Such Innocence

She was a small and thin woman, barely 40 years old. She looked poor and unwell.
"Sir, she has a vaginal vault prolapse following an abdominal hysterectomy" I was told.
"Why was the uterus removed?" I asked her.
"I had fibroids" she said simply.
"How much time after the operation did this new condition develop?" I asked her.
"A couple of years" she said.
"How did it happen?" I asked her. "Do you lift heavy weights? Do you have chronic cough or constipation?"
"No" she said, "when my husband died, I cried a lot. Those screams probably broke my stitches and this thing developed."
"Ah!" I said. I had a lump in my throat and could not speak anything for quite some time. The poor woman had no husband, probably no resources to look after herself, had a condition that would require major surgery, and was so innocent that she believed that her heart rendering cries had broken the stitches in the vaginal vault making it prolapse out. I could not console her because she did not want any consolation. I was glad that I could at least cure her illness and let her move on.

Locate the Liver

Clinical methods is something very basic. They used to expect expertise from us in that area in the junior clinical term as undergraduate students. I never thought the standards had changed. Well, change is the essence of life. They showed me it was high time I learned that.
Obliteration of the liver dullness is one test that is performed during laparoscopy to confirm that an adequate volume of carbon dioxide has been filled in the peritoneal cavity. I was assisting my house officer perform a laparoscopy. When the time came to do this test, she stopped.
"Percuss for liver dullness" I advised.
She hesitated a bit, and proceeded to percuss in the left hypochondrium. I was stunned. I had heard that women are prone to confuse between right and left. Perhaps this was a case that proved it.
"Show me your right hand" I said. She did that correctly. So the theory I had heard was wrong, at least in this case.
"Are you left handed?" I asked. I think it was an attempt at asking a sarcastic question, though I knew it was a bad attempt even as I asked it. Her right or left handedness had nothing to do with the location of the patient's liver.
"Do you think the patient has situs inversus?" I asked. She was as confused as ever. "The liver is on the right side" I finally said. Then she proceeded to percuss on the right side.
The next week I was in for another surprise. I was assisting another resident doctor perform a laparoscopy. When the time came to percuss for liver dullness, she started percussing in the right midclavicular line at the level of the umbilicus. I was aghast.
"How did they give you a case of massive hepatomegaly to perform a laparoscopy on?" I asked in mock surprise. I knew the patient had no hepatomegaly, but I had to be sarcastic. The best candidates came to us as postgraduate students, and this was shocking to me. "Is that where you percuss for liver dullness?"
"No sir" she said, "we percuss in the right hypochondrium."
"That is still an enlarged liver" I said. "Have you sold off your clinical medicine books?" She kept quiet. She probably had sold her books. "Read clinical methods today" I said. Then I percussed in the 5th right intercostal space, confirmed that the liver dullness was gone, and allowed to proceed with laparoscopy.
I wonder if the current teaching teaching of clinical methods is too casual, or current learning by the students is too casual, or both are too casual.

Chairperson for Garbage Disposal

It is a curious thing that people shun honorable work when it is a part of their regular job, but will do what they would shun in the normal course of things.
I could never imagine that rich superior consultant, who normally gets people to do menial work happily undertake the job of food taster, ensurer of cleanliness, and garbage disposer. The unbelievable happened when someone diplomatically appointed this consultant as the chairperson of a subcommittee of a national conference. The subcommittee had no menial workers, incidentally. The job of the subcommittee should be clear from the following part of the appointment letter.

Such is the power of a prestigious sounding title. It is the feel-good factor that some people use to fool their followers.. Those who fall for it get what they deserve.

Ovarian Cyst Torsion: Dilemma

When I was a student, the standard teaching was not to remove the torsion of a twisted pedicle of an ovarian cyst or tumor. It was recommended that the cyst/tumor be removed. It was stated that if the twist was removed, thrombi and toxic materials would escape into circulation and harm the patient.

