Loose Ends 2

I dislike leaving loose ends. So I don't leave any. I also dislike when other people leave loose ends in my life. Unfortunately they do. I remember them for years, though not constantly. But they must be there in the reticular formation, or for people with computers on their minds, in the RAM. Suddenly I remember things that I would have preferred to have seen to their ends. That bothers me and disturbs my work.
There was that woman who had a bicornuate uterus, and a large leiomyoma in one horn. She had come to us more than 20 years ago. I had advised her to get it removed, so that it would not cause problems in future. She went away and never came back. She need not have got operated in our hospital. But she could have just informed us of whatever she got done.
There have been many loose ends since then. The latest was a few weeks ago. A senior engineer of the civic body brought his wife to us for treatment. She had a condition that could lead to cancer in a few years. I spent a lot of time explaining things to the couple who dropped in not in the outpatient clinic where we see patients, but in my office where I was busy going through files that have a tendency to arrive in large numbers. I explained the risk and consequences of her condition, all forms of treatment and their pros and cons, and left the decision to them. They said they wanted a hysterectomy. I made special arrangements for her admission to the hospital on a day when I was going to be in a scientific meeting elsewhere. I reserved a slot for her in the operation theater. On the day of the operation, I discovered that she had not turned up. I called the engineer. He was not there. I left a message for him. He never called. I have another loose end given to me for keeps when I never wanted it.
I think I need to learn to not get involved, to forget and to move on.

Round Ligament Confusion

The uterus has three structures attached to it near the cornu on each side, the round ligament in front, the fallopian tube in the middle, and the uteroovarian ligament behind. All three appear tubular (though only the fallopian tube is truly tubular, the other two are solid inside). One of them may be confused for any of the others, if the operative field is very small, as in tubal ligation during puerperium or during a minilaparotomy. Ligation of any of the two ligaments instead of the fallopian tube is a not infrequent cause of failure of female sterilization.
Usually this mistake is made by a junior resident doctor in training. He/she has to be reminded to trace the structure held laterally to see if it ends in fimbriae. If it does, it is truly the fallopian tube. During laparoscopic sterilization, it is often not possible to trace the tube laterally to see the fimbriae, because one performs it under local anesthesia (except in teaching hospitals) and insertion of multiple instruments is not possible. A rule of thumb is to visualize three tube-like structures at the cornu, the middle of which is the fallopian tube. If a person ranking higher than a resident doctor in training confuses something else for the fallopian tube, there is indeed good reason to get worried.
"Hey, look at the fallopian tube" exclaimed the Professor and Head of the unit while performing a laparoscopic sterilization. The fact that such a distinguished person found something different about a fallopian tube should suggest it was indeed different. I was a much junior person at that time. I put my eye to the eyepiece of the telescope.
"It is funny. It is curved and going to the internal inguinal ring" the Professor said.
The description was quite diagnostic and there was actually no need to look. It had to be the round ligament. I was already looking anyway and continued to do so as asked.
"There is another fallopian tube behind the one you have found" I declared politely after a respectable time interval. "That looks like a normal fallopian tube."
The Professor took charge of the laparoscope, looked inside, and ligated the tube without saying a word.
This must have been one of the many reasons the Professor considered me an enemy. I could have exclaimed "indeed it is an unusual fallopian tube" and allowed the Professor to ligate it. I would not have caused any feelings of enmity that way. I could not do it because I could not allow the poor woman to get pregnant due to ligation of a wrong structure.
I thought of this story after many years, when I saw another senior person (not as senior as that Professor though) make the same mistake the other day.

VLC Logo Fun

VLC is my favorite media player. It plays virtually all media files, is robust, fast, permits muting or adjusting volume with keyboard, permits taking snapshots, and is totally free. A couple of days ago I noticed that its logo on the user interface (without any media file loaded) had a Santa cap above the usual traffic cone. I did a Google search and found out that it was an Easter egg, which changes the usual logo to one with Santa cap between December 18, one week before Christmas, and January 1. I decided to confirm that, but did not want to wait till January 1. I also wanted to see if they were changing it online accessing my computer or it was built in (an Easter egg). I did not want to turn off the internet connection. So I launched VLC player and reduced its window in size so that it occupied 40% of the screen. Then I changed the system date to December 3 and launched another instance of VLC player. It showed the logo in the old form. So it was indeed an Easter egg, functional between the dates mentioned above. I placed the two windows near each other, so that my readers can appreciate what I am saying.

Cool, huh?

Name Muddle

The PCPNDT advisory committee work is quite boring. But God is kind. He usually arranges it so that even the most boring task has some part that is funny. Here is something that supports this statement.
There was an application for registration under the PCPNDT act. The applicant's name was Shavvin Gajrhena Neyakat (changed to protect his/her identity) as seen on the form A of the application.On his/her M.B.B.S. and M.D. degree certificates, it was Shavvin Neyakat Gajrhena. On the undertaking he/she had given on a stamp paper of Rs. 100/- it was Gajrhena Shavvin Neyakat. For ease of understanding, I shall put it in a tabular form.

Place	Full Name
Form A	Shavvin Gajrhena Neyakat
M.B.B.S. and M.D. degree certificates	Shavvin Neyakat Gajrhena
Undertaking he/she had given on a stamp paper	Gajrhena Shavvin Neyakat

All three documents are legal documents. How the full name can be different on these documents is beyond comprehension of an average person. Besides being entertaining, it has potential as a means to keep the old brain stimulated if it is seen as a puzzle. The person solving the puzzle has to figure out what his first, middle, and last names are.

Pouch of Douglas Occlusion

There was a patient who was undergoing an abdominal hysterectomy for menorrhagia and uterine leiomyomas. They called me half way through the surgery for an opinion.
"Sir, the rectum is adherent to the back of the supravaginal cervix. Shall we perform a subtotal hysterectomy and leave the rectum attached to the cervix undisturbed?"
I could understand the thought behind this suggestion. There was risk of rectal injury if one tried to separate it. Removal of the uterus above that level would get rid of the leiomyoma and the patient's problems."
I looked at the operative field. It looked like this (Sorry, there was no time to take a snapshot). I have drawn the structures as they would have been prior to any operative steps for better understanding of the readers.

The rectum was drawn up and stuck just above the anterior ends of both the uterosacral ligaments.
"Wait. Let me wash up and have a feel of it" I said.
I scrubbed and joined them. The rectum would indeed be injured if the uterosacral ligaments were clamped without separating it, and it could be injured during an attempt to separate it.
"I think I can get around this problem" I said.
Then I cut the posterior uterine wall transversely to a depth of 2-3 mm, just above the level of the uterine pedicles. I held the edges with Allis' forceps and cut sharply under the surface downward in the direction of the vagina. Once I reached the vagina, the posterior flap with the rectum attached to it could be pulled away from the uterus and uterosacral ligaments. I cut the ligaments within this cuff and ligated them. Then I cut the vagina all around and removed the uterus.
"This was somewhat like an intrafascial hysterectomy" I said. "The difference was that I kept a cuff of cervical fibrous tissue along with the fascial cuff to give additional protection to the rectum on the outside. After all, the serosa and fascia are thin and can get torn during dissection. Cervical fibrous tissue strengthened the cuff. Now will you close the vagina within this cuff? It won't injure the rectum, which is well away."
"Yes, Sir" they said happily.
I went away happy for having removed the patient's cervix successfully and also for having taught our doctors something new."

