, she will still stick to her original diagnosis. Trishi is not alone. There are quite a few Trishis or Trishs around with somewhat similar behavior.

Hospital? Nah! Laboratory

The place where I work is a tertiary level hospital, receiving referrals from all over the country. However there are a few who believe its primary job is not to care for those in need, but to cater to the needs of those who want free laboratory facilities. I had a patient today who was brought by one of the hospital employees. He introduced her and went away. When I called her in to see her, she said her problem was repeated pregnancy wastage. I checked her history and then asked her to go into the examination room. Then she said she was in the difficult time of the month from today. I asked her to come next week, when the time would not be difficult. Then she smiled a little and said she had actually been referred to our hospital to have some tests done. I saw her referral note. It was written by a consultant in private practice. He had sent her to get some tests which I knew were quite expensive in private laboratories. Some of them were relevant, others were not. Some were done in our hospital, others were not. I asked her if she had come to us for management of her problem, or just wanted to get the tests done and then go back to her referring doctor. She said she wanted to go back. I told her I would not advice those tests which were irrelevant as per our protocols. That she found acceptable. She said she would come back next week. I am wondering how justified are we in getting those tests done for her, since she is treating our hospital as a free laboratory. I also wonder if I can refuse to do those tests, because she could have very well lied to me and got those tests done as if she planned to get treated at our hospital, but not do so once she had all the reports. When the senior staff nurse in the clinic heard of this, she said a number of patients wanted this done. Just last week she had caught one running away with an ultrasonography form, obviously to get the ultrasonography done and go away with the report. There had been others who had asked her to go with them to the labs to expedite matters too, mentioning names of the private practicing referring doctors, as if the names commanded prompt service. I wonder whether the patients have faith in our laboratories, but not our clinicians or they just want the comfort of treatment in a private set up and save money on investigations when they can do so.

The First Mouse My Wife Caught: Part 2

So we decided to open the grinder from the back and get the mouse out from the hiding place. When the time came to do it, I discovered that the wife’s role was to stay inside the house and lean against the closed door while I battled it out alone with the mouse. Seeing that there was no other option, I opened the back panel and the top basin by removing all the screws. I found the fellow sitting under the basin, looking at me with occasionally blinking eyes. It wouldn’t move from there despite the interrogation light on its eyes. I decided to spray it with air freshener as the helpful neighbor had suggested the previous day. The mouse took it, and I think it liked the fragrance. It stayed put, looking at me expectantly for more. Then my wife suggested I blow air on it with vacuum cleaner. I did that. This time he retired from under the basin to the back of the grinder, under the motor. I shone the torch into its eyes from the back. It just kept looking at me, not making a sound. I left the door and the back panel open and went into the house, hoping it would come out and go its way. I waited a half hour, but it stayed put. It probably liked the duplex box of the grinder, with its wires and smell of flour, now mixed with the fragrance of the air freshener. People going up and down the stairwell looked curiously at the whole thing. I got tired of it all, and closed the door as well as the back panel, with a plan to leave the door open at night so that it would go away looking for food and hopefully not come back to the grinder. The cleaning woman came to clean, and was not very happy that the mouse was not yet gone. She finished cleaning and opened the door to go away. Then she screamed and slammed the door shut. She had seen the fellow sitting just outside the door, and he had lovingly put his tail on her foot too. We launched into another debate. He must have escaped by pushing the back panel out, since I had not fixed it with screws. Now he wanted to come back into the house. We decided we did not want him at any cost. The neighbors had heard the commotion. We heard their door being doubly bolted from the inside. They also did not seem keen on having him. The cleaning woman wanted to go to clean up some other places, provided we guaranteed her safe passage. So I banged on the door a few times to warn him that I was coming out armed and he shouldn’t try anything funny. My wife stood safely away. I opened the door. The fellow was in hiding or had gone away through the grill of the outside safety door. The cleaning woman hurried away. I closed the door. We couldn’t stay inside indefinitely though. Finally we decided we needed expert help. I rang up the security fellow and requested him to send the gardener to get rid of the mouse. We warned the neighbors on phone to keep their door closed until we gave the all clear signal. They said OK. The gardener arrived. He took stock of the situation, and slay the mouse after five minutes of furious combat. The neighbors came out relieved, and blabbered excitedly. I kept thinking of the helpless eyes of the fellow as he had looked at me in the torchlight. Then I spent one and a half hours cleaning the grinder with isopropyl alcohol, detergent and water, thinking about the cuts I acquired in the process and leptospirosis.

