Being Back To Work

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

100 New Medical Colleges

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

Vacation Calls

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

Take a baby Home or All Your Money Back!

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

Partogram: Update

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

Age of Retirement

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

Diplomate Struggle

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

Attitude 11

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

Placenta Previa: Who Changed the Definition

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

Trafficking Women

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

Ethics Fee?

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

Women Achiever Award

I received a letter from one International Friendship Society that my name was under consideration for their 'Women Achiever Award'. They said they were quite confident about my meritorious services and achievements. Then they requested me to send my biodata highlighting my achievements and latest photograph. They had attached a pamphlet showing color pictures of some people receiving such awards. There was description of the Society too. I read the details and found that amongst the many objectives of the Society, the following was included. 1.To enroll members throughout the world among people of Indian origin. Recipients of honor will be members of the Society. 2.To collect a most reasonable delegate fee from the Awardee, in order to raise the necessary funds. The delegate fee, however, is strictly voluntary and no delegate is under any obligation to pay. 3.The Society reserves the right to present or reject the Award even after selection of the candidate without assigning any reason whatsoever, without being answerable to anyone. I discovered subsequently that many of our staff members had received this letter. I had received similar letters in the past, but the award had not been only for women at that time. It seemed they did not know me or anyone else in my department. They thought I was a woman! They probably got faculty names from some source like our website, and sent us letters. They had not selected us for the award based on our achievements, because they did not know the achievements. They wanted us to tell them about our achievements. As I saw it, I had to pay membership fee so that I would be eligible to receive the award. Then I would pay the delegate fee to receive the award. It was not mandatory, but then they held the right to refuse the award. Perhaps if I did not pay the delegate fee, they might refuse to give me the award for no reason (though not that reason). Then I lost my membership fee. They had not specified how much the membership and delegate fees would be, not what the award would be. If the award was a certificate, the fee being in money form I would make a net loss equal to the amount I paid, plus my travel and accommodation to the city where the function would be held. This letter achieved a few things. It told me how some Societies functioned. It also told me how one of our previous Deans had 48 awards, from people whose titles I had not even heard of.

Placenta Previa on USG

My Registrar informed me on ward round that one particular patient at term presented with antepartum hemorrhage. Her ultrasonography revealed the placental edge to be 2.45 cm from the internal os. "So is that placenta previa or is it not?" I asked. "It is not" she said after deep thinking for six seconds. "Find out the correct distance from the internal os, beyond which it is not placenta previa at term" I said. "In the meantime treat as type I placenta previa." That gave me an idea. I decided to conduct a survey, using one question. I called my four Assistant Professors (formerly called lecturers) and asked them the same question independently. The answers were 2.5 cm, 3 cm, 5 cm and 2.5 cm. Then I talked to all the Assistant Professors in the department and asked the same question. The answers ranged from 2.5 cm to 6.75 cm. I was amazed that on such a basic issue there was no consensus. I do not perform ultrasonography myself. But I know that the lower segment lies below the line at which the peritoneum on the anterior surface of the uterus ceases to be firmly adherent to the uterus and gets reflected onto the urinary bladder. Thus when the urinary bladder is full, if the placenta is found to extend below the upper limit of the urinary bladder anteriorly, it is previa. The distance between the internal os and the upper limit of the urinary bladder is the length of the lower segment in that woman at that gestational age. It can then be applied laterally and posteriorly to diagnose lateral or posterior type I placenta previas. I think the term 'low lying placenta - not previa' is superfluous, because if the placenta is not previa, it does not matter whether it is lower or higher.

