Friday, January 28, 2011

Mom and baby....Who is more important?????

One of my very dear patient,a Lady is her mid twenties ,first time pregnant and around 20 weeks in her Pregnancy fractured her ankle.Orthopaedicians of various hospitals agreed on the fact that she needed surgery but a few of them were hesitant to take a call on the surgery as she was pregnant.
Here as Obstetrician,what has been taught to me and is accepted worldwide guideline is that though mother and child both are important,MOTHER always comes first.An unborn baby comes in consideration only after mothers health has been optimally taken care off.
Though tocolysis and thromboprophylaxis needs to be taken care off post surgery,such a patient clearly needs surgery

Thursday, January 27, 2011

Rubella vaccination and pregnancy

There was great rush in the OPD yesterday.Maybe because of 26th Jan being a national Holiday.
There were quite a few patients for second opinion and 'second opinion' means some complication.I actually got held up in my OPD till very late.The last patient was a Caucasian Lady with Indian husband.Quite distraught and anxious.Inadvertently she had Rubella vaccination before she detected her pregnancy.Apparently the doctor she visited before me wasn't very sure which left this Lady quite distressed.

Now just for those of you who inadvertently find themselves in such situation:
Pregnancy should be avoided for 3 months after Rubella vaccination, as its a live vaccine BUT AN INADVERTENT USE OF VACCINATION IN CASE OF PREGNANCY ISN'T AN INDICATION FOR TERMINATION OF PREGNANCY 

Tuesday, January 25, 2011

My Team

Sometime back I tried to make a team of my own with a junior friend Dr AS and she picked the threads of Laparoscopy well.But as soon as she was little better trained Dr VB 'hijacked' her to make her team at a different.Dr A my team and joined a bigger set up(atleast that is what it looked at that time),bigger name and fatter pay cheque leaving me a little heart broken.Pledged never to make a team or get emotionally involved with working partners.
My registrars and Jr Consultants were trying to assist and help me to best of their capacity but the problem was : we weren't a team and thus lacked the coordination as every time I had a different assistant.In the meantime I had started performing Total laparoscopic hysterectomies and all other high end laparoscopic surgeries.So ,I applied the Shouldice Hospital technique to my practice,just before I read Dr Gawande.Shalabh was no Gynaecologist but an excellent laparoscopic GI surgeon.I was a qualified gynaecologist in desperate need of a team and dependable surgical assistant.Shalabh is my husband ,so he can't be 'hijacked' too.
And I wished to give the best care to my patients even in most difficult of surgeries.I suggested Shalabh to become a 'team'.I let my ego go to drains(A surgeon can't enter a Blue blooded gynecologist's OR,once I had pledged) when I thought of the well being of my patients and very much my own as well.We canrehearse the steps of surgery as many times as we want,even at home.
Thank God,he agreed.We have a stable team now,much in sinc.We as a team of Dr kaushiki Dwivedee and Dr Shalabh Mohan are doing many complicated surgery very smoothly.Now I have also started assisting Shalabh for his laparoscopic GI surgeries.Sounds interesting....a gynaecologist assisting GI surgeries but then 'We are the team'.And over all 'The Shouldice Theory' seems to be working fine in our case.
Those who have seen the Movie Band ,Baaja ,Barat..........Can put it simply that we have Shruti Kakkar and Bitto Sharma's team......'Surgery Mubarak' :))))  .Agreed Surgery is no laughing buisness but but it helps to keep the things light.
Ranveer Singh and Anushka Sharma in Band Baaja Barat

Who works better?

In his book complications Dr Gawande mentions about a study where learning curve of various groups consisting of different surgeons and surgical teams were studied.It was found that after learning this new operation all these surgeons initially took around 6 hours to perform.Later on one group which had least complication and worked fastest took 3 hrs and the group of surgeons which took the longest was taking 6 hours.To utter surprise it was found the group which took less time was headed by a young surgeon but he worked with same team every time and they revised all the steps before surgery.
While the group which took longest had senior surgeon as the head who was no less efficient but was working with different set of doctors every time who weren't so well coordinated and thus the difference.
So the take home message I got was a well coordinated team work is needed for high end and high risk Surgeries where the stakes are very high as far as patients safety is a issue.