Scientific thinking changed over time. Now we have Doppler to help us decide preoperatively if the circulation through the ovarian vessels is obstructed or not. It is believed that if ovarian circulation is not interrupted, the ovary may be salvaged by removal of just the cyst in it. If it is obstructed, removal of the cyst is recommended.

We had a 14 years old girl who presented with bilateral large ovarian cysts, with features of torsion of one of them. Doppler studies revealed absence of flow in its vessels. By standard teaching one would have to remove the ovary. But we were reluctant to do so in view of her young age. Should we remove one ovary and some time later even the other ovary had to be removed for a similar reason, the girl would develop surgical menopause very early in her life.

“Counsel the patient and her guardians/parents that we can try to salvage the ovary” I told my Registrar on phone in the middle of the night. “We will remove the twist and enucleate the cyst. If the raw tissues bleed freely, the circulation can be presumed to be OK. Then we can reconstruct the ovary. There is some risk that the vessels may get thrombosed due to endothelial damage sustained due to the torsion, and she may need another operation to get the ovary removed. If they agree, do as I have just described.”

Things went as I wished, and they saved her ovary. We still need to wait and see, but the patient and her conserved ovary seem to be doing well.

“Don’t always trust the Doppler report blindly” I told my resident doctors. “Give the patient a fair chance. If the flow is indeed found to be absent during dissection, you can always remove the ovary. If you just clamp and cut the pedicle right away after opening the abdomen, there is no way you can reverse it.”

I am sure they will carry this message into their own practice when they qualify and go away.

Wacky Ideas - Blow Horn

It is official. I read in the papers that the supreme court has told the government to set up norms for the decibel limit on the noise vehicle horns can make on the roads. It has always been my contention that they make a lot of noise, sometiems weird ones (with the reverse horns). The bikes are fitted with horns that blow like those fitted on heavy duty vehicles.That noise is likely to give someone a heart attack, if the biker is just behind that vulnerable one.I have had a solution for this problem. Now that the court wants the menace curbed, and my gut feeling tells me the government is unlikely to find a solution to it, I might put down mine. Another reason for posting a blog on it is my new ability to make three D models. The image below is my 3D model of such a horn.

My theory is that a lot of people step on the horn because it takes very little effort to do so - whether it is in a car or on a bike. The blow horn I have shown above is still fitted on the city buses. One needs to squeeze the rubber blower real good to make it work. If the government makes such horns compulsory for all vehicles, the noise pollution should reduce significantly. After all, no one likes to exert except when it is absolutely necessary. This should be eco-friendly too, the consumption of electricity being totally avoided. Some youngsters might love it, when they realize that it will help develop their forearm muscles. I wonder if they can implement it, because a lot of owners of posh cars will dislike it. It is a long shot that some really wacky government-babu or politician reads this post and loves the idea. I understand that and still am happy with this post. It has at least afforded me an opportunity to show off my skills at 3D designing.

Retrovisionary Walkers

I wrote a fun book entitled "WALKING STYLES (Your Survival Manual to...)", which was published by
Krimiga Books. I just googled it to see if it was on the net. It was. Amazon is selling it. I thought of it because I felt I had not included one walking style in it. I call this style 'retrovisionary walking'. It goes like this.
You are walking along using standard technique - walking in as straight line as possible, amintaining whatever speed you have, watching where you go, maintaining lane discipline, and then suddenly out of an adjacent open doorway walks out a person who is walking towards you and looking backwards to the direction of your walk. A collision is inevitable, unless you scramble to avoid it. We have some such walkers in our department.
I was walking along the corridor between wards towards my office. One woman resident doctor walked out of an adjacent ward, turned and started walking towards me, all the while craning her neck to see something in the opposite direction, i.e. where I was headed. I tried to dodge her. My reflexes are OK, but she was fast. I managed to avoid a collision, thank God, or she would have floored me, what with me moving towards old age and she being three inches taller than me and weighing quite a bit more than I do. But she managed to hit me with her swinging arm. When she realized whom she had hit, she mumbled "sorry, Sir." "I wish you would look in the direction you are headed" I said. "Yes, Sir" she said, and I knew she would repeat performance at the next opportunity or the next one, no matter what she promised me. I only hope I won't be the victim again.

