The Unsung, Underpaid Heroes

I watched her insert the IV cannula effortlessly. She made it look like a piece of cake. Deceived, I tried it on the next patient as she stood by the patient reassuring him. He yelled out in pain and most probably cursed me in his head! She quickly took over and completed the procedure smoothly. “Its alright Doctor! We all learned with practice.” The male nurse who helped me with my first catheterization attempt (it ended up more like him doing the procedure with me assisting!) had the same piece of advice for me. And how can I forget the other nurse who gave me the confidence as my hands trembled trying to put my first sutures on a six year old boy. The head nurse who would whisper to you during rounds that there are sweets in the nursing station (look malnourished, resemble her daughter and be a workaholic…you are definitely getting more food) and the sisters who made the extra cup of coffee for you during night duties… It was many such kind and efficient nurses in my Alma mater who taught us interns basic medical procedures. Though we learned the theory and many important procedures from seniors and consultants, it was the nurses who taught us the basics. And every doctor has the similar story to tell. The nursing staff taught us, scolded (throw the gloves in the wrong bin and they would make sure you paid for it!), and most importantly tolerated our haughtiness.

Are these caregivers not truly unsung heroes? Nursing is the largest occupational group in the health sector, accounting for approximately 59% of the health professionals. According to the World Health Organization, state of the world’s nursing 2020 report, nurses constitute 47.0% of health workforce in India. They literally “nurse” the patient back to good health. It is not just the medicines that the doctors prescribe, it is this care and watchfulness of the nurses that help a patient recover and get back on the road to health. If they don’t do their job well, no prescription from the doctor will do the hospitalized patient any good. Yet they are paid so poorly and treated with so little respect in India. During this pandemic, let us remember all the nurses who are struggling in PPEs to help patients survive. But this annual remembrance is not enough. Maybe it is time, we call out for better payment and benefits for nurses. With that, I pay my honors to all the nurses who cared for me during my hospital admissions, who taught me the basics of patient care and dedicate this to my favorite nurse, my mother.

Breath and Lies

27/04/21

What is the worst feeling in the world? Looking at the pulse oximeter on your finger and seeing a SP02 level of 55% in spite of being on oxygen support? Or being this patient’s doctor and having to lie to him that he will be fine? My heart was sinking as I helped my colleague in the ICU fix the BIPAP mask on this patient. He was just 36 years old. After admission to our ward two days back, he seemed to be stable though he was on high oxygen support. We had started him on all the medicines being tried for severe COVID-19 disease. But his oxygen levels started dropping in the morning. We tried dual oxygen support and simultaneously sent out the SOS to all the ICUs. But there were no vacant ICU beds. It was by 11:00pm that we got a vacant ICU bed. But we were late.

At around 11;30pm, I watched helplessly as the young man started to panic seeing his pulse oximeter reading. His brother had to hold his hand down and lie to him that his saturation was improving. I said a prayer for him and went on to lie to him. “Please don’t worry, its improving. Relax. You will be fine”. But I knew it was a lie as I saw his saturation not improving despite the ventilator settings. “Going to intubate him”, my ICU colleague informed after a few minutes. “Ma’am, let’s go back. I am really tired and the ambulance is waiting down to take us back to the ward”, the ward boy was almost pleading me through his sweat stained PPE. He had struggled to push the wheel chair and an oxygen cylinder through the unending maze of the hospital in a PPE in this summer. I nodded and walked out as the ICU team surrounded the patient with the intubation set.

“Ma’am, will he live?”, his friend/relative wanted to know. This man had literally carried an oxygen cylinder over his shoulders as we were unable to find a trolley to transport the patient from the ambulance to the ICU. How do I explain to him that all his efforts were most probably in vain? Hence, I looked him in the eye and told,” The condition is a little serious. The ICU team is doing everything they can. Let us hope for the best.” A little lie. Or maybe twisted truth. The ambulance took me and the ward boy back to the ward. It was 12:00 AM. The road was empty. Yet, the driver had turned the ambulance siren on. Maybe it was a habit for him. Just like it is a habit for us doctors to not let our mind ponder too much about the little lies we tell dying men.