Monday, January 17, 2011

shouldice Hospital and hernioplasty

This post is a total lift off of Dr Atul Gawande's experience shared by him in his book Complications.But It has  made me think and perhaps in times to come this will change my practice as well.I will share that in my next post.
Shouldice hospital is well known for it's hernia surgeries and they have least complication rates and maximum success rates in repairing hernias.This hospital just deals with hernia which means they are superspecialized in repairing hernia and as they are doing it day in and day out with similar technique,same team and same staff,their results are better than the rest.Well this is something which is quite accepted but what made me think was that the 3 surgeons Dr Atul Gawande watched operating were not a 'qualified Surgeon' by American standards and would not have even been even allowed to operate if they were operating outside Shouldice hospital.
Dr Sang was a former family physician.
Dr Byrnes Shouldice had come straight out of medical school.
The Surgeon-in Chief was an Obstetrician
And they were giving better results than credentialled Surgeons.And for a patient what matters is an outcome!!
Amazing isn't it?There is one more experience shared by Dr Gawande which i found interesting and will share soon.
And then I would come to that post in prelude of which I have written these 2 posts.

Saturday, January 15, 2011

A night to remember

Somewhere in early 2007,I don't remember the month or the date there happened certain incident or you can say series of incidents which I think helped me immensely in me developing my current mental attitude.

There was this third time pregnant Lady in the antenatal ward of my the then Hospital in United Kingdom.She had two normal deliveries in past and this time was in early labour.The labour room midwife informed, Dr Dwivedee ,xyz was having  foetal distress and she was being shifted to Labour Room.

I assessed the Lady and she was already about 8 to 9 cms dilated with decreased foetal heart rate.I gave her the option an instrumental delivery as she was progressing real fast.I don't know what struck her and she declined to give a consent for the same and wished to have a Cesarean section.I tried to reason out for couple of minutes but then I had to take action fast.Didn't want to give a depressed baby.So she demanded CS and CS it was under General anaesthesia.Baby came out fine.I started closing the uterus and realized that at one particular place there was no spurt of bleeding but despite spending almost 5 minutes to control a small little ooze I wasn't really satisfied.Consultant on call was requested to come.When he arrived and inspected he said' a small ooze.We will win it'.Almost 2 hrs later still that ooze was still very much there despite many stitches by my consultant.That's when I could see glistening sweat drops on his forehead.I suggested do we call the senior most consultant and to which he said a prompt yes.The senior most consultant arrived and by that time the Lady was already in DIC(Her blood wasn't clotting).She had started to bleed from all over the place and one point of time her blood pressure was just 15mm Hg.I was already imagining her figuring in next confidential inquiry .There was another lady fully dilated in occipitoposterior position since last 4 hours.Head consultant asked me to go and conduct a ventouse delivery on her in the meantime as they struggled with that lady.As I was descrubbing I suggested 'Maybe we should involve a cardiovascular surgeon'.They agreed.By the time I was back cardiovascular surgeon was there. Not a very confident one but surely better than us.
By that time a consent was taken to remove the Lady's uterus which was no longer contracting,had become atonic and was blocking the whole operative field as now the lady was bleeding from all over not just uterus.
We kept on struggling overnight and after 7 hours of surgery and 35 units of blood , she survived.
Next night was again a night shift for me.Whole day I had a disturbed sleep where I was just seeing blood all over.A doubt in mind,how will others take?After all I am an overseas doctor.Not one of them.May be I will be the one who will be blamed.Anyways at 8 pm again I reached for my night shift.I got a call from Mr Plemming ,the consultant on call for that day and also the consultant under whom this ill fated lady was booked in clinics.
He asked if,how I was and then he said well done!! you managed the case very well.Though few midwives gave me a different story but the senior most consultant was all praises for you.I started feeling a little better.But any such unexpected incident leaves you and you confidence shaken.A self doubt creeps in.I was trying to help myself come out of this emotional trauma which I had suffered the previous night.That night turned out to be a very busy night.I ended up performing 4 cesareans and 3 instrumental deliveries.Usually registrars used to call the consultants after 2 lscs in a night to help them out.I was determined not to.This was my way of helping me get my confidence back in which Mr Plemming helped me immensely.When I informed him 3rd time in night about a patient needing Cesarean he asked me,Dr Ddwivedee you had a horrible night yesterday and today its so damn busy where routinely registrars call for help.Do you think you can handle it safely?I said very firmly - yes Mr Plemming and if I need your help I will call you.he relied on me,gave me the chance to gain back my shaken confidence.Today,I find that, these 2 nights contribute highly to the mental strength I have today to face adverse events.
The case of Mrs XYZ was audited within a weeks time.I was asked 'why didn't I give her an option of forceps under General Anaesthesia'?In hind sight every one can give you various options but it is only the one facing the situation' then' knows 'being so wise is not easy.'
As far as Mrs XYZ ,she survived and recovered well.Was out of ITU in a day.Discharged with 4 to 5 days.She realised that she shouldn't heve asked for an unnecessary Cesarean.But what she didn't realise was my trauma and my efforts to recover from it were no less than her efforts to recover from her morbidity.

