Honorary Clinical Clerk

A part of the work of an intern is to write clinical histories of patients attending the gynecological outpatient clinic. It is not very interesting, since most of the interns are not interested in the subject, and those who are d not get to examine those patients. So it becomes a mechanical job. I like writing histories, because I know that a diagnosis can often be reached from the history, and examination is required to confirm the diagnosis. Investigations are required in a small fraction of the total number of women attending the clinic. Sometimes I write histories when there are too many patients in the clinic and the interns and house officers do not seem to be able to cope. When one colleague mentioned that one particular honorary gynecologist in another hospital run by the corporation used to sit in the outpatient clinic and write down patients' histories, I thought the reason must be one of these two. “I used to feel quite awkward when he would sit there and write histories. I was quite junior to him. So I would offer to write the histories myself, and let him examine the patients. But he would not listen to me.” “Why did he write histories himself?” I asked. “He would write histories and then give the patients the address of his private clinic, so that they would go there.” Good grief! The fellow was stealing poor patients from a corporation hospital to flourish in his private practice. Then I recalled the stories that this same honorary used to write scientific papers over weekends using imaginary data, when he was an assistant professor in another hospital run by the corporation. I also recalled the time we were examiners together when one medical student who had refused to accept his private tuition for a fee had been given just passing marks by him as a punishment. I could not do anything about it, because I came to know about it later, and anyway there was no provision for changing anyone's marks given by another examiner.

Reserve a Bed

It was late evening. My doorbell rang. "Hello." He was an old friend of my late brother. "Come in" I said. "Come in" he said to the person accompanying him. Both of them entered and sat down. "This is the uncle of the patient who was under you treatment." "I was the person who rang you up today" the other fellow said. I remembered. I was working in the OT when he rang up and told me one of my old patients was coming to Mumbai. I had told him to take her to the emergency room in the hospital. Now here he was at my residence. "Has she arrived and gone to the hospital?" I asked. "No. She is on a bus. She will reach the hospital at night." "I have told the resident doctors to see her and do the needful" I said. "What do you want me to do now?" "Umm... well. We want you to reserve a bed for her at the hospital." I laughed. "This is not my private hospital that I can reserve a bed for her. My department is under repair and my patients from seven wards are put in 1.67 wards. AT present there are three patients on one bed in the main ward. I am out of my department building and the Boss has given me, the head of department no place to sit. He had told me bluntly that no one would have any office during the repair work. The Deputy Dean has given me desk space in the bill section where I have been sitting to do paperwork and computer work for more than a year. If I as a head of my department has no right to any space, how can I reserve a bed for a patient who has not even reached the hospital. Take her to the emergency room and we do the best possible thing. If you want a reservation, you talk to a politician or administrative boss." They went away. I found the next day that she was admitted at 2:00 A.M. and was sharing a bed with two other women. She was receiving required medical treatment as promised.

Attention Deficit Disorder: 6th Post Syndrome

Residency is of three years for those seeking a postgraduate degree in medicine. It comprises of six posts of six months each. A lot of them take a long time to get adjusted, and hence their abilities as clinicians get restricted in the first six months. But that is because of the pressure of something that they have not experienced before and an inability to cope. It has nothing to do with any deficit in attention. When they start their last post, they develop a syndrome which we call the '6th Post Syndrome'. In this syndrome they are physically present in the hospital, though their minds are elsewhere. There was a time when they used to go on French leave in some units. When we became senior enough to control this, we held a joint meeting and decided that no unit head would permit this. Then they made their juniors function as Registrars just remained present for the rounds, not doing any work actually. That was detrimental to their training. So we stopped that too. Now they work until they can go on leave to prepare for their exams. But their attention is on their dissertations, reading for exams, and perhaps some other things which are not academic. The following example of morning round of the wards should illustrate this point. “Sir, this patient has preeclampsia. Now her blood pressure is under control.” “What are the results of her anticardiolipin antibody and lupus anticoagulant tests?” I asked. “She has given negative consent for undergoing those tests. She cannot afford those tests.” “Why do you not undergo those tests?” I asked the patient. “I don't know which tests” she said. “I have not been told about any tests.” “Sir, her husband was told and she was present there. He said he did not have money at that time” the Registrar said. “But now he may have money. Have you asked again in these many days after her hospitalization?” “Umm... no sir.” she said. I advised the patient to talk to her husband and then tell us if she would get those tests done. “Sir, this patient is seven months pregnant. When she came, she had fever and her Widal test was positive. She received treatment for typhoid, and now her VDRL test is negative.” “VDRL?” I asked. “Umm... sorry sir. Her Widal test is negative.” “OK.” “Sir, this patient has undergone anterior colporrhaphy yesterday morning. Her input was 25000 ml and output was 1650 ml yesterday.” "How did you transfuse her 25000 ml in less than 24 hours?" I was aghast. "Sir?" "25000 ml input is unbelievable" I said. "Umm... no sir. It was 2500 ml." Then I remembered. This same Registrar had once said a patient's input had been two thousand sixteen hundred in 24 hours. “Why is she still on intravenous fluids? Why have you not started oral intake?” I asked. “Her peristalsis are feeble.” “Why did the peristalsis become feeble?” “....” “Sir, this patient underwent a hysterectomy. The one who underwent anterior colporrhaphy is the next one” the Assistant Professor said, to avoid further unnecessary discussion. I examined that patient, gave appropriate instructions, and then moved on to the next patient, who had undergone anterior colporrhaphy. She was also on intravenous fluids. “Why is she still on intravenous fluids? Why have you not started oral intake?” I asked. “Umm... sir, we keep them nil by mouth for 24 hours after major surgery” the Registrar said. I checked her. She had good peristaltic sounds, and that was no surprise because there was no reason for the peristalsis to get affected. I advised to start oral liquids for her. I had taught all of them this point in past, but they seemed not to retain any information given to them.

