Nightmares in Obstetrics & Gynecology: 5

When I started my postgraduate studies, I was enthusiastic, eager to learn new things, and keen to apply all that theory I had learned as a student. Unfortunately I soon learned that life was not so simple. There were many things that traumatized me; things that had no business being in the academic environment, but were there because there were people and people will be people. There was my Registrar, who probably was unsure of herself. She was a locum of the regular one. She would ask me to be ready for the morning round at 7:30 A.M., and would let me go for breakfast after the round. She would keep me waiting till 8:15 A.M., and then start the round. After the round it would be time for starting the outpatient clinic or operation theater, so that there would be no breakfast. At night, she would keep me waiting to start some intrapartum monitoring until 9:30 P.M., at which time the mess would close. Then she would allow me to go for dinner. There would be no dinner. I missed 75% breakfasts and 50% dinners as a first post resident, and lost 6 kilogram weight in 6 months. She apparently had all her meals in time and actually gained weight. I shudder even now thinking of those days. Then there was my lecturer, who had borrowed my notes when I was a student and she was a Registrar. I had to ask for them back repeatedly after a few months. She finally did return them, but probably held a grudge against me. When I became a houseman in the unit where she was a lecturer, she saw to it that I would not get any operative work. I spent 6 months dressing wounds while my classmate in the next unit kept operating regularly. I did get sufficient operative experience in the subsequent years, but the pain of denial did remain with me for years. I am feeling awkward writing about the Associate Professor of that unit. She had a rich husband, and even without his money she was OK because she drew salary much higher than the stipend I received as a houseman. One day she asked me to give her twenty INR for going to the canteen with another staff member. It was surprising neither had any money. I had that amount in my pocket, and I gave it to her. She said she would return it later. A week went by. We met every day, but she did not return the money. Then she said in front of a number of people she remembered she had to return my money. A month went by. She said the same thing again publicly, but still did not return it. Now it is 24 years since. She met me a few times after I became head of my department, while she had moved on to an affiliated institute as an honorary gynecologist. She has not returned that amount. I resented the loss of that amount then because I was paying for my education from my stipend as a postgraduate student, and the money was important to me. If I had invested it in fixed deposit in a bank, it would have become 960 INR today. I moved on long ago. But life would have been much better without such people around.

Vesical Lymph Node?

We were performing a laparotomy. When we opened the abdomen, we found dense bowel adhesions and a cyst in the sigmoid mesocolon. Ours is a multispecialty hospital. So we called for a surgeon. While we were waiting for him, I had an idea. The patient was thin and the bulb of the Foley's catheter placed in her bladder was seen as a bulge in the dome of the bladder. I asked the resident who was operating what the bulge was. He palpated it for some time and declared it was a lymph node. I was surprised. So I asked the Registrar who was assisting for the operation what her opinion was. She felt it for some time and said it could be a lymph node. I was lost for words. How they expected a lymph node to be under the vesical peritoneum and that too a mobile one was beyond comprehension. I kept shaking my head until it dawned on her that it was the bulb of the Foley's catheter. I am beginning to feel they get confused when I ask them a question, thinking the answer must essentially be a complex one.

