It is a wonderful thing to sit in the last row during a lecture, when you are student and are not interested in listening to the lecture or answering questions by the teacher or both. It is also convenient if you want to go to sleep without being caught at it. If the classroom has a back door too, which is not locked after the lecture starts, one can run away more easily from the last row than from the first few rows.
I know all this because I have been a student before I qualified and became a teacher. Knowing the condition well, it becomes easier to find a solution to it. One way to deal with the situation is to just say:
“Hey, you all in the last two rows. Come up front. The first two rows are empty.” It works by the same mechanism of people doing your bidding at gunpoint. There is no happiness in it, for the people I mean. There is a better method. Before you begin your lecture, you look at the back rows, crane your neck for getting a better view, and move your lips as if saying ‘can you hear me?’ If you cannot mime, you may speak the line softly, so that perhaps only those in the first row can hear you. But you must move your mouth sufficiently to make it appear that you are speaking quite loudly. All the students in the back row look at you blankly, because they cannot hear you anyway. Then you repeat performance, pointing at your lips first and then at them and then at your ears. They get at what you are saying, and promptly say:
“No, Sir.”
Then you point to the first two vacant rows and gesture for them to come forward and sit in those rows. They comply without feeling too bad about it. The students in the front rows understand your trick right away, but they cannot put the back benchers wise in time. By the time of your next lecture for them, everyone knows about your trick, but they occupy the front rows before you enter the class, because they understand that a teacher who can play that trick can have a few more tricks up his sleeve, and if not, he can always brandish the virtual gun.
Saturday, December 31, 2011
Friday, December 30, 2011
Unsigned Application and the Boss
I was going through the paper work that is a part of my job as administrative head of the department. Nothing (written or printed) is supposed to go out of the department to anywhere else without the signature with/without the remarks of the head of the department. Sometimes it is relevant. Sometimes it is not. But rule have to be followed, or the papers come back like a bad penny. That day there was a proposal and an application for clearance of a research proposal by the ethics committee of the institute. It was made by a resident doctor, for working on a topic for her dissertation. The multi-page document was filled quite elaborately. It was duly signed as co-investigator by the teacher and boss of the resident doctor. But the place for the signature of the applicant was blank. I could have signed it then and instructed the clerk to obtain the applicant’s signature before sending it away. But it would be wrong, and I wanted to find out a couple of things about it anyway. So I kept the paper pending and requested the clerk to advise the applicant to see me when she was free. The applicant arrived in half an hour.
“Sir, I have come because you called me” she said.
“I did not call you right away” I said. “You have an outpatient clinic at this time. I wanted you to come when you were free. Is your boss not angry because you are away?”
“I told him it was about my dissertation” she said.
“Have a seat. Look at your application and see if you spot anything wrong” I said.
She sat down and went through all the papers of her application. When she reached the end, she found out that she had sent the application for my forwarding signature without signing it herself. She promptly took out her pen and started signing.
“Wait, wait!” I said. I said ‘wait twice, so that she would register the second one if she missed the first one. It is my experience that they tend to miss single word commands. She caught one or both of the commands, and stopped.
“You can sign it after you answer my questions” I said. She waited for the questions patiently. “Why did you put up an application without signing it? It is like giving an unsigned cheque.”
“I am sorry” she said, “I forgot.”
“How did your boss sign it without you having signed it first?” I asked. “He is quite particular about paper work.”
“He had advised me to sign. I meant to, but I forgot.”
“He is in the outpatient clinic, right? Let me ask him” I said and reached for the phone.
“Sir, no!” she cried.
“What is the matter?” I said. “I will just ask him nicely how he signed it without your signature. Then he won’t do that again” I said.
“Sir, please, no! He will be furious and will fire me” her face was quite worked up and I was afraid she would start crying. I don’t like grown people crying, and definitely not because of me in any way. So I moved my hand away from the phone far enough to relieve her anguish.
“OK. I won’t ask him” I said. “But what will you tell him when you go back? He will want to know the reason for my calling you.”
She thought that over and said “I will tell him the truth.”
“If you tell him the truth, he won’t be angry with you, but if I do it, he will be? How is that so?” I said.
She kept quiet. I was slow, but finally I understood. She had understood her boss’ nature better than I had. I signed the paper without any further questions and she went away without shedding any tears that had threatened to appear just a short while ago.
“Sir, I have come because you called me” she said.
“I did not call you right away” I said. “You have an outpatient clinic at this time. I wanted you to come when you were free. Is your boss not angry because you are away?”
“I told him it was about my dissertation” she said.
“Have a seat. Look at your application and see if you spot anything wrong” I said.
She sat down and went through all the papers of her application. When she reached the end, she found out that she had sent the application for my forwarding signature without signing it herself. She promptly took out her pen and started signing.
“Wait, wait!” I said. I said ‘wait twice, so that she would register the second one if she missed the first one. It is my experience that they tend to miss single word commands. She caught one or both of the commands, and stopped.
“You can sign it after you answer my questions” I said. She waited for the questions patiently. “Why did you put up an application without signing it? It is like giving an unsigned cheque.”
“I am sorry” she said, “I forgot.”
“How did your boss sign it without you having signed it first?” I asked. “He is quite particular about paper work.”
“He had advised me to sign. I meant to, but I forgot.”
“He is in the outpatient clinic, right? Let me ask him” I said and reached for the phone.
“Sir, no!” she cried.
“What is the matter?” I said. “I will just ask him nicely how he signed it without your signature. Then he won’t do that again” I said.
“Sir, please, no! He will be furious and will fire me” her face was quite worked up and I was afraid she would start crying. I don’t like grown people crying, and definitely not because of me in any way. So I moved my hand away from the phone far enough to relieve her anguish.
“OK. I won’t ask him” I said. “But what will you tell him when you go back? He will want to know the reason for my calling you.”
She thought that over and said “I will tell him the truth.”
“If you tell him the truth, he won’t be angry with you, but if I do it, he will be? How is that so?” I said.
She kept quiet. I was slow, but finally I understood. She had understood her boss’ nature better than I had. I signed the paper without any further questions and she went away without shedding any tears that had threatened to appear just a short while ago.
Thursday, December 29, 2011
Laparoscopy: Two Breath Technique
Training resident doctors is a part of my job. Their training includes operative techniques. Laparoscopy is one of the operations they have to learn. It is my observation that no matter how strong and healthy the resident doctor may be, he/she finds inserting the trocar and cannula through the abdominal wall during their early days of training. They huff and puff and still the instrument does not enter the peritoneal cavity. Perhaps they are afraid. Perhaps there is some other reason. I usually try the following technique when everything short of my taking over fails.
"Stop all efforts" I say. "Leave the instruments aside. Take two long breaths and keep the air inside for some time before breathing it out."
They do it as told, because the other option is I take over and insert the laparoscope.
"No insert the trocar and cannula while your red blood cells and muscles are still highly oxygenated. It must work. It always works."
They try and it does work. They are happy that they have managed to get the trocar and cannula inside.
"Sir, what made you advise this two-breath technique?" my inquisitive Assistant Professor asked me once.
"Well, it is not described in any book, and I am not sure the scientific explanation of blood and muscle oxygenation I give is the real explanation of its success. I have not done any study to prove it statistically that it is really effective."
"But what gave you the idea?" he asked.
"I saw a movie once. The hero is an American cop, who is kidnapped and recruited by a Korean martial arts teacher to destroy some villains. He trains the cop. One of the things in the training is deep breathing for oxygenation. The teacher believes it improves strength and performance. The hero excels in martial arts possibly because of the oxygenation, or more likely because that is in the script. But I liked the idea. I use it as a joke, and to give the poor resident one last chance to succeed. Perhaps the ultimatum works. Perhaps his/her faith in me works. May be one day I will write a scientific paper on it, and some journal might print it too!"
This happened a long time ago. I still use the trick, but have not got around the writing the paper. Perhaps I have to take long breaths so as to be able to get started.
"Stop all efforts" I say. "Leave the instruments aside. Take two long breaths and keep the air inside for some time before breathing it out."
They do it as told, because the other option is I take over and insert the laparoscope.
"No insert the trocar and cannula while your red blood cells and muscles are still highly oxygenated. It must work. It always works."
They try and it does work. They are happy that they have managed to get the trocar and cannula inside.
"Sir, what made you advise this two-breath technique?" my inquisitive Assistant Professor asked me once.
"Well, it is not described in any book, and I am not sure the scientific explanation of blood and muscle oxygenation I give is the real explanation of its success. I have not done any study to prove it statistically that it is really effective."
"But what gave you the idea?" he asked.
"I saw a movie once. The hero is an American cop, who is kidnapped and recruited by a Korean martial arts teacher to destroy some villains. He trains the cop. One of the things in the training is deep breathing for oxygenation. The teacher believes it improves strength and performance. The hero excels in martial arts possibly because of the oxygenation, or more likely because that is in the script. But I liked the idea. I use it as a joke, and to give the poor resident one last chance to succeed. Perhaps the ultimatum works. Perhaps his/her faith in me works. May be one day I will write a scientific paper on it, and some journal might print it too!"
This happened a long time ago. I still use the trick, but have not got around the writing the paper. Perhaps I have to take long breaths so as to be able to get started.
Wednesday, December 28, 2011
Tea… Coffee… Sherbet…IV Fluid Manners
I was raised to understand that nothing should be wasted. I was told to drink a beverage given to me leaving the glass empty. I was told to eat all food on my plate. If I did not want the quantity given, I was to get it reduced first, so that I could finish everything I started to eat or drink. The reason was that in many parts of the world many people go without enough to eat and drink, and we cannot be wasting stuff only because we can afford to. We actually cannot afford to waste any morally, because all resources are limited, and money power does not give us the power to throw away food or drink. My mother taught me this when I was small, and I have not forgotten it ever.
But I am aware that there is a class of people out there who believes that to make the glass empty or clean up one’s plate is bad manners. It is supposed to indicate that one does not have enough, that one is not satisfied and hence one eats the last morsel or drinks the last drop offered. This group believes that the correct thing to do is to leave about 10-20% of the drink or food behind, so that the host does not believe you to be poor or dissatisfied. Such people are seen to heap their plates with food in buffets and then throw away half of it.
There is nurse from this group in one of our wards. I have not observed her eating or beverage-drinking habits. But I have watched her IV fluid administration habits. I found out today that she had started a new bottle of IV fluids for a number of operated patients in our recovery ward, discarding previous bottles with about 10% of the IV fluid still there. And there was a patient who had received IV antibiotic infusion that came in a small plastic bottle. The fluid has orange color, so that residual fluid could be seen clearly. About 10% of the antibiotic was still left behind, and an infusion of Ringer’s lactate had been started. A patient losing 50 ml of saline is perhaps OK (though a waste), but losing 10% of the antibiotic is not OK. The said nurse, whose identity I don’t know, had gone somewhere and was not available for education. I hope she will be there tomorrow, so that I can advise her to restrict her etiquettes to her social eating and drinking habits, and not apply them to patients’ treatment.
But I am aware that there is a class of people out there who believes that to make the glass empty or clean up one’s plate is bad manners. It is supposed to indicate that one does not have enough, that one is not satisfied and hence one eats the last morsel or drinks the last drop offered. This group believes that the correct thing to do is to leave about 10-20% of the drink or food behind, so that the host does not believe you to be poor or dissatisfied. Such people are seen to heap their plates with food in buffets and then throw away half of it.
