Category Archives: surgery

SAVING THE TERRORIST

I have been in Mumbai in the situation it finds itself in at present. I have been in the forefront of a disaster management team (to flatter a rag-tag army of residents, nurses, ward-boys and Superintendents in a Hospital) when the Babri Masjid riots took place in 1992, and, not much later, when the Bombay Stock Exchange and Air India were blown up.

I saw from close quarters how barbaric people can be in the headwinds of the irrationality of collectivism (often religion). I am talking of general wholesale slaughter of any person of a community if he made the mistake of being seen. It cut both ways, and this was doubly unfortunate during the Babri Masjid riots.

I wonder, upon learning that the poor little innocent boy who shot a few people in the railway station (the name changed from Victoria Terminus to the more elegant-sounding and hip CST), wants to live. Poor baby! How can you not want to?
I was thinking if I were the surgeon operating on him (assuming he had major gunshot wounds-which he had not), wouldn’t I have been tempted to let my knife slip near a major vessel and see some major bleeding, thereby causing, if not death, definitely major morbidity?

I would well be tempted, truth to tell. I would have controlled my temptation by telling myself, “He is precious to the country for what secrets he will reveal and your job is to heal, not to kill”. A moment after I think this, I am reminded of the Afzal Mahmoods of the world who got escorted and released by a rat-faced Indian Foreign Minister when Taliban terrorists hijacked an Indian plane to Kandahar.

I am happy I am not treating this dear little kid. I would have actually wrung his neck with my bare hands. Forget the knife (I cannot commit surgical murder-for that I expect to be paid), but with my bare hands, I would have loved to pinch his jugulars and lovingly choke his larynx. A ‘thank you for visiting India’ on behalf of the hundreds of people killed and maimed by him and his friends.

Nevertheless, I wonder: “What is the duty of a doctor to the enemy in times of war?”
I know the textbook answer. I am not sure how real it is. Especially in this kind of war.

WORLDS APART!

My daily life is replete with ugly sights, foul smells, and sad sounds. Such is the life of practising doctors. I had accepted this long back as a part of surgical life, and trained myself to disconnect my non-professional life from the feedbacks of life with the sick and suffering.
A very minor taste of this:

My nephew, award-winning car designer Harsha Ravi, lives in a different world, as do many of you.
Here is what he is up to. Take a look.

Is it small wonder, then, that I strongly discourage youngsters from getting into medicine? With so many things to be passionate about and excel in, why choose medicine, with all the tensions, ugliness, etc.? What do you think?
One other thing, too: I consider youngsters like Harsha to be not merely lucky to have lives like this, but also smarter, in that today’s kids know what not to do!

Pics: patient pics mine; others from Harsha’s article.

IRAN AS THE WORLD’S ROLE MODEL?

According to certain highly educated and qualified people, Iran could be a surprising model for the rest of the world. No, not just in creating nuclear plants and forcing the West to blink, but in their system of allowing organ trade.
An article in Nature India underpins this point along with some interesting ethics issues. If you do not have access to Nature, you could get the same article here. The author of this piece is a familiar name to some of the readers of this blog, as we have discussed some of his earlier publications.
What is the beef of the article?

In India, a huge demand exists for about 200,000 kidneys, with an estimated annual sale of 2000 kidneys. By making organ sale illegal, this market is pushed underground, and organized rackets thrive by working outside the society’s laws and regulations. One of the spin-offs is the phenomenon of organ theft. Such an organ harvest is obviously illegal. Organ theft and organ sale, however, are not the same thing. Every sane person will surely condemn the stealing of a poor man’s kidney, but if such a person volunteers to sell it for money, would it be all bad?

THE i-UNTOUCH?!

You must have got that email forward that says that your keyboard carries more germs than your backside. The message, apparently, is not that you can scratch your backside and eat with the same hand. The message is that you shouldn’t type on your computer keyboard and then eat without washing your hands. The real implication may be clinical: a new technology that allows surgeons to review CT-scan or x-ray images while operating, without touching the computer keyboard, may actually help prevent wound contamination.
According to the New Scientist, this new touch-me-not technology (likened to that in the movie Minority Report) allows a surgeon to wave his hands in mid-air in front of the computer to flip over to the next pic.

…a screen and gesture-recognition system that allows surgeons to flip back and forth through radiology images, such as MRI and CT scans, by simply groping in mid-air. Their system, called Gestix, comprises a colour video camera above a flat, widescreen monitor placed next to the operating table. The video signal from the camera is fed to a PC, where software trained to detect the colour of the surgeon’s gloves tracks the movements of their hand.

