REMEMBERING PROF. G.P. AGARWAL BY HIS BEDSIDE TEACHING

 

Prof. Giridhar Prasad Agarwal was our teacher in Surgery in King George's Medical College in Lucknow. He was Professor in charge of experiment surgery and was a very kind hearted soul. He was a dog lover, and not only his own pet dog, but even the ones brought for experimental surgery were treated with great care like guests in true Lucknavi style. Though in those days Good Laboratory Practices and Institutional Animal Care and Ethics committees were in their infancy, but Prof. Agarwal was far ahead of his time. He would emphasize to us that dogs experience pain, fear, and attachment. This created a high moral duty on our part to protect them from unnecessary harm and treat them with kindness. He would critically analyze the necessity of an animal experiment, ensure pain free procedure with sedation, anaesthesia and analgesics, and insist on good postoperative care and painless animal sacrifice if required.

 

However, if a surgical resident's thesis did not involve experimental surgery, this aspect of Prof. Agarwal always remained hidden from them. When Prof. P. C. Dubey was our Head of the Department, and Prof. R. P. Sahi was No. 2, Prof. G. P. Agarwal was No. 3 and easily the most benign in the surgical stratosphere. Always smiling, and always very loving, a rotation in his unit was a celebration. Dr. I.D. Sharma was the lecturer designated to his unit, and the latter enjoyed complete independence in running his breast unit. In fact, when Dr. Sharma needed space for his newly installed Thermography unit, Prof. Agarwal created a nice and cozy place for the same in Experimental Surgery building. He always encouraged Dr. Sharma to follow his passion and helped him in every possible way. I have, in the past, written about Prof. I.D. Sharma. In case you have missed it please click: https://surajitbrainwaves.blogspot.com/2026/04/remembering-prof-i-d-sharma-early.html

 

Prof. G. P. Agarwal's rounds would start from the General wards of Surgery, where he would often stop to conduct bedside teaching of the undergraduate students, who were since morning being taught by his residents. He would briefly examine the patient, while he is being told the history, and then start teaching, as if it was a prepared lecture. The two hallmarks of his bedside teaching were his bedside manners and his insistence on correct elicitation of physical signs. He could make a roadside beggar feel like a VIP by his immaculate manners and kind and respectful words. Every patient considered him to be their family member. Greeting the patient, seeking permission before examining them, comforting them from time to time, sharing a joke with them, admonishing them, every thing about that conversation was picture perfect and a life lesson for the students and residents. He would never forget to greet the nurses and thank them at the end of the rounds. As he was a food lover, many senior nurses and ward matrons would bring home cooked food or snacks for him, and we all devoured them.

 

From the General Wards we would move to the private wards and here the picture was absolutely different. Every patient was his 'bhai sahab', or 'Bhabhi ji' or 'didi' or 'beta' or 'beti'. Not only did he know them personally, but he knew everything and everyone in their family! Again snacks awaited his arrival and his surgical team was treated as his family, which has come to visit them. When these private patients were discharged and we would keep their bill in front of him, he would often scratch the amount mentioned against 'surgical fee' and write 'zero'. Naturally different patients reacted differently, some were embarrassed and insisted on paying, but he would politely refuse. Some came back with loads and loads of sweets and gifts for him and his team. I often wondered why would he refuse his surgical fee, when these people could afford. But, the answer was not so simple. Once, a jeweler returned with his wife, who was operated for cholecystectomy two weeks back and while leaving, with a lot of hesitation, pressed a set of two keys into his hands while shaking it. Prof. Agarwal said, "Lala ji, your car keys!" 'Lalaji, aapke garhi ki chabhi'.The jeweler politely said, "Sir, they are yours" 'aap hi ki hai!'  He was cementing a life long relationship with these families and with their communities, and the surgical fee was a very small price to pay. He was truly a member of their family, attending the weddings and standing in the funerals with these families. 

 

Our rounds usually never ended without refreshments and if after the rounds we were left famished then Prof. Agarwal would take all of us to Kwality, an up market restaurant in Hazratganj for coffee and cakes and pastries. To say that he was a food lover would be a huge understatement. Despite being a diabetic he loved sweets and fried snacks, and must have been the worst patient of his poor physician. He was in charge of food and catering every time not only the Department of Surgery, but any department hosted a conference in KGMC. Later Dr. R.K. Tandon joined him and the two could handle even massive conferences like the 1984 Annual Conference of Association of Surgeons of India in Lucknow.

