The MRI Rush

One of my aunts called the other day. “I think I need to see you” she said. “I have this terrible pain low down, where I sit. One doctor has advised me to undergo MRI scan.” “Come to the hospital tomorrow morning, and I will see you” I told her. She was waiting for me the next day. I saw her. Her gynecological condition for which she had come to me was nonprogressive, mild, and not responsible for her pain over the coccyx. I checked her papers. There was a gynecologist, who had advised her MRI of the whole spine. “Why did you go to the gynecologist when I had already seen you?” I asked her. Perhaps she was unhappy with my advice. “Actually I had gone for an eye check up. After getting my eyes checked, I said I had this pain. So the ophthalmologist told me to see her husband, who was a gynecologist consulting in the same clinic. He said I should get an MRI scan done.” I checked his notes again. There was no mention of any gynecological symptoms or signs. He had mentioned she had back pain and advised an MRI scan. “He had advised something beyond his field of expertise” I said. “You should see an orthopedic surgeon and do whatever he says.” “I will see my nephew, Dr. XXXX” she said. He was my distant cousin, and a good orthopedic surgeon. “Yes. That is a good idea” I said. A couple of days later I called her. “He said it is related to my age, and nothing needs be done except taking a couple of tablets, and daily walk” she told me happily. “There is no need for an MRI scan.” When I mentioned this to a colleague and wondered why a gynecologist had advised an MRI scan of the spine, he said “that is because they give 30% cut to the referring physician.” Suddenly it made a lot of sense. My aunt does not know this and many of his future referrals may not know it. Well, that is how it is.

Power of Suggestion

It is the usual practice in my institute that the resident doctors and interns write the clinical history of patients presenting to the outpatient clinic. Then the patients are examined by senior staff members, who confirm the history obtain additional details if available. This saves time, which is essential if we have to see more than a hundred patients in three and a half hours. But it has its downside too. If the person writing the history has a bad handwriting, it becomes quite troublesome to understand the understand history. One of my house officers has quite bad handwriting. That day I found a number of case papers with his handwriting and decided to do something about it. I called him, gave him a piece of unlined paper and asked him to write a couple of lines of clinical notes. When he had written enough, I took the paper and inspected it. There were three lines of text on that paper, going in three different directions. The letters looked Chinese, while the language was actually English. The size of the letters was varying widely. Then I wrote below his text whatever he had written, getting his help to read whatever I could not read. I wrote in straight parallel lines, with the letters of even size and looking like English letters. Then I gave the piece of paper and said "Study this. If you get any idea from that, I will be happy. If not, forget the whole thing and move on." He went away looking at the paper. He came back after half an hour, with another piece of paper, similar to the one we had written on initially. He gave it to me. He had written the same text on it, now in straight parallel lines, and legible print. "That is wonderful" I said. He went away happy. Now it remains to be seen if it was a temporary change, or a permanent one. I will know in the next outpatient clinic.

Plus Minus

I was working in the clerical office of the department, reading and signing some documents, when one of our professors walked in . "Type this document" he told the typist. She took it. "How do I type plus-minus?" she asked. It was to give a range, e.g. 23 plus or minus 3, meaning 20 to 26. "Um ... your computer keyboard does not have that minus below the plus sign key?" he asked. "No" she said. Actually no keyboard has that sort of key. But I did not educate him. Usually he seemed to know everything, and would not welcome new suggestions. "In that case type as plys followed by a forward slash and then minus" he said. She seemed to be happy with that. he went away. "Do you have a word file open?" I asked her. "Yes" she said. "Go to the end and press enter" I said. She did so and looked at me for the next instruction. "Now type +" I said. After she had done that, I said "Now select the + with your mouse and press Ctrl and U keys together." She did that. "Now click somewhere else and look at what you have got" I said. She did that and looked at me with new happiness. She had the minus sign below the plus sign typed. "There you are!" I said. "quite easy!"

