An open letter to the Honourable High Court

To,

The Honourable Chief Justice Manjula Chellur and Justice G.S Kulkarni.

 

Respected Sir/Madam,

I am writing in response to the statement issued by the division bench of the High Court that heard the PIL filed by one Afaq Mandaviya and chaired by yourselves.

It was observed that doctors were behaving like factory workers, must show more compassion towards patients, should resign if they demand better security for themselves and shouldn’t feel threatened as senior doctors are working while the junior doctors are on strike.

I’ll start out with a story of a patient who started haemorrhaging (bleeding profusely, in case you don’t understand what haemorrhaging means) in the ICU on Sunday evening, the day the junior resident doctors chose to go on a ‘mass leave’.

The patient was operated for a distal cholangio-carcinoma (a cancer of the common bile duct, the tube that connects the liver to the intestines) 18 days ago. The surgery usually takes around 8-16 hours, depending on the complexity of the case. The junior resident who scrubbed in for the surgery was handed the sole task of retraction, akin to the job of a bailiff in the court. He didn’t see much while the surgery was going on, didn’t learn much, but still stood on his feet for the entire duration of the surgery, while his seniors scrubbed in and out of the case. Just like the bailiff in the court stands guard as judges keep changing through the day.

Precisely 18 days later, on the fateful Sunday evening, I received a call saying the same patient was bleeding profusely and had lost close to 1 litre of blood (the body circulates around 3-5 litres of blood, just for your reference), from the same resident who was scrubbed in for the case initially. He was on duty on a Sunday, and I’m certain would be unable to tell you the last time he took a Sunday off.

By the time I had arrived (45 minutes later due to traffic, most of which was heading towards Phoenix Mills, comprising of those who had worked hard all week and were enjoying their weekend), the patient was on a trolley, intubated (a tube in the wind pipe to ensure she breathes well), with one of my residents holding a blood bag while it was being transfused, the other wheeling the trolley (as the Class IV employee whose job it was to do so, hadn’t reported on time), and a third resident from another unit holding a mop over the bleeding site to control it.

We rushed the trolley to the emergency OR, where I realised that the residents had called for a ‘mass leave’ to protest violence against the doctors. The residents changed into OR clothes and scrubbed into the case with me. Not only the two residents from my unit, but also the third resident from the other unit. They were well within their rights to shun the case. To go on ‘mass leave’ just like their colleagues. But without them, I would be like the judge without the bailiff. I knew how to operate the patient, but I wouldn’t be able to navigate the system with the minimal possible delay.

We operated the patient, stopped the bleeding and shifted her to the ICU. All three waited for the entire duration of the surgery, shifted the patient to the ICU and ensured that she was stable and conscious. Every residents had gone on ‘mass leave’ in the late afternoon, these three only went on leave, later that night after ensuring that we saved the patient from exsanguinating. This done by junior residents, who have been compared to Class IV workers (factory workers) who perform their duties to the minimal level expected and shun overtime work if they aren’t compensated for the same. So much for compassion and dispensing duties.

Senior doctors, you say, don’t feel threatened while continuing work, when the junior doctors have gone on ‘mass leave’. This is based more on your whimsical notions than on facts. Ask any senior doctor the reason for not joining the ‘mass leave’ movement, and your notions will be dispelled. Every doctor, whether senior or junior, working in the emergency department, in private hospitals, nursing homes etc. fears that he will someday be thrashed by relatives of a patient who couldn’t make it. The only reason that senior doctors haven’t joined strike is to ensure emergency services remain unaffected, as also the fear of ESMA being used against them, being permanent employees of the Municipal Corporation, as opposed to the resident doctors who are temporary employees.

You tell us that doctors don’t need security, and that if they do need security they must live 100 metres from the hospital, and let those who aren’t scared, dispense their duties. How do you explain 53 assaults on doctors without a single conviction. If you have the (pardon my language) balls to convict and imprison these individuals who assault doctors, instead of passing ludicrous and biased observations, attacks on doctors might actually decrease in number. Why have a bailiff in the court, why have policemen guarding the premises, if you are confident that you discharge all your duties honourably?

Lastly, we Indians have a pathological problem of neglecting the root cause and escalating the matter on hand. The matter on hand is serious, no doubt, but the root of the problem lies in the lack of infrastructure, and a defined referral pathway among government hospitals, amongst others. Would the doctor in Dhule be assaulted if there was a neurosurgeon available at the facility? Would he have been assaulted had there been a defined referral pathway from Dhule Civil Hospital to a nearby one that had a neurosurgeon available.

I request yourselves and the Honourable High Court to review your observations and be compassionate towards the poor resident doctors, who form the backbone of the public health system. Condemn the ‘mass leave’ if you must, but, ensure that the grievances are heard. Ensure that security is provided, that residents are not over-worked and under-paid. Doctors need this assurance and compassion, failing which, the profession will see a sharp decline in numbers.

