Reporting Woes

We have a service run by a state organization working in our institute under the national organization to control AIDS. It is coupled with the civic body in a way ill understood by us. The employees are not of the civic body, but work for it.
Blood is collected for every woman who consents to have HIV antibody tested on her blood. The report is generated by the technician paid by that organization. The report does not have the patient's name for (it is claimed) confidentiality. There is a serial number, and two identification marks of the patient. If the patients exchange their reports, we have no way of knowing about it. A patient with a positive report may somehow get hold of a report which is negative and pass it as her own. We have not come across a case as yet, perhaps because we cannot check it any way. Some patients are known to hide their positive reports, possibly to avoid discrimination. Though we do not discriminate, they must have had such experiences elsewhere. When I wrote to the chief of that laboratory and asked her to put the patient's names and registration numbers on the reports, she said it could not be done because the state and central governmental rules did not permit it. I could not see the wisdom of it, but then less intelligent people cannot see the wisdom behind action of more intelligent people. This could be an example of that rule.
A pregnant woman came to my antenatal clinic this week. Her HIV report was missing. Only the upper left corner was still attached to the file, identifiable by the logo printed there.
"Where is the remaining report?" I asked her.
"I don't know" she said, looking at that fragment.
"Your paper has the date of collection of your blood sample, and the registration number given by the laboratory. Please ask them to give you a duplicate report" I said. She went to see the concerned social workers and came back.
"They said they cannot give a duplicate report" she said.
So I went to see them, with the patient following me. I asked them why they would not give a duplicate report.
"We have never done that before" one of them said. The other was busy talking on a cell phone.
"So do it now" I said. "There is always a first time for everything. Surely you have records of all reports?"
"We cannot give it" she said.
"Who decided it cannot be given" I asked.
"We talked to each other. Since neither of us knew how, we decided we could not give it." The other one continued to chat on her phone, ignoring us. She probably treated all doctors, including the Head of Department just like she treated HIV positive patients.
I directed the patient to the person in charge of this work in our department, who sent her to the laboratory to get the report. The patient came back in ten minutes.
"The laboratory technician refused to give me the report" she said. "He pointed out on my case paper the place where someone has written my report is negative. He said that was enough. He asked me to undergo the test again if I wanted a report from the laboratory."
If I could afford to be speechless, I would have done so. But the poor woman was depending on me, the only person who was fighting for her. I took her to the person who was in charge of the matter and asked her to sort out the issue. Two days passed. Today she told me "I called the chief of microbiology. She said getting a duplicate report was superfluous. We should be repeating the test on all negative cases every 3 months."
"Since they are not doing that for any patient, they should not cite that as a reason for not giving this woman her report" I said.
"She said the other reason is that they have no record of identification marks."
That was a deep one. I refused to be confused anyway.
"Since they have records of the patient's name, date of collection of her blood and her registration number, they can easily get the report" I said. It really was quite simple.
"She has promised to give the report if I write a special note to her."
I was aghast. Working out the psychology and strategy behind such thoughts and actions was beyond my abilities. I knew both of these persons had been in States for three months, all expenses paid by States funding agency, to learn intricacies of this matter. Perhaps they learnt these things there!

Neo Original Thinkers in Obstetrics

In motivational approach to self development, it is said one has to dream to be able to achieve something. In management approach, the stress is on original thinking for taking one far ahead of others.
It is the dream of being far ahead of others that probably drives to people to original thinking in many fields including obstetrics. I wrote about original thinking of some obstetricians who used double the recommended dose of intracervical PGE2 to ripen the cervix for induction of labor when there is an urgency for induction of labor. The thinking is definitely original, but bordering on dangerous. Today I heard of another original thought. We were seeing patients in the postoperative ward. There was a patient who had had postpartum hemorrhage at the time of a cesarean section.
"They gave her everything" said the Associate Professor who had taken that call.
"Oxytocin, methy ergometrine, intramuscular PGF2alpha, rectal misoprostol?" I asked.
"Yes" she said. "The bleeding was finally controlled."
"Did she required any blood transfusion?" I asked.
"No."
I suddenly had an idea. "I hope they did not put misoprostol in the uterine cavity" I heard myself say. Sometimes I feel something instinctively and say it without thinking about it. It turns out to be right. It is something like what Malcolm Gladwell wrote in 'Blink'.
"No!" they were scandalized.
"Sir, they put misoprostol into the uterine cavity at the time of a cesarean section in my native place" said one Assistant Professor. "Probably to achieve local action."
So I was right. Somebody had thought along those lines and done it.
"But how would it act, being put in the blood pooling in the uterine cavity, spilling out through the uterine incision, draining out of the cervix into the vagina, and being removed by suction by the second assistant?" asked the Associate Professor.
"It would not act" I said. "But that does not prevent original thinkers from thinking and doing it. Someone like that started giving intramyometrial PGEF2 alpha for atonic postpartum hemorrhage. It was foolish. It was intramuscular injection of a sort. The injection site to heart distance was longer there as compared to intra-deltoid injection, so that the action would be slower in onset. And if the uterus contracted in response to it, its blood vessels would be constricted by the oblique fibers of the uterus, so that further absorption would be stopped. The drug would not spread locally in the myometrium as the original thinker had thought. But a lot of people loved the idea and there was a rush of scientific papers on that. Now watch the journals. Soon there may be scientific papers on intrauterine administration of misoprostol."
All people on our round seemed amused. That encouraged me to come out with even more weird ideas. "Why do they not put misoprostol in the conjunctival sac? They put it in the mouth, vagina, rectum, and now even the uterine cavity." The smiles of many of them were even broader.
"Is the misoprostol sterilized? Or it may cause puerperal sepsis." I said.
"It is not" said the Assistant Professor who had reported this event.
Now I am sure my people will not do such dangerous things.

