Self Punishment

“Sir, I have to tell you something” the sister-in-charge of the antenatal ward said apologetically when I was taking a round of the ward.

“What is it?” I asked. She was not one to complain needlessly.

“Look at this” she said. I looked. There was a trolley, on which there was a used syringe with needle attached to it and blood inside it. The cover of the syringe and a couple of blood-stained swabs were there too. A vial lay on its side. There was blood all over the floor and also on the mattress of the adjacent cot.

“Who has done this?” I asked. It was very much against safe practices.

“The unit which had outpatient clinic yesterday” she said. Luckily the doctors of that unit were also in the ward taking ward round. I called them and advised their Associate Professor to find out who it was and take some constructive disciplinary action against the person. I proceeded to see other patients in other wards. When I went back to that ward, the culprit had been found.

“Sir, this is the House Officer who made a mess during her blood collections” the Associate Professor said. “I have asked her to explain all the information on safe practices for infection control and biohazardous waste disposal to the other resident doctors in the unit. That will be her punishment.”

“OK” I said, and looked at the guilty one. She was an embarrassed looking girl, tired after emergency duty the previous day, and scared too. I looked at her apron. Usually they have blood on it. Hers was not very clean, but it would not be after 24 hours in the emergency ward. But there was no blood on it.

“Show me your hands” I said, and demonstrated how by holding my hands forward, palms down. She complied. There was little tremor in the fingers, but no blood on them.

“Turn them around” I said, and showed how by turning my palms up. She copied my movement. There was a 2 mm diameter solid-looking dark red spot on her right palm.

“What is that?” I asked, pointing at it. It looked like blood to me. She wiped it with fingers of her other hand, but it did not go away. Her colleague tried to help by wiping it away, but she would not let her do it. She scraped it away with her nail. It came off. It was a small blood clot, and it was someone else's blood, as her skin underneath was intact.

“It is a patient's blood” I said. “We do not have to punish her in any way. She does not wear gloves while collecting blood, and does not wash her contaminated hands. If we just let her be herself, she will punish herself in due course.”

I did not say 'by infecting herself', but I could see from her facial expressions that she had understood. It was a new but effective way of educating those who do not get educated by the conventional means.

Condolences

A professor working in our institute passe away untimely and unexpectedly at the age of 50. I had been in a meeting which even he had attended once. We had never interacted. But he had struck me as a balanced, quiet, reasonable, intelligent, and soft spoken person. A condolence meeting was held a couple of days later. I did not want to speak there. I did not want to know what others would speak there. I attended because somewhere inside me I hoped against hope that an 'Undo' would happen somehow and I should be there to witness it.
The auditorium was nearly full. His family came, though I could not understand how they could manage it in all their grief. I remembered how devastated I had been when my father passed away after a brief illness, and I had been much older than his two children.
A departmental colleague sang a prayer - "Vaishnav Jan To Tene Kahiye". Two of his students spoke, one of them actually addressing him. All three times I wiped my tears, because their grief moved me, and I could think of the grief of his family sitting there with us and hearing all this.
"There was no high risk factor, the institute's cardiologists claimed" someone said.
"He was so nice, we asked him to attend Sunday calls at the hospital when we were on call, because he stayed right opposite the hospital" a senior colleague said.
"He was so efficient - we never had to do anything about any job we asked him to do" another senior said.
"He was dependable. We always called him to organize exams" a third person said.
"He would do the tendering work so well. We had to do hardly any work with him there" a fourth person said.
"He had no enemies" a number of them said. "He fought with no one."

I knew what had gone wrong with him. He was a person who never said 'no' to anyone. He pleased everyone, and the world probably took disadvantage without giving it a second thought. He had no enemies, probably because he did not fight back even those who wished him ill, or treated him badly. After all, the world is full of people of all sorts, and he could not have met only the nice ones. He probably collected all that hurt inside him and built up stress until it took its toll one day.
"Has his wife not come" a late comer asked me. She was curious, I could see, but not grieved.
Some people spoke about how good they themselves were, referring to him in that reference alone. I could see that they could not give him his due even after his death.
"We lost two doctors in last 15 says" said someone, and mentioned a name.
"Who was the other person" asked the curious late comer. I had to clear my throat a couple of times before I could answer her - I was feeling all choked up.
Someone kept strutting about, showing no grief.
Someone commented on someone else wearing a full suit, as in a business meeting.Then a staff member walked in towards the end of the meeting, wearing less makeup than usual, and clothes 10-20% less glamorous than usual. I wonder if there was anyone who did not notice her.