I was going through the patient list on the online portal. And there was a familiar name. But then I noticed the “current status” column…. “Expired on 28/04/21, 4:00 am.”

To whoever is still holding to the belief that “COVID is a myth” or “I am young and strong. Nothing will happen to me.”……He was just 36 years old. And not being able to breath is a terrible way to die. So, stay home. Stay safe. Follow COVID protocols. If not, some doctor will have to lie to you that you will be alright as he/she struggles to help keep you alive.

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Why the hurry my friend?

I have simply never been able to compromise on the window seat. It is probably the joy of craning through to get the first glimpse of hometown when the flight starts to descent. Or maybe that’s just an excuse. But as the scene outside changed from blue to green, I was already singing. As soon as the flight had completed landing, the stewardess made a gentle request for all passengers to remain seated and to get up only after the person in front exits. A sensible policy to prevent crowding and maintain social distancing. But guess I was the only one who heard that announcement (my excitement to be home giving me hallucinations?!). As soon as the doors opened, EVERYONE had to get up and take their bags out. Was it fear that they might get stranded? Or were they all more excited than me to be home? Or did they want to check if their precious bags are alright? Why the hurry, I wondered.

“All passengers travelling by xxxxx flight, please collect your face shields and masks,” the airport staff announced. The very next second, people crowded around him for the personal protective items being distributed. I found that crowd quite ironic! Why could everyone just not wait and come in a line? It was absolutely assured that one will not be allowed to enter the flight without a mask and a face shield. So these items would surely be provided. But I guess, we are so impatient. We humans simply have to hurry. We need to make sure we have it before others. But will this hurry cost us our lives?

Yet another factor I am still trying to get around is the hurry to board the flight. When you have a boarding pass and you are at the boarding gate, the flight will surely not leave without you. Unlike a public transport bus one does not have to hurry to get a seat. Your seat is reserved for you and there is no way you will have to travel standing. So then why? Why crowd at the boarding gates?

Man is always in a hurry and my air travel experience during COVID-19 times reminded me of it. This was a personal emergency and I could not cancel this trip. But I hope I don’t have to travel soon. The airlines provide you with PPE and give instructions about social distancing, wearing face masks and hand hygiene. But I worry about the hurry this world is in. Will this rush lead us straight to our graves?

Towards a Fairer, Healthier World

Alas my lad, why is the world so bad?
In her shanty she gives birth
While for his cold, the specialist is called forth.
His parents argue about best schools in town
While she helps in the fields without a frown.
A mother walks miles
For a pot of water all these trials.
While the lady in the shower
Splashes away for more than an hour.


Alas my lad, can we not improve a tad?
The famished and the rotund
The starving and the glutton
The destitute and the opulent
The queer and gender intolerant
Unfair, oh how unfair! One cannot stand such despair!
Pollution and poverty. Disease and discord. Filthy water and baleful diet.
All to our health create a riot.
Unhealthy, how unhealthy! Death does eat us away so stealthily!

Alas my lad, let our cry be heard.
Come. Cry. Cry out to build a fairer world, a healthier world.

World Health Day was celebrated on 07 April, 2021 with the apt theme – Building a fairer, healthier world.

The Palette of Anemia

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White.

White is the color of her nails.

Underneath which little blood tails.

Red.

Red is the color of her pill

That she said made her ill.

Blue.

Blue is the color of sheet in which her baby lies

Asleep as his mother in despair cries.

Green.

Green is the color of her hospital gown

That in her blood and tears drown.

Yellow.

Yellow is the color of the flowers

That on her grave her family showers.

In India around 50.3% of pregnant women are anemic. Hence it is no surprise that I rarely found a pregnant women with normal hemoglobin levels at the PHC. Anemia during pregnancy decreases the woman’s reserve to tolerate bleeding either during or after child birth and is associated with increased risk of intra uterine growth restriction, premature delivery, low birth weight (LBW), maternal and child mortality. How can we improve this situation?

Another New Year

New year seems like the best time to glance back at the previous year and retrospect. 2020 is definitely not in the good books of most people yet I would like to look back in gratitude.

