क्रुतीशीलता

"गुरुजी, नवे वारे वाहू लागले आहेत हो" आटपाटनगरच्या राजाच्या रुग्णालयांतील राजवैद्यांनी जाहीर केले. "आमचे जुने ठोकताळे आता बहुधा मागे पडणार."
गुरुजी राजवैद्यांना चांगले ओळखत होते. ते जरा तिरकस बोलत आहेत हे त्यांच्या लगेच लक्षांत आले.
"ते कसे काय?" गुरुजींनी विचारले.
"पूर्वीसारखे र्वैद्यकशास्त्र आले की झाले असे हल्ली उरले नाही. नव्या दमाचे वैद्य आणि जुन्या दमाचे पण केस काळे केलेले वैद्य व्यवस्थापन वगैरेच्या कार्यशाळा करून येतात. क्रुतीशीलता (ज्याला management मध्ये proactivity असे म्हणतात) वगैरे मुळे रुग्णांवर उपचार अधिक कुशलतेने करता येतात असे ते म्हणतात."
"म्हणजे काय ते नीटसे कळले नाही" गुरुजी म्हणाले.
"गुरुजी, क्रुतीशीलता म्हणजे पुढे काय होणार याचा विचार करून आधीच योग्य ती पावले उचलणे. अतिशय योग्य अशी संकल्पना आहे ती. आता आमच्या क्रुतीशील वैद्यांनी काय केले ते पहा. आमच्या एका रुग्णाला आंतडे अडकण्याचा विकार झाला होता. ती दोन महिन्यांची गर्भार पण होती. शल्यक्रिया करून तिचे आंतडे सोडवावे अशी विनंती आम्ही शल्यक्रिया करणाऱ्या वैद्यांना केली. पण त्यांनी कार्यवाहीत विलंब केला. तिला जंतूसंसर्ग झाला. रक्तांत दोष निर्माण झाला आणि रक्त गोठण्याची प्रक्रिया थांबली (ज्याला disseminated intravascular coagulation किंवा DIC असे म्हणतात). पोटात गर्भाचा म्रुत्यू झाला तरीही हा विकार होऊ शकतो. पण तिला तो विकार आधी झाला आणि नंतर तिच्या गर्भाचा म्रुत्यू झाला. कालांतराने तिची शल्यक्रिया झाली पण ती दगावली. माताम्रुत्यू अन्वेषणाच्या वेळी शल्यक्रिया करणऱ्या वैद्यांनी असा मुद्दा माडला की गर्भाच्या म्रुत्यूमुळे तिला तो रक्ताचा विकार झाला. आणि त्यामुळे ती दगावली."
"यांत क्रुतीशीलता कोठे आली? उलट निष्क्रियता दिसून आली" गुरुजी म्हणाले.
"गर्भ म्रुत झाल्यावर पांच आठवड्यांनी हा रक्ताचा विकार होतो. या रुग्णामध्ये आता गर्भ मरेल अशी परिस्थिती आली आणि शल्यक्रिया करणारे वैद्य क्रुतीशील असल्यामुळे हा रक्ताचा विकार आधीच झाला. निदान असे त्यांच्या म्हणण्यावरून वाटते. हे क्रुतीशीलतेचे उदाहरण असावे" राजवैद्य म्हणाले. "मी भरल्या बैठकीत तसे सर्वांसमोर म्हणालो देखील."
"मग ते काय म्हणाले?"
"काही नाही. गप्प बसले."
(Keywords: proactivity in medicine)

Bed-Cum-Slide

Our maternity wards have sturdy steel cots. They used to elevate the foot end of the cots in certain obstetric situations in the past, most of which are not considered valid indications for giving a head-low position in modern times. They used to put wooden blocks under the legs of the cots to achieve this. If the wooden blocks were kept vertical, the head-low used to be steep. If they were kept sideways, it used to be mild. We do have special situations in which a head-low position is still required, such as hemorrhagic shock and fetal umbilical cord prolapse. We have special cots for this purpose, which have mechanical arrangement to give head-low position. A steep head low position using wooden blocks is shown in the following 3D model I made to illustrate the point..

