Fimbrial Prolapse: Diagnostic Test

I had read about posthysterectomy fimbrial prolapse in Jeffcoate’s Gynecology as an undergraduate student. It was stated that it could occur due to improper closure of the pelvic peritoneum after a hysterectomy, vaginal rather than abdominal. It was also stated that it was such a rare occurrence, that whenever one saw something like it, one should diagnose vault granulations rather than fimbrial prolapse. After all, statistics is more accurate than one’s personal feelings. I followed that rule all my life and was never proved wrong. Time and again a hopeful resident doctor or a young lecturer would show me a case and call it fimbrial prolapse. Perhaps it was wishful thinking, wanting to cut the vagina all around it, excising it, and then repairing the defect in the vagina, as was described by Jeffcoate. I would tell them it was vault granulation, they would not believe me (as young people tend to do with all seniors), I would hold it with sponge holding forceps, it would come off easily, and I would tell tem to send it for histopathological examination to confirm that I was right. A couple of weeks later they would come to me with the histopathology report showing it was granulation tissue, and I would give them a ‘henceforth-it-will-be-better-if-you-remember-I-am-smarter-and-it-would-be-better-to-believe-me’ look. But the other day one lecturer called me to see a fimbrial prolapse that looked different from the many I had been shown before. I hald I gently with a sponge-holding forceps and made traction.
“Ouch!” she said, while the mass showed no sign of separating out.
“This is fimbrial prolapse” I said. I performed a bimanual pelvic examination, and found that she had an ovarian tumor too. We performed an exploratory laparotomy to remove the ovarian mass, prior to which I removed the prolapsed lateral part of the fallopian tube vaginally so as not to contaminate the peritoneal cavity later by its abdominal removal. Histopathological examination confirmed the diagnosis of fimbrial prolapse.
I am unlikely to see another case in my lifetime, and cannot add statistics to support this new sign. But I can confidently say that if the fimbriae-like mass comes off very easily when held with a sponge-holding forceps, it will be granulation tissue in the vault of vagina, while if it does not and the woman experiences pain when traction is made on it, it will be fimbriae.

Caricatures

I always wanted to do caricatures. I should have gone to an art school and learnt how to do it. But they do not run part time courses for doctors, and I could not find anyone who could teach me. I would look at the caricatures in the newspapers and wish I could draw as well. Finally I decided to do it by studying the artists’ finished works. It was not difficult, because I had access to the photographs of the people whose caricatures were found in the newspapers. When I thought I had the general idea, I tried my hand at it. Here is one I made of Saif and Bebo. I know it is not possible for me to keep doing it as easily as I can perform hysterectomies, but now I am satisfied.

Multipurpose Engineers

It never occurred to me that it would be possible to change specialization of a specialist, only because you paid his or her salary. After all, one spends the prescribed time getting a basic degree. Then one spends some more time getting advanced education in a subject of one’s interest. The idea is that one will be do advanced work in that field that a person with a basic degree cannot, and achieve something that will benefit mankind in some way.
The civic body seems to think otherwise. I learned about it quite accidentally. I have to interact with engineers of the civic body for procurement of new equipment and repair of existing equipment. I am aware that there are civil engineers, electrical engineers and electronic engineers. There are lots of other types of engineers out there, but the civic body probably does not need them in the hospital. One day one electronic engineer ceased to be seen. I asked what happened to him, and heard that he was posted in the water department. Then his boss got promoted as a ward officer, and another engineer came in his place.
“Where was he before?” I asked them when I realized he did not know electronics much.
“He was in the sewage processing department” came the answer.
“How come you people do not work in the area of your specialization?” I asked incredulously.
“We have a common seniority list. Whenever there is a vacancy anywhere, the next person in the list gets promoted, irrespective of his specialty” I was told.
“But that is like sending a gynecologist to work in the orthopedics because there is a vacancy there and he in the next person in the seniority list” I said.
“Perhaps it is different in the medical line” he said. “But that is how it is for engineers in the civic institutes.”
I related this to a friend.
“It is simple. The engineers have to move papers, not actually do any work. The work is done by contractors. So it does not matter if one does not know what it is all about. The knowledge acquired while obtaining the basic degree is adequate, and one can learn on the fly from juniors who know all about it if they are from that specialty.”

