Sir!

Sir!
I knew the armed forces officers said ‘Sir!’ whenever their bosses told them to do something and the wanted to convey that they had understood the instructions absolutely and they would obey them completely. It probably saves energy for combat, when they say one word (Sir!) instead of two words (Yes, Sir). It also saves time for action, when they spend less time talking. Recently there was that Hindi movie ‘Mausam’, in which the hero keeps checking his aircraft prior to take off on a mission by running his hand on the fan, undercarriage and whatever he can reach (like a mother does before her young one takes off for nursery school). The other impressive thing he does in that movie to show that he is truly an airforce officer of substance is to say ‘Sir!’ whenever his boss tells him something. When I heard that, I knew I had heard it before too. It soon came to me, because it had struck me as something different at those times too.
It was my House officer who later became my Registrar a few years ago. She used to say ‘Sir!’ in the same tone whenever I told her to do something in patient care. Then I heard it from an additional civic chief, when she interrupted our meeting to talk to her boss, the civic chief himself. That time I recalled what my old Registrar had been doing, and I happened to remember that she had been daughter of the civic chief of that time. She must have heard others speak to her father that way. Finally I heard our boss say it the same way to the civic chief on phone the other day. Now I am educated that the IAS cadre officers are like armed forces officers, at least in this respect. A couple of weeks ago I heard the head clerk of the tender-equipment department speak to me (!) the same way. I was flattered. I was also convinced that he had a bright future, like the armed forces officers and IAS officers.

Simultaneous Open Heart Surgery and Cesarean Section

A third gravida second para presented to our emergency room with 32 weeks of pregnancy and congestive heart failure due to a tight mitral stenosis. Her respiratory rate was 50 per minute and heart rate 140 per minute. She was urgently rushed to cardiology department, where they started treatment for her cardiac condition. They attempted a balloon mitral valvatomy, on an emergency basis. Unfortunately it failed. So they scheduled her to undergo an open mitral valvotomy the next morning. When I reached the hospital in the morning, my Assistant Professor came to meet me.
“Sir, the cardiac surgeon wants us to perform a cesarean section on her at the time of the open heart surgery” he said.
“But she does not need it” I said. “She will surely die if we do that.”
“I explained that to him, but he refuses to listen” he said.
Just then the said cardiac surgeon called.
“The woman should be delivered by a cesarean section at the same time as the cardiac surgery” he said. “Or the fetus has a 99% chance of dying.”
“But the baby is preterm” I said.
“These days they have excellent neonatal care” he said. “Surely the baby will survive.”
“Not unless we mature the baby’s lungs with betamethasone. We have not done that.”
“Uh!” he said. That was new to him, I thought. “But she is already anesthetized. It is so easy to perform a cesarean section.”
“If she is already anesthetized, by the time we send someone over and arrange for a cesarean section, the fetus will be so depressed due to general anesthesia, it will be birth asphyxiated and may die or be extremely moribund” I said.
“Hmm…” he said.
“Besides, open heart surgeries are done during pregnancy world over, in selected cases, without the fetuses dying” I said.
“Hmm..” he said. He must have been surprised I knew about it.
“You will heparinize her during your surgery, I suppose” I said. “Then she will keep bleeding from the placental bed and the uterine and abdominal suture line until you reverse the action of heparin with protamine sulfate. That will surely kill her.”
“…” he seemed to have nothing to beat this logic. “But send a faculty to be a standby during our operation” he said.
There was nothing to be done obstetrically, and keeping a staff member sitting in their OT was meaningless. But it would keep his mind at peace and he would operate better. So I consented. “OK” I said. “Our Assistant Professor will reach your OT in ten minutes.”
They made our Assistant Professor stay in their OT for more than four hours. They even asked for a baby tray to keep the baby if the woman delivered during the cardiac operation. He was quite amused by whatever happened. He narrated the whole thing after coming back with a grin on his face.
“Sir, the baby was dead in utero. It must have died sometime during the night due to maternal cardiac failure causing hypoxia.”
“So they wanted us to do a cesarean section to save a dead baby from dying again?”
“They did not know it then. But even after I told them about it, they kept asking me if it was safe to give aminophylline and adrenaline, in view of the fetus still being in utero” he said.
I was speechless for a few moments.
“But he has M.B.B.S. degree. Does he not know that a woman does not pop out a baby just like that? She has to go in labor and remain in labor for many hours” I said.
“I don’t know. He was quite ‘hyper’ about it” he said.
He must indeed have been hyper. He called us the next day moring, asking us to extract the fetus so that they could extubate the patient.
Perhaps we shoud invite him for a continuing medical education program, perhaps better termed as a refreshing medical education program.
"Where did he get this idea of performing a cesarean section and an open heart surgery at the same time?" my Assistant Professor asked me.
"We had a Professor in our department who was very friendly with the cardiac surgeons. She would go to their OT and perform a cesarean section at term if they were performing a cardiac surgery for any reason. It would save another anesthesia, should the woman require a cesarean section later - the cardiac-obstetric team apparently believed. That team has left this institute. But this fellow might have been a junior resident doctor at that time. He might have recalled those wonderful days" I said.

