Sunday, October 30, 2011

Tearing through the night (Part III)

- Written by Dr M.

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

After much manipulation and struggling, when Dr M managed to pull down the cervix, he saw a full thickness tear on the left lateral cervical wall, along the whole of the vaginal part of cervix, about 5 -  6 cm in length. He had never seen a cervical tear before in his life. Definitely not a full thickness one like what he was seeing. He now wonders for a while how he can repair the tear in his current situation. The cervix is no more continuous, no more cylindrical. Tear is too small a word to describe the magnitude of the injury. Rupture can come close, perhaps. Dr M demonstrates the tear to the nurse and explains to her that repairs of such injuries should ideally be done in the OT, with anesthesia, good light, proper retraction and most importantly, by an obstetrician. He then tries to just pack the vaginal vault, and wait for hemostasis, but the patient continues to bleed profusely. She must have bled at least a liter of blood by then. She looks pale, shivering, pulse 90 and thready, but BP is stable at 110.

Second pint of RL is dripping through the small blue scalp vein now. The nurse becomes presyncopal looking at all the blood and sits down on the floor. This is the second time she has become dizzy that night, as the patient continues to drench many a dupatta with blood. The nurse once again asks anxiously, the same question that she has asked multiple times that night: "Sir, you will be able to stop this, right?” Dr M's answer to that has now changed from a strong and confident 'yes' to a small, hopeful 'yes'.

He requests the nurse to call the senior in-charge, it is 12am. After repeated pushing of the redial button, the senior answers the call, and Dr M explains the situation and says that he can attempt to close the cervix but he may not be successful and without proper retraction it would be very difficult. Dr M gets the green signal. But then, he already knew he would, which is why he had called the senior at this hour. Who would not allow a repair at this stage, when the patient is actively bleeding to the extent of going into shock, at midnight, and at a place from where transportation to a higher center was impossible? Dr M just required this permission so that he was in the clear if anything went wrong, and he got it. Perfect timing, he thinks. Dr M is now relieved.

Dr M jokingly asks for a gown. He is amazed when they actually bring one. He changes his gloves, of course the gloves are also being reused after 'autoclaving'. As he puts on the gown, the lights go out. A single tube light at the patient's head end starts to ionize the gas inside it. This still means it is dark at the working end of the patient. Dr M always carries a torch in his pocket; it has other uses as well. This was not the first time the torch had come in to save the day. Few months back it had helped in a taxi delivery at his parent hospital. Dr M uses the needle holder to remove the No 0 chromic catgut, holding the round bodied 3/8th circle needle. He rubs the 40cms of the thread with isopropanol based solution and keeps it aside. The peon holds the torch, the nurse holds the Sim’s and AV retractor, the assistant holds the sponge holder and volsellum attached to the torn ends of the distal most cervix, the mother-in-law holds one of the patient's leg onto her chest while the other leg is held by the patient herself.

Dr M still isn't able to visualize the apex of the tear as the retraction is insufficient, he can barely see the tear at all. He adjusts the retractors again and asks the nurse to hold still and give fundal pressure to cause descent of cervix; it works to some extent. He takes the sponge holder in his hand and gives the first bite to the anterior end of the tear, exchanges the sponge holder for the volsellum and finishes off the first suture with three throws. As he starts to readjust the retractors and forceps, the assistant pulls on to the volsellum too hard and unknowingly takes a part of cervix along with her. New bleeding point. Luckily this is easily visualized and closed with a single interrupted suture. Dr M continues to toil, trying very hard not to shout at the nurse. How does one not learn how retractors are to be held, he wonders. After the second suture, Dr M's right hand starts to ache. He had fractured one of his metacarpals in a boxing match few days back, remembering that match brings back good memories. After the 5th suture at the distal most part, there is no more active bleeding. It is 1:00am now. The patient hasn't passed urine and her bladder feels empty on bimanual exam. He orders a pint of NS after the RL and then leaves, saying "We will wait for 15mins to confirm hemostasis".

As he waits in the gown sans the gloves, he chats with his colleagues about the events that ensued. They make him realize that he has forgotten about the infant, and that feeding hasn’t been initiated. They wonder for how long the infant can survive without the first feed. The mother is hypovolemic and in too much pain to begin feeding. There is nothing he can do at the moment. Dr M looks down at his brown leather shoes, there are blood stains over them. All his attire is in shades of brown that night. Auburn colored pants, dark brown belt and buff brown shirt. He is regretting not clearing his shoes from the path of blood.

He goes back to check on the bleeding, there is none. To be safe he wants to pack it with tampons. Tampons this time are recovered from the floor. They are previously used ones, and have been soaked in phenol and then Betadiene. Phenol came into the picture when the nurse confused phenol for Betadiene and poured some over them instead of Betadiene. Dr M is forced to use those phenol drenched tampons anyways, since he has nothing else to pack the vault with.

