'Special' 'General' Pediatric Ward

I remember pain and the unbiased crude uninterrupted company it can keep with no sympathy or apathy. As a mature individual, I remember it even better when exactly a year ago I was operated on my shoulder for tearing my glenoid off my acetabulum by falling off a slippery staircase once and then pushing too hard in more than one swimming meets. I remember that white ceiling I had stared for hours before I was led into the OT. I remember having joked to my friends that I would skip a few numbers in the count down, as the gaseous anesthesia would be administered just to confuse my anesthetist and as if he heard that, he knocked me off before I realized pushing that nitrous gas into my lungs but saying that he was only administering oxygen. Very clever. I only remember waking up to the white ceiling again after 6 long hours of uninterrupted sleep gasping for breath and wheezing as I did. I knew it was an experience to write about but the operated hand had to remain in sling day and night for the next 6 weeks. Therefore, I didn’t find time or the energy to write with the same hand and type it later again after having spent a neat 15 minutes just buttoning my shirt. It was the first time in college in 4 long years that I began to miss home. Of course, friends were there to help but there is an extent help can help you. You can’t blame anyone, everyone have their own errands to run and own deadlines to meet while I took an hour and half to get ready to class every morning.

It’s 3:00 am now and I’m not sleepy yet. I guess, my sleep-wake cycles have changed significantly in the last few days. Work or no work, to be on call makes you stay as close to the hospital as possible and the duties and responsibilities take over your time. Apart from work, the past few days have been exciting as well from going jogging, regularly eating good mess food, new born resuscitations, awaiting TOEFL, BLS ACLS and the not-to-be-forgotten upcoming IFMSA General Assembly- AM 2012 Mumbai, India that lets me stay on conference call with 10 people at once spread across the country for hours! Today was another such day as I was on my now routine late night Skype group chats when I was called from the hospital and the postgraduate insisted on me coming. It feels good to be asked for assistance by your senior even though all you might get to do is to hold stuff for them- a retractor to keep the wound open or hold the baby while they establish the intravenous (i.v) line or write case sheets as they dictated in their vernacular fashions but hungrily waiting for a chance to at least hold the knife or knit the open wound with a thread that says ‘cat gut’ but is actually made of sheep gut!

For the last 3 hours my job was to just hold and keep the baby  17 day old infant in position with the crude strength of my bare hands as the training postgraduate pierced through her skin to get to those little hardly visible veins to get a sample of blood to prove that she is suffering from Septicemia with meningitis which her clinical signs clearly suggest. I, with my little knowledge wasn’t sure if it was sepsis but now was sure that with the multiple punctures we were giving her she sure was going to end up septic. But the protocol had to be followed and the sample had to be taken, therefore I was their watching as they pierced her failing to thrive body again and again to extract the little blood she had to fill our adult sized lavender capped vacu-containers with adequate sample. She clenched her fists throwing up bile stained vomit with occasional unrolling of eyes and did all she could do and the only thing she could to resist- CRY.

I felt disgusted. I felt nauseous. The reasons were many. For the first time since my completion of my final year MBBS I hated medicine for once. What did this girl do in her 17 days of life to undergo this suffering? Well, Karma isn’t an answer good enough. We in that room knew what her life was going to be and how much of her significant lifetime could be spent around hospitals. Her next few months definitely in the Neonatal Intensive Care unit and the next few years with Pediatricians and their team for the possible post meningitis sequel- global development delay and several others and the later adolescent life with the Obstetricians considering the Ovarian cysts she was gifted with birth if her operation at the age of 3 doesn’t go well.

After 3 long hours last night establishing i.v lines, giving all the loading doses and boluses with syringes half her size, the medicine at the secondary hospital didn’t work. So, I accompanied the PG in the ambulance to shift them to a tertiary care center (who don’t trust even our microscopes) to try the same medicines again under more efficient hands. The system disappointed me and me being a part of this health care system was even more disappointing. Sitting in the ambulance, I couldn’t help recollecting the early morning today when the baby’s health was deteriorating and everybody in the hospital ran around blaming each other. Nobody wanted the blood of an 18-day-old infant on their hands. Who would?!