Super Ultrasonography

We have some very enthusiastic doctors in the institute. It is people like them who are responsible for bringing about a change.
One patient came to the outpatient clinic with chronic pelvic pain. We treated her with a course of antibiotic. After her symptoms persisted, we decided to perform a laparoscopy on her, thinking it could be endometriosis. In the meantime, an ultrasonography was done on her, to see if there were any masses that could not be detected clinically. Her report showed:
‘An ovarian cyst measuring 6.4 mm X 4.4 mm, with echoes within, suggestive of a complex ovarian cyst’. We have had such reports in past, when the overworked resident doctor performing ultrasonography had written mm in place of cm. So we sent the patient back for clarification and a reassessment if required. The same resident doctor reassessed her and confirmed that the size of the complex ovarian cyst was indeed 6.4 mm X 4.4 mm. I called her and spoke to her on phone. She was sure of her diagnosis. I asked her superior officer if their machine had such resolution that the diagnosis of a complex ovarian cyst of such a small size could be made. She said ‘no’. It is possible the resident doctor is very good, and what we would believe to be an ovarian follicle turns out to be a complex ovarian cyst. Though I am not willing to bet on it, I will look at her ovary during laparoscopy and find out what she has actually got.

Curious Case of MRKH Syndrome with Vaginal Eversion

A woman aged 35 presented to our outpatient clinic with a complaint of something coming out per vaginum. She had undergone investigations in past for primary amenorrhoea and had been diagnosed to have Mullerian agenesis or Meyer Rokitansky Kuster Hauser syndrome. She had been advised vaginoplasty by he gynecologist at that time, but she did not undergo that procedure. Notes of her previous clinical and endoscopic evaluation were not available. She was single. We found her to have 3 cm eversion of thevestibular epithelium, lateral limits of which had medial aspects of the labia minora included in the eversion. She had no visceroptosis. It was possible that she had been sexually active and the chronic penile pressure had developed the vagina. However she refused having had any sexual activity. The lateral attachments of the vagina were also lost, besides loss of support to its vault.
We planned to perform sacrospinous suspension of the vault. However her ligament was quite small and there was no space in the pelvis to place the suspensory suture without risk of injury to the pudendal or sciatic nerve. We performed iliococcygeus suspension of the vault on theleft side. She withstood the procedure well and was found to have adequate elevation and suspension of the vagina at follow-up examination.

Paperwork

Paperwork is one of the most boring things in the life of a resident doctor. But it one of the most critical part of the patient’s management. It forms the backbone of one’s defence should the patient sue the doctor for any reason. Hence we train the resident doctors quite rigorously in paperwork. This year I started skills workshop for them, and put one session on paperwork. All sessions were compulsory for all of the resident doctors. However some of them missed some, because of illness or some other reason for being absent. Even without any training, filling up the indoor paper should not be difficult. There are printed headings on the case paper. One just has to fill in the blanks. Should not require too much intelligence and much training, one would think. Alas, no! One such resident doctor had completed a patient’s indoor case paper as follows.
Provisional diagnosis: Vaginal hysterectomy was done.
Final diagnosis: by Dr ‘so and so’
Operation performed: assisted by Dr ‘so and so’
Complications: and Dr ‘so and so’
Disaster: spinal anesthesia by Dr ‘so and so’
(I have put ‘so and so’ in places of names of doctors involved to protect their identity.)
The resident doctor felt that the space provided for putting the name of the operation, the names of the operationg surgeon and his assistants and the anesthetist was not sufficient. So she used up the space available above and below the heading ‘Operation’, breaking up all that information into so many more lines, without any regard to the information that should have been entered there but was not and could not ever be thanks to her efforts. I read out the stuff she had written on my ward round, and all the other residents listened with boredom until I read Disaster: spinal anesthesia by Dr ‘so and so’, at which point they burst out laughing. Perhaps the statement had a ring of truth to it. The poor anesthetist is not aware how his work has been appreciated by our resident doctor.