No Corruption Zone

"Sir, there is a circular for doctors" the clerk told me. I looked at it.
"All doctors are prohibited from accepting gifts and covers from pharma representatives. If they do so, they will be punished."
But that was known in times of Hippocrates too, and he had put it in his oath too (not to do so, I mean). Some modern Hippocrates wanted doctors to take their oaths again.
"Put it up on the noticeboard" I advised. That was done.When the staff members had had time to read the circular, they started a discussion, not knowing I was around.
"The service rules state we cannot accept gifts, except may be a flower" someone said.
"Not you cannot take even a flower" someone else said.
"No junkets?" a seasoned traveler asked.
"No!"
"Not even conferences abroad or in India?"
"No!"
"New year calendar or diary?"
"Probably not."
"Drug samples?"
"Probably yes."
"But why only doctors?"
"That is the current fashion in the media. A lot has been said and nothing has been done about politicians, administrators and clerical bribe recipients. Now it is our turn."
"You mean nothing will be done about doctors who receive gifts?" This sounded like an optimist.
"Only time will tell" a wise one said. "If you will take the chance, I am ready to wait and see what happens if you get caught." He said this with a smile, and everybody laughed.

Dynamic Arrows in PowerPoint

I thought of going beyond the conventional use of a laser pointer while making a PowerPoint presentation. I had a number of reasons for doing so.

1. Not everybody has a laser pointer.
2. Not everybody has a steady hand. If one's hand shakes, it is evident to those who pay attention to the slides, because the laser dot shakes erratically.
3. Not everybody can aim the laser point accurately.
4. The laser pointer needs cells, which cost quite a bundle.
5. Laser pointer can be harmful to the eyes, if the user is not careful where he points it.
6. It cannot be incorporated in a slide show that runs by itself, with narration so that one does not have to be present personally.

I have developed dynamic pointers and blinking pinpoint fluorescent lights, which can be placed at the point of interest in a slide. The arrows look something like this:

These are GIF animations, each of size 1 KB. One can place them by the structure to be pointed out, and say that the green arrow points to the uterine artery and the yellow arrow points to the ureter. Blinking lights work equally well. These images can be inserted by the standard method Insert >> Picture >> From File. They can be positioned wherever one wants them. One with some knowledge of computer graphics and animations can make them oneself. Those of my readers who want ready made pointers may send a request email to me. Appreciation by the viewers of the slides which contain them will be reward enough for me.

Statistical Shortcuts - No Data

The government has launched a prestigious healthcare scheme for the poor people. It is the Rajiv Gandhi Jeevandayee Arogya Yojana. It aims at giving free treatment to poor people who need any one or more of a list of procedures that have been selected. The civic body took it up for some civic hospitals. The erstwhile Big Boss called us all and told us to work on it.
"We can expect to get 25% of our operative procedures under the scheme" he said. "Is that right?"
"Yes" said a superspecialty Boss, "20%". The Big Boss nodded in satisfaction. I could not see how they arrived at those figures. But then, these guys probably had access to information I did not have.
The scheme rolled on. The civic administration got extremely unhappy with the performance, and Big Boss summoned us. "The performance is very poor. The civic boss wants 10% coverage of all procedures under this scheme today, 20% at the end of the next month and 30% thereafter" he said. Then he started calling out names of specialties and asking their heads for explanation for the dismal performance. When he called for Obstetrics Gynecology and looked at me questioningly and accusingly together, and said "only 0.6% of your cases have been performed under the scheme. What is your explanation?"
We performed more than150 procedures, of which just about 10 were included in the scheme. The scheme was just for 8 districts, not the entire state.
"Sir, I denominator in the calculations is wrong" I said.
"Don't give excuses" Big Boss thundered. The civic boss had probably thundered at Big Boss for this. I shrugged my shoulders and said "if you won't let me say anything, I won't." Big Boss wanted an explanation, so he asked me what it was. I told him what I have written above. "The true estimate is really 0.6% and not 20-25%. When you take out a percentage, you have to consider the denominator as patients whose eligibility is based on the procedure list, not ALL procedures."
"But YOU gave me the percentage as 20%" he thundered. Civic boss must have been really annoyed with the performance and the person responsible for the implementation of the scheme.
"I did not" I said.
"Who did?"
I pointed at the superspecialty boss who had said that. He was speechless. He made some statement that made no sense to me and was not loud enough for other people to hear anyway.
"I am sorry" Big Boss said to me "if I have shouted". I kept quiet. He had used the word 'if' superfluously, and had omitted to say 'wrongly'. Words mattered little to me, intentions did.
"How did the Big Boss and Superspecialty Boss reach the figures 25% and 20% to start with?" someone asked me later.
"That is a statistical technique of generating results without having any data to analyze" I said. "It is often done by people who reach high positions."

