(Delhi Branch)
ISA Delhi President’s Secretariat Department of Anaesthesia and
Intensive Care
Vardhman Mahavir Medical College & Safdarjung Hospital, New
Delhi -110029, India.
Email:
[email protected]
Website: https://www.isawebdelhi.in
ISA Delhi Secretariat Operation theater complex, 5th Floor, Fortis
Hospital Shalimar Bagh
New Delhi 110088
HONORARY SECRETARY- DR NAVEEN MALHOTRA
TREASURER- DR VIRENDRA SHARMA
EDITOR-IN-CHIEF- DR. LALIT MEHDIRATTA
GC MEMBER- DR SUKHMINDER JIT SINGH BAJWA(PUNJAB)
GC MEMBER- DR J BALAVENKATA SUBRAMANIAN (Coimbatore, TAMIL
NADU)
GC MEMBER- DR S C GANESH PRABHU (Madurai, TAMIL NADU)
GC MEMBER- DR. RAJIV GUPTA (DELHI)
GC MEMBER- DR. BHARAT BHUSHAN BHARDWAJ (UTTAR PRADESH)
GC MEMBER- DR. SURAJIT GIRI (ASSAM)
GC MEMBER- DR. ASHOK VASANTA RAO DESHPANDE (MAHARASHTRA)
GC MEMBER- DR. CHINTALA KISHAN (TELANGANA)
EX OFFICIO MEMBERS
ORG SECRETARY 68TH ISACON 2020- DR. BHADRESH ARVIND SHAH
ISA DELHI BRANCH EX OFFICE BEARERS
PRESIDENT- DR ANIL JAIN
SECRETARY- DR RAJIV GUPTA/ GIRISH CALLY
TREASURER- DR GIRISH CALLY
EDITOR- DR DEEPANJALI PANT
ISA DELHI BRANCH LIST OF OFFICE BEARERS, GOVERNING COUNCIL MEMBERS,
EXECUTIVE COMMITTEE MEMBERS, ADVISORY
COMMITTEE AND HEADS OF DEPARTMENT OF ANAESTHESIOLOGY
OFFICE BEARERS
VICE PRESIDENT DR G USHA VMMC & SJH
[email protected]
8447795934
SECRETARY DR UMESH DESHMUKH FORTIS SHALIMAR
BAGH
[email protected] 9810101445
BAGH
[email protected] 9958895659
NATIONAL GOVERNING COUNCIL MEMBER
HOSPITAL
[email protected] 9811084288
NORTH ZONE DR AASHISH DANG HINDU RAO
[email protected]
9810710458
SOUTH ZONE DR RANJU GANDHI VMMC & SJH
[email protected]
9818941341
WEST ZONE DR ARUN K MEHRA BHAGWATI HOSPITAL
[email protected]
9818134998
EAST ZONE DR ARVIND ARYA IHBAS
[email protected]
9871013556
CENTRAL ZONE DR AMIT KOHLI MAMC & LNJP
[email protected]
9818073402
EXECUTIVE COMMITTEE MEMBERS
1 AAKASH HOSPITAL
2 ABVIMS AND DR RMLH DR UMA HARIHARAN 9811271093
[email protected]
3 ACHARYA SHREE BHIKSHU DR RAMINDER KAUR 9717691899
[email protected]
4 AIIMS, NEW DELHI DR RAKESH KUMAR 7838043581
[email protected]
5 AIIMS DR BRAIRCH DR RAKESH GARG 9810394950
[email protected]
6 APOLLO HOSPITAL DR ANIL KUMAR
SHARMA 9810417880
[email protected]
7 ARMY HOSPITAL (R&R) DR ANURAG GARG 6284858040
[email protected]
8 BALAJI ACTION DR NEETA TANEJA 9811032535
[email protected]
10 BATRA HOSPITAL DR VIVEK CHOPRA 9719962626
[email protected]
11 BHAGWAN MAHAVIR
12 BJRMH DR SUMITA
14 CHACHA NEHRU BAL
15
18 DHARAMSHILA
NARAYANA SSH
20 ESIC HOSPITAL OKHLA DR TARANG JAIN 9811827264
[email protected]
21 FORTIS LA FEMME DR GURPREET SINGH
POPLI 9871557556
[email protected]
TILAK 9910234015
[email protected]
24 GURU GOVIND SINGH
25
COLLEGE DR SUNIL KUMAR 9910279828
[email protected]
27 IHBAS, DELHI DR ARVIND ARYA 9871013556
[email protected]
28 ILBS DR LALITA GOURI MITRA 9971792343
[email protected]
29 JAIPUR GOLDEN DR ABHA AGGARWAL 9811091792
[email protected]