The father blamed the false reassurance of the previously treating doctor, the professor blamed the partially treated previous episode of sepsis, the parents for having delayed the treatment and the post graduate for not putting a tube (ryle’s) down the throat to the stomach and not replacing the fluids lost as blood and vomit, the still training 1^st year postgraduate blamed the experienced nurse for not taking late night calls and the consulting professor for having over trusting him with competence and the nurse blamed the interns for not knowing where the switch board is and where she keeps her scissors. I, as an intern though only knew an iota what these people do took the opportunity to sound sophisticated and blamed the fire fighter approach our system and the unpreparedness until the last calling minute. Though the lab assistant was out of the scene in his lab cared to pass by and blame a particular hospital in Honnavar whose every third delivery inevitably ends in our NICU as he was sure that the samples from their water tanks would grow Burkholderia cepacia! Crap! The mother didn’t blame any but wept miserably all along. But lucky for us, we did have men on the scene that didn’t blame anyone but took the responsibility and answered medicine with medicine- explained the absent venous back flow due to shock, the bradycardia due to phenobarbitone and the tachycardia due to hyperthermia or their heroic injection of fluid boluses!

As the monitor showed falling heart rate and dangerous saturation levels in the ambulance on our way to Manipal, my heart almost stopped for a minute or two. I thought I was strong for medicine but only realized how weak a heart I have- so weak and fragile. I wasn’t sure of her survival until we reached and looked at all those intense faces around but I wasn’t going to carry a corpse to the hospital. I asked the mother to stop crying and constantly stimulate the child. The snapped at the father for having mistakenly sat on the infusion machine and I realized that I was behaving like on of them- those many professors in college for their behavior, attitude and incapable of being nice to us. I for once realized the agony all those doctors carry day in and out including my parents and judged my interpretations.

I’m fascinated by the amount of ‘direct’ impact doctors have on the lives of others. Being posted in pediatrics as an intern and considering the fragile nature (so much so that even a bleb on their buttocks can bring them to the hospital with failure to thrive!) of the newborn it even makes better sense. We are the first hands that touch the baby welcoming it to the world even before the mother. Their first crucial minutes of life, which determine the rest of their lives, are by our decisions. The time we record carelessly with a glance at those outdated watches will decide his/ her stars, their astrology read and their marriages fixed. You could even use the excuse of a very very busy labour day to mix up a few babies and let a fisherman’s son grow in Ambani’s palaces and vice-versa. Just to sound dramatic, we would never do that, right ;p

The baby is stable now and crying again, this time for good and the smile on my face missing since last night has returned again.

The 'Labour' 'Theater'

Today is the last day of my posting in the Dept. of Obstetrics and Gynecology at the TMA Pai Hospital at Karkala 40km away from my home in Manipal. Today is therefore, also the last day I would get to spend in the best place in Karkala (the air conditioned theater, labor theater that is) considering the heat currents of the current year. I’m not sad. I’m just introspecting. A little pensive, perhaps. I haven’t got to sleep much in the last 3 days- ½ hour once, 25 minutes onetime, 2 hours another time and a lil’ longer last night. I can’t remember what day each of these naps belong to. You would be nodding your head with me, if you ever had a chance to skip sleep for a couple of consecutive nights. Like me, you would fail to differentiate those sleepy days with those sleep-deprived nights and slumber is essentially the one thing that differentiates one day from another. Well, it wasn’t always work that had the privilege of keeping me awake. One night, it was an idea of a crazy nighttime adventure. A few late night games of ‘Taboo’ and ‘Charades’ during the jobless night shift. And one night, I just didn’t feel like going to sleep and spent the night with the lame excuse that it has been months since I’ve watched a movie!

Today is my last day and I’m ‘on call’ again for the 5^th time in the last 10 days owing to the 5 day leave for my glamorous 2000$ winning Mumbai trip this month (yes, correct. You can learn a few tips about modesty from me) and all alone in the labor theatre (hereby, referred to as ‘LT’). Being on call essentially means what it stands for- people can call you anytime in those 12 hours and you better respond in the first 3 calls, from the LT phone ringing to fetching teas and files, being treated like shit and just playing ‘freeze’ as the sleep deprived frustrated post graduates relieve their stress on you as they play in their ‘pool of estrogen’. Remember that the interns are at the bottom of the ‘doctor food chain’.

My friends say that I exaggerate. I wouldn’t disagree but a wee bit of exaggeration in a narration adds spice and might occasionally make few events sound dramatic but gets everybody all ears and drives the message home. I may exaggerate a little but facts will remain facts no matter what I say or write.