There is nurse from this group in one of our wards. I have not observed her eating or beverage-drinking habits. But I have watched her IV fluid administration habits. I found out today that she had started a new bottle of IV fluids for a number of operated patients in our recovery ward, discarding previous bottles with about 10% of the IV fluid still there. And there was a patient who had received IV antibiotic infusion that came in a small plastic bottle. The fluid has orange color, so that residual fluid could be seen clearly. About 10% of the antibiotic was still left behind, and an infusion of Ringer’s lactate had been started. A patient losing 50 ml of saline is perhaps OK (though a waste), but losing 10% of the antibiotic is not OK. The said nurse, whose identity I don’t know, had gone somewhere and was not available for education. I hope she will be there tomorrow, so that I can advise her to restrict her etiquettes to her social eating and drinking habits, and not apply them to patients’ treatment.
Tuesday, December 27, 2011
ISO 9002 Certified Doctor
ISO is short for International Standard of Organization. ISO 9002 (last revised in 1994) was a Model for quality assurance in production, installation, and servicing. had basically the same material as ISO 9001 but without covering the creation of new products. It was very applicable for contract manufacturing. I understand organizations now use ISO 9001 standard and ISO 002 is obsolete. It came as a surprise when one of our colleagues working in another civic institute used it on his letterhead.
One patient came to our outpatient clinic. She had been seen by this gynecologist in his private clinic and advised some operation. Her husband worked in our institute. So they came to us. One of my junior colleagues saw her and advised appropriate management. He found this gynecologist’s letterhead amongst her papers.
“Look at this, Sir” he said. The clinic was quite crowded, and there was little time to waste. But my juniors never wasted time, neither mine nor theirs, when the clinic was crowded. I looked. I found that he had written his position at that civic hospital below his name on the letterhead, and then written ISO 9002 certified.
“Sir, does one write ISO certified like this?” he asked.
“If it is your clinic or hospital, and it is ISO certified, you can write that, because it signifies a certain level of standard of the place. But if you are just attached to a place as a visiting consultant, you don’t write that, because your letterhead is for yourself, not for one place amongst many that you visit.”
“So what does it mean, Sir? Is he trying to take credit for something one of the institutes to which he goes has?” he asked.
“Looks like that” I said.
“Sir, but that is unethical!”
“I think so, too” I said. “But in the rat race of today, he may be under pressure to resort to such means to survive.”
“That is not right, Sir!”
“Well, we are not the authority to put a stop to it” I said. I can make a few more suggestions for this fellow. His institute must can a lot of equipment which is CE certified, and US FDA certified. The medicines the civic body purchases for patients are WHO GIMP certified. This fellow can write CE certified, US FDA certified and WHO GIMP certified in addition to ISO 9002 certified. It will add so much more prestige to his reputation.”
My colleague saw the sarcasm in this suggestion and smiled.
“He can even write MRCOG as one of the degrees he possesses. It is not recognized my our medical council. SO they will not object to it. The MRCOG board does not know what happens in this corner of the world, and it has no jurisdiction here anyway. So it will be all right. If anyone does take him to task, he can produce a certificate showing he is a Member of Residential Colony of Goregaon or Govandi or any place with a name starting with a G.”
One patient came to our outpatient clinic. She had been seen by this gynecologist in his private clinic and advised some operation. Her husband worked in our institute. So they came to us. One of my junior colleagues saw her and advised appropriate management. He found this gynecologist’s letterhead amongst her papers.
“Look at this, Sir” he said. The clinic was quite crowded, and there was little time to waste. But my juniors never wasted time, neither mine nor theirs, when the clinic was crowded. I looked. I found that he had written his position at that civic hospital below his name on the letterhead, and then written ISO 9002 certified.
“Sir, does one write ISO certified like this?” he asked.
“If it is your clinic or hospital, and it is ISO certified, you can write that, because it signifies a certain level of standard of the place. But if you are just attached to a place as a visiting consultant, you don’t write that, because your letterhead is for yourself, not for one place amongst many that you visit.”
“So what does it mean, Sir? Is he trying to take credit for something one of the institutes to which he goes has?” he asked.
“Looks like that” I said.
“Sir, but that is unethical!”
“I think so, too” I said. “But in the rat race of today, he may be under pressure to resort to such means to survive.”
“That is not right, Sir!”
“Well, we are not the authority to put a stop to it” I said. I can make a few more suggestions for this fellow. His institute must can a lot of equipment which is CE certified, and US FDA certified. The medicines the civic body purchases for patients are WHO GIMP certified. This fellow can write CE certified, US FDA certified and WHO GIMP certified in addition to ISO 9002 certified. It will add so much more prestige to his reputation.”
My colleague saw the sarcasm in this suggestion and smiled.
“He can even write MRCOG as one of the degrees he possesses. It is not recognized my our medical council. SO they will not object to it. The MRCOG board does not know what happens in this corner of the world, and it has no jurisdiction here anyway. So it will be all right. If anyone does take him to task, he can produce a certificate showing he is a Member of Residential Colony of Goregaon or Govandi or any place with a name starting with a G.”
Sunday, December 25, 2011
My iPad … My Blackberry … My …
It was an email from someone. The contents were not very important. I would have deleted the email and thought no more of it in routine course of things. But it was a bit different. At the bottom of the email was a single line in italics: ‘sent from my iPad’. When the email was seen by a colleague who was also working on the same project in connection with which the email had been sent to us, he said “What is the idea of putting that line at the bottom?”
I could see that he was not very happy with it.
“It is a marketing strategy” I explained to him. “The manufacturers of such gadgets program their gadgets so that such a line is inserted automatically at the end of every email sent from the gadgets.”
“What does it achieve? It just makes the recipients feel bad that they don’t have such gadgets” he said angrily.
“That is the crux of the matter” I said. “When one feels jealous of someone who has that gadget, one goes and buys one so that he too has it. That improves sales. In the meantime, the person who possesses that gadget keeps feeling good that he has that gadget and the world knows about it. It is like flaunting what one has got. If you send an email using a Blackberry phone, the end of the email will have a line in italics ‘sent from my Blackberry’. I could give you a number of examples of what men and women flaunt, besides gadgets that send emails.”
“No, thanks” he said with a half smile. “I don’t want to possess gadgets which I don’t need, and don’t want to flaunt what I got.”
If you get angry with people who flaunt these gadgets, you could get back at them” I said.
“How?” He seemed to like the idea of getting back at them.
“You could manually type the following at the end of your reply to such emails. Put it in italics. You could save a text file with this text in it, for use any time you want. If you do not want to make the effort again and again, you could put that as your signature by going into settings of your email service, where people usually put their names or positions.”
The text for email signature could be as follows. Readers could make alterations in it to suit their own sense of sarcasm.
‘Sent from my iPad, my Samsung Galaxy, my BlackBerry Playbook, my BlackBerry, my iPhone 4S, my Windows Phone, and my Samsung Galaxy Nexus.’
I could see that he was not very happy with it.
“It is a marketing strategy” I explained to him. “The manufacturers of such gadgets program their gadgets so that such a line is inserted automatically at the end of every email sent from the gadgets.”
“What does it achieve? It just makes the recipients feel bad that they don’t have such gadgets” he said angrily.
“That is the crux of the matter” I said. “When one feels jealous of someone who has that gadget, one goes and buys one so that he too has it. That improves sales. In the meantime, the person who possesses that gadget keeps feeling good that he has that gadget and the world knows about it. It is like flaunting what one has got. If you send an email using a Blackberry phone, the end of the email will have a line in italics ‘sent from my Blackberry’. I could give you a number of examples of what men and women flaunt, besides gadgets that send emails.”
“No, thanks” he said with a half smile. “I don’t want to possess gadgets which I don’t need, and don’t want to flaunt what I got.”
If you get angry with people who flaunt these gadgets, you could get back at them” I said.
“How?” He seemed to like the idea of getting back at them.
“You could manually type the following at the end of your reply to such emails. Put it in italics. You could save a text file with this text in it, for use any time you want. If you do not want to make the effort again and again, you could put that as your signature by going into settings of your email service, where people usually put their names or positions.”
The text for email signature could be as follows. Readers could make alterations in it to suit their own sense of sarcasm.
‘Sent from my iPad, my Samsung Galaxy, my BlackBerry Playbook, my BlackBerry, my iPhone 4S, my Windows Phone, and my Samsung Galaxy Nexus.’
Saturday, December 24, 2011
Medicinal Geyser and Us
We were taking round of the labor ward and waiting ward. They had kept in the entry corridor along the wall a huge wooden frame of a set of cabinets, with the laminated doors attached to it. We entered the ward and found the cabinet from which it had come off.
“The entire door had come off in out theater” another Head of Department in the renovated building had said last, I recalled. It seems they had fixed it again.
“Sister, how did this come off?” I asked the sister-in-charge of that ward, pointing towards the frameless and doorless set of cabinets.
“Sir, I am fed up!” she said. “Less than six months from giving us the renovated ward, and things are coming off already. Shoddy work!”
“Hmm…” I said. It did look shoddy. I did not tell her about the other examples of such work I had seen in the other parts of he department. My job was to listen more and take action on what I heard, rather than tell things. Since I was the boss, my complaints to my juniors would not achieve anything more than venting my feelings.
“Sir, that is noting” she said “as compared to what happened the other day.”
She seemed to want me to ask ‘what happened?’ “What happened?” I asked.
“Sir, the top of the tap that supplies hot water from the solar geyser on the terrace blew off. Out poured very hot water that would not stop. The whole bathroom was full of steam. Finally they had to shut of the water supply in that line totally. Now the patients are without hot water.”
“You have informed the contractor, I trust” I said.
“I have. He says his job is finished after giving the ward to us. Now our people have to sort out any problems as they arise.”
“But that is not true” I said. “He has not given charge to the civic administration.”
“I will be pursuing the matter” she promised.
“That sounds like those natural geysers at Vajreshwari, which give out hot water containing sulfur. A lot of people visit that place for its medicinal value and religious feelings” I said to my Assistant Professor. “If people come to know about the eruption of hot water from a tap in a hospital, they will definitely throng the hospital to get some of the medicinal water coming from it. Had they not thronged the seashore when someone spread a rumor that the seawater had turned sweet?”
“Yes, sir” he said obediently. He knew it was useful to agree with the boss.
“The civic body can make a bit of money if every visitor is charged some amount. They could keep it free for those below poverty line.”
He kept quiet. Perhaps he sensed my sarcasm. Perhaps he was against charging people money for seeing a medicinal geyser.
“The entire door had come off in out theater” another Head of Department in the renovated building had said last, I recalled. It seems they had fixed it again.
“Sister, how did this come off?” I asked the sister-in-charge of that ward, pointing towards the frameless and doorless set of cabinets.
“Sir, I am fed up!” she said. “Less than six months from giving us the renovated ward, and things are coming off already. Shoddy work!”
“Hmm…” I said. It did look shoddy. I did not tell her about the other examples of such work I had seen in the other parts of he department. My job was to listen more and take action on what I heard, rather than tell things. Since I was the boss, my complaints to my juniors would not achieve anything more than venting my feelings.
“Sir, that is noting” she said “as compared to what happened the other day.”
She seemed to want me to ask ‘what happened?’ “What happened?” I asked.
“Sir, the top of the tap that supplies hot water from the solar geyser on the terrace blew off. Out poured very hot water that would not stop. The whole bathroom was full of steam. Finally they had to shut of the water supply in that line totally. Now the patients are without hot water.”
“You have informed the contractor, I trust” I said.
“I have. He says his job is finished after giving the ward to us. Now our people have to sort out any problems as they arise.”
“But that is not true” I said. “He has not given charge to the civic administration.”
“I will be pursuing the matter” she promised.
