Height of Lethargy or Curious Case of Dyslexia?

We schedule didactic lectures for undergrads in one of the 5 lecture theaters in the college building. One of the nonclinical departments looks after each of the four theaters other than the main theater. Sometimes the theater allotted to us is not available because it is given for some other work like university examination or activity like a workshop or conference arranged by some department. The Head of the Department responsible for the maintenance of the theater informs us in advance so that we can reschedule the lectures which were originally scheduled on those days.
I received a letter from one of those department. It was as follows, a few of the words masked to protect the identity of all concerned. No critical content of the letter is masked.

The curious part is that out of the two options 'is / is not available', none is struck out. So one cannot make out if the theater is available on those days or not. Common sense tells one that it would be 'not available', since no one would send a letter stating that it was available. No word from 'Sir / Madam' is struck out too, which reinforces the idea that the sender of the letter is lethargic. It bears no signature, which suggests that the Head of the Department is lethargic too, and has assigned the job to someone. An odd thing is that the sender has struck out the word 'Ref', and also written the letter 'M' and struck it out. This shows activity which goes against the idea that the sender is lethargic. Perhaps he/she suffers from a curious type of dyslexia, in which wrong words are struck out. Such dyslexia has not been described in the literature so far - but well, there is always the first case of everything. :-)

OT Time Please

We have two operation tables in the emergency OT, because it functions as the routine OT in the mornings and requires two tables at that time. The work is so much in the emergency hours that we require two tables at that time too. Unfortunately the civic body had made arrangements for nurses and servants for only one table in emergency hours in 1926 and has not increased the number after the population has increased so much over 88 years. The nurses and servants overworked for many years and somehow kept two tables operational in emergency hours. But the labor union has put its foot down and refused to run two tables at one time. My efforts over ten years have yielded nothing. Now there are queues of patients waiting for emergency surgery. When a more serious patient comes along, a less serious patient is shifted down the line.
That day we had a patient in early labor. She required to undergo a cesarean section for pelvic contraction in the afternoon. But she was still in the labor ward awaiting her turn in the OT when I reached the labor ward for my morning round the next day.
"Doctor, I have been waiting. They have been taking other patients for operations, though they came much later than I did."
"We are sorry" I said. "But we could not help it. They were quite sick and needed operations urgently. They had to be given priority."
"I want water" she said. "I have not eaten or drunk anything since yesterday afternoon."
"If you take anything orally, there may be difficulty in giving you anesthesia safely" I explained. "We are giving you saline intravenously."
"When will my operation be done?" she asked.
"As soon as we get the operation theater" I said.
"I have not slept all night" she complained.
I had a solution for this problem. "You can go to sleep right now" I said. "We will wake you up when we get the operation theater."
She probably saw the joke and did not pester me any further. We performed her operation soon after, and now she is in the postnatal ward, her troubles forgotten with the happiness of holding her baby in her arms.

New Method of Inquiry

One of the Assistant Professors came to me with a complaint about a resident doctor in another specialty.
"He was quite rude. He told us to get our patient out of the theater. I told him that was a ruptured ectopic pregnancy and needed urgent surgery. He said that was not an emergency like fetal distress. He said she needed blood first, not an operation. I told him I was an Assistant Professor and I knew what was an emergency. Finally the operation started. Even during the operation he kept on making comments and being rude."
"OK. It does not sound good. Do you want to lodge a formal complaint?" I said.
"Yes, Sir."
"OK. Write a complaint letter. I will send to the head of the department of that specialty."
That was done. A couple of days later, an Associate Professor of that department met me and asked if this complainant was working or on leave.
"On vacation for 18 more days" I said.
"My Head of Department has made inquiries. It is found out that a few of our people also have complaints against this complainant. If this person wants to pursue the matter, he/she has to be ready to hear a few harsh words."
I was stunned. Finally I found my voice. "The complaint is against a Resident Doctor by an Assistant Professor. The inquiry is of that Resident Doctor, not that of the complainant. If there are complaints against the complainant, they have to be lodged by proper method and sent to me. Your Head of Department cannot offer harsh words as remedy. Now if complaints are lodged against the complainant, it will appear as if there is an attempt to cover someone's error by counter complaints. That is not how complaints are dealt with in this institute or anywhere else where principles of justice are followed."
I wonder how much this middleman understood and how much he/she would convey to his/her Head of Department. I am even more doubtful how much a person who had that weird method of conducting an inquiry would understand. Going by my past experiences, I actually should have no doubts. I should know that that person will not understand anything at all.
"What do you think of all this?" someone who was listening to this asked me.
"I think such people have not progressed beyond their childhood, when they had fights with other children and dealt with them in this manner. I think it is a tragedy that such people reach high positions without any training on dealing with situations like this."

