Honorarium of One Rupee

The Boss’ Boss decided to have the performance of Honorary doctors in the civic hospitals checked. It appeared that some of them were not regular in their work The Boss made a committee of three heads of departments and put me on it. I am unable to see myself in judgmental position at any time. It is one of the reasons I refuse to be examiner for undergraduates and postgraduates. But I could not refuse, because that reason would perhaps be seen as pseudo-philosophical rather than practical. So we went around looking at various civic hospitals. The order was to get data about the qualifications and honorarium of the honorary doctors, and then assess their performance.

“These honoraries seem to be getting Rs. 1000/- per month as honorarium” I said.

“Yes. But that does not cover even half of what they spend on petrol to reach the hospital” the medical superintendent said.

“But there are four doctors who are getting one rupee per month each” I said, quite surprised.

“Yes. They have been getting that for years.”

“Why?”

He shrugged.

“Have they refused to get what the others get?”

“No. The civic body pays them one rupee each.”

The civic body wanted them to work for twenty hours a week, week after week, year after year, for one rupee a month! They must be extremely keen to serve the poor people selflessly, or they would not continue like this. And there was our team, evaluating their performance. I had never felt so ashamed at being judgmental as I felt then, even when I wrote their performance was exemplary (as it actually was), because I felt I was violating something sacred by the act of judging such people.

Hospital Innovations: Gloved Tap

I have written about the brilliant people who go in the making of a hospital's employee pool. The motto is to keep things going, no matter what. When things do not work out as required and when the official solutions are beyond one's control, they find novel solutions. Here is an example.

The scrub tap had a sprinkler type nozzle. The spray angle was adjusted to wide. So the person scrubbing for an operation got water not only on his upper limbs from elbows to hands, but all over the torso. The contractor would not come to narrow the angle, nor would the local plumbers do it. I could not do it, because there seemed to be no adjusting mechanism, and I did not want to break it. We kept on using it the same way, until one day I found this innovative solution.

The water would fill up the glove tied around the nozzle. Two gingers had been cut at the tip, so that the water would pour out in a stream rather than as a wide angled spray. It was very innovative. Only thing not known was whether it was a new glove or a used glove. Getting all sorts of pathogens was a real possibility in case it was a used glove. With great sadness I had to get it removed.

Midstream Dressings and Injections

We were taught as students the method of collection of midstream collection of urine for microbiologic studies. The idea was that the bacteria contaminating the distal urethra would be washed away with the stream of urine in the early part, and a noncontaminated sample of urine would be available. We teach our students and residents the same thing, and get our patients to give their urine samples that way.
When I was an undergraduate student, I had seen our Professor of Surgery dress a patient's wound. When the time came for application of antiseptic cream over the cleaned wound, he got a resident doctor to squeeze the tube of the antiseptic craem, discard the first portion that came out and then used the subsequent portion. He did not explain why he did so, but it appeared he wanted to not use the part near the opening of the tube because it could be contaminated.
That day we were taking round of our emergency ward. On the bedside table of a patient, there was a syringe loaded with amber colored solution. It was on the unsterile surface of the table. Its nozzle was open.
"What injection is that?" I asked. No one knew. "It could be sodium thiopentone" I said. "It used to look like that when I was a House Officer. I could be urine too. The may have kept it for testing for proteinuria."
"Sir, it must be antibiotic" the Registrar said.
"But how will they use it? Its nozzle is open. The injection must be contaminated." Then I thought of my erstwhile Professor of Surgery. "Perhaps they will discard the first couple of drops and inject the remaining part which won't be contaminated."
My Assistant Professor got the joke and expanded on it. "Midstream injection!" he said.

Make It Sound Better

The patient was scheduled to undergo a laparoscopy. I was going through the reports of various tests she had undergone.
"Essentially normal" said the report of the chest radiograph.
I knew what 'normal' was. The adjective 'essentially' was not essential. But it was found on 90% of the reports coming from that department. There was a pelvic ultrasonography report. It read 'essentially normal.' Both reporting doctors were from the same department. Probably they told them to write like that when they were inducted. Perhaps they learned that watching their seniors. Perhaps they thought that additional word gave them protection from litigation, as 'normal' was so absolute, while 'essentially normal' implied that something could be abnormal, though most of the components were normal.
Then there was the anesthesia fitness report. After filling in all clinical details and reports of various investigations, the anesthesiologist had written 'fit for anesthesia with due risk'. That was also routine. Once I had asked them "how much risk is due in this case?"
They had been unable to clarify.
"There are grades of risk" I said. "What is the grade in this given case?"
"She is OK."
"Then why not just say she is fit? If she had a severe mitral stenosis, the 'due' risk would be much more than when she is totally normal."
"Yes."
despite my logical argument, they have not changed their practice. Either it sounds grand and so they persist, or they are scared of committing outright that all is OK.

