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.

Radiology Revelations

A physiologist in the quiet blackness of the night observes how bats navigate in complete darkness.

A Physicist invents a transducer using sound waves to detect ice bergs after the sinking of the Titanic.

A neurologist uses it to detect brain tumours in Russia.

Students in the last bench of a Physics class stare dreamily at the professor talking about the properties of sound waves.

A Philanthropist donates a large sum of money to a Mission hospital.

A teenage girl feels a lump in her breast.

A company produces medical equipment in Japan.

An elderly gentleman visits the anaesthetist to get clearance for his cataract surgery.

A little baby with a very large head and recurrent episodes of vomiting gets admitted to the ICU.

A college going boy is brought to the emergency room with abdominal injury after ramming his car in a drunken haze.

A first time mother 24 weeks pregnant visits an obstetrician.

An unborn baby floats in her womb swallowing amniotic fluid and wiggling its tiny fingers.

An obstetrician palpates her abdomen and writes out an investigation to rule out anomalies.

A recent MBBS graduate starts her first day at a mission hospital.

A radiologist turns to his third ultrasound of the morning.

An ultrasound machine unites them all.

A world of greys and blacks and whites. Of shadows and densities. Of depth and gain. Of flow and colour. Of angles and pressure. A real time wonder of physics.

Its language is completely different, and to describe what one sees therein takes years of practise and reporting. That single transducer, as it makes contact with the abdomen, opens a portal to another world, the unseen, is demystified for us to see in plain sight. A little angulation of the probe, slight variation in pressure as you glide your probe across the slippery jelly, leads you through various cross sections and fleeting glimpses of human anatomy. You can pick up gallstones, ovarian cysts, free fluid in the abdomen, aqueduct stenosis, breast lumps, a calcified valve, and ejection fraction – just a few simple examples of its varied use in the medical field.

But as is the case with all good things, examples of its misuse are also very prevalent. It is shrouded in litigation over prenatal sex diagnosis, with sonologists levying large sums of money to dish out illegal sex determination, greeting the prospective parents with a ‘Jai Mata Di!’ if it’s a girl and a ‘Jai Shri Ram!’ if it’s a boy. I wonder, why that shifts the blame entirely on the sonologist for female foeticide, since the sex ratio in our country has been bad, even after - implementation of the PNDT act and even before – the advent of prenatal sex diagnosis.

In recent months I have seen many antenatal ultrasounds with developing foetuses at different gestations. It fills me with awe and wonder to see little fingers moving, a foetus swallowing amniotic fluid, the circle of willis twinkling colourfully in the Doppler, the four chambered heart thumping energetically, valves flapping open and shut in lively rhythm, the spine from cauda equina to the craniovertebral junction and the continuity of skin along it, developing eye balls, the infantile nasal bone, a little human taking shape and form so rapidly and with such organisation that it puzzles me how anyone thinks all this doesn’t have a creative maker behind it. I realise the great significance of a normal scan when we encounter a baby having anencephaly with everything else in perfect order, when a patient with bleeding per vaginum for the last week is told that she’s had an abortion, or when you don’t hear the foetal heart on auscultation and rush hurriedly to the USG room only to encounter intrauterine fetal demise - an ominously still heart.

The USG is an unsung hero, the little overlooked brother of the more glamourous and imposing CT, MRI (Not that they aren’t mighty useful and fascinating!), very modest and very helpful when in the right hands.

The oft heard dictum which stands true when peeping into the monitor of an ultrasound is this –

‘The eyes cannot see, what the mind does not know’. 

Pre Exam Epiphanies.

Stop. I've decided I need to Stop, Look, and Listen.  It's like all the visual and auditory stimulus I receive is shelved by my mind, blissfully ignored, in much the same manner as the sound of clashing cymbals on a deaf persons ears. Except the deaf person doesn't have a choice and he doesn't consider it blissful. I have the choice; not just to see and forget, but to understand and process, you know? So I did. A little.

Inconsequential things, like why would people on a platform move closer to the train they're meant to catch ,when they know its going to come and stop right in front of them anyway. Why would you deny a beggar money, just because they're not blind or as conventionally unable , yet stuff a 10 rupee, 500 calorie pack of Lays down your throat, a momentary high for your taste buds, which is probably taking you and him closer to your deaths.

Pre-Exam Epiphanies. I'm quite sure there'll be more.

I Study in Med School

What I’m writing about is no different from what most of us have probably realized at some point or the other while having stayed here, in a Medical College. It is not a new, sudden or remarkable realization, different from anything that has ever been thought. Here, is a leaf out of an non-descript medical students life, 9 days after joining and almost 2 years after having joined. 

