Virtual Bags for Waste Disposal

The world has some parts which have a lot of resources and a lot of money to spend on those resources. Then there are some parts where both are scant. These parts are of two types - one part likes to think they have enough of resources and money, and their situation is as ideal as in the affluent parts. The other type knows it is poor and behaves accordingly.
When the hospital infection committee started functioning, I was made a member. I knew we belonged to the non affluent group, and myself preferred to behave accordingly. The chairman of the committee believed we had a plenty and wanted to behave as such. When the matter of waste disposal came up, the decision was made to follow the universal rule - black bags for household waste, red bags for biohazardous non-sharp waste, and yellow bags for body parts.
"Do we have funds for such wastage on bags?" I asked. "We might dispose off the household waste like the whole city does. Why use bags? They will not get biodegraded too."
"We have enough funds. We must follow rules."
I kept quiet. One of the big bosses even declared that the bags were biodegradable plastic. I could not confirm that despite extensive research. But they did not want my opinion. They had all three types of bags to start with. They situation was as shown below.

Then the supply and funds started running out. The servants started using one bag for another type which was not available. The nurses had innovative thinking. They put labels on the walls behind the bags as shown below, so that people would know what should be thrown into which bag. They situation was as shown below.

How the waste managers would identify the contents of the bags when the bags were taken away leaving the labels behind is beyond my imagination. Finally all supply stopped. Then they started throwing the waste in sterile plastic surgical drapes placed inside plastic drums or buckets. All bigwigs who had maintained we have everything a plenty have superannuated and gone away.  The members and enforcers of the infection committee are not to be seen around. So I cannot ask them if they still believed we had a plenty. I had resigned from the infection committee long ago because I could not live with pretense. So I don't know what is their take on the current situation. I had known I was right, but I had not wanted myself to be proved right in this way.

Structural Warning

When they repaired the old hospital building, it looked nice and shiny and everyone was happy. Usually the servants would sweep and mop my office floor to keep it looking good. But they would not clean the window sill, Oe day they sent a new servant who was temporary and wanted to make a good impression. So he cleaned the windows and the window sill.
"Sir, the outside wall is all cracked up" he said.
"Huh?" I said. The wall was not cracked up before the repairing work. How could they produce a crack in it by repairing work? Anyway I went to have a look, because if there was a crack, it had to be repaired before the warranty ran out.

There was really a big crack running pretty deep.
"Sir, do not lean on the wall here" he warned. "You might fall out of the room if the wall collapses."
He sounded so matter of fact about it that I knew he must have seen it happen. I dared not ask him when he had seen that happen, because it might have been a tragedy involving near and dear ones.
"I won't" I said. "Thamk you for bringing it to my attention."
Then I sent a letter to the chief asking for a structural audit of the newly repaired building to check if it was safe for occupation. Our civil engineer came, had a look at it, learned that there were other defects in the repair work too, and fixed up a meeting with chief, concerned heads of department, and engineer from civic head office. The said engineer came for the meeting, checked his files to see if I had certified the work as satisfactory, failed to find it, and went away with the understanding that he would come the next day and check out all problems. That was long ago. He has not come. I am thinking of putting a warning on that wall for visitors. I am not leaning on that wall. But if my blog stops being updated, one of the possible reasons might be that I forgot and leaned on the wall. :-)

Patient Dumping Trolley

I have seen dumping trucks which are used in building and construction business. They load them with sand or stones and take them to the construction site. At the desired site, the park the truck and elevate the front of the container so that the contents are dumped on the ground. It is a motorized procedure. Some of the new trolleys supplied by the contractor are innovative, seem to be built on similar principles. They were like other trolleys initially. But they evolved with time. In the new state, when the trolley is raised by pumping on a foot pedal, the head end goes up, until it is so steep that the patient slides down the trolley.

"Sir, the patients will fall down from the trolley" the House Officer said when I saw this first.
"They do not come for repairing it" the Sister in charge said :despite repeated calls."
"As it is, there is shortage of servants for shifting patients" someone said, "the patient's relatives often have to pull the trolleys."
"Perhaps someone with out of the box thinking has developed these trolleys" someone else said. One just takes the trolley to the patient's bed, and raises the head end, so that the patient slides off and gets on the bed."
That sounded sarcastic, but perhaps it was the truth.
"Don't use it that way" I advised.

Innovations in Theater Technique: Surgical Gowns

It is wonderful the human mind works. It is even more wonderful when the mind belongs to an intelligent person. I appreciated the surgical repair of a torn surgical gown achieved by one of our resident doctors. It seems it had to be done because the gown was otherwise OK, and we could not just discard it owing to a big operation list and a limited supply of sterile gowns. If they had waited for a new lot of gowns to be ready, they would have had to postpone a few operations for lack of time.

The torn portion was held at the center, and a ligature of a rolled up piece of sterile gauze was tied all around it over intact portion. It was something like burial of the stump after an appendectomy. After the operation was over, the gown was sent for repair by the tailor.

Patients in a Hurry

Life in Mumbai is always on the fast track. So it would not be surprising if the patients are in a hurry to get their treatment and do away. But one would think they would want the doctor to listen to them patiently, check them up thoroughly, and get their treatment explained properly before making a move. Well, some of them are in a greater hurry than most of the others.
I see a number of women who get on the examination table after waiting for an hour or two. They should want to spend some time with the doctor after such a long wait. But I find that when I finish with a speculum examination, put the speculum away and turn back to check them up internally, , they are already up from the examination table. Surely getting up before the doctor says he is done with the check-up is a sign of a hurry? I have seen so many such patients, that now I do not get surprised by this behavior any more.
But something happened today that would beat this hurry. We had a patient scheduled to undergo a gynecological surgical procedure. The anesthesiologist gave her a spinal block after a bit of difficulty. When he finished the administration of the block, he said with satisfaction "OK, done!" As soon as he said this, the patient got up from the operation table and started stepping down to go back to her ward. We had to stop her and put her back on the table.
"....!" the anesthesiologist said.
"We could have allowed her to walk until we found out when she could walk no more. That would have made a good case report. The vice chancellor of the health university wants us to do research or he will stop our promotions" someone said.
"....!" the anesthesiologist said.

Concealed Plumbing: Heritage Style

People define heritage in different ways, not based on which dictionary they use, but what their occupation is. The architectural consultant who planned and got executed the repair and renovation of our building possibly interpreted it as something that must be seen from the outside (what they call facade of the structure) as it was when the structure was created. Probably in order not to mar the beauty of the building in any way, he has put the drainage trap in plain view of the operation theaters, staff room, and corridors.

Probably the heritage, in his opinion, lies in what people can see from the outside rather than what the contents of the structure are in reality, both physical and traditional. I recall when one of them started leaking soon after we moved in, and the whole corridor was flooded by the waterfall - what could be termed 'heritage waterfall'. It was fixed somehow - I hope not by a bypass.

Adults Stuck in Childhood

Sigmund Freud proposed that some people get stuck in oral phase and some others in anal phase. I am no psychiatrist, but I feel with conviction that all people remain stuck in their childhood. As they grow, they just do things differently, but they think as they did as children when their guard is down. That would explain adult pranksters' pranks. That would explain adult bullies. That would also explain why some women throw tantrums when stressed, while others sulk or cry.
We had this three day workshop on research methodologies, where senior faculty were made to be students. Senior consultants were children in school again. Many ran away from class periodically - some to do child things, some to do adult things, and many to get away from boring stuff. When asked what 'statistics' was, one frankly said 'boring'. Some of them refused to sit at tables assigned to them and were absent for group activities. A few came to class in fancy dresses like six year old girls. Some of these women-girls giggled uncontrollably at times while the men-boys looked on uncomprehendingly. Some of them refused to concentrate when a session got prolonged and the lunch hour was past without any lunch. One came on the first day and disappeared for the remaining two days. One took special leave for three days, attended on the first day, declared it was toxic stuff and did not come on the second day, came back on the last day hoping the absence on the day in between would not be noticed. This one even cheated, because the special leave granted for academic work was used for having fun at home. They checked their notes when answering the post test, and they even took help from supervisors and neighbors.
I rest my case.

