"KNOWN TO"

Doctors fight fiercely with one another. It’s true. We are all concerned about our patients, but when it comes to responsibility, we fight. The only time we don’t fight about responsibility, is when we have to treat a fellow doctor. We help each other in every way possible. Call it professional courtesy. Call it a ‘you scratch my back, I scratch yours’ kind of attitude, or just call it a community feeling. It was during this sort of help that I got introduced to a very useful term- the ‘known to’.

 

As doctors in government hospitals, where treatment is cheap, but waiting periods are long, we often get requests to speed up the process by personal recommendation, often by those with less means. Friends, relatives, maids, car washers, laundry men, drivers, almost anyone we know ask for advice, tests or referrals. So instead of enquiring about what the person being sent to me for ‘special’ referral means to the doctor who sent him or her to me, we just call them a ‘known to’. If a doctor is famous for showing a lot of people to other doctors in the hospital, we just say that he has a lot of ‘known to’ s. We don’t really care about the relationship. The person being sent to us might be a friend’s friend’s maid’s son. All we know is that the patient is a ‘known to’ of the doctor who sent him to us. It was only recently though that I had a ‘known to’ come to me for treatment.

I help people out, to show them to doctors in the best way I can. But usually I take them to see specialists. For the first time, a friend of mine recommended to his driver who had been carrying around a hydrocoele of the scrotum for a good number of years to see me for the surgery. A physical examination and a blood report later, I requested my seniors to place him on the next free minor operation slot in our unit. His name went down in the list as a ‘known to’ of Dr Nishant- no questions asked.

On the Operation day, while we had two other cases for the minor OT, I was allowed to operate on my ‘known to’ first, and to take all the time I wanted. It was when I was scrubbing for the surgery that the wisdom of my seniors hit me. My reputation was sort of on the line

.

I know it’s odd for a first year post graduate to talk about a reputation. But it was true. The friend who had recommended my name and approached me to treat his driver, would definitely doubt me if the smallest complication arose due to the surgery. I knew he wouldn’t say anything, but he wouldn’t be happy either.

In medical practice we like to say that we should treat every patient like he or she is a member of our family. I don’t believe in this. Not in surgery anyway. I wouldn’t be able to operate on a member of my family. I believe that the best approach is to treat a patient like a human being. Someone who has, a family. I think that’s professional. And I reminded myself of this before I started the procedure. Complication’s happen. What’s important is to do the best you can

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Half an hour later the procedure was complete, stamped by the approval of my second year post graduate, and packed to go home. Now there was nothing to do but wait. Any real complication would present itself in a day or two. So when I didn’t get a call from my friend about his driver for four days straight, I was relieved.

A week after his surgery, the man came to me for having his stitches removed. His wound was healthy. And he was very thankful. He had a procedure done for free, when he was told that it would cost 20000 rupees by a private clinic. He went home with a smile, and I, with a peaceful mind. I guess that’s how you build a practice. With ‘known to’ s and by placing your reputation on the line when you see them.

Sometimes we like Jam

these are links to videos of me jammin' with Dr Reuben and his cousins in his hostel room..we played and sang time of your life, love hurts and when you say nothing at all..on guitar are Dr Reuben and Laam, I helped with the singing, and Randomly lying around is my co-Pg Dr Shailesh..
Good times..

http://www.youtube.com/watch?v=MUIUDTiLTpc&feature=youtu.be  (When you say nothing at all)


http://youtu.be/_HDbZXBJElY  (love hurts)


http://youtu.be/uTYXKxEtDek  (time of your life)

SCREW IT, LET"S DO IT!!

