Normal Hysterectomy?

When we teach students, we teach them about different types of hysterectomy operations. We tell them about total, subtotal, and radical hysterectomies, depending upon the extent of uterine removal.. We tell them about abdominal, vaginal and laparoscopic hysterectomies, depending upon the route of surgery. Some patients are aware of the routes, and even have their own choices. I have heard about laser hysterectomies from some patients, which probably meant laparoscopic hysterectomies, though hardly anybody uses laser for hysterectomies by laparoscopy.
"Doctor, will you be performing normal hysterectomy on me?" one patient asked me one day. I did not think a hysterectomy could be normal by any stretch of imagination.
"What is normal hysterectomy?" I asked.
"Normal... you know..." she said. That explained everything, to her at least.
"Huh?" I said. Either that 'huh' or my facial expression conveyed to her that I had not understood what 'normal' was.
"You know, one that is done from below" she said. She was probably reluctant to call it 'vaginal'. Calling a spade a spade was one thing, and calling the vagina by that name was another.
"That is called 'vaginal', not 'normal'" I said. "Did anyone tell you it was called 'normal'?"
"Well, a delivery from below is called vaginal delivery. So I thought a hysterectomy from below would be normal hysterectomy" she said.
"Ah!" I said. I would have explained to a student that all vaginal deliveries were not 'normal' deliveries. But a woman who had reached the age and stage requiring a hysterectomy did not need that education.

Communication Skills At Worst

I have not undergone any special training in communication skills. I just  believe in speaking what I mean, and I make a point of being very precise when I give instructions to people I work with. I think that works fine. Well, it used to until recently. The following two stories should be illustrative enough.
We had a young patient who was bleeding and would not stop doing so despite therapy with tranexamic acid and later with progestins. "Give her combination contraceptive pills three times a day for 48 hours, by which time bleeding will stop, and then reduce the dose to twice a day. Give that for 18 days. She should require two packs of the pills" I told my Resident Doctor. Three days later she was back with a question -
"Sir, you said I should give that patient combination pills three times a day. then stop for 48 hours and then give the pills twice a day for 18 days" she said.
I was amazed. I repeated what I had said in exactly the same words, speed and tone as before. I could do that because I have been saying that for the last 31 years."How did you understand you had to stop the drug administration for 48 hours when I said the bleeding will stop in 48 hours?" There was no answer, and I am without a clue how she heard that way.
The other story is about my communication with a nurse. Someone asked for information about deliveries in our center on 28-12-10 (dd-mm-yy format). The question had to be answered because it was asked under the right to information act. I called the labor ward nurse and asked for the confinement book (the register in which all data on childbirth are entered) with the record of 28-12-10. A half hour later she sent a register with the desired page marked. I opened it. It had entries for 28-10-12. I explained to the servant that I wanted data of 28-12-10 and not 28-10-12. He went back. Another half hour later she sent him with another register with a page mark. I opened it expectantly. It had data for 28-12-12. I was without a clue what made her do so. I finally wrote on the page mark itself '28-12-10' and sent it back, asking for record of the date I had written. I hope she sends me the correct record tomorrow.
I know I have to improve my communication skills to get work done, because there seems no way to improve listening skills of people I communicate with. I just don't know how.

Halter Top for Men

There should be no dispute over the fact that women are more fashion conscious than men. But now the times are changing, if one can go by the trend seen in our operation rooms. I never could have imagined it, but it is true. See the men using halter tops below. The faces are masked to protect their identities.

I have seen black and red halter tops on men in operation rooms too, but did not have a camera handy at those times. Well, some things can be left to the readers' imagination.

