Cyst in the Uterus

I had just begun lunch when they called me to the OT.
"Sir, please come to the OT. There is a cyst in the uterus" my House Officer told me.
I knew they were operating on a 42 years old woman with uterine leiomyomas and infertility. They were doing removal of a couple of small leiomyomas (seen on ultrasonography) because the woman had uncontrollable dysmenorrhea. They were also checking tubal patency for her infertility.
"It must be cystic degeneration in a leiomyoma" I said.
"Sir, it is different" she said. "Please come and have a look."
I packed away my unfinished lunch and went to have a look.

The uterus was open on the left of its posterior wall. A cystic structure was seen inside.
"She had menses two weeks ago, but the flow was scanty this time" the operating surgeon told me. "It looks like a pregnancy, which must have been there when she bled. Shall I close the uterus and let the pregnancy have a chance to continue?"
"But where is the leiomyoma?" I asked. "You were going to make an incision over the leiomyoma you palpated when I went for lunch."
"...."
"I will wash up and have a look" I said. "Don't do anything until I come."
While I was washing up, I suddenly remembered they had put a Foley's catheter in the uterine cavity for chromopertubation. Perhaps this was the balloon of the catheter. I rushed back to the OT.
"Deflate the balloon of the catheter and see if the 'cyst' goes away" I said. A House Officer did that and the 'cyst' disappeared. Comprehension dawned on everyone.
"What you called a leiomyoma was the balloon of the catheter" I said. "She has just one leiomyoma which she had two years ago when we performed a laparoscopy on her. Now she has adenomyosis too, which is causing all that pain." I pointed out the uniform enlargement of the uterus and three endometiosis-like nodules under the fundal serosa. "She won't be cured by anything other than hysterectomy." We had discussed the option of hysterectomy with the patient preoperatively, and she had consented for it if it was deemed necessary. A hysterectomy was duly performed. The specimen showed adenomyosis. She made an uneventful recovery.
I don't think I have to write down the morals of the story.

I Can't Watch This

It was not just another nightmare come true for two reasons. The first was that I had not had a nightmare like that any time. It was original reality. The other reason was that it was far from the usual nightmarish experiences.
A laparoscopy was being performed by a Registrar. An Assistant Professor was assisting. I was standing nearby, with a watchful eye, waiting while they were anesthetizing another patient. Suddenly I happened to look at the Veress' needle, and I got s**t scared. It was thrust in the patient's abdomen, left free, while carbon dioxide was being insufflated through it.Both the operating surgeon and his assistant were watching the dials of the insufflator and the needle was attended.
"Look at the Veress' needle" I whispered, afraid to speak loudly. The Assistant Professor put his hand out to hold it. "No! Don't touch it. Just look at it" I siad urgently. They looked at it. It was moving up and down rhytjmically, at a rate of about 70 per minute.
"It is moving with the patient's vascular pulsations" the Assistant Professor exclaimed.
"Yes" I said. "It is probably sitting right on the abdominal aorta. A minor push and it will enter the aorta. Withdraw it NOW."
He withdrew it.
"Any blood in it?" I asked.
"None."
"Are the patient's vital parameters OK?" I asked the anesthetist.
"Quite all right" the anesthetist said.
"God be praised" I said. They continued with the remaining steps of the laparoscopy. "I can't watch this" I said and turned back on them. The OT became silent. I looked back through the corner of my eye to watch them. The students laughed thinking I was just being funny. I was not.
"I know I cannot watch this" I said, because I am afraid. But I have to watch it because it is my job to do so."
The laparoscopy was successfully completed. There was no hemoperitoneum. The patient went home fine the next day. I hope neither I nor anyone else has to watch an oscillating Veress' needle anytime.

Hotei of Pure Gold

I wanted to write that they gave me this Hotei made of pure gold, but I knew no one would believe it. No one makes sculptures of pure gold for giving to someone else, no matter how accomplished or how well liked. So I will write the truth. I made this sculpture myself, in 3D, on my computer. I have put it here so that I can share my happiness at this creation with you all. I know there must be scores of others who could have sculpted better than this, but then I am willing to bet there will be no Gynecologist who can do it like me.
(Note: Hotei is erroneously called 'Laughing Buddha' by many people.)

Dengue Pronunciation Queries

I had written something interesting about different ways my staff members pronounced 'dengue' That artile is available at:
http://shashankparulekar.blogspot.in/2011/09/dengue-pronunciation-deng-dengu-dengi.html

I use a service provided by 'Statcounter', which tells me who visits which pages my blog. I used to get a couple of hits a week for this page, all of them using 'Google' to find out how to pronounce this word. Suddenly there is a sort of tidal wave of hits to this page. Over the last 3 and a quarter days, I have had 24 hits. Their details are as follows.