I am glad that we made it through. Many fellow beings were not so lucky as the virus or some other mishap cut short their stay on earth. By the grace of the Almighty, all my dear ones with whom I began 2020 are still around even if we are separated by distance. All of them are alive and happy. This is the greatest blessing this year. And it reminds me-” not by our might, but by His grace…”

There were no major life changing events last year. No milestones were achieved. Yet it was a great year. I learned to enjoy and appreciate the little things in life. Last year was all about getting out of my comfort zone. It was not easy but I tried, failed, tried and succeeded.

An important lesson learned was that many an adventure awaits just at the other side of fear. The person who was petrified about driving was blessed to learn to drive. It was a moment of praise and joy when I was able to drive on my own.

My legs would simply refuse to rise as I tried to swim. Just go in and try to let go, Bawana’s simple advice worked like magic as I tried to swim towards her extended arms. Nope.. Can’t swim well yet.. But I am over the fear of water. This also taught me that it’s never too late to learn or be anything new. All that is needed is that first step.

The hike to watch the sunset at Nainital was the first attempt at hiking. I was panting like a dog yet made it to the top. It was a moment of personal pride, one that many may not understand. All thanks to the friend who had the patience to be with me in spite of the fact that I was slowing him down. He let me move at my pace and we made it to the top. Note for self: Do this to others too…..in any field at any point in time.

From being the one whose heart would skip a beat if she saw a dog coming towards her, I became a dog person. All thanks to Joey. He was a lost puppy. Someone in the hostel found him and decided to keep him. I am glad she did. With Joey, I learned to get over my fear of dogs. Now I am no longer scared of them. I can stop to pat them and even let them sit next to me. Long way indeed.

Testing positive for COVID-19 took away almost a month of this year. But it was a time for retrospection. A time of rest and healing. Understood that people who are meant to be will stick by, no matter what.

Then there were the little things. Learned to cook myself a decent dinner. Made an attempt to eat healthy and exercise. Laughed tears of joy and cried pools of despair. Enjoyed dancing(no matter how awkward). Learned to play cards. Spent quality time with family and friends. Painted a wall. Published a research paper and a review article. Read more than a dozen books. Learned to do French braid. Wrote a poem. Little things.

Also learned to set small goals for myself. It was good realization that it is better to compete with yourself than others. “A flower does not think of competing with the flower next to it. It just blooms.”…This was a great life lesson. It is no longer about being like someone else. All I try is to be a better person than I was. And that gives a lot of respite from problems in life.

I write this sitting under a pine tree with the musical of the sea in the background, my heart content. Nothing grand happened, but I leave 2020 with gratitude and a hope of being a better person.. And as I continue this journey, I am grateful for the small bunch of people who have stood by and walk with me to the new year.  


World No Tobacco Day- 31 May, 2020

TOBACCO

I was fifteen.

Whorls of smoke rose from father’s lips

But my first smoke felt like lung whips.

Routine. Ritual. Habit, it became

And life would never be the same.

I continued.

They the heroes took the puff

And I bought it on the cuff.

It seemed cool

Till I knew I was made a fool.

I smoked.

I was twenty.

Colleagues with teeth stained red.

Try it, they said.

Red stains. Pan and gutka stains. Tobacco stains.

And Alas, it brought all these pains.

I chewed.

Bitter it tasted

And my money was wasted

Yet, I spat out red

Until the day I spat out blood.

I bled.

I realized.

 Importance of life’s most

 Is realised not till it’s lost.

People. Time. Money.  Love. Air.

No, this isn’t fair.

I gasped.

Every breath a struggle

Machines giving all oxygen they could smuggle.

Now it is too late

To create a new slate

I knew.

I left.

A warning note

To my son I wrote.

Slow death. Painful death. Breathless death

This tobacco steals your breath.

I cried.

Little packets of lies

Your pocket it dries.

To life I bow

Thanks to tobacco.

I died.