Dr M is reminded about the Pepsi he had bought by the peon. He goes to the refrigerator located in the dispensary and has half of it. 20 minutes later the tampons are removed and they are soaked in blood. So they start exploring again. Dr M decides to take few more stitches even though the patient begs him not to. Every time retractors are placed she winces in agony. Two relatives are now required to hold her down. Dr M picks up the catgut, it has dried up and there is no more solution left to wet it. With great difficulty he maneuvers it through the tissues in spite of the great deal of friction. He applies two more sutures and that’s as far as he can go. He knows for a fact that a 100% hemostasis will require going up to the apex, something that is out of the question in his situation. So he stops. There is still some minimal bleeding for which there is nothing he can do except pack the vault again, with used tampons and cotton ie. He allows moving the patient out of the labor room and prompts her to initiate feeding, and starts a pint of DNS as well. The infant takes up feeds well. Dr M removes the gown which he was told will be reused in the future. He doesn’t ask how it would be washed or sterilized, he knows the answer. As everyone retires to their beds, Dr M goes back to his cell phone, searches for causes and prevention of cervical tears. He wants to know if he went wrong somewhere. Turns out there was nothing much he could have done to prevent the tear, except maybe he could have been harsher to the nurse and assistant for their fundal pressure practice. Another breath of relief and then Dr M too retreats to his bed at 3:30am.

In the morning, his alarm will ring at 6:10am but he is up a few minutes before that. Soon he goes and checks on the patient. Subjectively she is fine and so is the infant. He can't examine her without the nurse present. She is sleeping, so he goes off to stroll in the farms nearby, looks at the sunrise and thinks to himself "This is a day that follows a night of no losses, no regrets. It was a great night, perhaps the best till date".

When the nurse wakes up, they go to examine the patient. The packing is soaked in blood but that is it, no active bleeding at all, and the most satisfying part is that she has passed good amounts of urine. The infant too has passed both urine and stools by now and OPV is administered. Dr M writes puerperal orders and generous analgesics and antibiotics to cover all the infections he can think of. He waits for the senior doctor to arrive and give him the thumbs up to leave. He gets done with one bottle of Pepsi and opens the other. At around 8 am, another patient in labor comes in. Gravida 4 this time, with contractions every 5minutes. Within half an hour she is done delivering, very uneventfully that too. Very vanilla. Good for the patient, as there isn’t a single unused piece of equipment left at the centre. Between then and 10am, two other patients come in with vague complaints, then turn out to be UPT postive. Coincidence? Whenever Dr M thinks about coincidence, the words of Dr Sheldon Cooper flash before him: "Coincidence is for those who don't understand the law of large numbers".

Saturday, October 29, 2011

Tearing through the night (Part II)

Tearing through the night (Part I)

The new nurse panics and requests Dr M for a referral or to at least call the senior in-charge. Both are politely denied. Another dose of Nifedipine goes in, and the increase in duration and frequency of contractions is reassuring. Dr M at this point consults his colleagues. But he has already decided to accelerate the events of labor. He thinks about artificially rupturing the membranes but then decides against it and is fixed on only stripping them for now. He starts creating a partograph of the data he has gathered. Graph makes it obvious that the labor is progressing normally, but what bothers Dr M is that it will take another 2-3 hours at this rate. By 9:45pm, the cervix is fully dilated. Dr M now approaches the relatives, explains the high risk and the chances of poor prognosis to them, and that referral is required urgently. Of course, he knows very well that they will not agree to it, now that she is so close to delivering, no matter how near the referral centre is or how the grave the patient can become. The same was presented in writing and without hesitation they signed the high risk/poor prognosis write up. A grin appears on Dr M's face, it grows in size as he turns away from the relatives and walks towards the patient. Dr M is now getting all the action he hoped for at the start of the night.

Dr M swabs the perineum, albeit not liberally on account of limited betadiene that is left, introduces two fingers and gleefully strips the membranes off the lower uterine segment.

Back at his table, Dr M is approached by the peon who offers him food from his own house. By the time Dr M realized it was time for food, everything around had closed down, so he had been prepared to fight the MMC that would eventually come to trouble him. But of course Dr M couldn't turn down such an offer, so he agreed to eat with the peon. They were joined by the nurse and another assistant. During dinner conversations it became known that the assistant was asked to come over by the nurse as she had been present in a number of deliveries at the centre. Dr M didn't mind. He was open to any help he could get, but none that would interfere with his autonomy.

