BELIEVE-LEARN-SERVE

If you can only believe, all things are possible for he who believes.


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Declaration of Death

 

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.

 

Post Script

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.

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Mothi- The Legacy, A Deviant, and An Adoption: There is a higher power taking care of even two stranded puppies..

 

The Legacy

 

‘Mothi’ is the Urdu word for a pearl. And for my family this name is reserved for our dog (or rather the leader of the pack, if there are more than one).

 

Mothi-I, lived about fifty years back with my Father, his three brothers, and my grandparents, in a beautiful village set against the Western Ghats. He used to protect and accompany the family even during the then dangerous walk in late hours for attending the prayers held in the nearby monastery. His loyalty was so high that in the days the family used to fast, he too would not take even a morsel and used to stubbornly stay away even from his favourite delicacies.  His death at the age of fourteen was mourned deeply; and henceforth he has had four successors, all worthy of the name, and greatly adored.

 

All the bearers of the name are from the Rajapalayam breed and well known for certain common traits. Mothi would invariably be the leader of all the dogs in the neighborhood. He prefers to move in swift and graceful equine strides and has a bark that resonates through the place. His temper is rather volatile though and he often brings forth the darker side by ruthlessly murdering the unfortunate rodents or even felines who decide to encroach upon his territory. Yet, with snakes the dog is ultra-cautious, and wise enough to protect himself as well as anyone in the family, by tactfully trapping the snake, and making it coil in a circle on a tiled surface, until his master comes with a rod to put away the venomous intruder. In short, if there is a scale to measure the intelligence, loyalty and ferocity of these members of the indigenous breed, they would surpass the exotic genres and would be well beyond the 99th percentile in the graphs. I am sure that anyone who has reared a Rajapalayam along with a member of another breed would be agreeing vehemently as they read the above statement.

 

The Story of a Deviant Hound

 

Mothi IV was slightly different from his predecessors- He had done what no other family pet would have even thought of doing- while he was two years old he had bitten his master- my grandfather, on the palm, creating a large gash which took about a month to heal. My grandfather, being compassionate and understanding, forgave him and gave him the love and care as to a troubled child. But my siblings and I could not forgive Mothi; we used to scold him for the cruel deed, until he would lose his usual dignified look, assume a guilty face and start whining as though apologizing for the mistake (he used to make multi-syllable voices, which his canine friends would have written off as coming from a human’s vocal cord.) And that incident in fact, cost him his life about eight years later.

 

There is a veterinary hospital near our home and the place has a full time veterinary surgeon. Being a friend of the family, he would come over to the house when given a call, bringing the vaccines or medicines. We had got a new pup, a Japanese Spitz; the breed is known to contract distemper, and so he had brought with him two vials of the distemper vaccine, one each for Mothi and the spitz. Knowing the history of how the dog had bit the owner, the vet tried to sedate him with tablets dissolved in milk before giving the vaccine. To our amazement and distress Mothi did not sleep even after being given more than the therapeutic dose. By then the vet had got scared of this strong, barking, ferocious dog that was immune to sedatives and left without administering the vaccine to Mothi.

 

Mothi used to be let free in the property close to dusk, and he would walk around like a watchman, and at times cantering like a horse, alert and never dozing off. Sometimes he would pick a fight of words with the stray dogs across the walls or with drunkards who taunted him as he furiously barked and tried to scramble over the gate. After one such night when Mothi seemed to have had fought for over an hour, he could not be found in the morning. A short search was done over the premises and he was found lying limp under the garden tap. He seemed to have developed a weakness on one leg, and could manage only a faint yelp. The vet was called and he could not identify the problem initially. The dog was drinking water though his appetite was markedly reduced, and over the week the paraesis became bilateral and ascended gradually. The diagnosis was made finally as canine distemper and all the while, the spitz, named mickey, remained immune to the disease, owing to the vaccine she had received.

 

No one who had seen and admired Mothi in his glorious days could have endured the sight of this wasting lethargic dog who tried hard to wag his tail every time one of us went near him. It was difficult for all of us to finally decide to put him to sleep. And that evening, before the dog kill could be brought, Mothi breathed his last, with eyes closed, peaceful and at ease, as though asleep.

 

The Adoption

 

The day Mothi IV passed away; I was in our rented apartment. I had just received the news when I heard a thud, a piteous squeal and the sound of a motorcycle passing by. About the same moment my husband drove in and from the window i could make out what looked like a cat getting into the garden through the opened gates. I went downstairs and saw that my husband was shining a torch underneath the car where something seemed to be moving. Then I saw them, two puppies, one milky white and the other deep brown, huddled together, with eyes tightly closed. They were softly  whimpering and tried to move away each time we got near. The pups were thrown in front of our gate by the motorcyclist who had abandoned them for some reason we could not understand.

