Apnoea positive

It’s 9.30 pm. The admissions to the emergency room continue to pour in – the beds have been exhausted, but the floor still has a few square feet of room. The interns and residents rush to complete their unfinished tasks, constrained by the limits of a 24-hour day. Away from this hustle and bustle, patients in the wards prepare for bed. The ward workers roll out their mats, hoping it will be an uneventful night. It rarely is.

In the meanwhile, far from sight, four of the hospital’s senior consultants gather in a small unassuming room on the sixth floor that holds a single patient.

“9.41 pm, ventilator disconnected”, calls out the nurse, as all eyes glance at the rhythm on the ECG monitor and the saturation on the pulse oximeter. The 26-year old boy on the bed lies motionless, without breathing. The trained eyes of the people in the room are nonetheless able to see the chest pulsate with every impulse of the heart – a heart that continues to beat in a body that has become incapable of living. The silence is punctuated only by the alarms from the disconnected ventilator and the scratch of the Anaesthesiologist’s pen as he meticulously records the patient’s vitals every few seconds.

The minutes roll by until the nurse calls out the time again – 9.49 pm. The Anaesthesiologist draws a blood sample and reconnects the ventilator. The Internist reads out the blood gas analysis, and records his findings in the case sheet: “Second apnoea test positive”. The patient is now essentially a living cadaver.

Brain-death occupies that very precipice between life and death, when the brain, the seat of consciousness, has completely and irrevocably ceased function, yet the patient continues to have an intact circulation; a beating heart. Oblivious to its predicament, the intrinsic automaticity of the heart ensures that, when supported with artificial ventilation, it continues to pump blood, even if it is to a dead brain.

Yet from this grimmest of circumstances, this particular patient’s final act is one of noble sacrifice. A few hours from now, in the dead of the night, three or even four individuals will be rushed into operating rooms across the city to prep for surgery – a surgery to replace a failed liver, a failed kidney, even a failed heart – an organ obtained from the still body of a young boy on the sixth floor.

“So long as men can breathe, or eyes can see,

So long lives this, and this gives life to thee”

- Sonnet 18

"Know Your Status"

For the past couple of months I have begun to start showing the classical signs of long-term unemployment, reflected by a sleep cycle that swings from anywhere between 5 am and 5 pm (sometimes extending a complete 12 hours) and over-grown unkempt hair that a crow could easily mistake for a nest.

Given that I now have an infinite amount of time to ponder about the mysteries of life, the universe and everything, I decided to get myself an HIV test. Before your imaginations run wild, let me clarify that I've worked with a lot of blood during internship, and sometimes been less careful than I should have been.

This would probably be a good time to describe myself. I am thin. Very thin. Some call it malnourished, emaciated and anorexic, but these are just jealous fat people. Incidentally, weight loss of more than 10% qualifies as Stage 3 HIV, as per the World Health Organisation. Added to this, my erratic sleep cycle means I'm quite sleep-deprived if I have to venture into the outside world during the day. In short, if you ever meet me, I look like the textbook description of an HIV-positive cocaine-smoking drug addict.

(I'm sure that paragraph made some of the ladies swoon)

I walked into the lab, and, being sufficiently vague since there were people around me, told the lady at the counter that I'd like to take a blood test. I don't fault her for asking "Which one?". I said the word "HIV" loud enough for the guy standing next to me to hear. Despite his shock at just being told that the tests in his prescription would cost him 3.5K, he looked even more shocked at what I had just said. I proceeded to say that I was a 23-year old, without a prescription, presenting for testing voluntarily and without a referral.

I probably looked quite suspicious at this point because the nurse who drew the blood was totally cold shouldering me. None of the usual "So what did you have for lunch?" or "Don't worry this won't hurt" lines. The only thing she actually said to me was "You can go". Hand gestures sufficed for everything else. 

Obviously I could've just said upfront that I was a doctor, and probably even gotten myself a discount, but hey, where's the fun in that right? It's not everyday that you have the pleasure of switching roles with a drug dealer.

Anyway, that was two days ago. Today I get to resume pondering about the mysteries of life, the universe and everything.

PS. I like the way they say "Please" at the end

Oh, To Be In England

Two months of studying for the Indian post-grad medical entrance exam makes you feel like you've aged a few decades. Mercifully, a little holiday in the UK seems to have done me some good (though the hair loss seems to be permanent).

I realised that cows have a very good life in the UK. They're fat, well fed, lazy, have amazing weather and do nothing all day but eat. They even have actual bridges across the highway that were built especially for them to cross (If I was any good at blogging I would probably insert a "Why did the cow cross the road?" joke here, but I dont know any). Cows in India are much like the house surgeons - emaciated and overworked. But then I suppose English cows do tend to get eaten a lot, so I'd still say that's India - 1, England - 0.

Another thing weird about the UK is the birds. Apparently, people arent just nice to each other, they're nice to wildlife as well. This has led birds to view the human species as walking food-dispensers, and nothing more. Now they act almost as if we're in a real-life Rise of the Planet of the Birds. They all ganged up on us when we went to the Lake District, thinking we had food for them. Like we were going to spend a whole one pound on bird food! I just wish I had some chicken nuggets to chew on though. Just to show them who's still at the top of the food chain.

