Kicked by a Horse!

I'm back after a long hiatus....and kicked about it. All it took to get me back to blogging was a horse! If only this had happened sooner.

I am sure this is common in the wild wild west, but this is the first time I've heard of someone coming into a clinic in Bombay because he was kicked by a horse!

What makes it even more strange is that the patient was a 10 year old boy, who was doing his daily chores when he happened to see two horses 'get into an argument' so to speak! He said the two horses were fighting apparently and he went to try and calm one horse down when the other kicked him in the head.

The kid was hit pretty hard and according to his mother, he was lying unconscious for about 10 minutes. He came around and had a huge swelling over his head and required stitches.

The only good thing to come out of it was that when the time came to take him in the O.R. and suture him, he wasn't the slightest bit afraid of the injections and instruments. What a way to get rid of fright! Maybe next time he would kick the horse back!! (No offense meant to PETA members)

He's doing well now and the wound has healed completely, but I doubt he's going to be riding a horse anytime soon. Maybe he'd just go hide in a tree.

Laparoscopic Surgical Treatment of Pain From Chronic Prostatitis

Laparoscopic radical prostatectomy is a technical and demanding technique used to remove the prostate.  Since the late 1990s, this surgical technique has been used for the treatment of prostate cancer. However, its possible uses may be expanding – in very carefully selected and unusual cases – to include the treatment of chronic prostatitis. Should every patient with pain rush to have his prostate removed?

Some forms of pain are good. For example, pain is good when it forces us to remove a hand from a fire. Other forms of pain are bad. Pain is bad when it chronically distracts us from our appointed rounds. For example, an amputee may have pain in a hand that no longer exists; this kind of pathological pain, which fulfills no apparent constructive purpose, can keep the amputee from concentrating on other things.

Pathological pain can also arise from the viscera: The abdominal contents. Common examples are Irritable Bowel Syndrome and Endometriosis, the pain of which is can be hard to localize and treat. For all intents and purposes, visceral pain is not treated surgically. Should the pain of prostatitis be treated surgically?

Prostatitis falls into two broad and general categories: Infectious and non-infectious. The infectious kind is generally associated with bacteria, causes fever and pain, and is easily treated with antibiotics. The non-infectious kind, which can last for years and even decades, is characterized by episodic pain, fatigue, inability to think clearly, depression, and social isolation. Its causes are not known and the treatments have remained elusive. One theory to explain severe, treatment-resistant, chronic prostatitis is that it is really a psycho-somatic manifestation of neurosis and distress. In other words, the theory holds that severe, treatment-resistant, chronic prostatitis is “all in your head” and should be treated with psychotherapy, massage, and trigger point release.

Beginning in 2007, evidence has been anecdotally accumulating that severe chronic prostatitis may be completely curable with laparoscopic radical prostatectomy. Specifically, a 55-year old man with an 8-year history who had exhausted all other options had this surgery and was instantly cured. Since then, a handful of other men have had such treatment as part of an ongoing, IRB-approved prostatitis treatment clinical trial that follows symptoms measured by the Chronic Prostatitis Symptom Index (CPSI) over time. They seem to be also improving, although the response is not completely uniform, the symptoms are receding at different rates, and a minority appears to be getting little, if any, therapeutic effect.

So why should a man in pain not try laparoscopic radical prostatectomy? The answer lies in the risk analysis. Laparoscopic radical prostatectomy is associated with infertility, which for men at child-bearing ages as is the case with prostatitis sufferers, is a major issue. It is also associated with risk of urinary incontinence, erectile dysfunction, bladder neck contracture, cardiovascular complications, infection, and treatment failure. Given that some prostatitis prostates are embedded in a dense reaction that causes adherence of the prostate to the rectum, there is risk of rectal injury.

Men with severe, treatment-resistant, chronic prostatitis have no good options. It may be that laparoscopic radical prostatectomy can help some of them to feel better. However, the promise of this approach is only in the earliest phases of validation and the risks associated with it are serious and real.

To learn more, readers are invited to follow the Prostatitis News Blog, which will post results of the trial as they come in, as well as information on many other facets of prostatitis.

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Guest blogger Arnon Krongrad, MD is Medical Director of the Krongrad Institute for Laparoscopic Prostate Surgery.

What else could a Lipoma be?

In a follow up to the post on What else could an Umbilical hernia be? a strikingly similar experience prompts this post.