Free Open Access Journal

Those who do not want to read the background, but want to visit the journal directly, here is the link to the journal.
Journal of Postgraduate Gynecology & Obstetrics 
I have toyed with the idea of publishing a journal of gynecology and obstetrics time and again. I always knew it would be a lot of work, but that did not matter much. There were a few journals which were free, and did publish articles we sent them. At those times, my enthusiasm for publishing a journal would wane. Unfortunately times changed. People started becoming editors of journals because it was prestigious. But they either did not recognize good material, or had nonacademic reasons to reject good material. I recall an article on a copper IUD that had become bare after retention in the uterus for years. It was sent by a colleague of mine to a 'prestigious' journal in the west against my advice. They returned it saying copper devices were not used any more. My colleague pointed out that copper devices were very much in use all over the world. Then the editor wrote back saying the article would not interest their readers.There was another 'prestigious' journal in town, where we had sent an article on an intramyometrial pregnancy, with a photograph. The editor returned it with the comment - 'the case seems fictitious'. I could not understand how anyone could produce a photograph showing a tunnel from the uterocervical canal going into the myometrium, with a pregnancy at the end of the tunnel. We published it in a national journal. Now the journals have turned fancy. They have online submissions, peer reviews, online or offline payments and publications. Unfortunately they understand that academicians are required to publish scientific articles. So they charge the sky. One such journal wanted me to publish my article in it. I asked the price, which turned out to be more than my salary for a month.All this and much more of it that I find too distasteful to write led me to start a journal of our own. It would disseminate useful experiences of doctors. It would also help the faculty and Resident doctors meet the requirements of the medical council and health university respectively.
Its title is 'Journal of Postgraduate Gynecology & Obstetrics'. It is open access, peer reviewed, and totally free. The first issue is scheduled to come out on first January 2014. Those who want to see what it will be like may see it at the following link. I invite all gynecologists and obstetricians to write for it.
Journal of Postgraduate Gynecology & Obstetrics

Wren and Martin & Doctors

English is taught as first or second language in schools. After the higher secondary school board examination, students lose all contact with English grammar and composition. It is a long way to medical graduation and even longer to postgraduation. A lot is forgotten in this time. As a result, the use of spoken and written English often leaves much to be desired. Read the following two sentences which I heard during a scientific meeting recently, the speaker being a doctor and Director in a Government research organization.

1. That was the very good.
2. They are a very important.

I am an editor of a journal of Gynecology and Obstetrics. I will write more about it some other time. I want to write on only one aspect of it here. I receive a lot of articles for publication in this journal. Some are in good English, others are not. The punctuation marks are just before the next word or sentence instead of at the end of the previous one. The verb is in plural form while the subject is in singular form. Articles are missing, or a definite article is used instead of an indefinite article. The list is endless. I even find SMS language in the text. This is a very discouraging experience. But it has a very great advantage. It helps me check for plagiarism.
"How?" someone asked me when I said this.
"It is simple" I said. "When the grammar, composition, spellings and punctuations are horrible, I am sure it is all original. When it is good English, it is very likely to be copied from some source and pasted."
"That is brilliant detecting" that someone said. "But doctors do that?"
"They are human beings and many human beings want an easy way out. It is so easy to find something on the net or in ebooks, which can be copied and pasted, to be passed as one's own work. It is much more comfortable and the results are so much more pleasing than thinking out text and typing it."
"But plagiarism is copyright violation. It is against the law."
"I wish they would believe me when I told them so" I said. "I had made one of my Resident doctors buy a copy of 'Wren and Martin' (a grammar book) to improve her/his English. The book remained in mint condition even after this Resident doctor qualified and went away."
"Huh?"
"Unfortunately, yes" I said.

Velcro for Buddy Splint

My wife is a family physician. She sees patients with different conditions - mainly medical and pediatric, but also from other specialties including orthopedic. She saw a patient with a fracture of the middle phalanx of the little finger. There was no displacement. The treatment was to apply a buddy splint and give analgesia as required. Conventionally one applies adhesive tape encircling the little and middle fingers, so that the little finger gets immobilized.
"There are some problems with the use of adhesive tape to apply a buddy splint" she explained to me. "It gets wet some time or other during the day, and then the skin of the fingers gets sodden. If it happens too often, the fingers smell. Another problem is that the skin gets pulled on when the bandage is removed, and it hurts. Imagine changing it every day. With movements of this nature, how will the fracture site be immobilized?"
"So what did you do?" I asked. "Did you prescribe a ready splint?"
"I could have done that. But the patient was poor. She did not afford a ready splint. There was also no fun in using a ready splint."
"Hmm...." I said. She enjoyed her work like I enjoy mine. It is the fun part of work that makes it more enjoyable.
"I used Velcro to make a splint" she said. "I passed a strip around the two fingers, adhesive surface out. Then I stuck the counterpart of the strip over it, the adhesive surfaces in contact with each other. It worked like a charm."
The figure below is my depiction of the splint in 3D.

"Did it not irritate the skin?" I asked.
"No. The nonadhesive surface in contact with the skin is smooth. It is tolerated very well. Removal and reapplication are easy. It can be cleaned easily too."
"Congrats" I said. "You have found a new use for Velcro."
"Write about it on your blog" she said. "It will help someone out there looking for a good method to apply a buddy splint."
"Yes, I will" I said. She thought like I did about disseminating useful ideas on the net.

Master Sleeper

I have known some people who can go to sleep at any time, any place, and even under extremely uncomfortable conditions. These are the gifted ones. I know someone who would go to sleep even in standing position, that too without falling down. That person was treated for narcolepsy and is doing well. I had not known any resident doctor who could do it.
"Sir, Dr. XXXXXX was assisting a vaginal hysterectomy. Suddenly she/he stumbled."
"Stumbled? While stationary?"
"Yes. Then we realized she/he had gone to sleep while assisting in a standing position."
"That is great" I said.
"Sir, that is nothing. The other day she/he was injecting oxytocin into a bottle of normal saline hung on an IV stand. She/he went to sleep with the syringe poised close to the bottle. The patient then woke her/him up and said 'doctor, please put the injection into the bottle.' The patient must have got upset because the doctor's sleep was delaying her treatment."
"That is awesome" I said.
The fun part apart, there is something quite upsetting in all this. If our resident doctors have good time management, they will not spend their free time working and will have time to catch up with their sleep. Then such things will not happen. I recall conducting a time management workshop for them, which many of them did not attend because they had either no time or no interest. Now I am in the process of working out rules so that they get more time to sleep. In the meantime, our master sleeper will continue to sleep while standing, and I can only pray that she/he does not fall down and injure herself/himself.
(Note: The 'she/he and her/him business as an attempt to protect the identity of the person."

Sixth Sense or Black Spot?

I am not writing this to boast of something. I am also not writing this to prove I have something special that most other people don't have. I cannot claim credit for it because I have not earned it by any efforts. I am writing it so that in case I forget it in my old age, I can read about it and remember. What better place than free web space provided by dear old Google? :-)
Many colleagues have told me I have a black spot on my tongue. Many times something I say comes true. I prided myself in believing it was my clinical acumen. Something happened yesterday that proved perhaps it was not always so. I got up in the morning and thought about the Sudoku puzzle it would have. I solve one every day because solving puzzles is fun, and it is said to keep senile dementia at bay. I had a sudden thought. 'What if the Sudoku comes with all the blank squares filled in?' I thought. 'That would be terrible. I would have no puzzle to solve'. A half hour later the newspaper guy delivered our Times of India. When I reached the funnies and puzzles page, there was the Sudoku, all squares completely filled in. You can look at the image below to see what I mean. You can access the archives of the newspaper to confirm what I have written is true. There is no way you can confirm that I truly had that thought. You just have to trust me on that one.

