Hospital Dogs

There are stray dogs. There are pet dogs. There are police dogs. Our hospital has hospital dogs. They oam freely all over. The intensive care units and labor ward are as yet  to be invaded by them. In fact, one  erstwhile Boss used to go around with one such dog, whom we can call The First Dog (like the First Lady in some country). This one used to be in the Boss' office too, where civic dignitaries came to meet the Boss, and where erring personnel were summoned to get scolded. When this Boss retired, the First Dog was heartbroken and was adopted by a Professor of psychiatry who is said to have cured the dog's depression. This is also the first case in the world literature of a psychiatrist for human beings successfully treated an animal. Our erstwhile head of radiology once told an august gathering of all department heads that these dogs had divided the hospital into territories and each dog guarded his own territory. I wonder if he had put RF collars on those dogs to track them and thus reach this conclusion. At present, none of them has any collar.
I gathered opinions of various people on the value these dogs have added to our hospital. The results are as follows.

Security officer	These dogs can be trained to detect explosives. We do not get any equipment to detect anything that could be a security threat.
Neurosurgeon	These dogs may prove a substitute for security guards, who seem unable to control crowds effectively.
Medical officer: antirabies vaccination	It is better they bite people in hospital campus rather than outside. The vaccine can be administered very early.
Psychiatrist	These dogs can be used as therapy dogs. Our could be the first hospital in the country to offer this therapy.
Pharmacologist	These dogs remind me of the good old days when we had dog lab for experiments. The noises they made 24X7 kept the personnel awake and alert too.
Environmentalist (Sweeper)	They help keep the corners free of red spit (creation of people who chew betel leaves-tobacco (paan). People do not spit in those corners where dogs are sleeping.
Professor of Humanities	Dogs teach humility to all hospital personnel. They make people walk respectfully with their heads bowed (to see that they do not step on dog poop).
Men students	They make the girls understand the importance of boys – girls are scared of dogs, boys shoo the dogs away.
Gardener	Dog poop is good as manure.
Pantry officer	They help keep the cats away.
Hopefuls	One day some people will kick these dogs, and then the pretty PETA girls will come to hold demonstrations in their charming ways.
Religious fanatics	Feeding stray dogs creates good karma, which ensures our departed ancestors go t heaven and we will follow in their footsteps when we pass away. It is so much easier to have dogs in campus, rather than go looking for them on the road.

(Note: there are a number of people employed by the institute in each category. If anyone feels I have quoted him or her, I make it clear that it is someone other than him/her.)

Water Recycling in Ward?

One of the things that I did after taking charge of my department was to install a water purifier in each ward, so that the patients would get safe drinking water. It should have already been a part of the wards, but unfortunately had somehow been missed for 75 years. The only method known in those days was to filter water and boil it, which I trust was being done in most of the wards before I took over as head. Procuring purifiers was an uphill task for me too. But now it is OK.
The wards have 40 sanctioned beds each, and usually house double or triple the number of patients. In order to make it convenient for the patients, a servant fills a big container with water from the purifier, and patients draw water from it using a tap fitted to it. Any water spilling from the tap during the process is collected in a bucket put below it as shown in the following 3D picture I made to illustrate the point.

The tap of the container in the postnatal ward which has about 100 to 120 patients at a time leaks. The engineers seem unable to fix it, and the sister seems unable to get it replaced. So the water leaks all the time. While I was going away from the ward after seeing my patients the other day, I found the water leaking at a brisk pace. The bucket below the tap was 25% full. I tried turning the tap, but it did not stop the leak. I inspected the water in the container. It seemed OK.
"Sister, the water seems to be leaking more than usual today" I said.
"Yes, Sir" she said.
"It is a good thing you have got a bucket below the tap to collect all that water" I said.
"Yes, Sir" she said.
"I trust you are putting the water back into the container above whenever the bucket gets filled?" I asked with my best innocent expression.
She looked at my face for a moment with a startled expression, grinned and said, "No! We put it in the toilets and bathrooms. We fill the container with fresh water from the purifier whenever the container gets empty."
I smiled and went away. I must admit that I had not asked that question as a joke. I have learned to think of the impossible, and very often it turns out to be true. It was good to find that it was not true this time.

