The fact that the five years of MBBS were easier as compared to the subsequent practice was only in hindsight. I really got a shock when I first had to venture into the clinics.
My first clinical posting in Medicine as a third year was stressful.
But I was not too stressed to notice that Sheeba was among the four posted with me. The days with Meena were long over. Sheeba was a small dark girl I had been interested in for a long time. She was small but shapely.
‘It is all about proportions, Jimmy,’ Sudhish had said, looking down at me from a foot taller vantage point. ‘Size is not important, at least for girls. But don’t think the same is true for guys.’ I think he had Sheeba in mind when he said that.
‘It is not only about the proportions, Sudhish,’ I could have answered. ‘It is about baby smooth skin, her shy demeanour, and eyes that laugh when she smiles.’
Till now I had never spoken to her much. This was an opportunity when we would be thrown into close proximity. We were two girls and three boys in the group.
I surveyed the opposition briefly. Sunil was a spent force as he had once been caught jumping down the wall into the ladies hostel at two in the morning, fortified with a generous dose of alcohol.
Some girls who admired that kind of thing would go for him. But I did not count Sheeba among them. Mohit was a geek, complete with thick glasses.
He was not known to be interested in anything other than studies. But that could be deceptive. It would be a mistake to ignore him, as girls like Sheeba were likely to fancy boys like Mohit who buried themselves in textbooks.
I heard Dr. Baburaj droning on in the background about feeling for the apex beat to assess heart-size and the first and second heart sounds. I had read a little about clinical examination.
But I was distracted by Sheeba, who stood right in front of me. She was so short that I could see her cleavage. But the damned overcoat hid everything else.
‘Yes, Jimmy, what is the murmur of aortic regurgitation?’ the professor asked me.
Rudely snatched back into the world of clinical examination, I stood up and gaped stupidly.
‘Presence of mind is an essential prerequisite to be a physician. And there is no substitute for diligence.’
‘Sorry, sir,’ I mumbled.
‘It would be nice if you could auscultate all thirty patients in this ward with your stethoscope and find out which ones have valve lesions. There are three such patients among them. Don’t look at the case records.’
After the clinical class, we had to go back for our afternoon lab work. Where was the time?
The professor looked at me with a hyper-paternal smile.
‘You can come back after five and do it. The patients will be very much here. They don’t disappear after class hours. You may not be aware but qualified doctors work after that.’
The other four of my batchmates snickered. I was horrified to see Sheeba laughing louder than the rest, hiding her lips with her tiny hands. On top of that, she was ridiculing me. My heart sank lower than a grazing cow’s nose.
As far as I was concerned, after-class hours were sacrosanct, strictly for lazing and fooling around with friends. A few hours of study to break the monotony were allowed on special occasions.
After the class was over, all of us walked to the lab. I jogged to catch up with Sheeba, who was walking alone in front of me.
She acted as if she had not seen me, but allowed me to walk beside her. I bent down and said softly, ‘You should not have laughed at me, Sheeba’
You may note that I, like Jeeves, was a keen observer of the psychology of the individual.
The one great weakness of reticent girls like Sheeba was conscience. Stimulate their guilt-nerve endings, and you are through.
It had an instant effect. She stopped walking, turned and looked up at me.
‘Gee, I am sorry. I did not mean to – The way the prof said it, it was so funny,’ she said.
I mentally cursed the man’s misplaced sense of humour. I may have looked suitably miserable, for Sheeba continued.
‘I have an audio cassette on heart sounds and murmurs. A cousin of mine got it from the US. I will give it to you. I think I have it with me now.’
She rummaged in her bag and came up with the cassette. I pocketed it.
‘Thanks. May be we could –’ I hesitated. Could she read my feelings? ‘You know, go to the wards together to look at the patients?’
‘No, I don’t think so,’ she replied firmly. ‘Okay then, bye.’
She walked on, without looking back. I kicked myself for pressing the fast-forward button. In real life. It does not work.
I admit I cheated on the assignment that evening. I did not check the case records, but I asked the interns in charge of the ward. They pointed out to me the patients with heart valve defects.
I examined all of them after taking their history. Then I went and played the audio cassette. I became really interested in physical examination, especially of the heart, due to that professor.
I presented a nineteen-year-old with breathlessness four days later.
‘The ejection systolic click after the first heart sound and the systolic murmur along with the enlarged heart found during palpation points to aortic stenosis – a narrowed aortic valve,’ I concluded.
‘But in the history you said that there was nothing suggestive of prior rheumatic fever. No joint pains in childhood,’ Dr. Baburaj countered.
‘It points to a congenital aortic stenosis. It is the most common valve birth defect,’ I said.
‘Hmm. Why the breathlessness now?’
‘Now his heart has started failing, sir. The jugular venous pulse is prominent.’
‘Good. Your judgement is acceptable,’ Dr Baburaj said. Coming from him, it was a big compliment. Mohit looked at me with open envy. I was gratified to see admiration in Sheeba’s eyes.
After the class Sheeba asked me, ‘How did you come to aortic stenosis?’
‘Come, let us discuss this over a cup of coffee,’ I said.
‘Uh, okay. I will have an ice-cream,’ she smiled.
The next day too we went for ice-cream, even though we had nothing much to discuss.
That evening I sat in my room and thought about Aneesh, the patient with aortic stenosis, who had provided me with an opportunity to ask Sheeba out. He was nineteen. The same age as me.
