Laryngoscope Blade Sterilization

Infections is one thing every doctor dreads, more so if he is a surgeon. The dread is as much for surgical infections as for other infections. I have spent a long time, almost all my professional lfe trying to reduce infections, if not eliminate them totally. It has involved scrupulously following and teaching others to follow the correct aseptic and antiseptic techniques, and also finding out and eliminating dangerous practices which are there by tradition.
One of such practices is sterilization of a blade of a laryngoscope after use for administration of anesthesia or resuscitation. I spoke to a number of anesthetists about it over years. But the practices persisted. The following chart shows the practices in different OTs.

I talked to people in different institutes. I found the practice of scrubbing and washing with water even in some corporate starred hospitals. One semi government hospital did use gluteraldehyde.
“Why do you not use gluteraldehyde?” I asked anesthesiologists.
“It is not necessary” one from a corporate hospital told me.
“We have always done it this way” another one said.
“The bulb would get damaged” another one said.
“Actually that thought never occurred to us” one said apologetically.
“There are too many patients. There are not enough laryngoscopes to go around, if we use gluteraldehyde” another one said.
In one study, out of all blades or handles without any visible blood on them after use, 20% tested positive for blood on chemical analysis. Thus the risk of transmission of nosocomial and blood borne infections from patient to patient is real when the laryngoscope is not sterilized after use. The CDC guidelines are quite clear on sterilization of laryngoscopes. Unfortunately they are just there, not necessarily read or followed. I managed to implement the technique of cleaning with povidone-iodine scrub, washing with water and disinfecting with gluteraldehyde in our operation theaters. But what about the rest of the world? If I have to undergo surgery, I will have to ask how they sterilize their laryngoscopes, amongst other things, even if it is a starred hospital, because it is manned by the same people who have passed out from places where tradition prevails.

Blissful Ignorance

“Doctor, my wife is in your ward. Please discharge her from the hospital today” a man approached me while we were moving from one ward to another during rounds of all the wards. He looked poor. There was a child in his arms, its back towards me, its chin on his shoulder.
“What is the reason for you to take her away from here?” I asked him after I found out who his wife was and what she suffered from.
“I have a problem at home. There is no one to look after our child when I go to work.”
“We can discharge her at your request” I told him and we moved on with the round.
“That child had mongolism” our Associate Professor told me.
“I wonder if he has shown the child to any doctor” I said. “What about the baby she is carrying now? Has it been tested for mongolism?”
“No. I noticed the child just now. No tests have been done on her as yet.”
“Anyway her pregnancy is beyond 20 weeks, and a medical termination cannot be done” I said.
The man followed us to another ward, accompanied by another man who also wanted his wife discharged from that ward. This time I had a good look at the child in his arms. It did look like it had mongolism.
“Have you shown this child to any doctor?” I asked him.
“No.”
“The pediatric outpatient clinic is in the afternoon every day except Sunday” I said. “Take the child there.”
“Why?”
“We think it has a condition that requires treatment” I told him.
“The child eats, drinks, sleeps. Nothing is wrong with it” he said.
“The child may eat and drink all its life, but may not develop normally mentally. There could be other things wrong with it too. Meet a pediatrician. Nothing will be lost by doing that” I said.
He said nothing. ‘Just discharge my wife, don’t bother about this child’ his eyes seemed to say. I could not convince him more, because he did not want to be convinced. I hope he sees a pediatrician, and pray that the child the couple is expecting turns out to be normal. There seems to be nothing more that can be done.

Hat Code

"Sir, what do we do when the tubelights fall on our head?"
"You can go to the emergency room for treatment. You will get free treatment, if you have your family card" I said.
"But can that not be prevented?"
"The contractor and the architect do not seem willing to do anything about it" I said, "and the engineers of the civic body do not answer any letters we send them. So there is nothing that can be done to ensure that tubelights do not fall on your heads. You could always stand or sit away from the spots directly under the tubelights to protect yourselves."
"Even the tiles fall off the walls. What do we do about them?"
"Keep safe distance" said another Professor, "like they print on the rear bumper of state transport buses and trucks."
"Huh?"
"That means do not stand near the walls."
"That is no solution."
"It seems the contactor is fitting steel plates over the tiles so that they do not come off."
"You can thank your stars the contractor fitted vitrified tiles instead of marble, as we had been promised before. Imagine what would have happened if a marble slab had fallen on your head instead of a 2x2 vitrified tile."
"Yes, we are indeed lucky. The architect must have been a blessing in disguise."
"You could always wear protective headgear" said an Associate Professor "like this one." He showed us a photograph, which I show here with thanks to that Associate Professor.

