THE JOURNEY through Palakkad is always scenic. The place had a hole in the wall of the Western Ghats. This mountain stretched between Kerala and Tamil Nadu, lush green, like a barricade between neighbourhoods festooned with moss.
I was on the way to JIPMER: Jawahar Lal Nehru Institute of Post-Graduate Medical Education and Research. I had been chosen to do my three year residency in Surgery there.
This would enable me to add an M.S (Master of Surgery) to my name. That would mean I had become a qualified surgeon.
The thick evergreen woods on both sides of the road slowly became fields of paddy and sugarcane.
Then the land took on a dry earthy hue as the greens disappeared. Occasional oil palms thrust their heads high in the air, finally free from the oppression of the coconut trees.
The change of scenery affected me like the bereavement of a dear one. I was never far from home. I could have chosen to go away from Thrissur for my Medical School, but I didn’t.
I had always liked to stay put. But some things were inevitable. My mother had told me that I had been very hard to wean from the breast, fighting bitterly for my comforting right.
One had to travel twelve hours by bus to reach Pondicherry, a small sea side town nestling by the beach in the middle of Tamil land. When we finally reached the place, what struck me was the profusion of two things: bars and bicycles.
Tiny cubicles selling liquor lined the roads, while a melee of bicycles thronged them. As Pondicherry was a Union Territory, the taxes were lower than the State of Tamil Nadu in which it was enmeshed, making the demon brew in all varieties substantially cheaper than the surrounding areas. People came from far and wide to slake their thirst for ethyl alcohol and drown their existential despair in its watery haze.
Poorer people from all over Tamil Nadu and even from the nearby State of Andhra Pradesh travelled to Pondicherry to come to the Central Government-run institution of JIPMER. Free tertiary medical care was what they came for.
The auto stopped outside the gate and I could see the arched gateway and high wall. The narrow median on the road was lined with sleeping men and women, like sardines lined up on the slab at a fishmonger’s.
They slept soundly, oblivious to the whir and horns of the vehicles that fled past. I learned that that these were patients waiting after fixing an appointment.
It took days, on occasion. Some were relatives whose near and dear ones were admitted in the hospital.
A few modern buildings enclosed in acres of lush campus met me as I walked past the gate. It was as if you had walked into an air-cooled room as one came in from the hot, dry and dusty world just outside.
A thin slice of green Kerala preserved for me. I felt happy about that. About everything else I felt anxious. This was the place where I had to spend the next three years.
Colossal tales, both awesome and intimidating, were the stuff of urban legends among medical students about the three most prestigious central government set-ups, of which JIPMER was one.
After a flurry of formalities that lasted half a day, I stood in front of the unit in which I had to work. Two consultants and Four residents.
The contrast was unmistakable. The unit chief and the associate were immaculately dressed and draped in pressed white coats.
The residents looked as bedraggled as a bunch of beggars clad in coats that must have been immaculately white once upon a very long time.
‘Ah, the new guy. Please report tomorrow by seven a.m. to the ward. Join them. They will be there.’ The unit chief indicated the residents by a sweep of his hand.
I ran back to the Institute’s administrative office. I had to get into the hostel and settle down by tomorrow.
Many friends had warned me that after the duties start, it may become impossible to take time off.
By evening, I had a small room at Harvey house, the resident’s hostel. The fact that I could do this much in one day told me that JIPMER was ten times better than any public sector health care facility I had hitherto encountered.
I slept on the hard cot, with a sheet that I had brought from home rolled up into a pillow. I slept fitfully, and dreamt of monsters in surgical masks picking at my exposed liver. I was awake by six.
I entered the surgical wards. I could see residents rushing to and fro, looking preoccupied.
Some stared at me for a second and moved on. One tall slim chap with abundant hair falling into his eyes spoke to me.
‘I am Arjun Shetty, the final year resident in S4. You are with us. Come.’ He motioned for me to follow him. I went with him to a large ward. It was filled with cots like a sheet of postage stamps.
Each cot contained a sick human being. He explained to me that he had already seen and examined most of the patients.
There was a chart hanging at the edge of every bed. He had written a list of blood tests and other investigations that had to be done.
My job was to do them. After conveying this, he went back to examining the patients.
I ran around frantically. Where were the syringes and needles? And the small bottles to put the blood in?
I had to sift through stacks of papers to get at the right form that had to be filled with the patient’s IP number and details.