We have one consultant who still uses this old time arrangement, for the old time indications. The nurses have not thrown away the old wooden blocks, and they prove useful to this consultant. This position is so uncomfortable, that the patients dislike it intensely, and resort to some other use of the arrangement as is evident from the following comments made by different faculty members after looking at such cots.
"Look at that woman. She is sleeping in head-high position. The Boss' round must be over. Or she would not have dared put her head at the foot end of the cot" I heard on one such occasion.
"Perhaps he/she has prescribed this position to accelerate labor, reverse of head-low position to control preterm labor" someone sniggered.
"Where is the patient on this full-block head-low cot?" I heard on another occasion.
"She is sleeping on the adjacent vacant cot" someone answered with a smile.
"Oh, look at that child enjoying itself on a slide" I heard on a third occasion. Everyone looked. A small child was climbing at the foot end of the cot, and sliding down the length of the cot over the smooth McIntosh that was placed over the mattress. Its mother was sitting on an adjacent cot, watching her child with love.
"I bet the child loves visiting its mother in the hospital more than going to the garden. Here it gets the company of the mother and a slide all to itself" someone said. That actually seemed to be the case.

A Mother's Grief

She was a very young woman. She was admitted in the hospital because her very first pregnancy had ended in a missed abortion. A missed abortion is one in which an early pregnancy dies and the dead fetus is retained in the uterus. This is not a text book definition, but it will do. She was to be subjected to an operation called D&C, for evacuation of the dead products of conception. When we reached her during the ward round, she was sitting on her cot, her head down. Her mother or mother-in-law was standing near her.
"Sir, this patient is a primigravida ...."
While my Registrar was telling us about this patient, I happened to see what the patient was doing. She had her ultrasonography plate in her hand, and she was looking at the plate very intently. She was so engrossed with it that she did not even notice us.
"See what she is doing" I whispered to our Associate Professor.
"She is looking at the picture of her unborn baby that is no more" the Associate Professor murmured.
I developed a lump in my throat and could not trust myself to say anything right then.

New Indications For LSCS

LSCS is short for lower segment cesarean section (for those who are not medicos who have not undergone one or have undergone one but don't know what it is called) The list of indications was quite limited about 50 years ago. With advances in maternal-fetal medicine, the list has got quite exhaustive. When we were discussing this issue once, I came to know about some other indications that have not been put down in text books and journals yet.
"Did you know what XXX used to do?" asked someone. "It was a modification of 'failure of induction of labor' as an indication for an LSCS." XXX was a person who worked in our hospital as a unit head, who left for greener pastures some time ago.
"What?"
"Once I saw a patient of that person in the labor ward. She was a staff nurse with a prior LSCS. She was receiving an oxytocin infusion for induction of labor. We both reached the patient simultaneously. I noticed that the oxytocin drip was running like a tap."
"Huh?" I said. "That would cause fetal death or uterine rupture."
"Exactly. I drew attention of XXX to the drip rate. Instead of promptly reducing the drip rate, he/she merely smiled. You know what it means."
"What?"
"There was no oxytocin in the infusion bottle. It was plain 5% dextrose."
"Huh?"
"Yes. The plan was to do an LSCS. But the drip was given to make the patient think that all efforts were made to achieve a vaginal delivery before LSCS was done when induction of labor failed."
"...." I was speechless.
"I heard this was not a one time occurrence. XXX must have made the resident doctors privy to this plan too, since the drip is always prepared, administered and monitored by the resident doctors."
"....: I was still speechless.
"This was subtle" said another person. "ZZZ was more direct." ZZZ was another unit head who joined another institute some time back, for many reasons including a greener pasture.
"How?" asked the person who had told the first story.
"He/she would subject all staff nurses registered with that unit to LSCS. It had got so that when anyone asked about the indication for LSCS in any given case, the Associate Professor in the unit would say 'staff nurse'. Of course the patient herself would be told some other reason."
"But why? Why not treat them like any other patients?" I asked.
"Your guess is as good as mine" I was told.
(Note: XXX, ZZZ, and he/she have been used to protect the identity of persons concerned. This note is superfluous anyway, when you read the warning at the bottom of the page, which reads 'All characters except me and all places and incidents described are fictitious and any resemblance to actual persons, places or incidents will be entirely accidental or coincidental.')

Innovations In Intravenous Fluids Management

We usually administer intravenous fluids to a patient for 24 hours after a cesarean section. Since cesarean sections are performed at all times, there are patients who have received intravenous fluids for 0 to 24 hours in the postoperative ward at any given time. We often find that a patient is without any fluid going into her vein even if it has been a short time after the cesarean section. The nurses offer different reasons for the same, some of which are as follows, and all of which I trust are true.

