Sunday, October 25, 2009

Games Doctors Play: A Play

Scene 1: Medical College Hospital, Ward 1.

Actors: Dr1, Dr2, Dr3

The stage is too brightly lit with numerous over-head lamps, with only one hanging mike at the center visible to the audience. Walls are painted regulation drab yellow - plaster peeled off in patches. Red spit marks bottom right. One old fashioned ceiling fan with cob-webs making creaky noises occasionally.

Drs 1 and 3 are sitting at a table at the end of a long ward. They are both male, in their mid - twenties, unshaven and apparently tired. Dr1 is sulking, Dr3 is writing into a case-record.

Dr1: "I hate him. God, How I hate him!"

Dr3 looks up from the case-record, looks at Dr1, and resumes writing.

Dr1: "I could kill him with my bare hands right now."

Dr3: "I am sure you could."

Dr1: "How could he? I had it all planned for the evening."

Dr3 does not respond. He appears not to have heard.

Enter Dr2 (Right). She is of about the same age as Dr1 and Dr3. She is wearing a white coat, and is greatly excited.

Dr2: "Guess what?"

Dr1: "Him dead?"

Dr2 looks at Dr3, who winks back. She chooses to ignore the remark.

Dr2: "Not yet, but we got another H1N1 admission today. Lady, pregnant, 7 months."

Dr3 stops writing. "One of our own?"

Dr2: "Nope. This one's ref from _________ multi-specialty. Software engineer."

Dr1: "So, What's new? Just another swine flu case."

Dr2: "My! You are today worse than usual, what happened? On second thoughts, dont tell me."

Dr3: "They got a bed for her?"

Dr2 looks at Dr3 with an expression of surprise.

Dr2: "And since when has that started to matter? They throw out, the moment a patient is diagnosed, and we take them in, no questions asked. You ought to know that."

(Exits Left)

Chorus: "You ought to know that. You ought to know that."

Faint wails arising from Right.

Dr1: "I can hear them now, that should be them."

Dr3 rises from his seat, goes to Right, looks out and returns to his seat

Dr3: "You're right. Its the new party. How did you know?"

Dr1: "What do you think how I know? I've been in this ward for a month, 've been on duty here 24 straight hours now, and next to the H1N1 quarantine unit as we are, I can hear them day in and day out."

"I can even tell what's happening just by listening to them. Here, last week, remember the old woman with her beads?"

Dr3 tries hard to remember for a moment. He does not respond.

"I could hear her non-stop reading from the scriptures, day in and day out, and the once or twice I went past that way, I saw that not only was she reciting her prayers, but she was counting her holy beads without pause, as if her daughter's life depended on it."

Dr3: "I remember now. That was one of our own. But she.."

Dr1: "Yeah, the same one that passed away last week. I was the first to know 'cause the old lady had quit praying. I had a good night's sleep that day. She was beginning to get on my nerves."

Chorus: "He had a good night's sleep. He had a good night's sleep"

Dr3: "And now that you've been asked to stay on for another shift, am sure you'll get closely acquainted with the new party as well."

(Exits Right)

Dr1 stays in his seat for a while, gets up, looks out (Right), returns to his seat.

Sound of Loud crying can be heard once again from Right. Enter Dr2 (Right).

Dr1: "Not dead is she?"

Dr2: "No. But the baby.."

Dr1: "That one was a goner alright. They'd be lucky to get the mother."

Dr2: "That they'll be. She got Oxygen Saturation less than 40% in her blood, I am told."

Dr1: "I really wish they wouldn't make so much noise. Its giving me a headache."

Dr2: "Could you for once stop being so cynical?"

Dr1: "Cynical! What's cynical about asking for some peace and quiet? And what's with all these lights anyway? Ask them to replace a broken one in the OP and it takes ages, and here, just look at it, burning away without a care! The obscenity of it!"

Dr2: "Relax. Have you forgotten this is a play and we are on a stage? They need to watch your every move."

(turns and gestures to audience)

Dr1: "Then why just one mike? Wouldn't they want to listen to me as well.. perhaps hang on to every word I say?"

Dr2: "Tell you what.. I don't think they do. I think they would rather look at you than listen to you...(Chuckles) you especially. Who wants to see a doctor whine anyway?"

Dr1: "What's this, a bloody pantomime show? What sort of an audience is this?"

Dr2: "You have been working too many hours"

Dr1: "The old man doesn't think so. Just gave me another shift."

Dr2: "Still do you have to be so bitter? Don't you know half the work-force is on strike?"

Dr1: "May be its better this way. At least I wont have to go to my room at the Quarters"

Dr2: "How's that a good thing to be?"

Dr1: "The room mates are all at the Labour room. Our focus of H1N1 outbreak, you know. Their colleagues had been confirmed to be infected last week. Now they have started showing symptoms as well, and yet they are asked to report for duty."

Dr2: "And yet you share the same room!"

Dr1: "You got a better idea? They did not throw me out when I got dengue fever 3 months ago."

Dr2: "Get yourselves diagnosed as infected or not. They have begun to take nasal swabs at the labour room, I hear"

Dr1: "You hear a lot, dont you? And yet you hear only so much"

Dr2: "Then get it done from the General Hospital. They have an H1N1 cell too."

Dr1: "That they do. And I had planned today to get myself checked there today evening. Guess its not to be"

Enter Dr3 (Right)

Dr3: "Its in the news. The labour room as the focus of infection. They have started shifting the patients out."

Dr2: "As usual. Too little, too late"

Dr1: "My! THAT was Cynical of you"

(Loud wails arising from Right.)

Dr1: "I think I am gonna sleep comfortably tonight after all"

Dr2 goes right, looks out, looks back at Dr1, exits Left.

Dr3: "She's much to learn yet. She still believes."

Dr1 is silent, lost in thought. He goes to right, looks out, and doesn't look back.

Over-head lights are dimmed one by one, until only one over the right window, illuminating Dr1, remains. It stays lit for a small while, and then that too is put out.

Wednesday, October 7, 2009

The day I spoke to Rahul Gandhi

It happened, really, in three parts, and may be that's the way It should be told.


I was on night duty at medicine casualty, on the night of 6th October, 09. It was a particularly hectic shift, having barely been able to sit down for a few minutes until midnight. A first year nursing student at some college in the private sector had jumped off the roof of her hostel, and so in addition to the usual crowd we had hoards of media people going about their job, and in doing so interfering with everyone else going about their's.

At around midnight, there was a momentary lull in the end-less parade of people with heart attacks, snake-bites, 'Bronchial Asthma's and plain high fever of a few days duration. The three of us on duty sank down to our seats for a moment of respite. I was the junior officer. In addition, there was a post-graduate resident and the casualty medical officer (CMO), who was the one in charge.

I listened then to a conversation between the resident and the officer. There was talk of having received instructions from the HOD - Internal Medicine, to the effect that one ventilator machine at the casualty was to be kept free for the night. Mr.Rahul Gandhi was visiting the city on Wednesday, and for the entire duration of his visit the ventilator had to be kept ready and waiting in case of an emergency. To avoid any last minute complications, no patient was to be admitted during the night.

I remember having thought, that the security protocol in case of someone as important to the nation as Mr.Gandhi might actually justify this rather elaborate and costly gesture (in terms of the human and ethical cost involved), and the doctor, who at the end of the day was merely a glorified technician, was only expected to carry out instructions just like the rest of them. I knew the CMO on duty to be a good clinician, and - more importantly - a man of integrity, yet the coolness with which he relayed the instruction down to his immediate sub-ordinate, that was chilling.

Here was what I was most terribly afraid that this system might do to me as well over the years - make me as cynical as the next man, render me incapable of noticing the cost of my actions, and in doing so take my refuge behind the steel curtain of bureaucratic indifference and impersonality. I believe I am halfway there already, having seen time and again how similar steps were taken to mollify the giant egos of even local political wannabes.

The medical casualty has two ventilator machines - which are important in acute life support (please see my post 'The Reluctant Fisherman' for a bit more about acute life support and the ethical dilemmas therein), and usually we have only one of them functioning properly. To keep it vacant for an entire day - for an eventuality that only might occur, and that too when there were scores of such machines in the private hospitals in the city readily available, that was obscene. I know there might be dictates of protocol that necessitate such extreme measures, but I think its about time that more people began asking a few dirty questions around this country.

