New Design for Hospital Wall Tiles

The fellow who fitted wall tiles during the repair and renovation work of our institute must have been hard pressed to save money, having had to bid a low price in competition with other contractors, and allegedly having to spend a significant bit of it to pay off people for many reasons. Guy probably saved on the cement and any other adhesive used to stick the tiles to the walls. After the adhesive property of the stuff wore off, the tiles have started coming off. He fitted them with long screws over steel plates at some places. But that must be expensive. He must have also realized that finally the entire wall would be stainless steel armor plated, which he probably could ill afford. Now he has left the sites of the fallen off tiles alone. I have a suggestion for him and others like him who have to do what he had to do. I have a new design for wall tiles.

It looks exactly like the surface left behind when the tiles fall off. When the surrounding white tiles remain in place, the sites of fallen off tiles look ugly. But if the original tiles look similar, no one will notice it when a few fall off. The only problem would be to convince the administration to accept that design of wall tiles. One can sell the idea by calling it modern art and the current fad. If that fails, one can use the conventional universal motivator used in public sector – one that rarely fails.

Liquid Paraffin Dressings

"Sir, this patient's wound has gaped. The slough is just not going away" my Registrar told me.
"Have we finished her course of antibiotics?" I asked.
"Yes, Sir."
"I will look at it" I said. When I looked, I was surprised to find something oily inside the wound.
"What are you applying to it?" I asked.
"We put liquid paraffin on the floor, and povidone-iodine on the sides of the wound" she said.
"Liquid paraffin?" I was surprised. "What is the rationale in the use of liquid paraffin?"
"Sir, it is like glycerine. It absorbas water and reduces edema around the wound."
"That is not possible. It is a product of petroleum. It is not miscible with water."
"Um... it stimulates formation of granulation tissue" she said.
"It is inert. How will it stimulate anything?" I asked.
"...."
"When you coat the surface with this oil, the antiseptic cream will be kept away from the wound surface" I said. "You are actually harming the patient."
"....."
"Is it sterile?" I asked. "Let us look at the bottle. So she looked at the bottle and handed it over to me reluctantly. I also looked at the bottle.
"It just says liquid paraffin" I said. "It does not say the contents are sterile. It does not even say 'sterilized by so and so method'. The contents are not sterile. You are dressing her wound with unsterile substance, which does not have any medicinal property to promote clearing of the infection or healing of the wound."
"....."
"It is as it came from an oil well" I said. "It contains bacteria which you can call Petrococcus arabia, Petrococcus irania, Petrobacillus iraqa, or Petrobacillus canadia, depending on where the oil well is situated."
"No, Sir."
"The names are fictitious. But I suggest you get microbiological tests done. You could write a paper on it. You will be famous."
"No, Sir."

Sponge Holder for Post Cervical Biopsy Hemostasis

Cervical punch biopsy is an outpatient procedure, usually performed without any anesthesia. If the cup of the biopsy forceps is not very small, the chunk of tissue removed leaves behind a small crater which keeps on bleeding. It stops by itself in some cases. It may stop on pressure with a folded piece of gauze in some cases. But usually the bleeding starts when the gauze is removed to see if it has achieved the desired effect. Electrocauterization is a possibility that is quite effective, but not very comfortable for an non anesthetized patient. It has its attendant complications too. Placing a hemostatic stitch is not desirable in an outpatient setting. Electrocauterization and a stitch are not often possible in the outpatient setting. I use a sponge holding forceps for this purpose. I apply the forceps to the bleeding site and keep it applied for a few minutes. The patient does not experience any pain once it is applied. Its flat surface compresses the bleeding vessels and achieves their thrombosis, so that there is no further bleeding after the removal of the forceps. The instrument is atraumatic, so there is no risk of damage to the surrounding cervical tissue. It saves on suture material too, which is important in a resource poor country. It does away with the need for an electrocautery, which also is important in a resource poor country.

