January 09, 2012

Life as a doctor---The Hippocratic Oath

A sharp mind should know to care,
a fiery tongue should neither curse nor swear,
for a caring mind is the one that wins,
and a tongue that swears is a tongue that sins...

"Mr Dattatray Dessai, you can go home today.You are completely fit for discharge" I said handing out the discharge card to the dhoti clad man sitting upright on the hospital bed.
The air smelled of incense sticks and talcum powder.Entering that private 'VIP' hospital room was like entering a parallel universe especially after having inhaled the smell of savlon and betadine dressings in the general ICU outside.

There were no follow up details to be mentioned and neither was there any prescription to be instructed upon.The patient had insisted on getting admitted and much to my disdain, the authorities had decided to humour him.
But there was not much a humble intern could say in such a situation---and so I had watched a perfectly healthy Mr Dattatray Dessai (bag et al) comfortably walk into the private room with a cheeky grin on face and an apparently long holiday in mind.

It was just the beginning of my internship then.After the tumultous 4 and a half years of MBBS torture, I had finally started living my dream (one that every medical student looks forward to, right from the first day of medical school) in the department of internal medicine.

...life as a doctor had just begun.

"I have already informed that i would like to stay here for atleast another couple of weeks" frowned Mr Dessai, like an angry tenant who had been suddenly told to vacate from a comfortable lodging.

A little taken aback by his rude reaction, i said "You are absolutely fine, Mr Dessai.Yours was just a case of mild diarrhoea which could very well be managed at home itself."

I was trying my best to smile but my patience was wearing thin.
On the one hand, there was this Mr Dattatray who had been seeking shelter under a hospital roof, in the comforts of a private ward in the ICU for the last one week for no specific medical condition.While on the other hand, there was a shortage of available ICU beds due to which a lot of patients had to be shifted out into the general ward as soon as they would show the slightest sign of recovery.

"Doctor, we have spoken to your senior in charge about this.You seem to be new here.The matter has been settled." snapped the relative standing near the bed.

He then proceeded to punch some numbers in his cell phone and talk to a man he addressed as 'bhau'.
All this while, Mr Dattatray was comfortably peeling oranges and popping them in his mouth.
The room now smelled tangy and soon it would smell of all the other fruits kept on the side table.
This man was a threat to the fruit kingdom, i thought to myself---there had not been a single time i had entered his room and seen his mouth at rest.

Visions of mafia had started drifting in my head with the utterance of the name 'bhau'.
I whisked it away as a case of over imagination combined with a rather generous dose of bollywood influence and thought it was better to confirm what the senior resident in charge thought about the case, before i said anything more.

"You don't understand, Priyanka.This 'Bhausaheb' is a very powerful man.He has a lot of political connections.Dattatray Dessai has been working with him for over 15 years now and is almost like an older brother to him.I cannot take the risk of declining him any sort of privilege, no matter how unreasonable.One call to the dean and my job can be at risk."

In a low voice, he continued, "Look, everybody at the hospital knows that this man does not require any treatment anymore.In fact he never needed any hospital care to begin with.
When he insisted that we admit him, we tried to talk him into being shifted in the 'observation room' in the general ward.
But the private room is the only room in the whole medicine unit which has a functioning AC and now that he is so comfortable with all the other VIP facilities there, he is refusing to budge."

"But sir, there is a serious case of Falciparum malaria in ward 115.We cant deny that patient intensive care.You know that there are only two interns in that ward and 80 beds there.He needs to be here instead...under constant vigilance."
I could not believe my ears.We were bargaining a life for a stupid air conditioner.How much sillier could it get?

"I know about that Falciparum case and i have discussed it with the consultants as well.Everyone knows the seriousness of his situation.His latest blood reports show a haemoglobin level of 4gm% which could prove fatal." He looked at me for a second, his eyes reflecting a helpless guilt.

"We had planned on shifting him on to Mr Dessai's bed....but..." he stopped with the realisation that i already knew the story.
Looking at the residents crestfallen face, i realised that he was pretty much helpless.
From what it seemed, the Dean was in a vulnerable spot too---the pressures of hierarchy.