When you learn how to swim, there’s usually a process that’s followed. You place your feet in the water, you just bounce about in the shallow area, then you practice beating your legs and floating while holding the railing, then you learn to float around, use your hands, go to the deeper parts, and then you work on your stroke. If surgery was swimming, it would go something like this- you read about how to swim, you look at a lot of different people swimming, you place your feet in the water one day, you hold the railing the next day, then you dive into the pool from high above and hope you can surface fast enough to breathe. Only, the water you dive into, isn’t always the one you practice in, it maybe murky , dirty with things swimming around at the bottom that you never noticed. Knowing all this, there comes a point in every surgeons practice, time and again, when he has to take a deep breath and just dive in.

That’s what happened when I performed my first minor surgical operation independently. A hydrocoele is a collection of fluid around the testes (commonly called a man’s balls), that can grow to enormous sizes. Decompressing this collection and making certain it doesn’t recur is one of the first minor operations a surgeon learns.

Even in this, there are many variations. Some open the sac (the part that contains the fluid) early and then dissect it out while some do the dissection first. Some don’t believe in using electric coagulation, while others consider it a necessity. Some take more bites of their suture, others take fewer. I had seen them all. So one fine Operation theatre day, when a patient with a large classical right sided hydrocoele was posted for surgery and every other person other than an intern of ours was busy, I said to myself- screw it, let’s do it.

It was all going well. The intern was a good assistant. The local anaesthesia worked well, so the patient didn’t make a sound, and I began with a good incision. Then I deepened it. The fluid filled sac should’ve shown itself as a nice white surface. But it didn’t. I deepened it further. Nothing. Maybe I had missed it. That’s a stupid thought, how could I have missed it? It’s a water filled balloon. When you cut open a balloon, the water has to flow out. I cut deeper. Next layer, then another, then another. What? Where was this damn thing? Then sac rotated a bit in its place and I found my mistake. My assistant hadn’t fixed the sac properly, it kept moving left and right. Plus the local anaesthetic I had given had infiltrated some of the deeper layers, causing them to swell and distorting the anatomy of the layers. I had kept making incisions at the same layers repeatedly at different points. I had him fix the swelling in place. That’s it. Just a few layers deeper and I’d reach the sac. So I placed my scalpel on an incision I had made earlier, and bang, a spray of fluid hit my face.

I had incised the sac early and without knowing it, I quickly caught the edges of the incision with artery forceps. My face mask was wet, and it was a bad feeling. But I had to get this done. On my own.  I widened the incision on my sac with a scissors, careful to visualize that the testis underneath doesn’t come in the way. It didn’t. phew! Cutting the testis would’ve been a bleeding disaster. I drained the rest of the fluid. And the testis popped out of the scrotum (the skin and other layers covering the balls). But wait a minute- the testis wasn’t in the sac. It was outside it. That, was unexpected. The testis was supposed to be inside the sac. What had I cut? Was I in the wrong plane? The sac was just a blind fluid filled cavity. Was this even a hydrocoele? It said so, according to the seniors who had seen him.

I had had enough. I called my second year post graduate. She said it wasn’t just a hydrocoele. It might even be a hernia. That thought scared me. I had no idea what to do with a hernia. One of our consultants just happened to walk about around that time, so I called him. “It’s a hydrocoele of the cord you idiot”, he said. Just excise it and stitch the edges. I did, and he helped me, and the patient went home with normal sized balls. But somehow, my dive hadn’t gone too well.

The next week, I got to do another hydrocoele. The same intern and I shifted the patient, again while the senior resident was stuck up. This time, I incised the planes in one line. I opened the sac, so that the fluid didn’t hit my face. This time the testis was in the sac, where it usually is. I everted the sac and fixed it. I closed the incisions, making sure there was no bleeding. By the time my senior resident came to check up on me, I was dressing the patient. A week later, when I removed the patient’s stitches, and found no complications, somehow I just felt a sublime happiness. I wasn’t ecstatic. I just felt satisfied, and more capable.

I saw these moments in surgeons at all levels after that. No matter how many years of practice you have, there are always procedures that you have just started to learn. Only the difficulty rises as you progress. That’s the excitement of being a surgeon- the moment when you look at a problem, you know you have what it takes, but you’ve never done it alone. And then you say- what the hell, screw it, let’s do it.

