Nails Problem

It is a common practice amongst surgeons to cut their nails short, so that dirt does not accumulate under them and scrubbing for surgery is more effective. It is a not uncommon practice amongst girls and women to grow their nails, and sometimes paint them. What happens with women surgeons is unpredictable.
I was assisting my Registrar the other day. She was performing vaginal hysterectomy. Suddenly her nail of right index finger poked my hand through two surgical gloves on her hand and two on mine. So it was long. I asked her how she could operate and hope to have less postoperative infections. She kept quiet. I assisted my Senior Registrar after that operation. Her nail also poked my hand the same way, and our discussion went the same way. I think they were unhappy with me for some reason, and would have loved to scratch my face or something. That not being possible, they perhaps poked my finger.  :-) That would perhaps was excusable, but breach of aseptic technique was not. I let a week pass, and on the next operation day took a camera along to the OT. I photographed the fingers of all of those who had long fingernails, with or without dirt underneath. It looked like this.

Since half of them were already operative or assisting when I started the photo session, I had to wait until they washed out. One house officer came out with blood all over her gown's sleeve.
"Go wash your hand" I told her "there is blood all over your sleeve."
She went away, but would not come back. I grew impatient after ten minutes and asked for her. She came, her hands all wet.
"Show me your nails" I said.She held out her hands for me to inspect her nails. The nails were cut flush with the finger tips. There seemed to be not even a minute's growth after having cut them.
"Did you cut them just now?" I asked her.
"Yes, Sir" she said.
"I felt cheated, but at least the nails were now short.

Source of Funds

We received a circular from the government, which was sent to us by honorable boss of the boss, asking us to state how much money was required to give all services free to mothers and babies. The government had promised to take care of it. We worked out the expenses for antenatal outpatient and inpatient care, laboratory tests, operative treatment, ultrasonography, other imaging, critical care etc. We sent the letter for further action. A month passed by. Then the clerk who had been processing this proposal came to see me.
"Sir, I got a telephone call from the auditor asking me to explain how this huge expense was being funded up to now" he said.
I was aghast. To ask me how the civic body was meeting the expenses for patient care was not bordering on ridiculous, but was actually ridiculous. I think the auditors are trained or conditioned to ask this question, irrespective of its relevance.
"What can I say?" I asked. "I am a doctor working here to give healthcare. It is beyond me to explain how the civic body gets the funds to meet the expenses for this healthcare."
"The auditor wants an explanation" he said.
"Well, if you give me a letter asking for an explanation, I will answer it. I will say the civic body uses its funds, the source of which is best explained by the civic administrators who sanction the budget of the hospital. Whatever expenses the civic body cannot meet are met by the patients, unless there are some donors."
"OK" he said. "I will ask the auditor to ask me this question in writing."
"an we also find out why he needs to know that, since the government is asking us to give an estimate of the expenses so that it will provide the money. The government is not concerned how the expenses were met in the past. Then why are the auditors concerned about it?"
The clerk went away. I am yet to receive the letter, on which I look forward to answer as above.

The Comma Misplacers

The only typing I see in my institute is of two types - one is by typists employed by the civic body for that purpose, and the other is by doctors, who write their own letters, articles, or make their own Powerpoint slides. The former has grammar and spelling mistakes of medical and nonmedical types, but the punctuation marks are usually correctly placed. The latter typing is of two types- good and bad. In the latter group, I find a curious subgroup. Please read the following line to understand the nature of this group.
'The causes of anemia include iron deficiency ,hook worm infestation ,excessive bleeding from any site ,hemolysis due to any cause ,poor bone marrow funtion ,etc.'
In case you have not noticed, I will tell you. Check out the space around the commas. Conventionally the comma follows a word, then there is a space, and then another word. These people place the spacebar first, then type a comma and follow it with another word without any space in between. In simpler language, their commas are stuck to the following words rather than the preceding words. They are probably proud of what they do, since they send their typed letters and articles out for the whole world to see, and show their Powerpoint slides with confidence in conferences attended by peers. Perhaps it is a cult, and this is their trademark. Perhaps that is the way it is done in modern times. I am thinking of doing a study of this group, but I am afraid they will not consent for it, and without their consent the institute's ethics committee will not permit the study. :-)

'It Depends' Gambit

I first heard the use of 'It Depends' when I was in school. It used to show wisdom of great depth, when instead of a straightforward answer, one chose to give a complicated answer. One did not give the answer straight out. One said 'it depends' and waited for the listener to ask details. Then one would say what the variables were and how the answer changed for each variable.
Yesterday my Registrar tried it on me. There was a young patient with very high values of serum FSH and LH. Poor woman was suffering from gonadal failure. I thought it was a good opportunity to educate the Registrar.
"What are the normal values of serum FSH and LH in a woman?" I asked her.
"She looked at me intently, apparently trying to find out if it was a trick question. After some time she realized there was no trick in it. Her frown cleared, but she did not answer the question. So I asked again, in a slow, patient, understanding manner. She realized she had to answer it.
"It depends" she said and paused.
"What does it depend on?" I asked, as I knew the routine was.
"It depends on which phase of the menstrual cycle the blood sample is collected in" she said.
"OK. Please tell me the values in different phases of the menstrual cycle" I said.
"I don't know any" she admitted.
I think this goes to show that one cannot fool an examiner by stalling tactics like 'It Depends' ga