This, they believe, could help stop the spread of the deadly MRSA bug in hospitals.
The catch is that surgeons would have to be taught eight hand movements. Now, isn’t that expecting too much of a surgeon, who is, by popular consensus, the Kanishka (headless/brainless king) of medicine?

(pic source: http://www.exoticindiaart.com)

CAN A ROBOT BECOME AN INDIAN ‘SURGEON’?

You have heard of robotic surgery, if you have heard of You Tube, the iMac or the subprime crisis. What you may not know about is the story behind the man who devised the first (da Vinci) medical robot.
For a fascinating and short story of Frederic Moll, read this NYT article.
In the past, I had written a rather decent article on medical robots, and you could check it out here.
The capital investment of a robot for laparoscopic surgery is to the tune of $1.6 million. Not much for the rich Indian companies that run hospitals, I thought. I approached a hospital Chief Financial Officer.
“I would love it if you buy the da Vinci robot for my department. I will do great work for the hospital.”
“True, but then what about the return on investment?”
the CFO asked.
“Em, arr, the procedure will cost around $1500 in disposables per case. That comes to around Rs.60,000 only. Plus all the rest of the hospital costs. Imagine how much you can make per case!”
“Great, so a gall bladder surgery will cost around one lakh-odd (around $2500), you think?”
“Yeah, ballpark!”
“Tell me, doctor, how many cases could we get in a month?”

I wonder how many Indian patients could afford to spend that kind of money for a gall bladder surgery, and keep quiet.
“I think you are getting late, doctor?”
“Sure, actually I am. I need to go to the bathroom to rub butt.”
Bottomline: if Intuitive Surgical, the maker of the da Vinci robot, are making millions, someone has to pay for their prosperity. Can we Indians do so? I don’t think so.

SURGICAL EXPERIENCE

What is the foremost quality you look for when you are looking for a surgeon? Chances are most of you will say ‘experience’. If there is one thing young surgeons would envy older ones for, it is the fact that the latter are known to have experience.

Isn’t it a given that experience is good, then? Yes and no. Experience has made me a man. But it has also made me a sadder man. It has reduced my expectations from people and from life. It has made me harder and stronger (in the wrong places). It has tempered my emotions, but also made me less receptive to the emotions of others. Experience has not only made my arteries hard, but also my heart harder. It has made me a wiser, but balder, man.

Experience is the sum of one’s mistakes in life, they say. A more discerning person would say ‘no’. There are three kinds of experience:
First hand experience: you have been in battle, and are scarred. No one knows it better than you.
Second hand experience: you have studied the phenomenon of the experience and analysed it.
Third hand experience: you have heard of it from somewhere or someone.

Of the three, which would you prefer your doctor to have? Instinctively, I think we all would prefer to have had first hand experience of the various aspects of life. In the case we started out with (surgery), surgeons would all prefer to have seen complications and disasters in our own lives so as to avoid or solve them in future. This is the best thing for a doc, right? Wrong!

Though it is great for a doc to have first hand experience, it is perfectly likely that he would be biased or plain wrong in the lessons he has learnt from them. In a typical (hypothetical) case, a surgeon uses no mesh to repair his hernia cases because the one time he did use it in 1982, his patient got an infection and lots of problems. This is the main problem with first hand experience. While life must have taught a lesson to the doc, it might have taught him the wrong lesson!

Third hand experience is, obviously, of limited value: who knows what someone told you is right or wrong?
Which brings us to second hand experience.

If you have seen, observed and analysed someone do the right or wrong things, you will have learnt the right lessons. You don’t need to start off with a steep learning curve and create all the complications and make all the mistakes others before you had made. Because you have trained for it. Forewarned is forearmed. It is this second hand experience that is commonly called wisdom. So, it is better to be wise than to be experienced. Therefore, whether it comes to choosing a surgeon or a spouse, better chose a wise, rather than an experienced, one!
Finally, should you not choose a young surgeon? Remember, you can be young once, but you can be immature forever! Hence, young and trained is not a bad combination to have, especially in the present days of changing technology and evolving treatment methods.

(pic source: forgotten. Sorry!)

