Phases of Junior doctoring - Part 1

‘How’s bond going?’ asked a senior of mine.

‘Pretty good, I’m busy, learning and doing lots of things!’ I replied, as I launched into an exhaustive list of all the things I was getting confident in doing day by day.

‘That’s great!’ he answered. ‘But what happens when you know everything? Will you still feel as eager when you’ve learnt what there is to learn, or when this time next year all your classmates are preparing hard for NEET and you’re still doing the same things? The newness of it might wear off… How has this experience changed you?’

I was stumped. What will I do when the newness wears off? I was already beginning to feel it, and this conversation made me think about the past 6 months. Was I any different from when I started? Was I supposed to be? As any good product of the system would answer this question, I have set out to categorize the various phases of Junior Doctoring I’ve gone through. Sometimes Dr Jekyll and at other times, Mr Hyde!

Phase 1 - The Enthusiastic Learner.

We all start this way, young, idealistic, fresh from college, raring to go, and new to everything. The enthusiastic learner is awed by everything from a baby sucking it’s thumb on ultrasound, to the neat squaring of a suture knot, to the remarkable slipperiness of amniotic fluid covered gloves when delivering a baby (what if I drop it?!) This learner is not scared of asking questions or making mistakes and says yes to everything. She even claims to enjoy the mess food, seldom complains, always agrees to play with the campus kids, calls the consultant for everything from a common cold to ‘Ma’am, do you have a broom?’, desaturates when the patient is gasping, hyperventilates in the presence of tachycardia and sleeps with one eye open during on calls for fear of sleeping through them, but sleeps through them anyway.

Dear Enthusiastic learner, please don’t lose your sense of wonder.

Phase 2 - The Dizzy Learner.

It has been one month and the learner you met earlier is in the thick of things slowly but surely taking on more responsibility. Skin one day, Rectus the next, Uterus, Baby out. She has gotten a sense of the routine, and figured out alternate paths to avoid the onslaught of the kids after a long day at work. She is busy and has no time to do her laundry, call her mum or look at the pretty blue skies, smell the flowers or admire the red litchis – it’s okay! I’m learning. But one day while in the operation theatre, she feels dizzy and has to step out and sit down. ‘Darn this sign of weakness!’ she scolds herself. It happens again, and again, till she starts dreading the embarrassment of stepping out each time and prays as she scrubs – no fainting this time. It still happens. Advise pours in – ‘don’t be scared of blood!’, ‘it’s postural hypotension’, ‘get more sleep’, ‘arey, just wiggle your toes!’ Many deep breaths, toe wiggling sessions, prayers and dizzy OT exits later, it stops, just as suddenly as it started.

Dear Dizzy Learner, when you feel like giving up, reconsider. And, always, ALWAYS stop to admire the sky.

Phase 3 - The Late-comer.

The learner is getting tired and is faced with the same tasks over and over again. The learner has also figured out ways of accumulating ‘loose change’ sleep and her friend procrastination has come to visit. Together, they are persistently late. They are running against time, stumbling into rounds, moving around bleary eyed and staying up when they should be asleep. For example right now, she should be asleep.
Dear Late-comer, please don’t tell me you’re here to stay!

And in keeping with my promise to be up on time tomorrow morning (It’s Monday after all!) I will introduce you to ‘The Unmarried-Loner’, ‘The OPD Monster’, ‘The Weight Gainer’ and ‘The Jack of all Trades’ tomorrow.

Signing off,

The Junior Doctor.

A fatal kiss

Our small two bedded casualty was full to capacity, on one bed a pregnant lady in labour pains twisted fitfully surrounded by concerned relatives as sisters  while a curtain separated her from a middle aged  as lady who’d received an electric shock and lay comparatively still while her ECG was done. The moniter bleeped confident rhythmic heart rates and displayed reassuring oxygen saturations. I surveyed the scene with some satisfaction - investigations were underway, plans for treatment had been made, relatives spoken to. Now I could return to a busy OPD and all the waiting patients there.

The moment I sat down to see the next patient, Sister ran up to me, ‘Ma’am, snake bite aaya hai!’, I asked with trepidation, ‘Ptosis hai?’ to which she replied, ‘Haan ma’am, hai toh!’ The next half an hour played out like a dramatic episode in what could be called an Indian version of the popular American medical saga Grays Anatomy (minus McDreamy). She was brought in to casualty with each arm draped loosely around the shoulders of two men who were struggling to support the dead weight of a person who is fast losing consciousness. Her bindi was askew to one corner of her forehead, and her sweaty face caked with what appeared to be and smelt like, a combination of atta and chuna (lime stone powder) most probably smeared by a ‘faith healer’. She had on a bright stripped orange cotton saree with a parrot green blouse, against which her heaving chest was straining as she gasped for breath. But by far the most striking thing about her appearance was the ominous manner in which her eyelids were half closed, and her swollen upper lip.

