Dr Ashokan Kanjikuzhi adjusted his tie, looking into the corner mirror. It was the one with blue oblique stripes against off-white. One of his favourites. He checked the length. Lately, it was getting difficult to get the right length because of his bulging stomach. He would have to start exercising. The almost bald head, and the prominent double chin, depressed him. When he was satisfied with his tie, he turned to the expensive rotating chair with a cushioned support for his back. It had been made especially for him. On his vast desk was a nameplate with his name and designation. It said, Head of Department, Surgery. His qualifications followed: FRCS (Glasgow), FRCS (London), FRCS (Edinburgh). On the wall behind him, hanging in fancy frames, were the three certificates.
Ashokan swivelled his chair to face Dr Arun Nair, who had walked in a few minutes ago. He was a bit surprised to see Dr Arun already seated. He remembered Sudhir, another junior doctor a year back, being more respectful when he had joined as the head of department. Arun was an insolent dog – a junior surgeon, with an MS from one of the busiest but most inadequate institutes in India. Ashokan did not consider the three year post-residency experience even worthy of mention. Yet, the boy had a habit of keeping him on his toes.
“Sir, I wanted to talk to you about Mr Kuriakose,” Arun started off without preamble.
“Yes.” Ashokan could not hide his irritation. “Who is Mr Kuriakose?”
“The patient who came into the casualty last night with abdominal pain.”
“Yes, I remember. I examined him in detail this morning. What about him?”
“I think we need to open him up. Exploratory laparotomy.”
“The surgical practice in civilized countries like England is not like this. The diagnosis has to be proper and, if needed, we will operate on him. Don’t open up people just like that to see what is inside.” Ashokan’s voice barely disguised his contempt. “Besides, his abdomen is soft. The ultrasound is normal. It is not peritonitis.”
Arun stared at him, unblinking, for a few seconds before replying. “Sir, there is a tender palpable bowel loop, and a history of abdominal surgery. The details are not available. It happened a year ago. The severe pain is unrelated to the physical findings.”
“R – really? He’s had a surgery before? I didn’t…” For a moment Ashokan appeared unsure, but quickly regained his composure. “If you suspected intestinal gangrene, why didn’t you do a CT scan? Or a technetium scan?”
“Well, sir, the CT Scan and the ultrasound are equally ineffective in detecting gangrene. And you know very well that radioactive tracer scans are not available at this hospital. The patient may not be able to afford expensive investigations either.”
“This is the problem here. You know, in the UK, the system is so good that you don’t have to think. There are protocols for every eventuality. And the patient never pays. The NHS does.”
Arun tried to suppress a sardonic smile. “But here you have to, sir. I mean, you do have to think. Please tell me what to do about Mr Kuriakose.”
It was evident from Ashokan’s face that he had registered the sarcasm very well. Arun was unconcerned.
“Get a CAT Scan, fast. Call up Apollo to see whether a technetium scan can be arranged. And don’t try to teach me what to do. I was trained in one of the best institutes in the world. Understand, Dr Nair?” Ashokan’s tone did not hide the suppressed rage. He watched the retreating back of his colleague with hatred.
He was still scowling, when there was a soft knock on the door. It was Mr Dandapani, the managing director of the hospital. Ashokan’s grimace was replaced by a broad smile. Dandapani was a gaunt old gentleman with slightly stooped shoulders. His vast forehead was marked by streaks of chandan and vibhuti that made it an interesting work of art. The benign smile was ever-present. His eyes were sharp and narrow. Dandapani, though practically illiterate, was a self-made and very successful businessman. He had made his empire, and transferred it to his sons, by his late fifties. Then he had started the hospital.
“Hello, Doctor, how are you?” Dandapani’s enquired courteously.
“Very well, sir.”
“It is a popular hospital, sir.” Ashokan was suddenly radiant. Enthusiasm oozed out of his body.
The director looked at the sleek glasses, tie, and polished shoes of the surgeon, and beamed. “Well, I just wanted to say hello, that’s all. How is the new doctor doing – your assistant surgeon, Dr Arun Nair?”
“Err … he is okay, I guess, but still not very well trained. You see, I have to teach him a lot of things – the discipline, the systems, so important in the West. But I will take care of it, don’t worry.”
Dandapani’s father had been a housekeeper for one of the British officers in the pre-Independence days. He had immense admiration for the West and its work culture.
“Yes, Doctor,” he smiled again, “please carry on. The patients are waiting.”