 

Your sincerely,

A disgruntled doctor not on strike out of fear and not choice.

 

An occupational hazard

Lyla hustled her way across the crowded corridors from the male to the female surgical ward to draw blood from the patients, a part of her everyday job as an intern. Interns are unanimously exploited, forming the bottom rung of the ubiquitous hierarchy in the medical profession. Not only are they answerable to professors and associate professors, but also the resident surgeons, who are just one step above them in the hierarchal ladder.

Blood draws, filling in forms, shifting patients from one end of the hospital to the other, scrubbing in, but only to retract tissues to clear the surgeons field, were just some of the measly jobs entrusted to them. However unimportant their work seemed, it was still critical in the broader scheme of things.

Lyla, unlike her compatriots, willingly performed her duties.During a twenty four hour emergency duty on a fateful Monday, Lyla was just going about her business, until a spate of trauma cases trickled in through the narrow door leading to the spacious emergency surgical services. There were patients with broken jaws, bleeding foreheads, fractured legs and the like. All these patients had been part of a four car pile-up on a the expressway connecting two neighbouring cities, aptly referred to as the death bed for motorists.

Three of the resident doctors were scrubbed in to operate on patients inside the operating complex. The two resident doctors who remained outside, were the junior most resident doctors, who seemed overwhelmed with the situation.

Lyla, who was edging towards the end of her three month rotation in the surgical services, picked up the mantle to stabilise the injured patients. Having mastered the art of triaging patients, she waltzed around the emergency surgical services ward with the acumen of a seasoned clinician. Tending to the unconscious patients, placing a cervical collar, checking their parameters, placing a venous catheter to resuscitate them, and calling in the radiology resident to perform a screening ultrasound to rule out any abdominal injuries. After ensuring that none of these patients had a falling blood pressure or a rising pulse, she moved on to the more conscious patients with fractures. Using a cardboard and strings available by default in the ward, she immobilised their fractures and prescribed other investigations.

The radiology resident had arrived by this time and confirmed that one of those patients had fractured ribs and a collapsed lung with air having accumulated in the chest cavity and the other one had some fluid in the abdomen (indicative of a severe injury that had caused one of the abdominal organs to rupture). The others were cleared to get their CT scan’s done.

Lyla immediately organised an intercostal drainage kit for the patient with the fractured ribs and collapsed lung and informed the residents who were scrubbed in. Patient 2 with the abdominal trauma was shifted to the operating room under the care of the senior residents and patient 1 was positioned for the placement of a tube into his chest cavity to drain the accumulated air.

Junior resident 1 placed the chest tube and junior resident 2 rushed to the operating room. Lyla’s colleague, overwhelmed and under slept, took on the measly job of shifting the unconscious patients for the CT scan, having realised Lyla’s presence in the emergency ward in these desperate times was mandatory.

At last, an exhausted Lyla proceeded to the patients with the least serious injuries, the last of which was a wound over the forehead, requiring four to five sutures to stop the bleeding. The first suture was placed uneventfully, then the second and the third. Lyla was accustomed to this, having entered the final week of her three month stint. Her experience and skills allowed her to suture in a preposterously inconvenient position. The patient lay down on a bench and Lyla bent over in a most un-ergonomic manner. She was surrounded by other patients and caretakers of those patients, but was just too exhausted to ask them to leave.

While placing the fourth and what seemed to be the final suture, she received an inadvertent shove in the back from one of the other patients. She lost control over her instruments and the needle that had pierced one end of the laceration (a wound that requires suturing) pierced one finger of her other hand. Her glove tore and blood trickled down the sides of her finger.

Lyla halted, her bookish knowledge suddenly surfaced from a part of her cerebral cortex. “Wash the wound in running water with soap, and rush to the nearest ART centre.”

She did exactly that. Washed her finger with soap and water, sent a blood sample from the patient to rule out any infectious diseases spread via blood (HIV, Hepatitis B and C) and asked her seniors for permission to go to the ART centre in the hospital.

The anti-retroviral therapy given to exposed patients within 72 hours of exposure is meant to prevent these patients from contracting the infection.

The patients blood sample was positive for HIV. Notwithstanding the low incidence of contracting the infection (0.3%) from a needle prick, Lyla was shattered. She knew she had had a deeper prick. She knew that her chances of contracting the infection were higher. She started her course of prophylactic anti-retroviral therapy (drugs effective against HIV) and pinned her hopes on a false positive result.

The confirmatory results on the patients sample came in a week later. The patient indeed harboured the virus and Lyla would have to continue the drugs for 28 days and bear with the intense nausea, bloating, belching and burning sensation the drugs caused in her tummy. She wouldn’t know whether or not she was infected till at least 3-6 months later.

