Prayer

Those people who read my blog have enough of everything required for a reasonably good life, or they would not spend time reading blogs. I wish they continue to be happy. But I also wish the New Year sees others who don't have much get at least enough to meet their survival needs.
There are many who have so much they don't know what to do with it.
May the New Year see them do something that will make a difference to others.
The world has evolved to the present state with the help of those who thought differently and dared to do differently.
May the New Year see many more such people do their thing.
The world has many differences between people, which is causing much grief to many people. The differences are unlikely to go away.
May the New Year see more people who will talk people into being tolerant to those with differences.

I could wish for many more things. But expecting too much in one year is not wise. I think I will leave the rest for the years to come, hoping this New Year sees at least these wishes come true.

New Cause of Hypocapnia

A famous psychiatrist conducted a workshop on stress management for us. He told us the following story.
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I always knew anger was bad for physical and mental health of the person who got angry. But I decided to avoid getting angry only recently. Actually I had planned to practice it and even conduct a workshop for Resident Doctors on anger management. I had collected a lot of theoretical as well as practical material for it. But somehow it remained to be done. Implementing those ideas in my own life also remained not done. Finally I decided to do it. I even made a video for teaching anger management.
One of the techniques that was easy and effective was deep breathing. I liked it. Whenever someone did something that would make me angry, I started breathing deeply. That calmed my anger. I was happy that I had managed it. But there is one Resident Doctor who is very good at making me angry. Something or the other keeps happening in the hands of this person. One day so much happened that I was deep breathing almost continuously for quite some time. So much so that I started feeling faint.
"I am feeling faint" I thought.
"Naturally you will feel faint if you hyperventilate for this long" an alert part of my brain said. "It is due to carbon dioxide washout. It is hypocapnia."
"Yes. I realize that" I thought. "I got rid of my anger, but at what cost."
"Is it not better to be hypocapnic rather than angry?" that alert part of my brain asked.
"Not really" I thought. "I must use other methods to control my anger, at least until this particular Resident Doctor completes residency and moves on. Or very soon I will have no carbon dioxide left in my body."
One good thing that came out of all this was that I discovered a new cause of hypocapnia - aggressive anger management.

Did Or Might Have?

This story is from another anger management workshop, where one speaker told this as a part of the exercise set by the person conducting the workshop.
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It is all in the manner of speech.
I prefer to say what I want to say or at least what I have to say. There is no hiding from it. Most of the people do the same thing. If they don't want to say something, they keep quiet. But not everyone is so. See the following example to know what I mean.
"Why did you do this?" I asked one resident doctor who had goofed up big time in patient management. Luckily we had been around and not allowed things to go wrong.
"But I did not do so" she said.
"But you did. People saw you do it" I said mildly. I have learned finally that anger harms me rather than the person who makes me angry. So now I try and not get angry.
"I did not do it intentionally. It might have just happened from me" she said.
"Ah!" I said. It looked like a case of someone using this person like a puppet. She probably could not help what happened. "But I don't think you did not know what you were doing. Would you not go to sleep in some corner of one of the wards during emergency duty, where no one could find you? You would even switch off your phone so that you would not be woken up."
'I did not sleep like that" she said indignantly. "My eyes might have shut on their own."
"And you lie to save yourself many times" I said. It troubled me saying all those things. But they were true complaints, and they caused trouble to patients and her coworkers.
"I don't lie" she said. "Some untruths might be slipping out of my mouth."
I gave up. "OK. You can go to your work" I said.
"But when ..."
"See, I have managed not to get angry because I am working on it. But now my breaking point is approaching. Go before I get angry" I said.
She turned and started going. She stopped twice in the six feet distance to the door, turned around and opened her mouth to say something, saw the look on my face and finally went away. I congratulated myself on having maintained my cool, and also thanked her mentally for the training session in anger management she had not conducted on her own, but had somehow been instrumental in its occurrence.

Merry Christmas

Hey!
Wishing You All......

How People Paint

It was not actually an experiment, but turned out to be one anyway. I was having trouble filling color in black-and-white vector graphics, as I wrote in my previous post. I managed somehow, and the result was as shown below.

