LeFort: RIP

There is some magic in LeFort's operation. It draws some gynecs like honey draws some bees. I remember the time I was a first post resident in Gynecology. My room partner was working as a resident in the other unit in our ward. All residents in that unit were a different breed. They used to post eight major operations on one day, knowing the boss would operate on two of them, which would leave six and the houseman would get to operate on one of them. The boss started performing a vaginal hysterectomy on a patient with alleged menorrhagia. Unfortunately the cervix came off after dividing the uterosacral ligaments, and there was no uterus above it. Then it turned out that the patient had undergone abdominal subtotal hysterectomy in the past. How she had menorrhagia is beyond comprehension. The boss got wild and ordered them to take the next patient, one scheduled to undergo LeFort's operation. After induction of anesthesia, she discovered that the patient had no prolapse at all. How they posted a patient without genital prolapse for LeFort's operation is also beyond comprehension. Perhaps they did not manipulate the OT list very well. That was 29 years ago. I thought things would have improved with time. But today they informed me that there was a very high risk patient scheduled to undergo LeFort's operation tomorrow. The registrar informed me that the patient had second degree uterine prolapse, and minimal cystocele and rectocele. She further told me that I had advised LeFort's operation for that patient. I knew I had not, because my concepts on indications for LeFort's operation are clear and firm, and this one did not fit in those concepts. So I asked them to recheck. Then it turned out that my Assistant Professor and Associate Professor had seen her and advised LeFort's operation. So I finally went to see the patient myself. She had only uterine prolapse, C point at +1 in POP-Q classification. There was no cyctocele or rectocele. "How can you perform LeFort's operation if there is no cystocele or rectocele?" I asked my registrar. "You have to make bladder and rectal surfaces bare and suture them to each other, as we did a month ago on another patient. If there is no prolapse, that will not be possible." "But madam has advised that" she said. "You will qualify at the end of this post. How will you practice gynecology if you cannot think for yourself?" I countered. She had no answer. "I agree that the patient is at ASA grade III for anesthesia. But if a condition is not treatable by LeFort's operation, it cannot be treated by LeFort's only because it can be done under local anesthesia. If at all, you have to perform hysterectomy under local anesthesia." Then I counseled the patient and left her to decide what she wanted, hysterectomy or living with the minimal uterine prolapse she had. Poor LeFort must have been turning in his grave because of what people do with his operation. May his soul rest in peace.

Continuing Medical Education

It was about ten to fifteen years ago. I was a member of the academic committee. I felt that we failed to get educated about what was happening in other specialties after we specialized in one particular subject. So I suggested to the committee that we should get all departments to hold continuing medical education (CME) programs which all staff members should be able to attend. We could then get the education we needed without having to attend fancy conferences in five star hotels. They misunderstood me, and developed a scheme that included finding sponsors for the CMEs. Finally the scheme died, as all schemes eventually die unless they are a part of the curriculum. Now the Medical Council wants all doctors to get 30 hours’ CME credits every 5 years. The scope is not planned. One can get the credits in a variety of ways, including attending conferences, CME programmes, writing scientific articles in indexed journals, speaking in CMEs, and writing chapters in books published by recognized organizations. That does not mean one ends up getting the required knowledge, but it is better than nothing. It is even compulsory for us teachers, who actually teach undergraduate and postgraduate students. I feel a multispecialty curriculum must be planned for every 5 years and that must be made compulsory for all doctors. I hope someone in the council reads my blog. I would have written to the council, but I am discouraged by my past experience of writing to administration, universities and councils – there is no response.

Logical Journal

I had an interesting case of primary abdominal ectopic pregnancy diagnosed early. She insisted on operative treatment rather than observation or medical therapy. So we performed a laparoscopy on her and removed it from the surface of the back of the right broad ligament. Since there is no documentation of such an image in the literature, I sent it to our staff society journal. It is a high tech journal. It accepts articles online. I received a reminder from the editor that I had not responded to his request to correct the reference to required format. It reminded me of municipal working style, where reminders are sent without having sent a prior letter. Anyway I corrected the reference the way he wanted it and sent it. Then the online system told me that I had to send a glossy print of the image to the journal's office because I had sent a revised manuscript. I was surprised, because the journal does not require a print primarily, but only if a revision of the article is required. It has no logic. It seems to be a method of teaching people a lesson when they do not send the manuscript as required. The journal also asked me for an image of ultrasonogram of the patient, when I had not even mentioned it in the text. I think the people on the editorial board have some funny concepts only because they are on that board. They are like our politicians. They get elected in staff society elections, they run the journal using money deducted from our salaries without our consent, and then boss over us. I have half a mind to withdraw the article and post the image on my blog.

More Repairs

We have been away from our wards and offices for one year and three months. I have been forced to sit in the hospital's bill section with the clerk, because there is no place for anyone during the repairs. Now they have started breaking the floor and walls of the staircase and landing of fifth floor where my desk space is. I wonder if there is a transit- transit desk space available for heads of departments sent to a transit desk space when that space goes under repair. I must say they are probably going to make that place beautiful beyond imagination, because it was looking OK before, and they are still breaking it down. I cannot see any other reason for the same. In the meantime, the contractor has taken away our marble in the OTs and put lower priced vitrified tiles in its place. All promises have been like those made by politicians before the elections. The tender term is the contractor will take away all rubble resulting from the repair work. Marble is rubble!