Ashokan leaned back in his chair after finishing off with a few waiting patients, and tried to relax. He was doing well but, five years ago, while travelling to the UK, he had never thought of returning to work in India – ever.
Ashokan remembered the day Prof. Stan Brown from King’s College visited his medical school in Chennai. He was in the first year. He had listened to the world-famous biochemist talk about the recent research on Cancer. Ashokan could claim to be one of the few who became interested in the UK for a truly noble reason: research. Later, his leanings changed to clinical medicine.
“The exchange rate is an amazing thing,” Narayanan, a senior doctor, told him. “And it’s tax-free.”
Ashokan desperately wanted to reach the Western shores. It became an obsession with him. The UK was an obvious choice. The pound sterling, and the letters ‘FRCS’ attracted thousands from the third world every year.
The first barrier in his path was the mandatory rural service for the new MBBS graduates. It was an attempt by the Indian government to wrest some service from them before they entered the private sector or made for foreign countries. Ashokan worked feverishly, and cracked the post-MBBS residency entrance exam to enter the first year MS (Surgery). The law exempted doctors, who had started residency within six months of completing internship, from the rural service.
He spent the intervening four months, before joining the course, with an anaesthetist at the Chennai Municipal Medical College and Hospital, who was a fellow at the Royal College of Anaesthesiologists (FRCA), London. He managed to wrangle from him an experience certificate of six months in critical care, and started the first year of residency in Surgery at the same centre where he had done his under-graduate studies and internship. But even then the work came as a shock. The crowded, smelly, buzzing wards frightened him. The strict consultants, shouting seniors, and indifferent nurses, tested his patience. How could he survive the set-up for a whole year? But it was necessary for his grand plan.
He had to utilize the time to clear the PLABB – the licensing exam, and the first part of the FRCS exam. He had to travel to the UK for both after proper preparation. Then he had to take the IELTS, the English language test. Finally, he had to arrange for the money. The application fee for the FRCS exam cost around fifty-thousand rupees. The amount for the second part of the exam was similar. Shamelessly, he shirked responsibilities and feigned uselessness at the hospital. If your superiors thought you were incompetent, in Surgery, you had it easy. Nobody dared to give you much work. An imaginative mind and a thick skin helped.
“Ashokan, what is your problem?” the chief, asked eventually. Though a terror at work, he was known to have a big heart. Ashokan was banking on that fact. “Unfortunately, Surgery is not for you. But expulsion would be a black mark on your career. I wouldn’t want to do it.”
“No, sir, I will resign. I am not made to be a surgeon, sir. I realized my mistake a few months into the programme. But I have been trying my best.”
“All right, that will be fine,” the HOD said hastily, perhaps moved by Ashokan’s supposed plight.
“Please, sir, I would need an experience-certificate, just to show that I trained under a great man like you, if only for a short period,” Ashokan implored.
“Sure. I don’t know what good it would do you. But you have to make a promise.”
“Yes, sir. Anything sir.”
“You have to promise me never to take up any surgical specialty in your life.”
“Yes, sir, I promise.”
Getting the visa was the final hurdle. The embassy officials were apparently despots, doling out arbitrary judgements. But some insisted there was a science to it.
They will refuse you if they don’t like the look of you, one of Ashokan’s predecessors had told him. There were professional consultants for these things, and Ashokan arranged for the fee for one with a lot of difficulty. Besides that, he had to show a bank balance of ten lakh in Indian rupees, and immovable property of some value, which his mother managed with the help of some reluctant relatives.
“They are only concerned about whether you will return to India after you finish higher studies. I know you don’t want to return, but they should be convinced that you will. So, the more assets you have here, the better,” the consultant said.
What is the point going abroad if you are already a billionaire here? thought Ashokan, but remained silent.
“One more thing,” the consultant spoke up, as Ashokan rose to go.
“The moustache. It has to go.”
After arriving in London, for a period, Ashokan felt comfortable. Dr Narayanan, in an unguarded moment of drunkenness, had promised Ashokan, who was still a medical student, that he could stay with him if he ever chose to come and work in the UK. He had never imagined that four years later Ashokan would land up in London, smiling, and hold him to his promise. Being one of the few who still believed that promises were meant to be kept, Narayanan welcomed Ashokan to his apartment where he lived with his wife – not exactly with open arms, but with tight lips and creased brows.