Six months later, when a new Big Boss was in position and was reviewing the dismal performance, the same old superspecialty boss said with wisdom "perhaps the estimate of percentage was wrong. Let us collect some data and see what it actually is." The new Big Boss liked the idea. Then this superspecialty boss saw the expression on my face, did some quick thinking, and asked me for any suggestion.
"I had suggested this five months ago" I said dryly. It is to his credit that he kept his expression bland.

VIP Syndrome

It is probably the dream of many people to be someone who is important. Some are more ambitious and they want to be very important people. Being important is different from showing the world that one is important.
We see those in ministerial positions. They want those cars with beacons showing they are important.
We see those politicians who are chiefs of states or countries. They want outriders and a fleet of cars and the roads cleared for them.
We see those in administrative service, placed in civic bodies. They want people running backwards ahead of them, some running by their sides, and others following them, and still others standing up when they arrive.
We also see Big Bosses in hospitals who want a security officer clearing the road for them, getting the elevator while they wait regally, and get locked doors opened exclusively for them while mere mortal employees walk taking the longer routes.
We see unit heads in hospitals who want their resident doctors to carry their bags to their cars and get their things from their offices, and to serve food to the examiners when they conduct university exams.
I thank God for not making me a very important person.

360 x 179 Degree Rotating 3D Instruments

I had developed 3D models of my instrumentsl which would rotate through 360 degrees around a vertical axis. I had kept them at the following address. But I removed the website because they started putting ads which were not to my taste, and I could not stop them because it was a free web site.
http://svp.coolpage.biz/Instruments/Instruments.html
But I was not very happy. I wanted my students and other viewers to be able to see the instruments from sides, up and down, i.e. I wanted them to rotate through 360 degrees in all possible axes. It comes to 360 x (180-1) i.e. 360 x 179 or 64440 axes. I developed these three 3D models using CAD software. But I could not get them to be seen in a web browser. I looked for some solution on the net and found none that would work without a plugin for the web browser. I finally asked my son, who is a computer engineer and game programmer to see if he could help me out. He said he could and he did it in less than a week. He did a very good job of it. Now you can look at these 3D instruments in Obstetrics and Gynecology from any angle you desire, and rotate, enlarge and move them around to your heart's content. You have to use the left mouse button to rotate them, and the scroll wheel to enlarge them (zoom in and out). You have to select the models from a drop down list and click on the >>> button to load them.
I will say it is a remarkable piece of coding. You can view these models at his website at the following address.
http://demos.wirywolf.com/viewer/
Now I have developed 3D models that can be viewed in any WebGL enabled browser. They can be viewed at the following link.