9^th August 2011: A Bone in the Common Room                         Written by, The NAÏVE First Year

My hostel room consists of a few oddities, a bag of bones, scalpels, forceps, and surgical gloves, all of which I am very proud. As of now the bag of bones is sitting next to me on my bed. I am alone in my room, my roommate is out for dinner, yet the bag of bones is now sitting next to me on my bed. The remains of another human being, are sitting next to me. A human, a person, maybe a father, mother, sister, friend, flesh and bone, ligament, tendon, fascia and periosteum, vascular supply and nerve fibres, once upon a time innervated and gave life to these set of bones. Yet here they are in the hands of a first year medical student, as tools of learning, all 17 of them; fibula, tibia, femur, vertebrae, radius, ulna, humerus etc. I got them on loan for Rs 700. The remaining legacy of a person(s) who once lived, who was conceived and born, who lived and grew, who spoke a language, who had beliefs, for Rs 700.

I received my ‘bones’ in the Dissection Hall today. It’s a long white tiled hall, with metal stretchers arranged across its length. The tube lights are a bit too bright, like you’ve walked into an incandescent, florescent world. There are skeletons hanging in each corner, like morbid watch guards. It’s funny, I thought it was morbid the first day, but that’s also the only thing that’ll be left of me once I’m dead and gone. Maybe I will end up being an unclaimed body which ends up hanging on one of those hinges. Life is so transient. Life, a word I have come to reconsider in the last 2 weeks. A cement washbasin lines the wall, the dull grayish hue of the mosaic pattern, giving it a primal bare aura. Add to the whiteness of the room, our newly bought, well ironed, and spotless lab coats and you realize with a jolt to the gut that you’re in Medical College. Mind you, it’s been way different from what I thought it would be, like discovering the little asterix saying ‘conditions apply’ on a clearance sale poster. And that brings me back to the very ‘odd topic of this discourse, the bone in the common room.

Yesterday I was making maggi with my friend in the common room. It’s this room with a hot plate and a wash basin. Oh, and it has a dustbin. Pretty much. While cooking the maggi I started shuffling the stuff on the counter around, uncooked dal, long expired black pepper powder, used greasy pans and dismal looking rags, I was thinking about how people could be that dirty when I saw it. The bone. The scapula. In the common room. On a basin. Probably long forgotten by a medical student very much like me. Maybe I shouldn’t think it unusual to find a scapula just lying around the place, but I did. And I’m writing this down because when I’m a year into this course and I forget the awe that overtook me every time I thought about where I am and what I’m responsible to accomplish, I would read this.

24^th February 2013: The Babaji                                      Written by, the still NAÏVE Third Year

Talk about getting demoralized. If ever someone needs a check on their bloated egos, they don’t need to go any further than, Clinics. And I mean this not only for the poor student, but also for that ‘patient’ patient (pun intended) whose dignity and pride is slowly bartered off to all of us aspiring ‘doctors’ willing to percuss and prod him. I wonder where all those lofty ideals of ‘treating the patient as though they were your loved ones’ went.

I think my version of today is so very vastly different from what it’s supposed to be. Today I met a babaji, Ajaib Singh in Ward 2. He was a man slight in demeanor, with jolly twinkly eyes and laugh wrinkles on the edges of his eyes, like crinkled up butter paper. He had on an orange turban, a clean crisp off-white kurta and sheet pulled up to his waist. As I approached him I noticed under his bed a series of urine sample bottles and by his side was sitting his wife, knitting and chatting away with great agility at express speed. As I proceeded to get a ‘good’ history and find some of the ‘findings’ which always seem to elude me, he told me about how he’d been a shopkeeper till ‘peshap mein problem ho gaya’… his wife gave me an incessant backup of the details about how life changed after ‘peshap mein problem ho gaya’. I think I spent close to 40 minutes chatting with them completely forgetting to go and present my case, and therein lay the problem. Needless to say, I stuttered and stammered through the whole ordeal once I did get back to class, and received mirth-filled looks from the rest of my class mates, for the show had begun.

Now if I’d done things the way I was supposed to have, my day would’ve consisted of having worked up a patient, Ajaib Singh, male, 60 years old from Ludhiana who was apparently well till 5 days ago when he came to OPD with complaints of frequent and painful urination. End of story- teacher happy, student happy and patient? Well, who really cares right?

Note: Although the incidents may seem unrelated, and well, not that big a deal, slowly, ever so slowly, our consciences are getting blunted out and shaped. At the end of the day, it’s still in each of our hands to decide what shape that’s going to be.