Chasing Gall Stones…

Old men seem to be attracting gall stone disease like the swine flu. Unfortunately, for them, they also seem to be progressing to choledochoduodenal fistulas (gall bladder bursting into the first part of the intestines for non medicos) far too often for comfort. They also seem to be ending up with us for laparoscopic cures. Of course it's good experience and it's something you don't get to see too much of in your career, so it was great in that sense.

The case we had was nice too. We could get the fistula separated quite easily and managed to suture off the duodenal orifice well. The gall bladder came out with some effort but was not a problem either. Then what? There must be something or it wouldn't have reached this blog, right? Right!

The stone which had passed into the intestine decided to be stubborn and play hide and seek with us. We knew it was fairly big (approx 6-7 cms) so it couldn't hide forever. We also knew that it was causing some amount of obstruction distally since that was what he presented with.

We managed to find it at the upper end of the jejunum and traced it all along till it was close to the umbilical port. We had decided to basically extend the umbilical port incision, exteriorise the bowel and take the stone out and completely close the enterotomy before repositioning it into the abdomen. Good idea right? 

The stone had other ideas. In spite of having held on to the bowel, it started slipping back once we extended the incision. We had left the grasper so we were trying to finger our way in and coax it out. The scared little stone ran far back and ultimately we could feel it no more. We had to reinflate the abdomen, and try and locate it again. Of course, we couldn't. It became agonisingly obvious that it had gone all the way up to the DJ (not me, duodeno-jejunal junction). We really did not want it to go further up to the duodenal anastomosis. We tried getting a head high, tried feeling our way to bring it down. We figured that we would need a gastroscope to try and push it down. 

As is expected in such situations, it was the middle of the night (as usual) and we did not have a gastroscope on hand. So, we had to call the endoscopy department and try and arrange for it to come in at midnight. The nurse who had the keys had, of course, left for home and had to come all the way back. We were told it would take half hour. We then started praying for it to come down, sang to it, did a little dance when we saw something filling up, stopped dancing when we realised it was just gas...(reminds me of infants smiling because of gas!).

Finally, the scope came. We connected everything, inserted the end into the mouth and just before we could do anything more, down comes the stone rolling out of the DJ. From then on, it was routine and we closed up around 2 am, with me returning home only to get sleep around 3.30!

Cosmetic or Fanatic

The world today amazes me. I realise that I am beginning to sound old and fuddy duddy types by saying something like this but I guess the change in perception of people towards people is just stark.

A lady who was to deliver her second child through a C section came into our path recently. What are surgeons doing with a delivery you might ask. Well, the thing is this lady was quite obsessed with her abdomen, in the sense that she wanted the perfect flat tummy that most people crave for. Towards this, she realised she had a swelling around her umbilicus which she thought was a hernia, and thats where we came in. Thats not all though, she also realised that having two babies made her tummy look like a stack of tyres so she also wanted a tummy tuck (liposuction), and she was quite adamant on this.

Without getting into the technical details of surgery, her previous pfannensteil incision was used along with a vertical one which went around the umbilicus upto the hernia. Only, there was no hernia. It was a perception of one, with lax rectus sheath being the cause. She delivered the baby (fortunately healthy), and got the tummy tuck under general anaesthesia.

The point in question is this: Would you rather take care of your new born baby and bother about how it looks or worry about how fat your tummy is going to look because you've had two babies? Worry about breast feeding or worry about staving off an infection because the surgery you asked for would need you to take antibiotics?? Are looks so important that you put it in the same league as having a baby??

I agree its a personal choice (even though it may be an unwise one) but this is a personal opinion. You'd have to be fanatical to worry so much about cosmesis!

Aloe Vera Condoms!

What a life the condom is having.

Starting as a material made out of skin and chemically treated linen, some reports of Goat's bladder and animal intestine abound (The Intestine Condom), moving on to rubber in the 1800s and latex invented in 1920. Latex condoms required less labor to produce than cement-dipped rubber condoms, which had to be smoothed by rubbing and trimming. Because it used water to suspend the rubber instead of gasolene and benzene, it eliminated the fire hazard previously associated with all condom factories. Latex condoms also performed better for the consumer: they were stronger and thinner than rubber condoms, and had a shelf life of five years. Until the 1920s, all condoms were individually hand-dipped by semiskilled workers. So, someone had touched what you thought was previously unused!

Finally we have the advanced materials we use now that allow them to be coloured, flavoured, ribbed, striped etc etc. Maybe its all a marketing gimmick, maybe it has some value to it. I was ready to accept it as something people would take interest in and at least it would cause them to use it more often preventing unecessary dieases and babies!

What takes the cake is that some genius has now come out with an Aloe Vera Condom. Aloe vera is having the year of its life with its use coming up in skin diseases, scalp conditions, stretch mark ablation, sun tan lotions and what not. I don't know if Aloe vera ever imagined it would be coating a condom. So now along with chocolate, strawberry, banana we also have aloe vera as an option. Its supposed to be very good for you as it is a natural product and has many beneficial properties when applied onto skin.

I'm not too sure whether this is a good thing for males, females or both. However, according to reports, its supposed to be very good for wrinkled skin (if you know what I mean)

The Great Toe Nail Removal

Toe nail removals need not always be routine and boring. I had to do a toe nail removal for a man who was borderline diabetic, neuronally fired (abused his nerves with alcohol for a long time), quietly fussy and intensly frightened about the situation.
While I could have done it at the minor OT in the clinic, I decided it was better to do it at a nursing home with sterile facilities and all the required instruments and machines for monitoring him.

The left great toe nail was clearly ingrowing and the nail bed had become infected and was oozing pus. There was no question that the nail had to go. At the same time, his right great toe nail was also ingrowing. It wasn't causing him any problem yet, but it would for sure sometime in the near future. I offered him the option of getting both done at the same time so he wouldn't have to travel again to the hospital and for dressings. Also, it would pain less now that it wasn't infected as opposed to the one that was. He said he needed time to think and I should start with the necessary one.

I gave him local anaesthesia, checked it and proceeded to remove the offending nail. To be fair to him, it must have hurt as local anaesthesia rarely acts well in places with infection because of the pus. The funny thing is that the block actually worked well as he had no pain immediately after the removal.