 

I knew Prof. Agarwal personally even before joining KGMC because his daughter Neelu and I were classmates in Lucknow University. While I got selected first in AFMC and then in KGMC, Neelu got admission in B.R.D. Medical College, Gorakhpur. His son, Vivek was my wife's classmates. Unfortunately, both of them are no more with us today. I assisted Prof. Agarwal in his private practice. He lived in a luxurious campus bungalow in Shahmina Road, where the Centenary Hospital stands proudly today. His garage, a part of driveway, and one adjoining room were converted into an OT and post operative ward. We would operate hernia, hydrocele, appendectomy, cholecystectomy, ovarian tumours, hysterectomy, superficial thyroidectomy and amputations all in that O.T. The legendary Chotey Lal would assist us, and he would always tell me to closely watch the skin sutures and the dressings done by Prof.Agarwal. Chotey would tell me that this is the bit of Surgery that the patient would observe. You have to do this meticulously to make a good impression! Surgery at home naturally ended with refreshments and Mrs. Agarwal would insist on another refill even when our stomach was about to burst! After retirement he moved to his own home in Mahanagar and operated in Neera Hospital.

 

Today, I am reminded of a bedside teaching in a patient who presented with nausea. I was a Junior Resident in his team then. He took the class away from the patient to the middle of the ward where there were benches for the students and a chair and a blackboard for him. The class took 2 minutes to settle down and by that time he had planned his teaching format.

 

Prof Agarwal insisted on a detailed clinical history and a focused abdominal examination. The purpose was to rule out acute surgical emergencies like bowel obstruction or acute abdomen, and order baseline laboratory investigations, and an upper GI endoscopy as indicated. In those days we did not have ultrasound and peptic ulcer was fairly common, and still a disease being treated by surgeons. So, this is how his class went:

 

History and Physical Examination

• Symptom duration: Ask if the nausea is acute or chronic.
• Associated signs: Check for vomiting, fever, pain, or weight loss.
• Abdominal examination: Check for tenderness, distension, masses, or bowel sounds.
• Surgical history: Review past operations for potential adhesions or strictures.

 

Diagnostic Testing

• Blood tests: Order a complete blood count, electrolytes, and liver function tests.
• Imaging: Get an upright chest and abdominal X-ray to check for free air or obstruction.
• Fractional test meal: A method of examining the secretion of gastric juices; the stomach contents were sampled at intervals via a stomach tube after a test meal of gruel and an acid curve was generated. After the meal, assessments of gastric emptying, gastric acidity, pancreatic secretion, or nutrient absorption could be undertaken.
• Barium swallow/meal - Barium tests are used to help see the outline of various parts of the gastrointestinal tract. These include the oesophagus, stomach, and small intestines. 
• Endoscopy: Consider an upper GI endoscopy if symptoms are chronic or non-acute. 

 

Who demands immediate attention?

All patients presenting with nausea who exhibit signs of

     ·        a surgical abdomen
·        hemodynamic instability
·        severe metabolic depletion

require immediate admission. Admitting these patients promptly is vital to prevent life-threatening complications like organ perforation, septic shock, or irreversible tissue ischemia.

The specific patient profiles requiring immediate admission, along with the physiological reasons why, include: 

1. Patients with Signs of Peritonitis (Acute Abdomen)

• Clinical Presentation: Severe, localized, or generalized abdominal pain that worsens with the slightest movement, accompanied by involuntary guarding, rigidity ("board-like" abdomen), and rebound tenderness. 
• Why Admission is required: These signs indicate inflammation of the peritoneal lining, usually caused by a perforated hollow organ (e.g., a perforated peptic ulcer, ruptured appendix, or diverticulitis). Immediate admission allows for emergency surgery to patch the perforation and wash out the peritoneal cavity before overwhelming sepsis develops. 