Appreciation Apathy

"You are looking unhappy" I said to the employee who was retiring from the laboratory. "What happened?"
"I received my best laboratory technician award today" he said unhappily.
"I know" I said. "I had nominated you for the award. You should be happy you got it."
"I know" he said and offered his certificate of merit to me to have a look. I looked.
"Oh, they have not bothered to strike out one of the two printed options 'Shri' or 'Smt' before your name." For people who do not know Marathi or Hindi - 'Shri' is equivalent of 'Mr' and 'Smt' is equivalent of 'Ms'
"Yes. They have even spelled my name wrong. Did they really appreciate my work? Though the gesture of giving me the award suggests they did, the shabby way they made out the certificate indicates they did not."
"Do not feel disheartened. They just have apathy.  They just do not want to exert enough to strike out words which are not applicable. I will show you a certificate given by them to a department" I said and showed him a copy of one such certificate of merit. He studied it.
"It has both the words 'Shri' and 'Smt', none of them struck out. But it is not awarded to any person. It is awarded to a department, which cannot be either 'Shri' or 'Smt'. They should have printed certificates without either of these words, or at least struck out both the words" I said.
"Why do they do this?" he asked me.
"I think the work is assigned to a person who does not like it, but is forced to do it. His superior officer is not motivated enough to see if he/she has done it properly" I said sadly. "There is another possible explanation, which I hope is not the real explanation."
"What is it?" he asked because I did not elaborate."
"Perhaps this is the best they can do. They do not know what errors they are committing" I said even more sadly.
Here is a copy of that certificate, some parts masked to protect the identity of the concerned department.

 

Innocent or Smart?

"Will you please advise me?" A patient asked me in my outpatient clinic. " I want to undergo a test-tube-baby procedure."
"Please show me your case paper" I said. She produced her case paper from her bag. I looked at it.
"You are registered with Dr. XXXXX, whose outpatient clinic is on WWWWWWday. That doctor will be able to answer all your questions. Medical ethics does not permit me to see another doctor's patients."
"But I want your advice" she said. Then she had a new thought. "You are Dr. Parulekar, are you not?"
"Yes I am" I said. "But why do you want my advice?"
"The senior doctor of my unit does not talk to us. Only the trainee doctors speak to us. I think I am not getting the right treatment. I was sitting in a queue for undergoing ultrasonography. I got talking to the woman next to me and told her about my woes. She said I should see you, that you were nice and would give me proper advice."
No one had said this to me directly in my life. I looked at her face closely. She did not seem to be indulging in false flattery. I thought back quickly on my clinical practices and realized that I did talk to all patients irrespective of whether they were sent by important people or not.
"OK. If you make my unit's case paper, I will see you. India is a free country and patients can change doctors if they so wish. We do not do test-tube-babies, but I will check out your test results and give you advice."
She thanked me and went away happy.
I want to believe she was innocent and told me the truth rather than get what she wanted from me by flattering me. Come to think of it, she must have genuinely wanted my advice, because there was no other apparent reason for her to say what she did.
I understood today that this was job satisfaction as much as doing a complex or innovative operation.

