Maternity - Solution to Residency Problem

We have this problem of an abundance of residents when new residents join shortage of residents when a number of them go on exam leave. Before the Health University took over the medical colleges from different universities in the state, our college was affiliated to Bombay University, now known as Mumbai University. Postgraduate students used to be admitted twice a year. It was good sense to do so. When the students of the first batch went on exam leave, students six months their juniors would be there to take over the job of Registrars. After the Health University took over, the postgraduates are taken only once a year. This year they gave two students per year to each professor instead of one per year as per the old rule. Now there are so many residents at one time that they do not get enough work. There are too many, so that everyone feels someone else will do the job, and sometimes no one ends up doing it. When they go on exam leave, there is suddenly a shortage, and second year residents have to take over the job of Registrars for which they are often not ready. I had written to the directorate of the medical education asking for reverting to the old method of taking students in twice a year, but they seem not to have received my letter, or did not think it was good sense. So the trend continues, and neither the students nor the institutes benefit. I used to feel that students should concentrate on education first, and think about marriage and family afterwards. It was my observation that either their studies or their babies suffered if they married and had babies before they obtained their degrees. They would not listen to me and get married and get babies anyway, irrespective of how far they were through their residency program. Now I have started feeling differently. By the time they qualify and start their professions they get to be about twenty eight to thirty years old, which is no time to get married and start families. They might do it in time and enjoy the best years of their lives in a way different from enjoying their studies. From the point of view of the institute and residency program managers, this move is a good move. The women go on maternity leaves and drop a post, sometimes two posts. When they drop a post, they lag behind the regular ones by six months. They have their families, and we have residents in a staggered manner. Everyone is happy.

Fundal Pressure – Update

I have written about fundal pressure preventing measures and related stories in my previous posts. When they pulled down our old labor ward, my designer (meaning handmade) posters saying 'Say No To Fundal Pressure' and with a sketch of a fellow giving fundal pressure to a distressed patient went down. I believed the message had gone home and the evil had been rooted out. Yesterday I was giving a lecture on controlling bleeding. It was for the postgraduate freshers. When I got around to using pressure for hemostasis, i explained how it works when there are vaginal lacerations that cannot be sutured. One example of such a situation was after giving fundal pressure to aid childbirth, I said. And then I had an idea. These freshers did not know me so well. I could speak without fear of my true feelings being recognized. So I asked them one by one about their work experience. “How long have you worked in the department? I asked. “Two months, excluding our allied postings” they said. “Have you got adequate work?” I asked. “How many fundal pressures have you got to do?” I asked the girl sitting at the end of the first row of chairs. “Two” she said brightly. “That's good” I said with a straight face. “What about you” I asked the guy sitting next to her. “Seven” he said proudly. “That is great” I said. I had a hard time keeping a straight face. “How many did you get” I asked the next person. It seemed she had none. And so did the next eight residents, including all three residents from my own unit. I was relieved they had not made fundal pressure at any time. But I was in the mood to carry on the charade a little longer. “That is not justice,” I said “we work in the antenatal clinic till five or five thirty P.M., and all our registered women seem to be delivering with them; at least those who require fundal pressure.” They kept quiet. I checked the units of the two who made fundal pressure and then of those who didn't. There were two girls from the same unit as the boy who had a proud seven to boast of. “How come you got seven and they did not get even one?” I asked him. “Do you shove them aside and take the case over whenever fundal pressure is required?” He just smiled broadly. “Or do you make the poor fellow give fundal pressure for you too because he is tall and strong?” I asked the two girls. They smiled unsure of where it all was going. I asked the others and it appeared none of them had had the opportunity to make fundal pressure. At that point I was unable to hold back my true facial expressions. Two units out of six practicing fundal pressure was serious business. “I know I shouldn't have taken you for a ride” I said “but my strategy of catching the innocents worked, did it not? I got positive answers to a question that the senior residents always answer with a no. Can't you two understand that fundal pressure is a dangerous thing to do; that it leads to seniors taking over for managing lower genital tears, uterine ruptures, and sometime postmortems? Don't ever make fundal pressures. It is a crime against humanity.” I got the two to mark their names on the attendance sheet so that I could identify them later, got the next resident to confirm that they had marked their own names and not of someone else, and then let them go. I hope the transaction has taught them what they actually should have known on their own.

Chits for Rounds

The wards are crowded with patients. The residents' minds are crowded with many things. Sometimes the nurses reshuffle patients' beds after the residents' ward rounds. Hence it becomes difficult to remember which patient has what, and hence they have to resort to memory aids when they present patients to seniors on ward rounds. Our current Registrars carry this information in a written form. Some of them carry it on small chits used for writing prescriptions. Others write it on bigger sheets of paper. I have told them repeatedly not to waste time and energy writing things down which are already on indoor papers. They should refer to the indoor papers while telling us about the patients' details. But they think they know better. Today my Registrar kept looking at a small yellow chit of paper and kept making mistakes like calling a given patient by another patient's name, stating the time of operation differing by the actual time by 12 hours, and not describing the delivery findings or intraoperative findings. I asked her to refer to the indoor papers, but she wouldn't. If a question appeared to be a little difficult, she would turn to the Associate Professor seeking inspiration, support or a ready answer. Finally I confiscated the yellow slip of paper and gave it to the co-Registrar for safe keeping. Then the Registrar started telling me about the patients from her memory, without looking at any record anywhere. I was worried, because I knew she would make even more mistakes without the information on the yellow piece of paper. So I started checking whatever she said against the indoor papers, and started finding disparities between the two. Even after pointing out this fact, she would not touch the indoor papers. It must be some sort of phobia, I thought. After some time, I found a yellow piece of paper in her hand again. So I turned to the co-Registrar and asked her why she had returned the yellow paper I had given to her for safe keeping. Then it turned out that this one was another piece of similar paper, while the first one was still with the co-Registrar. The Registrar had not understood that the ban was not on only the first piece of paper, but was on any piece of paper. I confiscated the second piece of paper too. But her apron pockets seemed full, and yellow chits were seen protruding from the top as well as from the bottom of the pockets where the stitch had become loose. I had to make her surrender all pieces of paper from her pocket before the round could be continued in a more professional manner. I hope she will finally learn not to waste national resources on duplication of records, of which one set will be thrown away after the rounds. I wonder if she writes a new set every day or uses the same old set day after day. That would save national resources to a large extent, and would also explain the disparities between her presentation and the actual facts.

