Female Sterilization: New Technique

Each method of female sterilization has a failure rate of its own. Failure rates are higher if the procedure is carried out along with cesarean section, medical termination of pregnancy, or in early puerperium or postabortal state. That is so because the fallopian tubes are often edematous at such times, and the ligatures over them become loose when the edema goes away. There are some methods which have a zero failure rate, such as Shirodkar’s method, Uchida’s method, and Oxford method. The success of these methods depends on separation of the cut ends of each fallopian tube from each other, so that recanalization cannot develop. I have developed a new method for female sterilization in which the two ends are separated from each other using the utero-ovarian ligament and adjacent part of the broad ligament. The steps of the procedure are as follows The fallopian tube is divided between two hemostats in the isthmic portion, and each hemostat is replaced by a ligature of a nonabsorbable suture like linen or black silk. One thread of each ligature is kept long. The thread of ligature over the lateral cut end is threaded on a half circle round-body needle. The needle is then passed through the broad ligament just below the corresponding side utero-ovarian ligament, from behind forwards, so that it emerges close to the ligated medial cut end. The two threads are tied to each other. Thus the lateral portion of the fallopian tube passes over the uteroovarian ligament, and the lateral cut end lies on the posterior surface of the broad ligament, while the medial cut end lies on the anterior surface of the mesovarium under the ligament. Thus the two cut ends are separated by two layers of broad ligament below the utero-ovarian ligament, and cannot unite to cause recanalization. The animation of the operation shown here is without the instruments like hemostats and needle holders. I did not include them because it would have taken me 2 weeks instead of the 2 hours I needed to do it. The interrupted red lines at the beginning show the cuts made in the fallopian tubes.

CME

The medical council realized that medical education was not a continued process for many medical practitioners, and made it compulsory. One now requires 6 credits per year, or 30 in 5 years. Suddenly there was a spurt in educational activity - both teaching and learning. I dislike speaking in conferences, because I cannot understand why one should spend a few thousand rupees to attend a conference, which is actually an academic activity. Probably it has to do with relaxation or 'sharpening the axe' as in management. I prefer to teach and learn for free. So we organized a continuing medical education program in our department, and kept it free for all. The stalwarts were skeptical that anyone other than our own residents and staff members would attend. We posted an electronic notice on our intranet, and sent two notices to two other colleges run by the civic corporation. We had 178 registrations, though only 154 could make it. The skeptics were stunned, and the all others were thrilled. We showed 8 videos of different operations, each followed by interactive discussion. It was appreciated by all. For those of you who want to attend the next one for free, block 31st of March 2011, 9:30 A.M. to 4:00 P.M. It is on 'labor - update'.

Flag hoisting ceremony

I heard this conversation in the canteen. The speakers were sitting behind me and they could not see me. “Are you going for the Republic Day celebrations?” “Where” “To the college.” “No. I have to go to the celebrations in our housing society. A celebration is effective wherever it is done. It is like praying to God. You do not have to go to a particular temple to do it. God gets the prayer no matter from where you offer it.” “I understand. Is that the only reason you are not going?” “The other reason is that it is at 7:00 A.M. I cannot reach the college at 7:00 A.M. I do not get up at that time.” “Now I can see why they invite a retired professor to hoist the flag on Independence day and Republic day.” “What do you mean?” “This is their only chance to get the professors to the institute early, who otherwise reached by 11:30 A.M. to noon while they are working there.” I was tempted to turn around and see who it was. But then they would have seen me and realized I had heard them. So I waited until I heard them leave.