The First Mouse My Wife Caught: Part 1

My wife is a physician, and has the womanly instinct to keep a safe distance from rats, mice, lizards, cockroaches etc. We would never have believed she would catch a mouse. But she did. We have this grain crusher and grinder that we use once a month. With a keen sense of using our real estate fully, we use the storage space of the grinder to store onions and potatoes for the remaining month. Its door has to be kept open to let air in, so that the contents don’t go bad. We never thought a mouse would climb to the third floor and enter our clean and tidy apartment. But that day one did so. It nibbled a tomato and two onions and then shitted all over the place. We were aghast the next day. That evening she closed the door of the grinder before going to bed to save onions from the monster. But the fellow had arrived before that and he got trapped in it. I got up in the middle of the night to the noise of the fellow biting through the plastic mesh covering the air outlet. I must admit 3:30 a.m. is the not a time at which I am at my best, especially with a terrified wife standing next to me giving instructions on methods of getting the fellow out of the house. So I put a wire mesh over the plastic mesh and stuck it in place with packing tape. I shut off the other vents with the tape and went to bed. But the fellow wouldn’t let us sleep. He continued to nibble his escape tunnel with loud noises. I had to get up and push the grinder out of the house. Then we slept. The next day we debated the best way to get rid of him. We agreed it would be foolish to just let him go, because he would come back with a vengeance. We knew rats and mice had shredded our neighbor’s fancy clothes in the recent past. We were not keen on having our clothes treated similarly. I knew I was not fast and accurate enough to hit him if I just opened the door. So we settled on giving him a poisoned biscuit. Mice were said to go away looking for water once they ate such biscuits and not come back. She bought one in the evening. I banged on the grinder a few times to let him know I was opening the door and was armed and he should not try anything foolish. Then I opened the door and blinded the mouse with an LED torch that police would use on criminals during interrogation. There was no mouse there! It was in the inside somewhere. I quickly put the biscuit inside and closed the door. We had a peaceful night. I opened the door the next morning, the torch on as last night, expecting to find the fellow belly up, not breathing. The biscuit was nibbled, but the mouse was nowhere to be seen. I closed the door. We started another debate on what to do next. She had heard of a mouse catching board. We decided to buy one. I came home in the evening to find a board ready. It was like the hard cover of a book, folded in the middle, with strong glue on the inside. After going through the now familiar routine of banging on the grinder as warning and switching on the torch, I opened the door of the grinder and tried to place the board inside. It wouldn’t fit in. Finally I had to keep half on the bottom and the other half inclined against one of the side walls. The fellow was inside somewhere not making a noise. The neighbors had learned about the mouse by this time, and were keeping the door closed at all times, observing the proceedings through the peeping hole. That was fine with me. We had another peaceful night. I opened the grinder door the next morning after going through the standard ritual, to find that the fellow was definitely not stuck to the board, but had closed it so that he could move about freely. He was still hiding inside. There was no time for a debate, since I had a big operation list waiting for me at the hospital. In the evening I googled and found out that mice can stay alive for 16 to 20 days without food and water. We could not starve the fellow to death, because the thought of a live mouse there was quite unsettling. The cleaning woman and the neighbors were also demanding more prompt action.

The Name Game

Everyone has his or her own name, and most of the people are proud of their own names. Some don't like their names, and some of these unhappy ones get their names changed officially. It is also necessary that we honor people's names and write and pronounce them properly. It is important not only for keeping their feelings unhurt, but also for legal purposes. Our patient's case papers have their names written on all the pages. When the patient gives a consent for an operative procedure, she writes her own name and then signs under the details of the consent. If the patient cannot write very well, the resident doctor in charge of the ward writes her name and she signs or puts her left thumb impression, depending on how literate she is. Yesterday I was checking the case paper and consent of a patient scheduled to undergo an operative procedure. Her name was सुवर्णा गणपत पाटील (Suvarna Ganapat Patil). That was how it was written on the case paper. She wasn't very literate. So the resident doctor had written it in the consent form. Unfortunately the doctor wasn't very good with Devnagari script (the local language). So she wrote it as सुवर्णना गणपत पाटील (Suvarnana Ganapat Patil). सुवर्णा means one with a good complexion. The word सुवर्णना does not exist, but it would mean one who has a good description. The patient either did not notice any difference or did not mind it even if she noticed it. She signed her name as सुवर्णा गपत पाटील (Suvarna Gapat Patil). Either she did not like her husband's name and wanted to spite him, or was less literate than one who can at least write her name. The word गपत has no meaning. At the end of it all, I am still a little confused about the legal validity of the consent document.