Nightmares in Obstetrics & Gynecology: 4

There was a time when a midline vertical incision was made in the upper segment of the uterus for performing a cesarean section. But that time is long gone, many years before I began my residency. In modern times, everyone makes a transverse incision in the lower segment of the uterus, because the upper segment incisions are associated with a high incidence of complications like severe hemorrhage, postoperative infection spreading to the peritoneal cavity, adhesions between the scar and bowel, rupture of the scar in a future pregnancy. I recall a time when I was doing my house post in obstetrics and happened to be in the OT when my room partner’s unit was performing a cesarean section. Their lecturer was among many things greedy and would try and operate herself when someone else was supposed to operate. The operation was about to begin when she suddenly decided to join the operating team. They knew she would take over if she joined. So the residents rushed through the steps while she went to wash up. The Houseman made a bold midline incision in the abdominal wall as instructed by the Registrar. The incision happened to be so bold that it went right through the abdominal wall and cut the outer part of the upper segment of the uterus. The Registrar hid the uterine cut with a mop and they proceeded with the lower segment operation. The lecturer arrived, saw what was happening, ordered the Registrar to remove the mop to show what was underneath, and realized what had happened. “You guys did this so that you would deliver the baby before I joined you” she said with disgust and walked away. Ten years later history repeated. It was my operation day, and there was an emergency cesarean section of another unit. Their Registrar decided to perform a fast operation and made a bold midline vertical abdominal incision. It happened to be bolder that my roommate’s of 10 years ago. It went through the abdominal wall and the front of the upper segment of the uterus in a single stroke. The uterine opening was 2-3 cm long and part of the baby was seen through it. The tragedy of the patient was that the Registrar extended the incision upwards and downwards to make it an entirely upper segment operation, instead of performing a lower segment operation and then suturing the upper segment incision. She did this before we could stop her. Whether she did this because she was too dumb or because she always wanted to do one remains unknown to date. She is an associate professor of Obstetrics and Gynecology in a teaching institute today. I just hope she has improved in the meantime.

Nightmares in Obstetrics Gynecology: 3

She had come to us as an ad hoc lecturer. She had filled a vacancy for which I suppose we should have been grateful to her. After all, she was one more employee required for fulfilling requirement of recognition of our institute by the medical council. She was one more qualified person to be on emergency duty, so that the existing lecturers and senior residents would be relieved somewhat. However it wasn’t long before we realized that all was not well. Her husband had a couple of nursing homes, but she said she was not desirous of working there. Then reports started coming in that she did not know much of operative work. She was with us to learn rather than serve. “Sir, do we have to have her?” “Sir, she is dangerous (to the patients).” “Sir, I would prefer to work without her.” (This one was from her boss) I did not know what to do. She was appointed by the institute’s administrators, and her removal before her tenure was over would be a major maneuver best not attempted. Then one day she stormed into my office with a complaint against her residents. “Sir, they are saying I am here as a lecturer, so I should teach rather than expect to be taught. If I want to learn, I should take a resident’s job.” The tip of her nose and her eyes were red. Apparently she had been crying. I called the resident doctor who had said so and asked her if that was true. “Yes sir” said the resident. “Do you have any explanation for such rude behavior?” I asked. There was no answer. I suppose what she said was true, and residents can be blunt and cruel, especially when a not so competent person joins as a senior person and hogs their operative work undeservingly. The final shock came when her boss revealed that she would not assist the house officers in performing puerperal tubal ligations. So I called her and asked her explanation for such behavior. “I don’t assist the residents because the boss does not teach me how to perform laparoscopic sterilization” she retorted. I was stunned. “Do you realize that your post is a teaching post, not a student’s post? You are showing negligence in discharging your duties.” That seemed to insult to insult her. “Tomorrow was to be my last day in this job” she stormed, “but I will resign today! Now! This moment!” With that she stormed out of the room. All lecturers and senior residents were upset because she was scheduled to be on emergency duty that day and had run away without doing it. “Why don’t you help her learn laparoscopic sterilizations” I asked her boss afterwards. “She is incompetent. She cannot get a laparoscope into the peritoneal cavity. She might kill a patient” the boss said. I thought that fear was reasonable. We could not let patients die because a lecturer was desirous of learning but could not go through the basic stuff. A year went by. The one day we got news that I could not believe. “Sir, did you hear this one?” said the said boss. “Our lecturer who resigned because I would not teach her laparoscopic sterilization? She is joining the new corporate hospital in the city as an endoscopic surgeon.” “Huh?” I said. “How did she manage that?” “Her father in law is the chief administrator there.”

