ACTORS

Contrary to what people might believe, surgical wards are relatively quiet and clean. Occasionally you’ll hear someone screaming in the silence, but only momentarily. Its clean because no matter how dirty the wound, the thick white bandaging makes it look as nice as wrapped candy. You’ll be surprised if you see how dirty the wounds are when people come to us in the emergency and how neat they look (or are made to look) after a day or two in our ward. That’s why many of our patients love being in the ward, especially the ones who are destitute, or don’t get any attention at home. Not to forget the attraction of three square meals a day-free. And so, when the time comes to pack up and go home all fixed up, they become actors.

The first time I met a serious actor, it was the Mother of a 25 year old girl with cancer of the Rectum (almost the last part of the Gut).  We had diagnosed that the Cancer had spread so much that surgery at that stage wouldn’t have been feasible. She needed radiotherapy, which isn’t available at our hospital, so the patient had to be referred to a center which had this facility. For some reason the Mother of this patient believed we were making an excuse to get rid of the patient (a common perception among many patients in government hospitals). She liked the standard of care we had given her daughter. She liked the cleanliness we maintained and the helpful attitude of our nursing staff. She kept asking for us to treat her ourselves. But it wasn’t possible. This girl needed radiotherapy. So she started to butter me up. She kept referring to me as her son. She kept telling me how much I resembled her son. She said she had gotten us fruits, she asked for my shirt size and when I refused to co-operate, she kept pulling on my cheek and grabbing my chin to draw my attention, like they do to little children! That’s when I lost it. “Firstly”, I told her, “I’m not your son. Second, unless you can spend a few million and buy the radiotherapy machine for this hospital, you are wasting your daughter’s precious time by staying here. So go get her some help and stop stalling”. You should’ve seen the frown on her face when she left.

Probably the best actor I’ve met so far was a 30 year old man who had suffered an assault at his home. He had been beaten by a bunch of guys with fists and slaps and had landed in our hospital with the police. He had no severe external injuries. But he complained that his head and chest were paining. Although we were quite confident in our clinical diagnosis, this was a Medico-Legal case. That meant that it could go to court and we might be asked to testify. So we left no stone unturned. We got a CT scan of the head and an X-ray of the chest and as we expected, he had no internal injuries either and was good to go. But he wouldn’t. He just lay in bed with his head down and pretended not to be able to sit up. His voice was normal and he seemed fine, but when I made him sit up he just fell back on the bed. It was too obviously, fake. We gave him some time. But he wouldn’t move. So my senior told me a little trick he used during his PG days. I went and told him that we needed to place a Ryle’s tube into his stomach. This is a plastic tube that goes through the nose, then through the throat and into the stomach. It’s perfectly safe and very useful in patients with intestinal obstruction, but it’s very discomforting for the patient during insertion. He was so stubborn in his efforts though, that he agreed. He actually bore the discomfort of the tube and had it inserted. Seeing all this, his relatives asked to speak with me in private. They told me that the reason why he wasn’t ready to leave was because if he went home, the guys who beat him up might just do it again. He was scared. But staying in the hospital was no solution. He wasn’t ready to tell the police the truth either. He had to go home sometime.

We decided to get him a psychiatric consultation, but just before we did, one our most senior residents joined us during the duty change. When we explained what was happening to him, he went and saw the patient immediately. He asked the patient about his complaints. He looked and sounded very sincere and serious about the patient’s condition. Then he had his attendants pick him up and make him stand. It’ll be interesting to know that a man cannot voluntarily fall from a standing position with the intention to hurt himself. The body reflexly protects itself. He acted as if he was wobbling of course, and my boss was acting as if he was encouraging a disoriented man to walk. In the end, the man walked a good distance and back and told us that his aches had mysteriously disappeared, that his head wasn’t turning and that it was all because of the Ryle’s tube (that had practically done nothing) that we had placed in him. We took out the tube and he left voluntarily. I silently gave him (and my boss) a standing ovation for the entire performance.

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Running for blood

If you see a first year post graduate student of surgery running in the hospital, it’s probably due to one of three reasons. The first, is if there’s a patient dying, probably due to a sudden cardiac arrest – this is not very common in the surgery ward. The second, is if the PG is late, and there’s a senior waiting for him- this is very very common. The third, is if he’s running for blood.

If you think you know how much blood it takes to keep the hospital running, your wrong. It takes more. That way, the blood bank is like the heart of the hospital, constantly circulating blood from donors and giving it to the needy. Its like a Robin Hood of sorts- take from the rich and give to the poor. Give to the poor…that’s the complicating part. Because the poor are so many. Not only are there those who have no one to donate for them, there are those who’s blood group is so rare that its hard to find blood for them. That’s what happened to a patient of mine recently.