After dinner, Dr M goes out to get others and himself a bottle of Pepsi. The general store is a 5 min walk, but has closed down by then. The shopkeeper is there however, and recognizes Dr M. Turns out he had come in the late afternoon that same day with his son who may or may not have swallowed a coin, to the centre. He opens the shop; Dr M buys two bottles of Pepsi, a liter each. As Dr M walks towards the health center, he is greeted by many who invite him into their homes. It is an auspicious night, a night of celebrations. That is another reason why Dr M wants to hasten the delivery, besides him being bored of repeated observations of course. The fetus could be born on this auspicious night if his efforts are successful. Not that he cares when it is born. Yes, Dr M referred to fetuses as 'it'.

Back at the centre, he can't find anyone. He grabs his stethoscope and rushes to the labor room. Stripping has worked. Labor pains have accelerated, membranes have ruptured and liquor is clear. She is getting contractions every 2 minutes lasting half to a full minute. Prior PV exams had confirmed vertex presentation in occipitolateral postition. On PV now, head is well flexed and internal rotation has occurred. Her contractions and efforts to bear down forcibly are disproportionate to the outlet provided by the perineum, as a result of which caput is evident over the occiput even before crowning. The assistant starts applying fundal pressure. Dr M instructs her to stop, but she continues anyway. The mother was getting exhausted and crowning wasn't occurring. She had already taken many a hit from the peon and assistant. Dr M, though violent by nature himself, contributed nothing to that. On the contrary, he asks them to stop hitting her. They slowed down. Dr M at this point expresses his concern that an episiotomy will be required. The nurse remarks that they aren't ready for it and that nobody has ever performed an episiotomy over there. So the labor continues in the same way and forcible crowning is achieved after which the neonate is delivered.

No cord cutting scissors or cord clamp is available. With a suture cutting scissors, the cord is cut and ligated with two ties. A female neonate is delivered at 10:30pm weighing 2.6kg with caput and acrocyanosis. APGAR at 1 and 5 mins were 10. Placenta was delivered 15 minutes later and it was evident that a segment of it was retained. Dr M inserts his hand inside the uterus and removes the retained placenta, and whatever clots he can discern. Bleeding still doesn’t stop.

He orders 4 misoprostol tabs and gives them orally to the patient. There are no other oxytocics available. Half an hour later, the bleeding still continues. Dr M once again introduces his hand to inspect for clots or placenta, none found. The uterus is well contracted and hard to feel on PA exam. Dr M now starts swabbing the vaginal walls to inspect for tears. Swabbing is done with cotton, as gauze is not available; this leads to strands of cotton fibers being stuck everywhere, on the vaginal vault, on the instruments, on the gloves, all mixed with blood. It is difficult to work in the bloody mess, but Dr M manages somehow.

Vaginal walls seemed intact after inspection. Only plausible option now was the cervix. What worries Dr M is the possibility of coagulopathy. There is nothing he can do for that and from what he has heard, the referral unit doesn't send help after 10pm, another thing that he had been informed of and had ignored earlier. When Dr M asks for speculums and retractors, the staff looks at him as if he had spoken in an alien language. He instructs them to get all the instruments they have along with a veinflow, RL and Foley's. They return with two instrument trays, a scalp vein, DNS and nothing instead of a Foley’s. Apparently those are all the obstetric instruments they have. Dr M searches for an RL and startsa pint. He inserts a Sim’s and an AV wall retractor and can now see the cervix. He tries to teach the nurse and assistant how to hold them, and fails. With great difficulty the cervix is held with a sponge holding forceps and a single volsellum. There is no other atraumatic instrument available. Small tears are found on the anterior and posterior cervical walls. On swabbing them, none bleed actively. Dr M starts walking around the cervix with the sponge holder and is shocked to his core with what he finds over there.

Tearing through the night (Part III)

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)