Rest Room Approach

Rest Room Approach I had read a couple of books that highlight the fact that women and men think differently. I knew it was right, and that was the reason of many marital conflicts. One of the books gave an example which said that it was perfectly normal for a woman to ask another woman “I am going to the rest room. Would you like to go too?” The other woman finds nothing abnormal in that and they happily go there together. It further stated that a man would never ask another man this question, and if he did, the other one and others listening in would think he was crazy. It stated that the woman used this opportunity to talk, empathize, interact on different issues etc. I never could confirm this, because they don't say this in front of men. I am proud to say that my institute has given me that opportunity. They have been repairing the building where my department was. It has been going on for more than a year now, and in the meantime they have given me desk space in the bill section. This room and an adjacent room have a joint rest room for women. The rest room no less unattractive and unclean than most of municipal facilities. There are doors opening into both the rooms. The procedure is that if anyone goes into the rest room, she locks the other door from inside for the duration of use of that room. Thus no other woman surprises her by entering it accidentally. I don't see the purpose of this arrangement, because solo entries into that room are practically unknown. Usually the employees enter this restroom from the adjacent room because in our room there is a male clerk and me, and they probably find it uncomfortable passing in front of us to such a destination. But occasionally the women in the adjacent room lock up their room from inside or outside, and then our room is the only access point for the other women. Usually they go there is pairs. But for the last two days, things have been different. They have a workshop of some sort in the auditorium on the third floor. Yesterday, five women came together and went into the rest room. The noise made by two women is within reasonable limits. One can continue to work though the efficiency is reduced. But five women made so much noise, that we had to stop all work and do deep breathing to control the blood pressure. Today seven women marched in. I wished I had ear plugs. I wonder how they can be so merry in such a small and so unclean a space.

Attack

“Do you have one Dr. XXXXX in your department?” It was my classmate from college on phone. He has a flourishing dental practice. “Yes, what about her?” “She has been maligning me” he sounded upset. “What happened?” I asked. “I had a patient. She underwent a tooth extraction in my clinic and went home. Half an hour later, she fainted. This Dr XXXXX has her clinic next to that woman's residence. So she was called. She saw this and said it was an attack. Then the relatives gathered in my clinic and accused me of negligence so that the patient got an attack.” “What attack?” I was puzzled. “Attack as in a cerebrovascular accident or heart attack” he said. “The word 'attack' means this to these people.” I thought about it a bit. It was too late for being a vasovagal attack. But then I remembered this professor rushing to every one who fainted in the department and calling it vasovagal attack. That clicked. “She must have meant a vasovagal attack” I said. “She has a thing about vasovagal attacks.” “Oh God!” he said. “She should specify that. Now she has instigated my patients against me.” “Explain to them what I said, and everything will be alright.” “But she should not do such things” he protested. “Keep safe distance” I advised. “I do the same thing myself.”

Delayed Vasovagal Attack

My wife told me about a small boy who went to her clinic for a booster shot of a vaccine. He was five years old. His mother and grandfather were with him. The grandfather waited in the waiting room, while the mother took the child into the examination area and put him prone on the table. She moved his shorts down and my wife started giving him the injection. He had not been aware till that moment that he was to receive an injection. So when the needle touched him, he screamed, threw himself in the air, and became uncontrollable in general. So the grandfather was summoned, who helped hold him down and then the injection was administered uneventfully. But the child did not forget the insult easily. He continued to bawl. The mother cuddled him, spoke sweetly to him, distracted him by telling him about other things of interest. He would become quiet for a few seconds, and then remember the whole matter and start bawling again. Five minutes passed like this. Then the bag held by the mother slipped from the mother's hand, the bottle of medicine fell on the floor, her eyes rolled up, and she followed the bottle to the floor. The grandfather panicked and requested the doctor to put some medicine in the mother's mouth. The doctor reassured him, put her flat with her head turned to one side, and sprinkled some water on her face. Then the mother gradually came to. A history of fear of dispensaries was obtained retrospectively. One good thing from the mother's vasovagal attack was that the child's bawling stopped instantly, and did not start again even after the mother was revived.