I was on call that night and i couldn't sleep a wink.As i repeatedly called Ankita, the intern in ward 115, i was informed of how much Gangaram Shirodkar--the F.Malaria patient, needed to be moved to the ICU.
While we cribbed and ranted about the hypocrisy of the entire system, i saw Bhau Saheb's relative sleep peacefully, snoring away to glory in the cool confines of the air conditioned room which was now smelling of what seemed to me, a nauseous mix of fruit salad and sandalwood.

I had to wake up for a few RBSL (Resting Blood Sugar Level) checks at 5.30 am.That meant there was hardly a couple of hours left and all the patients were stable.
The only sign of instability in the ICU was the whirring motion of the ceiling fan in the duty room and the racing thoughts in my head which kept going back to Gangaram, who should have been there instead of Dessai who could have very well gone home.

Since i was not sleeping anyway, i decided to go and help Ankita in the ward by then.Asking the nurse to call me on my cell in case of any emergency, i walked out of the ICU.
Along the long corridor which connected the ICU to ward 115, i saw one relative of Mr Dattatray Dessai, leaning against a wall and talking loudly into his cellphone, like he owned the hospital.
On seeing me, he smirked a little---as a sign of acknowledgement.

When i reached ward 115, Ankita greeted me with a nervous look on her face.She was entering with two pints of blood in hand.

"for the Falciparum patient?" i asked.

"Yes Pri, I don't know what is happening.There are so many patients here.I cant manage all this at once.Rashi has called in sick.I'm the only intern managing all this commotion." I was almost beginning to feel Ankita would collapse any moment.Her teary eyed face spoke volumes of responsibility.
Besides it was unfair of Rashi to have not arranged for another intern to compensate for her absence.But then, we couldn't blame her either---Sickness doesn't come with warning, does it?

I took the pints from her hand and asked her the details.She seemed like she could need all the relief one could possibly give her.I had one hour and 50 minutes to offer, if all went well back at the ICU.
Walking towards bed 22, i noticed a scrawny man of about 30.He looked pale and emaciated.The charts showed a fever which was peaking every two hours that day.Gangaram Shirodkar 32/M, the case papers read.
Below in big bold letters, the diagnosis read 'F.Malaria' with the used falcivax kit taped to the paper, showing a line at the place marked 'F' for falciparum.
As soon as i reached the side of the bed to transfuse the blood, a woman who was sleeping on the floor crawled out from underneath the bed.
Adjusting her tattered but clean cotton Saree, she greeted me and asked when her husband could be discharged.
When I told her that we would be shifting her husband to the ICU for better care, she immediately asked me when that would be possible.
Snippets from the conversation with Mr Dessai and later with the SR came to mind, and I fumbled for an answer.
"soon" I muttered.

She said nothing.She just smiled like someone who had been promised life so many times, that she did not believe in life (leave alone 'promises') anymore.

Behind that smile, i saw pain---pain of seeing her husband suffer in the suboptimal conditions in the ward when he needed intensive care.
Behind that smile, i saw hurt---hurt that we doctors were not doing anything about it and still claiming that the govt organisation was there to help the needy.
Behind that smile, i saw terror---terror of the unknown, of the darkness that lied ahead had the sole earning member of her family to disappear, leaving her and her three children in the jaws of poverty and inhumanity.

That was when i couldn't take it anymore.As i transfused the pint of blood, i felt a hot shame flush my face.

If we doctors ignored our judgement skills and refused to take action on something as simple and clear cut as this, then what use was our medical education, our long hours of burning the midnight oil to study for the exams and vivas that we rejoiced so much on clearing, the Hippocratic Oath we had taken such great pride in reading on graduation day?
What use was a medical degree if it enabled us to save a life and we still refused to save it?
My chain of thoughts was interrupted by the sudden grunting sounds coming from Gangaram.Even in his sleep, his wheezing could not be ignored---a sure sign of respiratory distress.
His rapid breathing, chest retractions, weak appearance screamed of his ailing condition, albeit in silence.

As i saw the woman fold her hands and shed tears in front of me, a surge of anger came over me---anger at the hypocrisy...anger at the injustice...anger at the politics...anger at the indifference.

Leaving a baffled Ankita alone to deal with the patients, i rushed back to the ICU.
Some things could not wait.

"Mr Dessai, can i come in?"
It was 5 am in the morning.A sleepy Mr Dessai mumbled a lazy 'good morning doctor' and shifted his posture from one arm to another.
I went inside and switched on all the lights in the room.By this time, he was fully awake and covering his eyes to accustom himself to the sudden brightness in the otherwise dimly lit room.