It did not trouble Ashokan much. What troubled him was that he was without a job. During the first week, his host made it clear that he was welcome at his house after eight in the evening – to sleep, and had to leave by seven in the morning before breakfast. Ashokan zealously checked the papers and the Net for vacancies, and appeared for interviews one by one. He visited the gurudwara almost every day, and marvelled at the way they gave away free food.
After roaming around for several days, Ashokan realized that the place was crawling with young, brown doctors from India, Pakistan, Bangladesh and God knew where else – armed with the PLAB, hope in their hearts, and a single aim – to get a British degree and find a job in the UK. The restaurants were full of them, not as diners but waiters. The petrol pumps were manned by them. A good number of young lads working in the supermarkets were qualified doctors from south Asia.
Finally, after two months of countless interviews, Ashokan got a job as senior house officer in a Geriatrics unit in Lancashire. It was a contract for six months. The work was mundane: collecting samples, writing case sheets, charting investigation results, and the usual formalities relegated to the junior-most person.
“Please, Ashok, check the damn guidelines, will ya?” his registrar would say, clearly annoyed.
“Eh? Pardon me?” he would stare back at him blankly. Under pressure, he found it difficult to understand the accent. George would repeat it syllable by syllable, as if talking to a half-wit.
Whenever an elderly patient was admitted, Ashokan had to take care of all the auxiliary duties as well. Who would take care of the house? The dog? If there was no one, the social services would have to be alerted. Upon discharge, it was his duty to see that social workers and the system took care of the lonely eighty-year old. They provided food, regular allowances, and even a nurse. Slowly, he began to understand why people from the third world wanted to migrate to first-world countries.
The working pattern was also civilized: eight hour shifts with weekends off. When you had to do weekend or holiday duties, you received extra cash in addition to compensatory offs, a far cry from the thirty-six or forty-eight hour continuous duties he was used to doing back home. There were no sweaty, swearing, jostling crowds to spoil your day.
Finally, Ashokan got a job as a junior house officer in a surgery unit, and completed his requirements. He crammed for the highly orchestrated FRCS examination in his free time.
When the final results came, he became Dr Ashokan Kanjikuzhi, FRCS (London), FRCS (Glasgow), FRCS (Edinburgh).
With this major hurdle taken care of, Ashokan was given a post equivalent of a non-PG senior resident in India. This degree made one eligible for a registrar’s post, but did not make one an independent, full-fledged surgeon in the UK. He still needed a trainee rotation programme of six or seven years to become a fully qualified surgeon. He was all set for it, when two things happened that upset all his plans.
The British government suddenly decided that it had enough home-grown talent, and people from other European countries, and didn’t need more South Asian doctors. Secondly, he still went for night duties and holiday duties here and there, and an unexpected development occurred at the wrong time.
One evening a nurse-in-charge asked him, “Dr Ashokan, why are you doing so many locums without a break?”
“For centuries your people plundered India,” Ashokan replied jokingly. “Now I am trying to get a little bit back.”
The nurse, however, found out that he had once done a night at two hospitals simultaneously, the second hospital being just a few kilometres away. Night calls were infrequent enough to manage this. But the nurse informed the chief of surgery, and Ashokan had to face two weeks of suspension.
“I will see to it personally, Dr Ashokan, that you never get into the training programme,” he said.
If he wanted to continue in England, he would have to hop from place to place every six months, attending interviews in between, and even risk going jobless for months at a time due to the revised policy of the government.
He was sinking into depression when he received a call from India.
“Hello. I am the managing director of DIOS hospital in Chennai, Dr Ashokan,” he said, and went on further with explanations. After a few minutes, he came to the point. “Would you be willing to work as the chief surgeon with us, Doctor? Our offer will be extremely generous.”
Ashokan was taken aback.
“How do you – my experience –. Yes, I have considerable experience in the UK,” he managed to utter.
“You are Dr Ashokan, FRCS, aren’t you? You have the FRCS?”
“Yes, yes. Three. From all the three royal colleges, actually.”
“Excellent. I trust you have the tie?”
“You wear a tie, right? All doctors from England wear a tie.”
“Of course. Always. I always wear a tie.”
“Good. You are appointed.”
The clock on the wall struck eleven times. Ashokan broke out of his reverie. That was almost three years ago. The three years had been stressful, adapting to the surgery practices in India, with very little experience. A succession of assistant surgeons had come and gone. He had to admit that he learnt a great deal from them. Now he had Arun Nair, and a fresh MS, Saravanakumar. Arun was efficient, but made him more than slightly insecure.
