THE GOOD thing about high hierarchy set-ups like JIPMER was that by final year, you had some illusions. I mean, you were looked up to by a small group of people. First year was slavery.
The second year you are a glorified slave. The only difference is that then you are a second year slave. That was no consolation. But you definitely do move up the ranks.
In third year, I was still somewhat of a slave. But it was slavery of a sneakily different kind. One with some responsibilities. But a final year resident could be a hero among other slaves.
Some students hung around you like flies around some waste product. The comparison was apt, as you usually smelt faintly of sweat, grime and pus from the previous thirty six hours in the hospital.
I was also supposed to oversee the work of interns and residents junior to me.
They may not obey you. Then you can complain to no one. But the responsibilities are yours. The senior residents expect you to do them.
The consultants will talk only to you and the senior resident. I had to lord over my minute battalion of slaves by raw moral force.
It was six in the evening, and some students wanted me to take a class for them. I dashed to the toilet and liberally gargled my mouth with the antiseptic chlorhexidine kept in a corner.
I had not brushed my teeth in the morning. I had not gone back to my room after the previous night’s duty. Then I rushed back.
The students were crowded around a patient who had a swelling in the abdomen. I took a quick class for them.
‘It could be a Hepatoma. It is a dangerous tumour and very vascular. It bleeds heavily if you operate on it and sometimes the bleeding is difficult to control. Some surgeons consider it to be an emperor among intra abdominal tumours,’ I concluded. I spied Sindhu looking at me from the corner of my eye.
Sindhu was an intern posted to our unit for two months. She had been with me for the last few weeks. The women had to tie their hair at the back inside the hospital. That was the rule.
Now it was six and the official hours were over. The tie was gone and the hair hung loose. A silky cascade in stylish layered cut framed a distractingly beautiful face. She was light brown, like milk chocolate. And looked, to me, as delectable as one.
I moved away from the students. Sindhu seemed to exert a gravitational pull and I drifted towards her.
‘Did you send the blood sample for Anpazhagan?’ I asked her.
‘No, I didn’t.’ She smiled seductively and pouted at the same time. The schizophrenic expression mesmerised me into silence. ‘I have no interest in surgery. Let us go out for a coffee.’
The wind got knocked out of me with a faint but audible whoosh. I reeled from the pleasant pummelling feeling. The reprimand that I should have uttered hung in the air like a disembodied question mark.
I had been trying to muster enough courage to ask her out alone for a coffee for the past four weeks.
And this invitation affected me like a million rupees thrown into the air in crisp notes. The stupid sparkle in my eyes would have been obscenely obvious.
She didn’t want to walk to the nearby coffee shop. So I took my old Maruti 800 and we drove to the beach road.
She crinkled her nose at the cluttered and tattered interior of my faithful vehicle.
‘It is an old car. But I like it,’ I said defensively.
‘Get a new one,’ she said.
We had a great night out. The food at the beach side cafe was interesting. She was interested in me, or so I thought. I was interested in her.
It was one big interesting evening.
She asked me about surgery. She just could not understand how anyone could be interested in such a morbid speciality.
But she leaned against my body as we came out of the restaurant.
On the way back, a most interesting thing happened. The car stopped and I could not start it. It had a habit of breaking down at crucial moments, just like some members of the gentler sex.
‘Your car is useless, and so are you!’ she fumed. But she was smiling. But I did not smile. I felt humiliated.
Suddenly a sleek sedan pulled up in front of us. Two tall men in safari suits alighted and walked over.
‘Is there any problem, madam?’ one asked.
‘The car will not move,’ she said. Together the men pushed the car to the side of the road.
When I hesitated to board their car, Sindhu said that she knew them. Then they drove us back to JIPMER. Nobody said a word on the way.
‘See you tomorrow,’ she said shyly. I walked back to the resident’s hostel.
‘Hey man, a very interesting thing happened.’ I narrated the entire evening’s incidents to my friend Harish, with special emphasis on the men in safari suits.
‘I cannot shake off the feeling that they were shadowing us all throughout,’ I said.
‘You mean to tell me that you honestly don’t know?’ Harish asked me.
I gaped at him.
‘My dear innocent Romeo, Sindhu is the daughter of the Chief of Police in the province of Pondicherry. Her mother’s father is a minister in the current state cabinet of Tamil Nadu. Carry on, and you might become an emperor in this corner of our country.’
‘Or they might bump you off. Who knows?’ He shrugged.