Outsourcing

“Sir, the ultrasonography services for outpatients are closed” my resident informed me. “Why?” I asked. “There is a notice which says so. The reason is that they have no machines and no probes. This patient just came back saying they have sent her away even though she had an appointment for today. She is due to deliver in a week's time. New patients are being sent away without any appointment.” Just then a hospital employee arrived with an ultrasonography report. She was 11 weeks pregnant. I checked the date. It was the same day. “When did you get this done?” I asked. “Just now” she said. “Actually they did it twice today. The first time was not so satisfactory.” I was surprised. I rang up the department. The most senior person present was a resident doctor. He gave me a number where his seniors would be present, he said. I rang up that number. The resident doctor there informed me that no staff member was present there. He said the ultrasonic scan I was referring to must have been done by the senior sonologist as a special case for the hospital employee. “What about the patients for whom the hospital was meant to work?” I asked. He did not have an answer to that one. He did not know where his seniors were. I rang up the head of their department. He was not there as well. I did not know what to do. A couple of hours passed while I examined other patients. Then one patient came along with an ultrasonography report. It had been done the same day, in a center right across the road from us. I had a weird feeling about the whole thing. “Why did you do this ultrasonography at this center?” I asked her. “They have stopped doing it in this hospital for an indefinite period” she answered. “But how did you know about this center? I myself did not know about it” I said. “A person in that department told my husband it was at this place across the road” she said. “He said it was owned by a doctor who was trained in the same department.” Since none of the seniors in that department were available, I could not ask anyone for an explanation. Since the patients were not complaining about the outsourcing, I did not know if I should really be asking for any explanations.

Clean-up Drive

It was late evening when my aunt rang up. “Hello” I said. “Hello!” she said. “I rang up to find out if you were also involved in the 'clean up drive' of your hospital.” “I am perpetually involved in keeping the hospital clean” I said. “I educate people who make it dirty in front of me. These people includes patients, their relatives, visitors, and hospital employees.” “No, I don't mean that. I am talking about the new drive that was in the newspapers yesterday and today.” “No, I was busy with my patients until half an hour past closing time.” “Is it true the head of the institute and leading doctors took up brooms, water pipes and cleaned up dirty floor and such?” she asked. “So I heard” I said carefully. “Do you think it will make people feel ashamed and make the sweepers work harder and people stop making the hospital dirty?” I started suspecting my aunt had become a journalist. Who else would ask such questions? “Since such senior people are doing this, it is likely to work. Would they do it otherwise?” I said. “Don't they find it dirty to clean up peoples' mess?” “We have to ask them” I said pointedly. “But when these three hundred doctors do the sweepers' work, what will the sweepers do?” “We have to wait and see” I said noncommittally. Either they would sit around and enjoy life, or they would do their work. They could even go on strike because someone else was doing their work and their job opportunities were reduced. Only time would tell what they would do. “Are these doctors going to do this menial work in their duty hours or outside their duty hours?” she asked. This seemed to be going on dangerous grounds. “I don't know” I said. “This is a voluntary activity and I did not volunteer. I have so much work that I cannot do this work.” “But they did it in their duty hours today, is that not so?” she said. “Um.... yes.” “Then who looks after their patients?” “They must be doing both the things” I said. “Do they always have so much time?” she must be really mad at our doctors, I thought. Otherwise why would she resent our doctors having free time? “And I read in the papers there are 110 vacancies of sweepers in your hospital. Why are those posts kept vacant while doctors have to do sweepers' work?” “Auntie, you really don't expect me to know the answer to this question, do you? I am just a doctor working there. This recruitment business is done by people in administration in the head office.” “OK. But I think you have 300 doctors doing this extra work with no extra pay up to 11th September, so that the deficiency of 110 sweepers is nullified at least until 11th September. In the meantime, the labor union will be losing face and public sympathy for making doctors do sweepers' work” she said triumphantly. That was brilliant. She was brilliant to have thought of it. If it was indeed true, it was a brilliant move. “Auntie, you are brilliant” I said. “You will do very well as a journalist. Have you started working as one?” “No” she laughed. “I do this to pass time pleasantly. Now here is my last question. Did they do a good job? Was the result better than that of the sweepers?” “Auntie, we will speak some other time” I said hurriedly “I have to go now. My other phone is ringing. I think the residents at the hospital want me.” I put the phone down before she could say another word.