Now the question was whether we do the other toe or not. He said he wanted to think about it and we went out of the OT to the waiting room. His wife then cajoled him into a major guilt trip and how he should get it done if not for himself then for her. Unfortunately, by this time about half an hour had passed and the nurse had washed all the instruments. As is expected in these situations, he chooses that particular time to agree and we had to go in and do the other toe with a fresh set of instruments.

Bottom line: Waste of time (what should have taken 30 mins took 2 hours), resources and money (they charged for the new set of instruments again)

Aachoo! The latest cure for clogged sinuses...

A beautiful lady I know recently had a spat of early morning headaches which she attributed to nose blocks and congestion in her sinuses. Her clogged head would not let her wake up happy and lasted till late morning after which she was fine.

She decided to do something about it. As she was quite opposed to using snuff, she decided to be an innovative genius. She brought out her handkerchief, twirled it into a probity probe (sorry Harry Potter fans) and shoved it in her nostril.

What followed was about a thousand and twenty sneezes, each regularly interrupted with more kerchief shoving nose tickling goofy smiling antics of the woman.

Surprisingly though, the head cold (as people call it) with the clogging and headache all disappeared for the day. The bad thing about this was one that her eyes were watering like the ganges and two that poor poor handkerchief.

I know for a fact that this will now continue as the preferred choice for any kinds of cold and clogging till something better can provide quicker relief. Power to alternative medicine!

Holy Cow!

India is a mystical place. The people of India, even more so.

Today, while on the way to the hospital, I saw with my own two eyes, in broad daylight, a sight that might never leave my scarred occipital lobe (part of the brain that receives visual input).

A cow was walking on the road (yes it happens in India) and decided to relieve itself of its bladder pressure. To put it simply, it pissed on the road. Before I could say sheeesh and yuck, a man from across the street came running in, held his hand out to the urine, collected some, poured some on his head (as is customary in cases of ganga jal and other holy water) and proceeded to drink the rest. Yup. DRINK! Swallowed it all.

Now, although its disgusting to most, I decided to give him the benefit of doubt and research a bit. This is what I found.

There is actually a Cow Urine Treatment and Research Center at Indore. Its findings say that it is capable of curing diabetes, blood pressure, asthma, psoriasis, eczema, heart attack, blockage in arteries, fits, cancer, AIDS, piles, prostrate, arthritis, migraine, thyroid, ulcer, acidity, constipation, gynecological problems, ear and nose problems and several other diseases.

Cow's urine or Gaw-mutra (in sanskrit apparently) is one of the Panchgavya Amrit (Five Cow Nectar). "Panchgavya" is said to cure major diseases and is made up of five cow products, viz. milk, curd, ghee, urine and dung. (Wiki)

If one spoon of pure ghee is poured on burning cow dung (in homa) then they can produce one-ton of pure air, therefore ghee made with cow milk is used in sacrificial fires and havans (Hindu Rituals). All the 330 million Gods have cow as their prime temple being.

Cow's urine has actually been patented in the U.S. (US patent# 6410059 has been granted to Indian scientists for the invention on June 25, 2002)

Actually quoted on a website "Cow urine contains copper, which is converted into gold inside the human body."

The one I like best "The cow is a mobile medical dispensary."

To make it very clear on where I stand, "I do not believe any of this, but I'm open to people doing what they want"

What do you think? Would you try this as a last resort for cure to say HIV or Cancer??

English Etiquette at the Hospital

There's just something about guju/madwadi women in closed spaces, especially where silence is mandatory, that makes them screech at the top of their voice.

The other day I was fortunate enough to witness what I thought was the beginning of the correct english usage revolution in the above mentioned ethnic group. I was travelling in an elevator from the 10th floor of the hospital to the ground with a lady from the sect.

She was trying to explain to some of her relatives (I presume) how to get to the hospital. She was loud on the 10th, louder on the 8th (OT floor) and grew progessively louder as we reached the ground floor. Maybe she thought she had to complete the instructions before she got off the elevator.

She tried explaining it to the other end of the phone in gujarati but clearly the relatives were not familiar with the place. She then goes on to tell them that now she will say it in english and they should even write down the spelling.

She shrills, " Ess Aaaayy Efff Why" (S A F Y). " Aa english ma che"!

I rest my case.

Appendicular Hernia

Very interesting case.

This lady had an incisional hernia where her umbilicus should have been. She had undergone an abdominoplasty (like a tummy tuck / liposuction) someplace and had come here for the hernia which had recently become irreducible. The plastic surgeon who did the abdominoplasty obviously wasn't very good at his job because along with the obvious incisional hernia, he also managed to give her some really ugly dog-ears at either end of her scar!

Anyway, we went in laparoscopically and as expected we found a large defect with the previous surgical sutures cutting through the sheath. The contents were clearly bowel and we started reducing them into the abdominal cavity. As we reached towards the end, we realised that the lead to the contents was actually her appendix. It formed the engine that led the entire train of bowels to enter through the defect and lie in the subcutaneous tissue!

We started the meshplasty using our technique of unabsorbable sutures and a port closure needle. Somewhere between the 2nd and 3rd tie, the needle bent to such an angle that we thought it was broken for good. To make matters worse, the only other needle in the OT was unsterile, and the needle from our personal set was not with us at that point in time. We sent the 2nd needle for sterilisation and tried innovative methods in the meanwhile to try and continue the sutures. We tried using a Veress Needle (didn't work), intracorporeal suturing (worked for distant sutures but not for the ones close to the camera port and tackers.

Finally after prolonging for an hour unnecessarily, we got the second needle and finished the case in 3 hours for what should have taken us 1.

Om Mangalam Mangalam

Every surgeon at one point of time has done a dressing for a patient. Each will have a story about it. None will be as wierd as this one.

This patient was one of those if-you-touch-me-I-will-scream-with-pain types who thought even a simple dressing would hurt her oh so much. What needed to be done was simple and painless. He abdominal drain needed to be adjusted as we thought it was blocked or irritating some part of her abdomen. Open the dressing, pull out the abdominal drain by a cm or two and re-dress.

