Hello everyone. I don’t know how to start this narrative, as I am rather inexperienced in writing. My name is Sai Krishna, and I am a cardiac surgeon. I am forty-six years old. I don’t remember writing a single letter in my life, though my aunt, Thankamma, insists she received one from me when I was six years old. Some of the memories of that time are rather blurry, so I will not contest that claim. But it is possible that it was my brother, Suresh, who’s two years elder to me. He is a software engineer now, is earning well, and putting away the money in the bank. And his six year old younger son often writes to me. Sometimes I email people, but that is different. The mails are short and crisp. Sending brochure – conference – see attachment or Arriving with Dr Kuruvilla, Wednesday, 10:00 am. Pick up and drop at Hotel Marriot. Thanks. PS: He’s vicious. Might raise hell if there’s any fuck up.
I cannot understand why Dr Jimmy asked me to write about my life for his readers. I did not read his first book, though he offered to give me one for free. And what business has a doctor to write a book, other than a technical one, I fail to understand. That makes him some kind of a freak.
My story starts on the day I began the cardiac surgery residency at the Indian Institute of Medical Science (IIMS). Cardiac surgery is not a very coveted specialty amongst surgeons. It is quite the opposite. I remember writing the entrance exam for the super speciality residency programmes at IIMS in Mumbai. Around eight hundred surgeons had applied for one seat available in Gastrointestinal Surgery, and five hundred had applied for Urology. Plastic and Re-constructive Surgery had around three hundred applicants. The total number of aspirants for Cardiothoracic Surgery was sixteen, and they were competing for two seats.
I was thrilled at getting in, of course. I had read a lot about the great minds in Medicine, and how the early barber-surgeons struggled for respectability. And the heart was the last organ to be conquered by these specialists. It was easily the most exalted specialty in the entire field of Medicine. Imagine being introduced at a party as a cardiac surgeon.
Little did I realise that my partying days were over. It was a challenging career. But I was mentally prepared to do whatever it took. I was desperate to become a part of this fearless, inspiring group of professionals.
Dr V N Ganapathy, VNG for short, the most dictatorial and feared head of the department in the whole medical world, was my boss for the next three years. And it was no consolation that I had cheated him while being admitted. You see, it was VNG’s policy never to take married men or women as residents. I knew that. I was not married yet, but my wedding with Sushma had been fixed for the month after. I saw no reason to reveal this during the interview, and spoil my chances. By the time I joined, I was already married. I was given only a small cubicle with a single bed. But it was a co-ed hostel, and a lot of women stayed in the rooms nearby. I brought my wife to stay with me in my spartan bachelor accommodation.
The first day is still fresh in my mind. I met VNG in his lair, and timidly showed him the letter of appointment. He was a man with a steely glint in his eyes, and a cruel mouth.
“Are you from the south?” He just arched his eyebrows, and hardly looked up. I noticed he had a deep, contemptuous baritone voice.
“Good.” A slightly mollified tone emerged from the great man.
It was a well-known fact at IIMS that residents from the south were generally docile, knowledgeable, efficient, and less likely to cause trouble when pushed to the extreme.
“Have you settled in? Did you get your room?”
“Yes, sir, thank you.”
“Well, you won’t need it much.”
If I thought, for a moment, that he was joking, I was a fool.
“Sign this.” He pushed a paper towards me.
“Your resignation letter.”
I was so stunned that I just stood there, gaping. Seeing my confusion, the great VNG condescended to explain. “This is your resignation letter, addressed to the HOD – that is me. It is not dated. Cardiac surgery is not for everybody. If, at any point during your three years of residency here, I feel you are not suitable, I will put a date on it and forward it to the director. It is in your own interest, you understand?”
I signed it, but I couldn’t understand the matter then. Now, I understand it very well.
My work started straight away. I was led into the theatre. There were three tables occupied. Six to eight cases – all major open-heart surgeries – were posted that day. Later, I came to understand that we had a similar list six days a week. I could see that the senior-most surgeons operated; junior consultants assisted. The residents were in the background – bullied by even the perfusionist, a trained technician who handled the heart-lung machine.