Shock

I can recognize an electric shock when I get one. I had received a jolt as a child when I tried to make a magnet out of a paper clip by putting it into a wall socket. I lived and also discovered that it was not the recommended method of making a magnet. In fact the clip remained unchanged. A had a more frightened jolt when I was a professor and tried to move my slide projector during a teaching session. There was some malfunction and the current passed into my hand instead of the projector's circuit. I remembered that time that alterante current was safer than direct current because it threw the person away from the contact while the latter kept the shock producing object in contact. Unfortunately the projector was an inanimate object that did not done school physics. So it remained stuck to my hand and kept the shock ongoing. I screamed for my students to switch off the current, but they just gaped at my face uncomprehendingly. Finally I somehow managed to fling it away, and was OK. The other day our computer in our office temporarily shifted to the OPD block gave me an electric shock. It was far milder than the two I just described. But it was definitely there. 'The earthing is gone' I said. The electrician was called. He confirmed my diagnosis. 'The earthing is gone' the electrician confirmed my diagnosis. 'But I cannot do a proper wiring, because the contractor who did the wiring four years ago during repair of the heritage bulding did not give a map of the concealed wiring.' He gave us a temporary earthing by putting a wire from the wall socket to a pipe in the wall. The shocking stopped. 'Sir, how did a wiring done just four years ago lose the earthing?' one of our professors asked. 'Substandard work' I answered. 'No one knew it was substandard?' she asked. 'I knew it' I said 'because the heritage architect told us that on an inspection round. He asked the wireman to pull out the concealed wiring. It wouldn't get pulled out as it should. There would be no way it could be rapaired later when the need arose. He couldn't control the contractor. I told the Dean. She thought for a moment and told me it would be sorted out by engineers when there was a need for repairs. She knew she would have retired in a year's time and would not be questioned when there was a need for any repair. The contractor was paid fully even without certification from us and I hear even from the architect.' 'Why?' 'It is a corrupt world' I said 'and we are insignificant parts of that world. Or perhaps we are worse than insignificant parts. We probably don't exist.' 'What if someone blew the whistle?' 'Have you not read about the whistleblowers being killed in last couple of months? I asked. The professor kept quiet. No one wanted to get killed for protecting the tax-payer's money, when the true protectors seemed to be turning a blind eye.

Verb or Noun?

It is probably a firm belief of some municipal employees that the rules of grammar are different for them as compared to the rest of the world. It is with this conviction that they draft letters. Their superior officers either share the belief or are not bothered enough to check spelling and grammar in the letters they sign. The result is that people receive letters from the concerned persons which sometimes bordering on hilarious. Look at the following example. The university has asked for detail information of all teaching staff. All heads of departments concern should send the information to the undersigned by tomorrow noon without fail. I would have been happier if 'detailed' had been printed in place of 'detail' and 'concerned' in place of 'concern'. The part 'without fail' should be removed totally. An unfortunate part of the use of bad grammar is that new appointees believe this is the approved grammar and spend an entire career writing such English. Since most of these letters are circulated within the institute or withing corporation offices at the most, the outside world does not come to know about it. That is a great face saver.

Academic Woes

One of our senior residents lodged a complaint to me in writing about some students. They had been caught copying in term ending theory examination. I asked why the students were not told not to copy and the matter ended there. Then I was told that one of our Associate Professors was told about this verbally, and she advised the said resident to put up a written complaint. Written words have great power in this world. I knew there was no action recommended for this offence by the university. It recommended action only for misconduct during the university examination, though marks of the term ending examination were counted in the internal assessment of the students. I send the letter to the academic committee. For those not aware of what the academic committee is, I will state briefly its structure and function. Great brains from all the academic departments in the institute are invited members of the committee. They meet once in a couple of months and storm their brains (same as brainstorming, I guess) on various academic issues. So they met on this issue and did their stuff. I received their answer two weeks later. They wanted to know why the students were not told not to carry their mobiles and books into the exam hall, as in university examination. Presumptuous of them. They had been told, but they disobeyed. I suppose body search of medical students prior to entry into the exam hall would be in poor taste, even if we had the appropriate manpower for it. They advised us to inform the students a week in advance about the consequences of such a malpractice, though they admitted they had not yet decided what the consequences would be. They had formed a subcommittee to decide the action to be taken in such cases. I think they missed the main point. The academic committee should deliberate on the issue of why bright medical students resort to copying in exams. Something must be seriously wrong with the system so that they have to do this. I have written before in some posts what is wrong and what should be done to correct it. But the decision makers seem to have missed those posts. The committee wants us to inform the students that copying is a crime. As if they don’t know it. They have gone through school and junior college, and then four years of medical exam, sitting for countless exams. It is extremely naïve to think they would not know it at this stage. The information is clearly given on the website of the university, in a language they understand very well. Informing the same again is superfluous. The academic committee seems to have evolved into a committee of municipal ‘Babus’ asking for explanations bypassing the main important issue, and forming subcommittees so that they can pass the buck. It also seems funny that they should try to decide what the disciplinary action should be on a matter concerning the university. They should ask the university. I did not ask the university myself because the inquiry should go through the head of institute rather than head of one department. Perhaps there are too many fine brains in a single committee so that coherent thinking becomes somewhat taxing.