Off Label Use of Computer Monitor

As a gynecologist working in a civic hospital, I understand the value of multi-use instruments. What it means is that an instrument that has multiple uses is far better than one which has a single use. That is owing to paucity of funds to buy instruments. After some time, one gets trained to find other uses for instruments which have actually one prescribed use. At least I learned it over the last 33 years.
'Off label' is a term that is applied to drugs which are approved by an agency like FDA for specific use(s). However scientific studies show that these drugs are useful for other indications too. These other uses are called 'off label' uses, meaning these uses are not listed on the label or product insert of the drug.
I have found an off label use for a computer monitor. It so happened that my Registrar came to my office to inform me about a patient. She had brought along the patient's excretory urogram. Since the office was administrative office and not clinical office, there was no X-ray viewing box there. For those who don't know, let me state that we call a device used for viewing radiographs as X-ray viewing box because a radiograph is conventionally called X-ray. I had two options. Either I could hold the radiograph up towards the fluorescent light on the ceiling and inspect it, or hold it towards the window and view it. The first option meant risk of straining my neck muscles and ligaments. The other option meant having to get up and roll up the window blind. It was then that I thought of using my computer monitor as an X-ray viewing box. I opened a new document in my word processor and zoomed in to dill the entire width of the screen with the document. Now the screen was back lit and white like an X-ray viewing box. I put the radiograph over it and I could read it as well as with an X-ray viewing box.
'Voila' as the French say.

Medical Practice and Apocalypse

One of the dailies that we subscribe to carried a news item. It was about an open forum type meeting planned by an NGO to discuss removing all evil from medical practice. It said the medical practice today involved doctors (check), patients (check), laboratories (check), pharmaceuticals (check) and pharmacies (check). Then there was a list of the speakers, which included a dean with national honors, an ex-VC and ex-ex dean, a current VC of a deemed university, a preventive and social medicine specialist, and someone else I cannot recall. There would be interaction with the audience.
When I mentioned this to a colleague, he/she said "great speakers. But does talk improve anything? If these stalwarts had solutions to these problems, why have they not applied them and got rid of the evil?"
That sounded true. So I said "hmm..."
"Everything that happens out there these days is just business. You want something, you pay. Nobility of the medical profession is a myth."
That sounded more or less true. It was different for some of us working in medical college hospitals for salary, but the statement was a broad statement, not one for the minority.
"What do you think will happen after all that talk?" I asked.
"People will feel good that someone cares" he said. "Perhaps the sale of the said newspaper will increase."
"What else?"
"The speakers will feel good. They will feel they have done something noble. They will get more invitations for such speeches too."
"The evil will not go away from current medical practice?" I asked.
"Oh, that!" he said. "That will not go away with anything less than an apocalypse."
That was true for all evil, not just evil in medical practice. So I said "hmm..."

ESR Fiasco

I wonder what makes me ask my people questions which are such that every one with a bachelor's degree in medicine would know answers to. What never ceases to surprise me is the result of such questioning.
There was a patient in the antenatal ward. She was quite emaciated. I gave appropriate advise on her management. Then I had an urge to ask a question that belonged to the category described above.
"Suppose we check hemogram of normal gravid women in the antenatal clinic. The first woman's erythrocyte sedimentation rate (ESR) is found to be 52. What will you do?" When no one took any initiative to answer that, I asked my Registrars. When I heard their answers, I was appalled. Then I took an opinion poll of all resident doctors with bachelor's degrees, and MS qualified residents and Assistant Professors. Their answers were as shown in the following graph.

No one with a postgraduate qualification answered correctly. 'On fence' category included those who stated that the ESR was raised in pregnancy, but also recommended further investigations to find out the source of infection even if the woman was clinically OK. It pained me to find that doctors with graduate qualifications gave wrong answers, and it frightened me that doctors with postgraduate qualifications gave wrong answers too.
I did not tell them the correct answer. I am waiting for them to find it out on their own, or ask me what it is. In case they read this post, and also for the readers who are reading it, the correct answer is as follows.
ESR is raised in pregnancy to levels shown in the following table. Since the patient is clinically normal and her ESR is in the pregnancy range, it is physiological elevation and requires no further investigation or management.

Non pregnant state	First trimester	Second trimester	Third trimester
0-20	4-57	7-47	13-70

Teacher-Students Sleepy All

"I just took a lecture for the resident doctors."
I looked up from my work to find one of our faculty at my door grinning all over his face. I looked at him questioningly.
"They were sleeping" he said, the grin now a fixture on his face.
"Huh?" I said.
"It was a clinical topic. But they kept sleeping. Even when they were signing their attendance, they were sleeping."
"Hmm..." I said. It must be a remarkable feat to sleep while one signs one's name.
"I taught them anyway" he said and turned away.
No wonder they slept, I thought. They must have found something that transferred from him to them telepathically. Or perhaps it was contagious? After all, he had regularly been sleeping during our clinical and administrative meetings over years, and still did. Was that the reason why he was grinning, having found his like?