PCPNDT and Planning Commission

I am the chairman of the local advisory committee of the city for PCPNDT. That sounds a great thing, but is merely a position on a committee for passing proposals for registration of eligible applicants under PCPNDT act. They do not call me for any policy making meetings. They do not even inform me of new policies made by whoever wherever. The only thing that happens due to my position is that a lot of people talk about it to me whenever something happens in that connection.
“Sir, I read in the newspapers about what the planning commission recommended. It seems they want the act changed to permit people to have the sex of their unborn babies determined. They suggest that unwanted female children should be adopted by the (state?) governments so that people will not abort them after knowing their sex” someone said.
“What is more Social organizations slammed the commission, stating that such adoption would be dangerous, since the children in such institutes are already exploited sexually and otherwise and it will get even worse. But I feel they did not slam the commission enough. The commission has probably not understood the concept. If the state is going to adopt an unwanted female newborn, what is the need of knowing the sex of the baby in advance? In fact, the only measure necessary (if it is going to work at all) is to adopt the female child. Perhaps the commission feels the parents will have to fill out application forms in advance, stand in queues to submit them, bribe some people to have them approved, make affidavits, and all that would take time which they cannot afford to spend after delivery” someone else said.
“Then there was another clarification in the news item. The state would spend for rearing of the girl child for the first two years of its life. The commission seems to believe that the first two years of the girl’s life are the years that the parents find most difficult. The expense for feeding the child during the first six months is none, since the child is breast fed. Then it is partly breast fed and partly top fed for another six months. The quantity of food consumed by the child is the next year is much less than it will consume per each subsequent year. The expenses on clothes in the first two years are negligible as compared to those incurred later. School education is free for girls in selected schools, but not professional or advanced education” the first person said.
“Perhaps the honorable members have not heard about dowry, which though illegal is very much there. Perhaps the members do not know that the parents feel that all the money spent on a girl is virtually wasted, because she is married off and is no more useful to the family. Perhaps the commission does not know that a male offspring is a must to perform the final rites and to keep the family (dynasty) running” a third person said.
“The erstwhile prime minister of India Mr. Rajeev Gandhi had allegedly called the members of the planning commission jokers, and the head of the commission of that time went on to become prime minister of the country later. I did not read in the newspaper that the same prime minister called the current commission members jokers” a fourth person said.
“The reason is rather obvious, is it not?” another person said with a grin.
“There was a hue and cry when the planning commission set the poverty line so low for our country. I did not see one thousandth of that when the commission proposed allowing prenatal sex determination” the first person said.
“That is the way it goes” I said.

Tuboplasty: Postoperative 3 Month Extremes

The trend now is not to be perform tubal reconstructive surgery if infertility is due to tubal disease. Assisted reproduction is recommended in better off countries. However the cost of the assisted reproduction is exorbitant and many poor women do not afford it. We still perform tuboplasties in such cases. I thought there would be no confusion in the management of these patients after they recovered totally from their operations. I was wrong.
One patient had undergone reversal of tubal ligation at the hands of my Assistant Professor in June. She came yesterday with a report of a hysterosalpingography. I looked at the report. It showed normal findings.
“Who advised her to undergo a hysterosalpingography?” I asked.
“The Assistant Professor who had operated on her” my Registrar answered after going through her case paper. So I called that person and asked, “why did you advise her to undergo a hysterosalpingography?”
He looked confused for some time. Then he answered, “that was the practice in the medical college hospital where I worked when I was studying for my MD.”
I thought for awhile, wondering if I should say it. Finally I said “that could be the case. But you studied the subject from different books and journals. Did you find any such recommendation anywhere?”
He considered the question gravely (at least he made a grave face while he waited) and answered “no!”
“Then you should not do it. You have not given her sufficient time to conceive after the operation. The hysterosalpingography was unwarranted. Not only that, but it was dangerous too. If she developed pelvic infection due to that procedure, the fallopian tubes could get blocked, turning all efforts into waste.
He made a face suggesting sudden comprehension and a desire to do as I told him to. I hope he sticks to that decision, whether he was convinced or not. That reminded me of another extreme. My Registrar at that time has advised oral combination contraceptive pills for three months to a patient who had undergone a reversal of tubal ligation. When the patient came for a follow-up examination, I found this out and was duly aghast.
“This is criminal” I told the Registrar. “The months following recovery from the operation are the best time for the patient to conceive. If you wait, the tubes may get blocked again due to slow inflammatory process, like chronic infection. Why did you deny her the best chances to conceive?”
“Um… ar… I thought she required that much time to heal the tubes” she said.
Most of our residents who do such things pass in their MD examination. I was afraid she would too. Somehow she goofed so much that they failed her. But I think she is unlikely to change all of her dangerous concepts before she passes. In the meantime, all those who have already passed and are yet to pass continue to do weird things after such procedures, despite which life seems to go on. God is really great.