1. I was going to start the next bottle of fluid just now.
2. I disconnected the fluid infusion because the servant was changing the patient's dirty gown.
3. I have just come on the duty, and learned that IV fluid is to be given to this patient. I will do it right away.
4. The nurse who has to do it has gone somewhere on duty. I will do it right away.

Despite clear instructions, the Resident Doctors are unable to enforce continued administration of IV fluids, because the disconnection usually happens when they have gone away from the ward. That day I found a patient with an intravenous cannula in place, but no fluid bottle connected to it through an infusion set. There were three infusion bottles hung on an IV stand as shown in my 3D model below. It had been just 11 hours since the patient had undergone a cesarean section.

"Where is her IV infusion?" I asked. The Registrar put on a confused expression and said nothing.
"Are all of these bottles for this patient?" I asked. Someone called the nurse, who declared,
"Yes. We have her remaining fluid bottles ready on the stand. We will give them to her one after another."
"Keeping all bottles opened will result in contamination of their external surface, and those bacteria will enter the bottles when the bottles are pierced with the end of the infusion set" I said.
"Um..." the nurse said. I took it to mean she had understood it and would not do so again.
"There is no infusion tube between any of the bottles and the intravenous cannula" I pointed out. "Is the connection WiFi?"
The Associate Professor laughed. I think the others either did not get the joke or were to scared to laugh.

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.

Gravidity Parity Dilemma

One of the most basic instructions given to an undergrad is on the concept of gravidity and parity. Gravidity is the number of times a woman has got pregnant. Parity is the number of times she had delivered a viable baby. One adds abortion to the list, the number denoting the number of pregnancies that ended as abortions. If the woman is not pregnant at present, her gravidity is the sum of her parity and abortion number. If she delivers more than one fetus in a given pregnancy, her parity remains one irrespective of the number of fetuses she delivers.
The hospital nurses assign confinement number to every woman who delivers a viable baby. A tag with that number is ties around the wrist of the mother and another one with the same is tied around the wrist of the baby.
There was a curious situation the other day. The sister-in-charge of the labor ward stopped me during my ward round with a problem.
"Sir, a woman delivered a baby yesterday. Actually she had twins, but one of the babies had died in the uterus at 3 months of pregnancy. That small fetus came out after she delivered the first baby of nine months. We gave a confinement number to the first baby and the mother. We also gave the number to the other baby which had died at the gestational age of 3 months."
"You mean you tied a tape with that number around the very tiny wrist of a fetus of three months?" I asked incredulously."
"Yes" she said sheepishly.
"How did you manage that?" I asked. "That tape would have gone around the entire baby, not just its wrist."
"We managed" she said briefly. Obviously she did not want to go into the details of how they managed the feat. "What I want to know is that the Registrar told us not to give that number to that fetus. Were we right or was he?"
"He was right" I said.
She looked at me with accusing eyes. She probably did not take it well that I supported the doctor.
"By definition, if a fetus dies before the age of viability, it is called an abortion. If it is not expelled, it is called a missed abortion. So this woman with twins had a term delivery and an abortion together."
She looked at me skeptically. There must have been no such situation in their nursing books, nor in her nursing experience. My unit doctors looked like they thought I was putting them on. I assured them I was not. When I explained the logic, they were convinced.
"Now there is a problem in this" I said. "A woman pregnant for the first time in such a situation becomes Gravida 1 Para 1 Abortion 1 after her delivery of the fetuses, one being term and the other being an abortus. But the sum of her parity and abortions exceeds her gravidity. That is against the basic principle. What can be done to resolve this confusion?"
They thought about it, but had no solution. I had no solution too, mainly because I left it there and moved on with my ward round. I found the solution just now, when I reached the end of this post. It is as follows.
'The conventional teaching does not offer any solution here. No one has thought of such a situation before, though death and retention of one of twins is a known condition. We will have to accept the situation of having to call her Gravida 1 Para 1 Abortion 1, and write 'twins' in bracket.'
That sounds satisfactory to me. It is unlikely to find its way into obstetric textbooks, because I do not plan to write one, and people who write textbooks usually do not read blogs to get new ideas. :-)

Dynamic Handling of Tocodynamometer

The well being of the baby during labor is assessed by recording the fetal heart rate and maternal uterine contractions during labor. The uterine contractions are recorded using a simple gadget called as a tocodynamometer, which is shown below.

