by Anirban Bose
Second MBBS is the best time in the life of a medical student. The four subjects – Pathology, Pharmacology, Microbiology and Forensic Medicine – are relatively easy, and since the foundation of medical knowledge is on firmer footing, the subject matter is easier to comprehend. However, the piece-de-resistance of this momentous transition is the newly earned right to wear those hallowed white coats and carry stethoscopes around one’s neck, which comes with starting to see patients. No second MBBS student could be caught anywhere near a clinical rotation without his stethoscope and long white coat. If the coats bore a few patches of blood, they added an arresting authenticity, the story of their acquisition becoming a natural conversation piece.
Adi’s first clinical rotation was Obstetrics and Gynaecology (ob-gyn) in a peripheral hospital called Cama, right next to Victoria Terminus in the heart of downtown Bombay. Adi didn’t care too much for the subject and reconciled to it reluctantly after some active encouragement from Pheru, who pointed out that if not the subject, the location at least was idyllic. Across from Cama was a huge open field, lined by numerous food joints; a few blocks down was St. Xaviers College, with the best-looking and most adventurous girls in Bombay, and within walking distance were all the major movie halls. If he played his cards right, Pheru suggested, Adi could be at the hospital in the morning, eye the Xavier girls in the afternoon over lunch, and with some debonair manoeuvring end up seeing a movie with one of them in the evening. More than luck, it would need an overdose of providential blessing for this scenario to materialize, but Adi’s newfound confidence didn’t have a problem with fantasies.
On the very first day, Adi managed to show up late. Negotiating the pedestrian traffic on the streets of Bombay during rush hour took its toll. By the time he reached the floor, rounds with the attending doctor were well underway.
Their attending, Dr Choksi, a tall, thin, serious-looking man, was dressed in a partially crumpled suit that had seen much better days. Wisps of long thin hair struck out defiantly from an awkward hairdo, and big glasses gave his eyes an owlish intensity. Huge ears, that seemed to bend under their own weight, framed his longish face and, combined with the way he stooped when he walked, seemed to convey a heightened susceptibility to gravity. Around him hovered a petite resident, dragging a cartload of charts. Behind her, in a procession of seniority and importance, followed two junior residents and the rest of Adi’s batch, all twenty-four of them, in their spotless white coats and sporting brand new stethoscopes around their necks.
Adi tried to slip in unobtrusively. As he tiptoed across the ward to join the rest of the group, one of the patients called loudly out to him, ‘Oh, doctor…can you come here?’
Everyone turned to look at Adi. He was about twenty feet from them, on tiptoes, trying to get the caught-in-the-headlights look off his face. Dr Choksi studied him through his thick glasses silently.
The patient called out again. ‘Doctor…here…can you come here?’
Adi wanted to tell her that he wasn’t a real doctor; the white coat he was wearing had been bought the previous night at the store across from their hostel. In the glare of everyone’s gaze, he stood vacillating for a few seconds before smiling and waving at her sympathetically. Then he walked over to join the rest of the group.
‘What did she want?’ Dr Choksi asked him as soon as he reached them.
Adi shrugged uncertainly.
‘What is wrong with her?’ Dr Choksi asked again.
‘I don’t know, sir,’ replied Adi. ‘I… I just came in.’
‘What do you think is wrong with her?’
Surprised at his persistent questioning, Adi ventured a guess. ‘Maybe she is…pregnant.’
‘Good diagnosis, doctor,’ said Dr Choksi, sarcastically. ‘This is the Obstetrics floor. Everybody here is pregnant.’
The others burst out laughing. Turning to the senior resident, Dr Choksi said, ‘What is the case, Uma?’
Uma, the senior resident, replied, ‘Sir, she is Mehzabeen, a 32-year-old G3, P2, admitted with a 28-week gestation for uncontrolled hypertension, pre-eclampsia.’
Dr Choksi turned towards Adi again. ‘Did you find out what she wanted you for?’
Adi shook his head to indicate he hadn’t.
‘Don’t you think it’s important to know what she wanted? Why don’t you go and find out?’ ordered Dr Choksi.