Self Medication for MTP

She came for antenatal registration with a retired sister-in-charge who had worked with us in the past. I started taking her history. “I had a normal delivery 4 years ago” she said. “Then I got an MTP by taking abortion pills.” “Who prescribed the pills?” I asked. “My sister-in-law” she said. “Is she a gynecologist?” I asked. “No. She is not a doctor. She had used such pills herself and told me to take the same because I did not want that baby.” “Do you know the pills are to be prescribed by a qualified person, and can be dangerous to health if taken without a check up and supervision.” “I am a staff nurse myself” she said. “Where do you work” I asked. “In a primary health center” she said. “Do you give abortion pills to women coming to the center?” I asked. “No!” she said. “Why not? You trust them to work on yourself. Then why not on those patients?” She kept quiet. “Do you know that if they are used when the pregnancy is more than 9 weeks, the abortion can be incomplete and there can be severe bleeding?” She said neither yes nor no. “DO you know that if the pregnancy is ectopic, e.g. in the fallopian tube, it can rupture when you take these pills and you can die if not operated on in time?” “But I had done a urine pregnancy test on myself. It was positive” she said. “Urine pregnancy test is often positive in an ectopic pregnancy” I said. She did not seem to have known about it. “An operation for a ruptured ectopic pregnancy is also not all that safe. One often required blood transfusions. That can be associated with a number of complications, including transmission of infections like HIV infection. The patient then dies sooner or later.” She seemed happy that she had not required an operation of that nature. “Actually I did not intend to take those pills” she said. “I took them by mistake.” “Huh? You mean they were in a box of chocolates, and you took them thinking they were chocolates?” I could be sarcastic. I was her doctor and had to educate her. She smiled rather than giving a smart answer. After all I was her doctor and she needed me. “How is this sister-in-law related to you?” I asked. “Is she your husband’s sister?” “Yes” she said. “That perhaps explains it” I said. “Sisters-in-law often do not get along well. Perhaps they would find another wife for your husband when you died.” “No, no” she said, but her heart was not in it. Perhaps she believed that was the sister-in-law’s intention. “You seem bent on harming yourself” I said. “You failed once. Why don’t you find a good sized rock and slam it on your foot? We have building repair work in progress. There are plenty of rocks outside.” “I won’t take abortion pills by myself again” she promised. I hoped she would discourage others from taking such pills to, even that sister-in-law.

Night Consultation

She registered with us for antenatal care today. She already had a pediatric surgical opinion on her unborn baby from our hospital. That was unusual, since the normal sequence is obstetric consultation followed by pediatric surgical referral if required. “How did you go to pediatric surgeons before registering with us?” I asked her. “We had come here before, and the doctor who examined me asked me to go to the pediatric surgeons” she answered. That sounded like prior registration with some other unit. “Show me the papers of your previous visit to the hospital” I said. She produced a casualty paper. It was indeed our previous emergency. The time of her examination in the emergency room was 1:30 A.M. “Why did you go to the emergency room at 1:30 A.M.” I asked. What complaints did you have?” “We had registered in KDMC hospital. They asked us to go to this hospital for neonatal care, because my baby has a malformation on ultrasonography.” “But were you having labor pains or vaginal bleeding or some such acute symptom?” I asked. “If not, you have to register in the antenatal clinic at 1:30 P.M. on any week day.” “No. I did not have any acute symptom” she said. “We have an acquaintance who works in this hospital. He said we should go there in the middle of the night, when there is no crowd and our work would be done well, the doctors being able to devote more time to us.” I was aghast. She was accompanied by her mother-in-law and husband both. I asked her to get them both. When all three of them came to me, I said, “Do you know that patients without acute symptoms have to come to the clinic in day time and not at night?” “We did not know that” the mother-in-law and husband said. “That is not believable. You are all adults and have visited KDMC hospital and private doctors before. You know the routine. Did KDMC doctor tell you to come to our hospital in the middle of the night?” “No.” “You came here in the middle of the night because there would be no crowd of patients and your work would be done quickly, and with greater attention of doctors who would have more time” I said. “That was not the reason” the mother-in-law said. “Your daughter-in-law told me that was the reason” I said. The mother-in-law and the husband kept quiet. “Do you know that the doctors working here work day and night on the emergency day, and they are very tired at night?” I asked. They kept quiet. “Do you know that they work at night to give healthcare to serious patients, and you deprived some serious patient of their attention, by drawing them away to examine you and perform your ultrasonography?” They kept quiet. “Do you realize this is abusing the system, which is meant for poor patients in need?” “We are sorry” the husband said. It was simple. One abuses the system to get what one wants, and if caught, just says ‘sorry’. “Saying sorry to me does not achieve anything” I said. “Will you go and say sorry to those serious patients who were deprived of the doctors’ care for the duration of your examination and ultrasonography?” They kept quiet because either they did not know how to do that, or did not want to do that. “Who was the person who gave you this advice?” I asked. “One Mr. Vinod” the husband said. “He is my friend. He knows someone who works in this hospital.” It identity of that fellow seemed to be covered by multiple proxies. I gave up. I directed the patient to an intern, and moved on to see another patient.