Free CME

I had started motivating colleagues in other specialties to conduct continuing medical education (CME) programmes about 20 years ago, because I knew that one would not be able to keep abreast of all developments in all fields of medicine. Only if specialists told specialits in other fields what was happening in their own fields would the doctor have up to date knowledge of all fields. Unfortunately our institute made it into a semicommercial venture, looking for pharma sponsors to pay for the expenses. My stand that there need not be any expenses went unheard. There had to be good food and free stationery, and grand functions. It was more show business than educational activity. It dies its own death in due course. The medical council made CME mandatory for all practioners. Now it had to be done. Organizations of different specialties started arranging CMEs in star hotels, and charged fancy fees to give CME credit hours. I had stopped attending those lomg ago because I could not mix politics (internal, of those organizations) and show business with something sacred like education. I started CMEs in my own institution, and kept those free for all. I expected other specialties to reciprocate, so that all would get recent education and free CME credit hours to meet the requirements of the medical council.
"Sir, most of the specialty CMEs are not free. They are charging fees for CME" one of our staff members told me.
"I will see if anything can be done" I told that person. Then I made a plan. In the notice that I put up on the online notice board of our intranet, I added the folloing lines.
'This CME is free for those whose departments arrange free CMEs for all. It is free also for those who charge money for their CMEs, and those who do not organize any CMEs.'
I thought this sarcasm would improve people and motivate them not to charge their own colleagues in an educational institute. I was wrong. I received an invitation for a CME today from one of the paraclinical departments. They were charging a fee. I showed our notice to the person who had come to invite me personally and asked him why they could not keep it free, when the auditorium and audiovisual aids were free, and they were not obliged to give any lunch.
"We have kept it free for all professors" he said proudly. "We will charge all others."
"That is even worse" I said. "If I attend this one free while my people have to pay for it, it will create a rift in my department. They will resent me getting it free and resent me for it. Besides, my salary is three times that of my Assistant Professors and 1.5 times that of my Associate Professors. I can afford to pay more than they can. Please tell your head of department I thank for the invitation but I will not attned it for the reasons I gave you. I will get the education by self education, and earn my CME credit hours by conducting CMEs on my own."

Load Shedding

Perhaps this is a term that people in the rest of the world do not know about, though it must exist there in some form or other. It is known that the energy requirements far exceed the energy available. Some countries use alternative sources when the electricity generated is not enough. There is solar energy, windmill generated electricity, nuclear power generated electricity, to name a few. It is sad that none of these exist in any significant quantity in my country. In order to meet the demands, the suppliers are forced to supply electricity for some time and shut it off for some time of the day. This is called load shedding. Sometimes there is no electricity for 18 hours at a time. Some places have no electricity at all. In the city of Mumbai, there is no load shedding. As a result people do not understand the value of electricity and waste it without giving it a second thought. Those who have a lot of money use it for showing off.
"Did you see the photograph of the new tower in today's newspaper?" my wife asked me.
"No. What is it about?"
"It shows the colorful light display on its top."

I checked it. The article had praised new light displays that towers are placing at their tops, as beacons for aircraft. There are many lights, which keep changing colors. I was aghast. A newspaper should be writing against wasteful practices, not praise them. Those huge billboards of ads, with powerful lights illuminating them, those buildings which flood their exteriors with light, those establishments which keep their neon signs on all night even when they are closed. Now this! Have a look at it in the accompanying illustration. God knows how much electricity it consumes. I found others like it which I have not filmed yet. I know that the civic body or the government will not stop such a wastage, because enough letters have been written by people to editors of newspapers, and nothing has come of it.

Reassess Till You Approve

“How many times are they going to call us to check the same material?” one head of department grumbled. I could understand his frustration. It was the fourth time. The civic body purchases consumables like drugs and suture materials by a complex process. Tenders are floated, then offers of eligible tenders are opened and their samples are checked by experts. Of those which are OK, the lowest tender is accepted. This one under consideration was for suture materials. After careful scrutiny, the various heads of surgical departments had recommended some and rejected some. But they kept calling us again and again to see if those rejected could be accepted.


“Why are they doing this?” another head of department asked. “Will they call us until we approve those sutures which we rejected before?”

“If we rejected something, it was because it was not meeting the requirements. If we approve that stuff now, people will say there was corruption, and the administration will say we do not have integrity.”

“Not only that, the people who lose the tenders may go to court against us, and the administration will throw us to the wolves. After all, it will be our signatures on the approval.”

“The administration feels rejections should not be without sound reason” explained the person in charge. That was new to me. Most of the items rejected once were not reassessed.