A fairly large lady of middle eastern descent presented to us with a soft, non expansile, mobile, swelling over her left thigh just about where the groin fold meets the leg. She said she'd had it for years and it gave her no trouble other than cosmetic and she wanted it taken out for that specific purpose.

She underwent a Sonogram which confirmed our clinical diagnosis of it being a Lipoma. Happy with our findings we posted her for surgery under local anaesthesia (which is usually the case) in day care!

We started off, dissected around it, it looked like a lipoma and we dug deeper and higher. Down to the muscle layer, carefully avoiding the femoral vessels. Until we reached what we thought was the femoral canal. She was under local so we asked her to cough. No impulse. Asked her again. No impulse. No luck either as my finger was going all the way up through what was now confirmed as the femoral canal.
This was no lipoma. It was a full fledged femoral hernia!

Luckily the anaesthetist was close by and was able to reach us in 10 minutes. We carried out the repair completely and the lady is doing fine.

I wonder what else a lipoma could be? Until I find another presentation.....

Is English Important To Medicine?

Language has always been a big issue in India, and more so in Maharashtra and Bombay or Mumbai depending on which side of politics you're on. That it was a big issue in the field of medicine has only just started to receive prominence.I've been meaning to write about this for a long while now, but haven't got that push required. I think this week's post graduate examinations were just what I needed.

A twitter friend of mine is an examiner for Medical Students. The Consultant I work with is also an examiner for DNB (Diplomate of National Board) students. Both these intelligent and hard working doctors give up their precious time and practice to examine students in their viva-voce exams and decide whether they are fit to practice medicine. I always wondered how an examiner felt when coming across thousands of students, some of whom excel at medicine and some who are just about there with medicine but speak English fluently.

I would think that holding a command over the language would give the student an immense advantage over his counterpart who would falter in grammar, no matter where he stood on the knowledge scale of medicine. This comes from personal experience as well. I don't think I was even half as good as other students appearing for their examinations with me, but I could speak English well (almost better than half the teacher's taking my exam) and that gave me an upper hand. 

From a patient point of view, the whole thing takes a rather wierd turn. Some people would prefer talking in their native tongue to their doctor and some would cringe if a doctor didn't know how to speak English well. 

My view on this is that if the books are written in English and the syllabus is taught in English and the exams are conducted in English, the students must, simply must have a working knowledge of the language. That being said, would it be too bad an idea to have a compulsory cut off for English along with the Sciences that we need after college? Should English as a language be a subject along with Anatomy, Physiology and Biochemistry?

I think it should. Please let me know what you think....

What else could an Umbilical Hernia Be?

As a Surgeon, every time I settle down and think to myself that I've seen a case like this before and it should be routine, God intervenes and reminds me that nothing in surgery is as it seems. Least of all when you expect it to be.

We had a lady who presented with a fairly simple small swelling just around her umbilicus at the lower edge. She had had it for about a year. She was keen on getting it out and got the relevant investigations for the surgery ready.

We took her into the O.T. and gave her the necessary sedation and local anaesthesia and proceeded with the usual 'smiling' umbilical incision. On dissection, we noticed a very well circumscribed localised blob of fat = Lipoma. Could it be?? As simple as a Lipoma? No way.

We dissected further. It wasn't extending beyond the subcutaneous plane. I had not even reached the rectus sheath and it was almost out. I was just about ready to call it a Lipoma and then I reached the rectus sheath. It seemed to be growing out of it. I had to really dig deep into my long forgotten medical school knowledge bank kept at the back of my head somewhere in the pits of my cerebrum.

I showed it to my senior. He confirmed. It was a 'Fatty hernia of the Rectus'. Strange, I thought. That's something I've heard in relation to the Linea Alba. Extraperitoneal fat in the epigastrium is known, but paraumbilical at the rectus?? Anyway, that's what we left it as since there was no sac, so it couldn't be a hernia and it was only fat and the defect was less than a cm in size.

Strange!

Doctors and Parents!

I am intruding on my son's space but this blog is the first amongst many things I intend to share with him.
There are countless books on parenting telling Mom's what they should do. Very few focusing on what the dad should do, or even feel. Numerous books on what to expect, what Mom will be feeling, how to cope with those feelings, how its normal to be emotional etc etc.

