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The Poverty Vow

(c) Dr. Rajas Deshpande

Long day. Came home. Ritual steamy hot bath to wash away the hospital feel, followed by steaming hot dinner. Switched on jazz, and I picked up the pasta. Heaven descended upon my tongue.

“How perfect this moment is!” I thought, and that’s where I was wrong. The phone rang.

“Sir, 18 year old buy, had fever since a day, took some tablets, became unconscious, now comatose. Vitals are stable, although he is coughing occasionally. No past history significant. Poor family, cannot afford treatment. Father is a labourer. What should I do?”

“Get him into the ICU, intubate if required and stabilise. Arrange for an MRI”

“OK Sir, but Sir they don’t even have a deposit. They had first gone to the government hospital, but as they were not happy there they have come here”. (c) Dr. Rajas Deshpande

“We will work something out. I am on my way” I replied.

In an hour, after examining the boy and seeing his MRI and other tests, we concluded that he had viral encephalitis. The standard medicines were started.

The boy’s father, an obvious poor slum dweller, was in a state of shock. The mother, sobbing, told me the history. I reassured them. When I explained the diagnosis and treatment they asked some questions.

“We don’t understand anything, we are illiterate and poor. Do anything Sir, Just save my son, Sir” the father folded his hands together. Private hospitals have a quota for free patients, but usually it is always overloaded. I requested the hospital management to please make this a free case, they accepted.

The next day, the child opened his eyes. On the third day he started responding. I was quite elated to have his mother speak with him. However, his respiration was still shallow, and blood presure very low. His heart rate was fluctuating due to the effect of viral infection. He was still critical. I spoke to his parents twice every day, specifically reassuring them. Poor patients must never feel that they are not equally cared for. (c) Dr. Rajas Deshpande

That evening, as I attended my patients in the OPD, the patient’s father came in, requested that he wanted to have a word. He came in with six other people. None of them could possibly be poor, given their get ups.

“Yes?”I asked.

The patient’s father looked at the giant next to him. “You ask” he said to the giant.

The giant, chewing his gutkha, askked me “What’s wrong with his son?”

“I have explained them thrice”I replied, “he has viral infection of the brain. There’s a lot of swelling upon his brain”.

“How come he is not improving? His BP was normal when he came. He did not have any heart problems. Now you tell us his heart is not functioning well” asked another medical superstar with white linen and gold teeth. (c) Dr. Rajas Deshpande

“Yes, this happens commonly with viral infections” I replied, feeling hopeless. How to teach complicated medicine to this pure- muscular class? I wondered.

“But you said he had infection in the brain. How come now he has it in the heart? Is the treatment wrong?” Asked someone similar among them, in a tone nastier than medical examiners.

I looked at the patient’s father. He was looking at the ceiling, deliberately avoiding eye contact with me.

“Listen, Sir”, I told them, “Your patient has viral infection, it has primarily affected the brain, but involvement or dysfunction of other organs is well known with such infections, this is not something new to us. We are on guard, dealing with the situation. Nothing is wrong about the treatment, in fact his brain swelling has improved, and he is conscious now. Ask his mother” I looked at her.

“I don’t know” she said, “we don’t find any improvement in my child. Nobody tells us anything”.

“Haven’t I explained you and his father patient’s condition every day?” I asked. They did not reply.

The white linen gold teeth spoke again: “We want a report. We want to show the case to another doctor”

That was a relief. I gladly wrote them a report. They went doctor-shopping all day. They returned next day. Almost everyone had asked them to continue the same treatment that we had advised, except some desperate non-specialist telling them to shift the patient immediately for a surgery at his hospital. Even our gold-toothed medical superstar understood that it was wrong! (c) Dr. Rajas Deshpande

“We will continue treatment here only. But our patient must survive” came an open threat.

”I will do my best, but I cannot guarantee you anything. You may please transfer the patient under the care of any doctor of your choice” I told them.

“No no, you continue to treat him.But if anything goes wrong, we will file a police complaint. We will ruin this hospital”said one of them.

I am allergic to threats. I don’t allow them twice from the same source in my life. How could any doctor guarantee that there could be no complications? How could I say that the patient could not react to any medicine in such a critical condition? If every patient could have guaranteed improvement, what’s the need for a doctor?

“I am sorry, I am planning for a leave next few days. I won’t be able to see your patient. I have requested our management to transfer your case to another doctor” I told them.

There was a movie “Teesri Kasam”in which the lead character, at the end of the movie, vows never to help the character of the lead actress in the movie, because the very wish and effort to help her has shattered his life, caused him regret. Most Doctors are now being forced to take such a vow. Urban Poverty is not so simple and innocent in a hospital as it appears to the media and society. Whether it is the roadside rowdiness of slum dwellers who roam around with weapons or a maid’s drunkard husband in civilised society, we all understand the misuse of poverty status well anywhere outside hospital, but somehow when this happens in a hospital, the blame is automaytically pinned upon the hospital or the doctor.

But who among the vote-mongers will speak against the majority voting bank?