But besides the birds and animals, a certain group of people enjoy a particularly privileged life in Britain - cyclists. Now I'm no stranger to cycling. Every working day of my third and fourth years at Chengalpet Medical College I huffed and puffed and rode my 10-year old bike through 40 degree temperatures, through the great Cyclone Nilam of 2012, through flat tyres and malfunctioning brakes, through roads that cavemen could build better, through buses and bikes, through autos and cars - all to have it stolen while I was terrorizing children during my Paediatrics internship. 

But in the UK, cyclists are treated like kings. You don't get honked off the road like you would in India; no, in the UK you quite literally race the guy who had the gall to try and overtake you. No more "I'll just go off the road for a bit so you can pass me". Here you use an entire lane and ride your bicycle bang in the middle of it. I once saw a cyclist single-handedly create a mini-traffic jam just by cycling down a one-lane bridge. And by cycling, I dont mean actually pedalling. No, she was just letting the wind and gravity do the work, blissfully unaware of the 10-car pile-up behind her. Try doing this in India and not only would the deafening noise of car horns quickly make you aware of your situation, but those same cars would probably run you over, just for good measure.

Now I'm back in India, though, and was welcomed back to class with an extremely fascinating 10-hour lecture on biochemistry. More hair loss to come, I suspect.

Flogging a dead horse

The day you finish your year-long work-like-a-slave internship, you find yourself slightly delirious and roaming the streets at two in the morning, singing about happy days being here again. I was under the impression that this would be followed up by an entire year of just letting loose and chillin'.

I, of course, was wrong.

Being unemployed isn't all its cracked up to be. Especially if the said unemployment is justified by your intention to focus all of your energy on sincere and determined study to pass an examination in 6 months.

Not sufficient that the exam in question decides the specialty you're stuck with for the remainder of your sane lifespan, it's syllabus includes everything that you've "learnt" over the last five and a half years. And more.

To aid you in your impossible quest, you enroll yourself into an "Institute" that deals with this kind of thing. It's mildly disheartening that the price of this enrollment is approximately half of all the of money you made during the entirety of your 1-year internship.

You then find out that much like a meal at a restaurant, you're given a menu card of the different courses available. Calling myself an average student would be over-stating my abilities, so I skipped right past the "Achiever's batch" and the "Deligents batch" and went straight for the "Beginners batch" package. Unfortunately, and I say this with a touch of pride, I was over-qualified for this, having finished both my 3rd and 4th years of under-grad. I therefore settled for just plain old "Regular" (Yes that's what it's called, I kid you not)

"Regular" classes are a behemoth 11, or sometimes 12-hour session (with a 30-minute lunch break of course). I generally tend to start seeing stars somewhere about half an hour into the lecture, as evidenced by the sudden epileptiform discharges recorded in my class notes. I find that a lot of people in this class are surprisingly resistant to these hypnotic effects that I experience on a daily basis. I suppose they've either been rendered catatonic by their stint as interns or they were blessed at birth with all the emotion of a pot noodle.

While I was sitting there in Psychiatry class today, being told of the important differences between illusions and delusions and psychoses and neuroses, I was left thinking "We are all just prisoners here; Of our own device"

AIPGMEE 2013 – First day, Second show

There’s two sets of people who take PG entrance exams, and you can tell them apart just by looking at them. Many of them will have some sort of reading material with them, and generally appear quite serious as they complete their last-minute preparations. These are the ones who are there to actually try and get a post-graduate seat.

Then there’s people like me – interns. This group of people are in attendance merely because their parents had insisted on paying Rs. 3500 for an exam they couldn’t dream of passing, and more importantly, because this provides them with a fool proof excuse to take the day off.

They began the long complicated process of allowing us into the building about an hour before the exam was scheduled to begin. We all had to have our photo ID’s and other documents verified first before being let into the waiting room on the inside. A lot of people were sent away at this point because of some slight irregularity in their paperwork. Believe me, it’s harder for a candidate with all his papers to get into that waiting room than for a terrorist with a bomb to slip past airport security.

Once I got into the waiting room, I found everyone sitting in absolute silence, while one of the organisers informed us that we were under video and audio surveillance. He began to rapidly pace up and down the room, making us feel like we were suspects in a murder investigation. He would swoop down on anyone who dared turn his head more than 15 degrees to the right and left, and say “Can I help you?” in a tone that sounded more threatening than anything else, and with a facial expression that reminded me of my textbook descriptions of risus sardonicus.

This was followed by each of us being individually escorted to our seats, after intentionally being led past a row of computers with live video feeds of the room we were to take the exam in.

Before we began the actual exam, there was a tutorial that was meant to acquaint us with the user interface, and I found this to be extremely beneficial. I would have been completely lost without such vital information as this:

The test itself was three and a half hours long, but I was done with my three hundred questions in just over an hour. This left me with nothing to do (solitaire was out of the question, unfortunately), in a room that was completely quiet, but for the incessant clicking of a hundred computer mice (or mouses; whatever), occasionally punctuated by a yawn or two from my fellow exam-takers.