 

I was never much of a pet lover and we had no intention of taking care of a dog let alone thinking of adopting two puppies. But somehow the timing was perfect, and the decision did not seem to rest upon us. So i lured the brown one with a slice of bread dipped in milk and as it came near my husband caught hold of its coat and carried it upstairs to the terrace outside the kitchen. I took a cardboard box and lined it with rugs and newspapers, and slowly placed the pup inside. This one is calm, I thought; it was shivering, and licked clean a bowl of milk within minutes, without showing any anxiety. That was when my husband came in with the second pup. It was shrieking at the top of its voice and struggling to break free. Our first pup put its paws over the edge of the box and gave out a similar shriek. Now we were the ones who were scared. Then, surprising us, the brown puppy got out of the box and slowly walked towards the white one and actually placed its front paws on the back of the newcomer, as though consoling it. Then they walked to the box, and started drinking from the bowl together.

 

We browsed the names of a few animal shelters and found that there was a hospital and shelter, run by SPCA just a couple of miles away. That was when a thought struck us, would my grandparents want another, or may be two dogs? We took some snaps and messaged them, and from the call we immediately received it was obvious the puppies would be welcomed. A vet known to the family gave us instructions on prophylaxis of canine distemper and we took brownie and snowy (we just decided the names taking cues from their colours) to the hospital the very next day for their first shots.

 

So this was how the confusion began. The senior vet at SPCA told us that they were about eight weeks old, needed to get rid of fleas, must receive a couple of follow up shots for rabies and distemper, and then asked us the question (which from then on, we were fated to hear several times again) – are they male or female?  We had not given this a thought till then, and to be honest, were taken aback. (Consider asking this question to a human patient…)  So the vet with over twenty years of experience could not tell. These could not be hermaphrodites, right? Anyhow it did not matter much to us and our only concern was naming them right, and the names we had given were sort of neutral.

 

As the weekend came, the fleas were about halved in number; the pups had gained weight, and had grown quite playful and friendly with us. So we put them in a large box in the back of the car and took them to my grandparents’ home. On the way, we visited my husband’s place and were asked the question again by about seven more people; and received varying opinions on the gender of brownie and snowy. Then we stopped by a vet’s home to get some extra supplies of vermifuges and vitamin drops. This doctor was a retired veterinary surgeon who pursued the passion nonetheless by turning one half of his house into a veterinary clinic. We asked him the question we had been hearing the whole day.  He looked at them in detail, and gave the verdict- I think snowy is male and brownie is female. We heaved a sigh in relief; finally an authentic answer. That was when he asked us; so, how do they pee?

 

Thus back to square one (they used to pee in ‘both ways’) with our new additions to the family, we reached my home. There, no one seemed to bother about the gender of the puppies, and through the evening my sister and her husband held them on the lap and combed the remaining fleas from their coats; the puppies seemed to enjoy the grooming and began bonding with everyone in the family.The next morning about a dozen neighbours came in to see them, and the question popped up again. Then, they too offered assertive suggestions, which made either both of them males, both females or one male and the other female. I realized something else too; none of them were expecting us to keep female puppies and regarded the gender as some kind of a burden. Also they did not seem to think so about mickey, which had the advantage of being a foreign show dog. The opinions which came up were that the dogs would get pregnant, would look ugly henceforth, shall attract strays, and may not be vigilant enough to be proper guard dogs…

 

We decided to ask my grandfather, who has reared a houseful of pets over the years. He said that without doubt these puppies were females and that whatever the neighbours might say, we are keeping them. So the puppies, now with full backing entered their new kennel. Within minutes they found that through the bars they could slip into mickey’s half of the enclosure. As we watched with apprehension, they did just that, and found themselves facing a growling, jealous Spitz. Then, they did the unthinkable; the pups pushed themselves bravely to the place where mickey’s milk producing apparatus should be, snuggling under her; while the eight year old dog seemed to revel in her newly found motherhood and let them remain there.

 

Two weeks later, we were told that a companion was needed for an old female Labrador in the monastery and thus, snowy was sent to her new home, while brownie stayed behind. Over the weeks brownie became agile and healthier and started displaying the traits similar to a pure bred hound. Meanwhile my husband and I had travelled north for an exam and could not visit her for some time.

 

Then, one evening, about three months later, as our car crossed the gates of my ancestral home, we were greeted by loud reverberating barks, and were astounded to find that they came from Brownie’s kennel. As we went near she grew quiet and began to wag her tail vigorously in recognition. That was when we heard our grandparents calling her, the name that no other female dog was given before and the one earmarked just for the alpha dog, ‘Mothi’.

 

 

 

 

 

 


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WOMAN:

WOMAN:
The Womb from which love is formed.
The Orbit in which the universe revolves.
The Miracle of creation and sustenance of life.
The Assurance that patience, forgiveness and fortitude live on.
The Name of all virtues, courage and truth.

It is wonderful that the world would pause on this day every year, to think about the respect a woman deserves, to acknowledge how precious each woman is, and how in every girl born there is hidden, a mother. These verses are written with love and wonder for the woman who has been and shall be forever my rolemodel, strength and benchmark of all that is beautiful and true, my Mother.


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MEDICAL SPECIALTY: choosing wisely

When you are one in one lakh, How to CHOOSE your speciality?