A Curious Case of Uterine Perforation by Copper-T

Uterine perforation by an intrauterine device is known for ages. The incidence has fallen with the use of devices that use the withdrawal technique instead of the older push-out technique. The T-shaped devices have a higher incidence of downward perforation of the cervix by the stem, the uterine contractions driving the device downwards. Today I found a curious mode of uterine perforation by Copper-T 380. The woman had had two cesarean sections in the past. She underwent a Copper-T 380 insertion postmenstrually 6 months ago. She came for a check up after 6 months, when the threads of the device were found to be missing. An ultrasonographic examination of the pelvis showed the device to be located in the right adnexal structures. Anteroposterior and lateral radiographs of the pelvis with a uterine sound in the uterine cavity also showed the device lateral to the uterus on the right side. We performed a laparoscopy on her. The threads of Copper-T were seen protruding through a small hole in the posterior leaf of the right broad ligament at the bottom. The ball at the tip of the vertical limb was just seen. We extracted the Copper-T by making traction on the threads. Half a milliliter of pus escaped with it. The patient made an uneventful recovery and was sent home the next day on antibiotics. It was curious that the lower end of the device had perforated into the right broad ligament, not into the cervix. It was even more curious that the threads had escaped into the peritoneal cavity first while the device remained in the broad ligament. What drove the device so far laterally is beyond imagination. The initial appearance of the Copper-T is shown below. The Copper-T is seen after extraction from the broad ligament.

Nightmares in Obstetrics Gynecology: 2

I had read with interest about inversion of the uterus in obstetric practice. Though I did not get to see one as a resident doctor, I had read all about it from every book and journal available. When I became head of my unit, the Registrar called me at midnight once and reported a case of acute inversion of the uterus. Since it has to be corrected by the person available on the spot, I asked him to correct it. He was very happy he got to do it, because he had expected I would go to the hospital to do it myself. He did not realize it had nothing to do with my personal happiness but with appropriate treatment of the patient. We did not get any inversion of the uterus in my unit in the next twenty three years. Though as an academician it was my wish to see one sometime, I could not wish that on any patient. It came as a bolt from the blue when I least expected it. I was assisting my Registrar during a cesarean section on a patient with two previous cesarean sections. She separated the bladder from the lower segment properly, incised the lower segment and delivered the baby. While I lost visual contact with the operative field and her operating hands momentarily placing the baby in the baby tray, she planted her right foot on the ground firmly, grabbed the umbilical cord with the cord clamp, and pulled out the placenta mightily. When I turned around to the operative field, there was something I could not comprehend for a moment. She was holding the clamp and the cord, the placenta was hanging down at the lower end of the cord, and there was no uterus. “Where is the uterus?” I asked her. “It is in this only” she said, indicating the placental mass with her chin. I looked carefully and realized I was looking at an acutely inverted uterus that I had always wanted to see but had hoped I would never have to see. The uterus lay under membranes which spread out from the edge of the placenta covering the endometrial surface of the inverted uterus. I have shown it diagrammatically below. There was no time to think. I placed the fingers of both hands on the placenta and corrected the uterine inversion. Then I asked the anesthetists if the patient's blood pressure had fallen. It had not. Then I turned my attention to the surrounding structures and found that the urinary bladder had torn where it had been adherent to the lower segment above the place of the incision. I repaired it satisfactorily. After the patient was wheeled to the postoperative ward I asked the resident why she had pulled on the cord before the placenta had separated. She either did not have answer or she would not answer the question. The patient made an uneventful recovery. But that is beside the point. I was given a learning opportunity by my resident, but I cannot be grateful to her for that. The bottomline is that the nightmare called my Registrar continued to remain where it was, to do whatever it chose to do unless we were nearby to stop it.