30 LHMC AND ASSOC.
31 LAL BAHDUR SHASTRI
32 MAMC AND LNJP DR MONA ARYA 9968604412
[email protected]
33 MANIPAL HOSPITAL
34 MATA CHANAN DEVI
36 MAX SSH, SAKET DR RAHUL CHOPRA 7872835168
[email protected]
37 MAX SMART, SAKET DR MUKUL KAPOOR 9971888773
[email protected]
38 MAX SSH, PATPARGANJ DR RAVI BHASKAR 9582329720
[email protected]
39 MAX SSH, VAISHALI DR VICKY JAISWAL 9582265897
[email protected]
40 MAX SSH, SHALIMAR
41 MEDANTA, THE MEDICITY DR HIMANSHU SURI 9891789001
[email protected]
42 NORTHERN RAILWAY
43 PGIMSR-ESI
44 RAJIV GANDHI CANCER
45 SANJAY GANDHI
46 SANT PARMANAND
47 SARDAR VALLABH BHAI
48 SAROJ HOSPITAL DR VIVEK GUPTA 9810020953
[email protected]
49 SHANTI MUKAND
50 SIR GANGA RAM
51 SWAMI DAYANAND
52 UCMS AND GTBH DR ASHA TYAGI 9818606404
[email protected]
53 VENKATESHWAR
ADVISORY COMMITTEE
DR VP KUMRA PAST VICE PRES ISA- NATIONAL 981113221
DR BALJEET SINGH PAST VICE PRES ISA- NATIONAL 9810131295
DR ASHOK SAXENA PAST PRES ISA- DELHI 9868399703
DR ANIL JAIN IMM. PAST PRES ISA DELHI 9811005826
DR GIRISH CALLY IMM. PAST SECRETARY & TREASURER ISA DELHI
9810031679
S.NO HOSPITAL NAME OF HOD MOBILE NO E MAIL ID
1 AAKASH HOSPITAL DWARKA DR. GURPREET SINGH POPLI
9871557556
[email protected]
2 ABVIMS AND DR RMLH DR MOHANDEEP KAUR 9868952253
[email protected]
3 ACHARYA SHREE BHIKSHU
4
9810079229
[email protected]
7 AIIMS NEUROANESTHESIA DR ARVIND CHATURVEDI 9871045824
[email protected]
8 APOLLO HOSPITAL DR SANJEEV ANEJA 9810511510
[email protected]
9 ARMY HOSPITAL (R&R) DR VIKAS KR SHANKHYAN 9418865691
[email protected]
10 BALAJI ACTION DR. NEETA TANEJA 9811032535
[email protected]
11 BASE HOSPITAL DELHI
12 BATRA HOSPITAL DR PAVAN GURHA 9811088632
[email protected]
13 BHAGWAN MAHAVIR
14 BJRMH DR SUMITA KULSHRESTHA 9868875244
[email protected]
15 BLK SUPERSPECIALITY
16 CHACHA NEHRU BAL
17
(NDMC)
HOSPITAL
20 DHARAMSHILA NARAYANA SUPERSPECIALITY HOSPITAL
DR. MANISH TANDON 9871437478
[email protected]
21 ESI FARIDABAD DR. SUVIDHA SOOD 9999302616
[email protected]
22 ESIC HOSPITAL OKHLA DR ARCHANA LAKRA 9871107058
[email protected]
23 FORTIS LA FEMME DR UMESH DESHMUKH 9810101445
[email protected]
24 FORTIS SB DR. UMESH DESHMUKH 9810101445
[email protected]
25 FORTIS VK DR AMRISH KUMAR TILAK 9910234015
[email protected]
PGMER DR PRAGATI GANJOO 9718599407
[email protected]
27 GIRDHARILAL HOSPITAL DR RASHMI DUGGAL 9810138257
[email protected]
28 GURU GOVIND SINGH
29
RESEARCH
COLLEGE DR ALKA CHANDRA 9560044454
[email protected]
31 IHBAS DR ARVIND ARYA 9871013556 9867396825
[email protected]
34 LHMC AND ASSOCIATED
35 LAL BAHDUR SHASTRI
36 MAHARAJA AGRASEN
37 MAMC AND LNJP DR KIRTI NATH SAXENA 9968604215
[email protected]
38 MANIPAL HOSPITAL
39 MATA CHANAN DEVI
40 MAX LAP AND BARIATRIC DR APARNA SINHA 9810035503
[email protected]
41 MAX SSH, SAKET DR KAMAL KUMAR
FOTEDAR 9873003832
[email protected]
43 MAX SUPER SPECIALITY HOSPITAL PATPARGANJ
DR ARUN PURI 9811074379
[email protected]
44 MAX SUPER SPECIALITY
46 MEDANTA, THE MEDICITY DR SURINDER.M. SHARMA 9811082995
[email protected]
47 NORTHERN RAILWAY CENTRAL HOSPITAL
DR ANIL KUMAR SHARMA 9717630508
[email protected]
48 PGIMSR-ESI BASAIDARAPUR DR. MADHU GUPTA 9873581030
[email protected]
49 RAJIV GANDHI CANCER
50 SANJAY GANDHI MEMORIAL
52 SARDAR VALLABH BHAI
53 SAROJ HOSPITAL DR. VIVEK GUPTA 9810020953
[email protected]
54 SHANTI MUKAND HOSPITAL DR RAJESH DHALL 9810110405
[email protected]
55 SIR GANGA RAM HOSPITAL PROF JAYASHREE SOOD 9811294608
[email protected]
56 SWAMI DAYANAND
57 UCMS AND GTBH PROF AK SAXENA 9810431367
[email protected]
58 VENKATESHWAR HOSPITAL DR KALPANA GOYAL 9891682605
[email protected]
59 VMMC AND SJH DR. G. USHA 8447795934
[email protected]
EBM DR IRA BALAKRISHNAN M VMMC & SJH
[email protected]
7838867927
EBM DR NIKHILESH CHANDRA VMMC & SJH
[email protected]
8989792136
EBM DR AMANDEEP JASWAL VMMC & SJH
[email protected]
9582142904
Dear Friends,
Wishing you all a very very happy, healthy and prosperous New Year
2021! I pray that this
year we all can bid farewell to the corona virus and its mutants
and get back some normalcy
in our lives.
The year has begun well for India with the incidence of covid
showing a downtrend: Also, the
launch of two Indian vaccines namely Covishield and Covaxin , has
provided hope and cheer
to most of us. The vaccination drive undertaken by the Government
of India on a war footing,
is fast gathering momentum and will surely help eradicate this
deadly disease from the face
of the earth.
ISA Delhi has also started the new year on a very positive note.
Max institute of Laparoscopy,
Endoscopy and Bariatric surgery, organized an excellent webinar on
“Bariatric Anaesthesia-
Troubleshooting the catastrophes and near misses in the
perioperative care of the morbidly
obese” on 16th January 2021.It was well attended. The debate on
“Aerosol protection box is
an indispensable tool in the management of covid airway”, was well
contested and generated
a lot of interest.
Department of Anaesthesiology and Critical care, Deen Dayal
Upadhyay hospital, organized
the first monthly clinical meeting of this year on 22nd January
2021, in which four interesting
papers were presented by the postgraduates of the department.
“Impact of Covid 19 on
doctors affected by it” was the sharing of experiences, especially
the psychological effects of
a resident doctor who contracted the covid infection while on duty.
It gave an insight into the
mind of this young doctor and what he had to go through.
ISA Delhi along with Teleflex, organized a webinar on Intraosseous
route for vascular access,
through a webinar on 28th January2021. It was very informative and
helpful.
I wish to share some important decisions taken by our National body
of ISA. I am in receipt of
an email from the hon’ble secretary ISA National, Dr Naveen
Malhotra, that it has been
decided that from 20-21, the change of guard of all state branches
will happen together on
16thOctober, i.e., the World Anaesthesia day. The annual
conferences of all branches will be
held around that time. This implies that we, the current office
bearers, now have an extended
tenure up to mid October 2021. I solicit the valuable opinion of
all members, more so the
heads of all institutions and our executive committee members, to
give suggestions regarding
ISA Delhi branch activities during this extended time period from
April to October2021.
Elections for the new office bearers for the next term will be held
in June-July, dates for which
will be announced later.
Thank you all for the support that you are providing to the ISA
Delhi branch’s activities. We
must strive to further innovate, improve and add greater value to
all that we do in the next few
months and try to take ISA Delhi branch to greater heights.
Wishing everyone a very happy Republic Day!