Hello Lazy Bum

I was sitting at the Sister's table in the ward, conducting term ending examination of undergraduate students. The Sister was away doing work in the ward. The intercom rang. “Hello,” said a woman's voice. “Is it ward 14?” “Yes,” I said. “Please tell me ward 14A's number” said the voice. Telephones are often time wasters. No matter how important the work you are doing, you tend to pick up the phone because it could be something important. But to ring up a busy ward just to ask intercom number of another ward was a bit too much. It wasn't as if she had called help desk or the telephone operator. “Who is it?” I asked politely. “I am a staff nurse” said the voice. “This is not the operator” I firmly told her. Why don't you look up the telephone numbers' list instead of disturbing people working somewhere else?” She put the phone down without even a “sorry”. I know I should not get irritated by small, silly things like people hanging up without even a “sorry” when they have troubled me unnecessarily. But I need to work on that some more. In the meantime I am wondering if I should have given her a number that just does not exist on our intercom list just to get even. But I had no way of knowing that she would be the type to hang up without an apology. When the Sister of the ward returned, I told her what had happened. She said this was a routine. Many people called her to get intercom number of ward 14A. I could have done even better, if I had thought about it. All intercom numbers are 4 digit numbers. Those for the wards have 71 in the beginning, and the ward number after that. For example, number of ward 14 is 7114. They put up some wards without distinct two digit numbers of their own, such as 14A and 15A. Then the formula of 71 followed by the ward's number could not be applied. Then they gave numbers from a list of available numbers to these wards. I wish I told the caller the intercom number of ward 14A was 7114A, instead of telling her to check the intercom list.

Paradigms

Life should be simple, and it indeed will often be simple, if only we permit it to be so. Let us take the example of resident doctors in training. Some of them do things in ways that are beyond sound logical explanation. The other day I found a patient was receiving oxygen by face mask in the postoperative ward. I asked them why she was receiving oxygen, thinking there must be some serious problem. The resident promptly turned off the oxygen flow and remocved the face mask. Poor woman must have cursed me for stopping her oxygen supply if she was enjoying it. On the other hand she may have blessed me for getting that mask removed from her face, because it is not an enjoyable experience, and oxygen is anyway odorless and not necessarily pleasant to breathe. I was not satisfied with the act, and expressed desire to know why she was being given oxygen. They wouldn't tell me, but finally told my associate professor who is kindly, sympathetic and motherly. It turned out that she had undergone a cesarean section early morning, and it was their practice to give oxygen postoperatively to all women. I asked if it was done under general anesthesia. It wasn't. She had received spinal anesthesia. I asked if she had a cardiac or respiratory disorder causing hypoxia. She didn't have any such disorder. So I asked the rationale behind oxygenating all women postoperatively. They again mumbled something into the Associate Professor's ear, who informed me that they gave it as a safety precaution, since there was no recovery room as such, and patients who underwent operations under general anesthesia might become hypoxic if taken out of the operation theater before full recovery took place. Somewhere down the line, the minimal rationality of this action was lost. Now they did it because that was the way things were done around there. It was a paradigm shift. If only they had bothered to ask us if they should do so, and what was the reason for doing so or not doing so, as the case may be. But they prefer to do what residents one or two years senior to them tell them to do, who in turn have picked up that wisdom from residents a couple of years senior to them. The reason why they don't ask the boss could be any of the following. 1. They are afraid of the boss. 2. They believe it is not worth the bother. 3. They believe the boss is unlikely to know. 4. They believe the resident advising them is more knowledgeable than the boss. 5. They believe it must one of the management guidelines of the institute. 6. They trust the paradigm. I wish I could give this multiple choice question to them as a test, but wonder if they will know the right answer. A clinical psychologist would perhaps be able to tell me, but I don't know any.