Spinal Level Work

I started my residency in 1981. The first post I did was an incoming post meant for future anesthetists, for one month prior to regular residency, which I wanted to do because I knew I would get my Registrar’s post after one year of house job, and would not do any allied posts. I wanted to learn CPCR and spinal anesthesia. The Head department of anesthesiology was very kind. He gave me the post even after the last day for application had gone. I owe him. I learnt what I wanted to, and also a bag of tricks that anesthetists believe the surgeons know nothing about. There used to be a guy in anesthesia those days, who used to induce spontaneous GA, but the patient on inhalation agents ventilating self, and go and sit in the anesthetists room while the surgeon performed laparotomy. That was his laziness to give controlled GA, which was a lot of work. These days I find anesthetists who want to give spinal anesthesia for everything, so that they don’t have to give GA. Ventilating patients is a lot of work. They showed me as a reference a line in the footnote of a chapter on anesthesia for laparoscopy, that spinal anesthesia was a possible form of anesthesia for that. Now they give spinal anesthesia for all of our laparoscopies. Some patients scream with pain, because it does not block shoulder pain from irritation of the diaphragm. They ask us to instill local anesthetic into the peritoneal cavity for relieve that. If the patient still howls, they give GA. God help the patient if she develops a complication like a vascular injury or gas embolism under spinal anesthesia. They have a double standard. For laparoscopic sterilization they give general anesthesia, because they are scared of inquiry by a governmental agency if anything goes wrong. A remark in this connection made by a staff member is very amusing. “They give spinal anesthesia for everything except a craniotomy, cataract extraction and tonsillectomy.”

Saviors in Green

People go abroad and visit hospitals. They also watch medical hospital soaps on television. One of the chic things experienced is those dashing hospital personnel going about in scrub suits. Some of them are tempted to do such a thing in their own hospitals back home or at home, as the case may be. It is also more comfortable to wear scrub suits at work, because of higher environmental temperatures, and air conditioners being allowed only for ICUs, operation theaters, and offices of only officers who matter. It is also a nuisance when the people outside the hospital and at home smell hospital odors on one when one works in one's street clothes and goes home wearing the same clothes. That does not happen if one wears a scrub suit at work. It is troublesome to bring one's own scrub suit from home, take it back, get it washed and laundered and then use it again. The hospital does not provide scrub suits for this purpose. So the best way out is to use OT clothes for this purpose. For personnel working in OTs every day, it is very convenient. Those who work in OT only twice a week or so, it is possible at least on those two days. As a result, we see those men and women in green in our hospital wards, labs, and corridors frequently. I wonder if they don't realize that they have to use these OT clothes only in the OTs, and if they go out in those clothes they pick up microorganisms which they carry back to the OTs and contaminate them, promoting surgical wound infections. The doctors and nurses are trained to know this. The other employees have to be told about this by their superior officers, i.e. The doctors and nurses. Either they know and ignore it, or they don't know for reasons unknown, and continue to move around wearing green OT clothes. In the meantime, the unsuspecting public is thrilled to see these saviors in green going about their business, the saviors are happy to bask in the admiration received, and life goes on.

Waxing in Gynecological Residency

I suppose waxing is a well known method of removal of unwanted body hair. It has its place in the cosmetic therapy of hirsutism. That was the only form of waxing I knew until today morning. But my resident doctors are full of surprises and one of them gave me one today. It was a patient's consent for undergoing a gynecological operation. I had instructed them about the exact words to be used because it was an unusual case. When they showed me the consent before induction of anesthesia on that patient, I found that it was not as I had wanted it. I pointed out the errors, and explained why it should be in a different way. They promised to change it. A little while later I found my senior house-officer doing something I had not seen before. She had cut a 1.5 cm long and 5 mm wide strip of transparent adhesive tape that is usually used for retaining dressings. I could not imagine any use of such a small piece of adhesive tape. So I watched. She proceeded to put it firmly on the patient's case record sheet, and pull it away. She repeated this procedure twice. Then she put away the adhesive tape and wrote on the part she had doctored. Then it dawned on me that she had removed unwanted words from the consent and put new words in their place. An eraser is a thing of school life. An adhesive tape is an essential item for the resident doctors. So if it can be used in place of an eraser, so much the better. The tape pulls out a superficial layer of the paper on which it is applied and leaves a reasonably blank though thinner paper behind, on which corrections can be made. The expertise with which she carried out the maneuver suggested that she had done that many times in the past, and was quite good at it. That perhaps qualifies as lateral thinking.

