Friday, October 28, 2011

Tearing through the night

Today I present to you a medical tale, in three parts, which was sent to me yesterday via email by someone who calls himself Dr M, in response to my call for guest posts. He sent me a short profile about himself when I requested it:

Dr M is a medical intern at a Government hospital in a metropolitan city of India. He is slightly obsessed with all things medicine, and socially inept otherwise. He loves taking risks and is known to frequently take leave of rational thinking. He often seems to lack a sense of self-preservation. He used to sketch well in his childhood, but later gave up on sketching as he thinks no one in this world is worth sketching anymore. He also feels that the need for love and the need for food are complementary to each other, so he stuffs himself with a lot of food in order to balance out his need for love.

After enjoying reading the story he sent me so much, I was more than eager to publish it. The story will be published in three parts, one part each day, starting from today.

Warning: People outside the medical fraternity, read this story with caution. It is full of difficult medical terminology and gore, and might scare you off doctors for life.

Tearing through the night: Part I (by Dr M)

At a distant peripheral health center in an Indian village, it’s 6 in the PM and Dr M is in-charge tonight, alone. Desperately hoping for some action in the seemingly boring night shift ahead of him, he happens to overhear the staff talking about a woman admitted in labor. He doesn't say anything, finishes off with his dull patients and quickly checks on the patient in the labor room without the knowledge of the nurse. A 25yr old, second gravida with contractions 30 minutes apart in no distress at all. With this brief information, he says to himself "There is still a lot of time to while away".

He goes back to his chair - a comfortable blue reclining chair with adjustable height which also rotates. He plays with the height and rotation, changes his moment of inertia, observing the change in angular velocity. His thoughts jump to the unification of electromagnetic and weak forces and how it was explained on the basis of energies at different speeds of rotation. These flights of thought are interrupted by patients, again. Routine injury cases, nothing to do. Reassuring them that their injuries are nothing serious never worked, and eventually he was forced to yield to their perceived need for a parenteral analgesic.

He looks behind him, realizes that the patient will be pricked by a used needle, sterilized only by dipping in spirit for the amount of time allowed between two patients asking for the same drug. He also realizes that there is nothing more he can do. The patients know for a fact that Dr M is here only for this one night, and their tone of voice reflects the confidence in their demands and the lack of trust in Dr M. Maybe they will realize their mistake when they contract HIV and the source is unknown, he thinks with a shrug. Unlikely even then, he knows. Dr M prescribes with a heavy hand, going against his principles, and calls the next patient to the chair.

Amidst all this the nurse comes in and takes the sphygmomanometer and walks away, Dr M knows why, or at least he thinks he knows. The nurse comes back, keeps the apparatus in place and goes back to her chair, but then comes back once again in half a minute and in a low voice says "Sir, a patient has been admitted, she is in labor. At admission her BP was 160/80 and it is still the same. What should we do? "

Dr M raises both his eyebrows, wrinkling his forehead to give a look of concern, one that shows him looking startled. The forehead gradually clears as his eyes close, and all that can be seen through his glasses are closed eyelids that appear smaller than they actually are without any activity underneath. He is listing in his mind the problems the patient could have, and what he is supposed to do, as he gets up from his chair and approaches the patient. The thought process continues as he grabs the BP apparatus and walks hastily with the nurse towards the labor room, while the other hand supports the stethoscope hanging around his neck. Some would not even call this patient a patient, thinks Dr M. They would argue that pregnancy is a part of normal physiology and not a deviation from it. Well, for all those, the pregnancy in question was no more normal, and she was now a patient by all definitions, Dr M thought to himself with satisfaction.

As he nears the patient and starts securing the BP cuff around the patient's right arm, he hopes the BP would be actually elevated and not an error on the nurse's part. The mercury is at 170 when he starts hearing the taps. Dr M is delightfully distressed even before the taps; he had already felt the pulse even as the mercury rose to 160. He informs the nurse, in a pseudo-forced tone, a tone that would not divulge his joy, that the BP was 170 over 100 millimeters of mercury. Dr M asked the nurse if there was any Aldomet or Nifedipine available. On receiving a negative response, he went back to his desk and wrote a prescription for Nifedipine 10mg. The patient's husband took the prescription in his hand and tried to read what appeared to be something scribbled in a flow. Dr M explained to him why that drug was required and its urgency. Also scribbled in the prescription was Hydralazine and MgSO4, which Dr M explained the husband, had to be checked about for availability only, and not to be purchased as of now. Dr M then goes back to the patient, this time with a full formed set of questions in his head.

