The Certificate Fiasco

"Sir, that application of the resident doctor has come back from the office. The Academic Boss has written the certificate asked for cannot be given."

I remembered the case. This resident doctor had been our postgraduate student. She needed a certificate that she had observed obstetric ultrasonography, because the local civic medical officer was sealing ultrasonography machines of doctors who were MD but did not have such a certificate. It was blatantly illegal, but civic employees in a position of power often harassed people who could be harassed. I had got her claim verified and sent the application to the Big Boss that the certificate could be issued. He had attested it. Now it was back to us.

"Let me see" I said. The clerk handed the paper over to me.

"Observing ultrasonography is not a part of Obstetrics Gynecology curriculum" it was remarked. "This office has never issued a certificate like this before. So it will not be possible to issue one now.” It was signed by the Academic Boss.

“It is funny” I said. “I must find out how this happened.” I called the office, and traced the head clerk who had drafted that letter, and had got the Academic Boss to sign it.

“I am new here” she said. “The clerk met the Academic Boss and got it done.”

Please put him on the line” I requested. He came on line after a delay.

“How do you understand something is not in the obstetric and gynecological curriculum, or how does the Academic Boss do so, being from a different specialty, when I as the head of obstetrics and  gynecology have certified that it is?”

He had no answer.

“And if the Big Boss has consented to issue a certificate, how do you get his junior officer to cancel the decision?” I asked.

“The Big Boss does not understand anything” he said. “He signs on any letter.”

I was aghast. A low level clerk thought he knew much better than the chief of the institute and controller of many other major hospitals and medical education. Not only that, but he had the expertise to manipulate the Academic Boss to reverse a decision of the Big Boss. I only hoped that no one would tell the Big Boss what one of his clerks thought and said about him. “But it is known. Was it not a mere clothes washer (there were no launderers then) who had maligned Lord Ramachandra and Goddess Sitamai in Ramayana?

Spinach and Sausages

I am not sure these two items go together on a menu. Perhaps they do, perhaps they don't. But I found a link between them, and quite a curious one at that.
I was teaching transverse lie to the undergraduate students. The textbook description of the bag of forewaters during labor is 'sausage-shaped', which I described as such because otherwise some of them might feel I had not read the textbooks. But I had a feeling about it. So I asked,
"How many of you do not know what a sausage is?"
One of the 100 students raised his hand, followed by another student, who probably took courage from him and decided to raise her hand. That did not mean that the remaining 98 students knew what it was. In an opinion poll, when I ask people with a positive answer to rasie their hands, a few do so. Then when I ask those with a negative answer to raise their hands, a few do so. A vast majority never raise their hands. They may be considered to be neutral, though they might be too lazy to do so, or afraid of committing, or having a problem of emotional disconnect or a host of other things.
"No harm. Vegetarians need not know what a sausage is" I said. Since they did not need to know about it, I did not tell them what it was. They could always look it up in a dictionary or on Google. "For those, we shall describe the bag of forewaters as 'banana-shaped'."
This made me think of a classmate of mine, who during an undergraduate bedside clinic had answered a question on factors predisposing to urinary calculi as 'spinach'.
"What is spinach?" the Lecturer asked.
"I don't know" the guy said after a moment's thought.
"What made you say 'spinach' then?"
"I read that in surgery book by Bailey and Love" he answered.
This guy went on to become a surgeon in due course, tried his hand at practice for some time, did not make it, and went to US. Last heard of, he was working there. His patients there must be able to understand his dietary advice, even if he does not know what the dietary items he talks about are in reality.

Five Degrees to Vascular Catastrophe

Laparoscopy is a blind procedure. One does not know where the tip of the Veress’ needle of the trocar and cannula is located. One relies on merciful God and enters the peritoneal cavity. It becomes safer only after the telescope replaces the trocar and one can see inside the abdomen. Complications are few if one adheres to strict discipline while performing the procedure. The resident doctors in training, and even their seniors often do not realize that it can be very dangerous. They go through the prescribed steps, sometimes skipping a few, and not always adhering to the rules of safety.

“Your Veress’ needle is oblique. It is directed towards retroperitoneal pelvic vessels. Bring it back to midline” I admonish “or you will cause a vascular injury. I am that careful because I know women can die of it. They don’t believe it because they don’t believe it can happen and that I must be just nagging. They correct the direction somewhat, only to go obliquely again in a minute or two. The other day a second year resident was performing laparoscopy. An Assistant Professor was assisting, guiding every step. I had already corrected the direction of the Veress’ needle twice. Then she inserted the trocar and cannula, passing it an angle with the midline before I could stop her. I had a premonition of danger. Then she hooked up the endoscopy camera to the telescope. There was no blood anywhere, which was a good sign. I washed up and had a look inside the patient’s abdomen, moving the telescope all around.

“What is that you see there?” I asked.

“…..”

