Almost immediately after completing internship, I got a job in a Public Health Centre in Thoovar, a semi-rural hamlet in the outskirts.
The PHC is the most basic unit of our Indian public health service. It was one of the thousands of vertebrae that together made up the backbone of the free healthcare provided by the government.
It was a temporary contract job. I was a junior to the Chief Medical Officer, a mature veteran named Dr. Raghavan. There were about ten in-patient beds in this centre.
To tell you the truth, after internship, I had developed a swollen head. I knew an enormous lot about a lot of diseases; or so I thought. I knew complex diagnostics and complicated treatment protocols.
The very latest in therapeutics coursed through my neurons, eager to be of practical service. But within a week, my ego deflated like a punctured balloon.
One day a four year old girl was brought in. There were a gang of relatives including the parents. They were frantic. They had a right to be.
The child looked horrific. She was alive but not responding. The tongue was forcefully protruded outside. The eyes fixed to one side in a grotesque glare. The neck was rigidly twisted to the same side.
I examined her as best as I could. Being away from the structured system of my teaching hospital made me feel absolutely out of place, like a watch thrown in the mud.
I could not make out anything. I had no clue. The soft wail of someone – maybe the mother – rose in the background. I wiped my eyes to clear them from the sweat that had leached in from my forehead.
A confused babble of voices arose behind me from the assembled people. I could hear mutterings and impatient comments.
‘Where is Dr. Raghavan? Please, do something,’ a voice said.
At that moment, Dr. Raghavan came in. I breathed normally. The thick atmosphere cleared, like fog lifting from a sultry morning as the sun came out.
He took one look at the girl. Then he turned to the father and asked: ‘Was any medicine given for vomiting?’
‘Yes, doctor. Last night she vomited a few times. A bottle of medicine bought earlier for the elder child was there at home. We gave this girl some of it,’ he said.
‘Okay.’ He turned to the nurse. ‘Give her a shot of phenergan.’
A mere ten minutes later, the child was sitting up and drinking milk, surrounded by the relieved parents. One could not believe that just moments before, she was so frighteningly sick.
‘This is a not an uncommon side effect of “Reglan”. You know that, right?’ the older doctor asked me later. I nodded. ‘I know, sir. The extra pyramidal side effects of phenothiazine group of drugs,’ I recited from my enormous store of brute theory.
‘Right. I have forgotten all those details,’ he said.
I understood one thing. One can afford to forget many things. In fact, it is essential to do so. It would be fatal to forget some others.
An ocean of things to learn stretched pitilessly before me. There was only one way to learn practical skills, like Medicine. Work under someone who knows the job.
This basic fact is usually forgotten in our country when we educate people. There are so many highly educated ignorant ones roaming around.
Then Dr. Raghav went on leave for a week. I was the only doctor in the PHC. By this time, I had learned to manage, after a fashion.
My heart stopped doing fluttery somersaults just for the fun of it, whenever I was at work.
A few people brought in an unconscious old man. He was apparently all right and was walking around. Suddenly he felt dizzy and lied down.
Then no one could wake him. He had become insensate. That was what the relatives told me.
I examined him. My impression was that it was a stroke. His breathing, blood pressure and pulse were normal. That meant he was clinically stable.
I thought it best to refer him to the medical college in the city, without wasting time by keeping him there.
Further tests and expert treatment were probably needed. It was not that far away and the van was waiting. They agreed and took him away without delay.
The next day a policeman came as I was conducting the OPD. He was dark and burly. The moustache curled like twin bows.
Bushy eyebrows and a pot belly lay testimony to the liberal amount of testosterone coursing through his blood stream.
He barged in and without any preliminaries, sat down on the chair, facing me across the table. I looked at him with a question.
‘Didn’t you send an unconscious patient to the medical college yesterday?’ His manner was brusque.
My first thought was that the patient had died. It could have happened on the way. It was a common hazard when one is referring critical patients.
The law, and common clinical sense tells us that a doctor or trained paramedic has to accompany such a patient in an adequately equipped ambulance.
But what should one do when your set-up is devoid of any resources even nearing the ideal? Keep the patient and wait for the bystanders to beat you up when the patient dies of inadequate care in your impoverished centre?
I looked at the policeman sitting opposite me across the table. He was a large swarthy man with a moustache. A villainesque keeper of the law- just like in the movies.
‘Didn’t you refer a patient to the medical college yesterday?’ he asked me. His gravelly voice grated rudely on my nerves.
‘In a bad condition, wasn’t he?’
I kept quiet.
‘He had a fall and hit his head. That was how he became unconscious. We have a complaint. Apparently someone pushed him. I am the sub-inspector of police at Thoovar.’
This was completely unexpected. The doctor can get the history of a patient brought unconscious only from the fellows who brought him. If they mislead you, clinical conclusions can go very wrong.
Anyway further expert evaluation and investigations like CT scan were urgently needed. That was why he was referred. It is almost impossible to form a diagnosis of head injury when an external wound to the head was not there.
I tried to explain all this to the police officer.
‘See here, doctor, I don’t want to hear all this. You are the person who examined him first. This was a medico-legal case. You should have intimated the police. You should also have furnished the wound certificate that has all the details of it. Don’t you know that? I need the wound certificate now.’
He was quite curt about it. His expression resembled that of my fifth grade class teacher. I had an irrational fear of that man.
Let us get real. I was scared of this guy also. In our part of the world, most people fear policemen. Me, being a natural coward from quite a young age, was no exception. Being a doctor didn’t help me much. I was a fledgling. I had no idea what to do. I became drenched in sweat.
