MTP Act Versus Right of Women

The MTP Act in India is quite clear about who can have an abortion (MTP) and who cannot. There are a number of conditions listed in it. If the woman has any of those, she can have an abortion. If she does not have any indication from the list and an MTP is performed, it becomes a criminal abortion, for which both the doctor and the patient are at risk of punishment as per the Act. But usually the doctor goes to jail and the patient goes free, unless some mishap like death has drawn the attention of the authorities to that abortion.
The act is liberal. If the couple has been using contraception and the pregnancy has resulted from a failure of that contraception, an MTP is permitted. If a couple says it has used contraception, one has to believe it. No proof is required. So virtually anyone can have an MTP.
Once we had a series of meetings, which was aimed at improving the functioning of the PCPNDT Act and MTP Act together. A few specialists and a few NGOs were called. I was invited as the local specialist. The representatives of the NGOs were quite vocal and they had very strong opinions. One of them said,
"We have good cooperation from XXXX hospital. Whenever a woman goes there to have an MTP, the doctors in that hospital do it. But some other hospitals are not so cooperative. They trouble those women about the indications."
"What do you mean?" one specialist asked.
"See, it is the right of a woman to have an MTP. If she wants it, it must be done" the activist NGO representative said.
"Even without a valid indication?" the specialist asked.
"It is the right of the woman. She cannot be denied that right."
"But the MTP Act is quite clear about the indications for an MTP" the specialist said. "One cannot just have an MTP because one does not want the baby."
"That is what I meant by saying that some doctors are cooperative while others are not" the activist said. Turning to me she asked, "what do you do in your hospital?"
"We do MTP when they require it" I said. I knew there was no point in arguing with her. That would just make me her enemy in her mind.
"Good" she said. So I had said what I wanted to say and she heard what she wanted to hear. Good use of ambiguous language, huh?

Hail Those Independent Minds!

We have an outpatient case paper for women attending antenatal clinic. It is something like a printed spreadsheet. All one has to do is to fill in the blanks under appropriate headings. It makes sense to do so, because one can always check what the previous readings were, and note if there is a trend, like weight gain or increase in fundal height. A sample of that case paper is reproduced below.

It did not work out as was intended by the civic body which gets these papers printed. So I gave strict instructions that all parameters should be checked and written in respective columns. It still would not work, so I kept giving the same instruction again and again. Still I find the following variations repeatedly, involving faculty and resident doctors equally. On a given case paper, when the patient has been seen by different doctors on different days, there is utter chaos.

1. Some of them move the columns showing fetal size (by date, clinically and by USG) one column to the right. So the successive readings are not one below another.
2. A few of them move the columns showing fetal size (by date, clinically and by USG) one column to the left. So the successive readings are not one below another.
3. Some of them do not fill rows horizontally. They write the three parameters one below another in three paragraphs.
4. One of them has a unique style. There are only two readings in place of three. One is written on the left half of the paper, the other on the right half, in a huge letter size. No one has any clue about the heading of either of them. It looks like the following. It does not serve the purpose it is supposed to serve, and wastes a lot of paper too.

                                

All this stresses me out when the patient comes to me for a check-up the next time. The only solution to this problem is to stop going to the antenatal clinic, like a number of senior faculty in many hospitals did and do, or take voluntary retirement. At the moment I have chosen to take the stress and keep working, because working is what I got to do.

Curse of Illegible Handwriting

When there are many doctors running an outpatient clinic, and the same patient is seen by different doctors on different days, illegible handwriting can become a great problem. This is the situation in a civic or government run hospital. As head of the service, I have to see all patients who need a senior to see them, and I also see a lot of others in the course of the clinic. When the previous records are not legible, I get stuck. Sometimes I have to ask my resident doctors what the written records are. They usually can make out what I cannot, like a pharmacist can read doctors' prescriptions when doctors cannot do so. There was one particular resident who would not improve her handwriting despite measures like counseling, sweet talk, admonition, and threats of disciplinary action. Finally I did a Google search and found out the reasons for an illegible handwriting. They are listed below.

1. doesn't have the inclination or time to write legibly.
2. laziness.
3. thinking faster than fingers can move to write.
4. emotional stress.
5. hysteria.
6. dishonesty: hiding intentions behind poor writing.
7. an illness resulting in muscular impairment.
8. alcohol or drug abuse impairing physical or mental vitality.