Then I spoke to someone much younger than me (but an adult). He offered to find a solution to my problem. So I sent him the same original graphic. He returned it in five minutes, saying he had no problem filling it up with color. He ran Windows 8. The result was as follows.

This post is not about the version of Windows one runs. It is about painting. I am aware an actual snail does not have colors as shown in either of the illustrations above. Both look nice, and I cannot decide which one looks nicer. Both of us ended up painting the eyes blue. Some psychologist might interpret the use of different colors differently. My own interpretation is that there is a child in each of us, and that child loves colors and filling colors in drawings, and in the mind of each the color of the same object can be different.

(Acknowledgement: I have used a black-and-white drawing from the following web page of ClipArtBest.com, which gives free images for use. The coloring and write up are my own.
http://www.clipartbest.com/black-and-white-cartoon-animals)

Black-and-White To Color Trick

Sometimes you have a black-and-white image that you want to be colored. There are actually two types of images - vector and raster. The vector images are easier to fill with color. You just have to use the fill or flood tool of a Paint program. You select a color with a color picker tool, click on the fill tool button, and click in the middle of the area you want to fill. It gets filled instantly. At least, that is the theory. In case of raster graphics, there are no such well defined boundaries around areas you want to fill. You need a more powerful graphics program like Gimp. It puts a transparent later over the original, and you paint in it using a brush tool. It is easier with a specialized tool like 'Black Magic', which does the same thing, but without you having to actually insert a transparent layer.
A problem with the Paint programs is that if you open a black-and-white image, the software recognizes it as a black-and-white graphic, and replaces the colors you choose with shades of gray. Gimp and Photoshop do the same thing. You can actually see the color palette, select a color of your choice, and then you end up watching a shade of grey where you wanted color. The only way to beat the software is to open a new blank image, which is a color image by default. Then you paste your black-and-white image in it. Now the color palette is enabled and you can put whichever colors you want in it. This works with both the Paint programs and more advanced ones like Gimp and Photoshop.

(Note: this one is applicable for those who run Windows XP like me. It is OK on Windows Vista and higher. I am unwilling to upgrade because Windows XP is otherwise working fine for me, and I don't want to throw away good money.)

Repairing A Potato Peeler

I wanted to take up woodcarving as a hobby. It would have given me satisfaction from doing something with my hands, other than delivering babies and performing operations, which I do for both happiness and making a living. The main problem was that I could not find any woodcarving tools in the local market. I gave up that idea because there was no way to make it work. But if I had those tools, I would have been able to at least repair our potato peeler much more easily. It was a simple instrument, with a metallic peeler fitted over the end of a cylindrical wooden handle. The metallic part remained fine, but the wood rotted inside the grip of the metallic part, and the handle came off. I tried to fit it again, passing small nails through them both. But the rotted end of the handle would not hold the nails. I could not find another piece of wood that would fit in place of the old handle. I had no tools to shape any other piece suitably.

Then I had an idea. I reversed the handle, so that its other end would fit into the metallic part. But it was broader than the cylindrical base of the metallic part. I had to shave off the extra portion so that it would fit. I was back to my old problem - no tools. I knew it would be a lot easier to buy a new one. But there would be no sense of achievement in it. Besides, the ones available in the market have flat plastic handles, which do not sit well in the fist when you peel potatoes. Luckily I had another idea. We have this machine that we use to sharpen our kitchen knives and scissors. If it could grind metal, why would it not grind wood? I tried and it did that very well.

In the figure above, 'A' shows the metallic part (golden colored) and the handle. Please do not say the other end of the handle does not look rotted. I had to spend a very long time making these 3D drawings. To show one end of the handle rotted would have taken ages. 'B shows the upper end of the handle ground all around such that the cylindrical part of the metallic part would fit over it. 'C' shows the two fitted together. I passed two small nails through the base of the metallic part and the handle within it. 'D' shows the finished potato peeler.
A note of caution for those who want to try this out. Try to fit the base of the metallic part over the handle periodically as you grind it, so that you do not make it too thin. If it gets too thin, you will have to find a new handle and start all over again.

How To Give Away Free eBooks?

This is something that I need advice on.
I have written two eBooks recently, mainly for resident doctors in training. They might help medical students too. They are in PDF format. Their front covers look like this.