How shocking it must have been to turn breathless suddenly and then to find out that he had a birth defect that had affected the heart so much that it had started failing.
I had put the stethoscope to my own chest many times and listened. But, suddenly, it occurred to me that after being acquainted with the technicalities, I had never done it.
I put the diaphragm of the stethoscope on my chest, put the earpiece over my ears, and listened.
Lub-dub, Lub-dub it went. Was there a slight ticking sound after the first sound? Yes, there was. It became unmistakable as I listened further. lub-tick-dub, lub-tick-dub.
God, I had an ejection systolic click! But it was usually accompanied by a systolic murmur. When I listened for it, it was there. A faint whoosh.
I sat for some time, petrified. Realising you have a serious illness is disconcerting. Denial – that is the first defence of the mind. But I was a medical student. I knew all about heart sounds. It could not be wished away. The click was there.
There was a faint ringing in my ears and drops of sweat damped my forehead. A flutter in my chest grew. Was I developing heart failure?
I barely slept that day. I moved around like a robot all through the clinical session. In the middle of the class, I furtively auscultated my chest. I heard the click again.
The chest discomfort and ringing in my chest came on again. I felt a little breathless. Sheeba said something to me, but it did not register. I was preoccupied with my own suffering.
After class she came to me and smiled brightly.
‘My sister had a baby boy yesterday. Today I’m getting a treat.’
I should have been thrilled by the invite. My lame ‘congrats’ did not go down well with her. But what did it matter? Who was I? A terminal case of cardiac failure, with no hope of recovery. Even if I managed to win her heart, what was the point?
All through the ice-cream session, she talked about her sister and the baby.
I thought about how I would never marry or have children. Was my diagnosis correct? Maybe I should ask her to confirm.
‘He is so cute and small,’ she was saying.
‘Like you,’ I should have said. Instead, I said, ‘Hey, can you take a look at my chest?’
‘What! I didn’t get you,’ she replied, confused.
‘I meant, can you auscultate my chest and see? I think I have an ejection systolic click,’ I blurted out.
She lowered her head shyly. ‘No, I don’t want to, Jim. I know you are one wily fox. But don’t try your tricks with me.’
I looked at her incredulously. She was still smiling, and that was good. But didn’t the miniature dumbo realise that it was a matter of life and death? She was belittling my trust.
She laughed softly. ‘Why don’t you show Dr. Baburaj? That would be better, don’t you think?
I left it at that.
Then, while walking back to the building, I felt dizzy and breathless again. Sheeba’s suggestion was sensible.
I excused myself on some pretext, decided to bunk the afternoon lab work, and consulted Dr. Baburaj.
‘Yes, Jimmy, what is it?’
‘Sir, I have a vague pain in the chest. And breathlessness.’
‘Did you examine yourself?’
‘Y – yes. I think I have an ejection systolic click. A systolic murmur is doubtful, sir.’
Dr. Baburaj made me take off my shirt and examined me in detail. Finally, he put the stethoscope on the four crucial areas on my chest and straightened up.
‘Your power of clinical examination is really good. I agree there is a faint click. But there is no murmur,’ he said.
I was more angry than upset. One of his students had a serious cardiac disease and was that how he should have reacted? Maybe that was what experience did to doctors – it made them callous.
‘Let us do an ECG.’
Those ten minutes that I waited for the ECG were the longest ten minutes of my life. Dr. Baburaj read carefully through the sheet. When he looked up, his face was sombre.
‘Jimmy, you do have a condition.’
I could hardly control my tears.
‘Can anything be done, sir? What is the disease?’
‘It is called the third-year syndrome. It is brought on around two days after you have seen a similar case. It is basically a mental problem.’
I couldn’t believe it.
‘But what about the pain, ringing in the ears and all that? You said there was an ejection click.’
‘These are all classic signs of acute anxiety inspired by patients who have such problems. Since you examine them constantly, after a while, you begin to looks for such signs in your own body. A faint click is sometimes normal in thin people. The murmur is your imagination.’
This consultation magically removed my symptoms. It convinced me that the professor was right. It is such a relief to have your life back. It was as if a death sentence had been revoked.
I never mentioned any of this to Sheeba. We had regular ice-cream sessions now, and she smiled and laughed more readily.
One day she appeared sad and dejected.
‘Jim, I want to tell you something,’ she said.
‘Go on.’ I was a little alarmed. Did she want to end everything? Some girls were like that. They didn’t want their man talking to other girls.
Or perhaps she had thought about it and decided that I was not the man of her dreams.
‘You are a close friend. That is why I am telling you this.’
I waited with steadily mounting dread.
‘I – I think I have some deadly disease. I feel dizzy and there is ringing in my ears. And there is a tightness in my abdomen.’
‘Yes. It looks like I have colon cancer. I think there is a lump in my abdomen. I can feel it.’
I feigned a concerned look.
‘Do you get these symptoms while palpating your own abdomen?’
‘Did this start day before yesterday, maybe towards the evening?’ We had discussed a patient with colonic mass four days ago.
‘Yes, but how do you know all this?’
‘You know, I don’t want to sound arrogant, but I am very good clinically. I have a fair idea about your condition.’
‘Is it, Jim? I am very worried. I don’t know what to do.’ She was frantic and looked at me. I had to help her.
‘Don’t worry.’ I said. ‘I will take care of everything. Come to the duty room. First let me do a physical examination and then palpate your abdomen for the mass. Dr. Baburaj has taught me all about it.’ (Jimmy Mathew)