(c) Dr. Rajas Deshpande

A Thumb Impression Of Our Society

© Dr. Rajas Deshpande

As the highly educated family: patient, his wife and daughter stared at my face, I bought a moment of thought by continuing to write instructions. Although the intensity of what I was going to say would affect them now, I knew what the future held a difficult and mentally traumatic, draining corridor they would have to go through in coming years. How to say this? I felt sad. Even after decades of experience, no doctor feels comfortable telling the patient or relatives about a bad or incurable diagnosis. It is a curse we must shoulder. Because someone must say it, someone must sympathize and stand by the patient and family, someone must face the anger and frustration of a family that was till yesterday living in the comfort of good health, completely oblivious to the fact that things may go wrong anytime with anyone. . © Dr. Rajas Deshpande

“You have a type of Parkinson’s disease with dementia. The Parkinson’s is causing your slowness and stiffness, and the dementia is causing the memory loss and change in personality. It is good that you have come at an early stage, we will be able to prolong lifespan with a better quality of life. With your cooperation I think we can do the best possible for the patient. I will give you some links to read from. Please read them and meet me again next week, I will be happy to answer all your queries, doubts and concerns”.

The stunned wife started sobbing. The husband closed his eyes in agony. The daughter, unable to speak, held her father’s hand. Offering them some water and coffee, I explained the daughter instructions about the medicines, tests to be performed, and asked them to see me next week. I wanted to spend more time with them, but the relatives of a critical patient in ICU were waiting outside for me.

“Dr. Rajas, my husband has been a brilliant scientist. He loves reading, writing and intellectual interactions. In fact that’s why we fell in love back then when I was his student. Intellect is his life. We will both die if that is taken away from us”. It was then that I looked at the lady carefully, because till now my mind was occupied with the patient. A very graceful, intelligent, upright and hence beautiful face, the one that tells stories about the highest culture and upbringing that there is. The grey hair added to the loving kindness of her expression. Intelligent Humility, that one element often absent from so many beautiful faces, was abundant upon hers. Somehow I remembered my mother.© Dr. Rajas Deshpande

“I understand, mam. Things are not so bad as of now, and we are still in the evaluation phase. I can give you a better idea about the future once I see the results of all the tests.

It was then that the daughter spoke: “Doctor, I am in India for only the next week. Can we complete the workup before next week, because I cannot postpone my travel back to the US. And yes, I want the best to be done for my father. ” the daughter said.

“Ok” I said. I have now come to accept the socio-cultural changes.

They came next week, the diagnosis was confirmed, I counseled them.

Then I explained the medicines and other care to the patient’s wife.

“Did you understand it well, mom?” asked the daughter, “because I will not be able to help you with this everyday”. The mother replied with her kind smile.

Three months later, the patient came back, with the daughter and her husband.

‘Doc, mom passed away with a sudden heart attack a month ago. She never told us she had any complaints”.

This happens so often: that when a family member is affected, everything revolves around their health, and the warning signs of caretaker’s disease are ignored till the last moment.

“Dad has become worse now. He doesn’t eat well, doesn’t speak with us. . We tried to encourage him to make new friends with his old age home society, but he doesn’t want to interact with others, he has always been stubborn. We have arranged for a caretaker, but dad doesn’t talk to him either.”

Looking at the patient, I realized how much emotional support he needed at that moment.

“I am sorry to know about your mother. Such a nice and kind lady!” I said.

“Thanks, doc. But now you must help us. Please help us find a good old-age nursing home for dad. I cannot stay back. We can pay well”.. she had a hint of “please let us get this over fast” in her speech.

“You said you wanted to do the best for your father. The best would be for you to be with him in these days, talk with him, connect him back with life for whatever remaining awareness he has left. There’s no other person upon earth that he will ever connect with, so this becomes your responsibility”. She knew the truth well, for she broke down. “I know doctor, but I have my family to look after. I cannot take my father with me. I am sorry”.© Dr. Rajas Deshpande

She visited again with the patient, before leaving for the US. A bank officer and a lawyer accompanied them.

“Dr. Deshpande, I need a certificate, my father cannot sign, and is in no condition to think coherent now. So we want to get his banking and legal formalities about our property completed with thumb impressions. I need you to authenticate dad’s thumb impression”.

The old man printed his thumb impression in my presence. Somewhere within, I knew he was violently crying although he must be hiding it just so that his daughter doesn’t feel bad while leaving him.

That Thumb impression, Decoded, was in fact the stark face of today’s society.

© Dr. Rajas Deshpande

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The Deadly ‘Vegetable’

The Deadly ‘Vegetable’

“How is my mother, Doctor?” The smiling politician, a tower of patience, surrounded by his impatient bouncer cronies, and a drooling doctor, asked me at the door of the critical care unit.

I examined the patient, a case of a large bleeding that had caused severe damage in the brain. Inputs were whispered in my ears by the cautious doctors of the unit. The poor lady had been treated by many excellent doctors in Mumbai and Delhi, as the family of that politico had that free facility. However, she had stopped the blood pressure medicines as some “Herbal Baba” had criticized them on National TV. © Dr. Rajas Deshpande

“She is conscious, but cannot understand or respond at all. Her heart is beating well, blood pressure is holding up, and her breathing is fine too. She can move her hands and legs, but it all appears meaningless movement. This may last for weeks or months, and in some cases, even permanently”.

The ‘doctor’ with that group authoritatively asked “That means she is a vegetable now?”.

“The correct word is ‘Vegetative’, the medical condition is called ‘Persistent Vegetative State’, and I cannot say as of now if this will be persistant. There are some chances of recovery” I replied with a carefully acquired masked face.

“Is there anything we can do anywhere in the world to make her brain normal again? I can take her to the best centers in the world” said the Politico. The drooling doc came forward again. His desperation to be significant was almost killing him. “Are there any medicines that can make her recover faster? We can afford anything” he asked.

