Clash of Exhausts

We have this wonderful arrangement, in which there is a corridor that runs from the college building towards the hospital, passing between the lavatory block on one side and the canteen on the other. There are exhaust fans fitted, quite justifiably, for the lavatory block and the kitchen of the canteen.

The exhaust generated by the fans is directed as shown by the arrows. A seasoned employee knows the trick of walking along the corridor, such that he gets to inhale only the aroma of good food and avoids inhaling the pungent odors from the lavatory block. If one walks with the kitchen on one's left, one has to rotate one's head towards left through 30 degrees, close the right nostril and inhale with the left nostril. If one is passing in the reverse direction, one has to turn one's head towards right through 30 degrees and close the left nostril and inhale with the right nostril. The results are remarkable. If one keeps both nostrils open, the results are variable, depending on which odor is stronger. If one does exact opposite of the recommended maneuver, the results are terrible, one ending up with urinary smell that persists for a long time. I have written this article for visitors and new persons who join this place for various reasons.

Obsessive Compulsive Mobile Losing

A new type of obsessive compulsive neurosis has been named (by me, who else?). It is called Obsessive Compulsive Mobile Losing. Mobile phones have long been associated with a psychiatric disorders - addiction. There is even an obsessive compulsive disorder associated with it - that of peering into the mobile phone. There is a phobia of losing mobile phones. But the neurosis I am about to describe is the first time it has been reported in the world literature. I will give two examples of this disorder.
The first one is of a relative who loses his mobile phones in public places. The first time he lost it in a cab, when he placed it elaborately on the seat next to him, along with a small packet of some food article he had purchased. While getting down, he carefully picked up the packet and left, leaving the phone behind. He never found it again. At another time, he was riding pillion with a friend on a bike. Over one of the potholes found all over the city roads, the bike jumped quite a bit. The mobile phone from his shirt pocket jumped out, and landed on the road as the bike sped on. While he was telling his friend to stop so that he could go get it, a truck ran over it, and made it sort of flat. He had no heart to pick it up. He lost one more mobile in some equally exotic way, but did not get around to recounting the story to me.
The other story is that of a neighbor. He places his mobile in his trousers pocket. When the trousers are put into the washing machine, the mobile goes in, gets washed, rinsed and spun and does not recover from the insult. He has lost three instruments in this manner.
"I lose them to the washing machine" he says. "That is why I do not buy expensive ones."
I leave it to my psychiatry colleagues to analyze the underlying mechanism of this disorder. I have an idea, but am afraid of putting it down, lest I upset these two people, and more like them that must be about.

Helen Keller School of Medicine!

We were taking a round of the postoperative ward. There was a patient 16 hours after undergoing a cesarean section. Her abdomen looked like this.

"What is that scribbled on her abdomen?" I asked.
"Sir, it is her abdominal girth" the Registrar told me. "We have written it there, so that when anyone measures it, he would know immediately if the girth had increased.
"But why write on her abdomen?" I asked.
"........"
"Why such big letters?" I asked. I got a smile which was even bigger than the letter size.
"Who wrote it?" I asked.
"The smile continued.
"It must have been written by someone from Helen Keller School of Medicine" I said.
The smile diminished a bit, while new smiles appeared on other faces.
"If I underwent an operation and someone wrote some such thing on my body, I would sue that person" I said mildly.

Whatever - The Attitude

One of my Registrars went to UK for appearing for MRCOG examination some time ago. She wanted a recommendation letter from me. I gave it to her. The UL authorities asked me about her, with a view of verifying the statements therein. The answer was to be faxed.

“Sir, will you please fax it urgently” she asked me on phone from UK.

“First thing in the morning” I assured her.

I sent the fax the next morning. It was pretty expensive, compared to local faxes. I noticed the cost also because I had to spend the money myself, which perhaps would not have happened if the office had sent it, after charging the student appropriate fee. Anyway I did not mind doing it for my one time student. In the afternoon I got a call from her again.

“Sir, the local office says they have not received your fax” she said in semi-panic.

