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. 

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.

Jugaad: Surgery in India’s rural interior

Year: 1985

Location: A remote village hospital in West Bengal’s Burdwan district

Clinical situation: A full term pregnant woman in the first stage of active labour. This is her first pregnancy. Her membranes ruptured as she entered the hospital and a vaginal examination revealed a 4 cm dilated cervix with the baby’s head pushing down on a thick pulsating umbilical cord.

Diagnosis: Cord prolapse in first stage of labour

Treatment required: Immediate Caesarean section to deliver the baby otherwise the head would compress the cord and cause the baby to die as labour progresses.

Nearest hospital where facilities for caesarean section were available: Asansol, 70 kilometres away.

Facilities available at the village hospital:

  • One unsterile caesarean section tray with instruments and suture material.
  • Operation table – One metal stretcher on which the woman was lying
  • One vacant room with open windows where a surgical procedure could be done
  • One bottle ether, one bottle of Savlon and one bottle of spirit
  • A large roll of cotton, rolls of gauze and plaster
  • Rubber gloves – available in plenty, boiled and ready
  • One sphygmomanometer (blood pressure instrument)
  • IV stand and IV normal saline and glucose-saline bottles
  • A washbasin with running water and one Lifebuoy soap
  • Three dedicated and courageous nurses and one attendant                                                                                                                                                 Facilities not available:
  • Anaesthetist
  • Anaesthesia machine and drugs
  • Blood – if transfusion was required
  • Sterile operating room
  • Sterile instruments
  • Sterile masks, gowns and caps                                                                                                                                                                                             There was no time to lose. One nurse wore gloves, sat on the stretcher and pushed the baby’s head up through the vagina in order to relieve the pressure on the baby’s umbilical cord. A bed sheet was thrown over the woman to preserve her modesty and both were wheeled into the next room by the attendant. The woman’s family members crowded outside the windows to watch the proceedings.

The second nurse rapidly boiled the instruments in a saucepan and then cooled them under tap water. So much for sterilization! The third nurse took charge of the BP instrument. Nurse 2 took a wad of cotton and put it on the woman’s face covering her nose. Ether was slowly poured on the cotton, drop by drop, till the woman fell unconscious. She kept a strict watch on the cotton to see if it was moving up and down which indicated that the woman was breathing. No movement of cotton – stop ether drops. Any groan or movement by the woman – continue ether drops.

By this time, the attendant had washed his hands and worn gloves to assist in the operation. The instruments were surprisingly good, probably because they had never been used. We managed to deliver a healthy screaming baby. A collective “Aaaaah” came from the crowd outside followed by some clapping. Once the baby was delivered, Nurse 1 was able to remove her cramped fingers. Nurse 2 continued with the ether administration till I had stitched up the woman completely.

No postoperative complications, no wound infections, no complaint of pain at all throughout her hospital stay. This is a testament to the physical and mental strength and stamina of rural women in India. She made an absolutely uneventful recovery and was discharged in 5 days.