Amnioinfusion: New Concept

The credit for this post goes to an undergrad student. I was taking the prelim exam. At this time, the undergrad students are supposed to be all ready with their preparations for the final exam. They are given this exam for practice of the real thing that decides their future. There was this student who was presenting a case of oligohydramnios. He managed to convince me that his diagnosis was accurate.
"How will you treat her now?" I asked.
"I will treat her with amnioinfusion" he said after beating around the bush for some time.
"How will you perform an amnioinfusion?" I asked instead of saying 'great, you have done well'. I do that because it is my experience that a lot of people say the right word, but do not know more than that word in that context.
"I will infuse amniotic fluid" he answered.
"Where will you get amniotic fluid to infuse into this patient?" I asked trying not to show incredulity in my voice or on my face. I must have managed that well, because he went on to answer that one without any change in his expression.
"A preparation is available outside" he said.
"Huh? Who markets it?" I asked.
"I don't know who markets it" he said. I wondered if there was a hint in his voice to suggest that I should stick to academic questions and not ask questions about commercially available preparations.
"Is there a commercially available preparation of amniotic fluid for amnioinfusion?" I asked my Assistant Professor standing nearby with as straight a face as possible. "This student wants to use one for his patient of oligohydramnios." His MD dissertation had been on amnioinfusion. He looked at me for a second and grinned all over his face.
I could not spend any time educating that student because there were a lot of students left to be examined and time was short. I hope he reads on the topic before he appears for his final examination.

HIV, Cancer, and Opinions

I had not thought anyone would claim HIV infection and AIDS are hoaxes. There was a pregnant patient with this infection. I had sent her to a specialist. While giving me the details of her treatment, this specialist said,
"Do you know Dr. xxxxxxx says HIV infection is a hoax?"
"Huh?" I said. Dr. xxxxxxx is an alumnus, now pretty old, though still around quite a bit.
"Yes."
I was aghast. When I found my speech, I said, "This same doctor also says cancer is not a problem. He says it is a solution. I man of his age and seniority would be expected to speak more sensibly, when he knows that he makes wrong impressions on developing minds of students."
"Yes. He does say weird things. But in this HIV business he is not alone. There are many pages on the internet where the same thing is said. They claim it is a hoax to help pharmaceuticals make money."
"They should not give a wrong message. They  may make controlling the disease more difficult" I said.
When I related this story to someone else, he said "perhaps someone should challenge them to take an injection of a body fluid containing the virus. Or marry a person who is HIV positive. Let us see if they back out or take down their posts or blogs."
That sounded like a good idea. The only person I actually know is this doctor. The others are just virtual persons on the net. I wonder if this doctor reads this post and accepts that challenge to prove HIV is hoax. He will go down in history if he proves his point, or he will go down and prove it is not a hoax.

Handprint Interpretation in Opinion Poll

We have an extensive practical training program for our postgraduates. However our theory training was not very good. After overcoming a lot of hurdles in its possible implementation, I finally managed to chalk out a program that would ensure teaching the entire syllabus to all postgraduates. However I thought it prudent to ask them if they wanted this. After all, there was no point in teaching them if they would try and recover their lost sleep during those lectures. I conducted an opinion poll, in which the instructions were-
"Write down 'yes' or 'no' on a piece of paper each, along with your residency. Do not write your name. That should remove any inhibitions you may have in giving your opinion on whether you want it or not."
 I collected the ballot papers and analyzed them. The results were as follows.
All of them wrote 'yes'. That was a relief. But some of them had written in sentence case, some in capital case. That gave me an idea. I reanalyzed the opinions.

