by Joan Arakkal
When asking our questions, we tried to stick to the orderly fashion we had been taught. The question ‘Are you married?’ was followed by ‘Have you any children?’ If the answer to the first question was ‘No’, we would hesitate to ask about children, especially if the patient was a woman. Having children outside marriage was unacceptable to the social norms of the time.
Ravi was a clever student who always did well in the examinations. But his social interactions were awkward, and often left us wondering how he managed in the real world.
‘Do you have children, Mrs Rao?’ he had asked a serene lady the previous day.
‘Yes, I have four,’ she replied.
‘Are you married?’ he continued.
The woman’s tranquil look faded and she got up to leave. Ravi was totally confused and looked to us for an explanation. He looked even more confused when we said, ‘Ravi, you changed the order of the questions. Next time, try to get it right.’
Forty-five minutes later, we had enough information from the patient’s answers and a physical examination to arrive at the most likely diagnosis. When Dr Padmanabhan arrived to conduct the bedside clinical discussion, we trembled. What clinical signs had we missed? After the presenter rattled off the patient’s history, Dr Padmanabhan asked me to describe the physical findings that I had determined by inspecting the patient without touching him. It isn’t difficult to see the indicators of a lung ravaged by tuberculosis. From the putrid smell of his breath, the expanded blue fingertips that look like drumsticks and the matted lymph nodes distorting his neck, the emaciated man showed all the telltale signs of a body playing host to the rod-shaped bacteria Mycobacterium tuberculosis.
It was now the turn of one my fellow students to take part in the ritual of the physical examination. Under the watchful eyes of Dr Padmanabhan, he palpated the patient’s neck and armpits, feeling for the lymph nodes that had grown and stuck to each other and left the skin stretched over a wavy mound, giving it an irregular ‘bosselated’ feel. With his hands pressed gently across the patient’s bony chest, the student watched the tips of his thumbs move apart as the man breathed in and out. It was now time for the next step in the physical examination – percussion. Dating back to the Austrian physician Leopold Auenbrugger, who learnt to discern the levels of wine casks by tapping on them, this time-honoured technique of tapping the areas of the chest with the physician’s middle fingers allows doctors to make out the hollow sounds of a cavity, the stony dullness of fluid and the drum-like, tympanic note of a well-aerated lung.
‘That is the dullness of the liver,’ Dr Padmanabhan said when the student percussed an area in the lower chest and mistook it for a consolidated lung. It was as though Dr Padmanabhan’s light-blue eyes could peer into the chest wall of the sickly patient and see what we could not.
We were now on the final stretch of the examination. We placed the stethoscope on the man’s chest wall. As he breathed in and out, some of us struggled to differentiate the sounds. ‘Rales,’ said Dr Padmanabhan, ‘sounds like cellophane being crumpled and indicates fluid in the airways. Ronchi, on the other hand, is a rattling sound and is suggestive of obstruction to the airways.’ Trying hard to appear as if we had understood and heard the sounds, we moved on to the next step. The patient repeatedly whispered ‘one-two, one-two’ as we listened through the stethoscope. The sound was filtered out from the areas where his lung was filled with air. But when we moved onto areas where air had been replaced with solid secretions, the numbers could be heard loud and clear. We had just heard the signs of ‘whispering pectoriloquy’ that indicated a solid area in his lung. With all the information at hand, we came up with a provisional diagnosis of ‘tuberculous consolidation of the right inferior lobe of the lung’. Dr Padmanabhan nodded in agreement, much to our relief.
The man’s chest X-ray, which had not been available to us, was now revealed. As we systematically described the findings of the X-ray, starting from the outer edges of the film and moving into the inner field, we saw a white patch replacing the grey, air-filled areas of the lower lung. The X-ray confirmed what we had pieced together from our physical examination.