Preinduction Acute Abdomen

It was a curious case, probably the first in the world literature.
She was a young woman, scheduled to undergo a transobturator tape insertion for urinary stress incontinence. Rports of her investigations for fitness for anesthesia were all normal . She had no other illness except for the urinary stress incontinence. She went through the preoperative preparation uneventfully. On the OT table, they inserted the intravenous line and attached the chest leads for heart monitor and the probe for pulse oximetry. The surgeons got ready awaiting induction of anesthesia. But there was some disturbance around the patient and a definite delay in induction of anesthesia. Time being a precious thing in our OT management, I had to find out the nature of the problem that was holding things up.
"Is there a problem?" I asked the anesthesiologists.
"She has acute upper abdominal pain" the anesthesiologist said. "We have given her ranitidine and an antispasmodic. If the pain is relieved, we will give her anesthesia.
"Where does it hurt you" I asked the patient.
"Here" she pointed towards her epigastrium.
"When did the pain start?" I asked her.
"I get it sometimes. Today it started in the midmorning."
There were no local findings on examination. The pain did not go away. So we postponed her operation and sent her back to the ward.
She is well fed patient, I thought, looking at her body weight.
"She will go back to the ward and eat to her heart’s content" said our Associate Professor who had been watching the event with some amusement. That was almost an echo of what I had thought. The pain was just hunger pangs, the patient being kept starving overnight for surgery. The patient’s pain was relieved after eating. No cause has been found for her abdominal pain after evaluation by appropriate specialists.
"Shall we post her for surgery?"
"We can do that. But what do we do if she cannot stand the hunger pangs again?" I said. "If we book the OT time for her and have to postpone the operation again, another patient who could have been operated on in that time would be denied treatment."
"So what can we do?"
"We could give her a stomach wash with lignocaine solution on the morning of the operation. It has not been done before. But you have to think out of the box to find a solution to a unique problem."
They stared at me, wondering if I was serious or just sarcastic.

Naming Trees

I was standing at the window of the OT, looking out at the trees outside, the lawn beyond, and the open space of the tennis and basketball courts. Suddenly the happiness was broken by an incongruous sight. The stem of the tree near the window had been painted white in an area of 1 square foot. There was the name of one professor of surgery painted crudely in black on that white square. The initials were in the first line, and the surname in the second line. The work was crude. The reason for putting a professor’s name was not clear. I called my Assistant Professor who was waiting for the next patient to be given anesthesia.
“Look at that” I said. “What do you think about it?”
“It is the name of a professor of surgery” he said.
“Could it be the gardener’s name” I said.
“Perhaps. But a gardener would not be knowing English and painting.”
“Perhaps the gardener’s wife or son or he himself were saved from death by the surgeon, and he has named the tree after the surgeon.”
“It is possible” he said.
“But why do it near our department? He should do it near the surgeon’s department.”
“Yes.”
“Will this not make Boss angry?” I said. “I don’t see any tree named after the Boss?”
“The adjacent tree has a white square on its stem too. Perhaps it is for the Boss?”
“The Boss should come first, in the hierarchy.”
“Sir, they should name one tree after you. You are the head of this department” the nurse said.
“I get salary for being head of this department” I said. “I have not done anything wonderful that should be rewarded with a tree being named after me.”
“Does anyone have power to name trees after someone, when the trees belong to the civic body” another person asked.
“I think this is more like what children do on school benches or backs of seats of public transport buses, or tourists do at tourist spots” I said.
I checked the tree the next week and the following week too. The name was scratched off by peeling the bark off the tree after two weeks.
“The Boss must have seen that” said my Assistant Professor. “Poor professor of surgery. He lost his name from the tree and probably got on the wrong side of the Boss too.”
“Poor tree” I said.

Protective Signatures

Some things are instinctive. Protection of self tops the list of these instinctive things for most people. Resident doctors are quite justified in trying to protect themselves. We teach them to do everything properly, document everything they do, talk to patients and relatives of the patients to explain the treatment plan and progress, and even take medical indemnity insurance. I would be happy if they did all this. But they want to do more. Something quite ingenious.
I came to know about this safety measure when I was looking at the call books used for calling them to see patients. None of the calls had legible signatures. I will show some samples of the signatures I found there.