Punishment

It happened quite some time ago. I cannot forget it because it is tearful and funny at the same time. "If you admit you have committed a grave willful error in that patient's management, what punishment do you think you should have?" I asked my residents. I do not believe in treating them like children. I prefer an adult to adult relationship, as in transactional analysis of Eric Burne. But if they continue to commit the same misconduct despite repeated instructions to the contrary, and when asked for an explanation come up with only 'sorry, sir', I cannot take any other stand but that of a strict parent. Probably punishment is the only method, if at all, of correcting such people. "I think I must tell the Dean to take disciplinary action on you." "Please don't tell the Dean. We will take any punishment you give, sir" they said. There were two of them both girls, and quite scared girls at that. I was not going to tell the Dean. It was my job as head of the unit to correct treatment errors of residents so that patients still got the best treatment and and to prevent residents committing mistakes so that they became better doctors. But there was no point in telling them so. "Any punishment?" I asked incredulously. "Any punishment!" they confirmed. "OK. Write down the entire text-book of Williams' Obstetrics ten times" I said quietly. They were too upset to look stunned. They kept quiet. "If not that, let us stop your operative work for the remaining duration of your current posting. How long do you have?" "Three and a half months, sir." "OK. So no operative work for that period" I said. "Please sir, I want to learn how to operate. Not this punishment, sir" said the first year resident. "Then write Williams' Obstetrics ten times" I suggested. "OK sir" she said tentatively. "Do you think you have enough time left to write that much?" I asked mildly. The second year resident was scheduled to go on exam leave in one and a half month's time. She had no time. She kept quiet. "Have you seen Williams' Obstetrics?" I asked the first year resident. Perhaps she thought it was a tiny booklet, like our labor ward protocol book. "Yes sir. It is that thick" she spread her fingers as much as possible to show how thick it was. "The how will you write it ten times?" "I will try" she said. So she would probably write two pages and then declare she had failed. "Can you not think of any other punishment?" I asked. "We will go to the patient and apologize" they offered. They were truly idiots if they believed it would work. Either the patient and her relatives would bash them up or take them to a consumer court. "Go away" I said. "Sir, please" they begged. "Please go away" I corrected myself. "Sir, please" they said again.They must have missed what I said. "Now what do you want?" I asked. "Please give us punishment" they said. "Write down what you did" I said and gave them two sheets of paper. "Sir, please" they said. "You don't want to write Williams' ten times. You don't want to write even one sheet of paper. That is not fair." I got up and left because they would not go away, and to watch two girls cry was a punishment for me. A half hour later they found me and handed me two sheets of paper with their apologies. I still have them. I am toying with the idea of framing them and giving them to the two girls perhaps as their graduation gifts, to be hung where they can see them periodically and behave.

A new syndrome

"Why are you upset?" a friend asked me. "I am upset because I see a syndrome and I cannot find a cure for it: I said. "A new syndrome? You mean you have actually found a new syndrome yourself?" "Yes. It affects mid-level staff members in surgical branches in civic medical college hospitals." "What is it?" "As you know, the staff members are teachers. They have to teach resident doctors how to perform operations. This teaching involves assisting them when they operate on patients. The syndrome I have found affects these doctors who are going beyond what can be called youth. There are no symptoms. The signs vary. One sign is a decrease in speed when performing the second last major case of the day, so that it ends beyond the time at which the last case can be induced. Then the poor houseman does not get to operate, and the staff member does not end up assisting him and breaking his back and going away late. Another sign is to perform simpler operations oneself and leave the complicated ones till the end, so that the only case available for the houseman to operate on is so complicated that he cannot be given the chance to operate. The third sign is to give the last case to a senior resident doctor and say one was not aware that it was the junior houseman's turn to operate. Fourth sign is to treat patients medically when they actually need surgery, so that there are fewer patients to operate on. Fifth sign is to develop an illness like a diarrhea suddenly when it is time to assist the houseman." "These seem like excuses for not assisting the houseman" the friend said. "Excuses are voluntary. these signs are probably involuntary. No doctor would consciously postpone an operation for being unwilling to assist a beginner." "Perhaps. But have you seen enough cases of this syndrome to justify calling it a syndrome?" "Plenty!" I said. "Each of these signs has been observed in real mid-level doctors, and not just once, but repeatedly. The signs are pathognomonic." "Have you named this syndrome yet?" "I cannot call it by my name. There are two problems with that. One is that people will call me egomaniac (which I am not) for giving it my name. The other problem is that many people may believe it is called so by the name of the first person in whom it was identified (which is far from the truth). I cannot come up with a name that is interesting enough." "Why don't you name it after the first person in whom you diagnosed it? Or if you feel that would look bad, a new word formed by the first letter of the first or last name of all the persons suffering from it." "I had thought of that. That would be a very long word." My friend became quiet after that. If any of my readers comes up with a catchy name, please email me the suggestion.