Lyla didn’t lose hope. She continued her internship as planned. 6 months remained and she wouldn’t let a stray incident affect her.

She went through her OB-GYN postings learning how to deliver babies and suture cuts made to the birth canal in the process, learnt new techniques to secure intravenous access in the paediatric age groups, assisted neonatal resuscitations and managed out-patient departments successfully in the rural outposts.

6 months hence, Lyla had moved on. She had put the incident behind her, deciding against approaching the ART centre to repeat her blood test.

A week before her convocation, Lyla was approached by the ART centre. They wanted to test her for the virus. Lyla was skeptical initially, but acceded eventually. Her samples were collected and Lyla was to be informed only after absolute confirmation.

On the day of her convocation ceremony, after receiving her doctorate, Lyla was summoned to the ART centre. The chief called her into the cabin.

“Lyla, the reports just came in today.” Lyla’s gaze was fixed downwards. She had an inkling, but she needed to know.

“You have tested positive.” Lyla maintained her poise.

“This isn’t the end, Lyla. You know that we can start you on ART and keep you on regular follow-up. You can still practice medicine and lead a life that may be as normal as most around you. Just be careful when it comes to………………..”

Lyla had zoned out. The bookish knowledge re-surfaced. She faced a normal life with a regular career pathway. But the books didn’t take into consideration her emotional state. She didn’t smoke, was a teetotaller, had never even tried drugs, was a virgin, never had a medical or surgical illness, and lived a regular healthy life. Yet, here she was, infected with a deadly virus, known to affect those who had been transfused with blood or those that lived their life on a edge.

She sat through the counselling session, exchanged pleasantries, promised to follow up and take care of herself.

Lyla was the unfortunate intern, amongst the thousands of fortunate interns and residents who come in contact with blood and other body fluids in dangerous circumstances every single day.

In spite of being utterly cautious, in every sphere, the odd mistake or mishap does occur. In other occupations, one pays with financial instability, loss of a job or at worse loss of limbs or injuries to body parts. Healthcare workers, however, face the daunting occupational hazard of illnesses, both physical and mental. Safety for oneself must take priority over everything else. Only then can healthcare workers adequately care for and nurture their patients back to health.

Lyla sailed into obscurity, daunted by the long and winding road she faced ahead.

 

An Incurable Disease?

pancreas-and-kidneys

Surender wasn’t the typical patient suffering from cancer. A healthy north Indian male with a voracious appetite and a waist circumference substantiating it, he depicted no signs and symptoms of the ‘crab’ growing inside his pancreas. His only complaint was an unbearable desire to itch.

Physical examination revealed a deep yellowing of his eyes. This coupled with the unbearable itch convinced us to admit him to the wards, to investigate the cause further. Not only were his eyes yellow, but his skin also wore a golden tinge, the color of pusillanimity and inadvertent cowardice. The culprit being that tumor, inconspicuously growing in the seat of the endocrine system (a system which produces and distributes hormones to the body), the pancreas, an organ hidden away in the upper abdominal cavity behind the stomach and intestines, beneath the liver and in close proximity to the spleen. So complex is the location of this organ, that any surgical therapy requires removal of not only the tumor mass, but even parts of the intestines, the stomach and the tract carrying juices from the liver to the intestines (billiary tract).

So abysmal is the survival rate amongst patients with such a tumor, that some ‘humane’ surgeons even go to the extent of leaving patients to their fate. The aggressive nature of the tumor coupled with an equally bellicose surgery reduces the chances of survival.

Falling amongst the healthier cohort of cancer patients, Surender demonstrated a strong resolve to take on the challenge. His work-up for surgery was effortless, and within a week Surender lay on the operating table in the OR.

“Doctor, come what may, please do not prolong my misery if things don’t go well. But leave no stone unturned to make things go well,” Surender told us just before he went ‘under’ (a colloquially used term amongst anesthetists to describe a patient who has been anesthetized)

The surgery commenced as the clock in the OR struck ten. Bit by bit, the insignificant organs were reflected carefully so as to reach the organ of interest. So deep and conspicuous is the pancreas, that exposing the organ alone takes up a significant amount of time during surgery.

The duodenum (part of the intestines running from the stomach to the small bowel) was mobilized around the pancreas and cut out right from the stomach to the upper part of the small intestines, the bile duct entering the pancreas from the liver was dissected and cut open and finally the pancreas was transected, removing the culprit.This was the easy part. Cutting things out took little skill and precision, the real challenge lay ahead. The small bowel was meticulously juxtaposed against the stomach, the cut end of the bile duct and the cut end of the pancreas.

Using all the skill garnered over the uncompromising years training as a surgeon, the lead surgeon skillfully sewed the small bowel to the cut ends to maintain continuity in the digestive system.