A NEW FREEDOM FOR THE FUTURE

There is a bomb girl who frequents the same gym I go to. She looks like a movie star, and works ferociously at the various sculpting machines there. She keeps looking back at an imaginary fold of fat at the waist, and keeps whining to the trainer, “I am putting on weight!”
This beauty is spending money, time and effort to beat a non-existent disease: obesity. She is also, potentially, damaging her joints and heart when she pounds the treadmills and pumps the weights. Shouldn’t someone stop her before its too late?
There is another girl I know who wants to trim her inner labia. She seeks a cosmetic gynecologist who does vaginoplasties. And another one who wants a surgery to make her a virgin again, before she gets married a few weeks later. These girls are looking to seek potentially dangerous and complication-prone operations that treat no disease. They are merely expressing some inner wish to change their structure, though there may be nothing fundamentally wrong with them.
I had previously highlighted how the American College of Gynecologists (ACOG) is hotly after the man who has made vaginoplasty a commercial money-spinner. This merely illustrates the fact that there are people in the world, including medical experts, who want to stop procedures that alter one’s physical state. Sex change surgery is another example. There are countries where this is illegal.
The future is fraught with potentially more complex and controversial issues like using genetic engineering and cloning to create a new type of human being that may be peculiarly enhanced. For example, a mother may be able to select a baby who is genetically engineered to see in the dark. Or one who will be free of certain deadly diseases. If you have not read my article on ‘Disruptive Medicine’, this is your lucky day. Check it out.
A Swedish organisation called Eudoxa talks of this morphological freedom, defining it as “an extended right to your own life, including your body.”
Why would a man or woman want to alter his structure for overtly trivial reasons?

We express ourselves through what we are becoming.
Self-development is an intense motivational factor for most humans, and by its
nature this is a very personal and challenging achievement.

Look at tattooing. The way many conservative people see it, it is a kinky and perverse thing to do. It is, however, considered quite cool and contemporary by much of modern society.
It is a personal morphological alteration without specific reasons beyond an individual’s personal choice and freedom of expression.

But wouldn’t genetic modification of children alter society and endanger it? Should we not stop this before it is too late?

Recognizing the right to choose among the many options made available through
morphologic freedom also supports the right not to choose them; the positive and
negative rights are two sides of the same coin.
Purely negative goals like the EU Commission’s directive on children’s right to be
born with unmodified genes will often end up in conflict with positive goals such as
providing children with the best possible medical attention. This right is also
mentioned by the Commission, but is undermined by the negative goal.
One of the many ways this positive goal can be attained is through surgery in the
womb for certain congenital defects. This type of operation changes the body and
the potential person much more than any genetic modification we can bring about.

In other words, apart from the issues of personal freedom and choice, these same disruptive technologies that could change future generations could also save countless lives and improve the lifestyle of the suffering. For example, see the use of intelligent prostheses for amputees that work better than normal limbs.
For more details, check out this link and download a pdf of the statement of Eudoxa.

Whatever be one’s views on this, this issue is a sure one for the future. You haven’t heard anything yet!

NO FUTURE FOR SUTURE

MIT scientists have invented a sticky tape that will aid healing without the need for stitches. The tape will also break down in time, without needing you to bother about when to go to the surgeon to take it off. These stitches would hold good on the body surface as well as the internal parts.

The adhesive is inspired by geckos’ feet, which allow the reptiles to walk along the ceiling and up and down smooth walls. Gecko toes are sticky because they are covered with millions of flexible nanopillars, giving them a very large surface area. The MIT tape, which relies on both nanoscale pillars and a chemical glue, is the first such tape to show good adhesive strength and safety in animals.

Read full article here.

If this tape becomes reality, I predict that entrance exams to go into surgery will finally stop. After all, the most difficult and tricky issues in surgery deal with situations that demand suturing skills of a very high order. Once the need for suturing is gone, all surgeons have to do is to blunder their way into surgery. If they injure anything, they just superglue it. Simple!

Finally, it will prove that surgeons are basically morons with quicker hands, practising what essentially is a monkey science.

NO KIDDING ABOUT KIDNEYS

Finally, someone echoes my thoughts exactly!
An article in The Liberty Institute website says things I would have.
The topic is the kidney scam and the free market. There are several others, even better, on the same subject you can easily find there.
Check it out.

DEATH BY IMPOTENCE!

ED AND THE MALE WORLD

Erectile Dysfunction (ED), originally from the Latin Impotentia coeundi, is one of the major diseases of mankind, and can be loosely defined as an inability to achieve an erection for successful penetration.

In normal populations, the incidence of major Erectile Dysfunction (ED) is 5 to 20%. Even in the young, ED occurs in around 13%, according to a study on boys between 18 and 25 years. This is remarkable, because ED is known to be seen in older, not younger men, as a rule.

One of the most respected and cited studies on the epidemiology of erectile dysfunction is the Massachusetts Male Aging Study. The study showed that 52% of 1,290 men aged 40 to 70 years had some degree of dysfunction, and almost 10% had total absence of erectile function.

