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Friday, November 27, 2009

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.

Tuesday, November 24, 2009

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!

Thursday, November 19, 2009

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)

Friday, November 13, 2009

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!

Thursday, November 12, 2009

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??

Friday, November 06, 2009

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.

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