Ultimate Faith or Cute Thinking?

She was a young woman. She came to us with a complaint of white discharge. She had some infection, which was treated appropriately.
"Doctor, I still have some discharge" she said.
"Do you have any itching" I asked.
"No. But the discharge comes off and and on" she said.
"With respect to the beginning of the cycle, could you tell me when it is sen and when it is not?" I asked her.
"It is seen about 2 weeks from the beginning of the cycle" she said.
I checked her and found nothing wrong with her. It was physiological discharge. I had to explaint it to her.
"This discharge is natural. Ovulation takes place about 14 days after the beginning of a 28 day cycle. If the discharge is abundant and watery at this time, the sperm find it easier to travel up and fertilize the ovum. It is the arrangement made by God so that women can have babies. Who am I to try and stop God's wish and who are you to wish it stopped?" I said.
"But I have had a sterilization operation" she said. "Now I don't need the discharge."
I was speechless. She believed in God and was innocent enough to believe that God would stop the discharge when He realized that she had undergone sterilization and did not need it any more. Served me right to bring God into it, when I could have said it was the way human body was made.
"God probably cannot keep watching what every human being needs and change physiology accordingly" I told her. "Be happy there is nothing wrong with you and live happily with what He has given you."
She went away not unhappy.

Schizophrenic Wiring

I had had no occasion to examine the electric wiring done in the examination room of that ward, except that of the examination light. It had seemed OK. It came as a surprise to me when I happened to look at the back of the storage shelves. The contractor, as per the design of the architectural consultant for the heritage building, had put up an electric board with sockets behind the shelves, as shown below. The arrows indicate the vertical divider of the storage shelf.

"Sister, how do you use this electric socket?" I asked the nurse on duty. "This three-pin socket has its one hole on one side of the vertical dividing stone slab of the shelf, upper hole almost behind the divider, and the other lower hole is also behind the divider, but obliquely accessible from the other side. How do you put a three-pin plug into it?"
"We don't" she said. "We have never had occasion to use it."
"So the contractor got his payment, the consultant got 10% of that amount as his fee, and the users are without the benefit of the great work!" I said.
"It must be lack of coordination between the civil and electrical contractors" my Assistant Professor said.
"The consultant made great drawings in Autocad" I said "with precision of millimeters. The civil and electrical contractors do not need to coordinate. They just have to work according to the drawings."
"Well, then what went wrong?"
"God knows. Perhaps the consultant wanted to make the work suit the hospital environment. Perhaps he thought this was a psychiatric ward, and he put a split socket to suit the split personalities of the patients in the ward."
"Sir, he knew it was an obstetric ward."
"I know he knew" I said. "I was just joking."

Hardware with Emotions

I would not have believed it if anyone had told me this story. ‘Fibber’ I would have said if I had been a small boy and another boy had told me this. As a young adult, I would have said ‘Are you trying to be funny?’ As a mature adult (meaning old man) I would have probably ignored to story teller as a foolish person, and not said anything, because there is no point telling a fool that he is a fool. But it happened to me, and I am telling the story. So I cannot take any of these stands.

I am still using a desktop computer and the conventional hardware that goes with it. I have a mouse that has served me OK for quite some time. Then it started acting up. The left mouse button would not produce a click on clicking it, or it would click three or four times like a machine gun, producing four windows when I wanted only one. This became especially troublesome when I was using a graphics software. In place of a continuous line, I would get a segmented line. I should have got a new one, but somehow it remained to be done. One day the mouse got so bad, that the left button would not produce any effect no matter how many times I clicked and with how much force. Work stopped. I normally do not get angry with my hardware because it is inanimate. But that day I had such a rage that I lifted the mouse and slammed it on the desk surface. I half expected it to break into pieces. It did not. I tentatively clicked it a few times and it worked like a charm. That reminded me of radio sets which used to get OK with such treatment when I was small. Well, this corrected mouse worked well for a few days and then started going bad again I decided to buy a new one before it stopped totally – after all, slamming it hard might not have worked a second time. So I bought one and kept it in its box pack near the old mouse, planning to attach it the next day. I have not had to attach it for a week now, because the old mouse has started showing exemplary behavior. It does not miss a click, and does not show any confusion between right and left.

You may say it is just coincidence. But two coincidences in a row is a bit too much. I want to believe (even if it sounds irrational) that the old mouse is like a child – it behaves under threat of a beating, and behaves even better when it fears a new mouse will replace it. I am glad I am not in Norway or US, where they put Indian adults in jail for disciplining their own children. I am afraid the PETA activists might read this post and start a demonstration in front of my house tomorrow, for showing cruelty to an animal (even if it is hardware). :-)

Cesarean Section: 3 Unique Difficulties

My Resident doctors presented a seminar on difficulties in cesarean section. They did a good job, listing all possible difficulties and then giving their solutions. At the end I felt compelled to narrate three unique case reports, (not my own, but which I knew of) because I thought they should not encounter them sometime without knowing about them.
Case 1: Where is the uterine incision
They performed a lower segment cesarean section and delivered the baby. Then they started defining the lower segment incision so that it could be sutured up. There was no incision. The uterovesical fold was intact and there was no question of an incision being present underneath. It seems they called the consultant down, who gave it considerable thought and finally found the uterine incision on the posterior wall of the lower segment. The explanation was that the uterus had dextrorotated through 180 degrees, and they had not corrected it prior to making the incision. I have heard of two such cases in 32 years. Both patients made uneventful recovery.
Case 2: Where is the uterus?
A lower segment cesarean section being performed in a case of previous cesarean section. The baby was delivered. One moment the uterus was there and the next moment it was not there.
"I just looked at the multipara monitor and in that time the uterus disappeared" the consultant assisting the operation said. "Where is the uterus?"
"It is in this only" the operating surgeon replied, pointing towards the placental mass and membranes in the field.
"What did you do when I was not watching you? the consultant asked.
"I made cord traction to deliver the placenta" the operating surgeon said.
Then the consultant discovered that it was a case of iatrogenic inversion of the uterus through the lower segment incision. The uterus was not seen because it was under the placental mass. He rapidly corrected the inversion. All this happened so rapidly that there was no hemodynamic change or shock. The patient made an uneventful recovery.
Case 3: Where is the baby?
The patient was taken to the oT for an emergency cesarean section for fetal distress in advanced labot. When the made the lower segment incision and put a hand inside the uterus to deliver the baby, they found there was no baby in there.
"Where is the baby?" shouted the operating surgeon.
There was a muffled cry in response, from under the surgical drapes over the patient's thighs. Someone lifted the drapes and found the baby there. It had delivered vaginally while they were approaching the lower segment surgically. The mother and baby made uneventful recovery.
"How did that happen?" someone asked me later.
"When the cesarean section is done in advanced labor for acute fetal distress, if the obstetrician is faster than the patient, the baby is delivered by a cesarean section. If the patient is faster than the obstetrician, she delivers the baby vaginally in the OT before a cesarean section can be performed. In this case both of them must have been equally fast, such that the woman delivered vaginally while the obstetrician reached the uterine cavity to take the baby out."