I asked the nurses for directions. They laughed at my discomfiture.
‘The new guy,’ they said to each other. ‘Poor chap.’
I drew blood from a dozen veins. I labelled dozens of bottles. I filled scores of forms. But I never talked to any patient. I couldn’t remember any of their faces.
The work had to be done before the consultants came for the rounds.
Just as I finished with it and wiped my brow, Shetty was at my elbow.
‘Keep all the wounds and dressings open for the consultants to see,’ he said casually.
I ran around once more. Donned gloves and removed the dressings. Sped to the waste bin and back like the pendulum of a clock doing its thing.
Gloves appeared and disappeared in my hands in the twinkling of an eye.
‘Don’t waste gloves, doctor,’ the head nurse said. I barely heard her. She glared at me.
The consultants came with the authority and manner popularised by kings of yore touring their inherited kingdom. The unit chief was the emperor and the Associate Professor his faithful vassal.
The senior Resident, Dr. Ramesh Pai greeted them with respect bordering on reverence. Senior Residents are those who complete their MS and then join back on one year contracts for work experience.
We went from one patient to another. Arjun Shetty presented the cases and new developments, if any. Dr. Pai added appropriate sounds whenever needed.
‘This is the jejunal perforation with peritonitis. Today we can start oral sips, Bowel sounds have come back, sir,’ Arjun Shetty said.
‘Yeah, sir. Totally settled. No problem there,’ Ramesh Pai said.
‘This is Thursday’s or yesterdays?’ the unit chief asked.
It went on like that for an hour. All the patients had to be seen. Apparently, we had to be quick. Today was our unit’s admission day. That meant we had an outpatient clinic to run today.
Patients with general surgical problems as well as our previously treated patients will come from far and wide to see us. Patients coming to the emergency room for the next twenty four hours with surgical problems had to be seen and managed by us.
The routine work in the wards had to continue through all this. We had two such admission days every week. Then there was one Sunday every month.
‘And don’t forget the two routine operation days every week,’ Arjun Shetty said, as we walked to the Surgical OPD. I learned that Raj Sunder, the second year resident was already in the ER, managing the patients there.
A hundred patients were waiting in the OPD. The consultants and the two residents started seeing patients one by one. I loitered here and there trying to be inconspicuous.
I accompanied Arjun Shetty to the adjoining minor theatre to drain an abscess, dress a painful wound, or to do a sclerotherapy injection for piles.
Each procedure was accompanied by protracted screams from the patients, as no anaesthesia was available.
‘We cannot afford to post everything under anaesthesia. Whatever can be done here we have to finish,’ Arjun Shetty explained, as a particularly piercing scream reverberated across the narrow room.
I felt slightly overwhelmed. I was trying to take it all in when the door opened and a fair short young man barged in. He had a hassled look.
‘What took you so long, dammit? Chatting with the nurses in the Emergency Room? The OPD is busy, man.’ Arjun Shetty raised his voice.
I assumed that the newcomer must be Raj Sunder, the second year resident.
‘The bloody casualty is already full, man. Two ulcer perforations and three diabetic foots for amputation. Five call slips already sent to the theatre.’
‘Gosh. That is fast. The day is just beginning. You do one thing. Take the first year with you.’
Shetty removed his shit-stained gloved finger from a patient’s anus and waved it at me. Then he put it back in.
I ran with the patient down to the casualty. The casualty, or ER, was in an adjacent building in the ground floor. We ran far enough to become breathless by the time we reached.
I had seen Emergency Rooms. My internship was at a busy government set-up at Trichur. They were all hot, stuffy and filled with patients.
This one was hotter, stuffier and brimming over with people. Metal trolleys lay scattered all around, with a patient in each. Relatives and companions of the patients milled around, with bulging anxious eyes.
‘Take BUSE, catheterise and start intravenous line in these patients.’ Raj Sunder pointed at three trolleys, one after the other.
‘BUSE?’ I asked.
‘Blood urea, sugar and electrolytes.’
I got down to work. The first patient was a thirteen year old child. She was very sick. She seemed to be gasping for air.
The child had a bad infection in the soft tissues of her thigh and leg. She was as hot as an oven to the touch. The parents stood by the side.
‘Operation will save her, sir?’ the mother asked.