Nightmares in Obstetrics Gynecology: 1

As a child I had a couple of nightmares about ghosts, when I was into reading ghost stories. But that phase passed and I stopped getting nightmares. Many years passes without nightmares, and now I have started again. But these nightmares are different. The old ones were experienced when I was asleep and they woke me up in terror. The new ones are experienced when I am awake and the resultant terror prevents me from going to sleep. These nightmares are some of my residents. They are probably quite decent and pleasant people in real life i.e. life away from their residency. But some of the things they do are nightmarish and so also is their not doing things that they ought to be doing. There was the call in the middle of the night, when my Registrar called to say there was a patient who was wife of chief bodyguard of a leading political party known for its power methods of settling issues. Two housemen took the patient to the OT for a D & C without the Registrar along with them. They started. Something started coming out of the uterus, but they could not make out what. The helper told the performer of the D & C to pull it out and see what came out. What came out looked weird. Then they panicked and called the Registrar. They got an ultrasonic scan done, which showed two bright speckled tracks from the cervix up into the uterus. The sonographer had not seen anything like that in his life. The patient was not bleeding from the uterus. So I told them to observe her and show her to me the first thing on morning round. I could not go back to sleep. I kept thinking of the husband and his fellows running amok in the hospital with swords in their hands. Luckily that did not happen. I performed a D & C on her. It turned out to be a carcinoma, which we treated appropriately and she went home fine.

Quitting Time?

A couple of days ago a young doctor from our institute killed himself in his car on his way home from the college library. It seems he had tried to get admission to a postgraduate course and failed twice. He had been a good student. Being unable to do postgraduation was not the end of the world, but he seemed to think so. I am thinking of his mother who had nurtured him in her womb and then for some twenty five odd years, smiling when he was happy and crying when he hurt, who must have been more disturbed than he was when he couldn’t make it because he was hurting, and now whose all life was a big hurt. I am thinking of his father who must have loved the son as much but perhaps not have been as open as the mother in his expression of his emotions, who must have been proud when the son became a doctor, and who must have dreamt of his son’s life in future as he had had his own life with his son and his achievements. I am thinking of some girl who might have set her heart on building a life along with him because they were made just for each other. There will be many others who will also miss him, but not like these three who perhaps are in a frame of mind not unlike his own before he quit. I am sad because he did not see what life had to offer with these people who wanted him for what he was. I am sad because he did not see what he could have done even if he did not do postgraduation and perhaps been happier than he would have been with a postgraduate degree. I am sad because he did not meet someone who could have explained it all to him so that he would be amongst us, satisfied with self, happy with self. I am sad because this rat race in which our growing children find themselves is here to stay, killing their happiness while they run, killing a few who cannot run fast enough.

Who Changed My Obstetrics Gynecology?

I am calling Obstetrics Gynecology mine not in the sense I developed these sciences. I am doing that because they are the subjects I love. It is probably obvious from the title that whoever changed these did not do it for better but for worse. When I realized what they had done, I got so upset that it took a lot of time to get down to the question “who did it?” It would be a dissertation if I listed all the ways they have changed these subjects for worse. It cannot be put in a blog entry. But I can give an example or two. We had a patient whose episiotomy had gaped. After controlling the infection, it was covered with healthy granulation tissue and was ready to be sutured. I told them they could suture it. My sixth sense prompted me to ask them what they used to suture episiotomies secondarily. They looked at me with surprise and said ‘chromic catgut’. Even my MS qualified senior resident and almost Associate Professor said the same thing. Good grief! We suture episiotomies primarily with chromic catgut because the hospital is for poor patients who get free treatment, and the hospital cannot afford to provide synthetic absorbable suture material. But to use catgut for secondary suturing of a broken down wound was unimaginable. I then asked the same question to others. I am proud to say one tutor and one senior resident said ‘monofilament nylon’. There were others who said ‘polyglactin 910’. One head of unit said the same thing, stating she did not trust nylon there. There are people who don’t read textbooks, who don’t believe in following established practices and develop their own practices without much evidence in support only because there is no one to question them, and we have changed science. I wonder if it has to do with admitting and recruiting on basis of things other than merit. There are a lot more examples, which I may post when I am upset again.

Which Body?