The transducer used for this is strapped to the patient's abdomen over the upper part of the uterus. It has a disk projecting out from the middle of the maternal surface. There is a spring under the disk. When the uterus contracts, it rises forwards and compresses the spring. This mechanical energy is converted into an electrical signal, which is carried through a cable to the recorder, which writes on a moving strip of paper. The fetal heart rate is recorded on the same paper using another device.
The job of fetal heart rate monitoring is usually done by the Resident Doctors. Actually all transducers have to be strapped to the patient's abdomen, so that they do not fall down. They break if they fall down. Another reason for strapping the tocodynamometer is that the spring has to be compressed to a fixed level when the uterus is relaxed, and only then it can give an idea about the force and duration of the uterine contractions.
Once we were taking a round of the labor ward. I found a patient connected to a monitor there. The patient was holding the tocodynamometer with her hand, while the heart rate transducer was strapped with a belt. The Resident Doctor who was doing the monitoring was with another patient.
"May I ask why the transducer is not strapped to the patient's abdomen?" I asked.
She promptly replaced the patient's hand with her own. "The other transducer is strapped" she said.
I took the transducer from her and asked her if it was recording uterine contractions well. She said it was. I held the disk over the spring facing away from her and pressed it. The record immediately showed a powerful contraction which just would not go away, because I kept pressing on the disk.
"What a strong and long uterine contraction!" I said.
She looked suspiciously at my hand. "You are pressing on the disk" she said accusingly.
"Exactly" I said. "The same thing can happen when the patient gets a painful uterine contraction, or just holds the transducer tightly. She might let the grip become loose, which will result in loss of recording of the contraction. If you are holding it and someone calls you, you turn around and the hand presses the transducer on the patient's abdomen. That produces a false record of a contraction." I demonstrated what I meant. It did what I had just said it would do.
"Now I hope you understand why both the transducers should be strapped to the patient's abdomen."
I hope she understood it. I am hoping against hope she will do what I told her to do - after all there are many reasons for not following standard operating procedures.

T-Shirt Design to Reduce Maternal Mortality

Our people were so charged by the pep talk and valuable suggestions to reduce maternal mortality given in the maternal mortality reduction meeting (see my previous post), that they were rearing to go. They had a lot of suggestions on how to carry the message far and wide.
"Let us have bumper stickers made. They could read - Zero Maternal Mortality" one of them said.
"We could get BEST and State Transport to carry the message on the back of the buses - Drive Safely, Prevent Maternal Deaths" another one said. "And like they put next to the driver - Today is the Day of Zero Maternal Deaths."
"They write that in buses?" someone asked incredulously.
"Of course not, silly" came the answer. "They write 'Today is the Day of Zero accidents' next to the driver."

"That message for gynecologists about putting stethoscope in the ears seems important" a third person said. "Perhaps we could have T-shirts made to carry that message."
"We could help" one of the students said. "We have this annual college festival going on. There is a T-shirt design competition. If we give this theme, we could have a few good designs to choose from. I could do one right now."
"Please do" a lot of us said. Here is what he made on the fly. It shows the front and the back of the proposed T-shirts.

"Cool" the third person said.
"If we wear it to the maternal death audit meeting of the quality assurance committee, they will know we mean business, and will not harass us unduly" an optimist said.