Trick Question: Gas in Peritoneal Cavity

When we perform a laparoscopy, we put in a needle first to introduce carbon dioxide there. When the needle is inside, we attach a needle to it and aspirate.
"If we get urine, we are in a full bladder. If we get stools, we are in the bowel. If we get blood, God forbid, we are in a blood vessel" I teach the resident doctors. "Now aspirate and see."
The one performing the operation aspirates into a syringe containing normal saline. Air bubbles enter the syringe from its distal end.
"Where did that air come from?" I ask. I know I cannot keep a straight face, but the mask worn in the OT helps. They think about it. Some of them keep quiet. Some of them smile in answer. Some of them do not answer that question even the next time they are performing a laparoscopy and I am assisting them. A few of them give an interesting answer - "Normally there is some air in the peritoneal cavity."
I have not told them the answer yet. They all have forgotten that the peritoneal cavity is a potential cavity that contains just a film of fluid. There is no air or any gas there. The air enters the syringe because the syringe does not fit the needle very well and permits entry of air. I will continue to ask this question when I assist them perform laparoscopy. Makes them think. If they answer, either they are good, or they have read my post. I won't know which one, but both the possibilities would make me happy.

Technical Specifications From Doctors

Modern Medicine relies heavily on technically complex equipment. Such equipment is not just supplied but has to be procured by the doctors like us in civic and government institutes. The process is quite complex. One part of it is to provide technical specifications of the equipment, so that vendors can bid in tenders only if their equipment is appropriate. It also maintains uniformity in all bids and prices can be compared correctly. It is the job of the engineers and doctors to prepare the specifications. They are called to the tender meetings to answer any questions related to the specifications. Unfortunately the administrators are in the habit of asking the doctors about the technical specifications, and if they cannot give satisfactory answers, they are held responsible for the deficiencies.
We had a pre-bid meeting where I was called for a high pressure sterilizer that we needed. The vendors were present and some of them raised questions about allegedly contradictory specifications.
"How do you explain the discrepancy" the administrator in charge asked me. I had suffered such trauma in past, had thought about it a lot and had my answer ready.
"I don't know the answer because I am a doctor. I am not trained to understand engineering. I just know that the stuff coming out of the autoclave should be sterile. Technical details like valves, chips, circuits, cycles, automation are prepared by engineers, who should answer this question."
There was a brief period of silence in which they digested this answer the like of which they had not heard any time in past.
"He is right, you know!" said a committee member with a note of wonder in her voice. "
"Yes. He should just have clinical requirements, and technical specifications should be provided by the engineer" another member said.
"Yes, yes" others chorused.
Then they asked the engineer his opinion.
"I did not make these specifications. Another engineer did" he said.
"But give us your opinion as an engineer" the administrator said.
"I have no exposure to this equipment" he said. So they expected a doctor to answer technical questions that an engineer could not answer. The doctors present were relieved that they need not know technical details henceforth.

Unparalleled Tangle

We were taking a round of the postnatal ward, when I saw a young intern with a sack on his back and a sheaf of papers in his hand moving slowly along a row of patients under care of another unit head. He would ask something of each patient and hand over a sheet of paper to her.
"What do you think he is distributing?" I asked my resident doctors.
"Discharge summaries" they said.
"He reminds me of a courier. He looks similar, has a sack on his back, and he is distributing paper stuff. The only difference is that he does not take acknowledgements." They could not find any fault with what I said. "What if he gives a discharge summary of one patient to another patient?" They did not think it was likely.
"Anyway the nurse will check the names before discharging the patients" my Assistant Professor said.
"Listen to a true story and perhaps you will think differently" I said. "A few days ago we received a request from the police for stating the true facts of a case under police investigation. It was about a patient treated in this hospital. It was a woman seen on outpatient basis by another unit in Gynecology. They had advised her a vaginal hysterectomy with repair, which was never performed. Yet she had a discharge summary stating this operation had been done. The indoor number on that summary was that of a male surgical patient, photocopies of whose papers were attached. There was a photocopy of an under-treatment certificate of a male patient, who was himself a professor and head of a medical specialty. Can you explain how a woman treated as an outpatient got a discharge summary stating she had undergone a major operation, got an indoor number of a male surgical patient, and under-treatment certificate of a male medical patient who himself was a professor and head of a medical specialty?"
They could not explain it. I wonder if the police have managed to explain it all.