Armor Plating in Hospitals

"Sir, the new lockers unit is broken" I was told.
"Broken? How?" I could not see how a brand new steel unit of six lockers could be broken by anybody.
"Its one side has come, Sir."
"Let us see" I said, skeptical such a thing could be done by anybody. So we went to the lockers unit in the OT. Its one vertical face on left side had indeed come off. There was a big dent on the side, as happens on bodies of cars in vehicular accidents. I looked at carefully and knew what it was.
"The person who shifts patients on a trolley has banged the side of the unit with the trolley. The patient must have been on it, considering the amount of force that would be required to achieve it. Who was the servant on duty when this happened?" I asked.
"Um... ar... ah..."
They are afraid of naming the culprits, probably afraid of their labor union.
"Send it to the workshop and get it repaired" I said. There would be no point in asking manufacturer to repair it, because the warranty would be void when the damage was not due to manufacturing defect, but negligent use. The engineers kept the unit for a month and wanted us to condemn it.
"I condemn the act that achieved this damage" I said "but I cannot condemn the unit. It is new. If they do not know how to repair it, ask them if it is OK if I get it repaired by an outside agency."
That did the trick. They drilled holes in the side and fixed it to the main body with nuts and bolts.
The following week, there was another occurrence of similar nature. The brand new refrigerator in the labor ward developed three dents. On inspection, it was evident it was caused by patient shifting trolleys colliding against it.
"Perhaps we should shift the refrigerator elsewhere and keep an old one in its place" one staff member suggested.
"We don't need another refrigerator" I said. "We need armor plating for our cupboards, lockers, and refrigerators."

Afterthoughts

She was a middle aged patient. The Resident Doctors called me to see her.
"She has complaints suggestive of urinary stress incontinence" the Registrar said.
"OK" I said. The patient was already on the examination table. "When I ask you to cough, I want you to cough twice" I told the patient. "Please cover your nose and mouth with a handkerchief when you cough."
"Yes. doctor" she said.
I took up the examiner's seat and said "Please cough".
She coughed twice as instructed, but did not cover her mouth despite instructions. My facial expression must have showed my feelings, because she covered her nose and mouth after the act was long over. I had a sudden thought.
"May I know what is your husband's occupation?" I askd her.
"He drives a taxi" she said.
"Ah!" I said.
"What did you mean by that 'Ah!' Sir?" my Assistant Professor asked me after she went away.
"A taxi driver cuts the lane and comes into your lane without a signal. When you honk in protest, he puts out a hand to give the signal that indicates he will enter your lane ahead of you. He does that to show that he has gone through the motion, and you should be satisfied. His wife was like that. She covered her mouth and nose after coughing, only to satisfy me. Both of them either did not understand that doing those things after the harm was already done by their primary acts was no good, or they thought we were dumb enough to be satisfied with what they did as an afterthought, or did not care what we thought. They seem to be made for each other."
He laughed and then said "Sir, but how do you know her husband does that when he drives?"
"Yeah, you have a point there" I said. "He may be the type who cuts into your lane without a signal and makes no response when you honk in protest."

Eloquent One Word Explanation

A part of my job is to forward leave applications of employees in my department to the head of the institute. I have to check the validity of the reason given for asking for leave. Then I have to write my remarks and send it for sanction. There was one such application asking for leave for one day. There was just one word scribbled on the three lines offered for giving the reason for application for leave. It was 'Children'. It was an extremely eloquent word. I did not need any words before or after that word. No verbs, adjectives and punctuation marks were necessary. Even mental visualization of the usually tired and harassed looking face of that applicant was not required. I wrote 'Recommended' without any hesitation and signed on that leave application.

The High - The Crash

I was on my way home after a day at work. I had just got out of the gate of the institute, when I saw a couple of boys riding a bicycle. They were coming hurtling down the single lane left after the monorail work had occupied half the width of the road. The thing was that both of them were on a high. They had wide grins on their faces, their hands were off the handle or any other support, held high in the air. They would have looked good in a bicycle stunt show. What is shown below is my computer aided reproduction of my memory of the duo.

They went about 40 feet and crashed where the monorail pillar had reduced the single lane from the side too. I ran to see if they needed help. By the time I reached them, a crowd had collected around them. One of them had dragged his friend and then the cycle5to the side of the road. The fellow who had been so dragged was sitting on the edge of the pavement, wincing in pain. Nothing seemed to be broken. A couple of policemen happened to come by on a bike. One of them advised the fellow to call his mother on a phone. The other advised him to site on the pavement away from the road. Elderly women criticized them for reckless riding of the bicycle, and blamed their mothers for them being what they were.
They just needed time to recover their morale. So I went my way. On the way I was thinking of what had happened to them just outside our compound, and something similar that had happened recently to someone inside our compound - an intense ride on a high and then a crash.

Dangerous Obstetric Forceps Applications:

A correct cephalic application of the obstetric forceps leaves no mark on the baby's face, because the blades do not touch the face. If the application is correct pelvic when the rotation is not complete, it can produce such marks on the baby's face. In my years of study of such applications done by some people, I have reached the following classification. The red marks in the following diagrams are the positions of the marks left on the babies by the application of the forceps.
Nose sparing application

It is an occipitofrontal application, the anterior blade missing the nose of the baby.
Eye sparing application 1

It is a brow-mastoid application. The rim of the anterior forceps blade stops short of the baby's eye.
Eye sparing application 2

It is a brow-mastoid application. The anterior forceps blade encircles the baby's eye.
I can say two things about these.

1. God be praised for sparing the nose and eyes of the babies.
2. God help the babies if these forceps applications cause intracranial hemorrhages in the babies.

Intercom Abuse

The telephone is an instrument for communication. If it is put to that use, life would be simple. However human nature wants complexities, most often for unreasonable gain.
I remember once our office peon complained to me about one such thing.
"Sir, some of the staff members call on the intercom and say they have reached the campus and request us not to put a cross on their names in the muster."
"So?" I asked.
"Sir, with the new intercom system, one has to dial the intercom number after the exchange code - 2410, and one is connected from any land line or mobile phone. It is no proof that those people are actually in campus."
"OK, We will state that being in campus is not enough, that they have to sign on the muster before the deadline."
That put a stop to it. The person who used to do that finally left the institute for greener pastures, where such problems were not permitted to crop up, I hear.
Then there was another one. I called that staff member in OT on the intercom. Another staff member took the call and said the staff member was teaching the students outside the OT, and had no access to an intercom. I was told that she would contact me when she came to the OT. I realized that this was a lie. The said staff member had not reached the institute, and was being covered by the other one. She had no business being outside the OT, because the students had to be inside the OT, learning operative procedures. I let is go at that, because I do not believe in correcting people who know very well that they are wrong. I got the expected call quite late, by which time the work that I wanted to assign to her was already done by someone else. The covering staff member left the institute later, and the covered one has to be in the OT now, there being no one to cover for her absence.