I opened her dressing and she yelped for her aunt to come and hold her hand. I put on a pair of sterile gloves and she almost threw a fit. She had a pundit (Hindu Priest) in her room! She tells her aunt to tell her pundit to chant a mantra (prayer) for her pain. I start cleaning. He starts chanting. She starts screaming. She can't hear him. She actually orders him to chant aloud so we can hear. My face contorted in ways I cannot describe. I felt like you feel when you've found out your girlfriend is a transsexual. I almost couldn't help rolling my eyes. People who know me know my reactions to such people. It's not something I can write publically. Damn!!!

Well, anyway, i finished pulling out the tube. I even asked her if it hurt. She said no, no, not at all. I wonder whether that was because it was never supposed to or because in her head her pundit was chanting mantras.

Doctor Libel?

First of all many many thanks to my fellow writer (author of What is an insight) and best buddy for the title(needed help with actual usage of the word libel, didn't want to get sued...pun intended).

Over the past week it has been brought to my notice by more than one source (thankfully readers of my blog) that I may be writing too openly about something that till now at least in India has been considered taboo. What goes on in a hospital, inside the ot should stay in the ot. What happens between doctor and patient must remain confidential. While I agree with confidentiality, I must impress that what I am writing in no way implies one person or the other. At the same time, while people close to me may know who I am talking about, for the general people who have access to this blog, they have no clue.

With the issue of whats going on in the hospital staying in, I must reiterate that this blog started off with the Municipal Hospitals and the standards in them with the hope of showing the general population the problems in there. While I moved on to better (private) hospitals, the problems continued albeit not as bad. This is why the blog continues to date. I think its not fair to not write about the bad things involved in medicine and only write about the good (even miraculous) cases and situations as that would give a wrong impression. One such impression already exists wherein Doctors are treated like pseudogods. There is no such person on earth. Doctors are just humans, not superintelligent, not supremely skillful, not even close to perfect. The fact remains that we are just a hard working group of people with the knowledge to heal and cure maybe 40% of the problems that can affect people.

If we as Doctor's don't learn to talk about our mistakes and shortcomings, be it at the hospital, in private practice or even in our heads, we will never reach the level at which we can truly say that we can help people.

The other thing that most doctor's seem to be afraid of is the malpractice law. My answer to that is that if you've done nothing wrong, you've got nothing to fear. If you have done something wrong, admitting it is the best thing you can do for the patient simply because that patient will have even more faith in you that he/she did before the mistake. So, what exactly are we afraid of?

At this time, what I ask of you, my readers (faithful or not) is to let me know whether I should keep writing about my experiences as they come or should I sugar coat them and write only about the victories and brush the controversies below the rug.

If you've never commented on the blog, this is the one time I really ask you to do so. Take the effort and let me know how you feel.

Continuing the Nightmare

In continuation with my previous post, I am glad to inform you all that the patient is doing well. She is still in the ICU but 4 of 8 tubes are out, she's not spiking fevers any more, she is tolerating jejunal feeds (feeds directly into the intestine through a tube) and she has got off the bed and started walking with help.

The ryle's tube (through the nose) is out. The abdominal drain was zero so it came out. The neck drain was harldy anything so that came out as well. Neck staples from the skin are also out. Since she is now able to walk a bit we also took out the urinary catheter just to be nice.

By no means is she back to normal. She's not even close. She still has an ICD in place and a subcutaneous drain. She has a subcutaneous infection at her chest site where we had to open up the thorax. However, compared to her situation I think she's doing really well and should pull through.

Now I can go back to writing my blog with a smile on my face!

Living a nightmare on a manic monday.

Manic Monday has taken on a new meaning. People have nightmares. We worked through one.

I started work on Monday morning at 8 am. I finished work on Tuesday evening at 8 pm. 36 hours! We operated non stop for 12 of those hours. All of which were at night. 10 pm to 10 am. One break around 7 am.

I will not discuss the case in detail owing its sensitive nature. What I can tell you is what I went through, how we managed and how I felt.

We started Monday with our regular cases which went off smoothly, other than a minor glitch which was solved on table itself. That was a warning. Towards the afternoon, we got to know that we might have to re-operate on a patient from out of town. She was on her way and was not doing well. We planned to do an X ray and decide if it was required.

It was.

We had a plan. Go in, find the problem area, do minimal handling, leave abdominal drains and come out. Murphy's law was in full force. Nothing went right.


10 p.m. We started laparoscopically, found the rent in the oesophagus, tried to get at it, tried and tried. The liver was getting in our way, the spleen was oozing blood because its capsule was stretched to tearing, the camera kept fogging up, the omentum was playing policeman in the abdomen sealing everything off. 12 midnight. We got a stitch in. It wouldn't hold. Cut through. We stitched again, it cut through again, and again. We lost length of the oesophagus in the abdomen. We were literally pulling it from the thorax into the abdomen through the hiatus. 1 a.m. I know this is getting technical but there is no other way to say it. Once we knew we had lost a lot of length, we also unfortunately knew that now we couldn't just leave abdominal drains and come out.

The only option now was to open. Open and do what? We weren't entirely sure this time, but we knew we had to open. We did. 2 a.m. We tried to reach, we cleared blood, we started giving blood to replace losses. We endoscoped to look from above and find the defect. We did. We took a stitch. It gave way again. We decided to try the circular stapler. 3 a.m. We struggled and managed to insert it somehow through the oral cavity for the orvil. We fired. It gave way. We now had two rents, one in the oesophagus and one in the stomach where the circular stapler was fired from. 4 a.m Boss was exhausted and running out of options. We stood there with our mouths hanging open, knowing that this was not ending anytime soon.

Stenting the oesophagus was an option. Somewhere in the timeline we tried to get hold of a stent. All the company people were sleeping. Stenting would not happen this night. 5 a.m. We asked for help cause we needed an extra set of hands. We called the on call R.M.O. (Resident Medical Officer) No answer. People sleep at 3 a.m. We tried calling the surgical registrar for the O.T. No answer.

6 a.m. Blood pints given 4 FFP 1. We needed help and we knew it. They say a great surgeon is one who knows when to call for help. It was decided to do a thoracotomy and get the oesophagus through the chest and anastomose (join) it to the jejunum (intestine) bypassing the stomach.. We needed a thoracoscopic surgeon and we called for one. The one we called said he had prior commitments later that morning but would come in at least and also advised us to call one more surgeon so that in case he had to leave, the other could take over. Smart idea. I respect that man and this was just one more reason to. We called and the other thoracic surgeon also came.