"There but for the Grace of God go I" I was thinking looking at his projected photograph on the screen, while a professor was looking at his watch impatiently.
I told my wife all this that evening. Then I said "God will call me away one day. If they ask you to attend my condolence meeting, please do not attend it. You might tell them it was my wish that they did not hold a condolence meeting for me. After all, there will be some who will grieve, some who will think' good riddance' and some who will not care either way. If my soul will be hovering around nearby, it will be upset watching all that goes on."
"Oh, be quiet" she said. But I think she understood what I meant.

Medical Negligence and Diplomacy

It was first of its type situation. They had sent a patient for an emergency cesarean section to the emergency OT. The emergency team oprated and when they were about to close the abdomen, the scrub nurse declared -
"The string loop on one of the surgical mops is missing."
"I think it was not there when I took the mob" declared the House Officer who had operated on that patient.
"I think it was there" the nurse said.
So they searched the whole of the pelvis and abdomen, but could not find it. The Assistant Professor assisting the House Officer was sure it was not there. They called me for advice.
"I could come to the OT and check myself" I said. "But I cannot do better than the Assistant Professor. Get the general surgeon emergency duty to check between the bowel loops and mesentery."
"Sir, the surgeon told us on phone that it was lost by us and he had nothing to do with it and he would not come to have a look" my Registrar reported.
"OK. Write a call to him and request him to write that on the call. Then if the case goes to a court, he will be found negligent in performance of his duty."
They sent the call, and he wrote that on the call. But some time later, he turned up to the OT and checked the abdomen for the missing loop of string. He could not find it."
"Why did he come when he had refused initially" someone asked me.
"I think he did not want involvement because he would be dragged into a medicolegal case for no fault of his" I said. "That was unavoidable. But he would not be found negligent, because the negligence would be that of the operating surgeon. He must have spoken to his boss, who must have realized that a refusal to give surgical assistance in checking a field that belonged to the surgeons would make him guilty of negligence. He would never have come if we had not asked him to document his refusal, because in that case it would have been his word against ours. He could always claim he had never been called."
"It was a difficult situation."
"I was indeed. It takes diplomatic maneuvering to get such people to cooperate" I said.

May Lord Ganapati Bless All

I drew this sketch of Lord Ganapati without lifting the pen even once, using a javascript paint program. The pen could not be lifted, because if it was, the drawing would start from the beginning again.

28th September 2018

Eco friendly decoration for Lord Ganapati.

Almost Killer Girls

I wonder if anything is turning the young girls violent. It is a trend to blame violent computer games for violent attitudes of young boys these days. But I know for a fact that the girls do not play these games. It must be something else.

I was conducting prelims for the undergraduate exam going students. The I asked the same questions to all candidates I examined, and the answers left much to be desired. One girl was particularly less well prepared than others.

“Are you related to xxx or yyy?” I asked. These two persons with the same surname as hers were known to me and I could talk to them about getting her to study more, if they were related.

“No” she said briefly.

“From where have you come?” I asked her.

“U.P.” she said.

“So you must have studied well and scored well in the All India Entrance Test and come to this premier institute.”

“Yes” she said.

“If you could study well then, why are not studying now?” I asked in a mild voice.

“.......” she probably had no answer or did not think the question worthy of an answer.

“What will you do after M.B.B.S.?” I asked, knowing well that everyone passed that exam some time or other, usually at the first attempt.

“Postgraduation” she said in a tone that suggested that it was a ridiculous question.

“In which subject?” I asked.

“Pediatrics” she said. She seemed pretty confident she would get it, no matter how poor her preparation was.

“Good.” I said. “Do not choose obstetrics and gynecology. You will do better in other subjects.”

She got up and went away, shooting me a glance that was much more than dark, venomous or whatever adjective that you can think of. If she had laser power in her eyes, she would have drilled a hole right in the middle of my forehead, going through and through to exit through the occipital bone.

The next day I was conducting an interview for selection of Assistant Professors. I asked one candidate about obstetric forceps after she had answered other questions. I have written about her before. She was a good candidate, one of the other experts had vouched after the interview.

“What is correct axis of application of obstetric forceps?” I asked.

She started with a long description. I stopped her. “Just tell me the axis of application” I said.

“It is applied over the parietal bones” she said, in a tone that suggested my question had really no answer, that this was the nearest she could offer as an answer.

“That is almost the entire vault of the skull” I said. “That cannot be the axis. All right. You can go.”

She got up and shot me a glance before going away. The glance was an exact replica of the one I had received the day before.