"Sorry Sir" Syndrome

There is a new syndrome on the block. No matter which institute the students come from, they are affected by this uniformly. It starts in the undergraduate days, and continues in the postgraduate days. "Why did you not attend the teaching session yesterday?" "Sorry Sir." "Why did you run away from your duty in the emergency ward?" "Sorry Sir." "Why did you enter the operation theater without changing into OT clothes?" "Sorry Sir." "Why did you go out of the OT wearing OT slippers? Do you not know that it carries dirt and microorganisms into the OT and contaminates it, increasing our surgical infection rate?" "Sorry Sir." "Saying sorry does not solve the problem. What do you propose to do about it?" "Sorry Sir." There is a great book by Thomas A Harris - 'I am OK, you are OK'. It is on Transactional Analysis. It is a practical guide to using Transactional Analysis as a method for solving problems. As described by that author, I wish my students would respond to my adult questions with adult answers, so that the adult-adult interaction would produce results satisfying to both parties. Unfortunately no matter how much I try, they adopt the parent-child interaction. Then everything I ask is just a 'lecture' on bad behavior, to be suffered silently until it gets over, and the only response is "Sorry Sir." In fact it is I who is sorry, not them, that they suffer from this syndrome.

Laptop Table

I had always used a desktop PC, which I took pride in opening and repairing when it gave trouble. But I needed something smaller that I could put on my tummy while I reclined on a bed, and read my huge collection of books and articles. I wanted to buy an Amazon Kindle ebook reader, but there were no dealers in India, and I did not trust internet transactions with credit cards. So I bought a netbook, and it worked wonderfully. Unfortunately I realized by and by that its fans put out heated air from its undersurface, and it burned my abdomen. When I kept it on my lap, it burned the lap. I also realized that when I kept it on a table or a mattress, the heat would not escape readily, and would heat the surface it was on. I had to leave the undersurface open to let the heat escape. Then I had an idea. We had a folding container for newspapers and magazines. Its sides were of cloth and skeleton of light wood. I have drawn a rough picture to give you an idea. It is much prettier than that :-). I keep the netbook on its upper transverse bars, and sit under a fan. The warm air is easily dissipated. I keep the mouse and USB multihub in the cloth part. It has been working fine for quite some time. I thought about it when I saw an ad in the newspaper today. It was about a USB laptop table. It has two USB fans where the laptop sits. I wonder if those fans actually cool the laptop. My make-shift table cost me nothing as compared to 2100/- INR for this table, and my fan cools me and my netbook very well, while the USB fans of that table would never cool me. My make-shift table reminds me of my religion too. They used to keep their holy books on such tables (or stands) for reading convenience. Perhaps technology has taken me back by a century or so.

Prelunch Hand Wash

I heard that our clerical employees had become health conscious and were using a special hand wash prior to lunch. I got curious, and asked them to show what they were using to wash their hands. One of them opened the steel cupboard and produced the bottle of the hand wash solution. “This is the hand wash solution the doctors use after examining a patient, before examining another patient, so as not to transfer infection from the first patient to the next one” I said. “Yes. The nurse gave it to us. It is on schedule” they explained. “That is all right” I said. “Please read the ingredients of the solution.” So the person who had taken the bottle out of the cupboard took it from me and read the ingredients. “Dextropropoxy polyethoxy ... something, and ....something propanol... and ....” “Those are alcohol based antiseptics” I said. “There is a color added too. Please see if they are safe to be ingested.” So she searched the label of the bottle and finally said “the label does not say the contents are safe for ingestion.” “How long have you been using this hand wash prior to lunch?” I asked. “One month” they said. They seemed a little worried. “So you have been ingesting these chemicals for month. We don't know what are the effects of these on the human body if ingested. Perhaps you are chronically poisoned. Show me your hands” I said. The leader showed me both of her palms. “See these dirt marks? That dirt does not go away with this hand wash. You are ingesting all the dirt you pick up during your journey to the workplace and during your work too. Why do you not use soap and water instead?” “We were using soap and water in the past. But the nurse said ...” Perhaps they were impressed with the technology, which was supposed to kill all germs and resulted in dry hands. “I wonder if the nurse is using the same hand wash before her lunch and if so, for how long” I said. The nurse was not around, so I could not educate her. “Think carefully before you change your health practices.” “Yes sir” they said.