7 a.m. My first break. My anaesthestist watched me falling asleep on my feet and rightly told me to go wash and come back. I did. Ate breakfast which was a roll ordered last night for dinner. Had to get something in for energy.

The surgeons had arrived and taken over. Literally. We were too exhausted to be the lead team. We assisted. Chest cut, neck cut, oesophagus mobilised, nasogastric tube inserted. The tube came through the food pipe into the abdomen. What more could go wrong. We were no longer flustered. We just continued on instinct.

10 a.m. Skin closed with 4 drains. One ICD for the chest, One abdominal drain for the abdomen, one neck drain for the neck, one subcutaneous for the wound..

Unfortunately, the day did not end there. The regular cases posted were to be operated and we had commited to them so we did. It took longer than normal but we did it. 8 p.m.Finally we were done.

If you get nothing else from this post, get this. The level of respect for boss has gone up skywards. He just did not give up. I pray that she makes it. She's in the ICU now. Will follow this up once she's better (fingers crossed)

4 for the price of 1.

Scheduled for a lap. sleeve gastrectomy, a patient of ours was given accomodation in day care wards which is basically 4 beds in a room, fair enough for day care where you expect to leave the hospital in a day. The reason for this was that the class he had opted for which was a single room was full and so were the deluxe rooms. He was told that as soon as the room becomes available he would be shifted there. It is now his 3rd day in the hospital and he still lies in the 4 in 1 room. As luck would have it, his bunk mates consisted of the following:

The first came for a minor surgery and left the same evening.

The second was in for his chemotherapy. His relatives decided to wait with him till the chemo injections had run in. This was to be till 2 am which led to them watching tv till then to keep awake thereby keeping our patient awake as well.

Just when he thought it was finally done, in comes number three who had arrived from Iraq at 4.30 am and brought with him a bunch of relatives all speaking in arabic with their volume louder than the tv could possibly go. Our patient did not sleep very well.

The first thing he said to us this morning was not about his discomfort from the surgery he had yesterday, nor was it that he was hungry or thirsty (he was nil by mouth) neither did he say anything about the machine compressing his calves. All he wanted was to change his room. One that he had paid for. One that cost almost double. One that was not available when he got admitted. One that is not even available now as I write this.

The most innocent but relevant question was asked by his wife: If the room we wanted wasn't available, could we not have postponed the case? Could we not have waited till that class became available before admitting him and lastly could we not have discharged him if he didn't get the room he wanted?

I guess we all know that answer to that but I won't write it just yet!

Asses can be stubborn!

Sometimes, I think medicine is just being re learnt and that our ancestors knew everything there was to know, without the genetic testing and millions in research being spent today. All they did was study nature.

Take for instance the fact that Asses are the most stubborn creatures out there! Now, I know you're thinking what the hell does this have to do with medicine. I'm getting there...

A Pilonidal sinus (a small opening at the cleft of the buttocks which usually results from hair in that area getting into the skin and causing an infection and a break in the skin) is an incredibly intelligent disease which chooses that particular region of the body which would be the most stubborn to heal (namely the Ass). It is more common in males (more males are asses than females), has been known as jeep's bottom and truck driver's disease (these particular male drivers are known to behave like asses) and occurs in hairy young men and hardly ever once you cross the age of 40 (need I say more).

Over the years, I've seen patients with pilonidal sinuses getting operated, choosing conservative treatments, trying ayurveda and homeopathy, lasers, photocoagualtion, cryosurgery and everything else you can think of. It just does not heal and though the recommended treatment is surgery, there is a 20% chance of it recurring. This increases if you close the wound. So what I'm saying is that it needs to be left open to heal, which can take about 8 weeks. 8 weeks of discharge, slime, pus, hair, blood with no riding on a bike or driving a car. Stubborn isn't it.

Funnily enough, the thought that came to my mind when I first read about it was whether the ass in humans was named after asses in nature based on this disease? Another thing, asses almost never ever suffer from pilonidal sinuses. So, who's the real ass here??

IBD - Inflammatory Bowel Disease / Idiotic Brainless Doctor!

Coming off from my previous post on P.U.O. wherein I fully supported doctors saying they did not know what to do, this week came a rather unpleasent situation wherein a Doctor did not know what to do even though he should have. While P.U.O. is an unknown entity (in relative terms) the fact that so many Doctor's seem to be shying away from their responsibilities when it comes to emergency situations is a trend we need to nip in the bud.

Someone's mother is suffering from Ulcerative Colitis ( a part of inflammatory bowel disease) in which there is tremendous suffering caused by numerous ulcers in the intestines causing fair amounts of bleeding and subsequent anemia. This mother was diagnosed with it and was under the treatment of some doctor at H.H. Unfortunately for her, she lived in a distant suburb (even further than the regular suburbs) approx. 2 hours away from H.H.

When she became seriously ill, she was taken to a small nursing home for her complaints of severe anemia and bleeding last night. The doctor there told her to go back to H.H. and get admitted immediately as the situation was critical. I respect that opinion, as sometimes these emergencies cannot be handled in smaller hospitals.However, as luck would have it, there were no beds in H.H. free and numerous calls around the city couldn't arrange for one in that particular hospital. In this case, the doctor should have made alternative arrangements for admission at a bigger hospital elsewhere, more importantly close by and not 2 hours away.

The advice given was wrong to begin with, because if it was an emergency, how was the patient supposed to travel 2 hours in Mumbai traffic to reach a hospital. The daughter who works with my wife called me up for help. All I could think of at that time was to get her admitted to any reputed Intensive Care Unit around her area at that time and control the situation following which we could wait for a bed at H.H. where she was originally being treated and her history was known.

The shocker came when she told me that the doctor who had advised her to go to H.H. was himself attached to the wok hospital branch in her area, but he said she couldn't get admitted there as there was no gastroeneterologist at that hospital.
The reason this is shocking is this, (all gastroenterologists reading this may comment here) -  What exactly is a G.E. doc gonna do in an emergency when all she needed was supportive care and monitoring of her anemia and extreme weakness. She could have been stabilised and then a call could have been taken as to where to shift her.