The third year residents sometimes got to open the chest cavity by cutting through the sternum to expose the mediastinum. Then they moved away respectfully for the junior consultant to come and open the pericardium, and expose the heart. He also cannulised the aorta and the major veins to divert the flow, and handed over the tubes to the perfusionist.
“Start bypass… Ten, nine, eight … four, three, two, one, zero. On bypass.”
Pin-drop silence dominated the theatre – a contrast to the light banter characteristic of the general surgery I was used to.
He administered the cardioplegia solution with potassium chloride to stop the heart. VNG made his grand entrance. The atmosphere, already tense, became a great deal worse. Everyone made way for the big man. Armed with an ocular magnifying loupe, he swiftly finished the surgery with remarkable precision and economy of movement. Then he went into the next room, where everyone was waiting for the bypass, and repeated the routine.
I had to stand absolutely still, a good three metres away, and watch the proceedings. That was what first years were supposed to do. We could see very little of the field of surgery, buried in the chest, surrounded by the surgeons and assistants. If one of us as much as sneezed, well, that person had it. By 8:00 in the evening, all the elective surgeries were over.
This had no effect on the frenetic schedule. The surgeons and residents moved en masse to the Intensive Care Unit, where all the post-operative cases were shifted. I followed them. It was a massive, fifty-bed ICU with thirty ventilators, continuously in use. Food, I realised, was a dirty word that nobody ever mentioned. It was two days before I could go back to the room to my overwrought wife. Sushma was a nervous wreck by then. Those were the days before mobile phones. Such a time existed, you may note, even though now it seems unbelievable. Eventually, after running around the unfamiliar hospital for the better part of a day, she found out I was in the department.
She was livid. Why hadn’t I called her on the hostel phone from some extension number in the hospital? And why couldn’t I excuse myself for ten fucking minutes to inform her?
The fact was, I had forgotten completely about her. As I got more involved with work, the going got worse. I had to be more responsible.
The working hours were deliberately kept vague. Basically, the idea was not to leave the patient alone at any time. From the theatre I followed the patient to the ICU. Each patient was on a ventilator. The ventilator had modes like CMV, SIMV, BIPAP, etcetera. These things were completely new for me, and I had to learn quickly. The percentage of oxygen, breath rate, inspiratory time and expiratory time, had to be adjusted every half an hour according to various parameters. I also had to keep an eye on all the substances that went into the patient.
I had to look after fifteen or twenty patients, and was supposed to manage the problems myself and inform the doctor on duty. Once, I gave a ten-milligram Lasix injection to a patient whose cardiac failure appeared to have worsened. I did not inform the duty consultant. The next day, VNG caught me in the middle of the ICU rounds.
“Sai, was it you who ordered the Lasix?”
“Y … yes, sir.” I could feel my sphincters relaxing, I was so terror-stricken.
“Did you confirm whether there was any pericardial effusion, before giving it?”
I hung my head. It was a cardinal rule. Never look the chief in the eye. It was also an admission of guilt. Another lesson I had learnt was: never justify your position.
“Don’t enter the theatre for two weeks,” he said.
I was relieved. Maybe I could leave the wards early and spend some time with Sushma – cuddle up with her, and feel that warm body against mine. I could press her cheeks to mine and say, ‘Soon, it will be over, and we can start living.’
“Stand in the corridor of the OT until all the cases are over, everyday. And don’t go back to the room for two weeks,” VNG continued.
The next morning, eight patients were ready for the theatre. And the day after that. Oh yes, Sunday mornings were busy as usual. On Sunday afternoon, we had teaching programmes which went on till 8:00 in the evening. In short, residency in Cardiac Surgery was not boring. We never had a dull moment.
The ICU had no couch or stool on which one could rest or sit down. We had to spend the entire night walking or standing. At least once every night VNG would come, at 2:00 or 3:00 in the morning, to his room, from the window of which he could observe the ICU. Any resident caught idling or talking to the nurses … well, you get me, don’t you?
During the latter half of the second year, I passed tar-black stool for some days. I also had abdominal pain. Finally, I fainted during a surgery. When the doctors checked my haemoglobin, it was five. An endoscopy revealed multiple bleeding stress ulcers in my stomach. I was granted ten days of rest, which I spent alone in the hospital room. That is right – alone.