YES, MASTER!

Have you seen those Kung Fu movies, where an enthusiastic student searches for the ultimate master of a Kung Fu style, so that he can fight the bad guys who’ve wronged him? Learning surgery is exactly like that. The master is often very different from what the student expects. He might be a hard-ass, who makes the student hate him, only till the end, when the student actually realizes how much he has learnt and changed. True masters are rare in surgery. True teachers are rarer.

The face of the surgical unit that I am part of is changing drastically. From the first of January, I will be the only one left in my unit, who was there originally when we started in May. The exit and entry of new teachers made me wonder about how surgery is taught and learnt in our hospitals.

In the beginning it takes a while to just get used to the body that’s deeper than skin. Just holding instruments and internalizing them takes months. Soon, the hand starts to work subconsciously. You look at the problem, and that’s all you look at, for the instruments are just extensions of your fingers.  And that’s when you start to understand the difference between those who teach you.

Some surgeons are fast in their manner. They go through the procedures in surgery like darts. Other’s are slow and meticulous, taking their time with every step of the process. Don’t get the wrong idea here. Both kinds are excellent surgeons. I believe speed is a matter of practice yes, but after a point it’s more a matter of character.

There are standard textbooks of course, but no other branch in medical science provides as much independence and ambiguity as surgery. Once you perform a procedure, it is yours. It is your imprint on that person for the rest of that person’s life. Did you use two sutures or one? Did you give a subcutaneous stitch, a mattress suture or just a simple knot? Did you cauterize the tissue or did you dissect it with the scissors, or even with your fingers? Did you skeletonize the structures? Did you clamp them together? The variations that are possible with every single part of every single procedure seem endless. And the more the masters that teach you, the more the variation, the more the styles.  But just like that, subconsciously and before you can put your finger on it, you have a character of your own.

One of my master’s once asked me when I thought I’d become a surgeon. Would a degree, a Masters in Surgery, make me a surgeon? Or adequate practice in a certain procedure? No matter how many procedures a student learns, there are more that he hasn’t, and there are more ways of doing one than he can learn. I believe, that you call yourself a surgeon when you are comfortable with providing the solution. When you don’t stand limply in front of a suffering patient, when something surgical from your side can save him. Even, if all you can do, is make constant calls for help.

You become a master, when you can do this, calmly, swiftly and precisely.

So here’s to the masters that have taught me, and those that I look forward to. May I prove a worthy disciple, and come out a master in my own right someday.

" SIR, THERE'S A LIVER IN YOUR CHEST ! "

The X-ray in front of my eyes said little about the person to whom it belonged. The lung on the right side looked almost completely collapsed. And still, the patient in front of me, a 48 year old office worker was standing normally, walking, talking, and doing everything a man at his age was expected to do. His only complaint was that that he didn’t take exertion too well. Climbing more than two flights of stairs would cause him to breathe heavily. It didn’t affect his daily work too much, but it had concerned him that his capacity to do the things that were once easy for him to do had started to get so exhausting over the last four years. My boss in the mean time was looking at a C.T. scan of this patient’s chest and abdomen. Handing me the films, he said to the man, “Sir, your liver is in your chest”.

A couple of days later R. N. Singh (name changed to protect identity), was lying on a bed in our ward, while I prepared his file for the elective operation he was about to have the next day. “I was perfectly well four years ago,” he told me, “until I had an accident. I was on my scooter and crashed into a car in front of me which had braked quite suddenly. I had dislocated my left shoulder which I got fixed and other than a mild ache in my lower right chest that lasted about a month, I thought I was fine. But over the course of a few months, I found it harder to catch my breath after straining myself. I just thought I was getting old, but it got worse in the last couple of months, so I thought I’d get myself checked just to get some peace of mind. And now I’m here.”  Mr. Singh had a post-traumatic diaphragmatic hernia.

