How important are the credentials of your treating doctor for U?

We all doctors study and then on completion of our graduate study are provided  with the degree of M.B.B.S.
Following which majority of us apply for PG entrance test,Pass it if lucky and complete a 3 years residency.
Few  manage to get only 2 years diploma course and are confered with DGO(Diploma in Obstetrics and gynaecology).There are few others who are not able to pass the Indian competetive exam and opt for DNB exams which is equivalent to the MD/MS.There are a few who are born with golden spoons in their mouth and are sent to  Manipal  university or any other donation college to get a paid PG training.
In our current private practice scenario ,we have a mish mash of such doctors.....genuine postgraduates,Diploma holders who could complete DNB and still further who couldn't and still write DNB along with in their list of degress.They work with big corporate hospitals and strangely their credential is still not checked .Then these sons and daughters of rich parents who went to Manipal ,who returned back,joined fellowship under a big name and are a big name them selves today.
As a patient are you able to tell a difference between a well read and hard working and not so hard working short cut holders?I am sure you are not.I know atlease two of our very popular Gynaecologists in Gurgaon who aren't even a DNB.DGO is their greatest claim to any sort of educational degree.es,both of them are DNB1
(Some doctors get cheeky by writing MRCOG1 or DNB1,which simply means MRCOG or DNB fail.)

Any suggestions : whom would you prefer ,a well read competent doctor or a not so well read doctor who by practice  has learnt to behave like a parrot by being repetitive and doesn't have an indepth knowledge of ones subject.

May be it will be a good idea to ask for your doctors credentials next time you pay a visit.........mind it at times DNB might simply mean DNB part 1 :))
I won't be catty any further.Won't divulge those names as it will leave many a patients heart broken ...............Life is no less than Bigg boss ka ghar.Who knows tomorrow I might just loose it and divulge the names.Keep Guessing till then!!

Hypothyroidism in pregnancy

It is not an uncommon scenario.......You are Pregnant and during routine antenatal screening it is detected that your TSH is raised while a FT3 and FT4 is normal or borderline low.It means your thyroid gland is underfunctioning and in order to overcome the deficiency your pituitary starts over functioning leading to a increased TSH levels.
As today's generation is so used to 'googling' everything they end up being a nervous wreck when there is no reason to get so hysterical about it.A thyroid deficiency in pregnancy is associated with increased rate of miscarriage and chances of Cretinism i.e ,mental retardation in baby's if the fault is not corrected.With an appropriate dose of thyroid supplement TSH can be controlled quite fast and once under control the pregnancy is as high risk as any oneelses.By repeated TSH levels in each trimester one needs to adjust the dose of thyroid supplement.
Clinicians are no less responsible for this unnecessary panic as I have seen quite a few prescriptions where doctors have prescribed HCG injections,micronized progesterone,low dose aspirin and  the patient is freaked out with the risk of pre term labour pains.
Give hypothyroidism the share of importance it deserves but don't loose sleep over it.
Hyperthyroidism in pregnancy is surely more difficult to take care with a possibility of a crisis but thankfully hyperthyroidism is much less common than the hypothyroidism.

Surgery for Urinary leakage(GSI)

Yesterday was a good day after not so good previous day.I started my day with a surgery ,I really love to perform ,TVT and I have shared the pics with you guys to have a look.Then a chit chat.....gossip over hot cup of tea at the OT lounge with anaesthetist friends.Some one just mentioned,it is good to have nuisance value (oxymoron but none the less useful).There are some consultants who shout so much and get so nasty with others that not out of respect but by their sheer nuisance value you get your patients shifted to OT first,get them anaesthetised first and so on .The down side of not shouting and yelling as a surgeon when OT is really busy despit a scheduled operation you might get delayed if one such shouting consultant is in the OT and gets thing done out of turn.And then someone talked of 'Silk'......Dirty picture.SoI just decided that whatever it might take today I have to watch her.So I cancelled all my appointments to watch this movie.It is a good movie but this Lady silk drank so much of whisky,I felt like throwing up.the end was sad ,but that is how the life is.Anyways had to rush back home and then come back for evening OPD which finished just 2 hours late,

The following pictures are stills of Cystocele repair and TVTO ( a surgery for Genuine Stress incontinence) done at Max hospital ,Gurgaon

A post Subtotal hysterectomy,post caesarean patient with a small cystocele and GSI

So much blood from a small little cystocele.