“That sounds like those natural geysers at Vajreshwari, which give out hot water containing sulfur. A lot of people visit that place for its medicinal value and religious feelings” I said to my Assistant Professor. “If people come to know about the eruption of hot water from a tap in a hospital, they will definitely throng the hospital to get some of the medicinal water coming from it. Had they not thronged the seashore when someone spread a rumor that the seawater had turned sweet?”
“Yes, sir” he said obediently. He knew it was useful to agree with the boss.
“The civic body can make a bit of money if every visitor is charged some amount. They could keep it free for those below poverty line.”
He kept quiet. Perhaps he sensed my sarcasm. Perhaps he was against charging people money for seeing a medicinal geyser.
Thursday, December 22, 2011
Wrong Orifice!
I understand people can make mistakes. That is how one learns. But I also feel that people should not mistakes about things that they know or at least must know very well. If they do and someone finds out that they did, one may sue them and win.
There was that case of a qualified gynecological fourth year resident who had put the Sims’ speculum into the poor woman’s rectum while that woman was undergoing a vaginal hysterectomy under spinal anesthesia. One moment it was in the vagina, and the next it was in the rectum. Perhaps a few moments passed after that until I noticed what she had done. I was flabbergasted when I found it there and stool on its surface. I got it removed, the parts cleaned and re-draped, and completed the operation with a prayer on my lips. The patient did well postoperatively. She did not develop fecal incontinence or surgical infection. Now it is a long time since, and one can say all is well that ends well. But is it really so? When a qualified gynecologist does such a thing, all cannot be well.
"Sir, perhaps it was an accident" said someone.
"Possibly" I agreed. "But avoidable!"
"Sir, was it the first time you saw such a thing?" someone asked me.
"No" I said "there was a fourth year resident, MD qualified, who had put a Sims’ speculum into a woman’s rectum to cut a suture that had inadvertently been passed through the rectum while suturing an episiotomy. She did that without anesthesia. She should have known Sims’ speculum was not the instrument meant for that purpose, that it would hurt a lot, and better instruments were available. Still she did what she did. That was criminal."
"It must be lack of knowledge of anatomy that resulted in that error" someone said.
Both of these doctors were gynecologists" I said. Anatomy of the woman’s genital tract is the most primary thing a gynecologist has to learn. Surely they must have known that. Besides, both of them were women. I suppose a doctor woman would know anatomy of a woman well?"
"Umm… yes, Sir"
"Did I tell you there are people who mistake the vagina for the urethra too?" I asked.
"No, Sir" said a Professor "how can be so?"
"Well, I don’t know how. But it has happened before. We had this fellow who was a gold medalist at M.B.B.S. examination, and was doing MD in obstetrics and gynecology with us. I asked him to catheterize a woman before an operation. He passed a catheter and reported that there was no urine draining through it. I had a feeling that something was not right. So I checked and found that he had passed it into the vagina. I pointed out his error to him. He made a face showing ‘so what?’ expression and went away. There have been others too who have erred similarly."
"I will tell you something that will beat all these stories" said a professor. "In the other civic hospital, they held the anterior lip of the external urinary meatus of a woman and dilated the urethra thinking they were dilating the woman’s cervix. Then they tried to evacuate uterine contents by entering the urinary bladder and perforated it, which was sutured by the urologists."
This story indeed beat my stories. I was suddenly happy I did not have such residents.
There was that case of a qualified gynecological fourth year resident who had put the Sims’ speculum into the poor woman’s rectum while that woman was undergoing a vaginal hysterectomy under spinal anesthesia. One moment it was in the vagina, and the next it was in the rectum. Perhaps a few moments passed after that until I noticed what she had done. I was flabbergasted when I found it there and stool on its surface. I got it removed, the parts cleaned and re-draped, and completed the operation with a prayer on my lips. The patient did well postoperatively. She did not develop fecal incontinence or surgical infection. Now it is a long time since, and one can say all is well that ends well. But is it really so? When a qualified gynecologist does such a thing, all cannot be well.
"Sir, perhaps it was an accident" said someone.
"Possibly" I agreed. "But avoidable!"
"Sir, was it the first time you saw such a thing?" someone asked me.
"No" I said "there was a fourth year resident, MD qualified, who had put a Sims’ speculum into a woman’s rectum to cut a suture that had inadvertently been passed through the rectum while suturing an episiotomy. She did that without anesthesia. She should have known Sims’ speculum was not the instrument meant for that purpose, that it would hurt a lot, and better instruments were available. Still she did what she did. That was criminal."
"It must be lack of knowledge of anatomy that resulted in that error" someone said.
Both of these doctors were gynecologists" I said. Anatomy of the woman’s genital tract is the most primary thing a gynecologist has to learn. Surely they must have known that. Besides, both of them were women. I suppose a doctor woman would know anatomy of a woman well?"
"Umm… yes, Sir"
"Did I tell you there are people who mistake the vagina for the urethra too?" I asked.
"No, Sir" said a Professor "how can be so?"
"Well, I don’t know how. But it has happened before. We had this fellow who was a gold medalist at M.B.B.S. examination, and was doing MD in obstetrics and gynecology with us. I asked him to catheterize a woman before an operation. He passed a catheter and reported that there was no urine draining through it. I had a feeling that something was not right. So I checked and found that he had passed it into the vagina. I pointed out his error to him. He made a face showing ‘so what?’ expression and went away. There have been others too who have erred similarly."
"I will tell you something that will beat all these stories" said a professor. "In the other civic hospital, they held the anterior lip of the external urinary meatus of a woman and dilated the urethra thinking they were dilating the woman’s cervix. Then they tried to evacuate uterine contents by entering the urinary bladder and perforated it, which was sutured by the urologists."
This story indeed beat my stories. I was suddenly happy I did not have such residents.
Wednesday, December 21, 2011
Virus Wish
In conventional psychiatry there is something called a ‘death wish’. In modern technical world of computers, ‘virus wish’ is its equivalent.
It was that conference arranged by that government’s research agency. They had a woman oncologist speaking. She looked elderly, motherly, and scholarly. She was tech savvy too - had a PowerPoint presentation on a pen drive. That was where the trouble started.
The compere got the pen drive to load the presentation prior to her talk. It auto read, and gave the option of scanning it for viruses. A wise move, I must say, on the part of the antivirus software they had installed. The compere seemed to care for the laptop of the institute, and chose that option. The antivirus software started scanning. The LCD projector was on, and we could see what was happening on the laptop. The warning window of the software showed that 6548 files had been scanned, 68 viruses were found, and it was still going strong. The number of files scanned kept on increasing, and the number of viruses kept pace with them too. It got so embarrassing for the projectionist that he rotated the lens of the projector and put it out of focus, so that the results of the scan would not be seen by everyone.
"My presentation is not seen!" complained the eminent speaker. So he rotated the lens back into focus. In the time lapsed, the number of files scanned and viruses found had gone up, and it required no test to prove that the difference was significant.
"Launch the slide show" said the speaker impatiently. The slide show button was covered by the antivirus window. The compere closed it and launched the show. The antivirus warning reappeared immediately and kept itself on top, That marred the beauty of the show and covered text in the slides too. The speaker clucked like an angry hen. The compere tried to shut down the window twice, and both times the window reappeared promptly because new viruses had been found. The speaker clucked again. The compere hesitated. I could make out the turmoil in her mind. To stop the scan meant leaving all those viruses on the pen drive, and the pen drive connected to the system. To continue with the scan meant delaying the talk, or continue it with angry protests from the speaker. Finally she stopped the scan.
"Do you really want to stop the scan" asked the antivirus in surprise. She clicked on ‘Yes’. I could almost hear the antivirus say ‘OK. It’s your funeral’, though the programmer had refrained from putting a message box actually saying so. The talk continued without any further interference from the antivirus software.
I would have loved to tell the speaker about viruses, antivirus software, keeping her pen drive clean of viruses at all times, not stopping antivirus programs when they found viruses in the system or on the pen drive, and the consequences of deviating from these practices. But when I returned from lunch and found that she had moved my pad and papers from my chair and put her bag there during the lunch break, I got angry and decided to let her be and let her infect her own system with all those viruses. Not a principle-centered behavior, Stephen Covey would have said. But a person who keeps so many viruses in her pen drive and stops people from removing them is similar to a person who does not take a bath for days, and wears the same dirty clothes day in and day out. If this person is an adult holding a responsible position in society, I think it is wiser to distance oneself from such a person rather than try to change her.
It was that conference arranged by that government’s research agency. They had a woman oncologist speaking. She looked elderly, motherly, and scholarly. She was tech savvy too - had a PowerPoint presentation on a pen drive. That was where the trouble started.
The compere got the pen drive to load the presentation prior to her talk. It auto read, and gave the option of scanning it for viruses. A wise move, I must say, on the part of the antivirus software they had installed. The compere seemed to care for the laptop of the institute, and chose that option. The antivirus software started scanning. The LCD projector was on, and we could see what was happening on the laptop. The warning window of the software showed that 6548 files had been scanned, 68 viruses were found, and it was still going strong. The number of files scanned kept on increasing, and the number of viruses kept pace with them too. It got so embarrassing for the projectionist that he rotated the lens of the projector and put it out of focus, so that the results of the scan would not be seen by everyone.
"My presentation is not seen!" complained the eminent speaker. So he rotated the lens back into focus. In the time lapsed, the number of files scanned and viruses found had gone up, and it required no test to prove that the difference was significant.
"Launch the slide show" said the speaker impatiently. The slide show button was covered by the antivirus window. The compere closed it and launched the show. The antivirus warning reappeared immediately and kept itself on top, That marred the beauty of the show and covered text in the slides too. The speaker clucked like an angry hen. The compere tried to shut down the window twice, and both times the window reappeared promptly because new viruses had been found. The speaker clucked again. The compere hesitated. I could make out the turmoil in her mind. To stop the scan meant leaving all those viruses on the pen drive, and the pen drive connected to the system. To continue with the scan meant delaying the talk, or continue it with angry protests from the speaker. Finally she stopped the scan.
"Do you really want to stop the scan" asked the antivirus in surprise. She clicked on ‘Yes’. I could almost hear the antivirus say ‘OK. It’s your funeral’, though the programmer had refrained from putting a message box actually saying so. The talk continued without any further interference from the antivirus software.
I would have loved to tell the speaker about viruses, antivirus software, keeping her pen drive clean of viruses at all times, not stopping antivirus programs when they found viruses in the system or on the pen drive, and the consequences of deviating from these practices. But when I returned from lunch and found that she had moved my pad and papers from my chair and put her bag there during the lunch break, I got angry and decided to let her be and let her infect her own system with all those viruses. Not a principle-centered behavior, Stephen Covey would have said. But a person who keeps so many viruses in her pen drive and stops people from removing them is similar to a person who does not take a bath for days, and wears the same dirty clothes day in and day out. If this person is an adult holding a responsible position in society, I think it is wiser to distance oneself from such a person rather than try to change her.
Tuesday, December 20, 2011
Very Very….Many Many
I was attending a symposium organized locally by a government research organization. Something curious happened there, which reminded me of a conference I had been to attend, organized by the Health University. The enthusiasm of the comperes at the two places was identical. The curious method of speech was common, not only of the comperes, but also of some of the speakers.
“We are pleased that this workshop on this very very important topic is being attended by so many doctors” said the compere at the University workshop.
“Today’s topic is very very important in the management of cancer patients” said the compere at the other workshop.
“There are many many reasons for development of malnutrition in children” said a speaker at the University workshop.