Mock Viva Fiasco

Education of undergraduate students is chalked out by the medical council and health university very well. However what exists on paper and what actually transpires are poles apart. We have these students who want self education or automatic (i.e. without learning anything) education. So they do not attend lectures and practicals. The Boss felt that we have to draw them back to clinical education and he conceived a novel idea for the same. He conducted mock viva for all students. They were put in an auditorium housing 300 students. Mock examiners and students were made to conduct mock viva, which was shown on two giant screens. The program was conducted by the surgery department. We could not do it last year because of H1N1 epidemic. This year the surgery department conducted the program again. I heard they had a bit of a problem getting students to attend. But the captive students doing clinical terms were caught and made to attend. Our program was scheduled after they finished their all clinical postings. We did not raise the money required through kind pharmaceuticals as suggested. We used our laptop, web camera, LCD projector, and existing audio system of the auditorium. The money for the equipment was our own money, not that of the corporation and not from pharmaceuticals. Our Assistant Professors carried the instruments and pathology specimens themselves when they could not find a servant to do it. One professor was program director who spent days planning and organizing the whole thing. I gave them my 3 D images of instruments and photographs of specimens, to be shown in addition to the actual instruments and specimens. We invited external examiners from a sister institute. All of our professors and associate professors turned up for the event. Then the waiting began. We waited for a half hour. Not a single student arrived. After we got tried and left, four students (one of them the class representative) arrived and said they could not get students to attend and could the program be please cancelled? Comments of different people on that occasion were as follows. “But the students are in the canteen, common room, and katta” the custodian said. “Could they not tell us in advance, so that we would not have wasted our time?” an angry professor said. “They are like that. That day there were only 8 students out of 180 for the Director's lecture” said the attendant. “We spent our own money on this. Now that is also lost” said another professor. “And Sir went to Lamingtom road to buy the web camera himself! Can't they understand” said an associate professor. “We are going to be their examiners. Let us be properly strict with them during the exam” suggested a senior professor. “I know that will not happen. The country needs doctors. So all examiners pass almost all the students, unless the students don't appear for the theory exam or keep their mouths shut during the viva. The people's health seems to be OK despite doctors of such quality. So what does it matter anyway?” said a cynic. “We will cancel the program. I will write to the director and inform him about the response to his wonderful idea. We will let the students learn such things only during their clinical postings in future, and if they don't attend that time, so be it” I concluded.

Publishers' Tricks

I had written a book on 'Conversation Games'. I wrote it because a lot of people played a lot of such games with me and that experience was more than enough to write it. The main problem with writing a book begins after one completes writing it. It is to find a publisher. The publishers of my medical books would not publish this book, because it was not a medical book and they would not be able to sell it. Then one day I saw an ad in a newspaper. It was about a psychology book being published by MaiXXXya Prakashan, written by a psychiatrist. I thought they would do, since they seemed to have done something in that field. I called them. After telling the guy on the phone who I was and what was the purpose of my call, he asked me what my book was about. “It is about conversation games. I saw your ad about the book written by a psychiatrist and I thought my book being from a similar field, you would be interested in my book.” “Come and meet me with your manuscript” he said. I met him. I gave him my manuscript. “I will call you with my answer in two weeks” he said and wrote that down on his acknowledgement slip. Two weeks passed and still there was no call from him. I knew the ways of book publishers and I decided to wait. I waited for four months and then I called him. “What is it?” he asked. “It is about the manuscript I gave you four months ago” I said. “Yes. I cannot do that book” he said. “Can I collect the manuscript tomorrow?” I asked. “No. I am a bit busy right now” he said. “That is OK” I said. “We don't have to talk. You can leave the manuscript with the receptionist. I will collect it.” “No. You don't understand. I am busy for 3 to 4 days. I will call you next week.” I could not understand how a fellow with a desk job could be so busy that he could not take out my manuscript from the drawer and give it to the receptionist. The next week passed without any call. Finally the receptionist called in the following week and said she would send the manuscript unless I could send someone over. I requested her to send it by post. I hope she does. When I thought about the whole thing more, I realized the only reason he got hold of my manuscript and kept it blocked for four and half months was probably to keep a book that could possibly compete with his book from being published, to cut down competition. I knew that was most probably the case, because something like that had happened to my son. He wrote two books on making aeroplanes by origami, when he was seven years old. There was a book in market, published by a 'JyXXXna Prakashan'. It was different from an origami book. It had models of card board, which were to be constructed after cutting them out of the book. When I contacted the publishing house and stated my interest, the guy called us, took charge of the manuscript and kept it for many months, before returning it with regrets that he could not publish it. By then he had sold his book well. My son's book were published by another publisher later. But the bad aftertaste of the dealing with the first publisher we had approached has still not gone away.

Alms

We were taking ward round when I noticed this guy. He was in his early sixties. He was carrying a plastic bag with packs of glucose biscuits. He was handing over one pack to each patient. The packs were small, probably carrying five biscuits each. What was peculiar was that he was wearing a face mask, as used by surgeons in operation theaters. He was probably afraid of catching some disease while distributing his biscuits. What was more peculiar was that his mask was covering only his mouth, while his nose was wide open. He had probably seen some of our surgeons operating, and thought that was the only way to wear the mask. Perhaps he had seen those monks of a certain religion who wear masks so that they do not harm even microbes. Those monks also wear masks over their mouths only. I tapped him on his shoulder. He turned around. “I am the head of the department here” I said. I want to talk to you.” “Is it about permission to distribute biscuits here? I have …” he said, his hand moving towards his pocket. “No. You must have the permission, or the Sister in charge of the ward would not have allowed you in this ward. I want to talk to you about your mask. You have to cover your nose to make it effective.” So he put up his mask over his nose. “Please do not give biscuits to patients receiving intravenous fluids. They are not allowed to eat anything” I told him. He took back the pack he had given to my patient receiving IV fluids. Then he went about his way distributing biscuits, and I went on to see my patients. Three days later I found him doing the rounds of the ward again, his mask below the nose. My Assistant Professor looked at my face, looked at his mask, and started tapping him on his shoulder to get him to cover his nose. “Wait” I said “don’t correct him. Probably he cannot breathe through the mask. He is wearing the mask for his own protection. His open nose cannot harm our patients. So let him be.” A month later, I found him again doing his thing in our ward. His nose was covered. I wonder who corrected him today. I also wonder if the patients are so poor that they happily take whatever is given to them, or they believe that he is a part of the hospital personnel. I also wonder if they realize that he thinks they have diseases he is afraid of and still have no self respect and take the five-biscuit pack that he hands out free.

