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.)

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.