“Let us look at the materials and get it over with” said a third head of a department. So we all sat down and re-looked at the sutures we had rejected earlier.

“This one was 2 cm less than the minimum length required last three times” I said. “It is still 2 cm short.”

“How could it increase?” someone asked.

“If it could not increase, why are we looking at it again?”

There was no answer to that question. I wrote my report on the papers provided. It was the same as that written the previous three times.

“Here, take it” I gave it to the person in charge of the process. “Feel free to call me again whenever you like. I am here for seven more years.”

“Not when I like, when the Boss wants me to do so” he explained lamely.

“OK, whenever the Boss likes” I said. “I get salary to work. If I don’t mind performing the same operations day in and day out, why should I mind looking at the same suture samples again and again?”

The HIV Scare

We were in a meeting called at the civic office. One of the members, a professor of a clinical specialty, was unhappy with having to travel to the place every now and then.
"You have a vehicle. Why don't you send it to our hospital to get us here? There are three members who can come together" she said.
"They give you taxi-fare" I said. "Take a cab."
"No cabbie is willing to come for such a short distance" she said. "The vehicle would be ideal."
"But the vehicle will have to keep waiting for all members to arrive before it can leave" I said. "I prefer to come on time and finish my work in time. The vehicle will prevent me from coming on time."
"But I don't like to walk in the sun. It gives me skin rash" she said.
"We gave you taxi-fare" said the civic administrator, "you should come by a cab."
This was getting us nowhere, while time was short.
"The vehicle they use is a van" I showed the size of the van by spreading my hands wide and high. "They do not disinfect it."
"Disinfect? What for?" the professor asked.
"They use it to transport HIV positive patients" I said gravely, looking at the civic administrator with a look warning her not to contradict me. After all, I was doing it to resolve a conflict and move on.
"Oh, my God? They transport HIV patients in that van?" the professor asked incredulously.
"Yes. Would you like to travel in it knowing they do not disinfect it?"
"No! I will walk" she said.
That was that. I thought a clinician would not think traveling in a vehicle used by HIV infected persons would infect her, nor would a clinician be afraid of HIV. After all, treating them is a part of our job. Well, this professor proved me wrong on both counts. What I had said as a half joke turned out to be gospel truth for her.

Listen Listen

It was a high profile meeting, involving processing of work costing millions of rupees. Heads of multiple departments were involved, and all were present, along with auditors, administrators, and tenderers. Things were moving too slowly, probably because mistakes could not be made.
"What was the reason for not doing this the way it should have been done?" the Boss asked one person.
"It was not done because the equi..."
"Yes. I would like to know why it was not done the way it should have been done" quipped one head of a department, far below the Boss in hierarchy.
There was no point in interrupting the answer that was being given, by asking for that answer again! The said person had not been listening well. I winced but kept quiet. I was not chairman anyway.
"Listen listen" the Boss said without showing any irritation. "He is answering that question."
Then there was no further interruption. The meeting was adjourned after two hours of debate. We met the next day again, when the architect joined us.
"I have no objection to anyone making any civil changes in the structure" he said. "Only thing is that the 5 year warranty of the civil work will be passed on to the person who makes the changes, and the architect-contractor who did the work will be free. He was the architect involved. I could understand his happiness at the thought of transferring the warranty to someone else, because I knew and he knew that the work was shoddily done.
"I would like you to remove the entire window of the place and move stuff into the room from outside using a lift. Move the workers in and out the same way. Then work in adjacent rooms will not be compromised" said the same head of department.
Removing the window and its grill meant major civil work again. The archiect repeated the statement he had made about it a while ago. The Boss said the stuff and people would enter the room as anyone else did, through the door. It was left at that.
"There is no reason why the window cannot be removed for the duration of the work" the said head of department said to us after the meeting.
"The reason is that the architect wants to transfer the warranty to the person who makes civil changes, so that he is free of the responsibility" I explained. "That's why it cannot be done."
"But there is no reason why the window cannot be removed for the duration of the work" that head of department said again.
"I raised my arms in a gesture of helplessness and left. You cannot make a person see reason when he or she hears but cannot listen.

How to Make a Pelvitrainer

Coordinating two hand instrument movements during laparoscopic surgery is a skill that should be learned on a model first, and used inside a patient. Pelvitrainers and virtual laparoscopic surgery systems are available in the market. But they are expensive. The lowest priced model costs 20000/- rupees. We are not exactly poor in this institute, but there are many things to be purchased, and the waiting period is long. So I decided to build a pelvitrainer myself.