System restore

"Sir, that computer in the office has a problem. The 'AVG' and 'Microsoft security essentials' antivirus software installed on it has been inactivated automatically. I cannot get either of them to do antivirus scanning. The is a new security software that pops up periodically and says there are some viruses which it won't remove unless we buy that software." our professor in charge of the computers in the department said. "It is a malware. Somehow it tempted someone sitting on that computer to install it. It has maliciously inactivated our two licensed programs" I said. "If you uninstall and reinstall them, this will inactivate them again." "I tried to uninstall them. The computer said the system administrator has stopped me access to do that. But I was logged in as administrator." "The malware makes changes that makes the system believe what it said to you" I smiled. "So I will have to format C and install Windows XP again." "No. There is an easier way. Restore the system to the earliest date possible. Then this problem will go away" I said. Two days passed. Finally the professor got time out of her clinical and administrative work when some other pressing work was not being done on that computer by other people. "Sir, the system is restored. The problem is solved." I was happy. The system engineers of the institute would have been happy too if they had known we had saved them a visit and some work. The other computer users in the institute would have been happy too because we had kept the engineers available for them instead of keeping them on our system. I will be further happy if any of my reader or a new reader who reaches this page by 'Google' search and finds this information useful.

Follow-up after 6 years

"Sir, this patient is married for six months. She has amenorrhea for three months." It was my outpatient clinic. My Registrar wanted my advice. "Is she pregnant?" I asked. "No. Actually she has been menstruating regularly for last six years with cyclical medroxy progesterone therapy. She has not taken that drug for the last three months because she thought it might interfere with her chances of conceiving. You had seen her six years ago and advised her that. You had also told her to see you after she got married." I looked at the patient's face. I could not remember seeing her six years ago, but that advice rang a bell. "Why do you think I called her to see me after she got married?" I asked. I must have told the patient the reason, but either she had forgotten it, or my Registrar had forgotten to ask her the reason. The Registrar shook her head. "Think what the reason could be" I encouraged. "May be to see if she got pregnant" she guessed. Bad guess. I suppressed a smile and asked her, "what will you do for her now?" "I will regularize her period with hormones" she said. I wanted to say 'Oh God!' but did not. "She wants a pregnancy, does she not?" I asked. "Yes sir." "So you will induce progesterone withdrawal bleeding and then you will induce ovulation with clomiphene citrate" I said. "I had called her after her marriage for ovulation induction in case her menstruation had not become regular by that time." I hoped she got the thought process correctly. That was what would make good gynecologist out of her.

Medical jargon

Every profession has its own jargon. There is actually no need for it. Probably people use it so that others do not come to know what they mean, and thereby their importance is maintained. We had a patient in the hospital once, whose father in law was a lawyer. There was no servant available, and he had to give bed pan to the patient. He complained, stating he had to pass an instrument into his patient. I was horrified that he had passed some solid instrument into the patient. I was wondering into which part he had passed it.The patient had not complained of any such occurrence. Later on another lawyer told me he meant he gave the bed pan. Medical jargon is equally confusing. In first year of my education, I was deeply impressed by Gray's anatomy. So much so that I started saying I had to get down from the exit at the anterior end of a bus. It gradually passed away as I moved on to subsequent period of my education. Just the other day I asked my Registrar how a particular patient in the medical ICU was. "She is all right. She was self extubated yesterday" she said. I was confused. After a couple of seconds I understood what she meant. "Do you mean she pulled out her endotracheal tube herself?" I asked. "Yes, sir" she said. "Then why do you not say so?" I asked. "Because the medical Registrar said so" she said. I knew then how jargon developed in each profession.

Blood collection technique: the correct components

"Today I found something interesting" one of our professors said. "I found an intern collecting a patient's blood in a novel way." I knew interns were innovative. This would be good. "He was collecting the blood while the patient was standing." Great. Fellow looked dangerous. If the patient fainted at the sight or thought of blood, she could develop a head injury. I could see the medicolegal implications. "He was wearing no gloves." So the fellow was dangerous not only to others, but also to self. I could see him catching HIV, HBV and whatever else that gets transmitted through blood. "He had tied a glove to the patient's arm in place of a tourniquet." This was a new use of a surgical glove. I had seen it used as a glove, a drain, a reducer during laparoscopy (my own innovation), an ice bag, hot water bag, air-filled ball for playing, projectile for throwing into the red bag after use (one has to stretch it and then let go of the two ends in a correct sequence so that it launches itself and hopefully lands in the bucket), to scare people (one kid had once filled one glove with water, tied its opening, and thrust it into the handle of my car before I sold it off for different reasons), to prevent finger prints from going on gun triggers and knives (in crime movies), to dye hair, to polish, to paint walls, and to lift garbage. My readers may have witnessed a few more uses of a surgical glove. "So ultimately he did use gloves for blood collection!" I said.