I knew the exact words to reply him with.© Dr. Rajas Deshpande

“No Sir. Just as you cannot shorten the period of pregnancy, you cannot convert it to three months in the best of the hospitals , however rich you may be, the recovery of brain happens at its own speed. The medicines that can help her are already on”. This usually stops further discussion in that line, it did.© Dr. Rajas Deshpande

I went to the cafeteria to cool down. I couldn’t understand whether it was the tail-wagging doctor or the politico with ‘everything exists to serve me’ attitude that irritated me more. A cyclone of the big picture started rising in my mind.

The state of our “Government run” healthcare, is more or less the same: Vegetative. Big plans, big declarations, more investment, more land and buildings, more equipment, all surfaces, especially during elections. But the brain: good doctors in the system: is dead. No good healthcare system can be created or run by those appointed without merit, without quality. Thousands of huge set-ups declared and erected by the various governments are lying vacant, or serving far below their purpose because there are no good doctors/ technicians in most. The last battalion holding the flag of good healthcare: good medical teachers in medical college are on the verge of extinction. Best of the government-run hospitals and services are often reserved for those in power and their families. The shameless orders for “reserving ICU beds and ventilators, operation theaters etc.” for a patient known to a politician are a daily affair, they least care if someone else without an influence dies.© Dr. Rajas Deshpande

Appointments of drooling, medal-hungry shoelickers on various key medical posts has crippled the system. The real poor and deserving are thrown from one window to another to submit documents and applications to claim the benefits that they deserve.

The whole blame of a this deadly “Vegetable” healthcare is cunningly shifted upon those who refuse to work as ‘personal servants’ to the government, those who go into private practice, and private hospitals. Now almost all doctors complete their bonds, yet there is a gaping hole in the system that cannot retain specialists for long. Only the compromised, beginners, and failures stay for long in adverse, sycophancy based, low-cost environments. The very politicians who say “Don’t worry about money” when asking treatments for their own family, accuse the doctors of being “greedy”, when they leave govt. services.© Dr. Rajas Deshpande

The simple solution, the recovery of the brain, i.e induction and retaining of good, meritorious, non-shoe-licking and highly qualified specialists in the government-run healthcare departments and set-ups will probably change this scenario. But this looks impossible, now that even many doctor’s organisations have started losing their autonomy, self respect, to fall in line with the glorified slogans and to lick the bottoms of those who run such failed healthcare systems. The addictions to blow up any tiny good news, modify data to appease masses, hide the blaring failures, deficits and corruption in the healthcare have become a norm, and even our society seems to be ecstatically happy to just hear loud speeches of big plans rather than facing ground realities.

Indian Healthcare run by various governments, except for very few honourable exceptions, has become a brainless “Persistent Vegetative Healthcare System”. A ‘deadly vegetable’, for the understanding of the drooling docs. Unless someone sane and responsible in healthcare department acts quickly, we will lose this healthcare battle.

© Dr. Rajas Deshpande

PS: During the writing of this article I received over 20 phone calls from patients, and 12 of them dropped, cut, hanged. This is our technical progress. Before we send men in space, can we deal with this?

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The Greater Squint

The Greater Squint

© Dr. Rajas Deshpande

“Why didn’t the doctor tell us? Is it allowed for the doctors to hide such information? I will sue him” the angry mother kept shouting as she cried. Her husband told her to calm down.

“I know the other doctor well, I will talk with him today. He must have his reasons” I replied.

“No doctor, we don’t want you to talk to him about this” said the father.

Their fifteen year old brilliant daughter had developed mild headache and occasional giddiness. They had first read blogs about these symptoms, and after trying out various “natural” remedies and lifestyle changes, visited their family physician. He had started with the routine medicines for headache, and advised them to visit a specialist if the symptoms persisted for a week. As the headache didn’t subside, they visited a specialist. His notes indicated a normal neurological examination, and some higher medicines for headaches and giddiness. After a week, the girl developed a squint, double vision and slurred speech suddenly, and was unable to walk. She was brought to our emergency, her MRI of the brain showed multiple sites of infection including the lower part of the brain. Although most infections are treatable, those in the lower part of the brain (called brainstem) are extremely dangerous, and can cause even coma or death. This part has all the vital centers of the body, controlling heart rate, blood pressure and respiration. © Dr. Rajas Deshpande

When I explained this and advised admission for further treatment, they had panicked. That is when the mother had lashed out at the earlier doctors.

After admitting the child, the father came back.

“Doctor, I must make a confession. My wife is quite anxious, and she was crying when we saw the last doctor. That’s why the doctor didn’t tell her everything, but asked her to wait outside and informed me that there were such dangerous possibilities as cancer, tumor or infection, and that an MRI was necessary. I requested him not to write that on paper, thinking that my wife will panic. She is very emotional. That’s why we waited for a few days, thinking that things will improve. Please understand us, doctor”. I reassured him, and treatment was started.

The inflow of blatant allegations against allopaths/ modern medical practitioners is now so wide and strong, that this has sensitized some of the best doctors. Some have started to entirely avoid mentioning the tests required for a complete evaluation of a condition, knowing that if the doctor advises any tests, the only interpretation in our society is that those are for earning more money.

