Puerperal Purpura

Purpura is a condition found but rarely in our pregnant or puerperal patients. It is a serious condition, like any other bleeding condition. When residents talk of purpura in any of our patients, I develop apprehension for the sake of the said patients. It is not that we do not have facilities and expertise to treat these patients. We have both. We have a hematology department with enough doctors and a state of the art laboratory to manage these patients' hematological problems. But I understand that these things do not necessarily guarantee cure and good outcome in every case. Each disease has its own morbidity and mortality despite the best of treatment. "Sir, this patient is suspected to have purpural sepsis" my Registrar told me during ward rounds. I looked at the patient with a combination of apprehension and confusion. The apprehension was for reasons explained before. The confusion was because I had not known anything called purpural sepsis. Purpura may develop in a septic condition, but 'purpural sepsis' was beyond my comprehension. The patient seemed OK. She had no purpura on the skin visible to us. Perhaps it was in the parts covered by her clothes. "Why do you suspect she has this condition?" I asked, avoiding to say 'purpural sepsis'. "Sir, she delivered yesterday. She has fever and leukocytosis." "Where is the purpura?" I asked, hoping against hope she would not have any. "Purpura ...." the Registrar was confused. Why was I talking about purpura? "There is no purpura. She has purpural sepsis." Then I recalled suddenly that another resident a few years ago had also been talking about 'purpural sepsis' which had turned out to be puerperal sepsis. An external examiner from the same geographic region had also been talking about 'purpural' conditions. I looked at my Registrar's face carefully. I realized that the current and past Registrars had similar facial features and probably hailed from the same community. Perhaps they found the pronunciation of the word 'puerperal' difficult and preferred to call it 'purpural'. "Do you mean 'puerperal?' I asked, "as up to 6 weeks after delivery?" "Yes, Sir" she said. "That is puerperium. You have to say 'puerperal sepsis', not 'purpural sepsis'." "OK" she said, sounding like 'if you say so'. I am sure if she writes blogs, she will write about me perhaps someone else she met in past who called it 'puerperal' rather than 'purpural'.

Ethical People

The ICMR has laid down guidelines for ethics in clinical research. It is expected that these guidelines are followed strictly. Any violation is liable to criminal proceedings against the violator. But I don't think it should be necessary to put this fear into the minds of researchers. Doctors should be ethical people and should always do the right thing for their patients. Three days ago I found out that both the premises are wrong. The fear element does not work. And not all researchers are ethical people. We had one professor who was so ethical that when I circulated a questionnaire to the resident about what they lacked in their work environment and time for food, sleep and relaxation, this professor put up a front of a couple of resident doctors to resist this questionnaire, and publicly said that it should have been put up after obtaining permission from Ethics Committee. 95% residents shot down this front and responded, hoping I would do something to improve their life. I did. This professor tried to get rid of me somehow, but failed, and finally left looking for greener pastures. Two days ago an ICMR doctoral student came to see me for starting a new project. "I would like to start data collection on patients from tomorrow" she said. "Have you obtained permission of our Ethics Committee?" I asked. I knew the answer would be negative, because the application form needed my forwarding signature, and I had not signed any such form. "We have ICMR's permission" she said. "We do not need permission of your ethics committee." "You are wrong" I said mildly. "For doing research on our hospital patients, you need permission of our ethics committee." "But the previous study we did here was done without such permission. It was Dr. XXXXX from your department who gave us patients." XXXXX was the same doctor who did this and all other ICMR studies. I knew no such permission had been obtained that time, because I had been the chief that time too, and I had not signed any such application. "That was most unethical on part of the said doctor" I said. "I do not want to initiate any inquiry into what has happened, unless someone complains about it. But you will not do anything unethical with my knowledge." That student left with a promise to be ethical and has not returned. I wonder what kept the said doctor from obtaining ethics committee permission. Today I found another example of this phenomenon. I had written about use of spinal anesthesia for laparoscopy in our OTs. The anesthetists had vehemently denied repeatedly that it was a research project and had maintained that it was a service. Today I picked up a patient's records file and a sheaf of papers dropped out of the anesthetists' folder under the file. I picked up those papers, and found that they were informed consent forms for spinal anesthesia trial for laparoscopy patients. The chief anesthetist was different this time, but the trial was the same. "We have ethics committee permission for this" the anesthetist said. If they had permission for conducting the trial on my patients, it was necessary to involve me too. They had lied about it. I wonder what drives people to lie in academic matters.