Tuberculosis Leave

It goes without saying that tuberculosis is a terrible disease (as most diseases are, from the patients' point of view). The government and civic bodies give none month's leave to their employees suffering from tuberculosis. No substitute employee is provided to do the work of these employees on leave. It either taxes the healthy employees who keep working, or the work is compromised. As doctors, we compensate for the absence of all doctors away from work, because patients' health is our primary job, and it cannot be deferred. But we expect that those on such sick leave should not abuse the system and their coworkers while they get well.
We had one lecturer who developed tuberculosis of lymph nodes. She started therapy and went on tuberculosis leave. She had no functional disability. In fact, she looked the picture of health while her overworked colleagues looked sick. However she remained on leave for the duration of therapy. "I got the disease in the hospital. Now the hospital has to give me leave, as a part of compensation." Her argument was flawed. She could have got the disease anywhere, not necessarily in the hospital. Furthermore, she must have got it long before she joined the hospital, considering the latent period and the duration of her service. Anyway, I did not argue the point, because she was sick. After joining, she asked for three more months of leave, citing ill health of some not very close relative, whom she wanted to nurse. 'She must be practicing privately' people said 'and this must be an excuse to get time for it while retaining the security of a permanent job to which she can return should the attempt at private practice fail.' This leave was not sanctioned by the administration She resigned, without compensating for the efforts of her colleagues who had done her work in her absence.
We had one senior staff member, who developed tuberculosis and went on leave for nine months, in one month increments. Modern therapy of tuberculosis is shorter, but the leave is still up to nine months. Ill health was cited as the reason for extension of the leave every month. This person put up an application for special leave to go to a foreign country for a conference while on tuberculosis leave. It was rejected by administration as per rules. Then this person put up an application for sick leave for going to the conference. It was even stated that change of atmosphere would help recovery from tuberculosis (even if the duration was less than a week). I am not aware of what happened, because this person has not joined duty from ongoing sick leave yet and we are not in communication. But what troubles me is that a person is too sick to work, but not for going to conferences, while colleagues are overworked.
The system permits such abuse and conscience is overcome by need for self satisfaction. As a result such occurrences will continue. It reminds me of a story of a Lecturer who was taking sick leave for one month at a time, for 'speedy recovery' from prolapsed intervertebral disc. After three months of leave were over, she applied for fourth month of leave. The day after she sent in this application, she was seen running around the Shirdi, a holy place for devotees of Saibaba. When she saw the Lecturer who saw her in pink of health, she ran away at a speed that would not be possible for any patient of a painful disease of the spine. The matter was duly reported to the administration. I heard an inquiry was initiated, but am not aware of the result of the same.

Green Show in Obstetrics

When you search this term on Google, you find 2540000 hits that deal with shows which are in theaters, fashion industry, television, and shows related to being eco-friendly. In all these hits, there is not a single one related to obstetrics. After I complete this post, there will be one.
For those of my readers who do not know what is 'show' in obstetrics, I will explain. It is the vaginal discharge that is found in a woman who has gone into labor. It is the cervical mucus plug along with a  little blood that comes out when the plug comes off the cervix. It is one of the signs of onset of labor. Every student of obstetrics knows this. There is another term that may not be understood. It is 'meconium'. It is the stool passed by the fetus while in the mother's uterus. It is green in color, and its presence often indicates fetal distress, which may lead to fetal death if it is not delivered soon. Every student of obstetrics must know this, and every Resident Doctor knows this. At least that is what I believed until the other day.
I am on vacation. However someone got so upset with something that happened in my department, that he/she sent me an email. It was about a Resident Doctor'.
'This girl noted that a woman in labor had meconium in the vaginal discharge. She did not document it on the patient's case paper. When it was discovered by the Registrar a few hours later, and when she asked this Resident Doctor why she had not done anything about it, she answered that she thought it was 'green show' and hence she did not do anything about it. The Registrar was aghast.'
When I read the email, even I was aghast,
"This Resident Doctor is doing her fourth house post. How could she not diagnose meconium?" I asked someone.
"Beats me" was the answer.
"And Green Show?" I said. "Show is always red, never green. There is nothing called 'Green Show' in Obstetrics."
"That Resident Doctor is making history" was the reply. "She seems to be original."
"You are being sarcastic" I said.
"Of course. This doctor must have known all along that it was meconium.  She must have been very lazy, and decided to ignore it so that she would not have to treat that complication."
"But that jeopardized the fetal well being" I said.
"She must have been very selfish too. Nothing must have mattered more than her personal comfort."
"And what if she genuinely thought it was 'Green Show'?" I asked.
"Then her future would be very dark. She does not seem fit to practice obstetrics."
I will say that was an honest and frank opinion. I will find out the truth only after I join duty.

Fashion Statements for Patients?

These two patients were admitted in two different wards and had two different nurses looking after them. What they had in common was that both of them were to undergo an operation in our OT that day. One was scheduled to undergo a diagnostic laparoscopy while the other was to have an emergency cesarean section. The standard procedure is that the nurse prepares the patient for OT, including confirming removal of undergarments and ornaments, putting a name tag on the patient's dress, covering her hair with a cap and giving her premedication.The House Officer is supposed to confirm that the preparation is as expected. I was to assist the House Officer perform laparoscopy. The patient was anesthetized, and lithotomy position was given. Then I suddenly realized that the patient had her um... upper undergarment on, so far covered by the OT dress but not partly exposed. The nurse had goofed up, and the House Officer had been too busy or lazy to do her job. The anesthetists had also goofed up. They had inserted the chest leads of ECG under that garment, probably happy that they would be held in place by the tight garment and would not come off due to poor adhesive.
"Have we started leaving the undergarments on when patient go to OT?" I asked.
"Arrey, the patient's bra is still there" my Registrar declared. She did not feel awkward to say that word aloud in OT. Houseman, remove it."
"It should not be worn because it is a tight garment and may restrict ventillatory movements under anesthesia" I said. I don't know how they managed to remove the garment while the patient had chest leads, IV line and pulse oxymeter attached. I was to embarrassed to watch.
The other patient was sent from the labor room. She had no hospital dress. Instead she was wearing an OT gown, which covered her full height all right, but was open along the entire front. It was held in place by three strings, one at the upper end, one in the middle, and one a little lower down. The poor woman was clutching it around herself, trying to cover her modesty desperately despite labor pains. I called the ward and spoke to the nurse.

"Why did you send the patient without a hospital dress?" I asked her.
"I asked the doctor" she said "who said it was OK."
"The doctor says she asked you to give the patient hospital dress" I said. "The poor woman is almost naked., that too in front of all people in OT."
"I am new in this ward" she said.
"So what?" I was getting quite angry by then. "You must know hospital routine - giving a dress to a patient is the most basic of nursing care."
"OK. I am sorry" she said.
"But what about the patient on the OT table? She is still almost naked" I said.
"I said sorry, did I not?" she retorted.
I knew I could not improve things any way. After all, I was not involved in the selection process of the employees, nor were they answerable to me. I could just wonder at the coincidence, one patient being unduly clothed and the other hardly at all. Perhaps there was a cruel balance there, positive and negative nullifying errors due to extremes in each other.

Strategic Applications

There is a curious tendency for my staff members to apply for leave when I am on vacation or leave myself. On the first day of my last vacation, the Assistant Professor who had joined duty after six months of earned leave just the day before put up her notice of resignation and application for leave without pay for a month, to which she was not entitled because no such leave is granted in vacations, when the hospital is working with 50% staff members. The idea was to avoid the deposit being confiscated by the institute for resigning without any notice, and still not work for a single day after a six months' leave. She knew I would not sanction it. My next in command promptly sanctioned it, claiming ignorance of rules.
The day after I went on vacation this time, my Assistant Professor put up notice of resignation. I wonder why he was afraid to do so in my presence. I would not hold back anyone - not that I could if I wanted to. He was working during vacation anyway. I think they discuss strategies amongst themselves, and apply a strategy at inappropriate times.
That reminded me of two of my staff members, both Professors at that time. One would put up long leave application when I was away, and get the other Professor's signature on that application. The other one had put up an application for permission to publish about ten scientific papers, none of them ready anyway. It was just a list. It was dispatched just the day before I took charge as Head of the Department. It was probably fear that I would not forward the application.
Only a person who knows he or she is wrong and still wants to do that wrong behaves in such a manner. I wish they had read Stephen Covey's masterpiece - 'Seven Habits of Highly Effective People'.

In House Litigations

When I was placed first on the selection list of Lecturers, I was placed at the most peripheral place, while people lower down, including Dr ^^^ was placed at the most prestigious place. This rule was not made applicable to all specialties, probably because it did not suit some privileged candidates in some other specialties. My representation to the civic boss in charge of this affair fell on deaf ears. If I had sued, I would have won the case. I did not. I got a letter from the University that the place where I was posted was not a teaching institute, and got transferred to the place where I have worked for 27 years.
However everyone has not been as tolerant of injustice, real or imaginary, as I was. There was Dr. ***, a Registrar, who was unhappy that someone two years her senior was selected to be a Lecturer ahead of her, though she was MD while *** was not. She got a stay on that appointment. That post stayed vacant forever and was wasted. In due course, both of them became Lecturers in another institute.