“Patients themselves do so many tests and take so many medicines without consulting a doctor. But if we advises any tests, the immediate allegation is that we want to earn more money. That affects our practice. So shall we still advise tests?” asked a colleague during a recent seminar. © Dr. Rajas Deshpande

The answer is a definite, loud yes. The duty of a doctor, besides being well qualified, skillful and compassionate, is also to boldly state fact and possibilities, advise the best investigations and treatments to every patient, poor or rich, VIP or AAP, and write these all on the patient’s case paper. The workup / investigations advised should be according to the global best practice guidelines. Poverty and illiteracy are neither the faults or responsibilities of a doctor, and like other professionals or even some governments, a doctor cannot provide “low grade” service to any poor patient. From the eyes of a doctor, even a penniless beggar should get the same advice about tests, medicines and surgery that the Prime Minister of the land gets. If ministers can go to corporate hospitals or even abroad for treatment, every citizen should also be sponsored for the same benefits by the same administration through the same funds, without preaching the doctors to do more “charity”. Otherwise we are a hypocritical society. © Dr. Rajas Deshpande

Whether to do those tests or not, where to do them is the patient’s choice. Whether to take the advised medicines is also upto the patient. The doctor may suggest the best place, request concessions, and if the patient is poor, suggest options to get financial help or refer to charity. But the quality of medical advice should never change. The only exception is an accusative, angry patient who is making paranoid efforts to find faults with everything that you do. One may politely decline to accept such a patient.

If the treating doctor has not advised all the tests necessary for the evaluation of relevant diagnostic possibilities, he/ she may be found guilty of negligence. To avoid advising tests just to please the patient would also be a moral crime. One must also refrain from crossing over to other specialties and advising tests before referral to the right specialist. Some “pretending to know everything from every specialty”, doctors advise various tests incorrectly, and even attempt treatments out of their expertise without a working diagnosis. . Such dangerous doctors may add to the woes and defamation of the profession. © Dr. Rajas Deshpande

The girl above is improving, although her balance is off, and she has developed t a squint. Most likely her squint will never improve. She is missing school for over three months now. She will now onwards live a compromised life: incomplete education, compromised marriage and the condescending Indian society where shame of physical disability like squints and lisps, slurring and imbalance are the essential components of most enjoyed comedies.

However, her squint is far lesser a problem than the one that our society has, against doctors.

© Dr. Rajas Deshpande

PS: Many people comment often that “Doctors should introspect”. I do not know how many of these people introspect about their own habit of finding faults with others before self. But the article above is an honest attempt to do so.

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The Duty And The Reward

The Duty And The Reward

Highly educated and informed, Mrs. Vinodini Bapat came with a worried face about a year ago. Her MRI had shown a tumour. When I told her that it was likely a large Tuberculoma (A tumor mass caused by tuberculosis of the brain), she was naturally very worried. There was no definite way to know if it was a cancer.

After a long discussion based upon what she researched herself, helped by her loving husband and daughter, she was convinced that we can take a chance and start anti-tuberculosis medicines.

I was quite pleasantly surprised when I found that the whole family had completely trusted everything I had explained. To be very honest, doctors expect disbelief and multiple opinions mostly with the well educated and literate patients. However, although they asked many questions, tried and understood every step in the treatment, they were extremely polite and cooperative.

The test time came when her brain swelling increased, as happens with some Tb patients in the first few weeks if starting the treatment, and she threw a mini-fit. We had to admit her and treat as an emergency. Many questions popped up, but the family was as cooperative as ever, with complete trust.

The medicines caused many side effects, and we adjusted the doses to suit the patient best. She was extremely patient and tolerant in spite of so many ups and downs.

Now, one year later, Mrs. Bapat followed up today with her fresh MRI scan: the brain was now completely normal, there was no trace of tuberculosis. The tumor had disappeared!

When she handed over this beautiful note written for me, I told her that she and her husband were extremely cooperative and I was grateful for that.

Then they told me what I Wish every medical student learns: that it is important not to get annoyed with patient’s questions so long as they are relevant, to understand that it is the patient’s desire and right to know the details of their illness, treatment options and side effects, to participate in decision making, and above all, to be treated respectfully with compassion.

Educated patients who keep their faith in their doctors intact, and ask relevant questions without paranoid accusations should not be misunderstood. It is the duty of a treating doctor to honestly keep all the cards on the table and let the patient understand and participate whenever possible.

Once again my day is blessed with the ultimate rewards in medicine: a happy patient and words of gratitude.

©️Dr. Rajas Deshpande

Humanity Face / Off

Humanity Face / Off

© Dr. Rajas Deshpande

“Your father in ICU has probably had bleeding in the brain. We need an urgent CT scan” I told the son waiting outside. The old man was admitted late in the evening, although he had had severe headache and weakness on one side since that morning. His son had just returned after a “one-hour” quick meal. Besides flaunting many brands upon his person, he had already told me that he was the vice president of a well known software company.

“Yes, doctor, I am just waiting for the approval from his insurance company.” The son replied. For doctors running in and out of critical care units, the “Cool Calm” of such educated relatives is beyond understanding. Most insurance companies work office hours, approvals come at their own speed, they are least concerned about the patient outcome.

Everything was being kept on hold. Hospitals do not want to proceed with costly tests and investigations unless they are life saving, because most relatives flatly refuse to pay if the insurance company denies approval. The doctor suffers a double blow emotionally: because things are delayed and also because relatives blame only the doctor.

“This is urgent. Please consider making the payments and filing for reimbursement later, so we can make decisions faster” I told him.