All the signatures had something in common. There was no English alphabet in any of them. There were curves, tails, and lines. But NO ALPHABETS. None of them was able to tell me which signature belonged to whom. Since I had been trying to find out who had noted a particular call but had not attended it, knowing the identity of the person was important. I could not ask the servant who had taken the call, because it had been taken by the patient’s relative, as is the routine these days. All doctors look alike to the patients’ relatives. When no one would own up having signed the call, I realized they signed in this manner so that they would not be caught and be taken to task for not attending the call. Being scientific in my approach, I visited other wards of other specialties, and looked at their call books. Their resident doctors were just like ours. Same sort of signatures were found there too.
When I mentioned this to a colleague, he said, "the resident doctors should be made to write their names below their signatures. Then they can sign whatever way they want."
"It is a good idea. I can enforce it in our department, but then our resident doctors will resent it when resident doctors in other departments don’t have to do it too, and continue to be protected."
"How do they get this idea? Seniors teach juniors?" he asked.
"Perhaps" I said. "Or it is an instinct. Like a newborn suckles without being taught."
"Don’t they realize it is inappropriate and won’t help them in their future ?" he said.
"But it does sometimes" I said, suddenly thinking of one of our professors who left our institute for a greener pasture. "You remember Professor xxxxx, who had been called by our erstwhile Dean in the middle of the night to negotiate with resident doctors who were threatening to go on strike? When they declined to listen to the Dean and other negotiators, they were issued memos. Our Professor was asked to sign memos given to resident doctors of our department. The signatures on the memos were like these resident doctors’ signatures, distinctly different from the usual signature of that Professor. This Professor had been a resident doctor in our institute 29 years ago." My colleague was surprised at that.
The other day, one of our Registrars came to me to get my signature on the dissertation to be sent to the Health University for his postgraduate examination. I looked at his signature, and asked him, "this signature has only one alphabet at its end. The rest of the signature has no alphabets. How come?"
"That alphabet is the last letter of my surname, Sir" he said.
"And the rest of it?" I asked.
"It is just like that" he said. I wondered how he planned to protect himself from the university by making a signature like that, should the dissertation turn out to be not to the liking of the examiners.

Ray of Hope

I have seen students for more than thrity years. I have been upset over the changes that have occurred in their attitude towards medical education over the last few years. So much so, that I have stopped feeling good when I teach them, and even more so when I examine them. I avoid being University Examiner, because I hate to think of being in a position which would decide their fate. I don’t want to feel responsible for passing some, who in my opinion would be a menace to the society, but whom many other examiners would pass without a second thought. Unfortunately I have to examine them in their internal assessments, because it is a part of my job. They are even less prepared for these examinations than for their university examinations. So the process becomes quite traumatic to me. I understand it is traumatic to them too, when they do not get good marks from me, and get a warning instead to study more or their future may not be bright.
I was conducting one such examination. The candidates were reinforcing my experiences of past examinations, and I was looking forward to the end of the examination. Then came along a student, who was different. She was at ease when she answered questions. She answered all my questions correctly and without any tension. It sounded as if we were having a simple conversation instead of an examination. She answered questions that my postgraduate students do not answer, and that too with the ease that comes from clinical experience rather than reading undergraduate books.
“If you answer the next question correctly, I will give you 9 marks out of 10” I said. “I will have to cut one mark because you did not look at your watch when you checked fetal heart rate.” She took that challenge without any apprehension.
“If you have a patient at term in labor with umbilical cord prolapse, what will you do?” I asked.
She answered it logically, considering a live baby and a dead baby. I was quite happy. I had not heard that answer from many candidates while conducting interviews for appointment of Assistant Professors.
“If the baby is dead, I will start an Oxytocin infusion and deliver the woman” she said.
I could have said ‘gotcha’ or something similar gleefully, but that thought never entered my head. Here was a good candidate, and I just wanted to make her a little better.
“The fetus was in transverse lie. Your oxytocin infusion caused uterine rupture. You just killed a patient” I said. She looked grave. “No! We managed to suture the uterine rupture, and she lived” I reassured her. “But then she sued you for giving an Oxytocin infusion when the baby was in a transverse lie. Such a baby cannot deliver vaginally, which she said you ought to have known. Now she wants a hefty compensation.”
She looked less grave but apologetic for having blundered. It was all make believe, not a real patient, which we both knew. But she understood exactly what I meant. Suddenly I had a thought.
“Will you please show me your college identity card?” I asked.
She fetched her identity card and showed it to me. I checked. She was indeed a third year undergraduate student, not a senior pulling a fast one on me.
“You are indeed a third year student, not a Resident Doctor appearing for you” I said. “Your answers were accurate. You are good. I cannot say you will have a successful career, because it depends on a lot of other things too. But you will make a very good obstetrician.” She thanked me and went away happy. She probably did not know that I was even happier. I had lost hope that there would ever be any students who were good and interested in that subject. Now I knew I was wrong. I had found one and perhaps there would be more.

To Rod or Not to Rod?

The Oxford English Dictionary keeps adding new word to itself every year. People speaking different languages feel proud when words from their languages are added to the English language. I do not feel proud about it, because there is no reason to do so. But I feel good that people who keep using their own language words in English will be able to feel assured that the listeners will understand what they are saying, if necessary with the help of a dictionary.
But the Oxford dictionary has not, to the best of my knowledge, made an English noun a verb too. Perhaps the continued efforts of English and non-English people will force the change one day. Here is one such example.
We had complaints about the civil work done by the contractor in our institute. One of the complaints was leakage of water through the drain of the OT sink. The water was just pouring out of the building. The consultant who had orchestrated the work wrote back, putting the blame on OT servants.
"The leakage is due to rodding of the outlet" he wrote. I was sure that there was no 'rodding' in English. Even now, my spell check software has underlined this word. But moving papers to and fro is not the fastest method of getting work done. So I called the contractor's workman and asked him what the cause of the leakage was.
"It is due to putting a rod into the outlet to remove a choke up, and pushing it repeatedly to remove the obstruction" he said. "That dislocates the joint in the PVC pipes. They are not secure like the metal pipes."
So that was what 'rodding' was about. I admire the architect who coined this word, not just for speaking, but to put down in official communications. We advised the OT servants not to do so, assured the architect that they would not do so, and got the dislocated joint repaired.
I am thinking of putting a poster near the sink, stating "When to rod or not to rod is the questions, don't". But perhaps I better wait for the Oxford dictionary to make 'rod' a verb.

