Google vs Malware

I was taken by surprise when I started seeing ads on my Google search home page. Google had never done that before. Then there were ads on the search results page, which were suggestive of adult content, below which it was written (presumably by Google)  ‘Ad not by this site’. Someone had fixed the system so that Google pages would show their ads without receiving any revenue. This happened consistently in Firefox, but not in Google chrome. So it was probably malware targeting some security hole in Firefox only. I mentioned this to my son, a software consultant.

“It is malware. I had got it too. Use Superantispyware to get rid of it.”

I got rid of it by using antispyware he had advised. It was OK for four days and then the ads returned, as adult as possible, and would not go away with Superantispyware. Finally I uninstalled Firefox, including all settings and other things it wanted to keep behind in case I wanted to install it again. I wanted to install it again all right. But leaving that information behind meant leaving the malware behind. Then I installed a new copy of Firefox and the ads have not appeared again over a period of one month. I have written this so that any readers who experience this trouble and do not have a software specialist to advise them can read about it and fix their problem.

Terms and Conditions

The Health University has arranged a competition entitled 'Inclusive Innovations -2013'. I found it when looking for a circular, which I did not find anyway. The thing looked like this.

I clicked on submit an idea button, hoping it would lead me to a page which would give me more details. It turned out to be a web form, asking for all sorts of details of the participant. At the bottom of the form was a link for submission of the filled form. One had to click in a check box indicating that one agreed to the terms and conditions. It looked like this.

I clicked on a link which promised to show the terms and conditions. It took me to another page, which looked like this. It has been like this for the last one week.

I wonder if participants are expected to click in the check box without actually reading the terms and conditions, as most people do while filling web forms or installing new software. Or has someone just forgotten, and not put the terms and conditions there. There seems to be no last date. If I find one, I plan to check out on that day if the terms and conditions have made it to the web. It is not that I want to submit a proposal. I am just curious what the terms and conditions are. I could have written to the university. But none of my letters sent as a Professor has been answered from the beginning of the university. So writing one more would not achieve much.

Human Shelf

When I was an undergraduate student, the Professor of Psychiatry taught us about how a human being needs a private zone around him, and does not like people to invade this zone. While talking, he casually placed his hand over that of one student, who moved his hand away. The Professor advanced his hand some more, and the student moved his hand further away.
"This is it!" he said, and we understood what he was talking about.
This private zone seems to have gone away in the minds of residents these days, at times during gynecological surgery. A lot of gynecological operations are done in lithotomy position. The gynecologist sits on a stool in front of the patient, and two assistants stand on his either side. When any surgical instrument is removed by an assistant, it has to be returned to the nurse. When the nurse is on the other side of the gynecologist, it becomes difficult for the assistant to return the instruments. For quite some time, I have observed that a number of the assistants place the instruments on the lap of the operating gynecologists. The weight becomes a distraction and the concept of the private zone is clearly violated, which adds to the discomfort. I had one resident doctor a while ago, who was not very bright. He would rest his hand on my knee when he had nothing in particular to do as an assistant. I requested him twice to rest his hand elsewhere. When it happened a third time, I lost my patience.
"See, it is distracting me, and it is important I concentrate on the operation. You may have developed this habit because others did not object to it. I am an elderly man, and it may not matter much if you do it while I am operating. But if you do it when a woman is operating, you will get into no end of trouble." The whole theater heard this, because I made it a point of saying it clearly and loudly enough. He improved in a hurry. I had forgotten about this, until something happened the other day.
A senior resident was performing an MTP, and a junior resident was assisting. When the senior removed some tissue with ovum forceps, she would place it on the dorsum of the assistant's gloved hand, instead of getting the nurse to remove it from the jaws of the forceps. The junior resident not only did not mind this, but seemed not even to notice it. Both of them realized what was happening only when I pointed it out. Then it stopped.
Are the times so changed that parts of human beings are a part of the furniture part of the time in the operation theaters?