Copper-T & Weight Gain

It is one of the most commonly used contraceptives world over. Like any contraceptive, it also has a few adverse effects of its own. But these are encountered by a few women. Unfortunately these few women spread the word pretty fast. Potential users want all their fears allayed before they will hace copper-T insertion done. Some of these fears are real, and some are imaginary. After all, a user gets any symptom, she is likely to attribute it to the poor Copper-T. I was sitting in this transit office of mine, working on something, when along came two office employees. One of them wanted to ask me about her copper-T that had been inserted by another doctor in another institute. She had trusted that doctor to do the insertion, but seemed to trust me to answer her questions about the copper-T. The other one wanted to ask questions about menstrual irregularities. They somehow managed to ask their questions interrupting each other without seeming to offend each other. They must have a wonderful rapport. Their concerns were genuine, and I answered truthfully. There was nothing seriously wrong with either of them. One wanted to have the copper-T removed and have a sterilization done. When I told her about the complications of a sterilization procedure, she seemed to hesitate. So I advised her to continue using the copper-T, which she had had inserted only a few months ago. “But doctor, it sometimes causes a little irregular bleeding.” “What is a little blood loss compared to the benefits of the copper-T? We can fix it with medicines, and it will settle down.” “Doctor, does it cause giddiness, pain in hands and feet?” “No. The hands and feet are pretty far away from the copper-T. The giddiness is from the head, which is even farter away” I said. She seemed to be more tired and worried than she should have been. But not because of her copper-T. “Doctor, does it cause weight gain?” All women are probably concerned about weight gain, and she definitely was. This was the first time heard this alleged effect of a copper-T. “No! If it caused weight gain, wouldn't I have tied a copper-T around my arm? I want to gain weight but cannot.” I said. I am not gaining weight because I watch my diet and exercise. But I did not tell them that. They looked at my thin frame, laughed, and went away relieved.

Makeshift Valve For Laparoscopy

The cannula for insertion of a laparoscope or an accessory instrument has a rubber valve at the outer end. It fits like a cap on it, and has a central hole. The diameter of the hole is a little less than that of the instrument. So when the instrument is passed in through that hole, its edges grip the instrument quite firmly and carbon dioxide used for making the pneumoperitoneum does not leak out. With wear and tear, the hole may become a bit larger. Sometimes a cannula with an inappropriate size is used by mistake. Then the gas leaks out if the instrument is smaller than the cannula. I was called from the adjacent operation theater that day for this problem. The gas was leaking out through the second port. One option was to remove the port and insert a cannula of appropriate size. Unfortunately the instrument was the thinnest of the accessories, and the cannula was also the thinnest of all cannulas available. They wanted to drill the ovaries for polycystic ovarian disease, but could not because there was no pneumoperitoneum. Then I had an idea. I took a sterile surgical glove, placed it palm above the hole in the valve, and pierced it with the drilling needle. The needle went into the peritoneal cavity, with the two layers of the glove hugging it tightly. I wrapped the glove around the cannula. Now the gas remained inside the peritoneal cavity. This was a reducer of sorts. The surgical team was quite happy because they could operate and probably also because they could use this trick the next time they encountered this problem.

Bill Section

There was no reason to know that there would be a bill section in our hospital, and to believe that I would have an occasion to go there any time. But that is where I have been sitting for the last five months when not treating patients or teaching students. This room is one of the offices on the fifth floor of the cardivovascular building. The administration could not find any other place for me to sit and do office work, while they repaired my wards and offices in the old building. The other option was to put my handkerchief on the floor of the main corridor of the hospital and sit there, like many relatives of patients do when the benches are full. I was tempted to do that because it would have been quite convenient. It takes a half hour to reach bill section and go back to the starting point in my transit ward at present. I did not do it because my colleagues said it would have looked terrible. The clerk who manages bills sits right next to me, and I answer his clients when he is away. I have to guide them to the next room, where his colleagues sit. Some of the clients argue that they have been guided to see him in this room only. Then I am helpless. I have to tell them to wait until he comes back, whenever. They ask me when he will come back, and I have to say God knows, because he does not always tell me when he would be back. One of our old assistant engineers, now happily retired, came along the other day looking for him. He found me instead, but did not recognize me because I was in a wrong setting. “You haven't recognized me” I said. He looked at me again and exclaimed “Oh! What are you doing here, Sir?” “They have transferred me from my post of head of gynecology to the bill section” I said with a straight face. “Now I take out bills.” He was stunned for a couple of seconds. Then he realized that it couldn't have happened. Finally I explained the situation to him. He went away shaking his head, muttering “whatever next”. I must say I am actually enjoying my tenure in the bill section. There is less time-wasting traffic of people into my office because it is so far away from the heart of things. Only people who genuinely need to see me visit this place. The air is purer than in my first floor office where dust would come in from construction work all the time. There is less noise pollution too, since the clerks in the offices nearby don't make as much noise as patients' relatives did near my old office. The toilet is marginally cleaner, and well away from the place where I sit, so that there is no stink around. The only negative point is that I am in the bill section, but cannot bill them and make a bit of money myself. :-)