Ear Plugs: Doctor’s Take

Noise pollution is extreme in the city. There are all those festivals, and they are adding to those every year. Gods rarely remembered are now remembered once a year, for their own festivals. The celebrations are the same irrespective of which God it is. There are loud songs played with huge speakers and amplifiers. There are religious mantras chanted on those speakers. Functions like marriages are celebrated the same way publicly. There are processions on all these occasions, with the music mounted on huge trucks, so that it is mobile public music.Then there are those crackers, whose loudness is far beyond the permitted legal limits, and which are burst far beyond the time limit. One wishes for effective ear plugs, so that all this deafening noise can be shut off.
I tried the ear plugs they give out in airlines. They did not work for me.
I tried the sound mufflers they use in shooting ranges. They were effective, but they pressed on the ears so much, that one could not wear them for any length of time. I tried putting shaving foam on the external ear. It cut off sound quite a lot, but it was messy. One could not keep it there for prolonged periods anyway, and go about one’s work. Putting alternative music into the ear with iPod would work, but would be as damaging in the long run. Finally I devised ear plugs of my own design.

I took two ear pieces of a stethoscope. These are available in medical instruments shops, and doctors usually have spare pieces from their past purchases of stethoscopes. I filled their holes with candle wax. Then I got ear muffs that people put on their ears to keep out cold from the ears in windy cold seasons. It has a spring in the middles portion and two broad soft pads attached to its ends. One has to put the ear pieces in the ear canal. They would fall off unless supported. The ear muffs are worn over them to keep them in place. This works wonderfully. My readers are free to use them. I request them not to apply for a patent for the design in US. :-)

Smart Registrars

The Bosses think they are smart because they have managed to become Bosses. Some of the residents think they are smarter than their Bosses, and sometimes they are. The smarter of that lot know it is safer not to let the Boss know that they are smarter. I read about one of the Resident who had been asked to go stand in a corner until he was sorry that he had dared question his Boss’ management plan for one patient. That reminded me of two of my past Registrars. Their work left much to be desired. On one particular day, they jointly and independently goofed up so much that I decided they were dangerous to the patients undergoing operations that day, even if seniors were present in the OT. After all, we could not supervise them at all times.
“Please leave the OT” I told them. “Sit in the ward just outside the OT. If we need you, we will call you. I think we can manage without you.”
We were in transit area that time, owing to repair work of the hospital building. The antenatal ward was in the corridor outside the OT. It was the place which was crossed by practically everyone who went to all the other wards. The idea was that they would be seen by everyone, who would wonder what both of the Registrars were doing there, when their patients were being operated on. That would perhaps humiliate them and encourage them to function better. They would not move even an inch. After telling them in reasonable voice and tone three times, I finally told them sternly to leave. So they turned and went towards the exit. I went into the OT. After one operation got over, I needed to talk to the OT nurse. When I entered her office, I found both of these Registrars hiding there.
“You are here?” I was stunned. “My instructions were for you to go out and sit in the antenatal ward, in full view of all people.”
They avoided meeting my gaze and kept quiet. “You have disregarded my instructions totally” I said. They knew that already. Finally I turned and went away. It was beyond me to improve them. They left after they completed their residency, not much different than they had been before. Though they did not pass their exams then, they will do so one day. What I am afraid of is they may not reach the standard required to treat patients well. Smartness of this type is not what a Boss wants in his students.
Another of my Registrars in the past had been so deficient in work, that I did not know what to do to improve her. One day, she committed three major errors that a House Officer would not have committed, except perhaps she herself when she had been one.
“What disciplinary action should we take against you for harming these many people” I asked her.
She kept quiet for a long time, and after repeatedly being asked the same question, she said “whatever you think fit.”
“Think again” I said.
“I will take whatever punishment you give” she said.
“OK. We demote you to a House Officer’s job, until you improve. The other two Registrars will manage in the meantime” I said.
She was smart. She went on leave immediately without taking my permission. That reminded me of politicians who fall sick and get admitted to hospitals whenever they are sent to jail. She passed her exam and went away. I hope she is not harming patients wherever she is.

