Babu-ism

We had this offer of a small donation from the funds in the whatever Jubilee Society Trust, for purchase of equipment that we cannot procure following civic resources. I had trouble getting sphygmomanometers for the labor ward. So I took this opportunity and asked for 30 of them. The standard procedure is to ask for three quotations from different vendors, and order from the lowest quoter, provided it is approved by the trustees of the trust. With an extensive experience of their modus operandi, I got three quotations in prescribed format, tabulated the prices and recommende the lowest quoter. Then I went on vacation. In my absence, the letter was answered as follows.
'You are granted the required amount. Please get three quotations, get the approval of the trustees, then place order, and submit the bill for payment in 60 days.'
The working staff members started getting quotations, but did not make much progress until I resumed duty. When I learned about all this, I called the trust office and asked why they had asked me to get new quotations. They made me wait, checked records and said,
"We have your three quotations."
"Then why ask me to get three quotations again?"
"We get many proposals, and we cannot write different letters to different people. Our chief told us to send a standard letter."
I was aghast. Such administration is indeed praiseworthy!
"I cannot get three quotations again. All that work took a lot of time, efforts and energy."
"No, no! You can place order" the clerk said.
"Do you have the authority to allow me to do so? The last time you asked me to something, I did it. Then the trustees raised hue and cry, and you were nowhere in the picture" I said. "Your letter tells me to get trustees approval before placing an order. I won't place an order because you tell me on phone to do so."
"But we have the approval here. You ask for the approval paper."
I started losing patience and temper both.
"See, I send you a comprehensive proposal and expect an answer to it. I do not get paid to make multiple efforts when my first effort is perfect, only because you cannot write appropriate answers to proposals. I have to do other work in that time."
"OK, I will send you all papers with the necessary approval."
"Please do" I said and put the phone down "though it would have been better if you had done without me losing time, temper and getting stressed out trying to make you understand procedures." Readers must understand that I said the latter part after putting the phone down, so that the trust's finer feelings would not be hurt, though I could not see why I should bother.

Opportunities in a Full Time Job

"I am trying very hard to become head of my department" the visiting professor told me. "Actually I am the most snior person and the job should be mine. But others with vested interests are stopping me."
"But why?" I asked. "The salary is not different, and it is not much fun doing all that paperwork as a head of the department."
"It is not the salary" he said. "It is the opportunities."
"What opportunities?" I asked. I did not anything that one could not do only because someone else was the head of the department.
"Opportunities to go abroad" he said. "As a head of a government medical college's head of a department, I can go to US twice or thrice in two years. It is fun., One gets to visit one's children settled there. One saves a bit of money too."
I would never know that bliss because I was head of a department in a civic hospital, where people are not sent abroad on civic money. Anyway i was not interested - I did not even possess a valid passport, and did not want one too.
Then I heard of opportunities in civic hospitals too. One colleague was speaking of another head of department.
"That is a horrible head of department. He does not want anyone else in the department to get any opportunities."
"What opportunities?" I asked.
"Going for meetings to other cities or at five star hotels in town" came the answer. "Any such thing comes along, he grabs it for himself."
So the scale was tone down a lot, but the concept existed in civic hospitals too.
Then one day came the big break for the speaker. There was a paid trip to the US for a few months. I was told only when the visa was given, meaning all other things were done.
" I will be going tomorrow" I was told. I understood it was the fear of the opportunity being lost that had prevented that person from opening up earlier.
I said 'happy journey' or something to that effect. I could not have said what was upsetting me because it could not be understood and acted upon by the opportunity seekers. In a job like ours, I expected one to seek opportunities to exel, to do something that would make a difference for someone or better still, for the medical field as a whole, to leave a mark on this world when one finally passed away. Someone looking for a free lunch could not grasp that concept, and perhaps would not be able to make good use of any of those opportunities I had in mind. Well, that is life.