The chest (called thorax) is separated from our stomach (called abdomen) by a large flat muscle called the diaphragm. The movement of the diaphragm helps us expand our lungs and draw air into our body. Various important structures, like major blood vessels and the food pipe go through this muscle crossing from the thorax to the abdomen or vice versa. In Mr. Singh’s case, the accident that he had, had caused a break in the muscle fibers at the right side of his diaphragm at the back where it attached itself to the posterior part of the rib cage.  His liver, had helped form a block at this opening, plugging it. But due to the continuous expansion and deflation of his lungs, the liver kept getting sucked into his chest albeit very slowly. Gradually, the right lung started to get compressed by the large liver abutting it at the bottom. Since the process went on over four years, his body had undergone some compensatory changes and so had he, in terms of his lifestyle. By the time he came to us, his liver had compressed more than half of his right lung, and was much higher than where it was supposed to be.

The plan for the operation was to take a look at the hole in the diaphragm before opening the abdomen. So we did a diagnostic laparoscopy. We filled the abdomen with air, to help distend it. Then we placed a long scope with a camera into the abdomen through a 1 cm incision just above his belly button. We were surprised to find very little liver actually in the abdomen. The larger part of it had now gone into the chest. Once we confirmed the location of the defect in the diaphragm, we planned our incision accordingly.

Once we entered the abdomen the process seemed simple enough. We thought we’d pull the liver back into the abdomen and close the defect with an artificial mesh. Although the defect was deep, the senior operating surgeon placed a hand around the liver, and was pleased to find that three of his fingers could slide around it, through the defect to its superior part. And then he pulled at it, to bring it down. But it didn’t. He tried to insinuate his fingers at various points around the liver, but no matter how much he yanked it, it wouldn’t budge. The part inside the chest seemed too wide to be able to be pulled back out. But then, how the hell did so much of it get in there?

We had to find out what was causing the problem. We needed eyes inside the chest. The only way  to do this seemed to be to  put a scope through the chest to see the superior part of the liver. But we weren’t prepared for a thoraco-scopy. So we took a different approach. We took the long camera that we had used for the abdomen in the beginning, and we tried insinuating it through the defect in the diaphragm below. It worked. We could see that the liver had actually gotten attached to the lower part of the lung at various places. These adhesions had made it continuous with the lower part of the covering of the lung. The two organs had gotten abnormally stuck together. 

This was tricky. Not only was it dangerous to try to remove the adhesions, we had only a one centimeter  gap to work with. We tried using long thin laparoscopic scissors, graspers and ultrasound based dissectors. And they worked on the outer ends, but we couldn’t even see the deep surface let alone reach it through the space that we worked with. It was time to make a tough decision. Open the chest or enlarge the hole.

Both options were risky.  The post operative complications of either approach could be dangerous. Finally after much debate with consultants lining up on either side, our senior most surgeon decided on increasing the size of the opening in the diaphragm. He let out a prayer, took a scalpel in his hand and made an incision in the diaphragm so that the defect that had caused all the trouble had gotten bigger. 

The laparoscopic instruments now fit through the new opening, and as we began to dissect the adhesions between the liver and the lung covering (pleura), we started to get more and more exposure, so that it became easier to pull down the liver. Soon, the liver was back in its rightful place. The large defect in front of us, now completely exposed had been about twice the size of a man’s fist. We closed it, and placed a mesh right under it, to help prevent it from opening up again under pressure.  We then placed a chest tube into the right chest of the patient to get rid of residual air and debris and then we waited.

We had the patient sedated and on mechanical ventilation for forty eight hours, allowing the radically repaired body to settle down. Then we took out the mechanical tube in his lungs and let him breathe. He was ok. 