“After many many efforts we have been able to isolate this protein in the tubal fluid” said a speaker in the other workshop.
“We are very very grateful to Dr. xxxxx who has come all the way from Pondicherry to deliver a lecture here” said the person giving vote of thanks at the University workshop.
“We hope there will be many many more workshops like this in future, and we are very very grateful to the government for giving the financial aid for conducting workshops of this nature” said the thanks-giver in the other workshop.
I have typed this article using a word processor with the ‘highlight spelling errors as you type’ option turned on, and it has highlighted every second ‘very’ and every second ‘many’ in the pairs. I suppose they turn this feature off when they type their speeches, or they don’t know its significance, or they don’t type their speeches but use manuscripts instead. I know the ‘very very’ is free translation of vernacular equivalent into English, meant to indicate a lot more than a single ‘very’, and ditto for ‘many many’, and I appreciate the spirit behind it. But they got the Swedish bloke so impressed by their English, that he also used ‘very very’ once in his lecture. I knew some Swedish doctors who were not very comfortable with English, and perhaps this fellow thought he was hearing good English when he heard these speakers. I want to see if they manage to impress English or American speakers equally well and get them to use these words in pairs. If they manage it, I will certainly post it on this blog.
“We are pleased that this workshop on this very very important topic is being attended by so many doctors” said the compere at the University workshop.
“Today’s topic is very very important in the management of cancer patients” said the compere at the other workshop.
“There are many many reasons for development of malnutrition in children” said a speaker at the University workshop.
“After many many efforts we have been able to isolate this protein in the tubal fluid” said a speaker in the other workshop.
“We are very very grateful to Dr. xxxxx who has come all the way from Pondicherry to deliver a lecture here” said the person giving vote of thanks at the University workshop.
“We hope there will be many many more workshops like this in future, and we are very very grateful to the government for giving the financial aid for conducting workshops of this nature” said the thanks-giver in the other workshop.
I have typed this article using a word processor with the ‘highlight spelling errors as you type’ option turned on, and it has highlighted every second ‘very’ and every second ‘many’ in the pairs. I suppose they turn this feature off when they type their speeches, or they don’t know its significance, or they don’t type their speeches but use manuscripts instead. I know the ‘very very’ is free translation of vernacular equivalent into English, meant to indicate a lot more than a single ‘very’, and ditto for ‘many many’, and I appreciate the spirit behind it. But they got the Swedish bloke so impressed by their English, that he also used ‘very very’ once in his lecture. I knew some Swedish doctors who were not very comfortable with English, and perhaps this fellow thought he was hearing good English when he heard these speakers. I want to see if they manage to impress English or American speakers equally well and get them to use these words in pairs. If they manage it, I will certainly post it on this blog.
Monday, December 19, 2011
Hermit in Hospital
We were in the brainstorming session for developing technical specifications for modular OT for the hospital. The three heads of departments to get the OT were present because they had to decide what they wanted and what they did not. The main coordination was assigned to another person who had already acquired a modular OT in the past, and presumably knew all about it. Sample specifications were adopted from that developed by another department which had almost acquired a modular OT. It had been a near miss.
“Why did they not get one?” someone asked. It was long story, and there was no time to explain it again. The explanation would have made no difference anyway.
“They were shown the carrot and then it was taken way” I said. They liked that explanation. We moved on with the brainstorming, which by now had started getting on nerves of most of the storm troopers, because there were a number of things which seemed to be have been copied from the product catalogue of one particular company including their trade names which meant little to our engineers and nothing to the doctors.
“I don’t agree with the statement ‘the door to the OT should be hermetically sealed” said the chief engineer.
“It has to be hermetically sealed, or bacteria will go in” said the chief coordinator specialist.
“Hermetic sealing is a special type of sealing, in which even moisture cannot pass through” explained the engineer patiently. “That cannot be applied to OT door.”
“You cannot have a gap in the door” said the chief specialist, quite irritated by the objection. He usually got this away when anyone dared say anything contrary to his opinion. He started shouting, banging the table with his hand, and throwing his considerable weight around. I was sitting next to him, and was the most affected of all present. I realized why everyone was sitting so far from him, leaving the chair next to him vacant, where I had sat unwittingly.
“I agree with the engineer” I said. “Sealing is a process in which something is closed in a way that it cannot be opened again, without breaking the seal. Hermetic sealing is a special type of sealing, in which even gases and moisture cannot pass through. If we seal the OT door in that manner, how can we get into the OT, get patients into it, and operate on them?”
That made sense to most of the people present. The chief specialist was known never to relent, but he did. Hermetic sealing was removed from the specifications. In the meantime I had realized it was best to distance myself from him. It would protect my ear drums, lessen my nerves’ fraying from his table banging, protect my trousers from his shoes every time he crossed his legs, and protect me from being pushed whenever he rolled his chair on castors in my direction. I moved from the chair next to his to one in the back row. He probably wanted to be a hermit, not only because he insisted on hermetic sealing when there was no call for any sealing at all, but also because he seemed to have qualities which made people to want to distance themselves from him.
“Why did they not get one?” someone asked. It was long story, and there was no time to explain it again. The explanation would have made no difference anyway.
“They were shown the carrot and then it was taken way” I said. They liked that explanation. We moved on with the brainstorming, which by now had started getting on nerves of most of the storm troopers, because there were a number of things which seemed to be have been copied from the product catalogue of one particular company including their trade names which meant little to our engineers and nothing to the doctors.
“I don’t agree with the statement ‘the door to the OT should be hermetically sealed” said the chief engineer.
“It has to be hermetically sealed, or bacteria will go in” said the chief coordinator specialist.
“Hermetic sealing is a special type of sealing, in which even moisture cannot pass through” explained the engineer patiently. “That cannot be applied to OT door.”
“You cannot have a gap in the door” said the chief specialist, quite irritated by the objection. He usually got this away when anyone dared say anything contrary to his opinion. He started shouting, banging the table with his hand, and throwing his considerable weight around. I was sitting next to him, and was the most affected of all present. I realized why everyone was sitting so far from him, leaving the chair next to him vacant, where I had sat unwittingly.
“I agree with the engineer” I said. “Sealing is a process in which something is closed in a way that it cannot be opened again, without breaking the seal. Hermetic sealing is a special type of sealing, in which even gases and moisture cannot pass through. If we seal the OT door in that manner, how can we get into the OT, get patients into it, and operate on them?”
That made sense to most of the people present. The chief specialist was known never to relent, but he did. Hermetic sealing was removed from the specifications. In the meantime I had realized it was best to distance myself from him. It would protect my ear drums, lessen my nerves’ fraying from his table banging, protect my trousers from his shoes every time he crossed his legs, and protect me from being pushed whenever he rolled his chair on castors in my direction. I moved from the chair next to his to one in the back row. He probably wanted to be a hermit, not only because he insisted on hermetic sealing when there was no call for any sealing at all, but also because he seemed to have qualities which made people to want to distance themselves from him.
Sunday, December 18, 2011
Voice Command Controlled OT
Our hospital is in the process of installing three modular OTs, one in my department. A number of experts have been brainstorming on technical issues, when none of them is actually a specialist on this subject. The discussion keeps going off track, on tangents, and somehow comes back to the beginning time and again.
That day someone introduced the idea of putting voice command operated equipment.
"When we say 'table up', the OT table goes up" he said. "When we say 'head-low', the head end of the OT table goes down."
People were impressed. I had my doubts.
"It probably will not work in my OT" I said. "There are so many people talking at the same time, on many topics. How will the system understand which command is directed to it? there are those nurses handing over charge of the case when they go off to lunch. Then the anesthetists keep discussing adjustment of emergency duties. A number of people talk on private matters on mobile phones while an operation is in progress. Then the surgeons keep telling funny anecdotes when they are in a good mood."
"We can ask people to keep quiet" someone said doubtfully.
"Some surgeons are confused in the choice of terms. They say table, when they may mean their OT chair and the system may think it is the OT table the surgeon is talkig about. Some surgeons say elevate the table, and when the table starts going up, they say, 'no no, lower it'. So the system may have to be taught to reverse its action when the surgeon says something like 'oops'. When the surgeon cuts something like a blood vessel which he did not plan to cut and says something like 'shit', the system may not be able to comply with the order and may do the next nearest thing. That could be very awkward."
"....." the brain stormers said.
"Then on any given issue, there are usually ten different opinions of ten different people. When someone says 'table up', someone else will say 'head-low', and a third person will say 'OT chair up'. The end result may be a complex position found in yogic exercises."
"We can program the system to recognize a given voice, so that other commands are ignored" the proposer said.
"OK. Then there will be no compliance from the system when the guy giving commands develops a cold" I said.
All further discussion was drowned in a loud burst of laughter from everyone.
That day someone introduced the idea of putting voice command operated equipment.
"When we say 'table up', the OT table goes up" he said. "When we say 'head-low', the head end of the OT table goes down."
People were impressed. I had my doubts.
"It probably will not work in my OT" I said. "There are so many people talking at the same time, on many topics. How will the system understand which command is directed to it? there are those nurses handing over charge of the case when they go off to lunch. Then the anesthetists keep discussing adjustment of emergency duties. A number of people talk on private matters on mobile phones while an operation is in progress. Then the surgeons keep telling funny anecdotes when they are in a good mood."
"We can ask people to keep quiet" someone said doubtfully.
"Some surgeons are confused in the choice of terms. They say table, when they may mean their OT chair and the system may think it is the OT table the surgeon is talkig about. Some surgeons say elevate the table, and when the table starts going up, they say, 'no no, lower it'. So the system may have to be taught to reverse its action when the surgeon says something like 'oops'. When the surgeon cuts something like a blood vessel which he did not plan to cut and says something like 'shit', the system may not be able to comply with the order and may do the next nearest thing. That could be very awkward."
"....." the brain stormers said.
"Then on any given issue, there are usually ten different opinions of ten different people. When someone says 'table up', someone else will say 'head-low', and a third person will say 'OT chair up'. The end result may be a complex position found in yogic exercises."
"We can program the system to recognize a given voice, so that other commands are ignored" the proposer said.
"OK. Then there will be no compliance from the system when the guy giving commands develops a cold" I said.
All further discussion was drowned in a loud burst of laughter from everyone.
Saturday, December 17, 2011
Comprehensive Security
I had been to a conference at a place near our hospital. It ended about an hour before the closing time of my department. So I went to my office, planning to put in an hour’s work even though I was on leave that day. I went in through the gate used by patients and their relatives. There was a security guard from a private firm hired by our institute. He stopped me and asked me to go in through another gate where they could screen the contents of my bag with an X-ray scanner. I went back out, and then in through the other gate. I got my bag through the screening machine. The woman guard manning the place did not find any bomb or gun or any such thing in it and let me pass through. It seemed like a wonderful security arrangement, and I wanted to know more about it. So I put my identity card around my neck, went back to the first guard from the inside of the gate and asked him, “I see the other gate in the distance does not have a screening machine like this one. What about people going in with bags through that gate?”
“I don’t know” he said, “I am new here.”
So I left him and went to the main entrance to the hospital. One local guard and two private guards were sitting and chatting there.
“I am the Head of Obstetrics & Gynecology here” I said. “Could you tell me about the security arrangement at that gate over there? There does not seem to be any X-ray screening machine for checking bags.”
They looked at that gate. “It is for going out” one of them said.
“It is the gate for cards to go out” I said. “People walk in and out through it. See those two guys walking in with bags without any security check?”
They could see them all right. They had nothing to say about it.
