by Joan Arakkal
GANGA HOSPITAL
It was now five years since the diagnosis. The spectre of breast cancer was fading into the background; clever implants and meticulous surgery had restored form and normalcy to my body. I nourished it and kept it active, swaying and gyrating to Bollywood melodies. Oxygen flooded my being with each deep breath I took during meditation. I felt rejuvenated as my body posed as a mountain, curled as a cat and unfurled as a cobra on my yoga mat. As I returned to the land of the living, a deep yearning gripped me. My research progressed and I continued working as an assisting surgeon, but it was time to push again to realise my career goal of being a hand surgeon.
It appeared as if the surgeon who had sat in on my feedback session some years earlier and had asked me if I would stay on in Australia on receiving a FRACS qualification, and some others, were not keen on me hanging up my orthopaedic shingle on their turf. The doors of orthopaedic training in Perth were unoffically shut to me. I was disappointed but refused to give up on my lifelong passion. I contemplated further possibilities.
I knew knocking on the training door would be futile so I set out to refresh my skills in hand surgery instead. My opportunity came in the form of a fellowship at a hospital in Coimbatore. I was one of two surgeons chosen for the coveted fellowship, which was named after Carl Zeiss, the nineteenth-century German maker of optical instruments. The focus of the fellowship was on hand and reconstructive microsurgery. I packed my bags and flew back to the land where I had learnt the fundamentals of medicine.
As I walked into the 400-bed Ganga Hospital, a feeling of deja vu descended on me. Listening to the babble of Tamil spoken around me, I recalled my early medical student days when I had struggled with the nuances of the language and my friends had jokingly pleaded with me not to murder the language. As the years went on, I had become proficient in the language. Here I was, many years later, keen to test my ability to speak it once again.
I joined the team headed by the charismatic plastic surgeon Dr S Raja Sabapathy, fondly called SRS. Packed with vision, energy and an indomitable spirit, he and his brother, Dr Raj Shekar, an orthopaedic surgeon, had built up a seventeen-bed family enterprise into a state-of-the-art institution with 480 beds. When I was eighteen I had been admitted to this once-small hospital and SRS’s father had anaesthetised me for a tonsillectomy and encouraged me to eat ice-cream, a rare treat. I was delighted when the now-retired senior anaesthetist saw me on the corridors of the vastly expanded hospital and recognised me from all those years ago. The hospital was now a centre of excellence for microvascular, orthopaedic and spinal surgery. With hand trauma comprising a major part of their work, I was gratified to be there.
As the men of science put mutilated hands back together, they invoked higher powers to do the healing. A deep spirituality and respect for women coursed through the institution. Never failing to acknowledge and honour their mother’s vision and her role in building up the institution, the brothers ministered to the maimed and unwell and their mother’s presence permeated the hospital. Major new projects were accompanied by the presence of poojaris, Hindu priests whose incantatory chants before an idol reverberated through the temple of healing. As medicine and faith effortlessly mingled, I was reminded of my debating days at school. At an inter-school competition, I had argued passionately in favour of science and religion being complementary rather than contradictory.
It had been many years since I left medical practice in India. Outside India, any references to god or spiritual practices were kept private for fear of being seen as weak or unprofessional. When I stood in the foyer of Ganga Hospital and listened to the chanting, I sensed the yoga of spirit and emotions coming together. It was not unusual for doctors to appear in their white coats for prayers and leave for their morning rounds with white ash smeared on their foreheads and the smell of incense clinging to their coats. It was easy to see how the spirit of service was extended to patients who could not afford to pay for their treatment. ‘Service to man is service to God’ was not an empty slogan here.