"Look Mr Dessai" i continued, "this is a Government hospital and the first duty of a Government hospital is to treat patients who cannot afford treatment elsewhere.I am not saying that you don't deserve to be treated here..but the simple fact is that you do not require any treatment and you should be extremely happy about being so lucky."
He was now sitting upright and staring at me.I felt like a ghost and hoped that he was awake enough to comprehend what i was saying.

"There is a patient in ward 115 who needs critical care.He is a daily wages labourer on a construction site, has a wife and three children to support.
While your relative is constantly with his ear attached to the phone, his children are crying in the hospital corridors because they are starving.
There is an intern in that ward going crazy with the workload and still trying her best to make sure that all her patients there receive at least half the treatment they are actually supposed to be receiving, hoping against hope that her effort will be enough to keep them alive.

and do you know who is responsible for all this?"

He looked at me like a lost child now.

"YOU Dessai...its you." The bitterness had started to surface in my voice.

"You mean to say that I am responsible for all the people suffering in your ward? how many people do you think would fit in this room if I vacate it?" he snorted angrily.

I had to maintain my cool now.I reminded myself of the power this identity had over the authority and I still had 11 months of internship to finish.

"Well, you are a wise man.You should understand that its not of luxury or comfort that we are debating about.
One case of Falciparum Malaria, if admitted in the ICU can receive much better care and optimal monitoring than in the wards which has over 80 beds.In fact its not even about the private room or the air conditioner.
These comforts are of no significance to that mason or his family---all they want is to get out of here...get out of this hospital, so that he can start working again and feed his hungry children.
Unfortunately, for that he needs your help."
my voice trailed off again.

Mr Dessai was quiet for a while.

"Watch it, Doctor. Do you know who you are talking to? One call to the dean and you could be interning in some Godforsaken rural place instead." he said, in a haughty tone as he pulled the plate of fruit near him.

It was true, i had gotten myself into a sticky situation.But by now i no longer cared.

In a firm and clear voice i said, "Very well sir.If that is what it takes to stand up for what you believe in, i don't mind that at all.
Because no matter where i am, that one family out there will never forget me for what i tried to do but could not...
and never forgive you for what you could have done but did not."

"These are VIP rooms.You cannot depend on these.As far as i know, they are opened up only when special people are admitted." he muttered.
I noticed his tone had sobered down.I was not going to give up now.It was true that the room was labelled as a VIP room and it was also true that someone who the authorities feared, was considered a VIP.
I had to come up with a satisfactory reply to convince him.

After a moments pause, i asked "Mister dessai, what does VIP mean?"

"Very Important Person" he answered with a quizzical expression wondering where this was leading.
"Exactly!! Now take a wild guess, between a patient with F.Malaria requiring blood transfusions and one admitted for a simple bout of treated diarrhoea, which according to you would be more important to treat?"
I smiled and continued "You mister dessai, might read this sign here as 'Very Important Person' but I as a doctor would always read it as 'Very Important Patient'.
The abbreviation is the same.But when used at a hospital, it changes meaning and that makes all the difference."

The chair creaked as i got up to leave.

"Have a good day" i said and walked to the door keeping my fingers crossed, hoping the man would have a change of heart.
But this time he did not say anything.

As i continued with the BP (Blood Pressure) check, sugar level monitoring and morning rounds, i noticed that the lights in mister dessai's room never went off...they stayed on, just like how i had left them.

Tired from the night's duty, i dragged my feet back to the hostel at around 8.30 in the morning.
It was lucky that our new time table gave us interns a day off after night calls---I silently blessed Vithal, the ward boy who had helped us make the duty time table.
I slept the whole morning and woke up right on time for lunch.

There were 3 missed calls from Ankita and one text message waiting to be opened.

I could not help but smile as i read the text.
It was from the ICU SR and it said, "Dessai agreed to the discharge--told me to thank you..Falciparum patient moved to ICU.Good job!"

...life as a doctor had just begun!

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A special thanks to KFC and Indiblogger for the KFC gift voucher---a small excuse which stood testimony to a wonderful day out with friends.

