Friday, April 20, 2012

Ultrasounds in Pregnancy-How much is too much?

Just like any other question in life you don't have a tailor made answer to it or a perfect answer to 'how many ultrasound scans should one have in pregnancy'?
To begin with many pregnant Ladies and their family members have a strong doubt about the 'radiation' emitted by ultrasound scan and safety profile of the scan.These scans have been found to be safe for both the mother and the child.
second very frequent worry is about transvaginal scan (TVS).For dating scan around 6 weeks most of the time an ultrasonologist needs to perform a TVS and so many times that has left the pregnant lady and her family almost hysterical ( no exaggeration here) .They suspect an imminent miscarriage and an unfortunate miscarriage is most of the time blamed on an internal probe.In fact even in a low lying placenta at times TVS is recommended for better visualization and assessment.
Now ,here I deviated a little from the main question of how many of them are safe ........The guidelines are three mandatory ones for dating,for Downs Screening and for congenital anomaly screening.Rest it is not mandatory.In a high risk pregnancy many more can be needed.In an obese lady without any other high risk multiple scans can be needed.
There are four types of patients
  • Those who are alright with as many number of scans as prescribed by the doctor
  • Those who don't wish to get even the mandatory and recommended 3 scans
  • Those who are not satisfied with only 3 scans as their friends /family had multiple scans but they question the doctor about inadequate scans but if asked to get a scan done if they wish to as there is no harm except the money involved they are not inclined to.
  • Those who think that their doctor should have prescribed more than 3 scans and themselves visit the ultrasonologist every month for a scan.
None of the four types of approach I would say is wrong.May be less than 3 ,mandatory ones at times can be little risky but to the maximum number.........I don't think that there is a limit as such as long as patient and doctor are happy with each other.

Thursday, April 19, 2012

Parasitic twin

Recently the media has widely covered the birth of a six legged baby in Pakistan.This baby actually isn't six legged.As in many of my previous posts I have mentioned that twin Pregnancy or multiple pregnancy to be precise can cause a lot of complications and this is one such complication.
Here one twin is developing fine while the other most of the time doesn't have a head or heart but is attached to the body of the healthy twin and derives it's nutrition from it.That is the reason the baby without a head is called parasitic twin.
The 'healthy' twin has most of the time many associated congenital structural defects like cardiac anomalies which are most commonly the reason for non survival of the baby.The attachment between the two twins can be at times very minimal and the parasitic twin can be separated easily by surgery performed by a joint team of surgeons,orthopaedicians,plastic surgeons etc.At times the attachment is much more and there might be sharing of viscera like liver when the surgery is quite complex.
Most of them are epigastric parasitic twins but at times there might be two hips or two heads as well.
The optimal time for surgery is between 9 months to 12 months but if the baby is in cardiac failure it might need to be performed even before 6 months.The overall prognosis as said earlier depends on the associated anomaly in the Baby.It can be detected inside the uterus by Ultrasound Scans and in more detail by MRI.
The case is quite rare and the incidence is 1 in 2 million births but the cases might be under reported as well as parents in third world countries might hide such a child thinking it to be a' monster'.Usually such babies are delivered by Cesarean unless it is a very preterm delivery.