I told her to open her eyes, but no matter how hard she tried she couldn’t – this is ptosis (a small but characteristically alarming sign). I tapped her on the shoulder and asked her what happened – the syllables came out slurred, and her tongue kept falling back as she tried hard to swallow back spit. But she couldn’t. She was quickly laid on a trolley for lack of room and hooked to the moniter which bleeped uncertainly as her saturation dropped – 95… 90… 87… 82… 79% she was slowly going to stop breathing on her own. She was rushed to the ICU, cannulised, and given Anti Snake Venom along with antihistamines to prevent a reaction. We breathed a sigh of relief as that was done and prepared to intubate and put her on the ventilator. Even as I gazed at her I saw her slowly blowing up like a red balloon, and I’m not exaggerating one bit. Her lips, eyelids and cheeks were puffy and rashes erupted across her arms and legs. It took me a minute to realize she had developed a reaction to ASV. I was boggled by the irony of it, but there was no option but to continue the ASV and deal with the reaction. Once more there was a scramble for adrenaline and rapid intubation.

Once intubated and stabilized, I had a chance to speak with the relatives. A snake had bitten her on her upper lip (which is why it was swollen) in her sleep at 12pm last night, and she had only been brought to us about 10 hours after the bite. Why did it take so long? I asked. A chorus of answers erupted, ‘We took her to johla chaap (village doctor)!’, ‘…Jhadphook ke liye le gaye the madam (we took her to the witch doctor)’, ‘sarkari aspataal mein bhi gaye (and to the government hospital as well)’. When I asked them for some receipt or prescription they produced a small pitiful piece of paper with an assortment of drugs listed including antibiotics, steroids and every variety of IV fluid. Clearly they’d been swindled of their money and better sense.

In a community which is so steeped in superstition it is extremely hard for us to expect an immediate trust in hospitals which offer ‘angrezi ilaaj (western treatment)’. There are many barriers, cultural, social, religious and definitely financial which need to be overcome in order for such patients to reach us. And by then it’s often too late. Most often it is the poorest of the poor who get bitten by poisonous snakes, either while tilling their maize or rice fields, or while going into the forest to relieve themselves as most villages lack toilets. Yet they can’t afford to get bitten by a snake. The antidote alone costs anywhere from Rs 600-1000 a vial, and we give 10 vials – Rs 6000-10000 for Anti venom alone! Not to mention the cost of transport, ICU admission, moniters, oxygen, ventilation. In which land is this a fair plight? To me it seems like a cruel joke that to those who need it the most, care is not accessible or affordable.

The picture above is from one of the times a patient decided to bring us the culprit himself to see if it was poisonous or not!

India's 'Everywoman'

More than a decade ago I read an article of the same title in the Hindu Newspaper. I was a little girl then and an avid collector of interesting articles. I would cut out things from the newspaper and stick them in my scrapbook; everything from Harry Potter trivia to Calvin and Hobbes cartoons. This particular article spoke about an old widow who’d worked as a domestic help all her life laying alone in a hospital bed. ‘She did not how old she was,’ it said. This was very hard for my young mind to comprehend, it was almost silly to me – how could one not know when they were born? How could one not know their age?! How on earth would you celebrate your birthday? How would you know how many candles to stick on a birthday cake? Where did such ladies live? Did the maid at my home also not know her age? I decided that this lady needed my prayers and instead of sticking the article in my scrap book I folded it and slipped it in my Bible. Someday if when I met such ladies I would try to help them. And with that I tucked her away in one corner of my mind.

I’ve passed through years of school and college since then. Recently I started working at a rural hospital and I meet her often these days.

On Monday I met, Ruby Devi.

 ‘Aap ki umar kya hai?’
‘Yahin kuch bis, pachees.’
‘Kitne bacche?’
‘Teen ladki.

 She had three girl children. She had gotten married at the age of fourteen and had her first child about seven years after that and that child is now 12 years old. She claimed she was 20/25 years old, and yet she looked like she was at least 35.

‘I hadn’t even started getting my period when I got married,’ she giggled, tugging the edge of her sari pallu across her face and nervously chewing on the edge as I not-so-subtly gawked in surprise. ‘You see I’m one of six sisters and two brothers, my mother had no choice but to marry me off. My father died when I was twelve and I was just a liability.’

On Tuesday I met, Jhuniya.