A few years ago, whenever anyone asked me,’ what speciality would you Choose? ‘ my answer was always, ‘Oh whatever i get!’ while i would be thinking, ‘SPM yes? , medicine n..o, Surgery NO, Paeds yes, pharmac Y..e..s….’. well i finally got the answer last year. In the most painful way possible.

Well i guess one has to be honest with oneself.
I had taken some of the tests available for this purpose, and found them not only tedious, but yielding results not consistent with our scenario. Also, I put lots to decide. That doesn’t mean i choose the lot. I get to know the real thing i would need , if the wrong lot falls. Then i pick the choice my mind has just revealed. This one usually works, yet i could not utilize it when i was in the allotment room. So after seven months of ultimate torture and suffering brutal bullying, i left my course; and ended up with my choices again.
I really wished at some point that i had visited the institution where i joined, that i had spoken to at least one person working there, that i had sought the guidance of anyone doing pg in the same speciality ; before i said yes to the seat.

Somehow graduation is like your gender and post graduation is like marriage; well i divorced my pg, guess we sabotaged each other, were not meant to be together..Well, lots of excuses, i know, and since we were not a celebrity couple, let us end it there.

Your basic Interest matters:
If you like Biochemistry for instance, write down Medicine, Paediatrics, and of course, Biochemistry.
If your interest includes anatomy, then think of Surgical specialties, Radiodiagnosis(RD), Radiotherapy.

Your basic intution matters:
Can you really see yourself there? Pursuing the course? In the theatre/ OP/USG room/wards?
Can you see the degree after the letters M.B.B.S?
Can you accept it when people refer to as the specialist in’…………..’?
Can you imagine yourself there after 40 years?

Your talents matter:
A creative doctor with high manual dexterity would do wonders as a surgeon. Along with that, If you are good at visualizing what you cannot see, think ENT or Ophthalmology; If you are strong, and like physically changing things, consider Orthopedics; and if, you can empathize with a woman in pain, consider Obstetrics.

Your Personality matters:
A type A personality, with excess of energy, some amount of extroversion and constant need of action, would fit like a glove in the ER, Surgery, ENT and Orthopedics. I guess this is the group of Anaesthesia specialists who would rather be in the ICU and ER rather than in the OT where the rare chances of action and more of inaction bores them.

Your Attitude Matters:
Do you highly value and love being acknowledged and worshipped by patients? Be extremely truthful to yourself here, no one else is listening.. then it might hit hard when your patient may not recognize you as the RD, Psychiatry, Anaesthesia, Pathology, Microbiology, or Biochemistry specialist who laboured for him/her.

Your Mode of learning matters:
If you are a kinaesthetic person, you can consider Psychiatry, While, being visual makes you fit for RD, Dermatology, Pathology, Microbiology, and, Surgery.

Your Commitments matter:
If a nonclinical or paraclinical specialty provides you the stability needed in your circumstances, consider opting the subject. now this comes with a clause. You must be comfortable with the decision as to never blame another person of forcing you into it.

Your flaws matter:
A small fish may skip through a net while bigger ones are trapped inside. What might have been judged as your flaw could be your strongest faculty.

-Promises to keep.. : It may not be easy to run a family, and prepare for entrance exams, let alone trying to balance your work and studies as a postgraduate student with the duties as a spouse or parent. The bright side is not just the sense of belonging and security a beautiful family life imparts , but also knowing that you can see the future in a better perspective; and having the choice to select the subject that blends in with your multidimensional responsibilities. If wisely chosen, your student days as a pg would be where you can implement all those home-running, planning-executing skills which would give you an edge over the rest. Also, needless to say, your communication skills would be higher.

-Solitary reaper..: If being with people bothers you and, you are often labelled as a loner in his or her world, it won’t be a bad idea to choose the branch that lets you work at your own pace. Avoid branches that demand your constant commitment, like obstetrics or pediatrics, and think about RD, or Pathology. Also academic subjects like pharmacology,physiology, biochemistry or transfusion medicine could be considered.

-The lateral world: If your talents and skills are those of an administrator or researcher rather than those of a doctor, this might be the chance to define yourself. Health administration, Community medicine,or Pharmacology would suit the creative and lateral thinker who has more than a handful of ambition.

Some things do not matter:

TREND.. changes. A subject everyone is after now could be way down the list in another 5 years. In the last fifteen years, it was first medicine, then paediatrics crawled in, followed by RD, then, anaesthesia and dermatology.. Well its wonderful being trendy, provided you are assured of being happy with the subject even if it is pushed out of the ramp.

MONEY.. is not as important as being contented. If you are best in what you do, wealth shall come on its own. Yet, if there are financial matters to take care of, draw up a long term plan where you can settle down in the most compatible way possible.

YOUR PERCEPTION DURING STUDENT YEARS…might be slightly prejudiced. This would have been based on several factors; your rapport with the teachers or seniors, patient load or facilities in your undergraduate institution. Speak to more than one person specialized in the subject, browse the books you might be required to learn as a pg in the subject, get an idea about the working/student environment of the institute of your choice, download the curriculum from the respective websites, visit the institute if possible, and if you get a chance spend some time there.

Wishing all a prudent and wise decision-making day, so long.