The Dilemma

Victoria was a young, confident lady of all but 21 years of age. Just over 6 months ago, she had graduated from being Ms. Victoria to Dr. Victoria. Life had changed. The comfort and the carefree attitude which the student phase had afforded was over. She was joyous, nervous and enthusiastic as she continued through her internship. She had learnt a few new skills, could now establish IV access, suture cuts and lacerations, ligate bleeding vessels and set broken bones and of course, prescribe the multivitamins to the odd patient who asked for one.

Yet, while she thought that she had seen it all, she actually hadn't. Even while working in those emergency shifts, she didn't realise that she still was in a controlled environment. Which patient she saw was filtered, and even though she felt otherwise, per se, she wasn't yet responsible for anything. The only major worry which clogged her mind was that of the upcoming entrances for her postgraduate studies which were no more than 3 months away, and how little time she was managing to squeeze out for studies.

Her current rotation was away from her parent institute. A "Peripheral" posting, in the medical lingo. It was no small hospital by any means, just not as big as her mater. Smaller place, fewer people, more work, a little more responsibility. She liked that...... just that, if only had it been after the exam she could have put in a little bit more heart into it.

It was her first night shift in the ICU at the new centre. She would get to learn a lot of new skills and procedures here, because the short staffing afforded her that luxury. Probably, resuscitate a gasping patient or two. In her parent institute, one, the number of patients were so high that after finishing her alloted menial jobs there wouldn't be any time left to learn new things and two, there were despite the rampant short staffing, sufficient number of seniors for the difficult things.

At around 8 pm she began her shift. The very first patient she attended to had been in coma since 3 days. She performed het mandatory blood collections. Over the next hour or so he started regaining consciousness. His illiterate relatives thought that her hands were blessed and so they told her repeatedly. "Aapka haath lag gaya na is liye accha hua ye!! Nahi to 3 din aankh bhi nahi kholta tha!!" She knew, that miracles don't happen. She also knew that she had technically done nothing, the medications were doing their job. But, to possess a "miracle hand" is every doctor's dream. We know the realities, yet we dream. And here, just six months into her career, she was being cannonised. How could she let that go! She just smiled, ear to ear. All her worries, anxieties, fatigue, just evaporating into the thin air.

The night went along uneventful, she worked with a skip in her steps. At about midnight, a patient trollied in, referred from the casualty. A middle aged woman, surrounded by her two kids, a daughter of about 15 yrs and a boy of about 10 and her husband. She looked into the casualty paper. The woman had consumed rat poison.

Different people have different reactions to grief and emergencies. The boy was unaware of what was happening, the girl was clearly distressed yet palpably numb. The husband had lost his head, he was inconsolable. He was shouting, blaming himself for being a bad human, rebuking her for not thinking about her children, cursing the creator for destroying his happy family in a split second. The woman, still conscious, didn't look anyone in the eye, didn't answer any of his accusations, just lay there accepting her fate. In between, she would roll her eyes around, glance at her children, but not a drop of tear rolled down anyone's cheek.

There was an eerie vibe to the whole situation that Dr. Victoria had never faced before. She was intrigued by the happenings and felt so sad for the kids. Somewhere she even blamed the mother for being careless.

"Array he kaay kelaaaa...aaa... tu!!!" The husband started yelling again. There were other patients in the ICU who required quiet. Dr. Victoria wanted to sympathise with the man, but was treating all the patients.

"Please go out and do not make so much noise." she said, trying to sound kind and firm simultaneously, having not managed to calm the storm within herself.

"Array doctor!!!! We were having food. Nicely enjoying our dinner and watching TV. Look at my kids, doctor. She just got up, doctor. Went to the cupboard and removed this bottle of rat poison. And then she told me I will drink it. I thought she is fooling..... So I said, OK go ahead.......... Doctor, I did not know she was actually going to drink it. And then, before I could do anyting, she had the whole bottle..... Doctor..... Look at my kids, doctor"

"Go out". The daughter replied. Still numb, still shaken, but her voice firm. Dr. Victoria was puzzled. Here was a 40 year old behaving irrationally. And here was a 15 year old displaying a level of maturity and composure that she, despite being a qualified medical practioner would not have managed, had she been in her position.