Dad's are expected to wing it. Go to work, be the breadwinners, be practical, sensible anything but emotional. Well, we feel it too. Unfortunately, all those books on motherhood and babyhood are written by women. I suspect its because Dad's don't get the time to write or just can't get down to doing it (peer pressure??). Don't close this window just yet...I'm not about to write a book.

This is what I felt in the weeks leading up to the delivery.

When he kicked for the first time - Mom was elated. I felt joy. Immense joy. Not because he kicked. Because she was elated. At that time, he was still a foetus to me. Something I had studied in medical school. The kicking was something we took for granted because we saw pregnant women all the time. But my wife was glowing....and I felt Joy. Immense Joy.

When she started getting Braxton Hicks Contractions - Mom was elated and confused. She had tons of questions. It started to sink in. This was my child. Something I had helped make! My flesh, my blood, possible looks like me. We talked about the contractions. Explained to her it was normal. It's just your uterus getting ready. I am convinced it is an act of God, not to help the uterus get ready or the mother, but for the Dad to realise he's having a baby.

She gets backaches - She felt tired and hassled. It hurt! I said I know. I had no idea. It's impossible to know what kind of pain someone is in unless you've suffered it before. No matter how much you say you know. It was her uterus getting bigger and ready.

She dropped her mucous plug - I was the doctor that my brain is conditioned to be. "It's ok", I said. It's part of the process. I completely missed the fact that this was the first sign of progressing into labour. Of course, it takes days after this for labour to begin, but I am not a gynaec and I missed it. The dad in me began to stir.
I drove slower, much slower. I watched signals with more concentration than ever before. I chose roads according to her convenience. It should not hurt her back. No chances with traffic snarls and accidents. 

She was lying in pain when I got back - I realised this was labour. Dad had kicked in. Spoke to Mom. She was our gynaec. She's the quick thinker in the family. Said lets waste no time. We're off to the hospital. I remained calm. Medicine training kicked in involuntarily. Wife asked can you believe we're in labour. I said yes. It didn't register. She stayed at the hospital from then till delivery. I didn't. Mom did. She would decide progress. I wouldn't.

 

I went home that night and checked my emails. I had one saying June 20 is Father's day. I thought, "What shall we get dad for this one?"

Then it hit me. Smack in the face. By June 20, I too would be a father. My own child. That I had to care for and worry about. I don't usually worry about things. I'm cold like that. But I melted that night. I believed we were in labour. I understood that I was having a son. I knew that I would do anything for him to be born healthy. It kicked in. 

This was the first lesson my son taught me. Better than any book could ever explain! Better than any other parent could tell me what to feel. Better than my wife knowing before I did. My Son! 

Grand Rounds Vol.6 No. 36 - Let the Lol's Begin!

I've had a rather interesting time compiling this post for this edition of Grand Rounds. I must say the motive for the theme being humour and laughter was purely selfish. This is the first time I am hosting here and I knew that if I had to keep up the good work of the previous hosts I would have to be totally involved with the selection process of so many many fantastic entries that this event brings on! The only way to screen them would be to enjoy reading every bit and what better way to do that than over a laugh.

So, in no particular order, here are this week's lol posts!

Every doctor would remember the first day in Medical school for various reasons. In my case it was finally wearing the crisp white apron and carrying around a stethoscope for all the world to see that I was a doctor. Fortunately, for me the first day back home wasn't complicated by a medical question like the one at John's Glass Hospital - The Magic Curtain. He bravely answered questions at home and got hands on into Medicine  early in his internship.

Insurance is more often than not thought of as a necessary evil. In a country like mine, where insurance is just starting to rear its ugly head, we are just about bracing ourselves for the impact it would create on Doctors. Unfortunately, InsureBlog has this burden of pointing out something that the doctor's should have noticed even with their eyes closed. Prompts me to say "What a bunch of arses" Avoid the NHS and travel abroad is my say on the matter!

A simple but sweet reminder -  Mother is always right! Grandmom's even more so. Clearly this ATS Speaker was given a mouthful before leaving home that morning when she went on to announce the simple golden rules to Care for ICU Patients Successfully. Grandma Protocols  almost makes me feel like employing it at my surgery!

Maybe we should all use the Grandma protocols to deal with difficult patients. On the other hand the list given here is almost always bound to take care of those particular cases where the patient is just not going to be happy no matter what. Dr. Woodward’s Checklist is the ultimate how to guide for dealing with difficult patients, be they yours or some other Physicians!