Six months after joining the place, Sushma had developed severe viral fever. Was there any way I could take a two-hour break, and arrive a little late to the theatre? I asked a final-year resident. None of the consultants knew I was married.
“What is your problem, man?” he asked me.
“My wife, Suresh, I am telling you she has –”
He cut me short abruptly. “Is your wife the problem? Then you get rid of her and come. Otherwise, you can’t complete your residency.”
He was not mean; just matter-of-fact.
Then, realizing what he had said, he rephrased his sentence. “I mean, send her off somewhere. Ask her to go and stay with your parents. Or hers.”
I could get back to Sushma only the next morning, and she was worse. She was sweating and shivering, and looked really sick. Sensing my helplessness, she said in a weak voice, “I am all right, Sai. You carry on. I will go to the Medical OP after sometime.”
My eyes filled with tears.
“Are you sure you want to do this?” she said suddenly. “Why can’t you take up some other specialty?” Her voice was more forceful, as if some strength had returned.
I didn’t answer her question. It was my life’s calling. Turning back now was unthinkable. The beating heart lured me like a mirage in the desert. I had never touched one yet.
“I will ask Goutham to help you,” I replied.
Goutham was a Dermatology resident. He was my neighbour, and belonged to my home town. He had done MBBS from the same college as me. Initially, he was reluctant, but agreed to take my wife to the Medicine OP. The next day, he readily took her for a follow-up.
Come to think of it, some guys did give me hints that after the incident Goutham and my wife were seen together in the town many a time, but I did not take them seriously. In fact, I was too busy to bother about anything. One night, I came back to the room from the hospital, and she was not there. She had packed her bags and moved to Goutham’s room. The good thing about my residency was that you never had the time to brood over anything. The next morning I was back at work, as if nothing had happened.
Sushma was not really a bad woman, but I hadn’t wanted to marry before completing the residency. My mother was insistent. Sushma was pretty, and had a nice smile. I liked her.
“I don’t know much about doctors, or Medicine,” she said, when I told her I had plans to do cardiac surgery. She was a History major.
“My life may be difficult. You may not be able to cope. Please think before you marry me,” I laughed. But I was not joking, of course.
“Yes, I will. I am not looking for an easy life though,” she smiled back.
I had looked at her pretty lips and white teeth, and hoped she would not mind too much.
Tears come more easily nowadays. I hope I become the chief cardiac surgeon somewhere before long. Recently, I have taken to reminiscing about my past more and more. It is not a good sign. If I look back at all the bridges I have burnt, I will go mad. Damn Jimmy for making me go through this.
My training period had its high points. I can remember an incident during my final year vividly. I think it was at night in the ICU. You can never be sure inside that place. Day and night look the same. Overhead lights are perpetually on. Myriad monitors go beep-beep. The cascading whirrs of ventilators, an occasional groan of pain, remind one that humans are at the centre of all this technology. Nurses and residents quietly move to and fro. Alarms go off now and then.
VNG was already in the theatre, doing a re-exploration, and most of the residents were with him. I was alone in the ICU when, suddenly, there was a cardiac arrest. A cardiac arrest was nothing new. At least one or two happened every day. The patient was a fifty-five year old man, a prominent politician and former minister – a VIP. VNG had operated on his blocked coronary arteries that morning. Four vein grafts had been put in, by-passing the various atherosclerotic blockages.
I promptly started cardiopulmonary resuscitation. The nurses, with their emergency drugs, and equipment – like the defibrillator – crowded around me. The patient was already on the ventilator, and I did a short cardiac massage, pressing rhythmically on the lower part of the sternum. The ECG monitor showed a flat line. When three DC shocks from the defibrillator, and two shots of intravenous adrenaline, failed to revive him, I had to take drastic measures. There was no time to call anyone else.
Quickly, I donned gloves and cut through the stitches on the front chest, exposing the stainless steel wires holding the split sternum together.
“The cutter!” I cried.