“If it is urgent, why don’t you get it done? I will not pay, his insurance company will have to approve” said the son.

I thought about the patient. In the waiting room, the patient’s wife, an old lady, kept praying. I wished she was also praying for a better son. © Dr. Rajas Deshpande. I requested the hospital authorities, and as always, they agreed to help. A CT scan was done, it did show bleeding in the old man’s brain. When informed, the son winced. “How many more days in the hospital?” he asked.

“Usually it takes a week for such patients to stabilize” we told him.

“Can you discharge him? I will arrange for some nurse to give him treatment at home. Just write the medicines he needs” he said. His mother, hesitant, asked “Is it necessary to treat here, doctor? If his health is in danger, we will stay”.

Angrily, the son cut off his mom. “No, mom, this has become a business. They will extend stay even if it is not necessary. If it is only medicines, why does he need to be in hospital?” he asked me.

“Because such patients often develop excess swelling in the brain, or other complications. They can also develop convulsions or lapse into a coma if swelling worsens” I unchained my patience.

“Do you guarantee that those complications will not happen if we keep him here?” he asked.

“No. Only that he can be managed in time, if any complication develops” I replied. There’s no word called “Guarantee” in the medical dictionary. It is only a quack’s favorite trick. © Dr. Rajas Deshpande

“Then why stay here? I have a nursing home nearby, we will go there if there is any problem” the son said, turning his back upon his mother.

The open-secret was revealed soon: the insurance cover that he had bought for his father was minimal, it was over now, and he didn’t want to pay anything from the pocket.

I explained the patient’s wife about the medicines and care, updated her with the warning signs of danger in such cases. © Dr. Rajas Deshpande

“Doc, I am alone at home with my husband all day. My son and daughter in law both work and return late. What will I do in case there is an emergency?” I gave her some contacts near her home, ambulance numbers and doctors.

“Is it okay if she calls you daily to inform the patient’s condition and ask what medicines are to be given in case of an emergency?” the son asked.

“Sorry, we cannot manage patients on phone” I replied.

“Sorry doc, don’t take this personally, but there’s no humanity left in this profession now a days. No one wants to help even an old patient” he commented. I didn’t reply.

They returned in three days, the patient comatose. The brain swelling had increased to dangerous levels. Patient was operated in emergency, saved with a great effort. The son had to foot the whole bill this time. “This is quite unfortunate” he kept saying, reminding me to keep expenses “lowest” because he was paying from his pocket. Finally came the day of discharge. Knowing the questions, I explained them the medicines on discharge.

“Doc, he is a senior citizen. You must give us discounts” said the son.

“Sorry, the hospital decides the billing. My charges are already minimal”. I told him the truth.

“Just as I said, there’s no humanity left” he looked at his mother and said. It was now the time to chain my patience. I knew the right reply this time.

“Yes, Sir”, I said “ I agree. Humanity is indeed on a decline, but more in your family than in my profession”

© Dr. Rajas Deshpande

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ICU Seventeen

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ICU Seventeen
© Dr. Rajas Deshpande
 
11 PM. Just as I finished my OPD I received a call from the ICU resident doctor: “Sir, you have a call from ICU seventeen”. I was tired and exhausted, feeling feverish that day. I was not on call, so could request them to send this call to another neurologist who was on call.
But it was ICU seventeen. I hated going to that cabin, my legs dragged heavy, my mind exploded, but I had to. © Dr. Rajas Deshpande
 
I went there, assessed the middle aged lady on the bed. She was already on a ventilator, had been unconscious since after a head injury. She had been knocked down by a speeding drunkard while crossing the road. This was day two. Examining her, I found feeble signs that indicated that her brain was not dead. . CT scan showed many injuries to the brain. I told her relatives –the husband and the son- about this, and also explained them the uncertainty and unpredictability of outcome.
“Shall we continue the treatment or let go? We are not rich, we can try only if there are good chances of her survival” said the husband and son. The husband was visibly fatigued with the situation, the son was talking to me without looking up from his iPad.
 
“Although the outcome is unpredictable, in my opinion, you must continue to try. This is not yet a hopeless case”. © Dr. Rajas Deshpande
As expected, they were unhappy.
They wanted quick answers that would either guarantee a good outcome or enable them to bank upon a doctor’s decision to withdraw life support which would make them guilt free. I did not want to hurry a decision for their convenience. My first duty was to protect the patient’s life, not to cater to anyone else’s expectations. A doctor who does not respect life in all its depth has no right to be a doctor. Especially in case of an unconscious patient, a doctor’s responsibility peaks, and sometimes he/she has to even struggle to convince the family to continue treatment. Notions like “dead patient kept on ventilator in ICU” created and catered by some stupids add to this situation. ICU expenses are indeed high. In such a scenario, any doctor who advises to continue treatment in a hope of saving life is indeed suspected to have “financial” motives.
But even that fear was below my duty to the patient. I told them that in my opinion they should not withdraw life support. I told them to continue to try.
 
“Doctor, what would you have done if your mother was in her place?” asked the son, looking up with a cunning expression from his iPad.
The explosions in my mind restarted. © Dr. Rajas Deshpande
In this same ICU seventeen, just a few weeks ago, I had witnessed my mother’s death. For three days and nights, my own colleagues had fought to tackle the umpteen complications that took away my dearest, and I stood at the door, telling them: do whatever you must, try your best, but save her. In her earlier life, mom had always wanted to live, live longer, and be with her family every moment at any cost. There was no reason for me to presume she did not want to survive. From Geeta to Bible, ever sacred book has advised “Do unto others as you would have them do unto you”. Medicine or law aren’t yet wiser than that.
I am a middle class doctor myself, not rich. I could not afford prolonged treatment. But I was willing to even sell myself if it was required to make my mother survive, even for a day more. She would have done the same for me, even more. There is no age and illness when a mother would want her child to die, and as her dearest son, it was upon me to become her mother when she grew old.
 