Notwithstanding the skill required and the mammoth proportion of this surgery, the survival rates after surgery were also abysmal. But, human beings are hopeful creatures. They repose faith in even the remotest of chances working out for them.

Surender woke up to the sound of his wife reciting the Gita as she ensconced herself onto a  small chair that lay beside his ICU bed. The recovery was quick and painless.

Surender bid adieu to us ten days after surgery.

2 weeks after an uneventful and unforeseen recovery, Surender reported to us again, complaining of a foul smelling discharge from the operative wound. Concerned and anxious, we whisked him off to the radiology suite and performed a plethora of imaging tests. None were conclusive. Baffled at this idiosyncratic development, he was admitted to the wards once again to monitor his progress.

Copious amounts of discharge warranted us to innovate a different method of dressing to prevent his clothes from soiling. The wound was surrounded by an adhesive paste sprinkled with granules of activated charcoal, with a bag placed over the adhesive to collect the fluid. The bag drained the fluid and the charcoal adsorbed the gases responsible for the foul smell.

Four weeks passed by and the amount of discharge hadn’t decreased. It was by then established that a tract had formed from the pancreas to the skin and the pancreatic juices found an alternate escape route. However, our team wasn’t convinced.

On a whim, a week later, the senior resident decided to open up the wound to explore the problem further.

“The smell,” he said, “isn’t that of pancreatic juices.”

Relying solely on his keen sense of smell, we took the patient into the operating room again. The wound, which had mostly healed by now at all places barring the discharging portion, was injected with a local anesthetic and incised.

A horrific smell engulfed the operating room, strong enough to weaken even the strong hearted. There lay the culprit. The fat in the subcutaneous space had liquified and formed a roundish structure, no larger than the size of a fist. Pus emanated from the structure and was well contained by the thick walls formed around it. This surprised us. The initial CAT scans didn’t reveal the abscess, and it continued to grow in size.

For every major surgery, surgeons always expect major complications, sometimes ignoring the smallest ones. Look no deeper, if you haven’t looked superficially.

There was an immediate improvement. Surender was sanitized of all the bacteria breeding in his wound and was soon discharged to go home. The real challenge was his subsequent survival. Such patients usually survived for no longer than a year post surgery.

Chemotherapy was given to Surender, as a part of his treatment course, taking care of not only the tumor site, but also the small fragments that tried to enter the bloodstream and seed themselves elsewhere.

6 months later, Surender was actually gaining weight and showed no signs of spread of the tumor to other parts of the body. He was eating well, exercised daily and even went for long trips to the Himalayas.

“I feel better now than I have ever felt,” Surender said.

We still warned him that a sudden deterioration would not be wholly unexpected. Surender brushed us off, saying, “If I live with the fear of dying everyday, I will not live life the way I should. Don’t worry doc, I still have plenty of time.”

His optimism was encouraging, but we all knew that the end would come. Sooner rather than later. What were the odds of him beating the odds!

Surender went incognito after that day. It was assumed that the worst had befallen him. That the disease won the battle. Cancer had once again reigned supreme and brought a premature end to a jolly good life.

Our myth was shattered three years later when Surender re-emerged. He had taken a trip to his hometown and went on to reside there uneventfully for the three years that we hadn’t seen him. It didn’t seem like a tumor had once swallowed a part of his pancreas. That he had undergone a surgery so mutilating and challenging, that people often succumbed to complications arising from surgery before cancer stepped in.

A momentous occasion to celebrate survival of a patient with a tumor in the pancreas, a tumor so indolent and debilitating that sufferers actually welcomed death when it came to their doorstep.

When the going gets tough… (III)

The night before Jeenal was to follow up with the unit head, she presented to the casualty with weakness and pain in her belly. She had been running a fever throughout the day and felt uneasy and giddy. Her mother called the unit head, who advised her to come over to the hospital as soon as possible.

Before she could reach the emergency surgical ward, Jeenal had collapsed. She was unconscious, her fever now transmogrified into an eerie coldness, a sure shot sign of a drop in blood pressure. Her pulse rate had slowed down and acquired a feeble quality. Sweat had started dripping off her brows and forehead, a cold sweat, one that made every attending doctor nervous.

Jeenal took laborious breaths, and with every passing moment, it became obvious that she required artificial ventilation.

Even though the on-call unit wasn’t the same as the one that had treated Jeenal, they still knew how special this patient was.

Jeenals blood pressure was unrecordable, her heart rate had slowed down dangerously, and she had become incapable of breathing independently. The ABCD approach (A-airway, B-breathing, C-circulation, D-differential diagnosis or disability assessment) mandated an endotracheal tube to be placed in-situ (a tube that entered the airway through the mouth and provided air directly to the respiratory tract), followed by artificial ventilation with an AMBU (ambulatory mobile breathing unit), and eventually the placement of an access line into the neck veins, in order to infuse fluids and drugs to maintain the circulatory system.