Resident Stress

All my resident doctors are of about my son’s age. I suppose the age difference and our positions at opposite ends of the organizational chart of the department prevents them from talking to me about any issues that concern us.
She was one such resident doctor. She had worked with two other specialists before she came to work in our unit. I liked her. She was quietly efficient. I had always wanted a daughter, and I would have loved to have a daughter like her.
Then one day I found that some resident doctor had been doing something that was against scientific principles and departmental policies. I asked them who had done it, and they would not answer that question. Finally I had to request my Associate Professor to interview the patient who had been the subject of that particular form of therapeutic misadventure. I made all resident doctors sit in my office so that they would not interfere with the process of truth finding. When that was being done, this young doctor got up and owned up. I was stunned, because I had not thought she would have done it. Then it turned out that all the residents were doing that, and some Assistant Professors were asking them to do it. I advised them to improve their practices and left it at that.
A couple of months passed. This young doctor had a couple of bad obstetric experiences in a single day. There was no apparent evidence that she had been negligent in any way. Perhaps it was what they called a bad hair day for her. But it was also true that she did not inform me of the mishaps, and I came to know about them after a couple of days during ward rounds. I could not talk to her for two more days because she had been busy with emergency duty and postemergency duty. Finally on the third day, I called her. She entered my office looking all tense.
“Please sit down” I said. She sat down.
“What is wrong?” I asked her. “You had two complications in one day.”
“Sir, I did everything correctly. It was not my fault in the first case.”
“I believe you. It could have happened to me too. But what about the other case? How could you do such a thing?”
“Sir, I was actually not there when it happened.”
“But you told me yourself during ward round two days after the episode that you did it” I said.
“That was because I was the doctor on duty. I had gone to get a bottle of saline when that happened.”
“But you did not tell me the truth” I said. “Why do you not tell me the truth right in the beginning?”
“Sir, it takes a lot of courage to talk to you” she said.
“Huh?” I said. “At my age and with my physique, I cannot imagine anyone would be afraid of me. I cannot beat up anybody, even if I want to.” I knew they were afraid of me as a head of the department, not because of the physical threat I could pose.
“Sir, can I talk to you?” she asked with a tense face.
“Of course” I said. “That is the purpose for which I called you.”
“Sir, I am quite upset and tense. Whenever I go to the labor ward, all of them look at me in a funny way and talk about me, as if I have done something terrible.”
“But you yourself said you did it. You asked for it. Now tell them the truth.”
She shook her head. It did not seem possible.
“I just don’t know what to do. I feel all alone and terrible. I have not spoken to my mother for three days.”
“Why? A mother is the best person to talk to in such a situation. She helps one relieve the stress. Talk to your mother.”
“I have no courage to tell her what happened. She will think I am a fool.”
She seemed to be misguided about mothers. “A mother and a father know exactly how foolish and useless their child is. They just love and support the child even if it is a fool. Your mother knows you inside out. She won’t think differently because of what you tell her. Talk to her.”
“Sir, I am afraid I will burst out crying if I talk to her” she said. A couple of tears rolled out of her eyes, which she wiped absently.
“Crying is essential in your current condition” I advised. “It will reduce your pent up stress. Have you seen the movie ‘Three Idiots’?”
“Yes, Sir.”
“If you don’t wind down, you may end up doing what the young guy did. If he had spoken to his mom or dad, he would not have killed himself” I said. I was genuinely afraid she would end up doing such a thing. But I could not comfort her like her mother could. She probably did not believe in father figures. She had not mentioned her father even once.
“I won’t do that” she said firmly. The tears had stopped. Perhaps I had assured her in some way. She went away from my office looking free of tension.

Trial and Error?