Pathology and Frustration

Sending a sample for histopathology should be a very starightforward thing, and there should not be any factor that can cause any frustration. At least, I thought so until forces far beyond my control proved otherwise. They used to send samples of endometrium and cervical biopsies in test tubes for histopathological studies. One sad day a few years ago the servant dropped the entire lot of the test tubes on his way to the pathology department. All the tubes broke and the tiny bits of endometrium fell on the ground. The operation theater people wanted to pick up the tiny bits and put them into new tubes. But I stopped them because we would not know which bits belonged to which patients, and all the bits had picked up dirt from the ground. None of the patients sued the hospital. We got the nurses to change the containers to small unbreakable bottles, and this unfortunate thing did not happen again. I thought no one would get frustrated with the act of getting samples to the histopathology laboratrory any more. I was wrong. I performed laparoscopy on a patient with an ectopic pregnancy two weeks ago. Her beta-hCG levels had been rising, but not doubling every 48 hours. Her uterus was empty on ultrasonography, and the sonographers had found a gestational sac of 5 weeks in the right fallopian tube. She would have done well with medical treatment, but insisted on surgical treatment. I found that she had convoluted fallopian tubes (as with a past inflammatory disease) without any evidence of a pregnancy in either of them. There was a disc measuring less than a centimeter in diameter on the back of the right broad ligament. It looked yellowish, and had a central compact part, making it look somewhat like a flat flower. I could lift its edges with my forceps quite easily. It came off easily, whout causing any bleeding from its bed. I removed it and sent it for histopathological study. I told them it could be primary abdominal ectopic pregnancy, and they should take extra care to see that it reached the pathology department properly. I was curious, because I had not seen such a lesion in 31 years. I got the histopathological report yesterday. It said the sample was completely autolysed and a report could not be given. The patient's endometrium sent in another bottle at the same time was not autolysed and showed decidua but no chorionic villi. Her beta-hCG levels started falling after the operation, and reached zero in less than a week. So in all probability it was indeed primary abdominal ectopic pregnancy. But I have no histological proof, and I know I am unlikely to get another case like this again. I wonder if there can be any more frustration possible for an academician?

Overwhelmed

Three of my senior residents have gone on examination leave, and I am left with two second year residents and three first year residents. No wonder they are overwhelmed. They have been used to having seniors tell them what to do, and now suddenly they have to decide what to do and do it themselves. They did not tell me so in so many words. But their actions clearly suggest that. One of my second year residents wrote in the first line of a patient’s history that she had undergone a sterilization operation (where she should have written the chief complaint), and in the place for operative history that she had not undergone any operation. She also referred a patient to radiology registrar to have a patient’s electrocardiogram reported. Luckily I intercepted the paper and changed ‘radiology’ to ‘medicine’ using her pen so that no one would be any wiser. One of my first year residents wrote a patient’s complaint was ‘defacuation’, which I could not comprehend. The patient told me she had difficulty in passing stools. I called this resident what he meant by the word ‘defacuation’, and after thinking for a while he said he was thinking of constipation when he wrote that. Another of my first year residents got a patient’s blood pressure checked by an intern and advised to write it on the patient’s right palm instead of her case paper. She had no explanation for that. I asked her if the pathologists wrote their autopsy reports on the backs of the dead bodies. I knew they did not, but I wanted her to get the message. She showed no indication of having got the message. So I told her that I would write her post-completion certificate on her right palm too. Finally I told them I would write all this in my blog. I hope they do not get further overwhelmed by that.

