Two Consents

I had a shock when the emergency unit wheeled in a patient into my operation theater.
"She needs a cesarean section for previous cesarean section and meconium in amniotic fluid now" the emergency unit Registrar told us. The patient was a long way from a normal delivery and there was this indication of fetal asphyxiation. She needed a cesarean section. That was standard obstetrics. The shocking thing was yet to come.
"The boss of the parent unit (with whom the patient was registered) wants a sterilization operation performed on her if this baby is a boy, and a copper-T inserted if it is a girl" I was told. That was the shocking thing. To consolidate the shock, they had attached two consents from the patient - one was for sterilization and the other was for copper-T insertion."
"We cannot do that" I said. "Get the parent unit Boss to talk to me."
I discussed the issue with my people in the meantime.
"What do we do if the baby comes out depressed, even if it is a male?" my Assistant Professor said. "Do we still sterilize her? What if the baby dies afterwards? And what if the baby has ambiguous genitalia? If we cannot determine if it is a boy or a girl, what shall we do?"
Everyone laughed.
"We cannot have a conditional consent. The patient has to give a consent prior to the operation. If she cannot, it shows she is not mentally prepared. She needs further counseling" the other Assistant Professor said.
"That is right" I said. "You are good."
"But this unit always does that. It is their unit policy" someone said.
"What do they do with the other consent? Tear it up after the operation? Or do they keep both the consents on the patient's file?" I asked. No one knew the answer.
The parent unit Registrar called us. I asked her to get her boss on the phone. She could not. I waited. Finally the said boss turned up in my OT. I explained our stand to him. Then I also said,
"The patient and her relatives are required to identify the sex of the baby after looking at it. How is an anesthetized woman going to do that and give advise on what to do?"
"You operate with your eyes closed?" he asked. He made up in guts what he lacked in wisdom, I thought.
"Legally we cannot do identification of sex of the baby, and an anesthetized woman cannot do that too. I thought you would know that as a senior Professor."
"You are very adamant as a head of the department" he said. I had the same thought about him that I had had a few seconds ago.
"I am not saying all this as the head of department" I explained. "I am speaking as a head of unit working in this OT today, whom you are asking to do something illegal, for which I will remain liable. I won't do it. If you want, you come into my OT and do it."
He backed out totally and went away. I understood why he had not signed the advice he had given for his patient, but had asked the emergency unit to just write it. I also understood why he wanted a third party to do something that he was unwilling to do himself.
We counseled the patient and her spouse, and they understood the matter. They decided not to have a sterilization operation with the cesarean section.
Later I took an opinion poll on this matter as an academic exercise, without giving out any personal specifics. All heads of units unanimously said they would not accept such conditional consent and would not sterilize the woman.
"We cannot take a conditional consent. There is no provision for that on the consent form prescribed by the government. If we take consent for sterilization and do not perform it, what reason do we give for denial of sterilization on the consent form" one of them asked. "We cannot say it is because the baby is a girl. Furthermore, if we do not sterilize her, she can sue us later for not doing so despite her wish and consent to do so."
"Why did you ask us this?" another unit head asked me.
"There was a situation" I said briefly. "I asked you because I had to know what my faculty think. After all, your students will learn what you teach and practice. If they learn this, their future could be very bleak, if they get involved in a medicolegal case on this issue."
"Another point of concern is that if a person who believes this becomes, examiner, he/she will fail students who believe otherwise" another Professor said. I nodded. It had occurred to me too.
Update:
I checked. They take two consents and then tear one up. It is also heard that if they take one consent with two options, they rub out one afterwards. I am aghast.