I had just become head of a clinical unit. I was quite young. Perhaps I did not look senior enough. But people working in the institute knew about me. They would drop in some time when they needed advice. One day a youngish looking fellow came to see me.
“Sir, I am a clerk in the college office” he said. “My mother has a gynecological problem and has been advised a hysterectomy by someone. My father would like to talk to you. We want your opinion.”
“OK” I said.
“I have her case papers and reports. Will you see us now?”
I had something important scheduled some time after. This woman was not registered in our hospital, and she had not come herself. I probably should have asked them to bring her for a check-up in my outpatient clinic before offering an opinion. But I could not refuse that young fellow who was concerned about his mother.
“OK.” I said. He brought his father and the file with all documents related to her treatment. I read through all the documents. She was middle aged. She had had menorrhagia for a few months. Her uterus was of normal size. Her endometrium had not been examined.
“She requires a dilatation and curettage. If the histopathological report does not show any malignancy, she should be treated with medicines, norhormonal, and if they do not work, hormonal. If that fails, a hysterectomy may be required.” I was quite happy that I had explained an ethical and conservative management algorithm to them.
“So it is all trial and error!” the fellow’s father and the patient’s husband said. Then they got up and went away.
I was speechless. He made it out as if he had obliged me by allowing me to give an opinion on his wife’s illness, even when she was not my patient, and tried to humiliate me by saying my scientific approach was just trial and error. Even if I had not become speechless, I would not have said anything in retaliation, because it was not in me to do so. I kept the hurt inside me and moved on. I met the clerk after a month or so in the college corridor.
“How is your mother?” I asked him. “Is she OK?”
“Yes” he said “she underwent hysterectomy.” He looked embarrassed while talking to me. I smiled at him to ease his discomfort and we went our different ways.
Many years have passed since. I have not forgotten the hurt yet. I have learned about human nature from that episode and also from a lot of people I have met professionally subsequently. I have not allowed another person to do that to me again.

Fetal Heart Rate and Fan

I was giving viva voce to undergraduate students. The instrument being discussed was Pinard’s fetal stethoscope.
“How do you check fetal heart rate using this instrument?” I asked.
“The room should be quiet. I will switch off the fan” she said.
“Switch the fan off?” I was confused. “Why do you switch the fan off before checking fetal heart sounds?”
“To make the room quiet” she offered.
“A room is an inanimate object. How do you make it quiet?”
I normally do not ask such questions. But the fan thing had baffled me.
“By switching off the fan” she said.
“Where did you read this piece of information” I asked, suddenly suspicious that some book had this wisdom. “Please show me the book. I am quite curious.”
She fetched her book. It was a book on Practical Gynecology and Obstetrics written by a local author, whom I knew well. She opened the book and pointed out the first instruction for using Pinard’s fetal stethoscope: ‘In a quiet room (switch off fan)’
“Since it printed in a book, I will not consider your answer wrong” I said. “But does a fan make any sounds that interfere with auscultation of fetal heart sounds? Besides, if you have a busy practice, will you keep switching the fan on and off every five minutes, as you examine a number of pregnant women?”
She kept quiet.
“Who advised you to read this book? Is it in the list of books prescribed by the university?”
“Students senior to me told me to read it” she said.
This fellow was older than me by a few years, and was reasonably intelligent, I had thought. He had a private practice of his own, and was making enough money, I had believed. If he had wall mounted or ceiling fans instead of an air conditioner in his clinic, perhaps he was not making enough money. If his fans were old and in such a bad shape that they made noises that interfered with the auscultation of fetal heart sounds, he was even worse off, despite his practice and the royalty on the books sold to all the students who were reading that book. (:-) :just joking.

19 Years 0 Months 0 Days

The central government has a scheme in aid of poor and underprivileged women who deliver babies in hospitals. Any woman who is more than 19 years old and gets up to second live baby is paid 600 INR. The scheme is to aid her in caring for herself and her baby.
“Sir, how can we pay this woman, who is exactly 19 years old? She has to be above 19” the clerk said.
I looked at her indoor paper. The indoor paper of each patient is computer generated. The clerk feeds data and printout becomes the indoor paper of that patient. This patient’s age was recorded as 19 years, 0 months and 0 days.
“When a woman says she is 19 years old, it means she has completed 19 years and is in the twentieth year” I explained.
“But how?” he asked.
“How old are you?” I asked him.
“Fifty six” he said.
“Is your birthday today?” I asked him.
“No! It was three months ago” he said.
“But you stated that you were 56 years old, not 56 years 3 months old” I said.
“Sir, I understand that. But this is government matter. The rule says incentive should not be given unless the woman is above 19. This paper says she is exactly 19 years old.”
“OK. Let is see the date and time of admission” I said. “She seems to be admitted yesterday at 10:00 A.M. That time she was exactly 19 years old. She delivered at 4:30 P.M. So she was 19 years and 6.5 hours old when she delivered. Is that above 19?”
“It is” he said grudgingly.
“Then you can pay her 600 INR, following the rule” I said.
He paid her that amount.
I understood that the computer of the registration clerk was programmed to record months and days as zero if a particular value was not provided. The clerk did not bother to ask and record those months and days, probably because he thought it did not matter. The only thing that could be done to help the patient receive the amount due her was to do what I did. It does take imagination to beat the civic clerks’ attitude and their computers’ deficient programs.

