IT WAS internship. It was the same hospital. It seemed so familiar now, like a close relative. My first posting as a qualified doctor was in Medicine, with Dr. Baburaj. I have taken you there, in a brief encounter previously.
I started learning about responsibility. It was not always great fun.
My next posting was in Surgery. I was not at my most confident when I faced Dr. PK Mohanan, or PKM as he was commonly called, in his room. Four of us had been posted to his unit for three months.
‘Any future surgeons amongst the lot?’ he asked.
I hesitated. As a student, whenever I voiced my preference, the surgeons were derisive and sceptical. Physicians were enthusiastic, and even evangelical regarding their specialty, but surgeons looked at you with silent appraisal and sometimes even shook their heads imperceptibly.
I raised my hand.
‘Good. At least there’s one person,’ PKM smiled.
My posting started on a ward day. I had to first go to the so-called dirty wards on the ground floor. For every bed, there were two or three patients on the floor. They lay around with bandages, groaning softly.
Patients with diabetic feet, ischemic gangrene, and cancerous ulcers, occupied the beds looking resigned. In the corner were a few beds for the severely burnt, who lived in a world of silent misery. A mixed stench of urine, rotting flesh, and unwashed bodies hung in the air.
I would hold my breath to prepare case notes. Then I would run to the clean lecture hall, open my Bailey’s Practice of Surgery, and inhale the scent of fresh paper trying to clear my head of all other smells, pain and suffering.
With a shock I realised that I had to spend days at a time in this place for the next three months. We had to practically live here. Just thinking about it made me feel claustrophobic. In between theatre duties and OPDs I ran every half hour to the wards, did a few dressings, wrote some discharge summaries, and then went back in a panic as I thought about all the other chores piling up.
Twice a week, our unit had twenty-four-hour emergency duties. There was no off following those. It was a continuous thirty-six-hour grind.
On my first ER duty, I felt I had been dunked in cold water. All the patients seemed to be complaining about dressings not done, investigations not sent. I was the doctor responsible.
‘Where the hell were you yesterday? My foot smells. See it dripping?’ a patient said.
I lowered my head guiltily. The dressing was indeed soaked with pus, and smelt bad.
‘Hasn’t the chest x-ray been done? It was ordered yesterday. Don’t be bloody lax, man, if you want to be a surgeon,’ said PKM.
I gasped for air. I felt like running away. I longed for the green and sunny world outside, and wondered whether I would ever be able to do it.
What distressed me most was that in the inadequate government set-up, the ‘ideal’ was almost an esoteric idea.
I could not even aspire towards achieving it. Nobody could. I was forced to do the dressings of five or six patients with the same set of instruments dipped cursorily in the boiler.
I must have transferred numerous staphylococci, klebsiella, and pseudomonas from one patient to another. The wounds in the ward seemed to culminate into one giant festering sore.
I had to learn to fight with my fellow interns for access to the coveted dressing trolley. If the dressing material ran out, I had to go and fight with the ward-in-charge nurse – which was a worse prospect.
‘If you want to be a surgeon, fall in love with the ER,’ PKM advised us.
The emergency room was a prototype purgatory. How could anyone love it? The mere thought of the next stint in the ER gave me nightmares.
The crimson blood spread everywhere coloured my mind. The cries of the dying, and the desperation of the relatives, numbed my skull.
Drunks with minor injuries showered me with abuse when I attended to the severely wounded.
While I sutured the scalp of one patient, another patient on the trolley awaiting my care worried me. Did he have an intra-abdominal injury? Would he bleed to death?
My hands shook. My head hurt. How could anybody learn any skills in the midst of this battle?
A couple was brought in, in a critical state, following an accident. I was alone in the ER. The duty surgeon was in the theatre, and my colleagues were in the ward. The man was bleeding profusely from a wound on the face. He was screaming.
The woman had no external injuries, and was quiet. I took the man inside the procedure room, examined him, and started suturing the wound. Next, I asked the nurses to start IV fluids for the other patient.
‘There is an arrest. Doctor!’ the nurse shouted.
I had just finished with the man. I rushed to the woman’s side. She was unresponsive.
I started CPR with a desperation I had never known before. The duty surgeon came running and took over. I prayed fervently for the patients’ recovery.
The woman recovered first. She had had a head injury which I could not identify at first.
‘You have to prioritise,’ PKM berated me the next day. ‘Haven’t you heard of triage?’
Fortunately, there was only mild disapproval in his eyes. If he had shouted, I would have died stewing in guilt.
What if either patient had died? It burst upon me that even at the level of an intern, my job was not trivial. My status might be low down in the hierarchy, but I had to be responsible. People’s lives depended on my vigilance.
By the end of two weeks I could breathe more easily. I got somewhat used to the work, and could no longer hear my heart thudding all the time.
Then came a case where the patient had an abscess in the armpit. PKM was busy elsewhere with a serious patient.