One cruel night took her away. I will never overcome that feeling of standing in the door of ICU seventeen, with the resident doctor and nurse, both crying too, tried to wrestle out my mom from the claws of death. That cabin, that door, that corridor brings back those moments. I cannot show that upon my face, I am a doctor. I work at the same hospital, see these places almost every day, and carry on what I must. © Dr. Rajas Deshpande
 
I paused to contain the agitations in my mind, then replied.
‘Yes, Sir” I told the son of the iPad: “I am suggesting you exactly what I would have done for my mother”. Still trustless, he continued fingering his iPad. His father sat clutching his head. They continued the treatment, but bitterly.
A week later, she opened eyes. In ten days, I received a call again “Sir, can we shift that lady out of ICU seventeen? She is fine now, conscious and oriented, accepting orally” the resident doctor asked.
 
“Yes please”, I replied, not without a tear. We couldn’t get my mother back, I will never recover from that memory, but we had defeated death in the same room! © Dr. Rajas Deshpande
Every doctor has had such experience: illness, death and extremely disturbing memories associated with it. They still have to keep their calm and continue to try for their patients what they could not achieve for their dearest ones. It is mostly taken for granted: that doctors have no feelings, that it is so routine for them to see pain and death that they are not affected by these anymore.
 
It takes a grand courage: that of a brave soldier, to be able to walk again in the corridors of death that have taken away one’s dearest people. The same diseases, illnesses, problems affect doctors and their families too, we fight them, we win or lose, but we come back to the battleground again, every day, to protect every single life we can.
Therein lies the pride of saying “ I am a doctor”.
© Dr. Rajas Deshpande
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The Changing Blood Group

The Changing Blood Group

(c) Dr. Rajas Deshpande

“He is sinking” shouted Dr. Siya.

The casualty registrar rushed to the bed, checked the vitals. Pulse very fast. Blood Pressure very low. Lips and nails white, hands and feet cold. The young man, unconscious, was on the verge of death.

“He must be bleeding inside. Get an urgent sonography of his abdomen”said the registrar to Dr. Siya, and call the blood bank. He will need at least two units of blood urgently”.

It was Dr. Siya’s first week into internship, she was thrilled with the idea of actually saving lives. At the young age of 22, she was witnessing death almost every other day. Along with that she was amazed to see the darkest sides of human nature: the potential of humans to hurt each other: via rapes, accidents, murders, fights. She had decided to not let this affect her attitude, and to continue to try and save every life she could.

That late night, this young man of about her own age was brought in unconscious by someone, who had just dropped the patient in the casualty and left without leaving any identity of himself. “I found him lying unconscious on the road. I don’t know anything else about him. I am just doing my duty, I have a train to catch”said the stranger and left. The patient was reeking of alcohol. He had a visible head injury. A quick CT scan had revealed minimal bleeding due to a small skull fracture. He also had had bleeding from wounds from his hands and legs, they were sutured. The patient had no identity marks, wallet or cellphone. The policy of the hospital was to provide basic treatment and shift the patient to the government hospital. The police station was already informed. Treatment was started.

Dr. Siya requested two units of blood. The blood bank called. They had only one unit of the blood for his blood group. The registrar had the same blood group, and like many doctors working in the emergency departments, he went down to donate blood.

It was nearly midnight. The fate of the life of a young man depended upon what the junior doctor did just then. There was no one to sign any consents, the protocol was to inform the hospital’s medical director and obtain consent for emergency transfusion or procedure. Dr. Siya finished the formalities, obtained the permission, and started the transfusion. If the patient had reacted or something went wrong now, they all feared, there will be a havoc in the media: that they had let an unknown patient die because they wanted money!

Dr. Siya kept on managing the show. The angry and disturbed relatives of other critical patients kept on taunting her, speaking rude and reluctant to complete simple formalities and paperwork.

The sonography was thankfully normal.

Just as the first unit of blood was over, the patient became conscious, and revealed his name. He was quite shaken with the surrounding, but told in broken sentences about his friend’s number and address. He revealed that while returning from a party, his bike was interrupted by a bunch of goons, he had fallen down, they hit him upon the head and left with all this belongings.

The friend was called, and came in. He revealed that the patient was used to smoking weed and drinking alcohol in huge quantities. They were staying in the hostel of a famous college.

The second blood unit was started, and in a short while the patient threw a convulsion. He was immediately given injectables for controlling the convulsions, he slept off with the effect.

His parents arrived early next morning.. The shocked mother was consoled and explained about the situation by Dr. Siya. The elderly father, like all fathers, equally shocked but being a father unable to cry, kept mum, just holding hands of the boy.

When the patient woke up again, the father came to Dr. Siya, and touched her feet. Too embarrased, she told him that the registrar had donated blood for the patient. The father went and thanked the registrar, again trying to touch his feet.

As Dr. Siya had finished her night duty, she prepared to leave. “Beta, Will you come soon please?”asked the tearful mother to her. “Yes Auntie, I will be back soon. Don’t worry, he is ok now”she reassured and left.

