The Feeding Jejunostomy Lesson

Non Medicos version

Dr. Tarun Kumar Chaturji (Fictional Name) had joined as a junior resident doctor in the Dept. of Surgery, AIIMS, New Delhi. A patient suffering from cancer of the food pipe (esophagus) was admitted in his unit. Due to the cancer tumor blocking her food pipe she was not able to take liquids or even drink water. The patient and her relatives had delayed in seeking proper medical attention. At the time of admission, the patient was sick and in a moribund condition. 

Dr. Chaturji discussed with his senior resident about the feasibility of making a feeding jejunostomy. 

For Non-Medicos: In feeding jejunostomy, the abdomen is opened and a small tube is inserted in the small intestine (bowel). The patient can be given liquids diet through this tube directly into the small intestine. This improves the patient’s nutritional status and allows the patient to be kept and managed even at home.

Since the general condition of the patient was very poor, the anesthetist, refused to give general anesthesia to the patient. 

For Non-Medicos: Anaesthetist is a doctor specializing in putting patients to sleep at the time of operation and keep the patient unconscious and pain-free. In general anesthesia, drugs and inhaling gases are administered to the patient, so that they remain unconscious and pain-free at the time of operation. 

Since Dr. Chaturji did not want the opportunity to operate on the patient to be missed, he along with another fellow junior resident, took up the patient for surgery under local anesthesia. 

For Non-Medicos: In local anesthesia, certain drugs are injected around the area where the doctor is operating to make only that area of the body insensible to pain. 

In the Operation Theater, they injected the local anesthetic drug and started to operate on the patient. Initially, the patient made some sounds to show here discomfort. Since some amount of discomfort is inevitable while operating under local anesthesia, they did not pay much attention to it and got busy in finishing the operation as soon as possible. 

Near the end of the operation, they noticed that the patient has stopped making sounds of discomfort. They assumed that their local has worked well, congratulated themselves on giving such good local anesthesia and continued their operation. 

When they finished their operation and removed the clothes covering the patient, they found the patient was not breathing. She did not have a pulse and her heart was not beating. She was dead. 

Since the patient was already very sick and in a moribund condition, the patient’s relatives accepted the news of her death without blaming the doctors. The head of the unit did not take this so coolly and Dr. Chaturji received some heavy verbal reprimand from the unit head.

Do not operate on sick patients without adequate monitoring and back up facilities. For example, it is now standard medical protocol to have a dedicated doctor monitoring the patient’s condition, such as pulse rate, blood pressure, respiration, even when operating under local anesthesia.

The same holds true in a variety of situations in life. 

Perhaps you have joined an organization and you have not been given any major or important project or duty to handle. You may be tempted to take up something which others may be avoiding. If you carry out it well, you may get recognition. If you fail, it may be a disaster for someone just starting his career. So before going in for a do or die situations, take care to adequately cover yourself. 

When you are engrossed in an activity, you may not able to see the complete picture. You may miss the forest for the trees. In such a situation it is invaluable to have someone to monitor the complete picture and place your efforts in the right perspectives. 

 (Based on an allegedly true incident)

— ND

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norms. 

The Onco-Surgeon

Non Medicos version

After passing his Master of Surgery (MS) exam from AIIMS, New Delhi, Dr. SV (Fictional Name) surprised everyone by joining the newly started cancer center at AIIMS. 

This surprise among his colleagues was based on multiple reasons. As the work was still going on in the under-construction cancer center, the operation theatre (OT) was not ready and was not likely to be operational for a few months. There may be many months before the first major operation will be done. 

Most surgeons are an embodiment of the adage, ‘choose a work you like and you may not have to work again in your life’. For the diehard surgeons operating on patients is a pleasure and not work. Many surgeons feel unhappy if they have to go without doing some operation for some time. This dose of pleasure will be missing for some time in the new cancer center. 

Further, being a cancer center, only cancer-related surgery will be done in the new center. Surgical oncology (Treatment of cancer by surgery) was not a recognized / well established separate field at that time. There was skepticism that what new things they will be able to do in the cancer center as good cancer surgery was already being done in the general surgery department of AIIMS, New Delhi. 

Despite these facts, Dr. SV made the move to surgical oncology in the new cancer center. 