It was little difficult to take the buttress suture due to distorted anatomy due to previous surgeries

Marking at the level of the clitoris

Dynamesh Applicator

Right sided applicator inserted in the trans obturator Canal

Dynamesh SIS pulled out on the right side



Left sided Mesh applicator



TVT at the bladder neck

Mesh trimmed off from both sides

Repaired Cystocele and corrected GSI

How is Dr Kaushiki Dwivedee, any feedbacks?

I am a person who likes to be online when I get time.And I do come across reviews about me,questions about me and some very nice and heartwarming comments by my patients.I would be a liar if I say a good comment doesn't flatter me.It does and motivates me to atleast carry on doing what my patients like about me.
I thought of making an attempt to understand how I am as a doctor and my mindset when I approach my patients as well as other aspects of life.

Let us start with my negative side first

• I am not a die hard professional ready to work 24/7/365
• I take a break from my OPD on Sundays.
• I tell you the truth and only truth about your health and not what you might like to hear
• I do get irritated when someone asks me question again and again when I have already explained it in great detail.I can't mask my face and you can very easily make out when I am irritated.you might then consider me rude.
• I don't prefer to attend phone calls while in OPD,operating and conducting a delivery and if you call I request you to 'text' me please.
• If you are a VIP used to special attention I might not be the correct doctor for you as I don't practice to boost anyone's ego.
• If I am over busy  and I think I can be an unsafe doctor I may refuse to take your case.
• I don't believe in marketing gimmiks like discounted fees etc and neither do I like people who complain about my fees(there aren't many who complain though)
• I don't pamper my patients .

My Positives are

• I work  hard between Monday to saturday in my OPD and OT
• I am available for an emergency booked under me 24/7/365
• I give you plenty of time when you come for routine consultation to me.Give you lots of evidence based medicine and I am in no rush to get you out of my OPD.
• You are assured of a quality health care whether you are a commoner or a celebrity.
• I follow evidence based protocols and am confident and clear when I am treating you.
• I would not prescribe you any single investigation without an explainable reason and won't send you to any specified Lab /Radiologist unless you ask for one.
• While I don't pamper you ,I am well behaved and I treat you in a textbook manner.

 Now Overall I strongly believe that Doctors and patients deserve each other.And if you don't come to me  for treatment I again am convinced that if I lost a patient,you lost a good doctor ;-)
In nutshell if you are a sensible person who is used to respect others and get respect in return most probably I am the doctor for you.If you like to be pampered then I am not the best choice.If you like a doctor who chats to you over mobile I am not the person.But if you are savvy enough to text me or mail me you will find yourself in continous touch with me.

I have tried to give an honest feedback of mine for all those people who keep on posting in various Forums to know the kind of person and doctor I am. 