Architectural Innovations

The heritage architect planned our offices in such a way that he took away our carpet space but did not give it to any one. “Sir, he has moved the front wall in and reduced our office area.” This sounded weird. “I will see what it is” I said. So we went up to the second floor to see the new offices. The fellow had broken down the front walls, so that he could work on the floor to stop the leakages. When he put up the new walls, he had put up wooden planks as walls in place of bricks and mortar. Must be hand in gloves with people who had fallen trees in municipal areas, making a lot of wood available suddenly. After all, one has to keep the market on the move. There was that shortage of sand too, because of some policy of the government and ban on taking out sand from rivers or sea-bed. “Why has he put wood in place of original brick walls?” I asked. “He was very strong on maintenance of heritage structure of our building. Now he has destroyed it.” “He said he has the liberty to do what he wants as an architect.” “Ah!” I said. There did not seem to be anything else to say. An architect given a free hand by the civic administration was not controllable with mere words. “But look at this. He has moved the walls in.” I looked. Indeed he had put the walls in line with the inner edges of the pillars, instead of the outer edges as they were originally. So the corridor was now wider and the offices smaller. He had put up rectangular box-shaped cabinets on the ground so freed, but the door was inside by a foot or so, anyway. “He said he has given us storage space by moving the walls in.” But the storage has to be inside the room, not outside it!” I said. “That's what!” the professor sounded quite upset, with full reason for being upset. “Another problem is that he has put a 5 X 5 feet glass in the front wall instead of wood.” There was indeed a transparent glass of 5 X 5 feet where the front wall should have been. “It must be so that you can admire the view of the corridor” I said, “like French windows – only in concept.” “What a view!” the professor snorted in disgust. “So you have less space than before, loss of privacy, and need for going out of the room to put things away or get them from the storage space!” I summarized. “In a nutshell” the professor said. “Must be recent advances in architecture” I said. “Don't hire such an architect when you redo your house.” “No chance! Who will hire such a Dodo?”

MARD Strike

MARD is the resident doctors' association. It functions in many ways, including striking work. They called for a 24-hour strike today. When I arrived for work, almost all of them were away. Unfortunately the person who is making a documentary on our hospital was scheduled to shoot some footage today, and I was the person she wanted to show working in our renovated wards. The team found me signing muster, and said they would follow me in the wards, with their audio and video equipment. As I entered the first ward, I found one Registrar and one Houseman still working on indoor papers. "You have not proceeded on strike?" I asked conversationally. I have seen so many such strikes and their uniformly dismal outcomes, that I have lost all emotions on this topic. "..." they smiled apologetically. "The television crew is here" I informed them. "They want to show the proceedings of the strike on television." They thought I was pulling their legs, which I sometimes do. "You don't believe me?" I said. "Look, here they are." So they turned towards the door and found the fellow with a huge video camera slung over his shoulder and the anchor alongside of him. "Now you will be on television live, and all people will know you have been working despite the MARD calling for a strike." That got them worried. The Registrar disappeared in the background somewhere. The Houseofficer started walking away, but unfortunately in the same direction as I and the team were going. So he turned his head away from them to hide his face and kept walking. We kept pace. When he realized that he was still on camera, he made his pace into a semi-trot and disappeared. They were not shooting him, but I did not tell him that. If the MARD people wanted to strike work and trouble poor patients, they deserved a little mental agony, I thought.

Let There Be Light

He said 'Let there be light', and there was light. We are talking about about our heritage building architect. For each cabin on my staff members, he has put four twin tube lights of full length. So in a room of 12'X12' there are eight tube lights when originally there were only two. Each room had enough windows. My own room had three, others have two or three. Plenty of sunlight streams in. But it must be in some book of heritage architecture that a room of such a size requires eight tube lights. He has saved some money though. He has put a single switch for all the tubes. You flick one switch, and the room is flooded with light, as in a studio. Saves on physical effort, I must admit. It must be important for older people with limited energey inside them. But it is a all or none phenomenon. We have no option of switching on only one or two tubes. Either we get eight or none. Perhaps he believes we are so popular that there will be media people around us every day, shotting pictures and videos. They should not be inconvenienced if they don't have flash lights or video camera lights.