Long live ISA National & ISA Delhi
Jai Hind!
Best Wishes
Nikki Sabharwal
Vice President’s Message
Dear Friends
I wish this year is loaded with happiness, prosperity and good
health for each one of us.
Past few months have been very difficult but we all stood bravely
and faced each and every
obstacle that came our way. I pray to God and hope that this year
the world gets corona free
and we have no more of tough challenges to face.
The academic activities conducted by Delhi ISAians last year have
been commendable. The
quality of presentations done by each and every institute have been
praiseworthy. I hope this
year too we shall keep up with the great academic activities.
I request you all to participate wholeheartedly in your own ISA
Delhi activities.
Long Live ISA!
Dr G Usha
Message from Secretary
Friends,
Without doubt immunization is one of the biggest success stories in
our fight against infectious
disease. In this regard it is similar to the success story of
Anesthesia. Just as anesthesia made
surgery safer, vaccines make our lives safer. I hope most of you
have received their scheduled
doses of Vaccines against COVID.
On the ISA front our success story with online clinical meetings
continues, Thanks to all of you. I
request all of you to participate in large numbers.
Long live ISA! Long live ISA Delhi!
Jai Hind!
From the Editor’s Desk
Dear Members,
Worldwide, there have been serious concerns regarding the
laparoscopic surgical procedures
causing aerosolization and operation room contamination and thus
increasing the risk of
SARS CoV2 transmission. Dr Aparna Sinha, in review article,
“Laparoscopy in COVID times,
what is the current practice?” has highlighted the clinical
recommendations and suggestions
to mitigate the risks and to help clinicians take a decision.
Dr Arun K Mehra, has contributed an article, “Mental Health of Care
Providers”
to the series - “Ethics in Covid Times”. I am sure our readers will
find it useful.
In our experiences section, Dr AR Gogia has shared with us valuable
information on
Goswami Tulsidas. I hope the art gallery, photography, word game
and poetry section of our
newsletter will bring you joy.
Please do send to us your contributions for the newsletter in the
form of interesting write up,
poetry, paintings, photography etc. You may send your piece of work
through email at
[email protected]
I also urge all the anaesthesiologists who are not yet ISA members
to become life members;
For membership form, please log in to website
https://www.isaweb.in/webpages/MembersRegistration.aspx
September 2020
1. 11th Sept Friday 4-6 pm Clinical mtg, LHMC
2. 18th Sept. Friday 4.30 - 6.30 pm, CME, LHMC, Hypertensive
disorders in pregnancy'
October 2020
1. 2nd to 4th Oct. ISACON 2020, SGRH
2. 16th Oct. Friday 5 - 7.30 pm World Anaesthesia Day celebrations
by all ISA Delhi members
3. 29th Oct. Friday, 5-7 pm clinical mtg by ESIC group of
Hospitals
November 2020
1. 7th Nov. Saturday, 5-7 pm clinical mtg by Max Smart Hospital,
Saket
2. 20th Nov. Friday 5-7 pm, clinical mtg by MAMC
3. 27th Nov. Friday, 5-7 pm, clinical mtg, Dr RMLH
December 2020
1.4th Dec. Friday 5-7 pm, clinical mtg by UCMS
2. 12th and 13th Dec, 5-7 pm, webinar on NIV by m/s Resmed
3. 18th Dec.Friday,5-7 pm, CME, Hindu Rao hospital
4. 28th Dec Monday, 5-7 pm clinical mtg Apollo hospital
January 2021
1. 8th Jan Friday, 5-7 pm, clinical mtg, Army hospital
2. 15th Jan. Friday, 5-7 pm, CME Bariatric, MAX Saket
3. 22nd Jan. Friday, 5-7 pm clinical mtg DDU
February 2021
1. 5th Feb Friday 5-7pm, clinical mtg, Hindu Rao hospital
2. 19th Feb. Friday clinical mtg by Dwarka group ie Akash,
Venkateshwar and Balaji Action
hospitals
1. 5th March, Friday, 5-7 pm, clinical mtg AIIMS
2. 12th March Friday 5 -7 pm clinical mtg by Ambedkar and Sanjay
Gandhi hospital.
CME (16/1/2021)
The Max Institute of Laparoscopy Endoscopy and Bariatric Surgery
organized a CME on Bariatric
Anaesthesia, under the aegis of ISA Delhi branch on 16th January
2021. The theme of the CME
was “Troubleshooting the catastrophes and near misses in the
perioperative period in morbidly
obese”.
To begin, Dr Aparna Sinha welcomed the gathering and invited Dr
Dinesh Punhani, to carry out
further proceedings. ISA flag hoisting was done. Dr Dinesh Punhani,
welcomed the office bearers of
ISA Delhi branch and invited Dr Kamal Fotedar to address the
gathering. Dr Nikki Sabharwal,
President ISA Delhi branch was requested to say a few words. This
was followed by a very well
organized and interesting scientific session.
The scientific programme comprised of the following
presentations:
• Monitoring the obese for procedural sedation by Dr Lakshmi
Jayaraman
• Analgesia failure in the morbidly obese and the NIV in
perioperative failure by Dr Aparna
Sinha
• Tips to manage postoperative respiratory failure in the morbidly
obese by Dr Vikas Mittal
• Debate on “Aerosol production box is an indispensable tool in the
management of Covid
Airway” by Dr Abhishek and Dr Gaurav
• Newer concepts in perioperative fluids management by Dr
Sandeep
The program ended with a vote of thanks proposed by Dr Aparna
Sinha.
The CME was registered by 415 and attended by over 1400 people
across the globe (Middle East,
Libya and London) and was highly appreciated. For the first time
there was Live Streaming of the
CME on Anaesthesia TV.
We would like to congratulate Dr Pradeep Chowbey, Dr Kamal Fotedar,
Dr Aparna Sinha, Dr
Lakshmi Jayaraman, Dr Dinesh Punhani and team for such a wonderful
academic feast.
Clinical Meeting (22/1/2021)
The clinical meeting of ISA Delhi branch was hosted by the
Department of Anaesthesia and Critical
Care, Deen Dayal Upadhyay Hospital on the 22nd January 2021. Dr
Vatsala Aggarwal welcomed
the gathering and invited Dr Ritu Aggarwal to carry out further
proceedings. ISA flag hoisting was
done. Dr Ritu Aggarwal welcomed the ISA office bearers and invited
Dr Nikki Sabharwal to address
the gathering. This was followed by the scientific session that
included four very interesting and
novel presentations.