That is exactly what I advised her daughter to do and fortunately she was educated enough to grasp the situation and handle it well (unlike the doctor).Point being made - Think logically and patiently, don't just get the patient out of your way because you think her situation is bad. Help, compassion, understanding and most important support to relative is what makes a doctor, not a diagnosis of emergency and referral to a higher centre.

Pyrexia of Unknown Origin (P.U.O.)

A fancy way for Doctor's to say they don't know what is causing the fever is Pyrexia of Unknown Origin or P.U.O. When we say it to our patients, it makes us feel good about ourselves, in the sense that we have at the least given them something and proved that we are on the job. In reality, we know just about as much as the patient's relative at that point of time. The relative's guess will probably come true in the end. The only difference being that we will get the answer at the end of the day and the relative will speculate.

I, unfortunately, had the experience of being both the doctor and the patient in terms of P.U.O.

Now, you must understand that it takes a hell of a lot of guts for a doctor to say he doesn't know what is wrong with you or what is causing the fever and the reason for that is simple. Our psyche in India is such that if a Doctor says he doesn't know what is going on, we head off for 2nd and 3rd opinions and when that doesn't satisfy us, we change tracks completely and go to the homeopaths and ayurveds! I have nothing against alternative medicine other than the fact that it is not an exact science in the sense that most of it relies on general build up of immunity and helping the body battle the problem on its own. While this might sound like a good thing, in most cases it is not. There is usually a particular cause for a particular problem, even if it is labelled as P.U.O. initially, and the doctor will find that cause and treat it specifically leading to resolution of symptoms and signs.

Back to the problem at hand. While being the doctor for a P.U.O. patient, I was at the stage where I was to say that I don't know what is cauing the fever. I said it as if it was the most pausible explanation in the world and it should satisfy the patient. For the initial few days it does. Then its upto the doctor to realise that we need to order a few tests to find out exactly what the unknown origin is. We did that. Initial tests were the usual blood counts and liver profiles followed by a blood culture which finally gave us the answer. Typhoid, enteric fever, typhus, salmonella whatever you want to call it.

Soon after that, I had the fortune of being the victim of P.U.O. I say fortune because that would be the only way I would realise the meaning of the sentence given by docs to the patients. Its pyrexia of unknown origin I was told. Being a doctor it didn't make sense to me. I wasn't ready to accept it. What do you mean unknown origin? There has to be a cause. My wife was even more vociferous! Do some tests, find something. There has to be a cause. We did the blood tests, we did ct scans (I was coughing violently), we did an ultrasound (abscess) we did everything and came up with the answer.

The point I'm trying to make here is this - If we as doctor's are sure we are going to get to the answer in the end, why must we give some bullcrack about fancy latin sounding Pyrexia of Unknown Origin to patients when we wouldn't like to hear it oursleves. Secondly, why must we as patients not have enough faith in a doctor to take his time and figure out what is wrong, instead of houding him every hour with temperature updates and the ever lasting question...what is it? what is it?

If our forefathers were to be asked, they would blame it on technology and stress and hectic lifestyles. I think they would be correct. We are in an age of instant updates, live chats, google wave, skype and we want instant answers and instant solutions. This is the problem, this should be the solution and I should be up and about tomorrow. Sometimes, thats just not how it works.

P.U.O. is a way of our bodies telling us to slow down and take time off.

SILS Sleeve Gastrectomy

On 14th September 2009, the CODS (Centre for Obesity and Diabetes Support) team of doctors created history at the hospital by successfully performing the first ever true single incision laparoscopic surgery (SILS) for sleeve gastrectomy in the whole of Asia. I was fortunate enough to be part of this team!

The SILS procedure is one of advanced laparoscopy wherein a single port of entry is devised using a special flexible port so that we can enter the abdomen through just one incision on the umbilicus and perform the surgery which would otherwise use 5 ports.

The advantages are immediately evident:

Single port (I can't emphasise this enough)
Less pain
Less recovery time
Obviously better cosmetic outcome
Done correctly the scar from the single incision hides within the umbilicus so virtually scarless!
Absolute boon for young women who need surgery but don't want it to be seen.

For the other side of the coin (and there always is one), it is marginally more expensive (should not be a problem for the kind of patients we're targetting) and requires a learning curve that would be greater than regular laparoscopic surgery.

It was tough, it required skill which my boss very capably handled and it required patience which I think came to the team knowing that we could become part of history.

We have had the company confirm that this was the first of its kind in Asia. We know that other surgical procedures have been carried out using the single port and have been published as well. We know that in the States this procedure is already on the way.

Keeping all this in view, We are all still quite damn proud to be the first in Asia to do what we did because we know that what we did was technically far superior to the other procedures done so far and its only a matter of time till we catch up with our compatriots in the States.

Bottom Line: We did it first!

This is a link for all those who can bear to watch.
Click here to You Tube It!

Squeamish people can stop reading here. Attached below is the picture of the port used and the final appearance on the umbilicus which will be difficult to find in about 3 weeks.

Touring Mumbai Again

For all those who thought Bhilad was something I did as a one off instance, let me tell you about the wonderful day I had touring all areas of Mumbai by almost all means of transport.

The day started with me taking my bike to Sea View Hospital, parking it in the basement, taking rounds quicker than I ever have and running off for the next stop. Hospital for the Stars was reached by traveling in a local train from Charni Road to Bandra. From Bandra, I took the cheap public transport option - auto rickshaw to reach the hospital. All good so far. Did 2 hysterectomies, at some pseudolunch at the hospital and left for the next leg of the journey. This was to be from Bandra to Thane and was done with the car. We had a case there which was a hysterectomy and that took its own time as the instruments and equipment were meant to be ours and that takes time to set up.

We finally left for our next stop around 5 in the evening. This leg was to take us to Bhiwandi from Thane. Thanks to fate which makes it a point to jab you in the butt ever so often, we ran into a huge traffic jam on the highway which delayed us even further. We reached only after 7, 2 hours for what is usually a 40 minute journey. We got some food at Bhiwandi as it was 'Party's' house and hospital we went to.
From his nursing home I quickly took a 15 mins detour and went to visit my old friend and room mate from college Dr. Bhatinda!