I want to give these free to anyone who wants them. The problem is I don't know how to do that. Perhaps there is some place on the internet where I can upload them, and give a link so that people can download them. I would welcome people to give them to anyone who wants them, just so long as one does not print and sell them. The idea is just to let people learn what I learned the hard way. I cannot email them, because that would take away a lot of time, in which I could do something else that also might help people.
If anyone can suggest how I can do this, I will be obliged. Please email me.

05-01-2015
A kind soul advised me to put them on Google drive. Thanks to him/her (did not reveal identity), now you just have to click on the image of the book and the ebook will download. Open it in any PDF reader.

The 7.5 Size Gloves

Our surgery professor used to tell this story.
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It was not a great way t start a busy outpatient clinic.
"Where are 7.5 size gloves?" I asked the attendant.
"Sister has not given any" she said.
"Sister, why do we not have 7.5 size gloves for examining patients?" I asked when the sister arrived on the scene after I called her.
"The stores clerk said there were no gloves of that size" she said.
"So what did you do about it?" I asked. "I cannot examine patients for four hours with smaller gloves."
"What could I do?" she asked.
"You could have let me know then, rather than I discovering it now."
There was no pint in calling the stores clerk. It was 9:00 A.M. The time of arrival of the clerk was 10:30 A.M., and the expected time of arrival was not before 11:00 A.M., if one went by past experience of other clerical personnel. I called the administrative office.
"The person who looks after the purchase of gloves has not yet arrived" I was told. "I will tell her as soon as she does."
"Do I not work until then?"
"........"
"In an emergency, I have used even size 6 gloves. I have put left hand glove on my right hand and worked too" I said. "The economy of this place has made me do that a number of times. But this is not an emergency. I have to see patients one after another. I cannot do that meaningfully with my hand in cramps.  Since I am head of the unit, I have to see my share of all patients, plus all patients that my juniors want me to see and opine on. If you cannot supply gloves, we will have to prescribe a pair to each patient I examine."
"I will try and get 7.5 size gloves from somewhere, and see that new ones are purchased" I was promised.
Some gloves were brought from a place that had stopped functioning for last 6 months for reasons other than nonavailability of gloves..
"Sister, if you do not get gloves in future, write a call to the purchase officer and ask for permission to prescribe gloves to patients. She gives us gloves or she gives us a permission to prescribe them to patients" I said.
"Yes, Sir" the sister said.
This method seems to have worked. I get gloves of 7.5 size now quite regularly.

Innovative Blood Pressure Control

Life is so full of surprises. Who would have thought a resident doctor would come up with such a novel way to control blood pressure of a patient?

I found the patient in the ward where we keep patients in early labor. She was lying down with her head on a sphygmomanometer. It was a little surprising, because it must have been quite uncomfortable for her. It was a mercury type instrument, housed inside in a long, flat metallic box. To balance a head on such a narrow thing must be difficult. It must have been painful too, since it was hard. Other problems with leaving it on the patient's bed were making it non available to other doctors, and breaking it by accidental fall.

"Who has left the sphygmomanometer on the patient's bed, under her head?" I asked. None of the resident doctors answered in the affirmative. I repeated the question and got no response once again. They must have thought that would beat me. They always believe the Bosses believes the patients are dumb and do not ask them any questions. I am different. So I asked.

"The doctor checked my blood pressure with it and forgot it here" the patient said as she got up.

"Which doctor?" I asked.

"This one" she said, pointing the doctor out. So I asked the doctor, "why did you leave it there and not own up when I asked?"

"But I had taken it back, because it belonged to another unit" she said.

"So you think the patient brought it back and kept it under her head and now is lying to me?" I asked. Actually telling me the truth - that she forgot - was so much easier and time saving. But perhaps face saving was more important to her than time saving.

"......" she said.

In the meantime I noticed that the patient had decided that we had finished talking to her and was back to her lying down position. She had carefully positioned her head over the hard, long, narrow, metallic box. Whether the frown on her face was due to the pain of labor contractions or the pain caused by the box was difficult to opine on. That suddenly gave me the idea.

"She seems to believe the instrument is for controlling the blood pressure. Have you given her the idea that putting her head on it controls her blood pressure?" I asked.