Hand Position: Correction of Uterine Inversion

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

Iatrogenic Dystocia

I was teaching my postgraduate students 'Dystocia' when I remembered this story. For those who don't know what 'Dystocia' means - 'Dystocia' is difficult labor. It can be caused by many factors in the mother and the baby. For those who don't know what 'Iatrogenic' means - 'Iatrogenic' is some problem for the patient caused by the treatment of a doctor.
Some of the students were half sleepy - poor souls who work day and night without sleep at times. I decided to tell them this story partly to educate them and partly to wake the sleepy ones up.
'This happened when I was a resident doctor. There was an honorary Professor in the department. This one had a lot of rich patients in private practice. Some of the patients were foreigners. It seems they expected the Professor to deliver them personally, for which they paid well. If the Professor was busy elsewhere and an assistant delivered them, the payment would be less. A resident doctor from my batch was working with this honorary doctor. That day they were in the OT. There was a call for this honorary doctor. I can put down only the honorary doctor's part of the conversation as heard this resident doctor, who recounted it to us later.
"Oh, she has gone in labor, huh?"
"............"
"How much is the dilatation?"
"............"
"Full?"
"..........."
"Of course she will deliver if you let her bear down."
".........."
"Ask her to breathe in and out, in and out, deeply." (That prevented the patient from bearing down or pushing the baby out, we knew). "And ask her to cross her lower limbs and hold them tightly together." (That would keep the lower end of the birth passage tightly closed and the baby would not be able to come out, no matter how much the poor woman pushed). "I am on my way to the hospital."
With that, the honorary doctor jumped into the car waiting outside and rushed off to deliver the patient.
"What must have happened to that baby?" someone asked.
"Its head must have been compressed by the patient's thighs preventing exit" I said. "That could have caused injury to the head and its contents."
"Oh!"
"Yes, oh!" I said. "Nothing bad might have happened to the baby too. I call this 'iatrogenic dystocia'. When you practice after you qualify, I advise you never to do this."
They shook their heads.

White Noise

I had read that white noise was used as a form of labor analgesia. That was when I was an undergraduate student, and the the book was, I believe,  by Holland and Brews. I did no find it in other books during my subsequent reading. But perhaps it works. The nurses and resident doctors must not have read about it, but they seem to know all about it and they use it extensively too. When I take round of the labor ward, if one of the women is delivering at that time, I get fresh evidence of it.
"Come on, push, push, push" shouts one person.
"PUSH! PUSH! PUSH!" shouts another..
"बाई जोर कर, बाई जोर कर, बाई जोर कर" shouts a third person.
The main thing is that all three or six or whatever number of them shout their thing at the same time. The poor woman is with clenched teeth, her entire concentration on that phenomenal effort of pushing. I wonder if she hears anything in that state, and if she does, if anything registers. Even if it does, no one can make out the individual components of the white noise.
"What is the purpose of this shouting?" I asked during the ward round once.
"Encourage her to bear down" answered one Resident doctor.
"As if she can make out what they are saying" said an Assistant Professor.
"It is like the crowd cheering their hero in a game - cricket, soccer, boxing, whatever" said another Assistant Professor. "She knows all of them are on her side - are with her. That gives her strength."
"I think it is labor analgesia" I said. "The midwives have perpetuated it through all these years from time long forgotten."
"Does it work?" asked one Assistant Professor.
"God knows. It is actually causing a headache rather than relieving any pain" I said. "Perhaps that is how it works - like a counter irritant.. Causing a pain greater than the labor pain makes her forget the labor pains."

Amnioinfusion: New Concept

The credit for this post goes to an undergrad student. I was taking the prelim exam. At this time, the undergrad students are supposed to be all ready with their preparations for the final exam. They are given this exam for practice of the real thing that decides their future. There was this student who was presenting a case of oligohydramnios. He managed to convince me that his diagnosis was accurate.
"How will you treat her now?" I asked.
"I will treat her with amnioinfusion" he said after beating around the bush for some time.
"How will you perform an amnioinfusion?" I asked instead of saying 'great, you have done well'. I do that because it is my experience that a lot of people say the right word, but do not know more than that word in that context.
"I will infuse amniotic fluid" he answered.
"Where will you get amniotic fluid to infuse into this patient?" I asked trying not to show incredulity in my voice or on my face. I must have managed that well, because he went on to answer that one without any change in his expression.
"A preparation is available outside" he said.
"Huh? Who markets it?" I asked.
"I don't know who markets it" he said. I wondered if there was a hint in his voice to suggest that I should stick to academic questions and not ask questions about commercially available preparations.
"Is there a commercially available preparation of amniotic fluid for amnioinfusion?" I asked my Assistant Professor standing nearby with as straight a face as possible. "This student wants to use one for his patient of oligohydramnios." His MD dissertation had been on amnioinfusion. He looked at me for a second and grinned all over his face.
I could not spend any time educating that student because there were a lot of students left to be examined and time was short. I hope he reads on the topic before he appears for his final examination.