We finally left Bhiwandi around 9 pm. Schumacher's reincarnation drove like he is used to and we managed to reach saat rasta around 10.45 which is a really good feat. This was to mark my last bit of traveling for the day, for we had decided to go for a happy budday party at phoenix mills on this very night.

My night finally ended around 2 am with the final drive of the night being in 'Rachel', taking us faithfully from phoenix to home. Oh and yes I had to get up and go to work at 8 am the next day!!

Snitz!!!!

We were supposed to have a really straight forward Lap. Cholecystectomy this afternoon. It was a case of BawiDoc who generally never comes in but expect our boss to come in and do the work inspite of us being there.Bawi doc unfortunately works only with Snitz n. Informal,(snitz) a person who is really irritating.

This case turned out to be slightly more difficult than normal, but not something we would not be able to handle without boss. The Snitz, however, starts getting ants in her pants after about 45 mins, saying why is it taking so long, maybe we should call sir, should I call bawidoc etc etc to which all replies were no.

The Snitz then slyly goes outside the ot and comes back in about 5 mins. A couple of minutes later bawidoc's face is at the glass in the door looking in wondering whats going on. We reassure her that it is a difficult case and it will take some time but we do not need to call sir. She goes off and we continue our task of getting that Gall Bladder out! Mrs. Motivator is now beginning to lose patience, which is quite a rare thing.

The Snitz over the next half hour goes on and on about how we should use a wash so we can see better, maybe we should use only and iv set instead of a TURP set for the wash, we should clip the artery beforehand so we can then see the duct, we should call sir (again). Mrs. Motivator is almost ready to jab a scalpel into the snitz. She even had the audacity to go out again, (assumption here, but really the only possibility), tell bawidoc to call sir on her phone, gets the phone in and puts sir on the loudspeaker. We calmly (barely) proceed to tell sir that we're almost done and he does not need to worry about anything. Mrs. Motivator is almost ready to jab a scalpel into the snitz.

We finish the case with the feeling of having gone through an examination of our skills. Mrs. Motivator who is usually very very very very (you get the drift) cool and composed is about ready to buy a voodoo doll and stick some pins in some unmentionable places. She even went on to say that the only decent nickname for the snitz would be one of the B words!!!!

Swain Flue

A couple of days ago, I was to travel to the state border to a small town called Bhilad, which is next to Valsad (both of which birdy refuses to believe, exist) to perform surgery there.

When you travel to places you've never heard of before, you know things aren't going to go smooth during the day. The start was horrid with the hospital being unable to find our instruments which we needed to take there. Boss' driver, Wireface. had sweetly forgotten to have them picked up the night before. Well, the one box that we found was lugged by be by local train to a predestined spot where we were to meet and commence our drive to Bhilad.

The drive was a fairly nice one, sure some traffic with trucks driving in the fast lane, but green like you wouldn't believe possible, almost forest like and smooth highways.

When we almost reached the Gujrat border, we came across a check point at which was boldly printed, 'Swain Flue Check Point' in bright red. Not only did they spell really badly, they almost stopped no one crossing it. We had a good laugh at the sign and reached the hospital soon after, where we proceeded to tell the locals about it.



As the day was supposed to go, it turned out that the docs posted at that check point were from the very same hospital where we were to operate.
Anyway, the surgery went off well and they insisted we have lunch with them and see the new farm house that the doc was building for himself. The way to the farm house was like going through a jungle where we saw this huge one foot lizard. As the day was supposed to go, the lizard died under one of the car tires!!



Lunch was amazing with desi Murg (village chicken), Paplet (pomfret) and Mutton Kebabs....Yuummmm The house was really great with the hall ceiling being at 2 floors height, which really is just a huge thing to have so close to the city.

All in all a great experience and came back without Swain Flue to boot!

The Beard Mask

I've been looking for a topic to blog about for the past few weeks and I just couldn't get something interesting enough to write about. I asked on the web, questioned friends I bumped into at the market, looked for inspiration at the office, watched for signs in the OT but nothing came to me.

Until one day, when I was changing in the operating room and went to grab my cap and mask. I saw a rather unique looking invention. I'm sure this must be an Asian find / discovery / invention / contraption or something. It was a mask with a veil, grand and green, extending from ear to ear, with strings attached, and quite wierd.

At first I didn't understand it and let it go. When I went in to the OT for the case, another doc walked in after sometime as a spectator. Now, usually we are too busy looking at the screen to look at someone who has walked in, but as luck would have it, I turned. Inspiration struck with the force of lightening (bijli even), and I realised that I would eventually write about it.

There he stood, looking quite innocent, with his face covered in a cap and mask, only it was the Beard Mask! It completely hid his face leaving only his eyes uncovered. What a wonderful invention. In the world where people are looking to sue for every possible mishap and incident, here is something that would finally allow doctor's sporting beards to operate without actually having to tie it up in a rubber band (painful) or worry about whether it is long enough to reach the table before they do!

It truly was an eye opener. I will post a pic of the same for people who have never seen it (maybe alongside a regular mask even).

Laughing Hyena

About a week ago, I came across a patient who had met with a motorcycle accident and came frantically to the casualty, brought by his dad, with a rather ugly gash on his left heel.

It was not too dirty and was fresh so I thought we could take sutures and let it heal in peace. He agreed, and we went to the minor OT to get this done. He was a rather young fellow, must be in his twenties, so I thought a little pain won't be a hassle and went on to explain to him how I would give him some local anaesthesia and then take the stitches after which he could go home and rest for some days before coming to take the stitches out.

From the minute I took the syringe in my hand to the last knot on the dressing, this guy went on to laugh like a hyena or jackass or something that makes a funny funny sound while laughing, baring all his teeth, confusing the heck out of me as I didn't know whether his feet were ticklish or it was his way of dealing with the pain.
Well, I thought that it must be the pain and let it go.

This morning he came back to remove the stitches. No local injections required here. As soon as I started cleaning his wound before I could even get the instruments out for removal of the stitches, he started with his laughter again. I wish I had an audio clip to put up here but I don't so let me try and write it out the best I can. It sounded like Aahhaahhaaheeeheeehaa Aahhaahhaaheeeheeehhhaaayaaa repeated relentlessly.