Jinx of SUI

SUI is short for 'stress urinary incontinence'. It is a condition in which a woman loses a few drops of urine when she coughs, sneezes, laughs loudly or in severe cases, suddenly gets up from a lying down position. Victor Bonney described an ingenious test to diagnose it clinically, now popularly known as Bonney's test. In this test the woman in a dorsal examination position is asked to cough. If she loses a few drops of urine, the bladder neck area is elevated above the urogenital diaphragm by placing tips of index and middle fingers on either side of the urethrovesical junction. Then she is asked to cough again. If there is no loss of urine, the test is positive and the woman had SUI.
I have been performing Bonny's test for years. In the last few days something funny has been happening. There was a stout woman with symptoms suggestive of SUI. It is prudent to stand well away from the expected path of the urine that spurts out on coughing. I stood well away, and that too well on the right side rather than in front of her. When I asked her to cough, she coughed. The urine spurted out, but instead of remaining in the midline, it spurted to extreme right, exactly on my forearm, hand, and sleeve of my apron. I completed the test, washed away the urine and went to change my apron. A week later, there was another woman, of similar size and complaint. I was more cautious than the last time. I hid myself behind her leg and stayed as much to the right as was possible. When she coughed, her urine spurted more to the right than the last time. It soaked my forearm and hand, but spared my apron. I completed the test and washed away the urine. The third week, I decided that there was something wrong with the examination table and that caused a deviation of the stream of urine to the right. So I stood on the left side this time, well behind her left leg. When she coughed, the urine spurted to the left, on my left forearm, hand, and apron sleeve. I washed away the urine and changed my apron. But I could not get rid of a feeling that someone had put a jinx on that table. That jinx, which can be called the 'jinx of SUI', seemd to make the urine spurt on the examining hand, whether it was in midline, on the right or on the left. When I told my wife about this, she said with an amused look on her face,
"So what will you do now?"
"I have a plan to see what it exactly is" I said. "I plan to ask other clinicians if they have experienced this when examining patients on that table. If not, I will examine the next patient and then ask a colleague to examine her standing in the same position. If the urine spurts on both of us, the table is jinxed. If it spurts on my hand but not on my colleague's, someone has jinxed me."
"What if it spurts on your colleague's hand and not on yours?" she asked with the same amused look.
"Then one can say the jinx got confused or shifted from me to my colleague" I said.
She looked hard at my face and said nothing.
"Just kidding" I said.

Vaginal Myomectomy - 2

I had done a myomectomy by this technique long ago. It had been just 1.5 cm diameter leiomyoma that had arisen from the anterior lip of the cervix. It had no pedicle. I had cut its surface, enucleated it, and reconstructed the cervix. This time it was about 6 cm in diameter. It had arisen from the lower 1 cm of the anterior wall of the cervical canal. The cervix was 5-6 cm dilated, 50-60% effaced, and had only right, left and posterior lips. The anterior lip had been taken up by the leiomyoma. There was a broad base attached to the cervix, and no pedicle. Conventionally one would have cut it near the base and occluded the raw area with sutures. I decided to do otherwise. Normally one does not expect submucosal leiomyomas to have a pseudocapsule. I decided to see if that was true. So I cut its mucosal cover and underlying tissues with cutting electrocautery over 4-5 cm in midline. Then I dissected bluntly, and found that it did have a pseudocapule. I enucleated the entire leiomyoma from inside the pseudocapsule. The upper part of the cavity left behind was quite high. There was no active bleeding from it. I sprayed it with Feracrylum solution to ensure that any potential bleeder there would be stopped, placed a piece of oxidized cellulose in it as an additional safety measure, and then excised redundant part of the pseudocapsule and mucosa. Then I sutured the rest to the anterior wall of the cerical canal with polyglactin sutures, occluding the cavity in that process. The leiomyoma had expanded the cervical canal circumferentially, and the internal os was far away from the suture line.
The experience was very satisfying, and so was the result. I think this method is a better alternative to conventional method of treating such leiomyomas.

Privileged Communication

A patient wants the doctor to listen to her. That is understandable. Unless the doctor hears what the patient suffers from, he/she cannot make a diagnosis and treat her. Some patients have a greater need. They want someone to just listen to their woes, and a doctor will do as well as any other person. In a way, a doctor is better. He cannot walk away when bored. He does not send one away, because he gets paid for treating the patient and anyway it is not a decent thing to do - sending one away I mean. What amazes me is that some of them cannot keep quiet even when one is examining them. It becomes especially bothersome when the doctor is auscultating the patient's heart or lungs and the patient chooses that moment to pour her heart out. I wonder if they know what a doctor does when he put the stethoscope on the patient's chest and puts the earpieces in his ears. If they knew, they would not speak at that time.Here are some of the things I feel like saying to the patient who does so. They change from time to time, especially when a few have already done that to me that day.

