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.