Rope in the Old Ones

A function is scheduled to be held the next week, at which all doctors who have reached or passed the age of 80 years and who had worked at our institute will be felicitated, The felicitation is probably for managing to remain alive and kicking (figuratively) that long. A prerequisite was that they should have contributed to the name and fame of the institute.
"How can we decide who made such contribution and why did not?" asked the professor who was looking after the job of compilation of the list.
"Yes. We cannot discriminate. We have to send names of all who were here, and are 80 years or older today. Have they asked to mention their contributions?" I asked.
"No. Just their names, addresses, and telephone numbers."
"I hope we do not miss out anyone. It would be terribly insulting to anyone who was missed out, unintentionally though it might be” said another staff member.
“Why do they want us to send the list? Do they not have a database of all old staff members and their dates of birth? It would be a simple matter to query the
database and get a complete list." I said.
"That would be a dream as far as the civic body is concerned” said a knowledgeable person. "They cannot keep even our confidential history sheets securely, At the time of promotions, they ask for previous 'confidential reports many year's to be filled again.” That was true. One of my jobs was to keep filling our staff member's' confidential reports again and again, The job seemed to be mechanical, without regard to the fact that one could not remember back a few years, unless one was expected to write the same good things about everyone.
"Should we not felicitate any one posthumously?" asked another person. “After all, we are felicitating them for their contributions, not their ability to survive to 80, We could call their spouses or children if they are no more."
“That sounds like a good idea” said the professor who was handling our department’s list. “Unfortunately we are not asked for our suggestions, we are just expected to send a list of names and then attend the function in large number so that the auditorium would not be filled with just the people who are being felicitated.”
“Ha! As if the invitees would notice who were attnding, what with problems of vision and perception that visit people at that age” said a cynic. I would probably never know, because I might not make that age, or they may not felicitate us at that time, the whole thing depending on who was at helm of the institute at that time.
“But is it a pure felicitation function, or is it to remind these people that they might do something for the institute, like a donation?” said the cynic.
“Or bequeath something to the institute in their wills?” said another person, who was an advanced cynic.
That sounded possible. Whenever schools or social organizations invite people as their chief guests, the usually expect fancy donations.
“That sounds possible” said another person. “Even the federation of practitioners of our specialty offers chairmanship of scientific sessions to people who can raise 25000 INR for the conduct of the annual conference” said a professor who was once connected with the federation, but later fell out from it. Perhaps this was the reason for that falling out, I thought.
“No body gives money to the institute like that” said the cynic. “Did the past students who were invited for a get-together when our institute turned 80 give anything?”
“No” I admitted. “They just gorged on the free snacks, made speeches, and went away feeling good. Some of them made promises, which are unfulfilled five years later.”
“Or has one of the previous head of a department whose farewell party had gone on for three days given anything to the institute?”
”Not a dime” I admitted. “But there must be no harm in trying. Even if 5% of the invitees make donations, it may be worth while.”

Burst Abdomen Without Sepsis?

It is not nice thing to have a patient develop postoperative wound breakdown and burst abdomen. It must be a terrifying experience to see one's own bowels come out of one's abdomen. It is scary for the doctor too, because he knows the serious causes of the complication, and the associated morbidity.
We had a patient with an ovarian tumor and a bad pulmonary problem who could not be operated upon because we could not get a ventilator. After a month and a half, she underwent the operation. The operating surgeon told me it was uneventful. Then I went on a short leave. When I resumed duty, I found her on IV fluids again, looking sick.
"What happened?" I asked.
"She developed a burst abdomen" they told me. "It happened on the fifth postoperative day.
"What was the cause?" I asked.
"There was no cause" the Registrar said.
"The sutures must have cut through tissues" I said.
"No. They did not" she said. "The skin and subcutaneous tissue were OK. the peritoneum and rectus sheath had separated."
"The sutures have to cut out of one edhe of the abdominal wall wound, unless the sutures broke. That does not happen. had the sutures broken?" I asked.
"No."
"Then they had cut through tissues" I said. "What is the microbiologic report of the wound discharge?".
"It was a clean wound" said the person who was in charge of the case. "There was no sepsis. It was her retching that caused the burst abdomen."
I was surprised. A number of patients vomit postoperatively. That does not cause the abdominal wound to burst.
"There has to be sepsis. She did not have any factor that impaired wound healing. Only sepsis can explain what happened."
"She had a lot of discharge" she said.
"That is the inflammatory discharge" I said. "That was sepsis."
"But there was no pus" said the Registrar.
"It looks like pus if the organisms are pyogenic" I said. "Other infections can produce clear fluid in large quantities. Even peritonitis can have a lot of clear fluid."
"Er... remember that patient of xxx unit who had such clear discharge? She had infection" said the senior of the two doctors claiming there was no infection.
"It is a known fact" I said mildly. "You don't have to quote a case report to support what I said. Have you sent that discharge for microbiologic study?"
"Yes" the Registrar said. We moved on to see other patients. Both of them had a facial expression that showed they still believed there was no sepsis, and they were humoring me because I was boss and could not be contradicted.
The microbiologic report came a day later. They grew MRSA and pseudomonas, sensitive to linezolid and piperacillin. The patient is doing well on these two antibiotics. I refrained from asking them if they still believed there was no sepsis. I do not like rubbing it in. Had I said so, they would have just added to the grudge they hold against me too.