Episiotomy Controversy

The most basic operative procedure performed by a junior resident doctor in Obstetrics is episiotomy and its suturing. I had made a few and sutured them as an intern too. There would not be any controversy about it, one would think. Well, one can often be wrong. I was conducting viva for undergraduate students. I asked a question on episiotomy and the controversy came to light.
"The muscle layer of the episiotomy is sutured with figure-of-eight sutures of absorbable material" he said. I visualized the poor muscles of the woman's perineum being strangulated by the sutures and winced.
"Figure-of-eight?"
"Yes, sir. That is how I have seen it being done in 12 cases when I worked in the labor ward. I sutured three myself the same way." He must have been telling the truth, I realized. I let him go, and called a couple of resident doctors I spotted in the ward. I asked them the same question and they gave the same answer. That got me worried. Simple sutures was what I had read as a student and practiced as a doctor.I spotted an Associate Professor, and mustered up courage to ask that question.
"Figure-of-eight."
I was aghast. Then I conducted a survey of all staff members and resident doctors who were willing to participate. A few Assistant professors put figure-of-eight sutures, a lot more resident doctors did so, and all others put simple sutures. I even asked a resident doctor who had passed out recently and was working in another institute.
"Figure-of-eight. "
"Does it not cut off the blood supply of the muscle and cause its necrosis? What did you read in Williams' Obstetrics?" I asked him.
"Sir, the 23rd edition of Williams says simple sutures or continuous noninterlocking sutures achieve the same result. But I put figure-of-eight sutures. Now I will switch to simple sutures."
The following graph shows distribution of doctors who used the two types of the sutures. SI is short for 'simple interrupted' and FOE is short for 'figure-of eight'.

I checked Williams' Obstetrics. The 22nd edition put simple sutures in the muscle, while the 23rd edition did say simple or continuous sutures could be put. I wonder why those obstetricians saw any need to try out a continuous suture, when it is known fact that nowhere else in the body the muscle is sutured that way, how they got institutional ethics committee's permission to do so, and what the achieved by that. I must admire the spirit of the doctors who have independent minds, who put sutures of their choice, instead of doing what is taught by their teachers or what is written in books. I will continue to put simple sutures myself.

Travels of a Sperm

It was a conference on infertility. The academic discussion was over. There were sales representatives of a pharmaceuticals who had kept stalls at the venue. One of them decided to show off.
"Doctors, do you know how much distance a sperm travels to fertilize an ovum?"
I kept quiet because I do not speak in conferences. No one answered the question. Some thought it was presumptuous of a nonmedical sales representative to test the knowledge of doctors. Some thought it was a trick question and did not want to get caught.
"It is not a few centimeters, as you must believe" he said when he could not get anyone to answer his question. "It is 4.6 kilometers."
There was a stunned silence. I was polite and did not want to contradict him publicly. Some people thought he was off his rocker and were afraid he would assault them if they dared contradict him. Some thought he might be right, since he represented a pharmaceutical company, pharmaceuticals have a lot of money, and moneyed people are right and should not be contradicted. Since no one took the bait, he gave up. When I met him afterwards, I asked him,
"What makes you say a sperm travels 4.6 kn to fertilize the ovum?"
He looked proud that he knew the answer while I did not.
"It is not the distance between the vagina and the ovary" he said, "it is the distance the tiny sperm has to travel. It is 4.6 kilometers."
"The length of the uterine cavity is 6.25 cm and that of the fallopian tube is 8 cm. So the sperm has to travel 14 cm or so, not 4.6 kilometers" I said. "May I know the source of your information?"
He beat about the bush for some time and finally said "I heard that being said in the FOGSI conference."
That sounded interesting. "Exactly who said that?" I asked.
"Um... er..." his salesman's instinct prevented him from quoting a person for fear of losing potential customer.
"You are not correct" I said. "May I point out that a lot of young resident doctors heard you, and they will say this in their exam and perhaps fail."
He managed to look uncomfortable.
"Poor sperm would die of exhaustion if it had to swim 4.6 kilometers. Even if it did not die, it would be in no mood and condition to do something romantic like fertilizing an ovum" remarked another Professor nearby.