 

After initial stabilization, Jeenal was shifted to the SICU (surgical intensive care unit) and placed on ventilatory support.

She was in a state of septic shock, a condition wherein the infecting organisms released proteins into the circulation to activate various immune defense mechanisms, which when over activated, can cause more harm than good.

It was strongly suspected that the anastomosis performed during surgery had given way. The sutures that held the tissues together had fallen apart and caused all the organisms within the gut to spill out into the abdominal cavity. The only option left for Jeenal was another surgery.

The sutures had indeed given way, as could be seen during surgery and her entire abdominal cavity was filled with the toxic substance, bile, an agent so corrosive that it could cause even the skin to break down when applied over it.

A through washout of the abdominal cavity was performed along with a restructuring of the failed anastomoses. Even though the procedure had been performed fairly quickly, Jeenal continued to remain unresponsive and passive.

 

I saw Jeenal in the SICU the following morning. Her hair had been oiled and tied back, her eyes were padded with moist gauze to prevent excoriations on the exposed parts, a tube stuck out of her mouth and connected to a large machine which beeped constantly, the ventilator.

The smile that adorned her face, when she was leaving to go home, lingered on in my memory. But, all I could see now, were a pair of dried lips with crusts on them. Her face was expressionless, and her hands tied to the railings along the side to prevent her from pulling out the tubes, but it seemed unnecessary. This was the one time that I hoped for one of her tantrums or an angry outbursts, but none was forthcoming.

Her mother came and hugged me. She was inconsolable. She cursed their poor luck and herself, for giving in to Jeenals demand to go home earlier than the doctors would’ve liked.

I spent the day moving in and out of the SICU, running personal errands for Jeenals family and hanging around to support them.

Jeenal life support system was the only thing that kept her going. There were four infusion pumps, six stands to hold the intravenous fluids and drugs and a colossal ventilator that surrounded her. Above her lay the pulse oximeter and electrocardiographic monitor sending out multiple channels which lay haphazardly over her chest.

At 9:40 pm that evening, two days after Jeenal had turned twenty, her heart, which was being flogged like a tired horse, gave up. The monitors showed us a flat line and she had stopped breathing. Dr. P and I were both present there at the time, and tried everything we could to revive her. But it was all in vain.

Jeenal had passed away.

Her mother and brother were heartbroken and Dr. P was gallant enough to offer them support.

A terrible gloom fell over the unit and the surgical wards after Jeenal passed away. Such was her presence, such was her power to liven up a conversation, such was her grit, to go through it all before she even turned twenty.

 

Could we blame her luck, her stubborn nature, the surgeons expertise (which was never in doubt), or just fate!

A surgeons knife is a powerful tool. Not only can it heal and cure, but it can also complicate and kill. The cure rates are always higher than the rate of complications. But, that single complication can prove to be fatal.

 

Some patients just disappear after treatment and are forgotten, some valiantly escape death and immortalize themselves in the hospital folklore, but a minority group of patients continue to linger on in your memory even years after they move on.

They aren’t the strongest, bravest and haven’t necessarily escaped death. These patients may have given you a terrible time whilst under your care, but they’re the ones who stand up and truly take it in their stride, when the going gets tough!

 

(The End)

When the going gets tough… (II)

A month later:

The head of unit made a quiet exit as soon as the out-patients queue receded. The residents were entertaining some medical representatives from the pharmaceutical industry, a task that they had to endure, no matter how much they disliked it.

Patients and their relatives were being herded out of the out-patient department like cattle in a farm. Thats how patients were treated in government hospitals, unfortunately. They were literally the ‘cattle class’, a term colloquially used for travelers in the economy class of airlines. Whereas the airline travelers had the means to pay for an airline ticket, the class of people in the government hospitals were truly penurious.

Whilst the commotion occurred outside, we sat within our chambers, entertaining information about drugs from these representatives. In the midst of it entered a frail girl, looking middle aged, with a hunched back and a solemn look. She walked in alone with a hand over her belly and a natural fish-face, owing to the loss of her buccal fat (fat over the cheeks). Her hair was shaggy and her eyes sunken in. She took a seat in the chamber and waited. Puzzled, Dr. P and I immediately left our seats to tend to her.

Just a few minutes later, her mother and brother entered our chamber. It was Jeenal. A month had passed by, and Jeenal hadn’t followed up. We presumed she was feeding well and wouldn’t need the follow ups. However, that was clearly not the case.

Unrecognizable from her past form, Jeenal had stopped feeding from the jejunostomy tube. On prodding her, we realized that the tube had been blocked since a week and she hadn’t bothered to come in. Jeenal had been starving for an entire week and ignored it.