Speed Breakers in Hospital

The heritage building of the hospital had been extended some time after the first part was built. For some curious reason they had built it at a higher level. Perhaps the ground was a little higher there, and it was easier to build it higher than to dig the ground to make it level. They had to put slopes to connect the two parts of the building, on which the patients could be wheeled to and fro. When the architect repaired the extended wing of the building, he repaired the slope too. In order to prevent people from slipping on the slope, he fitted it with parallel strips of tiles embedded obliquely. The central one foot wide longitudinal strip was left smooth for the trolley puller to walk on. It looked terrific, but the effect was not that terrific. "Sir, the slope is not good for shifting patients on a trolley" our OT attandant told me. "There are too many vibrations. and the person who pulls the trolley slips over the central smooth portion. A woman attendant slipped over it yesterday, hit her head over the edge of one of the tiles and hurt herself." "Let us go see it" I said. "Bring along a trolley with a box of stuff on it." He put three boxes of intravenous fluids on top of the trolley in a row, to act as a dummy for a patient. Then another attendant and he pulled the trolley up the slope and then down the slope again. On each edge of the tiles, the boxes jumped violently. It was like driving over a speed breaker made by embedding multiple pipes in parallel on the road. "An endotracheal tube inside a patient will get dislodged if we move the patient over this" the attendant said. "Stitches of an operated patient may break while moving her to the postoperative ward" the other attendant said. So I contacted the architect and the contractor. They agreed to grind the edges. They did that, but the work was not enough. It was still a speed-breaker. Perhaps they thought helpfully that they ccould slow down the journey of critically ill patients to heaven or hell by making them pass over the speed breakers.

Head-Low Head-High

There are very few situations in obstetrics in which the patient has to be given a head-low position, and even fewer in which a head-high position is required. Owing to the repair-renovation of the building and having had to put all patients in a very crowded ward, we had some curious situations. One day we found a patient in head-low position on one cot. She was under care of another doctor, and I would not comment on the need for giving her that position. There was a patient of mine on the same cot. In order to accommodate themselves better, the patients were lying down with the heads in opposite directions. So the feet of one patient were next to the head of the other patient. As a result my patient was in a head-high position. "Are you comfortable in this position" my Associate Professor asked her. The patient smiled weakly in response. She was not at all comfortable, having unwashed feet of the other patient next to her nose, and with the head high and feet low. "Shift our patient to the antenatal ward" I advised. I don't know if the nurses put another patient in our patient's place, again in head-high position.

Such A Head

We have a record department, where all medical records are stored. It usually works fine. Sometimes there is a mix-up, but the chief record officer is co-operative, and usually understands a valid suggestion and takes necessary steps to correct any errors pointed out. However, 'usually' does not mean 'always'. "Sir, I had asked you to give me a certificate, advising maternity leave from 1st April. You had written that on my paper and sent me to the certificate department" one pregnant woman told me in the antenatal clinic. "The clerk in the said department sent me away three times, refusing to give that certificate." The procedure followed is the patient submits the papers to the certificate department, which is a part of the record department. Then our doctors go to that department and fill out the certificates in duplicate. The patient collects the certificate in the afternoon the same day. This seemed a serious matter. Patients should not be sent away just like that. So I called the chief record officer and told him about the situation. "Sir, you cannot ask us to do irregular work" he told me. "What is irregular in giving a certificate like this?" I asked. "Maternity leave can be given when the woman delivers. May be you send the patient one day before delivery and we will give the certificate" he said. "How do I know when she will deliver?" I asked. "Only God would know the exact day." "That is true. But we cannot give that certificate." "But we are the people who fill out the certificates. You just have to issue them" I said. "No! We have to check them. Otherwise doctors will give out illegal certificates and we remain answerable for that" he said. "See, obstetrics is our specialty. I as head of my department understand obstetrics. If I give a certificate, do record office personnel know better than I do?" i was beginning to lose my temper. Clerks stopping doctors from giving illegal certificates was a grave accusation. "I am also head of my department!" he said. "I understand my work well." "Please show me the standard operating procedure for this work" I told him. If a pregnant woman desires to go on maternity leave before her due date, and the doctor thought it was OK, there was no prohibition for that. "Everything is not written down. This is how things are done around here" he said. "Let us go to the Director and sort it out right now" I suggested. That worked. "I will look at her paper and ask the clerk who refused to give that certificate why he did what he did" he said. She has not come back with further complaints. So probably she got what she wanted.