The thought of Mr Kuriakose troubled him. He quietly walked out of the room and, through the corridor, to the surgical wards. He examined the patient again.
“The pain is worse, I think, Doctor,” the old man said.
Ashokan looked at the charts again and turned to the nurse. “Sheila, what was the last BP?”
“Hundred over sixty, sir. Down by six from the last hour.”
“That is all right.” Ashokan looked at Kuriakose’s son, who was watching his movements anxiously.
He palpated the man’s abdomen. It was soft, and yet there was a gurgle and subtle firmness beneath his palm.
“Ahh…” The patient groaned.
“Come,” Ashokan gestured to the old man’s son to step out of the room so that they could talk.
Collecting his suitcase, Ashokan followed the chauffeur who had come up to the room. His flight was due at one o’ clock for the conference in Delhi, where he was supposed to present a paper:
Surgical Audit – An English Perspective. Ashokan scowled as he thought about it. He had asked Arun for help in preparing the power-point presentation, and the rat had conveniently skirted the issue.
On the plane, he was not at ease. He kept thinking about Mr Kuriakose. Arun was there at the hospital. He wondered what he was doing. They had had more than a few arguments already, and he did not like Arun’s attitude that challenged his authority. He was the senior doctor after all. Arun suspected gangrene in Kuriakose’s stomach; in fact, he was very confident about it – so confident that it made Ashokan uneasy. But he was not willing to allow Arun’s fancies to overrule his diagnosis.
Arun had been on leave for the day, and had spent the evening cosily downing a few beers. He didn’t know when he nodded off, but his cell phone woke him up an hour or so later. The light was still on, and he looked at the wall clock squinting in the glare. It was half-past eleven. Groggily, swearing under his breath, he answered.
“Dr Arun?” the nurse-in-charge said urgently. “The patient, Mr Kuriakose, has had critical hypoxia, and has been put on the ventilator. He also has hypotension. Can you please come quickly?”
“What! When? Where is Saravanan? He was on call, wasn’t he?”
“His phone is switched off, Doctor. We have been trying to call him for the last half an hour.”
Arun rushed across to the hospital building. The bugger is growing more and more irresponsible, he cursed as he pushed open the ICU door and entered. Mr Kuriakose was fully sedated, with the endo-tracheal tube in his throat. The ventilator hummed dutifully in the background. The machine expanded and contracted as it took over the breathing function for the patient.
“Why didn’t you call me earlier?” he barked at the nurse, who had arrived at his side. Without waiting for an answer he turned to Dr Rajagopal, the anaesthetist who had put the patient on the ventilator.
“What is your take on this, Raj?”
The doctor shrugged. “Hypovloemic shock, I guess. I don’t know. Hypotension came first, then the respiratory failure. He is on pressure supports.”
Arun noticed the twin infusion pumps marked ‘Noradrenalin’ and ‘Dopamine’ – pumping blood pressure-raising drugs into the unconscious patient. Each had a monitor, displaying eight micrograms a minute.
“God, he is critical!”
“Yes, man, you want to open him up now? I should warn you, it is very risky.” Rajagopal looked weary.
“But that is the only hope. Wheel him to the theatre. I will brief the relatives.”
Arun usually dreaded the encounter with relatives, but it was surprisingly easy. Before leaving for Delhi, Dr Ashokan Kanjikuzhi had examined the patient in the ICU. He had explained to his son that the old patient was critically ill with Pancreatitis, and could become worse any moment. Arun was not aware of the visit.
Ashokan was relaxing in his hotel room. His presentation had gone well. The moderator had praised him for ‘an in-depth exposition’. But he could not sleep. His phone rang. It was Arun. He was not really surprised. With a creased brow, he listened for a while. Had he made a mistake? It seemed unlikely. Arun was simply being an arrogant ass. He was jealous of his UK degrees – simple. All the symptoms clearly indicated the patient was suffering from Pancreatitis.
“What? Hypotension? Hmm … Treat him conservatively,” he said. “Take a blood sample for serum amylase.” He waited for the response. “I know it will be elevated in both cases. Don’t teach me. On no account must you operate on him.”
“Retractors, please,” said Arun to the nurse, as he prised open both edges of the wound in the operation theatre. He was nervous, but calm. He had tried to reason with his senior several times for the sake of the patient’s health but, even till the last moment, Ashokan had stayed obstinate. The intestines, which should have been a healthy pink, glistened purple under the powerful theatre lights.