Thursday, October 27, 2011

The Nairite's guide to rural posting

1. Attend your rural posting at Ganeshpuri. Take those twenty days off from your year of internship and whatever it is that you're doing with it, to attend this posting. It really won't make any difference in your entrance exams, but it will make a lot of difference in your lives.
2. Pray that you have great batchmates. You'll be living with them for twenty days, and not having a good batch sucks. That said, it is very easy to bond with almost anyone, including the weirdest alien in your class, during these 20 days of your rural post. So give it a shot. You may just acquire a brand new set of friends.
3. Don't run home on the weekends. Takes out all the fun from the posting!
4. Go for early morning walks, to make the most of the best weather in the day and the fog. Though I wasn't posted there in the summers, so I can't say how the weather will be in summer (from what I hear it's unbearably hot in the daytime during summers).
5. Every night, climb up to the terrace and watch the stars. If you're a girl, throw the guys out of their hostel so as to get access to the terrace.
6. Places to visit: Usgaon dam, river nearby, bridge in the market, Vajreshwari temple, hot water springs, Akloli kund, Gorad village for Warli painting, Great Escape water park near Parole, and Mount Mandagni if you have suicidal tendencies.The village is a great place to buy some Warli merchandise.
7. In the midst of all this, do not forget to attend your postings.
8. While at Ganeshpuri you will experience a new high in the quality of drugs available, at Parole you will experience a new low in the quality of drugs as well as medical care available. Experience both.
9. You will get a chance to sit in the ART OPD, I think this is the only time you get this opportunity in internship. You get to see follow-up cases of HIV patients, deal with their complaints, learn about the side-effect profiles if various anti-retroviral drugs. 
10. If a certain pan-chewing MO asks you to take off your apron (female interns) tell him to take a hike.
11. You will get many opportunities to learn a lot of new things, don't waste them.
12. Cook often, if you posses any culinary skills. Otherwise, eat at the local restaurants.
13. Go snake spotting. Also revise how to treat snake bites before you do the same.
14. Go with the mobile unit for medical camps to obscure, untouched villages.
15. Experience personally the Indian people's belief in black magic, till date, as a working cure to all disease.
16. Learn the way of life in a village. Wait for hours for ST buses, stuff yourself into share-e-rickshaws, have random conversations with old ladies you are very likely to meet, and do everything slowly and without a care in the world. Forget that you live in an instant age, for once.
17. Ride the bicycle everywhere, if, unlike me, you do know how to ride one. Easiest and best mode of transport you are likely to find.
18. Do not try to find cake or cheese or butter in the village. All attempts will be unsuccessful. Ice cream, though, you are likely to find.
19. Do not forget to look for fireflies. You will definitely find one. Or tons of them. Depending on your luck.
20. Go with old friends for this trip, or make new friends. Either ways, it will be a memorable affair, that, I promise you.

Sunday, October 2, 2011

Movie Review: Drive

Drive tells the story of a man we know only as 'Driver' or 'Kid' (Ryan Gosling, of Half Nelson fame). Driver is a man of very few words, with a toothpick sticking out of his mouth, and a wide eyed non-judgmental look at the world most of the time. He works as a getaway driver for criminals, as a stunt driver for the movies, and also as a mechanic at a garage. He mostly does what his boss tells him to do, he gives his criminal clients a strict 5-minute window period to avail of his services, and he performs his stunts with unnatural nonchalance and precision. He also has a liking for an ugly silver jacket with a scorpion on the back.

Soon, Driver meets his neighbor, Irene (Carey Mulligan), eavesdrops over her and her son in the supermarket, plays staring games with the son, and well, begins to fall in love with the neighbor (or so we're told). Driver continues to behave like an innocent child who doesn't really know how to react or what to say in a situation like this. There's a scene where both the leads just keep smiling alternately at each other, for at least 5 minutes, and though you laugh initially at all the sweetness, you just wish someone would get on with it.

The entire first half of the movie plays out with minimal dialogues, a captivating background score, and a slightly irritating song called A real hero playing multiple times throughout the movie, each time while Driver is doing stuff which the director thinks would make him look like 'a real hero'. The first time especially, it just ends up looking super-pretentious. Every time Driver opens his mouth and actually says something, it comes as a slight shock and an achievement, since he looks like he is incapable of uttering any words.

Though nothing much is really happening in the movie in the first half, everyone seems to be overstrung, both the people on-screen and those in the audience. We know something is going to happen, so we watch and wait. I spend most of the time trying to guess which psychiatric condition Driver has.

Soon enough Irene's husband, Standard, is released from jail, and comes back into their lives. He is in trouble and is being blackmailed by some goons. When Driver realizes that Irene and her son are in danger, he decides to help Standard out in order to save them. But, things start going wrong, and that's when you sit up in your seats and start enjoying the movie.

There's a scene when half the theater jumps out of their seats, which signifies the start of the second part of the movie with its uninhibited violence. Thus begins a series of kills, and every time a person enters the frame from that point on, you can't help but hold on to your seat and wonder how he is going to die. The violence, the sheer amount of controlled and ruthless rage which Driver displays, and the novel ways in which people are killed without the use of firearms, is, according to me, the USP of this movie.

Driver manages to look devastatingly terrifying, which is a wonderful contrast from his innocent wide-eyed look in the first part. There's a sequence where he wears a mask and kills someone on the beach, it is so brilliant, you should go watch the movie just for that sequence. There are also two brilliant car chase sequences in the movie, likely to leave you open mouthed with awe.

Ryan Gosling acts fabulously well, and so does most of the supporting cast. Carey Mulligan does nothing much but stare at Driver. This movie isn't good or bad, it is an experience, and one I think you should have. Don't expect entertainment, don't expect a sweet romance, don't expect an action movie with a hero who punches everyone and then gets the girl. No. Expect something different, and, in it's own way, beautiful. You'll be glad you watched this movie, if nothing, just cause you got a change from our regular fare.

Rating: 8.5/10.