Dress Code for Patients

The patients in our wards are given white tops which reach up to their knees. These are called night gowns. The reason for such a nomenclature is unclear. Either they all are expected to remain in bed, and the dress to be worn in bed is presumed to be a night gown. Or any time for a patient is presumed to be night time. As long as they are supplied with clean and decent dresses, it probably does not matter what the dress is called. If a patient is transferred from one ward to another, the nurse in the receiving ward is expected to give a night gown to the ward from where the patient is transferred. Unfortunately junior nurses do not give gowns at all times, for different reasons. The senior nurses should replace the gowns the next day, but many times do not do so. As a result the original wards develop a shortage of gowns. In order to avoid such a thing from happening, they started an unorthodox procedure without approval. They started asking the patients to change into their home clothes before transfer. Then they would be given night gowns in their new wards.
Finally we started seeing patients in colorful clothes in the wards. The colors were OK, but there was no guarantee that their clothes were clean and hygienic. It became difficult to differentiate between patients and their relatives. It took me two days to organize a meeting of all nurses.
"Why should be attend the meeting" complained a nurse who was creating the problem by not replacing the night gowns. "My ward does not have the problem."
"You are creating the problem, and hence you have to attend the meeting" I said.
I was the only person present for the meeting at scheduled time. It took another 15 minutes to call the nurses from six wards and start the meeting. The Matron and Assistant Matron arrived at the time of the conclusion of the meeting. When I told them about the standard operating procedure evolved by us, they said "but that is the existing laid down procedure!"
"Yes, it is" I said. "Unfortunately it is not being followed. They have evolved another procedure on their own. Now I have their signatures on the minutes of this meeting, and if there is any change in the dress code of the patients, we know whom to catch. Do you all agree?"
"Yes" they said. There was no alternative but to agree with me.

Elective Clinical Pelvimetry

I have always maintained that the clinical protocols that I recommend for patients will be based on standard teaching on text books, and evidence-based articles in journals. I have always welcomed academic discussion on any point where another person thought otherwise, and if any evidence would be produced contrary to my belief, I would change my opinion and adopt a new policy. After all, it is all for the patients’ sake, and personal ego satisfaction has no place in it.
I think I have failed on two fronts while dealing with a few of my subordinates. On one hand I have not been able to convince them that my approach would be scientifically correct, despite the effort I put in to collect information, analyze it, and present it. On the other hand I have failed to inspire confidence in them that I would welcome any adult-adult discussion with them. It is not that they tried and found that I discouraged discussions. Some of them never tried. Those others who did found that I presented logical arguments which beat their emotional arguments. Perhaps they find it easier to criticize my scientific approach and ridicule it in my absence. Perhaps it assures them that they are better than me and satisfies their ego.
Luckily such people are few. I recall one of our policies of assessing clinically the pelvic adequacy of all nulliparous women and all women with previous cesarean section at 37 weeks or later. My logic was that if the pelvis was inadequate, one could perform a cesarean section electively, rather than allow the woman to be in labor for a variable interval before a decision is made to perform a cesarean section. The senior staff members are home in the evening and night hours unless called for a serious patient. Thus the pelvic assessment would be left to junior doctors and there was a greater possibility of error than if it was performed electively in the antenatal period. Unfortunately one day a person not previous trained by me was promoted and came to my unit in a senior faculty position. She did not choose to hold an adult-adult dialogue with me. But one day another staff member came to see me and said,
“Sir, your junior colleague was heard saying that you have such a ridiculous policy of assessing pelvis at 37 weeks in a nulliparous woman. How can the pelvic capacity be assessed accurately at 37 weeks? Does the fetus not continue to grow after that time?”
I was hurt partly because this junior doctor had chosen to ridicule me instead of discussing the issue in a mature fashion, and partly because at such a senior position she did not know that pelvic capacity is absolute and remains constant, whether the fetus grows or not. For an average sized baby, a pelvis found to be adequate clinically would be adequate during labor. Fetopelvic disproportion would always be assessed during labor. The idea behind my clinical pelvimetry was not to stamp some pelvises as absolutely adequate for labor, but to find those which were inadequate. I would have explained all this to her if she had just asked. Years later I read Stephen Covey and understood that I should not have got upset being people-centered, but should have been principle-centered and should have continued to use my protocol because it was the right protocol. In the meantime I did talk to her and explain my stand, partly to get her cooperation rather than force a policy on her, and partly to prevent her from educating her students wrongly, or they would believe the protocol was wrong and had to be followed only because it was the boss’ whim. After all, her wrong concepts must have stemmed from her teachers’ teachings, since she could not have picked them up from a text book, unless that text book was also written by those teachers. She had to be stopped from doing the same to future generations of students.

Corruption by Force

A young pregnant woman had been admitted in our antenatal ward for prenatal diagnosis. Someone had tested her serum alpha fetoprotein level in a private clinic and had found it to be elevated. She was sent to our center for amniocentesis and checking of amniotic fluid alpha fetoprotein levels and amniotic fluid cellular karyotype to detect trisomy 21. I found her in the ward during my morning round after being away for a couple of days. The resident doctors told me she had an appointment for today. It was actually to be done in the sonography department, and analyzed in a private laboratory. She was in our ward for lodging, pre- and post-procedure management.
“Follow the standard procedure for prenatal diagnosis as per the PCPNDT act” I said.
The day passed in a flurry of activities. Just about the time I was to go home, a couple of men came to see me.
“We have come to complain that the sonologists kept our patient waiting from noon till now and sent her back without doing the procedure she was to undergo” they said, and showed me the patient’s indoor case paper. I checked it and found that she had undergone an anomaly scan, but no amniocentesis. There were no anomalies.
“They would keep her case paper at the bottom every time it reached the top” one of them complained. “They kept taking all other patients. We requested them to take her, but they wouldn’t.”
That did not sound convincing. The sonologists worked diligently. Perhaps her bladder had not been full enough.
“We both are also working in the civic institutes” one of them said “and still this is the treatment we received. When someone would come and give a greenback to the servant, he would promptly take her in and she would come out shortly thereafter, her work done. What about those who have no money to offer?”
This sounded like a charge of corruption. They did not look like those who did not have money. They working for the civic body, they had said. They had salaries that others would envy.
“I called the corporator and he has told me to get this work done somehow, and he will root out the corruption later.”
That sounded wonderful. A civic corporator to weed out corrpution was just great news. Leaving the corporator to do that, I called the sonography department and found out that the patient did not have an appointment for amniocentesis. She had to go for that appointment after the anomaly scan, which she did not do. Her relatives had taken her to the ward and come to me to get their work done. The senior sonologists would give her an appointment the next day in the morning.
“We have fixed it in a private setup in Thane” the main speaker of the two said. “Please arrange to have her discharged.”
So I called the resident doctor on duty and advised her to discharge the patient at request.
“It is atrocious that civic employees are treated in this shabby way” the main speaker said. “To ask for money to do the work they should be doing as a part of their job!”
“They treat me, a professor in a civic hospital and medical college just like that” I said. “It is everywhere. They demand money even to trim trees growing into our houses and to clean gutters which are choked. When I had gone to the ward to office to seek permission to repair my house which was leaking, I met the engineers. They all ranked much lower than me. Despite showing them my identity card, they treatment me shabbily. They kept relaxing in their chairs while I stood there, looked at me like I had a contagious disease, told me to submit my letter in the dispatch section and they would be along to inspect my place later. That was 10 years ago. I am yet to be honored by their visit. I am told they would have come immediately if I had offered a wad of greenbacks.”
The two guys kept quiet.
“Which department do you work in?” I asked.
“Octroi” the main speaker said.
“Ah. Octroi and water department are said to be the most corrupt departments of the civic body” I said. “It is said only bribes can get any work done there. Is it so?”
The guys had not expected a frontal attack. They hesitated. Then the main speaker said, “Yes. But if one does not accept the money, the others get him transferred elsewhere.”
So they were averse only to giving bribes, not taking bribes. They left soon after that. I had not known one could be forced to be corrupt. Well, one learns something new every day.