Three days later, I found my boss unexpectedly at Mr. Singh’s bedside. This was odd, because he usually informed us when he came for his ward rounds. He had a bright smile on his face. Handing me the fresh X-ray of Mr. Singh’s chest, he told him how lucky he was. The surgical result had been much better than we had expected. In front of my eyes, was the X-ray film showing a completely expanded right lung, which in every way looked absolutely normal. Mr. Singh breathed a sigh of relief. It was a deep, fulfilling breath.

BOMB BLAST BABA

In the early hours of one emergency duty morning, a ‘BabaJi’ rolled into our midst. ‘Babaji’ is a blanket term for the long haired, thickly bearded old street dwellers who land up in our hospital mostly with rotting legs and a host of other medical problems. This one was no different. He had a badly necrosed left foot with maggots in it. We cleaned it, cut off the necrosed parts, removed the worms and dressed it up nice and good. It isn’t the best part of our work, specially that early in the morning, but it is very much a part of our work. We thought we’d keep the Baba overnight, give him a somewhat decent bed to sleep in for once, and then he would be on his way in the morning, to wherever he came from. My God, we were wrong!

The next morning, he refused to go. He just lay there semi naked, on the bed. And because he was so disheveled, no one else wanted to sit or lie on the same bed as him. So even when there were two, even three patients on each bed in the emergency, he lay alone and comfy on his own. We gave it up trying to convince him after a few minutes. Besides, there was no one to take him anywhere anyway. He had just walked into the hospital with that leg. The day after an emergency is quite hectic. We got busy handling our OPD and the critical patients that had been operated the previous night. Besides, he wasn’t hurting anyone just by lying there.

That evening we got a call from the nurse at the emergency. The ‘Babaji’ was still there and they were getting angry. They needed the bed for new patients that were coming in. We requested them to keep him the night. We dressed his leg again. It was obviously better. All he had to do was come in once a day for the dressing, but he just wouldn’t leave. We aren’t in the business of throwing people out of our hospital. We’d talk to the consultants about it the next morning we thought.

The next day, our consultants got pretty busy in the operation theatre doing a complicated laparoscopic operation. And then we got the news. There had been a bomb blast at the High Court in Delhi. There were orders to cancel all pending elective surgeries. Soon, the OT would be flooded with Bomb Blast victims.

We all got pretty involved with handling the Bomb blast casualties soon. The consultants started operating, the senior residents inserted chest tubes, classified and prepped patients. Us junior residents started stitching, cleaning, removing shards and debris and managing burns. By that afternoon, the situation had been controlled and things had settled down. That’s when there was an alert from the hospital police post. A line of white and black government vehicles with flashing red lights were arriving. There was a lot of press around, and soon the emergency was surrounded by cops and kurta klad politicos.

We were cleared from the emergency, and I decided to get a snack since I hadn’t eaten the whole day. I met one of my interns in the canteen. He was excited. He told me to come to the T.V room. Rahul Gandhi-yup THE Rahul Gandhi- at the time the president of the Youth wing of the Congress (and heir apparent to the political legacy of the Gandhi Family), was in the Surgical Emergency ward, meeting the bomb blast victims and assessing the situation. He looked at all the patients there, and then stood right beside one of them. This was an old shaggy ‘Babaji’, who had been covered by a blue gown by our nurses to hide his semi-nudity. It was our Babaji. Bur hold on just a minute. He wasn’t a Bomb Blast victim. And here was Rahul Gandhi promising him adequate compensation for his pains, pointing to his bandaged leg, and calling it an attack on our integrity. Babaji had made national television, although for the wrong reasons!

The next morning when the nurse told him to go back home, he said very rudely “Why? I haven’t even had Breakfast yet”. We got a call immediately. That evening, we had a discussion with one of the smartest sisters in the emergency- although some people might have called it a scolding and not a discussion. “This is not a hotel doctor. I wont have the nurses here being treated like waitresses. I won’t have our critical patients lie on the floor because that man stinks so much that you can’t stand near him.” She understood that we were all but helpless about it. She just asked us to go and be on our way. “I’ll handle it”, she said.