Friday, April 13, 2012

The supreme Power

There is one ritual which now I have been following since ages.Before any surgery even if minor I pray to The God for a safe outcome of the surgery.Not for myself.......but for the patien'ts family for whom that Lady is as important as say for example my mom for me.God has been so far very kind and my field of medicine is such that we don't encounter much morbidity and mortality.I am scared of death,loss......loss which is irreparable.That is the reason perhaps why I didn't pursue my interest in cancer surgery.It is see so much human suffering.
What prompted me to write this post was a spate of unfortunate happenings with few of my patients in last few weeks,where I find myself totally helpless.Don't have answer to few of these unfortunate events......and then I realise I am just a medium,it is HE who decides our fates.
The first one was a lady who after multiple failed attempts of IVF,a surgery for fibroids ( Myomectomy)conceived spontaneously.But unfortunately her fibroids has come back in the meantime.....big huge ones.In her level 2 ultrasound scan it was found that the mouth of the womb was opening up.Did an urgent OS tightening surgery.She was just 19 weeks pregnant then.Within a week her membranes ruptured.Today she is 21 weeks and few days.A very positive person she is fighting the odds which are very heavily against her.Reread all the guidelines and high risk pregnancy books to find out a way to help her and found that I can't do much but to pray and treat her empirically with IV fluids and antibiotics etc..Both of us are still struggling in the hope that at least if she reaches 24 weeks........foetus has some chance of survival.There is only one hospital in Delhi the NICU team of which has agreed to take such a case and I am grateful to them.
As if that wasn't enough another patient came in emergency with pain of few hours in which she aborted a 15 weeks fetus.She had a early pregnancy loss in last pregnancy.She didn't cry.Had become stoic.I felt devastated.She didn't even asked me the reason for her miscarriage.Ironically I had examined her for her monthly check up just the evening before where everything was fine.As of now I don't have the answer of her sudden pain followed by miscarriage.Will get her investigated after 6 weeks to see if I can help her in her next pregnancy.And same day another one presented with spotting at 12 weeks...... a scan later it ,missed miscarriage.God .........she cried and cried and cried........felt so very helpless.This was her first pregnancy.I never thought Obstetrics can be no less traumatic than oncology or oncosurgery.Again I read and re read the guidelines on miscarriages and recurrent miscarriages.......But again have realized I might think I am the one who is responsible for successful treatment of patients of recurrent miscarriage in past.As of now.......I firmly believe it is the supreme power.......I am just a medium!!Nothing More!! Am trying to make myself understand the very famous shloka of Bhagwad Geeta ........कर्मण्ये वाधिकारस्ते फलेषु कदाचना
कर्मफलेह्तुर भुरमा ते संगोस्त्वकर्मानी॥

Tuesday, April 10, 2012

Money minded doctors

Hi everyone.......Good to be back after days and now weeks.Initially it was work and then some play(vacation) which kept me away from you.
Thought of giving my perspective of 'money minded doctor'......and I am sure it will help you too.Few doctor friends might not like it as much but that is OK because they are anyways in minority and who would openly accept that they are the'money minded doctor'.
I have read in many forums,sites etc doctor is money minded or not money minded? What do you mean by that?Without exception all the doctors in corporate hospitals are 'money minded doctors' including Me!!No single person is working for charity.I work hard,I work honestly but at the end of the day I wish to earn money just like anyone of you like it.I wish to buy the best designer labels for me........and why not?I know that my profession is such that I have to make money out of your suffering but that is nature of my job.Majority of doctors fall in this hard and earn more.
Now at times we doctors also tend to behave human just like any other profession and look for easy money.Majority of the doctors don't fall into the category I am about to describe.At times there are surgeries which are unindicated or in grey zone where a self control is required because as a patient even if you have googled a lot you can't decide whether a surgery or a more conservative option is better for you.Your doctor can help you in coming to a decision and sometimes the money gets better of us.There are referral fees for Ultrasounds and investigations.(Though good ultrasonologists don't give such referral fee and depend on their expertise for the patients and same with the labs).BTW I don't take referral fees as a principle as it is good for my self esteem and ego which is equally important as money.It also makes me feel different.........and I love the feeling of being different.It sounds very egoist but have always accepted in life that modesty isn't my strong doctors usually don't get you unnecessarily investigated because they get referral fees but they might have preference for a particular diagnostic centre based on their monetary equations with them.At times you are subjected to lots of investigations,not because doctor is money minded.........they are being defensive,to protect themselves legally.It does leave a hole in your pocket but then in some way you are also responsible for it.Patients can get really aggressive if things go wrong and in hindsight can ask why didn't you get xyz investigation to begin with(Which obviously might not have been indicated the doctors play safe).
Prolonging the stay in times it is actually required and if communicated properly patients do understand.Touch wood till date no patient has ever had a problem on this account with me.They understood that it was required.At times it is not required but again doctor isn't money minded but scare and over cautious.And yes can't deny there are doctors who won't mind making few more bucks by keeping you in for a while .How will you know that..........well you won't most of the times or even if you know what can you do.Not much........I realize in my day to day how i am taken for ride in different spheres of life......I know it and take it with pinch of salt and so can you.