When Dr Padmanabhan explained the nature of the disease to the patient and offered him the triple regime of tuberculous treatment (a triple whammy of antibiotics given to avoid resistance developing in the bacteria), the man’s palms kissed again, this time in gratitude. He had been touched, felt and heard and knew that the X-ray and the sputum and blood that were tested all pointed to a diagnosis. His faith in the treatment had already begun to make him feel better and he had hope for a recovery in the months ahead.
In the final year of medical school, the big three clinical specialities – surgery, medicine and the dual field of obstetrics and gynaecology – along with psychiatry and paediatrics, kept us fully stretched. Many students were already being drawn towards particular disciplines. It was generally considered that the more cerebral and analytical students would lean towards general medicine, while those attracted to action, especially unpredictable action, would gravitate towards obstetrics and gynaecology. Surgeons found their place in the middle of the spectrum, between the extreme thinkers and intense doers.
Professor Ganesan was head of general medicine. His bedside clinics were legendary and attracted large groups of medical students. Tall and somewhat overweight, he possessed wit and wisdom that made the drabbest topic interesting. He helped us make sense of the various clinical signs we elicited, allowing us to make defensible diagnoses. He quizzed us on other possibilities that could be considered, often bursting our bubble with a loud guffaw and a simple diagnosis in the place of a more exotic and convoluted one we had offered. We realised the genius lay in simplicity. It took us a while to take on board the wisdom behind his words, ‘If it looks like a duck and quacks like a duck, it must be a duck’.
Professor Ganesan often dropped nuggets of wisdom alongside his clinical teaching. One day, six of us had been assigned a patient to examine and present to him. Chitra was nervous at the thought of facing the professor, but Sudhir was superbly confident. Ravi leafed through his well-thumbed Hutchison’s Clinical Methods and I took the patient’s history then watched as Sita calmly examined the patient.
Next, we gathered around the unwell man and employed the systematic, time-honoured methods of inspection, palpation, percussion and auscultation. On this day, we saw the patient’s red rashes and felt his swollen joints. After we had looked and felt, we drummed the patient’s chest with our fingers placed between the ribs and strained to differentiate between a hollow and flat sound. The stethoscope around our necks was saved for the end. The heart’s lub-dub tormented us when we tried to listen for tiny snaps and clicks among the gushing sounds of floppy valves and tight openings. A diagnosis of rheumatic heart disease seemed most likely. Though this was a grave verdict for the patient, we were reassured that the day’s clinical presentation would be easy and straightforward, so we relaxed.
Away from the patient, our conversation turned to less clinical matters. Chitra wanted to do dermatology, because she had heard that there were few emergencies and that patients kept coming back because they never got better. Murali wanted to do psychiatry, and it crossed our minds that his eccentric ways would suit that field perfectly. Sudhir declared, ‘I do not care what I do as long as I can make lots and lots of money.’ At precisely that moment, Professor Ganesan walked in. We saw his amusement as he looked at the squirming Sudhir.
The patient’s rheumatic heart disease was discussed at length and, as he was wheeled away to the wards for admission, Professor Ganesan sat on his chair and asked us to make ourselves comfortable.
‘It is good you are all thinking of specialising in various fields in the years ahead. No matter what you pick, remember there are three deities you could worship in the course of any career: the god of knowledge, the god of service, or the god of wealth.’
‘Which is the best god to pursue?’ Only Murali had the courage to ask such a qu
estion.
‘It does not matter which course you pursue,’ the professor replied with his trademark hearty laugh. ‘Just remember you do not move away from the ethical path in reaching your goal.’ This was another pearl of wisdom that we took with us into the world of medicine.
THE STICKY FLOOR
The year I turned twenty-two, I entered the year-long internship program at a tertiary hospital in Coimbatore. The pockets of my white coat were now stuffed with stethoscope, memo pads, knee hammer, syringes and hastily scribbled notes.
My colleagues and I ran hither and thither in the overcrowded wards, the smell of antiseptics mingling with that of festering wounds. Nurses in their smart frocks and caps dismissed us as wannabes, but their disdain did not dampen our enthusiasm and exhilaration. We were on a mission. Choked with youthful idealism, we hoped to change the system, right the wrongs and pull off the impossible.