Like I always love to say; ‘anything that happens in your life can be either enjoyed or at least will remain as a good experience’. This episode as I would call it is another experience because I can’t remember that I’ve learnt in the last 2 weeks. Zilch. But for one face I would never ever forget in my life and the tangible agony it carried. I was the same face that kept me distracted that day, even in the operation theater (another theater wherein man makes holes this time to pull out babies after losing his patience) wherein I was called to be the 2^nd assistant (the guy who gets to hold the retractor till his hand goes numb) and I was just lost in the blood till the crying baby just brought me back from that labyrinthine abyss! Most of my ‘on call’ days were very busy days. This, one day, like any other day, I was moving from one bed to another among the 4 beds, monitoring contractions and taking blood pressures allotting a generous 15 minutes for each ‘gonna-be- mother’ woman, as they moaned and groaned in pain with each contraction. My job was to carefully keep a record of these episodes of intense ‘grade- 10‘ pain and document them as ‘howmany’ for ‘howlong’ in ‘howmuch’ time until I get a satisfactory 3-4/ 35-45’’/10’ to write; ‘the patient progressed well into the second stage of labor with good uterine contractions’. You have to be professional to do that, meaning to turn into an emotion-less stone and a few jokes behind the scene even when people are dying does help. If you want the logistics of how it works, here it is. There are 4 beds in the LT here. The monitoring of BP and contractions should happen once every half hour for each patient and you give about 15 minutes to do all that stuff. Now, if you have added 2+2 along with me, you would have realized that by the time I finish with the last patient on bed 4, I’m already lagging by half hour in writing progress for the first patient! It only gets worse when suddenly one of the 4 women decide to deliver and you need to scrub in to be an assistant even for the simple SVD with RMLE (Spontaneous Vaginal Delivery with Right Medio-lateral Episiotomy) after which you realize that you’ve fallen behind in writing progress for the last 2 hours. Not only laborious but also exhaustive.

Among all this screaming, the bloodshed, the perpetual procreation of mankind, affectionate scenes of handholding and tears of joy, this particular woman entered the scene and handed over her file to me, which said ‘missed abortion’. There is a dead baby in her womb and she didn’t know it, until now. She will be induced for labor and will have to undergo the labor like any other expectant mother though she now knows that the end result of all of this is a dead piece of her flesh, blood and soul that shall enter the world with ‘no life’ but ironically with a face so calm and at peace that every being on this planet starting with the first moments of crying would strive for all his/her life. She had to stay in the LT even after expelling the dead fetus to be under observation and to her misfortune, the busier the day was getting they were just more and more deliveries happening the whole day. She was there on her bed watching all those crying babies, new mothers and so much life all around. To everybody’s surprise, she neither cried nor wept.

We, as doctors, knew that it was another misfortunate incident in the imperfect field of medical science. Some of us even went to examine the corpse out of curiosity to answer our questions and measured the infant like we measure any other with normal vitals. When we mention that a disease has just 1% mortality, do we realize that for that one person affected out of the 100, it is 100% mortality?! I requested the seniors to shift her to another room but they showed no concern. They said it happens and she’ll have to accept the fact one day, anyway. I don’t have anything against them; I have no sides to take for sides are only taken when you see the insufficient halves of the story but isn’t that so easy for us to say. I went up to her at the end of the long day and said to her not to over think about it and it’ll all be okay. She blankly looked at me and said ‘nothing’. I remember that face from before. It was the same look when my roommate who unfortunately failed in his final year MBBS university exams for no apparent reason known. For me, knowing the genius and the hard worker he is was worse news than hearing the news of my own passing. 

It was the same look that said, Why me? They haunt me- questions with no answers.

Reason

As I walked down the endpoint hill drenched in sweat, I see a sparrow bringing down a wriggling worm to its death in fury putting to torture as a part of the prey predator completing the cycle of hunger. The worm gave away in no time and left it’s flesh and blood for the sparrow to feed upon. The sparrow now flies away as it notices me nearer abandoning its hard earned food for it’s own life and spirit. I looked at the civilization from the hill. As these mere living forms fed, mated and struggled to survive; man made bows and arrows to tame the world, made BMWs and Benzs from class C to E and made the world the world a very big place to live in and then made telecommunications to make it smaller again. Cut trees and started the Global Warming campaign to save earth for its children tomorrow. Every bad act results in an inconspicuous vicious cycle that inevitably results in something bad unless intervened upon.