^^^ did not do much academically and *** went ahead of her, though three years her junior. ^^^ did not sue. But Dr. @@@ sued *** for being selected ahead of him, despite he being two years her senior. He lost the case.
A civic boss decided to place one Dr. $$$ as the Boss of Dr ###, only because $$$ was a full timer, while ### was an honorary doctor. ### threatened to sue, because he had been Professor while $$$ had been his resident doctor. The civic body transferred him elsewhere as assistant to a very senior Professor to avoid litigation. Later, $$$ resigned for reasons not known to me. ### was transferred back as head of his original unit, because they did not want to give him a unit chief's position at the prestigious institute where he had been transferred. This time ^^^ sued him for not being given the position despite being a full timer while he was honorary doctor. He was upset. He said he could have got her services terminated because he had proof that she was engaged in private practice though she was not permitted to do so. He did not do so. He fought the case and won.
I heard the story from ###, not an old man, but still quite upset with what had happened so long ago.
Just the other day, a doctor in service of the civic body sued the civic body for being denied permission to appear for an interview of selection as an Assistant Professor, and later for being not given the post though selected for it. She won and is now working as an Assistant Professor.
A person has a right to fight for his or her rights, and it is reassuring that people can exercise that right. What is not reassuring is that there are occasions of injustice which need never arise. For every unjust act that is taken to court, there must be a score of others which do not reach the court for various reasons, like mine did not, and that hurts.

Gossipmongers

It makes no difference whether a person is a doctor or an engineer, or anything else that is recognized as something important. It makes no difference whether the person is a man or a woman. At ground level, everyone is a human being, and most human beings will do things that other human beings will gossip about.

“Thanks for doing everything you did for my patient” the guy said. He was an engineer working for the civic body. “By the way, you stay at ***?”

I agreed that I did stay at the place he mentioned.

“You know Madam **** stays nearby?”

He was talking about a specialist in our hospital. I agreed that I had heard so, but not seen her myself anytime.

“I was there the other day” he said. “I was parking my car, when I saw this driver in the uniform of a driver of the civic body. He was the Boss’ driver. He said, ‘Sahib is gone up there to Madam’s house’ and pointed to an adjacent building. So I asked, ‘so what?’ Then he said, ‘So nothing, I am just saying Sahib is gone to Madam’s house.’ Then he kept looking at me.” He sniggered.

“He was trying to gossip with you” I said mildly, and kept quiet. I had no desire to gossip on that or any other issue.

“Well, thanks again, doctor” he said and went away. As he was going away, I remembered what one of our woman staff members had said about this specialist doctor and the Boss in front of a number of staff members in our staff room - “I heard her say ‘the air conditioner in Sir’s bedroom is so good you know!’ It was so … um,,, so …vulgar.” There was a smile on her lips and a wicked glint in her eyes as she said this.

“Huh?” I had said and left it at that.

I wonder if the gossipmongers gossip because they are inferior to those that they gossip about and by demeaning them they prove to themselves that they are actually superior to their subjects.

Cyst in the Uterus

I had just begun lunch when they called me to the OT.
"Sir, please come to the OT. There is a cyst in the uterus" my House Officer told me.
I knew they were operating on a 42 years old woman with uterine leiomyomas and infertility. They were doing removal of a couple of small leiomyomas (seen on ultrasonography) because the woman had uncontrollable dysmenorrhea. They were also checking tubal patency for her infertility.
"It must be cystic degeneration in a leiomyoma" I said.
"Sir, it is different" she said. "Please come and have a look."
I packed away my unfinished lunch and went to have a look.

The uterus was open on the left of its posterior wall. A cystic structure was seen inside.
"She had menses two weeks ago, but the flow was scanty this time" the operating surgeon told me. "It looks like a pregnancy, which must have been there when she bled. Shall I close the uterus and let the pregnancy have a chance to continue?"
"But where is the leiomyoma?" I asked. "You were going to make an incision over the leiomyoma you palpated when I went for lunch."
"...."
"I will wash up and have a look" I said. "Don't do anything until I come."
While I was washing up, I suddenly remembered they had put a Foley's catheter in the uterine cavity for chromopertubation. Perhaps this was the balloon of the catheter. I rushed back to the OT.
"Deflate the balloon of the catheter and see if the 'cyst' goes away" I said. A House Officer did that and the 'cyst' disappeared. Comprehension dawned on everyone.
"What you called a leiomyoma was the balloon of the catheter" I said. "She has just one leiomyoma which she had two years ago when we performed a laparoscopy on her. Now she has adenomyosis too, which is causing all that pain." I pointed out the uniform enlargement of the uterus and three endometiosis-like nodules under the fundal serosa. "She won't be cured by anything other than hysterectomy." We had discussed the option of hysterectomy with the patient preoperatively, and she had consented for it if it was deemed necessary. A hysterectomy was duly performed. The specimen showed adenomyosis. She made an uneventful recovery.
I don't think I have to write down the morals of the story.

I Can't Watch This

It was not just another nightmare come true for two reasons. The first was that I had not had a nightmare like that any time. It was original reality. The other reason was that it was far from the usual nightmarish experiences.
A laparoscopy was being performed by a Registrar. An Assistant Professor was assisting. I was standing nearby, with a watchful eye, waiting while they were anesthetizing another patient. Suddenly I happened to look at the Veress' needle, and I got s**t scared. It was thrust in the patient's abdomen, left free, while carbon dioxide was being insufflated through it.Both the operating surgeon and his assistant were watching the dials of the insufflator and the needle was attended.
"Look at the Veress' needle" I whispered, afraid to speak loudly. The Assistant Professor put his hand out to hold it. "No! Don't touch it. Just look at it" I siad urgently. They looked at it. It was moving up and down rhytjmically, at a rate of about 70 per minute.
"It is moving with the patient's vascular pulsations" the Assistant Professor exclaimed.
"Yes" I said. "It is probably sitting right on the abdominal aorta. A minor push and it will enter the aorta. Withdraw it NOW."
He withdrew it.
"Any blood in it?" I asked.
"None."
"Are the patient's vital parameters OK?" I asked the anesthetist.
"Quite all right" the anesthetist said.
"God be praised" I said. They continued with the remaining steps of the laparoscopy. "I can't watch this" I said and turned back on them. The OT became silent. I looked back through the corner of my eye to watch them. The students laughed thinking I was just being funny. I was not.
"I know I cannot watch this" I said, because I am afraid. But I have to watch it because it is my job to do so."
The laparoscopy was successfully completed. There was no hemoperitoneum. The patient went home fine the next day. I hope neither I nor anyone else has to watch an oscillating Veress' needle anytime.

Hotei of Pure Gold

I wanted to write that they gave me this Hotei made of pure gold, but I knew no one would believe it. No one makes sculptures of pure gold for giving to someone else, no matter how accomplished or how well liked. So I will write the truth. I made this sculpture myself, in 3D, on my computer. I have put it here so that I can share my happiness at this creation with you all. I know there must be scores of others who could have sculpted better than this, but then I am willing to bet there will be no Gynecologist who can do it like me.
(Note: Hotei is erroneously called 'Laughing Buddha' by many people.)

Dengue Pronunciation Queries

I had written something interesting about different ways my staff members pronounced 'dengue' That artile is available at:
http://shashankparulekar.blogspot.in/2011/09/dengue-pronunciation-deng-dengu-dengi.html

I use a service provided by 'Statcounter', which tells me who visits which pages my blog. I used to get a couple of hits a week for this page, all of them using 'Google' to find out how to pronounce this word. Suddenly there is a sort of tidal wave of hits to this page. Over the last 3 and a quarter days, I have had 24 hits. Their details are as follows.