Once the three and a half hours of agony had passed, my computer informed me that I had "run out of time" and my test had therefore ended. What a pity.

Now that the exam's over, all that remains is to wait for the rank list to be published. But I don't think I'll bother to check. Because the only answer I know for sure that I got right was the sample question in the picture above.

"And I was like Baby, Baby, Baby Noooo"

Being posted in Paediatrics is like being posted in a zoo, with my role being that of a chief zookeeper.

In the first half they let you deal with slightly older kids (with "old" here defined as 60 days from birth). Every morning, afternoon and night I get to terrorise them with syringes and needles. As pleasurable as this sounds, it gets dull after the first few days. There's only so many times you can hear screams of terror before your eardrums start to crack. Which is why they shift you out to the "Newborn" intensive care unit after two weeks.

Here you're placed in a huge room with 60+ newborn babies, most of them with tubes in their mouths, tubes in their noses, tubes in their urethras and tubes in their veins, all looking pretty much like aliens incubating. And the worst thing is that despite all of this, they're not the most alien thing in the room. That honour goes to the Staff Nurses.

Your one responsibility in the newborn unit is to "receive" babies when they're born by Caesarean section. It all starts off with a scribbled note from the Department of Obstetrics informing you that a certain number of pregnant women are scheduled to have a few kilograms taken out of them. This note comes at least four times a day (and night), at the most inconvenient of times.

You then make your way to the Emergency Operation Theatre, and get ready to wipe down a tiny wriggling newborn human being that's sometimes bathed in it's own faeces and choking on it's own secretions. It becomes a problem if the thing doesn't cry though; you then do the most doctor-ish thing you can think of - run and call somebody else for help.

The most difficult thing in this whole episode is carrying the baby. Some people hold the baby with a single hand, by the neck, during transport. I guess that's one way to do it. But being an amateur at baby-carrying, I tend to use both my hands, albeit awkwardly, while trying very hard not to drop it. Mothers "carry" babies. I "hold" them.

One month of Paediatrics is now nearly over, and it's only confirmed the one thing that I've always known. Children and babies are annoying. Terribly annoying.

O true apothecary! Thy drugs aren't quick enough.

Every admission day, my ward usually gets an assortment of cases - chest pain, hand pain, leg pain, finger pain, head pain, back pain and even tooth pain. Generally they come in their hundreds as a barbarous mob of angry (and allegedly sick) men and women all vying for the attention of 3-4 doctors (plus me) in what we call our Out-Patient Department.

This is fine.

What is not fine is when a guy drinks the night away, and then wakes me up at 3.00 in the morning to say his stomach hurts.

But even this is still tolerable. I just give him an antacid, tell him to go to sleep in whichever part of the floor he feels is least dirty, inform him that I will physically hurt him with a needle if he wakes me up again, and I can "abscond" him first thing in the morning.

[To abscond someone is to tell them "You're fine! See how much better you are now! You can go home today. Here, have a B-complex tablet! Cheers!"

The patient will then thank you profusely, say an almost tearful goodbye, think he's been discharged, and then leave. This is when you write in his case-sheet "Patient absconded", fold it up, and send it to the Medical Records Department]

But the worst type of "patients" are the nitwits who decide (usually while drunk) that it would be a good idea to ingest something poisonous. There's always at least 4-5 such geniuses everyday. Their choice of poison is a testament to their intellect. Even drunk people should know that rat-killer poisoning isn't even potent enough to kill rats.

Generally there isn't too much to be done for poisoning cases. They're welcomed to the hospital in the Emergency Room by a bunch of sour-tempered paramedical workers who yell, scream and slap them till a tube inserted into one of their nostrils reaches their stomach. They then proceed to rinse their bowels like yesterday's dirty laundry, yell at them some more, and then send them to the ward, where they're made to languish for a full 24 hours with no food or water and with their nasogastric tube draining disgusting yellow secretions from their insides.

I don't mind most poisons. If you want to willfully try to hurt/kill yourself, then be my guest. Just have the decency to do it somewhere where it won't affect me.

This is why I hate people who come with organophosphorous poisoning. Other poisons don't affect me. Organophosphorous poisoning does. These idiots need to be given up to SEVENTY vials of medication plus fluids - immediately. And this medication then makes them go into a delirium which means they start pulling out IV lines and creating general havoc. All this, while simultaneously having violent diarrhoea in a ward that already smells like the inside of a large intestine.

Some of the patients are nice enough to die before they reach the ward. Others die as soon as they reach the ward. Some others die right after you've put in about fifty vials of medication.

I think this is what is wrong with the world today. We lack an ideal poison - one that's cheap and will kill you faster than an Avada Kedavra. That way everyone's happy. Whoever wants to die can just die. And I can sleep on admission days. I think someone needs to start researching this ASAP.

And once all this drama has settled, the alcoholic guy in the corner will decide to once again remind you that his stomach still hurts. A few intentionally failed attempts at inserting an IV line will usually shut him up.