The usual beeps and toots emanated from the Boyle’s apparatus, the machine delivering anaesthesia which was at the head of the operating table. The surgery was well under way. I stood between the patient’s legs, which were propped up in a lithotomy position and covered with green surgical drapes. Dr V was operating, her movements precise and practised, while I, the senior surgical fellow, was on camera duty. In laparoscopic surgery, the assistant who holds the camera is doing an important job. The camera is actually a telescope that zooms into the area of interest inside the abdomen and sends a magnified, high-definition image to a screen for all to see. The camera person becomes the eyes of the surgeon, directing the telescope towards the surgical field and rotating it as needed to provide the correct angle for the surgery to proceed.
That day though, as I steered the camera cord this way and that, my stomach roiled as if at sea, and wave upon wave of nausea washed over me. I knew I had to leave that instant, or I would throw up right there all over the sterile drapes. Barely having made it to the washroom in time, I heaved until I emptied all the contents of my stomach into the toilet bowl. As I sank to the floor, I despairingly wondered what was wrong with me. After splashing cold water on my face, I made my way back to the operating room (OR) where the surgical team met me with concern and kindness.
‘You must get some rest’, said Dr V; her eyes remained on the screen as her hands danced with graceful ease.
I was reluctant to leave the OR. It felt like giving in to this sudden and hopefully temporary weakness of my body. As I stood staring at the screen with unseeing eyes, Dr A, the anaesthesiology chief, firmly but gently propelled me out of the OR’s automatic doors. She directed the staff nurse on duty to inject me with medication that would quickly relieve my symptoms while she gently probed into the history of my illness.
I confessed I hadn’t been feeling well the last few days but had been dragging myself in to work because we were short-staffed. I had gone to bed early the previous night, hoping a good night’s sleep would restore me to full function, but sleep had eluded me. Episodes of retching were followed by spells of my heart racing as though I had just completed a sprint, even though all I was doing was lying still in bed. Sometime around 11pm, I had been drifting off to sleep when my mobile phone rang loudly. I received the call, my heart pounding painfully in my chest. It was from the daughter of a patient our team had recently operated on. Her mother was vomiting and feeling uneasy; I listened to a description of symptoms surprisingly similar to the ones I was experiencing just then. In her case, however, these symptoms had a reason; they were not uncommon after bariatric surgery, as the patient learns to adjust their eating habits to the newly reconstructed digestive system. Her daughter had spoken to my teammate who was on night duty, and he had asked them to bring her in for admission. Still, she had wanted to let me know as well since she felt comfortable with me, looking up to me as an older sister. I assured her all would be well; I would see them the next day and returned to an unsettled night’s sleep.
As I finished telling Dr A this story, she grew increasingly perplexed. The head of our fellowship program encouraged us to share our personal mobile phone numbers with certain patients who needed more hand-holding after surgery. Even so, there was no reason for me to have received that call so late at night when I was feeling unwell. We had a system in place for precisely this reason; a dedicated 24-hour helpline number manned by a member of our unit as well as a surgeon from our team on night duty. In fact, even in this case, the unwell patient’s family were proceeding as per protocol and had only called me to reach out. When the mother-daughter duo heard I was unwell, they were profoundly apologetic for calling me. The question remained etched on Dr A’s face. Why on earth did I take the call? The answer was simple: habit. I had developed an entrenched habit of taking on excessive, and oftentimes unnecessary, responsibility.
That episode marked the beginning of a prolonged illness of sorts and an unusual one. I could eat nothing but the blandest of food for several months, and I could not step into the OR without being overwhelmed by nausea. We could not pin down the reasons for any of this; investigation after investigation, ECGs, a 2D echo, an ultrasonography and various blood tests all returned normal results. Only an endoscopy revealed a mildly inflamed stomach lining, but it did not account for the severity of my symptoms.
The genesis of this episode, my mysterious illness and the excessive sense of responsibility towards patients, lay in my surgical residency, which took place a decade before this incident.
While my fellowship had been in Delhi, I did my surgical training in Mumbai. My three-year surgical residency took place at one of the largest and busiest hospitals in the city, run by the municipal corporation of Mumbai. I remember walking into the surgical ward that first evening with great trepidation. I had spent the day completing admission formalities and shifting into the hostel room I was to share with the two other girls who were part of the cohort of new surgical trainees that year. We had three years of surgical residency before us; six semesters, two semesters to each year. You start off as a house surgeon, initially a lowly first poster, and then six months later, you become a more experienced second poster. You graduate to surgical registrar in the fourth post and hold that title until the final MS (Master of Surgery) examinations at the end of the sixth post. The surgical residency is a tight hierarchy, as I was to find out.