Medical Violence

The most common place of violence is in the movies. It is both general violence and violence against women. Going by media coverage and social media anger, the most common place for the violence against women would be Delhi and Mumbai, though by crime records it is anywhere in certain states in the country.
No one has talked about medical violence yet. That does not mean it does not exist. There is that occasional doctor who threatens to slap a woman screaming in pain in labor, unless she stops screaming. There was that House Officer a few years ago who had touched a woman's nose with the scissors he was holding while conducting childbirth, and said,
"Stop screaming or I will cut off your nose." She stopped, saved her nose, and now he is somewhere in UK. I trust he does not indulge in such practices there, or they would have deported him minus his nose long ago.
I have heard of House Officers who have slapped patients' thighs to stop non co-operation during childbirth.
"She was absolutely hysterical." the explanation would be given. "When I slapped her thigh (the only part nearby) she suddenly became co-operative and the delivery took place safely."
I had been aghast whenever I heard these stories. I thought nothing could be worse. I was wrong. Just the other day I heard another one that would beat any other story.
"He was Registrar when I was A House Officer" the story teller said. "He was quite rough on patients, many times abusive and at times violent. I remember two patients in particular. He had dislocated a patient's jaw once by slapping her face. The other one was given a broken finger. The reason was that they became hysterical with labor pains."
"Huh?" I was aghast again, this time more than at the previous times. "What does he do these days?" I thought he would have been stopped from practicing by some patient who went to a court against him.
"He is still around, practicing obstetrics and gynecology."
Lucky fellow and unlucky patients!

Chloasma - Radical Cure

She was a young woman in her second pregnancy. She was one among many in our outpatient clinic. But she was different. There was something distinctly unusual about her face.

"What happened to you?" I asked her, looking at her face.
"Doctor, I had this blackish pigmentation on my cheek bones. My husband went to a chemist, who gave him a cream that he said would cure me. I applied it to the pigmented area" she said.
"Ah!" I said.
"The skin just came off the next day. Then I went to the skin specialist in this hospital. He prescribed me some cream. Now I am much better after using that."
"That's good" I said. She had chloasma, and thanks to the chemist, she had no skin where there had been chloasma. There was just a raw pink area. It was a chemical burn, which was now thankfully healing.
"Will it remain like this?" she asked. I knew she must have asked the same question to the dermatologist too.
"It will heal" I said, avoiding to say what percentage of the original skin texture would be restored. "Did you not have such pigmentation in your first pregnancy?" I was wondering why she had tried such treatment only in her second pregnancy. After all, it occurred in susceptible women in successive pregnancies, and also with the use of combination type of oral contraceptive pills.
"No" she said. I thought there was some regret in her voice, though she did not voice the reason for that regret. She went away. Her experience reminded me of a popular skin preparation in market in my younger days. There used to be ads of that in the newspapers, claiming it cured all skin maladies.
"It removes all skin lesions" our dermatology professor had told us. It removes all skin it is applied to. naturally there is no skin disease left behind. Then we have to work on restoring the skin when the patient reaches us." Now I did not see such ads, but that or a similar product seemed to be in market.