1. I cannot hear you when I am auscultating your chest.
2. I cannot hear the sounds from your heart when you speak at the same time.
3. You will blow my eardrums if you speak while I auscultate you.
4. What have I done that you want to punish me by speaking into my stethoscope?
5. Do you know how it hurts my ears when you speak while I am auscultating you? Here, put these earpieces in your ears and I will speak into the chest piece.

Decency and an understanding of possibility of ignorance of the patients prevents me from saying anything to them. I could instruct them not to speak at that time, but there are so many of them to be seen in such a short time, that I cannot take that much extra time per patient. So I end up taking my chances, and end up with a few of them speaking into the stethoscope.

Defuse-Disarm

It was a busy antenatal outpatient clinic, like on all Mondays. We had five doctors less than usual due to various reasons. Naturally those present were struggling to get the work done before it got too late. A team of junior doctors was writing clinical histories and checking patients' blood pressures and laboratory reports. Senior doctors were busy examining these patients after the junior doctors were done. When I realized I had seen the last patient waiting to be examined in my clinic room, I went out to check the progress of work. A few patients were still waiting around the junior doctors. I found a vacant chair and settled down to write histories and check blood pressures.
"Doctor, the doctor who was sitting here before you checked my blood pressure, but did not write it on my case paper" complained a patient while I was pumping air into the cuff of a sphygmomanometer tied around another patient's arm. I turned around, looked at her face and realized she was upset. She had reason enough to be upset. She had been sent back from one of the examination rooms to get her blood pressure recorded. To get into the same queue twice was not fun. I deflated the cuff, noted the blood pressure, removed the cuff, and said to this angry patient,
"OK, I will write it. What blood pressure shall I write?"
She laughed, her anger forgotten. I had defused the situation and disarmed her, all in one go. I checked her blood pressure, wrote it down on her case paper, and said in a conversational voice,
"With so many patients to attend to, sometimes the doctors forget to write something."
She smiled and went away. I smiled and went on to check the blood pressure of the next patient, happy that I had avoided an unpleasant situation.

Laparoscope to Suit a Big Nose

"Sir, I have come to inform you something" one of our professors said.
"What?" I asked. I could not make out from his voice how serious the matter was.
"A nurse dropped the laparoscope and broke its eyepiece" he said in the same tone.
This was a catastrophe. A price tag of 0.15 million rupess, three to five years in processing of purchase by inviting tenders, and endless tender meetings of the civic body flashed in front of my eyes. I did not say anything because I could not.
"She was saying she could stick it back with an adhesive" he said.
"Please ask her not to do so. The polymerizing adhesive will make the lens in the eyepiece opaque" I said. "Send it to the engineers to see if it can be repaired."
"That's what I told her" he said. "She will show it to you tomorrow."
The next day she showed it to me, intercepting us on our round of the wards. It looked like 'A' in the image below, while an original laparoscope is shown as 'B'. These images are the result of my D modeling, of course, not the real ones. We had only one laparoscope of that size. I could not get an unbroken one for comparison in a photograph.

I looked at it gravely for a few seconds and said "Oh! Now it is suitable for people with big noses. All they have to do is to put the broken part next to their noses."
Everyone laughed. For that moment at least I forgot about the price tag, the pain and the time of the tendering process of the civic body.

Zoom For Education

When one sees an image on the net, one sometimes wishes that it would be better if one could see it magnified. It is often the case when it is photograph of an oepration, where details are important. Here I have a sample of what one can do. Hold your mouse over the image below. Move it over the image to view its magnified parts. It should prove to be an educational tool for those of my readers who are medical teachers, and a way to present one's data in medical conferences.

