Tuesday, July 16, 2013

Rectovaginal fistula-------So big in size ;-(

Sometimes God lets you live but life is far from being perfect.Think of a frail old woman of 63years,developing cancer cervix 12 years back.And being diagnosed at stahe IIIb and have radiotherapy.But after radiotherapy survive for 12 years without a recurrence.Not too bad.Living in a small Bhojpuri town with kids not very rich but placed well in kind of job to afford her treatment as and when needed.
And so what happens is that one month back she starts having loose motions and can feel stool in vagina and smells of stool.So they give her antidiarrhoeal but get her to Delhi.Visit quite a few big hospitals in Delhi and Gurgaon and are diagnosed with big Rectovaginal fistula,,,,,,,a hole between  vagina and rectum developed due to radiotherapy done years back.She is told that she has got a RVF which I don't think this Lady understands much considering her uneducated background where her whole life she might have depended on her father,husband or Sons to take decision for her.She is told and also is written on her prescription.....RVF,nothing can be done,onservative management.What does that mean??To sit in a puddle of puff.
Her sons get her to me.They have heard that I deal with such cases.And ofcourse I do.These case are not so difficult if one knows the pelvic anatomy well and can dissect in correct plain.So I say a yes to her.Yes I will operate you.Then I tried to rule out a recurrence of her cancer  by getting a MRI done.Take a biopsy with great difficult from the fistula tract which is quite hard and stenosed and avascular due to her radiotherapy.Both rule out a recurrence.
And Then time to get a fitness certificate from anaesthetist.Yes and we find that she had a recent Myocardial infarction as per ECG.So we need to get an angiography done.So,we arrange for that.And yup......2 vessels are involved.Will need a plasty and then blood thinners.So????? So then what.......try to repair her RVFunder high risk consent now as after angioplasty no surgery can be done for 6 months.Ask the Lady.....her opinion.She leaves it on me.Her sond they trust me blindly.
I am scared of such patients who don't question you and leave all the decision on you.You feel so weighed down by the trust they put on you unlike people who are oh so well educated as to know medicine just too well.Who have so many questions and those who take informed decisions.
Now I and Dr Shalabh decide a plan.Temporary diversion colostomy for sure to give sometime for repaired fistula to heal.then fistula repair.And after angio reversal of colostomy.
So Shalabh does a laparoscopic colostomy successfully in a plastered pelvis.Can't   dissect the rectum from above.
I start developing a plain between rectum and vagina.God,the defect is just too big.The biggest ever RVF seen by me.Anaesthetist asks....Have you done a dye test for fistula :-))?Here a three fingers of mine can pass through the fistula.Who needs dye to make a diagnosis!!So a plain was developed nicely on the right and anterior aspect.But on right side the rectum is tightly adherent to the bone and vagina.Did some dissection but not enough tissue to do a tension free suturing of the rectum.It is impossible.So both me and shalabh decide to close back the dissection.
She has a diverting colostomy now.She won't be sitting on a puddle of stool .But then it is not fair.A rent so big as is impossible to even approximate it.Hope her quality of life would be better,if not 100%,atleast 50%!!

Sunday, July 7, 2013

Feedbacks .........Ignore them!!

Of late Medicine doesn't excite me too much.........I find myself exhausted and tired .Multiple tasks......OPDs and consultations.....endless hours of talking.Trying to survive in the corporate culture.And yes Feed backs some good ,some bad.In older times Journalists had the privileges of bossing.......They were Media.They can make or break you.Now unfortunately,everyone is a media.You find a blog or a forum.You vent out against who so ever you want.

If you are a blog master of any successful blog you can write or publish only good feed backs about a doctor.Delete or hide the unfavourable ones.I just wish I had a friend or a patient like that..........who would just simply edit my bad feed backs.

As always,there is an incident which makes me write me a post.The latest one........the so popular Gurgaonwatch and it's posts on experience with Max Hospital,Gurgaon.I am sure many of my patients came to me after reading a few good comments by few of my patients.Recently there was a bad feedback about me.And I did request the blog master to withdraw it till the genuineness of that feedback was established,knowing the fact that in past he has deleted some unfavourable comments against his favoured doctor.So what happened......he did withdraw it for the time being till he has done the arbitration......established whether I am correct or the person who left the feedback was correct.Got the feeling of 'Media of past'.And a friendly advise ( I hope at least) that I went overboard in defending myself.

Now what was the feedback?Some unknown person 'A' states that Despite her request to get a downs screening test done between 11 to 13 weeks......I stopped her.Telling her it wasn't necessary.Why would I do it specially for her.when I don't let even a 20 years old get away without a downs screening test.

And then she requested for a quadruple marker and I told her to get a triple marker instead( which incidentally I have stopped writing at least 2 years back).Do I have a proof?Yes I have......My pregnancy folder.....I am so happy I came out with it never realizing that it will turn out to be a medico legal document for me in future.(Anyways there are many gynaecologists who are writing triple marker still and it isn't obsolete.They are at no fault if they get it done.)Now she forgets to write that the triple marker came low risk.I guess it was low risk only otherwise she would have written that I  missed a high risk report.

It contains a list of investigations........and double marker and quadruple marker are clearly mentioned there.FAQs in there also explain why should these test be done and are a must.

Double Marker,Triple Marker and quadruple marker all are screening tests and not confirmatory tests with their false positives and negatives both.Too bad if triple marker showed a false negative.Can't help as a gynaecologist.

Now the story is that she complains at 28 weeks of decreased foetal movement and I tell her that 1 movement a day is normal.I must be crazy enough to say so........when again my pregnancy folder clearly tells 10 movement or more in 12 hours.And the she comes to Max Hospital GGN to get a scan done in emergency which is normal as per the ultrasonologist.But she is still not convinced and visits another hospital and doctor whose name she won't divulge......they ask a Doppler ultrasound.........some doctors make the Doppler sound so special...........shows hydrops.No soft tissue marker but hydrops.And the next day there is no heart beat.And an autopsy later it turns out the foetus had Down's syndrome.So I am callous,as per her.I don't know how?I didn't report a triple marker and I didn't do an ultrasound.God hasn't blessed me with a power to predict.

I am not even sure that this is a real patient.......And if it is a real patient then,I don't understand or remember why I would manage her any differently from rest of my patients.

I don't feel like giving any clarification for such baseless allegations.......And this the last such allegation I am responding too.I don't need to prove anything.If I am wrong I will let you know and say a sorry but I don't feel like being responsive to such irresponsible person .