Rough and Tough Air-Conditioning

We have been very lucky to have an architectural consultant who has innovative ways probably not found anywhere else in the world. It makes us sort of unique. When he got central air-conditioners installed in our lecture halls, staff room, and one office, we were surprised.
"Sir, look at the air-conditioning unit" one Assistant Professor said. I looked and kept looking.

"It reminds me of the boiler room of a ship" chirped another Assistant Professor. I had not been in the boiler room of a ship before, but the huge pipes and cylinders and connectors did give it the look of a boiler room somewhere.
"Why not the boiler room of a submarine?" asked another Assistant Professor. Why not indeed, I thought.
"But why are all these pipes and things exposed" asked an Associate Professor. That was something that needed a thought. These things are normally concealed.
"Perhaps it is for ease of maintenance and repair" suggested someone. "The things are right there to open and repair or clean." That sounded likely, considering the rate at which other things were going out of order soon after installation.
"Perhaps it is a low budget job, like those no frills airlines" said someone who seemed to be a frequent flier.
"Perhaps it is a measure to increase profits of the contractor" accused someone. I could not say if it was true or not. The financial workings of the civic juggernaut was far beyond my jurisdiction.
"No! It is to give our place a rough and tough look, that will inspire confidence in the lower socioeconomic class patients which frequent our hospital" said someone who would do well in PR. That sounded a good idea, in which no allegations were made against the ability and intentions of anyone.

Pharmaceutical Confusion

“Doctor, do you have five minutes? Our country manager has come to meet you.”
It was a sales representative of a company that sold cervical ripening and uterine stimulating drugs. By country manager he must have meant sales manager, not prime minister or president of ruling party, I presumed. I had no time. But what with the Boss talking about public-private partnership enthusiastically, I decided to let them talk to me. I did not expect a ball point pen or a writing pad from them, as I used to when I had just qualified 31 years ago. I had stopped that as soon as I the medical council said it was unethical, and the civic body service regulation said may be we could take a flower from them. I buy my own pens and remain away from flower markets.
“Doctor, we want to know about your prescribing practices of our drugs” she said.
“Our practices are detailed on our website. They are same as what is written on your product inserts” I said.
“Yes doctor. We want to know the correct practices” she said.
“They are correct. They match ACOG and RCOG guidelines, which are available on the net” I said.
“Doctor, do you use oxytocin for active management of third stage of labor?” she asked.
“No. We use methyl ergometrine or misoprostol” I said.
“But I have a reference which says otherwise” she said.
“Which one?” I asked. She told me the name of a popular guide read by undergraduate students.
“I suggest you read Williams’ Obstetrics. It is costly, but scientific. For a pharmaceutical like yours, the cost is not an issue, I trust” I said.
“Doctor, what do you do when you are in a hurry to induce labor and the cervix is unripe?”
“We use intracervical balloon catheter or PGE2 gel” I said.
“DO you wait for 6-24 hours?”
“We wait for 6 hours” I said.
“But for an urgent case?” she asked. As if the waiting period could be shortened.
“You cannot shorten the waiting period, because the drug requires that much time to act” I said.
“Even if the case is urgent” she asked. Obviously she wanted another answer.
“Are you suggesting we use double the recommended dose or something?” I heard myself ask and was surprised to hear it. I was further surprised when she said that was what some doctors were doing.
“Who? Where?” I asked.
“In Bxxxxlxxe” she said. I have put xs to protect the identity of the city she mentioned.
“Tell me the doctors’ names. I cannot control their practice which can kill the baby and even the mother. But I can put their names on my blog” I said.
“No doctor. If you do that, they will not entertain me again” she said.
“But if they are consuming twice as much drug as they otherwise would, you should be happy because your sales are up” I said. “Anyway, what is the point in asking me about what others are doing?”
“Someone like FOGSI should correct them” she said.
“I am sorry I am not in the managing council of FOGSI. The medical council was going to bring out standard management guidelines which were going to be compulsory for all doctors. They had announced that a year and half ago. Perhaps you should approach the medical council” I said. “Now will you kindly excuse me? I have to finish quite a bit of work before I break for lunch”
“Thank you doctor” she said “have a nice day.”
They went away without offering me a ball point pen or giving me a flower, or giving a fat cheque to my institute as a token of appreciation and support. Well, it was not the first pharmaceutical which had picked my brains without doing anything for my institute, definitely would not be the last.