Sterilization With a Vengeance

Sterilization operation is viewed differently by different people. The government looks upon it as a program to be carried out like many others. Patients look at it as a means to stop having more babies. Motivators look at it as a means to earn money in the form of motivator's incentive. Surgeons look at it with dread, because anything going wrong with the health of the patient after the procedure is the trigger for semi-criminal investigations by the health department. It is rumored that some officials of the inquiry committees look at this as a means to harass people and/or prove their superiority over the criminals ... er ... doctors who performed that operation. I personally feel that the last one is not true, but I had to put down that viewpoint for completeness.
This story shows a totally different way one doctor looked at this operation.
"That patient had come for reversal of tubal sterilization operation" the storyteller said. "In those days, there was no laparoscope to look at the tubes before opening the patient's abdomen. So this patient's abdomen was opened. It was horrible."
"What?" I asked.
"The person who had performed the sterilization operation had applied three silastic bands to each fallopian tube, like beads on a string."
"My God" I said, "then reversal must have been impossible."
"Yes. The operation had to be abandoned. Poor woman! That doctor must have been practicing on that patient."
"Either that, or he/she must have performed the operation with a vengeance, such that the woman would never be able to get pregnant again."
For those of my readers who do not know what this all is about, I will explain in brief. There are two fallopian tubes attached to the uterus. They have to be blocked to prevent future pregnancies. Many methods are available to do this. In any method, each tube is occluded by some technique at one place. It damages the tube. If a lot of tube is damaged, the operation cannot be reversed. The following photograph shows a silastic band applied to a tube properly (on left) and what the patient had done to her ( on right). As you can see, there is no tube left to speak of that can be used to reverse the operation.

Get Even

Hey,
Guys. This one is a stress buster. Here you are looking at a picture of
the department's bigwigs in a meeting. Imagine you are angry with
someone in that group, and want to get even. It will not do if you
shout at that person or slap or kick him/her. He/she can make a police
complaint and get you in trouble. If your future is in the hands of
that person, such behavior is a sure way of ruining your future. But
you have to get that anger out of your system. Well, this stress buster
is just what the doctor prescribed. Get hold of the shoe or the boxing
glove with your mouse, and hit the person to your heart's content. I
wish I could add sound effects, like 'take that, and that, and that,
you #$&%$@#'. Too much programming would be required to do
that. However I could make it more realistic by putting that person's
face in place of one of the blurred faces in the picture. Just send me
that picture. :-)

Card Trick

I was working on some documents in my office when the clerk cum typist called.
“Sir, there is a patient’s husband who wants to see you. He says he has been sent by head of the ### department.” She knew it would disturb me in my work. She also knew I preferred to see all outpatients in the outpatient clinic unless there was an emergency. This did not look like an emergency. But he had come from the head of thee ### department. Heads of other departments deserved some courtesy, even if you were busy.
“Send him in” I said.
He came into my office. He had an ID card of a civic employee hung around his neck. He showed me a visiting card of the head of the ### department and said “we both come from the same place. He asked me to see you.” He proffered her papers. I looked at them. She had been to see us, and had been given progestin therapy for abnormal uterine bleeding, and had also been advised some tests. The reports seemed normal.
“So what do you want me to do for you?” I asked.
“She is bleeding despite treatment” he said.
“How much?” I asked. He did not know. So he called her on mobile and asked her. It turned out she was still on treatment and had stopped bleeding five days ago.
“She is OK” I said. “Bring her to my outpatient clinic on Monday after her next period.”
“I have come here while on duty” he said, pointing to his ID card. “Please treat her now.”
“But she is already on treatment. What else can I do?”
“She has these reports” he said.
“They are normal” I said. “Bring her as I advised you.”
He made a face.
“Where do you stay?” I asked, thinking it would be a far off place and hence he was reluctant to bring her. It turned out to be not very far from the hospital. “Bring her and show her to me. I will see her and advise.”
“OK. Can I have your visiting card?”
Suddenly I understood his modus operandi. He would get visiting cards of people with significant social standing, and use them to get work done by other people, saying the card owner had sent him. That was how he had got a card of the head of the ### department, and told us he had been sent by him.
“I never printed any cards because I do not visit people” I said truthfully. He went away to do what he should have done in the first place - bring his wife to my outpatient clinic on the day of her appointment.

Tea Threat

Tea

Tea is a social drink in India. It is offered to guests. When people get together, they often have tea while they socialize. When people get tired of working, they take a break and have tea. It may not be very nourishing, but is mentally rejuvenating most of the times.

Tea as a threat?