‘Post it in the theatre, and do it. It is a large one,’ he said.
I had never gone solo to the theatre before. During the past two weeks, all my adventures had occurred under the watchful eye of the duty surgeon. Going into the theatre meant facing everything alone.
It meant working on a much bigger canvas. It was threatening. It also meant meeting that temperamental king of the theatre – the anaesthetist on duty.
Doctor Mubarak gave the patient anaesthesia, muttering under his breath. I scrubbed the area with Betadine. He was annoyed whenever an intern came alone for a surgery.
I made a small cut with the knife at the apex of the bulge, which was clearly visible. White pus poured out. I breathed normally for the first time.
The pus changed colour. It became light pink, and then the colour deepened. Finally, blood began to pour out. It did not stop even after applying pressure for sometime. I panicked.
Dr Mubarak began to swear. ‘Why the hell did you come if you don’t know anything?’
I was paralysed. The surroundings felt strange and unreal. I heard him speaking into the phone. ‘Come immediately, Mohanan. Why do you send morons to the OT?’
PKM walked in calmly, and controlled the patient’s bleeding. It was only a small vessel at the edge of the wound.
He completed the dressing, while I slowly moved out. I walked back to the ER, humiliated and miserable. I wanted to go home and sleep, when PKM caught my eye.
‘I don’t think I will ever become a surgeon,’ I told him.
He smiled. ‘Come, other patients are waiting.’
I followed him. He never mentioned anything about that incident.
For the next few weeks he made me assist in a lot of cases. I spent all my time in the hospital. I was at the scene whenever there was a procedure.
I haunted the ER like a spectre around the clock, and was there every time a patient with a serious injury was wheeled in, even when I was not on duty.
The gloves never left my hands. My light brown leather shoe became spotted with ugly stains like a diseased Dalmatian’s skin.
###### ~ o ~ o ~
The Vadukkunadhan Siva temple was just opposite the hospital in the middle of the sprawling swaraj roundabout. Thrissur was the land of temple festivals and no pooram was complete without a herd of elephants being paraded before the deity.
The temple had several elephants on its grounds with a host of mahouts to attend to them through the year.
Even the domesticated elephant can be a very dangerous animal. I realised this a month later. A handful of drunken fellows carried in another inebriated chap, and dumped him on the examination table.
They introduced themselves as mahouts. One of them lifted up the lungi of the patient gingerly to reveal a split open scrotum, with the white testicles hanging out grotesquely.
‘Kesavan attacked his balls,’ one of the men said conversationally. The explanation was directed at PKM and me, as we approached the patient.
‘Don’t blame him. He meant no harm. It was an accident,’ the patient added.
The others nodded.
On further enquiry, the picture became clear. Surendran, the mahout, had been giving a bath to the elephant, and it had moved its head suddenly. One of its tusks had accidentally brushed against his groin.
PKM examined the wound with a gloved hand under an overhead light. He lubricated his index finger, and conducted a rectal examination. After that he straightened up to face the patient and his friends.
‘It is not a simple injury. We have to inspect the wound with the patient under anaesthesia, in the theatre, and then try to repair it. But don’t worry, men. This young doctor here is a scrotum and testicle expert. He will take charge of your friend and do what is necessary.’
I was flabbergasted.
‘Trained from England, no doubt?’ one of the mahouts said. ‘Is he a balls specialist?’
‘I shouldn’t wonder,’ PKM smiled casually.
###### ~ o ~ o ~
‘But, sir, I can’t do it,’ I protested, when we were out of earshot.
‘Yes, you can.’
‘Dr. Mubarak is on duty again today.’
‘Don’t mind him. Focus on what you have to do’
This was my second independent surgery in the theatre. I was terrified. I could feel my heart going mad in my chest. I was sure the nurse who assisted me would hear my heart beat.
I did not look at Mubarak, but painted and draped the area of the wound. Mubarak took one look at the testicles hanging with a cord, the veins visible like a mass of noodles, and gasped. He looked at me incredulously. I refused to meet his eye. I washed and inspected the wound carefully.
PKM had assessed the wound properly, and recognised it for what it was. It was a deep laceration. The twelve-centimetre scrotal skin breach had allowed the testicles to pop out, and they looked bizarre. But there was no deeper injury.
I gave it a thorough wash with saline water. This was followed by a two-layer closure with simple stitches.
Then I tied a tight bandage around the scrotum like a loincloth, and completed the surgery coolly as a seasoned surgeon would have. Then I looked boldly at Mubarak.
‘It is over, sir,’ I said. ‘Now you can turn the patient over. I will be back with the next case.’
He gave me a look of grudging respect.
Daily I inspected and dressed the wound and, by the tenth day, the sutures were removed and Surendran was discharged as good as new. It was very encouraging. My resolve about sticking to Surgery strengthened.