She was pregnant for the eighth time. She fit the textbook description of bad obstetric history, having had six recurrent abortions in the first three to four months of each pregnancy. Only her first baby had made it to full term – ironically, a girl, who is now 7 years old. Five of these aborted babies had been boys, and every aborted boy had been a blow to the family. Each year she conceived and each year she aborted. She lived in one room with her mother in law, brother in law and his wife, who had already borne three boys making her the jewel of the family. Along the way she had visited several pandits, witch doctors, expensive private clinics, contracted Hepatitis B and received numerous blood tranfusions on account of anemia. Finally she came to us. We told her that we would put a stitch at opening of her uterus to prevent the baby from aborting, we warned her it may or may not work, but it’s the best we could do. A few weeks later, she came to us frantic, ‘I can’t feel the baby moving!’ Fearing the worst, we did a scan to find that this time too, the foetus has not made it. She lashed out in anger and then she broke down and cried. A tiny gold nose ring adorned her tear streaked face, with two mis-matched earrings. The chain around her neck held six lockets with a little child depicted on each to keep away the bad luck of the children she had lost. Her hair was in disarray and her eyes pleaded to hear a different diagnosis. Through her sobs she said her husband was going to leave her if she didn’t produce a boy child. ‘He’s already chosen another bride for himself.’ On her left stood her little 7 year old, ignored. And on her right, her sister in law with her boys, a constant reminder of what she failed to achieve.

On Wednesday I met Bina Devi.

She arrived at 2am, in labour, her belly was funnily shaped with two symmetrical bumps as though a heart. On per vaginal examination where I had expected to feel the comfort of a solid foetal skull, I felt something soft and squishy pulsating against my finger, surely not – the cord! Although not very well versed in obstetrics my sleep hazed mind was jerked awake as it shouted – CORD PROLAPSE PREETI! In simple words, it’s the mother of all obstetric emergencies, most babies don’t survive it – it’s like slowly but surely tightening a noose. We rushed her to OT, and prepared for an emergency Caesarean. We separated the rectus muscle (popularly known as abs) and were looking straight at a very weird uterus. It was heart shaped, with two horns instead of one. ‘It’s uterus bicornuous unicollis,’ said Bina ma’am calmly. And visions of my first year anatomy class came flying back, as she asked, ‘Remember the paramesonephric ducts?’ It struck me as odd that I should be surprised at encountering a uterine anomaly in a lady from a village, as though deviation from normal anatomy is something that happens only in embryology textbooks. Her baby did not survive, but she did. She recovered phenomenally well, was very thankful for it and to this day does not understand why I felt the need to repeated explain to her that, ‘Aapke bachadani ka aakar alag hai.’ (The shape of your uterus is different.)

On Thursday, Baby of Laxmi was born.

This was Laxmi’s third pregnancy, she had two girls previously, both by Caesarean section. This was the third and last time she would be able to carry a child, because further pregnancy in someone who has undergone so many Caesareans is dangerous. The third baby was born at 4am, a healthy pink cute baby girl. Her face fell when we showed her. At 6am we got called by the sister in ward, ‘Ma’am, Laxmi’s baby is turning blue and is not able to breathe.’ Her mother had tried to smother her to death, and had been caught just in time. The baby was rushed to the Neonatal ICU, given Oxygen, resuscitated and slowly regained colour. Her small chest was heaving, she was breathing too fast, and there was a slight depression on her chest when it had been pressed. For days she hung by a thread like this, while I tried desperately to figure out what kind of pressures could push a mother to take such an extreme measures in a moment of weakness. The parents agreed to put her up for adoption. Baby of Laxmi stayed with us a long time, she got better, started feeding and breathing alright. She became an instant favourite with all the hospital staff. A real fighter, just like her mother, who returned a week later to take her home, determined to provide her a safe future.

 On Friday I met, Nilam Devi.

Referred from the government hospital, she was pregnant, past the nine months, and her baby had been dead for the past 2 days. She startled easily every time we came close to examine or speak to her. Her husband didn’t know what to do. He stood with his hands splayed open facing the ceiling and just asked us to do something, anything. He had been all the way to Patna to get a scan worth Rs 4000 to determine the sex of the baby. They had told them it was a boy, elated to have a boy at last they returned to Madhepura. When it was past her due date, she was taken to a government hospital where she was administered Oxytocin to initiate pains; when that didn’t help, four-five nurses pushed down on her pregnant belly to force the baby out (the infamous ‘fundal’). After all this pushing and pulling, the baby ceased to move and with the baby jammed in her pelvis she was sent to us. She hadn’t passed urine in 2 days as it was obstructed labour. She delivered a still born baby boy weighing 4 kilos. She was dehydrated, exhausted and mentally traumatised by the experience. She got better after a few weeks of hospital stay and she returns often, just to chat.

On Saturday, I met Sukhmayar.