You cannot imagine how a social drink like tea can be a threat. It can be if it is consumed at a stall on a pavement of the city. The stall owner washed the used cups by shaking them in a bowl of more turbid water, followed by a bowl of less turbid water. It can cause enteritis, typhoid, amebiasis, jaundice and similar illnesses. But you would not imagine tea to be a threat to health if it was offered in a meeting of department heads in a tertiary level civic hospital. I myself wouldn’t have believed that possible, but now I do.

The story

The tender committee meeting was quite boring. They offered tea at the end of the meeting. I had the half cup of tea, which was hot and sweet. I put the cup down and forgot about it. They did not clear the table quickly, and the cup remained there for some time. Suddenly I happened to look at it, and a wave of nausea shook me. Have a look, both panoramic and close up.

“What have you given me?” I managed to say in a strangled voice amidst waves of nausea. It looked like pubic hair to me. The people around me looked at me in surprise, then looked at the cup and grinned. It was like laughing when someone else slips and falls down. The servant took the cup and picked up the object inside.
“I may die of poisoning” I said. “What is it? Is it human or from a cockroach?”
“It is a piece of wire” the servant said. I looked at it closely. It indeed was a wire.
“Did you not wash the cups before using them?” one department head asked the servant.
“I did” he said. I knew it was true because I had seen him washing all cups in running water while I suffered from the proceedings of the meeting. “That wire came from the tea.”
The grins vanished from the faces of all, because they all had had the same contaminated tea, though the source of the contamination was found in my cup. One department head seated across from me listened to all this, and then put her cup to her lips, about to take a sip.
“Don’t drink it” I said. “Did you not see what was there in my tea?”
She looked miserable. She had seen it, and she still wanted to have the tea.
“OK. Have it. It was probably boiled with that thing in it” O said. She emptied her cup dutifully.

Aftermath

It seems they discussed the issue at length afterwards. They decided I could not sue them in a consumer court because the tea had been given free. But to play it safe, they apparently considered putting up a board in the board room (where such meetings are held) stating “Eat or Drink Here at Your Own Risk.”

Dissertation Economics

It was during a 'waiting for the Boss' time of a meeting of different department heads from different institutes that I heard of the dissertation economics.
"Do you know dissertations is a booming business these days?" Mr A asked.
"How?" Mr B asked.
"In ways you cannot imagine" came the answer. "They are selling dissertations for Rs. 20000/- a piece."
"Selling?" I was confused.
"Yes. You have to tell them the topic, and they give you five bound copies of a dissertation on that topic."
"Without you giving them any data?"
"Without you giving them any data. There are ads of this business stuck on the walls of our institute."
"But we check data of the students" I said.
"How many institutes do that?" someone else asked.
"Even in institutes where the teachers are strict, it is still a booming business for select people" Mr. A said.
 "How?"
The review board charges a fee from each student. But that is peanuts as compared to other expenses. There are two departments, the faculty of which understand medical statistics. You know which ones?"
We all knew which ones. We nodded.
"There are some staff members of those departments who charge about Rs. 6000/- for statistical analysis of each dissertation. Cash!"
"No income tax, huh?"
"No income tax" Mr A agreed. "No action by civic body for engaging in private practice too. Perhaps this is not private practice. Is it?"
None of us knew if it was private practice. I thought it was, but airing opinions on that did not prove anything. So I kept quiet.
"The university wants each dissertation in so and so manner, with such type of binding and such type of embossing on the cover. All that takes so much money."
"This must be a strong boost for the failing economy of the country" Mr C said.
'Not if it was all black money' I thought. But my opinion could be wrong - I had never studied economics.
"That is not all. Very few Resident doctors get their dissertations ready in time. Those who don't have to pay late fee to the university, which increases by the week."
"Yes!" said Mr D, who had been quiet so far. "Actually this is the main income of the university. Compared to this income, what it collects in the form of fees and grants is nothing."
I came out of the meeting educated but feeling faint for the experience.