Processor and RAM Power: Computer and Human

I had a huge collection of files in one folder on the netbook. Those were free ebooks. I decided to copy them to an external hard disk and delete them from the hard disk of the netbook. When I selected all the folders in the main folder, and gave the command to move them to the external hard disk, the netbook showed the transfer window, in which it showed that it was discovering the files to be transferred. After time it just disappeared, without having moved a single file. I tried the whole thing three more times, and had the same result. Then I tried to copy all of them instead of moving them. I tried that three times, and the result was the same. Finally I had to copy them about 50 at a time, and after 15 minutes of laborious efforts, the 3.4 GB data got copied to th external hard disk. Then I tried to delete the entire folder from the netbook, and it just sat idle after receiving the command. When four such efforts failed, I deleted the folders 50 at a time. After 15 minutes, two folders still remained, which would not get deleted. When I tried to open them, the netbook told me they did not exist. I wonder why they were seen there but the netbook could not see them. It was probably modesty, like virtues in a person others can see, but the modest person cannot see them in self.
When I tried moving them en masse from external hard disk to a desktop, they moved in 2 minutes, and I could delete the entire folder from the external hard disk in less than 30 seconds. The only difference between the desktop and netbook was that the desktop had twice as much processor speed and twice as much RAM.
That reminded me of a tiny tot I met once on a trip. This fellow was smart. He would repeat every word one said, irrespective of whether he knew its meaning. He thought it was a game, and he repeated anything anyone said, whether they wanted to play the game or not. Everyone in the group tried different words, and he pronounced them all. They were small words. When he pronounced two words of mine correctly, with a victorious smile, I tried “cosmopolyhilipilifilification” on him. He started “co…” and shut up, grin included. It was less of processor speed and RAM I suppose, as expected of his age. I understand the word has no meaning. When I was small, my sister told me it was the longest word in English, and that it meant 'worthless'. Even if the information was worthless, I somehow remembered the word and could reproduce it for testing the smart young fellow. It was not worthless, after all.

Marketing Fundamentals

I found this card in our outpatient clinic, inserted under the glass that covers the table top. One of the Pharmaceuticals has been using these cards for promotion of their products. The sales representative gives a card to the doctor and requests him to prescribe his product. The name of the product to be prescribed is printed on the back of the card. What the marketing people of the company do not seem to have realized is that a doctor is expected to prescribe a drug because a patient needs it, and he prescribes a particular one made by a particular company because it is of good quality and priced economically. It must never be prescribed to make the sales representative feel grateful for it. I do not like that ‘I’ in the request … it connotes a personal relationship, where the doctor is obliges the sales person by prescribing his product, which sounds unethical. If the sales person is going to reciprocate the obligation in some way, it is even worse.
(Note: I have covered parts of the faces of individuals shown in the photograph to protect their identities, which are anyway unknown to me.)

Spinal Anethesia to Kyphoscoliotic Patient

It was my minor OT. We had a few patients for endoscopy. One of them was a high risk woman with infertility. She had thoracolumbar kyphoscoliosis, among other factors complicating endoscopy. I had actually advised her to undergo a hysterosalpingography instead of endoscopy. But the test revealed a block in a tube, along with a unicornuate uterus and a crossed pelvic kidney. We had no option but to perform hystero- and laparoscopy. I reached the theater and asked my Registrar, “How far are they with the induction of anesthesia?”
“They have not induced anesthesia yet, Sir” she said. “I trust they will give her spinal anesthesia.”
“Spinal anesthesia to a woman with kyphoscoliosis?” I asked. “Tell me the problems that can arise with spinal anesthesia in a woman with kyphoscoliosis.”
“Perhaps her vertebrae will be fused, which will make the procedure difficult.”
“Have you done an allied post in anesthesiology?” I asked.
“No. That was made compulsory for batches after my batch.”
“But you must have read about it.” She kept quiet. Apparently she had not. “Read. There is no substitute for a sound knowledge base” I said. I spoke to the senior anesthetist who said she would give general anesthesia to the patient. We operated on that patient uneventfully. When I was relating this story to our Associate Professor some time later, she said, “Sir, while you were talking to our Registrar, the junior anesthetist was taking the patient's consent for receiving spinal anesthesia.” I was aghast. An anesthetist wanted to do that too! Luckily his senior decided to do otherwise. The patient must have been in luck these two juniors were not in charge of her treatment.