Threat of Atrocity & Sexual Assault

“Sir, we have this woman servant in our laboratory that is very abusive. She just used some unmentionable bad words and slapped this male servant. He is crying. She had similarly abused another male servant from the laboratory a few months ago.” This I heard from another servant. “Woman servant?” I was surprised. Bad words? Beating up a male servant? Male servant crying because a woman servant abused him and beat him up? May be the sequence was wrong. “Yes sir.” “What did he do to her?” “She asked him to do something, which was not in his job description. He told her so.” “But that is against the law. No one in this country can abuse or beat someone,” I said. “He is going to meet you and complain about it.” “But I cannot sort out a law and order situation. This is a matter for the police. Tell him to go to the security officer, and then lodge a police complaint.” I thought it was a good piece of advice. Apparently it wasn't. Four days later I learned that the woman servant had been transferred to another place in the hospital, and the laboratory had no servant to do her work. The person in charge of the laboratory had every reason to be upset. Then I made enquiries and found that they had got one of our Associate Professors to write a call to the time-keeper and get that woman transferred. I called the first servant who had arranged all this and asked him for an explanation. “Why did the aggrieved servant not lodge a police complaint?” I asked. “It does not work, Sir” he said. “Only transfer can be done.” “But that is no good. She will behave similarly wherever she is placed. She needs to be stopped or corrected. Police action and legal action would have sorted out the problem.” He was reluctant to explain the reason. But since I showed no signs of understanding the matter on my own, he explained, “Sir, if a police complaint is lodged, she lodges a complaint against the complainant under the Atrocities Act.” “Huh?” I was taken aback. This was something that had not occurred to me. “But you have witnesses.” “Sir, that has no standing. Furthermore she is bad medicine. She will also lodge a complaint of sexual assault.” “Huh!” I seemed to be developing a habit of saying 'Huh'. “Believe me, Sir. What we have done is the best way out. If she remains away from the department, I will thank merciful God.” “OK” I said. What a woman, and what a brilliant use of two weapons given to her by the constitution of the country! When I told this story to a colleague, he was not surprised. “This is the standard method,” he said. “It is done at all levels of the society. Don't you remember the minister who had shot a protected antelope and when the forest officer took legal action against him, filed a complaint against the officer under the Atrocities Act? I did remember reading about it in the newspaper and kept quiet.

Female Sterilization Tragedy

Female sterilization is one of the most commonly used contraceptive methods in our country. Since it is one of the healthcare programs run by the Government, it has acquired a unique status. Actually it is a minor procedure that we were required to perform as first post residents. We used to perform puerperal sterilizations in seven minutes each, and would be shouted at by the seniors if we took longer. There used to be only one student nurse to assist us. Now that it is a part of an important program, each sterilization is done by a qualified doctor or resident doctor assisted by a qualified doctor. The Government has laid down guidelines about who can perform it and who cannot. The rules are quite stringent about laparoscopic sterilization. There is a rule which states that no matter what the degree of training of the gynecologist, he or she must be trained to perform laparoscopic sterilization in a course conducted after one obtains a postgraduate degree. One has to perform 95 sterilizations in that course before one can be certified to perform it independently. Nowhere does one get so many sterilization operations, and I suspect all the certifications currently done in any institutes recognized for this purpose are done without meeting this criterion. The rule pertains only to laparoscopic sterilization. One may perform laparoscopic hysterectomy or pelvic lymph node dissection without any such certification, but not a sterilization operation. It is special. Not only is the person to be trained officially for this operation, but the institute must be accredited for that purpose too. The institute may be performing open heart surgery without such certification, but not a sterilization operation. It is special. The anesthesia fitness requirements are hemoglobin and urinalysis. Hemoglobin level of 9 g% is enough. I wonder why the operation which is so special can be performed when the woman is unfit because she is anemic. I also wonder why the stringent criteria for fitness for anesthesia are not applied to this operation, even if it is so special. The Government has laid down a list of conditions in which a sterilization must not be performed on a woman. There is an additional list in which there are conditions in which sterilization should be performed with caution. A doctor is expected exercise utmost caution in everything he does. There cannot be extra caution in any situation. What the rule means is that if one performs a sterilization in such a patient and the patient remains well, there will not be any problem for the doctor. However if the patient dies or gets any complication, the doctor hangs. If the woman who undergoes a sterilization dies, an enquiry is conducted by a quality assurance committee. The members of the committee are selected by the government. They are selected because they are in government service, not because they are experts on this issue. They conduct enquiry of the team of the gynecologists concerned including the head of the department who may have nothing whatsoever to do with the operation. They question everything that happened and did not happen. They split hair no end. All that is justified, since no young woman should die or even become seriously ill after an elective procedure like sterilization. She leaves behind a family including her young ones with perhaps no one to care for them. She does not need this operation for any health related problem. She would be alive and well if her husband had undergone this operation with practically no risk of any complications and death. Unfortunately husbands don't undergo this operation because they wrongly fear that it may cause impotency. The other unfortunate part of this is that the enquiry business is applied even when the woman dies of disease not related to the sterilization procedure. For example, if the woman is undergoing a laparotomy for a ruptured ectopic pregnancy with shock, and she desires a sterilization operation too, one may do it in an additional two minutes without increasing the morbidity. But if she dies due to shock, her death is considered as that due to sterilization and an enquiry is held. If the woman had a medical condition that contraindicates pregnancy, and she undergoes a cesarean section for obstetric reasons, one would want to perform a sterilization operation at the same time in her interest, without any increase in her morbidity. One wants to do this because her husband invariably does not undergo a sterilization himself, and she will get pregnant some time later and may die. But the Government prohibits this sterilization. She can undergo a cesarean section, but not a sterilization along with it. I don't think the Government has really understood this issue well. Our letters are never answered, so we cannot do anything much about it. The result of treating highly qualified and competent doctors like criminals and holding their enqiries in a derogatory manner, often stressing unimportant points has resulted in a setback for the programme. The sterilization rate has dropped drastically. Women badly in need of controlling their family size are refused sterilization. The nations' population is on the rise while the Government machinery is set only on following the guidelines blindly. Something needs to be done to set things right, or the country's population control will be an unrealistic dream.