1. I took a wooden box that used to house a microscope before. Even a plastic container measuring 1.25'X1'X1' will do. The box had a lid opening on one side, which was useful for fitting parts inside. I painted the inside of the box white. I painted its outside with a polymer polish to make it look better, but it could be optional.
2. At one end I drilled a hole and put in a 3-pin power cord. I connected it to a holder for CFL bulb to it and fitted the holder to the center of that side of the box from inside.
3. I fitted a closed circuit camera (Rupees 800/-) to the inside of the top of the box. I made a hole in the side of the box and put the cables for the camera through it. The camera had a power cable through an adapter so that it would run on mains.
4. I drilled holes for accessory ports for operative instruments on the top of the box, three on each side and one in the center.
5. I cut 7 pieces of rubber mat, made 5 mm wide holes in their centers, and pasted them over the drill holes for the accessory ports. They would prevent wobbling of the instruments when passed through the holes for manipulation.
6. I connected the output video cable of the camera to a 14" color television set (Rupees 4000/-)

The equipment cost us Rupees 5300/- only, which is a quarter of the cost in market. The happiness of designing and making it was a bonus.

Higher Order

The patient had been in the ward for quite some time. She had a bit of bad luck. On second thought I thin she had a lot of bad luck. She underwent an abdominal hysterectomy for a posterior wall leiomyoma which had grown into the broad ligament on the right side. It went off fine. But the second day she developed profuse melena. We treated her for stress induced gastritis and she responded. From the fifth postoperative day she started getting high grade fever. With her history of having received blood transfusions and the hospital area being endemic for malaria, we treated her for suspected malaria and also changed her antibiotic. Her report for malaria came negative, but her fever went away. Her wound healed well, but she started getting high grade fever from the 12th postoperative day. We performed a pelvic ultrasonography and discovered a small collection in the pelvis.

“Can the sonographers tap it?” I asked.
“No. They said the bowel is in between.”
We removed two sutures in the vault of vagina, hoping the collection would drain out from below. I did not. She responded to the third antibiotic, this one quite high up in the potency and cost scale, and her fever came down. So we waited. She started getting fever again.
“Ask a senior sonologist if the collection can be tapped” I advised. The senior sonologist said it could be, provided the patient purchased a special needle. But the patient had no money. Her husband somehow arranged for the money and bought the needle.
“Sir, the collection cannot be tapped” my Registrar informed me “because they do not have an ultrasonography machine. Tomorrow is Sunday. Now it can be done only on Monday.” That was too much. I called the ultrasonography department.
“Our one machine has started hanging” the Lecturer said. “If we start tapping and it hangs, there will be problems.”
“I understand” I said. “Do you have no other machine? Surely such an institute does not function on one machine.”
“Our other machine is taken for an imaging workshop.”
“By whose order?” I asked. This was sounding horrible.
"By higher order.”
Higher order? As in from heaven?” So now they were having hallucinations and were hearing God?
“No. higher means from surgery department.” She was scared of specifying names, but I knew. They all were scared of only one person there, who they thought had higher connections.
“See, I am asking you to request your boss and get the machine back for this tapping. This poor woman has received the highest possible antibiotics. She needs treatment urgently. We cannot postpone it to Monday, like an elective procedure. It is not like a girl getting her hair permed or straightened which can be put off by a couple of days.”
“How can I get the machine back from the workshop?”
“Now it is lunch time. All the grand people who attend workshops love to eat fancy food at this time. While they do so, the patient can get treated. If she is not treated, it will be a shame on all of us. I am not asking this for myself. I am asking it for a poor patient who cannot afford to go some place where they take money and give her her money’s worth.”
I put the phone down. I could do no more. My Registrar informed me later that they finally tapped her. The patient became afebrile and went home fine.
I wonder how many such higher orders are passed that I do not come to know about, and who requests, pleads, reasons, threatens to get something done for patients at such times.

Me Chameleon?

"Doctor, my patient is in your ward. What is wrong with her?"
The fellow caught me outside the labor ward and asked me this question.
"What is her name?" I asked. "Is she my patient."
"Yes, she is your patient" he said and told me her name.

When he told me the name, my Registrar told me she was registered with another professor.
I was surprised that he should mistake me for the other professor, and was hurt a little because I was proud of my appearance and did not like being mistaken for that professor:-)
"Your doctor is YYYY" I told the relative of that patient and after moving on a bit, asked my Assistant Professor "Do I look like professor YYYY?"
"NO SIR!" he said. "I was surprised why he thought you were him." That assured me.
The same evening, a woman stopped me outside the office when I was leaving for the day and asked me about her relative in the antenatal ward.
"Is she my patient?" I asked.
"Yes" she said.
"See me tomorrow in the ward at 9:00 A.M." I said.

When we were leaving the ward the day after that, she stopped me and asked me the same question again. When I asked my Registrar which patient she was talking about, she told me this patient was registered under professor XXXXX."
I was upset, because this woman had mistaken me for a woman professor, despite my moustache, and me being fair :-) and weighing 50 kilograms less than that professor. I guided the woman to the right person and then asked my Assistant Professor, "how could she mistake me for that professor" looking down at my flat stomach with a wondrous look on my face. They liked that one and laughed heartily.
I think I have been made into a chameleon without my knowledge.