Cart Before The Horse

We have five lecturer’s posts vacant for months. They advertised the posts about three months ago. We were asked to go for conducting the interviews of aspiring candidates during vacation, with a promise that the appointment orders would be given the next day. All that rush was to satisfy the medical council who had threatened to remove the recognition of the institute for not fulfilling the requirements. Today it is two months since the interviews were conducted and still we have not got a single person appointed. They first claimed our hospital office had not informed them of all the vacancies. I produced proof that they had received our letters about all the vacancies. Then they spent a long time doing something best known to themselves. Then they said they had put the proposal for sanction to the standing committee. The committee was not standing at attention as the name suggested. The meeting was postponed a few times, by one week or so every time. Finally they passed it. Then the matter went to the corporation. Still there were no lecturers. So I finally went to our office and asked about the status of the appointment activity. It would happen some time the head clerk said, unwilling to specify any date. I asked her why permissions were not obtained from the standing committee and corporation before advertising the posts. ‘Permission was first obtained from the commissioner. After the selections were made, permissions were sought from the standing committee and the corporation.’ I was stunned. ‘I know you are not responsible for the procedure’ I said ‘but does it not sound weird? Suppose the standing committee or the corporation does not give permission for these appointments, all the money, effort and time of all personnel involved are wasted. It is like sending invitation cards, booking a hall and getting guests for a wedding while the the bride and groom have not even decided to marry each other.’ She was speechless. That is the way things are done around her, she seemed to say. A paradigm is waiting for a shift. In the meantime were are overworked because we are understaffed, and the patients are suffering because we are not supermen and superwomen and cannot compensate for the absence of five doctors for a number of months.

Reservation Papers

A lot of people keep talking on the issue of reservation of jobs for people who have been socially oppressed in the past. I am not capable of saying anything new on the topic. I don't want to voice my opinion because it cannot affect the issue in any way. But I can always tell a couple of stories on this topic. There was a student nurse doing midwifery when I was a resident doctor in 1981. I remembered her for two reasons. One was that her name was almost the same as mine. There was just an extra 'a'. The other reason was that she was knowledgeable, and had the right attitude about work. She worked as a staff nurse in different parts of our hospital and finally reached our operation theater. She was still a staff nurse, though she still was knowledgeable and still had the same attitude as before. We talked about a few things and the topic of reservations in jobs came up. “They should keep reservations either for education or jobs, not both” she said. “They should keep reservations for education, not or jobs” I said. “Jobs are about giving service to people. We should have the best possible people giving service irrespective of cast and religion.” “Reservation policy has ruined everything” she said. “Look at me. I joined this institute in 1979 as a student. Today I am still a staff nurse while another person who was born in 1981 is a sister-in-charge of a ward, thanks to the reservation policy.” She said this with a smile on her lips, but I have a feeling there was moisture in her eyes. I am also thinking of my son. He wanted to get into IIT, the prestigious engineering institute. He had worked very hard. He was selected, but did not enter IIT because he did not get the subject of his choice. He opted for BITS, an almost equally prestigious institute. He is a brilliant engineer today. But I am a father who finds it difficult to move on. I still think he would have been happier with an IIT degree. The other day I was talking to a colleague, whose son got admission into IIT. I was happy for her and asked what his score in the entrance test was. It turned out it was quite low. Looking at the surprise on my face, she said: “My husband has a paper which states that he is of a reserved category. So my son got admission into IIT.” I was stunned. A highly qualified couple, with loads of money independent of the qualifications, lavish life-styles, frequent trips to the developed countries for pleasure, the works: and they get their son into IIT not because they belong to a reserved category but because 'the husband possesses a paper which states he belongs to a reserved category'. The husband also possesses another paper which states he is a farmer. So they have purchased a farmhouse, not for farming but as a second home for weekends. I and many other like me cannot buy agricultural land in this country even if we want to farm because we are not farmers. I think something is seriously wrong in our country when students with merit are denied educational opportunities they deserve while others get in because of possession of papers which state they belong to reserved categories. Real farmers commit suicides because they cannot make it, while people buy agricultural land for pleasure only because they possess papers which state they are farmers.

I Taught Them Punctuality?

I started working as a full time staff member in 1984. The memory of the early part of my residency was still fresh in my mind then. My Registrar would ask me to be present for the morning round at 7:15 A.M. But she would turn up at 8:15 A.M. The morning's work with the seniors would follow, so that I missed breakfast 60-70% of the times. She made me miss dinners 20% of the times for no reasons. I lost 11 kilograms of my weight in six months. I did not do a course in time management any time, but I started being punctual from the first day of my job a Registrar and continued later as a staff member of the hospital, because I did not want my juniors to suffer as I had suffered. When I became more senior, so that there were a couple of staff members junior to me in my unit, the difficulties started. The residents were quite happy with my punctuality, but the staff members were probably resentful because they had to report on duty on time. They did not voice their feelings, and I did not understand how they felt until much later. That they were not punctual came to my notice when I took a planned casual leave, canceled it at the last moment, and reported on duty. They all would come late that day, knowing I would not be there. They would often be late when I was on vacation. They were often late when they changed units or got units of their own. Many years have passed, but human nature has not changed. A large number of juniors have worked with me, and some are still working with me. Things are exactly as they were before. We had a lecturer, who went on a maternity leave, and then remained absent for three more months without sanctioned leave. Finally she joined duty, got promoted as an Associate Professor in another institute. The matter of her unsanctioned leave was still pending. So she called me and said she had learned a lot from me. I kept quiet. Considering her work while she had been with us, I was doubtful how much she had actually learned from me. So she said she had learned punctuality from me. That was hilarious. She had been late by three months when she came back to work after a maternity leave while I worked without a Lecturer, and she believed she had learned punctuality from me!