Everyone likes a good reception and waiting area. At ACP Internist, this adorable but albeit serious message of COPD grasping our lungs is nicely displayed over the Exhibit area with Exhibit Hall Silliness.

Doctors are shrewd aren't they! Here's a story about an Ob/Gyn who would be in a win win situation as regards the gender determination of an unborn child. Find out how he was always right in determining the gender with this maybe true, maybe not story at The Sterile Eye - Hedge your bets. Just to add, in India he would be arrested as it is illegal to determine the sex of the foetus due to the rise in female foeticide.

Laika has a wonderful story to tell regarding the perspective of little children towards doctors - even the one's that are PhD's. In this adorable post, the poor Doctor was reduced to a guinea pig's healer by his young daughter. A Strange Doctor Indeed.

Dr. Charles almost got me reliving my comic book days before I became a Doctor. The batman in each of us is so well described here that I feel it should figure in all medical schools and teachings as an inspiration to all medical  students ready to start of their lives as healers.

In India, the art of living is taking on big proportions. In this delightful video blog from Life in the Fast lane,  The Art of Sloughing, they highlight the plight of the poor ER doctor reporting to his attending. Also, check out the UCEM - Utopian College of Emergency for Medicine (yes that is not a typo) and the numerous link in there. All worth many clicks and laughs!

Inside Surgery - A medical information blog carried this rather strange piece of news read on the news wire posted by the FBI - Help wanted by plastic surgeons. I really want to know if this is really possible. Inside surgery also has many step by step procedures lined up - Anterior Cervical Fusion being one of them.

A late but brilliant post is this staunch Diabetic Mommy Kerri lists the things that make her a diabteic mommy with such humour that it is impossible not to leave this blog smiling! Her tag line for the blog reads 'Diabetes doesn't define me, but it helps explain me. She explains herself by that wonderful smiling photo in there. That according to me is the best way of tackling Diabetes. Smile!

Sticking with Diabetes, Diabetes Mine ( Read as Gold Mine for Diabetes) compiles this awesome list of glucose logging software for the mac even though she is now a self confessed PC person. Just a wealth of information here.

Just to end on a very funny note - this is something that happened very close to me. Its equivalent to the great Indian Rope Trick for Colds....

Hope you had a smiling time. I hope this edition was even close to expectations as I can barely claim to have matched the greats who have hosted before me. Meanwhile, keep a lookout for next weeks edition and happy blogging.

Call for Submissions - Grand Rounds Vol. 6 No.36

Hey!

First of, I would like to thank the creators of Grand Rounds for such a wonderful feat and giving me the honour to host this next edition.

With the last edition topping the charts at 33 Charts I would certainly have to pull my socks up and pull of the rounds with at least 50% near perfection that Dr. V did.

Without further ado, lets get into submission mode. I'd like to keep the theme for this edition as Humour in Medicine. This may not have to be restricted to doctor patient but may extend to anything happening in and around medicine with a funny end to it!

Submission can be made either here at the comments section or at my email - Techknowdoc

I am on twitter with the handle (Techknowdoc) and would accept DM's there too

Deadline for submissions would be 30th May - Sunday!

Looking forward to hosting a colourful and hopefully smiling edition!

Cheers

Follow up of the Condyloma Accuminata

In continuation with my previous post about the giant anal wart that turned out to be cancerous, this is the same patient after 10 days follow up post surgery.

In case you are wondering what it looked like before the surgery, you can check out the photo here or go through my last post Giant Condyloma Accuminata!

That is a pretty descent job if I may say so myself. The only thing is to now, somehow, convince him that radiation is absolutely necessary for complete cure of the carcinoma. He is quite reluctant though. Also, e had about 50 smaller finger sized warts on his bodice and neck and face which he now wanted removed because he was afraid he would get cancer in them too. Took about 1 hour but we got them all!!

He's about ready to go home in a week or so to consider radiotherapy.
Until I hear more from him....

Giant Condyloma Accuminata

For all the non-medical readers, the title is not something I made up just to arouse your curiosity. Unfortunately, we had a patient of middle east descent recently who presented to us with a large growth in his perineal area (close to the anus).