It was dramatic, it was scary, it was such a shame. She had been in labour for 2 days, the pains had once more been induced with Oxytocin artificially. She’d gotten many scans and investigations done in the past, but had not been able to deliver the baby. Somewhere during that time the baby had died, and she had started bleeding profusely. As I moved my hand to touch her abdomen she screamed even before I got within a few centimeters of her. Ultrasound showed a ruptured uterus, and a baby with a very larger than normal head full of fluid. I snatched back the scans they’d shown, read and re-read them. Not one scan mentioned the fact that the baby had an anomalous head - that it was too big to deliver normally. Not one of those scans was signed by doctor. Each said boldly, ‘Not valid for medicolegal purposes.’ It was a crime, murder in broad daylight, to not detect so obvious and significant a finding. She was taken up for surgery, and stayed many days in the ICU. She left early and never came back for follow up.

On Sunday, I’m off duty and I sit around scrolling down my Facebook newsfeed, to see what everyone else has been up to. It tells me loudly about what a celebrity wore on the red carpet at Cannes, or who the next feminist face of India is, or that we are progressing by leaps and bounds. Yes, urban India is changing, but what of the other rural 70% that knows, cares and profits nothing of this ‘progress’?

This is the original Hindu Article from which the title is derived.

Falling sick

What sort of people go to hospitals? 

Sick people. 

But what happens if the hospital falls sick?

I was confronted with this unfathomable concept a few months back. Two of our consultant specialists had to leave our hospital due to unignorably urgent needs back home. Suddenly there was a murmur going around the hospital and everyone from the sweeper to the staff where talking about it in hushed tones. Our hospital was going to become a ‘sick unit’ they said, ‘Salary time se nahi milega! Patients ka load decrease ho jayega!’ And from the way it was talked about, it was awful thing to be. I had never heard of this terminology before, but then again I hadn’t been working in a mission hospital for very long. 

I turned to a few sources to ask them what in their opinion a sick unit was. Google baba went first and said, ‘Sick (industrial) unit is defined as a unit or a company which is found at the end of the financial year to have incurred accumulated losses equal to or exceeding its net worth.’ I spoke to a few seniors - some say it is a term essentially describing the financial status of the hospital – ‘Used to refer to a hospital which is not doing well financially, usually in debt.’ Others said, and I quote, ‘I believe it is the state of the people in the unit rather than the infrastructure or finances or human resources of the unit. If the people in the unit are ‘alive’ the by-products like infrastructure and finance cannot be far behind.’ 

A lot our patients believe in ‘tatkal ilaaj (treatment for the time being)’ and we seem to have taken to the concept quite happily ourselves. Our current medical practise is very happy to treat symptomatically. Very happy to put some micropore on the tap but not fix the leak in the tank. Very happy to prune the hedge but not water the roots. Very happy to treat the X-ray or the raised counts but not look for the cause, take a detailed history and dig out the pathology. 

When filling out a death report there is always a direct cause, something acute which led to the person’s death. However, there is always an underlying cause, something vague and long standing that we refuse to make the effort to hammer out and treat. Because as we all know such causes take time, effort, consistency and some amount of hit and trial to figure out. The same analogy can be extended to hospitals which are considered sick. Maybe something acute (consultants leaving) may lead to death (shutting down a hospital) but what is the underlying morbidity? 

This brings up two questions, both of which I have very inadequate answers for. Firstly, Why does this happen? And secondly what do we do about it?

Is it enough just to have doctors fill an empty OPD chair every two years? Is it enough to ensure than there is someone manning emergency every night? Is it enough to downscale and lay low till things get better? When does one make the decision to pull the plug? Or do we keep running on ventilatory support and inotropes? 

During student years we hear of how one person started a one man clinic and turned it slowly into a hundred or two hundred bedded hospital. How the dedication of a few, changed the lives of many. We place these people on a pedestal and expect to find such powerhouses fuelling missions in India. Then we actually start working and get a close look at the real challenges Christian missions in India faces today. For how long can lone people charge and run a hospital? For how long and indefinitely can a few people surrender all, while others watch? In the end we find ourselves inadequate, inept and unwilling even to consider that the same could come of our efforts. 

Someone asked me a very apt question recently, what is the purpose of what you are doing? It took me a while to form a coherent thought on that. Why is that? Are we just working without a specific end or goal or vision? Or have we along the way, lost sight of it? 

What determines the ‘health’ of a hospital? Is the number of surgeries we do? Is the number of beds we have? The doctor to patient ratio? The amount of money we make? Is being able to pay salaries on time? Is it having more modern equipment? Or, is the happiness of the people who work there? Is it the impact we have on the community? Is it the transformation we see in our own hearts and lives? Is it kinder doctors, nurses and staff who live together with a common goal?

In the end I have many questions, and very few answers.