Internet Service Provider	Place
Road Runner (67.247.21.46)	New York, United States
Hutchison Max Telecom Limited (42.109.133.5)	Delhi, India
Bharti Telenet Ltd. Tamilnadu (122.183.183.102)	Chennai, Tamil Nadu, India
Bsnl (117.197.5.223)	Jaipur, Rajasthan, India
World Phone Internet Services Private Limited (14.102.124.2)	Meerut, Uttar Pradesh, India
Sify Limited (118.94.83.75)	Delhi, India
Virgin Media (77.96.122.53)	Raynes Park, Merton, United Kingdom
Bsnl (117.197.147.232)	Haryana, India
Sky Broadband (94.14.49.224)	Wimborne, Dorset, United Kingdom
Bsnl (117.197.112.46)	Chandigarh, India
Asianet Is A Cable Isp Providing (111.92.4.103)	Trivandrum, Kerala, India
Airtel (122.170.83.252)	Mumbai, Maharashtra, India
Bsnl (117.216.130.28)	Bangalore, Karnataka, India
Tata Indicom (14.97.97.151)	Mumbai, Maharashtra, India
Marquette University (134.48.158.121)	Milwaukee, Wisconsin, United States
Etrade (65.248.129.125)	Alpharetta, Georgia, United States
Bsnl (117.192.76.92)	Bangalore, Karnataka, India
Gprs Delhi Mobile Subscriber Ip	Pune, Maharashtra, India
Sky Broadband (90.220.139.61)	Saint Albans, Hertford, United Kingdom
Mahanagar Telephone Nigam Ltd.	Mumbai, Maharashtra, India
Chandigarh (125.62.112.59)	Lalon Khurd, Punjab, India
Bharti Broadband (122.169.109.247)	Mumbai, Maharashtra, India
Reliance Communications (115.248.154.247)	Chennai, Tamil Nadu, India

It indicates there is a serious outbreak of the condition. I was surprised that out of 23 hits, 5 have been from UK and one has been from USA. Those people whose language we have to learn and speak should have to do a 'Google' search and reach my blog to learn the pronunciation of this word is indicative of something that I do not want to put down here.

Pseudo Belladonna Eyes

Belladonna is Italian for "beautiful lady". Belladonna was used by 16th century women to give their eyes a sexy and dreamy look (by dilating the pupils). I was doubly surprised to see these eyes on a man recently.
This fellow was a retired gynecologist. I met him in a scientific meeting. He knew all about my institute, including a non-gynec professor who wanted to become a Dean once, had got selected by MPSC, had started clearing his desk, and suddenly declared he did not want to be a Dean. A lot of stories had circulated for this happening. I never knew the truth, because I did not ask that Professor.
This fellow asked me,
"Dr. xxxxxxx who is in your department still calls me on teachers' day."
I smiled politely.
Then he opened his eyes wide, fixed them on me in a dramatic way, and said,
"Is Professor xxxx still there?"
"He is there" I confirmed.
"He wanted to become a Dean once, but suddenly he stopped being keen on it...." he said with a half smile and even more belladona in his eyes. He stopped and waited for me to give an explanation for Professor's xxxx's mysterious behavior.
"There were some stories" I said and changed the subject.
I was surprised that a man could make such belladonna eyes. I was surprised also because he reminded me of Dr. xxxxxxx, who had apparently been his student. This doctor also used to make belladonna eyes at me and make unfinished statements and wait for me to provide information. The same eyes, the same look on the face, the same expectant smile, the same body language! I wish the student had learned good gynecology rather than making belladonna eyes from this person. Lucky I had not been fooled either by the student (on multiple occasions) or by the teacher.

Adjusting Hemoglobin Report

"Sir, this patient looks quite pale. I think she requires a blood transfusion."
"Huh?" I said. I knew looks could be deceptive. "How much is her hemoglobin?"
"Sir, the laboratory report is 9 g%. But it is from the emergency lab!"
"So?" I was confused.
"Their reports are not accurate. They told us on phone that this patient's report was 8 g%. The printed report came as 9 g%, where the 8 had been changed to 9 with a pen. We asked them what was the meaning of that. The Resident Doctor in the lab said that they had to wash the chamber of the autoanalyzer frequently owing to the work load, and they could not do that. So they looked at RBC pallor on microscopy, and changed the final report from the machine depending on the pallor they saw."
"That sounds like us looking at the patient's conjunctiva. Why don't you send them a picture of the patient's conjunctiva on phone?"
The answer was a broad smile.
"So now what>" I asked.
"So we correct their report depending on our clinical judgment."
The patient fortunately did not understand what was being said. She just lay there in blissful ingnorance, believing she was being looked after well.