"......."

Since she would not answer, I have no way of knowing the truth. But the patient seemed quite upset when they took the sphygmomanometer away from her.

Threat of DNA Analysis

It was an old trick they used to get away from work.
"Sir, we have a problem. The water supply to the labor ward shuts down once or twice a week regularly" the sister in charge of the labor ward complained to me, while I was taking a round of our patients in that ward.
"That sounds familiar" I said. "Where is the problem?"
"There is enough water in the  underground tank. But the inlet of the overhead tank is shut off."
"That is usually operated by the electricians who run the water pump" I said.
"We asked them. They said they were not closing the inlets. Someone else was doing that."
"I know who is doing it" I said. "The servants in the gynecological OT used to do that on my OT day because the operation list used to be big. If they shut off the water, there would be no list. Which meant
they did not have to work. I found that out and got it sorted out. The problem has not recurred for many years. Now one or more of your servants has learned the trick. Call the senior servant. I will talk to him."
The servant was duly called.
"I understand the water supply to our labor ward is shut off by someone" I said. He kept looking at me, confident that I could do nothing to catch the culprit. "The servants in the gynecological OT used to do that on my OT day" I continued conversationally. He kept looking at me. "I fixed that problem. It did not happen again after that."
That shook him up. Fixing gynecological OT servants was no small feat. If I did that, I must be good.
"Now I am warning you and the other servants. If this happens again, I will get DNA analysis done on the inlet valve of the overhead tank. That will catch the culprit. Then I will lodge a police complaint for interfering with work of the civic hospital. You understand the nature of the complaint and the consequences, don't you?"
It seemed he understood the consequences very well. I went away.
"Sir, will you really do that?" someone in the unit asked me.
"Well, no. We do not have funds to do such a test. I have just frightened him. Knowing my academic reputation, he has believed me. They won't do that again. Actually they could have beaten the trap by wearing gloves while doing this, just as they do while cleaning the ward. But he does not know that and I am not telling him."
In the next two months, the water supply to the labor ward stopped only once, but was soon restored. It was either accidental, or they decided to do it just to try and prove that they were not totally beaten.

Novel Solutions From a Printer

I wrote a book entitled 'Differential Diagnosis and Management Options in Obstetrics and Gynecology' a few years ago. Its two editions were sold out. Then the publisher did something funny. He did not reprint it, nor did he ask me to revise it. After 2.5 years, I thought it was time to revise the book. So I asked him, and came to know all this. The publishing house was quite big, and every time I communicated with it, there would be a new manager who talked to me. There was no explanation why this had been done. They had also printed my last edition on such horrible paper, like one used by tabloids, that it turned yellow after some time, and orange after a few years. They had no explanation for that too. They had no remedy for the loss of goodwill of the book and financial loss to me. I was unhappy with the publisher and decided to change him.
He gave me the publishing rights quite amicably. I think he was just not interested in publishing books any more. I revised the book. It was different from conventional books. It was in landscape mode. Each chapter was covered in just two pages facing each other. There would be an algorithm (flow-chart) on the page on the right side, and explanation of the algorithm on the page on the left side. A reader had to hold the book open, and read the pages alternately to understand the contents. Unfortunately a few algorithms got so big, that they encroached on the lower margin.
"See if the printed pages will look OK" I told my new publisher. He asked his printer to check it. Then he got back to me.
"The printer has three novel solutions to the problem" he said.
"What are they?" I asked disbelievingly. I could not find a single solution to it, and this person had three!
"The first is to remove some parts of the bigger flow-charts" he said.
"No. We cannot remove any matter" I said. "The stuff would not make any sense if we removed any matter from it."
"The second solution is to make the font smaller for those pages" he said. "It will be a reduction. You understand reduction?" he asked me, thinking reduction was a very technical term used by printers.
"I understand 'reduction' I said. I have been reading and writing in English for ages. I have written 21 books so far, all in English. We cannot reduce the font. I have used 10, and any smaller will not be readable easily."
"OK. The third solution is really novel. The printer says the book should open up and down instead of side to side. The spine of the book will be transverse, not the usual longitudinal." He meant like a laptop, I thought. For those of you who cannot visualize this idea, here is an illustration I whipped up.

