Are You 'Kid'ding me?

When I was born, my grandfather apparently told the family that this beautiful doe eyed child would make a fine doctor. Ever since I was 10, I wanted to be a doctor – logic or no logic. It never occurred to me that there was unchartered territory out there yet to be explored. And wanting to be a baby doctor caught my fancy early in life quite naturally influenced by my own paediatrician who I considered the modern day Midas.

There are some people out there who enter medicine unsure of how life is going to carry them forward and there are a few others who know exactly what they want to be when they grow up. For me, it was always Paediatrics. My heart did cheat on me by wandering to other specialities every now and then though. But 5.5 years later, I am back to square one – aspiring to be a paediatrician as always.

My college boasts of one of the finest Paediatrics department in the state. Every professor is better than the other. So it wasn’t surprising to see really rare textbook cases, first-hand.

I vividly remember an incident from 3^rd year of med school that I’d like to share. It was a bright Monday morning and everything about the day right from the sunrise to the breakfast was pretty perfect. I happened to take the history and examined a 10 year old girl diagnosed with type 1 diabetes with suspected Wilson’s disease. I spoke to her for a while, got chummy, and made her write out stuff in my notebook. 3 days later when I was walking in the wards, I felt someone nudging me softly. I turned around and saw this little girl, breathless, who had come running to tell me that she was getting discharged and going back home. She shook hands with me and gave me the most genuine smile I had seen in the longest time possible. I went back home, with my heart ready to burst. Such overwhelming joy!

Doctors are supposedly vaccinated against the constant emotional brunt that comes with disease and suffering. Yet, I haven’t met even a single paediatrician who doesn’t get involved with his patients and carry the burden of suffering themselves. Children are truly the hands by which we take hold of heaven.

I was so fortunate to rotate in the Neonatal Intensive Care Unit (NICU) for a month during my internship. My job was to counsel new mothers about feeding, contraception, keeping the baby warm and administering timely vaccinations for the babies. I realised that new mothers are some of the most receptive people we can ever find and for good reason. While some mothers had to be demonstrated the art of breast feeding, some others had to be coaxed into visiting their babies with cleft lips and dysmorphic features. The babies were all sick and needed constant attention and feeding. The work hours were killing but so very satisfying to go back to bed knowing that you had held a baby and tried your best for him/her.  

When I sit back and close my eyes, I distinctly hear the paroxysms of cough that a 1 year old child with pertussis had, a disease almost unheard of in the 21^st century; I hear the rumbling noise of a machine like murmur (heart sounds due to turbulent blood flow) in a 12 year old boy with a congenital condition called patent ductus arteriosus, which should have ideally been treated more than a decade ago in him; I see the rashes of Henoch Schonlein Purpura  on the thighs of a 9 year old girl; I stare into the puffy eyes and face of 2 year old Sahana (name changed) who cannot even comprehend that she is ill, leave alone having a renal condition called nephrotic syndrome; I remember the beautiful face of Mrs Geetha Parashuram’s (name changed) 10 day old baby who won my heart, the little baby girl who kept having myoclonus like jerks and went back home undiagnosed after a month because nothing we gave her made her any better and all the investigations they could afford came back clean.

We succeed sometimes and we fail sometimes. But children always push us to try the very best for them and in turn, ourselves. I am living my dream of becoming a doctor. I now begin my journey, in chase of another dream and hungry for more adventure.

THE BEGINNING OF THE END

My routine for the last few days has mainly involved rounding in the ward, saying hello to all the patients in my ward, checking blood pressures, changing dressings, cracking some flimsy jokes and trying to advise everyone regarding diet and general lifestyle. Being in orthopaedic surgery (as a good friend insists on calling) my contribution is very passive.

2 weeks back, we had a patient in our ward who was simultaneously diagnosed with depression. His main complaint more than pain was the lack of attention towards him by the nursing staff. We don’t do 5.5 years of med school to turn a deaf ear on such issues. We aren’t just taught to tackle diseases, we are trained to try and be super heroes. All I had to do was really assure him that he will be well in no time and we will take good care of him. In the sick room, ten cents’ worth human understanding equals ten dollars’ worth of medical science. A week after he was discharged, he came for a follow up visit to the OP. He came straight to me and thanked me for making him alright and wisely said that more than a doctor’s treatment, it’s the assurance that could truly make a difference, in both our lives. Hearing that from a person who is 3 times my age really made my day.