Architectural Wonders

We have this wonderful architect working as a consultant to the civic body for repair and renovation of the heritage hospital building. Fellow must be good, since the civic body pays him 10% of the entire project fee, which is in crores. This fellow did our labor ward. He put central air condioning system, as was asked. He also put four large exhaust fans in the same area. This was quite intriguing to me. So I asked his assistant (wonder boy does not speak to us himself directly). "Will the exhaust fans not increase electrical consumption?" "Not much. The motor is not very strong." "But the AC will keep going out through the open vents, and the consumption will increase because the cooling is lost and has to be restored." "The AC is quite strong. You will not be able to make out any rise in temperature." "Dust will keep coming in through the open vents, along with germs. The microbiology reports have come positive for pathogens even after washing and fogging with disinfectant three times." "Dust cannot come in. The exhaust fan will pull air out." "But why put the exhaust fans there at all? Do you leave the windows open at home when the air-conditioner is on." "um... no." Finally I convinced him to put shutters on the exhaust fan vents when it was not to be used. It was to be used only if the air-conditioning failed. Today I discovered another thing the wonder boy has done, or rather not done. He has not put any telephone line in the labor ward. It is all concealed wiring, and how he can put one there is beyond my imagination. "Why is there no telephone connection there?" the nurse of that ward asked his assistant. "It is the most important ward in this section. A lot of critical patients come here." "There is no line because it was not shown in the drawings." Drawings! The wonder boy makes drawings on Autocad. He had become furious when I had told him once that planning of our wards and OTs was not merely making drawings in Autocad. It needed planning based on the needs. So I was proved right after all. "You should make suggestions to us" the assistant said lamely. "I did. But your boss told me point blank that I should not communicate with him, and send all suggestions through the building and construction chief engineer. That fellow never responds to our letters. If the contractor makes 15 crore rupees, and the consultant 1.5 crore rupees, should they not be doing their work properly, instead of depending on my suggestions to correct every goof-up of their creation?" He had no answer to that question.

Fixing the Laptop

My laptop did a curious thing yesterday. I had used it for an hour or so before I shut it down for dinner. When I switched it on after dinner, it stopped boot process in the stage prior to appearance of the start button, taskbar, system tray and desktop. But it opened the My Documents folder and showed its contents. The display was 640X480. I could not do a thing to make it progress. I shut it down and restarted it using Ctrl+Alt+Del to launch Windows Task Manager. It repeated whatever it did before. After this happened three times in a row, I knew I had to do something else. I had prayed in the meantime, but it had not worked too. Then I decided to perform system restore. It sounded like a good idea, but was not easy. The start menu was not accessible, while the shortcut was in accessories. Then I decided to find the executable file in Windows folder. By navigating up the tree in the explorer window of My Documents, I reached the system 32 folder and checked each file. I found Paint.exe and found that I could launch Paint. So if I found the file that restored system, I could launch the utility by double clicking on it. I discovered it was svchost.exe with some flag that should do the trick. But the svchost file stayed calm on double clicking. It was nerly midnight when I had a new idea. I went to C drive, Documents and Settings, Start Menu, and Programs. There I found the Accessories folder, with the system restore shortcut. I double clicked on it. The rest was history. Now the laptop is behaving as if nothing happened yesterday. Another software had declared it has indexing errors, and wants to know if it should fix them the next time the laptop boots. I have told it to hold on until I find out how dangerous it is. The last time I had allowed Norton Utilities to fix errors on my PC, it had fixed the PC such that it would not restart. That was years ago, but the memory is burned indelibly on my mind.

Sleeping Chaperon

It is essential that a woman patient has a chaperone when a male doctor examines her. There are a problem with the implementation of this requirement in our center. The number of nurses and woman servants is far less than the actual requirement. So a number of times there is a male doctor without anyone to be a chaperone for his female patient. Proceeding without a chaperone is not only against the ethical practice, but also quite dangerous for both the patient and the doctor. On one hand the doctor may not behave inappropriately with the patient, and on the other the patient may falsely claim he did so in order to achieve some ulterior motive. We sometimes adjust by getting another female patient to stand in as a chaperone. There is always a big queue of patients. Usually they do not mind if another womann stands around while they are examined externally. For an internal examination, a nurse or woman attendant is summoned. I being a boss deserve more courtesy, they believe. So the nurse either helps me herself, or keeps a woman servant to help me. The servant assigned this work in my antenatal clinic is elderly, somewhat obese, somewhat lethargic, and often sleepy. She sits on a stool near a corner next to the examination table and dozes off while I see patients. I have to wake her up periodically. That day there were two male doctors examining patients in two adjacent cabins with a common door in between. There was only one attendant – the sleepy one. So I asked her to move her stool to the connecting door and sit on it. She could watch both the doctors and their patients from there. “The only problem with this arrangement is that she cannot sleep, sitting away from her corner. If she does, she is at risk of falling down” I said. This will keep her awake, I thought. She proved me wrong soon after I left the clinic. She went to sleep on the stool and fell down. I heard her head hit the floor, but was OK on radiographic tests. She took a few days off to recover. I hope she uses that time to catch up with her sleep, so that she will be alert when she resumes duty.