He had been harbouring it for 10 years. When it started it was about the size of a pea. At present it was about the size of a soccer ball. This is the actual photo. No kidding! What must have started at the anal region as a simple wart was now extending upto the anal cleft behind and the groin in front! What provoked the man to keep it in hiding for all this time eludes even his brain. Somewhere in this mass was his anal opening. Can you even imagine the logistics of hygiene!

Well, we had the honour of having to operate on it and excise what we could while trying to save his sphincter functions. No sooner had we started that we realised that this most likely has undergone malignant change (become cancerous). Every portion we touched would bleed like crazy. The condyloma had become so vascular that it was very like that it had progressed to squamous cell carcinoma as is bound to happen after such a long period of having it. We excised what we could and tried to suture his skin back in place while sending the specimen for histopathological examination.

As it turned out, it was squamous cell carcinoma but the margins could not be identified, meaning we didn't know if we got all of it or was some element left in situ. We asked him to go for an Oncologists opinion for radiotherapy.

He refused! He still is resistant to go there and is thinking of going back to his home country.

God help him!

How soon can we drink after surgery?

Modern medicine has been breaking bounds in the new era. Every year we come up with new and fantastic methods to fast track recovery after a surgical procedure. The entire day care surgery concept is based on this fact. Sometimes, however, our patients push us to the limit.

The gentleman we were operating upon for a bilateral hernia under day care surgery was a very good candidate for surgery. Medically fit, cooperative, not pain sensitive, motivated for day surgery, ready to walk back to his hotel room in the evening after surgery. He was given local anaesthesia in the inguinal region and we were operating upon him. We finished the Right side and went on to the left. All was going well until suddenly the patient decides to ask us a very interesting question.

"Can I have a beer as soon as the surgery is done?"

We were quite shocked and asked him to say that again. I think he realised what he said because he then tried something else. " I can smell beer in the OT. Can I have some. I can smell it in the oxygen tube" Maybe he thought it was an excellent way to recover early from surgery?

Now wouldn't that be a novel way to get drunk. Inhale some alcohol vapours! Superb absorption!

Abscess Drainage without Antibiotics?

I just read a paper this morning that gave conclusive evidence that antibiotics do not work after an Incision and Drainage procedure for an Abscess. That was rather surprising to me. How can a cavity that's filled with pus (essentially teeming with bacteria and what not) not respond to the very things that were invented to destroy said bacteria and what not!

The data suggested that there was no difference in the healing process in the placebo group and the group that received the antibiotics. They also report that the incidence of further infection was not affected by the antibiotics. So, 7 days after the incision, patients were no better no worse. I'm not so sure thats a good thing!

Taking this scenario and applying it in India would be akin to shutting your practice down. Why? Simple. Your patients will think you've lost it! "My doc is so stupid he didn't even prescribe me antibiotics". In a country that is widely known for abusing over the counter drugs, we have our chemist friends that happily dispense all antibiotics over the counter as well and almost no one I know asks for a prescription. Knowing this, do you think that even if I don't prescribe an antibiotic, I won't be asked for it? Wouldn't it just be bought anyway to 'be safe'?

Pharma companies - Lets not even get started there. They must already be conduction 'trials' to disprove this theory. Be realistic, if you won't prescribe antibiotics for an infection, what else is left??? (Of course, I'm generalising!)

                                                          

How about you? Would you feel comfortable not taking any antibiotics after getting a surgical procedure on your body to remove pus from an abscess cavity?? 

I want comments on this one!

Ice Ball Surgery.

In continuation with my anal surgeries experience the novel concept of freezing someone's ass off captured my interest yesterday!

Cryosurgery is one of the accepted methods of treating Piles. Why, I will never understand? Is it because in this heat its something to cool off with? Is it because thats the only way to send gas back up the ass? Is it because its convienient? I have no answers. I personally don't like it as a form of treatment, but nevertheless it is used, so here we go!

 What you do is first identify the pile mass, take the cryotip which is a nice rounded metal tip and apply that to the mucosa and let the freezing gas go through the tip to form a nice snowball over the mass!

Over to the left is the cylinder with the application tip attached.

The ice balls thus formed actually look like this but are stuck to the pile mass so the one's on the right are merely descriptive! The gas from the cylinder makes a godaweful noise when applied and the handle gets really cold too, so I imagine the patient is having an internal cooling like no airconditioner can provide (probably why this method is popular in the summers).

The question remains, with better and better methods of treatment including the Infrared photocoagulator (painless, anaesthesialess, 10 minute and out procedure which I use at my clinic) and the HAL doppler coming in will the ice balls survive!

