Friday, July 29, 2011

Babymoon Destinations in India

 I posted earlier in one of my posts that one of my patient wished to know of any Babymoon destination in India.I had no clue and googled out to understand the concept.
It is a western concept.A nice one though.It means that Usually the couples take a break in second trimester by 24 weeks of Pregnancy to a spa kind of place where ther can have compined Prenatal/antenatal classes with relaxation which ofcourse come for a price.( )
In India we don't have any such classes.Considering that the mindset has changed in the Indian urban population I think we do need such destinations.
As a blog reader,what is your opinion?Do share it on the blog.

Ectopic Pregnancy in Rudimentary Horn of Uterus

So,my last tuesday didn't end where I left in last post.There was more to come.When I visited the hospital again for my evening OPD,I was informed by the front office staff that the Lady who had caesarean in morning has been denied insurance for the time being till I answer as to why it was necessary to perform a caesarean.Enough to blow my fuse.

This kind of query ,asking for an Indication for Caesarean section has never been asked by any insurance company in past from any of the consultants in our hospital.I was obviously offended.Were they questioning my integrity?How dare they?I camed myself down.Replied back.
Then the OPD......which obviously was good interaction with my mostly ever so trusting patients.
And the a Lady on whom I had operated few months back for Ovarian cyst and had incidentally detected a rudimentary horn of Uterus with absent tube and ovary on that side.There was a very rare chance ( 1 in 70,000) that she would have an ectopic pregnancy in that horn of uterus.But still there was a chance and I had asked her to visit me as soon as pregnant.
10 -12 days back she detected her pregnancy ,came to me and to disgust of both of us ,she was that 1 in 70,000.I tried to manage it medically and failed.And that same night had to take her for removal of that rudimentary horn.It is a complicated surgery.Did it.Was happy that could help her and things went fine but by the time my day ended it was 2.30 am in the morning :))
And yes,even this Lady's claim was denied by the insurance .Had to reply in harsh words to get it claimed. 

Tuesday, July 26, 2011

Perils of a gynaecologist.......Need some sunshine badly

My head is reeling badly.Perils of being a doctor........They seem unending.It is a mix of two consecutive sleepless nights and the daytime surgeries and the OPD and the queries of patients in need and of course the duties to be fulfilled as a mother,wife and human being myself.

One of my patient got admitted yesterday early morning with a leaking at term.It was very easy to Induce the labour and be free latest by night specially when I had a Total lap hysterectomy posted on a huge Lady of BMI 36 early morning today.Tried to resist my temptation and followed the guidelines.Give her time to go in labour spontaneously.Waited till night and then Induced the labour after a wait of 14 hours or so.Got a call at 1 in  the night from the duty doc that she was getting some type 2 dips.Was easy to go and perform a caesarean.That would have meant at least I was free to sleep peacefully and be fresh for my morning case.The guideline bug said NO.Please change her sides and may be it settles down.And the baby's heart beats did settle down as they were variable ones.

5.30 am got another call from the duty doc.It is just a rim .I said OK,never mind I have to be there to start my TLH at 7.00 am ,so will be there anyways in time.6am again a call........mam doesn't look like a bandl's ring,head is low,it is occipito anterior  and rim is still there but something is wrong. 

Reached at 6 .45 am.she was fully dilated.looked like a Deep transverse arrest.Told the same to the patient.She wished a vaginal delivery come what may.Told her a high chance of failure of rotational ventouse.She was Ok.I regreted,I don't know how to use rotational forceps.

In the mean time the patient was under anaesthesia in OT and my other team member an accomplished GI surgeon was holding the fort there.Now it is just not that she is a high risk obese TLH patient but her insurance is under GIPSA.And her insurance company wishes me to do a TLH on her using best of instruments and best of expertise but should not charge more that Rs 73500 which is same as a conventional open hysterectomy.It isn't just medicine but also the business.I don't know how to provide my patients those services which they are entitled to when the cost of instruments and expertise involved is not covered in it.I am under too much of pressure.I speak last time and now I will think how will I manage next time,the stress involved isn't worth it.

Yup so,in between the lady in labour........I tried 3 pulls of ventouse and the baby's head came down a little but no rotation at all.

Time for a caesarean in 3rd OT.patient and her relatives are disappointed.The OT in charge isn't too happy with me.According to him it is too much chaos created by me.Now how do I anticipate an emergency?I would be the last person to wish an elective case and and emergency side by side.Maybe shouldn't have followed the guidelines.Early morning.......staff isn't yet in full capacity.I am already boiling and then try to calm myself down.Just the beginning of the day.....

And there comes a massage from my team member.....When will you finish caesarean???The Lady for TLH has lots of gut adhesion and he needs me there......Ok ,I finish my caesarean and rush there.By that time he is already done with the adhesion and we start TLH.It ended peacefully after a pushing her visceral fat and guts falling all over the place.All through out I have to remind every one in the OT to be cost effective as well.Remember she is a 'GIPSA patient...........'!!

It is too much of  a balancing........Guidelines,ethics,emergencies,insurance,colleagues and instrument failures as well........