Architectural Principles

For reasons unknown the architect appointed by the head office is usually funny. Funny is not funny as in case of a stand up comic, but funny as in case of a person who does not make appropriate decisions as required of his qualification and job description. I had written about the fellow who used to say he was giving us world class architectural service before. It was probably the third world or may be a fourth world he was speaking of. Now we have another fellow who gets architectural drawings done using CAD software, as anyone does these days. The funny part is that he makes us sign our approval on the plans submitted, and then whenever anything is found to be wrong with the work done by his contractor, he says it is as per plan approved by us. The other day they put a wall between the sitting area and examination area of our emergency receiving room, with a door in between. Originally there had been no wall and no door. But the Architectural Guru felt there should be both the structures. Unfortunately the door was so narrow that a trolley with a patient on it couldn't be wheeled in. We asked him to correct it. He said it was as per the plan signed by me. Hats off to a guy who expects a doctor to understand the dimensions of a door in inches on an architectural plan of 10000 sq ft put on A4 size paper. After explaining the need to him he randomly decided a width and asked us if that would be sufficient. I told him that he had to understand the location of the door and the width of a trolley both so that the width of the door could be decided to permit the trolley to be wheeled in. I would not state the requirement in inches myself because I was not expert on that topic. If I made a mistake, he would claim it was done as per my specifications. If he could not judge it, he could take our trolley and see if it would go in through the door made by him. I was a gynecologist. I did not ask a patient with a lump in abdomen if the size of the abdominal incision I proposed to make would be sufficient to remove that lump. He refused to go around with us any further to see what other errors had been committed by the architect-contractor duo. He must be assured of payment irrespective of whether the user department is satisfied with the work done.

Lift Management

What we call a lift is what others call an elevator. We were visiting one of our wards in the multistory building. The lifts were quite crowded. We entered one of the lifts. It soon filled to more than its capacity and wouldn't start up. It was one of the older generations which would just stand there with its door open rather than give an audio warning that it was overloaded. So we got the last entrant to exit. Then the door closed and we started up. It stopped on the first floor. There was no call for getting out, but my Registrar got out. There was a servant waiting for the lift, who promptly entered. My Registrar reentered. The door remained open because it was now overloaded. We asked the servant to exit, but she wouldn't. We told her it was overloaded and would not start unless she exited. She continued to glare at us sullenly, but wouldn't move an inch. Finally I told her that even if she was a hospital employee, the lift could not understand that would not start with the extra load. Finally it penetrated and she exited. But the lift still wouldn't start. Then a senior person from the back guided my Registrar to exit and reenter. She did so, and the door closed. I said it was wonderful lift-management, and he beamed all over his face, saying his expertise was owing to his experience of 35 years. I think he understands lifts and their quirks like a computer Guru understands computers. After all, there is a miniature computer chip that drives the lift.

Partogram

We used to have an obstetric indoor paper with a composite partogram in it. Unfortunately the hospital changed the indoor papers as many times as the administrators changed, sometimes more than once in the reign of the same administrator. They experimented with different designs, including a computerized first page of the paper, with just treatment sheets attached in place of the remaining pages. In these varied versions, the obstetric paper with a partogram in it was lost. Since it was such an essential thing in the management of the patients and training of the doctors, we decided to resurrect it. Municipal stationery is code numbered, there being a unique number for each type of paper. So we asked the Medical Record Officer to get us those type of indoor papers for our patients in labor. He could not find a sample. I offered to go through old archived indoor papers and find a sample. He declined, saying he would manage it. In the meantime, I downloaded from my website the partogram I had developed and gave it to the residents for use. A couple of months passed and we received a message from the central municipal press that they had the partogram ready for printing, and would one of us go there and approve the sample? Three more weeks passed before one of the two staff members assigned this job could go there. We were surprised to find that the printers had got hold of my own partogram and got ready to print ten thousand of those. Someone had signed approval on the back of the sample too, but the signature did not match that of anyone in my department. I had my doubts anyway that anyone else from my department would have gone there to approve of the partogram sample without being asked to do so. Whoever gave the printers that sample could have asked us to give a composite partogram, instead of the cervicographic progress graph I had developed. Whoever did meant well, but meaning well is not always enough. Well, that is life.

Biometrics and Us

It is an excellent idea to use a biometric system to keep tract of the arrival and departure times of employees, though their presence does not necessarily guarantee work output. But the chances are that a person forced to be present for the whole working day will do some work. It is quite possible some people will mark their arrival, go away, and come back at closing time to mark their departure. It is a bit inconvenient, but definitely effective for lazy bums who are not very accountable or when the disciplining authority is malleable. The biometrics cards were prepared. But the implementation was not even initiated because the middlemen did not want it implemented. Free minds do not like restrictions and compulsions like arrival at prescribed time and departure not before prescribed time. But some biggie at main office put his or her foot down, and the cards were distributed to the employees. It seems a large number of employees were shown to be in the department of Cardiology, while they belonged to a lot of other departments. Probably the person preparing the cards had a malady of the heart and wanted as many cardiologists around as possible. One of our employees had her first name OK, the middle name that of her husband, and the surname of her single days. Such a combination is being reported for the first time in the world literature. After receiving the cards, the employees tried them on the first available machine, which happened to be right outside the office of the chief. It was malfunctioning. No one had broken it intentionally, because a security officer is posted right there. His job is to guard the chief, but protection of the machine is a beneficial side effect of his duty at that station. So they tried other machines – it seems there are 30 such machines scattered all over the institute. The machines require the employee to show the card first, and then place his or her right index finger on a glass window when a red light flashes in it. It wouldn't work for one person, but it worked when she placed her thumb there. The machine has no method of distinguishing between arrival and departure. It will probably make a good guess based on the expected time of arrival and departure for a given employee. I had been religiously marking my arrival on a particular machine near the entrance, until a security officer noticed me doing that and told me the data cable of that machine had been stolen soon after its installation. So my attendance was not reaching the server. I changed over to another machine. The I went to see the engineer who installed the systems. He allayed my fear of my arrival time being marked as 4 P.M. and either not departing at all or departing at the same time as of arrival. He assured me that the system still did not have data on expected times of arrival and departure of all employees, which varied from department to department. The instructions from the main office were to install the machines and that had been done. It seemed the biggie at main office wanted clerks from different departments to go to a machine each and put in their pen drives to get data of attendance. When the engineer pointed out that a given employee could access any of the thirty machines randomly, and a clerk from a given department could not get data of employees of that department on a single machine. His statement was rubbished. But after discussion between the biggies, it was found to be correct. So the machines were connected by cables. The heritage building architect prohibited the engineers from fixing the cables in the heritage walls. So the cables are left hanging loose. Each machine has a time of its own like each person has a mind of its own. So people favor machines showing earlier time to mark arrivals, and machines with later time to mark their departures. People make a queue in front of the machines at departure time, so that they can flash their cards at the exact moment their duty ends. For that they leave their department well in advance. Some machines are near the ultrasonography department, where the patients' relatives and their children amuse themselves by punching the keys on the keyboards of the machines while they wait for the scan. That is expected to make the machines conk off earlier. It is not known what is to be done if anyone has an injury on the index finger and has a bandage there. The machines won't read bandaged finger prints. It is also not known what to do about people who work for 24 hours and continue working the next day. If they don't record their departure at departure time on the 24 hour duty day, they will be presumed to have run away before time. If they record departure, they cannot be working in the institute and cannot be medicolegally liable for any clams of negligence in patient management. The department heads and dean will probably have to keep sending corrected effective reports by manual method when the people have been present and working, but have been unable to mark their attendance due to various reasons. Most people in the know are predicting the machines will be killed by people so that the system dies. Since the machines are unguarded, this should not be difficult, they say.