Adi swallowed his embarrassment and retraced his steps towards the woman. He felt nervous dealing with a patient for the first time, especially since he knew so little about the subject. With the entire group looking at him, Adi quietly walked up to her and asked her what she wanted.
She pointed towards her foot, and Adi could instantly see what the problem was.
A safety pin, used to keep her bedsheet in place, had opened up. Every time she moved, its sharp end etched long scratch marks on her leg, punctuating it with droplets of blood. Sedated and attached to the IV pole, she had tried to remove her painful prickle, but had clearly found such coordinated action impossible in the foggy haze of her medicated brain.
A huge sense of relief washed over Adi when he realized the simplicity of the solution. He pulled out the safety pin and walked towards the rest of the group holding the pin above his head like a prizefighter’s trophy. Dr Choksi nodded and said to Adi, ‘So, doctor…what is your name?’
‘Adityaman,’ said Adi, confidently. ‘Adityaman Bhatt.’
‘So, Dr Bhatt. What did you learn today?’
The fairly obvious conclusion that removing an open safety pin might prevent somebody from getting scratched by it was the first thing that sprang to Adi’s mind, but he was quite certain that wasn’t the answer Dr Choksi was looking for. He tried to think of the medical terms he had heard Dr Uma use, but he didn’t really know what they meant.
Dr Choksi continued, ‘I hope you learned that coming in late and trying to sneak into my rounds can get you into trouble.’
Everyone laughed.
‘Besides that, what did you learn?’
Sheetal, eager to make a good impression, said, ‘She has pre-eclampsia and we are giving her IV anti-hypertensive to prevent seizures and control her blood pressure.’
‘Excellent,’ said Dr Choksi, as Sheetal beamed happily. ‘But that is not what I’m looking for. Why do you think she called out to you, Dr Bhatt?’
Adi didn’t have a clue. He joined the others in staring at Dr Choksi silently.
‘Because you wear a white coat, Dr Bhatt. She didn’t know who it was that had walked past. But when she saw the white coat, her sedated brain reasoned that it meant relief. It meant an escape from her pain. She gave your coat the meaning you didn’t, Dr Bhatt.’
Adi wrapped his coat a little tighter around himself, feeling a sudden respect for the modest garment.
Dr Choksi continued, ‘It’s a good lesson in the art of medicine: relief is the cornerstone of our profession. It is the oldest art, as old as life itself. Medicine arose from the art of providing relief, gradually transforming into a better, more exact science over hundreds of years. But the practice of being a doctor is using both the art and science of it. In olden times, it was mostly an art form, where you listened to the patient and prescribed medicines. With time, we have become better at the science . Our tools are more exact and give a wealth of information, and they have improved patient care tremendously. Unfortunately, as science has progressed, the art is slowly disappearing. Blood tests and CAT scans are replacing having a conversation with the patients. Under the guise of doing good, we are forgetting those we do good to. Like today, when Mehzabeen is sick and needs our care, she will get IV anti-hypertensives, she will go for an ultrasound, Dr Uma will prescribe medications to control her blood pressure, while somebody else will do a foetal stress test on her. The nurses will feed her and wash her, and I will examine her. But do you know what she’ll tell her family when they come to visit her today? She will talk about you, Dr Bhatt…how you helped her by pulling out the safety pin that was hurting
her. In spite of all the different interventions that we will perform on Mehzabeen, for today the only person who brought her real relief was Dr Bhatt. For today, her doctor was Dr Bhatt.’
Adi had never felt so proud of pulling out a safety pin before. He smiled self-consciously. As the batch slowly soaked in the wisdom of his message, Dr Choksi said, ‘So, today, what I want you to learn is what wearing that white coat and carrying a stethoscope around your neck means. It means you provide relief. Soon you’ll realize how little we can actually do to cure diseases in patients, but we can always bring relief by simply listening to them. I hope you will all remember this simple art of medicine: the art of listening.’
FOURTEEN
Every morning, at 6 a.m. sharp, the ob-gyn wards stirred to life. Junior residents were the first to walk in, gathering vital signs and examining patients for subsequent discussion with the senior resident and then formal rounds with Dr Choksi. The medical students’ arrival was a less celebrated, often unnoticed affair, usually dependent on the student’s personal interest in the subject. So, while Isha made it a point to walk in with the junior residents first thing in the morning, Adi barely managed to make it a few minutes prior to Dr Choksi’s arrival.