Something else happened today. I was on leave for 2 days. When I took a round of our wards, my Registrar told me about one patient who had been admitted with a pelvic mass anetrolateral to the supravaginal cervix. It had the feel of a leiomyoma. She also had renal failure. I recalled telling my Registrar to obtain an ultrasonic scan of the patient's abdomen and pelvis.
"She might have ureteric obstruction by the mass, producing hydroureter, hydronephrosis, and renal failure. We have to confirm that it is truly a leiomyoma, and not a bladder mass" I had said. The Registrar had said nothing, but I thought she had a skeptical look on her face on hearing it could be a bladder mass.
"Sir, this patient developed hematuria. We got her ultrasonography and pelvic CT scan done. She has a mass arising from the posterior wall of the bladder. The urologists have performed percutaneous nephrostomy for hydronephrosis."
"Ah! I had said it could be a bladder mass" I said.
"Yes, Sir" the Registrar said.
Was it my black spot (but black spots make things come true which have not happened at the time of the utterances, this mass from the bladder had already been there as a bladder mass, and my utterance had not changed a leiomyoma into a bladder mass), sixth sense (ditto as for black spot), or my clinical acumen (which I would love it to be)? When I recounted the two stories to someone, the response was "Perhaps you have both a black spot and clinical acumen."
Now would I love that to be true! :-)
(Note: in case you want to write to me to predict the number of winning lottery ticket or the winner in the next horse race, I want you to know that I have not done that any time.

Opportunistic Marketing

It was Saturday afternoon. I had been working and got late. I packed up my things, and left. As I was locking my door, two medical sales guys came from inside the department, having met whomever they wanted to meet, or having missed that person because it was Saturday afternoon. As I turned to go, they fell into step with me and one of them started,
"Doctor, we are from GSK."
"Oh, hello" I said, maintaining my pace. They kept up with me.
"Please prescribe our three products ...."
"I am on my way home. Surely I will not prescribe any medicines to anyone from my home" I said, interrupting him.
"One of the products important to us is ..." he kept up, ignoring my interruption. He must believe perseverance would achieve sales.
"This is called opportunistic marketing" I said. "Like we have a saying in Marathi - देखल्या देवा दंडवत", which means one offers a brief prayer to God when he come across a temple on his way somewhere, not while visiting the temple for offering a prayer."
They seemed to know what the saying in Marathi meant, and its analogy to the current situation.
"Doctor, your door was closed. So we thought you were busy" he said by way of an explanation.
"I was indeed busy" I said "and now I am going home. Bye bye."
I increased by speed, and this time they did not try to keep up. They seemed to know when to give up.

Clinical Method: AEBE

बुरी नजरवाले तेरा मुँह काला

Clinical methods are taught to all medical students everywhere, and if not, they learn them from reading books. Unfortunately they do not retain the knowledge at all times. They tend to sometimes believe their immediate seniors, like a first year resident believes what he/she is told by a second year resident rather than what he/she had learned before qualifying. The following example should make this point clear.
I had sent a patient to the Anesthesiology clinic to see if she was fit for receiving anesthesia for a surgical procedure I had planned for her. She came back certified fit for receiving anesthesia. Something caught my eye in her case record form. In front of the findings of examination of her respiratory system, a first year resident anesthesiologist had written only the word 'AEBE'. I got curious and decided to call him.
"You have just seen a patient of mine" I said after identifying myself and wishing him a good morning. "I want to know what the word 'AEBE' means. It is written as the finding of examination of her respiratory system."
"AEBE is short for 'Air Entry Bilaterally Equal'" he said.
"Ah!" I said. "I appreciate you have certified she is fit and thank you for that. But may I point out something?"
"Yes" he said (tentatively or encouragingly, I was not sure which).
"Air entry is equal on both sides. But what if it is reduced on both sides? If so, she would not be OK. There can be a lot of foreign sounds on auscultation, such as rhonchi and rales. If any of these are present, bilaterally equal air entry would not at all be reassuring. Do you agree with me?"
"Yes, yes" he said hurriedly.
"It could be a lot more meaningful and easier to just write 'normal' instead of AEBE."
"Of course" he said.
"May I ask where you learned this AEBE?"
"My senior told me to write like that" he said.
"Well, I hope you will refrain from doing so in future and will advise your juniors correctly" I said.
"Yes, yes, I will" he said.
"Great" I said and put the phone down, happy in the knowledge that I had made a change for better by correcting this trend.

Waste Disposal from a City Bus

Traveling on a city bus is satisfying not only because it is according to the principle of using public transport and conserving oil for the future, but also because one gets new experiences every now and then.
Today I was on my way home from the hospital. I was sitting near the window of the last seat. There were two women on the seat in front of me. After some time, I noticed them because they did something peculiar. The one sitting near the window was stout and elderly. She put out her hand out of the window and threw out a candy wrapper. The one by her side was a thin young girl (perhaps of college going age). She passed her hand behind her neighbor's back, in front of me, out of the window and threw out her own candy wrapper. Before I could get upset with this total lack of civic sense, the wrapper found its way back through the window (owing to the breeze) and landed on my knee. I looked at it. Its candy side was up, away from my trousers. I considered that a good sign. God had spared me getting candy remains on my trousers, especially when it was eaten by someone else. Before I realized what I was doing, I picked up the wrapper by its corner and gave it back to the girl. She looked at it for a second, identified it as the one she had just thrown out of the window, realized what had happened, and took it back sheepishly. I was curious to see what she would do. Perhaps she would get the message and put it in her purse, and throw it away in a dustbin later on. No such luck. She put out her hand out of the window, this time in front of her neighbor, and threw it out again, sure that it would not come back in. It did not.
My subtle attempt at educating her on civic ways, commanded by my right brain without telling the left brain of what it planned, had gone totally waste. The only thing I gained from that was something to post on my blog, and perhaps stop any of my readers from disposing off waste from the window of a city bus or train, if they feel so inclined.

