Unfulfilled Dreams.

Little ones who did not see the light of the day,
From tiny undefined forms in gray,
To well formed twins in full bloom,
Sat snugly encased in their mother's womb.

For nine long months, she waited with bated breath,
As weeks turned into months, the belly swelled
In hopes of pink and blue, the young mother dwelled,
Alas, she only saw them after their death.

Young and naive, she felt their plea for help,
Day after day, she heard their beating hearts aloud,
She pleaded in vain for them to emerge from her womb,
But alas, she would only see them entwined at their tomb.

In the memory of the unborn twins of S, who could have lived.

The Lessons and Learning in Medicine (2)

As the days wore on, we had an established pattern among ourselves to divide the duties. Of course, there were differences of opinion but somehow we managed to work it out in the better interest of the patients. There was no time to hold on to any disappointments because on duty day, you are always on your toes! A particularly fond memory I will hold is of finishing the rounds and catching up with Sanjana C, my co intern over the cases and how their treatment was progressing.

Rounds with each professor was a different experience. While some looked at the investigations to have a clear-cut evidence to their probable diagnosis, others relied on clinical features to base their treatment. While some discussed rare or important diagnostic features and 'never to miss features', others preferred to leave it open ended with questions to ponder over and get back rather than supply the answers themselves. On the whole, rounds was when we had an idea how each consultant would approach the same case and thus develop our own blueprint.

Thank you Sir :)

There was Sahana, the 19 year old who has been a puzzle I couldn't figure out. She came with icterus, h/o fever and passing high coloured urine and bilateral pedal edema and her Liver Function Test was completely deranged. She tested negative for Hepatitis B and Hepatitis C and her USG abdomen showed mild ascites and pleural effusion and her CT scan correlated with this. While her pedal edema decreased during the course of her stay in the hospital, her LFT did not show any improvement and hence her icterus remained.

Being a government set up and the festive season, the test reports for Leptospirosis and Hepatitis A were postponed and we had to discharge the patient and review with the reports. I did not have much hope of seeing her again but imagine my surprise and relief when I received a call (I still have no idea how her mother caught hold of my number) from her regarding her reports nearly a week after her discharge. We finally had a diagnosis! What I had suggested to the professor (after seeing in the Micro Lab that they carried out these investigations) actually turned out to be a valid diagnosis. She finally had a diagnosis! Hepatitis A it is and she was asked to review on a monthly basis with LFTs.

There was the patient with massive pleural effusion and my co intern and I did a pleural tap which yielded a straw coloured pleural fluid which on analysis had high levels of ADA (Adenosine DeAminase) which is an enzyme elevated in Tuberculosis.

Then there were the suspected cases of H1N1 which required early detection and intervention to prevent fatality. There had been a few suspected cases which went undetected and they had succumbed to secondary bacterial infection which ultimately led to respiratory failure. The protocol involves isolation of the patient in a separate ward, taking a throat swab and sending it in the VIM container to the DHO office who would then courier it to the Viral Research Centre of KMC, Manipal. The patient is usually started on 2nd line (failing which, 3rd line) antibiotics along with the antiviral Tamiflu  (Oseltamivir 75mg) and continuous nebulization and O2 inhalation. There have also been a few cases which were recognized early and treated accordingly even without the throat swab reports since that had been getting delayed.

Just when I had begun to regret how I had not performed an ascitic tap in the course of my medicine posting came a case on our Pre Duty day of Cirrhosis with gross ascites. As is the procedure we start the patient on appropriate medication to increase the fluid loss and also perform 'paracentesis' to drain the excess fluid from the abdomen which may be from 1-2L at a time. Unfortunately, the primary diagnosis of Myxoedema Coma couldn't be treated in time and she did not make it.

There are some moments when you know that under different circumstances, your patient would have survived; be it the young man with a haemorrhagic stroke who was referred back from NIMHANS who developed further complications and had massive internal bleeding and succumbed to it or the other young patient, again referred from NIMHANS for myoradiculoneuropathy and dysautonomia who was on ventilator support after he was here and had renal failure in a matter of time and he had a cardiac arrest soon after. There are several limitations in the set up so you know you are bound by those restrictions but it is the ones who can make it with the existing facilities who must not be missed!

Towards the end of my posting, I also had an experience of 'Protocol Duty' which is basically a duty doctor being available at all times to any
Politically Important Person (PIP) like the CM or the Ex PM or a certain MLA who were on a visit to the district. While it was mostly uneventful and spent in the sweltering heat of the ambulance understanding how bureaucracy works, it also gave an opportunity to visit the Hassanamba Temple which thronged by visitors when it is opened for a few days in the year.

But it was the last day which truly lived up to the intensity of Medicine duty with several MIs, CKDs and poisoning cases, several cases collapsed and some were resuscitated against odds. It was a truly memorable duty and at one point it was a matter of shunting from the ICU to the ICCU as there were alternate calls from either places.

Medicine had its highs and lows with moments of elation at a diagnosis made at the right time or a procedure that went well or a patient recovering well or even an attender recognizing your small contribution in the recovery of the patient. There were moments when you were frustrated by the delays in the system, the unavailability of even the simplest of medicines by government supply, the brash behavior of the patient attenders and sometimes their complete ignorance and lack of interest in the patient despite their deteriorating health. And then there were better moments when you see your patient successfully weaned out of the ventilator and wave you a goodbye after a prolonged stay. There are patients attenders who are thankful for the visible change in their patient or atleast for the efforts made towards their recovery. There were those who gave in every bit of their time and effort to see their patient turn over a new leaf and it was always a pleasure to interact with such folks.

All in all, Medicine was exciting and terrifying despite the patient load. It might have been physically and emotionally draining (when you realize you have been declaring deaths on such a regular basis, a sudden wave of emotion hits you over the fact that he/she is more than just their vital stats which is all you know about them.) But it offered a wonderful learning experience from the management of common cases to performing the basic procedures in the casualty, wards and ICU. From having the fear of facing the patient for not knowing what to do to approaching the patient to assess the vitals, starting the immediate treatment with a possible diagnosis in mind to explaining the prognosis of the patient to their attenders, it has been quite an eventful journey with some of the best cointerns and professors I could ask for.

With trepidation and excitement, I set foot into OBG, my home for the next two months. Here's hoping for new adventures :)