Laser Pointer in Ob-Gyn Surgery

When we were students, they used to have slide projectors and slides for teaching and in conferences. Times changed. Now we have digital slides, software to show them, and LCD projectors to project them on a screen. In those days there used to be pointers of different types. Some were optical pointers, attached to the slide projectors. Then there were long pointed sticks, which would cast a pointed shadow on the screen, the tip of which would be used to point out the area of interest to viewers. I used to use a collapsible antenna of a television set. When expanded, it would be about 4 feet long. I recall once there was no pointer in a conference in Ranchi. I had not taken one along, because the organizers usually provided one. Finally I had to use a broom stick as a pointer. Laser pointers have been in use for a long time now, and have replaced all other pointers. I use it to point out important parts of visuals while teaching.
We have a lot of resident doctors in training, who are assisted by faculty while performing different operations. If I am assisting one, I can always touch the part of the operative field where I want the resident to do something. But if someone else is assisting, and I am offering advice where the assistant may be doing things differently, I have to give instructions. The instructions are somewhat along these lines.
“Stop! Don’t cut that.”
“What, Sir?”
“That blood vessel!”
“Here?” the assistant points somewhere and asks.
“No! No! There, on your right” I say, pointing with my index finger in the space well above the operative field.
“Here?” he asks, pointing somewhere far away from where the vessels is actually is.
“No! Lateral to where you are.”
This usually continues quite frustratingly for some time. I got tired of this. So one day I brought my laser pointer to the operation theater and used it to point out areas in the operative field. The laser point was clearly seen even in the intense light of the double-dome OT spot lights. That made things simple. There was no risk of one accidentally touching something in the operative field while pointing with an extended index finger.

Medical Journalism at its Best

The resident doctors had gone on strike in civic and government hospitals. There was a pregnant woman who was refused hospital admission at a peripheral hospital, and also at another civic hospital. Then the political leader of the concerned geographic area called chief of our institute and made arrangements for admitting her to our hospital. Our hospital never refuses a patient. It is the final destination of all patients who are refused hospital admission by all hospitals including tertiary level care centers. She was admitted and given appropriate treatment.
The interesting part of the story was in the newspaper article carried the next morning. It read as follows.
'This patient would have died for lack of treatment. However she was admitted to this hospital and operated on in the nick of time. The doctors saved her life, but could not save her baby.'
I was surprised. I would have known if any baby had been lost. So I asked the doctors who had treated her.
"Was the baby lost as the newspaper article says?" I asked.
"Sir, it was an ectopic pregnancy in the fallopian tube. It had ruptured in the first trimester."
"OK" I said.
The baby can never be saved in a case pf tubal ectopic pregnancy, whether ruptured or not. The journalist made a sensational story to the best of his or her ability. It was not worth the trouble to write to the newspaper and make the correction which was appropriate. The boss and all other heads of departments had a good laugh at it in the meeting held to discuss the issue of the strike, and that was that.

Iron on Empty Stomach

"Sir, I want your permission to take patients from your unit for my dissertation."
She was a resident doctor working in another unit.
"What is the topic of your dissertation?" I asked.
"Identification of factors responsible for failure to respond to therapy of anemia in pregnancy" she said.
"What are you studying?" I asked.
"Mainly in therapy. Patients in other units take iron on full stomach. I want to use them as controls."
"OK" I said. "but my patients are instructed to take iron on empty stomach."
"I will take them in the study group" she said
Then a month later the resident doctors went on strike, and I had to go to that unit's antenatal clinic to see patients. I remembered what she had said, and wanted to see how their patients were managed.
I asked each patient I saw how she was taking her iron supplements. I did not find a single patient taking it on empty stomach. None of the prescriptions had instructions for taking oral iron. One patient examined by this same resident at the time of the previous visit was without any treatment for a month, being told to have her pregnancy diagnosed by ultrasonography first. She had been 16 weeks pregnant at that time. I informed the head of the said unit about the goings on.
"There are two things wrong" I said. "One is that the patients are not absorbing the iron they take. The other is the disturbing attitude of this resident, who claims that doctors in other units are not OK in the management of their patients, when she herself is deficient in both the treatment of her patients and her work on her dissertation."
"I will talk to her when she joins duty after the strike is called off" the head of that unit said.