"Go OUT." The daughter repeated.

The man stayed out of the ICU for the rest of the night while the daughter stayed by the bedside.

"What's her prognosis?" Dr. Victoria asked the registrar. This wasn't just an academic query, but she had become emotionally invested in her patient. She had committed a mistake, which no doctor should ever make, yet they make, irrespective of whether they are newbies fresh out of the eggs or whether they have lost all the hair on their heads. " She's come pretty early, so we should be able to save her na?" She added.

"This one is a very strong OPC preparation. Lot of patients come here after consuming this. Nahi bachegi." The registrar replied unfazed. He was time hardened, with just the right amount of asbestos coating around him, to insulate himself from the heat of the moment and make proper decisions.

"O!" was all that Dr. Victoria could mutter.

So many things had happened in the course of the night. From being the one with the miraculous healing hand, she was now forced to resign to her limitations. She saw as the police constable came, took the patient's statement and left. 

At 6 am she she began taking ECGs. When she reached the OPC patient and applied the cuff around her arm to measure her BP, the patient whispered, "Mala chhateet dukhtoy. (I have chest pain)." She was having angina, so Dr. Victoria began to leave to inform her registrar. The woman continued, "He beat me up. He beat me up a lot. He beat me all over my body. He punched me, he kicked me......." the woman continued.

"Do you want me to call the constable? Do you want to change your statement?" Dr. Victoria inuired.

"NO. I just wanted you to know." She said, and turned her head away in sorrow.

She only wanted her to know. Nothing more. Dr. Victoria was to be her secret keeper. But, the young doctor was shaken even more.

What was she to do? Was she to inform the police by her own volition? But, the woman wouldn't change her statement. So what was to come out of it? Suppose if she still went ahead, she would manage to get the husband convicted? But that would take time. Courts move at their own pace. She has a dream to be a superspecialist. Would this one step puncture and detract her career? The woman definitely doesn't want her husband to be punished. She has reasons. Maybe the children. With the mother gone and the father in jail, who would take care of the children? But, then a crime has been committed. Isn't it her duty as a good citizen to make authorities aware. But again, the woman won't change her statement. Dr. Victoria had been rebuked once earlier as well to reign in her enthusiasm and not take on responsibilities which aren't her due. So what if the woman won't change her statement, she could always claim that she had received a dying declaration. But does a dying declaration hold up in courts in India? Being an intern, was she even allowed to take a dying declaration? She hurried to her bag, got out her intern's log book. 

It clearly stated: "The intern will not involve himself/herself in medicolegal cases."

But, was that what was legally sound, ethically sound as well? 

It was nearing 7 am. Her shift was about to end. She was drained, physically, mentally and emotionally. Too much of a Roller'Coaster this night had been. She was 21 the previous day, but today she probably was feeling 50.

She had read somewhere," When something is too good to be true, it probably isn't."

She had also read,"There is always more than meets the eye." 

Today, she had a live hands on experience.

She glanced at the registrar. His face was dull and eyes soggy after the tiring night. Yet, he maintained his poise. His brain alert to any abnormality that crept up on the ECG monitor, or any discomfort that his patient developed, but still aloof!

(A work of fiction, with some inspiration from real life events.)

Daaktuur

I am not very fond of you Surgery. But it's not your fault, I just like medicine more. I like eliciting a knee jerk more than I would like fixing a broken knee. But this post is not about surgery per se, it's about a patient that I have recently come across in the ESR. Actually, his relative is what I am going to write about.

Abusive, violent, short tempered, drunk..... he isn't any of those. It's Saturday evening. (I always end up in units which have Saturday emergencies. No Sundays for me!! But, I also have my entrance classes on Saturday and Sunday, which I end up either missing inevitably or reaching them so dead tired and sleep deprived, I wonder if I should just ask for a refund. Hmmmmm..... no digressing, back to the topic.)

