Breast Cancer in Pregnancy

When I read the green top guideline on Breast cancer in pregnancy few years back,I read it as it is my habit to read any new green top guideline.Never thought that will need to use it ever in life.May be I was trying to be too optimistic.
Without going in the details of the patient and her condition,wish to write this blogpost for gynaecologist if anyone of you are reading this post.The RCOG guideline is very good.Read it.It will help you in managing such a complicated pregnancy better.
There is no need to deliver the foetus immediately if in late second or early third trimester.Let the surgeons proceed with Lumpectomy or Mastectomy as they consider appropriate.Then wait the foetus to reach upto atleast 34 weeks and if possible even 37 weeks if tumour isn't very malignant.Chemotherapy and radiotherapy can follow later,after the baby has been delivered. In my patient's case it is quite a malignant variety and I am aming to reach 34 weeks only.
Scary!!Her malignancy was diagnosed just by chance at 35years,first pregnancy!!Not fair at all.

LGBT issues

As chance would have been a patient turned friend recently started fighting with me for LGBT rights and within two days supreme court came out with it's ruling.I am no way ashamed to say that I am not a LGBT supporter,though I am against the discrimination they face because of their choices.
Now few thought provoking questions ( I know I am touching a sensitive issue)
IS it crime?My answer is ,I don't know but it is different from the normal,
Should it be encouraged? Again I don't know.If tomorrow my son turns out to be a gayI would be ashamed.I will feel unwell and no amount of justification will make me feel good that his chemicals are making him do it.Then what is the difference between human being and animals?
Tomorrow then bestiality,pedophilia and incest would be legalised as the involved people can always blame it on their chemicals.
To say bestiality is wrong as the animal can't give consent.What if it is found the animal is enjoying the act.Will it be legalised?
Fraser law gives alot of freedom to juveniles to indulge is sex,ask for OCPs,right of confidentiality etc.So tomorrow if we find Pedophiles are also guided by their hormones and aren't criminals,will it be legalised.
May be it will happen in future.
Few facts

Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations.

Haas AP, Eliason M, Mays VM, Mathy RM, Cochran SD, D'Augelli AR, Silverman MM, Fisher PW, Hughes T, Rosario M, Russell ST, Malley E, Reed J, Litts DA, Haller E, Sell RL, Remafedi G, Bradford J, Beautrais AL, Brown GK, Diamond GM, Friedman MS, Garofalo R, Turner MS, Hollibaugh A, Clayton PJ.

Source

American Foundation for Suicide Prevention, New York, New York 10005, USA. ahaas@afsp.org

Abstract

Despite strong indications of elevated risk of suicidal behavior in lesbian, gay, bisexual, and transgender people, limited attention has been given to research, interventions or suicide prevention programs targeting these populations. This article is a culmination of a three-year effort by an expert panel to address the need for better understanding of suicidal behavior and suicide risk in sexual minority populations, and stimulate the development of needed prevention strategies, interventions and policy changes. This article summarizes existing research findings, and makes recommendations for addressing knowledge gaps and applying current knowledge to relevant areas of suicide prevention practice

Med Ref Serv Q. 2011;30(4):393-401. doi: 10.1080/02763869.2011.608971.

Lesbian, gay, bisexual, and transgender health issues, disparities, and information resources.

McKay B.

Source

Texas A&M University Medical Sciences Library, College Station, USA. rlmckay@library.tamu.edu

Abstract

Lesbian, gay, bisexual, and transgender (LGBT) persons, while widely diverse in many ways, share health disparities related to the stigma and discrimination they experience, including disproportionate rates of psychiatric disorders, substance abuse, and suicide. Lesbians, gay men, bisexuals, and the transgender communities have additional health concerns and disparities unique to each population. This paper highlights the national recognition of these health issues and disparities and presents web-based information resources about them and their mitigation

American Academy of Pediatrics stated in Pediatrics in 2004:

“

Sexual orientation probably is not determined by any one factor but by a combination of genetic, hormonal, and environmental influences. In recent decades, biologically based theories have been favored by experts. [...] Although there continues to be controversy and uncertainty as to the genesis of the variety of human sexual orientations, there is no scientific evidence that abnormal parenting, sexual abuse, or other adverse life events influence sexual orientation. Current knowledge suggests that sexual orientation is usually established during early childhood.[ Now this is my belief.If you feel differently then please feel free to express.

Big Boss

So like many of you I am a big fan of big boss.Certain people call it third rate show.My sister in law Aditi Mohan is one such person,who finds me a'cheapda' for the same.And strangely this is the only show which I watch on television.
Why do I like it,I don't know.May be it is a teacher.If you look at the show closely there is myriad of human emotions........some fake and some genuine.You also see the best of sacrifices and the worst of bitching.People lie to each other as if water flowing out from a running tap.
All of us develop sympathy for certain contestsnts.Have you noticed usually who are they?
Either bitchy but strong human beings or some one benign.
In the current show I think Sangram singh should be the winner.Reasons are many.
He has stayed away from most of the fights.
He most of the time tries to fire fight.
On occasions where Arman Kohli fought with him,he was still so controlled.
Not just that he rarely bad mouths other contestants unless /until provoked.
He is busy in his yoga.
He has been a true friend to his friend Andy.
Also I have learnt a few lessons from him.On very rare occasions I have bad mouthed a couple of doctors in front of my patient.it was wrong and unethical.Mostly I try not to talk bad of my colleagues.(though my colleagues are free to bad mouth me as much a they want :-)
Secondly at times I become catty while chatting  with friends of different speciality I do make fun of my other department mates.After Sangram singh.A Big No to it too.

THe Feedback that moved me

I have got many positive  as well as negative feedbacks in past.But I have to say that this is the most honest feedback I have received so far which has moved me.The gentleman promised that it will be a 4 page feedback and I am amazed that he did take that time out despite being a father of a new born baby where you hardly get anytime to write so indepth and heartfelt write up.Thanks and I promise I will try to smile more often.

Hi all,

 

I became a dad on 1^st Dec 2013 to a lovely girl child… Thanks to Dr Kaushiki, both mom and baby are doing well….. Let me rewind 9 months ….