The scientific session comprised of the following
presentations:
1. Comparative study to assess the depth of anaesthesia with
preoperative single dose of
intravenous dexmedetomidine vs intravenous fentanyl using
bispectral index in patients
undergoing general anaesthesia – Dr Archana (DNB), Dr Waseem (DNB),
Moderator – Dr
Vatsala Aggarwal HOD
2. Segmental spinal: expanding scope of regional anaesthesia in
current practice: A review-Dr
Rupal (DNB), Dr Anshul (DNB), Moderator – DrVatsala Aggarwal
HOD
3. Central line in ICU: Boon or Bane- Dr Utkarshini (DNB), Dr
Akhila (DNB), Moderator – Dr
Vatsala Aggarwal HOD
4. Impact of COVID 19 on doctors affected by it- Dr Deepthi (DNB),
Dr Anshul (DNB), Moderator
– Dr Vatsala Aggarwal HOD
In the end, Dr Dr Vatsala Aggarwal proposed the vote of thanks. The
meeting was well attended and
appreciated. We would like to congratulate Dr Vatsala Aggarwal and
team for conducting an
excellent clinical meeting.
The abstracts of presentations are as follows:
1. Comparative study to assess the depth of anaesthesia with
preoperative single dose of
intravenous dexmedetomidine vs intravenous fentanyl using
bispectral index in patients
undergoing general anaesthesia
Moderator – Dr Vatsala Aggarwal (HOD Anaesthesiology)
Background - General anaesthesia (GA) is a drug-induced reversible
state consisting of
unconsciousness, amnesia, antinociception, and immobility, with the
maintenance of
physiological stability. Balanced GA comprises of amnesia,
analgesia, hypnosis, muscle
relaxation, and obtundation of reflexes.
Methods– We planned to assess the depth of anaesthesia with
preoperative single dose of
Intravenous Dexmedetomidine versus Intravenous Fentanyl using
Bispectral Index in patients
undergoing elective surgeries under general anaesthesia. 130 ASA
grade I patients scheduled
for elective surgeries under GA were enrolled in the study and
divided into two groups: GROUP
D: Patients received IV infusion of dexmedetomidine (0.6μg/kg) in
50 ml of 0.9% Saline. GROUP
F: Patients received IV infusion of fentanyl (2μg/kg) in 50 ml of
0.9% Saline. All patients received
a loading dose of study medication over 10 minutes before induction
of anaesthesia according to
group allocation.
Results- There was no statistical significance between the two
groups with respect to the
demographic data, type of surgery and duration of surgery. The
difference in mean HR rates,
SBP, DBP and MAP of the two groups was not statistically
significant till intubation but these
parameters were lower in group D at 5 mins to 60 mins after
intubation with p value (<0.05). No
significant difference in SpO2 between the study groups. The mean
BIS value was lower in
group D as compared to group F at various time interval after
intubation.
Conclusion- The BIS value was decreased in both groups as compared
to baseline values. But
it was more decreased in group D (Dexmedetomidine) as compared to
group F (Fentanyl). The
demedetomidine group achieved the target BIS value for GA faster
than the Fentanyl group.
The haemodynamics starting from 5 minutes after initiation of
infusion of study drugs to the
completion of the surgery were significantly more stable in group D
as compared to group F. The
stress response (laryngoscopy and intubation) at the time of
induction with propofol were better
attenuated with dexmedetomidine (group D).
2. Segmental Spinal: Expanding Scope of Regional Anaesthesia in
Current Practice: A
Review
Presenter: Dr Rupal Tiwari (DNB Resident) Dr Anshul Shrivastava
(DNB Resident)
Moderator: Dr Vatsala Aggarwal (HOD Anaesthesiology)
Regional anaesthesia is expanding its scope and pushing boundaries
in recent anaesthesia
practice. Thoracic spinal although has been known for long, its
practice is limited due to fear of
injury to the spinal cord. The anatomical characteristics between
the thoracic and lumbar spine
are significantly different and several MRI studies have
demonstrated that there is a greater
depth of the posterior subarachnoid space in thoracic spine.
Several articles published in the
literature have demonstrated the safety of performing thoracic
puncture for anaesthesia and thus
it provides with a very good alternative for general anaesthesia.
Thoracic and upper abdominal
surgeries which were considered out of scope for regional
anaesthesia are now being done with
segmental spinal anaesthesia. The puncture can be performed with a
single puncture with a cut
tip or pencil tip, or with the aid of the combined epidural-spinal
block. In thoracic puncture,
isobaric or hyperbaric anaesthetic agents can be used, with or
without adjuvants. Segmental
spinal provides a sensory block of longer duration than the motor
block, thus, it is an excellent
indication for outpatient surgery with low doses of local
anaesthetic agent and early discharge.
Most of these articles report only were transient paraesthesia,
with no occurrence of definitive
neurologic complications. Low doses of local anaesthetics for
segmental spinal anaesthesia
have already been performed in different types of surgery, moreover
it can be used in adjunct
with certain blocks for better post-operative analgesia. USG
Guidance for thoracic spinal can
infer more safety to the procedure. More studies are required to
establish its safety and efficacy
to be used in routine practice.
3. Central Line in ICU: Boon or Bane
Presenters: Dr Utkarshini Kedia, Dr Akhila Swarnakumar (Secondary
DNB)
Moderator: Dr Vatsala Aggarwal (HOD)
Central Venous Catheterisation is a widely used procedure in
medical care. William Forssman,
Andre Cournard and Dickinson Richards were considered as the
earliest pioneers of central
venous catheterization and they jointly shared the Nobel prize for
Medicine in 1956. It is used in
anaesthesia, critical care, surgery, acute medicine as well as for
medium to long term uses like
parenteral nutrition, cancer chemotherapy, prolonged antibiotics,
and other interventions. A wide
variety of professionals are involved with the insertion, care, and
removal of these devices. With
its rising risks and complications and the reduced role of central
venous pressure monitoring as a
hemodynamic variable, the extensive and mandatory use of the
central line in an ICU setting,
has been controversial. We present the pros and cons of central
line insertion in ICU.
4. Impact of COVID 19 on the doctors affected by it
Dr Deepthi (DNB), Dr Anshul (DNB), Moderator – Dr Vatsala Aggarwal
HOD
Objective of study: To assess the impact of COVID 19 disease on the
social, personal, work
related and economic aspects of the life of doctors affected by it.
Design: A descriptive
questionnaire-based study.
Setting: 49 doctors who were infected with COVID 19 in the line of
duty were asked to answer
the questionnaire. Method: A questionnaire having 21 questions
(subdivided into social,
personal, work related and economic impacts) was given to doctors
who were infected with
COVID 19.