Anyway, the night passes, thankfully uneventful, but for a few more heart attacks (Myocardial Infarction or MI as we refer to them), a couple more of snake bites, and the usual number of Diabetics with very low sugar in their blood. Nothing happened, that would necessitate use of a ventilator machine, until 8 in the morning, when my 12 hr shift ended.

Drearily, I made it back to the quarters, having handed over charge to the day-shift team. One of the perks of being the junior officer is that though you have to be the first person to report for duty, you also get to be the one that stays on his seat through the night - even as nurses and paramedical staff go to bed - and then get to the one to stay on until the next shift has arrived and duty is handed over.


My friend enters my room at the quarters, greatly excited, quite uncharactarestic for his quiet ways. He has a handful of cards in his hand bearing the picture of a smiling Rahul Gandhi. He asks me to grab my college ID card and go with him for the interaction programme with Mr.Gandhi, which was to start in one of the well-known arts colleges of the city in an hour's time. I declined at first, pointing out that I did not possess a valid college ID card just then, as was required by the instructions on the entry pass. However, it had been a while since we had gone out together, and my friends convinced me to try my luck as all the others had their papers in order. I thought of telling them that the Special Protection Group or SPG that was responsible for Mr.Gandhi's security were professionals of the highest order, and it would be futile - and unfair - to expect them to show any leniency, but in the end decided to go along with the fun as far as possible.

We make it to the venue, and surely, there's an obviously SPG person at the gate asking for our passes and college IDs: Clad in smart gray safari suit, tall and strongly built, eyes calm and intelligent. I knew we were gone beyond the point of no return, because to start walking away now would be to immediately rouse his suspicion. Expecting fully well to be turned away, I walk up to him, say 'Hi', show him the invite card, and tell him about the student ID card that has been submitted to the college office for renewal and upgradation to a faculty card. He takes his time to assess me, looking me up and down, and then looks at the IDs of my friends, some of them sporting brand new faculty cards, others fishing dilapidated student IDs out of their wallets, and then, almost to my disbelief, lets me in. I pause a moment to tell him I appreciate the risk he is taking in letting me in, and thank him for it. For a very brief moment, something like a smile fleets across his features, before they again become set in stone, and I realized why the SPG were regarded as the best in the country in what they did. It was not because they were burly robots that would follow rules blindly and to a T, but because they were sensible men who could assess situations and people using their own intellect. That was what made them invaluable and so highly effective.

We troupe in, my friends and I, and find ourselves seats in amongst one of the front rows of an auditorium that would eventually come to be filled with nearly a thousand people. Tired from the night, I start dozing off almost immediately. I was woken up by the sound of a thunderous standing ovation as Mr.Gandhi arrived, without the regular media entourage, which I learned later was deliberately forbidden from hanging in on the interactive session.

After the usual introductions, RG, clad in casual attire, rose up to speak, and went on to explain in some detail why he was making this trip. He talked of the core assets of India being its people, on the demographic advantage of having a higher percentage of youth than the other big nations of the world, and why it was hence important for the youth to take a more active interest in the running of the country. He started taking questions from the gathered students, and in answering their questions spoke of the other India, the India of superstitions and hunger and deprivations, the India that we had to strive to bring in to the mainstream. He gave the general impression of being someone who had learned at depth about the state of the nation - both its problems and possible solutions to the same. More importantly, he came across as someone who was neither blissfully ignorant of the complexities of the problems that we were faced with, but at the same time was not awed by the enormity of the task. He believed change was possible, here and now, if only we might exercise the will and faculties that we possessed. I felt he was someone who cared about this country, and had faith in the system's ability to correct itself from within, a faith that the people of this country seem to be losing dangerously fast. And lastly, it was obvious that this man did not take his authority for a traditional taken-for-granted fiefdom, but had made it a point to earn his entitlement. His faith and goodwill, was infectious.


It was then, that I decided it had to be told. I could see that this man was different from any other politician I had met: in that he possessed a basic sense of decency and respect. I knew then, that he would never ask that a ventilator be denied to anyone whose life might depend on it, and keep it for his possible use. I knew, with some degree of certainity, that he would actually not stand for something like that happening on his name. I could feel that he was capable of doing something, simply because it was the right thing to do. Change was possible, here and now, he had said. I believed him, something I had thought myself incapable of doing in so short a while.

I asked for the microphone, and when my turn came, stood up and told him that I had a question for him, but first, I had a tale to tell.

I told him about the ventilator that was kept vacant only because he was in city. I told him that I drew no conclusions or made no accusations, but I thought he would like to know.

Strangely enough, my microphone failed, and RG asked me to just shout at him, which I did gladly and at the top of my voice.

I was right in that RG shared my sentiment. But he was shocked, and I hadn't counted on that.

"Its disgusting", was his reply. He promised to get on top of it right away.

I went on to ask my question, about the need to more strongly promote social engineering, rather than leaving it up to the people themselves, with the result that different communities were experiencing vastly different standard of living and rates of improvement of living indices. I asked about our inability, or rather, unwillingness to counter the sort of propoganda that led to the two-nation theory and the partition. I was hoping he might suggest a uniform civil code and more aggressively encouraging all sections to form a value consensus with the mainstream. The question was nebulous enough to have begun with, and without the help of the microphone it was hopelessly lost on RG, who could only catch my beginning phrase about Democracy in India having been the imposition of an intellectual minority. He talked of their having been elements of democracy in our culture long before the republic was formed - something I totally agree with him on. Argumentative Indian is a must read on this subject.

Immediately after he had answered the question, Rahul came back to the story of the ventilator, and wanted to know the name of the hospital and the doctor who had issued the order. Not wanting to shout names just there, I offered to tell it to him after the meeting was over. A dignified person came to me and introduced himself as working for RG, and took down the details. He took me aside and asked me to wait there for a meeting with RG. Soon afterwards, Rahul came down and came to where I was standing, and repeated what I already knew - that he didn't have anything to do with it, and would have never allowed it to happen in the first place. He asked his secy to raise the matter with the SPG at the earliest. I was beginning to feel ashamed for having made this man apologize twice for what was clearly not his doing, and I felt to compelled to say something.

I told him, words I'd always remember. "I hadn't planned on saying any of this here when I had come in. But after seeing you, and listening to you, I felt you deserved to know what they were doing in your name."

"You are a good man, Rahul Gandhi."

And I dare say I had the nerve to pat him on his back. Twice.

I think he was moved as well. He paused two seconds, said thanks, patted me on the back as well, and got inside the SUV that took him away.

Change is here, Rahul Gandhi. Way to go.

Sunday, October 4, 2009

The Stench of the City, part III

I dont think anyone would want to read through in detail about what happened at the sewage plant, but I might as well finish it off for completion sake.

My team consisted of 2 health inspectors, 2 junior health inspectors, 2 public health nurses, 4 junior public health nurses, driver, and a police escort.

We could smell the place more than a km before we actually got there, especially as we happened to cross the path of downward wind.

The plant was located, not at a desolate stretch of wasteland, but on a somewhat thinly populated village.

The plant was not set up with the permit of the village panchayat, as such it could be called an illegal establishment. The panchayat had, for the past decade, been mired in a fight against the much stronger city corporation which was the sole beneficiary of the project.

While construction for the plant was under way, the gullible villagers were told that the corporation was preparing a garden and a flowering plant nursery. It was a reasonable explanation because 10 years ago the location of the plant had been a hill, which was a popular hang-out for local people. That hill was razed over the next decade to cover garbage in the sanitary land-fill. The hill was called, 'the sunrise-view'. By not giving them advance notice, probably because the govt knew it would never be able to establish a plant with the concurrence of the local population in this high density state, the govt had denied the local people the option to shift to other areas, and now their properties were un-sale-able due to proximity to the plant. Residents of nearby areas have not been re-settled to date.

So here the corporation was conspiring against a village panchayat, and because the plant was absolutely essential for the running of the capital city, the legal machinery and even political parties had decided to look the other way. The media, but for the occasional report, made no big hue and cry, as is its wont in such matters.