Checklist Manifesto Management

I came across a good book by Atul Gawande, titled 'Checklist Manifesto'. It was recommended to me by a colleague. I liked the concept. It goes something like this.
A disciplined adherence to essential procedures — by ticking them off a list — can prevent corner cutting and potentially fatal mistakes. He has used checklists in aviation, construction, and investing and advises their application in medicine. He has illustrated how their use cut down infections in central lines in intensive care units.
The colleague who lent me the book said "we should adopt such checklists in our practice, to reduce our complications."
"It is a very good idea. But I see a major problem with its implementation in our setup. It is likely that our people will treat this checklist as just another bit of paperwork that is stupid, but mandatory. They will tick all items in the checklist and attach it to the case records. They might even delegate the job of putting tick marks on the checklist to the most junior Resident Doctor or Intern, without actually doing all the things that are listed in the checklist."
"..."
The colleague was probably not convinced my my statement.
"Don't you remember the vital parameter charts of patients and fetal heart rate charts in labor, already filled up in advance up to the time some nurses went off duty, and the patient was found dead or the fetus was delivered before that time? Don't you remember patients' findings entered on the indoor treatment sheets by some Resident Doctors round the clock without actually seeing the patients at times?"
"Yes" the colleague said.
"Checklists on paper have little meaning. The checklists have to be in one's head, and the drive to implement them must be from one's heart. Then they will work" I said.

God Saved

See what Photoshop can do!

Scream-Grunt-Sigh Technique

I was busy repairing the display system of the endoscopy camera in the room adjacent to the emergency OT along with another colleague who looks after that work, when in walked a professor who was working in that OT that day.
"Hello" I said and went back to my work. That Professor was on a mobile phone, but must have seen me and heard the hello. Our work continued. Since it was quite absorbing, we did not pay much attention to the said Professor. After a few minutes, we heard:
"Kee-eeyagh-krum-arrrgh."
We were startled. We turned towards the source of the weird noise and found that our Professor had made tha noise. The mobile phone conversation was apparently over, and the Professor was standing, looking at us. Since there was no sign of any ill health, I said "you made that noise? What happened to you?"
"I also got worried" said the colleague working with me.
The said Professor did not answer, and continued to look healthy. So we went back to our work. The Professor went away, probably back to the OT.
When I related this story to my wife over tea that evening, she said "is this the first time such thing happened to that Professor?" My wife is a family physician and has extensive clinical experience. Her question was clinical rather than conversational.
I thought over and said, "No. The same noise was made by that professor about six months ago."
"Are you sure it is not the ring tone of that Professor's cell phone?" she asked.
That was a new thought. But it wasn't a ringtone. "It was not a ringtone. It was made only twice in last one year, while that Professor's phone rings in normal tones regularly. Besides, everyone around the Professor would have gone crazy if that were a ringtone."
Does this Professor make any other inappropriate noises?" she asked.
I thought about that one. "Yes. If we are sitting in the staff room or office and this Professor arrives, and is not greeted by anyone, that Professor coughs tow or three times."
"Dry cough or productive cough?" she asked.
"Dry cough" I said.
"This is attention seeking behavior" she said.
"Thanks for confirming my diagnosis" I said.

Vasectomy and Bite

There is something in vasectomy that is known to most people other than me. Consider the activists for animal rights. They are against killing stray dogs, even if they (the stray dogs) are a menace to people at times. I have been horrified to read in newspapers about children being bitten to death by packs of stray dogs. The civic body spends a chunk of money on administration of anti-rabies vaccine to victims of dog bites. But there is legal protection to the dogs. They cannot be killed. I wish there were activists demanding enforcement of such legal protection to fellow human beings. I don't want the dogs killed, because I am not in favor of killing anyone. But the measure recommended by the activists and court, and accepted by the civic body is to sterilize the dogs. It is beyond me to understand how it helps.
"The idea must be to sterilize them all, so that they will not procreate and one day become extinct" said a friend.
"But that is not right" said another friend. "It is against nature to make any species extinct. Privately owned dogs are so few, that it will be an endangered species in no time, and will be extinct sooner or later."
"No. That is not it" said another person. "The dogs who have been sterilized lose their bite. That is the mechanism of protection of humans from them."
"Huh...?" said the first friend.
I looked at the theorizer, and suddenly realized that was the truth. Vasectomy makes one lose his bite. everyone knows about it.
"Now I can see it" I said. "That is an accurate theory. That is why men shy away from a vasectomy. When you mention it as a method of permanent contraception, not only the man, but also his wife and mother suddenly clam up. Who would want the man in the family to lose his bite?"
:-)

Surgical Glove to Repair a Toilet Flush

When we renovated our house, we installed a pneumatic flush tank for the toilet. We felt it looked rather posh, what with a button to be pressed in place of a cord to be pulled to flush the toilet pot. It was a different type of exercise too, in place of the older exercise of pulling the cord.
“It is twice as costly as the older type” the contractor told us. “But the representative of the manufacturer will come and repair it if required.”
That sounded impressive too. Perhaps it should have sounded as a warning bell. But the hear only what the mind tells them to hear, at least when one is filled with visions of grandeur. The fellow messed up the installation somewhat, looked tense for some time, worked again in the loft where the flush tank was located, and then victoriously told us it was done. It was indeed done, and worked fine for a year or so. Then the malfunction started. The water would trickle rather than flow with force. The usual plumbers could not fix it. A couple of them advised us to call the company fellow, since it was beyond their abilities to repair it. We tried to contact our contractor to get the address of the company, but he did not turn up despite a promise to do so us so many times, and would not give any telephone number of the company, that we gave up on him. The only person I could think of who could repair the thing was me. So one Sunday morning entered the loft, removed the lid of the flush tank and examined the interior of the tank. Thanks to memories of physics learnt in secondary school and practical trial on the mechanism of the tank, I found the following.