“OK. I will ask your boss” I said. The local guard promptly called the security office on the intercom and told the boss that I wanted to talk to him. Then he put me on line. After exchanging pleasantries, I asked him the same question. Then I said “if terrorists take a bomb inside through that gate, we all will die when they blow it up, won’t we?”
“Um…” he said.
“The gate number 1 on the north side of the hospital has no checking mechanism. I go in and out of it every day with my bag, and so do a couple of hundred students and other people. What about that gate?”
“Um…” he said.
“What about terrorists who will take a bomb along in a car? We do not seem to be checking any cars” I said.
“Umm…” he said “what can I say? The Boss knows about it too.”
“Ah!” I said. “If it was with the approval of his Boss, what could he do?”
“Sir, at least there is a security guard there who moves the barrier up and down for cars. The gate on the east side of the hospital has no one. Any one can go in and out freely” said a knowledgeable porter who was standing nearby.
“So how are we protected in the hospital by security at gate number 2 alone?” I asked.
“Sir, that is the place where most of the people walk in and out. That is the gate the media people use. Thus they learn about the tight security at the institute and tell the world about it. The terrorists learn about it from the media and would use that gate. We take in the politicians and administrators through that gate and they are convinced about the adequacy of the security arrangements. After all, the terrorists are kept away by the fear of security, not by the actual ability of our guards. For the media and politicians, it is what they feel about it that matters. It is a psychological maneuver. We are all well protected.
I was amazed at the insight of the porter. I was also relieved that much more than physical security measures was at work to protect us and our patients at the hospital.
“I don’t know” he said, “I am new here.”
So I left him and went to the main entrance to the hospital. One local guard and two private guards were sitting and chatting there.
“I am the Head of Obstetrics & Gynecology here” I said. “Could you tell me about the security arrangement at that gate over there? There does not seem to be any X-ray screening machine for checking bags.”
They looked at that gate. “It is for going out” one of them said.
“It is the gate for cards to go out” I said. “People walk in and out through it. See those two guys walking in with bags without any security check?”
They could see them all right. They had nothing to say about it.
“OK. I will ask your boss” I said. The local guard promptly called the security office on the intercom and told the boss that I wanted to talk to him. Then he put me on line. After exchanging pleasantries, I asked him the same question. Then I said “if terrorists take a bomb inside through that gate, we all will die when they blow it up, won’t we?”
“Um…” he said.
“The gate number 1 on the north side of the hospital has no checking mechanism. I go in and out of it every day with my bag, and so do a couple of hundred students and other people. What about that gate?”
“Um…” he said.
“What about terrorists who will take a bomb along in a car? We do not seem to be checking any cars” I said.
“Umm…” he said “what can I say? The Boss knows about it too.”
“Ah!” I said. “If it was with the approval of his Boss, what could he do?”
“Sir, at least there is a security guard there who moves the barrier up and down for cars. The gate on the east side of the hospital has no one. Any one can go in and out freely” said a knowledgeable porter who was standing nearby.
“So how are we protected in the hospital by security at gate number 2 alone?” I asked.
“Sir, that is the place where most of the people walk in and out. That is the gate the media people use. Thus they learn about the tight security at the institute and tell the world about it. The terrorists learn about it from the media and would use that gate. We take in the politicians and administrators through that gate and they are convinced about the adequacy of the security arrangements. After all, the terrorists are kept away by the fear of security, not by the actual ability of our guards. For the media and politicians, it is what they feel about it that matters. It is a psychological maneuver. We are all well protected.
I was amazed at the insight of the porter. I was also relieved that much more than physical security measures was at work to protect us and our patients at the hospital.
Friday, December 16, 2011
New Test for Successful Pneumoperitoneum
I describe here a new test. It is new in the sense that I have not written about it before, nor has anyone else. But I have been using it for years.
It is essential that the potential cavity of the peritoneum is converted into one filled with carbon dioxide, because unless one looks at anything from a distance, one cannot see anything well. Putting the tip of the telescope in contact with intraabdominopelvic structures without any distance between them is no good, because the focal length of the optics cannot be zero. Putting a gas into the peritoneal cavity is a blind procedure. If the gas passes into a wrong tissue plane, the procedure fails and can even be catastrophic. Correct placement of the tip of the pneumoperitoneum needle in the peritoneal cavity can be confirmed by a number of tests.
1. A drop of saline placed on the hub of the needle gets sucked into the needle (because of negative intraperitoneal pressure).
2. Saline injected through the needle cannot be reaspirated (because it gets lost in the peritoneal cavity).
3. Urine, stool, or blood cannot be aspirated through the needle (negative tests showing that the needle tip does not lie in bladder, bowel or a blood vessel).
4. Pressure of gas being insufflated through the needle shows a pressure of about 15 mm Hg (while it is thirty of more if the needle tip lies in the abdominal wall).
5. The abdomen distends uniformly (while it is localized if the needle tip lies in the abdominal wall).
Adequacy of the pneumoperitoneum is conventionally indicated by loss of liver dullness on abdominal percussion. The new test I describe here is to place flats of fingers of a hand on the abdominal wall and press it in gently. It rocks as if it is filled with jelly or fluid. It happens with ascites too. Gas and liquid are both fluids and share some features. This does not happen if the gas is not enough, and also when it is too much (when the abdominal wall is tense like skin of a percussion instrument).
I must mention a dangerous test performed by some flamboyant gynecologists, who percuss the distended abdominal wall with a hand. It produces a note as on percussion of a drum. It is possible because the abdomen is full of gas, there is a taut membrane over it which is percussed, and the patient is anesthetized so that she cannot object to such degrading treatment. This test is dangerous because the sharp increase in the intraabdominal pressure caused by the percussion may cause regurgitation of the stomach contents, which may be aspirated unless there is a cuffed endotracheal tube in place. I mention this test only to be condemned.
_____________
It is essential that the potential cavity of the peritoneum is converted into one filled with carbon dioxide, because unless one looks at anything from a distance, one cannot see anything well. Putting the tip of the telescope in contact with intraabdominopelvic structures without any distance between them is no good, because the focal length of the optics cannot be zero. Putting a gas into the peritoneal cavity is a blind procedure. If the gas passes into a wrong tissue plane, the procedure fails and can even be catastrophic. Correct placement of the tip of the pneumoperitoneum needle in the peritoneal cavity can be confirmed by a number of tests.
1. A drop of saline placed on the hub of the needle gets sucked into the needle (because of negative intraperitoneal pressure).
2. Saline injected through the needle cannot be reaspirated (because it gets lost in the peritoneal cavity).
3. Urine, stool, or blood cannot be aspirated through the needle (negative tests showing that the needle tip does not lie in bladder, bowel or a blood vessel).
4. Pressure of gas being insufflated through the needle shows a pressure of about 15 mm Hg (while it is thirty of more if the needle tip lies in the abdominal wall).
5. The abdomen distends uniformly (while it is localized if the needle tip lies in the abdominal wall).
Adequacy of the pneumoperitoneum is conventionally indicated by loss of liver dullness on abdominal percussion. The new test I describe here is to place flats of fingers of a hand on the abdominal wall and press it in gently. It rocks as if it is filled with jelly or fluid. It happens with ascites too. Gas and liquid are both fluids and share some features. This does not happen if the gas is not enough, and also when it is too much (when the abdominal wall is tense like skin of a percussion instrument).
I must mention a dangerous test performed by some flamboyant gynecologists, who percuss the distended abdominal wall with a hand. It produces a note as on percussion of a drum. It is possible because the abdomen is full of gas, there is a taut membrane over it which is percussed, and the patient is anesthetized so that she cannot object to such degrading treatment. This test is dangerous because the sharp increase in the intraabdominal pressure caused by the percussion may cause regurgitation of the stomach contents, which may be aspirated unless there is a cuffed endotracheal tube in place. I mention this test only to be condemned.
_____________
Wednesday, December 14, 2011
Pushing Women!
Women have been an oppressed lot in many parts of the world, including this one. It has been so for a very long time, and though things look promising at present, I am not sure how long it will take for a total cure of this problem. I have avoided the word ‘radical’ and used the word ‘total’ to describe the cure, because some readers may interpret it as a sign that I am radical in my thoughts and action. I am not. But I definitely feel that no woman should be pushed around, oppressed or even suppressed.
It came as a surprise to me that women are pushed in modern obstetrics.
It came to our notice first when we heard about the proceedings of an audit into maternal mortality. The Assistant Professor from an affiliated hospital responsible for management of a case under discussion was telling us about the sequence of events that lead to the death of the woman. The technical aspects of the discussion ore too scientific and complicated for the readers. But she made a statement “we were pushing the woman into labor.”
That was a new one. We knew about induction of labor, which meant starting labor in a woman who was not in labor, with a view of achieving a delivery. We also knew about augmentation of labor, which meant improving uterine contractions in a case in which the labor is not optimum. But pushing a woman into labor?
“What do you mean by that” the chairman asked her. “What is pushing a woman into labor?”
“She was not in labor. We wanted her to deliver. So we forced labor.”
She probably meant they induced labor. There was no indication for induction of labor in that case. But then elective induction of labor for convenience of the obstetrician or patient is an old concept, though not approved by us. Perhaps it was rebellion on the part of this group of obstetricians in that hospital, who wanted to use a language of their own, instead of old, scientific terms.
That was not it. The trend was widespread. The other day there was a complaint about a resident doctor, who gave misoprostol to a pregnant woman at term. He said he gave half a tablet orally and a half sublingually. He said the tablet was of only 25 microgram, but it must have been 200 micrograms, since the woman developed a very powerful uterine contraction of such a long duration that the fetal heart rate dropped to a very low level and would not come up. They did a cesarean section and saved the baby.
“Why did you do such a foolish thing?” he was asked.
“I was pushing the woman into labor” he answered.
Mothers and babies die when women are pushed like this. I hope the new generation understands this and does not indulge in this manner.
It came as a surprise to me that women are pushed in modern obstetrics.
It came to our notice first when we heard about the proceedings of an audit into maternal mortality. The Assistant Professor from an affiliated hospital responsible for management of a case under discussion was telling us about the sequence of events that lead to the death of the woman. The technical aspects of the discussion ore too scientific and complicated for the readers. But she made a statement “we were pushing the woman into labor.”
That was a new one. We knew about induction of labor, which meant starting labor in a woman who was not in labor, with a view of achieving a delivery. We also knew about augmentation of labor, which meant improving uterine contractions in a case in which the labor is not optimum. But pushing a woman into labor?
“What do you mean by that” the chairman asked her. “What is pushing a woman into labor?”
“She was not in labor. We wanted her to deliver. So we forced labor.”
She probably meant they induced labor. There was no indication for induction of labor in that case. But then elective induction of labor for convenience of the obstetrician or patient is an old concept, though not approved by us. Perhaps it was rebellion on the part of this group of obstetricians in that hospital, who wanted to use a language of their own, instead of old, scientific terms.
That was not it. The trend was widespread. The other day there was a complaint about a resident doctor, who gave misoprostol to a pregnant woman at term. He said he gave half a tablet orally and a half sublingually. He said the tablet was of only 25 microgram, but it must have been 200 micrograms, since the woman developed a very powerful uterine contraction of such a long duration that the fetal heart rate dropped to a very low level and would not come up. They did a cesarean section and saved the baby.
“Why did you do such a foolish thing?” he was asked.
“I was pushing the woman into labor” he answered.
Mothers and babies die when women are pushed like this. I hope the new generation understands this and does not indulge in this manner.