Then I went for my routine round.And here I have my patient who delivered yesterday.She never complained throughout the pregnancy.Always used to ask me jokingly while in OPD......Doc ,what do all these pregnant ladies ask you/It takes them ages to come out of the chamber.And then she used to give a throaty chuckle.Same she did in her labour.Pushed the baby out with ease and confidence.Within an couple of hours of her delivery was moving around and today morning gave me a warm smile.Then followed her throaty laughter and she said.....'sab badiha hai!! When will you let me go'? Here was my sunshine.......

Sunday, July 17, 2011

You have 4 more weeks to live...........

Way back in  nineties I was appearing for my second M.B.B.S. exams.One fine morning I woke up with a high grade fever .I popped a tablet of paracetamol and 2 tablespoon of sulphonamide syrup ( which I had taken in past as well with no side effects).Within few hours I started feeling a  severe difficulty in breathing.My head was reeling badly and my joints were swollen and body was full of rashes.I had a very bad reaction with sulpha drug.It almost looked like serum sickness.I was alone in my hostel room and was just two days away from my Microbiology exam.It seemed the end was near.And suddenly someone knocked at my door.I gathered my strength ,opened the door and was surprised to see my mother who had come to see me from Patna to Gaya,as she felt that something was wrong with me.(I don't know whether it was just a coincidence or some supernatural help but fact of the matter was that she was there with me).It gave me immense confidence and after 7 to 8 hours I was still miserable but wasn't deteriorating any further.

Two days later I appeared for my Microbiology exam though it was a very painful experience as I was short of breath and was barely able to speak with very painful joints.Somehow I managed and with my mom I left for Patna ,where my parents used to live then.

Slowly I started feeling better but my swollen joints got worse.My brother who at that time was undergoing his postgraduate training in internal Medicine took me to his assistant professor who had returned from UK with a MRCP degree to his credit and was considered quite knowledgeable and smart.He listened to my whole history and advised CBC and Rheumatoid factor to be checked.

When I along with my mom went to the pathology lab to collect my reports,the technician asked us to wait as the pathologist wished to see the person whose blood had been tested.When he saw me, his looked visibly sad and gloomy.He forwarded the test report to me and said that he would like to perform a repeat test on me.
One look at the report and I knew the reason of his expression.My myelocytes and Myeloblasts were in very high numbers and my total leukocyte count was very very low.Myelocytes  and blasts are present in the blood of patients having blood cancer.My mom asked anxiously to the pathologist , 'what is wrong in the report'?
Before he could reply,I said mom he suspects that I have leukemia.He was shocked and asked me that how could I read the report.I told him that I was a medical student and that made him visibly more restless.I could sense his anguish with the idea of a young life which will be lost soon.He repeated my tests and same were the findings.He suggested a bone marrow test to confirm the findings.

In the mean time I got in touch with the Physician.He announced - you have atypical leukemia as the total counts are low rather than high.Visibly scared I asked him the prognosis expecting a comforting reply.He told me in a matter of fact tone,you are a medico,you know it that you don't have more than 4 weeks to live.(Not playing Chinese whisper here,actually these were his words)Ask your parents to arrange for money to take you to USA for a bone marrow transfer.

I contested,Sir to me it looks like ,that due to the drug reaction I had a bone marrow suppression and that explains my swollen joints.Total count is low,which again goes in favour of this.And a high myelocytes and blasts show that my body is trying to overcome this suppression.He looked at me and said .not at all!!I told you, you have leukemia .There was a tone of finality in his voice.He was an MRCP and I was just a second year medical student who was talking theory read in microbiology and pathology.My logic stood no chance.

I was scared.I didn't want to die at 17.My parents were upset and so was my brother.Life came to a stand still.I went for my bone marrow test.My sternum was pierced with a thick needle and then had to wait for 48 hours to get the report.It looked as if I was waiting for my death sentence.All the time I was measuring my temperature,as in Leukemia one can have fever.And with stress i did develop low grade fever.

I was again and again looking at my skin to see any purpura( blue spots) seen in leukemia.My mom was at Hanuman mandir and so was I.Death was very very near.My parents could not have afforded a treatment in USA.

Finally the wait was over.My brother had to collect the report but he just sat down hiding his face behind the news paper.May be he was crying.Ultimately after 10 to 12 visits to washrooms my dad gathered the courage to go and collect the report.

He came back,looking all relieved.There was no evidence of cancer.So ultimately my logic was the right diagnosis.I gave a victorious call to the physician,who sounded disappointed as his diagnosis had gone wrong.

That incident taught me empathy.whole throughout these years when ever I remember this incident I just wish if that Physician was little more compassionate and thank God that it was just a bone marrow suppression and I am still alive to share this story with you!!