Attendance Woes

Maintaining a strict discipline in attendance by the employees must have been a headache for the organization. The trouble was that the administrative seniors make decisions only because they are seniors, not necessarily experts. So class III and IV employees are marked present or absent at a central place by a fellow called time-keeper. The attendance at the actual place of work is immaterial. So people marked present get salary whether they actually work or not. I once read in the newspaper that in some places the time-keeper equivalent marks them present for a fee (like 50%) of the salary, and the employees actually remain totally away from the workplace and get full salary. I had suggested that the time-keeper should continue to mark their attendance, so that he can send substitutes at places where the employees do not turn up for work. But the place of work should have a person marking their attendance for work, so that an effective report can be sent to cross check with the time-keeper's report. I don't think such a simple solution must not have occurred to the biggies in the administration. But they had never tried to do it. When I made this suggestion to the chief a few years ago, the response was 'no response'. I wondered if she was afraid of the workers' unions. Or perhaps she did not want to become unpopular with many people. After all, this post was a just another stepping stone, to be treated as such, not for achieving anything useful while the foot was on the stone. Now the biggies at the main office want to keep up with the modern times and eliminate human factor in all this mismanagement. So they first tried swiping cards. The system never worked because the concerned clerical person also was against the idea of having to report on duty on time and work till the end of the duty hours. So the data was never retrieved from the computers, the buffer always remained full, and all new logs were rejected after the first week. The next step was to start biometric attendance system. That will be my next post.

Fetal Monitors & Negligence

We have a number of fetal monitors in our labor ward, antenatal ward and antenatal OPD. One problem with the use in the labor ward is that the residents want to do multitasking. At the same time they do not fix the transducer to the maternal abdomen with a belt provided for that purpose. They either ask the patient to hold it in place and go away, or just let it be there hopefully stuck with the sound conduction jelly and go away to do something else. If the patient gets a severe pain, she might let go of the transducer. If it is left to merciful fate, it drops down on its own. The end result is breaking up of the crystal within the transducer. The transducer is then fit to be thrown away. But they carefully pick it up and put it back in its drawer, so that no one is the wiser. When the machine does not work, we call the company service engineer. He shakes the transducer in front of us like a rattle and it rattles like a rattle. Then he says, “Your people are not using the machine with due care. The crystal is broken because they dropped it.” We are forced to keep quiet and buy a new transducer because we are at fault and service must go on anyway. Yesterday we had a demonstration of a fetal monitor made by the same company whose machines already exist in our department and whose transducers our people keep breaking. The service engineer was there along with his boss who was doing the demonstration. We already knew all about the machine because we had machines similar to the one being demonstrated. “I cannot demonstrate the vibroacoustic stimulator because I don't have the pencil cells for it” the fellow said. “But then how do we know it actually works?” I asked. “OK, I will get cells” he said. Then he left the transducer he was holding over the patient's abdomen and turned to his junior to ask him to go buy the pencil cells. The transducer remained stuck to the patient's abdomen precariously, the jelly barely holding it in place. “See, you have done what our people do and break the transducers. You blame them for not exercising due care, but you use the machine the same way” I said. He just smiled. There was a major difference. The negligence was the same, but he would have made a loss had the transducer dropped when he left it. He made profit every time he sold us a transducer in place of one our people broke.