Attitudes 9

“He has his favorite people” the staff member sniggered, “that he has brought here after he came here.”

I was sitting in the staff room, when I heard this from one of our staff members. It was a complaint that I could not do anything about even if I wanted to, because she was talking about my senior officer.

“Favorite people?” I asked. I had known bosses to take along their personal secretaries when they moved from institute to institute. This would be one such thing.

“Yes. Professors of xxxx, yyyy and zzzz.” I have put xxxx, yyyy and zzzz in place of names of three departments to protect the identity of these persons.

“So?”

“They are all women!” she sniggered again. She was suggesting something, but not saying it openly. I shrugged my shoulders and went about my work. I do not like people gossiping, and making accusations about other people's characters. Fifteen days passed. Then she was back again.

“Dr. xxxx was pulled out by the Boss to do something for him, and the work of that theater stopped.”

“Dr. xxxx?” I asked. I was not familiar with the name.

“You know, one of the people the Boss transferred here when he came here.”

“Must be very good at doing that work” I said in defence of Dr. xxxx, poor woman.

“Ha!” she said.

A month passed. Periodically there were comments showing disrespect for the Boss and his favorite people. Then one day things changed. The Boss was suddenly a very nice person. Dr. xxxx was a nice, decent, friendly woman.

“While we were talking ....” she said about Dr. xxxx.

“How did you get together?” I asked. I thought you did not like her.”

“The Boss has placed us on the same committee. We share a lot of viewpoints” she said. “He has made me in charge of the working of a new department the institute will start.”

“Hm....” I said. In the next meeting of hospital staff members, the Boss called this critic turned friend by her first name. She almost blushed.

Hats off to the management of this Boss. He had charmed an enemy into a loyal friend. All he had to do was to make her feel special (by calling her by her first name – makes them feel younger too), give her something others did not have (by making her officer-in-charge of something new), and give her recognition (by placing her on a committee). I have not heard a single word from her since then criticizing the Boss and his favorite people, or tarnishing their characters.

Busy Subordinates

“Sir, you won't believe this!” one of our Professors told me.

“What?” I asked. I thought I had seen enough and nothing would surprise me any more. But I could be wrong.

“We were in a meeting called by the Dean. It had to do with three clerks of two sections, who were called. Only one clerk out of three came. He said one of the others had gone to the head office, and the other one was busy and hence had not come. The Dean nodded her head. But another staff member got angry, and asked how could a clerk not come saying she was busy when the Dean herself had called her? Then the Dean also said what was the clerk busy with. The clerk was told in no uncertain terms to come and she came. Now a clerk has the guts to tell the Dean that she was busy and could not come when called.”

“Hmm....” I said. “I am not surprised because of two reasons. The first one is that the new Dean is mild by nature and kind. She would not take offense at such behavior by a person far junior in the hierarchy. The other reason is that I have seen such behavior before.”

“You have? Where?”

“In my own unit. I was in the OT. We had a patient who had had a copper-T inserted by my House Officer five months ago. I was in the process of its removal laparoscopically because it had migrated into the abdominal cavity. It had passed into the right broad ligament and then had partially exited into the peritoneal cavity through the posterior leaf of the ligament. 'Please call that House Officer' I said. She was in another unit after having finished six months of residency in my unit. She did not come. She did not meet me for another week. When I saw her next, I asked her why she did not meet me as I had asked her to do. She said she had been busy.”

“Huh? What did you do to her? In our days we would have got thrown out of the hospital if we dared try such a thing. Furthermore, we would never have passed M.D.”

“Nothing. I told her ignoring an order by the Head of the Department was inappropriate behavior. She went away. I would have shown her where she had gone wrong, and told her the right technique of avoiding such a complication. She missed out on that education. She passed M.D. and went away.I wonder who will remove the copper-Ts that she inserts after they migrate out of the uterus.”