His Master's Voice

When I was a child, there was a music company called HMV, which was short for His Master's Voice. The company's logo was a dog sitting in front of a gramophone listening to it attentively. Initially I thought the dog was just listening to his master's voice singing. When I grew older, I felt perhaps the company implied that the master was no more, but his voice was immortal, and the dog kept listening to it. I don't know what to think today, but the Wiki story states this notion was true.
Even if the company has stopped being, the concept has remained quite strongly. The masters continue to believe that their dogs should know their voices. I experienced this the other day. I was working in my office when the phone rang.
"Hello" I said.
"I got your letter" a high pitched female voice said. "I think..."
I held the receiver some distance some distance from my ear so as to protect it and said cautiously "Who is speaking?"
There was some silence and then the voice said in tones of irritation "I am the Academic Assistant Boss. Remember my voice in future. As I was saying ..."
What the Assistant Academic Boss was saying subsequently has nothing to do with our story, so I will not narrate it. But what she had already said supports my theory. This person believes she is the master, and also believes the others are similar to the dog in the HMV story who should remember the master's voice. If the dogs will not manage that on their owns, they have to be warned to do so, so that when the master calls, the dogs respond immediately, without having to be told who is calling.
I wonder if the true Master of all is watching from the heavens and enjoying the joke.

Paint - Catalyst Tool

I often encounter the problem of pasting images from the internet into a word processor (like MS Word) or a presentation software (like MS Powerpoint). The images get pasted in the word processor all right, but remain visible only as long as I remain connected to the net. So if I disconnect and clear the temporary internet files cache, there are no images in the document. So I cannot take the document on a pen drive and read it on a computer offline, nor can I see the images the next time I open the document when offline. In a presentation software, it is even worse. Often the images do not get pasted, or if they do, they just occupy space without the contents being seen. Or they take a very long time to load. One way to save the word document with images permanently available is to print it as a PDF file using a postscript printer. They remain in it even when I go offline. The other way is using MS Paint.
In this trick I copy the image and paste it into MS Paint. Then I cut it from there and paste it into the word processor document. Having come from MS Paint rather than from the net, it remains in the document forever. I think it has to be the address of the image on net being pasted as a link rather than the image itself, so that it has to be downloaded every time the document is being opened for reading. Using MS Paint as an intermediary solves this problem. It works very well when pasting images in presentation slides too.

The Magic Figure of 23

I needed data on the number of operations for urinary stress incontinence we had performed in the previous year, I had a meeting scheduled with the Boss and had to have this figure ready. I asked the Professor looking after the OT to get me the data. He immediately assigned the job to his Assistant Professors. The day of the meeting arrived, but the data did not. I reminded the said Professor, and asked him to send the concerned Assistant Professor to me, so that I could explain how it was to be done.
"It is simple" I told that Assistant Professor. "We have monthly data submitted by each unit. So there will be 12 figures per unit in one year, or 72 figures for all six units. You just have to add those 72 figures, some of which could be zero too."
"OK" he said and started going away.
"Don't go away" I said. "Do it bow! I have the meeting this afternoon, and I am going to the OT. I cannot stay to see what happens."
"I will send the Registrar to do it" he said.
"I can see what will happen" I said. "The Registrar will send the Houseman, the Houseman will send the intern. The intern will sit in the canteen and generate the figure in his mind. He will report it is 23."
"No, Sir. The Registrar will do it."
When I got the data, it was not for all units, but only for that one unit. I called the concerned Professor and asked why such a simple task could not be accomplished. He sent the concerned Assistant Professor again, who me with the data after an hour or so. He had not added up the figures, but at least he had figures for all the six units.
"Why did you not get this in the beginning?" I asked him.
"I misunderstood" he said suavely.
"I was quite explicit" I said. I repeated my words of instruction. He just kept quiet.
"You had to get away from work in the outpatient clinic for this" I said. "Now I suppose you will go to canteen instead of going back to the outpatient clinic?" I knew I should not have said this, but I was really angry, and I said it without conscious thought.
"No, Sir" he smiled and turned to go away. I did not turn away myself, but stayed to see where he went. He did not go in the direction of the outpatient clinic, but went in the direction of the canteen as I had said. I shook my head and checked the data. The figures added up to exactly 23, as I had said at the start. I wondered if I had to get the data next time this tedious way, or I could just guess it equally accurately. I also wondered if I was developing a sixth sense, guessing data and future actions of people so accurately. Or was I just an old hand at this game, having seen everything that they would do?