Year of residency	All Caps case	Sentence case	Total Number
1	6 + 3	9	18
2	4	4	8
3	2	5	7
Not specified	0	7	7
Total	12 + 3	24	36

If one considers that people who wrote their years of residency in sentence case and made it a point to write Yes in all capitals, one may conclude they felt very strongly about wanting this education. There were 6/14 such in the first year, 4/8 in the second year, and 2/7 in the third year. There were 3 who wrote 'Yes' in all capitals in the first year, but they had written their year of residency in all capitals too. So one may think that they wrote everything in all capitals when filling questionnaires. In that case there may not be a strong feeling behind that 'Yes'.
'Yes' was written in sentence  case by 7/16, 4/8, and 5/7 of the first, second, and third year residents respectively. It was encouraging that they wrote 'Yes', though it would have been even more encouraging if they had written 'YES'. But if my assumption about all capitals suggesting a deeper desire to say yes is not correct, perhaps some or all of them wanted this education deeply.
One of the first year resident wrote 'Yes' as 'YES', which was a special 'Yes'. The letters were very big, and were darkened by repeatedly overwriting. I think the effort was to make it look like a word made bold in a word processor document, to show its importance.
I had instructed the residents to write just their years of residency, and not their names so that they would not feel inhibited, in case they wanted to write 'No'. The year of residency was necessary because I needed to know what were the needs of residents in different years of residency. Despite such clear instructions, 7 residents had not written their years of residency. They had written 'Yes' in upper-lower case. So perhaps they were very busy and did not have time to spend on writing all capitals 'Yes' and definitely not for writing their years of residency. The other explanations could be that they did not understand what I asked them to do, or did understand that but were not bothered to comply with the instruction. They were protected anyway, since their anonymity was maintained.
On the other hand, one resident had written his/her name. That might have been due to not understanding instructions. But I think the reason was to make a good impression on me, to wipe out a previous bad impression. Commendable thinking, I must say.

Loose Ends

I don't remember who taught me to never leave loose ends. It must be my mother, who taught me values. I don't know if that made a better person out of me. I know it did not make a happier person out of me anyway.
There was that patient, who was referred to me by an old friend and colleague, now in US for years. She needed something done desperately. I saw her, and made all arrangements to get her treatment underway. She never came back. When I did not hear from her for more than a month, I wrote to my friend, because it bothered me a lot.  I got an answer after a few weeks. She had had to go out of state, and had got it done there. She was OK. There had been no deficiency in services in my institute that had made her go away.
Then there was that old intern, who had done postgraduation in another subject in some other institute. Now he was back. He wanted me to give him a certificate so that he could apply for residency in US. He wanted it urgently. I thought of the struggle a student has to make to get into US and the stress it causes. I told him to get the certificate typed and printed as soon as he could, and I would sign it immediately. I told him where he could contact me over the next two days, so that he would not have to spend time trying to find me. You might have guessed - he never came back.
Then there was that editor of a journal that runs on money deducted from our salaries without our permission for the deduction. Something like Jizya tax, perhaps? Anyway, that is besides the point. There were a few errors in the management of one of my articles. I wrote to the editor, who promised to 'revert to me in a fortnight'. After two fortnights passed, I wrote a polite reminder. Many more fortnights have passed without any answer.
There have been many more such loose ends. I would like to have them wound up, because they remain active in my mind, like a software program that keeps running in the background and consumes RAM of a computer. I would like my mind freed to do other things better. I wonder if no one taught these loose enders like my mother taught me. Some of them have been my students. I wonder why I could not instill in them values, if not directly, then at least by setting a good example. Or perhaps the bottom line is to get whatever one wants from life and move on, not bothering what one leaves in one's wake?

Economic Crisis In Hospital

I know there is an economic crisis in the country. Things grown or made in India are becoming more and more expensive almost day by day. Prices of things imported are sky high. But economic crisis had never touched civic institutes before. From media reports, one could conclude that consumption on petrol and diesel for Babus’ cars always remained unchanged. Air conditioners hummed unabated. The list is endless. I don’t want to go through the whole list because that is not the purpose of this post. I am writing about something that I had thought would never happen.

They used to serve tea to senior faculty called for meetings with the Boss. Those sitting near the table would be served in good quality cups and saucers. When the number of attendees was higher, others were accommodated on chairs arranged behind the first row around the table. These attendees would be served in plastic cups. One must not believe that the cups would be full and hence those persons served in cups would get more tea than those served in plastic cups. The cups would be less than half full.

Some time in between, while the economic crisis was deepening, the ceramic cups ceased being seen, the size of the plastic cups became half, and the tea level in the cups still remained below half. The next indicator of the very poor state of the economy was cessation of serving tea. For faculty used to getting tea on the house, this came as a shock. There was a withdrawal syndrome on a mass scale. Every time the door opened, people turned towards it to see if the peon had come in with tea. Alas, it was not to be.

“They should not have cut us off so suddenly” someone said. “They could have tapered the volume before stopping.”

