Study in Scarlet- The nosebleed.

THE LONGER stints in Medicine, Surgery and Gynaecology were followed by a series of short postings in various assorted departments. It was a whirlwind tour in bewilderment.

I went to each department with sweaty palms. Acute attacks of panic marked the first day. Over a few days I learned enough to manage my duties with a combination of hurriedly acquired skills, some bluster and forced bravado.

I left the place with a kernel of confidence in that specialty. Two weeks were all that you got. Medical college at Thrissur had no residents.

Higher specialty programmes had not started then. We interns were the ones who took all the lower level responsibilities.

Any area of Medicine was a terrifying jungle and there, we were scurrying mice and soaring eagles all at the same time. It was scary and exhilarating in equal measure.

It was ENT next. Ear, Nose and Throat diseases was self explanatory. We were always eager to learn. Learning clinical skills needed no justification.

We had to know as much as possible in the short period available. Unlike today, no intern held back thinking that this was not his or her planned chosen field that they might pursue later.

One had to learn everything possible about patient care. That was the motto.

I donned my headlights and plunged into it. That is right, headlights. You needed them to peer into people’s orifices. The ear, nose and throat were holes in the human body into which we had to look deeply and intently.

We had a variety of hand held mirrors on the ends of long sticks to assist us. If you want to see the back of the nose through the throat, you need to hold a mirror pointed up near the tonsils to see it.

The days got pleasant after a while. The consultants were always there. But after working hours, you were alone. That was scary. And exciting.

You see, in major specialties like Medicine, Surgery and Gynaecology, there is a continuous flow of patients in emergency.

A qualified consultant is always available to cater to them. We can always run, crying to them, if you can’t manage any patient. Or they can come running to any sick patient in need of urgent care.

We may need to fly solo for some of the time; that was all.

In a specialty like ENT, emergencies are relatively rare. The consultant is at home. He or she is not used to being disturbed at odd hours. You are expected to manage on your own till working hours the next day. What, you may be wondering, are the emergencies that we are talking about?

Suppose you are sitting at home, thinking profound thoughts after a busy day.

Just when you were wondering whether God actually created this world or there is infinity of many worlds and this one accidentally happened to be just right for life, a beetle flies in and wriggles deep into your ear.

Or it may be a small cockroach or a bee. Anything that wriggles, is vigorous and has stings, fangs or claws. It doesn’t enjoy being confined in a hole that seems to be in the middle of an earthquake.

The screams that it hears make it try to escape by burrowing in deeper.

You let out screams that makes the entire neighbourhood come running. They rush in, to see you dancing like a frenzied actor doing a badly choreographed item number. You try to convey your plight with bulging eyes and words punctuated by yells.

You try to put your index finger into your ear and realize that the creator, most inconveniently, has made the hole smaller than all your fingers. The surrounding good Samaritans want to help you.

One pours water into the ear. The insect struggles with renewed vigour. You scream with doubled enthusiasm.

Finally you end up in the casualty of Medical College, Thrissur, shouting for the ENT surgeon. A young dashing twenty four year old youngster walks up and pours some oil into your ear.

The insect dies and stops moving. Then he dons a headlight, peers into your ear and with a long instrument, delivers the offending insect out and shows it to you.

You weep with relief and gratitude. You realise that for that tiny fraction of a moment in your life, that young doctor is God.

You do not realise that the doctor is having an orgasm that only doctors have on certain occasions.

But when Rajani, a young woman came with blood pouring out of her nose, I didn’t have an orgasm. I almost peed in my pants.

The sight of a young woman with blood pouring from her nose isn’t pretty.

Such sights should not upset a medical man. But the implication that you are the sole person in charge and you are supposed to manage the problem will upset a medical adolescent.

This is true especially when he is acutely aware that he has no idea what to do.

But I had learned one thing, which was one of the cardinal rules of being a physician:

Never show indecision or confusion. Act as if you are in complete control and then ask for help discretely.

I asked her to sit, leaning forward. Then I requested her to pinch her nose tightly and wait. This much I knew.

‘Just wait for a moment. Don’t worry. Everything will be managed,’ I told the worried father and the terrified mother standing nearby.

My voice transmitted quiet calm and reassurance and it showed that I was well on my way to becoming a seasoned doctor.

I ran panting to Rajesh, who was the duty intern for Surgery that day. He had already finished ENT. This was how the system worked – a network of competencies and skills being transferred every day.

The informal process was much more extensive and effective than the former. That is how an applied science worked. The books are an afterthought.

Rajesh came with me to help. We put the patient on the minor theatre in the emergency room and packed the nose. It was a procedure called anterior nasal packing.

A long ribbon of gauze soaked with antibiotic ointment is pushed into both nostrils using a long narrow instrument. The entire roll of gauze had to go in, bit by bit.

Basically you stuff the nose with it to stop the bleeding.

Even with a spray of local anaesthetic into the nose, this is very uncomfortable practice for the patient. She was in panic, as she was brought in with blood streaming down her face.

Nearly hysterical with fright, she wailed and gasped in distress. But as we pressed reel after reel of cloth ribbon into both her nasal holes, she was calm, as if this was routine for her.

It turned out that it was. When the consultants came in next day, they were very familiar with Rajani. She was a regular visitor to the department.

She was admitted frequently with nosebleeds. How frequently? I gently probed.

