To Belong

Two deaths in my watch today. And where I come from, its considered a good score.

image1Doing shift in the ICU at a tertiary care centre has never been easy. Its an effort, and the fatigue seeps through your body as your soul. The dimly lit aseptic floor with its omniscient lull of beeping monitors hasnt been the most inspiring places i have been put at. It got 18 beds, and thus 18 critically ill lives’, holding to a slender thread that could snap any moment. Standing guard at that flimsy threshold where life ceases and nothingness reigns, it’s always been a challenge to hold your poise. And given the under-stocked over-burdened nature of healthcare out here, its a race against time, and that dire aftermath of life. Life is precious indeed. Its allure pulsates with every beat of my heart. It is death that’s come to lose its gravity, given the frequent encounters with the same.

My shift today which began with the break of dawn is to finish as the clock strikes 11 the night. The replacement already came-by at 10, as protocol dictates. I walked him over to each bed and gave a summary of the sick and their sickness. It as usual was a variegated mix, the little perks of interning at the apex institute in state. There were strokes, one where brain turns a mush for lack of blood, but different in the portion of brain that got afflicted, unique in the patient comorbidity, and involved given the consequent complications. There were demyelinating disorders, one where the nerve loses its insulation and the electrical wiring of the body goes berserk. To give a hint, the body doesnt even know how to fire the diaphragm rhythmically to cause them to breath. A cerebral malaria. Yes, its fatal if not intensively treated. Severe pneumonia. Chronic renal failure. Attempted hanging and its consequent hypoxic ischemic encephalopathy, one where your brain has been breathless for long. And few more. They were all curious serious cases, but as the saying goes, more interesting is the case from a medical perspective, poorer is the prognosis. And about the two empty beds vacated while in my care. One had disseminated sepsis, the infectious organism had spilled over throughout his body and caused multiple systems to shut down, and the other, we couldnt figure the cause. Her heart just stopped. I tried to resuscitate her for over quarter an hour, but to no avail.

With the handing-over done, i sat down to finish my notes. I had to write down each’s current status, and also file the death-reports of the two that we couldnt save. That i couldnt save. The staff in-charge had already brought over the list of patients in-queue for the vacant two beds. I told her to have the doc in-charge to take care of it. Once done, i gathered my stuffs, and started to walk away from that room where more have died than pulled through. I have often wondered if we indeed are this helpless with respect to critical care, but then, we get the toughest assortment of cases. Those on whom all other hospitals had given up hope. To save even a few amongst those, is a considerable achievement.

Outside, the corridors where quiet and the dark showed through the open windows. I climbed a flight of stairs to grabbed a cup of coffee from the doctor’s lounge. I had to keep wake for the drive back home. As i headed towards the entrance out the hospital, i caught sight of Room 205. It was the ortho emergency, and i knew who the doctor in-charge was. My heart grew heavy.

image3I walked over to the ward and peered in. She was standing by a patient and inflating the sphygmomanometer cuff. Guess her shift just began. Its routine to take vitals of each patient, which includes heart rate, breathing rate, blood pressure, blood oxygen saturation and temperature, at the beginning of each shift. These five values serve as baseline. Also, they give us an idea about how alive each patient is. She incidentally turned and saw me. We just looked at the other in a blank stare, and the mercury column in the BP apparatus fell too quick to take the reading. She adjusted her gaze at the meter and re-inflated the cuff. I let a sigh and turned around. Its been quite a while. But the ache is just as profound. My friends said give it time, and it will heal. But i don’t know. The pain, it just seems to remain, and resurface at every thought, every sight and every memory of her.

Just then, there was a scuffle of steps. A stretcher rolled in swift with a patient, near-unconscious, with his right side of body smeared in blood. Usually RTA cases, road-traffic-accident patients, with no obvious sign of injury to internal organs of abdomen or head injury are referred to ortho emergency. The doors were opened and in a moment, she was standing by the patient taking his pulse. It was a kid of 18, and from his looks, a college kid returning late home. I was standing at the door observing the patient with intent when i heard my name called out. There comes a point in your medical training when at sight of a patient, your mind goes into an overdrive trying to figure what’s wrong and the course of action to follow. At the second call, i noticed it was her. Her second in-charge had taken a break and she asked if i could step in. Whether it was the coffee, it was her, or the sheer call of duty, i was wide awake and walked resolutely to the patient.

She said she couldnt feel the pulse at his wrist. While his breathing remained laboured. I grabbed the BP apparatus from near the table and began inflating the cuff. She tried the neck vessels, and found a feeble pulse in his carotids. She then placed her stethoscope on his chest wall and said his heart is racing. Tell-tale signs of having lost blood. The blood pressure with systolic at a little over 80 mmHg only confirmed it. She also ran her steth around his chest to say lungs are otherwise clear. In any road-traffic-accident, we need to make sure lungs are well. Its just an air-bag and a cracked rib could easily puncture it. Worse still, cause a tension-pneumothorax, where air fills within your chest, compressing lungs to a corner and the patient suffocates.