Harish had a flair for cheap drama. But I half believed him. How else can one explain the safari suits?
The next day dawned, as it always did in JIPMER, and the sun came up with a sense of urgency. One had to be in the wards by seven in the morning.
It was again an admission day. Every fourth Sunday we had to undergo the agony of thirty six hours of work, while many of our friends spent the afternoon wading knee deep in cheap beer.
Sindhu came in at eleven in the morning. She was a law unto herself. Her self-proclaimed disinterest in surgery was an excuse.
I could easily empathise with her. I could forgive her for anything, though many of my colleagues thought otherwise.
The casualty was full by noon. As our senior resident was on sick leave, I was the man in charge of admissions. This happened only rarely. And it was a holiday.
This meant that I was the Chief Surgeon on duty for that Sunday in this high volume centre. The consultants were on call, but they were ensconced in high exalted orbits and usually not to be disturbed.
I ran around like a mad man assessing each patient by turn. I couldn’t bark orders, as that was not in my nature. I whispered urgent requests and followed them up with a forced smile.
I handed out to-do lists and lubricated them with a wry joke or comment. A couple of intestinal perforations were operated without incident.
I sent up a second year resident to do an amputation on a patient with a gangrenous limb.
By evening I felt the abdomen of a middle-aged man. He had fever and vague pain. The liver was swollen. I pointed this out to my team with a flourish. I was relaxed by then.
The duties had become routine. That is how self confidence is born. It is a product of knowledge and experience. More than that, I tell you – it was a result of the work becoming a pure habit.
This case was a liver abscess. An ultrasound was needed. That was routine.
I used to go with the patient to radiology for every scan. It was two floors up and in another building.
One can see the images and discuss with the resident in radiology. As the patient was being wheeled out for the scan I rose to go with him.
Sindhu tugged at my sleeve.
‘It is six in the evening and you expect us to work like dogs without even a coffee break?’
‘When did I deny you that? Please go.’
She looked at me with her smouldering eyes. Some girls have that ability. They can smoulder their eyes and increase the intensity at will.
‘You have been ignoring me the entire day. You thought I didn’t notice?’ Her full lips puckered in a bollywoodish show of pique.
I stepped outside with her for a cup of coffee. Some colleagues passed snide comments. That is the problem with India. Indians are notoriously intrusive. One cannot have a cup of coffee with a girl you like in peace.
I felt like running off to America after completing my surgical residency. That would not be a bad idea. Sindhu had told me that her ambition was to get to USA.
That was for her studies? No. She did not mention any further plans regarding her training. I would have explored this angle further but I had to get back to the ER.
Velmurugan, the man with the suspected liver abscess, was back in Casuality after his trip to Radiology. The ultrasound report was pinned to his case sheet.
The duty resident in Radiology had given a straightforward report of a liver abscess. He had marked a point on the chest wall where you could put a needle to drain out the pus.
That was promptly done. But we got only a few drops of blood-stained fluid. But then, that was okay. I put the patient on antibiotics used for amoebic liver abscess.
Sometimes the pus was too thick to come out by needle. We had to wait for the antibiotics to take effect before doing anything further.
Further cases kept me busy. The key factor in emergency duty was not to forget any patient. Especially those who are not operated, but were on medical treatment.
We had a tendency to think that they will remain stable. But they may not. So you have to keep checking them.
Sindhu distracted me by asking for my help in writing up a project in biochemistry that she was doing. This was crucial in applying for a position in the US. I had to help her.
The night went by in a blur of patients, procedures, pleasant chatter and episodes of partial sleep. I came out of the theatre at four in the morning. Then I started to see the patients.
Velmurugan was in shock. His blood pressure was very low. The abdomen was hard and board-like.
My diagnosis was instantaneous. The abscess had ruptured and the pus had spilled from the liver to the general abdominal cavity. This would lead to peritonitis. The bacteria breed exponentially in the cavity of the abdomen. Fluid seeps in from the body to counter the irritation.
The lost fluid leads to shock. The fluid becomes pus. The infection enters the blood and – well – you get the general idea. Things were not going well for the unfortunate patient.
We had to operate on him. Open the abdomen, wash out the pus and put drains. We had to do it fast.
‘Blast you, man. The patient is in shock. He is very pale. How much is the haemoglobin? Where is the electrolytes report?’ the anaesthesiology senior resident whined. There is this silent war of egos going on between the surgeons and the anaesthesiologists. Sometimes, it was not so silent.
‘There is no time to do all that,’ I said.
