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)

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)

Doctors: The Origins

So, how do people decide that they will become Doctors? Do they even decide that at all? What drives them, what inspires them? Ever wondered? I'll tell you how.

When you first thought about becoming a doctor, you must have been a bespectacled (or not) school kid bent under the weight of your school bag, who wrote an essay about "What do I want to become when I grow up?" (Obviously, everyone wrote that they wanted to become a doctor, it was the noblest profession of all, and the teachers and parents loved it!). However you may have ended up being one of the few who actually remember that essay from your school notebook, and then actually follow it in real life. You actually tried to become a Doctor after you got out of school. You remembered what you'd written.

Or you may have been a teenager who had lots doctors in the family, and it was always understood and assumed that you would carry on the tradition. Hell, you don't even have to think about it! It's in your genes. And, if your family's rich enough, you don't even have to get the marks for it! One way, or another, you find your way into a medical college.

It could have been your parents' biggest dream, you've heard them say, all your life: "Mera beta bada hoke Doctor banega" -  to the neighbour, to the relatives in the U.S., to your Daadima,  to the postman, to the God in that tiny roadside temple, to your friends' mothers, and anyone else who happened to listen. After hearing it being repeated to you for umpteen times everyday for 17 years of your life, how could you even have thought of anything else but to be a Doctor?

Another scenario would be that you had a life altering experience. Your loved one, a family member, a friend, or even a perfect stranger, could have suffered from a disease, borne a loss, could have died. You watched them go through it. There was nothing you could do. You decided, that day, you would change the world. You would not let that happen to someone else. You would become a Doctor.

It could have been that you were sailing through your life, carefree and clueless, as to where you were headed, you know, just enjoying the ride. One fine day, someone (could be absolutely anyone) happened to mention: "Hey, why don't you become a Doctor?" and you sat and wondered, "Yeah, why not?" And so you went about becoming a Doctor.

You could have been one of those hardworking, sincere competitive people. The ones who gave all the exams that came their way, because they loved to. It was their birthright to give exams. So, they ended up giving the entrance test for MBBS, and voila, they got admission (coincidentally or not), and then they puffed out their chests, and proudly, went on to become Doctors, and gave loads and loads more of exams.

Then there are some who are just plain masochistic. They see someone who's a doctor, slogging, working hard all the time, buried in books and patients, with no signs of a life, and they think: "I want that! Looks like so much fun! I'll torture myself, and one day I'll become a Doctor, and it will be awesome!" There goes.

Others get drawn in by the glamour. Their Doctor charges in four digit numbers for a 15 minute consultation, lives in a duplex flat, has bungalows in all the nearby hill stations, plays golf on the weekend, hob-nobs all across the world like he's taking an evening walk, and drives sports cars. Hell, who wouldn't want that?  So they decided to become a Doctor, and get that.

And then there are the few who actually develop an interest in science and medicine, they wonder about the sound of the heart beating through the stethoscope, the feel of the pulse thumping under their fingertips, the cold handle of the scalpel on their palm, the mystery of the shapes they see on the X-ray. They wanted to know more, they wanted to learn more. They were curious, and eager, and excited, and passionate. So, they became Doctors.

These stories are how most Doctors originate, that's how take birth. And then, provided they have the IQ, or the monetary power, they enter a medical college, and begin their journey.

What is my story? Well, I was a confused teenager, who didn't seem to have any particular interest in any vocation. My mom said, "You're intelligent, you should become a Doctor" (like all Moms should tell their kids). A Vocational Guidance Counsellor told me, "You're a lazy bum, incapable of studying for 8-10 hours a day, and slogging. I strongly advise you against becoming a Doctor." I looked at her with hatred, joined coaching classes for the medical entrance test, made it through with difficulty (the difficult part was altering my 'I never study' lifestyle) and managed to get admission into a medical college.

And then, all hell broke loose! But that story is for another post...

So. If you're reading this, and if you're a Doctor, tell me your story. How did you end up becoming a Doctor? What was your origin? Do you know other interesting stories I may have missed out? Or do you not agree that this is how Doctors are born? Let me know.
If you're not a Doctor, tell me what do you think about this. Is this why people should become Doctors? Or are these reasons not good enough? What's your opinion? Let me know.

Till later.