On her way back her genius young mind tried to look at the situation sitting upon her shoulder, the little third person that resides within each one who has a conscience. That booze and weed was easily available to youngsters in almost all Indian hostels, that even educated people rode bikes without helmet, that crimes were happening almost everywhere that injured and killed people, that law and order was a laughable term in many parts ofthe country, that there was no government mechanism in place to provide emergency medical / paramedic support ambulances to raod / traffic accident victims: which one is the most responsible cause, when patients like these died? Who is responsible?

She reached home, told her proud parents what had happened, that she had helped save a life. Her mother folded her hands towards the sky, said “God, let my daughter save many lives everday”.

While having the breakfast, her father turned on the TV. A famous but ill educated political leader, in his mind-and-other- organs blowing speech in Karnataka, was explaining the illiterate public how all Indian doctors charged in excess, how they were only after money, how everyone except himself was the enemy of the millions of patients surviving from critical heart attacks, accidents, strokes and other diseases. All patients getting better all over te country was only thanks to himself and his government!

Dr. Siya’s father laughed bitterly. “Next time you need blood for any poor or unknown patient, call him” he said.

Dr. Siya replied, laughing “That kind of ëver changing blood group doesn’t match anyone, it is useless for any patient, Papa”.

(c) Dr. Rajas Deshpande

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New Medical Criminals

New Medical Criminals
© Dr. Rajas Deshpande

“Doctor, Will My Dad Survive?” asked the anxious son.
“Very unlikely, we are trying our best though” said the desperate doc.
The highly qualified son had brought his father late night on a Friday, over 24 hours after he had developed a paralysis. Patient’s blood pressure was high, and heart status was fluctuating. An urgent MRI was advised.

“I will get the MRI done outside, I have a friend who gives me concession” said the son, and returned with an MRI after three hours, it did show a big clot in the patient’s brain. The son had insisted upon admission in the ward instead of a critical care unit, saying that his father “did not appear critical” to him and his family. “You want to admit in ICU because that will increase the bills. I know” he had bluntly told the doctor. The doctor had asked him to sign the refusal to admit in critical care, then sent the patient to the ward. Routine treatment for stroke and blood pressure was started, and tests sent.
“I will also get the medicines from outside the hospital, I have a pharmacist friend who gives me concession” he had told the doctor. © Dr. Rajas Deshpande

Early next morning, the father developed chest pain, and the cardiologist advised immediate stenting, as he was developing a block in the heart. . The son had insisted on using the cheapest stent. Although the angioplasty went well, the patient developed a bleeding in the brain, a complication known in stroke cases. He became unconscious. As the bleeding caused increased swelling and pressure upon the brain, a neurosurgeon was called in to decompress the brain (take off a small portion of the skull bone, to relieve pressure upon the brain). The surgery is usually safe, but the condition in which it is done is usually ultra-critical, thus risk to life is high. The son asked for a guarantee for a good outcome, and was explained that there cannot be any guarantees in medicine. He then refused the surgery, saying “I have read that surgeries are done without necessity by scaring the patient”.

Within hours, the patient’s brain swelling increased to the level of almost a certain fatal outcome. In the evening the son said he was willing for the decompression surgery, it was almost too late. The Neurosurgeon still operated him late night to make a last attempt to save life. After the surgery, the father was shifted to the recovery room. © Dr. Rajas Deshpande

It was here that the son had asked the doctor: “Will my father survive, doctor?”.
The doctor politely replied: “Sir, you have all the reports, you know what is his medical condition, so you can now google search and also ask your political leaders through their famous apps what will be the outcome, what is the next step”.

“But you are the treating doctor, you know better. You are like God for us” said the desperate son.

The doctor uttered the only two words that the doctor would want to use after hearing this:

“I Wish”.

Every Tom, Dick and Harry in the government and in the Media has become a critic of the extremely overburdened Indian medical profession made up of some of the best doctors in the world. Those who cannot run their own govt. hospitals well, cannot provide quality heatlthcare to the taxpayer, those who have corruption seeping through almost every office they own, those in whose authority (read govt. hospitals) hundreds of patients die helpless without care, compassion or treatment, those who suspend peons, ward boys, nurses and doctors for deaths that result from inadequacies like lack of essential facilities at hospitals owned by the govt., are out telling the world how Indian medical practitioners are corrupt, instead of praising how they shoulder what the govt. fails to recognize as its own responsibility: healthcare for the majority.

There are bad doctors, bad diagnostic centers, and bad pharma companies, protected by politicians and working on ‘lowest quality-lowest price’ principle. There indeed are “profit sharing set ups”. Among these, if a good doctor / specialist advises the patient to go to a particular doctor or lab or choose a particular brand, the patient automatically presumes that that the doctor is looking for extra money. So most doctors now tell the patient to “go wherever they want” for specialist consultation or tests. © Dr. Rajas Deshpande

When I must refer a patient to someone, the only thought in my mind is to offer the patient the best: because the patient’s trust is most important for me. This is how most doctors think, every doctor wants to make a good reputation, which is impossible without also good outcomes. I need to be able to discuss and be comfortable with that specialist, so we can plan best for the patient. If a suspicion about financial misappropriation looms over everything that a doctor does, it is difficult for any doctor to work. There must be accountability, but for both: the treatment and the doctor’s time, energy and skill. The doctor must be able to choose the best for the patient and the patient should have more trust in the doctor than the rumors. .