Question 2: Can we use it to cool ourselves down in the summer anyway??

Sit on a Seton.

A fistula in ano is a traumatic experience. Fistula literally means a connection between two epithelial lined surfaces. When it happens in the anal canal, it becomes a fistula in ano. Usually not painful, it presents with discharge from a tiny opening (usually) seen just around the anal opening with a connection somewhere inside. The low one's are relatively easy to treat but the high trans-sphincteric one's are a pain in the ass! Literally.


One of the ways to treat this is a Seton Stitch!  The procedure involves running a surgical-grade cord through the fistula tract so that the cord creates a loop that joins up outside the fistula. The seton loop will slowly cut through tissue inside the loop while scarring behind the loop, essentially "pulling out" the fistula without surgery.


Now to put forth a human perspective and what the patient feels. This man had a high fistula and to complicate things he also had Grade II Haemorrhoids (Piles). He was in pain due to both of the above conditions. He had already undergone a surgery for the fistula once somewhere in Bangkok, but it had recurred. I'm assuming that this was so because they must have not realised how high it actually was at the time of surgery. This is what he had to go through. Keep in mind this is what we Surgeon's do for a living!


 1.) Get examined with a proctoscope

2.) Have some methylene blue (ink) injected into the fistula

3.) Get probed with a probe 

 4.) Get Operated on

 5.) Take Sclerotherapy Injection into the Piles


 6.) Come for dressings and follow up  


 Only Steps 2-4 get anaesthesia. The rest are to be tolerated.


Can you imagine how painful it must be? 

The person we operated on today was done under sedation and local anaesthesia and he was still howling in pain. We couldn't do much more for him as he was unfit for general / spinal anaesthesia. Such is life.

Voldemortish experience?

 

Assuming everyone who can read has read Harry Potter, I am relating this past week's experience to he who must not be named! We had a patient who underwent a SILS Laparoscopic Sleeve Gastrectomy last week. The surgery went off well and the patient tolerated the anaesthesia and post op pain quite admirably. The visit in the evening led to this post.

 I went to see her to check that everything was well. She was made to go to the toilet, sit up and even walked a bit. She had some amount of pain which was understandable considering her surgery was performed only hours earlier. She also had a very dry mouth, again obvious, since she was still nil orally post op. She was permitted to gargle and moisten her lips.

 I was waiting outside whilst she was doing this and suddenly her siblings comes running up to me and exclaims, "There's something wierd coming out of her mouth, it looks like a snake or something." Not one to miss out on an opportunity to see something this dramatic, I went on inside, not alarmed but mildly curious.

The patient's face was a picture of perplexity as she proceeded to stare at me and tell me that something funny was coming out of her and were we sure the surgery went of well! I asked her to open her mouth.

Sure enough, looking me straight in the face, swollen to a certain extent, her mouth opening in a way that made it seem to be projecting outwards, hence resembling the dreaded 'nagina'  was what she perceived to be the snake of her insides....

Her Uvula!

P.S. At least it didn't look like this!

Non Obese Fat.

Its been quiet for a while now, but you can always expect things to get interesting when you're working in surgery! This is an incident involving a lot of fat.

 

A man came to the clinic the other day with a very simple request. He had a swelling on his forehead that he wanted to get rid of. Fairly straightforward lipoma, I thought. We had a discussion and he was fine with everything and fixed a time for the surgery. He clearly was happy with what he heard because he then showed me his hands. He had the same type of swelling on both his forearms. He wanted to get those out too. Fine, I said. More for me to operate on!

 He then turned around and shifted through his hair and showed me one more at the back of the skull. I thought this would be a cyst (as is most likely in that area), but it too felt like a lipoma.
 
By now I was sure that there would be more so I just went out on a limb and asked him, "How many you have" (nothing to do with the ad really). He casually mentioned that he had many but he would like to get rid of only these 4. He then let me examine him completely (another reason why a complete physical is a must)

 I must have counted at least 50!!! Spread all over his body.....back, abdomen, legs, everywhere! It wasn't so much ugly as it was sad! For no fault of his own, he was bestowed upon with these fat deposits by someone higher up with a wierd sense of humour! He wasn't even overweight. He was in fact quite fit other than these little fat deposits all over his body.