My 3D Instruments

Scrub Suit Solution

People want to appear great in the eyes of others. It is no wonder that may surgeons and some other personnel in operation theaters go around outside the operation theaters in their scrub suits. The visitors look at them in awe. That is OK. But moving about in the hospital corridors makes the scrub suits pick up germs, which are carried back to the operation rooms. That is likely to increase the risk of surgical wound infection. I have little control on my own people when I am not watching, and no control on people in other departments. I should care for patients in other departments too, for two reasons. One is that they are human beings just like my own patients. The other reason is that germs that cause disease in the hospitals are resistant to antibiotics, and they spread in the hospital. So even if they develop in other departments, they affect my patients too.
All my efforts at education of these wanderers in scrub suits have failed. In fact, one  erstwhile Big-Boss in the institute also used to go to OT from office wearing a scrub suit, right across the campus. That must have set a terrific example! Now I have come up with a solution, which may not be acceptable to the users and the administration for different reasons. I see no harm in proposing it anyway. The idea is to make scrub suits in colors as shown below, pink for males and fluorescent yellow for women.

For administrators, it may not be easy to get cloth of such colors and get the users to use the scrub suits made with it. The users will not want to use these because they will hate those colors. If the administrators read my post and implement the idea, all the users will hate me too. Well that is life.

Attitudes 13

The title has the number 13 because I have written on 12 different attitudes before. That it is the first in this vein in the year 2013 is purely coincidental. We have a staff member who has this funny response when an Assistant Professor or Resident Doctor in that unit is assigned duty for conducting examination or attending training camps organized for them by the civic body.
"I have OT or OPD on that day. I will not relieve this doctor" he declares.
"This is official work that is being done at the orders of a much higher authority" we try to explain.
"No. I will not relieve him/her. He/she is required to treat my patients here" he says.
Getting him to relieve that doctor requires all sorts of maneuvers, including the final one - threat of complaining to the Boss. What I cannot understand is that person's megalomania. The belief that he/she  is the supreme authority, despite knowing full well that he/she is a small peg in a gigantic machinery is unexplainable. Perhaps it is an effort at proving his/her non existing greatness to self rather than to others isthe motive.
This person has been around for a long time. I thought of this attitude today not due to him/her, but because I interacted with someone else who showed similar attitude. I am required to conduct confidential inquiry of all maternal deaths in the institute by the order of the government and the civic body. Doctors from different departments who had treated the deceased have to be called. There is a unit head in another specialty, who is quite junior, but has developed an attitude after getting the position of a head of unit, more so after being given some administrative job in addition to it.. This person refuses to send his doctors for the inquiry making the same statement our own person with that attitude makes. Doctors from that unit failed to come for the meeting we conducted this month too. When I met this person near the administrative office, I quietly asked him the reason why they did not come despite adequate notice.
"My doctors are very sincere. This is not possible."
"I am telling you they did not come.A notice has been received by your department" I explained.
"May be" this person said. "But I am telling you, you cannot talk to us the this way. This is not your department."
"This has nothing to do with my department and me being the head of it" I explained patiently. "I have to conduct this inquiry by the order of the state government as the chairman of the maternal death inquiry committee here."
"May be" this person said. This attitude of not accepting facts stated by a person years senior was amazing. Then he/she called the concerned doctors, came back and said, "my doctor got a call at the end of the meeting!"
"That was the last reminder" I said.
"You cannot talk to us like this" this person said again. "This is not your department."
"OK" I said and dropped the conversation. If this person with some management training did not know that acknowledgement of receipt was a solid proof while the word of mouth was not, he/she only an attitude but not much thinking power. The adrenalin surge in him/her was causing tremors in his/her pointing finger. I was worried he/she would develop a stroke if the matter continued any further. The senior faculty around us were aghast and remained aghast for quite some time after he/she left.
I kept thinking what had caused such an outburst in a person who had had no conflict with me in the past, especially when all I had said was a casual statement about his/her doctors not coming for an inquiry. Long after that encounter I remembered me writing a post, in which there was a line on this person. If he/she had read the blog, that one line must have really stung him/her owing to the underlying truth that he/she had probably realized only after reading that post. The post was at the following link. I bet no one else can make out which one line in those 50 lines is the line responsible.
http://shashankparulekar.blogspot.in/2012/09/condolences.html