‘But how could I know that was a medico-legal case? There was no suggestive history. I examined him, and I could find no head wound and no sign of internal head injury. Without a scan, how could I know? And if there was no wound, how will I give the wound certificate?’ I blabbered out my helplessness in a bleating voice.
‘See, we don’t want to know all these technical things. I want the wound certificate, doctor. I will come tomorrow. Please keep it ready.’
He got up and walked off. I sat petrified, a nervous wreck.
I had a sleepless night. I dreamed of imposing judges in flowing robes condemning me to a life in prison.
Next morning brought the man promptly to the health centre. There was no police uniform this time. But his civilian clothes made him more menacing than ever.
‘The wound certificate is ready? I have come to take it,’ he said, after sitting opposite me in the chair, as if he owned the place.
I tried to explain. With open palms, I tried to convince him of my helplessness. His face became serious, even menacing. His voice took on a threatening edge.
‘If I don’t get the certificate, I would have to register a case against you too. The person has died. Colluding with the murderer.’
I opened my mouth and tried to speak. My tongue lay paralysed in the floor of my mouth, like a dead fish on a slab.
My heart started vigorous callisthenics, like a gymnast competing in the Olympics. The sub inspector gave a parting shot:
‘Dont make me run around for this. I will come tomorrow.’
All my faculties froze solid. I sincerely wished that I hadn’t become a doctor. I cursed the day I decided to join government service.
Doctor Raghavan was back from his leave the next day. I greeted him with relief.
I briefed him frantically about the incident, and even described the inspector’s threatening demeanour to convey fully the horror of the situation that I was in. He smiled sympathetically.
‘Don’t worry. Just tell me when he comes tomorrow.’ That was all he said.
The next day dawned, replete with terrifying possibilities. Both of us sat in the OPD room, in adjacent chairs.
I kept glancing at the corridor. By twelve, the flow of patients had ebbed. Suddenly I could see him. The sub inspector was strolling in coolly in a civilian dress.
‘It is him,’ I whispered in an urgent undertone to Dr. Raghavan.
The policeman almost barged into the room, but hesitated for a moment at the door, seeing the senior doctor. He expected to be waved in.
Raghavan ignored him completely. He turned to me and started a detailed lecture on the management of cerebral malaria.
He reminded me that it was caused by ‘Malaria Falciparum’ and that it was a disease, that when detected, had to be notified to the authorities.
I sat with my mouth open in confusion. The inspector stood impatiently for some time and then came and sat down. Doctor Raghavan turned to him.
‘Did I tell you to come in? Please wait outside. We are discussing something important.’
The man scowled slightly and went out.
‘I had to go and see the minister about the leprosy project, you see? Tomorrow the District Collector will be here. You are the one who has to discuss it with him,’ Raghavan continued, as I nodded dumbly.
Finally he motioned at the policeman to enter. He entered, but he did not sit.
He stood respectfully by the table. Then he started explaining the situation. The senior doctor showed his hand in a gesture that bade him to stop.
‘Doctor Jimmy has told me everything. You want the wound certificate?’
‘Yes – er – sir.’
‘Who are you?’
‘I am the sub inspector at Thoovar police station.’
‘Really? I thought Mr. Vijayan was the SI now.’
‘He is on leave. I am the acting chief in his absence, sir’
By now, he sounded quite nice. Friendly and polite, as if he had suddenly remembered what his mother had told him about manners in his boyhood.
‘So, you have come for an official purpose?’
‘Then where is your uniform? Why did you not salute me? Don’t they teach you anything at the training school nowadays?’
I gaped. The policeman gaped. Dr. Raghavan just glared.
‘Don your uniform and come back tomorrow at nine,’ my boss told him.
The man, resplendent in a crisply pressed police uniform arrived promptly at nine. With a ‘dap!’, he stamped his shoes accompanied by one of the smartest salutes I have seen.
Dr. Raghavan gave him a long look as if he was unaware of the purpose of the man’s visit.
‘Er, the wound certificate, sir.’
‘Where is the request?’
The uniformed servant of the law wringed his hands faintly. He looked flustered.
‘Don’t you know that a signed and sealed official request is needed? Is this how you are ‘acting’ as an SI? You have lot to learn, man. Go and get it.’
He ran off, and came back with an official document in minutes. Raghavan looked at it and wrote underneath:
‘As the patient was in a critical condition, he was promptly stabilised and referred to the medical college. As the treatment and prompt referral was more important than any medico-legal formalities, none were undertaken. Please collect the wound certificate from the medical college.
Seal and signed.’
‘Okay, sir, thank you, sir.’ The acting sub inspector withdrew with a resounding salute.
I looked in awe at Dr. Raghavan.
‘Isnt this dangerous, sir? They may be vindictive,’ I said.
‘True. But I know the DYSP. All the local politicians are my buddies. A grassroots doctor has to be good at a lot of things, Jimmy.’
‘You can even get the amount of money that one has to pay, to prevent getting transferred frequently, if you are good to the politicians’- He continued.
‘But …..’ I stammered. These aspects were new to me.
‘These things, you will have to learn.’ He was matter-of-fact.
I realised that a lot of bureaucratic unknowns stretched before me. A grassroots physician had to be a politician- almost. Could I do it? I doubted it.
Keenly aware of my limitations, I decided to prepare with renewed vigour for my PG entrance examinations, which would enable me to become a specialist, and put off encountering the real world for a few precious years longer.(Jimmy Mathew)