Adhesive in Obstetrics

We have a few fetal heart rate monitors. We unfortunately have problems related to their use which outnumber them in a ratio of 2:1 to 3:1. The problems are not related to the hardware. They are related to the end users.
We were seeing our patients in the labor ward. On my way out, I saw a resident doctor who saw me at the same time, stopped in her tracks and ran back to the labor room. My sixth sense me go to the labor room, while I was wondering what I expected to see there. I found that there was a single patient in labor. Her fetal heart sounds were being monitored by this resident using a monitor. The transducer for fetal heart rate was held manually on her tummy by the resident, instead of being strapped with a nylon belt. I realized what the sixth sense had sensed. I had reason to worry about the transducer, because the quartz crystal inside breaks when the transducer falls down. It cannot be glued back. Replacing it takes a few thousand rupees, and a lot more number of months (not in thousands) going by the speed of work of the civic body workers.
"Who was holding the transducer in place?" I asked the resident. There was no answer.
"Was the patient holding it herself, was God's hand holding it, or the conducting jelly holding it?" I asked.
She did quick mental calculations, decided not to drag God into it, not lie since I was known to verify such answers by asking the patient about it, and said "The jelly was holding it".
"You have worked in my unit for 6 months. I think we both have failed in getting proper education for you. Or you would not do such a thing, knowing full well how to do it, how not to do it, and the financial and management reasons behind the method of using the monitor." I did not wait  for the conventional 'Sorry, Sir' and went away, because there was more work to be done, and no degree of training seemed to work on her.
The next day found me taking a round of the same ward. There was another patient there, and another resident doctor. The fetal monitor was next to the patient, not in use at that moment. I picked up the transducer out of habit, and inspected it. It was covered by the conducting jelly, instead of being wiped clean as was the requirement.
"Did the doctor check you with this machine just now?" I asked the patient.
"Yes" she said and indicated the doctor concerned.
"Doctor, why have you not wiped the jelly off the transducer after using it?" I asked, though I knew the answer. The answer was she did not care or she was too lazy to do it. She knew I knew the answer. She just picked up a piece of gauze and proceeded to wipe the jelly.
"If the jelly dries on the transducer, it does not work well" I told her. "The manufacturer says that it must be wiped away after use. Which post are you doing?"
"Third" she answered briefly. She did not enjoy conversing with me, I thought.
"If you have not picked this up after one year and three months, the chances seem small that you ever will" I said and turned away because there seemed no point in stressing myself over an impossible situation. On my way out, I saw the resident doctor who had let the jelly do her job the previous day. My right brain had an idea and I called her to accompany me back to the labor ward. We reached the resident doctor who had left the jelly behind.
"Please put you mask down so that she can see your face" I requested the resident doctor in the ward. She did so, confused. "Dxxxxa, meet Nxxa" I said to the yesterday's resident doctor. "Nxxa, this is Dxxxxa" I said conversationally. Nxxa looked as if I was off my rocker. If both of them were from the same batch, obviously they knew each other. I should have known that. If she had known me, she would not have been so confused, I thought.
"I know you must have met before" I said. "I am introducing you to each other for a new quality that connects you together. Dxxxxa left the transducer on a patient's tummy yesterday, held there by jelly alone. You left jelly on a transducer today to let it become a sticky stuff, so that for Dxxxxa, some other doctor, or you yourself can leave the transducer on the next patient's tummy without anything like a belt or anyone holding it safely."
If they cannot remember the procedure of fetal heart rate monitoring despite clear and repeated instructions, perhaps a dose of sarcasm will make them remember it. Even as I thought so, I knew I was hoping against hope.

Obstetrician Swordsmen

I had not thought there would be any confusion about operative steps that have been described in books. Now I realize time and again that I was wrong. The steps are often not learnt from text books, but from what a senior resident teaches the juniors. It is a chain in which one link goes out at the end of residency, and another one enters at the beginning. The knowledge base of the chain is carried forward, sometimes changed like Chinese whispers. When some of these residents become faculty, the science of Obstetrics and Gynecology changes.
The most recent example of this is as follows. A woman was undergoing an endocervical curettage and cervical biopsy under paracervical block. I had taught them how to administer that block, and I was secure in that knowledge. Unfortunately it had not been learned at all or had been unlearned. The woman was grimacing and moaning and was in pain. I investigated the cause and found that they had administered only half the dose and that too at not very appropriate place. I got the problem corrected and she settled down. That prompted me to conduct an in OT survey of how all of my people administered a paracervical block. The results are shown below.

Position of doctor	Volume	Position of injection	Depth of injection
1st year 1	10	4 and 8 o’ clock	2 cm
1st year 2	10	4 and 8 o’clock	2-3 cm
1st year 3	10	4 and 8 o’clock	2
2nd year 1	10	4 and 8 o’clock	Up to just below pelvic peritoneum
2nd year 2	10	4 and 8 o’clock	2-3 cm
2nd year 3	10	3 and 9 o’clock	2-3 cm
3rd year 1	10	3, 6, 9, 12 o’clock	2-3 cm
3rd year 2	10	4 and 8 o’clock	2-3 cm
Assistant Professor 1	10	4 and 8 o’clock	By judgment, varying from case to case, finally committed to 2-3 cm on forcing the answer.
Assistant Professor 2	20	4 and 8 o’clock	2.5 cm

All of them used 1% lignocaine, which was OK.  Only one Assistant Professor used 20 ml, all other fell short by 50%, which was not OK. Only one person used correctly 3 and 9 o'clock position. Why the others were stuck on 4 and 8 o'clock positions is explained by my theory elaborated at the beginning of this post. One was set on covering all bases and injected the drug at 12 and 6 o'clock too. All of them thrust the needle like swordsmen, deep enough to make a good job of it. Luckily no one thrust it right up to the hilt. I asked the same question to another resident doctor from another unit, to make sure that it was a phenomenon restricted to people in my unit. Her answer was similar, except that she thrust the needle for half its length.
"So it will be half an inch if the needle is 1 inch long, and 6 inches if the needle is 1 foot long" I said.
She made a face and settled on 2-3 cm.
"The right answer is1% lignocaine, 10 ml each at 3 and 9 o'clock positions, or 5 ml each at 4, 5, 7, and 8 o'clock positions, at a depth of 2-3 mm under the vaginal mucosa of the lateral fornix. Less drug or wrong position would not stop the pain, more than 3 mm depth would possibly puncture the uterine vessels and cause local bleeding and/or intravascular injection and complications like cardiac arrhythmia" I told them.