Blink and a Lucky Save

That patient came to our outpatient clinic like any other patient two weeks ago. She was 50 years old. She had had abnormal uterine bleeding, and had undergone a D & C operation in a private center. She came to us with a report of severe hyperplasia of the endometrium. I found that she had a six weeks’ size uterus and no other abnormality. “Shall we post her for a hysterectomy, sir?” asked my resident doctor. It seemed a reasonable question. The treatment for severe hyperplasia of the endometrium in a woman above 50 would be hysterectomy. But I had a thought without conscious thinking, like that fellow Malcolm Gladwell had written in his famous book ‘Blink’. “She will need hysterectomy” I said. “But let us be sure that we don’t make a mistake.” “Mistake?” “Let us ask for the slides and paraffin block from her pathologist, and request our pathologists to report the slides.” The resident doctor arranged for that. The patient came back to see me today morning. She had the report given by our pathologists. It was ‘endometrial adenocarcinoma’. “If we had believed that first report, we would have performed a total abdominal hysterectomy and bilateral salpingo-oophorectomy on her. That would have been grossly inadequate treatment for her. Now she can undergo extrafascial total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic and paraaortic lymph node dissection.” I told my wife about this and said “was the woman lucky to have a correct diagnosis made before undergoing surgical treatment!” “She was lucky she landed up in your cabin at the first visit” she responded. “Umm…” I said and I think I blushed (at the age of 53!). “Don’t look uncomfortable” she said. “My patients going to public hospitals tell me about their experiences there. What I said was correct, not something said just to please you.” I knew she would never say something just to please me, not after 23 years of married life.

Chocolates to Lower Tempers?

I was busy seeing patients in the outpatient clinic. The nurse called me to say that the building repair contractor had come to see me. So I went out to the waiting hall to see him. He was one of the supervisors of the building repair and renovation work appointed by the contractor. “What is it?” I asked. “I have brought chocolates for you, sir” he said. I looked at the bag he proffered. It was a white nondescript paper bag. “Why?” I asked. “Season’s greetings” he answered. “Oh! I would be happier if you had finished our work in time and that too satisfactorily” I said. “You are six months behind schedule, my patients are being denied adequate treatment because there is no space and no OT facilities. The complaints I had lodged are ignored.” ”We do whatever the architect tells us to do” he said. “So you are connected with the architect, not us. Is that right?” I asked. “Yes.” “Then please give the chocolates to the architect” I said. “I thank you for the offer, but no thanks. You might have a spy camera in place of one of the buttons on your shirt, or another person near the door might be video recording the whole thing as in a sting operation. This bag may be said to contain a bundle of bank notes. I do not want it claimed that I was given a bribe to overlook the deficiencies in the repair and restoration work.” He seemed surprised at that, but thankfully he went away. “Did you really think there would be a sting operation sir?” asked one of our professors when I related the story later. “It was possible” I said. “We are small fish. We are not give bribes on a regular basis like they are said to do to politicians and administrators high up. Giving us chocolates costing 50 to 100 rupees must be enough, compared to 20-50% of the total budget to those who are in control. If we are not appeased by the chocolates, they could always hold the threat of the recording of the sting operation over our heads.” Now I wonder if I was right or just paranoid.

Architectural Wonder in Our Hospital

“I always knew the architect appointed by the corporation as a consultant would be as wonderful as any consultants employed by the corporation” one of our professors said. I was surprised. I did not know for a fact that consultants employed by the corporation were always so wonderful. Furthermore, I was aware of the goof-ups of the current ones, so that I was surprised to hear from one of ours that he was so wonderful. “What happened that you are now convinced that he is so wonderful?” I asked. “He has removed the front wall of our offices. He has put a wooden partition there.” “That may be because there is a shortage of sand. He must not have been able to put a brick wall there” I offered. “There is no shortage of sand now” came the answer. “I think he has done that to make the rooms look stylish. Don’t you know that they have wooden floors in stylish places these days?” “I have seen wooden floors in some posh places. But those were floors. He has put walls” I said. “That is a modern concept. It is a concept of lateral thinking.” I had read de Bono’s ‘Lateral Thinking’. This did not seem to be anything like that. Our professor was being sarcastic, I decided. “But that is not all. He has left a huge open space in the front wall, where he is going to fit transparent glass.” “Huh?” I could not say anything else. Anyone could break that glass to enter that room and steal the contents. If there was a bomb blast (our hospital is on the hit list of terrorists and hence they have closed almost all gates) the glass shreds would kill the people inside. “He has recessed the front wall to make the room smaller. Then he has put a storage cabinet outside the door.” “Outside?” I asked incredulously. “Yes. He says that will be OK. He is putting a lock on the cabinet.” So when we had to get anything from the storage cabinet, we had to out of the room. If anyone wanted to steal anything from the cabinet, all he had to do was to kick the door of the cabinet or break its flimsy lock with a pointed object.” “I agree with you” I said. “The architect is indeed is corporation class.” “The process of selection of such architects must be very complex” said another professor. “Yes. Many factors must be considered in that process besides architectural abilities” I said. “No sir. Let me put it in a correct form. Many factors must be considered in that process other than architectural abilities” said the first professor. “Can we not protest?” asked the other professor. “I have protested enough” I said. The letter has been sent to the chief engineer of the corporation.” “What is the outcome?” “The usual – no response.”

