You can’t win in this job

A 60 year old lady waddled into my clinic.

“Doctor, I’m getting fat. I need some medicine to reduce my tummy and weight.”

“You’re in the wrong clinic, madam. I am a gynecologist, not a general physician.” 

“No doc, I was sent here by the physician doctor.”

I examined her. She had a grossly enlarged tummy, but the rest of her body was quite thin. A scan showed an enormous tumor.

We operated on her the next day. The tumor was 18 inches (45 cm) in diameter. With both my hands around the cyst I could not even budge it. The scrub nurse joined in and with double the biceps power we were able to remove the cyst. 

I cut the excess skin and tissues, located the muscles on either side and brought them together. The lady now had a flat tummy that any 20 year old model would be proud of.

Needless to say, m’lady was very happy with my cosmetic surgery. She did not care that she had an ovarian tumor. To her, I was the doctor who had made her slim again.

To this day, she sends all her overweight friends to me. All of them want a flat tummy like hers. 

Fleecing patients

The guy who cleans my car wanted to have a word with me this morning. He looked very worried.

” What is it?” I asked.

” Sir, can you tell me how much a CT scan costs?”

“Around 4000 to 5000 rupees,” I said. “Why, has someone asked you to get one done?”

” No Sir. My mother was admitted last night with vomiting and diarrhea. The doctors gave saline and medicines and told me to get a CT scan done. I got a bill today for 20000 rupees of which the scan alone is 15000 rupees.”

“15000 rupees for a scan!” I exclaimed. “That is three times the regular price! Why?”

” Don’t know Sir.”

” So did you pay the bill?”

” Yes Sir. Otherwise they were not going to discharge my mother today and would have charged me for an extra day in hospital.”

“So your mother is already discharged. Do you have the discharge card with you?”

The lady had received two bottles of intravenous glucose saline, antibiotic injections and an anti-emetic to stop the vomiting. Total cost would not have been more than 1000 rupees, inclusive of the overnight stay in the general ward.

This was shocking. The poor man earns no more than 8000 rupees in a month. His mother most probably had a mild form of gastroenteritis which responded to the medication. But why do a CT scan? 

It is obvious that the hospital wanted to make a fast buck from this man. To cheat any incoming patient by performing unnecessary costly  investigations has become the norm now and is assuming epidemic proportions. But to cheat a poor illiterate man not only by doing an unnecessary investigation but also charging three times the price is nothing short of criminal. This is what drives a third of Indians below the poverty line.

Unfortunately, hospitals and doctors have become so mercenary these days that medical ethics been thrown out of the window. You and I are helpless silent spectators to this grand looting and pillaging where men, women and children of all socioeconomic strata are plundered nationwide. 

When is surgery needed for back pain?

The first thing that we must do when we have severe back pain is to obtain a thorough evaluation by our local doctor or even better, an orthopedic surgeon. This will include a detailed medical history, clinical examination and possibly investigations such as a blood test, X-ray, CT or MRI scan. These investigations may show that the back pain:

  1. Is due to a serious spinal or other disorder that requires surgical management. These are known as “Red Flags.” Remember that ONLY 1% of all back pains come under this category
  2. Is due to a spinal or other disorder but can be managed with conservative treatments. It accounts for 10 – 15% of back pain cases.
  3. Does not have an identifiable spinal or other cause. Most back pains (85 – 90%) fall in this category.

Back pain does not mean surgery

Just because you see your physician or orthopedic surgeon does not mean surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In fact, surgery may do more harm than good.

This is why we need some strong indicators for surgery. These indicators are known as “Red Flags” and tell us that surgery must definitely be done if permanent damage is to be avoided and that the benefits of surgery far outweigh the complications that may arise due to the procedure.

Red Flags

So what are these Red Flags?

  1. Difficulty in urination or loss of bladder and/ or bowel control
  2. Saddle anesthesia – numbness around the genital area and buttocks
  3. Numbness/ tingling in one or both feet/ toes
  4. Difficulty in moving the ankle upward or downward or raising the great toe
  5. Gait disturbance – difficulty in walking
  6. Changes in reflexes in the legs (this can be detected by the physician).

If you have one or more of the above symptoms you definitely have a condition that may need surgery. The timing of surgery will depend on how severe the symptoms are.

The opposite is also true. IF THERE ARE NO RED FLAGS, SURGERY IS NOT REQUIRED.

  • Excerpt from “Say Goodbye to Back Pain” by Dr. V. Ranjan. Available at http://www.amazon.in/Say-Goodbye-Back-Pain-Ranjan-ebook/dp/B004S7BAO6

Operate in haste, repent at leisure

Let me tell you about the time I got a new junior resident doctor by the name of Dr. Thombie Singh. One day after 6 months of training, I decided that he was capable enough to do hysterosalpingography – a procedure where we push a contrast dye into the womb to see whether the fallopian tube on each side is open. 

When Dr. Thombie Singh reached the X-ray room, there was a middle aged lady sitting outside on a bench. Without much ado he shepherded her into the room. The poor lady did as she was told but became alarmed when she had to raise her legs in order to be strapped into lithotomy position. Thombie reassured her in his typical flamboyant style that this was a routine part of the X-ray procedure.