There was an outer cylinder, in which an inner cylinder resting on the outlet. It was connected by a connector to a piston that would rise within a cup pushed by a rubber diaphragm on pushing the button in the toilet. A plastic tube conveyed the pressure to the diaphragm from the button. The piston pulled up the inner cylinder along with it, which would drain the flush. The diaphragm was on the mouth of a cup connected to the tube, and was held in place by a ring-like lid with spiral ridge on the inner side and a central perforation. This lid was broken at one place by our original contractor which had caused a panic attack in him at the time of installation, and a leak of pressure now, permitting the diaphragm to move away from the edge of the cup. If I could get a replacement for the lid, the problem would be solved. But I could not, because no one was telling me where the company was located. So I used my surgical knowledge instead. I cut off a piece of a surgical glove, placed it over the diaphragm where the lid was broken and somewhat beyond that area, and refitted the lid. Now the air pressure inside the cup stopped leaking and the flush mechanism started working again. Now I have time to find the required spare part and fit it too.
It goes to prove training in school physics and use of surgical gloves can be combined, with a little imagination, to repair a flush tank that a plumber says he cannot repair.

Desire for Sterilization? Change Route of Hysterectomy!

“Sir, I am quite worried because of our second year Resident Doctor working in the gynecological ward” our Assistant Professor told me.
“What happened?” I asked.
“We have one elderly woman in the ward awaiting vaginal hysterectomy and repair of genital prolapse. The second year resident working in that ward asked me today morning during ward round whether we should change the route of her hysterectomy from vaginal to abdominal.:
“Abdominal hysterectomy in a case of genital prolapse? It does not make sense. If the uterus has come down, it has to be removed vaginally. The repair of the prolapse is to be done vaginally anyway. What is the point in operating abdominally?” I asked.
“It seems the patient told the Resident Doctor that she wanted to undergo a sterilization operation too, since she did not want to have any more babies. The Resident Doctor thought the sterilization operation would be done by the abdominal route, so it might be better to perform hysterectomy abdominally too.”
I was awestruck. After a couple of minutes I recovered sufficiently to say “ does the Resident Doctor not realize that a woman would become sterile if she underwent a hysterectomy, that an additional sterilization operation would not be required?”
“That is the point. This Resident Doctor will be our Registrar after a couple of months. That thought has got me worried, thinking of the trouble that may cause to our patients and us.”
“That has got me worried too. “I will find some solution to the problem.” I said, knowing full well that it was easier said than done.

Wasted Sarcasm?

The PCPNDT act requires that a notice be displayed prominently in the room where ultrasonography is done. The notice should be to the effect that prenatal sex determination is not done there and fetal sex is not disclosed to anybody. We have an ultrasonography machine in the labor ward. There was no such notice there after the renovation of the ward. I requested the ultrasonography department chief of our institute and got a notice for that room. I sent it to the labor ward sister and asked her to put it in the ultrasonography room. She held the key to that door and she alone could do it. I could not do it because I don’t perform ultrasonography and cannot enter the room by law, except for sight-seeing maybe.
I noticed later on that the notice was put up in the corridor outside the room rather than in the room. That was quite dangerous, since the law was quite precise and clear about where it should be, and it was not where it had to be. What with the civic authority sealing ultrasonography machines with even the most minute violation of the act like failing to fill some column in patient record form, we were at risk of penal action. I sent message to the ward sister to shift the notice to inside the ultrasonography room. Two days later it was where it was. So I met the ward nurse and personally told her to shift the notice. She assured me that she would do it. Another three days passed and I found the notice still in the same old place. It was a bit high up on the wall, and I could not reach it. Luckily my Assistant Professor could, being much taller than me. I requested him and got it down. Then we reached the labor ward and found the ward nurse, who was busy talking to another nurse. I handed the notice to her like it was a very valuable parchment and she took it equally ceremoniously and looked at me questioningly.
“The notice was hung on the wall quite high up, so your servant probably could not reach it to take it down. I got our tall Assistant Professor to take it down for me. Now will you please put it in the ultrasonography room?”
She thought quickly over what I had said and laughed loudly as if what I had just said was a good joke. Probably she thought that bit about the not so tall servant not being able to reach the notice was a joke. “OK” she said.
“That was lost on her” our Associate Professor said.
“I know” I said. I had done it partly to get it done, and partly to satisfy my need for justified sarcasm, not to improve the ward nurse in any way.