Not Me

We were visiting a relative who had undergone a spine operation in a star hospital and was recuperating at home. All was well since it had ended well. We were required to listen to the story and socialize rather than offer any professional advice. We were not qualified to give any professional advice anyway, since I specialized in Obstetrics and Gynecology and my wife in Ayurvedic Medicine.
"They have a wonderful system for preventing a patient from undergoing a wrong operation" the patient’s husband enthused. "If a right knee is to be replaced, they put a label on the left knee which reads "Not Me".
"But what if they take the patient inside and replace the hip joint instead of the knee joint?" I asked. "Or a shoulder, or even remove a cataract instead?"
"Uh?"
"Do they put ‘Not Me’ labels on all organs in the body other than the one to be operated on?" I explained.
"No."
"Then they can end up doing a wrong operation anyway" I said.
"They know in general that the operation is for a given area, and they put a label just to avoid right-left confusion" he explained.
I knew there was a condition called dyslexia in which there was right-left confusion. Surely the star hospital doctors did not all suffer from it? I did not talk about it, because they would not see the joke.
"They must have a system for not bypassing a wrong coronary artery while performing an operation for coronary artery obstruction" I said gravely. "No one would like a patent artery bypassed and obstructed artery left as it was."
They had not thought about it before.
"But there was a bit of confusion" said the patient. "They called me to the theater at 8:00 A.M. when the surgeon had told us that the operation was scheduled at 10:00 A.M. We explained again and again, but they would not listen. Finally we made them contact the surgeon’s assistant, who told them it was indeed scheduled at 10:00 A.M. Then they took me out of the theater."
That sounded funny. Surely the OT personnel ought to know who was to undergo which operation at a given time.
"When I was being taken back to my room, a nurse came along, grabbed by arm and said ‘Where are you going Mrs. Shah? Come into the theater. Your operation is to be done right away‘ I told her that I was not Mrs. Shah. They put our names on our wrist bands to avoid confusion. Still she got confused."
"Perhaps they out to put boards of ‘Not Me’ around the necks of the relatives of patients. Otherwise someone may wheel a relative into the operation theater and perform an operation on him or her."
When we left, they were considering putting that in the suggestion box of the hospital.

PCPNDT: Newer Update

The newspaper is the best and probably the only source of up to date information on new decisions made by the government and courts on the matter of PCPNDT. Though I am the chairman of the civic advisory committee, no one probably knows that the committee has to be informed of such things.
I read in the newspaper today that the radiologists lost their case in High Court. Now a portable ultrasound machine cannot be used for its portability. It has to be used only in the hospital where it is registered. A high court bench had passed that order. The activists struggling to curb female feticide were happy. They were pleased that now sonologists would not be able to determine sex of fetus prenatally. There was uproar in the hospital when they heard of it.
“Sir, a portable ultrasonography machine is meant to be taken to patients’ homes or smaller centers where ultrasonography needs to be done urgently. Now very sick patients in such situations will be deprived of sonography facility. Some of them may not be diagnosed adequately and may suffer. Some may even die” one person said.
“The court was told about it. The decision still went against the radiologists” I said.
“I hope relatives of these people who got this decision passed or they themselves need portable ultrasonography some time, and suffer when it is not available” another person said unkindly. I knew it was not unkindness towards the social activists or civic body pleaders or judges. It was due to deep sympathy for the patients.
“We cannot wish ill for anyone” I said mildly.
“But I cannot understand how stopping use of portable ultrasonography will stop prenatal sex determination” said another person. “The sonologist who does prenatal sex determination will continue to do it in the center where his ultrasonography machine is. Patients who want it done will go there and get it done. And the concept seems to imply that prenatal sex determination is done only when the machine is used in multiple places, some of them in really shady places. Does the court not know that it is done in hi-fi, perfectly posh places too?”
“Perhaps not” I said. “Do you know any such centers?”
“No” came the answer. “But I don’t know any shady centers too which do it.”
“Do the activists, pleaders and judges not know that it is the attitude of the patients and relatives which needs to be changed to stop prenatal sex determination?” said a third person.
“Who knows?” I said. “They do not seem to mention it any time. The emphasis seems to be on stopping portable ultrasonography machines being used in multiple centers.”
“I know a few people who have purchased a portable ultrasonography machine, for giving service to nursing homes which do not have workload large enough to justify purchase of a machine of their own. These sonologists do not have a place of their own. Now what will they do to make a living?” asked a fourth person.
“They can start a center of their own” someone said “if they can afford.”
“They will probably commit suicide if they cannot do that, and cannot pay the EMI of the loan they have taken to purchase the machines” said someone. That sounded terrible.
“After all, so far farmers have been committing suicides. Now some sonologists may join the club. What are a few deaths, if we save the female child in the bargain?” said a cynic.
“That may be so if the decision actually prevents prenatal sex determination” said the prophet of death. “What if it fails?”
“Well, then it will be another wrong decision made by people who run the country, and people who decide what is right and what is wrong by law” said the cynic. “In the meantime the activists, civic bosses and government will have convinced the people that great measures have been taken to curb the menace of female feticide.”
“That is the whole purpose of the exercise, is it?” asked someone indignantly.
“Sir, could you not tell the court the truth of the matter?” an optimist asked.
“My bosses would not permit me” I said. “After all, the civic body has initiated the action.”
“So what can we do?”
“We can pray that God puts wisdom in the minds that have erred” I said.