So, it's Saturday evening. My engineering friends are probably out in bars and discotheques partying hard after having worked harder through the week, probably gulping down shots of tequila till they can no longer stand on their own two feet. Well, why shouldn't they, they can afford. I am a teetotaller, but I know that one shot costs 1700 and taxes extra. 1700, is what an intern's stipend was two years ago. Then it increased, courtesy my seniors who went on a strike. But, it hasn't increased that much either, one can now probably afford 3 shots. And, here I am inserting IV lines, Folley's catheters, Ryle's tubes, and suturing drunkards who've fallen by the roadside and cracked their skulls open. All work, no study. Sorry, I digress.

So, it's a Saturday evening. I've missed one more class. Today has a heavier than usual. Around 9.30 pm one more fellow wheels in. I ready my set of IV lines, one pink and one blue, to be chosen on the condition of his veins, the three way connector and saline flush and adhesive tape. 3 red vials for viral markers, two purples for blood grouping and cross matching and HbCBC. All is done at spinal level. 

His relative approached me. From his attire, he seems like a Koli (Fisherman). His eyes are red shot, not of liquor, but of exhaustion, a lot of which overflows on his face as well. I take a look at him. He is barefoot. After explaining to him where to take the blood samples and all other things that we require before admissions, he goes away and I get busy with other patients.

At about 1.30 am the flow of patients has ebbed. The lecturer has taken his rounds of the esr and has gone to operate. The houseman has fallen asleep on a stool (wooden), the exhaustion of 18 straight hours taking a toll. He won't sleep long, the next patient will come up in 10 min. His head fallen back weirdly, he'll surely have a sprain tomorrow morning. Somehow, he isn't falling off the table.

I too think of catching a 5 min power nap. I look around for any place where I can rest my head and where there isn't blood stain or some such infective secretion. My back has already started getting spasms. Or should I just solve a few mcqs? The 3 mcqs that I'll manage in 5 min, may be the decider between me getting a seat or spending one more year preparing. I do not enjoy reservations either, so maybe I should go for the mcqs.

"Sir, uuu bluuud banka se khun ka report aa gaya." My thoughts are broken by the fisherfolk. I look at his blood group and tell him to attach the report in his file.

He smiles back. Even though his smile is laboured, and his teeth stained, it is still full of warmth and friendliness.

"Array suno!" I call out to him.
"Aise hospital me bina chappal ke mat ghoomo. Khoon vagaira neeche gira hua rehta hai. Needle, kaanch bhi niche rehta hai. Pair me lag jaayega. Bimar pad jaaoge."

He just smiled back again.

"Kidhar se aaye ho?" I ask.

He smiles even brighter, the exhaustion suddenly disappearing.

"Virar ke aage Arnala aata hai." 

I remember Arnala. When I was a kid we had once gone to celebrate holi at the Arnala beach. Back in those days it wasn't so famous and a lot of families only used to come there. We would board a train to Virar from Dadar. Then take a shuttle to Arnala and then there would be rickshaws to take us to the beach. About 2 hours fun packed journey.

"Haan. Mallom hai." I reply.

"Udhar Shivaji ka killa hai!"

"Acchha! Ye nahi maloom tha mujhe. Mai to sirf beach pe hi aaya hu."

"Udhar se hi killa pe jaate hai. Wo beach se ferry karke jaate hai. Killa pe jaane ka hai bolo. Le ke jaate hai. Do ferry hota hai din me. Ek sakali jaata hai aur ek sandyakali wapas aata hai."

"Algi baar gaya Arnala tab jata hu kille pe."

"Aaap aao hamare ghar pe. Taja taja macchli pakadte hai hum. Dega aapko."

"Array mai non-veg nahi khata."

"Koi baat naahi. Hamara ghar k bahar choota bagicha bhi hai. Aao tum. Taja shabji deta hai tumko."

"Lekin aapka ghar kaise milega mujhe?"

"Wo kuch nahi. Aake kisko bhi poocho, 'DAAKTUUR' ka ghar kidhar hai. Koi bhi leke aayega. Hamara idhar daaktuur nahi hai. To fir koi bhi bimar padta to mai ich sab ko leke jaata illaz ko. Karke sab log mere ko ich daaktuur bulate."