That evening, I entered the ward in search of the residents of the surgical unit I had been allotted to and found them, two third posters and one fifth-post registrar on their evening rounds. I joined them on the round, hanging back a little, half-awestruck, half-petrified as they examined patients, making them sit up to do their chest physiotherapy, chivvying them jovially out of their beds to be ambulated, emptying drain bags and peering at the fluid while suspiciously sniffing it, changing a soaked dressing while cajoling the patient to eat more protein, making notes, changing orders for medications. There was so much happening all at once, clinical assessment, decision-making, attending to the supportive parts of surgical care, providing the human touch, counselling about prognosis and expected timelines for recovery. I trailed after them until the rounds were done; then, Dr S, one of two second-year residents, took me off for an orientation chat.
As he unlocked the side room at the entrance of the ward, he ceremoniously and solemnly handed over a big jangling bunch of keys to me, saying, ‘These are now your responsibility.’
In case you watch Hindi television serials where the mother-in-law refuses to hand over an assortment of silver keys to her newlywed daughter-in-law, this was exactly the same, except in reverse.
The side room we entered was tiny. There were two cots which we sat on; this was where the residents crashed on days when we were too tired to go to our hostel room or when we had to monitor a sick patient. There were also a couple of cupboards and an enormous red suitcase. The keys I had just received opened these. Inside, Dr S explained, were surgical treasures. He opened the suitcase to show me what he meant.
It was crammed past bursting point with suture materials and meshes, drain pipes and drain bags, micropore tapes on cutters and crepe bandages. One could easily have performed a dozen surgeries ‘skin to skin’, as we say, using the contents of that suitcase, which were threatening to imminently spill out onto the side room floor. In the cupboards were even more precious jewels, surgical staplers and expensive, single-use cartridges, bags of parenteral nutrition, tins of specialised protein powder, some for ‘renal’ patients, others for diabetics, and larger-sized, specialised meshes that were used only for complicated hernia repairs.
As Dr S explained, all this belonged to our surgical unit and was to be used for patients admitted under our care; he and other house surgeons before him had carefully stockpiled these. It was now my responsibility to safeguard these, to make judicious decisions about when to dip into these precious resources and, most importantly, to add to the stock.
‘How?’ I asked, the confusion clear on my face. Many of these surgical goods were expensive; how was I, a mere house surgeon who earned a meagre stipend barely enough to take care of monthly expenses and the course fees, to add to this stock?
‘I’ll teach you’, he answered mysteriously. ‘The next most important thing is dinner. Let’s go to the canteen.’
The other members of our unit joined us in the canteen. Over a hearty dinner paid for by my seniors, they schooled me on the essential components of this meal, which would also be the only meal I would get time to eat. Dinner that night included chicken gravy; I was to make sure I consumed some form of protein, chicken or eggs or paneer (cottage cheese), every day as a hedge against contracting tuberculosis which was very common among resident doctors, and the meal was always to be washed down by an enormous glass of milkshake.
‘There’s no time for breakfast in the morning’, they told me, amidst bites of dinner. I soon found they were right. Any sane person would choose to sleep an extra 30 minutes rather than waste that time in the canteen which served a mediocre, tasteless breakfast. After all, any grousing by the stomach could be quieted with tea, which was freely available in every ward, and if we were lucky, the kindly nurses would share their biscuit stash with us. And this was how surgical residents normalised for each other an exceedingly unhealthy habit, consuming only one meal a day, that too a large one, just before turning in to catch a luxurious four hours of sleep.
As the days passed, I realised the truth of all I had been told that first evening. A good night’s sleep was four hours; endless cups of tea fuelled my days, and Dr S did indeed initiate me in the ways of stockpiling surgical materials as did the seniors in every surgical unit their own house surgeons.
Municipal corporation-funded hospitals, like this one, subsidised the expenses of surgery; there were only token charges for the utilisation of the ORs, which were well equipped with instruments but only had the most basic of suture materials and antibiotics. It was routine practice to write out a prescription for the various materials that would be needed during surgery. The patient’s relatives would purchase these from the in-house pharmacy and hand them to the house surgeon, who would lay them out in the OR ready to hand when needed.
Once the surgery was done, it was decision time. How poor was the patient? Should we hand back to their relatives all the unused material so that they could return it to the pharmacy in exchange for cash in hand? Or could they afford to have us keep some back and add to our stash, to be pulled out and used for an even poorer patient or an unknown patient brought in as an emergency with no one to run around on their behalf? This was one way by which we added to our surgical stock.