High Opinion

There is nothing like juniors who have a very high opinion about you to flatter your ego.
That day I was performing a difficult vaginal hysterectomy. After ligating the uterine vessels, I bisected the uterus. After two thirds of the way through, I had some difficulty. I waited for a couple of seconds, trying to decide if I should perform morcellation or continue with the bisection.
"Sir, perhaps if we try to ..." piped my Assistant Professor who was assisting me.
"Huh?" I was distracted.
"Well, if we try to ... perhaps ...to get the uterus out..." She seemed to believe her assisting her Boss was the same as assisting resident doctors. Or perhaps she believed her assistance was to be mental as well as physical.
 "Well, no. I am not looking out for a solution to any problem. If you will allow me to make my own decision, we will be able to move on to our next case in time." She allowed me, and I got the uterus out in the next five minutes. "Was your previous Boss often in need of your advice while operating?" I asked her after the case was over.
Um...no" she said. Whether he needed it or not, she must have given advice and he must have allowed her, I thought.
A few days passed. Then I was performing marsupialization of a Bartholin's cyst. Normally  I let the resident doctors do these cases. But we were way behind schedule and I had to get that case done quickly. I would have done it with resident doctors to assist. But this same Assistant Professor washed up and came to assist. I held the cyst steady and made an incision into it. The fluid spurted out.
"It opened!" piped the Assistant Professor.
"It did not open" I said. "I opened it by making an incision into it." Then I had a thought. "What is marsupialization?" I asked her.
"It is communicating the inside of the cyst with the exterior" she said.
"Then it cannot be done without opening it. Is that not so?" I said.
"Um..."
"Or were you thinking of excision of the cyst, where it is not to be opened, but gets opened accidentally?"
"Um.. no" she said. I knew that was it, but I let it go. By this time I had sutured the lining of the cyst to the outer epithelium with a few interrupted sutures.
"Sir, the Assistant Professor under whom I was trained used to suture the edges with a continuous stitch. You have placed interrupted sutures" said the other Assistant Professor who was watching the operation.
"So?" I said.
"I was thinking..."
It was obvious what she was thinking. We had another one who held me in such high esteem.
"It does not matter what he did. What did you read in your text book of operative gynecology?"
"Interrupted sutures" she said without much conviction. Had she not read it and relied on what she saw her senior do?
"Then you should call that fellow and ask him why he put a continuous stitch" I suggested. "Will you find out pros and cons of simple and continuous sutures in this operation?"
"Yes" she said. I know it is not written in any book. I hope for her sake she can think and reach the right answer. In the meantime it is my good fortune to have such admirers of my expertise working with me.

Internet Connectivity And Us

"Sir, my internet connection has been cut for the last two months. I cannot send the email you want me to send" our clerk-cum-typist (CCT) said.
"But you did not say anything all this time!" I said.
"I was trying to get it repaired" she said. "Now the network engineer has told me that the Professor himself has cut it on his server."
"I will speak to the professor" I said. For the readers who don't know about it -'professor' is not professor of network. It is one surgical professor who spends more time with stacks, switches, servers and fiberoptic cables than with scalpel and patients for the fun of it. We have a swell network manager and since we are not surgical patients coming to the hospital, we do not complain about the division of time between work and hobby. I called that professor and asked him the reason for such an action.
"We provide internet services for academic purpose to staff members and resident doctors. We do not have manpower to provide it to clerical employees. The civic body should do that" came the answer.
"But when you had done this in the past, and I had written to the Boss, and he had made you connect us again" I said. "Boss retired two months ago. So you did it again?"
"....." He was afraid of the previous Boss, and did not seem to be afraid of the new one.
"We pay 10000 INR or more per year for our connectivity. The cables have been laid to all terminals" I said. "Staff members can log in from the CCT's terminal anyway. Your network engineer has to work on that terminal if required. All you have to do is to give the CCT a password to login. It makes sense, because the civic body has refused to give her a connection, and your insistence will not change that. You have stalled important work done by her."
"That cannot be helped. Our policy is not to give a connection to clerical people" he said stubbornly. There was no official policy, I knew. It was what he wanted to do or rather did not want to do. I wrote to the new Boss again. The Boss directed my letter to electrical engineer, who expressed inability to connect our CCT to the net. I have lost interest because the administrators do not seem concerned about this work.
"Why does he do such things?" a colleague asked me. "He had upgraded to Window 2003 server from older Windows 2000 server without knowing the consequences. We had to replace all hardware that ran Windows 98 but could not run Windows XP, and had to buy licenses for Windows XP, so that internet would run. It had cost us a bundle. When we complained, he said we should always get the latest hardware and software. As if money grows on trees."
I remembered too well, but I did not express my view on the matter. "This fellow wants importance, and he gets it by troubling other people" another colleague said. I refrained from saying anything on that comment too.