He grinned again from ear to ear.

It's barely been 4 months since we've passed our final MBBS and taken the Hippocrates oath.

"Do no harm" is supposed to be our motto. But some of my colleagues have brushed it aside already! I too feel sometimes that I should take a few liberties and short cuts as well. Eventually, my future is going to be decided by my score in the exams and not by how well I have behaved with someone or how honestly and meticulously I have done my job.

"We are interns. Nobody's life depends on us." Says one of them as he sometimes (which is now becoming everytime) underfills samples in vials so that he can quickly finish his set of blood collections and rush away to the library. "Even if the lab sends sample inadequate, the houseman will send another sample in the evening to the elab. Nobody's life depends on you."

Now I have an existential dilemma, who is a doctor?
One who's declared that nobody's life depends on him or one who is the only source of hope to sick man on a desolate islet?

Perhaps the latter isn't. He will only be a daaktuur at best.

"Wo mera godhali dekha tumne? Hara tha. Idhar rakh ke gaya tha tabhi. Mil nahi raha. Raat ko soneko laya tha.Leke gaya koi lagata hai. Aise hi sona padega abhi. Dekho tumko milega to. Idhar hi rakhke gaya tha mai. Pccccchhhhhhh......"

Rural Postings for Doctors : Their resistance is illogical and futile.

One of the reasons I voted for the BJP, other than of course the fact that Narendra Modi had caught my imagination (the fact that I used to be a Modi hater from 2002 to 2012 notwithstanding), was the ass-licking appeasement policies of the previous government which I felt were anti-doctors in addition to, of course, being anti national.

My world view has evolved a great deal over the course of my 5 year journey in MBBS. From being a strong supporter of socialism (perhaps that's why I took up medicine in the first place), almost being a borderline communist sympathiser at times, to recently becoming a little right leaning. A part of this transition has been the realisation that the world we live in is not ideal, ideologies falter and collapse when personal benefits come in conflict, and that a logical argument can easily be distorted to shield a particular individual or group of individual's self interests and selfish intensions in the name of larger hardships of community; which, therefore, will always continue to persist and the gaps will always ever widen. Internship, of course, was the turning point, but the process may have begun earlier.

Facebook discussions now-a-days have gone from being one liner, pull your leg-blow my trumpet comments to literally large - Long answer monologues and discourses. This may partly be a sign of our individual maturity or we may probably have learnt to use the platform for appropriate and relevant matters with age.

When the proposal for compulsory rural postings came up last year, the Gymkhana organised a debate. I was a part of the team that was "against". We were supporting not serving poor people, not giving health to the diseased, running away from responsibilities, not repaying the debt of the society. In short, being selfish, immoral and arrogant and defending it too.

But, lecture hall debates end up in lecture halls and have no more importance.

I had a end stage full blown AIDS patient in the ward. Sending his blood work would be a very frightening experience. I am not judging him or chastising him, but just the amount of precautions to be taken and the anxiety of an accidental prick would make it all the more difficult. But, it was managed. Accidents do not happen if one is careful.

Then one day there was someone who looked like a priest by the patient.  I was happy to see him. Nothing consoles a patient more than a reading from a holy scripture when he knows that his time is running out. I was more happy, that his family members had accepted him, knowing full well the social stigma associated with his disease.

As I continued with the blood collections I couldn't help but be astonished by his mutterings.

"Shaitan is ke shareer se nikal jaa. Holy spirit kehta hai iske shareer se nikal jaa!" And these were the only 2 sentences he kept on repeating for all the ten minutes that I was by his bed side. I between the feeble man would try and say "Nikal Jaa!!"

 I felt like telling him, that your CD 4 count is only 24. Is baar to shaitan nahi nikalega, agli baar shaitani mat karna! I don't judge him for an act in his past, but this is and should be unacceptable.

Was it an exorcism being performed in a hospital? I have seen discovery channel documentaries about such things being done, especially in case of rabies, trying to force feed water to a person who had lost the ability to drink. The discomfort then would, logically be extrapolated as resistance by the devil. But, in 2014?