Camouflage Aprons

“Is that blood seropositive or exonerative” I asked a visiting Registrar. It was my OT and he had come visiting to my OT with his patient from another unit. He had blood smears and drops on his once white apron. He looked in the direction of my gaze, thought for a couple of seconds and answered “Negative”.


When we speak of seropositivity, we mean that related to HIV. We keep teaching our students and resident doctors about universal precautions, about what to do if they touch blood or blood smears their clothes. Still we find resident doctors wearing blood stained aprons. This phenomenon is more marked on the day following their emergency duty. Sometimes it is there on the third or fourth day after the emergency, either because they keep working without a break on some serious patient, or do not have a clean apron, or are too tired to find one.

“Surprising how the blood on your aprons always turns out to be seronegative” I said. “Lucky, too! The other day it was seronegative on my Registrar’s apron too.”

I hope he learned something and will take appropriate measures if a patient’s blood smears his apron again. In the meantime, this business got me thinking. If the resident doctors will continue to work the same way and sport blood smears on their aprons, which might frighten some patients or their relatives and might put the hospital infection committee in overdrive, why not design camouflage aprons for them? After all, there are camouflage dresses for soldiers and commandos. There might as well be such aprons for doctors. I have designed one such, as shown below. The arrows point out drops of blood. This design is open source and royalty free for personal use. :-)

Travel Voucher Tyranny

We have this Whatever Jubilee Society Trust, where we have to put funds generated through donors or for conferences, and they pay out for the expenses after deducting a hefty 10% as processing fee. We had conducted a few ‘continuing medical education’ (CME) programs. One of the minor expenses had been for the servant to go to the medical council office to submit CME certificates, and for another servant to go collect them after certification. They had to be paid Rs. 12/- each, which I could have done from my own pocket. But the CME funds had to be used appropriately. So I put their bus tickets in the expenses bills, and submitted all bills for reimbursement. They sent the bunch back, asking me to put travel vouchers, not tickets, as required by the auditor.

“I have put the tickets, and written in my covering letter what the travel was for” I said.

“That won’t do” the clerk told me, and gave me a blank voucher. “Fill this, sign it, paste it on another sheet of paper and submit it along with a covering letter.” I looked at it. On an A4 sized paper, there was a printout stating that Mr./Ms. xxx was authorized to travel to so and so place for so and so purpose, and should be paid Rs. xxx.

“That is wasting a national resource – paper!” I said. They would not budge. So I printed by covering letter with receipt summaries, and in which I printed the voucher, filled it up, signed it and resubmitted it. It came back promptly, stating that the voucher could not be a part of the printed letter, it had to be on a separate paper. The clerk or his boss seemed bent on deforestation, considering their penchant for using up paper. I wrote to the trust, asking to ask the auditor to correct the procedure, so that paper would not be wasted. In the meantime I submitted the remaining bills. They did not answer the letter. “Just ignore the letter” the boss person must have said. So finally I wrote a new covering letter, attached to it two vouchers in the names of the two servants, and asked the trust to pay them directly, as was stated in that voucher. I wanted to see if they would take out two bank cheques for the same. After all they always said “all payments by cheque.” That seemed to taught them a lesson. They paid the two servants cash. The next time we had another voucher business to sort out, the secretary wrote to me, asking me to paste it ona sheet of paper that I would throw away as waste. “I don’t throw away paper any time until I have used it” I wrote. I pasted the voucher on the wrapper of a sterile surgical glove and sent it to drive my point home. It did not bounce back. When I sat and calculated the expense incurred to get the Rs. 24/- reimbursed, it came to Rs. 6/- for only the paper, and Rs. 4/- for printing and pasting. If I count the time and energy spent trying to save paper, based on calculation of my earning per hour, it will be Rs. 625/- extra. I wonder if they will understand all this even if they read this.