I especially remember one household that I visited, a large, old house built in traditional kerala style, and could for one moment picture this place as it was, only a few years ago. A house that once had a joint family living in it. The big cattle shed with numerous animals. The fertile lands full of fruit-laden plantains and coconut trees. Now all those capable of doing so had moved away to the city or other villages. Those left behind, left without their earning hands, were barely eking out a living. They were unable to rear livestock anymore, because the local stream where they used to bathe the animals had turned vitreous. Man and animal was bound to get sick if they touched the water. These were our people, and we were disbanding them.

At one point the local people, tired of fact-finding missions, blockaded the corporation van, and I could see that the police escort was no ceremony.

And I knew with a sinking feeling in my heart, that this mission was a joke already, even without my going in as the expert. It was no anomaly, just that the joke, without any mirth, had become that bit more funny. What do you expect when the corporation is sponsoring the fact-finding mission that would investigate complaints against itself?

Just then, I could really feel the stench of the city.

Friday, September 11, 2009

An Expert of the Highest Order (The Stench of The City, Part II)

And so I waited, while my friend left.

"Dr.Pillai, sir?"

In full dress uniform stood an official of the High Court of Kerala, though I did not know it then. Not the khakhi dress of the hospital peon but starched white with a cap with a dignified bearing. Black boots polished with care till they shone. It was obvious this man, whoever he was, took his job quite seriously.

I nodded in confirmation, and motioned him to a seat. He preferred to remain standing.

"I represent the authority of Judicial Ombudsman. A complaint has been taken into file at the Hon: High Court of Kerala against the Corporation of the City of T_____, and you sir, are hereby directed to jointly conduct an enquiry into the facts of the case with other experts and submit your recommendations to the Court."

Now, I had just the slightest idea as to who or what an ombudsman was, but as for the rest of what he had said, It might as well have been Greek or Latin.

I took a long look at the man, to see if he would just burst out laughing, and tell me this was all just one hell of a practical joke.

"Hold on one sec. What exactly is it that you are asking me to examine, and who (the hell) told you I am an expert in these matters?"

"The court has asked for an advice from the dept of SPM. Your name comes highly recommended."

"The Old man, I mean, Prof V________ told you this? Yes? I see."

"And what exactly?"

In reply he said just one word: The name of the village panchayat that housed the waste-disposal establishment that handled all the waste generated by the city. The once obscure town was now a house-hold name, thanks to the decade-old struggle by the local population objecting to the operation of the waste-disposal plant close to their homes and places of living and sources of livelihood. I had vague memories of strikes turning violent, and being put down by force.

I groaned inwardly. This was getting worse all the time. Missing lunch seemed the least of my worries just then. I was frantically trying to remember newspaper reports I'd read years ago, about corporation officials on routine visits being held captive by the people.

He took my stunned silence as the cue to go on.

The people had formed a citizen's action council and made a submission to the court to immediately halt the running of the plant. It was posing a grave public health problem to the area, they claimed, and submitted a list of people who were allegedly suffering from health problems related to the running of the plant.

My job-definition would be to track each of them down, establish the veracity of their complaints, determine if the same was due to their proximity to the waste-disposal plant, and submit a report on the same.

The corporation had arranged for four teams to investigate. They had got people with qualifications and experience in public health, and nothing better to do on the week before Onam, for three teams, but they had to send one more 'expert' to head the last one.

"Your pick-up vehicle will be here in a short while. The other doctors have already agreed upon a questionnaire and flow-chart for everyone to follow, so that work of different teams can be standardized. That should help you."

Will surprises never cease? What did he mean 'In a short while'? Was it that they wanted me to go today and now? Then I remembered, and knew the reason behind the professor's good manners. Someone had backed out at the last moment, and I was to be the fill-in.

He saluted smartly, and left. Funny, I think, that he should.

Wednesday, September 9, 2009

The Stench of the City, part 1

The day had started well enough. The OP was rather light, and it looked like it was going to be that rare day when we might be able to shut shop before noon. It was the week before Onam, and there was a general festive mood that had rubbed off on everyone. The patients were probably bottling up all their troubles until the festive season was past. My colleague was already making plans for taking his friend out to a long-delayed matinee and buffet lunch. I was happy for him, having known one too many failed relationships amongst doctors only because he or she was never around when the other needed them. In a relationship, few things can be more damaging in the long term.

Just as we were about to call it a day, there came a call from the dept the of the rather elaborately named Social and Preventive Medicine or simply SPM. To have the officer in charge of public health calling you is bad enough, but when even she doesn't get to the point, but rather asks you to stay put and hands the phone to the professor, you get a really, really bad feeling in your stomach that this is going to be something really, really bad.

"Hi Dr! How are you? Got any plans for Onam?"

The Old bull-dog being courteous, even deferential! Who ever heard of that? Now I knew I was in trouble, probably with a capital 't'.

"Doctor, we got a situation. Could you please wait a few min until I can dispatch someone to brief you on it?"

"I know you are in some kind of mess you crusty old curmudgeon, and you want to wash your hands clean off it. Its not something you can ask me to in the normal course of things, but at the same time you need someone who you think can do the job. Well, beat it. I can see through your 'nice guy' act and I ain't buying it any more. I've done my tour of duty at more tight spots than anyone else you know, and this time am calling it quits."

How I would have loved to say that to him!

"Yes sir. Of course sir. My pleasure sir. Thank you sir".

That's what I actually said.

I looked at my colleague. He was not making eye-contact. The natural thing would be to ask what it was that the old man had wanted. That would be the decent thing too, for I could actually ask him to stay back instead of me, having already done more than my fair share of 'dirty jobs', as we both were sure this was going to be.

But if you take a good man, put him up against a wall, then put a gun to his head, and say, "Your life or your pal's", what do you expect?

I know what not to expect. I believe six years at this place has made me a good enough cynic to know better than that.

He leaves, not a glance exchanged, our greetings unsaid. Six years of friendship, probably our last posting together, and this is how it ends. I feel pity for both of us. That's the only emotion I am allowed to feel, they tell me. No anger or disgust or envy. They say its not becoming to someone in the white coat to feel any of that. So you internalize your emotions, nursing a feeling of being regularly if not constantly wronged against and not able to even say it out loud, of being alienated from the rest of society, from your near and dear, and even from yourself; of being de-humanized. And worst of all, the knowledge that you are being judged against by people without an ounce of commitment within themselves. So you put up a facade, one of impenetrable emotional stability, that often belies the turbulence just beneath. And the show goes on.

Of course, I did not think all that just right then. I don't think that well on an empty stomach. But I certainly did think of the Onam feast I might almost certainly have to miss that day.

To be continued..

Wednesday, August 26, 2009

Kindness of Murderers.

*Some parts of this post deal with graphic descriptions of violence, kindly be warned*

First of all, I must apologize to Kate Adie, chief reporter for the BBC, from the title of whose highly readable autobiography 'Kindness of Strangers' I got the idea to name this post.

I write this with reference to an incident that took place here earlier this week. The heir of one among the most well-established business house-holds, a young and upcoming entrepreneur in his own right, was found murdered by the highway in the wee hours of the night. The police sprung into action, forming a task force headed by a senior officer. To their credit, the gang behind what was obviously a 'professional' job were apprehended within 24 to 48 hours.

I learned the story through the Malayalam media, who had a field day over it. Lest we forget, TV channels gave round-the-clock coverage of the latest developments, repeatedly showing shots of the murder site, a damaged mobile phone, the vehicle that the deceased was driving when last seen, and such.

Also highlighted was the increasing goonda menace. Until recently keralites used to take pride in the law and order situation of their society. Using hit-men to settle scores with rivals, or for parents to secure possession of eloped children, for youngsters to get married safe from goons hired by the parents, or for ensuring smooth functioning of business interests without interference from other goonda groups - all this was not only unheard of, but positively inconceivable. Sure we used to have enough and more of our own special breed of murder and violence - of the political and ideological kind - but precisely because such incidents did not involve the common man going about his business, unless he inadvertently got involved with it, I think we may have developed an unhealthy degree of tolerance to a culture of violence over the years.

So here's how the story unfolded over the days in the media:

Day 1:

The media cried hoarse, and with good reason, about how cheap human life had become. How an up-coming entrepreneur was cut-down at the prime of his youth, and how if even the creamy layer of the society was not safe anymore, what did that say for the rest of us?