I think reasons 1 to 4 were most likely in the given case, 5 a remote possibility, and 5 to 8 unlikely. The good part of this exercise was that I knew the reasons behind the bad handwriting (while I had believed the reason was genetic, poor training or bad luck). The bad part was that there was no solution to the problem. The only thing that could be done was to call that resident every time I could not read what she had written, trying all the time not to get stressed.

Too Difficult Patients

"Sir, we had a patient who was too difficult" an Assistant Professor from another unit told me. She just refused to let anyone examine her."
"What do you mean by 'refused'?" I asked.
"She screamed, threw tantrums, was violent, the works."
"Why?"
"God knows. A number of people were required to restrain her so that a brief examination could be done."
"And then?"
"She delivered. She was completely quiet and docile after the delivery."
"Remarkable" I said.
"Did you experience any such thing?"
"Yes" I said. "Quite a few times. When I was doing my residency, there was a woman who refused to be examined. She was calm, firm, and in control. No tantrums. No screaming. Just refusal to be examined."
"So what did you do?"
"We told her that she would have to go to another doctor if she did not want to get examined."
"So she agreed?"
"No. She would not go away and she would not get examined too. Finally she delivered. Three days later she went home."
"Must be a psychiatric illness."
"Probably. We learned much later that we had to make psychiatric reference in such cases. There was another patient who behaved similarly. Her relatives threatened to break down the hospital if she was examined."
"Then what happened?"
"We had a smart Associate Professor.He checked her pulse, touched her tummy, and declared she needed a cesarean section. She submitted to a cesarean section and went home with a baby in her arms and two scars, one on her uterus and the other on her abdomen."
"Poor thing."
"By that I trust you mean poor doctor" I said. "Then there was one who would get up from the labor cot and hide under it, or run out of the labor ward. Then there was a smart doctor who was a patient herself. She delivered in the sister institute. She knew they would start an oxytocin drip for her and then take her up for a cesarean section. So she went to the toilet, locked herself in, sat on the commode, and came out only when she was about to deliver."
"That is unbelievable."
"Yes. They come in many types."

Happy Diwali

I wish
Everyone Out There
Friend or Foe (I hope none)
My Blog Reader or Non Reader
Admirer or Otherwise
Colleagues - Past, Present and Future (current students)
Patients - Past, Present and Future

A Very Happy Diwali & A Prosperous New Year

Grateful Lot, Huh?

I have been a teacher from 1980, though the first three years were of my residency. I did serious teaching then, and it got more and more so as years passed. I never expected anything from my students, because I was getting what I wanted from the teaching - happiness. Some of the students wanted something more than my job demanded. They wanted testimonials so that they could go abroad. I gave those too, not even asking for their email addresses or phone numbers abroad. I know some teachers who go abroad and expect their old students do things to make their stay and commute there comfortable. I never had such desires. I even got old students who came back years later and asked for certificates about their work in our institute, so that they could get what they wanted abroad. I always helped.
When I started an online, indexed journal of Gynecology and Obstetrics from our institute, I thought it would be nice to get some of our old students now settled abroad to send their articles to this journal. I wrote to one student whom I had taught well, and had even given a signature on a log book years after postgraduation, just so that he could become a consultant in UK. He answered promptly, congratulated me on having a new job, and wished us the best. It was not a new job. It was voluntary, honorary work spending our own money to keep the journal alive. But I did not correct him. I just replied I was looking forward to getting articles for the journal, from him and his colleagues. There was no reply and no articles.
There was another one, who wrote to me from UK, asking for references for sling operations that we did (and still do) in India for uterine prolapse. I obliged without considering it an obligation. A few years later he sent me a link to a video of some operation he did in UK and asked for my opinion. I downloaded the huge file spending my own money, spent a few hours studying it, and gave him my opinion - about its good points and bad points. Then I asked him to write on that operation for our journal. There was no response. I reminded him again after a couple of months. He said he was too busy and stopped corresponding.
There are more examples of this. I wonder if these guys whom we taught once think of us as suckers. Or have they become like those Britishers who ruled our country for years,  and thought we were people only to be exploited.
"What do you propose to do about it all?" my friend asked me when I told him this story.
"I don't know if I can force myself to do something" I said. "One option is to refuse to help these guys should they want something more from me in future. Another option is to refuse to help all newer guys thinking they might behave the same way as these older guys. But I will be very unhappy if I behaved like that. the third option is to help everyone, not thinking about how they may reciprocate."
"But you are unhappy because of what they have done to you" he said. "Can you take any more of that?"
"No" I said, "but I have to choose what makes me less unhappy."