Thinking out of the Box

I had a novel idea, I thought. They used to check patients’ blood pressure and then forget to return the sphygmomanometers to the nurses’ cubboard. Then someone would pull or push something near the instruments and the instruments would fall down and break. It was beyond our means to maintain an adequate flow of new instruments to keep pace with the rate at which they broke them. To overcome this problem, I acquired eight instruments for the labor ward, and fitted them to the walls, one next to each labor bed. Now they had enough instruments, and they could not drop them down. That worked fine until the ward was shifted for repair and renovation. Then without my knowledge the sister-in-charge of the ward shifted everything, but probably thought the instruments were a part of the fixtures and left them behind. The contractor probably thought they were outdated old decorations and threw them away along with the other junk. When we shifted back to the renovated ward, we had no sphygmomanometers.
I acquired a new set through a donation and got them fixed with twisted wire to the labor beds. The fixing would prevent them from being taken away and lost, and also being dropped and broken. It worked for a couple of months, until the sister-in-charge found two of the fixing wires cut and the instruments lying somewhere else in the ward. She complained to me.
“Lodge a manhunt and find the culprit” I said. “If we let it happen and go without punishment, it will keep happening.”
All resident doctors on emergency duty that day were intervied extensively. All other doctors who had patients of their own in the labor ward were also interrogated. No one admitted to the act. A week passed. Then the servants on duty identified an intern who had detached the sphygmomanometers. He admitted he had done it. I called him to talk to him.
“I am sorry sir” he said. That was the standard answer from interns and residents whenever they were caught on the wrong foot.
“But why did you do it?” I asked. “Surely there must have been some sound reason for us to wire the instruments to the labor beds?”
“I had to take blood pressure of a patient and there was no other instrument” he said.
“You could have asked for advice from some senior person” I said.
“It was the middle of the night” he said. As if all qualified doctors had gone to sleep leaving the intern to handle all cases.
“But why did you detach two instruments?” I asked.
“But I detached only one” he said. “It was our emergency …”
“But last Wednesday was not not your emergency” I said.
“It was not a Wednesday. It was a Monday two weeks ago” he said.
So there had been two such episodes. The first one had been covered up. He was being blamed for the second one, poor fellow.
“OK. Did you fix it back to the labor bed after you had finished your work?” I asked.
“No, sir. I am sorry sir” he said.
“Since you admit your mistake, let us make you compensate for it. So far you have caused a loss of four hours of my time, two hours of the sister-in-charge’s time, and one hour each of two other Professors, one Assistant Professor and one Registrar, trying to fix the blame. Let us start with compensation of my time lost. Will you attend a meeting with the Additional Civic Chief at the head office for one hour tomorrow, and another one of PCPNDT advisory committee next week? I am the chairman of that committee. The places of the meetings are air-conditioned. You will get taxi-fare to and fro. The Additional Civic Chief does not offer tea, but the PCPNDT peeople will give you snacks and tea. You should be comfortable.”
He seemed uncomfortable with the idea.
“What is the matter?” I asked. “That is the best way you could make up for my time lost.”
“I could do some clerical work instead” he offered.
“But I don’t do any clerical work myself. You need to do what I do.”
“Um…. I don’t think I can. How can I make decisions in those meetings?” he asked.
“That should not be difficult at all” I said. “If you could make the decision to cut the restraining wires to detach a sphygmomanometer belonging to the hospital, you can make these decisions in meetings quite easily.”
He seemed to get my point and kept quiet.
“OK. Go away. Do not do such things again. If you don’t know what to do in any situation, asked a senior person.”
“Yes sir, sorry sir” he said while beating a retreat.
“Don’t say that and get me started all over again” I said wearily.

Forbidden

One medical sales representative brought along his boss to see me. They wanted to ask me some questions on management of our patients. After a few questions on our practices in the labor ward, I got tired. After all, teaching obstetrics to a non medical person can be quite tiring, more so if there is nothing in it for the institute. She kept telling me about what the obstetricians did in other cities, like Bangalore. Finally I said, "I cannot explain why people do what they do. The standard management guidelines are available on the net, e.g. RCOG guidelines, ACOG guidelines, and our guidelines. Since you want to know about our policy on these matters, please visit our websitre at www.kem.edu and check out our department's section. I will show you on my computer." Then I tried to get the page www.kem.edu. The browser displayed the following message.
Forbidden
You don't have permission to access / on this server.
Additionally, a 404 Not Found error was encountered while trying to use an ErrorDocument to handle the request.
I was surprised. The website is for the whole world to see. If it is forbidden, what would be the purpose of putting it there? So I called the person in charge of maintenance of the website. He was away to see Boss, but someone else who took the phone told me, "people have been given access passwords. You have to have your own password to access the website."
I was taken aback.
"The website is for the whole world to see and learn about our institute. Do you mean to say you will give a password to each person who wants to see it?"
"Um... er... shall I get the webmaster to call you?"
"That would be nice" I said.
The webmaster called later. I explained the situation to him.
"There is a problem with the server. It is down" he said.
"But then the message should not be 'Forbidden. You don't have permission to access / on this server.' The message should be 'the server is down'. I was upset that I did not have permission to access our own website."
He got the joke and said he would get a proper message there. I wonder if he can manage that. The computer and internet messages tend to make out as if the user is at fault or inferior in some way, like Windows used to say "An illegal operation has been done", forgetting to say that it was done by the Windows and not by the user. I used to be in morbid fear that policemen would be swarming our place every time the computer gave that message. It was many years later that I discovered the truth.

Soldering Pleasure

It was one of my secret desires to solder one electric wire to another some time. When I was small, my mother would discourage all such activity on my part, saying such things were not for the likes of us to do. Unfortunately I selected a profession in which there was no call to do such work. Once I needed it done on one of my gadgets, when the engineer told me it was not suitable. Perhaps I would have done it myself successfully if I knew how. Another time I needed it done, the engineer did it himself and I could not ask him to let me try. It did not seem awfully difficult, provided you did not touch the hot tip. When my son wanted to do it as a child to put a 3D accelerator card on to the motherboard of his computer which did not have a slot for it, I discouraged him from buying a soldering iron because I was afraid he would burn a hole in his had by touching the hot tip. I upgraded his hardware instead. Last week my battery charger stopped working, and its soldered terminals came off when I was repairing it. Then I thought I should put a DC adapter in my lamp which worked with three AAA cells. Now that there was no one to discourage me, I decided to do both of these jobs myself. I purchased a soldering iron, and wire. The shopkeeper gave me working instructions. When I told my son about it during our video conference, he adviced me, “be careful with its tip.”
“I know” I said. “The tip is hot and it will burn my hand if I touch it.”
“It will make a hole in your hand if you touch it!” he said drily. Either he still resented my not allowing him to solder a game card on his motherboard when he was a child, or he did not like the idea of his father, a gynecologist, doing something that an electrician or engineer should be doing. Since I had already invested in the equipment and its consumables, I did the soldering anyway. The insulation of the wire came off when the tip was hot enough, the solder wire broke off the main bundle when touched with the hot tip, and fixed the desires in desired places. It worked, though perhaps not like a charm. I used up 100% more of the solder wire than an experienced guy would have done. That was somewhat damaging to my ego. But the happiness at having done it successfully was worth it. Now I won’t have to get frustrated next time when the engineer does not find time to do it for us, or says the job is not suitable for soldering.