Internet Service Provider	Place
Road Runner (67.247.21.46)	New York, United States
Hutchison Max Telecom Limited (42.109.133.5)	Delhi, India
Bharti Telenet Ltd. Tamilnadu (122.183.183.102)	Chennai, Tamil Nadu, India
Bsnl (117.197.5.223)	Jaipur, Rajasthan, India
World Phone Internet Services Private Limited (14.102.124.2)	Meerut, Uttar Pradesh, India
Sify Limited (118.94.83.75)	Delhi, India
Virgin Media (77.96.122.53)	Raynes Park, Merton, United Kingdom
Bsnl (117.197.147.232)	Haryana, India
Sky Broadband (94.14.49.224)	Wimborne, Dorset, United Kingdom
Bsnl (117.197.112.46)	Chandigarh, India
Asianet Is A Cable Isp Providing (111.92.4.103)	Trivandrum, Kerala, India
Airtel (122.170.83.252)	Mumbai, Maharashtra, India
Bsnl (117.216.130.28)	Bangalore, Karnataka, India
Tata Indicom (14.97.97.151)	Mumbai, Maharashtra, India
Marquette University (134.48.158.121)	Milwaukee, Wisconsin, United States
Etrade (65.248.129.125)	Alpharetta, Georgia, United States
Bsnl (117.192.76.92)	Bangalore, Karnataka, India
Gprs Delhi Mobile Subscriber Ip	Pune, Maharashtra, India
Sky Broadband (90.220.139.61)	Saint Albans, Hertford, United Kingdom
Mahanagar Telephone Nigam Ltd.	Mumbai, Maharashtra, India
Chandigarh (125.62.112.59)	Lalon Khurd, Punjab, India
Bharti Broadband (122.169.109.247)	Mumbai, Maharashtra, India
Reliance Communications (115.248.154.247)	Chennai, Tamil Nadu, India

It indicates there is a serious outbreak of the condition. I was surprised that out of 23 hits, 5 have been from UK and one has been from USA. Those people whose language we have to learn and speak should have to do a 'Google' search and reach my blog to learn the pronunciation of this word is indicative of something that I do not want to put down here.

Pseudo Belladonna Eyes

Belladonna is Italian for "beautiful lady". Belladonna was used by 16th century women to give their eyes a sexy and dreamy look (by dilating the pupils). I was doubly surprised to see these eyes on a man recently.
This fellow was a retired gynecologist. I met him in a scientific meeting. He knew all about my institute, including a non-gynec professor who wanted to become a Dean once, had got selected by MPSC, had started clearing his desk, and suddenly declared he did not want to be a Dean. A lot of stories had circulated for this happening. I never knew the truth, because I did not ask that Professor.
This fellow asked me,
"Dr. xxxxxxx who is in your department still calls me on teachers' day."
I smiled politely.
Then he opened his eyes wide, fixed them on me in a dramatic way, and said,
"Is Professor xxxx still there?"
"He is there" I confirmed.
"He wanted to become a Dean once, but suddenly he stopped being keen on it...." he said with a half smile and even more belladona in his eyes. He stopped and waited for me to give an explanation for Professor's xxxx's mysterious behavior.
"There were some stories" I said and changed the subject.
I was surprised that a man could make such belladonna eyes. I was surprised also because he reminded me of Dr. xxxxxxx, who had apparently been his student. This doctor also used to make belladonna eyes at me and make unfinished statements and wait for me to provide information. The same eyes, the same look on the face, the same expectant smile, the same body language! I wish the student had learned good gynecology rather than making belladonna eyes from this person. Lucky I had not been fooled either by the student (on multiple occasions) or by the teacher.

Adjusting Hemoglobin Report

"Sir, this patient looks quite pale. I think she requires a blood transfusion."
"Huh?" I said. I knew looks could be deceptive. "How much is her hemoglobin?"
"Sir, the laboratory report is 9 g%. But it is from the emergency lab!"
"So?" I was confused.
"Their reports are not accurate. They told us on phone that this patient's report was 8 g%. The printed report came as 9 g%, where the 8 had been changed to 9 with a pen. We asked them what was the meaning of that. The Resident Doctor in the lab said that they had to wash the chamber of the autoanalyzer frequently owing to the work load, and they could not do that. So they looked at RBC pallor on microscopy, and changed the final report from the machine depending on the pallor they saw."
"That sounds like us looking at the patient's conjunctiva. Why don't you send them a picture of the patient's conjunctiva on phone?"
The answer was a broad smile.
"So now what>" I asked.
"So we correct their report depending on our clinical judgment."
The patient fortunately did not understand what was being said. She just lay there in blissful ingnorance, believing she was being looked after well.

Attitudes 9

“He has his favorite people” the staff member sniggered, “that he has brought here after he came here.”

I was sitting in the staff room, when I heard this from one of our staff members. It was a complaint that I could not do anything about even if I wanted to, because she was talking about my senior officer.

“Favorite people?” I asked. I had known bosses to take along their personal secretaries when they moved from institute to institute. This would be one such thing.

“Yes. Professors of xxxx, yyyy and zzzz.” I have put xxxx, yyyy and zzzz in place of names of three departments to protect the identity of these persons.

“So?”

“They are all women!” she sniggered again. She was suggesting something, but not saying it openly. I shrugged my shoulders and went about my work. I do not like people gossiping, and making accusations about other people's characters. Fifteen days passed. Then she was back again.

“Dr. xxxx was pulled out by the Boss to do something for him, and the work of that theater stopped.”

“Dr. xxxx?” I asked. I was not familiar with the name.

“You know, one of the people the Boss transferred here when he came here.”

“Must be very good at doing that work” I said in defence of Dr. xxxx, poor woman.

“Ha!” she said.

A month passed. Periodically there were comments showing disrespect for the Boss and his favorite people. Then one day things changed. The Boss was suddenly a very nice person. Dr. xxxx was a nice, decent, friendly woman.

“While we were talking ....” she said about Dr. xxxx.

“How did you get together?” I asked. I thought you did not like her.”

“The Boss has placed us on the same committee. We share a lot of viewpoints” she said. “He has made me in charge of the working of a new department the institute will start.”

“Hm....” I said. In the next meeting of hospital staff members, the Boss called this critic turned friend by her first name. She almost blushed.

Hats off to the management of this Boss. He had charmed an enemy into a loyal friend. All he had to do was to make her feel special (by calling her by her first name – makes them feel younger too), give her something others did not have (by making her officer-in-charge of something new), and give her recognition (by placing her on a committee). I have not heard a single word from her since then criticizing the Boss and his favorite people, or tarnishing their characters.

Busy Subordinates

“Sir, you won't believe this!” one of our Professors told me.

“What?” I asked. I thought I had seen enough and nothing would surprise me any more. But I could be wrong.

“We were in a meeting called by the Dean. It had to do with three clerks of two sections, who were called. Only one clerk out of three came. He said one of the others had gone to the head office, and the other one was busy and hence had not come. The Dean nodded her head. But another staff member got angry, and asked how could a clerk not come saying she was busy when the Dean herself had called her? Then the Dean also said what was the clerk busy with. The clerk was told in no uncertain terms to come and she came. Now a clerk has the guts to tell the Dean that she was busy and could not come when called.”

“Hmm....” I said. “I am not surprised because of two reasons. The first one is that the new Dean is mild by nature and kind. She would not take offense at such behavior by a person far junior in the hierarchy. The other reason is that I have seen such behavior before.”

“You have? Where?”