Deep impacted foetal head.......Thank god we have Pathwardhan method

Today was a Sunday I was awaiting since the whole week.It was busy throughout the week.And today I had all the intentions of catching up with any of the shows of 'Dirty Picture' at DT Mega Mall.Think will have to wait for one more week.
One of my patient went in labour today morning.A lady whom I had seen only in the evening an on examining her after probably many months I thought.......Oh there seems some problem.The outlet looks contracted(The outer most bony part of  the pelvic bone which the baby must cross to deliver vaginally).Gave her a hint to the same.She became little nervous and few drops of tears rolled down.I thought not to talk about it further till she is actually in labour and as luck would have been ,I got a call around 4 am from Dr Asimita,a smart registrar,that the Lady was in with ruptured bag of membranes and contracting too.Things went fine and she progressed well till 7 cms and then I put her on syntocinon drip at least 10 hours of her admission.I thought,never mind can still watch Vidya Balan in one of the late evening shows.Ok ,she did progress and as anticipated was fully dilated as well and I kept on waiting and waiting and ultimately after an hour of wait decided to take her to OT for a trial of ventouse application.I would say it was a half hearted attempt from my side as deep within I felt that she won't deliver vaginally but baby's head which was already quite low(just at the outlet)will get stuck making a caesarean delivery also challenging.I am quite Ok with  second stage caesareans but this one I felt was going to test my Obstetrics skills to the max.And so it happened.
Abdomen opened in layers,uterus cut open and baby's shoulders were all what I could see,The head was deeeeeeeeeeeeeeep down in the pelvis.I asked the nurse whom I had requested to be ready for such an eventuality to push the  baby's head up,She had never done it before and thus was very scared(Told me later that in private set ups as such caesareans aren't so common she has not done it before).Anyways even if she wasn't scared still that would not have made any difference.The head was not buzzing up.My assistant Dr Dipti a fresh Postgraduate mumbled nervously....Patwardhan method mam.....I said yes of course.You just can't do anything else in such a situation.
So what is done is that both the hands of the baby are delivered out of the uterus first and then comes out the bum followed by body and lastly when there is enough space last comes the head.This might be 15th or 16th time that i have delivered baby by this method and it was one of the difficult ones cause my assistants lost the tract  somewhere.They had never seen it before and it horrified them.Our efficient OT technician sanjay came to the rescue who gave a good fundal push to deliver the bum as I pulled the body out gentlyy.It ended well.I realised i had a few drops of sweat on my forehead.Mirena one of my favourite nurse said.....mam haven't seen you nervous ever before in last 4 years.But that is Obstetrics.The baby is fine.Mother is fine too.Thanks to Dr Pathwardhan.But I missed silk Smitha Once again.better luck next Sunday :)))))) While I was managing my patient my poor husband waited very patiently for almost 2 hours in the car.So much for his Sunday!!


In today's case the head had come upto +3 and got stuck there!!!!!

Mesh repair of vaginal Prolapse

Uterovaginal prolapse is a well know problem related to the women health every year more than 100000 patients undergo surgeries for these conditions worldwide.
The traditional method of repairing a UV prolapse has been  removing the uterus vaginally followed by correcting the defect in the pubocervical fascia to correct the cystocele and like wise for the rectocele,As the pubocervical fascia is already weak ; a cystocele or retocele repair done by the new method of mesh plasty is a better option where the synthetic mesh  is used fo correction of the defect with less chance or recurrence,optimal vaginal lenth for sexual activity is saved and there is less evidence of dysperunia and better anatomical positioning.

The cost of the Mesh is RS 35000 and very few doctors are trained at this point of time in India to conduct such surgeries.The TVTO mesh for correcting leakage of urine costs around Rs19000.

These surgeries are learnt quickly and are very safe surgeries.It has been my good fortune when I was introduced to TVTO in 2006 by Mr Derek Klazinga as I have mentioned in my earlier posts as well.

Cost is a limitation but when we consider the advantages it gives the mesh is not so costly after all.

These are few pictures of the patients who had mesh plasty at Max Hospital Gurgaon

Transversus abdominis plane block

Transversus abdominis plane (TAP) block is gaining popularity as a method for pain relief after Laparoscopic surgery.
Here 20 mls of (0.25%) sensoricaine ( a local anaesthetic agent) is injected between the the internal oblique and the transversus abdominis muscle on both sides of the abdomen.

The bleb made of Sensoricane injected for TAP block as seen through the laparoscope

I use this method for pain relief for all my patients who have undergone any kind of laparoscopic surgery and majority of them don't comlain of any pain atleast for 24 hours and most of the time need very mild pain killers like a paracetamol and Voveron tablets.

Morcellation

In this post I wish to share with all my blog readers,few pictures depicting a procedure called MORCELLATION.