As expected the operation theatre was under construction and Dr. SV was free on the OT days. Instead of wasting his time, he used the time to practice endoscopy, which was available in the new center. He became an endoscopist as skilled as any gastroenterologist (a doctor super-specializing in the diseases of liver and bowel). 

When the OT was ready, they started doing regular operations in addition to endoscopic procedures. As time went, the field of surgical oncology and the cancer center become well established with Dr. SV earning national and international fame as a cancer surgeon.

An opening of a new division, unit, center, department or field may present an opportunity to make a leap in your career. Shifting to a new field/division may turn out to be very rewarding in the future. 

Don’t judge a thing by its immediate or near-future potential but by its long term potential. Dr. SV realized the long term potential of specialization in cancer surgery and made the career-enhancing move.

In the initial phase of a new beginning or even in the middle of your career, there may be time periods when you may be relatively free. Instead of wasting this free time, use this time to improve your skills, join a course, practice something new, read, research or even just build up a network of contacts.

 (Based on allegedly true incidents)

— ND

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DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purposes. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norms. 

The End of Trouble

A man was suffering from cancer, but his relatives and doctor had not told him the expected outcome. 

When he lay dying he called his doctor and asked him, “Doctor, six months ago you had told me that my troubles were going to end soon. But here I am dying.”

 The doctor replied, “I had told you that your trouble will end and not that you are going to be cured. If you die, won’t your trouble also end?”

(Fictional)

— ND

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DISCLAIMER: This article is intended only for fun purpose and not belittle or make fun of doctors or cancer patients. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

The Lymph Node Biopsy Lesson

A young boy came to AIIMS, New Delhi with complaints of fever and abdominal pain. On investigation, he was found to have multiple enlarged lymph nodes in the abdomen. 

For Non-Medicos: Lymph nodes are tiny bean-shaped organs found throughout the body. They may be 500 to 600 in number. They filter the lymph flowing in the body and are an important part of the body’s immune (defense) system against various germs. 

The lymph nodes are generally few mm in size with the largest being lymph nodes lying in the inguinal (groin) region where size up to 1 cm (10 mm) may be normal. They may become enlarged (increased) in size in a variety of disorders such as viral or bacterial infections, e.g. infectious mononucleosis, tuberculosis, skin infections, and even cancer.

He got admitted in the surgery department and a laparotomy, (opening the abdomen by making a surgical incision (cut) and examining the internal organs usually done under general anesthesia in the major operation theatre, and biopsy of enlarged lymph nodes was planned. This was the days before the spread of laparoscopic surgery.

For Non-Medicos: Lymph node biopsy is a surgical procedure where single or multiple lymph nodes are removed by operation and sent to the pathology department for histo-pathological examination to find if they are having any disease.

On routine check-up the junior resident found that he had minimally enlarged lymph nodes in the left inguinal (groin) region. This finding was discussed on the ward clinical round, and as tiny lymph nodes in the groin region are very common even in a normal person and the biopsy of these inguinal lymph nodes usually is not diagnostic, the original plan of laparotomy was followed.

On opening the abdomen the lymph nodes were found to be adherent to each other and to large blood vessels and covered with fibrous tissue. A small piece was taken for biopsy due to fear of causing any complications due to injury to the large blood vessel stuck to the lymph nodes mass.

The pathology report came back after a week. It was inconclusive, i.e. no clear opinion was possible and the pathologist advised to repeat the biopsy with a bigger piece.

The patient and his parents were upset when they learned that the patient will once again have to undergo the major laparotomy operation to get a fresh tissue sample for repeat pathological examination.

The junior resident looking after the patient noticed that those left groin lymph nodes which were initially tiny on admission had now grown to significant size since the patient had got admitted to the ward. This was discussed in the clinical ward round. Although biopsy from the groin lymph nodes are usually inconclusive, but after considering the risk-reward ratio, it was decided to do lymph node biopsy from the groin and wait for the result before doing a repeat abdominal operation.

The patient underwent the relatively minor operation of the lymph node biopsy from the groin region under local anesthesia in the minor operation theatre.

One week later the biopsy report came and there was the unequivocal diagnosis of lymphoma, a cancer of the lymphatic system. With the diagnosis made, the repeat laparotomy was canceled and the patient was referred to the oncology (cancer) department for further treatment such as chemotherapy.