I have spent 32 years as a teacher. I have always praised good students. I have criticized bad ones in a positive way, so that they would try and improve. None of them have looked at me with looks that could kill, if looks were guns. Now two girls had done that on two consecutive days. I have been wondering what makes them so these days. To be unable to take justified criticism and not wanting to improve is not the hallmark of a physician at any stage of his or her life, definitely not at the beginning. I wonder if it is praise and praise alone at all times, justified or not, that makes them so? I wonder if the time has come for me to stop offering any correction or criticism, though I know I have to do it as a teacher.

Obstetric Forceps Tragedy

There was a time when the Obstetric Forceps was a closely guarded family secret that was kept from others for three generations by the inventor. Fortunately it was opened up, and then there was a progress at a such a pace that it was mind boggling. The training of a resident doctor used to include use of Obstetric forceps applications, and we used to feel proud after teaching undergraduate students obstetric forceps in detail as much as after application of obstetric forceps to a fetus without producing a single mark on its head and without lacerating the mothers birth passage even a single bit. Years passed, when the art of teaching juniors was taken over by our juniors while we got busy with more advanced training. My first inkling of something being amiss was when I found a forceps mark on a baby’s head. I have written about that before. They did not read that blog before coming for the interview today, I guess.

It was an interview for selection of new Assistant Professors. Most of the candidates were young, recently qualified doctors.

“How many cesarean sections have you performed so far?” O asked one candidate.

“One fifty” she said.

“How many times have you applied obstetric forceps?”

“Fifteen.”

“Your cesarean section to obstetric forceps ratio is 10:1” I said surprised. “Is that not odd?”

“…….” Probably she did not find odd at all.

“Please tell me the axis of correct cephalic application of obstetric forceps” I said.

“The head should be …”

“No. Just the axis” I said.

“It is over the parietal bones” she said. So it looked like the blades could be applied almost all over the fetal skull. I gave up. She went away.

“She is a very good candidate” the expert from her institute said. That did not speak very highly of the other candidates, considering this candidate as a yard stick. Some time passed, a few more candidates came and went away. Then I asked another candidate about obstetric forceps and vacuum extraction.

“If you have to deliver a fetus with acute fetal distress at station +2 and occiput at 3 o’clock position, what will you do? Obstetric forceps, vacuum extraction …?”

“I will use obstetric forceps. Vacuum can slip.”

I was aghast. This meant obstetric forceps rotation, which is practically given up as a dangerous procedure in most centers. “Which forceps will you use? I asked.

“Wrigley’s forceps” she answered promptly. I was aghast again. I could not understand how she could use such short forceps for a rotation operation.

“That is for outlet operations” I said.

“OK. I will use longer forceps.”

“Which one? Kielland’s” I asked, terribly afraid that she would say yes.

“No” she said. “I will use Simpson’s forceps.”

“How will you rotate the head?” I asked.

She made a movement like moving a key in a lock. So she killed the baby and opened up the patient’s bladder and rectum at one go. I was sort of numb by this time and could not get aghast again. I let her go away before she could traumatize the woman, her fetus, and me any more.

“She is a very good candidate” said the same professor who had praised the other candidate some time ago. My physiological state prevented me from getting aghast, even if the causative agent was different.

Grecian Tip Gloves?

I was away from the hospital for a week or so. When I went to the outpatient clinic after this gap, I was in for a surprise. I knew there was a perpetual problem with the supply of latex gloves for examination of patients. This time I found they had supplied us with gloves that were so short, that I would have thought of those ultra mini skirts or shorts some people wear in modern times. I did not think of those at that time probably because I am no longer young. But the glove rim barely reached the junction of my forearm and hand, and it was so loose that I could see my palm through the gap. I felt sort of vulnerable. I examined all patients with those gloves, and prayed I would not catch anything dangerous. I washed my hands with a handwash regularly, but that was not primary prevention. Looking at those gloves, I thought of Grecian tip condoms.

"What are Grecian tip condoms?" I asked my Assistant Professor and Resident doctors.

"Don't know" they said. By today morning they had asked one another, and the entire lot did not know what it was.

"Could you not find the answer overnight?" I asked.

"I read all the relevant books, but could not find the answer" my Senior Resident said.

"Which books are relevant in your opinion?" I asked.

"Um... the regular ones" she said.

I Googled the term and was surprised that even Google had not heard of it. Of course Google found 14,400,000 results  in0.47 seconds, but not one of them was relevant. I did not check all the results, but definitely the leading ones. No wonder they could not find it. I am waiting for them to ask me again for the source of that information. If they had read my book that they read for their practical exams for MS, they would have found it right away. Perhaps that book is not relevant. Perhaps they will read my blog. In that case I will put it down here. Grecian tip condoms, also called as American condoms, were small sized condoms meant to cover only the glans penis. Highly inadequate for contraception, just like the gloves in our outpatient clinic were highly inadequate for health protection.