Mineral Water in Obstetrics

It happened on a Sunday, but I came to know about it only on the subsequent Friday. On that fateful Sunday there was no water in the labor ward and emergency OT both. The residents contacted the administrative officer on duty, who in the usual manner said water would be available in half an hour. Many half hours passed, but there was no water. In the meantime the women were delivering in the labor ward without any water for the subsequent cleaning. A woman developed acute intrapartum fetal distress and required emergency cesarean section. The resident doctors asked the servant in the OT to bring a bucket of water from the nearby ward for scrubbing. “I won't bring any water,” he said flatly. “If you want to operate, you bring water yourselves.” “Let us wash up with sterile normal saline” one resident doctor said. “I won't give you any normal saline” the nurse on duty said. “If I do, all our stocks will get over. Ask the patient's relatives to buy mineral water bottles for scrubbing.” So the senior houseman took the Registrar's consent and prescribed four bottles of mineral water. The patient was already on the OT table. The relative of the patient bought the required bottles. Just when the residents were ready to open the bottles, the senior Registrar reached the OT and saw what was happening. She put an immediate stop to this activity and got the water bottles returned to the relative. They somehow managed to get some water and successfully managed the OT work though the taps did not have any water for 48 half-hour intervals, i.e. 47 intervals more than the half hour the administrative officer had promised. I hear they are going to install one modular OT in my department at the cost of 22 million INR. Perhaps they will arrange for dry cleaning when that OT does not have water.

CAP "Babu"

I was working in my OT when the nurse arrived saying I had a call. “Hello” “Hello” said a guy “I am Dr. XXX speaking from the YYY department. I am in charge of the central assessment program of the university in our hospital. The examiners from your department have not come for correction of physiotherapy papers.” “Are you the same person to whom I spoke a couple of days ago?” I asked. He wouldn’t answer that one. “That fellow said he was in charge of CAP in your department. I told him to find out and tell me who the examiners were, so that I would send the concerned persons for the paper correction. I have no idea who they are. The university should tell me, but it has not.” “But you have to send the examiners” he said. “All other department heads have sent their examiners.” “Send me a letter to that effect” I said. I was getting tired of him. “We have sent that letter”.” “I have not received any letter.” “We have acknowledgement.” He seemed to be a typical municipal or government "Babu" rather than a doctor and a teacher. “Well tell me whom to send and I will send them” I said. “I have one name, a Dr. ******.” “That doctor is not in our hospital” I told him. “She is in the hospital across the road, affiliated to our college. Call that hospital and ask for her.” “All exams are conducted in our hospital, not outside the hospital.” He said. “I have been here since 1975” I said in a level voice, counting my undergraduate years as well, but not saying that in so many words. “Exams are conducted in that institute as well.” “Well, if examiners do not come and correct the papers, I will return the uncorrected bundles to the university saying the examiners were not available.” Now he was threatening me. He was a typical "Babu" angry with the work given to him, afraid of higher people and all too ready to threaten others to protect his own skin. I did not know why he was unwilling to call the concerned examiner. “You cannot say that truthfully. You know that person’s name. You know where she is. Ring up and ask her to correct the papers” I advised. “So I ring up medical superintendent of that hospital?” he asked. So that was the fear. He did not know how to call anyone outside the hospital. He could just dial the intercom. “That is right” I said and went back to my patients. I wonder how he managed to get a faculty position in our prestigious institute, even if in an unimportant department as far as patient care was concerned. Merit seems an unlikely method.

Demonstration of Errors

It was a demonstration of a fetal monitor to be purchased for my department, if found to be satisfactory. A young engineer from the company had brought along the equipment. He connected the cables and power cord and started the demonstration. He started showing various parts of the instrument. “The transducer has both of its surfaces looking similar. How do you know which end goes on the maternal abdomen?” I asked. “This is a demonstration piece. In a marketed piece, we put a sticker on the outer surface” he said. “And it is stuck with Feviquick” I said. The over-spilled sealant was clearly seen along the joints. He looked at it with nonchalance. After looking at the machine for some time, we decided to see if it actually worked when connected to a patient. So we got a patient who needed a nonstress test and he put the transducer on her abdomen to pick up the fetal heart rate. The machine started making appropriate noises but there was no tracing on the LCD display. “There is no tracing” I said. So he started fumbling with the machine. He connected and disconnected the cables. Finally the display was seen. “Show us the recording” I said. “Where is your printer?” I have not brought my printer. Your printer will do. It is compatible with my machine.” “I need to see if your printer is OK for purchase” I said. “I already know our printer is OK.” He ignored me. He did not seem to know that ignoring the buyer was a no-no for a sales person. He started the recording, and the machine went blank. “It has gone blank” I said just to let him know I had understood what had happened. “If you start recording simultaneously, it takes some time to start” he said. Funny. All the machines I had used before could do both things right from the start. “How much time?” my lecturer asked. “Um ... some time” he answered. “The volume is low” I said, after I had adjusted the volume control knob to the highest position. “It is low with some babies and high with some other babies” he said. I did not press the point. “Where is the twin recording facility?” I asked. “I have not brought it for demonstration.” he said “It is not commonly asked for. If anyone wants it, we give him a smaller separate unit.” He mimed showing a smaller unit next to the one he was showing us. “Its additional advantage is that you can use it as an independent unit if you want, on another patient at the same time”. “You mean it is not connected to this machine and the record does not come on the same paper?” I asked. “No.” “Then I can use just one machine, first for the first baby and then for the second baby. Why would we ask for a machine with twin monitoring facility?” He must have thought we all were retarded. He repeated his previous answer again. “I think he thinks I am so old that I will believe anything he says” I said conversationally to our hospital engineers. “Or perhaps he believes I am so old I will not understand anything.” He ignored me. Perhaps he did not know I was the buyer. “Your product's finish is also not good. See, the stopper on the power pin has not been pasted well.” “That is because this is just a demonstration piece. The marketed piece looks really good” he said. That was the last straw. He really did not know marketing. “See, when there is a marriage proposal, the boy and girl try to look their best when they meet each other. They cannot think of looking shabby, saying they will look good after marriage. Think of your machine like a bride or a groom. If it does not look attractive, no one will fall for it.” I knew I would not get even thanks for my free advice. But I hoped he would understand the value of the advice if he wanted to be successful in marketing.