Without giving it a second thought, we immediately admitted her to the ward. Unblocking the tube was an easy task, but making up for the malnourishment due stoppage of feeds was the biggest challenge. Overload her with nutrients and she wouldn’t tolerate it, underload her, and we risked causing further malnutrition.

To control her nutrient intake, we started Jeenal on parenteral nutritional supplementation (injection of nutrients through the veins, directly into the vascular system). The feeds through the jejunostomy tube were started simultaneously.

Our worry lines increased, and all of us in the unit put in extra hours to ensure Jeenal’s nutritional status would improve.

Two weeks later, Jeenal had gained sufficient weight to allay all our fears. Her jejunostomy tube was functioning well and the parenteral nutrition had ceased. It was time to discharge Jeenal again. However, this discharge came with a promise to follow up weekly.

Jeenal followed up diligently over the course of the next four months. A month before Jeenal was to undergo a definitive procedure, I moved to another unit in the same ward.

 

————————————————————-

 

I saw Jeenal in the ward, on the day before she was to undergo a definitive surgery. Her esophageal (food pipe) scars had healed, leaving behind a scarring of the outlet pathway of the stomach. She would be subjected to a commonly performed procedure, gastro-jejunostomy, wherein a part of her small intestine would be connected to her stomach, to bypass the narrowing at the outlet of the stomach due to scar formation.

Jeenal seemed happy and calm. There was a palpable excitement in her voice, when I mentioned that she would finally be able to eat through her mouth.

Jeenal’s mother had gone to the Gurudwara (temple) to pray for her well being. Her brother was alongside her, holding a polythene bag housing all the surgical materials (that wasn’t available at the hospital), required for the forthcoming procedure. Dr. P, who by now had been relieved of all his duties, to prepare for the forthcoming exams, strolled in at the same time.

“Jeenal!” he exclaimed. “Everything’s going to be alright. Boss is an excellent surgeon and he’s planned everything in detail.”

Jeenal smiled. Her brother clutched her hand, whilst holding on to the same polythene bag.

Dr. P politely enquired about the contents of the polythene bag, glanced at the prescription for the surgery and winced.

“How could anyone prescribe all this material worth thousands of rupees to this family? Haven’t they spent enough on her treatment already,” Dr. P mumbled to me in an tone that was inaudible to Jeenal and her brother.

 

Dr. P promptly called the chief resident to make arrangements for the surgical material. Jeenals brother was instructed to return all the material and retrieve the money that had been spent.

Jeenal was moved to tears. She’d repeatedly mentioned to us of the financial burden facing her family, due to her illness. Dr. P had the maturity to understand the sacrifice of her family and waive off the charge of surgical materials.

“I hope the both of you will be in the operating room while I’m being operated upon. I trust you two the most!” Jeenal pleaded.

Unfortunately, neither of us could be in the operating room while she was being operated. However, we did step into the ward to wish her luck, just prior to her being taken into the OT for surgery.

Jeenal had become a part of Dr. P’s and my residency. The three of them were our family in that hospital, a place where every doctor is treated in a ruthless and relentless manner. Jeenal and her family understood our travails and helped us out at every step along the way, while she was in the hospital. Be it carrying our instruments around while we rounded patients, or packing some food for us, when we were on emergency duty, with a seemingly never ending ingress of patients.

 

Jeenal was operated upon, laparoscopically (minimally invasive), as she was concerned about the scars that it would leave behind on her abdomen.

A fugacious stay in the Surgical Intensive Care Unit (SICU), was followed by a transfer to the general ward.

The clishmaclaver of the ward patients, a point of annoyance in the past, suddenly felt like music to her ears.

Two days after surgery, all the invasive tubes had been removed and Jeenal was walking around the ward and even sipped on water. The eudemonic pleasure of taking something (read:anything) orally was unparalleled.

Jeenal insisted on a discharge before her birthday, which happened to fall on the sixth post-operative day. However, on the fifth day post-surgery, Jeenal developed a fever, albeit a mild one. One that disappeared after its first appearance, flattering to deceive.

Inspite of the fever she had developed, Jeenal insisted on going home the next day, to celebrate her birthday. The crest of her tantrums forced everyone in the unit to bow down to her demands, and Jeenal was discharged on the sixth day post-surgery, without a hint of fever, albeit reluctantly. She was strictly instructed to follow up 2 days after discharge, in the ward, with the unit head.

The morning of her discharge, Jeenal had dressed up and ordered cake. She cut the cake in the presence of the nurses, her mother, Dr. P and myself. Her brother had planned an elaborate birthday party for her at home.

Jeenal’s gambol knew no bounds. This was her happiest moment since that fatal day seven months ago, when she’d ingested the corrosive poison.

She waved at us as she left the ward. But, something told me that this wasn’t the last time we’d see her as a patient!