We soon discovered other ways. The Medical Officer (MO) on duty could sanction heavy budget items or materials for the poorest of the poor, via a concept called PBCF (Poor Box Contribution Fund). You would be justified in asking why we didn’t always use this provision for those who couldn’t afford to buy any surgical material. My answer to this may seem inadequate, but this was our reality; the sanctioning process was a long one, involving visits to multiple offices and plenty of waiting. Also, sanctioning often depended on the whim of the MO; he may choose not to sanction the requested items or the quantity required.
During my training, there were even MOs who would ask, ‘Don’t tell me you don’t have this material in your stock?’
To circumvent this problem, we had to maintain our stock. House surgeons would write out their PBCF requests late at night and go themselves, after dinner, to get the requests sanctioned from the MO. There were three advantages to this. One, there was only a single MO on duty at night, and, hassled with attending to patients pouring into the Casualty, he was more likely to sign off on any request, no matter how bizarre. Two, the MOs were less likely to refuse a tired house surgeon than a patient’s attendant. Three, once the request was signed and stamped, it was fairly easy to convert a 1 into a 4 with a couple of strokes of a pen.
When the house surgeon went to collect four bags of parenteral nutrition from the pharmacy themselves, the pharmacist certainly knew what was happening but chose to look away. Parenteral nutrition is a system of supplying the nutritional needs of a person wholly or largely via an intravenous line, either because they cannot consume the amount of food needed orally or because they cannot digest and extract the required nutrients from orally consumed food. Those bags cost Rs. 1100 each, and each bag had to be consumed in 24 hours after being opened. Rs. 1100 a day was a fortune for most of our patients, who, once they were on parenteral nutrition, usually needed it for at least a week, if not longer. This was our way of subsidising it, because these patients were also the most critical or malnourished and had significant other expenses to deal with.
The PBCF method worked well for bags of nutrition, certain paid blood products and even expensive antibiotics and surgical staplers. For the latter two, we had an alternative source, the medical representatives (MRs) of pharmaceutical companies. We would befriend and cajole these MRs for free samples for our patients in exchange for prescribing their signature products to ‘affording’ patients. There has been such uproar about the nexus between pharmaceutical companies and doctors, but this relationship seemed to me to be strangely innocent; no different from any of the other things we did to maintain our stock, which we maintained in the first place with the only purpose of having to hand anything a patient might need.
It was the responsibility of that lonely, underpaid, pathetic overworked creature, the house surgeon, to make available anything that their seniors might demand. Although it was often hard to fulfil these demands, looking back, I can’t say that any of them were tyrannical; these were just the things that were necessary to fulfil our responsibilities towards our patients with a reasonable standard of care. And the hospital and system we functioned in and under had failed to make provisions for these essentials.
It is hard to explain this unshakeable sense of responsibility; but perhaps I can share an incident that would help. My colleague had once donated platelets the day before a patient’s surgery for thalassaemia because there were no platelets to be found in any blood bank in the city nor donors, and we wanted to get that child through his surgery. I was ineligible to donate platelets and donated blood instead. This was not an unusual act among residents. Besides sweat and tears, they would literally sacrifice their blood to make sure a patient’s surgery went ahead. Many kind volunteers donate blood regularly. But to donate it on the peculiar diet of a time-short resident, who would go from donating blood straight to the ward for a 20-hour workday, is arguably in a different league.
Now perhaps it makes sense that I would unnecessarily take a call from a patient at 11pm when I was ill. This sense of personal responsibility had been tattooed into my psyche during my training. It is essential, of course, for doctors to have a sense of responsibility towards patients, but in my surgical residency, that house surgeon was responsible for the systemic failure of the institute, and the extremely wealthy municipal corporation that ran it, to provide for the needs of the poor who sought treatment within its gates. And yet, I defy anyone who has ever examined a patient after listening to their sob story; who has looked into the pleading eyes of their relatives; who has watched patient attendants survive on one vada pav, a fried potato bun, which is among the cheapest and most easily available street food in Mumbai, to do anything other than what we did, even if it appears in hindsight to be the moral equivalent of stealing.
Six months of my residency passed in the blink of an eye. Since we shuffled units every six months, I did my second post in a new surgical unit. I carried all the advice Dr S had taught me about being a good house surgeon into the new unit, save one: to eat a hearty dinner because it is the only meal of the day.