Hand Position: Correction of Uterine Inversion

Childbirth is sometimes a very complicated process. I have always maintained that men have it easy. A woman runs so much risk in a single childbirth that a man cannot run in his entire lifetime, unless he is a soldier involved in war or a person involved in violent activities of nefarious nature. One of the serious complications of childbirth is uterine inversion, in which the uterus folds inside out after delivery of the baby. Unless treated promptly and effectively, the woman can die. In other words, the first doctor on the scene has to correct it, and she/he better know how. I often ask questions on such matters when I am an expert to select doctors as obstetricians and gynecologists for the civic body. Once there was discussion on this condition during our round of the labor ward. I felt I should check out how many of my people knew exactly how it was to be done. So I started from the first year residents, and progressed upwards through second, third, and fourth year residents and then Assistant Professors.
The first year residents kept quiet.
The second year residents kept quiet.
One of the third year residents made lip movements silently, the other reduced it with two fingers.
The fourth year resident said she/he would reduce the uterus with a fist.
One Assistant Professor made silent lip movements. Second one made a fist and showed it in a kung fu stance, saying she/he would do it with a fist.
"That looks like a kung fu stance" I said. "I have seen it palm up and palm down in movies. How will you hold your fist, palm up or down?"
"Palm up" she/he said with a smile on her face.
"You want to hit the inverted uterus like a kung fu specialist, or just press it?" I asked with a face as straight as possible.
"Press it" came the answer.
I looked at the last Assistant Professor. "What about you?" I asked.
He started answering "You hold your fingers spread out in a cone, tips in the vaginal fornices, and ..." and I remembered. "I remember asking you this question during your selection process interview" I said.
"Yes, Sir. I had answered it correctly, and that was why you selected me, you had said" he said.
I smiled for two reasons: remembering that episode and knowing that at least one person knew how it was to be done. I explained the technique to the others anyway, so that in the next case, they would be able to manage well.
This is how the various positions discussed look.

Getting Them Hooked

There is this company that markets products like diapers for babies, amongst other things. This company approached the elected head of the town and got a recommendation to be allowed to distribute to all mothers in the postnatal ward a pack of two 'world class' baby diapers, a photo frame, and a pamphlet describing importance of keeping a baby dry during the night so that it slept peacefully (and hence so did the mother). The institute chief advised us to allow the company to do so, and I presume they gave some mothers at least the diapers and a pamphlet. Four years later, they came back with a photocopy of the previous letter and wanted to do the same activity. The sister-in-charge of the ward brought them to me.
"Please show me records of how many times you did this, and when was the last activity" I said. "We will need the Boss' permission again, and the Boss will ask me these questions."
"I will send our boss to meet you" said the company representative and went away. The boss arrived the next day.
"We are just going to give a hamper of two diapers to each baby" he said.
"Your letter says a photo frame too" I said.
"Um... that was the previous scheme" he said. "Now we won't give any photo frames."
"OK. You need a new permission from the civic body" I said.
"Won't the old permission do?" he asked me. It looked like he did not want the hassle of obtaining a permission again."
"I am afraid not" I said. "The last time the activity was forced on us. Now if I get a directive to allow you to distribute your diapers, I will point out the problems to the civic body."
"What problems?" he asked.
"The mothers believe that whatever is given to them in the hospital is by the hospital, and is totally safe. If any baby gets an allergic rash with your product, the parents of the baby will sue us. The other problem is that I look upon this as unethical marketing."
"How?" he asked without much force. He probably knew how.
"You give two diapers free. The mothers like the idea of keeping the baby dry and not having to get up in the night to change wet diapers. Then they have to buy these expensive diapers. It is somewhat like drug peddlers giving free samples to school children to get them hooked. Once they get hooked, they have to buy the drugs."
His face was a study in emotion. I had hit the nail on the head.
"Can't we find a win-win solution to this impasse" he asked. The guy was good. I could not see how it could have been put better and still not appear to be offering a bribe.
"No," I said "the unethical marketing part cannot change even if you do anything for the institute. We don't need anything at the cost of making poor patients buy expensive diapers. I have nothing personal against you. I am just doing my job. I understand marketing your product is your job. Your best bet is to approach the civic body for a permission. I will put my remarks on the paper when it reaches me. My conscience will be clear, even if the civic body chooses to permit you to do what you want to do."
He went away, probably not very happy. I sat there, happy that I had seen the problem in time, and wondering who had allowed this activity the previous time, probably when I was on leave.