Risk Counseling

"Sir, this patient is demanding a hysterectomy" my resident doctor told me.
"What does she suffer from?" I asked.
"White discharge due to vaginitis."
I looked at the patient. She looked back at me.
"Why do you want a hysteretomy?" I asked her.
"I am tired of the white discharge" she said. "Remove my uterus."
"But removal of the uterus will not cure you. The discharge is not coming from the uterus. It is coming from the vagina. You have an infection that needs medical treatment."
"I have taken a lot of medicines. They do not work. Remove my uterus."
"Besides not curing you, the operation can have a number of complications for you too" I said. "It can sometimes be fatal. I would not like you to have any of those complications."
"But you perform this operation on other women. You did not advice the other woman just now against having a hysterectomy."
Our outpatient clinic is so crowded that often women overhear counselings not meant for them.
"But I told her about the possible complications" I pointed out.
"If she can have it, then why not me?" she asked stubbornly.
"There is a difference. She needs the operation for the disease she has got, you don't. It is like crossing the road at a busy intersection where the traffic signals are not working. It can sometimes cause a traffic accident. If you have to go somewhere, you have to cross the road, irrespective of the risk of the accident. But if you do not have to any place, you should not go stand in the middle of the road."
I think she understood what I was saying. She took the prescription she was given and went away without any more arguments.

Right Punishment For Wrong People

I was surprised that they wanted to schedule an operation that day. They had not done any operations on their scheduled day.
"Why are you scheduling one on some other unit's OT day?" I asked the Registrar who had come to take my permission.
"Sir, our unit head had told us not to keep any operations on our OT day. We had sent away all patients we had planned to operate on."
"Why?" I was surprised.
"Our unit head is rather unhappy with all of us" she said with some embarrassment.
"Now he is is not unhappy any more?" I asked.
"Now he had gone on vacation" she said.
"Ah" I said. I remembered he had done a similar thing two years ago, when week after week there would be no operations on that unit's OT day. "What happens to patients who come to you and need operative treatment?"
"Some of them have gone to other doctors for treatment" she said.
I signed the OT request letter she had brought. She went away. I sat there wondering. The doctors must have done something awful to make the unit head angry. Denying them operative work was punishment from their point of view and also from their boss' point of view. But the hospital was for poor patients who needed treatment for their ailments. This denial of operative treatment was adding insult to injury. They were being punished for possible wrong doing of someone else. The boss should operate on all the patients himself. if he wanted to teach the junior doctors a lesson, not deny treatment to the poor patients. I want to see his take on this matter when he resumes duty.

Effective Behavioral Control

Labor pains are so severe that many women cannot bear them. In modern world, they offer labor analgesia so that labor is a happy process. However such happy places are very few in this world. Considering the paucity of anesthesiologists in civic institutes, labor analgesia is given only when some anesthetist wants to make a career in it and wants to master the technique before stepping out into the world to cater to the wealthy types.
The nurses and doctors in the labor room suffer almost as much as the women in pain because of their screams. The overworked personnel sometimes lose their cool in face of such auditory trauma.
"You know what one resident doctor did?" someone asked me.
"What?" I asked obligingly.
"She slapped a screaming woman in labor twice to make her stop screaming."
"Huh?" Slapping would increase the screaming, not decrease it, I thought.
"Not only that, but she locked the patient in the delivery room?"
"Why?" I asked. This seemed very inhuman behavior for a doctor.
"I asked the doctor. She said she did not slap the patient. She just patted her mouth asking her to close it. As for the locking thing - she said she did it because the patient kept going out to meet her husband.
I could understand what the patient was doing. I have seen worse. I have seen women sit in the toilet for the duration of labor, save for the brief periods they were coaxed back to the labor tables. I have seen women go lie down on the floor under the labor tables when the pain became unbearable. I hope the resident doctor will mature one day and learn to bear with such behavior of her patients.
"I had another resident doctor a few years ago. When his patient screamed and screamed, he got angry and touched her nose with the scissors he was holding. 'Shut up or I will cut off your nose' he thundered. Then she shut up."
I was speechless. This was an unorthodox use of episiotomy scissors, bordering on homicidal.
"What is he doing these days?" I asked.
"He is in UK as a consultant obstetrician."
Well, if he tried this stunt there, they might do to him what he threatened to do to the patient, and deport him to India, I thought.