Cabbie's Attitude in Medicine

Those who have driven cars in a city would know all about cabbies and their attitudes towards driving. One classical attitude is seen when a cabbie cuts into one's lane without giving any signal. One gets irritated and honks loudly (actually the honking volume does not increase as per one's wish, the duration can). The cabbie understands the reason, and gives the appropriate signal for cutting into one's lane. He does not believe that a post facto signal is useless. He believes that once he has given a signal, he has done his job. So what if the signal followed the act?
The health university showed this attitude. It decided that postgraduate students must know how to carry out research, so that they can work on their dissertations. The circular came when the students had completed all work and submitted their dissertations to the university. As an afterthought, the university said it would allow them to appear for their examinations, but would withhold their results until they produced certificates as proof of having attended the prescribed course on research methodology. Attending a course even after the university exam was OK.
"Classical cabbie attitude" declared someone who disliked cabbies and university personnel equally."
There was this postgraduate student who was doing research on surgical infections. Somehow the work was not progressing as required. So the teacher asked,
"Are you taking all infected cases?"
"Yes."
"This woman with gaping abdominal would. Have you taken her as a subject?"
"Yes."
"Show me her consent form and her case record sheet."
"I have not yet taken her consent. I will take it when she gets cured and goes home."
"So you are studying her without her consent?" the teacher asked incredulously.
"That is what I do for all cases."
"Oh! Does your family own a fleet of cabs or something?" the teacher asked.
"No. Why?" the student asked.
"Post facto consent. Typical cabbie attitude!" the teacher said.
The civic body spent about five million rupees treating some accident victim, while the victim had been in a railway accident and the railways should have paid for that. One does not criticize the civic body if one plans to stay in the city limits. So no one criticized. But the funny part was that they put up the proposal for sanction of the expenses long after the money had been spent.
"Cabbie attitude!" roared someone in the media, who seemed to dislike cabbies and the civic body equally.
"What is your opinion on these things?" someone who told me these stories asked.
"I have no opinion to offer," I said "because I do not believe in judging anyone. But one of the reasons I gave up driving was the attitude of cabbies."

Who Was Shamed?

That woman was inconsolable. The nurse, doctor and relatives around her did not know what to do.
"What has happened?" I asked. "Has she lost a near and dear one? A stillbirth may be?"
"Um ... no" the Resident said.
"Then what?"
"She has come with placental abruption and intrauterine fetal death."
"Ah! That is why she is so distraught" I said.
"Um ... no. It was something someone said to her."
"Where? In our hospital?" I asked. I could not believe it.
"No, Sir. She went to another civic hospital at XXXX. She was in pain and a bit uncooperative. Some doctor said something which has hurt her."
"What could one say to upset a patient so?" I asked. I knew that the said hospital had a high delivery rate and the doctors were overworked. I knew they kept asking for more doctors, including ours. But that would not justify someone saying something that would have upset a patient so.
"...." there was no answer.
"What?" I said.
"...." there was till no answer.
"Tell me. I have heard everything in 34 years of practice in a civic hospital. Nothing can shock me" I said.
'You have not heard everything' the Resident's facial expression said. He looked at his feet and said, "that doctor allegedly said - 'you did not have pain when you slept with your husband. Now what is the problem in sleeping in front of a lady doctor?'"
I was stunned. I had indeed not heard everything in 34 years, as that Resident had thought. She was not my patient, and I thought it incorrect to talk to her.
"If she will lodge a complaint, I will see that she gets justice. Please tell her so" I said and left. I was told later on that the woman and her husband did not want to complain, because they did not care to suffer more, could not afford to skip work to keep visiting the hospital for inquiries, and that nothing would come of the complaint anyway. I knew nothing came of most of the complaints unless someone put pressure to move the machinery concerned. I knew she and her husband had no influence to exert such pressure. I also knew my influence had failed to get justice for such people in the past and would have failed this time too. But I was willing to try.
"Such shame" I said after I related the story to a friend.
"Who was shamed?" the friend asked. "The woman?"
"No" I said. "I was shamed because a doctor, a person of our fraternity, said this to a patient."