The PCPNDT Act

Preconception and prenatal diagnostic techniques act (PCPNDT Act) of India is a very important act. The progressively declining sex ratio is something that concerns the whole country, except those who contribute to the decline in the sex ratio. A day may arrive when there may not be any girls for boys to marry. It is wholly condemnable that one should select a baby of a desired sex before conception, or terminate a pregnancy if the fetal sex does not meet with parental approval. The act is very essential. Unfortunately very little is done towards actually stopping preconception and prenatal sex determination. The entire machinery seems to be working for registration of every centre and person which will have an ultrasonography machine. If the centre is not registered, or has a machine that is not included in the registration document, the centre and the machine are sealed, and the seal is removed after payment of a penalty 5 times the cost of the registration, i.e. 15000 INR. The persons employed to do this activity also check the centres doing ultrasonography, and if the form of ultrasonography has any blanks, the machine is sealed because the Act is violated. There is no activity towards actually stopping the sex determination. As if registration of the doctor and his machine will prevent him from determining sex prenatally. In other words, any criminals are now registered. The theme of the Act is to prevent the crime, not to ensure that any criminal is registered. The implementation of the Act has degenerated to such ridiculous levels, that even an ophthalmic ultrasonography machine and an echocardiography machine are forced to be registered. The Act also specifies who can register under this act. Obstetricians, pediatricians, registered practitioners with 6 months of training or 1 year of experience with performance of ultrasonography can register. It seems to imply that those who fit these criteria will not violate the Act. It also implies that only unregistered people violate the Act. That is as funny as presuming that those who make mistakes in filling the PCPNDT form for ultrasonography actually determine sex preconceptionally or prenatally. The real smart ones register themselves, their machines, see to it that the ultrasonography form is filled perfectly, and then determine the sex of the fetus anyway. They do not actually print the sex of the fetus in their report, nor do they tell the sex verbally. But I have heard there are methods that will not be interpreted as disclosure of the sex of the fetus. I have heard they perform the ultrasonography, and then the patient is told to take the blessing of the Goddess. The sweet offered as blessing is either a Pedha or a Barfi, both sweets. If it is a Pedha, it is a boy, and if it is a Barfi, it is a girl. Will any court convict a doctor for offering a pedha or a barfi to the patient? I doubt it very much. I don't deny that the Act should be followed to the word. But that is not enough. Instead of finding minor faults in the ultrasonography forms filled by doctors, and making a big issue of registering people and rejecting applications for registration over trivial matters, the machinery should be set up to change the attitudes of the society, to make them understand that a girl is as good as a boy and a female child must not be stopped from being born. The machinery should also actually find out who make such prenatal selection or diagnosis and then punish them severely. The fault lies not in unregistered machines and people, it lies in the hearts of those who make such a request and those who meet the request for a hefty fee.