‘Then I cannot give you the case.’
‘You have to. I am putting it as “no delay”,’ I countered. It was an extreme move, but I felt that it was justified.
Requesting a case as ‘no delay’ made it mandatory for the anesthesiologist to accept. But if it later turned out to be an unreasonable use of an emergency option, I was in a bad spot.
It would lead to unpleasantness at the highest levels. Polite abuse would fly in the form of interdepartmental memos between the offices of the chief of surgery and the chief of anaesthesiology.
A very impolite version of this abuse could be directed at me. But that one could face later. Now the job had to be done.
As I cut down on the many layers of the abdomen, my friend Gopalakrishnan, the second year resident, retracted the skin for me. As the last layer of the abdominal wall was cut, we entered the peritoneal cavity; I expected that rush of pus.
But what came out was blood. Thick and scarlet, it bubbled out in a frightening torrent. We opened the abdomen fully.
It took us a few minutes to suck out all the blood. There was litres of it.
‘Where is the blood?’ the anaesthesia resident barked in anger.
‘It is everywhere, man,’ I thought. But I understood him.
‘He needs to be transfused blood. You morons, you haven’t arranged for any blood.’ The anaesthesia senior resident ran around frantically, looking for bottles of the colloid solution that could temporarily stand in as a replacement for blood.
Meanwhile I was equally frantic. What was the source of the bleed? Suddenly it was obvious: the needle. We pulled the liver down from under the chest and we could see the brown smooth roundness of its surface.
There was a small point on it from which blood trickled slowly out.
Needled livers do bleed, sometimes. Usually, it stops on its own. I inhaled with relief. This small point should be easy to control.
Now we have opened the abdomen. We could see the bleeding point. It was a tiny, tiny hole. Everything was going to be all right.
I cauterised the bleeding point with the electric cautery. I had done it many times. When that didn’t work I took some stitches over it. This had to be done carefully as the liver was a friable organ.
Then I kept the hole pressed for ten minutes. Then I did them all over again twenty times. At first I was cool. Slowly my confidence evaporated and my actions took on a feverish tremulousness.
The needle hole sat nonchalantly, leaking blood in a steady stream. I had never seen anything so consistent. Nothing changed its unvarying, murderous rhythm.
I called my consultant over. He couldn’t do anything more. We tried every trick in the book.
‘It is time to pack and pray,’ he said. He took two large mops and wrapped it around the liver, tightly wedging the bleeding area between the chest wall and the liver. Then we closed the abdomen.
‘That will stop it. It should. It is only a small needle hole after all. We will take him in again after two days and remove the packs.’
By the time I came out, it was morning. When we finished the routine work, it was time for lunch. Then I got a call from the surgical ICU.
Velmurugan was dead. His abdomen looked bloated. A swollen bag filled with blood. Killed by a needle.
I walked back with heavy steps. Harish crossed me in the corridor.
‘Why so glum, O Emperor of Pondicherry?’ he called out. I ignored him.
Then I had a sort of epiphany. Emperor. The emperor of all tumours.
I ran to Radiology. Velmurugan’s scans were still in the computer. I looked at them carefully. An inexperienced man might mistake it for an abscess of the liver. A young consultant in radiology was looking over my shoulder.
‘Did you say liver abscess? Looks more like a hepatoma,’ he said.
I got out early from the hospital. The campus looked as leafy as before. The cheerful lushness contrasted with my mood. Sindhu came up behind me.
‘That patient is dead,’ I said.
‘I heard. So sad, isn’t it?’ She acted glum for a moment, and then piped up.
‘Let us go out. Today is my treat.’ She linked her arm in mine. The gesture was unexpected. I should have been thrilled. But I felt nothing.
‘I have to go to the mechanic, and then take my car back. It is still parked on the roadside, remember?’
‘Forget it. You get it tomorrow. I will call my dad and ask him to send the BMW. With driver.’ She smiled dazzlingly.
‘I am going to walk to the mechanic right now. It is two kilometres. If you want, you can walk with me.’
‘I can’t walk that much. Are you crazy? Why walk when we can go in my car?’ she said.
I gently disengaged her arm from mine and started walking. She did not follow.
In completing my medical training and then choosing Surgery, I had stumbled upon, some might say, an emperor among professions.
But that did not make me an emperor. It made me a servant of it. The emperor was a hard taskmaster. It did not give me much space. And I had none left for anyone else. Not now, anyway.
And I didn’t want to be emperor. At least, not yet.(Jimmy Mathew)