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

SITTING !!! The commonest cause of back pain

Back pain commenced the day we humans decided to spend our lives sitting down and stop using our back muscles. A fixed posture such as bending forwards while sitting stresses the spinal joints, discs and ligaments and as time passes, the body reacts to this stress resulting in loss of joint mobility and degenerative changes in the joints and intervertebral discs.

In people who sit hunched in front of computer and TV screens for long hours, the muscles on either side of the spine weaken due to disuse. Disuse leads to wasting of muscle tissues. Disuse and wasting of the back muscles is also seen in the case of taxi and truck drivers and desk jobbers like accountants and clerks, call centre and data entry employees, check out staff in supermarkets, accountants, software engineers and just about everyone in the IT industry. WOW!! That’s half or more of the entire working human population!

We have only ourselves to blame, since the most common causes for back pain are:

Slouching in chairs

Sitting puts almost twice the pressure on intervertebral discs as standing. Since the muscles and ligaments are the main components holding up the vertebrae, the loss of power means that the weight bearing responsibility is shifted to the bony parts of the spinal column. This poses a tremendous strain on the spine and is responsible for disc problems such as disc degeneration and disc prolapse.

When you sit in any chair, a number of important postural control muscles are inactivated, while others are being asked to work overtime. This leads to the following muscle problems:

  1. Shortening of the hamstring muscles
  2. Overworking of the Erector Spinae muscle group
  3. Overworking of the Iliopsoas muscle

Hamstring Muscle Shortening

When we sit down, the hamstrings are pulled and maintained in that position for as long as we are sitting, which could be hours. Although the hamstring muscles are inactive, they are held at a shortened length. This is a probable cause of tight hamstrings. Tight hamstrings are associated with back pain. The reason is that tight hamstrings stop the hips from flexing during forward bending. This forces the lower back to bend beyond its strong middle range. Rounded shoulders and a hunched (forward curved) back due to shortened hamstrings are typically seen in those who sit for long hours.

Overworking of the erector spinae muscle group

Chair sitting is unique in that the gluteus maximi (buttock muscles) are totally relaxed at the same time as having an upright torso, and they are therefore not able to contribute to extension of the lower back and stabilization as they usually do. It is the erector spinae muscles alone that are holding up the back without the help of the gluteal muscles. Prolonged sitting tires out the erector spinae muscles which give up the struggle to maintain the correct “hollow” in the lumbar spine. This again contributes to the forward curved lower back and a stooping posture when the person stands up.

Iliopsoas Muscle Strain

Assuming you are using a chair whose backrest slopes backwards or is too far behind, your iliopsoas muscles must continuously pull your body forward to stop you falling backward. If you are sitting for a long time, the iliopsoas muscle has to remain contracted for that period of time. That is a sure fire recipe for iliopsoas muscle shortening. Ten to fifteen percent of back pain is due to a tight iliopsoas muscle.

When we sit for a prolonged period, all these muscles are starved of blood supply and oxygen because they are constantly in a state of contraction.When we finally get up, the same muscles are unable to support our backs. Our entire body weight is now supported by the spinal column alone. No wonder we, the so-called modern human race, suffer from backache.

Other self-made mechanical causes of back pain

  1. Standing badly with rounded shoulders and/ or the pelvis thrust out
  2. Lifting heavy loads incorrectly
  3. Sleeping on sagging mattresses
  4. Being generally unfit and not bothered about regular exercise
  5. Obesity: Obesity per se can cause back pain due to the weight being carried by the spine and lack of exercise. In addition, once an obese person develops back pain, he/ she is caught in a vicious cycle since he/ she finds it difficult to move and without movement, the ability to burn calories and reduce weight is severely restricted. Hence both weight and pain will increase with time.
  • 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

Say Goodbye to Back Pain

Welcome to one of the commonest health problems on earth. At my age (and I have batted for a good many decades now) hardly a day goes by when someone or the other does not complain of back pain. It is a popular conversation starter and a condition that everyone seems to empathize with.

The problem with back pain is that it comes back (excuse the pun please!) again and again with increasing severity. It can affect our work and our daily routines to such an extent that we begin to live in perpetual fear of suffering another attack of back pain that could leave us bed-ridden. Wouldn’t it be wonderful therefore if we could say goodbye to back pain and be able to carry on with our lives as before?

YES YOU CAN provided you have access to the right information and are able to understand how back pain occurs. There is no review that provides a unified approach to the management of back pain. Newspaper or magazine articles or even books on back pain discuss a variety of options and then leave it to you and me to make up our mind as to which course of action to follow. At the end of it all, the vast majority of us simply soldier on, clutching at various therapies, in the vain hope that one day something will work and we will be all right.

Over the next few blogs you will learn precisely why you have backache and how to tackle it. You will have access to a flow chart that will enable you to take control of your back pain and GET RID OF IT, ONCE AND FOR ALL.

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

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.