Collector's Specials

It is true that everyone accumulates stuff throughout life. It is also true that most of this stuff is rarely used. There are people who collect special items that interest them. This is called having a hobby. There are those who collect expensive items as investment, such as art pieces. This post is about a person who passed away before old age awhile ago - may his soul rest in peace.
This person apparently had no heir. When the 10x10 office allotted to him was to be reclaimed as hospital space, the room had to be opened following the procedure called panchnama, where the security officers got the lock broken in the presence of two witnesses, and all things in the room were catalogued, and the room was locked again and sealed. Now we are awaiting instructions from the Boss, who has asked the State to take away the stuff or advise on its disposal. When I looked at the summary of the stuff found in that tiny office, I was stunned.

Item	Quantity
Books: brand new, in sealed plastic jackets, never opened and read.	262
Music disks: CD, DVD: in sealed plastic jackets, never opened and played.	1360
Expensive gift items, including 3 mobile phone sets, clothes, art pieces and many assorted items: all in mint condition.	178
A huge operating microscope: heavy, packed, unused.	1

Everyone was sorry that the poor soul had passed away without enjoying anything that he had collected. Everyone prayed for peace for that soul because it was felt that the soul would linger back, being attached to all those things. I hope at least a few learned that collecting stuff does not necessarily lead to happiness, and it might be better to let go and give stuff to people who can use it.

Maneuver The Idiots

There was a circular about a new medical college that the civic body wanted to start. It seemed the building was ready. There was already a hospital, now renovated, to be attached to the college. There would be an inspection by the Medical Council to decide if the college could be allowed to start. What remained was to employ people to run it. The circular stated that existing doctors-teachers in the medical colleges would be transferred to that college, and the posts that became vacant due to transfer of these doctors would be filled up in due course. They had asked the aspirants to attend a meeting. There was a huge rush, and many people had to stand during the meeting. There was no concrete decision about who would be finally transferred there. I had a few questions, which I asked the Boss, because I was concerned about continued recognition of my institute.
"What happens if Medical Council holds our inspection between my faculty is transferred and new persons are employed? What if the new people are not employed at all? After all, many of our posts remain vacant for years."
"The civic Boss has promised that these posts will be filled up. So they will be filled up" I was told.
"But why not fill up the posts in the new medical college directly? Why take away our people and fill up our posts later on?"
They have decided to do it this way. Trust the Civic Boss."
I definitely trusted this, until I heard about the court order during another meeting, where people were voicing their grievances to the Assistant Civic Boss, in presence of Boss and Boss' Boss.
"We are not getting promoted to Associate Professor and Professor" the people complained.
"We cannot promote anyone. There is a stay on all such appointments by the High Court. It has been there for many months" they were told.
'Ah!' I thought. 'That explains why they won't employ new teachers directly. They are ordered by the High Court not to employ any teachers. But then how were they going to fill up posts made vacant by taking away our faculty?'
When I voiced my concern to a knowledgeable person, he said, "this is called maneuvering the idiots."
"Who are the idiots?" I asked.
"Those who believe them" he said.

Water Bowl Story

It was very hot, as it is in October every year. My wife felt that the birds visiting our terrace garden would be quite thirsty. So she decided to put out a water bowl for them. She put a plastic bowl out there for them, and filled with clean water. The crows liked the idea, and kept coming to drink from it. It seemed like a worthwhile exercise. But the water bowl disappeared on the second day.

"It might have fallen down" she said, and put out another one. It disappeared the next day.

"The crows must be fighting over the water and displacing the bowl, so that it falls down" she said. I had never seen crows fight over water. But it was prudent not to dispute the idea. She put out a third bowl. The water level went down and she filled it again in the afternoon. The bowl had disappeared by the evening.

"Let us tie it with a string" I said, "so that it will not fall down. That is what they do at public drinking water fountains, so that people do not steal the water glasses."

She liked the idea. She gave me another bowl. I made a hole near the upper edge of the bowl and tied it to the grill with a strong string. I tied three surgical knots so that the crows would not be able to slip the knot and steal the bowl. Now the bowl remained, and water got drunk too.
The next day I was standing admiring the greenery in the terrace garden and also the trees by the side of the road that passes by our home. If you look carefully, you will notice two plastic bowls half hidden by the leaves of one of the trees nearby (arrow).

"Hey, look!" I said to my wife. "Two of our plastic bowls are in the branches of this tree."
"Stop putting me on" she said, continuing to do whatever she was doing. I did not blame her. I do sometimes put one on to bring about some amusement in life.
"No, really. Look at that tree."
She looked. "Why would they steal our bowls?" she said, upset that the crows had stolen three bowls.
"Perhaps they thought it would be easier to drink water in the comfort of their homes rather than coming here all the way."
"The bowls would fill with water by themselves?" she asked.
"So the crows must have believed. Or perhaps they are building nests, and wanted to lay one egg in each bowl."
"Now you are putting me on" she accused.
I smiled. "Yes, I am" I said.

