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’. 

Life in Madhepura Christian Hospital– A JMO's Point of View

‘I want a career in which I never have to sit at a desk for too long, or stare at a computer for days on end, a job where no two days are the same. I want to be useful!’ 

These were the big ambitious wishes of the young teenage me. It’s been a few years since then and my wishes have been more than fulfilled through my placement at Madhepura Christian Hospital.

When I first arrived at the airport, I was greeted by Manju bhaiya, a very happy man, who is the face of Madhepura Christian Hospital to all newcomers to the hospital. As we got closer to Madhepura the road got bumpier and the weather got cooler. Instead of seeing plump turban wearing uncles and the yellow mustard fields of Punjab, I now saw pineapple fields, paan chewing bhaiyas and the vast fertile land of Bihar with its flowing rivers and greenery. Our campus is a small haven in midst of the cramped town of Madhepura – with a collection of different fruit trees (Litchies, Mangoes, Chikus, Mulberries et al), full-fledged organic farming and nature study, spear headed by Arpita ma’am doctor/mother/homeschooler/organic farmer and her three home schooled kids in tow.

A typical day here leaves me breathless! We kick start the day with devotion, followed by General ward, ICU and NICU rounds, quickly completing discharges and rushing to OPD where patients are already waiting to see you and the cards begin piling up.

OPD consists of an USG room and two airy rooms with plenty of sunlight. The area where the doctors sit is separated by a curtain from the area where the patients wait – expectant mothers, crying babies, old and wrinkled grandpas and concerned relatives. It is a bustling hub of activity – the nurses screening patients, taking vitals, giving directions, ‘Char number – Billing! Aath number – Dawayi! Satra number – Lab!’

On the other side, Dr Timothy (our SAO and radiologist) hustles in and out, going back and forth, doing USGs, handling office work and overseeing construction. Everyday in OPD, USG probe in hand, he opens my eyes to the wonders of the developing fetus, physics, radiology and life, with a sprinkle of PG entrance MCQs and well timed jokes. What was once a blur of greys, whites and jargon now makes perfect sense thanks to him enabling me to learn how to do USGs. As a senior one would expect him to be strict and up tight, he on the other hand, is approachable and humble – no where else have I seen the JMO and MS alternating calls.

Dr Ilango, our Anesthesist sees medicine and paediatrics, patiently explaining and listening to what troubles the patients. The ICU where bleeping alarms of falling saturation often rattle my nerves, he once coolly sauntered in and asked me to intubate a patient absolutely unruffled by the cacophony that surrounds him or my feeble protest of, ‘But I’ve never done it!’

Dr Pradeep, a Paediatric Surgeon works part time at Madhepura Christian hospital and the rest teaching at government hospitals in Bihar. The days he’s here are packed with surgeries. From something as small as an Incision and drainage or cutdown to Hydrocoele repairs, Hypospadias repair, Hernioplastys, Laparotomies, Cholecystectomies and even a Hemiglossectomy – he takes equal effort to explain them all. With his kind smile and gentle touch he soon wins the trust of his patients.

Dr Bina, our Gynaec-ALL-ologist, is always multitasking - busy seeing Antenatal patients, and pretty much every other kind of patient as well. And here lies the remarkable speciality of working here – you get to see everything!

As the sole JMO in this 35 bedded hospital every on call night provides an opportunity to see and manage cases from all specialities – Ob-gynae, Paediatrics, Surgery, Medicine, Derm, Psychiatry, ENT, Community health. I have learnt more in the last two months than I ever did in my 5.5 years of college. MCH is small, but makes a significant contribution towards mending lives in the state of Bihar.
In the midst of the hullabaloo of OPD, we have patients coming into the Emergency Room adjoining OPD. Some are dramatic - Snake bites, Organophosphorus poisonings, Eclampsia, Ruptured Uteruses, Severe Anemia, Dehydration and Malnutrition, mothers in second stage of labour – in which case we drop all and rush to OT/ICU, some unique and others relatively docile – Common cold (the treatment of which is really an art!)

On an average we have 2-3 Caesarean sections a day, and a busy labour room – all managed single handedly by Dr Bina and the team of nurses headed by Sister Ancy. From never having done a PV on my first day here, to doing independent C-sections two months after, my learning curve has shot up steeply thanks to her patient instruction and excellent example. On many a busy nights we’ve groggily made our way back from OT after our third CS of the night, bleary eyed and low on sleep, but the next morning however tired she is, she’ll greet you with a twinkle in her eye, a pat on the back, her easy smile and yummy dosas for breakfast.

Some days are free, some insanely busy, some days I worry about how I don’t get time to study for PG, some days I realise I’m learning things that form the basis of my practise, some days patients fight, some days they walk out hale and hearty, some days are lonely, some days filled with the company of really wonderful people. This brings me to the sprightly youngsters of MCH – An animated troop of seven campus kids who make sure you never have a dull moment. From climbing trees, playing with guinea pigs, running behind chickens and reading story books to making me jump on the trampoline (‘Because it’s good for your lymphatic circulation, Preeti didi!’) they add colour to life.