Results: The study found that a majority of doctors were under
increased psychological and
work-related pressure in the current scenario. A fraction of the
doctors has also faced economic
worries during the pandemic.
Conclusion: Frontline workers especially doctors have held up an
armour over the general
public in their time of need. But what this study has shown are the
cracks in the armour. The
adverse effects this pandemic has caused on the affected
individuals, if unrecognized and
unaccounted for, will eventually result in burnout which can lead
to disastrous consequences.
Webinar (28/1/2021)
A webinar on “Clinical concept of vascular access through IO” was
organised by M/s Teleflex,
under the banner of ISA Delhi branch, on 28th January, 2021.
The program began with ISA flag hoisting and introduction of office
bearers of ISA Delhi branch.
Dr Nikki Sabharwal, President ISA Delhi branch, was invited to give
her welcome address. This
was followed by scientific presentation by Dr Vivek Vijayendra. The
presentation was very
exhaustive and informative. It generated a lot of interest and
question-and-answer that were very
interesting and educative.
The webinar was well attended and appreciated. We would like to
congratulate M/s Teleflex for
organizing such a wonderful webinar.
The abstract of presentation is as follows:
Intraosseous (IO) access has endured for more than 90 years as a
safe and effective alternative
for vascular access. The technique of intraosseous access (IO)
involves inserting a needle into
the bone marrow cavity for the purpose of administering fluids
and/or drugs. First proposed by
Drinker et al in the 1920s. IO vascular access was established as a
standard of care in Pediatric
Advanced Life Support (PALS) in 1988. With the advent of IO access
technology designed to
access the harder, thicker bone cortex of the adult, intraosseous
became an adult standard of
care when the American Heart Association added IO vascular access
to Advanced Cardiac Life
Support (ACLS) in 2005.
In this webinar we discussed on the Indications and
contraindications, including the difficult
vascular algorithm guide, and the anatomy as well as insertion site
selection criteria. For IO
access, potentially there are totally 8 sites (4 on each sites of
the body), namely Humerus
(greater tubercle), Proximal Tibia, Distal Tibia and Distal Femur
(for neonates). Of the various
insertion sites, the Humerus is preferred choice, due to large
medullary space has more
advantage with less infusion pain, faster access to central
vasculature (a dye fluoroscopy shown
to reach right atrium in 3sec from humerus site) better infusion
rate. (nearly 6.3 L/hr, as
compared to 1L/hr recorded from Tibia site)
The EZ IO®, Intraosseous vascular access system with 3 needle size
options, the needle
selection is based on the patient weight, anatomy and tissue depth
required to access at the
selected site of insertion. The caveat is depending on the site of
insertion and tissue depth, the
last black line near the hub of the needle should be clearly
visible to ensure the needle length is
sufficient to pass through the cortical bone to reach medullary
cavity. It is well discussed to be
able to identify the land markings, patient position, insertion
angle for each of the site.
The indication that the needle passed through the tough cortical
bone to medullary space is well
appreciated by tactile feedback of give away or loss of resistance
– a dip. With softer, smaller
and thinner bones, like those in pediatric patients, special care
must be taken during insertion to
avoid excessive pressure and recoil. Recoil can occur when the
clinician feels the lack of
resistance upon entry into the medullary space, releases the
trigger and inadvertently pulls back
on the driver. This recoil may displace the needle set from the
medullary space. It is encouraged
to practice insertion on a raw egg as part of the hands-on
component of training.
While the insertion pain is 3 on a scale of 1-10, the infusion pain
could be more due to pressure
(300mm Hg Pressure) exerted during infusion in a closed medullary
cavity. In pain sensitive
patients, 2% Lidocaine (preservative free, epinephrine free) based
pain management protocol (of
+4min) can be considered. Post insertion, the dwell time is for
24hrs and if the vascular access is
required to continue an alternate vascular access can be planned in
the meantime. An emphasis
on care, maintenance and removal was made during the discussion to
ensure adequate patient
care is imparted post insertion.
REVIEW ARTICLE
Dr Aparna Sinha, Director, Anesthesia Division of Institute of
Minimal Access, Metabolic and Bariatric
Surgery, Max Super Speciality Hospital, Saket
Laparoscopy in COVID times, what is the current practice?
The indefinite journey of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2),
from Hubei to more than 200 countries that it has invaded, has
jeopardised several aspects of
medical care. The pandemic infection has now 95,36,928 confirmed
cases and 1,38,301
confirmed deaths in India alone. This number is only on the rise.
Most unfortunately the
asymptomatic and undocumented infections have a major role in the
extensive spread of the
disease.1 As the pandemic began to get hold on human population
worldwide, the non-
emergent, non-cancer procedures had been put on hold to reallocate
and redirect the medical
and paramedical staff to take care of the patients affected by the
pandemic.
Concerns have been raised that laparoscopy and other minimal access
surgeries could be
procedures that are associated with tremendous aerosolisation and
carry potential of virus
diffusion in the operation room (OR) during surgery.
Laparoscopy and minimally access surgery have stood the test of
time and have become
indispensable for the advantages they offer in form of enhanced
recovery after surgery, less
bleeding quicker discharge. 2 The scope of these techniques is only
increasing .3-5 Even less
invasive approaches have been developed in recent years, such as
the use of very thin
instruments in mini- and micro-laparoscopy and the development of
single-port access
laparoscopy (SPAL). 6-9 Everything could change as; we are facing a
new respiratory virus
that has been a threat to all healthcare professionals and is
modifying our OR activity.
At the advent of the pandemic, concerns were raised about the
potential of laparoscopy and
other that minimal access procedures to increase the virus
diffusion in the OR during surgery.
We wish to highlight clinical recommendations and suggestions to
mitigate the risks and to
help clinicians take a decision.
By definition an aerosol is a suspension of solid or liquid
particles in a gas. This encompasses
aerosols, includes both the fragments and the suspending gas/es,
which includes air (as
during airway management), or CO2 as during laparoscopy. There have
been very infrequent
reports in the past to suggest the presence of viruses in the
surgical smoke. Laparoscopic
procedures have been implicated in possible aerosolisation and
presence of cell-size
fragments in the emanating smoke. Particles of size ranging from
0.1 to 25 μm have been
demonstrated in the smoke associated with cautery. 10,11 However,
it has never been
demonstrated that the pneumoperitoneum gas could carry bacteria in
aerosol form and
spread infection within the peritoneal cavity. The pneumoperitoneum
gas collected at the end
of the laparoscopy has not been shown to bear any bacterial
contamination.12 Yet another
study demonstrates, the hepatitis B and human papilloma virus DNA
in surgical smoke, with
no contamination of the personnel involved.13,14
Many practitioners believe and have published that SARS-CoV-2 can
be found in the surgical
smoke during laparoscopy, even in absence of a definite proof.