Sign of Impending Departure

I have seen a lot of people join the institute and leave it too. Now I have developed a method of predicting when they will leave.
I had assigned the task of preparing manuscripts for publication of scientific articles to my Assistant Professors and Resident Doctors. The latter managed their articles but the Assistant Professors did not. When one of the latter approached me and said he was leaving for a job in his home town with just a day's notice, I said, "I knew you were leaving."
"How did you know that?"  he asked with surprise. He had been trying for that job for quite some time, but had not told us if he had landed it.
"I knew it when you would not write the scientific article I had asked you to write, despite repeated reminders and deadline after deadline" I said. "This sign is diagnostic. I knew our erstwhile Boss was leaving, when everybody but he was saying he was leaving. He finally left without telling us after three months of gossip about it."
"How did you know it?"
"He used to get every tile fitted as soon as it came off the wall of the newly repaired building" I said. "He stopped doing that three months before he left."
"...." my answer apparently convinced him that the sign was diagnostic of impending resignations.
My other Assistant Professor has still not written his article despite repeated reminders and newer and newer deadlines. :-)

PCPNDT-New Trick?

It was during our advisory committee meeting that I came across this fun thing. There was an application made by three doctors for registration under PCPNDT act. They wanted their center registered so that they were legally allowed to perform ultrasonography there. Actually only one affidavit is necessary, the one made by the owner. But in this case even the two sonographers had also made an affidavit each. As per the prescribed format, they had stated that they would not do prenatal fetal sex determination. But there was a snag. The word fetus appears four times in that one small paragraph The word was printed as follows.
Foutes
Foefus
Foetus
Fetus
I got curious. So I checked the affidavits of the two soologists too. They were identical.
"Careless people" someone said, "they do not pay attention to spelling."
"It is quite surprising that doctors spell such a simple word so badly" someone else said.
"Do they actually read their own affidavits?" a knowledgeable person said. "They probably assign the job to their secretaries or receptionists."
"I don't think they are dumb or careless. This could be deliberate. If they do prenatal sex determination and get caught, they will be able to claim they never made an affidavit that they would not determine fetal sex. They would be right, because the word fetus is not spelled correctly in key positions in those affidavits."
"Oh, yeah!" the others chorused.

Dermoid and Bellyache

It was a new hypothesis, first written in the answer book of a student of final M.B.B.S. university examination in Obstetrics and Gynecology. It was a short answer question on a dermoid cyst or benign cystic teratoma of the ovary. One of the symptoms caused by a dermoid cyst in the ovary is abdominal pain. the student had hypothesized as follows.
'A dermoid cyst in the ovary causes pain due to caries of a tooth within the cyst'.
A dermoid cyst can have teeth in it. The remaining part of the statement was an example of extremely original thinking. The professors who were correcting the answer books were laughing without a break for 15 minutes. They stopped only when they were exhausted.

Pamenorrhea Samenorrhea

The usual practice in the outpatient clinic is that the interns or the junior residents write histories of new patients. Then the senior residents or staff members examine the patients. We confirm the history and ask additional questions when we see patients. But someone writing the history makes the job easier. After all, it is quite a job seeing more than 200 patients in 3.5 hours.
When we read the histories written by the juniors, sometimes we find something that could be unheard of. The following is an example of this. A patient's chief complaint was recorded as 'Samenorrhea'. It apparently was a menstrual disturbance, but I had not come across this term before. I asked the patient what her complaint was, and discovered that it was 'secondary amenorrhea'. I looked at the word again, and realized that someone with unique thinking powers had made a new word for 'secondary amenorrhea'.
"This person will be using the term 'pamenorrhea' for 'primary amenorrhea'" I said. I went out to the waiting hall looking for the maker of that term and found her.
"What is samenorrhea?" I asked her.
"Secondary amenorrhea" she said.
"What is pamenorrhea?" I asked her.
"Primary amenorrhea" she said.
"These terms from your text book of gynecology?" I asked her.
"Um ... no. I picked them up from a senior intern" she said.
"Why such lengthy terms?" I asked. "Why not just 'Sam' and 'Pam'?"
She was smart enough to catch my sarcasm and sensitive enough to blush a little.