Walking the plank in our college

They have dug up a trench at the entrance of the college, and lined it with cement. It is a gutter. I am sure they will cover it properly when ready. In the meantime, they have placed a one foot wide plant across it for people to walk over. The intention is good, or perhaps that is the law. Unfortunately it is all twisted and wobbly. So when one steps on it, one is threatened to fall right into the gutter. The good part is that it is dry. The bad part is that one can get oneself all dirty at best and break a leg at worst. I watched a few people carefully stepping on it and balancing their way precariously to the college building. Yesterday evening I was on my way out, and saw one of our Associate Professors walking gingerly over the plank. "You know, it is a lot easier and safer to just step over the gutter like this, instead of stepping over the plank" I said. The Associate Professor turned around. I stepped across the gutter, which was just a foot wide. There was no comment, but a small smile in return. I think it is making up the minds of people for them. One puts a railing, and people hold it while walking by it. One puts up a plank across a gutter, and people walk over it instead of bypassing it, because they think it must be right to do so; otherwise why would anyone put a plank there?

Attitude 12

"How is your child?" I asked one of our professors. "Still not OK. The reports are not showing much improvement. I showed them to a colleague in private. She did not offer much." "Why don't you show them to our specialist in the hospital?" "I tried. It was weird. I asked my Registrar to get that department head's mobile number. The Head said she would not take any calls on mobile. I had to call on the landline only." "You could have called on the landline." "I was driving at the time. I did not have the landline number." Suddenly I remembered something. "Calling on the landline perhaps would not have helped either" I said. "Her Registrar was batting one of our patients once. Finally I called her in her office on the landline. Her assistant took the call. When I identified myself, she checked and told me that the Boss was busy examining a patient and would call me back after examining the patient. I waited for one and a quarter hour before going home, but she did not call back. I have waited for three more years, but she has not called yet, nor has she expressed regret on meeting me in campus. Getting a call on mobile forces her to take the call, while the landline can be answered by assistants and she can be declared unavailable." "I remembered something else afterwards" said the professor. Twenty years ago there was this person's proposal for my brother!" "Which he rejected?" "Uh...huh!" "That perhaps explains this behavior" I said "though one should not let personal feelings interfere with one's professional work." It did not explain why she would not take my call though. There had been no marriage proposal between our families.

Improving Medical Education

We all feel that undergraduate and postgraduate medical education is not as good as it should be. Most of us end up saying this is so, and leave it at that. Perhaps it cannot be helped. Perhaps we need to improve the curriculum. But perhaps it may be enough to implement the existing curriculum, with a few modifications. We could take it more seriously, and see that each one of us covers the syllabus on a predefined schedule, rather than leaving practical training to cases and operations as they come to the clinic and OT respectively. The student can be made to learn by starting weekly assessment and giving them credit points and a CGPA at the end of the semester like they do in IIT and similar institutes. It is probably not going to work because it means so much more effort for both the teachers and students, and it is very difficult to break old habits, especially if they are synonymous with comfort.

Wonderful honesty

"Sir, did you notice what the T-shirt of that resident reads?" one AP asked after the ward round. "No" I said "where?" "The front of her T-shirt." "No. Where is she?" "She is gone now. But it read: I don't get headaches, I give them." "That is very funny" said another AP. "And very honest" said another AP. I wonder if the resident knew she was being honest, or if she thought it was just a jpke.