“It is gangrene!” Arun announced, feeling vindicated. Dr Ashokan had been wrong all along. Now, it had been proved. If only Dr Ashokan had allowed him to opt for surgery earlier!
Dr Rajgopal interrupted him in an urgent but controlled voice. He had been busy the last few minutes loading drugs and barking orders. Now he was still.
“Stop the surgery, Arun. Close the abdomen.”
“But without resecting…? I mean … I still have to…”
“Close the abdomen now,” said Rajgopal, quietly.
Arun stared at the anaesthetist, and then at the monitor by his side, in silence. He sewed up the abdomen in record speed. The patient was quietly whirled into the ICU, and moved back to the ventilator. Both the doctors went out, and explained to the waiting relatives that the surgery was over, but that it was too late. Half an hour later, Mr Kuriakose was declared dead. Because he had been operated on, Arun was forced to write ‘Hypotension – due to gangrene, intestine’ on the death certificate.
Two days later, Dr Ashokan and Mr Dandapani sat facing each other in the latter’s office. Ashokan wondered why he had been summoned at that hour. Dandapani usually never did.
“You wanted to see me, sir?”
“It is about Mr Kuriakose,” began Dandapani.
A small ember of anxiety glowed in Ashokan’s mind. “Yes, an unfortunate case of Pancreatitis, sir. We tried everything, but… They – the son – did not create any trouble, did he? I had explained everything to him.”
“No, he is a nice man. I know him personally, Doctor. You know Mrs Seethalakshmy. He is her nephew. But we are not concerned only about trouble, Dr Ashokan. In this hospital we want patients to receive the correct treatment.”
“What – what do you mean, sir?” Ashokan’s palms had begun to sweat, but he maintained control.
“Arun is a good surgeon, Doctor. I have noticed it. He has a future in this hospital.”
Ashokan stared at the director of the hospital, who wasn’t smiling. He knew he was in a false position. And he knew that if he didn’t act soon enough, he could lose everything he had built up for himself so far in his career. He thought about the years of hard work he had put into his quest. He thought about the substantial amounts he had spent on it. Dr Ashokan Kanjikuzhi, FRCS (London), FRCS (Glasgow), FRCS (Edinburgh) was in the danger of becoming a joke in the entire medical fraternity.
Ashokan sat in his room an hour later, thinking deeply. His body was not trembling any longer. He had thought things out and called Arun into his room. The junior doctor sat before him, as before, looking rather smug. Ashokan felt the hatred begin to bubble inside him once again.
“Why, Arun? Why did you operate on him against my orders? And – why did you go to Mr Dandapani?” he said.
Arun’s lips curled. “I expect if it was in the UK, there would be an autopsy and a disturbing audit report. The system must be so good that they would have caught you out.”
“The patient died of Pancreatitis,” Ashokan insisted calmly.
“But I saw the gangrenous loops!”
“Cool down, buddy. As you know, the autopsy was never done, as the relatives did not give consent. It is only your word against mine, Doctor. Or did you take a photograph?”
Arun fumbled for a moment, but said contemptuously, “You will not get away with this, Dr Ashokan, even though you may be my senior. I can prove it. The nurses saw it. So did Dr Rajgopal.”
“The sisters wont’ talk, Arun. Besides, they are never considered experts on the viability of intestines. As for Dr Rajgopal, he knows what’s good for him. No management likes a scandal. And,” he flourished an envelope in front of Arun, “here is the ICU nurse’s complaint that you were reeking of alcohol while you operated on Mr Kuriakose.”
Arun stared, dumbstruck.
“You proceeded to operate against my orders. The medical council might strike off your name from their register, at least temporarily. It can’t be good for your career, Arun.” Ashokan smiled. “In England, they wouldn’t be lenient like me. Integrity is very important for them; you get that?”
The young doctor glared at him, paralysed with incredulity.
Ashokan continued, “I need your resignation on my desk within two hours. If you do that, you’ll be all right, and the matter will be buried right there.”
As Arun Nair stormed out of the room, Dr Ashokan sighed, and spent a few minutes at his desk, staring into the emptiness. There was a certain feeling troubling his heart that he would spend weeks – maybe months – to vanquish. But man was born with the same set of Darwin’s rules. Doctors were not exempt. Besides, he had never liked Arun Nair. Slowly, he swivelled his chair to face the corner mirror and, leaning forward to look into it, adjusted his tie again. He smiled. It was another one of his favourites – with red oblique stripes on an off-white base.