"KNOWN TO"

Doctors fight fiercely with one another. It’s true. We are all concerned about our patients, but when it comes to responsibility, we fight. The only time we don’t fight about responsibility, is when we have to treat a fellow doctor. We help each other in every way possible. Call it professional courtesy. Call it a ‘you scratch my back, I scratch yours’ kind of attitude, or just call it a community feeling. It was during this sort of help that I got introduced to a very useful term- the ‘known to’.

 

As doctors in government hospitals, where treatment is cheap, but waiting periods are long, we often get requests to speed up the process by personal recommendation, often by those with less means. Friends, relatives, maids, car washers, laundry men, drivers, almost anyone we know ask for advice, tests or referrals. So instead of enquiring about what the person being sent to me for ‘special’ referral means to the doctor who sent him or her to me, we just call them a ‘known to’. If a doctor is famous for showing a lot of people to other doctors in the hospital, we just say that he has a lot of ‘known to’ s. We don’t really care about the relationship. The person being sent to us might be a friend’s friend’s maid’s son. All we know is that the patient is a ‘known to’ of the doctor who sent him to us. It was only recently though that I had a ‘known to’ come to me for treatment.

I help people out, to show them to doctors in the best way I can. But usually I take them to see specialists. For the first time, a friend of mine recommended to his driver who had been carrying around a hydrocoele of the scrotum for a good number of years to see me for the surgery. A physical examination and a blood report later, I requested my seniors to place him on the next free minor operation slot in our unit. His name went down in the list as a ‘known to’ of Dr Nishant- no questions asked.

On the Operation day, while we had two other cases for the minor OT, I was allowed to operate on my ‘known to’ first, and to take all the time I wanted. It was when I was scrubbing for the surgery that the wisdom of my seniors hit me. My reputation was sort of on the line

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I know it’s odd for a first year post graduate to talk about a reputation. But it was true. The friend who had recommended my name and approached me to treat his driver, would definitely doubt me if the smallest complication arose due to the surgery. I knew he wouldn’t say anything, but he wouldn’t be happy either.

In medical practice we like to say that we should treat every patient like he or she is a member of our family. I don’t believe in this. Not in surgery anyway. I wouldn’t be able to operate on a member of my family. I believe that the best approach is to treat a patient like a human being. Someone who has, a family. I think that’s professional. And I reminded myself of this before I started the procedure. Complication’s happen. What’s important is to do the best you can

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Half an hour later the procedure was complete, stamped by the approval of my second year post graduate, and packed to go home. Now there was nothing to do but wait. Any real complication would present itself in a day or two. So when I didn’t get a call from my friend about his driver for four days straight, I was relieved.

A week after his surgery, the man came to me for having his stitches removed. His wound was healthy. And he was very thankful. He had a procedure done for free, when he was told that it would cost 20000 rupees by a private clinic. He went home with a smile, and I, with a peaceful mind. I guess that’s how you build a practice. With ‘known to’ s and by placing your reputation on the line when you see them.

Sometimes we like Jam

these are links to videos of me jammin' with Dr Reuben and his cousins in his hostel room..we played and sang time of your life, love hurts and when you say nothing at all..on guitar are Dr Reuben and Laam, I helped with the singing, and Randomly lying around is my co-Pg Dr Shailesh..
Good times..

http://www.youtube.com/watch?v=MUIUDTiLTpc&feature=youtu.be  (When you say nothing at all)


http://youtu.be/_HDbZXBJElY  (love hurts)


http://youtu.be/uTYXKxEtDek  (time of your life)

SCREW IT, LET"S DO IT!!

When you learn how to swim, there’s usually a process that’s followed. You place your feet in the water, you just bounce about in the shallow area, then you practice beating your legs and floating while holding the railing, then you learn to float around, use your hands, go to the deeper parts, and then you work on your stroke. If surgery was swimming, it would go something like this- you read about how to swim, you look at a lot of different people swimming, you place your feet in the water one day, you hold the railing the next day, then you dive into the pool from high above and hope you can surface fast enough to breathe. Only, the water you dive into, isn’t always the one you practice in, it maybe murky , dirty with things swimming around at the bottom that you never noticed. Knowing all this, there comes a point in every surgeons practice, time and again, when he has to take a deep breath and just dive in.