Surgically Missed Pregnancy

When a woman is pregnant, and the doctor misses the diagnosis, it could be called a 'missed pregnancy'. That is possible when the pregnancy is very early, the woman has a rather stout tummy, and the woman is uncooperative during clinical examination. This can be avoided by performing a pregnancy test on her urine. What I am writing about is pregnancies that are missed surgically.
I recall that as junior residents we were so terrified of perforating a pregnant uterus during first trimester termination of pregnancy, that we tended to introduce the MTP cannula less than appropriate. Once I had suctioned only the cervical canal and thought the procedure was complete. A more experienced person showed me my error, and I did not repeat it again.
When I became a Lecturer, another Lecturer performed first trimester MTP on the daughter of one of class 4 employees, and the pregnancy continued. When the pregnancy reached second trimester and became palpable abdominally, this Lecturer declared it was an ovarian tumor and advised a laparotomy to remove it. Luckily her father changed the gynecologist, and brought her to us. We performed a second trimester MTP and she went home fine.
This story I heard from a colleague. There was a patient scheduled to undergo a second trimester pregnancy. She was given misoprostol and passed something in the toilet. The House Officer said that she had aborted. The Registrar confirmed the abortion. A day later she underwent an abdominal sterilization operation through a small incision. It was assisted by an Assistant Professor, under the supervision of a Professor. No one thought she was pregnant, despite such a large and soft uterus seen and felt directly. They could have even ballotted the baby and reported it as direct ballottement- a new technique, different from conventional external and internal ballottements.  The patient went home fine, but came back after two months with an ever enlarging tummy.
"She was 26 weeks pregnant" the colleague exclaimed. "Her husband is very angry. He wants the fetus out without spending any more money. He has talked to a civic corporator who is threatening t make trouble."
"But you cannot terminate the pregnancy at 26 weeks legally" I said. "You cannot induce labor too, because there is no indication, and if it fails, you will have to perform a cesarean section. Such measures are unjustifiable."
"What shall I do? Shall I tell the Dean?"
"That would be a good idea" I said.
The Dean was told.
"Get Head of Department from another civic hospital, and perform an MTP on that patient jointly" was the advice.
'God be praised' I thought because he had not asked me to get involved in this procedure that was against the MTP act, for violation of which one goes to jail. A week passed. The concerned consultant met me again.
"What happened to that failed MTP case?" I asked.
"The other head of department was reluctant to come. He advised me to go ahead and do it." Naturally so, I thought. WHo would want to go to jail because a Dean ordered it? But God is on my side" she continued. "The patient came back with premature rupture of membranesand cord prolapse. She aborted on her own. God saved me."
I wondered if God caused this outcome directly, or just gave a thought of discrete use of misoprostol.

Urinal Caution

The law requires that public places have toilets and urinals. So government offices, civic offices, colleges, hospitals and such have these things. The conventional design is shown as A. There is the ceramic bowl fitted in the wall. A guy has to stand in front of it and do his thing. The output is carried to a drainage channel near the floor through a pipe fitted at the bottom of the bowl. This pipe has a crucial role, which one can understand only when it is missing. About 30 to 70% of the urinals have these pipes missing. This percentage can be used as an index of the level of maintenance of these public places. If one uses such a urinal, the output falls to the floor under gravity, and its drops bounce back to spray one's trousers. The resultant embarrassment during the remaining part of the day is self evident. I caution people visiting the places mentioned above. If the pipe is missing, try another urinal, no matter how urgent the business might be, unless you plan to go home for a change of clothes.

Mouth Graffiti Artists in Hospital

Art comes in many forms, and is not the monopoly of those few who have been fortunate enough to have been able to go to art schools and get trained scientifically. There are those who can create art wherever they go, and on whatever surface they can find.

We have twenty thousand visitors a day, whose primary intention is to see their near and dear ones who are ailing and are receiving treatment in the hospital. Perhaps as a token of gratitude towards the hospital which treats their relatives/friends for free, they leave behind a piece of art on the hospital walls. They create art in red color. They have two hands, but they prefer to create art with their mouths, and can be called Mouth Graffiti artists. They come to the hospital well prepared with their art supplies. They chew a mixture of a special leaf, calcium hydroxide, tobacco, permissible food flavor, and some components that cannot be put down here because they are unknown to the English speaking world. Mastication without swallowing results in development of a mouthful of red liquid that is used by them as paint. Most of the average artists create art on the walls of the staircases, corners and walls of the corridors. Some advanced artists prefer a wall of an electric substation that stands opposite the first floor corridor of the main building t a distance of two meters. There they stand holding the railing for support, raise their heads at an angle with the horizontal, and spit on the wall. Some of the accomplished ones reach spots a meter higher than their mouths. The wall looks something like this.

There are 563 such patterns on the wall and the number is rising. The electricity supplying company does not paint the wall, because it hopes that one day all the blanks will be filled up by the artists and the wall will be entirely red. The hospital does not paint the wall, possibly because the artists need to express their art, and if that expression is suppressed, they will express it elsewhere, where it may not look very appropriate. Such ingenuity! Such finesse! I want to capture one of them on video doing it, and another pointing out proudly how high he reached. Unfortunately my duties keep me busy and I cannot get around to shooting ay video. If I can manage that some day, I will post the videos for you to see.