PCPNDT: Issue of Signatures
I suppose it shouuld be a simple matter to fill any application form, when there is information asked for and blank spaces are provided in which to enter the required information. It should be even simpler for highly intelligent persons like doctors with postgraduate qualification, considering their degree of education, command on English language, and basic cleverness owing to which they have landed up in this profession. What one supposes is not always true, even if it is based on hard logic. I see a large number of applications for new registration and renewal of old registrations. I come across so many errors in the applications, that I might be able to write a short essay on the subject. Owing to restraint of space, I will give just three unique examples.
I have seen an application that was without the signature of the applicant. I pointed that out to the medical officer of that civic ward.
“The form is submitted in duplicate” he said. The other copy will have the signature.” Then he proceeded to check the duplicate copy. While he was looking at it, I said “the duplicate copy is actually a photocopy of the original form. Hence it does not have the signature of the applicant too.” He finally found out that I was right. He took away the form for obtaining the much needed signature of the applicant.
I have found an application accompanied by an undertaking on a stamp paper. The contents of the undertaking were as per the PCPNDT Act requirements. The affidavit was notarized too I.e. there was a statement by an advocate and notary at the bottom of the affidavit that the person who had made that affidavit had signed in the presence of the notary, and the notary had signed below that statement and put his seal below his own signature. Unfortunately there was no signature of the applicant anywhere. It raises serious questions about the working of judiciary, besides shedding light on the shoddy working of doctors aspiring to work in the PCPNDT field. The concerned medical officer took away the application for necessary correction. He brought back the same affidavit the next time, bearing the signature of the applicant in the space which had been blank the first time. I had thought the fellow would have felt ashamed and made a new affidavit, and would have signed in the presence of the notary, who would then have notarized his signature. There was no such luck.
The third example is of an applicant whose signature on the application form and that on the affidavit were totally different. It did not take expertise of a bank teller to note the difference. They were as different as a cow differs in appearance from a cat. When I pointed out that to the medical officer who had brought that application, he said, “both of them might be his signatures.”
“I agree,” I said. “My signature for my bank account is different from the one I make on students’ journals. But when a person makes an application for a legal matter, and also makes an affidavit for the same legal matter, his signatures on those two documents must match. A minor difference is understandable. But these two signatures have zero similarity.” He took away the form for corrective measures without putting up further arguments.
I have seen an application that was without the signature of the applicant. I pointed that out to the medical officer of that civic ward.
“The form is submitted in duplicate” he said. The other copy will have the signature.” Then he proceeded to check the duplicate copy. While he was looking at it, I said “the duplicate copy is actually a photocopy of the original form. Hence it does not have the signature of the applicant too.” He finally found out that I was right. He took away the form for obtaining the much needed signature of the applicant.
I have found an application accompanied by an undertaking on a stamp paper. The contents of the undertaking were as per the PCPNDT Act requirements. The affidavit was notarized too I.e. there was a statement by an advocate and notary at the bottom of the affidavit that the person who had made that affidavit had signed in the presence of the notary, and the notary had signed below that statement and put his seal below his own signature. Unfortunately there was no signature of the applicant anywhere. It raises serious questions about the working of judiciary, besides shedding light on the shoddy working of doctors aspiring to work in the PCPNDT field. The concerned medical officer took away the application for necessary correction. He brought back the same affidavit the next time, bearing the signature of the applicant in the space which had been blank the first time. I had thought the fellow would have felt ashamed and made a new affidavit, and would have signed in the presence of the notary, who would then have notarized his signature. There was no such luck.
The third example is of an applicant whose signature on the application form and that on the affidavit were totally different. It did not take expertise of a bank teller to note the difference. They were as different as a cow differs in appearance from a cat. When I pointed out that to the medical officer who had brought that application, he said, “both of them might be his signatures.”
“I agree,” I said. “My signature for my bank account is different from the one I make on students’ journals. But when a person makes an application for a legal matter, and also makes an affidavit for the same legal matter, his signatures on those two documents must match. A minor difference is understandable. But these two signatures have zero similarity.” He took away the form for corrective measures without putting up further arguments.
Monday, December 12, 2011
Fire Safety in Hospitals
It was a tragedy that 93 lives were lost in a hospital in Kolkata owing to a fire. Then there were a series of articles on poor fire safety measures in civic hospitals in the city. I suppose the situation must not be different in government and private hospitals too. I had written the administration when I became head of the department that there should be fire extinguishers in our laboratory, which had a number of inflammable laboratory reagents. I had also written that the exit points of our department should not be locked and their keys kept with someone not on the spot, because should there be a fire, there would be deaths due to stampede to get out, and also from burns due to being trapped in the fire. All my letters went unanswered.
"There must be a reason for them not to answer our letters" consoled another professor.
"What reason can there be?" I wondered.
"Perhaps they know we have a special burns ward in the hospital" said the cynic in the department. It sounded cruel.
"Perhaps they have no money to spend on these measures, and no security officers to man the gates if they are left open."
That sounded possible. I do not mean to say it sounded justifiable. I spoke to the Dean of that time, who nodded with a look of great wisdom and said nothing. That Dean moved on to higher positions after retirement, and luckily no patient or patient's relative moved on to a higher world due to a fire.
Now suddenly everyone seems to have woken up, with the civic chief ordering audit and implementation of fire prevention and control measures in major civic hospitals. I hope the same is done for other civic and government hospitals too. There are too many patients in these hospitals, most of them poor. There will be far more deaths from a fire in such hospitals as compared to a star hospital in Kolkata.
"Sir, what happened to your letters to the administration for fire control measures?" someone asked yesterday.
"Probably the same thing that happens to unwanted letters" I said. "It takes a disaster or a court order for moving people into action, not letters."
"There must be a reason for them not to answer our letters" consoled another professor.
"What reason can there be?" I wondered.
"Perhaps they know we have a special burns ward in the hospital" said the cynic in the department. It sounded cruel.
"Perhaps they have no money to spend on these measures, and no security officers to man the gates if they are left open."
That sounded possible. I do not mean to say it sounded justifiable. I spoke to the Dean of that time, who nodded with a look of great wisdom and said nothing. That Dean moved on to higher positions after retirement, and luckily no patient or patient's relative moved on to a higher world due to a fire.
Now suddenly everyone seems to have woken up, with the civic chief ordering audit and implementation of fire prevention and control measures in major civic hospitals. I hope the same is done for other civic and government hospitals too. There are too many patients in these hospitals, most of them poor. There will be far more deaths from a fire in such hospitals as compared to a star hospital in Kolkata.
"Sir, what happened to your letters to the administration for fire control measures?" someone asked yesterday.
"Probably the same thing that happens to unwanted letters" I said. "It takes a disaster or a court order for moving people into action, not letters."
Funny Requests
We keep meeting medical representatives, who keep making requests for prescribing their products. Some of them have funny choice of words. Some examples are given here.
"Doctor, we have these five products" says one, and enumerates them. "Doctor, I majorly request our product xxxxx."
I wondered if the word 'majorly' was in English. I looked up the dictionary, and could not find it. Probably the fellow meant that his main request was for prescription of that product.
Sometimes some particular product is expensive, and costs much more than competitive brands from other companies. When I object that it costs too much, the fellow says "Doctor, I agree it is expensive. But I request you to prescribe it at least to your affordable patients."
I suppose the fellow means 'affording' and not 'affordable'. I don't dare to think what he means if he means to use the word 'affordable' appropriately. I never corrected anyone because I am reluctant to hurt someone's feelings who does that work for a living, not because he or she loves it. You may object to this sentence, saying they could be loving their job. Well, if they did, they would pay more attention to their grammar, wouldn't they?
There are many more such. Perhaps I will update this post some time.
"Doctor, we have these five products" says one, and enumerates them. "Doctor, I majorly request our product xxxxx."
I wondered if the word 'majorly' was in English. I looked up the dictionary, and could not find it. Probably the fellow meant that his main request was for prescription of that product.
Sometimes some particular product is expensive, and costs much more than competitive brands from other companies. When I object that it costs too much, the fellow says "Doctor, I agree it is expensive. But I request you to prescribe it at least to your affordable patients."
I suppose the fellow means 'affording' and not 'affordable'. I don't dare to think what he means if he means to use the word 'affordable' appropriately. I never corrected anyone because I am reluctant to hurt someone's feelings who does that work for a living, not because he or she loves it. You may object to this sentence, saying they could be loving their job. Well, if they did, they would pay more attention to their grammar, wouldn't they?
There are many more such. Perhaps I will update this post some time.
Sunday, December 11, 2011
Single Clamp Hysterectomy
The uterus undergoes atrophy after menopause. In a very old woman, it may be of the size of one distal phalanx of the middle finger of a good sized hand, or one and a half times the size of that phalanx of an average sized hand. If one has to perform hysterectomy in such a case, as one has to if she has a genital prolapse, clamping the uterosacral-cardinal ligament complex, uterine vessels, and corneal structures separately would be a rather difficult task. It is also unnecessary. If the ureter and the bladder are retracted away quite well, a single clamp can be applied to the three structures on one side. They are then cut together, and a single transfixion ligature is applied around them. I prefer to put a safety ligature around them, as I do for all pedicles at all times. This maneuver saves time spent by the patient under anesthesia, the amount of suture material left inside the patient’s body, and reduces morbidity related to these two things. It also reduces the time the assistants have to spend standing in an uncomfortable position.
I had seen this being done when I was a house officer. I did it successfully in appropriate cases many times thereafter. When I assisted a new Assistant Professor performing vaginal hysterectomy in a case of procidentia, I guided him to do it this way.
“Um… I have never done it this way before” he said. He probably meant that perhaps it was not OK.
“Well, you have to learn something new once in a while. If you keep doing the same thing every time, your life will stagnate” I said.
He did it successfully.
“Don’t do it if I am not around” I said. I was afrain he might not select a case properly, or might not retract the bladder anterolaterally sufficiently to retract the ureter too, so that ureteric injury would not occur. After all, the ureter falls away only after the uterosacral ligament is clamped, cut, and ligated. That does not happen if all structures on one side are clamped together.
“No, Sir.”
I realized that there was no mention of this technique in any of the books in the market or libraries, any of the journals, and even on the net. I had forgotten to write about it in my own books too. So here it is now. One of my Assistant Professors is fond of Googling for education. He and others like him will now find a reference to this technique next time they Google.
I had seen this being done when I was a house officer. I did it successfully in appropriate cases many times thereafter. When I assisted a new Assistant Professor performing vaginal hysterectomy in a case of procidentia, I guided him to do it this way.
“Um… I have never done it this way before” he said. He probably meant that perhaps it was not OK.
“Well, you have to learn something new once in a while. If you keep doing the same thing every time, your life will stagnate” I said.
He did it successfully.
“Don’t do it if I am not around” I said. I was afrain he might not select a case properly, or might not retract the bladder anterolaterally sufficiently to retract the ureter too, so that ureteric injury would not occur. After all, the ureter falls away only after the uterosacral ligament is clamped, cut, and ligated. That does not happen if all structures on one side are clamped together.
“No, Sir.”
I realized that there was no mention of this technique in any of the books in the market or libraries, any of the journals, and even on the net. I had forgotten to write about it in my own books too. So here it is now. One of my Assistant Professors is fond of Googling for education. He and others like him will now find a reference to this technique next time they Google.
Friday, December 9, 2011
Difficult Vaginal Hysterectomy: No Portio Vaginalis
I had not thought there would be any difficulty in performing a vaginal hysterectomy when there was no portio vaginalis of the cervix to catch and pull on. It came as a surprise when my people admitted a woman with cervical intraepithelial neoplasia diagnosed by cervical biopsy performed twice by others outside our hospital, and wanted to perform a total hysterectomy on her by the abdominal route.