And we all joined in our prayers for the deceased, his handsome face and gentle features evidencing a refined upbringing that had now come to a tragic end.

Day 2:

It turns out, that the car he was last seen in, did not belong to the deceased. Further, it is learned to be owned by the leader of one of the dreaded criminal gangs of the state: That there had been two co-passengers with him on the fatal night whom his driver, who was asked to follow in another car, had not seen before. The co-passengers are discovered to have had strong links with many criminal gangs. Questions are now raised regarding the pervasive nature of the influence of criminal elements at even the uppermost echelons of society, and how the business class was openly cavorting with them. New conspiracy theories are raised, that suggest that the victim may have been mistaken for the gang leader, as he was driving the latter's car, AND seen with his associates. Could it have been a case of mistaken identity, after all? There have been other instances too, when the wrong person was assaulted by gangs.

I have had opportunity to interact both with police officers, as well as some of the men involved in such occupation, in the course of my daily practice - and if I might say so here, what was unsettling about the ones I knew was not that they were giant brutes as seen in the movies.

What was most terrifying about them was their ordinariness. How they were not as radically different from the average man on the street as we might wish was the case. These were guys who laughed at silly jokes and still cried out when a simple injection was administered. In fact, If there must be one defining trait to be described, then it must have been an inability to put up with pain, physical and otherwise.

I had a patient once too, who had been bedridden for past 8 years, because he happened to match some else's description, and wore the wrong colour shirt. He still lives on, like the way the other (lucky) chap was supposed to have lived the rest of his days - with daily excruciating pains over both legs. Its not for nothing that these gangsters are called professionals. Whereas the amateurs might take it upon them to simply murder or thrash a victim, the 'professionals' do offer tailor-made services. Sometimes I think its a game played between the doctors and the 'quotation' team as they are called, with the victims life as the stakes. For eg, it might be possible to reattach a limb if brought within a certain time. So as to avoid this possibility the more experienced ones actually see to it that not only is a limb severed, but it is also mangled, so that there is no chance of it being re-attached. It would have been fascinating if it weren't so cruel.

Day 3:

It appears that the young industrialist had once been arrested for possession of narcotic drugs. A ladies' bag and dress is known to have been recovered from the car.

Day 4:

There is one final twist to the story, one that prompted me to write this post.

The police says it was a professional job, alright, in the sense that it was done by an armed 'quotation' gang. But it was done with altruistic intention, and not on contract. The deceased was driving the big SUV on the fatal night, when at a relatively sparse stretch of highway he hit a motorcyclist from the behind, toppling him. The biker who was going home was seriously injured, and was saved only because he had a helmet on.

He did not stop. He sped away, like so many car drivers do under similar circumstances, that has caused so many young men to die on the roads. Lives that could've been saved, had, instead of speeding away, the car or truck drivers had done the right thing and taken them to a hospital. He may have wanted to avoid being seen with the particular company he had that night, or may be he was drunk and didnt care, confident of his place in the world.

As things would have it, the armed gang was resting after a job elsewhere, just out of sight, and they were drawn by the commotion. They rushed the victim to a hospital in one of their vehicles, while in a bout of self-righteousness some of them followed the SUV in another vehicle. They overtook it after only a few kms, and in the ensuing scuffle, drunk to the bone as they were, ended up doing a professional job upon a man whom the law might not have touched for all its long arms. Only one person delivered the fatal wounds, and he was relatively a new member to the gang, with no history of violent crime.

There you have it, the entire incident, as it came to be revealed over the days in the media. I shall not venture to draw lessons or morals out of it, instead, presently I shall stop simply by remembering the immortal words of Alexander Sholtzhenitsyn:

"The line that divides good and evil runs not between nations, but cuts right across every man's heart."

Friday, August 21, 2009

Of Wallets and Bullets

I lost my wallet last Monday, the 17th.

More precisely, it was stolen from my person as I went to temple in the morning, it being the first day of the new year according to the Malayalam calendar.

It had nearly half my month's pay, driving license, identification card at the hospital, and my two ATM cards.

It hurt.

It hurt that I had lost the money, that I'd now have to go through the laborious process of getting another set of documents issued as well as preventing misuse of the original.

But what hurt most was the dent in self-image. The realization that some common crook could pinch it off me and I didn't even know it: That the apparently efficient and competent professional could be outwitted so completely by a professional of another kind. That hurt.

There was not much to do, retrieving a wallet lost in a sea of perhaps a thousand being what the old adage 'needle in a haystack' is exactly about.

'Hope' is a strong feeling. Sometimes, it is all that stands between man and madness. In such hope, for gaining a degree of apparent control over the situation if nothing else, for retrieving a bit of that lost self-esteem, we tend to do something – anything – that might be useful; often, in the face of overwhelming odds and reason that tells us otherwise.

So I go to the police station, report the theft, get a receipt for the same that says my driving license is stolen, and then – wait.

I need not have bothered.

But something did happen. Life went on. It was not as much of a catastrophe as I'd thought at first that it would turn out to be. It hurt still, the actual loss as well as the feeling of being outwitted, but fortunately – and this is important - there was no pressing engagement that I needed the money for.

There was a sense of Deja Vu, though. There have been other occasions too in my life, when something that I thought would hurt deeply, turned out to be not that bad to have happened, after all. It was the fearful anticipation that was harder to bear than the actual event when it happened.

The converse has been true too. Something one anticipates to be infinitely pleasing, turning out to be just one more good thing to have happened. Here I would remember how getting into Medical College turned out to be a mixed bag.

Then there were the times, those things that happened, that brought so much happiness that one could never have thought possible beforehand. Case in point my buying an old, second-hand Royal Enfield motorcycle that leaked oil from everywhere. Life has never been the same after that.

And finally, some things in life, you never know how much pain and hurt they will cause, until the day when finally lost. Ask anyone who's been in love and lost it.

So, it turns out there really is no telling how much something would please or hurt until we actually get there. Turns out it may not be a very good idea to plan your entire life ahead of you, for who knows how we might happen to not really like what we had planned for ourselves, or conversely, how we might actually like something we didn't quite bank upon.

I guess there is some merit to living under the stars after all.

Wednesday, August 5, 2009

Marital Bliss

The first time I saw her, her face was a bloodied mess. All puffed up under the left eye, a spreading blue over the lips, dried tears cutting through caked blood on the cheek and under the nostrils, like dying rivers across a desert. Smell of stale urine. Torn clothing hastily covered by a bed-sheet. The neighbors that brought her in did the talking: she was far too weak.

"Its the husband". One of the men volunteered, to my questioning gaze.

"Again". Whispered one of the women, talking half to herself and half to no one in particular.

I had a rapid look-over. Detailed examination will have to wait. There was the face, with injuries suggestive of a fracture of the nasal bone or septum. The right hand was bend at an unnatural angle halfway between elbow and wrist, swollen and exquisitely tender; possibly a broken arm. Smell of urine, incontinence probably from a kick to the groin.

The woman was in far too serious a condition to be managed at the peripheral center where I worked. At least for the first 48 hrs, she'd have to go to a higher center. I gave first aid, filed a police intimation, and referred her.

She came again a few days later. There was a cast over the arm, and the nose was in a protective covering too. She had been referred from the Medical College, back to my care.

I could see, then, that she was a young woman, younger than I had somehow assumed her to be, last time. Perhaps younger than I had thought possible to have undergone so much unkindness.

We talked.

"Its usual. When he is home, that is."

"The neighbors tried to help, until he started threatening them too. Then we were left to our own fate. Me and the two kids, that is."

"He was particularly mad yesterday. I had sent the kids away to my relations, where they might have had a chance at schooling."

She hadn't consulted him, apparently. Not that it would've made any difference. As far as he was considered, the kids were an accident, a vague annoyance at most. But to have a decision taken without his permission, that was to his way of thinking an unacceptable challenge to his authority. It didn't matter that he never wondered how and when they ate or whether the roof was repaired before the rains. It didn't matter too, that he was away most part of the year, sometimes for weeks together, only to return in the middle of the night reeking of alcohol. The only times he would be reminded of his family, would be if and when someone tried to help his wife make ends meet, wherein he'd be reminded of his pride that his wife had let down.