However, even during open
surgery, cauterization can produce aerosols, but the particle
concentrations in smoke might
be higher following laparoscopic interventions 15. This could be
even more pronounced during
evacuation of specimen and at the time of release of the
pneumoperitoneum.16
Recommendations
The Society of American Gastrointestinal and Endoscopic Surgeons
(SAGE) recommended
to stop elective surgeries and reinstated that in case of any
surgical emergency, the use of
devices to filter released CO2 for possible aerosolised particles.
They further suggest
reduction of number of medical personnel inside the OR, to the
minimum, and that the use of
personal protective equipment (PPE) should indispensable. 17
Surgery for any malignancies
should continue unless alternatives options are available.
Similar recommendations have come from the European Society for
Gynecological
Endoscopy (ESGE) and many other societies. They have also suggested
to defer elective
surgery until the end of the pandemic. (Table 1)
Any patient with suspected or confirmed SARS-CoV-2 infection should
be deferred until their
full recovery. In case of a life-threatening situation the surgery
can proceed with full PPE for
the entire OR personnel. The screening of patients for coronavirus
infection before an elective
procedure in now mandatory.
Closing the port taps before insertion,
Attaching a CO2 filter to one of the ports for smoke evacuation if
needed
Not opening the tap of any ports unless they are attached to a CO2
filter
or being used to deliver the gas
Reducing the introduction and removal of instruments through the
ports,
Deflating the abdomen with a suction device before removing
the
specimen bag from the abdomen,
Deflating the abdomen with a suction device and via the port with a
CO2
filter at the end of the procedure,
Minimizing the use of cauterization [25].
IAGES is Indian association of gastrointestinal and
endosurgeons,
SAGES is The Society of American Gastrointestinal and
Endoscopic
Surgeons and ESGE is European Society for Gynecological
Endoscopy
The Royal College of Obstetrics and Gynecology (RCOG) together with
the British Society for
Gynecological Endoscopy (BSGE) 18 and The American Association of
Gynecologic
Laparoscopists (AAGL), and many other surgical and women’s health
professional societies,
supports suspension of non-essential surgical care during the
immediate phases of the
coronavirus disease 2019 (COVID-19) pandemic 19.
Most societies worldwide provides similar recommendation on smoke
evacuation and
dispersion and prevention of aerosol transmission and in addition
suggests performing
laparotomies or deferring operations that have a risk of bowel
involvement due to an
increased theoretical risk in such cases. In addition to
suggestions to reduce aerosol diffusion
during and immediately after laparoscopy, there is advice on
screening patients before
surgery and suggests additional imaging evaluation (chest computed
tomography) prior to
any surgical procedure. 20
As per IAGES (Indian association of gastrointestinal and
endosurgeons), at the time of
desufflation, patient should be made supine and least dependent
port should be used for
desufflation wherever possible. All escaping gas and smoke should
pass through an
ultrafiltration system and if available, desufflation mode should
be used on the insufflator.
Surgeons should practice controlled evacuation of smoke using the
side channel of the port.
21
Surgical drains should be very limited and specimen removal, should
be either hand assisted
or with wound protection device, strictly after desufflation.
Fascial closure should be
considered mandatory following desufflation. Suture closure devices
which allow gas leak
should not be practiced.21
Whenever wall suction are used, appropriate filters should be
incorporated for ultra filtration
as this too can be a potential source of infection.
Conclusions
Our knowledge of this new virus is still very limited.
Consequently, the possible risks for
health professionals and the risks from operating on an
asymptomatic patient positive for
SARS-CoV-2 are still unclear. Certainly, in this period, the
surgical indications and accurate
patient selections should be thoroughly discussed in each case,
since it is mandatory to
reallocate medical and paramedical staff to face the
emergency.
In some countries there have been concerns over decreasing
operating room use in order to
increase the number of lung ventilators available for the great
number of coronavirus patients
that need respiratory assistance.
The need to limit virus diffusion and the published data on other
viruses in surgical smoke, in
particular in laparoscopy, should be taken into strongly addressed.
The ideal situation would
be to screen all patients before surgery. If this is not possible,
PPE should be used and all the
strategies to decrease aerosol diffusion in the operating theater
should be followed.
We suggest using a device like commercially available smoke
aspirators that have a close
circuit to maintain the carboperitoneum and to facilitate smoke
evacuation and filtration with a
0.01μm ultra-low particulate air filter (ULPA). Other measures such
as to use very low CO2
pressures and ensuring availability of experienced surgeons to
minimise surgical time. This
goal can even be obtained using a deep neuromuscular block to
optimize surgical space
conditions during laparoscopic surgery at very low insufflation
pressure.22 With all above
precautions we have not encountered any evidence to suggest that
laparoscopy can
potentially increase OR contamination. These strategies increase
would certainly contribute
towards improve safety and minimising OR contamination.
References
1. Li R, Pei S, Chen B et al. (2020) Song Y, Zhang T, Yang W,
Shaman J. Substantial
undocumented infection facilitates the rapid dissemination of novel
coronavirus (SARS-
CoV2). Science. Mar 16. pii: eabb3221. doi: https://
doi.org/10.1126/science.abb3221.
2. Mais V, Ajossa S, Piras B et al (1995) Treatment of
nonendometriotic benign adnexal
cysts: a randomized comparison of laparoscopy and laparotomy.