What really got me writing today is a small observation made in the wards today. As usual, I was going about my work. Surgical patients are generally retained in the wards for a longer period than medical patients. The bond patients foster with their treating personnel and co-sufferers is something purely amazing. They defy boundaries of all sorts – economic, religious and personal; and become united in suffering. What I wonder though, is if this is a rural attitude and would be wrong to extrapolate to the urban crowd.  One lady asked me about my background, my family and seemed to be in awe of me and everything I had to say and did. It is a feeling that can never be put to words. They look forward to my visits every day and the feeling is mutual, I am starting to believe. 

I am haughty enough to say that I wouldn’t miss anything about this place. As I walked the orthopaedics wards today, I knew what I would miss –Smiles in the face of adversity; the warmth, love and respect each and every patient and their attendant gave me in the last few days of my life as a junior doctor.

A STITCH IN TIME...

My mother has always had this inexplicable fascination for surgeons and their art of healing with a scalpel. So it is not surprising that I often found myself being a victim of her constant banter about what an amazing life I could lead as a surgeon, and she in turn, as the immensely proud mother of a young surgeon. But it never pushed me to like surgery more than I already did.

I vividly remember the very first surgery I observed. I was in my second year of med school. I had never seen the insides of an OR prior to that. I knew much less about the OR dress code and discipline. But that did not dent my enthusiasm even in the slightest of ways. Dressed in bottle green scrubs, we entered the OR bare foot.

It was a little intimidating at first, even though we were merely observors. In front of us, lay a 45 year old lady who was about to lose something that defined her very essence. She was scheduled for a right sided modified radical mastectomy, having been diagnosed with breast carcinoma. The psychological trauma of having her breast cut off, would probably leave her more scarred for life.

With all due respect, my unit chief was a very ordinary surgeon albeit with a fierce temper that could probably kill the patient before cancer could consume her. He began the procedure with an elliptical incision beginning on the inside of the breast. I had never seen so much blood all my life. Blood stained hands, scrubs, floors. It was mortifying. They kept suctioning all the blood and it still wouldn’t stop oozing out. I secretly thought she would bleed to death. The stench of the cautery slowly but mercilessly eating its way through the human tissue was dizzying and wasn’t helping. The surgery trudged on for what seemed like forever but lasted a good 2 hours. At the end of it, she was surely short of one breast, but the cancer? We were not sure. We could only wait and watch. And hope!

As I entered my surgical rotation for the second time in my final year of med school, I had taken a liking for it which rather surprised me. My unit chief was not just an extraordinary surgeon, he was also an extraordinary man. Watching him resect a gangrenous bowel and anastomosing it in the middle of the night was probably one of the best experiences of my lifetime. (Yes, just being a witness to it.) Its easy to fall hopelessly in love with surgery if you ever saw him playing around with vicryl and a needle holder. Deft and precise, he was everything a budding surgeon hoped to ever be. Being bold as a surgeon is the greatest gift that can be bestowed upon one. And he was gifted. In more than one way.   

Internship was an altogether different experience. I learnt slowly, but effectively (hopefully!!) basic surgical skills and techniques. I got plenty of opportunities to learn and practice with minimal adverse consequences.

Yet, the event that changed my mind about surgery came after I finished all my surgical rotations. It was during my brief stint in Anaesthesia. I was posted in the plastic surgery OT. A 55 year old man was posted for creation of an Arteriovenous fistula. He was diagnosed with diabetic nephropathy which meant his uncontrolled sugar levels had started to stunt his kidney functioning. Without dialysis on a regular basis, he would die very soon. People on dialysis undergo a procedure which involves creating an AV fistula called a Cimino fistula. Our body has two separate blood circulation systems – an arterial system (high pressure system) which contains all the good blood and oxygen that fuels the tissues of our body; and a venous system (low pressure system) carrying the bad blood away from the tissues to the heart which in turn gets filtered in the lungs and returns to the arterial system. It’s a simple cycle really. By creating an AV fistula, we are essentially connecting a small artery to a small vein thereby inducing a hyperdynamic circulation in the body.

The patient was made to lie supine and stretch out his right arm to find a vein. He was given a local anaesthetic, parts painted and draped. The plastic surgeon then got down straight to business! He made a small nick in his forearm and carefully dissected out the underlying tissues. His immense experience was testimony to him spotting the vein in no time. It was clamped. He then proceeded to find the artery adjacent to it. It was pulsating and breathing life, and hence hard to miss. It was clamped. Procedure half done. Sounds astonishingly simple doesn’t it? There is no way an amateur could do this procedure without causing some kind of damage to one of the blood vessels, The whole procedure would be totally futile even if it was only one small puncture. All along, he beautifully explained the entire procedure step by step. It was fascinating for an onlooker.