Perhaps he was simply mad that the children might get an education.

"I really thought he was going to murder me that night. The neighbors thought so too, probably, for they came looking for me in the morning. I had dragged myself out of the house, but couldn't make it up to the road. I'd have died, if they hadn't come looking for me."

I told her about the police intimation that I had filled, and urged her to follow it up with a complaint at the commission for prevention of atrocities towards women. I must have sounded more confidant than I felt, for she was cheered up instantaneously. She had a face that lit up when she smiled, and even through all the pain, I could see that she was beautiful, once, before all this.

She was discharged a few days later. Not once did he visit her.

I saw her a few times more during the following weeks, seeking to ease the pain of a body destroyed by more abuse than one should have to go through in an entire life-time, and the hard labour of raising two kids all by herself. However crowded the OP was, she'd wait till she caught my eye and give me a smile, which I'd always acknowledge without fail. Then, slowly, she was seen no more, and I forgot the whole episode in due time.

The next time was the happiest I ever saw her. She had come to get a certificate attested, she said. The kids were away at her relations, and going to school. They were both working hard, and she hoped of putting them through college. She was being offered a job as sweeper somewhere now.


She had followed up the police intimation. But even before her complaint could be lodged, he had done everyone a favor by getting arrested for some petty offence, and was sent to jail for 3 months.

That was 4 months ago.

I saw her again today. The light had gone out of her eyes, yet again.

"He came looking for me after he was released. Created such a scene where I worked, that the employers asked me to leave, for fear of having him back. He tried to get me to go back and live with him, but I wont have any of it. Neither will I allow him to get to the kids. He has threatened to hurt me, and I know he is perfectly capable of doing that."

She opened up her handbag, and after ensuring that no one was watching, showed me the kitchen knife she was carrying.

"I've a surprise ready for him, though. He wont hurt me or my kids for long now. I am waiting for him to show up".

I was shocked out of my trained calm demeanour. Too shocked to think coherently, I think I tried to say something. I am sure it must have come out non-sense.

She had a different air now: a confidence that terrified me.

"You are a good man, doctor" she said.

"But you are young. There are things you don't realize quite well as yet"

I knew she was not that old herself, but today was not the day for arguments.

"I know you could call up the police about this, but I don't think you would. Besides, do you think anyone gives a damn if I kill the bastard or he kills me?"

I tried to say something. She raised her hand to stop me.

"Please give me something for the back-pain, it has worsened this past week. I have difficulty getting up from bed in early mornings."

I wrote out an injection, two types of tablets, and one ointment of which I had a sample that I gave to her.

I sat there wishing there was something more I could do.

(slightly fictionalized)

Thursday, July 16, 2009

The Other

I was dining with four learned men only the other day.

And learned indeed they were, truly men of the world.

A little afar, sat huddled, almost afraid

The expatriate family.

Who they were, we knew not.

But this we knew, and knew above all else,

who they were not: Us.

They were The Other.

Thus spoke the first learned man:

Look there, if you will

Those people, over there

I've seen cleaner cattle, you know.

Said, the second learned man:

(And he was keen with numbers, as good as they come.)

They drain off what little we have,

And give but little in return.

The third learned man,

He was a man for order, apparently

for he pointed to their crying child,

and said something about lack of discipline.

And the fourth learned man,

he was a man of Religion.

He spoke with intensity,

of their corruption and ineptitude.

Thus they spoke, those wise men

Men of the world, who knew many a thing

But hadn't yet learned, in their long years

to see the man at the other side of the wall.

The expatriate child, noisy and unruly,

Running around our table, oblivious to contempt, as yet.

She plucks a flower from a potted Rose,

And smiling like an angel, she gives it to me.

Tuesday, July 14, 2009

That City

My time here is coming to an end.

Tomorrow, I'll be back to the city.

That city: with its polluted air, noise, the filth, and its total lack of kindness.

That city: with its beaches I love, civic amenities I value, theaters I frequent, libraries I visit.

That city, with its people: The confident, the suave, the hapless, the lost.

That city of endless demonstrations and the consequent break-down of order, while the law chooses to look the other way.

That city, with its dark obsession with people's private lives.

That city, with its palpable lack of enthusiasm and enterprise: where corner-shops remain closed on Sundays.

That city, with its pathetically repressed sexuality, where women are groped in broad daylight.

That city, where pedestrians fall into potholes, and die.

That city, which has my sweat and tears flowing through its sewers.

That city, where I once met a woman, and knew love.

That city, which I refer to as mine, but in truth belongs to no one.

Nobody's city.

That city, which I didn't think I'd ever come to miss.

Friday, July 3, 2009

How to save money at Aryanadu

I think its time now for some light-hearted stuff, after all that somber death-talk of the past week:

Something happened last week, that left me suddenly without the cash surplus I maintain at Aryanad. This being a place without ATMs, and I having left my bank pass-books back at the city, I had to push the week off with just whatever money I had on my person: One 500 rupee note I keep folded under the driving license, precisely for times like these, and loose change in 10s and 20s not amounting to more than 100.

I plan to change my 500 into smaller denominations, and then squeeze every penny until it cried for mercy.

I begin with the lone internet cafe in town, that doubled as a cultural center and recreation club for the youth. It has two not-too-new computers with a not-too-fast net connection that keeps on getting disconnected at least once every 30 min.

But that doesn't seem to deter the (predominantly) late adolescent crowd that has made this place their hang-out.

I can see the impressive boys and the impressionable pretty young ladies exchanging glances, and sometimes I see a notebook left casually by a girl, only to be picked up minutes later by some bright-eyed boy smiling ear to ear. I love this crowd.

I think they look at me as someone who has absolutely no interest whatsoever in their life, that I, being the dr, would never have run after a girl or been simply starstruck when after months of chasing around I received that most important smile of my life.

They give me a wide berth, never making me having to wait for net access, and cutting down on the profanity-ridden 'manly' talk with me around. But that apart, they think I am part of the furniture. So they seem to have no problem with freely interacting, exchanging glances and letters right under my nose.

I have read that in ancient Egypt the women royals had no qualms about undressing in front of their male slaves. De-humanisation can happen in both directions I guess.

I wish I could come out of this shell they wish to see me in, and share their laughter.

But I believe its a sin to kill a mockingbird, and I let them be.

So, at the 'Aryanad cultural centre', I use the net for a half-our, and offer the 500. The cashier respectfully hands me back the money, apologizing for not having change, and asking me to pay next time I go there, whenever that is.

Now I did have a 10 rupee note with me, but until I could change my 500, I was not going to part with it if I could help it.

Next I go to the small hotel where I have my lunch on most days. Have the usual, that costs around 25, and offer the 500.

Same: They handle the money back, THEY apologize for not having change, and so will I please pay next time I go, whenever that is.

I start to get the hang of things.

I needed some balm for my aching arm. Same there.

The bike needed a little tinkering from the mechanic. Same.

I love this crowd.

Thursday, July 2, 2009

To Kill a Mockingbird

"I'd rather you shot at tin cans, but I know you'll go after birds. Shoot all the bluejays you want, if you can hit them, but remember its a sin to kill a mockingbird"..

Tuesday, June 30, 2009

Reluctant fisherman, the final chapter

Cut back to the present:

Ayyavu on his deathbed, brought home as adviced by his doctor at the small rural hospital. As I approach his bed I can hear the laboured breathing suggestive of impending heart failure. I shift him to a safer posture so as to minimise the risk of aspiration, and give him blows over his back with a cupped hand.

Dad asking me what I thought needed to be done.

I, trying to give an answer that would sound wise and practical. And thinking some of the thoughts mentioned herein already.

I try to explain the various options before us: That we could, if we hurried, still get him to a higher centre with an ICU, where we could possibly resuscitate him; but without any assurance of being able to return to healthy living.

Or we could just let him be. As was obviously the opinion of his doctor.

I've only once met his doctor at the village hospital, and he surely has been there for a very long time. Perhaps, he had been there for far too long, having not known that he might be sued successfully for a considerable sum for having done what he did.

He didn't get what is known as 'informed consent' from the patient's party. He took it upon himself to decide on the fate of his patient, without going for a detailed discussion about the merits of the situation.

Informed Consent means the patient has the right to be completely informed about the treatment plan, and ultimately the right to choose or refuse a particular line of management.