The rest of the three months seemed to fly by. The busy schedule and the physical, mental, and emotional input made everything go fast-forward.
During my last week in the department, at around eleven one night, another mahout was brought in accompanied, as usual, by a few dark lungi-clad fellows talking calmly amongst themselves.
The smell of country liquor floated to me from their thin bodies.
They narrated a remarkably similar story to the previous incident. The elephant had moved its head, and the tusk had accidentally ripped through the thigh of the poor man.
But, this time, the damage was much more severe. The patient was almost in shock due to blood loss. The clothes, too, were soaked in blood. There was a huge wound on his upper thigh, deep enough to reveal the bone.
The swollen muscles pouted from it like large purple plums. The intervening fascia was a gruesome contrast. There were no distal pulses on the leg; it was insensate and cold. An arterial injury.
This was an emergency. PKM was the only surgeon in the institution who could do blood vessels. And, though it was not his duty day, he agreed to come.
I badly wanted to assist in this case, and volunteered to fetch him in the ambulance, so that I would be the first one to ask.
While changing into a gown and wearing gloves with him I realised what made great surgeons successful: the ability to do something complex like this. I would have given anything to acquire such skills at that time.
I looked on with admiration and envy, as a fleet of interns and nurses surrounded him. They rushed forward with towels and gloves, half of them pretty girls who completely ignored my presence.
Surgery was a kind of spectator sport, and the skilled really got an audience. In addition to the interns, two of the junior faculty had also come to watch. I retracted the muscles as PKM skilfully dissected the various layers of fascia, searching for the artery.
A good knowledge of the intricate cross-sectional anatomy and a three-dimensional orientation of the structures were essential. I found it baffling, even though I had completed anatomy relatively recently.
Slowly and meticulously, he exposed and isolated ten centimetres of the artery, glistening white, except for the five centimetres of blue- black discolouration in the centre. After stopping all the bleeders, he leaned back.
‘This is an area of contusion-crushed artery with thrombus inside,’ he said, indicating the black segment. Everyone looked on eagerly. ‘We will have to do a vein graft.’
Oh no, I thought. I was tired and hungry. My neck ached from being kept bent for too long. My hands were numb from the retraction.
PKM removed the crushed artery, and put the arterial ends in specially designed vascular clamps to prevent heavy bleeding.
I followed the surgery in a daze. I was afraid I would fall into the field.
The vein segment was reversed, and joined end-to-end with the artery using fine stitches. This was an extremely tricky business.
PKM had an ocular magnifying loupe on, as we did not have an operating microscope. He finished the surgery with finesse, leaned back, and released the clamps.
Initially, there was a lot of bleeding. Jets of blood pumped out through the microscopic needle holes, forming a dance of scarlet toothpicks. Slowly, the leaking subsided, as minute thrombi formed to plug them one by one.
The vein graft swelled to double the diameter, pulsated rhythmically, and transferred blood from one end of the cut artery to the other.
It was a magnificent sight. I felt fully awake now. I can still feel the thrill in my bones.
It was accompanied by a disconcerting doubt about whether I could ever do something similarly complex and intricate. I was tired as hell, just standing and assisting the senior doctor all these hours. PKM looked fresh, and his eyes twinkled with good humour.
I plunged into self-doubt. What was I thinking? Could I ever emulate these giants? I absently listened to his memoirs which he narrated only rarely.
He told me about the time he had treated a cabinet minister who was attacked by a bear near a resort. It had not come in the papers. He was not supposed to be there, apparently.
We walked out into the theatre lounge to meet the friends and relatives. By this time, it was four in the morning. The operation had lasted for close to seven hours.
Only one man was outside, and he was sprawled on the floor in drunken stupor. After a thorough shaking, he leapt up and stared blankly at PKM.
Then he perceived me standing in the background and bowed low with great respect.
Despite the fact that this so-called friend of the patient was under the influence, PKM, with great patience, started to explain the injury and the procedure we had done.
But he seemed strangely distracted. After a minute, PKM lost his cool and raised his voice.
‘Hey, are you listening to me?’
The fellow jumped. Again, he bowed low. Before me. I was becoming angry as well.
‘What are you looking at me for?’ I demanded.
‘Oh, saab, don’t you remember me?’
He promptly lay down flat on his back on the floor, oblivious to the various onlookers who had gathered around.
Then he lifted his lungi with his left hand, exposing all. With his right forefinger and thumb, he lifted the root of his penis, showing the under-surface of the scrotum. There was a jagged scar.
‘Surendran!’ I exclaimed.
‘You saved my balls,’ he said. ‘You’re a great balls specialist. You would agree, saab, that the balls are infinitely more important than a small gash in the thigh?’
I stared, dumbstruck. PKM looked at me and laughed. Then I smiled. Maybe I would take up Surgery after all. (Jimmy Mathew)