Wisdom of the Trustee

We have a finance trust in the institute called something like Heart, Club, Spade or some such Jubilee Society Trust. We will call it Some Jubilee Society Trust or SJST. Being a trust, it has trustees. Being a trust, it must be trustworthy. It handles all donations and grants brought in by staff members, deducts 10% of the amount as processing fee, and lets the said persons use the balance funds for buying equipment or consumables etc. It is a very closed group. So much so that despite the era of 'Right to Information', the secretary refuses to let us know who the trustees are. The refusal is more vehement when one of the trustees has passed some remarks we do not like and want to know who it is. It is rare to find such protective behavior in modern times and is quite laudable. The trustees are wonderful people too. It is not disclosed what the mode of their selection is. It is definitely not those who put up the money for the trust. We are the people who put up the money, and they just handle it, deducting 10% for the trouble. This is not the trouble they cause us. It is the trouble they take to handle our money and sometimes trouble us in the process. Troubling us is painful to them too, since they are very sensitive and empathetic. The trustees have a deep knowledge of technology, management, finance, and in general what is right and what is wrong. They decide how we should spend the money we generate and put in our accounts in the trust. They are inquisitive. They want to know our thought processes when we put up proposals for purchase of this or that. They are innovative. They keep coming up with newer terms and conditions, when we put up proposals based on the original terms and conditions. Such demanding nature ensures that the depositors of the trust are kept on their toes at all times. Some of the trustees have a knack of asking questions. They excel at this art so much that they ask for the sake of asking, even when the answers are in the original proposals or if the matter was not in the proposal. I recall they asking me who would read the ebook reader I wanted to buy with money I had deposited in the trust. I supposed whoever could read should read the reader. Then they asked me who would read it. that was beyond me. After all, I could just provide the reader, not force people to read it if they did not want to. Then they asked me about finance for downloading new books on the reader. I had not mentioned downloading, because I did not propose to do so. I had plenty of books myself for reading. One trustee is particularly vigilant. He questions if one particular vendor quotes a price much lower than the others. He wants us to buy expensive items, from the lowest quoter in the group. I had a vendor selling me a cautery for Rs. 85000/-, when two others wanted to sell me cauteries for Rs. 5 and 7 lac respectively. The latter were imported. But this trustee would have nothing of it. After all, imported goods must be so much better than Indian goods, though we poor people do not know that. It is people like this trustee see that our foreign trade thrives. Some trustees believe in improvement. When I get three quotations as asked, they want me to get more. One must always excel in whatever one does, they believe. I admire that spirit. Another good quality of the trustees is slow and steady method of working. even if something terrible is happening, they won't be rushed. I recall desperately trying to buy an electrocautery (with funds I had deposited) because I had only one in my emergency OT for two tables, the trustees obliged by going through my proposal before the meeting so as not to delay anything. That they took so long that it was anyway time for the meeting when they were through is the result of their slow and steady method of working. But they are elderly and have the wisdom to do so. They expect the younger persons who put up the proposals to answer with alacrity, or the proposals are postponed by another month, when they would hold another meeting. This time they sent me a list of questions ten minutes before the time of the meeting. They said the stress would do me good - puts adrenaline in circulation and releases steroids too. the secretary is especially wonderful. Must have known me for about forty years. Such a sport - she omits an e from my name's spelling, just to make me feel good. The qualities and abilities of the active trustees are endless. I will write more about them some other day.