So, a dr in a city hospital would discuss with the patient's party what i shared with my father: that we could take him to an ICU, or we could let him just die.

Now, who would want to let their father die, and do nothing?

So, shift him we would to an ICU, Where we would do many things.

And then, finally, we would go for informed consent, round two:

We would explain in some detail the measures taken so far, and how nothing seems to work. Now that the patient is hooked up to a ventilator, we will ask the son's permission to terminate treatment.

From passive spectator who didn't do enough to prevent his father's death, we would thus make him an active participant in his father's death, who gave the permission to go ahead and terminate his life, after having been duly informed that it was indeed possible to keep the patient 'alive' for an indefinite period.

Sometimes, they say enough is enough, just let him die in peace, please.

But sometimes, especially if the patient is not an elderly father but a college-going son involved in a road accident, then they sell, borrow, beg and steal all that they can to keep the circus going on for as long as they can.

What else is there to do?

Yet, at the end, all they accomplish is to delay the inevitable day of reckoning, not to avoid it altogether.

They'd still end up leaving the hospital feeling they let their son down.

That's the paradox of informed choice in life and death situations.

I could see all this unfolding before my eyes when called upon to answer that question.

And I could really think of no answer to give.

He was my grandfather after all. How could I ask my father to just let HIS father die, and not do anything about it?

What would I be telling my dad through it?

Ayyavu was a soldier who saw action in Burma during WW2. He was an artillery gunner, and machine gunner for advance patrols, alternately. During the years of my childhood, when I thought being a hero was about being a man with a gun, I would never leave his side, always hungry to hear stories about his tour of duty.

I'd, for example, listen with awe, over and over, to his stories about lying in wait for Japanese airplanes, along with a crew of 8 or 12, sometimes including British officers.

In the eye of my mind I could see the big, gleaming artillery gun, its muzzle raising its head upto the sky, not a bit of rust on its steel frame, the huge shells they would carry on mules.

I could even hear the ear-splitting boom of that mighty gun.

And each time I listened to the story, the gun just got bigger, and the boom even louder, in my vividly imaginative mind.

But there was one question that he would never answer me, no matter how many times I asked. For a boy in awe of the power of the gun, it WAS the most important question:

I asked him, over and over, if he had ever killed a man.

Each time he would avoid answering me: tell me a divertionary tale of adventure, give me a treat, or sometimes simply get angry.

Later on, when I got through medical entrances both at the biggest civilian teaching hospital in this part of the country, as also in the prestigious Armed Forces Medical College at Pune, my semi-literate grandfather did play a major role in allowing me to put things into perspectice and make the choice I did.

When I reached the stage when young people start demanding motorcycles, and I was adamant about getting an Indian Army vintage Royal Enfield, he remained aloof; but there was a twinkle in his eyes that let me know that he was secretly pleased.

He was a soldier, after all.

Just then my eldest aunt came out of the house and to the corner of the courtyard where I and dad were holding our discussion, and asked me to come to the house. By the way she asked me, I knew what it was.

Grandfather had died. In death as in life, he had decided the size of his serving.

And now I was being asked to confirm and declare death.

I went in. The eyes had turned lusture-less. The pupils were dilated and fixed, and not responding to light. A sure sign of death. I checked repeatedly, though I knew it to be pointless.

I turned and looked at my dad, a knowing look. He went out of the house. I disconnected the IV line and closed the eyes. In a practiced sombre tone, confirmed death to no one in particular. And then, not trusting myself to keep a lid over the sea of emotions roaring just beneath the surface, I went out too.


Monday, June 29, 2009

Reluctant Fisherman, part II

And so, hook him up we would to a ventilator. Start Total Parenteral Nutrition wherein all the nutritional requirements would be met through IV fluids. Use special auto-inflatable mattresses that avoid any one contact point from having to bear too much pressure, preventing bed sores.

In short, the machines would do the work of living for him. All he'd need to do is to play ball and to consent not to die.

And then, the waiting game. The participants in this game would be:

1) Us, the doctors, who think we are doing one hell of a job.
2) The patient, who is really only a spectator from now on. Or rather like the King piece in chess, around whom the game evolves, without doing much himself.
3)The patient's party, who have to pay for this entire circus.
4)Death, like Ingmar Bergmann's character from 'The Seventh Seal'.

Over the past few decades, the definition of death, the point of no return, has undergone revolutionary changes, thanks to the advent of newer treatment modalities, better access to healthcare, faster and safer methods of transferring patients to higher centres (like air-ambulance), and of course better paying capacity of the people allowing for protracted and expensive treatment.

Gone are the days when any patient without a palpable pulse was declared as dead. End-organ failure from chronic diseases have all been gradually challenged, more so with the advent of organ transplant. With plasma expanders and better networks of blood banks emergency surgeries in Road traffic accidents have become feasible and are increasingly commonplace. Now, stem cell research is being offered to us to push the frontiers even further.

Fascinating possibilities.

But what has sadly been missing is public debate on the same, apart from the occassional moralistic hue and cry over stem cell research and the possibility of human cloning. For the most part, our ability to protract death has increased at a much faster pace than our ability to subject them to scrutiny and debate by social institutions.

And the situation is only worsened by our reluctance to do so.

Post World-War II, the world was immersed in shocked disbelief at the massive scale of death and destruction. Suddenly, 'Empire' became a despised word. 'Nationalism' went out of fashion in a big way. Even 'Free Market' took a massive hit, and is yet to recover fully the lost grace.

But far more powerful was the change of public opinion against Eugenics, the science of improving (human) race by selective breeding, and Euthanasia, the act of offering painless death to patients who willed such, was suddently frowned upon: Thanks to horrendous barbarity perpetuated by the Nazis including doctors, in the name of science and racial purity.

And so we are, frightened shitless to talk about some sort of compulsory population control, even as grain stocks the world over are depleting at ever faster rates.
By voluntary population control as is practiced in my country we have a peculiar situation, wherein anyone with social concern and responsibility - precisely the kind of citizenry we need more of - abstains from having more than an offspring, or two at the most. On the other hand we have people openly proclaiming as their heavenly duty, to have all the sex they can in the world, and bring forth more of their kind. And having a welfare state firmly in place, the responsible citizen pays for the upbringing of the offspring of the one that couldn't care less if the country goes to the dogs. Those who proclaim as their heavenly duty to have all the offsping they can, do forget one basic fact: Nature has a population control strategy too.

It is called starvation.

Massive death from hunger would be a real possility before much of the world in future.

The very near future.

And hunger, it has long been understood, is not a problem for the agriculturist alone.

There can be no peace in a world with hunger. In recognition of this very fact was Norman Bourloug, the Brazilian scientist who made discoveries that led to the green revolution, awarded the Nobel Prize for Peace.

But as doctors, we are merely glorified technicians, and while we may think these thoughts, It is certainly not up to us to decide which life is worth living.

Who can say at what point a life becomes unworthy of living?

Who can say where a dream ends?

to be continued..

Friday, June 12, 2009

The reluctant fisherman

My grandfather, the one mentioned about in the previous post, died recently.

He died on a Wednesday.

Dad called me early in the morning.

Ayyavu had been discharged from the small hospital where he was when I had last visited him, brought home on Monday, and after a day, taken back and admitted again. On Wednesday morning, the bystanders had been asked to take the patient back home. By the time father was informed of the developments, the instructions had been complied with, and the patient brought home.

He wanted to know what I thought: whether it was alright for him to be brought back thus, obviously to die, or if he had to be moved to a higher center.

The few occasions that I've had to take similar decisions flash through my mind. No doctor, I am sure, will ever forget his first experience of declaring a death.

Mine was a 26 year old lady. Advanced cancer of the breast, spreading onto the spine. Death must have been due to impingement of the respiratory center in the brain-stem. Death would have come, swift and painless.

Like a leaf falling away she should have died.

But the living had to be dealt with. People who'd refuse to understand things like spinal metastasis involving respiratory center, as also doctor having taken the 20 min it would take to reach from one end of hospital to the other, after having finished the urinary catheterisation that was halfway through when the call came.

When I got there, the scene:

The nurse rushing away, apparently to load a hypodermic syringe with life-saving medication (adrenalin/ efcorlin), but in all probability just running away from the scene, now that the duty doctor had arrived.