The post-operative ward was the cleanest in the crowded hospital. Its sparkling floors, the tidy beds with fresh sheets and the well-equipped dressing trolleys were in stark contrast to the conditions on the medical and surgical wards where patients occupied mats on the floor because there were not enough beds to go around. It was difficult to restrict admission when so many sick patients came from near and far. The government-funded hospital provided a free service and enough money was allocated for the efficient running of the institution. However, corruption, red tape and unscrupulous authorities siphoned funds away from the system. Even the watchmen at the gates joined the opportunistic grabbing by demanding an entry fee.
When new wards needed to be constructed to accommodate the ever-increasing number of patients, the wheels of bureaucracy moved slowly. Basic necessities in the existing wards were often missing. In those ‘non-disposable’ days, anything that could be reused was. The sharp bevelled edges of steel hypodermic needles were worn out from penetrating the muscles of innumerable patients. Their blunt ends resisted entering the skin as we tried to inject thick white penicillin into the buttocks of stoic patients. We skimped and saved on dressings and bandages so that there would be enough to go around. It was a tribute to the hardy immune system of our patients that we did not see more cross-infections arise from the available ‘sterile techniques’. We soldiered on, knowing that things could, and should, be better.
During my two-week posting in the post-operative ward, I stood at the end of the bed looking at the chart of a deeply sedated young naval officer. Despite a slightly raised temperature, his pulse and respiration were normal. His input and output charts were balanced. I looked at his face in repose. There was no trace of the pain that had previously plagued him. He had presented to the outpatient clinic a few days earlier and his smart white uniform and handsome visage had caught my attention. As I took his history, I gathered he was a smoker and had been for some time. When he complained of pain in his limbs that prevented him from walking even a small distance, a diagnosis of Buerger’s disease was already entering my mind. The slight discolouration of his toes and the feeble pulses in his feet were more proof that the nicotine he had inhaled over the years had destroyed the lining of his blood vessels. India has a high prevalence of smoking, and this was a condition commonly seen on the surgical wards. Many patients came to the hospital only when their toes were black and shrivelled, at which point amputation was inevitable.
As I explained the consequences of further nicotine abuse, his resolve to quit smoking appeared genuine. When the consultant decided to operate, the young man consented quickly. I explained to him that the surgeon would get to his nerve cell cluster in the sympathetic chain lying close to his spine through an incision below his twelfth rib. Once the cluster was cut, his blood vessels could relax and dilate and supply his limbs with a better blood flow. He had very few questions, besides wanting to know how quickly he would be free of pain. He was soon on the surgical table. The procedure went smoothly and quickly. The surgeon’s deft fingers identified and snipped the nerve fibre that had caused the blood vessels to constrict. With the muscles put back in place, the large incision was sutured. It was not long before the patient was in the post-operative ward. As he recovered, his charming personality – previously hidden by pain – slowly emerged. The young nurses blushed as he appreciated their services and the lunch lady repaid his compliments with extra portions of dessert. As he entertained me with stories of his seagoing career, I too came under his spell.
On the fourth day after his surgery, the wound appeared to be knitting well and thoughts of discharge entered our minds. I picked up his chart on my early-morning ward round and looked at him. Something was wrong. He was spiking a fever and his blood pressure was high, yet his teeth shone in a strange grin. Puzzled, I asked him how he was. The unexpected irritability and the stiffness in his joints rang warning bells. Having never seen an established case of tetanus, I had mistaken his risus sardonicus for a cheeky grin. I alerted the consultant, who hurriedly transferred him to the isolation unit. Precautions were put in place to protect other patients and the operating theatres were shut down. The disease was reported and an investigation into the cause was undertaken.
I never saw that naval officer again. When I heard of his demise a few days later, I realised his death had been caused by the measures we had taken to cure him. Antisepsis had not yet come far enough to prevent such unnecessary deaths.