The reason for him to get the 4 out was that they were the one's that could be seen. Everything else would be covered by his clothing so he was not bothered about them. He had even tried exercising and weight loss techniques for losing these fat buddies of his because someone had told him that they were fat, but forgot to explain that they had nothing to do with being overweight or obese!

 This is one fat problem you can't get rid of by going to the gym or walking it out!!

Can you ever look at Water-balloons again?

An innocent comparison by a colleague has put me off water-balloons forever!

We had a male come into the clinic with long standing ascites (collection of fluid in his abdomen) due to liver problems. This was causing him extreme discomfort with breathing, as is known to happen in such cases. We decided the best course of action for him would be to do a tapping procedure (where we stick a needle into his abdomen and suck out fluid) and remove about a litre or two max. for some symptomatic relief.

My junior had never done one before, so I decided to teach it to her. I was needed in the O.T. anyway, so I thought I would start and leave her to monitor and finish the procedure once enough fluid came out.We got everything in place in the ward and started. It was clear straw coloured fluid, almost water like. It flowed easily and after the first 100cc or so I handed over my colleague. She was quite frightened (I don't blame her). As luck would have it, she must have moved the needle while trying to aspirate, and the fluid stopped draining. I was getting calls from the O.T. by now, so I showed her how to reposition the needle and left after confirming drainage again.

After about an hour or so, she phoned in the O.T. saying that the drainage stopped completely after 1 litre. She let the patient go. All went well, or so I thought. This is what I was faced with the next day when I entered the clinic.

The patient had now returned with what was being called a water-balloon by the staff. He developed a hydrocele secondary to ascitic tapping. 

A hydrocele is a collection of fluid in the scrotum. Most develop for no apparent reason, are harmless, and can be left alone. If needed, a small operation can usually cure the problem. This wasn't an ordinary hydrocele, and that's probably why they were referring to it as a water balloon. The fluid was as you can see bilateral and it was very very superficial. It moved like a water bed when touched. (sorry for the comparison but there is no better way to explain it)

I haven't read about such a thing ever, nor could I find it on the internet. If anyone knows of such a case, please do let me know. I am thinking of writing up a case report and sending it to a medical journal. The closest I've come to seeing something like this is at laparoscopic hernia repairs where the gas distends the scrotum!

Well, the person is much better now, the fluid has been absorbed and he will come again for his ascitic tap soon where I should be able to get a fresh picture to send a comparitive report to the journal.

Until such time, I'm off water balloons!

NIGHTMARE OF 26/11

This is a small write up of what an anesthetist went through on 26/11. I thought it was an amazing read and asked if it could be reproduced here. It is unmodified and exactly as she wrote it out. 

"It all started around 10 p.m. There was a lot of confusion in the casualty. We heard some terrorists were gunning down innocent people.

Patients were being brought to the casualty and directly being admitted to the ICU where the initial steps of resuscitation i.e. Airway, Breathing & Circulation were being taken care of. Patient’s that were brought unconscious were immediately intubated with Nasogastric Tube insertion, considering all were full stomach.

The anaesthesiologists were called in the casualty & ICU to help initially, but later, we realized this was turning out to be a mass casualty. As the patients were pouring into the hospital in battalions, we knew more was to be done. We got the Major O.T., the orthopedic O.T. and the neurology O.T. opened. All this took place in such a fast pace only due to the great co-operation of the O.T. Matron and sisters & ward boys. There was blood shed everywhere. Victims were being rolled in. We mobilized extra trolleys for anesthesia drugs. All 7 operation theatres were opened.

All the anaesthetist consultants were stuck at home because of the curfew situation so the anesthesia residents were left to manage this critical situation. I, Dr. P.R. was a 3^rd post anaesthesia resident with 5 more juniors with me. Our team was led by Dr. J.C. who was the chief resident. We were ordered to use Ketamine & scoline for crash induction & muscle relaxant Pavlon (Pancuronium) for maintenance. We assumed all patients to be full stomach & accordingly carried out crash induction.

Ketamine: Drug of choice for induction because unlike propofol / pentothal, it causes tachycardia & hypertension thus maintaining vitals in a haemodynamically compromised patient.

Scoline: Induction relaxant of choice as scoline brings up the pressure, also causes

excellent relaxation & is the agent of choice in crash intubation.