 

This was the first time we attempted and also conceived, we would be first time parents…. We didn’t know ABC of handling pregnancy… Like most people I started searching the internet on who is the best doctor etc… I must say that I too believed that any doc who can perform a normal delivery is a better doc… let me say that’s not true ( btw Dr Kaushiki helped us delivery via Vag Delivery !  ) .. There are many reasons for which many doctors perform a C-sec , most of the times the reason can be the money involved for the institution where they are employed… I understand that .. most big hospitals are run like corporations with strict P/L statements driving the underlying behavior, I don’t think its completely wrong way of functioning after all its not like they are running a charity. Everything comes at a cost …

 

 

As I said at the beginning I didn’t know much .. I think most people think this way that a doc is good if its vag delivery and a cheat if it’s a C-Sec ….. I read up lot of reviews ( women ) talking good about Dr Kaushiki, I did more research online….. and decided to make Dr Kaushiki my doc for my first baby… my wife didn’t have any opinion on this.. she had left the decision upto me… I learned of the pros and cons of C sec v/s Normal Delivery … … but my take was always… that “Doc !! Pls do what is best for the child/mother given the situation at hand “, it doesn’t matter if it’s a normal delivery or a c-sec. But since I read that Dr Kaushiki has a high rate of normal deliveries I approached her as my best case scenario. Its absurd to demand a normal delivery at any stage of the pregnancy and especially at the beginning, there are a million changes that are going to happen before you reach week 40 how can any one or any doc gurantee you that it will be a normal delivery ?

 

My first day at her clinic, she opened a big folder with lot of paper in it….. and I was like what is this… that big folder had “My Pregnancy Book” written on it…LifeCell had apparently created the binder .. which later changed to Cordlife… but that’s fine everyone does their branding… and Dr Kaushiki never recommended me that I should go with this cordbank or the other…( that’s what I love about her, she doesn’t dole out unnecessary suggestions which may potentially make you think she has vested interest in those deals )

 

 I liked it , Dr Kaushiki meticulously recorded each and every thing which was required to create a background of the pregnancy and try to zero in if it’s a high risk or low risk pregnancy…. In that first meeting I would say she came across a bit cold / professional ( may be she was not having a great day or I was expecting some one very jovial or happy or equally excited as we were that hurray we will be parents J ) but then it was the first meeting… and I would say its not a small fee to see Dr Kaushiki , it was 800 Rs then ( Apr 2013) for those 15 minutes..

 

The reason I approached Dr Kaushiki ( which I later also told Dr Kaushiki herself ) is I feel that she has “arrived” in her life… now I know all of us have different versions of being “arrived” and may be Dr Kaushiki has not yet “arrived” in her professional life.. and she may have many more personal milestones but I strongly felt that she would just not do a C-Sec to make dirty money for the hospital she may be working for… as at this point of her career she would definitely give much more importance to the quality of her practice and her Name than to some cheap money made by performing unnecessary operations……

 

 

Also Dr Kaushiki has vast experience of workin in NHS in UK, you should read up a bit if you are not aware of the healthcare system in the western world, I lived in US for few years and I often saw comparisons drawn up between the US and UK healthcare system. Working at NHS means that the focus is on the outcome and the compensation of the doctor will not change if it’s a csec or normal delivery, doctors get trained and habituated to do what is in the best interest of the mother/baby. So as Dr Kaushiki also shared I guess that has ingrained in her way of working as those might be her formative years…. So Patient first comes naturally to her.. and because of that attitude fame/money automatically follows… so that’s another plus for Dr Kaushiki.

 

 

 

When I reached home after that first visit I poured over the entire book she had prepared… there are some 250 plus questions she has answered… more importantly I liked the two page basic description of her practice at the beginning was something which made me believe I did the right thing by going to this doc…. In brief she said…..

-       My way of working will be based on scientific evidence

-       I will not recommend any ultrasound clinic or any other test/clinic 

-       I will not pamper you

-       I am not always reachable on phone, you may have to sms and wait for response or email me

-       Be prepared to be late while sitting out in the waiting room for your appointments, because If my patients ask questions I answer them and it may take 15 min to 1 hour.. you will have to be patient.

-       With all this said if you want to be my patient , then welcome lets start this journey.

These two pages sold me…. But I would not say that all this came our very professional and a bit cold but then again I consoled myself that its ok, atleast I am getting a honest doc who talks straight and calls it as it is…

 

In the age of internet every adult who can search in google thinks of himself as an expert…. This is a big mistake… what I have learnt is that google will give you what you are looking for…. It will corroborate your original belief.. for example if you type “Is Dr kaushiki bad”, it will give you results corresponding to your search and if you type “is Dr kaushiki good” you will get those good results…. Same goes for when you try to find out any specific things about pregnancy… Understand and accept the fact that if you are not a doctor you are not going to become one in 9 months and don’t even try to become one for that matter… dr kaushiki understands that we have lot of questions and hence she has put out answers to so many popular questions which would be parents have… I would say if you do want to learn , go to babycenter.com a trusted resource which will have researched material.. or the other best option ask your doctor.. email her if it’s a long question or set of questions..

 

Dr Kaushiki has a plan and she sticks to it…. I think she works in a venn diagram mode J which is very good… in the beginning itself she made it clear on when and why would she need ultrasound reports .. earlier I was skeptical of too many ultrasounds but that was one of my mistakes.. ultrasound is completely safe get it done as many times your doctor asks …

 

Our pregnancy continued uneventful for most of the period, my wife stuck to the diet prescribed and did what ever was asked of her…  all the meetings with Dr Kaushiki were brief and to the point not one meeting going over 15 mins.. we usually had our questions before hand and she always answered them promptly. I must say she didn’t recommend a ultrasonologist until we really forced her and that too she gave multiple options.. but were ok, we just wanted to go to Ultrasonologist whos work Dr Kaushiki was familiar with as this aspect is very critical, Your doctors decisions depend on the progress shown by the ultrasound reports…

 

During this time upto  34 weeks I never went for a second opinion or to another doctor… I am of the opinion that unless you really don’t trust your doctor, why go for a second opinion , this is not a movie you are going to watch over weekend.. say your second doctor says something completely opposite to your first doctor what would you do… whose opinion you would take.. would you take the opinion which you like ? does that mean your medical condition is being treated on what you “like” are you a doctor .. or are you a qualified person to even judge what is good for you and what is not ? Hence I would say try to put lot of thought in picking a doctor, then trusting them… otherwise you would keep on taking multiple second opinions…

 

I also used to keep going back to Dr Kaushikis blog, even though she is a proponent of Vag delivery , she says on the table its mostly the mother who asks for a C-Sec as these days women cannot / do not want to go through the actual pains of delivering normally , that was a revelation and I concur with that fact, some of my friends told me that doing a C-Sec was their wives first and only choice… so don’t go and paint all doctors in the same color, if some of them are doing C-Sec , they may be requested by the parents themselves… In one instance infact on the same day when my wife was to deliver I saw a would be father and his mother seeing off the would be mother into OT and the father shouting from behind 10:20 AM se pehle karna . 10:20 AM se pehle karna… ( Deliver before 10:20 AM ), so there you go another reason to have CSec so you can have the perfect kid based on planetary positions J, its not the doctors fault if they do CSec ….