Thursday, January 13, 2011

Money Minded Doctors

Just today someone complimented me for not being money minded as I told some medicine telephonically.
Before I talk about 'Money Minded Doctors',let me first give an overview of what an average gynecologist daily routine is like.
Everyday there are patients for consultation in OPD.the number can vary from any where 10 to 30 or even more.Most of the consultations need at least 20 to 25 minutes,at times much more if it is a complicated case.
Then indoor rounds.Cases in OT and of course emergencies and patients in labour which can mean a lot of night shifts as well.
Doctors have family too with responsibilities like any of you.
So you can well understand now that its not easy being a doctor and it leaves very little time for oneself.
How can one forget the telephonic calls which on average can be any where from 20 t0 25 or even more every day.And they can be anytime of the day,during OPD,during conducting a delivery or while the doctor is high on adrenaline levels operating most difficult of cases.Patients want their doctor to be available and easily accessible.Now after reading this post you can understand the average day of a doctor and its not fair to call any doctor money minded if they are not able to answer all the calls or request you make a visit to them for prescription of any medicine.Telephonically, conditions can misunderstood particularly if the doctors mind is preoccupied with some other patient.If they ask you to visit them personally,it isn't because they are money minded but because that is what is medico legally recommended practice and that's for your own safety. 

Monday, January 10, 2011

Which Hospital is better for Delivery?

It was 27th of July 2007.I had returned back from UK for good.Still jet - lagged,in my sleep I got a call from my aunt who at that point of time was out of country and a senior Gynecologist herself directing me to perform Cesarean of one of her American patients in one of the posh hospitals of Gurgaon.Still Groggy with sleep I reached the Hospital.Parking was a problem but then I had my driver to take care of that.
Hospital looked quite welcoming from inside.Nicely laid couches and sofas,a coffee shop with a gang of young doctors sipping their morning cuppa welcomed me with a friendly smile.The administrator of the hospital asked a friendly sari clad front desk lady staff to escort me to the patients room.

Then I reached the room.A big LCD screen , big patient beds and bigger attendant room looked impressive.So far so good!!

I reached the Operation theatre as it was a planned Cesarean.But there were no slippers.Patients husband who was happily moving around the OT to picturise his 4th child's birth offered me his slippers which I gladly grabbed.He started moving without slippers .I was amazed and amused.Till a day back I was working in UK where it would be great safety concern and clinical Governance issue,a human being walking bare feet in OT with a possibility of spattering of blood and amniotic fluid on floor.By the time I got scrubbed a friendly anaesthetist had already rubbed the patients abdomen clean with betadine.My jaw dropped a little at the sight.And then came the scalpel(Blade) which won't cut properly.Asked if there was a blood bank-answer was No.That horrified me.But things went well in her case.So all is well that ends well and she was back again to her swanky room and the comforts of her cosy bed.

Few days later I visited the same hospital,again on request to see a patient who post delivery was having severe neck and back pain and no medicine was working.X ray and ultrasounds were not conclusive.So I suggested an MRI.'We don't have MRI in the hospital mam' replied the registrar.For that we need to send patients out of hospital to associated hospitals having MRI.Not impressive at all.This patient's room was no less swish.Nurses no less friendly.But she needed an investigation and the place was not equipped for it.

So,I find a number of my patients requesting me to deliver them in Posh hospitals as their friends found the staff friendly for would be moms,room bigger and that oh so girly feel,Choo Chweet.......

Dear friends when you are opting for a place of delivery chose it carefully.Things which are important and decisive should be in order of priority :

1) Competent and committed doctor ( Gynaecologist and neonatologist) and other health care providers

2)Basic infrastructure

3) Multidisciplinary stand back arrangements and team like,ICU,Intensivists,Physicians,Surgeon,nephrologist,Cardiologist,Blood bank,haematologist (Things not always go right.And on one that occasions where things go wrong you don't wished to be sent to a far off bigger centre just because your hospital,though has big and welcoming rooms but doesn't have the multidisciplinary team)

4)Friendly help desk staff to take you around the hospital during your initial visits.

5)A comfortable room (Not necessarily plush)

I would say a safe child birth and good outcome is more important than frills like Hospital Brand,Fruit champagne,flowers and balloons,Pink and blue attires provided by the hospital.To translate a Hindi saying,these things can be sugar in the curd but not the curd itself.

Wishing you a safe and happy motherhood.