Ligaments being cut using harmonic

470 gms fibroid

Endometriotic gelationous lesions over the uterosacral ligament

Morcellator grasping the fibroid

Morcellation in progress

A Morcellated piece of the same 470 gms fibroid

What do you do with the uterus? Do you melt it inside with laser?It is such a big uterus how will you remove it out from a 1 cm cuts and so on ............?My patients have so many questions to ask and are very worried when they are opting for a TLH for big fibroids,When this instrument morcellator wasn't available I would do the TLH and then blindly chop the pieces from vaginal end and take it out.With the availability of morcellator the TLH of huge size fibroids has become easy and much less time consuming and it is all done under vision. The big uterus and fibroid is shredded into pieces like 'pasta' and then removed out from one of the 1 cms skin cut.
The same instrument is used for laparoscopic myomectomy where one intends to just remove the fibroid and save the uterus for the purpose of future reproduction.

Atrophic Endometrium

Atrophic endometrium

At times very thinned out endometrium rather than thick endometrium is the cause of heavy  vaginal bleed as the exposed blood vessels start bleeding.Progesterone isn't successful in such cases and one might need a mixed estrogen and progesterone pill.

Thanks and congratsDr Vinita Salvi and Aishwarya Rai Bachchan

Now as the excitement regarding delivery of Ashwarya Rai Bachchan is settling down I would like to first of all congratulate her and secondly thanks her.
She has broken the stereotype of a well decked up celebrity entering the hospital.All planned.Elective caesarean and baby is out!!" Too posh to push"!!She tried a normal delivery at 38 years of age and managed it.Ladies who love to follow her please take a few cue from her this action as well.
I have rich words of appreciation for her obstetrician who handled such a high profile delivery nicely and didn't succumb to the usual pressure  of VIP syndrome which very frequently leads to a caesarean section to prevent any medicolegal problem.I am sure she must be a very competent doctor.



Dr Vinita Salvi

 As a team,Very good Performance!!I respect the Prof for handling a delivery the way it should be rather than going in the merits of patients profile.
And Media when gives credit to Aishwarya  for her normal should also write a few lines about her doctor who gave her the option,took care of her and led to a safe and happy outcome.As I wrote in one of my blogs Normal delivery these days is not just about the doctor being patient but also is about knowing one's subject well,being competent in one's work and having the confidence that she can handle the pressures of normal delivery which needs much closer monitoring than a planned caesarean section.

Bleeding Heavily???

Thickened Endometrium at the level of internal OS

Thickened endometrium which in biopsy turned out to be cancerous

Endometrial Polyp

same Polyp from a different angle

Removal of the same Polyp using recetoscope

Thickened endometrium which in biopsy suggested simple hyperplasia

It is a common problem when you notice that your periods have become heavy or Irregular.Now this post is for Ladies above 40 years of age.If you have any such irregularity with your periods like a heavy or irregular bleeding it should be taken seriously.majority of the time it is just a hormonal imbalance which corrects of it's own but at times it can be problems like Polyp,Thickened inner lining of the womb,also called Endometrial hyperplasia(which can have pre cancerous potential),fibroids and in very small percentage endometrial cancer itself,which has a very good prognosis if detected early.Thus it is important not to ignore your problem.Your Gynaecologist might suggest you Hysteroscopy and biopsy of the inner lining of the womb.Go for it if suggested.It is a small minimally invasive procedure done under anaesthesia with a very quick recovery time and one can come back home the same day.A stitch in time saves nine............

For further details visit http://www.gynelaparoscopy.co.in/

Advanced laparoscopy in gynaecology

Using harmonic to cut the round ligament

Opening of anterior fold of peritoneum

same as above

Ligation of uterine artery

A clearly visible uterine artery

Uterine artery ligated on the other side

Opening the vagina

White coloured colpotmizer visualized



Hysterectomy over with the colpotimzre seen very clearly lifting the diseased uterus

 There have been immense advancements in performing laparoscopic surgeries in recent past.It no longer is a domain of a few selected blue eyed laparoscopist and in India we have many good laparoscopic gynaecologist performing much complicated gynaecology surgeries with great ease and deftness.Following are the pictures from a Total Laparoscopic Hysterectomy for fibroids uterus  performed by me which finished in 35 minutes.
For more details visit http://www.gynelaparoscopy.co.in/