 

Our case was getting complicated as it neared its term… Dr Kaushiki asked us to take a call on a matter and also gave her opinion on it…. at this point I took second opinion ( which I didn’t want to but was forced to ) those second opinions were not good at all in the sense of the clarity of thought… they just said continue as it is…. ? but why ? what are the repercussions to continue or induce labour, and all of them said it will be a CSec, which was not a concern to me as what I read up on the subject at times the baby is not strong enough to take the strain of a Vag Delivery and the doctor may take a call to do a CSec to protect the baby…. On this too Dr Kaushiki didn’t say that it will be normal delivery or a Csec, which was fair, I again iterated to Dr Kaushiki that the reason I came to her was that she will do the right thing , so I was convinced that if it has to be a Csec there will be good grounds for it.. and in the end Dr Kaushiki told me that don’t worry if anywhere in the world your baby can be delivered normally it will be delivered here… J I went with Dr Kaushikis opinion and moved my wife to the hospital…within 18 hours Dr Kaushiki helped us deliver the kid normally … it was just excellent… there was so much support in the labor room , everything went like clock work…. It was just another day for Dr Kaushiki in office but life changing event for us….

 

I am so proud , not just because Dr Kaushiki took care of us during the 9 months , not just because her advice was based on scientific evidence, not just because she helped us Vag Deliver the baby.. but because she definitely upheld my belief in doctors that not all doctors are alike…. And some of them are honest….

 

Max Hospitals – if you are reading this.. feel lucky and be proud that you have Dr Kaushiki working for you.. kindly don’t put any kind of “assurance” schemes on Dr Kaushiki and let her be… she is the queen of your chess board and a queen works best when she is allowed the freedom to move anywhere anytime…. Please note she is one of those doctors which brings credibility and good will to your institution. If I were you , I would have held biweekly calls with Dr Kaushiki just to know if there is something that Max Administration can do for her to help her see patients , deliver babies better.

 

Other Gyne Doctors – When I took second opinion, I spoke on phone with few of them, I must say no matter how good a doctor you are , but when you ask my Gyne’s name and then smile/laugh first and then talk.. you have already lost me… Please be professional and respect your peers, even if you don’t have a high opinion of any doctor kindly don’t let that be known in no uncertain matter to your patients, the patients anyways are under lot of stress, you smiling laughing and doing a “know all” attitude and making the patient feel that they are in wrong hands is not winning you any brownie points…. Its then I realized that the curt behavior of Dr Kaushiki is better where only professional inputs are given to qualified questions… no drama.

Most importantly please try to have an honest practice like Dr Kaushiki has, even Sachin Tendulkar has said in his farewell speech "Fame and Fortune will automatically come to you if you pursue Excellence" , and try to be humble, you will get more respect.

 

Dr Kaushiki – cannot thank you enough for you are reinstalling the belief patients carry in doctors, which is being steadily eroded by some doctors by not being honest … also you have a great smile, flash it often… I know you don’t want to pamper the would be mother J , but a reassuring smile always works J

 

 

A Few things I learnt from my experience…..

 

-       Try to get a doctor who works close to your home/office , it will convenient esp In the later months as last thing you want is to deal with traffic while commuting to then frequent trips to ultrasound clinics and doctor visits.

-       Put a seat belt on your pregnant wife no matter how slow the car is going.

-       Massage your wifes feet every alternate day in upward motion , it will relieve her off the swelling and pain.

-       Would be mothers – all through the pregnancy keep massaging olive oil or any other good massage oil all over your belly and back area if you want to minimize the damage done by stretch marks.

-       Would be mothers – don’t skip any meal, most of you have smart phones, make an account in caloriecount.com and ensure you eat right… you don’t have to eat fatty stuff but just eat enough quality stuff.

-       Read up and follow babycenter.com , the smart phone app version of the website is very nice, it only brings up those things ( changes in your body ) which come at the right time ( week wise ) so you are aware of what is happening with your body and you will not panic or worry.

-       Get a juicer / blender and whip up fresh juices off mausmi etc , avoid canned food/juices.

-       Avoid Cut fruits at any cost… ie don’t cut an apple and keep in refrigerator.. consume the food immediately.

-       Do go for cordblood banking, which company , I will leave it upto you.. but do go for it, its not costly and it’s the only opportunity to save the cord blood and cord tissue , once in a life opportunity it will never come back, and who knows in next 20 years how much would science progress, god forbid should you never need to use it , but its like an insurance. Companys have EMI options and as little as 2500 rs per month for 2 years you can get this service done.

-       Try to get a Ultrasonologist who your doctor trusts…. Believe me there is +-15% variation in every reading they give.

-       If you are a smart phone user, keep a todo app handy, I regularly use Wunderlist app on iphone and I used to jot down any doubt / question that I may have for the doctor , I used to bring up the list of questions when I used to visit my doc. Make your appointments count and try to get your questions doubts answered….

-       Its very important that you trust your doctor, if you don’t trust your doctor and feel he/she is inept or taking you for a ride , leave immediately , you are wasting your and the doctors time.

-       Having a single or double loose loops around the babys neck is not the qualifying condition to do a C-Sec, if your doctor is saying that’s the case then do take a second opinion. Its time that patients are not scared into CSec by doctors..

-       (For Guys) Leave the decision of Csec or Vag Delivery to your doctor and your wife.. don’t force your opinion on what is right or wrong.. you are not the one who is going to deliver and you cannot even imagine the pain a woman goes through. Also understand there may be many situations where a CSec is better for your wife and baby than a normal delivery, like I said since you and I are not doctors , find a good doc and trust her.

-       Be patient while waiting in the waiting room for the doc, because if you are not patient or irritated that its taking so long to see the doc, one you are going in with a bad mood to see the doctor, two you are taking unnecessary stress. Please understand if a couple is taking time, it must be important , you could be that couple..

Rahagiri needs to be better organised

It looks so nice.On a balmy Sunday morning ,Moms , dads, children , dogs , Grandparents  and Girl Friends and boyfriends can roam around safely on the Gurgaon Roads.They can ride their cycle and show few tricks as well.Skateboard skills look good too.What to say of Zumba on road.It is so colourful and we already have mimicked the European concept of walking and cycling and enjoying the physical activity for a healthy us and better environment control.

So where is the problem? The blocked roads near emergency services like Hospitals.Not acceptable at all.There is no sign post to say that the road has been blocked.there is no sign post to suggest the alternative road.