‘Each time she has a bleed, ten of his hairs turn grey.’ The distraught mother indicated the father, a very worried looking man. He had a head full of thick hair, all grey. I got the general idea.

What was the cause of her nosebleed?

‘Sir, what are the causes of epistaxis?’ I asked a youngish Assistant Professor. Epistaxis meant ‘nosebleed’. Don’t ask me why they complicate these things with Latin and Greek names.

Medicine is as much tradition as science. I had learned about it in my third year, but had forgotten. But that was what internship was all about – an opportunity to forget all the trivia and learn the practical, useful stuff.

The man looked at me.

‘There are local and systemic causes. The common causes I can recite at least a hundred. You want me to do it or will you look it up in the books?’

I agreed humbly to refer to the book.

‘But what is the cause of the bleed in this particular patient?’ I persisted.

‘No one knows. We have investigated her like anything. Complex blood tests, CT Scan, MRI, the works. Endoscopy shows some aberrations and clots. We are really stumped with this patient.’

I wanted to ask: then what is the point in knowing a thousand causes of nosebleeds? But I didn’t. This was a frequent problem in Medicine. You may know an awful lot, but still your knowledge and means may fall pathetically short.

For one day the patient rested with the pack on. The bleed had stopped with the packing. The next day we removed the pack. There was no further bleeding.

That night I was on duty. The ENT duty room was in one corner of the ward. I was one of the two interns posted in ENT that week. That meant alternate day duties.

The night calls were frequent enough to disturb your sleep thoroughly. After a few days one got a little zombified, though not as much as in the busier major specialties. I tried to sleep in between calls.

When you are sleep deprived, dozing off meant instantaneous plunge into dreamland. Reality, dreams and hallucinations blend into a nightmarish kaleidoscopic march.

I walked out of the room sleepily and through the corridor stepped out of the hospital. My watch showed two a.m. There was no moon. The shadow of the building cocooned me in darkness.

Suddenly Rajani emerged from behind a tree. Her face was not clear, but by a certain sixth sense I felt sure of her identity. There was a flash of lightning and I saw her face for a fleeting moment.

It was strangely altered, as if she had aged into a middle-aged lady overnight, and blood was streaming down her nose. She came close to me in one swift movement and raised her hand. A knife blade glinted vaguely.

I woke with a start. Sweat poured from my forehead. It took me a few seconds to realise that it was a dream. I sat up. I was wide awake now. I looked at my watch. It was exactly two in the morning.

I decided to take a walk. Kuttappan’s tea shop will be open now. I moved into the corridor. A series of rectangular pillars separated me from the wards. Everything was quiet.

The nurses were probably sleeping sitting in their station at the other end of the ward. I saw, from the corner of my eye, Rajani slowly getting up from her bed.

The mother was sleeping on the floor beside her. She moved to the wash basin that was just behind the pillar on the other side.

I ducked behind it, on an impulse. Then she turned her back and started walking back to the bed.

I had heard it. Tiny sounds get amplified in the dead silence of the night. The soft ‘clang’ made me lunge and reach for the floor.

What I picked up was half of a razor blade. It was stained with blood. Rajani stopped and turned to face me. Blood streaked down her nostrils in perfect parallel lines.

She looked at me, covered her face with her hands and ran back to her cot. Her mother woke up.

‘Oh look, she is bleeding again. Lord, what will we do?’ She wailed.

I walked up and made Rajani sit up and pinch her nose. This time, the bleed stopped on its own. I went back to sleep.

In the morning, they were gone. I never discovered what she told them or how she convinced her parents to leave with her.

That was my first encounter with Munchausen syndrome. These patients fake, wound themselves or take poisons and medicines and become ill.

They happily allow doctors to operate and do procedures on them. In fact, that would seem to be their main motivation.

Repeated stints in hospitals are what they crave.

It is different from pure faking or malingering. That is a deliberate ploy to avoid work, get extra compensation etc. Munchausen patients just do it compulsively.

They probably can’t help it. It is not even clear whether they have any insight into the fictitious character of their disease.

Minds are strange things. And some minds are stranger than others. 

Sometimes, coincidences turn out to be even more convoluted and plot-like than the most ingenious novel.

Twelve years later I happened to pass by the children’s ward in the hospital where I was working. I stopped to chat by a friend of mine, a paediatrician.

‘There is a child with a mysterious bleed from her eyes. We have no idea what is happening,’ he said.

On the way back to my room I stopped by the coffee machine. Among the crowd of coffee drinkers, Rajani stood sipping. She eyed me surreptitiously.

I had recognised her in a trice. I walked up to her.

‘The child with the eye-bleed, isn’t she your daughter?’

She moved away without looking at me.

Munchausen syndrome by proxy – I knew about it. It was not only the patient herself who could do the damage.

Someone could do it for them. When it is done to a child it becomes abuse. We had to get the police involved. But that was another story. (Jimmy Mathew)

Dr Jimmy

I am a Doctor, Writer and Science Communicator. I am a member of Info- Clinic, and have written a few books. This site features my blog posts and stories. Thank you for visiting. ഞാൻ എഴുതാൻ ഇഷ്ടമുള്ള ഉള്ള ഒരു ഡോക്ടർ ആണ് . നിങ്ങളുടെ താത്പര്യത്തിന് നന്ദി .