Placebo

Pelvic infection is a not infrequent condition encountered in the patients attending the outpatient clinic. Our standard management protocol is to treat it with doxycycline and metronidazole. Microbiologic study on the patient’s cervical discharge is helpful in deciding the choice of antibiotic in some cases. But often the results are so weird and inappropriate, that we do not perform the test as a routine.
Some patients have a partial response after a week, and they are advised to complete the course of another week. Some have no response. A curious phenomenon seen in some patients. They claim that they are free of pelvic pain while they are on antibiotic therapy. But there is a recurrence of the pain if they miss a dose or two. It is my opinion that these patients have a placebo action of the antibiotic. They feel that the medication has a symptomatic action as well, and hence the relief from pain with medication and a recurrence of pain when they miss out a dose due to any reason. These patients invariably have a recurrence of symptoms on completing antibiotic therapy, and require a laparoscopy for evaluation of chronic pelvic pain. They do not have any disease in the pelvis, and are diagnosed to have somatoform pain. They do well with treatment by a psychiatrist.
This should serve as a useful test for predicting early which patients will prove to have somatoform pain mimicking pelvic infection.

Kolaveri Style Case Presentation

Some people speak well, some don’t. Some pause when they don’t know what to say. Some use filler words to fill the gaps. Some use ‘um…’ or ‘ah…’ or ‘ar…’ when they are thinking of what to say next. All this is not very impressive. But if you have no option, you have to live with it.
We were taking a round of all our wards. We were in the antenatal ward.
“Sir, this is 27 year old um… third gravida um… second um… para um… who presented with um… high blood pressure um…” my Registrar was presenting a case. Saying ‘um… was an old habit of his. But he seemed to be overdoing it today.
“It is three days since the new year started. Still, can you make a new year resolution not to say um… while you speak?” I asked him. He seemed unwilling to male a resolution that late, or unwilling to give up such a comfortable habit. Or perhaps he did not want to commit for a period as long as one year.
“Perhaps you can do it one day at a time. So it for one day. If it works, do it for another day. Finally you will manage it for one year” I encouraged. He did not seem to like that idea too. Then I suddenly had an idea. Perhaps he did not want to give it up because that was his style of speech. I had heard such a thing before, to which there had been millions of hits on You Tube.
“Is it like that Dhanush fellow in the Kolaveri Di song?” I asked. “Sir um…, this patient um… has come um… with high um… blood pressure um…” I think I managed to say like Dhanush did in his song, without that exotic music of course. Not only all of the doctors laughed spontaneously, but the patient also turned her face away from us and laughed. I think that was it.
“Dhanush is from Tamilnadu, while you are from Karnataka” I said. But they are reasonably close that your accent can be explained on the basis of geography.” I must have been right. He continued to um… us during the remaining round.

Head Count

The Health University is quite strict about attendance of medical students in their lectures. There are some departments who mark the students present irrespective of whether they are present or not. We do not, because we are conscientious, and also because it would be unfair to those who make all the efforts to be present.
I had a lecture this afternoon. The audience seemed august enough. But I could not afford to spend time on taking attendance, because the topic was such that I could not finish teaching it in one hour. So I circulated the attendance sheet and proceeded with teaching them. At the end of the class I got the attendance sheet back. Now there are sometimes some students who mark attendance of their friends who are elsewhere. To discourage that tendency, I requested two students one boy and one girl, seated at two ends of the first row to perform a head count i.e. count the number of people present. The idea was to see if their numbers coincided with each other and with the number of signatures on the attendance sheet. The girl got a count of 76, while the boy got a count of 136. I was surprised.
"Did you count only the girls?" I asked the girl.
"No, Sir. I counted only half the students" she said.
"Where was your dividing line?" I asked.
"There" she said, pointing to the middle of the room somewhere. This seemed highly inaccurate, to say the least. So I requested this girl's neighbor to perform the count. She got a count of 124.
"Either the fellow is helpful to those who are absent but are marked present, or the girl has made a mistake. I will count myself" I said and counted them myself.
"I will update you on the results" I said. "We have three counts. The other two counts are known to you. My count came as 140."
The whole class laughed. "I think the girl made a mistake. I myself also must have made a mistake too. Whenever I withdraw money from the bank and there are a lot of bank notes, I get a different count every time I count the bundle. It must be the same with a head count for me. The fellow is right. Thanks to all three of you who helped me with the count. But the girl ..." I wiggled my finger in her direction a few times, but could not say anything. the whole class laughed again. I think my pantomime must have stimulated the class more than my teaching.