I zoomed in.

“It is an injury. But is not bleeding actively” the Assistant Professor said. It was penetrating injury in the parietal peritoneum and underlying tissues close to the right pelvic brim. He was right, it was not bleeding actively.

“What is that just medial to it?” I asked. They all looked carefully.

“Those are arterial pulsations” he said.

“If the tip of the trocar had been five millimeters lateral, it would have punctured the vessel and produced an instant hemoperitoneum, and possibly death of the woman” I said.

“Yes, Sir.”

Now look carefully at the positions of the telescope and watch the field on the monitor” I said. I focused first on the vessel, and then brought the telescope to midline. I repeated the maneuver a couple of times.

“Did you notice through what angle the telescope moved from midline to be directed to the vessel?” I asked.

“About five degrees.”

“Now do you realize you can cause a catastrophic vascular injury just by deviating from midline by 5 degrees?”

“Yes, Sir.”

I was happy I had taught them something that they would remember for ever. I was also happy about the novel method of teaching I had used without actually thinking and planning.

Nothing lasts forever. My happiness lasted for one month. Then the Veress’ needle got directed again away from midline. I think God must be moving these vulnerable structures away from the tips of Veress’ needles and trocars temporarily, like the trees and buildings moved from the flying bus in the Harry Potter series.

Five Millimeters to Bladder Catastrophe

The juniors watch the seniors perform some operations and think it is a piece of cake or something. They perform the operations following the same steps, and often nothing gos wrong, more out of luck than good planning. One example of this is while performing a vaginal hysterectomy. They make a transverse incision on the anterior vaginal mucosa, not knowing exactly where they make the incision and why exactly there and not elsewhere. They keep cutting the fascia underneath, not knowing how close the urinary bladder is.

“Why do you cut where you are cutting?” I ask when I feel one of them is particularly dangerous.

“To open the uterovesical fold of peritoneum.”

“Where do you place your incision?” I ask.

“Here.”

“But what landmark do you use to decide where to cut?” I persist.

“About an inch from the external os” is the most precise answer I have received to date.

“No. You cut at the junction of the portio vaginalis and the anterior vagina” I say.

“Uh …” is the usual answer or there is no answer and I rejoice that it is not “Duh…”

“You seem to be cutting rather boldly” I say. “Do you know where the urinary bladder is?”

“Here” the resident points in the direction of the anterior vagina.

“Yes. But how close to your incision?”

“…”

Then I proceed to put a bladder sound through the urethra into the bladder and show that the limit of the bladder is just within 5 mm of the incision. That hopefully scares them.

“Remember you can open the bladder if you go 5 mm beyond” I warn. I do not make it a routine, because I do not like to risk introduction of infection into the bladder. The other day my Assistant Professor told me a story, which added another reason for not doing so.

“Where I trained, the professor used to put a bladder sound into the bladder as a routine, to show where the limit of the bladder was. One day, the Registrar did that to show the Houseman where the bladder was. Unfortunately he did not know how much force to use. The bladder sound perforated the bladder and came out of the anterior vagina. Then they had to call the urologist to repair it.”

Correcting Boss' Spellings

When people start correcting you in a tone meant for not hurting you, you should know that you have become old, started losing your grip on things and perhaps are already suffering from Alzheimer's disease. Even if it is not true, at least you can rest assured that the speaker believes it to be true. I have this Associate Professor in my department, who has always been completing my sentences in meetings by uttering the last words. She probably believes I would not know what I wanted to say, or would have forgotten it by the time I reached the end of the sentence even if I had known it when I started at the beginning of the sentence. I put it down as a flaw in her character and ignore it. But when your resident doctors start correcting you, you should get worried. It is a dangerous situation, because they are supposed to learn from you, and if they believe they know better, there is going to be trouble for patients, unless what they believe is true. If it is, it is time you left and did something else.
I had examined a patient the other day, and was listing the investigations she needed. I prefer to write the clinical notes and advice myself, and I was doing exactly that. The Registrar was watching what I did, though she should have been seeing another patient - there were a lot of them waiting.
"Sir, you have written that test wrong" she said in soft voice.
"Which one?" I asked, sure that I gad done no such thing.
"You have written 'Urinalysis' when it should be 'Urine Routine'." She was probably afraid the patient would not get the test done if she went to the laboratory with that request.
"It is a correct English word found in the medical dictionary" I said.." It means routine and microscopic examination of urine. The laboratory people know it, and all my patients have come back with reports when I asked for it over the last thirty two years."
She kept quiet. I hope she checked the dictionary. She has not corrected my English subsequently. But I am afraid of her for the patients' sake anyway. God knows what other things that I do she thinks are wrong, and corrects them without telling me.

Boss Knows Zilch?

"Sir, that application of the resident doctor has come back from the office. The Academic Boss has written the certificate asked for cannot be given."

