Agnipath

Thursday, 3 May 2018

The Heart Sound Quandary

Dr. Jitender Kumar (Fictional Name) was appearing for his final MD (Medicine) exam in AIIMS, New Delhi. Being a brilliant student he was the favourite resident of the Head of Department (HOD) of Medicine.

In the MD (Medicine) practical exam. Dr. Jitender Kumar was allotted a patient suffering from damaged heart valve.

For Non-Medicos: There are four heart valves, two each on right and left side. Abnormality of this valves can produce abnormal heart sound know as murmurs which can be heard with the use of a stethoscope (the Y-shaped tube like thing which doctors put in their ear to listen to your heart and lung). Murmurs produced when the heart is pumping out blood are known as systolic murmurs. Murmurs produced when the heart is filling with blood is known as diastolic murmur. Knowing if a murmur is systolic and diastolic and whether on right or left side of the heart the physician can diagnosis which heart valve is damaged even without other investigations such echo-cardiography.

The Head of Department of Medicine, AIIMS, New Delhi and another examiner, the external examiner, from a different medical college were jointly taking the viva in the practical exam.

When it was Dr. Jitender Kumar’s turn to present his case; the discussion reached to what type of murmur the patient was having? Dr. Jitender Kumar replied, “Sir, the patient is having a systolic murmur.”

The external examiner listened to the patient’s heart sound with his stethoscope and raised his head in amazement. “What are you saying?” inquired the external examiner, “the patient is clearly having a diastolic murmur!” Turning to the HOD Medicine he requested, “Sir, Kindly listen to the patient’s heart and confirm it is a diastolic murmur.”

The HOD – Medicine was in a quandary. A systolic murmur is as different from a diastolic murmur as sunrise is from sunset. If he confirms it is to be a diastolic murmur, it will be difficult to justify passing his favourite resident in front of the external examiner after committing such a blunder.

The HOD – Medicine applied his stethoscope to the patient’s chest, listened for few minutes and gave his verdict, “It is a systolic murmur.”

The external examiner was surprised, to say the least, “Listen again carefully, Sir,” he demanded, “It is a diastolic murmur, not a systolic murmur.”

The HOD – Medicine looked at the external examiner and said, “You and I have become old. Our hearing is not what it used to be. If the candidate is saying it is a systolic murmur, then it must be a systolic murmur. But if you are having any doubt then let us call the cardiologist to find out what type of murmur it is.”

So a message was sent to the cardiologist on call with the instruction, ‘Come and listen to the patient’s heart and whatever the murmur is, say it is a systolic murmur!’

So teachers go to extreme length to protect their favourite students. Lucky are the students who get such teachers. Having a good relationship and creating a good impression on your teacher can prove quite beneficial in the exam.

(Based on a true incident)

— ND

© Author. All rights reserved.

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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behaviour 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 behaviour 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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Thursday, 26 April 2018

The Axillary Block

One patient suffering from infection of hand came to AIIMS, New Delhi, for treatment. He was seen by Professor Tarun Kumar Chaturji (fictional name) and advised I & D operation.

For Non-Medicos: I = Incision / cut in the skin over the site of infection and D = Drainage / letting out of the pus / infected material.

The infection was in advanced stage and normally require general anesthesia (G.A.) for adequate drainage / operation.

In G.A., the patient is made fully unconscious. For G.A. the patient normally requires blood investigations, a chest X-ray, E.C.G., etc. He has to be absolute fasting for 4 to 6 hours before general anesthesia, i.e. he has to stop taking even take water for at least 4 hour before the operation. He also needs to be admitted and monitored after operation. There is also the slight but definite risk of general anesthesia.

Dr. RG (fictional name) was junior resident at that time in AIIMS, New Delhi. Dr. RG was very dynamic and enthusiastic resident doctor. He was always looking for new ways to serve the patients. He thought of operating on the patient using only regional anesthesia, i. e. axillary block.

For Non-Medicos: In axillary block, a local anaesthetic injection is given near the axillary artery in the axilla (armpit) blocking the pain sensation in hand, forearm and arm.

At that time the concept of regional nerve block was in nascent stage in India. Even most of the anesthetist had not done many of the regional blocks such as axillary blocks. Dr. RG had not done this procedure before although he had studied the theory of the block in great detail and practiced mentally the entire procedure many times.

The patient was bought in the Emergency O.T. (Operation Theater) in the AIIMS, New Delhi and positioned on the operating table.

Dr. RG had especially purchased a book on anesthesia for its detail instructions on nerve blocks meant for non-anesthetist. To make sure the block will work perfectly, Dr. RG decided to follow word to word the instructions given in the book.

Since he had don sterile gloves and was doing the block, Dr. RG asked the nursing staff to read aloud the steps from the anesthesia book, so that he could follow them exactly word to word without any margin for errors.

Following the instructions, Dr. RG gave an excellent block. The patient had excellent anesthesia and did not feel any pain during the otherwise very painful procedure.

Two days later, Professor Tarun Kumar Chaturji called all the residents doctors to his office.

Professor TK Chaturji asked, “Have any of you operated on the patient with hand infection two days ago?” “Yes sir, I did the I & D in that patient”’ replied Dr. RG.

“What anesthesia did you used in the operation?” inquired the Professor.

“Axillary block sir,” proudly Dr. RG replied. His sense of pride was justified as perhaps he was the only surgeon in AIIMS, New Delhi at that time who had given such an excellent axillary block.

“Well the patient’s relatives have complained that you are doing operations while reading from books”. informed Dr. TK Chaturji. “You are treating the patients as experimental guinea pigs.”