During an ongoing treatment of a patient, a project, a journey, etc. the situation may change. As in this patient, there were only tiny lymph nodes on admission but they increased to a significant size during the hospital stay. Keep on continuously monitoring the situation and if something new occurs then you may change your plan accordingly.

Do not disregard the observation and suggestion of any member of the team, no matter how low in the hierarchy he/she is. This is especially true if the team member is closely involved in the day to day care/function of the patient/project. For example, the junior resident is junior most in a medical college unit, yet due to his keen observation, the patient was saved from undergoing another major surgery.

In real life, sometimes there may be an exception to general rules or guidelines, such as in this case. Biopsy from the groin lymph nodes is not usually done but in this patient, biopsy turned out to be diagnostic from the groin region. So be open to making exceptions to rules and guidelines according to the actual situation.

(Based on an allegedly true incident)

— ND

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm.

The Rectal Cancer Patient

An elderly patient suffering cancer of the rectum (the last part of the digestive tract, just before the anal canal and anus opening) got admitted to the Surgery Department of AIIMS, New Delhi.

Cancer of the rectum is uncommon in India, so there was a great academic interest among the doctors regarding this patient. Unfortunately, as the cancer is inside the rectum, the only way to examine the lesion is by digital per-rectal examination, i.e. inserting the gloved finger inside the anus to reach the tumor and blindly feel it. Since the tumor is usually ulcerated, the procedure can be very painful.

Due to an academically important case, the patient was directly admitted to the Surgery ward without getting the investigation done on the OPD basis, which would have taken him 3-4 days. The patient was advised to get all the investigations done in the ward along with CT scan of the abdomen and pelvic region for which he got an appointment for 5 days later.

While waiting in the ward for the CT Scan, all the doctors of the unit examined the patient with a per-rectal examination.

When the MS exam going batch came to know of this patient, they came in a group and examined the patient including per-rectal examination and presented the case to the faculty member.

The MBBS batch posting was also going on and they also had a class of the patients with the per-rectal examination by some of the students.

Fed up with the frequent painful per-rectal examination and without any specific treatment by the doctors, the patient the approached the consultant on the morning round and said, “If the only treatment for my condition is putting a finger in my anus multiple times, then please discharge me as I will go home and get this treatment there from my three sons.

 (Based on allegedly true incident)

— ND
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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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The Delayed Examination

A patient with rectal cancer came to a free surgical camp for consultation. He consulted Dr. KG Daniel, (Fictional Name) who was the senior surgeon of the city. Dr. Dev (Fictional Name) who was also the consultant at the camp was in the same room. Dr. Daniel said he would like to do an examination of the rectal cancer using his finger.

Hearing this, Dr. Dev observed that the patient’s face became miserable as he had undergone a per-rectal examination before and could not forget that painful experience.

For Non-Medicos:  In the rectal examination the surgeon inserts a gloved finger in the patient’s anus and digitally examines the cancer for such characteristics such as size, surface, its extent, fixity to surrounding structures, etc. Being an ulcer the finger moving over it feels very painful, but there is no better alternative.

Dr. Daniel asked the patient to get in the position for the rectal examination. Once the patient was in position Dr. Daniel looked around but could not find the gloves of appropriate size for his hands. The patient’s face becomes more miserable. The nurse went in search of gloves of the proper size.

When finally the gloves came, it was found that the lubricating-cum-anesthetic jelly was missing. The nurse again went to get it from the store. The waiting patient’s face became more miserable in anticipation of the coming rectal exam.

When everything was arranged for satisfaction, the receptionist came with tea for the doctors. Dr. Daniel asked her to wait until he finishes the rectal examination. The receptionist beseeched Dr. Daniel to have the tea first or it will become cold as it was the month of December. Ever a gentleman, Dr. Daniel could not turn down the receptionist’s request and sat down to sip the hot tea.

By the time Dr. Daniel had finished his tea the patient was tossing and turning while waiting for his ordeal to begin and get over. He breathed a sigh of relief when the painful rectal examination finally started.

In medical profession or in other areas of life, don’t let people wait for unpleasant things unless you take pleasure in torturing them. If something unpleasant needs to be done then get it done fast and let the person have the least amount of time worrying about the coming ordeal.

(Based on true incident)

— ND
© Author. All rights reserved. 

If viewing from Mobile, switch to Webpage view to see a list of popular posts and index of topics of previous posts.

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norm. 

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