 

(to be continued…)

When the going gets tough… (I)

The out-patient department was busy as ever. The senior resident (Dr. P) was seeing patients by the dozen, his hands were constantly moving and so was his mouth. His pen left the warmth of his hand only at such times as would be absolutely essential. This was a daily occurrence for the doctors at the bustling government hospital, which managed far more patients on a daily basis, than it was  equipped to handle.

Wiggling his way past the scores of patients, a ward boy from the medicine ward managed to find his way into the chamber of the senior resident. I happened to be sitting alongside, observing, helping and occasionally writing down a few prescriptions. Seated firmly in his grip, so that it couldn’t fall while navigating the mad rush, was a book, no bigger than the size of his palm, but as thick as the vintage spectacle frame that adorned his face. This book was unkempt, looked ugly and showed off signs of wear and tear.

Inscribed, on one of the worn out, discolored pages of the book was a statement.

To,

The Surgical Registrar on call,

Kindly call over to assess patient Jeenal, a 23 year old female with a history of accidental corrosive acid ingestion. The patient has undergone endoscopy and the gastroenterologists have advised a surgical reference.

It isn’t everyday that one got to manage a case of corrosive acid poisoning.  There was a spark in Dr. P’s eyes. Without even giving it another thought, he wrote back,

Kindly transfer the patient to Ward 8 by 6 pm today. A bed will be made available accordingly.

The archaic world of exchanging written notes, to call doctors over for a reference, still prevails in government hospitals. The Internet of things finds it almost impossible to percolate into these settings.

 

I met Jeenal for the first time on my evening rounds. A pretty girl with a charming smile, it didn’t seem like she belonged there. She sat silently, cross-legged on the bed, alone. A naso-jejunal tube (a tube that was placed through her nose and passed through the stomach into the intestines) was stitched onto her nose, and, as if that wasn’t enough, an unaesthetic adhesive tape reinforced its position there.

It was evident that the tube bothered her. She fiddled around with it and tried to conceal it from everyones view, albeit unsuccessfully. She was noticeably uncomfortable around the patients in the ward and looked unsettled. As I went around the ward surveying the patients admitted under our care, Jeenal called out to me,

“Doctor, are you in charge here?”

“Yes”

“Good. Please come here and remove this menace from my nose. It hurts me and I look so damn ugly.” She spoke impeccable english, which was surprising for patients seeking healthcare in the government setup.

I walked over and took a look at her file.

A h/o (history of) corrosive acid poisoning (accidental). Endoscopy has been performed and revealed mucosal injury to the esophagus and parts of the stomach. Naso-jejunal tube has been placed during endoscopy to provide nutrition.

Strictly, NPO (nil per orally, i.e nothing to be taken orally)

There was no way I could remove that tube from her nose, even though I empathized with her, having undergone a naso-gastric intubation myself at some point in my life.

“Sorry Jeenal, I will not be able to remove this tube. Its very important that it stays in, so that you can take some food through it. The acid that you ingested has scarred your food pipe and stomach.”

That was all I could offer her at that time, being the junior most resident in the unit.

She was visibly miffed and turned her face away, ignoring my presence and failing to acknowledge the ensuing questions. As if on cue, her caretakers walked in just then.

A mother and a brother, were her only family in the city. They were as jocular, as Jeenal was gloomy. They offered to answer my questions, even offered me a seat (which was very unusual) and at the end of the history taking and examination, struck a conversation with me completely unrelated to work.

The accidental ingestion of the acid was dubious and uncertain. No one had seen her drinking the acid. Her version was that it looked like a soft drink. There was no reason to disbelieve her.

Other than a very recent development. As we spoke, her brother volunteered that she had been involved in an affair gone bad, recently. It was possible that there was some intent behind her action.

 

Jeenal was all of 19. She threw tantrums, had mood swings and even craved for chocolate, just like any other 19 year old girl. Her friends had been given strict instructions not to visit her, as she wouldn’t want to be the butt of all jokes. Especially, after an insensitive friend labelled her as an anorexic version of Lord Ganesha (due to the naso-jejunal tube that extended outwards from her nose, à la the elephant trunk of Ganesha).

The aiguille of her tantrums occurred on the unit head’s rounds a few days later, when she pulled the tube out of her nose. Dr. P and I were flabbergasted, expecting a barrage of angry comments from the unit head.

Instead, he allowed her to play the role of a thespian to perfection. He had a plan in mind.

When he reached her, she was crying, her nose had a reddish hue in lieu of spilled blood and her mother was trying to restrain her. Dr. P and I immediately rushed over to take care of the bleeding and calm her down.

“Leave her alone,” the unit head said.

“Jeenal, we shan’t put that thing in your nose again. But, we need to feed you to keep you healthy. How about we perform a small surgery to put the tube directly into your intestines (a feeding jejunostomy).

You can easily conceal the tube then. In time we shall discharge you and call you back once you’re ready for the final surgery.”