Generic Medicine Prescription

"Sir, the union health minister has said that Deans of all medical colleges have been informed to inform doctors working in those hospitals to prescribe only generic medicines" one colleague said.
"I read about it in the newspaper" I said. "It seems to be the decision made by the medical council to prevent doctors being unethically influenced by pharmaceuticals to prescribe their products."
"But the chemists do not have generic medicines."
"I know" I said.
"So when we write generic names, they will dispense brands they want. So now the pharmaceuticals will woo chemists rather than doctors."
"That sounds likely" another colleague said. "Anyway, some chemists are known to substitute one brand for another- one that gives them greater profit margin."
"But what do they mean by asking us to prescribe generic medicines before making generic medicines available?" someone asked.
"That is to reassure people that measures are taken to curb unethical practices" a cynic said. "Mind you, it is 'measures' without any mention of the effectiveness. People want to hear something, and when they hear that, they get satisfied and move on to another topic."
I had heard the preceding arguments from different people before, but that last thing about psychology of people was a new one.
"There is nothing to worry about" someone else said. "The Deans have not informed any doctors to do so yet. And even when the doctors are so informed, there is no machinery in place to check if they follow instructions, or to take action on doctors who don't comply."
There were a few knowing smiles at this.

Final Counseling

We get patients who have been to other doctors and have been advised on their conditions. They reach us because ours is a free hospital, and they cannot afford the treatment in private centers. Sometimes they reach us because they have doubts about what they have been told about their treatment. Sometimes other people bring them, promising better treatment than in private centers.
We counsel them the same way as we would patients who have not been to see other doctors. We tell them what they suffer from, and what the treatment will be. Some of them accept what they hear from us and get treated. Some are not satisfied with that.
"But doctor, the previous doctor said I had *** condition and I needed *** treatment."
"After examining you and checking reports of tests you have undergone, we feel that you have ### condition and you need ### treatment" I say.
"But then why did that previous doctor say differently?"
"That is a question you should ask the previous doctor" I say. "I cannot say why someone else says something."
"But now what should I do? Which treatment should I take?"
I can see that the patient is confused, not only about her diagnosis and treatment, but also about whom to ask which question.
"Now you have to think about what you have heard. Then you should follow that doctor whom you believe to be more intelligent" I say. When that does not make sense to her, I sometimes say "you could always consult a third doctor, and then follow the advice of the majority." I cannot say what she should do if the third doctor advises something that is different from the first two doctors' advice.

Non-dyslexic Right-Left Confusion

I read somewhere that women have a tendency to confuse between right and left sides. I did not believe it, because women are far more accomplished than men are. Surely such a simple thing would not confuse them. I would not have tested this hypothesis out, but I was bored waiting for the next case to be induced. So I asked our resident doctors to show me their left hands. I was dumbfounded. 70% of those showed me their right hands without a moment's hesitation. When I explained why I had asked such a thing, they grinned. After coming home, I thought back to my childhood, and remembered a woman relative making a movement of putting food in her mouth to confirm which was her right hand before answering that question asked by someone else. I also recalled girls touching their right cheeks when someone told them that there was dirt on their left cheeks.
I would have still put this away as a joke. But I see diagrams of laparoscopy findings made by some women resident doctors. The view drawn is as seen. But they label right side as left and left as right. I remember them writing the fallopian tube on the right side was transected when actually the left tube is transected. I remember them percussing the left side of the patient's chest for liver dullness while describing the action as performed on the right side.
I know what I am saying here may not be statistically correct. Someone should conduct a randomized controlled study on an equal number of men and women to see if this hypothesis is correct. I cannot do it, because the only captive population I have for a study is medical students and resident doctors, and women outnumber men in both the groups.