Repairing a Thermometer

We had given our son a thermometer when he went to college and later to a job in another city. When he came home last week on vacation, he brought it back because it was not working. "I have to keep it in the axilla for long periods, and still the temperature does not rise much." He did not tell us why it was so. "Let us throw it away and give him another one" my wife said. We gave him another one, instead of asking him to get one after going back after the vacation, because we were more concerned about his health, and knew he would procrastinate. But I wanted who see why the thermometer would not work. I had fixed electrical appliances, mechanical appliances and computers in the past, but not a thermometer. I examined it and found that a small bit of mercury was lying in the capillary tube at the level of 1080 F. I wondered how it got detached and reached such a high level. Perhaps he had dipped it in warm water. I kept the thermometer in the refrigerator but it remained as it was. Then I had another idea. I dipped it in warm water and the mercury expounded and met the tiny part at 1080F. I shook it back to the bulb anal all of it went back. I tested it and it worked. It did show the temperature one degree less than on another thermometer. But then I could always add one to whatever reading I got.

Postpartum intrauterine device

She was with what can be called an NGO. The NGO was affiliated to Johns Hopkins in US. She said they were working with our central government on a program for insertion of intrauterine-devices immediately after delivery of the baby and placenta, vaginally or after a cesarean section. She wanted us to do it in our patients too. "It will be possible only if you can convince heads of all other clinical units in my development" I said. " I will need references too." After all Johns Hopkins published Population Reports, and there had been no issue published recently on this technique. We had been using modified devices for early puerperal insertions. We used to put No. 2 chromic catgut sutures on the transverse bars of the devices so that they would stick in the decidua of the uterine fundus. By the time the catgut got absorbed, the uterus would be involuted and the device would not get expelled. Now they wanted us to use regular devices without any modifications. She sent me a CD with a number of published articles, mostly abstracts. She also arranged a meeting in which all questions we would ask would be answered. I read the references. They could not make it in time for the meetings and I had to leave for a planned teaching session. But the following points emerged in the discussion before I had to leave. I. The expulsion rates were far higher than after interval insertion. 2. The threads of the devices could remain above the cervix in 4 to 5 per cent cases. Ultrasonagraphy would be required in these patients every time the continued existence of the device in the uterine cavity had to be ascertained. 3. All the studies had been performed in developing counties and none in the developed countries.

Lethargy or Overwhelming

I come across a lot of people, doctors, patients, relatives of patients, visitors and others. Study of their nature is something that I do not really enjoy, but somehow I end up doing it. I have noticed a curious thing among some (actually more than some) doctors in my institute. They indulge in some practices that they ought to be aware are not recommended. These things are part of the undergraduate and postgraduate curriculum. Surgical asepsis and antisepsis are quite basic. Just in case they did not study very well as students, I make it a point to teach them about these issues, when they join my department, and then periodically when I find them deviating from the norms. But I have now realized that they continue to go back to their original practices sooner or later, usually sooner. Wearing a cap and mask during surgical procedures, not touching contaminated things when washed up, wearing surgical gloves without touching the outer surface of the gloves, waste disposal.... the list is endless. I have also found that the only explanation they offer when caught deviating from standard practices is "sorry sir!". So I really do not know what the real reason is for not practicing something that is essential for optimum healthcare. I have been able to come up with only two possible reasons for this. Lethargy could be one reason. Following a more complicated procedure is more taxing than a simple one, even if it is dangerous to someone else. Being overwhelmed by the work could be the other reason. In such a state of mind, perhaps one tends to perform without conscious thought. People with the first reason are criminal in nature. People with the second reason are inadequate. Both are dangerous to the society. Since appealing to their conscience does not work, the only solution to the problem seems to be constant policing and penalizing when caught. It is sad that it is the only option, and even sadder that it is not a feasible option, unless one employs people specially for that job.