The Grandeur Syndrome

There are people who aspire to be something better than they are, These are of three types. One type of people make efforts to reach their goal. The other type of people just wish but make no efforts. The third type of people suffer from the Grandeur Syndrome, distinct from delusions of grandeur, which are due to a psychiatric illness.
We had two such persons in our department. I came to know about them when I came across letters sent to them from others in connection with their work. Both were desirous of being the Head of Department at that time. Unfortunately they could not owing to lesser merit, being lower in seniority list or whatever. They were holding charge of some work areas, and used to get independent correspondence for the same. They fulfilled their wish by sending and receiving letters as Head of Department. It did not change their designations to that of Head of Department, nor their salaries. But they must have got happiness. In due course they went away from the institute for greener pastures. One of them went to a star hospital, and the other to a public institute as a head of the department. The latter was heard to tell around that he was Dean of the institute. The concerned Dean did not hear of it, I suppose. I forgot about their suffering from the Grandeur Syndrome until a sales representative from a leading publishing house came along that day and gave me two books for our library. I was expected to review them. While going through the books, I discovered that one of our syndrome subject had written a chapter in one of the books, and had her designation written as Head of Obstetrics Gynecology Department of my institute.
"This person has never been head of my department" I emailed the publishing house. "She has left the institute and does not belong here any more. How come you have stated that she is Head of the Department? Please withdraw all copies and correct the error before redistributing the book."
"We will look into the matter and check truth of the matter" they wrote after a week. After another week they wrote "we have checked and found that there was an error. We will correct the error in future editions of the book."
That was not as per procedure. SO I wrote back "I suggest you correct the error now" because they were getting advantage of the prestige of our institute under false pretense. "Please let me know if it was your error or the concerned author gave you that information." I needed the information just to confirm that the syndrome continued the affect the said person.
They did not answer that email. I sent them a reminder, and I am yet to receive an answer for it.

OCR Trick for Old Books

I was a book lover when I was a child. I used to spend all my allowance on buying books. I had a few hundred books by the time I became an adult. Unfortunately the storage capacity of the house remained the same. People at home were not ready to chuck out things to make room for my books. I did not know what to do. White ants had eaten through a huge pile of bound volumes of my childhood comics which I loved even when I had grown up. During one vacation for school, the bunch was there. In the next vacation a ghost of the bunch was there, seen from outside, but just a sticky mass full of the ants on the inside. It broke my heart. The thing would not catch fire too. In those days there were no computers and scanners. When those were invented, I converted my books into ebooks by scanning and optical character recognition (OCR). Then I gave away all my books. Unfortunately the old books had their pages all yellowed. With the standard parameters for OCR scanning, using 300 dpi black and white image, nothing coule be converted to text. Then I had a bright idea. I scanned the book pages as 300 dpi color images, and then did OCR on them. It worked like a charm. The images were quite larger. But image size is not a problem with huge hard disks in modern computers. The images are deleted anyway after the OCR is complete. Now all my books are ebooks. Using Calibre, I have converted them into MOBI format books, and I can read them on Amazon Kindle too.

Uterovaginal Prolapse and Bladder Stone

A 52 years old postmenopausal woman presented with a uterovaginal prolapse which was irreducible. My Assistant Professor saw her and called me. She had a third degree uterine prolapse and a large cystocele. The cystocele was quite tender to touch, and stony hard. There was a 3 cm diameter stony hard mass withing the prolapse bladder.
"This is a case of bladder stone that has developed due to prolonged retention of residual urine in the cystocele" I said.
"It did feel hard" he said.
"If we reduce it, the bladder wall will get traumatized" I said. "We have to remove the bladder stone first. Then the infection associated with it can be cleared. Only then we can treat the prolapse."
The urologists wanted a radiograph of the kidney-ureter-bladder area (KUB). The area of interest is shown in the photograph in this post. The laminated appearance of the stone is quite clear.

Consent for Anesthesia

The anesthetists in our institute never took consent for giving anesthesia to patients. That was left for the surgeons to handle. The surgeons did that because they wanted the patients anesthetized to operate on. We would not mind the extra work, because we wanted the patients treated at any cost.
But I realized that that the courts also regarded the surgeons responsible even if the error in management had been that of an anesthetist, stating that the surgeon was responsible for what the anesthetist did, something like vicarious liability. Anesthesiology is a separate science. The doctors of that specialty get a degree of their own, and work independent of the surgeon. As a step towards making the judges understand this, I thought it would be better if the anesthetists obtained consents from patients for giving anesthesia. They knew what anesthesia they would give to a given patient, and would be the best persons to explain the associated risks of the same. I also realized that many private high end hospitals had separate consents for anesthesia. So I told our anesthetists to prepare their own consent forms and use them. Then I went on vacation while they were working on it. But when I came back from my vacation, I found out that they had not started taking their own consents.
"Why are you not separate consent for anesthesia?" I asked the anesthetist in charge of our OT.
"Our consent form is ready. But our head of department has not yet permitted us to use those forms" she said.
"Why?"
"She wants approval from the legal department."
"Use those forms until legal department approves them. If any change is suggested, use the changed form subsequently."
"I cannot do it until the head of department permits me" she said.
"Then call her and ask her again" I said.
"She has not yet decided on it" she said.
"Indecision does not put off troubles" I said. She smiled in response, but made no move to call her head of department.
I knew I would get nowhere. Inactivity was the most approved method of handling troublesome issues in civic offices and even in some parts of civic hospitals. So I called my Registrar and instructed her in front of that anesthetist, "from now on write clearly on our consent forms that consent for anesthesia is not taken. Let them give anesthesia without consents if they want."
That did it. Within a half hour, one hundred printed forms for consent for anesthesia arrived in the OT.