Send It Yesterday

"Sir, the central office has sent us a circular today."
The clerk sounded upset. So I left what I was doing and looked at that circular. It wanted us to send our Aadhar card information by 12th, or they would freeze our salaries.
"The circular is dated the tenth, it reached us on the twelfth, and they want us to send the information on the eleventh" the clerk said.
"I noticed that" I said.
"How can people send information in the past, Sir?"
"They cannot" I said.
"The dispatch section delayed it by a day" she said.
"It is quite remarkable that they sent it in two days. I have seen them taking a month to do it, when the walking distance between their section and the farthest point in the institute is of ten minutes" I said. "I have seen them send letters to wrong sections. In fact, one of the previous Deans would tell us to have patience, when our letters to her would not reach us with her remarks. She would say the dispatch section could take weeks to deliver letters."
"...." the clerk kept quiet. She knew that particular Dean used to keep certain letters in her own possession, and blame the delay on the dispatch section. That Dean had kept my appointment letter for a month with herself, and maintained that it had been dispatched.
"But they have not sent us any letter before this one. How can they threaten to take disciplinary action for failure of compliance, when they give just one day to do it?" one staff member asked.
"They must have received a strict memo from the head office" I said.
"But why?"
"Because the responsibility of getting the work of the Aadhar cards done in this city was put on the civic chief, I hear. Charity begins at home. So probably all civic employees are forced to show that they have done it."
"Are they going to replace our 'employee code number' with this 'unique identification number' on the Aadhar card?" another staff member asked.
"Let us wait and see" I said. In the meantime, send your Aadhar card information as asked."
"Shall we send it yesterday?" my people seemed to be quite angry.
"Send it now. The timeline in the civic body is so warped, there seems to be a fourth dimension here. Send it tomorrow, with dispatch date of three days ago, and they will receive it yesterday" I advised.
They looked at me with respect. If anyone could handle the civic body's timeline, it was I.

Aadhar Card

“What is this Aadhar card?” someone asked in the staff room.
“The central government started a wonderful scheme of giving a unique identification number to each person in the country” a knowledgeable person replied.
“But why?” the less knowledgeable one asked.
“They must have it in US or in the greatest dictatorship in the world – I don’t know which because I don’t know the political inclination of the person who brought the idea up. He sold the idea to the democratic government anyway, so that now it an idea in the greatest democracy in the world.” I marveled at the depth of understanding of this person. Apparently there was more to come.
“What is the need? We had ration card, then PAN card, passport, driving license, and identity cards at the job. Why one more? Were they all not unique in their own turn?”
ut up a lot of money for this ambitious project – it is always about money, is it not?”
“Umm …” I did not know the reason for the ‘umm …’ After all everything is about money, is it not?
“They roped in a great software wizard from industry and gave him a position equivalent to that of a cabinet minister” a third person said.
“So there must be more money in it than in software industry!” said the less knowledgeable one. “But is it working?”
“The money is spent – so it has worked for those who ran the program” the answerer said.
“No. I mean has it worked for the common man?”
“Not really. It has a photograph that has been taken by webcam. So it looks like hell. The iris scan and fingerprint data is not embedded in the card. They are just developing a database for criminal investigations, looks like. Many people have not received the card, even if other members in their families have got theirs months ago, all having registered at the same time and place. The centers have closed, so people do not know where to ask for their cards. They don’t know how many people have not registered, probably more than those who have registered. They have not replaced all other cards with these cards for all transactions – so the apparent purpose does not seem to be served. They have not said if every citizen is expected to carry the cards around, as in a police state, or for foreign nationals in US.”
I started feeling dizzy after hearing all this.
“Why does the civic body want our card details? They have threatened to freeze our salaries if we are not registered” another person said. This I knew about – there was a circular to this effect.”
“We get salary for the work we do. The civic body has given is identity cards itself with unique employee code numbers, so it knows us. Why does it want our national unique numbers?”
“Probably because the civic chief was entrusted the responsibility of getting the registration of all people in the city done” the knowledgeable one said.
“Employees of the civic body are just a fraction of the total number residents of the city. Registering the latter cannot get the whole work done. Can the civic chief freeze salaries of all people, in government service, private sector too? Can he stop businessmen and entrepreneurs earnings too? And what about those masses who have no income at all?”
This was sounding like mutiny. So I stepped in.
“It is better to submit proof of your Aadhar card rather than hold lengthy discussions on it” I said. “A photocopy will cost just one rupee. All the time spent on the discussion is worth a lot of money, if used productively.”
“We are discussing this issue because the constitution has given us freedom of expression and we enjoy using that freedom. No amount of money can equal the happiness we get out of our gift of gab” said the department’s cynic and grinned.