“In my own unit. I was in the OT. We had a patient who had had a copper-T inserted by my House Officer five months ago. I was in the process of its removal laparoscopically because it had migrated into the abdominal cavity. It had passed into the right broad ligament and then had partially exited into the peritoneal cavity through the posterior leaf of the ligament. 'Please call that House Officer' I said. She was in another unit after having finished six months of residency in my unit. She did not come. She did not meet me for another week. When I saw her next, I asked her why she did not meet me as I had asked her to do. She said she had been busy.”

“Huh? What did you do to her? In our days we would have got thrown out of the hospital if we dared try such a thing. Furthermore, we would never have passed M.D.”

“Nothing. I told her ignoring an order by the Head of the Department was inappropriate behavior. She went away. I would have shown her where she had gone wrong, and told her the right technique of avoiding such a complication. She missed out on that education. She passed M.D. and went away.I wonder who will remove the copper-Ts that she inserts after they migrate out of the uterus.”

Surgically Missed Pregnancy

When a woman is pregnant, and the doctor misses the diagnosis, it could be called a 'missed pregnancy'. That is possible when the pregnancy is very early, the woman has a rather stout tummy, and the woman is uncooperative during clinical examination. This can be avoided by performing a pregnancy test on her urine. What I am writing about is pregnancies that are missed surgically.
I recall that as junior residents we were so terrified of perforating a pregnant uterus during first trimester termination of pregnancy, that we tended to introduce the MTP cannula less than appropriate. Once I had suctioned only the cervical canal and thought the procedure was complete. A more experienced person showed me my error, and I did not repeat it again.
When I became a Lecturer, another Lecturer performed first trimester MTP on the daughter of one of class 4 employees, and the pregnancy continued. When the pregnancy reached second trimester and became palpable abdominally, this Lecturer declared it was an ovarian tumor and advised a laparotomy to remove it. Luckily her father changed the gynecologist, and brought her to us. We performed a second trimester MTP and she went home fine.
This story I heard from a colleague. There was a patient scheduled to undergo a second trimester pregnancy. She was given misoprostol and passed something in the toilet. The House Officer said that she had aborted. The Registrar confirmed the abortion. A day later she underwent an abdominal sterilization operation through a small incision. It was assisted by an Assistant Professor, under the supervision of a Professor. No one thought she was pregnant, despite such a large and soft uterus seen and felt directly. They could have even ballotted the baby and reported it as direct ballottement- a new technique, different from conventional external and internal ballottements.  The patient went home fine, but came back after two months with an ever enlarging tummy.
"She was 26 weeks pregnant" the colleague exclaimed. "Her husband is very angry. He wants the fetus out without spending any more money. He has talked to a civic corporator who is threatening t make trouble."
"But you cannot terminate the pregnancy at 26 weeks legally" I said. "You cannot induce labor too, because there is no indication, and if it fails, you will have to perform a cesarean section. Such measures are unjustifiable."
"What shall I do? Shall I tell the Dean?"
"That would be a good idea" I said.
The Dean was told.
"Get Head of Department from another civic hospital, and perform an MTP on that patient jointly" was the advice.
'God be praised' I thought because he had not asked me to get involved in this procedure that was against the MTP act, for violation of which one goes to jail. A week passed. The concerned consultant met me again.
"What happened to that failed MTP case?" I asked.
"The other head of department was reluctant to come. He advised me to go ahead and do it." Naturally so, I thought. WHo would want to go to jail because a Dean ordered it? But God is on my side" she continued. "The patient came back with premature rupture of membranesand cord prolapse. She aborted on her own. God saved me."
I wondered if God caused this outcome directly, or just gave a thought of discrete use of misoprostol.

Urinal Caution

The law requires that public places have toilets and urinals. So government offices, civic offices, colleges, hospitals and such have these things. The conventional design is shown as A. There is the ceramic bowl fitted in the wall. A guy has to stand in front of it and do his thing. The output is carried to a drainage channel near the floor through a pipe fitted at the bottom of the bowl. This pipe has a crucial role, which one can understand only when it is missing. About 30 to 70% of the urinals have these pipes missing. This percentage can be used as an index of the level of maintenance of these public places. If one uses such a urinal, the output falls to the floor under gravity, and its drops bounce back to spray one's trousers. The resultant embarrassment during the remaining part of the day is self evident. I caution people visiting the places mentioned above. If the pipe is missing, try another urinal, no matter how urgent the business might be, unless you plan to go home for a change of clothes.

Mouth Graffiti Artists in Hospital

Art comes in many forms, and is not the monopoly of those few who have been fortunate enough to have been able to go to art schools and get trained scientifically. There are those who can create art wherever they go, and on whatever surface they can find.

We have twenty thousand visitors a day, whose primary intention is to see their near and dear ones who are ailing and are receiving treatment in the hospital. Perhaps as a token of gratitude towards the hospital which treats their relatives/friends for free, they leave behind a piece of art on the hospital walls. They create art in red color. They have two hands, but they prefer to create art with their mouths, and can be called Mouth Graffiti artists. They come to the hospital well prepared with their art supplies. They chew a mixture of a special leaf, calcium hydroxide, tobacco, permissible food flavor, and some components that cannot be put down here because they are unknown to the English speaking world. Mastication without swallowing results in development of a mouthful of red liquid that is used by them as paint. Most of the average artists create art on the walls of the staircases, corners and walls of the corridors. Some advanced artists prefer a wall of an electric substation that stands opposite the first floor corridor of the main building t a distance of two meters. There they stand holding the railing for support, raise their heads at an angle with the horizontal, and spit on the wall. Some of the accomplished ones reach spots a meter higher than their mouths. The wall looks something like this.

There are 563 such patterns on the wall and the number is rising. The electricity supplying company does not paint the wall, because it hopes that one day all the blanks will be filled up by the artists and the wall will be entirely red. The hospital does not paint the wall, possibly because the artists need to express their art, and if that expression is suppressed, they will express it elsewhere, where it may not look very appropriate. Such ingenuity! Such finesse! I want to capture one of them on video doing it, and another pointing out proudly how high he reached. Unfortunately my duties keep me busy and I cannot get around to shooting ay video. If I can manage that some day, I will post the videos for you to see.

Self Punishment

“Sir, I have to tell you something” the sister-in-charge of the antenatal ward said apologetically when I was taking a round of the ward.

“What is it?” I asked. She was not one to complain needlessly.

“Look at this” she said. I looked. There was a trolley, on which there was a used syringe with needle attached to it and blood inside it. The cover of the syringe and a couple of blood-stained swabs were there too. A vial lay on its side. There was blood all over the floor and also on the mattress of the adjacent cot.

“Who has done this?” I asked. It was very much against safe practices.

“The unit which had outpatient clinic yesterday” she said. Luckily the doctors of that unit were also in the ward taking ward round. I called them and advised their Associate Professor to find out who it was and take some constructive disciplinary action against the person. I proceeded to see other patients in other wards. When I went back to that ward, the culprit had been found.

“Sir, this is the House Officer who made a mess during her blood collections” the Associate Professor said. “I have asked her to explain all the information on safe practices for infection control and biohazardous waste disposal to the other resident doctors in the unit. That will be her punishment.”

“OK” I said, and looked at the guilty one. She was an embarrassed looking girl, tired after emergency duty the previous day, and scared too. I looked at her apron. Usually they have blood on it. Hers was not very clean, but it would not be after 24 hours in the emergency ward. But there was no blood on it.

“Show me your hands” I said, and demonstrated how by holding my hands forward, palms down. She complied. There was little tremor in the fingers, but no blood on them.

“Turn them around” I said, and showed how by turning my palms up. She copied my movement. There was a 2 mm diameter solid-looking dark red spot on her right palm.

“What is that?” I asked, pointing at it. It looked like blood to me. She wiped it with fingers of her other hand, but it did not go away. Her colleague tried to help by wiping it away, but she would not let her do it. She scraped it away with her nail. It came off. It was a small blood clot, and it was someone else's blood, as her skin underneath was intact.