Hospital Innovations: Bird Bath

I think either the Indian mind is innovative, and it becomes more so in our campus. This one is about the contractor doing the building’s repair and renovation. He put up a generator for emergencies, should the electricity supplied by the city’s supplier fail any time. The first time it failed, it was the middle of the night. The generator did not kick in, and the OTs were in blackout mode for a half hour. The next time it happened right in the morning, when the routine OTs were in full swing. The first time the Boss did not know about it because it was the middle of the night. The second time he had first hand experience, when the endoscopy monitor blinked off and the operative field became void.


‘It must be the rainwater leaking through the corrugated roof of the shed on the generator’ the contractor must have thought. He put up thick plastic sheets over the roof to stop the rainwater. This being the routine for all illegal huts in the city and roadside hawkers during monsoon, we had known about it.

“See that water collected at the edge where the plastic has sagged?” someone pointed out through an upper storey window. “It should not collect there.”

The roadside vendors push off the collected water by elevating the middle of the plastic sheet during rains. The contractor did not want to do any maintenance. He just want to finish work, get paid, and move on. The water remained.

“Get the water off” I told his supervisor.

“Let it be” he said. “The birds can drink it.”

“They can even bathe in it” I said. But there are a lot of puddles around. We don’t want one more.”

“This is a rooftop puddle” joked a colleague.

“It is not possible to get the water off every now and then” he said. “The shed is pretty high.”

“It does not matter” I said. “It is hazardous. It is breeding mosquitoes. It is spreading malaria in the hospital from patient to patient. The civic administration will not like it.”

That did the trick. The next day the plastic was wrapped around the edges so that it could not sag and collect rainwater.

Two questions remain unanswered. Why did a brand new roof leak? Was the generator trouble sorted out by the plastic cover over the roof?

Hospital Innovations: Psychiatrist's Couch

The corridor is the place where the relatives of patients sit while they wait for their patients in the ward to get well. We had sturdy, teak wood benches, which were pld and had stood the test of time while generations of relatives sat on them and generations of bed bugs were said to have lived in their crevices and thrived on the relatives' blood. When they renovated the building, the architect-contractor pair managed to put stainless steel benches, while the heritage wooden benches went their own way or someone else's way. We found the following near one ward, and they remained just like that for months.

"Why do they not repair them?" I asked. I was not expected to know, because the benches were not given to any of my ward sisters to manage. "Sir, it is said that the personnel of the concerned area have deliberately removed the legs on one side, so that the relatives do not sit on them" someone told me.
"Whyever not? That is what they are meant for."
"The relatives throw wrappers of food articles, empty water bottles and other stuff where they sit."
Ah!" I said. I knew they did that.
"That is why they do not get them repaired."
"That is quite innovative" I said. "I don't think any man or woman can sit on these benches in their current state."
"Sir, we can do better" said another innovator. "We could send them to the psychiatry department. The psychiatrist's couch is like that."
"Luckily I have not had to see a psychiatrist's couch. I have seen pictures, but they did not show such a tilt. "Are you sure they have such a tilt?" I asked.
"Yes, Sir. It is meant to counter the tilt of the brains of those patients."
Then I knew he was pulling my leg.

Ill-Wishers

Very few people are well wishers, some are neutral, and all the remaining are ill wishers. The ill wishers are of two types – sometime-ill-wishers and all-time-ill-wishers. The former wish someone ill only sometimes, and are neutral at other times. The latter hate that someone so much that they wish that person ill at all times. If wishes could kill, the earth would soon be extinct of all human beings.


I have my quota of ill-wishers, like everyone else.

There was one Professor who was junior to me, but probably wished otherwise. She would pump me to get ill comments on that time Head of the Department, and would go tell tales to create trouble for me. Fortunately I could read character and was wise to these moves. That could reduce trouble from the Head of the Department, but not the bad feeling coming from ill wishes. I recall the time when I was getting fever for quite some time. I kept working, because there was no one else in my unit to work in my absence. Initially the tests were all negative, though it used to respond to antimalarials, only to recur. One day this Professor came along and asked me how I was. I told her how I was.

“If all tests are negative, there is only HIV infection left” she said in a voice full of hope.”