I took a quick look at his pupils, and flashed my torch-light. His brain-stem seemed ok. Though he was becoming increasingly unresponsive. When he was brought in, he was responding to his name with faint grunts, while now he only reacted to deep pinch. She concluded he needed two pints of blood immediately and said she will give me a sample to type his group. I saw a bulge in his back pocket and withdrew his wallet. It said A+. But we still needed blood to cross-match with that in blood bank. She brought a Venflon, a long wide-bore needle for Intra-venous access and some cotton-and-spirit. Meanwhile, i cut blood stained pants off and blinked in surprise. There was no flesh wound. Only his thigh appeared grossly swollen, which explained the blood loss. He bled within. Though it doesnt explain the soiled pants. I looked over to the stretcher boy and asked if there was anyone else involved in the accident. He drew a blank. Though the traffic police who had just appeared said there was a girl riding pillion. She was at surgery. She had her skull cracked open. And i reminded myself to tell my wayward sister for the nth time to wear helmet while riding pillion with that stupid boyfriend of her’s.

image4I held his wrist and she established IV access. She withdrew me a few samples and i rushed to the blood bank. I typed it again, and cross-matched two blood bags. Meanwhile, i put the bags on warmer to bring them to body temp. They are stored at -20*. I returned with the blood and she had connected some colloids to the IV access to maintain the circulating blood volume. The heart needs a pressure to pump against. Also the blood column needs a pressure front to flow through the body. Can’t happen if the vasculature is drained off blood. She quickly disconnected the colloid and attached the blood bag. And now all we had to do was stand back and hope. The human body is a resilient system. But it can regain its steady state, that of life, only if pushed to within a critical limit. The capability to re-establish homeostasis while huge, is nonetheless, finite. We hoped his heart could pitch back and restill circulation. She kept a tab on his peripheral pulses, particularly the one on his right foot, and blood oxygen saturation while i keep a tab on his blood pressure. And after five minutes, his breathing improved, as does his blood pressure. But the swelling in his thigh seemed to grow tense.

It was apparent from start that he had fractured his right femur, which was obvious from the abnormal mobility and lack of transmitted moments between his proximal and distal thigh. Femur is pretty vascular a bone. As a matter of fact, all long bones in young adults are vascular structures. Femur more so. And the blood loss made sense. While its protocol to check for pulse distal to fracture site, the general fall in BP made it impossible to discriminate that. But now with systemic pressure regaining, he had pulse in his wrist and neck, even left foot, but not in the right foot distal to the fracture in thigh. The diagnosis was pretty certain. He had fractured his femur, but also, the fractured ends which happen to be sharp serrated structures seem to have severed his femoral artery, a wide-bore vessel that runs close by. This would account for the absent pulse conspicuously only in his right foot. But this also meant, the blood we were transfusing would soon flow out the ruptured artery and his vitals would start to drop again. The artery needed to be repaired, ASAP.

She told me to keep by the patient while she placed a call for the Vascular surgeon. We had the surgical team prep the Operation theater. In not more than 10 minutes, the patient was prepped and rolled to the theater. The vascular surgeon had made a request for 4 additional bags of blood. Vascular surgeries are blood-intensive affairs. I was at the blood bank and this time, as I wasnt in too much of a hurry, I placed a requisition for the 4 blood bags and told the staff in-charge to do the cross-matching. It was half past 12. My weary frame complained and i dropped into the nearest chair.

Just then, she walked in and sat beside. She said her second in-charge returned and she had left the emergency in her charge. We sat beside, silent. I, in my bloodied white-coat, with the steth weighing down my neck, and the stench of weariness subsuming my being. While she too had blood stains on her blue kurta. I thought she looked good in blue. I did not have the courage to look into her eyes. We hadnt spoken in over a month. I did not know what to speak. And i couldn’t find my voice even for a casual greeting. We could hear each other’s breath over the silent lull of the blood bank with its odd sanguine odour. She finally asked, “How are you doing?”. I turned to look at her. Resplendent as ever she was. And my being ached. A knot formed in my throat. And tears began to well in my eyes. I looked away hoping she hadnt notice. Just then i felt a calm touch on my hand. It felt soft, it felt warm. She turned my chin to look into my eyes filled with tears that were a flicker away from flowing over. She pulled me into an embrace. I did not want to look weak and do the stupid crying. But i couldnt help the tears. And she said into by ears, “It’s all right. Everything will become ok.” The care in that voice, with that loving suffusion of compassionate concern only made me miss her all the more. I wanted the moment to remain. But the staff nurse who had appeared with the blood bags cleared her throat, and i secretly wiped my tears.

image2I stood up, took the blood and started for the Operation theater. Then i had to go get some sleep. My shift starts in another 5 hours. And i needed to regain some strength to survive another day in this place. As i was leaving, i turned to look at her. She was pretty. As resplendent as ever. She had her head bowed. I followed her gaze which was looking at that wet patch in her lap, beside the stain of red, where my tears were slowly drying up. I started to walk before my resolve would weaken. I wanted to walk away from there. From the ICU where i helplessly watched people die. Away from the operation theater, where that teen college kid was being operated, as was his friend, the girl, in a theater beside. Away from the blood bank, where she sat, where i wept. Though knowing well, i would return to it all. To the hospital, to help. To her, in hope. For it’s in company of the two, did i feel i belonged. I felt wanted. I saw a purpose. All the while wondering, i cried because of her, or because of the toll this placing is taking as upon.