Uterus and Gender Issue

"Sir, this patient came with 7 months of amenorrhea and preterm labor. We gave her tocolysis and betamethasone. Now she is relaxed."
"Which of the two drugs is a sedative?" I asked,
"Sedative, Sir?"
"Since she is now relaxed, she must have been tense before. Which drug relaxed her?"
"No, no. She is not relaxed. her uterus is relaxed."
"Is that what you meant when you said she was relaxed" I asked. I knew that was what the registrar meant. All of them always said so.
"Yes, Sir."
"So 'uterus' is word of feminine gender" I said.
"Um..."
"I always used to call a uterus 'it', but now that we all are gender-sensitive, perhaps the grammar is changed too. It is but right. If the woman has to bear the baby and go through all those hardships of motherhood, and if the uterus is the organ which has to hold and nurture the baby, it is but right that it becomes of feminine gender."
"Um..."
I am sure they will say 'she is relaxed' in their MS exams too, even if I pull their legs on this issue repeatedly. The wonder is that they all pass. Perhaps their examiners had also said 'she is relaxed' when they were resident doctors.

Resection of Lateral Uterine Walls

"Sir, this patient has come to us with scanty menstruation for three months."
"What seems to be the cause?" I asked. There would be some problem, or they would not tell me about one patient amongst a hundred and fifty which came to the outpatient clinic.
"She was operated on in a private hospital. They performed hysteroscopic resection of the lateral uterine walls."
Who did this?" I asked. This was something not found in the textbooks and journals.
"Dr xxxxxxx."
"Have you heard of this operation?" I asked my Assistant Professors.
"Sir, these new endoscopic surgeons keep doing this" they said
"What does it achieve?" I asked.
"Don't know."
We evaluated the woman further. She had developed Asherman's syndrome, thanks to the resection of the lateral uterine walls. I wish someone tells them to refrain from such an operation.

Color of Heritage

I have seen people either not willing to understand or not caring that their activities damage the facade of their building. They keep potted plants on their windowsills, water them to their heart's content, and feel good when the plants survive and blossom. They probably never look at the facade and realize that the paint gets damaged by the soil and water running down the walls, or they see that and don't care. Perhaps they feel what happens outside their homes does not matter.
It gets even more unfortunate when these people engage in the same practice at their workplace, and even worse when the workplace happens to be a recently repaired and renovated heritage building.
Someone has put a pt with a plant in it in one of the wards not under my jurisdiction. There are two muddy stains running down the wall, one from the pot and the other from water leaking from one joint in drainage pipe. It looks like a person's clothes after he has been stabbed. Perhaps the building feels like that. I spoke to the concerned head of the department, who seemed unaware of this, though both of us have the same view of the building when we arrive for work everyday.
"I will look into the matter immediately" I was told. "If a pipe is leaking, it will damage the building." So the plant and muddy stain were OK?
Now a week has passed. The plant is taller, the stains are longer and wider, and my heart bleeds a little everyday as I watch it, just as it bleeds a little every time I see the corners inside the building where some visitors have spat red saliva after chewing paan and tobacco.

Low-placed IUCD: Clinical Diagnosis

We had a patient who came to us with a pregnancy of 6 weeks and a Cu-T 380 in situ. The threads of the IUD were seen at the external os. She wanted a medical termination of the pregnancy on grounds of a failure of contraception.
"I think the reason for failure of the IUD could be a low-placement, so that the transverse bars are not close to the fundus," I said. "if not, it is bad luck."
"How can we confirm the diagnosis?" the Registrar asked.
"We could a pelvic ultrasonography" I said. "But that costs money. Since she wants a medical termination of pregnancy, we can make the diagnosis clinically."
"Clinically?"
"Yes. At the time of the MTP. Work it out" I said.
They could not work it out. Finally I watched the MTP and told them it was indeed a low-placed IUD.
"How, Sir?"
"The length of the cervical canal was 2.5 cm. Correct?"
"Yes, Sir."
The length of the threads attached to the IUD was also 2.5 cm. Correct?"
"Yes, Sir."
"That means the lower end of the IUD was at the internal os. That means the transverse bar of the IUD was below the uterine fundus, since the uterine cavity length was more than the length of the IUD."
 "Yes, Sir."
"There would be some enlargement of the uterine cavity with pregnancy" I said. "But that draws the IUD up, rather than keep it down while the fundus rises."
That convinced them.