I opened my mouth to speak. Then I remembered. There was no time. I merely nodded, finished with her and moved on to the next patient.
I learned one thing very rapidly. Here you started at the bottom. That meant doing all the work. I had to draw blood and send it to the lab. Then I had to run to the lab three floors up to collect the reports.
If I wanted a quick ultrasound scan for a patient, I had to push the trolley with the patient in it to the radiology department half a kilometre away and then beg the Radiology resident to do it fast. I had to change dressings at lightning speed and then run up to the ward and do the dressings there.
Arjun Shetty and Raj Sunder came and went. They took turns to go to the theatre.
The senior resident Ramesh Pai was mostly in the theatre and came down only occasionally to examine a patient and take some crucial decision or the other.
‘Don’t fuck up, fellows. It is all on my head. Tomorrow Benz and Cads will eat me alive if there is any screw-up,’ he kept saying.
I learned that Benz and Cads were nicknames for the two consultants.
By seven in the evening, my mind had become blank. I had forgotten about food. I took occasional gulps of water from the water filter kept in a corner.
Events went by in a blur.
I lost count of the number of patients that I saw and sent up to the Operation Theatre. I wondered what was happening there.
The next patient, a fifty year old man with a bloated abdomen and gasping breaths, put a stop to my wondering.
Raj examined him. ‘My god, this is peritonitis. Very advanced. He must have been walking around with a perforated ulcer for two or three days. How could he do it?’
Inadvertently he had slipped into Thamil language [editor1] and the patient understood his words.
‘I have a daughter to marry off,’ he said weakly. An eighteen year old girl stood by her, crying bitterly. ‘She has no mother. Save me, doctor. I have to marry her off. It is my duty. She will have nobody.’
‘Don’t worry, we will take care of you, Uncle.’ A group of men stood around. They looked like thugs. I guessed they were distant relatives. Or, were they?
The girl, still crying, looked at them with something like fear. I understood the dynamics perfectly. I could make out why she was crying so much.
This patient’s name was Muniyandi. I went to work without delay. The BUSE, the line, the urine catheter.
Call slips duly filled up for the theatre. Arjun Shetty came in and saw the patient. Then he looked into my zombified face.
‘You had better go and give the call slip in the theatre. And stay there for the case. I will come up with the patient.’
I ran. I felt relieved to go into the air-conditioned theatre. Besides, that was what I was here for, wasn’t it?
When the patient’s abdomen was all painted and draped, Arjun motioned me to stand by the right side of the patient. I did so, puzzled. To assist, one had to stand on the left side.
‘You can open the abdomen.’
The nurse handed over the knife to me. I had seen many abdomens being opened. First the skin, then the superficial fat, and finally the thick leathery sheath in the midline, taking care not to injure the underlying membrane bulging with fluid and intestines.
Arjun Shetty guided me throughout. As I punctured the membrane and entered the abdominal cavity, a gush of greenish pus erupted like lava.
‘I will take over from here,’ he said. We switched sides.
It was a duodenal ulcer perforation. Duodenum was a part of the intestine where you get ulcers. If one neglects it, the ulcer can perforate into the abdominal cavity.
The food and fluids from the intestine will escape into it. So would billions of bacteria, leading to catastrophic infection.
Arjun Shetty washed out and cleaned the abdominal cavity with litres of saline. Then he closed the hole in the intestine with sutures. His hands moved deftly. Then he closed the abdomen in layers.
I stayed and assisted for one more case. Shetty did the entire thing. It was a case of obstructed hernia. A loop of intestine had got stuck in a natural hole in the groin. This time as Shetty did the surgery he was chatty.
‘Doing residency is all about survival. You have to just hang in there. Just do it. One day at a time. No point in wasting your time thinking about what you are doing. And a thick skin helps.’
I nodded through the surgical mask.
‘When you deal with consultants, there are three rules.’
I pointed my ears.
‘Be available. Be affable. And don’t try to be capable.’
I looked up.
‘I mean, more capable than them,’ he clarified. I nodded. It was all common sense.
We walked down to the ER. It was past three early in the morning. I felt dizzy. I wanted to sleep, eat and go to the bathroom all at the same time.
My entire body ached. I had a bad headache. I looked longingly at some of the trolleys that were empty.
We found Raj Sunder sleeping, curled up in a foetal position on top of a bare table half his size. I wondered how he did it. I later became an expert at it.