Iatrogenic Hypoprolactinemia

We had a patient who came to us for infertility. She had galactorrhea, but was otherwise normal. Her investigations were normal, including serum prolactin (10 ng/ml). Actually she should have been assured that all was OK and she should proceed with evaluation and treatment of infertility. Unfortunately one consultant put her on bromocriptine. She took that medication for two weeks. Then someone realized she had to undergo hysteroscopy and laparoscopy for evaluation of infertility.
"Sir, shall we post her for endoscopy?"
"Yes" I said after checking all of her reports. There was no need to treat galactorrhea when there was no endocrine abnormality. I was unhappy with her bromocriptine therapy, but it could not be undone.
When I reached the OT the next day, I had a surprise waiting.
"Sir, we got  an endocrinologist's opinion while she was in the ward awaiting surgery" my Registrar told me. "He advised serum prolactin, T3, T4 and TSH assay."
"What were the results?" I asked.
"The hyroid function is OK. The serum prolactin level is 0.2 ng/ml."
I was aghast. I had not seen such a low level any time."
"We shall call this iatrogenic hypoprolactinemia" I said.
"Sir, the patient is OK."
"God be praised" I said.

Attitudes: Controlled Noncooperation

I was filling the confidential history sheets of people working in my department. There are multiple items, with multiple choices for each. One has to select one of the choices. There is a column about the nature of the people. One of the options is 'cooperative'. That one started me thinking about a new thing: controlled noncooperation. A couple of examples should make this clear.
Once I had written about a management problem to one of the Deputy Deans of the institute. It was a serious problem, and required a solution quickly. The paper came back after four days. The concerned Deputy Dean had written 'I don't look after this work.' There was no mention of the person who looked after that work, though as Deputy Dean he should have been aware of the person whose job it was. Finally I had to write to the Dean to get that work done. I don't know who he was not cooperating with - me or that person whose job it was.
The other day, someone asked for information on child mortality in the institute. The request came through 'right to information act'. I assigned the job to a person who lookedafter this bit of information and had answered such questions in the past.
"We should not be giving this information" that person told me. 'The term children includes a lot of age groups, while we have only newborns."
"I understand. Let us provide information about newborns, and tell them collect information from  departments of neonatology and pediatrics about deaths of other age group children."
The concerned person went away unhappy. When I received the paper for signature, it had information about neonatal deaths, and a note stating information about other children's deaths should be obtained from other departments. I could not do what this person had done. So I cancelled the word 'other' and put pediatrics and neonatology there, and sent that letter. I wonder who this person was not cooperating with, me or the information officer. When I was talking to someone about this, I suddenly remembered that this non-cooperator's previous boss used to behave similarly. When we had needed a computer scanner for our department, I had asked this boss to process for one, because the Dean had assigned the job of looking after computers to her. She had written a letter to the engineers stating 'provide us with a scanner' in just one line. There was no mention of what sort of scanner was needed - computer scanner, CT scanner, MRI scanner, ultrasonoic scanner or any other. Obviously there were no technical specifications attached, as was a standard requirement when procuring any  equipment. I had to throw away that letter and do the whole thing myself. I got a scanner, as I knew I could. But if I had to do all the work, were these non-cooperators there just for a salaried ride?
Now I think the concept of controlled noncooperation should be clear. It means not to cooperate while giving the impression that one is cooperating.

Who Was I?

It is a question that has troubled many a philosopher, but not in the past tense. 'Who Am I?' has been said by many people with deep thinking abilities, trying to find out deep things about self. I asked this question in a different context.
I use StatCounter, which a wonderful free net service, that tells one about the visits to one's website or blog. It tells many things related to it, including how a person reaches one's website or blog. I had a visitor the other day, who had reached my blog using another wonderful free net service - Google. The search terms he had used were 'Who was s v purulekar?'
He/she was from West Bengal. A few things about the Google search made me wonder. One was that my initials were in lower case, and so was the p at the beginning of my surname. Perhaps the guy had forgotten to press the shift key while typing. The other thing was that he had put 'u' in place of 'a' in my surname. Credit goes to Google search engine, which got him to 'S.V. Parulekar' when he had asked for 's v purulekar'. The main disturbing thing was that he thought I belonged to the past tense, while I was still around - perhaps not around his hometown, but definitely somewhere out there. Perhaps he thought all great people belonged to the past? :-)