Adi’s passive participation was rooted in his dislike for obstetrics. It was not the usual image of the happy pregnant woman he had in mind. Most of them lay in bed, sleeping, or tossing and turning, pretending that the unnatural bulge in their middle was a natural part of their body. Those huge ‘ripe’ bellies with the upturned navels repelled Adi. After some tentative initial efforts, he learned to place his stethoscope over the spot marked with an ‘X’ by the trainee nurses (affectionately called missy babas) and convince himself that those vague rumblings in the distance were the tireless thumps of the foetal heart. As medical students, their inexperience in clinical medicine dictated an auxiliary role anyway, limited to hovering around the residents, inserting IVs or collecting blood, all the while trying to appear doctor-like in their demeanour. Adi often wondered if the patients noticed his lack of confidence or thought poorly of his abilities. Fortunately for him, the strata of patients seeking care in government hospitals like Cama ensured that he needn’t have worried. Poor and illiterate, these women were easily impressed by the white coats and stethoscopes, not to mention the ability to discuss bombastic medical terms in English. Consequently, they accorded the medical students a level of respect distinctly out of proportion to their training.
Halfway into his ob-gyn rotation, Adi started coming into the wards very early, walking in with the junior residents at the crack of dawn. This dramatic shift in commitment had the desired effect of drawing Isha’s attention. She, of course, ascribed his change of heart to a newfound enthusiasm for ob-gyn.
Adi knew Isha and Payal always ate lunch together. One day, he followed them to the canteen. He began to draw up a chair when they spotted him and beckoned him to join them.
‘Hi Adi. Are you coming this evening?’ asked Payal.
‘Where?’ he asked eagerly. ‘Is everyone going somewhere?’
‘No, no,’ she replied. ‘Dr Uma said that my patient is being induced this evening. We can watch her conduct the delivery.’
Adi’s enthusiasm died.
‘No way!’ he said.
‘Why?’ asked Isha. ‘We have to witness twenty-five deliveries this rotation.’
‘I think I’ll try and watch them while rounds take place, not spend extra time in the evenings,’ replied Adi. ‘That’s why I’ve started coming in early.’
Isha nodded understandingly. ‘What happened with Dr Choksi today?’ she asked.
‘Oh that,’ said Adi. ‘He asked me on rounds to tell him the foetal heart rate. I can’t ever hear them. So I just put my steth close to the “X” that the missy babas made, and rattled out “120”. Dr Choksi was surprised and checked it himself. He couldn’t hear anything at the site where I had placed my steth because, as it turns out, the woman had a breech. The missy babas make up the sounds and the numbers too. I felt like an idiot.’
Both of them laughed.
‘Yeah, the venous hum of the uterine vessels in these patients is so loud that you have to press the steth really hard on their bellies to hear the foetal heartbeats,’ agreed Isha.
‘But don’t you find that scary?’ said Adi. ‘Their bellies look like balloons and I feel they might burst if I press too hard!’
Isha started to laugh again. Adi couldn’t help but stare at her face when she laughed. She was so pretty.
They chatted some more over lunch. As they got up to leave, Isha walked ahead to pay for her meal, leaving Payal and Adi a few feet behind.
Payal tuned to Adi and said, ‘So, Adi, you are definitely not coming this evening, right?’
‘Not a chance,’ replied Adi. ‘I have much better things to do in the evenings than watch a delivery.’
‘Hmm…fine,’ she said. Then, smiling mischievously, she whispered, ‘I’m not going either. Isha is going to be there alone. Nobody else from the batch.’
The look on Adi’s face gave away the sudden change of plans in his head.
Payal grinned. ‘I think Isha is meeting Dr Uma at around 6.30 in the delivery room.’
Then she walked ahead to join Isha.
For Adi, it was a date any way he chose to look at it. The incidental distraction of parturition was an inconvenience that he schemed to turn into an advantage.