Arjun Shetty gave him an unkind prod in the ribs. He woke with a violent start that was almost comical.
‘Get up, you bugger. Let us take rounds.’
We went around the patients still on trolleys. Most of them were stable. All pending surgeries were over. Some patients had gone to the ward.
Suddenly Shetty pointed to a corner. The thirteen year old girl with blood infection was still lying there. Her surgery was pending. We crowded around her. Shetty shouted at Raj. Raj made semi-defiant mumbling voices.
‘Will she die, doctor?’ the mother asked again.
‘An operation has to be done fast,’ Shetty said, as he moved away from the girl’s earshot. The parents followed him.
‘It is highly likely that she may not make it. Even after the best treatment that we can give,’ he said.
This was the longest conversation I had heard with a patient or their relatives on that and the previous day.
‘We will take her home, then,’ the father said. His voice was cracked. But he did not cry. He had work to do. He went outside to get an autorickshaw. The mother had tears.
‘Make them sign LAMA,’ Arjun Shetty ordered. I looked at Raj quizzically.
‘Left Against Medical Advice,’ Raj said, as he hunted for the form. ‘If she dies, they are not allowed to get the body back to their native village by public transport. The private ambulances will charge enough to ruin them. That is why they are so anxious to get her back while she is still alive.’
I realised then that a lack of money was sometimes worse than death. It becomes an overarching concern. Priorities get twisted then. They balance themselves on their head.
For us, survival was the only aim for the period of our training. For a large proportion of our people, survival was a hard task at which they had to toil every day for all their lives.
I felt a momentary pang as I saw them carry the girl, half-conscious, out into the road. But I had to run to the Surgical ICU with Raj.
Muniyandi, whom we had operated on, was getting severe chest pain and breathlessness.
Shetty told me to run one floor down and get the ECG machine. I pushed the heavy thing along the corridor, up one floor and into the ICU.
Raj connected the leads to Muniyandi’s chest and pressed some buttons. A strip with ECG reading came out.
It was a revelation to me that a doctor could take an ECG like that. Till now I had seen only technicians do it.
Shetty thrust the ECG at me. I leafed through it.
‘Looks like Myocardial Infarction. Heart attack,’ I said.
‘Are you an expert?’ he asked. I shook my head.
‘Run down to Casualty, wake up the Medicine Senior Resident on duty and show it to him.’
I ran. I was becoming good at it. I shook the Medicine Senior Resident awake. I felt no hesitation to do that. My finer sensibilities were fading away. That was good.
He read the ECG in between muttered curses. The patient had a heart attack. He would send his Final Year.
I ran back. By the time I reached, the patient had died. Arjun Shetty and a critical care resident tried resuscitating him for twenty minutes.
I pitched in with chest compressions on my knees after jumping onto his bed. I was drenched in sweat in minutes.
‘Abandon it. He is gone,’ someone said.
I would have liked to say that I felt despair and remorse. But I felt only relief.
The night was over. I was looking forward to some breakfast, a bath and some sleep.
We walked slowly to the hostel.
‘You got to open the abdomen on the first day, bugger!’ Raj slapped me on the shoulder.
My mood lifted a little. It had been a long twenty four hours. I had already learned a lot. I had learned the routine. I had become efficient at doing what had to be done. My squeamishness was gone.
I hardly noticed that I was sweaty, smelly and that my underwear was drenched with the fluid spilled over from the abdominal washes.
I had forgotten the dying girl and the dead man whose abdomen I had opened. I didn’t think about his eighteen year old daughter or her large, hunted eyes.
On my bad days, even now, I wonder what had happened to them. And scores of others like them. There were too many.
I was so good that they let me open an abdomen on the first day. I had done it with finesse. I felt a glow of pride. I had learned to bask in the satisfaction of competence rather than the satisfaction of work. For a surgeon, the former was easy to achieve, and the latter would always be a mixed bag. I was on my way to being a fine technical surgeon.
‘Be back in the ward in an hour,’ Arjun Shetty reminded us. I gave a small jump.
‘There is no duty-off?’ I squeaked.
Arjun Shetty and Raj Sunder laughed like hyenas enjoying a decaying carcass. I felt like one. It was not going to be easy. But I had to do it. I clenched my teeth.(Jimmy Mathew)
[editor1]Can you please clarify this? ‘Thmil’ seems like a typo.