In response to my desperate bark, the wire cutter was thrust into my right hand. Within seconds I was inside his chest. I wriggled my hands, blood bubbling up and splashing on to my bare forearms. I felt for the heart, grabbed it with my right hand, and started compressing it rhythmically. It was a direct cardiac massage. I could feel the splish-splosh as the heart filled with, and pushed out blood, aided solely by my hand.
The patient was wheeled into the theatre, with my hand safely inside his chest, doing the job. The anaesthetist and the perfusionist were ready. VNG suddenly appeared at my side, fully gowned and gloved. Within minutes the patient was safely under cardiopulmonary by-pass, the machine whirring softly as it took over the heart’s pumping function. All four grafts were thrombosed. VNG worked swiftly, moving his fingers like a machine as he re-did all the anastomoses. He was mostly silent, except for the one time when he growled, “You have ruined all my grafts.”
Or the grafts might have thrombosed first, and he probably had an arrest due to that, I thought. It was highly unlikely that VNG would consider that possibility. Chief cardiac surgeons always saw the world through a lens tinged with infallibility and omnipotence.
But VNG surprised me. “Then again, you might not have,” he murmured.
I thought I detected a smile, though it was hard to tell through that surgical mask. The patient went home walking ten days later. And I was the only resident to pass the MCH in the first attempt in many years.
After that I was mostly here. The prestigious BMAS where cardiac surgery is a flagship speciality – under Dr Kuruvilla.
At that time we had no residents. So I was basically doing the same resident’s job over and over again for the last fourteen years. Yes, I did get a bit frustrated and did try an independent job at Sri Ganapathy Mission Hospital after five years at BAMS. But it was a premature move. You see, the whole team – anaesthesiologists, Nurses, ICU set up, theatre set up – everything is important. And cardiac surgery is extremely skill dependent. A few initial post-operative deaths finished off my fledgling career there. Within a year I was back at BMAS at my previous post, toiling away as usual. I am extremely grateful to Dr Kuruvilla for taking me back. Usually they take leaving as a personal insult and ostracise you forever, or maybe he did not get a good replacement. I guess I got lucky. I cannot go back to general surgery, for I have forgotten everything. Besides, it is simply not done. There is no going back in this.
It is not that there has been no progress. We got residency accreditation two years back, so now I have a few people to yell at, after so many years of being yelled at. Kuruvilla allows me to do an occasional valve replacement and I get to do most of the major vessel aneurysms which he is too busy to do. The patients don’t know that I have done the surgery but. Officially, all surgeries are done by Dr Kuruvilla himself. I can’t blame him for that. That is the name of the game. Usually I get to see the patients and their imaging results immediately before surgery in the theatre. So I was surprised to get a call from the big boss one day. Actually, the following is the story I wanted to tell you. I got carried away and recited my life story instead.
“Sai, I want you to see one patient with aortic aneurysm. Do what you can for him. I will send him down to see you.”
I waited in the small duty doctor’s cubicle by the side room contemplating the meaning of this magnanimous gesture. Aortic aneurysms were pathological dilations of the aorta, the chief artery arising from the heart. They were mostly caused by atherosclerosis, the same process that causes blockages in coronary arteries. Left alone, they would burst, sooner or later, leading to a swift death from massive bleeding, either into the abdomen or the thoracic cavity. Albert Einstein, if I remember correctly, died due to a similar aneurysm.
Mr Ahmed, a seventy year old pleasant gentleman was ushered into my room. A younger man introduced himself as Ahmed’s son. Ahmed’s wife, a motherly old lady, had very worried look. The men talked, but the lady was withdrawn and silent. I asked them to sit.
“Well, doctor,” Ahmed started after preliminary introductions were over.
“It started as a slight discomfort in the chest. Nothing else. I guess I had it for a long time. I have a tile business and was quite busy throughout my life, building it from scratch. I really don’t know exactly when it started. Noticed it only after I retired and handed over the whole thing to my son.” He smiled.
“When was that?” I probed.
“One year back. You notice these small things when you have nothing else to do.”
“Otherwise you are healthy?”