“Take down the fax number and acknowledgement number” I said and gave her the numbers. An hour later I got a call from her father, who had been a civic body big boss before superannuation.

“This fax that you say you have sent or whatever” he said. “The UK office has not received it yet.”

I wanted to get mad at him because I did not like his insinuation that I was just saying that I had sent it without actually having sent it. Furthermore, I had sent it spending my own money, when it was not my job to do so. If the guy did not want to spend money for it, he could at least be grateful for it. I kept my temper.

“I have the acknowledgment” I said quietly.

“Will you give it to me?” he asked.

“If you send someone to collect it, I will.”

“I think the letter should be faxed again” he said.

“I will give the letter to you” I said. “You can fax it.” I should have done that the first time, I felt. But I had done it for my old student, not her father. He sounded unhappy about it, but agreed to do so. He asked another very senior professor to collect it from me and fax it. That person obliged, probably because it was a give and take of some sort.

All this happened many years ago. But every time someone uses the word ‘whatever’, which I dislike for the attitude behind, I think of this person who thought it was his right to get his work done by civic employees, even when he was not civic bid boss any more. Perhaps it has to do with the power the IAS cadre wield throughout their careers.

Cocoon

Some moth or butterfly visited us sometime and laid down a cocoon which we noticed long after it was formed. I searched the net and did not find a similar picture anywhere. It has nothing to do with my profession. But I thought I might as well put it up for anyone interested to see. In case anyone thinks it is not a cocoon, please feel free to email me. These are the side, front and bottom views.

Sticking plaster as eraser

People in my institute specialize in the use of sticking plaster (adhesive tape) in ways more than one can imagine. Practically every department uses it in innovative ways.I had done extensive research on the topic before writing an article on this topic and thought I had listed all possible uses of the sticking plaster, conventional as well as unconventional, as found in our institute. But I was wrong.

The other day we were working in the OT. I was checking the consent given by a patient for undergoing an operation. There was an error in the form.

“This is an error” I pointed it out to my Registrar. “Please correct it.”

I thought she would get a new consent form, fill it up, and get the patient’s signature again. Either she had no spare form, or she was eco-friendly and did not want to waste a sheet of paper, or there was no time. I think it was the last reason. They are very particular about time slots in the OT. They do not permit induction of anesthesia after 1:00 P.M. Any wastage of time means one or two operations getting postponed. SO she took out a strip of sticking plaster, stuck it over the word to be changed, and pulled it off. A thin layer of the paper came off with it, removing the unwanted word. Then she proceeded to write a new word in place of the one just removed. I suppose this would not be acceptable on a bank cheque or an affidavit, but was OK on a consent. She took the patient’s signature on the change. She achieved two things – one was a correction in the consent, and the other was my education on a newer use of a sticking plaster.

Knife Without Sheath

We needed to cut a piece of a sticking laster in the OT the other day. We could not find the scissors kept there. While we were looking for the scissors, the anesthetist took out long, stout looking scissors from his pocket and offered it to us. My House officer took it and cut the sticking plaster. In the meantime, I got a little worried.
"Do you keep the scissors in your OT pajama pocket like this?" I asked him, pointing towards his pocket located over the right groin area, "especially when you sit down flexing your hip joints?"
"Yes" he said.
"Are you not afraid that the point of the scissors might penetrate your body and harm you ... um... in that sensitive area?"
"Ah, no" he smiled. I had goosebumps all over, thinking of that injury, while he seemed OK.
"Why do you not use folding scissors" I asked.
"Those are quite weak and do not cut sticking plaster easily" he said.
A month and half, history repeated itself in our other OT. It was another male anesthetist, who produced long, stout scissors from his pajama pocket, located similarly as in the case of the first one. I asked him the same questions and he gave the same answers. I had goosebumps like the previous time.
"Do you not have a sheath in which you can place the scissors?" I asked.
"Ah, no" he said, somewhat amused by that thought.
I must talk to my surgical colleagues if they have had any anesthetists with scissors injuries. In the meantime, I am just hoping against hope that no one gets a penetrating injury by scissors.