“No. It is resistant vivax and falciparum malaria” I said, having just received the report from an advanced lab.

“Uh…” she said. I was upset at the unhappiness on her face at that news. No one should wish HIV infection on another, even if doctors are known to get it through contact with patients’ blood!

There was another all-time-ill-wisher, a Professor who was also head of her department. Our dislike for each other was mutual. But the comparison ended there. She hated me, while I pitied her for her incompetence, megalomania, and a few other traits. That day we were in a meeting with the Dean.

“What happened to your hand” the Dean asked me, looking at band-aids on two of my knuckles.

“I had minor injuries while cleaning our domestic flour mill” I said.

“You had tendon injuries too?” this ill-wisher Professor asked, her voice dripping with hope and happiness.

“No, just abrasions” I said. I actually wanted to say ‘Unfortunately no, you idiot. Tendon injuries are not managed by application of band-aids” But I refrained. I could not lower myself to her level. But the ill wish was upsetting anyway.

Then there was that Associate Professor, who was a weird ill-wisher. She wished ill for all critical patients I operated. If there was any untoward event in her opinion, she would come forward gleefully, with an evil glint in her eyes and point out what she believed was wrong with what I had done. When I explained what had been done, and that there was not the complication she thought was there, she would go away crestfallen. This happens quite periodically, but she does not mend her ways.

I have not done anything to these three persons. I have not wished them ill because I understand my negative thoughts about others would hurt me too. Luckily one of them left for greener (!) pastures, while another retired before they increased the retirement age by four years. I tolerate the third one somehow. I have tried to analyze why they wish me (and others too) ill. I have found a common factor. Two of them lost their husbands, while the third failed to find one. I don’t know if this is statistically significant. I am trying to learn statistics better. I hope the sample size is OK, because I just cannot stand to have more studies done in this regard. :-)

Desi Formula 1

Kissing Ovaries

The two ovaries normally lie on the posterolateral aspect (behind and to one side in simple English) of the uterus, near the cornua. They may come to lie behind the uterus, stuck to each other in the midline. Then they are called 'kissing ovaries'. It must have been someone romantic who coined the term. Since it is quite appealing to most people, it has stuck. Most of the cases are due to ovarian endometriosis. But I have seen a few with pelvic inflammatory disease too.
Today my people were operating on a case of bilateral endometriomas, which were about 2-3 cm in diameter each. The laparoscope was inside the peritoneal cavity, and the camera was attached to it. The picture was seen on the endoscopy monitor.
"They are kissing ovaries" the operating surgeon said. But when they were manipulated, they moved away from each other, only to go back to original lip-lock when the pressure was removed.. They were not adherent to each other. They were just held next to each other by their adhesions to the adjacent part of the uterus.
"They are not truly kissing" I said. "It is just a platonic kiss."
They proceeded to remove the endometriomas. When that was done, I said, "Now suture up the ovaries".
"Umm ..." said the operating surgeon, "I think I will not suture them. I cannot do that."
"If you do not suture the cut edges, the raw surface will invite adhesions" I said.
"Yes. But I won't because I have not done that before."
"Then they will actually stick to each other as they appeared to be doing. Then the kiss will no longer be platonic" I said.

Training on Walking Styles

One of our Assistant Professors was getting married.
"Now you must learn to walk like a woman" said another woman Assistant Professor to her. "You need to appear delicate and womanly, not like a soldier on march."
The to-be-married one smiled at that. I did notice a little slowing of her gait for a few days afterwards, but not much change in the style. She went to have a good marriage. When I mentioned this to my wife, she said there were grooming institutes which taught such things. One of the methods recommended by a knowledgeable person was to keep a heavy book on the top of the head and walk without dropping it. She wanted to show me how.I had my Gray's anatomy. But I loved the book, so I decided to give it to her. I settled for the preventive and social medicine book, which she dropped on the third step. I had dropped it enough times when I had gone to sleep reading it, so it was not damaged further noticeably. But I got the idea. That was quite some time ago. I noticed something new recently, which reminded me of that training exercise. Two of our senior resident doctors were walking ahead of me towards the hospital building. their gait was real slow and careful, quite different from the usual rush to get things done. Such gait is usually seen only in TV ads. I wanted to ask them if they were in training, or if they were getting married and someone had advised them to walk differently. When I drew abreast of them, I saw they were holding small plastic cups of tea filled to the brim, walking carefully so that the hot tea would not spill and burn their fingers. I distanced myself from them, lest they spill the tea trying to show respect to me [which they do until they pass out :-)]. But this could be an exercise better than the one with a book on the head - books are expensive and have a better use.