Yesterday I was stuck in this whole 'Tamasha' near park plaza hotel and my patient was fully dilated and pushing.It was just God's grace that Dr Deepa Maheshwari was there to attend to her delivery ,but I couldn't make it in time.It can be unsafe.In just my last post I mentioned of Shoulder Dystocia.What if something like that had happened and I was stuck for 20 to 30 minutes just because of ill organised Rahagiri.

SINCERE REQUEST

• Don't block roads near emergency services
• Please think the repercussions of your actions
• Please handle the traffic properly as all Rahgirs reach the venue in their cars and thus adds to chaos .
• People who load their cars with bicycles ,please see that it is safely chained and not going to affect other people on road and also that it doesn't cover your number plates.Traffic police should Chalan such drivers.

Finally ,make separate cycle tracks and bus tracks.Separate paved area for people who wish to walk.Please don't block the existing roads which anyways are in pathetic situation.

 

I am not trying to be spoilt sport,but fact is fact........even if harsh 

 

 

 

 

 

Shoulder Dystocia,When you wish those 7 minutes never end

Normal Delivery is good.It is simple and it is easy.You just have to hold the baby who anyways the mother is pushing out.True most of the times,Normal deliveries can be quite scary at times.Thus a doctor who isn't well versed in managing acute Obstetric emergency shouldn't try a vaginal delivery without adequate back up.
In Uk and other countries which have structured protocol based training Shoulder Dystocia drill happens quite frequently.In India in the absence of such drills it can be a nightmare if encountered in one of the deliveries.
Recently One of my patient had shoulder Dystocia and quite bad at that.Shoulder dystocia is a condition when the shoulder of the baby can't come out vaginally after the baby's head has been delivered.It can happen at any weight of the baby.So the lady was in labour for more than 15 hours or so and then she got exhausted.Asked for help in the form of assisted delivery.I successfully pulled the baby out who was in occipito posterior position ( Baby's back was towards mother back).And then started the struggle.The shoulder receded back.And an attempt by Dr Deepa to pull the baby out failed.And flexing the thigh and macroberts maneuver and all failed.
Now in this situation 'seven minutes' is all what you have got to deliver the baby or otherwise the baby is brain dead.So injury to mother,fracture of baby's hand bones( humerus) and clavicle is the last concern.You just want the baby out.
Having attended many drill in Uk,I managed to keep myself calm.Did a wood screw maneuver.and baby delivered with some difficulty.In bargain he got a crack in the clavicle.
Why did I write this post
a) I am proud of myself :-) that I could keep my calm.
b) To make would be parents aware that shoulder dystocia is a reality and expect the possibility during any delivery.My patients were very understanding and they had all the good words to say for the good work done.
C) Last but not the least .......all junior Gynaecologists please go through the shoulder dystocia management guidelines and please review thw maneuvers and it's techniques.

Shoulder Dystocia Delivery

This Video is equally good for Patient's and doctors alike.Just to remind any delivery has the potential to have shoulder dystocia

Whom do we sue?

Came across a bizarre scenario today morning..There were few youngmen,police men and our security personnel.A man who suffered a massive heart attack yesterday night was taken to a local nursing home.They brought him to our emergency when nothing much was left but still the doctor on call who is bound to do the CPR,did it.Unfortunately he died,Now the relatives were fighteing with the hospital that why did the doctor try to save the person and they won't make the payment for the medicines etc used.
It is a lost battle for us doctors
If they do a CPR they are still at fault as that increases cost on an almost dead person.If they don't do then obviously they are ' Criminals'

Surgical Count :a team work

To make a Doctor Successful,it is hard work of a complete team including assistant surgeons,Anaesthetists,Scrub Nurse,Circulatin Nurse and OT Techinicians.The chief Doctor is the face of all the activities and the contace point for the patient but the fact remains that to give them a good surgical outcome a complete team is working hard and well coordinated.A lack in coordination can lead to mistakes which can compromise on surgical saftey despite all the competence of the surgeon.
Let me give you an example.To ensure the a surgery goes safely,before the surgeon starts the surgery the Scrub Nurse counts the Mops,Gauzes and instruments and the circulating nurse puts it on a white board in the OT.All the Mops and swabs aren't opened all at once but on demand of a busy operating surgeon who isn't supposed to keep a swab count,the circulating nurse hands it over to the scrub nurse.They count it together.Once the surgery is over and before the abdomen is closed the surgeon asks the scrub nurse to recount and confirm loudly that the initial count matched the second count.Again the scrub nurse with a circulating nurse double checks.Two scrub nurse or two circulating nurse are not supposed to count it between themselves.It has to be a circulating and scrub nurse.If in between scrub or circulating nurse leaves inbetween the surgery the documents are recounted ,documented and handed over all afresh to the new member of the operating team.
After which surgeon starts the closure of abdomen.
Once the abdomen is closed once again the count is correct is asked loudly by the surgeon and is confirmed by the scrub nurse.
After which the Scrub and circulating nurse sign on a WHO recommeneded saftey check list and also tick that the Surgeon has been informed.And finally surgeon signs that she has been informed.
So if next time you hear a story that a doctor left a foreign body inside ,you know it isn't the butcher negligent doctor.She was not supposed to count the mops but to rely on the team with whom they have been working for years..
So a teamwork which is well coordinated is very important for patient safety.



 

Thanks to my patients

This post is dedicated to you Priyanka ( if you are reading the post) and to many other such patients who have 'tolerated' me months and years all together,have shown their immense faith and continued to come back to me as a doctor.
Yesterday I was little upset as two of my old patient's decided to go to Fortis Memorial Hospital to deliver for the Glitz and the Glamour of the place.I don't blame them but it did hurt as you know you have done your best as a doctor,given them your time ( ofcourse they have paid me the consultation fees) and they even like you as a doctor but then they still decided to move on.
And then I came across priyanka who now is very close to her date of delivery.Realised she has been visiting me from her 4 weeks of pregnancy and has been so trusting and low profile that I didn't even realise that she was coming to me for so long.And I it gave me immense happiness......I just asked her........so you have been tolerating me for a while now.And her husband said......my sister delivered under your care.There was so much faith and trust in his voice.He had made my day.I had forgotten the disappointment the remaining two patients had caused.For this couple I was more important than any hospital :-)
And then I realised that I have many such patients who have been associated with for last 6 years ( since I started my practice).Who come to me for their smallest problem and I take them fore granted ( not actually).What I mean to say is that I never valued that trust,the faith and reliance shown by them,They had so many options but still they have been following me.
I thank all of you for the immense faith shown in me and it a a genuine heartfelt thanks!!
As I am typing these words so many names and faces I can think of,who deserve this thanks.
Recently I did something which I think was probably not the best thing to do.There is a saloon in DLF phase 1 which I visit for my hair cuts etc.The staff is well behaved,know their job and even go out of their way to keep me happy as a client.And recently I visited them without an appointment to get my son's hair cut,demanded for a particular stylist and when they said that I had to wait 30 minutes,I left the place and went to a new saloon.......just because I didn't wish to wait.They did a good job too but I felt guilty somewhere.There has to be a strong reason to change loyalities.
In today's fast pace world loyality probably is not the biggest virtue but then it is virtue none the less.
So thanks once again to all those who have tolerated me so far and continue to do so...........................   