Like corticosteroids are tapered? The next smaller volume would be the plastic 5 ml container that comes with medicine bottles for pediatric patients. Surely the speaker did not expect tea in those plastic measures of medicines? Anyway I did not voice my thoughts. A person in acute withdrawal state cannot listen to reason.

Jigsaw Puzzles In Hospitals

The heritage contractor under the masterly direction of the heritage architect of the civic body did a superb job of repairing our hospital building. The art work on the walls in the form of tiles started coming off in parts within the first month of we moving back in, though we did not contribute to it in any way. The Boss got the tiles refitted again a few times. After that either the warranty got over, or the Boss' decided to leave (which he eventually did) or Boss' Bosses told Boss to lay off. Whichever way, now there are blank areas left, which look like this.

Some of the pieces which came off did not manage to remain whole. They broke into a number of pieces on falling down. They look like this, when spread out on a flat surface.

This post is to invite both the contractor and the architect to participate in a game of jigsaw on the walls. The way to play is to fit the pieces in place. There are actually two jigsaw puzzles, one within the other. The first one is to fit the small pieces together to make whole tiles. The other is to fit the whole tiles in their places on the walls. The winner gets a certificate of merit. I would have liked to say the winner gets to keep the tiles. But they belong to the civic body, whether in place or not, and whether intact or broken. I would have loved to let visitors play too. But I cannot. because some miscreants may make away with the tiles, intact or broken.

The Second Mouse I Repaired

One mouse is different from another one, and you need different strategies to repair them. The first one which was acting up on me was a stout and rebellious type. I had put it in line by slamming it on the desk a few times. It has been working smoothly for many months now. The second mouse was different. It was a tiny one, made in China. It was lying on a laptop. When someone lifted the laptop without checking what lay on its top, the mouse fell down from a height of about 1.5 feet. Out flew two T-shaped pieces of mouse body, plastic or acrylic or whatever.
"This mouse is probably gone" said the mouse dropper, and tried it. It threw out the red light from its bottom all right, and mouse cursor moved on the screen on moving the mouse, but the right and left clicks would produce no effect. "Yes, it is really gone" he said.
"Leave it" I said. "I will see what can be done."
I checked it out. If I clicked the terminal parts of the mouse buttons, they did not work. But if I clicked the proximal parts with good force, they worked, albeit with some difficulty. This mouse could not be slammed on the desk, I decided. It was far too delicate. It would just break into pieces. So I opened it up by removing a screw in its bottom.. Its insides showed a circuit board, a wheel, and two shelves below the mouse buttons. I checked them and found out that when a mouse button was pressed, a rectangular block on its under surface pressed down an identical block on the floor of the mouse. That produced the click effect. I made a 3D model of the insides of the mouse without the circuit board. Its top and bottom views are as follows, the top being elevated from the floorboard, and the sides swung up only for demonstration.

After some thought I figured out that those tiny pieces which had flown out of the mouse had probably supported the floorboard and it had sunk a bit having lost that support. Hence there was no contact between the blocks and the clicks were not working. I tried putting tiny pieces of an old ultrasonography plate under the mouse buttons to improve contact. That stopped clicking of the buttons totally. Then I had a brainwave. I folded the tiny pieces of the ultrasonography plate into the shape of a 'V', and placed them under the floorboard at the level of the mouse buttons, one limb of the V in contact with the bottom of the mouse. That elevated it in a dynamic manner. On clicking the buttons, the rectangular blocks got pressed with alacrity. On releasing the button, the elastic recoil of the V elevated the floorboard again. The elastic V gave me a leeway, which packing with folded paper would not have given.
I am waiting the see if the manufacturers of that mouse send me consultant fee for suggesting a method of repairing their mouse, or if they hack into my blog and remove this post so that people will not repair their mice using my method.  :-)

