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Thursday, December 31, 2009

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!

Sunday, December 27, 2009

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!

Friday, December 25, 2009

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)

Tuesday, December 22, 2009

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)

Friday, December 18, 2009

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!

Monday, December 14, 2009

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??

Tuesday, December 08, 2009

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.

Saturday, December 05, 2009

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.

Friday, December 04, 2009

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.

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