Thrombotic Thrombocytopenic purpura and pregnancy

Recently have started to spend less time with blogs.Realized recently that net has many fold reach
than what I used to imagine.Few Australian doctors  were communicating with me on phone.And their 99 % discussion was related to my blog posts.I was amazed as well as amused.
But then it made me understand that whetever I write should be a responsible comment/statement and even if I am not feeling too good about something,better to avoid writing it if it is controversial.

Life is as usual.So is work.Nothing new really to share.


Let us talk about a very rare condition TTP or thrombotic Thrombocytopenic purpura.It is very rare condition which can happen in women after pregnancy.Suddenly the blood cells start getting haemolysed,platelets are cosumed which gives patchy appearance to the person,Kidney and liver shuts down and a person can be quite sick with this condition.Even immunity gets compromised.The medicines associated with it are Contraceptive pills,blood thinners ,cholesterol lowering simvastatin,quinine and few cancer medication like beomycin.mitomycin etc.
 etc



Almost 25 % TTP are caused by pregnancy and other who are prone to it are those who are immunocompromised,have H/O HIV


Having said that don't get scared of either pregnancy or  taking these drugs if indicated.IT is a very rare condition which if not treated leads to the death of the Lady.


It's simple treatment is a procedure called plasmapheresis  .

Goes without saying-------- a patient of mine had this rare condition which is as rare as 6 in 1000000 !! 

One Medicine but multifactorial uses

 let me talk about medicines which originally was invented for a different reason and now is being for used for treatment various unrelated condition.
Let us start with the Cancer drug METHOTREXATE. Given to patients with choriocarcinoma and not fibroid as some one very erroneously wrote some where very recently.
The another very important use of Methotrexate is helping both unmarried as well as married women with ectopic pregnancy which otherwise can kill them if undetected and ruptures. The dose recommended is 50 mg/m2 which means for a 5 feet 1 inch female with 65 kgs the dose would be around 82.5 mgs. It is a small dose therapy unlike high dose therapy used for cancers in the dose of 500 mgs/m2.You would expect hair fall, mouth ulcers, patches, bone marrow suppression at high dose but  at 50 mg/m2 it is quite safe medicine recommended by RCOG and ACOG. One would be really unlucky to be sensitive to such a minuscule dose of such a wonderful 'cancer' medicine.

Another one is metformin. It was and is used for Type II Diabetics but with equal vigour it is being used in women with PCOD and that doesn't make them diabetic.

Oral contraceptive pills are used for treating various hormonal imbalance apart for contraception.

Vit B complex is a supplement but at times in patient's with recurrent miscarriage and homocysteinuria it becomes the treatment.


SO KNOW THE EXACT REASON WHY YOUR DOCTOR PRESCRIBED YOU A MEDICINE.

Midwives in a system........such a boon

I come across so many expectant couples everyday.All of them are so excited.They wish me to talk with them.When I say talk with them,not just about the science and skills of Pregnancy,labour,delivery etc.but to talk and share how they are feeling.Their happiness,their excitement.Few good words for the baby who is still in the womb.To tell how their baby is different from the rest.Use some pampering words for the Lady.....sweety,darling,love etc......It does make a difference.It makes them feel positive.But unfortunately the training of us doctors is very matter of fact.You find that 'all is well'.Convey so.Listen the query,give a scientific answer.I have realised that it makes the couples feel good but the lady wishes much more.The husband knows that he can just hear baby's heartbeat but would loom over your head,just in case you can show if something.
And it is all so very nice and cute.There is were comes the role of midwives.They are well read.They know the obstetrics and at the same time they fulfill the lacuna in social communication left by the specialist doctor.they Pamper the Lady.....is her strong support,feels her wanted,visits even her home if needed.They share their problems much more with the midwives rather than doctor.May be they see them as their friends
Unfortunately in Indian system,we don't have a well defined role for midwife.A doctor doubles up as both.They result is never the same .A overburdened doctor cuts a very sorry figure as even more tired  midwife.May be our health system needs a drastic change......change for the good!!

Getting your fibroids treated in Gurgaon

Today I am talking specifically about you and me.It isn't a vague ,beating around the bush blog.You have a condition and I know I can treat you well.Let us try to talk it out.
Fibroids are the commonest non cancerous tumour in Women of child bearing age.Majority of time it doesn't need any active treatment and keeps on growing inside our body without any problem.
But at times it can cause you symptoms.Symptoms like
heavy bleeding not corrected by medicine
Painful periods
Pressure in pelvis and difficulty in pee and poo.
That means your fibroid has become symptomatic and it needs my intervention.So here is Dr kaushiki Dwivedee the Lead consultant laparoscopic Gynaecologist,Max Hospital,Gurgon at your service.We have got various options.If you wish to preserve your uterus a Laparoscopic Myomectomy is the answer.If you have completed your family even a 4 kgs fibroid can be removed Laparoscopically(TLH) be me.
Unfortunately Max Hospital has been so far associated with deliveries,but it can give you much more,just you need to know the correct specialists.


 

Ovarian cysts and laparoscopic Ovarian cystectomy

Ovarian cysts are of different variety,

There are some,which are called functional cysts,which body produces and dissolves it.One doesn't need to get operated for it.A follow up scan after 6 weeks is recommended.

The second type is non cancerous non functional benign ovarian cyst.Which won't get absorbed,neither is cancerous and would not get corrected unless operated by key hole surgery.If too big even laparotomy might be needed.

Then the third and most sinister type.Cancerous.As per the protocol I perform a staging laparotomy or send for chemotheraphy first as considered appropriate in the tumor board meeting.

Diseases are a part of life.No point trying to deny them.It is better to understand them so that one can either prevent it and for a non preventable condition llike ovarian cyst to identify it as soon as possible and currect it

My Training at Tata Memorial Cantre

So,I am back today after a week long certification course at Tata Memorial Centre.It was my second visit to Mumbai in last 10 years.Hasn't changed much.Felt good to see a centre so world class dedicated to cancer patients.I was a trainee in the Gynaecology cancer  department.Just Wish I had more time to xtend my training programme.Dr Maheshwari is fantastic with her surgical skills.Hats off.Learnt a lot from the wonderful doctor.Just hope that Iif I am able to do even 5 % of what she does for  her patients,I would have no regrets...................