A is the one he had suggested, while B is the way my book was to be.
"We cannot do it" I said. "It will still put matter in the lower margin. The other reason is that God has made our hands one on each side of the body. So it is comfortable to hold the book open sideways. To hold it open in up and down position will strain the hands and cause fatigue. A laptop remains open by itself, while a book won't."
"So what can we do?" he asked.
"Either we print it as it is, or we just put it in electronic format. to be read on laptops, tablets and smart phones."
I cannot sell eBooks" he said unhappily.
"OK. Then I will give it free to whoever wants it" I said.

Pedunculated or Sessile Polyp?

I was in the second year of my graduate course studying pathology. It was then that I learned that all tumors that grew from any surface either had a stalk or pedicle, or did not have one. Those with pedicles were called pedunculated and those without were called sessile. A little later I studied Gynecology. I learned that leiomyomas arising from the outer or inner surface of the uterus could be pedunculated or sessile. A pedunculated mass arising from a mucosal surface was also known as a polyp. This information has an important bearing on the management of the tumor. A benign pedunculated tumor can be removed easily by dividing its pedicle. A sessile tumor cannot be removed so easily, and has to be dissected out of its bed. All this information is quite basic, and is required to be known by the graduate and definitely the postgraduate students.
We were in a clinicopathologic meeting, attended by our doctors as well as pathologists. One case was being discussed, who had a polyp of the uterus.
"Polyps can be pedunculated or sessile" a Professor from the other department said.
There was a deadly silence among both gynecologists and pathologists, at least those who were paying attention or not dozing. No one said anything for quite some time. Then the resident doctor who was presenting the case started where he had been interrupted. The meeting moved on.
"Has she/he* gone bonkers?" someone said after the meeting. "How can she/he make such a statement?"
"She/he is known to make such statements. That is how God has made her/him" a knowledgeable person said.
"But what about the students taught by her/him? They will remember that and get in trouble in exams" a third person said.
"They don't pay attention to the teachers. They read books for their education" a fourth person said.
"I hope she/he has not written a book and if she/he hasn't, is not planning to write one" a fifth person said.
"I think she/he was not concentrating, and said polyp in place of a leiomyoma" I said. That sounded correct. It also fitted in the behavior of the person concerned.
(* She/he is used to protect the identity of the person concerned).

Dig Deeper

"Sir, we have received the histopathology report of Mrs. XXXX" my Registrar said.
"What about it??" I asked. We got such reports of all our operative cases. There had to be something unusual about it for her to say so.
"It says 'material inadequate. Do a deeper curettage'".
I remembered that patient. The material had been scanty when we had done a dilatation and curettage. But that had not been due to any lack of effort.
"I remember. The operating surgeon had done a really good curettage, despite which  there was hardly any material" I said.
"So what shall we do?" the Registrar asked.
"The endometrium was atrophic. So there was no material. We cannot get any material if we repeat the curettage and curette deeper as the pathologist has suggested. We have to treat her condition appropriately, based on her symptoms. Let her see me when she comes to the outpatient clinic the next time."
The Registrar went away. This was the second time someone had erroneously told us to dig deeper into the endometrium. This time it had been an Assistant Professor of Pathology, while I was Professor and Head of my department. The first time it was the Assistant Professor of my department while I was a first year resident doctor 34 years ago. That patient was young. She had abnormal uterine bleeding.
"Admit her and do her endometrial curettage" the Assistant Professor told me.
I did that. The patient came for a follow up. Her histopathology report was 'proliferative endometrium'. She was still bleeding. Instead of treating her with appropriate medicine, like a progestin, the Assistant Professor said, "you have not done a good job. Admit her and do her endometrial curettage again."
I knew I had done a good job the first time. But there was military discipline in the civic hospital. So I followed orders and repeated the curettage. The report was still the same, and the patient continued to bleed.
"Can't you do a good curettage? I am telling you, do a GOOD curettage" the Assistant Professor said.
So I admitted the poor woman and did a good curettage a third time. The third report was ' endometrium in prolifeative phase. Bits of myometrium seen.' When the Assistant Professor saw that report, she said, "I think you have done a good job. Though she is still bleeding, don't do a curettage again. She cannot afford to lose myometrium. We will treat her medically." I don't know what treatment she gave to that patient. But I do know that she did not teach me the right management of such a patient, probably because she did not know it herself. I had to learn it from her mistake, and by reading books on my own.