A faint smile engulfed her face. The liberty of living life on her own terms outside the hospital was enticing. Details were explained and a plan was drawn out to operate on her a couple of days later.

The decision to operate eased the pressure on us. While she still remained demanding and continued throwing her tantrums, she showed us what she was like in reality.

Dr. P and I spent a chunk of our time on rounds with Jeenal and her mother. Her brother showed up too, but sparingly, as he was working, to bear the expenses of treatment.

Jeenal and her mother felt comforted in our presence, and we in turn learnt something new about Jeenal everyday. She was a singer, a dancer, and an excellent student, who had to give up her pursuit of higher education after her fathers death, to care for her mother and younger brother.

The transformation, after the tube had been removed from her nose, was astounding. We saw a self confident girl, who was ready to fight everything that came her way.

The time before her surgery, established our relationship not only as a doctor-patient, but as friends.

Jeenal was eventually operated upon, a tube was placed in her intestines and test feeds were started the same evening. She insisted on my presence in the operating room, even though I was instructed by the unit head to be elsewhere.

As always, she got her way. And in the process, also happened to be the patient on whom I performed my first feeding jejunostomy surgery.

 

But, this wasn’t the last surgery Jeenal had to endure. The poison had eaten up a part of her stomach, which needed surgery too. But, that had to wait for the healing process to take its natural course.

6 more agonizing months awaited Jeenal, wherein, she wouldn’t take a single morsel of food through her mouth..

 

 

Painfully yours (5)

15 years later: 

My dearest Geet,

I write to you to tell you how wonderful our marriage has been. It has been a privilege to be your husband, your support and your problem-solver.

It doesn’t feel like 18 years have passed by, since I underwent the surgery and suffered from pain as a result of the surgery. I remember conversing with you, till the early hours of the morning, and telling you about my travails. At that time, never had I experienced your silence in a conversation. But you stayed silent, listened to everything, and broke down with me.

You’ve been nothing but supportive ever since. I didn’t need anyone to tell me what was wrong or how I could fix it. I needed you to be there and tell me that it was alright to crib and cry about my problems, as long as I would at least attempt to heal them.

You have been the biggest support, both in sickness and in health. You took care of me at my worst and have consequently seen me at my best. Life and health have been kind to me for the biggest part of the last 15 years.

However, and unfortunately, the chronic pain has come back to haunt me. It has been lingering on since the past 5 years. I ignored the symptoms, initially, as it was bearable. It has now progressed to a form that is no longer tolerable. I haven’t told you about it, as I didn’t want you to worry about me. I have been on a cocktail on medications. My pain specialist even asked me to try marijuana again, to help myself get through it.

The pain that I experienced years ago pales in comparison to this pain. Its constant, nagging and feels like a pin is poking me all over my thigh and back, all the time. I have seen all the doctors, the old ones as well as the newer ones. The solution is elusive, if at all possible.

A miracle is my only hope, and we both know that its unlikely to occur. Some doctors say it is a reactivation of that latent infection that my spine and vertebral column suffered in the first place, some say it is a cry of the dying nerves, and still others say it is completely psychological. To the last group, I say ‘to hell with you’ll’

There is nothing even remotely psychological about this pain. I feel it, I endure it, and I try to forget about it. But to no avail. If only, I knew how to overcome this barrier.

I write this letter to re-iterate my feelings for you, and to tell you that I wouldn’t do this if I wasn’t in pain. I have cherished our life together and enjoyed every moment. But I can’t carry on any longer.

Some will say I’m being a coward, some will sympathize with my plight. I do not care about them. I do care about you and I don’t want you to hate me for doing this.

My reasons are simple. I have lived a long and fulfilling life thus far. I have dispensed most of my duties towards my family and have secured their future.

But, what about my duty towards you? 

Would you like to see me living a crippled life, whining and crying in pain all the time! If I carry on, my misery will not be limited to me, but rub onto you as well. We will not be as happy as we have been thus far.

This quandary has been plaguing me for the past few months. But, I have realized, the time has come. I wonder how people suffering from such chronic pain manage to lead their lives in such misery for prolonged periods of time. A big salute to them.

I am not one of them. I am a part of the other group of sufferers, who end their lives before their condition disrupts their family and engenders hatred amongst their loved ones.

I am extremely apologetic for doing this without consulting with you, but, have faith in my judgement. Even after I leave the worldly creations, a part of me will always live on inside of you.


Painfully yours,

Samar.

P.S.- I will always love you.


[This is the concluding part in a series of 5 blog posts that follow Samar’s journey in dealing with his chronically acute pain.
Chronic pain is one of the leading causes of depression and anxiety, eventually causing the sufferers to contemplate or attempt to commit suicide. This series is dedicated to all those suffering from chronic pain.]