The last person who should play with trust and faith in other professions is a politician.

The patient did not survive. Neither the leaders who spoke lose and caused paranoia to affect the outcome, or the son who delayed admission, the pharmacy that sold cheapest drugs, nor the family that refused a life saving surgery had any blemish upon their reputation.

It was easier for all of them to blame the doctors who tried hardest for the patient.
© Dr. Rajas Deshpande

Thank You Dr Nusli Ichaporia for the technical assistance.

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The Extinction of Precious: A Medical Horror Story Happening Right Now!

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The Extinction of Precious:
A Medical Horror Story Happening Right Now!
©️ Dr. Rajas Deshpande

“Sir, we have come from Konkan”, said the father, “to seek your advice and blessings . My son has passed the medical postgraduate exams with national rank 30. He wants to decide which branch he should choose”.

I congratulated the genius. Passing medical entrances with high merit requires great talent. It does not earn the glamour, claps and appreciation of stage and limelight, for we live in a society that only worships looks, muscles, bhashanbazi, financial success and sports (sorry, one sport. Even if someone wins a world gold in any other sport than cricket, they go home in an auto rickshaw when they return to India!).

Speaking with the boy, I realised that he was very sensitive, compassionate and had an excellent logic and reasoning. Besides having a calm bearing, he was also a hard worker. A perfect blend for becoming a great physician or a surgeon, in a world that is fast losing able clinicians. I suggested him to prefer Internal medicine.© Dr. Rajas Deshpande

They looked awkwardly towards each other. The boy garnered some courage to speak.

“Sir, I saw our family doctor being beaten up by a local politician, his clinic was ruined. He was humiliated in the worst language in front of his wife and children, and instead of protecting him, other patients in his hospital kept on recording videos of the incident, which later became viral. He left, we don’t know where he went. I cannot ever think of directly dealing with patients now. I want to choose a non- clinical or para-clinical branch.”

I appealed to the father: “Your son has a great potential and matching talent to become a good clinician, we desperately need many more. It is not necessary that he practices in your own town or even in India. The whole world needs good doctors. Please think about this”.

The father, a simple teacher from a primary school, thought for a prolonged moment. His eyes reddened up.
“I don’t know, Sir. When he said he wanted to become a doctor, his mother and I always thought that he will become a saviour, running around saving people’s lives. We were never interested in only money. But the day that we saw our own doctor being beaten up by a crowd and the local politician, we realised how helpless a doctor’s life is. We knew our doctor for over 25 years, he was like a God for many in our town. All he did in 25 years became a zero in a few minutes, thanks to a hooligan politico and his crowd. We don’t want our son to ever face that. If we had a daughter in his place, we wouldn’t even have made her a doctor, women as doctors suffer a lot more trouble and get no returns, sometimes even from their family. And this is our only son, we want him to stay in India near us.”

Somehow I didn’t want to give up convincing him, he was an ideal candidate for becoming an excellent clinician.© Dr. Rajas Deshpande “Think of the future. Hopefully there will be better laws, he can also consider working in bigger, safer hospitals if he is scared”.

“What would you advise your own son if you were in my place, Sir?” asked the father.

He had bombed my mind.
I was trained by parents and teachers to always do good, be compassionate and kind. My kids had a potential to become great doctors coming from this background. I worry a lot about the extremely critical condition of deteriorating healthcare standards and reducing number of good clinicians that is destined to cause a havoc in a few years. Still, honestly, I did not wish upon my children the insecurities and threats I face. I don’t want them to live under the perpetual fear of being vandalised, defamed, tortured by over-expectation and punished by committees made up of politicians and medically inexperienced judicial experts. I won’t want their lives, work hours and remunerations to be dictated by a corrupt bunch living for votes of free mongers.© Dr. Rajas Deshpande

It would be hypocrisy to advise someone else what I wouldn’t choose for myself. That’s how a doctor makes the best possible decision. With a heavy heart, I advised him what I always advised my children:

“I agree. Please choose what suits your heart most, what gives you fearless happiness in your work and also leaves you with some time for yourself and your family, ensures a good income and is not dependent upon jealous people’s expectations of what you should do and for what price. You have so many options for social service other than becoming a clinician. I am sure you will stay a good human being all your life.” I suggested him two para-clinical branches that offer good scope.© Dr. Rajas Deshpande

The world indeed will have to suffer the gradual extinction of good clinicians. We need many more excellent doctors in para clinical and non clinical areas too, but the face of the profession is the clinician, and we certainly, desperately need many thousand more. It is a fact that in spite of increasing number of doctors, patients still die travelling in an ambulance to reach good healthcare far away from most homes in India. Many federal orphans who cannot even afford government healthcare die at home.© Dr. Rajas Deshpande

The father asked his son to touch my feet. As he did so, the melancholy of my own advice bit my heart. I couldn’t let down the flag of my noble profession.

“Listen, dear. I am speaking this against my own convictions. I am struggling. Think about becoming a good clinician and practising in a safe country, take your parents with you. I will be happy whatever you finally decide, but not everyone has the ability and talent to become a good doctor, it is rarest of the rare traits.”© Dr. Rajas Deshpande

They left. So did a part of my hope for the future of good healthcare.

When the next couple walked in with an infant baby in their hands, I looked at the smiling baby, and forced a smile. She didn’t know it yet, but I had just bought a precious gift for her.

©️ Dr. Rajas Deshpande

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