Perks of an Honorary Professor

“Sir, did you know they are putting up a multispecialty hospital at Andxxri and giving very good salary to even resident doctors?” “Yes. It is twice as much as of our resident doctors.” “The faculty positions are also being filled up. There is going to be a medical college attached to it, run by the government.” “Yes, I heard that.” “Do you know who is heading the department of Obstetrics and Gynecology?” “No. Who is it?” I asked. “Dr. XXX, who was honorary professor at government medical college.” “Hmm...” I said “I recall her. How did they land up with her?” “We don't know. But because she is going to head the department, a number of us who had applied for Assistant Professor's post did not go for the interview.” “Why?” I asked. It seemed a bit too much. There must be something I did not know about that person. “She used to expect coconut water kept ready for her when she arrived for her morning ward round.” “Who was expected to do it?” “Anybody.” “Who paid for it?” “Anybody. It just had to be there, or else.” “That sounds familiar” I said. “I recall what she used to do when she came to our college as MBBS examiner. She would arrive a little late, and exclaim 'get me a cold drink. It is so terribly hot.' So we would give her a cold drink while the exam remained suspended. It would start after she finished the drink. A half hour later she would say 'I need hot coffee. I can't examine another student until I have had hot coffee.' So an intern would rush to the canteen to get her hot coffee. One day she said 'I have developed headache. Get someone to get me Sxxxxr oil.' Sxxxxr oil was a rubifacient oil for local application for relieving pain. One intern went to the chemist and purchased it. She took it, but did not pay for it. Finally the examiner whose intern had gone for that purchase reimbursed the intern.' “So now you know the reason for the applicants' not going for the interview” the informant grinned.

Isometrics in Cesarean Section

Somehow I don't cease to be surprised by new trends in obstetric practices of resident doctors. We had a patient who underwent a cesarean section. She had developed fetal distress and cesarean section was performed by residents of another unit. She developed hypotension and shock in the postoperative period. She was explored by our Associate Professor and resident doctors. She was found to have extraperitoneal hemorrhage staring from the rectus sheath and dissecting underneath the peritoneum. It was behind the posterior peritoneum too. On questioning it was found that the residents had stretched the edges of the abdominal incision. The method was to grab the side of the incision with both hands, one resident on either side of the incision. Then they would stretch the incision with their body weights by falling backwards with their upper limbs held extended. "Do you not understand that this barbaric method is likely to tear the recti and even extend the incision irregularly? That may produce extensive damage, as in this case." "...." "Do you do this in our unit too?" I asked. "Yes sir". "Will you stop it with immediate effect?" I asked. "Yes sir" they promised. "Do our assistant professors who have come from three other institutes in this city do the same?" I asked. "Yes sir" they said. "Stop" I said. "Yes sir" they said. There was another case undergoing cesarean section in our OT today morning. Our junior resident doctors had changed three days ago. The operating surgeon was a local candidate, while the first assistant was from Down south somewhere. Before I realized what they were doing, they grabbed the sides of the incision on their respective sides and stretched the incision by leaning backwards. "Stop stretching the incision" I said. They looked at me uncomprehendingly. "Do not stretch the incision by hanging onto its edges" I said. The stopped. The senior resident who was the first assistant apologized later. I explained the reason for not indulging in that practice. Then I asked him where he had learned that technique. "In our college during postgraduation" he said. I was intrigued. How bad practices without scientific evidence of their usefulness spread all over the country was beyond me to understand. I wonder if they use 'Facebook' or 'Twitter' or any other social networking site for this purpose.