Arrogance Par Excellence: IV

Arrogance is a trait not uncommon in government and civic organizations. Perhaps that is so because productivity is not an issue, accountability is most probably not an issue most of the times, and jobs are permanent. nationalized bands are like government organizations.
The income tax system of this country is such that the tax payer is required to know in advance his estimated income, so that he can pay advance tax in three installments, 25% by 15th September, 50% by 15th December and 100 by 15th March every year. If someone earns more money in later part of the year, he pays penalty or hides the money (the latter is illegal). I am salaried and do not have a problem about paying tax on salary - they deduct it at source. But the interest on my bank fixed deposits is another thing. The nationalized band where I used to put my savings in term deposits just would not tell me how much interest I expected to earn and how much tax they would deduct at source. I got it done by a kind clerk in the bank a couple of times. But then one day the officer told me it could not be done. He said it would be known only after it happened. I got tired and gradually moved by deposits to another bank as my deposits matured. I used to go to the bank every March and ask for the projected interest and tax, until my last deposit matured. Every year there would be a new manager. The manager I asked the last time said,
"We cannot do it."
"It should be possible" I said. "After all, you are deducting tax at source. How can you do it if you don't know how or how much?"
"The system does not give that information" he said.
"Your clerk gave it to me a couple of years ago" I said.
"That is impossible" he said and asked the clerk concerned if she had done so. She got scared and said she had not.
"So how do I do my advance tax calculations unless you give me the interest paid out to me?" I asked.
"I don't know" he said. "We won't do it."
"It is OK" I said. "I will manage somehow. I had Rs xxxxxxxx in term deposits in this bank. I have moved away all that money over the last few years. I suggest you contemplate this issue and see if you understand why I have done so. I shall move my last remaining deposits away when they mature."
I went away. The next day the watchman of my residential place gave me an envelope when I reached home.
"The bank manager came today and gave this for you" he said.
I thanked him and checked the contents of the envelope. There was the statement of the interest and tax cut on it by the bank. The arrogance of the fellow seemed not to have lasted when he realized what staggering amount (all my life's savings) had been moved away from his bank and why.
This year there was a new manager, who told me he could not give the interest and tax statement to me. I went away, and when my last deposit matured a couple of weeks later, liquidated it and moved it to another bank. Some people never learn, no matter how much you try. And the arrogance is there to stay.

Arrogance Par Excellence: III

This story is about a bank. I had a saving account there, and some funds in term deposit. The account was in joint names of my wife and I. The bank had no photograph of my wife. So I submitted a photograph there.
"This photograph will not do" the bank fellow told me, after having asked his manager.
"Why not" I asked.
"It is best you ask the manager" he said. So I asked, because the bank was far from my residence, and I did not have another print.
"It is grainy" the manager said.
"It looks like her" I said. "Another branch has accepted this photograph. Please see if it can be accepted. I stay far and have taken leave today to do this work."
"It will not do" he said.
I went back to the first fellow and asked him if I could do any work on that account.
"You can do anything only when the photograph is submitted" he answered.
So I went home, collected another photograph, and went back after one and half hour. The fellow took the photograph and said "this is fine."
Then I gave him a letter requesting the bank to close the account permanently.
"But now all formalities are over" he said. "Now why do you want to close the account?"
"Because I do not like the service and treatment given by the bank officials" I said. He went to the manager, explained the situation got his signature on my letter, and gave me a token for collecting the balance amount. I sat down on a bench and waited. I kept listening to the announcements, checking if they called my token number.
"Token 72... token 72"
Mine was 71, so I continued to wait. After 5 minutes, the announcer shouted again "token 72 ... token 72" No one went to claim the money. After a minute, the announcer shouted my name. So I went to the counter.
"Are you Mr Parulekar?" one of the two women behind the counter asked me.
"Yes" I said.
"Then why do you not come when I called your token number. I have been calling token number 72 for last 5 minutes" she said rudely.
"That is because my token number is 71 while you have been calling 72" I said quietly. She looked at my token to confirm that I was right, shut her open mouth with an almost audible snap, and grabbed the token I offered.
"Now do you understand why I want to close my account?" I asked the fellow who had asked me the reason for closing my account. He was right behind her. She refused to look up from the counter top in front of her, he tried to show some expression on his face, but filed because he was confused about which expression to show.
This happened fifteen years ago. I get upset every time I think about it.