Voluntary Dyslexia

When I entered the medical college I had no idea what dyslexia was. I learned about it in the course of my studies later. When I entered residency program five and a half years later, I did not have any reason to suspect that I would have to adopt some features of dyslexia voluntarily to survive during residency. By the time I finished the postgraduate course, I had become an expert at it.
Basically it is the right left confusion of dyslexia that one has to voluntarily adopt. Gloves which are supplied for examination of patients are not repacked, sterile ones, but unsterile ones packed and autoclaved in the hospital. When one is examining patients using gloves packed by a nurse who either does not want to check the right and the left side or suffers from dyslexia herself, one may end up with left sided glove when it is meant to be right sided. One may discard it, though it is a waste. Furthermore, the next glove to come out of the drum is also likely to be for the left hand, since the same nurse has packed all gloves in the drum. So one has to either invert the glove before donning it, or put the left hand glove on the right hand. Inverting it is not only boring when one has a lot of patients to examine, but also not very useful because the powder goes on the outside and the non-lubricated inner surface does not slip easily over the hand. Now I pride myself in being able to wear a glove meant for the left hand on the right hand, and work well despite the glove trying to move my thumb and fingers to suit itself. I also pride myself in being able to don size six glove though my hand requires size seven and a half.
What applies to hands applies to feet too. When one enters the labor ward or the operation theater, one has to change from street footwear to clean theater footwear, which happens to be identical to bathroom slippers. Depending on the foot used by majority of people for kicking off when going on or off duty, more number of slippers of one side are broken as compared to those for the other side. I am yet to see an even balance in thirty one years. So one has to wait indefinitely for someone else to exit, whose slippers one can claim, or enter wearing slippers meant for the same side on both feet. I pride myself in being able to wear and walk comfortably without any mishap slippers meant for left foot, one on left foot and the other on the right foot. I pride myself further in being able to wear a size seven slipper on one foot, size eight on the other foot, both belonging to the same side, and still not be bothered by it. I pride myself further in being able to walk wearing slippers with broken straps. Sometimes that results in a high-stepping gait so that the slipper clears the ground when stepping forward. When a strap is broken on both sides and is held in place with the front anchor only, the resultant gait is dragging-foot gait. When the two slippers have straps broken in different locations, the bipedal gait can be quite bizarre and not described in any book on clinical medicine or neurology.
The institute gives the same salary to me and to those who won’t work unless they get the glove of the right side and right size, and footwear of correct size and side. They don’t give me any medal for my application of voluntary dyslexia and adaptability to extreme conditions so as to be able to work without making a lot of noise or developing stress. I am not unhappy, because being able to do what I do is a reward in itself.

Revenge of the Staircase

A staircase is an inanimate object. It cannot think, feel, and act. Well, that is the worldly wisdom. But perhaps all such wisdom is not true at all times.
We have an elevator, and the staircase goes all around it from the ground floor to the top floor. The side walls of the staircase are painted in the upper part and have tiles in the lower part. Near the landing, there are one foot wide tiles from the floor to the roof, probably to make it look good. The visitors have a pastime of chewing paan, which contains a special leaf, calcium hydroxide, betel nut, tobacco, and some flavor. The process of chewing this paan results in collection of saliva in the mouth which is colored red due to the juices coming out of the concoction. The juice is not to be swallowed, but to be spat out. They believe that the road, pavements, ground, and staircases and corridors of the hospital are at par as spitting places. They are aesthetic people, and they always spit on the walls or in the corners, rather than in the middle of the corridor or staircase. A servant cleans the muck every morning, as advised by the Boss. That has kept the place clean. Otherwise people feel the corridors and staircases are the right places to spit when they see the red spit of others who have been there before them, and contribute to it.
We used to be asked to write short autobiographies of things like school blackboard or bench when we were in school. It used to be an exercise in composition, where we had to imagine ourselves to be those things and write about their lives as if they were our own. I could write a good autobiography of the hospital staircase, what with my experience of last 36 years.
“Sir, look what has happened” the OT servant called my attention to the staircase. The tile in the upper part of the wall near the landing had fallen off and broken into a number of pieces. There was some red fluid under it. I thought it was blood.
“Did it fall on someone’s head?” I asked. “That seems to be blood.”
“No, Sir” he said. “It is the spit of a person who had chewed paan. “It is something quite weird.”
“A new tile fitted not more trhan 8 months ago coming off like that is indeed weird” I said. “It cannot have been hit by something, because it is above the level of our heads.”
“No, Sir. That is not weird. That keep happening everywhere in the newly repaired and renovated building of the hospital. What is weird is that when the man was spitting there, there was an angry roar-like noise and the tile came off and fell almost on his head. His friend pulled him away just in time, or his head would have been bashed in.”
“That sounds dangerous” I said, “bit what do you mean calling it weird?”
“Sir, the angry sound came from the wall, much before the tile fell off. I think the staircase got angry at people spitting in it, and dropped a tile to punish that man.”
This sounded weird all right. I could not believe it as an intellectual, a doctor. I would have passed it as his imagination and superstition, but he was an intelligent fellow and usually did not make such statements. And then I recalled a small story like this one that I had read in ‘Peanut’ comics by Schulz, where the school wall had dropped a brick on Lucy as punishment. Was our hospital building following the school in ‘Peanut’ comics?