He proceeded to cut the vein and made a tiny nick on one side of the arterial wall without damaging the rest of it. (This was all of course done after clamping the vessels and obtaining a bloodless field) All he had to do was connect  one end of the cut vein to the cut side of the artery by placing sutures anteriorly and posteriorly. He used 7-0 prolene sutures which are visible to the naked eye only if you have perfect vision. Procedure completed. He released all the clamps and just like that, the now conjoint vessels sprang back to life, pulsating and pushing harder than ever. The operating surgeon let me palpate the vessels after stitching back the skin together. The mixing of the bloods had caused the blood flow to become turbulent which I could appreciate as a thrill. On auscultating, I could hear a low rumbling noise like that of a machine. It only meant one thing – it was a job beautifully done!

“The night fissured and stars rained down on me. Queen of the night, I knew love at last.”

PILOT

So let me begin by introducing myself. I am an intern (popularly called a House Surgeon too) working in a fairly good, old and reputed medical college of Karnataka. One of the perks of joining my medical college was receiving private education but being exposed to the atmosphere of a government hospital simultaneously – The best of both worlds to sum it up, a privilege bestowed upon only 2 Medical colleges in the state. That also meant that as an intern I got to work in both kind of set ups which probably would give me an edge over my contemporaries.

I have a story to narrate, one that I like to repeat often - I absolutely detested Obstetrics and Gynaecology through my undergrad days – Women wincing in pain, the nauseating stench of the post op wards, the horrifying sight of a big head stretching out a woman’s vagina and the utterly boring tiny-lettered textbook we had to cram to pass. Yet, when I got posted to the government hospital for 2 months of rotation in OBGyn department, I was really excited about possibly the only prospect of learning how to conduct a delivery. The very first day I was pushed into a tiny examination room where I had to palpate a woman’s tummy to gauge the gestation period based on the size of the uterus; the position of the baby – if the head was at the lower pole or the limbs. I couldn’t hear the foetal heart beat of even one case with my stethoscope in the first hour. None of the theory I had read to become a doctor helped me that day. I felt cheated and worthless. I vowed to hate OBGyn even more.

The ‘Government hospital experience’ honestly came as a rude shock initially. The hospital was full of people always trying to make quick money – nurses who’d take 500 bucks to hand over a male baby and 300 for a female (what discrimination even there!!), aayahs charging 30 bucks to change one ‘gulcose bottli’, a job that a nurse does essentially but aayahs did due to gross shortage of manpower and the one fat nurse who wouldn’t move her ass from the chair; OT boys who’d pocket 50 bucks everytime they wheeled a patient from one ward to another or the OT to the ward on a stretcher.

As days passed, I picked up. I learnt the art of counselling pregnant women who didn’t want their babies, dejected women who were trying hard to get pregnant in vain and hopeful mothers. We were about 7 doctors examining and counselling about 150 patients between 9:30am-4:30pm every alternate day in a room about the size of my 10^th grade classroom in school. You can probably picture the mad rush and the patients constantly fighting to be tended to first.

If Out Patient days were busy, OT days were draining in their own way. We, interns, would forever over work tirelessly to impress professors and residents because that meant more chances for us to scrub in on surgeries, even if we only got to be the ‘retractor girl’. If we were lucky enough, we’d get a chance to close up the abdomen, which was an achievement by itself. Post op monitoring was one of the more crucial things that is usually underrated – a job given to interns again. The post op ward had 7 beds in all, facing each other which ended in about 10 footsteps, poorly lit and dismally ventilated; and always brimming with the kith and kin of the patients breathing into each others’ faces.

My 15 day stint in the Labour Room really put life into perspective – 7 days of morning shift from 8am-8pm and 7 days of night shift from 8pm-8am. I witnessed and heard second hand stories about horrifying things that my residents did – injudicious over usage of Buscopans and Drotaverines to hasten labour, pinching a patient’s butt skin because she wouldn’t bear down, the sounds of a doctor slapping a patient’s thigh resonating through the room, giving unnecessary fundal pressure to push the baby out faster, using utterly foul language to converse with a woman about to deliver and ultimately a young doctor’s banter about how she hates her job.

None of that is really justified, I know. But here is the reality, another perspective that the world often chooses to ignore – there were about 4 doctors (3 residents and 1 intern) who needed to take care of 20-30 patients every day, half of who would possibly deliver. They required constant monitoring as they are in active labour which stretches upto 24 hours from the onset of labour pains. Labour pains are pains felt like never before in your life. Epidural analgesia to lessen the pain was ruled out because that would mean constant vigilance by anaesthetists, who were always busy running some emergency surgeries.