I had written on correct identification of the patient, the disease and the side of the body on which to operate to avoid criminal negligence. It was but a few days ago. Yesterday I read something in the newspapers that topped everything that might have happened in this vein before. It seems in one of the hospitals in the city the nurse told the servant to pack a dead body and send it to the mortuary. The servant removed intravenous line of the patient he thought was dead, and packed his nostrils with cotton, as is the practice followed before sending the body to the mortuary. The relative of this patient kept telling him that it was not this fellow who was dead, but the one on the next bed. The patient himself was in coma so that he had no say in the matter. The servant refused to listen to the relative and did what he had to do. So this live one also died, allegedly due to suffocation. He could have opened his mouth to breathe and would not have died so. But the relatives were not expected to understand this. Even if they understood this, the gravity of the situation is not lessened a bit by that fact. It was criminal negligence of the utmost type. Why the servant would not listen to the relative is beyond understanding. He may be under the influence of something he should not be while on duty at least. Or he thought he could diagnose death much better than the relative. Or perhaps the nurse showed him the wrong body. It is also beyond understanding why the relatives did not physically stop the servant from doing what he did. After all, it was murder in their opinion. Perhaps the servant was very strong while the relative was relatively weak.

Difficult Vaginal Hysterectomy: New Technique

Difficulty may be encountered in vaginal hysterectomy due to conditions like absence of uterine descent, large size of the uterus, pelvic adhesions, and uterine distortion. It is our policy not to perform vaginal hysterectomy for uteri larger than 12 weeks of gestation. We prefer abdominal hysterectomy in such cases. But sometimes the patient has risk factors that make abdominal hysterectomy less desirable than vaginal hysterectomy. Extreme obesity is one such condition. The degree of access is limited, the duration of suergery is longer, and the risk of wound sepsis and breakdown is increased manyfold. In such cases we try and achieve removal of the uterus vaginally, with full understanding that we may have to abandon the approach and complete the surgery abdominally. We usually adopt methods like uterine bisection, myomectomy, uterine morcellation, and Lash procedure to facilitate vaginal removal of the uterus. These methods reduce the bulk of the uterus and make removal of the large uterus easier. However the bisection by itself does not reduce the bulk much. It has to be combined with myomectomy (if there are uterine leiomyomas) or uterine morcellation (if there is adenomyosis). If the uterus is enlarged in a craniocaudal as well as transverse direction by adenomyosis, even morcellation may not be adequate. The top of the uterus lies at a level much higher than the level of attachment of the cornual structures. In such situations we modify the conventional method. After ligation and division of the uterine blood vessels we displace the uterine mass to one side. With the uterine corpus still inside the pelvis, we clamp, cut and ligate the cornual structures on one side, made accessible by uterine displacement to the opposite side. It may not be possible to clamp the structures together. In that case they are clamped, cut and ligated step by step. The location of this clamping is often very lateral in the operative field owing to the large size of the uterus. Once the uterus is freed from the adnexa on one side, its separated lateral surface is held with instruments like Allis' long forceps, tenaculum, vulsellum, bulldog vulsellum, Jacob's clamp etc. and the corpus is swung downwards around an anteroposterior axis, delivering the part of the corpus on that side first, then the fundus, and finally the part of the corpus on the opposite side. Then the round ligament, fallopian tube and uteroovarial ligament on the opposite side can be clamped, cut and ligated and the uterus can be removed. It is our observation that the smooth surface of the uterus (owing to its serosal covering) glides quite easily, so that the specimen can be delivered even without reducing the size of the corpus.