I frequently lose my thoughts to understand the meaning and purpose of things imagining a beautiful destination, a beautiful answer but mindlessly wandering through the streets without knowing directions. The time spent on such an adventure in all our lives have innumerate examples each of us constantly ending up somewhere that we want to believe is our destiny or reach there and then accept it as our destiny or nowhere NOWhere questioning destiny and still wandering hoping to find light at the end of the tunnel.

Through all of mankind’s survival, the thought to reason I feel has been the most significant change that altered the very essence of survival and progress we made across our existence. There is something in the evolution of the human brain that we have developed to understand, logically reason and prioritize a particular fact or statement. Tagging a reason to any interpretation of the many from the most complicated human brain validates it over its counterparts. Eason is all we look out for. Why? Reason again!

We find those reasons in different things, every one of us in different objects, persons in love and other abstract emotions and in passion. Irrespective of a possibility that this all could be a meaningless existence we constantly endure pain, suffering and seek the ‘Pavlonian’ pleasure consciously or subconsciously in search of the purpose in our lives for reasons many.

How does it happen that all life you believe in something or someone and suddenly it all crashes into abyss like an ambitious wave shattered as it dives into its own waters only to be embraced gently as it returns again. Is it that a person acts superior to make up for his inferiority complex or is it just that he is superior. Does somebody say something to mean it or acts like to mean it or because it sounds best in a given situation or may be for no reason at all only to be interpreted, analyzed and talked about by people who are themselves so lost and confused.

To me, we are desperate to find patterns cramming up our Anatomy, Physiology and Medicine ultimately trading it in an attempt to fulfill another man’s need in an existence wanting to mean something to somebody in life or after death perhaps only to return again.

On a very broad perspective we see that life isn’t in its whole in our hands despite our best efforts and most serious thoughts from, to whom we were born to whom we meet and to where and when we meet our awaiting death. The best I understand we can do is to accept things as they are and to make the best out of life in being a good friend to a friend, a good son to a father and a father to your son, a husband to a wife and a master of yourself all as an ‘expression of HappYness’ to make tomorrow, a ‘better’ tomorrow.

 

Autonomic dysfunction!

14/01/2012, Manipal.

Yesterday’s night was one of the most dreadful nightmares of my life. 3 weeks ago when the grand finale was finally about to commence I wished for just a few things. One, I should not fall sick or meet with accidents, both in and out of hell. Two; Nobody I know (or don’t know too, if possible) should fall sick (and need me). Three; Let me be a machine and just pass this phase.

2 days ago as I was walking up and down the corridor trying to master the science of Carpentry in the given day, I suddenly felt a strong surge from the inside. This surge was no enthusiasm or the spirits or the usual episodes of exacerbated palpitations that have been in last 3 months and in not less than 2 minutes, I was staring into the washbasin, vomiting out everything I ate since morning. I never vomited even the times I got drunk and wondered if it was food poisoning or the force-fed excessive knowledge to the brain in the last few months.

I continued to roam around the house to keep myself just enough distracted with a book in my hand but ran to the basin every 20 minutes. I ate nothing so I guess I had to vomit ‘just water’. The nightmare of unknown origin [MUO] healed magically by that mid-night. Love from the housemate and the neighbors fastened the cure. The next day, after a satisfying theory exam I came home and convinced myself to take a short nap to freshen up and start preparation for the 5 specialty Surgery paper-2 subjects for the next day morning. The aim of revision was to basically turn the pages without reading much but the latest I got a look at those pages was 2 weeks before, since I began with Surgery paper 1 and Medicine followed since. As great God would have it, my landlord aunty happened to take her first dose of Tramadol for her usual backache and suddenly felt dizzy and I had to respond. They were very sorry for the disturbance but I wouldn’t pass it either, at least not after they fed me with easy digestible Idlis before I left for exam today as I was on an empty stomach since yesterday morning.  It was not only a social responsibility but also the word that 2 to-be-docs live upstairs and none of them around when the need arose; at the least to call it an emergency and to respond to the moment. I thought of it more of a moral responsibility that presents itself with greater complications than answering on the blank papers and scoring marks. That night, running through the incessant names of surgeons and their surgeries and distances from the anal verge, I found myself at the verge. I was lost and then like always began to worry about nothing. I finished, closed and then the next day filled the 16page booklet served to me. The paper was easy, so simple that our immediate seniors who had to face the brunt of the previous year paper and sat to write the exam again with us were seen literally jumping with joy and hitting their chests and fists against each other as the bell rang and I only thought to myself that I survived this- a nightmare.