By the time I went with the scissors and finished the job the minor OT was filled with laughing sisters, ward boys and me....Oh and the patient of course. Funny thing, he didn't seem to mind, just laughed it off (excuse the pun)

Corporate Efficiency or Losing the Plot?!?!?!

The past week has been a revelation in terms of corporatization and efficient productivity. We've been on a roll in terms of planning plans, implementation of plans, installing various means of easing our lives (or is it complicating our lives), sending professional sms's, getting investigations organised etc etc.

So, everything is getting computerised, which is a good thing in terms of the amount of trees we may save in the end by sparing paper. The system is that we are trying to get all the pre-op reports delivered to us by email. What this amounts to is that the patient has to come meet us once, his/her first visit, decide what surgery he/she wants to do, talk about the payment and leave. Then, we send someone home to collect blood, send the contact details of the patient to the investigations lab, and vice-versa so they can go and get their X-rays, USG's, etc done there if needed. Everything comes back to us by email, we go ahead and schedule surgery, the patient gets admitted, operated the next day, discharged the next and the story repeats.

Now, in all these major events in the patient's time with us, the doctor is seeing the patient a grand total of once before surgery, once during surgery (maybe if we reach before anaesthesia induction) and once when we tell the patient all if fine and its time to go.

Where is the doctor - patient relationship in this? What happened to talk to your doc and let him know your feelings? What happened to half the healing that happens only on talking to your doctor? Where is the 'connect' that is sooo important that we have ethics committee's telling us spend time listening to the patient?

I think we're losing this very important quality that makes patients want to come to doctors instead of us having to go to them. In the corporate world, time is money, so this system would work, as it leads to the best possible use of time and resources. No doubt about it. However, in the medical world, time is not as much money as a patient is livelihood! If you don't have patients coming to you and 'Bonding' (to use a word my wife has made me understand, thankfully) it's just not going to work.

Let's see how this goes. Any inputs are welcome.

Bombs away.....

Hello hello.
Here's the latest in the world of obesity surgery. We just did a sleeve on a guy weighing 201 Kgs (442 Pounds). Now this guy is fairly young, smokes, drinks, and obviously enjoys eating. Unfortunately for him, he is short - 160 cms which is roughly about 5'4". I wuold urge you to streeeeetchh your imaganation to view this person in your third eye (chances are he won't fit)

The question in my mind is that most people get overweight and start doing something about it (gym, walk, diet something). What was this person thinking, going on drinking, smoking, eating etc etc.

The answer I think is more mental than physical. By the time they hit 120-130 kgs they've given up hope on ever losing weight, running, sleeping well, enjoying life and the only thing that gives them pleasure is drinks and smokes (lets face it you don't have to move too much for either of the above)

Now that philosophy is over and done with, let me tell you the problem I had which brought this particular case to the blog. I was to insert Jonac suppositories into the guy (pain relief). For the uninitiated, a suppository (looks like a white melted torpedo) goes into your rectum and is absorbed from there providing good and sustained effects. This guy was really big see, so he would not be done with one but needed three. The problem I had was like entering a dark damp cave with no end in sight. By the time I could actually find the rectum I was in upto my wrists and basically feeling my way through the process. It was not a happy moment, let me tell you. To be honest, I was still wondering, as I washed up for the case, as to where exactly did I put those damn torpedoes.
Fortunately for me, he wasn't complaining of pain after coming out of anaesthesia so they must have hit the target!
Bombs away.....

My Left hand works...

Forgive the bulk posting but till I learn to use my new phone correctly the posts will come as and when I have time and the time is now.
The other day we were at the hospital of the stars and were doing one of those hysterical hysterectomies. Since the usual docs were unwell, two of us needed to wash up as opposed to only boss as is usually the case.
Mrs. Motivator decided that she was too sleepy that day and makes me wash up.
I was to hold the camera in my left hand and a myoma screw in my right.
Started off easy enough as most of the times all you need to do with the screw is just hold it in one direction or the other.
The camera in that hospital is one for the stars though. It has its own set of tantrums with the light cable pulling it off to one side or the other whenever it feels like it. So the camera becomes left tilted or right tilted depending on where the karmic cosmic forces are biased at that point of time in the universe.
When that happens, one can easily use the other hand to hold the cable and right the wrong or left the right (excuse the pun couldn't help it haven't cracked a bad joke all day today). However, in this case the left hand is tied up right. With the screw it was managable but when time came to suture the defect in the vagina, retraction came into play and it was a whole new ballgame. Retract bowel, retract bladder, right camera, left camera, clean lens, suck fluid, show needle tip, show suture end all in a matter of 3 seconds!
It was managed with sweat pouring down the forehead (mainly for effect, no real sweat like Dr. Broadwalk a couple of years ago: Ref older posts)

At the end of it all, boss casually remarks that finally my brain is beginning to understand that my hands need to work independently of each other. So, there it is folks....my left hand is starting to be independent....and cramping in protest even as I type this......

The Core

Its been 3 months now and I've sort of settled into the new workplace without much of problems.
Mr. Gottogo has had to go!
I'm not going to elaborate on that as we have a strict confidentiality policy and I don't want to be the next fake IPL player types.
I still haven't introduced the core of our team without whom I think we would just be a bunch of surgeons going about our day to day surgery. For lack of a better name I shall call this person 'The Core'. As and when I come up with a better name that is not hanigarak to my well being I shall update.
The Core can be perceived by many people to be many things. A go getter, a driving force, quick decision maker, strong headed and yet adjustable with a perpetual cold as of now.
For me to write so favourably towards the core, I must have a good reason and I have plenty. The core has taught me the importance of public presence and appearance, of marketing and strategy, of planning and execution. Now I was tuned into all this before but I never laid stress on it as much as I am doing now. So much so, that I think its one of the reasons the MBA bug bit me again and I started doing my research on that front.
However, in case I am given the chance to stay here in the long term, I don't think I need to worry about an MBA but should focus on perfecting what I am learning now. This includes not only surgery but presentation, appearance, conversation and overall business leadership.

To the core in particular - I hope this is enough flattery to get my permanence on a fast track and for me to be in your good books at least for the coming months.
In case it isn't, let me know what was lacking so that when I write about boss I miss out on nothing.

Till later

M.S / M.B.A.

It has been an interesting last week.