And so I joined the team, keen to learn what they had to teach. It was not long before a young factory worker arrived in the emergency room accompanied by a friend holding a clear plastic bag filled with ice. Amidst the ice cubes lay a smaller bag containing a fingertip with part of the nail still on it. Coimbatore is an industrial city. Lagging safety standards in the factories and an increasing number of traffic accidents meant that severed fingers and limbs were not uncommon. Ganga Hospital had come to be known for its successful replantation work. People knew they had to transport the severed parts in plastic bags, avoiding direct contact with ice. Dr SRS and his team performed the impossible and the expectations placed on them were high. They were known to be so skilled that it is said an angry assailant once not only chopped off his enemy’s thumb but also flung it far away, hoping the victim could not retrieve the part and take it to Ganga Hospital where it would be put back on!
Watching the surgeons untiringly suture tiny blood vessels under a microscope with tiny curved needles, making sutures so fine that they were barely visible to the naked eye, their dedication and commitment to their patients was hard to overlook. Later, I sat in the microsurgical labs suturing the arteries and veins of anaesthetised rats with Ravi, the technician, close by to give me a helping hand. I had moments of elation when blood flowed freely on releasing the tiny clamps. At other times, I was frustrated and dejected when my badly placed sutures obstructed the free flow.
The theatres functioned round the clock, because trauma does not take a break. Unlike the American medical dramas splashed across our television screens, the crises were managed with quiet efficiency. There were no loud orders as the dignified Dr Bhat and his anaesthetic team blocked the nerves to the injured part. With a good knowledge of anatomy, and experience garnered over the years, Dr Bhat was a legend in the field of anaesthetic blocks. I watched in admiration alongside anaesthetists who had travelled from distant countries to watch the maestro’s deft finger mark out the anatomical landmarks. No ultrasound images were needed. He placed the needle at just the right angle and slowly injected the numbing fluid. The patient’s anguish faded quickly and they lay in quiet repose while bloody bandages were unravelled to expose the maimed part. Nurses glided in with efficiently stacked trolleys. They cleansed and sterilised the area with antiseptic-soaked gauze and the mindless wastage in Australian theatres flitted through my mind. With non-disposable sterile drapes in places, the scrubbed-up surgeons moved in to clean, debride, anastomose and suture. Peering into their microscopes as their deft hands tried to restore mangled anatomy, I felt as if the pooja I had witnessed in the foyer had moved into the operating theatre. This time, however, the deity was the anaesthetised patient.
When the fellowship ended, Dr Langer and I were farewelled at a well-attended ceremony in the large auditorium of Ganga Hospital. I was asked to address the audience, and I reflected on the profitable and inspiring time I had spent at the hospital. I mentioned that my association with the hospital went back to my teenage tonsillectomy and talked about how my career had taken me to the UK and Australia. I had no doubt that the quality of clinical work and research being carried out at Ganga Hospital was among the best in the world. I said it felt wonderful to come back to India in search of expertise, reversing the trend from years past when professionals had looked abroad. Expatriate Indians like me, who now had families in the West, were likely to remain anchored there but I was gladdened by the pursuit of excellence in institutions such as Ganga.
I also expressed my delight at how this success was happening within the Indian culture. Growing up in Coimbatore, there was a perceived connection, albeit indirect, between ‘progress’ and ‘Westernisation’. Leading economists at the time had explained the Indian malaise as a reflection of the ‘Hindu growth rate’.
Walking around the hospital, the quotations on the walls from Swami Vivekananda and the smell of lingering incense after an early morning worship struck me as a nat
ural backdrop to the pursuit of excellence.
The Ganga brothers had also left India and trained in the UK and the US. Dr SRS had brought back plenty of his experience from Louisville, Kentucky. The microsurgery course offered at the hospital was based on the classic instructions of Dr Robert Acland, with whom SRS had co-authored the Manual of Microvascular Surgery. American fellows who came for a two-week microsurgery training course found their experience exceeded that in the US.
I recognised that the clinical work sat within a cultural and ethical milieu that was quintessentially Indian. Seen in its totality, the brand of surgical expertise fostered at Ganga Hospital appeared to me to be more a renaissance of the tradition of Sushrutha, the plastic surgeon who predated Hippocrates, than simply an emulation of the West.