Harry Potter and Obstetric Forceps

The newborn baby in the postnatal ward was quite cute. But most of the newborns are cute. What drew my attention to this baby was a mark on its forehead. I leaned close and inspected it. It was a curved double edged red mark, of the size and shape of distal edge of an obstetric forceps’ blade. I straightened. The mother was watching my face anxiously.
“Nice hair” I said and smiled as I touched the baby’s cheek. The mother smiled too. We moved on with the ward round. When we were out of earshot of the woman, I asked my Registrar, “what was that mark on the baby’s forehead?”
“Um… er… it is forceps mark.”
“Who applied forceps to the baby?” I asked.
“I did” she said.
“But there should not be a mark if the application is correct cephalic” I said.
“…….”
“It is my theory that Harry Potter had an obstetric forceps mark on his forehead, which the wizards proclaimed to be the result of the dark lord’s curse.”
“…..” either she had not read Harry Potter or thought it wise not to contradict me.
We saw the same baby two days later. I checked its forehead.
“The mark is gone” I said.
“Yes, Sir” my Registrar sounded happy.
“Won’t be another Harry Potter, what?”
“No, Sir.”

Nail Cutter and a Mother

We were in the postoperative ward seeing operated patients. There was a patient who had undergone a cesarean section two days ago. She was standing next to her bed. She was OK. The baby was wrapped up in a blanket. It also looked OK. Something caught my attention. It was a nail cutter.
“What is that for?” I asked.
She smiled and said something I could not hear.
“It is for warding off evil” my Registrar told me.
“Huh?” I said and looked at the patient questioningly.
“A metal object kept in the bed wards off evil, she believes” my Registrar said.
“Is that so?” I asked the patient. I thought I had seen all sorts of customs and beliefs of mothers and their relatives. This was a new one.
“Yes” the woman admitted.
“But the cot is made of metal” I said. “Is that not enough?”
“It has to be on the mattress, where the baby is kept.”
“Uh…” I said.
“She had fever two days ago” my Registrar continued. “Now she is afebrile.”
“After she put that nail cutter there?” I asked. I got a smile for an answer.
“Be careful. Do not cut the baby’s nails with it” I told the woman. She shook her head. “Some relative may come to see you, find that your baby’s nails are long, and may cut them with this while you are not looking” I warned.
“I will take it away and put a spoon in its place” she promised.

GOPD

They run a general outpatient clinic called GOPD (General Out Patient Department). It is manned mainly by interns, and probably by resident doctors of preventive and social medicine. It is like the general practice of doctors who go into private practice after obtaining their M.B.B.S. degree and practice family medicine. Clinical examination is often cursory and prescriptions are based solely on the patients’ symptoms. It is not supposed to be so, neither in GOPD nor in family practice. But many interns do not realize this, I suppose. How they change when they start family practice is beyond my comprehension.

One patient was referred to my outpatient clinic from GOPD for genital prolapse. She had gone to GOPD with breathlessness and prolapse. I looked at her case paper. There were no examination findings. She had been given iron, calcium and multivitamin tablets at the first visit to the GOPD. She had not improved. At the next visit she had received the same medicines, plus tablet salbutamol. She had not improved with that too. I checked her up. She had uterovaginal prolapse. Her respiratory and cardiovascular systems were normal. There was no bronchospasm. I advised her appropriate tests and made a medical reference for her breathlessness. Finally it turned out to be just old age and poor stamina, and having to keep working to survive. We treated her prolapse and she went away happy.

That intern who prescribed asthma medicine without clinical evidence of any bronchospasm reminded me of a student who was in my class. The fellow was supposed to be reasonably bright. When we were posted at an urban slum as interns, he prescribed aspirin tablets to one patient in a dose of 2 tablets four times a day. I was running the dispensary. I dispensed 1 tablet three times a day and went looking for him.

“Why did you prescribe such a large dose?” I asked him.

“The patient said he had ‘verrrry’ severe pain” he said, drawing out the word ‘very’ to indicate a very high degree of ‘very’.