Professor Cleans Boss' Toilet

I could not believe it. We had this old acquaintance, a professor and head of his department once in a civic hospital. He was visiting us socially. We were discussing things from the past. Suddenly he said, "I have cleaned the assistant commissioner's toilet once." He was a man of great dignity, integrity and professional standing. I could not believe he would ever do such a thing. I kept quiet, but he was good at face reading. "We were having a meeting in that fellow's chamber. A number of senior doctors and senior civic officials were present. The air-conditioner was on full blast, and the elderly people had to visit the rest room frequently. The fellow had a toilet built right inside his chamber." I continued to keep quiet. "This fellow was a crook of the top order. He had kept troubling our department for a long time, only because he wanted to favor some individuals for unethical reasons. Our complaints to the civic chief went unanswered. I was very angry. So ..." He took a pause to drink some water. I had no clue what it was leading to. "When I went to relieve myself, I had a sudden idea. I pissed all over his pot, then took his clean white Turkish towel from the stand and wiped the pot clean. Then I put the towel back on the stand. He and his colleagues who were party to the decisions which led to troubles for us had all day to wipe their hands on my piss." He completed his story and sat back, grinning all over his face, while I just sat there stunned.

Obstetrician Wearing a Two-Piece

It was a case of a rupture of the gravid uterus. The woman’s abdomen was full of blood and I knew it would spill all over me the moment my Assistant Professor opened her abdomen. I had to assist him because I was afraid to let him do it alone. The problem was that there was no plastic apron to wear. The general store ran out of stuff in April or May when the new year’s funds were made available on first April. This was March! “Sir, wear a sterile plastic drape” the House-officer advised me. “Professor X X XXXX was wearing one the other day” I said. “He had made a hole in it to pass his head through it. The other end had slipped up his thighs up to the groin level when he sat down. It looked so funny … like a mini skirt, only much higher. He said he had to wash his feet twice during the MTP, to get the spilled blood off.” The House-officer had no solution to that problem. So he kept quiet. Perhaps he was lost in thoughts imagining our elderly Professor in rolled up mini skirt-like plastic drape. I have spent a life-time making adjustments to make things happen in the institute I love so much. So I found a way. The case was well under way. All the blood spilling out of the open abdomen had been suctioned by the Registrar who was second assistant. I had told him that if any of the blood spilled over my way and wet my clothes, he would be personally responsible for it. He had believed it, and took great care to see that not a drop came my way. The uterus was being sutured. A big crowd had gathered to watch the operation, because uterine ruptures were uncommon, and one always learned something new in such cases. “Sir, where did you find a plastic apron?” one observer Professor asked. The shortage of plastic aprons was well known to all faculty. Perhaps they thought I received special treatment being the boss, and was given one by the nurse from a secret cache. “I did not find any” I said. I am wearing a two-piece.” “Two-piece …” the professor’s voice trailed. Imagining a male professor wearing a two-piece was sort of scandalous. It was also beyond comprehension how a two-piece would keep one’s clothes underneath safe from soiling with blood. “Yes” I grinned under the surgical mask. “I made a hole in one plastic drape and pushed my head through it. It is protecting my upper body. I wrapped another plastic drape around my waist and lower body. It is a two-piece of sorts.” They all roared. I think it must be polite to roar at a boss’ jokes.

Superannuate Now!

The Government has raised the age of superannuation (retiring in simple English) of teaching staff in medical and other colleges to 62. We teachers in the civic hospitals are still stuck at 58. There is a proposal to follow suit, but a lot of people are resisting it. The things said during the full-time teachers’ association meeting were somewhat as follows. “We don’t want it” I heard someone say. “They want us to stop private practice if the age for superannuation is raised to 62. How can we stop private practice?” They could go back to the old days, when they were practising privately on the sly, I thought. Then they would not have to give up their non-practising allowance too. “It is our right to get promotions” said one Associate Professor. “We won’t be denied.” “It will result in a four-year delay for our promotions” another person said. “That is injustice to us.” It was correct, I thought. I knew they had made statement to these effects in the newspapers. But they would have four more years later. “Let us postpone the decision for a few years, until we get our promotions” said a union leader type. So that was it! Get the Professors out. Then pass the proposal, so that they would remain Professors for four extra years. I was feeling somewhat sick inside, thinking about what these people whom we had taught everything we knew were thinking about us. I wanted out not at 58, but that day because there was no fun in working with people who thought of self more than anything else. Some politicians were in favor of the proposal, some were against it, depending on their party decisions. The junior doctors were against the proposal because of need for immediate gains. No one had bothered to consider what the people wanted, for whom it would make a difference if the senior doctors stayed to treat them. That was the way things always were, I thought with an odd sense of detachment.