I also expressed my satisfaction that the success of institutions like Ganga was being driven through the private sector. Previously, the centres of national excellence like the All India Institute of Medical Sciences, Post Graduate Institute or the Indian Institute of Technology were entirely a product of government grants and not subject to the constraints of cost-effectiveness. Providing excellent services to the community in a cost-effective way meant that these successes were more likely to be durable and able to be reproduced by other institutions.
I also spoke about what I saw as the main difference between standards in Australia and India. Because of more stringent regulations and the litigious nature of medical practice in Australia, poor practices were addressed urgently and weeded out quickly. This did not appear to happen as efficiently in India. However, at the other end of the spectrum, the culture of excellence is blunted in Australia. As a result, at the lower rungs of performance India almost certainly lags behind Australia, but at the top end India substantially outdoes Australia.
I finished by expressing my gratitude to both generations of the family that had created this institution of national pride and global excellence. I hoped that while Ganga Hospital continued with its world-class work, I could take my experience back to Australia and put it to use in the service of its people.
HAND IN HAND
I arrived back in Perth with my bags full of Indian goodies and my head full of aspirations. As I waited for the quarantine officers’ verdict on my mother-in-law’s fish pickles and my mother’s jackfruit jelly, I knew they could not touch my most precious import – the finer techniques of microvascular hand surgery. With customs behind me, I stepped into the bright blue skies of Perth. There was not a cloud in sight. The crisp autumn day welcomed me back to the land I had chosen to call home for the past thirteen years.
Weeks turned into months as I looked for opportunities to practise my new skills. The realisation that I was stranded began to settle on me. Not wanting to lose touch with mainstream orthopaedics, I continued to assist orthopaedic surgeons with their theatre lists. Standing on what I saw as the wrong side of the operating table, I actively participated in the blood and drama of the procedures. I looked for the silver lining in the job I was doing – the flexibility that it allowed for my maternal role to flourish. Francis’s career continued, helped along by my less-demanding job. Through all this, a yearning to work in the field of hand surgery remained. I longed to put back torn tendons, straighten crooked fingers and reattach nerves. I wanted to restore form and function to hands.
I went looking for a job in orthopaedics at the public hospitals, with a view to working in hand surgery. When I heard of a possible job at the Armadale-Kelmscott District Memorial Hospital, I felt a glimmer of hope. I was known to the administration because I had been both a visiting medical officer and an assisting surgeon there for some years.
I set up a meeting with someone I knew to sound out what they thought of my chances but, as the meeting progressed, it became clear that he was not willing to employ me in the orthopaedic department without the imprimatur of the AOA. I asked him why a private body like the AOA had the power to make decisions about a public hospital appointment. He shrugged his shoulders and gave me a weak smile. While the unspoken words ‘guilds’ and ‘cartels’ hung heavy in the air, he blurted out as if in his defence, ‘We have to be careful. Look at what happened at Bundaberg Hospital with Dr Jayant Patel.’
Dr Jayant Patel, a surgeon from the US, had been employed as the director of surgery at the Bundaberg Base Hospital. The medical board and the hospital had failed to properly vet him, probably because he was an American citizen. The hospital was desperate for a surgeon and they overlooked the red flags and chose to employ him. A few years later, amidst widespread publicity, he was convicted of negligence, cowboy procedures and patient deaths. Now labelled ‘Dr Death’, his fraud and manslaughter charges were splashed across newspapers, radio and television. The public devoured sensational reports that emphasised his Indian birthplace. Yet, what was the relevance of the country of his birth when he was clearly employed because of his American training and background? It occurred to me that there was no reference to Wales when describing Australia’s first female prime minister, Julia Gillard; neither was the adjective ‘American-born’ frequently used to describe Kristina Keneally, the premier of New South Wales. Why did the media constantly make reference to the ‘Indian-born’ Jayant Patel?
The frenzy whipped up in the media had dire consequences for local doctors of Indian origin. Comments like ‘You’re not related to Dr Death, are you?’ and patients declaring they did not want to be treated by an Indian doctor were not uncommon. I wondered if anyone would ever ask me if I was related to the Hollywood actor Dev Patel.