After about 10 minutes, the husband returns. By now he has gathered that the patient has conceived after 11 years and has had no antenatal care till date, with her first delivery being at home. She had an uneventful current pregnancy except for the bilateral swelling of feet that comes and goes with various factors  that the patient hadn’t paid attention to. Dr M is told that there are no sterile, packed needles available when he asks for them, and is told to use ‘autoclaved’ ones instead. Dr M lets out a sigh on hearing this, not because of the non-availability of sterile needles, which he had expected, but because he hears about the so-called ‘autoclaved’ needles. He uses an 'autoclaved' needle and places the capsule under the patient's tongue, instructing her not to swallow it as a whole, all the while hoping his instructions weren’t going to vain. He checks his wrist watch, the two arms of his watch were apart by 2/8ths of a circle and the hour was 6th. He wore this same watch all the time, felt incomplete without it, and yet he maintained it poorly.  Dr M elevates his right arm to visualize his watch again, this time noting the FHS, as, unsurprisingly, the Fetal Doppler at the facility isn’t working.

Dr M informs the nurse that the FHS is 130, and tells her that he wishes to do a PV exam. 2FT/O/engaged/intact is what he jots down on the paper over which he decides to record his findings throughout the course of labor. The nurse seems tense, and informs Dr M about a referral center that has dedicated labor services and an obstetrician, 10 minutes away from their centre. Dr M had already anticipated a concern for referral and was prepared with a confident explanation against the same. He wilily imparts only selected information to the nurse about the implications of the case, so as to ensure she does not bother him too much. She then asks if the senior in-charge should be informed, and is quickly dismissed once more by Dr M. Finally she asks if Dr M had conducted a delivery before and if he could handle this one. On hearing an affirmative reply to the last question, the nurse informs Dr M that she will be leaving and another nurse will come for change of duties.

It is 7:15pm now; the new nurse comes in and informs Dr M that she has had very little experience in delivering. She walks with Dr M as he enters the labor room again; he records the BP and renews his faith in medicine on noting that BP is 130/80, FHS 120, P 90. As the nurse tries to monitor the patient, Dr M soon realizes that she doesn’t even know how to record BP, and has no idea what the normal range for BP is. And here he had been thinking that he would learn from her the palpatory method of recording BP that he had always wanted to master, since she seemed to know it well, at first glance. Now Dr M can feel his hopes getting crushed. He then takes over the apparatus with resignation and operates it, all the while explaining to her how to record BP.

Another PV exam record reads 2FL/1/engaged/intact in Dr M's paper with a BP of 130 systolic. He goes back and orders slow sips of water to the patient. Between half hourly exams Dr M fiddles with his cell phone, browsing the net, chatting, and getting advice for further events which were to be expected. In fact his phone was irreplaceable to him and he had gone great lengths to get it back. This was, as he understood, the reason for his sanity over the past few weeks given one of his vitals was not available to him. A repeat exam at 8:45 gives him a scare. BP is 150/100.

Tearing through the night (Part II)
Tearing through the night (Part III)


  1. Why not labetalol? Would have enhanced uterine contractility too instead of the tocolysis provided by nifedepine.

  2. Look forward anxiously to preceeding posts

  3. Sorry not preceeding but forthcoming next posts

  4. sphygmomanometer... umm toxic.. :P And Dr. M might have to be Superman to help the needy :D

    Weakest LINK

  5. @mkk: I haven't written this, so I have no clue why Dr M didn't use Labetolol. My guess is that it must not have been available.

  6. Dear aayushi
    wonderful story..........wud like to read whole case..plz post soon next tale..

  7. @anonymous #3: Blogs are not for you then.


  8. The big lesson i learn fr ths blog s tht its better to shout on ppl if they dont listen to ur soft word so as to prevent bigger loss to happen,u may say sorry afterward.Dr.M u r most welcome to share ur experiences over here.