Post Facto Training

The postgraduates have to do some research of sorts and write a dissertation on it in order to be able to appear for the university examination and pass it. That is a part of the MS or MD course. Usually it is 1-2 years after joining the three year course, before they get their research proposal to the institutional ethics committee, and the time for submission to the university is usually 6 months before the final exam. So they work on the research for 6 months, sometimes one year. One wonders how anyone can do any serious research in this short period. Luckily the university does not wonder about it. But the university is quite particular that the requirements are met as per standards in the best of universities in the world - at least on paper.
The university decided that they should be trained in research methodology before they do any research. The courses run by the university are few and can take only a few students at a time. So it would take months to years to train all students. The colleges were not allowed to conduct courses on their own. Thus the students were ready to appear for their final examinations, their dissertations having reached the university six months earlier, but none had been trained in research methodology. Then one day they sent out a circular that the students should get trained right away or they would not be allowed to appear for their exams. We conducted courses for them on war footing. Their course completion certificates were sent to the university. All was apparently well, until there was another order from the university asking each student to submit a letter to the university that he/she had not undergone the training, and that he/she understood that if he/she did not get trained by the time of the result, his/her result would be withheld.
"Why does the university do such a thing?" a staff member asked. "It is so stressful for the students."
"Can the university not see the certificates it has received?" asked another.
"It is a dumb thing to do" said another.
"It was dumb to ask them to get trained in research methodologies after they had finished their research. It is dumber to make them say they have not got trained when they have submitted their certificates along with their exam forms."
"The college clerk says the letters must be sent" piped in another person, "or hall tickets will not be given."
Finally I drew the Boss' attention to this chaos, though the postgraduates in Boss' department should have done so much earlier. The Boss called the university and sorted out the issue. In the meantime the students sent their letters in prescribed format, contradicting the contents by adding that they had already done the course and sent the certificates to the university along with the exam forms.
"Can there not be more intelligent management?" asked a staff member in frustration. "Can't we do anything to improve things?"
"No. The university is like an elephant walking along the road. Nothing anyone says or does to it sways it. It goes where it wants to go and does what it wants to do, ignoring everyone and everything."
"Except politicians...." someone said and some of them snickered.

Pillar To Post?

She was a young woman with an early pregnancy. She was admitted to the ward meant for a short stay, until she would be fit t be discharged, or was found to have a persistent problem, which would necessitate her transfer to the antenatal ward. We were taking a round of the ward.
"Does it hurt in the abdomen?" I asked her.
"..." she barely moved her lips, not looking at me.
"I did not get it" I said. "Does it hurt in the abdomen?"
"A little" she said, turning to one side to face a pillar nearby.
"Is there any bleeding?" I asked with some concern.
"No" she murmured, turning through 180 degrees to face another pillar.
"Is she moving from pillar to post?" I asked, knowing full well she was avoiding the doctors on the round. It was beyond me to know what she planned to achieve by not answering the doctors' questions, and by even avoiding them.
"No. She is moving from pillar to pillar" came the answer with a grin from an Assistant Professor.

Now I Know Why

This story is pretty old. It has remained in my mind, in a plane of uncomfortable turbulence, if you can understand what I mean. It surfaced time and again, and I suppressed it every time, knowing full well it would surface again sometime and trouble me.
I had been suffering from resistant malaria. I had had four episodes in three months, and my energy level was almost zero. The therapy was not as advanced as it is today. Finally I could stand it no more, and decided to take leave to help the new experimental medications work and to let my energy level build up. This story happened on my last working day before the leave. There was a pregnant young woman with a solid ovarian tumor. She needed an emergency cesarean section. We decided to perform a it along with removal of the tumor and check it for malignancy by frozen section. Unfortunately the Associate Professor suddenly pulled a back muscle and said was unable to operate. The Lecturer said he had a cut on the hand and could not operate. There was no one else qualified to wash up and operate. I washed up and performed the cesarean section and unilateral oophorectomy, though I could not even stand straight. I would sit down on an OT stool every five minutes, and get up to operate again. The others watched. I was about to close the abdomen, when the frozen section report arrived. It was 'adenocarcinoma of the ovary'. I looked at the others, who looked back at me. I knew I had to go alone on this one. I got the Resident Doctors to take the relative's consent. Then I performed total hysterectomy and removal of the other ovary and both the fallopian tubes. I sat down every five minutes during the ordeal. Perhaps it was more frequent than every five minutes, because I was doing two major surgeries in a row, without a break in between. The others watched. No one said anything sympathetic, though I am not sure if that would have helped.
I refused to think of this story all these years, because I was afraid it would hurt. Finally I decided to sort it out in my head, so that it would not bother me again and again. Why did they not help me, despite knowing I always gave my 100% to everything I did, and this was one time when I needed some help? Were they not my friends? I have been afraid of the answer to this question being 'no'. Were they getting back at me for something I had done, though I could not think of anything like that? I have been afraid of the answer to this question being 'yes'. Well, today I thought that perhaps they felt more handicapped than I was and wanted me to help them out. Perhaps they trusted me to do it, like children trust their father to help them out of any trouble. Then the other question that had been bothering me popped up. Why did I do it? Could I not have ordered one of them to do it? Today I knew why. I did it because I was the head of my unit, and the final call was mine. Giving the patient the right treatment was my responsibility, and I had to do what the others could or would not do. It had nothing to do with friendship with junior colleagues. It had nothing to do with their expectations from me. If I had not done it, I would not have been comfortable with myself. I was not being grand. I was just doing my job.