Alcoholic Security

It was 8:45 A.M. I was walking towards the main gate of the institute going to work. A girl was walking out of it. The bar for preventing vehicles from passing through was being lowered with a remote control. Before I could shout a warning, it came down and hit her on the center of her head. She grabbed her head, looked around in confusion, looked in the direction of the watchman's hut, and went out without saying a word. I hoped she did not collapse somewhere on the road with an internal hemorrhage. I reached the gate, went in by the side of the lowered rod, and looked at the watchman's hut. The fellow was sitting inside without a care in the world. I walked toward him and asked, "did you not see the girl walking through? You should have stopped the bar from getting further down and hitting her." He looked at me through bloodshot eyes and mumbled "What?" So I repeated what I had said. "That bar did not hit her" he slurred. "It goes up automatically if it is going to hit someone." "I saw it it hit her. If she bleeds inside her head and dies, there will be a police inquiry and a court case against the institute and you" I said. "She should have watched for the bar coming down" he said. I showed him my identity card and told him I was Professor and Head of my department. That did not seem to register. I asked him for his name so I could complain to his senior officer. "You don't need my name" he said with a slurred speech. "Just complain to my boss." "Have you consumed alcohol?" I asked. "Your eyes are all red". "Alcohol?" he asked indignantly. "Ha! My eyes have been red right from my childhood. Have YOU consumed alcohol?" Now I was sure he was deeply under the influence of alcohol. I told him I would complain to the head of the institute as soon as he arrived. Then I went in search of the senior security officer. I found two of them and they went one after the other to find out who it was and if he was drunk. I followed them. By now the drunk had managed to get out of the hut and was standing on unsteady feet, trying to explain his innocence in as coherent manner as the fuddled brain would permit. I advised them to get his breath alcohol level done in the emergency room and left. On my way to the ward I met a union leader and asked him about this guy. "He drinks quite heavily" the leader said. Perhaps there was some reason for it. But to drunk at 8:45 A.M. on security duty was unpardonable. He was meant to stop terrorists from entering the campus and protect all people withing. Perhaps he thought the young girl was a terrorist and was trying to stop her by hitting her on the head with the bar. Why he should stop a terrorist from leaving the campus was beyond me. Perhaps he wanted to stop this terrorist permanently from harming others, either by coming back to the campus or elsewhere. I went to the ward and started my morning round with my staff members and residents. In five minutes this guy arrived, looking surprisingly sober, and said, "I apologize. What happened to day will not happen again." I left it at that, because his speech was still slurred and the sobriety must have been temporary, either due to shouting of his sober colleagues warning him of the consequences, or putting cold water on his head. "He was dead drunk" confirmed my Assistant Professor after the guy left. I went to see the chief security officer after the ward rounds. He was not in the office. I told them who I was, what the situation was, and requested them to tell him to call me when he came back. He did not call. Perhaps they protect one another. Perhaps they have a deeper bond. I had heard our institute had been turned into a castle to protect us from security threats from terrorists after the attack by Ajmal Kasab et al. Perhaps they should provide for hot oil to be poured on heads of people approaching the gates. Technology must have been so advanced by now that the security personnel will be able to tilt the pots and pour the oil using remote controls, just like they raise and lower the traffic bars with remote controls. If any of their own gets burnt, we could reserve beds permanently for them.

Paperless Office

I think we have made great moves towards going green. We seem to be doing away with paper and working only in ether. Sound travels in ether too. "Have you moved to the renovated wards?" the Boss asked on phone. "We are waiting for your letter" I replied. The Boss had asked us to submit a plan for moving, and we had submitted it a month ago. It seemed he had wanted us to move back then, but there was no written word to that effect as we had requested. "What do you mean?" he seemed angry. "I have sent two letters to that effect a month ago." "We have not received any in the dispatch" I said politely as ever. As if we would dare to disobey administrative command to move, even if we loved to work where we were and our patients loved being two or three on one bed. The dispatch people must really be understaffed to not send us such important letters from the Boss. Or they might be selective, because I keep receiving semi-trash from them regularly. "I am asking you to move now" he said. "Now will you shift?" "We will" I said. We must indeed be going paperless. administrative orders seemed to be becoming verbal. But then I recalled that one of the previous Bosses had asked us to something about Residents' schedule verbally, and when a question was raised allegedly from Delhi, that Boss had asked me to produce her written order. When I had stated firmly that it had been her verbal order, backed by the person in charge of the schedules, that Boss had told me to put down such verbal orders on paper and sent them to her for affirming. I could not see why she could not dictate the letter to her steno and send it to me. I had suggested that, but she had firmly declined. So I called my clerk a block away, and gave instructions about the arrangements to be made for shifting the department back from the transit area. Then I dictated a letter to be sent to the Boss for affirming the order to shift. I could not be paperless. Ten minutes later the Boss called again. "I have sent two letters on these two dates" he said, reciting the dates. "However I am sending a third letter now." "OK" I said. It would have been easier to send a photocopy of the previous letter, which I would have been able trace and see who had dared not send it to me when the Boss had wanted it to reach me. But the Boss knew administration better, and there must be a reason for not doing so, I thought. Ten minutes later the Boss' secretary called, asking us to send someone over to collect that letter. "Is it a copy of a previous letter or is it a new letter?" I asked. "It is a new letter" the secretary said.