We got a call at 8 AM the next morning. “Just come and dress his leg nice and good”, said the sister to my colleague. When I met my colleague for lunch that day, he seemed visibly impressed. He had gone to the emergency expecting another scolding. Instead, he found a nice and clean ‘Babaji’, with some fresh clothes. He dressed his leg and made it look peachy. An hour later, some people arrived from an NGO which helped old street dwellers. She had convinced them that all he needed was daily dressing from a local dispensary and he’d be well. The national attention he had gotten had probably helped their decision to take him. Half an hour later, he was in a van to an institution with three meals a day and probably better than the street where he came from.

Where we failed, the sister came through. It happens much more often than we doctors would like to accept. This time, the effort was undeniable. I wonder sometimes what became of Bomb blast Baba, and everytime another Babaji walks into our emergency, I still can’t believe the series of events that happened with that Babaji that week.

INTO THE VALLEY OF DEATH

Seeing a person bleed is a tough thing for most people. I know girls who faint at the site of a needle entering a vein. Now imagine making a large cut on the skin, then going deeper and deeper to the deepest reaches of the human body. Controlling blood loss is one of the pillars of modern surgery.  And after a while, it seemed easy enough to me as well. Until one night,when we got a call from our colleagues in Nephrology.

The department of Nephrology (Kidney doctors), helps a lot of people with end stage kidney disease. These are people whose kidneys are so badly damaged that they can’t continue living without dialysis. This doesn’t have much to do with general surgery though, so getting a call from them at our emergency at 11 pm was a bit odd for us. My senior resident attended the call and 15 minutes later, he called me in the emergency room to tell me that I had to get the Emergency Operation Theatre informed and prepped for a case of trauma to the abdomen.

The patient that rolled in on a trolley was a young boy, who must’ve been 17 years old. He seemed to be in shock, and when I saw his Hemoglobin (the red pigment in the blood that carries oxygen), I flipped. It was 2.7. The normal should’ve been over 10. As soon as they laid him on the table and exposed his abdomen (called the stomach in lay terms), I saw a strong reddish –purple discoloration of the right side and the back. The senior resident quickly filled me in while we waited a few minutes for the Consultant to arrive.

This boy was a patient of End Stage Renal Disease. His body had turned on his own kidneys and damaged them to the point of no repair. He used to come to our hospital for dialysis twice in a week. And that night he had an accident. While walking home, he had been hit by a car. The driver, who was drunk, had swiveled on a curb. The car had skidded and the boy had been hit hard on the right side of his abdomen from the back. Instead of coming straight to the emergency, the father took him straight to the Nephrology Department, the only doctors he was most familiar with.

The Consultant arrived and we opened him.  As soon as we opened into the abdominal cavity, we were greeted by a large blood clot. We got it out of the way, fast. On further exploration, we couldn’t find a single large blood vessel that had been injured. The blood was coming from a large laceration of his right kidney. We had to take it out. There was no way of fixing it. Whatever minimal function it was providing would go. But the patient was on lifelong dialysis anyway. So we took it out. We controlled the blood loss. We closed him. We transfused him with lots of blood and platelets. We saved his life. Almost.

The next morning he seemed better. We had placed a drain in the place where the kidney was and there was no blood coming from it. That was good news. His Hemoglobin though, had only risen to 4.8. Given that we had transfused him adequately, it seemed too low. Still, we were hopeful. We had an Ultrasound scan of the abdomen done just to check anyway. This time, I called the senior resident, and we went back to the Emergency Operation Theatre. On the Ultrasound scan, we found a large clot in the same area where his kidney used to be. Although, we had placed the drain, a large blood clot had occluded it. He had to be operated again.