While the patient was being operated in the Emergency OT, the patient's relatives were standing just outside the operation theater door had overheard the staff nurse reading from the book. They found that Dr. RG was doing the block for the very first time that too from reading a book.

They were shocked that even at a premier institute like AIIMS, New Delhi, doctors were learning while doing operations and had complained to Professor TK Chaturji for entrusting the operation of their patient to such a novice surgeon.

This raises some important ethical, moral and medico-legal questions. Any doctor has to do all his procedure or operation for the first time some time in his lifetime. Should we expressly tell the patient that we are doing the procedure for the first time? If a doctor does only those procedure / operation that he has done before how will his surgical repertoire improve.

But why only the doctors? There must be a first time when a taxi driver takes his first passenger on a ride, bus driver drives the bus independently or pilot flies a commercial flight independently. Do we ask or do they tell their experience before getting in a taxi, bus, or airplane.

Clear practical guidelines should be made so that doctors doing or learning new procedure does not get unnecessary victimized or criticized depending on the complexity of the procedure and / or the potential for complications.

Tip: Following word to word instruction when doing any new procedure can reduce your chance of committing an error.

Tip: At that time better keep the patients relatives away from the operation theater while doing any operation for the first time (Just Joking).

(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.

You can share this post on Facebook, Twitter, Pinterest, Google +, etc, using the Buttons above 'Labels' and below 'Posted by:'.
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Tuesday, 26 December 2017

The Phimosis Operation

One incident occurred with Prof. Tarun Kumar Chaturji (fictional name) while he was resident at AIIMS, New Delhi.

One of Dr. Chaturji's fellow doctors was going to USA for further studies. He was suffering from phimosis.

For Non-Medicos: In phimosis, the foreskin at the end of the penis is tight with small opening. The foreskin cannot be pulled back causing difficulty in passing urine and other related activities. The cure is circumcision which involves cutting the tight foreskin and stitching the inner and outer surface of the remaining penile skin together.

He requested Dr. Chaturji to perform circumcision on him, before he left for USA. Due to nature of his disease and the organ affected, his friend requested Dr. Tarun Kumar Chaturji to protect his privacy and do other operation with utmost secrecy.

One evening Dr. Chaturji took his friend to the Emergency Operation Theatre or EOT in the Emergency Department. This operation theatre was isolated and few doctors or para-medical staffs used to come there.

Before starting the operation Dr. Tarun Kumar Chaturji even requested that only one staff nurse to stay in the operation theatre (OT) and other staff members to stay outside while his friend's genitalia was exposed during operation. Dr. Chaturji did not ask any other resident to assist him for sake of privacy.

Dr. Tarun Kumar Chaturji started the operation. He first cleaned the operative body part with antiseptic lotion and put sterile sheets (drapes) around the area of operation. He then gave an injection of local anaesthetic agent around the penis to numb the area and started the operation.

As the staff nurse was assisting both as scrub nurse and assistant surgeon, Dr. Tarun Kumar Chaturji, placed some instruments on his friend's thigh for quick and easy access to them during operation.

As Dr. Chaturji neared the end of the operation he started to stitch the remaining cut end of the penile skin together. As he took a stitch near the fraenulum of the penis, his friend gave a loud yell and jerked his body of the table.

The fraenulum is very sensitive to pain and difficult to anesthetise with local anaesthesia. Also with the passage of the time, the effect of the local anaesthetic had become less. These factors combined to cause severe pain to the friend.

Due to the sharp jerking of the friend, the instruments lying on his thigh went upwards, sailing towards the roof as if launched by a rocket-launcher.

According to Newton's law of Gravity, what must go up must come down. The instruments which included a surgical knife with sharp blade come down with equal velocity.

Unfortunately the surgical knife came down sharp end first and its tip first pierced the surgical drapes, then Dr. Tarun Kumar Chaturji's friend skin, his subcutaneous fat, the thigh fascia and finally pierced his femoral artery.

For Non-Medicos: The Femoral artery is the main blood vessel carrying oxygenated blood from the heart to the lower thigh, leg and foot. Damage to it can lead to gangrene of the lower limb.

Now a jet of red arterial blood spurted towards the roof from the wound in the femoral artery.

Fortunately, Dr. Tarun Kumar Chaturji, showing quick reflexes and presence of mind immediately pressed a sterile gauze dressing over the bleeding wound, stopping the bleeding. While maintaining pressure with his hand over the wound, Dr. Chaturji reluctantly asked the nursing staff to call for help.

Dr. Tarun Kumar Chaturji's unit consultant came and saw what was happening, others doctors working in the emergency department also came. Finally the CTVS vascular surgeon was called to repair the artery with anaesthetist to give general anaesthesia for the operation.

So what started as an operation in secrecy turned out to be an open day and Dr. Tarun Kumar Chaturji, his friend and his operation became the talk of AIIMS, New Delhi, for days to come.

Remember Dr. N. K. Dewanda's Law of Medical Secrecy: The more you want an operation to remain secret, more is the chance that due to some complication or other it will become public.

Tip: Never keep any instruments, especially sharp instruments on the patient's body. They may fall down and injure the patient or the operative team members. This is also not desirable from a sterility point of view.

Tip: Most bleeding can be easily controlled by applying pressure with sterile gauze, etc. Don't release the pressure until competent help arrives.

Tip: In a tricky situation, no matter how embarrassing, never hesitate to call for help.

Tip: If some complications develops, it is better to let someone more experienced or qualified to handle it. Dr. Tarun Kumar Chaturji resisted the urge to repair the bleeding vessel on his own.