“See, her cervix is flush with the vagina. We had a great difficulty catching the cervix for performing end cervical curettage” the Associate Professor said. She was showing me the cervix by performing a speculum examination. The external os and the outline of the portio vaginalis were seen, but there was no elevation of the cervix. I performed a mimanual pelvic examination and found that the uterus was not enlarged or fixed.
“But why do you want to operate abdominally? It can be done vaginally” I said.
“Sir, there is no cervix to hold. What will we hold and pull on during vaginal hysterectomy?” she asked me.
“We elevate a vaginal cuff all round the cervix, and then catch the supranational cervix” I said. “Then the hysterectomy can be done as usual. It is unnecessary to perform the operation abdominally only because there is no cervix to hold.” I knew it. I had done that before, without thinking about it.
No one said anything.
“I will do it. Once I get the supranational cervix held with Allis’ forceps or a suture for traction, you can complete the hysterectomy” I said.
“We will do it” she said with uncertainty. I was afraid of that uncertainty and decided to do it myself. Two days later the patient was scheduled for the operation. I reached the OT in time and told them I would do it. There was indeed no way of holding the cervix. The Allis forceps slipped off its surface. So I held the vagina around the cervix, incised it with the tip of a scalpel blade, and elevated a cuff of the vagina all round. The space was very limited, but it was possible. Then I applied a tenaculum across the front and the back of the supranational cervix and made traction. It held. The remaining hysterectomy by the vaginal route was uneventful.
“It would have been too much performing it abdominally only for that indication” the Associate Professor said. She was repeating to me what I had said to them all two days ago.
“Sir, I read some books and searched the net for difficult vaginal hysterectomy” said my senior Assistant Professor. “I did not find this technique anywhere.”
“Now you know how to do it” I said. I am writing it here, so that others who search the net for it will find it in future.
“See, her cervix is flush with the vagina. We had a great difficulty catching the cervix for performing end cervical curettage” the Associate Professor said. She was showing me the cervix by performing a speculum examination. The external os and the outline of the portio vaginalis were seen, but there was no elevation of the cervix. I performed a mimanual pelvic examination and found that the uterus was not enlarged or fixed.
“But why do you want to operate abdominally? It can be done vaginally” I said.
“Sir, there is no cervix to hold. What will we hold and pull on during vaginal hysterectomy?” she asked me.
“We elevate a vaginal cuff all round the cervix, and then catch the supranational cervix” I said. “Then the hysterectomy can be done as usual. It is unnecessary to perform the operation abdominally only because there is no cervix to hold.” I knew it. I had done that before, without thinking about it.
No one said anything.
“I will do it. Once I get the supranational cervix held with Allis’ forceps or a suture for traction, you can complete the hysterectomy” I said.
“We will do it” she said with uncertainty. I was afraid of that uncertainty and decided to do it myself. Two days later the patient was scheduled for the operation. I reached the OT in time and told them I would do it. There was indeed no way of holding the cervix. The Allis forceps slipped off its surface. So I held the vagina around the cervix, incised it with the tip of a scalpel blade, and elevated a cuff of the vagina all round. The space was very limited, but it was possible. Then I applied a tenaculum across the front and the back of the supranational cervix and made traction. It held. The remaining hysterectomy by the vaginal route was uneventful.
“It would have been too much performing it abdominally only for that indication” the Associate Professor said. She was repeating to me what I had said to them all two days ago.
“Sir, I read some books and searched the net for difficult vaginal hysterectomy” said my senior Assistant Professor. “I did not find this technique anywhere.”
“Now you know how to do it” I said. I am writing it here, so that others who search the net for it will find it in future.
Thursday, December 8, 2011
Saving a Patient from the Boss
Life is a management of sorts. Life of a doctor is no different. We had a patient in the outpatient clinic, who had undergone a uterine sling operation for a nulliparous type of uterine prolapse at the hands of a gynecologist who was in a peripheral non-teaching civic hospital. He used to do a hybrid operation, which was a combination of two operations described by two eminent gynecologists – one on the right side and the other on the left side. He called it by his own name. Nothing wrong with that from his point of view, I suppose. But it failed and the uterus popped out postoperatively. So he proposed to do it again. There was a senior resident doctor working in his unit, who decided to save the patient and verbally advised her to go to a government hospital. That didi not save the patient. She underwent a sling operation described by a third eminent gynecologist, but that failed too. She finally came to us. We had the option of performing an operation described by a fourth eminent gynecologist. But I advised her to try and have a baby first, using a ring pessary until she got pregnant and during pregnancy too if required. The prolapse was likely to recur after a childbirth, and I did not want a third failure for her.
“Sir, that fellow who referred her to the government hospital was with us for six months in past” my Assistant Professor said.
“I know” I said. “He was trained in a government hospital and must have faith in the government rather than the civic body.”
“Does it not sound a little funny that he should advise the patient against undergoing treatment at the hands of his own boss?”
“He must think he knows better” I said. “In our own hospital, resident doctors of a particular unit used to scare away patients of cervical carcinoma after their boss ligated both ureters of a patient during radical hysterectomy, which was diagnosed only at autopsy.”
There was stunned silence.
“I recall one of my own subordinate sending away without treatment a patient who was referred to that person by someone. That patient had a massive lymphangiocele of the genital tract I had diagnosed correctly and asked for referral to a surgeon for excision of the lymphangiocele and its drainage tracts. The patient came back without treatment when it grew until it ruptured and spilled milky fluid everywhere. Now the patient will develop it again and the cycle will repeat itself.”
“Sir, perhaps that person did not trust any surgeon.”
“That person did not trust even me thoughI had been saving patients from dangerous decisions of that same person for a long time. I have a reputation for playing everything safe, avoiding trouble for patients at all costs. I have always said one should know what not to do more than what to do. But still this person would wash up with me whenever I was operating on a patient who had any condition out of the ordinary, and try to do something before I did it. This person would try to sweet talk me into changing my decisions, and if I did not relent, change them in my absence, even after being given fully scientific and logical explanations for whatever I had advised.”
There was another silence.
"Sir, that person must have meant well" he said.
"I agree" I said. "But good intentions without wisdom or expertise are not worth much. Mistrust for a more knowledgeable and experienced person is dangerous."
“That does not sound like team work and trust in the team leader, Sir” he said.
“It doesn't and it isn’t” I said sadly. “But as our psychiatry department head says, there is no medicine for attitudes, including this one.”
“Sir, that fellow who referred her to the government hospital was with us for six months in past” my Assistant Professor said.
“I know” I said. “He was trained in a government hospital and must have faith in the government rather than the civic body.”
“Does it not sound a little funny that he should advise the patient against undergoing treatment at the hands of his own boss?”
“He must think he knows better” I said. “In our own hospital, resident doctors of a particular unit used to scare away patients of cervical carcinoma after their boss ligated both ureters of a patient during radical hysterectomy, which was diagnosed only at autopsy.”
There was stunned silence.
“I recall one of my own subordinate sending away without treatment a patient who was referred to that person by someone. That patient had a massive lymphangiocele of the genital tract I had diagnosed correctly and asked for referral to a surgeon for excision of the lymphangiocele and its drainage tracts. The patient came back without treatment when it grew until it ruptured and spilled milky fluid everywhere. Now the patient will develop it again and the cycle will repeat itself.”
“Sir, perhaps that person did not trust any surgeon.”
“That person did not trust even me thoughI had been saving patients from dangerous decisions of that same person for a long time. I have a reputation for playing everything safe, avoiding trouble for patients at all costs. I have always said one should know what not to do more than what to do. But still this person would wash up with me whenever I was operating on a patient who had any condition out of the ordinary, and try to do something before I did it. This person would try to sweet talk me into changing my decisions, and if I did not relent, change them in my absence, even after being given fully scientific and logical explanations for whatever I had advised.”
There was another silence.
"Sir, that person must have meant well" he said.
"I agree" I said. "But good intentions without wisdom or expertise are not worth much. Mistrust for a more knowledgeable and experienced person is dangerous."
“That does not sound like team work and trust in the team leader, Sir” he said.
“It doesn't and it isn’t” I said sadly. “But as our psychiatry department head says, there is no medicine for attitudes, including this one.”
Wednesday, December 7, 2011
Right Brain Trusted Uterine Stimulant
I am perpetually afraid that some resident doctor will use fundal pressure to aid childbirth and cause a serious complication for a woman in labor or her baby. So when I saw a very short and thin woman in the postnatal ward and learned that she had delivered normally, I asked my residents “did you make fundal pressure to deliver her?”
“No, Sir! We don’t make fundal pressure” they said.
“Shall I ask the patient and verify?” I asked.
“Yes, Sir!”
So I turned towards the patient and asked, “did you get tired during labor, trying to push the baby out?”
“Yes” she said.
“I hope the doctors were helpful” I said.
“Yes, they were quite helpful” she said.
“Did they put their hands on your abdomen and push so that you could deliver?”
“Yes” she said.
“So you did make fundal pressure” I said to my Registrar.
“No, Sir. It was not fundal pressure. We just tickled her abdomen to stimulate uterine contractions.”
“Tickle her abdomen?” I said. Then it came back in a flash. When I was a resident doctor, the midwives had taught me to make flicking movements on the woman’s abdomen with the tips of the fingers to stimulate uterine contractions. We used to do it even if we had not read anywhere that it was effective in stimulating uterine contractions. My lecturer of that time, who has passed away long since, did that herself too, or if not at least never told us it was useless. We stopped doing that when we knew better.
“How does it stimulate uterine contractions?” I asked.
“Only in the second stage of labor” he confided.
“OK, only in the second stage of labor. How does it act?” I asked.
He smiled but did not answer.
“It is probably a right-brain conviction” I said.
“No, Sir! We don’t make fundal pressure” they said.
“Shall I ask the patient and verify?” I asked.
“Yes, Sir!”
So I turned towards the patient and asked, “did you get tired during labor, trying to push the baby out?”
“Yes” she said.
“I hope the doctors were helpful” I said.
“Yes, they were quite helpful” she said.
“Did they put their hands on your abdomen and push so that you could deliver?”
“Yes” she said.
“So you did make fundal pressure” I said to my Registrar.
“No, Sir. It was not fundal pressure. We just tickled her abdomen to stimulate uterine contractions.”
“Tickle her abdomen?” I said. Then it came back in a flash. When I was a resident doctor, the midwives had taught me to make flicking movements on the woman’s abdomen with the tips of the fingers to stimulate uterine contractions. We used to do it even if we had not read anywhere that it was effective in stimulating uterine contractions. My lecturer of that time, who has passed away long since, did that herself too, or if not at least never told us it was useless. We stopped doing that when we knew better.
“How does it stimulate uterine contractions?” I asked.
“Only in the second stage of labor” he confided.
“OK, only in the second stage of labor. How does it act?” I asked.
He smiled but did not answer.
“It is probably a right-brain conviction” I said.
Tuesday, December 6, 2011
Utmost Security
There is a posh place called Sahyxxri Guest House. One would think is a place for lodging and boarding, situated conveniently near a railway station, for people who have nowhere else to stay during their visit to the city. Well, it is not named well. It is like the name 'Circuit House' which sounds as if it is the electricity supply company's place with transformers and such, when in reality is the place where Ministers and top level government officials stay. Sahyxxri Guest House is a place where top level meetings of Ministers and top level government officials take place, and they can stay there if they have come there from out of state.