Sleep Well O Vigilant One

“This is too much” the voice of the associate professor (AP) saying this was three octaves higher than usual. “Something must be done about it.” It was likely that someone was someone higher than that AP, and since I was the head of the department, it could be I who had to do something about it. So I asked “what happened?” “I came down to the OT yesterday at 2 A.M. for an emergency case.” That was not a very common thing, because the lecturer or senior resdient on duty can usually manage all emergencies well. It must have been a complicated case. “It was a bad case of uterine rupture. When I arrived, the two security officers at the entrance to the ward were sound asleep in their chairs, and so was the nurse on duty.” That sounded like the night watchmen of residential complexes. They are usually asleep after midnight, and if a resident arrives in his car later than that, he has to honk loudly a few times to wake the security fellows up to open the gate and let the resident in. I had not known the same practice was followed by the hospital security personnel. “The nurse on duty in the ward was sound asleep in her chair too. I have taken their photos on my mobile camera, but unfortunately they are blurred.” That was not surprising. I mean the blurring was not surprising. I will comment on the nurse's alleged sleep later. If the AP had to go to the hospital after travelling for one hour at 2 A.M. to find the people who should be awake and vigilant fast asleep, the hand would shake and the photos would be blurred. “This is atrocious. Something must be done about it.” I knew that I could not do anything more than complaining in this matter, because the security officers and the nurse worked under someone else's supervision and control. Complaining to appropriate authorities was something the AP could also do. The vigilance people like the senior AMO and night superintendent were really the people who had to note such occurrences and take preventive action. But was such an action safe? I knew the MCI wants the institute to provide a duty room for the nurse on duty. That is spelled out clearly in the MCI book on requirements for medical colleges' recognition. Though the purpose of the duty room is not stated clearly, it is obvious that the nurse has to sleep in the room if it is there. If she is to remain awake and keep working, what is the purpose of the duty room? So if anyone actually complained about the nurse going to sleep in her chair, the MCI may actually pull up the authorities for not providing a room for her to sleep. It is better to say 'sleep well' while leaving the ward after the day's work, if the people on night duty feel inclined to go to sleep.

Civil Work in Time

It was a wonderful day when the civil work for repair and renovation of the heritage building started. Actually we thought it would not be done until the building finally collapsed and then they would build a new one at the same place. But they managed before that happened. It was a pleasant surprise to hear that the work would be finished in six months and we would be back to the original place giving our best to the patients. It was not just saying it, it was guaranteed. Our estimate was 2 years, but they seemed to want to do it in six months. So we shifted to about 20% of the original space and gave healthcare to the same number of patients as if nothing was amiss. Six months passed and the work was not even halfway over. They couldn't help it. Sand was not available. That did not explain why they had not even started breaking down 25% of the area, but perhaps we were unable to understand the connection. We never know when sand finally became available. Work seemed to progress somewhat, but still was not halfway through. Now they seem to be likely to take a few months more, because they seem to be doing quality work and that naturally takes more time. We wondered if it was not the original plan to have quality work done so that it would be over in six months. It looks like our old estimate of 2 years will be proven to be appropriate. We are still wondering what was the need for telling us it would take just six months. They could have said it would take as long as it would take. Salaried doctors have to work under whatever conditions imposed. Perhaps they don't know that it is psychologically more upsetting to promise something and then keep breaking the promise an unspecified number of times.

Superannuate at 62

It is a universal truth that few people doing a salaried job want to superannuate at the prescribed age. It is 58 for full time doctors in public institutes. The government has proposed to increase it to 62 recently, not because the doctors were keen to continue beyond 58, but because a lot of them were superannuating in a couple of months and the medical institutes would lose recognition owing to deficiency in the staff requirement. It is a trend that municipal corporations do what the government does after a latent period of a few to many months. So now the municipal doctors in teaching hospitals are likely to get 4 more years to work. But it may not be as simple as that. It seems the associate professors became unhappy that the professors would take 4 more years to superannuate and hence the associate professors’ promotions would be delayed by 4 more years. It seems they went to the chief, who wanted to appease them and proposed that after 58 the head of departments would step down as heads but continue as professors. I cannot see how the associate professors get promoted 4 years earlier by this method, except that the professor number 2 becomes head, and perhaps get to be boss of the fellow who had shot down all his proposals and his happiness all these many years. Another rumor voiced by the president of full time teachers’ association was that only doctors who were below 50 would be allowed to work up to 62, while those aged 50 or more would superannuate at 58. The reason was that continuing so many senior doctors would burden the treasury much more in the form of payment of salaries. That rumor upset a number of teachers. I joined work after a leave of a month. I got used to having fun at home so much that I was upset I would have to work up to 62 instead of 58, because it meant having to face the same silly troubles every day instead of sitting back and enjoying life. I have never run away from life and so I will continue anyway.