General Insurers Public Sector Association (GIPSA) and it's effects

Since last few months GIPSA packages have been implemented and my hospital is also allowing cashless facility for GIPSA  patients.
As per this GIPSA package whether a patient has paid premium for a triple sharing room(thus a lower premium) or a single sharing room(higher premium)they are entitled to same amount of money being released by their insurance company to the hospitals for a particular procedure.Fore example whether a patient delivers in in shared room or a single room ,hospital and doctor will get a total of Rs 35000,which includes bed charges,medicines,disposables,surgeons charge and all other expenses.At the moment most of the time hospital ends up spending more than what they get ultimately from these packages.Even for doctors the payout has gone down drastically.Now to cut costs,we have to compromise somewhere and so will the patients.We have to be particular to use minimal possible consumables which will ultimately reflect in patient care.
Whether it is conventional open hysterectomy or advanced laparoscopic TLH GIPSA package will pay only 73000 all inclusive to the hospital.While in an open hysterectomy you don't need costly instruments neither as much skill as a laparoscopic procedure,the payout to hospital and doctor will be same.Even if it is a very small uterus or the most difficult of Hysterectomy again the payout is same.Agreed that Hospitals and doctors will suffer badly but what about the patients?Despite paying huge amount of premium they will be deprived of good services.For a total laparoscopic hysterectomy one needs disposable items like harmonic,morcellators etc,the cost of which runs into several thousand.So if the hospital isn't paid for the instruments used how can it provide the services to the patients?So even if a patient could have had a laparoscopic hysterectomy will end up with open surgeries because of these rules.
God forbid if during delivery a lady has any unforseen complication like Post partum haemorrhage,it isn't covered by GIPSA and whatever the extra cost patient ends up paying from the pocket.Insurance copanies do say that incase a doctor tells these special circumstances,the bills will be taken care of,but in my daily practice till date I have seen patients paying it from their own pocket as their claims are denied by insurance companies.
Who will gain out of it?surely the insurance companies.These kind of packages will also increase unethical practices.Don't know what the future holds but it seems quite complicated at the moment.
Imagine......every year the house rent goes up ny 10%,driver's salary has gone up from 10 k to 15k,quarterly school fees of the child has gone from 28 k to 45 k........and if the earning of a doctor is coming down year by year it isn't fair.But then who said life is fair ?????

Friday, July 15, 2011

Meconium Aspiration Syndrome (MAS)

Meconium is the stool which baby passes inside the mother's womb.It usually happens when baby is in distress,getting reduced oxygen which leads to dilatation of anus and thus passage of stool.All cases of
Meconium don't need a caesarean section but at the same time it isn't a very easy situation for the obstetrician.As the meconium starts to thicken baby can aspirate it in the lung with problems of various severity.
Last month only I did manage to deliver two ladies with thin meconium vaginally,but yes I do get stressed while waiting.It is no win situation for the doctor.If you say it calls for caesarean patients don't like it.If you wait and baby's aspirates it(no one can predict beforehand whether baby will or won't)then it is the doctor who gets all the beating.
In last two days I came across two ladies who are second time pregnant and both had bad experiences due to MAS in 1st pregnancy.First one lost her new born child and the second one has a child with Cerebral palsy.MRI of this Child done at the time of birth is suggestive of lack of oxygen during labour.Both of them were understandably sad and blamed their Gynaecologists.While as a neutral person I couldn't find fault in management of either of the doctor.It was sheer bad luck both for the doctor and the patient.
We need to understand that doctors are no God.They can try their best but after some point there is a supreme power who decides all our fates.
And after these two incidents which I came across this week,my threshold for performing caesarean following passage of meconium would be much less.

Thursday, July 7, 2011

Prevention is better...........

How many of you have been for a preventive health check up?Many of you have been and most of you have not been for one.At least till date I haven't got a preventive health check up done.Some of us think that'' I don't need it.These deadly diseases affect others not me", while others are too scared to go for it.What if there is something wrong?I belong to the second category.
But not any more.Have decided to go for a Preventive health check up soon.Even if there is a disease it can be detected early and can be fixed.
Someone close in family was detected with a breast cancer recently.Luckily for her it was still very early and hopefully she has many more years in front of her to live and enjoy life.But she is just like you and me,who enjoys life,young with young kids and no symptoms at all .About a week back she was oblivious of even her condition and celebrating life.A week later she has been operated for her cancer.It is shocking.I have been asking myself a question,if it could be her why it can't be me?Of course it can be me and you too.
Plan your Preventive health check up if it is due. And all the best .Wish you many more years of healthy and happy life.

Tuesday, July 5, 2011

Vaginal Delivery ,has it got anything to do with doctor's skills?

What do you think of a gynaecologist whose patients have more of vaginal delivery?That she is honest,ethical, has patience,considerate,compassionate.But has it ever crossed your mind that it needs something more than that as well.....'SKILL'.Somehow we don't associate a vaginal delivery with doctor's skills.Majority of normal deliveries are surely about being honest,ethical,having patience,considerate,compassionate but not all of them.During the course of labour there are many stages when it is very crucial how skillfully your doctor takes a decision.If baby has passed stool inside the womb,does it mean performing a caesarean section or wait for couple of takes science,art and skill and of course experience.
When a lady is fully dilated and still not able to deliver a child and your doctor helps you out with Vacuum or forceps without causing any harm to you or the baby it needs immense amount of skill.
I have got lot many compliments for conducting vaginal deliveries but the one compliment which I still have to hear is 'Doc you are skilled'.I am awaiting to hear that.Maybe it will be you,who says so :) !!