The labour room had 8 beds placed one next to the other with no privacy to the women whatsoever. One pregnant woman could see another deliver her baby. Before they deliver, every woman needed some basic investigations like Haemoglobin, blood group, HIV and HBsAg status and I’ll tell you why - Haemoglobin to rule out anemia which could cause severe post partum haemorrhage and death of the mother (Neonatal mortality is somehow more acceptable than maternal mortality even today); blood group to know the Rh status of the mother and avoid complications in her subsequent pregnancies; HIV and HBsAg status to ensure not only safety of the doctors who were risking their lives trying to treat them but also to save their baby from contracting it by administering timely vaccines and drugs. The ones who came with high blood pressure (about 30% of the cases we got) needed their own separate investigations and treatment to prevent them from throwing a fit during delivery.

We had to be vigilant about a woman breaking her water and follow it up with a PV examination to rule out meconium stained liquor, which essentially means that the baby is starting to swallow its own poop and could possibly choke to death on it if we don’t intervene soon enough. If a woman was delivering for the first time and her body hadn’t created the required space for the baby to get out, we’d have to rush her to the Operation theatre to do an emergency Caesarean section. But if she had delivered before, her already roomy pelvis would make way for the baby’s exit faster and all we’d have to do is hasten the delivery. And then there were those who broke their water too early and still didn’t experience any pains, at the risk of contracting infections. The majority of the first time mothers needed an episiotomy – cutting a part of her vaginal wall to let the baby come out, the timing of which was extremely crucial. Too early and she’d bleed a lot, a tad bit late and the baby’s head would tear through anything that came in its way. Of course, that had to be stitched up following the birth of the baby and expulsion of placenta.

It’s therefore, easy to understand that pregnant women are easily one of the most vulnerable groups of the lot. Accurate decisions regarding their management is ever so crucial. I cannot even start explaining the various complications associated with pregnancy to the common man. We read about it for 4.5 years but were expected to take decisions within fractions of a minute. This ultimately put the doctors who were in charge of them under tremendous pressure. Every professional has work pressures but imagine the kind where one wrong move on your part can kill a mother or her dream of delivering a healthy, live baby. Experience can deceive anybody at times. It was therefore not too surprising that residents would often lose their cool. Dealing with anxious attenders, 20 odd women whose cries echoed through the empty corridors of the hospital in the dead of the night, unexpected complications in the last minute, sick babies popping out at 3:30 am when you’re trying to fight fatigue was all never easy. We have had cases where babies have delivered spontaneously into buckets because too many of them were delivering simultaneously and we were too few doctors. It is sometimes inevitable and beyond what we can do.

All I could do was go about my job honestly, be kind on my part to patients and treat them with the dignity any human being deserved irrespective of their socioeconomic status. It paid off in a wonderful way because 2 months later, my parents came visiting me. We were walking to a food joint. One old lady on the road smiled at me and asked me how I was. I didn’t remember her. But she remembered me as the kindest doctor in the labour room who delivered her daughter’s baby. I was overwhelmed.

In another incident, an old lady came and held my hands asking me to treat her other daughter during my emergency medicine posting in another hospital because I monitored her first one. Funnily, I remember her pregnant daughter who underwent a Caesarean section and ate right after the surgery despite instructions not to, causing her abdomen to swell. We had to insert a Ryle’s tube through her nose into her stomach to get all those contents out.

As an intern, we are at the bottom rung of the ladder. My job has ranged from stuff like examining my patient’s urine to feeding them, putting canulas and changing intravenous fluid bottles to catheterizing patients, arranging blood for my patients by actually roaming the city in the dead of the night to donating some myself, riding in the scorching heat to get some snacks for my professors to typing out part of my resident’s thesis, writing case sheets and drawing blood samples to monitoring patients hourly, scrubbing in on surgeries to actually doing tubectomies as primary surgeon skin to skin, doing Per Vaginal examinations (where you introduce your index and middle finger into a woman’s vagina to assess the status of her cervix and estimate the feasibility of a normal delivery) to actually conducting about 76 deliveries in 15 days.

Turns out that my 2 month stint in OBGyn was the best 2 months of internship so far in terms of learning lessons for life. It taught me tolerance, empathy and a thing or two about supporting pregnant women during the most important phase of their reproductive life. It has enabled me to take on my profession with a new found zeal and immensely respect my seniors for the effort they put in. So the next time some senior treats us badly or says “Aye intern”, let us remember that although we treat a patient and spend more time with them than anyone else, we’re less responsible for them than the higher ups. Ultimately they take the blame if something goes wrong.

In 4 months, I will be climbing onto the next rung. I am ready for a little more responsibility.