I have learnt that in a mission hospital there is nothing that is ‘not your job’, there is no job description, you learn to juggle multiple roles and manage your time (or at least you try to!)

I have learnt that well trained nurses are the backbone, the hands, the feet, the circulatory system (or whatever simile you’d like to use) of an effective mission hospital.

I have learnt that if you keep an open mind there is something valuable to be learnt from everyone, the sweeper, the staff, the OT technician, the patients, the relative, the doctors and the nurses. You learn integrity, dedication, hard work, humility, compassion and you see a side of India which we often choose to ignore. For how long can we ignore the elephant in the room?

It is impossible not to be downcast at some of the things we see, to not get angry at the injustice meted out to those who can’t fight for themselves, but this is the stuff of reality. In working here I truly feel useful in my small way, and I am glad I’m able to be of service to the one who looks after the greater scheme of things. When one hears of Bihar it always brings to mind images of derelict women and children, extreme poverty and illiteracy. Clearly, the harvest is plenty, but the workers are very few.

They called her Devi

She walked gingerly into the emergency room, her eyes looked tired, her saree was old and worn out, the once vibrant colours now tattered at the edges. She was pregnant with her third child – her tummy looking disproportionately large as compared to her tiny malnourished frame. She was white as a sheet, holding her hands to her back and clearly in labour pain. She smelt musty, a mixture of sweat, blood and neglect met my nostrils as I reached out to examine her. She was burning with a fever, and when I asked her what was wrong unable to answer she turned to her husband. He too was a tiny man, his big eyes shown with hopelessness as he spread his calloused hands and proceeded to explain what had happened. She was pregnant with her third child, the first one had been delivered by Caesarean section only 4 years ago, the next one was a normal delivery at home, and this was her third. She had been to a few ‘doctors’ before us where multiple unsterile per vaginal examinations had been performed and the last one had indiscriminately administered Oxytocin to induce labour. When the labour did not progress they referred her to a higher center. She had been bleeding for a few days, her urine was blood tinged, her pulse was racing, her blood pressure was unrecordable, and even after giving her fluids was dangerously low. She had ceased to feel her child moving for the last 2 days and on doing an ultrasound we found that her baby was dead.

Her haemoglobin was very low, her white cell counts very high, her fever never seemed to subside, they had no relatives to donate blood, and no money to pay for the surgery she most urgently needed. In the operation theatre, on opening her abdomen we found that her uterus had ruptured from the pressure of contracting against resistance for days, the torn ends were sealed by a huge clots of blood, the anatomy was hard to make out, her baby was lying in one corner of the abdomen, a perfectly healthy baby which would’ve had a 100% chance of thriving had the Caesarean been done electively before the pain started. Lower down we saw the bulb of the urinary catheter sticking out through a huge rent in the wall of the bladder, it had also burst. This explained why her urine was blood tinged. The bladder and uterus were repaired and her abdomen closed. She was stable, for now.

Over and over, we tried to measure her blood pressure, at the most optimistic of times the reading was still very low. In the ICU her condition worsened, and still no blood. Her husband sat next to her bed on a little wooden stool staring at the moniter beeping loudly, and the alarms going off as her vitals destabilized. She lay on the bed with multiple supports going through veins which we had struggled to cannulise before the surgery and as I stood there looking at the moniter I felt the sinking feeling that she wouldn’t make it. I thought back to the time before the surgery when we had shifted her to the operation table and tried to distract her from the pain of the IV cannula pricking her. I remember asking her why she didn’t go to a hospital earlier, and she just laughed and said, ‘Humko kya pata’ (How was I to know?). She had laughed completely oblivious to the fact that those would be her last words. Like she rightly said, how was she to know? Even when she did go to a so-called doctor, she was given grossly faulty treatment all in the name of ‘normal delivery’. ‘Do no harm’ a dictum from the Hippocratic oath, isn’t said without good reason. She died that night, without resistance, without a fight. A result of incorrect medical treatment. When the very people you trust to fix you are so grossly out of line, who does one turn to?

I checked her pupils – dilated and fixed. No pulse, no heart rate, no breath sounds. A fresh JMO, I went over the motions of confirming her death once, twice and a third time, and turned to tell her husband. He shook his head and thanked me for all our efforts. He explained that he was a daily wage worker, he and his wife were both orphans with no close relatives to support them. ‘I wish I’d known what to do,’ he said, and with that he left.

Her name was Phekni Devi, doomed from the day she was born, her very name shows us that. Phek meaning thrown away. Abandoned. Unwanted. A fate a large number of girl children in rural India meet. Devi, referring to a goddess. A surname every woman adopts once she is married. In a country which worships female goddesses like Kali, Sita, Laxmi while mourns the birth of every girl child, it seems to me, like the worst kind of hypocrisy and the cruellest contradiction, for nothing could be farther than the truth. When I stepped out of the ICU I heard devotional songs blaring through the loudspeakers all over our little town of Madhepura.

Ironically, Bihar was celebrating Saraswati puja.