Attitudes 12

The old woman had undergone a hysterectomy in another hospital. They realized she was bleeding inside late evening. They transferred her to our hospital in the night. Our people found she had a severe hemorrhage inside. She required urgent treatment to stop that bleeding. They contacted the Associate Professor at 2:30 A.M. There was no one experienced enough to open her abdomen in campus. The lecturer had completed her 3 months of maternity leave and was absent without sanctioned leave despite reminders to join duty. Out of six posts of lecturers, only one was filled. The others were kept vacant because the machinery could not fill up two of them for reasons unknown and three because they felt they were forced to keep them vacant since they were due to ad hoc promotions of concerned lecturers. The fourth year residents did not feel confident of handling the emergency. The AP advised embolization of the bleeding vessel by interventional radiology. It was done. When I reached the hospital in the morning, I learned about all this. The patient was in the OT and so was the AP. I asked them what was being done. “I have asked them to explore her: the AP said. “But she underwent embolization of the bleeding vessel successfully” I said. “Why explore her now?” “She had a large amount of blood inside. It has to be removed. If not, it may get infected.” “But she had all that blood inside her when you got the embolization done” I said. “If you were going to explore her abdomen anyway, why did you get an embolization done? That was undue intervention, will all the attendant risks and expense.” “That is correct” said the AP. “But it was 2:30 A.M. I could not come down that time from my home in the suburbs. So I advised embolization in the meantime.” I was appalled. “But I would have come down if you could not” I said. I stay nearer to the hospital than you do.” The AP did not say anything to that. I remembered coming down like this a number of times in the past because another AP could not come down. I hope they remember what I said and act accordingly in future.

Calls for a Purpose

I got a call from one of our Associate Professors at 12:30 P.M. “Sir, this regarding the meeting we hold for every new batch of residents. We have not held it for the current batch.” There was no need to call me for that. It could have been done when we met in the staff room, as we often did. “All residents have not joined yet. Let us wait until they do” I said. “Yes, of course” the AP said “ I am just saying we should prepare for that”. “OK” I said. I got another call from the same AP at 1:45 P.M. “Sir, this is regarding the workshop we have to hold for the new residents, explaining the breastfeeding details.” “The pediatric department holds it every year. Why do we want to duplicate the effort?” I asked. “They call only two residents. We have many more.” “OK, Do it after all residents join duty” I got a third call at 2:30 P.M. It was for some equally minor thing. I wondered what it was. Normally all such matters are discussed during staff members' regular meetings. Three calls in such a small period was something unusual. At 3:15 a new resident came to see me. She had got admission for postgraduation in another institute for a subject of her choice and wanted to be relieved from our institute. “Sir, I wanted to get my boss' signature, but the boss seems to have gone to another institute for a meeting. So the clerk sent me to you directly”. I signed her application. I had had three calls from the AP, but the meeting was not mentioned in any of the calls. Suddenly it was quite clear why I had received so many calls in a short time. It was my psychological preparation in anticipation of a planned departure before closing time.

Attendance in “Bandh”

The opposition parties called for All India “Bandh” (stop all work) to protest against hike in petroleum products prices. The public transport was to keep working. I took a bus and reached the hospital before time and started working. I discovered that a number of my staff members had not come, and later found out that they would not come. So I arranged for the emergency services to be looked after by those of us who had managed to report on duty. I was conducting the outpatient services simultaneously. Some time in between, a fellow from the administrative office called. He wanted a list of all those who had reported on duty. “None of my clerical people have come. How do you think I should generate the report?” I asked the fellow on the phone. “Well, others are sending that information” he said, implying it would look bad if I did not do so. So I stopped working long enough to call places and finalize the list of persons who were present. I got the hand written list sent to the administrative office. Later when the flow of patients slowed down, I called the same fellow again. “I have sent the list of people present” I said. “Please tell me why you need the list.” “Why?” he could not understand the question. “The Director wants the list. He has to know who have come on duty and who have not.” “OK. But I want to know the purpose. Are you going to send people where there is a shortage of persons so that services can be given efficiently?” “Well, if you ask the Director, he may be able to do something about it. Do you have a shortage?” “The staff members in charge of the emergency OT have not come. The staff member on emergecy duty has also not come. I have arranged duties of others so that the work will be looked after by those who are present. Now I want to know why you need that list today. It could have been sent tomorrow when the clerks come on duty.”. “Well, it is required to give information to the media- newspaper reporters, TV reporters etc.” I suddenly understood why we were asked for the list of persons working in situations like this and in strikes of municipal employees and resident doctors. Those working to give healthcare had to keep that work aside and generate a list of attendance not so that additional help would be given to them if required, but to brief media. The world had to know who won politically and who lost.

Architects, Civil Contractors & Maternal Fetal Position

It probably cannot be imagined how architects and civil contractors can have anything to do with maternal position. Maternal fetal position also seems to be a new concept. Well, the unthinkable unknown has been achieved by our architects and civil contractors. They were responsible to complete our building's repair and renovation work in six months. It is already nine months since they moved us out of our seven wards to a transit area of one and two thirds wards. The number of patients in our wards has either remained the same or probably increased over this time, keeping pace with increase in the population of the country. There are often two women on one cot in the postnatal ward, along with their respective babies. The only way two women can lie down and sleep on one cot is by assuming fetal positions along the width of the cot. Their babies lie in supine position between them. If the babies were awake long enough and could understand positions, they would wonder why their mothers had adopted the position that they themselves have given up after birth.