Persistent Sleepers

I had a lecture for the undergraduate students in the post-lunch session. It seemed to be a merry crowd. The students kept filing in at a slow and leisurely pace. I had said 'Good afternoon' to the class before beginning of the class. But I could not keep saying it every time someone walked in.
"Will you kindly say 'Good afternoon' for me to people who keep walking in?" I asked the fellow sitting near the door. He did not say anything - neither yes nor no. But he did not seem enthusiastic about it, and did not say that to the next batch which walked in. So I kept saying it every time a group walked in. I think they missed the sarcasm, and thought I was a very well mannered teacher.
Once they all had settled down in their cushioned comfortable seats, they started their usual activities. A boy in black T-shirt and a girl also in black T-shirt started an animated chat, which I could not hear owing to the distance between us, but could see very well. After some time, I realized they had no intention of letting up, nor were they discussing some point in m my lecture that they had not understood.
"Will you kindly stop chatting?" I said. "It is distracting me."
They stopped. The fellow immediately put his head between his forearms on the bench and went to sleep. His chatting friend started showing some interest in what I was saying, probably out of fear of being caught once. Two other girls - one in the last row near the exit and one in the middle near aisle went to sleep. All three kept sleeping throughout my lecture. When I ended, I solved the questions some of the students raised. Then I said,
"Like the problem of persistent occipitoposterior position that we discussed today, there is another problem in medical education - that of persistent sleepers. I request the neighbors of such persistent sleepers in this class to wake up the sleepers after I leave?"
I hope they did as I requested, partly because I was feeling guilty having interrupted a chat between the chatters, and partly because the next teacher would not perhaps take it so kindly if they slept during the class.

Designer Benches

They have put designer benches in the waiting area in the corridor of the hospital building. They have some interesting features. While we were taking round of different wards today, suddenly there was a crash. We all turned around to see what it was. The joint between two halves of a bench had given way and the occupant f the seat was on the floor.
"These joints always give way" one resident doctor said. I knew that. There were a number of such benches along the corridors on all floors of the building. I had thought of sending some to the psychiatry department as their couches for psychoanalysis sessions.
"Let us call this casualty prone area" I said.
"Yes. We should put up boards saying 'sit here at your own risk' " my Registrar said.
We moved on. Then we came across another such bench, and suddenly knew what the purpose of such benches was. At the low end of the bench was a toddler, sitting comfortably with its feet reaching the floor. At the other end was an adult, his feet also reaching the floor comfortably.
"These benches are designed so that a family with members of different heights can sit together, without the feet of shorter people dangling in the air" I said. "What I do not understand is why they did not ship the benches in this final form? Why put them up straight and let them break at the joints one fine day?"
"The idea is probably let people find a bonus unexpectedly" suggested someone.