 

Rectovaginal fistula-------So big in size ;-(

Sometimes God lets you live but life is far from being perfect.Think of a frail old woman of 63years,developing cancer cervix 12 years back.And being diagnosed at stahe IIIb and have radiotherapy.But after radiotherapy survive for 12 years without a recurrence.Not too bad.Living in a small Bhojpuri town with kids not very rich but placed well in kind of job to afford her treatment as and when needed.
And so what happens is that one month back she starts having loose motions and can feel stool in vagina and smells of stool.So they give her antidiarrhoeal but get her to Delhi.Visit quite a few big hospitals in Delhi and Gurgaon and are diagnosed with big Rectovaginal fistula,,,,,,,a hole between  vagina and rectum developed due to radiotherapy done years back.She is told that she has got a RVF which I don't think this Lady understands much considering her uneducated background where her whole life she might have depended on her father,husband or Sons to take decision for her.She is told and also is written on her prescription.....RVF,nothing can be done,onservative management.What does that mean??To sit in a puddle of puff.
Her sons get her to me.They have heard that I deal with such cases.And ofcourse I do.These case are not so difficult if one knows the pelvic anatomy well and can dissect in correct plain.So I say a yes to her.Yes I will operate you.Then I tried to rule out a recurrence of her cancer  by getting a MRI done.Take a biopsy with great difficult from the fistula tract which is quite hard and stenosed and avascular due to her radiotherapy.Both rule out a recurrence.
And Then time to get a fitness certificate from anaesthetist.Yes and we find that she had a recent Myocardial infarction as per ECG.So we need to get an angiography done.So,we arrange for that.And yup......2 vessels are involved.Will need a plasty and then blood thinners.So????? So then what.......try to repair her RVFunder high risk consent now as after angioplasty no surgery can be done for 6 months.Ask the Lady.....her opinion.She leaves it on me.Her sond they trust me blindly.
I am scared of such patients who don't question you and leave all the decision on you.You feel so weighed down by the trust they put on you unlike people who are oh so well educated as to know medicine just too well.Who have so many questions and those who take informed decisions.
Now I and Dr Shalabh decide a plan.Temporary diversion colostomy for sure to give sometime for repaired fistula to heal.then fistula repair.And after angio reversal of colostomy.
So Shalabh does a laparoscopic colostomy successfully in a plastered pelvis.Can't   dissect the rectum from above.
I start developing a plain between rectum and vagina.God,the defect is just too big.The biggest ever RVF seen by me.Anaesthetist asks....Have you done a dye test for fistula :-))?Here a three fingers of mine can pass through the fistula.Who needs dye to make a diagnosis!!So a plain was developed nicely on the right and anterior aspect.But on right side the rectum is tightly adherent to the bone and vagina.Did some dissection but not enough tissue to do a tension free suturing of the rectum.It is impossible.So both me and shalabh decide to close back the dissection.
She has a diverting colostomy now.She won't be sitting on a puddle of stool .But then it is not fair.A rent so big as is impossible to even approximate it.Hope her quality of life would be better,if not 100%,atleast 50%!!

Feedbacks .........Ignore them!!

Of late Medicine doesn't excite me too much.........I find myself exhausted and tired .Multiple tasks......OPDs and consultations.....endless hours of talking.Trying to survive in the corporate culture.And yes Feed backs some good ,some bad.In older times Journalists had the privileges of bossing.......They were Media.They can make or break you.Now unfortunately,everyone is a media.You find a blog or a forum.You vent out against who so ever you want.

If you are a blog master of any successful blog you can write or publish only good feed backs about a doctor.Delete or hide the unfavourable ones.I just wish I had a friend or a patient like that..........who would just simply edit my bad feed backs.

As always,there is an incident which makes me write me a post.The latest one........the so popular Gurgaonwatch and it's posts on experience with Max Hospital,Gurgaon.I am sure many of my patients came to me after reading a few good comments by few of my patients.Recently there was a bad feedback about me.And I did request the blog master to withdraw it till the genuineness of that feedback was established,knowing the fact that in past he has deleted some unfavourable comments against his favoured doctor.So what happened......he did withdraw it for the time being till he has done the arbitration......established whether I am correct or the person who left the feedback was correct.Got the feeling of 'Media of past'.And a friendly advise ( I hope at least) that I went overboard in defending myself.

Now what was the feedback?Some unknown person 'A' states that Despite her request to get a downs screening test done between 11 to 13 weeks......I stopped her.Telling her it wasn't necessary.Why would I do it specially for her.when I don't let even a 20 years old get away without a downs screening test.

And then she requested for a quadruple marker and I told her to get a triple marker instead( which incidentally I have stopped writing at least 2 years back).Do I have a proof?Yes I have......My pregnancy folder.....I am so happy I came out with it never realizing that it will turn out to be a medico legal document for me in future.(Anyways there are many gynaecologists who are writing triple marker still and it isn't obsolete.They are at no fault if they get it done.)Now she forgets to write that the triple marker came low risk.I guess it was low risk only otherwise she would have written that I  missed a high risk report.

It contains a list of investigations........and double marker and quadruple marker are clearly mentioned there.FAQs in there also explain why should these test be done and are a must.

Double Marker,Triple Marker and quadruple marker all are screening tests and not confirmatory tests with their false positives and negatives both.Too bad if triple marker showed a false negative.Can't help as a gynaecologist.

Now the story is that she complains at 28 weeks of decreased foetal movement and I tell her that 1 movement a day is normal.I must be crazy enough to say so........when again my pregnancy folder clearly tells 10 movement or more in 12 hours.And the she comes to Max Hospital GGN to get a scan done in emergency which is normal as per the ultrasonologist.But she is still not convinced and visits another hospital and doctor whose name she won't divulge......they ask a Doppler ultrasound.........some doctors make the Doppler sound so special...........shows hydrops.No soft tissue marker but hydrops.And the next day there is no heart beat.And an autopsy later it turns out the foetus had Down's syndrome.So I am callous,as per her.I don't know how?I didn't report a triple marker and I didn't do an ultrasound.God hasn't blessed me with a power to predict.

I am not even sure that this is a real patient.......And if it is a real patient then,I don't understand or remember why I would manage her any differently from rest of my patients.