Arrogance Par Excellence: II

I have explained about the types of arrogant people in my previous article. In case you have missed it, you may read it at
http://shashankparulekar.blogspot.in/2012/03/arrogance-par-excellence-i.html
Today we are going to see two examples. The first one is a Professor who wanted to enter the Rest Room (which uncultured people call toilet, some cultured people claim) for private business. I happened to be inside, with the door closed. I was suddenly shaken by a loud shaking of the door. It appeared that the door would come off its hinges. I finished my work as fast as I could and exited, only to find this professor standing there is all her majestic glory, with a frown to indicate displeasure at anyone who dared not anticipate that she would need the facility and keep it available for her.
"I had a feeling it would be you" I said, respecting the Professor physique. Such arrogance, I thought. Perhaps she did not realize that one could not hurry someone inside a rest room. Perhaps she did not realize that in front of God and inside a toilet all are equal.
The other story is about an Associate Professor. This person makes statements like 'even I could not do it" when she really should be saying "I could not do it". I trust you have caught the difference. That day I was in the operation theater's changing room, changing from street clothes into OT clothes. Suddenly the door shook violently, with a loud order 'come on out!' The voice was recognizable. It was my OT and she had no apparent reason for being there, and none for such behavior. When I exited, she looked at me and murmured a grudging apology - words only, no feelings type. Such arrogance, I thought. She could not even think that there could be someone superior (and senior) to her in the changing room. She also did not realize that in front of God and inside a changing room all are equal.
I trust you have put both of them in category 4, unless you want to create a new category, possibly great and arrogant.

Arrogance Par Excellence I

Human nature is variable. There are four type of people, in one classification amongst many.
1. Great and humble.
2. Great and arrogant.
3. Not great and humble.
4. Not great and arrogant.
Of these two traits, greatness is relative. Someone could be greater than some people, and not compared to some other people. Arrogance is absolute.
We had a patient who was pregnant for the sixth time, with four living children. She was receiving antituberculous therapy, and had conceived. She came to us for medical termination of pregnancy.
"Did you not know that you should have avoided a pregnancy while on this therapy?" I asked her. "The drugs are harmful to your baby."
"No one told me" she said.
"Who is treating you" I asked her.
"Doctors from this same hospital" she said and showed me her case paper. Her doctor was indeed in our institute.
"Please ask him why he did not tell you about avoiding a pregnancy while on this therapy" I told her. I was unhappy with this doctor, because I had repeatedly told this department to advise all patients being put on antituberculous therapy to use contraception. Still we continued to get patients for MTP. MTP would be difficult, because the patient had active tuberculosis, possibly hepatotoxicity due to the drugs, and anesthesia could not be given safely. I wanted the doctor to feel the patient's wrath, which perhaps would educate him better than my polite requests. The patient went to see her doctor and came back after some time.
"What did your doctor say?" I asked her.
"He said nothing was wrong with getting pregnant while on antituberculous therapy" she said. "He has given me this number you can call if you want to."
I called that number. The Registrar took the call. He said he would get the concerned doctor on the phone. The concerned doctor turned out to be the other Registrar.
"I am the head of Ob Gyn" I told him. "Who am I speaking to?"
"I am Registrar" he said.
"I want to know why you did not advise this patient who just met you to use contraception while on antituberculous therapy?"
"We are overworked" he said, "too many patients."
"That cannot be justification for not counseling her" I said. "If she goes to court against you, you will lose if you give this explanation." He kept quiet. "Why did you tell her that there was nothing wrong with getting pregnant while receiving this therapy?" I asked. He kept quiet. Then I told him about difficulties in performing MTP on a patient of tuberculosis receiving therapy, and the advantage of avoiding this MTP totally by using contraception. "Now will you please tell me why you told them it was OK and gave them your intercom number for me to call if I needed any explanation?"
"The patient's husband was very arrogant" he said.
"He had reason to be so" I said. "His wife has to undergo MTP because you did not counsel them. But how can you afford to be so arrogant when you were in the wrong?"
He had no answer. I knew the answer anyway, he was in category 4.

Future Gynecologist

I was in the outpatient clinic. A new patient came in. An intern had written her history, which began as follows.
'History by Intern S.D. in SVP unit.
Complaint of heavy menorrhagia, associated with clotting, weakness and bodyache.'
I called that intern. She did not seem keen on seeing me, but that could not be helped.
"I called you to find out a few things" I said. "What is S.D.? They call me SVP as a convention in this hospital, which I cannot change. But why initials when you have a full name?"
She did not answer. I never learned what S.D. was for. I would not have written her name here anyway.
"Besides 'heavy' menorrhagia, are there other categories of menorrhagia?" I asked. "Like light and moderate?"
She would not answer that question even after I explained that twice in simple language. Finally she said she had written 'heavy menstrual bleeding', and changed to 'menorrhagia' when advised by the House Officer. it seemed she had forgotten to cancel the word 'heavy'.
"OK. Where does she have those clots? I am quite worried. Does she have them in her cerebral circulation, coronaries, mesenteric veins, deev veins of lower limbs?"
"In her menstrual blood" she answered.
"Oh!" I said. "I am relieved. "But every woman has clots in the menstrual blood. Blood always clots. Normally the clots are not seen because they are lysed in the menstrual blood. If one gets a heavy flow, there is not enough time for the lysis and she passes clots."
She kept quiet. My remarks did not warrant a reply, she must have thought.
"what do you want to do after internship?" I asked. "Ophthalmology?" she seemed the type who would become a good ophthalmologist, I thought without a good reason. Just thin slicing, as described in the book 'Blink' by Malcolm Gladwell. I was wrong.
"Obstetrics Gynecology" she said. I was so taken aback that I dropped my glasses and pen, which I was holding in my hands. When I used the now freed hand to hold my head, she smiled.
"Study well" I said and sent her away for further adventures in history writing.