“It is a patient's blood” I said. “We do not have to punish her in any way. She does not wear gloves while collecting blood, and does not wash her contaminated hands. If we just let her be herself, she will punish herself in due course.”

I did not say 'by infecting herself', but I could see from her facial expressions that she had understood. It was a new but effective way of educating those who do not get educated by the conventional means.

Condolences

A professor working in our institute passe away untimely and unexpectedly at the age of 50. I had been in a meeting which even he had attended once. We had never interacted. But he had struck me as a balanced, quiet, reasonable, intelligent, and soft spoken person. A condolence meeting was held a couple of days later. I did not want to speak there. I did not want to know what others would speak there. I attended because somewhere inside me I hoped against hope that an 'Undo' would happen somehow and I should be there to witness it.
The auditorium was nearly full. His family came, though I could not understand how they could manage it in all their grief. I remembered how devastated I had been when my father passed away after a brief illness, and I had been much older than his two children.
A departmental colleague sang a prayer - "Vaishnav Jan To Tene Kahiye". Two of his students spoke, one of them actually addressing him. All three times I wiped my tears, because their grief moved me, and I could think of the grief of his family sitting there with us and hearing all this.
"There was no high risk factor, the institute's cardiologists claimed" someone said.
"He was so nice, we asked him to attend Sunday calls at the hospital when we were on call, because he stayed right opposite the hospital" a senior colleague said.
"He was so efficient - we never had to do anything about any job we asked him to do" another senior said.
"He was dependable. We always called him to organize exams" a third person said.
"He would do the tendering work so well. We had to do hardly any work with him there" a fourth person said.
"He had no enemies" a number of them said. "He fought with no one."

I knew what had gone wrong with him. He was a person who never said 'no' to anyone. He pleased everyone, and the world probably took disadvantage without giving it a second thought. He had no enemies, probably because he did not fight back even those who wished him ill, or treated him badly. After all, the world is full of people of all sorts, and he could not have met only the nice ones. He probably collected all that hurt inside him and built up stress until it took its toll one day.
"Has his wife not come" a late comer asked me. She was curious, I could see, but not grieved.
Some people spoke about how good they themselves were, referring to him in that reference alone. I could see that they could not give him his due even after his death.
"We lost two doctors in last 15 says" said someone, and mentioned a name.
"Who was the other person" asked the curious late comer. I had to clear my throat a couple of times before I could answer her - I was feeling all choked up.
Someone kept strutting about, showing no grief.
Someone commented on someone else wearing a full suit, as in a business meeting.Then a staff member walked in towards the end of the meeting, wearing less makeup than usual, and clothes 10-20% less glamorous than usual. I wonder if there was anyone who did not notice her.

"There but for the Grace of God go I" I was thinking looking at his projected photograph on the screen, while a professor was looking at his watch impatiently.
I told my wife all this that evening. Then I said "God will call me away one day. If they ask you to attend my condolence meeting, please do not attend it. You might tell them it was my wish that they did not hold a condolence meeting for me. After all, there will be some who will grieve, some who will think' good riddance' and some who will not care either way. If my soul will be hovering around nearby, it will be upset watching all that goes on."
"Oh, be quiet" she said. But I think she understood what I meant.

Medical Negligence and Diplomacy

It was first of its type situation. They had sent a patient for an emergency cesarean section to the emergency OT. The emergency team oprated and when they were about to close the abdomen, the scrub nurse declared -
"The string loop on one of the surgical mops is missing."
"I think it was not there when I took the mob" declared the House Officer who had operated on that patient.
"I think it was there" the nurse said.
So they searched the whole of the pelvis and abdomen, but could not find it. The Assistant Professor assisting the House Officer was sure it was not there. They called me for advice.
"I could come to the OT and check myself" I said. "But I cannot do better than the Assistant Professor. Get the general surgeon emergency duty to check between the bowel loops and mesentery."
"Sir, the surgeon told us on phone that it was lost by us and he had nothing to do with it and he would not come to have a look" my Registrar reported.
"OK. Write a call to him and request him to write that on the call. Then if the case goes to a court, he will be found negligent in performance of his duty."
They sent the call, and he wrote that on the call. But some time later, he turned up to the OT and checked the abdomen for the missing loop of string. He could not find it."
"Why did he come when he had refused initially" someone asked me.
"I think he did not want involvement because he would be dragged into a medicolegal case for no fault of his" I said. "That was unavoidable. But he would not be found negligent, because the negligence would be that of the operating surgeon. He must have spoken to his boss, who must have realized that a refusal to give surgical assistance in checking a field that belonged to the surgeons would make him guilty of negligence. He would never have come if we had not asked him to document his refusal, because in that case it would have been his word against ours. He could always claim he had never been called."
"It was a difficult situation."
"I was indeed. It takes diplomatic maneuvering to get such people to cooperate" I said.

May Lord Ganapati Bless All

I drew this sketch of Lord Ganapati without lifting the pen even once, using a javascript paint program. The pen could not be lifted, because if it was, the drawing would start from the beginning again.

28th September 2018

Eco friendly decoration for Lord Ganapati.

Almost Killer Girls

I wonder if anything is turning the young girls violent. It is a trend to blame violent computer games for violent attitudes of young boys these days. But I know for a fact that the girls do not play these games. It must be something else.

I was conducting prelims for the undergraduate exam going students. The I asked the same questions to all candidates I examined, and the answers left much to be desired. One girl was particularly less well prepared than others.

“Are you related to xxx or yyy?” I asked. These two persons with the same surname as hers were known to me and I could talk to them about getting her to study more, if they were related.

“No” she said briefly.

“From where have you come?” I asked her.

“U.P.” she said.

“So you must have studied well and scored well in the All India Entrance Test and come to this premier institute.”

“Yes” she said.

“If you could study well then, why are not studying now?” I asked in a mild voice.

“.......” she probably had no answer or did not think the question worthy of an answer.

“What will you do after M.B.B.S.?” I asked, knowing well that everyone passed that exam some time or other, usually at the first attempt.

“Postgraduation” she said in a tone that suggested that it was a ridiculous question.

“In which subject?” I asked.

“Pediatrics” she said. She seemed pretty confident she would get it, no matter how poor her preparation was.

“Good.” I said. “Do not choose obstetrics and gynecology. You will do better in other subjects.”

She got up and went away, shooting me a glance that was much more than dark, venomous or whatever adjective that you can think of. If she had laser power in her eyes, she would have drilled a hole right in the middle of my forehead, going through and through to exit through the occipital bone.

The next day I was conducting an interview for selection of Assistant Professors. I asked one candidate about obstetric forceps after she had answered other questions. I have written about her before. She was a good candidate, one of the other experts had vouched after the interview.

“What is correct axis of application of obstetric forceps?” I asked.

She started with a long description. I stopped her. “Just tell me the axis of application” I said.

“It is applied over the parietal bones” she said, in a tone that suggested my question had really no answer, that this was the nearest she could offer as an answer.

“That is almost the entire vault of the skull” I said. “That cannot be the axis. All right. You can go.”

She got up and shot me a glance before going away. The glance was an exact replica of the one I had received the day before.

I have spent 32 years as a teacher. I have always praised good students. I have criticized bad ones in a positive way, so that they would try and improve. None of them have looked at me with looks that could kill, if looks were guns. Now two girls had done that on two consecutive days. I have been wondering what makes them so these days. To be unable to take justified criticism and not wanting to improve is not the hallmark of a physician at any stage of his or her life, definitely not at the beginning. I wonder if it is praise and praise alone at all times, justified or not, that makes them so? I wonder if the time has come for me to stop offering any correction or criticism, though I know I have to do it as a teacher.