A lady co-house surgeon who happened to be in the next ward standing near the bed, drawn by the commotion.

The patient in her bed, not moving or breathing.

All the patients in the other beds, on the floor between the beds, and on the verandah, encircling the bed in a sort of three-tier human shield.
The bystanders of all the patients mentioned above, forming another three tiers.

I knew instantaneously that the patient was in cardiac arrest. She must have been for at least a minute or two before I arrived. Brain functions are irrepairably damaged after only 4 minutes of impaired cerebral perfusion. I jump onto the bed and start to give CPR: the chest-thumping routine one sees in movies every now and then. (Only, when done for real, it is done with far greater force - sufficient impact to break the ribs and reach the heart, and at a rate of 100 per minute, or as close to it as u can). We did it, I and my colleague, I doing the thumping and she ventilating from the ambu bag twice for every 30 thumps. There was no response even after 5 minutes.

I knew the patient was gone. The eyes had turned lustreless. Even before the pulse goes feeble or the body goes cold, the eyes turn lusteless in death. My colleague, I am sure, did notice it too, but she obediantly helped me for as long as I continued giving CPR. After all, it was not her day to make decisions.

I was the duty doctor.

But confirmation and declaration of the same will have to wait.

I tried to gain some degree of control over the situation. I knew only too well how easily situations such as these could get out of hand, that the grievances of the people, real and imagined, coupled with frustration and disbelief at the death before their own very eyes of a young and apparently healthy person could all build up to pure mob anarchy very soon.

I was into only my first month of internship training, and already made something of a name for myself as a good man to have in a bad situation. There's something that's drilled into every medical student through the 5 and half years of training : that a doctor, even a green-behind-the-ears fresh graduate, has to be seen to be in charge. He has to make the patients, their party, AND himself believe that he can handle the situation.

Even when he doesn't know two hoots about what he's up against.

So, much to the surprise of my colleague, I call for an oxygen trolley. I move the patient down one floor and into the ICU, keeping an ambulatory ventilation bag over the face all the time, for death was all too apparent by now. Kept the deceased in the resuscitation area outside the ICU for a respectable duration of time, before declaring death.

The post-graduate on duty at the ICU was irked by the increase in paperwork. He thought the act had been carried far too long. Even I wondered if the right thing was not to have plainly confirmed the death, declared to the crowd, called in security if necessary, and left.

After all I had other calls to attend, AND that lunch I had missed by 5 hrs.

There will be a report of the same to the professor, the post-graduate assured me. So I was not surprised when asked to come forward during morning rounds the next day.

The professor asked me to step forward, and commented me for having been a good man in a bad situation.

The situation, according to the post-graduate at the ICU, was merely one of confirming an anticipated event. But as I saw it, and later as my professor chose to see it, the 'situation' was not merely limited to dealing with the dead.

That was easy. But we had to deal with the living.

So, when dad asked me what had to be done about grandfather, I knew it was not only about Ayyavu. It was a question, the response to which would affect all of us for a very long time to come.

I thought of what would have been the obvious thing to do, if we were in a city, like the one where I am based now. Or for that almost any part of my state, where healthcare options to the population are plenty and in competition with one another for a larger share of patients.

The obvious thing therein to do would've been to shift to him to a higher center, one with a properly fitted Intensive Care Unit. The doctors there would start him on continuous intravenous fluids to keep the heart beating, Catheterize for continuous bladder drainage, insert endo-tracheal tube for ease of breathing, connect him to a cardiac monitor that would produce a continuous electrocardiogram recording (that produces the beep sounds that characterize ICU s), free flow oxygen (if necessary) using a hood over the face, and pump him with adrenaline, atropine, steroids, broncho-dilators, dopamine, aminophylline and what not. When finally, the tired body can take it no longer, and life breath is slipping out in spite of our best efforts, we would hook him up to a ventilator. And then the waiting game would begin. A deadly game of cat and mouse. We would congratulate ourselves on having cheated death, for we can now keep the patient alive for an indefinite period of time.

(hi folks, since I am now posted at a place called Aryanadu, which is an end-of-civilization sort of place, I have limited access to net these days. The only computer center in town is much in demand, and it is only by being the doctor 'saab' that am able to access net as and when I want. But I hate to push my weight around, and so will be updating the rest of this post at another date. Thanks for reading me.)

Thursday, May 28, 2009

Homecoming, again

I had to go home last week.
I say, 'Had to.'

One grandfather's gone, the other on his way probably. Must go and see.

Started as late as possibly could.
Stayed with the old man long enough, and thus,

delayed reaching home as much as possible.

Once at home talked as less as possible.

Polite, courteous, distant.

Mother tried to initiate conversation.
Gave polite replies that couldn't lead to lengthy conversation.

She got the message, and retired to her bed room, hurt.

In the morning, asked if I needed any money.

That cruel question, again.

No specific need, I said.
If u want to give, there's the bank account. I added.

Stick it down your throat, I said in my mind.

She gave me some money.
'Thanks' I said, and shoved the money inside my wallet.
'No big deal', I said in my mind.

She then offered me some of the jackfruit halwa she'd made.
An exquisite delicacy, very difficult to make too.
I said sure, and thanks.

U cant replace harsh words with sweet taste, I said in my mind.

I was about to get on my bike and commenced the rather elaborate procedure of cold-starting an old Royal Enfield motorcycle

She came rushing with a hurriedly made packet.
I didn't even ask her what it was. I was already late.

Or may be I didn't care.

I asked her to toss it somewhere into my bag.

She did, and i did not think any further about it.

I returned to my quarters at the large teaching hospital where until recently I was a student,
And am now at a no-man's land between being a student and an independent professional.

Was drenched to the skin. That and a fall into a rain drain, having lost control in the heavy downpour.

Called in a leave for the day, surfed net for a while, went to sleep.

Woke up late in the afternoon.

It was raining outside my window. Moisture peeping into the room through cracks in the ceiling.

I was cold and lonely and hurt and hungry.

There was no food.

There was no heat and no warmth either.

I remembered the packet that mother had tossed into the bag. Fished my hand inside the bag and found the packet.

A half-finished bag of chips, and in another plastic cover, one last ariyunda out of a packet for a dozen.

All that she had in the house.

All that she had.

If only I could have a good cry..

Tuesday, May 26, 2009

a dime and a thought

I figured out something the other day. That I am a cheap miser.

The Bus conductor, I am sure, must have thought so, by the way he pushed 50p change into my hand and that too only when I had reminded him that, well, he owed me 50p.
I gave him 5 rupee for a Rs 4.5 bus ticket, for which I received a ticket, and no change. I waited for the half hour that the journey lasted, and then as I was about to disembark, gently reminded him that he owed me money. At which point he took out his black regulation leather bag, opened it with far more force than was necessary, fished out a 50p coin with the facial expression of someone being troubled for something far beneath what was worth his time, and then pushed the coin into my open palm.

I think he took me for a cheap miser.

Later during that same day, I ordered something worth Rs 9.50 (I have become wary of ordering items ending at prices other than whole numbers since) and paid with a 10 rupee note. My baker thanked me, as if to signal the end of the transaction. But I being the stingy miser that I am, the transaction was far from over as far as I was concerned.

He owed me 50p.

I asked for my change.

I like my baker. He is just about as straight forward as they come. He doesn't confuse me.

He told me I was a cheap miser to have asked for my change.

I like my baker. He, like me, knows the value of 50p.

Two people giving you similar feedback over two separate incidents on the same day, deserves to be given some thought.

So they, my baker and the bus conductor, had me thinking, could it really be that I am as impossible as to be a misfit amongst my peers? After all, on both occasions I had had no lesser than two thousand rupees in my wallet, and another 12 easily accessible via ATM card. I maintain a motorcycle, the way some people maintain antique cars - though it costs me at least as much as it'd to maintain myself in style. Only that day had I had a light breakfast for 25rs from a hotel, given the boy that served me Rs 30, and walked away. As a matter of policy, I do not wish to talk about the amounts that I have from time to time spent on poor patients in our wards over the years.

I will only say this much, that I have donated my lifeblood 7 times, and on 4 of these occasions for total strangers.