Superspecialists and Us

This story is a little old. I remembered it in connection with another thing, which I will write about some other time. In the first story, my Registrar was agitated.
"Sir, we have a woman with warfarin toxicity and hemoperitoneum. She has been taking warfarin without supervision and her PT-INR is above 30."
I was taken aback. I had never seen so high PT-INR. Warfarin is a drug used to prevents blood clotting. Its effectiveness is measured by checking the recipient's PT-INR. PT-INR is calculated by using a formula comparing the patient's prothrombin time (PT) to a normal control's PT, the result being known as international normalized ratio (INR). Recommended value for that woman was 2.5
"Ask the hematologists to transfer her to their ward and treat her" I said.
"They won't do it" the Registrar said. "now that she is admitted in our ward. Their Registrar has advised a huge list of investigations and gone."
I was not surprised. Specialists always advised a big list of investigations, super specialists even more so. But they practically never transferred a patient in need of their treatment.
"I will talk to their boss" I said and called their ward. It turned out their boss away somewhere. I was disappointed but not surprised. I am usually unable to contact big bosses in their offices, and I am reluctant to call them on their mobiles, because I believe they must be doing something important wherever they are. I spoke to the next in command, who was an Assistant Professor.
"Why don't you transfer this patient and treat her coagulation abnormality?" I asked her/him.
"We do not have vacant beds" came the answer.
"My wards are full too. In fact the bed occupancy is about 200%" I said. "We keep the extra patients on low cots or even on mattresses on the floor. But we treat them all."
"Our boss' policy is not to take such patients" came the answer. The boss was not there to answer my question, I thought.
"OK. Why have you asked for such a lot of investigations? Surely warfarin toxicity can be managed without all of them? Our hospital does not have facility to perform those tests, and the patient is poor. She cannot get them done in a private lab."
"Which test are you talking about?" I was asked.
"D-dimer" I said. "Why do you need that?"
"D-dimer" she/he sniggered "is required to diagnose disseminated intravascular cogaulation (DIC)."
I could hear the satisfaction in the voice of the super specialist of having put an ordinary gynecologist in his place - especially when he was Professor and Head of his department. Fancy him not knowing what D-dimer was tested for, I could almost hear the thought behind that snigger.
"I know its purpose" I said patiently, "but why do you think a woman with warfarin toxicity would have DIC too?"
There was profound silence. DIC is a condition in which the blood has used up all clotting factors due to some disease and hence the patient can bleed from anywhere and everywhere. It is a dictum of clinical medicine that one should not suspect and diagnose two different conditions at the same time, though rarely they may co-exist accidentally. This person had no business thinking of DIC when there was proved warfarin toxicity and no disease that could cause DIC.
"Um..." she/he said breaking the silence eventually "just to rule it out, if it is ... um...there too."
"I understand perfectly" I said. "Thanks."
I put down the phone, and told my Registrar "we will treat the woman ourselves. You heard my part of the conversation and you understood it, I hope."
"Yes, Sir" she said. That patient went home fine from our ward after receiving appropriate treatment.
"There is no wisdom in considering everyone else a fool" I told my Registrar, especially when one is not perfect oneself. Humility comes with true wisdom. Beware of those who show no humility. Beware of those even more if they lack expertise themselves and still show no humility."

Liquid Paraffin for Dressing: 2

I had written about how our Resident Doctors use liquid paraffin to dress an abdominal wound, when it is an adherent burst. For those of you who missed it, here is the link.
Liquid Paraffin for Dressing: 1
I had impressed on their minds that the commercially available preparation was not sterile and could not be used to dress wounds. I had told them to get it sterilized by putting it a hot air oven (dry heat) at 150 degrees Celsius for one hour. They did that for that patient.
There are two universal truths about things like this. One is that memories fade with time. The other is that history repeats itself.
"Sir, one patient with cesarean section has developed wound breakdown " the Registrar told me. "The surgeons have advised us to dress the wound with liquid paraffin."
"I trust you know how to sterilize liquid paraffin before using it for wound dressing" I said.
She looked at me blankly. One of the two universal truths had proved itself to be true.
"You have to put it a hot air oven (dry heat) at 150 degrees Celsius for one hour. Use it only after doing so" I said.
They looked at each other. After some time, they sent the Associate Professor to break it to me gently.
"Sir, they have ...um... already used liquid paraffin without sterilizing it. What shall we do now?"
They all kept looking at me, expecting me to explode. I have understood that anger does not do any good to anyone, and not desiring to be a victim of its effects myself, I spent time that I would take to count to ten.
"The germs have already passed into the wound" I said quietly. "See if you can put the whole woman in the hot air oven, which will sterilize the wound and the liquid paraffin in it."
They laughed. I thought it was sarcasm, while they thought it was a joke. The Associate Professor looked scandalized and worried.
"Don't worry" I told her. "I know they cannot follow my advice even if they try, because we do not have any oven big enough to take a human being."

Hibiscus - Two Flower Types on One Plant

My wife loves her potted plants garden. I love the look of the garden and the flowers that grow in it. We have a large variety of plants, which grow different types of flowers that look good. We have three types of Hibiscus. One is the common Indian red hibiscus, technically called Abelmosk: It grows large pink-red 5 petal flowers. Its pot is located on the east side. On the south side, we have two. One is white Hibiscus, which grows white flowers similar to the first one, but smaller and more delicate. The other is Hibiscus rosa-sinensis or China Rose. Its flower is layered. While the Abelmosk and white Hibiscus flowers have a single pistil and a few stamens bunched on its terminal part, the China rose has three sets of the same.
We have had the plants for a few years. They blossom regularly, without any surprises. The day before yesterday, the China Rose grew five flowers, of which three were of the regular type, while two were of five-petal type (like Abelmosk) in a single layer. The pistil was much thicker than the usual stamens of the China Rose. Shape of each petal was like the China Rose type. Both types had come from the same single plant. Here is a snap of those flowers. There are three of China Rose type in the back row and two of the variant type in the front row.

I have zoomed and put one flower of each type side by side for comparison in the following picture. 

Yesterday we had a large number of flowers from the three plants (28 to be exact), but there were no variants. Today we had six on the China Rose plant, of which 5 were the normal, usual type, and one was a variant. I took a snap of two of those to show that they actually came from the same plant. The upper one is a variant, while the lower one is the usual one.

We have not grafted another Hibiscus type one the China Rose. Since a single stem has come out of the pot and then branched out, there is no possibility of two plants growing side by side. It could not have happened without our knowledge anyway, because my wife planted a single twig which took roots and grew up in front of us. Thus it is a unique case of two different flower types growing on a single Hibiscus plant. I did an exhaustive Google search and failed to find any instance of such an occurrence. If we were not doctors, we would have perhaps called it a miracle. Being doctors, we think it is a genetic mutation. Either way we are proud that God chose to put its first occurrence in our humble home.
Update: 09-01-2014
Actually it is three flower types, not two as I had originally written. This week we had a flower that had only two rows of petals arranged concentrically, not four and not one. There was a single stamen. Its picture is shown below.

 Update: 12-02-2014
 I found an interesting variant of the China Rose, shown as B in the following picture. Flower marked A is the usual type. Usually the sepals are small and green on both the inner and outer surfaces. This variant had large sepals (though smaller than petals). These were green on the outer surface, and red like the petals on the inner surface.

Update: 10-03-2014
I found the first variant of the white Hibiscus, shown in the following photograph. The usual type shown in A has the petals overlapping the edges of the previous petal going anticlockwise. The variant shown in B has the petals overlapping the previous petal going clockwise.

Adventure Sport: Riding A City Bus

A ride on a city bus can be an adventure. One needs to run after it to catch it at times, when the driver decides to skip a bus-stop. You may want to jump off a running bus when you have some work in between two bus-stops. It is easier when it slows down while turning. You often have to ride on the foot board because the bus is so crowded that there is no place in it. If verbal sparring can be considered a sport, there it is, played with the conductor on the matter of him not returning the balance amount on excuse of not having loose change, especially when you have given him a large denomination note (what Americans call a bill).

There can be extreme adventure sport while riding a city bus. One may be pressed for time, especially with long traffic jams. So one is forced to take a bus to a spot short of one's destination, and then take another from that spot onwards, rather than wait for a bus going directly to the destination. Check out the following illustrations to understand how this extreme adventure sport is played.

One is on bus number 1, going in the direction of the blue arrow.

Bus number 2 (going in the direction of red arrow) cuts in front of bus number 1 breaking a red signal. Bus number 1 has to stop. Bus number 3 is right behind bus number 2. One notes that he needs to be on bus number 3 to reach his destination.

Bus number 1 cuts in front of bus number 3, forcing it to stop. One hops down in that split second before bus number 1 starts, and runs along the pink path and boards bus number 3. He has to be so fast that he does not get under the wheels of any of those buses, and driver of none of the buses can get to shout at him or stop him in his path.
After I decided to use public transport as a social obligation and sold off my car, the commuting to and from work has become increasingly difficult. Finally one day I got so late going home from work that I succumbed to temptation and engaged in this extreme sport. The adrenaline surge started after boarding bus number 3. I probably used up all the adrenaline in my reserves. Though it was reassuring that I had a sound heart (considering the fact that I did not get angina or worse), I decided not to test my heart again in this manner, and leave this sport to younger people.
(Warning: do not try this- you may end up with a few fractures, a head injury, or worse.)