Get Us into Guinness' Book?

It was 8:00 P.M. I was home, reading a book when the phone rang. It was from the hospital. The casualty officer was on the line.
“Is that the head of ob gyn?” he asked.
“Yes” I said.
“I have been trying to get in touch with the resident doctors on duty, but none is available. Only nurses pick up the phone in the labor ward, and they cannot answer questions about a patient. The Lecturer on duty is not contactable.”
The whole thing sounded impossible. But I had to sort out the problem, whatever it was.
“What is the problem?” I asked.
“There is a patient related to a politician, of the party which is in power. She is admitted since morning for a cesarean section, but it is not being done. I am getting calls from the politician.”
“I will talk to the doctors on duty and get them to call you” I said. Then I called the emergency room, and found the Registrar as well as the House Officer working there. I wonder why the casualty officer failed to get them. I asked them about the situation.
“Sir, we have a line of emergency cesarean sections. As usual, there is only one sanctioned nurse and one servant on duty to help for operations on two tables.”
I knew that was the truth. One cannot imagine how, but right from the days I was a House Officer there, this has been the number of employees for running two OT tables at one time. Now the situation is twice as bad, because the delivery rate has doubled. I had put three proposals from 2008 to date, and all of them had magically disappeared in the black holes in administrative offices. My letter asking for the status of all of these past proposals was answered after three reminders and a number of phone calls curtly as ‘New posts cannot be created. You have to manage with the existing number of workers.’ I think we can be put in the Guinness’ book of records for operating on two OT tables at a time with staff for only one.
“Please call the casualty officer and tell him when you will be able to operate on the patient he is concerned about” I said.
“Yes, sir” she said.
This politician used his clout to get his patient operated on and moved on. I wonder why he or others like him did not use their clout to increase the number of nurses and servants for the sake of poor patients for who the hospital is meant.

Patients as Writing Boards

It is to be impressed on the minds of doctors and nurses right at the beginning of their training that patients are human beings with self respect and rights, and are not merely objects for learning. It has not been a part of the curriculum, probably because it is presumed that everyone should understand it without being told about it. Then patients are not patients but interesting cases, troublesome cases, or unwanted work, as the case may be.
One manifestation of the attitude of healthcare providers is that they mark on or write on the bodies of the patients without impunity. I recall the student midwives used to put a cross on the abdomen of the pregnant woman in the antenatal ward and labor ward to indicate the position of the fetal heart sounds. It was to make things easy, since they used to monitor the fetal heart sounds in those days. Now we do not find those marks, because they have stopped monitoring the fetal heart rate. That work is left to the doctors. It is quite sad, but true. The nurses are all overworked with paperwork, it seems.
That day I was examining patient in the antenatal outpatient clinic. There was a woman who did not have her blood pressure on the case paper.
"Please have your blood pressure checked before coming for an examination" I told her.
"But I have had it checked" she said.
"Where is the record of your blood pressure on your case paper?" I asked.
"It is on my hand" she said. I looked at her right palm that she showed me, and indeed "120/80" was written there with a blue ball-point pen.
"Who wrote it there?" I asked her.
"The doctor" she said.
So I went with her to find the doctor who had done it. It was an intern.
"Why did you write the patient's blood pressure reading on her hand instead of her case paper?" I asked the intern.
She looked at me for a couple of seconds, and said "sorry, sir!"
We repeated the question and answer cycle five times, with the same result. She would not tell me the answer.
"All right! Tell me your name" I said. "I will write about you on blog." That did the trick. She jumped in her skin.
"No, no! Not on the blog" she said. "A lot of people read your blog."
"Then tell me why you did that" I said.
"The house officer was writing her history on the case paper when I checked her blood pressure" she explained.
"You could have told her to write the value of the blood pressure" I said. "You cannot treat patients like this. They are human beings too. How would you like me to give you your completion certificate written on your hand?"
"Sorry, sir. I won't do that again" she said.

Darkness Prevails

It was 9:15 A.M. I was taking a round of a ward on the ground floor, when suddenly the lights went off. I could just see vague shadows which were actually people. I was through seeing all patients in that ward. I turned in the direction of the exit and took a couple of steps. Suddenly I slipped and fell. I supported my weight on my outstretched right hand. Luckily I did not develop a Colles' fracture or any of the other injuries that can occur in the upper limb with this maneuver. But my right wrist was sprained. My left quadriceps femoris got pulled. My right hand was in a pool of soap-water. I asked the nurse why it was there.
"The servant is mopping the floor" she answered.
"Why so late, when the doctors take ward round?" I asked.
"He is a temporary servant I got from another ward, because our regular one is absent" she said.
"Luckily I have not broken any bone. But I don't want to fall on another pool of soap-water. Please get him to walk in front of me. He will avoid all such water and I can walk in his wake safely" I said.
"There is no water anywhere else" she said, instead of asking him to do as I asked.
"If you don't want him to walk in front of me, please walk in front of me yourself" I said.
She did that and both of us made it safely to the door in that almost pitch darkness. Then I went to the emergency OT to see if the generator had kicked in and started the emergency lights. It had not. All four OTs in the building were in total darkness, with anesthetized patients on the OT tables. Luckily they had not started operating in either of my both OTs.
"The emergency lights should come on in 15 seconds by the generator starting automatically. The contractor has made a mess of the work during repair of the building. Last time it had happened, I had complained to administration. The architect has stated in his answer that the generator had been started after 15 minutes."
I arranged to get the contractor's workmen to rush and start the generator. Their engineer arrived after 25 minutes and started running around in a panic because our boss had arrived on the scene. I recalled the same engineer had arrogantly answered me last time that maintenance was not his job. The OT got lights after 50 minutes. No woman or no baby dies or developed any complication. I thanked God profusely, but still wondering why He would not make the contractor and architect understand that emergency generator had to start in 15 seconds of the main supply going off, or some patients would die or get seriously compromised.