The above post has been written for the contest 'Sets you on fire'organised by KFC on IndiBlogger.
If you liked reading this post, do vote for it here.

Cheers to faith,
cheers to life!!! :)

KFC Fiery Grilled IndiBlogger Contest Runner-up


niki said...

You should come out with a book.You write amazingly well doc.

Anonymous said...

I am very proud of you.
You are not only a good doctor but also a wonderful human being :)

this blog is straight from the heart.best of luck for the contest.

Latha Vijayakumar said...

Hats off to you dr.

Vyankatesh said...

A very proud moment.

You stood for what you believed in. And if there are any people who would be most proud of you, it would be Mr. Dessai and Gangaram.

LeoPaw said...

Wow, that was amazing. Both deed and the writing. You should write a book.

Aabha Vatsa said...

Hello Doc,

Excellent narration and a wonderful spirit.

You must be an inspiration to your colleagues.

Best wishes for the Contest and 2012 :)

Pri said...

@ niki
thanks dear, im honoured you think so :)

Pri said...

@ anonymous
thankyou.that means a lot to me :)

Pri said...

@ Latha
Gracias! :)

Pri said...

@ vyakatesh
Thankyou.It sure was a important moment for me, because it thought me the importance of speaking out one's mind (if you want to be heard).
It was also a moment of realisation because it was only then that i first understood that i had the courage to make a call based on my knowledge and judgement and stick to my decision even when an important facet of my life-my career, was at stake (which i believe, is the ethical duty of every responsible doctor.)

I dont know about Mr Dessai being proud of me or not.But seemed like he was pretty much ashamed of his behaviour.Whatever the case, he did not complain.
As for Gangaram, he recovered after a few weeks and went back home, a healthy man.
I was happy that i could restore their faith in doctors and the medical profession---and that to me was proud moment enough. :)

Pri said...

@ Leo
Thanks Leo.Im flattered you think that way :)

Welcome to my Nostalgic Moments.

Pri said...

@ Aabha
Hi Aabha.I guess its the first time you are visiting my space.Welcome aboard! :)

Thanks for the kind words as well as the wishes.
Happy 2012 to you as well.

Blasphemous Aesthete said...

Good job doctor! You saved the face of doctors. It is a tough job handling life and death on one side and authoritarian pressure on the other, that too when the former is more crucial, as it always is.
To stand your ground is necessary, and you did.

Blasphemous Aesthete

Kunal said...

First I thought, I was reading fiction..but from the comments, I can see that it is not the case...

And I am so happy it isn't a fiction...well done..and Bravo...nothing feels like speaking up for what one believes in and standing up to it..


Pradnya said...

It left me spell bound. Felt like i read an excerpt from a novel :) amazing story and intriguing story telling.must say i loved it
Kudos :)

Tanmay said...

That's a great act. Being true to oneself is the bravest act in my opinion. Wonderfully narrated. Loved it thoroughly.

Dr Roshan Radhakrishnan said...

i know i wouldnt have that much guts.. good for ya :) and all the best

Prabhavathi said...

hi,well done pri...
Happy to see some nice doctors like you.I met one such person like you few years back.

you have done a wonderful job...
All the best for the contest...

Pri said...

@ Blasphemous Aesthete
thankyou...and yes, it did feel good standing up for what what i believed in and living the true meaning of the Hippocratic Oath we doctors promise to adhere to :)
In fact, even though we cross our heart and hope to stick by it on Grad day, that was the actual day i promised to abide by it all my life---the first step had been taken...

Pri said...

@ Kunal
thanks kunal :)

///...nothing feels like speaking up for what one believes in and standing up to it..///

I totally second that feeling.

Its great to have you drop by here.

Pri said...

@ Pradnya
Thanks pradnya.Im flattered that you read me :)

Pri said...

@ Tanmay
Thankyou :)
I agree with you---eventually, all that matters is being able to meet the eyes of the one in the looking glass.

Pri said...

@ Rosh
Well, im sure you would have done pretty much the same thing in a similar situation.
Im not someone who can be easily provoked.But sometimes the injustice just gets to you.and you are forced to take a stand.

All the best to you too :)

Pri said...

@ Prabhavati
Thanks dear.
I wish for a world in which every single person takes a stand against the basic injustice to human rights.
Sometimes a lot is at stake and we are forced to back out...but at the end of the day, happy is the man who can sleep a guiltless night :)

Sameera Ansari said...