Single Uterus - Two cervixes

One pregnant woman came to our hospital in preterm labor. My Assistant Professor had seen her and admitted her for tocolysis and betamethasone therapy to hasten fetal lung maturation. "Sir, she has a longitudinal vaginal septum and two cervixes." "I will see her" I said. I checked her up, and indeed, she had a longitudinal septum in the upper part of the vagina. Sometimes it so happens that there is a single cervix, and the septum has its upper edge at some distance from the cervix. Hence the examining finger can pass from one side of the septum and feel the cervix, then pass on the other side of the septum over its upper edge and feel the same cervix. But one gets the impression that there are two cervixes, one on either side of the septum. In order to avoid this confusion, I put the right index finger on the left side of the septum, the right middle finger on the right side of the septum, and could pass each finger through one cervix each, 1 cm dilated. Fetal membranes and the fetus above them were felt by each finger. "There is a single uterine cavity with the fetus in it. There are two cervixes, each communicating with the uterine cavity. Treat her preterm labor. When the time comes, she will deliver through either of the cervixes. We may have to divide the septum during labor if it obstructs childbirth" I said. It was not to be. The fetus died inside the uterus the next day. No cause was found for the fetal death. We had to induce labor to deliver her. During labor, there was obstruction, and they had to divide the septum. Someone who had not understood the anomaly operated on her. I came to know all about it the next day. I wanted to see what had happened inside her. When I examined her, I found that they had divided not only the septum, but also the tissue between the dilated cervixes. So she had a single cervical opening, sort of a figure-of-eight rotated through 90 degrees. "We do not have to do anything for her right now. I would have preferred the cervixes were left intact. Give her contraception of her choice, and let her register early in her next pregnancy. She may need a cervical cerclage in that pregnancy." The patient went home happy that no surgery was required at that time. I am still worried what may happen to her if she goes to another hospital in her next pregnancy.

Car in a Circus

When I was small, I used to go with my father to see a circus whenever one was in town. There were many things that I liked. One of them was a car that would be driven all around on the stage. As it drove around, its different parts would fall off one by one - a door, another door, boot cover, bonnet, headlights, body; until finally the driver would be on the chassis, still going round and round. I have not been to a circus for a long time now. But I often think of the good old days. I thought about it again after repair and renovation of our hospital building. The tube lights started falling off the ceiling first. Then the plumbing started coming off at places. The electric wall sockets broke off at places, and so did internet connection sockets. Granite came off walls and door frames. Now finally the plaster has started falling off the ceiling. In barely four months this has happened. We had moved out so that the breaking and broken things could be repaired. Now a lot of money has been spent and we are probably back to where we were before the repair started. "What shall we do?" the sister in charge of the concerned ward asked me, when the plaster fell off the ceiling in the ward's toilet block. "Inform the civil engineers, ask the patients to avoid going to the toilets near the danger zone, and if they have to go, tell them to go with God" I said.

Unprepared Professor

We are quite particular in preparation of the teaching program for students. The lecture series is prepared a few months in advance, and displayed on notice boards for students and teachers. The teachers are reminded in advance by the record assistant, so that they get to prepare themselves, and do not forget to teach on the scheduled day too. We have this professor, who was scheduled to teach on a particular day after my lecture last month. I finished my class on time, but he did not arrive as expected. Later on I heard that he did teach. Today I heard the remaining part of the story. His lecture was on ‘puerperium.’ He tried to get it rescheduled, because his unit residents were to present a journal club. Rescheduling for personal reasons is not possible, and the request was refused by the concerned officer. He had to arrange with someone else and exchange teaching sessions mutually. He was probably unable to find anyone willing to exchange the session with. Finally he took a lecture himself. I heard he taught ‘how to appear for an examination’ instead of ‘puerperium’. Probably he had not prepared for the class, and did not have any slides, nor could get slides from anyone else. Now the students have to learn the topic on their own, or go through life without knowing about it. “Sir, but how can a professor as senior as he can not know enough to teach undergraduate students even without any preparation?” the concerned officer asked me. “That is the way it is” I said.