Until then I had been trying to make sense and reason out of that meeting. But now I was left facing the full impact of his statement. It appeared to me he was judging me by the lowest common denominator and I had been proclaimed guilty until proven innocent.
Sitting with him, I realised the poison had seeped widely and was being used to cover up dubious employment policies. With one brushstroke, a whole section of the medical community – including me – was tainted with the spectre of death. The caring profession could not have cared less about dispelling the danger of a single story.
Though I was in limbo, I continued to look for possible opportunities. Thirteen years earlier, I had had a conversation with an upper-limb surgeon in Perth. This was the conversation that made me decide to continue the pursuit of FRACS as opposed to working as a specialist in a peripheral non-teaching hospital. Now a chance to do a stint as an ‘upper-limb fellow’ with that same surgeon came my way, entirely by accident.
During a break at a Hand Surgery Society meeting, I saw Dr Moody.
‘You probably don’t remember me, Dr Moody. I spoke to you years ago, seeking your advice on pursuing hand surgery.’
‘I probably wasn’t very helpful,’ he replied insightfully.
He asked me what I was doing and if I would like to join him as a fellow. His British fellow had left suddenly the week before. I did not hesitate. It would be wonderful to work with someone considered to have so much hand surgery experience in Perth. The paperwork was put in place and I joined him in his private practice. Not long after, I realised what he needed was an assisting surgeon who could go between the two theatres he ran simultaneously, ensuring patients were turned over quickly. The theatre lists were predictable. Day in, day out, he freed carpal tunnels, scraped out ganglions from tiny, arthritic fingers joints and released Dupuytren’s contractures. The Dupuytren was named after a French military surgeon who had the dubious honour of operating on Napoleon Bonaparte’s haemorrhoids. Unlike Dr Moody, Dupuytren’s repertoire of surgical expertise extended from the fingers to writing a treatise on the artificial anus.
The pedestrian procedures were distributed between two theatres and I learnt very little as I sutured wounds in his wake.
As one of the advertised features of Dr Moody’s Fellowship was research, I tried to engage with him at that level. I gave him a brief outline of my work on the digital gradient that could serve as a biomarker for likely non-union in the s
caphoid. A few days later, I asked him about his thoughts on the work. ‘That is just a bloody waste of time. Much easier to put in a screw.’ Overriding science, he appeared more comfortable in his role as a technician.
In a serendipitous meeting with a plastic surgeon I declared my interest in hand surgery. Dr Sloan suggested I approach the plastic surgery department of Fremantle Hospital. Their hand unit, situated in the plastic surgery department, was looking for a hand surgeon. They were short-staffed and had a backlog of patients. It seemed like a match made in heaven. I was elated that I would finally be rendering a public service in an area in which I longed to work.
When I offered my services to Fremantle Hospital, the administration had no problem with me working, as all my paperwork was in order, but they were not able to pay me until a position was created. I was happy to do unpaid work in clinics and theatres while the surgical division pushed for my appointment as a paid consultant.
The hand clinic was unusually quiet one day. I looked at the notes of the patient who should have been here ten minutes ago. A series of ‘DNA: Did Not Attend’ stamps ran across the page. Today would be no different. I hoped the young man’s injury had healed well. While I waited for my next patient, I took a trip down memory lane – all the way back to my days as an intern.
Halfway into our internship, my friend Smita announced her marriage. We were surprised. Smita was a quiet, scholarly and studious woman who seldom joined us in our outings and frivolities. She had set her eyes on pursuing her studies in the US, where her dreams of studying cancer could be realised. She was determined to pass the licensing exams.
Her marriage announcement came out of the blue. Our hopes for a clandestine love affair were quickly put to rest. She explained in a matter-of-fact tone that her parents had introduced her to Prakash, an American citizen, who was looking for an Indian bride. They met and spoke while their parents had visited the astrologer. The horoscopes matched and Smita and Prakash liked each other. An auspicious day had been picked and arrangements for the wedding were underway.