2. Patients with Hemodynamic Instability or Shock

• Clinical Presentation: Nausea accompanied by tachycardia (HR > 100 bpm), hypotension (SBP < 90 mmHg), tachypnea, cold/clammy skin, or altered mental status. 
• Why Admission is required: The patient is experiencing circulatory failure. In a surgical setting, this points toward septic shock (from a severe intra-abdominal infection like ascending cholangitis) or hemorrhagic shock (from conditions like a ruptured abdominal aortic aneurysm or ruptured ectopic pregnancy). They require immediate intensive monitoring, aggressive intravenous resuscitation, and definitive source control. 

3. Patients with Complete Bowel Obstruction (Strangulation Risk)

• Clinical Presentation: Nausea and bilious or fecal vomiting paired with abdominal distension, severe cramping pain, and obstipation, which is inability to pass both stool and flatus. 
• Why Admission is required: A mechanical blockage (from adhesions, hernias, or tumors) halts the normal flow of the GI tract. If left unmanaged, the intraluminal pressure can compromise the intestinal blood supply, leading to bowel ischemia, gangrene, and necrosis. Immediate admission ensures gut decompression via a nasogastric (NG) tube and monitoring for emergency surgical resection. 

4. Patients with Abnormal Vomit Content (Gastrointestinal Bleeding)

• Clinical Presentation: Nausea accompanied by vomiting frank blood or "coffee-ground" material. This is hematemesis. A history of black tarry stools is melena which suggests bleeding in upper G.I. tract. 
• Why Admission is required: This indicates active upper gastrointestinal bleeding from causes such as a bleeding peptic ulcer or a Mallory-Weiss tear. Admission is mandatory for active resuscitation, blood type matching, and an urgent diagnostic/therapeutic upper GI endoscopy to achieve hemostasis.

5. Patients with Severe Dehydration and Metabolic Derangement

• Clinical Presentation: Persistent vomiting resulting in, minimal to no urine output, extreme lethargy, and labs showing profound hypokalemia, hyponatremia, or metabolic alkalosis.

• Why Admission is required: Severe electrolyte imbalances can trigger lethal cardiac arrhythmias, and severe hypovolemia can result in acute renal failure (ARF) The patient requires inpatient IV fluid resuscitation and structured, continuous electrolyte replacement.

 

Causes of Nausea

Surgical Causes

• Gastroparesis: Delayed stomach emptying often linked to prior vagus nerve injury during abdominal surgery.
• Bowel Obstruction: Partial or intermittent blockages from scar tissue or adhesions after past operations.
• Dumping Syndrome: Rapid gastric emptying occurring after gastro-jejunostomy.
• Post-Surgical Retained Foreign Body: Rare surgical complications leading to chronic irritation and nausea.

 

Non-Surgical Causes

• Medications: Side effects from chemotherapy, opioids, antibiotics, or nonsteroidal anti-inflammatory drugs.
• Metabolic Disorders: Conditions like uremia, diabetic ketoacidosis, or thyroid imbalances.
• Neurological Conditions: Migraines, increased intracranial pressure, or vestibular disorders.
• Gastrointestinal Disease: Peptic ulcer disease, gastroesophageal reflux disease, or chronic hepatitis. 
• Pregnancy: Morning sickness is common in first trimester of pregnancy - between 6 to 14 weeks it is most frequent - almost 70% ladies have it.

 

Psychological Causes

• Anxiety and Depression: Mental health conditions that strongly alter gut motility and brain-gut signaling.
• Chronic Nausea and Vomiting Syndrome: A functional GI disorder where nausea occurs without physical blockage.
• Cannabinoid Hyperemesis Syndrome: Nausea linked to regular cannabis use, often relieved by hot showers.
• Eating Disorders: Conditions like anorexia or bulimia nervosa that cause persistent gastrointestinal distress. 

 

That is how the bedside teaching of Prof. G.P. Agarwal ended. Teachers like Prof. Agarwal never taught from books, but from their experience. They would revise the important bits again and again, ask every person of that small batch which was attending the bedside teaching, and ensure that the even the last in the class has understood the subject. A patient and unthreatening approach in the morning would be followed up by the evening teaching by his Senior Resident revising the same lesson with the same batch. This is what made our bedside teachings matchless!