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A new article in The International Journal of Impotence Research has some interesting things to say, based on a large study on the sexual habits of more than four thousand men, both gay and straight.

Most men in the prime of their sexual lives (18 to 44 years) use no drugs for sex, while some do it for recreational use, and fewer because they need to use them medically.

The recreational use of ED drugs is increasing, and seems to have a negative effect. The study says that, on surveying the participants’ perceptions and self assessments after taking ED drugs, their confidence and performance suffered unless they took drugs again.

As lack of confidence in one’s ability to gain and hold erections has been identified as an important psychogenic risk factor for ED, the findings have important implications. Recreational users of ED medications may be vulnerable to becoming psychologically dependent on pharmacologically induced erection.

Therefore, the young kids out for a trip on Viagra are rooting for trouble!

WHO CARES ABOUT ED, A BORING MALE DISEASE?

ED is now more than an andrologist’s way of making bread. It is now a sentinel for a variety of diseases. What are they?

* ED may be the first symptom of coronary heart disease in a young man. In fact, ED is now considered a strong indicator of heart disease, with strong correlation as to severity. In other words, the more severe the heart disease, the greater the liability to be having ED. Men who have less than expected degree of erection, or have it only to lose it midway (lazy erections) are likely to have a cardiovascular cause of ED.

* ED may present in an undetected diabetic.

* It is seen in long-standing smokers, alcoholics (whiskey dick or brewers’ droop), and those with lipid disorders, prostatic diseases, etc.

* Evidence has linked hypertension to ED.

* Drugs used in the treatment of various diseases can also cause ED.

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IMPOTENCE IN INDIA

India has been called the country of unconsummated marriages because of the phenomenon of ‘honeymoon impotence’, when ED manifests on the first attempt. Impotence in India is mainly psychogenic, unlike the rest of the world, where three-fourths of cases are said to be due to organic, not psychological causes. Of course, once a man becomes impotent, he suffers enormous loss of confidence and self-image, leading to further performance anxiety. So the psychological overlay (no pun intended, for once) is also visible here.

HOW DOES ONE TREAT ED?

If you are a man facing ED, the sensible thing is not to hide it, but come out with it to a physician. Screening for hypertension, diabetes and heart disease will follow. Smoking should stop, as should excessive boozing.
Then what?
Based on what is wrong with the patient, the treatment is commenced.
Usually, drugs like Cialis (tadalafil) are the first line of treatment. Among the ED drugs, a lot has changed since Pfizer came out with Viagra. Leftist limpos: please note that Viagra was not invented by a Government pharma company.
Cialis (Tadalafil) is now a preferred drug for ED patients. It works for 36 hours, can be taken irrespective of food, and one does not need to time the drug intake with sex, thereby making for a better experience. In contrast, Viagra (sildenafil) works for only four hours and needs to be taken half an hour or so before sex.
In some cases, the doctor may advise the patient to inject a substance like papaverine or a prostaglandin (Alprostadil) into the penis just before sex. Rigidity is best achieved with injections.
In psychological cases (performance anxiety, depression, schizophrenia, etc.), counselling and appropriate treatment is advised.
Specific cases where the penis loses rigidity due to blood leaking from the veins respond well to vacuum suction devices.

SURGERY FOR IMPOTENCE?

In a small percentage of cases, where there is no response to any of the above, the andrologist might consider implants. These are devices that are implanted inside the penis (and partly in the scrotum). One device (essentially a semi-rigid rod of silicone with metal wires), called the AMS prosthesis, may lead to a permanent semi-erect state. In India, it costs around 60,000 rupees (around 1150 USD). A local version has been made by andrologist Rupin Shah and costs only Rs. 10,000 ($250). The better prostheses (e.g., the three-part inflatable AMS prosthesis) enable erection only during sex (on demand). A pump (implanted in the scrotum) needs to be activated to push in fluid inside an implant in the penis. The implant fills with water, and the penis becomes hard. This costs around Rs.220,000 ($5050).

One problem with the penile implant is that any infection is disastrous, leads to removal of the device, and permanent impotence. Hard luck!

It should also be remembered that any treatment of ED, like drugs or injections, may cause a persistent, painful, permanent state of erection, called priapism. This condition is an emergency.
Unless treated within four hours, it leads to permanent impotence.

To sum up, a man’s inability to achieve a satisfactory erection is not a laughing matter. It may be a sign of serious underlying disease which can eventually kill him.

Note: pictures are mine!