Carry Your Own Slippers

I thought getting slippers for labor ward and operation theaters should be a simple matter. Keeping adequate stock and placing orders to supplier well in time should also be fairly easy, since the turnover is known. Well, things are not simple in a corporation hospital. There had been a time a few months ago, when almost everyone had started going into the labor ward wearing street footwear because there were no slippers. I had to do a lot of work do get the concerned persons to do their work to get a supply. After coming back from vacation last week, I found out that there were few slippers in the labor ward, and one had to enter the ward bare foot. I talked to the sister in charge of that ward, who pointed a finger at the stores clerk. I managed to find the stores clerk (the act deserves accolades!) and asked her the reason for the short supply. “We have placed an order and the supplier will supply the slippers in due course” she said. That was a standard 'babu' type answer. “But this is not a municipal ward office” I explained “where a delay in moving files is the rule and it does not perhaps matter very much. This is a hospital for patient care, and we cannot afford to have no supply of essential items. Buy some in open market and supply urgently.” “I will speak to Dr. XXX, the Assistant Dean and see what can be done” she said. That meant nothing. It was another stalling tactic. It is a tragedy that a tertiary level hospital doctors are forced to do something like this to ensure that they get slippers to enter the labor ward or operation theater, while the concerned clerks and Assistant Deans go through life sitting in comfortable chairs in comfortable offices, not concerned about anything much.

Final Diagnosis

“Sir, we have a case for discussion in today's maternal mortality meeting”. “OK. Is there anything unusual?” I asked. I had been on vacation and had just joined. So I did not know about any maternal deaths which occurred in my absence. “Yes, sir. The patient was transferred to our hospital in a bad shape, with systolic blood pressure of 70 mm Hg and semiconsciousness. She had had a convulsion before being transferred. Her fetus was alive and well at that time. She deteriorated despite all supportive treatment. The next day the fetus died. Then she died too.” “What is the point of discussion?” “The pathologists have given the cause of death as disseminated intravascular coagulation in a case of intrauterine fetal death.” “Did she have DIC?” “Yes, sir. Her coagulation profile was abnormal on admission.” “OK, I will discuss it in the meeting.” The pathologists were present for the meeting. I asked them why they had given that diagnosis. “Well, the fetus was dead and she had DIC” said the pathologist. “When you say DIC in a case of IUFD, it implies that the DIC was due to IUFD. But in this case the patient had DIC on admission, when the fetus was alive and well. It died the next day. So the fetal death was due to maternal illness including DIC rather than the cause of it” I explained. “Stating the diagnosis in the way you have done is like saying 'DIC in a case of vitiligo or leukoderma'. There should be a cause-effect relationship if you want to put the two together in the cause of death.” They seemed to have understood that. “The minutes of the meeting will be sent to higher offices, including state and central government. The people who will see the report may not be active clinicians and they may feel a woman with IUFD was not treated in time and hence developed DIC. That is the reason I want the diagnosis put correctly.” They promised they would do it that way in future. I hope they tell their colleagues too, because it is beyond me to tell all pathologists myself.

Ego Crash

That fellow was about ten years older than me. He stayed in the same building as I. He knew my academic career very well, and also my professional career. He became a dentist and set up practice in a nearby place. He moved to another place, but kept visiting our building periodically because his brother stayed there. I met him today when he was there on one of his visits. "So how are you?" he slapped my back. "Very well, thank you" I said, "and you?" "OK" he said. "So what are you doing now? Where are you working?" "I am still at KEM Hospital" I said. "I am not going to leave at this age." "Which department?" he asked. I was all shaken up. If he had asked this question thirty years ago, it would have been understandable. But his asking it today meant all my achievements and contributions to the subject I loved were so insignificant that he did not know about them." "I am shocked you asked this question" I said lightly. "I am an obstetrician and gynecologist. How do you not remember, especially when you had brought your sister to me for treatment, and she had got well with my treatment?" He seemed surprised. "It must be loss of memory due to aging" he said jokingly. "But I said 'hello' to you. That is something." "I think I better leave now" I said. "I will write about you on my blog." "Yes, please do that. I will read your blog" he said walking away. I am wondering how he will read my blog, when he does not know the web address of my blog. I wonder if the blow to my ego was intentional, accidental, or he has got Alzheimer's disease."

Thrombocytopenia due to Menorrhagia?

"Sir, I want to inform you about this patient" my Registrar said in the outpatient clinic. "What is it?" I asked. "She has menorrhagia for the last 3 cycles. Her pelvic findings are normal. Her hemoglobin is 5.2 g%, and platelet count is 35000/cmm." "So what do you think?" I asked her. "I think her hemoglobin and platelets are low because she has been bleeding." I was aghast. "Low hemoglobin is understandable if she is bleeding and does not have iron and folic acid replacements" I said, "but why platelet count should be low?" "Because the platelets are used up in the bleeding" she explained. "Do you think it is the other way round?" I asked. "Could she be having menorrhagia because she has a low platelet count due to whatever cause?" "Yes, I think that is the way it is" she agreed. I wonder what she has learned in last 2.5 years of residency, and what she will do in her MS examination after six months. Checking bleeding time, clotting time, and platelet count is a part of the investigations of every abnormal and excessive uterine bleeding in our unit. Why she would keep doing it and still not understand it is beyond me. I dared not ask her that question, because I could not stand the usual answer: "Sorry sir" with a semi-negative shake of the head.