3. Obstet Gynecol 86(5):770–774
4. King CR, Lum D (2016) Techniques in minimally invasive surgery
for advanced
endometriosis. Curr Opin Obstet Gynecol 28(4):316–322
5. Tinelli R, Litta P, Meir Y et al (2014) Advantages of
laparoscopy versus laparotomy in
extremely obese women (BMI>35) with early-stage
6. endometrial cancer: a multicenter study. Anticancer Res
34(5):2497–2502
7. Fagotti A, Perelli F, Pedone L, Scambia G (2016) Current
recommendations for minimally
invasive surgical staging in ovarian cancer. Curr Treat Options in
Oncol 17(1):3
8. Mereu L, Dalpra F, Terreno E, Pertile R, Angioni S, Tateo S
(2018) Minilaparoscopic
repair of apical pelvic organ prolapse (POP) by lateral
9. suspension with Mesh. Facts Views Vis Obgyn 10(3):139–145
10. Angioni S, Pontis A, Sedda F et al (2015) Single-port versus
conventional multiport
access prophylactic laparoscopic bilateral salpingo-oophorectomy in
high-risk patients for
ovarian cancer: a comparison of surgical outcomes. Onco Targets
Ther 25(8):1575–1580
11. Baekelandt J, De Mulder PA, Le Roy I et al (2017) Postoperative
outcomes and quality of
life following hysterectomy by natural orifice transluminal
endoscopic surgery (NOTES)
compared to laparoscopy in women with a non-prolapsed uterus and
benign
gynaecological disease: a systematic review and meta-analysis. Eur
J Obstet Gynecol
Reprod Biol 208:6–15
12. Angioni S, Pontis A, Pisanu A, Mereu L, Roman H (2015)
Single-port access subtotal
laparoscopic hysterectomy: a prospective case-control study. J
Minim Invasive Gynecol
22(5):807–812
13. DesCoteaux JG, Picard P, Poulin EC, Baril M (1996) Preliminary
study of electrocautery
smoke particles produced in vitro and during laparoscopic
procedures. Surg Endosc
10(2):152–158
14. Weld KJ, Dryer S, Ames CD et al (2007) Analysis of surgical
smoke produced by various
energy-based instruments and effect on laparoscopic visibility. J
Endourol 21(3):347–351
15. Taffinder NJ, Cruaud P, Catheline JM, Bron M, Champault G
(1997) Bacterial
contamination of pneumoperitoneum gas in peritonitis and controls:
a prospective
laparoscopic study. Acta Chir Belg 97(5):215–216
16. Kwak HD, Kim SH, Seo YS, Song KJ (2016) Detecting hepatitis B
virus in surgical smoke
emitted during laparoscopic surgery. Occup Environ Med
73(12):857–863
17. Zhou Q, Hu X, Zhou J, Zhao M, Zhu X, Zhu X (2019) Human
papillomavirus DNA in
surgical smoke during cervical loop electrosurgical excision
procedures and its impact on
the surgeon. Cancer Manag Res 29(11):3643– 3654
18. Li CI, Pai JY, Chen CH (2020) Characterization of smoke
generated during the use of
surgical knife in laparotomy surgeries. J Air Waste Manage Assoc
70(3):324–332
19. Englehardt RK, Nowak BM, Seger MV, Duperier FD (2014)
Contamination resulting from
aerosolized fluid during laparoscopic surgery. JSLS 18(3)
20. SAGES - Society of American Gastrointestinal and Endoscopic
Surgeons
Recommendations Surgical Response to COVID 19. 2020
https://www.sages.
org/recommendations-surgical-response-covid-19/
https://www.bsge.org.uk/news/joint-rcog-bsge-statement-ongynaecological-
laparoscopic-
procedures-
22. AAGL Joint Statement on Minimally Invasive Gynecologic Surgery
during the COVID-19
Pandemic. https://www.aagl.org/news/covid-19-jointstatement-
on-minimally-invasive-
gynecologic-surgery/
23. Ai T, Yang Z, Hou H, Zhan C, et al. (2020) Correlation of chest
CT and RTPCR testing in
coronavirus disease 2019 (COVID-19) in China: a report of 1014
cases. Radiology. Feb
26:200642. doi: https://doi.org/10.1148/radiol. 2020200642. [Epub
ahead of print]
24. IAGES (Indian Association of Gastrointestinal Endoscopic
Surgeons) Covid Surgery
Recommendations, (11th April 2020) released on
https://www.iages.in/.
25. Bruintjes MH, van Helden EV, Braat AE et al (2017) Deep
neuromuscular block to
optimize surgical space conditions during laparoscopic surgery: a
systematic review and
meta-analysis. Br J Anaesth 118(6):834–842
ETHICS IN COVID TIMES (PART-6)
Dr Arun K Mehra
Senior Consultant, Bhagwati Hospital
Mental Health of Care Providers
Mental health is a part of overall health, and cannot be considered
as something “separate”,
compartmentalized.
Doctors and other health care workers are human beings, subject to
all the same feelings, the
same psychological states and the same emotions as other people,
including all the same
stresses and strains. They need psychological support, as much as
others do. Sadly, this is
often forgotten by the society, which expects them to be
“super-humans”.
The pandemic, with its severe disruption of normal life, has taken
a heavy toll on the mental
health of large sections of the society. It’s possible that the
price paid by health care workers
may be even higher than the general population, with long duty
hours, isolation, sometimes
unsafe conditions, tough decisions, and much else.
Thus, it’s noteworthy that while there is an immediate need of
physicians, anesthesiologists,
pulmonologists, critical care specialists, and others who are
experts at handling the
immediate medical problems, later on psychiatrists will be
needed.
Some of the major problems that the population as a whole is facing
now is loneliness and
economic uncertainty, resulting in depression, substance abuse,
violence and even suicide.
The most fundamental basis from which psychological disorders arise
in a time of great crisis
is a feeling of insecurity, out of a fear of the unknown. In this
the social media has played a
role in increasing that anxiety, by spreading much
misinformation.
In the case of doctors and other healthcare workers, there is also
moral injury from being
forced to take tough (at times ethically confusing) decisions.
Besides this, other issues are
quarantine and isolation after duty stints, fear for family, and
other similar problems, all
resulting in frustration, demoralization, post-traumatic stress
disorder, embitterment and social
problems. Added to this is the long-term fear of economic
uncertainty.
Doctors have, at times, also lost autonomy, and also transparency
(which is the basis of trust,
the most basic building block of the doctor-patient
relationship),
Besides, there is social stigmatization (and at times even
ostracization from their residential
areas), unrealistic expectations by the society with unfair blame,
and even assaults.
Long term neurological damage can result from hyper-focus and
continuous stress, resulting
in fear, anger, and even schizophrenia and obsessive-compulsive
disorders.
So, what is to be done?
Look for warning signs. This should be done in each institute and
in each individual
department. It’s important to remember that doctors don’t
voluntarily seek help anyway.
Set up help groups, and bring in professional counselling if
needed.
We all need time to grieve, whether for personal or professional
reasons. It’s a catharsis.
Never worry alone, never grieve alone. Don’t be ashamed to express
grief.
We all also need a private space, at times, to contemplate, or else
just sit and mentally relax,
and to “let go”.
Never be afraid to say “we are in pain”. Accept the fear, don’t act
as if you are fearless.
There are also some things to NOT do.
Pseudo mental health has come up, with all kinds of claims. Avoid
it.
Don’t push for “perfectionism”.
Don’t be rigid in your views, and change your mind as new findings
arise and facts change.
What is ultimately needed is a positive resilience.,
Let’s also remember that all issues cannot be resolved.