I have always believed that the body finds wonderful means to cope up with anything presented to it. During our classes and clinics, I was amazed to see how an infant adopts a squat to tolerate a cyanotic spell, how a man with a varicocele walked into the OPD wearing 2 undergarments to alleviate the dragging pain (though the increased temperature due to the double wear might exacerbate a lil’ bit). Stress too precipitates something of a similar response making our body go nuts and finding ways to ‘let go’, both through voluntary (movies and addictions) means and involuntary (autonomic dysfunction) means.

A friend of mine said over stress manifests in him as allergy/ hypersensitivity reaction. Another friend said he and his roommate had to be on Proton pump inhibitors for their gastritis. Mine usually being insomnia and a lil’ worry, this time was accompanied by a few episodes of nausea, vomiting, diarrhea, not to forget palpitations, pale stools (steatorrhoea) and high colored urine that resolved spontaneously with the last exam giving me no chance to see which one of my differentials were correct! 

WHAT’S YOURS?

   

Night mares and hares

Owing to my yet to heal broken shoulder and the recent radiculopathy, I sat at home and just like any other exam season I began to question everything in life. Where was I headed and what I was doing.

It’s about 2 into the dark. I ran out into the balcony hearing a ‘scream of death’. It was the second of the 3 kittens that Tony, the landlord’s dog downstairs has killed in the past few days. I stood there in strange agony wondering if it died the same way as it’s sibling; the same foul play along the narrow edges of the roof?! The last one among Kitty kitty’s (the name of the cat that adopted us) litter tremblingly leaned over the edge and looked as the dog bit the body of it’s dead brother again and again. Do they ever learn from their mistakes like we do, I thought in curiosity.

Maybe, the key to our evolution is that we learn from the mistakes of our ancestors not only through history but also very quickly than other genes and species that need greater Pavlovian conditioning.

As Kitty kitty jumped on the roof to return home with a fresh dead rat, I wondered if she realized that all of her litter is reduced to one. Not surprisingly she did more than I thought she would, she purred in agony all night long searching for the missing kitten, the same purr that the black cat owing to its unlucky color gives away in the neighborhood. Only now did I know what the sound meant. A dose of Alprazolam or Diazepam in the night’s milk could be of some help to her, I thought. The last kitten with blue eyes was fear struck with the death of it’s 2 brothers and didn’t let her mother leave to go hunting for food and played with it’s tail all day. The next day everything seemed fine again and Kitty kitty got herself pregnant again! The black cat helped. 9 weeks later, not in my house Kitty!

p.s 9 weeks is the gestational period for cats.

p.s.s Cats eat rats and eat them with delight but why do dogs have to bite cats when they don’t eat them?!

p.s.s. Do they experience love as the same way as we do?

Insomnia- I

After sitting hours straight and have accumulated enough toxic gases, my head erupted in a yawn and I was glad that sleep was coming because if the human brain truly had any limit or capacity, I think mine just exceeded the limits. When the altered consciousness says that it can’t take it anymore, sleep is a wonderful thing. It makes everything go away and gifts you a new silent start tomorrow.

I turned the lights off and holding my 14week potbelly like a pregnant women with lardosis and wondering what I would be dreaming today, I reached my bed 4.5 feet away with great difficulty. May be one of those Richie Rich dreams where I get to be the king and have to play a 3D virtual ‘Game of scratch’ to save my queen and the kingdom or oh ooh, one of those where the world is about to an end only to survive at the climax of the dream where the whole of mankind spent all of it’s money, resources or finished off with it’s ‘bucket list’ that many of us had nothing to live for after the unexpected survival! Death as a whole, when it comes it all, at once, doesn’t seem like a bad idea at all now. In one of those dreams which I still vividly remember, I was at Marine drive when the skies began to crack open and spill down avalanches and I ran to save myself all across the globe, from the Pyramids to the Red sea and the Alps of Europe all at once. Ooh! I think I even spotted a few dinosaurs! 

But it’s been a while I dreamt in sleep. Actually, I have to admit that I began to have trouble sleeping. It’s not the barking of the dogs or the cats that find way inside the house that disturb me anymore but my own pounding heart. It beat so hard and gave me a constant company like pain during my post-operation that I worried if I would have to lay in bed all night awake until the first rays of the morning would forcibly make me throw the blanket off. I doubted even if any sleeping pill would be an antagonist to this disease. A few years ago, I enjoyed a 7-hour sleep even before my 1^st year university exams and there was never a problem before either. Oh good great sweet killer education, I ask thou, what have you done to me?