The Health University had called a meeting there to educate professors and heads of Pediatrics, PSM and Obstetrics Gynecology on pediatric nutrition. I had to attend the meeting. When I reached there, they asked for my identity proof. I had none, because as a citizen of the biggest democracy in the world, I had thought I would not be required to carry an identity proof anywhere. They do require it at airports if you have an e-ticket, but that is different.
"I have come for university's work. If you won't let me in, I will be too happy to go away. I will just tell them the police at the gate did not let me in."
"They should have told invitees to carry identity cards" the policeman said. But he let me in. Unfortunately the University had cancelled the meeting, without any information to the Guest House, and also to the invitees. So I went back. The next time they called me, I carried an old identity card, because I was afraid I could lose the new one with my biometric data on it.
"Please show your identity card" the policeman at the gate said. He was different from the one I had met the first time.
I showed him the twenty years old card. He did not know my hospital (which I thought everyone in the world knew) though he was a resident of the same city. Then he asked for my letter of invitation. I showed him a poor quality photocopy sent to me by our office. He looked at it for some time. He probably could not read it, either because it was of bad quality, or was in a language he did not know. He let me in. The meeting was uneventful. When I left, the policemen at the gate did not even glance at me.
I read in a newspaper later that the tight security at that place was for protecting the VIPs who went there, and also to protect the building from terrorists. Did they not know that elderly and scholarly looking professors without identity cards were not any danger to the building or the people in it, but smart people who could make authentic looking duplicate identity cards and letters of invitation were. If I could get through with an ancient identity card and unreadable letter of invitation, a terrorist may get in over a red carpet.
The Health University had called a meeting there to educate professors and heads of Pediatrics, PSM and Obstetrics Gynecology on pediatric nutrition. I had to attend the meeting. When I reached there, they asked for my identity proof. I had none, because as a citizen of the biggest democracy in the world, I had thought I would not be required to carry an identity proof anywhere. They do require it at airports if you have an e-ticket, but that is different.
"I have come for university's work. If you won't let me in, I will be too happy to go away. I will just tell them the police at the gate did not let me in."
"They should have told invitees to carry identity cards" the policeman said. But he let me in. Unfortunately the University had cancelled the meeting, without any information to the Guest House, and also to the invitees. So I went back. The next time they called me, I carried an old identity card, because I was afraid I could lose the new one with my biometric data on it.
"Please show your identity card" the policeman at the gate said. He was different from the one I had met the first time.
I showed him the twenty years old card. He did not know my hospital (which I thought everyone in the world knew) though he was a resident of the same city. Then he asked for my letter of invitation. I showed him a poor quality photocopy sent to me by our office. He looked at it for some time. He probably could not read it, either because it was of bad quality, or was in a language he did not know. He let me in. The meeting was uneventful. When I left, the policemen at the gate did not even glance at me.
I read in a newspaper later that the tight security at that place was for protecting the VIPs who went there, and also to protect the building from terrorists. Did they not know that elderly and scholarly looking professors without identity cards were not any danger to the building or the people in it, but smart people who could make authentic looking duplicate identity cards and letters of invitation were. If I could get through with an ancient identity card and unreadable letter of invitation, a terrorist may get in over a red carpet.
Sunday, December 4, 2011
Goof Up for Evidence
We were taking a round of the postnatal ward. I had not known what had happened in the wards during the previous two days because I had been away.
“Sir, this patient was desirous of undergoing a puerperal sterilization operation. She could not undergo the operation because her urinalysis showed 46 pus cells per high power field. We have sent her urine for microbiologic studies” my Registrar said.
“OK” I said. “Let me know the report.”
We moved on. The third patient after that one with pyuria was similar.
“Sir, this patient also wanted a puerperal sterilization operation. She could not undergo the operation because her urinalysis showed 56 pus cells per high power field. We have sent her urine for microbiologic studies too” my Registrar said. The Associate Professor and Assistant Professor in charge of that ward nodded their heads in agreement and with sympathy for the patient.
This was sounding weird. “How may red blood cells were present in their urine?” I asked. They had not thought of checking and hence did not know the answer. The urinalysis reports of the two patients were checked. “That one had 80 red bleed cells per high power field and this one had 76” the registrar said.
I looked at them and they looked back at me, most of them blankly and one with the beginning of comprehension.
“They did not have urinary infection. The urine samples were mixed with early lochia and were inappropriate for testing. If the lochia had been washed away before collecting the samples, they would have been fit to undergo the operation they desired” I said.
The next day the microbiologic reports were ready.
“Sir, there was no growth of any organisms on culture of urine of both of those women” the Registrar informed me.
“Are the two patients ready to undergo the operation now?” I asked.
“Um… one of them had gone home, and the other does not want the operation now” she said.
I have learnt to look at the positive aspects of everything. I applied that principle to this goof-up. “This business proves that the lochia is sterile. That is a scientific achievement” I said. None of the people involved turned a hair. They have probably got used to my sarcasm.
“Sir, this patient was desirous of undergoing a puerperal sterilization operation. She could not undergo the operation because her urinalysis showed 46 pus cells per high power field. We have sent her urine for microbiologic studies” my Registrar said.
“OK” I said. “Let me know the report.”
We moved on. The third patient after that one with pyuria was similar.
“Sir, this patient also wanted a puerperal sterilization operation. She could not undergo the operation because her urinalysis showed 56 pus cells per high power field. We have sent her urine for microbiologic studies too” my Registrar said. The Associate Professor and Assistant Professor in charge of that ward nodded their heads in agreement and with sympathy for the patient.
This was sounding weird. “How may red blood cells were present in their urine?” I asked. They had not thought of checking and hence did not know the answer. The urinalysis reports of the two patients were checked. “That one had 80 red bleed cells per high power field and this one had 76” the registrar said.
I looked at them and they looked back at me, most of them blankly and one with the beginning of comprehension.
“They did not have urinary infection. The urine samples were mixed with early lochia and were inappropriate for testing. If the lochia had been washed away before collecting the samples, they would have been fit to undergo the operation they desired” I said.
The next day the microbiologic reports were ready.
“Sir, there was no growth of any organisms on culture of urine of both of those women” the Registrar informed me.
“Are the two patients ready to undergo the operation now?” I asked.
“Um… one of them had gone home, and the other does not want the operation now” she said.
I have learnt to look at the positive aspects of everything. I applied that principle to this goof-up. “This business proves that the lochia is sterile. That is a scientific achievement” I said. None of the people involved turned a hair. They have probably got used to my sarcasm.
Friday, December 2, 2011
The Last case Syndrome
If one is working in an institute where the last operation will be permitted to be done only if the patient is on the operation table by a specific time, you experience this syndrome in its various flavors. Let us take a random time, say 1:00 P.M. They do not permit new cases after that time because then the operation does not get over by the time the nurses and servants of the first or morning shift go off duty. The hospital does not provide personnel for the second shift, even for a short duration. The solution is denial of service. The poor patient who has been anxious overnight and till 1:00 P.M., has remained starving, has received an enema and an injection of atropine or equivalent drug in the morning (now useless because the action has worn off for quite some time) useless is asked to go back to the ward and eat something, to wait for another week only to go through the same experience again.
There are many etiological factors for this syndrome. We shall list them.
1. The operating surgeons arrive late, so that the operations start late.
2. There are no sweepers and/or ward boys in the morning, because they remain absent together. Substitute arrives quite late. So the theater work starts late.
3. There are not enough nurses, many remaining absent. This occurs around festival time, or when children’s examinations are due or going on. So the theater work starts late.
4. The senior or qualified anesthetist does not arrive early enough, and the junior anesthetists keep waiting, not giving anesthesia to any patient. So the theater work starts late.
5. A patient found fit on the anesthetists’ round the previous day develops a cardiac murmur or hypertension or dyspnea which requires a specialist’s or superspecialist’s opinion. Then about 45 minutes are lost from the total time available.
6. The resident doctors spend a lot of time between two operations, getting the operated patient out or a new patient in. Though the job is that of the ward boys, they need to be told to do it, and the resident doctors just remain in a festive mood that the operation got over successfully.
7. Trainee anesthetist takes multiple attempts at finding the subarachnoid space to give spinal anesthesia. Sometimes they move up in the hierarchy serially, from house officer to Associate Professor until the last person to try gets the correct space.
8. Spinal anesthesia fails and general anesthesia has to be given. That adds the induction and recovery time of the general anesthesia to the total time lost.
9. Trainee resident surgeons take a long time to operate, partly because they do not know the exact steps, partly because they know the steps but do not have the technical expertise, partly in tentative steps taken to avoid actually cutting something (out of fear), partly due to spending a lot of time between operative steps doing nothing except holding hands hovering over the operative field.
10. Senior assistants going slow so that the operation does not get over before 1:00 P.M. so that they do not have to assist a trainee doctor until late, or because they have something else to do which in their minds is more important than that patient’s operation.
The result of this syndrome on the victims (patients scheduled for operations) is described in the beginning. The effect on the other victims (surgeons who were looking forward to performing that operation is depression, frustration, anxiety, and anger against the system. If they become victims of the syndrome repeatedly, they may develop suicidal tendencies, destructive tendencies, tendency to make fit patients unfit as revenge against seniors who keep operating. Coincidental victims are the bosses who are stressed trying to somehow rush through the operation so that it gets over before the deadline and the next case can be operated on. Suggestions to prevent this syndrome are not included in this post, because that would be just an academic exercise, never to be implemented.
There are many etiological factors for this syndrome. We shall list them.
1. The operating surgeons arrive late, so that the operations start late.
2. There are no sweepers and/or ward boys in the morning, because they remain absent together. Substitute arrives quite late. So the theater work starts late.
3. There are not enough nurses, many remaining absent. This occurs around festival time, or when children’s examinations are due or going on. So the theater work starts late.
4. The senior or qualified anesthetist does not arrive early enough, and the junior anesthetists keep waiting, not giving anesthesia to any patient. So the theater work starts late.
5. A patient found fit on the anesthetists’ round the previous day develops a cardiac murmur or hypertension or dyspnea which requires a specialist’s or superspecialist’s opinion. Then about 45 minutes are lost from the total time available.
6. The resident doctors spend a lot of time between two operations, getting the operated patient out or a new patient in. Though the job is that of the ward boys, they need to be told to do it, and the resident doctors just remain in a festive mood that the operation got over successfully.
7. Trainee anesthetist takes multiple attempts at finding the subarachnoid space to give spinal anesthesia. Sometimes they move up in the hierarchy serially, from house officer to Associate Professor until the last person to try gets the correct space.
8. Spinal anesthesia fails and general anesthesia has to be given. That adds the induction and recovery time of the general anesthesia to the total time lost.
9. Trainee resident surgeons take a long time to operate, partly because they do not know the exact steps, partly because they know the steps but do not have the technical expertise, partly in tentative steps taken to avoid actually cutting something (out of fear), partly due to spending a lot of time between operative steps doing nothing except holding hands hovering over the operative field.
10. Senior assistants going slow so that the operation does not get over before 1:00 P.M. so that they do not have to assist a trainee doctor until late, or because they have something else to do which in their minds is more important than that patient’s operation.
The result of this syndrome on the victims (patients scheduled for operations) is described in the beginning. The effect on the other victims (surgeons who were looking forward to performing that operation is depression, frustration, anxiety, and anger against the system. If they become victims of the syndrome repeatedly, they may develop suicidal tendencies, destructive tendencies, tendency to make fit patients unfit as revenge against seniors who keep operating. Coincidental victims are the bosses who are stressed trying to somehow rush through the operation so that it gets over before the deadline and the next case can be operated on. Suggestions to prevent this syndrome are not included in this post, because that would be just an academic exercise, never to be implemented.
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