Arun K Mehra is a Senior Consultant at Bhagwati Hospital. Besides
Anaesthesiology, he has also done an
MBA in Healthcare Administration from the Faculty of Management
Studies (FMS) Delhi University, a
Diploma in Creative Writing from the Indira Gandhi National Open
University (IGNOU), and Certificate in
Bio-Ethics and Human Rights from UNESCO. His special interest is
the sociology of medicine. He also
has vast experience as a writer, blogger, and editor.
EXPERIENCES ….
“GOSWAMI TULSIDAS”
Recently I had the great fortune of visiting Chitrakoot and
Varanasi with my family. During this
trip, I gathered a lot of information about Goswami Tulsidas which
I feel privileged to share
with all of you.
Idol of Goswami Tulsi Das
Tulsidas was a Vaishnava saint and poet and renowned for his
devotion of the deity Rama.
He wrote several popular works in Awadhi and Sanskrit but is best
known as author of the
epic Ram charitmanas based on Rama’s life in the vernacular Awadhi.
He was born in
Rajapur town of Chitrakoot district (UP) on August 1497. His
parents were Atma Ram Dubey
and Hulsi.
Legend goes that Tulsi was born after staying in the womb for
twelve months, he had all
thirty-two teeth in his mouth at birth and he did not cry at time
of birth but uttered Rama
instead. He was therefore named Rambola. Due to an inauspicious
astrological configuration
at time of his birth he was abandonded by his parents and given to
Chuniya a female servant.
She looked after him for fine and half years after which she died.
He was then adopted by
Narharidas, his guru.
He was given diksha by his guru and a new name Tulsi. He was taken
to Ayodhya and Soron
(a holy place dedicated to Varaha) boar avtar of Vishnu where guru
narrated Ramayana to
Tulsidas. Tulsidas then came to Varanasi and started reading
Sanskrit grammar, Veda and
Hindu philosophy for 15-16 years. He got married to Ratnavali of
Mahewa village across
yamuna in 1526.
Once Tulsi Das had gone to a Hanuman temple, Ratnavali went to her
father’s house with her
brother. When Tulsidas came to know this on his return, he swam
across Yamuna river
holding on to a dead body,thinking it is a raft ,in the middle of
the night. He reached her
house and found a rope hanging from her house. He climbed with the
help of rope and
reached her room. Ratnavali was surprised and discovered that the
rope was infact a snake.
Ratnavali chided Tulsidas for this and remarked that if Tulsidas
was even half devoted to God
as he was to her body of flesh and blood, he would have been
redeemed. Tulsidas left her
instantly and left for Prayag , where he renounced householder's
life and become a Sadhu.
After renunciation, Tulsidas spent most of the time at Varanasi,
Prayag, Ayodhya and
Chitakoot. Tulsidas did his meditation in Tulsi cave at Ramghat in
Chitrakoot after he met
Hanuman in woods, where present day Sankat Mochan temple stands in
Chitrakoot. He
wanted to meet his duty Rama face to face. When Rama appeared as
child, Tulsi was making
sandalwood paste and when a child came and asked for a tilak.This
time Hanuman appeared
in the form of a parrot and gave a hint to Tulsi, ( , , , ') Tulsi
was so charmed that he forgot about sandalwood paste
and Rama took the sandalwood pasteand put a tilak himself 'on his
forehead and Tulsi’s
forehead before disappearing.
Tulsidas started writing Ramacharitmanas at the age of 76 years. It
took more than 2½ years
to compile it. It is written on paper and restored with help of
tissue paper and only Ayodhya
Kand of the original epic is present in Rajapur Tulsi temple, where
it is kept in a safe by the
descendents of Tulsi’s main disciple Ganpat Ram Das ji
Maharaj.
The manuscript was stolen by a pujari hired by the descendents of
Ganpat Ram Das to look
after Tulsi temple, for the intention of selling it and on being
followed, he threw the manuscript
in Ganga. It was retrieved by Maharaja Kala Kankar and and now only
Ayodhya Kand of
original manuscript remains.
He died at age of 126 years (in1623) at Assi ghat in Varanasi.
Ganpat Ram came back to
Rajapur and brokethe news of his demise to his followers who
started weeping and then Tulsi
came in their dream and asked them to retrieve his idol from
Yamuna. People dived at the
site as directed by Tulsi in the dream and retrieved a shivling, a
Shaligram and black idol of
Tulsi das. All three are present at Tulsi Dham in Rajapur at banks
of Yamuna. Tulsi’s idol is
complete with all parts and in padmason mudra with praying bead in
one hand.
Shivling And Shaligram Original Manuscript of Ramcharitmanas
It is a pity that we know so little about the greatest poet of all
times and who is believed to be reincarnation of Balmiki. I had the
good fortune to visit all these places and see Ramcharitmanas in
original form.The other popular works of Tulsidas are Vinay
Patrika, Geetawali, Dohawali, Hanuman Chalisa, Janki Mangal and
Parvati Mangal etc.
Yamuna River at Tulsi Dham
PHOTOGRAPHY
Dr Smita Prakash, Professor & Consultant, VMMC & Safdarjung
Hospital
PHOTOGRAPHY
Dr Girish V, PG student 3rd year, VMMC & Safdarjung
Hospital
ART GALLERY
VMMC & Safdarjung Hospital and her daughter Kamakshi
Sabharwal
ART GALLERY
, , !
, ,
!
, , , ,
!
, , ,
, ,
,
!
, , , ,
, , , ,
, , ,
, ,
Written by: Dr Tapesh Maurya, PG Student, VMMC & Safdarjung
Hospital
ANSWERS TO DECEMBER WORD GAME
There are 15 famous personalities hidden in there…let’s see if u
can find them all
M O R T O N B Q X J
O C J V I I A U O O
R O P B E G I I E H
A L H R O B N N G N
N T W E I Y S C R S
G O E A N E L K E N
U N L I T R B E E O
E R L B O E Y I N W
D E S F L U R E E S
E D A L T O N S N H
L M A C I N T O S H
1. Morton 9. Greene 2. Bier 10. Waters 3. Bains 11. Guedel 4.
Quincke 12. Wells 5. John Snow 13. Rees 6. Colton 14. Dalton 7.
Boyle 15. Macintosh 8. Henry
WORD GAME
1.
2.
D S I O E H C I L V
3.
4.
B U I D N A M T O E
5.
E I R V I M S R D E
6.
S A E N U L F D E R
7.
E R A N I A D I B V
8.
9.
10.
C V I E N R A I A O P
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1. 5th Feb Friday 5-7pm, clinical meeting, Hindu Rao hospital
2. 19th Feb. Friday clinical mtg by Dwarka group i.e. Akash,
Venkateshwar and Balaji
Action hospitals