It started with the workshop we were to hold for bariatric surgery. Monday and Tuesday were the designated days but the action was unfolding about a week before that where we were busy trying to set everything up well.

I was up to my ears in work, which included printing, designing, artwork, writing, proofreading, logistics, etc. etc. Basically anything but medicine; that part was thankfully handled by my colleagues...Mrs. Motivator and Mr. Gottogo. To be honest, if I had to do both I would have probably faltered somewhere. Although I enjoyed doing all the extracurricular work, it did get me thinking. Maybe I should get up from my lazy fat cushy backside and do what I know I can if I try hard enough. Get an M.B.A.

Being in the interactive information superhighway era that we are in now, I decided to put up my ambitions on everyone's favourite social networking site. The response was startling albeit pleasing. Firstly, I never expected so many people to read what I wrote, thereby reinforcing the fact that facebooking can be dangerous. Secondly, I was astonished at how many people thought I could actually do it. Thirdly, I began to realise that even though I may be good at doing things when they're to be done just for the heck of it, doing it in the form of a syllabus could be beyond my reach as I don't react well to guidelines!

As of now the idea remains just that....an Idea! Maybe I should act on it; maybe I should concentrate on one thing at a time...who knows?

On the lighter side, I finally have a name for our nutritionist that she herself provided me by doing things in the way only she can. From this day forward, she has been christened as "Mandakani"

Anyone who needs reasons for the above must get off their lazy fat cushy backsides and either comment here and ask or make that dreaded phonecall that we all say we will make but never do!

Hopefully by the time I write my next post we shall know where the management question has reached. Till then....

Human Morcellator! Watch out uterus...her she comes!!!

Hysterectomy is a procedure in which you remove a lady's uterus. Usually the uterus is small and comes out willingly through nature's birth canal (yes yes Vagina)
Sometimes though, the uterus will be too big to pass through. Here again, as is the trend with human beings, we interfered with nature to create a cesarean delivery for the larger than life uterus. We created what is known as a Morcellator. This evil little device is a machine which rotates with a blade and carves out slices of the muscle tissue that makes up the bulk of the uterus to take it out bit by bit from the ports we use in laparoscopy.

So, one day we were in the "Hospital of the Stars"(will clarify on request), doing what we do best...helping people do laparoscopy, when a particularly stubborn Morcellator refused to do its job properly. There we were with a fairly large uterus inside a somewhat small abdomen with a smaller vaginal opening which refused to morcellate with that darned machine.

Doctor's are known to be people who don't give up easily....I think its something we learn while undergoing medical training in our colleges and during our internship, because if you give up then you just can't make it in this business. So anyway, in walks a lady doctor who earns the title of this blog. Boss, (who I'm considering calling Woody but think its too impersonal and has nothing to do with Woody Allen but is just as famous) cracks one of those cracks that make the entire room reverberate with laughter. He calls her a Human Morcellator becuase she has this uncanny ability to remove such uteri from the vagina by a crude process which involves a lot of pulling, tugging, slicing, shaving and what have you!
She proudly accepts the fact that she can do it. Its now an ego issue you see because she has been throned on the proverbial tree of chickpeas (colloquially known as Chane ka Jhaad).

New Hospital, New Work, New People, Same blog

I've changed my place of work yet again. I know its been too often now, but when opportunity knocks....I tend to grab it by the balls!

I am now officially a fellow in advanced laparoscopic and bariatric surgery, closer to home, better work environment and more academic than before. I was thinking of creating a seperate blog for this seeing as I could do some damage with inflammatory lines but I think it will be taken in the spirit intended, so we shall continue with this one.

I should have a lot less emergency work here but it should be more challenging work nevertheless. We deal with obese people all the time and I'm beginning to look at people walking on the streets and saying...hmmm we could operate on that one.
Its surprising how many people have gone from overweight to obese in the last five years. Either they have no idea what recession is or they're trying to eat their way through it.

We have a full fledged team here and that means more people to write about and more bloopers to be committed. Our nutritionist, Miss Mandakani, aka Konkan Sundari aka Ratna ki Rani (she'll figure out why she's called that) is obsessed with photo's of herself and losing weight by July. My colleague fellow, Mr. Gottogo, will not stay 5 mins more than he needs to, but he's probably got a reason for it. The senior member, Mrs. Motivator, loves dogs, reeks politeness and always encourages us, will soon be fed up of being nice to people(or so I think). Our anaesthetist, Miss FBaddict, cannot get enough of the fact that the best invention in recent time has been that facebook is accessible on the Blackberry. She is excellent at her job, always pushes us to do more for ourselves, lives life queensize and is going to be my source for novels to real. The boss, is an established name in the industry and shall not be written about too much for fear of losing my job...hehehe.

Now that we're done with yet another introduction to work places, we shall have something better with the next blog, hopefully.

My Parents don't love me....

Now that I'm at HH I expected a bunch of nice interesting cases to write about but Mumbai is too full of stupid people for them to be only interesting. So, this one is interesting but its even funnier.

This young guy comes into the casualty, full hero type, walking in with one hand holding the other forearm and proudly announces that he has cut his hand.
We take him onto the minor ot table and open his dressings to find out that he has 'very cleverly' managed to slice through his forearm muscle into an artery that fountains like the hot springs of varanasi!

Questioning reveals that he cut his hand because nobody loves him and he is fed up and his parents don't care for him...as told to the police. Now, people who know me will understand that I don't take this bullcrap as being true at any given point of time and there has to be another reason for stupidity in teenagers...most likely girls. I put on my rudest, meanest tone of voice and ask him flat out, "When did you fight with your girlfriend?" He proceeds to deny it, I ask him again, he denies again, I proceed to give him an injection real hard and ask him again. Out it comes, half hour ago, at a prominent centrally located park in the city, close to the hospital.

He says he loves her but she is scared of her parents, he says he had sex with her, wants to marry her(no she's not pregnant), but her parents won't allow it. He begs me not to tell his parents. My junior is sitting there with her jaw hanging down not believing this could be done because of a girl. Well, we manage to patch him up, his dad arrives, we don't tell him much other than that the boy needs a psychiatrist for his uncontrollable emotions.

Bottom line - Guys, if you want to cut yourself for a woman at least do it right! Don't just slice out some skin, go for the throat and at least make it more interesting.