Proxy Applicant

The institute takes a deposit from students, which is refunded after their undergrad course is over. They have to obtain 'no-dues' certificate from each department before they can get a refund. The certificate is a form with names of the various departments printed on it. I sign all such forms once a week. It is a routine job, which does not require any conscious thought, and which is devoid of any surprises. But that day was different. There was a surprise that I could not have thought of in my wildest imagination. I reproduce an image of the application letter accompanying the form here.

The name of the applicant is written at the top right corner. The signature of the applicant is at the bottom right corner, below which is the name of the applicant. In the said application, the name at the top was quite different from the name at the bottom. I kept the form aside and left a message for the applicant to see me. He/she* arrived in due course. When I drew his/her* attention to the anomaly, he/she* gave the following explanation.
"Actually this is my friend's application. He/she* has gone home, and asked me to get it signed by all department heads."
"What is the your friend's name?" I asked.
"It is the one at the top" he/she* said.
"Whose name is at the bottom?" I asked.
"That is mine" he/she said. "I did not realize he/she* had written his/her* name at the top."
I could see he/she* was distressed, and I did not have the inclination and time to stress him/her* any more. So I returned the form, advising him/her* to submit a properly filled and signed application. But the truth of the matter was that the applicant had filled the application in his/her* own name, but not signed it. The proxy applicant had signed it in his/her* own name instead of the applicant. Can we call this innocence or something else? I wonder what happens to the great minds during the 5.5 years they spend  in undergrad medical education.
(Note: * use of 'he/she' is to protect the identity of the persons involved, just as the intentional blurring of their names on the form is.)

Attitude 15

It is hard to believe I have already written 14 posts on different attitudes, and still I find one more topic for the series. Well, it looks like this may not be the last attitude I may write on.
"Sir, we want to write case reports in JPGO, our journal" someone told me.
"That is nice" I said. "I started the journal and got it indexed only so that people could write scientific papers without having to spend any money."
"Yes, Sir. But none of us in our unit can."
"Why not?"
"Our unit head has taken possession of all our papers, and is not allowing us to publish any."
"Why?" I asked. "Your unit head had promised to send papers to our journal."
"He/she* wants to send all papers in his/her* name for getting an honorary MRCOG."
"Huh?" I said. I did not know MRCOG degree was conferred on anyone, like they give PhD degrees to even uneducated people, for having excelled in some sport or something. "I will ask your Boss" I said. I did ask him/her*, though I knew it would not be very fruitful.
"Of course I am sending papers to JPGO" he/she* said. "I am looking at the papers so that there are no errors in them."
We have published four issues of the journal so far at a rate of one per month. While all other units have got very good quality papers published in this journal, the faculty and Resident Doctors of this unit have not been able to send a single one. The faculty has remained without any credit, and the Resident Doctors do not have any scientific papers, though the health university requires that they have sent papers to indexed journals before they appear for their final examinations..
"Why do you think this unit head behaves like this?" someone asked me.
"Because he/she* is jealous" someone else answered when I did not offer any answer. "The attitude is that no one other than him/her* should get any importance."
That could be it, I thought. But personal feelings should not interfere with growth of others working under one, I thought.
"Can one not improve this person in any way?" someone asked.
"No. Trouble from such people ceases to be when they retire and go away, or pass away" a cynic among us said.
That sounded quite ruthless, I thought. I wondered if it was true.
(Note: * is for protecting identity of the person.)