Mechanical Minds

She was a young woman undergoing evaluation for infertility. She had been with us for quite some time. When I saw her, I found that she had undergone all possible tests, including endoscopy, and all were normal. She had undergone three cycles of follicular monitoring, and had been found to be ovulating in all three cycles. I also found that she had been advised the second and third cycles by another unit as well as by my own unit residents. I could not question the other unit residents because they were working in the OT. But I could question mine.
"If she has been found to be ovulating once, why did you advise her more cycles of the same? It was not as if you were performing some procedure like intrauterine insemination/"
"....." the face of the resident concerned was blank.
"What is the rationale of subjecting her to to repeated ultrasonography? Think of the discomfort associated with prolonged periods of full bladder, the expense, the time wasted, and also the time and energy wasted of the sonographers? Think of the money wasted."
"....." the face of the resident concerned was still blank. She kept looking at the patient's case paper intently.
"Do you have no answer?" I asked. "You cannot find the answer in the patient's case paper.
"Er......um...."
I left it at that. I knew many others did this. The idea that follicular study had to be repeated only if the woman did not ovulate and her treatment was modified in the next cycle to achieve ovulation was eluding these poor residents.
Another event was on the next day. They showed me a pregnant woman in the ward. "She has undergone laparoscopic myomectomy prior to this pregnancy, but the details are not available" I was told.
"Let her get old case papers" I said. the papers were duly produced the next day.
"The papers state she has undergone only a diagnostic laparoscopy, not myomectomy" I was told.
"Did the doctors show you the lumps they had removed? How were they?"
"They were tiny brown lumps, 2 mm X 2 mm in size" she said.
"That must have been endometrium removed by dilatation and curettage" I said. "By the way, how many ports' insertion scars does she have on her abdomen?"
"Only one" said the same resident who had contributed to the other patient's repeated follicular studies.
"If she has a single scar, and single port laparoscopy is not done anywhere in our country much, you had to know she could not have undergone laparoscopic myomectomy" I said.
"Um ... I did not realize that" she said.
"I want you to think. Think. A mechanical mind would be a great thing perhaps for a mechanical engineer, but not you as a doctor."
I said it only to make my statement more interesting. I did not mean to insult mechanical engineers, who I know have great innovative minds. However if I hurt them, I apologize for my inadvertent slip.

Karma From A Past Life?

Hindu philosophy believes in Karma. What you in a past life (or past lives) gets credited to your account - I suppose it is credit for good deeds and debit for bad deeds. One is reborn to pay for debits and get paid for credits.
There is that House Officer, who believes in self, which is a good thing and a bad thing together. It is a good thing because it is good to believe in self. It is a bad thing because the belief is misplaced. There was a time when a patient's husband got a blood bag from an outside blood bank for her, as per a request from our blood bank which did not have any blood of that blood group. The standard recommended practice is to get it grouped and cross matched with the patient's blood, and then get it from there and transfuse it to the patient. The husband brought the blood bag and gave it to this House Officer. She was about to start the transfusion, when the Registrar caught her and told her to send it to our blood bank for checking. After the Registrar went to see another patient, this House Officer transfused the blood as it was right away. The patient lived without any mishap. When I was told about this after a week, I asked her to explain why she did so.
"I thought it was OK to give the blood like that" she said.
"But the Registrar told you not to do so" I said. "She told you to get it tested in our blood bank first."
"But I thought it was OK to give it like that" she said stubbornly.
I gave up after a number of times the same question was asked by me and the same answer was given by her.
This resident doctor has done a few other more or less disturbing things after that. One more I remember more than others is that of a young unmarried girl that had a cystic ovarian tumor. We removed it laparoscopically. In Indian culture, it is considered important for an unmarried girl to have the hymen intact. Though gynecologists understand that the hymen can get torn by events other than sex, many lay people don't. So I took great care to put a narrow bladed right angled retractor in the vagina for painting the vagina with povidone-iodine using a thin wick of gauze, and then  inserting a small manipulator in the uterine cavity. I advised the assistant to be gentle while manipulating the uterus, so as not to tear the hymen. After the operation was over, I advised this resident doctor (who was the assistant holding the manipulator) to remove the vulsellum on the cervix and the uterine manipulator. She did that and then without my knowledge shoved a thick swab soaked with povidone-iodine into the vagina with two fingers. When I noticed this, I was aghast.
"We have made great efforts to keep the woman's hymen intact throughout the procedure, and now you have torn it with passing two fingers through it? Why?" I asked.
"Ma'am told me to paint the vagina with iodine" she said. I cursed that ma'am under my breath for not telling her to use a thin wick of gauze and plain forceps to do it.
"Did you have to tear her hymen for that? Would you like something like that done to your relative by anyone?"
"..." she looked at me sullenly. There was no answer despite asking the same question again. I sent her away for the peace of my mind. I requested the anesthesiologists to not reverse her just yet, sat down and repaired the torn hymen patiently.
"Why does she do such things?" someone asked me.
"I think I must have done something bad in my previous lives. It  probably is my Karma that makes me have a resident doctor like her. It must also be the Karma of those patients who get so treated by her" I said. "They go home well because of the grace of God and/or the good Karma of we others who notice these problems and rectify them in time."