The Notice

The staff room is the place where the staff members sit when they are free. They have their lockers there, so that they can keep their stuff there. It is expected that they treat the place as their home away from home, rather than the waiting room at a railway station. I am happy that most of us treat our staff room as such. There are some exceptions to this generalization, though I do not know who, since they never own up after they mess up. When they leave the table dirty after a meal, the servant cleans up the mess. So the room remains clean. But when they throw their junk, like literature given by medical sales representatives, empty wrappers of drug samples and stuff, the servant does not throw those things away because he thinks they could be important. The stuff looks terrible on windowsills, tables, tops of lockers and cupboards or the fridge. I requested people in meetings to throw away their unwanted things in the dustbin rather than scatter them about the room. But the things continued to remain where they were. Finally I got bugged and put up a notice in the staff room. It read as follows.

"Feel free to throw unwanted stuff here. It is OK. Most idiots do so."

Now new stuff is not being thrown around there. I have left the notice there as a continued reminder to people not to litter, and also to the person(s) concerned that they are idiots in my opinion. I think I have been fair - I gave adequate notice before doing such a thing.

Hospital Innovations: Sail in OT

The contractor is guided by the architect, so that the work is done expertly. It was an architect who put eight fluorescent tube lights in my office, to be switched on or off with only a single switch. That is to save money, and is also eco friendly. Each switch would get heated up, and if there is only one switch to get heated up, it reduces the carbon footprint. Also, when the repairs are to be done again, there will be only one switch in the waste rather than eight, which reduces environmental pollution.

The same architect got an air conditioner installed in an OT. His efforts must be appreciated. But for the installation, the anesthetists would not have been forced to think out of the box and develop the contraption shown below. It is thinking new thoughts that prevents Alzheimer's disease. So the architect contributed to that preventive process.

The vents for blast of cooled air are so located that the blast is directly on the patient and the anesthetists. That perhaps is important when the patient is to be subjected to hypothermia as in cardiac surgery, and the anesthetist is prone for fits of anger and needs to be cooled down periodically. Fortunately both of these conditions are not applicable to the OT under consideration. The anesthetists fixed the problem by tying a plastic surgical drape between two IV stands as shown. The black arrows show the direction of the blast and the sail stopping the blast quite efficiently. The anesthetists could apply for the patent of this contraption, and stand to earn millions through its royalties. The architect may demand for a percentage of the fees, just as he gets 10% of all expenditure of the work done in the building.

Hospital Innovations: Patient Wagon

It goes without saying that highly intelligent people join medical college hospitals. They put their brilliant minds to solving problems ranging from minor to gigantic. One such problem is that of transferring patients from one ward to another. This is a significant problem for labor ward, where patients who need to be transferred are found in a large number. After all, every woman who delivers a baby has to be transferred to the postnatal ward. Some innovative mind found a solution which would transport a number of patients at one go. It is called a 'patient wagon'. Here is how it is done.

Maneuvers

A meeting was arranged with the Boss' Boss in the latter's office, 7 km from our work place. Four Heads of Departments were asked to attend, three superspecialists and one Specialist. The four reached the place in time, but were informed that the meeting was postponed by a half hour.

“Let us go to the canteen, the most senior superspecialist (MSS) said. The Specialist did not want to eat or drink anything, but had to remain in the group, in case they discussed anything related to the meeting. So he tagged along. The canteen was self service type, where you paid in advance, and collected your food and beverage, carried it to a place of your choice (if there was a choice) and enjoyed. The three orderers (those who wanted to order things) Superspecialists stood in a queue, while the Specialist stood at a respectful distance.

“What do you want?” asked MSS.

“Nothing” he said.

“OK, hold this” he said and handed over a dish even before paying for it. He had a greenback in his hand, and he made out that he wanted to pay, in which time the non-orderer Specialist should oblige by holding his dish. He held it. This took some time, in which one of the Superspecialists paid the joint bill of the three. MSS pocketed his greenback. He turned to go sit at a place of his choice.

“Take your dish” said the non-orderer Specialist.

“Bring it along” MSS said nonchalantly and walked away to the most distant place he could find vacant in the canteen. The Specialist carried the dish along he was not going to eat anyway. MSS settled down in the seat of his choice, the others joined him.

“Have something” said MSS to the dish-carrier.

“No, thanks” he said.

While he sat there and thought about the attitude of MSS, he suddenly realized the double maneuver MSS had executed. He had avoided paying the bill (the free lunch maneuver) and made someone else do his work of carrying his dish (the exploitation maneuver). He also realized MSS had started resembling his political master-godfather not only in size and appearance, but also in political maneuvering.

(Note: the words 'orderer and non-orderer are used for want of better words which could express the meaning as accurately, even if these words are not in the dictionary.)