December that year was one of the coldest winters the city of Mumbai has seen in my remembered history. I was bogged down with work and had no time to eat even dinner anymore, so much so that I scarcely noticed that I also had no appetite. While everyone felt the unusual cold, I seemed to feel it more than anyone else. I would wear three or four layers of clothes until suddenly all at once I would be too hot and in fact burning up with high fever; then, I would rush to the ward side room to pull all the excess clothes off me that very instant.
Many years later, a patient whom I attended during this period hesitantly inquired if she could ask me a personal question; then, presuming on my ‘yes’ without waiting for an affirmative reply from me, she said, ‘Why did you change your clothes so often each day?’ I flushed with embarrassment; I had not expected my patients to have noticed or cared. At that time, though, the first people to be alarmed were the staff nurses; they often found me slumped asleep on the desk at the nursing station, sweat beading my forehead and dotting the area above my lips, breathing heavily through my mouth. They would rouse me gently and force me to drink a cup of warm milk to wash down a fever tablet because they knew I had skipped dinner. Then they would send me off to sleep in my hostel quarter, gazing worriedly at my retreating slumped back.
The next set of people to notice my unwellness and worry about me were my coresidents. They forced me to get a chest X-ray done, assuming, rightly, as it turned out, that I had contracted tuberculosis. The fever, loss of appetite and unintentional weight loss should have cued me in, but I clung instead to denial, using the absence of a cough to lend it plausibility. When the first X-ray appeared to be normal, my coresidents persuaded me to get another one done. Then they argued with the radiology resident, who reported even that second X-ray as normal, and made him cross-check with an ultrasound. The radiology resident exclaimed as he moved the probe over my chest and back; there was thick loculated fluid in the lining outside my lungs, the pleural cavity. Scornfully ignoring him, my mates took me and these reports to the assistant professor of my surgical unit. A CT (Computerised Tomography) scan confirmed the diagnosis of tuberculosis; it was confined to the pleural cavity. Since it did not affect the lungs themselves, and I was not coughing, I was not infectious, not a potential source of tuberculosis that vulnerable surgical patients could contract if exposed to me.
I took a week off work to start the treatment course, four drugs daily for two months and then two tablets a day for the next four months; this was the standard drug regimen for tuberculosis. The pulmonologist advised me, like he would any other patient with tuberculosis, to take all the medicines except one with meals and to consume an acid suppressant, for the tuberculosis medicines were harsh on the stomach. I followed these instructions scrupulously for a fortnight, and then, as I got right back in to the swing of residency, I reverted to my ingrained eating habits and work pattern and popped all four pills together, on an empty stomach, with no breakfast and no acid suppressant either, joking instead that my stomach was lined with lead.
Nothing we do is without consequences, and my stomach was certainly not lined with lead. Though cured of tuberculosis, my stomach paid the price for my casual attitude to regular meals and bravado about the tuberculosis antibiotics a decade later. My digestive apparatus broke down when subjected to a similarly stressful situation which I had been trying to power through with multiple shots of tea and coffee.
It took me months to get through these stomach issues and get back into the OR. Not only did it take bland food and swearing off the caffeinated beverages, it also took support, understanding and genuine caring from the people I worked with at the time. I would not have overcome this illness without cofellows and junior fellows who took up the slack on the work front. My mentors and guides allowed me to return to the OR in my own time, encouraging me in the meantime to at least show up to work and sit in the changing room; the nurses would come and talk to me while I sat idly this way. They made me feel cherished and cared for instead of lazy and weak for being ill. In my time off work, I took up meditation, and that helped calm my highly strung nervous system and supersized emotions. Later, when I was stronger, I started recreational running, and the endorphin high cleared my mind and refreshed me.
‘Physician, heal thyself.’ I have heard that phrase often enough, and just as often, I have ignored it. So have other doctors. Medical professionals are well-known for doling out advice that they themselves never follow. Physical and mental illness is so rampant among doctors that the moniker ‘wounded healer’ is apt.
But it is not just doctors who are unwell. The medical system in large parts of India, and dare I say, in many countries of the world, is itself an ailing entity. Doctors and hospitals are the vanguards of the health of the community. Without systems in place that can account for most, if not all, eventualities, the burden of failure of the medical establishment will fall on individual doctors. This not only adds to their burn out and ill health, but the consequences of the fallout are borne by hapless patients who have nowhere else to turn to. This scares me, and yet, it also motivates me to write about these issues. Having borne, in my body, the consequences of excessive personal responsibility and having healed through the help of a caring community, I have learnt the value of well-thought-out systems.
I feel a different sort of responsibility these days, to speak up about these issues which are not well-known outside medical circles and are ignored inside them but that, nevertheless, affect society more widely than we can imagine. This account is an attempt to live up to that responsibility.
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