Come right in

I had finished my OT and was changing into my street clothes in the changing room. There was only one changing room for the entire OT complex and I had had to wait in queue for some time before I could get in. I rushed through the changing process because I knew others would be waiting. It was less than a minute (I timed it with my breathing - 16 breaths a minute, there being no watch) when someone banged loudly on the door. I knew it would not be my unit staff members or residents, because they were sitting nearby the door and chatting. I was through, so I opened the door and said loudly,"Come right in". There was no one outside the door. Everyone outside laughed loudly at my invitation to come right in. "She ran away, Sir" my assistant Professor informed me. I looked in the direction he pointed out, and saw a Registrar of the other unit hiding near the door of the other OT. "Sorry Sir" she said. "It is OK" I said. "Everyone around here believes he or she is more important than anyone else, and that results in this sort of thing. No one would remain inside a changing room or a toilet longer than necessary. But would anyone outside that closed door believe that? Once I was in the toilet near our office. Suddenly someone shook the door so powerfully that I was afraid it would come off its hinges. It must be Dr. XXXXX, I thought because there was no one stronger than her in the department. I Opened the door and there was Dr XXXXX as predicted, glaring angrily at whoever who had dared to occupy the toilet when she needed it. "I knew it would be you, from the way you rattled the door" I said. "Oh, it was you! I did not know it was you" she offered lamely. So a courtesy of not hurrying someone inside a toilet was to be shown only to senior or higher ranking officers.

Uterine rupture and misoprostol

We had one patient referred to us from a private hospital. She had intrauterine fetal death at 16 weeks of gestation. They had also diagnosed a cervical fibroid by ultrasonography. They had inserted 200 microgram misoprostol vaginally twice and given it orally once, before sending her to us for further management. She came to us some time in the night. When I saw her in the morning, she was receiving a blood transfusion, and had already received oxygen for breathlessness. "Sir, she has ascites and hepatomegaly too" the Registrar said. "The pulmonologist has seen her and advised to give her nebulization" the Assistant Professor said. "I will examine her" I said. So a screen was arranged somehow in that overcrowded ward and I checked her up. "I think she has a uterine rupture" I said. "The fibroid you feel by the cervix is in my opinion the fetal head which has escaped the uterus." They did not believe me. "Get an ultrasonography done by a senior person" I advised "as early as possible." An hour later they informed me that the uterus had indeed ruptured. But the fetus was within the uterus and there was hemoperitoneum." "Arrange for an immediate exploratory laparotomy" I advised. That was done. When we opened her abdomen, it was full of blood. The membranes were bulging out of the uterus and the fetus was in the sac. The placenta had also been expelled. The top of the uterus had sort of blown off and was looking like a wild flower in full bloom. There was a white fibrous ridge all around the rupture site. We repaired the uterus, but could not put back the part of the uterus that was already lost. "How did you think of uterine rupture, Sir?" asked one Assistant Professor. "We were thinking of septicemia because she was breathless." "She was breathless because she was anemic" I said. "She had abdominal pain because the uterus had ruptured. On bimanual examination she had the fetus felt very superficially in the fornices, and there was no uterus above the cervix, that should have been there holding the baby." After some time the other Assistant Professor asked me the same question. He must have been concentrating on the uterine suturing when I had answered the same question a little while ago. I gave the same answer. "What was the cause of the rupture?" someone asked. "She probably had a uterine fundal weakness due to past perforation which she did not reveal to us. The precipitating factor was misoprostol" I said.