Liver Dullness: Anatomical Landmarks

It is a funny nightmare to teach some of them laparoscopy. It is a nightmare because it is scary finding out that they don't know basic clinical skills of percussion. It is funny because some of their answers are hilarious.
I was teaching that second year resident doctor the technique of performing a laparoscopy. It was her first hands-on case. I expect them to know the theory before they do it, but they do not often expect it of themselves.
"Now check if the liver dullness is gone on percussion" I said, when a liter and half of carbon dioxide had gone into the peritoneal cavity. "here will you percuss?"
"In the fifth right intercostal space" she said, and proceeded to place her finger below the costal margin. So here was one who knew in theory where, but did not actually know where that 'where' was.
"You will get a dull note there only if there is hepatomegaly" I said. "How do you find the 5th intercostal space?"
"How?" she asked, sounding like 'what do you mean by how?'
"How do you locate the fifth intercostal space? What is the landmark?" I asked. I meant the lower edge of manubrium sterni, which is at the second intercostal space.
"Landmark?" she asked. So she did not know about the manubrium sterni business.
"Where is the fifth intercostal space?" I reframed the question.
"Between ribs" she said.
"There are 12 ribs" I said. "Which ones are you referring to? How will you find the correct space?"
"The fifth intercostal space is between the fourth and sixth intercostal spaces" she said. She had perseverance and guts to keep answering despite knowing full well she did not know the right answer. I could have kept on and got some more funny answers. But the patient was under anesthesia, and I could not prolong it without reason. I percussed for liver dullness, found that it had gone, and advised her to proceed with the next steps. I wonder if she realized where I had percussed, or if she went to her clinical medicine book from her undergraduate days and found out where the liver dullness is found.

Funky Knife Handle

Good things are said not to last forever. Well, we had a good knife. One morning its handle came off the blade. We could not use it any more because we dared not cut anything holding only the blade. We could not embed the blade into the handle, because it is a machine process and we did not have any machine that could do it. I could throw it away and buy another, but was reluctant to throw away a perfectly good blade. Then being a gynecologist helped. I had a sturdy plastic applicator that came with a tube of vaginal antifungal cream tube. I had given the tube to some patient while the applicator had remained. I removed its plunger. Then I held one end of the knife with pliers and embedded its other end into the tube. I was lucky that it was a tight fit.

It works wonderfully. I think I can apply the same principle to fitting scalpel blades when the Bard Parker handle is not available due to any reason. I will need a smaller diameter stiff plastic tube though.

Innovations in Problem Solving 1

Resident Doctor community is an  intelligent community. Combined with the need to find unorthodox solutions to problems like shortage of consumables, failure of support personnel, or administrative troubles, they come up with innovative solutions.

Stainless steel rotating top stools are used to sit on while performing minor procedures in the labor ward, such as suturing episiotomy, perineal tear, vaginal tear, and instrumental vaginal delivery. There is often some blood spilled on the stool tops. The persons responsible for cleaning the area often do not get around to cleaning the stool tops, due to various reasons. One option the Resident Doctor has is to clean it him/herself. Getting the cleaner to clean it is not a workable option due to various reasons. The photograph shows such a stool, the blood on its top covered by a sterile paper wrapper of surgical gloves. It is the innovative solution found by the Resident Doctors. The wrapper of the gloves they wear are put on top of the stools so that the blood on the stool top does not contaminate their clothes. Throwing the wrapper away after use is a simple matter.
That reminds me of poor people who sleep on the ground after covering it with newspaper.

Hit and Repair

I had written before how I had repaired my optical mouse. It had started acting up, and when it would not let me do my 3D modeling despite repeated efforts on a single step, I had slammed it hard in a rage. It had started working. After the same treatment over a week whenever it acted up, it kept working. Now it is a couple of months since then, and it is working like a charm.
The method works. It used to work when our radio stopped working. I recall thumping its top as a child 50 years ago, and it would start working. When my keyboard stopped skipping certain keys, I could not type in my passwords for log ins, and type out text without spelling errors. Replacing keys does not work, because the error is below the keys, and replacements are not available anyway. I tried cleaning it with a vacuum cleaner and also with a blower. Both methods failed. Before throwing it away and buying a new one, I decided to give my 'Hit and Repair' a method a go. I lifted it and banged on the desk. It worked. Now it is typing smoothly for the last three days. If it stops working again, I will thump it again. Next time you have mouse or keyboard trouble, try this method. What do you have to lose? If it does not work, you can always replace the hardware as you would have done anyway.