Vacation Arrangements To Water Plants

We were going to be away for about 7 days. We have 15 potted plants in our terrace garden. it would have been great to have a sprinkling system to run at predetermined time every day to water the plants. Unfortunately we don't have one, and I would not develop one only for once a year. So I devised a system that works on capillary action. I placed a big bucket full of water on a table. Then I placed all the potted plants around the table. Then I ran a long piece of string (made by braiding of multiple threads)from the bottom of the bucket to each pot. The idea was to let water pass along the strings from the bucket to the soil in the pots by capillary action until we returned home. I covered the top of the bucket with a plastic sheet to prevent loss of water by evaporation. That was important because no fresh water would be added to the bucket while we were away and that water had to last for 7 days. When we returned 7 days later, the plants were as alive and fresh as when we left. The strings were wet, and the bucket was only 20% empty. I think is beats a computerized water sprinkling system any day.

The Worst Department

"Sir, the inspector from the health university said ours was the worst department in the hospital" our clerk cum typist said. She sounded upset. I would have been upset in her place too, because we all were intensely proud of our department and the institute. "Why did he say so?" I asked. "we took along all the sealed bundles of answer books of students for him to inspect. He did not like that. He wanted them to be open like the other departments had." "But that is against the university rules" I said. "The bundles have to be sealed as soon as the result was ready for each exam." "He also wanted the answer books of each student from all three exams to be put together." "That is not possible because the exams take place 6 months apart, and we cannot break the seal of each bundle, even if he wants it that way" our professor in charge of this matter said. "I explained it to him, and he finally understood it." "But if he is the inspector sent by the university, he should be aware of all the rules" I said. "Yes. Unfortunately he was not" the professor said. The clerk was still upset. "Don't think about what he said. He called our department the worst department because he was inadequate, and believed what the other departments did was the right way, not what is laid down by the university. It was his job to inspect the internal assessment result and go away, not pass judgment on departments. If it is any solace to you, let me point out that he was from an unknown Ayurvedic college. People take admission in such colleges when they cannot get admission in institutes like ours. That the university gave him a job of an inspector that truly busy people do not want does not make him God. His saying that we are the worst does not make us so. We remain what we are - the best. Never worry about what people say about you. Be principle-centered and be happy that you always do the right thing for the sake of doing the right thing, not to please anyone." She seemed happy after that.

Poverty and Obesity

The hospital I work in is a hospital for poor patients. It was my belief that poor people have little money and they cannot afford to eat much. So they would be underweight if not outright malnourished. In recent years I find a different trend. A large number of women especially elderly ones, coming to us for treatment of gynecological conditions are quite obese. It becomes a nightmare to operate on them by whichever route. Vaginally one encounters little of that fat, but the postoperative course can be quite difficult. The trouble begins with having to shift them from the OT table to the trolley and from the trolley to the bed in the ward. The abdominal or laparoscopic route has the additional problem of having to go through layers and layers of fat. The time required for opening and closing the abdomen is quite long. The intraabdoominal fat makes surgery difficult. Wound breakdown rates are high. To find their veins for intravenous injections and transfusions can be a nightmare. Luckily we do not face deep vein thrombosis and pneumonia so often as compared to the US or Europe. I often counsel them to reduce their weight preoperatively, both for the sake of success of the operation and their future health. I am yet to find a single patient who managed that. All of them claim they eat virtually nothing. The diet they describe is virtually nothing. One would believe they gain weight by drinking water. But now I have found out that they consume a lot of coconut, which is not mentioned in the diet unless specifically asked for. Even then many of them avoid answering that question unless one insists on getting an answer. To get a solution to a problem that the patient herself does not want solved is beyond me. 'That is the way it goes' Schultz would have said about this issue, were his characters to bring it up in his comic strip 'Peanuts'.

The Fothergill Story

The Manchester Donald Fothergill operation (popularly known as Fothergill's operation) is a very old operation for uterovaginal prolapse. The textbooks we read as undergraduates had a brief description of the same, including the main components only. As postgraduates we never found the original description of the operation in any book. We saw the honorary gynecologists in our institute perform a modified version of the original Fothergill operation and we performed a similar operation ourselves as residents and later as staff members. I wrote a book in 1987 in which I described this modified form because it was the best for our patients. I later wrote an atlas of operative techniques along with my Registrar Dr Shah, who shot all the pictures in the Atlas himself. The technique in that book was also what we did. Now I am about to write a new edition of my book. I thought I should describe the original technique, and started looking for it. I found the original article dated sometime in 1935 on internet. It was available on the site of Obstetric Gynecological Survey for a fee. I don't do net banking and don't use credit cards. I would not pay so much money just read an article for historical interest. I asked colleagues who had worked as juniors in other institutes, and realized that they had different concepts of what the original operation was like, none but one had apparently read the original article, and that one did not put the Fothergill stitch while performing that operation. I finally found the article in my old edition of Shaw's Operative Gynecology. I would not perform it that way myself, but I will describe it in the new edition of my book on Practical Gynecology and Obstetrics, so that students will know what it was like instead of believing a Chinese whisper version they get taught or shown.