Teetotaler Music System

This is a true story. If you are wondering if it means my other stories are not true, please read the intro on the home page of my blog.
I have a Panasonic music system, which can play CD, cassette, FM and AM radio. I have not used the cassette player part for a long time, and now it does not work. I decided to clean the playing head of the player to see if it was magnetic dust collected on the head that was the cause of the loss of function. So I took a brush, dipped it in methylated spirit (we use it to disinfect the skin prior to giving an injection to a patient) and cleaned the head of the player. My old practice was to use a piece of cloth soaked with spirit for this job, which I used on my old music system. But I disliked the smell of alcohol on my finger. So I used a brush. After that. I started the system, and it just went crazy. The CD tray would come out, wait for 2 seconds and close again. It continued to do this tirelessly, and I knew it would continue to do so till eternity or until the power was switched off, whichever was earlier. So I switched off the power. It was smarter than I thought. It went on again on its own and continued its antics. I was smarter. I switched off the mains before it could power itself. After giving it a rest for a few minutes, I powered it on again. Now luckily it did not play the CD tray trick again. But it rapidly cycled through all its commands - some of which I knew and many of which I didn't. I could read the commands it was executing on the display - CD1, CD2, CD3, CD4, CD5, AM, FM, Cassette, Normal, Movie, Bass, Treble, Sleep, Wake, Manual, Auto, Record, Eject, Hello, Goodbye, and a number of others I did not register in my amazement. It started making me dizzy. So I switched it off.
I powered it on the next morning. Its behavior was exemplary. It played like a music player should - a sane one I mean.
"What was wrong with it?" my wife asked me.
I thought it over.
"If we believed in ghosts and spirits, I would say it was possessed" I said. "If it were computerized and connected to the net, I would say a hacker had taken it over. My best guess, believe it or not, is that it was drunk."
"Drunk?" she asked incredulously.
"Drunk" I said. "I put alcohol on the head of the cassette player with a brush. It must have evaporated and spread inside the system's box. Having never been exposed to alcohol, it probably got intoxicated with that small amount. So it started its monkey tricks. After a day, it got sober. So now it is working OK."
"Oh!" she said. I knew she did not believe me. I did not believe myself. But then, there was no other explanation. In fact, I think the sound coming out of the speakers was a little gruff - like it had a hangover. (:-)

Salary Payment Through SAP

The civic employees are paid salary electronically into their bank accounts. That is a lot better than having to stand in a queue and taking cash. There is also the risk of carrying so much cash home in view of pickpockets being active. They would become even more active on the day of salary if it were paid in cash.
There are civic body administrators who always want to improve on a system that is working well. They acquired a software called SAP for all purchases and other financial transactions. That the employees could not master it was the reason the supply of a lot of things suffered. Then they decided to pay the salary through SAP. This post is about that decision.
"Sir, there is this letter asking for employees to fill up the form for receiving salary through SAP" I was informed.
"But we have filled up SAP forms twice in past, about six to eight months apart" I said.
"They want it again" I was informed.
I read the form. It was in Marathi, our state language. For the curious types, I present images of the two pages of the form.

"Why do they want to know about the state of an employee's marriage?" I exclaimed. "The marriage may be good or about to break up. Irrespective of that, he/she has to be given salary for work done by him/her."
"Not only that" said someone, "but they want to know about employment of spouse and offspring, and their monthly incomes too."
"That is collecting private data" said another person. "The civic body cannot collect such private data!"
"They are doing that" I said. "If you don't provide all the information asked for, they will stop paying your salary from first January. That is what the circular states."
"There is a gender bias" exclaimed a gender sensitive person. " The statement at the end has the verb करणे in the form for masculine gender alone. They have to give both masculine and feminine genders, and ask one to strike out inappropriate one."
"There are 11 spelling mistakes and two grammar mistakes" said a person who was well versed with Marathi language, in which this form was written, and in which all work of the civic body has to be done. In fact, each employee was expected to produce a certificate of having passed Marathi examination, or he/she would not be promoted, and without which new persons would not be even employed. "How can our employers who insist that we must know Marathi well themselves make 13 mistakes in just a 2 page form?"
I checked the form and found all the mistakes. For the curious types, I have marked them in red in the images above. If anyone finds more mistakes, please write to me. I will inform the civic body about those too.

Facial Expressions in Faculty and Resident Doctors

Some people watch other people's facial expressions during interactions, others don't. I do, because expressions tell a lot of things that mere words don't or sometimes things that are different from those implied by the words uttered. What follows is the graphical expression of various facial expressions I find in the people who work with me. Just sit back and watch.

Please write to me if you think of any expressions that I may have not included either out of oversight or because I have not encountered them yet. I will try and draw those too, to be put in the next version of this animation.

Baby Name

People name babies differently. Some name them after their parents' names. Some name them after names of Gods they worship. Some name them after their heroes. Some use nice sounding words for their babies' names, even if they don't mean a thing. These days people search the net for baby names.
That patient had it easy. She had some gynecological problem, which I looked into and started the management.
"Doctor, I have come to you because you had treated me well the last time."
I kept a smiling face, though I could not remember her."
"I had infertility. I got a baby after you treated me. I was very happy."
I broadened my smile.
"I have named my baby after you" she said. My surprise must have shown on my face. "I have given my baby your name" she explained.
I smiled genuinely.
"Has he started going to school?" I asked.
"Yes" she said.
"Is he bright?"
"Yes" she said.
"That is nice" I said. "He will do you proud."
"Yes, doctor. Thank you doctor" she said, smiled some more and went away.
This was the first time (as far as I knew) some patient had named her baby after me. This woman had made my day.

Breath Holding

People hold breath for different reasons. Swimmers hold breath while swimming underwater. Spectators hold breath when a batsman hits a high one and a fielder runs to make it to the expected spot of landing to catch the ball. A guy holds breath when he pops the question and the girl is about to answer.
In hospital, we hold breath when:

1. a baby delivers and is yet to cry.
2. someone is doing a cesarean section and is struggling hard to deliver the baby's head.
3. a Resident doctor is trying hard to pass a trocar and cannula into a patient's tummy during laparoscopy.
4. a junior anesthetist puts in a lumbar puncture needle for the nth time and everyone bends down to see if the cerebrospinal fluid escapes out of the hub of the needle.
5. we pass by the college wash room.
6. we pass by the central garbage dump.
7. we pass by a cat or dog poo on the staircase, especially when someone has already stepped on it.
8. when someone sneezes in the hospital corridor without covering his/her nose and mouth.
9. when someone coughs nearby in the hospital corridor without covering his/her nose and mouth.
10. in the elevator jammed with people, some of them going to the RNTCP center, where they treat patients with tuberculosis.
11. a Resident doctor calls in the middle of the night and keeps on talking about some patient in the past tense, but does not reach the part when something happened to the patient.

In case you cannot make out why we hold breath for any of these happenings, feel free to write to me.