That’s what happened when I performed my first minor surgical operation independently. A hydrocoele is a collection of fluid around the testes (commonly called a man’s balls), that can grow to enormous sizes. Decompressing this collection and making certain it doesn’t recur is one of the first minor operations a surgeon learns.

Even in this, there are many variations. Some open the sac (the part that contains the fluid) early and then dissect it out while some do the dissection first. Some don’t believe in using electric coagulation, while others consider it a necessity. Some take more bites of their suture, others take fewer. I had seen them all. So one fine Operation theatre day, when a patient with a large classical right sided hydrocoele was posted for surgery and every other person other than an intern of ours was busy, I said to myself- screw it, let’s do it.

It was all going well. The intern was a good assistant. The local anaesthesia worked well, so the patient didn’t make a sound, and I began with a good incision. Then I deepened it. The fluid filled sac should’ve shown itself as a nice white surface. But it didn’t. I deepened it further. Nothing. Maybe I had missed it. That’s a stupid thought, how could I have missed it? It’s a water filled balloon. When you cut open a balloon, the water has to flow out. I cut deeper. Next layer, then another, then another. What? Where was this damn thing? Then sac rotated a bit in its place and I found my mistake. My assistant hadn’t fixed the sac properly, it kept moving left and right. Plus the local anaesthetic I had given had infiltrated some of the deeper layers, causing them to swell and distorting the anatomy of the layers. I had kept making incisions at the same layers repeatedly at different points. I had him fix the swelling in place. That’s it. Just a few layers deeper and I’d reach the sac. So I placed my scalpel on an incision I had made earlier, and bang, a spray of fluid hit my face.

I had incised the sac early and without knowing it, I quickly caught the edges of the incision with artery forceps. My face mask was wet, and it was a bad feeling. But I had to get this done. On my own.  I widened the incision on my sac with a scissors, careful to visualize that the testis underneath doesn’t come in the way. It didn’t. phew! Cutting the testis would’ve been a bleeding disaster. I drained the rest of the fluid. And the testis popped out of the scrotum (the skin and other layers covering the balls). But wait a minute- the testis wasn’t in the sac. It was outside it. That, was unexpected. The testis was supposed to be inside the sac. What had I cut? Was I in the wrong plane? The sac was just a blind fluid filled cavity. Was this even a hydrocoele? It said so, according to the seniors who had seen him.

I had had enough. I called my second year post graduate. She said it wasn’t just a hydrocoele. It might even be a hernia. That thought scared me. I had no idea what to do with a hernia. One of our consultants just happened to walk about around that time, so I called him. “It’s a hydrocoele of the cord you idiot”, he said. Just excise it and stitch the edges. I did, and he helped me, and the patient went home with normal sized balls. But somehow, my dive hadn’t gone too well.

The next week, I got to do another hydrocoele. The same intern and I shifted the patient, again while the senior resident was stuck up. This time, I incised the planes in one line. I opened the sac, so that the fluid didn’t hit my face. This time the testis was in the sac, where it usually is. I everted the sac and fixed it. I closed the incisions, making sure there was no bleeding. By the time my senior resident came to check up on me, I was dressing the patient. A week later, when I removed the patient’s stitches, and found no complications, somehow I just felt a sublime happiness. I wasn’t ecstatic. I just felt satisfied, and more capable.

I saw these moments in surgeons at all levels after that. No matter how many years of practice you have, there are always procedures that you have just started to learn. Only the difficulty rises as you progress. That’s the excitement of being a surgeon- the moment when you look at a problem, you know you have what it takes, but you’ve never done it alone. And then you say- what the hell, screw it, let’s do it.