Loose Ends 2

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

Round Ligament Confusion

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

VLC Logo Fun

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

Cool, huh?

Name Muddle

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

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

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

Pouch of Douglas Occlusion

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

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

Free Open Access Journal

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

Wren and Martin & Doctors

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

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

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

Velcro for Buddy Splint

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

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

Master Sleeper

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

Sixth Sense or Black Spot?

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

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

Opportunistic Marketing

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

Clinical Method: AEBE

बुरी नजरवाले तेरा मुँह काला

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

Waste Disposal from a City Bus

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

Superspecialists and Us

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

Liquid Paraffin for Dressing: 2

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