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.
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?”
“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..