A few years ago I had seen a patient with herpes. He had taken medicine for a week and so would obviously be cured. But his sister took him to some Baba who swept a broom over his vesicles and then when they went away she proclaimed that the Baba had cured him. So much for our Acyclovir!

A man would stand outside the KEM arthritis opd entrance with "Bhallo ka baal and Whale ki haddi". As patients would crawl out with their painful joints he would entice them, dupe them and tie a Bhalloo ka baal around their arm and a Whale ki Haddi around their throat. If only it was that easy, wouldn't all pharma companies market bear hair? All natural and no side effects.

These are instances where they only eat away our credit, at least patients take the treatment. But, there are many other instances where such beliefs prove counter productive especially in psychiatric illnesses. Psychiatric illnesses where time of patient contact is perhaps the most important determinant of successful outcome. People would rather kill their patients doing woo-doo and what not, but never take them to a psychiatrist. And it is not just the poor, but rich (cast, community, creed, colour, gender no bar) more often who engage in such hoolabaloos.

Indians are spiritual. And our spirituality is often misguided, as much as Hitler's nationalism was misguided.

Its been a year since Dr. Dabholkar, an anti superstition activist was murdered. No arrests have been done. More importantly, no anti-superstition law has been passed. Communities take to roads demanding reservations, cities come to a standstill fighting corruption, police commissioners get transferred if a rape occurs in a remote corner of their jurisdiction, but no noise is raised, rather political parties shout down a legislation that would have corrected a very wrong that is routed in the community.

"Matters of belief"  is a very wide based argument, misused often. May be reintroduce Sati, hadn't Britishers interfered with out faith then?

When I hear the argument that every Indian is Hindu, I don't feel like refuting it.Don't they walk with a mouthful of saffron and spit and colour every corner available in shades of orange to red. Perhaps, it's animal instinct, just as dogs can't let go of their affinity for car tyres.

As much as you tell a patient that he has to throw the cotton swab in the red bag, even be polite enough to point it out to them. Yet, you can always see from the corner of your eye that it goes right under their cot. Blood soaked cotton swab, the most fertile medium for the most notorious germs to grow, stocked up under 70 beds in each ward.

We raised points of unavailability of medicines, of poor security conditions (especially for our female colleagues), the fact that resident doctors go on a strike almost 4-5 times in a year because some short tempered relative vents his ire on a treating doctor. Such instances occur in civic hospitals with in-house security cops, the rural scenario is left to one's imagination. We've all had experiences with those guys with running noses demanding 'INJJESHUN'. And last, but not the least, also about bad roads and no ambulances in rural areas. 

The persistent counter from the jury was "So isn't that your responsibility? Will you run away?"

Non-medicos (except medico's parents, spouses, children and immediate kin) have unexceptionally high expectations of social service from medicos. Partly our seniors have been responsible for that. They managed to keep high moral standards when everyone around was faltering. It is expected that the police will not lodge an FIR even if a murder takes place without first taking Gandhiji's blessings. But, doctors have always sacrificed their personal lives for the sake of strangers and made their sufferings their own.

Today, these expectations have sky rocketed to unreal heights perhaps infringing into administrative and executive domains. Thinking that doctors going to the villages will bring medicines and roads is perhaps acknowledging us for more than what we can do. Dr. Dabholkar was a Medical doctor, not a Ph. D. in sociology. Forget his life, did the society stand with him in his death?

This is why I feel, that the medico's resistance to rural postings is illogical. Without the periphrenalia that we require, we will be useless. But, it may not be wrong to look at it as a year long paid vacation in the greenery and heart of nature. We have been living sleep deprived existence since we were 15, perhaps this is our gift at 24!

Its true that our opposition is because we can foresee that this exercise will be futile, that it will breed in more corruption into the field, that sending demotivated cadres will in fact be counter productive, that the nation will eventually loose its cream to the brain drain.

But, when people want only to be beaten by broom sticks, tie Bhaloo ka baal and Whale ki haddi, and look towards us a potential tool to win them elections, so be it.

So guys, just chillax!