One Fetus Per Week

The sonologists had a busy time.
"Sir, this patient has undergone an ultrasonic scan three weeks ago. There was a single intrauterine fetus 5 weeks old" I was told.
"OK" I said. I sensed there was more, but could not guess what it was.
"They could not see the fetal pole that time. So they performed another scan after a week. That time they found two fetuses in the uterine cavity."
"Huh?"
"Yes, sir. Then they asked the patient to undergo another scan another week later, just to confirm which of the two sonologists was right. They took some time, argued a bit. The final verdict was three fetuses in the uterine cavity."
I was stunned. I had not known fetuses could multiply so late, and that too serially. :-)
"Now what?" I asked.
"Not the patient has refused to undergo another scan at the hands of those people. She thinks their technique or their machine or both together are causing her fetuses to multiply."
"In her place anybody would be scared. This must be the first case in the world literature. Why don't we publish it in a scientific journal?"
They had worked with me long enough to know when I said something that actually meant the opposite. They just grinned.

Impossible Situation

A young woman came to our outpatient clinic.
"Doctor, I think I may be pregnant" she said. "I performed a urine pregnancy test at home. But I am not sure of the result."
"What makes you think so?" I asked.
"There was one distinct line, and one faint line." she said and showed me the strip.
"It has two distinct lines" I said looking at the strip. "When did the faint line become distinct?"
"I don't know. May be I did it wrong."
I checked her up. The pregnancy was too early to detect by clinical examination.
"OK, we will perform the test again" I said. We got another pregnancy test kit, performed the test and asked her to wait. In the meantime another patient came for a similar complaint.
"Please get the test kit and come back" I told her. "We will perform the test."
She went away. After sometime she came back, with a test performed. It was a mess. Instead of three drops of urine, there was a flood of urine on the strip.
"Did you do the test yourself?" I asked her.
"No. The person in the lab gave me the kit and asked me to get it done by personnel here."
"Show me who did it" I said. She took me to the waiting area and showed me who had done it. It was our first patient. I was incredulous.
"Did you perform the test for this patient?" I asked her.
"Yes" she said. "She said she did not know how, so I did it for her."
Every time I believe I have seen it all, along comes someone who proves me wrong, and how!

Short Trial Of Labor

I recall learning by heart a very complicated and detailed definition of a trial of labor, when I was an undergraduate student. I read much more about it during my postgraduation, and some more subsequently. I heard a lot about a 'short trial of labor' from seniors, colleagues and juniors, but did not read about it anywhere. Considering the elaborate description of a trial of labor, there cannot exist anything like a short trial, nor a long trial. The duration of each trial is determined by a number of factors, and there are criteria about discontinuing trials, about calling them a success or a failure. Clearly a short trial of  labor exists only in a parallel obstetrics that a number of clinicians practice. Happily for them they are not called upon to write on evidence-based obstetrics. Unluckily for students, they become examiners and if the students stick to what they have learned from text books and journals, they can fail in exams at the hands of such examiners who probably believe such a thing actually exists. After all, have they not heard of it from their bosses when they were younger?
I conducted an opinion poll on 'short trial of labor'. Various answers received are listed below.

1. 'It is, um... shorter than a normal trial of labor.'
2. 'It is a trial to be terminated at the slightest indication of anything going wrong.'
3. 'It means a cesarean section is to be performed unless the gravida progresses really fast.'
4. 'If the woman does not deliver in two hours, the trial is said to have failed.'
5. '........' (this was the response of a lot of them).

My interpretation of the term is as follows.

1. It means a cesarean section is to be done based on one's personal feelings, but that does not sound right when one is in an academic institute.
2. One hopes that something will happen in the short period of the trial which will necessitate a cesarean section. On the other hand if it is God's wish that the woman delivers vaginally, she will have a rapid progress of labor and will deliver safely vaginally.