Telephone Shield

"Sir, there is someone on the phone for you" the servant said. "Who is it?" I asked. Telephones are time wasters as per my management guru Stephen Covey. No matter what you are doing, you tend to leave it to take a call, which may be extremely unimportant. "Someone called XXXX" he said. "He would not say who it was, until I told him who I was. Does not say what his work is too." I was pressed for time, but I took the call. "Who is speaking?" he asked. I told him who I was. "I want to talk to you for 2-3 minutes. Can I meet you?" "Talk on the phone" I said. "No. I want to speak to you in person" he said. "What is it about?" I asked. "I will tell you when I meet you" he said. "Is it for some patient?" I asked. "Ur... no" he said. "Does it have anything to do with the corporation?" I asked. I was asking all these questions so that I could guide him to an appropriate person, instead of spending time on something someone else should be doing. "No." "See, the corporation pays me to work for it. I cannot spend time on other things. Is it reasonable for you to ask me to see you when you won't tell me what it is that you want to talk about?" i asked. "...." "DO you have to have call the most senior doctor?" "So you won't see me because you are the biggest doctor?" he asked. He had started to get on my nerves. My work was left pending. "Senior doctors have a lot of administrative work too, and I cannot spend time if it is to be done by someone else." "What do you do after your work?" "I go home at 4:00 P.M. after I finish my work. Why don't you tell me what it is all about?" "OK. In that case I will talk to the Dean" he said. "You do that" I said. I don't like people threatening to go to my boss when I won't meet the unreasonable demands they make. Perhaps he was a person with intentions to harm me to get even for some dissatisfied patient in the hospital. Perhaps he was some lawyer trying to fix things for his client treated in our hospital. I wonder what God had in mind when he made people like this person. Finally I rang up the senior administrative medical officer before leaving for the day, told him the story in brief, and asked him if he knew any such person. He did not. So I told him that if he should indeed see the Dean and the Dean wanted me to see him, he should be advised accordingly to see me tomorrow or the day after.

What Drives Them?

A maternal instinct is a understandably a very strong instinct. But one would expect sensible people to understand that if they have to choose between life and having a go at having a baby, they would choose life. Apparently that is not so. In the last week I had two patients. The first one weighed 130 kg in nonpregnant state. One and a half years ago she underwent a cesarean section with another consultant in my hospital. They had to join two OT tables side by side to accommodate her. She lived and went home with the baby. Then she got pregnant again and registered with me. I advised to go back to her own doctor, but she said she would prefer to be with my unit. She still weighed the same. I asked her why she got pregnant without losing some weight first. I could not understand her answer because she answered quite vaguely. She underwent a cesarean section while I was on leave. Four days after the section she started soaking her dressing with copious amounts of blood-stained fluid. We suspected a burst abdomen. Removal of sutures confirmed the diagnosis today. We resutured her abdomen. She wants her stitches to heal. I want her to live. The other woman had afibrinogenemia. She had had four abortions in the past. She had bled in a life threatening manner all four times, ending up in an ICU at the last time. She presented with massive hemorrhage vaginally in the first trimester in her fifth pregnancy. She was transfused 12 cryoprecipitates, blood, and FFPs. Then the pregnancy was terminated. Both of these women seem bent on having babies, apparently not caring whether they live or not in the process. If they themselves want it, they are either driven by their maternal instinct beyond reason, or stupid. If their spouses, in laws and parents are driving them, they are victims and their relatives need to be booked for abetting suicides. In the meantime we-their treating obstetricians continue to toil and despair.

Endoscopic Knot Pushing: New Application

We use a knot pusher for tightening extracorporeal knots during laparoscopic surgery. It is cute little instrument with a bifid tip for pushing the knot around the structure to be tied. I had a pleasant experience of using the technique for other than endoscopy. I was taking a brisk walk in the terrace as a part of my daily exercise routine, when along came our neighbours. They wanted to move a TV cable away from the existing location and fix it in a new location away from their balcony, so that rats would not climb into their balcony along the cable. After moving it, they wanted it fixed to a drainage pipe well below the terrace, so that it would remain there. It would be dangerous going to the pipe, because one could fall down five storeys to one's death. It was then that I had a bright idea. I offered to place the knots. They were too happy to let me do it. I threw turns of their plastic rope around the pipe and the cable and tied a knot. Then I used a piece of bamboo lying around there to slide the knot up to the pipe and tighten it. I threw four more knots, partly because I knew surgically that knot quality of plastic would be poor, and partly because I enjoyed the process of pushing the knots with that bamboo. The neighbours knew of my position at the hospital, but had not experienced my surgical prowess so far. They were truly impressed. I think I did better than Richard Gordon who wrote the Doctor series. In his novels he used to repair holes in his socks with purse-string sutures when he was in training as a doctor.