Procedure done, the woman was helped to her feet and she hobbled away muttering about doctors and what she would do to them on a dark night. Dr. Thombie Singh then realized with growing horror that the woman had come for a thyroid scan and not hysterosalpingography.

The rookie gynaecologist

It was a roasting hot day in June with temperatures reaching 40 degrees Celsius. My clinic, as usual was choc-a-bloc with over 50 patients crowding in the narrow corridor.

I was examining them in conveyor belt fashion, one sitting opposite my table listing her complaints while another one lay down on the examining table and a third stood by waiting for her prescription.

Patient number 22 was a case of third degree uterovaginal prolapse. The woman, a 55 year old villager, had had four vaginal deliveries. As a consequence the tissues had relaxed so much the entire womb was lying outside. I managed to gently push the organs back in place and inserted a self retaining Cusco’s speculum. At this point, the lady waiting for her prescription collapsed in a heap. The nurse yelled for me. I ran out of the examining room to find the woman sitting on the floor being given water to drink by a second nurse. She was simply suffering from dehydration due to the heat.

By this time the UV prolapse lady came out of the examining room. I gave a prescription for some lab tests and asked her to come next week to fix a date for hysterectomy.

She came the following week as scheduled. I explained the reasons for the prolapse and that the only treatment was surgery to remove the womb and tighten the lax tissues. She listened carefully.

“But doctor, you solved my problem last week itself. My womb is no longer hanging out. In fact, I feel much better now.”

I was stunned. “No, that’s not possible!” I exclaimed.

“Yes doctor. If you want you can have a look.” Saying this she lay down on the examining table.

I was shocked to see the Cusco’s speculum still in the vagina. It had done an excellent job of holding the womb in place. I had obviously forgotten to remove it last week when I rushed out of the examining room. The nurse was grinning from molar to molar. The next tea session would be hilarious.

Why women suffer more from back pain

Women tend to suffer more from back pain than men. Physiological reasons for this disparity are:

  1.  Periods – Backache is common during periods but is usually cyclical and disappears once the periods are underway or end. However, there is a condition called endometriosis where cells from the lining of the womb implant abnormally in the pelvis and back. This can give rise to excruciating pain many days before the period starts and persist long after the period ends.
  2. Pregnancy increases women’s vulnerability to back problems. During pregnancy, hormonal and other body changes result in:                    a. Loosening and weakening of ligaments                                                b. Abnormal lordotic posture with the tummy jutting out in front and the      buttocks thrust backwards.                                                                c. Progressively increasing weight due to increase in fat and the growing        baby                                                                                                               It is estimated that between 40% and 60% of pregnant women get back pain due to these changes.
  3. Caring for babies and young children – breast feeding, bathing, picking up, etc. adds to the risk of back pain. These acts involve lifting the baby at a time when the ligaments and muscles of the back are still lax. Incorrect lifting may result in severe back pain.
  4. Menopause and peri-menopause – Estrogen is essential for Vitamin D3 formation in the body. In turn, Vitamin D3 is required for calcium absorption from the food in the intestine and its uptake in bone. As estrogen levels decline at and around menopause, the bones start becoming brittle, a condition known as osteoporosis. Neck and back pain often begins or increases with age.

Social causes

  • Domestic:

There are also social reasons as to why women are at greater risk of back pain than men. Women still undertake the majority of domestic tasks that places them at high risk of back pain:

  • Shopping – carrying heavy loads
  • Cleaning – bending, twisting, pushing and pulling
  • Ironing – standing and twisting
  • Carrying heavy objects
  • Gardening
  • Vacuuming

Thus while back pain in men is often a result of an injury, women suffer from back pain as part of their everyday lives, a result of long-standing conditions or activities, including domestic work and child care.

  • At the workplace:

The kind of jobs women do in the workplace also contributes a great deal to the increased incidence of back pain amongst them. Women are generally given tasks that involve:

  1. Repetitive tasks such as pushing, pulling or twisting of the body in jobs such as those performed by supermarket check out staff, production line workers, cleaners and machinists
  2. Sitting or standing for long periods. Women are more likely to get back pain if they work in the health services, retailing, hotel and catering, banking, finance and insurance industries. Shop and factory floor workers, keyboard and telephone/call centre workers and bank tellers who stand or sit for long periods are especially prone to get back pain
  3. Lifting, bending, stretching and reaching in jobs such as child and social care workers, nurses, teachers of small children and counter staff. Nurses often get back pain when lifting patients from the bed or chair.

Lifestyle causes

Women have additional lifestyle demands that lead to back pain:

  1. High heels to make the legs look longer and tilt the back
  2. Tight clothes to emphasize slimness – this also restricts easy movement
  3. Breast implants that increase breast size and strain the back
  • Excerpt from “Say Goodbye to Back Pain” by Dr. V. Ranjan. Available at http://www.amazon.in/Say-Goodbye-Back-Pain-Ranjan-ebook/dp/B004S7BAO6