I don't feel like giving any clarification for such baseless allegations.......And this the last such allegation I am responding too.I don't need to prove anything.If I am wrong I will let you know and say a sorry but I don't feel like being responsive to such irresponsible person .




 

jo tum hasoge to duniya hasegi

My dad is no more ,but time and again incidents take place and remind me of the words,phrases,couplets,poems or a piece of song which was so very relevent to life.One of his favourites was lines of a song sung by Kishore Kumar
jo tum hasoge to duniya hasegi rovoge tum to na royegi duniya na royegi duniya, tere aansuo ko samjh na sakegi tere aansuo pe hansegi ye duniya hansegi
Do you relate with it???
We all work very hard......very very hard.Even I do.You work hard because that is your job.But then you work hard also because you wish to do justice to your job.And then comes a point  when you realise that your Machinery needs a break.Your body cries.....give me a break to work further or I will crash.Same happens with me.I work for months and months,almost 15 to 16 hours a day.And then my mind and body needs some break.And then as you are working there is a time when you feel unwell yourself,,,,,physically.mentally or emotionally.But then who cares....... jo tum hasoge to duniya hasegi rovoge tum to na royegi duniya na royegi duniya, tere aansuo ko samjh na sakegi tere aansuo pe hansegi ye duniya hansegi
Why am I writing all this?
Recently I was on vacation for a week.......yes just a week after 6 months of hard work and as soon as I returned someone very dear passed away at a very young age.( That deserves a separate post).So what happened......I got mail at my personal email id from one Mr XYZ,who was sending his wives reports to me.And despite an autoreply that I am out of country and to contact my fellow team mate Dr Deepa Maheshwari he choose to wait for me.Such an honour for me and I am touched.But I forgot to check his mail.Assumed he has contacted Dr Maheshwari.And then that gentle men sent me another mail the next day of this death and again I missed his mail as luck would have been.Surprising......as rest of the mails were answered.So what do I get as a mail yesterday........I AM DISAPPOINTED.YOU COULD HAVE BEEN MORE COMMITTED :-) Yes I should have been more committed even if my body cried for rest or if a dear one had passed away.That is my Problem after all.
jo tum hasoge to duniya hasegi rovoge tum to na royegi duniya na royegi duniya, tere aansuo ko samjh na sakegi tere aansuo pe hansegi ye duniya hansegi  (QED)

Angelina Jolie and the mystery of her breast removal surgery

Since morning I was visited by two Ladies  in my OPD.Both of them had very vague complaints.After talking for a while both of them revealed that they were scared after reading the news that Angelina Jolie went for some kind of breast removal surgery for preventing breast cancer and they wished to know if they also needed the same. At times I wonder if information has eased our lives or complicated it many fold.

 

Anyways ,let me try to simplify what she did and who need it.In our body there are two genes BRCA1 and BRCA 2.The purpose of them is to suppress cancer.Any mutation in them makes a person prone to various types of cancers.In women the associated cancers are Breast cancer,ovarian cancer,Fallopian tube cancer and peritoneal cancer.

 

The ladies who should be tested for BRCA 1 and 2 mutations are as follows

Women with a personal history of both breast cancer and ovarian cancer

Women with ovarian cancer and a close relative—defined as mother, sister, daughter, grandmother, granddaughter, aunt—with ovarian cancer, premenopausal breast cancer, or both

Women of Ashkenazi Jewish decent with breast cancer who were diagnosed at age 40 or younger or who have ovarian cancer

Women with breast cancer at 50 or younger and who have a close relative with ovarian cancer or male breast cancer at any age

Women with a close relative with a known BRCA mutation

Now the question is what is the role of removing Breast,ovaries,fallopian tube and uterus.
It has been found the in BRCA positive Ladies a prophylactic removal of breast can prevent up to 90 % of Breast cancers.Removal of Ovaries and fallopian tube also decreases the incidence of ovarian cancer.But removal of these organ doesn't mean an absolute peace of mind. There is still a 4 % chance of peritoneal cancer in these ladies despite removing the ovaries.

To go for it or not?If you have a BRCA 1 or 2 mutation,have completed your family it can be a choice for you but yes it is not an easy decision to take.And remember 99 % of us don't have a BRCA gene mutation.



Also Read
http://edition.cnn.com/2013/05/17/opinion/welch-jolie-mastectomy/

Being Doctor is a huge responsibilty

For almost over a month I have been thinking to speak out on this topic.It is the sensitive nature of the topic which prevented me from writing down the post.I will have to choose my words carefully.Don't wish to come out as a traitor trying to spill the inside beans ........but my inner voice......it has pushed me a little too hard and I think,a small post on this topic won't to any harm.
As doctors we are dealing with human life.Just like anyone else we are also prone to errors and complications in our profession.Just that our margin of error is very low.It can lead to a botched up life of somebody.Now should all the doctors be crucified for a complication?Are all of them incompetent or negligent who have a complication in a patient.The answer is No.Despite our best attempts we might at time have complications in surgery/delivery/Cesarean etc.
Now suppose you have been visiting to a doctor with very good references and word of mouth or Internet reviews support the person.You end up with a complication( Which at times can be life threatening and landing you in ICU).Your doctor either himself or herself or with the help of other senior doctors manages your complication or at times partially manages the complication.Comes out of OT and tells you......It was a complicated Surgery.Let us see what happens.......few days later patient is out of danger.How do you know that it was a really complicated surgery or the doctor botched up?Unfortunately as a lay person you would never know.If I were not a doctor even I can't differentiate between a genuine complication despite doctors competence and one due to lack of competence.
Many times doctors who are very good in their field after a single complication derive a bad name which they don't deserve and at times case after case with a good communication skill and helpful colleagues keep on performing the so called 'difficult complicated' surgery.They are unsafe doctors.In a system like UK........you can't thrive with such practice.General medical council is very stringent in these matters and such a doctor would be sent for retraining.What happens in India........Well you have a good practice,so you are a revenue generator.There are a whole bunch of people to hide your incompetence.And so what happens.......you never try to improve.
Are such doctors at fault?May be they are up to a certain extent but then it is our system which encourages mediocrities.
Though I wish to speak more.........but won't be able to speak any further.It is the system and even I have to survive in it.But yes,it would be a request to all the health care professionals as well as to my self.....self audit.And if you think you can do more harm,take help and that too in time.  
As a patient.......Please just don't go by internet reviews (including mine).Try to find the credentials of the person.Try to find the educational qualifications.Not every surgeon is the same.Not every Gynaecologist is the same.Not every urologist is the same.Not evry orthopaedician is the same.Not every cardiologist is the same.If you look carefully you can see a difference in their qualification.Try to find who was trained where.An Mch Surgeon is more qualified than a DNB/fellow.If the same person has Mch as well as DNB.Fellowship,that is different.Diploma in a subject is nor same as the degree. I am sure..........for your own health you can do a little bit of research.
In various sites I find people asking if the doctor talks nicely,gives time in the OPD,picks the phone,has delivered a celebrity.........but I have never seen anyone of you concerned about the real stuff ------Qualification and competence !! so think next time you visit a doctor.