Women

Saturday, March 07,2020

That clacking of heels stood out despite the cacophony in the OPD room. I glanced up to see the source and the grimace (that sometimes involuntarily jumps onto my face while trying to scold a non-compliant patient) ebbed into a smile. She was the next patient. Standing tall at a little more than four feet, she walked in with a confident smile and wished me good afternoon. She looked like a twelve year old gifted with more maturity than her childish eyes could contain. She was accompanied by an older girl who was around twenty years old. They were tailed by a young lad with a squint who was busy playing with the OPD door. Yes, even a normal door can fascinate a young child.

I inquired of my young patient as to what brought her to me. “I am having weakness…” she said in a sing-song manner. I tried my best not to smile too much. By then the older girl had taken over and narrated a story that would pull my heartstrings ( and hence find a place here). The young girl and the little boy were her neighbors. Their mother had passed away few years back. Their father had remarried and their step mother had given birth to a baby boy few days back. So our little lady was now taking care of the household. “So, does she not go to school?”, I had to interrupt. Apparently, she does. She wakes up early in the morning, cleans the house, cooks food and then goes to school. After returning, she has to do the laundry and prepare food. “So ma’am, please do write some tonic to improve her strength,” the older girl requested. One part of me wanted to yell at her that a twelve year old will not have the strength to do so much, no matter what magic potion I prescribe. But that would not change anything. “Is there no one else to help her?” , I asked rubbing my forehead. I was having a headache by now( or was that a heartache?). “No, not really”, the older girl was the one still replying. The little lady still stood as poised as ever. And the young lad’s latest fascination was the blood pressure monitoring apparatus.

I gave her a prescription and made her promise she will not stop going to school no matter what. “No ma’am, I will not. I love going to school. I want to become a teacher when I grow up”, her confident voice was reassuring. More reassuring than what I could imagine would happen to her. Probably that was all the reassurance I would have about this meeting. She thanked me and her heels clacked away. I sat still till that sound faded. She was the strongest woman I had met today. Yes, sometimes, age is just a number. Some of us are blessed to retain our childishness forever. But some like that little lady are forced to grow up faster and adorn roles beyond their age. This women’s day, as I think of all the women that have inspired me, this little one also makes it to the list. She will never know that though.

Sunday, March 08,2020

“Ma’am, I am getting discharged today. What about my medications?”, a thin hand was waving a prescription slip at me. It was her third post natal day and she was taking her little one home today. An older man was standing next to her. “Is this your first baby?”, I asked her. Looking down, she replied, “No, its my fourth child”. “So you will be coming back for sterilization right?”, I asked. “No”, the lady and the old man answered in unison. “How many kids do you want? Do you know having another baby will not be good for your health?”. “But it is a girl this time too…”, came the most logical explanation from the older man. “So??”, my tone had definitely become harsh by now. The man grumbled something and left the room. The woman looked at me helplessly. “How old are you?” “Twenty four”. Wow. Twenty four and four kids. Since this was not too uncommon in this setting, I had taught myself not to be too shocked.

“Ma’am, I do not really want another baby. I will talk to my husband and plan about sterilization.” The absence of the older man in the room had installed a new confidence in the lady. I wrote her medications and counselled her on breastfeeding and vaccinations. “Make sure you come back……”, with that I handed her the prescription. I really hoped she would come back…but not come back pregnant. Despite all the talk on women empowerment these days, the quest for the boy child still continues. She was just one of the many. One of the many woman who survive one child birth after the other to gift their family with a male heir.I hoped this lady would have the courage to stand up for herself and her four girls. If only her family realized that these four girls were blessings and strove to bring out their maximum potential….I opened Whats app and replied to all the “Happy Women’s Day” messages with a pang. How many women out there are really blessed to be happy? Worth a thought.

Stigma

A frail hand held out the OPD card towards me. One look at her and I prayed she was not pregnant. When you are posted in the OBGyn OPD in a Primary Health Centre, it is not uncommon to find such frail figures coming for their fourth or fifth delivery. On probing her complaints, she looked down, covered her mouth with the edge of her saree and said “cough”. Sometimes, certain images get pasted in our minds. There is often no specific reason for it. But your eyes would have captured an image and your crazy brain just gets fascinated by it and decides to store it in a folder titled, “Worth a Thought”. That frail lady. Her yellow saree. The way she looked down. The swift movement of her hands as she covered her face. All of it got imprinted in my head. And there was just one caption that could be given- Stigma.