Partial Biophysical Profile

		Well-being of a fetus is assessed by different methods. One of them is a nonstress test, in which acceleration of the fetal heart rate with fetal movements is assessed electronically over a period of 20 minutes. It is one of the oldest tests and quite reliable. Then came the biophysical profile, which assesses 4 ultrasonographic parameters in addition to a nonstress test. These are fetal movements, fetal breathing movements, fetal tone and amniotic fluid index. These are assessed over a period of about 30 minutes. It is said that a nonstress test may be omitted if the other four parameters are normal.

As luck would have it, the hospital has no fetal heart rate monitor for use in the emergency hours, the monitors having been condemned long ago, and the new purchase being stuck at an unknown (to us) level for a very long time. So our smart residents send all patients who need such monitoring for a partial biophysical profile in emergency hours, which is to be done by the ultrasonographers. The most important parameter is not assessed. Why the textbook of obstetrics (Williams 23rd edition) made this recommendation of omitting a nonstress test is beyond my comprehension. Surely that posh hospital in US does not face the same deficiency of fetal monitors as we doo in a poor country? The ultrasonography residents are overworked and as smart as our residents. So the 4 parameters get assessed in 4-5 minutes and the patients come back with a score of 8/8.

I know both the sides of the story. My final solution is to ask the gravida "does your child move well?" If she says yes, the fetus is well. If not, I get a nonstress test done in office hours the next day. That is going back to basics.

Handling a Thief

We had had a series of thefts in the institute. The thief used to steal brass deadbolts. He would break down locks and remove the deadbolts. He would not steal anything else. We had captured his video on CC camera. I handed over the video clip to the security officers.But still he kept on with his work for more than three months after that. Finally they caught a thief yesterday and brought him to me for identification. They had lost the video I had given them.
"Is he the same one?" they asked. He looked similar. The same bitemporal baldness, the same facial features, the same haversack on his back. But he had no shirt and trousers on. There was just a sort of loin cloth to cover his modesty (yes, even thieves have modesty).
"He looks the same" I said. I will show you the video for confirmation. But why is he wearing just a loin cloth?"
"We removed his shirt and trousers and gave him a loin cloth" the security officer told me. Now he won't run away."
That was indeed a novel way of keeping a thief from running away.

Tolite? Jim?

We have this elderly clerical person, who is quiet, cooperative, helpful and willing to work.  One thing she probably cannot do is write good English, but she manages. One of the jobs done by her is to maintain various keys of different places in the department. The other day I wanted the key to the department's toilet. You may wonder why we need to lock the toilet door. Well, that is to keep visitors out (they have their own toilet) and keep the taps safe from thieves. When I got the key, I looked at it and was confused by the label on the key chain.
'Tolite" it read. I used to solve jubled words puzzles as a child, and I have not forgotten the art. After a few seconds I understood it was 'Toilet' and not 'Tolite'.
"Who has written 'Tolite' on this key chain?" I asked her.
She looked at my face. She also knew by experience  that when I asked some question, there would be something wrong with it.
"It is the other clerical person" she said.
When I met the other clerical person, and asked her about this 'Tolite' business, she maintained it was not her, but the first clerical person who had written it, as a part of her job. I left it at that. Then the other day I had to fix the exercise bicycle in our department's gymnasium (not a part of my job, but the engineers would not do it and I had to do it), I asked for the key to the gymnasium. I took the key and looked at its label to confirm that I had got the right key.
'Jim' it read.
Oh, they probably mean 'Gym' I thought and went to fix the cycle. When I returned the key, I asked the second clerical person and got confirmation that the first clerical person had labelled this one too.
"Do you know what is on the label?" I asked her.
"Jim something" she said.
"What does it mean?" I asked.
"Umm ..." she said with a confused face.
So even if we had switched their job descriptions, the result would probably have been the same.