Hibiscus on Mango Tree

We have a huge mango tree outside our balcony. I saw something very curious that day. The tree had a hibiscus flower right on top of it, which is about half a story below our window. Since it is a tree growing on the sidewalk, no one has experimented by transplanting a hibiscus branch on the mango tree, and anyway that would not be two and a half storeys above ground level. I have not made that picture using Photoshop or GIMP, because I dislike untruths, and also because I am not good in the use of graphics software of such complex nature. I am putting up the picture for the curious ones, and also in the hope that someone can offer an explanation for the same.

Heritage Keepers

I was on my way from the office to the wards, which are at the opposite ends of the main corridor of the heritage building of the hospital. The corridor was full of people, either going places or waiting. A middle aged guy entered the corridor on my left, walked a couple of paces, turned his head on his left, and blew his nose in the corridor in the general direction of the outside world by pressing on one nostril at a time quite methodically. Then he kept walking in the direction of his destination, and wiped his fingers on three consecutive stone pillars to rid them of the mucus he had so methodically expelled from his nose. “Do you know you have dirtied the hospital building at four places?” I asked him conversationally. He turned toward me with an air of one ready for a fight. There must have been something in my face or appearance that told him I must be a senior doctor in the hospital or perhaps an administrator. “Four...” he said. “Could you not blow your nose outside? All you had to do was to lean out over the railing of the corridor” I said. “.....” “Then you wiped your fingers on three pillars. Do you know that you are spreading disease in a hospital that is meant for treating diseases?” I asked. That should have concerned him, because most probably he was there in connection with a patient related to him. “I have this cold” he said in the way of an explanation for his dirty behavior. “You have to carry this for that purpose” I said and took out a handkerchief from my pocket to show him. He looked at it. He seemed incredulous that anyone would carry a handkerchief in his pocket.

Distortion of Intrauterine Device

“Sir, there is a patient who wants to get her IUCD removed. But the threads are not seen on speculum examination. She has an ultrasonic scan report which shows that the IUCD is in the uterine cavity” my new Assistant Professor said. “In that case the threads have either fallen off, or they are drawn up. If they are drawn up, the IUCD has most probably undergone a somersault” I said. I examined that patient. She had normal pelvic anatomy. There was a mild pelvic infection. “Let us try and get the threads of the IUD out using a brush” I suggested. Accordingly he inserted a cytobrush into the uterine cavity and rotated it around a number of times. Unfortunately the threads did not get entangled in the bristles of the brush and come out. He repeated the procedure two more times, but the threads remained where they were. So I inserted an IUCD removing hook into the uterine cavity and hooked the IUCD out. It came out smoothly at the very first attempt. It was hooked at the center of the vertical limb. It was Copper-T 380. The threads were along the vertical stem. The transverse bars were bent forward at an angle of about 160 degrees with each other. The vertical stem was bent forward at a similar angle at its midpoint. I knew what the problem must have been. So I asked the patient why she wanted the IUCD removed, whether for having another baby or any other reason. “I get intense pain in the lower abdomen and pelvis during and in between menses” she said and grimaced. That confirmed my diagnosis. “What must have bee her symptoms and what was the cause of the distortion of the IUCD?” I asked my Assistant Professors and fourth year resident. Based on the answers given by them, none of which was incidentally correct, I asked the same questions to all Assistant Professors in the department. No one out of 17 of them answered that question, which was a little disturbing, because they all were freshly qualified doctors and were expected to be very knowledgeable. One did not come for the survey, while another opted out after hearing the question. Their reasons for the distortion of the IUCDas follows. 1.The uterus must have been anteverted while the IUCD must have been inserted in a retroverted direction. 2.There must be a uterine fibroid. 3.The uterine cavity must have been distorted. 4.There must be a partial septum in the uterine cavity. 5.The IUCD must have been inserted by the push-out technique rather than by the withdrawal technique. 6.The IUCD must have lost its elastic memory. 7.The IUCD must have a manufacturing defect. 8.The hook must have distorted the IUCD while pulling it out. 9.The tips of the transverse bars must have been embedded in the myometrium. 10.The IUCD must have been embedded into the endometrium. 11.The IUCD is normal. There is no distortion. None of them had any clue about the symptoms the patient must have had. After I completed the survey, I told them the reason for the distortion and the patient's symptoms. “The IUCD may have been inserted into a uterus whose cavity was larger than normal, as after a first trimester abortion. That must have given the IUCD some extra space, so that it was a little malaligned. Uterine contractions trying to expel it out must have caused it to somersault. That would draw up its threads. Repeated uterine contractions would distort the IUCD, and that would cause severe pelvic pain and spasmodic dysmenorrhea. Distortion does not occur often with T-shaped devices due to their slim shape fitting well in the uterine cavity. The rate was much higher with first generation devices like Lippes' loop. This is not my imagination. The medical literature has a large number of such records for those who wish to find those.