“Not exactly, doctor. I am a diabetic since thirty years, has severe hypertension and kidney failure. Doctor Kuvuvilla hinted that my heart may be failing; I get these attacks of breathlessness…”
I had noticed that he was slightly breathless, even at rest. After examining him and going through his CAT scan and echocardiography reports, I understood why Kuruvilla had sent the case to me. He had a huge aneurysm involving the coronary arteries and extended infrarenally. They were the worst kind to operate. He was a severe diabetic, chronic hypertensive and was in diabetic renal failure. His ejection fraction was only thirty percent. The worst surgical risk imaginable. After looking at the latest blood results and thinking for a while, I looked up and started tentatively:
“May be I can talk it over with your son… You and your wife can have a coffee or something.”
“Oh no doctor, please tell me directly. I can take it.” He was very firm and decisive. It was clear that he was the boss from the way the son did not try to take over.
After a slight hesitation, I explained in brief the nature of the disease and the problem of the high risk of surgery. Mr Ahmed listened with rapt attention, asking intelligent questions in between. I pegged the risk of surgical mortality at around ninety percent; may be more.
“I can still do the surgery, you understand, if you can accept the risk…” I made myself clear. Ahmed appeared nonchalant. As a sick man, he must have contemplated his own mortality before. The son and the wife were stricken.
“But why I would accept a risk like that and lose this much money for a surgery that will kill me and deprive my wife and son of that much money?” He was a hardcore business man. He raised a hand to restrain his son when he started to protest.
“Well, without surgery, the condition is highly dangerous. It may rupture, you know, severe bleeding…” I was now distinctly uncomfortable.
“How much time exactly, till that happens? Doctor? The rupture?”
I grew more distraught, and seemed to be more upset than the old man, who was calm. I had no choice but to come out with the truth.
“It can happen any time. With its present size, may not last … maybe two three months…”
“And what will be the symptoms? What will I feel?”
Now, this was something totally new. I was having such a conversation with a patient for the first time. How does it feel to die? I really had no idea.
“You will probably have a sharp pain in your back. Then you may feel dizzy and then maybe you will lose consciousness?”
The old man was silently listening, but his wife had started crying softly. Even his son had tears streaming down his face. Then he slowly rose to leave.
“Thank you very much doctor, for being so honest and understanding.”
After the couple had gone out of the room, the son returned quickly and asked my phone number, which I wrote in a piece of paper and gave him.
All this was around two months back. I am telling you this because three days back around seven PM I had a call on my mobile phone. A clear, but rather weak voice, very familiar:
“Hello doctor, Ahmed speaking, you remember me?”
I had him placed the instant I heard the voice.
“The pain has started doctor, sharp, in the back, as you told that day.”
“Who else is with you?” I had a strange feeling of unreality.
“Allah be praised! Both my sons are here. Grand children all around my bed. My wife is holding my hand,” his voice grew progressively weaker.
“Good bye, doctor; I think I am … slowly…” The phone went blank.
Yesterday his son called me:
“Doctor, I am Ahmed’s son.”
“Yes; what happened.”
“Died, doctor. Quite peacefully. I just called to inform you. You have made the whole thing easy. Thank you. Thank you for everything. You have been so good and understanding.”
Gratitude, for what? I wondered. I was left queerly weak and confused. Satisfaction? Mingled with a vague yearning. The old man clearly perceived a continuity that was beyond his own life time. Will it ever be possible for me? I don’t know. I had better stop here. Have to wash up to assist the next case.
P.S.: it was seven years before, that Saikrishna penned this narrative. He is still not the chief cardiac Surgeon anywhere. But lately he has started taking all his leaves and spends considerable amount of time with his nephews, brother and old parents. There is a rumour going around the hospital that he has a thing going with the pretty perfusionist, Stella, a divorcee with two kids. May be he will still become the chief cardiac surgeon at BAMS soon. Kuruvilla has had a massive heart attack and underwent emergency by-pass surgery only yesterday. He was operated on by Dr Saikrishna himself. He was the next senior most after Kuruvilla but, by his own admission, not that much experienced in complex multiple bypass grafts. I don’t know whether he has really endeavoured to do his best. But I am sure he must have.