Big Shot Language

I am used to writing complete words and complete sentences. Younger people write SMS language. I had a resident doctor who in the first week of her residency in my unit wrote that an infertile woman and husband were 'staying 2gether' while filling up the patient's case paper. There are others who use even more cryptic language. We have a third variety of people in the hospital who write words in places of sentences and those words often exclude letters. We had a Dean once who would write 'Pl sp' on letters sent by us. We learned gradually that its meaning was 'please speak'. Perhaps it suggests strongly that the concerned person is so busy that he or she cannot spare the time to write complete words and sentences, leave alone grammatically correct English. Since we had no option but to suffer this, we suffered. But then that Dean's subordinate officers caught on and started doing the same. It gave us occasions for hearty laughs. I had received a letter from an administrative officer asking for my remarks on some request from a small time vendor. It had to do with sale of items required by newly delivered mothers and babies. I wrote back extensively covering all legal aspects of the same. Then I wrote that we did not have space owing to repair and renovation work going on in the department. The letter came back to me with 'pls rply' with a cross next to it, and also at the place where I had written about the nonavailability of space. I could not understand the meaning of this remark of an elderly administrative officer (i.e. Non-SMS generation person). I also could not understand what was not clear to this person when I had answered the original letter in grammatically good English and more than legible hand. So I wrote back 'I cannot make out the meaning of the remark. Please clarify.' I could have wasted a lot of time trying to get this person, then more time telling him what it was all about, and then getting some wise remark from him. My stress level would mount, and happiness reduce proportionately. I think I did very well, considering my consistent track record of catching the concerned person immediately and debating the issue with an intent to win. Now I understand that I have to go the level of the person I am dealing with.

Footwear And Us

A few years ago I was taking a round with my unit doctors. We reached labor ward. We had been repeatedly telling the all doctors and other personnel not to mix street footwear with labor ward footwear so as to minimize contamination of the labor ward. But either they would not remember it, or did not care or did not think it was right. When I found street footwear of some woman doctor (nurses have white shoes) in the labor ward, I decided to settle the issue. I asked who it belonged to, but no one would own up. I lost my patience. I picked it up, and threw it out of the window. The ward was on the ground floor, but the window was grilled. The owner would have to go out of the building and around it to retrieve the footwear. I requested the nurse on duty to tell the owner who came asking for it that I had thrown it out of the window as a disciplinary measure. The practice of carrying street footwear into the labor ward stopped for some time after that. In our temporary labor ward in the transit area, we have placed two racks in a row. The first one is for street footwear and the second one is for labor ward footwear. The instructions are not to place footwear on a rack meant for the other type. A couple of weeks ago I noticed street footwear of a woman doctor on the other rack. No one in the labor ward would own up. Since the ward is on the first floor, I did not have the heart to throw it out of the window. So I threw it behind the rack for the street footwear. The concerned person would have to search for it for some time, and that would be punishment enough, I thought. All of the doctors in my unit watched me do this, and got educated, I hoped. Apparently they did not. Today I found a fancy looking woman’s footwear on the wrong rack again, while the labor ward with my unit doctors. I picked it up and was about to throw it behind the correct rack, when my new Assistant Professor stopped me and said “Thank you.” “Is that yours?” I asked. “Yes” she said. I wonder if she thought I was being nice by picking up her footwear for her, though there was no reason for that. The direction of movement of the footwear in my hand was clearly to the back of the rack. I gave it to her and said, “The next time I find it on the wrong rack, I will take it away. It won’t fit my feet, but still I will take it away.” “Yes sir” she said. I hope she does not do it again, because I really don’t know what I will do with her footwear if I have to keep my promise and take it away.

Wrong Person To Mess With

“Sir, we have a problem.” It was my job to listen to people and suggest solutions to problems reported. “What is it?” I asked. “We have this first year resident doctor, who is creating problems. He is extremely irregular in his work. He disappears on his on call day. Then the other first year resident ends up doing his call. The seniors have told him not to do that, but he does not listen. The other houseman is tired because she is overworked. Finally she complained to me. Now she has disappeared too.” “That is a serious matter” I said. “But that is not all. The really serious matter is far worse. He has threatened a patient and also the other houseman.” “What threats had he given? I asked. “The patient he threatened was undergoing daily dressing for wound breakdown. That day he told the patient to say that he had dressed her wound, if asked by a senior doctor. He said he would dress the wound an hour later. But he never went to do the dressing. The patient's relative reminded him repeatedly throughout the day, but to no avail. Finally he threatened the patient he would slap her.” “Did you ask him for an explanation?” I asked. Threatening patients was criminal behavior. “Yes. He said he did not actually mean to hit her. He just said it.” “Verbal threat is as bad as actually hitting someone” I said. “What about the threat to the other houseman?” “She has run away, so I cannot get any information from her. But the others who were present that time said that he said 'You have messed with a wrong person' to her.” That sounded like villain from a B or C grade movie. The said houseman was from a wealthy family, with highly qualified parents. This sort of behavior was not expected from a doctor, that too from such a family. “Give him a memo for running away from duty” I said. “We will send a complaint to the administrative office when we get a complaint from the houseman he has threatened.” “He seems to be psychotic” the said boss said. “I am inclined to agree with you” I said. “Oh God! Why do I land up with resident doctors with psychiatric disorders all the time? They keep troubling me so!” That must have been due to bad luck. Actually this boss was quite strict and had good control on the resident doctors. “Deal firmly with him” I advised. “Let him understand he is messing with the wrong person.”