Assault on Resident Doctors

The resident doctors have gone on a strike, because some patient’s relatives beat up a resident doctor in another civic hospital today. There is a law that makes assault on doctors in a civic hospital a cognizable offense for which the police can arrest the offenders. The hospital has a security force for protection of the hospital, its personnel, and patients. Despite this some dissatisfied relatives of patients keep assaulting doctors. Then the resident doctors keep going on strike. The civic body has not been able to find a solution to this problem.
The solution to this problem is perhaps reciprocation. The doctors could be trained in self defense, using martial arts techniques. If communication skills are mandatory in their curriculum, I don’t see any reason why self defense cannot be a part of the curriculum too. It is understandable that one or two doctors cannot defend themselves if there is mob of people. But there is police force for the protection of people in the state which can be called upon in such a situation. And there is the hospital’s security force too. When there is an assault on doctors, the security personnel should come down heavily on the offenders. It could be something like Rapid Action Force. When the offenders are beaten up well a couple of times, new offenders will not dare assault doctors again. When reason and civic sense do not prevail, only fear works. Now the time has come for putting this last method to work, so that the soft targets in the form of doctors can do their work in peace and without fear.

Mindless Destruction of Heritage Structures

The architect had said the estimated cost for repair and renovation of our part of the heritage building was Rs. 15 crore, or 150 million rupees. It might have cost more since the cost of raw material like sand went up quite a bit in between. After spending so much money, one would expect the hospital personnel to use the place and things carefully. Alas, one expects too much sometimes, it would seem.
“Sir, look at what they have done to the cover of the drainage hole.”
I looked where our Associate Professor was pointing during our ward round. Someone had hammered the perforated metal cover of the drainage hole along the wall and made an ugly big hole in it. We checked the other such covers in the ward and found all of them broken open in a similar manner.”
“Who has done this and why?” I asked.
"I don’t know” the sister-in-charge of the ward said. “Probably it is done by those who wash the floor to make the floor washing water drain faster.”
“The resistance to flow is not because of the smallness of the holes in the cover” said our Associate Professor. “It is due to choking of the drainage pipe beyond.”
“Destroying hospital property is a criminal offense. Damaging a heritage structure is another offense. The offender can be sent to jail.”
“Here he is!” said the staff nurse. The chief servant of the ward came forward grinning, as if he were a child caught doing something mischievous.
“I don’t want to conduct his enquiry” I said. “Sister, since you are the superior officer of the offender, you are responsible too unless you take appropriate action against this person. I advise you to hold an enquiry and report the matter to the appropriate authority.”
I left, leaving the offender grinning all over his face foolishly, and the sister-in-charge looking somewhat worried.

Dewash: A New Verb

I needed some information from one of our staff members urgently. It was her day for performing major operations. I called the or and asked if she was free.
“I will check” said the house surgeon politely, “please wait.”
I waited. The house surgeon returned after awhile.
“Sir, madam is dewashed. She is in the staff room.”
I was in a hurry. So I resisted the urge to have the word ‘dewashed’ interpreted. I called the staff room, found the professor, obtained the information I wanted and continued with my work.
It was the next day afternoon when I met that house surgeon in the corridor.
“Good afternoon sir” she said.
“Good afternoon” I said. “I know what ‘washed’ means. I also know what ‘unwashed’ means. I do not know what ‘dewashed’ means. You should be able to tell me since I heard that one from you yesterday.”
She smiled but offered no verbal answer.
“Does ‘dewashed’ mean ‘unwashed’?” I asked with what I thought was a straight face. It was probably not straight, because she smiled, with a little mischief added to her original simple smile. “No, Sir” she said politely, still offering no meaning for the word ‘dewashed’.
“All right,” I said “Perhaps you used the word as when you use ‘decaf’ or ‘decongested’ to indicate the opposite of ‘caffeinated’ and ‘congested’. I take it to mean ‘washed out after performing an operation’."
She smiled a 'yes'.