A Girl, A Doggie, and Me

I was in a hurry. I had to reach the hospital urgently and I was a little late. The footpath available to walk on was narrow, thanks to hawkers. Suddenly I had to slow down. There was a guy who was walking his doggie on a leash, going in the same direction as I. There was a girl walking on a collision course with me. I thought she would respect my age and move a little to one side, so that both of us could pass without interruption. But she did not think so. I could have moved behind the guy and his doggie until the girl passed, and then moved on by their side. But that would have taken some time, given that the doggie's stride was one fifth mine, and the girl's stride two thirds mine. I looked at the girl again, hoping she would adjust. She still showed no sign of letting up. It was then that the doggie decided to help me. It moved right in between me and the girl, so that now it was on a collision course with the girl. The girl was not afraid of an elderly man who was a foot taller than her, but was afraid of the doggie barely a foot tall. She immediately changed lanes and made our lane free for the doggie. The doggie seemed to like her or was determined to help me. It moved back to its original lane. The girl was fast. She started moving back to her original lane. I was faster. I had been watching not just the doggie like her, but both the doggie and the girl together. So I planned my strategy faster than her. I made longer strides and passed by her even before she could set even one foot in her old lane. The doggiedid not bite her. I did not have time to turn back and see, but I can say it did not because there was no scream.
Some smartxxx reader may say I should have let her pass, like I would have if she had been my daughter. Well, I thought she should have let an old, anxious man pass like perhaps she would have if he had been her father.

Abdominal Vaginal Cesarean Section?

A cesarean section is delivery of a viable baby by making an incision into the maternal abdominal and uterine walls. This distinguishes it from delivery of a baby that is ectopic in the peritoneal cavity (advanced abdominal ectopic pregnancy), which is delivered by just making an incision in the maternal abdominal wall. What I am going to describe now is a unique case, quite different from the other two. In this case the baby was delivered by an incision into the maternal abdominal wall and anterior vaginal wall.
It happened in the emergency hours. The woman had been in labor for a long time. The cervix had been fully dilated and effaced for a couple of hours. The baby had been jammed in the maternal pelvis. They took the patient up for a cesarean section for non progress of labor. They followed the standard steps. The divided the peritoneum between the uterus and the bladder and pushed the bladder down. Then they made a transverse incision on the distended 'lower uterine segment' and delivered the baby. But when they started to suture the 'lower segment' incision, they discovered that the incision was not in the lower segment. It was in the anterior vagina. The edge of the vaginal part of the cervix was above the incision.
"It was almost paper thin" said one of them the next day morning during our ward round.
"Stretched out vagina would be that thin" I said. "Have you realized what happened?"
"...." they probably had realized what had happened, but were reluctant to put it in words.
"The fetal head had passed through the cervix and was in the upper vagina. The baby was not delivering because of pelvic contraction below that level. You made an incision in the vagina abdominally and delivered the baby. This must be the first case of this event in the world literature."
"...." they either did not think it was the first case in the world literature, or were not thrilled by that idea.
"You can publish this case in a scientific journal" I said enthusiastically.
"....." they did not seem to think much of the idea.
"This woman has some advantages over other women who undergo a cesarean section" I said. "She will not be at risk of complications like placenta previa, accreta, increta or percreta, and also of rupture of the scar in a future pregnancy."
This should have pleased them, but all I could see there was bewilderment. Perhaps they thought I was being sarcastic.
"What can we call this?" I asked. There was no answer. "We cannot call this abdominal vaginal cesarean section, because a cesarean section requires a uterine incision. We can call this abdominal vaginal delivery."
I moved on with the ward round, not waiting to see their expressions.