Virtual Patient Virtual Operation

I thought I had seen all possible mess ups, but I was wrong.
That patient was scheduled for hysterectomy. Someone else was operating, and assisting. I just checked the case record sheet and consent, in case I had to assist some time in between. The patient's name was 'Shuxxxx' on the paper, as well as in the consent document. I knew that no Maharashtrian woman would have a name 'Shuxxxx', and it would be 'Suxxxx'. Just to be sure, I asked her,
"What is your name?"
'Suxxxx' she said.
"They have put your name as 'Shuxxxx' on all of your case papers as well as on the consent form. Did you write your name like that on the consent document?"
"No. Doctors wrote it. I just put my left thumb impression to indicate my consent" she said.
"They changed your name" I said, "that too at the age of 50".
She smiled in resignation. By this time she was already under spinal anesthesia and the operation was to start. I called the concerned resident doctor and the Registrar and asked them about this. They kept a blank face.
"This patient is not even admitted in our ward" I said. "It is another woman with a different name. This woman has not given a valid consent for the operation, because her name does not appear on the consent form. You are performing an operation on a woman who is not admitted in our ward and has not given a consent for the operation. If there is any complication and she goes to court, you will lose the case."
They kept quiet.
"Get her name changed" I said. they did that. the patient went home fine and all was well. I hope they learned something from all this..

Interns' Convocation

I received a letter from the preventive and social medicine, asking me to relieve all interns on Saturday, as it was their convocation, and the Boss had given OK for it. I had no reason to hold them back, so I relieved them. But I was curious how they had a local convocation. Dictionary meaning of the word convocation was 'An academical assembly, in which the business of the university is transacted' (Oxford University). There were other meanings too, such as 'An assembly or meeting', and 'An assembly of the clergy, by their representatives, to consult on ecclesiastical affairs'. Obviously the last one was not applicable to the interns. They keep on meeting every day for one thing or other. So the second meaning also was not applicable. So it was something like the function held by the university in which they were given their degree certificates and medical oath. I was convinced it was not that because it held by the university, while the other civic hospital interns had held their convocation just a week ago. I knew that because one of our relatives had gone there as an extern and had attended that function. His parents and grandparents had attended it too. That sounded like the graduation ceremony in US where people fly thousands of miles to attend their son's or daughter's graduation ceremony. When a couple of interns came to invite me for that function, I asked them,
"How come you have a local convocation? They had one at the other civic hospital recently."
"Sir, we just gather, give speeches, have fun and lunch. Our parents come too."
"So it is a social gathering" I said.
"Yes, Sir. Please come for the function and lunch afterwards."
"Thank you" I said. "But I am afraid I cannot make it. I have meetings all morning. But you have my blessings. Do well."
That day indeed was glorious day for the interns, because I saw a large number of modern princes and princesses, the former in full suits and the latter in their mothers' expensive sarees, moving around, having photographs taken together and having fun.
I wish we had such convocations when I graduated.

Tubular Vision and Multiscoping

She was a middle aged woman. She came to our outpatient clinic, referred from a superspecialty clinic for pelvic pain and dysmenorrhea. The referring person had already prescribed an antibiotic and an NSAID. I checked her history and reports of various tests and procedures she had undergone before coming to us.
"You have undergone an MRI Scan?" I asked. She looked poor. MRI scans are costly.
"I came from the state insurance scheme hospital. They also performed an upper gastrointestinal scopy on me before performing the MRI scan. Then they sent me to GI medicine."
"Then what happened?" I asked her.
"They put an endoscope through my anus" she said. That was the proctosigmoidoscopy she had undergone.
"Then?"
"Then they sent me to GI surgery, from where I was referred to this clinic."
The GI surgeons were good. They had diagnosed the condition to be gynecological in origin, started the treatment we would have given, and sent her to us before any more endoscopes could be put in her by other people. I checked her up, and made a tentative diagnosis of pelvic endometriosis.
"Have you taken the medicines which were prescribed by the referring doctor?" I asked her.
"No. I am tired of taking medicines" she said. She should have been tired of getting endoscopes inserted through her natural orifices too, I thought.
"I will give you some medicines, considering there might me some pelvic infection. If they do not cure you, we will have to perform laparoscopy on you, an even perform some operation like cauterization of endometriotic spots and excision of endometriotic tissue" I said. then I explained what it was all about, and she went away.
"Poor woman" our Assistant Professor said.
"I agree" I said. It is surprising that someone would perform esophagogastroduodenoscopy and proctosigmoidoscopy and MRI on a woman who has pelvic pain and dysmenorrhea, and no GI symptoms. If we have to perform a laparoscopy on her, her total experience may be labelled as 'multiscoping' I wish she had come to us first."
"Sir, why would they do that?"
"It is probably tubular vision that specialists develop, being unable to see beyond their own specialty" I said.