HIV Therapy Misinformation

One woman came to our outpatient clinic demanding a laparoscopy. This seemed unusual.
"Why do you want a laparoscopy?" I asked her.
"I want to have another baby" she said.
"But why laparoscopy?"
"When I could not conceive, that nice doctor XXXX performed a laparoscopy on me and I had a baby. Now I want another."
"OK. But I don't think you need a laparoscopy. Did he tell you to have a laparoscopy again?" I asked.
"He does not want to treat me" she said shortly.
"Why?" I asked. This was getting weirder and weirder.
"Um... I am HIV positive" she said.
I was taken aback, for a number of reasons. That a doctor should refuse to treat her because she was HIV positive was not OK. Then he had advised her a laparoscopy, when she had conceived and had a baby. So that advise was also probably not OK. The main thing was that she knew she was HIV positive, and that she could get AIDS and die some time, leaving behind children who would be orphans. The fact that she came to a civic hospital indicated that she was not well to do. How would she provide for two children?
"The risk of transmission to the baby was substantially reduced but not eliminated totally with drugs administered to the mother" I said."You have a baby Why not take good care of that baby rather than have another one, when that baby can get infected? Besides, if your disease progresses and your life is cut short, who will raise your babies?"
"The person at the therapy center  has told me that with medicines for HIV, I can have a normal life span" she told me.
"OK.Are you going to buy your own medicines?"
"No! Government gives these medicines free" she said indignantly. Poor woman did not seem to be reading the newspapers and did not know that government healthcare schemes worked at times and did not at other times. For those who do not believe me, read the following news in Times of India that appeared just two days ago. For the last one year, medicine kits given by the same agency to pelvic infection cases are not available. The medicine kit given for vaginitis by the same agency has been available for a few days and not available for most of the days in the previous year.`
Stock-out hits HIV treatment across India

"OK. It is good that you trust you will get an uninterrupted supply of the drugs you will need. I will treat you to help you get a baby. But We will not perform a laparoscopy. From your history and examination findings, I don't think that is required. It is a dangerous procedure that can cause serious complications at times. We never do it without proper indication"
She looked at me suspiciously and went away. She reappeared after half an hour with another woman who said she was a social worker in the agency that gave HIV drugs.
"Why are you not performing a laparoscopy on her?" she asked me. "She will have a normal life span with medication and raise her babies well."
"That is good. Perhaps you will tell me why patients are dying in the medical ward with AIDS?"
She just looked at me. She probably knew a few lines that she was supposed to tell patients, but not the hard facts of life in a poor country. Or was she forbidden to talk about those hard facts?
"Anyway, it is good to know that patients are doing well in your opinion. We will treat this woman's infertility, but we will not do a laparoscopy because it is not required and doing an unnecessary operation on her might pose a threat to her life. Let her follow up in our infertility clinic and we will treat whatever problem she has got."
They went away. That woman never came back. She would not believe me probably because she wanted to believe what she thought suited her best. No degree of wisdom and explanation from me would convince her otherwise.

Novel Contraception

Usually the histories of new patients are written by the resident doctors in the outpatient clinic, and then the patients go for a clinical examination to senior doctors. But there was a big queue for history taking and no patients for examination. So I went to write a few histories. There was a 24 year old patient, who had come for a check up because she had missed her menstruation by 5 days. After asking about the complaint, menstrual, obstetric, medical, surgical, and personal history, I asked her about her use of any contraception.

"Yes. My husband uses condoms" she said.

I had known that most of the couples coming to our clinic were not very regular in their use of condoms, when they used condoms at all. So I asked, "when does your husband use condoms? Does he use a condom every time?"

"No, not every time" she said. "He uses only during my menstruation."

"What does he use at the the other times?" I asked when I had recovered from the shock I experienced.

"Nothing" she said.

 Poor woman, I thought. No one has taught her that contraception is not required during menstruation. Poor woman, also because no one had taught her husband to leave her alone during her menstruation.