Why Myomectomy? For Fibroids, Silly.

History repeats itself.
A year ago, there was a patient in the ward. She had undergone a myomectomy. For those who don't know, myomectomy is an operation which is done for removal of a benign tumor called leiomyoma(s) (formerly known as fibroid) from the uterus and then restoring the uterus. Leiomyomas can cause different  symptoms in different parts of the uterus, and sometimes they cause no symptoms and no complications at all. Which means all leiomyomas need not be removed by myomectomy (or hysterectomy). In a young, married, aymptomatic woman with small leiomyomas, the best advise would be to have the babies she wants before doing anything to the leiomyomas. In case of a near or post menopausal woman with asymptomatic leiomyomas, just observation may suffice, as the leiomyomas shrink after menopause.
"Sir, this patient underwent myomectomy in another hospital" my Registrar told me during our ward round.
"Why did they do myomectomy?" I asked, which meant 'what were her symptoms for which myomectomy was done?'
"For fibroids" she answered brightly. Though she did not say so, I heard what she meant 'for fibroids, silly'. The 'silly' was silent because she probably understood one did not call the Boss silly in his presence.
I kept quiet, but my face must have spoken volumes. The Associate Professor hurriedly explained what I meant. Then the Registrar proceeded to check the patient's old papers and find out the indication for myomectomy. I was not surprised that she believed her Professor perhaps would not know that myomectomy was done for leiomyomas. It is quite fashionable with residents to believe their professors do not know their stuff.
A year later, the Second year Resident of the previous year was Registrar now. We were taking round in the antenatal ward. This one should have witnessed the educational proceedings of the previous year and remembered. One of the two (witnessing or remembering) must have failed. When we came to a pregnant woman who had undergone hystereoscopic and laparoscopic myomectomy in another hospital prior to this pregnancy, I asked the old question "why did they do myomectomy?"
"For fibroid" the Registrar answered after wondering for a second why I asked that silly question. I heard the answer and kept as straight a face as I could when I asked, "is Dr XXXXXX, our previous Registrar your cousin? She had also given me the same answer to this question, about another patient who had undergone a myomectomy.
"She is not my cousin" she answered. She could have said, 'cousins don't think similarly and speak the same thing, silly' and would have been more right than when she had answered my first question. But I did not sense that answer in her voice. ThisReistrar probably believed I was testing her knowledge. It turned out she did not know the indication for that myomectomy.
"When you say myomectomy was done for a fibroid, it implies that in your opinion every fibroid needs to be removed. If your examiner senses that in your answer, you may not pass your MS examination. Be careful" I said.

Leiomyomas With Pregnancy: Can Hysterectomy Be Done?

A woman with a large uterus containing multiple leiomyomas can pose a diagnostic problem if she gets pregnant. If she misses a period, one can suspect that she could be pregnant. If she has symptoms suggestive of a pregnancy, it would help. One may not be able to appreciate signs of early pregnancy in her case, because the uterus with leiomyomas would not soften appreciably so early in pregnancy, and an enlargement in size would not be appreciated. One can do a pregnancy test on urine and make a diagnosis. But what if she does not miss a period? She might have had irregular and heavy periods due to the leiomyomas prior to the pregnancy. If she gets threatened abortion, she will have vaginal bleeding which may be misinterpreted as menstrual bleeding or abnormal uterine bleeding. Then one does not suspect a pregnancy and does not perform a pregnancy test.
There are some patients who are elderly, and are scheduled to undergo hysterectomy for multiple leiomyomas. If they happen to get pregnant, and if the pregnancy is diagnosed, there is a therapeutic dilemma. Would one perform an MTP first, and a hysterectomy after the postabortal period is over? Or would one perform a hysterectomy and get rid of both the conditions at the same time?
I checked all resources - medical databases, books, journals, search engines like Pubmed and Google - and found nothing on this topic. I asked all faculty in my institute. They promised to answer this question, and only five of thirty three answered. The others may be considered to be neutral or unwilling to commit on this issue. Those favoring MTP first stated that the blood loss would be excessive if a hysterectomy was done primarily, the vascularity of the uterus being increased due to the pregnancy. Those in favor of performing only hysterectomy had a number of arguments to support their choice.