Generating Work

I thought there was so much work at the hospital that no one would think of generating some. I was wrong.
"Sir, this patient with uterine leiomyomas is to be posted for abdominal hysterectomy" my Registrar said. "But the anesthetists have found hepatomegaly and splenomegaly. They have asked for opinion from hematologists and gastrointestinal surgeons."
"Let me see her" I said. I palpated her abdomen, but could not feel the liver and spleen. "Liver and spleen are not enlarged" I declared.
"Even her abdominal ultrasonography does not show any enlargement of the liver and spleen" the Registrar said.
"Let us speak to the anesthesiologists" I said. I found senior anesthesiologist and told him about this patient.
"I asked for opinions of hematologist and gastrointestinal surgeon because my House officer found hepato-splenomegaly" he said.
"But there is no hepato-splenomegaly" I said."neither on palpation nor on ultrasonography."
"It is better to take those opinions" he said. "The patient looks emaciated."
"We will take all opinions required if there is hepato-splenomegaly" I said. "We cannot increase work of those superspecialists, who are understaffed and overworked. I suggest you palpate her abdomen yourself before asking for such opinions." I should have added 'they will laugh us out when they find no hepato-splenomegaly', but decided to let it go unsaid.
Finally he palpated the patient's abdomen and said  'there is no hepato-splenomegaly. I thought the House officer was right."
"Don't trust a person blindly" I advised. "Confirm that he/she is good before you trust him/her." I wanted to add 'or we will end up doing a lot of things, some of them bad for the patients', but decided to let it go unsaid.
Lately I have been leaving a lot of things unsaid, because I have realized that though I like to state the truth, people often do not like to hear it.

Meeting at 12 P.M.

English is taught in schools. It is more advanced when it is taught as the first language and less so when it is second. The importance of the language is not emphasized then because one does not know where the student is headed for higher education. Professional courses do not have English as a subject in the curriculum. So whatever English the student has learned in school and has retained will be used by him/her whenever there is need for it.
When the person starts working in clerical capacity in an organization, like ours, he/she may have to compose letters for the Boss, who signs those letters and then those letters reach whoever they are meant for. Often the Boss just signs them after scanning them briefly. A few Bosses read the letters and correct the grammar before sending it. Most of them don't. One such letter reached me asking me to attend a meeting.
"The meeting is scheduled at 12:00 P.M." it read. I was perplexed for a few seconds. Knowing what I have described in the early part of this post, I realized what it meant.
"For a moment I thought the meeting was at midnight" I said to our clerk. "The term 'A.M.' stands for the Latin phrase 'Ante Meridiem' —which means 'before noon'—and 'P.M.' stands for 'Post M': —which means 'after noon.' 12:00 A.M. and 12:00 is wrong usage of the language. If at all, 12:00 P.M. would mean midnight. However some people do not understand that very clearly, and write 12:00 P.M. when they mean 'noon'. I was not confused in this case because generally no one schedules meetings at midnight. There was a Boss in this institute some years ago, who used to keep meetings at midnight or in the wee hours. Luckily there has not been another one like that subsequently. This sort of confusion is best avoided, and it is easy to avoid it - one should write 12:00 noon and 12:00 midnight or use 24 hour clock in which midnight is 00 hours and noon is 1200 hours."
Now I am certain that at least one clerk will not create this confusion in the civic offices.

FIGO Classification of Abnormal Uterine Bleeding

The International federation of Obstetrics and Gynecology has some pretty detailed stagings of gynecological cancers. They keep modifying these periodically. I had not thought they would go beyond that, but they did. I came across their classification of abnormal uterine bleeding (AUB) on the internet. Surprisingly it has not found its place in text books of Gynecology. I also found out that hardly anyone knew about it, though it came out in 2011. I tried to find out why. There were several reasons.

1. They had done away with the age old terminology of menorrhagia, polymenorrhea, oligomenorrhea, metrorrhagia, hypomenorrhea, cryptomenorrhea etc, and replaced them with descriptive terms. The old terms were fine, brief, precise and well accepted. They caused no confusion and there was no need to change them.
2. They had left things half way. While leiomyomas had been subclassified a lot, other lesions like polyps, adenomyosis had not been subclassified at all.
3. They had pooled endometrial hyperplasia and malignancy together. Putting benign and malignant conditions of the uterus together made no sense.
4. They had scrapped the term 'dysfunctional uterine bleeding' which was quite satisfactory.
5. The purpose of this new classification was not clear. No purpose seems to have been served in the two years after they put out the classification.
6. They put one condition - iatrogenic - in the list. They did not put any in which the patient ingested hormones on her own and caused abnormal uterine bleeding.
7. They put a 'not yet classified' category. If they brainstormed and came up with a whole new classification which was to replace the old one, the new one had to be comprehensive. Leaving a big unclassified chunk does not make sense.

"Why have they done this?" someone asked me.
"To justify their existence?" someone else suggested. That sounded like justifying a trip to the city of the meeting, all expenses paid.
"To feel good at having created something new?" a third person suggested.
"To provide material for newer editions of textbooks?" someone snickered.
"I found the following explanation on the internet" I said. "These are quotes of the committee members.

1. There has been general inconsistency in the nomenclature used to describe ...AUB in reproductive aged women, and there is a plethora of potential causes—several of which may coexist in a given individual.
2. It seems clear that the development of consistent and universally accepted nomenclature is a step toward rectifying this unsatisfactory circumstance. Another requirement is the development of a classification system for the causes of AUB, which can be used by clinicians, investigators, and even patients themselves to facilitate communication, clinical care, and research.
3. The goal of our panel was to develop an agreed pragmatic classification system with a standardized nomenclature to be used worldwide by researchers and clinicians investigating and treating women of reproductive age with AUB."

 They all were stunned.
"What does it all mean?" the first person asked.
"Does it mean anything?" the second person asked.
"It all reminds me of the preventive and social medicine text books. A lot of words, and you are blank after reading them" the third person said. I neither agreed nor disagreed with any comment.
"The concluding remarks included this line" I said. "We recommend a scheduled systematic review of the system on a regular basis by a permanent committee of an international organization such as FIGO."
"Now we know what it is all about" they said and laughed.

SVP's Test

One of my old Resident Doctors was visiting us.
"We had fun" she said. "I still remember your SVP's test. Do you still do it?"
I smiled. I used to do things which were unorthodox, but would help the Residents remember things better. This test was to demonstrate how loose a ligature was, so that they would remember to tie tighter ligatures.
"No" I said. "The fun wears out if you do the same thing over and over."
After she went away, I sat thinking of the test. I used to call it SVP's test for want of a better term, not to immortalize my name. Anyway, there was nothing wrong with naming the test after me - after all I had developed it myself. Nothing great I suppose, but effective.
After a Resident Doctor had tied all ligatures while performing a hysterectomy, I would take a curved hemostat and try to pass it gently between the pedicle tied and the ligature. If it passed through, the ligature was loose. If it did not, the ligature was tight. Then I would make him/her put a figure-of-eight ligature over the ligated pedicle to avoid postoperative bleeding from the loosely ligated pedicle. Later I made it a policy to place figure-of-eight ligatures on all ligated pedicles for safety. Then this test became superfluous. I performed the test recently because a doctor trained in another institute wanted to do away with the placement of the safety ligatures - or rather did not know about them. The results are shown in the following picture.

The hemostat is seen to have passed through the ligatures on two pedicles. The test was thus positive on both the  pedicles tested. Needless to say, I made that doctor place safety ligatures on all pedicles and advised to do so in all cases operated on subsequently.