Deviani was seventeen years old when she was admitted to the surgical ward of the tertiary hospital in Coimbatore. Her frail mother pitched in with answers to my questions. Deviani worked in a factory to supplement her widowed mother’s income. In the early hours of her shift that morning, Deviani’s long black hair got caught in the wheels of the spinning machine. The machine was turned off, but only after she had been completely scalped. She travelled for miles before arriving at the hospital. Her unsalvageable scalp had been consigned without ceremony to the rubbish bin. Slowly, I unfurled the bandage sitting like a turban on top of her delicate face. When I saw her glistening skull, I wondered how it could ever again be covered with skin.
On the morning ward round, I presented Deviani to my consultant. He struggled to answer my questions about how to manage this terrible injury. Skin grafts do not take kindly to a bony bed. Covering Deviani’s skull was going to be difficult. As the days went by, we attempted to create a raw surface by chiselling the outer table of bone until blood appeared. This would encourage tiny blood vessels and connective tissue to form, over which we could apply skin grafts. As the slow laborious process trundled on with many trips to the operating theatre, I watched Deviani waste away. The hope in her eyes had been replaced by acceptance. As if the mutilation of the skull was not bad enough, we started shaving skin from her thigh to cover her skull. It was like robbing Peter to pay Paul. For Deviani, lying on a steel-framed spring-bed in an open hospital ward, infections were never far away. As I gently cleaned the pus forming on her scalp and dressed it daily, I learnt more about her.
Her father had passed away after a sudden illness. Deviani left school to support her mother and bring home an income, so that her younger brother could attend school. Mother and daughter were a strong team and were determined to make a future against all odds. But the wheel of destiny had other plans for this family. When I completed my internship a few months later, Deviani’s skull was still resisting being covered with skin and I watched her and her mother spiral down the tunnel of hopelessness and poverty.
What prevented these women from rising was not a glass ceiling, but a sticky floor that mired them in their misery. All the antiseptic and bleach in the world could not scrub away the glue that trapped these unfortunate women.
Although many Indian women were stuck in seemingly hopeless conditions, I also saw those who were not shackled by poverty and low socio-economic constraints, soaring high. Discrimination based on gender did not always seem to be a significant issue. It was not unusual to see a female surgeon operating beside her male counterparts. I saw female doctors heading busy medical and surgic
al units in the hospital. The highest office in the country was held by a woman. Once they prised themselves away from the sticky floor, Indian women could usually rise as high as they chose – there were few glass ceilings to stop them. It appeared that sexism, although a reality, did not preclude a woman from doing what she desired once she broke free of economic bonds and systemic corruption.
As my internship progressed, I began to feel I was in the best profession in the world. I even felt sorry for people in other jobs – until an incident changed my view.
Public transport took us to our destinations, any time of the day or night. Coimbatore had an extensive network of buses that ran the length and breadth of the city and out to the rural areas. Over the years, these buses had been part of our lives. The Number 11 dropped us at the railway station, where we walked the few remaining metres to the hospital with our white coats draped over our arms. Kind drivers with whom we had bonded over many trips slowed down as we desperately flagged a bus that was moving away from the stop. They chided us gently as we scrambled into the bus. We smiled. The bonds deepened.
During peak hours, the red buses that headed down Avinashi Road were packed with future engineers, science and art graduates, and doctors-to-be. We were dropped off at institutions studded on either side of the highway. Young women in colourful cotton saris boarded the front of the bus, while the men entered through the rear door. Friendships were forged and romances bloomed as the bus rocked, swayed, stopped and sped along, depositing young lovers, debutantes and Casanovas at their destinations. The more daring young men got on at the front, only to be told off by the bus conductor as he weaved his way through the sardine-packed bus issuing tickets. I often thought about how treacherous his job was, having to worm through the crowds, moving from one end of the bus to the other, giving the right colour tickets and collecting jingling coins into the leather satchel slung across his neck. The conductor in the early-morning Number 11 bus was kind and efficient. He did not appear to be much older than us and I wondered if he would remain a bus conductor for all his working life and if he had missed out on a university education by choice or circumstances.