Cough for two months. Productive. Considering her malnourished appearance, the obvious thought in my head was Tuberculosis. “Have you had your sputum tested?”, I probed. She bowed her head even lower, turned around to see if anybody was listening, and then whispered, “Yes. And I was told it shows TB. I have been sent here to get my blood sugar and other tests done”. After getting the rest of her history and examining her, I wrote the slip for the necessary investigations and referred her back to the RNTCP DOTS centre for initiation of treatment. But my conscience told me, there was something more I had to deal with here. Stigma.

The time that you regret a language barrier at work place is when you really want to try and counsel someone. I made the best effort to tell her that Tuberculosis is curable if treatment is followed properly. After two minutes, she was in tears. And she poured out her fears. The main demon in her eyes was not the disease. It was the stigma. What would people say now? She was standing at the edge of a dark pit. One push and she might succumb. Succumb to stigma.

India has come a long way in management of Tuberculosis. As a matter of fact, we are trying to achieve the sustainable development goal of ending TB by 2025, five years ahead of the global targets. Our National programme, Revised National Tuberculosis Control Programme (RNTCP)has been recently renamed as National Tuberculosis Elimination programme (NTEP). We have more efficient and feasible methods of diagnosis and better chemotherapy. The mycobacterium can now be detected easily and terminated. But none of these drugs can deal with the fear I saw in that lady’s eyes. A fear called Stigma.

We definitely have a long way to go. To tell people that falling sick is not a mistake. That it could have been anyone, including ourselves. Compliance is important and the cure will be just around the corner. Tell them how to prevent disease from spreading. Tell them what to do. Tell them what not to do. Tell them stigma is just the reflection of people’s ignorance.Tell them it is OK. Tell them there is hope.

We have reached the point of eliminating TB. Laudable beyond doubt. Next stop might just about be eradication. But as we try to give the best treatment to our patients, lets not forget the small (yet significant) issue of stigma. This is the social evil that could turn that yellow saree into a loop for the poor woman to end her life. Yes, we have a long way to go. Miles more. Like Robert Frost penned,

“The woods are lovely, dark and deep,   
But I have promises to keep,   
And miles to go before I sleep,   
And miles to go before I sleep.”

Yes, we have miles to go before we can outrun stigma. But at least lets start by trying. I wondered how much of my broken Hindi the lady had understood. But as she was leaving the room, she no longer had the saree over her face. Her eyes were no longer downcast. There was some light in them. Stay strong and fight, I wished her in my head. She sure has a long way. But at least she will try and cut the Gordian knot of stigma. Hopefully.

Tiny Heartbeats

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Her expression was blank as she carefully placed her hands over an obviously pregnant tummy. She was the first patient I was to see at the Primary Health Center that day. Taking her outpatient slip, I inquired of her complaints. “I have not been able to appreciate my baby’s movements since last two days.” I went through her previous records. She was 37 weeks pregnant and this was to be her first baby. Her eyes reflected fear and I felt her silently pleading me to tell her all was fine. Two days!!!Why didn’t you come earlier? I had to ask her. She gave some vague response as she positioned herself for examination.

Lord Jesus, please let this baby be alive. I prayed silently as I approached to examine her. My heart was honestly troubled and I hoped I didn’t have to tell her that she had lost her precious little one . With that prayer in my heart, I placed my hands on her abdomen. And the very second, the little life inside her budged! I looked at the mother’s face. She was beaming. Phew. Praise God!! Next I tried desperately to listen for the heartbeat using my stethoscope. But my ears failed to pick up the sound I yearned to hear. So I got the Doppler Fetoscope out to auscultate. After few failed attempts, a beautiful sound filled the room- Lub Dub Lub Dub…The tiny heartbeat was a solace to the mother’s ears and unknown to her, mine too. Sometimes, certain sights or sounds can simply make your day. It seems more beautiful than anything else around. And such moments always manage to draw out a song of praise from our hearts. Thank God for such beautiful reminders of grace!