Bravo! That was so inspiring. Congratulations :)

Pri said...

@ sameera
It was a small yet proud moment of courage :)

Ugich Konitari said...

I've seen this kind of behaviour. And am fed up of reading about VIP fake chest pains and hiding ICCU's as I call them . Very proud of what you did, and may your tribe increase. Bravo, we need more docs like you ....

Please do consider compiling your doctor-experience posts into some kind of book. You write wonderfully well ....

And I am so glad I chanced upon your post first thing this morning....

Pri said...

@ Ugich Konitari
I am glad you stumbled upon my space and am really flattered by your kind words :)
thankyou and seeya around!

VNP said...

Very Important Patient - was truly awesome. Given its spontaniety and punch, I would say its a masterpiece. I should say.. Very Intelligent, Priyanka (VIP)!

I will make a note to come back to your blog, whenever possible.

BTW, just a passing thought. In the event that Dessai didn't vacate, could you have pursued alternate options to take care of Mr.Gangaaram? The real purpose of shifting him to ICU to give him a better monitoring right? Why not the nurse who monitors the ICU monitor Gangaaram in the general ward itself? Dessai doesn't need any monitoring so slight shift of focus wouldn't affect him. The reason I say this is because of two reasons, one, not all VIPs could be so understanding and you will be forced to look for alternate options, and two, what if there are multiple Gangaaram cases at the same time? Whom will you keep in ICU and whom will you ignore?

Pri said...

@ vicky dada
Firstly, welcome to my space...and thanks for commenting :)

Your question is totally valid.But in this particular case, Mr Gangaram was diagnosed with falciparum malaria---his hb had dropped to 4%...he was in an altered state of consciousness---the fatal results of which could very well be metabolic complications include hypoglycaemia, metabolic acidosis, lactic acidaemia and electrolyte imbalance---which could cost the patient his life if not attended to in an intensive care unit.

Shifting the patient to the ICU was not only important for the monitering aspect but also had a crucial role to play in the management---exchange transfusion, electrolyte therapy can be better undertaken...The respiratory distress can be better managed etc--so much so that even the dialysis unit (in case of renal failure posed as complication) is linked with the ICU and not to the general ward.
As for the nurse option, ours being a Govt setting---transferring an ICU nurse (who is much more experienced in that area of expertise) to the general ward would pose a problem since we would have to replace her with a nurse from the general ward (the limitations of a Govt hospital).

I agree that the issue could have been much worse had there been multiple critical patients and just one single available bed---like i said, that is when medical judgement comes in the picture..But somehow making the best of the situation is an art known most to those with limited resources.
Where there is the will to treat, there is often a way to cure :)

VNP said...

Thanks for the detailed reply, doctor. I glossed over the medical details as it seems greek-latin to me.

On a flip side - maybe you could have tried some Munnabhai MBBS style. What would be the impact of a 'jaadu ki jhappi' on Mr.Dessai, I wonder? But anyways, that wouldn't have made it to the KFC contest though.. :)

Pri said...

@ vicky dada
LOL!!! no wayyy...
In that scenario, Mr Dattatray Dessai was more of a potential candidate for 'one tight slap' (if only...sigh!)
so 'jaadu ki jhappi' was out of the question---even munna bhai would be forced to adhere to circuit's advice :D

VNP said...

I guess 'sarkit' was already around there, but in the form of Dessai's relative.. who spoke to bhau instead of bhai. The funny sarkits of reel life become the evil sidekicks in real life..

Final note - when I pictured that scene of you in the fiery mood putting Dessai in 'Desspair', I saw it like one of those Roadies auditions. ha ha

Pri said...

@ vicky dada
hahaha...i wish i could be that intimidating.
That would be fun!!! :D

Maliny said...

being a doctor myself i could relate to every single detail of your note . . very well penned . . and congrats on your prize :)

Rahul said...

Wooooooooooooooooooooooooooooooooooooooooooooooooow!!!!!!!!!I admit I am reading this late.But I am glad I read it.It was an amazing read and brilliantly inspiring.:-) Respect...

NYK eCigs said...

A bow to you doc for this well-written post. For sure, your writing is as superb as your medical skill. Carry on sharing your awesome write-ups.