This patient was an 18 year old girl with tuberculosis of the abdomen. Her gut was so horribly stuck together that no food could pass through. She had started to develop signs of infection that ran into the blood vessels and was circulating to the rest of her body (septicemia). We had tried to operate her once, but we avoided aggression, lest the bowel tore in its place and we made things worse. She improved after the first operation for a few days, but soon, it became clear that she would need another surgery.

On the morning of the second surgery her Hemoglobin level ( a measure of the red pigment in blood that carries oxygen to our organs), was 8.5 gm/dl. The normal for her would have been 11 or 12, but 8.5 was a safe enough level for her to have emergency surgery. We sent a repeat hemoglobin level just before she went into the Operation theatre which was at 11 pm at night. An hour into the operation the report revealed a level of 6.8. And, she had probably lost one unit (about 1 more point), during surgery already. The anesthetist freaked. But there was a solution of course. The patient had a lot of donors, and we had been prepared for such an eventuality. We called our blood bank and sent for blood, only to discover that the blood needed for her type-O negative- a very rare blood group, was unavailable. They had just sent it for two women who had had too much blood loss during childbirth. We had least expected this. The anesthetist literally had a stroke. Get me blood Nishant, she screamed. I don’t care how you do it, just get me blood.

Thankfully the guy at the blood bank had a solution. The Red Cross blood bank had the kind of blood group she needed. But they needed a stamp and signature from someone at the hospital. So I ran. I ran to the Emergency officer who didn’t have the stamp. I ran to the Boss of the Emergency officer, who didn’t have the stamp. Finally I woke up a senior consultant and drove my bike to his place and had him stamp and sign the blood requisition form half asleep in the middle of the night and then back to the blood bank. They were ready and waiting. They sent their guy and got 2 units of blood. I came back with a sigh of relief. The blood would arrive soon. I changed into my scrubs waiting to be proclaimed a hero. But our patient had bled more than I had expected. She had lost at least another two units more. More blood Nishant, we need more blood!!

I called the Red Cross blood bank personally. They had no more O negative blood. The two units they gave us were their last. The blood bank in our hospital called everyone they knew. All the major government hospitals. But they were at a distance. I looked at the blood soaked towels in the operating room. Something had to be done. I looked at her family waiting outside. Something had to…wait.. Her family wasn’t poor. It wasn’t rich, but it wasn’t poor. I could tell from the clothes they wore. Maybe they could buy the blood. But this had never been done before. None of my seniors had told me about this route. I didn’t even know if people could sell blood legally. There was only one way to find out.

At three in the morning I called the only people I trusted for information about pizza places and movie shows in and around Delhi. Just Dial. You know those phone based companies that give you information about places you want to know about in your city. This was the one we used in Delhi. I called and the response was prompt. I explained to him the situation, the urgency and the need for fast information. As soon as the guy realized that this wasn’t the usual call for late night eating joints he started speaking quickly and vociferously as if a timer had been set and he was about to win a million dollars. I liked him. There was indeed a blood bank close to our hospital that sold blood. The Lions Blood bank.  I called them. They had the blood. They charged 1900 Rs per unit. It was worth it. I got the address and sent the relatives who probably drove like madmen, because they reached there much faster than I’d expected them to. Back in the OT, the anesthetist was looking for me. She needed to vent, and I was the chimney. There aren’t too many places to hide in the OT complex.

The Relatives were taking too long at the blood bank, so I called them. The technicians there were making them wait, because they had a 40 minute processing time for matching the patient’s blood to the blood they were giving us. This was longer than usual, so I asked them what the holdup was for. “We have a world class matching process sir”, said the voice on the phone, “ We test for antibodies that few centers do in Delhi, giving you quality matched blood”. He sounded like a salesman. “ Listen my friend”, I said to him, “ This girl is being operated right now. She’s losing blood fast. And she needs blood. Those extra antibodies you test for to prevent reactions in 0.0001% of patients won’t really prevent anything if she dies.  Just do the usual cross match and give us the damn blood”. I heard a few ‘ but, but, buts’, on the phone, but there was nothing more to be said. He probably followed the whole procedure anyway. I wouldn’t know, because I was called back into the OT. The operation was over. She was going to be shifted to the Intensive Care Unit. The Anesthetist was still tense, but at least there wasn’t going to be any more bleeding. By the time we shifted her, to our grand elation, there were two units of O negative blood waiting for her. It was our very own hospital blood bank. They had managed to find O negative blood at the Army Hospital blood bank nearest to our hospital. It had been unconventional for them, but hey, it had been a weird night. And by the time we gave her those two units, the blood that her family had gone to purchase had arrived.

After fighting a significantly long battle in the ICU, the patient, I’m glad to say, did well and is to be discharged soon. I had promised the anesthetist and her PG assistant a Samosa treat if this patient made it. Guess I’d better go buy some. I’ll be relaxed when I do. Not like when I’m running for blood. The patient’s attendants wanted to thank me for my efforts. Instead I redirected them to some real heroes. The people at the blood bank. They run for blood every day. They don’t even come to know if they manage to save the patient most of the time. They just run.