This time, we took out the blood clot again. It was significant. Almost 130 cc. we tried to search for the bleeding. But we couldn’t find the source. There was no bleeding vessel or organ. It seemed to be emerging from the walls. Just diffusely pouring down in little drops everywhere to form a puddle in the area where his kidney used to be. We cauterized the bleeding points (made small burns that coagulate and block the points of bleeding). Most of the bleeders stopped. Except from this little crevice at the upper part of the cavity we had opened. The bleeders here were so tiny, that the blood just seemed to emerge out of nowhere. No problem. We tried to cauterize it. But it didn’t work.  The bleeding re-emerged. We took an Artery forceps and tried to tightly clamp a good part of the underlying tissue. Five minutes later, when we removed it, the blood emerged with the forceps. We took a good bite of the tissue in a hemostatic suture. We tied it, and tied it, and it failed. In fact, the act of putting the needle through the tissue just made it worse. We extended the skin incision so we could see the area better. Maybe there was some large blood vessel we had missed. But there wasn’t. The blood just refused to stop coming. The puddle would just emerge out of nowhere in that deep tiny, crevice. We were scared that if we explored further, we’d just make things worse.

We had used all our tricks in our bag. There was only one thing left to do. We packed that crevice nice and tight, with Surgicel, an absorbable sponge that would pressurize it temporarily and over that with snugly fit towel mops. Eight of them to fill the entire opening. Then we tied the area with bandage. And we waited. We waited for 48 hours.

Meanwhile, we investigated the patient for the cause of such inconspicuous, unstoppable bleeding. His coagulation profile seemed deranged. But not by too much. And then, our nephrologist friends pitched in with a D-Dimer report that showed more than moderate elevation. This meant that this boy had Disseminated Intra vascular Coagulation. His weakened state due to his pre-existing kidney condition, and his blood loss had made his blood clotting system go haywire. His body had probably consumed all his clotting factors in making the large clot that he came with. If he just had a bleeding vessel, the clot would have stopped it. But his kidney had been lacerated due to the accident in such a way that it bled slowly and continuously from multiple small parenchymal arteries in the kidney. The irony was that this had kept him alive till he got to the hospital. The blood hadn’t emptied form him fast enough to kill him quick. But this had also led to his present dangerous condition.

We tried correcting whatever abnormalities we could. But by evening, even through the eight towel mops we had placed in him, we could see blood soakage from the corner of his wound.  Thankfully, his Hemoglobin wasn’t dropping. So we decided to keep waiting for the standard 48 hours to get over. It was a tough 48 hours. The pressurizing mops had irritated and obstructed his gut. It wouldn’t move and so he kept vomiting every hour. The pain was very bad. He was drowsy from lack of sleep, because the pain and the fullness and the nausea kept him awake inspite of medication. 48 hours, I said to myself. Just hold on. I was scared that in his drowsiness, he would aspirate his vomitus. That would be fatal. We tried placing a stomach tube to prevent that situation, but he wouldn’t tolerate it.

Somehow, the 48 hours went by and we took him back to the OT. We started removing the mops, slowly, very slowly, one at a time. It reminded me strangely of a poem I had read in my early schooling- The charge of the Light Brigade. “Into the Valley of Death, rode the Light Brigade”, it said. Reaching that little crevice in the upper part of his wound, where walls of muscle created a valley where a little stream of blood would flow to become a pool and then a flood was one of the most tense moments I’ve seen in my six months of operative surgery. The deeper towels were soaked thickly with blood, but they were otherwise dry. That was a good sign. We took that last towel out so slowly, it seemed like an eternity. And there it was, the ‘Valley of Death’. Clean, dry, without blood. We went a step further and washed the whole wound. There was no blood. We placed a drain, and closed him.

After ten days under our care, the boy improved. Not only did he not have any more bleeding, his health got better with repeated dialysis. It was a miracle he survived. He comes for his dialysis regularly like he used to. Someday soon, we might re-enter that valley, on peaceful terms, and transplant a new kidney there.