The Questioning Woman

I have been listening to people all my life. Initially I had to do at as a child, because I had no option. Then in school and college, it was the discipline that made me do it. When I qualified, I had to do it professionally, and I have been doing it well all the time. I have listened to so many people, that I would have been surprised if I met someone with a new style of speech. Well, I was surprised the other day. She was a young woman, who came to the outpatient clinic. She kept hovering around for some time. She would approach my table, stay there for a minute and then move back. After she went through these cycles thrice, I presumed she wanted to see me, but was not being able to do so.
"Do you want to see me?" I asked her.
"Yes, doctor? I want to see you?" she said.
"What is the problem?" I asked. The outpatient clinic was so crowded that I had to get to the point immediately, rather than spend time on pleasantries.
"I had a 2 months' abortion doctor? I had to undergo a curettage? Now I am having blood stained discharge?"
I was surprised by her questions. The sentences ended in question marks, but the content of her speech was information, not questions.
"How long do you have this problem?" I asked.
"Fifteen days? Right from the time of the abortion?" she said.
"You need a check-up" I said. "Will you please pass urine and go into that cabin for a check-up?"
"OK, doctor?" she said. "I hope it is not something serious?"
"Don't worry. I does not sound very serious" I said.
She was seen by another person in the clinic. I saw her again the next day while we were taking ward round.
"Who is getting her microbiologic report?" asked my colleague who had seen her the day before.
"My husband has gone to get the report?" she said.
We moved on to the next ward after seeing her.
"Did you notice anything different about the last patient we saw?" I asked the colleague who had admitted her to the ward.
"The one who asks questions?"
That was answer enough.
"Why do you think she ends each sentence as a question?" I asked.
"Perhaps she is stressed."
That woman had been relaxed the day before, and definitely on that day. I think she must have been impressed by some actor in some movie(s) she must have watched, and was trying to imitate that person's style of speech.

Three Piece

The contractor has supplied our wards with cots and mattresses. The mattresses seemed OK, until the other day the sister in charge of the ward disillusioned me.
"Sir, look at these mattresses" she said.
I looked. The mattress was made of sponge. There were three sections of equal length, placed end to end. A single covered was stitched over all of them. The cover was torn exactly at the junction of adjacent pieces.
"Sir, the cover got torn in one day after supply. I asked the contractor to replace it. The new one tore similarly."
I was aghast.
"There are many defective mattresses like this" she said.
"Who is the manufacturer?" I asked.
"It is said to be Godrej."
I could not believe it.
"Perhaps it is outsourced to another supplier" I said.
"Perhaps. There is no brand name printed anywhere on the mattress."
"Irrespective of who the manufacturer is, do not accept defective supply" I advised. "If you acknowledge receipt, state it is pending approval after checking quality."
She seemed to like that idea. I left wondering how the contractor dare supply defective goods without any qualms.

Cover the Blood

We have so many patients, that it is not unusual to encounter something new in their practices almost every week. One such thing was finding a fancy looking cloth covering the blood bag on an IV stand, while a blood transfusion was being administered. When I saw it for the first time, I thought it was a baby towel put there by the woman for drying. Many of them are quite poor and are used to using whatever place and facility are available for whatever work that must be done. Washing and drying a nappy or a towel is one such work, and any pointed object is used to hang the wet towel or nappy. When I saw this another time, I wondered aloud.
"Why does she hang a piece of cloth like this? It does not look like a baby's towel or nappy."
"Sir, this patient is afraid of looking at the blood bag. She feels giddy by the sight of it. So she covers it with a cloth."
Since there was nothing against covering a blood bag with a piece of cloth in the SOP for blood and blood product transfusion, I let it be.
"Let it be. But inspect the blood bag periodically to confirm that it is not empty, and to shake it to mix the red cells in the plasma, if they have settled down" I said.