Ban on Medical Sales Representatives

"Sir, our hospital has banned medical sales representatives from entering wards and outpatient clinics. It is in the newspaper today" my Assistant Professor told me.
"Why?" I asked.
"It is said the hospital took the decision after a sting operation by Zee Business showed a doctor from the medicine department accepting a gift voucher of Rs5,000, along with a list of medicines from a leading pharmaceutical company’s sales representative."
"Oh, God!" I said. "I had heard about the sting operation. It seems the pharmaceutical's representative did the sting operation to teach his bosses a lesson for giving him a notice for something. Otherwise which company would do it to harm itself? It could not be done by the TV channel, because the doctor would not meet an unknown person and accept a gift."
"True."
"I had stopped the medical representatives from entering our outpatient clinic 2009 for sticking their promotional posters to our walls and furniture. Then one of them wrote a  letter to our Director on his stationery as an office bearer of a local political party. He maligned me for that decision, asked who had given me the authority to stop them, said I had started thinking I was God, and asked the Director to allow them to enter the outpatient clinic again. A meeting was held by the Director, attended by a bunch of medical representatives and I. I pointed out that defacing MCGM property was a crime, especially when the building was a heritage building. Entry of sales representatives in area where patients are treated was also a crime. Entry by unauthorized males in an area where women are examined would invite ire of human rights ministry and activists both."
"Then?"
"The Director told them that they came to us asking for something, and they should not take such a high handed approach, and they definitely could not deface our premises. He allowed them to enter our premises after they promised to behave and not stick anything anywhere."
"That was good."
"When the Academic Dean called a meeting of all heads of departments after this sting operation and asked my opinion on the issue, I told I supported the idea of another professor that the medical representatives should be banned from entering our premises. I narrated the story I just told you. I said it would happen if they had the political will to do so. It seems now they have found the will. Now let us see what that smartaxx representative who wrote that maligning letter about me will do. All this would not have happened if they had implemented my idea that time three years ago."
"True!"

Laparoscopy: Pneumoperitoneum Scare

My Assistant Professor was performing a laparoscopy. He had just performed a hysteroscopy on that patient. When he put a Veress' needle into the peritoneal cavity to create a pneumoperitoneum and aspirated with a syringe, he got a free flow of fluid.
"Oops!" he said. Perhaps the needle was in the urinary bladder, though the woman should not have had any urine in her bladder, having passed urine before entering the OT. He withdrew the needle and reinserted it. He aspirated fluid again.
"Wait for me" I said. "Don't do anything until I come." I washed up, put on sterile gown and gloves and took over. My efforts at putting the needle into the peritoneal cavity met with similar results.
"I think the tip of the needle is lying in a pool of Ringer's lactate that you used for distending the uterine cavity for hysteroscopy. That fluid must have entered the peritoneal cavity through the fallopian tubes." I proceeded with the laparoscopy. I was right. There was a big pool of fluid in the anterior peritoneal pouch, though it is usually in the pouch of Douglas. The urinary bladder was empty. There was no abnormal finding. The tubes were patent, as confirmed by chromopertubation.
"False scare!" I declared.
One month later I was assisting my Registrar perform a htysteroscopy-laparoscopy on another patient. The month old history repeated.
"I think it is the hysteroscopy fluid collected in the pelvis that you have aspirated" I said. "Anesthetist, please auscultate her while we insufflate carbon dioxide through the needle. See if there are bubbling sounds."
He auscultated and declared there were bubbling sounds.
"That is the gas escaping into the pool of fluid" I said. I wonder if gas is insufflated into a partially full urinary bladder, similar bubbling sounds will be heard.

Key Holder

We have this control room which is the nerve center of the department's closed circuit security cameras (CCTV), and also the stack for the entire building's internet connections. The cost of the equipment is unimaginable, and the importance immense. The room is locked and the key is kept by the contractor who installed the equipment. If there is any need, he opens the place so that work may be done in the room.

When we had a break-in into many rooms in the department, the hospital security personnel wanted to see the CCTV footage. They could not find the person holding the key, probably because he had been withdrawn from the premises for reasons unknown. There was some internet connectivity problem that day, and we needed access to the stack too.

“I cannot open the room” said the Professor who is amateur network engineer and looks after our network. “The key is closely guarded by the contractor.”

We kept waiting for the contractor to be contacted.

“Sir, we found the key” said the chief security officer after a long wait. “It was kept with the person who sells baby towels and sanitary napkins near the labor ward.

I was aghast, as I frequently am these days. “But he is a handicapped person allowed to sell these things there for helping him make a living. He is not employed by our hospital, and cannot hold a key to such an important place” I said.

“We are trying to find out how he came in possession of the key” he said.

I have been waiting for a month, but the answer to that question is still unanswered.