1. It would involve a single procedure instead of two, so that the risk of complications (including those of anesthesia) would be reduced.
2. If the fetus were implanted near the fundus, reaching it through the distorted uterine cavity could be difficult and the MTP could fail totally or partially (incomplete abortion).
3. There would be some risk of postabortal sepsis which could make recovery and subsequent hysterectomy more difficult.
4. The blood loss would not be significantly increased with hysterectomy as the only procedure, as there would not be any blood loss after ligation of the uterine vessels.

Since I have mentioned only one point in favor of MTP first, and four points in favor of hysterectomy primarily, perceptive readers must have guessed that I am in favor of the latter. Please let me know what your choice will be, should you get one patient like this.

City Bus Mischief

The city transport service has employees of all sorts. Some are good people, some are not. Well, I don't blame the city transport service for that. Don't we have the same situation in every job and profession?
The bad sorts come in all types and flavors. There was that conductor today who did not stop the driver who had taken off from a bus stop without the signal from the conductor. Small children were getting down, ready to go for their school exam. Their only fault was that they were exiting from the back door of the bus, not the front one near the driver. He even encouraged them to get off the bus while it was in motion. After some time, when the bus was well away from the stop and the school, he stopped the bus and made them get down. The poor frightened children got down, and walked in the sweltering heat at 1:00 P.M. to the school. I could have got his badge number and complained to the city service administrators, but I knew nothing came of it, other than perhaps the employees beating up the complainant.
The bad sort exist even in the bus workshop too, I suppose. They fix the seats, hand grips, windows and stuff that need fixing. That day I was commuting to work on a city bus. It was hot and humid. People were sweating. I got a seat near a window, which was closed. I tried to open it and found that it had no stopper. There was no way it could be pushed up. I started feeling very warm and suffocated. I should have had second thoughts about selling off my car and opting for public transport to conserve national oil resources. But I was too uncomfortable to have any thoughts other than those on somehow opening that window. I looked carefully and found that the stopper was fitted on the outside of the window while the other window stoppers were on the inside. I have shown a 3D view of the same in the image below. The top part shows the view from the inside of the bus, and the bottom part shows as it would be seen from the outside. The first window on the right side of the top part of the image (which happens to be the front end of the bus) is the one with the wrongly fitted stopper.

The guy at the workshop probably hated commuters, most of whom made much more money than he did. Perhaps he had other reasons to hate people. So he must have fitted the stopper on the outside, so that the commuters would not be able to open the window from the inside of the bus. The other possibility was that he was plain dumb, though I do not think anyone would tolerate a dumb worker for long. What he had not considered was that some of the commuters would be smarter than him too. I put my hand out of the window in front of the closed one, released the catch of the stopper from outside the window and pushed it open. I was used to troubleshooting so many things that went wrong in the civic hospital, that this was a child's play for me.

Gynecological Table To Orthopedic Table

The operation tables are basically same. They have different attachments for suiting needs of different patients. Our operation tables have a semicircular cut at the lower end of the table, where the leg sections come off. That permits surgery in lithotomy position. Orthopedic tables have trochanteric stirrups which permit surgery with the lower limbs extended and abducted. Generally we do not need theirs and they do not need ours. But we had a patient who had a lower limb problem that did not permit flexion at the knee and hip joints, and she needed a medical termination of pregnancy.
"Let us borrow those orthopedic stirrups from orthopedic OT" I said.
Unfortunately it was not possible because the orthopedic OT had only one pair of such stirrups and they needed the stirrups.
"Let our house officers hold the patient's legs straight during the procedure" the Associate Professor suggested. They agreed because they could not say no to a boss.
"We cannot have doctors doing such work" I said. "How long can anyone hold a patient's lower limbs straight out like that, and what if the grip becomes unsteady due to fatigue and the patient moves? It may cause a uterine perforation. Let us put the limbs on Mayo's trolleys at the sides. Their height can be adjusted."
There were not enough Mayo's trolleys for this purpose.
"What about the leg sections of the table?" the Associate Professor asked.
"The leg sections are removed during surgery by rotating them around a vertical axis first and then pulling them out of the table" I said. "We can just rotate them through a suitable angle and place the patient's lower limbs on them in extended and abducted position."
The following 3D image shows the OT table in standard position in 'A' and with the leg sections rotated in 'B' part of the image.

We did what I suggested, and the patient got operated on without any problem including any injury to the affected lower limb, as would have occurred in lithotomy position.