“If the patient had said he had ‘verrrrrrrry’ severe pain, would you have prescribed 4 tablets four times a day?” I asked him. I hear he went to UK to do FRCS, came back to India to try his hand on patients, was dissatisfied by the lukewarm response, went to US and did MS to settle down there. I wonder if he still holds a grudge against me for asking that question.

Heavy Menorrhagia – Light Menorrhagia

The clinical histories of patients coming to our outpatient clinics are written by interns. Based on how much attention they paid to their teachers when they were students, and how much knowledge they acquired when they prepared for their exams, the interns wrote clinical histories of varying quality. One of them wrote the chief complaint of a patient as ‘Heavy menorrhagia’.

“Will you kindly explain what is heavy menorrhagia” I asked him.

“That is very heavy menstrual blood loss” he said.

“Since there is heavy menorrhagia, there must be light menorrhagia too” I said.

“….” He had probably not heard of that one.

“Will you tell me where you learned the term ‘heavy menorrhagia’?” I asked him.

“I picked it up while working as an intern” he said.

“From whom?” I wanted a complete answer.

“From a senior intern or a house officer. I am not sure which one” he said.

“Will you kindly stick to just ‘menorrhagia’ in future, and describe the patient’s blood loss in terms of sanitary pads used per day, the duration of blood loss, and passage of blood clots?” I asked.

“Yes” he said. I suppose he did, because I have not encountered that complaint again on any patient’s case paper, thought there have been plenty with ‘menorrhagia’.

Cancer Institute Maneuver

We have a prestigious cancer institute to which we send our patients with cncer for management. They used to take all of them and treat them sooner or later – usually later if they were free patients. Poor patients accepted the delay because they knew beggars could not be choosers. We did not attempt to treat the patients ourselves because they operated much better than us on cancer patients (being superspecialists) and had facilities for radiotherapy and chemotherapy under the same roof.

“Sir, this patient with ovarian cancer has come back from the cancer institute” my Registrar told me about a patient one day. “They have told her she does not have cancer and she can be operated on by us here.”

I was surprised. I knew she had undergone a hysterectomy in the past and now had an ovarian cancer. Perhaps they had done a fine needle aspiration biopsy of the tumor through the abdominal wall – something we did not recommend for fear of spread of the disease. So I checked her reports.

“There is no report that shows that your tumor is not malignant” I told the patient. “The doctors in cancer institute have not written that it is benign anywhere.”

“They verbally told me so” she said.

I did not want to be involved medicolegally in something like that. I remembered a court case one of the previous directors of that institute had lost recently.

“Please get them to write that report on your paper. I will then operate on you at your insistence, though I maintain that it is a malignant tumor and will not be responsible for any deficiency in service. After all, I am not an oncosurgeon.”

She went back, only to come back again the next day. “Doctor, here is a report from your hospital which states I have no cancer” she said. She showed me the report of Pap smear that we do on all patients, including those who have undergone a hysterectomy in the past. It was normal.

“That one cannot show the tumor cells you have inside your abdomen” I told her. “The top of your vagina is closed after hysterectomy. A Pap smear very rarely shows ovarian cancer cells, even when the uterus has not been removed. Please go back to the cancer institute, get treated and get well soon.”

She went away and hopefully got treated. When I mentioned this event in a meeting, another professor told me that three of his patients had come back in a similar manner, being told verbally they had no cancer when they actually had cancer. A couple of days later, another patient came to me to get a second opinion. She had been advised an operation at the cancer institute. I checked her reports and found that she had ovarian cancer.

“They did not ask you to go back to your doctor for an operation?” I asked.

“No. They asked me to get admitted and operated at the earliest. I saw them yesterday and they are going to operate tomorrow.”

“How much are they charging you?” I asked.

“I don’t know. All my medical expenses are covered by the company I work for” she said.

That looked like selective refusal of referrals by the cancer institute – based on the inability of the patient to pay much, though there were beds reserved for poor patients as per government regulations.