He went over the book on obstetrics and tried to memorize the stages and management of a delivery. A few hours into the confusing positions, lies and presentations of the foetus, he had managed to glean some very elementary concepts of childbirth. Concerned that the prefatory nature of his knowledge would be insufficient to impress Isha, he tried to think of a few jokes and some interesting anecdotes as he prepared to meet her.
Adi reached Cama hospital at 6.30 sharp. The delivery, he estimated, would last an hour or two. That would place them together right around dinnertime: a chronological convenience that would make his suggestion for dinner at ‘Kamats’ seem casual and spontaneous. He would naturally offer to share a taxi back to campus: another proposal as innocuous as the one preceding it. That way, he reasoned, any hint of his interest being overt, would be camouflaged in the spontaneity of the events.
The delivery room was situated at the end of the ward. A narrow, dimly lit passageway half-choked with rusty stretchers and crooked wheelchairs separated it from the rest of the floor. Adi had never been there before and would have been most happy if he could have avoided it altogether. Occasionally, while making ward rounds, he had heard the cries of women giving birth. Those screams, echoing along the dingy passageway, made the delivery room seem more like a torture chamber than a place where new life was ushered in.
Isha arrived while he was standing at the entrance to the passageway, staring in the direction of the delivery room and having second thoughts about his plan. She was surprised to see him.
‘Hi, Adi!’ she said. ‘I thought you were not coming. How come you changed your mind?’
Adi smiled and said, ‘I thought it would be a good opportunity to see a delivery being managed…what better way to learn more about Obs…’
‘Great…you’re really making an effort, Adi. I’m glad you are here. I think Dr Uma is already inside the delivery room. Shall we go?’
‘Sure,’ Adi replied, suddenly feeling very happy that she was ‘glad he was here’.
He followed Isha into the shabby passageway. As they approached the delivery room, a terrible smell hit Adi’s nose, sending a wave of queasiness through his body. The nauseating fetor of blood, urine, amniotic fluid and mucus seemed viciously pervasive and he held his fingers over his nose in a vain attempt at sieving out the smells. He tried to overcome his disgust by reminding himself of the impending payoffs.
Although much wider, the delivery room was only slightly better lit than the passageway. Its whitewashed walls were bare and, except for the green hospital curtains, the room
lacked any hint of colour. Two stretchers separated by a flimsy white curtain served as the birthing tables. The sparse furnishings conveyed a sense of austere seriousness as if to remind one that childbirth was no joking matter. A couple of ceiling lights reflected off the glass panes on the cold steel cupboards which were full of neatly arranged obstetrical instruments, awaiting their turn to pull out a baby. The patient lay on one of the stretchers, struggling in her semi-somnolent state with the grogginess of pain-killing drugs and the agony of contractions. Her belly straddled the space between her splayed out legs, trying hard to deliver its contents through the narrow opening in between. Dr Uma and a nurse stood beside her, helping her coordinate the contractions. The sheet underneath her legs was covered with a translucent, shiny fluid, liberally spotted with jelly like blotches of blood. Every few minutes she would clasp the rails on the stretcher with desperate strength, scrunch her face with superlative effort and let out a bloodcurdling scream. Then, as the contraction subsided, she would lie back, thankful for a few moments of respite, even as her eyes grew large with trepidation at the thought of the impending one.
Adi felt sick to his stomach. But what dismayed him more was the presence of five other students from their batch, standing a few feet away from the patient’s legs, watching the birth. He stood at the back next to Isha, behind the first row of observers, feeling sorry for the poor woman and sorrier still for himself. He couldn’t imagine any circumstance in which this ambience would be conducive to his plans. Adi felt betrayed… Payal had promised there would be no one else!
Still struggling to breathe, he tightened his fingers around his nose as tactfully as possible.
‘Chalo, Ameena, zor laga ke…’ encouraged Dr Uma. Then, turning towards them, she said, ‘Look closely…you can see the baby crowning.’
The audience leaned forward for a better look. Adi saw a mass of hair smudged with mucus appear near the gaping vagina. Adi wondered why God had made childbirth such a disgustingly agonizing ordeal. And why fate had afforded him an opportunity like this to try and make a suitable impression. As another wave of queasiness hit his insides, he reflexively tightened his fingers around his nose. He couldn’t remember a time when he had felt quite so sick.