So I cant be that bad a man afterall, I reason.

I asked for my change, because on both occasions the other party failed to acknowledge its existence.

In doing so, they insulted my hard toil that went into the earning of that dime.

That, and, that alone, made me ask for my change.

Read somewhere, sometime back: He who wastes one hour of time, is yet to learn the true value of life. I'd like to say something similar about a dime too.

I dont understand money. Both my dad and my brother are financial experts and they have both given up on me. For the love of God, I do not understand the stock-market. Though I would love to make some money there by sitting by a computer and merely playing with numbers. Some day, if I make enough money, my brother or dad might be able to do that for me so am not overly worried though.

What I am worried, is that I might someday come to disrespect hardwork and take its fruits for granted.

I think it is precisely because I have 2 thousand rupees in the wallet and another 12 in the bank and more coming, that I have to be on the guard against myself.

But of course, I might just be a hopeless romantic pining away about such mundane things as a dime.

I think I'll, alongwith my baker and the conductor, join the party.

I plan to pay Rs 9.00 and Rs 4.00 respectively, next time.

I am sure both these gents wouldn't even notice the 50p then either.

PS: I have a few 25p coins with me too. I wonder if I should quietly bury them and move on..

Money given away is not a waste. That's what money is all good for - to be given away. And woe to the man that worships money as an end in itself.

But perhaps I am just a hopeless romantic.


a place by the sea

Bernada is the name of a nearly 100 year old clinic by the beach, in this city.

A quaint little place, still run pretty much the same way as it was when first established by some missionary with a sense of beauty.

I say it, because the place is beautiful.

An ancient building, and an even more ancient sister in charge. Neat white half-curtains on wooden windowpanes. Everything in its place.

A lone mangotree.

A sense of permanence.

The duty doctor's room having an old table and chair, bed and almirah.

Too bad the bed is not a four-pillar complete with mosquito nets, completing the colonial set-up. Not that a mosquito net was necessary, with gentle breeze from the sea flowing through the building at all times there are no mosquitoes to speak of.

As of now, the duty doctor's room has a regulation iron frame hospital bed. There are other indications too, of cracks in this otherwise picture-perfect place. Like the attached bathroom with missing toilet cover. I am sure Mr Romantic Missionary that started the place would never have stood it.

Perhaps, all is not quite well about this picture-perfect place.

Bernada is a place on the decline. As sad as it is true. Sadder still that it doesn't have to be. As I said, its still run pretty much the same way as when it was first established. A Nursing home giving basic healthcare. There must've been a time, before the city grew upon itself and extended right upto the beach, before the airport and not far-away tourist village were established, that it was the highlight of the area populated mostly by christian fisherfolk. Back then, the place must have been indispensable.

That is not the case today. Or Atleast that's what most people seem to think anyway. There being no dearth of fanciful multi-speciality hospitals in the city, they say the day of the nursing home, manned by a single doctor or at most a handful of non-specialists, is over. That they'd rather pay extra and go to one of those places that you couldn't at first sight differentiate from a star hotel lobby.

Now, I have nothing against multi-speciality hospitals. Or star hotels for that matter. And I honestly do wish everyone had the money and opportunity to get the level of healthcare that they deserved.

But there is still a strong case in favour of your neighbourhood nursing home. Your friendly neighbourhood doctor you would want to visit not just to talk about your ailments, but also about your daughter's marriage. Its About a whole value system that is being withered down by the onslaught of corporate culture (or the lack of it)

I have nothing against corporate culture either.

Its just that the relationship between doctor and patient is a sacrosanct one, and the best part of it is irrevocably lost when you try to manage it along the lines of a consultant-client contract.

I know how that one sounds. Repetitive and Pedagogous.

But that doesn't make it untrue.

Emotional issues apart, there is a really strong case in favour of having small nursing homes alongside large multi-speciality hospitals.

I say alongside, not instead of.

The issue is not just one of spiralling costs of healthcare.

It is also about local responsibility.

About inclusive access to healthcare.

About not losing your identity, Anonymity being the hallmark of what is known as Evidence Based Medicine or simple EBM.

They figured that out in the west a while ago: That corporate logics dont work that well in healthcare. They are going back to small single-doctor clinics in the UK right now. The Americans know it too, but since its bad business they would rather not talk about it. One look at comparative figures of UK and US health statistics will tell you the rest of the story. Guess who is better off - the Brits or the Americans?

I had ample time to think of all this while I worked night shift at Barnada Nursing Home recently.

For there were not very many patients that came to the hospital. I wonder if they had been forewarned about a certain doctor being on duty on a certain date. I wish that had been the case.

But I know that it was not. That Barnada, alongwith many other small clinics like it, is facing closure.

Patients dont want to go there. Doctors dont want to work there. Unable to hire full-time doctors, small-time nursing homes time and again fall upon a pool of just-graduate (and sometimes not yet graduated) doctors to mann their services.

That's where the person who wrote this comes from.

I once read while in school, many years ago, that Home is the place, where, when you have to go, They have to take you in. I did not understand one bit of it, but for some reason the words stuck in my memory. It was only much later, when I had understood a little more about the tortuous ways of love in the world, that I learnt what whole turbulent world was hidden beneath them.

There's still very much a case in favour of your neighbourhood nursing home indeed.

The end of an era.

(This happened way back in 2004. As a mark of respect to the person mentioned below, I choose to make this my first post.
Described as written on a rainy afternoon in september, 2004. Most of this is copied verbatim from that year's personal diary. I first thought I would make a new note, but then realized that, with time, this too has become just another memory and I'd be better off going back to what I first wrote down about it)

Today morning, mother informed me that an elderly lady in the neighbourhood, who was particularly fond of myself and my brother, and was rehallly like a godmother to our whole family, had passed away few days back. She said this casually, and without any sense of urgency, along with news of everything else that had happened in my hometown since my last visit. She didn't feel it necessary to inform me immediately of the demise, for indeed it was not a spectacular event at all. An old lady in her eighties passing away in her sleep. Just like that. But that was the end of a whole lot of things for me.

We used to call her as "sarammoomma". In fact, everybody who ever knew her that I know of, called her by that name. That was all there was that was needed. The name "sarammoomma". In that way I never got to know her real name when I was a kid, and I never learned it later on. "ammoomma" means an old lady or a grandmother, "sar" for 'sir' because she used to be the one people would take their children to, to have their first schooling, or to ward off evil luck. The people believed she had a goodness in her that could ward off evil luck, and sending their children to her, they believed, made the best investment for their children's character.

For as long as I can remember, "sarammoomma" had always been the same. Things changed continually all around while we were growing up. The primary school where we studied might have closed for the christmas week, and we would return, only to find the previously dull white-coloured walls now in refreshing pink. And that they had constructed new lavatories. Seperate for boys and girls! The changes became more profound when I went away to study in far off places and became a monthly ,or at times even yearly, visitor. Whole buildings might have disappeared, and new bilanes carved out of old trails. Suffice to say, I would be surprised if I did not find anything new or different since my last visit. But in the middle of all that chaos, there would be sarammoomma, always the same, smelling of her sweet herbal oils, giving me the news about a lot of people I didn't know, racing off in the evenings to be in time for the evening ritual at the temple, always present at all special occassions with those she considered dear - and there were quite a few of them. My memories of the goddess temple near our house will never be complete without sarammoomma in the front line, directing everybody including the priest, and nobody, not even the priest, would dare question her authority in temple matters.

There was a time, a few years back, when I had returned home after a year or so and was so pleasently surprised to find her fighting fit - and not one bit changed. A couple of visits later, and always my enquiries to my mother about sarammoomma's health having been positively reassured, I had sort of accepted that sarammoomma would somehow stay like that for a long time to come. So perhaps that's why I couldn't accept an old and ailing lady in her eighties passing away in her sleep: because she was sarammoomma, and that meant a lot.

That was the snapping up of an umbilical link to a childhood I now realize is never going to come back. And when I say that, I mean not just for me.

I realize its a childhood that my children would only be able to guess at.

I dont think we would ever again have a simple, uneducated old lady who, by sheer force of her goodness, would have the love and respect of one and all. Or that people, without caring about identities, would want their children to learn their first alphabet from her.

Loss of innocence has been one defining trait of moving into adulthood.