God.....the indirect evidence

This post is not about health,Not about women.But I still feel an urge to share it with you.Yesterday night at around 2 am I returned home after finishing an emergency surgery.Tried to sleep but couldn't .Was feeling thirsty.I had a bottle of water just next to my bed.But then I thought I will walk down to the fridge to have some chilled water.And I walked down towards the kitchen.From the light which came out of the aquarium tube light I could see something on the ground.I was groggy.....half asleep.Still I put the light on in the living area.I thought I saw a rubber toy,shaped like a big Fish.With a new puppy at home ,I thought may be my mom has got him a soft toy to chew.And then i thought I was hallucinating.Looked like the mouth of the rubber fish was opening and closing very gently.In those few seconds I thought too much and too fast.I looked at the aquarium where the fishes were moving in.And then I realised that it wasn't hallucination.....the mouth of the toy was moving.....like shallow gasps before one is dying.But this fish was at least 4 feet away from the aquarium.God.....it was the fish who had jumped out of the aquarium and was having her last few breaths.Being a pucca vegetarian it was difficult for me to hold the fish,but if I didn't put it to water it had no chance at all.And I held it on a news paper and just threw inside the tank.It moved and then sank to the bottom of the aquarium.It started to breathe.......very hard and very strained.It's fins looked all dried and shrivelled up.I thought it won't make it.I thought it was a dream.Called my husband to confirm what I had just seen and done.
In the morning when I got up I expected it to be dead.But no.........it looked better.Definitely unwell but not dead.Slowly over the day it improved and is almost 50 to 60 % of it's normal.
Do you have an explanation.......how the fish came out of aquarium.........What made me have the urge to have cold water from fridge while mostly I don't bother in night.How I reached just when the fish was having it's last few breathes and the body was not at all moving?What stopped the puppy to follow me(who otherwise would not have left the fish)at the point of time.Just like Life of pi I got an indirect evidence of God..........We are nothing.It is he who decides who will we were doing what and also the outcome.The fish could have died even after being put in the aquarium.But he choose to make it live.Amazing.......though a small incident,it has touched me from deep within.

Stem Cell banking- to go for it or not?

Lot many parents are interested in getting stem cell collected for their Kids as apart of 'future Investment'.There is an emotional angle and it leaves parent feel guilty if it haven't got the banking done.Yesterday I attended a CME on stem cell and it made me think that how less do the counsellors and even the doctors who advise you to go for it or don't go for it know about the stem cell banking.
Stem cell is a bright concept with a huge potential to treat many medical conditions.That we are talking about Public banks,where just like public blood banks umblical cord cells are donated and stored as stem cells.The stem cell is released at a price when a person needs it for therapy .
Now coming to the Private stem cells,the idea again is good but then there are few aspects which you need to know before you take any such decision.

1. If your baby has Metabolic disorder ,he can't be treated by his own blood.Reason being even the stem cells are having the same disorder.
2. Leukemia can't be treated in the child by the stem cell,as it has been found that these stem cells have the potential to get transformed to cells having leukemic antigens.Moreover when donor cells are given there is a preventive Graft VS tumor reaction,which is beneficial and can fight with the cancer cells.When the child's own sample is used this protective graft vs tumour reaction is absent.
3. For a good unit of stem cell at least 60 mls of umblical cord blood is needed.Below which the cells retrieved would be less and thus useless.
4. When needed this 60 mls is sufficient for only one transfusion of the child.For adults this one unit won't be sufficient.Ask you blood bank ,God forbid if you need it tomorrow........how will you get more units?
5. Umbilical cord blood should not be collected in woman who are less than 34 weeks pregnant as the cell retrieval will be very less due to small size of placenta.IN a twin pregnancy the collected sample should be checked for cross contamination.If Lady has uterine infection then sample should be discarded .Goes without saying if mother has HIV or any other blood borne Infection,,,,,collection shouldn't be done.

In India as of now we don't have a full fledged public stem cell bank and till than private banks are better than nothing.
All the Hospitals and Gynaecologists worldwide are paid some collection charges for stem cell, from all of these companies and that is ethical and doesn't come into the category of unethical cuts.

NIFTY(Non invasive foetal Trisomy Test)

I am excited to share some recent advancement in the management of Pregnant Ladies,particularly those who wish to become mother at a later age.
The biggest fear of these mothers are 'I hope my baby doesn't have Down Syndrome'.
Till now the options available were screening tests ( Level 1 scan and Double Marker and quadruple Marker).A serum integrated test was considered the best screening test.But it has it's pit falls.There is a possibility of false negative as well as positive.
So the confirmatory test used to be invasive Chorionic Villi Sampling or amniocentesis which was a major cause of concern of these Ladies as these procedures can lead to miscarriage or infection.
NIFTY (Non Invasive Foetal Trisomy test) a new test and still under trial seems to be coming up as a very good,practical and safe solution for confirming the Downs syndrome.It has a false positive value of less than 1 %.It can be done from 2mls of mothers blood.The test works on the basis of identifying foetal cell in the maternal blood and process it.
At the moment the test can be done in Hongkong,Dubai and Germany.But if you are an Indian who unfortunately needs this test,the sample can be sent to Hong Kong.

A New begining

More than three months of dilemma and I realise I lack the quality to be cut throat required to reach the top.I will never reach the top of a corporate ladder and I am a mere clinician .But then I think that is what I was trained to be .
To all my friends whom I told that I am moving to another hospital as the departmental Head,I am not.I am very much at Max Hospital Gurgaon.It has been a stressful 4 to 5 weeks of thinking and rethinking and logic and counter logic and ultimately it was my emotions which got  better of any logic.There were people at Max Hospital who I value more than my gains.............. It is perhaps stupidity.And as few of you thought I had a counter offer.No there was none.I am still the unit head with no financial gains as one would like to believe.I know in bargain I have made a few people unhappy.Have not been at my best possible behaviour with few friends.But then you can't keep everyone happy. .
The decision to leave one hospital from another would be so difficult,I never thought so.I wonder how doctors switch over so fast from one institution to another and with so much of ease.Maybe I made a mountain of a mole hill.Anyways I am still where I was.......at clinic Nirvana and Max Hospital ,Gurgaon.