Iatrogenic Dystocia

I was teaching my postgraduate students 'Dystocia' when I remembered this story. For those who don't know what 'Dystocia' means - 'Dystocia' is difficult labor. It can be caused by many factors in the mother and the baby. For those who don't know what 'Iatrogenic' means - 'Iatrogenic' is some problem for the patient caused by the treatment of a doctor.
Some of the students were half sleepy - poor souls who work day and night without sleep at times. I decided to tell them this story partly to educate them and partly to wake the sleepy ones up.
'This happened when I was a resident doctor. There was an honorary Professor in the department. This one had a lot of rich patients in private practice. Some of the patients were foreigners. It seems they expected the Professor to deliver them personally, for which they paid well. If the Professor was busy elsewhere and an assistant delivered them, the payment would be less. A resident doctor from my batch was working with this honorary doctor. That day they were in the OT. There was a call for this honorary doctor. I can put down only the honorary doctor's part of the conversation as heard this resident doctor, who recounted it to us later.
"Oh, she has gone in labor, huh?"
"............"
"How much is the dilatation?"
"............"
"Full?"
"..........."
"Of course she will deliver if you let her bear down."
".........."
"Ask her to breathe in and out, in and out, deeply." (That prevented the patient from bearing down or pushing the baby out, we knew). "And ask her to cross her lower limbs and hold them tightly together." (That would keep the lower end of the birth passage tightly closed and the baby would not be able to come out, no matter how much the poor woman pushed). "I am on my way to the hospital."
With that, the honorary doctor jumped into the car waiting outside and rushed off to deliver the patient.
"What must have happened to that baby?" someone asked.
"Its head must have been compressed by the patient's thighs preventing exit" I said. "That could have caused injury to the head and its contents."
"Oh!"
"Yes, oh!" I said. "Nothing bad might have happened to the baby too. I call this 'iatrogenic dystocia'. When you practice after you qualify, I advise you never to do this."
They shook their heads.

Google, Spikebuster and Me

Life is full of surprises. Here I am, a gynecologist who spends almost all working time treating women patients, and the rest managing problems of all sorts at workplace. Here I am too, spending a chunk of my private time thinking of solutions to problems, including technical nonmedical issues. One of these problems used to be spikebusters which would go 'phut' without any notice.
"They must be made in a certain country" said someone who read newspapers knew all about that country flooding Indian and also World markets with cheap products which would go 'phut' anytime. I refrain from naming that country (which that someone had named), because of two reasons - one is that my country is not flooding the markets with any products even half as good, and the other is that one should not buy these products on one hand (having a fixed ideas on their quality) and criticize them on the other. Anyway, all that is besides the point. I had a number of non-working spikebusters on my hand, which our engineers would/could not repair, and advised me to buy new ones instead. Finally I opened them, bypassed the circuit boards, reestablished electric circuits, and made them functional again. For like minded people, I drew up a diagram of their circuit boards and put it up on my blog, along with an explanation on how to repair them.
I used to get repeated hits for that article, mainly from my own country, that too mainly from Hyderabad. I was happy that my article was helping people. Today I had a surprise. I got a hit from Hewlett-Packard Company, Palo Alto, California, USA. Google search had directed that person to my blog article. I know there might be a few who will not believe me. So here goes a screenshot of the same.

There are number of issues here.

1. The hit came from a country known for its technical superiority and consumerism both. Someone there wanted to repair a spikebuster rather than throw it away and buy a new one.
2. The hit came from California, the silicon valley known for software and also hardware. They seemed not have a solution to a minor problem like this.
3. The hit came from Hewlett-Packard Company, a company known for its hardware. If the Boss knew what an employee had done, he would hit the roof, unless the Boss himself had done the search and reached my blog :-)

I thought it was funny that my article link, probably on 12th or 34th page of a Google search would be reached by anyone. Just to be sure, I did Google search thrice, using different keywords each time. Here is the biggest surprise. Google ranked my article first in all three, including my circuit board image in Google images. I know the Google search results vary from country to country. But it seemed to be doing that in Hyderabad, India and California, USA. After all this, one is left wondering about the following.

1. Has Google gone nuts, ranking a gynecologist's article on repairing a spikebuster first?
2. Is Hewlett-Packard Company so down in the dumps that the employees have to repair their spikebusters and also that they do not have the technical know-how to do it?
3. Am I going to choose a PC, laptop, or printer made by that company next time I buy one for myself or my department?

Update: 3rd December 2013
Another person working in Hewlett-Packard (making computer hardware), Europe, must be a gynecologist. Today he did an encrypted search and found my article on making a pelvitrainer. Here is proof of that.

White Noise

I had read that white noise was used as a form of labor analgesia. That was when I was an undergraduate student, and the the book was, I believe,  by Holland and Brews. I did no find it in other books during my subsequent reading. But perhaps it works. The nurses and resident doctors must not have read about it, but they seem to know all about it and they use it extensively too. When I take round of the labor ward, if one of the women is delivering at that time, I get fresh evidence of it.
"Come on, push, push, push" shouts one person.
"PUSH! PUSH! PUSH!" shouts another..
"बाई जोर कर, बाई जोर कर, बाई जोर कर" shouts a third person.
The main thing is that all three or six or whatever number of them shout their thing at the same time. The poor woman is with clenched teeth, her entire concentration on that phenomenal effort of pushing. I wonder if she hears anything in that state, and if she does, if anything registers. Even if it does, no one can make out the individual components of the white noise.
"What is the purpose of this shouting?" I asked during the ward round once.
"Encourage her to bear down" answered one Resident doctor.
"As if she can make out what they are saying" said an Assistant Professor.
"It is like the crowd cheering their hero in a game - cricket, soccer, boxing, whatever" said another Assistant Professor. "She knows all of them are on her side - are with her. That gives her strength."
"I think it is labor analgesia" I said. "The midwives have perpetuated it through all these years from time long forgotten."
"Does it work?" asked one Assistant Professor.
"God knows. It is actually causing a headache rather than relieving any pain" I said. "Perhaps that is how it works - like a counter irritant.. Causing a pain greater than the labor pain makes her forget the labor pains."

Happy Diwali

Happy Diwali


Let us be Happy this Festive Season
If we can remain so for the rest of the year...
Nothing like it
If we cannot...
At least the memories of this happiness should last
Until the next year.

PCPNDT Immunity

"Sir, the civic body wants to run a training course of ultrasonography in our hospital."
"So be it" I said.
"In our department. They want to give hands-on training to doctors working in peripheral civic hospitals. They are going to bring two ultrasound machines for the training."
"Huh?" I said. Being chairman of the PCPNDT Advisory Committee , I knew the PCPNDT act well. "They have to have the proposal passed by the Advisory Committee. The committee needs to see if the trainees qualify to be trained as per the act. The machines need to be registered for being brought here."
"..."
"I will speak to the concerned person" I said. That was easy, because they needed me to make arrangements locally. The officer in charge came to see me about it.
"We have to follow the act" I said. "If not, I hang, the violation of the act being done in my department."
"But there is no time, Sir" she said. "The Civic Boss wants the training done now."
"But you seal ultrasonography machines of private practitioners if they are no registered or if persons not registered under the act carry out ultrasonography. How can you commit both of those wrongs?"
"It is us who have to take that action against offenders. We will not take action against our own people" she said, appearing pained at having to explain such a simple thing to me.
I was speechless for some time. When I recovered, I said, "that is like Policemen committing crimes. They have to catch the criminals, and they will be safe if they do not catch their own. By newspaper reports, it seems such a thing happens sometimes. By the same reports, it seems there is a big stink and heads roll when this is found out. If you have to violate the PCPNDT Act, please do it elsewhere, not in my department."
After we repeated ourselves multiple times (through no fault of mine - I had to repeat myself when she repeated herself), she went to see the Boss. The Boss called me.
"Please explain the situation to me" the Boss said. The complainant sat there expecting compliance from me.
I explained the situation to the Boss. Then I said the penalty for violation of the PCPNDT Act was imprisonment and fine, and since the PCPNDT certificate was in the name of the Boss, the Boss was at risk of getting the punishment for violation of the act. That settled the issue.
"I knew there would be legal trouble when he objected to the arrangement" the Boss said, pointing at me. "We agree that this training is very important. But at the same time, we must follow the law very scrupulously. Get the necessary permissions and only then start the training."
The officer arranged an urgent meeting of the PCPNDT Advisory Committee. We got the certificate from the civic body the same day.
"That must have been the fastest permission given by the civic body in its entire history" someone said.
"No. It is the second fastest" a knowledgeable person said. "The fastest was given to the new civic hospital that was inaugurated recently by chief of the ruling party and Boss' Boss' Boss. It was given as soon as the day of inauguration was finalized, without going through the standard procedure of getting the proposal finalized and approved."
They all looked at me.
"The concerned officer told me the main Boss gave a temporary registration to that hospital, pending approval by the Advisory Committee."
"Does the act permit that? Was the proposal OK?" a principle centered person asked.
I smiled twice, once for each question, and said nothing.

