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.