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.)