Confusion in Anesthesia: New Take

One Professor was visiting us and talking about his own experiences.

“I don’t know how to cope” he said. “I have not experienced anything like this from anyone else before.”

“What do you mean?” I was confused and showed it.

“It is my Associate Professor” he said. “The other day, I found a patient in the postoperative ward, recovering from anesthesia and surgery. She has undergone cryocauterization of cervical erosion, the Registrar said. I was surprised. It is something that requires no anesthesia and no hospitalization. So I asked why she was in the postoperative ward. Madam asked us to give her anesthesia, so we gave her TIVA, the Registrar explained. I remembered the said Associate Professor making a fist of her right hand, saying ‘now cryosurgery’ and marching towards the OT as if going on a mission. I was surprised, but never thought she would get it done under TIVA. So I told the Registrar not to use anesthesia again, but two weeks later the Associate Professor got another cryocauterization done under TIVA again. I had to speak to her firmly to break this habit.”

“Hmm…” I said. There was nothing else worth saying.

“Then there was a patient who was undergone an MTP in another civic hospital. She had some retained products of conception, and had come to us. When I asked her why had she not gone back to the doctors who had performed the MTP, she started crying and said they had done it without any anesthesia and it had been very painful. So I told my entire unit, including the Associate Professor to do her D & C under general anesthesia, like TIVA. But when I reached the OT, I found this patient screaming on the operation table, undergoing D & C. It turned out they were told to do it under local anesthesia by the Associate Professor, even when she was reminded that I had specifically asked them to do it under general anesthesia. The patient was fit for anesthesia.”

“She must have guts, overruling the boss” I said.

“I suppose so” he said. “I asked her why she did that, and she just kept looking at me.”

“Did you give her a memo?” I asked.

“No. I think she has a lot of baggage that memos will not get rid of” he said.

“Maybe she wanted to just get the list finished and run away” I suggested. “Or may be she does not like to be told what to do, even by the boss.”

“Perhaps. But the painful thing is that this same person keeps preaching kindness to patients, bioethics and humanities all the time.”

“Heavy stuff” I said.

“I don’t understand that myself” he said, “but now I wonder if she understands it herself.”

“Perhaps the explanation is quite simple” I said. “She does not know what anesthesia is required for what procedure, either because her teachers did not teach her, or she did not read on her own, or both.” That left him as confused as his Associate Professor was about the choice of anesthesia.

Confusion in Anesthesia: The Government’s Take

There are generally quite clear guidelines on the choice of anesthesia for every surgical procedure. Some operations can be done totally under local anesthesia. Some require general or regional anesthesia. Some are best done under general or regional anesthesia, but may be done under local anesthesia with parenteral analgesia if the patient is unfit for general or regional anesthesia. The choice of the patient also needs to be considered. If a patient demands a particular form of anesthesia despite counseling by the anesthesiologist to the contrary, it has to be given provided it is not contraindicated. Then there is the government to be considered. For female sterilization procedures, the government regulation is to administer only local anesthesia. Only in teaching hospitals, a regional or general anesthesia can be given, because there are doctors in training. Poor patient has to suffer pain (the local anesthetic often proves to be inadequate, we have seen) because the government feels so. Well, if the government can decide what people can eat, what water people can drink, at what age people can drink (not water), and at what age people can have sex, why can the government not decide what anesthesia can people have for undergoing a sterilization procedure?