Intermezzo!!!

Working on something new to debate on! (Quite, a few topics actually!) So to fill the void, to liven up things, (or more appropriately, to eat up webspace!) here is an interesting anecdote:

This allegedly happened in one of the premier government teaching hospitals in New Delhi!
(Although, I did not witness the same!)

Prologue

Vesico-vaginal fistula or VVF is a distressing condition in females (naturally!) wherein there is an abnormal communication (due to disease, obstetric trauma or congenital) between the urinary tract and the female reproductive tract leading to urinary incontinence or dribbling of urine through these abnormal orifices! The symptomatology depends also on where the communication is; whether it is at the level of the urethra-vagina, bladder-vagina or the ureter-vaginal vault. But the common features in all of them include incontinence, signs and symptoms of skin irritation due to constant wetness, fungal infections, and lastly pruritus at the affected area (intense desire to itch, uncontrollable in some cases)!

However, it does not constitute a medical emergency in most cases, unless a serious co-morbid condition is present! In that case, VVF does not take precedence in the order of treatment anyway! End of story: It is a case for routine work-up and management (surgical) in an elective environment under the care of attendings/consultants and not residents in an emergency setting!

Also, antihistaminic drugs, steroids and emollients, antimicrobials are used in the treatment (or rather, the control) of pruritus in most cases! However it shall persist so long as the offending factor persists (for which the treatment in this case is surgery!)

The Incident
It was sometime in the month of January, when winter was at its peak and it took an extra mug of coffee to keep you awake in the wee hours of the night in the Emergency Room! There was this new OB-GYN resident posted in the OB-GYN Emergency for the whole 24 hours! Given the new surroundings and the eagerness to impress his/her peers, this resident was working his/her ass off throughout the course of the day!

And winter is the season of births: an average 24 hour period in a labor room can see as many as 70 deliveries (and these are the normal uncomplicated ones!) that a sole resident (with his/her juniors to help) has to oversee sometimes! And then there are the complicated cases as well!

Probably he/she expected the same enthusiasm from all residents in all departments. (Pity!)

At around 1.30 a.m., there came a young couple with the lady presenting with the above mentioned condition of VVF. This resident did a complete workup (including "lab-work") of the patient and came to the diagnosis of a VVF with no co-morbid conditions, (the patient had normal renal and liver function tests as well), that necessitated an admission into the emergency, then! And this was communicated to the patient who was further advised to return in the morning in the OPD for consultation with an attending for further surgical management to correct the cause!

She was given the necessary antihistaminics and other drugs (as per protocol) to alleviate her symptoms of pruritus for the time being!

But the OPD queues in govt. hospitals in the national capital are notorious for the enormous number of patients attending and this couple was in no mood to let the opportunity of an admission into the hospital go by!

They went out of the OB-GYN Emergency only to return again within 15 minutes with hue and cry about the patient's condition and the resident's refusal to admit the patient in the emergency! [Though intensely distressing, the patient's condition was not serious and did not merit an admission into an already overcrowded OB-GYN emergency!]

This resident was in a quandary, for he/she was never accustomed to such open hostility in the middle of the night, in a new environment! The result was obvious, the patient was admitted

for the night! Given the benign condition of this patient, and that there were other serious patients to take care of, the resident now paid attention to the others admitted!

Obviously, this patient was offended that she was not being given exclusive attention and she kept calling for the resident again and again! This resident obviously harrowed now, then sent for an in-patient referral for a dermatological consultation by the on-call resident in dermatology!

It was almost 3 a.m.!

Now, there are very few emergencies in dermatology in general on an average night, and you can't fault an average resident in dermatology for taking a snooze in the on-call room at night on such occasions! And this one posted that night was no different!

He/she, however promptly responded to the call in the wee hours of the night and evaluated the patient earnestly, came to the same diagnosis that the OB-GYN resident had! And since the treatment already given had been sufficient, no further treatment was added to the patient's chart! The dermatology resident then left for his/her ward!

But the patient was inconsolable, and the tired resident sent for the dermatology resident again within 20 minutes of his/her departure!

The dermatology resident was not amused this time around! Although he/she said nothing to express the same, but it was obvious! [As I said, dermatology residents are not accustomed to nightly adventures on a regular basis unlike some other branches!]

In a cool and calm manner, he/she came and evaluated the patient again, recorded the findings in the patient's case report; and the following was seen added to the patient's treatment chart as the dermatology resident left:

"In case severe itching persists, scratch the affected area SOS or as required!"

Epilogue: Nothing more was left to be said!