Bulk Supply Gimmick

The hospital makes purchases of approved items - suture materials, sterile plastic drapes, and many others. Though the quality is initially approved when the tender document is processed, the periodic supplies need to be approved before the supply is accepted.
I received a packet of 50 sterile drapes for approval. They were going to buy 25000 such, which comes to 125000 drapes. The label on the packet was OK. It stated the contents were sterile. When I opened the packet to check the contents, I found that all of the 50 drapes were packed together, without a plastic cover for each drape. While I was doing this, a professor came to see me about some other work.
"Please look at this pack of drapes and tell me if they can be approved" I said.
She looked at the pack and said "the pack is open, the contents will not be sterile now."
The pack was closed when I got it, and its contents were sterile. I have just opened it to check its contents. Would you approve it if the pack was closed?"
"Yes" she said after reading the label for details like expiry date, size etc.
"No. We cannot approve it" I said. "All drapes are packed in a single plastic bag. That means one has to use all 50 drapes when one packet is opened, or throw away the remaining drapes after the intended use is over. That is not economical. rather, it is wasteful."
"This is ridiculous" she said.
"Yes. Or perhaps it is a trick. They want to increase the order, by using the consumption somehow."
"But what if people do not realize this and keep using the contents till the pack becomes empty?"
"That will be the tragedy of patients coming to this hospital" I said. "That is the purpose of sending the items to us for approval."
I had prepared the professor for stepping into the department head's position when the time came, at least for management of stores.

External Support Personnel

Running a hospital is gigantic work. That is managed wonderfully well by the civic body, especially in view of the tremendous rush of patients from the city as well as from rest of the country. These patients' relatives find it difficult to bring food and stuff from home in time, to supplement whatever is supplied by the hospital. As a result, a number of enterprising persons have taken over the role of businessmen cum support personnel.
There is that woman who arrives at 6:30 A.M. with breakfast of home cooked food. A number of patients buy that breakfast.
"Sir, she comes before the sister in charge arrives on duty and can stop her" someone told me."
"The security personnel do not seem to stop her too" I said.
"There could be an understanding between them"
"Hmm..." I said.
"Her food may not be hygienic."
"The condition of the food at their homes could be equally unhygienic" someone said.
"Yes. And they need the food without inconveniencing their relatives."
"She has to make a living too."
"If the persons responsible do not stop her, we should not worry about it, as long as the patients do not catch food borne infections. Warn the diabetic patients not to eat her food if it is not as per their diet."
That seemed to settle the issue.
"Sir, there is that fellow who brings tea in visiting hours, to sell to patients and their relatives."
"He heats the tea in the ward's pantry before giving it to people."
"Using cooking gas for free."
"How come?"
"He gives free tea to the ward servants."
"That is not right. He should be stopped."
"It can be stopped only if he is caught."
"We will tell him not to use our cooking gas and to take away all those plastic cups that people throw around and out of the windows."
That seemed to settle that too.

Controlled Hypotension

We were performing an abdominal hysterectomy. My senior resident was operating and I was assisting her. When we finished the operation, we asked the anesthetist what the patient's blood pressure was.
"It is 80/50 mm Hg" the anesthetist said.
"That is low" I said.
"She is young and healthy. This BP is OK for her" the anesthetist said.
"OK. But why is it low? You cannot have produced controlled hypotension. She is under spinal anesthesia. Controlled hypotension is produced under general anesthesia, I thought."
"This is a sort of controlled hypotension" the anesthetist said. "Spinal anesthesia lowers blood pressure."
"We have not produced controlled hypotension" I said "by causing bleeding to occur."
They laughed.
"Her BP has to be more for us to confirm that the hemostasis is proper" I said. "Or she may have reactionary hemorrhage when the blood pressure comes up."
"I understand" the anesthetist said. She infused the patient, elevated the BP a bit, the patient bled a bit to show us the points of bleeding, which we secured and closed the abdomen.

Stealing Security Cemaras

They put security cameras everywhere in our department, so that any miscreants would be caught. It was also made mandatory by High Court for prevention of baby thefts in the hospital.
That day we were rushing to catch the lift. The door was closing on an empty lift. I pressed the button, which usually makes the door open again. This time it didn't. My Assistant Professor tried to open the door with all his strength while I pressed the button fully in. It did not work and the lift did go up without us.
"See how I exercise self control" I said jokingly to my unit doctors. "I wanted to kick the door when it would not reopen for us. I controlled myself and did not kick it."
They laughed obediently.
"Anyway I would not do it, because it would just hurt my foot, and would be seen on the CCTV" I said and looked towards the ceiling where the camera was.
"Where is the camera?" I said with surprise.
"Sir, all cameras are missing for the last one month" our Assistant Professor said.
So I checked and found out that it was true. I asked everyone concerned, and no one knew about it, including the Boss and Deputy Boss.
So the petty thieves stole the security cameras! Or was it the work of someone planning a robbery?