Oil Can Engineering

Edible oil is available in plastic cans. We buy it in cans of capacity of 5 L. We transfer a small quantity at a time from that can to a small container, and replenish its contents as required. A problem with this system is that the oil pours out in an unruly manner. That makes the process messy, and wastes a bit of the oil too.
"See if you can fix this problem" my wife told me. I was home because I was on Diwali vacation. I was glad to have something to do. I had known the problem, having carried out the procedure myself once. I thought about it a bit, and realized that the oil poured out of the can creating a sort of empty space inside the can. The can had to suck in air before it could pour out more oil. That produced a very turbulent flow, waxing and waning, and spilling out in different directions with time. There had to be an inlet for air, so that the oil would pour out in a smooth flow. I burned two small holes in the hollow handle of the can using a heated nail. The fixed oil can looked like this (arrow on the holes).

Then I tilted the mouth of the can over the small container. The oil poured out in an even stream, spilling not one drop outside the container. After filling the small container, I put a piece of adhesive tape over the holes, so that air and bacteria would not enter it.
"That was wonderful" my wife said with a broad smile. "How did you think of it?"
"I must have remembered laws flows of fluids from school or college physics" I said. For those who have not been able to visualize what I have described, I have put the illustration below. The left part shows the unruly spill, and the right part shows the smooth flow after fixing the oil can.

Insult the Professor?

This one is about one of our Assistant Professors who left in search of greener pastures, as young people should do and do. We always train people, whether they be resident doctors or newly appointed Assistant Professors. Some of the latter are good when they come to us. Most of them are like the Resident doctors who have just passed M.S., but have not learned the nuances of the subject.
This one was OK. There were a few things that he/she* messed up a little. There was a particular operation that he/she had not understood well, and would not despite my instructions. I had a scientific article with illustrations that would be quite useful to him/her, I thought.
"Take that article from me on your pen drive and study it well" I said.
"OK" he/she said.
A month passed without any action, until the next time the same operation was attempted by him/her with similar confusion as ever. I asked him/her why he/she had not taken the article from me, despite a reminder in between.
"I am worried about virus" he/she said. "Can you not email me the article?"
"Don't worry," I said "I have AVG and Microsoft Security Essentials on my system. If your pen drive has a virus, my antivirus programs will remove it and not let my system get infected."
"Quick Heal is good" he/she said "which I have on my system." Then he/she left. He/she left the institute a few months later, without taking the article from me.
I thought about it a bit over a few days, and one day suddenly realized that he/she was worried about getting a virus from my system, not putting one into my system. I felt like one would if someone suggested that one had a dirty disease. I had built four computers from start, installed Windows innumerable times, installed antivirus software programs on multiple systems after researching on the merits and demerits of different ones, recovered data from pen drives and hard drives of people who had lost their data to viruses, and written two decision making software programs of my own in Visual Basic. After doing so much work, I thought no one would say such a thing about me. I did Google search and compared Quick Heal to the ones I was using. I was assured I was doing the right thing. I did not send him/her the comparative data I compiled, because I knew I could not improve his/her knowledge on antivirus software, just as I could not improve his/her technical knowledge and abilities. Though I have been discouraged, I have not stopped trying to help people. I would have stopped but for the sensible part of me telling me that I had to be principle centered, not people centered, as taught by late Mr. Stephen Covey (Seven Habits of Highly Effective People).
(*: I have used he/she to protect the identity of the person concerned. I cannot say he/she deserves if his/her identity is known to all, because I know I should not be judgmental and condemn anyone.)

Doctors and Strikes

It is a tradition that Resident Doctors go on strike every few years. They used to strike work every fourth year like clockwork, when the issue used to be raise in stipend. Now there are many issues and the strikes occur more often. Usually the strikes begin on Tuesday. My theory is that it takes them that long to get out of Monday morning blues. Or perhaps they believe the administrators should not be in Monday morning blues when they strike work, so that their demands will be met. Another good time to begin a strike is when the Faculty proceed on vacation. All leave including vacation gets cancelled when the strike begins. Faculty have to do their own work plus the striking doctors' work. The strikers probably believe that pressurizing the Faculty will result in Faculty pressurizing the administrators to settle matters to the satisfaction of the Resident doctors. Poor dears do not realize that no one listens to the faculty on any issue. Today they went on a token strike. It is a Thursday, not Tuesday. But it is the second day of vacation for the Faculty. So they proved my theory. What follows is graphic representation of what used to happen when I was a Resident doctor and later an Assistant Professor. I believe little has changed since.
Day -1

Collection of union membership dues prior to the strike. These days stipends get credited to bank accounts. So the dues are probably collected one time when new Residents join.
Day 0: Eve of Strike

The main activity is packing bags for going home on a fully paid long holiday.
Day 1 of Strike: Warning potential strike-breakers

I am warning you, you @#$$%&%^. If you break the strike, we will lock you up in your room when you go to sleep.
Day 2 of the strike: The stage of negotiations with the health minister.

Day 5 of the strike

It is Saturday today. Let us enjoy this Sunday and call the strike off on Monday.

Every day of the strike

Ring up the mortuary in the morning to find out if the strike is having the desired impact on the patients' health.
Day 6 of the strike

A humble request to chemists for a generous donation to the strike ... or else...
Day 6 of the strike

An appeal to the professors to donate generously for the strike, so that their ordeal ends quickly too.
Day 8 of the strike

An outpatient clinic is set up outside the hospital for the convenience of the poor patients.
Day 12 of the strike

March at 12 noon in candlelight. The purpose is to be noticed by people, not to show them light.
Day 14 of the strike: Opinions of professors on the strike

"Why do I say the strike is ethically, morally and legally justified? Because by daughter is one of the striking doctors."
Day 28 of the strike

Finding the professor doing ward-work and getting him to check and sign one's dissertation for MD examination.
Day 31 of the strike

Relay hunger strike: Location? Near the canteen, where the hunger striking doctors can rush into the canteen as soon as their 2 hour turns get over.
Day 51 of the strike

Strike breakers: "we can take those ad hoc lecturers' posts. That will not amount to breaking the strike, because we will not be resident doctors, we will be full-timers.
Day 56 of the strike

Stage of negotiations for at least granting of term and pay for the period of absence from duty during the strike.
Day 57 of the strike

Face of Victory!: "We are very proud of our struggle for justice. And we even managed to get a promise that they will not mention the strike on our post-holding certificates.
Day 1 after the strike

"God knows what the objectives of the strike were. But it gave me time to get engaged and finish my dissertation too."