Odd Relaxation

My Registrar was presenting a case to me.
"Sir, per abdomen she is 32 weeks, relaxed."
"It is nice to know she is relaxed. Usually patients are not relaxed" I said tiredly. I was tired because the Resident Doctors always said the patient was relaxed when they meat the uterus was relaxed. They continued to do that despite the seniors telling them repeatedly not to do so.
"Um...err..." she said. She probably could not understand why I could not understand what she meant. I must not  have been too tired to let it go at that. So I continued in the same vein.
"What do you say when a patient passes away? She is relaxed in the pupils? Her heart is relaxed permanently? Her respiratory muscles are relaxed?"
"Um...err..." she said. She probably would say 'per abdomen she is 32 weeks, relaxed' for the next patient after patient too. Only time will tell if she will.

Tremors

I am a trusting soul - I trust people to be OK until proved otherwise. My definition of OK may not be that of some others. To give you an example - if someone I know has tremors, I believe the person has essential tremors (unless he/she is very old), the most benign cause of tremors, especially one not related to any vices. For some others, vices causing tremors may be OK. For those who don't know, essential tremors are benign tremors without any apparent cause.
"I then asked him why he had tremors" the Boss said to me once about a faculty member. "I found out he/she* was drinking quite heavily."
"Huh?" I said. I had not thought any faculty member, especially one who operated on patients, would drink heavily enough to have tremors. I had always thought this person's tremors had been essential.
"Yes. I asked him/her to bring a relative so that he/she* could undergo deaddiction."
That got me thinking. This person's puffy look supported this diagnosis, at least in hindsight. I also thought of others who had tremors. There had been a Professor and Head of one Department in the past, who had tremors. They had been so bad that this person had to hold the suturing needle on the patient's drape after passing it through tissues, so that it would remain steady and could be caught with the needle holder held by the other hand. I had always thought those were essential tremors. Now I suddenly wondered if she/he* used to drink heavily too.
The latest example was quite recent. There was this senior Professor of a surgical specialty that I met in a meeting of the civic body. Food was served in the lunch break. Since I never ate any food at such meetings, I had time to observe others. This person's hands shook while holding the plate. The I looked at the face. It was quite puffy. I looked at the tummy. It was quite prominent. I suddenly knew he/she* was a heavy drinker. That explained many things. It also explained the Boss' remark in a meeting. It was 10:30 A.M. The agenda was on a matter in which this person was quite knowledgeable. I suggested he/she* should be called, since his/her* help would be required eventually. The Boss looked at the clock and said, "But will he/she* be up already?" He/she* was called as suggested by me, and he/she* arrived half an hour later, looking disheveled and puffy.
I don't know why I should be blind to clinical signs when interacting with professional colleagues while I am quite alert when seeing patients? Is my trusting nature a flaw? If it is indeed a flaw, I am not sure I want to correct it.

Proxy Urine Sample

There should be no reason to get a urine sample for self from someone else. But one does encounter such reasons time and again.
I remember my student days. Someone had recruited us as volunteers for a clinical trial of some oral tablets. As a part of the investigations after the medication, we were asked to submit our urine samples. One of my friends did not want to submit his sample. Perhaps he had not taken the tablets. Perhaps he could not produce a sample in the lab because of some reason. He came out of the rest room with the urine bottle containing what looked like tap water. Though he claimed it was his urine, I believe to date that it was tap water supplied by the civic body, or very little urine plus a lot of tap water. Or perhaps he borrowed a little urine from someone else's bottle and added a generous portion of water to it.
Our Associate Professor told us of a crime TV serial, in which a guy in a campus used to sell his urine samples to other guys for drug testing, he alone being non user of the drug.
One of the resident doctors told us a story the other day. She had asked a patient in the ward to get her urine sample for microbiologic study. She had explained the procedure in detail, including thorough cleaning of the local parts first, and catching the middle of the stream of urine in the culture bottle. After some time an old woman arrived with the urine bottle containing some urine. She was the mother in law of the patient. "My daughter in law is sleeping. So I brought my own urine sample instead" she explained.
(Note: I am sure that resident doctor will write this story herself somewhere some time. I acknowledge her for the story, and maintain that the copyright of that story will be hers.)