Pavlon: (Pancuronium) long acting muscle relaxant. Relaxant of choice as it causes sympathetic stimulation, tachycardia, hypertension. Also due to long duration of action requires less top ups for maintenance. As we were short staffed & had to manage multitude of tasks including fluid electrolyte balance & blood management, pavlon really helped us.

Most patients brought in were critical with multiple bullets, in a state of shock, so patients were maintained on100% oxygen and muscle relaxant top ups. These patients were not reversed at the end of operation & were sent to I.C.U with the tube for staged weaning after confirming their general condition.

Some patients with minor injuries were extubated on table provides they had good vitals to begin with & were conscious.

Aspiration prophylaxis Ondensetron & Rantac were given.

Patients with multiple bullet injuries were brought in, most of them with shock, feeble pulse, unrecordable blood pressure. A direct arterial line was managed in those cases where central lines were not possible. Peripheral lines with wide bore cannulae were used to push blood. ‘O’ Rh –ve blood was used when cross matches were not available. Fluid management with initial crystalloids & colloids was carried out and as blood became available after cross matching, we pushed it along with Fresh Frozen Plasma and Platelets.

Ionotropes namely dopamine, adrenaline and nor adrenaline were started to maintain falling blood pressures.

Resuscitation was done in full swing and monitoring of Pulse, Blood Pressure and SPO2. Keeping the blood pressure in mind, sedatives like midazolam were avoided.

One of the cases was a Japanese National who was very critical with multiple bullet wounds in the liver & intestines. We tried our best to resuscitate him along with CPR and shock but alas, couldn’t save him.

Of particular interest was the case of J. N. This female was brought in with multiple bullet wounds with a multitude of fractures including arms, pelvis, spine and left brachial artery tear. Her pulse was feeble, blood pressure unrecordable and only after crash induction were we able to obtain a Right Femoral arterial line (left femur was bruised and fractured). We started ionotropes alongside fluid resuscitation and blood, FFP and platelet transfusions.After 12 hours of surgery, on the next day she was taken to the ICU where further management of her DIC (disseminated intravascular coagulation) and general care took place. We thought she wouldn’t survive but miraculously she pulled through.

Totally 23 operations took place that night, out of which two expired on the table. The cases kept rolling in, some commando’s included in them. For 4-5 days the hospital was a war zone. In this way, the mass casualty was managed in a hospital in Bombay!"

I could actually feel what she must have gone through. This post is dedicated to her bravery and spirit of working right through the calamity. We will never forget!

Are you Branded?

I came across a man who was recently married and was unable to concieve. His preliminary reports pointed towards azoospermia (an absolute zero sperm count) and bilateral varicocele. He was from the middle east and had a diagnosis of infertility. He knew about the varicocele and had heard that in some cases its responsible for azoospermia. He also mentioned that he sometimes saw semen in his urine (retrograde ejaculation). He had no issues with potency and secondary sexual characters were well developed.

He insisted on a full workup and even consented to a testicular biopsy. He also mentioned a procedure he had undergone back home, but due to language issues, we weren't very clear what it was. Until we took him on the table for the biopsy. He was branded. With a red hot iron rod. Thinking that it would cure the varicocele and all his problems!

These are the actual pictures on his skin. The first one is something he underwent when he was small. It was a pattern of five such prints on his upper back, supposedly to cleanse his blood.
The second one was at his left lower abdomen, and was done specifically to cure his varicocele and increase his sperm count!!

The process of branding the skin is known as scarification (scaryfication is more like it). Generally voluntary, though often under severe social pressure, branding may be used as a painful form of initiation, serving both as endurance and motivation test (rite of passage) and a permanent membership mark.  Endorphins can be released in the scarification process that can induce a euphoric state. 

The longer for a wound to heal, the more pronounced the scar will be. Thus, in order to have pronounced scars, the wound is kept open for a protracted time. This is by abrading scabs and irritating the wound with chemical or natural irritants such as toothpaste or citrus juice. All this can be understood when it comes to the tribes and ancient cultural practices.


What amazes me, is that this very same practice is being carried out in the modern world with the tag of it being a cure for certain diseases, which now have a scientific basis and known cure!
The line between modern medicine and traditional values is running very thin and sometimes these practices may be lethal. (Read here for the post on alternative therapies taking lives)


Another strange fact is this, if the person getting branded develops an infection, the tribes apparently have a code - LITHA - literally translating to leave it the hell alone!!