Amazon Kindle Charging Technique

They do not ship a charger with Amazon Kindle in India. One has to connect it to a computer's USB port in order to charge it. I do not like it very much, because I do not want to switch a computer on solely for the purpose of charging my Kindle. After all, I bought a Kindle so that I could read books without using a computer. Since I had no option, I charged my Kindle on my laptop. A problem with that was that the charging would stop when I shut down the laptop. Then one day I connected it to my desktop, and found that the carging continued even after I shut down the desktop, but did not switch off the mains supply. Yesterday I connected it to the USB port of the desktop, and switched on the mains supply, but did not boot the desktop. Even then the Kindle got charged. Not only did it get charged, it showed a green indicator when the charging was complete and then shut off all indicator lights. Thus a desktop PC is a charger for a Kindle, even without booting it. I wonder if the makers of the Kindle know this. After all, if they knew, they would said so in their manual.

Dengue Pronunciation: Deng? Dengu? Dengi?

बुरी नजरवाले तेरा मुँह काला

The most common method of learning pronunciation of different words in our country seems to be by hearing elders pronounce those words, or imagining the pronunciations based on those of similarly spelt words. Elders include elders in family, friends, neighbors, and teachers.
Dengue is a febrile illness found quite often in the monsoon season in our city. Our doctors are very good at detecting it and treating it. Unfortunately the opinion seems to be divided on its pronunciation. This becomes quite obvious in medical meetings. There was one such meeting which was attended by faculty and residents from departments of medicine, intensive care unit, pathology and obstetrics-gynecology. One patient died of some unknown cause. She had preterm labor, and died a few hours after initiation of treatment to control it. Even autopsy did not reveal any cause for sudden death. During the discussion of that case, one professor said,
“But what about her blood report? The autopsy report says she was positive for dengue.” She pronounced dengue as ‘deng’. Probably it was based on the logic that if ‘tongue’ is pronounced ending with ‘g’, then dengue should also be pronounced ending with ‘g’.
“Was the blood sample really sent? She did not have fever.”
“It was sent when she arrested” someone said.
“Perhaps it was dengue” said another professor, pronouncing dengue as ‘dengu’. That was the most common pronunciation of the word around here.
“Which test came positive for dengue” asked another professor, pronouncing dengue as ‘dengi’. It takes guts to pronounce it as ‘dengi’ when everyone else seems to call it ‘dengu’.
“A blood test might have been positive for dengue, but that was not the cause of her death” said another professor, carefully pronouncing the word as something between ‘dengu’ and ‘dengi’, more towards ‘dengu’ than ‘dengi’. That was quite an achievement, I must say.
There are sites on the internet which actually read words out loud so that you know the right pronunciation. One such site very succinctly pronounces it as ‘dengi’, and actually raises its volume if you click on the hear button a second time. :-)

Iron Sucrose and Anaphylactic Reactions

When they launched iron sucrose complex for intravenous use, the pharmaceutical representatives kept telling us that the new molecule did not have any risk of allergic and anaphylactic reactions. They said there was no need for any test dose, as with the older iron dextran complex, and hence it was superior. Being superior and newer, they said it would be a little more expensive; but they said this only when we asked the price. There were some amongst us who fell for the new technology, only because it was new, and perhaps they did not want to appear backward in company of others in medical conferences and meetings. One of them gave it as a topic for dissertation to a postgraduate student (where the subjects would pay for the drug contrary to the guidelines of the Ethics Committee). I searched various medical databases and found a couple of references which reported anaphylactic reactions with the use of iron sucrose. The incidence was far less as compared to iron dextran complex. I did not use it because I knew the patients in our hospital really did not afford it, and also because the manufacturers did not state the method of giving a test dose of the preparation. My patients must have been lucky. One and a half year ago, one patient from a unit headed by one such enthusiast developed acute anaphylactic reaction when iron sucrose was administered to her intravenously. I think she survived, but with a lot of morbidity. Less than three weeks ago, another patient from another enthusiast’s unit developed acute anaphylactic reaction with intravenous use of iron sucrose. She developed cardiao-respiratory arrest, from which she was resuscitated with difficulty. She developed cardiao-respiratory arrest eight more times over the next two days and finally could not be revived any more.
“It is safer to give a test dose of iron sucrose prior to intravenous use” said an intensivist Professor “because pharmaceutical companies cannot protect one from litigation by a patient or her relatives (should the patient die), even if they are saying it does not cause such reactions.”
“It is safer to give a test dose from the patient’s point of view” I said. “Even if the doctor is not sued, the patient’s death would still be wrong because it would have been prevented by giving a test dose and withholding the drug if the patient developed allergic reaction.”
We have decided to give a test dose to all patients prior to administration of iron sucrose, whether the manufacturers and text books recommend it or not.