Give and Take? Nah!

“Sir, we have only one electrocautery in the operation theater” the sister of the emergency operation theater told me. That was bad. We had two OT tables, and needed two machines at a time. I had done my three year residency working in the same OT without a single cautery in early eighties. But that did not mean we should go back to that time. “Have you condemned both the cautery machines that the engineers said were not repairable?” I asked. “Yes, and they don’t have any spare cautery machines to lend us.” “I have processed for purchase of two new machines” I told her, “but you know how long it takes the corporation to purchase anything because of the complex procedure involved. Why do you not try to get one on loan from another OT?” “I will ask other sisters” she promised. A couple of days later, she found one. “The XXX OT sister has a spare machine. She will get permission of the head of department and then lend it to us” she said. I knew we would get the machine. I had lent a box packed cardioscope with defibrillator to that OT because they had none and their OT would have closed down without one. They had kept it for two and a half years because they could not procure one. It broke down. Finally they gave us a new one when they got their new machines. Another couple of days later the sister had bad news. “Their head of department does not want to lend us the machine” she said. I called the XXX OT. The sister took the phone. “Sister, good morning” I said “I am the head of Ob Gyn.” “Good morning” She said. “Sister, how many electrocauteries do you have? I asked. “Six, four for the four OTs, and two spare ones. One of them gives an electric shock, but the other one is fine.” “Then why don’t you lend us one” I asked. “Our head of department said we will wait and see if we would need it.” “Do you remember you borrowed out brand new cardioscope for two and a half years, without which you would have had to close down the theater?” I asked. “Yes sir” she said. “Is your head of department there?” I asked. “No, she has not come in yet” she said. I should have expected it. The seniors in that department were known to arrive by 10 to 10:30 A.M., not 9:00 A.M. as required. They were probably privy to the information that the biometric attendance system was not operational yet. “Please tell her that I said she should have lent us the cautery machine to reciprocate what we did for her department and the patients seeking care in this hospital. Please tell her that I will put all this on my blog too” I said. “Yes sir” she said. I knew she would do it, from the happy note in her voice. I also knew I would still lend another piece of equipment to that department if requested in future, because it would be for the benefit of the patients coming to the hospital for healthcare, and it would have nothing to do with behavior of ungrateful people.

Ringtone

“Has anyone lost his cell phone?” our AP asked in a loud voice, drawing attention of all in the OT. Several heads turned, but no one responded. She moved to another part of the OT and repeated the question. It was met with the same response. She went to the adjacent OT and asked. There was no answer. She came back. “Have you found a phone that no one claims to be his?” I asked. “Yes, I am waiting for someone to turn up asking for it.” “Why don’t you call yourself using that phone?” I said. “Then you will get that person’s number.” “I did. It is an unknown number.” Then I had an idea. “Call that number using your phone. The owner will hear the ring tone and come running.” She was skeptical, but she tried that anyway. The owner did not come running. He just came along looking around for the source of the ring tone, and started going away after seeing a group of senior staff members from amidst whom the sound seemed to be emanating. She stopped him and asked him if he had lost his phone. “Yes” he said, “Sorry Madam.” He took his phone from her. The ‘sorry, Madam’ sounded like a resident doctor, they kept saying that. “Who are you” she asked. “I am a resident in neonatology” he answered. Times have indeed changed. Now people do not hear other people talking to them, but they hear ring tones of distant people calling them on mobile phones.