In the medical college, we had one year of internship after completion of the course. For me it started off with a bang, as I was posted in a Community Health Centre for the first two months and had a schedule in which the 5 hours of morning OP was followed by 5 hours in the ER, and had a 12 hour night shift every five days. The training was excellent and by the end of rotations, I was confident that I could manage a ward and that I had received a taste of all that I could possibly face as an intern. I did not realize then that my brain had made a serious omission. I was snapped back to reality by my first weekend in the department of Internal Medicine in my College.
In the CHC if a patient died, I was not supposed to get involved in the procedures thereafter due to strict rules which made these the duty of the medical officer in charge. That had meant that I was to stay away from the relatives once a patient died, whether in the wards or ER. This law was to avoid any statement or action from the inexperienced junior intern which might cause a legal liability to the senior doctors and to the hospital.
The first week in the Medicine wards had gone really well. I had learnt some procedures and was comfortable dealing with even the so called ‘difficult’ patients and by-standers. (in the general ward, every patient had a helper, who would usually be a family member; only one person was permitted to be with the patient at a time, and this was regulated by an entry pass).
Assured of my new found skills, I was least worried when the first all night shift came that Friday. There were some notes and summaries to be written and being somewhat of a night owl I was at my desk in the ward at 2am when a balding middle aged gentleman came there and addressed me as ‘Doctor’ (I had been hearing this only since a couple of months, and as with all the newly initiated interns, I used to feel exultant every time someone addressed me with the word).’ My father is not moving’, I grabbed my stethoscope and made sure I had some other necessary gadgets, called the nurse from the duty room for the emergency tray and with haste accompanied the person to the other end of the very very long ward. Little did I know what awaited me there..
I reached the bed side and all i could see were the rears of ten people who had gathered around the patient. ‘The doctor is here’ someone said. Then they gave way and I saw something strange. Two women were reading aloud from a religious text, and a man was placing the patient’s hands in a folded position with fingers interlocked while another was draping him from feet upwards in a white blanket. Focus, I told myself. My first action should have been to call security because instead of one, I was surrounded by fifteen relatives of the same patient. In case something went wrong the ratio of 15:1 had me in a terribly disadvantageous position.
The patient was unresponsive and not moving, and following the protocol, I found that there were no respiration, pulse, heart-beat or reflexes and that his pupils were fixed and dilated. What I have described above are the textbook symptoms of a condition called: death. The nurse reached by then and started shouting at the crowded relatives, thus waking all the other 49 patients and their relatives; while hearing all the noise two attenders ran in to help.
Now these people were working in the department for years and knew what to do next better than me. The nurse (who was a very senior person) gave me the case sheet and shoved into it a couple of yellow coloured papers (these were the forms to be filled in case of a death, I didn’t know that then) and the attenders quickly transferred the patient to a trolley and wheeled him away. All these happened very fast, and could not have taken more than two minutes. And all I had to do was to just go with it. I had to give some explanation to the mob and so told them that the patient is being shifted for resuscitation. Now I did not know where they were taking the patient to, and so, had to run after the trolley to keep up with the pace.
With a quick movement with the back of one foot, the first attender had opened the doors leading to the Critical Care Unit while the other pushed the trolley and the patient on it into the CCU. I knew that the patient was dead, and that he had been dead for at least some minutes. So I assumed that the attenders must have thought that the patient needed resuscitation and so had shifted him to the CCU. Anyway I connected the ECG leads and found that there was no cardiac activity at all. So, the patient was indeed dead.
To my relief the CCU Resident came by then and told me the fact which I should have known way beforehand- Even if a patient is dead the attenders shall wheel the patient into an enclosed place in ER or CCU when a junior person is on duty, because the declaration of death is a sensitive subject in which there should be no room for error. And she trained me the routine short speech with which the interns were supposed to convey the news. Its first sentence could be roughly translated as- ‘we did all that we could, but even after trying several times the patient could not be resuscitated.’ Then I asked her, ‘can I just skip that part, since I had nothing left to do here’. And she said, ‘no, it is mandatory to say that if it is an intern who is declaring the death.’ And I was advised to wait at least half an hour before committing the declaration. (There was an incident in a nearby hospital some time back, where the patient got up from the cot while being wheeled into the morgue. The staff was shaken for sure, and the hospital managed to somehow make a narrow evasion from being sued).
So I used the time to fill up the forms which the resident then checked and signed, and finally when the half an hour was over, collected courage and walked towards the relatives. Now I had expected them to be tensed or in tears, but they were looking extremely pleased and some of them were chatting away on phones. This made me more upset because It would have been easier for me if they had been as worried as me or looked as though expecting a bad news. I didn’t want to go to the crowd first, so I decided to talk to the patient’s son. After searching around the place I found him sipping a coffee and talking loudly on his mobile. Then he saw me and asked, ‘yes doctor, so what happened?’. I started with the sentence, ‘we did all that we could, but even after’; ‘Oh we knew that he was gone already’, he said interrupting me there. ‘But since you seemed to doubt and wanted to try bringing him back, we just let you do that. Though its not that we hoped you would; the old man was giving us such a hard time. So are there any forms in which I have to sign’.
I gave him the papers and went back to my desk.
During the internship I had said the statement for death declaration at least forty times, and there were times in which death was unexpected or too painful to go by the formal words to convey the message. I am grateful that this incident had occurred on my first experience of declaring death, because the event which is usually traumatic for a fresh intern turned out to be something different and lighter for me.