I remembered the case. This resident doctor had been our postgraduate student. She needed a certificate that she had observed obstetric ultrasonography, because the local civic medical officer was sealing ultrasonography machines of doctors who were MD but did not have such a certificate. It was blatantly illegal, but civic employees in a position of power often harassed people who could be harassed. I had got her claim verified and sent the application to the Big Boss that the certificate could be issued. He had attested it. Now it was back to us.

"Let me see" I said. The clerk handed the paper over to me.

"Observing ultrasonography is not a part of Obstetrics Gynecology curriculum" it was remarked. "This office has never issued a certificate like this before. So it will not be possible to issue one now.” It was signed by the Academic Boss.

“It is funny” I said. “I must find out how this happened.” I called the office, and traced the head clerk who had drafted that letter, and had got the Academic Boss to sign it.

“I am new here” she said. “The clerk met the Academic Boss and got it done.”

Please put him on the line” I requested. He came on line after a delay.

“How do you understand something is not in the obstetric and gynecological curriculum, or how does the Academic Boss do so, being from a different specialty, when I as the head of obstetrics and gynecology have certified that it is?”

He had no answer.

“And if the Big Boss has consented to issue a certificate, how do you get his junior officer to cancel the decision?” I asked.

“The Big Boss does not understand anything!” he said. “He signs on any letter.”

I was aghast. A low level clerk thought he knew much better than the chief of the institute and controller of many other major hospitals and medical education. Not only that, but he had the expertise to manipulate the Academic Boss to reverse a decision of the Big Boss. I only hoped that no one would tell the Big Boss what one of his clerks thought and said about him. “But it is known. Was it not a mere clothes washer (there were no launderers then) who had maligned Lord Ramachandra and Goddess Sitamai in Ramayana?

Free eBooks and Mobile Phones

It was a meeting of the library committee. I am a member. I meet the members something like once a year, because they seem reluctant to call a meeting more often. We meet mor often if any members retire and have to given farewells.
"Let us digitize our holdings" I proposed. "Let us have them as eBooks. Then if the library catches fire, like the Mantralay did some time ago, all will not be lost."
They liked the idea. Even members who sometimes behave like my enemies said it was a good idea. Perhaps they were looking at digital books they could take away free. Then the issue of buying text books for not so well off students came up. There was a grant of Rs. 70000/- Purchase of such books was approved by all.
"Perhaps we could by eBooks for them using this fund" one member suggested. It had been more than a year, but I remembered the funny demands she had made then, and how she had kept on, ignoring my rational explanation why it was not practical to do so. I was not prepared to let history repeat.
"She is like our prime minister. He has just declared free mobile phones and free talk-time to all families below the poverty line. Not free food - but free mobile phones. Here she is proposing free eBooks to students who have no money to buy books in print costing a few hundred rupees. Do they have eBook readers that cost thousands?"
That worked. She must have been happy having been compared to the prime minister.

Tender Scandal Solution

"So, is the scandal about purchase of equipment by the civic body settled or not?" an acquaintance asked me. They believe I should have all inside information about working of the civic body because I work in one of the civic hospitals.
"Since there is nothing much about it in the newspapers, it must have settled" I said.
He looked at me with disappointment. He must have hoped for a bit of fresh info - gossip perhaps.
"Do you know the reason the tenders are inflated when meant for government and civic bodies?"
"Are they?" I asked.
"They are. The reason is the vendors have to make some profit at the end of paying off everybody who is to be paid off." I wondered how this fellow had this information which I did not have despite not being connected with the civic body in any way.
"Who is to be paid off?" I asked.
"Huh?" he could not believe his ears. What a naive question - his expression suggested.
"There must be a solution to the problem of paying more than the market price" he said.
"There can be" I said, "provided they change their procedure."
"How?" he asked.
"They ask for sealed tenders, open them together, disqualify people who do not meet the criteria, check equipment quoted, and then check price bids of all those who qualify. Thus there can be no manipulation of prices in order to get the lowest bids. But then some politician claimed there was a fraud in the last civic tender despite all these steps being followed. He claimed the companies had quoted far higher than the market rates. He showed an offer for half the price from the same company which had quoted for the civic tender. I have a solution to this problem."
"What is it?"
"There should be a provision that after the entire process is over, any other vendor should be awarded the tender if he could have the qualification, equipment as per specifications, and a price bid at least 50% lower than the lowest bid for that tender. There should also be transparency and a guarantee by the civic body that the payment will be made within one month of delivery and installation of the equipment."
"That sounds like a wonderful solution!" he exclaimed. "Why don't they do it?"
"They do not have this idea" I said. "Only two of us know about it."
"Why do you not tell them?"
"They have IAS cadre officers and management specialists to do it."
"Write to them" he urged.
"All the letters I have sent to places like the civic body and health university have remained unanswered. What makes you think this one will be any different?"
He had no answer to that one.