Fitness Certification

When the civic body employs anyone, a certificate of fitness is required. When I had got into the service ages ago, they had sent me for fitness test too. The medical officer was a dark and stout woman of forty or so. She asked me to to the end of the queue and wait my turn. There were a lot of class 3 and 4 persons waiting, who needed a job more than I did. They had reached there before I did, so in all fairness they should be checked up first. So I went to the end of the line and stood there. That she was just M.B.B.S. and I was M.D. did not matter to me. She was going to certify me fit, and I was going to do what she wanted me do. But the local clerical people and servants thought I should be treated better because I was a doctor, to be appointed as a class 1 officer. So they got me to the head of the queue and made me stand there. “Why have you come here when I asked you to go to the end of the queue?” the medical officer shouted. Before I could answer her, the people who had got me there told her they had got me there, and for what reason. “OK” she grunted “come inside.” I followed her. She looked at my conjunctiva. “Do you have ear problem or a hydrocele?” she barked. “No” I said. “OK. Get a CBC and chest radiograph done and come back.” I got those done and I was certified fit. I always wondered what a hydrocele had to do with it, and how could she rely on my statement that I did not have one. She did not even touch me, leave alone checking my heart or lungs. Well, that was the way things were. Today a potential employee came looking for my Assistant Professor for being certified fit for employment. I found the doctor she wanted and the doctor certified her. The employee-to-be came back after half an hour, with a form. “They sent me back” she complained “asking me to get this form filled by the doctor.” I called the said doctor and checked in the meantime what was not filled by our doctor. They had given her a form for ophthalmic check up, with all details of eye examination printed on it. Someone had written ‘Gyn’ with a pen on it. “This is a form for ophthalmic check up” I said “not gynecological check up.” “That is what they always do” another Assistant Professor standing nearby said. “Writing ‘Gyn’ on it does not make it a Gynecological checkup form” I said. “We have to write our findings in the blank space” the doctor informed me. The employee-to-be got the necessary gynecologic details filled on the ophthalmologic form and went away. “This is the way things are” I said to no one in particular and went back to my office to continue with my work.

Tug on Stethoscope

I had an idea to conduct skills workshops for the resident doctors. My staff members strongly supported that idea and barring a couple of them, they came up with teaching modules too. The resident doctors cannot be free on all days. So we decided to conduct each session three times, on different week days. Thus every resident would be able to attend the sessions.We prepared a schedule and I started with the first module. The response was good, and their participation was active. My module on objective training on monitoring different parameters of progress of labor, including accurate assessment of parameters like cervical dilatation, which are usually very subjective. The residents seemed to like it. Though they liked it, some of the residents would doze off, probably because of emergencies in the labor ward the previous night. "Hey, wake up" I said to a dozing girl. Her neighbor nudged her and she woke up, only to doze off again after five minutes. "Hey, please sit in front of me in the first row" I said "so that you will not doze off. The stuff we are discussing is important, and I don't want you to miss it." She sat in the first row. Then she dozed off again. I had an idea that I had seen in a movie of Jackie Chan. His teacher had tied a string to Jackie Chan's great toe, and the other end to his toe when going to bed. So when Chan tried to run away during the night when the teacher was asleep, the teacher's toe got pulled and Chan got caught. I had no string, but the resident doctor had a stethoscope. "Hey! Let us do one thing. Hold the chest piece of your stethoscope in your hand, and put the remaining stethoscope over the back this chair, so that I can reach its other end. If you doze off, I will tug on the other end of the stethoscope, so that you will wake up." All other resident doctors laughed. The girl became alert. But unfortunately she dozed off after a couple of minuted. I tugged on the other end of her stethoscope, and she woke up. Then she remained alert until the teaching session got over. I liked this idea so much that I used it on the second day too. It worked like a charm. On the third day, there was need for the use of this idea. I got that sleepy girl on the first row, and after she still dozed off, I used the stethoscope trick. All residents were hilarious, but that did not put her off. As soon I started talking, she went to sleep and dropped the stethoscope chest piece. They laughed and the noise of the laughter and the stethoscope hitting the floor woke her up. Five minutes later she was asleep again. I tugged on the end of the stethoscope, and she woke up. I thought she would not go to sleep after all this. But she proved me wrong. When she dozed off again and tugged on the stethoscope, she just kept nodding her head and continued to sleep. Even the laughter of other residents could not wake her up. "I could make you stand" I said "so that you will not sleep. But it is risky. If you go to sleep while standing, you may fall down and get head injury. It is better you sleep, even if it means missing out on your education." She did not sleep subsequently until the teaching session ended, because there were only three minutes to the end.